Introduction

Although biliary plastic stents (BPS) are frequently utilized in ERCP procedures, their effectiveness and associated complications can vary significantly. This study aimed to determine the risk factors associated with BPS patency within our patient population.

Aims & Methods

We conducted a retrospective analysis of patients who underwent endoscopic cholangiopancreatography (ERCP) at our facility from January 2021 to December 2022, excluding those with a malignant cause. The study included patients who underwent at least one ERCP reintervention within the past 23 months and received a biliary plastic stent during their initial ERCP

Results

Over a period of two years, our Gastroenterology department performed a total of 1354 procedures, with 1077 of these being for benign conditions. Of the 1077 benign cases, 212 (19.7%) required reintervention due to their etiology, and therefore had biliary plastic stents placed previously.
Out of a total of 212 subjects, 45% were male and had a mean age of 68.36±14.96 years. Among these subjects, choledocholithiasis was found to be the cause of obstruction in 81.1% of cases, common biliary duct stenosis in 9.5% of cases, chronic pancreatitis in 7% of cases, and other causes in 2.4% of cases.
The median interval between the initial procedure and the reintervention was 90 (1-1095) days. Acute cholangitis was the reason for reintervention in 32% (68/212) of the subjects, with 34% of them having Tokyo grade 3 cholangitis. In univariate regression analysis, the following factors were identified as independent predictors of cholangitis in patients with biliary plastic stents: total bilirubin levels, AST levels, ALT levels, number of days until reintervention, and CRP levels (p<0.05)

Conclusion

Within our cohort, 19.7% of patients required a reintervention for a benign condition following the initial placement of a biliary plastic stent. Of these patients, 32% experienced acute cholangitis as a reason for the reintervention. Our findings revealed that acute cholangitis in patients with biliary plastic stents was associated with days until reintervention, TGO levels, TGP levels, total bilirubin levels, and CRP levels.

Introduction

The use of lumen-apposing metal stents (LAMS) in therapeutic endoscopy has significantly increased in recent years due to their expanding role in a variety of procedures, such as drainage of pancreatic fluid collections, endoscopic ultrasound (EUS)-guided choledochoduodenostomy, EUS-guided gallbladder drainage, gastro-enteric anastomoses, or abscess drainage.

Aims & Methods

This study aims to analyze the spectrum of indications and complication rates between 2016 and 2024. It includes a retrospective analysis of all patients who received LAMS at our center during this period.

Results

A total of 201 LAMS placements were performed: 82 for biliary drainage, 69 for peripancreatic collections, 41 for gastric outlet obstruction, 8 for abscesses, and 1 for endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE). Initially, LAMS were primarily used for the drainage of collections; however, in recent years, anastomoses have become the predominant indication. Overall, we performed 124 anastomoses (61.7%) over the observation period. Among the patients, 86 (42.8%) had malignancies necessitating LAMS placement.
The overall complication rate was 7.5% (15 cases): 6 cases of primary stent maldeployment, 5 bleeds, 2 infections related to walled-off necrosis (WON)/LAMS obstruction, and 2 buried stents. Three patients required surgery, and one underwent radiological embolization for a leak from a splenic artery pseudoaneurysm. No 30-day mortality was observed, although one patient died 65 days post-drainage, 36 days after LAMS extraction, due to splenic artery bleeding.

Conclusion

LAMS use has evolved substantially at our institution, shifting from drainage to anastomotic applications, with EUS-guided gallbladder drainage now being the most common procedure.
Despite the broad spectrum of indications, the complication rate remained low (7.5%) and was managed non-surgically in 80% of cases.
These findings support continued expansion of LAMS in therapeutic endoscopy.

Introduction

Endoscopic biliary stenting is a well–established therapy in the management of hepatobiliary diseases. However, migration is reported in 5%-10% of cases. Management of proximally migrated stents using standard techniques(guidewire cannulation, snare, forceps, Schohenra stent retriever) can be technically challenging sometimes. Cholangioscopy and retrieval under direct visualization could be a useful tool in such difficult cases.

Aims & Methods

To evaluate the application of single-operator cholangioscopy in the management of proximally migrated biliary stents in terms of efficacy and safety.
Methods:We performed a retrospective analysis of the data of a prospective group of patients. The cohort included consecutive 100 cases of proximally migrated stents from January 2018 through March 2024. We evaluated the retrieval technique, success rate, and adverse events.

Results

Patients were divided into two groups. In the first collective of patients- cholangioscopy was not performed n=62/62%/. We found a technical success rate – defined as successful stent extraction in 69,35% of cases/n=43/. In 19 of the cases removal was not achieved, followed by placement of new plastic stent n=19/30.65%/.In the second group, n=38/38%/ cholangioscopy with single operator cholangioscope was the retrieval technique with a technical success rate of 100%. There was a statistical difference between the two groups in terms of technical success in favor of the group with cholangioscopy - Pearson chi-square χ 2 =21.534, p< 0.001. Cholangioscopy was performed either after the failure of standard techniques or as the first-choice tool for stent removal. In five cases we performed pancreatoscopy for extraction of migrated pancreatic stents with only one case of postprocedure pancreatitis. We experienced adverse events/AE/ in 17 cases as pancreatitis was the most common complication n=11/64,71% of all AE/, followed by cholangitis n=5/29,41% of all AE/ and one case of bleeding n=1/5,88%/. In the first group, the rate of adverse events was 17,74%/n=11/ against 13,95%/n=6/ for the second group. There was no significant statistical difference in the rate of AE between the two groups. The mean procedure duration was 34,35 minutes for the first group and 42,24 minutes for the second with a statistically significant difference p=0.029 in favor of the first group. However, it is important to note that in some cases cholangioscopy was performed after the failure of standard techniques which by ilself prolonged the procedure time.

Conclusion

Cholangioscopy is a safe and effective technique for the extraction of migrated biliary stents with a high rate of efficacy and an acceptable rate of adverse events. It could be proposed as a first choice in cases where failure of standard techniques is suspected/persistent stenosis, residual bile duct stones/.

Introduction

Anastomotic biliary strictures represent a significant burden after orthotopic liver transplantation, with challenging endoscopic treatment. The selection of the optimal approach regarding type of stents remains controversial due to the absence of strong evidence. The European Society of Gastrointestinal Endoscopy recommends stricture remodeling using multiple plastic stents (MPS),¹ whereas the American College of Gastroenterology supports the use of fully covered self-expandable metal stents (FC-SEMS),² as for every benign biliary stricture. In the absence of cumulative comparisons and considering the development of intraductal SEMS (ID-SEMS), which are promising for this type of strictures, this systematic review with meta-analysis aimed to evaluate the potential differences in the performance of the available stents in post-transplant anastomotic biliary strictures management.

Aims & Methods

The systematic research was performed in MEDLINE, Cochrane, and Scopus databases until April 2023 for comparative studies evaluating the successful stricture management using MPS and SEMS, including FC-SEMS and ID-SEMS. The primary outcome was stricture resolution after completion of therapy, documented by cholangiogram or cross-sectional imaging. Secondary outcomes included stricture recurrence (clinical and biochemical relapse with imaging confirmation) during the follow-up period, stent migration and adverse events. Quality assessment was based on the Newcastle-Ottawa scale. Meta-analyses were based on random effects model and the results were reported as odds ratios (OR), with 95% Confidence Intervals (95%CI). Subgroup analyses by type of metal stent were performed to explore the diversity among the results of different studies.

Results

Nine studies with an overall number of 687 patients were included in our analysis, with three of them being randomized controlled trials. Metal stents were placed in 251 cases (82 ID-SEMS and 169 FC-SEMS) and MPS in 436. Considering the primary outcome, metal and plastic stents did not differ significantly in stricture resolution with OR: 0.99 (95%CI: 0.48-2.01; I²=35%). Stricture recurrence and migration rates were also comparable between the two arms [OR: 1.71 (95%CI: 0.87-3.38; I²=55%) and OR: 0.73 (95%CI: 0.32-1.68; I²=56%) respectively]. All of these outcomes presented with moderate heterogeneity. Finally, the difference between adverse events rates was non-significant [OR: 1.47 (95%CI: 0.89-2.43; I²=24%)]. Interestingly, in the subgroup analysis ID-SEMS provided significantly higher complete resolution rates with low heterogeneity compared to the MPS [OR: 3.48 (95%CI: 0.89-13.62; I²=5%)], whereas the comparison between FC-SEMS and MPS did not reach significance [OR: 0.76 (95%CI: 0.42-1.39; I²=11%)]. Relative recurrence rates did not differ between subgroups [for ID-SEMS vs MPS, OR: 1.01 (95%CI: 0.51-2.03; I²=0%; for FC-SEMS vs MPS, OR:2.39 (95%CI: 0.87-6.56; I²=66%)]. On the other hand, migration rates were significantly lower for ID-SEMS compared to MPS, with OR: 0.28 (95%CI: 0.11-0.70; I²=0%), and equivalent for FC-SEMS and MPS [OR: 1.25 (95%CI: 0.54-2.88; I²=40%)]. Complication rates were similar for ID-SEMS and MPS [OR: 0.90 (90%CI: 0.28-2.84; I²=47%)], but their prevalence after FC-SEMS were significantly higher compared to MPS [OR: 1.76 (95%CI: 1.06-2.93; I²=0%)].

Conclusion

The comparison between metal stents and MPS did not result to significant differences in any outcome. However, ID-SEMS appeared superior to MPS in stricture resolution and migration rates, whereas FC-SEMS provided comparable outcomes to MPS.

References

1. Dumonceau JM, Tringali A, Papanikolaou I, Blero D, Mangiavillano B, Schmidt A, et al. Endoscopic biliary stenting: indications, choice of stents, and results: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline – Updated October 2017. Endoscopy. 2018 Sep 7;50(09):910–30.
2. Elmunzer BJ, Maranki JL, Gómez V, Tavakkoli A, Sauer BG, Limketkai BN, et al. ACG Clinical Guideline: Diagnosis and Management of Biliary Strictures. American Journal of Gastroenterology. 2023 Mar;118(3):405–26.

Introduction

Endoscopic retrograde cholangiopancreatography /ERCP/ is the standard technique in the treatment of unresectable malignant biliary obstruction/MBO/, unfortunately, a failure rate of 3% up to 12 % and a rate of complications up to 6,85% have been reported in the literature. Endoscopic ultrasound-guided biliary drainage/EUS – BD/ is a feasible alternative for biliary drainage, applicable especially with surgically altered anatomy. With several techniques available, hepaticogastrostomy /EUS - HGS/ and choledochoduodenostomy/EUS - CDS/ are most commonly performed amongst them.

Aims & Methods

To compare the most commonly used techniques for endoscopic ultrasound-guided biliary drainage in terms of efficacy and safety.
Methods:Retrospective analysis of a prospective database of patients undergoing EUS -BD in a single tertiary referral center. EUS–BD was performed after the failure of ERCP or as a first choice of drainage procedure in patients with altered anatomy. 102 patients were included in the EUS-HGS group 94,12%(n=96) with malignant biliary obstruction and 5.12%(n=6) with benign underlying disease. Of 24 patients included in the EUS–CDS group 95,83% (n=23) had underlying malignancy against one patient with benign disease.

Results

Considering the application of EUS – BD as a first choice of drainage procedure for patients with surgically altered anatomy we had 46 patients in the HGS group (45.1%) against 16.67%(n=4) for the CDS group. In 56/44,44%/ cases EUS BD was performed during the same session after unsuccessful cannulation. Evaluating results in terms of technical success rate, defined as successful stent placement – we found a 98,04 % success rate for the EUS-HGS group and 95,83% in the EUS–CDS group. We defined clinical success as a drop in the bilirubin levels by one-half in the first week following the procedure. The results between the two groups were not significantly different - 80.46% for the HGS against 80,95% for the CBS group. Concerning adverse events during the procedure, we found a ratio of 7.84% for the patients undergone HGS and 4,76% for EUS – CDS with no significant difference. The most common AE found was proximal stent misdeployment/n=3/. All of the events were managed either conservatively or during the same session with the placement of fully covered SEMS. Concerning early AE /during the first 7 days / we experienced 14,71% early adverse events in the HGS group/n=15/ and 16,67% /n=4/ in the CDS group with most common event postprocedure infection with no significant difference.

Conclusion

The two most common transluminal techniques for EUS biliary drainage - HGS and CDS are a promising tool with comparable technical and clinical success rates, adverse events, and overall survival. Both procedures are valid alternatives after failed ERCP or as a first step especially in patients with surgically altered anatomy.

Introduction

Plastic biliary stents that have not been removed for more than 12 months are considered forgotten stents. In this study, we sought to evaluate which factors are associated with forgetting biliary stents and their consequences.

Aims & Methods

Retrospective analysis, in a high-volume ERCP unit, of patients who underwent ERCP between 2016 and 2023 with placement of plastic biliary stents. Procedures in which the patient died or the prosthesis was surgically removed less than 1 year after its placement were excluded.

Results

A total of 555 procedures in 425 patients (49% female, age 68.9±16.8 years) were included. The reasons for placement were: malignant stenosis 29.2% (n=162); choledocholithiasis 23.8% (n=132); benign stenosis 22.7% (n=126); bile leak 7.2% (n=40); acute cholangitis 6.7% (n=37); Mirizzi syndrome 4.7% (n=26); gallstones 4.3% (n=24); post-sphincterectomy bleeding 0.9% (n=5); intrahepatic lithiasis 0.5% (n=3).
Thirty-four procedures (6.1%) with forgotten stents were identified in 34 patients (35.3% female, age 64.4±17.3 years). The most frequent reasons for non-removal were: non-referral after cholecystectomy (n=15) or after hospital discharge (n=11). Among the indications for placement, gallstones (OR 9.71, p &lt; 0.001) and Mirizzi syndrome (OR 3.02, p = 0.049) were associated with an increased risk of forgetting the device.
In 10 patients, extraction was endoscopic, 2 had spontaneous migration, 1 had surgical extraction, and 7 patients died for unrelated reasons. The rest (n=14) were recruited for removal during this study. A total of 9 patients of this group responded to the call and it was confirmed the spontaneous migration of the plastic stent in na abdominal radiography.
8 patients (23.5%) presented complications: acute cholangitis (n=4), jaundice (n=2), abdominal pain (n=1) and liver abscess with septic shock (n=1).

Conclusion

Forgotten stents constitute a rare event but with a significant risk of complications. Following this analysis, we created a database in order to improve the timing until the extraction of stents and reduce related adverse events.

Introduction

Malignant biliary obstruction/MBO/is generally managed by biliary stenting however major following problem is stent patency. Recent studies show the advantages of endoscopic retrograde cholangiopancreatography-guided intraductal radiofrequency ablation/ ERCP ID-RFA/ as adjunctive therapeutic modality.

Aims & Methods

Aims: To evaluate the efficacy and safety of ID-RFA in terms of stent patency,symptom–free survival and adverse events/AE/.Primary endpoints–evaluating the period of stent patency and survival;secondary endpoints-assessing AE.
Methods: We performed retrospective analysis of a prospective database including all consecutive patients who underwent ID-RFA for the period July 2021 – December 2022.17 procedures in 16 patients who were unresectable or poor surgical candidates were performed followed by stenting in the study period.

Results

Endobiliary RFA/EB-RFA /catheter (ELRA, STARmed, Taewoong Medical) and RF generator system (VIVA combo, STARmed) were used in 15 of the procedures. In two cases ID-RFA was performed with Habib EndoHPB catheter/Boston Scientific.After passing a guidewire the catheter was positioned at the targeted lesion, followed by 120 s of ablation (target temperature 80°C, 7–10 W,temperature control mode)–in two to three sessions,unilaterally or bilaterally depending on the type and lenght of the stenosis verified by the proceding cholangiogram. The mean period of stent patency defined as time between the date of the procedure and the last follow up of the patient without signs of stent occlusion was 144,36 ± 89.3 days. In this period all of the patients were symptom–free with good quality of life and without any signs of cholangitis.The indications were:10 patients with CCA,two patients/n=2-12.5%/ with intraductal extension of papillary adenoma-both poor surgical candidates -one with HGD;one with HGD with intramucosal carcinoma who underwent endoscopic snare papillectomy /ESP/ followed by endoscopic ID-RFA and placement of stents,2 patients with gallbladder cancer,2 patients with bile duct occlusion due to metastasis.In 9 of the patients with CCA /90% of patients with CCA ;56,25 % of the total number/chemotherapy with Cisplatina/Gemcitabine followed with no interruption of the courses during the period of treatment; one refused chemotherapy.In three of the patients/18.75%/ we performed ID RFA in order to prolong stent patency in occluded by tumor ingrowth metal stents.The rate of the AE was 18.75%/n=3/ - 1 patient with self-limited bleeding;1 patient with postprocedural cholangitis and 1 patient with liver abcess – managed percutaneously.There were no deaths or ICU admissions. We experienced two stent occlusions – in one in patient with papillary adenoma with HGD–on day 169– managed with second session of ID- RFA followed by metal stent placement - asymptomatic up to the last follow up,the second with tumor ingrowth from endobiliary metastasis in previously placed metal stent -the patency after RFA was 116 days – managed with metal stent in stent placement

Conclusion

ID-RFA is a promising new tool which provides improved outcomes in patients with MBO both in stent patency and symptom free survival.It has many advantages – easy delivery of controlled temperature application and good safety profile.Therefore ID-RFA can be proposed as adjunctive treatment in patients with MBO although more randomized studies are needed.