Endoscopic treatment of esophagogastric and esophagojejunal anastomotic leaks: A single tertiary center experience

Anastomotic leakage in esophagogastric and esophagojejunal anastomoses after esophagectomy/gastrectomy is a severe complication with a high mortality rate. We aimed to evaluate the technical and clinical success and outcomes of endoscopic placement of fully covered self-expanding metallic stents (FCSEMSs) for treating anastomotic leaks that develop after cancer surgery. All consecutive patients treated at the Gastroenterology Department, Ankara City Hospital, Ankara, Turkey, who underwent endoscopic FCSEMSs for leaks of esophagogastric or esophagojejunal anastomosis between February 2015 and December 2021 were included in the study. We analyzed the data on leak characteristics, technical success, clinical success, stent-related complications, and mortality to investigate the clinical efficacy and safety of endoscopically implanted FCSEMSs. A total of 24 patients, 12 of whom were male were included in the study. The median age of the patients was 60 years (min-max: 38-84). Nineteen patients underwent esophagojejunal anastomosis, and 5 patients underwent esophagogastric anastomosis. The median stent follow-up time was 68.8 (26-190) days, and the median hospital stay was 62.7 (24-145) days. Complications related to stent placement were observed in of 50%. The most common complication was stent migration, occurring at a frequency of 37.5%. The median follow-up period time was 11.4 (2-37) months. While the clinical success rate was 87.5%, 3 patients died. Endoscopic placement of FCSEMSs is a relatively safe and beneficial treatment for esophagojejunal and esophagogastric anastomotic leaks.

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 Treatment of Stump Leakage Related to the Ileal Conduit

Background: Ileal conduit with leakage from either the anastomotic site or the stump is associated with high morbidity and mortality rates. The standard treatment of stump leakage is surgery.

Case Presentation: A 60-year-old male patient was admitted to our hospital with complaint of hematuria and bladder carcinoma was diagnosed. After performing radical cystectomy and ileal conduit, he developed fever with abdominal pain within the first week of surgery. Stump leakage was diagnosed by endoscopic examination performed through a gastroscope. After two over-the-scope clips (OTSCs) were applied to the stump, vinyl mesh was inserted into the space between the OTSCs. Later, cyanoacrylat and lipiodol were repelled on the OTSCs and vinyl mesh. Subsequently, stump leakage was resolved.

Conclusion: This is the first case of stump leakage related to ileal conduit that has been treated endoscopically, according to the current literature.

Can Serum ST2 Levels Be Used as a Marker of Fibrosis in Chronic Hepatitis B Infection?

Interleukin 33 (IL-33) is a cytokine belonging to the IL-1 superfamily. Soluble ST2 (sST2) binds to IL-33 and by functioning as trap receptor inhibits signal sending to Th2 via transmembrane ST2. Because Th2-type cytokines play an important role in fibrosis, the aim of this study is to determine whether sST2 can be used as a marker of fibrosis in chronic hepatitis B (CHB) patients or not.The study included 19 healthy controls, 54 patients with CHB, and 14 patients with cirrhosis because of CHB. The aspartate aminotransferase-to-platelet ratio index (APRI) and fibrosis index based on the 4 factors (FIB-4) scores also calculated, and correlations between liver biopsies, sST2 levels, and these scores were analyzed in CHB and cirrhosis patients.The sST2 levels in patients with CHB were significantly higher than those in the control group subjects (median: 1133 pg/mL vs 762.5 pg/mL, respectively [P = 0.035]). In CHB patients, the METAVIR fibrosis score (stages from 0 to 4) showed a moderate correlation with serum sST2 level (r = 0.396, P = 0.004) and a weak correlation with FIB-4 score (r = 0.359, P = 0.008), but no correlation with APRI score (r = 0.253, P = 0.06). The under the curve value of serum sST2 was 0.68, and its prediction of significant fibrosis (METAVIR score ≥2) in values >674 pg/mL had a sensitivity of 91.7% and specificity of 40% (P = 0.009). According to multiple logistic regression analysis, only METAVIR fibrosis stage was found to be an independent predictor of serum sST2 elevation in CHB patients (P = 0.04).The sST2 level can be used for differentiating significant fibrosis from mild fibrosis in CHB patients. However, the efficacy of this marker should be verified by larger studies in the future.

Endoscopic extraction of proximally migrated biliary stent by intrastent balloon inflation

Endoscopically placed bile duct stents are commonly used to relieve obstruction in patients with benign or malignant biliary disease. These stents may become dislodged and migrate in about 5-10% of patients. Distally migrated stents can be managed expectantly, allowing the foreign body to pass through the rectum. However, proximal migration of biliary stents usually necessitates endoscopic stent removal. We present a case of a proximally migrated stent that was extracted successfully with intrastent balloon inflation during endoscopic retrograde cholangiopancreatography (ERCP).

Interesting rendezvous location in a liver transplantation patient with anastomosis stricture

An endoscopic or radiologic percutaneous approach may be an initial minimally invasive method for treating biliary strictures after living donor liver transplantation; however, cannulation of biliary strictures is sometimes difficult due to the presence of a sharp or twisted angle within the stricture or a complete stricture. When an angulated or twisted biliary stricture interrupts passage of a guidewire over the stricture, it is difficult to replace the percutaneous biliary drainage catheter with inside stents by endoscopic retrograde cholangiopancreatography. The rendezvous technique can be used to overcome this difficulty. In addition to the classical rendezvous method, in cases with complete transection of the common bile duct a modified technique involving the insertion of a snare into the subhepatic space has been successfully performed. Herein, we report a modified rendezvous technique in the duodenal bulb as an extraordinary location for a patient with duct-to-duct anastomotic complete stricture after liver transplantation.

Systemic phaeohyphomycosis resembling primary sclerosing cholangitis caused by Exophiala dermatitidis

Exophiala dermatitidis, one of the saprophytic dematiaceous fungi, is a cause of local and disseminated phaeohyphomycosis. We report a case of systemic phaeohyphomycosis resembling sclerosing cholangitis caused by E. dermatitidis in a 24-year-old woman.

Rectal angiolipoma: A case report and review of literature

Angiolipoma is a rare vascular variant of the benign lipomatous tumors and is generally seen in subcutaneous tissues. We report a 70-year-old female with abdominal distension not related to rectal small polypoid mass with peduncule described as angiolipoma by histologically, and review the literature.

Effect of interferon and ribavirin combined with amantadine in interferon and ribavirin non-responder patients with chronic hepatitis C (genotype 1)

AIM: To evaluate the efficacy of amantadine plus interferon-alpha and ribavirin in non-responder patients with chronic hepatitis C.

METHODS: Twenty-six non-responder patients received the regimen of IFN-α-2a at a dose of 6 million units three times a week, 1000-1200 mg of ribavirin daily, and 200 mg of amantadine daily in divided doses over 48 wk. After the end of treatment, at the 72^nd wk, a sustained viral response rate was determined.

RESULTS: An early (after 12 wk of therapy) response was seen in 34.6% (9/26) of patients. Response rate at the 24^th wk was 42.3% (11/26). End of treatment response (ETR) was 53.8% (14/26). Sustained viral response (SVR) was 42.3% (11/26). There was a statistically significant difference between 0 and 12 wk (P = 0.04), 0 and 24 wk (P = 0.01), 0 and 48 wk (P = 0.00), and 0 and 72 wk (P = 0.001). No patient had severe adverse effects during the treatment.

CONCLUSION: Combination regimen of interferon-α, ribavirin and amantadine can enhance sustained viral response on IFN-α and ribavirin non-responder patients with HCV. Triple therapy with amantadine should be evaluated in further studies.