Clinical Case Summary

A 65-year-old woman with previous diagnoses of lung adenocarcinoma treated with radiotherapy and pancreatic head adenocarcinoma requiring placement of covered metal stent for biliary drainage was admitted with acute cholangitis. An abdomino-pelvic computed tomography (CT) scan revealed proximal migration of the biliary stent. First attempt of ERCP was failed due to esophageal stenosis secondary to ulcer that obstructed the passage of the duodenoscope. Biopsies of the ulcer ruled out malignancy. Fully covered metal esophageal stent was placed and fixed with endoscopic suture. Subsequently, the duodenoscope was introduced through the esophageal stent, progressing to the papillary area. Using cholangioscopy, biliary stent inside the proximal biliary tract was identified and removed using biopsy forceps. Another covered metal biliary stent was placed with a double pig-tail stent inside to prevent migration. Esophageal stent was removed a month later without complications. Patient recieved neodjuvant chemotherapy and was perfomed a pancreaticoduodenectomy and is now in clinical remission.

References

Dumonceau JM, Tringali A, Papanikolaou IS, et al. Endoscopic biliary stenting: indications, choice of stents, and results: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline - Updated October 2017. Endoscopy. 2018;50(9):910-930. doi:10.1055/a-0659-9864
Tringali A, Lemmers A, Meves V, et al. Intraductal biliopancreatic imaging: European Society of Gastrointestinal Endoscopy (ESGE) technology review. Endoscopy. 2015;47(8):739-753. doi:10.1055/s-0034-1392584

Introduction

Endoscopic biliary stenting is a well–established therapy in the management of hepatobiliary diseases. However, migration is reported in 5%-10% of cases. Management of proximally migrated stents using standard techniques(guidewire cannulation, snare, forceps, Schohenra stent retriever) can be technically challenging sometimes. Cholangioscopy and retrieval under direct visualization could be a useful tool in such difficult cases.

Aims & Methods

To evaluate the application of single-operator cholangioscopy in the management of proximally migrated biliary stents in terms of efficacy and safety.
Methods:We performed a retrospective analysis of the data of a prospective group of patients. The cohort included consecutive 100 cases of proximally migrated stents from January 2018 through March 2024. We evaluated the retrieval technique, success rate, and adverse events.

Results

Patients were divided into two groups. In the first collective of patients- cholangioscopy was not performed n=62/62%/. We found a technical success rate – defined as successful stent extraction in 69,35% of cases/n=43/. In 19 of the cases removal was not achieved, followed by placement of new plastic stent n=19/30.65%/.In the second group, n=38/38%/ cholangioscopy with single operator cholangioscope was the retrieval technique with a technical success rate of 100%. There was a statistical difference between the two groups in terms of technical success in favor of the group with cholangioscopy - Pearson chi-square χ 2 =21.534, p< 0.001. Cholangioscopy was performed either after the failure of standard techniques or as the first-choice tool for stent removal. In five cases we performed pancreatoscopy for extraction of migrated pancreatic stents with only one case of postprocedure pancreatitis. We experienced adverse events/AE/ in 17 cases as pancreatitis was the most common complication n=11/64,71% of all AE/, followed by cholangitis n=5/29,41% of all AE/ and one case of bleeding n=1/5,88%/. In the first group, the rate of adverse events was 17,74%/n=11/ against 13,95%/n=6/ for the second group. There was no significant statistical difference in the rate of AE between the two groups. The mean procedure duration was 34,35 minutes for the first group and 42,24 minutes for the second with a statistically significant difference p=0.029 in favor of the first group. However, it is important to note that in some cases cholangioscopy was performed after the failure of standard techniques which by ilself prolonged the procedure time.

Conclusion

Cholangioscopy is a safe and effective technique for the extraction of migrated biliary stents with a high rate of efficacy and an acceptable rate of adverse events. It could be proposed as a first choice in cases where failure of standard techniques is suspected/persistent stenosis, residual bile duct stones/.

Clinical Case Summary

Biliary pathology is a frequent motive for consultation in hospitals, and abdominal ultrasound is the first line-imaging test for its study. The genetic syndrome LPAC (Low Phospholipid-Associated Cholelithiasis) leads to the development of intrahepatic lithiasis. In this syndrome, there is a decrease in biliary phospholipids secretion caused by a mutation in the ABCB4 gene, responsible for a dysfunction of the MDR3 transporter. Despite being considered a rare entity, it accounts for 1-5% admissions for biliary pathology, affecting young women more frequently.
Two of three clinical criteria must be met for its diagnosis: symptoms onset before the age of 40, recurrence after cholecystectomy and compatible ultrasound appearance (presence of intrahepatic hyperechogenic spots, &quot;comet tail&quot; images or intrahepatic lithiasis with acoustic shadowing). Identification of the ABCB4 gene mutation is not a diagnostic criterion since it only appears in 50% of patients. Medical treatment with ursodeoxycholic acid is effective and cholecystectomy can be avoided.
We present a 23-year-old male who consulted for epigastric pain associated with vomiting. Laboratory tests showed elevation of amylase greater than three times above the upper limit of normal, which allowed the diagnosis of acute pancreatitis. Liver profile, calcium and triglycerides were within normal limits. The patient had no previous alcoholic intake. Abdominal ultrasound ruled out cholelithiasis but identified multiple intrahepatic hyperechogenic spots and &quot;comet tail&quot; signs. The patient was diagnosed with LPAC syndrome and treatment with ursodeoxycholic acid was initiated. During follow-up he did not present new episodes of biliary symptomatology.
The detection of the typical ultrasound signs of LPAC syndrome is the main tool for its suspicion. This disease is not as uncommon as it may seem, so it is essential to think about it in order to make a correct diagnosis and treatment of these patients.

References

Ultrasound image of intrahepatic lithiasis

Introduction

Currently, we can reliably and non-invasively determine steatosis and liver fibrosis by CAP/ATI/PDFF and ET/2D-SWE/MRE, respectively. However, it is not possible to accurately determine the inflammatory component without biopsy. In addition to 2D-SWE and Attenuation Imaging, some new multiparametric US devices incorporate the tissue viscosity-dependent 2D-SWD dispersion slope parameter. The liver is not a purely elastic but a viscoelastic organ, so that 2D-SWD measurement could be useful in the determination of necroinflammation. Our aim was to evaluate the correlation of SWD with the inflammatory component of MAFLD.

Aims & Methods

Prospective study. Immediately prior to liver biopsy (Tru-Cut 16G) in patients with suspected MAFLD, SWD (Canon Aplio i800) was performed. Exclusion criteria were: liver biopsy length <1.5 cm/<11 portal tracts, absence of MAFLD on final biopsy result (steatosis <5%). MAFLD was classified according to NASH-CRN. Normally distributed quantitative variables were described using the mean; otherwise, the median was calculated.

Results

112 patients were included: age 53 years, women 55%, BMI 30.9 kg/m², diabetes 39%, GPT 62 U/L. Biopsy: 2.5 cm, 14 portal spaces. Fibrosis distribution was: F0 53 (46%), F1/F2 37 (32%), F3/F4 25 (22%). Steatosis distribution was: S1 35 (34%), S2 30 (29%), S3 39 (37%). Steatohepatitis: definite 52 (45%), absent 47 (41%), indeterminate 16 (14%). SWD values showed statistically significant differences between patients without steatohepatitis/indeterminate vs. steatohepatitis (13 (m/s)/KHz vs. 13.750 (m/s)/KHz; p=0.015). A positive linear correlation was also observed between SWD and NAS score (rho = 0.216; p=0.028). For the lobular inflammation component, a value of 14.5 (m/s)/KHz had Esp 89.5%, PPV 93.1%, while 10.5 (m/s)/KHz had Sens 90.5%, NPV 80.9%.

Conclusion

The SWD dispersion parameter determined by mulparametric ultrasound could be useful in the non-invasive assessment of liver inflammation and the diagnosis of steatohepatitis in MAFLD patients.

Introduction

The endoscopic transpapillary bile duct brushing cytology and biliary forceps biopsy with endoscopic retrograde cholangiopancreatography are generally performed for pathological diagnosis of biliary strictures. The sensitivity of the conventional cytology and biopsy was reported to be 30% to 81%. The diagnosis of biliary strictures may not be reached, especially of those caused by pancreatic cancer.

Aims & Methods

The Trefle (Piolax Medical Devices, Yokohama, Japan) is a new device that consists of looped metallic wires to scrape and aspirate the tissue along with bile juice. The aim of the study was tocompare the diagnostic performance of the new device with that of conventional cytology and biopsy. A total of 264 cases with biliary stricture underwent transpapillary biopsy and cytology between 2012 and 2021, of which 124 were diagnosed using the new device. We retrospectively analyzed the diagnostic utility of the new device compared with that of conventional cytology and biopsy.

Results

The locations of biliary strictures were perihilar in 73 cases and distal in 191 cases. Of the 264 cases, 195 were diagnosed with a malignant stricture. 122 cases had biliary cancer, whereas 72 had pancreatic cancer. The sensitivity of the new device and the conventional cytology and biopsy was 61% and 55%, respectively. Adding a biopsy to the new device increases the sensitivity to 89%. In the cases with biliary strictures caused by pancreatic cancer, the sensitivity of the new device and the conventional cytology and biopsy was 49% and 39%, respectively.

Conclusion

Our study suggests that the new device was more useful than conventional cytology and biopsy for the pathological diagnosis of biliary strictures, especially those caused by pancreatic cancer. Adding a biopsy to the new device to the new device is expected to increase sensitivity.

References

1) Sakuma Y, Kodama Y, Sogabe Y et al. Diagnostic performance of a new endoscopic scraper for malignant biliary strictures:a multicenter prospective study. Gastrointest Endosc 2017; 85: 371-9.
2)Meara R S, Jhala D, Eloubeidi M A et al. Endoscopic ultrasound-guided FNA biopsy of bile duct and gallbladder: analysis of 53 cases. Cytopathology. 2006;17:42–9.

Disclosure

No COI

Introduction

Biliary strictures are defined as narrowing in the intrahepatic or extra hepatic biliary system, resulting in upstream dilatation, stagnant bile flow, ultimately causing biliary obstruction. Patients may present with a variety of symptoms including jaundice, pruritis, weight loss, along with development of recurrent cholangitis, stone formation and liver abscesses. This results in immediate and long term morbidity and mortality. It therefore warrants immediate investigation and treatment. In ERCP, endoscopic techniques exist that allow strictures to be traversed. These include wire guided catheter techniques, balloon dilators and stent placement. When traditional techniques fail, Soehendra stent retriever can be used.

Aims & Methods

Patients with evidence of benign/malignant biliary or pancreatic stricture were retrospectively analyzed. The pancreatic or biliary strictures allowed passage of 0.035 inch guidewire, without allowing passage of >5.5fr cannultomes, 5.8fr balloon dilators, or sohendra stricture dilator. After successful biliary cannulation and guide wire access, a SSR would be passed through the wire to the distal end of the stricture. The SSR handle would be rotated clockwise, allowing the SSR to cross the stricture. Once the stricture is dilated, a stent would then be placed.

Results

A total of 72 patients were analyzed. Of these, 38 (52%) were female and 35 (48%) were male. The average age was 44.8 years. Predominant symptoms included jaundice in 36 (50%) patients, and abdominal pain in 35 (48.6%). A total of 59 (81.9) ERCPs were for biliary strictures, and 13 (18%) were for pancreatic strictures. The predominant findings prior to biliary ERCP included evidence of CBD stricture in 31(52%) cases, unspecified obstructive jaundice in 30 (50.8%) cases, peri-ampullary growth in 13 (22%) patients, and cbd stones in 11 (18%) patients. The main indication for pancreatic ERCP was Chronic Pancreatitis in 100% cases. Out of the 72 patients, 2 (2.7%) developed brief hemobilia during ERCP controlled spontaneously. No patient was demonstrated to have major bleed. No evidence of duct injury, evident by dye extravastion, or perforation was observed. A stent could not be passed in 7 cases (9.7%) despite SSR traversing stricture.

Conclusion

SSR is a useful device for crossing biliary and pancreatic stricture that otherwise could not be negotiated with established techniques. It is safe, and tolerable ​for strictures defying conventional wire guided techniques

Introduction

Anastomotic biliary strictures represent a significant burden after orthotopic liver transplantation, with challenging endoscopic treatment. The selection of the optimal approach regarding type of stents remains controversial due to the absence of strong evidence. The European Society of Gastrointestinal Endoscopy recommends stricture remodeling using multiple plastic stents (MPS),¹ whereas the American College of Gastroenterology supports the use of fully covered self-expandable metal stents (FC-SEMS),² as for every benign biliary stricture. In the absence of cumulative comparisons and considering the development of intraductal SEMS (ID-SEMS), which are promising for this type of strictures, this systematic review with meta-analysis aimed to evaluate the potential differences in the performance of the available stents in post-transplant anastomotic biliary strictures management.

Aims & Methods

The systematic research was performed in MEDLINE, Cochrane, and Scopus databases until April 2023 for comparative studies evaluating the successful stricture management using MPS and SEMS, including FC-SEMS and ID-SEMS. The primary outcome was stricture resolution after completion of therapy, documented by cholangiogram or cross-sectional imaging. Secondary outcomes included stricture recurrence (clinical and biochemical relapse with imaging confirmation) during the follow-up period, stent migration and adverse events. Quality assessment was based on the Newcastle-Ottawa scale. Meta-analyses were based on random effects model and the results were reported as odds ratios (OR), with 95% Confidence Intervals (95%CI). Subgroup analyses by type of metal stent were performed to explore the diversity among the results of different studies.

Results

Nine studies with an overall number of 687 patients were included in our analysis, with three of them being randomized controlled trials. Metal stents were placed in 251 cases (82 ID-SEMS and 169 FC-SEMS) and MPS in 436. Considering the primary outcome, metal and plastic stents did not differ significantly in stricture resolution with OR: 0.99 (95%CI: 0.48-2.01; I²=35%). Stricture recurrence and migration rates were also comparable between the two arms [OR: 1.71 (95%CI: 0.87-3.38; I²=55%) and OR: 0.73 (95%CI: 0.32-1.68; I²=56%) respectively]. All of these outcomes presented with moderate heterogeneity. Finally, the difference between adverse events rates was non-significant [OR: 1.47 (95%CI: 0.89-2.43; I²=24%)]. Interestingly, in the subgroup analysis ID-SEMS provided significantly higher complete resolution rates with low heterogeneity compared to the MPS [OR: 3.48 (95%CI: 0.89-13.62; I²=5%)], whereas the comparison between FC-SEMS and MPS did not reach significance [OR: 0.76 (95%CI: 0.42-1.39; I²=11%)]. Relative recurrence rates did not differ between subgroups [for ID-SEMS vs MPS, OR: 1.01 (95%CI: 0.51-2.03; I²=0%; for FC-SEMS vs MPS, OR:2.39 (95%CI: 0.87-6.56; I²=66%)]. On the other hand, migration rates were significantly lower for ID-SEMS compared to MPS, with OR: 0.28 (95%CI: 0.11-0.70; I²=0%), and equivalent for FC-SEMS and MPS [OR: 1.25 (95%CI: 0.54-2.88; I²=40%)]. Complication rates were similar for ID-SEMS and MPS [OR: 0.90 (90%CI: 0.28-2.84; I²=47%)], but their prevalence after FC-SEMS were significantly higher compared to MPS [OR: 1.76 (95%CI: 1.06-2.93; I²=0%)].

Conclusion

The comparison between metal stents and MPS did not result to significant differences in any outcome. However, ID-SEMS appeared superior to MPS in stricture resolution and migration rates, whereas FC-SEMS provided comparable outcomes to MPS.

References

1. Dumonceau JM, Tringali A, Papanikolaou I, Blero D, Mangiavillano B, Schmidt A, et al. Endoscopic biliary stenting: indications, choice of stents, and results: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline – Updated October 2017. Endoscopy. 2018 Sep 7;50(09):910–30.
2. Elmunzer BJ, Maranki JL, Gómez V, Tavakkoli A, Sauer BG, Limketkai BN, et al. ACG Clinical Guideline: Diagnosis and Management of Biliary Strictures. American Journal of Gastroenterology. 2023 Mar;118(3):405–26.