Abstract : Pancreatobiliary malignancy is relatively rare; however, it remains one of the most lethal malignancies and has a dismal prognosis. Endoscopic retrograde cholangiopancreatography (ERCP)-guided intraductal radiofrequency ablation (ID-RFA) is a promising, minimally invasive treatment for unresectable malignant biliary strictures by delivering high-frequency alternating current to the target tissue, leading to coagulative necrosis. Recent studies have provided evidence that ERCP-guided ID-RFA is a safe, well-tolerated, and effective adjunctive treatment in terms of stent patency as well as overall survival. Compared with other local treatments, such as photodynamic therapy, ERCP-guided ID-RFA has advantages, including ease of delivery, controlled application of thermal energy, low cost, and fewer systemic side effects, with an acceptable safety profile. ERCP-guided ID-RFA has been proposed as an attractive endobiliary ablative therapy and is regarded to be an adjuvant method for the palliative care of patients with unresectable malignant biliary strictures. However, due to the ongoing lack of comparative studies, the choice of local ablative therapy remains, in each case, an individual decision by the multidisciplinary team.
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Abstract : The prognosis of bile duct cancer (BDC) is limited due to tumor spread along the biliary tree leading to refractory obstructive cholestasis, cholangitis, and liver failure. Palliation with biliary endoprostheses yields median survival times between 4 and 6 months for advanced BDC. Photodynamic therapy (PDT) is a local photochemical tumor treatment that consists of a photosensitizing agent combined with laser irradiation of a distinct wavelength. Tumor ablation with PDT combined with biliary stenting reduces cholestasis and significantly improves the median survival time. However, the treatment is not widely available, and the photosensitizer used for PDT causes prolonged photosensitivity. Optimal control of tumor spread along the bile ducts and control of cholestasis and cholangitis will prolong survival in 33% to 66% of patients and render them suitable for other antitumor therapies.
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Abstract : Despite advancements in endoscopic retrograde cholangiopancreatography (ERCP), direct endoscopic visualization of the biliary tree by cholangioscopy is required to improve the diagnosis and treatment of the underlying disease. Although several types of peroral cholangioscopy (POC) systems are available, single-operator cholangioscopy (SOC) has been widely used for interventions in the biliary system. The first SOC was SpyGlass direct visualization system (Boston Scientific, Natick, MA, USA) expanded to a digital version of the SOC (SpyGlass DS; Boston Scientific). More recently, single-operator direct POC using an ultra-slim upper endoscope has been proposed. The remarkable developments in POC and available specialized accessories continue to improve therapeutic procedure of the biliary diseases. POC allows the visualization of bile duct stone and guide wire placement across difficult strictures and selective cannulation of the intrahepatic and cystic ducts. It is also demonstrating its utility in investigational applications such as intraductal ablation therapy for bile duct tumors, removal of foreign body in the bile duct and evaluation of hemobilia.
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Abstract : Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy (SAA) of the upper gastrointestinal tract is a more technically challenging and arduous procedure accompanied by a low success rate of reaching the target orifice and a relatively high rate of complications, compared to those with normal anatomy. Since the introduction of device-assisted enteroscopies such as balloon enteroscopy (BE) and manual spiral enteroscopy (SE) for small bowel disorders, they have also been used for ERCP in patients with SAA. The recent development of short-type BE makes ERCP in patients with SAA technically easier with high success rates and short procedural duration, and then short-type BE is considered the gold standard endoscopic procedure in these patients. Laparoscopy-assisted ERCP is another therapeutic option, especially for patients with a long excluded afferent limb of SAA. The choice of procedure for high success rates should be individualized according to patient characteristics and available physician competence. Moreover, novel motorized SE is a promising alternative procedure for the successful performance of ERCP.
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Abstract : Patients with indeterminate biliary stricture frequently pose a challenge in the clinical management. Discrimination between benign and malignant biliary strictures is important to prevent the morbidity and mortality associated with incorrect diagnoses. Traditional tissue sampling using endoscopic retrograde cholangiography does not always produce a definitive diagnosis, with a considerable proportion of cases remaining as indeterminate biliary strictures. Recent advances in endoscopic and molecular techniques have the potential to improve the diagnostic and prognostic accuracy of biliary strictures. This article reviews various etiologies of biliary strictures and discusses the recent advances of diagnostic approaches for indeterminate biliary tract obstruction.
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Abstract : Advanced malignant hilar biliary obstrucion (HBO) is commonly caused by hilar cholangiocarcinoma, gallbladder cancer, hepatocelluar carcinoma, or metastatic tumors. Although surgical resection is the only curative treatment, the majority of patients can not undergo surgery due to an advanced inoperable state upon presentation. Therefore, effective biliary drainage is currently the mainstay palliative treatment for symptomatic improvement of HBO. Percutaneous access has been preferred traditionally, especially for advanced HBO because of technical difficulty involved. Recently, primary endoscopic palliation using plastic or metal stents has shown higher technical feasibility and clinical success without increasing the risk of adverse events compared to percutaneous access, even for high-degree HBO. Endoscopic ultrasound (EUS)-guided intervention has also been introduced for primary cases having a failed endoscopy or surgically altered anatomy and for reintervention. However, primary approach methods such as percutaneous, endoscopic retrograde cholangiopancreatography, and EUS have numerous issues involving the use of stents, including the type of stents, the number of stents, the deployment method, and additional efficacy of local therapies. This review describes current effective biliary drainage methods for advanced inoperable HBO based on reported studies.
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Abstract : Background: Five to ten percent of all patients undergoing radiofrequency ablation (RFA), which is the most established technique for Barrett’s esophagus (BE) ablation-develop strictures. Hybrid-argon plasma coagulation (APC) combines APC with submucosal saline injection that was recently developed to tackle this problem. The aims of this pilot study were to evaluate the feasibility, tolerance, safety and long-term efficacy of hybrid-APC for the treatment of BE. Methods: Patients with histological proven BE were selected for hybrid-APC. Prior to APC thermal ablation the mucosa was lifted using a submucosal high-pressure water jet injection system (Erbejet 2; Erbe, Tuebingen, Germany). Short-term (< 48 hours) and long-term (> 48 hours) safety were evaluated. Efficacy of ablation was measured at 3, 6, 12 and 24 months at follow-up endoscopy by evidence of macroscopically complete resolution of BE mucosa and/or histologically complete resolution of intestinal metaplasia (CRIM). Results: Eleven patients were included in the study (average age, 68.2 years; male 72.7%). Eight patients (72.7%) were treatment naive, 9.1% (n = 1) had prior RFA and 18.2% (n = 2) had prior endoscopic mucosal resection. Two patients were excluded from the study. Nine patients (100%) had macroscopic remission and 88.9% (n = 8) had macroscopic remission and microscopic CRIM at 24 months after hybrid-APC ablation. No treatment-related stricture or other major complications were observed, 1 patient (11.1%) reported minor adverse effects. Conclusion: In this prospective pilot study, hybrid-APC appears safe, feasible and effective after 24 months, which has not been evaluated so far. Further large, multi-centre trials are warranted to confirm the present results.
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Abstract : Gastroduodenal artery steal syndrome is an uncommon complication occurring after orthotopic liver transplantation (OLT) that results in hypoperfusion of the hepatic artery increasing the risk for graft dysfunction. Its non-specific clinical and imaging findings often delay diagnosis and increase the chance for re-transplantation or death. The lack of diagnostic criteria and definitive risk factors for developing the syndrome creates a need for angiography to visualize anatomical and perfusion characteristics indicative of the phenomenon. We present a 47-year-old male who underwent OLT and developed gastroduodenal artery steal a week after surgery. The diagnosis was confirmed with angiogram and successfully treated with coil embolization of the gastroduodenal artery. Arterial steal syndromes should be part of the broad differential when encountered with findings suggestive of an arterial complications in post-OLT patients.
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Abstract : Roux-en-Y gastric bypass (RYGB) is the most common bariatric surgery in the United States. RYGB is a successful and safe procedure that promotes weight loss, improves medical comorbidities and overall quality of life. Following RYGB, endoscopic access to the biliopancreatic limb and the excluded stomach is limited due to altered anatomy. Access to the excluded stomach maybe needed for management of complications following RYGB as gastric remnant decompression duo to biliopancreatic limb obstruction or nutritional support due to postoperative malnutrition. We report three cases of RYGB complications that necessitated percutaneous gastrostomy.
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Abstract : Leiomyomas are the most common benign tumor of the oesophagus. symptomatic patients are candidates for excision, we have discussed a case report of a 43-year-old male patient who had complains of progressive dysphagia. Imaging studies suggested a distal oesophageal mass with calcific foci. The tumor was enucleated laparoscopically with an operative time of 160 minutes. The patient was gradually started on oral feeds from the 3rd postoperative day after an upper gastrointestinal contrast study. The patient was discharged on the 5th postoperative day. We found this minimally invasive approach to be effective with a shorter hospital stay and a faster recovery as compared to a thoraco abdominal approach.
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Abstract : A 65-year-old Japanese male presented with a substantial amount of bright red and burgundy rectal bleeding. A colonoscopy confirmed the presence of fresh blood and coagulation in the orifice of the appendix. A suitable position was found using an endoscopic hood to visualize the exposed vessel clearly. We placed two hemo-clips on the appendix orifice at opposite sides of the exposed vessel and then stirred them with an endoscopic hood to visualize the exposed vessel clearly. Finally, we placed other two hemo-clips near the exposed vessels and carried out a complete hemostasis with vessel thrombosis.
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Paul R. Tarnasky, and Prashant Kedia
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Karel Volenec, and Ivan Pohl
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Adarsh M. Thaker, and V. Raman Muthusamy
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