Covered metal stents for the treatment of biliary complications after orthotopic liver transplantation.

BACKGROUND: Biliary complications, a major source of morbidity after orthotopic liver transplantation (OLT), are increasingly being treated by endoscopic retrograde cholangiopancreatography (ERCP). Endoscopic management has been shown to be superior to percutaneous therapy and surgery. Covered self-expandable metal stents (CSEMSs) may be an alternative to the current endoscopic standard treatment with periodic plastic stent replacement. OBJECTIVE: To assess the safety and efficacy of temporary CSEMS insertion for biliary complications after OLT. METHODS: From November 2001 to December 2009, the 242 OLT performed in 226 patients included 67 cases that developed post-OLT leaks or strictures (29.6%), excluding ischemic biliary complications. CSEMSs were used in 22 patients (33%), 18 male and 4 female, with an overall median age of 55 years (range, 29-69). In-house OLT patients underwent an index ERCP at 26 days (range, 8-784) after OLT. Their records were reviewed to determine ERCP findings, technical success, and clinical outcomes. RESULTS: ERCP with sphincterotomy was performed in all 22 patients, revealing 18 with biliary strictures alone (82%), 3 with strictures and leaks (14%), and 1 with strictures and choledocholithiasis (4%). All strictures were anastomotic. All patients had 1-2 plastic stents inserted across the anastomosis (11 had prior balloon dilation); stones were successfully removed, for an initial technical success rate of 100% (22/22). CSEMSs, were placed at the second ERCP in 14 patients, at the third in 7, and at the fourth in 1. With a median follow-up of 12.5 months (range, 3-25) after CSEMS removal, 21/22 patients (95.5%) remain stricture free and one relapsed, requiring repeat CSEMS insertion. Four patients experienced pain after CSEMS insertion. At CSEMS removal, migration was noted in 5 cases, into either the distal duodenum (n=4) or the proximal biliary tree (n=1), and embedding was seen in 1 case. There were no serious complications; no patients needed hepatojejunostomy. CONCLUSIONS: ERCP is a safe first-line approach for post-OLT biliary complications. It was highly successful in a population with anastomotic leaks and strictures. The therapeutic role of ERCP to manage biliary complications after OLT in the long term is not well known. In our experience, the high rate (close to 95%) of efficacy and its relative safety allowed us to use CSEMS to manage refractory biliary post-OLT strictures. CSEMS insertion may preclude most post-OLT hepatojejunostomies.

Estudio retrospectivo sobre la endoscopia pediátrica desarrollada en un servicio de endoscopias de adultos / A retrospective study of pediatric endoscopy as performed in an adult endoscopy unit

La endoscopia gastrointestinal es una técnica segura y eficientecon mínimas complicaciones, así como una útil herramienta diagnósticaen la población pediátrica. En condiciones ideales, las endoscopiasen niños deberían ser realizadas por endoscopistas pediátricosexperimentados. En este estudio reportamos nuestraexperiencia en la realización de endoscopias pediátricas en la Unidadde Endoscopias general de adultos de nuestro hospital.El objetivo es cuantificar la cantidad de endoscopias realizadasen niños, así como las indicaciones y hallazgos de las mismas, eltipo de sedación o anestesia empleado y el tiempo de espera parala realización de la prueba. Nuestra experiencia demuestra que losendoscopistas de un servicio de gastroenterología general de adultos,en colaboración con pediatras, pueden realizar un númeroimportante de endoscopias a niños, de forma rápida, segura y eficaz(AU)

Gastrointestinal endoscopy is a safe, efficient technique withminimal complications, and a useful diagnostic tool for the pediatricpopulation. Under ideal conditions endoscopies for childrenshould be performed by experienced pediatric endoscopists. Inthis study we report our experience with pediatric endoscopy atthe general adult endoscopy unit in our hospital. Our goal is toquantify the number of endoscopies performed in children, as wellas their indications and findings, the type of sedation or anesthesiaused, and the time waiting for the test to occur. Our experiencedemonstrates that endoscopists in a general adult gastroenterologydepartment, working together with pediatricians, mayperform a relevant number of endoscopies in children in a fast,safe, effective manner(AU)

FibroScan evaluation of liver fibrosis in liver transplantation.

INTRODUCTION: Liver biopsy remains the gold standard to evaluate fibrosis. However, it is invasive and uncomfortable as well as associated with complications. Transient elastography (FibroScan) is a simple and noninvasive method to assess liver fibrosis by measuring liver stiffness in kilopascals. Body mass index (BMI) greater than 28 is associated with high rates of invalid tests. Liver transplant patients show increased rates of obesity. We do not yet have many data about the usefulness of FibroScan in liver transplantation. AIMS: To analyze the applicability of FibroScan to assess fibrosis in liver transplantation and study the association between obesity and valid tests. MATERIAL AND METHODS: We prospectively assessed the performance of transient elastography in 29 liver transplant patients from February to May 2008. We prospectively studied the success rate, the elasticity (stiffness) in kilopascals, and the BMI. RESULTS: The BMI was greater than 30 kg/m(2) in four patients; 25 to 30 kg/m(2) in eight; and 17 had BMI < 25 kg/m(2). The overall success of FibroScan was 24/29 (82.7%). However, among patients with BMI > 30 kg/m(2), it was 2/4 (50%), whereas for BMI <25 kg/m(2) it climbed to 100%. The average duration of the procedure was 211.52 seconds for BMI <25 kg/m(2); 236 seconds for BMI between 25 and 30 kg/m(2); and 361 seconds in patients with a BMI > 30 kg/m(2)-differences that were statistically significant. CONCLUSIONS: FibroScan seemed to be a promising approach to assess liver fibrosis.BMI is a limiting factor toward achieving a valid test; FibroScan had limited usefulness in obese patients.