BACKGROUND:Endoscopic biliary drainage for malignant hilar biliary obstruction (MHBO) remains a highly complex endoscopic retrograde cholangiopancreatography (ERCP) procedure. Each case requires an individualized approach, with outcomes influenced by the expertise of the medical center and access to advanced endoscopic tools. AIM:To compare different stent types and drainage strategies, including the use of adjunctive therapies, in patients with MHBO treated endoscopically. METHODS:We retrospectively analyzed 164 patients with MHBO (Bismuth types 3-4) who underwent exclusive endoscopic drainage. Patients were grouped by stent type-uncovered self-expandable metal stents (UCSEMS), bilateral plastic stents, or a mixed approach (fully covered self-expandable metal stents + plastic)-as well as by drainage strategy (unilateral/bilateral) and use of radiofrequency ablation (RFA) or chemotherapy. RESULTS:Patients receiving UCSEMS had significantly longer overall survival compared to those with plastic stents or the mixed approach (P < 0.0001). Mean stent occlusion times were 80 days (bilateral plastic), 84.4 days (mixed approach), and 122.5 days (UCSEMS; P < 0.0001). The mean number of ERCP reinterventions was highest in the UCSEMS group (5.4) compared to bilateral plastic (2.5) and mixed approach group (4.5; P < 0.0001). Patients who received RFA or chemotherapy had significantly longer survival (P < 0.0001). CONCLUSION:Bilateral UCSEMS stenting appears most effective for palliative treatment of MHBO. Adjunctive use of RFA and chemotherapy may further enhance survival, supporting a personalized, multidisciplinary approach.

BACKGROUND:Primary sclerosing cholangitis (PSC) is a chronic liver disease characterised by inflammation and fibrosis of the bile ducts, conferring an increased risk of cholangiocarcinoma (CCA). However, detecting CCA early in PSC patients remains challenging due to the limited sensitivity of conventional diagnostic methods, including imaging or bile duct brush cytology during endoscopic retrograde cholangiopancreatography (ERCP). This study aims to evaluate the potential of bile cell-free DNA (cfDNA) mutational analysis, termed the Bilemut assay, as a tool for CCA detection in PSC patients. METHODS:Sixty-three PSC patients undergoing ERCP due to biliary strictures were prospectively recruited. Bile samples were collected, and cfDNA was extracted and analysed using the Oncomine Pan-Cancer Cell-Free assay. Twenty healthy liver donors were included for comparison. Samples with a mutant allele frequency (MAF) ≥ 0.1% were considered positive. Correlations between mutational status and clinical characteristics were assessed. RESULTS:cfDNA mutational analysis was successful in all bile samples. Mutations predominantly in KRAS, GNAS, and TP53 were detected in 36.5% (23/63) of PSC patients, compared to 10% (2/20) of healthy donors (p = 0.0269). The clinical characteristics of Bilemut-positive and -negative patients were comparable, though there was a trend towards a lower prevalence of inflammatory bowel disease in the Bilemut-positive group. Among PSC patients diagnosed with CCA during follow-up, 75% were Bilemut-positive, suggesting an association between mutational status and malignancy risk. CONCLUSIONS:Mutational analysis of cfDNA obtained from bile collected from PSC patients undergoing ERCP is feasible. Implementing the Bilemut assay may help identify patients needing closer surveillance and further imaging studies.

This document presents a comprehensive overview of the management of postinflammatory pancreatic and peripancreatic fluid collections, with a particular emphasis on endoscopic treatment, developed by a team of experts based on the latest clinical and scientific evidence. The guidelines present a detailed scheme of treatment of patients with local complications of acute pancreatitis in the form of postinflammatory pancreatic and peripancreatic fluid collections.

Banaszkiewicz, Aleksandra MD, PhD; Bukowski, Jan MD; Pertkiewicz, Jan MD, PhD; Dembiński, Łukasz MD, PhD; Kluczewska, Ewa MD, PhD; Kwiecień, Jarosław MD, PhD Author Information

Joanna Ligocka: NO financial relationship with a commercial interest | Slawomir Koziel: NO financial relationship with a commercial interest | Jan Pertkiewicz: NO financial relationship with a commercial interest | Krzysztof Zieniewicz: NO financial relationship with a commercial interest

Background and aim The aim of the study was to assess efficacy and safety of endoscopic treatment in BS after pediatric LTx. MethodsResultsWe retrospectively reviewed data of patients with DDA who developed BS and underwent ERCP. Of 189 transplanted patients with DDA, strictures developed in 30 (16%). In this subgroup, the median age at LTx was 14.7 (1.5-17.6) and follow-up period was 3.9 (1.3-11.3). ABS were in 76% and NABS in combination with ABS in 24% of patients. Overall, 95 ERCP sessions (3.0 per patient) were performed with successful outcome in 22 (73%) cases. Duration of treatment was 9.1 (1.8-24.1) months. Five patients underwent surgical revision and three patients retransplantation (10%). Risk factors of endoscopy failure were HCV or HBV infection, prolonged CIT and treatment before 2007. The most common complications after ERCP were cholangitis (8.2%) and pancreatitis (4.2%). There were worse overall prognosis and higher risk of post-ERCP complications in NABS. ConclusionsERCP is safe and effective in the majority of patients with post-transplant duct-to-duct BS, and it is currently recommended as the first-line treatment.

BACKGROUND Biliary strictures (BS) are frequent after pediatric liver transplantation (LTx) and in spite of ongoing progress, they remain a significant cause of morbidity. In children, the majority of reconstruction is hepatico-jejunal anastomosis (HJA). The aim of this study was to analyze our experience in percutaneous transhepatic treatment of BS. MATERIAL AND METHODS Between 1998 and 2014, 589 (269 living donor) pediatric LTx were performed in our institution. We retrospectively reviewed clinical data of patients with HJA who developed BS and who underwent percutaneous transhepatic biliary drainage (PTBD). RESULTS Out of 400 patients with HJA, 35 patients developed BS. There were 27 cases (77%) of anastomotic BS (ABS) and 8 cases (23%) of multilevel BS (MBS). Ninety-two PTBD sessions (2.5 per patient) were performed, with successful outcomes in 20 cases (57%). Fifteen patients, after failed PTBD, underwent surgery which was successful in 11 cases. Overall good outcomes were achieved in 31 cases (88.5%). The most common complication of PTBD was cholangitis which occurred in 5.4% of the cases. We did not find any risk factors for PTBD failure, except for treatment occurring before 2007. CONCLUSIONS Percutaneous treatment is effective and safe in BS and is recommended as a first-line approach. The majority of patients in our study required multiple interventions, however, the overall risk of complications was low. Surgery is essential in selected cases and always should be considered if PTBD fails.

We read with interest the report by Usatin et al.1Usatin D. Fernandes M. Allen I.E. Perito E.R. Ostroff J. Heyman M.B. Complications of endoscopic retrograde cholangiopancreatography in pediatric patients; a systematic literature review and meta-analysis.J Pediatr. 2016; 179: 160-165Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar Although experience with endoscopic retrograde cholangiopancreatography (ERCP) in children is growing, there is a lack of well-documented ERCP safety information in children with chronic pancreatitis.1Usatin D. Fernandes M. Allen I.E. Perito E.R. Ostroff J. Heyman M.B. Complications of endoscopic retrograde cholangiopancreatography in pediatric patients; a systematic literature review and meta-analysis.J Pediatr. 2016; 179: 160-165Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar, 2Kolodziejczyk E. Jurkiewicz E. Pertkiewicz J. Wejnarska K. Dadalski M. Kierkus J. et al.MRCP versus ERCP in the evaluation of chronic pancreatitis in children: which is the better choice?.Pancreas. 2016; 45: 1115-1119Crossref PubMed Scopus (17) Google Scholar, 3Oracz G. Pertkiewicz J. Kierkus J. Dadalski M. Socha J. Ryzko J. Efficiency of pancreatic duct stenting therapy in children with chronic pancreatitis.Gastrointest Endosc. 2014; 80: 1022-1024Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar, 4Wejnarska K. Kolodziejczyk E. Wertheim-Tysarowska K. Dadalski M. Sobczynska-Tomaszewska A. Kierkus J. et al.The etiology and clinical course of chronic pancreatitis in children with early onset of the disease.J Pediatr Gastroenterol Nutr. 2016; 63: 665-670Crossref PubMed Scopus (16) Google Scholar The authors reviewed most of the known studies concerning ERCP and its safety in children. However, the authors did not cite our recent study.3Oracz G. Pertkiewicz J. Kierkus J. Dadalski M. Socha J. Ryzko J. Efficiency of pancreatic duct stenting therapy in children with chronic pancreatitis.Gastrointest Endosc. 2014; 80: 1022-1024Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar We reviewed our database of children with chronic pancreatitis with particular attention to complication rate of ERCP. Between 1988 and 2016, a total of 641 ERCP procedures were performed in 223 patients. Overall, 626 of 641 ERCP examinations (97.6%) resulted in successful cannulation of the pancreatic duct, with a complication rate of 3.1% (20 in 641 procedures). Post-ERCP pancreatitis was the most common complication, documented in 14 patients. Hemorrhage after papillotomy was observed in 3 patients. Perforation of the duodenal wall was observed in 1 patient. One examination was discontinued owing to sudden decrease in saturation. Furthermore, a lithotripter basket was broken in 1 patient and had to be evacuated with a salvage lithotripter. The successful completion of 98% of ERCP procedures in our group is comparable with the success seen in the adult population, and is similar to that found in other pediatric studies.1Usatin D. Fernandes M. Allen I.E. Perito E.R. Ostroff J. Heyman M.B. Complications of endoscopic retrograde cholangiopancreatography in pediatric patients; a systematic literature review and meta-analysis.J Pediatr. 2016; 179: 160-165Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar, 2Kolodziejczyk E. Jurkiewicz E. Pertkiewicz J. Wejnarska K. Dadalski M. Kierkus J. et al.MRCP versus ERCP in the evaluation of chronic pancreatitis in children: which is the better choice?.Pancreas. 2016; 45: 1115-1119Crossref PubMed Scopus (17) Google Scholar, 3Oracz G. Pertkiewicz J. Kierkus J. Dadalski M. Socha J. Ryzko J. Efficiency of pancreatic duct stenting therapy in children with chronic pancreatitis.Gastrointest Endosc. 2014; 80: 1022-1024Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar, 4Wejnarska K. Kolodziejczyk E. Wertheim-Tysarowska K. Dadalski M. Sobczynska-Tomaszewska A. Kierkus J. et al.The etiology and clinical course of chronic pancreatitis in children with early onset of the disease.J Pediatr Gastroenterol Nutr. 2016; 63: 665-670Crossref PubMed Scopus (16) Google Scholar Complications of Endoscopic Retrograde Cholangiopancreatography in Pediatric Patients; A Systematic Literature Review and Meta-AnalysisThe Journal of PediatricsVol. 179PreviewTo systematically review risks and summarize reported complication rates associated with the performance of endoscopic retrograde cholangiopancreatography (ERCP) in children during the past 2 decades. Full-Text PDF ReplyThe Journal of PediatricsVol. 186PreviewWe appreciate Dr Oracz's interest and for bringing these articles to our attention. We performed a comprehensive literature search of MEDLINE/PubMed, Ovid Embase, and Web of Science, which yielded 1642 unique articles. From this result, articles were screened and assessed for eligibility. Additionally, citations for included articles were hand searched to identify additionally resources. Full-Text PDF

Introduction Approximately 20% of cases of colorectal cancer are accompanied by acute colonic obstruction. While emergency colonic surgery is associated with high mortality and morbidity rates, placement of a self-expanding metal stent (SEMS) has been suggested as an alternative method. The SEMS placement can serve as either a definitive treatment in palliative cases or a bridge to surgery. Aim To summarize the experience of our center in the treatment of malignant colonic obstruction using SEMS placement. Material and methods A retrospective review was conducted of all patients who underwent a SEMS placement for colorectal stricture in the study period. The procedures were performed under fluoroscopic guidance with colonoscopic assistance, and uncovered stents were used in all patients. Results The study population consisted of 28 patients treated with SEMS placement due to malignant colonic obstruction. The majority of procedures were performed with palliative intent. The overall technical success rate was 96.5%, and clinical success was achieved in all of the successfully placed SEMSs. One fatal complication due to colonic perforation occurred. In the bridge-to-surgery group, all patients experienced tumor resection with no stoma creation. Conclusions The SEMS placement is an optimal treatment in the vast majority of acute colonic obstruction cases. Due to the possibility of potentially fatal complications, SEMS procedures should be performed by proficient endoscopists.

Objectives To systematically review risks and summarize reported complication rates associated with the performance of endoscopic retrograde cholangiopancreatography (ERCP) in children during the past 2 decades.Study design A systematic literature search of MEDLINE, Embase, and Web of Science from January 1995 to January 2016 was conducted for observational studies published in English. Studies reporting ERCP complications in patients <21 years without history of liver transplant or cholecystectomy were included. A summary estimate of the proportion of children who experienced complications following ERCP was derived via a random effects meta-analysis.Results Thirty-two studies involving 2612 children and 3566 procedures were included. Subjects' ages ranged from 3 days to 21 years. Procedures were performed for biliary (54%), pancreatic (38%), and other (8%) indications; 56% of ERCPs were interventional. The pooled complication rate was 6% (95% CI 4%-8%). Procedural complications included post-ERCP pancreatitis (166, 4.7%), bleeding (22, 0.6%), and infections (27, 0.8%). The pooled estimate of post-ERCP pancreatitis was 3% (95% CI 0.02-0.05), and other complications were 1% (95% CI 0.02-0.05). In the subgroup with neonatal cholestasis, the pooled complication rate was 3% (95% CI 0.01-0.07). Adult and pediatric gastroenterologists and surgeons performed the ERCPs. Available data limited the ability to report differences between pediatric-trained and other endoscopists.Conclusions Complications associated with pediatric ERCP range widely in severity and are reported inconsistently. Our review suggests 6% of pediatric ERCPs have complications. Further studies that use systematic and standardized methodologies are needed to determine the frequency and risk factors for ERCP-related complications.

Objectives: To evaluate the diagnostic accuracy of magnetic resonance cholangiopancreatography (MRCP) in the detection of chronic pancreatitis (CP)-specific changes in the pediatric population.Methods: The study included 48 children with pancreatic disorders subjected to both endoscopic retrograde cholangiopancreatography (ERCP) and MRCP within a 1- to 4-month interval. The sensitivity, specificity, positive predictive value, and negative predictive value of MRCP in the detection of CP-specific changes were determined using ERCP as a diagnostic standard.Results: Diagnostic ERCP pancreatograms were obtained in 41 (85.4%) of 48 patients and diagnostic MRCP images in all 48 children. The sensitivity and positive predictive value of MRCP were 77.1% and 90%, respectively, and its specificity and negative predictive value amounted to 50% and 27.3%, respectively. The patients with consistent results of MRCP and ERCP (ie, true-positive and true-negative cases) and individuals with incompatible results of the tests (ie, false-positive and false-negative cases) differed in terms of their median age at MRCP (14.17 vs 10.33 years) and median CP stage according to the Cambridge Scale (4 vs 2).Conclusions: Magnetic resonance cholangiopancreatography provides diagnostic information equivalent to ERCP in a large percentage of pediatric patients with CP and should be used as the imaging method of choice, especially if the likelihood of therapeutic intervention is low.

The success rate of ameliorating the preoperative symptoms of biliary dyskinesia in a pediatric population has been reported to be approximately 80%. The purpose of this study was to identify patient characteristics that may help to predict successful clinical outcomes in pediatric patients with biliary dyskinesia by comparing 2 groups of pediatric patients: those who underwent cholecystectomy and those who received no surgical intervention (control group).The medical charts of pediatric patients who had an ejection fraction of less than 35% and no other identifiable abnormalities revealed on diagnostic testing were retrospectively reviewed. Information regarding psychological diagnoses/treatment, diagnostic examination findings, histologic findings, and outcomes were collected. Patients were evaluated at 1 month and 2 years postoperatively.From 1995 through 2003, 55 pediatric patients were identified. All patients had an abnormal ejection fraction on hepatobiliary iminodiacetic acid scan. The patients were divided into 2 groups: those who underwent cholecystectomy (n = 35) and a control group who did not receive surgical intervention (n = 20). Of those who underwent cholecystectomy, 74% improved, whereas 75% of the control group showed improvement after 2 years. Of all patient characteristics evaluated, only weight loss was found to be significant for determining patient outcomes.When followed for a long enough period of time, outcomes were similar between the 2 groups. Of the patients whose symptoms improved, those who underwent cholecystectomy had a quicker resolution of abdominal pain than those who did not undergo surgery. With the exception of weight loss, none of the patient characteristics evaluated in this study proved to be statistically significant for predicting a positive outcome.

Objective Endoscopic submucosal dissection (ESD) has a high curative resection rate for gastrointestinal mucosal lesions, but is not used widely in Europe because of a high complication rate and a long learning curve. This study analyzed the ESD learning curve at a single European treatment center. Materials and methods ESD and hybrid-ESD (hESD) procedures were used to treat large colonic lesions that could not be resected in one piece by other endoscopic methods. Procedure duration and speed, and en-bloc, complete (R0) resection, and complication rates were analyzed. Results Fifty-three patients underwent ESD (37 pure ESD, 16 hESD), most with rectal lesions (n=34, 64.2%). The mean lesion diameter was 3.7±1.1 cm (range 2.0–7.0 cm), the median procedure duration was 70.0 min [interquartile range (IQR) 31.0–113.0 min], and the median treatment speed was 0.086 cm2/min (IQR 0.055–0.152). En-bloc and R0 resection rates were 86.5% (32/37) and 81.1% (30/37), respectively. Procedure speed increased significantly after about 25 cases (P=0.0313). The median hESD procedure treatment speed was 0.159 cm2/min (n=16, IQR 0.094–0.193), which was better than with classical ESD (P=0.04). The hESD en-bloc and R0 resection rates were comparable to those of classical ESD (P>0.05). The only complication was bleeding, 5.7% (3/53); no perforation occurred. Recurrence was detected during follow-up (median 30.0 months, IQR 12–48) in one patient (1.7%). Conclusion ESD is useful and safe for resection of large colorectal polyps, and procedure speed increased considerably after 25 procedures. hESD was faster than ESD, with a high therapeutic resection rate.

AIMTo investigate the indications, resection rate, and safety of endoscopic submucosal dissection (ESD) for neoplastic lesions in the gastrointestinal tract at a European referral center.METHODSWe carried out a retrospective analysis of the ESD procedures performed in our center for mucosal neoplastic and submucosal lesions of the gastrointestinal tract. The duration of the procedure, en bloc and complete (R0) resection rates, and complication rates were evaluated. Variables were reported as mean ± SD or simple proportions. Univariate analysis and comparisons of procedure times and resection rates were performed using Mann-Whitney U tests, or χ(2) tests for dichotomous variables.RESULTSBetween 2007 and 2011, ESD was performed in a total of 103 patients (46.7% male, mean age 64.0 ± 12.7 years). The indications for the procedure were epithelial tumor (n = 54), submucosal tumor (n = 42), or other (n = 7). The total en bloc resection rate was 90.3% (93/103) and R0 resection rate 80.6% (83/103). The median speed of the procedure was 15.0 min/cm(2). The complete resection rate was lower for submucosal tumors arising from the muscle layer (68%, 15/22, P < 0.05). Resection speed was quicker for submucosal tumors localized in the submucosal layer than for lesions arising from the muscularis propria layer (8.1 min/cm(2) vs 17.9 min/cm(2), P < 0.05). The R0 resection rate and speed were better in the last 24 mo (90.1%, 49/54 and 15.3 min/cm(2)) compared to the first 3 years of treatment (73.5%, 36/49, P < 0.05 and 22.0 min/cm(2), P < 0.05). Complications occurred in 14.6% (n = 15) of patients, including perforation in 5.8% (n = 6), pneumoperitoneum in 3.9% (n = 4), delayed bleeding in 1.9% (n = 2), and other in 2.9% (n = 3). Only one patient with delayed perforation required surgical treatment. During the mean follow-up of 26 ± 15.3 mo, among patients with R0 resection, recurrence occurred in one patient (1.2%).CONCLUSIONESD is an effective and safe method for resection of neoplastic lesions with low recurrence. Speed and the R0 resection rate increased after 50 procedures.

INTRODUCTION Narrow-band imaging (NBI) is a new, promising technique that might be helpful in the detection of colorectal polyps during colonoscopy.OBJECTIVES The aim of the study was to compare the usefulness of NBI with white-light endoscopy (WLE) for the detection of polyps as well as to determine the distribution of missed polyps.PATIENTS AND METHODS This was a randomized controlled trial. A total of 253 patients were included, in whom colonoscopy was performed twice: 126 patients underwent 2 procedures using white light, while in 127 patients NBI was used for the second procedure. The number and location of colorectal polyps identified during the second colonoscopy were recorded.RESULTS No significant differences were observed in the rates of detected polyps, adenomas, and hyperplastic polyps between the WLE and NBI groups (38 vs. 48, P < 0.2051; 11 vs. 19, P < 0.12; 27 vs. 29, P < 0.4647, respectively). A half of all missed adenomas (n = 15) were found in the cecum and the ascending colon.CONCLUSIONS WLE and NBI seem to be equally effective in identifying missed adenomas and hyperplastic polyps during colonoscopy. Repeated endoscopy of the cecum and ascending colon may significantly increase the number of detected adenomas.

BACKGROUND:Endoscopic submucosal dissection (ESD) is a well-accepted method for removing superficial mucosal tumors; however, there is limited data on the use of this method for removing subepithelial tumors. OBJECTIVE:To investigate the efficacy, safety, and outcome of ESD for gastric subepithelial tumors and determine factors related to treatment success. DESIGN:Retrospective analysis of a prospectively maintained database. SETTING:Single tertiary academic center. PATIENTS AND INTERVENTIONS:From April 2007 to November 2010, 37 patients with gastric subepithelial tumors were treated with ESD. MAIN OUTCOME MEASUREMENTS:Macroscopically and microscopically complete en block resection rate (R0), complication rate, and endosonographic features predictive of R0 resection. RESULTS:The median tumor diameter was 25.0 mm, (range 10-60 mm, IQR 17-37). The overall rate of R0 resections was 81.1% (30/37, 95%CI: 61.8-90.2%), including 100% (15/15, 95%CI: 78.2-100.0%) of tumors from the submucosa and 68.2% (15/22, 95%CI: 45.1-86.1%) of tumors from the muscularis propria. Seventeen patients had a final diagnosis of gastrointestinal stromal tumor. The severe complication (perforation) rate was 5.4% (2/37, 95%CI: 0.0-9.5%). One patient required surgery; the other was treated conservatively. No recurrence was observed in patients with R0 resections at a median follow up of 21.0 months (IQR 11-35). Successful R0 resections were predicted by the observation of no, or only narrow, tumor connections with the underlying muscle layer during EUS (OR=35.0, 95%CI: 3.7-334.4, p=0.001). LIMITATIONS:Single-center, retrospective analysis, short follow-up. CONCLUSIONS:ESD is an effective and relatively safe method for removing gastric subepithelial tumors. Endoscopic ultrasonography findings can predict complete tumor resections.