Genetic Investigations in Turkish Idiopathic Pancreatitis Patients Show Unique Characteristics.

BACKGROUND/AIMS: Pancreatitis is one of the leading causes of digestive system-related hospital admissions, and it has a genetic background in a considerable portion of the patients. In this study, we aimed to investigate the genetic risk factors of idiopathic pancreatitis in Turkish patients and the contribution of copy number variations to the pathogenesis. MATERIALS AND METHODS: Idiopathic pancreatitis is defined as failure to detect risk factors despite comprehensive clinical assessments. Next-generation sequencing and multiple ligand-dependent probe amplification of PRSS1, SPINK1, CTRC, and CFTR were performed. For further genotype-phenotype correlations, patients were also questioned for the age of onset, family history, and pancreatic divisum. RESULTS: A total of 68 idiopathic pancreatitis cases were enrolled. Variants with potential clinical significance of PRSS1 were identified in 13.4%, SPINK1 in 6.3%, CTRC in 4.7%, and CFTR in 26.5% of the patients. No copy number variants were seen in any of these genes. At least 7.4% of the participants had complex genetic etiology involving 2 genes. CONCLUSIONS: At least 42.6% of the participants had a potential genetic risk factor. Five novel genetic variants were identified, and distinctive genetic risk factors of Turkish population were shown. The results showed that genetic etiology was frequent in pancreatitis and it was even more prominent in patients with early-onset disease. Considering that genetic risk factors may be informative for decisionmaking in the treatment options in addition to providing extensive prognostic value and familial genetic consultation; clinicians need to be more eager to offer genetic tests to pancreatitis patients.

Pancreaticobiliary maljunction in Turkish patients: a multicenter case series.

BACKGROUND AND AIMS: Pancreaticobiliary maljunction (PBM) is a malformation in which the pancreatic and bile ducts join outside the duodenal wall. It is associated with various biliary and pancreatic diseases. In addition, patients with PBM carry a substantial lifetime risk of developing biliary or gallbladder carcinoma. We aimed to present a multicenter case series of PBM from Turkey. METHODS: This study was conducted in adult and pediatric PBM patients who were referred to three tertiary reference centers of Turkey for endoscopic retrograde cholangiopancreatography (ERCP) between July 2007 and May 2020. The clinical presentations, types of PBM, ERCP findings, surgical histories, and the postoperative courses, including the development of biliary malignancies, were retrospectively reviewed. RESULTS: The study group included 47 (31 adult and 16 children) patients. Type D PBM was more frequent (13/41: 27.7%) than that reported in Eastern studies. Type A PBM was more common in the adults (51.6% vs. 12.5%, p < 0.05), whereas type C was more common in pediatric patients (31.3% vs. 13.2%, p < 0.05). Although fusiform anatomy was predominant in both of the groups, cystic dilatation was more common (25.8% vs. 12.5%) in adults and the common bile duct diameter was greater [22 mm (range 11-58) vs. 12 mm (range 5-33)] in adult patients compared to pediatric patients. Resective surgeries were more frequently done in pediatric patients (73.3% vs. 53.6%), whereas cholecystectomy was more frequently performed in adult patients (21.4% vs. 6.7%). CONCLUSION: Although our findings were compatible with Eastern studies, type D PBM (associated with pancreas divisum) was more frequent in our study population.

Incidence, Risk Factors, and Treatment of Proximally Migrated Pancreatic Stents.

AIM: The aim of this study was to investigate the incidence, risk factors, and treatment strategies of proximally migrated pancreatic stents. MATERIALS AND METHODS: The data of 626 sessions of 421 patients with pancreatic duct stenting were retrospectively analyzed between 2010 and 2018, and patients with proximally migrated stents were included in the study. RESULTS: Of 626 stents examined, 77 migrated proximally (12%). The migration rate (MR) was 16%, 2%, and 7%, respectively, in patients treated with chronic pancreatitis, malignancy, and pancreatic leakage indication. The MR was 14% in procedures with pancreatic duct stenosis, 21% in procedures with pancreatic sphincterotomy, and 27% in procedures performed from minor papillae. The MR of the 5, 7, and 10 Fr stents was 4%, 17%, and 10%, respectively. Of the 77 migrated stents, 64 were successfully removed (83%). This success rate (SR) was 84% in procedures with chronic pancreatitis indication, 83% in procedures with pancreatic duct stenosis, 79% in procedures with sphincterotomy, and 75% in procedures performed from minor papillae. The SR of the 5, 7, and 10 Fr stents was 100%, 79%, and 92%, respectively. It was also determined that 33 stents were fractured and migrated (43%). The SR of the fractured stents was 76%. Moreover, of the stents that were successfully removed, 35 were removed with forceps (55%) and 15 (23%) were removed with a balloon. Furthermore, in 47 cases, the stent was removed in the first session (73%). Acute pancreatitis occurred in 5 patients (8%) and perforation occurred in 1 patient (2%). CONCLUSION: In this study, it was shown that proximal migration of pancreatic stents is frequent and most of these stents can be removed successfully.

Endoscopic retrograde cholangiography via a permanent access loop.

BACKGROUND/AIMS: The aim of this study was to investigate the indications, technical and clinical success, and complications of the endoscopic retrograde cholangiography (ERC) via a permanent access loop (PAL). MATERIALS AND METHODS: Twenty patients who underwent ERC through PAL between 2009 and 2017 were included in this study. The technical success was described as achieving access to the bile ducts through PAL and the clinical success was described as the clinical and laboratory improvement of the patients after the procedure. RESULTS: The study was performed with 20 patients. The median follow-up duration was 24 months (3-96) and the median number of ERC sessions was 3.9 (1-10). The most common ERC indications through PAL were stones (40%) and cholangitis (30%). In 16 patients (75%), anastomotic or branched strictures were observed. The improvement of strictures via intermittent stenting and dilatation was observed in 6 patients, but no improvement was observed in 5 patients. The treatment of those 5 patients continues. In this study, the technical success was 100% and clinical success was 85%. While no mortality due to PAL-mediated ERC was observed, free wall perforation was seen in one patient who was referred to surgery. CONCLUSION: PAL-mediated ERC procedure is a technique with high technical and clinical success and low complication rate in patients who require frequent percutaneous procedures and those with difficult access to the biliary tract.

Endoscopic Treatment of the Coloanal Anastomotic Dehiscence and Stricture: Stenting Via Rendezvous Technique.

An anastomotic leak is a serious complication of colorectal surgery. Leak management is often grueling, and a definitive stoma is often mandatory for rescue therapy. Herein, we present a patient who experienced coloanal anastomotic dehiscence and complete stricture at the proximal part of the anastomosis. This case was successfully treated with a fully covered self-expandable metallic stent placement via the combined endoscopic (per ileostomy) and manual (per anal channel) rendezvous technique.

Endoscopic papillectomy of benign ampullary lesions: Outcomes from a multicenter study.

BACKGROUND/AIMS: Endoscopic papillectomy (EP) has emerged as an alternative to surgery in the management of ampullary lesions. The aim of this study is to evaluate feasibility, efficacy, safety, outcome, and impact of EP in the management of benign ampullary lesions. MATERIALS AND METHODS: This is a multicenter, retrospective study of 44 patients who had EP of benign ampullary lesions. RESULTS: Over the 11-year period, 44 (55.7%) of 79 patients underwent EP for benign ampullary lesions. Complete resection was achieved in 40 patients (91%). An underlying adenocarcinoma was the only risk factor for incomplete resection. Twenty-eight lesions (63.6%) were resected en-bloc and 16 lesions (36.4%) were resected in piecemeal fashion. Post-papillectomy histopathologic diagnoses were tubular adenoma in 14 patients (32%), invasive adenocarcinoma in 9 patients (20.5%), tubullovillous adenoma in 7 patients (16%), tubullovillous adenoma with carcinoma limited to the mucosal layer in 5 patients (11.3%), adenoma with high-grade dysplasia in 4 patients (9%), neuroendocrine tumor in 1 patient (2.3%), ganglioneuroma in 1 patient (2.3%), hamartomatous polyp in 1 patient (2.3%), adenofibroma in 1 patients (2.3%), and Brunner gland hyperplasia in 1 patient (2.3%). Seven (15.9%) procedure-related complications occurred: 3 (6.8%) bleeding, 2 (4.5%) pancreatitis, 1 (2.3%) abdominal pain, and 1 (2.3%) stent migration to the pancreatic duct. Seven patients (17%) had recurrence. CONCLUSION: Endoscopic papillectomy is a safe and effective method and can be considered as a first-line approach in patients with benign ampullary lesions with intent for cure. It also allows for correct histological diagnosis and staging.

Endoscopic Treatment of the Zenker Diverticulum With Flexible Endoscopic Myotomy: A Single Tertiary Center Experience.

INTRODUCTION: The Zenker diverticulum (ZD) is the most common type of esophageal diverticula. Management of ZD has different options; however, there is a recent increase in treatment with flexible endoscopic myotomy (FEM). In our study, we aimed to investigate the efficacy and safety of FEM among patients with ZD. MATERIALS AND METHODS: The data of patients who underwent FEM for ZD in our clinic between January 2008 and May 2016 were retrospectively analyzed. Myotomy was performed with a needle-knife sphincterotome by using pulse-cut or forced coagulation electrocautery mode. Myotomy was performed on the common wall of the diverticulum up to 0.5 to 1 cm of the distal end. A handmade diverticuloscope, which was modified from an overtube, was used in most of the patients to focus more carefully on the septum. Dysphagia scores of the patients before and after the procedure were compared and complications were evaluated. RESULTS: A total of 17 patients were enrolled in the study. The mean age was 65.3 years, and mean diverticular diameter was 3.2 cm. The most common symptoms were dysphagia and regurgitation. The mean in-hospital stay was 5 days. The dysphagia score was significantly decreased after FEM among the patients (0.17±0.39 vs. 2±0.79; P=0.0001). Complications were observed in 3 patients (17.6%); however, there was no procedure-related mortality. DISCUSSION: FEM is an efficient and safe procedure as a treatment modality for ZD. However, lack of a standard algorithm is a remarkable disadvantage.

Endosonogragphic features of lesions suggesting gastricectopic pancreas: experience of a single tertiary center.

BACKGROUND/AIM: We aimed to present the endoscopic ultrasound (EUS) features of gastric lesions suggesting gastric ectopic pancreas during upper gastrointestinal endoscopy that were diagnosed in our gastroenterology unit, which is a tertiary center for endoscopic procedures in Turkey. MATERIALS AND METHODS: The data of patients who underwent upper gastrointestinal EUS in our center between April 2012 and July 2014 were retrospectively analyzed. RESULTS: All of the lesions suggesting gastric ectopic pancreas were localized in the gastric antrum. Thirty-six of 44 lesions (81.1%) showed central dimpling. Lesion borders were shown to be definite in 10 (22.7%) lesions, whereas the borders of 34 lesions (77.3%) were indefinite. Thirty-nine lesions (88.6%) had heterogeneous and 5 lesions (11.4%) had homogeneous echo patterns; whereas 29 lesions (65.9%) were hypoechoic, 9 lesions (20.5%) were hyperechoic and 6 lesions (13.6%) had mixed echogenicity. Forty-two lesions (95.5%) were shown to affect only a single sonographic layer of the gastric wall. CONCLUSION: EUS features of lesions that strongly suggest gastric ectopic pancreas endoscopically, without any histopathological evidence and without either endoscopic or surgical resection, are as follows: indefinite border appearance, minimal heterogeneous hypoisoechoic echo pattern, existence of anechoic duct-like structures inside the lesion, common localization in the submucosal layer, and existence of umbilication.

Management of suspected common bile duct stone: diagnostic yield of current guidelines.

BACKGROUND: The American Society for Gastrointestinal Endoscopy (ASGE) has recently published a guideline for suspected CBDS with the intention of reducing unnecessary ERCP and thereby complications. The aim of this study was to assess the diagnostic efficacy of the ASGE guideline. METHODS: Data of patients who underwent ERCP with suspected CBDS were analyzed retrospectively. Patients were classified into high, intermediate and low risk groups based on predictors that have been suggested by the ASGE. Very strong predictors of the presence of ductal stones included: CBDS on transabdominal ultrasonography (US), clinical ascending cholangitis or total bilirubin (TBIL) >4 mg/dL). Strong predictors included dilated CBD >6 mm on US with gallbladder in situ and TBIL level of 1.8-4.0 mg/dL whereas moderate predictor included abnormal liver biochemical test other than bilirubin, age more than 55 years and clinical findings of biliary pancreatitis. RESULTS: Of 888 enrolled patients, 704 had CBDS demonstrated by ERCP and the remainder did not. All very strong and strong predictors were found to be significantly higher among patients who had CBDS. Detection of CBDS by ultrasonography and a dilated common biliary duct were observed to be independent risk factors associated with the existence of CBDS. The high risk group had a high (86.7%) positive predictive value (PPV), however, sensitivity and specificity were observed to be moderate (67.8% and 60.3% respectively). PPV was 67.9% in the intermediate risk group and the sensitivity and specificity were very low (31.9% and 42.3%). DISCUSSION: The probability of CBDS was observed to be high in the intermediate and high risk groups. However due to low sensitivity and specificity values, the ASGE guideline needs additional or different predictors.

Large Balloon Dilation Treatment for Retrieval of Embedded Sharp-pointed Objects in the Esophagus: A New Technique.

Most ingested foreign bodies are best treated with endoscopically. If the sharp-pointed objects embedded in the esophageal wall, it may not be able to be removed by conventional endoscopic devices and surgery is required. Herein, we described a new technique for the extraction of both ends embedded sharp-pointed objects in the esophageal wall.

Double balloon enteroscopy: A 7-year experience at a tertiary care Centre.

BACKGROUND: Double Balloon Enteroscopy (DBE) provides the opportunity not only to investigate but also apply endoscopic therapeutic interventions for small intestinal disturbances. The aim of this study is to assess the indications, diagnosis, therapeutic interventions, complications and safety in clinical practise of DBE procedures that have been performed in our clinic. MATERIAL-METHODS: The data of patients who had undergone DBE procedure in our clinic between October 2007 and December 2014 were retrospectively investigated. All features including indications, findings, histopathological results, applied interventions and complications due to procedure were noted. RESULTS: A total of 297 patients, 160 (53,9%) male and 137 (46,1%) female were enrolled in the study. Total number of procedures for these 297 patients were 372 [256 (68,8%) oral and 116 (31,2%) anal]. Mean age of the patients was 46,9 (14-94) years. The most common indications were; obscure gastrointestinal (GI) bleeding (28,3%), iron deficiency anaemia (17,5% ) and abnormal findings in a prior imaging study (13,8%), respectively. The rate of new diagnosis with DBE was 11.8%, where the rate for confirmation of a possible diagnosis was 16.2%, rate of endoscopic treatment with definite diagnosis was 11%, rate for ruling out possible diagnosis or showing normal findings was 34.7% and rate for insufficient or unsuccessful procedures was 26.3%. Ulcers, inflammation and erosions (13%), polyposis syndromes (9.8%) and vascular pathologies (7.4%) were the most common endoscopic findings. CONCLUSION: Our study shows that DBE has high efficacy for diagnosis and ability to perform treatment of small intestinal disturbances with safety.

Assessment of the endoscopic retrograde cholangiopancreatography grading system: A prospective study from a tertiary care center.

BACKGROUND/AIMS: The American Society for Gastrointestinal Endoscopy (ASGE) endoscopic retrograde cholangiopancreatography (ERCP) grading system was proposed but has not been fully evaluated with prospective clinical studies. In this study, we aimed to evaluate the effectiveness of the ERCP difficulty grading system for predicting success and adverse event rates related to the procedure. MATERIALS AND METHODS: A total of 1057 ERCP procedures performed on 752 patients were included in the present study. The complexity grades of the procedures were recorded according to the ASGE grading system. Specific complications of ERCP (pancreatitis, cholangitis, bleeding, and perforation) were also defined and graded. RESULTS: The procedure difficulty was determined as 1st degree in 153 patients (14.4%), 2nd degree in 498 patients (47.1%), 3rd degree in 271 (25.6%), and 4th degree in 135 patients (12.7%). The success rate for the entire procedures was 88.4%. The success rate for 1st degree procedures was 99.3%, 97.2% for 2nd degree procedures, 86.7% for 3rd degree procedures, and 46.7% for 4th degree procedures (p<0.005). When the difficulty of the procedures increased from 1 to 4, the adverse event rates increased from 1.3% to 10.4%. CONCLUSION: The findings support the evidence that the difficulty degrees of ERCP procedures can help predict the success and complication rates of the procedure. Because of the increased rates of failure and complications in more difficult cases, the procedures should be performed by experienced endoscopists in advanced centers.

Can a Fully Covered Self-Expandable Metallic Stent be Used Temporarily for the Management of Duodenal Retroperitoneal Perforation During ERCP as a Part of Conservative Therapy?

PURPOSE: There are no reports comparing the results of conservative/nonsurgical management with the addition of fully covered self-expandable metallic stents (FCSEMS) with the conservative approach in endoscopic retrograde cholangiopancreatography (ERCP)-related duodenal retroperitoneal (type II) perforations. The aim of this study was to evaluate whether the addition of FCSEMS to conventional treatment provides further benefits in the course of type II perforations. METHODS: A total of 7471 ERCP with sphincterotomy performed between 2007 and 2014 were evaluated, and a total of 25 type II perforations (0.33%) were identified. About 20 patients who were detected during ERCP and biliary cannulation was accomplished were included in the study. Patients were divided into 2 groups: the conservative treatment group (10 patients) and the FCSEMS group (10 patients). Groups were compared for clinical findings, results of serial white blood cell (WBC) counts, the length of hospital stay, the need for surgery, and death, retrospectively. RESULTS: Five patients in the conservative treatment group and none of the patients in the FCSEMS group had pain requiring narcotic and/or nonsteroidal anti-inflammatory analgesics during the follow-up period (P=0.005). On post-ERCP day 1, in the conservative and the FCSEMS groups, mean WBC counts were 13,218±4410×10 and 8714±3270×10, respectively (P=0.029). The perforation-related length of hospital stay was 15.77±5.21 days in the conservative group and 11.7±3.19 days in the FCSEMS group (P=0.053). Excluding the patient with severe pancreatitis in the conservative group, there were no deaths or need for surgery. CONCLUSIONS: Compared with conservative treatment alone, the addition of FCSEMS provides further benefits in terms of a painless course, lower WBC counts, and a short hospital stay. FCSEMS can be used as an additional treatment modality in type II perforation.

Biliary stenting in difficult common bile duct stones: a single tertiary center experience.

BACKGROUND/AIM: We aimed to examine the effect of plastic biliary stenting in the treatment of common bile duct (CBD) stones. MATERIALS AND METHODS: The data of 13,034 patients in our unit who had endoscopic retrograde cholangiopancreatography (ERCP) between 2008 and 2015 were scanned retrospectively. RESULTS: A biliary stent was placed in 61 of 74 patients. While the plastic biliary stent was placed in patients, the mean stone size after the 1st ERCP was 20 mm and the bile duct size was 13 mm. At the time of the 2nd ERCP conducted approximately 73.9 days later, the mean stone size was found to be 15 mm and the bile duct size was 12 mm. With recurrent ERCPs, the CBD stone was successfully removed in 53 patients but could not be removed in 8 patients. Among the 53 successful cases, 29 removals were successful in the 2nd ERCP session, 16 were successful in the 3rd session, 2 were successful in the 4th session, 1 was successful in the 5th session, 4 were successful in the 6th session, and 1 was successful in the 7th session. CONCLUSION: For CBD stones that cannot be removed by standard methods, temporary plastic stenting is an alternative method.

Is there a safer electrosurgical current for endoscopic sphincterotomy in patients with liver cirrhosis?

BACKGROUND: Endoscopic sphincterotomy has a higher risk of bleeding in patients with cirrhosis. Advanced Child stage and coagulopathy are well-known risk factors. We aimed to determine the role of electrosurgical currents in the development of endoscopic sphincterotomy bleeding in cirrhotic patients. METHODS: The study was a retrospective observational study and included 19,642 patients who underwent endoscopic retrograde cholangiopancreatography between 2004 and 2013. The incidence of endoscopic sphincterotomy bleeding in cirrhotic patients who underwent sphincterotomy after 2009 with an electrosurgical generator applying alternating current in the pulse cut mode (Group 2) was compared with a historical control group who underwent endoscopic sphincterotomy between 2004 and 2009 via blended current (Group 1). RESULTS: Group 1 included 15 patients (six women, nine men, mean age: 62.2 ± 12.9 years). Group 2 included 14 patients (six women, eight men, mean age: 63.6 ± 16.9 years). There was no statistically significant difference between the demographic and clinical characteristics of the two groups. Endoscopic sphincterotomy bleeding was observed in three patients in Group 1 (two endoscopic bleeding and one clinically significant bleeding) and none of the patients in Group 2 (p = 0.77). There were no cases of perforation or pancreatitis in both groups. One patient in Group 2 developed cholangitis. CONCLUSIONS: Endoscopic sphincterotomy bleeding is less frequently observed in patients with cirrhosis who underwent sphincterotomy with alternating mixed current in the pulse cut mode compared with those with blended current.

The Detection of Cholangiocarcinoma in Primary Sclerosing Cholangitis Patients: Single Center Experience.

PURPOSE: Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease. Cholangiocarcinoma (CCA) is one of the feared complications of PSC. In our study, we aim to establish the success of brush cytology and CA 19-9 in putting the diagnosis of CCA. METHODS: The data of 30 PSC patients was retrospectively screened whom had brush cytology performed due to dominant strictures. The definitive diagnosis was established by histopathological examination or via radiological/clinic follow-up for at least 12 months. RESULTS: A total of four patients were excluded from the study. Twenty-six patients diagnosed with PSC, six of which were also diagnosed with CCA, were included in the study. The sensitivity and the specificity of the brush cytology in the diagnosis of CCA in PSC patients were 66.7 and 95%, respectively. CA 19-9 had high correlation with bilirubin level. The optimal level of CA 19-9 in the diagnosis of CCA was determined to be 138.5 U/ml. Superiority of Ramage scoring over CA 19-9 in the diagnosis of CCA in PSC patients was not established (sensitivity and specificity were 50%, 94.7% and 83.3%, 85%, respectively). CONCLUSION: Brush cytology has moderate sensitivity in differentiating strictures in PSC patients. CA 19-9 has high sensitivity but bilirubin level can affect the CA 19-9. Therefore, advanced techniques and parameters are needed for detecting CCA in PSC patients.