Endoscopic management of biliary complications after liver transplantation: An evidence-based review

Biliary tract diseases are the most common complications following liver transplantation(LT) and usually include biliary leaks, strictures, and stone disease. Compared to deceased donor liver transplantation in adults, living donor liver transplantation is plagued by a higher rate of biliary complications. These may be promoted by multiple risk factors related to recipient, graft, operative factors and post-operative course. Magnetic resonance cholangiopancreatography is the first-choice examination when a biliary complication is suspected following LT, in order to diagnose and to plan the optimal therapy; its limitations include a low sensitivity for the detection of biliary sludge. For treating anastomotic strictures, balloon dilatation complemented with the temporary placement of multiple simultaneous plastic stents has become the standard of care and results in stricture resolution with no relapse in > 90% of cases. Temporary placement of fully covered self-expanding metal stents(FCSEMSs) has not been demonstrated to be superior(except in a pilot randomized controlled trial that used a special design of FCSEMSs), mostly because of the high migration rate of current FCSEMSs models. The endoscopic approach of non-anastomotic strictures is technically more difficult than that of anastomotic strictures due to the intrahepatic and/or hilar location of strictures, and the results are less satisfactory. For treating biliary leaks, biliary sphincterotomy and transpapillary stenting is the standard approach and results in leak resolution in more than 85% of patients. Deep enteroscopy is a rapidly evolving technique that has allowed successful treatment of patients who were not previously amenable to endoscopic therapy. As a result, the percutaneous and surgical approaches are currently required in a minority of patients.

Endoscopic management of complications of chronic pancreatitis

Pseudocysts and biliary obstructions will affect approximately one third of patients with chronic pancreatitis(CP).For CP-related,uncomplicated,pancreatic pseudocysts(PPC),endoscopy is the first-choice therapeutic option.Recent advances have focused on endosonography-guided PPC transmural drainage,which tends to replace the conventional,duodenoscope-based coma immediately approach.Ancillary material is being tested to facilitate the endosonography-guided procedure.In this review,the most adequate techniques depending on PPC characteristics are presented along with supporting evidence.For CP-related biliary obstructions,endoscopy and surgery are valid therapeutic options.Patient co-morbidities(e.g.,portal cavernoma)and expected patient compliance to repeat endoscopic procedures are important factors when selecting the most adapted option.Malignancy should be reasonably ruled out before embarking on the endoscopic treatment of presumed CP-related biliary strictures.In endoscopy,the gold standard technique consists of placing simultaneous,multiple,side-by-side,plastic stents for a oneyear period.Fully covered self-expandable metal stents are challenging this method and have provided 50%mid-term success.

Endoscopic ultrasonography-guided fine needle aspiration:Relatively low sensitivity in the endosonographer population

AIM:To assess the characteristics and quality of endoscopic ultrasonography-guided fine needle aspiration(EUS-FNA) in a large panel of endosonographers.METHODS:A survey was conducted during the 13th annual live course of endoscopic ultrasonography(EUS) held in Amsterdam,Netherlands.A 2-page questionnaire was developed for the study.Content validity of the questionnaire was determined based on input by experts in the field and a review of the relevant literature.It contained 30 questions that pertained to demographics and the current practice for EUS-FNA of responders,including sampling technique,sample processing,cytopathological diagnosis and sensitivity of EUS-FNA for the diagnosis of solid mass lesions.One hundred and sixty-one endosonographers who attended the course were asked to answer the survey.This allowed assessing the current practice of EUS-FNA as well as the self-reported sensitivity of EUS-FNA for the diagnosis of solid mass lesions.We also examined which factors were associated with a self-reported sensitivity of EUS-FNA for the diagnosis of solid mass lesions > 80%.RESULTS:Completed surveys were collected from 92(57.1%) of 161 endosonographers who attended the conference.The endosonographers had been practicing endoscopy and EUS for 12.5 ± 7.8 years and 4.8 ± 4.1 years,respectively;one third of them worked in a hospital with an annual caseload > 100 EUS-FNA.Endoscopy practices were located in 29 countries,including 13 countries in Western Europe that totaled 75.3% of the responses.Only one third of endosonographers reported a sensitivity for the diagnosis of solid mass lesions > 80%(interquartile range of sensitivities,25.0%-75.0%).Factors independently associated with a sensitivity > 80% were(1) > 7 needle passes for pancreatic lesions or rapid on-site cytopathological evaluation(ROSE)(P < 0.0001),(2) a high annual hospital caseload(P = 0.024) and(3) routine isolation of microcores from EUS-FNA samples(P = 0.042).ROSE was routinely available to 27.9% of respondents.For lymph nodes and pancreatic masses,a maximum of three needle passes was performed by approximately two thirds of those who did not have ROSE.Microcores were routinely harvested from EUS-FNA samples by approximately one third(37.2%) of survey respondents.CONCLUSION:EUS-FNA sensitivity was considerably lower than reported in the literature.Low EUS-FNA sensitivity was associated with unavailability of ROSE,few needle passes,absence of microcore isolation and low hospital caseload.

Carbon dioxide for gut distension during digestive endoscopy:Technique and practice survey

AIM:To assess the adoption of Carbon dioxide(CO2)insufflation by endoscopists from various European countries,and its determinants.METHODS:A survey was distributed to 580 endoscopists attending a live course on digestive endoscopy.RESULTS:The response rate was 24.5%.Fewer than half the respondents(66/142,46.5%)were aware of the fact that room air can be replaced by CO2 for gut distension during endoscopy,and 4.2%of respondents were actually using CO2 as the insufflation agent.Endoscopists aware of the possibility of CO2 insufflation mentioned technical difficulties in implementing the system and the absence of significant advantages of CO2 in comparison with room air as barriers to adoption in daily practice(84%and 49%of answers,respectively;two answers were permitted for this item).CONCLUSION:Based on this survey,adoption of CO2 insufflation during endoscopy seems to remain relatively exceptional.A majority of endoscopists were not aware of this possibility,while others were not aware of recent technical developments that facilitate CO2 implementation in an endoscopy suite.

Severe delayed complication after percutaneous endoscopic colostomy for chronic intestinal pseudo-obstruction: A case report and review of the literature

经皮的内视镜的结肠开口术(PEC ) 逐渐地作为外科的一种选择被建议对待各种各样的混乱，包括尖锐结肠的伪阻塞，长期的肠的伪阻塞和复发的 sigmoid 肠扭传。我们在 PEC 放置以后在发生的严重复杂并发症上报导二个月。有自从 8 年起，演变的长期的肠的伪阻塞的历史的一个 74 岁的人被重新接纳到我们的医院并且收到了 PEC 提供长期的地势。过程是平静的并且极大地改进了病人生命的质量。二个月以后，病人开发了尖锐粪的腹膜炎。在剖腹术，结肠开口术凸缘在腹壁被嵌入，但是没有压迫性坏死在结肠的墙的水平被发现。这复杂并发症与结肠开口术试管的不经心的拖拉有关是可能的。有终端回肠造口术的小计结肠切除术被执行。我们考察迄今为止报导的 PEC 的 60 个案例的主要特征，包括指示和复杂并发症。

A body-packer with a cocaine bag stuck in the stomach

Management of patients carrying packets of drugs in the digestive tract is a frequent medical problem.Wereport on a patient who was referred by the police after ingestion of packets of cocaine.After spontaneous elimination of 81 drug packets,the patient had three unremarkable stools.A plain abdominal X-ray disclosed no residual packet but computed tomography(CT) scan showed one in the stomach.As this was not eliminated during the 10 d following ingestion,it was removed through gastrotomy.This case stresses the usefulness of the CT scan to ensure that no residual packet is present before hospital discharge.