Response to endoscopic therapy for biliary anastomotic strictures in deceased versus living donor liver transplantation.

BACKGROUND: Endoscopic therapy has been successful in the management of biliary complications after both deceased donor liver transplantation (DDLT) and living donor liver transplantation (LDLT). LDLT is thought to be associated with higher rates of biliary complications, but there are few studies comparing the success of endoscopic management of anastomotic strictures between the two groups. This study aims to compare our experience in the endoscopic management of anastomotic strictures in DDLT versus LDLT. METHODS: This is a retrospective database review of all liver transplant patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) after liver transplantation. The frequency of anastomotic stricture and the time to develop and to resolve anastomotic stricture were compared between DDLT and LDLT. The response of anastomotic stricture to endoscopic therapy was also analyzed. RESULTS: A total of 362 patients underwent liver transplantation between 2003 and 2011, with 125 requiring ERCP to manage biliary complications. Thirty-three (9.9%) cases of DDLT and 8 (27.6%) of LDLT (P=0.01) were found to have anastomotic stricture. When comparing DDLT and LDLT, there was no difference in the mean time to the development of anastomotic strictures (98+/-17 vs 172+/-65 days, P=0.11), likelihood of response to ERCP [22 (66.7%) vs 6 (75.0%), P=0.69], mean time to the resolution of anastomotic strictures (268+/-77 vs 125+/-37 days, P=0.34), and the number of ERCPs required to achieve resolution (3.9+/-0.4 vs 4.7+/-0.9, P=0.38). CONCLUSIONS: Endoscopic therapy is effective in the majority of biliary complications relating to liver transplantation. Anastomotic strictures occur more frequently in LDLT compared with DDLT, with equivalent endoscopic treatment response and outcomes for both groups.

Wire assisted transpancreatic septotomy, needle knife precut or both for difficult biliary access.

BACKGROUND AND AIMS: Pre-cut techniques, the most commonly described being needle knife papillotomy (NK), have been used to facilitate biliary access in failed standard biliary cannulation (BC). Transpancreatic septotomy (TS) is a pre-cut technique with limited outcome data. We aim to assess the outcomes of wire assisted transpancreatic septotomy (WTS) as the primary pre-cut technique after initial failed attempted BC and to compare these with outcomes of primary NK. METHODS: We retrospectively reviewed all endoscopic retrograde cholangiopancreatographies (ERCPs) performed by endoscopists who performed WTS over a 3-year period. We selected cases where WTS and/or NK were performed, and these cases were reviewed to assess for procedure related complications and BC success. RESULTS: During the study period 1336 ERCPs were performed. WTS was performed in 53 cases. In seven cases WTS and NK were performed sequentially (resulting in immediate cannulation in all these cases). Immediate BC was achieved on first attempt in 36 (68%) WTS cases and in a further 14 cases on a repeat attempt (cumulative BC rate 94%). During the same period 66 (5%) patients underwent primary NK. In these cases initial cannulation was achieved in 50 (76%) cases and cannulation on repeat attempt in six cases (cumulative success rate 85%). Complications occurred in three WTS patients (5.6%) and seven NK patients (10.6%). The differences were not statistically significant. CONCLUSIONS: Wire assisted transpancreatic septotomy is a safe and effective alternative technique to traditional NK in patients who have failed standard BC techniques. It also allows other pre-cut techniques such as NK to be used should initial WTS be unsuccessful.

ERCP in the management of choledocholithiasis in pregnancy.

The physiological changes of pregnancy increase the risk of gallstone formation, and choledocholithiaisis is the most common indication for endoscopic retrograde cholangiopancreatography (ERCP) during pregnancy. ERCP has been performed during pregnancy for over 20 years. Despite the apparent efficacy and lack of adverse fetal outcomes in published case series and reports, there remains a concern for the use of fluoroscopy during pregnancy. Recent focus has centered around avoidance of the use of fluoroscopy during ERCP, including the use of alternative techniques to confirm biliary cannulation and ductal clearance. The benefits of these techniques over traditional ERCP technique are unclear. In this article, we will review the epidemiology of gallstone disease during pregnancy, outline the risks of ERCP during pregnancy, and describe recent novel techniques in endoscopic biliary intervention for biliary drainage and ductal clearance.

Esophageal squamous papilloma lacks clear clinicopathological associations.

AIM: To determine the prevalence of esophageal squamous papillomas (ESPs) in a tertiary teaching hospital and to assess for any clinical associations, including relations with esophageal squamous cell carcinomas (SCCs). METHODS: Data from a total of 6962 upper gastrointestinal endoscopies over a five year period were retrospectively obtained and analysed. RESULTS: ESP was found in sixteen patients (0.23%). Eight (50%) patients had a high body mass index, seven (44%) had history of cigarette smoking. Reflux esophagitis was found in four (25%) patients. All ESPs were solitary with a mean endoscopic size of 3.8 mm and located in the mid to lower esophagus. Human papilloma virus (HPV) was tested in three (19%) patients and was negative. Esophageal SCC was found in seven patients (0.10%) during the same period. None of the specimens were tested for HPV, and none had associated papillomatous changes. CONCLUSION: ESP is an uncommon tumour with unclear clinical associations and malignant potential.

Endoscopic management of benign biliary strictures.

Endoscopic retrograde cholangiopancreatography (ERCP) is the first-line management in most situations when a benign biliary stricture is suspected. Although management principles are similar in all subgroups, the anticipated response rates, need for ancillary medical and endoscopic approaches, and use of less proven strategies vary between differing causes. Exclusion of malignancy should always be a focus of management. Newer endoscopic techniques such as endoscopic ultrasound, cholangioscopy, confocal endomicroscopy, and metal biliary stenting are increasingly complementing traditional ERCP techniques in achieving long-term sustained stricture resolution. Surgery remains a definitive management alternative when a prolonged trial of endoscopic therapy does not achieve treatment goals.

A novel two-step approach for retrieval of an impacted biliary extraction basket.

Biliary extraction baskets are a commonly used instrument for the removal of choledocholithiasis in endoscopic retrograde cholangiopancreatography (ERCP). Impaction of the extraction basket is a recognized complication of ERCP, and is usually the result of discrepancy between the size of bile duct stone and the diameter of the distal bile duct. Whilst mechanical lithotriptors can be used to crush the stone or break the wires of the basket to allow its release, failure of the lithotriptor device can occur. We describe the case of a 59-year-old gentleman who had an ERCP performed for choledocholithiasis. Basket impaction was encountered, and the mechanical lithotriptor failed to dislodge the stone/basket complex. A two-step technique involving balloon dilatation and forceps manipulation of the basket was applied to successfully dislodge the impacted basket. We believe this simple and safe technique should be adopted to rescue impacted biliary extraction baskets to avoid the need for potential surgical removal.