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Percutaneous retrieval of a misplaced transjugular intrahepatic portosystemic shunt stent using the rigid endobronchial forceps.

John VU ; Seung Kwon KIM

Gastrointestinal Intervention.2016;5(2):156-158. doi:10.18528/gii160001

Summary of Event: A transjugular intrahepatic portosystemic shunt (TIPS) stent (Viatorr) was misplaced into main portal vein and superior mesenteric vein. This misplaced covered stent was then successfully retrieved using the rigid endobronchial forceps. Teaching Point: Before release the covered portion of the TIPS stent (Viatorr), it is necessary to confirm the position of uncovered portion in portal vein and covered portion in parenchymal tract. The endobronchial forceps technique is a safe and efficient method for retrieving a misplaced TIPS stent.
Device Removal ; Mesenteric Veins ; Methods ; Portal Vein ; Portasystemic Shunt, Surgical* ; Portasystemic Shunt, Transjugular Intrahepatic ; Stents* ; Surgical Instruments*

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Percutaneous colonic stent insertion via a radiologically placed distal 'cecostomy' tube for the management of acute malignant bowel obstruction.

Pavan Singh NAJRAN ; Jins KALLAMPALLIL ; Jon BELL ; Hans Ulrich LAASCH ; Damian MULLAN

Gastrointestinal Intervention.2016;5(2):153-155. doi:10.18528/gii160003

Percutaneous cecostomy is an uncommon procedure but is reported as an effective temporising measure to achieve acute decompression of bowel obstruction. It has been reported as a safe procedure in the setting of bowel obstruction providing relief of symptoms. The insertion of a cecostomy in the distal colon is not routinely advised as it will not allow passage of formed faeces. Cases of antegrade stenting of proximal colonic obstruction via cecostomy have been described; however, antegrade stenting of the distal colon from access in the ascending colon can be technically challenging. We describe a case of a percutaneous colostomy inserted temporally at the splenic flexure, which provided close access to an obstructing descending colonic tumour, allowing definitive management with placement of a colonic stent. This technical feasibility case provides evidence that a temporary cecostomy placed in the distal colon can be performed as a measure to facilitate definitive management.
Cecostomy ; Colon* ; Colon, Ascending ; Colon, Descending ; Colon, Transverse ; Colostomy ; Decompression ; Stents*

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The use of self-expanding metal stents in the cervical esophagus.

Andrew THROWER ; Ayesha NASRULLAH ; Andy LOWE ; Sophie STEPHENSON ; Clive KAY

Gastrointestinal Intervention.2016;5(2):149-152. doi:10.18528/gii160002

A case series was conducted at our institution on the the use of self-expanding metal stents (SEMS) in the cervical esophagus and their tolerability. Departmental records identified 20 consecutive stents placed in the cervical esophagus of 12 patients at our institution. There were 6 men and 6 women, mean age 67.2 years (range, 47.6-91.6 years). Ten patients had either primary or recurrent malignant disease and two had benign disease; a recalcitrant stricture at the oesophago-gastric anastomosis following oesophagectomy and a tracheo-oesophageal fistula secondary to tracheomalacia. Three patients received multiple stents on separate occasions requiring 2, 3, and 6 stents. Nineteen stents were placed radiologically with fluoroscopic guidance via a per-oral route under conscious sedation, and one was placed under direct endoscopic visualisation. Patients were followed up until death or to date. All stents were successfully deployed across the strictures. There was no foreign body sensation (FBS) reported after 16 of the procedures (80%). One patient reported transient FBS. Three stents were removed without complication because of symptoms; the endoscopically placed stent which was within 5 mm of cricopharyngeus and two which were inadvertently deployed across cricopharyngeus. There were no other significant complications related to the stent or procedure. All patients reported significant improvement in dysphagia with dysphagia scores improving from a mean of 3.1/4 to 0.9/4 (Wilcoxon matched-pairs signed-ranks test, P = 0.0158). One stent migrated in a patient with malignant disease; however, all 6 stents placed across the benign stricture migrated. Hence our case series concludes that SEMS can be safely and effectively deployed in the cervical esophagus.
Conscious Sedation ; Constriction, Pathologic ; Deglutition Disorders ; Esophagus* ; Female ; Fistula ; Foreign Bodies ; Humans ; Male ; Pharyngeal Muscles ; Sensation ; Stents* ; Tracheomalacia

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Enteral stents: Complications and their management.

Jorge E LOPERA ; Miguel Angel DE GREGORIO ; Alicia LABORDA ; Rodrigo CASTAÑO

Gastrointestinal Intervention.2016;5(2):138-148. doi:10.18528/gii160005

The treatment of malignant colonic and gastric outlet obstruction with self-expanding metallic stents (SEMS) is an established technique that can be performed by radiologic or a combination of radiologic and endoscopic guidance. The procedure is very effective to relieve the obstructive symptoms of advanced malignancies, with important clinical benefits and significant improvement in quality of life for the patients. Despite much advancement in the designs of SEMS, enteral stent placement is still associated with some significant early and late complications. Stent dysfunction mainly caused by tumor ingrowth/over growth, and stent migration when covered stent are used, are relatively common complications and many times require reinterventions.
Colon ; Colonic Neoplasms ; Gastric Outlet Obstruction ; Humans ; Pancreatic Neoplasms ; Quality of Life ; Stents*

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The obstructed afferent loop: Percutaneous options.

Damian MULLAN ; Raman UBEROI

Gastrointestinal Intervention.2016;5(2):129-137. doi:10.18528/gii160019

Endoscopic drainage can be considered the treatment of choice in benign and malignant obstruction of the distal biliary tree, with percutaneous intervention reserved for cases of difficult access or complex hilar strictures. However in patients with altered anatomy due to pancreatico-duodenectomy gastrectomy, or Bilroth II reconstruction, endoscopy can be exceptionally challenging and often impossible. Surgery remains the gold standard for benign causes of obstruction of a bilio-enteric anastomosis or afferent loop, and percutaneous management remains controversial. Novel endoscopic techniques such as double balloon enteroscopy and endoscopic ultrasound guided procedures can overcome some of the anatomical challenges, but a percutaneous approach is a more established technique for cases of malignant obstruction of a bilio-enteric anastomosis or afferent loop. The altered anatomy presents unique challenges which must be fully contemplated and understood before intervention should occur, to avoid the risk of permanent external drainage.
Afferent Loop Syndrome ; Bile Ducts ; Biliary Tract ; Biliary Tract Neoplasms ; Constriction, Pathologic ; Double-Balloon Enteroscopy ; Drainage ; Endoscopy ; Gastrectomy ; Humans ; Self Expandable Metallic Stents ; Ultrasonography

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Endoscopic approaches to afferent and Roux-en-Y limb obstruction.

Richard A KOZAREK

Gastrointestinal Intervention.2016;5(2):124-128. doi:10.18528/gii150017

Afferent limb syndrome can be seen following Billroth II gastric resection, Whipple procedure with duodenojejunostomy, or in association with an obstructed Roux-en-Y limb following hepaticojejunostomy. This syndrome classically presents with jaundice or cholangitis but may also be associated with abdominal pain alone or pancreatitis, especially in patients with surgically created pancreaticojejunostomies. Obstructions may be a consequence of benign or malignant disorders. Historically treated with surgery or percutaneous transhepatic biliary drainage, this review describes currently applied and evolving endoscopic techniques to include balloon dilation, double pigtail plastic stent placement, and insertion of self-expandable metal stents or lumen-apposing stents.
Abdominal Pain ; Cholangitis ; Drainage ; Extremities* ; Gastroenterostomy ; Humans ; Jaundice ; Pancreaticojejunostomy ; Pancreatitis ; Plastics ; Stents

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Enteral stents in the management of gastrointestinal leaks, perforations and fistulae.

Hany SHEHAB ; Todd H BARON

Gastrointestinal Intervention.2016;5(2):116-123. doi:10.18528/gii160006

Gastrointestinal leaks and fistulae are grave conditions associated with substantial morbidity and mortality. Expandable stents have shown significant success in the management of leaks and fistulae, providing an efficacious minimally invasive approach in patients who are frequently poor surgical candidates. Most reports, however, are limited by their small size or the pooling of different stents, techniques and locations of leaks and fistulae. Despite the numerous alterations in stent design, migration remains the pivotal drawback of this technique. In this article, we review the current status of expandable stents in the management of gastrointestinal leaks and fistulae, available anti-migration techniques and evolving innovations in stent design.
Anastomotic Leak ; Esophageal Fistula ; Fistula* ; Gastric Fistula ; Humans ; Mortality ; Stents*

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Through the keyhole: Radiological management of malignant gastric outflow obstruction beyond the pylorus.

Robert Charles STOCKWELL ; Ji Hoon SHIN

Gastrointestinal Intervention.2016;5(2):111-115. doi:10.18528/gii150026

This review article presents the radiological options for management of malignant gastric outflow obstruction distal to the pylorus. We place these options in context with surgical and endoscopic alternatives and recommend their use, particularly in those institutions where endoscopic alternatives may not be readily available.
Duodenal Obstruction ; Pylorus* ; Self Expandable Metallic Stents ; Technology, Radiologic

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Malignant gastroduodenal obstruction: An endoscopic approach.

Fred LEE ; Rehan ABDUL-HALIM ; Owen DICKINSON ; Iruru MAETANI

Gastrointestinal Intervention.2016;5(2):105-110. doi:10.18528/gii160018

Malignant gastric outlet obstruction describes a constellation of symptoms that can result as a common endpoint from a variety of primary tumours, particularly those of the upper gastrointestinal tract and pancreas. Affected patients face a dismal, undignified and rapid decline in health secondary to malnutrition, dehydration and constant nausea with associated vomiting. Palliative treatment has traditionally involved a gastrojejunostomy—a major undertaking given the functional status of these patients. More recent advances in the endoscopic placement of metal stents to relieve obstruction have clear benefits over the surgical method. We look at the factors involved in patient selection, the techniques and considerations involved in stent deployment and the potential complications associated with this method.
Dehydration ; Duodenal Neoplasms ; Endoscopy ; Gastric Outlet Obstruction ; Humans ; Malnutrition ; Methods ; Mortuary Practice ; Nausea ; Palliative Care ; Pancreas ; Patient Selection ; Stents ; Upper Gastrointestinal Tract ; Vomiting

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The challenges: Stent materials from the perspective of the manufacturer.

Karel VOLENEC ; Ivan POHL

Gastrointestinal Intervention.2016;5(2):98-104. doi:10.18528/gii160008

The article presents an overview of the basic data influencing the choice of materials for the manufacture of self-expanding metallic stents to be implanted into gastrointestinal tract, particularly esophageal stents. The data are evaluated primarily in terms of the manufacturer of stents. The text emphasizes not only the importance of the materials themselves, but also the biological environment in which the stent is used. Brief history of materials used in gastrointestinal stents mentions stainless steel, cobalt-chromium and nickel titanium alloys and polymers (polyester and polydioxanone). The text describes the properties of metal materials (composition, corrosion, mechanical properties) with particular focus on nickel-titanium alloy—nitinol. It lists advantages and disadvantages of nitinol. At the end of the review the authors briefly present their opinion on future materials of gastrointestinal stents and their covering.
Alloys ; Biocompatible Materials ; Biomedical and Dental Materials ; Corrosion ; Gastrointestinal Tract ; Nickel ; Polymers ; Self Expandable Metallic Stents ; Stainless Steel ; Stents* ; Titanium

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