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Ding S, Dong S, Zhu H, Zheng S, Li Q. Does T-tube indwelling prolong the procedure of endoscopic retrograde cholangiopancreatography for healing duct-to-duct anastomotic bile leakage after liver transplantation? Medicine (Baltimore) 2024; 103:e40191. [PMID: 39470552 PMCID: PMC11521000 DOI: 10.1097/md.0000000000040191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 06/12/2024] [Accepted: 10/03/2024] [Indexed: 10/30/2024] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is the preferred treatment for duct-to-duct anastomotic bile leakage (D-D aBL) after liver transplantation (LT). This study aimed to compare the time required for ERCP and D-D aBL recovery in post-LT patients with and without T-tube drainage. A total of 40 patients (11 with T-tube drainage and 29 without T-tube drainage) with confirmed D-D aBLs treated successfully with ERCP from July 2016 to September 2021 were reviewed. The mean interval from LT to initial ERCP was significantly longer in patients with T-tube drainage than in those without T-tube drainage (41.9 vs 25.1 days, P < .05). However, there was no significant difference in the time required for ERCP to result in D-D aBL healing between patients with T-tube drainage and those without T-tubes (33.4 vs 23.0 days). T-tube indwelling did not significantly prolong the course required for ERCP to resolve D-D aBL in post-LT patients.
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Affiliation(s)
- Songming Ding
- Division of Hepatobiliary and Pancreatic Surgery, Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University, Shulan International Medical College, Hangzhou, Zhejiang, P.R. China
| | - Shanjie Dong
- Division of Hepatobiliary and Pancreatic Surgery, Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University, Shulan International Medical College, Hangzhou, Zhejiang, P.R. China
| | - Hengkai Zhu
- Division of Hepatobiliary and Pancreatic Surgery, Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University, Shulan International Medical College, Hangzhou, Zhejiang, P.R. China
| | - Shusen Zheng
- Division of Hepatobiliary and Pancreatic Surgery, Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University, Shulan International Medical College, Hangzhou, Zhejiang, P.R. China
| | - Qiyong Li
- Division of Hepatobiliary and Pancreatic Surgery, Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University, Shulan International Medical College, Hangzhou, Zhejiang, P.R. China
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Brinkmann F, Uhlig K, Sambale A, Stommel M, Berning M, Babatz J, Sulk S, Krasz S, Schmelz R, Brückner S, Hampe J, Zeissig S. Anchoring fins of fully covered self-expandable metal stents affect pull-out force and stent migration. Gastrointest Endosc 2024; 99:377-386.e3. [PMID: 37863243 DOI: 10.1016/j.gie.2023.10.036] [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: 06/29/2023] [Revised: 08/29/2023] [Accepted: 10/06/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND AND AIMS Stent migration and subsequent adverse events are frequently observed in the use of fully covered self-expandable metal stents (FCSEMSs) for distal biliary stenosis. In this study, we identified predictors for stent migration based on biomechanical stent characteristics and associated these findings with clinical outcomes. METHODS The migration resistance of FCSEMSs was quantified by measuring the pull-out force. We analyzed a single-center retrospective cohort of 178 FCSEMSs for treatment success and adverse events occurring during 180 days of follow-up. RESULTS Biomechanical measurements revealed a 4-fold higher migration resistance of FCSEMSs with anchoring fins (AF-FCSEMSs; Fmax = 14.2 ± .1 N) compared with FCSEMSs with flared ends (FE-FCSEMSs; Fmax = 3.8 ± 1.0 N; P < .0001). Clinically, AF-FCSEMSs showed lower rates of migration compared with FE-FCSEMSs (5% vs 34%, P < .0001). Unscheduled ERCP procedures because of stent dysfunction were less frequent in the AF group compared with the FE group (15% vs 29%, P = .046). Cholangitis because of stent dysfunction was observed in 5% of the AF group compared with 19% in the FE group (P = .02). Stent patency rates at 1, 3, and 6 months were higher in the AF group (96%, 90%, and 80%, respectively) compared with the FE group (90%, 74%, and 66%; log-rank test: P = .03). CONCLUSIONS The pull-out force as a biomechanical stent property predicts the migration resistance of FCSEMSs in distal biliary stenosis and may thus be used to classify stents for this application. AF-FCSEMSs showed a significantly lower rate of migration and adverse events compared with FE-FCSEMSs.
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Affiliation(s)
- Franz Brinkmann
- Department of Medicine I, University Hospital Dresden, Technische Universität Dresden (TU Dresden), Dresden, Germany; Else Kröner Fresenius Center for Digital Health, Technische Universität Dresden (TU Dresden), Dresden, Germany
| | - Kai Uhlig
- Department Materials Engineering, Leibniz Institute of Polymer Materials, Dresden, Germany
| | - Anna Sambale
- Department Materials Engineering, Leibniz Institute of Polymer Materials, Dresden, Germany
| | - Markus Stommel
- Department Materials Engineering, Leibniz Institute of Polymer Materials, Dresden, Germany; Institute for Materials Science, Technische Universität Dresden (TU Dresden), Dresden, Germany
| | - Marco Berning
- Department of Medicine I, University Hospital Dresden, Technische Universität Dresden (TU Dresden), Dresden, Germany
| | - Jana Babatz
- Department of Medicine I, University Hospital Dresden, Technische Universität Dresden (TU Dresden), Dresden, Germany
| | - Stefan Sulk
- Department of Medicine I, University Hospital Dresden, Technische Universität Dresden (TU Dresden), Dresden, Germany
| | - Susanne Krasz
- Department of Medicine I, University Hospital Dresden, Technische Universität Dresden (TU Dresden), Dresden, Germany
| | - Renate Schmelz
- Department of Medicine I, University Hospital Dresden, Technische Universität Dresden (TU Dresden), Dresden, Germany
| | - Stefan Brückner
- Department of Medicine I, University Hospital Dresden, Technische Universität Dresden (TU Dresden), Dresden, Germany
| | - Jochen Hampe
- Department of Medicine I, University Hospital Dresden, Technische Universität Dresden (TU Dresden), Dresden, Germany; Else Kröner Fresenius Center for Digital Health, Technische Universität Dresden (TU Dresden), Dresden, Germany; Center for Regenerative Therapies Dresden, Technische Universität Dresden (TU Dresden), Dresden, Germany
| | - Sebastian Zeissig
- Department of Medicine I, University Hospital Dresden, Technische Universität Dresden (TU Dresden), Dresden, Germany; Center for Regenerative Therapies Dresden, Technische Universität Dresden (TU Dresden), Dresden, Germany
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3
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Kouladouros K, Kähler G. [Endoscopic management of complications in the hepatobiliary and pancreatic system and the tracheobronchial tree]. CHIRURGIE (HEIDELBERG, GERMANY) 2023; 94:469-484. [PMID: 36269350 DOI: 10.1007/s00104-022-01735-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/13/2022] [Indexed: 05/04/2023]
Abstract
Endoscopic methods are nowadays a priceless tool for the treatment of postoperative complications after hepatobiliary, pancreatic and thoracic surgery. Endoscopic decompression of the biliary tract is the treatment of choice for biliary duct leakage after cholecystectomy, hepatic resection or liver transplantation. Postoperative biliary duct stenosis can also be successfully treated by endoscopic balloon dilatation and implantation of various endoprostheses in most of the patients. In the case of pancreatic fistulas, especially those occurring after central or distal pancreatic resections, endoscopic decompression of the pancreatic duct can significantly contribute to rapid healing. Additionally, interventional endosonography provides a valuable treatment option for transgastric drainage of postoperative fluid collections, which often accompany a pancreatic fistula. Various treatment alternatives have been described for the bronchoscopic treatment of bronchopleural and tracheoesophageal fistulas, which often lead to the rapid alleviation of symptoms and often to the definitive closure of the fistula.
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Affiliation(s)
- Konstantinos Kouladouros
- Zentrale Interdisziplinäre Endoskopie, Chirurgische Klinik, Medizinische Fakultät Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland.
| | - Georg Kähler
- Zentrale Interdisziplinäre Endoskopie, Chirurgische Klinik, Medizinische Fakultät Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
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4
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Interventional endoscopy for abdominal transplant patients. Semin Pediatr Surg 2022; 31:151190. [PMID: 35725058 DOI: 10.1016/j.sempedsurg.2022.151190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Interventional endoscopy can play a significant role in the care and management of children pre-and post- abdominal solid organ transplantation. Such procedures primarily include endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound (EUS), and balloon-assisted enteroscopy (BAE), though additional interventions are available using standard endoscopes (gastroscopes, colonoscopes) for therapeutics purposes such as endoscopic hemostasis. The availability of pediatric practitioners with the advanced training to effectively and safely perform these procedures are most often limited to large tertiary care pediatric centers. These centers possess the necessary resources and ancillary staff to provide the comprehensive multi-disciplinary care needed for these complex patients. In this review, we discuss the importance of interventional endoscopy in caring for transplant patients, during their clinical course preceding the potential need for solid organ transplantation and inclusion of a discussion related to endoscopic post-surgical complication management. Given the highly important role of interventional endoscopy in patients with recurrent and chronic pancreatitis, we also include a discussion related to this complex disease process leading up to those patients that may need pancreas surgery including total pancreatectomy with islet autotransplantation (TPIAT).
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Boeva I, Karagyozov PI, Tishkov I. Post-liver transplant biliary complications: Current knowledge and therapeutic advances. World J Hepatol 2021; 13:66-79. [PMID: 33584987 PMCID: PMC7856868 DOI: 10.4254/wjh.v13.i1.66] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 11/01/2020] [Accepted: 12/02/2020] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation is the current standard of care for end-stage liver disease and an accepted therapeutic option for acute liver failure and primary liver tumors. Despite the remarkable advances in the surgical techniques and immunosuppressive therapy, the postoperative morbidity and mortality still remain high and the leading causes are biliary complications, which affect up to one quarter of recipients. The most common biliary complications are anastomotic and non-anastomotic biliary strictures, leaks, bile duct stones, sludge and casts. Despite the absence of a recommended treatment algorithm many options are available, such as surgery, percutaneous techniques and interventional endoscopy. In the last few years, endoscopic techniques have widely replaced the more aggressive percutaneous and surgical approaches. Endoscopic retrograde cholangiography is the preferred technique when duct-to-duct anastomosis has been performed. Recently, new devices and techniques have been developed and this has led to a remarkable increase in the success rate of minimally invasive procedures. Understanding the mechanisms of biliary complications helps in their early recognition which is the prerequisite for successful treatment. Aggressive endoscopic therapy is essential for the reduction of morbidity and mortality in these cases. This article focuses on the common post-transplant biliary complications and the available interventional treatment modalities.
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Affiliation(s)
- Irina Boeva
- Department of Interventional Gastroenterology, Acibadem City Clinic Tokuda Hospital, Sofia 1407, Bulgaria
| | - Petko Ivanov Karagyozov
- Department of Interventional Gastroenterology, Clinic of Gastroenterology, Acibadem City Clinic Tokuda Hospital, Sofia 1407, Bulgaria.
| | - Ivan Tishkov
- Department of Interventional Gastroenterology, Acibadem City Clinic Tokuda Hospital, Sofia 1407, Bulgaria
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6
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Raza A, Omer A, Iqbal S, Gudsoorkar V, Koduru P, Krishnan K. Efficacy of Nasobiliary Tubes and Biliary Stents in Management of Patients with Bile Leak after Liver Transplantation: A Systematic Review. Clin Endosc 2019; 52:159-167. [PMID: 30959587 PMCID: PMC6453846 DOI: 10.5946/ce.2018.118] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 10/06/2010] [Indexed: 02/07/2023] Open
Abstract
Background/Aims Bile leak is one of the most common complications of liver transplantation. The treatment options for bile leaks include conservative management, surgical re-intervention, percutaneous drainage and endoscopic drainage. We aimed to perform a systematic review to identify the efficacy of endoscopic treatment in the resolution of post-transplant bile leaks. Methods Two independent reviewers performed systematic literature search in PubMed, ISI Web of Science, grey literature and relevant references in May 2017. Human studies in English with documented post-liver transplant bile leaks were included. Results Thirty-four studies were included in the final analysis. The pooled efficacy of biliary stents for the resolution of post-transplant bile leaks was 82.43% compared with 87.15% efficacy of nasobiliary tubes. The efficacy of biliary stents was lower for anastomotic leaks (69.23%) compared to T-tube (90.9%) or cut-surface/ cystic duct stump related leaks (92.8%). Similarly, the efficacy of nasobiliary tube was also lower for anastomotic leaks (58.33%) compared to T-tube or cut-surface related leaks (100%). Conclusions In this systematic review, the overall efficacy was 82.43% in biliary stent group, and 87.15% in nasobiliary tube group. Both biliary stent and nasobiliary tube were more effective in managing non-anastomotic leaks compared to anastomotic leaks.
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Affiliation(s)
- Ali Raza
- Division of Gastroenterology, Department of Medicine, Houston Methodist Hospital, Weill Cornell Medicine, Houston, TX, USA.,Division of Gastroenterology, Department of Medicine, The University of Texas-Houston, McGovern Medical School, Houston, TX, USA
| | - Anam Omer
- Department of Medicine, Houston Methodist Hospital, Weill Cornell Medicine, Houston, TX, USA
| | - Sara Iqbal
- Department of Medicine, Houston Methodist Hospital, Weill Cornell Medicine, Houston, TX, USA
| | - Vineet Gudsoorkar
- Division of Gastroenterology, Department of Medicine, Houston Methodist Hospital, Weill Cornell Medicine, Houston, TX, USA
| | - Pramoda Koduru
- Division of Gastroenterology, Department of Medicine, Houston Methodist Hospital, Weill Cornell Medicine, Houston, TX, USA
| | - Kumar Krishnan
- Division of Gastroenterology, Department of Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
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Crismale JF, Ahmad J. Endoscopic Management of Biliary Issues in the Liver Transplant Patient. Gastrointest Endosc Clin N Am 2019; 29:237-256. [PMID: 30846151 DOI: 10.1016/j.giec.2018.11.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Biliary complications remain a common problem after liver transplantation (LT). The therapeutic endoscopist encounters a variety of situations in LT including strictures at the duct-to-duct biliary anastomosis, strictures elsewhere in the biliary tree caused by an ischemic injury, and bile leaks at the anastomosis or from the cut surface and stone disease. Biliary complications lead to significant morbidity and occasionally reduced graft and patient survival. Several factors increase the risk of strictures and leaks. Endoscopic intervention in experienced hands is successful in the management of biliary complications following LT and percutaneous or surgical correction should seldom be required.
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Affiliation(s)
- James F Crismale
- Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
| | - Jawad Ahmad
- Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA.
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8
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Moy BT, Birk JW. A Review on the Management of Biliary Complications after Orthotopic Liver Transplantation. J Clin Transl Hepatol 2019; 7:61-71. [PMID: 30944822 PMCID: PMC6441650 DOI: 10.14218/jcth.2018.00028] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 09/23/2018] [Accepted: 10/29/2018] [Indexed: 02/07/2023] Open
Abstract
Orthotopic liver transplantation is the definitive treatment for end-stage liver disease and hepatocellular carcinomas. Biliary complications are the most common complications seen after transplantation, with an incidence of 10-25%. These complications are seen both in deceased donor liver transplant and living donor liver transplant. Endoscopic treatment of biliary complications with endoscopic retrograde cholangiopancreatography (commonly known as ERCP) has become a mainstay in the management post-transplantation. The success rate has reached 80% in an experienced endoscopist's hands. If unsuccessful with ERCP, percutaneous transhepatic cholangiography can be an alternative therapy. Early recognition and treatment has been shown to improve morbidity and mortality in post-liver transplant patients. The focus of this review will be a learned discussion on the types, diagnosis, and treatment of biliary complications post-orthotopic liver transplantation.
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Affiliation(s)
- Brian T. Moy
- Department of Medicine, Division of Gastroenterology-Hepatology, University of Connecticut Health Center, Farmington, CT, USA
| | - John W. Birk
- Department of Medicine, Division of Gastroenterology-Hepatology, University of Connecticut Health Center, Farmington, CT, USA
- *Correspondence to: John W. Birk, Department of Medicine, Division of Gastroenterology-Hepatology, University of Connecticut Health Center, Farmington, CT 06030, USA. E-mail:
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9
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A systematic review of biodegradable biliary stents: promising biocompatibility without stent removal. Eur J Gastroenterol Hepatol 2018; 30:813-818. [PMID: 29782386 DOI: 10.1097/meg.0000000000001167] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Biodegradable self-expanding stents are an emerging alternative to standard biliary stents as the development of endoscopic insertion devices advances. The aim was to systematically review the existing literature on biodegradable biliary stents. In-vivo studies on the use of biodegradable stents in the biliary duct were systematically reviewed from 1990 to 2017. Despite extensive research on the biocompatibility of stents, the experience so far on their clinical use is limited. A few favorable reports have recently been presented on endoscopically and percutaneously inserted self-expanding biodegradable polydioxanone stents in benign biliary strictures. Another potential indication appears to be postcholecystectomy leak of the cystic duct. The main benefit of biodegradable stents is that stent removal can be avoided. The biocompatibility of the current biodegradable stent materials, most prominently polydioxanone, is well documented. In the few studies currently available, biodegradable stents are reported to be feasible and safe, also in humans. The initial results of the endoscopic use of these stents in benign biliary stricture management and for treating postcholecystectomy bile leaks are promising. Further controlled studies on long-term clinical results and cost-effectiveness are needed.
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10
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Mark JA, Mack CL, Marwan AI, Kramer RE. Use of Fully Covered Self-expanding Metal Biliary Stents in Pediatrics: A Case Series. J Pediatr Gastroenterol Nutr 2018; 66:e71-e75. [PMID: 28837510 DOI: 10.1097/mpg.0000000000001723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Endoscopic retrograde cholangiopancreatography is used to manage biliary pathology in pediatric patients. Plastic biliary stents have been used in this population for obstructive lesions and bile leaks; however, they are sometimes not effective due to migration, occlusion, or ineffective sealing. Fully covered self-expanding metal stents (FCSEMS) have larger diameters making them more suitable for some situations. Their use in pediatrics has, however, not been defined. The aim of the present study is to describe our experience with FCSEMS at our institution. METHODS We present a series of all patients who underwent FCSEMS placement at Children's Hospital Colorado including 3 adolescents and 1 young adult with complex medical needs. RESULTS Patient age range was 12 to 24 years and the weight ranged between 36 and 75 kg. All patients underwent previous endoscopic retrograde cholangiopancreatography and 1 or more rounds of plastic stenting without adequate clinical response before consideration of FCSEMS placement. Indications included recalcitrant biliary anastomotic stricture after liver transplant, persistent bile leak after needle perforation, recurrent obstructive choledocholithiasis after cholecystectomy, and malignant biliary stricture. Sizes of FCSEMS depended on patient bile duct size and biliary pathology. Dwell time was 6 to 8 weeks. Three patients had resolution of biliary pathology after FCSEMS therapy. One patient had distal migration of FCSEMS necessitating repeat stenting. There were no adverse events from FCSEMS placement or removal. CONCLUSIONS FCSEMS therapy should be considered in appropriate pediatric patients when plastic biliary stents are not effective. Further studies are needed to evaluate the safety and efficacy of FCSEMS in the pediatric age group.
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Affiliation(s)
- Jacob A Mark
- Section of Gastroenterology, Hepatology and Nutrition and the Digestive Health Institute
| | - Cara L Mack
- Section of Gastroenterology, Hepatology and Nutrition and the Digestive Health Institute
| | - Ahmed I Marwan
- Division of Pediatric Surgery, Colorado Fetal Care Center, Children's Hospital Colorado, University of Colorado Denver School of Medicine, Aurora, CO
| | - Robert E Kramer
- Section of Gastroenterology, Hepatology and Nutrition and the Digestive Health Institute
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11
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Alves AR, Gomes D, Furtado E, Tomé L. Efficacy of Endoscopic Retrograde Cholangiopancreatography in the Treatment of Biliary Complications following Liver Transplant: 10 Years of a Single-Centre Experience. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2017; 25:10-17. [PMID: 29457045 DOI: 10.1159/000480704] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 03/20/2017] [Indexed: 12/16/2022]
Abstract
Background and Aims Biliary tract complications following liver transplant remain an important source of morbidity and mortality. Endoscopic retrograde cholangiopancreatography (ERCP) has become a common therapeutic option before other invasive procedures. The aim of this study was to evaluate ERCP efficacy in managing this type of complications. Methods Retrospective study of all patients who underwent therapeutic ERCP due to post-liver transplant biliary complications between September 2005 and September 2015, at a deceased donor liver transplantation centre. Results Therapeutic ERCP was performed in 120 patients (64% men; mean age 46 ± 14 years). Biliary complications were anastomotic strictures (AS) in 70%, non-anastomotic strictures (NAS) in 14%, bile leaks (BL) in 5.8%, and bile duct stones (BDS) in 32%. The mean time between liver transplant and first ERCP was: 19 ± 30 months in AS, 17 ± 30 months in NAS, 61 ± 28 months in BDS, and 0.7 ± 0.6 months in BL (p < 0.001). The number of ERCP performed per patient was: 3.8 ± 2.4 in AS, 3.8 ± 2.1 in NAS, 1.9 ± 1 in BDS, and 1.9 ± 0.5 in BL (p = 0.003). The duration of the treatment was: 18 ± 19 months in AS, 21 ± 17 months in NAS, 10 ± 10 months in BDS, and 4 ± 3 months in BL (p = 0.064). Overall, biliary complications were successfully managed by ERCP in 46% of cases, either as an isolated procedure (43%) or rendez-vous ERCP (3%). Per complication, ERCP was effective in 39% of AS, in 12% of NAS, in 91% of BDS, and in 86% of BL. Globally, the mean follow-up of the successful cases was 43 ± 31 months. Percutaneous transhepatic cholangiography and/or surgery were performed in 48% of patients in whom ERCP was unsuccessful. The odds ratio for effective endoscopic treatment was 0.2 for NAS (0.057-0.815), 12.4 for BDS (1.535-100.9), and 6.9 for BL (0.798-58.95). No statistical significance was found for AS (p = 0.247). Conclusions ERCP allowed the treatment of biliary complication in about half of patients, avoiding a more invasive procedure. Endoscopic treatment was more effective for BDS and BL.
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Affiliation(s)
- Ana Rita Alves
- Serviço de Gastrenterologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Dário Gomes
- Serviço de Gastrenterologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Emanuel Furtado
- Unidade de Transplantação Hepática Pediátrica e de Adultos, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Luís Tomé
- Serviço de Gastrenterologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
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12
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Sendino O, Fernández-Simon A, Law R, Abu Dayyeh B, Leise M, Chavez-Rivera K, Cordova H, Colmenero J, Crespo G, Rodriguez de Miguel C, Fondevila C, Llach J, Navasa M, Baron T, Cárdenas A. Endoscopic management of bile leaks after liver transplantation: An analysis of two high-volume transplant centers. United European Gastroenterol J 2017; 6:89-96. [PMID: 29435318 DOI: 10.1177/2050640617712869] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 05/06/2017] [Indexed: 12/28/2022] Open
Abstract
Background Bile leak after liver transplantation (LT) is commonly treated with endoscopic retrograde cholangiopancreatography (ERCP); however, there are limited data regarding the optimal treatment strategy. Objective We aimed to examine the role of ERCP in LT recipients with bile leaks at two large institutions. Methods We reviewed all ERCPs performed in LT recipients with bile leak and duct-to-duct biliary anastomosis at two high-volume transplant centers. Results Eighty patients were included. Forty-seven (59%) patients underwent ERCP with plastic stent placement (with or without sphincterotomy) and 33 patients (41%) underwent sphincterotomy alone. Complete resolution was obtained in 94% of the stent group vs. 58% of the sphincterotomy group (p < 0.01). There was no difference in three-month survival among both groups. Percutaneous transhepatic therapy and surgery were required in 4% and 6% in the stent group vs. 12% and 42% in the sphincterotomy group, respectively (p = 0.22 and p < 0.001). The only predictive factor of bile leak resolution was stent placement. Conclusion ERCP with plastic stent placement is highly successful and more effective than sphincterotomy alone for post-LT bile leak treatment. These results indicate that ERCP and plastic stent placement should be considered the standard of care for the treatment of bile leaks in LT.
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Affiliation(s)
- Oriol Sendino
- GI/Endoscopy Unit, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, and University of Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS), Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| | - Alejandro Fernández-Simon
- GI/Endoscopy Unit, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, and University of Barcelona, Spain.,GI Unit, Hospital Sant Joan Despí Moises Broggi, Barcelona, Spain
| | - Ryan Law
- Department of Medicine and Division of Gastroenterology, University of Michigan, MI, USA
| | - Barham Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Michael Leise
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Karina Chavez-Rivera
- GI/Endoscopy Unit, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, and University of Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS), Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| | - Henry Cordova
- GI/Endoscopy Unit, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, and University of Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS), Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| | - Jordi Colmenero
- Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS), Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.,Liver Unit, Institut de Malalties Digestives i Metabòliques, Hospital Clínic and University of Barcelona, Spain
| | - Gonzalo Crespo
- Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS), Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.,Liver Unit, Institut de Malalties Digestives i Metabòliques, Hospital Clínic and University of Barcelona, Spain
| | - Cristina Rodriguez de Miguel
- GI/Endoscopy Unit, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, and University of Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS), Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| | - Constantino Fondevila
- Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS), Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.,General and Digestive Surgery, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, and University of Barcelona, Spain
| | - Josep Llach
- GI/Endoscopy Unit, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, and University of Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS), Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| | - Miquel Navasa
- Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS), Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.,Liver Unit, Institut de Malalties Digestives i Metabòliques, Hospital Clínic and University of Barcelona, Spain
| | - Todd Baron
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA
| | - Andrés Cárdenas
- GI/Endoscopy Unit, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, and University of Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS), Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.,Liver Unit, Institut de Malalties Digestives i Metabòliques, Hospital Clínic and University of Barcelona, Spain
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13
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Cantù P, Tenca A, Parzanese I, Penagini R. Covered metal stents in endoscopic therapy of biliary complications after liver transplantation. Dig Liver Dis 2016; 48:836-42. [PMID: 27238164 DOI: 10.1016/j.dld.2016.04.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 04/14/2016] [Indexed: 12/11/2022]
Abstract
There is growing interest in using covered self-expandable metal stents for the treatment of benign biliary conditions, and the presence of anastomotic biliary strictures and leaks after liver transplantation provide a valuable opportunity for testing them. The performance of the stents is encouraging, and the technical success rate is high. They provide larger diameter dilation and are easily removed, and can potentially limit costs by reducing the number of procedures needed to treat anastomotic biliary strictures. However, drawbacks such as sub-optimal tolerability and migration may affect both patient management and costs. New stent designs are currently being evaluated. Randomized controlled trials and cost-effectiveness analyses comparing covered metal stents with multiple plastic stent endotherapy are warranted in order to define the role of the former as first-line or rescue treatment.
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Affiliation(s)
- Paolo Cantù
- Gastroenterology and Endoscopy Unit, Department of Pathophysiology and Transplantation, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico and Università degli Studi di Milano, Milan, Italy
| | - Andrea Tenca
- Clinic of Gastroenterology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ilaria Parzanese
- Gastroenterology and Endoscopy Unit, Department of Pathophysiology and Transplantation, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico and Università degli Studi di Milano, Milan, Italy
| | - Roberto Penagini
- Gastroenterology and Endoscopy Unit, Department of Pathophysiology and Transplantation, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico and Università degli Studi di Milano, Milan, Italy.
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14
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Siiki A, Jesenofsky R, Löhr M, Nordback I, Kellomäki M, Gröhn H, Mikkonen J, Sand J, Laukkarinen J. Biodegradable biliary stents have a different effect than covered metal stents on the expression of proteins associated with tissue healing in benign biliary strictures. Scand J Gastroenterol 2016; 51:880-5. [PMID: 27003149 DOI: 10.3109/00365521.2016.1156153] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Benign biliary strictures (BBS) are primarily treated endoscopically with covered self-expandable metal stents (CSEMS). Biodegradable biliary stents (BDBS) may be the future of endoscopic therapy of BBS. The aim was to assess the expression of proteins related to tissue healing in BBS compared with the intact bile duct (BD), and to study the protein expression after therapy with CSEMS or BDBS. METHODS Pigs with ischemic BBS were endoscopically treated either with BDBS or CSEMS. Samples were harvested from pigs with intact BD (n = 5), untreated BBS (n = 5), and after six months of therapy with BDBS (n = 4) or CSEMS (n = 5) with subsequent histologic analysis. Two-dimensional electrophoresis with protein identification was performed to evaluate protein expression patterns. RESULTS In BBS, the expression of galectin-2 and annexin-A4 decreased, compared to intact BD. Treatment with biodegradable stents normalized galectin-2 level; with CSEMS therapy it remained low. Transgelin expression of intact BD and BBS remained low after BDBS treatment but increased after CSEMS therapy. Histologic analysis did not show unwanted foreign body reaction or hyperplasia in the BD in either group. CONCLUSIONS The expression of proteins related to tissue healing in BBS is different after treatment with biodegradable stents and CSEMS. Treatment with biodegradable stents may bring protein expression towards what is seen in intact BD. BDBS seem to have a good biocompatibility.
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Affiliation(s)
- Antti Siiki
- a Department of Gastroenterology and Alimentary Tract Surgery , Tampere University Hospital , Tampere , Finland
| | - Ralf Jesenofsky
- b Department of Medicine II , University of Heidelberg , Mannheim , Germany
| | - Matthias Löhr
- c Karolinska University Hospital, Gastrocentrum , Huddinge , Sweden
| | - Isto Nordback
- a Department of Gastroenterology and Alimentary Tract Surgery , Tampere University Hospital , Tampere , Finland
| | - Minna Kellomäki
- d Biomaterials and Tissue Engineering Group, BioMediTech and Department of Electronics and Communications Engineering , Tampere University of Technology , Tampere , Finland
| | - Heidi Gröhn
- e Department of Clinical Physiology and Nuclear Medicine , Kuopio University Hospital , Kuopio , Finland
| | - Joonas Mikkonen
- d Biomaterials and Tissue Engineering Group, BioMediTech and Department of Electronics and Communications Engineering , Tampere University of Technology , Tampere , Finland
| | - Juhani Sand
- a Department of Gastroenterology and Alimentary Tract Surgery , Tampere University Hospital , Tampere , Finland
| | - Johanna Laukkarinen
- a Department of Gastroenterology and Alimentary Tract Surgery , Tampere University Hospital , Tampere , Finland
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15
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Canena J, Horta D, Coimbra J, Meireles L, Russo P, Marques I, Ricardo L, Rodrigues C, Capela T, Carvalho D, Loureiro R, Dias AM, Ramos G, Coutinho AP, Romão C, Veiga PM. Outcomes of endoscopic management of primary and refractory postcholecystectomy biliary leaks in a multicentre review of 178 patients. BMC Gastroenterol 2015; 15:105. [PMID: 26285593 PMCID: PMC4545536 DOI: 10.1186/s12876-015-0334-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Accepted: 08/10/2015] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Biliary leaks have been treated with endoscopic management using different techniques with conflicting results. Furthermore the appropriate rescue therapy for refractory leaks has not been established. We evaluated the clinical effectiveness of initial endotherapy for postcholecystectomy biliary leaks using an homogenous approach (sphincterotomy + placement of a 10-French plastic stent) in a large series of patients as well as the optimal and efficacy of rescue endotherapy for refractory biliary leaks. METHODS This was a multicenter, retrospective study of 178 patients who underwent endoscopic management of postcholecystectomy biliary leaks with a combination of biliary sphincterotomy and the placement of a large-bore (10-French) plastic stent. Data were collected to analyze the clinical outcomes and technical success, efficacy of the rescue endotherapy and the need for surgery, adverse events and prognostic factors for clinical success of endotherapy. RESULTS Following endotherapy, closure of the leak was accomplished in 162/178 patients (91.0%). The multivariate logistic model showed that the type of leak, namely a high-grade biliary leak, was the only independent prognostic factor associated with treatment failure (OR = 26.78; 95% CI = 6.59-108.83; P < 0.01). The remaining 16 patients were treated with multiple plastic stents (MPSs) with a success rate of 62.5% (10 patients). The use of fewer than 3 plastic stents (P = 0.023) and a high-grade biliary leak (P = 0.034) were shown to be significant predictors of treatment failure with MPSs in refractory bile leaks. The 6 patients in whom the placement of MPSs failed were retreated with a fully cover self-expandable metallic stent (FCSEMS), resulting in closure of the leak in all cases. CONCLUSIONS Endotherapy of biliary leaks with a combination of biliary sphincterotomy and the placement of a large-bore plastic stent is associated with a high rate of success (90%). However in our series there were several failures using MPSs as a strategy for rescue endotherapy suggesting that refractory biliary leaks should be treated with FCSEMS especially in patients with high-grade leaks.
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Affiliation(s)
- Jorge Canena
- Department of Gastroenterology, Doutor Fernando Fonseca Hospital, IC 19, 2720-276, Amadora, Portugal.
- Department of Gastroenterology, Pulido Valente Hospital at Centro Hospitalar Lisboa Norte, Alameda das Linhas de Torres n° 117, 1769-001, Lisbon, Portugal.
- Department of Gastroenterology, Santo António dos Capuchos Hospital at Centro Hospitalar Lisboa Central, Nova Medical School-Faculty of Medical Sciences, Alameda Santo António dos Capuchos, 1169-050, Lisbon, Portugal.
- Department of Endoscopy, José Joaquim Fernandes Hospital at Unidade Local de Saúde do Baixo Alentejo, Rua Doutor António Fernandes Covas Lima, 7800-309, Beja, Portugal.
| | - David Horta
- Department of Gastroenterology, Doutor Fernando Fonseca Hospital, IC 19, 2720-276, Amadora, Portugal.
| | - João Coimbra
- Department of Gastroenterology, Santo António dos Capuchos Hospital at Centro Hospitalar Lisboa Central, Nova Medical School-Faculty of Medical Sciences, Alameda Santo António dos Capuchos, 1169-050, Lisbon, Portugal.
| | - Liliane Meireles
- Department of Gastroenterology, Pulido Valente Hospital at Centro Hospitalar Lisboa Norte, Alameda das Linhas de Torres n° 117, 1769-001, Lisbon, Portugal.
| | - Pedro Russo
- Department of Gastroenterology, Santo António dos Capuchos Hospital at Centro Hospitalar Lisboa Central, Nova Medical School-Faculty of Medical Sciences, Alameda Santo António dos Capuchos, 1169-050, Lisbon, Portugal.
| | - Inês Marques
- Department of Gastroenterology, Pulido Valente Hospital at Centro Hospitalar Lisboa Norte, Alameda das Linhas de Torres n° 117, 1769-001, Lisbon, Portugal.
| | - Leonel Ricardo
- Department of Gastroenterology, Doutor Fernando Fonseca Hospital, IC 19, 2720-276, Amadora, Portugal.
| | - Catarina Rodrigues
- Department of Gastroenterology, Doutor Fernando Fonseca Hospital, IC 19, 2720-276, Amadora, Portugal.
| | - Tiago Capela
- Department of Gastroenterology, Santo António dos Capuchos Hospital at Centro Hospitalar Lisboa Central, Nova Medical School-Faculty of Medical Sciences, Alameda Santo António dos Capuchos, 1169-050, Lisbon, Portugal.
| | - Diana Carvalho
- Department of Gastroenterology, Santo António dos Capuchos Hospital at Centro Hospitalar Lisboa Central, Nova Medical School-Faculty of Medical Sciences, Alameda Santo António dos Capuchos, 1169-050, Lisbon, Portugal.
| | - Rafaela Loureiro
- Department of Gastroenterology, Santo António dos Capuchos Hospital at Centro Hospitalar Lisboa Central, Nova Medical School-Faculty of Medical Sciences, Alameda Santo António dos Capuchos, 1169-050, Lisbon, Portugal.
| | - António Mateus Dias
- Department of Gastroenterology, Santo António dos Capuchos Hospital at Centro Hospitalar Lisboa Central, Nova Medical School-Faculty of Medical Sciences, Alameda Santo António dos Capuchos, 1169-050, Lisbon, Portugal.
| | - Gonçalo Ramos
- Department of Gastroenterology, Santo António dos Capuchos Hospital at Centro Hospitalar Lisboa Central, Nova Medical School-Faculty of Medical Sciences, Alameda Santo António dos Capuchos, 1169-050, Lisbon, Portugal.
| | - António Pereira Coutinho
- Department of Gastroenterology, Pulido Valente Hospital at Centro Hospitalar Lisboa Norte, Alameda das Linhas de Torres n° 117, 1769-001, Lisbon, Portugal.
| | - Carlos Romão
- Department of Gastroenterology, Pulido Valente Hospital at Centro Hospitalar Lisboa Norte, Alameda das Linhas de Torres n° 117, 1769-001, Lisbon, Portugal.
| | - Pedro Mota Veiga
- Curva de Gauss - Research, Training and Consulting, Rua Doutor Eduardo Maria dos Santos, Lote 1, Loja 3, 3525-000, Canas de Senhorim, Portugal.
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16
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Canena J, Liberato M, Meireles L, Marques I, Romão C, Coutinho AP, Neves BC, Veiga PM. A non-randomized study in consecutive patients with postcholecystectomy refractory biliary leaks who were managed endoscopically with the use of multiple plastic stents or fully covered self-expandable metal stents (with videos). Gastrointest Endosc 2015; 82:70-8. [PMID: 25771064 DOI: 10.1016/j.gie.2014.11.038] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2014] [Accepted: 11/21/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Endoscopic management of postcholecystectomy biliary leaks is widely accepted as the treatment of choice. However, refractory biliary leaks after a combination of biliary sphincterotomy and the placement of a large-bore (10F) plastic stent can occur, and the optimal rescue endotherapy for this situation is unclear. OBJECTIVE To compare the clinical effectiveness of the use of a fully covered self-expandable metal stent (FCSEMS) with the placement of multiple plastic stents (MPS) for the treatment of postcholecystectomy refractory biliary leaks. DESIGN Prospective study. SETTING Two tertiary-care referral academic centers and one general district hospital. PATIENTS Forty consecutive patients with refractory biliary leaks who underwent endoscopic management. INTERVENTIONS Temporary placement of MPS (n = 20) or FCSEMSs (n = 20). MAIN OUTCOME MEASUREMENTS Clinical outcomes of endotherapy as well as the technical success, adverse events, need for reinterventions, and prognostic factors for clinical success. RESULTS Endotherapy was possible in all patients. After endotherapy, closure of the leak was accomplished in 13 patients (65%) who received MPS and in 20 patients (100%) who received FCSEMSs (P = .004). The Kaplan-Meier (log-rank) leak-free survival analysis showed a statistically significant difference between the 2 patient populations (χ(2) [1] = 8.30; P < .01) in favor of the FCSEMS group. Use of <3 plastic stents (P = .024), a plastic stent diameter <20F (P = .006), and a high-grade biliary leak (P = .015) were shown to be significant predictors of treatment failure with MPS. The 7 patients in whom placement of MPS failed were retreated with FCSEMSs, resulting in closure of the leaks in all cases. LIMITATIONS Non-randomized design. CONCLUSION In our series, the results of the temporary placement of FCSEMSs for postcholecystectomy refractory biliary leaks were superior to those from the use of MPS. A randomized study is needed to confirm our results before further recommendations.
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Affiliation(s)
- Jorge Canena
- Center of Gastroenterology, Cuf Infante Santo Hospital-Nova Medical School/Faculty of Medical Sciences, Lisbon, Portugal; Department of Gastroenterology, Pulido Valente Hospital do Centro Hospitalar Lisboa Norte, Lisbon, Portugal; Department of Endoscopy, José Joaquim Fernandes Hospital da Unidade Local de Saúde do Baixo Alentejo, Beja, Portugal
| | - Manuel Liberato
- Center of Gastroenterology, Cuf Infante Santo Hospital-Nova Medical School/Faculty of Medical Sciences, Lisbon, Portugal
| | - Liliane Meireles
- Department of Gastroenterology, Pulido Valente Hospital do Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - Inês Marques
- Department of Gastroenterology, Pulido Valente Hospital do Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - Carlos Romão
- Department of Gastroenterology, Pulido Valente Hospital do Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - António Pereira Coutinho
- Center of Gastroenterology, Cuf Infante Santo Hospital-Nova Medical School/Faculty of Medical Sciences, Lisbon, Portugal
| | - Beatriz Costa Neves
- Department of Gastroenterology, Pulido Valente Hospital do Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - Pedro Mota Veiga
- Curva de Gauss-Research, Training and Consulting, Canas de Senhorim, Portugal
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Martins FP, Kahaleh M, Ferrari AP. Management of liver transplantation biliary stricture: Results from a tertiary hospital. World J Gastrointest Endosc 2015; 7:747-757. [PMID: 26140103 PMCID: PMC4482835 DOI: 10.4253/wjge.v7.i7.747] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Revised: 09/30/2014] [Accepted: 05/11/2015] [Indexed: 02/05/2023] Open
Abstract
AIM: To review results of endoscopic treatment for anastomotic biliary strictures after orthotopic liver transplantation (OLT) during an 8-year period.
METHODS: This is a retrospective review of all endoscopic retrograde cholangiopancreatographys (ERCPs) performed between May 2006 and June 2014 in deceased OLT recipients with anastomotic stricture at a tertiary care hospital. Patients were divided into 2 groups, according to the type of stent used (multiple plastic or covered self-expandable metal stents), which was chose on a case-by-case basis and their characteristics. The primary outcome was anastomotic stricture resolution rate determined if there was no more than a minimum waist at cholangiography and a 10 mm balloon could easily pass through the anastomosis with no need for further intervention after final stent removal. Secondary outcomes were technical success rate, number or ERCPs required per patient, number of stents placed, stent indwelling, stricture recurrence rate and therapy for recurrent anastomotic biliary stricture (AS). Stricture recurrence was defined as clinical laboratorial and/or imaging evidence of obstruction at the anastomosis level, after it was considered completely treated, requiring subsequent interventional procedure.
RESULTS: A total of 195 post-OLT patients were assessed for eligibility. One hundred and sixty-four (164) patients were diagnosed with anastomotic biliary stricture. ERCP was successfully performed in 157/164 (95.7%) patients with AS, that were treated with either multiple plastic (n = 109) or metallic billiary stents (n = 48). Mean treatment duration, number of procedures and stents required were lower in the metal stent group. Acute pancreatitis was the most common procedure related complication, occurring in 17.1% in the covered self-expandable metal stents (cSEMS) and 4.1% in the multiple plastic stent (MPS) group. Migration was the most frequent stent related complication, observed in 4.3% and 5.5% (cSEMS and MPS respectively). Stricture resolution was achieved in 86.8% in the cSEMS group and in 91% in MPS group. Stricture recurrence after a median follow up of 20 mo was observed in 10 (30.3%) patients in the cSEMS and 7 (7.7%) in the plastic stent group, a statistically significant difference (P = 0.0017). Successful stricture resolution after secondary treatment was achieved in 66.6% and 62.5% of patients respectively in the cSEMS and plastic stents groups.
CONCLUSION: Multiple plastic stents are currently the first treatment option for AS in patients with duct-to-duct anastomosis. cSEMS was associated with increased pancreatitis risk and higher recurrence rate.
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18
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Blero D, Huberty V, Devière J. Novel biliary self-expanding metal stents: indications and applications. Expert Rev Gastroenterol Hepatol 2015; 9:359-67. [PMID: 25231201 DOI: 10.1586/17474124.2015.960395] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Endoscopic insertion of a self-expanding metal stent (SEMS) through a malignant common bile duct stricture is the first line of palliation for malignant jaundice. Patency of these stents remains a major concern. SEMS dysfunction can result from tumor ingrowth, overgrowth and/or clogging. Initial SEMS modifications involved covering the central part of the stent in order to reduce ingrowth and ultimately increase patency. Fully covered stents became available shortly after reports of their use in human patients. The potential removability and radial strength of SEMS have led to evaluation of their use in new indications including benign biliary strictures, post sphincterotomy bleeding and perforation. Other aspects of development include the addition of features such as anti-reflux valves, drug elution and spontaneous biodegradability. These aspects and their clinical implications are reviewed and discussed.
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Affiliation(s)
- Daniel Blero
- CHU Charleroi et Vésale, ISPPC, Université Libre de Bruxelles, 1 boulevard Zoé Drion, 6000 Charleroi, Belgium
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19
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Mangiavillano B, Manes G, Baron TH, Frego R, Dinelli M, Radaelli F, Teruzzi V, Amato A, Pallotta S, Santoro T, Masci E. The use of double lasso, fully covered self-expandable metal stents with new "anchoring flap" system in the treatment of benign biliary diseases. Dig Dis Sci 2014; 59:2308-2313. [PMID: 24748231 DOI: 10.1007/s10620-014-3158-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 04/05/2014] [Indexed: 01/28/2023]
Abstract
BACKGROUND Many benign biliary diseases (BBD) can be treated with fully covered, self-expandable metal stents (FCSEMS) but stent migration occurs in up to 35.7 %. The aim of this study was to prospectively assess the rate of, safety and effectiveness and stent migration of a new biliary FCSEMS with an anti-migration flap (FCSEMS-AF) in patients with BBD. PATIENTS AND METHODS This was a prospective study from four Italian referral endoscopy centers of 32 consecutive patients (10 females and 22 males; mean age: 60.1 ± 14.8 years; range: 32-84 years) with BBD who were offered endoscopic placement of a FCSEMS-AF as first-line therapy. RESULTS Were 24 strictures and 8 leaks. Stent placement was technically successful in 32/32 patients (100 %). Immediate clinical improvement was seen in all 32 patients (100 %). One late stent migration occurred (3.3 %). FCSEMS-AF were removed from 30 of the 32 patients (93.7 %) at a mean (± SD) of 124.4 ± 84.2 days (range: 10-386 days) after placement. All patients remained clinically and biochemically well at 1- and 3-month follow-up. One patient (3.3 %) with a post-laparoscopic cholecystectomy stricture developed distal stent migration at 125 days. CONCLUSION This new FCSEMS with anti-migration flap seems to be a safe and effective first-line treatment option for patients with BBD.
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Affiliation(s)
- B Mangiavillano
- Gastrointestinal Endoscopy, Azienda Ospedaliera San Paolo, Universitary Hospital, University of Milan, Via A. di Rudinì no. 8, 20142, Milan, Italy,
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20
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Covered self-expanding metal stents may be preferable to plastic stents in the treatment of chronic pancreatitis-related biliary strictures: a systematic review comparing 2 methods of stent therapy in benign biliary strictures. J Clin Gastroenterol 2014; 48:635-43. [PMID: 24275713 DOI: 10.1097/mcg.0000000000000020] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Covered self-expanding metal stents (CSEMS) are being increasingly used in the endoscopic treatment of benign biliary strictures (BBS). There is no solid evidence yet to support their routine use. GOALS To evaluate feasibility, success rate, and complications of CSEMS compared with multiple plastic stents (PS) in BBS in a systematic review. STUDY A systematic search of electronic databases (Medline, Scopus, and Embase) for studies published from 2000 to 2012 combined to hand-search of reference lists resulted 4977 articles. Out of 99 potentially relevant studies selected for full-text review, 12 CSEMS (376 patients) and 13 PS studies (570 patients) met the final inclusion criteria. A systematic review comparing the 2 methods was made using proportion meta-analysis. RESULTS A tendency to successful use of CSEMS in strictures related to chronic pancreatitis (CP) was shown: clinical success of 77% and 33% [95% confidence interval (CI), 61%-94% vs. 4%-63%, P=0.06] was achieved with CSEMS and PS at 12 months follow-up, respectively. There were no differences in the success rates of other etiologies except CP or in the early complications. In CSEMS, incidence of late adverse events was lower in CP-related strictures (3% vs. 67%, 95% CI, 0%-13% vs. 17%-99%, P=0.02). The median number of endoscopic retrograde cholangiopancreatographies was lower with CSEMSs: 1.5 versus 3.9 (P=0.002). CONCLUSIONS Improved clinical success with fewer endoscopic sessions and corresponding complication rate may be achieved with CSEMS treatment compared with PS in BBS secondary to CP. In other BBS etiologies, this systematic review remains inconclusive.
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21
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Irani S, Baron TH, Akbar A, Lin OS, Gluck M, Gan I, Ross AS, Petersen BT, Topazian M, Kozarek RA. Endoscopic treatment of benign biliary strictures using covered self-expandable metal stents (CSEMS). Dig Dis Sci 2014; 59:152-160. [PMID: 24061590 DOI: 10.1007/s10620-013-2859-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Accepted: 08/22/2013] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIMS Traditional endoscopic management of benign biliary strictures (BBS) consists of placement of one or more plastic stents. Emerging data support the use of covered self-expandable metal stents (CSEMS). We sought to assess outcome of endoscopic temporary placement of CSEMS in patients with BBS. METHODS This was a retrospective study of CSEMS placement for BBS between May 2005 and July 2012 from two tertiary care centers. A total of 145 patients (81 males, median age 59 years) with BBS were identified; 73 of which were classified as extrinsic and were caused by chronic pancreatitis, and 70 were intrinsic. Main outcome measures were resolution of stricture and adverse events (AEs) due to self-expandable metal stents (SEMS)-related therapy. RESULTS Fully covered and partially covered 8-10 mm diameter SEMS were placed and subsequently removed in 121/125 (97 %) attempts in BBS (failure to remove four partially covered stents). Stricture resolution occurred in 83/125 (66 %) patients after a median stent duration of 26 weeks (median follow-up 90 weeks). Resolution of extrinsic strictures was significantly lower compared to intrinsic strictures (31/65, 48 % vs. 52/60, 87 %, p = 0.004) despite longer median stent duration (30 vs. 20 weeks). Thirty-seven AEs occurred in 25 patients (17 %), with 12 developing multiple AEs including cholangitis (n = 17), pancreatitis (n = 5), proximal stent migration (n = 3), cholecystitis (n = 2), pain requiring SEMS removal and/or hospitalization (n = 3), inability to remove (n = 4), and new stricture formation (n = 3). CONCLUSIONS Benign biliary strictures can be effectively treated with CSEMS. Successful resolution of biliary strictures due to extrinsic disease is seen significantly less often than those due to intrinsic disease. Removal is successful in all patients with fully covered SEMS.
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Affiliation(s)
- Shayan Irani
- Department of Gastroenterology, Virginia Mason Medical Center, Seattle, WA, USA
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Moon JH. Covered self-expandable metal stents for the treatment of benign biliary strictures after liver transplantation: when and how? Dig Dis Sci 2013; 58:2449-51. [PMID: 23861112 DOI: 10.1007/s10620-013-2786-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Kaffes AJ, Liu K. Fully covered self-expandable metal stents for treatment of benign biliary strictures. Gastrointest Endosc 2013; 78:13-21. [PMID: 23548962 DOI: 10.1016/j.gie.2013.02.019] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Accepted: 02/13/2013] [Indexed: 12/21/2022]
Affiliation(s)
- Arthur J Kaffes
- A.W. Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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24
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Cameron R, Binmoeller KF. Cyanoacrylate applications in the GI tract. Gastrointest Endosc 2013; 77:846-57. [PMID: 23540441 DOI: 10.1016/j.gie.2013.01.028] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2012] [Accepted: 01/22/2013] [Indexed: 02/06/2023]
Affiliation(s)
- Rees Cameron
- Paul May & Frank Stein Interventional Endoscopy Center, California Pacific Medical Center, San Francisco, CA, USA
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Mangiavillano B, Luigiano C, Tarantino I, Barresi L, Dinelli M, Frego R, Bassi M, Fabbri C, Cennamo V, Viaggi P, Traina M, Santoro T, Masci E. Fully covered, self-expandable metal stents for first-step endoscopic treatment of biliary leaks secondary to hepato-biliary surgery: a retrospective study. Dig Liver Dis 2013; 45:430-432. [PMID: 23280159 DOI: 10.1016/j.dld.2012.11.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Revised: 11/12/2012] [Accepted: 11/24/2012] [Indexed: 12/11/2022]
Abstract
BACKGROUND Fully covered self-expanding metal stents are now being used to treat benign biliary diseases. AIMS To assess the outcomes of these stents as first-step therapy in patients with biliary leaks secondary to hepato-biliary surgery. METHODS Thirty patients (56.7% males; mean age: 60.2 ± 13 years) were retrospectively evaluated. The data collected included technical and clinical success, adverse events and follow-up findings (1, 3 and 6 months). RESULTS Technical and clinical success rates were 100%. One early mild post-procedure pancreatitis occurred and resolved spontaneously. Three late stent distal migrations occurred, however cholangiography showed correct leak sealing in all patients. Stents were removed after a mean of 55.9 days. During follow-up no other complications occurred. CONCLUSION In our experience fully covered self-expanding metal stent placement was safe and efficacious as first-step therapy for post-operative biliary leaks. However, prospective comparative studies with plastic stents are required to validate these findings.
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Affiliation(s)
- Benedetto Mangiavillano
- Gastrointestinal Endoscopy, Azienda Ospedaliera San Paolo - Universitary Hospital, University of Milan, Milan, Italy.
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Tewani SK, Turner BG, Chuttani R, Pleskow DK, Sawhney MS. Location of bile leak predicts the success of ERCP performed for postoperative bile leaks. Gastrointest Endosc 2013; 77:601-8. [PMID: 23357499 DOI: 10.1016/j.gie.2012.11.026] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2012] [Accepted: 11/21/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND ERCP is effective for treating a bile leak (BL) after cholecystectomy (CCY), but few data exist on its effectiveness after hepatobiliary surgery (HBS). OBJECTIVE To determine the effectiveness of ERCP for treating BLs after HBS compared with BLs after cholecystectomy and to identify factors associated with treatment success. DESIGN Retrospective cohort. SETTING Academic tertiary-care referral center. PATIENTS Patients referred from 2001 to 2009 for ERCP treatment of BL after cholecystectomy or HBS. INTERVENTIONS ERCP. MAIN OUTCOME MEASUREMENTS Resolution of BL after a single ERCP. RESULTS A total of 223 patients were identified and 46 were excluded. Fifty underwent ERCP for treatment of BL after HBS and 127 after CCY. A single ERCP was successful at resolving BL in 89% of patients. Failure occurred in 7 HBS patients (14%) and 12 CCY patients (9%) (P = .379). After multiple ERCPs, success improved to 95% of the CCY group and 86% of the HBS group (P = .033). HBS patients underwent 30% more ERCPs (P = .049). ERCP was 3.3 times more likely to be successful in patients with cystic duct or duct of Luschka BLs (P = .028). Patients undergoing biliary stent placement were significantly more likely to have successful outcomes (odds ratio 71.0, P < .001). Surgical history or biliary sphincterotomy did not affect outcome. Odds of treatment failure were 3.5 times higher for each additional ERCP performed (P < .001). LIMITATIONS Single-center, retrospective study. CONCLUSIONS ERCP is effective for treating postoperative BLs. Location of a BL and placement of a biliary stent are the best predictors of endoscopic treatment success.
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Affiliation(s)
- Sumeet K Tewani
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
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Canena J, Liberato M, Horta D, Romão C, Coutinho A. Short-term stenting using fully covered self-expandable metal stents for treatment of refractory biliary leaks, postsphincterotomy bleeding, and perforations. Surg Endosc 2012; 27:313-24. [DOI: 10.1007/s00464-012-2368-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Accepted: 05/02/2012] [Indexed: 12/15/2022]
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Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is the first-line management in most situations when a benign biliary stricture is suspected. Although management principles are similar in all subgroups, the anticipated response rates, need for ancillary medical and endoscopic approaches, and use of less proven strategies vary between differing causes. Exclusion of malignancy should always be a focus of management. Newer endoscopic techniques such as endoscopic ultrasound, cholangioscopy, confocal endomicroscopy, and metal biliary stenting are increasingly complementing traditional ERCP techniques in achieving long-term sustained stricture resolution. Surgery remains a definitive management alternative when a prolonged trial of endoscopic therapy does not achieve treatment goals.
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Akbar A, Irani S, Baron TH, Topazian M, Petersen BT, Gostout CJ, Levy MJ, Gan I, Gluck M, Ross A, Kozarek RA. Use of covered self-expandable metal stents for endoscopic management of benign biliary disease not related to stricture (with video). Gastrointest Endosc 2012; 76:196-201. [PMID: 22726483 DOI: 10.1016/j.gie.2012.02.034] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Accepted: 02/20/2012] [Indexed: 02/08/2023]
Affiliation(s)
- Ali Akbar
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota 55905, USA
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Poley JW, Cahen DL, Metselaar HJ, van Buuren HR, Kazemier G, van Eijck CHJ, Haringsma J, Kuipers EJ, Bruno MJ. A prospective group sequential study evaluating a new type of fully covered self-expandable metal stent for the treatment of benign biliary strictures (with video). Gastrointest Endosc 2012; 75:783-9. [PMID: 22325806 DOI: 10.1016/j.gie.2011.10.022] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Accepted: 10/15/2011] [Indexed: 12/16/2022]
Abstract
BACKGROUND Fully-covered self expandable metal stents (fcSEMSs) are an alternative to progressive plastic stenting for the treatment of benign biliary strictures (BBS) with the prospect of a higher treatment efficacy and the need for fewer ERCPs, thereby reducing the burden for patients and possibly costs. Key to this novel treatment is safe stent removal. OBJECTIVE To investigate the feasibility and safety of stent removal of a fcSEMS with a proximal retrieval lasso: a long wire thread integrated in the proximal ends of the wire mesh that hangs freely in the stent lumen. Pulling it enables gradual removal of the stent inside-out. A secondary aim was success of stricture resolution. DESIGN Non-randomized, prospective follow-up study with 3 sequential cohorts of 8 patients with BBS. SETTING Academic tertiary referral center. PATIENTS Eligible patients had strictures either postsurgical (post-cholecystectomy (LCx) or liver transplantation (OLT)), due to chronic pancreatitis (CP), or papillary stenosis (PF). Strictures had to be located at least 2 cm below the liver hilum. All patients had one plastic stent in situ across the stricture and had not undergone previous treatment with either multiple plastic stents or fcSEMS. INTERVENTIONS The first cohort of patients underwent stent placement for 2 months, followed by 3 months if the stricture had not resolved. The second and third cohort started with 3 months and 4 months, respectively, both followed by another 4 months if indicated. Treatment success was defined by stricture resolution at cholangiography, the ability to pass an inflated extraction balloon and clinical follow-up (at least 6 months). MAIN OUTCOME MEASUREMENT safety of stent removal. Secondary outcomes were complications and successful stricture resolution. RESULTS A total of 23 patients (11 female; 20-67 yrs) were eligible for final analysis. One patient developed a malignant neuroendocrine tumor in the setting of CP. Strictures were caused by CP (13), OLT (6), LCx (3) and PF (1). In total 39 fcSEMS were placed and removed. Removals were easy and without complications. Transient pain after insertion was common (13 of 23/56%) but was easily managed by analgesics in all patients. Other complications were cholecystitis (1), cholangitis due to stent migration (1, stent replaced) or stent clogging (2, managed endoscopically) and worsening of CP (2). In these patients, the fcSEMS was removed and replaced after pancreatic sphincterotomy and PD stent placement. Median follow-up was 15 months (range 11-25). Overall treatment success was 61% (14/23); in the CP group 46%, in the remaining patients 80% (p = 0.11). Patients with stricture resolution after removal of the first stent (n = 7; success 6/7) showed a trent towards a more sustained treatment success than patients who needed a 2nd stent placement (n = 16; success 8/16); p = 0.12). LIMITATIONS Small number of patients with regard to secondary outcomes. CONCLUSION Removal of a new type of fcSEMS with a proximal retrieval lasso in patients with BBS proved easy and uncomplicated. Treatment success for CP strictures was higher compared to what is known from results of progressive plastic stenting protocols. For other indications treatment success was comparable to progressive plastic stenting, but with the prospect of fewer ERCP procedures.
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Affiliation(s)
- Jan-Werner Poley
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands.
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Scherübl H, Jensen RT, Cadiot G, Stölzel U, Klöppel G. Management of early gastrointestinal neuroendocrine neoplasms. World J Gastrointest Endosc 2011; 3:133-9. [PMID: 21860682 PMCID: PMC3159501 DOI: 10.4253/wjge.v3.i7.133] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2011] [Revised: 05/04/2011] [Accepted: 05/18/2011] [Indexed: 02/05/2023] Open
Abstract
Neuroendocrine neoplasms (NENs) of the stomach, duodenum, appendix or rectum that are small (≤ 1 cm) and well differentiated can be considered “early” tumors, since they generally have a (very) good prognosis. In the new WHO classification of 2010, these neoplasms are called neuroendocrine tumors/ carcinoids (NETs), grade (G) 1 or 2, and distinguished from poorly differentiated neuroendocrine carcinomas (NECs), G3. NETs are increasing, with a rise in the age-adjusted incidence in the U.S.A. by about 700 % in the last 35 years. Improved early detection seems to be the main reason for these epidemiological changes. Both the better general availability of endoscopy, and imaging techniques, have led to a shift in the discovery of smaller-sized (≤ 10-20 mm) intestinal NETs/carcinoids and earlier tumor stages at diagnosis. Endoscopic screening is therefore effective in the early diagnosis, not only of colorectal adenocarcinomas, but also of NETs/carcinoids. Endoscopic removal, followed up with endoscopic surveillance is the treatment of choice in NETs/carcinoids of the stomach, duodenum and rectum that are ≤ 10 mm in size, have a low proliferative activity (G1), do not infiltrate the muscular layer and show no angioinvasion. In all the other intestinal NENs, optimal treatment generally needs surgery and/or medical therapy depending on type, biology and stage of the tumor, as well as the individual situation of the patient.
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Affiliation(s)
- Hans Scherübl
- Hans Scherübl, Departments of Gastroenterology, Gastrointestinal Oncology and Infectious Diseases, Vivantes Klinikum Am Urban, Berlin 10967, Germany
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