Search

Background: Lumen-apposing metal stents (LAMS) have displaced double-pigtail plastic stents (DPS) as the standard treatment for walled-off necrosis (WON),β but evidence for exclusively using LAMS is limited. We aimed to assess whether the theoretical benefit of LAMS was superior to DPS. Methods: This multicenter, open-label, randomized trial was carried out in 9 tertiary hospitals. Between June 2017, and Oct 2020, we screened 99 patients with symptomatic WON, of whom 64 were enrolled and randomly assigned to the DPS group (n = 31) or the LAMS group (n = 33). The primary outcome was short-term (4-weeks) clinical success determined by the reduction of collection. Secondary endpoints included long-term clinical success, hospitalization, procedure duration, recurrence, safety, and costs. Analyses were by intention-to-treat. ClinicalTrials.gov, NCT03100578. Results: A similar clinical success rate in the short term (RR, 1.41; 95% CI 0.88–2.25; p = 0.218) and in the long term (RR, 1.2; 95% CI 0.92–1.58; p = 0.291) was observed between both groups. Procedure duration was significantly shorter in the LAMS group (35 vs. 45-min, p = 0.003). The hospital admission after the index procedure (median difference, − 10 [95% CI − 17.5, − 1]; p = 0.077) and global hospitalization (median difference − 4 [95% CI − 33, 25.51]; p = 0.82) were similar between both groups. Reported stent-related adverse events were similar for the two groups (36 vs.45% in LAMS vs. DPS), except for de novo fever, which was significantly 26% lower in LAMS (RR, 0.26 [0.08–0.83], p = 0.015). Conclusions: The clinical superiority of LAMS over DPS for WON therapy was not proved, with similar clinical success, hospital stay and similar safety profile between both groups, yet a significant reduction in procedure time was observed. Trial registration number: ClinicalTrials.gov, NCT03100578. [ABSTRACT FROM AUTHOR]

Background: Post-cholecystectomy transected bile ducts (TBDs) are not amenable to standard endoscopic management. Combined ERCP and endosonography (CERES) including EUS-guided hepaticoenterostomy enhance therapeutic biliary endoscopy. CERES treatment of post-cholecystectomy TBDs is evaluated. Methods: Among 165 consecutive patients who underwent ERCP for post-cholecystectomy bile duct injury (Amsterdam A/B/C/D grades [%] = 47/30/7/16) between January 2009-November 2020 at a tertiary-care center, 10/26 (38%) with TBDs (6 female; 32–92 years old) underwent CERES before attempted endoscopic repair (staged CERES, n = 7) or surgical repair (preoperative CERES, n = 1), or as destination therapy (definitive CERES, n = 2). Short-term clinical success rate, final clinical success rate and comprehensive complication index (CCI) were retrospectively determined. Additionally, number of follow-up procedures, adverse events, recurrences, final patency grades and definitive cure rate were determined in patients with staged CERES. Results: Index CERES (hepaticogastrostomy, 60%; hepaticoduodenostomy, 40%) achieved bile leak and jaundice resolution in 10 patients (100% short-term clinical success rate). Overall, 9/10 patients maintained good/excellent biliary drainage over a median 3.2 years without any unplanned percutaneous/surgical procedures (90% final clinical success rate; median CCI = 8.7). Staged CERES using recanalization (n = 6) or diversion (n = 1) strategies achieved Grade A patency in 5/7 (71%) patients after a median of 2 follow-up procedures over a median 12-month treatment period; 2 failed recanalization patients were salvaged by indefinite hepaticoenterostomy stent or elective surgery, respectively. Among staged CERES, 2 treatment-related cholangitis occurred (29%) and 2 recurring strictures (29%) developed over a median 8.4 year follow-up; recurring strictures were endoscopically remodeled (n = 1) or indefinitely stented (n = 1); final Grade A/B biliary patency was achieved in 5/7 (71%) and definitive cure in 4/7 (57%). Conclusions: CERES controls acute symptoms in selected post-cholecystectomy TBD patients allowing subsequent staged endoscopic therapy. Definitive cure or long-term biliary drainage is possible in most cases and elective surgery can be facilitated in the remainder. [ABSTRACT FROM AUTHOR]

EUS-cholangiography revealed a dilated common bile duct (CBD) and a patent cystic duct above a distal stricture (Fig. In malignant biliary obstruction, EUS-guided gallbladder drainage allows symptomatic decompression when the cystic duct is involved [3] and rescue biliary drainage when it is patent [4]. [Extracted from the article]

Background: Delayed gastrointestinal (GI) bleeding and stent migration are known adverse events which may occur following placement of lumen-apposing metal stents (LAMSs).Methods: All consecutive patients who underwent LAMS placement between May 2011 and June 2017 at a single tertiary medical center were included. Demographics and procedural details were prospectively collected. Post-procedure follow-up and outcome measures were retrospectively collected. The cumulative risks of migration and LAMS-related GI bleeding were estimated using the life-table method. Risk predictors were assessed using Cox proportional hazards models.Results: We analyzed 250 patients (64.8 % men; median age 71.6 [interquartile range (IQR) 57.9 - 83.6]). Median follow-up was 78.5 days (IQR 31 - 246.5 days). Thirty-four stent migrations (13.6 %) occurred (5 symptomatic). On multivariable analysis, associations with migration included nasocystic drains (hazard ratio [HR] 6.5, 95 % confidence interval [CI] 2.2 - 19.3), pancreatic fluid collections (PFCs; HR 4.2, 95 %CI 1.8 - 10.1), and double-pigtail stents (HR 2.4, 95 %CI 1.2 - 4.9). Migration risk at 12 months was 25.5 % (95 %CI 17.9 % - 35.7 %) and was higher for PFCs 48.9 % (33.4 % - 66.9 %) than other indications 8.4 % (4.9 % - 17.5 %; P < 0.001). LAMSs placed for longer durations (i. e. enteral anastomoses, biliary and gallbladder drainage) presented an 8.4 % cumulative risk at 2 years. There were 13 LAMS-related GI hemorrhages (5.2 %), two of them fatal, presenting a median of 3 days (IQR 1 - 9 days) after deployment. The cumulative risk of bleeding at 12 months was 6.9 % (3.6 % - 12.7 %).Conclusions: LAMS migration occurs in 1 out of 7 cases and is most common when treating PFCs. Bleeding related to LAMS placement occurs much less commonly but can be life-threatening. [ABSTRACT FROM AUTHOR]

: Referring to Kongkam P et al. p. 55-62 Complete drainage of complex MHBO improves patient outcomes; however, complete drainage in high-grade MHBO is not only difficult to achieve but also difficult to maintain, as clogging and ingrowth result in limited stent patency. For two decades now, EUS-guided biliary drainage (EUS-BD) has increasingly been performed in malignant biliary obstruction (MBO) following failed ERCP as an alternative to PTBD, the historical gold standard for difficult biliary drainage. [Extracted from the article]

The article presents a case study of a 59-year-old man who had unresectable ampullary adenocarcinoma which causes biliary obstruction and gastric outlet that was palliated through placement of duodenal self-expandable metal stents (SEMSs).