Application of ultra-fine metal stents to malignant hilar biliary strictures / 中华消化内镜杂志

Objective:To evaluate the feasibility, efficacy, and safety of ultra-fine metal stents for malignant hilar biliary strictures (MHBS).Methods:Ultra-fine metal stents were simultaneously placed into the intrahepatic duct of 30 patients with unresectable malignant hilar biliary strictures of Bismuth type Ⅱ or higher (based on imaging or histological and/or cytological findings) by using the stent-by-stent mode from January 2014 to June 2021 at the Department of Gastroenterology, Eastern Hepatobiliary Surgical Hospital. The technical success rate, clinical efficacy and incidence of complications were observed.Results:The technical success rate was 100.0% (30/30), and the clinical success was achieved in 28 patients (93.3%) . The mean procedure time was 55.7±20.7 min and the placement time was 28.3±18.2 min. Early adverse events included mild acute pancreatitis ( n=2) and cholangitis ( n=5). The median stent patency and the median overall survival were 243 days (95% CI: 186.6-299.4 days) and 237 days (95% CI: 149.0- 325.0 days), respectively. The incidence of late cholangitis was 36.7% (11/30). Stent malfunction occurred in 14 of the 30 patients, and 5 of them received endoscopic reintervention. The technical success rate for the reintervention was 4/5 with the mean procedure time of 49.8±6.9 min. Conclusion:Malignant hilar biliary obstruction endoscopic palliation with ultra-fine metal stents using the stent-by-stent mode is safe, feasible and effective.

¿Son útiles las prótesis metálicas autoexpandibles en el control de la hemorragia digestiva varicosa refractaria? / Are self-expanding metal prostheses useful for controlling refractory variceal digestive hemorrhaging?

Resumen El sangrado varicoso es una urgencia médica con altas tasas de morbimortalidad. De los pacientes que llegan para recibir manejo hospitalario, hasta un 10% no responden a medidas hemostáticas convencionales, por lo que se ha planteado el uso de prótesis metálicas autoexpandibles para el manejo con resultados prometedores de dichos pacientes. En el presente documento se discute la literatura mundial disponible acerca de la experiencia en el uso de dichos dispositivos; la eficacia en el control agudo; el pronóstico a largo plazo; el tipo de prótesis utilizadas y las alternativas, complicaciones y retos del manejo de pacientes con esta técnica, que puede considerarse emergente en nuestro medio.

Abstract Variceal bleeding is a medical emergency which has high rates of morbidity and mortality. Up to 10% of these patients treated in hospitals do not respond to conventional hemostatic measures. For this reason, the use of self-expanding metal stents (SEMS) has been proposed for management of these patients. It has had promising results. This paper discusses the literature available internationally about experience with the use of SEMS, their efficacy for acute control, long-term patient prognoses, types of stents, alternatives, complications, and challenges for the use of SEMS for patient management that should be considered in our environment.

Manejo de las fístulas de las anastomosis esófago-intestinales con prótesis autoexpandibles (PAE) en pacientes con cáncer: Reporte de casos / The Use of Self-expanding Metal Stents to Manage Fistulas of Esophageal Intestinal Anastomosis in Patients with Cancer

Objetivo. Mostrar la experiencia en el manejo de pacientes con dehiscencia de las anastomosis esófago-yeyunales o esófago-gástricas con prótesis autoexpandibles esofágicas (PEA). Material y métodos. Durante los años 2012 y 2013 se registraron las complicaciones posgastrectomía total en pacientes con cáncer gástrico con anastomosis efectuadas a nivel abdominal o a nivel torácico. Se incluyeron solo los pacientes con dehiscencias o fugas de las anastomosis. Se elaboró una hoja de registro donde se consignó de cada paciente la edad, sexo, localización de la lesión, estado clínico, si recibió repleción nutricional, quimioterapia y o radioterapia, día de presentación de la fístula o dehiscencia, cuantificación del tamaño, tipo de manejo, mortalidad, prótesis utilizada, número de prótesis, migración y retiro. Resultados. Se registraron 6 pacientes, 5 con dehiscencia a nivel abdominal y uno a nivel torácico. Cinco con adenocarcinoma gástrico y uno por GIST gástrico con metástasis hepáticas. Dos habían recibido repleción nutricional por perdida mayor de 10% de su peso corporal. A todos los pacientes se les realizó anastomosis con sutura mecánica. Cuatro hombres y dos mujeres. A cinco pacientes se les realizó estudio radiológico con medio de contraste hidrosoluble, confirmando la dehiscencia en tres de ellos. Todos los pacientes fueron manejados con reexploración quirúrgica y drenaje. Solo a dos pacientes se les colocó la prótesis durante la nueva cirugía. Dos pacientes requirieron de una segunda prótesis por migración. En total la migración se observó en 50% de los pacientes. La estancia hospitalaria más larga fue de 68 días, con una mortalidad de dos pacientes (33%), uno con una fístula crónica manejada con dos prótesis y el otro el mismo día de su reintervención. Las prótesis fueron retiradas después de la cuarta semana. Conclusiones. La frecuencia de esta complicación varía de 0 a 30%. El reconocimiento temprano y manejo oportuno son esenciales ...

Objective: The objective of this study is to show our experience in the management of patients with dehiscence of jejunal-esophageal or esophageal-gastric anastomoses through the use of esophageal self-expanding stents. Materials and Methods: During 2012 and 2013 all complications following gastrectomies in gastric cancer patients with anastomoses were recorded. Only patients with dehiscence or anastomotic leaks were included in this study. An information form was used to record each patient’s age, sex, location of lesion, medical condition, whether nutritional repletion had been received, whether patient had undergone chemotherapy or radiation therapy, date of presentation of the fistula or dehiscence, measurements of size, type of management used, mortality, stent used, number of stents used, stent migration and stent removal. Results: Six patients, four men and two women, five of whom had abdominal dehiscence and one who had thoracic dehiscence, were included. They had five gastric adenocarcinomas and one gastric GIST with liver metastasis. Two had received nutritional repletion because they had lost 10% of their body weight. All patients were had their anastomoses stapled. Five patients underwent radiological studies with water-soluble contrast which confirmed dehiscence in three of them. All patients were managed with surgical re-exploration and drainage. Only two patients had their stents replaced during surgery which were required because of stent migration. Migration was observed in 50% of these patients. The longest hospital stay was 68 days. Two patients (33%) died, one had a chronic fistula managed with two prostheses and the other died on same day as his second surgical intervention. Stents were removed after the fourth week. Conclusions: The frequency of this complication varies from 0% to 30%. Early recognition and appropriate management are essential when faced with this complication. A few years ago this complication was ...

Prótesis Choostent como método de paliación de la disfagia secundaria a patología maligna / Use of Choostent prosthetic device for palliation of dysphagia secondary to esophageal cancer

Background: Esophageal cancer causes disabling dysphagia and swallowing problems. Aim: To prospectively analyze the outcome of the insertion of a covered self-expanding metallic Choostent type prosthesis as a method of palliation of dysphagia, esophageal fistula or leak secondary to malignant disease of the esophagus or cardia. Material and Methods: A total of 30 consecutive patients aged 75 +/- 8.8 years (63 percent males) with malignant disease of the esophagus or cardia were studied. Results: In 27 patients (90 percent) the stenosis was located in the esophagus, in two (6.7 percent) at the gastroesophageal junction and in one (3.3 percent) at the esophago - jejunal anastomosis due to tumor recurrence. In 24 cases (80 percent), the indication of the prosthesis was dysphagia, in three (10 percent) the presence of a tracheo-esophageal fistula and in the remaining three (10 percent), the suspicion of a perforation. Patients were followed until death. The prosthesis was inserted without incidents in 29 patients (96.6 percent). One patient had a pneumomediastinum, which evolved favorably. Dysphagia subsided in all patients. Early evolution was satisfactory in 12 patients (66.7 percent). The most common early complication was a transient chest pain in 3 cases (10 percent). Four patients (13.3 percent) died within 30 days post procedure. Of the remaining 26 patients, 14 (53.8 percent) had late complications (recurrence of dysphagia in 42 percent and hemorrhage in 11 percent). The mean interval between stent insertion and death was 169 +/- 142.5 days. Conclusions: The Choostent esophageal prosthesis improves dysphagia immediately and safely. However, its use is associated with a high rate of late complications, directly related to prosthetic dysfunction.

Objetivo: Analizar en forma prospectiva los resultados de la inserción de una prótesis metálica autoexpandible cubierta tipo Choostent como método de paliación de la disfagia, fístulas o fugas esofágicas secundarias a patología maligna del esófago o cardias. Material y Método: Se estudiaron un total de 30 pacientes consecutivos portadores de patología maligna del esófago o de cardias. La edad promedio fue de 75 +/- 8,8 años. 19 (63,3 por ciento) eran del género masculino. En 27 pacientes (90 por ciento) la estenosis comprometía el esófago, en 2 (6,7 por ciento) la unión gastroesofágica y en 1 (3,3 por ciento) la anastomosis esófago yeyunal por recidiva tumoral. En 24/30 casos (80 por ciento), la indicación de la prótesis fue la disfagia, en 3 (10 por ciento) la presencia de fístula esófago-traqueal y en los 3 restantes (10 por ciento), la sospecha de perforación. Los pacientes fueron controlados hasta su fallecimiento. Resultados: La prótesis se insertó sin incidentes en 29/30 pacientes (96,7 por ciento). Un caso (3 por ciento) presentó neumo-mediastino, que evolucionó favorablemente. La disfagia cedió en la totalidad de los enfermos. La evolución precoz fue satisfactoria en 12/30 pacientes (40 por ciento), siendo la complicación precoz más frecuente el dolor torácico transitorio en 3 casos (10 por ciento). Fallecieron precozmente 4 enfermos (13,3 por ciento). De los 26 restantes, en 14 (53,8 por ciento) se presentaron complicaciones tardías, siendo las más frecuentes la recidiva de la disfagia (42,3 por ciento) y la hemorragia (11,5 por ciento). Conclusión: Las prótesis Choostent mejoran la disfagia en forma inmediata y segura. Son efectivas en el manejo de las fístulas traqueo-esofágicas y perforaciones. Sin embargo, su uso se asocia a una alta tasa de morbilidad tardía directamente relacionada a la disfunción protésica.