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Background Endoscopic ultrasound (EUS)-guided ductal access and drainage (EUS-DAD) of biliary/pancreatic ducts after failed endoscopic retrograde cholangiopancreatography (ERCP) is less invasive than percutaneous transhepatic biliary drainage (PTBD). The actual need for EUS-DAD remains unknown. We aimed to determine how often EUS-DAD is needed to overcome ERCP failure. Methods Consecutive duct access procedures (n = 2205; 95 % biliary) performed between June 2013 and November 2015 at a tertiary-care center were reviewed. ERCP was used first line, EUS-DAD as salvage after ERCP, and PTBD when both had failed. Procedures were defined as “index” in patients without prior endoscopic duct access and “combined” when EUS-DAD followed successful ERCP. The main outcomes were the EUS-DAD and PTBD rates. Results EUS-DAD was performed in 7.7 % (170/2205) of overall procedures: 9.1 % (116/1274) index and 5.8 % (54/931) follow-up. Most index EUS-DADs were performed following (46 %) or anticipating (39 %) ERCP failure, whereas 15 % followed successful ERCP (combined procedures). Among index procedures, the EUS-DAD rate was higher in surgically altered anatomy (58.2 % [39 /67)] vs. 6.4 % [77/1207]); PTBD was required in 0.2 % (3/1274). Among follow-up procedures, ERCP represented 85.7 %, cholangiopancreatography through mature transmural fistulas 8.5 %, and EUS-DAD 5.8 %; no patient required PTBD. The secondary PTBD rate was 0.1 % (3/2205). Six primary PTBDs were performed (overall PTBD rate 0.4 % [9/2205]). Conclusions EUS-DAD was required in 7.7 % of ERCPs for benign and malignant biliary/pancreatic duct indications. Salvage PTBD was required in 0.1 %. This high EUS-DAD rate reflects disease complexity, a wide definition of ERCP failure, and restrictive PTBD use, not poor ERCP skills. EUS-DAD effectively overcomes the limitations of ERCP eliminating the need for primary and salvage PTBD in most cases.

Background: Delayed gastrointestinal (GI) bleeding and stent migration are known adverse events which may occur following placement of lumen-apposing metal stents (LAMSs). Methods: All consecutive patients who underwent LAMS placement between May 2011 and June 2017 at a single tertiary medical center were included. Demographics and procedural details were prospectively collected. Post-procedure follow-up and outcome measures were retrospectively collected. The cumulative risks of migration and LAMS-related GI bleeding were estimated using the life-table method. Risk predictors were assessed using Cox proportional hazards models. Results: We analyzed 250 patients (64.8 % men; median age 71.6 [interquartile range (IQR) 57.9 – 83.6]). Median follow-up was 78.5 days (IQR 31 – 246.5 days). Thirty-four stent migrations (13.6 %) occurred (5 symptomatic). On multivariable analysis, associations with migration included nasocystic drains (hazard ratio [HR] 6.5, 95 % confidence interval [CI] 2.2 – 19.3), pancreatic fluid collections (PFCs; HR 4.2, 95 %CI 1.8 – 10.1), and double-pigtail stents (HR 2.4, 95 %CI 1.2 – 4.9). Migration risk at 12 months was 25.5 % (95 %CI 17.9 % – 35.7 %) and was higher for PFCs 48.9 % (33.4 % – 66.9 %) than other indications 8.4 % (4.9 % – 17.5 %; P Conclusions: LAMS migration occurs in 1 out of 7 cases and is most common when treating PFCs. Bleeding related to LAMS placement occurs much less commonly but can be life-threatening.

Direct-acting antivirals (DAAs) have revolutionized the treatment of hepatitis C, including transplant recipients with an advanced fibrosis stage. Our aim in this study was to assess the clinical and functional benefits and improvement in liver fibrosis after treatment with DAAs in liver transplant recipients with chronic hepatitis C virus who achieved sustained virologic response (SVR).We retrospectively analyzed 42 patients who underwent liver transplantation (LT) at our institution and were treated with DAAs from June 2014 to December 2015. Two patients died, so we ultimately included 40 transplant patients with chronic hepatitis C who received DAAs and achieved SVR. We assessed liver function, fibrosis stage, and clinical features at the start of the treatment, and then at 6 and 12 months after SVR. The indication for LT was hepatocellular carcinoma in 8 patients (20%) and Child-Pugh score B/C in 32 patients (80%).The DAAs regimens were sofosbuvir plus daclatasvir (45.0%), simeprevir plus sofosbuvir (42.5%), sofosbuvir plus ledipasvir (7.5%), and ombitasvir/paritaprevir/ritonavir (5%). The mean Modified End-stage Liver Disease (MELD) score pretreatment was 10.78, and was 8.46 at 1 year after treatment (P .05). In addition, fibrosis stage decreased significantly from 14.81 kPa to 9.07 kPa (FibroScan) at 12 months after SVR. Clinically, there was a significant improvement, including control of ascites and chronic hepatic encephalopathy.DAAs were used successfully in the treatment of hepatitis C after orthotopic liver transplantation and resulted in significant improvement in liver function as measured by MELD score, fibrosis level, and cirrhotic clinical condition, even in patients with very advanced disease.

Survival after orthotopic liver transplantation (OLT) has increased over the last decades, focusing on the metabolic complications that contribute to patient morbidity and mortality. The aim of our study was to describe the prevalence of metabolic syndrome (MS), its components, and its associated factors in patients who underwent OLT in a hospital in Spain. From November 2001 to January 2014, we performed 415 transplantations in 386 patients. We analyzed 204 patients with a minimum follow-up of 1 year (77.6% were male and the mean age was 54.2+/-9.5 years). The most frequent etiology was alcohol (41%), followed by hepatitis C virus (29.1%). The indication was decompensated cirrhosis in 51.8% and hepatocellular carcinoma in 34%. According to modified National Cholesterol Education Program-Adult Treatment Panel-III (NCEP-ATP III) criteria, 5 years post-transplantation MS was diagnosed in 38.2% of patients. Significant independent predictors of post-transplantation MS on logistic regression analysis were as follows: pretransplantation obesity (odds ratio [OR], 3.09; P = .056), 1-year post-transplantation obesity (OR, 3.95; P = .009), pretransplantation diabetes (OR, 4.63; P = .001), 1-year post-transplantation diabetes (OR, 3.01; P = .015), 1-year post-transplantation hypertension (OR, 1.85; P = .176), and hypertriglyceridemia at the first year after transplantation (OR, 2.32; P = .063). In our center the prevalence of MS at 5 years after OLT is slightly lower than published. The most important risk factors were obesity and diabetes (both pretransplantation and the first year post-transplantation).

The clip Ovesco (Ovesco, Tübingen, Germany) is a novel endoscopic method for mechanical compression of tissue in the gastrointestinal tract. The indications for treatment are closure of perforations and fistulas and control of bleeding in which the conventional endoscopic treatment has failed. We report two cases about the use of an Ovesco (over-the-scope clip, OTSC) system to control persistent bleeding postpolypectomy after failure of usual treatment.

A 72-year-old man presented with acute cholangitis. He underwent endoscopic retrograde cholangiography (ERCP), which revealed a type IIIb Klatskin tumor. An 8.5-Fr, 12-cm plastic biliary stent was placed. Cholangiocarcinoma was confirmed cytologically and this was deemed unresectable. One month later, the patient presented with abdominal pain and cholestasis without peritoneal signs, fever, or leukocytosis. A computed tomography (CT) scan revealed that the stent had migrated and caused a duodenocolic fistulawithout any associated collection (●" Fig.1). Broadspectrum antibiotics were commenced and a repeat ERCP confirmed that the 8.5-Fr stent had perforated the duodenal wall (●" Fig.2a). The stent was retrieved with a foreign-body forceps. A punctate perforation was evident following removal of the stent (●" Fig.2b) and this was closed with a through-the-scope clip (●" Fig.2c). Cholangiography demonstrated left intrahepatic biliary dilatation and an uncovered biliary metal stent was implanted (●" Video1). The patient was discharged 3 days after the procedure. There are only three reported cases of duodenocolic fistula due to biliary stent migration [1–3]. The most common mechanism of perforation after biliary stent migration is direct contact [4]. Gastrointestinal perforations can be treated endoscopically with clip placement in acute or deferred presentation in patients where there are no signs of peritonitis [4, 5]. The over-the-scope clip has also been used to close duodenocolic fistulas secondary to a migrated biliary stent [6–8], though this is probably not required in chronic cases with small fistulas or perforations. Clinicians should be aware of the endoscopic management options in such cases, thereby avoiding the need for surgical intervention, even in the setting of colonic involvement. This is the first report of a patient who underwent endoscopic removal of the migrated biliary stent and closure of the fistula with a clip.