Introduction

Endoscopic Retrograde Cholangiopancreatography (ERCP) is pivotal in managing complex biliary strictures due to various causes like Cholangiocarcinoma (CCA), Primary Sclerosing Cholangitis (PSC), and mass-related intrahepatic strictures. Traditional ERCP relies on two-dimensional (2D) X-ray imaging, which often presents challenges in accurately localizing and selectively cannulating specific intrahepatic ducts. This study aims to assess the feasibility and effectiveness of three-dimensional (3D) fluoroscopic ERCP in diagnosing and treating complex biliary strictures.

Aims & Methods

We conducted a prospective pilot study, approved by the Institutional Review Board. Adult patients scheduled for ERCP for complex biliary strictures were enrolled. Exclusions included inability or unwillingness to consent, existing percutaneous biliary drainage, or unfeasible selective trans-papillary biliary cannulation.
Performance of 3D ERCP Patients were positioned on a 3D fluoroscopic table. ERCP followed standard protocols, with high-volume contrast injections opacifying bile ducts. After achieving full biliary tree opacification, a balloon was inflated in the distal bile duct in preparation for 3D imaging. To minimize radiation exposure to staff, the endoscope was fixed in a holder, and the room was evacuated before 3D image acquisition. These images were reconstructed to produce detailed 3D visuals of the target area, aiding real-time therapeutic maneuvers like selective intrahepatic duct cannulation.
Data Collection and Analysis Data included continuous variables (mean ± standard deviation) and categorical variables (percentages). Radiation exposure was quantified separately for ERCP and 3D reconstruction, using thermoluminescent dosimeters. Results were reported as Effective Surface Dose (ESD) in mGY and Dose Area Product in mGY.cm^2.

Results

Eighteen patients (median age 66.6) underwent 3D ERCP. 40% had a malignant biliary structure etiology, with 50% showing both intrahepatic and extrahepatic bile duct involvement. 3D reconstruction facilitated successful selective wire cannulation in 80% of cases, previously unachievable with conventional ERCP. One case provided crucial imaging for liver resection planning. The additional radiation dose was 16.44 mGY.cm².

Conclusion

This pilot study proves the feasibility of 3D ERCP in managing complex biliary strictures. This first-of-its-kind study highlights the utility of 3D reconstruction in ERCP. While significantly aiding selective intrahepatic duct cannulation and surgical planning for cholangiocarcinoma resections, it doubles the procedure's radiation exposure, potentially raising cancer risk to 1 in 1000. However the dose needed is significantly lower the IR guided biliary interventions.Further larger studies are required to evaluate the clinical efficacy of 3D ERCP.

Introduction

Hemorrhoidal disease (HD) is the most common pathology in proctology, with an estimated prevalence of between 4.4% and 39%. It can be managed in a variety of ways: hygienic-dietary measures, medical, instrumental or surgical treatment. The latter is considered especially after failure of medical and instrumental treatment.

Aims & Methods

Aims : The aim of our study is to report our experience with Milligan and Morgan technique in the management of hemorrhoidal disease.

Materials and methods: This was a monocentric retrospective descriptive-analytical study conducted over a 12-year period: from January 2011 to January 2023. The data studied were age, sex, clinical manifestations, stage of HD on proctological examination and therapeutic data. All patients who underwent Milligan and Morgan hemorrhoidectomy (MMH) and presented with stage IV and III hemorrhoids (after failure of instrumental treatment) were included in our study. Excluded were asymptomatic patients, patients with surgical contraindications and other stages treated by non-surgical means. The statistical study was carried out using IBM-SPSS 20.0 software. The chi-2 test was used to compare categorical variables.

Results

468 patients were enrolled during the study period. The mean age of this population was 41 years (22-71). The sex ratio M/F was 2,1. Clinical expression was dominated by rectal discharge in 246 patients (74%), proctalgia in 132 patients (28%), anal pruritus in 119 patients (25%) and anal oozing in 56 patients (12%). Proctological examination revealed stage IV haemorrhoids in 201 patients (43%) and stage III haemorrhoids in 267 patients (57%). 25 patients (5.3%) had an associated anal fissure. Anemia was present in 341 patients (72.8%), with a mean hemoglobin value of 7.8 g/dl. Transfusion was required in 65 patients (14%) who presented with severe anemia of less than 7g/dl. Colonoscopy was indicated in 87 patients (18.5%) over the age of 45 with rectal bleeding, and in 42 patients (9%) with a history of digestive cancer. Milligan and Morgan's indication was stage III hemorrhoids with severe anemia in 65 patients (14%), after failure of infrared photocoagulation in 194 patients (41.4%); after failure of HAL-RAR treatment n=8 (1.7%) and stage IV hemorrhoids in 201 patients (43%). The procedure performed was a hemorrhoidectomy.An open pedicle MMH type was performed. Patients with an associated anal fissure (5.3%) underwent the Bellan procedure in addition to hemorrhoidectomy. Immediate post-operative complications included post-operative pain in all our patients, urinary retention in 31 patients (6.6%), significant post-operative bleeding in 2 patients (0.5%) treated by electrocoagulation in the OR, and minimal post-operative bleeding in 117 patients (25%) treated by compression bandaging. The latter was reported in 43 patients (36.7%) with stage III hemorrhoids and 74 patients (63.2%) with stage IV hemorrhoids. This difference was statistically significant (p<0.001). Late complications included delayed healing in 9 patients (1.9%), 4 of whom were diabetic, anal stenosis in 5 patients (1%), requiring sphincterotomy combined with anoplasty in 3 patients, and finger dilatation in 2 patients. Anal stenosis was reported in 4 patients who did not undergo postoperative digital rectal examination and 1 patient who did. This difference is statistically significant p=0.03.

Conclusion

MMH remains the gold standard for the treatment of hemorrhoidal disease. The results are satisfactory, especially in the long term. Post-hemorrhoidectomy anal stenosis remains the most serious complication.

Introduction

The enhanced recovery after surgery (ERAS) protocol is an evidence-based standardised multimodal programme formulated to reduce surgical stress and optimise recovery after surgery. The ERAS represents the best care practice for patients undergoing colorectal surgery. To ensure high compliance with active ERAS elements, patients must be educated to actively participate in the perioperative care pathway. ERAS protocols were originally designed to treat patients with CRC, only few studies have assessed this protocol in IBD patients.

Aims & Methods

The aim of this study was to investigate the adherence to ERAS in IBD patients. This retrospective study enrolled adult patients who underwent elective colorectal surgery and the ERAS protocol at our institute between May 2020 and December 2022. The patients were divided into IBD and non-IBD group. Data on medical history were collected from electronic health records.Preoperative, intraoperative, and postoperative data were collected for each procedure using a self-reported mobile application. Adherence was calculated for at least 75% of active ERAS items. Chi-square test was used to compare categorical variables.

Results

619 patients, 492 non-IBD and 127 IBD, were enrolled. The overall adherence to ERAS protocol items was similar between the two groups (84% vs 82%, p 0.2). Adherence was evaluated during the three ERAS phases in the groups: preoperative (92% vs 90%, p 0.11), hospitalization (63% vs 62%, p 0.8), post-discharge period (96% vs 93%, p 0.2). Moreover, focusing on the preoperative ERAS items adhrence, there were significant difference between non-IBD and IBD group in nutritional optimization (84% vs 67%, p <0.001) and smart communication (93% vs 89%, p 0.002). No difference were reported in the patient’s prehabilitation adherence (74 % vs 71%, p 0.4).

Conclusion

Clinical Case Summary

A 28-year-old patient presented with recurrent episodes of overt gastrointestinal bleeding, requiring multiple blood transfusions over the past two months (5 units of packed red blood cells). Despite undergoing UGI endoscopy and colonoscopy twice at other medical centers, no abnormalities were detected. CT enterography with CT angiography yielded normal results. To further investigate, the patient underwent antegrade and retrograde power spiral enteroscopy, revealing gross active bleeding from a site of hookworm bite in the jejunum. Following the procedure, the patient was discharged with antihelminthic therapy. However, a week later, he experienced abdominal pain, difficulty passing stools, intermittent rectal bleeding again, and low-grade fever. A relook sigmoidoscopy revealed a large hematoma with intraluminal compression in the sigmoid colon. CT scan confirmed a localized sealed-off perforation along with the hematoma. Management included percutaneous aspiration of the hematoma, intravenous antibiotics, and repeat blood transfusion. Anti-helminthic therapy continued, and the patient recovered completely after approximately four weeks which was confirmed by sigmoidoscopy. The mechanism of this sigmoid colon hematoma involves potential mechanical injury by the overtube's spiral tip during insertion or manipulation. Although the localized perforation was sealed off in this case, the preceding bleeding and drop in hemoglobin complicated the initial treatment plan. Considering such technical challenges, the equipment and technology have now been withdrawn globally by the manufacturer. Close monitoring of patient symptoms, and vital signs, and prompt discontinuation of the procedure in case of discomfort or pain are crucial in preventing such complications. As advanced endoscopic techniques become more prevalent, maintaining a cautious approach towards technology and addressing complications promptly is essential for ensuring patient safety and effective care

Clinical Case Summary

We report the case of 20 year old female patient with Crohn's disease who was shifted to Combo therapy (Infliximab + Azathioprine) for failing to reach mucosal healing on Conventional treatment. Quantiferon test, virology panel and a CT chest were negative prior to therapy. After one year of treatment she presented with high grade fever, weight loss, and abdominal pain. COVID-19 PCR and CT chest were negative. However, quantiferon test was positive. CTE abdomen showed marked thickening and stricture in the ileocecal area. Colonoscopy (Video available) was done to obtain biopsies; serpiginous ulcers with narrowing were noted. Histopathological assessment showed heavy Inflammatory cells with no more specification. A gene Xpert PCR on the tissue biopsy was positive for MTB. Given the septic state of the patient biological therapy was held for the duration of her treatment. She started Anti-TB and improved as the fever subsided and she gained weight. Colonoscopy was re-attempted after 4 months of treatment to confirm resolution (Video available). An impassable fibrotic stricture was noted the biopsy forceps could however be introduced and biopsies were obtained. Gene Xpert test was negative. The patient was started on Ustekinumab monotherapy with good response.
TB infection in patients on Anti-TNF therapy is a well-recognized potential side-effect of these drugs. To the best of our knowledge, this is the first reported case of Ileocecal TB on top of Crohn’s disease. A major challenge was weighing how much of the active inflammation shown in the endoscopy, biopsy and imaging was due to TB infection and how much was because of Crohn's disease activity. The time to re-initiate therapy was difficult given that the patient's bad general condition before starting antimicrobial treatment. While recommendations suggest starting immunosuppressives after 8 weeks of treatment in active tuberculosis, the evidence support this in pulmonary rather than extrapulmonary tuberculosis.

Introduction

The incidence of pancreas cysts is increasing, and the use of EUS-guided through-the-needle-biopsy (EUS-TTNB) is gradually increasing for accurate diagnosis. However, studies including a large number of patients on clinical outcomes and safety of EUS-TTNB for pancreatic cysts are still lacking. In this study, we evaluated the diagnostic yield, adverse events(AE), and risk factors of AE related to EUS-TTNB in a large number of cohorts.

Aims & Methods

We reviewed the prospectively collected EUS-TTNB for pancreatic cysts database at Asan Medical Center, between January 2019 and December 2022. We analyzed technical success rate, diagnostic yield, AE, and risk factors for AE.

Results

A total of 248 patients were analyzed. Technical success could be achieved in 247 patients, except one patient (100%). Among them, 191 patients had a specific histologic diagnosis (diagnostic yield, 77.3%). There was no significant difference in diagnostic yield according to the number of biopsy specimen, the presence of septation in the cysts, the size of cysts, and location of cysts. AE occurred in 41 patients (16%), and there was no serious AE. Acute pancreatitis was the most common AE (12/248, 12%) following cyst hemorrhage (7/247, 3%). In univariate analysis on the risk factors of acute pancreatitis related to EUS-TTNB, male (HR 2.22, 95% CI: 1.02-4.83, P=0.045) and IPMN (HR 3.08, 95% CI: 1.35-7.03, P=0.01) were statistically significant. In multivariate analysis, IPMN (HR 2.75, 95% CI: 1.24-6.11, P=0.01) was the significant risk factor of acute pancreatitis after EUS-TTNB.

Risk factors of acute pancreatitis after TTNB

Conclusion

EUS-TTNB showed a relatively high technical success rate and diagnostic yield. IPMN was the most significant risk factor of AE related to EUS-TTNB.

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