Sung Ill Jang

Magnetic compression anastomosis is useful in biliary anastomotic strictures after living donor liver transplantation

BACKGROUND An anastomotic biliary stricture is a complication of living donor liver transplantation (LDLT) performed using duct-to-duct anastomosis. Despite advances in treating this complication, there is no one established treatment protocol. OBJECTIVE To investigate the safety, effectiveness, and mid-term outcome of magnetic compression anastomosis (MCA) for treating biliary obstruction after LDLT when the obstruction cannot be resolved by using percutaneous or peroral methods. DESIGN Retrospective, observational study with standardized treatment and follow-up. SETTING Tertiary-care academic medical center. PATIENTS Twelve patients underwent MCA procedures to treat anastomosis site stricture after LDLT. INTERVENTIONS MCA. MAIN OUTCOME MEASUREMENTS Bile duct patency, technique performance, and complications were evaluated. RESULTS We achieved magnet approximation at the anastomotic stricture in 10 of 12 patients (83.3%). The magnets failed to approximate in 2 patients. We achieved recanalization of the stricture site in 10 of 10 patients. We removed an internal catheter in 9 patients. The mean interval from magnet approximation to removal was 74.2 days (range 14-181 days). The mean time from recanalization to removal of the internal catheter was 183 days (range 51-266 days). Patients were examined regularly after removing the internal catheter with a mean follow-up period of 331 days (range 148-581 days). The observed MCA-related complications consisted of 1 case of mild cholangitis and 1 recurrence of the anastomotic stricture. LIMITATIONS Nonrandomized study design. CONCLUSIONS MCA safely and effectively resolved post-LDLT biliary duct-to-duct anastomotic strictures that could not be resolved using conventional methods, such as ERCP and percutaneous transhepatic biliary drainage.

Drug-eluting stent in malignant biliary obstruction

Endoscopic stent insertion is the treatment of choice for patients with malignant biliary obstruction. However, conventional stents enable only mechanical palliation of the obstruction, without any anti-tumor effects. Drugeluting stent (DES), which was first introduced in coronary artery disease, are currently under investigation for sustaining stent patency and prolonging patient survival by inhibiting tumor ingrowth in malignant biliary obstruction. Many factors affecting efficient drug delivery have been studied to determine how drugs with antitumor effects suppress tumor ingrowth, including the specific drugs incorporated, means of incorporating the drugs, mode of drug release, and stent structure. Advances have resulted in the construction of more effective non-vascular DES and ongoing clinical research. Non-vascular DES is expected to play a vital role in prolonging the survival of patients with malignant biliary obstruction.

Porcine feasibility and safety study of a new paclitaxel-eluting biliary stent with a Pluronic- containing membrane

BACKGROUND AND STUDY AIM Metal stents for malignant biliary obstruction are susceptible to occlusion by tumor ingrowth or overgrowth. Therefore, we previously reported our use of a metal stent covered with a paclitaxel-incorporated membrane giving an antitumor effect to prevent occlusion from tumor ingrowth. We have also developed a new generation of paclitaxel-eluting biliary stent using a membrane containing Pluronic F-127 for effective drug delivery. The aim of this study was to investigate the safety and efficacy of drug delivery for this newly developed stent in the biliary tract. METHODS Metal stents were coated with paclitaxel and various concentrations of Pluronic F-127 in phosphate-buffered saline solution. Stents containing varying concentrations were placed in the bile ducts of eight pigs divided as follows: group I, 0% Pluronic + 0% paclitaxel; group II, 0% Pluronic + 10% paclitaxel; group III, 10% Pluronic + 10% paclitaxel; group IV, 20% Pluronic + 10% paclitaxel. The histology of the porcine bile duct and the amount of paclitaxel in the porcine serum were examined. The amount of paclitaxel released was also measured in vitro. RESULTS Histologic changes in the porcine biliary epithelium were acceptable in terms of safety, based on inflammatory cell infiltration and fibrotic reaction. No significant differences in histology were observed between the groups. In the porcine serum analysis, released paclitaxel was detected for 28 days with the 10% Pluronic concentration (group III). However, released paclitaxel was observed for only 7 days in groups II and IV. In the in vitro experiments, long-lasting release of paclitaxel was also noted from the stent with 10% Pluronic. CONCLUSIONS The new paclitaxel-eluting stent with 10% Pluronic F-127 is safe and provides enhanced local drug delivery.

Recanalization of refractory benign biliary stricture using magnetic compression anastomosis

BACKGROUND AND STUDY AIMS Endoscopic or percutaneous treatments are preferentially attempted for benign biliary stricture (BBS). However, these methods are not feasible if a guide wire cannot be passed through the stricture. This study evaluated the usefulness and technical requirements of magnetic compression anastomosis (MCA) in refractory BBS. PATIENTS AND METHODS MCA was performed in patients with BBS that had not been resolved with conventional treatments. One magnet was delivered through the percutaneous transhepatic biliary drainage tract and the other magnet was advanced through three different routes. After magnet approximation and recanalization, an internal drainage catheter was placed for 6 months and then removed. RESULTS Seven patients underwent MCA, and recanalization was successfully achieved in five. MCA failure in two cases was attributed to long stenotic segments and parallel alignment of the axes of the magnets. The mean follow-up period after recanalization was 485.2 days. Five patients with successful recanalization showed no MCA-related complications or restenosis. CONCLUSIONS MCA represents an alternative nonsurgical method of BBS recanalization that cannot be treated with conventional methods.

Percutaneous biliary approach as a successful rescue procedure after failed endoscopic therapy for drainage in advanced hilar tumors.

Palliative endoscopic or percutaneous biliary drainage is used for unresectable advanced hilar cancer (HC). The best option for drainage in Bismuth type III or IV HC has not been established. The aims of this study are to identify factors predictive of endoscopic stenting failure and evaluate the effectiveness of rescue percutaneous stenting in patients with advanced HC.

Clinicopathological features of choledocholithiasis patients with high aminotransferase levels without cholangitis: Prospective comparative study.

AbstractCommon bile duct (CBD) stones are generally associated with greater elevations of alkaline phosphatase and gamma-glutamyl transpeptidase levels than aspartate aminotransferase and alanine aminotransferase levels. However, some patients with CBD stones show markedly increased aminotransferase levels, sometimes leading to the misdiagnosis of liver disease. Therefore, the aim of this study was to investigate the clinicopathologic features of patients with CBD stones and high aminotransferase levels.This prospective cohort study included 882 patients diagnosed with CBD stones using endoscopic retrograde cholangiopancreatography (ERCP). Among these patients, 38 (4.3%) exhibited aminotransferase levels above 400 IU/L without cholangitis (gallstone hepatitis [GSH] group), and 116 (13.2%) exhibited normal aminotransferase levels (control group). We compared groups in terms of clinical features, laboratory test results, radiologic images, and ERCP findings such as CBD diameter, CBD stone diameter and number, and periampullary diverticulum. Liver biopsy was performed for patients in the GSH group.GSH patients were younger and more likely to have gallbladder stones than control patients, implying a higher incidence of gallbladder stone migration. Also, GSH patients experienced more severe, short-lasting abdominal pain. ERCP showed narrower CBDs in GSH patients than in control patients. Histological analysis of liver tissue from GSH patients showed no abnormalities except for mild inflammation.Compared with control patients, GSH patients were younger and showed more severe, short-lasting abdominal pain, which could be due to a sudden increase of CBD pressure resulting from the migration of gallstones through narrower CBDs. These clinical features could be helpful not only for the differential diagnosis of liver disease but also for investigating the underlying mechanisms of liver damage in obstructive jaundice. Moreover, we propose a new definition of “gallstone hepatitis” based on the specific clinicopathologic characteristics observed in our patients.

Maintenance of the fistulous tract after recanalization via magnetic compression anastomosis in completely obstructed benign biliary stricture

Abstract Objective: This study compared the efficacy of a percutaneous transhepatic cholangioscopy (PTCS) catheter and a fully covered self-expandable metal stent (FCSEMS) for maintaining biliary tract patency after magnetic compression anastomosis (MCA). Methods: This study included patients with completely obstructed benign biliary stricture (BBS), which was resolved by MCA and subsequent insertion of a PTCS catheter or FCSEMS. We compared the restenosis-free time after removal of the PTCS catheter or FCSEMS, and the rate of complications. Results: A total of 49 patients were analyzed. The mean ages of the patients in these groups were 50.1 and 49.6 years, respectively. The predisposing conditions causing complete BBS were liver transplantation (n = 38), abdominal surgery (n = 10) and trauma (n = 1). The mean indwelling durations were 176 and 128 days in the PTCS catheter and FCSEMS groups, respectively. The mean follow-up duration after removal of the PTCS catheter and FCSEMS were 2259 and 680.5 days, respectively. Three patients in the PTCS group and three patients in the FCSEMS group experienced stricture relapse. The mean duration between recurrence and stent removal were 924 and 265 days, respectively, and the numbers of stricture-free days did not differ significantly between the two groups. The adverse event rate did not differ significantly between the PTCS and FCSEMS groups (50% vs. 24.2%, respectively). Conclusions: FCSEMSs have an efficacy and safety similar to those of PTCS catheters for maintaining biliary tract patency after MCA, but are more convenient for patients.

Comparison of endoscopic papillary large balloon dilation with or without endoscopic sphincterotomy for the treatment of large bile duct stones

BACKGROUND Endoscopic papillary large balloon dilation (EPLBD) without prior endoscopic sphincterotomy (EST) produces excellent outcomes for the treatment of large common bile duct (CBD) stones. However, it remains unclear how the outcomes of EPLBD alone compare with those of EPLBD with EST. In this study, we assessed the safety and therapeutic outcomes of EPLBD with vs. without EST for the removal of large bile duct stones. METHODS This prospective, multicenter study was conducted on 200 patients with bile duct stones of ≥ 10 mm in diameter. Patients were randomly assigned to an EPLBD alone group (n = 100) or an EPLBD with EST group (n = 100). These two groups were compared with respect to overall procedure-related adverse events, overall stone removal success rate, number of endoscopic sessions required for complete stone removal, need for mechanical lithotripsy, and total procedure time. RESULTS The incidence of adverse events was not significantly different between the groups (EPLBD alone vs. EPLBD with EST: overall adverse events 6 % vs. 4 %, P = 0.75; pancreatitis 1 % vs. 3 %, P = 0.62). Overall success (P = 0.35), initial success (P = 0.28), and the need for mechanical lithotripsy (P = 0.39) were also similar between groups. Median total procedure time tended to be greater in the EPLBD alone group (20.5 minutes) than in the EPLBD with EST group (18 minutes; P = 0.08). CONCLUSION The therapeutic outcomes and adverse events of EPLBD alone for the removal of large bile duct stones were comparable to those of EPLBD with EST.

Tu1931 Gemcitabine-Eluting Membrane Inhibits Pancreatic/ Cholangiocarcinoma Tumor Growth and Metastasis by Blocking the Epidermal Growth Factor Receptor Signaling Pathway

G A A b st ra ct s death or censored at time of last contact (median follow-up 251 days (d), range 0-1758 d). Survival rates were analysed using the Kaplan-Meier method. Pearsons correlation analyses were performed with respect to survival times and concentrations of IGF-1 and DKK-1. Results. At the time of the analysis 54 patients had died. The concentrations of IGF-1 significantly correlated with survival (0.324, p < 0.01) while the concentration of DKK-1 did not (-0.109, p = 0.197). Survival times using previously published cut-offs for BALAD2 score [-0.91] and IGF-1 [30 ng/ml] are given in table 1. Conclusion. IGF-1 and the BALAD-2 score are valuable to predict survival in patients with hepatocellular carcinoma.

Sa1320 Eicosapentaenoic Acid Dissolves Cholesterol Gallstones by Attenuating Cholesterol Saturation and Suppressing Mucin Production in Mice

Background/aim: Gallbladder (GB) polyps larger than 10 mm have been recommended to be resected because of the high risk of malignancy. However, previous reports have been studied in subjects who underwent surgical resection. So, the calculated odds ratios of risk factors for malignant GB polyp could have a bias against their true meaning. There have been no reports on the natural history of GB polyp greater than 10mm. In this study, we examine the natural history of GB polyps larger than 10 mm and confined to mucosal layer evaluated by EUS. Methods: Patients who had GB polyps larger than 10 mm measured by EUS but was not operated were retrospectively enrolled at a single tertiary center, Seoul National University Hospital in Korea, between Dec. 2004 and Dec. 2013. Those who were not followed up less than one year were excluded. Results: A total of 56 patients were managed by regular follow-up with ultrasonography. The mean age was 49.9 ± 12.1 yo. Male to female ratio was 22:33. The mean diameter of polyp was 11.4 ± 1.5 mm. Multiple polyps were found in 30 patients, sessile poly in 29, hyperechoic polyp in 44, and irregular polyp margin in 18. The median follow-up duration was 3.5 yrs (range, 1 9.3 yrs). During follow-up, polyp size increased in 13 (23%) and the mean velocity was 2.7mm/yr. Thirteen (23.2%) patients underwent cholecystectomy during follow-up. Carcinoma was found in one, adenoma in 7 and cholesterol or inflammatory polyp in 5. The risk factors of size increase during follow-up were presence of symptom (P=0.041) and age≥50 (P=0.004) in the univariate analysis. Age≥50 was an independent risk factor of progression in the multivariate analysis (RR=10.1; P=0.009; 95% CI, 1.802-56.124). Conclusion: Natural history of GB polyp larger than 10 mm is usually good especially if the age of the patient is under 50 yrs.