Benign biliary strictures associated with recurrent pyogenic cholangitis: treatment with expandable metallic stents

OBJECTIVE: The purpose of this study was to determine the long-term effectiveness of expandable metallic stents in benign biliary strictures associated with recurrent pyogenic cholangitis and the differences in primary patency of the various types of stents deployed. SUBJECTS AND METHODS: During a 20-month period, 26 metallic stents (19 Gianturco-Rosch Z stents and seven Strecker stents) were used to treat benign biliary strictures associated with recurrent pyogenic cholangitis in 23 patients (11 men and 12 women; mean age, 42 years; range, 30-78 years). Insertion routes were percutaneous transhepatic biliary drainage tracts for 16 stents, T-tube tracts for seven stents, and retrograde endoscopic routes for three stents. The deployed locations were common hepatic or common bile ducts for 11 stents, right or left hepatic ducts for 10 stents, and segmental ducts for five stents. RESULTS: The initial technical success rate was 100%. Two stents in one patient migrated spontaneously. Primary stent patency for the remaining 24 stents was 34 months (range, 3-58 months). Primary stent patency of the Gianturco-Rosch Z and Strecker stents was 50 and 10 months, respectively (p < .05). Primary stent patency for the intrahepatic and extrahepatic ducts was 50 and 18 months, respectively (p = .05). Primary patency rates for all stents at 6, 12, 24, and 36 months were 92%, 75%, 67%, and 46%, respectively. The causes of stent obstruction were recurrent stone or sludge in eight stents and epithelial hyperplasia in five stents. CONCLUSION: We believe that metallic stent placement is not an effective long-term treatment technique for benign biliary stricture associated with recurrent pyogenic cholangitis.     

Ureteroileal anastomotic strictures: an innovative approach with metallic stents

PURPOSE: We report our experience with the use of self-expandable metallic stents to bypass anastomotic strictures after ureteroileal urinary diversion. MATERIALS AND METHODS: We evaluated 3 men and 1 woman with invasive bladder carcinoma who underwent radical cystectomy and ileal conduit urinary diversion. Ureteroenteric anastomotic strictures developed after a mean of 16 months. Self-expandable metallic stents were successfully placed (bilaterally in 2) comprising 6 stented ureters that bypassed strictures. Mean patient age was 64 years and mean followup was 12 months. RESULTS: No restenosis was observed in 3 patients during followup. The stricture recurred 1 month after stent placement in the remaining patient and additional intervention was necessary, consisting of placement of a totally coaxial overlapping metal stent. No sepsis or other complication was observed. One patient died of metastatic disease 12 months after stent placement. CONCLUSIONS: We propose the use of metal stents as an adequate, safe and effective alternative treatment for anastomotic strictures after ureteroileal diversion.     

Yamakawa prosthesis with prolonged placement as a therapy concept exemplified by benign biliary stricture

AIM: As an alternative method to the operative revision of benign bile duct strictures, we report the use of a large-bore bile duct prosthesis (Yamakawa prosthesis) in one patient. METHODS: Bilateral percutaneous transhepatic implantation of Yamakawa prostheses (14 F right side, 12 F left side) was performed without adjunctive balloon dilatation. The prostheses were exchanged every 8 weeks under continuous antibiotic treatment and were finally removed after 8 months. RESULTS: Control cholangiography showed a normal intrahepatic biliary system on the right side and a 50% stenosis at the orifice of the left hepatic duct. Follow-up over 18 months showed no signs of recurrent disease. CONCLUSIONS: In comparison to balloon dilatation and implantation of metallic stents, prolonged bilateral splinting with large-bore Yamakawa prostheses seems to be an alternative for the treatment of benign bile duct strictures.     

Expandable metallic biliary stents

Eighteen expandable metallic biliary stents were inserted in patients with malignant (16 patients) or benign (two patients) biliary strictures. Four were the Gianturco-Rosch biliary Z-stents and the remaining 14 were the Wallstent. The stents were delivered through either the endoscopic transpapillary (10 patients), percutaneous transhepatic (five patients) or combined percutaneous-endoscopic (three patients) route. No failure in implantation was encountered. Bile drainage was successful in all patients. Stent occlusions were observed in four patients with hilar obstruction due to tumour overgrowth above the stents at 30-67 days (mean 47.75 days) after insertion. The occlusions were drained percutaneously (two patients) or endoscopically (two patients). Migration of stent did not occur. After a median follow-up period of 170.5 days (range 57-731 days), 11 patients were still alive and free of jaundice. The median patency period of the stents for common bile duct and hilar obstruction was 288.5 days (range 117-731 days) and 61.5 days (range 30-188 days), respectively. The overall median patency period was 165 days. It is concluded that expandable metallic biliary stent is a useful adjunct to the treatment of malignant biliary obstructions with a better result in distal obstruction.     

Usefulness of cholangioscopy in patients with focal stricture of the intrahepatic duct unrelated to intrahepatic stones

BACKGROUND: Intrahepatic duct strictures are usually caused by intrahepatic duct stones and cholangitis. However, focal strictures of the intrahepatic duct unrelated to intrahepatic stones often pose diagnostic problems. This study was undertaken to prospectively evaluate the usefulness of percutaneous transhepatic cholangioscopy in patients with focal intrahepatic duct stricture and no evidence of a stone. METHODS: Seventeen patients with focal strictures of the intrahepatic duct without any evidence of a stone were included. Percutaneous transhepatic cholangioscopic examination including procurement of biopsy specimens was performed after percutaneous transhepatic biliary drainage. RESULTS: A histopathologic diagnosis was obtained in all patients (9 adenocarcinomas, 1 squamous cell carcinoma, 2 hepatocellular carcinomas, 2 adenomas, and 3 benign strictures). Of the 9 patients with bile duct adenocarcinoma, 8 underwent surgery and a curative resection was possible in 7 patients (88%). Five patients (63%) had early-stage bile duct cancer in which cancer invasion was limited to the mucosa or fibromuscular layer and there was no evidence of lymph node metastasis. CONCLUSIONS: Percutaneous transhepatic cholangioscopy in patients with focal stricture of the intrahepatic duct unrelated to choledocholithiasis is useful for diagnosis including the detection of early bile duct cancer.     

Application of rectal stents for palliation of obstructing rectosigmoid cancer

BACKGROUND: The rationale of palliative endoscopic treatment is to avoid a colostomy in patients with advanced disease and limited life expectancy. This study was conducted to evaluate the role of endoscopic stent implantation for palliation of obstructing rectal cancer. METHODS: Overall, 19 patients (aged 47-87 years) with nonresectable or metastatic rectal cancer were treated by stent insertion after laser recanalization or dilation. Three types of stents, i.e., plastic tubes (n = 8), self-expanding mesh stents (n = 6), and endocoil stents (n = 5), were used to maintain luminal patency. RESULTS: Endoscopic stent implantation was successfully performed in all 19 patients. Long-term luminal patency and satisfactory bowel function were achieved in 16 of 19 patients (84%). After a median follow-up of 6 months, eight of the patients have died and eight are still alive without evidence of recurrent obstruction. Dislocation of the endoprosthesis occurred in two of eight plastic tubes and one of five mesh stents. Recurrent obstruction due to tumor ingrowth was only observed in patients treated with self-expanding mesh stents (n = 2). In spite of reinsertion and laser therapy a colostomy was required in three of 19 patients. There was no evidence of treatment failure in five patients who received endocoil stents. None of the patients experienced serious complications related to the endoscopic procedure. CONCLUSIONS: Endoscopic stent implantation seems to be a safe and efficient palliative approach to selected patients with obstructing rectal cancer. Currently, self-expanding coil stents are superior to other devices because of lower risk of dislocation and tumor ingrowth.     

Characterization and specificity of B-cell responses in lupus induced by Mycobacterium bovis in NOD/Lt mice

BACKGROUND: Endoscopic treatment of postoperative benign bile duct strictures (BBDS) is technically challenging, and the long-term outcome after stricture dilation remains poorly defined. METHODS: Forty-eight cases of postoperative BBDS with attempted endoscopic treatment (either transient plastic stenting or definitive metal stent insertion) were reviewed. RESULTS: Endoscopic stricture dilation succeeded in 47 of 48 cases (98%). No procedure-related mortality was observed; 16 (33%) procedure-related or stent-associated complications were observed during treatment. Endoscopic treatment was interrupted in five patients. Stricture relapse occurred in 6 of 6 (100%) and 7 of 36 (19%) patients after metal stent insertion and plastic stent removal, respectively (p < 0.001) (mean follow-up periods 50+/-12 and 44+/-34 months, respectively). After plastic stent removal, stricture relapses were more frequent among patients with strictures related to liver transplantation as opposed to other surgical procedures (p < 0.05); these recurrent strictures were successfully treated by repeated insertion of plastic stents on a temporary basis. At the end of follow-up, all but one patient treated with plastic stents had normal serum alkaline phosphatase values. CONCLUSION: Metal stents proved to be inadequate for treating postoperative BBDS. Temporary insertion of a plastic stent (possibly repeated) provided long-term results equal or superior to those reported for surgical biliary drainage. Repeated insertion of plastic stents was more frequently indicated for strictures related to liver transplantation compared with other surgical procedures.     

Benign and malignant esophageal strictures: treatment with a polyurethane-covered retrievable expandable metallic stent

PURPOSE: To evaluate the clinical effectiveness of a polyurethane-covered, retrievable, self-expandable metallic stent and hook catheter in the treatment of esophageal strictures. MATERIALS AND METHODS: Stents were constructed of 0.4-mm stainless steel wire in a cylindric zig-zag configuration of six to nine bends. Four to eight stents were connected in tandem by dipping in a polyurethane solution. A nylon loop was hooked inside to each bend of the proximal portion of the stent and strung with a thread. Under fluoroscopic guidance, 22 stents were placed in 16 patients with a malignant stricture and five patients with a benign stricture. The stent was removed with a hook catheter 2 months after placement in patients with a benign stricture and when complications occurred in patients with a malignant stricture. All patients had dysphagia with ingestion of soft foods or liquids. RESULTS: Stent placement was technically successful and well tolerated in 20 patients. In one patient, the stent was misplaced but relocated successfully. After stent placement, all patients were able to ingest solid and/or soft foods without dysphagia. After stent removal, strictures showed improvement but recurred in two patients. CONCLUSION: Use of polyurethane-covered, retrievable expandable stents seems to be a feasible and effective method of treatment of benign and malignant esophageal strictures.     

Difficulties in diagnosing pulmonary visceral forms of rheumatoid arthritis in tuberculous hospital

We describe the diagnostic workup and therapeutic management of patients with hepatolithiasis from the viewpoint of the interventional radiologist. The diagnosis is best established by direct cholangiography such as percutaneous transhepatic cholangiography or endoscopic retrograde cholangiography. We consider percutaneous transhepatic stone removal a highly successful, minimally invasive, and safe procedure. Access can be gained to the biliary system in almost 100% of patients and complete stone clearance through percutaneous techniques, including stone fragmentation, removal of stones and fragments by baskets, and dilatation of underlying strictures in more than 90%. The role of these radiologic techniques is discussed vis-à-vis endoscopic and surgical alternatives.     

Long-term results of endoscopic treatment of biliary duct obstruction due to pancreatic disease

BACKGROUND/AIMS: Endoscopic stenting has become an established method of providing palliative treatment in cases of malignant biliary obstruction, as well as in benign biliary stenosis. Several problems associated with the types of stent used have not yet been resolved, and an ideal stent has yet to be designed. Observation of the clinical course for patients with biliary obstruction of various etiologies, and evaluation of the results with various treatment methods are the aims of this study. METHODOLOGY: In 1993 and 1994, biliary obstruction was treated endoscopically in 47 patients with a malignant pancreatic tumor and in 18 patients with chronic pancreatitis. The primary intervention was assessed retrospectively on the basis of the patients' records, and information concerning the clinical course was obtained by contacting the patients or their relatives or general practitioners. RESULTS: Primary endoscopic drainage was successful in all cases. Only one of the patients with pancreatic tumors is still alive; survival after stent placement averaged 6.2 months. Metal stents remained patent significantly longer than plastic stents and percutaneous transhepatic biliary drains (PTBDs)(8.2 versus 3.5 or 1.9 months; p < 0.001). In cases of chronic pancreatitis, three of the nine patients who received only endoscopic treatment, without stenting, were able to continue without stents in the longer term, whereas seven of the nine who underwent surgery had no further problems. CONCLUSIONS: Endoscopic drainage of biliary obstruction provides excellent short-term results. In long-term treatment for purely palliative purposes, metal stents remain patent for longer than plastic stents. In chronic pancreatitis, surgical treatment clearly seems to provide better long-term results than endoscopic therapy.     

Percutaneous and transpapillary laser lithotripsy of intrahepatic gallstones

PROBLEM AND OBJECTIVE: In the last few years several intra- and extracorporeal endoscopic methods have been developed for treating intrahepatic gallstones, but as yet no ideal instrumentation has been found. This study was undertaken to test the efficacy and possible complications of intracorporeal laser lithotripsy for intrahepatic gallstones. PATIENTS AND METHODS: 16 consecutive patients were included (13 women and 3 men, median age 64 [28-82] years) with intrahepatic biliary tract stones which could not be removed by conventional endoscopy. A rhodamine-6G-laser with an integrated stone recognition system was used. The glass fibres of the laser instrument were introduced perorally or percutaneously and placed at the stone. RESULTS: The percutaneous procedure under cholangioscopic control succeeded in four of the patients, while 12 were treated by a transpapillary approach (two under fluoroscopic, ten under cholangioscopic control). In eight of the latter group all stones were completely fragmented, i.e. 12 of the total were successfully treated. Of the remaining four patients two were cleared of stone by additional measures (extracorporeal shockwave lithotripsy and electrohydraulic lithotripsy, respectively), two were treated pallatively by endoprosthesis. One patient developed an acute cholangitis which was successfully treated with antibiotics and biliary drainage. There were no deaths. CONCLUSIONS: Particularly when performed transcutaneously, laser lithotripsy provides effective treatment of intrahepatic gall stones. Cholangioscopic monitoring, to place the glass fibre at the stone, is usually required in the transpapillary approach.     

MR imaging of idiopathic trigeminal neuralgia: correlation with non-surgical therapy

Urinary drainage by indwelling double J ureteral stent is well documented in the urologic literature. We used these stents in 91 patients. The majority of stents were placed endoscopically (68%). Indications were: -Ureteral obstruction (39 cases) such as tuberculous ureteral strictures, obstruction due to urolithiasis and pelvic malignancies. -Upper urinary tract surgery (29 cases) mainly pyeloplasty, pyelolithotomy, ureterovaginal fistula repair and ureteroneocystostomy. -Adjunct to endourologic treatment (16 cases) such as ureteroscopy and endopyelotomy. -Preparation for extracorporeal lithotripsy (7 cases). The complication rate associated with placement of double J stents was minimal (6.6%). The major complication was migration (3 cases). The average drainage time was 5.8 weeks. In view of these results we conclude that double J stent is safe, effective and has minimal complications.     

Automatic typing of bacterial isolates

PURPOSE: To assess the use of self-expanding metallic stents in patients with inoperable malignant antrum-pylorus-duodenal obstruction. METHODS: Six patients underwent implantation of a Wallstent self-expanding metallic endoprosthesis (20 mm in five patients and 16 mm in one). In five patients a catheter (Berenstein) was introduced perorally into the stomach. A guidewire (Terumo) was introduced through the catheter and advanced through the antrum-pylorus-duodenal stenosis. The guidewire was removed and a 260-cm-long, 0.035" superstiff guide (Amplatz) was introduced. After the catheter was removed the stent assembly was introduced. In the last patient the stent was implanted through a percutaneous gastrostomy. RESULTS: Treatment of inoperable gastric outlet obstruction caused by tumor compression is difficult and unsatisfactory. Peroral implantation of self-expanding metallic stents resulted in successful palliative therapy of antrum-pylorus-duodenal stenosis in six patients in whom surgery was not possible because of advanced disease and poor general condition. On average, patients were able to eat during 41 days. One patient is tolerating oral intake at 3 months. CONCLUSION: Implantation of stents resulted in palliative relief of malignant antrum-pylorus-duodenal obstructions.     

A stereologic study on the influence of stent tube pressure on bilio-intestinal anastomotic scar formation

Biliary tract injury results often in biliary scar stricture causing obstructive jaundice and biliary cirrhosis. Choledocho-jejunostomy with tube stent is the routine to prevent anastomotic stenosis, but how long the stent tube should be in place is controversial and little is known on the influence of the stent tube on anastomotic scar formation. In canine experimental models, bili-intestinal scar was sampled 3 weeks, 3, 6, 9 and 12 months after anastomosis for ultrastructure stereologic image analysis. It was found that the internal pressure of the stent tube exerting on anastomotic stoma inhibits scar formation, and the stent tube should be remained inside the stoma for not less than 9 months.     

Crohn''s disease and sclerosing cholangitis: CT and PTC diagnosis, with MR findings

Computed tomography (CT), percutaneous transhepatic cholangiography (PTC) and magnetic resonance imaging (MRI) findings in a case of sclerosing cholangitis associated with Crohn's disease of the colon and terminal ileum are described. CT gives additional information on dilatation of peripheral bile ducts and confirms findings of PTC, i.e. a decreased arborization of the biliary tree, a nodular appearance of the common bile duct and multifocal bile duct strictures. CT findings could be recognized on MRI which provided no additional information.     

Use of multiple urolume endourethral prostheses in complex bulbar urethral strictures

PURPOSE: We evaluated patients who received multiple UroLume Wallstents during the North American UroLume trial for the treatment of recurrent bulbar urethral strictures. MATERIALS AND METHODS: A total of 41 patients received multiple UroLume stents. The clinical histories and therapeutic outcomes of these patients were reviewed. RESULTS: Of the patients 23% required placement of multiple urethral stents. Stents placed at the initial procedure were required for strictures longer than 2.5 cm. and for multiple, separate strictures. Indications for secondary insertion included recurrent stricture adjacent to the stent, hyperplastic tissue growth within the stent and gaps between previously adjacent stents. The repeat treatment rate was 43.9% versus 14.3% for the study group overall. Urine flow rates and symptom scores in the multiple stent group showed improvement similar to that of the study group overall. CONCLUSIONS: Patients who required multiple stents had greater rates of repeat treatment but similarly improved urine flows and symptom scores, which were maintained at 2 years.     

Percutaneous bile duct drainage; experiences with a new type of endoprosthesis]

Self expandable stents were placed percutaneously in 105 patients with malignant biliary obstruction. Stent diameter was 1 cm; length, 3.5-10.5 cm. Of the 60 patients with common bile duct obstruction, 50 died 0.2-12 months (median 3 months) after stent insertion. Two patients developed recurrent jaundice and cholangitis after 6 and 12 months, respectively. One patient underwent reintervention. Ten patients, one after a successful reintervention, were alive without jaundice 1-8 months (median 5 months) after stent placement. Of the 45 patients with hilar lesions, 26 died 0.7-18 months (median 5 months) after stent placement, five of them with signs of cholangitis. Nineteen are alive 1-21 months (median 7 months) afterwards. Reinterventions were carried out in 13 patients (29%). The most common cause of stent malfunction was tumour overgrowth. Stent-related complications were seen in three patients.     

Effect of growth hormone therapy in children with achondroplasia: growth pattern, hypothalamic-pituitary function, and genotype

PURPOSE: To evaluate the success rates of the implantation of stent grafts in the treatment of peripheral aneurysms. MATERIALS AND METHODS: In 13 patients with 15 aneurysms at the common iliac artery (n = 6), external iliac artery (n = 1), hypogastric artery (n = 2), femoral artery (n = 2) or popliteal artery (n = 4), implantation of dacron-covered nitinol stents was performed. The patients were followed up for three to 20 months (mean, 8.8 months) with intravenous digital subtraction angiography, CT or colour-coded Doppler sonography. RESULTS: In all cases, the aneurysm was successfully occluded after stent implantation. In one case with a popliteal aneurysm, kinking of the vessel caused thrombosis of the stent. The stent was successfully reopened. The aneurysm however, had to be surgically treated 9 months later. The primary and secondary patency rates at 6 months were 93% and 100%, respectively. CONCLUSION: The method described might be an alternative therapy to surgery. There are some limitations in respect of treatment of popliteal aneurysms.     

Outcome of percutaneous intervention in iliac artery stents

PURPOSE: To assess the safety and efficacy of secondary procedures in iliac artery stents. MATERIALS AND METHODS: Thirty-four patients (36 limbs) underwent one or more interventional procedures in iliac artery stents to treat restenosis (n = 30) or occlusion (n = 6). All patients were followed up by means of clinical and angiographic examination. Primary and secondary patency were assessed with angiography, duplex ultrasound, or both. Primary patency was determined after one interventional procedure, and secondary patency was determined at the end of the study (mean +/- standard deviation, 20.1 months +/- 17.5; range, 1-58 months). RESULTS: Immediate angiographic success was achieved in all cases. Four complications were observed. The primary and secondary cumulative patency rates were 77.5% +/- 7.6 and 94% +/- 4.1 at 6 months, 73% +/- 8.4 and 89.3% +/- 6 at 12 months, and 51.4% +/- 10.9 and 78.8% +/- 8.8 at 2 years. At the end of the study, 80% of the arteries were still nominally patent. CONCLUSION: Restenosis and chronic occlusion in iliac artery stents can be treated with percutaneous interventional procedures; however, stenosis can still recur.     

Stent implantation as a palliative therapeutic measure in stenosing tumors of central airways

PURPOSE: Stent implantation was used to treat patient with malignant tracheobronchial obstructions to determine the effectiveness in producing symptomatic palliation. METHODS: 18 patients (15 men and three women; median age 57 years) with malignant tracheobronchial stenosis were treated by application of metal stents (15 Palmaz-, 10 Gianturco-, 4 Wallstents). The indication for stent implantation was given in 13 patients by clinically significant dyspnea, besides in 5 patients by therapy resistant postobstructive pneumonia. RESULTS: In 17 patients correct positioning of the stents was achieved and the symptoms completely disappeared until tumor related death. Median survival was 137 days (min. 10 days to max. 322 days). In one patient symptoms recurred three months after stent implantation. CONCLUSION: The application of metal stents in patient with malignant tracheobronchial obstruction appears to be a useful palliation procedure. The treatment was well tolerated and very effective.