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ORIGINAL ARTICLEStent-associated esophagorespiratory fistulas:incidence and risk factors

Benjamin L. Bick, MD, Louis M. Wong Kee Song,MD, Navtej S. Buttar, MD, Todd H. Baron, MD,Francis C. Nichols, MD, Fabien Maldonado, MD,David A. Katzka, MD, Felicity T. Enders, MD, PhD,Mark D. Topazian, MD

Esophageal self-expandable stents (SESs) effectively treat stricturesand leaks, but may be complicated by a stent-associated esophago-respiratory fistula (SERF). Little is known about SERFs. The objective

of this study was to determine the incidence, morbidity, mortality, and risk factors for SERF. This was a retrospective case-control studyin a single referral center including all adult patients undergoing esophageal SES placement during a 10-year period. Sixteen of 397(4.0%) patients developed SERF at a median of 5 months after stent placement (range 0.4-53 months), including 6 of 94 (6%), 10 of71 (14%), and 0 of 232 (0%) of those with lesions in the proximal, mid-esophagus, and distal esophagus, respectively (overall P � .001).SERF occurred in 10% of those with proximal and mid-esophageal lesions, including 14% with benign strictures, 9% with malignantstrictures, and none with other indications for SES placement (P � .27). The risk was highest (18%) in patients with benign anastomoticstrictures. Risk factors for development of SERF included a higher Charlson comorbidity index score (odds ratio [OR] 1.47 for every1-point increase; P � .04) and history of radiation therapy (OR 9.41; P � .03). Morbidity associated with SERF included need for lifelongfeeding tubes in 11 of 22 (50%) and/or tracheostomy or mechanical ventilation in 5 of 22 (23%). Median survival after diagnosis was4.5 months (range 0.35-67), and 7 patients survived less than 30 days. Dr Bick and colleagues concluded that SERF is a morbidcomplication of SES placement for strictures of the proximal and mid-esophagus. The dominant risk factors for development of SERFare prior radiation therapy and comorbidity score.Read this article on pages 181-9 in this issue.

ORIGINAL ARTICLEDoes leaving a main pancreatic duct stent in place reduce the incidence of precut biliary sphincterotomy-associated pancreatitis? A randomized, prospective study

Sang-Woo Cha, MD, Wesley Leung, MD, Glen A. Lehman, MD, James L. Watkins, MD, Lee McHenry, MD,Evan L. Fogel, MD, Stuart Sherman, MD

Pancreatitis is the most common major complication of ERCP and precut endoscopic sphincterotomy (ES). Prophylactic pancreatic duct(PD) stent placement has been shown to reduce the incidence and severity of post-ERCP pancreatitis (PEP) in high-risk settings. Theobjective of this study was to determine whether leaving a main PD stent in place after precut ES would reduce the incidence andseverity of PEP. This was a single-center, randomized, prospective study in a tertiary care ERCP referral center including consecutivepatients who underwent ERCP with a clear indication for biliary access and standard biliary ES whereby free cannulation of the bileduct was not possible and precut ES was undertaken. When free bile duct cannulation for ES was not possible and selective PDcannulation was achieved, a PD stent was placed. Using the PD stent as a guide, the authors used a needle-knife sphincterotome toperform precut ES. The patients were then randomized to either leaving the PD stent in place for 7 to 10 days (stent group) orimmediate removal after the procedure (stent-removed group). The remaining patients who did not undergo selective PD cannulationand stent placement were not randomized (no-stent group) and had a free-hand needle-knife ES performed. Patients were prospec-tively followed for development of complications. Standardized criteria were used to diagnose and grade the severity of PEP. A totalof 151 patients were enrolled. The groups were similar with regard to patient demographics and patient and procedure risk factor forPEP. The overall incidence of PEP was 13.2% (20/151). It occurred in 4.3% (2/46), 21.3% (10/47), and 13.8% (8/58) of patients in thestent, stent removed, and no-stent group. The stent group had a significantly lower frequency and severity of PEP compared with thestent-removed group (4.3% vs 21.3%; P � .027 for frequency and 0% vs 12.8%; P � .026 for moderate and severe pancreatitis). Inconclusion, these data suggest that placing and maintaining a PD stent for needle-knife precut ES reduces the frequency and severityof postprocedure pancreatitis.Read this article on pages 209-16 in this issue.

www.giejournal.org Volume 77, No. 2 : 2013 GASTROINTESTINAL ENDOSCOPY 14A