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The evaluation of biliary strictures poses a challenge due to the low sensitivity of standard diagnostic approaches, but the advent of direct single-operator cholangioscopy (DSOC) has revolutionized this paradigm. Our study aimed to assess the diagnostic performance of DSOC and DSOC-targeted biopsies, intraductal ultrasound (IDUS), and standard brush cytology in patients with indeterminate biliary strictures (IBS). We reviewed patients who underwent advanced diagnostic evaluation for IBS at our endoscopy unit from January 2018 to December 2022, all of whom had previously undergone at least one endoscopic attempt to characterize the biliary stricture. Final diagnoses were established based on surgical pathology and/or clinical and radiological follow-up spanning at least 12 months. A total of 57 patients, with a mean age of 67.2 ± 10.0 years, were included, with a mean follow-up of 18.2 ± 18.1 months. The majority of IBS were located in the distal common bile duct (45.6%), with malignancy confirmed in 35 patients (61.4%). DSOC and IDUS demonstrated significantly higher accuracies (89.5% and 82.7%, respectively) compared to standard cytology (61.5%, p < 0.05). Both DSOC visualization and IDUS exhibited optimal diagnostic yields in differentiating IBS with an acceptable safety profile. [ABSTRACT FROM AUTHOR]

Purpose: Postoperative cholangitis and anastomotic strictures (AS) are long-term complications of biliary-enteric anastomosis (BEA). Methods: We retrospectively reviewed data of patients who underwent bile duct resection with or without hepatectomy and investigated the risk factors for postoperative cholangitis, benign AS, and incidence of Clavien–Dindo (C–D) > Grade III complications. Results: Overall, data of 189 patients (115 men and 74 women) were retrospectively analyzed. The median patient age was 73 years. Thirty-five patients (18.5%) developed postoperative cholangitis, and 16 (8.4%) developed postoperative AS. Male sex and serious postoperative complications (C–D ≥ Grade III) were independent risk factors for cholangitis. The incidence of serious postoperative complications was 32.3%. Hypertension, preoperative biliary drainage, C-reactive protein–albumin ratio ≥.22, and bile duct resection with hepatectomy were potential risk factors for serious postoperative complications. Conclusions: The incidence rates of postoperative cholangitis and AS after BEA were 18.5% and 8.4%, respectively. Male sex and serious postoperative complications (C–D ≥ Grade III) were independent risk factors for postoperative cholangitis. [ABSTRACT FROM AUTHOR]

Endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) are both crucial for the endoscopic management of biliopancreatic diseases: the combination of their diagnostic and therapeutic potential is useful in many clinical scenarios, such as indeterminate biliary stenosis, biliary stones, chronic pancreatitis and biliary and pancreatic malignancies. This natural and evident convergence between EUS and ERCP, which by 2006 we were calling the "Endoscopic ultrasonography retrograde colangiopancreatography (EURCP) concept", has become a hot topic in the last years, together with the implementation of the therapeutic possibilities of EUS (from EUS-guided necrosectomy to gastro-entero anastomoses) and with the return of ERCP to its original diagnostic purpose thanks to ancillary techniques (extraductal ultrasound (EDUS), intraductal ultrasound (IDUS), cholangiopancreatoscopy with biopsies and probe-based confocal laser endomicroscopy (pCLE)). In this literary review, we retraced the recent history of EUS and ERCP, reported examples of the clinical applicability of the EURCP concept and explored the option of performing the two procedures in only one endoscopic session, with its positive implications for the patient, the endoscopist and the health care system. In the last few years, we also evaluated the possibility of combining EUS and ERCP into a single endoscopic instrument in a single step, but certain obstacles surrounding this approach remain. [ABSTRACT FROM AUTHOR]

The evaluation of biliary strictures poses a challenge due to the low sensitivity of standard diagnostic approaches, but the advent of direct single-operator cholangioscopy (DSOC) has revolutionized this paradigm. Our study aimed to assess the diagnostic performance of DSOC and DSOC-targeted biopsies, intraductal ultrasound (IDUS), and standard brush cytology in patients with indeterminate biliary strictures (IBS). We reviewed patients who underwent advanced diagnostic evaluation for IBS at our endoscopy unit from January 2018 to December 2022, all of whom had previously undergone at least one endoscopic attempt to characterize the biliary stricture. Final diagnoses were established based on surgical pathology and/or clinical and radiological follow-up spanning at least 12 months. A total of 57 patients, with a mean age of 67.2 ± 10.0 years, were included, with a mean follow-up of 18.2 ± 18.1 months. The majority of IBS were located in the distal common bile duct (45.6%), with malignancy confirmed in 35 patients (61.4%). DSOC and IDUS demonstrated significantly higher accuracies (89.5% and 82.7%, respectively) compared to standard cytology (61.5%, p < 0.05). Both DSOC visualization and IDUS exhibited optimal diagnostic yields in differentiating IBS with an acceptable safety profile.

Endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) are both crucial for the endoscopic management of biliopancreatic diseases: the combination of their diagnostic and therapeutic potential is useful in many clinical scenarios, such as indeterminate biliary stenosis, biliary stones, chronic pancreatitis and biliary and pancreatic malignancies. This natural and evident convergence between EUS and ERCP, which by 2006 we were calling the “Endoscopic ultrasonography retrograde colangiopancreatography (EURCP) concept”, has become a hot topic in the last years, together with the implementation of the therapeutic possibilities of EUS (from EUS-guided necrosectomy to gastro-entero anastomoses) and with the return of ERCP to its original diagnostic purpose thanks to ancillary techniques (extraductal ultrasound (EDUS), intraductal ultrasound (IDUS), cholangiopancreatoscopy with biopsies and probe-based confocal laser endomicroscopy (pCLE)). In this literary review, we retraced the recent history of EUS and ERCP, reported examples of the clinical applicability of the EURCP concept and explored the option of performing the two procedures in only one endoscopic session, with its positive implications for the patient, the endoscopist and the health care system. In the last few years, we also evaluated the possibility of combining EUS and ERCP into a single endoscopic instrument in a single step, but certain obstacles surrounding this approach remain.

Objective: Dyna computed tomography (DynaCT) is an innovative clinical imaging tool used to obtain three-dimensional (3D) images of biliary structures via the Artis Zee DSA system (SIEMENS Company, Germany). DynaCT is a type of 3D cone beam computed tomography (CBCT) reconstruction produced from a two-dimensional (2D) cholangiography system by rotating the C-arm without moving the patient. The aim of this study was to evaluate the technical approach and application value of DynaCT to diagnosis hepatolithiasis and biliary stenosis., Methods: This was a retrospective single-centre series of 37 hepatolithiasis patients with tubes receiving one-step percutaneous transhepatic cholangioscopic lithotripsy (one-step PTCSL) between October 2021 and October 2022: twenty-one patients were guided by CT (CT group) and sixteen by DynaCT biliary reconstruction (DynaCT group). We compared DynaCT biliary reconstruction technology with computed tomography (CT) in the application of bile ducts., Results: DynaCT biliary reconstruction was successfully performed in 37 patients. Biliary stenosis, including anatomy, morphology, and size, was visualized via DynaCT. Compared with the CT group, the DynaCT group was characterized by significantly more target biliary branches with stones (92 vs. 48, P < 0.05), a higher percentage of secondary stenosis (75.76% vs. 24.24%, p < 0.05), a greater percentage of biliary infection (37.5% vs. 9.5%, P = 0.041), a shorter overall stone clearance time (26.38 ± 13.49 vs. 52.67 ± 30.10, P = 0.001), and a lower rate of reoperation for residual stones (25.00% vs. 66.67%, P = 0.012). DynaCT had a lower contrast agent (25.61 ± 5.13 vs. 42.69 ± 11.15, p < 0.05). However, DynaCT increased radiation exposure (38.12 ± 10.59 vs. 25.79 ± 4.76, p < 0.05). There were no significant differences between the two groups regarding the clearance ratio of the calculus or several postoperative complications., Conclusion: DynaCT for biliary reconstruction has the potential to be a powerful evaluation tool for one-step PTCSL surgery and could lead to new possibilities for hepatobiliary surgery., Advances in Knowledge: DynaCT was used for the first time in patients with hepatolithiasis and biliary stenosis. Compared with CT, DynaCT for biliary reconstruction results in higher-quality 3D biliary, blood vessel and liver images. On the basis of the DynaCT biliary model, one-step PTCSL has the potential to improve the stone clearance ratio and shorten the stone clearance time and reoperation ratio., (© The Author(s) 2024. Published by Oxford University Press on behalf of the British Institute of Radiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Purpose: To prove feasibility and safety of percutaneous endoluminal radiofrequency ablation (eRFA) using a monopolar approach in treatment of occluded biliary stent in malignancy. Materials and Methods: The study included 11 patients with occluded biliary metal stent that had been implanted due to malignant biliary obstruction. All underwent metal stent recanalization by percutaneous eRFA in monopolar setting. Sixteen eRFA procedures were performed under fluoroscopic guidance with an EndoHPB 8F radiofrequency ablation catheter. The effect of stent recanalization was assessed based upon change from pre- to post-procedural diameter of the patent lumen of the metal stent (Wilcoxon test), primary and secondary stent patency (compared by log-rank test), catheter-free period, and overall survival. Adverse events were evaluated according to Common Terminology Criteria for Adverse Events (CTCEA) 4.0. Results: Recanalization of the metal stent by monopolar radiofrequency ablation was successful in all 11 patients. Diameter of the patent lumen of the stent significantly widened after the eRFA inside the stent (median 2 vs. 7 mm, p = 0.003). Grade 1 complications were observed in one-third of procedures. Median stent patency after recanalization by eRFA was non-inferior to primary metal stent patency (154 vs. 161 days, p = 0.27). Median catheter-free survival and overall survival after stent recanalization were 149 and 210 days, respectively. Conclusion: Endoluminal radiofrequency ablation in monopolar setting was shown to be a feasible and safe method for recanalization of occluded biliary metal stents. Level of evidence: Level 4, Case Series. [ABSTRACT FROM AUTHOR]

A 50-year-old woman was referred to our hospital for elevated hepatobiliary enzymes. She had a medical history of mastectomy for left breast invasive ductal carcinoma about 10 years ago, and no apparent recurrence had been observed. Contrast-enhanced computed tomography (CT) revealed soft-tissue shadows surrounding the portal vein, celiac artery, and other vessels. The lesions involved the hilar bile duct, and the upstream bile ducts were dilated. Endoscopic retrograde cholangiography showed an obstruction in the hilar bile duct, and biopsies were taken at the site of biliary stenosis. H&E staining showed that cells with strong nuclear atypia and prominent chromatin staining infiltrated in the stroma. Immunohistochemical analysis revealed that the cells were positive for CK7, GATA3 and weakly positive for CK20. Based on these results, we made the diagnosis of biliary stenosis due to retroperitoneal metastasis from breast invasive ductal carcinoma. Biliary inside stents were placed across the biliary stricture, and she received chemotherapy plus endocrine therapy for breast cancer. So far, the partial response has been maintained for 1 year since the diagnosis of retroperitoneal metastasis. Although retroperitoneal metastasis from breast cancer, especially breast invasive ductal carcinoma, is extremely rare, it could be a differential diagnosis for biliary stenosis. [ABSTRACT FROM AUTHOR]

Background: The technique of « en bloc» liver and small bowel transplantation (L‐BT) spares a biliary anastomosis, but does not protect against biliary complications. We analyze biliary and duodenal complications (BDC) in our pediatric series. Methods: Between 1994 and 2020, 54 L‐BT were performed in 53 children. The procurement technique included in situ vascular dissection and pancreatic reduction to the head until 2009 (group A). Thereafter, the whole pancreas was recovered (group B). Results: Nine BDCs occurred in 8/53 (15%) patients (7 in group A and 1 in group B): leak of the donor's duodenal stump (2), stenosis of the extra‐pancreatic bile duct (5), and intra‐pancreatic bile duct stenosis (2). Median delay for diagnosis of stricture was 8 months (4–168). Interventional radiology was successful in one child only, the others required reoperations. Two patients died, of biliary cirrhosis or cholangitis, 15‐month and 12‐year post‐L‐BT. One was listed and liver re‐transplanted 13 years post‐L‐BT. At last follow‐up, two patients only had normal liver tests and ultrasound. Conclusion: BDC after L‐BT can cause severe morbidities. Pancreatic reduction might increase this risk. Early surgical complications or chronic pancreatic rejection might be co‐factors. Early diagnosis and treatment are key to the long‐term prognosis. [ABSTRACT FROM AUTHOR]

Aim Validate the biliary carcinoembryonic antigen-related cell adhesion molecule 6 in differentiating malignant from benign biliary lesions. Background The nature of biliary stenosis needs to be diagnosed early and accurately to give the patient the best chance of therapy. Imaging techniques still lack the high accuracy for this purpose. Different biomarkers were postulated to increase the diagnostic accuracy, and of them, carcinoembryonic cell adhesion molecule 6 (CEAM6) in bile was investigated in this study. Patients and methods Forty-four patients with biliary stenosis were enrolled in this prospective study in Assiut University Hospital from 2017 to 2019. CEAM6 concentration in bile and serum was measured using human carcinoembryonic antigen-related cell adhesion molecule 6 ELISA kit from SinoGeneClon Biotech Co. Ltd, and CA19-9 concentration in serum was assessed by the ELISA kit for CA19-9 from USCN Life Science Inc. Results The area under the curve, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of bile CEAM6 for diagnosis of stricture type among the study population were 0.841, 83, 74, 77, 82, and 78.5%, respectively, at a cut-off value of 6.15 ng/ml. Multivariate analysis showed age, CEAM6, CA19-9, and alkaline phosphatase as good predictors of malignancy. Conclusion CEAM6 in bile could be a good diagnostic tool to detect the nature of biliary stenosis.

Background: Liver transplantation (LT) is the best treatment for end-stage liver disease; however, biliary complications (BCs) still pose a significant challenge. Among the post-transplant BC, strictures and biliary fistulas are the most common. Biliary strictures are classified as anastomotic and non-anastomotic. Some previous studies suggest an association between post-transplant biliary strictures and cytomegalovirus (CMV) infection. In this study, we aimed to identify whether there is an association between CMV infection and biliary strictures in patients undergoing LT., Methods: A retrospective study of 175 patients aged ≥18 years undergoing LT at Felicio Rocho Hospital between 2011 and 2017 was conducted. All included patients received grafts perfused with Institut Georges Lopez-1 (IGL-1) solution from brain-dead donors, survived post-transplantation for more than 120 days, and had a minimum follow-up of 12 months after LT. The diagnosis of CMV was made by antigenemia and biliary strictures by magnetic resonance cholangiopancreatography (MRCP)., Results: The average age of the recipients was 54 years. Postoperative BCs occurred in 12% of transplants. The most common BC was stricture (9.1%), with a predominance of anastomotic strictures (AS) over non-AS (NAS) (87.5% vs. 12.5%, respectively). CMV infection was confirmed in 22.9% of patients. In the univariate analysis, post-transplant CMV infection correlated with the development of BCs (P=0.01), as well as biliary strictures (P=0.008). In the multivariate analysis, however, only model for end-stage liver disease (MELD) >21 was a risk factor for the development of BCs in general (P=0.02) and biliary strictures (P=0.01)., Conclusions: CMV infection was not an independent risk factor for the development of non-anastomotic post-transplant biliary strictures in this study., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tgh.amegroups.com/article/view/10.21037/tgh-23-110/coif). The authors have no conflicts of interest to declare., (2024 Translational Gastroenterology and Hepatology. All rights reserved.)

It is frequently challenging to make the correct diagnosis in patients with biliary strictures. This is particularly important as errors may have disastrous consequences. Benign-appearing strictures treated with stents may later be revealed to be malignant and unnecessary surgery for benign strictures carries a high morbidity rate. In the first part of the review, the essential information that clinicians need to know about diseases responsible for biliary strictures is presented, with a focus on the most recent data. Then, the characteristics and pitfalls of the methods used to make the diagnosis are summarized. These include serum biomarkers, imaging studies, and endoscopic modalities. As tissue diagnosis is the only 100% specific tool, it is described in detail, including techniques for tissue acquisition and their yields, how to prepare samples, and what to expect from the pathologist. Tricks to increase diagnostic yields are described. Clues are then presented for the differential diagnosis between primary and secondary sclerosing cholangitis, IgG4-related sclerosing cholangitis, cholangiocarcinoma, pancreatic cancer, autoimmune pancreatitis, and less frequent diseases. Finally, algorithms that will help to achieve the correct diagnosis are proposed. [ABSTRACT FROM AUTHOR]

Résumé: La radiofréquence est une approche thérapeutique utilisée aujourd'hui dans de multiples indications dans le tube digestif. Son intérêt est démontré ou en cours d'évaluation pour des maladies de l'œsophage, de l'estomac, des voies biliaires, du pancréas et du rectum. L'avantage de cette méthode de traitement est, dans les maladies luminales, une capacité à traiter de façon uniforme de larges zones cibles, et dans les maladies bilio-pancréatiques d'offrir une alternative mini-invasive à la chirurgie. La faisabilité technique est dans l'ensemble excellente, moyennant une formation préalable adéquate. L'efficacité est, elle, variable. Celle-ci est démontrée dans l'endobrachyœsophage, mais nous disposons de moins de données pour les lésions œsophagiennes malpighiennes. Elle est insuffisante et trop coûteuse dans les ectasies vasculaires antrales, et en passe d'être supplantée par la ligature endoscopique antrale. Son intérêt dans les voies biliaires et le pancréas est croissant, notamment chez les patients non opérables pour qui les options thérapeutiques sont limitées. Mais une meilleure compréhension des propriétés thermocinétiques du pancréas et des voies biliaires, ainsi qu'une évaluation plus approfondie de son efficacité semblent nécessaires. Enfin, elle a une certaine efficacité dans la proctopathie radique hémorragique par ailleurs réfractaire aux traitements de première ligne (argon, tamponnement au formol). Son utilisation nécessite un matériel dédié et coûteux, ainsi qu'une expertise, constituant un frein à l'utilisation de cette technique à plus large échelle. Plusieurs voies de recherche se dégagent pour préciser la place de ces techniques dans ces indications frontières. Tout d'abord, les paramètres les plus adaptés (densité et puissance d'énergie, nombre d'impacts) doivent être mieux déterminés. Par ailleurs, l'efficacité à long terme doit être évaluée. Enfin, le rapport coût/efficacité méritera d'être étudié. Radiofrequency ablation (RFA) is a treatment method used today in a variety of settings in the gastro-intestinal tract. Its efficacy has been proven or is currently being evaluated in diseases of the esophagus, stomach, biliary tract, pancreas and rectum. Its strong suit in gut afflictions resides in the ability it conveys to treat large target areas in a uniform fashion. In biliary and pancreatic diseases, it offers a minimally invasive alternative to surgery. Given proper training, its feasibility is excellent. Its efficacy on the other hand is variable. The efficacy of RFA has been proven in the setting of dysplastic Barret's esophagus, but data are scarce regarding squamous lesions of the esophagus. Regarding gastric vascular ectasia, RFA caries a significant cost burden and lacks efficiency as compared to band ligation. The use of RFA in biliary and pancreatic diseases is attracting more and more attention, specifically in non-operable patients in which treatment options are limited. However, a better understanding of the thermo-sensibility of the pancreas and the bile duct is warranted, as well as a better assessment of its efficacy. Finally, RFA is efficient in refractory hemorrhagic chronic radiation proctopathy (resistant to argon or formalin instillation). Performing RFA requires specific and costly equipment as well as an expertise, which limit its wider use. Several key issues have emerged as research topics to determine the place of RFA in some of its more recent fields of application. First, the optimal settings (density, intensity, number of impacts) need to be determined. Second, the long-term efficacy needs to be better assessed. Finally, the cost-benefit balance should be evaluated. [ABSTRACT FROM AUTHOR]

ABSTRACT Background: Biliary reconstitution has been considered the Achilles’s heel of liver transplantations due to its high rate of postoperative complications. Aim: To evaluate the risk factors for occurrence of biliary strictures and leakages, and the most efficient methods for their treatment. Method: Of 310 patients who underwent liver transplantation between 2001 and 2015, 182 medical records were retrospectively analyzed. Evaluated factors included demographic profile, type of transplantation and biliary reconstitution, presence of vascular and biliary complications, their treatment and results. Results: 153 (84.07%) deceased donor and 29 (15.93%) living donor transplantations were performed. Biliary complications occurred in 49 patients (26.92%): 28 strictures (15.38%), 14 leakages (7.7%) and seven leakages followed by strictures (3.85%). Hepatic artery thrombosis was present in 10 patients with biliary complications (20.4%; p=0,003). Percutaneous and endoscopic interventional procedures (including balloon dilation and stent insertion) were the treatment of choice for biliary complications. In case of radiological or endoscopic treatment failure, surgical intervention was performed (biliodigestive derivation or retransplantation (32.65%). Complications occurred in 25% of patients treated with endoscopic or percutaneous procedures and in 42.86% of patients reoperated. Success was achieved in 45% of patients who underwent endoscopic or percutaneous procedures and in 61.9% of those who underwent surgery. Conclusion: Biliary complications are frequent events after liver transplantation. They often require new interventions: endoscopic and percutaneous procedures at first and surgical treatment when needed. Hepatic artery thrombosis increases the number of biliary complications.

Traumatic neuromas are lesions considered as tumor- like secondary hyperplasia, not true neoplasms. Traumatic neuromas seen in the biliary system develop as a late complication of cholecystectomy in the cystic duct stump, and patients generally present to the clinic with jaundice due to stricture or obstruction. They may occur several months to 40 years after cholecystectomy. Although neurinoma of the biliary tract has been reported very rarely before, it seems useful to emphasize it as a diagnosis. This lesion is an unusual cause of benign strictures of the biliary tract and may cause difficulties in diagnosis.We aimed to present a 28-yearold jaundice case in the light of the literature.Biliary stenosis was detected in the examinations but could not be distinguished from malignancy. Post-operative choledochal pathology was reported as a neuroma. [ABSTRACT FROM AUTHOR]

It is important to emphasize that the presence of intrahepatic or extrahepatic biliary stenotic foci in an HIV-positive patient with low CD4 count suggests a possibility of AIDS-associated cholangiopathy, which may be an indicator of progression of the disease. It presents with a clinical variable presentation, although right upper quadrant pain and fever accompanied by an elevated serum alkaline phosphatase (ALP) level are the most common manifestations. We present a case of a young female patient diagnosed with AIDS cholangiopathy as evidenced by clinical features, altered liver function profile indicating obstructive jaundice, classical imaging features on USG, MRI and MRCP, and very low CD4 count.

Adequate biliary drainage with endoscopic or percutaneous placement of self-expandable metal stents represents the goal of palliation in patients with inoperable malignant obstruction of the biliary tree. As an adjunct to stenting, various tissue ablation treatments have been proposed with conflicting results. The aim of this study was to test the effect on biliary tissue of a new ablation technique based on Nd:YAG laser light delivery. The study was conducted on ex vivo specimens of 18 healthy farm pigs, using cystic ducts that are the simplest biliary structures to isolate and cannulate ex vivo. A 22G cannula was positioned into the cystic duct and a quartz optical fibre, with a prototypal cooling system, was inserted into the cannula. Nd:YAG laser output powers of 10, 12, and 15 W were tested, with a total delivered energy of 1000 J in continuous mode in each case. After laser treatment, histological analysis was performed. At macroscopical examination, no lesions of the external wall of the cystic ducts were detected. At histopathological examination, a coagulative necrosis involving the entire mucosa up to the muscolaris propria without significant changes of periductal tissues was observed in all specimens. This study shows the possibility of using Nd:YAG laser on ex vivo porcine biliary ducts with the effect of obtaining a coagulative necrosis involving the whole mucosa. [ABSTRACT FROM AUTHOR]

Background This study was conducted to evaluate the predisposing factors, microbiology, treatment, and outcomes associated with hepatic abscess, a rare but serious complication which may accur after an orthotopic liver transplant ( OLT). Methods This was a retrospective study based on a prospectively maintained database of 1100 patients who underwent OLT at the Medical University of Warsaw. An abscess was defined on imaging as solitary or multiple localized parenchymal collections in patients with clinical signs of infection, with or without positive cultures from blood or abscess aspirate. Results Fifteen patients (1.4%) developed hepatic abscess, including 12 (80%) with multiple abscesses. Predisposing factors included biliary pathology (eight patients), hepaticojejunostomy (six patients), and hepatic artery stenosis or thrombosis (five patients). Ten patients were treated using multiple percutaneous and endoscopic interventional procedures in addition to antimicrobial treatment whereas five were treated solely with antibiotics. Five patients (33.3%) died due to multi-organ failure secondary to abscess treatment, including one unsuccessful case of re- OLT. Thirteen patients (87%) had bacterial growth and five (33.3%) had fungal growth in their blood or abscess aspirates. Conclusions Hepatic abscess after liver transplantation may be treated successfully with percutaneous and endoscopic intervention, along with antibiotics according to the results of microbial cultures of blood and/or abscess aspirates. [ABSTRACT FROM AUTHOR]

Background Failure to differentiate benign and malignant hilar bile duct stenosis may lead to inappropriate treatment. We retrospectively analyzed the methods for differentiation. Materials and methods A total of 53 patients with hilar bile duct stenosis were included, comprising 41 malignant cases (hilar cholangiocarcinoma) and 12 benign cases (six primary sclerosing cholangitis and six IgG4-associated sclerosing cholangitis). Data of clinical histories, laboratory tests, imaging studies, and liver pathologies were collected, and comparison was made between benign and malignant groups. Results Compared with malignant group, patients in the benign group were more likely to have multiorgan involvement of clinical histories ( P < 0.001). There was no difference on bilirubin, liver enzyme, and serum tumor marker between the two groups, whereas serum IgG4 levels were higher in the benign group ( P = 0.003). Patients in the benign group were more likely to have pancreatic changes ( P < 0.001) and multiple-segmental bile duct stenosis ( P < 0.001) on imaging. Compared with the malignant group, patients in the benign group were more likely to show severe periportal inflammation in noninvolved liver ( P < 0.001), fibrosis around intrahepatic bile duct ( P < 0.001), and more IgG4-positive plasma cells ( P < 0.001) on liver pathology. Conclusions Benign lesion should be considered for patients with history of multiorgan involvement, pancreas changes, or multiple-segmental bile duct stenosis on imaging. Liver biopsy could be helpful for differential diagnosis before surgery. [ABSTRACT FROM AUTHOR]

Background: Biliary stricture is a common cause of morbidity after liver transplantation. We previously developed a duct-to-duct biliary anastomosis technique using a biodegradable stent tube and confirmed the feasibility and safety of biliary stent use. However, the duration and mechanism of biliary stent absorption in the common bile duct remain unclear. Materials and methods: Radiopaque biodegradable biliary stents were created using a copolymer of L-lactide and ε-caprolactone (70: 30) and coated with barium sulfate. Stents were surgically implanted in the common bile duct of 11 pigs. Liver function tests and computed tomography (CT) scans were performed postoperatively, and autopsies were conducted 6 months after biliary stent implantation. Results: After the surgery, all 11 pigs had normal liver function and survived without any significant complications such as biliary leakage. A CT scan at 2 months post-procedure showed that the biliary stents were located in the hilum of the liver. The stents were not visible by CT scan at the 6-month follow-up examination. Conclusions: The surgical implantation of radiopaque biodegradable biliary stents in biliary surgery represents a new option for duct-to-duct biliary reconstruction. This technique appears to be feasible and safe and is not associated with any significant biliary complications. The advantage of coated biliary stent use is that it may be visualized using abdominal radiography such as CT. [ABSTRACT FROM AUTHOR]

Background: Living donor liver transplantation (LDLT) entails a significant number of bile duct complications. We aimed to diminish the biliary complication rate with the use of a resorbable biliary stent (RBS) during LDLT. The objective of this study is to describe the surgical techniques and the associated outcomes, especially in terms of safety, of RBS use in LDLT. Methods: From 2011 to 2014, 12 LDLT recipients were enrolled in a clinical trial with the use of a specifically designed RBS. These patients were followed according to the clinical protocol. Specific complications derived from RBS as well as biliary complications were recorded. Results: One patient underwent early retransplantation due to a small-for-size syndrome. None of the patients had a complication attributable to the placement, remaining in place, or degradation of the stent. Four of the remaining patients presented with a biliary complication: 1 (9.1%) with a biliary leak alone, 1 (9.1%) with a biliary stenosis alone, and 2 (18.2%) with both. However, none of the leaks could be directly attributed to the RBS. Patient and graft 1-year survival was 100 and 91.7%, respectively. Conclusion: The use of an RBS in LDLT is not associated with complications, and initial results regarding efficacy and safety are encouraging. The need for a larger and prospective study is warranted. [ABSTRACT FROM AUTHOR]

Background Endoscopic retrograde cholangio-pancreatography is the gold standard of treatment in patients with biliary complications after liver transplantation. The benefits of fully covered self-expandable metal stents (FCSEMS) lie in their relative simplicity and the need for only two procedures, one for insertion, and the other for removal. Several case series have been published on such stents with generally good outcomes. Objective is to analyze definitive long-term outcomes of this treatment. Methods Prospective, observational study in a single, tertiary-care referral centre. All consecutive patients with post-transplant biliary stenosis/leak were treated with FCSEMS after failure of conventional treatment. Recurrence was evaluated after four years. Results From February 2008 to April 2012, 70 patients were included. In all patients, the metal stent was successfully placed. After a mean of 86.7 ± 38.4 days, the stent was removed. Forty-six patients (65.7%) showed resolution. After a mean of 4 ± 1.2 years, 61% of patients maintained the results, but 39% showed recurrence. On the tested variables the diagnosis of stenosis, the number of previous procedures and plastic stents placed correlate with better long-term results. Conclusions This series suggests a lack of long-term advantages of FCSEMS over plastic stents in the management of biliary stenosis after liver transplantation. [ABSTRACT FROM AUTHOR]

Endoscopic insertion of a self-expanding metal stent (SEMS) through a malignant common bile duct stricture is the first line of palliation for malignant jaundice. Patency of these stents remains a major concern. SEMS dysfunction can result from tumor ingrowth, overgrowth and/or clogging. Initial SEMS modifications involved covering the central part of the stent in order to reduce ingrowth and ultimately increase patency. Fully covered stents became available shortly after reports of their use in human patients. The potential removability and radial strength of SEMS have led to evaluation of their use in new indications including benign biliary strictures, post sphincterotomy bleeding and perforation. Other aspects of development include the addition of features such as anti-reflux valves, drug elution and spontaneous biodegradability. These aspects and their clinical implications are reviewed and discussed. [ABSTRACT FROM AUTHOR]

Background: Many benign biliary diseases (BBD) can be treated with fully covered, self-expandable metal stents (FCSEMS) but stent migration occurs in up to 35.7 %. The aim of this study was to prospectively assess the rate of, safety and effectiveness and stent migration of a new biliary FCSEMS with an anti-migration flap (FCSEMS-AF) in patients with BBD. Patients and Methods: This was a prospective study from four Italian referral endoscopy centers of 32 consecutive patients (10 females and 22 males; mean age: 60.1 ± 14.8 years; range: 32-84 years) with BBD who were offered endoscopic placement of a FCSEMS-AF as first-line therapy. Results: Were 24 strictures and 8 leaks. Stent placement was technically successful in 32/32 patients (100 %). Immediate clinical improvement was seen in all 32 patients (100 %). One late stent migration occurred (3.3 %). FCSEMS-AF were removed from 30 of the 32 patients (93.7 %) at a mean (±SD) of 124.4 ± 84.2 days (range: 10-386 days) after placement. All patients remained clinically and biochemically well at 1- and 3-month follow-up. One patient (3.3 %) with a post-laparoscopic cholecystectomy stricture developed distal stent migration at 125 days. Conclusion: This new FCSEMS with anti-migration flap seems to be a safe and effective first-line treatment option for patients with BBD. [ABSTRACT FROM AUTHOR]