Michele Amata

Definitive outcomes of self-expandable metal stents in patients with refractory post-transplant biliary anastomotic stenosis.

BACKGROUND Endoscopic retrograde cholangio-pancreatography is the gold standard of treatment in patients with biliary complications after liver transplantation. The benefits of fully covered self-expandable metal stents (FCSEMS) lie in their relative simplicity and the need for only two procedures, one for insertion, and the other for removal. Several case series have been published on such stents with generally good outcomes. Objective is to analyze definitive long-term outcomes of this treatment. METHODS Prospective, observational study in a single, tertiary-care referral centre. All consecutive patients with post-transplant biliary stenosis/leak were treated with FCSEMS after failure of conventional treatment. Recurrence was evaluated after four years. RESULTS From February 2008 to April 2012, 70 patients were included. In all patients, the metal stent was successfully placed. After a mean of 86.7 ± 38.4 days, the stent was removed. Forty-six patients (65.7%) showed resolution. After a mean of 4 ± 1.2 years, 61% of patients maintained the results, but 39% showed recurrence. On the tested variables the diagnosis of stenosis, the number of previous procedures and plastic stents placed correlate with better long-term results. CONCLUSIONS This series suggests a lack of long-term advantages of FCSEMS over plastic stents in the management of biliary stenosis after liver transplantation.

Esophagojejunal anastomotic dehiscence successfully repaired by endoluminal suture and stent positioning: Report of a mini-invasive approach

A 32-year-old gentleman underwent a laparoscopic wedge resection of the stomach for gastrointestinal stromal tumor, with subsequent anastomotic dehiscence treated with urgent surgical revision. Following acute abdominal pain and severe sepsis, the patient was directly referred for a total gastrectomy with esophago-jejunal anastomosis. This article is protected by copyright. All rights reserved.

Chronic tracheoesophageal fistula successfully treated using Amplatzer septal occluder

Tracheoesophageal fistula (TEF) is a serious life-threatening condition that appears in critically ill patients with a prolonged history of mechanical ventilation. Enteral feeding and dietary support combinedwith surgery is the gold standard. In selected patients, TEF healing can be ensured by a mini-invasive approach using an Amplatzer septal occluder (AGA Medical Corporation), intended for cardiac septal defect closure [1]. The Amplatzer septal occluder, which is composed of a nitinol mesh, has two self-expandable disks connected by a thin diameter waist (▶Fig. 1) and ensures mechanical closure of the two sides of the fistula, making a potential platform for subsequent tissue ingrowth [2]. This technique was used in a 44-year-old man with tracheostomy and a history of protracted invasive lung support. He had been diagnosed as having a TEF after numerous episodes of aspiration pneumonitis and had subsequently undergone anterior cervicotomy with surgical closure of the fistula. After 7 months, his dysphagia relapsed. Endoscopy confirmed recurrence of the TEF (▶Fig. 2), which was initially treated unsuccessfully by submucosal injection of acrylic glue. Given the poor clinical condition of the patient and the failure of both surgical and endoscopic therapy, it was decided to try positioning of an Amplatzer septal occluder (▶Video1). The procedure was performed using a gastroscope (GIF-1TH190; Olympus Europe) and a bronchoscope (BF-1T180; Olympus Europe). The TEF was cannulated using a papillotome (TRUETome; Boston Scientific) and a 0.025-inch guidewire (Jagwire; Boston Scientific) was inserted into the bronchial segment. The wire was then grasped with a biopsy forceps (Endo-Jaw; Olympus Europe) passed through the bronchoscope, providing countertraction by maintaining a straightened position. The septal occluder catheter was introduced and the two ends were released into the trachea and esophagus, respectively (▶Fig. 3). Successful closure of the TEF was confirmed by contrast medium injection (▶Fig. 4). The procedure was uneventful. E-Videos

Salvage procedure following lumen-apposing metal stent maldeployment during endoscopic ultrasound-guided biliary drainage

A jaundiced 82-year-old-woman was diagnosed with a cephalopancreatic, locally advanced adenocarcinoma. Endoscopic retrograde cholangiopancreatography was planned, but biliary cannulation was not achieved because of a large periampullary diverticulum (▶Fig. 1). We therefore decided to perform endoscopic ultrasound (EUS)-guided biliary drainage using an 8-mm electrocauterytipped lumen-apposing metal stent (LAMS; AXIOS-EC, Boston Scientific, Marlborough, Massachusetts, USA). The dilated common bile duct (CBD) (▶Fig. 2) was accessed from the bulb under EUS guidance with the electrocautery-tipped delivery system in a “freehand” fashion [1]. The distal flange did not fully expand because the tip of the catheter was too close to the facing wall of the CBD in an oblique direction, leaving insufficient room for the stent to fully open (▶Fig. 3). To secure the access to the CBD, a guidewire was inserted through the catheter into the biliary tree (▶Fig. 3). To allow the distal flange to fully open, the catheter was slightly withdrawn; however, the stent slid out of the CBD, with the fully released flange, into the abdominal cavity (▶Fig. 4). The catheter was then retrieved, and the open flange was re-sheathed by repositioning the stent deployment hub to the original position (▶Video1). The delivery system was reinserted over the wire, under endoscopic view, into the CBD without any further device energizing. The distal flange was then deployed under EUS view, and the proximal flange under endoscopic view (▶Fig. 5). Cholangiography confirmed that the stent was in place. The post-procedural course was uneventful. Stent maldeployment during EUS-guided biliary drainage is a severe adverse event. In cases where the CBD is not well dilated, with the potential for subsequent difficulty in stent deployment, the preventive placement of a through-the-stent guidewire is advisable. The described salvage procedure avoids the need for a second access to the CBD, maintaining the same route with a guidewire, and reintroducing the re-sheathed stent. This avoids the ▶ Fig. 1 Endoscopic view of the major papilla located on the inferior margin of the diverticulum (*). The common bile duct could not be cannulated with the guidewire because of marked tortuosity of the distal part. ▶ Fig. 2 Endoscopic ultrasound view of a 40-mm solid inhomogeneous hypoechoic lesion with irregular borders (*) in the head of the pancreas, infiltrating the portal vein (arrow) and the intrapancreatic common bile duct, and dilated up to 18mm at the upper/middle third (**). ▶ Fig. 3 Fluoroscopic view of the maldeployed distal flange of the stent inside the common bile duct (CBD). The tip of the releasing catheter (arrow) of the stent is closely facing the distal wall of the CBD (dashed white line), resulting in a slight kinking of the catheter axis (dashed red line). A 0.035-inch guidewire was inserted through the stent catheter to secure the access to the CBD.

Buried lumen-apposing metal stent (LAMS) following endoscopic ultrasound-guided gallbladder drainage: the LAMS-in-LAMS rescue treatment

A 70-year-old woman with jaundice who had been diagnosed with unresectable malignant distal biliary stricture underwent endoscopic ultrasound (EUS)-guided gallbladder drainage following failed endoscopic retrograde cholangiopancreatography (ERCP). EUS-guided bile duct drainage was impractical because of the presence of an intervening vessel, and an EUS-guided cholecystogastrostomy was created with placement of an 8×8-mm lumen-apposing metal stent (LAMS) [1]. After 1 month, the patient complained of a recurrence of her jaundice and was scheduled for follow-up endoscopy. This revealed that the proximal flange of the stent was completely buried in the gastric wall (▶Fig. 1). A linear echoendoscope was then used, and a bending cannula (SwingTip; Olympus) was smoothly inserted through the fistula into the buried LAMS under combined fluoroscopic guidance. Injection of contrast medium revealed a distended gallbladder and slightly dilated intrahepatic biliary tree with no contrast leakage, confirming that the distal flange was still in the correct place (▶Fig. 2). A 0.035-inch guidewire was then passed through the cannula and coiled within the gallbladder. The delivery catheter of a 10×10-mm electrocautery-tipped LAMS (AXIOS-EC; Boston Scientific) was advanced over the wire into the gallbladder without energizing the device (▶Video1). The distal flange of the second LAMS was deployed in the gallbladder beyond the distal flange of the buried LAMS under fluoroscopic guidance. Slight traction was applied on the endoscope–stent coupled system, which allowed the proximal flange of the second LAMS to be deployed in the gastric cavity under endoscopic vision (▶Fig. 3). A through-the-LAMS-in-LAMS cholangiogram confirmed that the stent was correctly in place and that there was no contrast leakage. The post-procedure course was uneventful. A buried LAMS is a rare complication, previously reported for various indications and managed, when possible, by endoscopic stent removal [2–4]. In fact, stent removal is not only a technically demanding procedure but also, in the setting of biliary drainage, it increases the risk of bile leakage and subsequent peritonitis. The above-described LAMS-in-LAMS technique allows the endoscopist to recreate a safe drainage conduit without the need to remove the buried stent. ▶ Fig. 1 The buried stent is seen in the wall of the gastric antrum: a on endoscopic view, showing the proximal flange of the lumen-apposing metal stent completely buried in the gastric wall with a 2-mm fistulous orifice visible on the covering tissue overgrowth (arrow); b on endoscopic ultrasound view, showing the proximal flange (arrowheads) within the gastric wall; a clearly visible hypoechoic gastric muscular layer (*); and the distal flange in place in the gallbladder (arrow).

Endoscopic ultrasound-guided angiotherapy in refractory gastrointestinal bleeding from large isolated gastric varices: a same-session combined approach

A 36-year-old Asian man with severe portal hypertension due to hepatitis B virusrelated cirrhosis had been previously treated for acute gastrointestinal bleeding from a large isolated gastric varix (IGV-1) by injection of endoscopic cyanoacrylate glue at a local hospital (▶Fig. 1). Following an episode of massive recurrent hematemesis, the patient was hemodynamically stabilized and referred to our institute. Radiological evaluation revealed the presence of numerous collaterals in the gastric fundus with a large-caliber splenorenal shunt. With the patient under general anesthesia, it was found that the portal gradient did not decrease significantly with a transjugular intrahepatic portosystemic shunt (TIPS) positioned across the left hepatic and left intrahepatic veins [1], confirming that blood outflow was predominantly diverted towards the shunt (▶Fig. 2 a). We then decided to use a same-session combined technique involving balloon-occluded retrograde transvenous obliteration (B-RTO) of the left renal vein [2] and selective endoscopic ultrasound (EUS)-guided variceal embolization [3, 4] by coils and n-butyl2-cyanoacrylate (CYA) injection. A B-RTO was performed to obliterate the left renal vein before EUS-guided selective treatment in order to protect the pulmonary circulation from systemic embolization (▶Fig. 2b). Gastric varices (IGV-1) were then visualized from the stomach with a linear-array echoendoscope. Selective EUS-guided intravascular puncture was performed with a 22-gauge fine needle aspiration (FNA) needle (EZ Shot 3 Plus; Olympus Europe) and three 0.018-inch coils (MReye Embolization Coil; Cook Medical) were released through the needle under EUS and fluoroscopic control (▶Video1), the endovascular coils being advanced into the targeted vessel using the pushing acEndoscopy E-Videos E-Videos

Novel lumen-apposing stent to treat benign esophageal stricture

A 58-year-old patient underwent an esophageal epiphrenic diverticulum resection with a video thoracoscopic approach. The surgery was complicated by an esophageal pleural fistula, which was successfully treated using a fully covered self-expandable metal stent. One week after stent removal the patient experienced dysphagia and vomiting. The endoscopy showed a short esophageal stenosis in the proximal esophagus about 25 cm from the dental arch (▶Fig. 1 a). Two consecutive endoscopic hydropneumatic balloon dilations of the stenosis were attempted but failed, as the stenosis recurred. In order to achieve the desired dual effect of maintaining the patency of the esophageal lumenwhile continuing dilation, we decided to place a novel lumen-apposing fully covered metal stent (Spaxus stent– body diameter 16mm, flare diameter 31mm, length 20mm; Taewoong Medical Co., Gyeonggi-do, South Korea) (▶Fig. 2). Under endoscopic and fluoroscopic guidance, we released the stent across the stricture (▶Fig. 1b, ▶Video1). The contrast dye injection showed correct placement of the stent, which kept the esophageal lumen open. The patient was fed a liquid diet 24 hours later, and 1 week later, the patient started a semiliquid diet. At 2 months after stent placement, using crocodile tooth forceps, we grasped the knot situated in the proximal flange of the stent and retrieved the stent (▶Fig. 1 c). There were no periprocedural or delayed adverse events. Following removal of the stent, the patient was put on a normal diet. The post-treatment 6-month follow-up showed no recurrence (▶Fig. 1 d). Refractory benign esophageal strictures can be a challenge for clinicians. After failure of standard therapeutic options, E-Videos

Enteroscopy-Overtube-Assisted Over-the-Wire Stent Placement to Treat an Enteral Stenosis

A 77-year-old man underwent duodeno-cephalo-pancreatectomy with Roux-en-Y reconstruction for pancreatic head cancer. After two years developed recurrent cholangitis with obstructive jaundice. In suspicion of obstruction of biliary tree, a percutaneous transhepatic cholangiography (PTC) was attempted. Contrast dye injected troughs the catheter shower an intestinal stenosis about 10 centimeters above the bilio-enteric anastomosis. Following PET-CT scan showed no cancer recurrence. This article is protected by copyright. All rights reserved.