Antimigration versus conventional fully covered metal stents in the endoscopic treatment of anastomotic biliary strictures after deceased-donor liver transplantation.

INTRODUCTION: Migration of fully covered metal stents (FCMS) remains a limitation of the endoscopic treatment of anastomotic biliary strictures (ABS) following orthotopic liver transplantation (OLT). The use of antimigration FCMS (A-FCMS) might enhance endoscopic treatment outcomes for ABS. METHODS: Single center retrospective study. Consecutive patients with ABS following OLT who underwent ERCP with FCMS placement between January 2005 and December 2020 were eligible. Subjects were grouped into conventional-FCMS (C-FCMS) and A-FCMS. The primary outcome was stent migration rates. Secondary outcomes were stricture resolution, adverse event, and recurrence rates. RESULTS: A total of 102 (40 C-FCMS; 62 A-FCMS) patients were included. Stent migration was identified at the first revision in 24 C-FCMS patients (63.2%) and in 21 A-FCMS patients (36.2%) (p = 0.01). The overall migration rate, including the first and subsequent endoscopic revisions, was 65.8% in C-FCMS and 37.3% in A-FCMS (p = 0.006). The stricture resolution rate at the first endoscopic revision was similar in both groups (60.0 vs 61.3%, p = 0.87). Final stricture resolution was achieved in 95 patients (93.1%), with no difference across groups (92.5 vs 93.5%; p = 0.84). Adverse events were identified in 13 patients (12.1%) with no difference across groups. At a median follow-up of 52 (IQR: 19-85.5) months after stricture resolution, 25 patients (24.5%) developed recurrences, with no difference across groups (C-FCMS 30% vs A-FCMS 21%; p = 0.28). CONCLUSIONS: The use of A-FCMS during ERCP for ABS following OLT results in significantly lower stent migration rates compared to C-FCMS. However, the clinical benefit of reduced stent migration is unclear. Larger studies focusing on stricture resolution and recurrence rates are needed.

Cecal ameboma and a liver abscess mimicking metastatic colonic cancer. An autochthonous infectious disease in Spain?

We present the case of 52 years-old male without any recent travel. He was admitted to our department for a history of fever and abdominal pain. A CT scan showed a cecal thickening and liver mass with suspected cecal carcinoma with infected necrotic liver metastasis. Although the colonoscopy revealed a bulky submucosal wall thickening with a fibrined ulcer with yellow granulating located in the cecum, the percutaneous drainage revealed a positive PCR for Entamoeba histolytica, with improvement with metronidazole treatment. Ameboma are ulcerative, exophytic, inflammatory masses up to 15 cm in diameter in patients with long standing colonic amoebic infections containing granulation tissue with pseudotumor appearance. It affects less than 1.5% of colonic invasive amebiasis. Moreover, concomitant hepatic amoebic can be observed up to 30%, mimicking colonic cancer with necrotic liver metastasis. Although no epidemiological risk factor for amoebic infection was detected. We therefore highlight the awareness of amoebic infection and different manifestation even in non-endemic areas.

Lumen apposing metal stents versus tubular self-expandable metal stents for endoscopic ultrasound-guided choledochoduodenostomy in malignant biliary obstruction.

BACKGROUND AND AIMS: EUS-guided choledochoduodenostomy (EUS-CDS) is an effective option for biliary drainage in malignant biliary obstruction. Lumen apposing metal stents (LAMS) are increasingly been used for EUS-CDS. It is unknown how LAMS compare to tubular self-expandable metal stents (SEMS) for EUS-CDS. Our aim is to compare the clinical outcomes of LAMS versus SEMS for EUS-CDS. PATIENTS AND METHODS: Single-center retrospective cohort study of consecutive patients with unresectable malignant biliary obstruction who underwent EUS-CDS after failed ERCP for initial biliary drainage between 2011 and 2019. Clinical outcomes were compared between patients who had conventional covered SEMS and LAMS placed for EUS-CDS. Outcome measures included unplanned procedural events, technical success, clinical success, adverse events and reinterventions. Survival was analyzed by the Kaplan-Meier method. RESULTS: During the study period 57 patients met inclusion criteria (37 LAMS, 20 SEMS). All EUS-CDS were technically successful (LAMS group 95% CI 90.3-100%, SEMS group 95% CI 83.2-100%). There were no differences between groups in unplanned procedural events (4 LAMS deployment issues, 2 mild bleeding in SEMS group; 10 vs 10.8%), clinical success (37/37 [100%] vs 19/20 [95%]), and short-term adverse events (5/37 [13.5%] vs 4/20 [20%], p = 0.71). Complete follow-up data were available in 41 patients for a mean of 376 ± 145 days. Endoscopic reintervention was required for duodenal stent placement (n = 9) or biliary stent dysfunction (n = 4), with no difference between LAMS and SEMS group (6/37 [16.2%] vs 7/20 [35%]). There were no differences in overall survival between both groups. CONCLUSIONS: EUS-guided choledochoduodenostomy after failed ERCP has equally high technical and clinical success rates with either LAMS or SEMS in patients with malignant biliary obstruction. No differences in adverse events, reinterventions and survival were seen with either type of stent. The cost-effectiveness of LAMS vs SEMS for EUS-guided choledochoduodenostomy remains to be proven.

CPRE vía gastro-acceso transprotésico USE-guiado en pacientes con bypass gástrico en Y de Roux con prótesis de aposición luminal o prótesis duodenales metálicas autoexpandibles: técnica y resultados en la primera serie europea / No disponible

INTRODUCCIÓN: la colangiopancreatografía retrógrada endoscópica vía acceso transprotésico USE-guiado (CPRE-GATU) es una opción emergente en el bypass gástrico en Y de Roux. MÉTODOS: estudio unicéntrico de revisión de 14 pacientes consecutivos para evaluar los resultados de la CPRE-GATU. RESULTADOS: se realizaron 14 gastrogastrostomías/gastroyeyunostomías USE-guiadas en las que se emplearon prótesis de aposición luminal (PAL; n=10) o duodenales metálicas autoexpandibles (PMA; n = 4). Se obtuvo éxito clínico en la CPREGATU en sesión única en 9/12 (75%) y en la CPRE-GATU en dos tiempos por abordaje diferido o por seguimiento en 6/7 (85% Se obtuvo acceso papilar y canulación biliar en todos los casos. No se logró extraer una prótesis biliar migrada, por lo que el éxito clínico final de la CPRE-GATU fue de 13/14 (93%). Hubo 4/19 desalojos protésicos, todos ellos rescatados endoscópicamente. Se registraron 3 eventos adversos leves (16%). Las prótesis transgástricas se retiraron tras una media de 30 días; 256 días después de la retirada de la prótesis transgástrica no se registraron recidivas sintomáticas ni presencia de fístulas persistentes. CONCLUSIONES: tanto las PMA duodenales como las PAL pueden emplearse en sesión única o diferida de CPRE-GATU en pacientes con bypass gástrico en Y de Roux

No disponible

Endoscopic ultrasound-directed transgastric ERCP in patients with Roux-en-Y gastric bypass using lumen-apposing metal stents or duodenal self-expandable metal stents. A European single-center experience.

INTRODUCTION: endoscopic ultrasound-directed transgastric ERCP is emerging in Roux-en-Y gastric bypass. METHODS: a review of 14 consecutive patients. RESULTS: fourteen EUS-directed gastro-gastrostomy/gastro-jejunostomy were performed using lumen-apposing metal stents or duodenal self-expandable metal stents. Single-session ERCP was successful in 9/12 cases and deferred procedures or follow-up in 6/7 cases. Papillary access was obtained in all cases. Dislodgment occurred in 4/19 patients and was handled successfully endoscopically. Transgastric stents were removed after a median of 30 days. No recurrence/fistula were noted after a median of 256 days post-removal. CONCLUSIONS: duodenal self-expandable and lumen-apposing metal stents can be used for single-deferred endoscopic ultrasound-directed transgastric ERCP in Roux-en-Y gastric bypass.

Safety and efficacy of endoscopic ultrasound-guided gallbladder drainage combined with endoscopic retrograde cholangiopancreatography in the same session.

BACKGROUND AND AIM: Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is an emerging option for acute cholecystitis in non-surgical candidates. Combining endoscopic retrograde cholangiopancreatography (ERCP) for common bile duct stones with EUS-GBD in a single session might become a non-surgical management strategy to comprehensively treat gallstone disease in selected patients. METHODS: Single-center retrospective cohort study comparing outcomes between EUS-GBD alone (group A) and single-session ERCP combined with EUS-GBD (group B). Consecutive patients who underwent EUS-GBD with a lumen-apposing metal stent (LAMS) between June 2011 and August 2018 were analyzed. Exclusion criteria were subjects included in randomized clinical trials, patients who had had ERCP within 5 days of EUS-GBD, patients in whom ERCP or EUS-GBD was carried out for salvage of one or the other procedure, and patients who underwent concurrent EUS-guided biliary drainage. RESULTS: One hundred and nine consecutive patients underwent EUS-GBD with LAMS during the study period. Seventy-one patients satisfied the inclusion criteria and 34 patients were in group A and 37 in group B. Baseline characteristics were similar in both groups. There were no significant differences in technical (97.1% vs 97.3%; P = 0.19) and clinical success rates (88.2% vs 94.6%; P = 0.42) of EUS-GBD in group A versus group B. Rate of adverse events was similar in both groups, five (14.7%) in group A versus five (13.5%) in group B. CONCLUSIONS: Single-session EUS-GBD combined with ERCP has comparable rates of technical and clinical success to EUS-GBD alone. A combined EUS-GBD and ERCP procedure does not appear to increase adverse events and makes possible comprehensive treatment of gallstone disease by purely endoscopic means.

Safety and clinical outcomes of endoscopic ultrasound-guided gallbladder drainage with lumen-apposing metal stents in patients with dwell time over one year.

BACKGROUND: Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) has proved effective in patients with cholecystitis at high surgical risk. The long-term risks of gallstone-related disease and stent-related adverse events are unknown. METHODS: We performed a retrospective evaluation of a case series including subjects who underwent EUS-GBD using lumen-apposing metal stents (LAMS). Patients were identified from a prospective LAMS registry at a single tertiary center. Patients with a stent indwell time <1 year were excluded. Data regarding stent deployment and adverse events were retrieved from the prospective LAMS registry, while emergency room visits, admissions and causes of death were retrieved from electronic medical records. RESULTS: We included 22 patients with a median age of 88.3 years (interquartile range [IQR]: 82.6-92.7), 14 (63.6%) were male. Median follow up was 24.4 months (IQR: 18.2-42.4) and median time to the last available imaging procedure was 607 days (IQR: 463-938). No LAMS-related adverse events were identified beyond the first year of follow up. During follow up, 12 patients (54.5%) visited the emergency room 34 times (1 visit/patient, IQR: 0-3) and a total of 36 hospital admissions were required, with a median of 1 admission/patient (IQR: 0-3). Fourteen (63.6%) patients died during follow up. Only 1 patient (4.5%) required new hospital admissions for gallstone-related disease. CONCLUSIONS: There were no adverse events beyond the first year after stent deployment, with only 4.5% of subjects requiring gallstone-related admissions. Permanent EUS-GBD with LAMS may be a definitive treatment for acute cholecystitis in patients ineligible for cholecystectomy.

Análisis retrospectivo multicéntrico de las incidencias asociadas a las prótesis de aposición luminal tipo Axios(TM) / A retrospective, multicenter analysis of incidents associated with Axios(TM) lumen-apposing stents

Introducción: existe controversia respecto a los riesgos asociados a las prótesis de aposición luminal (PAL), con importantes variaciones entre los trabajos disponibles. Objetivos: describir el tipo y la proporción de complicaciones durante la permanencia y retirada de PAL tipo Axios(TM). Describir la relación entre tiempo de permeabilidad, diana terapéutica y presencia de complicaciones. Métodos: serie de casos retrospectiva y multicéntrica que incluyó todos los pacientes consecutivos a los que se les colocó una PAL para acceder a estructuras extraluminales durante el año 2017. Se registraron únicamente aquellos casos que alcanzaron éxito técnico. Resultados: se incluyeron 179 pacientes de siete centros (rango 4-68 casos/centro) con edad media de 64,3 años (DE: 15,8, rango 24,6-98,8 años), 122 (68,2%) de ellos varones. Las indicaciones más frecuentes fueron las necrosis encapsuladas (58, 32,4%), seguidas de pseudoquistes (31, 17,3%) y drenajes vesiculares (26, 14,5%). Durante la permanencia de la PAL se documentaron complicaciones en 19 pacientes (10,9%), siendo las más frecuentes las obstrucciones de la luz protésica o del marco gastroduodenal en ocho (4,5%) casos y las hemorragias en siete (3,9%) pacientes. Las PAL no se retiraron en 86 pacientes (48%) por los siguientes motivos: intención permanente de la PAL en 46 (53,5%), pérdida del seguimiento en 18 (20,9%), fallecimiento del paciente en 16 (18,6%) y migración en seis (7%). Durante la retirada se observaron cinco complicaciones (5,4%), tres casos de hemorragia y dos perforaciones. No observamos una asociación entre el tiempo de permanencia y las complicaciones (p = 0,67). Conclusión: la aparición de complicaciones secundarias a la inserción de PAL es poco frecuente, aunque pueden ser graves. En este estudio no se ha observado una asociación entre la aparición de complicaciones y el tiempo de permanencia de la prótesis

Introduction: there is controversy with regard to the risks associated with lumen-apposing metal stents (LAMSs), with significant variations between available reports. Objectives: to describe the types and proportions of complications that arise during the permanence time and removal of Axios(TM) LAMS. Furthermore, the relationship between patency time, therapeutic target and the presence of complications was also described. Methods: a retrospective, multicenter case series study was performed of all patients with an implanted LAMS to access extra-luminal structures during 2017. Only technically successful cases were recorded. Results: a total of 179 patients from seven sites (range, 4-68 cases/site) were included in the study, with a mean age of 64.3 years (SD: 15.8; range: 24.6-98.8 years) and 122 (68.2%) were male. Most common indications included encapsulated necrosis (58, 32.4%), pseudocysts (31, 17.3%) and gallbladder drains (26, 14.5%). Complications during LAMS stay were reported in 19 patients (10.9%); stent lumen or gastroduodenal obstruction (8, 4.5%) and bleeding (7, 3.9%) were the most common. LAMS were not removed in 86 (48%) patients due to the following reasons: a permanent stent was used (46, 53.5%), loss to follow-up (18, 20.9%), patient demise (16, 18.6%) and stent migration (6, 7%). Five (5.4%) complications were reported during stent removal, which were three bleeds and two perforations. No association was found between stent duration and complications (p = 0.67). Conclusion: complications secondary to LAMS insertion are uncommon but may be serious. This study found no association between complications and stent duration

A retrospective, multicenter analysis of incidents associated with Axios™ lumen-apposing stents.

INTRODUCTION: there is controversy with regard to the risks associated with lumen-apposing metal stents (LAMSs), with significant variations between available reports. OBJECTIVES: to describe the types and proportions of complications that arise during the permanence time and removal of Axios™ LAMS. Furthermore, the relationship between patency time, therapeutic target and the presence of complications was also described. METHODS: a retrospective, multicenter case series study was performed of all patients with an implanted LAMS to access extra-luminal structures during 2017. Only technically successful cases were recorded. RESULTS: a total of 179 patients from seven sites (range, 4-68 cases/site) were included in the study, with a mean age of 64.3 years (SD: 15.8; range: 24.6-98.8 years) and 122 (68.2%) were male. Most common indications included encapsulated necrosis (58, 32.4%), pseudocysts (31, 17.3%) and gallbladder drains (26, 14.5%). Complications during LAMS stay were reported in 19 patients (10.9%); stent lumen or gastroduodenal obstruction (8, 4.5%) and bleeding (7, 3.9%) were the most common. LAMS were not removed in 86 (48%) patients due to the following reasons: a permanent stent was used (46, 53.5%), loss to follow-up (18, 20.9%), patient demise (16, 18.6%) and stent migration (6, 7%). Five (5.4%) complications were reported during stent removal, which were three bleeds and two perforations. No association was found between stent duration and complications (p = 0.67). CONCLUSION: complications secondary to LAMS insertion are uncommon but may be serious. This study found no association between complications and stent duration.

Retrospective cohort study comparing endoscopic ultrasound-guided and percutaneous drainage of upper abdominal abscesses.

BACKGROUND AND AIM: Endoscopic ultrasonography (EUS)-guided drainage (EUS-D) has become the standard treatment for peripancreatic fluid collections. Its use in other intra-abdominal abscesses has been reported, although there is limited evidence. METHODS: We carried out a single-center retrospective cohort study comparing percutaneous drainage (PCD) and EUS-D of upper abdominal abscesses between January 2012 and June 2017. Pancreatic fluid collections and liver transplant recipients were excluded. Primary endpoints were technical and clinical success rates. RESULTS: We included 18 EUS-D (nine hepatic and nine intraperitoneal abscesses) and 62 PCD. There were no differences regarding age, gender and etiology. Size was larger in the PCD group (80 vs 65.5 mm, P = 0.04) and perivesicular location was more frequent in the PCD group (24.2% vs 11.1%, P = 0.003). In the EUS-D group, metal stents were deployed in 16 (88.9%) subjects (eight lumen-apposing metal stents and eight self-expandable metal stents), coaxial double-pigtail plastic stents in six (33.3%) and lavage/debridement was carried out in five (27.8%). There were no significant differences in technical success (EUS-D: 88.9%, PCD: 96.8%, P = 0.22) or clinical success (EUS-D: 88.9%, PCD: 82.3%, P = 0.50), with no relapses in the EUS-D group and 10 (16.1%) in the PCD group (P = 0.11). There were four (22.2%) adverse events in the EUS-D group, none of them severe, and 13 (21%) in the PCD group (P = 0.91). CONCLUSIONS: EUS-D is an alternative to PCD in the treatment of upper abdominal abscesses, reaching similar success, relapse and adverse events rates.