Endoscopic ultrasound-guided biliary drainage in benign biliary pathology with normal foregut anatomy: a multicenter study.

BACKGROUND AND AIMS: Biliary drainage using endoscopic ultrasound (EUS-BD) has been developed as a novel technique to obtain biliary access and drainage when ERCP fails. Numerous studies have demonstrated its safety and efficacy specifically pertaining to those with malignant distal biliary obstruction or altered foregut anatomy. The aim of this study is to evaluate the safety and efficacy of EUS-BD in benign indications in patients with normal foregut anatomy. METHODS: We performed a retrospective comparative study from 5 academic medical centers (2008-2018) involving patients with benign biliary obstruction and native foregut anatomy who had an initial failed ERCP with subsequent attempt at biliary decompression via EUS-BD or by repeating ERCP. RESULTS: 36 patients (mean age 61.6 ± 2.2, 38.9% female) who underwent attempted EUS-BD following initial failed ERCP were compared to 50 patients (mean age 62.7 ± 2.3, 73.5% female) who underwent repeat ERCP following an initial failed cannulation. EUS-BD was technically successful in 28 (77.8%) patients with rendezvous being the most common approach (86.1%). A higher level of pre-procedural bilirubin was found to be associated with technical success of EUS-BD (3.65 ± 0.63 versus 1.1 ± 0.4, p value 0.04). Success of repeat ERCP following failed cannulation was 86%. Adverse events were significantly more frequent in the EUS-BD cohort when compared to the repeat ERCP (10 (27.8%) versus 4 (8.0%), p = 0.02, OR 4.32. CONCLUSIONS: EUS-BD remains a viable therapeutic option in the setting of benign biliary disease, with success rates of 77.8%. Adverse events were significantly more common with EUS-BD vs. repeat ERCP, emphasizing the need to perform in expert centers with appropriate multidisciplinary support and to strongly consider the urgency of biliary decompression before considering same session EUS-BD after failed initial biliary access.

Case Series Regarding Parastomal Variceal Bleeding: Presentation and Management.

Parastomal variceal bleeding (PVB) is a serious complication occurring in up to 27% of patients with an ostomy and concurrent cirrhosis and portal hypertension. The management of PVB is difficult and there are no clear guidelines on this matter. Transjugular intrahepatic portosystemic shunt (TIPS), sclerotherapy, and /or coil embolization are all therapies that have been shown to successfully manage PVB. We present a case series with five different patients who had a PVB at our institution. The aim of this case series is to report our experience on the management of this infrequently reported but serious condition. We also conducted a systemic literature review focusing on the treatment modalities of 163 patients with parastomal variceal bleeds. In our series, patient 1 had embolization and sclerotherapy without control of bleed and expired on the day of intervention due to hemorrhagic shock. Patient 2 had TIPS in conjunction with embolization and sclerotherapy and had no instance of rebleed 441 days after therapy. Patient 3 did not undergo any intervention due to high risk for morbidity and mortality, the bleed self-resolved and there was no further rebleed, this same patient died of sepsis 73 days later. Patient 4 had embolization and sclerotherapy and had no instance of rebleed 290 days after therapy. Patient 5 had TIPS procedure and was discharged five days post procedure without rebleed, patient has since been lost to follow-up.

An Evidence-Based Approach to Orthobiologics for Tendon Disorders.

Tendinopathy is a chronic injury that affects both the athletic and general population. Recalcitrant tendinopathy is both frustrating for patients and providers once typical conservative treatments have been exhausted. Current research in orthobiologics shows that they are safe and could improve pain and function in recalcitrant cases. Unfortunately, many studies show inconsistency in the content of the orthobiologic injectate and approach in treatment protocols. There are robust data to support the use of platelet-rich plasma for the treatment of recalcitrant common extensor tendinopathy and plantar fasciopathy, but high-quality random control trials are needed before drawing definitive conclusions for other tendinopathies.

Enteral Stents for Malignant Gastric Outlet Obstruction: Low Reintervention Rates for Obstruction due to Pancreatic Adenocarcinoma Versus Other Etiologies.

BACKGROUND AND AIM: Enteral stents (ES) have emerged as first-line therapy for the treatment of malignant gastric outlet obstruction (GOO). Stent occlusion arising from tissue ingrowth may require endoscopic or surgical reintervention. The objective of this study was to compare rates of reintervention following palliative ES for patients with GOO due to pancreatic adenocarcinoma (PDAC) versus other malignant etiologies. METHODS: Patients who had undergone ES for palliation of malignant GOO between 2009 and 2018 were retrospectively identified and demographic, clinical, and procedural data were collected. Primary outcome was procedural reintervention for recurrent symptomatic GOO following ES placement. RESULTS: Forty-three patients were included in the study cohort. 62.8% (27/43) of patients had PDAC while 37.2% (16/43) of patients had other malignant etiologies. 11.6% (5/43) of patients were alive at follow-up. Thirty-day and 90-day mortality rates were 22.8% and 70.7% for PDAC and 25% and 56.3% for other malignant etiologies, respectively. Seven patients required reintervention for symptomatic GOO: 14.3% (1/7) had PDAC and 85.7% (6/7) had GOO due to other malignancy (P < .01). Ninety-six percent (26/27) of patients with PDAC required no further intervention for GOO prior to death or end of follow-up. On multivariate analysis, patients with PDAC were significantly less likely to require reintervention than patients with other malignant etiologies (OR 0.064, 95% CI 0.01-0.60). CONCLUSION: ES offer durable symptom palliation without requirement for reintervention for the overwhelming majority of patients with malignant GOO due to PDAC. Reintervention rates are higher following ES placement for GOO due to other malignant etiologies and future study may be needed to define the optimal palliative intervention for this group of patients.

Endoscopic plastic stent therapy for bile leaks following total vs subtotal cholecystectomy.

Background and study aims Plastic biliary stents are standard therapy for treatment of post-cholecystectomy bile leaks. An increasing proportion of patients now undergo subtotal cholecystectomy and are at perceived risk for high-grade bile leak. Data are limited regarding the optimal endoscopic therapy following subtotal cholecystectomy. The aim of this study was to compare outcomes of endoscopic plastic stent therapy for treatment of bile leak following total vs subtotal cholecystectomy. Patients and methods A retrospective cohort of patients with bile leak following cholecystectomy and treated with biliary stent was identified from an institutional database. Primary outcome was defined as cholangiographic resolution of leak at follow-up endoscopic retrograde cholangiopancreatography (ERCP). Results Sixty-one subjects met study inclusion criteria, 27 following total cholecystectomy and 34 following subtotal cholecystectomy. A single plastic biliary stent was placed in 87 % of subjects (53/61), while a fully covered self-expanding metal stent (FCSEMS) was placed in 13 % (8/61). Leak resolution was evident at first follow-up ERCP in 96 % of subjects (26/27) who had undergone total cholecystectomy and 91 % of subjects (31/34) who had undergone subtotal cholecystectomy ( P  = 0.25). Among subjects who had received a plastic stent at index ERCP, leak resolution was evident at first follow-up ERCP in 96 % (23/24) of those who had undergone total cholecystectomy and 90 % (26/29) of those who had undergone subtotal cholecystectomy ( P  = 0.62). Conclusions High rates of leak resolution can be achieved with placement of a single plastic biliary stent for treatment of post-cholecystectomy bile leaks, including after subtotal cholecystectomy.

Timing of Endoscopic Necrosectomy Following Transmural Stent Placement for Pancreatic Necrosis.

PURPOSE OF THE REVIEW: Pancreatic walled-off necrosis (WON) may require adjunctive direct endoscopic necrosectomy (DEN) following transmural stent placement. DEN is performed immediately or delayed in relation to index endoscopy. There is currently no consensus on the optimal timing of DEN. We review the most recent literature addressing each practice. RECENT FINDINGS: Some expert opinion prefer delayed DEN; however, recent data reveal immediate DEN may reduce the number of endoscopic sessions required for successful clinical resolution of WON. Future studies are needed to determine the optimal timing for DEN following transmural stent placement for the management of WON.

Mucinous cystic neoplasm diagnosed by EUS-guided microforceps biopsy.

Background and study aims Mucinous cystic neoplasms (MCNs) of the pancreas have malignant potential. Current methods for diagnosing MCNs are inadequate. The aim of this case series is to present a novel method for establishing the diagnosis of MCNs. Clinical information from three patients seen at our institution was collected for a case series presentation. Patients were selected retrospectively based on diagnostic results. Three patients were diagnosed with MCNs based on histopathology obtained via microforceps biopsy. Evolving tissue acquisition techniques, such as microforceps intracystic biopsy, have improved the diagnostic yield of endoscopic ultrasound (EUS).

Socioeconomic Status and Race are both Independently associated with Increased Hospitalization Rate among Crohn's Disease Patients.

Racial disparities are observed clinically in Crohn's Disease (CD) with research suggesting African Americans (AA) have worse outcomes than Caucasian Americans (CA). The aim of this study is to assess whether socioeconomic status (SES) rather than race is the major predictor of worse outcomes. We designed a retrospective cohort study of 944 CD patients seen at our center. Patients' billing zip codes were collected and average income and percent of population living above or below poverty level (PL) for each zip code calculated. Patients were separated by quartiles using average state income level and federal PL. Demographics and hospitalization rates were collected. Poison regression models estimated incidence rate ratios (IRR) for CD-related hospitalizations. Incidence rate (IR) of hospitalization per 100-person years for the lowest income group was 118 (CI 91.4-152.3), highest income group was 29 (CI 21.7-38.9), Above PL was 26.9 (25.9-28.9), Below PL was 35.9 (33.1-38.9), CA was 25.3 (23.7-27), and AA was 51.4 (46.8-56.3). IRR for a CD-related hospitalization for lowest income group was 2.01 (CI 1.34-3.01), for Below PL was 1.26 (CI 1.12-1.42), and for AAs was 1.88 (CI 1.66-2.12). SES and race are both associated with hospitalization among CD patients and need further investigation.

Effect of Hepatitis C Treatment on Renal Function in Liver Transplant Patients.

Background and Aims: Hepatitis C Virus (HCV) is uniformly recurrent after liver transplant (LT) and recurrence is associated with an increased risk of mortality. Immunosuppressive medications increase the risk of chronic kidney disease, and the presence of chronic kidney disease presents a challenge for HCV treatment in LT recipients. The aim of this study was to assess changes in glomerular filtration rates (GFRs) of LT recipients receiving HCV treatment. Methods: This is a retrospective study of LT patients who received HCV treatment between 2015 and 2016 (n = 60). The outcomes of interest were differences in serum creatinine levels and in GFR, measured at treatment initiation and at 24 weeks after treatment. The average age of the patients was 59 years-old, and 17% were cirrhotic and 67% were treatment-experienced. All patients received sofosbuvir/ledipasvir without ribavirin. Results: All patients achieved sustained virologic response at 12 weeks after treatment (SVR12). At baseline, 55% of patients had GFR <60 mL/min per 1.73 m2. Among those patients, GFR did not change in 18%, 33% had improved GFR, and 48% had worsened GFR. Up to 45% of the patients had a GFR >60 mL/min per 1.73 m2. Among those patients, GFR did not change in 81%, and 19% had worsened GFR. In the entire cohort, 65% of patients had improved or stable GFR and 35% had worsened GFR. The average change in serum creatinine between baseline and 24 weeks was 0.10 (p = 0.18). Conclusions: This study showed improved or unchanged GFR in 65% and worsened GFR in 35% of LT recipients who achieved SVR12. Worsening of GFR was more frequently encountered in those with impaired renal function at baseline. Caution should be used when treating HCV in LT recipients, especially those with baseline status of renal impairment.

Ledipasvir/sofosbuvir without ribavirin is effective in the treatment of recurrent hepatitis C virus infection post-liver transplant.

BACKGROUND/AIM: Recurrent hepatitis C virus infection is a challenging complication post-liver transplant. Current guidelines recommend the combination of ribavirin and ledipasvir/sofosbuvir for 12 weeks for the treatment of recurrent HCV genotype 1 post-liver transplant. Data are limited on the use of ledipasvir/sofosbuvir without ribavirin. The aim of this study was to evaluate the use of ledipasvir/sofosbuvir without ribavirin for the treatment of recurrent hepatitis C virus post-liver transplant. METHODS: This is a retrospective study of liver transplant patients who received ledipasvir/sofosbuvir without ribavirin for the treatment of recurrent hepatitis C virus in our liver center from 2014 to 2016. RESULTS: A total of 60 patients were enrolled of which 70% were male, 88% Caucasian, age 60 ± 7 years, 15% cirrhotic, and 45% treatment-experienced with recurrent hepatitis C virus infection genotype 1 post-liver transplant. Treatment duration varied from 8 to 24 weeks. There were no serious adverse events and no discontinuation of treatment. A total of 71% of patients had undetectable serum hepatitis C virus at 4 weeks. However, irrespective of treatment duration, 100% of patients had undetectable serum hepatitis C virus at the end of treatment and 100% of patients achieved sustained viral response at 12 weeks. CONCLUSION: Ledipasvir/sofosbuvir without ribavirin is an effective treatment of recurrent hepatitis C virus infection post-liver transplant. The entire group achieved sustained viral response at 12 weeks irrespective of the length of treatment. The combination of ledipasvir/sofosbuvir was well tolerated without serious adverse effects or discontinuation.

Budesonide Use and Hospitalization Rate in Crohn's Disease: Results From a Cohort at a Tertiary Care IBD Referral Center.

BACKGROUND: Budesonide is generally not used for periods > 90 days in Crohn's disease (CD). We sought to study the association between cumulative outpatient budesonide use in days and hospitalization rate in CD patients seen at our institution. METHODS: Using a retrospective cohort study design, we selected CD patients > 19 years old and followed for at least 1 year. Days of outpatient budesonide use were calculated by reviewing outpatient clinic notes. Treatment groups included patients who were not given budesonide, received budesonide from 1 to 90 days, and received budesonide > 90 days. We performed univariate analyses and developed generalized Poisson regression models for rate data to estimate incidence rate ratios (IRRs) and 95% confidence intervals (95% CIs) for CD-related hospitalization. RESULTS: Of 767 CD patients, 664 did not receive budesonide, 45 received budesonide from 1 to 90 days, and 58 received budesonide for > 90 days. Incidence rates of hospitalization in patients who received no budesonide vs. 1 - 90 days of budesonide vs. > 90 days of budesonide were 31, 26, and 19 per 100 person-years, respectively. Adjusted models demonstrated that receiving outpatient budesonide from 1 to 90 days and for > 90 days was associated with a lower likelihood of being admitted for a CD exacerbation (1 - 90 days: IRR 0.85; 95% CI 0.65 - 1.10; > 90 days: IRR 0.71; 95% CI 0.56 - 0.91). CONCLUSIONS: Outpatient budesonide use appears to be associated with a lower likelihood of a CD-related hospitalization, notably when used for > 90 days. This association needs to be further assessed before recommending this agent for routine use for > 90 days.