Melissa S. Phillips

Temporary placement of fully covered self-expandable metal stents in benign biliary strictures: midterm evaluation (with video)

BACKGROUND Benign biliary strictures (BBS) have been endoscopically managed with placement of multiple plastic stents. Uncovered metal stents have been associated with mucosal hyperplasia and partially covered self-expandable metal stents with migration. Recently, fully covered self-expandable metal stents (CSEMSs) with anchoring fins have become available. OBJECTIVE Our purpose was to analyze the efficacy and complication rates of CSEMSs in the treatment of BBS. DESIGN CSEMSs (10-mm diameter) were placed in 44 patients with BBS. CSEMSs were left in place until adequate biliary drainage was achieved, confirmed by resolution of symptoms, normalization of liver function tests, and imaging. SETTING Tertiary care center with long-standing experience with metal stents. PATIENTS A total of 44 patients with BBS (28 men, median age 53.5 years) were included. The preprocedure diagnoses included chronic pancreatitis (n = 19), gallstone-related strictures (n = 14), post liver transplant (n = 9), autoimmune pancreatitis (n = 1), and primary sclerosing cholangitis (n = 1). INTERVENTION ERCP with temporary CSEMS placement. Removal of CSEMSs was performed with a snare or rat tooth. MAIN OUTCOME MEASUREMENTS Stricture resolution and morbidity. RESULTS The median time of CSEMS placement was 3.3 months (interquartile range 3.0-4.8). Resolution of the BBS was confirmed in 34 of 41 patients (83%) after a median postremoval follow-up time of 3.8 months (interquartile range 1.2-7.7). Complications were observed in 6 (14%) patients after CSEMS placement and in 4 (9%) after CSEMS removal. LIMITATION Pilot study from a single center. CONCLUSION Temporary placement of CSEMSs for BBS may offer an alternative to plastic stenting. Further investigation is required to further assess safety and long-term efficacy.

Elevated stricture rate following the use of fully covered self-expandable metal biliary stents for biliary leaks following liver transplantation

BACKGROUND Biliary leaks and strictures are common complications after liver transplantation and can be managed surgically or endoscopically. Endoscopic management using fully covered self-expandable metal stents (FCSEMS) might provide some advantages over the commonly used plastic stents in the management of bile leaks after liver transplantation. METHODS Between December 2006 and January 2009, 17 liver transplant recipients underwent placement of a FCSEMS for treatment of biliary leaks. RESULTS FCSEMS were deployed at median of 18 days (range: 6 - 160) after liver transplantation and left in place for a median of 102 days (range: 35 - 427), with a median follow-up after FCSEMS removal of 407 days (range: 27 - 972). Long-term leak control was obtained in all but one patient. Complications included 6 clinically significant biliary strictures (35 %), which were treated with repeat stent placement, and two clinically insignificant strictures (12 %) which required no intervention. Additionally, three patients (18 %) had biliary ulcerations after stent removal, confirmed by choledochoscopy, and were managed conservatively. Two patients required repeat liver transplantation due to hepatic artery thrombosis, and one patient died from sepsis unrelated to FCSEMS stenting. CONCLUSIONS FCSEMS treat biliary leaks effectively, but carry a relatively high stricture risk in patients who have received liver transplants. FCSEMS cannot be recommended for management of biliary leaks following liver transplantation at this point.

Overview of Enteral and Parenteral Feeding Access Techniques: Principles and Practice

The importance of adequate nutrition has long been established in the surgical patient population. Enteral nutrition provides the safest, most cost-effective approach with endoscopic and surgical options for permanent access. Parenteral nutrition should be reserved for patients in whom enteral nutrition is contradicted. This article summarizes the routes of access for both enteral and parenteral nutrition as well as the indications, procedural pearls, and complications associated with each approach.

Takotsubo cardiomyopathy in a liver transplant recipient: a diagnosis of exclusion?

Tiwari and D’Attellis1 recently reported on transient takotsubo cardiomyopathy (TCM) during liver transplantation (LT). his was only the second case of this type of ventricular dysfunction ever reported in a LT recipient. The first such reported omplication occurred several hours after LT.2 In 1 case, major complications triggered the event and in the other it developed pontaneously. In both cases, myocardial infarction was assumed; both patients underwent coronary arterial angiography, hich excluded coronary artery disease as a cause in both cases. However, in both patients, profound left ventricular ysfunction was shown on echocardiography, and they recovered from the event within a few days with normal cardiac unction. We would like to add another case but emphasize the differential diagnosis of this obscure clinical picture in LT ecipients. Our 60-year-old female patient had been diagnosed with primary biliary cirrhosis in 1990 and was treated with rsodeoxycholic acid. Her past medical history was remarkable for a positive PPD test, osteopenia, and a prior abdominal ysterectomy. There was no evidence for underlying cardiac or pulmonary disease. LT was performed in June 2008 without ajor complications. Also, the immediate post-transplant course was uneventful. The initial immunosuppression included acrolimus (trough levels of 8-12 ng/L), mycophenolate mofetil (1,000 mg daily), and a steroid taper. On day 4 post-LT, the atient experienced acute dyspnea, which was accompanied by signs of right-heart failure. Because of significant renal ysfunction, no computed tomography pulmonary angiogram was performed; however, an ultrasound confirmed a right ommon femoral vein deep vein thrombosis and, on echocardiography, a dilated right ventricle and pulmonary artery were ound supporting the suspected diagnosis of acute pulmonary emboli. Treatment included intravenous heparin, sildenafil, and asopressors. The patient quickly recovered from this event; however, she developed increasing renal failure requiring ontinuous venovenous hemofiltration. In addition, Clostridium difficile–associated colitis was successfully treated with etronidazole and oral vancomycin. She was transferred to the general surgical floor 5 days after the pulmonary embolism. uring the next days, she was intermittently dialyzed; nevertheless, a right-sided pleural effusion increased continuously. The atient became increasingly hypoxic and experienced acute respiratory distress, requiring emergent intubation and placement f bilateral pigtail catheters. An electrocardiogram showed ST-elevation, and an echocardiogram showed severely decreased eft ventricular systolic function with an ejection fraction of 20% and akinesis of the anterior, anteroseptal, and apical regions. n emergency cardiac catheterization was performed, finding only a 20% stenosis of the left main coronary artery without emodynamic significance, leading to a diagnosis of TCM. The patient was treated with metoprolol and aspirin. The global ardiac insufficiency combined with renal failure and temporary worsening of liver function with hypoalbuminemia resulted n significant pleural effusions with a daily output of greater than 1,000 mL from her pigtail drains. Continuous hemofiltration as restarted, the patients condition slowly improved, and she was discharged from the intensive care unit 4 days later. ntermittent hemodialysis was continued, graft function improved, and no other complications developed. On repeat chocardiography 7 days after her decompensation, the ejection fraction had returned to 60%. Renal function slowly mproved, and hemodialysis was no longer required. The patient was discharged 20 days post-LT in good condition, with no igns of cardiac insufficiency and a well-functioning liver graft. TCM is an obscure and poorly understood acute dysfunction of the left ventricle, and usually the septum is also involved.3 he absence of CAD is diagnostic and a typical picture on echocardiography with ballooning of the left ventricle close to the pex, which imitates the shape of a Japanese octopus trap, can be observed. TCM has been linked to major stress such as ambling, acute psychologic events, and significant medical conditions. In LT recipients, a high level of stress can be xpected, and in the case of an intraoperative or postoperative complication, this can be significantly increased. Interestingly, o cases of TCM in recipients of other organs have been reported. The condition has been observed during the induction of nesthesia4 and in immunocompromised individuals such as HIV-infected patients.5 Table 1 summarizes the 2 cases reported hus far and our case of TCM post-LT.1,2 In all 3 cases, massive complications occurred, but all 3 patients survived the episode ith normalization of the ejection fraction.1,2 As for our case, the time between LT and TCM was several days as opposed o the other cases, which occurred intraoperatively and only a few hours after LT. Hemodynamic, toxic, metabolic, and nfectious origins should be included in the differential diagnosis in these patients. In fact, our patient received several agents hat have been reported to be cardiotoxic such as the antibiotics. Clinicians must be aware of the possibility of this acute ardiac dysfunction. It may be worth considering a coronary arterial computed tomography scan instead of angiography in uch cases; magnetic resonance imaging may also be a useful alternative. The acute onset of typical symptoms and the picture

Biliary leak in post-liver-transplant patients: is there any place for metal stent?

Objectives. Endoscopic management of bile leak after orthotopic liver transplant (OLT) is widely accepted. Preliminary studies demonstrated encouraging results for covered self-expandable metal stents (CSEMS) in complex bile leaks. Methods. Thirty-one patients with post-OLT bile leaks underwent endoscopic temporary placement of CSEMS (3 partially CSEMS , 18 fully CSEMS with fins and 10 fully CSEMS with flare ends) between December 2003 and December 2010. Long-term clinical success and safety were evaluated. Results. Median stent indwelling and follow-up were 89 and 1,353 days for PCSEMS, 102 and 849 for FCSEMS with fins and 98 and 203 for FCSEMS with flare ends. Clinical success was achieved in 100%, 77.8%, and 70%, respectively. Postplacement complications: cholangitis (1) and proximal migration (1), both in the FCSEMS with fins. Postremoval complications were biliary strictures requiring drainage: PCSEMS (1), FCSEMS with fins (6) and with flare ends (1). There was no significant differences in the FCSEMS groups regarding clinical success, age, gender, leak location, previous treatment, stent indwelling, and complications. Conclusion. Temporary placement of CSEMS is effective to treat post-OLT biliary leaks. However, a high number of post removal biliary strictures occurred especially in the FCSEMS with fins. CSEMS cannot be recommended in this patient population.

Recent Innovations & Daily Problems.

RECENT INNOVATIONS & DAILY PROBLEMS

Percutaneous Endoscopic Feeding Tube Placement

Enteral access is a safe, reliable, and cost-effective way to provide nutrition to those who are unable to take adequate oral intake. Indications for access may include neurologic diseases causing dysphagia, malignancies of the aerodigestive tract, trauma, and others. Access to the gastrointestinal tract can be obtained through surgical and endoscopic approaches, most commonly through placement of a percutaneous endoscopic gastrostomy (PEG). This chapter details techniques for placement of orally introduced methods including the “pull” and “push” PEG as well as the abdominal wall introducer method. The role of jejunal access for enteral nutrition is also explained.

Mortality in patients undergoing covered self-expandable metal stent revisions in malignant biliary stricture: Does pathology matter?

BACKGROUND AND AIMS Partially covered metal stents have been extensively used for palliation of obstructive jaundice in malignant distal biliary strictures and can be removed in cases of malfunction or need for tissue diagnosis. We investigated independent predictors of mortality in patients undergoing partially covered metal stents revision (i.e., removal and replacement). METHODS Patients with a distal malignant biliary obstruction palliated with a partially covered metal stent were followed-up prospectively over 5 years until malfunction or death. All patients who required removal of their partially covered metal stents were captured in a specific database. Multivariate analysis was performed on non-surgical patients to assess for independent predictors of death using known risk factors including type of malignancy (adenocarcinoma versus all others), age greater than 55, gender, and exposure to adjuvant chemotherapy and/or radiotherapy. RESULTS Forty-two patients (28 men, mean age of 62±12 years) underwent partially covered metal stents removal. Of these, biliary drainage was achieved in 38 patients by placement of a new partially covered metal stent (n=32) or plastic stent (n=6). The remaining 4 patients did not undergo stent replacement because of refusal (2), resolution of obstruction (1) and unrelated death (1). Long-term follow-up post removal in patients who were not surgical candidates (n=31) was 35 weeks (95% CI 28-40), with a survival rate of 29% at 10 months. Logistic regression analysis in the 31 patients with unresectable disease showed that a histologic diagnosis of adenocarcinoma was associated with increased mortality post partially covered metal stents revision. CONCLUSIONS Partially covered metal stents revision should be undertaken especially when dealing with a non-adenocarcinoma type cancer.

30. Complications of Endoscopic Retrograde Cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP) offers many diagnostic and therapeutic options for the management of biliary and pancreatic diseases. It carries associated risks of pancreatitis, hemorrhage, cholangitis, perforation, and other rare complications. This chapter details the rates of occurrence and predisposing factors for the development of these complications. Technical details are highlighted as prevention strategies to decrease complication rates. Medical, endoscopic, and surgical treatment options for these conditions are also discussed.

28. Endoscopic Retrograde Cholangiopancreatography: General Principles

Endoscopic retrograde cholangiopancreatography (ERCP) has emerged as the preferred option when direct visualization of the ampulla and direct access to the distal common bile duct are desired. This chapter describes facilities, equipment, and techniques for successful performance of ERCP in the patient with surgically unaltered gastroduodenal anatomy.