-
VideoGIE : An Official Video Journal of... Jun 2024Video 1A novel method of bilateral biliary decompression by EUS-guided hepaticogastrostomy with bridging stenting using the partial stent-in-stent method for...
A novel method of bilateral biliary decompression by EUS-guided hepaticogastrostomy with bridging stenting using the partial stent-in-stent method for reintervention of multiple metal stent failure.
Video 1A novel method of bilateral biliary decompression by EUS-guided hepaticogastrostomy with bridging stenting using the partial stent-in-stent method for reintervention of multiple metal stent failure.We report a case in which anterior and posterior drainage was performed using the partial stent-in-stent method via the transpapillary approach. The patient had a bismuth type IV biliary obstruction, but only the right hepatic lobe was drained due to obstruction of the left portal vein. For the recurrent stent dysfunction, the patient underwent placement of a plastic stent within an uncovered self-expanding metal stent to correct stent dysfunction. A 7F plastic stent inside a metal stent is shown.The patient later experienced stent failure and jaundice due to tumor progression and was admitted for plastic stent replacement. Neither imaging results nor symptoms suggested duodenal stenosis. The transpapillary approach was attempted first but was unsuccessful. Duodenoscopy was challenging to perform because of duodenal stenosis. Fluoroscopy confirmed the duodenal stenosis. The plastic stent was extracted using an upper endoscope. Multiple uncovered metal stents are shown (1 stent in the anterior bile duct and 2 stents in the posterior bile duct). Jaundice did not resolve despite plastic stent removal.The patient refused to undergo percutaneous biliary drainage, so a decision was made to perform an EUS-guided hepaticogastrostomy (HGS) instead. The left bile duct was observed in the stomach. The left bile duct was punctured with a 19-gauge FNA needle. A 0.025-inch hydrophilic guidewire was directed into the left bile duct. Enhancement of the bile duct showing malignant hilar biliary obstruction (bismuth IV) is seen. Insertion of the guide wire into the posterior bile duct is shown.The stent mesh was then dilated using a balloon dilator. However, there was difficulty inserting the catheter. Additional dilation was performed using a spiral dilator. This instrument is a tapered tip dilator that fits into 0.025-inch guidewires and is expandable to 7F. Insertion of a second guidewire with a larger caliber was done to straighten the bile duct and help stabilize stent insertion. A 0.035-inch hydrophilic guidewire into the posterior bile duct using a double-lumen cannula and insertion of a 0.025-inch hydrophilic guidewire into the anterior bile duct are shown.The stent mesh was then dilated using a spiral dilator. A metal stent was placed through the anterior bile duct at a steep angle. Insertion and deployment of the first uncovered self-expanding metal stent (8 × 60 mm) from the anterior bile duct into the left bile duct is shown. Multiple metal stents were implanted into the hilar area, and the new stent was placed using the partial stent-in-stent method to prevent overexpansion. Guidewire seeking the posterior bile duct from inside the deployed stent through the stent mesh is shown.The stent mesh was then dilated using a balloon dilator. Insertion and deployment of an uncovered self-expanding metal stent (8 × 60 mm) from the posterior bile duct to the left bile duct using the partial stent-in-stent method is shown. Enhancement of the bile duct shows drainage from the right bile duct. The fistula of the HGS was only dilated with the spiral dilator. The risk of bile leakage was low, so we decided to implant a plastic stent. A 7F × 15-cm plastic stent was placed from the posterior bile duct into the stomach. Anterior and posterior segment drainage by EUS-HGS with bridging stenting using the partial stent-in-stent method is shown, with left segment drainage by EUS-HGS with the plastic stent.We performed EUS-HGS on a patient with multiple metal stents in place. There were no adverse events, and total bilirubin levels were reduced by more than half within 2 weeks. Six months have passed without stent dysfunction.
PubMed: 38887729
DOI: 10.1016/j.vgie.2024.02.015 -
Clinical Endoscopy Jun 2024Advanced pancreatic and biliary tract cancers can invade the duodenum and cause duodenal hemorrhagic stenosis. This study aimed to evaluate the efficacy of covered...
BACKGROUND/AIMS
Advanced pancreatic and biliary tract cancers can invade the duodenum and cause duodenal hemorrhagic stenosis. This study aimed to evaluate the efficacy of covered self-expandable metal stents in the treatment of cancer-related duodenal hemorrhage with stenosis.
METHODS
Between January 2014 and December 2016, metal stents were placed in 51 patients with duodenal stenosis. Among these patients, a self-expandable covered metal stent was endoscopically placed in 10 patients with hemorrhagic duodenal stenosis caused by pancreatobiliary cancer progression. We retrospectively analyzed the therapeutic efficacy of the stents by evaluating the technical and clinical success rates based on successful stent placement, degree of oral intake, hemostasis, stent patency, and overall survival.
RESULTS
The technical and clinical success rates were 100%. All 10 patients achieved a Gastric Outlet Obstruction Scoring System score of three within two weeks after the procedure and had no recurrence of melena. The median stent patency duration and overall survival after stent placement were 52 days (range, 20-220 days) and 66.5 days (range, 31-220 days), respectively.
CONCLUSIONS
Endoscopic placement of a covered metal stent for hemorrhagic duodenal stenosis associated with pancreatic or biliary tract cancer resulted in duodenal hemostasis, recanalization, and improved quality of life.
PubMed: 38872407
DOI: 10.5946/ce.2023.155 -
Wiadomosci Lekarskie (Warsaw, Poland :... 2024Aim: To improve treatment outcomes of patients with unresectable pancreatic head cancer complicated by obstructive jaundice by improving the tactics and techniques of... (Comparative Study)
Comparative Study Randomized Controlled Trial
Comparison of the clinical effectiveness of hepaticojejunostomy and self-expanding metal stents for bypassing the bile ducts in patients with unresectable pancreatic head cancer complicated by obstructive jaundice.
OBJECTIVE
Aim: To improve treatment outcomes of patients with unresectable pancreatic head cancer complicated by obstructive jaundice by improving the tactics and techniques of surgical interventions.
PATIENTS AND METHODS
Materials and Methods: Depending on the treatment tactics, patients were randomised to the main group (53 people) or the comparison group (54 people). The results of correction of obstructive jaundice by Roux-en-Y end to side hepaticojejunostomy (main group) and common bile duct prosthetics with self-expanding metal stents (comparison group) were compared.
RESULTS
Results: The use of self-expanding metal stents for internal drainage of the biliary system compared to hepaticojejunostomy operations reduced the incidence of postoperative complications by 29.9% (χ2=13.7, 95% CI 14.38-44.08, p=0.0002) and mortality by 7.5% (χ2=4.16, 95% CI -0.05-17.79, p=0.04). Within 8-10 months after biliary stenting, 11.1% (6/54) of patients developed recurrent jaundice and cholangitis, and another 7.4% (4/54) of patients developed duodenal stenosis with a tumour. These complications led to repeated hospitalisation and biliary restentation in 4 (7.4%) cases, and duodenal stenting by self-expanding metal stents in 4 (7.4%) patients.
CONCLUSION
Conclusions: The choice of biliodigestive shunting method should be selected depending on the expected survival time of patients. If the prognosis of survival is up to 8 months, it is advisable to perform prosthetics of the common bile duct with self-expanding metal stents, if more than 8 months, it is advisable to perform hepaticojejunal anastomosis with prophylactic gastrojejunal anastomosis.
Topics: Humans; Jaundice, Obstructive; Male; Female; Pancreatic Neoplasms; Middle Aged; Aged; Self Expandable Metallic Stents; Treatment Outcome; Stents; Drainage; Postoperative Complications; Jejunostomy; Adult
PubMed: 38865614
DOI: 10.36740/WLek202404102 -
Case Reports in Medicine 2024Duodenal atresia or stenosis are different degrees of the same abnormality. They usually occur at the level of the ampulla of Vater and are thought to be an embryologic...
BACKGROUND
Duodenal atresia or stenosis are different degrees of the same abnormality. They usually occur at the level of the ampulla of Vater and are thought to be an embryologic defect during the development of the foregut, leading to abnormal recanalization. Complete duodenal atresia is usually symptomatic in the early neonatal period, while partial obstruction (web, stenosis) may have a late presentation and a more challenging diagnosis such as in our case. . The patient, a 16-year-old girl, presented with abdominal pain, recurrent vomiting, and growth failure. An upper GI study with barium showed an image compatible with gastroptosis. Further diagnostic procedures confirmed a rare finding such as congenital duodenal stenosis. She underwent surgical intervention, and the recovery period was uneventful.
CONCLUSION
Gastroptosis is not diagnostic for a particular disease. This rare radiological finding in children may obscure uncommon diagnosis, such as congenital duodenal stenosis, which can present a diagnostic challenge beyond early childhood.
PubMed: 38736458
DOI: 10.1155/2024/1070253 -
Nihon Shokakibyo Gakkai Zasshi = the... 2024A 67-year-old man presented to our hospital with vomiting. Esophagogastroduodenoscopy revealed duodenal stenosis and atypical epithelium. A tumor in the pancreatic head,...
A 67-year-old man presented to our hospital with vomiting. Esophagogastroduodenoscopy revealed duodenal stenosis and atypical epithelium. A tumor in the pancreatic head, about 30mm in size, involving the superior mesenteric artery and a superior mesenteric vein was identified using abdominal contrast computed tomography (CT). Locally advanced pancreatic cancer was diagnosed in the patient through an endoscopic biopsy. Due to the duodenal stenosis complication, duodenal stent placement was conducted. After stent placement, oral intake was resumed, and improvement of the systemic condition led to chemotherapy (modified FOLFIRINOX). After chemotherapy, CT revealed decreased carcinoma progression and vascular invasion. Conversion surgery was improved, and R0 resection was achieved. Our study showed that duodenal stent placement could enhance prognosis;as a result, it was regarded as a good choice for multidisciplinary therapy.
Topics: Humans; Male; Aged; Pancreatic Neoplasms; Stents; Duodenal Obstruction
PubMed: 38735749
DOI: 10.11405/nisshoshi.121.407 -
International Journal of Surgery Case... Jun 2024Congenital causes of duodenal obstruction can be grouped into intrinsic and extrinsic causes. The degree of obstruction caused by such etiologies determines the severity...
INTRODUCTION
Congenital causes of duodenal obstruction can be grouped into intrinsic and extrinsic causes. The degree of obstruction caused by such etiologies determines the severity and timing of symptom presentation. Early neonatal diagnosis is common in patients with etiologies that present with high degrees of obstruction such as atresia whereas etiologies that cause lesser degrees of obstruction such as malrotation and duodenal stenosis can go undiagnosed into adulthood.
PRESENTATION OF CASE
We report a case of a 24-year-old female who presented with acute on chronic abdominal pain with bilious vomiting. She was diagnosed with intermittent small bowel volvulus which resolved spontaneously but was found to have adult intestinal malrotation diagnosed intraoperatively. She had a Ladd procedure done but had persistent obstructive small bowel symptoms after the Ladd procedure. She was found to have duodenal stenosis from fibrosis of the duodenum on relaparotomy which was treated surgically with Heineke-Mikulicz strictureplasty leading to total resolution of symptoms.
DISCUSSION
Congenital extrinsic and intrinsic causes of partial duodenal obstruction such as Ladd bands in malrotation and duodenal stenosis respectively, can co-exist and persist into adulthood due to their lesser symptomatology and degree of obstruction. Surgical treatment must identify and correct both conditions when they co-exist to ensure complete resolution of symptoms.
CONCLUSION
This case report highlights the association of duodenal stenosis with adult malrotation which may account for persistent symptoms after the Ladd procedure and suggests the use of Heineke-Mikulicz strictureplasty as a complementary procedure for complete symptom resolution.
PubMed: 38703614
DOI: 10.1016/j.ijscr.2024.109713 -
Frontiers in Pediatrics 2024Eosinophilic gastrointestinal diseases (EGIDs) are rare, chronic inflammatory disorders characterized by eosinophilic infiltration of the gastrointestinal tract....
Eosinophilic gastrointestinal diseases (EGIDs) are rare, chronic inflammatory disorders characterized by eosinophilic infiltration of the gastrointestinal tract. Symptoms and clinical presentations vary depending on the site and layer of the gastrointestinal wall infiltrated by eosinophils. Gastrointestinal obstruction is a serious, though uncommon, presentation. Management can be extremely challenging because of the rarity of the condition and the lack of robust scientific evidence. Current treatment approaches for EGIDs mainly focus on elimination diets, proton pump inhibitors and corticosteroids, which present high refractoriness rates. Novel targeted therapies are being investigated but not routinely used. Surgery should be avoided as far as possible; however, it may be the only option in gastrointestinal obstruction when long-term remission cannot be attained by any medical strategy. Herein we report the case of an adolescent boy affected by an eosinophilic gastrointestinal disease with progressive duodenal stenosis, refractory to medical therapy, who successfully benefitted from surgical management. He presented with a one-year history of gastrointestinal obstructive symptoms with feeding intolerance. After the diagnostic workup, he was diagnosed with an eosinophilic gastrointestinal disease (esophagitis and enteritis) with a duodenal involvement causing a progressive duodenal stenosis. Due to refractoriness to the conventional medical therapies and the consequent high impact on his quality of life, related both to the need for enteral nutrition and repeated hospitalizations, we decided to perform a gastro-jejunum anastomosis, which allowed us to obtain a clinical and endoscopic long-term remission. The early discussion of the case and the involvement of all experienced specialists, pediatricians and pediatric surgeons is essential.
PubMed: 38699150
DOI: 10.3389/fped.2024.1390946 -
Surgical Endoscopy Jun 2024Laparoscopic repair of duodenal atresia (LRDA) remains a technically challenging procedure and its benefits ambiguous. To assess the safety and efficacy of LRDA, we... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Laparoscopic repair of duodenal atresia (LRDA) remains a technically challenging procedure and its benefits ambiguous. To assess the safety and efficacy of LRDA, we performed a systematic review of techniques and material for LRDA and a meta-analysis comparing outcomes with open repair (OR).
METHODS
Comprehensive search of EMBASSE, PubMed and Cochrane was performed from 2000 to 2023. Studies comparing LRDA with OR were identified and outcomes extracted included operative time, time to enteral feeds, length of hospitalisation, anastomotic leaks and stricture and total complications. χ was used to assess associations between complications and conversions rates of different LRDA approaches (laparoscopic technique, suturing technique). Comprehensive meta-analysis was used for Meta-analysis.
RESULTS
Twelve studies were identified and 1731 patients were enrolled in the study (398 [LRDA] and 1325 [OR]). Total rate of complications and conversion for LRDA was 15.58% and 18.84%, respectively. Complication rates were not significantly affected by operative technique and suturing technique. Conversion rates were not significantly affected operative technique; using a combination of interrupted and running suturing was significantly higher than using running or interrupted (χ = 7.45, p < 0.05). Anastomotic leaks, strictures and total complications were equivocal between LRDA and OR (OR 1.672, 95% CI 0.796-3.514; OR 2.010, 95% CI 0.758-5.333; OR 1.172, 95% CI 0.195-7.03). Operative time was significantly greater for LRDA (SDM 1.035, 95% CI 0.574-1.495, p < 0.001). Time to initial and full enteral feeds and length of hospitalisation were shorter in the LRDA group (SDM - 0.493, 95% CI - 2.166 to 1.752, p = 0.466; SDM - 0.207, 95% CI - 1.807 to 0.822, p = 0.019; SDM - 0.111, 95% CI - 1.101 to 0.880, p = 0.466, respectively).
CONCLUSIONS
LRDA showed equivalent complication rates compared to OR with an additional benefit of quicker establishment of feeds. There was no significant difference in complication and conversion rates between laparoscopic techniques. Despite a longer operative time, LRDA provides a safe minimal access approach for neonates after this consistent implementation of the technique in the past decade.
Topics: Humans; Laparoscopy; Intestinal Atresia; Duodenal Obstruction; Operative Time; Postoperative Complications; Suture Techniques; Anastomotic Leak; Length of Stay; Treatment Outcome
PubMed: 38658389
DOI: 10.1007/s00464-024-10828-5 -
Archives de Pediatrie : Organe Officiel... Apr 2024
Topics: Humans; Esophageal Atresia; Anorectal Malformations; Duodenal Obstruction; Intestinal Atresia
PubMed: 38485570
DOI: 10.1016/j.arcped.2023.10.013 -
Endoscopy Dec 2024
Transpapillary biliary drainage using a forward-viewing endoscope for distal malignant biliary obstruction after placement of a duodenal stent for type I duodenal stenosis.
Topics: Humans; Duodenal Obstruction; Stents; Endoscopes; Drainage; Cholestasis; Intestinal Atresia
PubMed: 38485156
DOI: 10.1055/a-2271-6994