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Lee SY, Jang SI, Chung MJ, Cho JH, Do MY, Lee HS, Yang J, Lee DK. A Short Fully Covered Self-Expandable Metal Stent for Management of Benign Biliary Stricture Not Caused by Living-Donor Liver Transplantation. J Clin Med 2024; 13:1186. [PMID: 38592022 PMCID: PMC10931574 DOI: 10.3390/jcm13051186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 02/05/2024] [Accepted: 02/18/2024] [Indexed: 04/10/2024] Open
Abstract
Background: This study evaluated the effectiveness of short fully covered self-expanding metal stents (FCSEMS) with an anti-migration design in treating benign biliary strictures (BBS) not related to living donor liver transplantation (LDLT). Methods: A retrospective analysis was conducted on 75 patients who underwent FCSEMS insertion for BBS management. Stents were initially kept for 3 months and exchanged every 3 months until stricture resolution. Adverse events and stricture recurrence after FCSEMS removal were assessed during follow-up. Results: The study outcomes were technical success, stenosis resolution, and treatment failure. Technical success was 100%, with stricture resolution in 99% of patients. The mean onset time of BBS post-surgery was 4.4 years, with an average stent indwelling period of 5.5 months. Stricture recurrence occurred in 20% of patients, mostly approximately 18.8 months after stent removal. Early cholangitis and stent migration were noted in 3% and 4% of patients, respectively. Conclusions: This study concludes that short FCSEMS demonstrate high efficacy in the treatment of non-LDLT-related BBS, with a low incidence of interventions and complications. Although this is a single-center, retrospective study with a limited sample size, the findings provide preliminary evidence supporting the use of short FCSEMS as a primary treatment modality for BBS. To substantiate these findings, further research involving multicenter studies is recommended to provide additional validation and a broader perspective.
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Affiliation(s)
- See-Young Lee
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (S.-Y.L.); (S.-I.J.); (M.-J.C.); (J.-H.C.); (M.-Y.D.)
| | - Sung-Ill Jang
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (S.-Y.L.); (S.-I.J.); (M.-J.C.); (J.-H.C.); (M.-Y.D.)
| | - Moon-Jae Chung
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (S.-Y.L.); (S.-I.J.); (M.-J.C.); (J.-H.C.); (M.-Y.D.)
| | - Jae-Hee Cho
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (S.-Y.L.); (S.-I.J.); (M.-J.C.); (J.-H.C.); (M.-Y.D.)
| | - Min-Young Do
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (S.-Y.L.); (S.-I.J.); (M.-J.C.); (J.-H.C.); (M.-Y.D.)
| | - Hye-Sun Lee
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (H.-S.L.); (J.Y.)
| | - Juyeon Yang
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (H.-S.L.); (J.Y.)
| | - Dong-Ki Lee
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (S.-Y.L.); (S.-I.J.); (M.-J.C.); (J.-H.C.); (M.-Y.D.)
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Ramchandani M, Pal P, Costamagna G. Management of Benign Biliary Stricture in Chronic Pancreatitis. Gastrointest Endosc Clin N Am 2023; 33:831-844. [PMID: 37709414 DOI: 10.1016/j.giec.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
Endoscopic therapy is the first line of management for chronic pancreatitis (CP)-related benign biliary strictures. Multiple plastic stents (MPS) exchanged at regular intervals and temporary placement of fully covered self-expanding metal stents (FCSEMS) are preferred modalities of endotherapy. FCSEMS placement is non-inferior to MPS and requires fewer sessions of endoscopic retrograde cholangiopancreatography than MPS placement. The presence of head calcifications, severe CP, and length of stricture are predictors of failure or recurrence after endotherapy. Failure of endotherapy should be considered after 1 year when surgery should be considered.
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Affiliation(s)
- Mohan Ramchandani
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad, Telangana, India; Interventional Endoscopy, AIG Hospitals, Plot No 2/3/4/5 Survey, 1, Mindspace Road, Gachibowli, Hyderabad, Telangana 500032, India.
| | - Partha Pal
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad, Telangana, India
| | - Guido Costamagna
- Department of Translational Medicine and Surgery, Catholic University, Rome
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3
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ACG Clinical Guideline: Diagnosis and Management of Biliary Strictures. Am J Gastroenterol 2023; 118:405-426. [PMID: 36863037 DOI: 10.14309/ajg.0000000000002190] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 12/13/2022] [Indexed: 03/04/2023]
Abstract
A biliary stricture is an abnormal narrowing in the ductal drainage system of the liver that can result in clinically and physiologically relevant obstruction to the flow of bile. The most common and ominous etiology is malignancy, underscoring the importance of a high index of suspicion in the evaluation of this condition. The goals of care in patients with a biliary stricture are confirming or excluding malignancy (diagnosis) and reestablishing flow of bile to the duodenum (drainage); the approach to diagnosis and drainage varies according to anatomic location (extrahepatic vs perihilar). For extrahepatic strictures, endoscopic ultrasound-guided tissue acquisition is highly accurate and has become the diagnostic mainstay. In contrast, the diagnosis of perihilar strictures remains a challenge. Similarly, the drainage of extrahepatic strictures tends to be more straightforward and safer and less controversial than that of perihilar strictures. Recent evidence has provided some clarity in multiple important areas pertaining to biliary strictures, whereas several remaining controversies require additional research. The goal of this guideline is to provide practicing clinicians with the most evidence-based guidance on the approach to patients with extrahepatic and perihilar strictures, focusing on diagnosis and drainage.
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Xu X, Guan L, Wu Y, Ke H, Zhao Y, Liu P. One hundred most cited articles related to Endoscopic retrograde cholangiopancreatography: A bibliometric analysis. Front Surg 2022; 9:1005771. [PMID: 36439532 PMCID: PMC9681810 DOI: 10.3389/fsurg.2022.1005771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 10/20/2022] [Indexed: 11/11/2022] Open
Abstract
Background Endoscopic retrograde cholangiopancreatography (ERCP) has developed over the past few decades into a reliable technology for diagnostic and therapeutic purposes. Through a bibliometric analysis, this research attempted to evaluate the characteristics of the top 100 articles on ERCP that had the most citations. Methods We extracted pertinent publications from the Web of Science Core Collection (WoSCC) on July 9, 2022. The top 100 ERCP articles with the most citations were identified and analyzed. The following data were extracted: publication year, country/region, organization, total citation times, annual citation times, research type and research field, etc. To implement the network’s visual analysis, a bibliographic coupling network based on keywords was built using the VOSviewer 1.6.17 program. Results The journal with the most publications were GASTROINTESTINAL ENDOSCOPY, with 45 articles. Most of the top 100 articles came from the United States (n = 47) and Italy (n = 14). Indiana University and the University of Amsterdam were among the most important institutions in ERCP research. ML Freeman of the University of Minnesota contributed the highest number (n = 9) and the most highly cited paper. The age of the paper and article type is closely related to citation frequency. Of the 100 most-cited articles, clinical application in the field of ERCP has focused on three aspects: diagnosis, treatment, and complications. Clinical use of ERCP has shifted from diagnosis to treatment. Post-ERCP pancreatitis is the focus of attention, and the clinical application of technically complex therapeutic ERCP is the future development trend. Conclusion This study lists the most influential articles in ERCP by exposing the current state of the field, and showing the evolution of research trends to provide perspective for the future development of ERCP.
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Affiliation(s)
- Xuan Xu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
- First Clinical Medical College, Nanchang University, Nanchang, China
| | - Lulu Guan
- First Clinical Medical College, Nanchang University, Nanchang, China
| | - Yao Wu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Huajing Ke
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yuanbin Zhao
- Second Clinical Medical College, Nanchang University, Nanchang, China
| | - Pi Liu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
- Department of Gastroenterology, The People’s Hospital of Longhua, Shenzhen, China
- Correspondence: Pi Liu
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5
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Benign biliary strictures associated with acute biliary pancreatitis. Surg Endosc 2022; 37:2587-2594. [PMID: 36348167 DOI: 10.1007/s00464-022-09753-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 10/29/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND AND AIMS There are limited data about the benign biliary strictures (BBS) which can develop during the clinical course of acute biliary pancreatitis (ABP) due to compression of the common bile duct (CBD) by edematous and inflamed pancreatic tissue. We aimed to determine the incidence of BBS due to ABP and its clinical course after endoscopic management. METHODS The study was retrospectively conducted among patients with ABP who were admitted to a single tertiary reference center during 3 years. BBS-ABP was defined as distal narrowing of the CBD with proximal dilatation and delayed drainage of the contrast into the duodenum. Endoscopic treatment was performed by inserting a single 7F or 10F plastic stent which was exchanged every 3 months until stricture resolution. Patients were followed for 1 year after stricture resolution. RESULTS Seven hundred and twenty-one patients had ABP during the study period. Among them, 257 (35.6%) patients underwent ERCP and 26 patients (3.6%) had CBD stricture due to ABP. A 7 Fr plastic stent was inserted in 18 patients and 10 Fr in 8 patients. The stricture was completely resolved at 3 months in 66.7%, at 6 months 23.8% and at 9 months (9.5%) of the patients. There was no procedure-related complications other than asymptomatic stent migration in 4 (19%) patients. None of the patients had recurrent biliary stricture during the 1 year stent-free follow-up period. CONCLUSION BBS-ABP is a frequently seen clinical entity. In most patients, the stricture improves within 3 months and temporary endoscopic stenting prevents the patients from the consequences of the obstruction during this period.
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6
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Schepis T, Boškoski I, Tringali A, Costamagna G. Role of ERCP in Benign Biliary Strictures. Gastrointest Endosc Clin N Am 2022; 32:455-475. [PMID: 35691691 DOI: 10.1016/j.giec.2022.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Benign biliary strictures (BBS) can be associated with several causes, with postoperative and inflammatory strictures representing the most common ones. Endoscopy represents nowadays the first-line treatment in the management of BBS. Endoscopic balloon dilatation, plastic stents placement, fully covered metal stent placement, and magnetic compression anastomosis are the endoscopic techniques available for the treatment of BBS. The aim of this study is to perform a review of the literature to assess the role of endoscopy in the management of BBS and to evaluate the application of the different procedures in the different clinical settings.
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Affiliation(s)
- Tommaso Schepis
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Ivo Boškoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica Del Sacro Cuore di Roma, Italy.
| | - Andrea Tringali
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica Del Sacro Cuore di Roma, Italy
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica Del Sacro Cuore di Roma, Italy
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7
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Metal versus plastic stents in the management of benign biliary strictures: systematic review and meta-analysis of randomized controlled trials. Eur J Gastroenterol Hepatol 2022; 34:478-487. [PMID: 35170533 DOI: 10.1097/meg.0000000000002352] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Benign biliary strictures (BBS) are usually treated with endoscopic retrograde cholangiopancreatography (ERCP) with the placement of multiple plastic stents (MPS) or a covered self-expandable metal stent (CSEMS). In this meta-analysis, we compared the efficacy and safety of MPS and CSEMS in the management of BBS. We reviewed several databases from inception to 28 April 2021 to identify RCTs that compared MPS with CSEMS in the management of BBS. Our outcomes of interest were stricture resolution, stricture recurrence, adverse events, stent migration and mean number of ERCPs to achieve stricture resolution. Data were analyzed using a random-effects model. We included eight RCTs with 524 patients. We found no significant difference in the rate of stricture resolution (risk ratio, 1.02; 95% CI, 0.96-1.10), stricture recurrence (risk ratio, 1.68; 95% CI, 0.72-3.88) or adverse events (risk ratio, 1.17; 95% CI, 0.73-1.87) between groups. Mean number of ERCPs was significantly lower in the CSEMS group (SMD, -1.99; 95% CI, -3.35 to -0.64). The rate of stent migration was significantly higher in the CSEMS group. CSEMS are comparable in efficacy and safety to MPS in the management of BBS but require fewer ERCPs to achieve stricture resolution.
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8
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Dirweesh A, Trikudanathan G, Freeman ML. Endoscopic Management of Complications in Chronic Pancreatitis. Dig Dis Sci 2022; 67:1624-1634. [PMID: 35226223 DOI: 10.1007/s10620-022-07391-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/04/2022] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Management of complications in patients with chronic pancreatitis is often suboptimal. This review discusses detailed endoscopic approaches for managing complications in CP. LITERATURE FINDINGS CP is characterized by progressive and irreversible destruction of pancreatic parenchyma and ductal system resulting in fibrosis, scarring, and loss of glandular function. Abdominal pain remains is the most common symptom of the disease and the main aim of medical, endoscopic, and surgical therapy is to help relieve symptoms, prevent disease progression, and manage complications related to CP. In fact, advances in our understanding of CP have improved medical care and quality of life in these patients. With significant sequela, morbidity and a progressive nature, a thorough understanding of the pathophysiology, natural course, diagnostic approaches, and optimal management strategies for this disease is warranted. The existing modalities and new innovations in this field are safe, effective, and likely to have a positive impact on management of complication in CP whenever used in the right context.
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Affiliation(s)
- Ahmed Dirweesh
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, MMC 36, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Guru Trikudanathan
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, MMC 36, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Martin L Freeman
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, MMC 36, 420 Delaware St SE, Minneapolis, MN, 55455, USA.
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9
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Nabi Z, Lakhtakia S. Endoscopic management of chronic pancreatitis. Dig Endosc 2021; 33:1059-1072. [PMID: 33687105 DOI: 10.1111/den.13968] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/02/2021] [Accepted: 03/05/2021] [Indexed: 02/05/2023]
Abstract
Chronic pancreatitis (CP) is an inflammatory process characterized by irreversible morphological changes in the pancreas. Pain is the predominant symptom observed during the course of CP. The etiopathogenesis of pain in CP is multifactorial and includes ductal hypertension due to obstruction of the pancreatic duct (PD), neuropathic causes, and extrapancreatic complications of CP like pseudocyst and distal biliary obstruction. A sizeable proportion of patients with CP are amenable to endoscopic treatment. The mainstay of endotherapy includes decompression of PD with one or more plastic stents in those with stricture, and fragmentation of PD calculi using extracorporeal shock wave lithotripsy. Nearly two-thirds of the patients achieve pain relief in the long term with endotherapy. Upfront assessment for the suitability of endotherapy is paramount to achieve the best outcomes. The predictors of poor response to endotherapy include multifocal disease, like those with multifocal strictures or multiple calculi throughout the pancreas, or a combination of both PD strictures and stones. With the emerging use of covered metal stents, the outcomes are likely to improve in cases with refractory PD strictures as well as CP-related distal biliary obstruction. The optimum stent design and indwell time of metal stents in cases with refractory PD strictures need further evaluation. Endoscopic ultrasonography has emerged as a complementary endoscopic modality in the management of CP as well as associated complications like pseudocysts, refractory pain, and vascular complications.
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Affiliation(s)
- Zaheer Nabi
- Asian Institute of Gastroenterology, Hyderabad, India
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Fang A, Kim IK, Ukeh I, Etezadi V, Kim HS. Percutaneous Management of Benign Biliary Strictures. Semin Intervent Radiol 2021; 38:291-299. [PMID: 34393339 DOI: 10.1055/s-0041-1731087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Benign biliary strictures are often due to a variety of etiologies, most of which are iatrogenic. Clinical presentation can vary from asymptomatic disease with elevated liver enzymes to obstructive jaundice and recurrent cholangitis. Diagnostic imaging methods, such as ultrasound, multidetector computed tomography, and magnetic resonance imaging (cholangiopancreatography), are used to identify stricture location, extent, and possible source of biliary obstruction. The management of benign biliary strictures requires a multidisciplinary team approach and include endoscopic, percutaneous, and surgical interventions. Percutaneous biliary interventions provide an alternative diagnostic and therapeutic approach, especially in patients who are not amenable to endoscopic evaluation. This review provides an overview of benign biliary strictures and percutaneous management by interventional radiologists. Diagnostic evaluation with percutaneous transhepatic cholangiography and treatment options, including biliary drainage, balloon dilation, retrievable/biodegradable stents, and other innovative minimally invasive options, are discussed.
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Affiliation(s)
- Adam Fang
- Division of Vascular and Interventional Radiology, Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Il Kyoon Kim
- Division of Vascular and Interventional Radiology, Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Ifechi Ukeh
- Division of Vascular and Interventional Radiology, Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Vahid Etezadi
- Division of Vascular and Interventional Radiology, Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Hyun S Kim
- Division of Vascular and Interventional Radiology, Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
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11
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Kotha S, Berry P, Raja U, Wong T. Benign biliary strictures: utility of novel biodegradable biliary stents in surgically altered anatomy. Endoscopy 2021; 53:E281-E282. [PMID: 33003216 DOI: 10.1055/a-1261-2800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Sreelakshmi Kotha
- Department of Gastroenterology, Guy's and St Thomas' Foundation Trust, London, United Kingdom
| | - Philip Berry
- Department of Gastroenterology, Guy's and St Thomas' Foundation Trust, London, United Kingdom
| | - Usman Raja
- Department of Interventional Radiology, Guy's and St Thomas' Hospital, London, United Kingdom
| | - Terry Wong
- Department of Gastroenterology, Guy's and St Thomas' Foundation Trust, London, United Kingdom
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12
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Ramchandani M, Lakhtakia S, Costamagna G, Tringali A, Püspöek A, Tribl B, Dolak W, Devière J, Arvanitakis M, van der Merwe S, Laleman W, Ponchon T, Lepilliez V, Gabbrielli A, Bernardoni L, Bruno MJ, Poley JW, Arnelo U, Lau J, Roy A, Bourke M, Kaffes A, Neuhaus H, Peetermans J, Rousseau M, Reddy DN. Fully Covered Self-Expanding Metal Stent vs Multiple Plastic Stents to Treat Benign Biliary Strictures Secondary to Chronic Pancreatitis: A Multicenter Randomized Trial. Gastroenterology 2021; 161:185-195. [PMID: 33741314 DOI: 10.1053/j.gastro.2021.03.015] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 03/01/2021] [Accepted: 03/06/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Benign biliary strictures (BBS) are complications of chronic pancreatitis (CP). Endotherapy using multiple plastic stents (MPS) or a fully covered self-expanding metal stent (FCSEMS) are acceptable treatment options for biliary obstructive symptoms in these patients. METHODS Patients with symptomatic CP-associated BBS enrolled in a multicenter randomized noninferiority trial comparing 12-month treatment with MPS vs FCSEMS. Primary outcome was stricture resolution status at 24 months, defined as absence of restenting and 24-month serum alkaline phosphatase not exceeding twice the level at stenting completion. Secondary outcomes included crossover rate, numbers of endoscopic retrograde cholangiopancreatography (ERCPs) and stents, and stent- or procedure-related serious adverse events. RESULTS Eighty-four patients were randomized to MPS and 80 to FCSEMS. Baseline technical success was 97.6% for MPS and 98.6% for FCSEMS. Eleven patients crossed over from MPS to FCSEMS, and 10 from FCSEMS to MPS. For MPS vs FCSEMS, respectively, stricture resolution status at 24 months was 77.1% (54/70) vs 75.8% (47/62) (P = .008 for noninferiority intention-to-treat analysis), mean number of ERCPs was 3.9 ± 1.3 vs 2.6 ± 1.3 (P < .001, intention-to-treat), and mean number of stents placed was 7.0 ± 4.4 vs 1.3 ± .6 (P < .001, as-treated). Serious adverse events occurred in 16 (19.0%) MPS and 19 (23.8%) FCSEMS patients (P = .568), including cholangitis/fever/jaundice (9 vs 7 patients respectively), abdominal pain (5 vs 5), cholecystitis (1 vs 3) and post-ERCP pancreatitis (0 vs 2). No stent- or procedure-related deaths occurred. CONCLUSIONS Endotherapy of CP-associated BBS has similar efficacy and safety for 12-month treatment using MPS compared with a single FCSEMS, with FCSEMS requiring fewer ERCPs over 2 years. (ClinicalTrials.gov, Number: NCT01543256.).
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Affiliation(s)
| | | | - Guido Costamagna
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Digestive Endoscopy Unit, Università Cattolica del Sacro Cuore, Roma, Italia
| | - Andrea Tringali
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Digestive Endoscopy Unit, Università Cattolica del Sacro Cuore, Roma, Italia
| | - Andreas Püspöek
- Centre for Endoscopic Research Therapeutics and Training (CERTT), St. John's Hospital, Eisenstadt, Austria
| | | | | | | | | | | | - Wim Laleman
- University Hospitals Leuven, Leuven, Belgium
| | | | | | | | - Laura Bernardoni
- Università degli Studi Verona Policlinico G.B. Rossi, Verona, Italy
| | | | | | - Urban Arnelo
- CLINTEC, Division of Surgery, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
| | - James Lau
- Prince of Wales Hospital, New Territories, Hong Kong
| | - André Roy
- Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Michael Bourke
- Western Clinical School, University of Sydney, Westmead Hospital, Sydney, NSW, Australia
| | - Arthur Kaffes
- Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Horst Neuhaus
- Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany
| | - Joyce Peetermans
- Endoscopy Division, Boston Scientific Corporation, Marlborough, Massachusetts
| | - Matthew Rousseau
- Endoscopy Division, Boston Scientific Corporation, Marlborough, Massachusetts
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Kim HJ, Kim HJ. [Centrally Mediated Abdominal Pain Syndrome]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2021; 77:277-284. [PMID: 34158447 DOI: 10.4166/kjg.2021.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/07/2021] [Accepted: 06/07/2021] [Indexed: 11/03/2022]
Abstract
Centrally mediated abdominal pain syndrome (CAPS), known as functional abdominal pain syndrome in the Rome III criteria of functional gastrointestinal diseases, has a reported population prevalence of between 0.5% and 2.1%, with a female preponderance. The pathogenesis of CAPS has not been completely established, and various studies are being conducted. On the other hand, central nervous system sensitization with disinhibition of the pain signaling pathways appears to play a more important role than the up-regulation of peripheral afferent neuronal excitability. The diagnosis of CAPS is based on the Rome IV criteria (2016) and is established around the gastrointestinal symptoms combination. Various new treatment trials and effective patient-physician relationships showed progressive results.
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Affiliation(s)
- Hee Jin Kim
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Gyeongsang National University College of Medicine, Changwon, Korea
| | - Hyun Jin Kim
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Gyeongsang National University College of Medicine, Changwon, Korea
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14
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Tomishima K, Ishii S, Fujisawa T, Ikemura M, Ushio M, Takahashi S, Yamagata W, Takasaki Y, Suzuki A, Ito K, Haga K, Ochiai K, Nomura O, Saito H, Shibuya T, Nagahara A, Isayama H. Evaluation of the Feasibility and Effectiveness of Placement of Fully Covered Self-Expandable Metallic Stents via Various Insertion Routes for Benign Biliary Strictures. J Clin Med 2021; 10:jcm10112397. [PMID: 34071678 PMCID: PMC8198386 DOI: 10.3390/jcm10112397] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 05/17/2021] [Accepted: 05/28/2021] [Indexed: 12/11/2022] Open
Abstract
Background and aims: The goals of the management of benign biliary stricture (BBS) are to relieve symptoms and resolve short-/long-term stricture. We performed fully covered self-expandable metallic stent (hereafter, FCSEMS) placement for BBS using various methods and investigated the treatment outcomes and adverse events (AEs). Methods: We retrospectively studied patients who underwent FCSEMS placement for refractory BBS through various approaches between January 2017 and February 2020. FCSEMS were placed for 6 months, and an additional FCSEMS was placed if the stricture had not improved. Technical success rate, stricture resolution rate, and AE were measured. Results: A total of 26 patients with BBSs that were difficult to manage with plastic stents were included. The mean overall follow-up period was 43.3 ± 30.7 months. The cause of stricture was postoperative (46%), inflammatory (31%), and chronic pancreatitis (23%). There were four insertion methods: endoscopic with duodenoscopy, with enteroscopy, EUS-guided transmural, and percutaneous transhepatic. The technical success rate was 100%, without any AE. Stricture resolution was obtained in 19 (83%) of 23 cases, except for three cases of death due to other causes. Stent migration and cholangitis occurred in 23% and 6.3%, respectively. Stent fracture occurred in two cases in which FCSEMSs were placed for more than 6 months (7.2 and 10.3 months). Conclusion: FCSEMS placement for refractory BBS via various insertion routes was feasible and effective. FCSEMSs should be exchanged every 6 months until stricture resolution because of stent durability. Further prospective study for confirmation is required, particularly regarding EUS-guided FCSEMS placement.
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Kamp EJCA, Dinjens WNM, Doukas M, Bruno MJ, de Jonge PJF, Peppelenbosch MP, de Vries AC. Optimal tissue sampling during ERCP and emerging molecular techniques for the differentiation of benign and malignant biliary strictures. Therap Adv Gastroenterol 2021; 14:17562848211002023. [PMID: 33948111 PMCID: PMC8053835 DOI: 10.1177/17562848211002023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 02/15/2021] [Indexed: 02/04/2023] Open
Abstract
Patients with cholangiocarcinoma have poor survival since the majority of patients are diagnosed at a stage precluding surgical resection, due to locally irresectable tumors and/or metastases. Optimization of diagnostic strategies, with a principal role for tissue diagnosis, is essential to detect cancers at an earlier stage amenable to curative treatment. Current barriers for a tissue diagnosis include both insufficient tissue sampling and a difficult cyto- or histopathological assessment. During endoscopic retrograde cholangiopancreatography, optimal brush sampling includes obtaining more than one brush within an individual patient to increase its diagnostic value. Currently, no significant increase of the diagnostic accuracy for the new cytology brush devices aiming to enhance the cellularity of brushings versus standard biliary brush devices has been demonstrated. Peroral cholangioscopy with bile duct biopsies appears to be a valuable tool in the diagnostic work-up of indeterminate biliary strictures, and may overcome current technical difficulties of fluoroscopic-guided biopsies. Over the past years, molecular techniques to detect chromosomal instability, mutations and methylation profiling of tumors have revolutionized, and implementation of these techniques on biliary tissue during diagnostic work-up of biliary strictures may be awaited in the near future. Fluorescence in situ hybridization has already been implemented in routine diagnostic evaluation of biliary strictures in several centers. Next-generation sequencing is promising for standard diagnostic care in biliary strictures, and recent studies have shown adequate detection of prevalent genomic alterations in KRAS, TP53, CDKN2A, SMAD4, PIK3CA, and GNAS on biliary brush material. Detection of DNA methylation of tumor suppressor genes and microRNAs may evolve over the coming years to a valuable diagnostic tool for cholangiocarcinoma. This review summarizes optimal strategies for biliary tissue sampling during endoscopic retrograde cholangiopancreatography and focuses on the evolving molecular techniques on biliary tissue to improve the differentiation of benign and malignant biliary strictures.
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Affiliation(s)
- Eline J. C. A. Kamp
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Winand N. M. Dinjens
- Department of Pathology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, The Netherlands
| | - Michail Doukas
- Department of Pathology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, The Netherlands
| | - Marco J. Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Pieter Jan F. de Jonge
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Maikel P. Peppelenbosch
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Annemarie C. de Vries
- Department of Gastroenterology & Hepatology, Erasmus MC, University Medical Center Rotterdam, Doctor Molewaterplein 40, Room Na-609, Rotterdam, 3015 GD, The Netherlands
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16
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Magro B, Tacelli M, Mazzola A, Conti F, Celsa C. Biliary complications after liver transplantation: current perspectives and future strategies. Hepatobiliary Surg Nutr 2021; 10:76-92. [PMID: 33575291 DOI: 10.21037/hbsn.2019.09.01] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Accepted: 08/29/2019] [Indexed: 12/29/2022]
Abstract
Importance Liver transplantation (LT) is a life-saving therapy for patients with end-stage liver disease and with acute liver failure, and it is associated with excellent outcomes and survival rates at 1 and 5 years. The incidence of biliary complications (BCs) after LT is reported to range from 5% to 20%, most of them occurring in the first three months, although they can occur also several years after transplantation. Objective The aim of this review is to summarize the available evidences on pathophysiology, risk factors, diagnosis and therapeutic management of BCs after LT. Evidence Review a literature review was performed of papers on this topic focusing on risk factors, classifications, diagnosis and treatment. Findings Principal risk factors include surgical techniques and donor's characteristics for biliary leakage and anastomotic biliary strictures and vascular alterations for non- anastomotic biliary strictures. MRCP is the gold standard both for intra- and extrahepatic BCs, while invasive cholangiography should be restricted for therapeutic uses or when MRCP is equivocal. About treatment, endoscopic techniques are the first line of treatment with success rates of 70-100%. The combined success rate of ERCP and PTBD overcome 90% of cases. Biliary leaks often resolve spontaneously, or with the positioning of a stent in ERCP for major bile leaks. Conclusions and Relevance BCs influence morbidity and mortality after LT, therefore further evidences are needed to identify novel possible risk factors, to understand if an immunological status that could lead to their development exists and to compare the effectiveness of innovative surgical and machine perfusion techniques.
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Affiliation(s)
- Bianca Magro
- Section of Gastroenterology and Hepatology, Dipartimento di Promozione della Salute, Materno-Infantile, Medicina Interna e Specialistica di Eccellenza (PROMISE), University of Palermo, Palermo, Italy.,Service d'Hépatologie et Transplantation Hépatique, Hôpital de la Pitié Salpétrière, AP-HP, Paris, France
| | - Matteo Tacelli
- Section of Gastroenterology and Hepatology, Dipartimento di Promozione della Salute, Materno-Infantile, Medicina Interna e Specialistica di Eccellenza (PROMISE), University of Palermo, Palermo, Italy
| | - Alessandra Mazzola
- Service d'Hépatologie et Transplantation Hépatique, Hôpital de la Pitié Salpétrière, AP-HP, Paris, France
| | - Filomena Conti
- Service d'Hépatologie et Transplantation Hépatique, Hôpital de la Pitié Salpétrière, AP-HP, Paris, France
| | - Ciro Celsa
- Section of Gastroenterology and Hepatology, Dipartimento di Promozione della Salute, Materno-Infantile, Medicina Interna e Specialistica di Eccellenza (PROMISE), University of Palermo, Palermo, Italy
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17
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Hyun JJ, Irani SS, Ross AS, Larsen MC, Gluck M, Kozarek RA. Incidence and Significance of Biliary Stricture in Chronic Pancreatitis Patients Undergoing Extracorporeal Shock Wave Lithotripsy for Obstructing Pancreatic Duct Stones. Gut Liver 2021; 15:128-134. [PMID: 32393009 PMCID: PMC7817933 DOI: 10.5009/gnl19380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 01/04/2020] [Accepted: 01/04/2020] [Indexed: 11/16/2022] Open
Abstract
Background/Aims This study assessed the significance of biliary stricture in symptomatic chronic pancreatitis patients requiring extracorporeal shock wave lithotripsy (ESWL) and endoscopic retrograde cholangiopancreatography (ERCP) to remove obstructing pancreatic calculi. Methods A total of 97 patients underwent ESWL followed by ERCP to remove pancreatic calculi between October 2014 and October 2017 at Virginia Mason Medical Center. Significant biliary stricture (SBS) was defined as a stricture with upstream dilation on computed tomography scan or magnetic resonance cholangiopancreatography scans accompanied by cholestasis and/or cholangitis. SBS was initially managed by either a plastic stent or fully covered self-expandable metallic stent (fcSEMS). If the stricture did not resolve, the stent was replaced with either multiple plastic stents or another fcSEMS. Data were collected by retrospectively reviewing the medical records. Results Biliary strictures were noted in approximately one-third of patients (34/97, 35%) undergoing ESWL for pancreatic calculi. Approximately one-third of the biliary strictures (11/34, 32%) were SBS. Pseudocysts were more frequently found in those with SBS (36% vs 8%, p=0.02), and all pseudocysts in the SBS group were located in the pancreatic head. The initial stricture resolution rates with fcSEMSs and plastic prostheses were 75% and 29%, respectively. The overall success rate for stricture resolution was 73% (8/11), and the recurrence rate after initial stricture resolution was 25% (2/8). Conclusions Although periductal fibrosis is the main mechanism underlying biliary stricture development in chronic pancreatitis, inflammation induced by obstructing pancreatic calculi, including pseudocysts, is an important contributing factor to SBS formation during the acute phase.
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Affiliation(s)
- Jong Jin Hyun
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea.,Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Shayan S Irani
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Andrew S Ross
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Michael C Larsen
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Michael Gluck
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Richard A Kozarek
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
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18
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Cantù P, Mauro A, Cassinotti E, Boni L, Vecchi M, Penagini R. Post-operative biliary strictures. Dig Liver Dis 2020; 52:1421-1427. [PMID: 32868211 DOI: 10.1016/j.dld.2020.07.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 07/14/2020] [Accepted: 07/23/2020] [Indexed: 12/11/2022]
Abstract
Post-operative biliary stricture is a cumbersome condition, secondary to biliary or vascular damage. Its risk factors include biliary or vascular anatomical variants, local inflammation, and poor surgical expertise. Intra-operative diagnosis is difficult, and in most cases, patients present with obstructive symptoms within a few weeks. Magnetic resonance cholangiography is a pivotal test to confirm the clinical picture, to study the level of the damage, and to guide treatment. Nowadays, endoscopic stenting is the first-line treatment in most centers. Multi-stenting treatment achieves long-term clinical success for more than 90% of patients, however multiple procedures are needed. In order to optimize healthcare provider costs, shorter duration endotherapies with covered metal stents are under evaluation. Radiological and surgical approaches are considered in the event of endoscopy failure.
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Affiliation(s)
- Paolo Cantù
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Via F. Sforza 35, 20122 Milan, Italy.
| | - Aurelio Mauro
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Via F. Sforza 35, 20122 Milan, Italy; Digestive Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, Viale Camillo Golgi 19, 27100 Pavia, Italy
| | - Elisa Cassinotti
- Department of Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Via F. Sforza 35, 20122 Milan, Italy
| | - Luigi Boni
- Department of Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Via F. Sforza 35, 20122 Milan, Italy
| | - Maurizio Vecchi
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Via F. Sforza 35, 20122 Milan, Italy
| | - Roberto Penagini
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Via F. Sforza 35, 20122 Milan, Italy
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Gao DJ, Zhang HZ, Hu B, Lu R, Wang SP. Establishment of a Swine Benign Biliary Stricture Model of Endobiliary Thermal Injury With a Diathermic Sheath. Surg Laparosc Endosc Percutan Tech 2020; 30:e52-e58. [PMID: 33075006 DOI: 10.1097/sle.0000000000000872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND A reliable large animal model of benign biliary stricture (BBS) is essential to study endoscopic management of BBS. The aim of this study was to establish a swine BBS model of endobiliary electrothermal injury with a diathermic sheath and screen out the optimal energy dose. MATERIALS AND METHODS Twelve swine were equally randomized into a low (20 W), a medium (30 W), and a high (40 W)-dose group. Endobiliary electrothermal injury was applied to the common bile duct using a diathermic sheath at different energy doses for 20 seconds via endoscopic retrograde cholangiopancreatography. Cholangiographic findings and liver function were evaluated weekly after thermal injury. Two animals from each group were sacrificed at 2 weeks and the other 2 sacrificed 4 weeks after thermal injury for histopathologic evaluation. RESULTS BBS was established successfully in 10 of the 12 animals. Two of the 4 animals in low-dose group did not produce biliary stricture at 4 weeks; in medium-dose group, BBS was induced in both animals at 2 weeks without causing severe complications; and in high-dose group, BBS was produced in 4 animals at 2 weeks, causing perforation and abdominal abscess formation in 1 animal. CONCLUSIONS A safe and reproducible swine model of BBS could be established successfully by applying endobiliary electrothermal injury with a diathermic sheath at 30 W for 20 seconds.
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Affiliation(s)
- Dao-Jian Gao
- Department of Endoscopy, Eastern Hepatobiliary Hospital, The Second Military Medical University, Shanghai, China
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20
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21
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Fairchild AH, Hohenwalter EJ, Gipson MG, Al-Refaie WB, Braun AR, Cash BD, Kim CY, Pinchot JW, Scheidt MJ, Schramm K, Sella DM, Weiss CR, Lorenz JM. ACR Appropriateness Criteria ® Radiologic Management of Biliary Obstruction. J Am Coll Radiol 2020; 16:S196-S213. [PMID: 31054746 DOI: 10.1016/j.jacr.2019.02.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 02/08/2019] [Indexed: 02/07/2023]
Abstract
Biliary obstruction is a serious condition that can occur in the setting of both benign and malignant pathologies. In the setting of acute cholangitis, biliary decompression can be lifesaving; for patients with cancer who are receiving chemotherapy, untreated obstructive jaundice may lead to biochemical derangements that often preclude continuation of therapy unless biliary decompression is performed (see the ACR Appropriateness Criteria® topic on "Jaundice"). Recommended therapy including percutaneous decompression, endoscopic decompression, and/or surgical decompression is based on the etiology of the obstruction and patient factors including the individual's anatomy. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | | | - Eric J Hohenwalter
- Panel Chair, Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Waddah B Al-Refaie
- Georgetown University Hospital, Washington, District of Columbia; American College of Surgeons
| | - Aaron R Braun
- St. Elizabeth Regional Medical Center, Lincoln, Nebraska
| | - Brooks D Cash
- University of Texas McGovern Medical School, Houston, Texas; American Gastroenterological Association
| | - Charles Y Kim
- Duke University Medical Center, Durham, North Carolina
| | | | - Matthew J Scheidt
- Central Illinois Radiological Associates, University of Illinois College of Medicine, Peoria, Illinois
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22
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Kitano M, Gress TM, Garg PK, Itoi T, Irisawa A, Isayama H, Kanno A, Takase K, Levy M, Yasuda I, Lévy P, Isaji S, Fernandez-Del Castillo C, Drewes AM, Sheel ARG, Neoptolemos JP, Shimosegawa T, Boermeester M, Wilcox CM, Whitcomb DC. International consensus guidelines on interventional endoscopy in chronic pancreatitis. Recommendations from the working group for the international consensus guidelines for chronic pancreatitis in collaboration with the International Association of Pancreatology, the American Pancreatic Association, the Japan Pancreas Society, and European Pancreatic Club. Pancreatology 2020; 20:1045-1055. [PMID: 32792253 DOI: 10.1016/j.pan.2020.05.022] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 05/29/2020] [Accepted: 05/30/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES This paper is part of the international consensus guidelines on chronic pancreatitis, presenting for interventional endoscopy. METHODS An international working group with experts on interventional endoscopy evaluated 26 statements generated from evidence on 9 clinically relevant questions. The Grading of Recommendations Assessment, Development, and Evaluation approach was used to evaluate the level of evidence. To determine the level of agreement, a nine-point Likert scale was used for voting on the statements. RESULTS Strong consensus was obtained for 15 statements relating to nine questions including the recommendation that endoscopic intervention should be offered to patients with persistent severe pain but not to those without pain. Endoscopic decompression of the pancreatic duct could be used for immediate pain relief, and then offered surgery if this fails or needs repeated endoscopy. Endoscopic drainage is preferred for portal-splenic vein thrombosis and pancreatic fistula. A plastic stent should be placed and replaced 2-3 months later after insertion. Endoscopic extraction is indicated for stone fragments remaining after ESWL. Interventional treatment should be performed for symptomatic/complicated pancreatic pseudocysts. Endoscopic treatment is recommended for bile duct obstruction and afterwards surgery if this fails or needs repeated endoscopy. Surgery may be offered if there is significant calcification and/or mass of the pancreatic head. Percutaneous endovascular treatment is preferred for hemosuccus pancreaticus. Surgical treatment is recommended for duodenal stenosis due to chronic pancreatitis. CONCLUSIONS This international expert consensus guideline provides evidenced-based statements concerning indications and key aspects for interventional endoscopy in the management of patients with chronic pancreatitis.
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Affiliation(s)
- Masayuki Kitano
- Second Department of Internal Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan.
| | - Thomas M Gress
- Department of Gastroenterology, Endocrinology, Metabolism and Infectiology, University Hospital, Philipps-Universität Marburg, Marburg, Germany.
| | - Pramod K Garg
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India.
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan.
| | - Atsushi Irisawa
- Department of Gastroenterology, Dokkyo Medical University, Mibu, Tochigi, Japan.
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan.
| | - Atsushi Kanno
- Department of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Kei Takase
- Department of Diagnostic Radiology, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Michael Levy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.
| | - Ichiro Yasuda
- Third Department of Internal Medicine, University of Toyama, Toyama, Japan.
| | - Phillipe Lévy
- Service de Pancréatologie-Gastroentérologie, Pôle des Maladies de l'Appareil Digestif, DHU UNITY, Hôpital Beaujon, APHP, Clichy Cedex, Université Paris 7, France.
| | - Shuiji Isaji
- Department of Surgery, Mie University Graduate School of Medicine, Tsu, Japan.
| | | | - Asbjørn M Drewes
- Centre for Pancreatic Diseases, Department of Gastroenterology, Aalborg University Hospital, Aalborg, Denmark.
| | - Andrea R G Sheel
- Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, UK.
| | - John P Neoptolemos
- Department of General Surgery, University of Heidelberg, Heidelberg, Germany.
| | - Tooru Shimosegawa
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Marja Boermeester
- Department of Surgery, Amsterdam University Medical Centers, location AMC, and Amsterdam Gastroenterology & Metabolism, Amsterdam, the Netherlands.
| | - C Mel Wilcox
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - David C Whitcomb
- Departments of Medicine, Cell Biology & Molecular Physiology and Human Genetics, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh and UPMC, Pittsburgh, PA, USA.
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Alvear Castro D, Gómez Rodríguez D, Houghton E, Pasten M, Finger López C, Acquafresca P, Palermo M, Giménez M. Transhepatic Percutaneous Sustained Dilation with Multiple Catheters for the Management of Hepaticojejunostomy Benign Stricture. J Laparoendosc Adv Surg Tech A 2020; 30:948-952. [DOI: 10.1089/lap.2020.0418] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
| | | | - Eduardo Houghton
- DAICIM Foundation, Percutaneous Surgery, Buenos Aires, Argentina
- Minimally Invasive Surgery, Hospital Bernardino Rivadavia, Buenos Aires, Argentina
- Surgery Department, University of Buenos Aires, Buenos Aires, Argentina
| | - Mauricio Pasten
- DAICIM Foundation, Percutaneous Surgery, Buenos Aires, Argentina
| | - Caetano Finger López
- DAICIM Foundation, Percutaneous Surgery, Buenos Aires, Argentina
- Percutaneous Surgery, Hospital Fernández, Buenos Aires, Argentina
| | | | - Mariano Palermo
- DAICIM Foundation, Percutaneous Surgery, Buenos Aires, Argentina
- Surgery Department, University of Buenos Aires, Buenos Aires, Argentina
- DIAGNOMED, Bariatric Surgery, Buenos Aires, Argentina
| | - Mariano Giménez
- DAICIM Foundation, Percutaneous Surgery, Buenos Aires, Argentina
- Surgery Department, University of Buenos Aires, Buenos Aires, Argentina
- Percutaneous Surgery, IHU IRCAD, University of Strasbourg, Strasbourg, France
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24
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Ogura T, Nishioka N, Yamada M, Yamada T, Ueno S, Matsuno J, Ueshima K, Yamamoto Y, Okuda A, Ashida R, Higuchi K. Technical feasibility and safety of transluminal antegrade dilation for hepaticojejunostomy stricture using a novel fine-gauge electrocautery dilator (with video). Endosc Int Open 2020; 8:E733-E737. [PMID: 32490157 PMCID: PMC7247889 DOI: 10.1055/a-1135-8804] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 02/25/2020] [Indexed: 01/15/2023] Open
Abstract
Background and study aims A novel fine-gauge electrocautery dilator (ED) has recently become available in Japan. The current study evaluated the safety and feasibility of transluminal antegrade dilation for hepaticojejunal stricture (HJS) using this novel ED. Patients and methods Patients who with complicated HJS were retrospectively enrolled. The primary and secondary endpoints of this study were rates of technical success defined as functional antegrade HJS dilation using the novel ED and types of adverse events, respectively. A total of 22 patients were enrolled. Among them, six were treated using an enteroscopic approach due to the absence of bile duct dilation or patient refusal to undergo EUS-HGS. Therefore, 16 patients underwent EUS-HGS. Results The procedure was successful in 15 of 16 patients (93.8 %). The contrast medium flowed from the intrahepatic bile duct to the intestine of 14 of 15 patients (93.3 %). The resolution rate of HJS was 13 of 14 (92.9 %) at 6 months. Conclusion Our technique might offer a new option with which to treat HJS, although a prospective study with long-term follow-up is needed.
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Affiliation(s)
- Takeshi Ogura
- 2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Nobu Nishioka
- 2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Masanori Yamada
- 2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Tadahiro Yamada
- 2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Saori Ueno
- 2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Jyun Matsuno
- 2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Kazuya Ueshima
- 2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Yoshitaro Yamamoto
- 2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Atsushi Okuda
- 2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Reiko Ashida
- Departments of Cancer Survey and Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Kazuhide Higuchi
- 2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
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25
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Nakai Y, Isayama H, Wang H, Rerknimitr R, Khor C, Yasuda I, Kogure H, Moon JH, Lau J, Lakhtakia S, Ratanachu‐ek T, Seo DW, Lee DK, Makmun D, Dy F, Liao W, Draganov PV, Almadi M, Irisawa A, Katanuma A, Kitano M, Ryozawa S, Fujisawa T, Wallace MB, Itoi T, Devereaux B. International consensus statements for endoscopic management of distal biliary stricture. J Gastroenterol Hepatol 2020; 35:967-979. [PMID: 31802537 PMCID: PMC7318125 DOI: 10.1111/jgh.14955] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 12/01/2019] [Accepted: 12/02/2019] [Indexed: 02/05/2023]
Abstract
Distal biliary strictures (DBS) are common and may be caused by both malignant and benign pathologies. While endoscopic procedures play a major role in their management, a comprehensive review of the subject is still lacking. Our consensus statements were formulated by a group of expert Asian pancreatico-biliary interventional endoscopists, following a proposal from the Digestive Endoscopy Society of Taiwan, the Thai Association for Gastrointestinal Endoscopy, and the Tokyo Conference of Asian Pancreato-biliary Interventional Endoscopy. Based on a literature review utilizing Medline, Cochrane library, and Embase databases, a total of 19 consensus statements on DBS were made on diagnosis, endoscopic drainage, benign biliary stricture, malignant biliary stricture, and management of recurrent biliary obstruction and other complications. Our consensus statements provide comprehensive guidance for the endoscopic management of DBS.
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Affiliation(s)
- Yousuke Nakai
- Department of Gastroenterology, Graduate School of MedicineThe University of TokyoTokyoJapan,Department of Endoscopy and Endoscopic Surgery, Graduate School of MedicineThe University of TokyoTokyoJapan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of MedicineThe University of TokyoTokyoJapan,Department of Gastroenterology, Graduate School of MedicineJuntendo UniversityTokyoJapan
| | - Hsiu‐Po Wang
- Department of Internal Medicine, College of MedicineNational Taiwan UniversityTaipeiTaiwan
| | - Rungsun Rerknimitr
- Division of Gastroenterology, Department of MedicineChulalongkorn UniversityBangkokThailand
| | - Christopher Khor
- Department of Gastroenterology and HepatologySingapore General Hospital and Duke‐NUS Medical SchoolSingaporeSingapore
| | - Ichiro Yasuda
- Third Department of Internal Medicine, Graduate School of MedicineUniversity of ToyamaToyamaJapan
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of MedicineThe University of TokyoTokyoJapan
| | - Jong Ho Moon
- Digestive Disease Center and Research Institute, Department of Internal MedicineSoonChunHyang University School of MedicineBucheon/SeoulSouth Korea
| | - James Lau
- Department of Surgery, Endoscopic Center, Prince of Wales HospitalThe Chinese University of Hong KongHong Kong, China
| | | | | | - Dong Wan Seo
- Department of Internal MedicineUniversity of Ulsan College of Medicine, Asan Medical CenterSeoulSouth Korea
| | - Dong Ki Lee
- Department of Internal Medicine, Gangnam Severance HospitalYonsei University College of MedicineSeoulSouth Korea
| | - Dadang Makmun
- Division of Gastroenterology, Department of Internal Medicine, Faculty of MedicineUniversitas Indonesia/Cipto Mangunkusumo National General HospitalJakartaIndonesia
| | - Frederick Dy
- Section of Gastroenterology, Department of Internal Medicine, Faculty of Medicine and SurgeryUniversity of Santo Tomas HospitalManilaPhilippines
| | - Wei‐Chih Liao
- Department of Internal Medicine, College of MedicineNational Taiwan UniversityTaipeiTaiwan
| | - Peter V Draganov
- Department of MedicineUniversity of FloridaGainesvilleFloridaUSA
| | - Majid Almadi
- Division of Gastroenterology, King Khalid University HospitalKing Saud UniversityRiyadhSaudi Arabia
| | - Atsushi Irisawa
- Department of GastroenterologyDokkyo Medical UniversityTochigiJapan
| | - Akio Katanuma
- Center for GastroenterologyTeine‐Keijinkai HospitalSapporoJapan
| | - Masayuki Kitano
- Second Department of Internal MedicineWakayama Medical UniversityWakayamaJapan
| | - Shomei Ryozawa
- Department of GastroenterologySaitama Medical University International Medical CenterSaitamaJapan
| | - Toshio Fujisawa
- Department of Gastroenterology, Graduate School of MedicineJuntendo UniversityTokyoJapan
| | | | - Takao Itoi
- Department of Gastroenterology and HepatologyTokyo Medical UniversityTokyoJapan
| | - Benedict Devereaux
- University of QueenslandRoyal Brisbane and Women's HospitalBrisbaneQueenslandAustralia
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The use of a 532-nm laser fitted with a balloon and a cylindrical light diffuser to treat benign biliary stricture: a pilot study. Lasers Med Sci 2020; 36:25-31. [PMID: 32157583 DOI: 10.1007/s10103-020-02992-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 02/26/2020] [Indexed: 01/29/2023]
Abstract
Endoscopic management of benign biliary stricture (BBS) remains challenging. Stenting is currently used for BBS management, but refractory BBS remains problematic. The aim of this study was to assess the safety and feasibility of a dilation balloon-equipped cylindrical light diffuser for BBS in a large animal model. A total of seven mini-pigs were used in the current study. Laser settings were chosen based on the findings of a previous animal study. Five animals were used in a preliminary study to establish process conditions. BBSs were created in the common bile ducts of the other two animals by intraductal radiofrequency ablation (RFA) via endoscopic retrograde cholangiography (ERC). At 4 weeks post-RFA, laser ablation was performed using a customized balloon-equipped cylindrical diffuser at 10 W for 10 s while maintaining balloon inflation for 10 s at 5 atm. A follow-up ERC was performed at 4 weeks post-laser ablation and the animals were sacrificed for histologic evaluation. BBS was observed in all animals by ERC at 4 weeks post-RFA. The mean bile duct stricture diameter in the two animals as determined by ERC was 0.8 mm. Laser ablations were performed without technical difficulty and no adverse event was encountered. At 4 weeks post-laser ablation, mean biliary stricture diameter had dilated to 1.6 mm on cholangiographic finding. On histologic examination, inflammatory cell infiltration in lamina propria and dense collagen deposition were observed, but there was no evidence of bile duct perforation. The devised balloon-equipped cylindrical laser light diffuser appears to be safe and feasible for the treatment of BBS. However, further studies and modifications are required before it can be applied clinically as a monotherapy.
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Efficacy of Different Endoscopic Stents in the Management of Postoperative Biliary Strictures: A Systematic Review and Meta-analysis. J Clin Gastroenterol 2019; 53:418-426. [PMID: 30807403 DOI: 10.1097/mcg.0000000000001193] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Endoscopic stents are the first-line treatment in the management of benign biliary stricture (BBS) which include multiple plastic stents (MPSs), fully covered self-expandable metal stents (FCSEMS) including the conventional and modified ones (FCSEMS-C and FCSEMS-M) and biodegradable stents. However, different stents have their distinct advantages and disadvantages. We aim to conduct this systematic review to compare the efficacy of different stents in the management of BBS. METHODS Several databases were searched from inception through March 2018. Studies including >10 patients with postoperative stricture treated with endoscopic stents were enrolled. Pooled odds ratio of outcomes were calculated to compare MPS with FCSEMS. Weighted pooled rates were calculated to show the efficacy of FCSEMS-M, FCSEMS-C, and MPS. RESULTS Twenty-two articles were reviewed including 4 randomized controlled studies, 4 cohort studies, and 14 case series studies. Comparing FCSEMS with MPS, the pooled odds ratio was 0.48 [95% confidence interval (CI): 0.22-1.05] (P=0.07) for stricture resolution, 0.3 (95% CI: 0.1-0.92) (P=0.03) for adverse event, 1.9 (95% CI: 0.3-12) (P=0.49) for stent migration, and 1.38 (95% CI: 0.36-5.3) (P=0.34) for stricture recurrence. The pooled rates for stricture recurrence of MPS, FCSEMS-C, and FCSEMS-M were 19%, 19%, and 7%, respectively. The pooled rates for stent migration were 4% of MPS, 25% of FCSEMS-C, and 3% of FCSEMS-M. CONCLUSIONS FCSEMS-M is more favorable in the management of BBS comparing with MPS or FCSEMS-C. The biodegradable stent may be a promising option but currently available data is insufficient to draw a firm conclusion.
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Bartel MJ, Higa JT, Tokar JL. The Status of SEMS Versus Plastic Stents for Benign Biliary Strictures. Curr Gastroenterol Rep 2019; 21:29. [PMID: 31098767 DOI: 10.1007/s11894-019-0696-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Benign biliary strictures can be treated with plastic stents and self-expandable metal stents (SEMS). This review article delineates the latest scientific evidence for their usage. RECENT FINDINGS Despite evolving literature on both type of stents as treatment modalities of benign biliary strictures, which encompass mainly anastomotic strictures and strictures related to chronic pancreatitis, no final conclusions can be drawn regarding the superiority of a particular stent. SEMS tend to have higher stricture resolution rates and fewer procedural requirements which are partly offset by higher stent migration and stricture recurrence rates compared with plastic stents. Additional studies focusing on new SEMS types with anti-migration features as well as cost-effectiveness calculations are necessary for clinical decision-making when treating patients with benign biliary strictures.
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Affiliation(s)
- M J Bartel
- Section of Gastroenterology, Fox Chase Cancer Center, Temple Health, Philadelphia, PA, USA.
| | - J T Higa
- Section of Gastroenterology, Fox Chase Cancer Center, Temple Health, Philadelphia, PA, USA
| | - J L Tokar
- Section of Gastroenterology, Fox Chase Cancer Center, Temple Health, Philadelphia, PA, USA
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Waldthaler A, Valente R, Arnelo U, Löhr JM. Endoscopic and Conservative Management of Chronic Pancreatitis and Its Complications. Visc Med 2019; 35:98-108. [PMID: 31192243 DOI: 10.1159/000499611] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 03/14/2019] [Indexed: 12/15/2022] Open
Abstract
Chronic pancreatitis is a progressive inflammatory disease of the pancreas potentially giving rise to several complications. For this reason, patients need long-term care and treatment by medical, interventional, and sometimes surgical measures. This article reviews current state-of-the-art strategies and guidelines for treating chronic pancreatitis with conventional and endoscopic measures.
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Affiliation(s)
- Alexander Waldthaler
- Department of Upper Abdominal Diseases at Karolinska University Hospital, and Clinical Science, Intervention and Technology (CLINTEC), Karolinska University Hospital, Stockholm, Sweden
| | - Roberto Valente
- Department of Upper Abdominal Diseases at Karolinska University Hospital, and Clinical Science, Intervention and Technology (CLINTEC), Karolinska University Hospital, Stockholm, Sweden
| | - Urban Arnelo
- Department of Upper Abdominal Diseases at Karolinska University Hospital, and Clinical Science, Intervention and Technology (CLINTEC), Karolinska University Hospital, Stockholm, Sweden
| | - J-Matthias Löhr
- Department of Upper Abdominal Diseases at Karolinska University Hospital, and Clinical Science, Intervention and Technology (CLINTEC), Karolinska University Hospital, Stockholm, Sweden
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Abstract
Benign and malignant biliary strictures are common indications for endoscopic retrograde cholangiopancreatography. Diagnosis involves high-quality cross-sectional imaging and cholangiography with various endoscopic sampling techniques. Treatment options include placement of plastic biliary stents and self-expanding metal stents, which differ in patency duration and cost effectiveness. Whether the etiology is benign or malignant, a multidisciplinary strategy should be implemented. This article will discuss general principles of biliary stenting in both benign and malignant conditions.
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Affiliation(s)
- Jason G Bill
- Washington University School of Medicine in St. Louis, 660 South Euclid Avenue, Campus Box 8124, St Louis, MO 63110, USA
| | - Daniel K Mullady
- Interventional Endoscopy, Washington University School of Medicine in St. Louis, 660 South Euclid Avenue, Campus Box 8124, St Louis, MO 63110, USA.
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Houghton E. Complex percutaneous biliary procedures: Review and contributions of a high volume team. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2019. [DOI: 10.18528/ijgii180036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Ogura T, Takenaka M, Shiomi H, Goto D, Tamura T, Hisa T, Kato H, Nishioka N, Minaga K, Masuda A, Onoyama T, Kudo M, Higuchi K, Kitano M. Long-term outcomes of EUS-guided transluminal stent deployment for benign biliary disease: Multicenter clinical experience (with videos). Endosc Ultrasound 2019; 8:398-403. [PMID: 31552912 PMCID: PMC6927148 DOI: 10.4103/eus.eus_45_19] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background and Objectives: Biliary drainage (BD) under EUS guidance is usually indicated for malignant biliary obstruction. Recently, EUS-guided transluminal treatment has been applied to benign biliary disease (BBD). This multicenter retrospective study evaluated the clinical impact of EUS-guided transluminal stent deployment for BBD with long-term follow-up. Patients and Methods: This retrospective study investigated patients treated between September 2015 and October 2016 at participating hospitals in the therapeutic endoscopic group. The inclusion criteria comprised complications with BBD obstructive jaundice or cholangitis and failed endoscopic retrograde cholangiopancreatography or inaccessible ampulla of Vater. Results: Twenty-six patients underwent EUS-guided transluminal stent deployment. Indications for EUS-guided transluminal stent deployment comprised anastomotic biliary stricture (n = 17), bile duct stones (n = 5), inflammatory biliary stricture (n = 3), and acute pancreatitis prevention (n = 1). Thirteen of these 26 patients underwent scheduled reintervention, with technical success achieved in all 13 patients. None of the deployed stents became dysfunctional. Among the 13 patients who underwent reintervention on demand, stents had become dysfunctional in six patients (stent patency: 48, 90, 172, 288, 289, and 608 days). Reintervention was successfully performed in all patients. During follow-up (median, 749 days), severe adverse events were not seen in any patients. Conclusion: We concluded that EUS-guided transluminal stent deployment for BBD is feasible and safe. Because metal stent dysfunction was more frequent when deployed on demand, such stents should be exchanged for plastic stents in a scheduled manner if a metal stent is used.
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Affiliation(s)
- Takeshi Ogura
- Therapeutic Endoscopic Ultrasound Group: TEUS; 2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Mamoru Takenaka
- Therapeutic Endoscopic Ultrasound Group: TEUS; Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Hideyuki Shiomi
- Therapeutic Endoscopic Ultrasound Group: TEUS; Department of Internal Medicine, Division of Gastroenterology, Graduate School of Medicine, Kobe University, Hyogo, Japan
| | - Daisuke Goto
- Therapeutic Endoscopic Ultrasound Group: TEUS; Department of Internal Medicine, Division of Gastroenterology and Hepatology, Tottori Red Cross Hospital, Tottori, Japan
| | - Takashi Tamura
- Therapeutic Endoscopic Ultrasound Group: TEUS; Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Takeshi Hisa
- Therapeutic Endoscopic Ultrasound Group: TEUS; Department of Gastroenterology, Saku Central Hospital Advanced Care Center, Nagano, Japan
| | - Hironari Kato
- Therapeutic Endoscopic Ultrasound Group: TEUS; Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Nobu Nishioka
- Therapeutic Endoscopic Ultrasound Group: TEUS; 2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Kosuke Minaga
- Therapeutic Endoscopic Ultrasound Group: TEUS; Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Atsuhiro Masuda
- Therapeutic Endoscopic Ultrasound Group: TEUS; Department of Internal Medicine, Division of Gastroenterology, Graduate School of Medicine, Kobe University, Hyogo, Japan
| | - Takumi Onoyama
- Therapeutic Endoscopic Ultrasound Group: TEUS; Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori, Japan
| | - Masatoshi Kudo
- Therapeutic Endoscopic Ultrasound Group: TEUS; Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Kazuhide Higuchi
- Therapeutic Endoscopic Ultrasound Group: TEUS; 2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Masayuki Kitano
- Therapeutic Endoscopic Ultrasound Group: TEUS; Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
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Mangiavillano B, Khashab MA, Eusebi LH, Tarantino I, Bianchetti M, Semeraro R, Pellicano R, Traina M, Repici A. Single brand, fully-covered, self-expandable metal stent for the treatment of benign biliary disease: when should stents be removed? MINERVA GASTROENTERO 2018; 65:63-69. [PMID: 29856174 DOI: 10.23736/s1121-421x.18.02506-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The two most relevant endoscopic treatable benign biliary diseases (BBD) are benign biliary strictures (BBSs) and biliary leaks (BLs), often associated with high morbidity. The most common endoscopic treatment for biliary strictures involves placement of multiple plastic stents (PSs), with or without balloon dilation, followed by planned exchange of the stents. Thus, there continues to be high interest in pursuing alternative endoscopic approaches that may achieve better results with fewer interventions. In this setting, the use of a fully-covered, self-expandable metal stent (FCSEMS) is an attractive alternative to single or multiple PSs for the treatment of BBDs. A single metal stent can remain in place for a longer period of time before removal; however, the maximum time the stent can be remain in place is still not well defined. The aim of this review is to determine the removal time of the TaeWoong® FCSEMS, placed for BBD. According to our data analysis, considering the absence of loss of the covering of the FCSEMS and of any adverse events during and after stent removal, leaving the TaeWoong medical FCSEMS in situ for an 8 months' period seems to be acceptable for benign biliary diseases. Further studies need to evaluate their removability at 1 year.
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Affiliation(s)
- Benedetto Mangiavillano
- Unit of Gastrointestinal Endoscopy, Humanitas - Mater Domini, Castellanza, Varese, Italy - .,Humanitas University - Hunimed, Milan Italy -
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Leonardo H Eusebi
- Unit of Gastroenterology, Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Ilaria Tarantino
- Gastroenterology and Endoscopy Unit, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IsMeTT), Palermo, Italy
| | - Mario Bianchetti
- Unit of Gastrointestinal Endoscopy, Humanitas - Mater Domini, Castellanza, Varese, Italy
| | - Rossella Semeraro
- Digestive Endoscopy Unit, Istituto Clinico Humanitas Research Hospital, Rozzano, Milan, Italy
| | | | - Mario Traina
- Gastroenterology and Endoscopy Unit, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IsMeTT), Palermo, Italy
| | - Alessandro Repici
- Humanitas University - Hunimed, Milan Italy.,Digestive Endoscopy Unit, Istituto Clinico Humanitas Research Hospital, Rozzano, Milan, Italy
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Diminished Survival in Patients with Bile Leak and Ductal Injury: Management Strategy and Outcomes. J Am Coll Surg 2018; 226:568-576.e1. [PMID: 29307612 DOI: 10.1016/j.jamcollsurg.2017.12.023] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 12/18/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND The increased incidence of bile duct injuries (BDIs) after the adoption of laparoscopic cholecystectomy has been well documented. However, the longitudinal impact of bile leaks and BDIs on survival and healthcare use have not been studied adequately. The aims of this analysis were to determine the incidence, long-term outcomes, and costs of bile leaks and ductal injuries in a large population. STUDY DESIGN The California Office of Statewide Health Planning and Development database was queried from 2005 to 2014. Bile leaks, BDIs, and their management strategy were defined. Survival was calculated by Kaplan-Meier failure estimates with multivariable regression and propensity analyses. Cost analyses used inflation adjustments and institution-specific cost-to-charge ratios. RESULTS Of 711,454 cholecystecomies, bile leaks occurred in 3,551 patients (0.50%) and were managed almost exclusively by endoscopists. Bile duct injuries occurred in 1,584 patients (0.22%) with 84% managed surgically. Patients with a bile leak were more likely to die at 1 year (2.4% vs 1.4%; odds ratio 1.85; p < 0.001). Similarly, BDI patients had an increased 1-year mortality (7.2% vs 1.3%; odds ratio 2.04; p < 0.0001). Survival of BDI patients was better with an operative approach (odds ratio 0.19; p < 0.001) when compared with endoscopic management. Operatively managed BDIs were also associated with fewer emergency department visits and readmissions, as well as lower cumulative costs at 1 year ($60,539 vs $118,245; p < 0.001). CONCLUSIONS The 0.22% incidence of BDIs observed in California is lower than reported in the first decade after the introduction of laparoscopic cholecystectomy. Bile leaks are 2.3 times more common than BDIs. Patients with a bile leak or BDI have diminished survival. Surgical repair of a BDI leads to enhanced survival and reduced cumulative cost compared with endoscopic management.
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Omodeo M, Malaga I, Manazzoni D, Curvale C, de Maria J, Guidi MA, Matano R. Insertion of fully covered self-expanding metal stents in benign biliary diseases. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 110:30-34. [PMID: 29106289 DOI: 10.17235/reed.2017.5092/2017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Benign biliary diseases are traditionally treated using plastic stents. However, fully covered self-expanding metal stents are currently gaining acceptance for the treatment of these pathologies. OBJECTIVE To assess the effectiveness and complications associated with the placement of temporary endoscopic fully covered self-expanding metal stents for the treatment of benign biliary diseases. MATERIALS AND METHODS This was a retrospective and observational study using a prospective database from a tertiary care center from March 2012 to May 2016. Some patients that had a fully covered metal stent due to a benign biliary disease were also included. The indications, resolution, technical success rates and adverse events were documented. RESULTS 31 patients were included with a total of 34 stents inserted. The indications were as follows: 8 (25%) post cholecystectomy biliary stenoses, 11 (31%) large or multiple choledocholithiasis, 3 (8.3%) biliary fistulas, 2 (6%) post-liver transplant stenoses, 2 (8.3%) papillary stenoses, 2 (6%) perforations and 2 (6%) bleeds. The global resolution success rate of the stents for all pathologies was 88%, this included 87.5% (7/8) in post cholecystectomy stenoses, 73% (8/11) in large choledocholithiasis and 100% for the remaining indications. Thirty-three of 34 stents were removed after an average of 133 days (ranging from 10 to 180 days). No complications were registered. CONCLUSION Fully covered self-expanding metal stents are an effective and reliable alternative for the resolution of benign biliary diseases.
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Tantau A, Mandrutiu A, Leucuta DC, Ciobanu L, Tantau M. Prognostic factors of response to endoscopic treatment in painful chronic pancreatitis. World J Gastroenterol 2017; 23:6884-6893. [PMID: 29085231 PMCID: PMC5645621 DOI: 10.3748/wjg.v23.i37.6884] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 08/13/2017] [Accepted: 09/05/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the endoscopic treatment efficacy and prognostic factors of long-term response to treatment for painful chronic pancreatitis.
METHODS This retrospective analysis identified 168 patients with painful chronic pancreatitis hospitalized during January 2010-January 2015 in a Romanian tertiary referral center. Data on demographics, medical history, alcohol consumption, smoking habit, clinical parameters, type and number of endoscopic procedures and hospital admissions number were collected from the medical charts and analyzed. The absence or substantial reduction of pain (mild pain) at the end of the follow-up associated with the technical success of endotherapy was considered as clinical success.
RESULTS Among the 168 patients with painful chronic pancreatitis admitted to our department during the study period, 39 (23.21%) had optimal response to the medical therapy. One hundred and twenty-nine patients required endoscopic treatment. The median follow-up period was 15 mo (range, 0-60 mo). Overall, technical success of endotherapy was achieved in 105 patients (81.39%). More than two-thirds of patients (82.78%) had substantial improvement of pain after the endoscopic treatment, including frequency and severity of the pain attacks. Patients younger than 40 years had significantly more successful endoscopic procedures (P = 0.041). Clinical success was higher in non-smoking patients (P = 0.003). The hospital admission rate was higher in patients with recognized alcohol consumption (P = 0.03) and in smokers (P = 0.027). The number and location of pancreatic stones and locations of strictures did not significantly influence the technical success (P > 0.05) or the clinical success (P > 0.05).
CONCLUSION Younger age than 40 years can be considered an important factor positively influencing endoscopic treatment outcome in patients with painful chronic pancreatitis.
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Affiliation(s)
- Alina Tantau
- Department of Internal Medicine and Gastroenterology, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca City, 400012 Cluj, Romania
- Department of Internal Medicine and Gastroenterology, 4th Medical Clinic, Cluj-Napoca City, 400015 Cluj, Romania
| | - Alina Mandrutiu
- Department of Gastroenterology, Gastroenterology and Hepatology Medical Center, Cluj-Napoca City, 400132 Cluj, Romania
| | - Daniel-Corneliu Leucuta
- Medical Informatics and Biostatistics Department, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca City, 400012 Cluj, Romania
| | - Lidia Ciobanu
- Department of Internal Medicine and Gastroenterology, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca City, 400012 Cluj, Romania
- Department of Internal Medicine and Gastroenterology, “Prof. Dr. Octavian Fodor“ Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca City, 400158 Cluj, Romania
| | - Marcel Tantau
- Department of Internal Medicine and Gastroenterology, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca City, 400012 Cluj, Romania
- Department of Internal Medicine and Gastroenterology, “Prof. Dr. Octavian Fodor“ Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca City, 400158 Cluj, Romania
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Wu J, Zhou DX, Wang TT, Gao DJ, Hu B. A New Fully Covered Self-Expandable Metal Stent for the Treatment of Postsurgical Benign Biliary Strictures. Dig Dis Sci 2017; 62:2550-2557. [PMID: 28776138 DOI: 10.1007/s10620-017-4698-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Accepted: 07/26/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Endotherapy with plastic stent (PS) placement is the main modality for treating benign biliary strictures (BBSs). Fully covered self-expandable metal stents (FCSEMSs) are being increasingly used for BBS management, with high stricture resolution. However, traditional metal tents are associated with high migration, causing treatment failure. METHODS We investigated the efficacy and safety of a new FCSEMS for postsurgical BBS treatment and compared these parameters between the FCSEMS and PS treatment through retrospective analysis. The primary outcome measurements included stricture resolution, stricture recurrence, and complications. RESULTS In total, 69 patients were included, of whom 32 underwent FCSEMS treatment and 37 underwent PS treatment. The technical success rate and the number of endoscopic retrograde cholangiopancreatography procedures were similar between the groups. The median stenting duration was 5.2 months (range 1.5-15.3) in the FCSEMS group and 10.7 months (range 2.5-22.6) in the PS group (P < 0.01). The stents removal rate was 96.9% in the FCSEMS group and 94.6% in the PS group. The stricture resolution rate based on intention-to-treat analysis was 83.8% in the PS group and 84.4% (27/32) in the FCSEMS group (P = 0.947), whereas the rates from per-protocol analysis were 88.6% (31/35) and 87.1% (27/31), respectively (P = 0.574). Early and late complications were similar between the groups. The median follow-up time was 43 months (range 13-71). The stricture recurrence rate was 11.1% (3/27) in the FCSEMS group and 16.1% (5/31) in the PS group (P = 0.435). CONCLUSIONS The new FCSEMS and the PS approach showed similar efficacy and safety in postsurgical BBS treatment. However, the FCSEMS required fewer procedural steps and shorter stenting time, making it an effective alternative modality.
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Affiliation(s)
- Jun Wu
- Department of Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, 225 Changhai Road, Shanghai, China
| | - Dong-Xun Zhou
- Department of Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, 225 Changhai Road, Shanghai, China
| | - Tian-Tian Wang
- Department of Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, 225 Changhai Road, Shanghai, China
| | - Dao-Jian Gao
- Department of Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, 225 Changhai Road, Shanghai, China
| | - Bing Hu
- Department of Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, 225 Changhai Road, Shanghai, China.
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Tierney J, Bhutiani N, Stamp B, Richey JS, Bahr MH, Vitale GC. Predictive risk factors associated with cholangitis following ERCP. Surg Endosc 2017; 32:799-804. [PMID: 28733732 DOI: 10.1007/s00464-017-5746-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 07/14/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) with stent placement is used for the management of many pancreaticobiliary disorders. It is generally safe with a few short-term complications. The risk factors for the development of post-ERCP cholangitis due to stent occlusion have not been previously described. This study identified such risk factors among patients undergoing ERCP and stent placement for pancreatic or biliary obstruction. METHODS 3648 ERCPs performed at the University of Louisville from 2008 to 2016 were reviewed. Data including patient demographics, diagnostic, laboratory, and ERCP related data were included. Patients were classified as having post-ERCP cholangitis if they developed jaundice, fever, right upper quadrant abdominal pain, and confirmatory findings of stent occlusion and/or purulent drainage at the time of repeat ERCP. These patients were compared to those who did not develop post-ERCP cholangitis using univariate and multivariate analyses. RESULTS A total of 431 patients met inclusion criteria. Of these, 57 (13.2%) developed post-ERCP cholangitis. The average age of patients was 57 years with 57% women and 43% men. On univariate analysis, patients developing post-ERCP cholangitis were more likely to be of increased age, have higher white blood cell count (WBC), total bilirubin (TBili), AST, ALT, and alkaline phosphatase (AlkPhos), and a decreased serum albumin level. Risk factors for post-ERCP cholangitis due to stent occlusion identified on multivariate analysis include: a diagnosis of cancer, the placement of multiple biliary stents at index ERCP, and low serum albumin level. CONCLUSIONS The development of post-ERCP cholangitis due to stent occlusion is strongly associated with the presence of malignancy, the placement of multiple biliary stents, and low serum albumin. A decreased threshold to monitor for stent occlusion, including routine liver function tests and prophylactic stent removal or exchange, should be employed in patients with these characteristics.
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Affiliation(s)
- Joshua Tierney
- Department of Surgery, University of Louisville, 550 S. Jackson Street, Louisville, KY, 40202, USA.
| | - Neal Bhutiani
- Department of Surgery, University of Louisville, 550 S. Jackson Street, Louisville, KY, 40202, USA
| | - Bryce Stamp
- Department of Surgery, University of Louisville, 550 S. Jackson Street, Louisville, KY, 40202, USA
| | - John S Richey
- Department of Surgery, University of Louisville, 550 S. Jackson Street, Louisville, KY, 40202, USA
| | - Michael H Bahr
- Department of Surgery, University of Louisville, 550 S. Jackson Street, Louisville, KY, 40202, USA
| | - Gary C Vitale
- Department of Surgery, University of Louisville, 550 S. Jackson Street, Louisville, KY, 40202, USA
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Asia-Pacific consensus guidelines for endoscopic management of benign biliary strictures. Gastrointest Endosc 2017; 86:44-58. [PMID: 28283322 DOI: 10.1016/j.gie.2017.02.031] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 02/23/2017] [Indexed: 12/11/2022]
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Therapeutic Endoscopic Retrograde Cholangiopancreatography in Pediatric Patients With Acute Recurrent and Chronic Pancreatitis: Data From the INSPPIRE (INternational Study group of Pediatric Pancreatitis: In search for a cuRE) Study. Pancreas 2017; 46:764-769. [PMID: 28609364 PMCID: PMC5502745 DOI: 10.1097/mpa.0000000000000848] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The aim of this study was to characterize utilization and benefit of therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in children with acute recurrent pancreatitis (ARP) or chronic pancreatitis (CP). METHODS From August 2012 to February 2015, 301 children with ARP or CP were enrolled in the INSPPIRE (INternational Study group of Pediatric Pancreatitis: In search for a cuRE) study. Physicians reported utilization and benefit of therapeutic ERCP at enrollment. Differences were analyzed using appropriate statistical methods. RESULTS One hundred seventeen children (38.9%) underwent at least 1 therapeutic ERCP. The procedure was more commonly performed in children with CP compared with those with ARP (65.8% vs 13.5%, P < 0.0001). Utility of therapeutic ERCP was reported to be similar between ARP and CP (53% vs 56%, P = 0.81) and was found to be helpful for at least 1 indication in both groups (53/99 patients [53.5%]). Predictors for undergoing therapeutic ERCP were presence of obstructive factors in ARP and CP, Hispanic ethnicity, or white race in CP. CONCLUSIONS Therapeutic ERCP is frequently utilized in children with ARP or CP and may offer benefit in selected cases, specifically if ductal obstruction is present. Longitudinal studies are needed to clarify the efficacy of therapeutic ERCP and to explore subgroups that might have increased benefit from such intervention.
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Bak J, Hwang J, Park S, Kang HW. Integration of optical applicator with balloon catheter for photothermal treatment of biliary stricture. Lasers Surg Med 2017; 49:781-786. [DOI: 10.1002/lsm.22688] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2017] [Indexed: 12/31/2022]
Affiliation(s)
- Jinoh Bak
- Interdisciplinary Program of Marine-Bio, Electrical & Mechanical Engineering; Pukyong National University; Busan Korea
| | - Jieun Hwang
- Interdisciplinary Program of Marine-Bio, Electrical & Mechanical Engineering; Pukyong National University; Busan Korea
| | - Suhyun Park
- School of Electrical and Electronics Engineering; Chung-Ang University; Seoul South Korea
| | - Hyun Wook Kang
- Interdisciplinary Program of Marine-Bio, Electrical & Mechanical Engineering; Pukyong National University; Busan Korea
- Department of Biomedical Engineering; Pukyong National University; Busan Korea
- Center for Marine-Integrated Biomedical Technology (BK21 Plus); Pukyong National University; Busan Korea
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Jang SI, Lee KH, Yoon HJ, Lee DK. Treatment of completely obstructed benign biliary strictures with magnetic compression anastomosis: follow-up results after recanalization. Gastrointest Endosc 2017; 85:1057-1066. [PMID: 27619787 DOI: 10.1016/j.gie.2016.08.047] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 08/27/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Although nonsurgical methods produce high clinical success rates in the treatment of benign biliary stricture (BBS), conventional methods are not always successful in cases of severe biliary stricture or complete obstruction. Therefore, the efficacy of magnetic compression anastomosis (MCA) for treatment of refractory BBS was evaluated in a single-center, nonrandomized study. METHODS MCA was performed in patients with BBS that was not resolved by conventional endoscopic or percutaneous treatments. One magnet was delivered through the percutaneous transhepatic biliary drainage tract, and the other advanced through 1 of 3 different routes. After magnet approximation and recanalization, an internal drainage catheter was placed for 6 months. RESULTS This study followed 39 patients who underwent MCA after the development of postoperative or traumatic strictures. Recanalization was achieved successfully in 35 patients. There was an acceptable procedure-related adverse event of mild cholangitis in 1 patient and no procedure-related mortalities. The average elapsed time from magnet approximation to removal was 57.4 days (range, 13-182 days), and the mean follow-up period after recanalization was 41.9 months (range, 7.1-73.4 months). Restenosis after MCA recurred in 1 patient, and partial restenosis occurred in another patient, but recanalization in these patients was successful using a guidewire via the percutaneous and endoscopic tracts. CONCLUSIONS MCA represents an alternative nonsurgical recanalization method for BBSs that cannot be treated by conventional methods. The rate of stricture recurrence after MCA was lower than that after conventional methods, likely because of the creation of a new fistula tract instead of dilation of a previous stricture.
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Affiliation(s)
- Sung Ill Jang
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea; Department of Medicine, The Graduate School of Yonsei University, Seoul, Republic of Korea
| | - Kwang-Hun Lee
- Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hong Jin Yoon
- Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dong Ki Lee
- Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
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Roos FJM, Poley JW, Polak WG, Metselaar HJ. Biliary complications after liver transplantation; recent developments in etiology, diagnosis and endoscopic treatment. Best Pract Res Clin Gastroenterol 2017. [PMID: 28624111 DOI: 10.1016/j.bpg.2017.04.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Biliary complications are considered to be the Achilles' heel of liver transplantation. The most common complications are leaks and bile duct strictures. Strictures can arise at the level of the anastomosis (anastomotic strictures; AS) or at other locations in the biliary tree (non-anastomotic strictures; NAS). Endoscopic treatment via endoscopic retrograde cholangiopancreatography (ERCP) is considered to be the preferred therapy for these complications. This review will focus on the diagnostic modalities, new insights in etiology of biliary complications and outcomes after different endoscopic therapies, in both deceased donor transplantation and living-donor liver transplantations. Advances in recent therapies, such as the use of self-expendable metal stents (SEMS) and endoscopic therapy for patients with a bilio-digestive anastomosis will be discussed.
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Zheng X, Wu J, Sun B, Wu YC, Bo ZY, Wan W, Gao DJ, Hu B. Clinical outcome of endoscopic covered metal stenting for resolution of benign biliary stricture: Systematic review and meta-analysis. Dig Endosc 2017; 29:198-210. [PMID: 27681297 DOI: 10.1111/den.12742] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 09/22/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND AIM Management of benign biliary stricture is challenging. Endoscopic therapy has evolved as the first-line treatment for various benign biliary strictures. However, covered self-expandable metal stents (CSEMS) have not been approved by the United States Food and Drug Administration for the treatment of benign biliary stricture. With this goal, we conducted the present systemic review and meta-analysis to evaluate the efficacy and safety of endoscopic stenting with CSEMS in the treatment of benign biliary stricture. METHODS Systematic review and meta-analysis by searching PubMed, MEDLINE and Embase databases. RESULTS In total, 37 studies (1677 patients) fulfilled the inclusion criteria. Pooled stricture resolutions were achieved in 83% of cases. Median stent dwelling time was 4.4 months, with median endoscopic retrograde cholangiopancreatography sessions of 2.0. Stricture recurrence at 4-year follow up was 11% (95% CI, 8-14%). Pooled complication rate was 23% (95% CI, 20-26%). CONCLUSIONS Placement of CSEMS is effective in the treatment of benign biliary stricture with relatively short stenting duration and low long-term stricture recurrence rate. However, more prospectively randomized studies are required to confirm the results.
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Affiliation(s)
- Xiao Zheng
- Department of Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai, China
| | - Jun Wu
- Department of Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai, China
| | - Bo Sun
- Department of Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai, China
| | - Ye-Chen Wu
- Department of Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai, China
| | - Zhi-Yuan Bo
- Department of Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai, China
| | - Wei Wan
- Department of Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai, China
| | - Dao-Jian Gao
- Department of Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai, China
| | - Bing Hu
- Department of Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai, China
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Ohyama H, Mikata R, Ishihara T, Sakai Y, Sugiyama H, Yasui S, Tsuyuguchi T. Efficacy of multiple biliary stenting for refractory benign biliary strictures due to chronic calcifying pancreatitis. World J Gastrointest Endosc 2017; 9:12-18. [PMID: 28101303 PMCID: PMC5215114 DOI: 10.4253/wjge.v9.i1.12] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 08/25/2016] [Accepted: 11/02/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate endoscopic therapy efficacy for refractory benign biliary strictures (BBS) with multiple biliary stenting and clarify predictors.
METHODS Ten consecutive patients with stones in the pancreatic head and BBS due to chronic pancreatitis who underwent endoscopic therapy were evaluated. Endoscopic insertion of a single stent failed in all patients. We used plastic stents (7F, 8.5F, and 10F) and increased stents at intervals of 2 or 3 mo. Stents were removed approximately 1 year after initial stenting. BBS and common bile duct (CBD) diameter were evaluated using cholangiography. Patients were followed for ≥ 6 mo after therapy, interviewed for cholestasis symptoms, and underwent liver function testing every visit. Patients with complete and incomplete stricture dilations were compared.
RESULTS Endoscopic therapy was completed in 8 (80%) patients, whereas 2 (20%) patients could not continue therapy because of severe acute cholangitis and abdominal abscess, respectively. The mean number of stents was 4.1 ± 1.2. In two (20%) patients, BBS did not improve; thus, a biliary stent was inserted. BBS improved in six (60%) patients. CBD diameter improved more significantly in the complete group than in the incomplete group (6.1 ± 1.8 mm vs 13.7 ± 2.2 mm, respectively, P = 0.010). Stricture length was significantly associated with complete stricture dilation (complete group; 20.5 ± 3.0 mm, incomplete group; 29.0 ± 5.1 mm, P = 0.011). Acute cholangitis did not recur during the mean follow-up period of 20.6 ± 7.3 mo.
CONCLUSION Sequential endoscopic insertion of multiple stents is effective for refractory BBS caused by chronic calcifying pancreatitis. BBS length calculation can improve patient selection procedure for therapy.
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Liu Y, Zheng S, Li N, Guo H, Zheng Y, Peng J. In vivo response of AZ31 alloy as biliary stents: a 6 months evaluation in rabbits. Sci Rep 2017; 7:40184. [PMID: 28084306 PMCID: PMC5234016 DOI: 10.1038/srep40184] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 12/01/2016] [Indexed: 11/09/2022] Open
Abstract
Mg-based metallic materials have been making continuing progress as vascular stents. However, the research of Mg-based materials as non-vascular stents is still at its primary stage. AZ31 stents hereby were implanted into the common bile duct of rabbits for 6 months. The results revealed an existence of 93.82 ± 1.36% and 30.89 ± 2.46% of the original volume after 1 and 3 month, respectively. Whole blood tests indicated an inflammation decreasing to normal level after 3 month implantation. A benign host response was observed via H&E staining. Nonuniform corrosion at the two ends of the stents was observed and considered the results of flow or local inflammation. Moreover, the application of Mg-based materials for different stenting treatment were reviewed and compared. Esophagus was hypothesized most destructive, whilst blood vessel and bile duct considered similar and less destructive. Trachea and nasal cavity were thought to be mildest.
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Affiliation(s)
- Yang Liu
- Department of Materials Science and Engineering, College of Engineering, Peking University, Beijing 100871, China
| | - Shengmin Zheng
- Department of Hepatobiliary Surgery, Peking University People's Hospital, Beijing 100044, China
| | - Nan Li
- Department of Materials Science and Engineering, College of Engineering, Peking University, Beijing 100871, China
| | - Huahu Guo
- Department of Hepatobiliary Surgery, Peking University People's Hospital, Beijing 100044, China
| | - Yufeng Zheng
- Department of Materials Science and Engineering, College of Engineering, Peking University, Beijing 100871, China
| | - Jirun Peng
- Department of Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
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Siiki A, Jesenofsky R, Löhr M, Nordback I, Kellomäki M, Gröhn H, Mikkonen J, Sand J, Laukkarinen J. Biodegradable biliary stents have a different effect than covered metal stents on the expression of proteins associated with tissue healing in benign biliary strictures. Scand J Gastroenterol 2016; 51:880-5. [PMID: 27003149 DOI: 10.3109/00365521.2016.1156153] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Benign biliary strictures (BBS) are primarily treated endoscopically with covered self-expandable metal stents (CSEMS). Biodegradable biliary stents (BDBS) may be the future of endoscopic therapy of BBS. The aim was to assess the expression of proteins related to tissue healing in BBS compared with the intact bile duct (BD), and to study the protein expression after therapy with CSEMS or BDBS. METHODS Pigs with ischemic BBS were endoscopically treated either with BDBS or CSEMS. Samples were harvested from pigs with intact BD (n = 5), untreated BBS (n = 5), and after six months of therapy with BDBS (n = 4) or CSEMS (n = 5) with subsequent histologic analysis. Two-dimensional electrophoresis with protein identification was performed to evaluate protein expression patterns. RESULTS In BBS, the expression of galectin-2 and annexin-A4 decreased, compared to intact BD. Treatment with biodegradable stents normalized galectin-2 level; with CSEMS therapy it remained low. Transgelin expression of intact BD and BBS remained low after BDBS treatment but increased after CSEMS therapy. Histologic analysis did not show unwanted foreign body reaction or hyperplasia in the BD in either group. CONCLUSIONS The expression of proteins related to tissue healing in BBS is different after treatment with biodegradable stents and CSEMS. Treatment with biodegradable stents may bring protein expression towards what is seen in intact BD. BDBS seem to have a good biocompatibility.
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Affiliation(s)
- Antti Siiki
- a Department of Gastroenterology and Alimentary Tract Surgery , Tampere University Hospital , Tampere , Finland
| | - Ralf Jesenofsky
- b Department of Medicine II , University of Heidelberg , Mannheim , Germany
| | - Matthias Löhr
- c Karolinska University Hospital, Gastrocentrum , Huddinge , Sweden
| | - Isto Nordback
- a Department of Gastroenterology and Alimentary Tract Surgery , Tampere University Hospital , Tampere , Finland
| | - Minna Kellomäki
- d Biomaterials and Tissue Engineering Group, BioMediTech and Department of Electronics and Communications Engineering , Tampere University of Technology , Tampere , Finland
| | - Heidi Gröhn
- e Department of Clinical Physiology and Nuclear Medicine , Kuopio University Hospital , Kuopio , Finland
| | - Joonas Mikkonen
- d Biomaterials and Tissue Engineering Group, BioMediTech and Department of Electronics and Communications Engineering , Tampere University of Technology , Tampere , Finland
| | - Juhani Sand
- a Department of Gastroenterology and Alimentary Tract Surgery , Tampere University Hospital , Tampere , Finland
| | - Johanna Laukkarinen
- a Department of Gastroenterology and Alimentary Tract Surgery , Tampere University Hospital , Tampere , Finland
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Coté GA, Slivka A, Tarnasky P, Mullady DK, Elmunzer BJ, Elta G, Fogel E, Lehman G, McHenry L, Romagnuolo J, Menon S, Siddiqui UD, Watkins J, Lynch S, Denski C, Xu H, Sherman S. Effect of Covered Metallic Stents Compared With Plastic Stents on Benign Biliary Stricture Resolution: A Randomized Clinical Trial. JAMA 2016; 315:1250-7. [PMID: 27002446 PMCID: PMC5544902 DOI: 10.1001/jama.2016.2619] [Citation(s) in RCA: 145] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IMPORTANCE Endoscopic placement of multiple plastic stents in parallel is the first-line treatment for most benign biliary strictures; it is possible that fully covered, self-expandable metallic stents (cSEMS) may require fewer endoscopic retrograde cholangiopancreatography procedures (ERCPs) to achieve resolution. OBJECTIVE To assess whether use of cSEMS is noninferior to plastic stents with respect to stricture resolution. DESIGN, SETTING, AND PARTICIPANTS Multicenter (8 endoscopic referral centers), open-label, parallel, randomized clinical trial involving patients with treatment-naive, benign biliary strictures (N = 112) due to orthotopic liver transplant (n = 73), chronic pancreatitis (n = 35), or postoperative injury (n = 4), who were enrolled between April 2011 and September 2014 (with follow-up ending October 2015). Patients with a bile duct diameter less than 6 mm and those with an intact gallbladder in whom the cystic duct would be overlapped by a cSEMS were excluded. INTERVENTIONS Patients (N = 112) were randomized to receive multiple plastic stents or a single cSEMS, stratified by stricture etiology and with endoscopic reassessment for resolution every 3 months (plastic stents) or every 6 months (cSEMS). Patients were followed up for 12 months after stricture resolution to assess for recurrence. MAIN OUTCOMES AND MEASURES Primary outcome was stricture resolution after no more than 12 months of endoscopic therapy. The sample size was estimated based on the noninferiority of cSEMS to plastic stents, with a noninferiority margin of -15%. RESULTS There were 55 patients in the plastic stent group (mean [SD] age, 57 [11] years; 17 women [31%]) and 57 patients in the cSEMS group (mean [SD] age, 55 [10] years; 19 women [33%]). Compared with plastic stents (41/48, 85.4%), the cSEMS resolution rate was 50 of 54 patients (92.6%), with a rate difference of 7.2% (1-sided 95% CI, -3.0% to ∞; P < .001). Given the prespecified noninferiority margin of -15%, the null hypothesis that cSEMS is less effective than plastic stents was rejected. The mean number of ERCPs to achieve resolution was lower for cSEMS (2.14) vs plastic (3.24; mean difference, 1.10; 95% CI, 0.74 to 1.46; P < .001). CONCLUSIONS AND RELEVANCE Among patients with benign biliary strictures and a bile duct diameter 6 mm or more in whom the covered metallic stent would not overlap the cystic duct, cSEMS were not inferior to multiple plastic stents after 12 months in achieving stricture resolution. Metallic stents should be considered an appropriate option in patients such as these. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01221311.
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Affiliation(s)
- Gregory A Coté
- Department of Medicine, Indiana University School of Medicine, Indianapolis2Department of Medicine, Medical University of South Carolina, Charleston
| | - Adam Slivka
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Daniel K Mullady
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
| | - B Joseph Elmunzer
- Department of Medicine, Medical University of South Carolina, Charleston6Department of Medicine, University of Michigan, Ann Arbor
| | - Grace Elta
- Department of Medicine, University of Michigan, Ann Arbor
| | - Evan Fogel
- Department of Medicine, Indiana University School of Medicine, Indianapolis
| | - Glen Lehman
- Department of Medicine, Indiana University School of Medicine, Indianapolis
| | - Lee McHenry
- Department of Medicine, Indiana University School of Medicine, Indianapolis
| | - Joseph Romagnuolo
- Department of Medicine, Medical University of South Carolina, Charleston
| | - Shyam Menon
- Royal Wolverhampton Trust, Wolverhampton, United Kingdom
| | - Uzma D Siddiqui
- Center for Endoscopic Research and Therapeutics, University of Chicago School of Medicine, Chicago, Illinois
| | - James Watkins
- Department of Medicine, Indiana University School of Medicine, Indianapolis
| | - Sheryl Lynch
- Department of Medicine, Indiana University School of Medicine, Indianapolis
| | - Cheryl Denski
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis
| | - Huiping Xu
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis
| | - Stuart Sherman
- Department of Medicine, Indiana University School of Medicine, Indianapolis
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Ferreira R, Loureiro R, Nunes N, Santos AA, Maio R, Cravo M, Duarte MA. Role of endoscopic retrograde cholangiopancreatography in the management of benign biliary strictures: What’s new? World J Gastrointest Endosc 2016; 8:220-231. [PMID: 26962404 PMCID: PMC4766255 DOI: 10.4253/wjge.v8.i4.220] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 08/18/2015] [Accepted: 12/15/2015] [Indexed: 02/05/2023] Open
Abstract
Benign biliary strictures comprise a heterogeneous group of diseases. The most common strictures amenable to endoscopic treatment are post-cholecystectomy, post-liver transplantation, related to primary sclerosing cholangitis and to chronic pancreatitis. Endoscopic treatment of benign biliary strictures is widely used as first line therapy, since it is effective, safe, noninvasive and repeatable. Endoscopic techniques currently used are dilation, multiple plastic stents insertion and fully covered self-expandable metal stents. The main indication for dilation alone is primary sclerosing cholangitis related strictures. In the vast majority of the remaining cases, temporary placement of multiple plastic stents with/without dilation is considered the treatment of choice. Although this approach is effective, it requires multiple endoscopic sessions due to the short duration of stent patency. Fully covered self-expandable metal stents appear as a good alternative to plastic stents, since they have an increased radial diameter, longer stent patency, easier insertion technique and similar efficacy. Recent advances in endoscopic technique and various devices have allowed successful treatment in most cases. The development of novel endoscopic techniques and devices is still ongoing.
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Weigt J, Kandulski A, Malfertheiner P. Anatomy-shaped design of a fully-covered, biliary, self-expandable metal stent for treatment of benign distal biliary strictures. Endosc Int Open 2016; 4:E79-82. [PMID: 26793789 PMCID: PMC4713183 DOI: 10.1055/s-0034-1393583] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND AND STUDY AIMS The treatment success of benign biliary strictures with fully covered metal stents (CSEMS) is altered by high stent dislocation rates. We aimed to evaluate a new stent design to prevent dislocation. PATIENTS AND METHODS Patients with benign biliary strictures were treated with a newly designed double-coned stent (dcSEMS). Mechanical analysis of the new stent was performed and it was compared with a cylindrical stent. RESULTS A total of 13 dcCSEMS were implanted in 11 patients (2 female, 9 male, median age 47, range 33 - 71). All patients had distal biliary strictures due to chronic pancreatitis. No stent migration occurred. In all but one patient the stents were removed. One patient refused stent extraction and was lost to follow up. Stent occlusion occurred twice leading to cholangitis in both cases. The duration of stent treatment was 170 days (range 61 - 254). After extraction only one patient had early recurrent stricture and received the same stent again. Three stents showed minimal tissue granulation at the papilla. One stent presented ingrowth at the proximal end and was removed after implantation of a second fully covered stent. Mechanical examination revealed significantly lower radial expansion force of the new stent as compared to the cylindrical stent. CONCLUSIONS The new stent design has a low rate of migration. Biomechanical properties may explain this effect.
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Affiliation(s)
- Jochen Weigt
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University, Magdeburg, Germany
| | - Arne Kandulski
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University, Magdeburg, Germany
| | - Peter Malfertheiner
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University, Magdeburg, Germany
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