A nomogram for prediction of ERCP success in patients with bile duct leaks: a multicenter study.

BACKGROUND: Bile duct leaks (BDLs) are serious complications that occurs after hepatobiliary surgery and trauma, leading to rapid clinical deterioration. Endoscopic retrograde cholangiopancreatography (ERCP) is the first-line treatment for BDLs, but it is not clear which patients will respond to this therapy and which patients will require additional surgical intervention. The aim of our study was to explore the predictors of successful ERCP for BDLs. METHODS: A retrospective analysis was conducted using data from six centers' databases. All consecutive patients who were clinically confirmed as BDLs were included in the study. Collected data were demographics, disease severity, and ERCP procedure characteristics. Univariate and multivariate analysis were used to select independent predictive factors that affect the outcome of ERCP for BDLs, and a nomogram was established. Calibration and ROC curves were used to evaluate the models. RESULTS: Four hundred and forty-eight consecutive patients were clinically confirmed as BDLs and 347 were excluded. In the 101 patients included patients, clinical success was achieved in 78 patients (77.2%). In logistic multivariable regression, two independent factors were negatively associated with the success of ERCP: SIRS (OR, 0.183; 95% CI 0.039-0.864; P = 0.032) and high-grade leak (OR 0.073; 95% CI 0.010-0.539; P = 0.010). Two independent factors were positively associated with the success of ERCP: leak-bridging drainage (OR 4.792; 95% CI 1.08-21.21; P = 0.039) and cystic duct leak (OR 6.193; 95% CI 1.03-37.17; P = 0.046). The prediction model with these four factors was evaluated using a receiver-operating characteristic (ROC) curve, which demonstrated an area under the curve of 0.9351. The calibration curve showed that the model had good predictive accuracy. CONCLUSION: Leak-bridging drainage and cystic duct leak are positive predictors for the success of ERCP, while SIRS and high-grade leak are negative predictors. This prediction model with nomogram has good predictive ability and practical clinical value, and may be helpful in clinical decision-making and prognostication.

EUS­guided antegrade stenting for malignant jaundice following Roux­en­Y reconstruction: the treatment of multiple biliary strictures.

Multiple malignant biliary strictures are rare, and the application of multiple stents can achieve better drainage. EUS-guided biliary drainage (EUS-BD) can be offered as an alternative technique when ERCP unsuccessful. We applied Endoscopic ultrasonic guided antegrade stenting technique to treat a case of multiple biliary strictures following Roux-en-Y reconstruction.

Transduodenal accessory papillary Rendezvous technique assisted ERCP in the treatment of severe pancreatic duct stenosis caused by chronic pancreatitis in children.

Chronic pancreatitis in children is an irreversible inflammatory disease, which can cause intractable abdominal pain and abnormal internal and external secretion function of the pancreas, seriously affecting the growth and development of children and the quality of life. ERCP has become the first choice because of its good effect and less trauma. However, the severe stenosis of pancreatic duct caused by chronic pancreatitis may make ERCP more difficult. Here we used the rendezvous technique to assist ERCP to complete the treatment of severe pancreatic duct stenosis and abdominal pain.

EUS-guided bridging technique for treatment of biliary-enteric anastomotic stenosis after pancreaticoduodenectomy.

Biliary-enteric anastomotic stenosis is one of the main long-term complications after pancreaticoduodenectomy, with an incidence of 2%-8%. Although the relevant reports and studies are relatively few, the consequences such as biliary obstruction and refractory cholangitis seriously affect the quality of life of patients. In this case, the patient is not willing to receive conventional surgery again. This paper provides a bridge technique of EUS-guided Biliary Drainage (EUS-BD) to treat biliary-enteric anastomotic stenosis and solve the problem of obstructive jaundice in the patient.

A whole new challenge: EUS-guided transhepatic antegrade stone removal (TASR) for the treatment of multiple choledocholithiasis after total gastrectomy.

EUS-TASR is a derivative of EUS-BD and serves as a remedy when ERCP fails. EUS-BD technology is commonly used in the diagnosis and treatment of biliary tract and pancreatic diseases with anatomical changes of the digestive tract. This article provides an experience of EUS-TASR and a new challenge in the treatment of common bile duct stones after total gastrectomy.

Bending the distal tip of a guidewire aids in cannulation of an occluded uncovered biliary metal stent / Doblar la punta distal de una guía de ayuda en la canulación de una oclusión stent metálico biliar descubierto

Biliary metal stent implantation is an effective treatment for malignant obstructive jaundice. But it's well known that stents put in for a long time can become occluded and cause jaundice and cholangitis. At this time, endoscopic intervention is usually required to replace the stent or re-insert the stent. Re-cannulation for metal stent occlusion is challenging because the guide wire may pass through the side holes of the uncovered metal stents, resulting in prolonged surgical time and exposure to radiation. Here we present a small tip that may help endoscopists complete the re-cannulation of an uncovered metal stent in a very short time.(AU)

The combination of EyeMax direct visualization system, EUS and ERCP for the precise treatment of intraductal papillary mucinous neoplasm / La combinación de EyeMax sistema de visualización directa, EUS y CPRE para la precisión tratamiento de intraductal neoplasia papilar mucinosa

Intraductal papillary mucinous neoplasm (IPMN) accounted for 5.0%~7.5% of pancreatic tumors and 21%~33% of cystic tumors. It usually occurs in people aged 60 to 70. The main treatment is surgical excision. The operation method is different according to the location of lesion, so we try our best to achieve accurate treatment. Here, we provide endoscopic ultrasonography combined with ERCP and eyeMax three endoscopic systems, so as to achieve accurate treatment of IPMN, which is recommended to the majority of endoscopists.(AU)

The combination of eyeMax direct visualization system, EUS and ERCP for the precise treatment of intraductal papillary mucinous neoplasm.

Intraductal papillary mucinous neoplasm (IPMN) accounted for 5.0%~7.5% of pancreatic tumors and 21%~33% of cystic tumors. It usually occurs in people aged 60 to 70. The main treatment is surgical excision. The operation method is different according to the location of lesion, so we try our best to achieve accurate treatment. Here, we provide endoscopic ultrasonography combined with ERCP and eyeMax three endoscopic systems, so as to achieve accurate treatment of IPMN, which is recommended to the majority of endoscopists.

Endoscopic ultrasound combined with enteroscopy for bilioenterostomy stenosis after pancreatoduodenectomy. The first attempt of a two-person operation.

Bilioenterostomy stenosis is very challenging, and effective endoscopic treatment can prevent patients from undergoing surgery. We present a case of a patient with extremely narrow bilioenterostomy treated with simultaneous endoscopic ultrasonography and enteroscopy. It provides a new and feasible idea of endoscopic therapy for the treatment of such patients.

Endoscopic management of stent displacement during EUS-guided pancreatic pseudocyst drainage.

The therapeutic effect of EUS-Guided Pancreatic Pseudocyst Drainage (EUS-PPD) is widely recognized, and intraoperative stent displacement is a rare but potentially serious condition. We report a case of the cyst stent displace into the cyst cavity during EUS-PPD, we successfully reduced the stent in time under the guidance of EUS and fluoroscopy in the final.

Two-step approach for recurrent pancreatic pseudocysts: endoscopic ring drainage of the stent transpapillary combined with the posterior gastric wall.

Pancreatic pseudocyst is a complication of pancreatitis, with an incidence of about 5-16% and a incidence of about 20-40% in chronic pancreatitis. There are various ways to treat pancreatic pseudocysts, but the recurrence rate of cysts is as high as 23.9%. There are not many clinical options for the treatment of recurrent pseudocysts, and there is still a high recurrence of pseudocysts after EUS guided drainage alone. We present here a promising endoscopic treatment for patients with recurrent pancreatic pseudocyst.

EUS-guided Rendezvous technique for the treatment of choledocholithiasis with difficult cannulation.

It is not uncommon to encounter difficult cannulation during endoscopic retrograde cholangiopancreatography (ERCP), most of which can be performed by double-guide wire, pre-cut and other techniques. Endoscopic ultrasound-guided biliary drainage (EUS-BD) can be used as a remedial solution for ERCP failure. This article provides a very well experience in ERCP combine with EUS-RV technique in cases where the duodenal papilla is located above the medial diverticulum. At the same time, some skills of EUS-RV are provided for endoscopists.

Treatment of hemorrhage after endoscopic ultrasonography guided pancreatic pseudocyst-gastric anastomosis.

Large symptomatic PPs that cannot be absorbed by themselves need intervention. Endoscopic ultrasonography (EUS) guided PP drainage is considered the preferred choice due to its minimally invasiveness and low recurrence rate(1). However, EUS-PP drainage is associated with certain bleeding risk compared to surgical drainage. Prompt diagnosis and appropriate management is the important. We report a rare case in our center.

Safety of high-carbohydrate fluid diet 2 h versus overnight fasting before non-emergency endoscopic retrograde cholangiopancreatography: A single-blind, multicenter, randomized controlled trial.

BACKGROUND: Although overnight fasting is recommended prior to endoscopic retrograde cholangiopancreatography (ERCP), the benefits and safety of high-carbohydrate fluid diet (CFD) intake 2 h before ERCP remain unclear. This study aimed to analyze whether high-CFD intake 2 h before ERCP can be safe and accelerate patients' recovery. METHODS: This prospective, multicenter, randomized controlled trial involved 15 tertiary ERCP centers. A total of 1330 patients were randomized into CFD group (n = 665) and fasting group (n = 665). The CFD group received 400 mL of maltodextrin orally 2 h before ERCP, while the control group abstained from food/water overnight (>6 h) before ERCP. All ERCP procedures were performed using deep sedation with intravenous propofol. The investigators were blinded but not the patients. The primary outcomes included postoperative fatigue and abdominal pain score, and the secondary outcomes included complications and changes in metabolic indicators. The outcomes were analyzed according to a modified intention-to-treat principle. RESULTS: The post-ERCP fatigue scores were significantly lower at 4 h (4.1 ± 2.6 vs. 4.8 ± 2.8, t = 4.23, P <0.001) and 20 h (2.4 ± 2.1 vs. 3.4 ± 2.4, t = 7.94, P <0.001) in the CFD group, with least-squares mean differences of 0.48 (95% confidence interval [CI]: 0.26-0.71, P <0.001) and 0.76 (95% CI: 0.57-0.95, P <0.001), respectively. The 4-h pain scores (2.1 ± 1.7 vs. 2.2 ± 1.7, t = 2.60, P = 0.009, with a least-squares mean difference of 0.21 [95% CI: 0.05-0.37]) and positive urine ketone levels (7.7% [39/509] vs. 15.4% [82/533], χ2 = 15.13, P <0.001) were lower in the CFD group. The CFD group had significantly less cholangitis (2.1% [13/634] vs. 4.0% [26/658], χ2 = 3.99, P = 0.046) but not pancreatitis (5.5% [35/634] vs. 6.5% [43/658], χ2 = 0.59, P = 0.444). Subgroup analysis revealed that CFD reduced the incidence of complications in patients with native papilla (odds ratio [OR]: 0.61, 95% CI: 0.39-0.95, P = 0.028) in the multivariable models. CONCLUSION: Ingesting 400 mL of CFD 2 h before ERCP is safe, with a reduction in post-ERCP fatigue, abdominal pain, and cholangitis during recovery. TRAIL REGISTRATION: ClinicalTrials.gov, No. NCT03075280.

Effect of Clostridium butyricum on the formation of primary choledocholithiasis based on intestinal microbiome and metabolome analysis.

AIMS: To investigate the function and probable mechanism of Clostridium butyricum in the development of choledocholithiasis. METHODS AND RESULTS: The lithogenic diet group and the lithogenic diet + C. butyricum group were used to develop the choledocholithiasis model. During the experiment, C. butyricum suspension was administered to the rats in the lithogenic diet + C. butyricum group. The findings demonstrated that the C. butyricum intervention decreased the Firmicutes/Bacteroidetes ratio in the colon of experimental animals given a lithogenic diet. The relative levels of Desulfovibrio (0.93%) and Streptococcus (0.38%) fell, whereas Lactobacillus (22.36%), Prevotella (14.09%), and bacteria that produce short-chain fatty acids increased. Finally, 68 distinct metabolic products were found based on nontargeted metabonomics, and 42 metabolic pathways associated to the various metabolites were enriched. CONCLUSIONS: We found that C. butyricum decreased the development of choledocholithiasis. It keeps the equilibrium of the rat's gut microbiome intact and lowers the danger of bacterial infections of the gastrointestinal and biliary systems. It is hypothesized that by controlling lipid metabolism, it may also have an impact on the development of cholelithiasis.

Bending the distal tip of a guidewire aids in cannulation of an occluded uncovered biliary metal stent.

Biliary metal stent implantation is an effective treatment for malignant obstructive jaundice. But it's well known that stents put in for a long time can become occluded and cause jaundice and cholangitis. At this time, endoscopic intervention is usually required to replace the stent or re-insert the stent. Re-cannulation for metal stent occlusion is challenging because the guide wire may pass through the side holes of the uncovered metal stents, resulting in prolonged surgical time and exposure to radiation. Here we present a small tip that may help endoscopists complete the re-cannulation of an uncovered metal stent in a very short time.

LncRNA FALEC increases the proliferation, migration and drug resistance of cholangiocarcinoma through competitive regulation of miR-20a-5p/SHOC2 axis.

BACKGROUND: LncRNA is an important regulatory factor in the human genome. We aim to explore the roles of LncFALEC and miR-20a-5p/SHOC2 axis on the proliferation, migration, and Fluorouracil (5-FU) resistance of cholangiocarcinoma (CCA). METHODS: In this study, the expression of FALEC and miR-20a-5p in CCA tissues and cell lines (HuCCT1, QBC939, and Huh-28) was detected by RT-qPCR. The FALEC in 5-FU-resistant CCA cell lines (QBC939-R, Huh-28-R) was knocked down to evaluate its effects on cell proliferation, migration, invasion, and drug resistance. RESULTS: Our analysis showed that compared with the adjacent non-tumor tissues, FALEC was significantly higher in the CCA tissues and even higher in the samples from 5-FU-resistant patients. Knockdown FALEC increased the sensitivity of 5-FU and decreased migration and invasion of CCA cells. Dual luciferase reporter confirmed that FALEC sponges miR-20a-5p and down-regulated its expression. Moreover, SHOC2 leucine-rich repeat scaffold protein (SHOC2) was the target gene of miR-20a-5p. We found overexpression of FALEC (FALEC-OE) increased resistance of CCA cells to 5-FU significantly, which might contribute to increased SHOC2 expression and activation of the ERK1/2 signaling pathway. CONCLUSIONS: In summary, our study revealed that down-regulation of FALEC could inhibit the proliferation, migration, and invasion of CCA cells in vitro by regulating the miR-20a-5p/SHOC2 axis and participating in 5-FU resistance by mediating the ERK1/2 signaling pathway.