Introduction

Management of poscholecystectomy complications has been variably discussed. Various options exist but the recent trend has been towards the endoscopic retrograde approach favoring a simultaneous diagnostic and therapeutic potential.

Aims & Methods

The outcome of endoscopic biliary dilatation and stent insertion for postoperative bile duct injuries was retrospectively evaluated.
Seventy-nine patients with biliary stenosis postcholecystectomy laparoscopic were included from January 2015 to December 2024. One to five stents were inserted for average of 12 months, with stent exchange every three months to avoid chlolangites caused by obstruction.

Results

Endoscopic stricture stent insertion successful was achieved in 76/76 (100%) patients. No procedure-related mortality was observed. The endoscopic therapy was feasible only in 76/76 the success rate was 100%. Endoscopic treatment was interrupted in three patients. Stricture relapse occurred in nine patients. Early complications occurred in three patients (1 perfuration, 1cholangites 1 stent migration) and stent occlusion that required early exchanges occurred in 6 patients.

Conclusion

Endoscopic retrograde cholangiopancreatography is a safe and feasible mode of therapy for patients presenting with suspected bile duct injuries. This form of intervention should be considered as the initial step in the diagnosis and treatment of postchlocystectom laparoscopic complications.

Disclosure

No conflict of interest

Introduction

Pre-cut sphincterotomy are most often used as a salvage procedure after failure of conventional methods of bile duct cannulation although its success is not guaranteed.　
When we performed initial pre-cut sphincterotomy, papilla is incited, with needle knife or sphincterotome, until the opening of bile duct is recognized to gain access to its lumen.
Our technique, in cases of not recognized the opening of bile duct, involves engaging the exposing underlying submucosal tissue layer of the papilla with the catheter and then seeking bile duct with the hydrophilic guide wire, completely dependent on fluoroscopic view.
The purpose of this study was to assess the efficacy and safety of our technique in cases of failed pre-cut.

Aims & Methods

We retrospectively analyzed the clinical records of consecutive patients undergoing ERCP between 1 January 2009 and 31 October 2024 at Mitsui Memorial Hospital, Tokyo, Japan.
Patients who underwent an ERCP plus pre-cut were included.
Patients were divided into two groups, in whom the common bile duct could be cannulated (Group A), and the common bile duct could not be cannulated and our technique was performed(Group B), after initial pre-cut.
The primary objective was a successful biliary cannulation, and the secondary objective was the complication in group B.
The complications and patient characteristics were compared between group A and B using Fisher’s exact test.

Results

Over a period of fourteen years ten months, 262 Pre-cut sphincterotomy (Needle knife sphincterotomy 108, Transpancreatic septotomy 126, Both 28) were performed. After initial pre-cut, we could achieve biliary access in 183 (Group A), and could not in 79. We performed our technique in 77 among these 79(group B).
In Group B, the therapeutic indications for ERCP were choledocholithiasis in 44 (57.1%) of cases, malignant and benign biliary obstruction in 29(37.7%) and 4(5.2%). The average age of the patients was 73 years (range 29-96) and 45 (58.4%) were male. Among 77 patients, a successful biliary cannulation was achieved in 72 (93.5 %). Complications were 15(19.5%). 2 patients presented bleeding (2.6 %) and required endoscopic treatment and transfusion of red blood cells. 9 (11.7 %) patients developed post-ERCP pancreatitis (1 severe, 8 mild pancreatitis). Guidewire related perforations that were resolved with conservative management occurred in 4(5.2%).
Alerted anatomy status was more frequently observed in group B than group A (p < 0.01). The other characteristics of both groups were similar. Total complications were more frequently observed in group B (p ＝ 0.03).

Conclusion

Our technique in cases of failed pre-cut sphincterotomy is found to be highly effective method to get biliary access, but carried a higher adverse event rate.

Clinical Case Summary

This case describes a middle aged female patient who had a background of liver transplant due to primary sclerosing cholangitis two years previously. She presented with a 3 week history of worsening right upper quadrant pain, lethargy and discharge from her surgical wound. As part of her work up she underwent a computer tomography (CT) scan that showed a retrohepatic soft tissue mass with enlarged surrounding lymph nodes.
The differential for this lesion was wide but most radiologically in keeping with post transplant lymphoproliferative disease (PTLD) or a haematoma. However, biopsy and tissue analysis revealed a surprising result as the histology showed Actinomycosis.
Unfortunately follow up CT scan at 5 months showed progression of the lesion that was now abutting the inferior vena cava. Given the technically challenging site of the lesion, it was not felt amenable to surgical resection. A lymph nodes was arranged to rule out dual pathology, which again demonstrated Actinomycosis.
In view of the above, the patient has been treated with a prolonged course of broad spectrum antibiotics and remains closely followed up by the Hepatology and Infectious Diseases departments.
Hepatic Actinomycosis presents with vague non specific symptoms including RUQ pain, lethargy and raised LFTs.
There are multiple causes of soft tissue hepatic masses with lymphadenopathy in a liver transplant recipient, including Hepatic Actinomycosis, and so early tissue diagnosis should be considered.
When treated via antimicrobial therapy alone, Hepatic Actinomycosis shows a delayed response and requires surveillance imaging and a prolonged course.

References

1. NHS Blood and Transplant. Annual Activity Report - ODT Clinical - NHS Blood and Transplant 2020-2021 [Available from: https://www.odt.nhs.uk/statistics-and-reports/annual-activity-report/.
2. Chegini Z, Didehdar M, Tabaeian SP, Khoshbayan A, Shariati A. A systematic review of case reports of hepatic actinomycosis. Orphanet J Rare Dis. 2021;16(1):192.
3. Yang XX, Lin JM, Xu KJ, Wang SQ, Luo TT, Geng XX, et al. Hepatic actinomycosis: report of one case and analysis of 32 previously reported cases. World J Gastroenterol. 2014;20(43):16372-6.
4. Laish I, Benjaminov O, Morgenstern S, Greif F, Ben-Ari Z. Abdominal actinomycosis masquerading as colon cancer in a liver transplant recipient. Transpl Infect Dis. 2012;14(1):86-90.

Introduction

Crohn’s disease (CD) is a chronic inflammatory disorder of the gastrointestinal tract often complicated by intestinal strictures. Accurate differentiation between inflammatory and fibrotic strictures is essential for guiding therapeutic strategies but remains challenging with current diagnostic tools. The capability of greyscale intestinal ultrasound (IUS) alone for characterizing inflammation versus fibrosis in CD strictures is not accurate enough to be used in clinical practice. This study investigates the diagnostic utility of advanced ultrasound techniques, including shear wave elastography (SWE), MV-Flow Doppler, and the Limberg score (LS), in the evaluation of strictures in patients with CD.

Aims & Methods

A prospective cross-sectional study enrolled 15 consecutive patients with ileal and ileocolonic CD scheduled for surgery due to symptomatic strictures. Each patient underwent intestinal ultrasound, including SWE, MV-Flow Doppler imaging, and LS assessment of the stenotic segment, within one week before surgery. Histopathological analysis of resected bowel specimens was then performed to grade inflammation and fibrosis according to a semiquantitative scoring system. Statistical analysis evaluated the correlation between ultrasound parameters and histological findings.

Results

SWE reliably differentiated fibrotic grades, with mean stiffness values significantly increasing from mild to severe fibrosis (P = 0.014). A cutoff of 24.85 kPa distinguished mild from moderate/severe fibrosis with 83.33% sensitivity and 88.89% specificity (AUC = 0.944). Conversely, SWE did not significantly distinguish between grades of inflammation (P = 0.643). MV-Flow Doppler values strongly correlated with histological inflammation grades (P = 0.007), with mean microvascular percentages increasing from 8.1% (mild inflammation) to 36.2% (severe inflammation). The LS also demonstrated high diagnostic accuracy for severe inflammation (AUC = 0.910, sensitivity 80.0%, specificity 90.0%).

Conclusion

This study underscores the complementary roles of SWE, MV-Flow, and LS in characterizing strictures in CD. SWE excels in assessing fibrosis, while MV-Flow and LS provide sensitive measures of inflammation. The integration of these modalities with conventional greyscale IUS offers a comprehensive and non-invasive approach to optimize diagnosis and management of CD strictures. Future research should validate these findings in larger, multicenter studies and explore their longitudinal applications.

Introduction

Metabolic-dysfunction-associated-steatotic liver disease (MASLD) affects more than half of obese subjects. To date, weight reduction by diet and physical activity is recommended to improve liver injury. Recent studies have shown that bariatric surgery induces stable weight loss and ameliorates metabolic parameters.

Aims & Methods

The aim of this study is to evaluate the effect of bariatric surgery on liver steatosis and fibrosis.
This is a monocentric prospective study including all patients with severe obesity and MASLD candidates for bariatric surgery in a single Italian-center. Other causes of chronic liver disease were an exclusion criteria. Clinical and biochemical data were collected. Liver fibrosis and steatosis were non-invasively assessed with Liver Stiffness Measurements (LSM) and Controlled Attenuation Parameter (CAP) by Fibroscan at three time-points: before surgery, 6- and 12-months after surgery.

Results

A total of 112 patients (63.4% female, mean age 41.5 years) were enrolled. Before bariatric surgery, the BMI was 43.6±6.2kg/m², the LSM was 8±5.8kPa and the CAP was 319.7±57.8dB/m. Ninety-six patients continued follow-up up after surgery. These patients demonstrated a significant reduction in BMI and CAP as early as 6-months post-surgery, while a significant decrease in LSM was observed only after 12-months. Specifically, the mean BMI was 31.9±5.1kg/m² after 6 months and 28.0±3.5kg/m² after 12-months, representing an overall decrease of 35.9% from baseline (p<0.0001). The mean CAP was 264.5±57dB/m after 6-months and 214.8±47.8dB/m after 12-months, reflecting an overall decrease of 32.8% from baseline (p<0.0001). Finally, the mean LSM was 6.3±2.5kPa after 6-months and 5.8±1.9kPa after 12-months, showing an overall decrease of 21.6% from baseline (p=0.02).

Conclusion

This study demonstrated a significant weight loss and liver steatosis decrease already at 6-months after surgery, while liver fibrosis reduction takes longer at 12-months after surgery. Therefore, in adults with MASLD and severe obesity, bariatric surgery should be considered as a valid therapeutic option for improving the liver damage.