Cholangioscopy-guided holmium laser lithotripsy of a stone trapped in a mechanical lithotripter

Large common bile duct (CBD) stones can be removed with mechanical lithotripsy, although over-the-basket techniques such as electrohydraulic or pulsed dye laser lithotripsy can be necessary in cases of stone impaction.1 We report the case of a 42-year-old woman with a 30-mm stone in the CBD in whom mechanical lithotripsy was attempted after wide sphincterotomy. However, during the procedure, a rupture occurred in the traction wire of the basket, next to the handle. Emergency lithotripsy (EL) with use of an external-type system was immediately attempted, but wire fracture occurred again (2 times), turning its length shorter than the metallic sheath of the EL and rendering EL impossible(undefined)info:eu-repo/semantics/publishedVersio

Endoscopic Ultrasound-Guided Biliary Drainage in Two Patients with Difficult Biliary Access

Endoscopic retrograde cholangiopancreatography is the method of choice for biliary drainage, although in some cases standard biliary access is difficult or even impossible. Endoscopic ultrasound (EUS)-guided endoluminal procedures are an alternative in these cases, although experience with these techniques is still limited.Introduction: Endoscopic retrograde cholangiopancreatography is the method of choice for biliary drainage, although in some cases standard biliary access is difficult or even impossible. Endoscopic ultrasound (EUS)-guided endoluminal procedures are an alternative in these cases, although experience with these techniques is still limited. Clinical Case: We present two cases of successful EUS-guided biliary drainage. In the first case, a hepaticogastrostomy was performed in a patient with stage IV gastric adenocarcinoma with obstructive jaundice due to compression of the hilum, where malignant gastric stenosis and previous palliative gastrojejunostomy precluded access to the second part of the duodenum. In the second case, a patient with a pancreatic head adenocarcinoma with duodenal invasion that precluded major papillae identification was submitted to a choledochoduodenostomy. Both procedures occurred without immediate or delayed adverse events, with technical and clinical success. Discussion: Although experience with EUS-guided biliary drainage is still limited, its efficacy and safety is favorable when compared with percutaneous and surgical drainage, and should be considered an alternative to these techniques where sufficient expertise existsIntrodução: A colangiopancreatografia retrógrada endoscópica é o procedimento de escolha para a drenagem biliar, embora em alguns casos o acesso biliar convencional é difícil ou até impossível. As técnicas de drenagem guiadas por ecoendoscopia são uma alternativa nestes casos, embora a experiência seja ainda limitada. Caso: Apresentamos dois casos de drenagem biliar eficaz guiada por ecoendoscopia. No primeiro caso foi realizada hepaticogastrostomia numa doente com adenocarcinoma gástrico estadio IV, com icterícia obstrutiva devido a compressão hilar pela neoplasia, na qual o acesso à segunda porção duodenal se revelou impossível devido à neoplasia gástrica estenosante e a antecedentes de gastrojejunostomia paliativa. No segundo caso, uma doente com adenocarcinoma cefalo-pancreático com invasão duodenal que impedia a identificação da papila foi submetida a coledocoduodenostomia. Em ambos os procedimentos foi conseguida drenagem biliar eficaz e não ocorreram eventos adversos imediatos ou tardios. Discussão: Apesar de a experiência com técnicas de drenagem biliar guiadas por ecoendoscopia ser limitada, o seu perfil de eficácia e segurança parece ser favorável quando comparada com as alternativas (drenagem percutânea ou cirúrgica), pelo que devem ser consideradas quando exista equipamento e experiência necessária(undefined)info:eu-repo/semantics/publishedVersio

Estriturotomia de anastomose esofágica: Incisão com needle knife

(undefined)info:eu-repo/semantics/publishedVersio

NOTES Híbrido: ressecção endoscópica completa da parede gástrica assistida por laparoscopia no tratamento de um tumor do estroma gastrointestinal do fundo gástrico

[Excerpt] Laparoscopic wedge resection with a linear stapler is widely accepted in the treatment of gastric gastrointestinal stromal tumors (GISTs) [1, 2]. Although not complex [3], this procedure has some major drawbacks, namely failure in identifying the lesion, possible rupture of the capsule with the linear stapler, excessive normal tissue removal, and technical difficulties in reaching areas such as the cardia, fundus, lesser curvature, or peri-pyloric areas [1–5].[...](undefined)info:eu-repo/semantics/publishedVersio

Precut fistulotomy - widening its limits

info:eu-repo/semantics/publishedVersio

Giant symptomatic rectal lipoma resected by endoscopic submucosal dissection

info:eu-repo/semantics/publishedVersio

Resultados da utilização da colangioscopia de operador único na litotrícia de cálculos difíceis biliares e pancreáticos

"Published online: May 16, 2018"Background and Aims: Endoscopic retrograde cholangiopancreatography is the preferred strategy for the management of biliary and pancreatic duct stones. However, difficult stones occur, and electrohydraulic (EHL) and laser lithotripsy (LL) have emerged as treatment modalities for ductal clearance. Recently, single-operator cholangioscopy was introduced, permitting the routine use of these techniques. We aimed to evaluate the clinical effectiveness of cholangioscopy-guided lithotripsy using LL or EHL in patients with difficult biliary or pancreatic stones. Methods: This is a prospective clinical study – conducted at two affiliated university hospitals – of 17 consecutive patients with difficult biliary and pancreatic stones who underwent single-operator cholangioscopy-guided lithotripsy using two techniques: holmium laser lithotripsy (HL) or bipolar EHL. We analyzed complete ductal clearance as well as the impact of the location and number of stones on clinical success and evaluated the efficacy of the two techniques used for cholangioscopy-guided lithotripsy and procedural complications. Results:Twelve patients (70.6%) had stones in the common bile duct/common hepatic duct, 2 patients (17.6%) had a stone in the cystic stump, and 3 patients (17.6%) had stones in the pancreas. Sixteen patients (94.1%) were successfully managed in 1 session, and 1 patient (5.9%) achieved ductal clearance after 3 sessions including EHL, LL, and mechanical lithotripsy. Eleven patients were successfully submitted to HL in 1 session using a single laser fiber. Six patients were treated with EHL: 4 patients achieved ductal clearance in 1 session with a single fiber, 1 patient obtained successful fragmentation in 1 session using two fibers, and 1 patient did not achieve ductal clearance after using two fibers and was successfully treated with a single laser fiber in a subsequent session. Complications were mild and were encountered in 6/17 patients (35.2%), including fever (n = 3), pain (n = 1), and mild pancreatitis (n = 1). Conclusions: Cholangioscopy-guided lithotripsy using LL or EHL in patients with difficult biliary or pancreatic stones is highly effective with transient and minimal complications. There is a clear need to further compare EHL and HL in order to assess their role in the success of cholangioscopy-guided lithotripsy.Introdução: A CPRE é o exame preferencial para a remoção de cálculos biliares e pancreáticos. Em situações de cálculos difíceis foram propostas novas modalidades terapêuticas como a litotrícia electro-hidráulica (LEH) e a litotrícia por laser (LL). Recentemente a disponibilidade da colongioscopia de operador-único tornaram estas técnicas mais acessíveis e fáceis de realizar. Procuramos avaliar a eficácia clínica de litotrícia guiada por colangioscopia recorrendo à LEH ou à LL em doentes com cálculos biliares e pancreáticos difíceis. Métodos: Estudo prospetivo, conduzido em 2 Hospitais associados à Universidade e englobando 17 doentes consecutivos com cálculos difíceis biliares e pancreáticos, estes doentes foram tratados com litotrícia guiada por colangioscopia recorrendo a LEH ou LL. Analisamos a limpeza completa dos ductos, bem como o impato do número de pedras e localização no sucesso clínico, associada à avaliação das 2 técnicas de litotrícia e complicações desta abordagem terapêutica. Resultados: Doze doentes (70.6%) tinham cálculos no colédoco/hepático comum, 2 doentes (17.6%) tinham um cálculo único no coto do cístico e 3 doentes (17.6%) apresentavam cálculos pancreáticos. Dezasseis (94.1%) doentes foram tratados com sucesso numa única sessão e o restante (5.9%) doente necessitou de 3 sessões incluído LEH, LL e litotrícia mecânica para obter limpeza dos ductos. Onze doentes foram tratados com LL e obtiveram sucesso clínico numa única sessão com uma fibra única de laser. Seis doentes foram tratados com LEH: 4 doentes obtiveram sucesso clínico numa única sessão com 1 fibra; 1 doente necessitou de 2 fibras para obter limpeza ductal numa sessão única. O último doente falhou a limpeza dos ductos com duas fibras de LEH e necessitou de sessão adicional com Laser (uma fibra) para obter fragmentação adequada dos cálculos. As complicações foram ligeiras em 6/17 (35.2%) doentes e incluíram febre (n = 4), dor (n = 1) e pancreatite ligeira (n = 1). Conclusões: A litotrícia guiada por colangioscopia com recurso a LEH ou LL em doentes com cálculos difíceis biliares e pancreáticos é muito eficaz e está associada a complicações transitórias e ligeiras. Existe clara necessidade de realizar estudos comparativos entre LEH e LL.(undefined)info:eu-repo/semantics/publishedVersio

Accuracy of faecal calprotectin and neutrophil Gelatinase B-associated Lipocalin in evaluating subclinical inflammation in UlceRaTIVE colitis-the ACERTIVE study

Background and Aims: Mucosal healing and histological remission are different targets for patients with ulcerative colitis, but both rely on an invasive endoscopic procedure. This study aimed to assess faecal calprotectin and neutrophil gelatinase B-associated lipocalin as biomarkers for disease activity in asymptomatic ulcerative colitis patients. Methods: This was a multicentric cross-sectional study including 371 patients, who were classified according to their endoscopic and histological scores. These results were evaluated alongside the faecal levels of both biomarkers. Results: Macroscopic lesions [i.e. endoscopic Mayo score >= 1] were present in 28% of the patients, and 9% had active disease according to fht Ulcerative Colitis Endoscopic Index of Severity. Moreover, 21% presented with histological inflammation according to the Geboes index, whereas 15% and 5% presented with focal and diffuse basal plasmacytosis, respectively. The faecal levels of calprotectin and neutrophil gelatinase B-associated lipocalin were statistically higher for patients with endoscopic lesions and histological activity. A receiver operating characteristic-based analysis revealed that both biomarkers were able to indicate mucosal healing and histological remission with an acceptable probability, and cut-off levels of 150-250 mu g/g for faecal calprotectin and 12 mu g/g for neutrophil gelatinase B-associated lipocalin were proposed. Conclusions: Faecal calprotectin and neutrophil gelatinase B-associated lipocalin levels are a valuable addition for assessment of disease activity in asymptomatic ulcerative colitis patients. Biological levels of the analysed biomarkers below the proposed thresholds can rule out the presence of macroscopic and microscopic lesions with a probability of 75-93%. However, caution should be applied whenever interpreting positive results, as these biomarkers present consistently low positive predictive values.Portuguese IBD Group [GEDII - Grupo de Estudo da Doenca Inflamatcria Intestinal]info:eu-repo/semantics/publishedVersio

Fatal hepatitis B reactivation treated with entecavir in an isolated anti-HBs positive lymphoma patient: A case report and literature review

Hepatitis B virus (HBV) reactivation is a well-recognized complication that occurs in lymphoma patients who undergo chemotherapy. Only very few cases of HBV reactivation in patients with isolated antibody against hepatitis B surface antigen (anti-HBs) have been reported. We present a case of a 78-year-old woman diagnosed with diffuse large B cell non-Hodgkin′s lymphoma who only displayed a positive anti-HBs, as the single possible marker of occult HBV infection, before starting therapy. She was treated with several chemotherapeutic regimens (including rituximab) for disease relapses during 3 years. Forty days after the last cycle of chemotherapy, she presented with jaundice, markedly elevated serum aminotransferase levels, and coagulopathy. HBV serology showed positivity for HBsAg, anti-HBc and anti-HBs. HBV DNA was positive. Antiviral treatment with entecavir was promptly initiated, but the patient died from liver failure. A review of the literature of HBV reactivation in patients with detectable anti-HBs levels is discussed