Profilaktikus sztentek alkalmazása az endoszkópos retrográd cholangiopancreatographiát követő pancreatitis megelőzésében

Összefoglaló. Bevezetés: Az endoszkópos retrográd cholangiopancreatographiát (ERCP) követő pancreatitis (PEP) incidenciája a magas kockázatú betegcsoportban 14,7%. Célkitűzés: A munkacsoportunk által szerzett tapasztalatok elemzése. Módszerek: A profilaktikus pancreassztentes (PPS), magas kockázatú betegek adatait tartalmazó prospektív adatbázisunkat elemeztük retrospektív módon. Az adatokat a PEP-incidencia és a súlyosság tekintetében összehasonlítottuk a korábbi, hasonlóan magas kockázatú, sztent nélküli beteganyagunkkal, illetve a sztenteléssel kapcsolatos szövődményeket és a különböző sztenttípusokat is elemeztük. A Cotton-kritériumok szerint értékeltük a PEP-t. Eredmények: A 317, magas kockázatú betegből 288 esetben (90,9%) volt sikeres a PPS-implantáció. A sztent nélküli kontrollcsoportba 121, magas kockázatú beteget választottunk be. A sikeresen sztentelt betegekben a PEP incidenciája 10,0% volt. Ez és a PEP súlyossága (enyhe: 8,3%, középsúlyos: 1,4%, súlyos: 0,3%) is szignifikánsan alacsonyabb volt a PPS nélküli beteganyaghoz (PEP: 31,4%, enyhe: 15,7%, középsúlyos: 10,7%, súlyos: 5,0%) és a sikertelenül sztentelt betegekhez (PEP: 41,3%, enyhe: 24,1%, középsúlyos: 13,8%, súlyos: 3,4%) képest. Az utóbbi két csoport közötti különbség nem volt szignifikáns. A sztenttel kapcsolatos szövődmények közül a leggyakrabban a korai sztentkicsúszást (5/288 beteg, 1,74%) és a proximalis sztentmigrációt (3/288 beteg, 1,04%) észleltük. A sztenttípusok közül a legkedvezőbb mellékhatás-profilúnak a Freeman-típusú, belső füllel és külső „pigtail” véggel ellátott sztenteket találtuk. Következtetés: A profilaktikus pancreassztentelés hatékonyan csökkenti a PEP incidenciáját, és a súlyosságát az enyhébb esetek felé tolja el. Alkalmazása viszonylag egyszerű, azonban ismerni kell használatának megfelelő technikáját, időben történő eltávolításának és a szövődmények felismerésének fontosságát. Eredményeink és a nemzetközi ajánlások alapján magas PEP-rizikójú betegekben a PPS rutinszerű alkalmazása minden ERCP-laborban ajánlott. Orv Hetil. 2021; 162(1): 31–38. Summary. Introduction: The most frequent complication of endoscopic retrograde cholangiopancreatography (ERCP) is post-ERCP pancreatitis (PEP). Its incidence in the high-risk patient population is 14.7%. Objective: To analyze 10 years experiences of our working group. Methods: We retrospectively analyzed our prospective database of high-risk patients treated with prophylactic pancreatic stents (PPS) including the period between 2009 and 2014. We compared PEP incidence and severity findings with our historical data of pre-PPS period of similarly high-risk patients (no-stent group), furthermore analyzed the complications of PPS insertion and different stent types. PEP was defined and categorized according to the Cotton criteria. Results: In 317 high-risk patients, PPS implantation was successful in 288 cases (90.9%). The no-stent group comprised of 121 patients. Incidence and the severity of PEP in the successfully stented group (all: 10.0%; mild: 8.3%, moderate: 1.4%, severe: 0.3%) were significantly lower compared to the no-stent group (all: 31.4%; mild: 15.7%, moderate: 10.7%, severe: 5.0%) and the unsuccessfully stented group (all: 41.3%; mild: 24.1%, moderate: 13.8%, severe: 3.4%). The difference between the latter two groups was not significant. Only early dislodgment (5/288 patients, 1.74%) and proximal migration (3/288 patients, 1.04%) were observed as stent-related complications. Freeman type (single inner flange, outer pigtail end) stent was the best based on the complication profile. Conclusion: Prophylactic pancreatic stenting effectively lowers the incidence and severity of PEP. We should recognize the proper technic of its application and the importance of proper timing of its extraction and identification of complications. Utilization of PPSs in high-risk patients is strongly recommended in every ERCP center. Orv Hetil. 2021; 162(1): 31–38.

The effect of preoperative ureteral stenting in retrograde Intrarenal surgery: a multicenter, propensity score-matched study

Background Stent placement before retrograde intrarenal surgery (RIRS) can theoretically expand the ureter to improve access and remove stones. The purpose of this study was to investigate the effect of preoperative ureteral stenting on access and surgery. Methods We retrospectively analyzed patients who underwent RIRS between January 2010 and December 2016 at multiple centers. The patients were divided into two groups based on whether or not a ureteral stent was inserted preoperatively. The characteristics of the stone (size, number, density, and location), the success rate of the access sheath placement, perioperative complications, operative times, hospitalization periods, the period for which the stents remained, postoperative urinary tract infection rates, stone-free rates, and additional treatment rates were analyzed. Results Overall, 727 patients were included in the study (113 were pre-stented and 614 were non-stented). The median stone size was 12.2 mm. The overall stone-free rate (SFR) was 85.8% for the pre-stented group and 83.2% for the non-stented group, showing no significant (p = 0.498) difference between the two groups. Preoperative ureteral stenting improved the success rate of sheath placement (93.8% vs. 85.3%, p = 0.023) during surgery. The access sheath size in participants in the pre-stented group showed a tendency to be larger than that in participants in the non-stented group. However, there were no differences in perioperative complications, operative times, additional treatment rates, and stone-free rates. Conclusions Although preoperative ureteral stenting did not affect operative outcomes, it increased the success rate of access sheath placement. Depending on the patient’s characteristics, preoperative ureteral stenting can be considered as an adjunctive option when access sheath insertion is considered during RIRS.

Eswl for Upper Ureteric Stone With and Without JJ Stent-A Comparative Study

Objective: To find out the outcome of stenting before ESWL in the management of upper ureteric stone. Methods and materials: This prospective comparative study was conducted in the department of urology, Sylhet Osmani Medical College Hospital from January 2011 to June 2012. Sixty two patients with upper ureteric stone, aged between 18 to 60 years irrespective of sex, unilateral radio opaque upper ureteric stone of greatest diameter 2cm, patients with normal renal function and negative urine culture and were agreed to participate in the study were selected. Selected 62 patients with upper ureteric stones were divided randomly into group-A and group-B each consisting 31 patients. The patients of group-A were treated with ESWL with a JJ stent and that of group-B without JJ stent. In the patients selected for JJ placement, a 5 fr JJ stent was placed under regional anaesthesia before ESWL. Siemens Lithotripsy ESWL machine was used to impart shock waves and 3500 shockwaves was given in a session. Both the groups were compared for stone clearance, ureteric colic, steinstrasse, fever, lower urinary tract symptoms (LUTS), number of ESWL sessions. Data were processed and analyzed using software SPSS. Results: The number ESWL session in stented group [single session 10 (32.3%) and multiple sessions 21 (67.7%)] and in non-stented group [single session 9 (29.0%) and multiple sessions 22 (71.0%)] was similar in both groups (p>0.05) Stones were cleared in 23 (74.2%) patients in stented group and 25 (80.6%) patients in non-stented group. Difference was not statistically significant (p>0.05). Ureteric colic was significantly fewer in stented group than that of non-stented group [4 (12.9%) vs 11 (35.5%); p<0.05] but surapubic pain was significantly more in stented group than that of non-stented group [13 (41.9%) vs 5 (16.1%); p<0.05]; while steinstrasse [3 (9.7%) vs 5 (16.1%); p>0.05] and fever [5 (16.1%) vs 2 (6.5%); p>0.05] did not differ statistically significant between groups. Lower urinary tract symptoms such as urinary frequency [15 (48.4%) vs 3 (9.7%); p<0.01]; urgency [17 (54.8%) vs 5 (16.1%); p<0.01] and dysuria [19 (61.3%) vs 6 (19.4%); p<0.01] were significantly more in stented group than that of non-stented group; but gross haematuria [21 (67.7%) vs 15 (48.4%); p>0.05] were more in stented group. Conclusion: ESWL is an effective and reasonable initial therapy in the management of upper ureteric stones measuring <2 cm. Pre-ESWL ureteric stenting provides no additional benefit over non-stented ESWL in their management. Moreover, stents are associated with signiûcant patient discomfort and morbidity. Bangladesh Journal of Urology, Vol. 16, No. 1, Jan 2014 p.17-22

A comparative study of outcome of pyeloplasty in stented and non-stented children

Background: It is a matter of debate whether to use a stent (double J) or not during pyeloplasty in patients of pelvic ureteric junction obstruction (PUJ obstruction). This study was conducted to assess which technique- stented or non-stented is better for paediatric patients with PUJ obstruction.Methods: 45 paediatric patients aged 0-12 years were included in this prospective comparative simple randomized sample study during the period of June 2015 to August 2017 in paediatric surgery division of department of surgery in M.Y. Hospital, Indore. All patients except one underwent open A-H dismembered pyeloplasty. The parameters used for comparison were renal parenchymal diameter, renal pelvis AP diameter, GFR (by DTPA scan) and rate of complications. Minimum follow up period was 3 months.Results: The M:F ratio was 2:1. Stented children had significant improvement in renal parenchymal diameter (i.e. increase) and GFR (of affected kidney) after pyeloplasty, whereas non-stented children too had improvement in renal parenchymal diameter and GFR (affected kidney) but was not significant. The percentage of postoperative complications were more in non-stented group as compared to stented group.Conclusions: In all paediatric cases with PUJO undergoing A-H pyeloplasty, both stenting and non-stenting have similar results and to place a double J stent should depend on choice of surgeon.

Iliac venous stenting for outflow obstruction does not significantly change the quality of life of patients with severe chronic venous insufficiency

Purpose Percutaneous endovenous iliac stenting has emerged as a new modality in the treatment of advanced chronic venous insufficiency with outflow obstruction. However, the effect of this intervention on the quality of life remains unclear. We examined the impact of iliac venous stenting for outflow obstruction as compared to conservative medical management on the quality of life in severe chronic venous insufficiency patients. Methods Medical records of all patients with CEAP class 5 and 6 disease (N = 172) who underwent ilio-caval venography with intravascular ultrasonography (IVUS) at a single institution over a seven-year period, were reviewed for this case–control study. Quality of life evaluation was performed utilizing the Chronic Venous Insufficiency Quality of Life Questionnaire (CIVIQ-20) one year after the index procedure. Results Of the 172 severe chronic venous insufficiency patients, 109 were stented and 63 patients were treated medically based on their venography and IVUS results. The indication for stenting was confirmation of IVUS determined surface area or diameter outflow stenosis of greater than 50% within the common or external iliac venous systems. Eighty patients (47%) responded with completed CIVIQ-20 questionnaires for analysis. Of these, 47 were from the stented group and 33 from the non-stented group. At least moderate persistent pain or discomfort post-procedure was reported by 20 (43%) stented group patients and 19 (58%) non-stented group patients. Scores for all the other criteria in the CIVIQ-20 were similar between the groups. The mean total CIVIQ-20 score was 45.23 and 47.13, respectively, in stented group and non-stented group patients. ( p = 0.678). Conclusion There was no significant difference in the quality of life reported by CEAP 5 and 6 patients who underwent iliac venous stenting versus those who were treated medically for presumed iliac outflow obstruction. Prospective studies are needed to determine the true value of iliac venous stenting based on IVUS criteria in the management advanced chronic venous insufficiency.

Stented versus Stentless Aortic Valve Replacement in Patients with Small Aortic Root

Objective The aim of the study was to compare hemodynamic and perioperative outcomes of stented against stentless aortic valve replacement in patients with small aortic root (21 mm or less). Methods A comprehensive search was undertaken among the four major databases (PubMed, Embase, Scopus, and Ovid) to identify all randomized and nonrandomized controlled trials comparing stentless to stented bioprosthetic valves in small aortic root patients. Odds ratios, weighted mean differences, or standardized mean differences and their 95% confidence intervals were analyzed. Results A total of seven studies with a total of 965 patients fulfilled the inclusion criteria. There was no significant difference in preoperative baselines including mean age between both groups ( P = 0.08), peak aortic valve gradient ( P = 0.06), and effective orifice area ( P = 0.28), whereas higher mean aortic valve gradient in the stented group ( P = 0.007). No difference in cardiopulmonary bypass time ( P = 0.74), aortic cross-clamp times ( P = 0.88), intensive care unit stay ( P = 0.13), and stroke rate ( P = 0.56) were noted. However, stented group of patients showed higher rate of patient prosthesis mismatch ( P = 0.0001) and longer total hospital stay ( P = 0.002). Postoperatively, stentless group showed lower peak and mean aortic valve gradient ( P = 0.003 and P = 0.008, respectively) with a better effective orifice area ( P < 0.00001) at 6 months of follow-up. Mortality rates while in-hospital and at 1 year were similar in both groups ( P = 0.94 and P = 0.86, respectively). Conclusions Stentless aortic valves offer superior short-term hemodynamic outcomes in patients with small aortic root when compared with stented aortic valves. Although both groups have similar perioperative complications rates, stentless valves bring about a shorter hospital stay. A further large multicenter randomized controlled trial should address the longer-term benefit of stentless aortic valve over stented valve.

Stenting versus non-stenting following uncomplicated ureteroscopic lithotripsy: Comparsion and evaluation of symptoms

Background/Aim. Currently, ureterorenoscopic (URS) stone fragmentation and removal is the treatment of choice for managing ureteral stones, especially mid and distal ones and is advocated as initial management of ureteric stones. The aim of this work was to evaluate the symptoms, necessity, potential benefits and adverse effects of ureteral stent placement after uncomplicated ureteroscopic lithotripsy. Methods. This retrospective-prospective study evaluated a total of 125 patients who had underwent ureteroscopic lithotripsy (URSL). The patients were divided into two groups: stented (59 patients) and unstented (controls, 66 patients). The outcomes measured and compared between the two groups included: stone free rate, postoperative patient pain validated by scale, lower urinary tract symptoms (LUTS), the need for unplanned hospital care, stent related complications, and functional recovery in the form return to normal physical activities. Results. A successful outcome, defined as being stonefree after 12 weeks, was achieved in all 125 (100%) patients. The stone-free rate showed no significant differences between the two groups. LUTS was frequent complaint in the stented group, with statistically significant difference in the domain of frequency/urgency (p = 0.0314). There was a statistically significant difference between the groups in the mean operative time and mean hospitalization time, mean pain visual analog scale (VAS) score and in the use of nonnarcotic analgesic. On the day of the surgery and until postoperative day 3 (POD 3) and postoperative day 5 (POD 5), the pain score was much higher among stented patients than among the controls (p = 0.0001) and non-narcotic analgesic use (p = 0.001) was frequently required in the stented group. Conclusion. Routine placement of ureteral stent after URSL is not mandatory and may be associated with stent side effects. Uncomplicated URSL is safe without stent placement after the treatment.

Short Term Outcome of Urethroplasty with or without Urethral Stent: A Comparative Study

Urethroplasty is the surgery for Hypospadias. The most common complication of Hypospadias surgery is urethro-cutaneous (U-C) fistula. We designed this study to compare the short term outcome of Urethroplasty with or without urethral stent postoperatively. A total 30 patients of distal penile hypospadias except glnular variety have been studied prospectively in Pediatric Surgery Department of Banga Bandhu Sheikh Mujib Medical University, Dhaka for a period of 20 months, from March 2005 to October 2006. All patients were divided into Group-A (pt with stent) and Group- B (pts without stent). Age ranges of all patients were 2-12 years. After operation no patient developed urinary retention in stented group (Group-A) and 3 patients developed urinary retention which was managed by suprapubic puncture. 5 patients developed urethra-cutaneous fistula in stented group (Group- A) and 2 patients developed fistula in non stented group (Group-B). Calibration was done in all patients after 2 weeks of operation. Before calibration 2 patients came to us with narrow urinary stream of Group-B. After analyzing the result, it was concluded that the short term outcome of Urethroplasty without postoperative urethral stent is better than with stent specially in terms of Urethro-cutaneous fistula. DOI: http://dx.doi.org/10.3329/medtoday.v24i1.14110 Medicine TODAY Vol.24(1) 2012 pp.23-26

Safety and Efficacy of Endovascular Treatment of Basilar Tip Aneurysms by Coiling With and Without Stent Assistance

BACKGROUND: Endovascular therapy is now the preferred treatment option for basilar tip aneurysms (BTAs). OBJECTIVE: To compare the safety and efficacy of common endovascular techniques in the treatment of BTAs. METHODS: A retrospective review was conducted of 235 patients with BTAs treated with endovascular means in our institution between 2004 and 2011. Categorization was based on the presence and type of stent assistance (none, single, and Y stenting). The rates of perioperative complications, recanalization, rehemorrhage, and retreatment were analyzed. RESULTS: A total of 147 patients were treated with coil embolization and 88 patients with stent-assisted coiling (72 single stents, 16 Y stents). Thromboembolic complications occurred in 6.8% of patients in both groups. There was no associated mortality. Angiographic follow-up (mean, 23.5 months) was available in 172 patients (77.1%). Stented patients had significantly lower recanalization (17.2% vs 38.9%; P = .003) and retreatment (7.8% vs 27.8%; P = .002) rates compared with nonstented patients. Four rehemorrhages (2.7%) occurred in the coiled group, whereas none were noted in the stented group (P = .3). In paired comparisons, lower recanalization (8.3% vs 19.2%; P = .21) and retreatment (0% vs 9.6%; P = .19) rates were seen in the Y-stent group compared with the single-stent group. Thromboembolic complications occurred in 6.9% and 6.2% of patients in the single-stent and Y-stent groups, respectively (P = .91). In multivariate analysis, larger aneurysms, nonstented aneurysms, incomplete initial occlusion, and subarachnoid hemorrhage were predictors of aneurysm recanalization. CONCLUSION: Stent-assisted coiling has significantly lower recurrence, retreatment, and rehemorrhage rates than coiling alone for the treatment of BTAs. Y stenting has the highest efficacy with low complication rates.

Stent-Associated Flow Remodeling Causes Further Occlusion of Incompletely Coiled Aneurysms

BACKGROUND: Incomplete coil occlusion is associated with increased risk of aneurysm recurrence. We hypothesize that intracranial stents can cause flow remodeling, which promotes further occlusion of an incompletely coiled aneurysm. OBJECTIVE: To study our hypothesis by comparing the follow-up angiographic outcomes of stented and nonstented incompletely coiled aneurysms. METHODS: From January 2006 through December 2009, the senior author performed 324 initial coilings of previously untreated aneurysms, 145 of which were Raymond classification 2 and 3. Follow-up angiographic studies were available for 109 of these aneurysms (75%). Angiographic outcomes for stented vs nonstented incompletely coiled aneurysms were compared. A multivariate analysis was performed to identify factors related to the progression of occlusion at follow-up, with adjustment for aneurysm location, size, neck size, Hunt-Hess grade, stent use, initial Raymond score, packing density, age, sex, and medical comorbidities. RESULTS: Of the 109 aneurysms, 37 were stented and 72 were not stented. With a median follow-up time of 15.4 months, 33 stented aneurysms (89%) progressed to complete occlusion compared with 29 nonstented aneurysms (40%). Recanalization rates were lower in the stented group (8.1%) compared with the nonstented group (37.5%; P &lt; .001). On multivariate analysis, stent use (odds ratio, 18.5; 95% confidence interval, 4.3-76.9) and packing density (odds ratio, 1.093; 95% confidence interval, 1.021-1.170) were significant predictors of the progression of occlusion. Aneurysm size was negatively correlated with the progression of occlusion (odds ratio, 0.844; 95% confidence interval, 0.724-0.983). CONCLUSION: Stent-assisted coiling causes progression of occlusion, possibly by a flow remodeling effect. The odds of progression of occlusion of stent-coiled aneurysms were 18.5 times that of nonstented aneurysms.