1
|
Kouladouros K, Kähler G. [Endoscopic management of complications in the hepatobiliary and pancreatic system and the tracheobronchial tree]. CHIRURGIE (HEIDELBERG, GERMANY) 2023; 94:469-484. [PMID: 36269350 DOI: 10.1007/s00104-022-01735-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/13/2022] [Indexed: 05/04/2023]
Abstract
Endoscopic methods are nowadays a priceless tool for the treatment of postoperative complications after hepatobiliary, pancreatic and thoracic surgery. Endoscopic decompression of the biliary tract is the treatment of choice for biliary duct leakage after cholecystectomy, hepatic resection or liver transplantation. Postoperative biliary duct stenosis can also be successfully treated by endoscopic balloon dilatation and implantation of various endoprostheses in most of the patients. In the case of pancreatic fistulas, especially those occurring after central or distal pancreatic resections, endoscopic decompression of the pancreatic duct can significantly contribute to rapid healing. Additionally, interventional endosonography provides a valuable treatment option for transgastric drainage of postoperative fluid collections, which often accompany a pancreatic fistula. Various treatment alternatives have been described for the bronchoscopic treatment of bronchopleural and tracheoesophageal fistulas, which often lead to the rapid alleviation of symptoms and often to the definitive closure of the fistula.
Collapse
Affiliation(s)
- Konstantinos Kouladouros
- Zentrale Interdisziplinäre Endoskopie, Chirurgische Klinik, Medizinische Fakultät Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland.
| | - Georg Kähler
- Zentrale Interdisziplinäre Endoskopie, Chirurgische Klinik, Medizinische Fakultät Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| |
Collapse
|
2
|
Efficacy and safety of primary, early and late needle-knife fistulotomy for biliary access. Sci Rep 2021; 11:16658. [PMID: 34404873 PMCID: PMC8371017 DOI: 10.1038/s41598-021-96142-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 08/02/2021] [Indexed: 11/08/2022] Open
Abstract
European Society of Gastrointestinal Endoscopy recommends needle-knife fistulotomy (NKF) as the preferred precut technique. However, there is little information on whether NKF performed at different times is associated with different success and adverse event rates. We compared the outcomes of 3 different timings of NKF. This was an observational study conducted at 4 institutions and this was a retrospective analysis of prospectively collected data. We included 330 consecutive patients submitted to NKF attempt for biliary access. Patients were divided into three groups: NKF as an initial procedure for biliary access (group A, n = 121); early NKF defined as after 5 min, 5 attempts, or 2 pancreatic passages (group B, n = 99); and late NKF: after at least 10 min of unsuccessful standard biliary cannulation (group C, n = 110). We assessed the success rate of biliary cannulation at initial ERCP, time to perform NKF until biliary cannulation, overall biliary cannulation rate (second ERCP when initial failure), adverse event rate, and predictors of post-ERCP pancreatitis (PEP). The initial cannulation rate was 98%, 91% and 94% for groups A, B and C respectively, p = 0.08, whereas overall biliary cannulation rate was 100%, 95% and 98%, p = 0.115. The adverse event rate/PEP was 4.1%/2.5%, 7.1%/4% and 10.9%/8.2%, for groups A, B and C respectively, (p = 0.197 and p = 0.190). Median time for creating the fistula was A = 4.0 min, B = 3.2 min, and C = 5.6 min, p < 000.1. Each additional minute spent attempting cannulation increased the odds ratio (OR) for PEP by 1.072, and patients with 3 or more risk factors for pancreatitis had a higher chance of PEP. In conclusion, the timing of NFK does not appear to influence success rates but late NFK is associated with a higher time to create a fistula and an increased risk of pancreatitis. Primary NFK is associated with a high rate of success and a low rate of PEP and deserves additional investigation.
Collapse
|
3
|
Tringali A, Reddy DN, Ponchon T, Neuhaus H, Lladó FGH, Navarrete C, Bruno MJ, Kortan PP, Lakhtakia S, Peetermans J, Rousseau M, Carr-Locke D, Devière J, Costamagna G. Treatment of post-cholecystectomy biliary strictures with fully-covered self-expanding metal stents - results after 5 years of follow-up. BMC Gastroenterol 2019; 19:214. [PMID: 31830897 PMCID: PMC6909597 DOI: 10.1186/s12876-019-1129-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 11/22/2019] [Indexed: 12/24/2022] Open
Abstract
Background Endoscopic treatment of post-cholecystectomy biliary strictures (PCBS) with multiple plastic biliary stents placed sequentially is a minimally invasive alternative to surgery but requires multiple interventions. Temporary placement of a single fully-covered self-expanding metal stent (FCSEMS) may offer safe and effective treatment with fewer re-interventions. Long-term effectiveness of treatment with FCSEMS to obtain PCBS resolution has not yet been studied. Methods In this prospective multi-national study in patients with symptomatic benign biliary strictures (N = 187) due to various etiologies received a FCSEMS with scheduled removal at 6–12 months and were followed for 5 years. We report here long-term outcomes of the subgroup of patients with PCBS (N = 18). Kaplan Meier analyses assessed long-term freedom from re-stenting. Adverse events were documented. Results Endoscopic removal of the FCSEMS was achieved in 83.3% (15/18) of patients after median indwell of 10.9 (range 0.9–13.8) months. In the remaining 3 patients (16.7%), the FCSEMS spontaneously migrated and passed without complications. At the end of FCSEMS indwell, 72% (13/18) of patients had stricture resolution. At 5 years after FCSEMS removal, 84.6% (95% CI 65.0–100.0%) of patients who had stricture resolution at FCSEMS removal remained stent-free. In addition, at 75 months after FCSEMS placement, the probability of remaining stent-free was 61.1% (95% CI 38.6–83.6%) for all patients. Stent or removal related serious adverse events occurred in 38.9% (7/18) all resolved without sequalae. Conclusions In patients with symptomatic PCBS, temporary placement of a single FCSEMS intended for 10–12 months indwell is associated with long-term stricture resolution up to 5 years. Temporary placement of a single FCSEMS may be considered for patients with PCBS not involving the main hepatic confluence. Trial registration numbers NCT01014390; CTRI/2012/12/003166; Registered 17 November 2009.
Collapse
Affiliation(s)
- Andrea Tringali
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Digestive Endoscopy Unit, Rome, Italy. .,Università Cattolica del Sacro Cuore, Centre for Endoscopic Research Therapeutics and Training (CERTT), Rome, Italy.
| | - D Nageshwar Reddy
- Gastroenterology and Therapeutic Endoscopy, Asian Institute of Gastroenterology, Hyderabad, India
| | - Thierry Ponchon
- Service de Gastroentérologie et d'Endoscopie Digestive, Hôpital Edouard Herriot, Lyon, France
| | - Horst Neuhaus
- Medizinische Klinik, Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany
| | - Ferrán González-Huix Lladó
- Unidad de Endoscopia, Servicio de Aparato Digestivo, Hospital Universitari Doctor Josep Trueta, Girona, Catalunya, Spain
| | - Claudio Navarrete
- Servicio de Endoscopía, Clínica Alemana de Santiago. Jefe de Departamento de Cirugia, Clinica Santa Maria, Santiago, Chile
| | - Marco J Bruno
- Maag-, Darm- en Leverziekten, Erasmus Universitair Medisch Centrum, Rotterdam, The Netherlands
| | - Paul P Kortan
- Division of Gastroenterology, Centre for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Sundeep Lakhtakia
- Service de Gastroentérologie et d'Endoscopie Digestive, Hôpital Edouard Herriot, Lyon, France
| | - Joyce Peetermans
- Boston Scientific Corporation, Marlboro, Massachusetts, United States
| | - Matthew Rousseau
- Boston Scientific Corporation, Marlboro, Massachusetts, United States
| | - David Carr-Locke
- The Center for Advanced Digestive Care, Weill Cornell Medicine, New York Presbyterian Hospital, New York, USA
| | - Jacques Devière
- Gastro-Entérologie et d'Hépato-Pancréatologie, Universite Libre de Bruxelles Hôpital Erasme, Brussels, Belgium
| | - Guido Costamagna
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Digestive Endoscopy Unit, Rome, Italy.,Università Cattolica del Sacro Cuore, Centre for Endoscopic Research Therapeutics and Training (CERTT), Rome, Italy
| | | |
Collapse
|
4
|
Efficacy of Different Endoscopic Stents in the Management of Postoperative Biliary Strictures: A Systematic Review and Meta-analysis. J Clin Gastroenterol 2019; 53:418-426. [PMID: 30807403 DOI: 10.1097/mcg.0000000000001193] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Endoscopic stents are the first-line treatment in the management of benign biliary stricture (BBS) which include multiple plastic stents (MPSs), fully covered self-expandable metal stents (FCSEMS) including the conventional and modified ones (FCSEMS-C and FCSEMS-M) and biodegradable stents. However, different stents have their distinct advantages and disadvantages. We aim to conduct this systematic review to compare the efficacy of different stents in the management of BBS. METHODS Several databases were searched from inception through March 2018. Studies including >10 patients with postoperative stricture treated with endoscopic stents were enrolled. Pooled odds ratio of outcomes were calculated to compare MPS with FCSEMS. Weighted pooled rates were calculated to show the efficacy of FCSEMS-M, FCSEMS-C, and MPS. RESULTS Twenty-two articles were reviewed including 4 randomized controlled studies, 4 cohort studies, and 14 case series studies. Comparing FCSEMS with MPS, the pooled odds ratio was 0.48 [95% confidence interval (CI): 0.22-1.05] (P=0.07) for stricture resolution, 0.3 (95% CI: 0.1-0.92) (P=0.03) for adverse event, 1.9 (95% CI: 0.3-12) (P=0.49) for stent migration, and 1.38 (95% CI: 0.36-5.3) (P=0.34) for stricture recurrence. The pooled rates for stricture recurrence of MPS, FCSEMS-C, and FCSEMS-M were 19%, 19%, and 7%, respectively. The pooled rates for stent migration were 4% of MPS, 25% of FCSEMS-C, and 3% of FCSEMS-M. CONCLUSIONS FCSEMS-M is more favorable in the management of BBS comparing with MPS or FCSEMS-C. The biodegradable stent may be a promising option but currently available data is insufficient to draw a firm conclusion.
Collapse
|
5
|
Lopes L, Canena J. ERCP in Portugal: A Wide Survey on the Prevention of Post-ERCP Pancreatitis and Papillary Cannulation Techniques. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2019; 26:14-23. [PMID: 30675500 DOI: 10.1159/000487150] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 01/18/2018] [Indexed: 01/05/2023]
Abstract
Background/Aims Recently the European Society of Gastrointestinal Endoscopy delivered guidelines on the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) and on the papillary cannulation and sphincterotomy techniques at endoscopic retrograde cholangiopancreatography (ERCP). There are no data concerning current practices in Portugal. The aim of this study was to capture practice patterns of Portuguese pancreaticobiliary endoscopists with special interest in the prevention of PEP and cannulation techniques. Methods A written survey was distributed to all pancreaticobiliary endoscopists attending the first Portuguese meeting dedicated to ERCP in November 2016. The main outcome measures were: technique used for standard biliary cannulation, use of nonsteroidal anti-inflammatory drugs (NSAIDs) in PEP, attempting prophylactic pancreatic stenting after using pancreatic guidewire (PGW)-assisted biliary cannulation in patients where biliary cannulation was difficult, and use of precut as the first rescue technique when biliary cannulation was difficult. Results Completed surveys were collected from 28 of the 32 pancreatobiliary endoscopists attending the meeting (answer rate 87.5%). Biliary cannulation was performed using a guidewire access technique by the majority (77%), usually with a sphincterotome. When cannulation was unsuccessful, precut was the first choice for 70%. NSAIDs were administered routinely for PEP by only 54%; PGW-assisted biliary cannulation was the first choice after failed standard cannulation for a minority of them, and only 27% reported to routinely attempt insertion of a pancreatic stent. High-volume endoscopists (> 150/year) tended to use NSAIDs and to insert a stent in PGW-assisted cannulation less often than low-volume-endoscopists (50 vs. 83.3%, p < 0.01, and 40 vs. 100%, p < 0.01, respectively). Precut was started without prior formal training by more than half of the endoscopists. Conclusions There is a pronounced discrepancy between evidence-based guidelines and current clinical practice. This discrepancy is more pronounced in PEP prophylaxis, especially among high-volume endoscopists. Some advanced techniques in ERCP are initiated unsupervised, without any previous formal training. Key Message There is a significant gap between guidelines and routine clinical practice.
Collapse
Affiliation(s)
- Luís Lopes
- Department of Gastroenterology, Hospital de Santa Luzia, ULS Alto Minho, Viana do Castelo, Portugal.,Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's - PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Jorge Canena
- Gastroenterology Center, Hospital Cuf Infante Santo - Nova Medical School/Faculdade de Ciências Médicas da UNL, Lisbon, Portugal.,Department of Gastroenterology, Hospital Amadora-Sintra, Amadora, Portugal.,Department of Gastroenterology, Hospital de Santo António dos Capuchos - CHLC, Lisbon, Portugal.,Cintesis - Center for Health Technology and Services Research, Porto, Portugal
| |
Collapse
|
6
|
Zheng X, Wu J, Sun B, Wu YC, Bo ZY, Wan W, Gao DJ, Hu B. Clinical outcome of endoscopic covered metal stenting for resolution of benign biliary stricture: Systematic review and meta-analysis. Dig Endosc 2017; 29:198-210. [PMID: 27681297 DOI: 10.1111/den.12742] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 09/22/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND AIM Management of benign biliary stricture is challenging. Endoscopic therapy has evolved as the first-line treatment for various benign biliary strictures. However, covered self-expandable metal stents (CSEMS) have not been approved by the United States Food and Drug Administration for the treatment of benign biliary stricture. With this goal, we conducted the present systemic review and meta-analysis to evaluate the efficacy and safety of endoscopic stenting with CSEMS in the treatment of benign biliary stricture. METHODS Systematic review and meta-analysis by searching PubMed, MEDLINE and Embase databases. RESULTS In total, 37 studies (1677 patients) fulfilled the inclusion criteria. Pooled stricture resolutions were achieved in 83% of cases. Median stent dwelling time was 4.4 months, with median endoscopic retrograde cholangiopancreatography sessions of 2.0. Stricture recurrence at 4-year follow up was 11% (95% CI, 8-14%). Pooled complication rate was 23% (95% CI, 20-26%). CONCLUSIONS Placement of CSEMS is effective in the treatment of benign biliary stricture with relatively short stenting duration and low long-term stricture recurrence rate. However, more prospectively randomized studies are required to confirm the results.
Collapse
Affiliation(s)
- Xiao Zheng
- Department of Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai, China
| | - Jun Wu
- Department of Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai, China
| | - Bo Sun
- Department of Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai, China
| | - Ye-Chen Wu
- Department of Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai, China
| | - Zhi-Yuan Bo
- Department of Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai, China
| | - Wei Wan
- Department of Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai, China
| | - Dao-Jian Gao
- Department of Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai, China
| | - Bing Hu
- Department of Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai, China
| |
Collapse
|
7
|
Canena J, Horta D, Coimbra J, Meireles L, Russo P, Marques I, Ricardo L, Rodrigues C, Capela T, Carvalho D, Loureiro R, Dias AM, Ramos G, Coutinho AP, Romão C, Veiga PM. Outcomes of endoscopic management of primary and refractory postcholecystectomy biliary leaks in a multicentre review of 178 patients. BMC Gastroenterol 2015; 15:105. [PMID: 26285593 PMCID: PMC4545536 DOI: 10.1186/s12876-015-0334-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Accepted: 08/10/2015] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Biliary leaks have been treated with endoscopic management using different techniques with conflicting results. Furthermore the appropriate rescue therapy for refractory leaks has not been established. We evaluated the clinical effectiveness of initial endotherapy for postcholecystectomy biliary leaks using an homogenous approach (sphincterotomy + placement of a 10-French plastic stent) in a large series of patients as well as the optimal and efficacy of rescue endotherapy for refractory biliary leaks. METHODS This was a multicenter, retrospective study of 178 patients who underwent endoscopic management of postcholecystectomy biliary leaks with a combination of biliary sphincterotomy and the placement of a large-bore (10-French) plastic stent. Data were collected to analyze the clinical outcomes and technical success, efficacy of the rescue endotherapy and the need for surgery, adverse events and prognostic factors for clinical success of endotherapy. RESULTS Following endotherapy, closure of the leak was accomplished in 162/178 patients (91.0%). The multivariate logistic model showed that the type of leak, namely a high-grade biliary leak, was the only independent prognostic factor associated with treatment failure (OR = 26.78; 95% CI = 6.59-108.83; P < 0.01). The remaining 16 patients were treated with multiple plastic stents (MPSs) with a success rate of 62.5% (10 patients). The use of fewer than 3 plastic stents (P = 0.023) and a high-grade biliary leak (P = 0.034) were shown to be significant predictors of treatment failure with MPSs in refractory bile leaks. The 6 patients in whom the placement of MPSs failed were retreated with a fully cover self-expandable metallic stent (FCSEMS), resulting in closure of the leak in all cases. CONCLUSIONS Endotherapy of biliary leaks with a combination of biliary sphincterotomy and the placement of a large-bore plastic stent is associated with a high rate of success (90%). However in our series there were several failures using MPSs as a strategy for rescue endotherapy suggesting that refractory biliary leaks should be treated with FCSEMS especially in patients with high-grade leaks.
Collapse
Affiliation(s)
- Jorge Canena
- Department of Gastroenterology, Doutor Fernando Fonseca Hospital, IC 19, 2720-276, Amadora, Portugal.
- Department of Gastroenterology, Pulido Valente Hospital at Centro Hospitalar Lisboa Norte, Alameda das Linhas de Torres n° 117, 1769-001, Lisbon, Portugal.
- Department of Gastroenterology, Santo António dos Capuchos Hospital at Centro Hospitalar Lisboa Central, Nova Medical School-Faculty of Medical Sciences, Alameda Santo António dos Capuchos, 1169-050, Lisbon, Portugal.
- Department of Endoscopy, José Joaquim Fernandes Hospital at Unidade Local de Saúde do Baixo Alentejo, Rua Doutor António Fernandes Covas Lima, 7800-309, Beja, Portugal.
| | - David Horta
- Department of Gastroenterology, Doutor Fernando Fonseca Hospital, IC 19, 2720-276, Amadora, Portugal.
| | - João Coimbra
- Department of Gastroenterology, Santo António dos Capuchos Hospital at Centro Hospitalar Lisboa Central, Nova Medical School-Faculty of Medical Sciences, Alameda Santo António dos Capuchos, 1169-050, Lisbon, Portugal.
| | - Liliane Meireles
- Department of Gastroenterology, Pulido Valente Hospital at Centro Hospitalar Lisboa Norte, Alameda das Linhas de Torres n° 117, 1769-001, Lisbon, Portugal.
| | - Pedro Russo
- Department of Gastroenterology, Santo António dos Capuchos Hospital at Centro Hospitalar Lisboa Central, Nova Medical School-Faculty of Medical Sciences, Alameda Santo António dos Capuchos, 1169-050, Lisbon, Portugal.
| | - Inês Marques
- Department of Gastroenterology, Pulido Valente Hospital at Centro Hospitalar Lisboa Norte, Alameda das Linhas de Torres n° 117, 1769-001, Lisbon, Portugal.
| | - Leonel Ricardo
- Department of Gastroenterology, Doutor Fernando Fonseca Hospital, IC 19, 2720-276, Amadora, Portugal.
| | - Catarina Rodrigues
- Department of Gastroenterology, Doutor Fernando Fonseca Hospital, IC 19, 2720-276, Amadora, Portugal.
| | - Tiago Capela
- Department of Gastroenterology, Santo António dos Capuchos Hospital at Centro Hospitalar Lisboa Central, Nova Medical School-Faculty of Medical Sciences, Alameda Santo António dos Capuchos, 1169-050, Lisbon, Portugal.
| | - Diana Carvalho
- Department of Gastroenterology, Santo António dos Capuchos Hospital at Centro Hospitalar Lisboa Central, Nova Medical School-Faculty of Medical Sciences, Alameda Santo António dos Capuchos, 1169-050, Lisbon, Portugal.
| | - Rafaela Loureiro
- Department of Gastroenterology, Santo António dos Capuchos Hospital at Centro Hospitalar Lisboa Central, Nova Medical School-Faculty of Medical Sciences, Alameda Santo António dos Capuchos, 1169-050, Lisbon, Portugal.
| | - António Mateus Dias
- Department of Gastroenterology, Santo António dos Capuchos Hospital at Centro Hospitalar Lisboa Central, Nova Medical School-Faculty of Medical Sciences, Alameda Santo António dos Capuchos, 1169-050, Lisbon, Portugal.
| | - Gonçalo Ramos
- Department of Gastroenterology, Santo António dos Capuchos Hospital at Centro Hospitalar Lisboa Central, Nova Medical School-Faculty of Medical Sciences, Alameda Santo António dos Capuchos, 1169-050, Lisbon, Portugal.
| | - António Pereira Coutinho
- Department of Gastroenterology, Pulido Valente Hospital at Centro Hospitalar Lisboa Norte, Alameda das Linhas de Torres n° 117, 1769-001, Lisbon, Portugal.
| | - Carlos Romão
- Department of Gastroenterology, Pulido Valente Hospital at Centro Hospitalar Lisboa Norte, Alameda das Linhas de Torres n° 117, 1769-001, Lisbon, Portugal.
| | - Pedro Mota Veiga
- Curva de Gauss - Research, Training and Consulting, Rua Doutor Eduardo Maria dos Santos, Lote 1, Loja 3, 3525-000, Canas de Senhorim, Portugal.
| |
Collapse
|
8
|
Canena J, Liberato M, Meireles L, Marques I, Romão C, Coutinho AP, Neves BC, Veiga PM. A non-randomized study in consecutive patients with postcholecystectomy refractory biliary leaks who were managed endoscopically with the use of multiple plastic stents or fully covered self-expandable metal stents (with videos). Gastrointest Endosc 2015; 82:70-8. [PMID: 25771064 DOI: 10.1016/j.gie.2014.11.038] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2014] [Accepted: 11/21/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Endoscopic management of postcholecystectomy biliary leaks is widely accepted as the treatment of choice. However, refractory biliary leaks after a combination of biliary sphincterotomy and the placement of a large-bore (10F) plastic stent can occur, and the optimal rescue endotherapy for this situation is unclear. OBJECTIVE To compare the clinical effectiveness of the use of a fully covered self-expandable metal stent (FCSEMS) with the placement of multiple plastic stents (MPS) for the treatment of postcholecystectomy refractory biliary leaks. DESIGN Prospective study. SETTING Two tertiary-care referral academic centers and one general district hospital. PATIENTS Forty consecutive patients with refractory biliary leaks who underwent endoscopic management. INTERVENTIONS Temporary placement of MPS (n = 20) or FCSEMSs (n = 20). MAIN OUTCOME MEASUREMENTS Clinical outcomes of endotherapy as well as the technical success, adverse events, need for reinterventions, and prognostic factors for clinical success. RESULTS Endotherapy was possible in all patients. After endotherapy, closure of the leak was accomplished in 13 patients (65%) who received MPS and in 20 patients (100%) who received FCSEMSs (P = .004). The Kaplan-Meier (log-rank) leak-free survival analysis showed a statistically significant difference between the 2 patient populations (χ(2) [1] = 8.30; P < .01) in favor of the FCSEMS group. Use of <3 plastic stents (P = .024), a plastic stent diameter <20F (P = .006), and a high-grade biliary leak (P = .015) were shown to be significant predictors of treatment failure with MPS. The 7 patients in whom placement of MPS failed were retreated with FCSEMSs, resulting in closure of the leaks in all cases. LIMITATIONS Non-randomized design. CONCLUSION In our series, the results of the temporary placement of FCSEMSs for postcholecystectomy refractory biliary leaks were superior to those from the use of MPS. A randomized study is needed to confirm our results before further recommendations.
Collapse
Affiliation(s)
- Jorge Canena
- Center of Gastroenterology, Cuf Infante Santo Hospital-Nova Medical School/Faculty of Medical Sciences, Lisbon, Portugal; Department of Gastroenterology, Pulido Valente Hospital do Centro Hospitalar Lisboa Norte, Lisbon, Portugal; Department of Endoscopy, José Joaquim Fernandes Hospital da Unidade Local de Saúde do Baixo Alentejo, Beja, Portugal
| | - Manuel Liberato
- Center of Gastroenterology, Cuf Infante Santo Hospital-Nova Medical School/Faculty of Medical Sciences, Lisbon, Portugal
| | - Liliane Meireles
- Department of Gastroenterology, Pulido Valente Hospital do Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - Inês Marques
- Department of Gastroenterology, Pulido Valente Hospital do Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - Carlos Romão
- Department of Gastroenterology, Pulido Valente Hospital do Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - António Pereira Coutinho
- Center of Gastroenterology, Cuf Infante Santo Hospital-Nova Medical School/Faculty of Medical Sciences, Lisbon, Portugal
| | - Beatriz Costa Neves
- Department of Gastroenterology, Pulido Valente Hospital do Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - Pedro Mota Veiga
- Curva de Gauss-Research, Training and Consulting, Canas de Senhorim, Portugal
| |
Collapse
|