BACKGROUND Traumatic pancreatic injury is relatively rare in children,accounting for approximately 3%-12%of blunt abdominal trauma cases.Most traumatic pancreatic injuries in boys are related to bicycle handlebars.Tra...BACKGROUND Traumatic pancreatic injury is relatively rare in children,accounting for approximately 3%-12%of blunt abdominal trauma cases.Most traumatic pancreatic injuries in boys are related to bicycle handlebars.Traumatic pancreatic injuries often result in delayed presentation and treatment,leading to high morbidity and mortality.The management of children with traumatic main pancreatic duct injuries is still under debate.CASE SUMMARY We report the case of a 9-year-old boy who was presented at our institution with epigastric pain after being stuck with his bicycle handlebar at the upper abdomen and then treated with endoscopic stenting because of a pancreatic ductal injury.CONCLUSION We believe that endoscopic stenting of pancreatic ductal injuries may be a feasible technique in certain cases of children with traumatic pancreatic duct injuries to avoid unnecessary operations.展开更多
This article discusses Wang et al’s essay.Endoscopic biliary stenting,a less invasive alternative to surgery,is effective for malignant obstructive jaundice.This article summarizes the pathophysiology of biliary obst...This article discusses Wang et al’s essay.Endoscopic biliary stenting,a less invasive alternative to surgery,is effective for malignant obstructive jaundice.This article summarizes the pathophysiology of biliary obstruction,the technical aspects of stenting,and the clinical outcomes.By comparison of endoscopic stenting with percutaneous biliary drainage,improvements and complications are focused on.Additionally,patient selection for stenting and future advancements in stent technology are important.Overall,endoscopic biliary stenting is a valuable palliative option for patients with malignant jaundice,especially those ineligibles for surgery.展开更多
This letter responds to Wang et al's recent publication on endoscopic biliary stenting for malignant obstructive jaundice(MOJ)by offering constructive feedback and suggestions for future research.We commend the au...This letter responds to Wang et al's recent publication on endoscopic biliary stenting for malignant obstructive jaundice(MOJ)by offering constructive feedback and suggestions for future research.We commend the authors for their comprehensive study design and execution,which included a clear delineation of study groups and a robust set of outcome measures.We suggest that future studies incorporate additional biomarkers,such as serum levels of liver enzymes and bilirubin,to provide a more nuanced understanding of liver function changes post-intervention.The study's focus on short-term survival rates is appreciated,but we recommend exploring longer-term follow-up periods to capture the full spectrum of survival outcomes.Additionally,the inclusion of quality of life assessments using validated instruments could offer a more holistic view of patient outcomes.From a critical care perspective,we advocate for the integration of advanced imaging techniques to better characterize biliary anatomy and potentially predict treatment response or complications.We believe that incor-porating these suggestions could enhance the understanding of endoscopic biliary stenting's role in MOJ management and its impact on patient outcomes,influ-encing future clinical guidelines and practice.展开更多
Background:Gastrojejunostomy(G J J)and endoscopic stenting(ES)are palliative treatments for gastric outlet obstruction(GO0)caused by gastric cancer.We compared the outcomes of GJJ with ES by performing a meta-analysis...Background:Gastrojejunostomy(G J J)and endoscopic stenting(ES)are palliative treatments for gastric outlet obstruction(GO0)caused by gastric cancer.We compared the outcomes of GJJ with ES by performing a meta-analysis.Methods:Clinical trials that compared GJJ with ES for the treatment of GOO in gastric cancer were included in the meta-analysis.Procedure time,time to resumption of oral intake,duration of hospital stay,patency duration,and overall survival days were compared using weighted mean differences(WMDs).Technical success,clinical success,procedure-related mortality,complications,the rate of re-obstruction,postoperative chemotherapy,and reintervention were compared using odds ratios(ORs).Results:Nine studies were included in the analysis.Technical success and clinical success were not significantly different between the ES and GJJ groups.The ES group had a shorter procedure time(WMD=-80.89 min,95%confidence interval[CI]=-93.99 to-67.78,P〈0.001),faster resumption of oral intake(WMD=-3.45 days,95%CI=-5.25 to-1.65,P〈0.001),and shorter duration of hospital stay(WMD=-7.67 days,95%CI=-11.02 to-4.33,P〈0.001).The rate of minor complications was significantly higher in the GJJ group(OR=0.13,95%CI=0.04-0.40,P〈0.001).However,the rates of major complications(OR=6.91,95%CI=3.90-12.25,P〈0.001),re-obstruction(OR=7.75,95%CI=4.06-14.78,P〈0.001),and reintervention(OR=6.27,95%CI=3.36-11.68,P〈0.001)were significantly lower in the GJJ group than that in the E S group.Moreover,GJJ was significantly associated with a longer patency duration(WMD=-167.16 days,95%CI=-254.01 to-89.31,P〈0.001)and overall survival(WMD=-103.20 days,95%CI=-161.49 to-44.91,P=0.001).Conclusions:Both GJJ and ES are effective procedures for the treatment of GOO caused by gastric cancer.ES is associated with better short-term outcomes.GJJ is preferable to ES in terms of its lower rate of stent-related complications,re-obstruction,and reintervention.GJJ should be considered a treatment option for patients with a long life expectancy and good performance status.展开更多
AIM: To review the usefulness of endoscopic biliary stenting for obstructive jaundice caused by hepatocellular carcinoma and identify problems that may need to be addressed.
Endoscopic luminal stenting(ELS)represents a minimally invasive option for the management of malignant obstruction along the gastrointestinal tract.Previous studies have shown that ELS can provide rapid relief of symp...Endoscopic luminal stenting(ELS)represents a minimally invasive option for the management of malignant obstruction along the gastrointestinal tract.Previous studies have shown that ELS can provide rapid relief of symptoms related to esophageal,gastric,small intestinal,colorectal,biliary,and pancreatic neoplastic strictures without compromising cancer patients’overall safety.As a result,in both palliative and neoadjuvant settings,ELS has largely surpassed radiotherapy and surgery as a first-line treatment modality.Following the abovementioned success,the indications for ELS have gradually expanded.To date,ELS is widely used in clinical practice by well-trained endoscopists in managing a wide variety of diseases and complications,such as relieving non-neoplastic obstructions,sealing iatrogenic and non-iatrogenic perforations,closing fistulae and treating post-sphincterotomy bleeding.The abovementioned development would not have been achieved without corresponding advances and innovations in stent technology.However,the technological landscape changes rapidly,making clinicians’adaptation to new technologies a real challenge.In our mini-review article,by systematically reviewing the relevant literature,we discuss current developments in ELS with regard to stent design,accessories,techniques,and applications,expanding the research basis that was set by previous studies and highlighting areas that need to be further investigated.展开更多
BACKGROUND Bile duct leaks(BDLs)are serious postsurgical adverse events.Typically,conservative management with ab-dominal drainage is the initial treatment option.However,prolonged abdominal drainage without improveme...BACKGROUND Bile duct leaks(BDLs)are serious postsurgical adverse events.Typically,conservative management with ab-dominal drainage is the initial treatment option.However,prolonged abdominal drainage without improvement can lead to biliary stricture and delay the optimal timing of endoscopic retrograde cholangiopancreatography(ERCP).AIM To identify the optimal timing for ERCP and the period during which clinical observation with conservative management is acceptable,balancing ERCP success and the risk of biliary strictures.METHODS We conducted a multicenter retrospective study involving 448 patients with BDLs between November 2002 and November 2022.The patients were divided into four groups based on the timing of ERCP:3 days,7 days,14 days,and 21 days.The primary outcome was clinical success,defined as the resolution of BDL and related symptoms within 6 months without additional percutaneous drainage,surgery,or death.The secondary outcome was incidence of biliary strictures.Univariate and multivariate logistic regression analyses were performed to identify factors associated with ERCP success and biliary stricture occurrence.RESULTS In a cohort of 448 consecutive patients diagnosed with BDLs,354 were excluded,leaving 94 patients who underwent ERCP.Clinical success was achieved in 84%of cases(79/94),with a median ERCP timing of 20 days(9.5-35.3 days).Biliary strictures were identified in 29(30.9%)patients.Performing ERCP within 3 weeks,compared to after 3 weeks,was associated with higher success rates[92.0%(46/50)vs 75.0%(33/44),P=0.032]and a lower incidence of biliary stricture incidence[18.0%(9/50)vs 45.5%(20/44),P=0.005].Subsequent multivariate analysis confirmed the association with higher success rates(odds ratio=4.168,P=0.045)and lower biliary stricture rates(odds ratio=0.256,P=0.007).CONCLUSION Performing ERCP for BDLs within 3 weeks may be associated with a higher success rate and a lower biliary stricture rate.If patients with BDLs do not respond to conservative treatment,ERCP is suggested to be performed within 3 weeks.展开更多
BACKGROUND Stenting as a bridge to curative surgery(SBTS)for obstructing colon cancer(OCC)has been associated with possibly worse oncological outcomes.AIM To evaluate the recurrence patterns,survival outcomes,and colo...BACKGROUND Stenting as a bridge to curative surgery(SBTS)for obstructing colon cancer(OCC)has been associated with possibly worse oncological outcomes.AIM To evaluate the recurrence patterns,survival outcomes,and colorectal cancer(CRC)-specific death in patients undergoing SBTS for OCC.METHODS Data from 62 patients undergoing SBTS at a single tertiary centre over ten years between 2007 and 2016 were retrospectively examined.Primary outcomes were recurrence patterns,overall survival(OS),cancer-specific survival(CSS),and CRC-specific death.OS and CSS were estimated using the Kaplan-Meier curves.Competing risk analysis with cumulative incidence function(CIF)was used to estimate CRC-specific mortality with other cause-specific death as a competing event.Fine-Gray regressions were performed to determine prognostic factors of CRC-specific death.Univariate and multivariate subdistribution hazard ratios and their corresponding Wald test P values were calculated.RESULTS 28 patients(45.2%)developed metastases after a median period of 16 mo.Among the 18 patients with single-site metastases:Four had lung-only metastases(14.3%),four had liver-only metastases(14.3%),and 10 had peritoneum-only metastases(35.7%),while 10 patients had two or more sites of metastatic disease(35.7%).The peritoneum was the most prevalent(60.7%)site of metastatic involvement(17/28).The median follow-up duration was 46 mo.26(41.9%)of the 62 patients died,of which 16(61.5%)were CRC-specific deaths and 10(38.5%)were deaths owing to other causes. The 1-, 3-, and 5-year OS probabilities were 88%, 74%, and 59%;1-, 3-, and5-year CSS probabilities were 97%, 83%, and 67%. The highest CIF for CRC-specific death at 60 mowas liver-only recurrence (0.69). Liver-only recurrence, peritoneum-only recurrence, and two ormore recurrence sites were predictive of CRC-specific death.CONCLUSIONThe peritoneum was the most common metastatic site among patients undergoing SBTS. Liveronlyrecurrence, peritoneum-only recurrence, and two or more recurrence sites were predictors ofCRC-specific death.展开更多
BACKGROUND In order to successfully manage traumatic pancreatic duct(PD)leaks,early diagnosis and operative management is paramount in reducing morbidity and mortality.In the acute setting,endoscopic retrograde cholan...BACKGROUND In order to successfully manage traumatic pancreatic duct(PD)leaks,early diagnosis and operative management is paramount in reducing morbidity and mortality.In the acute setting,endoscopic retrograde cholangiopancreatography(ERCP)can be a useful,adjunctive modality during exploratory laparotomy.ERCP with sphincterotomy and stent placement improves preferential drainage in the setting of injury,allowing the pancreatic leak to properly heal.However,data in this acute setting is limited.CASE SUMMARY In this case series,a 27-year-old male and 16-year-old female presented with PD leaks secondary to a gunshot wound and blunt abdominal trauma,respectively.Both underwent intraoperative ERCP within an average of 5.9 h from time of presentation.A sphincterotomy and plastic pancreatic stent placement was performed with a 100%technical and clinical success.There were no associated immediate or long-term complications.Following discharge,both patients underwent repeat ERCP for stent removal with resolution of ductal injury.CONCLUSION These experiences further demonstrated that widespread adaption and optimal timing of ERCP may improve outcomes in trauma centers.展开更多
First of all,I would like to congratulate Vilas-Boas et al on an interesting publication.In this letter the authors write about very interesting topics in the management of patients with malignant gastric outlet obstr...First of all,I would like to congratulate Vilas-Boas et al on an interesting publication.In this letter the authors write about very interesting topics in the management of patients with malignant gastric outlet obstruction(GOO).GOO developed in up to 20%of patients with advanced hepatopancreatobiliary disease both in benign and malignant form.For this reason,the issue is very current.I fully agree with Vilas-Boas et al that technical aspect of the procedures(surgeon’s view)often differs from the patient’s view(regarding such factors as cancerrelated survival,overall survival,body mass composition,nutritional biomarkers,chemotherapy tolerance and patient-reported quality of life).The mentioned factors should be taken into account when interpreting the effectiveness of treatment modalities for malignant GOO(mGOO),which should be also considered in the future studies in this subject.In my opinion,all above mentioned factors could be summarized in one term:“Improving quality of life of patients with mGOO”.展开更多
Malignant gastroduodenal obstruction can occur in up to 20%of patients with primary pancreatic,gastric or duodenal carcinomas.Presenting symptoms include nausea,vomiting,abdominal distention,pain and decreased oral in...Malignant gastroduodenal obstruction can occur in up to 20%of patients with primary pancreatic,gastric or duodenal carcinomas.Presenting symptoms include nausea,vomiting,abdominal distention,pain and decreased oral intake which can lead to dehydration, malnutrition,and poor quality of life.Endoscopic stent placement has become the primary therapeutic modality because it is safe,minimally invasive,and a cost-effective option for palliation.Stents can be successfully deployed in the majority of patients. Stent placement appears to lead to a shorter time to symptomatic improvement,shorter time to resumption of an oral diet,and shorter hospital stays as compared with surgical options.Recurrence of the obstructive symptoms resulting from stent occlusion,due to tumor ingrowth or overgrowth,can be successfully treated with repeat endoscopic stent placement in the majority of the cases.Both endoscopic stenting and surgical bypass are considered palliative treatments and,to date,no improvement in survival with either modality has been demonstrated.A tailored therapeutic approach,taking into consideration patient preferences and involving a multidisciplinary team including the therapeutic endoscopist,surgeon,medical oncologist, radiation therapist,and interventional radiologist, should be considered in all cases.展开更多
Perforation of the gallbladder with cholecystohepatic communication is a rare cause of liver abscess. Because it is a rare entity, the treatment modality has not been fully established. We report for the first time a ...Perforation of the gallbladder with cholecystohepatic communication is a rare cause of liver abscess. Because it is a rare entity, the treatment modality has not been fully established. We report for the first time a patient with an intrahepatic abscess due to gallbladder perforation successfully treated by endoscopic stent placement into the gallbladder who had a poor response to continuous percutaneous drainage.展开更多
Tumors of the minor papilla of the duodenum are quite rare.We successfully and safely treated an 18-mm adenoma of the minor papilla associated with pancreas divisum using endoscopic papillectomy.A 64-year-old man was ...Tumors of the minor papilla of the duodenum are quite rare.We successfully and safely treated an 18-mm adenoma of the minor papilla associated with pancreas divisum using endoscopic papillectomy.A 64-year-old man was admitted to our hospital for treatment of an asymptomatic mass in the minor papilla detected by upper gastrointestinal endoscopy.Endscopic analysis showed an 18-mm,whitish,sessile mass,located in the duodenum proximal to a normal-appearing major papilla.Endoscopic retrograde pancreatography did not reveal the pancreatic duct.Magnetic resonance cholangiopancreatography showed a lack of the ventral pancreatic duct.We suspected this case was associated with pancreatic divisum;therefore,we performed endoscopic papillectomy of the minor papilla tumor.Subsequently,endoscopic pancreatic stent placement in the minor papilla was done to prevent drainage disturbance.The patient has been asymptomatic without recurrence of tumor or stenosis of the Santorini orifice upon endoscopic examination for the past 2 years.展开更多
AIM To investigate the factors predictive of failure when placing a second biliary self-expandable metallic stents(SEMSs). METHODS This study evaluated 65 patients with an unresectable malignant hilar biliary obstruct...AIM To investigate the factors predictive of failure when placing a second biliary self-expandable metallic stents(SEMSs). METHODS This study evaluated 65 patients with an unresectable malignant hilar biliary obstruction who were examined in our hospital. Sixty-two of these patients were recruited to the study and divided into two groups: the success group, which consisted of patients in whom a stent-in-stent SEMS had been placed successfully, and the failure group, which consisted of patients in whom the stent-in-stent SEMS had not been placed successfully. We compared the characteristics of the patients, the stricture state of their biliary ducts, and the implemented endoscopic retrograde cholangiopancreatography(ERCP) procedures between the two groups.RESULTS The angle between the target biliary duct stricture and the first implanted SEMS was significantly larger in the failure group than in the success group. There were significantly fewer wire or dilation devices(ERCP catheter, dilator, or balloon catheter) passing the first SEMS cell in the failure group than in the success group. The cut-off value of the angle predicting stent-in-stent SEMS placement failure was 49.7 degrees according to the ROC curve(sensitivity 91.7%, specificity 61.2%). Furthermore, the angle was significantly smaller in patients with wire or dilation devices passing the first SEMS cell than in patients without wire or dilation devices passing the first SEMS cell. CONCLUSION A large angle was identified as a predictive factor for failure of stent-in-stent SEMS placement.展开更多
AIM:To evaluate the efficacy and safety of endoscopic removal and trimming of self-expandable metallic stents(SEMS).METHODS:All SEMS had been placed for distal biliary strictures.Twenty-seven endoscopic procedures wer...AIM:To evaluate the efficacy and safety of endoscopic removal and trimming of self-expandable metallic stents(SEMS).METHODS:All SEMS had been placed for distal biliary strictures.Twenty-seven endoscopic procedures were performed in 19 patients in whom SEMS(one uncovered and 18 covered) removal had been attempted,and 8 patients in whom stent trimming using argon plasma coagulation(APC) had been attempted at Tokyo Medical University Hospital.The APC settings were:voltage 60-80 W and gas flow at 1.5 L/min.RESULTS:The mean stent indwelling period for all patients in whom stent removal had been attempted was 113.7 ± 77.6 d(range,8-280 d).Of the 19 patients in whom removal of the SEMS had been attempted,the procedure was successful in 14(73.7%) without procedure-related adverse events.The indwelling period in the stent removable group was shorter than that in the unremovable group(94.9 ± 71.5 d vs 166.2 ± 76.2 d,P = 0.08).Stent trimming was successful for all patients with one minor adverse event consisting of self-limited hemorrhage.Trimming time ranged from 11 to 16 min.CONCLUSION:Although further investigations on larger numbers of cases are necessary to accumulate evidence,the present data suggested that stent removal and stent trimming is feasible and effective for stent-related complications.展开更多
Biliary duct injuries are frequently iatrogenic, being associated with surgery for gallbladder stones. However, blunt abdominal trauma such as a motor vehicle crash is a rare cause of extrahepatic biliary stricture. A...Biliary duct injuries are frequently iatrogenic, being associated with surgery for gallbladder stones. However, blunt abdominal trauma such as a motor vehicle crash is a rare cause of extrahepatic biliary stricture. A few reports have been published on biliary strictures treated with endoscopic therapy. In the present study, we describe a suprapancreatic biliary stricture associated with mesenteric tear following road traffic accident. We performed endoscopic stent placement, which was successful in relieving the biliary stricture.展开更多
Endoscopic retrograde cholangiopancreatography(ERCP)with stenting is the treatment modality of choice for patients with benign and malignant bile duct obstruction.ERCP could fail in cases of duodenal obstruction,duode...Endoscopic retrograde cholangiopancreatography(ERCP)with stenting is the treatment modality of choice for patients with benign and malignant bile duct obstruction.ERCP could fail in cases of duodenal obstruction,duodenal diverticulum,ampullary neoplastic infiltration or surgically altered anatomy.In these cases percutaneous biliary drainage(PTBD)is traditionally used as a rescue procedure but is related to high morbidity and mortality and lower quality of life.Endoscopic ultrasound-guided biliary drainage(EUS-BD)is a relatively new interventional procedure that arose due to the development of curvilinear echoendoscope and the various endoscopic devices.A large amount of data is already collected that proves its efficacy,safety and ability to replace PTBD in cases of ERCP failure.It is also possible that EUS-BD could be chosen as a first-line treatment option in some clinical scenarios in the near future.Several EUS-BD techniques are developed EUS-guided transmural stenting,antegrade stenting and rendezvous technique and can be personalized depending on the individual anatomy.EUS-BD is normally performed in the same session from the same endoscopist in case of ERCP failure.The lack of training,absence of enough dedicated devices and lack of standardization still makes EUS-BD a difficult and not very popular procedure,which is related to life-threatening adverse events.Developing training models,dedicated devices and guidelines hopefully will make EUS-BD easier,safer and well accepted in the future.This paper focuses on the technical aspects of the different EUS-BD procedures,available literature data,advantages,negative aspects and the future perspectives of these modalities.展开更多
Acute pancreatitis is the most common and the most fearful complication of endoscopic retrograde cholangiopancreatography (ERCP).Prevention of post-ERCP pancreatitis has therefore been of great interest to endoscopist...Acute pancreatitis is the most common and the most fearful complication of endoscopic retrograde cholangiopancreatography (ERCP).Prevention of post-ERCP pancreatitis has therefore been of great interest to endoscopists performing ERCP procedures.So far,only pancreatic duct stenting during ERCP and rectal administration of a non-steroidal anti-inflammatory drug (NSAID) prior to or immediately after ERCP have been consistently shown to be effective for prevention of post-ERCP pancreatitis.This commentary focuses on a short discussion about the rates,mechanisms,and risk factors for post-ERCP pancreatitis,and effective means for its prevention with emphasis on the use of NSAIDs including a recent clinical trial published in The New England Journal of Medicine by Elmunzer et al.展开更多
Acute colonic obstruction,a life-threatening condition often caused by malignant or benign strictures,necessitates rapid and effective intervention to avoid severe complications such as bowel perforation or sepsis.Sel...Acute colonic obstruction,a life-threatening condition often caused by malignant or benign strictures,necessitates rapid and effective intervention to avoid severe complications such as bowel perforation or sepsis.Self-expandable metal stents(SEMS)have emerged as a minimally invasive,effective treatment alternative,either as a bridge to surgery or for palliation in malignant cases.This editorial focuses on the current mechanisms and techniques for SEMS placement in acute colonic obstruction,discussing the various endoscopic approaches,stent design considerations,technical success rates,complications,and long-term outcomes.We explore cutting-edge techniques such as fluoroscopy-free endoscopic placement,two-person colonoscopy,and the use of advanced endoscopic equipment like slim gastroscopes and ultrathin endoscopes.Additionally,the editorial delves into complications associated with SEMS placement,such as stent migration,perforation,and occlusion,and discusses strategies to mitigate these risks.Finally,future directions in SEMS technology,including advancements in stent design and optimal timing for surgery,are presented.展开更多
Hilar cholangiocarcinoma has been reputed as a slow growth tumor in the past. Skeletal muscle is one of the most unusual sites of metastasis from any malignancy. We report herein a case of hilar cholangiocarcinoma wit...Hilar cholangiocarcinoma has been reputed as a slow growth tumor in the past. Skeletal muscle is one of the most unusual sites of metastasis from any malignancy. We report herein a case of hilar cholangiocarcinoma with synchronous metastases to skeletal muscle and breast, and review the literature. The patient was a 48-year-old woman who presented with jaundice and weight loss. An inoperable hilar cholangiocarcinoma was diagnosed. She was treated with a combination of endoscopic plastic stent biloiary drainage and three-dimensional conformal radiotherapy （3DCRT）. Good response was achieved. Ten months later, she exhibited with a painful metastatic mass in the muscle rectus femoris of left thigh and a painless mass in the left breast. She underwent operation to relieve the pain, but died from liver failure after 8 months. The literature only offers isolated cases of cholangiocarcinoma with distant metastases, of which the common sites were cervical lymph node, bone, and portal venous system. Most patients were presented with multiple metastases with extensive local disease.展开更多
文摘BACKGROUND Traumatic pancreatic injury is relatively rare in children,accounting for approximately 3%-12%of blunt abdominal trauma cases.Most traumatic pancreatic injuries in boys are related to bicycle handlebars.Traumatic pancreatic injuries often result in delayed presentation and treatment,leading to high morbidity and mortality.The management of children with traumatic main pancreatic duct injuries is still under debate.CASE SUMMARY We report the case of a 9-year-old boy who was presented at our institution with epigastric pain after being stuck with his bicycle handlebar at the upper abdomen and then treated with endoscopic stenting because of a pancreatic ductal injury.CONCLUSION We believe that endoscopic stenting of pancreatic ductal injuries may be a feasible technique in certain cases of children with traumatic pancreatic duct injuries to avoid unnecessary operations.
文摘This article discusses Wang et al’s essay.Endoscopic biliary stenting,a less invasive alternative to surgery,is effective for malignant obstructive jaundice.This article summarizes the pathophysiology of biliary obstruction,the technical aspects of stenting,and the clinical outcomes.By comparison of endoscopic stenting with percutaneous biliary drainage,improvements and complications are focused on.Additionally,patient selection for stenting and future advancements in stent technology are important.Overall,endoscopic biliary stenting is a valuable palliative option for patients with malignant jaundice,especially those ineligibles for surgery.
文摘This letter responds to Wang et al's recent publication on endoscopic biliary stenting for malignant obstructive jaundice(MOJ)by offering constructive feedback and suggestions for future research.We commend the authors for their comprehensive study design and execution,which included a clear delineation of study groups and a robust set of outcome measures.We suggest that future studies incorporate additional biomarkers,such as serum levels of liver enzymes and bilirubin,to provide a more nuanced understanding of liver function changes post-intervention.The study's focus on short-term survival rates is appreciated,but we recommend exploring longer-term follow-up periods to capture the full spectrum of survival outcomes.Additionally,the inclusion of quality of life assessments using validated instruments could offer a more holistic view of patient outcomes.From a critical care perspective,we advocate for the integration of advanced imaging techniques to better characterize biliary anatomy and potentially predict treatment response or complications.We believe that incor-porating these suggestions could enhance the understanding of endoscopic biliary stenting's role in MOJ management and its impact on patient outcomes,influ-encing future clinical guidelines and practice.
文摘Background:Gastrojejunostomy(G J J)and endoscopic stenting(ES)are palliative treatments for gastric outlet obstruction(GO0)caused by gastric cancer.We compared the outcomes of GJJ with ES by performing a meta-analysis.Methods:Clinical trials that compared GJJ with ES for the treatment of GOO in gastric cancer were included in the meta-analysis.Procedure time,time to resumption of oral intake,duration of hospital stay,patency duration,and overall survival days were compared using weighted mean differences(WMDs).Technical success,clinical success,procedure-related mortality,complications,the rate of re-obstruction,postoperative chemotherapy,and reintervention were compared using odds ratios(ORs).Results:Nine studies were included in the analysis.Technical success and clinical success were not significantly different between the ES and GJJ groups.The ES group had a shorter procedure time(WMD=-80.89 min,95%confidence interval[CI]=-93.99 to-67.78,P〈0.001),faster resumption of oral intake(WMD=-3.45 days,95%CI=-5.25 to-1.65,P〈0.001),and shorter duration of hospital stay(WMD=-7.67 days,95%CI=-11.02 to-4.33,P〈0.001).The rate of minor complications was significantly higher in the GJJ group(OR=0.13,95%CI=0.04-0.40,P〈0.001).However,the rates of major complications(OR=6.91,95%CI=3.90-12.25,P〈0.001),re-obstruction(OR=7.75,95%CI=4.06-14.78,P〈0.001),and reintervention(OR=6.27,95%CI=3.36-11.68,P〈0.001)were significantly lower in the GJJ group than that in the E S group.Moreover,GJJ was significantly associated with a longer patency duration(WMD=-167.16 days,95%CI=-254.01 to-89.31,P〈0.001)and overall survival(WMD=-103.20 days,95%CI=-161.49 to-44.91,P=0.001).Conclusions:Both GJJ and ES are effective procedures for the treatment of GOO caused by gastric cancer.ES is associated with better short-term outcomes.GJJ is preferable to ES in terms of its lower rate of stent-related complications,re-obstruction,and reintervention.GJJ should be considered a treatment option for patients with a long life expectancy and good performance status.
文摘AIM: To review the usefulness of endoscopic biliary stenting for obstructive jaundice caused by hepatocellular carcinoma and identify problems that may need to be addressed.
文摘Endoscopic luminal stenting(ELS)represents a minimally invasive option for the management of malignant obstruction along the gastrointestinal tract.Previous studies have shown that ELS can provide rapid relief of symptoms related to esophageal,gastric,small intestinal,colorectal,biliary,and pancreatic neoplastic strictures without compromising cancer patients’overall safety.As a result,in both palliative and neoadjuvant settings,ELS has largely surpassed radiotherapy and surgery as a first-line treatment modality.Following the abovementioned success,the indications for ELS have gradually expanded.To date,ELS is widely used in clinical practice by well-trained endoscopists in managing a wide variety of diseases and complications,such as relieving non-neoplastic obstructions,sealing iatrogenic and non-iatrogenic perforations,closing fistulae and treating post-sphincterotomy bleeding.The abovementioned development would not have been achieved without corresponding advances and innovations in stent technology.However,the technological landscape changes rapidly,making clinicians’adaptation to new technologies a real challenge.In our mini-review article,by systematically reviewing the relevant literature,we discuss current developments in ELS with regard to stent design,accessories,techniques,and applications,expanding the research basis that was set by previous studies and highlighting areas that need to be further investigated.
基金Supported by the National Key Research and Development Program,China,No.2022YFC2503603.
文摘BACKGROUND Bile duct leaks(BDLs)are serious postsurgical adverse events.Typically,conservative management with ab-dominal drainage is the initial treatment option.However,prolonged abdominal drainage without improvement can lead to biliary stricture and delay the optimal timing of endoscopic retrograde cholangiopancreatography(ERCP).AIM To identify the optimal timing for ERCP and the period during which clinical observation with conservative management is acceptable,balancing ERCP success and the risk of biliary strictures.METHODS We conducted a multicenter retrospective study involving 448 patients with BDLs between November 2002 and November 2022.The patients were divided into four groups based on the timing of ERCP:3 days,7 days,14 days,and 21 days.The primary outcome was clinical success,defined as the resolution of BDL and related symptoms within 6 months without additional percutaneous drainage,surgery,or death.The secondary outcome was incidence of biliary strictures.Univariate and multivariate logistic regression analyses were performed to identify factors associated with ERCP success and biliary stricture occurrence.RESULTS In a cohort of 448 consecutive patients diagnosed with BDLs,354 were excluded,leaving 94 patients who underwent ERCP.Clinical success was achieved in 84%of cases(79/94),with a median ERCP timing of 20 days(9.5-35.3 days).Biliary strictures were identified in 29(30.9%)patients.Performing ERCP within 3 weeks,compared to after 3 weeks,was associated with higher success rates[92.0%(46/50)vs 75.0%(33/44),P=0.032]and a lower incidence of biliary stricture incidence[18.0%(9/50)vs 45.5%(20/44),P=0.005].Subsequent multivariate analysis confirmed the association with higher success rates(odds ratio=4.168,P=0.045)and lower biliary stricture rates(odds ratio=0.256,P=0.007).CONCLUSION Performing ERCP for BDLs within 3 weeks may be associated with a higher success rate and a lower biliary stricture rate.If patients with BDLs do not respond to conservative treatment,ERCP is suggested to be performed within 3 weeks.
文摘BACKGROUND Stenting as a bridge to curative surgery(SBTS)for obstructing colon cancer(OCC)has been associated with possibly worse oncological outcomes.AIM To evaluate the recurrence patterns,survival outcomes,and colorectal cancer(CRC)-specific death in patients undergoing SBTS for OCC.METHODS Data from 62 patients undergoing SBTS at a single tertiary centre over ten years between 2007 and 2016 were retrospectively examined.Primary outcomes were recurrence patterns,overall survival(OS),cancer-specific survival(CSS),and CRC-specific death.OS and CSS were estimated using the Kaplan-Meier curves.Competing risk analysis with cumulative incidence function(CIF)was used to estimate CRC-specific mortality with other cause-specific death as a competing event.Fine-Gray regressions were performed to determine prognostic factors of CRC-specific death.Univariate and multivariate subdistribution hazard ratios and their corresponding Wald test P values were calculated.RESULTS 28 patients(45.2%)developed metastases after a median period of 16 mo.Among the 18 patients with single-site metastases:Four had lung-only metastases(14.3%),four had liver-only metastases(14.3%),and 10 had peritoneum-only metastases(35.7%),while 10 patients had two or more sites of metastatic disease(35.7%).The peritoneum was the most prevalent(60.7%)site of metastatic involvement(17/28).The median follow-up duration was 46 mo.26(41.9%)of the 62 patients died,of which 16(61.5%)were CRC-specific deaths and 10(38.5%)were deaths owing to other causes. The 1-, 3-, and 5-year OS probabilities were 88%, 74%, and 59%;1-, 3-, and5-year CSS probabilities were 97%, 83%, and 67%. The highest CIF for CRC-specific death at 60 mowas liver-only recurrence (0.69). Liver-only recurrence, peritoneum-only recurrence, and two ormore recurrence sites were predictive of CRC-specific death.CONCLUSIONThe peritoneum was the most common metastatic site among patients undergoing SBTS. Liveronlyrecurrence, peritoneum-only recurrence, and two or more recurrence sites were predictors ofCRC-specific death.
文摘BACKGROUND In order to successfully manage traumatic pancreatic duct(PD)leaks,early diagnosis and operative management is paramount in reducing morbidity and mortality.In the acute setting,endoscopic retrograde cholangiopancreatography(ERCP)can be a useful,adjunctive modality during exploratory laparotomy.ERCP with sphincterotomy and stent placement improves preferential drainage in the setting of injury,allowing the pancreatic leak to properly heal.However,data in this acute setting is limited.CASE SUMMARY In this case series,a 27-year-old male and 16-year-old female presented with PD leaks secondary to a gunshot wound and blunt abdominal trauma,respectively.Both underwent intraoperative ERCP within an average of 5.9 h from time of presentation.A sphincterotomy and plastic pancreatic stent placement was performed with a 100%technical and clinical success.There were no associated immediate or long-term complications.Following discharge,both patients underwent repeat ERCP for stent removal with resolution of ductal injury.CONCLUSION These experiences further demonstrated that widespread adaption and optimal timing of ERCP may improve outcomes in trauma centers.
文摘First of all,I would like to congratulate Vilas-Boas et al on an interesting publication.In this letter the authors write about very interesting topics in the management of patients with malignant gastric outlet obstruction(GOO).GOO developed in up to 20%of patients with advanced hepatopancreatobiliary disease both in benign and malignant form.For this reason,the issue is very current.I fully agree with Vilas-Boas et al that technical aspect of the procedures(surgeon’s view)often differs from the patient’s view(regarding such factors as cancerrelated survival,overall survival,body mass composition,nutritional biomarkers,chemotherapy tolerance and patient-reported quality of life).The mentioned factors should be taken into account when interpreting the effectiveness of treatment modalities for malignant GOO(mGOO),which should be also considered in the future studies in this subject.In my opinion,all above mentioned factors could be summarized in one term:“Improving quality of life of patients with mGOO”.
文摘Malignant gastroduodenal obstruction can occur in up to 20%of patients with primary pancreatic,gastric or duodenal carcinomas.Presenting symptoms include nausea,vomiting,abdominal distention,pain and decreased oral intake which can lead to dehydration, malnutrition,and poor quality of life.Endoscopic stent placement has become the primary therapeutic modality because it is safe,minimally invasive,and a cost-effective option for palliation.Stents can be successfully deployed in the majority of patients. Stent placement appears to lead to a shorter time to symptomatic improvement,shorter time to resumption of an oral diet,and shorter hospital stays as compared with surgical options.Recurrence of the obstructive symptoms resulting from stent occlusion,due to tumor ingrowth or overgrowth,can be successfully treated with repeat endoscopic stent placement in the majority of the cases.Both endoscopic stenting and surgical bypass are considered palliative treatments and,to date,no improvement in survival with either modality has been demonstrated.A tailored therapeutic approach,taking into consideration patient preferences and involving a multidisciplinary team including the therapeutic endoscopist,surgeon,medical oncologist, radiation therapist,and interventional radiologist, should be considered in all cases.
文摘Perforation of the gallbladder with cholecystohepatic communication is a rare cause of liver abscess. Because it is a rare entity, the treatment modality has not been fully established. We report for the first time a patient with an intrahepatic abscess due to gallbladder perforation successfully treated by endoscopic stent placement into the gallbladder who had a poor response to continuous percutaneous drainage.
文摘Tumors of the minor papilla of the duodenum are quite rare.We successfully and safely treated an 18-mm adenoma of the minor papilla associated with pancreas divisum using endoscopic papillectomy.A 64-year-old man was admitted to our hospital for treatment of an asymptomatic mass in the minor papilla detected by upper gastrointestinal endoscopy.Endscopic analysis showed an 18-mm,whitish,sessile mass,located in the duodenum proximal to a normal-appearing major papilla.Endoscopic retrograde pancreatography did not reveal the pancreatic duct.Magnetic resonance cholangiopancreatography showed a lack of the ventral pancreatic duct.We suspected this case was associated with pancreatic divisum;therefore,we performed endoscopic papillectomy of the minor papilla tumor.Subsequently,endoscopic pancreatic stent placement in the minor papilla was done to prevent drainage disturbance.The patient has been asymptomatic without recurrence of tumor or stenosis of the Santorini orifice upon endoscopic examination for the past 2 years.
基金Supported by Department of Gastroenterology,Fukushima Medical University,School of Medicine
文摘AIM To investigate the factors predictive of failure when placing a second biliary self-expandable metallic stents(SEMSs). METHODS This study evaluated 65 patients with an unresectable malignant hilar biliary obstruction who were examined in our hospital. Sixty-two of these patients were recruited to the study and divided into two groups: the success group, which consisted of patients in whom a stent-in-stent SEMS had been placed successfully, and the failure group, which consisted of patients in whom the stent-in-stent SEMS had not been placed successfully. We compared the characteristics of the patients, the stricture state of their biliary ducts, and the implemented endoscopic retrograde cholangiopancreatography(ERCP) procedures between the two groups.RESULTS The angle between the target biliary duct stricture and the first implanted SEMS was significantly larger in the failure group than in the success group. There were significantly fewer wire or dilation devices(ERCP catheter, dilator, or balloon catheter) passing the first SEMS cell in the failure group than in the success group. The cut-off value of the angle predicting stent-in-stent SEMS placement failure was 49.7 degrees according to the ROC curve(sensitivity 91.7%, specificity 61.2%). Furthermore, the angle was significantly smaller in patients with wire or dilation devices passing the first SEMS cell than in patients without wire or dilation devices passing the first SEMS cell. CONCLUSION A large angle was identified as a predictive factor for failure of stent-in-stent SEMS placement.
文摘AIM:To evaluate the efficacy and safety of endoscopic removal and trimming of self-expandable metallic stents(SEMS).METHODS:All SEMS had been placed for distal biliary strictures.Twenty-seven endoscopic procedures were performed in 19 patients in whom SEMS(one uncovered and 18 covered) removal had been attempted,and 8 patients in whom stent trimming using argon plasma coagulation(APC) had been attempted at Tokyo Medical University Hospital.The APC settings were:voltage 60-80 W and gas flow at 1.5 L/min.RESULTS:The mean stent indwelling period for all patients in whom stent removal had been attempted was 113.7 ± 77.6 d(range,8-280 d).Of the 19 patients in whom removal of the SEMS had been attempted,the procedure was successful in 14(73.7%) without procedure-related adverse events.The indwelling period in the stent removable group was shorter than that in the unremovable group(94.9 ± 71.5 d vs 166.2 ± 76.2 d,P = 0.08).Stent trimming was successful for all patients with one minor adverse event consisting of self-limited hemorrhage.Trimming time ranged from 11 to 16 min.CONCLUSION:Although further investigations on larger numbers of cases are necessary to accumulate evidence,the present data suggested that stent removal and stent trimming is feasible and effective for stent-related complications.
文摘Biliary duct injuries are frequently iatrogenic, being associated with surgery for gallbladder stones. However, blunt abdominal trauma such as a motor vehicle crash is a rare cause of extrahepatic biliary stricture. A few reports have been published on biliary strictures treated with endoscopic therapy. In the present study, we describe a suprapancreatic biliary stricture associated with mesenteric tear following road traffic accident. We performed endoscopic stent placement, which was successful in relieving the biliary stricture.
文摘Endoscopic retrograde cholangiopancreatography(ERCP)with stenting is the treatment modality of choice for patients with benign and malignant bile duct obstruction.ERCP could fail in cases of duodenal obstruction,duodenal diverticulum,ampullary neoplastic infiltration or surgically altered anatomy.In these cases percutaneous biliary drainage(PTBD)is traditionally used as a rescue procedure but is related to high morbidity and mortality and lower quality of life.Endoscopic ultrasound-guided biliary drainage(EUS-BD)is a relatively new interventional procedure that arose due to the development of curvilinear echoendoscope and the various endoscopic devices.A large amount of data is already collected that proves its efficacy,safety and ability to replace PTBD in cases of ERCP failure.It is also possible that EUS-BD could be chosen as a first-line treatment option in some clinical scenarios in the near future.Several EUS-BD techniques are developed EUS-guided transmural stenting,antegrade stenting and rendezvous technique and can be personalized depending on the individual anatomy.EUS-BD is normally performed in the same session from the same endoscopist in case of ERCP failure.The lack of training,absence of enough dedicated devices and lack of standardization still makes EUS-BD a difficult and not very popular procedure,which is related to life-threatening adverse events.Developing training models,dedicated devices and guidelines hopefully will make EUS-BD easier,safer and well accepted in the future.This paper focuses on the technical aspects of the different EUS-BD procedures,available literature data,advantages,negative aspects and the future perspectives of these modalities.
文摘Acute pancreatitis is the most common and the most fearful complication of endoscopic retrograde cholangiopancreatography (ERCP).Prevention of post-ERCP pancreatitis has therefore been of great interest to endoscopists performing ERCP procedures.So far,only pancreatic duct stenting during ERCP and rectal administration of a non-steroidal anti-inflammatory drug (NSAID) prior to or immediately after ERCP have been consistently shown to be effective for prevention of post-ERCP pancreatitis.This commentary focuses on a short discussion about the rates,mechanisms,and risk factors for post-ERCP pancreatitis,and effective means for its prevention with emphasis on the use of NSAIDs including a recent clinical trial published in The New England Journal of Medicine by Elmunzer et al.
文摘Acute colonic obstruction,a life-threatening condition often caused by malignant or benign strictures,necessitates rapid and effective intervention to avoid severe complications such as bowel perforation or sepsis.Self-expandable metal stents(SEMS)have emerged as a minimally invasive,effective treatment alternative,either as a bridge to surgery or for palliation in malignant cases.This editorial focuses on the current mechanisms and techniques for SEMS placement in acute colonic obstruction,discussing the various endoscopic approaches,stent design considerations,technical success rates,complications,and long-term outcomes.We explore cutting-edge techniques such as fluoroscopy-free endoscopic placement,two-person colonoscopy,and the use of advanced endoscopic equipment like slim gastroscopes and ultrathin endoscopes.Additionally,the editorial delves into complications associated with SEMS placement,such as stent migration,perforation,and occlusion,and discusses strategies to mitigate these risks.Finally,future directions in SEMS technology,including advancements in stent design and optimal timing for surgery,are presented.
文摘Hilar cholangiocarcinoma has been reputed as a slow growth tumor in the past. Skeletal muscle is one of the most unusual sites of metastasis from any malignancy. We report herein a case of hilar cholangiocarcinoma with synchronous metastases to skeletal muscle and breast, and review the literature. The patient was a 48-year-old woman who presented with jaundice and weight loss. An inoperable hilar cholangiocarcinoma was diagnosed. She was treated with a combination of endoscopic plastic stent biloiary drainage and three-dimensional conformal radiotherapy （3DCRT）. Good response was achieved. Ten months later, she exhibited with a painful metastatic mass in the muscle rectus femoris of left thigh and a painless mass in the left breast. She underwent operation to relieve the pain, but died from liver failure after 8 months. The literature only offers isolated cases of cholangiocarcinoma with distant metastases, of which the common sites were cervical lymph node, bone, and portal venous system. Most patients were presented with multiple metastases with extensive local disease.
