J Affronti

Proximal migration of biliary stents: Attempted endoscopic retrieval in forty-one patients

BACKGROUND Proximal migration of a biliary stent is an uncommon event, but its management can present a technical challenge to the therapeutic endoscopist. METHODS We reviewed the methods that have been used for retrieval of proximally migrated biliary stents in a referral endoscopy center. RESULTS Forty-four cases were identified; 38 stents (86%) were extracted successfully. Half of the stents were retrieved after first passing a guide wire through the stent lumen. Various accessories were then used to withdraw the stents, the Soehendra device being the most popular. Nearly one third were retrieved by grasping the stents directly, usually with a wire basket or forceps. The remainder were recovered after using a stone retrieval balloon alongside the stents to provide traction indirectly. Interventional radiology techniques were needed in two cases, and surgery in one. CONCLUSIONS Cannulating the stent lumen with a wire is often the best approach in patients with a biliary stricture or a nondilated duct. An over-the-wire accessory can then be used to secure the stent. In patients with a dilated duct, indirect traction with a balloon or direct grasping of the stent with a wire basket, snare, or forceps is usually successful. Using these techniques, most proximally migrated biliary stents can be retrieved endoscopically.

Fluoroscopy Time During Endoscopic Retrograde Cholangiopancreatography

Fluoroscopy Time During Endoscopic Retrograde Cholangiopancreatography Kamil Obideen, Maarouf Hoteit, John Affronti, Qiang Cai Background: Endoscopic Retrograde Cholangiopancreatography (ERCP) is a gastrointestinal endoscopic procedure that requires fluoroscopy. The radiation dose of fluoroscopy is much higher than that of routine X-ray examinations, such as a chest X-ray. A few studies regarding radiation exposure of patients and ERCP staff during ERCP have been published in recent years. However, information about radiation exposure during each step of the procedure is not well known.AIMS: This study aimed to provide data regarding radiation exposure during specific components of ERCP, such as during the deep cannulation of the common bile duct (CBD). Methods: In the last several months, patients referred to us for their first ERCP were enrolled in this study. The fluoroscopy time before, during and post deep cannulation of the CBD in each ERCP were recorded. Results: We analyzed 46 successful ERCP procedures during the study period. Those procedures can be divided into two groups: 18 were diagnostic ERCPs and 28 were therapeutic ERCPs. The latter included obtaining cytology, performing sphincterotomy, balloon extraction, and stent insertion, etc. The mean FT before deep cannulation of the CBD was minimal, less than 0.1 minutes for each procedure in both groups. The mean FTs during the deep cannulation of the CBD were 4.5G4.1 minutes and 6.4G7.9 minutes for the diagnostic group and the therapeutic group respectively. The mean FTs for the whole procedure were 6.1G5.0 minutes and 16.2G11.0 minutes for the diagnostic group and the therapeutic groups respectively. The FT during deep cannulation of the CBD accounted for a significant portion of the whole FT in both the diagnostic group (4.5/6.1, about 74%) and the therapeutic group (6.4/16.2, about 40%). Conclusions: The radiation dose of one-minute FT is approximately 15 mGy at skin entrance which is equal to almost 100 routine chest X-rays. If the cannulation time can be reduced thereby shortening the FT during deep cannulation of the CBD, it will significantly reduce the radiation exposure during ERCP.