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Objective: To discuss the relevant factors of biliary complications after liver transplantation and to investigate the value of comprehensive management for the complications., Methods: The data of 366 patients undergoing liver transplantation from October 2000 to March 2012 was analyzed retrospectively, and the risk factors were analyzed by univariate analysis and Stepwise Logistic regression. The cases with biliary leak were administered thorough drainage. The cases with anastomotic biliary stricture were administered sacculus dilatation through percutaneous transhepatic cholangiography (PTC) and endoscopicretrograde cholangiopancreatography (ERCP). If necessary, some cases were placed biliary tract brackets. The patients with nonanastomotic biliary stricture were treated with PTC plus choledochoscope., Results: All the 366 patients were followed up for 58.5 (10 to 129) months. Biliary complications after liver transplantation were diagnosed in 42 cases among these patients. The incidence for biliary complications was 11.5%. The univariate analysis and multivariate Logistic regression analysis showed that the second warm ischemia period and the blood loss and the damage of blood supply and the diameter of biliary anastmosis were significantly associated with biliary complications after liver transplantations (Wald = 9.474 to 17.208, P < 0.05). Twelve cases with biliary leak were cured through abdominal and nasobiliary drainage. Twenty-two cases with anastomotic biliary stricture were administered sacculus dilatation through ERCP or PTC and were cured, including 6 cases were placed biliary tract brackets. Among 8 cases with nonanastomotic biliary stricture, 6 cases were cured through PTC associating with choledochoscope. One case was treated second liver transplantation and another case got worse., Conclusions: Ischemic injury and the diameter of anastmosis are risk factors for biliary complications after liver transplantations. The interventional management of biliary stricture and bile leakage after liver transplantation is safe and effective.

Endoscopic treatment for stenosis of an anastomotic biliary stricture (ABS) after orthotopic liver transplantation (OLT) has been proven to be effective and safe, but the long-term outcomes and the risk factors for recurrence are unknown. All 374 patients who underwent OLT at Frankfurt University Hospital were screened for the occurrence of ABSs. ABSs were treated via the endoscopic insertion of a plastic endoprosthesis (29.8%), balloon dilation (12.8%), or a combination of the two (57.4%). The mean follow-up time was 151 weeks, and the mean survival time was 3.4 years. ABSs were observed in 47 patients (12.6%). The mean time from OLT to an ABS was 16.25 months (median = 3.25 months). The cumulative incidence rates for ABSs were 0.09 after 12 months, 0.10/24 m. and 0.11/36 m. In 12 cases (25.5%), ABSs were observed more than 12 months after OLT. ABSs recurred in 16 of the 47 patients (34%). The occurrence of an ABS 6 weeks or more after OLT was a significant predictor of ABS recurrence [P = 0.04, hazard ratio (HR) = 0.235]. There was a trend of hepatitis C virus (HCV) infections being predominant in patients experiencing ABS recurrence (30% for HCV etiology versus 4% for non-HCV etiology) in comparison with patients not experiencing recurrence (36% for HCV etiology versus 30% for non-HCV etiology, P > 0.05). The severity of the initial stricture predicted ABS recurrence (P = 0.046, HR = 2.78), but it did not influence overall survival. The long-term resolution of ABSs was observed in 45 of the 47 patients (95.7%), and ABS recurrence was treated with another attempt (n = 16 or 34%) or 2 more attempts (n = 1) at endoscopic treatment. In conclusion, the long-term success of the endoscopic treatment of ABSs is highly probable if recurrent strictures are again treated endoscopically. ABSs might occur late (>36 months) after OLT, and lifelong follow-up is essential for identifying OLT patients with ABSs., (Copyright © 2013 American Association for the Study of Liver Diseases.)

Endoscopic retrograde cholangiopancreatography allows intervention for a variety of diseases of the biliary tract. Cannulation of the bile duct is the prerequisite step for biliary intervention. Although obtaining biliary access is straightforward in many cases, it can occasionally be challenging. Multiple devices, all with additional wire-guided techniques, have been developed to aid cannulation. More advanced techniques have also been developed to aid biliary access if it is unsuccessful with standard devices. Multimodality techniques can be used if other approaches fail. This article provides an evidence-based discussion of these approaches, and provides insight into their appropriate application., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Acute abdomen can be defined as a medical emergency in which there is sudden and severe pain in abdomen with accompanying signs and symptoms that focus on an abdominal involvement. It accounts for about 8 % of all children attending the emergency department. The goal of emergency management is to identify and treat any life-threatening medical or surgical disease condition and relief from pain. In mild cases often the cause is gastritis or gastroenteritis, colic, constipation, pharyngo-tonsilitis, viral syndromes or acute febrile illnesses. The common surgical causes are malrotation and Volvulus (in early infancy), intussusception, acute appendicitis, and typhoid and ischemic enteritis with perforation. Lower lobe pneumonia, diabetic ketoacidosis and acute porphyria should be considered in patients with moderate-severe pain with little localizing findings in abdomen. The approach to management in ED should include, in order of priority, a rapid cardiopulmonary assessment to ensure hemodynamic stability, focused history and examination, surgical consult and radiologic examination to exclude life threatening surgical conditions, pain relief and specific diagnosis. In a sick patient the initial steps include rapid IV access and normal saline 20 ml/kg (in the presence of shock/hypovolemia), adequate analgesia, nothing per oral/IV fluids, Ryle's tube aspiration and surgical consultation. An ultrasound abdomen is the first investigation in almost all cases with moderate and severe pain with localizing abdominal findings. In patients with significant abdominal trauma or features of pancreatitis, a Contrast enhanced computerized tomography (CECT) abdomen will be a better initial modality. Continuous monitoring and repeated physical examinations should be done in all cases. Specific management varies according to the specific etiology.

Biliary cast syndrome (BCS) is an uncommon complication of orthotopic liver transplantation (OLT), so the long-term treatment outcomes of BCS are not well characterized. The purpose of this study was to evaluate the long-term treatment outcomes and prognosis of BCS after OLT. The medical records of 1097 patients who underwent OLT from January 2000 to September 2009 were reviewed. Those patients who had BCS were evaluated with respect to the treatment method, overall survival and relapse rates, and relapse-free time. Twenty-three patients (2.1%) were diagnosed with BCS with a mean overall follow-up of 59.9 months. All the patients had benign biliary strictures and repeatedly underwent balloon dilatation by an endoscopic or percutaneous approach. Primary biliary cast removal was tried with the endoscopic method from 11 patients and with the percutaneous methods from 12 patients. Casts were completely removed by repetitive procedures in 22 patients, but BCS relapsed in 12 patients (55%). Persistent biliary strictures were significantly associated with the BCS relapse frequency (0.37 versus 0.05 times per year, P = 0.006). The 5-year overall survival rate for BCS patients after OLT was 87%. The risk factors associated with early relapse were female sex, hepatic artery stenosis, and acute cellular rejection. In a multivariate analysis, acute cellular rejection was the only significant risk factor for early relapse (hazard ratio = 11.1, 95% confidence interval = 1.9-63.2, P = 0.007). In conclusion, patients with BCS frequently relapse, and multiple interventions and the treatment of biliary strictures are needed. Acute cellular rejection after OLT is a significant risk factor for early relapse., (Copyright © 2013 American Association for the Study of Liver Diseases.)

In this descriptive study, we examined the role of single-operator cholangioscopy (SOC) in the evaluation of biliary complications after liver transplantation (LT). We prospectively included adult recipients of deceased donor LT who were referred for endoscopic retrograde cholangiopancreatography between June 2009 and July 2011. All patients underwent SOC with biopsy of the biliary anastomosis. Sixteen patients were included: 12 with biliary anastomotic strictures (ASs), 2 with common bile duct stones, 1 with a bile leak, and 1 with sphincter of Oddi dysfunction. Patients with ASs displayed 1 of 2 patterns: (A) mild erythema (n = 9) or (B) edema, ulceration, and sloughing (n = 3). Those without ASs displayed a pale mucosa with mild edema at the anastomosis. Patients with ASs and pattern B required a longer period of stenting than patients with pattern A (457 versus 167 days, P = 0.02). In addition, patients with pattern A had a better response and better resolution of their strictures with endoscopic therapy than those with pattern B (66% versus 33%, P = 0.13). Histological examinations of ASs showed nonspecific intraepithelial inflammation in patients with patterns A and B. Biopsy samples from patients without ASs showed normal columnar epithelial bile duct cells. The total cholangioscopy time for all procedures was 26.8 ± 10.1 minutes. In conclusion, SOC in LT recipients is feasible and allows adequate visualization and tissue sampling of ASs and bile ducts. Two distinct visual patterns that are easily identified with SOC may help to predict the outcomes of endoscopic therapy in patients with biliary complications after LT., (Copyright © 2012 American Association for the Study of Liver Diseases.)

Background: We conducted a population-based cross-sectional study to examine gender differences in severity, management, and outcome among patients with acute biliary pancreatitis (ABP) because available data are insufficient and conflicting., Methods: We analyzed 13,110 patients (50.6% male) with first-attack ABP from Taiwan's National Health Insurance Research Database between 2000 and 2009. The primary outcome was hospital mortality. Secondary outcomes included the development of severe ABP and the provision of treatment measures. Gender difference was assessed using multivariable analyses with generalized estimating equations models., Results: The odds of gastrointestinal bleeding (adjusted odds ratio [aOR] 1.44, 95% confidence interval [CI] 1.18-1.76) and local complication (aOR 1.38, 95% CI 1.05-1.82) were 44% and 38% higher in men than in women, respectively. Compared with women, men had 24% higher odds of receiving total parenteral nutrition (aOR 1.24, 95% CI 1.00-1.52), but had 18% and 41% lower odds of receiving cholecystectomy (aOR 0.82, 95% CI 0.72-0.93) and hemodialysis (aOR 0.59, 95% CI 0.42-0.83), respectively. Hospital mortality was higher in men than in women (1.8% vs. 1.1%, p = 0.001). After adjustment for potential confounders, men had 81% higher odds of in-hospital death than women (aOR 1.81, 95% CI 1.15-2.86). Among patients with severe ABP, hospital mortality was 11.0% and 7.5% in men and women (p<0.001), respectively. The adjusted odds of death remained higher in men than in women with severe ABP (aOR 1.72, 95% CI 1.10-2.68)., Conclusions: Gender is an important determinant of outcome in patients with ABP and may affect their treatment measures.

Background: Single-operator cholangioscopy enables direct diagnostic visualization and therapeutic intervention in the biliary tree. There is increasing evidence of its clinical utility in the assessment of biliary strictures and treatment of difficult stones., Objective: To describe the first reported Canadian experience with managing biliary disease using single-operator cholangioscopy., Methods: The present study was a retrospective analysis of data collected from all sequential patients undergoing single-operator cholangioscopy for assessment of biliary strictures and treatment of biliary stones. The main outcome measures were the ability to make an overall diagnosis of stricture (based on visual appearances and tissue histology), and to fragment and extract biliary stones., Results: Thirty patients (17 women), mean age 66 years (range 41 to 89 years) underwent single-operator cholangioscopy. In biliary strictures (20 patients), overall accuracy for visual and tissue diagnosis was 84% and 81%, respectively. Successful electrohydraulic lithotripsy with stone clearance was achieved in 90% of the 10 patients who failed previous conventional therapy. The mean (± SD) procedure time was 61±21 min (range 20 min to 119 min). One patient developed mild postendoscopic retrograde cholangioscopy pancreatitis., Conclusion: The results of this experience reaffirms the clinical utility and safety of single-operator cholangioscopy for the management of biliary pathology. Further improvements can be achieved with increasing operator experience and refinements in optical technology.

Extra-intestinal manifestations (EIMs) are reported frequently in patients with inflammatory bowel disease (IBD) and may be diagnosed before, concurrently or after the diagnosis of IBD. EIMs in IBD may be classified based on their association with IBD disease activity. The first group has a direct relationship with the activity of the bowel disease and includes pauciarticular arthritis, oral aphthous ulcers, erythema nodosum and episcleritis. The second group of EIMs appears to follow an independent course from the underlying bowel disease activity and include ankylosing spondylitis and uveitis. The third group includes EIMs that may or may not be related to intestinal inflammation, such as pyoderma gangrenosum and probably primary sclerosing cholangitis (PSC). Genetic susceptibility, aberrant self-recognition and immunopathogenic autoantibodies against organ-specific cellular antigens shared by the colon and extra-colonic organs may contribute to the pathogenesis and development of these EIMs. The use of biological agents in the IBD armamentarium has expanded the treatment options for some of the disabling EIMs and these agents form the cornerstone in managing most of the disabling EIMs. PSC is one of the most common hepatobiliary manifestations associated with IBD in which no clear treatment options exist other than endoscopic therapy and liver transplantation. Future research targeting the pathogenesis, early diagnosis and treatment of these EIMs is required.

ERCP is a diagnostic and therapeutic imaging modality widely used in adult pancreaticobiliary disease, including the treatment of anastomotic strictures following liver and small bowel transplant. We have previously reported a large series of ERCP in children and demonstrated its safety and utility in pediatric disease. The aim of this study was to evaluate the safety of and indications for ERCP following abdominal organ transplant among pediatric patients by performing a subgroup analysis of our large cohort. Forty-eight ERCPs were performed on 25 children ages 62 days to 20 yr following isolated liver, isolated small bowel, or composite graft transplant. Mean time from transplantation at the time of ERCP was 18 months. The most common indication for ERCP was the evaluation of non-specific hepatobiliary complaints, including abdominal pain and elevated liver enzymes. ERCP was also commonly performed for the evaluation or treatment of known or suspected biliary tree strictures. Seventy-seven percent of cases included therapeutic intervention, including sphincterotomy in 40%, stent placement in 29%, and stone extraction in 19%. The overall complication rate among post-transplant patients was low (2.9%) and not significantly different than the complication rate reported in our previous study. A history of abdominal organ transplant was not associated with an increased risk of complication following ERCP (OR = 0.41, 95% CI = 0.05-3.33). In our experience, ERCP can be safely performed in children following liver, small bowel, and composite graft transplant with outcomes similar to those seen in a general pediatric population and may be especially useful for the diagnosis and treatment for biliary strictures following transplant. Further investigation of the relationship between the timing of ERCP relative to transplant and the safety of the procedure is needed., (© 2012 John Wiley & Sons A/S.)

Objective: Endoscopic retrograde cholangiopancreatography (ERCP) has long been a tool utilized by gastroenterologists for many years, but direct cholangioscopy has only recently begun to be available for regular use in clinical practice. The focus of this study was to evaluate the efficacy of a direct cholangioscopy system and its indications within our patient population., Materials and Methods: This retrospective analysis was carried out at North Shore University Hospital. After obtaining institutional review board approval, the charts of patients who had undergone cholangioscopy from January 2007 through October 2011 were reviewed. An excel spreadsheet was created to record demographic information, significant laboratory data, indications for ERCP, ERCP findings, indication for cholangioscopy, findings, interventions, and biopsy results (if performed). A total of 34 cases were included in the final review., Results: Cholangioscopy indications included incomplete or failed stone removal, biliary stricture evaluation, and retrieval of a migrated biliary stent, among others. Electrohydraulic lithotripsy was utilized with almost complete success in cases of previous failed stone removal. In 12 cases where a cholangioscopy-directed biopsy was performed, adequate tissue was obtained in all cases, and aided in the exclusion of malignancy., Conclusion: Direct cholangioscopy is a new technology whose use is currently limited in clinical practice, but is growing in popularity. Its continued recognition as an important adjunct in the management of biliary and pancreatic disease should prompt further research into its use of a prospective nature. Given the limited number of direct cholangioscopy cases performed every year, large, randomized-controlled studies evaluating its efficacy and effect on outcomes have not yet been performed, but small studies may still continue to yield valuable information on its efficacy and safety.

Background: EUS-guided cholangiopancreatography (ESCP) allows transmural access to biliopancreatic ducts when ERCP fails. Data regarding technical details, safety, and outcomes of ESCP are still unknown., Objective: To evaluate outcomes of ESCP in community and referral centers at the initial development phase of this procedure, to identify the ESCP stages with higher risk of failure, and to evaluate the influence on outcomes of factors related to the endoscopist., Design: Multicenter retrospective study., Setting: Public health system hospitals with experience in ESCP in Spain., Patients: A total of 125 patients underwent ESCP in 19 hospitals, with an experience of <20 procedures., Intervention: ESCP., Main Outcome Measurements: Technical success and complication rates in the initial phase of implantation of ESCP are described. The influence of technical characteristics and endoscopist features on outcomes was analyzed., Results: A total of 125 patients from 19 hospitals were included. Biliary ESCP was performed in 106 patients and pancreatic ESCP was performed in 19. Technical success was achieved in 84 patients (67.2%) followed by clinical success in 79 (63.2%). Complications occurred in 29 patients (23.2%). Unsuccessful manipulation of the guidewire was responsible for 68.2% of technical failures, and 58.6% of complications were related to problems with the transmural fistula., Limitations: Retrospective study., Conclusion: Outcomes of ESCP during its implantation stage reached a technical success rate of 67.2%, with a complication rate of 23.2%. Intraductal manipulation of the guidewire seems to be the most difficult stage of the procedure., (Copyright © 2012 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Cholangiopathies are a group of diseases primarily or secondarily affecting bile duct cells, and result in cholangiocyte proliferation, regression, and/or transformation. Their etiopathogenesis may be associated with a broad variety of causes of different nature, which includes genetic, neoplastic, immune-associated, infectious, vascular, and drug-induced alterations, or being idiopathic. miRNAs, small non-coding endogenous RNAs that post-transcriptionally regulate gene expression, have been associated with pathophysiological processes in different organs and cell types, and are postulated as potential targets for diagnosis and therapy. In the current manuscript, knowledge regarding the role of miRNAs in the development and/or progression of cholangiopathies has been reviewed and the most relevant findings in this promising field of hepatology have been highlighted.

Background and Aims: Juxtapapillary diverticula (JPD) can increase the difficulty of biliary cannulation. A number of additional methods have been defined in case of failed cannulation attempt by standard technique. We aimed to investigate the more commonly preferred and practical additional methods among them., Methods: A total of 1,205 endoscopic retrograde cholangiopancreatographies (ERCP) performed during a study period of 14 months were prospectively entered into a database. Of these, 222 (18 %) had JPD (123 women, 99 men, mean age 69 years) and 983 had no diverticula (523 women, 460 men, mean age 57 years). Additional cannulation methods used in patients with JPD were recorded. Biliary cannulation time, total procedure time, use of pre-cut papillotomy, and therapeutic success of ERCP were compared between the groups as well., Results: Biliary cannulation was performed by standard technique in 210 patients with JPD (94.5 %). Cannulation was achieved by placement of a guidewire into the pancreatic duct in 6 (2.7 %) and use of two devices in one channel in 2 (0.9 %) patients. There was no significant difference between the total procedure time and therapeutic success of ERCP between the groups. Cannulation time was significantly longer in patients with JPD. Pre-cut papillotomy was performed less in patients with JPD., Conclusion: Presence of JPD does not decrease the therapeutic success of ERCP. Placement of a guidewire in the pancreatic duct or use of two-devices-in-one-channel are practical, successful, safe, and preferred methods which can be used in patients with failed cannulation by standard technique.

A lady aged 26 years reported with a 2 months history of fever, upper abdominal pain and weight loss. Her abdominal ultrasonographic scan revealed a complex cystic mass in left lobe of liver suggestive of hydatid cyst that was confirmed on magnetic resonance imaging of abdomen and magnetic resonance cholangiopancreatogram. With strong suspicion of a hydatid cyst, endoscopic retrograde cholangiogram was performed which confirmed the diagnosis. During the procedure, hydatid membranes protruding from the papilla were removed after sphincterotomy. She was put on albendazole 400 mg twice daily after the procedure and showed a remarkable clinical improvement.

Purpose of Review: Endoscopic ultrasonography (EUS) has taken on more of a therapeutic role in recent years. This review will focus on the therapeutic applications of EUS., Recent Findings: Multiple studies on the therapeutic applications of EUS have been published. EUS facilitates endoscopic drainage of pancreatic fluid collections (PFCs) including walled-off pancreatic necrosis, management of refractory gastrointestinal bleeding from gastric varix or vasculature by fine-needle injection and decompression of obstructive pancreatic or biliary ductal systems following failed access by standard endoscopic or radiological techniques., Summary: The indications and role of therapeutic EUS have expanded rapidly in recent years. The procedures can be technically challenging, requiring expertise in both endosonography and endoscopic retrograde cholangiopancreatography. Refinement in echoendoscope design and dedicated accessories are required to further expand the applications of therapeutic EUS.

Aim: To report our experience using a recently introduced anchoring balloon for diagnostic and therapeutic direct peroral cholangioscopy (DPOC)., Methods: Consecutive patients referred for diagnostic or therapeutic peroral cholangioscopy were evaluated in a prospective cohort study. The patients underwent DPOC using an intraductal anchoring balloon, which was recently introduced to allow consistent access to the biliary tree with an ultraslim upper endoscope. The device was later voluntarily withdrawn from the market by the manufacturer., Results: Fourteen patients underwent DPOC using the anchoring balloon. Biliary access with an ultraslim upper endoscope was accomplished in all 14 patients. In 12 (86%) patients, ductal access required sphincteroplasty with a 10-mm dilating balloon. Intraductal placement of the ultraslim upper endoscope allowed satisfactory visualization of the biliary mucosa to the level of the confluence of the right and left hepatic ducts in 13 of 14 patients (93%). Therapeutic interventions by DPOC were successfully completed in all five attempted cases (intraductal biopsy in one and DPOC guided laser lithotripsy in four). Adverse events occurred in a patient on immunosuppressive therapy who developed an intrahepatic biloma at the site of the anchoring balloon. This required hospitalization and antibiotics. Repeat endoscopic retrograde cholangiopancreatography 8 wk after the index procedure showed resolution of the biloma., Conclusion: Use of this anchoring balloon allowed consistent access to the biliary tree for performance of diagnostic and therapeutic DPOC distal to the biliary bifurcation.

Objectives: Commercially available 10F cholangioscope systems have limitations in examination of the biliary tree. Further, they are not readily available in all endoscopy units. Direct cholangioscopy (DC) using slim and ultraslim gastroscopes have been utilized to detect and treat bile duct (BD) diseases. It often requires initial duodenoscope introduction, followed by over-the-wire exchange to a gastroscope for BD intubation. We report a novel single-step DC technique using forward-viewing endoscopes without requiring tandem-scope exchange., Methods: In patients with native papilla, a "J" maneuver, accomplished by retroflexing the endoscope in the second portion of the duodenum and withdrawing the retroflexed scope into the BD, was used to achieve free intubation. A variety of readily available standard endoscopes were used. For biliary-enteric anastomoses, balloon dilation, if necessary followed by enteroscope advancement, was utilized for BD visualization., Results: A total of 18 patients underwent 22 DC procedures (8 male, 10 female, mean age 69 years). Direct intubation was successful in all procedures. Indications included BD stone (n=10), BD stricture or tumor (n=8). A native papilla was present in 13 patients and biliary-enteric anastomoses in 5; 8 patients had altered gastrointestinal anatomy. Sphincterotomy was required in 12/13 native papilla patients to facilitate DC. Free intubation of the BD was accomplished in 19 of 22 exams, and 3 facilitated by guidewire (over-the-wire in 2 and alongside a guidewire in 1). Overtube-assisted enteroscopy was used to reach the BD in four patients. The findings were stones (n=6), strictures or tumors (n=7), abnormal mucosa (n=5), a dilated duct confirming stone clearance without stricture (n=3), and retained stent (n=1). Interventions were biopsy (n=8), stone extraction (n=5), electrohydraulic lithotripsy (n=3), chromoendoscopy (n=2), narrow-band imaging (n=2), through the scope stricture dilation (n=2), and argon-plasma coagulation of biliary tumor (n=1). Complications were cholangitis managed with intavenous antibiotics (n=1)., Conclusions: Single-step DC can be achieved without using tandem-scope exchange, and may be clinically useful for diagnostic and therapeutic purposes in managing select biliary tract diseases.

Despite significant advances in orthotopic liver transplantation (OLT), biliary tract reconstruction is still a major source of complications. Choledochocholedochostomy with a T-tube used to be the standard procedure for biliary reconstruction after OLT. However, many centers currently avoid use of the T-tube because of the high incidence of complications. Our aim was to study the biliary complications occurring at our center when end-to-end choledochocholedochostomy (EE-CC) over a T-tube was used as the standard procedure for biliary reconstruction. A retrospective review was conducted of all patients who underwent liver transplantation from February 1, 1996, to April 30, 2010. Only patients requiring any therapy to treat biliary complications were considered, whereas those with concomitant hepatic artery complications were excluded. The study cohort consisted of 743 patients who had EE-CC with a T-tube. Of these, 73 patients (9.8%) experienced any biliary complication. Anastomotic strictures occurred in 17 patients (2.3%), and non-anastomotic strictures in 2 (0.3%). Fifteen patients with anastomotic strictures were successfully treated by dilatation and stenting. Bile leakage was diagnosed in 39 patients (5.2%). Leakage occurred at the anastomosis in 15 patients (2%), and at the exit site of the T-tube in 24 patients (3.2%). Tube opening was the only treatment used in 30 patients with bile leakage (76.9%). Seven patients experienced leaks after elective T-tube removal (1%). Overall, repeat surgery to manage biliary complications was needed in 9 patients (1.2%). The mortality rate from biliary complications was 0.13%. In conclusion, EE-CC with a T-tube was followed by a low incidence of biliary complications. The complication rate after elective T-tube removal and the repeat surgery rate were extremely low. These results might challenge the current trend to avoid T-tube stenting in OLT., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Endoscopic retrograde cholangiopancreatography (ERCP) has become enormously popular throughout the world because of its proven value in the management of patients with known and suspected biliary and pancreatic disease. The results of ERCP are operator dependent, and there are significant risks. Adverse events are more likely when procedures are performed by endoscopists with inadequate training and experience. The best outcomes should occur when procedures are done for the best reasons, using optimal techniques in an ideal environment and a well-trained team, conscious of the risks and the ways to minimize them. This article discusses these intertwining elements of ERCP., (Copyright © 2012 Elsevier Inc. All rights reserved.)

For most ERCP endoscopists, the greatest hurdle to a successful procedure is deep cannulation of the bile duct. This article explores basic cannulation technique, then reviews a variety of instruments and techniques designed to increase the average endoscopist's success rate. Expert ERCP endoscopists have a few favorite techniques that have proved reliable over time. The most frequently used ones are highlighted in this review., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Over the last 40 years, endoscopic retrograde cholangiopancreatography (ERCP) has evolved from being a purely diagnostic to a primarily therapeutic procedure. The 2 recent developments in ERCP-based stricture management include the increased use of cholangioscopy-guided sampling and self-expandable metal stents. The role of ERCP in pancreatic diseases continues to evolve; ERCP-based pancreatic therapy requires advanced endoscopic expertise and is associated with a high rate of postprocedure complications. Therefore, a multidisciplinary team approach at a center with expertise in pancreatic therapy should serve as a basis for very careful patient selection., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Unlabelled: STUDY BACKGROUND AND AIMS: Predicting outcome at endoscopic retrograde cholangiopancreatography (ERCP) remains difficult. Our aim was to identify the risk factors for failed ERCP., Patients and Methods: A prospective multicenter study of ERCP was performed in 66 hospitals across England. Data on 4561 patients were collected using a structured questionnaire completed at the time of ERCP., Results: In total 3209 patients had not had an ERCP prior to the study period. Considering their first ever ERCP, 2683 (84 %) were successfully cannulated, 2241(70 %) had all intended therapy completed, 360 (11 %) had some intended therapy completed, and 608 (19 %) were considered to have had a failed procedure. For first ever ERCP, factors associated with incomplete procedure (odds ratio and 95 % confidence interval) were: Billroth surgery (9.2, 3.2 - 26.7), precutting (2.0, 1.6 - 2.7), common bile duct (CBD) stone size and number (3.2, 2.1 - 4.8 for multiple, large stones), interventions in the pancreatic duct (3.4, 1.6 - 7.0), and CBD stenting (2.8, 2.2 - 3.5). Analysis of the 1352 patients who had undergone an ERCP prior to the study period indicated previous failed ERCP was also predictive of incomplete therapy (1.5, 1.1 - 2.1). The modified Schutz score correlated with ERCP completion, as did the Morriston score, even when modified to include only variables measurable before the procedure., Conclusion: This study confirms that patient- and procedure-based variables are key predictors of technical success and validates current methods of rating ERCP difficulty. Of note, a correlation between outcome and institutional factors, such as unit and endoscopist caseload, was not demonstrated., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Percutaneous transhepatic balloon dilatation is an alternative to surgery when benign bilioenteric strictures (BBES) are inaccessible to endoscopic treatment. Our primary objective was to report long-term patency of balloon-dilated BBES., Methods: A total of 110 consecutive patients with 155 BBES had percutaneous transhepatic complete drainage of all biliary territories, balloon dilatation, and catheter stenting. Intracorporeal electrohydraulic lithotripsy treated associated biliary stones. Biliary drains were removed when no residual balloon waists were observed on at least 2 consecutive sessions, 6 weeks apart., Results: A total of 109 of 110 patients had complete drainage. Forty-five patients had successfully treated associated stones. Eleven patients had short-term complications. No patients died. The median follow-up period was 59 months (range, .5-278 mo). Twenty-three patients were lost to follow-up evaluation. Thirteen patients had recurrent biliary obstruction (15%). Life-table analysis showed 90.9% bilioenteric patency after 2,697 days., Conclusions: Percutaneous balloon dilatation and calibration of BBES provides acceptable morbidity and low long-term stricture recurrence., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Purpose: The aim of this study was to evaluate our experience with percutaneous treatment of biliary strictures after orthotopic liver transplantation in adult patients without the endoscopic access possibility and to evaluate the technical outcomes and long-term clinical results of this treatment., Materials and Methods: Thirty percutaneous procedures were performed in adult liver transplant recipients (13 men, 17 women, mean age 46.4 years) in our institution between 1996 and 2010. Patients were treated with balloon dilatation and biliary duct drainage due to anastomotic stenosis (n = 20), nonanastomotic stenosis (n = 7), or due to stenosis caused by lymphoproliferation (n = 3). The percutaneous procedure was the first line of treatment due to hepaticojejunoanastomosis (n = 18) or after unsuccessful endoscopic therapy (n = 12)., Results: Technical success was achieved in 27 patients (90%). The remaining three patients only achieved external drainage with subsequent surgery. There were two complications (6.3%). Long-term clinical success, defined as the absence of clinical, laboratory, or sonographic signs of stricture recurrence was achieved in 22 patients (73.3%) for a mean follow-up of 5.8 years., Conclusion: Percutaneous treatment--balloon dilatation and biliary duct drainage--is a first-line option to manage biliary duct strictures in liver recipient, when endoscopic treatment is not possible or unsuccessful. It has a high technical success rate and low complication rate with favorable long-term results., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Hepatic arterial infusion pump chemotherapy (HAIPC) contributes to the prolonged survival of selected patients with colorectal cancer liver metastases (CRCLM). The most clinically important adverse event after HAIPC with floxuridine (FUDR) is biliary sclerosis (BS). Little is known about the etiology of BS., Methods: HAIPC was administered to 475 consecutive patients who received HAIPC on prospective protocols from 1991 to 2008. The incidence, clinical features, variables related to demographics, comorbidity, medical history, CRCLM, surgery, chemotherapy, and laboratory data were reviewed. An analysis of factors potentially associated with BS, defined as a biliary stricture related to HAIPC requiring stent placement, was performed., Results: The incidence of BS was 5.5% (16 of 293) in patients receiving HAIPC as an adjuvant therapy after hepatectomy, and 2% (2 of 100) in patients receiving HAIPC with FUDR for unresectable disease. The common hepatic duct was the site most frequently affected (87.5%). In patients receiving adjuvant HAIPC, BS was associated with abnormal postoperative flow scans (18.8% vs. 1.8%, P = 0.006), postoperative infectious complications (50.0% vs. 14.8%, P = 0.002), and larger dose/cycle/weight of FUDR (2.6 vs. 2.0 mg/cycle/kg, P = 0.025) than patients without BS. No patient died directly of BS. Median survival was not compromised by the development of BS (BS vs. non-BS: 61.0 months [range 6.2-171.6 months] vs. 47.2 months [range 2.4-200.8 months], P = 0.316, respectively)., Conclusions: BS is an uncommon complication after HAIPC and does not compromise survival if adequately salvaged by stenting or dilatation. Surgical complications as well as type and dose of intra-arterial chemotherapy may contribute to the development of BS.

The success rate of deep biliary cannulation is high but still not perfect in endoscopic retrograde cholangiopancreatography (ERCP), even with aggressive techniques. With the development of linear-array echoendoscopes, the endoscopic ultrasonography-guided rendezvous technique (EUS-RV) has recently emerged as a salvage method for failed biliary cannulation. This review of current literature establishes that EUS-RV is a feasible and safe technique and should be considered as an alternative to percutaneous or surgical approaches. The availability of a percutaneous salvage (if EUS-RV fails) and well-trained endoscopists for both ERCP and EUS are mandatory in minimizing the potential complications of this procedure., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Traditionally, a 2-step protocol has been used for deep biliary cannulation. The purpose of the present prospective study was to find out the feasibility and safety of the novel sequential 3-step protocol (traditional cannula with guidewire, double-guidewire, and needle-knife techniques) for deep biliary cannulation. All consecutive patients admitted for endoscopic retrograde cholangiopancreatography (ERCP) to a single, very experienced ERCP endoscopist during the year 2009 with intended biliary cannulation and with unhindered access to a native papilla (n=105) were included in the present study. The overall success rate for deep biliary cannulation was 99% (104/105). Cannulation with cannula and guidewire was attempted in all patients and proved successful in 80% (84/105) of the attempts, the double-guidewire technique was applied in 19% (20/105) and was successful in 65% (13/20) of the cases, and the needle-knife technique was applied in 7% (7/105) with success in all cases. The median cannulation time was 1 minute (range, 0 to 27 min). The rate of post-ERCP pancreatitis was 3% (3/105) and post-ERCP cholangitis 2% (2/105). We conclude that in experienced hands, the novel sequential 3-step protocol for biliary cannulation tested herein proved to be an effective cannulation protocol with the overall success rate of 99%. The complication rate of these ERCP procedures (5%) was within acceptable limits.

Although some technical challenges in the development of dedicated devices need to be overcome, endoscopic ultrasonography (EUS)-guided anastomosis is promising as a minimally invasive technique for pancreatobiliary diseases., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Although liver injury scale does not predict need for surgical intervention, a high-grade complex liver injury should alert the physician to expect an increased risk of hepatic complications following trauma. The aim of the current study was to define hepatic related morbidity in patients sustaining high-grade hepatic injuries that could be safely managed non-operatively., Patients and Methods: This is a retrospective study of patients with liver injury admitted to Hadassah-Hebrew University Medical Centre over a 10-year period. Grade 3-5 injuries were considered to be high grade. Collected data included the number and types of liver-related complications. Interventions which were required for these complications in patients who survived longer than 24 hours were analysed., Results: Of 398 patients with liver trauma, 64 (16%) were found to have high-grade liver injuries. Mechanism of injury was blunt trauma in 43 cases, and penetrating in 21. Forty patients (62%) required operative treatment. Among survivors 22 patients (47.8%) developed liver-related complications which required additional interventional treatment. Bilomas and bile leaks were diagnosed in 16 cases post-injury. The diagnosis of bile leaks was suspected with abdominal CT scan, which revealed intraabdominal collections (n = 6), and ascites (n = 2). Three patients had continuous biliary leak from intraabdominal drains left after laparotomy. Nine patients required ERCP with biliary stent placement, and 2 required percutaneous transhepatic biliary drainage. ERCP failed in one case. Four angioembolizations (AE) were performed in 3 patients for rebleeding. Surgical treatment was found to be associated with higher complication rate. AE at admission was associated with a significantly higher rate of biliary complications. There were 24 deaths (37%), the majority from uncontrolled haemorrhage (18 patients). There were only 2 hepatic-related mortalities due to liver failure., Conclusions: A high complication rate following high-grade liver injuries should be anticipated. In patients with clinical evidence of biliary complications, CT scan is a useful diagnostic and therapeutic tool. AE, ERCP and temporary internal stenting, together with percutaneous drainage of intra-abdominal or intrahepatic bile collections, represents a safe and effective strategy for the management of complications following both blunt and penetrating hepatic trauma.

Background: Biliary complications are a major problem in pediatric liver transplantation. The aim of this study was to evaluate the management and outcomes of biliary complication after pediatric living donor liver transplantation (LDLT)., Methods: From 1994 to 2010, 157 pediatric LDLT due to biliary atresia were performed in our center. Doppler ultrasound was initially performed daily for 2 weeks postoperatively to evaluate biliary and vascular complications. Computed tomography and or magnetic resonance cholangiography were performed when complications were suspected. They were treated using radiological or surgical interventions., Results: Among the 157 cases, we observed 10 (6.3%) biliary complications, which were divided into three groups: bile leakage (n=3); biliary stricture without vascular complication (n=4); and biliary stricture with vascular complication (n=3). The three cases bile leakages recovered after interventional procedures. The seven biliary strictures underwent percutaneous transhepatic cholangial drainage (PTCD). All cases without vascular complications were completely cured after PTCD or a subsequent surgical re-anastomosis. In the vascular complication group, early recorrection of the HA occlusion with successful PTCD treatment were performed in two cases, but one other case with diffuse ischemic biliary destruction had a poor result., Conclusion: Successful interventional radiographic approaches are effective for anastomotic biliary complications but with poor results in diffuse ischemic biliary destruction., (Copyright © 2012 Elsevier Inc. All rights reserved.)

This article is part of a combined publication that expresses the current view of the European Society of Gastrointestinal Endoscopy about endoscopic biliary stenting. The present Clinical Guideline describes short-term and long-term results of biliary stenting depending on indications and stent models; it makes recommendations on when, how, and with which stent to perform biliary drainage in most common clinical settings, including in patients with a potentially resectable malignant biliary obstruction and in those who require palliative drainage of common bile duct or hilar strictures. Treatment of benign conditions (strictures related to chronic pancreatitis, liver transplantation, or cholecystectomy, and leaks and failed biliary stone extraction) and management of complications (including stent revision) are also discussed. A two-page executive summary of evidence statements and recommendations is provided. A separate Technology Review describes the models of biliary stents available and the stenting techniques, including advanced techniques such as insertion of multiple plastic stents, drainage of hilar strictures, retrieval of migrated stents and combined stenting in malignant biliary and duodenal obstructions.The target readership for the Clinical Guideline mostly includes digestive endoscopists, gastroenterologists, oncologists, radiologists, internists, and surgeons while the Technology Review should be most useful to endoscopists who perform biliary drainage., (© Georg Thieme Verlag KG Stuttgart · New York.)

In liver transplantation (LT), biliary strictures (BSs) are among the most common complications. The aim of this study was to evaluate the efficacy of percutaneous treatments in the management of post-LT BSs. Between 1999 and 2007, 48 patients underwent percutaneous treatments for posttransplant BSs. We divided the population into 2 groups according to the cause [ischemic (n = 14) or nonischemic (n = 34)] and into further subgroups according to the site [anastomotic (n = 34) or nonanastomotic (n = 14)]. All patients were treated with bilioplasty; in 9 patients who were refractory to bilioplasty, metallic stents were implanted. A technical success rate of 90% was achieved without differences between the ischemic and nonischemic groups or between the anastomotic and nonanastomotic subgroups (P = 0.10). The major complication rate was 4%. The overall 1- and 3-year primary patency rates were 94% and 45%, respectively, and better results were found for patients with nonischemic stenoses versus patients with ischemic stenoses (P = 0.032). The overall secondary patency rates were 94% and 83% at 1 and 3 years, respectively, and there were no statistical differences between the ischemic and nonischemic groups or between the anastomotic and nonanastomotic groups. In the stent subgroup, the overall primary 1- and 2-year patency rates were 100% and 71%, respectively, and the secondary patency rates were 100% and 100%, respectively. In conclusion, a percutaneous approach is highly effective for the treatment of post-LT BSs, and the best results are obtained for patients with simple, nonischemic BSs (technical success rate = 94%, 3-year primary patency rate = 81%, 3-year secondary patency rate = 75%). For patients with ischemic BSs, closer follow-up and retreatment are more frequently needed to achieve secondary patency rates comparable to (or even better than) those for patients with nonischemic stenoses., (Copyright © 2011 American Association for the Study of Liver Diseases.)

Objective: To evaluate the indications, clinical features, complications, and effect on patient management of Endoscopic retrograde cholangiopancreatography (ERCP) in paediatric patients of varying age., Methods: A prospective, descriptive cross sectional study was conducted at the endoscopy suite, Surgical Unit 4, Civil Hospital Karachi; from January 2007 to August 2010. All ERCPs performed during a 3-year period in patients aged 18 years or less were prospectively analyzed. Success was defined as having authentic diagnostic information or a successful endoscopic therapy., Results: A total of 40 children and adolescents (18 Males, 22 Females; mean age 13.6 +/- 3.37 years, range 3 to 18 years) underwent 52 ERCP procedures. Indications were biliary pathology in 21, and pancreatic pathology in 19. The ERCP findings were choledocholithiasis in 12 patients, choledochal cysts in 5, chronic pancreatitis in 8, pancreatic pseudocyst in 5, recurrent pancreatitis in 5, biliary ascariasis in 2, pancreatic divisum in 1, postoperative bile leak in 1, and benign biliary stricture in 1. ERCP was successful in 51 of 52 procedures. Single procedure was performed in 36 patients, where as two patients required 2 procedures and it was repeated 4 and 6 times in the remaining two patients. Endoscopic therapy was performed in 92% of the procedures. The complication rate was 1.9% (1/52 procedures) which included mild pancreatitis, whereas asymptomatic hyperamylasaemia was seen in 11% (6/52 procedures). No mortality related to ERCP occurred. ERCP affected management in 94% (49/52 patients)., Conclusion: ERCP is an effectual and safe therapeutic procedure in children and adolescents of different ages with a variety of pancreatobiliary disorders.

Objectives: This study was designed to audit current practice in percutaneous biliary drainage and stenting in the United Kingdom., Methods: In 2006, the British Society of Interventional Radiology set up the first web-based Biliary Drainage and Stenting Registry (BDSR). This consisted of a series of tick sheets, which were completed online. Data collection included technical and clinical success of the procedures and outcomes at discharge with a separate form for any follow-up visits. Two months before data analysis, all contributors were asked via email to complete any outstanding data. This paper reports on data collected between November 1, 2006 and August 18, 2009., Results: A total of 833 procedures were recorded and were entered by 62 operators from 44 institutions within the United Kingdom. There were 455 men and 378 women with a median age of 69 (range 20-101) years.The majority of procedures were performed by a consultant. Successful drainage of the biliary tree was achieved in 98.7%. Partial or complete relief of symptoms was seen in 65% of patients. Minor complications, predominantly pain (14.3%), were seen in 26% and major complications, predominantly sepsis (3.5%), were seen in 7.9% of patients., Conclusions: These figures provide an essential benchmark for both audit and patient information. Identifying areas of good practice and those that require improvement will ultimately result in better patient care.

Obstructive biliary jaundice is a common complication in patients with malignancies which infiltrate biliary ducts. If untreated efficiently the jaundice is fatal a short period of time. We present a case of 60-year-old male patient who had undergone Whipple procedure in the past and presented with local recurrence treated successfully by percutaneous stenting of obstructed biliary duct. When passing through the obstruction we observed a contrast-bile leakage at the level of occluded segment and instability of implanted stent which was a complication that extorted atypical approach. We applied a covered stent in association with oversized nitinol stent which allowed to form a funnel-like construction efficiently decompressing biliary tree. Thanks to this management we also avoided further complications.

The therapeutic efficiency of ursosan in 64 overweight patients with chronic noncalculous cholecystitis and dysfunction of biliary tract was evaluated. Including of ursosan in the complex therapy of patients with chronic noncalculous cholecystitis enhances the efficiency of therapy, causes the positive changes in clinical symptoms and indicators of the biliary tract function, diminishes the lithogenic properties of bile, normalize the food behavior.

51 patients with liver alveococcosis were operated on: radical operations with the whole hydatid tumor removal, cytoreductive operations with 50-80% of the tumor removal and alveococcal nodes' preserving on vital organs; and palliative manipulations, aimed the relief of complications were performed. According to the treatment results, the radical liver resection proved to be the most effective. When the complete tumor removal is impossible, cytoreductive operations are possible. Combination with antiparasitic therapy is required.

Background: Roux-en-Y gastric bypass (RYGB) surgery is one of the most commonly performed bariatric surgeries in the United States. Patients with prior RYGB are not amenable to conventional endoscopic retrograde cholangiopancreaticography (ERCP). Surgical gastrostomy (SG) tube placement enables transgastrostomy ERCP (TG-ERCP)., Materials and Methods: Eleven patients with RYGB anatomy received open Stamm gastrostomy after which the tract was then allowed to mature for an average of 45 days before therapeutic TG-ERCP. The success rate and procedure-related complications of both gastrostomy and ERCP were assessed., Results: TG-ERCP was performed on eleven patients (median age 52 years, range 37-61 years) with prior RYGB and pancreatobiliary diseases. Indications for ERCP in these patients included suspected gallstone pancreatitis (n = 4), ampullary/biliary strictures (n = 5), pancreas divisum (n = 1), and common bile duct clipping as a result of RYGB surgery (n = 1). Two individuals developed post surgical complications with stomal-related infections. TG-ERCP with therapeutic intervention was successfully performed in all patients. Intervention included stone extractions (n = 11), biliary stricture dilation (n = 11), biliary sphincterotomy (n = 11), biliary (n = 3) and pancreatic (n = 1) stent placement, ampullary biopsies (n = 3), choledochoscopy (n = 1), and pseudocyst drainage (n = 1). Complications included post-ERCP pancreatitis (n = 2), post-sphincterotomy bleeding (n = 1), gastrostomy site bleed (n = 1), and gastric perforation (n = 1). The total number of ERCP sessions for the eleven patients was 15 (1 or 2 per patient). Median follow-up was 42 days (range 7-123 days)., Conclusion: Surgical open gastrostomy followed by TG-ERCP enables therapeutic intervention but is associated with significant complications.