Case Report : Obstructive Jaundice after Bilioenteric Anastomosis: Transhepatic and Direct Percutaneous Enteral Stent Insertion for Afferent Loop Occlusion

( Hans Ulrich Laasch ) The Editorial Office of Gut and Liver 2010 Gut and Liver Vol.4 No.s1

Recurrent tumour after radical pancreaticoduodenectomy may cause obstruction of the small bowel loop draining the liver. Roux-loop obstruction presents a particular therapeutic challenge, since the postsurgical anatomy usually prevents endoscopic access. Careful multidisciplinary discussion and multimodality preprocedure imaging are essential to accurately demonstrate the cause and anatomical location of the obstruction. Transhepatic or direct percutaneous stent placement should be possible in most cases, thereby avoiding long-term external biliary drainage. Gastropexy T-fasteners will secure the percutaneous access and reduce the risk of bile leakage. The static bile is invariably contaminated by gut bacteria, and systemic sepsis is to be expected. Enteral stents are preferable to biliary stents, and compound covered stents in a sandwich construction are likely to give the best long-term results. Transhepatic and direct percutaneous enteral stent insertion after jejunopexy is illustrated and the literature reviewed. (Gut Liver 2010; 4(Suppl. 1):S89-95)

‘Radial force’ of colonic stents: A parameter without consistency, definition or standard

Hans-Ulrich Laasch,Graham D. Milward,Derek W. Edwards 소화기인터벤션의학회 2020 Gastrointestinal Intervention Vol.9 No.3

Background: To investigate the expansion force of current colonic stents and to match these to industry standards. Methods: Samples of all colonic stents were requested from manufactures world-wide. Expansion forces were tested with an RX650 compression tool (MSI, Flagstaff, AZ, USA). Measurements were averaged over three cycles of compression and expansion, independently performed at 37°C by specialist engineers of MSI. In parallel, a survey was undertaken on standards, and tests used by manufacturers in their production process. As a labbased study, Institutional Review Board approval was not required. Results: A literature search did not identify any industry standards for testing expansion force or a suggested range for this primary stent function. Median expansion force of all stents was 24.4 N, (35.1 N for braided, 20.7 N for knitted stents) with a vast range from 5.6–130.8 N. Covering braided stents in liquid silicone increased their median force 5.5-fold, separate membranes attached to knitted stents only had a minor effect on expansion force. Five of eight manufacturers replied, describing three different test methods with three different units for expansion force. Conclusion: There are no standards on assessing expansion force, or what the ideal range should be. Consequently, the variation is remarkable, but values are not published, and even if they were, they could not be compared. Consequently, interventionists are unable to discriminate between different stents and to select the most suitable device for their patients, and no recommendation can be made on the ‘best stent’. The industry needs an agreed test standard and an acceptable range of stent forces.

‘Radial force’ of colonic stents: A parameter without consistency, definition or standard

Hans-Ulrich Laasch,Graham D. Milward,Derek W. Edwards 소화기인터벤션의학회 2020 International journal of gastrointestinal interven Vol.9 No.3

Background: To investigate the expansion force of current colonic stents and to match these to industry standards. Methods: Samples of all colonic stents were requested from manufactures world-wide. Expansion forces were tested with an RX650 compression tool (MSI, Flagstaff, AZ, USA). Measurements were averaged over three cycles of compression and expansion, independently performed at 37°C by specialist engineers of MSI. In parallel, a survey was undertaken on standards, and tests used by manufacturers in their production process. As a labbased study, Institutional Review Board approval was not required. Results: A literature search did not identify any industry standards for testing expansion force or a suggested range for this primary stent function. Median expansion force of all stents was 24.4 N, (35.1 N for braided, 20.7 N for knitted stents) with a vast range from 5.6–130.8 N. Covering braided stents in liquid silicone increased their median force 5.5-fold, separate membranes attached to knitted stents only had a minor effect on expansion force. Five of eight manufacturers replied, describing three different test methods with three different units for expansion force. Conclusion: There are no standards on assessing expansion force, or what the ideal range should be. Consequently, the variation is remarkable, but values are not published, and even if they were, they could not be compared. Consequently, interventionists are unable to discriminate between different stents and to select the most suitable device for their patients, and no recommendation can be made on the ‘best stent’. The industry needs an agreed test standard and an acceptable range of stent forces.

Infra-colic gastrostomy: Technique and anatomical considerations

Jen-Jou Wong,Srujana Ganti,Damian Mullan,Derek Edwards,Hans-Ulrich Laasch 소화기인터벤션의학회 2021 International journal of gastrointestinal interven Vol.10 No.1

Background: Infra-colic radiologically inserted gastrostomy is not well documented, and the presence of an insertion window solely below the transverse colon is generally regarded as a contraindication to gastrostomy insertion. A perceived increased risk is due to the presence of vessels and lymphatics within the omental and peritoneal structures, such as the epiploic arteries, the arterial arcade of Barkow, and middle colic artery branches from the superior mesenteric artery. Colonic obstruction is also an additional theorised risk. We provide evidence that infra-colic insertion of a feeding tube through the greater omentum can be performed safely. Methods: A total of 1,156 gastrostomies were inserted over an 8-year period. A retrospective review of the 5 cases was conducted. Electronic patient records were reviewed including clinical consultations, procedure reports and images. Results: In all cases, barium was administered orally/per nasogastric tube the day before to delineate the colon. All patients underwent sedo-analgesia with insufflation of the stomach achieved by a temporising nasogastric/orogastric tube. Infra-colic gastropexy with three SafeTpexy T-fasteners was undertaken. Standard 12 Fr balloon retained tubes were inserted through the greater omentum with no post-procedural complications or tube malfunctions in four cases. A 16 Fr disc retained tube was inserted in a fifth case. Conclusion: Despite the perceived difficulties, we suggest that infra-colic gastrostomies can be performed with confidence, and with little deviation from standard insertion techniques. They can be inserted without an apparent increase in complications, although operators need to be aware of the anatomical differences and additional structures traversed when performing infra-colic gastrostomies.

Infra-colic gastrostomy: Technique and anatomical considerations

Jen-Jou Wong,Srujana Ganti,Damian Mullan,Derek Edwards,Hans-Ulrich Laasch 소화기인터벤션의학회 2021 Gastrointestinal Intervention Vol.10 No.1

Background: Infra-colic radiologically inserted gastrostomy is not well documented, and the presence of an insertion window solely below the transverse colon is generally regarded as a contraindication to gastrostomy insertion. A perceived increased risk is due to the presence of vessels and lymphatics within the omental and peritoneal structures, such as the epiploic arteries, the arterial arcade of Barkow, and middle colic artery branches from the superior mesenteric artery. Colonic obstruction is also an additional theorised risk. We provide evidence that infra-colic insertion of a feeding tube through the greater omentum can be performed safely. Methods: A total of 1,156 gastrostomies were inserted over an 8-year period. A retrospective review of the 5 cases was conducted. Electronic patient records were reviewed including clinical consultations, procedure reports and images. Results: In all cases, barium was administered orally/per nasogastric tube the day before to delineate the colon. All patients underwent sedo-analgesia with insufflation of the stomach achieved by a temporising nasogastric/orogastric tube. Infra-colic gastropexy with three SafeTpexy T-fasteners was undertaken. Standard 12 Fr balloon retained tubes were inserted through the greater omentum with no post-procedural complications or tube malfunctions in four cases. A 16 Fr disc retained tube was inserted in a fifth case. Conclusion: Despite the perceived difficulties, we suggest that infra-colic gastrostomies can be performed with confidence, and with little deviation from standard insertion techniques. They can be inserted without an apparent increase in complications, although operators need to be aware of the anatomical differences and additional structures traversed when performing infra-colic gastrostomies.

Safety of EEG BIS-guided nurse-administered procedural sedation during gastro-intestinal intervention

Alexander Oh,Sviatlana Vasileuskaya,Nabil Kibriya,Paula Puro,Damian Mullan,Hans-Ulrich Laasch 소화기인터벤션의학회 2024 International journal of gastrointestinal interven Vol.13 No.1

Background: Sedation remains a subject of contention and anxiety for many interventional teams. We reviewed our outcomes of electroencephalographic (EEG) bi-spectral index sensor (BIS) guidance, which allowed us to transfer the role of the sedation practitioner to the interventional radiology nurses. Methods: In total, 150 consecutive cancer-related interventional procedures were collected prospectively at a tertiary center. All patients were given 4 L oxygen via a nasal cannula and had conscious sedation administered by two trained interventional nurses. In addition to standard monitoring, frontal lobe EEG BIS monitoring was used. The initial amount of midazolam or fentanyl administered were dependant on the patient’s age and American Society of Anesthesiologists classification score. Thereafter, conscious sedation was maintained by titrating small incremental doses to maintain BIS between 80 and 85. The patients’ vitals were monitored at 5-minute intervals and recorded along with the Ramsay sedation scale and tolerance score. Results: The three most common procedures were: radiologically inserted gastrostomy (48%), percutaneous transhepatic cholangiography (35%), and esophageal stenting (11%). All procedures were completed without disruption or unexpected patient movements. No reversal agents or airway management were required and no incidences of hypoxia occurred. Conclusion: BIS monitoring is an invaluable tool that has successfully allowed the role of the sedation practitioner to be transferred to the interventional nurses. It allows sedation to be personalized to each patient and their individual susceptibility to combination sedation and represents a vast improvement over interval clinical assessment of patients’ responsiveness to stimuli.

The vanishing stent: Repeated fracture and dissolution of nitinol gastric stents in a long term cancer survivor

Christopher Randle Lunt,Pavan Najaran,Derek E. Edwards,Jon K Bell,Damian Mullan,Hans-Ulrich Laasch 소화기인터벤션의학회 2018 Gastrointestinal Intervention Vol.7 No.2

Nitinol self expandable metal stents are increasingly utilised for malignant obstruction in the proximal gastrointestinal tract. We describe a case in which repeated fracture of proximal duodenal stents with dissolution of the nitinol wire skeleton and covering membranes occurred in a long term cancer survivor. This necessitated placement of 4 stents for symptom control and to allow oral feeding until the patient’s death 20 months after the initial stent was inserted. Fracture of gastric and duodenal stents has rarely been described previously, some incidences of which were considered due to mechanical causes. Dissolution of stent metal skeletons has not previously been recognised in gastroduodenal stents but has been described in an oesophageal stent subject to reflux of gastric content and a biochemical mechanism has been proposed. With modern oncological treatment the prospect of patients outliving their stents is increasing and the need for repeat procedures should form part of the consent process.

Distal migration of a partially covered duodenal stent requiring emergency surgical extraction

Luca Giovanni Campana,Rebecca Fish,Owen Thomas Dickinson,Mairéad Geraldine McNamara,Sarah Theresa O’Dwyer,Hans-Ulrich Laasch 소화기인터벤션의학회 2022 International journal of gastrointestinal interven Vol.11 No.2

Duodenal stenting is an established alternative for the palliation of malignant gastric outlet obstruction (MGOO). Despite being relatively rare, stent migration remains an issue of concern. We present a case of duodenal stent displacement in a 71-year-old female with biliary and duodenal strictures secondary to pancreatic cancer. She presented with acute abdominal pain 10 days following the insertion of a 24-mm partially covered double-layer knitted device, which migrated to the ileocaecal junction. Since the priority was to minimise hospitalisation, we performed a laparotomy with extraction through an enterotomy combined with gastrojejunostomy to bypass the duodenum. The patient resumed oral intake on postoperative day 9 and tolerated a semi-solid diet for 3 months, until death. Despite continuous advances in enteral stent design, patient surveillance remains paramount. This report illustrates the complex decision-making around MGOO, addresses the management of stent migration, and highlights the role of surgery in simultaneously treating stent complications and palliating duodenal obstruction.

The vanishing stent: Repeated fracture and dissolution of nitinol gastric stents in a long term cancer survivor

Christopher Randle Lunt,Pavan Najaran,Derek E. Edwards,Jon K Bell,Damian Mullan,Hans-Ulrich Laasch 소화기인터벤션의학회 2018 International journal of gastrointestinal interven Vol.7 No.2

Nitinol self expandable metal stents are increasingly utilised for malignant obstruction in the proximal gastrointestinal tract. We describe a case in which repeated fracture of proximal duodenal stents with dissolution of the nitinol wire skeleton and covering membranes occurred in a long term cancer survivor. This necessitated placement of 4 stents for symptom control and to allow oral feeding until the patient’s death 20 months after the initial stent was inserted. Fracture of gastric and duodenal stents has rarely been described previously, some incidences of which were considered due to mechanical causes. Dissolution of stent metal skeletons has not previously been recognised in gastroduodenal stents but has been described in an oesophageal stent subject to reflux of gastric content and a biochemical mechanism has been proposed. With modern oncological treatment the prospect of patients outliving their stents is increasing and the need for repeat procedures should form part of the consent process.

Distal migration of a partially covered duodenal stent requiring emergency surgical extraction

Luca Giovanni Campana,Rebecca Fish,Owen Thomas Dickinson,Mairéad Geraldine McNamara,Sarah Theresa O’Dwyer,Hans-Ulrich Laasch 소화기인터벤션의학회 2022 Gastrointestinal Intervention Vol.11 No.2

Duodenal stenting is an established alternative for the palliation of malignant gastric outlet obstruction (MGOO). Despite being relatively rare, stent migration remains an issue of concern. We present a case of duodenal stent displacement in a 71-year-old female with biliary and duodenal strictures secondary to pancreatic cancer. She presented with acute abdominal pain 10 days following the insertion of a 24-mm partially covered double-layer knitted device, which migrated to the ileocaecal junction. Since the priority was to minimise hospitalisation, we performed a laparotomy with extraction through an enterotomy combined with gastrojejunostomy to bypass the duodenum. The patient resumed oral intake on postoperative day 9 and tolerated a semi-solid diet for 3 months, until death. Despite continuous advances in enteral stent design, patient surveillance remains paramount. This report illustrates the complex decision-making around MGOO, addresses the management of stent migration, and highlights the role of surgery in simultaneously treating stent complications and palliating duodenal obstruction.