Risk factors for congenital nasolacrimal duct obstruction in children under two years of age

·AIM:To identify various risk factors that may play a significant role in the development of congenital nasolacrimal duct obstruction(CNLDO).·METHODS:This observational case-control study included a case group of 122 children less than two years of age with CNLDO who underwent probing and irrigation treatment at the ophthalmology department of Imam Khomeini Hospital in Ahvaz,Iran,from June 2022 to June2024.A control group of 122 age-matched children without CNLDO was also included for comparison.Data was collected from the children's medical records.·RESULTS:The study found a significant correlation between the occurrence of CNLDO and several maternal factors,such as preeclampsia,the use of levothyroxine,hypothyroidism,having more than three pregnancies(gravidity>3),natural pregnancy,and gestational diabetes mellitus.Additionally,in children,factors,such as oxygen therapy,anemia,reflux,jaundice,and a family history of CNLDO in first-degree relatives were associated with CNLDO,and maternal preeclampsia and hypothyroidism were found to significantly increase the risk of developing CNLDO in children.·CONCLUSION:Given that CNLDO affects both premature and full-term children,the present findings may potentially facilitate the early identification of children and infants at risk of nasolacrimal duct obstruction,thereby preventing the onset of chronic dacryocystitis.

Long-term outcomes of laser dacryoplasty combined with intubation using a new silicon tube in patients with lacrimal duct obstruction

AIM:To determine the 15-year outcomes of laser dacryoplasty(LDP)in patients with lacrimal duct obstruction;and to evaluate LDP combined with intubation using a new silicone tube to treat complicated cases.METHODS:Patients with lacrimal duct obstruction and treated with LDP between April 2000 and April 2005 were investigated retrospectively.Totally 116 eyes with completed 15-year follow-up records were included in this study.For complicated cases(52 eyes of 52 patients),both LDP and intubation using a self-made silicon tube were performed.For patients with uncomplicated obstruction(64 eyes of 61 patients),only LDP was performed.Outcomes were assessed based on results of lacrimal irrigation and degree of symptoms during follow-up.RESULTS:At the follow-up time of 15y,81 eyes achieved full success(69.8%);21 eyes got improved(18.1%);and 14 eyes were considered failure(12.1%).The success rate was 71.2%(37/52 eyes)for complicated cases;and 68.8%(44/64 eyes)for uncomplicated cases.No statistically significant difference between two groups was observed(P=0.961).No postoperative complication was observed.CONCLUSION:LDP is a well-tolerated,simple,and effective procedure with satisfactory long-term outcomes in selected patients,which make it a good alternative to conventional dacryocystorhinostomy.In addition,intubation with the self-made mono-canalicular silicone tube facilitates the management of complicated cases with few complications.

Preliminary study on the efficacy of lacrimal duct reconstruction with pedicled conjunctival flap in the treatment of severe lacrimal canalicular obstruction with conjunctivochalasis

AIM:To determine the efficacy and safety of pedicled conjunctival lacrimal duct reconstruction in the treatment of severe obstruction of superior and inferior lacrimal canaliculi with conjunctivochalasis.METHODS:This study was per formed as a retrospective analysis of patients who received conjunctival dacryocystorhinostomy with pedicled conjunctival flap reconstruction combined with tube intubation due to severe superior and inferior lacrimal canalicular obstruction with conjunctivochalasis from January 2019 to October 2019.The clinical data included the degree of preoperative epiphora and postoperative relief,preoperative examination of lacrimal duct computed tomography and ultrasound biomicroscopy,postoperative evaluation of lacrimal duct function by chloramphenicol taste and fluorescein dye disappearance test,etc.Syringing was carried out to determine the reconstruction and patency of the lacrimal duct.RESULTS:All 9 patients(9 eyes)had severe canalicular obstruction with conjunctivochalasis.The patients included 4 males and 5 females aged between 47–65y with an average age of 52.2±6.7y.At 3mo follow-up,the tube was removed and the patients were followed for a further 3mo.After tube removal,6 patients showed no epiphora.These patients also had positive chloramphenicol tastes and normal fluorescein dye disappearance test results.Two patientshad epiphora.Also,syringing showed partial patency of the reconstructed lacrimal duct.One patient had no improvement in epiphora with negative chloramphenicol taste and fluorescein dye disappearance test results and obstruction of the reconstructed lacrimal duct.The total effective rate of the operation was 8/9,with no serious complications.CONCLUSION:Pedicled conjunctival lacrimal duct reconstruction conjunctival dacryocystorhinostomy is safe and effective for superior and inferior canalicular obstruction with conjunctivochalasis.

Nasal flap preservation in endoscopic dacryocystorhinostomy for nasolacrimal duct obstruction

AIM:To compare surgical outcomes between the conventional endoscopic dacryocystorhinostomy(DCR)and a modified endoscopic DCR for the treatment of nasolacrimal duct obstruction(NLDO),and evaluate factors associated with the surgical success rate.METHODS:Medical records of patients who underwent primary DCR surgery between January 2016 and July 2020 at the Otorhinolaryngology Department of Eye and Ear International Hospital,Lebanon were reviewed.RESULTS:The study group consisted of 50 consecutive modified endoscopic DCR and the control group consisted of 138 consecutive conventional endoscopic DCR.The success rates at 1y were 98.0%(49 out of 50)for modified DCR,significantly higher compared to 84.8%(117/138)for the conventional DCR;there was no significant difference in the success rate throughout the years in terms of both surgical techniques.The modified surgery vs traditional[adjusted odds ratio(aOR)=14.96]and having an adjunctive septoplasty surgery vs not(aOR=3.99)were significantly associated with higher odds of success.CONCLUSION:Mucosal flap preservation and apposition shows significant improvement in the surgical success rate.Moreover,there is no statistically significant difference found in terms of complication rate and mean operative time between the conventional and the modified techniques.

Bibliometric and visualized analysis of research hotpots and future prospects in lacrimal duct obstruction disease(1900 to 2024)

AIM:To reveal the research hotspots,trends,and future prospects of lacrimal duct obstruction disease(LDOD)from 1900 to 2024 through the bibliometric and visualized analysis,providing a directional guidance for research in this field.METHODS:The Web of Science Core Collection database was used to retrieve relevant literature.Data analysis and visualization were conducted using VOSviewer 1.6.20 and CiteSpace 6.3.1,including annual publication volume,trends,research areas,country/region and institution distribution,journal and co-cited journal analysis,author and co-cited author analysis,keyword and burst keyword analysis,etc.RESULTS:The study included a total of 1481 articles,revealing an overall upward trend in research on LDOD,with ophthalmology being the predominant field.While the United States previously led research efforts,India and China have emerged as key contributors since 2015.Mohammad Javed Ali stands out as the most influential author in this research area.Ophthalmic Plastic and Reconstructive Surgery has published the highest number of related articles,whereas Ophthalmology has the highest co-citation.The current focal points of research include minimally invasive and precise modifications to dacryocystorhinostomy,along with intubation,new materials for stents,and disease pathogenesis.CONCLUSION:LDOD research has garnered widely attention and exhibits a steady upward trend.Since 1900,the United States,China,and India have been the leading contributors to this field.Ophthalmologists continue to be the primary driving force behind LDOD research.The findings of this study suggest that at the forefront of LDOD research,our focus has long been on refining and innovating surgical treatment.The minimally invasive and precise modification of lacrimal surgery,represented by dacryocystorhinostomy,is the ongoing developmental direction of this field.Rapid interdisciplinary integration and in-depth exploration of pathogenesis and allergic inflammation will lead to the emergence of new materials,innovative technologies,and safer clinical treatment protocols.

A comparison between monocanalicular and pushed monocanalicular silicone intubation in the treatment of congenital nasolacrimal duct obstruction

AIM: To compare the success rate of monocanalicular versus pushed monocanalicular silicone intubation(PMCI)of the nasolacrimal duct for congenital nasolacrimal duct obstruction(CNLDO).METHODS: In a prospective randomized clinical trial 53 eyes of 49 patients with CNLDO underwent either monocanalicular silicone intubation(MCI)(n =28 eyes) or PMCI(n =25 eyes). All procedures were performed by 1oculoplastic surgeon. Treatment success was defined as the complete resolution of epiphora at 3mo after tube removal.RESULTS: The surgical outcome was assessed in 20 eyes with MCI and 20 eyes with PMCI. The mean age of treatment was 26.25 ±10.08mo(range, 13-49mo) for MCI and 26.85±12.25mo(range, 16-68mo) for PMCI. Treatment success was achieved in 18 of 20 eyes(90.0%) in the MCI group compared with 10 of 20 eyes(50%) in the PMCI group(P =0.01). In the PMCI group, the tube loss(30%)was greater than the MCI group(5%), however the differences between the 2 groups proved to be not significant(P =0.91).CONCLUSION: Our results indicate that MCI has higher success rate in CNLDO treatment compared with PMCI in this small series of patients.

Bicanalicular versus monocanalicular intubation after failed probing in congenital nasolacrimal duct obstruction

AIM：To investigate the clinical outcomes of different intubation techniques in the cases of failed primary probing.METHODS： This retrospective study was performed on338 patients with the diagnosis of congenital nasolacrimal duct obstruction with age 1-4y that had failed primary probing.Intubation was performed under light sedation in operating room and the stent was left 3mo in place.Clinical outcome was investigated 3mo after tube removal.RESULTS： Bicanalicular intubation method had higher complete and relative success rates compared to monocanalicular intubation（P =0.00）.In addition,Monoka intubation had better outcomes compared to Masterka technique（P =0.046）.No difference was found between genders but the higher the age,the better the outcomes with bicanalicular technique rather than monocanalicular.CONCLUSION： Overall success rate of bicanalicular intubation is superior to monocanalicular technique especially in older ages.Also,based upon our clinical outcomes,Masterka intubation is not recommended in cases of failed probing.

Mode of delivery, birth weight and the incidence of congenital nasolacrimal duct obstruction

AIM: To study any possible association of congenital nasolacrimal duct obstruction(CNLDO) with mode of delivery, birth weight and gestational age. METHODS: We retrospectively reviewed charts of all patients(n=2591) under the age of 3 y who were born between April 2015 and May 2017 and were examined at the Ophthalmology Clinic of Emsey Hospital Istanbul, Turkey. We identified patients(n=105) who were diagnosed as CNLDO. The mode of delivery, birth weight and gestational age along with any adverse event during or after delivery or any other health history were determined. Birth statistical data were obtained from the hospital’s medical records database. RESULTS: Gestational age of babies who were born via cesarean section(CS) was lower than gestational age of babies who were born via normal spontaneous vaginal delivery(NSVD;P=0.002). Babies who were born via CS were found to have 3.75 times higher risk of developing NLDO when compared to babies who were born via NSVD(OR=3.754). CONCLUSION: There is a possible association between CS and CNLDO.

Laser-assisted dacryocystorhinostomy in nasolacrimal duct obstruction：5-year follow-up

AIM：To evaluate the long-term sucess rate of laserassisted dacryocystorhinostomy （L-DCR） in patients with nasolacrimal duct obstruction （NDO）.METHODS：Forty-one eyes of forty patients aged between 21-85y （mean 56.7y） who underwent L-DCR for the treatment of NDO were included in this retrospective,non-randomized study. The follow-up time was 72mo.Functional sucess was defined as the disappearance of epiphora under normal conditions and the presence of a patent ostium on lacrimal irrigation. Anatomical success was defined as a patent lacrimal passage on syringing besides continuing epiphora. Surgical failure was defined as persistent epiphora and closed ostium.RESULTS：Twenty-seven of 40 patients （67.5%） were female and 13 of 40 patients （32.5%） were male. The NDO was right-sided in 17 （42.5%） patients and left-sided in 22（55%） patients whereas 1 （2.5%） patient had undergone bilateral surgery. In 11 （27.5%） patients there were additional nasal abnormalities requiring simultaneous surgical approach. The average time for L-DCR was 26.50±4.9min（16-39min） and the average total amount of laser energy used was 287±27.9 J （239-367 J）. At the 5y follow-up, anatomical sucess rate was 75.0%（30 patients） and functional success rate was 65.0%（26 patients）, whereas surgical failure was seen in 25%（10 patients）. Revision of surgery was performed in 10 cases （25.0%）; failure of revision surgery was seen in 2 cases（5.0%）.CONCLUSION： Transcanalicular L-DCR is a reliable and fast procedure in the treatment of NDO. It can be alternative to external DCR which is accepted as the gold standard currently. The functional and anatomical success rate is higher in the first months and years, but still satisfactory at fifth year.

Measuring nasolacrimal duct volume using computed tomography images in nasolacrimal duct obstruction patients in Korean

AIM: To investigate nasolacrimal duct(NLD) volume in Korean patients and to examine the correlation between NLD volume and obstruction. METHODS: Of patients who underwent orbital computed tomography from March 2013 to January 2016, patients diagnosed with NLD obstruction were classified into the patient group and patients without obstruction were classified into the control group. The NLD volume was measured using the Image J program, which showed the NLD in axial,coronal, and sagittal images on computed tomography. RESULTS: The average value of men's NLD volume,265.33±90.57 mm3, was significantly larger than women's,211.87±68.61 mm3(P=0.009). In the patient group, the NLD volume of the obstructed eyes, 242.49±82.93 mm3,and the non-obstructed eyes, 225.20±73.20 mm3, were significantly higher than the control group, 217.61±82.04 mm3(P<0.001, P<0.001). CONCLUSION: The NLD volume is larger in men than in women in Korean adults. If there is NLD obstruction in women, the NLD volume is larger and it is judged that inflammatory reaction caused a chronic change in the bone around the NLD and affect the measurement of NLD volume.

Results of Surgical Management of Malignant Obstruction of the Common Bile Duct in Yaoundé

Introduction: In Cameroon, surgery remains the only approach in malignant obstructions of the common bile duct (MOCBD) even in palliative situations. The aim of this work was to describe the modalities of surgical treatment of MOCBD, evaluate the results and detect the factors associated with postoperative morbidity and mortality. Patients and Methods: We conducted an analytical observational study, with retrospective data collection from the files of patients operated upon for MOCBD. This was done in four referral hospitals in the city of Yaoundé for a 42-month period spanning from January 1, 2020 to June 30, 2023. Demographic data, clinical presentation, surgical data, and 30-day postoperative outcomes were collected. Results: We collected 71 files. The sex ratio was 1.4 and the mean age was 56 ± 11 years. Fifty-three (53) patients (74.6%) were overweight or obese and 10 patients (14.1%) were hypertensive. A clinical cholestasis syndrome was present in 69 patients (97.2%). Fifty-five (55) patients (77.5%) had a cancer of the head of the pancreas, 8 patients (11.3%) had an extra-hepatic cholangiocarcinoma and 8 patients (11.3%) had an ampullary adenocarcinoma. Eight (8) resections (11.3%) with curative intent had been carried out and in 63 cases (88.7%), surgery was palliative. Postoperative morbidity was 55.7%, influenced by advanced WHO stage (p = 0.02). Postoperative mortality was 25.7%, associated with a high ASA score (p = 0.01). Conclusion: Pancreatic head cancer is the main etiology of malignant obstructions of the common bile duct in Cameroon. Surgical treatment is most often palliative. Postoperative morbidity and mortality are high, influenced by high WHO and ASA scores.

Curative effects of probing alone and probing combined with nasolacrimal injection of levofloxacin ophthalmic gel on congenital duct obstruction of children from 3–12 months of age

Background:To investigate the 1-time success rate of probing alone and nasolacrimal duct probing combined with nasolacrimal injection of levofloxacin ophthalmic gel on congenital nasolacrimal duct obstruction(CNLDO)in young children.Methods:A retrospective case series was performed on 494 cases(647 eyes)of 3–12 month-old children with CNLDO between July 2014 and July 2015.Material obtained from the lacrimal sac was cultured to isolate infectious agents.Susceptibility testing was done.Children from 3–12 months of age who were found to be sensitive to Levofloxacin(n=493 eyes)were separated into two groups:3–6 months of age(276 eyes)and 7–12 months of age(217 eyes).Each of the groups were then randomized into group A(138 eyes of3–6 months of age;102 eyes of 7–12 months of age)and group B(138 eyes of 3–6 months of age;115 eyes of7–12 months of age).Children in group A underwent nasolacrimal duct probing alone;those in group B underwent nasolacrimal duct probing plus nasolacrimal duct injection of levofloxacin and the efficacy of probing was evaluated.Results:The average detection rate of pathogenic bacteria in dacryocystitis was 75.1%,and Staphylococcus aureus was found to be the main pathogenic bacteria(42.59%,106 cases).Among children from 7–12 months of age,the 1-time success rate of nasolacrimal duct probing alone was 88.24%and the 1-time success rate of probing combined with nasolacrimal duct injection of levofloxacin ophthalmic gel was 96.52%(statistical significance,P=0.02<0.05).Conclusions:Most pathogenic bacteria(96.81%)were sensitive to levofloxacin.Nasolacrimal duct probing combined with nasolacrimal duct injection of levofloxacin may improve the success rate of probing in children older than 6 months of age.

Diagnosis and Treatment of Lacrimal Passage Obstruction by Lacrimal Endoscope

The diagnosis and treatment of the lacrimal passage obstruction with lacrimal endoscope was investigated and its subsidiary surgical procedures were evaluated. Ninety-three patients （109 eyes） with lacrimal passage obstruction, including presaccal canalicular obstruction （PSCO） and nasolacrimal duct obstruction （NLDO）, were examined under a lacrimal endoscope, and the obstruc- tions were treated with laser or micro-drill. All patients were followed up after the operation for 3--6 months. The difference between the laser and the micro-drill treatment was observed. During the period of follow-up, the curative rate was 82.57%. The healing rate in PSCO group and NLDO was 80.36% and 84.91% respectively （P〉0.05）. Alter treatment with the laser, the healing rate was 93.33% in the PSCO group and 66.67% in the NLDO group respectively （P〈0.05）. After treatment with the micro-drill, the healing rate in PSCO and NLDO groups was 65.39% and 94.28% respec- tively （P〈0.01）. The lacrimal passage obstruction can be observed and treated directly through the lacrimal endoscope. Choosing different surgical procedures in operation according to the locations of the obstruction is helpful to improve the effectiveness.

New tapered metallic stent for unresectable malignant hilar bile duct obstruction

AIM: To examine the usefulness of a new tapered metallic stent(MS) in patients with unresectable malignant hilar bile duct obstruction.METHODS: This new tapered MS was placed in 11 patients with Bismuth Ⅱ or severer unresectable malignant hilar bile duct obstruction, as a prospective study. The subjects were six patients with bile duct carcinoma, three with gallbladder cancer, and two with metastatic bile duct obstruction. Stenosis morphology was Bismuth Ⅱ: 7, Ⅲa: 3, and Ⅳ: 1. UMIN Clinical Trial Registry(UMIN000004758).RESULTS: MS placement was 100%(11/11) successful. There were no procedural accidents. The mean patency period was 208.401 d, the median survival period was 142.000 d, and the mean survival period was 193.273 d. Occlusion rate was 36.4%(4/11); the causes of occlusion were ingrowth and overgrowth in 2 patients each, 18.2%, respectively. Patients with occlusion underwent endoscopic treatment one more time and all were treatable. CONCLUSION: The tapered MS proved useful in patients with unresectable malignant hilar bile duct obstruction because it provided a long patency period, enabled re-treatment by re-intervention, and no procedural accidents occurred.

Endoscopic ultrasound-guided pancreaticogastrostomy for symptomatic pancreatic duct obstruction caused by migrated pancreatic stent

Endoscopic pancreatic stenting has been widely used in various pancreatic conditions. With the increasing use of pancreatic stents, many complications have been recognized. Especially, proximal stent migration presents a serious condition because of subsequent pancreatic duct obstruction, impaired drainage, ductal dilation, and pancreatic pain. Although endoscopic retrieval is the preferred treatment for proximally migrated pancreatic stents, it is not always successful, resulting in conversion to surgery. To date, endoscopic ultrasound-guided pancreatic duct drainage(EUS-PD) has never been reported for treatment of pancreatic duct obstruction caused by proximally migrated pancreatic stent. We herein describe a case of pancreatic duct rupture and obstruction caused by proximally migrated pancreatic stent that was successfully treated by EUS-guided pancreaticogastrostomy while keeping the former stent in situ after failed endoscopic retrograde cholangiopancreatography. We believe that this report adds to the increasing evidence of symptomatic pancreatic duct obstruction being successfully treated by EUS-PD.

Small serotonin-positive pancreatic endocrine tumors caused obstruction of the main pancreatic duct

We report 2 cases of pancreatic endocrine tumors that caused obstruction of the main pancreatic duct(MPD).A 49-year-old asymptomatic man was referred to our institution because dilation of the MPD was revealed by abdominal ultrasonography(US).No tumor was detected by endoscopic ultrasonography,computed tomography(CT),and magnetic resonance imaging(MRI).The diameter of the MPD was > 20 mm at the body,and no dilation was noted at the head.Although malignancy was not confirmed through cytology or imaging,pancreatic cancer was strongly suspected.Pancreaticoduo-denectomy was performed.Pathological and immunohistochemical examination revealed a 5 mm × 3 mm serotonin-positive endocrine tumor.Fibrosis was present around the MPD and seemed to cause stricture.A 32-year-old asymptomatic man had elevated serum amylase,and US demonstrated dilation of the MPD.No tumor was detected by CT and MRI.Pancreatic cancer was suspected due to stricture and dilation of the MPD.Pancreatectomy of middle part of pancreas was performed.Pathological and immunohistochemical examination revealed a serotonin-positive endocrine tumor sized 5 mm × 4 mm.We report 2 cases of serotonin-positive pancreatic endocrine tumors that caused stricture of the MPD in spite of the small size of the tumor.

The Effect of Resveratrol on Bone Status in Rats with Bile Duct Obstruction

Objective: We studied the influence of bile duct obstruction (BDO) after 28 days on bone metabolism status and their modification by resveratrol in male Wistar rats. Methods: The rats were divided into 3 groups: Sham group with laparotomy and vehiculum application, group BDO—bile duct obstruction and vehiculum application, and group RBDO—bile duct obstruction and resveratrol application (10 mg/kg dose of resveratrol orally once daily). The bone mineral density (BMD;g/cm2) and body composition were measured by dual energy X-ray absorptiometry. The physiccal strenght of femur was examined by controlled break biomechanical testing. The osteocalcin, procollagen type I N-terminal propeptide (PINP) and carboxy-terminal collagen crosslinks (CTX) were analysed by EIA in the bone tissue homogenate. Results: The total BMD was lower in group BDO (0.176 ± 0.005;p = 0.01) and R-BDO (0.181 ± 0.004;p = 0.052) vs Sham (0.209 ± 0.003). BMD of femur diaphysis in BDO group decreased significantly (p = 0.01) but not in R-BDO animals (p = 0.052). Body fat (g, median) was lower in BDO (19.0) and R-BDO (26.0) than in Sham (35.0). The force needed for fracture of femurs (N) significantly decreased in BDO (154 ± 6) and R-BDO (151 ± 13) vs Sham group (208 ± 7). The force needed for neck fracture decreased in BDO (105 ± 3) and R-BDO (115 ± 8) vs Sham (135 ± 9). The osteocalcin decrease in group R-BDO (2.9 ± 0.1) vs Sham (3.7 ± 0.4). Higher PINP/CTX were in BDO (20 ± 5/0.49 ± 0.08) and R-BDO (30 ± 4/0.55 ± 0.07) vs Sham (16 ± 4/0.48 ± 0.11). Conclusions: Our findings suggest that subchronic bile duct obstruction decreased body fat quantity and BMD with decrease of bone rigidity. Resveratrol showed protective effect on liver injury and consequently positive influence on bone tissue.

Persistent omphalomesenteric duct causing small bowel obstruction in an adult

An extremely rare case of persistent omphalomesenteric duct causing small bowel obstruction is presented. A 20-year-old female patient without medical history presented with colicky abdominal pain, vomiting, absence of passage of gas and feces, and abdominal distension of 24 h duration. Physical examination and blood tests were normal. Abdominal X-ray showed small bowel obstruction. Computed tomography of the abdomen demonstrated dilated small bowel and a band originating from the umbilicus and continuing between the small bowel loops; an omphalomesenteric duct remnant was suspected. In exploratory laparotomy, persistent omphalomesenteric duct causing small bowel obstruction was identified and resected. The patient had an uneventful recovery and was discharged on the 5^th postoperative day. Although persistent omphalomesenteric duct is an extremely infrequent cause of small bowel obstruction in adult patients, it should be taken into consideration in patients without any previous surgical history.

Cholangiocarcinoma and malignant bile duct obstruction: A review of last decades advances in therapeutic endoscopy

In the last decades many advances have been achieved in endoscopy, in the diagnosis and therapy of cholangiocarcinoma, however blood test, magnetic resonance imaging, computed tomography scan may fail to detect neoplastic disease at early stage, thus the diagnosis of cholangiocarcinoma is achieved usually at unresectable stage. In the last decades the role of endoscopy has moved from a diagnostic role to an invaluable therapeutic tool for patients affected by malignant bile duct obstruction. One of the major issues for cholangiocarcinoma is bile ducts occlusion, leading to jaundice, cholangitis and hepatic failure. Currently, endoscopy has a key role in the work up of cholangiocarcinoma, both in patients amenable to surgical intervention as well as in those unfit for surgery or not amenable to immediate surgical curative resection owing to locally advanced or advanced disease, with palliative intention. Endoscopy allows successful biliary drainage and stenting in more than 90% of patients with malignant bile duct obstruction, and allows rapid reduction of jaundice decreasing the risk of biliary sepsis. When biliary drainage and stenting cannot be achieved with endoscopy alone, endoscopic ultrasound-guided biliary drainage represents an effective alternative method affording successful biliary drainage in more than 80% of cases. The purpose of this review is to focus on the currently available endoscopic management options in patients with cholangiocarcinoma.

Successful stent-in-stent dilatation of the common bile duct through a duodenal prosthesis,a novel technique for malignant obstruction:A case report and review of literature

For patients suffering from both biliary and duodenal obstruction,endoscopic retrograde cholangiopancreatography(ERCP) with stent placement is the treatment of choice.ERCP through an already existing duodenal prosthesis is an uncommon procedure and furthermore no studies have reported installing a covered metal stent onto an already existing bare metal stent in the common bile duct(CBD).We describe a rare case of a stent-in-stent dilatation of the CBD through an already existing self-expanding metal stent in the second part of duodenum for the patient presenting with jaundice in setting of biliary and duodenal obstruction from pancreatic adenocarcinoma.The biliary obstruction was relieved with a decrease in bilirubin levels post-stenting.