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Background/aims: The aim of this study was to investigate the indications, technical and clinical success, and complications of the endoscopic retrograde cholangiography (ERC) via a permanent access loop (PAL)., Materials and Methods: Twenty patients who underwent ERC through PAL between 2009 and 2017 were included in this study. The technical success was described as achieving access to the bile ducts through PAL and the clinical success was described as the clinical and laboratory improvement of the patients after the procedure., Results: The study was performed with 20 patients. The median follow-up duration was 24 months (3-96) and the median number of ERC sessions was 3.9 (1-10). The most common ERC indications through PAL were stones (40%) and cholangitis (30%). In 16 patients (75%), anastomotic or branched strictures were observed. The improvement of strictures via intermittent stenting and dilatation was observed in 6 patients, but no improvement was observed in 5 patients. The treatment of those 5 patients continues. In this study, the technical success was 100% and clinical success was 85%. While no mortality due to PAL-mediated ERC was observed, free wall perforation was seen in one patient who was referred to surgery., Conclusion: PAL-mediated ERC procedure is a technique with high technical and clinical success and low complication rate in patients who require frequent percutaneous procedures and those with difficult access to the biliary tract.

Background: Fully covered self-expandable metal stents (Fc-SEMSs) have a challenging use in the treatment of anastomosis strictures after live donor liver transplantation (LDLT) because they can occlude secondary branch biliary ducts when placed above the biliary bifurcation. In this study, we evaluated the technical feasibility and safety of combining Fc-SEMSs with plastic stent(s) inserted to the secondary branch biliary ducts for the treatment of anastomosis stricture after LDLT., Methods: The study group included 22 patients (12 men, aged 51±11 years) with anastomotic biliary stricture after LDLT. A Fc-SEMS, 8 to 10 mm in diameter, was inserted to the straight, dilated main duct and plastic stent(s) were inserted to the secondary branches to avoid their occlusion. Stents were left in place for 2 months and removed with a stent retrieving forceps. Technical feasibilities, including technical success, successful removal, and adverse events of this novel strategy, were evaluated., Results: Fc-SEMSs were successfuly deployed and removed in all of the cases. Three (13.6%) patients had pain requiring intravenous analgesia and Fc-SEMS had to be removed because of unbearable pain in one of them. Three (13.6%) patients developed cholangitis due to occlusion of unrecognized secondary branch biliary ducts. Primary stricture resolution rate was achieved in 17 (89.5%) of 19 patients. Recurrence was observed in 3 (17.6%) patients after a mean follow-up duration of 154.3±52.6 (range, 104-304) days., Conclusions: Combination of Fc-SEMS and plastic stent(s) is technically feasible and safe for the treatment of anastomotic biliary strictures after LDLT.

Background and Aims: Endoscopic treatment is effective in the treatment of patients with bile duct injury after cholecystectomy. We aimed to investigate the long-term results of endoscopic treatment, factors predicting the recurrence of the stricture, and to determine the optimal endoscopic treatment., Methods: The study was a retrospective cohort analysis and conducted at a tertiary referral center in patients with major bile duct injury (Strasberg E1-4 and E5 patients with main bile duct injury). Patients with minor injury (Luschka and cystic duct leakage), complete transection, and isolated aberrant bile duct injuries were excluded., Results: The study group included 156 patients. The median follow-up period after stent removal was 6.5 years (range 1-16.5). Recurrence was seen in 18 patients (11 %) after a median duration of 9 months (range 2-96). Multivariate regression analysis revealed that the most important factors predicting the success of endoscopic treatment were: Rome type of treatment (inserting increasing number of stents every 3-4 months) (odds ratio 23.8, 95 % CI 1.46-390.7, p = 0.026) instead of Amsterdam-type treatment (replacing two 10F biliary stents every 3-4 months) and dilation of the stricture diameter to at least 76 % of the common bile duct diameter at the end of stent treatment (odds ratio 25.9, 95 % CI 2.46-272.7, p = 0.007)., Conclusions: Endoscopic treatment is an effective method in the treatment of patients with bile duct stricture after cholecystectomy. Inserting multiple stents as much as possible without leaving a scar in the bile ducts should be aimed.

Background: In patients with Roux-en-Y hepaticojejunostomy (HJ), endoscopic retrograde cholangiography (ERC) cannot usually be achieved since the anastomosis is not reachable via standard duodenoscope. In this study, we report our experience with ERC using double balloon enteroscope (DBE) (DBE-ERC) in patients with HJ., Methods: The DBE-ERC procedures performed since the index case done dated May 3, 2006 have been overviewed., Results: Fourteen patients underwent the procedure. DBE-ERC was successful in all but one patient, for whom the anastomosis could not be reached (success rate to reach anastomosis: 92.9%). The remaining 13 patients (7 female, 6 male; age 28-61 years, mean 45.3 years) had 20 sessions of DBE-ERC. The cannulation of the bile duct was achieved in all patients. The procedures, such as sphincteroplasty, dilatation, stone extraction and stent placement, were performed. Therapeutic procedures were all successful, except for in a single patient, who had the common bile duct filled with multiple stones and was referred for surgery. Three patients who had anastomotic stenosis treated by stenting are symptom free on follow-up at 3, 9 and 12 months, respectively, after stent removal. Retroperitoneal air was detected in a patient following stricturoplasty, but recovery was attained with medical treatment alone. Mean duration of the procedures was 75 +/- 62 min., Conclusion: DBE-ERCP enables us to perform ERC in a group of patients for whom it was impossible previously. Further experience is needed to evaluate its therapeutic efficacy compared with alternative methods.

Bile duct injury is a serious complication of laparoscopic cholecystectomy. We report a case of spontaneous hepaticoduodenal fistula following bile duct injury. Initially, Roux-en-Y hepaticojejunostomy had been planned for the patient, but as the patient did not show any symptoms or findings of biliary obstruction, we preferred a non-operative management. The fistula allowed adequate biliary drainage, and the patient has been followed regularly by the outpatient clinic with good clinical results for approximately five years.

Background and Study Aims: Stent migration occurs in about 5-10% of patients undergoing biliary stenting. The aim of this study was to analyze the risk factors for stent migration in patients with benign and malignant strictures., Patients and Methods: We retrospectively analyzed records of 524 biliary plastic stent placement procedures. Details noted included the cause and localization of stricture, characteristics and number of stents, direction of stent migration, presentation of patient with migrated stent, and the methods used for retrieval of migrated stents., Results: Two hundred and four (38.9%) of the procedures were performed for benign biliary strictures (BBS) and 320 (61.1%) for malignant biliary strictures (MBS). Thirty-four patients had 45 migrated biliary stents. The rate of migration was 8.58% (proximal 4.58% and distal 4.00%). Migration frequency was higher in BBS compared with MBS (13.7% versus 5.3%, p=0.001). In BBS, the rate of stent migration was higher in cases with one (19.3%) and two stents (20.9%) when compared with cases with multiple stents (2.7%) (p=0.001; p=0.001, respectively). Migration occurred more frequently (10.9%) in cases with two stents when compared both to cases with one stent (3.0%) and those with multiple stents (0%) in MBS (p=0.008; p=0.020, respectively). In BBS, short stents migrated more frequently proximally (77%) and long stents more frequently distally (73%) (p=0.008). In BBS, migration in cases with proximal stricture occurred more frequently distally (76.9%), while in those with distal stricture, migration was more frequently proximal (73.3%) (p=0.008). All of the proximally migrated stents could be successfully retrieved endoscopically., Conclusions: The risk of stent migration is higher in BBS compared with in MBS. The cases with multiple stents had significantly lower stent migration. In BBS, long stent, proximal and postcholecystectomy strictures were associated with distal migration, while short stent, distal and non-postcholecystectomy strictures were associated with proximal migration.

Background and aims: There are limited data about the benign biliary strictures (BBS) which can develop during the clinical course of acute biliary pancreatitis (ABP) due to compression of the common bile duct (CBD) by edematous and inflamed pancreatic tissue. We aimed to determine the incidence of BBS due to ABP and its clinical course after endoscopic management. Methods: The study was retrospectively conducted among patients with ABP who were admitted to a single tertiary reference center during 3 years. BBS-ABP was defined as distal narrowing of the CBD with proximal dilatation and delayed drainage of the contrast into the duodenum. Endoscopic treatment was performed by inserting a single 7F or 10F plastic stent which was exchanged every 3 months until stricture resolution. Patients were followed for 1 year after stricture resolution. Results: Seven hundred and twenty-one patients had ABP during the study period. Among them, 257 (35.6%) patients underwent ERCP and 26 patients (3.6%) had CBD stricture due to ABP. A 7 Fr plastic stent was inserted in 18 patients and 10 Fr in 8 patients. The stricture was completely resolved at 3 months in 66.7%, at 6 months 23.8% and at 9 months (9.5%) of the patients. There was no procedure-related complications other than asymptomatic stent migration in 4 (19%) patients. None of the patients had recurrent biliary stricture during the 1 year stent-free follow-up period. Conclusion: BBS-ABP is a frequently seen clinical entity. In most patients, the stricture improves within 3 months and temporary endoscopic stenting prevents the patients from the consequences of the obstruction during this period. [ABSTRACT FROM AUTHOR]

Background and aims: Pancreaticobiliary maljunction (PBM) is a malformation in which the pancreatic and bile ducts join outside the duodenal wall. It is associated with various biliary and pancreatic diseases. In addition, patients with PBM carry a substantial lifetime risk of developing biliary or gallbladder carcinoma. We aimed to present a multicenter case series of PBM from Turkey. Methods: This study was conducted in adult and pediatric PBM patients who were referred to three tertiary reference centers of Turkey for endoscopic retrograde cholangiopancreatography (ERCP) between July 2007 and May 2020. The clinical presentations, types of PBM, ERCP findings, surgical histories, and the postoperative courses, including the development of biliary malignancies, were retrospectively reviewed. Results: The study group included 47 (31 adult and 16 children) patients. Type D PBM was more frequent (13/41: 27.7%) than that reported in Eastern studies. Type A PBM was more common in the adults (51.6% vs. 12.5%, p < 0.05), whereas type C was more common in pediatric patients (31.3% vs. 13.2%, p < 0.05). Although fusiform anatomy was predominant in both of the groups, cystic dilatation was more common (25.8% vs. 12.5%) in adults and the common bile duct diameter was greater [22 mm (range 11–58) vs. 12 mm (range 5–33)] in adult patients compared to pediatric patients. Resective surgeries were more frequently done in pediatric patients (73.3% vs. 53.6%), whereas cholecystectomy was more frequently performed in adult patients (21.4% vs. 6.7%). Conclusion: Although our findings were compatible with Eastern studies, type D PBM (associated with pancreas divisum) was more frequent in our study population. [ABSTRACT FROM AUTHOR]

Background: Ectopic opening of the common bile duct into the duodenal bulb (EO-CBD-DB) is a rare disease that may be complicated by duodenal ulcer, deformity, stenosis and biliary stones. The aim of this study is to report clinical presentations, endoscopic diagnosis and treatment of this entity as well as to investigate its association with duodenal stenosis. Methods: Gastroduodenoscopic findings and radiological imaging were evaluated for ectopic papilla and duodenal stenosis. Diagnostic methods, endoscopic procedures and long-term outcomes of the endoscopic treatment were presented. Results: EO-CBD-DB was found in 74 (77.1%) of the 96 patients with duodenal deformity/stenosis (79 male, 17 female, mean age: 58.5, range: 30-87 years). The papilla with normal appearance was retracted to the bulb in 11 while it was at its usual location in the remaining 11. The history of biliodigestive surgery was more common in patients with EO-CBD-DB who were frequently presented with the common bile duct stone-related symptoms than the other patients. Thirteen (17.6%) of the patients with EO-CBD-DB were referred to surgery. Endoscopic treatment was completed in 60 (81.1%) patients after an average of 1.7 (range: 1-6) procedures. These patients were on follow-up for 24.8 (range: 2-46) months. Endoscopic intervention was required in 12 (20%) of them because of recurrent biliary problems. Treatment of the patient who had stricture due to biliary injury during laparoscopic cholecystectomy is still continued. Conclusions: The presence of EO-CBD-DB should be considered particularly in middle-aged male patients who have duodenal deformity/stenosis. Endoscopic treatment is feasible in these patients. The long-term outcomes of endoscopic therapy need to be compared with surgical treatment. [ABSTRACT FROM AUTHOR]

Background: Anomalous biliary opening especially the presence of the ampulla of Vater in the duodenal bulb is a very rare phenomenon. We report clinical implications, laboratory and ERCP findings and also therapeutic approaches in 53 cases. Methods: The data were collected from the records of 12.158 ERCP. The diagnosis was established as an anomalous opening of the common bile duct (CBD) into the duodenal bulb when there is an orifice observed in the bulb with the absence of a papillary structure at its normal localization and when the CBD is visualized by cholangiography through this orifice without evidence of any other opening. Results: A total of 53 cases were recruited. There was an obvious male preponderance (M/F: 49/4). Demographic data and ERCP findings were available for all, but clinical characteristics and laboratory findings could be obtained from 39 patients with full records. Thirty — seven of 39 cases had abdominal pain (95%) and 23 of them (59%) had cholangitis as well. Elevated AP and GGT were found in 97.4% (52/ 53). History of cholecystectomy was present in 64% of the cases, recurrent cholangitis in 26% and duodenal ulcer in 45%. Normal papilla was not observed in any of the patients and a cleft-like opening was evident instead. The CBD was hook shaped at the distal part that opens to the duodenal bulb. Pancreatic duct (PD) was opening separately into the bulb in all the cases when it was possible to visualize. Dilated CBD in ERCP was evident in 94% and the CBD stone was demonstrated in 51%. PD was dilated in four of 12 (33%) cases. None of them has a history of pancreatitis. Endoscopically, Papillary Balloon Dilatation instead of Sphincterotomy carried out in 19 of 27 patients (70%) with choledocholithiazis. Remaining eight patients had undergone surgery (30%). Clinical symptoms were resolved with medical treatment in 16(32%) patients with dilated CBD but no stone. Perforation and bleeding were occurred only in two patients, which stones extracted with sphincterotomy (each complication in 1 patient). Conclusion: The opening of the CBD into the duodenal bulb is a rare event that may be associated with biliary and gastric/duodenal diseases. To date, surgical treatment has been preferred. In our experience, sphincterotomy has a high risk since it may lead to bleeding and perforation by virtue of the fact that a true papillary structure is absent. However, we performed balloon dilatation of the orifice successfully without any serious complication and suggest this as a safe therapeutic modality. [ABSTRACT FROM AUTHOR]