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Placement of covered self-expandable metal biliary stent for the treatment of severe postsphincterotomy bleeding: outcomes of two cases.

Di Pisa M, Tarantino I, Barresi L, Cintorino D, Traina M - Gastroenterol Res Pract (2010)

Bottom Line: The bleeding was stopped.In the following days, both patients remained hemodynamically stable with no further episodes of bleeding.We believe that the application of a covered metallic stent in a severe postendoscopic-sphincterotomy bleeding, refractory to injection therapy, should be considered to avoid additional interventions, which carry a higher risk of complications, even in pediatric patients.

View Article: PubMed Central - PubMed

Affiliation: Gastroenterology Service, IsMeTT, UPMC, Via Tricomi 1, 90146 Palermo, Italy.

ABSTRACT
We report two cases of severe postsphincterotomy bleeding in an adult and a pediatric patient treated, as first options, with available techniques to induce hemostasis without success. Because of persisting bleeding, an expandable, partially covered, metallic stent was placed into the choledocho to mechanically compress the bleeding site. The bleeding was stopped. In the following days, both patients remained hemodynamically stable with no further episodes of bleeding. We believe that the application of a covered metallic stent in a severe postendoscopic-sphincterotomy bleeding, refractory to injection therapy, should be considered to avoid additional interventions, which carry a higher risk of complications, even in pediatric patients.

No MeSH data available.


No signs of bleeding after stent removal.
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Related In: Results  -  Collection


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fig10: No signs of bleeding after stent removal.

Mentions: An 8-year-old boy was admitted to our institute because of portal cavernoma, perhaps secondary to umbilical vessels that were cannulated for neonatal sepsis, and esophageal varices were treated with two sessions of banding ligation. Another comorbidity found was congenital combined immunodeficiency (SCID T-B+). During followup, a CT scan, performed in order to evaluate his vascular anatomy for a possible surgical shunt, showed a 6.5 cm hepatic fluid lesion of unknown origin with a suspected stone inside, mild intrahepatic biliary duct dilation, and a large cavernoma of the portal vein. Laboratory data were AST/ALT 42/74 U/L (normal: 5–40/65 U/L), bilirubin tot/dir 0.49/0.11 mg/dL (0–1.5 mg/dL), alkaline phosphates 362 U/L (40–134 U/L), gamma-GT 70 mg/(5–85 U/L), PLT 60 10  μL (50–400 10 μL), PT 84%  (80%–120%), and INR 1.16 (0.80–1.20 INR). With evidence of cholestasisand a CT scan that prompted suspicion of a biliary stone, an ERCP was planned. At admission, the patient was in good general conditions, and the physical examination was unremarkable (weight Kg 20, arterial blood pressure 86/52, and heart rate 84). On piperacillin/tazobactam and under general anesthesia, the patient, continuously monitored with electrocardiography, pulse oximeter, and automatic recording of blood pressure and pulse, underwent ERCP, showing hilar extrinsic compression, with several filling defects. The sphincterotomy was done with a sphincterotome on a guide wire (endocut: watt 120; coag: watt 40, PSD 60 Olympus). Severe bleeding occurred. The lumen was filled entirely with blood, and only after ten minutes of washout and compression with an 8mm dilation balloon catheter (8 mm × 2 cm Hurricane Microvasive, Boston Scientific Corporation, Natik USA) and then with a stone extraction balloon catheter (15 mm, Extractor XL, Boston Scientific Corporation, Natik USA) (Figure 6), the bleeding site was seen in the upper margin of the sphincterotomy (Figure 7). Several attempts at sclerosis with 1 : 10.000 epinephrine, total 20 mL, were injected without stopping the bleeding. The patient became hypotensive, and hemoglobin level dropped to 7 gr/dL (from 10.4 gr/dL). We immediately started volume replacement (almost 1 L) and transfusion of 450 cc of packed red blood cells. Given our previous experience with a metal stent in post-sphincterotomy bleeding in an adult patient, we decided, 90 minutes into the procedure, to insert an expandable, covered metallic stent (4 cm in length and 1 cm in diameter, Wallstent, Boston Scientific Corporation, Natik USA) into the choledocho to mechanically compress the bleeding site and simultaneously drain the biliary duct (Figure 8). The bleeding ceased and the patient was admitted to the intensive care unit, in hemodynamically stable condition (Hb: 8.3 gr/dL). On post-procedure day 5, the patient was discharged home in good clinical conditions. Two weeks later, he underwent an open procedure to construct a mesocaval shunt. He tolerated this well, and 3 days later an ERCP to remove the stent was planned. Under general anesthesia, a lateral view endoscope was introduced and advanced to the papilla, where the stent was seen. The stent was patent and was removed with alligator-tooth forceps (Figure 9). The cholangiogram was normal, and no signs of bleeding were seen (Figure 10). Now, at six months after the procedure, the patient is in good general conditions, asymptomatic, and without signs of cholestasis.


Placement of covered self-expandable metal biliary stent for the treatment of severe postsphincterotomy bleeding: outcomes of two cases.

Di Pisa M, Tarantino I, Barresi L, Cintorino D, Traina M - Gastroenterol Res Pract (2010)

No signs of bleeding after stent removal.
© Copyright Policy - open-access
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC2901612&req=5

fig10: No signs of bleeding after stent removal.
Mentions: An 8-year-old boy was admitted to our institute because of portal cavernoma, perhaps secondary to umbilical vessels that were cannulated for neonatal sepsis, and esophageal varices were treated with two sessions of banding ligation. Another comorbidity found was congenital combined immunodeficiency (SCID T-B+). During followup, a CT scan, performed in order to evaluate his vascular anatomy for a possible surgical shunt, showed a 6.5 cm hepatic fluid lesion of unknown origin with a suspected stone inside, mild intrahepatic biliary duct dilation, and a large cavernoma of the portal vein. Laboratory data were AST/ALT 42/74 U/L (normal: 5–40/65 U/L), bilirubin tot/dir 0.49/0.11 mg/dL (0–1.5 mg/dL), alkaline phosphates 362 U/L (40–134 U/L), gamma-GT 70 mg/(5–85 U/L), PLT 60 10  μL (50–400 10 μL), PT 84%  (80%–120%), and INR 1.16 (0.80–1.20 INR). With evidence of cholestasisand a CT scan that prompted suspicion of a biliary stone, an ERCP was planned. At admission, the patient was in good general conditions, and the physical examination was unremarkable (weight Kg 20, arterial blood pressure 86/52, and heart rate 84). On piperacillin/tazobactam and under general anesthesia, the patient, continuously monitored with electrocardiography, pulse oximeter, and automatic recording of blood pressure and pulse, underwent ERCP, showing hilar extrinsic compression, with several filling defects. The sphincterotomy was done with a sphincterotome on a guide wire (endocut: watt 120; coag: watt 40, PSD 60 Olympus). Severe bleeding occurred. The lumen was filled entirely with blood, and only after ten minutes of washout and compression with an 8mm dilation balloon catheter (8 mm × 2 cm Hurricane Microvasive, Boston Scientific Corporation, Natik USA) and then with a stone extraction balloon catheter (15 mm, Extractor XL, Boston Scientific Corporation, Natik USA) (Figure 6), the bleeding site was seen in the upper margin of the sphincterotomy (Figure 7). Several attempts at sclerosis with 1 : 10.000 epinephrine, total 20 mL, were injected without stopping the bleeding. The patient became hypotensive, and hemoglobin level dropped to 7 gr/dL (from 10.4 gr/dL). We immediately started volume replacement (almost 1 L) and transfusion of 450 cc of packed red blood cells. Given our previous experience with a metal stent in post-sphincterotomy bleeding in an adult patient, we decided, 90 minutes into the procedure, to insert an expandable, covered metallic stent (4 cm in length and 1 cm in diameter, Wallstent, Boston Scientific Corporation, Natik USA) into the choledocho to mechanically compress the bleeding site and simultaneously drain the biliary duct (Figure 8). The bleeding ceased and the patient was admitted to the intensive care unit, in hemodynamically stable condition (Hb: 8.3 gr/dL). On post-procedure day 5, the patient was discharged home in good clinical conditions. Two weeks later, he underwent an open procedure to construct a mesocaval shunt. He tolerated this well, and 3 days later an ERCP to remove the stent was planned. Under general anesthesia, a lateral view endoscope was introduced and advanced to the papilla, where the stent was seen. The stent was patent and was removed with alligator-tooth forceps (Figure 9). The cholangiogram was normal, and no signs of bleeding were seen (Figure 10). Now, at six months after the procedure, the patient is in good general conditions, asymptomatic, and without signs of cholestasis.

Bottom Line: The bleeding was stopped.In the following days, both patients remained hemodynamically stable with no further episodes of bleeding.We believe that the application of a covered metallic stent in a severe postendoscopic-sphincterotomy bleeding, refractory to injection therapy, should be considered to avoid additional interventions, which carry a higher risk of complications, even in pediatric patients.

View Article: PubMed Central - PubMed

Affiliation: Gastroenterology Service, IsMeTT, UPMC, Via Tricomi 1, 90146 Palermo, Italy.

ABSTRACT
We report two cases of severe postsphincterotomy bleeding in an adult and a pediatric patient treated, as first options, with available techniques to induce hemostasis without success. Because of persisting bleeding, an expandable, partially covered, metallic stent was placed into the choledocho to mechanically compress the bleeding site. The bleeding was stopped. In the following days, both patients remained hemodynamically stable with no further episodes of bleeding. We believe that the application of a covered metallic stent in a severe postendoscopic-sphincterotomy bleeding, refractory to injection therapy, should be considered to avoid additional interventions, which carry a higher risk of complications, even in pediatric patients.

No MeSH data available.