Mini-laparoscopy is superior in detecting liver cirrhosis and metastases in liver cancer: an over 10-year experience in 1,788 cases.

BACKGROUND/AIMS: Mini-laparoscopy has, since its first description in 1998, proven to be a valuable diagnostic method in liver diseases. We re-evaluated the significance of mini-laparoscopy for diagnosis and staging of liver disease and primary liver and bile duct cancer. PATIENTS AND METHODS: 1,788 consecutive patients who received a diagnostic mini-laparoscopy between 10/1998 and 06/2011 were included in this retrospective cohort study. RESULTS: In chronic liver disease, cirrhosis was detected by mini-laparoscopy in 27% of cases. A comparison of microscopic versus macroscopic diagnosis of cirrhosis revealed a sampling error for histology alone of 21%. Macroscopic inspection of the liver surface contributed to the diagnosis of unknown liver diseases in approximately 38%. In patients with bile duct or liver cancer, mini-laparoscopy led to upstaging of the disease in 33 and 23%, respectively. Major complications (bowel perforation and delayed bleeding) occurred in 0.39% of cases. CONCLUSIONS: Mini-laparoscopy is a valuable procedure with significant diagnostic impact in known and unknown inflammatory and malignant liver diseases. It can be safely performed even in patients with acute liver failure and severe coagulopathy and the diagnostic value does not differ from diagnostic laparoscopy performed with standard instruments.

Optimized endoscopic treatment of ischemic-type biliary lesions after liver transplantation.

BACKGROUND: Biliary strictures are the most common complication after liver transplantation. A particular problem is ischemic-type biliary lesions (ITBLs), which are often responsible for graft failure and early retransplantation. Although some encouraging results of successful endoscopic treatment have been reported, this has not yet resulted in a standardized therapeutic approach to date. OBJECTIVE: To evaluate an optimized algorithm for the endoscopic treatment of ITBLs. SETTING AND PATIENTS: All adult patients who underwent liver transplantation at the University of Essen between April 1998 and July 2006. DESIGN: Retrospective outcome analysis. MAIN OUTCOME MEASUREMENTS: Success or failure of 2 different therapeutic algorithms in terms of normalization of cholestasis parameters and graft survival. RESULTS: Forty-eight patients who had undergone liver transplantation and had an endoscopically determined diagnosis of ITBL were identified. The median interval between liver transplantation and first endoscopic intervention was 242.5 (range, 16-3677) days. Patients received a median of 6 treatment sessions (range 2-13) every 8 to 10 weeks. In 16 of 48 patients, a combination of balloon dilation (BD) and implantation of a plastic endoprosthesis (BD+EP) was performed; in the remaining 32 patients, BD alone was performed. Overall, endoscopic therapy was successful in 73%. BD+EP was successful in 5 of 16 (31%) and BD alone in 30 of 32 patients (91%; P = .0027). In the BD+EP group, severe cholangitis developed in 25% of patients, but only 12% of the BD group (P = .01). The median duration of therapy was 374 (range 11-808) days. Six of 48 patients underwent retransplantation because of chronic graft rejection at a median of 1288 (range 883-4204) days after the primary liver transplantation. Six of 48 patients underwent hepaticojejunostomy because of unsuccessful endoscopic therapy, and 1 patient underwent surgery because of portal vein thrombosis. LIMITATIONS: Retrospective design. CONCLUSIONS: An endoscopic treatment regimen for ITBLs, preferably BD alone, could prolong the time to or could completely avoid surgical revision and early retransplantation and seems to be superior to endoscopic stenting.

Successful photodynamic therapy for biliary papillomatosis: a case report.

Papillomatosis of the bile duct is a rare disease with a high risk of malignant transformation. Therapeutical options include partial hepatectomy and liver transplantation. A previously healthy 65-years old male developed jaundice and right upper abdominal quadrant pain in 1996. A villous adenoma of the distal bile duct was diagnosed. A Whipple procedure was performed. In 2002 the patient turned symptomatic again. Another adenoma was found in the right hepatic duct resulting in a right hepatectomy. Two years later the patient again developed cholestasis. After drainage of the left hepatic duct with a percutaneous transhepatic cholangial drainage (PTCD) catheter, a recurrent biliary adenomatosis was diagnosed by cholangioscopy. As there was no surgical option left, the patient received photodynamic therapy (PDT) for the recurrent biliary papillomatosis. Three mo after he received further photodynamic therapies, the bile duct epithelium appeared normal and the patient had no signs of adenomatosis, both macroscopically and histologically. The follow-up cholangioscopy in late 2005 revealed only a small papilloma without the need for intervention. In early 2006, the patient died of multi organ failure without signs of extrahepatic cholestasis or cholangitis at the age of 75, 10 years after the diagnosis of biliary papillomatosis was established. The patient exceeded the average life expectancy of patients with biliary papillomatosis by far. Thus, PDT might be a sufficient therapeutic option for recurrent papillomatosis patients with no significant side effects.

MR colonography vs. optical colonoscopy: comparison of patients' acceptance in a screening population.

The aim of this study was to compare optical colonoscopy to fecal-tagging-based MR colonography in a screening population in terms of comfort and acceptance ratings as well as for future preferences as colorectal cancer screening examinations. Two hundred eighty-four asymptomatic patients (mean age 59 years) underwent MRC and OC within 4 weeks. While MRC was based on a fecal tagging technique, OC was performed after bowel cleansing. For OC, sedatives and analgesics were used. Patients evaluated both modalities and certain aspects of the examination according to a 10-point-scale with higher scores denoting a worse experience. Furthermore, preferences for future examinations were evaluated. No significant difference was noted for the overall acceptance of OC (mean value 3.0) and MRC (mean value 3.4). For MRC, the placement of the rectal tube was rated as the most unpleasant part, whereas bowel purgation was regarded most inconvenient for OC. Patients aged 55 years and older perceived most aspects less unpleasant than younger patients. Of the patients, 46% preferred MRC for future screening examinations (OC: 44%). OC and MRC have comparable general acceptance levels in a screening population. Especially for patients declining endoscopy as a screening method MRC may evolve as an attractive alternative.

Magnetic resonance colonography without bowel cleansing: a prospective cross sectional study in a screening population.

BACKGROUND AND AIMS: To evaluate the diagnostic accuracy of magnetic resonance colonography (MRC) without bowel cleansing in a screening population and compare the results to colonoscopy as a standard of reference. METHODS: 315 screening patients, older than 50 years with a normal risk profile for colorectal cancer, were included in this study. For MRC, a tagging agent (5.0% Gastrografin, 1.0% barium sulphate, 0.2% locust bean gum) was ingested with each main meal within 2 days prior to MRC. No bowel cleansing was applied. For the magnetic resonance examination, a rectal water enema was administered. Data collection was based on contrast enhanced T1 weighted images and TrueFISP images. Magnetic resonance data were analysed for image quality and the presence of colorectal lesions. Conventional colonoscopy and histopathological samples served as reference. RESULTS: In 4% of all colonic segments, magnetic resonance image quality was insufficient because of untagged faecal material. Adenomatous polyps >5 mm were detected by means of MRC, with a sensitivity of 83.0%. Overall specificity was 90.2% (false positive findings in 19 patients). However, only 16 of 153 lesions <5 mm and 9 of 127 hyperplastic polyps could be visualised on magnetic resonance images. CONCLUSIONS: Faecal tagging MRC is applicable for screening purposes. It provides good accuracy for the detection of relevant (ie, adenomatous) colorectal lesions >5 mm in a screening population. However, refinements to optimise image quality of faecal tagging are needed.

Balloon dilatation vs. balloon dilatation plus bile duct endoprostheses for treatment of anastomotic biliary strictures after liver transplantation.

Biliary strictures after liver transplantation are a therapeutic challenge for endoscopy. Anastomotic strictures occur in 10% of patients after liver transplantation, leading untreated to mortality and ultimately to graft failure. Despite of successful reports, to date, there is no defined endoscopic therapy regimen for these cases. Therefore the aim of this study was to determine the most suitable concept for endoscopic treatment of post-liver transplant anastomotic strictures (PTAS). A total of 72 patients post-liver transplantation, who received endoscopic retrograde cholangiography (ERC) as a consequence of suspected biliary complications were retrospectively screened for the presence of PTAS. In all patients graft rejection or bile duct ischemia were excluded prior to ERC by liver biopsy or Doppler ultrasound respectively. We compared either balloon dilatation (BD) alone or dilatation plus placement of an increasing number of bile duct endoprostheses (BD + endoprostheses) in a retrospective analysis. A total of 25 of 75 patients showed PTAS. Overall, endoscopic therapy was successful in 22 of 25 patients (88%). BD was initially successful in 89% but showed recurrence in 62%. BD + endoprostheses was initially successful in 87%, and recurrence was observed only in 31%. All recurrences were successfully retreated by BD + endoprostheses. During 22 of 109 (20%) treatment sessions stone extraction was necessary. Complication rate was low with bacterial cholangitis in 8 of 109 (7.3%) sessions, mild pancreatitis in 10 of 109 (9%) sessions and minor bleeding in 2 of 25 (8%) sphincterotomies. Median follow-up after conclusion of endoscopic therapy is 6 months (range 1-43). In conclusion, our data confirm that endoscopic therapy of PTAS is highly effective and safe. As primarily successful BD shows a high rate of recurrence, we recommend a combination of BD followed by an increasing number and diameter of endoprostheses. Therapy sessions are effective at short intervals of every 2-3 months.

Endoscopic therapy of posttransplant biliary stenoses after right-sided adult living donor liver transplantation.

BACKGROUND & AIMS: Endoscopic treatment of biliary strictures after liver transplantation is a therapeutic challenge. In particular, outcomes of endoscopic therapy of biliary complications in the case of duct-to-duct anastomosis after living related liver transplantation are limited. The aim of this study was to evaluate the feasibility and success of an endoscopic treatment approach to posttransplant biliary strictures (PTBS) after right-sided living donor liver transplantation (RLDLT) with duct-to-duct anastomosis. METHODS: Ninety patients who received adult-to-adult RLDLT in our center were screened retrospectively with respect to endoscopic treatment of PTBS. Therapy was judged as successful when cholestasis parameters returned to normal and bile duct narrowing was reduced significantly after the completion of therapy. RESULTS: Forty of 90 RLDLT patients received duct-to-duct anastomosis, 12 (30%) showed PTBS. Seven of 12 patients were treated successfully by endoscopy; the remaining 5 patients were treated primarily by surgery. Most patients were treated by balloon dilatation followed by insertion of endoprostheses. A median of 2.5 dilatation sessions were necessary and the median treatment duration was 8 months. One patient developed endoscopy-treatable recurrent stenosis, no surgical intervention was necessary. Mild pancreatitis occurred in 7.9% and cholangitis in 5.3% of the procedures. One minor bleeding episode occurred during sphincterotomy. Bleeding was managed endoscopically. CONCLUSIONS: Endoscopic therapy of adult-to-adult right living related liver transplantation with duct-to-duct anastomosis is feasible and frequently is successful. The duct-to-duct anastomosis offers the possibility of endoscopic treatment. Endoscopic treatment of posttransplant biliary strictures is safe, with a low specific complication rate.

Palliation of nonresectable bile duct cancer: improved survival after photodynamic therapy.

OBJECTIVES: Preliminary uncontrolled studies of photodynamic therapy (PDT) of bile duct cancer (BDC) have shown astonishingly good results in the reduction of cholestasis, improvement of life quality, and potential improvement of survival time. Therefore, we investigated the influence of PDT on survival time in advanced BDC in a randomized controlled study. METHODS: Thirty-two patients with nonresectable BDC were randomized. In the PDT group 48 h after intravenous application of 2 mg/kg body weight of Photosan-3((R)), light activation was performed. In the control group, patients were treated with endoprostheses but no PDT. RESULTS: PDT group and the control group were comparable due to age, gender, performance status, bilirubin level, and BDC stage (Bismuth classification). The median survival time after randomization was 7 months for the control group and 21 months for the PDT group (p= 0.0109). In half of the initially percutaneously treated patients, we could change from percutaneous to transpapillary drainage after PDT. Four patients showed infectious complications after PDT versus one patient in the control group. DISCUSSION: PDT is minimally invasive but shows a considerable postinterventional cholangitis rate. PDT has the potential to result in a changeover of current palliative treatment of BDC.

Dark-lumen magnetic resonance colonography in patients with suspected sigmoid diverticulitis: a feasibility study.

To assess dark-lumen magnetic resonance colonography (MRC) for the evaluation of patients with suspected sigmoid diverticulitis. Forty patients with suspected sigmoid diverticulitis underwent MRC within 72 h prior to conventional colonoscopy (CC). A three-dimensional T1-weighted volumetric interpolated breath-hold examination sequence was acquired after an aqueous enema and intravenous administration of gadolinium-based contrast agents. All MRC data were evaluated by two radiologists. Based on wall thickness and focal uptake of contrast material and pericolic reaction including mesenteric infiltration on T1-weighted sequence the sigmoid colon was assessed for the presence of diverticulitis. MRC classified 17 of the 40 patients as normal with regard to sigmoid diverticulitis. However, CC confirmed the presence of light inflammatory signs in four patients which were missed in MRC. MRC correctly identified wall thickness and contrast uptake of the sigmoid colon in the other 23 patients. In three of these patients false-positive findings were observed, and MRC classified the inflammation of the sigmoid colon as diverticulitis whereas CC and histopathology confirmed invasive carcinoma. MRC detected additionally relevant pathologies of the entire colon and could be performed in cases where CC was incomplete. MRC may be considered a promising alternative to CC for the detection of sigmoid diverticulitis.

Small bowel hydro-MR imaging for optimized ileocecal distension in Crohn's disease: should an additional rectal enema filling be performed?

PURPOSE: To assess the impact of an additional rectal enema filling in small bowel hydro-MRI in patients with Crohn's disease. MATERIALS AND METHODS: A total of 40 patients with known Crohn's disease were analyzed retrospectively: 20 patients only ingested an oral contrast agent (group A), the other 20 subjects obtained an additional rectal water enema (group B). For small bowel distension, a solution containing 0.2% locust bean gum (LBG) and 2.5% mannitol was used. In all patients, a breathhold contrast-enhanced T1w three-dimensional volumetric interpolated breathhold examination (VIBE) sequence was acquired. Comparative analysis was based on image quality and bowel distension as well as signal-to-noise ratio (SNR) measurements. MR findings were compared with those of conventional colonoscopy, as available (N = 25). RESULTS: The terminal ileum and rectum showed a significantly higher distension following the rectal administration of water. Furthermore, fewer artifacts were seen within group B. This resulted in a higher reader confidence for the diagnosis of bowel disease, not only in the colon, but also in the ileocecal region. Diagnostic accuracy in diagnosing inflammation of the terminal ileum was 100% in group B; in the nonenema group there were three false-negative diagnoses of terminal ileitis. CONCLUSION: Our data show that the additional administration of a rectal enema is useful in small bowel MRI for the visualization of the terminal ileum. The additional time needed for the enema administration was minimal, and small and large bowel pathologies could be diagnosed with high accuracy. Thus, we suggest that a rectal enema in small bowel MR imaging be considered.

Diagnosis of biliary strictures after liver transplantation: which is the best tool?

AIM: To evaluate the diagnostic value of different indirect methods like biochemical parameters, ultrasound (US) analysis, CT-scan and MRI/MRCP in comparison with endoscopic retrograde cholangiography (ERC), for diagnosis of biliary complications after liver transplantation. METHODS: In 75 patients after liver transplantation, who received ERC due to suspected biliary complications, the result of the cholangiography was compared to the results of indirect imaging methods performed prior to ERC. The cholangiography showed no biliary stenosis (NoST) in 25 patients, AST in 27 and ITBL in 23 patients. RESULTS: Biliary congestion as a result of AST was detected with a sensitivity of 68.4% in US analysis (specificity 91%), of 71% in MRI (specificity 25%) and of 40% in CT (specificity 57.1%). In ITBL, biliary congestion was detected with a sensitivity of 58.8% in the US, 88.9% in MRI and of 83.3% in CT. However, as anastomotic or ischemic stenoses were the underlying cause of biliary congestion, the sensitivity of detection was very low. In MRI detected the dominant stenosis at a correct localization in 22% and CT in 10%, while US failed completely. The biochemical parameters, showed no significant difference in bilirubin (median 5.7; 4,1; 2.5 mg/dL), alkaline phosphatase (median 360; 339; 527 U/L) or gamma glutamyl transferase (median 277; 220; 239 U/L) levels between NoST, AST and ITBL. CONCLUSION: Our data confirm that indirect imaging methods to date cannot replace direct cholangiography for diagnosis of post transplant biliary stenoses. However MRI may have the potential to complement or precede imaging by cholangiography. Optimized MRCP-processing might further improve the diagnostic impact of this method.

Ceftriaxone is twice as cost-effective as standard therapy in biliary tract infection.

BACKGROUND/AIMS: Various antibiotics, mainly cephalosporins and broad-spectrum penicillins, are indicated in biliary tract infection. The primary endpoint was to compare the cost-effectiveness of ceftriaxone (Rocephin) 1 g once daily vs. standard therapy two or three times daily. METHODOLOGY: A prospective multicenter observational study, matched-pair analysis of 902 patients receiving ceftriaxone or standard therapy (second-generation cephalosporin, broad-spectrum penicillin or a combination of aminopenicillin and beta-lactamase inhibitor) in 75 hospitals yielded 173 pairs matched for definite risk criteria. Both groups received comparable accompanying endoscopic antiobstructive treatment. Cost parameters included primary antibiotic purchase, total antibiotic purchase (including combination and second-line drugs), and infusion preparation and administration. RESULTS: 87.9% of patients in the ceftriaxone group vs. 73.4% in the standard group received antibacterial monotherapy, for 7.5 vs. 9.1 days respectively (p=0.001). Therapy was equally effective in both groups. Overall treatment costs, including antibiotic purchase and infusion preparation/administration, were 170.84 vs. 320.46, respectively (p=0.0001). CONCLUSIONS: Ceftriaxone 1 g once daily is approximately twice as cost-effective as standard therapy in biliary tract infection: lower concomitant medication costs, a shorter treatment course, and lower antibiotic administration costs achieved an approximate 50% saving.

Endoscopic Doppler ultrasound after injection therapy for peptic ulcer hemorrhage.

BACKGROUND/AIMS: A positive Doppler signal in endoscopic Doppler ultrasound at index endoscopy predicts a high risk for rebleeding from peptic ulcer. The aim of this study was to evaluate if a negative Doppler status immediately after injection therapy may exclude a rebleeding from peptic ulcer in a high-risk cohort. METHODOLOGY: Twenty consecutive patients (pts) (age: 68 (33-91) yrs; 11 female) with peptic ulcer bleeding were enrolled. All patients with an actively bleeding ulcer and those with a non-actively bleeding, but Doppler-positive ulcer were treated by injection of adrenaline (1:10,000 dilution). Treatment was performed during index endoscopy until the Doppler status was negative. Patients were followed-up clinically and endoscopically (including Doppler ultrasound) for bleeding recurrence. RESULTS: Patients were treated by injection of 12 (6 to 20) mL of adrenaline solution until Doppler scan was negative. During follow-up four pts (20%) had a clinically overt rebleeding episode. At control endoscopy three ulcers were actively bleeding and another two were Doppler positive without rebleeding (total: five of eighteen (27.7%) Doppler-positive ulcers). Two of the twenty pts required surgical therapy due to rebleeding (10%). CONCLUSIONS: A negative endoscopic Doppler status immediately after injection therapy is not helpful to identify patients with no risk for rebleeding from peptic ulcer.