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Sharma SS, Maharshi S, Sapra B, Nijhawan S, Sharma D. Outcome of forgotten biliary stents for more than five years-A two-decade experience. Indian J Gastroenterol 2024; 43:768-774. [PMID: 38206449 DOI: 10.1007/s12664-023-01493-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 11/24/2023] [Indexed: 01/12/2024]
Abstract
BACKGROUND AND OBJECTIVES Prolonged biliary stenting may lead to complications such as cholangitis, stentolith and stent migration. There is limited data on forgotten biliary stents for more than five years in literature. The aim of this retrospective study was to analyze the complications and outcomes in patients who forgot to get their biliary stents removed or exchanged for more than five years. METHODS The study population included patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) and plastic biliary stent placements in a tertiary care center from 1990 to 2022 for benign biliary diseases. Loss to follow-up and subsequent forgotten stent for more than five years were observed in 40 patients who underwent ERCP during this study period. We retrospectively analyzed the indications of stenting, present status of stent, complications and outcomes in the study patients. RESULTS The mean age of the study patients was 51.5 ± 11.5 years with 27 females. Indications of biliary stent placement were choledocholithiasis (33, 82.5%), bile leak (3, 7.5%), benign biliary stricture (2, 5%) and choledochal cyst (2, 5%). The mean duration of forgotten stent was 5.9 ± 3.6 years. Presenting symptoms were abdominal pain (37, 92.5%), fever (26, 65%) and jaundice (32, 80%). Most commonly placed stent was 7 French double pigtail of 10 cm length. Complications in the study patients were cholangitis (35, 87.5%), internal migration (2, 5%), pancreatitis (1, 2.5%) and portal hypertension (1, 2.5%). The outcomes were stone removal (30, 90.9%), stent removal (31, 77.5%), stent reinsertion (19, 47.5%), broken stent (3, 7.5%) and surgery (2, 5%). CONCLUSIONS Prolonged duration (> 5 years) of forgotten stent is uncommon and is observed most commonly in patients with choledocholithiasis. The most common complication of long duration of forgotten stents was cholangitis followed by internal migration, pancreatitis and portal hypertension. Stone and stent removal was successful in a majority of patents, while surgery was required in less number of patients.
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Affiliation(s)
- Shyam Sunder Sharma
- Department of Gastroenterology, S M S Medical College and Hospitals, Room No. 218, Superspeciality Block, Jaipur, 302 004, India
| | - Sudhir Maharshi
- Department of Gastroenterology, S M S Medical College and Hospitals, Room No. 218, Superspeciality Block, Jaipur, 302 004, India.
| | - Bharat Sapra
- Department of Gastroenterology, S M S Medical College and Hospitals, Room No. 218, Superspeciality Block, Jaipur, 302 004, India
| | - Sandeep Nijhawan
- Department of Gastroenterology, S M S Medical College and Hospitals, Room No. 218, Superspeciality Block, Jaipur, 302 004, India
| | - Dhruv Sharma
- Department of Surgery, Mahatma Gandhi Medical College and Hospitals, Jaipur, 303 905, India
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Sugiura R, Kuwatani M, Kin T, Matsumoto R, Ikeda Y, Sano I, Hirata K, Yoshida M, Masaki Y, Ono M, Hirata H, Yamato H, Onodera M, Nakamura H, Taya Y, Ehira N, Nakajima M, Kawabata H, Ihara H, Kudo T, Kato S, Katanuma A. Risk factors for recurrent biliary obstruction following endoscopic biliary stenting in patients with unresectable ampullary cancer: A multicenter retrospective study. J Dig Dis 2024; 25:310-317. [PMID: 38973135 DOI: 10.1111/1751-2980.13288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 04/25/2024] [Accepted: 05/14/2024] [Indexed: 07/09/2024]
Abstract
OBJECTIVES Unresectable ampullary cancer (AC) is a rare disease entity. The risk factors for recurrent biliary obstruction (RBO) following endoscopic biliary stenting (EBS) for unresectable AC remain unknown. In this study we aimed to evaluate the cumulative RBO rate and to identify risk factors for RBO following palliative EBS in patients with unresectable AC. METHODS This multicenter retrospective observational study enrolled consecutive patients with unresectable AC who had undergone palliative EBS between April 2011 and December 2021. The cumulative rate of and risk factors for RBO following palliative EBS were evaluated via multivariate analysis. RESULTS The study analysis comprised 107 patients with a median age of 84 years (interquartile range 79-88 years). Plastic stents (PSs) and self-expandable metal stents (SEMSs) were placed in 53 and 54 patients, respectively. Functional success was accomplished in 104 (97.2%) patients. Of these, RBO occurred in 62 (59.6%) patients, with obstruction and complete/partial migration occurring in 47 and 15 patients, respectively. The median time to RBO was 190 days. Multivariate analysis showed that PS was associated with a higher rate of RBO compared to SEMS (hazard ratio [HR] 2.48; P < 0.01) and that the presence of common bile duct stones/sludge immediately after EBS was an independent risk factor for RBO (HR 1.99; P = 0.04). CONCLUSIONS The use of SEMS compared to PS during EBS reduced the time to RBO in patients with unresectable AC. Common bile duct stones/sludge immediately after EBS was a risk factor for RBO.
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Affiliation(s)
- Ryo Sugiura
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Masaki Kuwatani
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Toshifumi Kin
- Center for Gastroenterology, Teine-Keijinkai Hospital, Sapporo, Hokkaido, Japan
| | - Ryusuke Matsumoto
- Department of Gastroenterology, Obihiro Kosei Hospital, Obihiro, Hokkaido, Japan
| | - Yuki Ikeda
- Department of Gastroenterology, Oji General Hospital, Tomakomai, Hokkaido, Japan
| | - Itsuki Sano
- Department of Internal Medicine, Kushiro Rosai Hospital, Kushiro, Hokkaido, Japan
| | - Koji Hirata
- Department of Gastroenterology and Hepatology, Hakodate Municipal Hospital, Hakodate, Hokkaido, Japan
| | - Makoto Yoshida
- Department of Medical Oncology, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Yoshiharu Masaki
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Michihiro Ono
- Department of Gastroenterology, Steel Memorial Muroran Hospital, Muroran, Hokkaido, Japan
| | - Hajime Hirata
- Department of Gastroenterology, Tomakomai City Hospital, Tomakomai, Hokkaido, Japan
| | - Hiroaki Yamato
- Department of Gastroenterology, Iwamizawa Municipal General Hospital, Iwamizawa, Hokkaido, Japan
| | - Manabu Onodera
- Department of Gastroenterology, NTT East Sapporo Hospital, Sapporo, Hokkaido, Japan
| | - Hideaki Nakamura
- Department of Gastroenterology, Hokkaido Gastroenterology Hospital, Sapporo, Hokkaido, Japan
| | - Yoko Taya
- Department of Gastroenterology, Hokkaido Medical Center, Sapporo, Hokkaido, Japan
| | - Nobuyuki Ehira
- Department of Gastroenterology, Kitami Red Cross Hospital, Kitami, Hokkaido, Japan
| | - Masahito Nakajima
- Department of Gastroenterology, Aiiku Hospital, Sapporo, Hokkaido, Japan
| | - Hidemasa Kawabata
- Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Hideyuki Ihara
- Department of Gastroenterology, Tonan Hospital, Sapporo, Hokkaido, Japan
| | - Taiki Kudo
- Department of Gastroenterology, IMS Sapporo Digestive Disease Center General Hospital, Sapporo, Hokkaido, Japan
| | - Shin Kato
- Department of Gastroenterology, Sapporo City General Hospital, Sapporo, Hokkaido, Japan
| | - Akio Katanuma
- Center for Gastroenterology, Teine-Keijinkai Hospital, Sapporo, Hokkaido, Japan
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Dai C, Xu C, Zheng L, Wang M, Fan Z, Ye J, Su D. Characteristics and metabolic potential of biliary microbiota in patients with giant common bile duct stones. Front Cell Infect Microbiol 2023; 13:1259761. [PMID: 38029241 PMCID: PMC10661410 DOI: 10.3389/fcimb.2023.1259761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 10/23/2023] [Indexed: 12/01/2023] Open
Abstract
Background Endoscopic retrograde cholangiopancreatography (ERCP) is an effective minimally invasive operation for the management of choledocholithiasis, while successful extraction is hampered by large diameter of stones. Emerging studies have revealed the close correlation between biliary microbiota and common bile duct stones (CBDS). In this study, we aimed to investigate the community characteristics and metabolic functions of biliary microbiota in patients with giant CBDS. Methods Eligible patients were prospectively enrolled in this study in First Affiliated Hospital of Soochow University from February 2022 to October 2022. Bile samples were collected through ERCP. The microbiota was analyzed using 16S rRNA sequencing. Metabolic functions were predicted by PICRUSTs 2.0 calculation based on MetaCyc database. Bile acids were tested and identified using ultra performance liquid chromatography-tandem mass spectrometry. Results A total of 26 patients were successfully included into final analysis, 8 in giant stone (GS) group and 18 in control group. Distinct biliary microbial composition was identified in patients with giant CBDS, with a significantly higher abundance of Firmicutes at phylum level. The unique composition at genus level mainly consisted of Enterococcus, Citrobacter, Lactobacillus, Pyramidobacter, Bifidobacterium and Shewanella. Pyramidobacter was exclusively found in GS group, along with the absence of Robinsoniella and Coprococcus. The contents of free bile acids were significantly higher in GS group, including cholic acid (98.39μmol/mL vs. 26.15μmol/mL, p=0.035), chenodesoxycholic acid (54.69μmol/mL vs. 5.86μmol/mL, p=0.022) and ursodeoxycholic acid (2.70μmol/mL vs. 0.17μmol/mL, p=0.047). Decreasing tendency of conjugated bile acids were also observed. Metabolic pathways concerning cholelithiasis were abundant in GS group, including geranylgeranyl diphosphate biosynthesis, gluconeogenesis, glycolysis and L-methionine biosynthesis. Conclusions This study demonstrated the community structure and metabolic potential of biliary microbiota in patients with giant CBDS. The unique biliary microbial composition holds valuable predictive potential for clinical conditions. These findings provide new insights into the etiology of giant CBDS from the perspective of biliary microbiota.
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Affiliation(s)
- Chenguang Dai
- Department of Pathology, Nanjing Medical University, Nanjing, China
- Department of Gastroenterology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Chunfang Xu
- Department of Gastroenterology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Lu Zheng
- Department of Gastroenterology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Min Wang
- Digestive Endoscopy Department, First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Zhining Fan
- Digestive Endoscopy Department, First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Jianxin Ye
- Department of Gastroenterology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Dongming Su
- Department of Pathology, Nanjing Medical University, Nanjing, China
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Meng K, Zhang DY, Chen DX, Liu WJ, Fang KX, Chen S, Wu L, Li MY. Large common bile duct stones in high-risk elderly patients: Immediate endoscopic stone removal or elective stone removal? A single-center retrospective study. BMC Gastroenterol 2023; 23:344. [PMID: 37798726 PMCID: PMC10552253 DOI: 10.1186/s12876-023-02976-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 09/26/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND AND OBJECTIVE For high-risk elderly patients with chronic diseases, endoscopic stone removal for large common bile duct stones is associated with a high risk of adverse events and incomplete stone removal. The aim of this study was to investigate whether the treatment strategy of short-term biliary plastic stent placement followed by elective endoscopic stone removal is more effective and safer than immediate endoscopic stone removal. METHODS The data of 262 high-risk elderly patients who received endoscopic retrograde cholangiopancreatography (ERCP) for large common bile duct (CBD) stones from 2017 to 2022 were retrospectively analyzed. The patients were divided into group A (immediate stone removal) and group B (stent drainage + elective stone removal). The baseline data of the 2 groups were matched 1:1 by propensity score matching. The stone clearance rate, ERCP procedure time, total hospital stay, and procedure-related adverse events were compared between the matched groups. In group B, stone size before and after stent placement, hospital stay, procedure time and adverse events of two ERCPs were compared. RESULTS A total of 57 pairs of patients were successfully matched between the 2 groups. The stone clearance rate in group B was higher than that in group A (89.5% vs. 75.3, P = 0.049). The total hospital stay in group B was longer than that in group A (11.86 ± 3.912 d vs. 19.14 ± 3.176 d, P<0.001). The total adverse event rate in group A was higher than that in group B (29.8% vs. 12.3%, P = 0.005). The incidence of cholangitis/cholecystitis after ERCP was significantly higher in group A than in group B (7.0% vs. 0.9% P = 0.029). There was no significant difference in the incidence of post-ERCP pancreatitis, bleeding, pneumonia, and cardio-cerebrovascular events between the 2 groups. There were no perforation cases in either group. After plastic biliary stent placement in group B, the stone size was significantly smaller than before stent placement (1.59 ± 0.544 cm vs. 1.95 ± 0.543 cm, P < 0.001), and there was no significant difference in the total adverse event incidence between the two ERCP procedures (18.8% vs. 10.9%, P = 0.214). CONCLUSION For high-risk elderly patients with large CBD stones, the treatment strategy involving temporary placement of plastic stent and elective endoscopic stone removal is safer and more effective than immediate stone removal.
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Affiliation(s)
- Ke Meng
- Department of Gastroenterology, The First Medical Center, Chinese PLA General Hospital, Fuxing Road, #28, Haidian District, Beijing, 100853, China
| | - Da-Ya Zhang
- Graduate School, Hainan Medical University, Haikou, 571199, China
| | - De-Xin Chen
- Graduate School of PLA general hospital, Beijing, 100853, China
| | - Wen-Jing Liu
- Graduate School of PLA general hospital, Beijing, 100853, China
| | - Kai-Xuan Fang
- Graduate School of PLA general hospital, Beijing, 100853, China
| | - Shengxin Chen
- Graduate School of PLA general hospital, Beijing, 100853, China
| | - Lang Wu
- Graduate School of PLA general hospital, Beijing, 100853, China
| | - Ming-Yang Li
- Department of Gastroenterology, The First Medical Center, Chinese PLA General Hospital, Fuxing Road, #28, Haidian District, Beijing, 100853, China.
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Moutzoukis M, Argyriou K, Kapsoritakis A, Christodoulou D. Endoscopic luminal stenting: Current applications and future perspectives. World J Gastrointest Endosc 2023; 15:195-215. [PMID: 37138934 PMCID: PMC10150289 DOI: 10.4253/wjge.v15.i4.195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 01/30/2023] [Accepted: 04/04/2023] [Indexed: 04/14/2023] Open
Abstract
Endoscopic luminal stenting (ELS) represents a minimally invasive option for the management of malignant obstruction along the gastrointestinal tract. Previous studies have shown that ELS can provide rapid relief of symptoms related to esophageal, gastric, small intestinal, colorectal, biliary, and pancreatic neoplastic strictures without compromising cancer patients’ overall safety. As a result, in both palliative and neoadjuvant settings, ELS has largely surpassed radiotherapy and surgery as a first-line treatment modality. Following the abovementioned success, the indications for ELS have gradually expanded. To date, ELS is widely used in clinical practice by well-trained endoscopists in managing a wide variety of diseases and complications, such as relieving non-neoplastic obstructions, sealing iatrogenic and non-iatrogenic perforations, closing fistulae and treating post-sphincterotomy bleeding. The abovementioned development would not have been achieved without corresponding advances and innovations in stent technology. However, the technological landscape changes rapidly, making clinicians’ adaptation to new technologies a real challenge. In our mini-review article, by systematically reviewing the relevant literature, we discuss current developments in ELS with regard to stent design, accessories, techniques, and applications, expanding the research basis that was set by previous studies and highlighting areas that need to be further investigated.
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Affiliation(s)
- Miltiadis Moutzoukis
- Department of Gastroenterology, University Hospital of Ioannina, Ioannina GR45333, Greece
| | - Konstantinos Argyriou
- Department of Gastroenterology, Medical School and University Hospital of Larissa, Larissa GR41334, Greece
| | - Andreas Kapsoritakis
- Department of Gastroenterology, Medical School and University Hospital of Larissa, Larissa GR41334, Greece
| | - Dimitrios Christodoulou
- Department of Gastroenterology, Medical School and University Hospital of Ioannina, Ioannina GR45500, Greece
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Koksal AS, Eminler AT, Parlak E. Fully Covered Metal Stents Safely Facilitate Extraction of Difficult Bile Duct Stones. Surg Laparosc Endosc Percutan Tech 2023; 33:152-161. [PMID: 36821696 DOI: 10.1097/sle.0000000000001147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 01/02/2023] [Indexed: 02/25/2023]
Abstract
BACKGROUND Ten to 15% of the common bile duct (CBD) stones require advanced endoscopic extraction techniques during endoscopic retrograde cholangiopancreatography. The study aimed to evaluate the efficacy and safety of fully covered self-expandable metal stents (FC-SEMS) for facilitating the extraction of difficult bile duct stones. METHODS Patients who received FC-SEMS for the extraction of difficult CBD stones were retrospectively reviewed. Group 1 included patients with extrahepatic stones above a distal CBD stricture, Group 2 included patients with intrahepatic stones above a hilar stricture, and Group 3 included patients with complex stone(s) and no biliary stricture. Complete stone clearance rate and complications of FC-SEMS treatment were evaluated. RESULTS The study group included 33 procedures on 32 patients (mean age: 55±17, 56.3% male). FC-SEMS was placed as a primary treatment in 15 (45.5%) procedures. Complete stone clearance was achieved in 84.6% of the procedures in Group 1, 100% in Group 2, and 87.5% in Group 3 ( P =0.23). Overall, complete stone clearance was achieved in 30 of the 33 procedures (90.9%). None of the patients developed pancreatitis, cholecystitis, or cholangitis. Stent migration occurred in 4 procedures (12.1%), and all were clinically insignificant. CONCLUSION FC-SEMS is effective and safe for facilitating treatment of difficult bile duct stones.
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Affiliation(s)
- Aydin Seref Koksal
- Faculty of Medicine, Department of Gastroenterology, Sakarya University, Sakarya
| | - Ahmet Tarik Eminler
- Faculty of Medicine, Department of Gastroenterology, Sakarya University, Sakarya
| | - Erkan Parlak
- Faculty of Medicine, Department of Gastroenterology, Hacettepe University, Ankara, Turkey
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Difficult Biliary Stones: A Comprehensive Review of New and Old Lithotripsy Techniques. Medicina (B Aires) 2022; 58:medicina58010120. [PMID: 35056428 PMCID: PMC8779004 DOI: 10.3390/medicina58010120] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 01/05/2022] [Accepted: 01/07/2022] [Indexed: 12/14/2022] Open
Abstract
Biliary stones represent the most common indication for therapeutic endoscopic retrograde cholangiopancreatography. Many cases are successfully managed with biliary sphincterotomy and stone extraction with balloon or basket catheters. However, more complex conditions secondary to the specific features of stones, the biliary tract, or patient’s needs could make the stone extraction with the standard techniques difficult. Traditionally, mechanical lithotripsy with baskets has been reported as a safe and effective technique to achieve stone clearance. More recently, the increasing use of endoscopic papillary large balloon dilation and the diffusion of single-operator cholangioscopy with laser or electrohydraulic lithotripsy have brought new, safe, and effective therapeutic possibilities to the management of such challenging cases. We here summarize the available evidence about the endoscopic management of difficult common bile duct stones and discuss current indications of different lithotripsy techniques.
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Is the use of fully covered metal stents effective in the treatment of difficult lithiasis of the common bile duct? Surg Endosc 2022; 36:5684-5691. [PMID: 34993589 DOI: 10.1007/s00464-021-08919-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 11/21/2021] [Indexed: 12/07/2022]
Abstract
BACKGROUND The management of difficult lithiasis of common bile duct (CBD) often requires a multimodal approach. Fully Covered Metal Stents (FCSEMS) could fragment the stones, dilate strictures of the CBD and progressively enlarge the papillary orifice. The aim of the study was to evaluate the efficacy of FCSEMS in the treatment of difficult lithiasis of CBD. METHODS All consecutive cases of difficult lithiasis of CBD after an attempt of clearance with complete sphincterotomy were retrospectively considered from 2009 to 2019. Intrahepatic lithiasis cases were excluded. Multivariable analysis (stepwise logistic regression if p value < 0.1 at univariable analysis) was made to understand factors associated with efficacy of FCSEMS in difficult lithiasis of CBD. RESULTS 163 cases of difficult lithiasis over 1516 cases of lithiasis of CBD (incidence of 11%) were considered. Among eligible patients, 96 (mean age 78 ± 11.9 years, 43% males) placed a FCSEMS during the first ERCP. Mean diameter of stone was 17.5 ± 5.5 mm. An attempt of dilation during the same procedure was made in 18% cases. After removal of the stent, 52 (54%) patients had complete clearance of CBD at cholangiography. The rest of patients (44), subsequently underwent multimodal treatment (final success of 95%). After logistic regression, variables positively associated with clearance of CBD were sex male (OR 3.5) and stent permanence ≥ 30 days (OR 3.2). Diameter of the stone ≥ 2 cm was associated with failure (OR 0.2). 7 post-ERCP pancreatitis, 6 post-sphincterotomy bleeding and 3 cholangitis occurred. CONCLUSIONS FCSEMS are useful in the approach of difficult lithiasis of CBD with no significant adverse events associated.
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DUMAN AE, YILMAZ H, HÜLAGÜ S. Biliary stents are forgotten more frequently in elderly patients. Turk J Med Sci 2021; 51:3067-3072. [PMID: 34579509 PMCID: PMC10734834 DOI: 10.3906/sag-2104-108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 12/13/2021] [Accepted: 09/27/2021] [Indexed: 02/05/2023] Open
Abstract
Background/aim Plastic biliary stents that remain in situ for more than 12 months, called forgotten biliary stents (FBSs), can cause complications such as cholangitis, stent migration, stent occlusion, and perforation. Materials and methods The medical records of patients who underwent ERCP procedures from December 2016 to December 2020 were analysed retrospectively. Data on patient characteristics, indications for ERCP and stenting, stent types, stenting duration, complications, and causes of FBSs were obtained from the hospital’s database. Results A total of 48 cases with FBSs were analysed. The mean age (SD) of the patients was 71.23 years (±12.165), the male-to-female ratio was 23/25 (0.92), and the mean stenting duration was 27.12 months (range: 12–84 months). The most common indication for biliary stenting was irretrievable choledochal stones (40/48). Stone formation (79%) and proximal stent migration (26.4%) were the most frequent complications. The patients in the FBS group were significantly older than those from whom stents were removed in a timely manner (71.23 vs. 62.43 years, p < 0.001). Endoscopic treatment was possible in all cases; surgery was not required in any case. The most common cause of FBSs cited by patients was not having been informed about the need for long-term management of their stents (n = 14, 29.2%) Conclusion FBSs are potentially problematic particularly in elderly patients. Communication with the patient to remind them of the need for stent management is important for preventing FBSs.
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Affiliation(s)
- Ali Erkan DUMAN
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Kocaeli University, Kocaeli,
Turkey
| | - Hasan YILMAZ
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Kocaeli University, Kocaeli,
Turkey
| | - Sadettin HÜLAGÜ
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Kocaeli University, Kocaeli,
Turkey
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Kitagawa K, Mitoro A, Ozutsumi T, Furukawa M, Fujinaga Y, Nishimura N, Sawada Y, Namisaki T, Akahane T, Yoshiji H. Comparison of the efficacy and safety between palliative biliary stent placement and duct clearance among elderly patients with choledocholithiasis: a propensity score-matched analysis. BMC Gastroenterol 2021; 21:369. [PMID: 34629075 PMCID: PMC8504035 DOI: 10.1186/s12876-021-01956-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 10/05/2021] [Indexed: 12/07/2022] Open
Abstract
Objectives This study aimed to evaluate and compare the outcomes of palliative endoscopic biliary stenting (EBS) and complete stone removal among elderly patients with choledocholithiasis using propensity score matching. Methods
From April 2012 to October 2017, 161 patients aged 75 years and older with choledocholithiasis underwent endoscopic retrograde cholangiopancreatography at our institution. Among them, 136 (84.5%) had complete stone removal, and 25 (15.5%) underwent palliative EBS without further intervention until symptom occurrence. The median age of the EBS group was significantly higher than that of the complete stone removal group. The proportion of patients with dementia, cerebral infarction, preserved gallbladder with gallstones, and surgically altered anatomy was higher in the EBS group than in the complete stone removal group. Propensity score matching was used to adjust for different factors. In total, 50 matched patients (n = 25 in each group) were analyzed. Results The median duration of cholangitis-free periods was significantly shorter in the EBS group (596 days) than in the complete stone removal group. About half of patients in the EBS group required retreatment and rehospitalization for cholangitis during the observation period. Cholangitis was mainly caused by stent migration. There was no significant difference in terms of mortality rate and procedure-related adverse events between the two groups. Death was commonly attributed to underlying diseases. However, one patient in the EBS group died due to severe cholangitis. Conclusions Palliative EBS should be indicated only to patients with choledocholithiasis who have a poor prognosis.
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Affiliation(s)
- Koh Kitagawa
- Department of Gastroenterology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan.
| | - Akira Mitoro
- Division of Endoscopy, Nara Medical University, Nara, Japan
| | | | | | - Yukihisa Fujinaga
- Department of Gastroenterology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Norihisa Nishimura
- Department of Gastroenterology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Yasuhiko Sawada
- Department of Gastroenterology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Tadashi Namisaki
- Department of Gastroenterology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Takemi Akahane
- Department of Gastroenterology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Hitoshi Yoshiji
- Department of Gastroenterology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
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Dollhopf M, Schmetkamp H. Endoscopic management of difficult common bile duct stones. Minerva Gastroenterol (Torino) 2021; 68:144-153. [PMID: 34142521 DOI: 10.23736/s2724-5985.21.02876-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Common bile duct stones are a very frequent problem in the western world and endoscopic stone clearance is the method of choice for treatment. Despite its common use, endoscopic clearance of common bile duct stones is not always trivial especially in cases involving large or multiple stones. EVIDENCE ACQUISITION A literature review regarding different endoscopic techniques was performed for this article and a recommended therapeutic algorithm developed based on the guidelines of the European Society of Gastrointestinal Endoscopy (ESGE) and the German Gastroenterological Society (DGVS). EVIDENCE SYNTHESIS This review gives an overview of currently applied endoscopic techniques, their success and complication rates as well as alternative methods used for cases involving anatomic anomalies. The purpose of this review is to recommend a therapeutic algorithm for the treatment of difficult common bile duct stones. CONLCLUSIONS For the treatment of difficult common bile duct stones, combined sphincterotomy and endoscopic large balloon dilation should be first choice. Mechanical lithotripsy and cholangioscopy-guided lithotripsy are close alternatives with nearly equal clearance rates and should be used if accessible. The insertion of a temporary plastic stent is a good choice to gain time to explore further treatment options. Enteroscopy-based ERCP, PTCS or EUS-guided hepaticogastrostomy and stone treatment, while good alternatives for select cases involving anatomic anomalies, should be performed at specialised units.
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Affiliation(s)
- Markus Dollhopf
- Endoscopy Section, Gastroenterology, München Klinik Neuperlach, Munich, Germany
| | - Henning Schmetkamp
- Endoscopy Section, Gastroenterology, München Klinik Neuperlach, Munich, Germany -
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12
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Hormati A, Ghadir MR, Sarkeshikian SS, Alemi F, Moghaddam M, Ahmadpour S, Mohammadbeigi A, Sivandzadeh GR. Adding ursodeoxycholic acid to the endoscopic treatment and common bile duct stenting for large and multiple biliary stones: Will it improve the outcomes? BMC Gastroenterol 2020; 20:374. [PMID: 33172395 PMCID: PMC7653844 DOI: 10.1186/s12876-020-01523-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 11/02/2020] [Indexed: 02/06/2023] Open
Abstract
Background The role of common bile duct (CBD) stenting in the establishment of bile stream in the elderly patients and the ones who are not good candidates for surgery due to not responding to treatments was well documented in previous studies. The current study aimed at investigating the effect of adding Ursodeoxycholic acid (UDCA) to CBD stenting alone in order to reduce the size of large and multiple CBD stones.
Methods Clinical outcomes including success rates in CBD stones clearance, incidence of pancreatitis, perforation, bleeding, as well as, decrease in size of stones and liver enzymes after a two-month period were assessed in the UDCA + CBD stenting group. Results A total of 64 patients referring to Shahid Beheshti Hospital in Qom, Iran with multiple or large CBD stones (above three or larger than 15 mm) received standard endoscopic therapies and UDCA + CBD stenting (group B) and controls only received standard endoscopic therapies with only CBD stenting (group A). The mean reduction in the size of stones in group B was significantly higher than that of group A (3.22 ± 1.31 vs 4.09 ± 1.87 mm) (p = 0.034). There was no difference in the incidence rate of complications including pancreatitis, cholangitis, bleeding, and perforation between the two groups (P > 0.05). Conclusion Adding UDCA to CBD stenting, due to decrease in the stone size and subsequently facilitation of the stones outlet, can be considered as the first-line treatment for patients with large and multiple CBD stones. Also, in the cases with large or multi stones may be effective in reducing size and subsequently stone retrieval. Trial registry The study protocol was approved by the Ethics Committee of Qom University of Medical Sciences (ethical code: IR.MUQ.REC.1397.075); the study was also registered in the Iranian Registry of Clinical Trials (No. IRCT20161205031252N8). This study adheres to CONSORT guidelines.
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Affiliation(s)
- Ahmad Hormati
- Gastroenterology and Hepatology Diseases Research Center, Qom University of Medical Sciences, Qom, Iran.,Gastrointestinal and Liver Diseases Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Ghadir
- Gastroenterology and Hepatology Diseases Research Center, Qom University of Medical Sciences, Qom, Iran
| | - Seyed Saeed Sarkeshikian
- Gastroenterology and Hepatology Diseases Research Center, Qom University of Medical Sciences, Qom, Iran
| | - Faezeh Alemi
- Gastroenterology and Hepatology Diseases Research Center, Qom University of Medical Sciences, Qom, Iran.
| | - Majid Moghaddam
- Gastroenterology and Hepatology Diseases Research Center, Qom University of Medical Sciences, Qom, Iran
| | - Sajjad Ahmadpour
- Gastroenterology and Hepatology Diseases Research Center, Qom University of Medical Sciences, Qom, Iran
| | - Abolfazl Mohammadbeigi
- Research Center for Environmental Pollutants, Qom University of Medical Sciences, Qom, Iran
| | - Gholam Reza Sivandzadeh
- Department of Internal Medicine, Gatroenterohepatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Sugiura R, Naruse H, Yamato H, Kudo T, Yamamoto Y, Hatanaka K, Ito J, Kinoshita K, Miyamoto S, Higashino M, Hayasaka S, Sakamoto N. Long-term outcomes and risk factors of recurrent biliary obstruction after permanent endoscopic biliary stenting for choledocholithiasis in high-risk patients. J Dig Dis 2020; 21:246-251. [PMID: 32223015 DOI: 10.1111/1751-2980.12859] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Revised: 02/28/2020] [Accepted: 03/23/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To elucidate the long-term outcomes of permanent endoscopic biliary stenting (EBS) and risk factors for recurrent biliary obstruction (RBO) in high-risk or elderly patients with common bile duct (CBD) stones. METHODS The electronic database of Hakodate Municipal Hospital was searched to identify elderly or high-risk patients with CBD stones who had undergone permanent EBS using a plastic stent without stone removal and were followed up between April 2011 and May 2019, with no further intervention until symptoms occurred. RESULTS We analyzed a total of 47 patients, of whom 19 (40.4%) were men, with a median age of 86 years (interquartile range 80-90 years). RBO and death without biliary disease occurred in 14 (29.8%) and 19 (40.4%) patients, respectively. The cumulative RBO rates at 20, 40, and 60 months were 22.1%, 31.8%, and 35.5%, respectively. The median time to RBO was 13.0 and 38.0 months in the group with CBD stone ≥15 mm and 11-14 mm in diameter, respectively. The cumulative RBO incidence rate in the group with CBD stone ≤10 mm in diameter did not reach 50%. The cumulative RBO incidence rates were significantly different among the three groups based on the CBD stone diameter (competing risk analysis, P < 0.01). Multivariate analysis showed that an increase in CBD stone diameter predicted the increased risk of RBO (hazard ratio 1.26, P = 0.01). CONCLUSIONS Permanent EBS is a feasible option for high-risk patients with small CBD stones.
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Affiliation(s)
- Ryo Sugiura
- Department of Gastroenterology and Hepatology, Hakodate Municipal Hospital, Hakodate, Japan.,Department of Gastroenterology and Hepatology, Hokkaido University Faculty of Medicine and Graduate School of Medicine, Sapporo, Japan
| | - Hirohito Naruse
- Department of Gastroenterology and Hepatology, Hakodate Municipal Hospital, Hakodate, Japan
| | - Hiroaki Yamato
- Department of Gastroenterology and Hepatology, Hakodate Municipal Hospital, Hakodate, Japan.,Department of Gastroenterology, Iwamizawa Municipal General Hospital, Iwamizawa, Japan
| | - Taiki Kudo
- Department of Gastroenterology and Hepatology, Hakodate Municipal Hospital, Hakodate, Japan.,Department of Gastroenterology, Sapporo Hokuyu Hospital, Sapporo, Japan
| | - Yoshiya Yamamoto
- Department of Gastroenterology and Hepatology, Hakodate Municipal Hospital, Hakodate, Japan
| | - Kazuteru Hatanaka
- Department of Gastroenterology and Hepatology, Hakodate Municipal Hospital, Hakodate, Japan
| | - Jun Ito
- Department of Gastroenterology and Hepatology, Hakodate Municipal Hospital, Hakodate, Japan
| | - Kenji Kinoshita
- Department of Gastroenterology and Hepatology, Hakodate Municipal Hospital, Hakodate, Japan
| | - Shuichi Miyamoto
- Department of Gastroenterology and Hepatology, Hakodate Municipal Hospital, Hakodate, Japan
| | - Masayuki Higashino
- Department of Gastroenterology and Hepatology, Hakodate Municipal Hospital, Hakodate, Japan
| | - Shuhei Hayasaka
- Department of Gastroenterology and Hepatology, Hakodate Municipal Hospital, Hakodate, Japan
| | - Naoya Sakamoto
- Department of Gastroenterology and Hepatology, Hokkaido University Faculty of Medicine and Graduate School of Medicine, Sapporo, Japan
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Hormati A, Ghadir MR, Hasanpour Dehkordi A, Yadollahi F, Salehitali S, Afifian M. Consequences of Stenting and Endoscopic Papillary Balloon Dilatation in Treatment of Large and Multiple Common Bile Duct Stones. Middle East J Dig Dis 2019; 11:205-210. [PMID: 31824623 PMCID: PMC6895848 DOI: 10.15171/mejdd.2019.150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 09/01/2019] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Although stenting for the treatment of large and multiple common bile duct stones has been acceptable to everyone, its efficacy and outcome have not been studied in comparison with other endoscopic procedures. The purpose of this study was to compare the consequences of stenting and endoscopic papilla balloon dilatation for the treatment of large and multiple common bile duct stones. METHODS In a double-blind clinical trial, of 431 patients with bile duct stones referred to the treatment center, 64 patients with multiple common bile duct stones ( ≥ 3) and more than 15 cm were selected for the study, then by random allocation rule the participants were allocated in two groups. They were entered into two different endoscopic papillary balloon dilatation (EPBD) and common bile ducts stenting treatments so that both procedures were performed by a person. Both groups were assessed from the point of views therapeutic outcomes such as duct cleaning, pancreatitis, isolated pain, and duct rupture. Data were collected by a self-made questionnaire that was used before and after the procedure to obtain the needed information. Then data were analyzed using SPSS software version 22 and descriptive and analytical tests were used as appropriated. RESULTS Although the duct cleaning and the complete removal of the stones in the stenting treatment procedure was 93.8%, and in EPBD was 78.3%, no significant difference was observed between the two groups (p = 0.14). Pancreatitis significantly increased after the first and second endoscopic retrograde cholangiopancreatography (ERCP) in the stent group compared with EPBD (p = 0.02). Also, the most frequent cases of isolated pain were in the endoscopic group EPBD (p = 0.0). However, the occurrence of perforation after first ERCP and EPBD was zero, but in the second stage of ERCP, 3.3% of the patients had perforations (p = 0.99). The results indicated that the shape of the stone (circular and angled) was not effective in the result of treatment in the two groups. CONCLUSION The results of this study indicated that in case of experience and skill in conducting the ERCP, common bile duct stenting is still the first line of treatment for large and multiple stones of the common bile ducts.
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Affiliation(s)
- Ahmad Hormati
- Assistant Professor, Gastroenterology and Hepatology Disease Research Center, Qom University of Medical Sciences, Shahid Beheshti Hospital, Qom, Iran.,Assistant Professor, Gastrointestinal and Liver Disease Research Center, Iran University of Medical Sciences, Firoozgar Hospital, Tehran, Iran
| | - Mohammad Reza Ghadir
- Professor, Gastroenterology and Hepatology Disease Research Center, Qom University of Medical Sciences, Shahid Beheshti Hospital, Qom, Iran
| | - Ali Hasanpour Dehkordi
- Associate Professor, School of Allied Medical Sciences, Shahrekord, University of Medical Sciences, Shahrekord, Iran
| | - Farshad Yadollahi
- Medical Resident, Medical College, Shahrekord University of Medical Sciences, Shahrekord, Iran
| | - Shahriar Salehitali
- Assistant Professor , School of Nursing and Midwifery, Shahrekord University of Medical Sciences, Shahrekord, Iran
| | - Mahboobeh Afifian
- MSc of Health Information Technology of Tehran University of Medical Sciences, Tehran, Iran
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15
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Akazawa Y, Ohtani M, Nosaka T, Saito Y, Takahashi K, Naito T, Ofuji K, Matsuda H, Hiramatsu K, Nemoto T, Nakamoto Y. Long-term prognosis after biliary stenting for common bile duct stones in high-risk elderly patients. J Dig Dis 2018; 19:626-634. [PMID: 30117280 DOI: 10.1111/1751-2980.12656] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 07/19/2018] [Accepted: 08/10/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To evaluate the long-term outcomes of complete common bile duct (CBD) stone removal and biliary stenting in elderly patients (≥85 years) with CBD stones. METHODS We retrospectively examined 65 patients who underwent complete CBD stone removal (the duct clearance group) and 40 patients who underwent biliary stenting (the biliary stenting group) between July 2006 and March 2016. To reduce selection bias, we also conducted a propensity score matching analysis and generated 30 pairs of patients. Cholangitis recurrence-free survival and overall survival were compared between the two groups and independent prognostic factors of survival were identified by univariate and multivariate analyses. RESULTS Cholangitis recurrence-free survival was significantly better in the duct clearance group than in the biliary stenting group (P < 0.001). Their overall survival did not significantly differ after propensity score matching (P = 0.388). In all cohorts, univariate analysis demonstrated that poor performance status and biliary stenting were factors of poor prognosis, and in multivariate analysis only performance status remained associated with poor prognosis for survival. Similarly, in the propensity score-matched cohort, only performance status independently predicted poorer survival (hazard ratio [HR] 2.726, 95% confidence interval [CI] 1.105-6.675, P = 0.029). The choice of endoscopic treatment was not a significant factor associated with prognosis (HR 1.354, 95% CI 0.678-2.701, P = 0.391). CONCLUSIONS Biliary stenting was similar to complete stone removal in terms of prognosis for long-term survival. Biliary stenting for CBD stones could be an effective therapeutic tool in high-risk elderly patients.
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Affiliation(s)
- Yu Akazawa
- Faculty of Medical Sciences, Second Department of Internal Medicine, Fukui University, Fukui, Japan
| | - Masahiro Ohtani
- Faculty of Medical Sciences, Second Department of Internal Medicine, Fukui University, Fukui, Japan
| | - Takuto Nosaka
- Faculty of Medical Sciences, Second Department of Internal Medicine, Fukui University, Fukui, Japan
| | - Yasushi Saito
- Faculty of Medical Sciences, Second Department of Internal Medicine, Fukui University, Fukui, Japan
| | - Kazuto Takahashi
- Faculty of Medical Sciences, Second Department of Internal Medicine, Fukui University, Fukui, Japan
| | - Tatsushi Naito
- Faculty of Medical Sciences, Second Department of Internal Medicine, Fukui University, Fukui, Japan
| | - Kazuya Ofuji
- Faculty of Medical Sciences, Second Department of Internal Medicine, Fukui University, Fukui, Japan
| | - Hidetaka Matsuda
- Faculty of Medical Sciences, Second Department of Internal Medicine, Fukui University, Fukui, Japan
| | - Katsushi Hiramatsu
- Faculty of Medical Sciences, Second Department of Internal Medicine, Fukui University, Fukui, Japan
| | - Tomoyuki Nemoto
- Faculty of Medical Sciences, Second Department of Internal Medicine, Fukui University, Fukui, Japan
| | - Yasunari Nakamoto
- Faculty of Medical Sciences, Second Department of Internal Medicine, Fukui University, Fukui, Japan
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Tohda G, Dochin M. Management of endoscopic biliary stenting for choledocholithiasis: Evaluation of stent-exchange intervals. World J Gastrointest Endosc 2018; 10:45-50. [PMID: 29375741 PMCID: PMC5769003 DOI: 10.4253/wjge.v10.i1.45] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 11/30/2017] [Accepted: 12/07/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the best management of plastic stents in patients with choledocholithiasis who were unfit for endoscopic stone removal or surgery.
METHODS Between April 2007 and September 2017, 87 patients (median age 83.7 years) with symptomatic choledocholithiasis were treated with insertion of 7-Fr plastic stents because complete endoscopic stone retrieval was difficult, and their general condition was not suitable for surgery. Seventy of these patients agreed to regular stent management and stent exchange was carried out at every 6 mo (Group A, n = 35) or every 12 mo (Group B, n = 35). The remaining 17 patients did not accept regular stent exchange, and stents were replaced when clinical symptoms appeared (Group C). We evaluated the frequency of biliary complication and stent patency rate during follow-up periods.
RESULTS The patency rate of biliary plastic stents was 91.4% at 6 mo (Group A) and 88.6% at 12 mo (Group B), respectively. Acute cholangitis occurred in 2.9% of Group A patients and in 8.6% of Group B patients. In Group C, median stent patency was 16.3 mo, and stent exchange was carried out in 70.6% of cases because of acute cholangitis or obstructive jaundice. Although a high incidence of acute cholangitis occurred, there was no biliary-related mortality.
CONCLUSION Plastic stent exchange at 12-mo intervals is considered a safe procedure for patients with choledocholithiasis. Long-term biliary stenting increases biliary complications, but it can be an acceptable option for select patients who are medically unfit for further invasive procedures.
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Affiliation(s)
- Gen Tohda
- Department of Gastroenterology, Fukui Kosei Hospital, Fukui 918-8537, Japan
| | - Masaki Dochin
- Department of Gastroenterology, Fukui Kosei Hospital, Fukui 918-8537, Japan
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17
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Kwon CI, Kim G, Jeong S, Choi SH, Ko KH, Lee DH, Cho JY, Hong SP. Experimental study on the friction effect of plastic stents for biliary stone fragmentation (with video). Dig Endosc 2018. [PMID: 28622426 DOI: 10.1111/den.12906] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND AIM In patients with irretrievable or intractable bile duct stone, temporary insertion of a plastic stent (PS) followed by further endoscopic retrograde cholangiopancreatography (ERCP) or surgery has been recommended as a 'bridge' therapy. However, the exact mechanism of stone fragmentation has not been discovered. The aim of the present study was to evaluate whether PS shape can facilitate stone fragmentation. METHODS Using a new in vitro bile flow phantom model, we compared the friction effect among three different PS groups (straight PS group, double pigtail-shaped PS group, and screw-shaped PS group) and a control group. Each group had 10 silicon tube blocks that separately contained one stone and two PS. The control group had 10 blocks each with only a stone and no PS. We carried out analysis of the friction effect by stone weight and volume changes among the groups, excluding fragmented stones. RESULTS After 8 weeks, complete fragmentation was noted in one out of 34 cholesterol stones (2.9%) and in four out of six pigmented stones (66.7%). Fragmentation tended to be more prominent in the screw-shaped PS group than in the straight PS group, double pigtail-shaped group, and control group (volume change: -11.33%, 7.94%, 4.43%, and 2.05%, respectively, P = 0.1390; weight change: -9.30%, 0.71%, -0.10%, and -1.23%, respectively, P = 0.3553). CONCLUSION Stone fragmentation may be induced by PS friction effect. Also, screw-shaped plastic stents may improve friction effect. These results may help guide future PS development and clinical decisions.
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Affiliation(s)
- Chang-Il Kwon
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Gwangil Kim
- Department of Pathology, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Seok Jeong
- Division of Gastroenterology, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Sung Hoon Choi
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Kwang Hyun Ko
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Don Haeng Lee
- Division of Gastroenterology, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Joo Young Cho
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Sung Pyo Hong
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam, Korea
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Multiple plastic biliary stent placement in the management of large and multiple choledochal stones: single center experience and review of the literature. Wideochir Inne Tech Maloinwazyjne 2017; 12:231-237. [PMID: 29062442 PMCID: PMC5649504 DOI: 10.5114/wiitm.2017.69107] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2017] [Accepted: 06/27/2017] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy is the first step treatment modality of choledocholithiasis. In spite of an extended sphincterotomy, 10-15% of complex choledochal stones (larger than 15 mm and/or more than 3 stones) cannot be removed and recurrent ERCP procedures may be needed. AIM To evaluate the role and efficiency of multiple biliary stent application in the treatment of large and multiple choledochal stones. MATERIAL AND METHODS Patients with complex choledochal stones and patients with inadequate choledochal clearance during ERCP were included in the study. The study group was divided into 2 groups as the placement of single (n = 27 patients) or multiple stents (n = 58 patients). After a mean time interval of 21 days (10-28), the ERCP procedure was tried for the second time and a stent was placed in case of recurrence. RESULTS Successful biliary drainage was provided in both groups. The decrease in the longitudinal or transverse size of the stones after stent placement was found to be statistically significant in both groups (p = 0.001). Cholestatic enzymes (alkaline phosphatase (ALP), γ-glutamyltransferase (GGT)) and bilirubin levels decreased significantly in both groups following stenting (p = 0.001). Additionally, multiple stents functioned as a bridge starting from the first ERCP to full clearance in patients with large and multiple stones which could not be removed at once and saved them from the possible morbidities of an invasive operation. CONCLUSIONS Endoscopic multiple biliary stent placement should be preferred in the treatment of patients with complex choledochal stones and high rates of co-morbidity, as a safe alternative to surgery.
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Zimmer V. Transpapillary passage of a giant bile duct stone after endoscopic papillary large balloon dilation and short-term stenting. Clin Res Hepatol Gastroenterol 2017; 41:503-504. [PMID: 28373016 DOI: 10.1016/j.clinre.2017.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 02/10/2017] [Indexed: 02/04/2023]
Affiliation(s)
- Vincent Zimmer
- Department of Medicine, Marienhausklinik St. Josef Kohlhof, Klinikweg 1-5, 66539 Neunkirchen, Germany; Department of Medicine II, Saarland University Medical Center, Saarland University, 66421 Homburg, Germany.
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Tao T, Zhang M, Zhang QJ, Li L, Li T, Zhu X, Li MD, Li GH, Sun SX. Outcome of a session of extracorporeal shock wave lithotripsy before endoscopic retrograde cholangiopancreatography for problematic and large common bile duct stones. World J Gastroenterol 2017; 23:4950-4957. [PMID: 28785149 PMCID: PMC5526765 DOI: 10.3748/wjg.v23.i27.4950] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 05/03/2017] [Accepted: 06/12/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To compare the efficacy of a session of extracorporeal shock wave lithotripsy (ESWL) before endoscopic retrograde cholangiopancreatography (ERCP) vs ERCP only for problematic and large common bile duct (CBD) stones.
METHODS Adult patients with CBD stones for whom initial ERCP was unsuccessful because of the large size of CBD stones were identified. The patients were randomized into two groups, an “ESWL + ERCP group” and an “ERCP-only” group. For ESWL + ERCP cases, ESWL was performed prior to ERCP. Clearance of the CBD, complications related to the ESWL/ERCP procedure, frequency of mechanical lithotripsy use and duration of the ERCP procedure were evaluated in both groups.
RESULTS There was no significant difference in baseline characteristics between the two groups. A session of ESWL before ERCP compared with ERCP only resulted in similar outcomes in terms of successful stone removal within the first treatment session (74.2% vs 71.0%, P = 0.135), but a higher clearance rate within the second treatment session (84.4% vs 51.6%, P = 0.018) and total stone clearance (96.0% vs 86.0%, P = 0.029). Moreover, ESWL prior to ERCP not only reduced ERCP procedure time (43 ± 21 min vs 59 ± 28 min, P = 0.034) and the rate of mechanical lithotripsy use (20% vs 30%, P = 0.025), but also raised the clearance rate of extremely large stones (80.0% vs 40.0%, P = 0.016). Post-ERCP complications were similar for the two groups.
CONCLUSION Based on the higher rate of successful stone removal and minimal complications, ESWL prior to ERCP appears to be a safe and effective treatment for the endoscopic removal of problematic and large CBD stones.
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Laparoscopic surgery for choledocholithiasis concomitant with calculus of the left intrahepatic duct or abdominal adhesions. Surg Endosc 2017; 31:4780-4789. [DOI: 10.1007/s00464-017-5555-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Accepted: 04/01/2017] [Indexed: 02/07/2023]
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22
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Sohn SH, Park JH, Kim KH, Kim TN. Complications and management of forgotten long-term biliary stents. World J Gastroenterol 2017; 23:622-628. [PMID: 28216968 PMCID: PMC5292335 DOI: 10.3748/wjg.v23.i4.622] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 12/16/2016] [Accepted: 12/21/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate complications and management outcomes of retained long-term plastic biliary stents.
METHODS Endoscopic plastic biliary stent placement was performed in 802 patients at Yeungnam University Hospital between January 2000 and December 2014. Follow-up loss with a subsequently forgotten stent for more than 12 mo occurred in 38 patients. We retrospectively examined the cause of biliary stent insertion, status of stents, complications associated with biliary stents and management outcomes of long-term plastic biliary stents. Continuous variables were analyzed using the t test. Observed frequencies in subsets of the study population were compared using Fisher’s exact test and χ2 tests. Statistical significance was defined as P < 0.05 (two-tailed).
RESULTS Mean age of patients was 73.7 ± 12 years and male-to-female ratio was 2.2:1. Indications of plastic biliary stent insertion were bile duct stones (63.2%, 24/38) and benign bile duct stricture (52.6%, 20/38). Mean duration of retained plastic stent was 22.6 ± 12.2 mo, and in 10 cases (26.3%), stents were retained for more than 24 mo. Common bile duct (CBD) stones or sludge were found in most cases (92.1%, 35/38). The most common complication was acute cholangitis (94.7%, 36/38). Stent removal by endoscopic approach was successfully performed in 92.1% (35/38) of the cases. In 3 cases, an additional plastic stent was inserted alongside the previous stent due to failure of the stent removal. Endoscopic removal of bile duct stones was successful in 73.7% (28/38) of the cases. When patients were divided into two groups by duration of stent placement (12 to 24 mo vs over 24 mo), there were no differences in the development of cholangitis, presence of biliary stones, and success rate of endoscopic removal of stones and biliary stents.
CONCLUSION The most common complication of retained long-term plastic biliary stents was acute cholangitis associated with CBD stones. Endoscopic management was successfully performed in most cases.
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Gao Q, Huang C, Sun B, Aqeel BM, Wang J, Chen W, Mo X, Wan X. Fabrication and characterization of metal stent coating with drug-loaded nanofiber film for gallstone dissolution. J Biomater Appl 2016; 31:784-796. [PMID: 27698255 DOI: 10.1177/0885328216671239] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Stent insertion and chemical agents of ethylene diamine tetraacetic acid and sodium cholate for dissolving common bile duct stone diseases through extra biliary tract infusion have been believed a relatively effective therapeutics for the clinical symptom. Core-shell nanofibers produced by co-axial electrospinning to deliver chemical drugs, biomacromolecules, genes and even cells have been reported for various advanced drug delivery system and tissue engineering applications. In the present study, poly (lactide-co-ɛ-caprolactone) (PLCL) core-shell nanofiber-coated film of stent, loaded with ethylene diamine tetraacetic acid and sodium cholate in core layer, was fabricated by co-axial electrospinning for treating gallstone disease. Image of laser scanning confocal microscopy and transmission electron microscopy demonstrated core-shell structure of drug-loaded nanofiber. Fourier transform infrared spectra and the thermogravimetric analysis proved ethylene diamine tetraacetic acid and sodium cholate to be successfully loaded in nanofibers. Morphology of nanofibers after a period of degradation still keeps good shape. Drugs can continuously release for around five days, which was proved significant effectiveness for dissolving gallstone. Besides, unobvious cytotoxicity was exhibited from MTT results and cell kept good morphology in vitro research. The present coated stent showed a bright prospect for dissolving the biliary stone.
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Affiliation(s)
- Qiang Gao
- State Key Laboratory for Modification of Chemical Fibers and Polymer Materials, College of Chemistry, Chemical Engineering and Biotechnology, DongHua University, Shanghai, China
| | - Chao Huang
- Department of Gastroenterology, First People's Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai, China
| | - Binbin Sun
- State Key Laboratory for Modification of Chemical Fibers and Polymer Materials, College of Chemistry, Chemical Engineering and Biotechnology, DongHua University, Shanghai, China
| | - Bhutto M Aqeel
- State Key Laboratory for Modification of Chemical Fibers and Polymer Materials, College of Chemistry, Chemical Engineering and Biotechnology, DongHua University, Shanghai, China
| | - Jing Wang
- State Key Laboratory for Modification of Chemical Fibers and Polymer Materials, College of Chemistry, Chemical Engineering and Biotechnology, DongHua University, Shanghai, China
| | - Weiming Chen
- State Key Laboratory for Modification of Chemical Fibers and Polymer Materials, College of Chemistry, Chemical Engineering and Biotechnology, DongHua University, Shanghai, China
| | - Xiumei Mo
- State Key Laboratory for Modification of Chemical Fibers and Polymer Materials, College of Chemistry, Chemical Engineering and Biotechnology, DongHua University, Shanghai, China Shandong International Biotechnology Park Development Co., Ltd, Shandong, China
| | - Xinjian Wan
- Department of Gastroenterology, First People's Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai, China
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Mohammed N, Pinder M, Harris K, Everett SM. Endoscopic biliary stenting in irretrievable common bile duct stones: stent exchange or expectant management-tertiary-centre experience and systematic review. Frontline Gastroenterol 2016; 7:176-186. [PMID: 28839855 PMCID: PMC5369546 DOI: 10.1136/flgastro-2015-100566] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 04/08/2015] [Accepted: 05/05/2015] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Conventional endoscopic duct clearance may not be possible in up to 10%-15% of common bile duct stones (CBDS). Sphincterotomy and biliary drainage by endoprosthesis have for many years been the mainstay of management in irretrievable stones. Recent years have seen the advent of sphincteroplasty or cholangioscopically-guided electrohydraulic lithotripsy (EHL) permitting duct clearance in majority of cases. However, when bile duct clearance is not possible, options include long-term stenting followed by elective stent exchange (ESE) 6-12 monthly or permanent stent insertion (PSI) in selected cases, but it is not clear which management strategy among ESE and PSI is preferable. METHODS AND AIMS A retrospective review of all patients in Leeds Teaching Hospitals NHS Trust who underwent plastic stent insertion for biliary access for difficult CBDS from January 2006 to December 2011 was undertaken. Adult patients with irretrievable CBDS who had plastic stent insertions throughout the follow-up period were included. Patients who underwent PSI and ESE annually were retrospectively reviewed to determine the long-term outcomes. A detailed systematic review was also performed, examining the outcomes of CBDS managed with stents. RESULTS During the study period, 674 patients underwent 1769 biliary-stent-related procedures; of which, 246 patients met our inclusion criteria. 201 patients had subsequent duct clearance. 45 patients were, therefore, included in the final analysis, 28 of whom underwent annual ESEs and 17 PSIs. Patients in the PSI group had higher American Society of Anesthesiologists (ASA) scores compared with the ESE group. In the PSI group, 9/17 patients presented acutely with blocked stents, 5 of whom presented within 12 months. 2/9 patients were severely ill and died within a fortnight following the repeat endoscopic retrograde cholangiopancreatography (ERCP). In the ESE group, 4/28 patients had duct clearance in subsequent ERCPs, 1/28 patient presented with a blocked stent, and no biliary-related deaths were observed. The mean numbers of ERCPs performed were 0.52 and 1.95 in the PSI and ESE groups, respectively. CONCLUSIONS Over 50% of patients treated with long-term stenting re-presented acutely with stent blockage, though many of these were before 12 months, meaning planned stent exchange would not have affected the outcome. Duct clearance using all possible modalities is the preferred option, but where not possible, management with biliary stenting either with elective exchange or permanent stenting remains a possibility for carefully selected patients, though maybe best suited to those with limited life expectancy.
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Affiliation(s)
- Noor Mohammed
- Department of Gastroenterology, Centre of digestive diseases, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK,Leeds institute of Biomedical and Clinical Sciences, St James's University Hospital, University of Leeds, Leeds, UK
| | - Matthew Pinder
- Department of Gastroenterology, Centre of digestive diseases, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Keith Harris
- Department of Radiology, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Simon M Everett
- Department of Gastroenterology, Centre of digestive diseases, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Abstract
Many advances have been achieved in biliary stenting over the past 30 years. Endoscopic stent placement has become the primary management therapy to relieve obstruction in patients with benign or malignant biliary tract diseases. Compared with plastic stents, a self-expandable metallic stent (SEMS) has been used for management in patients with malignant strictures because of a larger lumen and longer stent patency. Recently, SEMS has been used for various benign biliary strictures and leaks. In this article, we briefly review the characteristics of SEMS as well as complications of stent placement. We review the current guidelines for managing malignant and benign biliary obstructions. Recent developments in biliary stenting are also discussed.
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Affiliation(s)
- Hyeong Seok Nam
- Department of Internal Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Dae Hwan Kang
- Department of Internal Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
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Easler JJ, Sherman S. Endoscopic Retrograde Cholangiopancreatography for the Management of Common Bile Duct Stones and Gallstone Pancreatitis. Gastrointest Endosc Clin N Am 2015; 25:657-75. [PMID: 26431596 DOI: 10.1016/j.giec.2015.06.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Biliary disease is a common cause of acute pancreatitis. Risk stratification for persistent pancreatobiliary obstruction is important for selecting a treatment approach. Most common bile duct stones are extracted with standard endoscopic techniques. However, prior foregut surgery, stones with extreme morphologic attributes, and at difficult positions within the biliary system are technically challenging and predict a need for advanced biliary endoscopic techniques. Surgical common bile duct exploration at the time of cholecystectomy is appropriate in centers with experience. We outline the options and approach for the clinician to successfully identify and manage patients with symptomatic choledocholithiasis with or without biliary pancreatitis.
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Affiliation(s)
- Jeffrey J Easler
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Stuart Sherman
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
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Attaallah W, Cingi A, Karpuz S, Karakus M, Gunal O. Do not rush for surgery; stent placement may be an effective step for definitive treatment of initially unextractable common bile duct stones with ERCP. Surg Endosc 2015; 30:1473-9. [DOI: 10.1007/s00464-015-4355-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 06/16/2015] [Indexed: 12/22/2022]
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28
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Aswad MG, Dennison AR, Neal CP, Metcalfe MS, Garcea G. Biliary stenting for benign and malignant obstructive jaundice: safe use of extended stent-change intervals. Surg Laparosc Endosc Percutan Tech 2014; 24:385-90. [PMID: 25077640 DOI: 10.1097/sle.0b013e3182a50e59] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
PURPOSE This study compared 2 methods of palliative stent placement, 6-monthly interval stent changes (RS), or a single-stent policy with no planned stent change (SS). RESULTS A total of 460 patients were identified. There were no significant differences in the proportion of patients requiring unplanned stent changes in the RS or SS group (22.3% vs. 22.8%). Median survival was not significantly different between the RS and SS groups, for both benign disease (96 vs. 92 mo) and malignant disease (9 vs. 6 mo). Patients undergoing unplanned stent changes had the poorest survival and the highest stent change-related complication rate. Patients with a blocked stent episode were more likely to develop further problems with stent patency, within a median interval of 2.5 months. CONCLUSIONS In carefully selected patients, a single stent may be adequate with no planned change of stent. There appears to be a clearly defined subgroup of patients who have recurrent problems with stent patency; these should have their interval exchange brought forward on a 3-monthly basis, or a self-expanding metal stent should be used.
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Affiliation(s)
- Mayar G Aswad
- Department of Hepatobiliary and Pancreatic Surgery, University Hospitals of Leicester, Leicester, UK
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29
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Cai XB, Zhang WX, Wan XJ, Yang Q, Qi XS, Wang XP, Lu LG. The effect of a novel drug-eluting plastic stent on biliary stone dissolution in an ex vivo bile perfusion model. Gastrointest Endosc 2014; 79:156-62. [PMID: 24125512 DOI: 10.1016/j.gie.2013.09.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Accepted: 09/11/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND Temporary plastic stent insertion has been considered a safe and effective bridge therapy for difficult common bile duct (CBD) stones. Infusing chemicals to directly dissolve stones through the bile duct might also be effective. However, there are no studies on the efficacy of the combination of these 2 approaches. OBJECTIVE To investigate the efficacy of a novel ethylenediaminetetraacetic acid (EDTA) and sodium cholate-eluting plastic stent on biliary stones. DESIGN Ex vivo model by using different doses of active ingredient. SETTING AND INTERVENTIONS An ex vivo bile duct model perfused with porcine bile was created. Stents coated with degradable membranes containing various concentrations of EDTA and sodium cholate were placed in the model with CBD stones. MAIN OUTCOME MEASUREMENTS The change in the weight of stents and stones was measured every week during perfusion until the coated membranes were completely biodegraded. RESULTS The time that the stents required to be fully degraded and the efficiency of stone dissolution were positively correlated with the percentage of EDTA and sodium cholate in the stent membrane. However, the 50% EDTA and sodium cholate stents achieved the greatest percentage of stone weight loss when the drugs were completely released. LIMITATIONS Ex vivo study. CONCLUSIONS The EDTA and sodium cholate-eluting plastic stent effectively dissolved CBD stones and has prospect in the therapy for patients with difficult CBD stones.
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Affiliation(s)
- Xiao Bo Cai
- Department of Gastroenterology, First People's Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai, China
| | - Wei Xing Zhang
- Department of Gastroenterology, Central Hospital, Songjiang District, Shanghai, China
| | - Xin Jian Wan
- Department of Gastroenterology, First People's Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai, China
| | - Qin Yang
- College of Chemistry, Chemical Engineering and Biotechnology, Donghua University, Shanghai, China
| | - Xiao Shen Qi
- Department of General Surgery, First People's Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai, China
| | - Xing Peng Wang
- Department of Gastroenterology, First People's Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai, China
| | - Lun Gen Lu
- Department of Gastroenterology, First People's Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai, China
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30
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Yasuda I, Itoi T. Recent advances in endoscopic management of difficult bile duct stones. Dig Endosc 2013; 25:376-85. [PMID: 23650878 DOI: 10.1111/den.12118] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Accepted: 03/21/2013] [Indexed: 12/12/2022]
Abstract
Endoscopic treatment is now recognized worldwide as the first-line treatment for bile duct stones. Endoscopic sphincterotomy combined with basket and/or balloon catheter is generally carried out for stone extraction. However, some stones are refractory to treatment under certain circumstances, necessitating additional/other therapeutic modalities. Large bile duct stones are typically treated by mechanical lithotripsy. However, if this fails, laser or electrohydraulic lithotripsy (EHL) is carried out under the guidance of conventional mother-baby cholangioscopy. More recently, direct cholangioscopy using an ultrathin gastroscope and the newly developed single-use cholangioscope system - the SpyGlass direct visualization system - are also used. In addition, extracorporeal shock wave lithotripsy has also been used for stone fragmentation. Such fragmentation techniques are effective in cases with impacted stones, including Mirizzi syndrome. Most recently, endoscopic papillary large balloon dilationhas been introduced as an easy and effective technique for treating large and multiple stones. In cases of altered anatomy, it is often difficult to reach the papilla; in such cases, a percutaneous transhepatic approach, such as EHL or laser lithotripsy under percutaneous transhepatic cholangioscopy, can be a treatment option. Moreover, enteroscopy has recently been used to reach the papilla. Furthermore, an endoscopic ultrasound-guided procedure has been attempted most recently. In elderly patients and those with very poor general condition, biliary stenting only is sometimes carried out with or without giving subsequent dissolution agents.
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Affiliation(s)
- Ichiro Yasuda
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan.
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31
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Slattery E, Kale V, Anwar W, Courtney G, Aftab AR. Role of long-term biliary stenting in choledocholithiasis. Dig Endosc 2013; 25:440-3. [PMID: 23808949 DOI: 10.1111/j.1443-1661.2012.01399.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Accepted: 09/11/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM Endoscopic retrograde cholangiopancreatography (ERCP) is the treatment of choice for the management of choledocholithiasis. Biliary stenting facilitates repeated attempts at stone extraction. The aim of the present paper was to assess long-term outcomes of patients where biliary stenting was used as the primary treatment for the management of choledocholithiasis. METHODS We undertook a review of a prospectively maintained database of all ERCP carried out at a single institution. All patients had stones not amenable to endoscopic retrieval. RESULTS Between January 1998 and December 2008, 3655 ERCP were carried out in our unit. Of these, 201 (120 female) patients met our inclusion criteria. All patients underwent ERCP and sphincterotomy, followed by insertion of a double pigtail 7-Fr plastic stent. Repeat ERCP was not scheduled routinely. Stent change was only carried out in patients when clinical suspicion of stent blockage occurred. Median stent patency was 59.6 months (interquartile range 47.7-71.2). At 6 months, stent patency was 93.5%, and at 24 months, it was 81.9%. Serious adverse outcomes with blocked stents were uncommon, and tended to occur early. Cholangitis was seen in only 7.4% (6) of patients (median stent patency 11.8 months) and jaundice was seen in 18.5% (15 patients, median stent patency 7.2 months). CONCLUSION Our data demonstrate median stent patency of almost 5 years. The low incidence of significant complications with blocked stents and excellent stent patency rates suggest that long-term biliary stenting is an acceptable alternative in elderly, frail patients with stones that are not endoscopically retrievable.
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Affiliation(s)
- Eoin Slattery
- Department of Gastroenterology, St Luke's Hospital, Kilkenny, Ireland.
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32
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Minakari M, Samani RR, Shavakhi A, Jafari A, Alijanian N, Hajalikhani M. Endoscopic papillary balloon dilatation in comparison with endoscopic sphincterotomy for the treatment of large common bile duct stone. Adv Biomed Res 2013; 2:46. [PMID: 24516846 PMCID: PMC3905354 DOI: 10.4103/2277-9175.114186] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2012] [Accepted: 09/08/2012] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND There are concerns on the efficacy and safety of endoscopic papillary balloon dilatation (EPBD) as an alternative to endoscopic sphincterotomy (EST) in the treatment of choledocholithiasis. We compared the efficacy and safety of EPBD and EST for removing large common bile duct (CBD) stones. MATERIALS AND METHODS One hundred sixty patients with CBD stones of 10-20 mm were randomized to undergo EPBD or EST. A 15-mm dilatation balloon was used for EPBD. Cotton's criteria were used to determine the incidence of post-EPBD or post-EST complications. CBD stone removal and complications were compared between the two methods. RESULTS CBD stones were completely removed in 97.5% of the EPBD and 96.2% of the EST group (P = 0.5). The incidence of postoperative pancreatitis (11.2% vs 8.7%) and bleeding (1.2% vs 1.2%) were similar between the EPBD and EST groups (P > 0.05). Perforation did not occur in any patient. CONCLUSIONS EPBD with 15-mm dilator balloon appears to be equally safe and effective compared with EST for removal of large CBD stones. So because of low complication and high success rate we recommend EPBD as the preferred method for removal of large (10-20 mm) CBD stones.
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Affiliation(s)
- Mahammad Minakari
- Department of Internal Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Rahil R Samani
- Department of Internal Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ahmad Shavakhi
- Department of Internal Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Alireza Jafari
- Department of General Surgery, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Neda Alijanian
- Department of Internal Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mehri Hajalikhani
- Department of Internal Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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Pfau PR, Pleskow DK, Banerjee S, Barth BA, Bhat YM, Desilets DJ, Gottlieb KT, Maple JT, Siddiqui UD, Tokar JL, Wang A, Song LMWK, Rodriguez SA. Pancreatic and biliary stents. Gastrointest Endosc 2013; 77:319-27. [PMID: 23410693 DOI: 10.1016/j.gie.2012.09.026] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Accepted: 09/20/2012] [Indexed: 02/08/2023]
Abstract
Biliary and pancreatic stents are used in a variety of benign and malignant conditions including strictures and leaks and in the prevention of post-ERCP pancreatitis.Both plastic and metal stents are safe, effective, and easy to use. SEMSs have traditionally been used for inoperable malignant disease. Covered SEMSs are now being evaluated for use in benign disease. Increasing the duration of patency of both plastic and metal stents remains an important area for future research.
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Yang J, Peng JY, Chen W. Endoscopic biliary stenting for irretrievable common bile duct stones: Indications, advantages, disadvantages, and follow-up results. Surgeon 2012; 10:211-7. [PMID: 22647840 DOI: 10.1016/j.surge.2012.04.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Revised: 04/24/2012] [Accepted: 04/26/2012] [Indexed: 12/23/2022]
Abstract
BACKGROUND The advantages of endoscopic retrograde cholangiopancreatography (ERCP) over open surgery have made it the predominant method of treating patients with choledocholithiasis. After sphincterotomy, however, 10%-15% of common bile duct (CBD) stones cannot be removed with a basket or balloon. Methods for managing "irretrievable stones" include surgery; mechanical, intraductal shock wave, and extracorporeal shock wave lithotripsy; chemical dissolution; and biliary stenting. Endoscopic biliary stent insertion, which is frequently used in specific situations, has both advantages and disadvantages. To maximize the advantages and minimize the complications of biliary endoprosthesis, it is important to recognize its proper indications and to apply the technique in proper situations. DATA SOURCES We reviewed all publications cited in Pubmed and published through July 2011 on biliary endoprosthesis in patients with irretrievable CBD stones. We analyzed the indications, advantages, disadvantages, and long-term follow-up results of this technique. RESULTS Despite the occurrence of related complications, such as cholangitis, endoscopic placement of an endoprosthesis may reduce stone size, allowing later clearance of unextractable stones. Permanent biliary stenting may be a definitive treatment in selected elderly patients who are poor candidates for surgery. CONCLUSION Endoscopic biliary stenting remains a simple and safe method for patients with stones difficult to manage by conventional endoscopic methods and those patients unfit for surgery or at high surgical risks.
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Affiliation(s)
- Jun Yang
- Department of Surgery, The Sixth People's Hospital Affiliated to Shanghai Jiao Tong University, Shanghai 200233, China
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Stefanidis G, Christodoulou C, Manolakopoulos S, Chuttani R. Endoscopic extraction of large common bile duct stones: A review article. World J Gastrointest Endosc 2012; 4:167-79. [PMID: 22624068 PMCID: PMC3355239 DOI: 10.4253/wjge.v4.i5.167] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2011] [Revised: 04/14/2012] [Accepted: 04/27/2012] [Indexed: 02/05/2023] Open
Abstract
Since therapeutic endoscopic retrograde cholangiopancreatography replaced surgery as the first approach in cases of choledocolithiasis, a plethora of endoscopic techniques and devices appeared in order to facilitate rapid, safe and effective bile duct stones extraction. Nowadays, endoscopic sphincterotomy combined with balloon catheters and/or baskets is the routine endoscopic technique for stone extraction in the great majority of patients. Large common bile duct stones are treated conventionally with mechanical lithotripsy, while the most serious complication of the procedure is “basket and stone impaction” that is predominately resolved surgically. In cases of difficult, impacted, multiple or intrahepatic stones, more sophisticated procedures have been used. Electrohydraulic lithotripsy and laser lithotripsy are performed using conventional mother-baby scope systems, ultra-thin cholangioscopes, thin endoscopes and ultimately using the novel single use, single operator SpyGlass Direct Visualization System, in order to deliver intracorporeal shock wave energy to fragment the targeted stone, with very good outcomes. Recently, large balloon dilation after endoscopic sphincterotomy confirmed its effectiveness in the extraction of large stones in a plethora of trials. When compared with mechanical lithotripsy or with balloon dilation alone, it proved to be superior. Moreover, dilation is an ideal alternative in cases of altered anatomy where access to the papilla is problematic. Endoscopic sphincterotomy followed by large balloon dilation represents the onset of a new era in large bile duct stone extraction and the management of “impaction” because it seems that is an effective, inexpensive, less traumatic, safe and easy method that does not require sophisticated apparatus and can be performed widely by skillful endoscopists. When complete extraction of large stones is unsuccessful, the drainage of the common bile duct is mandatory either for bridging to the final therapy or as a curative therapy for very elderly patients with short life expectancy. Placing of more than one plastic endoprostheses is better while the administration of Ursodiol is ineffective. The great majority of patients with large stones can be treated endoscopically. In cases of unsuccessful stone extraction using balloons, baskets, mechanical lithotripsy, electrohydraulic or laser lithotripsy and large balloon dilation, the patient should be referred for extracorporeal shock wave lithotripsy or a percutaneous approach and finally surgery.
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Affiliation(s)
- Gerasimos Stefanidis
- Gerasimos Stefanidis, Christos Christodoulou, Department of Gastroenterology, Athens Naval Hospital, 70 Deinokratous St, 115 21 Athens, Greece
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