Percutaneous Treatment of Biliary Strictures After Pediatric Liver Transplantation

Background

Biliary strictures (BS) are frequent after pediatric liver transplantation (LTx) and in spite of ongoing progress, they remain a significant cause of morbidity. In children, the majority of reconstruction is hepatico-jejunal anastomosis (HJA). The aim of this study was to analyze our experience in percutaneous transhepatic treatment of BS.

Material/Methods

Between 1998 and 2014, 589 (269 living donor) pediatric LTx were performed in our institution. We retrospectively reviewed clinical data of patients with HJA who developed BS and who underwent percutaneous transhepatic biliary drainage (PTBD).

Results

Out of 400 patients with HJA, 35 patients developed BS. There were 27 cases (77%) of anastomotic BS (ABS) and 8 cases (23%) of multilevel BS (MBS). Ninety-two PTBD sessions (2.5 per patient) were performed, with successful outcomes in 20 cases (57%). Fifteen patients, after failed PTBD, underwent surgery which was successful in 11 cases. Overall good outcomes were achieved in 31 cases (88.5%). The most common complication of PTBD was cholangitis which occurred in 5.4% of the cases. We did not find any risk factors for PTBD failure, except for treatment occurring before 2007.

Conclusions

Percutaneous treatment is effective and safe in BS and is recommended as a first-line approach. The majority of patients in our study required multiple interventions, however, the overall risk of complications was low. Surgery is essential in selected cases and always should be considered if PTBD fails.

Endoscopic treatment in biliary strictures after pediatric liver transplantation

BACKGROUND AND AIM

The aim of the study was to assess efficacy and safety of endoscopic treatment in BS after pediatric LTx.

METHODS

We retrospectively reviewed data of patients with DDA who developed BS and underwent ERCP.

RESULTS

Of 189 transplanted patients with DDA, strictures developed in 30 (16%). In this subgroup, the median age at LTx was 14.7 (1.5-17.6) and follow-up period was 3.9 (1.3-11.3). ABS were in 76% and NABS in combination with ABS in 24% of patients. Overall, 95 ERCP sessions (3.0 per patient) were performed with successful outcome in 22 (73%) cases. Duration of treatment was 9.1 (1.8-24.1) months. Five patients underwent surgical revision and three patients retransplantation (10%). Risk factors of endoscopy failure were HCV or HBV infection, prolonged CIT and treatment before 2007. The most common complications after ERCP were cholangitis (8.2%) and pancreatitis (4.2%). There were worse overall prognosis and higher risk of post-ERCP complications in NABS.

CONCLUSIONS

ERCP is safe and effective in the majority of patients with post-transplant duct-to-duct BS, and it is currently recommended as the first-line treatment.

Efficiency of pancreatic duct stenting therapy in children with chronic pancreatitis

BACKGROUND

Chronic pancreatitis (CP) is a rare disease in childhood. Although ERCP is commonly performed in children, the effect of pancreatic duct stenting therapy in children with CP is unknown.

OBJECTIVE

To investigate the efficacy of pancreatic duct stenting in children with CP.

DESIGN

Retrospective analysis.

SETTING

National referral center.

PATIENTS

A total of 208 children with CP hospitalized between 1988 and 2012.

INTERVENTIONS

ERCP with pancreatic duct stenting.

MAIN OUTCOME MEASUREMENTS

Results of endoscopic therapy and number of pancreatitis episodes per year before and after treatment.

RESULTS

A total of 223 pancreatic duct stenting procedures were performed in 72 children. The median number of stent replacements was 3 (range 1-21). A statistically significant decrease in the number of pancreatitis episodes per year was observed: from 1.75 to 0.23 after endoscopic treatment (P < .05). Pancreatic duct stenting was performed more frequently in patients with hereditary pancreatitis (61.5%) and in children with CP and anatomic anomalies of the pancreatic duct (65%; P < .05).

LIMITATIONS

Retrospective analysis with the assessment of adverse events based on medical history.

CONCLUSION

Pancreatic duct stenting therapy is a safe and effective procedure in children with CP. This therapy should be recommended especially for children with hereditary pancreatitis and patients with anatomic anomalies of the pancreatic duct.

Narrow‑band imaging and white‑light endoscopy for detection of colorectal polyps: a randomized study

INTRODUCTION

Narrow‑band imaging (NBI) is a new, promising technique that might be helpful in the detection of colorectal polyps during colonoscopy.

OBJECTIVES

The aim of the study was to compare the usefulness of NBI with white‑light endoscopy (WLE) for the detection of polyps as well as to determine the distribution of missed polyps.

PATIENTS AND METHODS

This was a randomized controlled trial. A total of 253 patients were included, in whom colonoscopy was performed twice: 126 patients underwent 2 procedures using white light, while in 127 patients NBI was used for the second procedure. The number and location of colorectal polyps identified during the second colonoscopy were recorded.

RESULTS

No significant differences were observed in the rates of detected polyps, adenomas, and hyperplastic polyps between the WLE and NBI groups (38 vs. 48, P <0.2051; 11 vs. 19, P < 0.12; 27 vs. 29, P <0.4647, respectively). A half of all missed adenomas (n = 15) were found in the cecum and the ascending colon.

CONCLUSIONS

WLE and NBI seem to be equally effective in identifying missed adenomas and hyperplastic polyps during colonoscopy. Repeated endoscopy of the cecum and ascending colon may significantly increase the number of detected adenomas.

Endoscopic submucosal dissection for the treatment of neoplastic lesions in the gastrointestinal tract

AIM: To investigate the indications, resection rate, and safety of endoscopic submucosal dissection (ESD) for neoplastic lesions in the gastrointestinal tract at a European referral center.

METHODS: We carried out a retrospective analysis of the ESD procedures performed in our center for mucosal neoplastic and submucosal lesions of the gastrointestinal tract. The duration of the procedure, en bloc and complete (R0) resection rates, and complication rates were evaluated. Variables were reported as mean ± SD or simple proportions. Univariate analysis and comparisons of procedure times and resection rates were performed using Mann-Whitney U tests, or χ² tests for dichotomous variables.

RESULTS: Between 2007 and 2011, ESD was performed in a total of 103 patients (46.7% male, mean age 64.0 ± 12.7 years). The indications for the procedure were epithelial tumor (n = 54), submucosal tumor (n = 42), or other (n = 7). The total en bloc resection rate was 90.3% (93/103) and R0 resection rate 80.6% (83/103). The median speed of the procedure was 15.0 min/cm². The complete resection rate was lower for submucosal tumors arising from the muscle layer (68%, 15/22, P < 0.05). Resection speed was quicker for submucosal tumors localized in the submucosal layer than for lesions arising from the muscularis propria layer (8.1 min/cm²vs 17.9 min/cm², P < 0.05). The R0 resection rate and speed were better in the last 24 mo (90.1%, 49/54 and 15.3 min/cm²) compared to the first 3 years of treatment (73.5%, 36/49, P < 0.05 and 22.0 min/cm², P < 0.05). Complications occurred in 14.6% (n = 15) of patients, including perforation in 5.8% (n = 6), pneumoperitoneum in 3.9% (n = 4), delayed bleeding in 1.9% (n = 2), and other in 2.9% (n = 3). Only one patient with delayed perforation required surgical treatment. During the mean follow-up of 26 ± 15.3 mo, among patients with R0 resection, recurrence occurred in one patient (1.2%).

CONCLUSION: ESD is an effective and safe method for resection of neoplastic lesions with low recurrence. Speed and the R0 resection rate increased after 50 procedures.

Endoscopic submucosal dissection for treatment of gastric subepithelial tumors (with video)

BACKGROUND

Endoscopic submucosal dissection (ESD) is a well-accepted method for removing superficial mucosal tumors; however, there is limited data on the use of this method for removing subepithelial tumors.

OBJECTIVE

To investigate the efficacy, safety, and outcome of ESD for gastric subepithelial tumors and determine factors related to treatment success.

DESIGN

Retrospective analysis of a prospectively maintained database.

SETTING

Single tertiary academic center.

PATIENTS AND INTERVENTIONS

From April 2007 to November 2010, 37 patients with gastric subepithelial tumors were treated with ESD.

MAIN OUTCOME MEASUREMENTS

Macroscopically and microscopically complete en block resection rate (R0), complication rate, and endosonographic features predictive of R0 resection.

RESULTS

The median tumor diameter was 25.0 mm, (range 10-60 mm, IQR 17-37). The overall rate of R0 resections was 81.1% (30/37, 95%CI: 61.8-90.2%), including 100% (15/15, 95%CI: 78.2-100.0%) of tumors from the submucosa and 68.2% (15/22, 95%CI: 45.1-86.1%) of tumors from the muscularis propria. Seventeen patients had a final diagnosis of gastrointestinal stromal tumor. The severe complication (perforation) rate was 5.4% (2/37, 95%CI: 0.0-9.5%). One patient required surgery; the other was treated conservatively. No recurrence was observed in patients with R0 resections at a median follow up of 21.0 months (IQR 11-35). Successful R0 resections were predicted by the observation of no, or only narrow, tumor connections with the underlying muscle layer during EUS (OR=35.0, 95%CI: 3.7-334.4, p=0.001).

LIMITATIONS

Single-center, retrospective analysis, short follow-up.

CONCLUSIONS

ESD is an effective and relatively safe method for removing gastric subepithelial tumors. Endoscopic ultrasonography findings can predict complete tumor resections.

Interventional radiological and endoscopical techniques in biliary tract obstruction

For years biliary tree was explored and treated exclusively by open surgery. These method, as a treatment of choice of obstructive jaundice, supported by intraoperative cholangiography or cholangioscopy is widely acceptable up to now despite questions of adequacy, technical problems in cancer patients, time needed either for procedure and postoperative care of patients. More than 50 years ago, first diagnostic (followed in a short time by therapeutical modalities) transhepatic opacification of bile ducts was reported. During next 20 years, to the era of endoscopy, such approach remained the most accurate diagnostic and interventional tool in this area. In 1968 first endoscopic opacification of bile duct was reported and 6 years after, first endoscopic sphincterotomy in patients with common bile duct stones was done in Germany and in Japan. In the late 70s first endoscopical nasobiliary drainage and endoscopical insertion of biliary stents was announced. Today noninvasive methods, like Magnetic Resonance Cholangiopancreatography, 3 D Ultrasound Scanning or Computed Tomography, replaced both techniques mentioned above in diagnostic field. However, therapeutical procedures and histological confirmation of the disease origin remains in hands of interventional radiologists and endoscopists. This brief description presents present and future techniques of less invasive therapeutical approach to the biliary tree.

[Pancreatic fistulas]

The aim of our study was retrospective analysis of causes and treatment results of pancreatic fistula. In years 1989-1996, 40 patients aged 14-74 years were treated for pancreatic fistula in the Department of Gastroenterologic Surgery of Medical University in Warsaw. The majority of patients (36 adults) were treated conservatively, with the use of parenteral nutrition, drainage and somatostatin (in case of 4 patients). The healing of pancreatic fistula occurred in 27 medically treated patients after 26 days of therapy (mean value), the remaining patients were treated surgically. The applied treatment was effective in 38 out of 40 cases, 2 patients died (5.0%) due to the complications not connected with pancreatic fistula. In our opinion, in early stages of treatment of pancreatic fistula the conservative therapy with the use of parenteral nutrition is the treatment of choice and elective surgery should be used in patients, in whom conservative treatment fails.