Management of post-liver transplantation biliary stricture inaccessible by endoscopic retrograde cholangiopancreatography:A case report

BACKGROUND One challenging scenario in the treatment of biliary stricture is that post-liver transplantation(LT)biliary strictures cannot be accessed using endoscopic retrograde cholangiopancreatography(ERCP).Here,we report such a case that was successfully treated using a novel endoscopic technique.CASE SUMMARY A 60-year-old man presented with obstructive jaundice caused by a post-LT biliary stricture.He underwent LT for compensated alcoholic liver cirrhosis and hepatocellular carcinoma.Laboratory investigations unveiled a cholestatic pattern of abnormalities in liver function and a total bilirubin level of 16 mg/dL.Magnetic resonance cholangiopancreatography revealed a stricture extending from the right intrahepatic bile duct into the common hepatic duct.Severe postoperative deformities made accessing the ampulla of Vater with a sideviewing duodenoscope impossible.Percutaneous transhepatic biliary drainage(PTBD)was performed to treat biliary obstruction.Moreover,to resolve the stricture completely,a fully covered self-expandable metal stent(FC-SEMS)with a novel proximal retrievable string was deployed into the post-LT biliary stricture through the PTBD tract.Before inserting the stent through the PTBD tract,the stent with the distal string was manually inverted to ensure that the distal part with the string became the proximal part for later endoscopic removal.After 6 mo,the FC-SEMS was successfully removed without complications,as the string was pulled out using a forward-viewing gastroscope.CONCLUSION Deployment and endoscopic removal of an FC-SEMS with a novel proximal string through the PTBD tract may be a viable option for treating post-LT biliary strictures that are inaccessible by ERCP.

Endoscopic ultrasound-guided tissue sampling induced pancreatic duct leak resolved by the placement of a pancreatic stent:A case report

BACKGROUND Pancreatic ductal leaks complicated by endoscopic ultrasonography-guided tissue sampling(EUS-TS)can manifest as acute pancreatitis.CASE SUMMARY A 63-year-old man presented with persistent abdominal pain and weight loss.Diagnosis:Laboratory findings revealed elevated carbohydrate antigen 19-9(5920 U/mL)and carcinoembryonic antigen(23.7 ng/mL)levels.Magnetic resonance imaging of the pancreas revealed an approximately 3 cm ill-defined space-occupying lesion in the inferior aspect of the head,with severe encasement of the superior mesenteric artery.Pancreatic ductal adenocarcinoma was confirmed after pathological examination of specimens obtained by EUS-TS using the fanning method.Interventions and outcomes:The following day,the patient experienced severe abdominal pain with high amylase(265 U/L)and lipase(1173 U/L)levels.Computed tomography of the abdomen revealed edematous wall thickening of the second portion of the duodenum with adjacent fluid collections and a suspicious leak from either the distal common bile duct or the main pancreatic duct in the head.Endoscopic retrograde cholangiopancreatography revealed dye leakage in the head of the main pancreatic duct.Therefore,a 5F 7 cm linear plastic stent was deployed into the pancreatic duct to divert the pancreatic juice.The patient’s abdominal pain improved immediately after pancreatic stent insertion,and amylase and lipase levels normalized within a week.Neoadjuvant chemotherapy was then initiated.CONCLUSION Using the fanning method in EUS-TS can inadvertently cause damage to the pancreatic duct and may lead to clinically significant pancreatitis.Placing a pancreatic stent may immediately resolve acute pancreatitis and shorten the waiting time for curative therapy.When using the fanning method during EUSTS,ductal structures should be excluded to prevent pancreatic ductal leakage.

Self-expandable metal stents for choledocholithiasis in Billroth II gastrectomy patients

Background: Efficient ampullary intervention is essential for endoscopic retrograde cholangiopancreatography(ERCP) in patients with a prior Billroth II gastrectomy. We retrospectively evaluated the safety and effectiveness of ampullary intervention using fully covered self-expandable metal stents(FCSEMSs) for the management of common bile duct(CBD) stones in a subset of patients with a history of Billroth II gastrectomy. Methods: This retrospective analysis involved patients with a prior Billroth II gastrectomy who underwent ampullary intervention with FCSEMSs for the management of CBD stones. The factors associated with FCSEMSs placement, treatment success, and procedural complications were analyzed. Results: A group of 15 patients(10 males; median age, 78 years) underwent biliary metal stent placement for high degree of CBD angulation(6), small or flat papilla with unclear margin(5), current use of double antiplatelet agents or an anticoagulant(2), unwanted instrumentation of the cystic duct(1), and insecure position of the scope(1). Ampullary intervention with FCSEMSs was successful in all patients. After dilating the ampulla of Vater and building a durable conduit with FCSEMSs immediately, CBD stones were removed successfully from all patients in a single session. A mild post-ERCP pancreatitis occurred in one patient, who recovered without complications. Conclusion: Ampullary intervention with FCSEMSs is safe and effective for the management of CBD stones in a subset of patients with a history of Billroth II gastrectomy.

Septic shock due to Granulicatella adiacens after endoscopic ultrasound-guided biopsy of a splenic mass:A case report

BACKGROUND Endoscopic ultrasound-guided fine needle aspiration or biopsy(EUS-FNA or FNB)has become a popular method for diagnosing various lesions of the gastrointestinal tract and surrounding tissue due to the accuracy and safety.To the best of our knowledge,no case report of severe infection after EUS-FNB of a solid lesion in the spleen has been described.Herein,we report a rare case of septic shock after EUS-FNB of a splenic mass.CASE SUMMARY A 45-year-old male patient presented to the outpatient clinic due to an incidentally detected splenic mass.A definitive diagnosis could not be established based on the abdominal magnetic resonance imaging.EUS of the spleen showed a 6 cm-sized,relatively well-demarcated,heterogeneous mass,and EUS-FNB with a 22G needle was performed.Ten days after the procedure patient developed septic shock and a splenic abscess was identified.Blood culture revealed growth of Granulicatella adiacens.After the treatment with antibiotics the patient underwent surgical resection,and the pathological examination showed diffuse large B-cell lymphoma.The patient received chemotherapy and he is in complete remission.CONCLUSION Infection of a splenic mass after EUS-FNB is a rare complication and prophylactic antibiotics might be considered.