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Background and Aims Although various methods are used in the treatment of peptic ulcer bleeding, there is not a standard recommended approach. The choice depends on multiple factors such as location of the ulcer, clinical experience of the endoscopist, and local facilities of the clinic. We aimed to compare the efficacy of monopolar hemostatic forceps soft coagulation (MHFSC) and hemoclips (HCs) in the treatment of peptic ulcer–related upper GI bleeding. Methods The study group included patients who had GI bleeding due to Forrest 1a, 1b, and 2a gastric or duodenal ulcers within 1 year. Patients with bleeding diathesis, history of gastrectomy, pregnancy, or younger than age 18 years were excluded. The remaining were randomized to MHFSC and HC treatment groups and compared in terms of clinical and endoscopic features, initial hemostasis success rates, recurrent bleeding rates within the first 7 days, time to achieve hemostasis, length of hospitalization stay, and adverse events. Results One hundred twelve patients were randomized to MHFSC (n = 56) and HC (n = 56) groups. There was no statistically significant difference between the groups with respect to demographic features, medications, underlying chronic diseases, location, and Forrest classification of the ulcers. The initial hemostasis success rate was 98.2% (55/56) in the MHFSC group and 80.4% (45/56) in the HC group (P =.004). Recurrent bleeding was detected in 2 patients in the MHFSC group (3.6%) and 8 patients in the HC group (17.7%; P =.04). The duration of endoscopic procedures (302 ± 87.8 vs 568 ± 140.4 seconds) and the length of hospital stay (3.50 ± 1.03 vs 4.37 ± 1.86 days) were significantly shorter in the MHFSC group. There were no adverse events in either group. Conclusions MHFSC is more effective in achieving initial hemostasis compared with HCs in the treatment of peptic ulcer bleeding and provides a shorter procedure time and a lower recurrent bleeding rate. [ABSTRACT FROM AUTHOR]

Background and Aims Cannulation of the major papilla can be problematic, and selective biliary cannulation may fail in up to 18% of cases. Various techniques, such as double-guidewire technique (DGWT), wire-guided cannulation over a pancreatic stent (WGC-PS), the precut endoscopic sphincterotomy (needle-knife precutting technique (NKP), and transpancreatic septostomy have been used to improve the success rate of biliary cannulation. We conducted a prospective, randomized study in order to compare the biliary cannulation success rates of DGWT and WGC-PS techniques in patients with inadvertent passage of guidewire to the pancreatic duct. Methods A total of 100 patients were included in the study and randomized to DGWT (n = 50) or WGC-PS (n = 50) groups. The primary outcome was successful selective cannulation, defined as deep cannulation with selective injection of radiographic contrast material into the common bile duct within 5 minutes by DGW or WGC-PS techniques without performing precut sphincterotomy. Results Successful selective cannulation was achieved in 45 patients in the DGWT group (90%) and in 27 patients in the WGC-PS group (54%) (P <.001). Five patients (10%) in the DGWT group and 23 (46%) in the WGC-PS group required NKP for biliary access (P <.001). The overall cannulation rate was 98% for DGWT and 98% for WGC-PS (P = 1.00). Conclusions In patients with unintentional passage of a guidewire into the pancreatic duct during biliary cannulation attempts, the WGC-PS technique significantly increased the need for NKP compared with DGWT. [ABSTRACT FROM AUTHOR]

Biliary strictures constitute 40% to 60% of the biliary complications after liver transplantation. They are more common after living donor related liver transplantation (LDLT) than orthotopic liver transplantation (OLT). Balloon dilation followed by multiple plastic stent insertion leads to a mean resolution rate of 84% in the treatment of ASs after OLT. Endoscopic treatment of ASs after LDLT is more difficult because of the small size of the ASs, their multiple number and peripheral location. Balloon dilation followed by multiple plastic stent insertion had a mean resolution rate of 53%. Percutaneous transhepatic biliary drainage was required in 16% to 44% of the patients. Refractory cases with complete biliary obstruction and severe stenosis, in whom the stricture could not be traversed with a guidewire, can be treated by magnetic compression anastomosis as a rescue therapy, if the anatomy of the bile ducts is suitable. In this review, we will focus on the endoscopic treatment of ASs, with special emphasis to refractory cases. [ABSTRACT FROM AUTHOR]

Background and Aims: Magnetic compression anastomosis is a rescue technique for recanalization of complete biliary strictures. Here, we present magnetic compression anastomosis with novel through-the-scope magnets in patients witn complete duct-to-duct anastomosis obstruction after liver transplantation. Methods: The magnets were 2 and 2.4 mm in diameter, with a hole at the center for inserting a guidewire. One of the magnets was advanced through the scope up to the distal site of the stricture by using a 7F pusher. The other magnet was pushed percutaneously through the 10F sheath. The procedure was terminated when the magnets were approximated or properly aligned. Recanalization was followed by percutaneous cholangiography. Patients underwent multiple plastic stenting after recanalization was achieved. Results: Nine patients with a stricture length of less than 1 cm, a stump in the donor bile ducts close to the stricture, and proper positioning of the bile duct stumps, underwent magnetic compression anastomosis. Seven patients had a live donor-related liver transplantation. The mean stricture time was 24.1 ± 17.1 months. The mean stricture length was 4.0 ± 1.2 mm. Recanalization was achieved in 7 patients (77%) after a mean recanalization time of 8.1 ± 4.7 days. There was no recurrence after 4.8 ± 3.8 months of stent-free follow-up. No adverse events were observed. Conclusions: The through-the-scope magnet procedure was effective in the recanalization of complete anastomotic biliary obstructions after liver transplantation in a selected group of patients with a short stricture length and an appropriate anatomy. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: To determine the safety, efficacy, and long-term results of percutaneous biliary balloon dilation (PBBD) of benign hepaticojejunostomy strictures and evaluate the necessity of repeated PBBD in this setting. Materials and Methods: PBBD was performed after traversing hepaticojejunostomy strictures in 89 patients (40 male, 49 female; age range, 19–84 y; mean age ± SD, 54.5 y ± 14.0), who were divided into three groups: group I (one satisfactory initial PBBD; n = 41), group II (two or more PBBDs with satisfactory initial PBBD; n = 33), and group III (two or more PBBDs without satisfactory PBBD; n = 15). Groups I and II were randomized. The primary outcome measure was the absence of clinical biliary obstruction symptoms at 24 months. Secondary outcome measures included technical and clinical success, primary and secondary patency, major complications, and mortality. Categoric variables were compared between groups I and II. Results: Procedure-related mortality and major morbidity rates were 0% and 5.6%, respectively. Mean primary and secondary patency durations were 45.3 months ± 2.2 and 71.3 months ± 15.4, respectively. The follow-up period was 36.4 months ± 15.1. The primary outcome measure was achieved in 73% of patients. Technical and clinical success rates (secondary outcome measures) were 97.8% and 84.3%, respectively. Repeated PBBD procedures were not satisfactory in 16.9% of patients. No significant differences in categoric variables were observed between groups I and II. Conclusions: PBBD of benign hepaticojejunostomy strictures is a safe and effective procedure. Repeated PBBD is not required when the first procedure is successful. [Copyright &y& Elsevier]

Background: The diagnosis of primary sclerosing cholangitis (PSC) is reached by typical cholangiographic findings and liver biopsy. The characteristic cholangiographic abnormalities consist of multifocal strictures and dilatations in the intrahepatic and/or extrahepatic bile ducts. Patients may develop cirrhosis and portal hypertension. Endoscopy may reveal esophageal/gastric varices and portal hypertensive gastropathy. Objective: To define a novel endoscopic finding in patients with PSC. Design: Case series. Setting: Single tertiary referral center in Turkey. Patients: Ten patients with PSC, 16 with liver cirrhosis, and 10 with PSC-like cholangiogram. Interventions: Inspection of papilla with duodenoscope and ERCP. Main Outcome Measurements: Retraction of papilla into the duodenum wall. Results: Ten patients with PSC (8 male, 2 female, mean age 38 y) underwent ERCP at our institution. Retraction of papilla into the duodenum wall was observed in 7 patients (70%). The mean time elapsed between the retraction of the papilla and onset of PSC was 5.1 years (range 2-7 y). In patients with retraction of the papilla, both of the intrahepatic and extrahepatic bile ducts were involved; however, only the intrahepatic bile ducts were involved in patients with no retraction of papilla. Of 7 patients with retraction of papilla, 5 had a history of sphincterotomy procedure 5.4 years previously (range 5-6 y). Two patients had native papilla. None of the patients had end stage liver disease. Retraction of papilla was observed in none of the 16 patients with cirrhosis of the liver and in 10 with PSC-like cholangiogram. Limitations: Only observational; absence of surgical and/or pathologic evidence. Conclusions: Papilla may be embedded in the duodenum wall in some patients with PSC. Extrahepatic involvement seems to be necessary for the occurrence of this finding. [Copyright &y& Elsevier]

Background: Endoscopic sphincterotomy (ES)–induced hemorrhage is a serious complication of ERCP and occurs in 1% to 2% of all procedures. A heat probe has been used effectively for many causes of GI hemorrhages. We prospectively investigated the efficacy and the safety of heat probe usage in patients with ES-induced hemorrhage. Methods: Between July 2002 and March 2004, ERCP procedures with ES were evaluated prospectively for complications. A heat probe was used to control ES-induced hemorrhages. Results: ES was performed in 703 of a total of 1262 (55.7%) ERCP procedures. ES-induced hemorrhage occurred in 16 patients (2.3%; 10 men, 6 women; 59.6 ± 15.2 years). Six of 16 patients bled during ERCP, and all bleeding was controlled by heat probe. Ten patients hemorrhaged after ERCP: 6 patients needed endoscopic treatment with heat probe, and 4 were followed up with supportive treatment without the need for any further treatment. There was no complication caused by the heat probe in this series. Conclusions: Heat probe is an easy, safe, and effective procedure for ES-induced hemorrhage treatment. [Copyright &y& Elsevier]

Background The American Society for Gastrointestinal Endoscopy (ASGE) has recently published a guideline for suspected CBDS with the intention of reducing unnecessary ERCP and thereby complications. The aim of this study was to assess the diagnostic efficacy of the ASGE guideline. Methods Data of patients who underwent ERCP with suspected CBDS were analyzed retrospectively. Patients were classified into high, intermediate and low risk groups based on predictors that have been suggested by the ASGE. Very strong predictors of the presence of ductal stones included: CBDS on transabdominal ultrasonography (US), clinical ascending cholangitis or total bilirubin (TBIL) >4 mg/dL). Strong predictors included dilated CBD >6 mm on US with gallbladder in situ and TBIL level of 1.8–4.0 mg/dL whereas moderate predictor included abnormal liver biochemical test other than bilirubin, age more than 55 years and clinical findings of biliary pancreatitis. Results Of 888 enrolled patients, 704 had CBDS demonstrated by ERCP and the remainder did not. All very strong and strong predictors were found to be significantly higher among patients who had CBDS. Detection of CBDS by ultrasonography and a dilated common biliary duct were observed to be independent risk factors associated with the existence of CBDS. The high risk group had a high (86.7%) positive predictive value (PPV), however, sensitivity and specificity were observed to be moderate (67.8% and 60.3% respectively). PPV was 67.9% in the intermediate risk group and the sensitivity and specificity were very low (31.9% and 42.3%). Discussion The probability of CBDS was observed to be high in the intermediate and high risk groups. However due to low sensitivity and specificity values, the ASGE guideline needs additional or different predictors. [ABSTRACT FROM AUTHOR]