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Completely obstructed benign biliary strictures (BBS) is a difficult-to-treat condition. Surgery is the main treatment modality with high morbidity and mortality. Recently, the magnetic compression anastomosis (MCA) technique was employed in such cases with low complication rates.To evaluate the effectiveness of the MCA in completely obstructed BBS.21 MCA procedures were performed in 19 patients with completely obstructed BBS. All patients had percutaneous biliary access. Magnets were located to the proximal side of the obstruction via percutaneous biliary sheath and the distal side endoscopically. The procedure was terminated as the magnets attracted. Either self-expandable fully covered metallic stent and/or a growing number of plastic stents were introduced after recanalization was achieved.A total number of 19 patients with completely obstructed BBS resulting from cholecystectomy or liver transplant underwent 21 MCA procedures. Among those, 19 (90.5%) interventions were successful. The median stricture length that had been measured after magnet attraction was 4 mm (range 1-10 mm). The median magnet coupling time in successful cases was 9 days (range 4-27 days). No correlation was found between magnet coupling time and stricture length (p = 0.27). Complications were observed in 6 (cholangitis:1, magnet migration:2, magnet entrapment:3) of 19 successful MCA procedures. Fifteen of the 19 successful procedures had at least a period of stent-free follow-up. Recurrence of stenosis occurred in 7 procedures, of which 4 remained stent-free with retreatment. Eventually, 12 procedures had stent-free last status.MCA is an effective and safe treatment option in completely obstructed BBS. Further studies are required for procedural standardization.

Aim The aim of this study was to investigate the incidence, risk factors, and treatment strategies of proximally migrated pancreatic stents. Materials and methods The data of 626 sessions of 421 patients with pancreatic duct stenting were retrospectively analyzed between 2010 and 2018, and patients with proximally migrated stents were included in the study. Results Of 626 stents examined, 77 migrated proximally (12%). The migration rate (MR) was 16%, 2%, and 7%, respectively, in patients treated with chronic pancreatitis, malignancy, and pancreatic leakage indication. The MR was 14% in procedures with pancreatic duct stenosis, 21% in procedures with pancreatic sphincterotomy, and 27% in procedures performed from minor papillae. The MR of the 5, 7, and 10 Fr stents was 4%, 17%, and 10%, respectively. Of the 77 migrated stents, 64 were successfully removed (83%). This success rate (SR) was 84% in procedures with chronic pancreatitis indication, 83% in procedures with pancreatic duct stenosis, 79% in procedures with sphincterotomy, and 75% in procedures performed from minor papillae. The SR of the 5, 7, and 10 Fr stents was 100%, 79%, and 92%, respectively. It was also determined that 33 stents were fractured and migrated (43%). The SR of the fractured stents was 76%. Moreover, of the stents that were successfully removed, 35 were removed with forceps (55%) and 15 (23%) were removed with a balloon. Furthermore, in 47 cases, the stent was removed in the first session (73%). Acute pancreatitis occurred in 5 patients (8%) and perforation occurred in 1 patient (2%). Conclusion In this study, it was shown that proximal migration of pancreatic stents is frequent and most of these stents can be removed successfully.

Giriş ve Amaç: Bu çalışmada 85 yaş üstü hastalarda endoskopik retrograd kolanjiyopankreatografinin endikasyonları, bulguları, başarısı ve komplikasyonları araştırıldı. Gereç ve Yöntem: Bu çalışmada 2015-2019 yılları arasında endoskopik retrograd kolanjiyopankreatografi yapılan hastaların kayıtları incelenmiş ve çalışma 85 yaş üzeri 289 hasta ile yapılmıştır. Bulgular: Çalışma 169 kadın (%58) ve 120 erkek (%42) olmak üzere toplam 289 hasta ile yapılmıştır. Hastaların ortalama yaşı 88 idi (85-108). Endoskopik retrograd kolanjiyopankreatografinin en sık endikasyonları izole karaciğer enzim yüksekliği (%39), kolanjit (%32) ve karaciğer enzim yüksekliği olmaksızın karın ağrısıydı (%21). Hastaların %66’sına yatırılarak, %87.2’sine sadece tek seans endoskopik retrograd kolanjiyopankreatografi yapılmıştı. Hastaların %28’inde divertikül mevcuttu ve %25’i sfinkterotomiliydi. Hastaların %99’u ilk seansta, tamamı ise ikinci seansta kanülize edildi. 241 hastada selektif (%83), 48 hastada precut (%16) yöntemi kullanıldı. En sık endoskopik retrograd kolanjiyopankreatografi bulguları koledok taşı (%71) ve malign biliyer darlıktı (%12). En sık görülen maligniteler ise pankreas kanseri (%38) ve kolanjiyokanserdi (%32). Taş çıkanlarda teknik başarı %99, malign hastalarda ise %100 idi. Çalışmamızda en sık görülen komplikasyonlar post-endoskopik retrograd kolanjiyopankreatografi pankreatiti (%5.8) ve kanama (%2) idi. Bir hastada tip 1 perforasyon gelişti ve hasta exitus oldu. Üç yıllık takipte mortalite oranı %26 iken 30 günlük mortalite oranı %8 olarak bulunmuştur. Sonuç: Eşlik eden kronik hastalıklara rağmen, 85 yaş ve üstü hastalarda endoskopik retrograd kolanjiyopankreatografi güvenli ve etkili bir tedavi yöntemidir., Background and Aims: We investigated the indications, findings, and success and complication rates using endoscopic retrograde cholangiopancreatography in patients aged ≥85 years. Materials and Methods: The study included 289 patients aged ≥85 years. The records of patients who had undergone endoscopic retrograde cholangiopancreatography between 2015 and 2019 were examined. Results: The study population included 169 females (58%) and 120 males (42%) with a mean age of 88 years (range, 85-108 years). The most common indications for endoscopic retrograde cholangiopancreatography were isolated liver enzyme level elevation (39%), cholangitis (32%), and abdominal pain without elevated liver enzyme levels (21%). Of the total, 66% patients were hospitalized and 87.2% patients required only 1 endoscopic retrograde cholangiopancreatography session. Diverticulum was present in 28% patients, and 25% had prior sphincterotomy. Cannulation in the first session was performed for 99% patients and in the second session for the remaining. Of the total, selective method was used in 241 patients (83%) and precut method in 48 patients (16%). The most common endoscopic retrograde cholangiopancreatography findings included choledochal stone (71%) and malignant biliary stenosis (12%). The most common malignancies included pancreatic cancer (38%) and cholangiocarcinoma (32%). A 99% technical success was achieved in patients with stone, which was 100% in patients with malignancy. The most common complications included post- endoscopic retrograde cholangiopancreatography pancreatitis (5.8%) and bleeding (2%). One patient experienced type 1 perforation and died. The 30-day mortality rate was 8%, which increased to 26% at the 3-year follow-up. Conclusion: Despite concomitant chronic diseases, endoscopic retrograde cholangiopancreatography is a safe and effective treatment for patients aged ≥85 years.

Background: Rectal indomethacin or a topical spray of epinephrine to the papilla of Vater has each shown efficacy alone in the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). We supposed that a submucosal epinephrine injection would be more effective and longer acting than a topical epinephrine spray and therefore would further reduce the incidence of PEP. Patients and Methods: A retrospective analysis was conducted of 412 patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) between January 2017 and December 2019. These patients were divided into 2 groups: the indomethacin group and the indomethacin plus the submucosal epinephrine injection group. The incidence rates and severity of PEP, post-ERCP hyperamylasemia, other outcomes, and any other adverse events were compared between the groups. Results: Baseline demographic and clinical characteristics and procedure-related parameters were similar between the 2 groups. The incidence of PEP was 0.4% in the epinephrine group compared with 5.1% in the indomethacin group (P

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with Billroth II gastrectomy is a difficult procedure. Although different endoscopes are used in these patients, comparative studies are limited. The aim of this study was to assess the efficacy and the safety of the forward-viewing gastroscope compared with the side-viewing duodenoscope. This study was conducted on 75 Billroth II gastrectomy patients who underwent ERCP by the same experienced endoscopist. Procedures were performed using side-viewing duodenoscope in the first 41 patients and forward-viewing gastroscope in the subsequent 34 patients. The success and complication rates of ERCP were compared between the two groups. Afferent loop intubation was achieved in 39 patients (95.1%) in the side-viewing duodenoscope group and in 34 patients (100%) in the forward-viewing gastroscope group (P = 0.49). The rates of reaching the papilla was 70.7% (n = 29) and 91.1% (n = 31), respectively (P = 0.06). Cannulation success rate after reaching the papilla was 100% in the side-viewing duodenoscope group and 90.3% in the forward-viewing gastroscope group. In the side-viewing duodenoscope group, 11 patients underwent sphincterotomy (EST), 14 patients underwent both EST and endoscopic papillary balloon dilatation (EPBD), and 4 patients underwent only EPBD. All but one patients in the forward-viewing gastroscope group underwent EPBD without EST. The technical and the clinical success rate did not statistically differ between the groups (70.7% vs. 82.3%, 68.3% vs. 79.4%, respectively). Adverse events included jejunal perforation in one patient (2.4%) in the side-viewing duodenoscope group, and pancreatitis in one patient (2.9%) in the forward-viewing gastroscope group (P > 0.05). This study indicates that forward-viewing gastroscope is as effective as side-viewing duodenoscope for ERCP in patients with Billroth II gastrectomy. Furthermore, EPBD without prior EST appears to be a safe and effective procedure in these patients.

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 Endoscopic ampullectomy (EA) offers an insignificantly intrusive strategy for viably treating mucosal and occasionally submucosal lesions of the ampulla of Vater and encompassing periampullary area with high achievement and is more secure. The aim of this study was to present safety, efficacy, and outcomes of EA in the treatment of benign lesions of ampulla Vater performed by single experienced endoscopists in a high volume center. Methods This retrospective study was conducted in patients referred to our hospital (Turkey High Speciality Training and Research Hospital, Turkey) for endoscopic evaluation of ampullary benign lesions over an 8-year period (between October 2011 and September 2019). Success rate was defined as complete resection of lesions. Results Twenty-nine patients with a median age of 64 years were included. Twenty-five patients had lesions confined to the ampulla vateri (86.2%). Accordingly, 2 lesions had intraductal extension adenoma (IDA) (6.9%) and 2 were lateral spreading adenoma (6.9%). The median size of the lesion was 17.5 mm (10 to 36 mm). Nineteen lesions (65.5%) were resected en bloc and 10 lesions (34.5%) were resected in piecemeal manner. Complete resection was achieved in 21 of 23 patients with benign ampullary lesions. The procedure success rate was 91.3%. Complications occurred in 6 patients (20.6%) of these 3 had (10.3%) bleeding, 2 (6.8%) had pancreatitis, and 1 had (3.4%) perforation. Four patients (13.7%) had a recurrence. Conclusions Deep resection of the benign ampullary lesions increases the complete resection rate, cannulation rate of the pancreatic duct, and stenting rate of the pancreatic duct. EA is a safe and successful procedure in patients with benign lesions of ampulla vater.

Endoscopic retrograde cholangiopancreatography (ERCP) is an important therapeutic tool for many biliary diseases. Selective biliary cannulation is the first step of the treatment process. Needle knife fistulotomy (NKF) and conventional precut sphincterotomy (CPS) are widely used in difficult biliary cannulation. However, there are different results in their effectiveness and safety. This study aimed to compare both methods regarding cannulation success and adverse event profile.All eligible consecutive patients with naive papillae who underwent biliary ERCP by a single experienced endoscopist over a 3-year period were included retrospectively. The standard cannulation method with a guidewire-loaded sphincterotome was initially used for biliary cannulation in all patients. Cannulation was accepted as difficult in the case of failure of standard cannulation within 5 minutes or despite 5 attempts or insertion of the guidewire to the pancreatic duct 5 times. Three modalities in patients with difficult biliary cannulation were employed according to the structure and configuration of the papillae in addition to unintentional pancreatic cannulation: (1) NKF, (2) CPS, (3) Double guidewire technique or guidewire orientation/precut following pancreatic stenting. Latter was excluded to enable direct comparison between NKF and CPS groups.A total of 644 patients were recruited. Analyses were performed with 541 patients after the exclusion of 103 patients. Mean (SD) age was 60.4 (18.2) years, and 257 (47.5%) patients were male. While standard cannulation was successful in 366 (67.6%), difficult biliary cannulation was observed in 175 (32.4%) patients. NKF was performed in 101 (57.7%) patients, and cannulation success was 100% in the first ERCP session. In contrast, CPS was performed in 74 (42.3%) patients with a lower cannulation success rate (79.7%) than NKF ( P0.001). Post-ERCP pancreatitis rate was higher in CPS (9.5%) than NKF group (3.0%, P =0.063). Bleeding and cholangitis were similar in both groups.In patients with difficult biliary cannulation with appropriate papillary structure and configuration, NKF should be used as the first choice in experienced hands because of high biliary cannulation success and low Post-ERCP pancreatitis risk.

Hemobili, hepatobiliyer trakttan kaynakli kanama olup ust gastrointestinal kanamanin nadir bir sebebidir. Hemobilinin en yaygin nedenleri iyatrojenik, travmatojenik ve neoplastik nedenlerdir. Tedavide ise endoskopik olarak kanama kontrolu ve kanayan damarin anjiyografik olarak embolizasyonu kombine olarak kullanilmaktadir. Biz bu vakada 71 yasinda inoperable safra kesesi kanseri tanisi olup hemobili ve bilier obstuksiyon semptomlari ile basvuran bir hastanin tedavisinden bahsedecegiz.

Objective: In this study, we investigated the technical and clinical success and complications of transpapillary gallbladder drainage with endoscopic retrograde cholangiopancreatography in patients with gallbladder or cystic duct related diseases accompanied by comorbid conditions. Material and Methods: This study was performed on 19 patients with acute cholecystitis who had already an indication for endoscopic retrograde cholangiopancreatography due to choledocholitiasis, cholangitis or Mirizzi syndrome between 2011-2017. After choledochal and cystic duct stones had been removed, or choledochal stents had been placed according to indication, transpapillary gallbladder drainage with nasocystic drain or pigtail stent were provided in all patients. The technical and clinical success of transpapillary gallbladder drainage and the complications of the procedure were evaluated. Results: 15 (79%) of the patients had at least one comorbid disease. Cystic duct stones were observed in 10 patients. Balloon lavage to all patients with cystic duct stones, basket and mechanical lithotripsy to 3 patients, and balon dilatation to the entrance of cystic duct to one patient were applied. Transpapillary gallbladder drainage was provided with 7F nasocystic drain in 8 patients, stent made from 7F nasobiliary drain in 6 patients, 7F double pigtail stent in 3 patients and 10F double pigtail stent in 2 patients. In this study, the technical success of transpapillary gallbladder drainage was found 100% and clinical success was found 89%. No complications including death were observed due to the procedure. Conclusion: Transpapillary gallbladder drainage with endoscopic retrograde cholangiopancreatography is a successful and less complicated procedure in patients who have gallbladder or cystic duct related diseases with comorbid conditions.

Giriş ve Amaç: Kendiliğinden genişleyebilen metalik stentler kolonun benign ve malign bir çok hastalığında giderek artan sıklıkta kullanılmaktadır. Malign ve benign darlıklar, kaçaklar ve perforasyonlar en sık görülen kullanım endikasyonlarıdır. Bu çalışmada amacımız kolona kendiliğinden genişleyebilen metalik stent yerleştirmiş olduğumuz hastaların verilerini retrospektif olarak değerlendirmektir. Gereç ve Yöntem: Türkiye Yüksek İhtisas Eğitim ve Araştırma Hastanesinde 2010-2017 yılları arasında kolona kendiliğinden genişleyebilen metalik stent yerleştirilen hastaların verileri retrospektif olarak incelendi. Hastalara kolon stentleri 2 farklı teknik kullanılarak yerleştirildi. Distal lezyonlarda kılavuz tel üzerinden yalnızca floroskopi yardımıyla, proksimal lezyonlarda ise kolonoskopun terapötik kanalından kendiliğinden genişleyebilen metalik stent geçirilerek endoskop ve floroskop birlikte kullanılarak yerleştirildi.Bulgular: Çalışmaya toplam 41 hasta alındı (yaş ortancası: 63,6, erkek/kadın: 28/13). 40 hastaya kolonik obstrüksiyon, 1 hastaya ise anastomoz kaçağı nedeniyle kendiliğinden genişleyebilen metalik stent yerleştirildi. Kolonik obstrüksiyonu olan hastaların 36 tanesinde neden kolorektal kanserken diğer 4 hasta benign nedenlere bağlı darlık gelişmişti. Genel olarak bakıldığında teknik başarı oranı %82, klinik başarı oranı ise %96 olarak izlendi. Toplam 4 hastada komplikasyon geliştiği görüldü; iki hastada erken dönemde perforasyon ve migrasyon gelişti. Diğer iki hastada geç dönemde reobstrüksiyon geliştiği görüldü. Tartışma: Kolonik metal stentlerin yüksek teknik ve klinik başarıları ve düşük komplikasyon oranları, bu stentleri uygun endikasyonu olan hastalarda önemli bir tedavi modalitesi haline getirmiştir. Bu nedenle sadece kolorektal kanserde değil, anastomoz darlıklarında ve kaçaklarında da kolonik metal stentlerin önemli bir tedavi metodu olduğu akılda tutulmalıdır.

Giriş ve Amaç: Kopuk pankreatik kanal sendromu pankreas kanalınınbütünlüğünün bozulmasıyla karakterizedir. Nadir görülen bu sendrom önemli bir morbidite ve mortalite nedenidir. Biz bu çalışmada kliniğimizde kopuk pankreatik kanal sendromu tanısı olan hastaların demografik özelliklerini, endoskopik retrograd kolanjiopankreatografi bulgularını ve bu hastaların aldıkları endoskopik tedavileri araştırdık. Gereç ve Yöntem: Bu çalışma Türkiye Yüksek İhtisas Hastanesi Gastroenteroloji Kliniği, Endoskopik Retrograd Kolanjiopankreatografi Ünitesinde Ocak 2010-Ocak 2017 tarihleri arasında kopuk pankreatik kanal sendromu tanısı alan hastalarla yapıldı. Kopuk pankreatik kanal senromlu hastalar etiyolojilerindeki nedenin pankreatit olup olmamasına göre ikiye ayrıldı. Kanal rüptürü 10 hastada olmak üzere en sık pankreas boynunda izlendi. Kanal rüptürünün baş ve boyunda olduğu hastalar distal grup, gövde ve kuyrukta olduğu hastalar ise proksimal grup olarak tanımlandı. Bulgular: Toplam 17 hastada kopuk pankreatik kanal sendromu vardı. Bu hastaların yaş ortancası 46 olup 14 hasta erkek, 3 hasta kadındı. Bu hastalara toplamda 27 endoskopik retrograd kolanjiopankreatografi seansı uygulandı. Etiyolojik neden olarak 9 hastada akut pankreatit, 2 hastada kronik pankreatit, 4 hastada travma ve 2 hastada ise insülinomadan dolayı yapılan pankreatektomi etiyolojik neden olarak izlendi. Akut pankreatit öyküsü olan hastaların 5 tanesi biliyer orjinliydi. 17 hastanın15’inde psödokist, 1 hastada ise walled-off nekroz vardı. Kanalrüptürünün distalde ve proksimalde olduğu hastalar arasında endoskopikretrograd kolanjiopankreatografi işlem sayısı ve pankreatite yolaçan etiyolojik nedenler karşılaştırıldı ve anlamlı bir farklılık bulunmadı(sırasıyla p=0,215, p=0,278). Sonuç: Çalışmamızda literatürle uyumluolarak kopuk pankreatik kanal sendromlu hastalarda en sık etiyolojikneden olarak akut pankreatit izlendi. Hastalarımızın çoğunda kopukpankreatik kanal sendromu boyun kısmında lokalize olup bu bulgu da literatürleuyumluydu. Bu sendroma uygun tanı konulamaması ve gereklitedavinin yapılamaması hastaların morbidite ve mortalitelerinde artışayol açacaktır.

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 Not Available] WOS:000572115500019 2-s2.0-85091601532 PubMed: 32303089

Kanama, endoskopik retrograd kolanjiyopankreatografinin (ERCP) ciddi komplikasyonlarından biri olup insidansı %1-2 arasında değişir. Kanama sıklıkla endoskopik sfinkterotomi ile ilişkilidir, bununla beraber vaka serilerinde sfinkterotomi ilişkisiz kanamalar da bildirilmiştir. Biliyer metal stentin barsak duvarında yaptığı irritasyona bağlı oluşan kanamalar sfinkterotomi ilişkisiz kanamalara örnek gösterilebilir. Biliyer stent öyküsü olan hastaların stentin olduğu yerde ağrı ile gelmesi stentin barsak duvarına yaptığı irritasyonu akla getirir. Literatürde migre olmadan deformasyonla barsak duvarı irritasyonu yapan ve kanamaya yol açan biliyer metal stent görülmemiştir. Burada öncesinden ERCP ile biliyer metal stent konulan ve metal stentin deformasyonuna bağlı duodenumda oluşan ülserin yol açtığı kanama ile gelen hastamızı sunduk.

Background and Aims: This study investigated the etiologic causes, stenosis locations, and endoscopic treatment options of caustic gastrointestinal injury. Material and Methods: This study was performed retrospectively, with 41 patients who were treated endoscopically for stenosis caused by caustic damage between 2005 and 2015. Data such as patients’ demographic characteristics, surgical information, ingested material, and stenosis locations were obtained from their medical records. Results: This study comprised 41 patients. The mean age of patients was 32±9.2 years. Of these, 25 patients were males (61%), and 16 were females (39%). The median number of endoscopy procedures was 9 and ranged from 1 to 32. The most common cause of caustic damage was ozone water (19%), degreasers (15%), and descaling agents (15%). Endoscopic examination revealed stenosis in the middle esophagus (41%), but less frequently in the proximal esophagus (19%), distal esophagus (19%), anastomosis (10%), and the entire esophagus (7%). Six patients were operated for strictures (15%). Savary-Gilliard and balloon dilatation were the most frequently applied treatments. Two patients had local steroid injections, and two had stents. Conclusion: Esophageal stenosis because of caustic ingestion develops most frequently by ingesting cleaning agents and most commonly involves the middle part of the esophagus, with the most commonly used treatment options being balloon and Savary-Gilliard dilatation., Giriş ve Amaç: Bu çalışmada gastrointestinal kostik yaralanma sonrası endoskopik tedavi uygulanan hastaların etiyolojik nedenlerini, darlık yerlerini ve uygulanan tedavileri araştırdık. Gereç ve Yöntem: Bu çalışma 2005-2015 yılları arasında kostik hasara bağlı darlık nedeniyle endoskopik olarak tedavi edilen 41 hasta ile retrospektif olarak yapılmıştır. Hastaların demografik özellikleri, ameliyat bilgileri, ne içtikleri ve darlık yerleri dosyalarından kaydedilmiştir. Bulgular: Bu çalışma 41 hasta ile yapılmıştır. Hastaların ortalama yaşı 32±9.2 idi. Hastaların 25’i erkek (%61), 16’sı ise kadındı (%39). Hastaların median işlem sayısı 9 olup, işlem sayısı 1 ile 32 arasında değişmekteydi. Kostik hasarın en sık sebebi ozon suyu (%19), yağ çözücü (%15) ve kireç çözücü (%15) idi. Endoskopik incelemede darlıklar en sık orta özofagusta (%41) görülmekle birlikte daha az sıklıkla proksimal özofagus (%19), distal özofagus (%19), anastomoz (%10) ve tüm özofagusta (%7) görülmekteydi. 6 hastanın darlıklar nedeniyle opere edildiği görüldü (%15). Hastalara yapılan terapötik işlemler incelendiğinde en sık buji ve balon dilatasyonu uygulandığı görüldü. İki hastaya lokal steroid enjeksiyonu ve iki hastaya da stent takıldığı görüldü. Sonuç: Kostik madde içimine bağlı özofagus darlığı en sık olarak temizlik maddelerinin içimine bağlı olarak gelişmekte, en sık özofagus orta kısmını tutmakta ve tedavide en sık balon ve buji dilatasyon tedavisi kullanılmaktadır.

Girişve Amaç: Etat mamillone endoskopikolarak gözlenen ve Helicobacter pylori pozitifolan hastalarda mukozal nodüler tutulum ile karakterizekolaylıkla tanınabilen karakteristik bir bulgudur. Bizbu çalışmada etat mamillone görüntüsü nedeniyle endoskopik biyopsi alınanhastalarda bu görüntünün histopatolojik tanıya göre doğruluğunu araştırdık. Gereç ve Yöntem: Bu çalışma Ocak2016-Aralık 2017 tarihleri arasında hastanemiz gastroenteroloji kliniğindeçeşitli sebeplerle endoskopi yapılan hastaların hasta kayıtları incelenerekretrospektif olarak yapılmıştır. Toplamda 5200 endoskopi kaydı incelenmiş, etatmamillion veya etat mamillone tabiri geçen 53 hasta çalışmaya dahil edilmiştir.Bulgular: Araştırma popülasyonu 41kadın (%77) ve 12 erkek (%23) erkekhasta olmak üzere 53 kişiden oluştu. Hastaların ortalama yaşı 29±11.2 (18-56)yıldı. Hastaların endoskopik biyopsi sonuçlarına bakıldığında 4 (%8) hastadaatrofik gastrit mevcut iken 49 (%92) hastada atrofi yoktu. Hastaların biyopsiörnekleri incelendiğinde 53 hastanın 45’inde Helicobacter pylori pozitifsaptandığı görüldü (%85). Bu hastaların Sydney sınıflamasına göre 12’sinde 1+ Helicobacterpylori (%23),17’sinde 2+ Helicobacter pylori (%32) ve 16’sında 3+ Helicobacter pylori (%30) saptanmıştır. Endoskopik etat mamillonegörüntüsü ile biyopsi sonuçları arasında %85 oranında korelasyon olduğu görülmüştür.Sonuç:Endoskopikolarak tanımlanan etat mamillone görünümü Helicobacter pylori gastrititanısı için kullanılabilecek non-invaziv ve yüksek doğruluk oranına sahip biryöntemdir., Background and Aims: Etat mamilloneis an endoscopic appearance characterized by mucosal nodular involvement inpatients with Helicobacter pylorigastritis. In the present study, we investigated the accuracy of this appearanceon the basis of histopathological diagnosis in patients who underwentendoscopic biopsy for etat mamillone. Materialand Methods: The present study was performed retrospectively betweenJanuary 2016 and December 2017 in the gastroenterology clinic of our hospital.A total of 5200 endoscopy records were examined, and 53 patients with etatmamillion or etat mamillone were included in the study. Results: The study population consisted of 53 patients, 41 of whomwere female (77%) and 12 male (23%). The mean age of the patients was 29±11.2years (range: 18–56 years). Atrophic gastritis was observed in four patients (8%),while 49 patients (92%) had no atrophy. Upon biopsy, 45 of the 53 patients(85%) were found to be Helicobacter pylori positive.According to the Sydney classification, 12 patients had 1+ Helicobacterpylori (23%),17 had 2+ Helicobacter pylori (32%),and 16 had 3+ Helicobacter pylori (30%).There was 85% correlation between the endoscopic etat mamillone appearance andbiopsy results. Conclusion: Endoscopic etat mamillone appearance is anon-invasive and highly accurate method for diagnosis of Helicobacterpylori gastritis.

Giris ve Amac: Calismamizda klinigimizde Dieulafoy Lezyonu tanisi konulan hastalari, yapilan endoskopik tedavileri ve bu tedavilerin basari oranlarini ortaya koymayi hedefledik. Gerec ve Yontem: Klinigimizde 2008-2016 tarihleri arasinda endoskopileri yapilan hastalar ‘Dieulafoy Lezyonu’ tanisi icin retrospektif olarak tarandi. Endoskopik tanisi Dieulafoy lezyonu olan hastalarin servis yatislari, laboratuvar degerleri, kac gun yattiklari, hastaliklarinin nihai sonucu tespit edildi. Bulgular: 18 hasta calismaya alindi. En sik basvuru sikayeti melenaydi. Hastalarin yedi tanesinde mortalite gerceklesti. Klips, tek basina veya kombine olmak uzere en sik basvurulan endoskopik tedavi yontemiydi. Klipsin tek basina uygulandigi hastalarla, klipsle beraber veya klips olmadan kombine tedavi uygulanan hastalar arasinda mortalite acisindan fark yoktu (p=0,9). Adrenalinle beraber heater yapilan olgular dislanarak yapilan subgrup analizinde klips uygulanan hastalarla klipsle beraber diger yontemlerin yapildigi hastalar arasinda mortalite karsilastirildi. Iki grup arasinda yine mortalite acisindan bir fark yoktu (p=0,6). Sonuc: Calismamiz klips tedavisine eklenecek adrenalin ve/veya heater koagu- lasyon gibi yontemlerle yapilan kombine tedavinin mortaliteyi azaltmada klips monoterapisine kiyasla herhangi bir ustunluklerinin olmadigini gostermistir.

Background Double Balloon Enteroscopy (DBE) provides the opportunity not only to investigate but also apply endoscopic therapeutic interventions for small intestinal disturbances. The aim of this study is to assess the indications, diagnosis, therapeutic interventions, complications and safety in clinical practise of DBE procedures that have been performed in our clinic. Material-methods The data of patients who had undergone DBE procedure in our clinic between October 2007 and December 2014 were retrospectively investigated. All features including indications, findings, histopathological results, applied interventions and complications due to procedure were noted. Results A total of 297 patients, 160 (53,9%) male and 137 (46,1%) female were enrolled in the study. Total number of procedures for these 297 patients were 372 [256 (68,8%) oral and 116 (31,2%) anal]. Mean age of the patients was 46,9 (14–94) years. The most common indications were; obscure gastrointestinal (GI) bleeding (28,3%), iron deficiency anaemia (17,5% ) and abnormal findings in a prior imaging study (13,8%), respectively. The rate of new diagnosis with DBE was 11.8%, where the rate for confirmation of a possible diagnosis was 16.2%, rate of endoscopic treatment with definite diagnosis was 11%, rate for ruling out possible diagnosis or showing normal findings was 34.7% and rate for insufficient or unsuccessful procedures was 26.3%. Ulcers, inflammation and erosions (13%), polyposis syndromes (9.8%) and vascular pathologies (7.4%) were the most common endoscopic findings. Conclusion Our study shows that DBE has high efficacy for diagnosis and ability to perform treatment of small intestinal disturbances with safety.

Background/Aims: Endoscopic papillectomy (EP) has emerged as an alternative to surgery in the management of ampullary lesions. The aim of this study is to evaluate feasibility, efficacy, safety, outcome, and impact of EP in the management of benign ampullary lesions. Materials and Methods: This is a multicenter, retrospective study of 44 patients who had EP of benign ampullary lesions. Results: Over the 11-year period, 44 (55.7\%) of 79 patients underwent EP for benign ampullary lesions. Complete resection was achieved in 40 patients (91\%). An underlying adenocarcinoma was the only risk factor for incomplete resection. Twenty-eight lesions (63.6\%) were resected en-bloc and 16 lesions (36.4\%) were resected in piecemeal fashion. Post-papillectomy histopathologic diagnoses were tubular adenoma in 14 patients (32\%), invasive adenocarcinoma in 9 patients (20.5\%), tubullovillous adenoma in 7 patients (16\%), tubullovillous adenoma with carcinoma limited to the mucosal layer in 5 patients (11.3\%), adenoma with high-grade dysplasia in 4 patients (9\%), neuroendocrine tumor in 1 patient (2.3\%), ganglioneuroma in 1 patient (2.3\%), hamartomatous polyp in 1 patient (2.3\%), adenofibroma in 1 patients (2.3\%), and Brunner gland hyperplasia in 1 patient (2.3\%). Seven (15.9\%) procedure-related complications occurred: 3 (6.8\%) bleeding, 2 (4.5\%) pancreatitis, 1(2.3\%) abdominal pain, and 1 (2.3\%) stent migration to the pancreatic duct. Seven patients (17\%) had recurrence. Conclusion: Endoscopic papillectomy is a safe and effective method and can be considered as a first-line approach in patients with benign ampullary lesions with intent for cure. It also allows for correct histological diagnosis and staging.

Giriş ve Amaç: Periampuller bölge tümörleri tüm gastrointestinal malignensilerinyaklaşık %0,5-2’sini oluşturmaktadır. Bu tümörler arasında en sıkolarak pankreas başı ve ampulla vateri kanseri görülmektedir. Bu tümörlerinerken tanısı ve benign lezyonlardan ayırımı tedavi şeklinin belirlenmesindeönem taşımaktadır. Çalışmamızın amacı, papiller forseps biyopsinin pankreastümürü ve ampulla vateri tümörü tanısında etkinliğinin değerlendirilmesive iki tümöre ait özelliklerin karşılaştırılmasıdır. Gereç ve Yöntem: ÇalışmaTürkiye Yüksek İhtisas Hastanesi endoskopik retrograd kolanjiopankreatografiünitesinde 7 yıllık periyotta endoskopik retrograd kolanjiopankreatografiyapılan ve papiller forseps biyopsisi alınan hastalar geriye yönelik tarandı.Bulgular: Çalışmaya toplam 135 hasta dahil edildi. Toplam 58 (%50) hastadamalignite tespit edildi. En sık saptanan malign tümörler ampulla vaterikanseri ve pankreas başı kanseri idi [sırası ile hastaların %28.4 (n=33) ve%12.1 (n=14)]. Papiller forseps biyopsinin periampuller bölge tümörü tanısındaspesifitesi %96.7 ve sensitivitesi %72.4 ölçüldü. Papilin endoskopikgörünümüne göre endoskopistin yorumunun periampuller bölge tümörü tanısındasensitivitesi %64.3 olarak ölçüldü. Pankreas başı kanseri ile ampullavateri kanseri arasında hastaların verileri iki kanser grubu arasında karşılaş-tırıldığında sadece CA-19.9 değerleri iki grup arasında farklıydı (sırası ile365 U/ml ve 78 U/ml; p=0.01). Sonuç: Periampuller bölge tümörleri’ninayırıcı tanısında duedonoskop eşliğinde gerçekleştirilen papiller forseps biyopsisioldukça yararlı bir yöntemdir. Ek olarak malign hastaların ayırımındapapilin endoskopi görünümünün değerlendirilmesi ve tümör markırlarınınkullanımı ile bu yöntemin etkinliği daha da arttırılabilir., Background and Aims: Periampullary area tumors account for about 0.5-2% of all gastrointestinal malignancies. Malignant tumors of pancreatic headand ampulla vater are the most seen tumors of this region. The early diagnosisof these tumors and separation from benign lesions are importantin choosing a treatment modality. The aim of our study is to evaluate theactivity of papillary forceps biopsy in the diagnosis of pancreatic and ampullavater tumors, and to compare the two tumors’ properties. Materials andMethods: Patients in whom papillary forceps biopsy was performed werescreened retrospectively in the endoscopic retrograde cholangiopancreatographyunit of Türkiye Yüksek İhtisas Hospital within 7-year period. Results:A total of 135 patients were included in the study. Malignancy was detectedin 50% of patients (n=58). The most frequent malignant tumors wereampulla vater cancer and pancreatic cancer [28.4% of patients (n=33); and12.1% (n=14), respectively]. The specificity of papillary forceps biopsy in thediagnosis of periampullary area tumors was found to be 96.7%, and sensitivitywas 72.4%. When the endoscopist view was evaluated according to thepapillary endoscopic appearance, sensitivity was measured as 64.3%. OnlyCA-19-9 levels were statistically different between pancreatic head cancerand ampulla vater cancer groups (365 U/ml and 78 U/mL, respectively; p =0.01). Conclusion: Papillary forceps biopsy performed with duodonoscopyis a useful method in the differential diagnosis of periampullary tumors. Thismethod can be further improved by the evaluation of endoscopic apparanceof papillae and additionally by using tumor markers.

Aim Drug-induced liver injury (DILI) is becoming a worldwide problem with its still unexplained properties. Methods The data of patients who were diagnosed with DILI between January 2008 and December 2013 were assessed. Results Five patients had been diagnosed with intrinsic and 82 patients with idiosyncratic DILI. The most common causative agents were antimicrobial drugs. The most common injury pattern was hepatocellular. When patients with bilirubin levels of more than 5 mg/dL were divided into two groups according to receiving steroid therapy (n = 11) or not (n = 40), there was not any significant difference according to their clinical results (P > 0.05). Five of the idiosyncratic DILI patients were diagnosed with drug-induced autoimmune hepatitis (DI-AIH). In histopathological examination, hepatic rosette formation and emperipolesis were observed to be more common among patients with DI-AIH when compared with ones without (P

An aberrant right posterior hepatic duct is present in 4.8-8.4% of the population. It is one of the causes of bile duct injury during laparascopic cholecystectomy. Herein we present a patient with complete transection of the common hepatic duct during laparascopic cholecystectomy (Stewart-Way class 3). Interestingly, the patient had an intact aberrant right posterior duct draining into the common hepatic duct distal to the obstruction site that prevented early diagnosis of the biliary injury because of drainage of the liver sufficient to prevent the development of jaundice.

Girişve Amaç: Malign mide çıkış obstrüksiyonu, özellikle pankreas ve mide kanserlerindeolmak üzere intraabdominal malignitelerin geç ve yaygın bir komplikasyonudur. Buhastaların çoğu küratif cerrahi tedaviye uygun olmadıkları için palyatif tedaviyöntemlerine gereksinim duymaktadırlar. Palyatif amaçlı yapılan cerrahiyöntemlere göre daha az invaziv bir yöntem olan endoskopik yolla duodenal kendiliğinden genişleyebilen metal stentyerleştirme son yıllarda daha çok kullanılmaktadır. Buretrospektif tek merkezli çalışmanın amacı, inoperabl malign mideçıkış obstrüksiyonu olan hastalarda endoskopik olarak uygulanan duodenal kendiliğinden genişleyebilen metal stent yönteminin güvenilirliğinive etkinliğini saptamaktır. Gereçve Yöntem: Endoskopi ünitemizde beş yıllık dönemdemalign mide çıkış obstrüksiyonu nedeniyle duodenalkapsız kendiliğinden genişleyebilen metalstent uygulanan hastaların verileri retrospektif olarak incelendi.Dudenal kendiliğinden genişleyebilenmetal stent yerleştirmenin teknik ve klinik başarısı ilekomplikasyonları değerlendirildi. Bulgular:Malign mide çıkış obstrüksiyonu olan toplam 28 hastayapalyatif amaçlı endoskopik yol ile duodenal kapsız kendiliğinden genişleyebilen metal stent yerleştirildi.Hastaların tamamında teknik başarı elde edildi. Klinik başarı ise 25 (%89.3)hastada sağlandı. Hastaların ortalama Gastrik Outlet Obstrüksiyon SkorlamaSistemi skorunun, duodenal stent yerleştirmeden önce 0.536 iken duodenal stentyerleştirildikten iki hafta sonra 2.39’a yükseldiği görüldü (P=0.0001). Majörkomplikasyon 2 (7.14) ve minör komplikasyon 2 (%7.14) hastada gelişti. Sonuç: Saptanan bulgular ışığında küratif cerrahitedaviye uygun olmayan malign mide çıkış obstrüksiyonlu hastalardaendoskopik olarak uygulanan kendiliğinden genişleyebilen metal stent güvenlive etkili bir palyatif yöntemdir., Background and Aims: Malignant gastric outlet obstruction is a late and common complication of intra-abdominal malignancies, particularly primary pancreatic or gastric carcinomas. The majority of patients considered as unsuitable for curative surgical treatment require palliative treatment methods. Recently, endoscopic self-expendable metal stent placement, which is a minimally invasive method compared with surgery, has been performed more frequently than palliative surgery. The aim of this retrospective study was to evaluate the safety and efficacy of self-expendable metal stent placement in patients with inoperable malignant gastric outlet obstruction. Materials and Methods: This study analyzed the data of patients who underwent endoscopic uncovered self-expendable metal stents placement in the duodenum for treating malignant gastric outlet obstruction during a period of 5 years in our endoscopy unit. Technical and clinical success of the placement of duodenal self-expendable metal stents and the complications of the procedure were evaluated. Results: A total of 28 patients with malignant gastric outlet obstruction underwent endoscopic self-expendable metal stent placement. Technical success was achieved in all patients, while clinical success was observed in 25 patients (89%). According to the gastric outlet obstruction scoring system, the mean score of the patients was 0.536 before stent placement and improved significantly to 2.39 at the second week after stent placement (p = 0.0001). Major complications were observed in two patients (7.14%), and minor complications were observed in another two patients (7.14%). Conclusion: These findings indicate that endoscopic self-expendable metal stent placement was a safe and efficient palliative procedure for patients considered as unsuitable for curative surgical treatment of malignant gastric outlet obstruction.

Hidatik kistin safra yollarına rüptüre olması sık görülenbir komplikasyondur (%5-25). İntrabiliyer rüptüre bağlı oluşankomplikasyonlardan biri de akut pankreatittir. Karaciğer kist hidatiğinintedavisinde ideal yaklaşım tartışmalıdır. Tedavide cerrahi yöntemler, perkütanaspirasyon, enjeksiyon ve reaspirasyon metodu ve endoskopik yöntemlerletedaviler (sfinkterotomi, nazobiliyer drenaj kateteri yerleştirilmesi, stentyerleştirilmesi, kist evakuasyonu) kullanılabilir. Uygun hastalarda safrayollarına rüptüre olmuş hidatik kistin tedavisinde endoskopik kist evakuasyonutek başına güvenli ve etkin bir tedavi metodudur., Ruptureof hydatic cysts into the biliary system is a common complication with 5%-25%frequency. Rupture into the biliary system can cause acute pancreatitis. Theideal treatment modality of liver hydatic cysts is controversial; however,surgery and endoscopic methods such as sphincterotomy, stent insertion, andcyst evacuation are well-known treatment options. In appropriate patients,endoscopic cyst evacuation is a safe and effective endoscopic treatmentmodality.

Otoimmün kolanjiyopati veya immünglobulin G4 ilişkili sklerozan kolanjitimmün sistem ilişkili bir kolanjit tipidir. Otoimmün pankreatit sıklıklabu duruma eşlik eder; bununla beraber hastaların çok az bir yüzdesindeotoimmün kolanjiyopati tek başına da görülebilir. 69 yaşında kadın hastakliniğimize halsizlik, kaşıntı ve sarılıkla başvurdu. Endoskopik retrogradkolanjiopankreatografi de intrahepatik safra yollarında çok sayıdadarlık ve dilatasyonlarla beraber ana koledok distalde darlığa rastlandı.Sklerozan kolanjitin diğer nedenlerini ekarte edebilmek için hastadanimmünglobulin G4 çalışıldı ve sonuç 1.200 mg/dl olarak geldi. Bu sonuçlaotoimmün kolanjiyopati tanısı kondu. Otoimmün kolanjiyopatiintrahepatik ve/veya extrahepatik safra yollarında darlık olan hastalardaayırıcı tanıda mutlaka akılda tutulmalıdır. Şüphe edilen hastalardaimmünglobulin G4 tarama amaçlı kullanılabilir. Otoimmün kolanjiyopatinintanı ve tedavisi hastaları ilerleyen zamanda siroz veya gereksizcerrahiden koruyacaktır., Autoimmune cholangiopathy or IgG4-related sclerosan cholangitis isan immune- mediated type of cholangitis. Autoimmune pancreatitis isfrequently associated with this condition. However, in a minority ofpatients, autoimmune cholangiopathy exist alone. A 69- year-old femalepatient was admitted to our hospital with fatigue, pruritus, andjaundice. There were multiple strictures and dilations in the intrahepaticbiliary tree with stricture in the distal part of the common bile duct. Toexclude other causes of sclerosan cholangitis, IgG4 was studied. TheIgG4 titer was 1200 mg/dl; therefore, the diagnosis was autoimmunecholangiopathy. Autoimmune cholangiopathy must be investigated inpatients with biliary strictures in either the intrahepatic or extrahepaticbile ducts. IgG4 can be used to screen for autoimmune cholangitis. Diagnosisand treatment of this condition prevents patients from cirrhosisand unnecessary surgery.

The outcome of endoscopic treatment for the management of surgical end-to-side hepaticoduodenostomy (HD) has not been extensively studied. The aim of this study was to evaluate the results of endoscopic management of HD.The medical records of 17 patients with HD stenosis who were referred to the ERCP unit between August 2003 and June 2012 for endoscopic intervention were retrospectively analyzed.Fourteen patients presented with cholangitis, of whom, jaundice was the presenting complaint in 3 patients. Eight patients (47.1%) who had stents placed for a median of 2 (min, 1; max, 3) ERCP periods remained asymptomatic for a median stent-free period of 19.5 months (min, 7; max, 96 mo). Five patients (29.4%) who had stents placed for a median of 2 (min, 1; max, 5) ERCP periods presented with an episode of stone-related cholangitis for a mean of 41.8±28.9 months after stent removal. These 5 patients remained asymptomatic for a median of 9.5 months (min, 5; max, 40 mo) after endoscopic stone extraction. Three patients with HD (17.6%) were followed up with stents for 4 to 19 ERC periods. One HD patient (5.9%) who had cholangitis associated with secondary biliary cirrhosis died of cholangitis-related complications, despite the treatment with stents for 4 ERC periods.Endoscopic management is also a realistic treatment option for stenotic HD anastomosis, although success rates may vary.

Background/Aims: Infection in the bile tract is a major cause of bacteremia and is related to high morbidity and mortality. We examined the changes in bacteria types and antibiotic susceptibility in bile cultures and simultaneous blood cultures taken from patients who applied for endoscopic retrograde cholangio pancreatography (ERCP)/ percutaneous transhepatic cholangiography (PTC) for different bile duct diseases in recent years. Materials and Methods: Bacteria types that reproduce in bile and blood cultures from patients who applied for ERCP/PTC between the years of 2007 and 2012 in our clinic were examined. All patients were evaluated together, and in addition, the periods between 2007 and 2009 (Group 1) and between 2010 and 2012 (Group 2) were compared. Results: In total, 550 patients applied to this study. There were 266 patients in Group 1 and 284 in Group 2. Reproduction occurred in 77.6% of bile cultures. In the order of frequency, these cultures consisted of Escherichia coli (32.8%), Enterococcus spp. (26.2%), and Pseudomonas aeruginosa (11%). Enterococcus spp. were determined to be higher in Group 2 than Group 1 (p

Background/aims Retraction of the main papilla toward the biliary system was observed in 70% of patients with primary sclerosing cholangitis (PSC). However, this observation was confounded by the fact that all of the patients with this finding had a prior history of sphincterotomy. The aim of the present study was to observe whether main papillary retraction can be seen in patients with naive papillae and accompanies the progression of the disease. Materials and methods The study was conducted in a single tertiary reference center and included 4 patients with PSC. Results Main papillary retraction was seen to emerge with progression of PSC after an initial presentation with intra and extrahepatic involvement in 2 patients and after progression from intrahepatic to extrahepatic bile ducts in 1 patient. Main papillary retraction was seen in 2 patients with naive papillae and could be detected by magnetic resonance cholangiography in 1 patient. Conclusion Retraction of the main papilla can be seen in patients with PSC regardless of prior sphincterotomy history.

Both complete transection and accidental ligation of the main bile duct because of a cholecystectomy are the injuries that are not amenable to endoscopic treatment and require an additional surgery. Leaks resulting from the severance of an aberrant bile duct may be treated endoscopically, although such injuries are difficult to be identified, thus resulting in treatment delays. Presented here are the details and follow-up results of 7 cases of patients with postcholecystectomy aberrant bile duct injuries, which were treated by endoscopic treatment.

Background/Aims: The American Society for Gastrointestinal Endoscopy (ASGE) endoscopic retrograde cholangiopancreatography (ERCP) grading system was proposed but has not been fully evaluated with prospective clinical studies. In this study, we aimed to evaluate the effectiveness of the ERCP difficulty grading system for predicting success and adverse event rates related to the procedure. Materials and Methods: A total of 1057 ERCP procedures performed on 752 patients were included in the present study. The complexity grades of the procedures were recorded according to the ASGE grading system. Specific complications of ERCP (pancreatitis, cholangitis, bleeding, and perforation) were also defined and graded. Results: The procedure difficulty was determined as 1 st degree in 153 patients (14.4%), 2 nd degree in 498 patients (47.1%), 3 rd degree in 271 (25.6%), and 4 th degree in 135 patients (12.7%). The success rate for the entire procedures was 88.4%. The success rate for 1 st -degree procedures was 99.3%, 97.2% for 2 nd -degree procedures, 86.7% for 3 rd -degree procedures, and 46.7% for 4 th -degree procedures (p

ABS TRACT In tra he pa tic cho les ta sis is a ra re ma ni fes ta ti on of pa ra ne op las tic syndro me and has be en re por ted to be as so ci a ted with va ri o us ma lig nan ci es. In tra he pa tic cho les ta sis wit ho ut a mec ha ni cal obs truc ti on has be en pre vi o usly re por ted in only thre e pros ta te car ci no ma ca ses in Eng lish li te ra tu re. In this re port, we des cri bed a new ca se of pa ra ne op las tic in tra he pa tic cho les ta sis in a pa ti ent with pros ta te car ci no ma tre a ted only with bi la te ral orc hi ec tomy. We al so dis cus sed the mec ha nisms of cho les ta sis in pros ta te car ci no ma in the light of the per ti nent li te ra tu re. Pa ra ne op las tic cho les ta sis sho uld be kept in mind in the ab sen ce of bi li ary tract obs truc ti on and he pa tic in vol ve ment in pros ta te car ci no ma. Pa ti ents with unexp la i ned cho les ta sis sho uld be in ves ti ga ted for a pos sib le pa ra ne op las tic syndro me. Pa ra ne op las tic cho les ta sis re sol ves fol lo wing orc hi ec tomy in pros ta te car ci no ma ca ses.

Background: Thrombosis in the portal system causes a wide spectrum of clinical pictures. There are few published studies describing the clinical features and consequences of portal venous system thrombosis. We aimed to document presentations and outcomes in patients with thrombosis in the portal and/or splenic veins. Patients and Methods: The study included 95 patients who were diagnosed with portal venous system thrombosis in the period September 2001 to April 2006. Demographics, clinical presentation, diagnostic investigation, management, morbidity, and mortality were recorded in their follow-up. Results: Of the 95 patients with portal vein thrombosis (PVT), 35 had isolated PVT (IPVT), 27 had isolated splenic vein thrombosis (ISVT), and 33 had thrombosis in both the portal and splenic veins (PSVT). The mean follow-up periods after diagnosis of IPVT, ISVT, and PSVT were 36, 31, and 32 months, respectively. Abdominal pain and gastrointestinal bleeding were the most common symptoms at presentation in the IPVT and PSVT groups, whereas abdominal pain was the dominant symptom in the ISVT group. During the follow-up period, no bleeding was seen in 26 of the 35 (74%) patients with IPVT, in 23 of the 33 (70%) patients with PSVT, and in 24 of the 27 (89%) patients with ISVT. Biliopathy developed during follow-up in 11 of 35 patients with IPVT, in 1 of 27 with ISVT, and in 5 of 33 with PSVT. In the ISVT group, there were 11 deaths, and one each in the IPVT and PSVT groups. Conclusions: The etiology of PVT varies in portal and splenic veins. IPVT has a higher morbidity (bleeding and portal biliopathy), whereas ISVT that is not associated with an underlying malignancy has a favorable prognosis.

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.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.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.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.

In hepatitis B virus (HBV)-related liver cirrhosis, patients with HBV replication show a higher mortality rate than those without. We aimed to investigate the long-term effects of lamivudine on HBV DNA suppression, Child-Pugh score, and survival in patients with hepatitis Be antigen (HBeAg)-negative liver cirrhosis.Sixty-eight patients (51 male, 17 female) diagnosed with HBV-positive liver cirrhosis, who were monitored by the hepatology and liver transplantation outpatient clinics of our hospital between June 1999 and May 2007, were included in the study. Lamivudine (100 mg/day) was administered orally. Follow-up visits were scheduled monthly during the first 3 months, and every 3 months thereafter. Complete blood count, haemostasis, biochemistry (aspartate aminotransferase [AST], alanine aminotransferase [ALT], amylase, urea, creatinine, total bilirubin, direct bilirubin, total protein, albumin), and alpha-foetoprotein were recorded every 3 months. HBV DNA levels, abdominal ultrasound and the Child-Pugh score were evaluated every 6 months.Sixty-eight patients (mean age, 52.05+/-12.6 years) were monitored for 49.51+/-18.51 months. Basal ALT, HBV DNA levels and Child-Pugh scores were 103.9+/-73.9 IU/ml, 4133+/-121,94 IU/ml, and 7.6+/-2.4, respectively. The ALT normalisation was 59.7% during the first year, 68.2% during the second year and 44.4% during the fifth year. There was a significant decrease in Child-Pugh scores in the first 3 follow-up years when compared with the baseline score (P0.05). During the treatment, HBV DNA positivity and YMDD mutations were determined in 20 of 68 (29.4%) patients at 46+/-17.9 months. Nine patients (13.2%) developed hepatocellular carcinoma at 44.8+/-21.5 months. Thirteen patients (19.1%) died during the treatment due to liver failure or variceal bleeding.Lamivudine is beneficial in patients with HBeAg-negative liver cirrhosis in terms of improvement in liver function and enhancement of survival and quality of life. An HBV DNA suppressive effect and improvement in Child-Pugh score were seen especially in the first years. It is important to be aware of YMDD mutation early, as addition of new antivirals is necessary to overcome unwanted results of the mutation.

Purpose There are no reports comparing the results of conservative/nonsurgical management with the addition of fully covered self-expandable metallic stents (FCSEMS) with the conservative approach in endoscopic retrograde cholangiopancreatography (ERCP)-related duodenal retroperitoneal (type II) perforations. The aim of this study was to evaluate whether the addition of FCSEMS to conventional treatment provides further benefits in the course of type II perforations. Methods A total of 7471 ERCP with sphincterotomy performed between 2007 and 2014 were evaluated, and a total of 25 type II perforations (0.33%) were identified. About 20 patients who were detected during ERCP and biliary cannulation was accomplished were included in the study. Patients were divided into 2 groups: the conservative treatment group (10 patients) and the FCSEMS group (10 patients). Groups were compared for clinical findings, results of serial white blood cell (WBC) counts, the length of hospital stay, the need for surgery, and death, retrospectively. Results Five patients in the conservative treatment group and none of the patients in the FCSEMS group had pain requiring narcotic and/or nonsteroidal anti-inflammatory analgesics during the follow-up period (P=0.005). On post-ERCP day 1, in the conservative and the FCSEMS groups, mean WBC counts were 13,218±4410×10 and 8714±3270×10, respectively (P=0.029). The perforation-related length of hospital stay was 15.77±5.21 days in the conservative group and 11.7±3.19 days in the FCSEMS group (P=0.053). Excluding the patient with severe pancreatitis in the conservative group, there were no deaths or need for surgery. Conclusions Compared with conservative treatment alone, the addition of FCSEMS provides further benefits in terms of a painless course, lower WBC counts, and a short hospital stay. FCSEMS can be used as an additional treatment modality in type II perforation.

Endoscopic sphincterotomy has a higher risk of bleeding in patients with cirrhosis. Advanced Child stage and coagulopathy are well-known risk factors. We aimed to determine the role of electrosurgical currents in the development of endoscopic sphincterotomy bleeding in cirrhotic patients. The study was a retrospective observational study and included 19,642 patients who underwent endoscopic retrograde cholangiopancreatography between 2004 and 2013. The incidence of endoscopic sphincterotomy bleeding in cirrhotic patients who underwent sphincterotomy after 2009 with an electrosurgical generator applying alternating current in the pulse cut mode (Group 2) was compared with a historical control group who underwent endoscopic sphincterotomy between 2004 and 2009 via blended current (Group 1). Group 1 included 15 patients (six women, nine men, mean age: 62.2 ± 12.9 years). Group 2 included 14 patients (six women, eight men, mean age: 63.6 ± 16.9 years). There was no statistically significant difference between the demographic and clinical characteristics of the two groups. Endoscopic sphincterotomy bleeding was observed in three patients in Group 1 (two endoscopic bleeding and one clinically significant bleeding) and none of the patients in Group 2 (p = 0.77). There were no cases of perforation or pancreatitis in both groups. One patient in Group 2 developed cholangitis. Endoscopic sphincterotomy bleeding is less frequently observed in patients with cirrhosis who underwent sphincterotomy with alternating mixed current in the pulse cut mode compared with those with blended current.