Clinical Case Summary

Placement of self-expandable metal stents (SEMS) is a standard treatment in the palliation of unresectable malignant biliary obstruction, whereas multidisciplinary oncology treatment prolongs patient survival. Consequently, the likelihood of stent-related complications has increased. Distal migration is a rare cause of stent dysfunction and SEMSs are relatively hard to extract after insertion. We present the management of a patient with dislocated SEMS using argon plasma coagulation (APC).
An 88-year-old man with unresectable ampullary cancer and consequential biliary stricture underwent a transpapillary placement of a 6-cm-long, 10-mm diameter uncovered SEMS (uSEMS).
Twelve months later, he presented to our department with vomiting. Given the high index of suspicion for stent dysfunction, a duodenoscopy was performed. Direct endoscopic visualization showed a distal 3-cm-long migration of the uSEMS. The distal end of uSEMS was firmly impacted in the contralateral duodenal wall resulting in reactive tissue ingrowth narrowing both the stent and the duodenal lumen. Significant malignant duodenal obstruction was detected below the dislocated uSEMS.
Subsequently, it was attempted to trim the distal 2 cm of the stent using an axial APC probe (power setting 80W, gas flow 0,8 L/min). The trimmed stent was removed with biopsy forceps. The procedure lasted 20 min, without immediate complications and the patient was discharged within 2 days.
One month after the procedure, the patient was readmitted with recurrent vomiting. Endoscopy revealed duodenal stricture below the papilla of Vater, due to malignant disease progression. Therefore, an 8-cm-long, 20-mm diameter duodenal SEMS placement was performed under simultaneous endoscopic and fluoroscopic control and symptoms were soon relieved.
This case highlights endoscopic APC stent trimming as an efficient procedure, which allows easy, reproducible and well−tolerated management of migrated uSEMS-related complications.

References

Fig. 1. Dislocated uSEMS and reactive tumor ingrowth
Fig. 2. (a) Trimming of the distal end using APC (b) the remaining stent in situ

1. Yokode, M., Matsumori, T., Uza, N., Kuwada, T., Shiokawa, M., Maruno, T., & Seno, H. (2022). Usefulness of a circumferential argon plasma coagulation probe in trimming a dislocated distal biliary metal stent. Endoscopy, 54, E802–E803. https://doi.org/10.1055/a-1816-7903
2. Azevedo, R., Libânio, D., Bastos, P., Dinis Ribeiro, M., & Brandão, C. (2019). Going through the Mesh: Argon Plasma Trimming of a Metal Biliary Stent. GE Portuguese Journal of Gastroenterology, 26(4), 295–297. https://doi.org/10.1159/000493352
3. Ishii, K., Itoi, T., Sofuni, A., Itokawa, F., Tsuchiya, T., Kurihara, T., Tsuji, S., Ikeuchi, N., Umeda, J., Moriyasu, F., & Tsuchida, A. (2011). Endoscopic removal and trimming of distal self-expandable metallic biliary stents. World Journal of Gastroenterology, 17(21), 2652–2657. https://doi.org/10.3748/WJG.V17.I21.2652
McDonald, N. M., & Amateau, S. K. (2022). Jailbreaking a metal biliary stent through a duodenal stent. VideoGIE, 7(6), 226–228. https://doi.org/10.1016/j.vgie.2022.02.002
4. Vanbiervliet, G., Piche, T., Caroli-Bosc, F. X., Dumas, R., Peten, E. P., Huet, P. M., Tran, A., & Demarquay, J. F. (2005). Endoscopic argon plasma trimming of biliary and gastrointestinal metallic stents. Endoscopy, 37(5), 434–438. https://doi.org/10.1055/S-2005-860989

Introduction

Sarcopenia defined as having low muscle mass, muscle strength and if combined with low performance indicate severe sarcopenia¹. It is associated with adverse outcomes in cirrhosis, including hepatic encephalopathy, ascites, infection, and increased hospitalisation. Prevalence of sarcopenia has been reported between 40 to 70% and are more common with alcoholic liver disease².

Aims & Methods

We aim to assess relationship between nutritional status/assessment, muscle quality and sarcopenia. Cirrhotic patients were recruited from a tertiary-hepatology-clinic for this prospective cross-sectional study. BIA was performed as the standard (SECA mBCA-525) for nutritional status and sarcopenia assessment. Appendicular skeletal muscle mass (ASM) calculated through sum of limb muscle masses in kg. sarcopenia was diagnosed with ASM/height²<7.0 kg/m² and <5.5 kg/m² for male and female respectively. Muscle quality was measured by mean handgrip strength in kg divided by ASM (HGS/ASM). Validated functional muscle metrics (handgrip and sit-to-stand), liver-frailty-index (LFI)³, Chronic Liver Disease Questionnaire (CLD-Q)⁴ and food-frequency-questionnaire (FFQ) were also analysed.

Results

49 patients, 57% (28) alcohol-liver-disease, 18% (9) non-alcoholic steatohepatitis, 5% (4) viral, 4% (3) autoimmune and 7% (5) mixed aetiologies, were included. 44 healthy controls (HC) were recruited as well. Most patients were male (n=28, 57%), with mean age 56yrs (SD=9), mean Child-Pugh score 6 (IQR= 5-7) and MELD 10 (IQR= 7-12). 35% (n=17) were actively drinking alcohol. 9 (18%) of patients were frail and 34 (69%) were pre-frail. 25 (89%) cirrhotic male and 14 (66%) cirrhotic female had sarcopenia diagnosed via BIA. 24/42 (57%) had lower total daily energy intake than is recommended by EASL guidelines⁵. Of those, 11 (44%) male and 6 (42%) had diagnosis of sarcopenia.
There was positive correlation between nutritional status measured with BIA as Phase angle analysis (PhA) with total skeletal muscle mass adjusted for height, SMM/H², (r=0.51, p<0.0001) and ASM/H² (r=0.04,p=0.7). There was strong correlation between PhA and HGS (r=0.71, p=<0.001). Higher PhA score predicts lower MELD score therefore longer survivals (β = -0.092, p=0.004).
Healthy control has significantly better muscle quality (HGS/ASM) compared to cirrhotic patient (mean 2.52 vs 1.85 kg, SD 0.6 and 0.4 respectively, p<0.001).
Using functional testing, sit-to-stand time was lower in HCs (13.35 vs 8.94 secs, p=0.0001) and hand-grip strength higher in HC (p< 0.001). QoL was negatively correlate with sarcopenia (r=-0.06,p=0.6), LFI (r=-0.2,p=0.1), MELD (r=-0.15,p=0.3) and Child-Pugh score (r= -0.08, p=0.6) although they were not statically significant.

Conclusion

Cirrhotic patients had lower muscle quality and functional status compared to HC. FFQ and PhA are good assessment tool to establish nutritional status. PhA correlated much better with SMM/H2 than ASM/H2 and is a good predictor for disease severity. QoL is multifactorial and couldn’t be explained with frailty scores or clinical severity scores.

References

1. Alfonso J Cruz-Jentoft et al. Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing 2019 Jan 1;48(1):16-31
2. Xinxing Tantai et al. Effect of sarcopenia on survival in patients with cirrhosis: A meta-analysis Journal of Hepatology 2022 vol. 76 j 588–599
3. Jennifer C Lai et al. Development of a novel frailty index to predict mortality in patients with end-stage liver disease. Hepatology 2017 Aug;66(2):564-574
4. Z M Younossi et al. Development of a disease specific questionnaire to measure health related quality of life in patients with chronic liver disease. Gut 1999;45:295–300
5. EASL Clinical Practice Guidelines on nutrition in chronic liver disease. J Hepatol. 2019 Jan;70(1):172-193.

Introduction

The success rate of endoscopic retrograde cholangiopancreatography (ERCP) is suboptimal in patients with complex surgically altered anatomy (e.g. Roux-en-Y anastomosis, pancreaticoduodenectomy) due to difficulty in advancement of scope to the target site and selective biliopancreatic duct cannulation. Although balloon-assisted enteroscopy can achieve a higher rate of intubation, its clinical application is limited by its small working channel and few compatible accessories.

Aims & Methods

We aimed to explore the feasibility and effectiveness of a novel endoscopic approach in patients with complex surgically altered anatomy.
This is a retrospective study of patients who underwent ERCP with complex surgically altered anatomy at our center with an annual ERCP volume of approximately 3000, between January 2018 and November 2022. The endoscopic procedures were performed by three senior endoscopists who had ERCP experience for at least 5 years. Long colonoscopy (measuring 168cm)-assisted ERCP was adopted as a first-line intervention, and selective biliopancreatic duct cannulation was performed after the target site (native papilla or the surgical anastomosis) was reached. For patients with failed cannulation, a plastic guide tube measuring 250 cm was inserted via the working channel of the colonoscope and its distal end was placed near the target site. The colonoscope was then withdrawn while the guide tube was left in-situ. By following the guide tube, a conventional side-viewing duodenoscope was cautiously advanced to the target site and biliopancreatic duct cannulation re-attempted.

Results

A total of 58 patients were recruited (mean age:56.7 years [standard deviation [SD]:14.4; male:36 [62.1%]]. The reconstruction methods were as follows – Roux-en-Y hepaticojejunostomy:32 (55.2%), Billroth-II gastrectomy with Braun anastomosis:11 (19.0%), pancreaticoduodenectomy:10 (17.2%) and Roux-en Y gastrectomy:5 (8.6%). Common bile duct stone was the most common indication for ERCP (n=30; 51.7%), followed by bilioenteric anastomotic stenosis (n=15; 25.9%), pancreaticojejunal anastomotic stenosis (n=7; 12.1%) and chronic pancreatitis (n=6; 10.3%). 55 (94.8%) of 58 had successful intubation by long colonoscope with a mean procedure time of 57.7minutes (SD:23.4). The mean time to reach target site was 19.1minutes (SD:9.0). The target site could not be identified in two patients and intestinal perforation occurred during endoscopic intubation in one patient. Among those with successful endoscopic intubation, biliopancreatic duct cannulation was achieved in 35 (63.6%) patients. For the remaining 20 patients with initial failure of biliopancreatic duct cannulation, intubation rate by duodenoscope was 100% by tracing the guide tube to target site. The success rate of biliopancreatic duct cannulation by duodenoscope was 85% (17/20) with a mean procedure time of 83.5 minutes (SD:21.1). The mean time to reach target site was 17.0minutes (SD:6.1). Notably, 90% (18/20) had either native papilla or pancreaticojejunostomy, in which selective biliopancreatic duct cannulation is known to be technically difficult with any type of forward-viewing scope due to unfavorable cannulation trajectory. For those with failed cannulation, two had anatomical stricture and one had impacted pancreatic stone.

Conclusion

ERCP by conventional duodenoscope with colonoscopy-assisted pre-placement of guide tube is a feasible, effective and safe alternative for patients with complex surgically altered anatomy in experienced endoscopists.

Introduction

HCC is the sixth most common malignancy worldwide and a major cause of death in patients with CLD and cirrhosis. it accounts for 90% of primary liver cancer.
it is important to detect patient with high risk to develop HCC. Liver fibrosis (LF) is a major risk factor regardless of its etiology.
Using of liver biopsy is limited by its invasiveness, poor acceptance, cost, intra and interobserver errors. TE for liver can rapidly measure liver stiffness and also can predict the absence or presence of significant fibrosis as well as advanced cirrhosis.

Aims & Methods

To assess the ability of TE for detection of LF and HCC in patients with CLD. we searched MEDLINE, Cochrane, EMBASE database until 2019, using the following search items: TE, fibroscan, HCC and hepatoma. Each title and abstract was reviewed to make sure it is relevant. The full text was studied if the abstract indicated that the paper reported HCC risk by fibroscan. sensitivity analysis and assessment of publication bias were performed.

Results

Forty-six studies were included, 18 studies evaluated the role of LSM in predicting HCC in CLDs patients, 6 studies evaluated the role of LSM in predicting hepatic decompensation, 1 study reported a composite outcome of HCC and hepatic decompensation, and 4 studies evaluated the role of LSM in predicting mortality.

Conclusion

HCC is associated with increased LS. Each unit increase in LSM was associated with an 11% higher risk of HCC. LSM may be a useful method to identify patients with CLD at risk for HCC.

Clinical Case Summary

Bullous cellulitis is a type of skin infection that forms large fluid-filled blisters or bullae. It is usually caused by bacterial infections, most commonly gram-positive bacteria, and can occur anywhere on the body. It can cause pain, redness, swelling, and warmth in the affected area, as well as fever and chills in more severe cases. Hepatorenal syndrome is a form of renal impairment that occurs in patients with liver cirrhosis. Here, we present the case of a patient with liver cirrhosis who developed bullous cellulitis of the left lower limb caused by E. coli and hepatorenal syndrome. A 55-year-old male patient diagnosed with alcohol-induced liver cirrhosis and type 2 diabetes mellitus comes to the hospital due to pain in the left lower limb that started on the same day. Physical examination revealed signs of inflammation in the area, so bacterial cellulitis was suspected, cultures were taken and empirical antibiotic treatment was initiated. On the fourth day of hospitalization, a blister was observed in the affected area, and he developed anuria. Paracentesis was performed, and cultures of the affected tissue were obtained, as well as laboratory tests. The patient had total leukocytosis, elevated creatinine levels were obtained in the following days, and the patient continued to be oliguric. A renal ultrasound was performed, finding no alterations. There was no improvement with albumin and norepinephrine was started, which resulted in spontaneous diuresis recovery, the patient was discharged. Weeks later, he recovered a normal creatinine level, as well as a normal leukocyte count. In patients with cirrhosis, gram-negative infections are frequently observed. However, gram-positive cocci are typically responsible for skin infections. In cases of severe bullous cellulitis in cirrhosis patients, gram-negative bacteria should be considered as a possible cause. Prompt medical attention is important to improve outcomes and avoid complications.

References

Horowitz, Y., Sperber, A. D., & Almog, Y. (2004). Gram-Negative Cellulitis Complicating Cirrhosis. Mayo Clinic Proceedings, 79(2), 247–250. doi:10.4065/79.2.247
Gupta, K. et al. (2021) “Acute kidney injury and hepatorenal syndrome in cirrhosis,” World Journal of Gastroenterology, 27(26), pp. 3984–4003. Available at: https://doi.org/10.3748/wjg.v27.i26.3984.
Brown BD, Hood Watson KL. Cellulitis. [Updated 2022 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK549770/
Horowitz, Y., Sperber, A.D. and Almog, Y. (2004) “Gram-negative cellulitis complicating cirrhosis,” Mayo Clinic Proceedings, 79(2), pp. 247–250. Available at: https://doi.org/10.4065/79.2.247.
Cirera I, Bauer TM, Navasa M, Vila J, Grande L, Taurá P, Fuster J, García-Valdecasas JC, Lacy A, Suárez MJ, Rimola A, Rodés J. Bacterial translocation of enteric organisms in patients with cirrhosis. J Hepatol. 2001 Jan;34(1):32-7. doi: 10.1016/s0168-8278(00)00013-1. PMID: 11211904.
Nadim, M.K. and Garcia-Tsao, G. (2023) “Acute kidney injury in patients with cirrhosis,” New England Journal of Medicine, 388(8), pp. 733–745. Available at: https://doi.org/10.1056/nejmra2215289.