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Because of significant advances in endoscopic techniques and the development of high-quality stents, endoscopic enteral stent placement is increasingly being performed for the management of malignant GI obstruction. Palliative stenting is now routinely performed for malignant esophageal, gastric, duodenal, and colon obstruction. In addition to palliative indications, preoperative stenting in the colon may be performed as a bridge to surgery to achieve immediate decompression and convert an emergent surgery into an elective, 1-stage procedure.The realm of enteral stenting has recently expanded to include management of benign conditions such as leaks, fistulas, and benign strictures in the GI tract. Further research is required to study the use of enteral stents in benign conditions and to adequately compare endoscopic stent placement with surgical intervention. Promising new technologies such as biodegradable stents and drug-eluting stents also require further investigation. With continued innovation in endoscopic techniques and stenting devices, the field of enteral stenting is likely to expand further, with an increase in indications and improvement in outcomes.

Background Bariatric surgery leaks can result in significant morbidity and mortality. Endoscopic placement of self-expandable stents (SESs) is emerging as a less-invasive alternative to surgery for the treatment of leaks. Objective To evaluate the success of SESs in the treatment of bariatric surgery leaks. Design Studies using SESs in the management of bariatric surgery leaks were selected. Success of SES treatment was defined as radiographic evidence of leak closure after stent removal. Articles were searched in MEDLINE, PubMed, Ovid, and Cochrane Register of Controlled Trials. Pooled proportions were calculated by using fixed- and random-effects models. Publication bias was calculated by using the Begg-Mazumdar and Harbord bias estimators. Results A total of 189 relevant articles were reviewed of which 7 studies (67 patients with leaks) met inclusion criteria. The pooled proportion of successful leak closures by using SESs was 87.77% (95% CI, 79.39%-94.19%). The pooled proportion of successful endoscopic stent removal was 91.57% (95% CI, 84.22%-96.77%). Stent migration was noted in 16.94% (95% CI, 9.32%-26.27%). Test of heterogeneity gave a P value >.10. There was no publication bias. Limitations Small retrospective studies, different types of stents used. Conclusion Endoscopic placement of SESs is a minimally invasive, safe, and effective alternative in the management of leaks after bariatric surgery. The use of SESs can minimize the need for surgical revision and improve patient outcomes.

Anastomotic leaks and fistulae are well-known complications of esophagogastric surgery that occur after 10% to 30% of such operations.1-4 Treatment of these complications is challenging, surgical repair may be ineffective, and the mortality rate may be as high as 60% whatever the mode of treatment.5,6 Several endoscopic methods have been proposed as alternative, noninvasive methods of fistula closure.7-9 Placement of expandable metal stents in the esophagus has become a major method of palliation for obstructing malignant lesions and fistulas.10-12 Placement of these stents, both covered and uncovered, has occasionally been described for the management of benign esophageal strictures and fistulae.13 A case is reported here of successful treatment of an anastomotic esophagomediastinal fistula, a complication of distal esophagectomy with total gastrectomy for adenocarcinoma of the cardia, by temporary placement of a new polyester, silicone-covered, expandable stent.

Paul Stephen Farkas, MD, Joshua David Farkas, Kenneth Paul Koenigs, MD The use of self-expanding metallic esophageal stents has become increasingly more common as experience has demonstrated these stents to be safe and effective in the palliation of inoperable esophageal carcinoma,1 management of esophageal perforation,2 and treatment of esophageal-tracheal fistulas.3,4 Complications associated with these stents include stent misplacement (at a rate of approximately 4.8%),5 stent migration (reported in as many as 36% of patients),6 failure to completely expand,7 discomfort,8 and acute airway compression.9 Any of these complications may necessitate endoscopic stent removal.7-9 We describe a new technique for endoscopic Z-stent removal that proved to be relatively easy to accomplish and well tolerated by the patient.

patients and review of the literature. Medicine 1990;69:33244. 7. Rossi RL, Heiss FW, Brassch JW. Surgical management of chronic pancreatitis. Surg Clin North Am 1985;65:79-101. 8. Duchmann JC. Endoscopic treatment of pancreaticopleural fistula. A case report. Gastroenterol Clin Biol 1995;19:837-40. 9. Kill J, Renning H. Pancreatic fistula cured by an endoprosthesis in the pancreatic duct. Br J Surg 1993;80:1316-7. 10. Saeed ZA. Endoscopic stent placement for internal and external pancreatic fistulas. Gastroenterology 1993;105:1213-7. 11. Mortensen J, Kruse A. Endoscopic management of postoperative bile leaks. Br J Surg 1992;79:1339-41. 12. Binmoeller KF. Endoscopic management of postoperative biliary leaks: review of 77 cases and report of 2 cases with biloma formation. Am J Gastroenterol 1991;86:22%31. 13. Kozarek RA. Pancreatic stents induce ductal changes consistent with chronic pancreatitis. Gastrointest Endosc 1990;36:93-5.

Endoscopic placement of polyethylene stents is a well-established therapy for treatment of a variety of benign and malignant biliary tract diseases. Stent clogging by bacteria, bacterial biofilm, and biliary sludge is a major late complication affecting all kinds of plastic endoprostheses.1, 2 Efforts to prevent stent clogging utilizing long-term oral antibiotics, gallstone dissolution agents, choleretics, mucolytics, silver or antibiotic impregnation of stents and modification of stent size, shape, and number of sideholes have met with little success.3-6 The expandable metal stents have recently been evaluated because of problems with plastic stent occlusion. However, their inability to be removed nonsurgically, relative high cost, and the potential for occlusion by tumor ingrowth may limit application of the currently available expandable stents.7,8 Until modifications to prevent plastic stent occlusion are developed, such stents will need to be exchanged periodically. Standard practice has been to remove the old stent by grasping the intraduodenal portion with a snare, basket, or forceps and withdrawing the scope, depositing the stent in the stomach for later removal or pulling the stent through the biopsy channel. The bile duct is then recannulated and a fresh stent inserted. This approach risks loss of access to the obstructed segment, which is of particular concern in hilar tumors. A wire-guided metal spiral retrieval device9 and a hydrostatic balloon1o have been utilized to circumvent this problem. However, both add additional cost to the procedure and require perfect alignment of the retrieval device and stent for successful stent removal. We report a new simple stent retrieval technique that allows for maintenance of position in

BACKGROUND: Some surgeons argue against preoperative stents for obstructive jaundice based on stent-induced inflammatory changes seen on biliary histology (Surgery 1992;111:562, J Am Coll Surg 1994;178:343). The purpose of this study was to test whether and how frequently endosonography (EUS) could demonstrate any changes in biliary morphology with the use of endoscopic biliary stents for obstructive jaundice. METHODS: Data were included from all patients undergoing upper EUS from 4/95 to 11/99 having non-stone associated obstructive jaundice from a distal common bile duct (CBD) lesion with no clinical evidence of cholangitis. Patients were divided into two groups, those having an EUS before any endoscopic stent was placed and those having EUS after a plastic stent had been placed for obstructive jaundice. Patient demographics, average CBD diameter and width and the presence of biliary sludge were ascertained in both groups. RESULTS: A total of 87 patients were studied (see table) with 22 patients in the stented group. Endoprostheses were in place for an average of 3 weeks at the time of EUS. There were no significant differences in the age or sex distribution, but malignant obstruction was more frequent in the non-stented group. Patients with stents had smaller duct diameters; however, the average duct wall thickness was almost twice that seen in non-stented ducts. Stented patients had CBD sludge more frequently. CONCLUSION: Confirming previous pathologic reports, this study demonstrates that endosonographically evident duct wall thickening and CBD sludge is indeed a frequent finding after stent placement for obstructive jaundice. Whether these changes contribute to the poorer surgical outcomes reported by some groups with preoperative stenting (Arch Surg 1998;133:149)is still unclear.

Background: Endoscopic stent insertion is the optimum method of palliation for malignant biliary obstruction. Plastic stents are much cheaper than the metal alternatives which are only cost effective in longer surviving patients. However plastic stents are prone to occlusion and the optimal strategy for replacement of plastic stents prior to occlusion remains uncertain. Aim: To compare the outcome of patients with inoperable malignant biliary obstruction palliated by either elective plastic stent exchange or symptomatic exchange when the stent occludes. Methods: Patients with inoperable malignant biliary obstruction that had been successfully treated by ERCP and plastic stent insertion were recruited from 3 centres. They were randomised to either elective plastic stent exchange every 3 months or exchange when symptoms suggestive of stent obstruction developed. All patients were followed up for a minimum of 4 months or until death. Results: Forty patients (18 male, mean age 75 yrs (range 47-90 yrs) were randomised to one of two groups: symptomatic (n=18) or elective (n=22) stent replacement. The cause of biliary stricture was pancreatic cancer in 21 cases, cholangiocarcinoma in 16, ampullary tumor in 2 and metastases in 1. The median follow-up period was 117 days (range 2 435 days) and 34 patients died during follow-up. Overall survival rates were 88%, 63% and 30% at 30, 90 and 180 days. Only 8 (36%) of the elective group actually underwent elective replacement at 3 months, the remainder died before exchange (8), refused exchange (2), occluded before exchange (1) or were unfit for procedure (3). In total, 18 repeat ERCPs were performed in the elective group and 6 in the symptomatic group (p=0.26). Treatment group did not significantly effect survival rates or frequency of stent exchange. Kaplan-Meier analysis showed no significant difference in survival between the two treatment groups (p=0.87). Conclusions: A strategy to electively replace plastic stents in patients with inoperable malignant biliary obstruction does not significantly improve patient survival and is only likely to impact on a minority of patients due to the generally poor survival of such cohorts.

Background: Endoscopic stent insertion is the optimum method of palliation for malignant biliary obstruction. Metal stents have several advantages over the polyethylene alternatives but are significantly more expensive. It has been reported that patients must survive beyond 6 months to make metal stents more cost effective. Aims: We audited the performance of expanding metal biliary stents in our endoscopy unit to identify factors that might improve patient selection. Methods: The records of all patients who were selected for endoscopic metal stent insertion at Royal Perth Hospital for malignant biliary obstruction between September 1994 and November 1998 were reviewed. Results: Thirty two patients (16 male, mean age 71yrs (range 34-88)) were identified and followed up for mean 201 days (range 3-810 days). Fifteen (47%) had cholangiocarcinoma, 13 (41%) pancreatic cancer and 4 had metastatic disease. Mortality rates after metal stent insertion were 16%, 41% and 55% at 30, 90 and 180 days. Twenty-four (75%) patients died during the follow-up period and eleven (34%) stents became obstructed with a median time to occlusion of 125 days (range 44 - 729). Patients who died from cholangiocarcinoma had significantly longer survival than pancreatic cancer cases (median 286 v 58 days, p=0.04). No other factors were found to correlate with survival or stent complications. Conclusions: Less than half of this mixed cohort survived beyond 6 months. Metal stent palliation of malignant biliary obstruction should probably be targeted at those with cholangiocarcinoma as these patients tend to survive longer.

We treated 35 patients with endoscopic stent placement across the major or minor papilla in an attempt to relieve suspected partial obstruction to pancreatic duct drainage in patients with pancreatitis. The patients subsequently have been followed for periods ranging from 6 months to 3 years (mean, 14 months). Endoscopic stents were successfully placed across the minor papilla in 19 of 22 patients with pancreas divisum associated with acute recurrent pancreatitis (19) and severe abdominal pain (3). 17 patients had symptomatic improvement manifested by a decrease in frequency of attacks of pain and emergency admission. Stents were placed through the major papilla in 14 of 15 patients with recurrent pancreatitis related to a variety of causes. 8 of the 14 patients improved during the follow-up period, including 4 of 5 patients with alcoholic pancreatitis complicated by a segmental stricture.