Diagnostic value of new biliary biopsy cannulae for malignant bile duct strictures via endoscopic retrograde cholangiopancreatography pathway.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) plays a major role in the diagnosis of malignant biliary strictures. ERCP fluoroscopy-guided biliary biopsy is more sensitive than brushing, but it is more difficult to perform and less successful. Therefore, a new technique of biliary biopsy using a new biliary biopsy cannula via the ERCP route was developed in our center with the aim of improving the diagnosis rate of malignant biliary strictures. METHODS: This is a retrospective study that included 42 patients who underwent ERCP-guided biliary brushing and biliary biopsy for biliary strictures using a new biliary biopsy cannula in our department from January 2019 to May 2022. The final diagnosis was determined after brushing, biliary biopsy under the new biliary biopsy cannula or adequate follow-up. Diagnostic rates were calculated and analyzed for relevant factors. RESULTS: The satisfactory rates of pathological specimens of 42 patients who underwent bile duct biopsy with bile duct brush and new bile duct biopsy cannula were 57.14% and 95.24% respectively. Cholangiocarcinoma was diagnosed in 45.23% and 83.30% of the samples by biliary brush examination and biliary biopsy using the new biliary biopsy cannula, respectively (p < 0.001). CONCLUSIONS: The ERCP route using a new biliary biopsy cannula for biliary biopsy technique can improve pathology positivity and benefit ratio. It provides a new approach in the diagnosis of malignant stenosis in the bile duct.

[Evaluation and management of urethral strictures-guideline summary 2024 : Part 2-posterior urethra]. / Diagnostik und Therapie von Harnröhrenstrikturen ­ Leitlinienübersicht 2024 : Teil 2 ­ posteriore Harnröhre.

In light of recently published international guidelines concerning the diagnosis, treatment, and aftercare of urethral strictures and stenoses, the objective of this study was to synthesize an overview of guideline recommendations provided by the American Urological Association (AUA, 2023), the Société Internationale d'Urologie (SIU, 2010), and the European Association of Urology (EAU, 2023). The recommendations offered by these three associations, as well as the guidelines addressing urethral trauma from the EAU, AUA, and the Urological Society of India (USI), were assessed in terms of their guidance on posterior urethral stenosis. On the whole, the recommendations from the various guidelines exhibit considerable alignment. However, SIU and EAU place a stronger emphasis on the role of repeated endoscopic treatment compared to AUA. The preferred approach for managing radiation-induced bulbomembranous stenosis remains a subject of debate. Furthermore, endoscopic treatments enhanced with intralesional therapies may potentially serve as a significant treatment modality for addressing even fully obliterated stenoses.

[Diagnosis and treatment of Dunbar syndrome]. / Diagnostik und Therapie des Dunbar-Syndroms.

The rare Dunbar syndrome or medial arcuate ligament syndrome (MALS) is defined as compression of the celiac trunk and/or ganglion by the medial arcuate ligament. It is often diagnosed after patients have suffered for a long time and is characterized by intermittent food-related pain, nausea, and unexplained weight loss. After exclusion of other causes of the above symptoms by gastroscopy, colonoscopy, CT, or MRI, the gold standard for diagnosis is dynamic color-coded duplex sonography, which may be supplemented by CT or MR angiography. The treatment of choice is a laparoscopic division of the arcuate ligament at the celiac trunk, although percutaneous transluminal angioplasty (PTA) with stent implantation may be performed in cases of postoperative persistence of symptoms or recurrent stenosis. Since symptoms persist postoperatively in up to 50% of cases, strict indication and complete diagnosis in designated centers are of great importance for successful treatment.

Clinical practice guideline on the use of single-operator cholangioscopy in the diagnosis of indeterminate biliary stricture and the treatment of difficult biliary stones.

BACKGROUND AND AIMS: Single-operator cholangioscopy (SOC) offer a diagnostic and therapeutic alternative with an improved optical resolution over conventional techniques; however, there are no standardized clinical practice guidelines for this technology. This evidence-based guideline from the Colombian Association of Digestive Endoscopy (ACED) intends to support patients, clinicians, and others in decisions about using in adults the SOC compared to endoscopic retrograde cholangiopancreatography (ERCP), to diagnose indeterminate biliary stricture and to manage difficult biliary stones. METHODS: ACED created a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. Universidad de los Andes and the Colombia Grading of Recommendations Assessment, Development and Evaluation (GRADE) Network supported the guideline-development process, updating and performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The GRADE approach was used, including GRADE Evidence-to-Decision frameworks. RESULTS: The panel agreed on one recommendation for adult patients with indeterminate biliary strictures and one for adult patients with difficult biliary stones when comparing SOC versus ERCP. CONCLUSION: For adult patients with indeterminate biliary strictures, the panel made a conditional recommendation for SOC with stricture pattern characterization over ERCP with brushing and/or biopsy for sensitivity, specificity, and procedure success rate outcomes. For the adult patients with difficult biliary stones the panel made conditional recommendation for SOC over ERCP with large-balloon dilation of papilla. Additional research is required on economic estimations of SOC and knowledge translation evaluations to implement SOC intervention in local contexts.

Congenital colonic stenosis: an unusual cause of colonic obstruction masquerading as Hirschsprung's disease in infancy.

Congenital colonic stenosis (CCS) is an extremely rare cause of large bowel obstruction in early infancy. Only 35 cases of CCS have been reported in literature to date. CCS often causes a diagnostic quandary as it is difficult to distinguish it clinically from Hirschsprung's disease. We report a case of an infant with CCS who was managed with resection of the diseased colonic segment with critical stenosis at two sites and colo-colonic anastomosis. In our report, we discuss the challenges faced in the diagnosis and surgical management of this unusual case.

Diagnostic utility of quantitative analysis of microRNA in bile samples obtained during endoscopic retrograde cholangiopancreatography for malignant biliary strictures.

BACKGROUND: The sensitivity of bile cytology for malignant biliary strictures is not adequate. To overcome this limitation, we evaluated whether quantitative analysis of microRNAs (miRNAs) in bile can provide a precise diagnosis of malignant biliary strictures due to pancreatic cancer (PC) and biliary tract cancer (BTC). METHODS: This was a retrospective evaluation of miRNA levels in stored bile samples of patients with PC, BTC or benign biliary stricture obtained during biliary drainage from April 2019 to December 2021 at our institution. A total of 113 patients (PC; n = 40, BTC; n = 38, control; n = 35) were enrolled. The miRNA candidates to be quantified were determined with microarray analysis from each 3 patients with PC, BTC and controls. RESULTS: Using microarray analysis, we confirmed four significantly up-regulated miRNAs (miR-1275, miR-6891-5p, miR-7107-5p, miR-3197) in patients with PC and BTC compared to control patients. Quantitative PCR was then performed in 113 bile samples for these miRNAs. miR-1275 was significantly upregulated in PC (p = 0.003) and BTC (p = 0.049) compared to controls, miR-6891-5p was significantly upregulated in PC compared to controls (p = 0.025). In particular, a combination of bile cytology and miR-1275 in bile showed a sensitivity of 77.5% (95% CI, 70.7-77.5%), specificity of 100% (95% CI, 92.2-100%) and an area under the curve (AUC) of 0.93, and provided a significantly greater additional diagnostic effect than bile cytology alone (p = 0.014). CONCLUSIONS: This study suggest that bile miRNAs could be potential biomarkers for pancreato-biliary diseases, particularly miR-1275 and miR-6891-5p may be helpful in the diagnosis of PC and BTC.

[Endoscopic intraluminal treatment of early biliary complications after orthotopic liver transplantation]. / Opyt endoskopicheskogo vnutriprosvetnogo lecheniya rannikh biliarnykh oslozhnenii posle ortotopicheskoi transplantatsii pecheni.

OBJECTIVE: To improve the outcomes after orthotopic liver transplantation (OLT) followed by early biliary complications via endoscopic bilioduodenal stenting. MATERIAL AND METHODS: The study enrolled 41 patients with early biliary complications within 90 days after OLT. All patients underwent endoscopic treatment between 2001 and 2021. There were 34 (82.9%) men and 7 (17.1%) women aged 48.5±12.5 years. Strictures and failure of biliary anastomosis occurred in 33 (80.5%) and 8 (19.5%) patients, respectively. RESULTS: After endoscopic treatment, serum bilirubin normalized in 3.3±0.86 days in patients with strictures (23.7 (16.4; 34.5) mmol/l, p<0.001). Diameter of lobar ducts as a criterion of biliary hypertension was normalized after 4 (2.5; 5.5) days (p<0.001). Bile leakage after stenting with a covered self-expanding stent regressed in all 7 patients after 3 (2; 5) days. In 1 patient, bile output through the drainage stopped in 8 days after bilioduodenal stenting with a plastic stent. CONCLUSION: Endoscopic bilioduodenal stenting is always effective and minimally invasive treatment after liver transplantation followed by early biliary complications (failure or stricture of anastomosis). This approach minimizes postoperative complications (9.8%) that do not require surgical intervention (Clavien-Dindo grade I).

[Surgical treatment of postintubation stenosis of the larynx in children]. / Khirurgicheskoe lechenie postintubatsionnykh stenozov gortani u detei.

Post-intubation laryngeal stenosis is the most common cause of upper respiratory obstruction in children. According to published data, the incidence of post-intubation stenosis ranges from 0.1 to 20%. Treatment of children with chronic laryngeal stenosis is a special branch of respiratory surgery. It remains one of the most complex and urgent problems in pediatrics, pediatric otorhinolaryngology, and pediatric surgery. Although numerous studies have described various methods for treating stenosis of the infraglottic space, there is no standard management approach. Currently, there are two main treatment methods: endoscopic interventions and open reconstructive surgery. Each method has its benefits and drawbacks. Despite the use of various techniques, the effectiveness of cicatricial laryngeal stenosis repair and decannulation in children is 63-64%, according to published data. With combined lesions of infraglottic and vocal cord parts of the larynx, especially with their cicatricial obliteration, reconstructive surgery is successful only in 50% of cases. Thus, treating children with post-intubation respiratory stenosis remains a complex problem and is a relevant direction for further research.

European Achondroplasia Forum guiding principles for the detection and management of foramen magnum stenosis.

Foramen magnum stenosis is a serious, and potentially life-threatening complication of achondroplasia. The foramen magnum is smaller in infants with achondroplasia, compared with the general population, and both restricted growth in the first 2 years and premature closure of skull plate synchondroses can contribute to narrowing. Narrowing of the foramen magnum can lead to compression of the brainstem and spinal cord, and result in sleep apnoea and sudden death. There is a lack of clarity in the literature on the timing of regular monitoring for foramen magnum stenosis, which assessments should be carried out and when regular screening should be ceased. The European Achondroplasia Forum (EAF) is a group of clinicians and patient advocates, representative of the achondroplasia community. Members of the EAF Steering Committee were invited to submit suggestions for guiding principles for the detection and management of foramen magnum stenosis, which were collated and discussed at an open workshop. Each principle was scrutinised for content and wording, and anonymous voting held to pass the principle and vote on the level of agreement. A total of six guiding principles were developed which incorporate routine clinical monitoring of infants and young children, timing of routine MRI screening, referral of suspected foramen magnum stenosis to a neurosurgeon, the combination of assessments to inform the decision to decompress the foramen magnum, joint decision making to proceed with decompression, and management of older children in whom previously undetected foramen magnum stenosis is identified. All principles achieved the ≥ 75% majority needed to pass (range 89-100%), with high levels of agreement (range 7.6-8.9). By developing guiding principles for the detection and management of foramen magnum stenosis, the EAF aim to enable infants and young children to receive optimal monitoring for this potentially life-threatening complication.

[Risk factors for pulmonary atelectasis in adults with tracheobronchial tuberculosis].

Objective: To investigate the risk factors for pulmonary atelectasis in adults with tracheobronchial tuberculosis(TBTB). Methods: Clinical data of adult patients (≥18 years old) with TBTB from February 2018 to December 2021 in Public Health Clinical Center of Chengdu were retrospectively analyzed. A total of 258 patients were included, with a male to female ratio of 1∶1.43. The median age was 31(24, 48) years. Clinical data including clinical characteristics, previous misdiagnoses/missed diagnoses before admission, pulmonary atelectasis, the time from symptom onset to atelectasis and bronchoscopy, bronchoscopy and interventional treatment were collected according to the inclusion and exclusion criteria. Patients were divided into two groups according to whether they had pulmonary atelectasis. Differences between the two groups were compared. Binary logistic regression was used to analyze the risk factors for pulmonary atelectasis. Results: The prevalence of pulmonary atelectasis was 14.7%, which was most common in the left upper lobe (26.3%). The median time from symptom onset to atelectasis was 130.50(29.75,358.50)d, and the median time from atelectasis to bronchoscopy was 5(3,7)d. The median age, the proportion of misdiagnosis of TBTB before admission, and the time from symptom onset to bronchoscopy in the atelectasis group were higher than those without atelectasis, and the proportion of receiving bronchoscopy examination and interventional therapy previously, and the proportion of pulmonary cavities were lower than those without atelectasis (all P<0.05). The proportions of cicatrices stricture type and lumen occlusion type in the atelectasis group were higher than those without atelectasis, while the proportions of inflammatory infiltration type and ulceration necrosis type were lower than those without atelectasis (all P<0.05). Older age (OR=1.036, 95%CI: 1.012-1.061), previous misdiagnosis(OR=2.759, 95%CI: 1.100-6.922), longer time from symptom onset to bronchoscopy examination (OR=1.002, 95%CI: 1.000-1.005) and cicatrices stricture type (OR=2.989, 95%CI: 1.279-6.985) were independent risk factors for pulmonary atelectasis in adults with TBTB (all P<0.05). Of the patients with atelectasis who underwent bronchoscopy interventional therapy, 86.7% had lung reexpansion or partial reexpansion. Conclusions: The prevalence of pulmonary atelectasis is 14.7% in adult patients with TBTB. The most common site of atelectasis is left upper lobe. The TBTB type of lumen occlusion is complicated by pulmonary atelectasis in 100% of cases. Being older, misdiagnosed as other diseases, longer time from onset of symptoms to bronchoscopy examination, and being the cicatrices stricture type are factors for developing pulmonary atelectasis. Early diagnosis and treatment are needed to reduce the incidence of pulmonary atelectasis and increase the rate of pulmonary reexpansion.

Pathogenesis, Evaluation, and Management of Pulmonary Vein Stenosis: JACC Review Topic of the Week.

Pulmonary vein stenosis (PVS) can arise from several etiologies, including congenital, acquired, and iatrogenic sources. PVS presents insidiously, leading to significant delays in diagnosis. A high index of suspicion and dedicated noninvasive evaluation are key to diagnosis. Once diagnosed, both noninvasive and invasive evaluation may afford further insights into the relative contribution of PVS to symptoms. Treatment of underlying reversible pathologies coupled with transcatheter balloon angioplasty and stenting for persistent severe stenoses are established approaches. Ongoing refinements in diagnostic modalities, interventional approaches, postintervention monitoring, and medical therapies hold promise to further improve patient outcomes.

[Atresia or severe stenosis of the external auditory canals with normal auricles in children]. / Atreziya ili vyrazhennyi stenoz naruzhnykh slukhovykh prokhodov pri normal'nykh ushnykh rakovinakh u detei.

In the article we present the experience of observing 27 children with bilateral stenosis or atresia of the external auditory canals with normal or slightly hypoplastic auricles. Three children had bilateral stenosis of the external auditory canals due to abnormal or premature fusion of the skull bones. The remaining 24 children had external auditory canals atresia in the bone part or throughout. 9 of them had a syndrome of deletion of the long arm of chromosome 18, 1 child had a mosaic form of Edwards syndrome. The average age at the time of diagnosis was 4 years 3 months. Atresia of external auditory canals in normal auricle is often caused by abnormalities of 18 pairs of chromosomes, and severe stenosis of external auditory canals can be observed in children with craniostenosis and other anomalies of the skull bones.

Loss of Wharton's jelly and fibrosis in umbilical cord stricture area: A case report.

INTRODUCTION: Stricture of the umbilical cord, though a rare condition, is one of the critical events that can be associated with intrauterine fetal death. CASE: A 27-year-old woman, primigravida, presented with USG report of fetus mortus at 37 weeks of gestation. There were no preceding warning signs. Postmortal examination showed Grade II macerated female fetus weighing 2372 g, measuring 49 cm, with haemorrhagic fluid in the brain ventricles. Microscopically, there were signs of amniotic fluid aspiration and autolytic changes. The macroscopic placental examination was normal, while signs of intrauterine asphyxia and intrauterine fetal demise were present histologically. Umbilical cord insertion was eccentric, on the cut three-vessel cord, 49 cm long, 1 cm in diameter. Extremely narrow segment measured 3 mm, approximately 1,5 cm in length, and was located 1 cm from fetal insertion site. In the further course, hypercoiling in 12 cm of the length was present. Examination of umbilical cord in stricture area revealed loss of Wharton's jelly, replacement with extensive fibrosis and capillary vessel formation. DISCUSSION AND CONCLUSION: The causality between umbilical cord stricture and intrauterine fetal demise has been established. Etiology is still unclear, therefore postmortal examination with umbilical cord evaluation and further research are needed.

Chronic Total Occlusion Techniques to Recanalize an Occluded Pulmonary Vein After Atrial Fibrillation Ablation.

Cardiac computed tomography (CT) scan was performed in a 69-year-old male with atrial fibrillation radiofrequency ablation who was admitted for transcatheter angioplasty of left inferior pulmonary vein (LIPV) stenosis due to recurrent hemoptysis. CT showed complete ostial occlusion in the area of the LIPV. Occlusion of the pulmonary vein ostium is a rare complication. We describe the successful use of chronic occlusion techniques in the treatment of this patient.

Small bowel obstruction: what a gastroenterologist needs to know.

PURPOSE OF REVIEW: Intrabdominal adhesions and intestinal hernias are the commonest cause of small bowel obstruction. Small bowel diseases, which cause small bowel obstruction, are rarer and often poses a challenge to gastroenterologists to diagnose and treat. In this review, small bowel diseases, which predispose to small bowel obstruction, are focused on, and their challenges in diagnosis and treatment. RECENT FINDINGS: Diagnosis of causes of partial small bowel obstruction is improved with computed tomography (CT) and magnetic resonance (MR) enterography. In fibrostenotic Crohn's strictures and NSAID diaphragm disease, endoscopic balloon dilatation can delay the need for surgery if the lesion is short and accessible; however, many may still inevitably require surgery. Biologic therapy may reduce the need for surgery in symptomatic small bowel Crohn's disease wherein the strictures are predominantly inflammatory. In chronic radiation enteropathy, only refractory small bowel obstruction and those with nutritional difficulties warrant surgery. SUMMARY: Small bowel diseases causing bowel obstruction are often challenging to diagnose and require numerous investigations over a period of time, which often culminate with surgery. Use of biologics and endoscopic balloon dilatation can help to delay and prevent surgery in some instances.

ACG Clinical Guideline: Diagnosis and Management of Biliary Strictures.

A biliary stricture is an abnormal narrowing in the ductal drainage system of the liver that can result in clinically and physiologically relevant obstruction to the flow of bile. The most common and ominous etiology is malignancy, underscoring the importance of a high index of suspicion in the evaluation of this condition. The goals of care in patients with a biliary stricture are confirming or excluding malignancy (diagnosis) and reestablishing flow of bile to the duodenum (drainage); the approach to diagnosis and drainage varies according to anatomic location (extrahepatic vs perihilar). For extrahepatic strictures, endoscopic ultrasound-guided tissue acquisition is highly accurate and has become the diagnostic mainstay. In contrast, the diagnosis of perihilar strictures remains a challenge. Similarly, the drainage of extrahepatic strictures tends to be more straightforward and safer and less controversial than that of perihilar strictures. Recent evidence has provided some clarity in multiple important areas pertaining to biliary strictures, whereas several remaining controversies require additional research. The goal of this guideline is to provide practicing clinicians with the most evidence-based guidance on the approach to patients with extrahepatic and perihilar strictures, focusing on diagnosis and drainage.

A real-time interpretable artificial intelligence model for the cholangioscopic diagnosis of malignant biliary stricture (with videos).

BACKGROUND AND AIMS: It is crucial to accurately determine malignant biliary strictures (MBSs) for early curative treatment. This study aimed to develop a real-time interpretable artificial intelligence (AI) system to predict MBSs under digital single-operator cholangioscopy (DSOC). METHODS: A novel interpretable AI system called MBSDeiT was developed consisting of 2 models to identify qualified images and then predict MBSs in real time. The overall efficiency of MBSDeiT was validated at the image level on internal, external, and prospective testing data sets and subgroup analyses, and at the video level on the prospective data sets; these findings were compared with those of the endoscopists. The association between AI predictions and endoscopic features was evaluated to increase the interpretability. RESULTS: MBSDeiT can first automatically select qualified DSOC images with an area under the curve (AUC) of .963 and .968 to .973 on the internal testing data set and the external testing data sets, and then identify MBSs with an AUC of .971 on the internal testing data set, an AUC of .978 to .999 on the external testing data sets, and an AUC of .976 on the prospective testing data set, respectively. MBSDeiT accurately identified 92.3% of MBSs in prospective testing videos. Subgroup analyses confirmed the stability and robustness of MBSDeiT. The AI system achieved superior performance to that of expert and novice endoscopists. The AI predictions were significantly associated with 4 endoscopic features (nodular mass, friability, raised intraductal lesion, and abnormal vessels; P < .05) under DSOC, which is consistent with the endoscopists' predictions. CONCLUSIONS: The study findings suggest that MBSDeiT could be a promising approach for the accurate diagnosis of MBSs under DSOC.