BILIARY FISTULAS ASSOCIATED WITH LIVER TRANSPLANTATION VERSUS OTHER ETIOLOGIES: WHAT IS THE SUCCESS RATE OF THE ENDOSCOPIC TREATMENT?

BACKGROUND: Biliary fistulas typically occur as surgical complications after laparoscopic cholecystectomy, liver transplantation, or partial liver resection. AIMS: This study aimed to evaluate the efficacy of the endoscopic treatment of biliary fistulae secondary to liver transplantation compared to that of other etiologies. METHODS: A retrospective study of 25 patients undergoing endoscopic retrograde cholangiopancreatography for biliary fistula from 2015 to 2021 was conducted at the Endoscospy Unit of Walter Cantídio University Hospital. Clinical characteristics and endoscopic success rates of the post-liver transplantation group were analyzed in comparison with those of other etiologies. RESULTS: The main causes of biliary fistula were liver transplantation (44%) and cholecystectomy complications (44%). The post-liver transplantation group had a significantly higher proportion of male sex (liver transplantation=81.8%, others=28.6%) and older age (liver transplantation=54.1 years, others=42.0 years) and a higher incidence of biliary stenosis (liver transplantation=90.9%, others=14.3%) than those of the group with other etiologies (p<0.05). The two groups received similar treatment types, among which sphincterotomy associated with biliary stent placement was most commonly used. Endoscopic therapeutic success rates showed no significant difference between the post-liver transplantation group (63.6%) and the group with other etiologies (71.4%). CONCLUSIONS: The endoscopic treatment of biliary fistulae secondary to liver transplantation presented a recovery rate similar to that of other etiologies despite the patients older age and the presence of biliary stenosis.

Biliary fistulas associated with liver transplantation versus other etiologies: what is the success rate of the endoscopic treatment? / Fístulas biliares associadas com transplante hepático versus outras etiologias: qual a taxa de sucesso do tratamento endoscópico?

ABSTRACT - BACKGROUND: Biliary fistulas typically occur as surgical complications after laparoscopic cholecystectomy, liver transplantation, or partial liver resection. AIMS: This study aimed to evaluate the efficacy of the endoscopic treatment of biliary fistulae secondary to liver transplantation compared to that of other etiologies. METHODS: A retrospective study of 25 patients undergoing endoscopic retrograde cholangiopancreatography for biliary fistula from 2015 to 2021 was conducted at the Endoscospy Unit of Walter Cantídio University Hospital. Clinical characteristics and endoscopic success rates of the post-liver transplantation group were analyzed in comparison with those of other etiologies. RESULTS: The main causes of biliary fistula were liver transplantation (44%) and cholecystectomy complications (44%). The post-liver transplantation group had a significantly higher proportion of male sex (liver transplantation=81.8%, others=28.6%) and older age (liver transplantation=54.1 years, others=42.0 years) and a higher incidence of biliary stenosis (liver transplantation=90.9%, others=14.3%) than those of the group with other etiologies (p<0.05). The two groups received similar treatment types, among which sphincterotomy associated with biliary stent placement was most commonly used. Endoscopic therapeutic success rates showed no significant difference between the post-liver transplantation group (63.6%) and the group with other etiologies (71.4%). CONCLUSIONS: The endoscopic treatment of biliary fistulae secondary to liver transplantation presented a recovery rate similar to that of other etiologies despite the patients older age and the presence of biliary stenosis

RESUMO - RACIONAL: As fístulas biliares geralmente ocorrem como complicações cirúrgicas, especialmente após colecistectomia laparoscópica, transplante hepático ou ressecção hepática parcial. OBJETIVOS: Avaliar a eficácia do tratamento endoscópico das fístulas biliares secundária ao transplante hepático em comparação com outras etiologias. MÉTODOS: Estudo retrospectivo de 25 pacientes submetidos a Colangiopancreatografia Retrógada Endoscópica por fístula biliar entre 2015 e 2021 no Serviço de Endoscopia do Hospital Universitário Walter Cantídeo. As características clínicas e as taxas de sucesso endoscópico do grupo pós-transplante hepático foram analisadas em comparação com as de outras etiologias. RESULTADOS: As principais causas de fístula biliar foram pós-transplante hepático (44%) e complicações da pós-colecistectomia (44%). O grupo pós-transplante hepático apresentou proporção significativamente maior de sexo masculino (pós-transplante hepático=81,8%, outros=28,6%) e idade mais avançada (pós-transplante hepático=54,1 anos, outros=42,0 anos) e maior incidência de estenose biliar (pós-transplante hepático=90,9%, outros=14,3%) do que o grupo com outras etiologias (p<0,05). Os dois grupos receberam tipos de tratamento semelhantes, dentre os quais a esfincterotomia associada à aposição de prótese biliar foi a mais utilizada. As taxas de sucesso terapêutico endoscópico não mostraram diferença significativa entre o grupo pós-transplante hepático (63,6%) e o grupo com outras etiologias (71,4%). CONCLUSÕES: O tratamento endoscópico das fístulas biliares secundária ao transplante hepático apresentou taxa de recuperação semelhante à de outras etiologias, apesar da idade avançada dos pacientes e da presença de estenose biliar.

Role of EUS evaluation after endoscopic eradication of esophageal varices with band ligation.

BACKGROUND AND AIMS: Variceal recurrence after endoscopic band ligation (EBL) for secondary prophylaxis is a frequent event. Some studies have reported a correlation between variceal recurrence and variceal rebleeding with the EUS features of paraesophageal vessels. A prospective observational study was conducted to correlate EUS evaluation of paraesophageal varices, azygos vein, and thoracic duct with variceal recurrence after EBL variceal eradication in patients with cirrhosis. METHODS: EUS was performed before and 1 month after EBL variceal eradication. Paraesophageal varices, azygos vein, and thoracic duct maximum diameters were evaluated in predetermined anatomic stations. After EBL variceal eradication, patients were submitted to endoscopic examinations every 3 months for 1 year. We looked for EUS features that could predict variceal recurrence. RESULTS: Thirty patients completed a 1-year endoscopic follow-up. Seventeen patients (57%) presented variceal recurrence. There was no correlation between azygos vein and thoracic duct diameter with variceal recurrence. Larger paraesophageal varices predicted variceal recurrence in both evaluation periods. Paraesophageal varices diameters that best correlated with variceal recurrence were 6.3 mm before EBL (52.9% sensitivity, 92.3% specificity, and .749 area under the receiver operating characteristic curve [AUROC]) and 4 mm after EBL (70.6% sensitivity, 84.6% specificity, and .801 AUROC). CONCLUSIONS: We conclude that paraesophageal varices diameter measured by EUS predicts variceal recurrence within 1 year after EBL variceal eradication. Paraesophageal diameter after variceal eradication is a better recurrence predictor, because it has a lower cut-off parameter, higher sensitivity, and higher AUROC.

Cholangioscopy in bile duct disease: a case series.

CONTEXT: Direct endoscopic visualization of biliopancreatic duct is certainly one of the greatest advances of therapeutic endoscopy. The use of a single-operator cholangioscopy platform (SpyGlass) is a promising technique in the evaluation of diseases such as indeterminate biliary stricture and giant choledocholitiasis. This is the first Brazilian case series using this technology. METHODS: We report a case series of 20 patients in whom SpyGlass was used with diagnostic and therapeutic intention. RESULTS: Most patients were female (60%) and the median age was 48 years (ranging from 14 to 94). Choledocholitiasis was the most common indication (12/20), and electrohydraulic lithotripsy was applied in eight (66%). Electrohydraulic lithotripsy was successful in seven (87.5%) patients. Partial stone fragmentation occurred in one patient with large stone causing stone-choledochal disproportion, which was conducted with biliary plastic stent placement and a second scheduled endoscopic approach in 3 months. In cases of undefined etiology of biliary strictures, it was possible to exclude malignancy due to direct visualization (7/8) or biopsy (1/8). One complication occurred (duodenal perforation) after papillary balloon dilation. CONCLUSION: The use of SpyGlass demonstrated the benefits, especially in cases of large bile duct stones and indeterminate biliary strictures. Other potencial improvements such as reduction on radiation exposure should be confirmed in prospective studies.

CHOLANGIOSCOPY IN BILE DUCT DISEASE: a case series / Colangioscopia nas afecções biliares: uma série de casos

Context Direct endoscopic visualization of biliopancreatic duct is certainly one of the greatest advances of therapeutic endoscopy. The use of a single-operator cholangioscopy platform (SpyGlass) is a promising technique in the evaluation of diseases such as indeterminate biliary stricture and giant choledocholitiasis. This is the first Brazilian case series using this technology. Methods We report a case series of 20 patients in whom SpyGlass was used with diagnostic and therapeutic intention. Results Most patients were female (60%) and the median age was 48 years (ranging from 14 to 94). Choledocholitiasis was the most common indication (12/20), and electrohydraulic lithotripsy was applied in eight (66%). Electrohydraulic lithotripsy was successful in seven (87.5%) patients. Partial stone fragmentation occurred in one patient with large stone causing stone-choledochal disproportion, which was conducted with biliary plastic stent placement and a second scheduled endoscopic approach in 3 months. In cases of undefined etiology of biliary strictures, it was possible to exclude malignancy due to direct visualization (7/8) or biopsy (1/8). One complication occurred (duodenal perforation) after papillary balloon dilation. Conclusion The use of SpyGlass demonstrated the benefits, especially in cases of large bile duct stones and indeterminate biliary strictures. Other potencial improvements such as reduction on radiation exposure should be confirmed in prospective studies. .

Contexto A visão endoscópica direta das vias biliopancreáticas é certamente um dos maiores avanços na endoscopia terapêutica. O uso da plataforma de colangioscopia de operador-único (SpyGlass) é uma técnica promissora na avaliação de afecções tais como estenoses de etiologia indefinida e coledocolitíase gigante. Essa é a primeira série de casos brasileira utilizando o método. Métodos Reportamos uma série de casos de 20 pacientes nos quais foi realizado Spyglass com objetivos diagnósticos e terapêuticos. Resultados A maioria dos pacientes era do sexo feminino (60%), com idade que variou de 14 a 94 anos (mediana de 48). Coledocolitíase foi a indicação mais comum (12/20) e litotripsia eletrohidráulica foi realizada em oito (66%). Litotripsia eletrohidráulica foi realizada com sucesso em sete (87,5%) pacientes. Fragmentação parcial dos cálculos ocorreu em um paciente com desproporção cálculo-coledociana, sendo conduzido com colocação de prótese plástica e reabordagem endoscópica programada em 3 meses. Nos casos de estenoses biliares de etiologia indeterminada, foi possível a exclusão de malignidade devido a visualização direta (7/8) ou biópsia (1/8). Uma complicação ocorreu (perfuração duodenal) após dilatação balonada da papila. Conclusão Foram demonstrados os benefícios do uso do Spyglass, principalmente nos casos de coledocolitíase gigante e estenoses biliares de etiologia indefinida. Outras potenciais vantagens como a redução da exposição à radiação deve ser confirmada em estudos prospectivos posteriores. .

Endoscopic treatment of large pancreatic fluid collections (PFC) using self-expanding metallic stents (SEMS) - a two-center experience.

UNLABELLED: Background/study aim: During the last several years, endoscopic ultrasound (EUS)-guided pancreatic fluid collections' (PFC) drainage has evolved into the preferred drainage technique. Recently, self-expanding metallic stents (SEMS) have been used as an alternative to double pigtail stents, with the advantage of providing a larger diameter fistula, thereby decreasing the risk of early obstruction and also allowing for direct endoscopic exploration of the cavity. The aim of this study was to evaluate the technical and clinical success, safety, and outcome of patients undergoing EUS-guided drainage of complex PFC using SEMS. PATIENTS/MATERIALS AND METHODS: The study was conducted at two tertiary hospitals from January 2010 to January 2013. All patients with PFC referred for endoscopic drainage were enrolled in a prospective database. The inclusion criteria were: (1) patients with pseudocysts or walled-off necrosis based on the revised Atlanta classification; (2) symptomatic patients with thick PFC; (3) PFC that persisted more than 6 weeks; and (4) large PFC diameter (≥ 9 cm). The exclusion criteria consisted of coagulation disorders, PFC bleeding or infection, and failure-to-inform written consent. RESULTS: A total of 16 patients (9 females, 7 males; mean age 52.6, range 20 - 82) underwent EUS drainage with SEMS. There were 14 cases of pseudocysts and 2 cases of walled-off necrosis. The etiologies of the PFC were mainly gallstones (8 of 16 patients, 50 %) and alcohol (5 of 16 patients, 31 %). Technical success was achieved in 100 % of the cases. All patients had a complete resolution of the PFC. CONCLUSION: Transmural EUS-guided drainage of complex PFC using SEMS is feasible, appears safe, and is efficacious. However, the exchange of the UC (uncovered)-SEMS for plastic stents is mandatory within 1 week. Future prospective studies, preferably multicenter studies, comparing SEMS versus traditional plastic stents for the drainage of PFC are warranted.

Esophageal intramural pseudodiverticulosis: a rare endoscopic finding.

A 76-year-old woman, presenting with a 4-year history of progressive dysphagia, was submitted to endoscopic examination. The upper endoscopy revealed a proximal esophageal stricture and inflammatory mucosa associated with multiples small orifices in the esophageal wall, some of them fulfilled with white spots suggestive of fungal infection. This was a typical endoscopic finding of esophageal intramural pseudodiverticulosis, a benign and rare condition, related to chronic esophagitis and others comorbid states, such as gastroesophageal reflux disease or infectious esophagitis, diabetes mellitus, alcohol consumption, and achalasia. Dysphagia is the predominant symptom and can be accompanied by esophageal stricture in 80% to 90% of patients. The pathogenesis is unknown, and as the pseudodiverticulosis is an intramural finding, endoscopy biopsies are inconclusive. The main histological finding is dilation of the submucosal glands excretory ducts, probably obstructed by inflammatory cells. The treatment consists in management of the underlying diseases and symptoms relief. In this particular case, the patient was submitted to antifungal drugs followed by endoscopic dilation with thermoplastic bougies, with satisfactory improvement of dysphagia.

Endoscopic Detection of Early Esophageal Squamous Cell Carcinoma in Patients with Achalasia: Narrow-Band Imaging versus Lugol's Staining.

Chromoendoscopy with Lugol's staining remains the gold standard technique for detecting superficial SCC. An alternative technique, such as narrow-band imaging (NBI), for "optical staining" would be desirable, since NBI is a simpler technique and has no known complications. In this study, we compare NBI without magnification and chromoendoscopy with Lugol's staining for detecting high-grade dysplasia and intramucosal esophageal squamous cell carcinoma (SCC) in patients with achalasia. This was a prospective observational study of 43 patients with achalasia referred to the Gastrointestinal Endoscopy Unit of the Hospital of Clinics, São Paulo, University Medical School, Brazil, from October 2006 to February 2007. Conventional examinations with white light, NBI, and Lugol staining were consecutively performed, and the suspected lesions were mapped, recorded, and sent for biopsy. The results of the three methods were compared regarding sensitivity, specificity, accuracy, positive predictive value, negative predictive value, positive likelihood value, and negative likelihood value. Of the 43 patients, one was diagnosed with esophageal squamous cell carcinoma, and it was detected by all of the methods. NBI technology without magnification has high sensitivity and negative predictive value for detecting superficial esophageal squamous cell carcinoma, and it has comparable results with those obtained with Lugol's staining.

Is there a correlation between right bronchus length and diameter with age?

OBJECTIVE: Right main bronchial anatomy knowledge is essential to guide endoscopic stent placement in modern era. The aim is to describe right bronchial anatomy, cross-area and its relation with the right pulmonary artery and patient's age. METHODS: One hundred thirty four cadaveric specimens were studied after approval by the Research and Ethics Committee at the University of São Paulo Medical School and Medical Forensic Institute of São Paulo. All necropsies were performed in natura after 24 hours of death and patients with previous pulmonary disease were excluded. Landmarks to start measurement were the first tracheal ring, vertex of carina, first right bronchial ring, and right pulmonary artery area over the right main bronchus. After mobilization, the specimens were measured using a caliper and measurement of distances was recorded in centimeters at landmarks points. All the measures (distances, cross sectional area and planes) were performed by three independent observers and recorded as mean, standard error and ranges. Student t test was used to compare means and linear regression was applied to correlate the measurements. RESULTS: From 134 specimens studied, 34 were excluded (10 with previous history of pulmonary diseases, surgery or deformities and 24 of female gender). Linear regression showed proportionality between tracheal length and right bronchus length; with the area at first tracheal ring and carina and also between the cross sectional area at these points. Linear regression analysis between tracheal length and age (R=0.593 P<0.005), right bronchus length and age (R=0.523, P<0.005), area of contact between right bronchus and right pulmonary artery and age (R=0.35, P<0.005). CONCLUSIONS: We can conclude that large airways grow progressively with increasing age in male gender. There was a direct correlation between age and tracheal length; as has age and right bronchus length. There was a direct correlation between age and the area of the right bronchus covered by the right pulmonary artery.

Endoscopic ultrasound-guided choledochoduodenostomy and duodenal stenting in patients with unresectable periampullary cancer: one-step procedure by using linear echoendoscope.

OBJECTIVE: Describe a case series of endoscopic ultrasound (EUS)-guided choledochoduodenostomy (EUS-CD) associated with duodenal self-expandable metal stents (SEMS) placement using solely the linear echoendoscope in seven patients with obstructive jaundice and duodenal obstruction due to unresectable periampullary cancer. MATERIAL AND METHODS: EUS-CD in the first portion of the duodenum, associated with duodenal SEMS placement was performed in seven patients with unresectable periampullary cancer with obstructive jaundice and invasive duodenal obstruction. Laboratory tests and clinical follow-up were performed until patient's death. The procedure was performed by an experienced endoscopist under conscious sedation. The puncture position was chosen based on EUS evaluation, at the common bile duct (CBD) above the tumor, through the distal part of the duodenal bulb. After that, the needle was withdrawn and a wire-guided needle knife was used to enlarge the site puncture in the duodenal wall. Then, a partially covered SEMS was passed over the guide, through the choledochoduodenal fistula. Duodenal SEMS placement was performed during the same endoscopic procedure. RESULTS: The procedure was performed in seven patients, ranging between 34 and 86 years. Technical success of EUS-CD, by the stent placement, occurred in 100% of the cases. There were no early complications. Duodenal SEMS placement was effective in 100% of the cases that remained alive after a follow-up of 7 and 30 days. CONCLUSION: The results suggest therapeutic EUS one-step procedure drainage as an alternative for these patients, with good clinical success, feasible technique and safety.

Endoscopic aspects of gastric syphilis.

Introduction. Considered as a rare event, gastric syphilis (GS) is reported as an organic form of involvement. Low incidence of GS emphasizes the importance of histopathological analysis. Objective. We aim to characterize GS endoscopic aspects in an immunocompetent patient. Case Report. A 23-year-old man presented with epigastric pain associated with nausea, anorexia, generalized malaise and 11 kg weight loss that started 1 month prior to his clinical consultation. Physical examination was normal except for mild abdominal tenderness in epigastrium. Endoscopy observed diminished gastric expandability and diffuse mucosal lesions, from cardia to pylorus. Gastric mucosa was thickened, friable, with nodular aspect, and associated with ulcers lesions. Gastric biopsies were performed, and histopathological analysis resulted in dense inflammatory infiltration rich in plasmocytes. Syphilis serologies were positive for VDRL and Treponema pallidum reagents. Immunohistochemical tests were positive for Treponema pallidum and CD138. The patient was treated with penicillin, leading to resolution of his clinical complaints and endoscopic findings. Conclusion. Diagnosis suspicion of GS is important in view of its nonspecific presentation. Patients with gastric symptoms that mimic neoplastic disease should be investigated thoroughly based on the fact that clinical, endoscopic, and histological findings can easily be mistaken for lymphoma or plastic linitis.