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Vedamurthy A, Krishnamoorthi R, Irani S, Kozarek R. Endoscopic Management of Benign Pancreaticobiliary Disorders. J Clin Med 2025; 14:494. [PMID: 39860499 PMCID: PMC11766296 DOI: 10.3390/jcm14020494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2024] [Revised: 01/09/2025] [Accepted: 01/09/2025] [Indexed: 01/27/2025] Open
Abstract
Endoscopic management of benign pancreaticobiliary disorders encompasses a range of procedures designed to address complications in gallstone disease, choledocholithiasis, and pancreatic disorders. Acute cholecystitis is typically treated with cholecystectomy or percutaneous drainage (PT-GBD), but for high-risk or future surgical candidates, alternative decompression methods, such as endoscopic transpapillary gallbladder drainage (ETP-GBD), and endoscopic ultrasound (EUS)-guided gallbladder drainage (EUS-GBD), are effective. PT-GBD is associated with significant discomfort as well as variable adverse event rates. EUS-GBD leverages lumen-apposing metal stents (LAMS) for direct access to the gallbladder, providing the ability to treat an inflamed GB internally. Choledocholithiasis is primarily managed with ERCP, utilizing techniques to include balloon extraction, mechanical lithotripsy, or advanced methods such as electrohydraulic or laser lithotripsy in cases of complex stones. Altered anatomy from bariatric procedures like Roux-en-Y gastric bypass may necessitate specialized approaches, including balloon-assisted ERCP or EUS-directed transgastric ERCP (EDGE). Post-operative complications, including bile leaks and strictures, are managed endoscopically using sphincterotomy and stenting. Post-liver transplant anastomotic and non-anastomotic strictures often require repeated stent placements or advanced techniques like magnetic compression anastomosis in refractory cases. In chronic pancreatitis (CP), endoscopic approaches aim to relieve pain and address structural complications like pancreatic duct (PD) strictures and calculi. ERCP with sphincterotomy and stenting, along with extracorporeal shock wave lithotripsy (ESWL), achieves effective ductal clearance for PD stones. When traditional approaches are insufficient, direct visualization with peroral pancreatoscopy-assisted lithotripsy is utilized. EUS-guided interventions, such as cystgastrostomy, pancreaticogastrostomy, and celiac plexus blockade, offer alternative therapeutic options for pain management and drainage of peripancreatic fluid collections. EUS plays a diagnostic and therapeutic role in CP, with procedures tailored for high-risk patients or those with complex anatomy. As techniques evolve, endoscopic management provides minimally invasive alternatives for patients with complex benign pancreaticobiliary conditions, offering high clinical success and fewer complications.
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Affiliation(s)
- Amar Vedamurthy
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason, Franciscan Health, Seattle, WA 98101, USA
| | - Rajesh Krishnamoorthi
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason, Franciscan Health, Seattle, WA 98101, USA
| | - Shayan Irani
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason, Franciscan Health, Seattle, WA 98101, USA
| | - Richard Kozarek
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason, Franciscan Health, Seattle, WA 98101, USA
- Center for Interventional Immunology, Benaroya Research Institute, Virginia Mason, Franciscan Health, 1100 9th Avenue, G-250B, Seattle, WA 98101, USA
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Azad MA, Patel R. Practical Guidance for Clinical Microbiology Laboratories: Microbiologic diagnosis of implant-associated infections. Clin Microbiol Rev 2024; 37:e0010423. [PMID: 38506553 PMCID: PMC11237642 DOI: 10.1128/cmr.00104-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024] Open
Abstract
SUMMARYImplant-associated infections (IAIs) pose serious threats to patients and can be associated with significant morbidity and mortality. These infections may be difficult to diagnose due, in part, to biofilm formation on device surfaces, and because even when microbes are found, their clinical significance may be unclear. Despite recent advances in laboratory testing, IAIs remain a diagnostic challenge. From a therapeutic standpoint, many IAIs currently require device removal and prolonged courses of antimicrobial therapy to effect a cure. Therefore, making an accurate diagnosis, defining both the presence of infection and the involved microorganisms, is paramount. The sensitivity of standard microbial culture for IAI diagnosis varies depending on the type of IAI, the specimen analyzed, and the culture technique(s) used. Although IAI-specific culture-based diagnostics have been described, the challenge of culture-negative IAIs remains. Given this, molecular assays, including both nucleic acid amplification tests and next-generation sequencing-based assays, have been used. In this review, an overview of these challenging infections is presented, as well as an approach to their diagnosis from a microbiologic perspective.
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Affiliation(s)
- Marisa Ann Azad
- Division of Infectious Diseases, Department of Medicine, The Ottawa Hospital, Ottawa, Canada
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - Robin Patel
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
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Rajendran J, Irrinki S, Gupta V, Singh V, Sinha SK, Lal A, Kurdia K, Das A, Yadav TD. Elastography for Evaluation of Regression in Liver Fibrosis After Surgical Biliary Drainage for Benign Biliary Strictures: A Practical Possibility? J Clin Gastroenterol 2024; 58:502-506. [PMID: 37725412 DOI: 10.1097/mcg.0000000000001895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 06/25/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Hepatic fibrosis and secondary biliary cirrhosis are consequences of long-standing benign biliary strictures. Evidence on the reversibility of fibrosis after the repair is incongruous. METHODOLOGY A prospective observational study on patients who underwent Roux-en-Y hepaticojejunostomy for benign biliary stricture. A liver biopsy was performed during repair and correlated with preoperative elastography. The improvement in liver functions and regression of fibrosis was compared with preoperative liver function tests and elastography. RESULTS A Total of 47 patients [mean age-38.9 y (Range: 21 to 66)] with iatrogenic benign biliary stricture were included. A strong female preponderance was noted. High strictures (type III and IV) comprised 72.7% of the study group. The median interval (injury to repair) was 7 months (2 to 72 mo). The median duration of jaundice was 3 months (1 to 20 mo). Both factors had a significant correlation with the stage of fibrosis ( P =0.001 and P =0.03, respectively). Liver biopsy revealed stage I, II, III, and IV fibrosis in 26 (55.3%), 11 (23.4%), 2 (4.3%), and 2(4.3%), respectively. The remaining 6 (12.8%) had no fibrosis. The severity of fibrosis had a good correlation with preoperative liver stiffness measurement-value on FibroScan. Significant improvement in liver function tests (bilirubin-3.55±3.48 vs. 0.59±0.52; Albumin-3.85±0.61 vs. 4.14±0.37; ALP-507.66±300.65 vs. 167±132.07; P value 0.00) and regression of fibrosis (liver stiffness measurement; 10.42±5.91 vs. 5.85±3.01, P value 0.00) was observed after repair of the strictures. CONCLUSION Improved biliary function and regression of liver fibrosis can be achieved with timely repair of benign biliary stricture and it is feasible to be evaluated using elastography.
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Affiliation(s)
| | | | | | | | | | | | | | - Ashim Das
- Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Pimpinelli M, Makar M, Kahaleh M. Endoscopic management of benign and malignant hilar stricture. Dig Endosc 2022; 35:443-452. [PMID: 36453003 DOI: 10.1111/den.14487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 11/28/2022] [Indexed: 12/03/2022]
Abstract
Management of hilar strictures pose a significant challenge for endoscopists. Several strategies have been demonstrated in the last decade beyond decompression, however, there remains controversy and minimal consensus in the literature. This review seeks to summarize the current literature and discuss emerging therapies, such as photodynamic therapy and radiofrequency ablation.
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Affiliation(s)
- Marcella Pimpinelli
- Department of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, USA
| | - Michael Makar
- Department of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, USA
| | - Michel Kahaleh
- Department of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, USA
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Muacevic A, Adler JR, Choi C, Verma S. Post-Endoscopic Retrograde Cholangiopancreatography (ERCP) Subcapsular Hepatic Hematoma. Cureus 2022; 14:e31691. [PMID: 36561579 PMCID: PMC9767655 DOI: 10.7759/cureus.31691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2022] [Indexed: 11/21/2022] Open
Abstract
Physicians need to recognize the potential complications of endoscopic retrograde cholangiopancreatography (ERCP), which are rare but can be serious. We describe a case of post-ERCP subcapsular hepatic hematoma (SHH). A 39-year-old man with a history of alcohol use, complicated by chronic pancreatitis and common bile duct (CBD) stricture, presented with right upper quadrant pain two weeks after the placement of a stent for CBD stricture. He was managed with pain control and antibiotics. SHH is a rare complication of ERCP. Hematomas can expand, resulting in significant anemia and liver function test (LFT) elevation, or can become infected. Patients with SHH must be carefully monitored in the post-ERCP setting.
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Iqbal U, Anwar H, Khan MA, Weissman S, Kothari ST, Kothari TH, Confer BD, Khara HS. Safety and Efficacy of Endoscopic Retrograde Cholangiopancreatography in Nonagenarians: A Systematic Review and Meta-Analysis. Dig Dis Sci 2022; 67:1352-1361. [PMID: 33770331 DOI: 10.1007/s10620-021-06950-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 03/08/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Recent advances in modern medicine have translated into increase in life expectancy in the USA and with that, a rise in the demand for invasive procedures in elderly patients. Endoscopic retrograde cholangiopancreatography (ERCP) is the procedure of choice for managing various benign and malignant pancreatobiliary conditions and can be associated with various adverse events. AIM We performed a systematic review and meta-analysis to evaluate outcomes of ERCP in nonagenarians. METHODS A comprehensive literature search was performed in Embase, MEDLINE, Web of Science, and Cochrane Review library until July 2020. Our primary outcomes were the rate of technical success and adverse events in nonagenarians. Secondary outcomes were comparison of technical success and adverse events compared with younger patients. RESULTS The initial search revealed 4933 studies, of which 24 studies with 5521 patients met our inclusion criteria. Pooled technical success rate of ERCP in nonagenarians was 92%, and pooled adverse event rate was 7.8%. There was no significant difference in technical success rate and overall rate of adverse events comparing ERCP outcomes in nonagenarians with a relatively younger population. The risk of post-ERCP bleeding was significantly higher in nonagenarians compared to younger patients with OR = 1.986 [1.113-3.544], I2 = 0. ERCP-related mortality was also significantly higher in nonagenarians compared to younger patients with OR = 4.720 [1.368-16.289], I2 = 0. CONCLUSION There was no significant difference in technical success rate and risk of adverse events related to ERCP in nonagenarians compared to younger patients. However, the risk of bleeding and procedure-related mortality was significantly higher.
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Affiliation(s)
- Umair Iqbal
- Division of Gastroenterology and Hepatology, Geisinger Medical Center, Danville, PA, 17822, USA.
| | - Hafsa Anwar
- Department of Internal Medicine, Capital Health Regional Medical Center, Trenton, NJ, 08638, USA
| | - Muhammad Ali Khan
- Division of Gastroenterology and Hepatology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Simcha Weissman
- Department of Internal Medicine, Hackensack Meridian Health, Palisades Medical Center, North Bergen, NJ, USA
| | - Shivangi T Kothari
- Department of Gastroenterology and Hepatology, University of Rochester Medical Center, Rochester, NY, USA
| | - Truptesh H Kothari
- Department of Gastroenterology and Hepatology, University of Rochester Medical Center, Rochester, NY, USA
| | - Bradley D Confer
- Division of Gastroenterology and Hepatology, Geisinger Medical Center, Danville, PA, 17822, USA
| | - Harshit S Khara
- Division of Gastroenterology and Hepatology, Geisinger Medical Center, Danville, PA, 17822, USA
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John ES, Tarnasky PR, Kedia P. Ablative therapies of the biliary tree. Transl Gastroenterol Hepatol 2021; 6:63. [PMID: 34805585 DOI: 10.21037/tgh.2020.02.03] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 01/23/2020] [Indexed: 01/04/2023] Open
Abstract
Cholangiocarcinoma, a malignancy of the epithelial cells in the intrahepatic or extrahepatic biliary tree, is often diagnosed at later stages. Median survival duration ranges from 3 to 9 months with a less than ten percent 5-year survival rate. Thus, often treatment strategies are aimed more towards palliation instead of cure. With the majority of patients presenting with unresectable disease at the time of diagnosis, surgical intervention is not feasible, making less invasive endoscopic therapies more suitable. Initially, biliary stents were utilized for biliary decompression to mitigate cholestatic symptoms and prevent cholangitis; however, this strategy did not prove to provide significant survival benefit. Therefore, efforts to treat the tumor burden itself in addition to maintaining biliary patency became a focus of innovation and research in the endoscopic field. This study has led to the advent of therapies such as photodynamic therapy, radiofrequency ablation, and intraluminal brachytherapy. These options combined with biliary stenting have shown to not only offer the benefit of biliary decompression, but also to potentially improve stent patency and survival. Further, there is an anti-tumor effect of each of these modalities, portending an additional benefit in this subset of patients. Despite numerous retrospective and prospective studies assessing these ablative therapies, there is still a paucity of appropriately powered randomized controlled trials, and further research has yet to be done in the field. This review details the current literature entailing endobiliary ablative strategies.
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Affiliation(s)
- Elizabeth S John
- Department of Gastroenterology, Methodist Dallas Medical Center, Dallas, TX, USA
| | - Paul R Tarnasky
- Department of Gastroenterology, Methodist Dallas Medical Center, Dallas, TX, USA
| | - Prashant Kedia
- Department of Gastroenterology, Methodist Dallas Medical Center, Dallas, TX, USA
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Wong M, Sánchez-Luna SA, Rustagi T. Endoscopic transpapillary gallbladder stenting to prevent acute cholecystitis in patients receiving FCEMS for benign biliary stricture. Endosc Int Open 2021; 9:E1386-E1390. [PMID: 34466363 PMCID: PMC8382500 DOI: 10.1055/a-1500-8028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 03/31/2021] [Indexed: 12/03/2022] Open
Abstract
Background and study aims Fully covered self-expanding metal stents (FCSEMS) are being increasingly used for benign biliary strictures (BBS); however, they are associated with risk of acute cholecystitis. Prophylactic endoscopic transpapillary gallbladder stenting (ETPGBS) can facilitate continuous gallbladder drainage and prevent acute cholecystitis from occlusion of cystic duct orifice by the FCSEMS. The aim of this study was to assess the technical feasibility, efficacy, and safety of ETPGBS to prevent acute cholecystitis in patients receiving FCSEMS for BBS. Patients and methods This was a retrospective analysis of a prospectively collected database at a single center of all patients who underwent prophylactic ETPGBS with FCSEMS for BBS between December 1, 2016 and November 30, 2020. Results A total of 71 ETPGBS were placed during the study period. Sixteen patients (mean age: 66.4 ± 19.8 years; 81 % male) underwent ETPGBS prior to biliary FCSEMS during the same endoscopic session. FCSEMS were left in place (stent dwell time) for a median of 173 days (range: 69-473; mean 196 ± 121) with resolution of BBS and successful removal of ETPGBS and FCSEMS in 12 patients. There was significant improvement in total bilirubin level (5.25 ± 5.53 vs 0.94 ± 0.85 gm/dL; P = 0.008). No episodes of acute cholecystitis or any other post-procedural complications were noted during the median follow-up of 337 days (range: 150-856; mean 394 ± 236). Conclusions ETPGBS prevented stent-related acute cholecystitis with continued efficacy of FCSEMS for BBS.
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Affiliation(s)
- Morgan Wong
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of New Mexico, New Mexico, United States
| | - Sergio A. Sánchez-Luna
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of New Mexico, New Mexico, United States
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of New Mexico, New Mexico, United States
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Osagiede O, Bolaños GA, Cochuyt J, Cruz LM, Kröner PT, Lukens FJ, Corral JE. Impact of supine versus prone position on endoscopic retrograde cholangiopancreatography performance: a retrospective study. Ann Gastroenterol 2021; 34:582-587. [PMID: 34276199 PMCID: PMC8276359 DOI: 10.20524/aog.2021.0609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 12/28/2020] [Indexed: 11/11/2022] Open
Abstract
Background Endoscopic retrograde cholangiopancreatography (ERCP) is frequently performed in the prone or supine position. We compared the technical success and other outcomes between these positions. Methods This was a retrospective cohort study using the Clinical Outcomes Research Initiative database. Demographics, procedure and fluoroscopy time, visualization of main structures, and technical success rates were compared between the supine and prone positions. Univariate and multivariate regressions were performed to adjust for age, sex, ethnicity and clinical setting. Results A total of 21,090 patients who underwent ERCP were included, of whom 1769 (8.4%) were supine and 19,321 (91.6%) were prone. The common bile duct (CBD) was visualized and cannulated in 89.1% of supine vs. 91.4% of prone positions (P=0.017), while the ampulla was visualized in 97.1% of supine vs. 97.7% of prone (P=0.414). The ERCP was incomplete in 10% of supine vs. 5% of prone cases (P<0.001). On multivariate analysis, supine position required shorter procedure times than prone (adjusted odds ratio [aOR] 0.98, 95% confidence interval [CI] 0.98-0.98; P<0.001). The supine position also yielded lower odds of CBD visualization and cannulation (aOR 0.63, 95%CI 0.44-0.91; P=0.011) and higher odds of an incomplete examination (aOR 1.84, 95%CI 1.46-2.30; P<0.001) vs. prone. Conclusions The supine position leads to shorter procedures but is more likely to result in poorer visualization and cannulation of the CBD and an incomplete examination. This may reflect the technical difficulty of performing ERCP in the supine position for the endoscopist. Our study supports recommendations for an individualized ERCP approach.
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Affiliation(s)
- Osayande Osagiede
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, New York (Osayande Osagiede)
| | - Gabriel A Bolaños
- Department of Medicine, University of South Alabama, Mobile, Alabama (Gabriel A. Bolaños)
| | - Jordan Cochuyt
- Department of Health Science Research, Mayo Clinic, Jacksonville, Florida (Jordan Cochuyt)
| | - Luisa M Cruz
- School of Medicine, Universidad Francisco Marroquín, Guatemala City, Guatemala (Luisa M. Cruz)
| | - Paul T Kröner
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida (Paul T. Kröner, Frank J. Lukens, Juan E. Corral), USA
| | - Frank J Lukens
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida (Paul T. Kröner, Frank J. Lukens, Juan E. Corral), USA
| | - Juan E Corral
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida (Paul T. Kröner, Frank J. Lukens, Juan E. Corral), USA
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Cantù P, Mauro A, Cassinotti E, Boni L, Vecchi M, Penagini R. Post-operative biliary strictures. Dig Liver Dis 2020; 52:1421-1427. [PMID: 32868211 DOI: 10.1016/j.dld.2020.07.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 07/14/2020] [Accepted: 07/23/2020] [Indexed: 12/11/2022]
Abstract
Post-operative biliary stricture is a cumbersome condition, secondary to biliary or vascular damage. Its risk factors include biliary or vascular anatomical variants, local inflammation, and poor surgical expertise. Intra-operative diagnosis is difficult, and in most cases, patients present with obstructive symptoms within a few weeks. Magnetic resonance cholangiography is a pivotal test to confirm the clinical picture, to study the level of the damage, and to guide treatment. Nowadays, endoscopic stenting is the first-line treatment in most centers. Multi-stenting treatment achieves long-term clinical success for more than 90% of patients, however multiple procedures are needed. In order to optimize healthcare provider costs, shorter duration endotherapies with covered metal stents are under evaluation. Radiological and surgical approaches are considered in the event of endoscopy failure.
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Affiliation(s)
- Paolo Cantù
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Via F. Sforza 35, 20122 Milan, Italy.
| | - Aurelio Mauro
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Via F. Sforza 35, 20122 Milan, Italy; Digestive Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, Viale Camillo Golgi 19, 27100 Pavia, Italy
| | - Elisa Cassinotti
- Department of Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Via F. Sforza 35, 20122 Milan, Italy
| | - Luigi Boni
- Department of Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Via F. Sforza 35, 20122 Milan, Italy
| | - Maurizio Vecchi
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Via F. Sforza 35, 20122 Milan, Italy
| | - Roberto Penagini
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Via F. Sforza 35, 20122 Milan, Italy
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Pivetta LGA, da Costa Ferreira CP, de Carvalho JPV, Konichi RYL, Kawamoto VKF, Assef JC, Ribeiro MA. Hepatic subcapsular hematoma post-ERCP: Case report and literature review. Int J Surg Case Rep 2020; 72:219-228. [PMID: 32544833 PMCID: PMC7298556 DOI: 10.1016/j.ijscr.2020.05.074] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 05/23/2020] [Accepted: 05/23/2020] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Endoscopic retrograde cholangiopancreatography (ERCP) is one of the most frequently performed minimally invasive procedures currently available for diagnosis and treatment of biliary and pancreatic diseases. Though considered a safe procedure, it has the highest rate of complications among the other endoscopic procedures, such as duodenal perforation and hepatic subcapsular hematoma (HSH). We are a presenting a case report and review of the current literature. METHOD We report one case HSH rupture, in a 25 years old female patient, 15 cm in diameter, affecting liver segments VI, VII and VIII, who underwent surgical treatment and performed a systematic literature review with the descriptors: endoscopic retrograde colangiopancreatography and hepatic subcapsular hematoma. All articles were reviewed and data on cases that presented rupture of the HSH analyzed separately. RESULTS Sixty one cases of HSH were described in the literature, fourteen of them ruptured. When analyzing only the subgroup of patients who had ruptured subcapsular hematoma, we showed a significant increase in the mortality rate of patients when compared to non-ruptured (21.4% × 2.2%). We also report that patients with rupture required some type of intervention, of which 78.6% required surgery. Conservative treatment may be the conduct and will suffice for most cases of non-ruptured hematomas. For patients who evolve with rupturing, surgical resolution, although non-mandatory, is necessary in most cases. CONCLUSION HSH ruptured is a rare and potentially fatal post-ERCP complication whose treatment is eminently surgical.
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Affiliation(s)
| | | | | | | | | | - Jose Cesar Assef
- Emergency Service of the Irmandade da Santa Casa de São Paulo (ISCMSP), São Paulo, SP, Brazil
| | - Mauricio Alves Ribeiro
- Emergency Service of the Irmandade da Santa Casa de São Paulo (ISCMSP), São Paulo, SP, Brazil
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Okuda N, Sugimoto S, Nakamura H, Hisada H, Temma T, Hashimoto Y, Hayashi S, Ito T, Takami M, Oyamada J, Kamei A. Is complete stone removal for choledocholithiasis always necessary in extremely elderly patients? JGH Open 2020; 4:16-21. [PMID: 32055692 PMCID: PMC7008169 DOI: 10.1002/jgh3.12198] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Accepted: 04/21/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIM Endoscopic stone removal has some complications. Although the life expectancy of elderly patients has increased dramatically worldwide, little information is available on the necessity of complete endoscopic stone removal in extremely elderly patients. This study aimed to evaluate the safety and efficacy of complete endoscopic stone removal in extremely elderly patients. METHODS All extremely elderly patients (>90 years) who underwent endoscopic stone removal for choledocholithiasis at our hospital between January 2012 and January 2017 were retrospectively evaluated. The included patients were divided into complete stone removal and incomplete stone removal groups. Complication rate, overall survival (OS), and disease-specific survival (DSS) rates were compared between the two groups. RESULTS Overall, 73 patients were included in this study. The median number of stones was one (range, 0-10) and two (range, 1-12) (P = 0.043), while the median diameter of the largest stones was 9 (range, 0-27) and 14 (range, 5-46) mm (P = 0.001) in the complete and incomplete stone removal groups, respectively. During the follow-up period, OS was 60% and 39% and DSS was 95% and 97% in the complete and incomplete stone removal groups, respectively. Kaplan-Meier analysis found no significant difference in OS and DSS between the two groups (P = 0.052 and P = 0.646, respectively). CONCLUSION Complete stone removal might not always be necessary in extremely elderly patients aged ≥90 years.
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Affiliation(s)
- Naoko Okuda
- Divisions of GastroenterologyIse Red Cross HospitalMieJapan
| | | | | | | | - Taishi Temma
- Divisions of GastroenterologyIse Red Cross HospitalMieJapan
| | - Yuki Hashimoto
- Divisions of GastroenterologyIse Red Cross HospitalMieJapan
| | | | - Tatsuya Ito
- Divisions of GastroenterologyIse Red Cross HospitalMieJapan
| | - Mayuko Takami
- Divisions of GastroenterologyIse Red Cross HospitalMieJapan
| | - Jun Oyamada
- Divisions of GastroenterologyIse Red Cross HospitalMieJapan
| | - Akira Kamei
- Divisions of GastroenterologyIse Red Cross HospitalMieJapan
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Laasch HU, Al-Islam S, Uberoi R. Percutaneous Intervention for Refractory Benign Biliary Strictures. ADVANCED ERCP FOR COMPLICATED AND REFRACTORY BILIARY AND PANCREATIC DISEASES 2020:49-67. [DOI: 10.1007/978-981-13-0608-2_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2025]
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14
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Yin S, Hong J, Sha T, Chen Z, Guo Y, Li C, Liu Y. Efficacy and Tolerability of Sufentanil, Dexmedetomidine, or Ketamine Added to Propofol-based Sedation for Gastrointestinal Endoscopy in Elderly Patients: A Prospective, Randomized, Controlled Trial. Clin Ther 2019; 41:1864-1877.e0. [PMID: 31345559 DOI: 10.1016/j.clinthera.2019.06.011] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 05/07/2019] [Accepted: 06/19/2019] [Indexed: 02/07/2023]
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15
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Larghi A, Rimbaș M, Tringali A, Boškoski I, Rizzatti G, Costamagna G. Endoscopic radiofrequency biliary ablation treatment: A comprehensive review. Dig Endosc 2019; 31:245-255. [PMID: 30444547 DOI: 10.1111/den.13298] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 11/12/2018] [Indexed: 02/08/2023]
Abstract
Radiofrequency ablation (RFA) functions by delivering thermal energy within tissue, the result of a high-frequency alternating current released from an active electrode, leading to coagulative necrosis and cellular death. Recently, a biliary catheter working on a guidewire has been developed and a number of studies have so far been carried out. The present article provides a comprehensive review of the literature on the results of the use of RFA for the clinical management of patients with unresectable malignant biliary strictures, benign biliary strictures, and residual adenomatous tissue in the bile duct after endoscopic papillectomy. Available data show that biliary RFA treatment is a promising adjuvant therapy in patients with unresectable malignant biliary obstruction. The procedure is safe, well tolerated and improves stent patency and survival, even though more studies are warranted. In patients with residual endobiliary adenomatous tissue after endoscopic papillectomy, a significant rate of neoplasia eradication after a single RFA session has been reported, thus favoring this treatment over surgical intervention. In these patients, as well as in those with benign biliary strictures, dedicated probes with a short electrode able to focus the RF current on the short stenosis are needed to expand RFA treatment for these indications.
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Affiliation(s)
- Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Mihai Rimbaș
- Gastroenterology Department, Colentina Clinical Hospital, Carol Davila University of Medicine, Bucharest, Romania
| | - Andrea Tringali
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Catholic University, Rome, Italy
| | - Ivo Boškoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Gianenrico Rizzatti
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Catholic University, Rome, Italy.,IHU-USIAS, University of Strasbourg, Strasbourg, France
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Wang CC, Tsai MC, Sung WW, Yang TW, Chen HY, Wang YT, Su CC, Tseng MH, Lin CC. Risk of cholangiocarcinoma in patients undergoing therapeutic endoscopic retrograde cholangiopancreatography or cholecystectomy: A population based study. World J Gastrointest Oncol 2019; 11:238-249. [PMID: 30918596 PMCID: PMC6425330 DOI: 10.4251/wjgo.v11.i3.238] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 01/16/2019] [Accepted: 01/29/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Cholangiocarcinoma is a highly lethal disease that had been underestimated in the past two decades. Many risk factors are well documented for in cholangiocarcinoma, but the impacts of advanced biliary interventions, like endoscopic sphincterotomy (ES), endoscopic papillary balloon dilatation (EPBD), and cholecystectomy, are inconsistent in the previous literature. AIM To clarify the risks of cholangiocarcinoma after ES/EPBD, cholecystectomy or no intervention for cholelithiasis using the National Health Insurance Research Database (NHIRD). METHODS From data of NHIRD 2004-2011 in Taiwan, we selected 7938 cholelithiasis cases as well as 23814 control group cases (matched by sex and age in a 1:3 ratio). We compared the previous risk factors of cholangiocarcinoma and cholangiocarcinoma rate in the cholelithiasis and control groups. The incidences of total and subsequent cholangiocarcinoma were calculated in ES/EPBD patients, cholecystectomy patients, cholelithiasis patients without intervention, and groups from the normal population. RESULTS In total, 537 cases underwent ES/EPBD, 1743 cases underwent cholecystectomy, and 5658 cholelithiasis cases had no intervention. Eleven (2.05%), 37 (0.65%), and 7 (0.40%) subsequent cholangiocarcinoma cases were diagnosed in the ES/EPBD, no intervention, and cholecystectomy groups, respectively, and the odds ratio for subsequent cholangiocarcinoma was 3.13 in the ES/EPBD group and 0.61 in the cholecystectomy group when compared with the no intervention group. CONCLUSION In conclusion, symptomatic cholelithiasis patients who undergo cholecystectomy can reduce the incidence of subsequent cholangiocarcinoma, while cholelithiasis patients who undergo ES/EPBD are at a great risk of subsequent cholangiocarcinoma according to our findings.
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Affiliation(s)
- Chi-Chih Wang
- Institute of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung 40201, Taiwan
| | - Ming-Chang Tsai
- Institute of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung 40201, Taiwan
| | - Wen-Wei Sung
- Institute of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan
- Department of Urology, Chung Shan Medical University Hospital, Taichung 40201, Taiwan
| | - Tzu-Wei Yang
- School of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung 40201, Taiwan
- Institute and Department of Biological Science and Technology, National Chiao Tung University, Hsinchu 30010, Taiwan
| | - Hsuan-Yi Chen
- School of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung 40201, Taiwan
| | - Yao-Tung Wang
- Institute of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan
- Division of Pulmonary Medicine, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung 40201, Taiwan
| | - Chang-Cheng Su
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung 40201, Taiwan
| | - Ming-Hseng Tseng
- Department of Medical Informatics, Chung Shan Medical University, Taichung 40201, Taiwan
- Information Technology Office, Chung Shan Medical University Hospital, Taichung 40201, Taiwan
| | - Chun-Che Lin
- Institute of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung 40201, Taiwan
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Tsai MC, Wang CC, Wang YT, Yang TW, Chen HY, Tseng MH, Lin CC. Major bleeding risk of endoscopic sphincterotomy versus endoscopic papillary balloon dilatation in hemodialysis patients. Saudi J Gastroenterol 2019; 25:106-112. [PMID: 30479319 PMCID: PMC6457181 DOI: 10.4103/sjg.sjg_246_18] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND/AIMS Endoscopic sphincterotomy (EST) and endoscopic papillary balloon dilatation (EPBD) are used for therapeutic endoscopic retrograde cholangiopancreatography (ERCP). The postprocedure bleeding rate for EPBD is low in the normal population; however, this bleeding rate in a group of patients prone to bleeding, such as patients with end-stage renal disease, is not well-established. We therefore evaluated the post-EST and post-EPBD bleeding rate among hemodialysis (HD) patients based on data from Taiwan's National Health Insurance Research Database (NHIRD). PATIENTS AND METHODS The NHIRD entries for a population of 2 million were screened for patients who had a catastrophic illness card for HD between 1st January 2004 and 31st December 2011 and these patients were enrolled as research subjects. The rates of major gastrointestinal tract bleeding events appearing within 14 days after EST or EPBD were compared between HD and non-HD patients. RESULTS A total of 3561 patients, over 18 years of age and without liver cirrhosis or hematologic diseases, underwent 3826 EST and 280 EPBD procedures during the 8 calendar years selected for our analysis. The total post-ERCP major bleeding rate was much higher in HD than in non-HD patients (8.64% vs. 2.16%, P < 0.0001). The rate of postprocedure major bleeding events was lower for non-HD patients who underwent EPBD than those who underwent EST (0.75% vs. 2.26%; P = 0.049), whereas the postprocedure major bleeding event rates were similar in HD patients who underwent either EPBD or EST (8.70% vs. 8.33%; P = 0.484). CONCLUSION Post-ERCP, post-EST, and post-EPBD major bleeding rates were all higher in HD patients in this study. EPBD resulted in lower postprocedure major bleeding events than EST in the non-HD population, but it failed to provide the reduction in bleeding events needed to perform endoscopic hemostasis in HD patients.
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Affiliation(s)
- Ming-Chang Tsai
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan,School of Medicine, Chung Shan Medical University, Taichung, Taiwan,Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Chi-Chih Wang
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan,School of Medicine, Chung Shan Medical University, Taichung, Taiwan,Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Yao-Tung Wang
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan,School of Medicine, Chung Shan Medical University, Taichung, Taiwan,Division of Pulmonary Medicine, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Tzu-Wei Yang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan,Department of Biological Science and Technology, Institute of Biological Science and Technology, National Chiao Tung University, Hsinchu, Taiwan
| | - Hsuan-Yi Chen
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan,Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Ming-Hseng Tseng
- Department of Medical Informatics, Chung Shan Medical University, Taichung, Taiwan,Information Technology Office, Chung Shan Medical University Hospital, Taichung, Taiwan,Address for correspondence: Prof. Chun-Che Lin, School of Medicine, Chung Shan Medical University, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chung Shan Medical University Hospital, No. 110, Sec. 1, Jianguo N. Rd., South Dist., Taichung City 402, Taiwan. E-mail: Prof. Ming-Hseng Tseng, Department of Medical Informatics, Chung Shan Medical University, Taichung, Taiwan. E-mail:
| | - Chun-Che Lin
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan,School of Medicine, Chung Shan Medical University, Taichung, Taiwan,Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan,Address for correspondence: Prof. Chun-Che Lin, School of Medicine, Chung Shan Medical University, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chung Shan Medical University Hospital, No. 110, Sec. 1, Jianguo N. Rd., South Dist., Taichung City 402, Taiwan. E-mail: Prof. Ming-Hseng Tseng, Department of Medical Informatics, Chung Shan Medical University, Taichung, Taiwan. E-mail:
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Park TY, Choi SH, Yang YJ, Shin SP, Bang CS, Suk KT, Baik GH, Kim DJ. The efficacy and safety of the left lateral position for endoscopic retrograde cholangiopancreatography. Saudi J Gastroenterol 2017; 23:296-302. [PMID: 28937025 PMCID: PMC5625367 DOI: 10.4103/sjg.sjg_121_17] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND/AIM Endoscopic retrograde cholangiopancreatography (ERCP) is typically performed in prone position. In cases of difficulty in prone position, ERCP can be performed in left lateral position. We aimed to evaluate the efficacy and safety of left lateral position for ERCP compared with those of prone position. PATIENTS AND METHODS Between August 2015 and March 2016, a total of 62 patients with native papilla who underwent ERCP were randomly assigned to undergo the procedure in left lateral position (n = 31) or prone position (n = 31). The outcomes of procedures were compared between the two groups. RESULTS There were no significant differences between the two groups in terms of the demographic data, indications for ERCP, comorbidities, anticoagulation agents, the types and doses of sedative agents, and procedural durations. The rates of technical success and adverse events were similar (96.8 and 40%, respectively, in left lateral group and 100 and 32.3%, respectively, in prone group). The rates of unintentional pancreatic duct (PD) cannulation and the acquisition of pancreatograms in left lateral group were significantly greater than those in prone group (9/30, 30.0% vs. 3/31, 9.7%, P = 0.046; 7/30, 23.3% vs. 1/31, 3.2%, P = 0.020, respectively). However, there was no significant difference in the rate of post-ERCP pancreatitis (6/30, 20% vs. 5/31, 16.1%, P = 0.694). CONCLUSION The left lateral position for ERCP can be as effective and safe as prone position. Due to increased rates of unintended PD cannulation and contrast injection, the initial use of left lateral position may be limited to cases that exhibit difficulty in prone position.
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Affiliation(s)
- Tae Young Park
- Department of Internal Medicine, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Gangwon-do, Korea
| | - Sang Hyeon Choi
- Department of Internal Medicine, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Gangwon-do, Korea
| | - Young Joo Yang
- Department of Internal Medicine, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Gangwon-do, Korea
| | - Suk Pyo Shin
- Department of Internal Medicine, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Gangwon-do, Korea
| | - Chang Seok Bang
- Department of Internal Medicine, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Gangwon-do, Korea
| | - Ki Tae Suk
- Department of Internal Medicine, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Gangwon-do, Korea
| | - Gwang Ho Baik
- Department of Internal Medicine, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Gangwon-do, Korea
| | - Dong Joon Kim
- Department of Internal Medicine, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Gangwon-do, Korea
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Hai R, Kuban J. Percutaneous intervention for bilioenteric anastomotic strictures: Current strategies and future directions. GASTROINTESTINAL INTERVENTION 2017. [DOI: 10.18528/gii160034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Rayhan Hai
- Department of Interventional Radiology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Joshua Kuban
- Department of Interventional Radiology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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20
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Wang CC, Tsai MC, Tseng MH, Yang TW, Wang YT, Lin CC. Major bleeding events after endoscopic sphincterotomy and endoscopic papillary balloon dilatation in cirrhotic patients: A nationwide population-based cohort study. ADVANCES IN DIGESTIVE MEDICINE 2017. [DOI: 10.1002/aid2.12026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Chi-Chih Wang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine; Chung Shan Medical University Hospital; Taichung Taiwan
- Institute of Medicine; Chung Shan Medical University; Taichung Taiwan
| | - Ming-Chang Tsai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine; Chung Shan Medical University Hospital; Taichung Taiwan
- Institute of Medicine; Chung Shan Medical University; Taichung Taiwan
| | - Ming-Hseng Tseng
- Information Technology Office; Chung Shan Medical University Hospital; Taichung Taiwan
- Department of Medical Informatics; Chung-Shan Medical University; Taichung Taiwan
| | - Tzu-Wei Yang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine; Chung Shan Medical University Hospital; Taichung Taiwan
| | - Yao-Tung Wang
- Department of Critical Care Medicine; Chung Shan Medical University Hospital; Taichung Taiwan
- School of Medicine; Chung Shan Medical University; Taichung Taiwan
| | - Chun-Che Lin
- Division of Gastroenterology and Hepatology, Department of Internal Medicine; Chung Shan Medical University Hospital; Taichung Taiwan
- School of Medicine; Chung Shan Medical University; Taichung Taiwan
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Kaino S, Sen-Yo M, Shinoda S, Kawano M, Harima H, Suenaga S, Sakaida I. Side-by-side placement of bilateral endoscopic metal stents for the treatment of postoperative biliary stricture. Clin J Gastroenterol 2016; 10:68-72. [PMID: 27744539 DOI: 10.1007/s12328-016-0694-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 10/06/2016] [Indexed: 12/15/2022]
Abstract
Postoperative biliary strictures are usually complications of cholecystectomy. Endoscopic plastic stent prosthesis is generally undertaken for treating benign biliary strictures. Recently, fully covered metal stents have been shown to be effective for treating benign distal biliary strictures. We present the case of a 53-year-old woman with liver injury in which imaging studies showed a common hepatic duct stricture. Endoscopic retrograde cholangiopancreatography also confirmed the presence of a common hepatic duct stricture. Temporally fully covered metal stents with dilated diameters of 6 mm were placed in a side-by-side fashion in the left and right hepatic ducts, respectively. We removed the stents 2 months after their placement. Subsequent cholangiography revealed an improvement in the biliary strictures. Although we were apprehensive about the fully covered metal stents obstructing the biliary side branches, we noted that careful placement of the bilateral metal stents did not cause any complications. Side-by-side deployment of bilateral endoscopic fully covered metal stents can be one of the safe and effective therapies for postoperative biliary stricture.
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Affiliation(s)
- Seiji Kaino
- Department of Gastroenterology and Hepatology, Yamaguchi University Graduate School of Medicine, 1-1-1, Minami Kogushi, Ube, Yamaguchi, 755-8505, Japan.
| | - Manabu Sen-Yo
- Department of Gastroenterology and Hepatology, Yamaguchi University Graduate School of Medicine, 1-1-1, Minami Kogushi, Ube, Yamaguchi, 755-8505, Japan
| | - Shuhei Shinoda
- Department of Gastroenterology and Hepatology, Yamaguchi University Graduate School of Medicine, 1-1-1, Minami Kogushi, Ube, Yamaguchi, 755-8505, Japan
| | - Michitaka Kawano
- Department of Gastroenterology and Hepatology, Yamaguchi University Graduate School of Medicine, 1-1-1, Minami Kogushi, Ube, Yamaguchi, 755-8505, Japan
| | - Hirofumi Harima
- Department of Gastroenterology and Hepatology, Yamaguchi University Graduate School of Medicine, 1-1-1, Minami Kogushi, Ube, Yamaguchi, 755-8505, Japan
| | - Shigeyuki Suenaga
- Department of Gastroenterology and Hepatology, Yamaguchi University Graduate School of Medicine, 1-1-1, Minami Kogushi, Ube, Yamaguchi, 755-8505, Japan
| | - Isao Sakaida
- Department of Gastroenterology and Hepatology, Yamaguchi University Graduate School of Medicine, 1-1-1, Minami Kogushi, Ube, Yamaguchi, 755-8505, Japan
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Finkelmeier F, Tal A, Ajouaou M, Filmann N, Zeuzem S, Waidmann O, Albert J. ERCP in elderly patients: increased risk of sedation adverse events but low frequency of post-ERCP pancreatitis. Gastrointest Endosc 2015; 82:1051-9. [PMID: 26089104 DOI: 10.1016/j.gie.2015.04.032] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 04/26/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The continually increasing life expectancy in man comes along with an increasing number of endoscopic interventions performed in patients with advanced or even very advanced age. Data on the feasibility and safety of ERCP in elderly patients are relatively scarce. METHODS By a systematic query of the University Hospital Frankfurt clinical database, patients undergoing their first ERCP procedure at our center were retrospectively identified. Patients were grouped according to age at the day of the intervention (>80 years, 61-80 years, 40-60 years, and <40 years). Demographic data, indication, outcome, and risk factors were compared among the indicated groups. RESULTS A total of 758 patients who underwent ERCP procedures at our center were identified and included in the study. Main indications for ERCP were intraductal gallstones in 345 patients (45%) and tumor obstruction of the bile ducts (distal common bile duct: n = 126 [16.5%], hilar cholangiocarcinoma: n = 89 [11.7%], tumor of papilla of Vater: n = 16 [2.1%]). Gallstones were the most common cause for ERCP in patients aged >80 years (53.8%), and normal findings indicating exclusion of relevant disease were more frequent in patients <80 years (13.4%) compared with older patients (4.3%) (P < .01). Sedation adverse events were significantly more common in individuals aged >80 years compared with younger patients (3.4% vs 0.5%; P < .01). However, post-ERCP pancreatitis was significantly less frequent in the older patients (>80 years) (0.9% vs 5.3%; P < .05). Other adverse events were equally distributed in all age groups. The ERCP success rate (>80%) was not different among age groups. CONCLUSIONS ERCP is safe and efficient in patients aged 80 years or older. However, conscious sedation must be carefully monitored in older patients because risk of sedation adverse events is increased. The incidence of post-ERCP pancreatitis is lower in older patients compared with younger ones.
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Affiliation(s)
- Fabian Finkelmeier
- Department of Medicine 1, J.W. Goethe University Hospital, Frankfurt, Germany
| | - Andrea Tal
- Department of Medicine 1, J.W. Goethe University Hospital, Frankfurt, Germany
| | - Mariam Ajouaou
- Department of Medicine 1, J.W. Goethe University Hospital, Frankfurt, Germany
| | - Natalie Filmann
- Institute of Biostatistics and Math Modeling, Faculty of Medicine, J.W. Goethe University, Frankfurt, Germany
| | - Stefan Zeuzem
- Department of Medicine 1, J.W. Goethe University Hospital, Frankfurt, Germany
| | - Oliver Waidmann
- Department of Medicine 1, J.W. Goethe University Hospital, Frankfurt, Germany
| | - Jörg Albert
- Department of Medicine 1, J.W. Goethe University Hospital, Frankfurt, Germany
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Abstract
The major causes of benign biliary strictures include surgery, chronic pancreatitis, primary sclerosing cholangitis, and autoimmune cholangitis. Biliary leaks mainly occur after surgery and, rarely, abdominal trauma. These conditions may benefit from a nonsurgical approach in which endoscopic retrograde cholangiopancreatography (ERCP) plays a pivotal role in association with other minimally invasive approaches. This approach should be evaluated for any injury before deciding about the method for repair. ERCP, associated with peroral cholangioscopy, plays a growing role in characterizing undeterminate strictures, avoiding both unuseful major surgeries and palliative options that might compromise any further management.
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Alkhateeb HM, Aljanabi TJ, Al-Azzawi KH, Alkarboly TA. Huge biloma after endoscopic retrograde cholangiopancreatography and endoscopic biliary sphincterotomy. Int J Surg Case Rep 2015; 16:7-11. [PMID: 26402876 PMCID: PMC4643346 DOI: 10.1016/j.ijscr.2015.08.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Accepted: 08/27/2015] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Biliary leak can occur as a complication of biliary surgery, endoscopic retrograde cholangiopancreatography manipulations and endoscopic biliary sphincterotomy. Consequently, bile may collect in the abdominal cavity, a condition called biloma. Rarely, it may reach a massive size. CASE PRESENTATION A 72-year-old man presented with gastric upset with gradual abdominal distension reaching a large size due to intra-abdominal bile collection (biloma) after endoscopic retrograde cholangiopancreatography plus endoscopic biliary sphincterotomy and stenting for post laparoscopic cholecystectomy common bile duct stricture. This huge biloma was treated by percutaneous insertion of a tube drain for a few days, evacuating the collection successfully without recurrence. DISCUSSION This patient might sustain injury to the common bile duct either by the guide wire or stent, or the injury occurred at the angle between the common bile duct and duodenum during sphincterotomy of the ampulla. Although any of these rents may lead to a bile leak, causing a huge biloma, they could be successfully treated by percutaneous drainage. CONCLUSIONS (1) Following endoscopic retrograde cholangiopancreatography, a patient's complaints should not be ignored. (2) A massive biloma can occur due to such procedures. (3) Conservative treatment with minimal invasive technique can prove to be effective.
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Affiliation(s)
| | | | | | - Taha A Alkarboly
- Kurdistan Center for Gastroenterology and Hepatology, Assulaymaniah, Kurdistan, Iraq.
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Singh RR, Singh V. Endoscopic management of hilar biliary strictures. World J Gastrointest Endosc 2015; 7:806-13. [PMID: 26191345 PMCID: PMC4501971 DOI: 10.4253/wjge.v7.i8.806] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 03/26/2015] [Accepted: 04/10/2015] [Indexed: 02/05/2023] Open
Abstract
Hilar biliary strictures are caused by various benign and malignant conditions. It is difficult to differentiate benign and malignant strictures. Postcholecystectomy benign biliary strictures are frequently encountered. Endoscopic management of these strictures is challenging. An endoscopic method has been advocated that involves placement of increasing number of stents at regular intervals to resolve the stricture. Malignant hilar strictures are mostly unresectable at the time of diagnosis and only palliation is possible.Endoscopic palliation is preferred over surgery or radiological intervention. Magnetic resonance cholangiopancreaticography is quite important in the management of these strictures. Metal stents are superior to plastic stents. The opinion is divided over the issue of unilateral or bilateral stenting.Minimal contrast or no contrast technique has been advocated during endoscopic retrograde cholangiopancreatography of these patients. The role of intraluminal brachytherapy, intraductal ablation devices, photodynamic therapy, and endoscopic ultrasound still remains to be defined.
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Lee S, Han JH, Lee HS, Kim KB, Lee IK, Cha EJ, Shin YD, Park N, Park SM. Efficacy and safety of a patient-positioning device (EZ-FIX) for endoscopic retrograde cholangiopancreatography. World J Gastroenterol 2015; 21:5995-6000. [PMID: 26019465 PMCID: PMC4438035 DOI: 10.3748/wjg.v21.i19.5995] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 01/15/2015] [Accepted: 02/11/2015] [Indexed: 02/06/2023] Open
Abstract
AIM To assess the efficacy and safety of a patient-positioning device (EZ-FIX) for endoscopic retrograde cholangiopancreatography (ERCP). METHODS A total of 105 patients were randomized to the EZ-FIX (n = 53) or non-EZ-FIX (n = 52) group in this prospective study. Midazolam and propofol, titrated to provide an adequate level of sedation during therapeutic ERCP, were administered by trained registered nurses under endoscopist supervision. Primary outcome measures were the total dose of propofol and sedative-related complications, including hypoxia and hypotension. Secondary outcome measures were recovery time and sedation satisfaction of the endoscopist, nurses, and patients. RESULTS There was no significant difference in the rate of hypoxia, but there was a statistical trend (EX-FIX group; n = 4, 7.55%, control group; n = 6, 11.53%, P = 0.06). The mean total dose of propofol was lower in the EZ-FIX group than in the non-EZ-FIX group (89.43 ± 49.8 mg vs 112.4 ± 53.8 mg, P = 0.025). In addition, the EZ-FIX group had a shorter mean recovery time (11.23 ± 4.61 mg vs 14.96 ± 5.12 mg, P < 0.001). Sedation satisfaction of the endoscopist and nurses was higher in the EX-FIX group than in the non-EZ-FIX group. Technical success rates of the procedure were 96.23% and 96.15%, respectively (P = 0.856). Procedure-related complications did not differ by group (11.32% vs 13.46%, respectively, P = 0.735). CONCLUSION Using EZ-FIX reduced the total dose of propofol and the recovery time, and increased the satisfaction of the endoscopist and nurses.
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Chathadi KV, Chandrasekhara V, Acosta RD, Decker GA, Early DS, Eloubeidi MA, Evans JA, Faulx AL, Fanelli RD, Fisher DA, Foley K, Fonkalsrud L, Hwang JH, Jue TL, Khashab MA, Lightdale JR, Muthusamy VR, Pasha SF, Saltzman JR, Sharaf R, Shaukat A, Shergill AK, Wang A, Cash BD, DeWitt JM. The role of ERCP in benign diseases of the biliary tract. Gastrointest Endosc 2015; 81:795-803. [PMID: 25665931 DOI: 10.1016/j.gie.2014.11.019] [Citation(s) in RCA: 96] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 11/17/2014] [Indexed: 12/29/2022]
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Singla S, Piraka C. Endoscopic retrograde cholangiopancreatography. Clin Liver Dis (Hoboken) 2015; 4:133-137. [PMID: 30992940 PMCID: PMC6448759 DOI: 10.1002/cld.441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Sumit Singla
- Division of GastroenterologyHenry Ford Health SystemDetroitMI
| | - Cyrus Piraka
- Section of Advanced Therapeutic Endoscopy, Division of GastroenterologyHenry Ford Health SystemDetroitMI
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Koh HR, Park CH, Chung MW, Park SY, Hong YJ, Jeong MH, Kim HS, Choi SK, Rew JS. Endoscopic retrograde cholangiopancreatography in patients with previous acute coronary syndrome. Gut Liver 2014; 8:674-9. [PMID: 25368756 PMCID: PMC4215456 DOI: 10.5009/gnl13301] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2013] [Revised: 11/11/2013] [Accepted: 01/09/2014] [Indexed: 12/19/2022] Open
Abstract
Background/Aims Endoscopic retrograde cholangiopancreatography (ERCP) is considered a high-risk procedure in patients with previous acute coronary syndrome (ACS); however, clinical studies are rare in the literature. The aim of this study was to investigate the safety and efficacy of ERCP in patients with previous ACS. Methods We retrospectively reviewed the medical records of patients with previous ACS who underwent ERCP between January 2007 and August 2012. The clinical characteristics, ERCP diagnoses, treatment results, and complications were analyzed. Results Fifty patients underwent ERCP an average of 41.6 months after ACS. The most common indication for ERCP was calculous cholangitis. After deep biliary cannulation, endoscopic sphincterotomy, biliary stone removal and endoscopic biliary drainage were successfully performed. Immediate postsphincterotomy bleeding occurred in seven patients, which was successfully controlled using endoscopic therapy. Elevation of cardiac troponin I levels were observed in three patients (6%) before ERCP, and all of these patients were diagnosed with pancreatobiliary disease combined with recurrent ACS, which was treated with coronary artery stent insertion (n=2) and balloon angioplasty (n=1). Conclusions Therapeutic ERCP is effective and safe in patients with previous ACS. Cardiac troponin I elevation should be considered a warning sign for recurrent ACS in patients who undergo ERCP.
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Affiliation(s)
- Han-Ra Koh
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Chang-Hwan Park
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Min-Woo Chung
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Seon-Young Park
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Young-Joon Hong
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Myung-Ho Jeong
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Hyun-Soo Kim
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Sung-Kyu Choi
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Jong-Sun Rew
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
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Abstract
Laparoscopic cholecystectomy has become the procedure of choice for management of symptomatic cholelithiasis. Although it has distinct advantages over open cholecystectomy, bile leak is more common. Endoscopic retrograde cholangiopancreatography is the diagnostic and therapeutic modality of choice for management of postcholecystectomy bile leaks and has a high success rate with the placement of plastic biliary stents. Repeat endoscopic retrograde cholangiopancreatography with placement of multiple plastic stents, a covered metal stent, or possibly cyanoacrylate therapy may be effective in refractory cases. This review will discuss the indications, efficacy, and complications of endoscopic therapy.
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Sugawara G, Ebata T, Yokoyama Y, Igami T, Mizuno T, Nagino M. Management strategy for biliary stricture following laparoscopic cholecystectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2014; 21:889-95. [PMID: 25159686 DOI: 10.1002/jhbp.151] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Biliary strictures following laparoscopic cholecystectomy (Lap-C), which are often associated with vascular injuries, remain a serious problem to manage. The aim of this study was to review our experiences with postoperative biliary stricture. METHODS This study involved 14 consecutive patients with biliary strictures that resulted from bile duct injuries during Lap-C between 1997 and 2013. Their medical records were retrospectively analyzed. RESULTS Percutaneous transhepatic biliary drainage (PTBD) catheter dilatation was first attempted in eight patients, and five patients were successfully treated. Biliary re-stricture recurred in one patient after 34-month follow-up period. This patient underwent repeated catheter dilatations, which led to recurrent stricture resolution. All five patients maintained biliary tract patency over 72-month follow-up period. The remaining nine patients underwent surgical procedures, including hepaticojejunostomy in two patients, re-hepaticojejunostomy in two patients, and the remaining five patients, with biliary strictures involving the secondary biliary branch and concomitant vascular injuries underwent right hemihepatectomy with cholangiojejunostomy. There were no major postoperative complications. After 80-month follow-up period, all nine patients were alive without biliary stricture. CONCLUSIONS PTBD catheter dilatation is recommended first for postoperative Lap-C-associated biliary strictures. In complicated injury patients with vascular injuries, right hemihepatectomy with cholangiojejunostomy should be indicated.
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Affiliation(s)
- Gen Sugawara
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
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Results of endoscopic treatment for the management of stenotic end-to-side hepaticoduodenostomy. Surg Laparosc Endosc Percutan Tech 2014; 24:502-5. [PMID: 24710249 DOI: 10.1097/sle.0b013e3182937bb2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE The outcome of endoscopic treatment for the management of surgical end-to-side hepaticoduodenostomy (HD) has not been extensively studied. The aim of this study was to evaluate the results of endoscopic management of HD. METHODS The medical records of 17 patients with HD stenosis who were referred to the ERCP unit between August 2003 and June 2012 for endoscopic intervention were retrospectively analyzed. RESULTS Fourteen patients presented with cholangitis, of whom, jaundice was the presenting complaint in 3 patients. Eight patients (47.1%) who had stents placed for a median of 2 (min, 1; max, 3) ERCP periods remained asymptomatic for a median stent-free period of 19.5 months (min, 7; max, 96 mo). Five patients (29.4%) who had stents placed for a median of 2 (min, 1; max, 5) ERCP periods presented with an episode of stone-related cholangitis for a mean of 41.8±28.9 months after stent removal. These 5 patients remained asymptomatic for a median of 9.5 months (min, 5; max, 40 mo) after endoscopic stone extraction. Three patients with HD (17.6%) were followed up with stents for 4 to 19 ERC periods. One HD patient (5.9%) who had cholangitis associated with secondary biliary cirrhosis died of cholangitis-related complications, despite the treatment with stents for 4 ERC periods. CONCLUSION Endoscopic management is also a realistic treatment option for stenotic HD anastomosis, although success rates may vary.
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Day LW, Lin L, Somsouk M. Adverse events in older patients undergoing ERCP: a systematic review and meta-analysis. Endosc Int Open 2014; 2:E28-36. [PMID: 26134610 PMCID: PMC4423280 DOI: 10.1055/s-0034-1365281] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Accepted: 01/20/2014] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Biliary and pancreatic diseases are common in the elderly; however, few studies have addressed the occurrence of adverse events in elderly patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). Our objective was to determine the incidence rates of specific adverse events in this group and calculate incidence rate ratios (IRRs) for selected comparison groups. PATIENTS AND METHODS Bibliographical searches were conducted in Medline, EMBASE, and Cochrane library databases. The studies included documented the incidence of adverse events (perforation, pancreatitis, bleeding, cholangitis, cardiopulmonary adverse events, mortality) in patients aged ≥ 65 who underwent ERCP. Pooled incidence rates were calculated for each reported adverse event and IRRs were determined for available comparison groups. A parallel analysis was performed in patients aged ≥ 80 and ≥ 90. RESULTS Our literature search yielded 7429 articles, of which 69 studies met our inclusion criteria. Pooled incidence rates for adverse events (per 1000 ERCPs) in patients aged ≥ 65 were as follows: perforation 3.8 (95 %CI 1.8 - 7.0), pancreatitis 13.1 (95 %CI 11.0 - 15.5), bleeding 7.7 (95 %CI 5.7 - 10.1), cholangitis 16.1 (95 %CI 11.7 - 21.7), cardiopulmonary events 3.7 (95 %CI 1.5 - 7.6), and death 7.1 (95 %CI 5.2 - 9.4). Patients ≥ 65 had lower rates of pancreatitis (IRR 0.3, 95 %CI 0.3 - 0.4) compared with younger patients. Octogenarians had higher rates of death (IRR 2.4, 95 %CI 1.3 - 4.5) compared with younger patients, whereas nonagenarians had increased rates of bleeding (IRR 2.4, 95 %CI 1.1 - 5.2), cardiopulmonary events (IRR 3.7, 95 %CI 1.0 - 13.9), and death (IRR 3.8, 95 %CI 1.0 - 14.4). Conclusions ERCP appears to be safe in elderly patients, except in the very elderly who are at higher risk of some adverse events. These data on adverse event rates can help to inform clinical decision-making, the consent process, and comparative effectiveness analyses.
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Affiliation(s)
- Lukejohn W. Day
- Division of Gastroenterology, San Francisco General Hospital and Trauma Center, San Francisco, California, United States
- GI Health Outcomes, Policy and Economics (HOPE) Research Program, Department of Medicine, University of California, San Francisco, California, United States
| | - Lisa Lin
- Department of Medicine, Mount Sinai School of Medicine, New York, New York, United States
| | - Ma Somsouk
- Division of Gastroenterology, San Francisco General Hospital and Trauma Center, San Francisco, California, United States
- GI Health Outcomes, Policy and Economics (HOPE) Research Program, Department of Medicine, University of California, San Francisco, California, United States
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Cholecystectomy-related aberrant bile duct injuries and their endoscopic treatment. Surg Laparosc Endosc Percutan Tech 2014; 23:e119-23. [PMID: 23752019 DOI: 10.1097/sle.0b013e3182751e6c] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Both complete transection and accidental ligation of the main bile duct because of a cholecystectomy are the injuries that are not amenable to endoscopic treatment and require an additional surgery. Leaks resulting from the severance of an aberrant bile duct may be treated endoscopically, although such injuries are difficult to be identified, thus resulting in treatment delays. Presented here are the details and follow-up results of 7 cases of patients with postcholecystectomy aberrant bile duct injuries, which were treated by endoscopic treatment.
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Pidigue RS, Chinnusamy P, Jategaonkar PA, Ramakrishnan P, Subbiah R, Palanisamy S, Natesan AVS, Palanivelu PR. Laparoendoscopic approach for refractory Roux-en-Y hepaticojejunostomy stricture in an acute setting: a unique case and technique. Asian J Endosc Surg 2014; 7:67-70. [PMID: 24450348 DOI: 10.1111/ases.12065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Revised: 08/28/2013] [Accepted: 08/29/2013] [Indexed: 12/22/2022]
Abstract
Roux-en-Y hepaticojejunostomy stricture is a substantial problem that develops in 10%-30% of patients and requires frequent intervention. Although endoscopic/percutaneous approaches are preferred, especially for refractory stricture, open surgical reconstruction remains the gold standard. However, such an operation may be highly challenging. The recently developed covered, self-expanding metallic stent is a useful option for such difficult cases. We present a case of recurrent Roux-en-Y hepaticojejunostomy stricture complicated by densely packed intrahepatic stones and suppurative cholangitis with failed percutaneous biliary draining. Enteroscopic manipulations were unfeasible, and the case was successfully managed by the laparoendoscopic approach. If treating surgeons have the necessary expertise, this technique may be considered in such difficult scenarios.
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Affiliation(s)
- Rajan Seshiyer Pidigue
- Department of Surgical Gastroenterology, GEM Hospital and Postgraduate Institute, Coimbatore, India
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Luo ZL, Cheng L, Ren JD, Tang LJ, Wang T, Tian FZ. Progressive balloon dilatation following hepaticojejunostomy improves outcome of bile duct stricture after iatrogenic biliary injury. BMC Gastroenterol 2013; 13:70. [PMID: 23607418 PMCID: PMC3637808 DOI: 10.1186/1471-230x-13-70] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2012] [Accepted: 04/17/2013] [Indexed: 01/20/2023] Open
Abstract
Background Iatrogenic biliary stricture (IBS) is a disastrous complication of cholecystectomy. Although the endoscopic treatments are well accepted as initial attempts for IBS, surgical hepaticojejunostomy (HJ) is often necessary for a considerable proportion of patients. However, the anastomotic stricture after HJ also occurs. Methods In the present study, a new procedure, progressive balloon dilation following HJ (HJPBD), was designed and utilized in the IBS treatment. We retrospectively compared HJPBD with the traditional HJ in term of the outcomes when used for IBS treatment. Results Between January 1997 and December 2009, 112 patients with IBS attributed to cholecystectomy enrolled in our hospital were treated with surgical reconstruction with either HJ (n=58) or HJPBD (n=54). Of the 58 patients in HJ group, 48 patients (82.8%) had a successful outcome, while 52 out of 54 patients (96.3%) in HJPBD group achieved success. The successful surgical reconstruction rates were significantly different between these two groups, with a further improved outcome in patient undergone progressive balloon dilation following HJ. Additionally, 8 of the 10 failure cases in HJ group were successfully rescued by HJPBD procedure. Conclusions Our findings suggest that the new procedure of HJPBD could be successfully applied to IBS patients, and significantly improve the outcome of IBS reconstruction.
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Affiliation(s)
- Zhu-lin Luo
- Department of General Surgery, General Hospital of Chengdu Military Command, Chengdu, Sichuan Province, People's Republic of China
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Shimada H, Endo I, Shimada K, Matsuyama R, Kobayashi N, Kubota K. The current diagnosis and treatment of benign biliary stricture. Surg Today 2012; 42:1143-53. [DOI: 10.1007/s00595-012-0333-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2010] [Accepted: 05/12/2011] [Indexed: 02/07/2023]
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Donatelli G, Mutter D, Dhumane P, Callari C, Marescaux J. Transhepatic metallic stenting for hepaticojejunostomy stricture following laparoscopic cholecystectomy biliary injury: A case of successful 20 years follow-up. J Minim Access Surg 2012; 8:99-101. [PMID: 22837599 PMCID: PMC3401726 DOI: 10.4103/0972-9941.97599] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2011] [Accepted: 06/30/2011] [Indexed: 11/05/2022] Open
Abstract
Laparoscopic cholecystectomy is still associated with a considerable rate of biliary injuries and related strictures. Advances in interventional endoscopy and percutaneous techniques have made stenting a preferred treatment modality for the management of these strictures. We report successful 20 years of follow-up of a case of trans-hepatic metallic stenting (2 Gianturco(®) prostheses, 5 cm long, 2 cm in diameter) done for stenosed hepatico-jejunostomy anastomosis after laparoscopic CBD injury. Percutaneous transhepatic stenting and long-term placement of metallic stents need to be re-evaluated as a minimally invasive definitive treatment option for benign biliary strictures in patients with altered anatomy such as hepatico-jejunostomy or in whom re-operation involves high risk.
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Affiliation(s)
- Gianfranco Donatelli
- Department of Gastrointestinal and Endocrinal Surgery, IRCAD/EITS, University of Strasbourg, Strasbourg, France
| | - Didier Mutter
- Department of Gastrointestinal and Endocrinal Surgery, IRCAD/EITS, University of Strasbourg, Strasbourg, France
| | - Parag Dhumane
- Department of Gastrointestinal and Endocrinal Surgery, IRCAD/EITS, University of Strasbourg, Strasbourg, France
| | - Cosimo Callari
- Department of Gastrointestinal and Endocrinal Surgery, IRCAD/EITS, University of Strasbourg, Strasbourg, France
| | - Jacques Marescaux
- Department of Gastrointestinal and Endocrinal Surgery, IRCAD/EITS, University of Strasbourg, Strasbourg, France
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Anderson MA, Fisher L, Jain R, Evans JA, Appalaneni V, Ben-Menachem T, Cash BD, Decker GA, Early DS, Fanelli RD, Fisher DA, Fukami N, Hwang JH, Ikenberry SO, Jue TL, Khan KM, Krinsky ML, Malpas PM, Maple JT, Sharaf RN, Shergill AK, Dominitz JA. Complications of ERCP. Gastrointest Endosc 2012; 75:467-73. [PMID: 22341094 DOI: 10.1016/j.gie.2011.07.010] [Citation(s) in RCA: 298] [Impact Index Per Article: 22.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2011] [Accepted: 07/11/2011] [Indexed: 12/11/2022]
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Ito K, Ito H, Kemeny NE, Gonen M, Allen PJ, Paty PB, Fong Y, Dematteo RP, Blumgart LH, Jarnagin WR, D'Angelica MI. Biliary sclerosis after hepatic arterial infusion pump chemotherapy for patients with colorectal cancer liver metastasis: incidence, clinical features, and risk factors. Ann Surg Oncol 2011; 19:1609-17. [PMID: 21989666 DOI: 10.1245/s10434-011-2102-8] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2011] [Indexed: 01/22/2023]
Abstract
BACKGROUND Hepatic arterial infusion pump chemotherapy (HAIPC) contributes to the prolonged survival of selected patients with colorectal cancer liver metastases (CRCLM). The most clinically important adverse event after HAIPC with floxuridine (FUDR) is biliary sclerosis (BS). Little is known about the etiology of BS. METHODS HAIPC was administered to 475 consecutive patients who received HAIPC on prospective protocols from 1991 to 2008. The incidence, clinical features, variables related to demographics, comorbidity, medical history, CRCLM, surgery, chemotherapy, and laboratory data were reviewed. An analysis of factors potentially associated with BS, defined as a biliary stricture related to HAIPC requiring stent placement, was performed. RESULTS The incidence of BS was 5.5% (16 of 293) in patients receiving HAIPC as an adjuvant therapy after hepatectomy, and 2% (2 of 100) in patients receiving HAIPC with FUDR for unresectable disease. The common hepatic duct was the site most frequently affected (87.5%). In patients receiving adjuvant HAIPC, BS was associated with abnormal postoperative flow scans (18.8% vs. 1.8%, P = 0.006), postoperative infectious complications (50.0% vs. 14.8%, P = 0.002), and larger dose/cycle/weight of FUDR (2.6 vs. 2.0 mg/cycle/kg, P = 0.025) than patients without BS. No patient died directly of BS. Median survival was not compromised by the development of BS (BS vs. non-BS: 61.0 months [range 6.2-171.6 months] vs. 47.2 months [range 2.4-200.8 months], P = 0.316, respectively). CONCLUSIONS BS is an uncommon complication after HAIPC and does not compromise survival if adequately salvaged by stenting or dilatation. Surgical complications as well as type and dose of intra-arterial chemotherapy may contribute to the development of BS.
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Affiliation(s)
- Kaori Ito
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
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Abstract
Benign biliary diseases include benign biliary strictures (BBS), choledocholithiasis, and leaks. BBS encompass postoperative injury, anastomotic stricture, chronic pancreatitis, primary sclerosing cholangitis, and gallstone-related stricture. Therapeutic options for benign biliary diseases include surgical, percutaneous, and endoscopic interventions. Endoscopic options include placement of plastic stents as well as self-expanding metal stents (SEMS). SEMS can be uncovered, partially covered, and fully covered, and have been used with some success in resolution of strictures and leaks; however, complications limit their use. This article reviews the currently published experience on SEMS and attempts to define their current role in the treatment of benign biliary diseases.
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Abstract
OBJECTIVE The aim of this study was to evaluate the safety and efficacy of endoscopic treatment for biliary fistulas after complex liver resection. BACKGROUND The role of endoscopy in the treatment of fistulas of the common bile duct is well documented. On the contrary, results of endoscopic procedures for fistulas arising from peripheral bile ducts after liver resections are poorly studied, although more complex hepatectomies are increasingly performed. We analyzed retrospectively the results of these procedures in our experience. PATIENTS Twenty-six patients aged 10 to 74 years were included. Fistulas arose after extended right hepatectomy, n = 14; extended left hepatectomy, n = 2; segmentectomy, n = 7; and split-liver transplantation, n = 3. All patients underwent radiologic or surgical external drainage before endoscopic retrograde cholangiopancreatography (ERCP). Mean bile outflow before endoscopy was 493.1 ± 386.1 mL/24 h (median, 400; range, 100-2000 mL). The mean time from surgery to diagnosis was 29.4 ± 45.5 days. RESULTS The ERCP was performed after a median of 13 days after the diagnosis of biliary fistula. A sphincterotomy was required in 96.1% of patients. A 5F to 10F polyethylene stent bypassing the leaking bile duct was implanted in 21 (80.7%) of 26 patients. Fistulas were dried up completely in 25 (96.1%) of 26 patients. The mean time from initial ERCP to running dry of the leaks was 17.5 ± 12.4 days. Procedure-related morbidity was 0%. There was no mortality. CONCLUSION Biliary fistulas arising from intrahepatic ducts after complex liver resections are more difficult to treat than distal fistulas arising from the common bile duct. However, despite a longer time for cure and the need for repeated ERCP, endoscopic therapy appears efficient and does not induce additional morbidity.
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Coelho-Prabhu N, Baron TH. Assessment of need for repeat ERCP during biliary stent removal after clinical resolution of postcholecystectomy bile leak. Am J Gastroenterol 2010; 105:100-5. [PMID: 19773748 DOI: 10.1038/ajg.2009.546] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES In patients who have undergone endoscopic retrograde cholangiopancreatography (ERCP) with biliary stent placement for postcholecystectomy bile leak there is limited evidence to support the repeat ERCP at the time of stent removal. Esophagogastroduodenoscopy (EGD) with biliary stent removal may suffice. The aim of this study was to describe the clinical course of patients who underwent biliary stent placement for a postcholecystectomy bile leak and determine whether repeat ERCP is necessary. METHODS We identified all adult patients who underwent biliary stent placement for postcholecystectomy bile leak from 1 January 1996 to 31 October 2008. Demographic data, cholecystectomy details, and procedural data were collected, specifically focusing on closure of the bile leak. Time to resolution of leak was calculated, up to either the date of the first repeat ERCP that demonstrated no persistent leak or the date of removal of any radiologically placed percutaneous drain, whichever came first. RESULTS Sixty-four patients underwent repeat ERCP with biliary stent removal. The median time to repeat ERCP was 36 days (interquartile range (IQR) 26-48). Fifty-seven (89%) patients had resolved the leak by time of repeat ERCP. Of those in whom the leak had not resolved, 6 had a repeat exam within 14 days of stent placement; 4 of these resolved the leak by day 39. There were no procedure-related complications in the ERCP group. Thirteen patients underwent EGD with stent removal after a median of 29 days (IQR 23-38). None had adverse events, with a median follow-up of 38 months. Overall, the median time to resolution of biliary leak was 33 days (IQR 22-44). Importantly, repeat ERCP altered the management in only one patient in whom bile duct stones were found. CONCLUSIONS Patients with uncomplicated postcholecystectomy bile leak who have clinically resolved their leak do not require cholangiography at the time of stent removal. In these patients, EGD with stent removal at 4-6 weeks seems to be sufficient and significantly less expensive.
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Endoscopic retrograde cholangiography by double balloon enteroscopy in patients with Roux-en-Y hepaticojejunostomy. Surg Endosc 2009; 24:466-70. [PMID: 19585072 DOI: 10.1007/s00464-009-0591-3] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2009] [Revised: 05/05/2009] [Accepted: 05/31/2009] [Indexed: 12/22/2022]
Abstract
BACKGROUND In patients with Roux-en-Y hepaticojejunostomy (HJ), endoscopic retrograde cholangiography (ERC) cannot usually be achieved since the anastomosis is not reachable via standard duodenoscope. In this study, we report our experience with ERC using double balloon enteroscope (DBE) (DBE-ERC) in patients with HJ. METHODS The DBE-ERC procedures performed since the index case done dated May 3, 2006 have been overviewed. RESULTS Fourteen patients underwent the procedure. DBE-ERC was successful in all but one patient, for whom the anastomosis could not be reached (success rate to reach anastomosis: 92.9%). The remaining 13 patients (7 female, 6 male; age 28-61 years, mean 45.3 years) had 20 sessions of DBE-ERC. The cannulation of the bile duct was achieved in all patients. The procedures, such as sphincteroplasty, dilatation, stone extraction and stent placement, were performed. Therapeutic procedures were all successful, except for in a single patient, who had the common bile duct filled with multiple stones and was referred for surgery. Three patients who had anastomotic stenosis treated by stenting are symptom free on follow-up at 3, 9 and 12 months, respectively, after stent removal. Retroperitoneal air was detected in a patient following stricturoplasty, but recovery was attained with medical treatment alone. Mean duration of the procedures was 75 +/- 62 min. CONCLUSION DBE-ERCP enables us to perform ERC in a group of patients for whom it was impossible previously. Further experience is needed to evaluate its therapeutic efficacy compared with alternative methods.
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Aksoz K, Unsal B, Yoruk G, Buyrac Z, Haciyanli M, Akpinar Z, Alper E. Endoscopic sphincterotomy alone in the management of low-grade biliary leaks due to cholecystectomy. Dig Endosc 2009; 21:158-61. [PMID: 19691762 DOI: 10.1111/j.1443-1661.2009.00878.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Endoscopic retrograde cholangiopancreatography (ERCP) is important in the diagnosis and management of postoperative bile leaks. Endoscopic sphincterotomy (ES) alone, ES with stent or nasobiliary drain (NBD) placement and stent or NBD without ES are the methods of choice. In the present study, we aimed to show the efficacy of ES alone in the management of low-grade (LGL) cystic duct stump (CDS) leaks due to cholecystectomy. METHODS Between September 2005 and January 2008, ES was carried out on 31 patients with LGL from the CDS due to cholecystectomy who were referred to the endoscopy unit of Izmir Ataturk Training and Research Hospital. Biliary leakage was detected by biliary discharge from a tube drain inserted during the operation. In cases of retaining common bile duct stones, balloon extraction was carried out. If bile discharge continued, a stent was introduced for cessation of the leak as a second procedure. RESULTS The success rate of ES alone was 87.1% (27 of 31 patients). In four patients (12.9%), ES alone was inadequate, therefore a stent was placed. The biliary leak ceased gradually and stopped in all patients at a mean of 11 (7-21) days. Balloon extraction of retained stones was carried out in six patients (19.6%). In two (6.5%) patients, mild hemorrhage and in two patients self-limited pancreatitis was seen (6.5%) as complications. CONCLUSION Endoscopic retrograde cholangiopancreatography is essential in the management of postoperative biliary leaks. Endoscopic sphincterotomy alone can be the initial procedure in the treatment of LGL from the CDS due to cholecystectomy.
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Affiliation(s)
- Kadir Aksoz
- Izmir Ataturk Training and Research Hospital, Izmir, Turkey.
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Pawa S, Al-Kawas FH. ERCP in the management of biliary complications after cholecystectomy. Curr Gastroenterol Rep 2009; 11:160-166. [PMID: 19281705 DOI: 10.1007/s11894-009-0025-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Open cholecystectomy has been associated historically with 0.2% to 0.5% risk of postoperative biliary injury. Laparoscopic cholecystectomy, which has become the first-line surgical treatment of calculous gallbladder disease, has been associated with a 2.5-fold to fourfold increase in the incidence of postoperative bile duct injury. The biliary endoscopist can expect to see a varied spectrum of complications after cholecystectomy by either technique, including postoperative biliary strictures, bile leaks, and retained calculi in the biliary tree. Proper diagnosis and treatment are paramount in ensuring a satisfactory outcome after bile duct injury. Endoscopic retrograde cholangiopancreatography (ERCP) has become the primary modality for treatment and effectively manages most bile duct injuries.
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Affiliation(s)
- Swati Pawa
- Georgetown University Hospital, Washington, DC 20007, USA
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Abstract
Biliary disorders were once only accessible by orthodox surgery but are now diagnosed and treated by multiple methods and specialists. Therapeutic endoscopic retrograde cholangiopancreatography has flourished and continues to grow after its introduction with the first biliary spincterotomies in 1974 in Germany and Japan. The therapeutic biliary endoscopist contributes to the management of all biliary disorders and in many cases endoscopy is the preferable approach. However, endoscopic retrograde cholangiopancreatography remains a risky procedure and risk is best reduced by strictly limiting its use.
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Tannapfel A, Brücher B, Schlag P. Peritoneales Mesotheliom – ein seltener Tumor der Bauchhöhle. ONKOLOGE 2009. [DOI: 10.1007/s00761-009-1576-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Butte JM, Devaud N, Jarufe NP, Boza C, Pérez G, Torres J, Pérez-Ayuso RM, Arrese M, Martínez J. Sleeve gastrectomy as treatment for severe obesity after orthotopic liver transplantation. Obes Surg 2008; 17:1517-9. [PMID: 18219781 DOI: 10.1007/s11695-008-9432-z] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Obesity is highly prevalent in both liver transplant candidates and recipients, and can have a significant impact on perioperative morbidity and mortality and the overall cost of transplantation. Herein, we describe an obese patient who was managed sequentially with an intragastric balloon in the pre-transplant setting and a gastric sleeve following transplantation, with good long-term results. Sleeve gastrectomy is a non-malabsorptive bariatric procedure with potential benefit for liver transplant patients due to its lack of influence on the absorption of immunosuppressive agents.
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Affiliation(s)
- Jean M Butte
- Department of Digestive Surgery, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
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