Biliary cast syndrome after liver transplantation: A cholangiographic evolution study.

BACKGROUND AND AIM: The aim of this study is to describe the cholangiographic features and endoscopic management of biliary cast syndrome (BCS), a rare specific ischemic cholangiopathy following liver transplantation. METHODS: Patients with biliary complications were identified from prospectively collected database records of patients who underwent liver transplantation at the Erasme Hospital from January 2005 to December 2014. After excluding patients with hepatico-jejunostomy or no suspicion of stricture, cholangiograms obtained during endoscopic retrograde cholangiopancreatography (ERCP) and magnetic resonance imaging were systematically reviewed. Biliary complications were categorized as anastomotic (AS) and non-AS strictures, and patients with BCS were identified. Clinical, radiological, and endoscopic data were reviewed. RESULTS: Out of 311 liver transplantations, 14 cases were identified with BCS (4.5%) and treated with ERCP. Intraductal hyperintense signal on T1-weighted magnetic resonance and a "duct-in-a-duct" image were the most frequent features of BCS on magnetic resonance imaging. On initial ERCP, 57% of patients had no stricture. Complete cast extraction was achieved in 12/14, and one of these had cast recurrence. On follow-up, 85% of the patients developed biliary strictures that were treated with multiple plastic stents reaching 60% complete stricture resolution, but 40% of them had recurrence. After a median follow-up of 58 months, BCS patients had lower overall and graft survival (42.9% and 42.9%) compared with non-AS (68.8% and 56.3%) and AS (83.3% and 80.6%), respectively. CONCLUSIONS: Particular magnetic resonance-cholangiographic and ERCP-cholangiographic features of BCS have been identified. Outcomes for BCS are characterized by high complete cast extraction rates, high incidence of secondary strictures, and poorer prognosis.

Prophylaxis of post-ERCP pancreatitis: a practice survey.

BACKGROUND: Prophylactic pancreatic stenting is widely used by expert biliary endoscopists to prevent post-ERCP pancreatitis (PEP); nonsteroidal anti-inflammatory drugs (NSAIDs) are thought to prevent PEP. OBJECTIVE: To assess the use of pancreatic stenting and NSAIDs for PEP prophylaxis among endoscopists and its determinants. DESIGN: A survey was distributed to 467 endoscopists attending a course on therapeutic digestive endoscopy. INTERVENTION: Completed surveys were collected from 141 endoscopists performing ERCP in 29 countries (answer rate 30.2%); practices were most often located in community hospitals with an annual hospital volume of < or = 500 ERCPs (in Belgium, Spain, Italy, and France in about half of cases). For all conditions listed, including needle-knife precut, previous PEP, suspected sphincter of Oddi dysfunction, and ampullectomy, less than half of the endoscopists reported attempting prophylactic pancreatic stenting in > or = 75% of cases. Thirty (21.3%) survey respondents did not perform prophylactic pancreatic stenting in any circumstance; this was mainly ascribed to lack of experience. Measurement of PEP incidence and an annual hospital volume of > 500 ERCPs were independently associated with the use of prophylactic pancreatic stenting (P = .005 and P = .030, respectively). Most survey respondents (n = 118, 83.7%) did not use NSAIDs for PEP prophylaxis. This was mainly ascribed to lack of scientific evidence of its benefits. MAIN OUTCOME MEASUREMENTS: Proportion of cases in which pancreatic stenting is attempted during ERCP; reasons for not using prophylactic pancreatic stenting or NSAIDs. LIMITATIONS: Survey, not an audit of practice. CONCLUSIONS: Despite scientific evidence of its benefits, use of prophylactic pancreatic stenting is not as widely adopted as previously thought; use of NSAIDs for PEP prophylaxis is marginal.

Endoscopic removal of dysfunctioning bands or rings after restrictive bariatric procedures.

BACKGROUND: Intragastric band migrations or dysfunctions are common long-term complications of both vertical banded gastroplasty (VBG) and laparoscopic adjustable gastric banding (Lap-Band) that classically require surgical treatment. OBJECTIVE: In this series, we describe the endoscopic removal of partially eroded Lap-Bands or Silastic rings and noneroded dysfunctioning rings after VBG. DESIGN: Case series. SETTING: A European, tertiary-care academic center. PATIENTS: This study involved 13 patients--3 with eroded Lap-Bands, 4 with eroded Silastic rings, and 6 with refractory outlet stoma stenosis after VBG. INTERVENTION: Endoscopic removal was performed within 1 or 2 sessions, according to the presence and extent of band erosion at presentation, including optional placement of a self-expandable plastic stent across the band, followed about 6 to 8 weeks later by extraction with transsection, if needed, by using a wire-cutting system. MAIN OUTCOME MEASUREMENTS: Technical success and safety. RESULTS: One failure was caused by huge adhesion formation around a Lap-Band on the lesser curvature of the stomach and the left liver lobe. Twelve of 13 endoscopic removals were successful in 1 (n = 2) and 2 (n = 10) sessions. LIMITATIONS: Highly selected patients (tertiary-case academic center). CONCLUSION: Endoscopic removal of dysfunctioning bands or rings is safe and feasible by the use of a 1- or 2-step endoscopic procedure.