Single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreaticography in patients with surgically altered anatomy: higher failure rate in malignant biliary obstruction - a prospective single center cohort analysis.

INTRODUCTION: The performance of endoscopic retrograde cholangiopancreaticography (ERCP) in patients with post-surgically altered anatomy is technically ambitious. Our study aimed at comparing a cohort of patients having successfully undergone single-balloon enteroscopy (SBE)-assisted ERCP to those in whom SBE-ERCP failed. METHODS: This trial is a prospective single center cohort study. Participants included 30 patients (median age 69.5 years, range 20-86 years) with previous pancreaticobiliary surgery. First, a conventional ERCP approach was attempted in all patients. Additionally, those patients in whom prior conventional ERCP had failed underwent SBE-ERCP (n = 26). Patients' baseline characteristics were retrieved and patient cohorts with and without successful SBE-ERCPs were compared and analyzed. Statistical analysis was applied. Univariate analysis was performed to detect possible risk factors of SBE-ERCP failure. RESULTS: The overall success rate of SBE-ERCP, including two patients with percutaneous transhepatic cholangiography- assisted rendezvous technique was 65.4% (17/26). Patients with malignant obstructive cholestasis had a significantly higher failure rate compared to those with benign strictures (84.2% vs. 14.2%, p < 0.001). DISCUSSION: SBE-ERCP is a promising tool for diagnostic and therapeutic procedures in the pancreaticobiliary system of selected, previously operated patients with failure of conventional ERCP. However, higher failure rates in malignant biliary obstruction should be taken into account.

Miniprobe endoscopic ultrasound accurately stages esophageal cancer and guides therapeutic decisions in the era of neoadjuvant therapy: results of a multicenter cohort analysis.

BACKGROUND: Despite recent advances in imaging techniques, adequate classification of esophageal lesions is still challenging. Accurate staging of tumors of the esophagus is a precondition for targeted therapy. In this retrospective, multicenter study, we report the role of high-frequency endoscopic ultrasound (EUS) catheter probes in pretherapeutic staging of esophageal neoplasms and thus guiding treatment decisions. METHODS: A total of 143 patients (mean age of 63.8 ± 10.7 years) with esophageal carcinoma were recruited from five German centers (Münster, Oldenburg, Hannover, Wiesbaden, and Lüneburg). Tumor type was adenocarcinoma in 112 (78 %) cases and squamous cell carcinoma in 31 (22 %). Tumor localization was as follows: proximal 3, mid esophagus 7, and distal third 133. Histological correlation either through EMR or surgery was available. In all patients, pretherapeutic uT and uN classifications were compared to pT/pN classification obtained from surgically (esophagectomy, n = 93) or endoscopically (EMR, n = 50) resected tissue. RESULTS: Overall, accuracy of uT classification was 60 % and of uN classification was 74 %. Sensitivity, specificity, and accuracy rates for local tumor extension were as follows (%): T1: 68/97/83; T2: 39/84/75; T3: 72/81/79; T4: 13/97/93; T1/2: 73/81/75; T3/4: 78/82/81. Relating to positive lymph node detection, sensitivity and specificity were 76 and 71 %, respectively. CONCLUSIONS: Miniprobe EUS is an established method for the staging of esophageal tumors. Our large multicenter cohort shows a solid accuracy of miniprobe EUS with respect to differentiating locally advanced from limited cancer and assisting to determine the treatment regimen in the era of neoadjuvant therapy; consequently, 78 % of patients would have been assigned to the adequate therapeutic regimen, whereas 11 % of patients would have been overtreated and 11 % undertreated.

Endoscopic transpapillary biopsies are of limited value in the diagnostics of bile duct strictures of unknown etiology-results of a histopathologically controlled study in 312 patients.

BACKGROUND/AIMS: Our investigation aimed to evaluate the impact of endoscopic transpapillary forceps biopsies (ETP) in bile duct strictures of unknown etiology based on the largest European patient cohort at a tertiary referral center. To date only studies with limited patient numbers exist. METHODOLOGY: Three-hundred-and-twelve patients (162 males, 150 females, mean age 62±12.7 years) with bile duct strictures of unknown etiology were examined with ETP. Sensitivity, specificity and accuracy of ETP were compared to the definite diagnosis proved by histopathology of surgical resection specimens or long-term follow-up of those patients not undergoing surgery. RESULTS: Using ETP a correct pe-interventional diagnosis was achieved in 211 out of 312 patients resulting in an accuracy rate of 67.6%. Eighty-six out of 187 malignant stenoses were correctly diagnosed by ETP, giving rise to sensitivity and specificity rates of 46 and 100%, respectively. Sensitivity of ETP in cholangiocellular carcinoma was significantly superior to that in pancreatic carcinoma (52.5% vs. 35.6%, p = 0.026). Sensitivity and accuracy rates of ETP did not depend on the localization of the stenosis in the common bile duct. CONCLUSIONS: ETP alone is not reliable enough in diagnosing bile duct malignancies as shown by low sensitivity and accuracy rates (false-negative rate of 32%).

Single-step versus multi-step transmural drainage of pancreatic pseudocysts: the use of cystostome is effective and timesaving.

BACKGROUND AND AIMS: Pancreatic pseudocysts are a major complication of chronic and acute pancreatitis and often require endoscopic intervention. Endoscopic single-step and multi-step transmural drainage techniques have been reported in the literature. The aim of this study was to evaluate and compare technical results and clinical outcome rates of the single-step versus multi-step endoscopic ultrasonography (EUS)-guided endoscopic transmural drainage in patients with symptomatic pancreatic pseudocysts of >4 cm size. DESIGN: Retrospective study at an academic tertiary referral center. PATIENTS AND METHODS: A total of 38 consecutive patients comprising 42 interventions were studied: 16 patients with pancreatic pseudocysts (18 interventions) had undergone single-step EUS-guided transmural cystostome drainage between 2007 and 2010. Results were compared with a cohort of 22 patients who had submitted to multi-step EUS-guided transmural drainage of pancreatic pseudocysts in 24 cases between 2005 and 2007. RESULTS: The technical success rate for using the single-step procedure was 94% compared with multi-step procedure with 83% (n.s.). Primary clinical success rate was 88% for single-step drainage and 90% for the multi-step approach (n.s.). The mean procedure time was 36 ± 9 min in the single-step group compared with 62 ± 12 min for the multi-step access (p < 0.001). CONCLUSIONS: The use of single-step cystostome appears useful in managing selected patients with symptomatic pancreatic pseudocysts as it is effective and timesaving.

Outcome of supraselective transarterial chemoembolization in patients with hepatocellular carcinoma.

OBJECTIVE: Hepatocellular carcinoma (HCC) is the most common tumor in cirrhotic patients with a median survival of only 8-10 months if untreated. Supraselective transarterial chemoembolization (STACE) is supposed to be a well-established method for treating HCC patients. In the present study, we evaluated the effect of STACE on post-transplant survival in patients with HCC. MATERIAL AND METHODS: The charts of 53 HCC patients were retrospectively analyzed. Twenty-seven patients had STACE as a bridging therapy while 26 patients were scheduled for liver transplantation (LTX) without prior STACE therapy. A total of 53% of the patients who underwent LTX preoperatively fulfilled the Milan criteria, while 70.6% fulfilled the expanded University of California, San Francisco (UCSF) transplant criteria. Primary endpoint was the post-transplant survival. Statistical analysis included Kaplan-Meier-method, log rank, and chi square tests. RESULTS: Between the LTX groups (STACE vs. non-STACE), there was no significant difference in terms of age, Child classification, Okuda stage, co-morbidities, underlying disease, and post-transplant survival (p > 0.05). Independent of prior STACE, however, disease-free survival after LTX was highly significantly prolonged if LTX was performed within 3 months after initial diagnosis of HCC (p < 0.01) or if patients met the expanded transplant UCSF criteria (p = 0.02). Post-transplant survival did not depend on tumor size. CONCLUSIONS: We conclude that STACE performed prior to LTX does not secure any post-transplant survival benefit, while early LTX, i.e. within 3 months after HCC diagnosis, does improve survival regardless of whether STACE was performed or not. Additionally, fulfillment of the expanded transplant UCSF criteria leads to a prolonged post-transplant survival.

Standard versus Endocuff versus cap-assisted colonoscopy for adenoma detection: A randomised controlled clinical trial.

BACKGROUND AND AIMS: Adenoma detection rate (ADR) in colon cancer screening is most important for cancer prophylaxis. This work is the first three-armed randomised controlled clinical trial aimed at comparing a head-to-head setting standard colonoscopy (SC) with Endocuff-assisted colonoscopy (EC) and cap-assisted colonoscopy (CAC) for improvement of ADR. METHODS: Patients from Poland and Germany with independent indication for colonoscopy were randomised into three arms of this trial: EC, CAC and SC. Exclusion criteria were age <18 years, active Crohn's disease or ulcerative colitis, known stenosis and post-colonic resection status. RESULTS: A total of 585 patients (195 SC, 189 EC and 186 CAC) were enrolled in this study. Indications were not different between the groups (colorectal cancer screening 51%, diagnostic colonoscopy in 31% and post-polypectomy follow-up in 18%; p = 0.94). Withdrawal time was a mean of 7 min in all groups (p = 0.658), and bowel preparation did not differ between the groups. The time to reach the caecum was significantly reduced when using the cap (a mean of 6 min for CAC vs. 7 min for SC; p = 0.0001). There was no significant difference in the primary outcome of the ADR between the groups (EC 32%, CAC 30%, SC 30%; p = 0.815). EC proved to be superior (EC vs. SC) in the sigmoid colon and transverse colon for polyp detection. CONCLUSION: The use of EC increased the total number of polyps seen during colonoscopy. In contrast to recent studies, no significant improvement of the ADR was detected.

Preoperative prediction of curative surgery of perihilar cholangiocarcinoma by combination of endoscopic ultrasound and computed tomography.

BACKGROUND: Perihilar cholangiocarcinomas are often considered incurable. Late diagnosis is common. Advanced disease therefore frequently causes questioning of curative surgical outcome. AIM: This study aimed to develop a prediction model of curative surgery in patients suffering from perihilar cholangiocarcinomas based on preoperative endosonography and computer tomography. METHODS: A cohort of 81 patients (median age 67 (54-75) years, 62% male) with perihilar cholangiocarcinoma was retrospectively analyzed. Multivariate logistic regression analysis of staging variables taken from the European Staging System was performed and applied to ROC analysis. RESULTS: The correlation of predicted rates of eligibility for surgery with actual rates reached AUC values between 0.652 and 0.758 for endosonography and computer tomography (p < 0.05 each). Best prediction for curative surgical option was achieved by combining endosonography and computer tomography (AUC: 0.787; 95% CI 0.680-0.893, p < 0.0001). A predictive model (pSurg) was developed using multivariate analysis. CONCLUSIONS: Our predictive web-based model pSurg with inclusion of T, N, M, B, PV, HA and V stage of the recently published European Staging System for perihilar cholangiocarcinoma results in highly significant predictability for curative surgery when combining preoperative endosonography and computer tomography, thus allowing for better patient selection in terms of possibility of curative surgery.

Single-operator cholangioscopy for biliary complications in liver transplant recipients.

AIM: To evaluate cholangioscopy in addition to endoscopic retrograde cholangiopancreatography (ERCP) for management of biliary complications after liver transplantation (LT). METHODS: Twenty-six LT recipients with duct-to-duct biliary reconstruction who underwent ERCP for suspected biliary complications between April and December 2016 at the university hospital of Muenster were consecutively enrolled in this observational study. After evaluating bile ducts using fluoroscopy, cholangioscopy using a modern digital single-operator cholangioscopy system (SpyGlass DS™) was performed during the same procedure with patients under conscious sedation. All patients received peri-interventional antibiotic prophylaxis and bile was collected during the intervention for microbial analysis and for antibiotic susceptibility testing. RESULTS: Thirty-three biliary complications were found in a total of 22 patients, whereas four patients showed normal bile ducts. Anastomotic strictures were evident in 14 (53.8%) patients, non-anastomotic strictures in seven (26.9%), biliary cast in three (11.5%), and stones in six (23.1%). A benefit of cholangioscopy was seen in 12 (46.2%) patients. In four of them, cholangioscopy was crucial for selective guidewire placement prior to planned intervention. In six patients, biliary cast and/or stones failed to be diagnosed by ERCP and were only detectable through cholangioscopy. In one case, a bile duct ulcer due to fungal infection was diagnosed by cholangioscopy. In another case, signs of bile duct inflammation caused by acute cholangitis were evident. One patient developed post-interventional cholangitis. No further procedure-related complications occurred. Thirty-seven isolates were found in bile. Sixteen of these were gram-positive (43.2%), 12 (32.4%) were gram-negative bacteria, and Candida species accounted for 24.3% of all isolated microorganisms. Interestingly, only 48.6% of specimens were sensitive to prophylactic antibiotics. CONCLUSION: Single-operator cholangioscopy can provide important diagnostic information, helping endoscopists to plan and perform interventional procedures in LT-related biliary complications.

[Acute liver failure after ingestion of death cap mushrooms]. / Akutes Leberversagen nach Knollenblätterpilz-Ingestion.

Amatoxins, which are mainly found in Amanita phalloides, Amanita virosa, and Galerina autumnalis, are responsible for the majority of fatal intoxication with green death cap. The intoxication is associated with acute liver failure, which explains the poor prognosis. Acute liver injury is generally preceeded by a gastrointestinal phase with nausea, vomiting and diarrhea. In the course, pre-renal kidney failure due to the associated fluid deficit and fulminant liver failure may occur. General guidelines for the treatment of amatoxin poisoning are yet not available. We report on three patients who suffered from amatoxin mushroom poisoning after ingestion of green death cap mushrooms. Based on the pathophysiology of amatoxin poisoning, we discuss a potential therapeutic approach.

Innovative video capsule endoscopy for detection of ubiquitously elongated small intestinal villi in Cronkhite-Canada syndrome.

Cronkhite-Canada syndrome (CCS) is a rare non-familial disorder with multiple gastrointestinal polyps and ectodermal changes. Adenomatous and carcinomatous changes have been reported. Video capsule endoscopy is a useful non-invasive tool to reveal polypoid lesions of the gastrointestinal tract suspicious for malignancy. We report a case of a patient with CCS with excessively elongated intestinal villi resembling dense sea grass under water as well as multiple polyps of the intestinal mucosa revealed by video capsule endoscopy. This report presents for the first time small bowel video sequences of CCS qualifying video capsule endoscopy for screening purposes and early detection of malignancy.

Clinical outcome and predictors of survival in patients with pneumocystis jirovecii pneumonia--results of a tertiary referral centre.

BACKGROUND AND AIMS: Pneumocystis jirovecii pneumonia also known as pneumocystis pneumonia (PCP) is an opportunistic respiratory infection in human immunodeficiency virus (HIV) patients that may also develop in non-HIV immunocompromised persons. The aim of our study was to evaluate mortality predictors of PCP patients in a tertiary referral centre. METHODS: Fifty-one patients with symptomatic PCP were enrolled in the study. The patients had either HIV infection (n = 21) or other immunosuppressive conditions (n = 30). Baseline characteristics (e.g. age, sex and underlying disease) were retrieved. Kaplan-Meier analysis was employed to calculate survival. Comparisons were made by log-rank test. A multivariate analysis of factors influencing survival was carried out using the Cox regression model. Chi-squared test and Wilcoxon-Mann-Whitney test was applied as appropriate. RESULTS: The median survival time for the HIV group was >120 months compared with 3 months for the non-HIV group (P = 0.009). Three-month survival probability was also significantly greater in the HIV group compared with the non-HIV group (90% vs 41%, P = 0.002). In univariate log-rank test, intensive care unit (ICU) necessity, HIV negativity, age >50 years, haemoglobin <10g/dl, C-reactive protein >5 mg/dL and multiple comorbidities were significant negative predictors of survival. In the Cox regression model, ICU and HIV statuses turned out to be independent prognostic factors of survival. CONCLUSION: PCP is a serious problem in non-HIV immunocompromised patients in whom survival outcomes are worse than those in HIV patients.

Endoscopic ultrasound in staging esophageal cancer after neoadjuvant chemotherapy--results of a multicenter cohort analysis.

BACKGROUND: Endoscopic ultrasound (EUS) is considered a gold standard in the initial staging of esophageal cancer. There is an ongoing debate whether EUS is useful for tumor staging after neoadjuvant chemotherapy (NAC). METHODS: Ninety-five patients with esophageal cancer were retrospectively analyzed. In 45 patients, EUS was performed prior to and after NAC, while 50 patients had no induction therapy. Histological correlation through surgery was available. uT/uN classifications were compared to pT/pN stages. Statistical analysis included calculation of sensitivity, specificity, and accuracy rates. Agreement between endosonography and T staging was assessed with Cohen's kappa statistics. RESULTS: For those patients with prior NAC, overall accuracy of yuT and yuN classification was 29 and 62%, respectively. Sensitivity, specificity, and accuracy rates for local tumor extension after NAC were as follows (%): T1: -/97/84, T2: 13/76/53, T3:86/29/46, T4:20/100/91, T1/2: 27/83/56, T3/4: 89/31/56. Cohen's kappa indicated poor agreement (kappa = 0.129) between yuT classification and ypT stage. Relative to positive lymph node detection, sensitivity and specificity were 100 and 6%, respectively (kappa = 0.06). T stage was overstaged in 23 (51%) and understaged in seven (16%) patients. CONCLUSION: EUS is an unreliable tool for staging esophageal cancer after NAC. Overstaging of the T stage is common after NAC.

Liver transplantation versus supraselective transarterial chemoembolization in palliative patients with hepatocellular carcinoma exceeding the Milan Criteria - is it time for a more individual approach?

BACKGROUND: This study evaluated the effect of liver transplantation (LTX) and STACE on overall survival in palliative patients with HCC exceeding Milan criteria. MATERIAL AND METHODS: At a single center 63 HCC patients exceeding Milan criteria were retrospectively analyzed. Forty patients underwent STACE as palliative therapy modality and 23 palliative patients were scheduled for LTX. The primary endpoint was overall patient survival. Statistical analysis included Kaplan-Meier method, log rank, chi squared tests and Cox regression model for the identification of prognostic factors. RESULTS: There was no significant difference when comparing the 2 groups (LTX vs. no LTX) in terms of Child classification, co-morbidities, underlying disease, and sex. Overall survival was significantly prolonged after LTX was performed (p=0.012). In the Cox regression model, LTX (p=0.021), LTX <3Mo (p=0.047), CHILD stage (p=0.007), AFP (p=0.020), and tumor size of largest HCC nodule <40 mm (p=0.028) were independent prognostic factors for survival. CONCLUSIONS: Palliative patients beyond Milan have a significant survival benefit after they received early liver transplantation in comparison with STACE. The current approach to waiting list candidacy based on Milan criteria should be modified with a more individualized approach that considers age, AFP level, and tumor size.

Ileal gallstone obstruction: Single-balloon enteroscopic removal.

Gallstone-induced ileus is a rare complication of cholelithiasis. Since localization of gallstones impacted in the small bowel, especially in the ileum, prevents access by conventional endoscopy in most cases, the mainstay of treatment remains surgical. Recent invention of double- and single-balloon enteroscopy has added much to the ability of imaging the small bowel and enables endoscopically directed therapy. Herein, for the first time, we report a successful endoscopic calculus removal via peroral single-balloon enteroscopy in an 81-year-old woman suffering from gallstone ileus of the ileum.