Search Results (99)

Background/Objectives: Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) using a fully covered self-expandable metal stent (FCSEMS) is an alternative to endoscopic retrograde cholangiopancreatography for biliary drainage; however, FCSEMSs may cause intrahepatic bile duct (IHD) obstruction and cholangitis. In this study, we developed an FCSEMS with multiple self-made side holes at its tip and evaluated its safety and efficacy. Methods: This retrospective study included 100 patients who underwent EUS-HGS with FCSEMS placement between April 2022 and October 2023. Fifty patients received a conventional FCSEMS, and 50 received an FCSEMS with multiple self-made side holes. Technical and clinical success, residual contrast in the IHD, recurrent biliary obstruction (RBO), and adverse events (AEs) were then evaluated. The clinical success rates were 98% and 90% for the side hole and conventional FCEMS groups, respectively. The amount of residual contrast in the IHD was lower in the side hole group (0% vs. 12%, p = 0.027). RBO incidence was significantly lower in the side hole group (8% vs. 30%, p < 0.001), with migration as the primary cause in the conventional group. Early AEs, including segmental cholangitis, occurred only in the conventional group. During reintervention, all stents were safely removed. Conclusions: The FCSEMSs with multiple side holes reduced IHD occlusion and cholangitis, improving biliary drainage and safety. Further studies are needed to confirm these findings. Full article

Background/Objectives: Esophageal anastomotic leaks (EALs) are among the most feared complications following upper gastrointestinal surgery, particularly esophagectomy, given their profound impact on patient outcomes and healthcare resource utilization. This study aims to synthesize the evidence and determine the most effective interventions for achieving leak closure in patients with esophageal anastomotic leaks. Methods: This umbrella review followed PRISMA guidelines. A comprehensive search was conducted in PubMed, the Web of Science, Scopus, Google Scholar, Cochrane, and PROSPERO. Systematic reviews/meta-analyses on esophageal anastomotic leak management were included. The outcomes analyzed included leak closure success, mortality, complications, hospital stay, and costs. Data were synthesized narratively, with disagreements resolved by a third reviewer. Results: A systematic search identified 730 records, from which six systematic reviews and meta-analyses (evaluating 65 studies and 2186 patients) met the inclusion criteria. Most studies compared endoscopic vacuum therapy (EVT) and self-expanding metal stents (SEMSs) for EALs, with Germany contributing the majority. EVT consistently demonstrated superior leak closure rates and lower mortality compared to SEMSs, with pooled odds ratios favoring EVT. EVT also showed reduced complication rates, particularly fewer major adverse events, although with a slightly higher risk of post-therapy strictures. Hospital stay durations varied, with some studies reporting shorter treatment periods for EVT but no significant differences in the overall hospitalization length. Limited data suggested that EVT incurs higher treatment costs, largely due to intensive care unit stays. Conclusions: EVT is the most effective intervention for EALs, offering superior leak closure, lower mortality, and fewer complications. However, its economic impact requires further evaluation. Full article

Background/Objectives: Data on the natural history and endoscopic treatment outcomes of recurrent anastomotic biliary stricture (RABS) after orthotopic liver transplantation (OLT) are limited. This study aimed to evaluate the incidence and outcomes of RABS after OLT. Methods: A retrospective single-center study on OLT patients who underwent successful endoscopic treatment of ABS was conducted. The incidence of RABS, risk factors for recurrence, and outcomes of repeat endoscopic therapy were recorded. Results: A total of 131 OLT patients with ABS underwent endoscopic treatment, of which 119 successfully completed an endoscopic treatment course. After a median follow-up of 51.5 months (IQR 18.5–86.25) from ABS resolution, 26/119 patients (22.7%) developed RABS. All patients with RABS underwent a second endoscopic treatment course; 24 patients received self-expandable metal stents and 2 received plastic stents. Re-treatment was successful in 21 patients (80.8%) after a median of 8.5 months (IQR 5.25–14.50) and a total of 62 ERCPs. Adverse events occurred in two patients (7.4%)—one bacteremia and one suprastenotic biliary stricture. After a median follow-up of 65.5 months (IQR 20.75–125.5) from stent removal, only one patient had a second recurrence, which was treated with a Roux-en-Y hepaticojejunostomy. Multivariate analysis showed that older age at ABS diagnosis (OR 1.1; 95% CI: 1.1–1.2 p = 0.04) was the only independent risk factor for recurrence. Conclusions: RABS affects more than 20% of patients after successful endoscopic treatment. A second endoscopic therapy with covered self-expandable metal stents is a safe and effective option and should be considered before more invasive options. Full article

Background: Over the last two decades, therapy for benign esophageal strictures has shifted from empirical dilatations and surgery to evidence-based and complex endoscopic and surgical procedures, aiming to achieve long-term esophageal patency. Aim: The purpose of our study is to provide descriptive evidence regarding the appropriate tailored medical, endoscopic, and surgical management of benign esophageal strictures. Methods: This retrospective study includes patients with benign esophageal strictures; the data collected encompass the complete patient profiles, detailed etiologic and anatomic workups of the strictures, comprehensive imaging, as well as management and follow-up details. Technical and clinical success rates, adverse events, stricture patency, and the need for additional therapy have been evaluated. Results: Most of the strictures (80.2%) were complex, requiring advanced techniques for management. The primary treatment involved endoscopic dilation, performed with Savary-Gillard bougie dilators in 76.7% of cases and pneumatic balloon dilators in 23.3% of cases. Clinical success was achieved in 95.3% of patients, with a significant improvement in the Ogilvie dysphagia score. Patients with caustic strictures required repeated dilations over the years, compared to shorter intervals for peptic strictures. Adverse events were minimal (e.g., perforation 2.3% and bleeding 4.7%) and managed predominantly endoscopically. Refractory strictures (16.3%) required advanced interventions, including fully covered self-expandable metallic stents (fc-SEMS) and corticosteroid injections. Conclusions: Both our data and the current literature support the use of tailored endoscopic strategies as the first-choice options for managing benign esophageal strictures. Our results strongly suggest against one-size-fits-all therapeutic alternatives. Full article

Anastomotic strictures are a common complication following esophagogastric surgery, with prevalence varying depending on the type of surgery and anatomical site. These strictures can lead to debilitating symptoms such as dysphagia, pain, and malabsorption, significantly impacting patients’ quality of life. Endoscopic treatment of anastomotic strictures has established a role as the first-line strategy in this setting instead of revision surgery, offering benefits in terms of lower morbidity. Various endoscopic methods are available for anastomotic stricture management, including balloon dilation, stent placement, the new lumen-apposing metal stent, and endoscopic incision techniques. However, there is currently no strong evidence and established guidelines for the optimal treatment strategy. Available data suggest that endoscopic treatments, when performed in tertiary referral centers, can provide favorable outcomes in terms of symptom relief and reduced need for rescue surgical intervention. Nonetheless, challenges remain regarding the management of recurrent strictures and procedural complications, underscoring the need for a personalized, multidisciplinary approach to optimize clinical outcomes. This review aims to provide an updated overview of endoscopic techniques and available evidence with a focus on the most recent technologies, supporting clinicians in effectively managing anastomotic strictures in complex clinical settings. Full article

Background and Objectives: This study evaluated the safety and efficacy of long-term indwelling self-expandable covered metallic stents (UVENTA; Taewoong Medical Co., Ltd., Seoul, Republic of Korea) used to manage benign and malignant ureteral strictures. Materials and Methods: We retrospectively identified and analyzed the medical records of all patients who underwent metallic stent insertion at our institution since September 2012. Additionally, we evaluated the technical and clinical success rates and complications of patients who underwent follow-up for more than 36 months. Results: A total of 25 patients underwent metallic stent insertion for ureteral obstructions at our institution. Among them, 18 underwent follow-up for more than 36 months. A total of 21 ureters (15 unilateral and 3 bilateral) were ultimately included in this study. Metallic stents were successfully placed in all ureters using a retrograde approach, with a technical success rate of 100%. The mean follow-up duration was 58.6 months (range, 36–107 months). However, the clinical success rates were 85.7% (18/21 ureters) by 12 months, 61.9% (14/21 ureters) by 24 months, and 52.4% (11/21 ureters) after 36 months. During follow-up, obstructions could not be resolved using metallic stents in eleven ureters (median time to failure, 18.4 months; range, 2−40 months); therefore, they were treated with nephrectomy (three ureters because of a nonfunctional kidney) or percutaneous nephrostomy and double J stent placement (four ureters). Major complications included the encrustation of the metallic stent, flank pain, and gross hematuria. A uretero-enteric fistula occurred in one ureter. In two patients, existing metallic stents were removed and patency was maintained. In another two patients, new metallic stents were inserted without complications. Conclusions: Benign and malignant ureteral obstructions may be treated effectively and safely with metallic stents. However, the patency rate drastically decreased and major complications occurred during long-term follow-up. Therefore, careful patient selection is necessary to achieve better results. Full article

Background: Endoscopic self-expandable metallic stent (SEMS) placement is a widely accepted treatment for malignant left-sided colorectal obstruction (LSO) because of its lower invasiveness and quicker symptomatic relief compared to surgery. However, SEMS placement for ileocecal valve obstruction (ICVO) has not been established due to its technical difficulties. Methods: This single-center retrospective study compared the clinical outcomes of patients who underwent SEMS placement for ICVO (ICVO group, n = 13) and LSO (LSO group, n = 146). Particularly in cases with severe small-intestine dilation, we applied a “Two-Step Strategy”, which involved long intestinal tube insertion followed by SEMS placement to ensure safety and overcome technical challenges. Results: Patients in the ICVO group were significantly more likely to undergo SEMS placement with the Two-Step Strategy compared to those in the LSO group (76.9% vs. 6.9%, p < 0.001). Both groups achieved similarly high technical and clinical success rates (100% vs. 98.6%, p = 1.000; 92.3% vs. 88.4%, p = 1.000), and the incidence of adverse events also showed no significant difference between the groups (7.7% vs. 13.0%; p = 1.000). Furthermore, the median time to recurrent colorectal obstruction and survival time after SEMS placement did not differ between patients with palliative stenting for ICVO and LSO (not reached vs. 430 days, p = 0.586; 119 days vs. 200 days, p = 0.303). Conclusions: SEMS placement for malignant ICVO is as safe and effective as it is for malignant LSO, and the Two-Step Strategy might be useful in ICVO cases. Full article

Colorectal cancer (CRC) is a leading cause of cancer mortality, with many patients presenting with malignant colorectal obstruction (MCO). Self-expandable metal stents (SEMSs) have emerged as a minimally invasive key intervention, both as a bridge to surgery (BTS) in curative setting sand for palliation in advanced disease. This review aims to provide an evidence-based analysis of SEMS indications, contraindications, and efficacy across curative and palliative contexts, with focus on long-term outcomes. Based on data from recent trials and guidelines, we examine SEMS placement outcomes, focusing on specific scenarios, including BTS for left-sided MCO, chemotherapy (with angiogenic agents) safety during stent therapy, the optimal timing between SEMS placement and surgery, and oncological outcomes. We also discuss the use of SEMSs in challenging contexts such as proximal colon obstruction and extracolonic obstruction, and the relevant technical considerations. Findings indicate that using a SEMS in the BTS setting reduces emergency surgery needs, minimizes complications, and decreases stoma formation. Long-term oncologic outcomes, particularly recurrence, are still debated, but recent evidence shows that SEMS placement is safe, without worsening long term outcomes. Palliative SEMS placement shows high efficacy in symptom relief with manageable adverse events. Success depends on patient selection and technical expertise, with multidisciplinary approaches essential for optimal outcomes. Full article

Endoscopic ultrasound (EUS)-guided interventions have revolutionized the management of malignant biliary obstruction (MBO) and gastric outlet obstruction (GOO), providing minimally invasive alternatives with improved outcomes. These procedures have significantly reduced the need for high-risk surgical interventions or percutaneous alternatives and have provided effective palliative care for patients with advanced gastrointestinal and bilio-pancreatic malignancies. EUS-guided biliary drainage (EUS-BD) techniques, including hepaticogastrostomy (EUS-HGS), choledochoduodenostomy (EUS-CDS), and antegrade stenting (EUS-AS), offer high technical and clinical success rates, with a good safety profile particularly when Endoscopic Retrograde Cholangiopancreatography (ERCP) is not feasible. EUS-HGS, which allows biliary drainage by trans-gastric route, is primarily used for proximal stenosis or in case of surgically altered anatomy; EUS-CDS with Lumen-Apposing Metal Stent (LAMS) for distal MBO (dMBO), EUS-AS as an alternative of EUS-HGS in the bridge-to-surgery scenario or when retrograde access is not possible and EUS-guided gallbladder drainage (EUS-GBD) with LAMS in case of dMBO with cystic duct patent without dilation of common bile duct (CDB). EUS-guided gastroenterostomy (EUS-GE) has already established its role as an effective alternative to surgical GE and enteral self-expandable metal stent, providing relief from GOO with fewer complications and faster recovery times. However, we do not yet have strong evidence on how to combine the different EUS-guided drainage techniques with EUS-GE in the setting of double obstruction. This comprehensive review aims to synthesize growing evidence on this topic by randomized controlled trials, cohort studies, and case series not only to summarize the efficacy, safety, and technical aspects of these procedures but also to propose a treatment algorithm based essentially on the anatomy and stage of the neoplasm to guide clinical decision-making, incorporating the principles of personalized medicine. This review also highlights the transformative impact of EUS-guided interventions on the treatment landscape for MBO and GOO. These techniques offer safer and more effective options than traditional approaches, with the potential for widespread clinical adoption. Further research is needed to refine these procedures, expand their applications, and improve patient care and quality of life. Full article

Self-Expanding Metallic (SEM) Y stents are a newer form of stent that is gaining popularity outside the USA, but still has limited data, especially in a community medicine setting. This study analyzed efficacy and complication rates in 14 patients who had a SEM Y stent placed between August 2022 and June 2024 at Harris Methodist Hospital in Fort Worth, Texas for either central airway obstruction (CAO) or fistulae. Of the 14 patients, 11 were requiring supplemental oxygen or mechanical ventilation prior to stent placement. Post-stenting 42.9% had decreased oxygen requirements, 21.4% unchanged, 14.3% increased, and 21.4% remained on room air. Complications included mucus plugging (42.9%), infection (35.7%), and granulation tissue (14.3%). There was no statistically significant correlation between gender/age and complications (p = 0.879/0.490, respectively). Complication rates were similar when compared to silicone Y stents based on literature review. In conclusion, SEM Y stents are a safe and effective alternative stent intended for palliative treatment with similar success and complications that can be easily and effectively implemented in a community hospital, with the added benefit of being able to be placed with flexible bronchoscopy. Full article

Background/Objectives: Colon cancer presents as an obstruction in almost 30% of patients. Self-expandable metallic stents emerged as an alternative to emergency surgery, despite early controversies around their use. Improved techniques led to stent incorporation in clinical guidelines. Our objective is to compare colectomies performed after the insertion of self-expandable metallic stents versus emergency surgeries in pT4 obstructive left colon cancer, analysing postoperative and oncological outcomes. Methods: This is an observational retrospective multicentre study involving 50 hospitals and analysing data from patients with pT4 obstructive tumours treated for curative intent between 2015 and 2017. Patients with left-sided obstructive colon cancer were included, with exclusion criteria being palliative surgery or incomplete resection. Primary outcomes were local, peritoneal, and systemic recurrence rates, overall survival (OS), and disease-free survival (DFS). Secondary outcomes were postoperative complications and the rate of surgeries without major complications. Results: In total, 196 patients were analysed, 128 undergoing emergency surgery and 68 receiving colonic stents. Stents more frequently allowed for minimally invasive surgeries: 33.8% vs. 4.7% (p < 0.01). The stent group showed fewer major complications (Clavien–Dindo ≥ 3) at 4.5% vs. 22.4% (p < 0.01), fewer infectious complications at 13.2% vs. 23.1% (p = 0.1), and fewer organ-space infections at 3.3% vs. 15.9% (p = 0.03). No significant differences in recurrence rates, 29.4% vs. 28.1% (p = 0.8); disease-free survival, 44.5 vs. 44.3 months (p = 0.5); or overall survival, 50.5 vs. 47.6 months (p = 0.4), were found between groups. Conclusions: Self-expandable metallic stents are a safe alternative for pT4 obstructive left colon cancer, improving postoperative outcomes without compromising short- and medium-term oncological results. Consideration of experienced clinicians and potential referral to centres with advanced stenting capabilities may enhance patient care. Full article

Developing an efficient recycling route for spent single-use medical devices is essential for recovering precious metals. The proposed complete hydrometallurgical route goes through the initial pyrolysis and acid digestion steps, expanding upon our previous relevant work in the field, followed by solvent extraction, stripping, and precipitation procedures. In this study, a complete hydrometallurgical process was developed for the recovery of gold, platinum, iridium, and tantalum, separating them from other metals, i.e., from iron, chromium, and nickel, also present in the examined medical devices, i.e., (i) diagnostic electrophysiology catheters, containing gold, (ii) diagnostic guide wires, containing platinum and iridium alloys, and (iii) self-expanding stents, containing tantalum. This study reports the experimental results of selecting an efficient extractant, stripping, and precipitation agent, along with the effects of key factors that influence each consecutive step of the process, i.e., agent concentration, aqueous to organic phase ratio, contact time, and pH, using simulated metal solutions and also applying the obtained optimal conditions to the treatment of real sample solutions. For the selective separation of gold, Aliquat 336 was used to extract it in the organic phase; it was then stripped using a thiourea solution and precipitated by utilizing an iron sulfate (II) solution and proper pH adjustment. The selective separation of platinum was achieved by using Aliquat 336 for the organic phase extraction and a perchlorate acid solution for stripping it back into the aqueous solution and adding a sodium bromate solution to precipitate it. Due to the similar chemical behavior, the selective recovery of iridium followed the same processes as that of platinum, and the separation between them was achieved through selective precipitation, as heating the solution and adjusting the pH value resulted in the selective precipitation of iridium. Lastly, the selective recovery of tantalum consists of extraction by using Alamine 336, then stripping it back to the aqueous phase by using sodium chloride, and precipitation by using potassium salt solution and proper pH adjustment. A total recovery of 88% for Au, 86% for Pt, 84% for Ir, and 80% for Ta was obtained, thus achieving a high uptake of precious metals from the examined real spent/waste samples. Full article

Background/Objectives: Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) often requires fistula dilation owing to the placement of a large diameter of the delivery stent. The recently developed delivery devices, which are as thin as 5.9/6.0 Fr, may save the need for fistula dilation. Therefore, we investigated whether large fistula dilation would be required or not in the case of this newly developed thin-diameter delivery stents. Methods: We conducted a retrospective study involving 33 patients implemented with a self-expandable metal stent (SEMS) during EUS-HGS. The patients were categorized based on the delivery device diameter into thin (n = 13; delivery device diameter: 5.9/6.0 Fr) and thick (n = 20; delivery device diameter: 8.5 Fr) groups. We compared the initial rate of success, technical success, and clinical success between the thin and thick groups. The initial rate of success was defined as successful stent placement without a balloon or large diameter mechanical dilation. Results: The rate of the initial stenting success was significantly higher in the thin group (100% [13/13]) compared with that in the thick group (65.0% [13/20]) (p = 0.027). In the thick group, seven cases with technical difficulty in terms of stent placement could be successfully completed with additional fistula dilation with a 9 Fr bougie dilator or 4 mm balloon dilator; this resulted in a technical success of 100% in both groups ultimately. The rate of clinical success was 100% and 95.0% in the thin and thick groups, respectively (p = 1.00). Conclusions: Thin delivery stents may facilitate stent placement without the need for a balloon fistula or large-diameter mechanical dilation. Full article

Several techniques exist to maintain oral and/or enteral feeding among esophageal cancer (EC) patients, but their impact on patient-reported outcomes (PROs) remains unclear. This systematic review aimed to assess the impact of nutritional support techniques on PROs in EC patients. We searched Medline, Web of Science, and CINAHL Complete from inception to 3 April 2024. Eligible studies included those evaluating EC patients, reporting PROs using standardized measures, and providing data on different nutritional support techniques or comparing them to no intervention. The reference lists of the included studies were also screened for additional eligible articles. The Mixed Methods Appraisal Tool was used to evaluate the quality of the included studies. Of the 694 articles identified from databases and 224 from backward citation, 11 studies met the inclusion criteria. Nine studies evaluated the overall quality of life (QoL), four assessed pain, and one evaluated depression. Among those submitted to esophagectomy, jejunostomy may be associated with higher QoL scores and less postoperative pain, compared to a nasojejunal tube, but no significant differences were found when compared to no intervention. For patients undergoing chemotherapy or receiving palliative/symptomatic treatment, expandable metal stents (SEMSs) were associated with higher levels of emotional functioning when compared with laparoscopic gastrostomy. Moreover, percutaneous endoscopic gastrostomy or SEMSs were associated with a higher QoL compared with nasogastric tubes. This review underscores the importance of considering PRO measures when evaluating nutritional support techniques in cancer patients, though further robust evidence is needed to fully understand these associations. Full article

Unmet needs in the treatment of chronic otitis media and Eustachian tube dysfunction (ETD) triggered the development of stents for the Eustachian tube (ET). In this study, for the first time, stents were placed in an artificially blocked ET to evaluate stent function. Eight adult female sheep were injected with stabilized hyaluronic acid (HA) on both sides to induce ETD. Subsequently, a tapered nitinol ET stent was inserted on one side, and animals were examined bilaterally by endoscopy, tympanometry, cone beam computed tomography, and final histology. Seven of the stents were placed in the desired cartilaginous portion of the ET. At the end of the study, one stented side appeared slightly open; all other ET orifices were closed. Tympanometry revealed re-ventilation of the middle ear in four out of seven correctly stented animals within 3 to 6 weeks after stent insertion. The major amount of HA was found at the pharyngeal orifice of the ET anterior to the stent. Thus, the stent position did not completely align with the HA position. While a functional analysis will require refinement of the experimental setup, this study provides first promising results for stent insertion in a sheep model of ETD. Full article