Dataset Information

Cholangioscopy-guided steroid injection for refractory post liver transplant anastomotic strictures: a rescue case series.

ABSTRACT: Background and aims:Post liver transplant biliary anastomotic strictures have traditionally been treated with balloon dilation and multiple plastic stents. Fully covered self-expandable metallic stents may be used as an initial alternative or after multiple plastic stents failure. Refractory strictures can occur in 10-22% and require revisional surgery. Alternatively, cholangioscopy allows direct visualization and therapeutic approaches. We aimed to assess the feasibility, safety, and efficacy of balloon dilation combined with cholangioscopy-guided steroid injection for the treatment of refractory anastomotic biliary strictures. Methods:Three post-orthotopic liver transplant patients who failed standard treatment of their biliary anastomotic strictures underwent endoscopic retrograde cholangiopancreatography with balloon dilation followed by cholangioscopy-guided steroid injection at a tertiary care center. Patients had follow-up with images and laboratorial tests to evaluate for residual stricture. Results:Technical success of balloon dilation?+?cholangioscopy-guided steroid injection was achieved in all patients. Cholangioscopy permitted accurate evaluation of bile ducts and precise localization for steroid injection. No adverse events occurred. Mean follow-up was 26 months. Two patients are stent free and remain well in follow-up, with no signs of biliary obstruction. No further therapeutic endoscopic procedures or revisional surgery were required. One patient did not respond to balloon dilation?+?cholangioscopy-guided steroid injection after 11 months of follow-up and required repeat balloon dilation of new strictures above the anastomosis. Conclusion:Cholangioscopy-guided steroid injection combined with balloon dilation in the treatment of refractory post liver transplant strictures is feasible and safe. This method may be used as a rescue alternative before surgical approach. Randomized controlled trials comparing balloon dilation?+?cholangioscopy-guided steroid injection to fully covered self-expandable metallic stents are needed to determine the role of this treatment for anastomotic biliary strictures.

SUBMITTER: Franzini T

PROVIDER: S-EPMC6713960 | biostudies-literature | 2019 Jan-Dec

REPOSITORIES: biostudies-literature

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Cholangioscopy-guided steroid injection for refractory post liver transplant anastomotic strictures: a rescue case series.

Franzini Tomazo T Sagae Vitor M T VMT Guedes Hugo G HG Sakai Paulo P Waisberg Daniel R DR Andraus Wellington W D'Albuquerque Luiz A C LAC Sethi Amrita A de Moura Eduardo G H EGH

Therapeutic advances in gastrointestinal endoscopy 20190101

<h4>Background and aims</h4>Post liver transplant biliary anastomotic strictures have traditionally been treated with balloon dilation and multiple plastic stents. Fully covered self-expandable metallic stents may be used as an initial alternative or after multiple plastic stents failure. Refractory strictures can occur in 10-22% and require revisional surgery. Alternatively, cholangioscopy allows direct visualization and therapeutic approaches. We aimed to assess the feasibility, safety, and ef ...[more]

PMID: 31489404

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Project description:Improved surgical techniques, as well as preoperative and postoperative care, have dramatically changed survival of children with esophageal atresia (EA) over the last decades. Nowadays, we are increasingly seeing EA patients experiencing significant short- and long-term gastrointestinal morbidities. Anastomotic stricture (AS) is the most common complication following operative repair. An esophageal stricture is defined as an intrinsic luminal narrowing in a clinically symptomatic patient, but no symptoms are sensitive or specific enough to diagnose an AS. This review aims to provide a comprehensive view of AS in EA children. Given the lack of evidence-based data, we critically analyzed significant studies on children and adults, including comments on benign strictures with other etiologies. Despite there is no consensus about the goal of the luminal diameter based on the patient's age, esophageal contrast study, and/or endoscopy are recommended to assess the degree of the narrowing. A high variability in incidence of ASs is reported in literature, depending on different definitions of AS and on a great number of pre-, intra-, and postoperative risk factor influencing the anastomosis outcome. The presence of a long gap between the two esophageal ends, with consequent anastomotic tension, is determinant for stricture formation and its response to treatment. The cornerstone of treatment is endoscopic dilation, whose primary aims are to achieve symptom relief, allow age-appropriate capacity for oral feeding, and reduce the risk of pulmonary aspiration. No clear advantage of either balloon or bougie dilator has been demonstrated; therefore, the choice is based on operator experience and comfort with the equipment. Retrospective evidences suggest that selective dilatations (performed only in symptomatic patients) results in significantly less number of dilatation sessions than routine dilations (performed to prevent symptoms) with equal long-term outcomes. The response to dilation treatment is variable, and some patients may experience recurrent and refractory ASs. Adjunctive treatments have been used, including local injection of steroids, topical application of mitomycin C, and esophageal stenting, but long-term studies are needed to prove their efficacy and safety. Stricture resection or esophageal replacement with an interposition graft remains options for AS refractory to conservative treatments.

Project description:BackgroundVessel-sparing anastomotic repair (vsAR) has been developed as a less traumatic alternative to transecting anastomotic repair (tAR) to treat isolated short bulbar urethral strictures. This vessel-sparing technique could result in improved functional outcomes without jeopardizing the excellent surgical outcome after (transecting) anastomotic repair. The purpose of this study is to directly compare vsAR and tAR for both surgical and functional outcomes.MethodsThis trial is a prospective, interventional, multi-center, single-blinded, 1:1 randomized, controlled, non-inferiority, phase II trial. Sample size calculation resulted in a required sample size of 100 patients (50 patients per arm). Trial participants will be randomized by an independent third party using a computer-based random sequence generator with permuted blocks of variable size. The primary objective of this trial is to show that vsAR is non-inferior to tAR in terms of failure-free survival after 24 months of follow-up, considering a non-inferiority limit of 10%. Failure is defined as the inability to pass a 16-Fr flexible cystoscope through the reconstructed area without damaging the urethral mucosa. Secondary end-points mainly include differences in postoperative complications and changes in functional outcome parameters, which will be assessed with validated questionnaires. All participants are scheduled for follow-up at 3, 12, and 24 months postoperatively.DiscussionThis trial will provide level Ib evidence about the differences in both surgical and functional outcome between vsAR and tAR, which may importantly scape the future of bulbar urethral reconstruction. Depending on the trial results, this phase II trial may generate a larger phase III trial with more statistical power and a lower alpha value.Trial registrationThis trial is registered at clinicaltrials.gov ( NCT03572348 ) and in the Belgian Clinical Trial Registry (B670201837335). The trial was registered prospectively. Registered on 28 June 2018.

Project description:Background and aimsEvaluation of indeterminate biliary strictures by brush cytology and intraductal biopsies is limited by low sensitivity. The utility of SpyGlass peroral cholangioscopy for diagnosis of malignant biliary strictures and cholangiocarcinoma (CCA), in particular, remains unclear. Our aim was to study the utility of SpyGlass peroral cholangioscopy and targeted biopsy for diagnosis of malignant biliary strictures and CCA.MethodsIn this systematic review, PubMed and Embase databases were reviewed for studies published to October 2014. The main outcomes of interest were sensitivity, specificity, and diagnostic odds ratio (DOR) of SpyGlass cholangioscopy in the diagnosis of malignant biliary strictures.ResultsThe search yielded 10 studies involving 456 patients. The pooled sensitivity and specificity of cholangioscopy-guided biopsies in the diagnosis of malignant biliary strictures was 60.1% (95% confidence interval [CI], 54.9%-65.2%) and 98.0% (95% CI, 96.0%-99.0%), respectively. The pooled DOR to detect malignant biliary strictures was 66.4 (95% CI, 32.1-137.5). Four studies included patients who had previous negative imaging and brushings and/or intraductal biopsies. Among these 4 studies, the pooled sensitivity and specificity for diagnosis of malignant biliary strictures was 74.7% (95% CI, 63.3%-84.0%) and 93.3% (95% CI, 85.1%-97.8%), respectively. The pooled DOR was 46.0 (95% CI, 15.4-138.1). Only 1 study directly compared the yield of SpyBite biopsies with standard brushings and biopsies. SpyBite biopsies had a sensitivity of 76.5% compared with brushings (5.8%) and biopsies (29.4%). Six studies specifically reported the role of cholangioscopy with targeted biopsies in the diagnosis of CCA. The pooled sensitivity and specificity to detect CCA was 66.2% (95% CI, 59.7%-72.3%) and 97.0% (95% CI, 94.0%-99.0%), respectively. The pooled DOR to detect CCA was 79.7 (95% CI, 32.7-194.7).ConclusionsOur study suggests that SpyGlass cholangioscopy with SpyBite biopsies has moderate sensitivity for the diagnosis of malignant biliary strictures.

Dataset Information

Cholangioscopy-guided steroid injection for refractory post liver transplant anastomotic strictures: a rescue case series.

Publications

Cholangioscopy-guided steroid injection for refractory post liver transplant anastomotic strictures: a rescue case series.

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