Atif Saleem

Meta-analysis of randomized trials comparing the patency of covered and uncovered self-expandable metal stents for palliation of distal malignant bile duct obstruction

BACKGROUND Self-expandable metal stents (SEMSs) are used for palliation of malignant biliary obstruction. OBJECTIVE We performed a meta-analysis to compare stent patency and stent survival of covered SEMSs (CSEMSs) and uncovered SEMSs (USEMSs) in patients with unresectable distal malignant biliary obstruction. DESIGN Meta-analysis. SETTING Tertiary-care facility. PATIENTS A comprehensive search of several databases (from each databases earliest inclusive dates to November 2010, any language, and any population) was conducted. The search identified 337 potential abstracts and titles, of which 16 were retrieved in full text. Review of references identified 17 additional studies. We found 5 multicenter, randomized trials involving 781 patients. INTERVENTION Placement of covered and uncovered SEMSs for treatment of distal malignant biliary obstruction. MAIN OUTCOME MEASUREMENTS Stent patency, stent survival, patient survival, and cause for stent dysfunction (ingrowth, overgrowth, migration, and sludge formation). RESULTS The median length of follow-up was 212 days. Compared with USEMSs, CSEMSs were associated with significantly prolonged stent patency (weighted mean difference [WMD] 60.56 days; 95% confidence interval [CI], 25.96, 95.17; I² = 0%) and longer stent survival (WMD 68.87 days; 95% CI, 25.64, 112.11; I(2) = 79%). Stent migration, tumor overgrowth, and sludge formation were significantly higher with CSEMSs (relative risk [RR] 8.11; 95% CI, 1.47, 44.76; I² = 0%), (RR 2.02; 95% CI, 1.08, 3.78; I² = 0%), (RR 2.89; 95% CI, 1.27, 6.55; I² = 0%). LIMITATIONS Relatively low number of studies available and the fact that 2 of the 5 studies were from one institution. Also, the limited availability of some stents used in the trials may limit the applicability of these results. CONCLUSION CSEMSs have a significantly longer duration of patency compared with USEMSs in patients with distal malignant biliary obstruction. Stent dysfunction occurs at a similar rate, although there is a trend toward later obstruction with CSEMSs.

Large-diameter therapeutic channel duodenoscope to facilitate simultaneous deployment of side-by-side self-expandable metal stents in hilar cholangiocarcinoma

BACKGROUND Hilar cholangiocarcinoma (CC) is unresectable in 80% to 90% of cases. Placement of side-by-side bilateral self-expandable metal stents (SEMSs) can be technically challenging in these patients because deployment of the first stent can preclude passage of the second stent. METHODS Using a prototype large-diameter therapeutic channel (6-mm) duodenoscope, we positioned guidewires into the right and left intrahepatic systems. Two predeployed uncovered SEMSs with 7.5F delivery systems were passed side by side over each guidewire and deployed simultaneously. DESIGN Observational clinical feasibility study. SETTING Tertiary referral center. RESULTS This technique was attempted in 6 patients with malignant hilar biliary obstruction. Successful placement was achieved in all, with significant improvement in symptoms and cholestasis. LIMITATIONS Small number of patients. CONCLUSION This simple technique using a prototype large-diameter therapeutic channel duodenoscope facilitates placement of bilateral side-by-side hilar SEMSs.

Intraductal electrohydraulic lithotripsy by using SpyGlass cholangioscopy through a colonoscope in a patient with Roux-en-Y hepaticojejunostomy.

The endoscopic approach to large bile duct stones may require the use of intraductal electrohydraulic lithotripsy (IEHL) performed under direct cholangioscopic visualization. In patients with Roux-en-Y biliary reconstruction after liver transplantation, endoscopic retrograde cholangiography is feasible using long-length endoscopes. We describe successful fragmentation of a large common hepatic duct stone by using cholangioscopy-guided IEHL delivered through a colonoscope in a patient with a Rouxen-Y hepaticojejunostomy.

Outcome of emergency ERCP in the intensive care unit.

There are limited data on the outcome of emergency endoscopic retrograde cholangiopancreatography (ERCP) performed in the intensive care unit (ICU). We sought to assess the frequency, indications, and clinical outcomes of ERCPs performed in ICU patients who were too unstable to be transported to the endoscopy unit. An electronic endoscopy database was used to identify the patients (n = 22) and to assess procedural success, complications, and mortality. The indications for ERCP included suspected biliary sepsis, suspected gallstone pancreatitis, and known choledocholithiasis with cholangitis. Biliary cannulation, which was attempted in all patients, was successful in 19 patients (86 %), and of these 18 (95 %) underwent a technically successful endoscopic therapy. There were no apparent endoscopic complications. Therefore, emergency bedside ERCP in ICU patients, which is primarily performed for the management of suspected biliary sepsis and gallstone pancreatitis, can achieve high technical success rates when performed by experienced endoscopists, although the 30-day mortality rate remains high due to multiorgan dysfunction.

Successful endoscopic treatment of biliary cast syndrome in an orthotopic liver transplant patient with a Roux‐en‐Y anastomosis via balloon enteroscopy

The endoscopic treatment of biliary cast syndrome after liver transplantation (LT) has been described; it has been performed only in patients with a duct-toduct anastomosis. We describe the successful endoscopic removal of a biliary cast via balloon enteroscopy–guided endoscopic retrograde cholangiopancreatography in an orthotopic liver transplantation (OLT) patient with Roux-en-Y reconstruction.

Laparoscopy Assisted Transjejunal ERCP for Treatment of Pancreaticopleural Fistula

CONTEXT Pancreaticopleural fistula is a rare complication estimated to occur in 0.5% of the patients with pancreatitis and even extremely rare in surgically altered anatomy (e.g. Roux-en-Y anastomosis) patients. The conventional ERCP is difficult to treat pancreaticopleural fistula in a patient with complex upper GI anatomy because of long anatomical route. CASE REPORT We represent a case of a 47-year-old female with remote subtotal gastrectomy with Roux-en-Y gastrojejunostomy admitted with recurrent left pleural effusion due to pancreaticopleural fistula. After failed ERCP through the anatomical route, pancreaticopleural fistula was treated successfully with laparoscopy-assisted transjejunal ERCP. CONCLUSION Laparoscopy-assisted ERCP is a useful modality in patients with surgically altered anatomy.

Outcomes and Predictors of Rebleeding After 2-Octyl Cyanoacrylate Injection in Acute Gastric Variceal Hemorrhage.

Background and Aim: Endoscopic injection of 2-octyl cyanoacrylate (2-OCA) is used on an off-label basis for gastric variceal hemorrhage (GVH) in the United States. We assessed the efficacy, safety, and predictors of rebleeding after gastric variceal obturation (GVO) with 2-OCA in patients with acute GVH. Materials and Methods: A retrospective analysis was performed of patients with GVH who underwent 2-OCA injection for GVO over a 15-year period. Rates of acute hemostasis, predictors of rebleeding, and cyanoacrylate-related adverse events were assessed. Results: A total of 95 patients (63 males, median age 59±14 y) were analyzed. Gastric varices were categorized as GOV-1 (3%), GOV-2 (61%), and isolated gastric varices type 1 (36%) per Sarin classification. Initial hemostasis was achieved in all patients. Successful GVO, defined as sustained hemostasis within a month after injection, was achieved in 87 (92%) patients. Failed GVO with in-hospital rebleeding was observed in 8 (8%) patients. On univariate analysis, only the model for end-stage liver disease score was associated with an increased risk of rebleeding (odds ratio 1.2; 95% confidence interval, 1.1-1.4; P<0.01). Glue-related adverse events consisted of pulmonary emboli in 2 patients (2.1%), resulting in death in 1 patient. All cause in-hospital mortality was 13% due to uncontrolled gastric variceal rebleeding (n=3), renal failure (n=6), metastatic hepatocellular carcinoma (n=1), hemorrhagic stroke (n=1), and pulmonary embolism (n=1). Conclusions: Injection of 2-OCA was effective at achieving hemostasis in a high proportion of patients (92%) admitted for acute GVH. The risk of glue-related pulmonary embolism approximated 2% in our patient cohort, including 1 fatality.

Early massive bleeding after duodenal self-expandable metal stent placement for palliation of malignant gastric outlet obstruction (with video)

v Enteral stenting is a safe and effective treatment option for palliation of gastroduodenal obstruction. A myriad of complications can occur after self-expandable metal stent (SEMS) placement.1 Severe complications of bleeding and perforaion are uncommon, and early massive bleeding after duoenal stent placement has not been reported. We describe a ase of massive bleeding within 72 hours of duodenal SEMS lacement.