Abstract : Background: To assess the usefulness of endoscopic pancreatography without contrast agents and efficacy of transpapillary intervention for pancreatic duct (PD) rupture in chronic pancreatitis. Methods: We retrospectively analyzed all cases of chronic pancreatitis with ductal rupture causing ascites, effusions and pseudocysts. We performed magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde pancreatography (ERP) without contrast. Results observed based on the possibility of wire crossing the leak or not and their resolutions were noted. Results: We performed ERP in 1,324 patients. Ductal disruptions in 321/1,324 (24.2%). We divided cases into two groups. Group 1 involves disruptions causing ascites in 60 cases (18.7%) and effusions in 34 cases (10.6%), and group 2 involves pseudocysts in 227 cases (70.7%). In group 1, 82 patients (87.2%) experienced successful cannulation of PD. Leak crossed in 70 (74.5%) with complete resolution in all. Leak did not cross in 12 cases of which 8 (8.5%) installed stents resolved while four (4.3%) did not resolve. In group 2, 219 (96.5%) PD cannulated. Leak did not cross but stents put in cyst (176, 77.5%). Complete resolution occurred without infection. Leaks were crossed in 43 (18.9%); complete resolution, 14 (32.6%). Complete regression was not achieved in 19 (8.3%). Eight cysts were not resolved (3.5%). Transmural drainage was done. Infection was noted in 2 cases (0.9%). Sites of leak in pseudocysts were jenu & body, 167 (73.6%); tail, 60 (26.4%). We recorded pancreas divisum in 24/321 (7.5%). ERP failed in 20 (6.2%). Three were managed medically (1.3%), 5 with distal pancreatectomy (2.2%), 4 with lateral pancreatico jejunostomy (1.8%), and 8 with transmural drainage (3.5%). Conclusion: PD rupture in chronic pancreatitis can be managed transpapillary, without any contrast during ERP. In majority, endosonography aspiration and transmural drainage are needed only when transpapillary fails. Leak from tail responded better than those from proximal duct with ERP.
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Abstract : Background: Having a clean esophagus is an integral part of the peroral endoscopic myotomy (POEM) procedure for ensuring safety and success. Conventional preparation is a tricky, because there is no defined definite timeline of fasting for the different types of achalasia. The present study introduces a simple yet effective preparation of esophageal clearance. Methods: All patients who underwent POEM were included. Patients were stratified in novel and conventional preparation groups by a random selection. In the novel preparation, the cases were maintained on lukewarm water and carbonated drink followed by nil per oral (NPO) prior to the procedure. In conventional preparation, the controls were maintained on clear liquid followed by NPO. Success rate of preparation and procedure related outcomes were compared using independent t tests and chi-squared tests. Results: A total of 150 patients (male 54.0%; mean age 41.2 ± 15.5 years) were included in the study. Known baseline and clinical factors which could affect esophageal clearance were evenly distributed between the two groups. Novel preparation had provided absolute esophageal clearance (97.3%) without the requirement of pre-POEM endoscopic cleaning. Moreover, Novel preparation demonstrates several advantages over the conventional preparation: decreased anesthesia aspiration risk (P < 0.0001), reduced preoperative hospitalization (P < 0.0001), and hospital stays (P < 0.005). Conclusion: Evidently, the novel preparation is very simple, efficient, safe and appropriate for all types of achalasia. Moreover, novel preparation provides absolute esophageal clearance without requiring prolonged period of liquid diet, fasting and pre-POEM endoscopic cleaning.
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Abstract : Background: Infra-colic radiologically inserted gastrostomy is not well documented, and the presence of an insertion window solely below the transverse colon is generally regarded as a contraindication to gastrostomy insertion. A perceived increased risk is due to the presence of vessels and lymphatics within the omental and peritoneal structures, such as the epiploic arteries, the arterial arcade of Barkow, and middle colic artery branches from the superior mesenteric artery. Colonic obstruction is also an additional theorised risk. We provide evidence that infra-colic insertion of a feeding tube through the greater omentum can be performed safely. Methods: A total of 1,156 gastrostomies were inserted over an 8-year period. A retrospective review of the 5 cases was conducted. Electronic patient records were reviewed including clinical consultations, procedure reports and images. Results: In all cases, barium was administered orally/per nasogastric tube the day before to delineate the colon. All patients underwent sedo-analgesia with insufflation of the stomach achieved by a temporising nasogastric/orogastric tube. Infra-colic gastropexy with three SafeTpexy T-fasteners was undertaken. Standard 12 Fr balloon retained tubes were inserted through the greater omentum with no post-procedural complications or tube malfunctions in four cases. A 16 Fr disc retained tube was inserted in a fifth case. Conclusion: Despite the perceived difficulties, we suggest that infra-colic gastrostomies can be performed with confidence, and with little deviation from standard insertion techniques. They can be inserted without an apparent increase in complications, although operators need to be aware of the anatomical differences and additional structures traversed when performing infra-colic gastrostomies.
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Abstract : Background: Increasingly interventional radiology has been used to stop uncontrolled gastrointestinal (GI) bleeding leading to a reduction in the requirement for surgical intervention. To examine the safety and efficacy of angiography and embolisation for the treatment of GI bleeding in a United Kingdom tertiary hospital. Methods: This was a single-centre retrospective study of 112 procedures performed on 105 patients who underwent catheter angiography for GI bleeding over 7 years. Fifty procedures were for upper GI bleeding and 62 were for lower GI bleeding. Primary outcome was clinical success rate. Other measures were re-bleeding rates and 30-day mortality. Results: In patients with upper GI bleeds, 71.6% of cases had a bleeding point that was identified at the time of initial catheter angiogram. Overall, the clinical success rate was 70.4% with a 20% 30-day mortality. Technical success with embolisation was 98% with no major complications. In patients with lower GI bleeds, 50% of cases had a bleeding point that was identified at the time of initial catheter angiogram. Overall clinical success rate was 83.0% with a 13.6% 30-day mortality. Technical success with embolisation was 100% with no major complications. Conclusion: Catheter directed angiography and embolisation is safe and efficacious in patients with GI bleeding who have a positive computed tomography angiogram and should be considered as an alternative to surgery.
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Abstract : Background: Malignant afferent loop syndrome occurs after biliary reconstruction and is difficult to treat because of the complicated anatomical changes. The aim of this study was to investigate the safety and efficacy of percutaneous metallic stent placement for malignant afferent loop syndrome via the blind end of the jejunal limb after biliary reconstruction. Methods: Percutaneous metallic stent placement via the jejunal limb was performed in five male patients (median age, 68 years; range, 51–88 years) with malignant afferent loop syndrome following pancreatoduodenectomy or bile duct resection with reconstruction at our institute from June 2009 to April 2019. Reconstruction was performed using a modified Child’s method or the Roux-en-Y method, and blind end of the jejunal limb was surgically fixed to the abdominal wall. Percutaneous drainage of the afferent loop was performed via the blind end of the jejunal limb. Subsequently, percutaneous metallic stent placement was performed via the same route. Technical success, clinical success, and complications were retrospectively evaluated. Results: Percutaneous metallic stent placement via the blind end of the jejunal limb was successfully achieved in all six procedures. Additional metallic stent placement was performed due to tumor ingrowth in a patient. Drainage catheters were removed from three patients, clamped in one, and could not be removed in one. Clinical success was achieved in four patients (80%) without major complications. Conclusion: Percutaneous metallic stent placement for malignant afferent loop syndrome via the blind end of the jejunal limb after biliary reconstruction could be a safe and effective procedure.
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Abstract : Amoebic liver abscess with jaundice is not uncommon, but jaundice with intractable pruritus due to it is extremely uncommon. We present a case of amoebic liver abscess who had mild icterus at presentation and improved within seven days of conservative management with the decrease in abscess size. One month later, he presented with severe pruritus and deep jaundice. On evaluation, no other cause could be identified to explain his jaundice and severe pruritus other than a residual abscess. Therefore abscess was drained but neither his jaundice nor pruritus responded to the aspiration of abscess. After one week he underwent endoscopic retrograde cholangiopancreatography (ERCP) and biliary stenting despite he not having any intra or extra-hepatic biliary dilatation. Following biliary drainage, his pruritus improved completely, and bilirubin became normal over the next few days. In conclusion, bilio-vascular fistulas, when present can lead to severe pruritus and, biliary drainage is an effective treatment for it.
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Abstract : Transcatheter arterial chemoembolization (TACE) is one of the most common treatment options for patients with unresectable hepatocellular carcinoma (HCC). HCC rupture following TACE is a rare but potentially life-threatening complication. This report described a patient who experienced HCC rupture after TACE. The patient was successfully managed by transarterial embolization and staged liver resection. Large tumor size, superficial tumor location, exophytic growth of the tumor, and vascular lakes during TACE may be predisposing risk factors for HCC rupture after TACE.
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Abstract : Capsule endoscopy is being widely used to identify the origin of an obscure gastrointestinal bleeding. Capsule retention is one of its complications. Herein, we present 2 cases of a retained capsule one in a gastric diverticula that was managed endoscopically, and one in jejunal diverticula managed by small bowel resection.
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