Therapy for benign rectal anastomotic stricture after surgery for colorectal cancer:A systematic review

Objective:To evaluate various treatment methods for benign rectal anastomotic stricture(AS)following surgery for colorectal cancer.Method:A systematic review of the literature was conducted,focusing on studies that reported outcomes of different treatment modalities for benign AS.The PubMed,Embase,Scopus,China National Knowledge Infrastructure,and Cochrane Library databases were searched from January 2000 to December 2023.The inclusion criteria were studies involving human subjects,published in English,and reporting on therapeutic outcomes for benign AS.Results:A total of 19 papers identified a range of therapeutic strategies,including nonoperative anastomotic dilation,endoscopic balloon dilation(EBD),transanal minimally invasive surgery(TAMIS),selfexpandable metal stents(SEMS),endoscopic incision(EI)and newer techniques such as prostate resection instrumentation.Nonoperative anastomotic dilation can serve as an initial treatment for lower AS.EI demonstrated promise in cases where EBD was ineffective,providing an alternative method for managing AS.TAMIS and SEMS showed higher efficacy in refractory cases,with TAMIS being particularly effective for severe fibrotic or completely closed AS.The use of rigid instrumentation with an electric knife for transanal incisions demonstrated precision but lacked the flexibility needed for complex procedures.Conclusion:While traditional methods such as nonoperative anastomotic dilation and EBD remain firstline treatments for benign AS,advanced techniques such as EI,TAMIS,and SEMS offer promising alternatives,particularly in refractory cases.The choice of treatment should be tailored to individual patient conditions,with consideration for the technical expertise required and the potential for complications.

Bilioenteric anastomotic stricture in patients with benign and malignant tumors: prevalence,risk factors and treatment

BACKGROUND: Stricture formation at the bilioenteric anastomosis is a rare but important postoperative complication. However, information on this complication is lacking in the literature. In the present study, we aimed to assess its prevalence and predictive factors, and report our experience in managing bilioenteric anastomotic strictures over a ten-year period. METHODS: A total of 420 patients who had undergone bilioenteric anastomosis due to benign or malignant tumors between February 2001 and December 2011 were retrospectively reviewed. Univariate and multivariate modalities were used to identify predictive factors for anastomotic stricture occurrence. Furthermore, the treatment of anastomotic stricture was analyzed. RESULTS: Twenty-one patients (5.0%) were diagnosed with bilioenteric anastomotic stricture. There were 12 males and 9 females with a mean age of 61.6 years. The median time after operation to anastomotic stricture was 13.6 months (range, 1 month to 5 years). Multivariate analysis identified that surgeon volume (<30 cases) (odds ratio:-1.860; P=0.044) was associated with the anastomotic stricture while bile duct size (>6 mm) (odds ratio: 2.871; P=0.0002) had a negative association. Balloon dilation was performed in 18 patients, biliary stenting in 6 patients, and reoperation in 4 patients. Five patients died of tumor recurrence, and one of heart disease. CONCLUSIONS: Bilioenteric anastomotic stricture is an uncommon complication that can be treated primarily by interventional procedures. Bilioenteric anastomosis may be performed by a surgeon in his earlier training period under the guidance of an experienced surgeon. Bile duct size >6 mm may play a protective role.

Outcome of nephrostomy balloon dilation for vesicourethral anastomotic strictures following radical prostatectomy： a retrospective study

To evaluate the efficacy of nephrostomy balloon dilation （NBD） for patients who developed vesicourethral anastomotic stricture （VAS） following radical prostatectomy. NBD was performed in patients who developed VAS following radical prostatectomy. Quality of life （QoL）, International Prostate Symptom Score （IPSS） and maximal urinary flow rate （Qmax） were evaluated. Four hundred and sixty-three prostate cancer patients underwent radical retropubic prostatectomy （RRP）, and 86 underwent laparoscopic radical prostatectomy （LRP）. Most patients （90.3%） had T2 or T3 prostate cancer and a pathological Gleason score of ; 7. Forty-five （8.2%） and four （4.7%） patients developed VAS due to radical or LRP, respectively. Forty （89%） patients underwent NBD, including three cases of repeat dilation. The median Qmax was 4 ml s- （interquartile range （IQR）, 2.3-5.6） before dilation and improved to 16 ml s- （IQR, 15-19） and 19 ml s-1 （IQR, 18-21） at the 1- and 12-month follow-up, respectively （P〈 0.01）. Fifteen （37.5%） patients had urinary incontinence prior to dilation, whereas only three （7.5%） patients had incontinence 12 months following dilation （P 〈 0.01）. The median IPSS score improved from 19 （IQR, 17-24） before dilation to 7 （IQR, 6-8） at 12 months following dilation, and the QoL score improved from 5 （IQR, 4-6） before dilation to 2 （IQR, 2-3） at 12 months following dilation （P 〈 0.01 in both）. VAS occurs in a small but significant proportion of patients following radical prostatectomy. NBD offers an effective remedy for VAS.

Outcomes of side-to-side conversion hepaticojejunostomy for biliary anastomotic stricture after right-liver living donor liver transplantation

BACKGROUND:Conversion hepaticojejunostomy is considered the salvage intervention for biliary anastomotic stricture,a common complication of right-liver living donor liver transplantation with duct-to-duct anastomosis,after failed endoscopic treatment.The aim of this study is to compare the outcomes of side-to-side hepaticojejunostomy with those of endto-side hepaticojejunostomy.METHODS:Prospectively collected data of 402 adult patients who had undergone right-liver living donor liver transplantation with duct-to-duct anastomosis were reviewed.Diagnosis of biliary anastomotic stricture was made based on clinical,biochemical,histological and radiological results.Endoscopic treatment was the first-line treatment of biliary anastomotic stricture.RESULTS:Interventional radiological or endoscopic treatment failed to correct the biliary anastomotic stricture in 13 patients,so they underwent conversion hepaticojejunostomy.Ten of them received end-to-side hepaticojejunostomy and three received side-to-side hepaticojejunostomy.In the end-to-side group,two patients sustained hepatic artery injury requiring repeated microvascular anastomosis,two developed restenosis requiring further percutaneous transhepatic biliary drainage and balloon dilatation,and two required revision hepaticojejunostomy.In the side-to-side group,one patient developed re-stenosis requiring further endoscopic retrograde cholangiography and balloon dilatation.No re-operation was needed in this group.Otherwise,outcomes in the two groups were similar in terms of liver function and graft survival.CONCLUSIONS:Despite the similar outcomes,side-to-side hepaticojejunostomy may be a better option for bile duct reconstruction after failed interventional radiological or endoscopic treatment because it can decrease the chance of hepatic artery injury and allows future endoscopic treatment if re-stricture develops.However,more large-scale studies are warranted to validate the results.

Fecal marker levels as predictors of need for endoscopic balloon dilation in Crohn's disease patients with anastomotic strictures

AIM To evaluate the accuracy and best cut-off value of fecal calprotectin(FC) and fecal lactoferrin(FL) to predict disease recurrence in asymptomatic patients presenting with anastomotic strictures. METHODS This was a longitudinal single tertiary center study based on prospectively collected data(recorded in a clinical database created for this purpose) performed between March 2010 and November 2014. Crohn's disease(CD) patients with anastomotic stricture who submitted to postoperative endoscopic evaluation were included. Stools were collected on the day before bowel cleaning for FC and FL. Endoscopic balloon dilation(EBD) was performed if the patient presented an anastomotic stricture not traversed by the colonoscope, regardless of patients' symptoms. Successful dilation was defined as passage of the colonoscope through the dilated stricture into the neotermimal ileum.Postoperative recurrence was defined as a modified Rutgeerts score of ≥ i2 b. RESULTS In a total of 178 patients who underwent colonoscopy, 58 presented an anastomotic stricture, 86% were asymptomatic, and 48(54% male; median age of 46.5 years) were successfully dilated. Immediate success rate was 92% and no complications were recorded. FC and FL levels correlated significantly with endoscopic recurrence(P < 0.001) with an optimal cut-off value of 90.85 μg/g(sensitivity of 95.5%, specificity of 69.2%, positive predictive value(PPV) of 72.4%, negative predictive value(NPV) of 94.7% and accuracy of 81%] for FC and of 5.6 μg/g(sensitivity of 77.3%, specificity of 69.2%, PPV of 68%, NPV of 78.4% and accuracy of 72.9%) for FL.CONCLUSION Fecal markers are good predictors of CD endoscopic recurrence in patients with asymptomatic anastomotic stricture. FC and FL may guide the need for EBD in this context.

Short benign ileocolonic anastomotic strictures-management with bi-flanged metal stents:Six case reports and review of literature

BACKGROUND The endoscopic management of benign short post-anastomotic ileocolonic stricture(PAICS) that is refractory to primary and secondary treatment modalities remains challenging.The lumen-apposing metal stent(LAMS) is a novel device recently developed for therapeutic gastrointestinal endoscopy.LAMSs have demonstrated significantly better results with regard to stent migration than fully covered self-expandable metal stents(FCSEMSs).CASE SUMMARY This article presents six cases of symptomatic PAICS successfully treated with a LAMS and a review of the relevant literature.We report a life-saving technique not previously documented and the use of technology to improve patient outcomes.The six patients(median age,75 years) suffered from vomiting,constipation and recurrent abdominal pain,with symptoms starting 23-25 wk post-surgery.The median stricture length was 1.83 cm.All six patients underwent successful and uneventful bi-flanged metal stent(BFMS)-LAMS placement for benign PAICS.All patients remained asymptomatic during the three months of stent indwelling and up to a median of 7 mo after stent removal.According to the literature,the application of LAMS for PAICS is associated with a < 10% risk of migration and a < 5% risk of bleeding.Conversely,FCSEMS has a high migration rate(15%-50%).CONCLUSION The evolving role of interventional endoscopy and the availability of LAMSs provide patients with minimally invasive treatment options,allowing them to avoid more invasive surgical interventions.The BFMS(NAGI stent) is longer and larger than the prototype AXIOS-LAMS,which should be considered in the management of short ileocolonic post-anastomotic strictures longer than 10 mm and shorter than 30 mm.

Diagnosis and Management of Biliary Strictures after Deceased-Donor Liver Transplantation Based on Clinical Practice

Biliary complications are still the main complications for liver transplantation recipients. Biliary strictures comprise the major part of all biliary complications after deceased-donor liver transplantation (LT). Biliary strictures following LT are divided into anastomotic strictures (AS) and non-anastomotic strictures (NAS). A Limitation of current published researches is that most studies aren’t based on clinical practice. The aim of this review is to summarize risk factors, clinical presentation, diagnosis and management in post-LT biliary strictures.

Novel magnetic compression technique for the treatment of postoperative anastomotic stenosis in rectal cancer:A case report

BACKGROUND The treatment of postoperative anastomotic stenosis after excision of rectal cancer is challenging.Endoscopic balloon dilation and radial incision are not effective in all patients.We present a new endoscopy-assisted magnetic compression technique(MCT)for the treatment of rectal anastomotic stenosis.We successfully applied this MCT to a patient who developed an anastomotic stricture after radical resection of rectal cancer.A 50-year-old man had undergone laparoscopic radical rectal cancer surgery at a local hospital 5 months ago.A colonoscopy performed 2 months ago indicated that the rectal anastomosis was narrow due to which ileostomy closure could not be performed.The patient came to the Magnetic Surgery Clinic of the First Affiliated Hospital of Xi'an Jiaotong University after learning that we had successfully treated patients with colorectal stenosis using MCT.We performed endoscopy-assisted magnetic compression surgery for rectal stenosis.The magnets were removed 16 d later.A follow-up colonoscopy performed after 4 months showed good anastomotic patency,following which,ileostomy closure surgery was performed.CONCLUSION MCT is a simple,non-invasive technique for the treatment of anastomotic stricture after radical resection of rectal cancer.The technique can be widely used in clinical settings.

Endoscopic stricturotomy in the treatment of anastomotic strictures in inflammatory bowel disease(IBD)and non-IBD patients

Backgrounds:Endoscopic stricturotomy(ESt)has been shown to be effective in treating inflammatory bowel disease(IBD)-associated anastomotic strictures.However,the outcome of ESt in benign,non-IBD conditions has not been described.The aim of this study was to evaluate the outcome of ESt in the management of IBD and non-IBD-associated strictures.Methods:Data of all consecutive IBD and non-IBD patients with benign anastomotic strictures treated with ESt from 2009 to 2016 were extracted.The primary outcomes were surgery-free survival and procedure-related complications.Results:A total of 49 IBD and 15 non-IBD patients were included in this study.The IBD group included 25 patients with Crohn’s disease and 24 with ulcerative colitis and ileal pouches.Underlying diseases in the non-IBD group included colorectal cancer(n=7),diverticulitis(n=5),large bowel prolapse(n=2),and constipation(n=1).Immediate technical success was achieved in all patients in both groups.Bleeding complications occurred on five occasions(4.7%per procedure)in the IBD group,while no complication occurred in the non-IBD group(P=0.20).Stricture improvement on follow-up endoscopy was found in 10(20.4%)and 5(33.3%)patients in the IBD and non-IBD groups,respectively(P=0.32).Six(12.2%)patients in the IBD group and four(26.7%)patients in the non-IBD group eventually required stricture-related surgery(P=0.23).IBD patients appeared to have a higher tendency formaintaining surgery-free after the procedure than non-IBD patients(P=0.08).Conclusions:Endoscopic stricturotomy was shown to have comparable outcomes,though non-IBD patients seem to have a higher need for subsequent surgery but a lower complication rate than IBD patients.

Percutaneous interventional therapy for anastomotic biliary strictures after orthotopic liver transplantation

Objective To describe the technique,efficacy, and safety of percutaneous interventional therapy for anastomotic biliary strictures after orthotopic liver transplantation ( OLT) . Methods From May 2004 to December 2009,25 patients with anastomotic biliary stric-

Posterior urethral stenosis:Contemporary management options

Posterior urethral stenosis(PUS)is a known complication following prostate cancer treatment as well as other benign endoscopic treatments.Patients with PUS often fail initial endoscopic treatments and have persistent symp-toms negatively affecting quality of life.In the past decade,a variety of dif-ferent surgical techniques and approaches have changed the landscape of PUS management.The goal of this review is to provide details on the his-torical,current,and future direction of the surgical management for PUS.

Endoscopic balloon dilation of crohn's disease stricturessafety,efficacy and clinical impact

AIM To evaluate the incidence of anastomotic strictures after intestinal resection in Crohn's disease(CD), demonstrate long-term efficacy and safety of endoscopic balloon dilation(EBD) in CD strictures and its impact on the diagnosis of subclinical postoperative endoscopic recurrence. METHODS Retrospective single tertiary center study based on prospectively collected data between 2010 and 2015including anastomotic and non-anastomotic strictures. RESULTS29% of 162 CD patients included developed an anastomotic stricture. 43 patients with anastomotic strictures and 37 with non-anastomotic strictures underwent EBD; technical success was 97.7% and 100%, respectively, however, 63% and 41% needed repeat dilation during the 4.4-year follow-up. Longer periods between surgery and index colonoscopy and higher lactoferrin levels were associated with the presence of stricture after surgery. Calprotectin levels > 83.35 μg/g and current or past history of smoking were associated with a shorter time until need for dilation(HR = 3.877, 95%CI: 1.480-10.152 and HR = 3.041, 95%CI: 1.213-7.627). Anastomotic strictures had a greater need for repeat dilation(63% vs 41%, P = 0.047). No differences were found between asymptomatic and symptomatic cohorts. Disease recurrence diagnosis was only possible after EBD in a third of patients. CONCLUSION EBD is an effective and safe alternative to surgery, with a good short and long-term outcome, postponing or even avoiding further surgery. EBD may allow to diagnose disease recurrence in patients with no clinical signs/biomarkers of disease activity.

Endoscopic management of biliary strictures after liver transplantation

Bile duct strictures remain a major source of morbidity after orthotopic liver transplantation (OLT). Biliary strictures are classifi ed as anastomotic or non-anastomotic strictures according to location and are defi ned by distinct clinical behaviors. Anastomotic strictures are localized and short. The outcome of endoscopic treatment for anastomotic strictures is excellent. Nonanastomotic strictures often result from ischemic and immunological events, occur earlier and are usually multiple and longer. They are characterized by a far less favorable response to endoscopic management, higher recurrence rates, graft loss and need for retransplantation. Living donor OLT patients present a unique set of challenges arising from technical factors, and stricture risk for both recipients and donors. Endoscopic treatment of living donor OLT patients is less promising. Current endoscopic strategies for biliary strictures after OLT include repeated balloon dilations and placement of multiple side-by-side plastic stents. Lifelong surveillance is required in all types of strictures. Despite improvements in incidence and long term outcomes with endoscopic management, and a reduced need for surgical treatment, the impact of strictures on patients after OLT is signifi cant. Future considerations include new endoscopic technologies and improved stents, which could potentially allow for a decreased number of interventions, increased intervals before retreatment, and decreased reliance on percutaneous and surgical modalities. This review focuses on the role of endoscopy in biliary strictures, one of the most common biliary complications after OLT.

Endoscopic therapy of benign biliary strictures

Benign biliary strictures are being increasingly treated with endoscopic techniques. The benign nature of the stricture should be first confirmed in order to ensure appropriate therapy. Surgery has been the traditional treatment, but there is increasing desire for minimally invasive endoscopic therapy. At present, endoscopy has become the first line approach for the therapy of post- liver transplant anastomotic strictures and distal （Bismuth ! and I） post-operative strictures. Strictures related to chronic pancreatitis have proven more difficult to treat, and endoscopic therapy is reserved for patients who are not surgical candidates. The preferred endoscopic approach is aggressive treatment with gradual dilation of the stricture and insertion of multiple plastic stents. The use of uncovered self expandable metal stents should be discouraged due to poor long-term results. Treatment with covered metal stents or bioabsorbable stents warrants further evaluation. This area of therapeutic endoscopy provides an ongoing opportunity for fresh research and innovation.

Digital single-operator cholangioscopy for biliary stricture after cadaveric liver transplantation

BACKGROUND Biliary strictures after liver transplantation(LT)remain clinically arduous and challenging situations,and endoscopic retrograde cholangiopancreatography(ERCP)has been considered as the gold standard for the management of biliary strictures after LT.Nevertheless,in the treatment of biliary strictures after LT with ERCP,many studies show that there is a large variation in diagnostic accuracy and therapeutic success rate.Digital single-operator peroral cholangioscopy(DSOC)is considered a valuable diagnostic modality for indeterminate biliary strictures.AIM To evaluate DSOC in addition to ERCP for management of biliary strictures after LT.METHODS Nineteen patients with duct-to-duct biliary reconstruction who underwent ERCP for suspected biliary complications between March 2019 and March 2020 at Beijing Chaoyang Hospital,Capital Medical University,were consecutively enrolled in this observational study.After evaluating bile ducts using fluoroscopy,cholangioscopy using a modern digital single-operator cholangioscopy system(SpyGlass DS^(TM))was performed during the same procedure with patients under conscious sedation.All patients received peri-interventional antibiotic prophylaxis.Biliary strictures after LT were classified according to the manifestations of choledochoscopic strictures and the manifestations of transplanted hepatobiliary ducts.RESULTS Twenty-one biliary strictures were found in a total of 19 patients,among which anastomotic strictures were evident in 18(94.7%)patients,while non-anastomotic strictures in 2(10.5%),and space-occupying lesions in 1(5.3%).Stones were found in 11(57.9%)and loose sutures in 8(42.1%).A benefit of cholangioscopy was seen in 15(78.9%)patients.Cholangioscopy was crucial for selective guidewire placement prior to planned intervention in 4 patients.It was instrumental in identifying biliary stone and/or loose sutures in 9 patients in whom ERCP failed.It also provided a direct vision for laser lithotripsy.A spaceoccupying lesion in the bile duct was diagnosed by cholangioscopy in one patient.Patients with biliary stricture after LT displayed four types:(A)mild inflammatory change(n=9);(B)acute inflammatory change edema,ulceration,and sloughing(n=3);(C)chronic inflammatory change;and(D)acute suppurative change.Complications were seen in three patients with post-interventional cholangitis and another three with hyperamylasemia.CONCLUSION DSOC can provide important diagnostic information,helping plan and perform interventional procedures in LT-related biliary strictures.

Impact of referral pattern and timing of repair on surgical outcome after reconstruction of post-cholecystectomy bile duct injury:A multicenter study

Background:Bile duct injury(BDI)after cholecystectomy remains a significant surgical challenge.No guideline exists to guide the timing of repair,while few studies compare early versus late repair BDI.This study aimed to analyze the outcomes in patients undergoing immediate,intermediate,and delayed repair of BDI.Methods:We retrospectively analyzed 412 patients with BDI from March 2015 to January 2020.The patients were divided into three groups based on the time of BDI reconstruction.Group 1 underwent an immediate reconstruction(within the first 72 hours post-cholecystectomy,n=156);group 2 underwent an intermediate reconstruction(from 4 days to 6 weeks post-cholecystectomy,n=75),and group 3 underwent delayed reconstruction(after 6 weeks post-cholecystectomy,n=181).Results:Patients in group 2 had significantly more early complications including anastomotic leakage and intra-abdominal collection and late complications including anastomotic stricture and secondary liver cirrhosis compared with groups 1 and 3.Favorable outcome was observed in 111(71.2%)patients in group 1,31(41.3%)patients in group 2,and 157(86.7%)patients in group 3(P=0.0001).Multivariate analysis identified that complete ligation of the bile duct,level E1 BDI and the use of external stent were independent factors of favorable outcome in group 1,the use of external stent was an independent factor of favorable outcome in group 2,and level E4 BDI was an independent factor of unfavorable outcome in group 3.Transected BDI and level E4 BDI were independent factors of unfavorable outcome.Conclusions:Favorable outcomes were more frequently observed in the immediate and delayed reconstruction of post-cholecystectomy BDI.Complete ligation of the bile duct,level E1 BDI and the use of external stent were independent factors of a favorable outcome.

Long-term outcome of gastric access loop in hepaticojejunostomy

BACKGROUND:?The incidence of hepaticojejunostomy stricture is 4%-10% in experienced centres. Many access loops have been designed and used to facilitate endoscopic intervention for this complication of hepaticojejunostomy. In this study, we investigated the effectiveness and safety of gastric access loop. METHODS:A retrospective analysis was conducted on 13 patients who had undergone hepaticojejunostomy with gastric access loop between June 1999 and September 2003. Eleven patients were followed up for a mean period of 51 months (range 20-81 months). Two patients were lost to follow up. RESULTS:?On follow-up, 8 patients had patent jejuno- gastrostomy (end to side anastomosis between Roux loop of jejunum and stomach) and hepaticojejunostomy. Three patients developed stricture of jejunogastrostomy at 41 months, 63 months and 81 months of follow-up. Among these 3 patients, one also had hepaticojejunostomy stricture. In the patient with hepaticojejunostomy stricture, dilatation of jejunogastrostomy stricture was attempted but failed. None of the patients had any evidence of bile gastritis/cholangitis. There was no procedure related morbidity/mortality. CONCLUSIONS:Further studies involving large numbers of patients are required before wide application of gastric access loop in hepaticojejunostomy though it is a safer option than percutaneous transhepatic manipulations or revision surgery.

Management of biliary complications after liver transplantation

Biliary complications(BC) currently represent a major source of morbidity after liver transplantation. Although refinements in surgical technique and medical therapy have had a positive influence on the reduction of postoperative morbidity, BC affect 5% to 25% of transplanted patients. Bile leak and anastomotic strictures represent the most common complications. Nowadays, a multidisciplinary approach is required to manage such complications in order to prevent liver failure and retransplantation.

Percutaneous transluminal angioplasty balloons for endoscopic ultrasound-guided pancreatic duct interventions

BACKGROUND Endoscopic ultrasound(EUS)-guided main pancreatic duct(PD)access may be used when conventional endoscopic retrograde cholangiopancreatography(ERCP)techniques fail.The use of a percutaneous transluminal angioplasty balloon(PTAB),originally developed for vascular interventions,can be used to facilitate transmural(e.g.,transgastric)PD access and to dilate high-grade pancreatic strictures.AIM To describe the technique,efficacy,and safety of PTABs for EUS-guided PD interventions.METHODS Patients who underwent EUS with use of a PTAB from March 2011 to August 2021 were retrospectively identified from a tertiary care medical center supply database.PTABs included 3-4 French angioplasty catheters with 3-4 mm balloons designed to use over a 0.018-inch guidewire.The primary outcome was technical success.Secondary outcomes included incidence of adverse events(AEs)and need for early reintervention.RESULTS A total of 23 patients were identified(48%female,mean age 55.8 years).Chronic pancreatitis was the underlying etiology in 13(56.5%)patients,surgically altered anatomy(SAA)with stricture in 7(30.4%),and SAA with post-operative leak in 3(13.0%).Technical success was achieved in 20(87%)cases.Overall AE rate was 26%(n=6).All AEs were mild and included 1 pancreatic duct leak,2 cases of post-procedure pancreatitis,and 3 admissions for post-procedural pain.No patients required early re-intervention.CONCLUSION EUS-guided use of PTABs for PD access and/or stricture management is feasible with an acceptable safety profile and can be considered in patients when conventional ERCP cannulation fails.

Endoscopic retrograde cholangiopancreatography and liver biopsy in the evaluation of elevated liver function tests after liver transplantation

BACKGROUND Abnormal liver function tests(LFTs)in post-liver transplant(LT)patients pose a challenge in the timing and selection of diagnostic modalities.There are little data regarding the accuracy of endoscopic retrograde cholangiopancreatography(ERCP)and liver biopsy(LB)in diagnosing post-transplant complications.AIM To evaluate the diagnostic performance of ERCP and LB in patients with nonvascular post-LT complications.METHODS This single-center retrospective study evaluated patients undergoing both ERCP and LB for evaluation of elevated LFTs within 6 mo of LT from 2000 to 2017.Diagnostic operating characteristics including accuracy,sensitivity and specificity for various diagnoses were calculated for ERCP and LB.The R factor(ratio of alkaline phosphatase to alanine aminotransferase)was also calculated for each patient.RESULTS Of the 1284 patients who underwent LT,91 patients(74.7%males,mean age of 51)were analyzed.Anastomotic strictures(AS,24.2%),acute cellular rejection(ACR,11%)and concurrent AS/ACR(14.3%)were the most common diagnoses.ERCP carried an accuracy of 79.1%(95%CI:69.3-86.9),LB had an accuracy of 93.4%(95%CI:86.2-97.5),and the combination of the two had an accuracy of 100%(95%CI:96-100).There was no difference between patients with AS and ACR in mean R factor(AS:1.9 vs ACR:1.1,P=0.24).Adverse events did not differ between the two tests(ERCP:3.1%vs LB:1.1%,P=0.31).CONCLUSION In patients with abnormal LFTs after LT without vascular complications,the combination of LB and ERCP carries low risk and improves diagnostic accuracy over either test alone.