Stavros Dritsas

Endoscopic placement of fully covered self expanding metal stents for management of post-operative foregut leaks

BACKGROUND: Fully covered self-expanding metal stent (SEMS) placement has been successfully described for the treatment of malignant and benign conditions. The aim of this study is to evaluate our experience of fully covered SEMS placement for post-operative foregut leaks. MATERIALS AND METHODS: Retrospective analysis was done for indications, outcomes and complications of SEMS placed in homogeneous population of 15 patients with post-operative foregut leaks in our tertiary-care centre from December 2008 to December 2010. Stent placement and removal, clinical and radiological evidence of leak healing, migration and other complications were the main outcomes analyzed. RESULTS: Twenty-three HANAROSTENT® SEMS were successfully placed in 14/15 patients (93%) with post-operative foregut leaks for an average duration of 28.73 days (range=1-42 days) per patient and 18.73 days per SEMS. Three (20%) patients needed to be re-stented for persistent leaks ultimately resulting in leak closure. Total 5/15 (33.33%) patients and 7/23 (30.43%) stents showed migration; 5/7 (71.42%) migrated stents could be retrieved endoscopically. There were mucosal ulceration in 2/15 (13.33%) and pain in 1/15 (6.66%) patients. CONCLUSIONS: Stenting with SEMS seems to be a feasible option as a primary care modality for patients with post-operative foregut leaks.

Loss of hepatitis B surface antigen in a real‐life clinical cohort of patients with chronic hepatitis B virus infection

Hepatitis B surface antigen (HBsAg) clearance is the main indicator of viral cure in patients infected with the hepatitis B virus (HBV). We sought to identify the parameters associated with HBsAg loss in a well‐characterized real‐life clinical cohort of chronically HBV‐infected patients.

New indications for fully covered lumen-apposing metal stents: biliary stenting to treat post-sphincterotomy bleeding or ampullary stenosis

Stenting with standard biliary fully covered self-expandable metal stents (FCSEMSs) has been reported as successful treatment for complications after biliary sphincterotomy such as bleeding, perforation, or stenosis [1]. However, in some situations, such as a dilated common bile duct (CBD) or large sphincterotomy, these stents are not watertight, which can lead to persistent bleeding and leakage, or a malfunction [1, 2]. A new, shaped, large covered stent could be an interesting solution, with maximal radial and axial force achieving adequate local compression to allow calibration of a stenosis, hemostasis, or a watertight seal to be created [3, 4]. Here, we report our early experience with the use of these new stents in the CBD in two patients (▶Video1). The first patient was an 89-year-old woman who underwent a maximal recut after a previous sphincterotomy for residual stones in a dilated CBD. She represented 12 hours later with hypovolemic shock and melena. After resuscitation, she underwent an emergency endoscopic retrograde cholangiopancreatography (ERCP), which showed active arterial bleeding from the roof of the sphincterotomy. Injection of adrenaline, insertion of a standard 10-mm diameter FCSEMS, and forced coagulation of the visible vessel using a CoGasper did not achieve hemostasis. Because of the size of the sphincterotomy and the dilatation of the CBD, we decided to place a fully covered lumen-apposing metal stent (FCLAMS). A 4-cm×14-mm FCLAMS was successfully delivered with complete hemostasis being achieved. Bleeding did not recur and the stent was removed 5 days later without complications. The second patient was a 67-year-old man who had undergone surgical resection of the pancreatic papilla for high grade dysplasia 3 months previously. He presented with acute cholangitis due to complete anastomotic stenosis of the CBD with marked dilatation. A 3-cm× 14-mm FCLAMS was successfully delivered. The patient was discharged on day 1 and has been scheduled for removal of the stent. The present cases suggest that placement of a transpapillary FCLAMS could be an interesting alternative for treating post-sphincterotomy bleeding and to calibrate stenosis, in patients with a dilated CBD and/or a large sphincterotomy orifice.

Portography: a potentially fatal complication during endoscopic ultrasound-guided choledochoduodenostomy

Endoscopic ultrasound (EUS)-guided choledochoduodenostomy (EUS-CDS) is a safe alternative to transhepatic cholangiography when endoscopic retrograde cholangiopancreatography (ERCP) has failed or in patients with altered anatomy [1]. There are however several adverse events that can be life-threatening in some circumstances [1, 2]. A 66-year-old woman presented with obstructive jaundice secondary to advanced pancreatic cancer. A gastrojejunal anastomosis had been previously performed to bypass a long duodenal stenosis. EUS-CDS was attempted because of difficulties in reaching the papilla. Temporary duodenal stenting as a bridge to ERCP was not considered given its high failure rate in the presence of tumor infiltration [3]. Under carbon dioxide insufflation, the dilated common bile duct (CBD) was punctured and bile was subsequently aspirated. The biliary tree was opacified and a 0.0025-inch angled guidewire was inserted quite easily. A fistulotomy was performed with some temporary bleeding, which was controlled, at the puncture site. Shockingly, at the re-opacification check, the vascular portal system was recognized (▶Fig. 1), indicating that it had been catheterized, probably secondarily to erroneous guidewire manipulation. Given the absence of bleeding and the patient’s stable vital parameters, the procedure was started again, and this time was successfully performed (▶Video1). The patient’s recovery was uneventful and she left hospital 48 hours later. Opacification and/or deep cannulation of the portal vein is a rare complication of ERCP [4], which occurs mainly in patients with biliopancreatic cancer during difficult cannulation or pre-cut, and may lead to potentially fatal air embolism. Balloon tamponade, covered stenting, or surgical repair is necessary in case of large defects. Being able to recognize an erroneous catheterization during secondary opacification is mandatory and should result in the procedure being stopped immediately, not wrongly considering that it is the CBD. This is the first report of portography as a complication during EUS-CDS. Certain technical steps are important to minimize the effects of this complication: gentle manipulation during deep insertion of the guidewire, followed by a ▶ Fig. 1 Images of the re-opacification check during endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) showing opacification of the vascular portal system with medium contrast wash-out, following accidental catheterization of the portal vein due, probably, to erroneous guidewire manipulation.

Think opposite: biliary guidewire-assisted pancreatic cannulation in chronic pancreatitis for transpapillary pseudocyst drainage

Pancreatic duct cannulation in chronic pancreatitis fails in up to 10% to 30% of cases because of difficult guidewire or catheter manipulation. Synthetic porcine secretin and more challenging techniques such as EUS-guided drainage or dorsal duct cannulation have been proposed. Pancreatic guidewire-assisted biliary cannulation, also known as the double-guidewire (DGW) technique, after failure of deep cannulation of the common bile duct (CBD) was first described in 1998 by Dumonceau et al. The aim of the DGW technique is to obstruct the pancreatic orifice and facilitate deep biliary cannulation. We report the case of a 40-year-old man with chronic alcoholic pancreatitis presenting with a dilation of the Wirsung duct complicated by a 4-cm fluid pseudocyst in the body of the pancreas in communication with the pancreatic duct (Fig. 1A, B, Fig. 2). Deep cannulation of the main pancreatic duct failed despite several attempts with different angles of cannulation. Cannulation of the CBD was eventually achieved. Therefore, we decided to leave the guidewire in the CBD (Fig. 3). Afterward, because of obstruction of the biliary orifice, a more precise cannulation of the pancreatic orifice was possible,

A sessile (diminutive) polyp within a sigmoid diverticulum--EMR or observe?

Endoscopic mucosal resection (EMR) is a well-established technique for excision of colo-rectal polyps, which can be technically challenging when the polyp is inside a diverticulum, as colonic perforation may easily occur due to the lack of muscular coats. Here we report, to our knowledge, the first case of sessile (diminutive) polyp inside a diverticulum being successfully removed entirely by EMR.