W. Veltzke-Schlieker

Ligation versus propranolol for the primary prophylaxis of variceal bleeding in cirrhosis

In this randomized controlled multicenter trial, we compared endoscopic variceal banding ligation (VBL) with propranolol (PPL) for primary prophylaxis of variceal bleeding. One hundred fifty‐two cirrhotic patients with 2 or more esophageal varices (diameter >5 mm) without prior bleeding were randomized to VBL (n = 75) or PPL (n = 77). The groups were well matched with respect to baseline characteristics (age 56 ± 10 years, alcoholic etiology 51%, Child‐Pugh score 7.2 ± 1.8). The mean follow‐up was 34 ± 19 months. Data were analyzed on an intention‐to‐treat basis. Neither bleeding incidence nor mortality differed significantly between the 2 groups. Variceal bleeding occurred in 25% of the VBL group and in 29% of the PPL group. The actuarial risks of bleeding after 2 years were 20% (VBL) and 18% (PPL). Fatal bleeding was observed in 12% (VBL) and 10% (PPL). It was associated with the ligation procedure in 2 patients (2.6%). Overall mortality was 45% (VBL) and 43% (PPL) with the 2‐year actuarial risks being 28% (VBL) and 22% (PPL). 25% of patients withdrew from PPL treatment, 16% due to side effects. In conclusion, VBL and PPL were similarly effective for primary prophylaxis of variceal bleeding. VBL should be offered to patients who are not candidates for long‐term PPL treatment. (HEPATOLOGY 2004;40:65–72.)

Biliary Complications After Liver Transplantation: Old Problems and New Challenges

Due to a vulnerable blood supply of the bile ducts, biliary complications are a major source of morbidity after liver transplantation (LT). Manifestation is either seen at the anastomotic region or at multiple locations of the donor biliary system, termed as nonanastomotic biliary strictures. Major risk factors include old donor age, marginal grafts and prolonged ischemia time. Moreover, partial LT or living donor liver transplantation (LDLT) and donation after cardiac death (DCD) bear a markedly higher risk of biliary complications. Especially accumulation of several risk factors is critical and should be avoided. Prophylaxis is still a major issue; however no gold standard is established so far, since many risk factors cannot be influenced directly. The diagnostic workup is mostly started with noninvasive imaging studies namely MRI and MRCP, but direct cholangiography still remains the gold standard. Especially nonanastomotic strictures require a multidisciplinary treatment approach. The primary management of anastomotic strictures is mainly interventional. However, surgical revision is finally indicated in a significant number of cases. Using adequate treatment algorithms, a very high success rate can be achieved in anastomotic complications, but in nonanastomotic strictures a relevant number of graft failures are still inevitable.

An outbreak of carbapenem-resistant OXA-48 – producing Klebsiella pneumonia associated to duodenoscopy

BackgroundCarbapenemase-producing Enterobacteriaceae (CPE) have become a major problem for healthcare systems worldwide. While the first reports from European hospitals described the introduction of CPE from endemic countries, there is now a growing number of reports describing outbreaks of CPE in European hospitals. Here we report an outbreak of Carbapenem-resistant K. pneumoniae in a German University hospital which was in part associated to duodenoscopy.FindingsBetween December 6, 2012 and January 10, 2013, carbapenem-resistant K. pneumoniae (CRKP) was cultured from 12 patients staying on 4 different wards. The amplification of carbapenemase genes by multiplex PCR showed presence of the blaOXA-48 gene. Molecular typing confirmed the identity of all 12 isolates. Reviewing the medical records of CRKP cases revealed that there was a spatial relationship between 6 of the cases which were located on the same wards. The remaining 6 cases were all related to endoscopic retrograde cholangiopancreatography (ERCP) which was performed with the same duodenoscope. The outbreak ended after the endoscope was sent to the manufacturer for maintenance.ConclusionsThough the outbreak strain was also disseminated to patients who did not undergo ERCP and environmental sources or medical personnel also contributed to the outbreak, the gut of colonized patients is the main source for CPE. Therefore, accurate and stringent reprocessing of endoscopic instruments is extremely important, which is especially true for more complex instruments like the duodenoscope (TJF Q180V series) involved in the outbreak described here.

Trigger mechanisms of secondary sclerosing cholangitis in critically ill patients

IntroductionIn recent years the development of secondary sclerosing cholangitis in critically ill patients (SSC-CIP) has increasingly been perceived as a separate disease entity. About possible trigger mechanisms of SSC-CIP has been speculated, systematic investigations on this issue are still lacking. The purpose of this study was to evaluate the prevalence and influence of promoting factors.MethodsTemporality, consistency and biological plausibility are essential prerequisites for causality. In this study, we investigated the temporality and consistency of possible triggers of SSC-CIP in a large case series. Biological plausibility of the individual triggers is discussed in a scientific context. SSC-CIP cases were recruited retrospectively from 2633 patients who underwent or were scheduled for liver transplantation at the University Hospital Charité, Berlin. All patients who developed secondary sclerosing cholangitis in association with intensive care treatment were included. Possible trigger factors during the course of the initial intensive care treatment were recorded.ResultsSixteen patients (68% males, mean age 45.87u2009±u200914.64xa0years) with a confirmed diagnosis of SSC-CIP were identified. Of the 19 risk factors investigated, particularly severe hypotension with a prolonged decrease in mean arterial blood pressure (MAP) to <65xa0mmHg and systemic inflammatory response syndrome (SIRS) were established as possible triggers of SSC-CIP. The occurrence of severe hypotension appears to be the first and most significant step in the pathogenesis. It seems that severe hypotension has a critical effect on the blood supply of bile ducts when it occurs together with additional microcirculatory disturbances.ConclusionsIn critically ill patients with newly acquired cholestasis the differential diagnosis of SSC-CIP should be considered when they have had an episode of haemodynamic instability with a prolonged decrease in MAP, initial need for large amounts of blood transfusions or colloids, and early development of a SIRS.

Therapy of chronic persisting biloma after liver resection by enteral drainage

Postoperative bile leaks represent a typical complication in liver surgery with a frequency ranging from 5 % to 12 % in large series. The treatment of choice is usually conservative. Using sufficient transcutaneous drainage with flushing of the biloma cavity and endoscopic retrograde cholangiography (ERC) with sphincterotomy and possibly stenting, the cure rate of bile leaks is approximately 95u2009%. In very rare cases all of these measures remain unsuccessful especially in cases of leakage from separated liver segments without connection to the main bile duct system. In relevantly separated liver segments this can lead to a chronically secreting bile fistula.We report a series of seven patients after complex liver resections, in which a chronic bile cavity was definitively treated with a jejunum loop as internal drainage. The prior conservative therapy included cavity suction drainage and optionally an additional ERC with or without stent insertion. After several weeks of bile leak persistence and radiological confirmation of suturable bile wall the operative treatment was carried out. The biloma cavity was careful dissected, opened and anastomosed with a jejunal loop. The further postoperative course was uncomplicated in all patients.It is possible to treat chronic persistent bile leaks safely and effectively by internal drainage through the jejunal loop after formation of a suturable biloma cavity membrane.ZusammenfassungPostoperative Gallelecks sind eine typische Komplikation in der Leberchirurgie. In der Literatur wird die Häufigkeiten in großen Serien zwischen 5 und 12u2009% angegeben. In den allermeisten Fällen ist das konservative Vorgehen die Therapie der Wahl. Unter suffizienter Drainage und ggf. Spülung der Biliomhöhle sowie, falls indiziert, Durchführung einer endoskopischen retrograden Cholangiographie (ERC) mit Papillotomie und ggf. Stenteinlage heilen über 95u2009% der Gallelecks unter konservativer bzw. interventionell radiologischer und/oder endoskopischer Therapie aus. In sehr seltenen Fällen bleiben alle genannten Maßnahmen erfolglos, meist bei Leckagen aus separierten Lebersegmenten ohne Anschluss zum Hauptgallengangsystem. Bei relevanten separierten Parenchymanteilen kann eine chronisch sezernierende Gallefistel resultieren.Wir berichten über eine Serie von sieben Patienten nach komplexen Leberresektionen, bei denen eine chronische Biliomhöhle als Ultima Ratio mittels einer Jejununmschlinge als innere Drainage definitiv versorgt wurde. Die vorherige konservative Therapie bei Auftreten eines Gallelecks beinhaltete eine äußere Spüldrainage und ggf. eine zusätzliche ERC mit oder ohne Stenteinlage. Nach mehrwöchiger Persistenz einer Gallefistel und bildmorphologischem Nachweis einer anastomosierungsfähigen Biliomwand erfolgte eine Relaparotomie. Nach vorsichtiger Adhäsiolyse und Eröffnung der Biliomhöhle wurde diese mit einer nach Roux-Y ausgeschalteten Jejunumschlinge anastomosiert. Der weitere postoperative Verlauf war bei allen Patienten weitgehend unkompliziert.Chronisch persistierende Gallelecks aus separierten Leberanteilen können nach Ausbildung einer nahtfähigen Biliommembran als Ultima Ratio sicher und effektiv durch eine innere Drainage mittels einer ausgeschalteten Jejunalschlinge versorgt werden.AbstractPostoperative bile leaks represent a typical complication in liver surgery with a frequency ranging from 5xa0% to 12xa0% in large series. The treatment of choice is usually conservative. Using sufficient transcutaneous drainage with flushing of the biloma cavity and endoscopic retrograde cholangiography (ERC) with sphincterotomy and possibly stenting, the cure rate of bile leaks is approximately 95u2009%. In very rare cases all of these measures remain unsuccessful especially in cases of leakage from separated liver segments without connection to the main bile duct system. In relevantly separated liver segments this can lead to a chronically secreting bile fistula.We report a series of seven patients after complex liver resections, in which a chronic bile cavity was definitively treated with a jejunum loop as internal drainage. The prior conservative therapy included cavity suction drainage and optionally an additional ERC with or without stent insertion. After several weeks of bile leak persistence and radiological confirmation of suturable bile wall the operative treatment was carried out. The biloma cavity was careful dissected, opened and anastomosed with a jejunal loop. The further postoperative course was uncomplicated in all patients.It is possible to treat chronic persistent bile leaks safely and effectively by internal drainage through the jejunal loop after formation of a suturable biloma cavity membrane.

Therapie chronisch persistierender Biliome nach Leberresektion durch enterale Drainage

Postoperative bile leaks represent a typical complication in liver surgery with a frequency ranging from 5 % to 12 % in large series. The treatment of choice is usually conservative. Using sufficient transcutaneous drainage with flushing of the biloma cavity and endoscopic retrograde cholangiography (ERC) with sphincterotomy and possibly stenting, the cure rate of bile leaks is approximately 95u2009%. In very rare cases all of these measures remain unsuccessful especially in cases of leakage from separated liver segments without connection to the main bile duct system. In relevantly separated liver segments this can lead to a chronically secreting bile fistula.We report a series of seven patients after complex liver resections, in which a chronic bile cavity was definitively treated with a jejunum loop as internal drainage. The prior conservative therapy included cavity suction drainage and optionally an additional ERC with or without stent insertion. After several weeks of bile leak persistence and radiological confirmation of suturable bile wall the operative treatment was carried out. The biloma cavity was careful dissected, opened and anastomosed with a jejunal loop. The further postoperative course was uncomplicated in all patients.It is possible to treat chronic persistent bile leaks safely and effectively by internal drainage through the jejunal loop after formation of a suturable biloma cavity membrane.ZusammenfassungPostoperative Gallelecks sind eine typische Komplikation in der Leberchirurgie. In der Literatur wird die Häufigkeiten in großen Serien zwischen 5 und 12u2009% angegeben. In den allermeisten Fällen ist das konservative Vorgehen die Therapie der Wahl. Unter suffizienter Drainage und ggf. Spülung der Biliomhöhle sowie, falls indiziert, Durchführung einer endoskopischen retrograden Cholangiographie (ERC) mit Papillotomie und ggf. Stenteinlage heilen über 95u2009% der Gallelecks unter konservativer bzw. interventionell radiologischer und/oder endoskopischer Therapie aus. In sehr seltenen Fällen bleiben alle genannten Maßnahmen erfolglos, meist bei Leckagen aus separierten Lebersegmenten ohne Anschluss zum Hauptgallengangsystem. Bei relevanten separierten Parenchymanteilen kann eine chronisch sezernierende Gallefistel resultieren.Wir berichten über eine Serie von sieben Patienten nach komplexen Leberresektionen, bei denen eine chronische Biliomhöhle als Ultima Ratio mittels einer Jejununmschlinge als innere Drainage definitiv versorgt wurde. Die vorherige konservative Therapie bei Auftreten eines Gallelecks beinhaltete eine äußere Spüldrainage und ggf. eine zusätzliche ERC mit oder ohne Stenteinlage. Nach mehrwöchiger Persistenz einer Gallefistel und bildmorphologischem Nachweis einer anastomosierungsfähigen Biliomwand erfolgte eine Relaparotomie. Nach vorsichtiger Adhäsiolyse und Eröffnung der Biliomhöhle wurde diese mit einer nach Roux-Y ausgeschalteten Jejunumschlinge anastomosiert. Der weitere postoperative Verlauf war bei allen Patienten weitgehend unkompliziert.Chronisch persistierende Gallelecks aus separierten Leberanteilen können nach Ausbildung einer nahtfähigen Biliommembran als Ultima Ratio sicher und effektiv durch eine innere Drainage mittels einer ausgeschalteten Jejunalschlinge versorgt werden.AbstractPostoperative bile leaks represent a typical complication in liver surgery with a frequency ranging from 5xa0% to 12xa0% in large series. The treatment of choice is usually conservative. Using sufficient transcutaneous drainage with flushing of the biloma cavity and endoscopic retrograde cholangiography (ERC) with sphincterotomy and possibly stenting, the cure rate of bile leaks is approximately 95u2009%. In very rare cases all of these measures remain unsuccessful especially in cases of leakage from separated liver segments without connection to the main bile duct system. In relevantly separated liver segments this can lead to a chronically secreting bile fistula.We report a series of seven patients after complex liver resections, in which a chronic bile cavity was definitively treated with a jejunum loop as internal drainage. The prior conservative therapy included cavity suction drainage and optionally an additional ERC with or without stent insertion. After several weeks of bile leak persistence and radiological confirmation of suturable bile wall the operative treatment was carried out. The biloma cavity was careful dissected, opened and anastomosed with a jejunal loop. The further postoperative course was uncomplicated in all patients.It is possible to treat chronic persistent bile leaks safely and effectively by internal drainage through the jejunal loop after formation of a suturable biloma cavity membrane.

Diagnostic and therapeutic single-operator cholangiopancreatoscopy with SpyGlassDS™: results of a multicenter retrospective cohort study

Background and aimsThe aim of the study was to evaluate the usefulness and diagnostic and therapeutic outcome of the single-operator cholangiopancreatoscopy (SOC) with SpyGlassDS™.MethodsIn a retrospective multicenter study between November 2015 and January 2017, SpyGlassDS™ procedures were analyzed in participating centers. Indications, accuracy of SOC-guided biopsies, management of large bile duct stones, and complications were analyzed. Follow-up was 4xa0months.ResultsTwo hundred and six patients out of 250 examinations were evaluated. Indications were biliary stones (nu2009=u2009132), bile duct stenosis (nu2009=u200993), stones and stenosis combined (nu2009=u200924), and bile duct leakage (nu2009=u20091). Of the 117 cases which were suspicious of malignancy, in 99 cases the lesion could be stratified into benign (nu2009=u200955) or malignant (nu2009=u200944) indicating a sensitivity of 95.5% and a specificity of 94.5% for the indication tumor. SOC-guided biopsies revealed a sensitivity of 57.7% with a specificity of 100%. In 107 examinations, biliary stones were visualized and could be completely removed in 91.1% with a need of three procedures (range 1–6) to achieve final stone clearance. In 75 cases, lithotripsy was performed and was successful in 71 cases (95%). Four out of 45 patients (8.9%) underwent cholecystectomy with surgical bile duct revision as a final therapy. Adverse Event (AE) occurred in 33/250 patients (13.2%) and Serious Adverse Event (SAE) occurred in 1/250 patients (0.4%). Cholangitis was 1% (nu2009=u2009102) after peri-interventional administration of antibiotics and 12.8% (nu2009=u2009148) without antibiotic prophylaxis (pu2009<u20090.001).ConclusionsSOC with SpyGlassDS™ became a new standard for the diagnosis of indefinite biliary lesions and therapy of large bile duct stones. The diagnostic yield of SOC-guided biopsies facilitated a definite diagnosis in most cases and should be improved by standardized biopsy protocols. SOC-guided interventions allowed removal of large biliary stones by SOC-guided lithotripsy. The complication rate of 13.2% can be considerably reduced by use of a single-shot antibiotic treatment.

Endoskopische Therapie bei akuter und chronischer Pankreatitis

ZusammenfassungDie endoskopischer Therapie hat sowohl bei der akuten als auch der chronischen Pankreatitis einen Stellenwert. Die frühe endoskopische Papillotomie scheint v.xa0a. bei schwerem Verlauf der akuten biliären Pankreatitis Vorteile zu haben. Eine endoskopische Drainage kann sowohl bei akuten Flüssigkeitsansammlungen und Nekrosen als auch bei der subakuten, nicht ausheilenden Pankreatitis oder bei Zystenbildung erwogen werden. Bei obstruktiver chronischer Pankreatitis mit Strikturen oder Steinen der Gallenwege kann durch Papillotomie, Dilatation und Stenteinlage eine Besserung der Schmerzsymptomatik erreicht werden, eine Besserung einer verminderten endo- oder exokrinen Funktion ist dagegen nicht zu erwarten. Die Studienlage zur endoskopischen Therapie bei Pankreatitis ist insgesamt allerdings noch sehr begrenzt, sodass Empfehlungen meist nur aufgrund retrospektiver Fallserien gegeben werden können.AbstractEndoscopic therapy is vaulable for both acute and chronic pancreatitis. Early endoscopic papillotomy appears, in the case of a severe course of acute biliary pancreatitis, to be advantagous. Endoscopic drainage can be considered in cases of acute fluid retention and necrosis as well as subacute, non-healing pancreatitis or cyst development. By acute chronic pancreatitis with strictures or bile duct stones, papillotomy, dilation and stent insertion can lead to an improvement in pain symptoms. An improvement in endo- or exocrine function, however, is not expected. Studies on the endoscopic therapy of pancreatitis are still very limited, and recommendations can usually only be made based on retrospective case series.

Endoscopic sleeve gastroplasty using Apollo Overstitch as a bridging procedure for superobese and high risk patients

In some cases, bariatric procedures cannot be performed via laparoscopic or open surgery because of surgical contraindications or high operative risk. Endoscopic sleeve gastroplasty (ESG) using an Overstitch (Apollo Endosurgery, Austin, Texas, USA) is a recently described procedure [1, 2] with good preliminary 1-year results in small series and low complication rates [3–5] for patients with a body mass index (BMI) ranging from 30–45 kg/m2. However, the routine use of ESG for superobese and high risk patients has not yet been described. The indications for ESGs performed in five superobese patients in our institution were as follows: (i) surgically impenetrable abdomen due to multiple operations or a giant incisional hernia; (ii) future liver or kidney transplant recipient; (iii) high risk patient with a contraindication to operation; (iv) a bridging procedure in a two-step concept (the first endoscopic, the second surgical 12–18 months later). Patients with BMI ranging from 51–72 kg/m2 with numerous co-morbidities were submitted to ESG after multidisciplinary evaluation. With the patient under general anesthesia and after installation of an overtube (Apollo Endosurgery), ESG was perE-Videos

Therapie chronisch persistierender Biliome nach Leberresektion durch enterale Drainage@@@Therapy of chronic persisting biloma after liver resection by enteral drainage

Postoperative bile leaks represent a typical complication in liver surgery with a frequency ranging from 5 % to 12 % in large series. The treatment of choice is usually conservative. Using sufficient transcutaneous drainage with flushing of the biloma cavity and endoscopic retrograde cholangiography (ERC) with sphincterotomy and possibly stenting, the cure rate of bile leaks is approximately 95u2009%. In very rare cases all of these measures remain unsuccessful especially in cases of leakage from separated liver segments without connection to the main bile duct system. In relevantly separated liver segments this can lead to a chronically secreting bile fistula.We report a series of seven patients after complex liver resections, in which a chronic bile cavity was definitively treated with a jejunum loop as internal drainage. The prior conservative therapy included cavity suction drainage and optionally an additional ERC with or without stent insertion. After several weeks of bile leak persistence and radiological confirmation of suturable bile wall the operative treatment was carried out. The biloma cavity was careful dissected, opened and anastomosed with a jejunal loop. The further postoperative course was uncomplicated in all patients.It is possible to treat chronic persistent bile leaks safely and effectively by internal drainage through the jejunal loop after formation of a suturable biloma cavity membrane.ZusammenfassungPostoperative Gallelecks sind eine typische Komplikation in der Leberchirurgie. In der Literatur wird die Häufigkeiten in großen Serien zwischen 5 und 12u2009% angegeben. In den allermeisten Fällen ist das konservative Vorgehen die Therapie der Wahl. Unter suffizienter Drainage und ggf. Spülung der Biliomhöhle sowie, falls indiziert, Durchführung einer endoskopischen retrograden Cholangiographie (ERC) mit Papillotomie und ggf. Stenteinlage heilen über 95u2009% der Gallelecks unter konservativer bzw. interventionell radiologischer und/oder endoskopischer Therapie aus. In sehr seltenen Fällen bleiben alle genannten Maßnahmen erfolglos, meist bei Leckagen aus separierten Lebersegmenten ohne Anschluss zum Hauptgallengangsystem. Bei relevanten separierten Parenchymanteilen kann eine chronisch sezernierende Gallefistel resultieren.Wir berichten über eine Serie von sieben Patienten nach komplexen Leberresektionen, bei denen eine chronische Biliomhöhle als Ultima Ratio mittels einer Jejununmschlinge als innere Drainage definitiv versorgt wurde. Die vorherige konservative Therapie bei Auftreten eines Gallelecks beinhaltete eine äußere Spüldrainage und ggf. eine zusätzliche ERC mit oder ohne Stenteinlage. Nach mehrwöchiger Persistenz einer Gallefistel und bildmorphologischem Nachweis einer anastomosierungsfähigen Biliomwand erfolgte eine Relaparotomie. Nach vorsichtiger Adhäsiolyse und Eröffnung der Biliomhöhle wurde diese mit einer nach Roux-Y ausgeschalteten Jejunumschlinge anastomosiert. Der weitere postoperative Verlauf war bei allen Patienten weitgehend unkompliziert.Chronisch persistierende Gallelecks aus separierten Leberanteilen können nach Ausbildung einer nahtfähigen Biliommembran als Ultima Ratio sicher und effektiv durch eine innere Drainage mittels einer ausgeschalteten Jejunalschlinge versorgt werden.AbstractPostoperative bile leaks represent a typical complication in liver surgery with a frequency ranging from 5xa0% to 12xa0% in large series. The treatment of choice is usually conservative. Using sufficient transcutaneous drainage with flushing of the biloma cavity and endoscopic retrograde cholangiography (ERC) with sphincterotomy and possibly stenting, the cure rate of bile leaks is approximately 95u2009%. In very rare cases all of these measures remain unsuccessful especially in cases of leakage from separated liver segments without connection to the main bile duct system. In relevantly separated liver segments this can lead to a chronically secreting bile fistula.We report a series of seven patients after complex liver resections, in which a chronic bile cavity was definitively treated with a jejunum loop as internal drainage. The prior conservative therapy included cavity suction drainage and optionally an additional ERC with or without stent insertion. After several weeks of bile leak persistence and radiological confirmation of suturable bile wall the operative treatment was carried out. The biloma cavity was careful dissected, opened and anastomosed with a jejunal loop. The further postoperative course was uncomplicated in all patients.It is possible to treat chronic persistent bile leaks safely and effectively by internal drainage through the jejunal loop after formation of a suturable biloma cavity membrane.