Lluís Secanella

EUS-guided methylene blue cholangiopancreatography for benign biliopancreatic diseases after failed ERCP

BACKGROUND AND AIMS When ERCP fails, EUS-guided interventional techniques may be an alternative. The aim of this study was to evaluate the general outcomes and safety of EUS-guided methylene blue cholangiopancreatography in patients with failed ERCP in benign biliopancreatic diseases. METHODS Patients with benign biliopancreatic diseases and failed ERCP were included. EUS-guided cholangiopancreatography plus injection of methylene blue was performed, and then ERCP using coloring agent flow as an indicator of papilla orifice was performed. Procedures were prospectively collected in this observational, single-center study. Technical success, clinical success, and adverse events were analyzed retrospectively. RESULTS Eleven patients were included (10 choledocholithiasis, 1 pancreatic stricture). The main reason for failed ERCP was an unidentifiable papilla. EUS-guided ductal access with cholangiopancreatography and papilla orifice identification was obtained in all cases. Technical success and clinical success rates of 91% were achieved, with successful biliopancreatic drainage in 10 patients. Adverse events included 1 peripancreatic abscess attributed to a precut, which was successfully treated. No adverse events were related to the first EUS-guided stage. CONCLUSION EUS-guided cholangiopancreatography with methylene blue injection seems to be a feasible and helpful technique for treatment in patients with benign biliopancreatic diseases with previous failed ERCP because of an undetectable papilla.

Double endosonography-guided transgastric and transduodenal drainage of infected pancreatic-fluid collections using metallic stents

A 34-year-old male was referred to our hospital for drainage of symptomatic pancreatic fluid collections (PFCs) secondary to an acute pancreatitis. He was affected by gastro-duodenal and biliary obstruction. CT scan images revealed 1 perigastric pseudocyst (well-defined wall, without necrosis content, 70 x 120 mm) and 1 periduodenal walled-off pancreatic necrosis (WOPN) (thickened wall, partially liquefied collection containing solid content, 80 x 90 mm). Both PFC were accessed under endoscopic ultrasound (EUS)-guidance with a 6 Fr-cystotom and dilation tract using a 10 mm balloon (Fig. 1). First, the pseudocyst was drained transgastrically with a fully covered SEMS with bilateral anchor Double endosonography-guided transgastric and transduodenal drainage of infected pancreatic-fluid collections using metallic stents

Safety of lumen-apposing stent with or without coaxial plastic stent for endoscopic ultrasound-guided drainage of pancreatic fluid collections: a retrospective study

BACKGROUND The aim of this study was to evaluate whether the placement of a coaxial double-pigtail plastic stent (DPS) within a lumen-apposing metal stent (LAMS) may improve the safety of endoscopic ultrasound (EUS)-guided drainage of pancreatic fluid collections (PFCs). METHODS This was a retrospective cohort study including patients with PFCs and an indication for transmural drainage. Two strategies (LAMS alone or LAMS plus DPS) were used at the endoscopists discretion. RESULTS A total of 41 patients were treated (21 LAMS alone; 20 LAMS plus DPS). The characteristics of the PFCs, and the technical and clinical success rates did not differ between groups. The LAMS alone group had a significantly higher rate of adverse events than the LAMS plus DPS group (42.9 % vs. 10.0 %; P = 0.04). Bleeding was the most frequent adverse event observed. CONCLUSIONS The addition of a coaxial DPS to LAMS was associated with a lower rate of adverse events in EUS-guided drainage of PFCs.

Trasplante hepático urgente tras resección completa del pedículo hepático durante una colecistectomía laparoscópica

Since the introduction of laparoscopic cholecystectomy, there has been an increase in the incidence and severity of iatrogenic lesions of hepatic pedicle elements. In open surgery the rate is 0.1% and 0.3%–0.6% in laparoscopic surgery. These lesions are classified as biliary or vascular. Biliary tract lesions are the most common and 47% can be associated with vascular lesions, mainly of the right hepatic artery, common hepatic artery or portal vein. Surgical reconstruction of the bile duct and a conservative approach to arterial lesions are usually possible, and the management of these situations is widely reported in several publications. In cases of hepatic ischemia with atrophy of the parenchyma and sepsis, hepatic resection is the treatment of choice. Orthotopic liver transplantation (OLT) is used in exceptional cases, when the vascular and biliary lesions are irreparable, or later in cases of terminal-phase secondary biliary cirrhosis. We present the case of a patient who underwent elective surgery for cholelithiasis at another hospital. Laparoscopic cholecystectomy was performed, and following the inadvertent complete resection of the hepatic pedicle, emergency OLT was required. A 58-year-old patient with no prior medical history presented symptomatic cholelithiasis and an episode of acute cholecystitis. He had been treated conservatively and he underwent elective laparoscopic cholecystectomy on August 16, 2012. During surgery, according to the report, there was heavy bleeding that was resolved with the placement of multiple clips at the sites of the hemorrhage, without the need for conversion. After 24 h, follow-up lab work showed significant changes in coagulation and a marked increase in the pattern of cytolysis. Therefore, due to suspected hepatic ischemia, the patient was referred to our hospital. On August 17th, upon admission the patient was afebrile and hemodynamically stable. The work-up showed: bilirubin 50 mmol/L (0–18 mmol/L), ALT 100.6 mkat/L (0–0.63 mkat/L), AST 174 mkat/L (0–0.5 mkat/L), TP 2.4 (0.8–1.2). CT showed a multitude of hemoclips in the hepatic pedicle, with complete occlusion of vascular structures of the hepatic hilum and generalized liver hypoperfusion (Fig. 1). Likewise, we observed acute thrombosis of the portomesenteric venous confluence with partial extension to the splenic vein and superior mesenteric vein. Given the extension and severity the injury, the patient was considered a candidate for emergency OLT. On August 18th, 7 h after inclusion on the emergency list, OLT was performed with a cadaveric donor. During surgery, massive hepatic infarction was observed due to resection of the entire hepatic pedicle, along with supraduodenal iatrogenesis caused by the use of clips as well as dissection of the common hepatic artery, portal vein and bile duct (Fig. 2). Orthotopic OLT was performed with arterial anastomosis directly to the supraceliac aorta as the hepatic artery of the recipient was considered inadequate. We performed thrombectomy of the portomesenteric venous axis with portal anastomosis, which required the interposition of an iliac vein graft. The bile duct was reconstructed by means of a Roux-enY hepatic jejunostomy because it was impossible to use the bile duct remains. The patient was discharged on the 17th day of hospitalization after an uneventful postoperative period. Four months after transplantation, the patient maintains normal activity with perfect liver graft function. The correlation between laparoscopic cholecystectomy and bile duct injuries and their management has been well studied. In all cases of suspected post-cholecystectomy iatrogenesis, conversion to open surgery is recommended in order to evaluate the severity of the lesions. c i r e s p . 2 0 1 4 ; 9 2 ( 1 ) : 5 3 – 6 7

Fluoroscopy-assisted vs fluoroless endoscopic ultrasound-guided transmural drainage of pancreatic fluid collections: A comparative study

INTRODUCTION The need for fluoroscopy guidance in patients undergoing endoscopic ultrasound-guided transmural drainage (EUS-TMD) of peripancreatic fluid collections (PFCs) remains unclear. AIMS The aim of this study was to compare general outcomes of EUS-TMD of PFCs under fluoroscopy (F) vs fluoroless (FL). METHODS This is a comparative study with a retrospective analysis of a prospective and consecutive inclusion database at a tertiary centre, from 2009 to 2015. All patients were symptomatic pseudocyst (PSC) and walled-off pancreatic necrosis (WON). Two groups were assigned depending on availability of fluoroscopy. The groups were heterogeneous in terms of their demographic characteristics, PFCs and procedure. The main outcome measures included technical and clinical success, incidences, adverse events (AEs), and follow-up. RESULTS Fifty EUS-TMD of PFCs from 86 EUS-guided drainages were included during the study period. Group F included 26 procedures, PSC 69.2%, WON 30.8%, metal stents 61.5% (46.1% lumen-apposing stent) and plastic stents 38.5%. Group FL included 24 procedures, PSC 37.5%, WON 62.5%, and metal stents 95.8% (lumen-apposing stents). Technical success was 100% in both groups, and clinical success was similar (F 88.5%, FL 87.5%). Technical incidences and intra-procedure AEs were only described in group F (7.6% and 11.5%, respectively) and none in group FL. Procedure time was less in group FL (8min, p=0.0341). CONCLUSIONS Fluoroless in the EUS-TMD of PFCs does not involve more technical incidences or intra-procedure AEs. Technical and clinical success was similar in the two groups.

Es la duodenopancreatectomía cefálica una intervención segura en el paciente cirrótico

INTRODUCTION Pancreaticoduodenectomy (PD) is usually contraindicated in chronic liver disease. The objective of the present study was to analyze PD results in cirrhotic patients, and compare them with non-cirrhotic ones. METHODS Between 1994 and 2014 we prospectively collected all patients with a PD for periampullar neoplasms in Hospital Universitari de Bellvitge. We registered preoperative, intraoperative and postoperative variables. We defined patients undergoing PD with liver cirrhosis as the study group (CH group), and those without liver cirrhosis as the control group (NCH group). A case/control study was performed (1/2). RESULTS We registered 15 patients in the CH group, all with good liver function (Child A), and included 30 patients in NCH group. The causes of hepatopathy were HCV (60%) and alcoholism (40%). For the 3 moments studied, the CH group had a lower blood platelet count and a higher prothrombin ratio, compared with NCH group. Postoperative morbidity was 60% and mean postoperative stay was 25±19 days, with no differences in terms of complications between CH group and NCG group (73% vs. 53%, P=.1). Presence of ascites was higher in the CH group compared with NCH group (28 vs. 0%, P<.001). There were no differences in terms of hemorrhage or pancreatic fístula. Four patients of the CH group and 2 patients of the NCH group were reoperated on (26.7 vs. 6.7%, P=.1). There was no postoperative mortality. CONCLUSIONS PD is a safe procedure in cirrhotic patients with good liver function although it presents high morbidity.

Technical options for outflow reconstruction in domino liver transplantation: A single European center experience

Venous outflow is critical to the success of liver transplantation (LT). In domino liver transplantation (DLT), the venous cuffs should be shared between the donor and the recipient, and the length can be compromised. The aim of this study was to describe and compare the technical options for outflow reconstruction used at our institution. This was a retrospective analysis of 39 consecutive DLT recipients between January 1997 and May 2013. Twenty‐seven men and 12 women (mean age, 61.8 ± 4.3 years) underwent LT and consented to receive a liver from a donor with familial amyloid polyneuropathy (FAP). The main indications were hepatocellular carcinoma and hepatitis C virus cirrhosis. All recipients underwent transplantation by a piggyback technique. Liver procurement in the FAP donors was performed with the classic technique in 22 patients and with the piggyback technique in the last 17. In these latter cases, for vascular outflow reconstruction, a cadaveric venous graft was interposed between the hepatic vein (HV) stump of the FAP liver and the recipient HV in 11 cases (28%). Since 2011, we have employed arterial grafts to be interposed between the vessels stumps: a tailored arterial graft in 5 patients and an aortic graft in 1 case. There was no postoperative mortality. Arterial and portal complications presented in 2 (5.1) and 4 patients (10.3), respectively. Postoperative outflow complications (post‐LT subacute Budd‐Chiari syndrome) occurred in 4 patients, and all of them had received a venous interposed graft for reconstruction. The incidence of outflow complications tended to be higher among patients with venous grafts than those with arterial graft interposition. Overall patient survival at 1, 3, 5, and 10 years was 97%, 79%, respectively. Arterial grafts constitute a feasible and safe option for vascular outflow reconstruction in DLT because they are associated with a relatively low incidence of complications. The recently proposed Bellvitge arterial graft technique should be added to the current range of available surgical modalities. Liver Transpl 21:1051‐1055, 2015.

Resultados del trasplante hepático con donantes de más de 70 años

UNLABELLED Organ shortage has forced transplant teams to progressively expand the acceptance of marginal donors. METHODS We performed a comparative analysis of the post-transplant evolution depending on donor age (group I: less than 70 years old (n=474) vs. group II: 70 or more years old [n=105]) over a 10 year period (2002-2011). RESULTS Donors over 70 years old were similar to donors less than 70 years old in terms of ICU stay, gender, weight, laboratory results, and use of vasoactive drugs. However, the younger donor group presented with cardiac arrest more often (GI: 14 vs. GII: 3%, P=.005). There were no differences in initial poor function (GI: 6% vs. GII: 7,7%; P=.71), ICU stay (GI: 2.7±2 vs. GII: 3.3±3.8, P=.46), hospital stay (GI: 13.5±10 vs. GII: 15.5±11, P=.1), or hospital mortality (GI: 5.3 vs. GII: 5.8%, P=.66) between receptors of more or less than 70 year old grafts. After a median follow up of 32 months, no differences were found in the incidence of biliary tract complications (GI: 17 vs. GII: 20%, P=.4) or vascular complications (GI: 11 vs. GII: 9%, P=.69). The actuarial 5 year survival was similar for both study groups (GI: 70 vs. GII: 76%, P=.54). CONCLUSIONS In our experience, the use of grafts from donors older than 70 years, when other risk factors are avoided (cold ischemia, steatosis, sodium levels), does not worsen the results of liver transplantation on the short or long term.

Indicaciones y resultados de la resección de metástasis pancreáticas. Experiencia en el Hospital Universitario de Bellvitge

OBJECTIVE To analyse the indications and results of pancreatic metastasis resection in a university hospital. PATIENTS AND METHODS An analysis was performed on a prospective database from 1990 to 2010. The clinical-pathological and perioperative details, as well the follow-up results were analysed. RESULTS Of the 710 pancreatic resections performed, 7 cases (0.99%) were due to a metastasis in the pancreas. The mean age of the patients was 53.3 years (20-77 years), and 5 were male and 2 were women. Five (70%) patients were asymptomatic. The origin of the metastasis was: colon (n=3), kidney (n=2), jejunum (n=1), and testicle (n=1). In 4 cases they were situated in the head, 2 in the tail, and one in the body. The metastases were metachronous in 4 (57%) patients and the disease free interval was 29 months (17-48). There were 3 cases (43%) of synchronous metastases, with a mean recurrence-free time of 14 months, and survival of 21.6 months. This was lower than that of patients with metachronous metastases, which was 27.8 months and with a survival of 32 months, respectively. The overall disease free interval and survival was 21.85 months and 27.5 months, respectively. CONCLUSION Resection of pancreatic metastases can extend survival in selected patients.