The Impact of Metabolic Factors and Lipid-Lowering Drugs on Common Bile Duct Stone Recurrence after Endoscopic Sphincterotomy with Following Cholecystectomy.

BACKGROUND: Recurrent common bile duct stone after endoscopic retrograde cholangiopancreatography is an undesirable problem, even when a following cholecystectomy is carried out. Important factors are the composition and properties of stones; the most significant etiology among these is the lipid level. While numerous studies have established the association between serum lipid levels and gallstones, no study has previously reported on recurrent common bile duct stones after endoscopic sphincterotomy with following cholecystectomy. MATERIALS AND METHODS: We retrospectively collected 2016 patients underwent endoscopic sphincterotomy from 1 January 2015 to 31 December 2017 in Linkou Chang Gung Memorial Hospital. Finally, 303 patients whose serum lipid levels had been checked following a cholecystectomy after ERCP were included for analysis. We evaluated if metabolic factors including body weight, BMI, HbA1C, serum lipid profile, and lipid-lowering drugs may impact the rate of common bile duct stone recurrence. Furthermore, we tried to find if there is any factor that may impact time to recurrence. RESULTS: A serum HDL level ≥ 40 (p = 0.000, OR = 0.207, 95% CI = 0.114-0.376) is a protective factor, and a total cholesterol level ≥ 200 (p = 0.004, OR = 4.558, 95% CI = 1.625-12.787) is a risk factor of recurrent common bile duct stones after endoscopic sphincterotomy with cholecystectomy. Lipid-lowering drugs, specifically statins, have been shown to reduce the risk of recurrence significantly (p = 0.003, OR = 0.297, 95% CI = 0.132-0.665). No factors were found to impact the time to recurrence in this study. CONCLUSIONS: The serum lipid level could influence the recurrence of common bile duct stones after endoscopic sphincterotomy followed by cholecystectomy, and it appears that statins can reduce the risk of recurrence.

Efficacy of Fully Covered Self-Expandable Metal Stents for Distal Biliary Obstruction Caused by Pancreatic Ductal Adenocarcinoma: Primary Metal Stent vs. Metal Stent following Plastic Stent.

Fully covered self-expandable metallic stents (FCSEMSs) are inserted in patients with unresectable pancreatic ductal adenocarcinoma (PDAC) to resolve malignant distal bile duct obstructions. Some patients receive FCSEMSs during primary endoscopic retrograde cholangiopancreatography (ERCP), and others receive FCSEMSs during a later session, after the placement of a plastic stent. We aimed to evaluate the efficacy of FCSEMSs for primary use or following plastic stent placement. A total of 159 patients with pancreatic adenocarcinoma (m:f, 102:57) who had achieved clinical success underwent ERCP with the placement of FCSEMSs for palliation of obstructive jaundice. One-hundred and three patients had received FCSEMSs in a first ERCP, and 56 had received FCSEMSs after prior plastic stenting. Twenty-two patients in the primary metal stent group and 18 in the prior plastic stent group had recurrent biliary obstruction (RBO). The RBO rates and self-expandable metal stent patency duration did not differ between the two groups. An FCSEMS longer than 6 cm was identified as a risk factor for RBO in patients with PDAC. Thus, choosing an appropriate FCSEMS length is an important factor in preventing FCSEMS dysfunction in patients with PDAC with malignant distal bile-duct obstruction.

Timing of endoscopic retrograde cholangiopancreatography in the treatment of acute cholangitis of different severity.

BACKGROUND: The optimal timing of endoscopic retrograde cholangiopancreatography (ERCP) in acute cholangitis (AC) is uncertain, especially in patients with AC of varying severity. AIM: To report whether the timing of ERCP is associated with outcomes in AC patients with different severities. METHODS: According to the 2018 Tokyo guidelines, 683 patients who met the definite diagnostic criteria for AC were retrospectively identified. The results were first compared between patients receiving ERCP ≤ 24 h and > 24 h and then between patients receiving ERCP ≤ 48 h and > 48 h. Subgroup analyses were performed in patients with grade I, II or III AC. The primary outcome was 30-d mortality. Secondary outcomes were intensive care unit (ICU) admission rate, length of hospital stay (LOHS) and 30-d readmission rate. RESULTS: Taking 24 h as the critical value, compared with ERCP > 24 h, malignant biliary obstruction as a cause of AC was significantly less common in the ERCP ≤ 24 h group (5.2% vs 11.5%). The proportion of cardiovascular dysfunction (11.2% vs 2.6%), respiratory dysfunction (14.2% vs 5.3%), and ICU admission (11.2% vs 4%) in the ERCP ≤ 24 h group was significantly higher, while the LOHS was significantly shorter (median, 6 d vs 7 d). Stratified by the severity of AC, higher ICU admission was only observed in grade III AC and shorter LOHS was only observed in grade I and II AC. There were no significant differences in 30-d mortality between groups, either in the overall population or in patients with grade I, II or III AC. With 48 h as the critical value, compared with ERCP > 48 h, the proportion of choledocholithiasis as the cause of AC was significantly higher in the ERCP ≤ 48 h group (81.5% vs 68.3%). The ERCP ≤ 48 h group had significantly lower 30-d mortality (0 vs 1.9%) and shorter LOHS (6 d vs 8 d). Stratified by AC severity, lower 30-d mortality (0 vs 6.1%) and higher ICU admission rates (22.2% vs 10.2%) were only observed in grade III AC, and shorter LOHS was only observed in grade I and II AC. In the multivariate analysis, cardiovascular dysfunction and time to ERCP were two independent factors associated with 30-d mortality. CONCLUSION: ERCP ≤ 48 h conferred a survival benefit in patients with grade III AC. Early ERCP shortened the LOHS in patients with grade I and II AC.

Predictive factors of needle-knife pre-cut papillotomy failure in patients with difficult biliary cannulation.

Predictors of needle-knife pre-cut papillotomy (NKP) failure for patients with difficult biliary cannulation has not been reported. Between 2004 and 2016, 390 patients with difficult biliary cannulation undergoing NKP were included in this single-center study. Following NKP, deep biliary cannulation failed in 95 patients (24.4%, NKP-failure group) and succeeded in 295 patients (75.6%, NKP-success group). Patient and technique factors were used to identify the predictors of initial NKP failure. Compared with the NKP-success group, periampullary diverticulum (28.4% vs. 18%, p = 0.028), surgically altered anatomy (13.7% vs. 7.1%, p = 0.049), number of cases performed by less experienced endoscopists, and bleeding during NKP (38.9% vs. 3.4%, p < 0.001), were significantly more frequent in the NKP-failure group. On multivariate analysis, surgically altered anatomy (OR 2.374, p = 0.045), endoscopists' experience (OR 3.593, p = 0.001), and bleeding during NKP (OR 21.18, p < 0.001) were significantly associated with initial failure of NKP. In conclusion, NKP is a highly technique-sensitive procedure, as endoscopists' experience, bleeding during NKP, and surgically altered anatomy were predictors of initial NKP failure.

Risk Factors of Duodenobiliary Reflux-Related Dysfunction of Covered Biliary Metal Stents after Treatment of Duodenal Stricture in Patients with Malignant Biliary and Duodenal Obstruction.

Duodenal obstruction is often accompanied with unresectable malignant distal biliary obstruction in patients who have undergone biliary self-expandable metal stent (SEMS) placement. Duodenobiliary reflux (DBR) is a major cause of recurrent biliary obstruction (RBO) after covered biliary SEMS placement. We analyzed the risk factors for DBR-related SEMS dysfunction following treatment for malignant duodenal obstruction. Sixty-one patients with covered SEMS who underwent treatment for duodenal obstruction were included. We excluded patients with tumor-related stent dysfunction (n = 6) or metal stent migration (n = 1). Fifty-four patients who underwent covered biliary SEMS placement followed by duodenal metal stenting or surgical gastrojejunostomy were included. Eleven patients had DBR-related biliary SEMS dysfunction after treatment of duodenal obstruction. There was no difference between the duodenal metal stenting group and the surgical gastrojejunostomy group. Duodenal obstruction below the papilla of Vater and a score of ≤2 on the Gastric Outlet Obstruction Scoring System after treatment for duodenal obstruction were associated with DBR-related covered biliary SEMS dysfunction. Thus, creating a reliable route for ensuring good oral intake and avoiding DBR in patients with duodenal obstruction below the papilla of Vater are both important factors in preventing DBR-related covered biliary SEMS dysfunction.

Simple and Reliable Method for Gastric Subepithelial Tumor Localization Using Endoscopic Tattooing before Totally Laparoscopic Resection.

BACKGROUND: Totally laparoscopic surgery for early gastric cancer and subepithelial tumors has been popularized worldwide, yet localization of early or small-sized tumors is a persistent challenge due to difficulty being identified with the lack of manual tactile sensation. Thus, accurate localization with tattooing before the surgery would help improve efficiency during surgery. There are multiple methods to localize tumors before laparoscopy, each with varying advantages and disadvantages. The use of endoscopic tattooing with dye has been carried out for several decades due to its safety, lower cost, and convenience. However, there is a lack of studies on endoscopic tattooing before totally laparoscopic resection. AIMS: To evaluate the effect of endoscopic tattooing with dye for gastric subepithelial tumors localization before laparoscopic resection and to evaluate the tattooing effect on different locations of tumors in stomach. METHOD: We retrospectively collected data of patients with gastric subepithelial tumors who underwent endoscopic tattooing before totally laparoscopic resection from 2017 to 2020 in a university affiliated medical center. All patients were analyzed for preoperative characteristics and then categorized into two groups based on tumor locations concerning the difficulty of laparoscopic surgery. The independent t test and Chi-square test were performed to compare perioperative outcome and complications between these two groups. RESULT: A total of 19 patients were included retrospectively at our center. The individuals were 5 male and 14 female patients with a mean age of 58.2 years old. Most patients had no symptoms, and the tumors were found incidentally in 12 patients (63%). All tumors were identified clearly during laparoscopic resection. The mean tumor size was 2.3 cm. The surgeries took an average of 111 min and a mean of 7 mL blood loss was found. All tumors had negative resection margins with no recurrence during follow-up. Gastrointestinal stromal tumor was the major pathologic diagnosis, found in 12 patients (63%), followed by the leiomyoma in 5 patients (26%). Only three patients had mild adverse effects after surgery and the symptoms were self-limited. Our analysis found no significant difference in preoperative patient characteristics and perioperative outcomes between patients with differing tumor locations. CONCLUSION: This study is the first and largest report on endoscopic tattooing with dye before laparoscopic resection of gastric subepithelial tumor resection. Our results emphasize that endoscopic tattooing with dye is a safe and reliable method for localizing subepithelial tumors in the stomach prior to totally laparoscopic resection, with no correlation to where the tumor is located.

Management of biliary diseases after the failure of initial needle knife precut sphincterotomy for biliary cannulation.

Endoscopic retrograde cholangiopancreatography is not always successful even with needle knife precut sphincterotomy (NKPS). How to manage these patients with initial NKPS failure has not been well studied. We report the outcomes of patients who received endoscopic and non-endoscopic rescue treatment after the initial NKPS failure. During the 15 years from 2004 to 2018, 87 patients with initial NKPS failure received interval endoscopic treatment (IET group, n = 43), percutaneous transhepatic biliary drainage (PTBD group, n = 25), or bile duct surgery (BDS group, n = 19) were retrospectively studied. Compared with the PTBD group, the prevalence of choledocholithiasis was higher (69.8% vs. 16.0%, p < 0.001), and malignant bile duct stricture were lower (20.9% vs. 76.0%, p < 0.001) in the IET group. Furthermore, the IET group had a significantly longer time interval between the first and second treatment procedures (4 days vs. 2 days, p = 0.001), a lower technique success rate (79.1% vs. 100%, p = 0.021), and a shorter length of hospital stay (7 days vs. 18 days, p < 0.001). Compared to the BDS group, the only significant finding was that the patients in the IET group were older. Although not statistically significant, the complication rate was lowest in the IET group (7.0%) while highest in the BDS group (15.8%). Complications in the IET group were also mild, as compared with the other two groups. In conclusion, IET should be considered after initial failed NKPS for deep biliary cannulation before contemplating more invasive treatment such as BDS. PTBD may be the alternative therapy for patients with malignant biliary obstruction.

Efficacy and Adverse Effects of Self-Expandable Metal Stent Placement for Malignant Duodenal Obstruction: The Papilla of Vater as a Landmark.

PURPOSE: Self-expandable metal stents are used for malignant duodenal obstruction. Outcomes between stents placed above and below the papilla of Vater differ, and no study has investigated these differences. We evaluated the efficacy and adverse events of stent placement in these two locations and reported our experience with self-expandable metal stent placement in patients. PATIENTS AND METHODS: We retrospectively analyzed the data of patients with unresectable metastatic cancers (n = 101), who underwent successful duodenal self-expandable metal stent placement between 2008 and 2018. Patients were divided into above and below the papilla of Vater groups. Patient demographics, technical and clinical outcomes, post-procedural morbidity, and stent patency were analyzed. RESULTS: Overall, 71 and 30 patients had intestinal obstruction above (including the papilla itself) and below the papilla of Vater and underwent successful stenting. Common bile duct obstruction was more common in the above-papilla group. Procedure time was similar between the groups, if an appropriate endoscope could facilitate stent placement in the below-papilla group. Both groups achieved symptomatic relief. Median stent patency duration was not significantly different between the groups; three patients had severe gastrointestinal bleeding due to postoperative vascular-enteric fistula. CONCLUSION: Self-expandable metal stents can effectively relieve symptoms of duodenal obstructions located above and below the papilla of Vater. Duodenoscopes could facilitate stent placement if the obstruction is located below the papilla of Vater; if gastrointestinal bleeding occurs postoperatively, the possibility of vascular-enteric fistula formation should be considered.

Predictors of re-bleeding after endoscopic hemostasis for delayed post-endoscopic sphincterotomy bleeding.

AIM: To predict the re-bleeding after endoscopic hemostasis for delayed post-endoscopic sphincterotomy (ES) bleeding. METHODS: Over a 15-year period, data from 161 patients with delayed post-ES bleeding were retrospectively collected from a single medical center. To identify risk factors for re-bleeding after initial successful endoscopic hemostasis, parameters before, during and after the procedure of endoscopic retrograde cholangiopancreatography were analyzed. These included age, gender, blood biochemistry, co-morbidities, endoscopic diagnosis, presence of peri-ampullary diverticulum, occurrence of immediate post-ES bleeding, use of needle knife precut sphincterotomy, severity of delayed bleeding, endoscopic features on delayed bleeding, and type of endoscopic therapy. RESULTS: A total of 35 patients (21.7%) had re-bleeding after initial successful endoscopic hemostasis for delayed post-ES bleeding. Univariate analysis revealed that malignant biliary stricture, serum bilirubin level of greater than 10 mg/dL, initial bleeding severity, and bleeding diathesis were significant predictors of re-bleeding. By multivariate analysis, serum bilirubin level of greater than 10 mg/dL and initial bleeding severity remained significant predictors. Re-bleeding was controlled by endoscopic therapy in a single (n = 23) or multiple (range, 2-7; n = 6) sessions in 29 of the 35 patients (82.9%). Four patients required transarterial embolization and one went for surgery. These five patients had severe bleeding when delayed post-ES bleeding occurred. One patient with decompensated liver cirrhosis died from re-bleeding. CONCLUSION: Re-bleeding occurs in approximately one-fifth of patients after initial successful endoscopic hemostasis for delayed post-ES bleeding. Severity of initial bleeding and serum bilirubin level of greater than 10 mg/dL are predictors of re-bleeding.

GALNT14 genotype effectively predicts the therapeutic response in unresectable hepatocellular carcinoma treated with transcatheter arterial chemoembolization.

AIM: Transcatheter arterial chemoembolization is currently the standard treatment in hepatocellular carcinoma patients with Barcelona Clinic Liver Cancer stage B. Genomic variants of GALNT14 were recently identified as effective predictors for chemotherapy responses in Barcelona Clinic Liver Cancer stage C patients. METHODS: We investigated the prognosis predictive value of GALNT14 genotypes in 327 hepatocelluar carcinoma patients treated by transcatheter arterial chemoembolization. RESULT: Cox proportional hazards model analysis showed that the genotype 'TT' was associated with shorter time-to-response (multivariate p < 0.001), time-to-complete-response (p = 0.004) and longer time-to-tumor progression (p < 0.001), compared with the genotype 'non-TT'. In patients with albumin <3.5 g/dl, genotype 'TT' was associated with longer overall survival (p = 0.027). Finally, genotype 'TT' correlated with higher cancer-to-noncancer ratios of GALNT14 protein levels, lower cancer-to-noncancer ratios of antiapoptotic cFLIP-S, and a clustered glycosylation pattern in the extracellular domain of death receptor 5. CONCLUSION: GALNT14 genotypes were significantly associated with clinical outcomes of transcatheter arterial chemoembolization. The differential status of extrinsic apoptotic signaling between cancerous and non-cancerous tissues might underlie the clinical association.

Double-balloon enteroscopy-assisted endoscopic retrograde cholangiography for Roux-en-Y reconstruction patients with papilla of Vater or bilioenteric anastomosis.

OBJECTIVE: Roux-en-Y reconstructions can be divided into intact papilla of Vater and bilioenteric anastomosis (BEA) with respect to endoscopic retrograde cholangiography (ERC). Double-balloon enteroscopy-assisted ERC (DBE-ERC) may produce different results between the two populations but lacks studies. MATERIAL AND METHODS: Forty-seven patients with Roux-en-Y anastomosis undergoing 73 procedures of DBE-ERC were enrolled between July 2007 and August 2013. There were 14 patients with intact papilla of Vater (group A) and 33 patients with BEA (group B). The effectiveness of DBE-ERC, including data of reaching the blind end, performance of ERC, results of endoscopic therapies, and follow-up were retrospectively analyzed and compared between the two groups. RESULTS: For reaching the blind end, the success rate was not different between the groups (85.7% vs. 81.8%, p = 0.7), but the mean procedure time was significantly shorter for group A (28 min vs. 52 min, p = 0.01). For ERC, the success rate was not different between the groups (91.7% vs. 96.3%, p = 0.53), but the mean procedure time was significantly longer for group A (28.4 min vs. 4 min, p < 0.001). All endoscopic therapies could be successfully performed in both groups. No group A patients and five (23.8%) group B patients developed recurrent biliary stricture/stones requiring interventions during a mean follow-up period of 26.1 months. CONCLUSIONS: DBE-ERC was effective for both populations with biliary disorders. Reaching the blind end was more difficult but ERC was easier for patients with BEA in terms of procedure time rather than success rates.

Residual common bile duct stones on direct peroral cholangioscopy using ultraslim endoscope.

AIM: To detect and manage residual common bile duct (CBD) stones using ultraslim endoscopic peroral cholangioscopy (POC) after a negative balloon-occluded cholangiography. METHODS: From March 2011 to December 2011, a cohort of 22 patients with CBD stones who underwent both endoscopic retrograde cholangiography (ERC) and direct POC were prospectively enrolled in this study. Those patients who were younger than 20 years of age, pregnant, critically ill, or unable to provide informed consent for direct POC, as well as those with concomitant gallbladder stones or CBD with diameters less than 10 mm were excluded. Direct POC using an ultraslim endoscope with an overtube balloon-assisted technique was carried out immediately after a negative balloon-occluded cholangiography was obtained. RESULTS: The ultraslim endoscope was able to be advanced to the hepatic hilum or the intrahepatic bile duct (IHD) in 8 patients (36.4%), to the extrahepatic bile duct where the hilum could be visualized in 10 patients (45.5%), and to the distal CBD where the hilum could not be visualized in 4 patients (18.2%). The procedure time of the diagnostic POC was 8.2 ± 2.9 min (range, 5-18 min). Residual CBD stones were found in 5 (22.7%) of the patients. There was one residual stone each in 3 of the patients, three in 1 patient, and more than five in 1 patient. The diameter of the residual stones ranged from 2-5 mm. In 2 of the patients, the residual stones were successfully extracted using either a retrieval balloon catheter (n = 1) or a basket catheter (n = 1) under direct endoscopic control. In the remaining 3 patients, the residual stones were removed using an irrigation and suction method under direct endoscopic visualization. There were no serious procedure-related complications, such as bleeding, pancreatitis, biliary tract infection, or perforation, in this study. CONCLUSION: Direct POC using an ultraslim endoscope appears to be a useful tool for both detecting and treating residual CBD stones after conventional ERC.

Comparison of Rockall and Blatchford scores to assess outcome of patients with bleeding peptic ulcers after endoscopic therapy.

BACKGROUND/AIMS: To determine the accuracy of Rockall and Blatchford scores for predicting outcome after endoscopic treatment in two groups of patients with bleeding peptic ulcers: those who initially presented with upper gastrointestinal (UGI) bleeding (Group A) and those who developed UGI bleeding during hospital treatment for another condition (Group B). METHODOLOGY: A total of 593 patients who had had endoscopic treatment for bleeding peptic ulcers from January 2009 to July 2010 were divided into Groups A and B. Endoscopic therapy including monotherapy (thermal therapy or hemoclipping) and combination therapy was applied. The Blatchford and complete Rockall scores for the two subgroups were calculated. Predictive statistics for the use of the two scoring systems were then compared for Groups A and B. RESULTS: Thirty-day re-bleeding and mortality rates increased with increased Rockall and Blatchford scores. Rockall scores were more accurate than the Blatchford scores for predicting mortality. However, neither the Rockall nor the Blatchford score could accurately predict recurrence of bleeding. When the results in Group B and Group A subgroups were compared, the average Rockall score for Group A was lower than that for Group B (5.6 vs. 6.3, p < 0.001). CONCLUSIONS: In high-risk patients with peptic ulcer bleeding, the Rockall score can better predict 30-day mortality than can the Blatchford score; this was particularly true for Group B patients.

Treatment of malignant gastric outlet obstruction with metallic stents: assessment of whether gastrointestinal position alters efficacy.

OBJECTIVES: Gastric outlet obstruction (GOO) is a late complication of advanced gastric, pancreatic, and duodenal cancer. Palliative treatment of the obstruction is the main aim of therapy for these patients. Self-expandable metal stents are used for treating GOO. From our experience, the placement of the stent across the pylorus is easier and makes the curve of stent better than when the stent is placed within the duodenal area. The purposes of this study were to assess the efficacy of stents placed in either the duodenal area or across the pyloric valve in relieving GOO symptoms and to evaluate whether the location of the stent affects treatment outcomes. MATERIALS AND METHODS: This was a retrospective single-site study of 44 patients with malignant GOO. Expanding metal stents were placed either across the pyloric valve (n = 22; group A) or in the duodenum area (n = 22; group B). Improvement in oral intake was monitored using the Gastric Outlet Obstruction Scoring System (GOOSS). The end of the study was death of the last enrolled patient or 6 months after enrollment of the last patient, or whatever came first. RESULTS: Stent implantation similarly improved the patients' tolerance for food intake from baseline for both groups A and B (median [interquartile range]; 2 [2-3] and 2 [2-3], respectively). Patients in group B who received adjunctive chemotherapy had greater improvement in GOOSS and survival than patients in group B who did not have chemotherapy or any group A patients (P < 0.05). Stent patency was not affected by stent position or chemotherapy. CONCLUSION: Palliative treatment of GOO with placement of an expandable metal stent improved the tolerability of food intake. The location of stent across the pyloric valve or within the duodenum did not affect the efficacy of the procedure or stent patency.

Poorly expandable common bile duct with stones on endoscopic retrograde cholangiography.

AIM: To describe characteristics of a poorly expandable (PE) common bile duct (CBD) with stones on endoscopic retrograde cholangiography. METHODS: A PE bile duct was characterized by a rigid and relatively narrowed distal CBD with retrograde dilatation of the non-PE segment. Between 2003 and 2006, endoscopic retrograde cholangiography (ERC) images and chart reviews of 1213 patients with newly diagnosed CBD stones were obtained from the computer database of Therapeutic Endoscopic Center in Chang Gung Memorial Hospital. Patients with characteristic PE bile duct on ERC were identified from the database. Data of the patients as well as the safety and technical success of therapeutic ERC were collected and analyzed retrospectively. RESULTS: A total of 30 patients with CBD stones and characteristic PE segments were enrolled in this study. The median patient age was 45 years (range, 20 to 92 years); 66.7% of the patients were men. The diameters of the widest non-PE CBD segment, the PE segment, and the largest stone were 14.3 ± 4.9 mm, 5.8 ± 1.6 mm, and 11.2 ± 4.7 mm, respectively. The length of the PE segment was 39.7 ± 15.4 mm (range, 12.3 mm to 70.9 mm). To remove the CBD stone(s) completely, mechanical lithotripsy was required in 25 (83.3%) patients even though the stone size was not as large as were the difficult stones that have been described in the literature. The stone size and stone/PE segment diameter ratio were associated with the need for lithotripsy. Post-ERC complications occurred in 4 cases: pancreatitis in 1, cholangitis in 2, and an impacted Dormia basket with cholangitis in 1. Two (6.7%) of the 28 patients developed recurrent CBD stones at follow-up (50 ± 14 mo) and were successfully managed with therapeutic ERC. CONCLUSION: Patients with a PE duct frequently require mechanical lithotripsy for stones extraction. To retrieve stones successfully and avoid complications, these patients should be identified during ERC.

Direct peroral cholangioscopy and pancreatoscopy for diagnosis of a pancreatobiliary fistula caused by an intraductal papillary mucinous neoplasm of the pancreas: a case report.

Here, we report a case of a pancreatobiliary (PB) fistula caused by an intraductal papillary mucinous neoplasm (IPMN) of the pancreas. The PB fistula was suspected after endoscopic retrograde cholangiopancreatography (ERCP) and diagnosed after direct visualization with a direct peroral cholangioscopy and pancreatoscopy by using an ultra-slim endoscope. No previous reports exist on the precise diagnosis of a PB fistula with direct peroral cholangioscopy and pancreatoscopy. In our case report, a 69-year-old man underwent an ERCP because of a pancreatic head mass and biliary tract obstruction. During ERCP, a fistula between the common bile duct (CBD) and main pancreatic duct (MPD) was suspected. After endoscopic sphincterotomy, we examined both the CBD and MPD with an ultra-slim videoendoscope (GIF-N260; Olympus Optical Co, Tokyo, Japan) under direct visualization and biopsy of the mass. The analysis of the biopsy specimen confirmed this mass to be an IPMN of the pancreas. When we examined the CBD, one fistula with copious mucin secretion was identified at the distal CBD. In conclusion, direct peroral cholangioscopy and pancreatoscopy using the ultra-slim endoscope is an efficient tool for diagnosis of PB fistula and pancreatic IPMN.

Endoscopic metal stents for the palliation of malignant upper gastroduodenal obstruction.

BACKGROUND/AIMS: Gastric outlet obstruction (GOO) is frequently caused by tumor. Recently, endoscopic implantation of self-expanding metallic stents (SEMS) has been introduced as an improved palliative treatment for GOO. This study aims to study the effect of SEMS placement on nutrient intake in patients with GOO and correlate different SEMS positions with postoperative clinical outcomes. METHODOLOGY: Fifty six non-operable patients with GOO were enrolled. Obstruction of the duodenum (n=23) or gastric outlet (n=33) were commonly found. Either Wallstent Enteral Stents, WallFlex Enteral Duodenal or partially covered Ultraflex esophageal stents were placed under endoscopic and fluoroscopic guidance. The Gastric Outlet Obstruction Score (GOOSS) was used as the main outcome measurement. RESULTS: The procedure was technically feasible in 100% of patients and gave satisfactory clinical results in 98.2% (55/56). The patients had a median survival time of 97.5 days (range 9-380). Median stent patency was 72 days with a range of 8 to 267 days. The average GOOSS, measuring oral intake, was significantly improved, regardless of obstruction site (p<0.05). We also found that the site of SEMS placement did not affect the clinical outcome. CONCLUSIONS: Palliation with SEMS is a safe and effective method for restoring gastric intake in patients with malignant GOO.

Achalasia combined with esophageal intramural hematoma: case report and literature review.

A 62-year-old male patient was admitted to our hospital due to severe chest pain, odynophagia, and hematemesis. Chest computed tomography showed an esophageal submucosal tumor. Esophagogastroduodenoscopy (EGD) revealed a longitudinal purplish bulging tumor of the esophagus. Endoscopic ultrasound (EUS) showed a mixed echoic tumor with partial liquefaction from the submucosal layer. The patient was diagnosed with esophageal intramural hematoma as well as achalasia by upper gastrointestinal endoscopy, esophagography and esophageal manometry. The patient was managed conservatively with intravenous nutrition, and oral feeding was discontinued. Follow-up EGD and EUS showed complete recovery of the esophageal wall, and finally, the patient underwent endoscopic dilatation for achalasia. The patient was symptom free at the time when we wrote this manuscript.

Double balloon endoscopy increases the ERCP success rate in patients with a history of Billroth II gastrectomy.

AIM: To evaluate the effect of double balloon endoscope (DBE) on the endoscopic retrograde cholangiopancreatography (ERCP) success rate in patients with a history of Billroth II (B II) gastrectomy. METHODS: From April 2006 to March 2007, 32 patients with a B II gastrectomy underwent 34 ERCP attempts. In all cases, the ERCP procedures were started using a duodenoscope. If intubation of the afferent loop or reaching the papilla failed, we changed to DBE for the ERCP procedure (DBE-ERCP). We assessed the success rate of afferent loop intubation, reaching the major papilla, selective cannulation, possibility of therapeutic approaches, procedure-related complications, and the overall success rate. RESULTS: Among the 32 patients with a history of B II gastrectomy, the duodenoscope was successfully passed up to the papilla in 22 patients (69%), and cannulation was successfully performed in 20 patients (63%). Six patients (2 with failure in afferent loop intubation and 4 with failure in reaching the papilla) underwent DBE-ERCP. The DBE reached the papilla in all the 6 patients (100%) and selective cannulation was successful in 5 patients (83%). Four patients (67%) who had common bile duct stones were successfully treated. One patient underwent diagnostic ERCP only and the other one, in whom selective cannulation failed, was diagnosed with papilla cancer proven by biopsy. There were no complications related to the DBE. The overall ERCP success rate increased to 88% (28/32). CONCLUSION: The overall ERCP success rate increases with DBE in patients with a previous B II gastrectomy.

Predictors of rebleeding and mortality in patients with high-risk bleeding peptic ulcers.

BACKGROUND AND AIM: Patients with bleeding ulcers can have recurrent bleeding and mortality after endoscopic therapy. Risk stratification is important in the management of the initial patient triage. The aim of this study is to identify the clinical and laboratory risk factors for recurrent bleeding and mortality. METHODS: A prospective study was conducted in 390 consecutive patients with bleeding peptic ulcers and high-risk endoscopic stigmata, e.g., active bleeding, a non-bleeding visible vessel, adherent blood clot, and hemorrhagic dot. We tested 13 available variables for association with recurrent bleeding and 15 were tested for association with mortality. A logistic regression model was used to identify individual correlates associated with these adverse outcomes. RESULTS: Bleeding recurred in 46 patients (11.8%) within 3 days and 21 patients (5.4%) had in-hospital mortality. In the full-factor analysis model, the incidence of recurrent bleeding was significantly higher in five of the 13 investigated variables and mortality was significantly higher in two of the 15 variables. In the final analysis model, significant risk factors for recurrent bleeding within 3 days, with adjusted odds ratios (OR), were in-hospital bleeding (OR 3.3), initial hemoglobin level<10 g/dl (OR 3.3) and ulcer>or=2 cm (OR 2.0). In-hospital bleeding was the only independent risk factor for mortality (OR 8.3). CONCLUSION: The study emphasizes the role of ulcer size, anemia and in-hospital bleeding as the determining high-risk predictors for adverse outcomes for bleeding peptic ulcers.