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BACKGROUND: Disposable digital single-operator cholangioscopy (D-SOC) and direct peroral cholangioscopy (D-POC) using an ultraslim endoscope are established POC modalities for the diagnosis and treatment of various biliary diseases. We compared the usefulness of D-SOC and D-POC for the diagnosis of intraductal superficial lesions of the bile duct (ISL-Bs). METHODS: 38 consecutive patients with suspected biliary diseases who underwent both D-SOC and D-POC were enrolled. The primary outcome was ISL-B detection rate, and the secondary outcomes were technical success of POC and POC-guided forceps biopsy sampling (POC-FB), procedure time, visualization quality, and tissue adequacy. RESULTS: D-SOC had a higher technical success rate than D-POC but the difference was not statistically significant (100% vs. 92.1%, P = 0.25). D-POC had a marginally higher ISL-B detection rate (34.2% vs. 28.9%, P = 0.68) and significantly higher visualization quality (P = 0.03). The mean (SD) procedure time was significantly shorter with D-SOC (11.00 [1.33] vs. 19.03 [2.95] minutes, P<0.001). The technical success rate of POC-FB and tissue adequacy did not differ between the two techniques (D-SOC vs. D-POC: 81.8% vs. 84.6%, P = 0.69 and 77.8% vs. 90.9%, P = 0.57, respectively). CONCLUSIONS: Both POC systems were safe and useful for the detection, characterization, and diagnosis of minute ISL-Bs. While D-SOC displayed a shorter procedure time and a tendency for higher technical success rate, D-POC provided superior visualization quality, allowing detailed observation of the surface structure and microvascular patterns.
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BACKGROUND AND AIMS: Indirect diagnostic modalities are unsatisfactory for detecting intraductal neoplasm of the bile duct (IN-B), which can be detected by peroral cholangioscopy (POC) with narrow-band imaging (NBI). We investigated the POC findings of IN-B and developed a feasible endoscopic classification system. METHODS: Four hundred seventy-one patients who underwent direct POC from April 2008 to July 2020 were enrolled. Intraductal superficial lesions of the bile duct (ISL-Bs) were classified according to surface structure and microvascular pattern on POC with NBI and correlated to histologic findings after POC-guided forceps biopsy sampling (POC-FB) or surgery. The primary outcome was the detection rate of IN-Bs, and the secondary outcomes were the associations of POC findings with IN-B, technical success rates of POC and POC-FB, and adverse events. RESULTS: Direct POC was successful in 458 of 471 patients (97.2%). Among the patients, 131 (27.8%) exhibited ISL-Bs. The technical success rate of POC-FB was 94.7% (124/131). Among the 124 patients who underwent POC-FB, IN-B was revealed in 54 (43.5%), for a detection rate of 11.8% (54/458). Papillary lesions (P = .041), nodular lesions (P = .044), and irregularly or regularly dilated and tortuous vessels (P = .004 and P = .006, respectively) were POC findings associated with IN-B. The area under the receiver-operating characteristic curve of the novel classification system was .899. CONCLUSIONS: POC with NBI can be useful for the detection of IN-Bs. Our novel classification system based on both surface structure and microvascular pattern may allow differentiation of IN-B from ISL-Bs.
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Neoplasias dos Ductos Biliares , Laparoscopia , Humanos , Endoscopia do Sistema Digestório/métodos , Ductos Biliares/patologia , Cateterismo , Neoplasias dos Ductos Biliares/patologiaRESUMO
BACKGROUND AND AIMS: EUS-guided hepaticogastrostomy (EUS-HPG) has a risk of serious procedural adverse events (AEs), but few dedicated devices for EUS-HPG are available. We evaluated the feasibility of a new partially covered self-expandable metal stent (PCSEMS) with an anchoring flange for EUS-HPG. METHODS: The feasibility of a stent featuring a proximal radiopaque uncovered portion 1.5 cm in length and a distal anchoring flange 20 mm in diameter was evaluated in consecutive patients undergoing EUS-HPG for unresectable malignant biliary obstruction. Primary outcomes were the technical and clinical success of EUS-HPG, and secondary outcomes were AEs, recurrent biliary obstruction (RBO), reintervention for RBO, and the technical feasibility of peroral cholangioscopy (POC) through the stent in situ. RESULTS: EUS-HPG was performed in 24 patients with unresectable malignant biliary obstruction. The technical and clinical success rates of EUS-HPG were 100% (24/24) and 91.7% (22/24), respectively. AEs developed after EUS-HPG in 8.3% of patients (2/24, cholangitis). RBO developed in 29.2% of patients (7/24), with a median cumulative time to RBO of 6.7 months. The causes of RBO were sludge formation (n = 4), hyperplasia at an uncovered portion (n = 2), and nonocclusive cholangitis (n = 1). Reintervention for RBO had a 100% success rate (7/7), and POC through the stent in situ was technically feasible in 7 of 8 patients with a stent diameter of 10 mm. CONCLUSIONS: EUS-HPG with a new PCSEMS can alleviate malignant biliary obstruction after failed ERCP. The novel stent evaluated in this study may prevent stent-related AEs, including stent migration, and allow advanced endoscopic interventions through the HPG route.
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BACKGROUND AND AIMS: Endoscopic ultrasound (EUS) guided choledochoduodenostomy using a lumen-apposing metal stent (LAMS) allows access to the biliary system with a sufficiently large diameter stent. However, an appropriate endoscope for this purpose is required. We evaluated the feasibility of per-oral cholangioscopy (POC) using a multibending ultra-slim endoscope through a LAMS for EUS-guided choledochoduodenostomy. METHODS: Twelve patients who underwent EUS-guided choledochoduodenostomy, followed by POC via a LAMS, were enrolled. POC was performed with an multibending ultra-slim endoscope. The primary outcome was technical success, defined as examination of both hepatic ducts and either the distal common bile duct or stricture site within 10 min. The types of intervention and adverse events were also assessed. RESULTS: Technical success was achieved in all cases with the multibending ultra-slim endoscope. Narrow-band imaging endoscopy was performed in five cases (41.7%) and POC-guided targeted biopsy was performed in three cases (25.0%). Stone extraction during POC was performed in two patients (16.7%) and foreign body removal from the intrahepatic duct was performed in one patient. One patient underwent additional metal stent insertion under direct visualization. After POC, no stent migration or severe adverse events were seen in any case. CONCLUSIONS: POC using a multibending ultra-slim endoscope for diagnostic or therapeutic purposes can be performed effectively and safely through a LAMS after EUS-guided choledochoduodenostomy.
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Coledocostomia , Endoscopia do Sistema Digestório , Humanos , Coledocostomia/métodos , Estudos de Viabilidade , Endoscopia do Sistema Digestório/métodos , Endoscópios , Ducto Colédoco , Stents/efeitos adversos , Endossonografia , Drenagem , Resultado do TratamentoRESUMO
BACKGROUND AND AIMS: Direct peroral cholangioscopy (POC) can be useful when combined with narrow-band imaging (NBI) to explore the etiologies of indeterminate biliary strictures. We evaluated the efficacy of NBI compared with that of conventional white-light imaging (WLI) during POC diagnosis of indeterminate biliary strictures. METHODS: Consecutive patients with indeterminate biliary strictures were enrolled from 2016 to 2019. The primary outcome was diagnostic accuracy, and secondary outcomes were technical success, adverse events, and visualization quality when predicting malignancy. RESULTS: Seventy-one patients underwent direct POC under NBI during targeted biopsy sampling. The strictures were successfully explored and adequate biopsy samples obtained in 67 of 71 patients (94.4%). In terms of visual impression, WLI and NBI afforded 75.0% and 87.5% sensitivity, 82.9 and 91.4% specificity, and 82.8 and 91.3% accuracy, respectively. The areas under the WLI and NBI receiver-operating characteristic curves were .80 and .96 (P = .01). Under NBI, the visualization quality of surface structures, microvessels, and lesional margins was higher than that under conventional WLI (P < .05). CONCLUSIONS: Direct POC under NBI effectively and accurately predicts malignancies of indeterminate biliary strictures. NBI effectively illuminated surface structures, microvessels, and lesional margins.
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Neoplasias dos Ductos Biliares , Colestase , Neoplasias dos Ductos Biliares/complicações , Neoplasias dos Ductos Biliares/diagnóstico por imagem , Biópsia/efeitos adversos , Colestase/complicações , Colestase/etiologia , Constrição Patológica/etiologia , Humanos , Imagem de Banda EstreitaRESUMO
BACKGROUND: Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) using a lumen-apposing metal stent (LAMS) has rendered endoscopic gallbladder assessment through a stent possible, but an appropriate endoscope is required. We assessed the feasibility of peroral cholecystoscopy (POCC) using a multibending ultraslim endoscope passed through a LAMS after EUS-GBD. METHODS: 14 patients with a LAMS for EUS-GBD who consecutively underwent POCC were included. POCC was performed using a multibending endoscope inserted through the LAMS.âThe primary outcome was the technical success rate, defined as complete endoscopic examination of the gallbladder from the orifice of the cystic duct to the fundus. The types of intervention and adverse events were recorded. RESULTS: 17 POCCs were performed in 14 patients. Of the 17 POCCs, 15 (88.2â%) were technically successful. Narrow-band imaging endoscopy was performed in 12 procedures (70.6â%), and cholecystoscopy-guided target biopsies were obtained in six. Gallstone extraction was performed in two patients. After POCC, all LAMSs remained stable and no adverse events were observed. CONCLUSIONS: POCC using a multibending ultraslim endoscope can be effectively and safely performed through a LAMS after EUS-GBD.
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Colecistite Aguda , Colecistite Aguda/etiologia , Colecistite Aguda/cirurgia , Drenagem/métodos , Endoscópios , Endossonografia/métodos , Estudos de Viabilidade , Humanos , Stents , Resultado do Tratamento , Ultrassonografia de IntervençãoRESUMO
BACKGROUND AND AIM: Durable biliary drainage is essential in patients with pancreatic cancer in the era of effective neoadjuvant chemotherapy (NACT). Plastic stent (PS) tends to occlude easily, and current metal stents are designed for nonresectable cancer. We evaluated the efficacy of a modified non-flared fully covered self-expandable metal stent (M-FCSEMS) during the perioperative period in patients with resectable or borderline resectable pancreatic cancer. METHODS: Consecutive patients with resectable or borderline resectable pancreatic ductal adenocarcinoma had a 12-mm M-FCSEMS (M-FCSEMS group) or 7-Fr PS (PS group) placed for biliary decompression before NACT or curative-intent surgery. The primary outcome was the re-intervention rate, and secondary outcomes were technical success, stent patency, and adverse events (AEs). RESULTS: Endoscopic stent placement was technically successful in all 60 patients. Twenty-three patients underwent surgery and 37 NACT before surgery. Re-intervention was performed in 10.0% (3/30) of patients in the M-FCSEMS group and 36.7% (11/30) of patients in the PS group (P = 0.030). The stent patency at 180 days was 89.8% (95% confidence interval, 77.3-100.0%) in the M-FCSEMS group and 30.2% (95% confidence interval, 11.4-80.0%) in the PS group (P < 0.0001). Stent-related AEs occurred in 10.0% (3/30) in the M-FCSEMS group and 40.0% (12/30) in the PS group (P = 0.015). Surgery-related AEs occurred in 10.5% (2/19) and 14.3% (3/21) in the M-FCSEMS and PS groups (P = 0.549). CONCLUSIONS: Modified non-flared fully covered self-expandable metal stents are effective and safe for durable biliary drainage in patients with resectable or borderline resectable pancreatic cancer during the perioperative period.
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Carcinoma Ductal Pancreático , Neoplasias Pancreáticas , Cuidados Pré-Operatórios , Stents Metálicos Autoexpansíveis , Carcinoma Ductal Pancreático/terapia , Drenagem , Humanos , Neoplasias Pancreáticas/terapia , Stents Metálicos Autoexpansíveis/efeitos adversos , Resultado do TratamentoRESUMO
BACKGROUND AND AIM: Endoscopic post-papillectomy bleeding is a serious adverse event with a prevalence ranging from 2% to 45.3%. Conventional hemostatic methods, including diluted epinephrine injection before papillectomy or argon plasma coagulation after papillectomy, did not show a preventive role in reducing immediate or delayed post-papillectomy bleeding. Therefore, we aimed to assess the efficacy and safety of a hemostatic powder spray for post-papillectomy bleeding and compare with those of conventional modalities. METHODS: Patients who underwent endoscopic papillectomy were enrolled in five tertiary hospitals. The group was divided into hemostatic spray and conventional control groups according to the bleeding control methods. The main outcome measurements were delayed bleeding rate and any adverse events related to the procedures. RESULTS: A total of 40 patients who received a hemostatic spray (n = 18) or conventional hemostatic methods (n = 22) after endoscopic papillectomy were included. The prevalence of delayed bleeding was not different in the two groups: 27.8% and 36.4% in hemostatic spray and conventional control groups (P = 0.564), respectively. The adverse events such as post-papillectomy pancreatitis and cholangitis were not different in the two groups. There were no procedure-related mortalities. CONCLUSION: Hemostatic spray is technically feasible and safe for the prevention or management of post-papillectomy bleeding. Hemostatic spray can be one of the options for post-papillectomy bleeding control methods owing to its convenient use.
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Hemostáticos , Pancreatite , Humanos , Endoscopia , Epinefrina , Coagulação com Plasma de Argônio , Pancreatite/epidemiologia , Resultado do TratamentoRESUMO
BACKGROUND AND AIM: There is no clear data to compare the effectiveness and safety of bilateral stent-in-stent (SIS) or stent-by-stent (SBS) deployment for advanced malignant hilar obstruction (MHO). This meta-analysis was done to investigate clinical outcomes of these deployment methods. METHODS: We did a literature search to identify studies that reported the clinical outcomes of bilateral metal stents in patients with advanced MHO. Weighed pooled rates (WPR) along with 95% confidence interval (95% CI) were calculated in order to compare outcomes including technical and clinical success, adverse events, and stent occlusion between the two groups. We conducted a meta-analysis using a random-effects model. RESULTS: Five comparative studies with 250 patients, and 20 single-arm studies for the SIS or SBS method were eligible for the meta-analysis and systematic review. The bilateral SIS deployment had a significantly higher technical success rate than did SBS deployment (OR 6.43; 95% CI 1.08-38.09). There was no difference in the clinical success (OR 1.23; 95% CI 0.45-3.38), overall adverse events rates (OR 0.42; 95% CI 0.15-1.18), or overall occlusion rate (OR 1.55; 95% CI 0.89-2.70). As a single-armed group, WPR of technical success of the SIS and SBS groups was 96.4% and 89.6%, respectively. Clinical success was 97.5% and 98.3%. Overall, adverse events were 35.9% and 22.6%. Occlusion rates were 27.7% and 37.7%. CONCLUSIONS: Although there was a lack of quality data and heterogeneity, bilateral SIS deployment had a higher technical feasibility than did the SBS method in patients with advanced MHO, without differences in terms of clinical success, adverse events, or occlusion rates.
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Neoplasias dos Ductos Biliares/complicações , Colestase/cirurgia , Drenagem/métodos , Endoscopia do Sistema Digestório/métodos , Stents , Colangiocarcinoma/complicações , Colestase/etiologia , Humanos , Tumor de Klatskin/complicações , Resultado do TratamentoRESUMO
BACKGROUND AND AIM: The detection of residual or fragmented common bile duct (CBD) stones after lithotripsy can be improved by the high-resolution imaging quality of digital, single-operator cholangioscopy (SOC). However, therapeutic interventions for the removal of residual CBD stones are limited by the lack of appropriate tools. We retrospectively evaluated the role of SOC and the newly developed Dormia basket for the evaluation and removal of stones remaining after lithotripsy. METHODS: Thirty-four patients who had undergone lithotripsy for retained CBD stones with no evidence of filling defects in occluded balloon cholangiography from March 2017 to October 2018 were included in the study. After balloon cholangiography, the bile duct was evaluated by SOC for complete evacuation of the stones. The detected residual CBD stones were directly retrieved by inserting the newly developed Dormia basket into the working channel of the SOC. The incidence of residual stones detected by SOC and the success rate of residual stone retrieval by SOC were investigated. RESULTS: Digital SOC was successfully performed in all patients. Of these, 11 patients (32.4%) had residual CBD stones. The residual stones were successfully removed in 10 patients (90.9%) by SOC using the Dormia basket, except in one case of residual stones left in the hepatic duct. There were no adverse events associated with the SOC procedures or direct stone removal. CONCLUSIONS: Digital SOC combined with the newly developed Dormia basket was useful for the detection and extraction of residual CBD stones under direct visualization after lithotripsy.
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Cálculos , Cálculos Biliares , Litotripsia , Colangiopancreatografia Retrógrada Endoscópica/efeitos adversos , Cálculos Biliares/diagnóstico por imagem , Cálculos Biliares/terapia , Humanos , Litotripsia/métodos , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND AND AIMS: Although cholangiocarcinomas (CCAs) can be diagnosed using several modalities, the detection of early-stage cancers remains unsatisfactory. We explored whether peroral cholangioscopy (POC) could be used to screen for neoplastic bile duct lesions including CCAs in patients with bile duct stones. METHODS: Two hundred seven patients who underwent endoscopic removal of bile duct stones were enrolled between August 2010 and July 2018. The primary outcome was the detection rate of intraductal neoplastic biliary lesions by direct POC. Secondary outcomes were the technical success rates of direct POC and POC-guided forceps biopsy sampling (POC-FB), the diagnostic accuracy of the direct POC findings, adverse events, and the number needed to screen to detect a neoplastic bile duct lesion. RESULTS: Direct POC was successful in 199 of 207 patients (96.1%). Mild cholangitis developed in 2 patients (1.0%) and was treated conservatively. Of the 199 successfully performed POCs, 31 patients (15.6%) exhibited abnormal intraductal mucosal lesions. The technical success rate of POC-FB was 90.3% (28/31 patients). The pathologic diagnoses after POC-FB were CCAs (n = 4), intraductal papillary neoplasms of the bile duct (IPN-B) (n = 2), an adenoma with dysplasia (n = 1), and benign lesions (n = 21). Direct POC correctly distinguished non-neoplastic from neoplastic bile duct lesions in 91.6% of patients. Curative surgical resection was performed for the 5 patients with CCAs or IPN-B. The number needed to screen to detect a neoplastic bile duct lesion was 29.6. CONCLUSIONS: Direct POC using a dedicated, ultraslim upper endoscope usefully screens for neoplastic bile duct lesions including CCAs in selected patients with bile duct stones.
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Procedimentos Cirúrgicos do Sistema Biliar , Cálculos Biliares , Ductos Biliares , Endoscopia do Sistema Digestório , Desenho de Equipamento , Cálculos Biliares/cirurgia , HumanosRESUMO
BACKGROUND: The use of a lumen-apposing metal stent (LAMS) capable of one-step endoscopic ultrasound-guided transmural drainage (EUS-TD) can increase the effectiveness of the procedure. We evaluated the newly developed electrocautery-enhanced (EC) delivery system with a LAMS for one-step EUS-guided gallbladder drainage (EUS-GBD) or choledochoduodenostomy (EUS-CDS). METHODS: In the animal experiment, an EC-LAMS was advanced into the gallbladder without prior tract dilation in four pigs. A conventional LAMS was inserted in another four pigs as a control group. After the animal experiment, 17 patients underwent EUS-TD using the EC-LAMS (EUS-GBD in 10 patients, EUS-CDS in 7). The primary outcome was the technical success rate. RESULTS: In the animal study, the mean procedure time was significantly shorter in the EC-LAMS group than in the conventional LAMS group. In the human study, the overall technical success rate was 94.1â%, with one EUS-GBD failure. The clinical success rate was 100â%. The overall adverse event rate was 17.6â%. CONCLUSIONS: One-step EUS-GBD or EUS-CDS using the novel EC-LAMS is a feasible approach that achieves a high success rate and maintains safety.
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Endossonografia , Vesícula Biliar , Animais , Ductos Biliares , Drenagem , Eletrocoagulação , Estudos de Viabilidade , Vesícula Biliar/diagnóstico por imagem , Vesícula Biliar/cirurgia , Humanos , Stents , Suínos , Resultado do Tratamento , Ultrassonografia de IntervençãoRESUMO
BACKGROUND AND AIM: Endoscopic management of a benign biliary stricture (BBS) on the hilum is complicated and challenging. Although the placement of a fully covered self-expandable metal stent (FCSEMS) is possible to increase effectiveness, stent migration and stent-induced adverse events are problematic. We aimed to evaluate the usefulness of a modified short FCSEMS with a long lasso in patients with a difficult perihilar BBS. METHODS: Patients with perihilar BBS within 2 cm from the hilar confluence that failed initially with plastic stents were enrolled. A modified short FCSEMS was deployed and then removed 5-6 months later. The primary outcome was clinical success. Other technical success, adverse events, endoscopic success of stent removal, and recurrence of stricture during the follow-up period were measured. RESULTS: Endoscopic intraductal placement was technically successful in all patients (n = 19). Combined contralateral plastic stent placement was performed in 13 patients (68.4%). The median duration of stent placement was 163 days (range, 138-196 days). Endoscopic stent removal was successful in all patients except one spontaneous distal migration. Stricture resolution without de novo focal stricture occurrence was 100%. Endoscopic stone removal after stricture improvement was successful in all 13 patients with bile duct stones above the stricture. During a follow-up period (median 635 days) after stent removal, only one recurrence developed. CONCLUSIONS: Temporary placement of a modified intraductal short FCSEMS with or without a contralateral plastic stent improved perihilar BBS in patients that primarily failed by plastic stents. Combined biliary stones were also successfully removed after stricture resolution.
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Ductos Biliares/cirurgia , Procedimentos Cirúrgicos do Sistema Biliar/métodos , Stents Metálicos Autoexpansíveis , Ductos Biliares/patologia , Constrição Patológica , Remoção de Dispositivo , Endoscopia do Sistema Digestório/métodos , Feminino , Seguimentos , Humanos , Masculino , Plásticos/efeitos adversos , Recidiva , Stents Metálicos Autoexpansíveis/efeitos adversos , Falha de Tratamento , Resultado do TratamentoRESUMO
BACKGROUND AND AIM: Endoscopic post-papillectomy bleeding occurs in 3% to 20% of the cases, and delayed bleeding is also problematic. However, there is no consensus on how to reduce delayed post-papillectomy bleeding. The aim of this study was to evaluate the efficacy of prophylactic argon plasma coagulation (APC) to minimize delayed bleeding and reduce the persistence of residual tumors after endoscopic papillectomy. METHODS: In a prospective pilot study of patients with benign ampullary tumors, the prophylactic APC group underwent APC at the resection margin following a conventional snaring papillectomy. Then, 24 h later after the papillectomy, all patients underwent a follow-up duodenoscopy to identify post-papillectomy bleeding and were followed up until 12 months. The main outcomes were the delayed (≥24 h) post-papillectomy bleeding rate and the tumor persistence rate. RESULTS: The delayed post-papillectomy bleeding rate was 30.8% (8/26) in the prophylactic APC group and 21.4% (6/28) in the non-APC group (P = 0.434). The post-procedure pancreatitis rates were 23.1% (6/26) and 35.7% (10/28), respectively (P = 0.310). The rate of tumor persistence did not differ between the two groups at 1 month (12.5% vs 7.4%, P = 0.656), 3 months (4.2% vs 3.7%, P = 1.00), 6 months (8.3% vs 3.7%, P = 0.595), and 12 months (0% vs 3.7%, P = 1.00). There were no procedure-related mortalities or serious complications. CONCLUSION: Prophylactic APC may not be effective in reducing delayed post-papillectomy bleeding or remnant tumor ablation immediately after conventional papillectomy (Clinical trial registration-cris.nih.go.kr; KCT0001955).
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Adenocarcinoma/cirurgia , Ampola Hepatopancreática/cirurgia , Coagulação com Plasma de Argônio/métodos , Neoplasias do Ducto Colédoco/cirurgia , Hemorragia Pós-Operatória/prevenção & controle , Esfinterotomia Endoscópica/efeitos adversos , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Esfinterotomia Endoscópica/métodosRESUMO
BACKGROUND AND AIMS: Fully covered self-expanding metal stents (FCSEMSs) are considered to be more effective than plastic stents for the treatment of main pancreatic duct (MPD) strictures associated with chronic pancreatitis (CP) because of their larger diameter and exertion of a radial expansion force. However, the current FCSEMSs have several limitations. To overcome these, a novel modified nonflared FCSEMS was developed. In this study we conducted a prospective long-term follow-up evaluation of the efficacy of the novel FCSEMS for the treatment of refractory benign PD strictures in patients with CP. METHODS: Consecutive patients with symptomatic CP associated with refractory MPD strictures were enrolled prospectively in this single-arm study. The nonflared FCSEMS was placed intraductally or transpapillary according to the location and length of the stricture. Stent removal was performed at 3 months after placement. The primary outcome was the resolution of the pancreatic ductal stricture. RESULTS: Endoscopic placement of modified nonflared FCSEMSs was technically successful in all 25 patients. Intraductal FCSEMS placement was performed in 14 patients (56.0%). Stents of diameter 8 mm were used in 17 patients (68.0%). Stents of lengths 3 and 5 cm were inserted in 22 (88.0%) and 3 (12.0%) patients, respectively. In 1 patient (4.0%), stent migration developed. All other stents were removed successfully. After stent removal, resolution of the MPD stricture was confirmed in all patients, and no FCSEMS-related de novo stricture was observed. During the follow-up period (median, 34 months; interquartile range, 25-56) after the stents had been removed from the 25 patients, reintervention for recurrence of MPD stricture with abdominal pain was performed in 2 patients (8.0%). CONCLUSIONS: Endoscopic placement of a novel modified nonflared FCSEMS resulted in long-term stricture resolution with pain relief and reduced the rate of stent-related adverse events, particularly stent migration and stent-induced de novo MPD stricture. (Clinical trial registration number: UMIN000035681.).
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Stents , Colangiopancreatografia Retrógrada Endoscópica , Constrição Patológica/etiologia , Constrição Patológica/cirurgia , Humanos , Ductos Pancreáticos/cirurgia , Pancreatite Crônica/complicações , Estudos Prospectivos , Resultado do TratamentoRESUMO
BACKGROUND AND AIM: Fully covered self-expandable metallic stent (FCSEMS) may be an effective modality for managing anastomotic biliary stricture (ABS) after liver transplantation. However, stent migration and stent-induced ductal injury are the main limitations. The objective of this study was to evaluate the usefulness of an unflared, intraductal FCSEMS that was designed to minimize migration and ductal injury for refractory ABS after living donor liver transplantation (LDLT). METHODS: A total of 32 consecutive patients with symptomatic ABS after LDLT unresolved by plastic stents with or without balloon dilation at four tertiary medical centers were prospectively enrolled. A short (3 or 5 cm) FCSEMS having long lasso (10 cm) used in this study had unflared convex ends to minimize tissue hyperplasia and smaller center portion to prevent migration. The FCSEMS was placed above the papilla and removed at 3-4 months after stenting. RESULTS: Technical and clinical success rates of intraductal placement with FCSEMS were 100% (32/32) and 81.2% (26/32), respectively. Early stent migration was observed in five (15.6%) patients. However, three patients with early stent migration had stricture resolution without needing additional intervention. Intended stent removal was successful in 27 (100%) patients (median, 101 days; range, 23-118 days). No stent-induced ductal change was observed in all patients. Stricture recurrence was observed in 11.5% (3/26) of patients during 639 days of median duration of follow-up (range, 366-2079 days). CONCLUSIONS: Intraductal placement of an unflared short FCSEMS may be a promising option for refractory ABS after LDLT with minimal stent-induced ductal injury and stent migration.
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Colestase/cirurgia , Transplante de Fígado , Doadores Vivos , Metais , Complicações Pós-Operatórias/cirurgia , Stents , Idoso , Ductos Biliares/lesões , Feminino , Seguimentos , Migração de Corpo Estranho/prevenção & controle , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/prevenção & controle , Estudos Prospectivos , Stents/efeitos adversos , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUNDS AND AIM: Multiple insertions of self-expandable metal stents (SEMS) for advanced malignant hilar obstruction (MHO) are now considered to be an effective palliative method for adequate drainage of liver volume. However, the efficacy of endoscopic reintervention in technically and clinically successful bilateral SEMS is limited. This study investigated the endoscopic revision efficacy in patients who underwent bilateral SEMS in MHO. METHODS: Primary endoscopic revision using plastic or metal stents or an alternative percutaneous approach followed by secondary endoscopic revision was performed in patients who underwent clinically successful deployment of bilateral SEMS. The primary outcome was a technical success. Secondary outcomes were clinical success, adverse events, and patency duration after reintervention. RESULTS: A total of 55 patients (83.3%) out of 66 enrolled patients underwent reintervention: primary endoscopic reintervention (n = 47) and secondary endoscopic revision following percutaneous drainage (n = 8). Intended technical success rates of primary and secondary endoscopic reintervention were 93.6% (44/47) and 87.5% (7/8), respectively (P = 0.47). Clinical success rates were 72.3% and 50%, respectively (P = 0.23). Stent malfunction rate after reintervention was 48.9% (23/47) and 37.5% (3/8) (P = 0.70) during follow up, and median cumulative stent patency duration was 119 and 55 days, respectively (log-rank P = 0.68). Stent patent rate after reintervention was not different according to the time interval. In univariate and multivariate analysis for stent patency duration-related factors after reintervention, there were no meaningful factors. CONCLUSION: Primary endoscopic reintervention for bilateral SEMS in MHO was feasible technically and clinically. However, there were no statistically meaningful factors for stent patency duration after reintervention.
Assuntos
Colestase Intra-Hepática/cirurgia , Endoscopia do Sistema Digestório/métodos , Ducto Hepático Comum/cirurgia , Reoperação/métodos , Stents Metálicos Autoexpansíveis , Idoso , Idoso de 80 Anos ou mais , Neoplasias dos Ductos Biliares/complicações , Colestase Intra-Hepática/etiologia , Estudos de Viabilidade , Feminino , Neoplasias da Vesícula Biliar/complicações , Humanos , Tumor de Klatskin/complicações , Masculino , Pessoa de Meia-Idade , Resultado do TratamentoRESUMO
Although endoscopic intervention is the mainstay for palliation of malignant biliary obstruction, a percutaneous approach has been preferred, particularly in patients with advanced high-grade hilar malignant biliary obstruction, because of the technical difficulty and risk of complications. However, recently, primary endoscopic palliation using plastic or metal stents has had higher technical and clinical success with fewer adverse events than the percutaneous approach. Endoscopic interventions are being done more and more frequently because of advances in metal stents, accessories, and techniques. However, several concerns, such as optimal stent type, number, and deployment method, remain to be resolved. Therefore, we reviewed the literature in order to identify the optimal biliary stenting strategy for patients with hilar malignant biliary obstruction, focusing on stent type (plastic vs metal), number (unilateral [single] vs bilateral [multiple]), and deployment method (stent-in-stent vs stent-by-stent).
Assuntos
Neoplasias dos Ductos Biliares/cirurgia , Colangiopancreatografia Retrógrada Endoscópica/métodos , Colestase/cirurgia , Cuidados Paliativos/métodos , Stents , Idoso , Neoplasias dos Ductos Biliares/complicações , Neoplasias dos Ductos Biliares/diagnóstico por imagem , Colestase/diagnóstico por imagem , Colestase/etiologia , Feminino , Humanos , Masculino , Metais , Pessoa de Meia-Idade , Invasividade Neoplásica/patologia , Estadiamento de Neoplasias , Plásticos , Prognóstico , Desenho de Prótese , Medição de Risco , Taxa de Sobrevida , Resultado do TratamentoRESUMO
BACKGROUND AND AIMS: Although the efficacy of palliative bilateral biliary drainage using self-expandable metal stents has been demonstrated, it is unclear which bilateral method is optimal for advanced malignant hilar biliary strictures (MHSs). This pilot study compared bilateral stent-in-stent (SIS) with stent-by-stent (SBS) deployment for advanced MHSs. METHODS: Patients with inoperable high-grade MHSs were enrolled in this prospective randomized multicenter study. The primary outcome was the rate of adverse events, whereas secondary outcomes were technical and clinical success, reintervention, therapeutic outcomes, stent patency, and survival duration. RESULTS: This study randomized 69 of 74 pathologically diagnosed patients to the SIS (n = 34) or SBS (n = 35) groups. The total adverse event rate after stent deployment did not differ between the 2 groups (23.5% in the SIS group vs 28.6% in the SBS group, P = .633). The primary technical success rate was 100% (34/34) and 91.4% (32/35) in the SIS and SBS groups, respectively (P = .081). The clinical success rate was 94.1% (32/34) and 90.6% (29/32), respectively (P = .668). The stent patency rate at 3 months was 85.3% in the SIS group and 65.7% in the SBS group (P = .059). At 6 months, the stent patency rate was 47.1% and 31.4%, respectively (P = .184). The median cumulative stent patency and survival probability did not differ between the 2 groups. CONCLUSIONS: Efficacy of bilateral SIS and SBS deployment may be similar in terms of total adverse events, technical and clinical success, stent patency, and survival. The stent patency rates at 3 and 6 months was higher in the SIS group without statistical difference. (Clinical trial registration number: NCT01141088.).
Assuntos
Colestase/cirurgia , Drenagem/instrumentação , Drenagem/métodos , Endoscopia do Sistema Digestório , Stents , Idoso , Idoso de 80 Anos ou mais , Neoplasias dos Ductos Biliares/complicações , Procedimentos Cirúrgicos do Sistema Biliar/instrumentação , Procedimentos Cirúrgicos do Sistema Biliar/métodos , Colestase/etiologia , Constrição Patológica/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Estudos Prospectivos , Índice de Gravidade de DoençaRESUMO
BACKGROUND AND AIMS: EUS-guided fine-needle aspiration/biopsy (EUS-FNA/B) has a high diagnostic accuracy for pancreatic tumors. Most reports have focused on the diagnostic yield of cytology or histology; the ability of various FNA/B techniques to obtain an adequate mass of cells or tissue has rarely been investigated. METHODS: Patients with suspected pancreatic malignancy underwent EUS-FNB using a 22-gauge ProCore needle by either the stylet slow-pull-back technique (group A), conventional negative suction after stylet removal (group B), or non-suction after stylet removal (group C) in the absence of an on-site cytopathologist. The adequacy of the 3 techniques based on the diagnostic yield, cellularity, blood contamination, and core-tissue acquisition was evaluated. RESULTS: A total of 50 patients (27 males) were analyzed. The mean tumor size was 21 to 40 mm in 54%. The rate of a good or excellent proportion of cellularity was highest in group A compared with groups B and C (72% vs 60% vs 50%, P = .049). A >25% rate of blood contamination was more prevalent in group B (30% vs 42% vs 10%, P = .009). The rate of adequate core-tissue acquisition was not different (52% vs 34% vs 50%, P = .140). Based on the multivariate generalized estimation equation, the stylet slow-pull-back technique and a tumor size >40 mm were favorable factors for diagnostic adequacy. CONCLUSIONS: The stylet slow-pull-back technique might enable acquisition of tissue and assessment of cellularity for the diagnosis of pancreatic tumors suspected to be malignant. (Clinical trial registration number: KCT0002190.).