Endoscopic neo-anastomosis by Rendez-vous technique for the treatment of complete occlusion of bilioenteric anastomoses and distal bile ducts (case series).

BACKGROUND AND AIMS: The complete occlusion of bilioenteric anastomoses is a rare and challenging clinical condition. Repeated surgery is burdened with technical difficulties and significant morbidity. We report the first series of completely occluded bilioenteric anastomoses resp. distal bile duct successfully treated by simultaneous percutaneous and retrograde endoscopic interventions. PATIENTS AND METHODS: This case series includes 4 patients with obstructive jaundice and/or recurring cholangitis and pain due to complete fibrotic occlusion of a hepaticojejunostomy (3 patients) and the distal bile duct (1 patient). After performing PTCD and stepwise dilation of the biliocutaneous tract, we tried to approach the occluded anastomosis from 2 sides by simultaneous percutaneous cholangioscopy and peroral device-assisted enteroscopy/duodenoscopy. By cutting through the separating tissue layer with a needle knife under endoscopic and fluoroscopic control using diaphanoscopy, a new anastomosis should be established followed by dilation of the neoanastomosis with subsequent percutaneous transhepatic drainage for a minimum of 1 year to prevent re-occlusion. RESULTS: The Rendez-vous maneuver was successful in 3/4 cases. In one case, the retrograde access to the anastomosis failed, so the neoanastomosis was cut under cholangioscopic and fluoroscopic guidance only. The neoanastomosis could be established successfully in all 4 cases. Jaundice, cholangitis, and pain disappeared. Minor periinterventional adverse events were cholangitis (n = 1) and pneumonia (n = 1) due to aspiration, which could be managed conservatively. No serious adverse events were observed, and no re-occlusion of any neoanastomosis occurred during the follow-up before and after removal of the percutaneous drainage. CONCLUSION: Simultaneous percutaneous cholangioscopy and device-assisted enteroscopy/duodenoscopy with endoscopic creation of a neoanastomosis is a possible concept for the treatment of completely occluded bilioenteric anastomoses and distal bile ducts. This case series confirms the feasibility, safety, and long-term effectiveness of this treatment.

Symptoms and clinical course of EHEC O104 infection in hospitalized patients: a prospective single center study.

OBJECTIVES: Shiga-toxin producing O157:H7 Entero Haemorrhagic E. coli (STEC/EHEC) is one of the most common causes of Haemolytic Uraemic Syndrome (HUS) related to infectious haemorrhagic colitis. Nearly all recommendations on clinical management of EHEC infections refer to this strain. The 2011 outbreak in Northern Europe was the first to be caused by the serotype O104:H4. This EHEC strain was found to carry genetic features of Entero Aggregative E. coli (EAEC) and extended spectrum ß lactamase (ESBL). We report symptoms and complications in patients at one of the most affected centres of the 2011 EHEC O104 outbreak in Northern Germany. METHODS: The courses of patients admitted to our hospital due to bloody diarrhoea with suspected EHEC O104 infection were recorded prospectively. These data include the patients' histories, clinical findings, and complications. RESULTS: EHEC O104 infection was confirmed in 61 patients (female = 37; mean age: 44±2 years). The frequency of HUS was 59% (36/61) in our cohort. An enteric colonisation with co-pathogens was found in 57%. Thirty-one (51%) patients were treated with plasma-separation/plasmapheresis, 16 (26%) with haemodialysis, and 7 (11%) with Eculizumab. Patients receiving antibiotic treatment (n = 37; 61%) experienced no apparent change in their clinical course. Twenty-six (43%) patients suffered from neurological symptoms. One 83-year-old patient died due to comorbidities after HUS was successfully treated. CONCLUSIONS: EHEC O104:H4 infections differ markedly from earlier reports on O157:H7 induced enterocolitis in regard to epidemiology, symptomatology, and frequency of complications. We recommend a standard of practice for clinical monitoring and support the renaming of EHEC O104:H4 syndrome as "EAHEC disease".

In silico characterization of the family of PARP-like poly(ADP-ribosyl)transferases (pARTs).

BACKGROUND: ADP-ribosylation is an enzyme-catalyzed posttranslational protein modification in which mono(ADP-ribosyl)transferases (mARTs) and poly(ADP-ribosyl)transferases (pARTs) transfer the ADP-ribose moiety from NAD onto specific amino acid side chains and/or ADP-ribose units on target proteins. RESULTS: Using a combination of database search tools we identified the genes encoding recognizable pART domains in the public genome databases. In humans, the pART family encompasses 17 members. For 16 of these genes, an orthologue exists also in the mouse, rat, and pufferfish. Based on the degree of amino acid sequence similarity in the catalytic domain, conserved intron positions, and fused protein domains, pARTs can be divided into five major subgroups. All six members of groups 1 and 2 contain the H-Y-E trias of amino acid residues found also in the active sites of Diphtheria toxin and Pseudomonas exotoxin A, while the eleven members of groups 3 - 5 carry variations of this motif. The pART catalytic domain is found associated in Lego-like fashion with a variety of domains, including nucleic acid-binding, protein-protein interaction, and ubiquitylation domains. Some of these domain associations appear to be very ancient since they are observed also in insects, fungi, amoebae, and plants. The recently completed genome of the pufferfish T. nigroviridis contains recognizable orthologues for all pARTs except for pART7. The nearly completed albeit still fragmentary chicken genome contains recognizable orthologues for twelve pARTs. Simpler eucaryotes generally contain fewer pARTs: two in the fly D. melanogaster, three each in the mosquito A. gambiae, the nematode C. elegans, and the ascomycete microfungus G. zeae, six in the amoeba E. histolytica, nine in the slime mold D. discoideum, and ten in the cress plant A. thaliana. GenBank contains two pART homologues from the large double stranded DNA viruses Chilo iridescent virus and Bacteriophage Aeh1 and only a single entry (from V. cholerae) showing recognizable homology to the pART-like catalytic domains of Diphtheria toxin and Pseudomonas exotoxin A. CONCLUSION: The pART family, which encompasses 17 members in the human and 16 members in the mouse, can be divided into five subgroups on the basis of sequence similarity, phylogeny, conserved intron positions, and patterns of genetically fused protein domains.