Ectopic Opening of Common Bile Duct to Duodenal Bulb: A Single Tertiary Center Experience.

BACKGROUND: The ectopic opening of the common bile duct(CBD) into the duodenal bulb is a rare biliary anomaly. The study aimed to reveal the experience with clinical and endoscopic outcomes in these patients. MATERIALS AND METHODS: This study was conducted on 57 consecutive patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) for ectopic opening of the CBD into the duodenal bulb at our institution between 2010 and 2020. RESULTS: The median age was 59 years (49 males). A total of 146 ERCP procedures were performed (once in 26 patients and 2 or more times in 31 patients). Ten patients had a history of unsuccessful ERCP in an external center. The median follow-up time was 14.6 months. All patients had a slit-like opening of the CBD into the duodenal bulb, apical stenosis, and hook-shaped distal CBD. ERCP findings were CBD stone or dilatation in 55 patients and post-cholecystectomy biliary leakage in 2 patients. Balloon dilatation was performed for apical stenosis in 7 patients and distal CBD stenosis in 26 patients. During the first ERCP session, biliary stent/nasobiliary drainage was placed in 37 patients, and CBD stones were extracted in 19 patients without stenting. Biliodigestive anastomosis was applied to 13 patients, 5 of whom had recurrent cholangitis, 7 required recurrent ERCP, and one was due to the technical difficulty of ERCP. CONCLUSIONS: Ectopic biliary opening should be remembered if the papilla cannot be seen in its usual place in a patient with apical stenosis. ERCP should be performed in experienced hands, and surgery should be considered in the need for recurrent ERCP.

A Step-Up Approach Using Alternative Endoscopic Modalities Is an Effective Strategy for Postoperative and Traumatic Pancreatic Duct Disruption.

BACKGROUND AND AIMS: Standard endotherapy for pancreatic duct (PD) disruption is pancreatic stenting and sphincterotomy. In patients refractory to standard treatment, treatment algorithm is currently not standardized. This study aims to report the 10-year experience with the endoscopic treatment of postoperative or traumatic PD disruption and to share our algorithmic approach. METHODS: This retrospective study was conducted on 30 consecutive patients who underwent endoscopic treatment for postoperative (n = 26) or traumatic (n = 4) PD disruption between 2011 and 2021. Standard treatment was initially applied to all patients. Endoscopic modalities used with a step-up approach in patients unresponsive to standard treatment were stent upsizing and N-butyl-2-cyanoacrilate (NBCA) injection for partial disruption, and the bridging of the disruption with a stent and cystogastrostomy for complete disruption. RESULTS: PD disruption was partial in 26 and complete in 4 patients. Cannulation and stenting of PD was successful in all patients and sphincterotomy was performed in 22 patients. Standard treatment was successful in 20 patients (66.6%). The resolution of PD disruption in 9 of 10 patients refractory to standard treatment was achieved with stent upsizing in 4, NBCA injection in 2, the bridging of the complete disruption in one, and cystogastrostomy after spontaneously and intentionally developed pseudocyst in one patient each. Overall, therapeutic success rate was 96.6% (100% for partial, 75% for complete disruption). Procedural complications occurred in 7 patients. CONCLUSIONS: Standart treatment for PD disruption is usually effective. In patients refractory to standard treatment, the outcome may be improved by step-up approach using alternative endoscopic modalities.

Comparison of urgent and early endoscopy for acute non-variceal upper gastrointestinal bleeding in high-risk patients.

OBJECTIVE: Data regarding early (within 24h) and urgent endoscopy (within 12h) in non-variceal upper gastrointestinal bleeding (NV-UGIB) revealed conflicting results. This study aimed to investigate the impact of endoscopy timing on the outcomes of high-risk patients with NV-UGIB. PATIENTS AND METHODS: From February 2020 to February 2021, consecutive high-risk (Glasgow-Blatchford score ≥12) adults admitted to the emergency department with NV-UGIB were analyzed retrospectively. The primary composite outcome was 30-day mortality from any cause, inpatient rebleeding, need for endoscopic re-intervention, need for surgery or angiographic embolization. RESULTS: 240 patients were enrolled: 152 (63%) patients underwent urgent endoscopy (<12h) and 88 (37%) patients underwent early endoscopy (12-24h). One or more components of the composite outcome were observed in 53 (22.1%) patients: 30 (12.5%) had 30-day mortality, rebleeding occurred in 27 (11.3%), 7 (2.9%) underwent endoscopic re-intervention, and 5 (2.1%) required surgery or angiographic embolization. The composite outcome was similar between the groups. Multivariate analysis showed only hemodynamic instability on admission (OR: 3.05, p=0.006), and the previous history of cancer (OR: 2.42, p=0.029) were significant in predicting composite outcome. In terms of secondary outcomes, the endoscopic intervention was higher in the urgent endoscopy group (p=0.006), whereas the number of transfused erythrocyte suspensions and the length of hospital stay was higher in the early endoscopy group (p=0.002 and p=0.040, respectively). CONCLUSIONS: Urgent endoscopy leads to a significant reduction in the length of hospitalization and the number of transfused erythrocyte suspensions in NV-UGIB, which can contribute to patient satisfaction, reduce healthcare expenditure, and improve hospital bed availability. The composite outcome and its sub-outcomes were the same among both groups.

Evaluation of Tp-e interval and Tp-e/QTc ratio in patients with inflammatory bowel disease.

BACKGROUND: Inflammatory bowel disease (IBD), a multisystemic inflammatory disorder, has been associated with increased risk of cardiovascular problems, including complications such as conduction defects and arrhythmias. Therefore, the early assessment of the risk factors predisposing to ventricular arrhythmias is crucial, since it can improve clinical outcomes. The objective of the present study is to evaluate ventricular repolarization by using Tp­e interval and Tp-e/QTc ratio as candidate markers of ventricular arrhythmias in patients with IBD. METHODS: The presented study was designed as a single-center prospective cohort study. The study population consisted of 175 patients with IBD and 175 healthy volunteers. The Tp­e interval, corrected QT (QTc), and Tp-e/QTc ratio were measured from the 12-lead electrocardiogram. These parameters were compared between groups. RESULTS: The groups were similar in terms of electrocardiographic findings such as heart rate, QRS interval, and QTc interval. However, Tp­e interval (87.0 ms, interquartile range, IQR 81.0-105.0 ms vs. 84.0 ms, IQR 74.0-92.0 ms; p < 0.001) and Tp-e/QTc ratio (0.21 ± 0.04 vs. 0.19 ± 0.05; p < 0.001) were significantly increased in IBD patient group compared to control group. Notably, a positive correlation was demonstrated between Tp­e interval, Tp-e/QTc ratio and disease duration (Spearman's Rho = 0.36, p < 0.001 for Tp­e; Spearman's Rho = 0.28, p < 0.001 for Tp-e/QTc). CONCLUSION: This study demonstrated that IBD patients are at increased risk of disrupted ventricular repolarization (increased Tpe, Tpe/QTc ratio). In addition, a positive correlation was demonstrated between Tp­e interval, Tp-e/QTc ratio, and disease duration. Therefore, IBD patients, especially those with long-standing diseases, should be more closely screened for ventricular arrhythmias.

Suprapapillary Needle Knife Fistulotomy Versus Conventional Precut Sphincterotomy in Difficult Biliary Cannulation: A Retrospective Comparative Study.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is an important therapeutic tool for many biliary diseases. Selective biliary cannulation is the first step of the treatment process. Needle knife fistulotomy (NKF) and conventional precut sphincterotomy (CPS) are widely used in difficult biliary cannulation. However, there are different results in their effectiveness and safety. This study aimed to compare both methods regarding cannulation success and adverse event profile. MATERIALS AND METHODS: All eligible consecutive patients with naive papillae who underwent biliary ERCP by a single experienced endoscopist over a 3-year period were included retrospectively. The standard cannulation method with a guidewire-loaded sphincterotome was initially used for biliary cannulation in all patients. Cannulation was accepted as difficult in the case of failure of standard cannulation within 5 minutes or despite 5 attempts or insertion of the guidewire to the pancreatic duct 5 times. Three modalities in patients with difficult biliary cannulation were employed according to the structure and configuration of the papillae in addition to unintentional pancreatic cannulation: (1) NKF, (2) CPS, (3) Double guidewire technique or guidewire orientation/precut following pancreatic stenting. Latter was excluded to enable direct comparison between NKF and CPS groups. RESULTS: A total of 644 patients were recruited. Analyses were performed with 541 patients after the exclusion of 103 patients. Mean (SD) age was 60.4 (18.2) years, and 257 (47.5%) patients were male. While standard cannulation was successful in 366 (67.6%), difficult biliary cannulation was observed in 175 (32.4%) patients. NKF was performed in 101 (57.7%) patients, and cannulation success was 100% in the first ERCP session. In contrast, CPS was performed in 74 (42.3%) patients with a lower cannulation success rate (79.7%) than NKF ( P <0.001). Post-ERCP pancreatitis rate was higher in CPS (9.5%) than NKF group (3.0%, P =0.063). Bleeding and cholangitis were similar in both groups. CONCLUSIONS: In patients with difficult biliary cannulation with appropriate papillary structure and configuration, NKF should be used as the first choice in experienced hands because of high biliary cannulation success and low Post-ERCP pancreatitis risk.

Magnetic Compression Anastomosis Is a Good Treatment Option for Patients with Completely Obstructed Benign Biliary Strictures: A Case Series Study.

BACKGROUND: Completely obstructed benign biliary strictures (BBS) is a difficult-to-treat condition. Surgery is the main treatment modality with high morbidity and mortality. Recently, the magnetic compression anastomosis (MCA) technique was employed in such cases with low complication rates. AIMS: To evaluate the effectiveness of the MCA in completely obstructed BBS. METHODS: 21 MCA procedures were performed in 19 patients with completely obstructed BBS. All patients had percutaneous biliary access. Magnets were located to the proximal side of the obstruction via percutaneous biliary sheath and the distal side endoscopically. The procedure was terminated as the magnets attracted. Either self-expandable fully covered metallic stent and/or a growing number of plastic stents were introduced after recanalization was achieved. RESULT: A total number of 19 patients with completely obstructed BBS resulting from cholecystectomy or liver transplant underwent 21 MCA procedures. Among those, 19 (90.5%) interventions were successful. The median stricture length that had been measured after magnet attraction was 4 mm (range 1-10 mm). The median magnet coupling time in successful cases was 9 days (range 4-27 days). No correlation was found between magnet coupling time and stricture length (p = 0.27). Complications were observed in 6 (cholangitis:1, magnet migration:2, magnet entrapment:3) of 19 successful MCA procedures. Fifteen of the 19 successful procedures had at least a period of stent-free follow-up. Recurrence of stenosis occurred in 7 procedures, of which 4 remained stent-free with retreatment. Eventually, 12 procedures had stent-free last status. CONCLUSIONS: MCA is an effective and safe treatment option in completely obstructed BBS. Further studies are required for procedural standardization.

Relationship Between Systemic Immune-Inflammation Index and Irritable Bowel Syndrome.

BACKGROUND: Irritable bowel syndrome is accepted as a functional disorder; however, there is growing evidence in favor of the inflammatory process contributing to its pathogenesis. We aimed to evaluate the role of the systemic immune-inflammation index as a marker of inflammation in patients with irritable bowel syndrome. METHODS: The study was conducted in the outpatient clinic of the Gastroenterology Department with patients having constipationpredominant irritable bowel syndrome diagnosis according to Rome IV criteria between March 1, 2019 and December 31, 2020. The systemic immune-inflammation index was calculated and compared with age- and sex-matched healthy controls. RESULTS: The study was performed with 214 participants, 107 patients and 107 control groups. Platelet and neutrophil counts (P < .001, for both) were higher, and lymphocyte count (P = .003) was lower in the irritable bowel syndrome group. The systemic immune-inflammation index was higher in irritable bowel syndrome patients (P < .001). Multivariate logistic regression analyses showed the role of the systemic immune-inflammation index as an independent predictor of the presence of IBS (odds ratio: 1.100, P < .001). CONCLUSION: Systemic immune-inflammation index may be a cheap, universal, and reliable indicator of the inflammatory process in irritable bowel syndrome patients.

Evaluation of cancer risk in patients with periodontal diseases

Background/aim: In this study, we aimed to assess the cancer risk among patients with periodontal disease. Materials and methods: Patients diagnosed with periodontal diseases at Hacettepe University between 2007 and 2012 were included and data on the diagnosis of any cancer after periodontal disease were collected from patient files. The age- and sex-standardized incidence rates (SIRs) were calculated using Turkish National Cancer Registry 2013 data. Results: A total of 5199 patients were included. Median follow-up was 7.2 years. Patients with periodontal diseases had 17% increased risk of cancer compared with the expected counts for the corresponding age and sex groups (SIR: 1.17; 95% CI: 1.04­1.3, P = 0.006). The increased cancer risk was statistically significant in women (SIR: 1.24; 95% CI: 1.05­1.45, P = 0.008) but not in men. Among women with periodontal disease, the risks of breast cancer (SIR: 2.19) and head and neck cancer (SIR: 4.71) were significantly increased. Among men, the risks of prostate cancer (SIR: 1.84), head and neck cancer (SIR: 3.55), and hematological cancers (SIR: 1.76) were significantly increased. Conclusion: This study showed that periodontal diseases were associated with increased risk of several cancers. Besides other well-known benefits for health, the provision of oral/dental health should be considered and employed as a cancer prevention measure.

Association between androgen receptor status and prognosis in triple negative breast cancer.

PURPOSE: Triple negative breast cancer (TNBC) is a heterogeneous disease group with a higher recurrence risk and poorer prognosis. In this study, we aimed to investigate the frequency and prognostic value of androgen receptor (AR) expression in tissues of TNBC patients. METHODS: A total of 84 TNBC patients treated between 2000 - 2015 in Hacettepe University Cancer Institute were included and their medical records were analyzed retrospectively. The available paraffin blocks were assessed immunohistochemically to determine AR expression. Tumors with ≥1% nuclear staining were considered AR-positive, while the ones with <1% staining were considered AR-negative. We analyzed the association between AR expression, and clinical-pathologic characteristics and prognosis in TNBC. RESULTS: Of the 84 TNBC patients, 25 (29.8%) were AR-positive. The frequency of grade 3 tumors was lower among AR-positive TNBC tumors compared to AR-negative tumors (40 vs 86.4%, p<0.001). In the AR-positive group, invasive ductal carcinoma (IDC) was less prevalent compared to AR-negative group (56 vs 86.4%, p<0.002). However, there were not statistically significant differences between AR positive and negative groups in terms of overall survival (OS) and disease free survival (DFS) (p=0.449, p=0.733, respectively). We found that grade 3 tumors were less frequent in AR-positive TNBC in our study. Nonetheless, we did not detect statistically significant difference in terms of overall survival and disease free survival between AR positive and negative TNBC. CONCLUSION: Routine evaluation of AR could contribute to further studies that may enlighten the role of AR targeting therapies in TNBC.