Vinay Sundaram

Temporary placement of covered self-expandable metal stents in benign biliary strictures: a new paradigm? (with video)

BACKGROUND Benign biliary strictures (BBS) are usually managed with plastic stents, whereas placement of uncovered metallic stents has been associated with failure related to mucosal hyperplasia. OBJECTIVE We analyzed the efficacy and safety of temporary placement of a covered self-expanding metal stent (CSEMS) in BBS. DESIGN Patients with BBS received temporary placement of CSEMSs until adequate drainage was achieved; confirmed by resolution of symptoms, normalization of liver function tests, and imaging. SETTING Tertiary-care center with long-standing experience with CSEMSs. PATIENTS Seventy-nine patients with BBS secondary to chronic pancreatitis (32), calculi (24), liver transplant (16), postoperative biliary repair (3), autoimmune pancreatitis (3), and primary sclerosing cholangitis (1). INTERVENTION ERCP with temporary CSEMS placement. Removal of CSEMSs was performed with a snare or a rat-tooth forceps. MAIN OUTCOME MEASUREMENTS End points were efficacy, morbidity, and clinical response. RESULTS CSEMSs were removed from 65 patients. Resolution of the BBS was confirmed in 59 of 65 patients (90%) after a median follow-up of 12 months after removal (range 3-26 months). If patients who were lost to follow-up, developed cancer, or expired were considered failures, then an intent-to-treat global success rate of 59 of 79 (75%) was obtained. Complications associated with placement included 3 post-ERCP pancreatitis (4%), 1 postsphincterotomy bleed (1%), and 2 pain that required CSEMS removal (2%). In 11 patients (14%), the CSEMS migrated. In 1 patient, CSEMS removal was complicated by a bile leak that was successfully managed with plastic stents. LIMITATION Pilot study from a single center. CONCLUSIONS Temporary CSEMS placement in patients with BBS offers a potential alternative to surgery.

Endoscopic ultrasound staging is adversely affected by placement of a self-expandable metal stent: fact or fiction?

Objectives: Accurate preoperative staging of pancreatic cancer (Pca) is crucial to direct management. There is a perception that endoscopic ultrasound (EUS) staging should be performed before biliary decompression because of artifact caused by self-expandable metal stents (SEMS). Our aim is to determine whether placement of SEMS affects the staging of Pca. Methods: Fifty-five patients (35 men; mean age, 67 years) with newly diagnosed Pca staged in the last 5 years and captured prospectively were divided into 2 groups matched by age, sex, and final staging. The staging accuracy of EUS in patients who had a SEMS (n = 28) was compared with patients without a SEMS (n = 27). The gold standard was surgical pathology, or cytologic confirmation of metastatic disease. Multivariate analysis was effected on age, sex, presence of SEMS, and presence of metastasis to assess prediction of staging inaccuracy. Results: Endoscopic ultrasound correctly staged 14 (52%) of 27 patients in the no-SEMS group and 13 (46%) of 28 in the SEMS group. Logistic regression analysis identified only metastasis as a predictor of inaccuracy in EUS staging. Conclusions: Endoscopic ultrasound staging of Pca does not seem to be affected by the presence of a SEMS. The major reason for misstaging in both groups was failure to detect metastatic disease.

Severe Prolongation of the INR in Spur Cell Anemia of Cirrhosis: True-True and Related?

Prothrombin time (PT), an in vitro test of coagulation based on levels of extrinsic pathway factors II, V, VII, X, and fibrinogen, is determined by adding a thromboplastin reagent to citrated plasma and recording the time needed for clotting to occur. Clinical uses of the PT include monitoring patients undergoing coumadin therapy and in assessing vitamin K or extrinsic factor pathway deficiencies. In liver disease patients, the PT is an integral part of several prognostic scores including the Child-Pugh classification (1) and the Model for End Stage Liver Disease (MELD) scoring system. The international normalized ratio (INR), introduced by the World Health Organization in 1983, was developed in order to correct variation which occurred in measuring PT, due to the use of different thromboplastin reagents (1, 2). It is calculated as the patient’s PT value divided by the mean normal PT value, raised to the power of the International Sensitivity Index, thereby standardizing the PT against a common international reference preparation. Although the INR is an accurate means of measuring anticoagulation for patients taking coumadin (3), there have been no studies demonstrating its precision in evaluating bleeding risk in liver disease. Studies have in fact reported the contrary, showing that the INR poorly correlates with bleeding risk (4, 5) and additionally varies among the same plasma sample, depending on the reagent used (6–8). We present a case of a cirrhotic patient admitted with severe spur cell anemia whose PT-INR rose

Placement of Covered Self Expandable Metallic Stents in Patients with Biliary Leak: a Pilot Study

Placement of Covered Self Expandable Metallic Stents in Patients with Biliary Leak: a Pilot Study Michel Kahaleh, Vinay Sundaram, Sarah A. De La Rue, Joshua D. Hall, Andrew Brock, Jeffrey L. Tokar, Charles M. Friel, Eugene F. Foley, Reid B. Adams, Paul Yeaton Background: Current management of biliary leaks includes ERCP and biliary stenting. Some biliary leaks can nevertheless be challenging and time consuming to treat when using plastic stents, and successful treatment may require a combination of techniques. The ability to place a removable partially covered self-expandable metallic stent (SEMS) may be advantageous in the treatment of biliary leaks, regardless of their location or etiology. The SEMS could easily be deployed to either cover the leak itself or to induce a significant decrease of pressure gradient at the ampullary level, permitting resolution of a duct of Luschka leak. Methods: Eight patients with biliary leaks were considered for covered SEMS placement. Preprocedure diagnosis included duct of Luschka leak (n Z 4), leak from partial cholecystectomy (n Z 2), stump leak (n Z 1) and anastomotic leak post liver transplant (n Z 1). Efficacy, morbidity and clinical response were used as endpoints. Results: SEMS were left in place for a median time of 3 months (range: 1-4) and were removed with a snare (four patients) or a rat tooth technique (three patients), while one patient spontaneously passed the SEMS. Median time of followup post removal was 4.5 months (range: 1-8). Only one patient with partial cholecystectomy relapsed and required drainage. No patient experienced complication for either placement or removal of the SEMS. Conclusion: Temporary placement of covered SEMS when a bile leak occurs offers a potential alternative to conventional ERCP with plastic stenting, and merits further investigation. A randomized study comparing both techniques should be performed.