Benign esophageal stricture is characterized by the narrowing of the digestivetract lumen due to multiple factors. Endoscopic treatment is the first treatmentchoice and includes endoscopic dilatation, drug injection, ...Benign esophageal stricture is characterized by the narrowing of the digestivetract lumen due to multiple factors. Endoscopic treatment is the first treatmentchoice and includes endoscopic dilatation, drug injection, stenosis incision, stentimplantation, stem cell flap transplantation, etc. However, there are currently nospecific clinical standards or guidelines to quantify a series of specific parametersin the treatment of benign esophageal stricture, such as the frequency of drugadministration, dosage, dilation inner diameter, and number of treatments. Thisleads to operator bias in clinical practice and inconsistent treatment outcomesamong patients. Therefore, this article reviews the current advances and existingchallenges in the endoscopic treatment of benign esophageal stricture, with theaim of exploring the possibility of achieving precision and standardization in theendoscopic treatment of this disease.展开更多
BACKGROUND Refractory esophageal strictures(ES)are defined an anatomical restriction without an active endoscopic inflammation resulting in dysphagia after a minimum of five seriated dilatations in a 4-weeks interval....BACKGROUND Refractory esophageal strictures(ES)are defined an anatomical restriction without an active endoscopic inflammation resulting in dysphagia after a minimum of five seriated dilatations in a 4-weeks interval.Recurrent ES(REES)refer to the inability to maintain a satisfactory luminal diameter for four weeks once an ageappropriate feeding diameter was achieved.Seriated endoscopic dilations are the reference maintenance for ES in pediatric age.Iterative dilations increase the risk of complications and may cause significant organic and psychological consequences in children and excessive costs for families and health systems.Furthermore,fibrotic modifications can make the surgery even more challenging.The surgical approach is burdened by high morbidity,with prolonged hospitalization and delayed oral refeeding in fragile patients with comorbidities.AIM To evaluate the efficacy and safety of the most recent adjuvant treatments,with the aim of avoiding or,at least,postponing surgery.METHODS Intralesional steroids or mitomycin C injections with antiproliferative and antifibroblastic properties have been attempted,but have been abandoned because of systemic adsorption,local complications,or lack of efficacy.Self-expanding metal stents are generally designed for the palliation of neoplastic strictures in adults and rarely employed in pediatrics because of the high risk of complications,in terms of stent migration,local pain and perforation.Our group developed a customized dynamic esophageal stent to stabilize esophageal patency and promote continuous dilatation determined by the food passage between the stent and the REES wall,but it requires an appropriate diameter for placement.RESULTS Recently peroral endoscopic tunneling for restoration of the esophagus has been employed to treat esophageal obstructions exploiting the submucosal space.Re-absorbable self-expanding stents(like SX-ELLA Stent Esophageal Degradable BD-BD stent)and energy-delivering surgical devices(HARMONIC ACE^(TM)+7 Laparoscope)have also been proposed.CONCLUSION After an overview about the historically applied adjuvant therapies,we aim to update the common knowledge with our recent experience of these new minimally invasive options for pediatric REES and refractory ES in three exemplary cases,focusing on their mid-term effectiveness and safety for the purpose of maintain the patency after standard endoscopic dilations and avoiding or,at least,postponing an invasive replacement surgery.展开更多
Biliary complications are still the main complications for liver transplantation recipients. Biliary strictures comprise the major part of all biliary complications after deceased-donor liver transplantation (LT). Bil...Biliary complications are still the main complications for liver transplantation recipients. Biliary strictures comprise the major part of all biliary complications after deceased-donor liver transplantation (LT). Biliary strictures following LT are divided into anastomotic strictures (AS) and non-anastomotic strictures (NAS). A Limitation of current published researches is that most studies aren’t based on clinical practice. The aim of this review is to summarize risk factors, clinical presentation, diagnosis and management in post-LT biliary strictures.展开更多
Esophageal stricture refers to a pathological narrowing of the esophageal lumen,causing dysphagia and impairing the patient's quality of life.There are various etiologies including esophageal malignancy,peptic inj...Esophageal stricture refers to a pathological narrowing of the esophageal lumen,causing dysphagia and impairing the patient's quality of life.There are various etiologies including esophageal malignancy,peptic injury,caustic ingestion,postsurgical anastomosis,radiation therapy,and inflammatory disorders such as eosinophilic esophagitis.The primary goal in managing esophageal strictures is to relieve dysphagia by maintaining luminal patency.Endoscopic dilation remains the mainstay of treatment for most benign strictures,with either bougie or balloon dilators.For patients who develop refractory or recurrent strictures that are difficult to manage with dilation alone,adjunctive therapies like intralesional steroid injections,topical or injected mitomycin C,incisional therapy,stent placement,and finally surgery may enhance outcomes and reduce the frequency of repeat procedures.The present review focuses on the basics of dilation and adjunctive strategies for the management of esophageal stricture.展开更多
BACKGROUND Esophageal stricture is a prevalent condition affecting the digestive system,primarily marked by dysphagia and the obstruction of food passage through the esophagus.This narrowing of the esophageal lumen ca...BACKGROUND Esophageal stricture is a prevalent condition affecting the digestive system,primarily marked by dysphagia and the obstruction of food passage through the esophagus.This narrowing of the esophageal lumen can significantly impact a person’s ability to eat and drink comfortably,often leading to a decrease in nutritional intake and quality of life.AIM To explore the current research status and future trends of esophageal stricture through bibliometric analysis.METHODS Literature on esophageal stricture from 2004 to 2023 was retrieved from the Web of Science Core Collection.Statistical analysis was performed using Excel,VOSviewer,CiteSpace,and RStudio.This study provides data on annual production trends,countries/regions,influential authors,institutions,journals,references,and keywords.RESULTS The study included 1485 publications written by 7469 authors from 1692 institutions across 66 countries/regions,published in 417 journals.The United States,China,and Japan are the major contributors to this field,with many quality papers.Song Ho-young,Diseases of the Esophagus,Gastrointestinal Endoscopy,and Mayo Clinic are the top authors,journals,co-cited journals,and institutions,respectively.The most frequent keywords are stent,endoscopy,management,etiology,and prevention;regenerative medicine,endoscopic injection,and autologous tissue transplantation are the latest research frontiers.These keywords reflect continuous advancements in technical innovation,treatment strategies,preventive measures in the esophageal stricture research field,and a sustained focus on improving patient prognosis.In contrast,the basic sciences were underrepresented.CONCLUSION This study provides an insightful analysis of the developments in the field of esophageal stricture over the past twenty years,with stent placement is currently a hot research topic.展开更多
BACKGROUND Strictures in ulcerative colitis(UC)are relatively uncommon but are associated with increased risk of malignancy and complications.Until recently,fibrogenesis and strictures have remained largely unexplored...BACKGROUND Strictures in ulcerative colitis(UC)are relatively uncommon but are associated with increased risk of malignancy and complications.Until recently,fibrogenesis and strictures have remained largely unexplored in UC.AIM To investigate the incidence,long-term prognosis and risk factors of colorectal strictures in a large cohort of UC patients.METHODS A total of 938 hospitalized UC patients at Peking Union Medical College Hospital were included from 2014 to 2024.Stricture was defined as a fixed localized narrowing of the colorectal lumen.Risk factors for stricture formation were identified by multivariable Cox regression.Prognosis was analyzed using the Kaplan-Meier or Fine-Gray method.Sensitivity analysis excluded malignant strictures due to their distinct pathophysiology.RESULTS The overall incidence of stricture was 12.4%over a median follow-up of 8.70 years,with a 10-year cumulative probability of 11.3%.Malignancy occurred in 8.6%of stricture cases.UC patients with strictures were at higher risk for intestinal complications,surgery and malignancy(P<0.05).The 10-year cumulative probabilities of surgery and all-cause mortality were 37.6%and 1.6%,respectively.Age≥40 years at diagnosis[hazard ratio(HR)=2.197,95%confidence interval(CI):1.487-3.242]and extraintestinal manifestations(HR=2.072,95%CI:1.326-3.239)were associated with higher stricture risk,while the use of biological agents such as vedolizumab(HR=0.382,95%CI:0.203-0.720)was protective against strictures(P<0.05).Sensitivity analysis on benign strictures showed consistent findings,with similar risk factors and worse longterm outcomes.CONCLUSION UC patients with strictures had worse long-term prognostic outcomes.Earlier endoscopic surveillance and biologic treatment should be considered in patients≥40 years or those with extraintestinal manifestations.展开更多
BACKGROUND Biliary anastomotic stricture(BAS)occurs in approximately 14%-20%of patients post-orthotopic liver transplantation(post-OLT).Endoscopic retrograde cholan-giopancreatography(ERCP)using multiple plastic stent...BACKGROUND Biliary anastomotic stricture(BAS)occurs in approximately 14%-20%of patients post-orthotopic liver transplantation(post-OLT).Endoscopic retrograde cholan-giopancreatography(ERCP)using multiple plastic stents(MPSs)or fully covered self-expandable metal stents(cSEMSs)represent the standard treatment for BAS post-OLT.Recently,cSEMSs have emerged as the primary option for managing BAS post-OLT.AIM To compare the resolution and recurrence of BAS rates in these patients.METHODS This retrospective cohort study was conducted in a single tertiary care center(Hospital Israelita Albert Einstein,São Paulo,Brazil).We reported the results of endoscopic therapy in patients with post-OLT BAS between 2012 and 2022.Patients were stratified into two groups according to therapy:(1)MPSs;and(2)cSEMSs.Primary endpoints were to compare stricture resolution and recurrence among the groups.The secondary endpoint was to identify predictive factors for stricture recurrence.RESULTS A total of 104 patients were included.Overall stricture resolution was 101/104(97.1%).Stricture resolution was achieved in 83/84 patients(99%)in the cSEMS group and 18/20 patients(90%)in the MPS group(P=0.094).Failure occurred in 3/104 patients(2.8%).Stricture recurrence occurred in 9/104 patients(8.7%).Kaplan-Meier analysis showed there was no difference in recurrence-free time among the groups(P=0.201).A multivariate analysis identified the number of ERCP procedures(hazard ratio=1.4;95%confidence interval:1.194-1.619;P<0.001)and complications(hazard ratio=2.8;95%confidence interval:1.008-7.724;P=0.048)as predictors of stricture recurrence.CONCLUSION cSEMSs and MPSs were effective and comparable regarding BAS post-OLT resolution and recurrence.The number of ERCP procedures and complications were predictors of stricture recurrence.展开更多
BACKGROUND It is well known that in case of high initial strictures of bile ducts surgical treatment is associated with a high risk of damage to the hepatoduodenal ligament elements,often involved in rough scarring,an...BACKGROUND It is well known that in case of high initial strictures of bile ducts surgical treatment is associated with a high risk of damage to the hepatoduodenal ligament elements,often involved in rough scarring,and with a significant risk of stricture recurrence.AIM To compare the long-term outcomes of different surgical treatment options for patients with high-grade benign biliary strictures.METHODS From 2012 to 2022,193 patients were treated at the A.V.Vishnevsky Surgical Center.All of them had different levels of strictures according to Bismuth-Strasberg classification:Type E1-2 in 32 patients,type E3-99,type E4-62.123 patients underwent open reconstructive interventions,70 percutaneous endobiliary interventions.RESULTS Long-term results were available for 192(99%)patients with a follow-up of 4.7±1.6 years after reconstructive surgery;3.0±1.4 years after percutaneous interventions.Excellent and good results(according to Terblanche classification)were achieved in 35%(42/122)of patients after open reconstructive surgery and in 13%(9/70)of patients after percutaneous transhepatic interventions(P-value<0.05).CONCLUSION Technically,the most difficult bile duct strictures for reconstructive and percutaneous transhepatic interventions with a high recurrence rate are Bismuth-Strasberg type E4 and E5.The comparative analysis of long-term results of percutaneous and open procedures showed a statistically significant advantage of percutaneous procedures compared to open reconstructive procedures.展开更多
Objective:To present the surgical technique of robotic buccal ureteroplasty for strictures after laser lithotripsy and its outcomes.Methods:This was a retrospective study conducted at the Department of Urology,Apollo ...Objective:To present the surgical technique of robotic buccal ureteroplasty for strictures after laser lithotripsy and its outcomes.Methods:This was a retrospective study conducted at the Department of Urology,Apollo Hospitals,Chennai,India from October 2012 to October 2022.Indications for surgery included worsening hydronephrosis,declining renal function,and recurrent urinary tract infections with obstruction.Apart from liberal exposure of the stricture,we stress upon use of indocyanine green to assess vascularity and quilting of the graft to bare area of the psoas muscle to increase graft vascularity.Results:Among the 15 patients,ureteropelvic junction strictures were observed in eight(53%),while five(33%)had proximal ureteric strictures,and two(13%)had mid-ureteral strictures.Notably,eight of the 15 patients(53%)had previous unsuccessful double-J stenting.The median stricture length was 3.5(range:2.0–5.0)cm,with a mean operative time of 167(range:126–214)min and estimated blood loss of 60(range:40–100)mL.After a median follow-up of 12(range:4–32)months,13 out of the 15 patients(87%)showed significant improvement in their follow-up functional scans.Conclusion:Robotic buccal ureteroplasty is a very effective technique for the management of laser-induced ureteral strictures with good long-term results and minimal morbidity.The results are comparable irrespective of previous failed stenting.展开更多
Despite advances in cross-sectional imaging and endoscopic technology,bile duct strictures remain a challenging clinical entity.It is crucial to make an early determination of benign or malignant nature of biliary str...Despite advances in cross-sectional imaging and endoscopic technology,bile duct strictures remain a challenging clinical entity.It is crucial to make an early determination of benign or malignant nature of biliary strictures.Early diagnosis not only helps with further management but also minimizes mortality and morbidity associated with delayed diagnosis.Conventional imaging and endoscopic techniques,particularly endoscopic retrograde cholangiopancreatography(ERCP)and tissue sampling techniques play a key in establishing a diagnosis.Indeterminate biliary strictures(IDBSs)have no definite mass on imaging or absolute histopathological diagnosis and often warrant utilization of multiple diagnostics to ascertain an etiology.In this review,we discuss possible etiologies,clinical presentation,diagnosis,and management of IDBSs.Based on available data and expert opinion,we depict an evidence based diagnostic algorithm for management of IDBSs.Areas of focus include use of traditional tissue sampling techniques such as ERCP with brush cytology,intraductal biopsies,fluorescence in situ hybridization and flow cytometry.We also describe the role of endoscopic ultrasound(EUS)-guided fine needle aspiration and biopsies,cholangioscopy,confocal laser endomicroscopy,and intraductal EUS in management of IDBSs.展开更多
Objective:We described the technique and outcomes of robot-assisted repair of uretero-enteric strictures(UES)following robot-assisted radical cystectomy(RARC)and urinary diversion.Methods:Retrospective review of our R...Objective:We described the technique and outcomes of robot-assisted repair of uretero-enteric strictures(UES)following robot-assisted radical cystectomy(RARC)and urinary diversion.Methods:Retrospective review of our RARC database from November 2005 to August 2023 at Roswell Park Comprehensive Cancer center was performed.Patients who developed UES and ultimately underwent robot-assisted uretero-enteric reimplantation(RUER)were identified.KaplaneMeier method was used to compute the cumulative incidence recurrence rate of UES after RUER.A multivariable regression model was used to identify variables associated with UES recurrence.Results:A total of 123(15%)out of 808 RARC patients developed UES,of whom 52 underwent reimplantation(45 patients underwent RUER[n=55 cases]and seven patients underwent open ureteroenteric reimplantation).The median time from RARC to UES was 4.4(interquartile range 3.0e7.0)months,and the median time between UES and RUER was 5.2(interquartile range 3.2e8.9)months.The 3-year recurrence rate after RUER is about 29%.On multivariable analysis,longer hospital stay(hazard ratio 1.37,95%confidence interval 1.16e1.61,p<0.01)was associated with recurrent UES after RUER.Conclusion:RUER for UES after RARC is feasible with durable outcomes although a notable subset of patients experienced postoperative complications and UES recurrence.展开更多
Objective:To describe and evaluate the technique using bilateral Boari flap ureteroneocystostomy(BBFUNC)for bilateral mid-lower ureteral strictures.Methods:We retrospectively reviewed five patients who underwent minim...Objective:To describe and evaluate the technique using bilateral Boari flap ureteroneocystostomy(BBFUNC)for bilateral mid-lower ureteral strictures.Methods:We retrospectively reviewed five patients who underwent minimally invasive BBFUNC in our institution(Union Hospital,Wuhan,China)between July 2019 and December 2021.The bilateral ureters were mobilized and transected above the stenotic segments.The bladder was isolated and incised longitudinally from the middle of the anterior wall.Then,an inverted U-shaped bladder flap was created on both sides,fixed onto the psoas tendon,and anastomosed to the ipsilateral distal normal ureter.Following double-J stenting,the Boari flaps were tubularized,and the bladder was closed with continuous sutures.The patients’perioperative data and follow-up outcomes were collected,and a descriptive statistical analysis was performed.Results:No case converted to open surgery,and no intraoperative complication occurred.The median surgical time was 230(range 203-294)min.The median length of the bladder flaps was 6.2(range 4.3-10.0)cm on the left and 5.5(range 4.7-10.5)cm on the right side.All patients had not developed recurrent ureteral stenosis during the median follow-up time of 17(range 16-45)months and had a normal maximum flow rate after surgery.The median post-void residual was 7(range 0-19)mL.The maximal bladder capacity was decreased in one(20%)patient.Conclusion:The present study demonstrates that minimally invasive BBFUNC is feasible and safe in treating is limited.展开更多
Indeterminate biliary strictures pose a significant diagnostic dilemma for gastroenterologists.Despite advances in endoscopic techniques and instruments,it is difficult to differentiate between benign and malignant pa...Indeterminate biliary strictures pose a significant diagnostic dilemma for gastroenterologists.Despite advances in endoscopic techniques and instruments,it is difficult to differentiate between benign and malignant pathology.A positive histological diagnosis is always preferred prior to high risk hepatobiliary surgery,or to inform other types of therapy.Endoscopic retrograde cholangiopancreato-graphy with brushings has low sensitivity and despite significant improvements in instruments there is still an unacceptably high false negative rate.Other methods such as endoscopic ultrasound and cholangioscopy have improved diagnostic quality.In this review we explore the techniques available to aid accurate diagnosis of indeterminate biliary strictures and obtain accurate histology to facilitate clinical management.展开更多
Introduction and Objectives: Urethral stricture is a reduction in the caliber of the urethral lumen impeding the outflow of urine. It predominantly affects males. The disease burden is severe in our milieu where acces...Introduction and Objectives: Urethral stricture is a reduction in the caliber of the urethral lumen impeding the outflow of urine. It predominantly affects males. The disease burden is severe in our milieu where access to specialized care is limited. Our goal was therefore to assess the management and outcome of male urethral stricture at two tertiary hospitals in Douala, Cameroon. Materials and Methods: This was a hospital-based retrospective study of patients managed for urethral stricture over 5 years (January 1st, 2017 to December 31st, 2021) at the Douala General and Laquintinie Hospitals. Data on sociodemographic, clinical, paraclinical, and treatment options were extracted using pre-structured forms. Data was analyzed using Statistical Package for Social Sciences (SPSS) version 28. Statistical significance was set at p-value Results: We exploited 130 medical records. The mean age of patients was 46.5 years. Dysuria and weak urine stream were the major presenting complaints (63.8% and 23.8% respectively). The etiology of urethral stricture was iatrogenic in 42.3% of cases. The strictures were mostly single (89.8%), and the bulbar urethra was most affected (46.9%). 28 patients had urinary tract infections and the most frequently isolated germ was E. coli in 29.6%. Direct visual internal urethrotomy (DVIU) was performed in 42.3% of cases. Surgery, especially excision and primary anastomosis (EPA) was done in 28.5% of cases. Major complications were wound infection, acute kidney injury (AKI), and urethrocutaneous fistulae affecting 3.1, 2.3, and 1.5% of cases respectively. The recurrence rate was 17% with a mortality rate of 0.08%. Conclusion: Urethral stricture is common in our adult male population. The cause is mainly iatrogenic and the bulbar urethra is most affected. Minimally invasive and open reconstruction are frequently used treatment options with significant recurrence rates in the long term.展开更多
Benign esophageal strictures refractory to the conventional balloon or bougie dilatation may be subjected to various adjunctive modes of therapy, one of them being endoscopic incisional therapy(EIT). A proper delineat...Benign esophageal strictures refractory to the conventional balloon or bougie dilatation may be subjected to various adjunctive modes of therapy, one of them being endoscopic incisional therapy(EIT). A proper delineation of the stricture anatomy is a prerequisite. A host of electrocautery and mechanical devices may be used, the most common being the use of needle knife, either standard or insulated tip. The technique entails radial incision and cutting off of the stenotic rim. Adjunctive therapies, to prevent re-stenosis, such as balloon dilatation, oral or intralesional steroids or argon plasma coagulation can be used. The common strictures where EIT has been successfully used are Schatzki's rings(SR) and anastomotic strictures(AS). Short segment strictures(< 1 cm) have been found to have the best outcome. When compared with routine balloon dilatation, EIT has equivalent results in treatment na?ve cases but better long term outcome in refractory cases. Anecdotal reports of its use in other types of strictures have been noted. Post procedure complications of EIT are mild and comparable to dilatation therapy. As of the current evidence, incisional therapy can be used for management of refractory AS and SR with relatively short stenosis(< 1 cm) with good safety profile and acceptable long term patency.展开更多
The treatment of urethral strictures remains a challenging field in urology even though there are a variety of procedures to treat it at present,as no one approach is superior over another.This paper reviewed the surg...The treatment of urethral strictures remains a challenging field in urology even though there are a variety of procedures to treat it at present,as no one approach is superior over another.This paper reviewed the surgical options for the management of different sites and types of anterior urethral stricture,providing a brief discussion of the controversies regarding this issue and suggesting possible future advancements.Among the existing procedures,simple dilation and direct vision internal urethrotomy are more commonly used for short urethral strictures(<1 cm,soft and no previous intervention).Currently,urethroplasty using buccal mucosa or penile skin is the most widely adopted clinical techniques and have proved successful.Nonetheless,complications such as donor site morbidity remain problem.Tissue engineering techniques are considered as a promising solution for urethral reconstruction,but require further investigation,as does stem cell therapy.展开更多
AIM To evaluate the incidence of anastomotic strictures after intestinal resection in Crohn's disease(CD), demonstrate long-term efficacy and safety of endoscopic balloon dilation(EBD) in CD strictures and its imp...AIM To evaluate the incidence of anastomotic strictures after intestinal resection in Crohn's disease(CD), demonstrate long-term efficacy and safety of endoscopic balloon dilation(EBD) in CD strictures and its impact on the diagnosis of subclinical postoperative endoscopic recurrence. METHODS Retrospective single tertiary center study based on prospectively collected data between 2010 and 2015including anastomotic and non-anastomotic strictures. RESULTS29% of 162 CD patients included developed an anastomotic stricture. 43 patients with anastomotic strictures and 37 with non-anastomotic strictures underwent EBD; technical success was 97.7% and 100%, respectively, however, 63% and 41% needed repeat dilation during the 4.4-year follow-up. Longer periods between surgery and index colonoscopy and higher lactoferrin levels were associated with the presence of stricture after surgery. Calprotectin levels > 83.35 μg/g and current or past history of smoking were associated with a shorter time until need for dilation(HR = 3.877, 95%CI: 1.480-10.152 and HR = 3.041, 95%CI: 1.213-7.627). Anastomotic strictures had a greater need for repeat dilation(63% vs 41%, P = 0.047). No differences were found between asymptomatic and symptomatic cohorts. Disease recurrence diagnosis was only possible after EBD in a third of patients. CONCLUSION EBD is an effective and safe alternative to surgery, with a good short and long-term outcome, postponing or even avoiding further surgery. EBD may allow to diagnose disease recurrence in patients with no clinical signs/biomarkers of disease activity.展开更多
AIM: To evaluate the diagnostic value of different indirect methods like biochemical parameters, ultrasound (US) analysis, CT-scan and MRI/MRCP in comparison with endoscopic retrograde cholangiography (ERC), for diagn...AIM: To evaluate the diagnostic value of different indirect methods like biochemical parameters, ultrasound (US) analysis, CT-scan and MRI/MRCP in comparison with endoscopic retrograde cholangiography (ERC), for diagnosis of biliary complications after liver transplantation. METHODS: In 75 patients after liver transplantation, who received ERC due to suspected biliary complications, the result of the cholangiography was compared to the results of indirect imaging methods performed prior to ERC. The cholangiography showed no biliary stenosis (NoST) in 25 patients, AST in 27 and ITBL in 23 patients. RESULTS: Biliary congestion as a result of AST was detected with a sensitivity of 68.4% in US analysis (specificity 91%), of 71% in MRI (specificity 25%) and of 40% in CT (specificity 57.1%). In ITBL, biliary congestion was detected with a sensitivity of 58.8% in the US, 88.9%in MRI and of 83.3% in CT. However, as anastomotic or ischemic stenoses were the underlying cause of biliary congestion, the sensitivity of detection was very low. InMRI detected the dominant stenosis at a correct localization in 22% and CT in 10%, while US failed completely. The biochemical parameters, showed no significant difference in bilirubin (median 5.7; 4,1; 2.5 mg/dL), alkaline phosphatase (median 360; 339; 527 U/L) or gamma glutamyl transferase (median 277; 220; 239 U/L) levels between NoST, AST and ITBL.CONCLUSION: Our data confirm that indirect imaging methods to date cannot replace direct cholangiography for diagnosis of post transplant biliary stenoses. However MRI may have the potential to complement or precede imaging by cholangiography. Optimized MRCP-processing might further improve the diagnostic impact of this method.展开更多
AIM:To report the largest patient cohort study investigating the diagnostic yield of intraductal ultrasound (IDUS) in indeterminate strictures of the common bile duct.METHODS:A patient cohort with bile duct strictures...AIM:To report the largest patient cohort study investigating the diagnostic yield of intraductal ultrasound (IDUS) in indeterminate strictures of the common bile duct.METHODS:A patient cohort with bile duct strictures of unknown etiology was examined by IDUS.Sensitivity,specificity and accuracy rates of IDUS were calculated relating to the definite diagnoses proved by histopathology or long-term follow-up in those patients who did not undergo surgery.Analysis of the endosonographic report allowed drawing conclusions with respect to the T and N staging in 147 patients.IDUS staging was compared to the postoperative histopathological staging data allowing calculation of sensitivity,specificity and accuracy rates for T and N stages.The endoscopic retrograde cholangio-pancreatography and IDUS procedures were performed under fluoroscopic guidance using a side-viewing duodenoscope (Olympus TJF 160,Olympus,Ltd.,Tokyo,Japan).All procedures were performed under conscious sedation (propofol combined with pethidine) according to the German guidelines.For IDUS,a 6 F or 8 F ultrasound miniprobe was employed with a radial scanner of 15-20 MHz at the tip of the probe (Aloka Co.,Tokyo,Japan).RESULTS:A total of 397 patients (210 males,187 females,mean age 61.43 ± 13 years) with indeterminate bile duct strictures were included.Two hundred and sixty-four patients were referred to the department of surgery for operative exploration,thus surgical histopathological correlation was available for those patients.Out of 264 patients,174 had malignant disease proven by surgery,in 90 patients benign disease was found.In these patients decision for surgical exploration was made due to suspicion for malignant disease in multimodal diagnostics (computed tomography scan,endoscopic ultrasound or magnetic resonance imaging).Twenty benign bile duct strictures were misclassified by IDUS as malignant while 14 patients with malignant strictures were initially misdiagnosed by IDUS as benign resulting in sensitivity,specificity and accuracy ratesof 93.2%,89.5% and 91.4%,respectively.In the subgroup analysis of malignancy prediction,IDUS showed best performance in cholangiocellular carcinoma as underlying disease (sensitivity rate,97.6%) followed by pancreatic carcinoma (93.8%),gallbladder cancer (88.9%) and ampullary cancer (80.8%).A total of 133 patients were not surgically explored.32 patients had palliative therapy due to extended tumor disease in IDUS and other imaging modalities.Ninety-five patients had benign diagnosis by IDUS,forceps biopsy and radiographic imaging and were followed by a surveillance protocol with a follow-up of at least 12 mo;the mean follow-up was 39.7 mo.Tumor localization within the common bile duct did not have a significant influence on prediction of malignancy by IDUS.The accuracy rate for discriminating early T stage tumors (T1) was 84% while for T2 and T3 malignancies the accuracy rates were 73% and 71%,respectively.Relating to N0 and N1 staging,IDUS procedure achieved accuracy rates of 69% for N0 and N1,respectively.Limitations:Pretest likelihood of 52% may not rule out bias and overinterpretation due to the clinical scenario or other prior performed imaging tests.CONCLUSION:IDUS shows good results for accurate diagnostics of bile duct strictures of uncertain etiology thus allowing for adequate further clinical management.展开更多
Biliary stricture complicating living donor liver transplantation(LDLT) is a relatively common complication, occurring in most transplant centres across the world. Cases of biliary strictures are more common in LDLT t...Biliary stricture complicating living donor liver transplantation(LDLT) is a relatively common complication, occurring in most transplant centres across the world. Cases of biliary strictures are more common in LDLT than in deceased donor liver transplantation. Endoscopic management is the mainstay for biliary strictures complicating LDLT and includes endoscopic retrograde cholangiography, sphincterotomy and stent placement(with or without balloon dilatation). The efficacy and safety profiles as well as outcomes of endoscopic management of biliary strictures complicating LDLT is an area that needs to be viewed in isolation, owing to its unique set of problems and attending complications; as such, it merits a tailored approach, which is yet to be well established. The diagnostic criteria applied to these strictures are not uniform and are over-reliant on imaging studies showing an anastomotic narrowing. It has to be kept in mind that in the setting of LDLT, a subjective anastomotic narrowing is present in most cases due to a mismatch in ductal diameters. However, whether this narrowing results in a functionally significant narrowing is a question that needs further study. In addition, wide variation in the endotherapy protocols practised in most centres makes it difficult to interpret the results and hampers our understanding of this topic. The outcome definition for endotherapy is also heterogenous and needs to be standardised to allow for comparison of data in this regard and establish a clinical practice guideline. There have been multiple studies in this area in the last 2 years, with novel findings that have provided solutions to some of these issues. This review endeavours to incorporate these new findings into the wider understanding of endotherapy for biliary strictures complicating LDLT, with specific emphasis on diagnosis of strictures in the LDLT setting, endotherapy protocols and outcome definitions. An attempt is made to present the best management options currently available as well as directions for future research in the area.展开更多
文摘Benign esophageal stricture is characterized by the narrowing of the digestivetract lumen due to multiple factors. Endoscopic treatment is the first treatmentchoice and includes endoscopic dilatation, drug injection, stenosis incision, stentimplantation, stem cell flap transplantation, etc. However, there are currently nospecific clinical standards or guidelines to quantify a series of specific parametersin the treatment of benign esophageal stricture, such as the frequency of drugadministration, dosage, dilation inner diameter, and number of treatments. Thisleads to operator bias in clinical practice and inconsistent treatment outcomesamong patients. Therefore, this article reviews the current advances and existingchallenges in the endoscopic treatment of benign esophageal stricture, with theaim of exploring the possibility of achieving precision and standardization in theendoscopic treatment of this disease.
文摘BACKGROUND Refractory esophageal strictures(ES)are defined an anatomical restriction without an active endoscopic inflammation resulting in dysphagia after a minimum of five seriated dilatations in a 4-weeks interval.Recurrent ES(REES)refer to the inability to maintain a satisfactory luminal diameter for four weeks once an ageappropriate feeding diameter was achieved.Seriated endoscopic dilations are the reference maintenance for ES in pediatric age.Iterative dilations increase the risk of complications and may cause significant organic and psychological consequences in children and excessive costs for families and health systems.Furthermore,fibrotic modifications can make the surgery even more challenging.The surgical approach is burdened by high morbidity,with prolonged hospitalization and delayed oral refeeding in fragile patients with comorbidities.AIM To evaluate the efficacy and safety of the most recent adjuvant treatments,with the aim of avoiding or,at least,postponing surgery.METHODS Intralesional steroids or mitomycin C injections with antiproliferative and antifibroblastic properties have been attempted,but have been abandoned because of systemic adsorption,local complications,or lack of efficacy.Self-expanding metal stents are generally designed for the palliation of neoplastic strictures in adults and rarely employed in pediatrics because of the high risk of complications,in terms of stent migration,local pain and perforation.Our group developed a customized dynamic esophageal stent to stabilize esophageal patency and promote continuous dilatation determined by the food passage between the stent and the REES wall,but it requires an appropriate diameter for placement.RESULTS Recently peroral endoscopic tunneling for restoration of the esophagus has been employed to treat esophageal obstructions exploiting the submucosal space.Re-absorbable self-expanding stents(like SX-ELLA Stent Esophageal Degradable BD-BD stent)and energy-delivering surgical devices(HARMONIC ACE^(TM)+7 Laparoscope)have also been proposed.CONCLUSION After an overview about the historically applied adjuvant therapies,we aim to update the common knowledge with our recent experience of these new minimally invasive options for pediatric REES and refractory ES in three exemplary cases,focusing on their mid-term effectiveness and safety for the purpose of maintain the patency after standard endoscopic dilations and avoiding or,at least,postponing an invasive replacement surgery.
文摘Biliary complications are still the main complications for liver transplantation recipients. Biliary strictures comprise the major part of all biliary complications after deceased-donor liver transplantation (LT). Biliary strictures following LT are divided into anastomotic strictures (AS) and non-anastomotic strictures (NAS). A Limitation of current published researches is that most studies aren’t based on clinical practice. The aim of this review is to summarize risk factors, clinical presentation, diagnosis and management in post-LT biliary strictures.
文摘Esophageal stricture refers to a pathological narrowing of the esophageal lumen,causing dysphagia and impairing the patient's quality of life.There are various etiologies including esophageal malignancy,peptic injury,caustic ingestion,postsurgical anastomosis,radiation therapy,and inflammatory disorders such as eosinophilic esophagitis.The primary goal in managing esophageal strictures is to relieve dysphagia by maintaining luminal patency.Endoscopic dilation remains the mainstay of treatment for most benign strictures,with either bougie or balloon dilators.For patients who develop refractory or recurrent strictures that are difficult to manage with dilation alone,adjunctive therapies like intralesional steroid injections,topical or injected mitomycin C,incisional therapy,stent placement,and finally surgery may enhance outcomes and reduce the frequency of repeat procedures.The present review focuses on the basics of dilation and adjunctive strategies for the management of esophageal stricture.
基金Supported by Beijing Science and Technology Planning Project,No.Z221100007422061the Natural Science Foundation of Shaanxi Province,General Project,No.2018SF-159.
文摘BACKGROUND Esophageal stricture is a prevalent condition affecting the digestive system,primarily marked by dysphagia and the obstruction of food passage through the esophagus.This narrowing of the esophageal lumen can significantly impact a person’s ability to eat and drink comfortably,often leading to a decrease in nutritional intake and quality of life.AIM To explore the current research status and future trends of esophageal stricture through bibliometric analysis.METHODS Literature on esophageal stricture from 2004 to 2023 was retrieved from the Web of Science Core Collection.Statistical analysis was performed using Excel,VOSviewer,CiteSpace,and RStudio.This study provides data on annual production trends,countries/regions,influential authors,institutions,journals,references,and keywords.RESULTS The study included 1485 publications written by 7469 authors from 1692 institutions across 66 countries/regions,published in 417 journals.The United States,China,and Japan are the major contributors to this field,with many quality papers.Song Ho-young,Diseases of the Esophagus,Gastrointestinal Endoscopy,and Mayo Clinic are the top authors,journals,co-cited journals,and institutions,respectively.The most frequent keywords are stent,endoscopy,management,etiology,and prevention;regenerative medicine,endoscopic injection,and autologous tissue transplantation are the latest research frontiers.These keywords reflect continuous advancements in technical innovation,treatment strategies,preventive measures in the esophageal stricture research field,and a sustained focus on improving patient prognosis.In contrast,the basic sciences were underrepresented.CONCLUSION This study provides an insightful analysis of the developments in the field of esophageal stricture over the past twenty years,with stent placement is currently a hot research topic.
基金Supported by the National Natural Science Foundation of China,No.82270567the Central High-Level Hospital Clinical Research Project of Peking Union Medical College Hospital,No.2022-PUMCH-B-022 and No.2022-PUMCH-C-055.
文摘BACKGROUND Strictures in ulcerative colitis(UC)are relatively uncommon but are associated with increased risk of malignancy and complications.Until recently,fibrogenesis and strictures have remained largely unexplored in UC.AIM To investigate the incidence,long-term prognosis and risk factors of colorectal strictures in a large cohort of UC patients.METHODS A total of 938 hospitalized UC patients at Peking Union Medical College Hospital were included from 2014 to 2024.Stricture was defined as a fixed localized narrowing of the colorectal lumen.Risk factors for stricture formation were identified by multivariable Cox regression.Prognosis was analyzed using the Kaplan-Meier or Fine-Gray method.Sensitivity analysis excluded malignant strictures due to their distinct pathophysiology.RESULTS The overall incidence of stricture was 12.4%over a median follow-up of 8.70 years,with a 10-year cumulative probability of 11.3%.Malignancy occurred in 8.6%of stricture cases.UC patients with strictures were at higher risk for intestinal complications,surgery and malignancy(P<0.05).The 10-year cumulative probabilities of surgery and all-cause mortality were 37.6%and 1.6%,respectively.Age≥40 years at diagnosis[hazard ratio(HR)=2.197,95%confidence interval(CI):1.487-3.242]and extraintestinal manifestations(HR=2.072,95%CI:1.326-3.239)were associated with higher stricture risk,while the use of biological agents such as vedolizumab(HR=0.382,95%CI:0.203-0.720)was protective against strictures(P<0.05).Sensitivity analysis on benign strictures showed consistent findings,with similar risk factors and worse longterm outcomes.CONCLUSION UC patients with strictures had worse long-term prognostic outcomes.Earlier endoscopic surveillance and biologic treatment should be considered in patients≥40 years or those with extraintestinal manifestations.
文摘BACKGROUND Biliary anastomotic stricture(BAS)occurs in approximately 14%-20%of patients post-orthotopic liver transplantation(post-OLT).Endoscopic retrograde cholan-giopancreatography(ERCP)using multiple plastic stents(MPSs)or fully covered self-expandable metal stents(cSEMSs)represent the standard treatment for BAS post-OLT.Recently,cSEMSs have emerged as the primary option for managing BAS post-OLT.AIM To compare the resolution and recurrence of BAS rates in these patients.METHODS This retrospective cohort study was conducted in a single tertiary care center(Hospital Israelita Albert Einstein,São Paulo,Brazil).We reported the results of endoscopic therapy in patients with post-OLT BAS between 2012 and 2022.Patients were stratified into two groups according to therapy:(1)MPSs;and(2)cSEMSs.Primary endpoints were to compare stricture resolution and recurrence among the groups.The secondary endpoint was to identify predictive factors for stricture recurrence.RESULTS A total of 104 patients were included.Overall stricture resolution was 101/104(97.1%).Stricture resolution was achieved in 83/84 patients(99%)in the cSEMS group and 18/20 patients(90%)in the MPS group(P=0.094).Failure occurred in 3/104 patients(2.8%).Stricture recurrence occurred in 9/104 patients(8.7%).Kaplan-Meier analysis showed there was no difference in recurrence-free time among the groups(P=0.201).A multivariate analysis identified the number of ERCP procedures(hazard ratio=1.4;95%confidence interval:1.194-1.619;P<0.001)and complications(hazard ratio=2.8;95%confidence interval:1.008-7.724;P=0.048)as predictors of stricture recurrence.CONCLUSION cSEMSs and MPSs were effective and comparable regarding BAS post-OLT resolution and recurrence.The number of ERCP procedures and complications were predictors of stricture recurrence.
文摘BACKGROUND It is well known that in case of high initial strictures of bile ducts surgical treatment is associated with a high risk of damage to the hepatoduodenal ligament elements,often involved in rough scarring,and with a significant risk of stricture recurrence.AIM To compare the long-term outcomes of different surgical treatment options for patients with high-grade benign biliary strictures.METHODS From 2012 to 2022,193 patients were treated at the A.V.Vishnevsky Surgical Center.All of them had different levels of strictures according to Bismuth-Strasberg classification:Type E1-2 in 32 patients,type E3-99,type E4-62.123 patients underwent open reconstructive interventions,70 percutaneous endobiliary interventions.RESULTS Long-term results were available for 192(99%)patients with a follow-up of 4.7±1.6 years after reconstructive surgery;3.0±1.4 years after percutaneous interventions.Excellent and good results(according to Terblanche classification)were achieved in 35%(42/122)of patients after open reconstructive surgery and in 13%(9/70)of patients after percutaneous transhepatic interventions(P-value<0.05).CONCLUSION Technically,the most difficult bile duct strictures for reconstructive and percutaneous transhepatic interventions with a high recurrence rate are Bismuth-Strasberg type E4 and E5.The comparative analysis of long-term results of percutaneous and open procedures showed a statistically significant advantage of percutaneous procedures compared to open reconstructive procedures.
文摘Objective:To present the surgical technique of robotic buccal ureteroplasty for strictures after laser lithotripsy and its outcomes.Methods:This was a retrospective study conducted at the Department of Urology,Apollo Hospitals,Chennai,India from October 2012 to October 2022.Indications for surgery included worsening hydronephrosis,declining renal function,and recurrent urinary tract infections with obstruction.Apart from liberal exposure of the stricture,we stress upon use of indocyanine green to assess vascularity and quilting of the graft to bare area of the psoas muscle to increase graft vascularity.Results:Among the 15 patients,ureteropelvic junction strictures were observed in eight(53%),while five(33%)had proximal ureteric strictures,and two(13%)had mid-ureteral strictures.Notably,eight of the 15 patients(53%)had previous unsuccessful double-J stenting.The median stricture length was 3.5(range:2.0–5.0)cm,with a mean operative time of 167(range:126–214)min and estimated blood loss of 60(range:40–100)mL.After a median follow-up of 12(range:4–32)months,13 out of the 15 patients(87%)showed significant improvement in their follow-up functional scans.Conclusion:Robotic buccal ureteroplasty is a very effective technique for the management of laser-induced ureteral strictures with good long-term results and minimal morbidity.The results are comparable irrespective of previous failed stenting.
文摘Despite advances in cross-sectional imaging and endoscopic technology,bile duct strictures remain a challenging clinical entity.It is crucial to make an early determination of benign or malignant nature of biliary strictures.Early diagnosis not only helps with further management but also minimizes mortality and morbidity associated with delayed diagnosis.Conventional imaging and endoscopic techniques,particularly endoscopic retrograde cholangiopancreatography(ERCP)and tissue sampling techniques play a key in establishing a diagnosis.Indeterminate biliary strictures(IDBSs)have no definite mass on imaging or absolute histopathological diagnosis and often warrant utilization of multiple diagnostics to ascertain an etiology.In this review,we discuss possible etiologies,clinical presentation,diagnosis,and management of IDBSs.Based on available data and expert opinion,we depict an evidence based diagnostic algorithm for management of IDBSs.Areas of focus include use of traditional tissue sampling techniques such as ERCP with brush cytology,intraductal biopsies,fluorescence in situ hybridization and flow cytometry.We also describe the role of endoscopic ultrasound(EUS)-guided fine needle aspiration and biopsies,cholangioscopy,confocal laser endomicroscopy,and intraductal EUS in management of IDBSs.
文摘Objective:We described the technique and outcomes of robot-assisted repair of uretero-enteric strictures(UES)following robot-assisted radical cystectomy(RARC)and urinary diversion.Methods:Retrospective review of our RARC database from November 2005 to August 2023 at Roswell Park Comprehensive Cancer center was performed.Patients who developed UES and ultimately underwent robot-assisted uretero-enteric reimplantation(RUER)were identified.KaplaneMeier method was used to compute the cumulative incidence recurrence rate of UES after RUER.A multivariable regression model was used to identify variables associated with UES recurrence.Results:A total of 123(15%)out of 808 RARC patients developed UES,of whom 52 underwent reimplantation(45 patients underwent RUER[n=55 cases]and seven patients underwent open ureteroenteric reimplantation).The median time from RARC to UES was 4.4(interquartile range 3.0e7.0)months,and the median time between UES and RUER was 5.2(interquartile range 3.2e8.9)months.The 3-year recurrence rate after RUER is about 29%.On multivariable analysis,longer hospital stay(hazard ratio 1.37,95%confidence interval 1.16e1.61,p<0.01)was associated with recurrent UES after RUER.Conclusion:RUER for UES after RARC is feasible with durable outcomes although a notable subset of patients experienced postoperative complications and UES recurrence.
基金supported by the Wuhan Municipal Science and Technology Bureau,Wuhan,China(No.2020020601012222 to Li B)Zhongnan Hospital of Wuhan University,Wuhan,China(No.rcyj20230102 to Li B)Natural Science Foundation of Hubei Province,China(China,No.2020CFB829 to Xiao X).
文摘Objective:To describe and evaluate the technique using bilateral Boari flap ureteroneocystostomy(BBFUNC)for bilateral mid-lower ureteral strictures.Methods:We retrospectively reviewed five patients who underwent minimally invasive BBFUNC in our institution(Union Hospital,Wuhan,China)between July 2019 and December 2021.The bilateral ureters were mobilized and transected above the stenotic segments.The bladder was isolated and incised longitudinally from the middle of the anterior wall.Then,an inverted U-shaped bladder flap was created on both sides,fixed onto the psoas tendon,and anastomosed to the ipsilateral distal normal ureter.Following double-J stenting,the Boari flaps were tubularized,and the bladder was closed with continuous sutures.The patients’perioperative data and follow-up outcomes were collected,and a descriptive statistical analysis was performed.Results:No case converted to open surgery,and no intraoperative complication occurred.The median surgical time was 230(range 203-294)min.The median length of the bladder flaps was 6.2(range 4.3-10.0)cm on the left and 5.5(range 4.7-10.5)cm on the right side.All patients had not developed recurrent ureteral stenosis during the median follow-up time of 17(range 16-45)months and had a normal maximum flow rate after surgery.The median post-void residual was 7(range 0-19)mL.The maximal bladder capacity was decreased in one(20%)patient.Conclusion:The present study demonstrates that minimally invasive BBFUNC is feasible and safe in treating is limited.
文摘Indeterminate biliary strictures pose a significant diagnostic dilemma for gastroenterologists.Despite advances in endoscopic techniques and instruments,it is difficult to differentiate between benign and malignant pathology.A positive histological diagnosis is always preferred prior to high risk hepatobiliary surgery,or to inform other types of therapy.Endoscopic retrograde cholangiopancreato-graphy with brushings has low sensitivity and despite significant improvements in instruments there is still an unacceptably high false negative rate.Other methods such as endoscopic ultrasound and cholangioscopy have improved diagnostic quality.In this review we explore the techniques available to aid accurate diagnosis of indeterminate biliary strictures and obtain accurate histology to facilitate clinical management.
文摘Introduction and Objectives: Urethral stricture is a reduction in the caliber of the urethral lumen impeding the outflow of urine. It predominantly affects males. The disease burden is severe in our milieu where access to specialized care is limited. Our goal was therefore to assess the management and outcome of male urethral stricture at two tertiary hospitals in Douala, Cameroon. Materials and Methods: This was a hospital-based retrospective study of patients managed for urethral stricture over 5 years (January 1st, 2017 to December 31st, 2021) at the Douala General and Laquintinie Hospitals. Data on sociodemographic, clinical, paraclinical, and treatment options were extracted using pre-structured forms. Data was analyzed using Statistical Package for Social Sciences (SPSS) version 28. Statistical significance was set at p-value Results: We exploited 130 medical records. The mean age of patients was 46.5 years. Dysuria and weak urine stream were the major presenting complaints (63.8% and 23.8% respectively). The etiology of urethral stricture was iatrogenic in 42.3% of cases. The strictures were mostly single (89.8%), and the bulbar urethra was most affected (46.9%). 28 patients had urinary tract infections and the most frequently isolated germ was E. coli in 29.6%. Direct visual internal urethrotomy (DVIU) was performed in 42.3% of cases. Surgery, especially excision and primary anastomosis (EPA) was done in 28.5% of cases. Major complications were wound infection, acute kidney injury (AKI), and urethrocutaneous fistulae affecting 3.1, 2.3, and 1.5% of cases respectively. The recurrence rate was 17% with a mortality rate of 0.08%. Conclusion: Urethral stricture is common in our adult male population. The cause is mainly iatrogenic and the bulbar urethra is most affected. Minimally invasive and open reconstruction are frequently used treatment options with significant recurrence rates in the long term.
文摘Benign esophageal strictures refractory to the conventional balloon or bougie dilatation may be subjected to various adjunctive modes of therapy, one of them being endoscopic incisional therapy(EIT). A proper delineation of the stricture anatomy is a prerequisite. A host of electrocautery and mechanical devices may be used, the most common being the use of needle knife, either standard or insulated tip. The technique entails radial incision and cutting off of the stenotic rim. Adjunctive therapies, to prevent re-stenosis, such as balloon dilatation, oral or intralesional steroids or argon plasma coagulation can be used. The common strictures where EIT has been successfully used are Schatzki's rings(SR) and anastomotic strictures(AS). Short segment strictures(< 1 cm) have been found to have the best outcome. When compared with routine balloon dilatation, EIT has equivalent results in treatment na?ve cases but better long term outcome in refractory cases. Anecdotal reports of its use in other types of strictures have been noted. Post procedure complications of EIT are mild and comparable to dilatation therapy. As of the current evidence, incisional therapy can be used for management of refractory AS and SR with relatively short stenosis(< 1 cm) with good safety profile and acceptable long term patency.
基金This work was supported by the National Natural Science Foundation of China(No.81670617).We are very grateful to the CureEdit Company for providing language editing assistance。
文摘The treatment of urethral strictures remains a challenging field in urology even though there are a variety of procedures to treat it at present,as no one approach is superior over another.This paper reviewed the surgical options for the management of different sites and types of anterior urethral stricture,providing a brief discussion of the controversies regarding this issue and suggesting possible future advancements.Among the existing procedures,simple dilation and direct vision internal urethrotomy are more commonly used for short urethral strictures(<1 cm,soft and no previous intervention).Currently,urethroplasty using buccal mucosa or penile skin is the most widely adopted clinical techniques and have proved successful.Nonetheless,complications such as donor site morbidity remain problem.Tissue engineering techniques are considered as a promising solution for urethral reconstruction,but require further investigation,as does stem cell therapy.
文摘AIM To evaluate the incidence of anastomotic strictures after intestinal resection in Crohn's disease(CD), demonstrate long-term efficacy and safety of endoscopic balloon dilation(EBD) in CD strictures and its impact on the diagnosis of subclinical postoperative endoscopic recurrence. METHODS Retrospective single tertiary center study based on prospectively collected data between 2010 and 2015including anastomotic and non-anastomotic strictures. RESULTS29% of 162 CD patients included developed an anastomotic stricture. 43 patients with anastomotic strictures and 37 with non-anastomotic strictures underwent EBD; technical success was 97.7% and 100%, respectively, however, 63% and 41% needed repeat dilation during the 4.4-year follow-up. Longer periods between surgery and index colonoscopy and higher lactoferrin levels were associated with the presence of stricture after surgery. Calprotectin levels > 83.35 μg/g and current or past history of smoking were associated with a shorter time until need for dilation(HR = 3.877, 95%CI: 1.480-10.152 and HR = 3.041, 95%CI: 1.213-7.627). Anastomotic strictures had a greater need for repeat dilation(63% vs 41%, P = 0.047). No differences were found between asymptomatic and symptomatic cohorts. Disease recurrence diagnosis was only possible after EBD in a third of patients. CONCLUSION EBD is an effective and safe alternative to surgery, with a good short and long-term outcome, postponing or even avoiding further surgery. EBD may allow to diagnose disease recurrence in patients with no clinical signs/biomarkers of disease activity.
文摘AIM: To evaluate the diagnostic value of different indirect methods like biochemical parameters, ultrasound (US) analysis, CT-scan and MRI/MRCP in comparison with endoscopic retrograde cholangiography (ERC), for diagnosis of biliary complications after liver transplantation. METHODS: In 75 patients after liver transplantation, who received ERC due to suspected biliary complications, the result of the cholangiography was compared to the results of indirect imaging methods performed prior to ERC. The cholangiography showed no biliary stenosis (NoST) in 25 patients, AST in 27 and ITBL in 23 patients. RESULTS: Biliary congestion as a result of AST was detected with a sensitivity of 68.4% in US analysis (specificity 91%), of 71% in MRI (specificity 25%) and of 40% in CT (specificity 57.1%). In ITBL, biliary congestion was detected with a sensitivity of 58.8% in the US, 88.9%in MRI and of 83.3% in CT. However, as anastomotic or ischemic stenoses were the underlying cause of biliary congestion, the sensitivity of detection was very low. InMRI detected the dominant stenosis at a correct localization in 22% and CT in 10%, while US failed completely. The biochemical parameters, showed no significant difference in bilirubin (median 5.7; 4,1; 2.5 mg/dL), alkaline phosphatase (median 360; 339; 527 U/L) or gamma glutamyl transferase (median 277; 220; 239 U/L) levels between NoST, AST and ITBL.CONCLUSION: Our data confirm that indirect imaging methods to date cannot replace direct cholangiography for diagnosis of post transplant biliary stenoses. However MRI may have the potential to complement or precede imaging by cholangiography. Optimized MRCP-processing might further improve the diagnostic impact of this method.
基金Supported by A research fellowship from the Faculty of Medicine,Westf lische Wilhelms-Universit t Münster
文摘AIM:To report the largest patient cohort study investigating the diagnostic yield of intraductal ultrasound (IDUS) in indeterminate strictures of the common bile duct.METHODS:A patient cohort with bile duct strictures of unknown etiology was examined by IDUS.Sensitivity,specificity and accuracy rates of IDUS were calculated relating to the definite diagnoses proved by histopathology or long-term follow-up in those patients who did not undergo surgery.Analysis of the endosonographic report allowed drawing conclusions with respect to the T and N staging in 147 patients.IDUS staging was compared to the postoperative histopathological staging data allowing calculation of sensitivity,specificity and accuracy rates for T and N stages.The endoscopic retrograde cholangio-pancreatography and IDUS procedures were performed under fluoroscopic guidance using a side-viewing duodenoscope (Olympus TJF 160,Olympus,Ltd.,Tokyo,Japan).All procedures were performed under conscious sedation (propofol combined with pethidine) according to the German guidelines.For IDUS,a 6 F or 8 F ultrasound miniprobe was employed with a radial scanner of 15-20 MHz at the tip of the probe (Aloka Co.,Tokyo,Japan).RESULTS:A total of 397 patients (210 males,187 females,mean age 61.43 ± 13 years) with indeterminate bile duct strictures were included.Two hundred and sixty-four patients were referred to the department of surgery for operative exploration,thus surgical histopathological correlation was available for those patients.Out of 264 patients,174 had malignant disease proven by surgery,in 90 patients benign disease was found.In these patients decision for surgical exploration was made due to suspicion for malignant disease in multimodal diagnostics (computed tomography scan,endoscopic ultrasound or magnetic resonance imaging).Twenty benign bile duct strictures were misclassified by IDUS as malignant while 14 patients with malignant strictures were initially misdiagnosed by IDUS as benign resulting in sensitivity,specificity and accuracy ratesof 93.2%,89.5% and 91.4%,respectively.In the subgroup analysis of malignancy prediction,IDUS showed best performance in cholangiocellular carcinoma as underlying disease (sensitivity rate,97.6%) followed by pancreatic carcinoma (93.8%),gallbladder cancer (88.9%) and ampullary cancer (80.8%).A total of 133 patients were not surgically explored.32 patients had palliative therapy due to extended tumor disease in IDUS and other imaging modalities.Ninety-five patients had benign diagnosis by IDUS,forceps biopsy and radiographic imaging and were followed by a surveillance protocol with a follow-up of at least 12 mo;the mean follow-up was 39.7 mo.Tumor localization within the common bile duct did not have a significant influence on prediction of malignancy by IDUS.The accuracy rate for discriminating early T stage tumors (T1) was 84% while for T2 and T3 malignancies the accuracy rates were 73% and 71%,respectively.Relating to N0 and N1 staging,IDUS procedure achieved accuracy rates of 69% for N0 and N1,respectively.Limitations:Pretest likelihood of 52% may not rule out bias and overinterpretation due to the clinical scenario or other prior performed imaging tests.CONCLUSION:IDUS shows good results for accurate diagnostics of bile duct strictures of uncertain etiology thus allowing for adequate further clinical management.
文摘Biliary stricture complicating living donor liver transplantation(LDLT) is a relatively common complication, occurring in most transplant centres across the world. Cases of biliary strictures are more common in LDLT than in deceased donor liver transplantation. Endoscopic management is the mainstay for biliary strictures complicating LDLT and includes endoscopic retrograde cholangiography, sphincterotomy and stent placement(with or without balloon dilatation). The efficacy and safety profiles as well as outcomes of endoscopic management of biliary strictures complicating LDLT is an area that needs to be viewed in isolation, owing to its unique set of problems and attending complications; as such, it merits a tailored approach, which is yet to be well established. The diagnostic criteria applied to these strictures are not uniform and are over-reliant on imaging studies showing an anastomotic narrowing. It has to be kept in mind that in the setting of LDLT, a subjective anastomotic narrowing is present in most cases due to a mismatch in ductal diameters. However, whether this narrowing results in a functionally significant narrowing is a question that needs further study. In addition, wide variation in the endotherapy protocols practised in most centres makes it difficult to interpret the results and hampers our understanding of this topic. The outcome definition for endotherapy is also heterogenous and needs to be standardised to allow for comparison of data in this regard and establish a clinical practice guideline. There have been multiple studies in this area in the last 2 years, with novel findings that have provided solutions to some of these issues. This review endeavours to incorporate these new findings into the wider understanding of endotherapy for biliary strictures complicating LDLT, with specific emphasis on diagnosis of strictures in the LDLT setting, endotherapy protocols and outcome definitions. An attempt is made to present the best management options currently available as well as directions for future research in the area.
