INTRODUCTION:
The Inferior Vena Cava filter is known as an effective method for preventing pulmonary thromboembolism in patients with deep vein thrombosis. Usually, the remaining IVC filters are ...asymptomatic and do not cause clinical problems. We report two cases of duodenal perforation caused by a remaining IVC filter which is very rare.
CASE DESCRIPTION/METHODS:
Case 1: 67 year old female patient with past medical history of heartburn,IVC filter placement presented at the GI outpatient clinic with complains of abdominal pain and heartburn for 6 months.After initial negative work up, Upper Endoscopy done showed small polyp at the metallic clip adjacent to the ampulla.Endoscopic ultrasound subsequently revealed a metal object traversing the duodenal wall. No biopsies or additional manipulation of the metal object were done until we did a CT scan which showed two distal anterior legs of the IVC filter extending into the transverse duodenum.This patient was referred to vascular surgeon for IVC filter removal but the patient's symptoms started resolving and after discussion with the patient it was decided not to proceed with the surgery and manage her conservatively. CASE 2: 37 y/o female seen in GI clinic for repeated episodes of nausea, vomiting, and abdominal discomfort which had been going on for 4 months and after negative initial work up, patient was scheduled for an Upper endoscopy which showed a metal like foreign body in the second portion of the duodenum and irritation of the opposite wall of the second portion of the duodenum with nodularity and represented a prong of the IVC filter which migrated into duodenum.Patient was referred to vascular surgeon for IVC filter removal and after the procedure post operatively she was kept on intravenous antibiotics and was discharged after she was able to tolerate regulate diet and was ambulating well.
DISCUSSION:
IVC filter perforation of the duodenum is fairly uncommon. It can manifest with abdominal pain, gastrointestinal bleeding, cava-duodenal fistula, or small bowel obstruction. Diagnostic evaluation include plain abdominal radiographs, CT scan and/or Upper Endoscopy.To prevent potential sequelae caused by IVC filter leg penetration, like that reported in this case, the removal of the IVC filter, when possible, is preferred.Also manipulations of the foreign body should be avoided until further confirmation is done by abdominal imaging.
INTRODUCTION:
Neuroendocrine carcinoma is predominantly found in the gastrointestinal tract (54-75%) with 44%, 19%, 16%, 10% and 7% in the small intestines, rectum, appendix, colon and stomach ...respectively. Primary liver neuroendocrine carcinoma comprises around 0.3% of all neuroendocrine tumors. This is a case of a neuroendocrine carcinoma with a focus of cholangiocarcinoma presenting as a biliary stricture diagnosed by ERCP using the spyglass visualization system.
CASE DESCRIPTION/METHODS:
A 75 year old female with a prior history of rheumatoid arthritis presented with persistent nausea, vomiting, diarrhea and abdominal pain and a 20 lb weight loss since December 2017. An ultrasound revealed intrahepatic biliary ductal dilation in the left lobe with no visible mass and a coarse hepatic echotexture. A subsequent MRI of the abdomen demonstrated left lobe intrahepatic biliary ductal dilation with a hypointense 1 cm region within the liver parenchyma associated with a biliary stricture. The biliary stricture in the left hepatic branch was visualized with the spyglass direct visualization cholangioscope introduced through an ERCP scope. Biopsies obtained through the cholangioscope revealed high grade dysplasia. The patient underwent a left lobectomy of liver with hepatic artery and portal lymph node dissection. Lymph nodes were negative for malignancy. The biliary stricture was from a high grade neuroendocrine carcinoma with a microscopic focus of cholangiocarcinoma with extensive lymphovascular and perineural invasion. The margin of the bile duct and hepatic hilum were involved by neuroendocrine carcinoma. Post operative PET scan showed a small focus of activity without any signs of distant metastasis.
DISCUSSION:
SpyGlass direct visualization system is a relatively new technique in ERCP. Recently published prospective data confirm that the overall success rates for adequate tissue sampling is nearly 90%. ERCP has limitations for sampling lesions in the bile duct without direct visualization. Conventional ERCP biliary sampling yields are 20% to 30% for cytology brushing to approximately 50% with a combined brush/standard biopsy forceps approach. If sampling is negative, the choice is either radical surgery or continual observation with an MRI. Nowadays, ERCP with spyglass technique and targeted direct visualization biopsy affords vastly higher yields. Direct visualization is now the gold standard to obtain biopsy samples in cases of biliary strictures.
Abstract
Background and study aims
Following colorectal surgery, anastomotic dehiscence and leak formation has an incidence of 2 % to 7 %. Endo-SPONGE has been applied in the management of ...anastomatic leaks (ALs) after colorectal surgery. This is the first systematic review and meta analysis to evaluate the efficacy and safety of Endo-SPONGE in the management of colorectal ALs.
Patients and methods
The primary outcomes assessed were the technical and clinical success of Endo-SPONGE placement in colorectal ALs. The secondary outcomes assessed were the overall adverse events (AEs) and the AE subtypes. Pooled estimates were calculated using random-effects models with 95 % confidence interval (C. I.). The statistical analysis was done using STATA v16.1 software (StataCorp, LLC College Station, Texas, United States).
Results
The analysis included 17 independent cohort studies with a total of 384 patients. The rate of technical success was 99.86 % (95 % CI: 99.2 %, 100 %;
P
= 0.00; I
2
= 70.69 %) and the calculated pooled rate of clinical success was 84.99 % (95 % CI: 77.4 %, 91.41 %;
P
= 0.00; I
2
= 68.02 %). The calculated pooled rate of adverse events was 7.6 % (95 % CI: 3.99 %, 12.21 %;
P
= 0.03; I
2
= 42.5 %) with recurrent abscess formation and bleeding being the most common AEs. Moderate to substantial heterogeneity was noted in our meta-analysis.
Conclusions
Endoscopic vacuum therapy appears to be a minimally invasive, safe, and effective treatment modality for patients with a significant colorectal leak without any generalized peritonitis with high clinical and technical success rates and a low rate of adverse events. Further prospective or randomized controlled trials are needed to validate our findings.
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