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Epidermolysis bullosa (EB) is a very rare inherited disease featured with skin blistering resulting from minor trauma. Sometimes the esophageal mucosa could also be involved, which leads to esophageal strictures. Here we report two cases of EB-related esophageal strictures who were successfully treated with esophageal balloon dilations. The two cases with EB had severe dysphagia. Clinical examination showed signs of malnutrition, skin blisters and loss of toenails due to EB. They underwent careful fluoroscopic balloon dilation with 10- and 16-mm-sized balloon catheters, respectively. They could ingest soft and some solid foods after the procedure and maintained during the 20 months and 16 months follow-up periods.
Background: Bleeding from duodenal varices is a rare but life-threatening complication of portal hypertension. The treatment of duodenal varices remains difficult and a definitive treatment strategy has not been established. The aim of this study was to report the technical aspects and outcomes of balloon-occluded retrograde transvenous obliteration (BRTO) using 5% ethanolamine oleate with iopamidol (EOI) for duodenal varices. Methods: Six consecutive patients with duodenal varices treated using BRTO were eligible. Endoscopic treatment was performed first in three patients with active bleeding. After coil embolization of collateral veins, stepwise EOI infusion was performed at intervals of 10–30 minutes under balloon occlusion until the main efferent vein, varices, and the main afferent vein were filled with EOI and clots. The techniques and outcomes of BRTO were retrospectively evaluated. Results: The main efferent vein of duodenal varices was the right (n = 4) or left (n = 2) gonadal vein. In three patients with ruptured varices, BRTO was performed after achieving hemostasis by endoscopic treatment. In five patients, 1–4 (mean, 2.4 ± 1.1) collateral veins were embolized with coils before EOI infusion. Furthermore, 11–21 mL (mean, 15.3 ± 4.2 mL) of EOI was infused by 3–5 (mean, 3.5 ± 1.0) stepwise infusions via the efferent vein under balloon occlusion. The duration of EOI infusion under balloon occlusion ranged from 82 to 118 minutes (mean, 87.8 ± 13.6 minutes). The varices were thrombosed in all but one patient. In the remaining patient, the varices were thrombosed by additional BRTO under overnight balloon occlusion performed 19 days later. The only complications were a transient fever and hematuria. All duodenal varices disappeared during a followup of 4–32 months (mean, 16.2 ± 11.1 months) after BRTO. Conclusion: BRTO using EOI is an effective treatment for duodenal varices.
Yuki Tanisaka,Masafumi Mizuide,Akashi Fujita,Tomoya Ogawa,Hiromune Katsuda,Yoichi Saito,Kazuya Miyaguchi,Ryuhei Jinushi,Rie Terada,Yuya Nakano,Tomoaki Tashima,Yumi Mashimo,Shomei Ryozawa 소화기인터벤션의학회 2022 Gastrointestinal Intervention Vol.11 No.1
Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard for diagnosis and intervention in patients with biliopancreatic disorders. However, ERCP in patients with surgically altered anatomy (SAA) is considered more difficult than in patients with normal anatomy. Since the introduction of balloon enteroscopes for patients with small intestine disorders, single-balloon enteroscopes (SBEs) and double-balloon enteroscopes (DBEs) have also been used for biliopancreatic diseases in patients with SAA. Nevertheless, the use of conventional SBEs and DBEs is limited, as a balloon enteroscope has a working length of 200 cm and a narrow working channel with a diameter of 2.8 mm; therefore, few ERCP accessories are available for use. A short-type SBE with a working length of 152 cm and a working channel of 3.2 mm in diameter, and a short-type DBE with a working length of 155 cm and a working channel of 3.2 mm were introduced to solve these difficulties. Favorable outcomes of these devices have recently been reported. Moreover, studies have reported several tips to achieve procedural success and factors affecting procedure failure. Difficult cases necessitate alternative techniques, such as percutaneous transhepatic biliary drainage and endoscopic ultrasound-guided biliary drainage.
Maged Tharwat Elghannam,Moataz Hassan Hassanien,Yosry Abdelrahman Ameen,Gamal Mohammed Elattar,Ahmed Ali El Ray,Emad Abdel Wahab Turky,Mohammed Darwish El Talkawy 소화기인터벤션의학회 2022 Gastrointestinal Intervention Vol.11 No.1
The transmission of infections through gastrointestinal endoscopy is a vital issue. The main problem lies in the use of duodenoscopes due to mechanical aspects of the scope design. Even with high-level disinfection, sterilization of the scope can fail. Hence, the Food and Drug Administration has encouraged a shift to single-use endoscopes. Available options include endoscopes with single-use components (mainly single-use endcaps), fully single-use duodenoscopes (SUDs), and even those with a disposable elevator mechanism. Clinical trials revealed that both reusable and single-use scopes have the same efficacy, while single-use scopes have benefits in terms of infection control, economic considerations, and ease of reprocessing. A few drawbacks are left to be dealt with. Reusable duodenoscopes with removable/disposable endcaps are satisfactory except in specific situations where SUDs are better to use.
Combined biliary and duodenal stent placement has been reported previously in multiple series. Rarely, colonic obstruction may present simultaneously with duodenal and biliary obstruction in advanced pancreaticobiliary cancers. Biliary, duodenal and colonic obstruction managed simultaneously using endoscopic modalities have been reported in only one case report previously. Here we report outcomes of a case of carcinoma of the gall bladder with biliary, gastric outlet and colonic obstruction managed by endoscopic placement of biliary, gastroduodenal and colonic self-expanding metal stents.
Iatrogenic air embolism is a rare and potentially fatal complication of gastrointestinal endoscopy. We present a 66-year-old male patient who developed cerebral arterial gas embolism shortly after therapeutic endoscopic retrograde cholangiopancreatography (ERCP) for acute biliary pancreatitis, which is the first case reported in Hong Kong according to latest literature search. Some risk factors of iatrogenic air embolism in this patient include cholangitis with intraductal stones, sphincterotomy and bleeding at papillotomy site which required haemostasis with balloon tamponade. Early diagnosis and timely treatment with hyperbaric oxygen therapy resulted in full neurological recovery of our patient.
Double pigtail plastic stents (DPTPS) are routinely placed with the lumen apposing metal stent (LAMS) during endoscopic ultrasound-guided gallbladder drainage. Several reasons are postulated for this practice. This case report highlights a previously unreported benefit from use of DPTPS within LAMS.
Transarterial chemotherapy (TACE) is the standard treatment for patients with intermediate-stage hepatocellular carcinoma (HCC), defined as large, unresectable, or multinodular HCC in patients with good functional performance. The definition of TACE refractoriness is not well established. Generally, TACE refractoriness is defined as an insufficient response after two or more consecutive TACE. An increase in the number of liver lesions, continuously elevated tumor markers, vascular invasion, and extrahepatic spread also suggest TACE refractoriness. Timely switching to systemic therapy for TACE refractoriness should be considered to improve the outcome. Although data are sparse, the combination of anti-angiogenic and immune checkpoint inhibitor therapies shows promise for TACE-refractory patients. In this article, we review the role of systemic therapy in TACErefractory patients with HCC.
Background: This study investigated the incidence and clinical outcomes of portal and hepatic vein thrombosis (VT) on imaging after transjugular intrahepatic portosystemic shunt (TIPS). Methods: A retrospective review of records at a single liver transplant center between 2010 and 2018 revealed 423 patients who underwent TIPS. Contrast-enhanced computed tomography and magnetic resonance images within 1 year post-TIPS were available for 138 patients and compared to assess the imaging findings of VT and liver infarction. The associations of VT with overall survival, patient characteristics, stent size, pre- and post- TIPS Model for End-Stage Liver Disease (MELD) scores, and post-TIPS hepatic encephalopathy at 90 days were analyzed. Results: The prevalence of VT on imaging within 1 year was 63.0% (n = 87). VT within the right portal vein was more common: 41 cases were in the right portal vein, 25 in the posterior portal vein, and two in the anterior right portal vein. Ten patients had VT in the left portal vein. Four had VT in the main portal vein (MPV), and one had shunt thrombosis extending into the superior mesenteric vein. Hepatic VT was seen in the right hepatic vein in 17 patients and in the middle hepatic vein in six patients. VT was associated with liver infarction (n = 9, P = 0.018). There was no relationship between VT and sex, age, cirrhosis etiology, indication for TIPS, stent size, or hepatic encephalopathy at 90 days. VT in the MPV had poorer survival (P < 0.001). Older age (P = 0.028) and higher pre-TIPS MELD score (P = 0.049) were poor prognostic factors. VT was not treated. Conclusion: Portal and hepatic VTs were common imaging findings after TIPS without worsened clinical outcomes unless VT involved the MPV. VT may cause liver infarction, but infarcts were not independently associated with poorer survival.
Hepatocellular carcinoma (HCC) is the most common primary liver cancer, the sixth most common cancer, and the fourth leading cause of cancerrelated deaths worldwide. There are curative local treatment options for HCC, including liver transplantation, surgical resection, and radiofrequency ablation, all of which are applicable for a few patients. For advanced HCC, systemic treatments, such as target agents or immunotherapies, are recommended, however, with unsatisfactory efficacy. Therefore, radiation therapy (RT) has been used as an alternative or combination therapy. With the advances of RT technique in image guidance and accurate beam delivery, its applications have increased for the management of HCC. Proton beam therapy (PBT) is a highly advanced RT technique. Since proton beams have unique physical properties with a finite range in the distal direction, PBT has the potential to escalate the radiation dose without a significant increase in the risk of complications compared with X-ray therapy in the treatment of HCC. Various studies have reported favorable oncological outcomes and toxicity risks of PBT for HCC patients. In this review, we discuss the physical and biological properties, technical issues, current clinical data, and future perspectives on PBT for the treatment of HCC patients.