EP.WE.46Stentolith as an uncommon complication of loss to follow up after endoscopic biliary stenting

Introduction Endoscopic biliary stenting is a common procedure, with indications from malignant obstruction to benign stone disease. We discuss a patient who re-presented after endoscopic stenting having been lost to follow up, with a large ‘stentolith’ requiring open CBD exploration. Case Presentation A 56-year-old female presented in 2013 with obstructive jaundice and a 2-week history of abdominal pain. She was a smoker, but otherwise had no past medical, surgical, or relevant family history. After initial workup, ERCP with sphincterotomy and pigtail stent placement was performed with interval laparoscopic cholecystectomy in 2014. Post-operative follow up was not arranged, the patient subsequently re-presented in 2020 with fatigue. MRCP confirmed a proximal CBD stone and linear artefact. Open exploration facilitated removal of the stone-stent complex. Discussion Complications of stenting include cholangitis, stent occlusion and migration. Stenting for failed biliary stone extraction is considered a temporary measure, with removal or exchange at three months. However, patients may be lost to follow up and return with non-specific symptoms. A rare cause is de novo formation of a gallstone calculus encasing the stent, a phenomenon termed “stentolith”. Proposed pathophysiology is through promotion of bacterial proliferation by the stent, with biofilm formation and calcium bilirubinate precipitation. Variation in formation has been described, with plastic stents developing circumferential stones, due to potential space between the wall and stent. Conclusion This highlights the importance of robust inter-disciplinary working, careful patient follow up and implementation of a mandatory registry at all hospitals for stented patients.

Radiation-Free Transabdominal Ultrasound-Guided Endoscopic Biliary Stenting in Pregnant Women with Choledocholithiasis

Background: Hepatobiliary disorders are common problems during pregnancy, causing significant morbidity and mortality in both mother and fetus. Biliary pancreatitis and cholangitis are common sequelae that warrant urgent endoscopic interventions. However, fetal radiation exposure is a major concern during endoscopic retrograde cholangiopancreatography (ERCP). Fetal malformation, preterm labor, and intrauterine fetal death are the recognized complications of ERCP. Objectives: To evaluate the application of transabdominal ultrasound (US) guidance in endoscopic biliary stenting as a substitute for fluoroscopy and contrast injection. Methods: In this study, we reviewed the data of ten pregnant patients, who had undergone endoscopic biliary stenting under US guidance without fluoroscopy between January 2018 and October 2020. An abdominal US examination was performed to confirm that the guide wire and the stent were placed inside the common bile duct (CBD) without fluoroscopy. The CBD clearance was postponed until after delivery. Results: The mean gestational age was 12 weeks (range: 5 - 33 weeks), and the mean maternal age was 23 years (range: 19 - 33 years). All procedures were performed successfully, with biochemical and clinical improvements after endoscopy. In none of the patients, maternal or fetal complications were reported after endoscopy or at birth. Also, no cases of post-endoscopic pancreatitis were documented. Conclusions: Based on the present findings, abdominal US guidance in endoscopic biliary stenting can be a safe and effective approach.

106 Stentolith As an Uncommon Complication of Loss to Follow Up After Endoscopic Biliary Stenting

Introduction Endoscopic biliary stenting is a common procedure, with indications from malignant obstruction to benign stone disease. We discuss a patient who re-presented after endoscopic stenting having been lost to follow up, with a large ‘stentolith’ requiring open CBD exploration. Case Presentation A 56-year-old female presented in 2013 with obstructive jaundice and a 2-week history of abdominal pain. She was a smoker, but otherwise had no past medical, surgical, or relevant family history. After initial workup, ERCP with sphincterotomy and pigtail stent placement was performed with interval laparoscopic cholecystectomy in 2014. Post-operative follow up was not arranged, and the patient subsequently re-presented in 2020 with fatigue. MRCP confirmed a proximal CBD stone and linear artefact. Open exploration facilitated removal of the stone-stent complex. Discussion Complications of stenting include cholangitis, stent occlusion and migration [2]. Stenting for failed biliary stone extraction is considered a temporary measure, with removal or exchange at three months (1). However, patients may be lost to follow up and return with non-specific symptoms. A rare cause is de novo formation of a gallstone calculus encasing the stent, a phenomenon termed “stentolith” [4]. Proposed pathophysiology is through promotion of bacterial proliferation by the stent, with biofilm formation and calcium bilirubinate precipitation [6]. Variation in formation has been described, with plastic stents developing circumferential stones [12-25], due to potential space between the wall and stent. Conclusions This highlights the importance of robust inter-disciplinary working; careful patient follows up and implementation of a mandatory registry at all hospitals for stented patients.

Newer Stents for Unresectable Malignant Distal Biliary Obstruction: Striving for Perfection!

Endoscopic biliary stenting is one of the most commonly used palliative procedure in patients with unresectable malignant distal biliary obstruction. Biliary stenting can be performed with either plastic or metallic stents. Stent occlusion and migration are important limitations of currently available stents. Variety of newer stents with varying designs and stent materials like stents with antimigratory properties, antireflux stents, drug-eluting stents, radioactive stents, and bioabsorbable stents are being developed to overcome the limitations of currently available stents. In this article, we are discussing two articles on the newer stent designs (plastic and metal stents) for biliary drainage in patients with unresectable malignant distal biliary obstruction.

Preoperative endoscopic biliary stenting before pancreatico duodenectomy: Does timing matter?

BackgroundRole of preoperative biliary stenting (PBS) before pancreaticodoudenectomy (PD) in patients with obstructive jaundice is debatable. The objective of the current study was to assess outcomes after PD in patients who underwent upfront surgery or PBS and determine the impact of stent to surgery duration on outcomes after PD. Methods We reviewed 147 patients who underwent PD between 2011 and 2019. Patients were grouped based on whether they underwent upfront surgery (N=76) or PBS (N=71). We further assessed outcomes based on stent to surgery interval < 4 weeks or > 4 weeks. We looked at 30 and 90 day morbidity and mortality rates in these patients.Results A significant increase in wound infections (7% vs 25%)(P=0.003), overall infectious complications (22.5% vs 38.1%)(P=0.04), re admissions (0 vs 10.5%)(P=0.005) and hospital stay (9 vs 10 days)(P=0.006) was seen in the PBS group. There was no significant difference in 30 day mortality (2.8 % vs 6.5%)(P=0.4). When compared with upfront surgery group, patients with stent to surgery duration > 4 weeks had higher rates of wound infection (7% vs 29%)(P=0.009), sepsis (11.2% vs 29%)(P=0.02), overall infectious complications (22.5% vs 45.1%)(P=0.02), re admissions (0 vs 12.9%) (P=0.007) and hospital stay (9 vs 10 days)(P=0.03). The lowest rate of infectious complications was seen when PD was performed within 2 weeks (22.2%) or 6-8 weeks (12.5%) after stenting. None of the patients with stent-surgery duration < 2 weeks developed sepsis. ConclusionsPBS appears to increase infection related morbidity after PD. In patients with PBS, low morbidity is seen with early (< 2 weeks) and delayed PD (6-8weeks).