Difficult Biliary Stones: A Comprehensive Review of New and Old Lithotripsy Techniques

Biliary stones represent the most common indication for therapeutic endoscopic retrograde cholangiopancreatography. Many cases are successfully managed with biliary sphincterotomy and stone extraction with balloon or basket catheters. However, more complex conditions secondary to the specific features of stones, the biliary tract, or patient’s needs could make the stone extraction with the standard techniques difficult. Traditionally, mechanical lithotripsy with baskets has been reported as a safe and effective technique to achieve stone clearance. More recently, the increasing use of endoscopic papillary large balloon dilation and the diffusion of single-operator cholangioscopy with laser or electrohydraulic lithotripsy have brought new, safe, and effective therapeutic possibilities to the management of such challenging cases. We here summarize the available evidence about the endoscopic management of difficult common bile duct stones and discuss current indications of different lithotripsy techniques.

Fetoscopic balloon dilation and stent placement of congenital high airway obstruction syndrome leading to successful Caesarian delivery

Introduction: Without fetal or perinatal intervention, congenital high airway obstruction syndrome (CHAOS) is a fatal anomaly. The ex utero intrapartum treatment (EXIT) procedure has been used to secure the fetal airway and minimize neonatal hypoxia, but is associated with increased maternal morbidity. Case Presentation: A 16-year-old woman (gravida 1, para 0) was referred to our hospital at 31 weeks gestation with fetal anomalies, including echogenic lungs, tracheobronchial dilation and flattened diaphragms. At 32 weeks, fetoscopic evaluation identified laryngeal stenosis, which was subsequently treated with balloon dilation and stent placement. The patient developed symptomatic and regular preterm contractions at post-operative day 7 with persistent sonographic signs of CHAOS, which prompted a repeat fetoscopy with confirmation of a patent fetal airway followed by Cesarean delivery under neuraxial anesthesia. Attempts to intubate through the tracheal stent were limited and resulted in removal of the stent. A neonatal airway was successfully established with rigid bronchoscopy. Direct laryngoscopy and bronchoscopy confirmed laryngeal stenosis with a small tracheoesophageal fistula immediately inferior to the laryngeal stenosis and significant tracheomalacia. A tracheostomy was then immediately performed for anticipated long term airway and pulmonary management. The procedures were well tolerated by both mom and baby. The baby demonstrated spontaneous healing of the tracheoesophageal fistula by day of life 7 with discharge home with ventilator support at three months of life. Conclusion: Use of repeated fetoscopy in order to relieve fetal upper airway obstruction offers the potential to minimize neonatal hypoxia, while concurrently decreasing maternal morbidity by avoiding an EXIT procedure. Use of the tracheal stent in CHAOS requires further investigation. The long-term reconstruction and respiratory support of children with CHAOS remain challenging

Emergency thrombectomy for cerebrovascular occlusion in a patient with mirror-image dextrocardia: a case report

Cases of patients complicated with dextrocardia who suffer from acute cerebral infarction with large vessel occlusion and receive emergency thrombectomy are particularly rare and have not been widely reported. This article aimed to increase the awareness and knowledge of these cases. We report the case of a patient with mirror-image dextrocardia who suffered from cerebral infarction with large vessel occlusion and received emergency thrombectomy. A male patient in his early 60s with dextrocardia had acute cerebral infarction with posterior circulation large vessel occlusion and underwent emergency thrombectomy. During the operation, the rapid confirmation of dextrocardia and use of flexible interventional instruments helped establish a pathway for blood flow. We used an intracranial thrombectomy stent and intracranial balloon dilation catheter to restore the cerebral blood supply. The Modified Rankin Scale score was 0 at 3 months after thrombectomy, indicating a good prognosis of the patient. Acute cerebral infarction with large vessel occlusion in patients with dextrocardia is extremely rare. Emergency thrombectomy is feasible to recanalize cerebral blood flow and give patients a chance to recover.

Airway Management and Anesthesia for Tracheal Resection in a 68-Year-Old: 3 Airways for the Price of 1

Subglottic tracheal stenosis can occur after prolonged intubation or tracheostomy. This stenosis can become severe and causes symptoms refractory to endoscopic interventions that require tracheal resection. This surgery presents unique anesthetic issues due to the airway anatomy, physiology, and shared airway management with the surgical team. We present the case of a 68-year-old patient who underwent cervical tracheal resection and reconstruction due to persistent symptoms despite balloon dilation and medical management with oxygen and heliox. Our anesthesia management involved several techniques that allowed the safe completion of this procedure. Firstly, we started the airway management with a combined size 4 Ambu® AuraStraight™ (Denmark) supraglottic airway device and flexible bronchoscopy to allow localization of the stenosis and dilation before endotracheal tube (ETT) placement. The conventional approach for this endoscopic evaluation phase is to use rigid bronchoscopy. Secondly, we used prior CT images to help guide our ETT tube size selection. Thirdly, we used total intravenous anesthesia during most of the procedure because of the intermittent apnea necessary to complete the tracheal resection. Lastly, extubation had to be done very carefully to minimize excessive patient neck movement and avoid any reintubation. Both could lead to a catastrophe with the newly reconstructed trachea.

BRONCHOSCOPIC BALLOON DILATATION COMBINED WITH ELECTRIC CAUTERIZATION OF TRACHEAL STENOSIS UNDER CONSCIOUS SEDATION: A CASE REPORT

Post intubation tracheal stenosis remains the most common indication of tracheal resection and reconstruction. It can cause respiratory symptoms that can often be misdiagnosed as obstructive lung disease. Various treatment modalities are available. As ofce-based procedures have been common, awake or mildly sedated endoscopic procedures with spontaneous ventilation are now being performed by exible bronchoscopy. We report a case involving a 45-year-old male who presented with dyspnea and stridor from 15 days. Patient had past history of intubation and icu stay one month back. After proper topicalization of upper airway of the patient, electric cauterization and balloon dilation was performed by exible bronchoscope under conscious sedation and spontaneous ventilation. Conscious sedation was achieved by graded doses of propofol and fentanyl. Post-operative period was uneventful, and patient didn’t describe any discomfort. Improvement in symptoms were reported. Endoscopic procedures for tracheal pathology under conscious sedation seems to be feasible and safe procedure.

The “needle re-entry” technique for infrainguinal arterial calcified occlusive lesions

Background Vascular calcification is a predictor of poor clinical outcome during and after endovascular intervention. Guidewire crossing techniques and devices have been developed, but chronic total occlusions (CTOs) with severe calcification often prevent subintimal re-entry. We propose a novel guidewire crossing approach combined needle rendezvous with balloon snare technique, named the “needle re-entry” technique, for treatment of complex occlusive lesions. Main text A 73-year-old female with severe claudication in her right calf with ankle brachial index of 0.62, and a computed tomography angiogram showed a long occlusion with diffuse calcification in superficial femoral artery. She was referred to our department to have peripheral interventions. Since the calcified vascular wall of the lesion prevented the successful re-entry, the “needle re-entry” was performed. First, a retrograde puncture of the SFA, distally to the occlusion, was performed and an 0.018-in. guidewire with a microcatheter was inserted to establish a retrograde fashion. Second, an antegrade 5.0-mm balloon was advanced into a subintimal plane and balloon dilation at 6 atm was maintained. Third, an 18-gauge needle was antegradely inserted from distal thigh to the dilated 5.0-mm balloon. After confirming a balloon rupture by the needle penetration, we continued to insert the needle to meet the retrograde guidewire tip. Then, a retrograde 0.014-in. guidewire was carefully advanced into the needle hole, named the “needle rendezvous” technique. After further guidewire advancement to accomplish a guidewire externalization, the needle was removed. Finally, since the guidewire was passing through the 5.0-mm ruptured balloon, the balloon was withdrawn, and the guidewire was caught with the balloon and successfully advanced into the antegrade subintimal space, named the “balloon snare” technique. After the guidewire was advanced into the antegrade guiding sheath and achieved a guidewire externalization, an endovascular stent graft and an interwoven stent were deployed to cover the lesion. After postballoon dilation, an angiography showed a satisfactory result without complications. No restenosis, reintervention, and limb loss have been observed for one year follow-up period after this technique. Conclusions The “needle re-entry” technique is a useful guidewire crossing technique to revascularize femoropopliteal complex CTOs with severe calcification which prevent the achievement of guidewire crossing with the conventional procedures.

Benefit, tolerance, and safety of hybrid argon plasma coagulation for treatment of Barrett's esophagus: US pilot study

Background and study aims A novel technique for Barrett’s esophagus (BE) ablation, termed hybrid APC, has recently been developed. The aims of this US pilot study were to evaluate the efficacy, tolerance and safety of hybrid APC for the treatment of BE. Patients and methods Patients with biopsy-proven BE referred to our tertiary care center over a 12-month period for mucosal ablation were eligible for this study. Efficacy of ablation was measured on follow-up endoscopy by demonstrating either a reduction of visible BE or biopsies proving complete resolution of intestinal metaplasia (CRIM). To evaluate tolerance and safety, patients were called on post-procedure days 1 and 7. Results Twenty-two patients with BE (4.5 % intramucosal carcinoma, 31.8 % high-grade dysplasia, 18.1 % low-grade dysplasia, 36.3 % non-dysplastic, 9.1 % indefinite for dysplasia) underwent 40 treatments with hybrid APC. All patients had endoscopic improvement of BE disease and 19 of 22 patients (86.4 %) achieved CRIM. With regard to tolerance, average pain scores (0 to 10 scale) on follow-up were 2.65 and 0.62 on days 1 and 7, respectively. With regards to safety, there were two treatment-related strictures (9.1 %) that required a single balloon dilation. Conclusions Hybrid APC appears to be promising in the treatment of BE. The ablation protocol used in this study demonstrated efficacy, tolerability, and a safety profile similar to radiofrequency ablation. Given the significant price difference between hybrid APC and other modalities for Barrett’s ablation, this modality may be more cost-effective. These results warrant further study in a large prospective multicenter trial.