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1.
Medicine (Baltimore) ; 99(16): e19750, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32311973

RESUMO

RATIONALE: Biliary drainage is essential to resolve jaundice in patients with malignant biliary obstruction. Recently, a biliary self-expandable metal stent (SEMS) with an antireflux valve was developed to prevent enteric-biliary reflux. Its antireflux valve was made of expanded polytetrafluoroethylene (ePTFE), a biostable and biocompatible material. Changes of the ePTFE membrane of medical devices are rarely reported in clinical practice. PATIENT CONCERNS: A 59-year-old woman was admitted with a complaint of jaundice. Around 1 month before, she underwent endoscopic biliary stenting using a SEMS with an antireflux valve. DIAGNOSIS: Acute cholangitis due to stent clogging was detected on abdominal computed tomography. INTERVENTIONS: Endoscopic retrograde cholangiopancreatography and removal of the SEMS with deformity were performed. OUTCOMES: The obstructive jaundice was rapidly resolved after the removal of the clogged stent. LESSONS: Although the ePTFE membrane is widely used to make medical devices, unexpected changes could occur after the membrane is exposed to bile juice in the duodenum. When performing biliary stenting using a SEMS with an antireflux valve, both the risk of early malfunction and the benefit of the antireflux effect should be considered.


Assuntos
Colestase/terapia , Stents/efeitos adversos , Adenocarcinoma/complicações , Colestase/etiologia , Feminino , Humanos , Pessoa de Meia-Idade , Neoplasias Pancreáticas/complicações
2.
Br J Radiol ; 93(1108): 20191046, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31971831

RESUMO

OBJECTIVE: To study the outcome of salvage percutaneous transhepatic biliary drainage (PTBD) in complex and technically challenging post-liver transplant (LT) biliary complications and analyse the reason for failure of endoscopic retrograde cholangiopancreatography (ERCP). METHODS AND MATERIALS: Hospital data were searched for all LT patients with biliary complications requiring salvage PTBD (upon failure of ERCP) from January 2010 to May 2017. Patients who underwent primary PTBD were excluded. Patients clinical and biochemical parameters were analysed for clinical, biochemical and imaging response, stent-free survival and the reason for ERCP failure. RESULTS: Salvage PTBD was performed in 32 patients with post-LT biliary stricture/bile leak presenting with deranged liver function in 12 (37.5%), cholangitis in 12 (37.5%) and cholangitis with cholangitic abscess in remaining 8 (25%) patients. Of 32 patients, 20 (62.5%) already had plastic biliary stent placed by ERCP, while in remaining (n = 12, 37.5%) a wire could not be negotiated across stricture by ERCP. These patients were found to have long/tortuous stricture (n = 18, 56.3%) and multiple duct disconnection at anastomosis (n = 14, 43.7%). Immediate as well as sustained (persisting for a year or more) clinical and biochemical improvement was seen in 26 (81.3%) patients, while failure of resolution of sepsis and death occurred in remaining 6 (18.8%). CONCLUSION: Salvage PTBD is an effective treatment in difficult-to-treat post-LT biliary strictures with deranged liver functions with or without cholangitis/cholangitic abscess. It can reduce graft loss with improved clinical outcome. Post-LT ductal anatomy at anastomosis is important to decide the appropriate approach (ERCP/PTBD). ADVANCES IN KNOWLEDGE: (1). PTBD as a salvage procedure in difficult anatomy or upon failure of ERCP-based intervention is effective and a good alternative strategy. (2). Postoperative surgical anatomy (type & length of stricture, number of ductanastomosis, location and graft-recipient duct alignment) is the key factor indeciding the appropriate therapeutic procedure.


Assuntos
Colangite/terapia , Colestase/terapia , Drenagem/métodos , Transplante de Fígado/efeitos adversos , Complicações Pós-Operatórias/terapia , Terapia de Salvação/métodos , Abscesso/terapia , Adulto , Fístula Anastomótica/terapia , Colangiopancreatografia Retrógrada Endoscópica , Constrição Patológica/terapia , Drenagem/estatística & dados numéricos , Feminino , Humanos , Masculino , Estudos Retrospectivos , Terapia de Salvação/estatística & dados numéricos , Stents/estatística & dados numéricos
3.
Surg Today ; 50(1): 21-29, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31555908

RESUMO

Small-for-size graft (SFSG) syndrome after living donor liver transplantation (LDLT) is the dysfunction of a small graft, characterized by coagulopathy, cholestasis, ascites, and encephalopathy. It is a serious complication of LDLT and usually triggered by excessive portal flow transmitted to the allograft in the postperfusion setting, resulting in sinusoidal congestion and hemorrhage. Portal overflow injures the liver directly through nutrient excess, endothelial activation, and sinusoidal shear stress, and indirectly through arterial vasoconstriction. These conditions may be attenuated with portal flow modulation. Attempts have been made to control excessive portal flow to the SFSG, including simultaneous splenectomy, splenic artery ligation, hemi-portocaval shunt, and pharmacological manipulation, with positive outcomes. Currently, a donor liver is considered a SFSG when the graft-to-recipient weight ratio is less than 0.8 or the ratio of the graft volume to the standard liver volume is less than 40%. A strategy for transplanting SFSG safely into recipients and avoiding extensive surgery in the living donor could effectively address the donor shortage. We review the literature and assess our current knowledge of and strategies for portal flow modulation in LDLT.


Assuntos
Circulação Hepática , Transplante de Fígado/métodos , Fígado/irrigação sanguínea , Doadores Vivos , Veia Porta/fisiopatologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/terapia , Esplenectomia , Transtornos da Coagulação Sanguínea , Encefalopatias/etiologia , Encefalopatias/terapia , Colestase/etiologia , Colestase/terapia , Humanos , Ligadura , Tamanho do Órgão , Artéria Esplênica/cirurgia , Síndrome
4.
Z Gastroenterol ; 58(2): 152-159, 2020 Feb.
Artigo em Alemão | MEDLINE | ID: mdl-31863426

RESUMO

Patients with indeterminate biliary stricture frequently pose a challenge in the clinical management. Patients with malignant and potentially resectable diseases should be treated surgically as soon as possible. On the other hand, in patients with benign diseases which might be cured with medial treatment, surgery should be avoided. This review shall provide a concise overview on the diagnostic yield of currently available endoscopic methods as well as describe methods of potential relevance in the future.


Assuntos
Ductos Biliares/patologia , Colangiopancreatografia Retrógrada Endoscópica , Colestase/terapia , Constrição Patológica , Colestase/etiologia , Drenagem , Humanos
5.
BMC Gastroenterol ; 19(1): 214, 2019 Dec 12.
Artigo em Inglês | MEDLINE | ID: mdl-31830897

RESUMO

BACKGROUND: Endoscopic treatment of post-cholecystectomy biliary strictures (PCBS) with multiple plastic biliary stents placed sequentially is a minimally invasive alternative to surgery but requires multiple interventions. Temporary placement of a single fully-covered self-expanding metal stent (FCSEMS) may offer safe and effective treatment with fewer re-interventions. Long-term effectiveness of treatment with FCSEMS to obtain PCBS resolution has not yet been studied. METHODS: In this prospective multi-national study in patients with symptomatic benign biliary strictures (N = 187) due to various etiologies received a FCSEMS with scheduled removal at 6-12 months and were followed for 5 years. We report here long-term outcomes of the subgroup of patients with PCBS (N = 18). Kaplan Meier analyses assessed long-term freedom from re-stenting. Adverse events were documented. RESULTS: Endoscopic removal of the FCSEMS was achieved in 83.3% (15/18) of patients after median indwell of 10.9 (range 0.9-13.8) months. In the remaining 3 patients (16.7%), the FCSEMS spontaneously migrated and passed without complications. At the end of FCSEMS indwell, 72% (13/18) of patients had stricture resolution. At 5 years after FCSEMS removal, 84.6% (95% CI 65.0-100.0%) of patients who had stricture resolution at FCSEMS removal remained stent-free. In addition, at 75 months after FCSEMS placement, the probability of remaining stent-free was 61.1% (95% CI 38.6-83.6%) for all patients. Stent or removal related serious adverse events occurred in 38.9% (7/18) all resolved without sequalae. CONCLUSIONS: In patients with symptomatic PCBS, temporary placement of a single FCSEMS intended for 10-12 months indwell is associated with long-term stricture resolution up to 5 years. Temporary placement of a single FCSEMS may be considered for patients with PCBS not involving the main hepatic confluence. TRIAL REGISTRATION NUMBERS: NCT01014390; CTRI/2012/12/003166; Registered 17 November 2009.


Assuntos
Colecistectomia/efeitos adversos , Colestase/terapia , Complicações Pós-Operatórias/terapia , Stents Metálicos Autoexpansíveis , Colangiopancreatografia Retrógrada Endoscópica/efeitos adversos , Constrição Patológica/terapia , Remoção de Dispositivo/efeitos adversos , Remoção de Dispositivo/estatística & dados numéricos , Feminino , Seguimentos , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Stents Metálicos Autoexpansíveis/efeitos adversos , Fatores de Tempo , Resultado do Tratamento
6.
Tech Vasc Interv Radiol ; 22(3): 135-138, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31623753

RESUMO

Percutaneous endoscopy operated by interventional radiologists has the potential to become an effective tool to both help diagnose and treat benign and malignant biliary strictures. This is particularly true in cases where endoscopic retrograde cholangiopancreatography fails or is not feasible due to surgically-altered anatomy. Both preoperative clinical and technical procedural factors must be taken into consideration when pursuing percutaneous endoscopy. In this article, clinical evaluation, perioperative management, and procedural techniques for biliary endoscopy for benign and malignant strictures are reviewed.


Assuntos
Colestase/diagnóstico por imagem , Colestase/terapia , Neoplasias do Sistema Digestório/complicações , Endoscopia do Sistema Digestório/métodos , Radiografia Intervencionista/métodos , Colestase/genética , Endoscopia do Sistema Digestório/instrumentação , Humanos , Valor Preditivo dos Testes , Radiografia Intervencionista/instrumentação , Fatores de Risco , Stents , Resultado do Tratamento
7.
Turk J Pediatr ; 61(1): 26-33, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31559718

RESUMO

Özkan H, Köksal N, Dogan P, Güney-Varal I, Bagci O, Özgür T. The effectiveness of serum amyloid A for prediction of neonatal cholestasis associated with parenteral nutrition in premature infants. Turk J Pediatr 2019; 61: 26-33. Parenteral nutrition (PN) has been widely used in premature infants untill enteral feeding can be tolerated. Cholestasis is an important complication of PN. The objective of this study was to evaluate the role of serial measurements of serum amyloid A (SAA) during PN and compare its` effectiveness with C-reactive protein (CRP) and procalcitonin (PCT). We also aimed to determine the risk factors for PN associated cholestasis (PNAC). Premature infants ( < 34 weeks` gestational age) who were started on PN during hospitalization were included in this prospective study. SAA, CRP and PCT levels were measured on days 0, 3, 7, 14, and 21 of PN in all infants. Infants who had PN for less than 2 weeks, who developed sepsis and/or necrotizing enterocolitis were excluded. A total of 85 infants were included. The mean birth weight was 1226±329 g, and the mean gestational age was 29.4±1.8 weeks. The birth weight of infants who developed cholestasis were significantly lower. Enteral nutrition was started significantly later in infants with cholestasis. CRP and PCT did not correlate with conjugated bilirubin levels at any time point. SAA levels on days 7 and 14 showed a significant correlation with conjugated bilirubin levels. SAA levels on day 7 was found to have the highest sensitivity for prediction of PNAC. Low birth weight, late commencement of enteral feeding, and prolonged PN were the main risk factors for PNAC development. This is the first study that shows the predictive value of SAA for PNAC development. We suggest that SAA may be used as an accurate and useful biomarker for prediction of PNAC in high risk premature infants receiving PN.


Assuntos
Colestase/diagnóstico , Colestase/etiologia , Doenças do Prematuro/diagnóstico , Doenças do Prematuro/etiologia , Nutrição Parenteral/efeitos adversos , Proteína Amiloide A Sérica/metabolismo , Biomarcadores/sangue , Peso ao Nascer , Colestase/sangue , Colestase/terapia , Diagnóstico Precoce , Nutrição Enteral , Feminino , Idade Gestacional , Humanos , Lactente , Recém-Nascido , Recém-Nascido Prematuro , Doenças do Prematuro/sangue , Doenças do Prematuro/terapia , Recém-Nascido de muito Baixo Peso , Masculino , Avaliação de Resultados em Cuidados de Saúde , Estudos Prospectivos , Fatores de Risco , Sensibilidade e Especificidade
8.
World J Gastroenterol ; 25(29): 3857-3869, 2019 Aug 07.
Artigo em Inglês | MEDLINE | ID: mdl-31413524

RESUMO

In the last years, endoscopic ultrasonography (EUS) has evolved from a purely diagnostic technique to a more and more complex interventional procedure, with the possibility to perform several type of therapeutic interventions. Among these, EUS-guided biliary drainage (BD) is gaining popularity as a therapeutic approach after failed endoscopic retrograde cholangiopancreatography in distal malignant biliary obstruction (MBO), due to the avoidance of external drainage, a lower rate of adverse events and re-interventions, and lower costs compared to percutaneous trans-hepatic BD. Initially, devices created for luminal procedures (e.g., luminal biliary stents) have been adapted to the new trans-luminal EUS-guided interventions, with predictable shortcomings in technical success, outcome and adverse events. More recently, new metal stents specifically designed for transluminal drainage, namely lumen-apposing metal stents (LAMS), have been made available for EUS-guided procedures. An electrocautery enhanced delivery system (EC-LAMS), which allows direct access of the delivery system to the target lumen, has subsequently simplified the classic multi-step procedure of EUS-guided drainages. EUS-BD using LAMS and EC-LAMS has been demonstrated effective and safe, and currently seems one of the most performing techniques for EUS-BD. In this Review, we summarize the evolution of the EUS-BD in distal MBO, focusing on the novelty of LAMS and analyzing the unresolved questions about the possible role of EUS as the first therapeutic option to achieve BD in this setting of patients.


Assuntos
Colestase/terapia , Drenagem/métodos , Endossonografia/métodos , Stents Metálicos Autoexpansíveis , Ultrassonografia de Intervenção/métodos , Colangiopancreatografia Retrógrada Endoscópica/efeitos adversos , Colangiopancreatografia Retrógrada Endoscópica/instrumentação , Colangiopancreatografia Retrógrada Endoscópica/métodos , Colestase/etiologia , Neoplasias do Ducto Colédoco/complicações , Neoplasias do Ducto Colédoco/patologia , Drenagem/efeitos adversos , Drenagem/instrumentação , Eletrocoagulação/efeitos adversos , Eletrocoagulação/instrumentação , Eletrocoagulação/métodos , Humanos , Invasividade Neoplásica/patologia , Neoplasias Pancreáticas/complicações , Neoplasias Pancreáticas/patologia , Resultado do Tratamento
9.
J Ultrasound ; 22(4): 437-445, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31368040

RESUMO

AIMS: Aim of this study is to describe a multicenter experience on percutaneous transhepatic biliary drainage (PTBD) performed with ultrasound-guidance to access the biliary tree, focusing on safety, effectiveness and radiation dose exposure; differences between right- and left-sided approaches have been also evaluated. METHODS: This is a multicenter prospective single-arm observational study conducted on patients affected by biliary tree stenosis/occlusion with jaundice and endoscopically inaccessible. The procedures have been performed puncturing the biliary system under US guidance and crossing the stenosis/occlusion under fluoroscopy. Beam-on time and X-ray dose have been evaluated. RESULTS: 117 patients affected by biliary tree stenosis/occlusion not manageable with an endoscopic approach have been included in this analysis. The biliary stenosis/occlusion was malignant in 90.8% and benign in 9.2%. Technical success, considered as positioning of a drainage tube into the biliary tree, was 100%. Overall clinical success, considered as decrease in total bilirubin level after a single procedure, was 95.7%. The overall mean number of liver punctures to catheterize the biliary tree was 1.57. The mean total beam-on time was 570.4 s; the mean dose-area product was 37.25 Gy cm2. No statistical significant differences were observed in terms of technical and dosimetry results according to right-sided and left-sided procedures. Complications rate recorded up to 30 days follow-up was 10.8%, all of minor grades. CONCLUSIONS: In this series US guidance to access the biliary tree for PTBD was a safe and effective technique with an acceptable low-grade complications rate; the reported radiation dose is low.


Assuntos
Colestase/terapia , Drenagem/métodos , Ultrassonografia de Intervenção , Adulto , Idoso , Idoso de 80 Anos ou mais , Ductos Biliares/diagnóstico por imagem , Colestase/diagnóstico por imagem , Drenagem/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Ultrassonografia de Intervenção/efeitos adversos , Ultrassonografia de Intervenção/métodos
11.
Biochimie ; 165: 179-182, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31377196

RESUMO

Multidrug resistance-associated protein 2 (MRP2/ABCC2), a hepatocyte canalicular transporter involved in bile secretion, is downregulated in cholestasis triggered by lipopolysaccharide. The human aquaporin-1 (hAQP1) adenovirus-mediated gene transfer to liver improves cholestasis by incompletely defined mechanisms. Here we found that hAQP1 did not affect MRP2/ABCC2 expression, but significantly increased its transport activity assessed in situ with endogenous and exogenous substrates, likely by a hAQP1-induced increase in canalicular membrane cholesterol amount. Our results suggest that hAQP1-induced MRP2/ABCC2 activation contributes to the cholestasis improvement.


Assuntos
Transportadores de Cassetes de Ligação de ATP/metabolismo , Aquaporina 1/fisiologia , Bile/metabolismo , Colestase/metabolismo , Hepatócitos/metabolismo , Animais , Aquaporina 1/genética , Colestase/terapia , Técnicas de Transferência de Genes , Hepatócitos/citologia , Masculino , Ratos Wistar
12.
Cleve Clin J Med ; 86(7): 454-464, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31291179

RESUMO

With recent medical advances, more patients with childhood-onset liver disease and more pediatric liver transplant recipients are surviving into adulthood, generating distinctive challenges to adult primary care providers. Young adults with pediatric liver disease are a unique cohort of patients with different evaluation and monitoring strategies, treatment, complications, and comorbidities. This creates a critical need for successful transition of these patients into adult care, with incorporation of a formal transitional model and multidisciplinary team.


Assuntos
Colestase/terapia , Hepatopatias/terapia , Transição para Assistência do Adulto , Adolescente , Adulto , Feminino , Humanos , Masculino , Equipe de Assistência ao Paciente , Adulto Jovem
13.
J Vasc Interv Radiol ; 30(8): 1233-1241.e1, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31208946

RESUMO

PURPOSE: To establish a nomogram for predicting the occurrence of early biliary infection (EBI) after percutaneous transhepatic biliary stent (PTBS) placement in malignant biliary obstruction (MBO). MATERIALS AND METHODS: In this multicenter study, patients treated with PTBS for MBO were allocated to a training cohort or a validation cohort. The independent risk factors for EBI selected by multivariate analyses in the training cohort were used to develop a predictive nomogram. An artificial neural network was applied to assess the importance of these factors in predicting EBI. The predictive accuracy of this nomogram was determined by concordance index (c-index) and a calibration plot, both internally and externally. RESULTS: A total of 243 patients (training cohort: n = 182; validation cohort: n = 61) were included in this study. The independent risk factors were length of obstruction (odds ratio [OR], 1.061; 95% confidence interval [CI], 1.013-1.111; P = .012), diabetes (OR, 5.070; 95% CI, 1.917-13.412; P = .001), location of obstruction (OR, 2.283; 95% CI, 1.012-5.149; P = .047), and previous surgical or endoscopic intervention (OR, 3.968; 95% CI, 1.709-9.217; P = .001), which were selected into the nomogram. The c-index values showed good predictive performance in the training and validation cohorts (0.792 and 0.802, respectively). The optimum cutoff value of risk was 0.25. CONCLUSIONS: The nomogram can facilitate the early and accurate prediction of EBI in patients with MBO who underwent PTBS. Patients with high risk (> 0.25) should be administered more effective prophylactic antibiotics and undergo closer monitoring.


Assuntos
Colestase/terapia , Técnicas de Apoio para a Decisão , Neoplasias do Sistema Digestório/complicações , Drenagem/efeitos adversos , Nomogramas , Infecções Relacionadas à Prótese/etiologia , Stents/efeitos adversos , Idoso , Antibioticoprofilaxia , China , Colestase/diagnóstico por imagem , Colestase/etiologia , Tomada de Decisão Clínica , Neoplasias do Sistema Digestório/diagnóstico por imagem , Drenagem/instrumentação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Redes Neurais de Computação , Seleção de Pacientes , Valor Preditivo dos Testes , Infecções Relacionadas à Prótese/diagnóstico , Infecções Relacionadas à Prótese/prevenção & controle , Reprodutibilidade dos Testes , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
15.
Cardiovasc Intervent Radiol ; 42(8): 1199-1203, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31073822

RESUMO

PURPOSE: We evaluated the safety and efficacy of transhepatic tract embolisation after a biliary intervention using n-butyl cyanoacrylate (NBCA) and autologous blood. MATERIALS AND METHODS: Between January 2017 and December 2018, 42 consecutive patients (mean age: 71 ± 15 years, 24 men) with malignant (n = 26) or benign (n = 16) biliary obstructions underwent percutaneous biliary intervention followed by tract embolisation within 2 weeks. Forty-six transhepatic tracts (4 bilateral) in 42 patients were embolised using a NBCA and lipiodol mixtures (1:1-1:2 ratios) after intraductal infusion of peripherally obtained autologous blood. The indwelling catheter diameters were 8.5-14 Fr. The median interval between percutaneous biliary drainage and tract embolisation was 10 days (range 3-14 days). Glue-cast formation via fluoroscopy and immediate complications were reviewed retrospectively in medical records. Follow-up data (median: 135, range 11-720 days) including computed tomography (CT) images (n = 17) were evaluated for delayed complications and glue-cast formation. RESULTS: Successful glue-cast formations were achieved in all 46 tracts. No patients experienced haemorrhage, and only one patient had external bile leakage. Eight patients complained of abdominal pain (numerical scale ≤ 5) immediately after embolisation, which was controlled by analgesics. Two patients had transient fever. Segmental (n = 11) or sub-segmental (n = 6) glue-cast patterns were identified along the transhepatic tract by follow-up CT. No biliary obstructions were caused by inadvertent glue spread. Fragmented glue was detected outside the stent in one patient. CONCLUSION: Transhepatic parenchymal tract embolisation with NBCA and autologous blood is a safe and feasible method for preventing bile leakage. LEVEL OF EVIDENCE: Level 4, Case Series.


Assuntos
Transfusão de Sangue Autóloga/métodos , Colestase/terapia , Drenagem/métodos , Embolização Terapêutica/métodos , Embucrilato/uso terapêutico , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Colestase/diagnóstico por imagem , Óleo Etiodado , Feminino , Fluoroscopia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
16.
Aliment Pharmacol Ther ; 49(9): 1195-1204, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30934130

RESUMO

BACKGROUND: Bodybuilding supplements can cause a profound cholestatic syndrome. AIM: To describe the drug-Induced liver injury network's experience with liver injury due to bodybuilding supplements. METHODS: Liver injury pattern, severity and outcomes, potential genetic associations, and exposure to anabolic steroids by product analysis were analysed in prospectively enrolled subjects with bodybuilding supplement-induced liver injury with causality scores of probable or higher. RESULTS: Forty-four males (mean age 33 years) developed liver injury with a median latency of 73 days. Forty-one per cent presented with hepatocellular pattern of liver injury as defined by the R > 5 ([Fold elevation of ALT] ÷ [Fold elevation of Alk Phos] (mean, range = 6.4, 0.5-31.4, n = 42) despite all presenting with clinical features of cholestatic liver injury (100% with jaundice and 84% with pruritus). Liver biopsy (59% of subjects) demonstrated a mild hepatitis and profound cholestasis in most without bile duct injury, loss or fibrosis. Seventy-one per cent were hospitalised, and none died or required liver transplantation. In some, chemical analysis revealed anabolic steroid controlled substances not listed on the label. No enrichment of genetic variants associated with cholestatic syndromes was found, although mutations in ABCB11 (present in up to 20%) were significantly different than in ethnically matched controls. CONCLUSIONS: Patients with bodybuilding supplements liver injury uniformly presented with cholestatic injury, which slowly resolved. The ingested products often contained anabolic steroids not identified on the label, and no enrichment in genetic variants was found, indicating a need for additional studies.


Assuntos
Doença Hepática Induzida por Substâncias e Drogas/epidemiologia , Colestase/induzido quimicamente , Suplementos Nutricionais/efeitos adversos , Músculos , Substâncias para Melhoria do Desempenho/efeitos adversos , Membro 11 da Subfamília B de Transportadores de Cassetes de Ligação de ATP/genética , Adulto , Biópsia , Doença Hepática Induzida por Substâncias e Drogas/genética , Doença Hepática Induzida por Substâncias e Drogas/patologia , Colestase/epidemiologia , Colestase/genética , Colestase/terapia , Suplementos Nutricionais/análise , Predisposição Genética para Doença/epidemiologia , Humanos , Transplante de Fígado/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Músculos/efeitos dos fármacos , Músculos/patologia , Substâncias para Melhoria do Desempenho/análise , Substâncias para Melhoria do Desempenho/química , Fatores de Risco , Índice de Gravidade de Doença , Somatotipos/fisiologia , Adulto Jovem
17.
Gastrointest Endosc ; 90(1): 35-43, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30928425

RESUMO

The American Society for Gastrointestinal Endoscopy's Gastrointestinal Endoscopy Editorial Board reviewed original endoscopy-related articles published during 2018 in Gastrointestinal Endoscopy and 10 other leading medical and gastroenterology journals. Votes from each individual member were tallied to identify a consensus list of 10 topic areas of major advances in GI endoscopy. Individual board members summarized important findings published in these 10 areas of adenoma detection, bariatric endoscopy, EMR/submucosal dissection/full-thickness resection, artificial intelligence, expandable metal stents for palliation of biliary obstruction, pancreatic therapy with lumen-apposing metal stents, endoscope reprocessing, Barrett's esophagus, interventional EUS, and GI bleeding. This document summarizes these "Top 10" endoscopic advances of 2018.


Assuntos
Endoscopia Gastrointestinal/tendências , Gastroenterologia/tendências , Adenoma/diagnóstico , Inteligência Artificial/tendências , Cirurgia Bariátrica/tendências , Esôfago de Barrett/diagnóstico , Esôfago de Barrett/terapia , Colestase/terapia , Neoplasias Colorretais/diagnóstico , Desinfecção , Ressecção Endoscópica de Mucosa/tendências , Endossonografia/tendências , Reutilização de Equipamento , Hemorragia Gastrointestinal/terapia , Humanos , Cisto Pancreático/terapia , Stents Metálicos Autoexpansíveis , Ultrassonografia de Intervenção/tendências
18.
Gut Liver ; 13(4): 471-478, 2019 04 17.
Artigo em Inglês | MEDLINE | ID: mdl-30970427

RESUMO

Background/Aims: Metallic stents designed to relieve malignant biliary obstruction are susceptible to occlusive tumor ingrowth or overgrowth. In a previous report, we described metallic stents covered with paclitaxel-incorporated membrane (MSCPM-I, II) to prevent occlusion from tumor ingrowth via antitumor effect. This new generation paclitaxeleluting biliary stent is further endowed with sodium caprate (MSCPM-III) for enhanced drug delivery. The purpose of this study is to examine the safety of its drug delivery system in the porcine biliary tract. Methods: MSCPM-III (10% [wt/vol] paclitaxel) and covered metal stents (CMSs) were endoscopically inserted in porcine bile ducts in vivo. Histologic biliary changes, levels of paclitaxel released, and various serum analytes (albumin, alkaline phosphate, aspartate transaminase, alanine transaminase, total protein, total bilirubin, and direct bilirubin) were assessed. Results: Based on the intensity of reactive inflammation and fibrosis, changes in porcine biliary epithelium secondary to implanted MSCPM-III were deemed acceptable (i.e., safe). Histologic features in the MSCPM-III and CMS groups did not differ significantly. In a related serum analysis, paclitaxel release from MSCPM-III stents was below the limit of detection for 28 days. Biochemical analyses were also similar for the two groups, and no evidence of hepatic or renal toxicity was found in animals receiving MSCPM-III stents. Conclusions: In a prototypic porcine trial, this newly devised metal biliary stent incorporating both paclitaxel and sodium caprate appears to be safe in the porcine bile duct.


Assuntos
Antineoplásicos Fitogênicos/farmacologia , Colestase/terapia , Ducto Colédoco/efeitos dos fármacos , Ácidos Decanoicos/farmacologia , Stents Farmacológicos , Paclitaxel/farmacologia , Stents Metálicos Autoexpansíveis , Alanina Transaminase , Fosfatase Alcalina , Animais , Aspartato Aminotransferases , Colestase/etiologia , Ducto Colédoco/patologia , Neoplasias/complicações , Paclitaxel/administração & dosagem , Albumina Sérica , Sus scrofa , Suínos
19.
J Hepatobiliary Pancreat Sci ; 26(6): 211-218, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30950234

RESUMO

BACKGROUND: Bilateral self-expandable metallic stent (SEMS) placement is effective for long-term management of unresectable malignant hilar biliary obstruction (UMHBO). However, endoscopic reintervention (ERI) for bilateral SEMSs is not well-studied. This study aimed to evaluate ERI efficacy after stent-in-stent placement. METHODS: Data of 31 patients who underwent ERI from May 2000 to July 2018 were analyzed. RESULTS: The technical success rate was 80.7% (25/31) and no adverse events occurred. The functional success rate was 100% (25/25). In a multivariate logistic regression analysis, the angle between the bilateral SEMSs (ABBS) >104° (odds ratio 50.49, 95% CI 3.370-2131, P = 0.0039) and overgrowth (odds ratio 25.70, 95% CI 1.121-1234, P = 0.0423) were risk factors for ERI failure. Multiple liver metastases, which sometimes cause overgrowth, were also risk factors. After ERI, some patients underwent additional SEMS (n = 4), plastic stent (n = 14) placement, or internal cleaning of the initial SEMS alone (n = 7). There were no significant intergroup differences in the 50% time to recurrent biliary obstruction. CONCLUSIONS: ABBS >104° and overgrowth were risk factors for ERI failure after stent-in-stent placement. In the decision-making process for initial SEMS placement for UMHBO, patient condition should be considered, including the angle between bilateral bile ducts and multiple liver metastases.


Assuntos
Neoplasias do Sistema Biliar/terapia , Colangiopancreatografia Retrógrada Endoscópica , Colestase/terapia , Stents Metálicos Autoexpansíveis , Idoso , Idoso de 80 Anos ou mais , Neoplasias do Sistema Biliar/complicações , Colestase/etiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Retratamento , Estudos Retrospectivos , Fatores de Risco
20.
Minerva Med ; 110(6): 564-574, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30994320

RESUMO

INTRODUCTION: Endoscopic ultrasound-guided (EUS) biliary drainage was used as an alternative method for patients who failed endoscopic retrograde cholangiopancreatography (ERCP). In recent years, an increasing number of patients was treated with EUS-biliary drainage (BD), but lack of data was available to value the efficacy and safety between EUS and ERCP. Therefore, a review was needed to evaluate the similarities and differences between the two methods and explored whether EUS-guided biliary drainage could be considered as first-line treatment. EVIDENCE ACQUISITION: We searched the Pubmed/Medline, Embase, Web of science, Google scholar, the Cochrane Library and Clinical trials of electronic databases till October 2018 for all English language. Primary outcomes to comparison included technical success, clinical success and adverse events. Secondary outcomes consisted of stent dysfunction requiring reintervention and procedure duration, Data from selected studies were collected to calculate the odds ratios (OR) and standard mean difference (SMD). EVIDENCE SINTHESIS: We searched 469 studies and at last identified 4 eligible trials. These included a total of 428 patients, 215 in the EUS group and 213 in the ERCP group. There was no difference in technical success (OR, 0.95; 95% CI: 0.45-2.02; I2=0%), clinical success (OR, 0.87; 95% CI: 0.42-1.79; I2=0%) and adverse events between 2 procedures (OR, 0.76; 95% CI: 0.29-2.00; I2=55%) but EUS-BD consisted of lower rate of reintervention (OR, 0.30; 95% CI: 0.14-0.63; I2=0%),and fewer procedure-related adverse events in pancreatitis and cholangitis (OR, 0.14; 95% CI: 0.04-0.51; I2=0%).There was no difference in length of procedure duration, with a pooled standard mean difference of 0.26 (95% CI: -0.15 to 0.66). CONCLUSIONS: EUS-BD and ERCP-BD in terms of relief of malignant biliary obstruction presented the similarity rate of technical success, clinical success and there is no significant difference in adverse events of two procedures. EUS-BD could be used as a substitute for ERCP-BD, even considered as first-line treatment.


Assuntos
Colangiopancreatografia Retrógrada Endoscópica , Colestase/terapia , Drenagem/métodos , Endossonografia , Neoplasias dos Ductos Biliares/complicações , Colestase/etiologia , Humanos , Resultado do Tratamento
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