nitinol and Common-Bile-Duct-Diseases

Several techniques have been developed to facilitate cannulation of the papilla during endoscopic retrograde cholangiopancreatography (ERCP). The position of the endoscope should generally provide a 'straight' route to the papilla, and the efforts should be directed at shortening the intraduodenal portion of the bile duct. If a guidewire is used, one should be chosen that possesses suitable tip and shaft characteristics, including flexibility, strength, low friction and trackability, but no one device is likely to be suitable for all purposes. The development of guidewires composed of nitinol has revolutionized endoscopic practice. Access papillotomy ('pre-cut') can be employed as an alternative to (or in addition to) insertion of a guidewire when cannulation of the major papilla has been unsuccessful. The same techniques may be used to allow deep cannulation of the bile or pancreatic duct after ductography, when fluoroscopy can also be used. The 'needle-knife', which must be used carefully because it cuts with even slight tissue contact, is moved in the expected direction of the intramural bile (or pancreatic) duct to gain direct access into the duct. Access papillotomy is a valuable procedure in difficult cases, but is associated with greater risks than standard ERCP techniques (except perhaps for a reduced likelihood of pancreatitis), and is best employed by personnel who have extensive experience with therapeutic endoscopy. Technical details for a variety of clinical situations are described. Success requires application of 'the four Ps': position, practice, patience and perseverance.

Topics: Alloys; Ampulla of Vater; Catheterization; Cholangiopancreatography, Endoscopic Retrograde; Common Bile Duct Diseases; Equipment Design; Humans; Practice Guidelines as Topic; Sphincterotomy, Endoscopic

Topics: Alloys; Cholangitis; Cholestasis, Extrahepatic; Common Bile Duct Diseases; Constriction, Pathologic; Device Removal; Female; Follow-Up Studies; Humans; Liver Function Tests; Male; Middle Aged; Pancreatitis, Chronic; Polytetrafluoroethylene; Prosthesis Failure; Recurrence; Silicones; Stents

Covered self-expanding metal stents (SEMSs) have proven effective for managing malignant bile duct strictures and may reduce risk of tumor ingrowth. A new nitinol partially covered biliary SEMS was prospectively evaluated.. 70 patients with inoperable extrahepatic biliary obstructions were enrolled in a prospective multicenter trial, and followed up to 6 months or death, whichever came first. Primary endpoint was adequate palliation defined as absence of recurrent biliary obstruction from partly covered SEMS placement to end of follow-up.. Mean age of the patients was 69 years and 52 % were men. Pancreatic carcinoma was present in 68 %. One stent was placed in 67 patients, two patients received two, and in one patient a guide wire could not traverse the stricture. In 55 % of patients the SEMS was inserted de novo and in 45 % for exchange with a plastic stent. Technical success was 97 %. At 6 months, 62 % of patients were free of obstructive symptoms; compared with baseline the mean number of symptoms per patient was significantly reduced (3.1 at baseline, 0.6 at 6 months; P < 0.0001) and total bilirubin levels dropped by 73 %. There were four cases of recurrent biliary obstruction, due to stent migration (2), tumor overgrowth (1), and sludge formation (1). Device-related complications included cholecystitis (3), right upper quadrant pain (1), and moderate pancreatitis (1). No tumor ingrowth was reported.. This new partially covered nitinol SEMS is easily inserted, and safe and effective in the palliation of biliary obstruction secondary to malignant bile duct strictures.

Topics: Adult; Aged; Aged, 80 and over; Alloys; Bile Duct Neoplasms; Cholestasis, Extrahepatic; Coated Materials, Biocompatible; Common Bile Duct Diseases; Female; Humans; Male; Middle Aged; Palliative Care; Stents

To determine the technical efficacy and safety of a flared polyurethane-covered self-expandable nitinol stent in the management of malignant biliary obstruction and to evaluate its clinical efficacy by estimating stent patency and patient survival rates.. Thirteen patients with common bile duct strictures (nonhilar) caused by malignant disease were treated by placement of 13 nitinol stents. The stents used include a flared section in the proximal portion (12 mm in diameter and 10 mm in length) and a section in the remnant portion that is fully covered with high-elasticity polyurethane, with an unconstrained diameter of 10 mm and a total length of 50-80 mm. Patient survival and stent patency rates were calculated with use of Kaplan-Meier survival analysis. The follow-up bilirubin and serum amylase and lipase levels were calculated, and the differences in means were evaluated with use of a Wilcoxon signed-rank test. The average follow-up duration was 22.9 weeks (range, 8-56 weeks).. Placement was successful in all cases. The 30-day mortality rate was 0%. The survival rates were 38% and 24% at 20 and 50 weeks, respectively. Seventy-seven percent of study patients had adequate palliative drainage during their the remainder of their lives. The stent patency rates were 71% and 48% at 20 and 50 weeks, respectively. Three patients (23%) presented with stent occlusion requiring repeat intervention. There were no procedure-related complications such as proximal or distal migration. No complications occurred other than stent occlusion. One patient's stent was removed under endoscopic guidance 15 weeks after its insertion. Bilirubin levels had significantly decreased 1 week after stent insertion (P <.001).. Preliminary results suggest that placement of a flared polyurethane-covered self-expandable nitinol stent is feasible and effective in achieving biliary drainage. The stents do not migrate, but there is tumor ingrowth into the flared portion of the stent. Treatment of a larger group of patients will be mandatory to validate these long-term results.

Topics: Adult; Aged; Aged, 80 and over; Alloys; Cholestasis, Extrahepatic; Coated Materials, Biocompatible; Common Bile Duct Diseases; Equipment Design; Equipment Failure; Female; Gastrointestinal Neoplasms; Humans; Male; Middle Aged; Polyurethanes; Radiography; Stents; Survival Rate

Topics: Alloys; Bile Duct Neoplasms; Bile Ducts, Intrahepatic; Biliary Fistula; Cholangiocarcinoma; Common Bile Duct Diseases; Humans; Male; Middle Aged; Postoperative Complications; Stents