Bruno Meduri

Prediction of common bile duct stones by noninvasive tests

OBJECTIVE To define accurate and useful predictors of common bile duct stones (CBDS). SUMMARY BACKGROUND DATA The ability to predict CBDS with noninvasive tests can avoid unnecessary, costly, or risky procedures. METHODS All patients referred for examination for CBDS by endoscopic ultrasonography (EUS) from 1993-1996 were prospectively entered in a database. In a first sample selected randomly from the whole population, predictors of CBDS were determined by univariate analysis and logistic regression. Predictors were subsequently tested in that sample and in the rest of the population. A separate analysis was done for patients planned for cholecystectomy. RESULTS Eight hundred and eighty patients (328 men, 552 women), aged 57.8 +/- 17 years (range 16-94), were included. The prevalence of CBDS was 18.8%. Age, serum levels of bilirubin, aspartate aminotransferase, alanine aminotransferase, gamma-glutamyl transferase (GGT), and alkaline phosphatase, and the existence of jaundice and fever, a dilated bile duct, and a pathologic gallbladder were found to be associated with CBDS. Logistic regression was undertaken separately for patients younger than 70 years (predictors: GGT >7 x normal; pathologic gallbladder; dilated bile duct) and older than 70 years (predictors: GGT >7 x normal; fever > 38 degrees C; dilated bile duct). Odds ratios were 3 to 6.7. The model was satisfactorily applicable to the second sample; age <70 years: chi2 = 3.3 (NS); age >70 years: chi2 = 3.8 (NS). In patients younger than age 70 and planned for cholecystectomy, the combination of the level of GGT and dilated bile duct predicted CBDS accurately. CONCLUSIONS A simple screening of patients at risk for CBDS can be achieved with three predictive criteria adapted for the patients age.

Closure of gastrointestinal defects with Ovesco clip: long-term results and clinical implications.

Background: The Over-The-Scope Clip (OTSC®, Ovesco Endoscopy GmbH, Tübingen, Germany) is an innovative clipping device that provides a strong tissue grasp and compression without provoking ischemia or laceration. In this retrospective study we evaluated immediate and long-term success rates of OTSC deployment in various pathologies of the gastrointestinal (GI) tract. Methods: A total of 45 patients (35 female, 10 male) with an average age of 56 years old (range, 24–90 years) were treated with an OTSC for GI defects resulting from a diagnostic or interventional endoscopic procedure (acute setting group) or for fistula following abdominal surgery (chronic setting group). All procedures were performed with CO2 insufflation. Results: From January 2012 to December 2015 a total of 51 OTSCs were delivered in 45 patients for different kinds of GI defects. Technical success was always achieved in the acute setting group with an excellent clip adherence and a clinical long-term success rate of 100% (15/15). Meanwhile, considering the chronic setting group, technical success was achieved in 50% of patients with a long-term clinical success of 37% (11/30); two minor complications occurred. A total of three patients died due to causes not directly related to clip deployment. Overall clinical success rate was achieved in 58% cases (26/45 patients). A mean follow-up period of 17 months was accomplished (range, 1–36 months). Conclusion: OTSC deployment is an effective and minimally-invasive procedure for GI defects in acute settings. It avoids emergency surgical repair and it allows, in most cases, completion of the primary endoscopic procedure. OTSC should be incorporated as an essential technique of today’s modern endoscopic armamentarium in the management of GI defects in acute settings. OTSCs were less effective in cases of chronic defects.

Acute pancreatitis associated with a pancreatic hydatid cyst: understanding the mechanism by EUS

The liver and lungs are the most frequent localizations f hydatid disease, whereas pancreatic hydatid cysts are are, accounting for less than 1% of cases.1 Acute pancretitis is associated with hydatid parasitosis in 2% of cases in ndemic areas.2 Like liver cysts,3,4 pancreatic hydatid cysts may cause cute pancreatitis.5-9 Whereas parasite migration into he common bile duct is advocated as the etiological echanism to explain acute pancreatitis caused by liver ydatidosis,3,4 it is unclear why some patients affected y pancreatic cysts develop this complication. Two hyotheses are advocated: main pancreatic duct (MPD) ompression caused by the cyst itself6,10,11 and MPD bstruction by hydatid scolices’ migration from the hyatid cyst.5,9,12 Unfortunately, neither of these hypothees has been confirmed at imaging/surgery. Preoperative diagnosis of a pancreatic hydatid cyst may be ifficult. Symptoms are often aspecific: pain,7,12-14 an epigasric mass,12,15 or weight loss.7 At imaging, hydatid cysts ay be mistaken for cystic pancreatic tumors or intrauctal papillary mucinous neoplasia, especially when ingle.11 The onset of acute pancreatitis may prompt rgent pancreas imaging, although, in these cases, a ydatid cyst may be misdiagnosed as a pseudocyst,6,7 hich is a common complication of acute/recurrent ancreatitis.

Endoscopic internal drainage as first-line treatment for fistula following gastrointestinal surgery: a case series

Background and study aims: Leaks following gastrointestinal surgery are a dreadful complication burdened by high morbidity and not irrelevant mortality. Endoscopic internal drainage (EID) has showed optimal results in the treatment of leaks following bariatric surgery. We report our experience with EID as first-line treatment for fistulas following surgery along all gastrointestinal tract.

Combined endoscopic and radiologic approach for complex bile duct injuries (with video)

4. Van Tienhoven G, Gouma DJ, Richel DJ. Neoadjuvant chemoradiotherapy has a potential role in pancreatic carcinoma. Ther Adv Med Oncol 2011;3:27-33. 5. Goldstein SD, Ford EC, Duhon M, et al. Use of respiratory-correlated four-dimensional computed tomography to determine acceptable treatment margins for locally advanced pancreatic adenocarcinoma. Int J Radiat Oncol Biol Phys 2010;76:597-602. 6. Van der Horst A, Wognum S, Davila Fajardo R, et al. Interfractional position variation of pancreatic tumors quantified using intratumoral fiducial markers and daily cone beam computed tomography. Int J Radiat Oncol Biol Phys 2013;87:202-8. 7. Park W, Yan B, Schellenberg D. EUS-guided gold fiducial insertion for image-guided radiation therapy of pancreatic cancer: 50 successful cases without fluoroscopy. Gastrointest Endosc 2010;71:513-8. 8. Sanders M, Moser A, Khalid A. EUS-guided fiducial placement for stereotactic body radiotherapy in locally advanced and recurrent pancreatic cancer. Gastrointest Endosc 2010;71:1178-84. 9. Varadarajulu S, Trevino JM, Shen S, et al. The use of endoscopic ultrasound-guided gold markers in image-guided radiation therapy of pancreatic cancers: a case series. Endoscopy 2010;42: 423-5.

Outcome of Leaks After Sleeve Gastrectomy Based on a New Algorithm Addressing Leak Size and Gastric Stenosis

We welcomed with great interest the masterpiece of Nedelcu et al. [1] concerning the outcome of leaks after laparoscopic sleeve gastrectomy (LSG) based on a new algorithm addressing leak size and gastric stenosis. The article stressed the importance of adopting this new algorithm in order to standardize leak management, thus reducing the number of endoscopic procedures. We agree with the authors about the use of endoscopic internal drainage (EID) by means of double pigtail to achieve complete healing. As already reported by our team [2], since March 2013, we adopted EID as the only endoscopic treatment in case of fistulas after LSG or gastric bypass, irrespective to leak size. Moreover, we believe in the importance of introducing a well-defined algorithm in order to standardize the endoscopic treatment modality for leak following bariatric surgery. However, according to our experience, we have some remarks to do. Here, we report a case of a 59-year-old woman, presenting an early fistula [3] following laparoscopic sleeve gastrectomy. At day 12 after surgery, she underwent reoperation for peritonitis with lavage and drainage of peritoneal cavity, and two peri-gastric surgical drainage were left in place. No primary repair was attempted due to severe local tissue inflammation. Endoscopy showed a 2-cm-long dehiscence, of the last staple fire line, allowing passing through with the scope. Swallow study through the scope showed the persistence of intra-abdominal collection in the left hypochondrium and the presence of a left bronchial tree fistula (Fig. 1). EID was performed and two 10 Fr double pigtail drains (DPD) were positioned with the aim to drain and promote re-epithelialization of the cavity. After four endoscopic sessions, an Ovesco® clip (OTSC®; Ovesco Endoscopy GmbH, Tubingen, Germany) was delivered to close the remaining blind cross-fistula.

Colic and gastric over-the-scope clip (Ovesco) for the treatment of a large duodenal perforation during endoscopic retrograde cholangiopancreatography.

Successful management of endoscopic retrograde cholangiopancreatography (ERCP)-related duodenal perforations, up to 20 mm, has been reported using several endoscopic devices [Von Renteln et al. 2010; Buffoli et al. 2012; Dogan et al. 2013; Donatelli et al. 2013; Meduri et al. 2014], however, surgery remains the standard of care management of larger defects [Wu et al. 2006; Lee et al. 2013]. Here we report, to the best of the authors’ knowledge, the first case of successful treatment of a large duodenal perforation (>20 mm) during ERCP, using several Ovesco clips. A 66-year-old white man was addressed for biliary drainage due to important cholestasis secondary to a liver metastatic lesion of an urothelial cancer treated by surgery and chemotherapy. During ERCP and while delivering the third plastic 10F stent (Figure 1) a movement of the endoscope provoked a large retroperitoneal duodenal perforation occupying 1/3 of the duodenal wall (Figure 2), opposite to the papilla at the early beginning of second duodenum. The size of perforation was important, mostly because the duodenal wall is thin and injury provoked a mucosal laceration with tearing of the wall. The decision to deliver a plastic stent instead of a metal one was taken given the poor prognosis of the patient, and namely because the stenosis was evaluated as ‘Bismuth IV’, and in the case of no improvement of liver function tests, a radiological percutaneous transhepatic approach would be compromised. Then the duodenoscope together with the partially delivered stent were immediately retrieved. A standard gastroscope loaded with an 11t Ovesco (OTSC®; Ovesco Endoscopy GmbH, Tubingen, Germany), under CO2 insufflation, was introduced but unfortunately the duodenal tear was too large, both in length and width, making it impossible to aspirate both edges of the tear in the cap or approach using a Twin Grasper®. A coloscope loaded with a 14t Ovesco was subsequently introduced and endoscopic suturing was started between the greater omentum and one edge of the duodenal tear (Figure 3). Since a closure defect persisted at the other end as shown after contrast-medium injection (Figure 4), the gastric Ovesco was delivered while aspirating the omentum incarcerated between the first colic clip and the free edge of the perforation, achieving full closure without contrast-medium extravasation (Figure 5). A nasogastric tube was left in place in soft aspiration. The patient was then transferred to the intensive care unit (ICU), for surveillance, where he remained for 7 days before being discharged. During his stay in the ICU, no fever was detected, the liver function tests were improved, and no further ERCP was needed to add the third stent. We only noticed a transient rise of the C-reactive protein, before its complete normalization, and CT scan as well as water-soluble contrast upper-studies performed on days 2 and 5 postoperatively were normal (Figure 6). Oral nutrition was started on day 6. At 1 month after endoscopy, the patient is fully asymptomatic. Figure 1. Hilar stenosis with 2 plastic stents in place. The guidewire in the left duct is about be placed, in order to deliver the third stent. Figure 2. Large duodenal defect. Figure 3. Colic clip Ovesco in place incarcerating greater omentum. Figure 4. Contrast-medium extravasation at the one end of the duodenal perforation despite colic Ovesco placement, given the large size of the defect. Figure 5. Watertight closure achieved using a ‘bridge technique’ using Ovesco on Ovesco. Figure 6. CT scan showing clips in place with no extravasation of contrast medium. In conclusion OTSC is a surgery-sparing device, and colic and gastric clips together can be a useful tool for the closure of large duodenal defects. However, the use of a colic Ovesco should be considered too, mainly because of its size, for upper gastrointestinal interventions in an expert’s hands.

Revision of biliary sphincterotomy by re-cut, balloon dilation or temporary stenting: comparison of clinical outcome and complication rate (with video)

Background and study aims Revision of endoscopic retrograde cholangiopancreatography (ERCP) may be necessary following previous biliary endoscopic sphincterotomy for recurrent biliary symptoms related to biliary stone recurrence, cholangitis or post-biliary endoscopic sphincterotomy (bEST) papillary stenosis and cholestasis. The aim of this retrospective study was to evaluate the clinical outcome and complication rate associated with re-cut, balloon dilation and biliary metal stenting in revision ERCP. Patients and methods From January 2010 to January 2015, 139 subjects with stigma of a previous sphincterotomy required a revision ERCP (64 Men/75 Women; mean age 71 years; range 32 – 101 years). The most appropriate technique (re-cut, balloon dilation or fully covered self-expandable metal stent [FCSEMS] placement) was tailored according to underlying pathologies and anatomical features. Results Technical success was achieved in all cases (100 %). Clinical success (definitive clearance of common bile duct stones and liver test normalization) was achieved in 127 out of 139 patients (91.4 %) with a mean follow up of 12 months. 12 clinical failures occurred: 11 patients required a new ERCP after an average of 9 months meanwhile 1 patient required surgery for definite treatment. The overall complication rate was 9 % (13 /139) with 5 acute complications (intra-procedural) and 8 short-term complications (before 1 month). Group specific overall complication rates were as follow: re-cut 11.5 % (8 bleeds and 3 perforations), balloon dilation 25 % (4 mild PEP [post-ERCP pancreatitis]), FCSEMS 14.3 % (1 moderate PEP), re-cut + balloon dilation and re-cut + FCSEMS 0 %. A statistically significant higher risk of post-ERCP pancreatitis was highlighted in the balloon dilation group meanwhile re-cut was burdened by a higher risk of bleeding and perforation. Conclusions Revision ERCP following previous bEST is a feasible procedure enabling clinical success in most cases. Different approaches are available and must be considered according to underlying pathologies. Re-cut is burdened by a higher risk of perforation and bleeding compared to balloon dilation and SEMS meanwhile balloon dilation is associated to increased risk of PEP.

Fully covered self-expandable metal stent in the treatment of postsurgical colorectal diseases: outcome in 29 patients:

Background: Self-expandable metal stent (SEMS) placement is a minimally invasive treatment for palliation of malignant colorectal strictures and as a bridge to surgery. However, the use of SEMS for benign colorectal diseases is controversial. The purpose of this retrospective study is to evaluate the efficacy and safety of fully covered SEMS (FCSEMS) placement in postsurgical colorectal diseases. Methods: From 2008 to 2014, 29 patients with 32 FCSEMS deployment procedures were evaluated. The indications for stent placement were: 17 anastomotic strictures (3/17 presented complete closure of the anastomosis); four anastomotic leaks; seven strictures associated with anastomotic leak; and one rectum-vagina fistula. Results: Clinical success was achieved in 18 out of 29 patients (62.1%) being symptom-free at an average of 19 months. In the remaining 11 patients (37.9%), a different treatment was needed: four patients required multiple endoscopic dilations, 4 patients colostomy confection, one patient definitive ileostomy and three patients revisional surgery. The FCSEMS were kept in place for a mean period of 34 (range: 6–65) days. Major complications occurred in 12 out of 29 patients (41.4%) and consisted of stent migration. Minor complications included two cases of transient fever, eight cases of abdominal or rectal pain, and one case of tenesmus. Conclusion: FCSEMS are considered a possible therapeutic option for treatment of postsurgical strictures and leaks. However, their efficacy in guaranteeing long-term anastomotic patency and leak closure is moderate. A major complication is migration. The use of FCSEMS for colonic postsurgical pathologies should be carefully evaluated for each patient.

Post-biliary sphincterotomy bleeding despite covered metallic stent deployment

Objectives: Several endoscopic techniques have been proposed for the management of post-sphincterotomy bleeding. Lately, self-expandable metal stents deployment has gained popularity especially as a rescue therapy when other endoscopic techniques fail. Methods-results: We report the case report of a massive post-sphincterotomy bleeding in a patient with a self-expandable metal stent in the biliary tree. Despite the presence of a correctly positioned self-expandable metal stent, a new endoscopic session was required to control the bleeding. Conclusions: Self-expandable metal stent may be useful to manage post-endoscopic sphincterotomy bleeding. However, up to now there is no specifically designed self-expandable metal stent for such complication. Large new designed self-expandable metal stent may be a useful tool for biliary endoscopist.