Meandering main pancreatic duct (MMPD) refers to an uncommon ductal variant of the normal smooth curvilinear course of the pancreatic duct. More specifically, MMPD is characterized by a hairpin ...(reverse Z-type) or loop (loop-type) turn in the pancreatic head. It has been suggested as a predisposing factor for the development of pancreatitis. Studies regarding treatment are scarce.BackgroundMeandering main pancreatic duct (MMPD) refers to an uncommon ductal variant of the normal smooth curvilinear course of the pancreatic duct. More specifically, MMPD is characterized by a hairpin (reverse Z-type) or loop (loop-type) turn in the pancreatic head. It has been suggested as a predisposing factor for the development of pancreatitis. Studies regarding treatment are scarce.We conducted a narrative review of the current literature regarding MMPD. Additionally, we present a cohort of 9 symptomatic patients treated endoscopically at our tertiary center.MethodsWe conducted a narrative review of the current literature regarding MMPD. Additionally, we present a cohort of 9 symptomatic patients treated endoscopically at our tertiary center.Seven retrospective cohort studies and 4 case reports were included in our review. Only 1 study focuses on the clinical significance of MMPD and describes a positive association between MMPD and the onset of pancreatitis, especially recurrent acute pancreatitis. Only 1 case reports an endoscopic treatment. In our cohort of 9 MMPD patients, 7 did indeed present with recurrent acute pancreatitis. Endotherapy provided substantial regression of symptoms in 6 patients, all of whom had signs of ductal hypertension.ResultsSeven retrospective cohort studies and 4 case reports were included in our review. Only 1 study focuses on the clinical significance of MMPD and describes a positive association between MMPD and the onset of pancreatitis, especially recurrent acute pancreatitis. Only 1 case reports an endoscopic treatment. In our cohort of 9 MMPD patients, 7 did indeed present with recurrent acute pancreatitis. Endotherapy provided substantial regression of symptoms in 6 patients, all of whom had signs of ductal hypertension.Our review shows the scarcity of data regarding MMPD, especially concerning treatment, in the current literature. With our cohort, we not only hope to raise awareness of this often-neglected entity of recurrent acute pancreatitis, but also support the case for endotherapy for the first time in 9 symptomatic MMPD patients, especially in the presence of ductal hypertension.ConclusionsOur review shows the scarcity of data regarding MMPD, especially concerning treatment, in the current literature. With our cohort, we not only hope to raise awareness of this often-neglected entity of recurrent acute pancreatitis, but also support the case for endotherapy for the first time in 9 symptomatic MMPD patients, especially in the presence of ductal hypertension.
Objectives
Long‐term outcomes of endoscopic ultrasound‐guided choledochoduodenostomy (EUS‐CDS) performed with lumen apposing metal stents (LAMS) have been poorly evaluated in small or retrospective ...series, leading to an underestimation of LAMS dysfunction.
Methods
All consecutive EUS‐CDS performed in three academic referral centers were included in prospectively maintained databases. Technical/clinical success, adverse events (AEs), and dysfunction during follow‐up were retrospectively analyzed. Kaplan–Meier analysis was used to estimate dysfunction‐free survival (DFS), with Cox proportional hazard regression to evaluate independent predictors of dysfunction.
Results
Ninety‐three patients were included (male 56%; mean age, 70 years 95% confidence interval (CI) 68–72; pancreatic cancer 81%, metastatic disease 47%). In 67% of procedures, 6 mm LAMS were used. Technical and clinical success were achieved in 97.8% and 93.4% of patients, respectively, with AEs occurring in 9.7% (78% mild/moderate). Dysfunction occurred in 31.8% of patients after a mean of 166 days (95% CI 91–241), with an estimated 6 month and 12 month DFS of 75% and 52%, respectively; mean DFS of 394 (95% CI 307–482) days. Almost all dysfunctions (96%) were successfully managed by endoscopic reintervention. Duodenal invasion (hazard ratio 2.7 95% CI 1.1–6.8) was the only independent predictor of dysfunction.
Conclusions
Endoscopic ultrasound‐guided choledochoduodenostomy shows excellent initial efficacy and safety, although stent dysfunctions occurs frequently during long‐term follow‐up. Almost all stent dysfunctions can be managed successfully by endoscopic reinterventions. We propose a comprehensive classification of the different types of dysfunction that may be encountered and rescue procedures that may be employed under these circumstances. Duodenal invasion seems to increase the risk of developing EUS‐CDS dysfunction, potentially representing a relative contraindication for this technique.
Patients with heterotaxy syndrome (HS) can present with an associated complete dorsal pancreas agenesis (DPA). They are considered to be at increased risk for developing diabetes due to a reduced ...functional beta cell mass (FBM) as well as for chronic pancreatitis leading to unmanageable pain. We report the case of a young woman with chronic pancreatitis due to HS and associated DPA. She presented with a severe persisting upper abdominal pain refractory to nonsurgical treatment. Unlike in previously reported cases, she had a high FBM (ie, 150% of normoglycemic controls) as determined by hyperglycemic clamp. She underwent a total pancreatectomy followed within 24 hours by an intraportal autologous islet cell transplant containing 4 × 106 beta cells (4700 islet equivalent)/kg body weight. After surgery, the pain resolved, eliminating the need for analgesics. The intraportal implant established an adequate FBM (72% of controls at posttransplant month 2), achieving glycemic control without need for insulin administration. A hyperglycemic clamp can assess the utility and efficacy of an intraportal islet cell autotransplant following total pancreatectomy in patients with HS and complete DPA.
Total pancreatectomy followed by islet autotransplantation is a treatment option for chronic pancreatitis due to heterotaxy syndrome and dorsal pancreas agenesis.
Background
Recently, the term metabolic dysfunction‐associated fatty liver disease (MAFLD) was proposed to replace non‐alcoholic fatty liver disease (NAFLD). This concept enables diagnosing liver ...disease associated with metabolic dysfunction in patients with alcohol‐related liver disease (ALD), a main indication for liver transplantation (LTx). We assessed MAFLD prevalence in ALD patients undergoing LTx and its prognostic value on post‐LTx outcomes.
Methods
We retrospectively analyzed all ALD patients transplanted at our center between 1990 and August 2020. MAFLD was diagnosed based on the presence or history of hepatic steatosis and a BMI > 25 or type II diabetes or ≥ 2 metabolic risk abnormalities at LTx. Overall survival and risk factors for recurrent liver and cardiovascular events were analyzed by Cox regression.
Results
Of the 371 included patients transplanted for ALD, 255 (68.7%) had concomitant MAFLD at LTx. Median follow‐up post‐LTx was 72 months (IQR: 34.50–122). Patients with ALD‐MAFLD were older at LTx (p = .001), more often male (p < .001) and more frequently had hepatocellular carcinoma (p < .001). No differences in perioperative mortality and overall survival were found. ALD‐MAFLD patients had an increased risk of recurrent hepatic steatosis, irrespective of alcohol relapse, but no superimposed risk of cardiovascular events.
Conclusions
The co‐presence of MAFLD at LTx for ALD is associated with a distinct patient profile and is an independent risk factor for recurrent hepatic steatosis. The use of MAFLD criteria in ALD patients might increase awareness and treatment of specific hepatic and systemic metabolic abnormalities before and after LTx.
In the management of gastric outlet obstruction (GOO), EUS-guided gastroenterostomy (EUS-GE) seems to be safe and more effective than enteral stent placement. However, comparisons with laparoscopic ...GE (L-GE) are scarce. Our aim was to perform a propensity score–matched comparison between EUS-GE and L-GE.
An international, multicenter, retrospective analysis was performed of consecutive EUS-GE and L-GE procedures in 3 academic centers (January 2015 to May 2020) using propensity score matching to minimize selection bias. A standard maximum propensity score difference of .1 was applied, also considering underlying disease and oncologic staging.
Overall, 77 patients were treated with EUS-GE and 48 patients with L-GE. By means of propensity score matching, 37 patients were allocated to both groups, resulting in 74 (1:1) matched patients. Technical success was achieved in 35 of 37 EUS-GE–treated patients (94.6%) versus 100% in the L-GE group (P = .493). Clinical success, defined as eating without vomiting or GOO Scoring System ≥2, was achieved in 97.1% and 89.2%, respectively (P = .358). Median time to oral intake (1 interquartile range {IQR}, .3-1.0 vs 3 IQR, 1.0-5.0 days, P < .001) and median hospital stay (4 IQR, 2-8 vs 8 IQR, 5.5-20 days, P < .001) were significantly shorter in the EUS-GE group. Overall (2.7% vs 27.0%, P = .007) and severe (.0% vs 16.2%, P = .025) adverse events were identified more frequently in the L-GE group.
For patients with GOO, EUS-GE and L-GE showed almost identical technical and clinical success. However, reduced time to oral intake, shorter median hospital stay, and lower rate of adverse events suggest that the EUS-guided approach might be preferable.
Objectives
Combined biliary obstruction and gastric outlet obstruction (GOO) represent a challenging clinical scenario despite developments in therapeutic endoscopic ultrasonography (EUS) as GOO ...might impair EUS‐guided biliary drainage. Little is known about the effectiveness of different therapeutic combinations used to treat double obstruction, especially regarding stent patency.
Methods
All consecutive patients with double obstruction treated between 2016 and 2021 in three tertiary academic centres were eligible for inclusion. Five combinations involving enteral stenting (ES), EUS‐guided gastroenterostomy (EUS‐GE), hepaticogastrostomy (EUS‐HGS), choledochoduodenostomy (EUS‐CDS), and transpapillary biliary stenting (TPS) were evaluated for dysfunction during follow‐up, either as proportions or dysfunction‐free survival (DFS) using Kaplan–Meier estimates.
Results
Ninety‐three patients were included (male 46%; age 67 interquartile range 60–76 years; pancreatic cancer 73%, metastatic 57%), resulting in 103 procedure combinations. Different combinations showed significantly different overall dysfunction rates (p = 0.009), ranging from the null rate of EUS‐GE+HG to the 18% rate of EUS‐GE+TPS, 31% of EUS‐GE+EUS‐CD, 53% of ES+TPS and 83% of ES+EUS‐CDS. Sub‐analyses restricted to biliary dysfunction confirmed these trends. A multivariate Cox proportional‐hazards regression of DFS, a stenosis distal to the papilla (HR 3.2 1.5–6.9) and ES+EUS‐CDS (HR 5.6 2–15.7) independently predicted dysfunction.
Conclusions
Despite a lack of statistical power per combination, this study introduces new associations beyond the increased risk of GOO recurrence with ES versus EUS‐GE. EUS‐CDS showed reduced effectiveness and frequent dysfunction in the context of GOO, especially when combined with ES. EUS‐GE+HGS or EUS‐GE+TPS in this setting might result in superior patency. These results suggest that a prospective evaluation of the optimal endoscopic approach to malignant double obstruction is needed.
Background
Diffuse splanchnic thrombosis may render standard LTx difficult or even technically impossible. A 19‐year‐old woman with acute‐on‐chronic Budd‐Chiari syndrome and complete splanchnic ...thrombosis underwent conventional LTx. Only limited anatomical portal inflow could be restored, and urgent re‐transplantation for recurrent splanchnic vein thrombosis became necessary.
Methods
At re‐transplant, and in addition to the reestablishment of some portal inflow through the preserved original porto (native)‐portal (graft) connection, a cavoportal shunt was created (first partial via 30% tapering of the vena cava, but eventually complete by total occlusion of the vena cava).
Results
The postoperative course was then uneventful, and interestingly, the native portomesenteric axis gradually reopened. Two years post‐transplant, the liver graft is perfused via both physiological and non‐physiological sources. Liver function is normal. There is no IVC syndrome and no residual PHT. She is leading a normal life.
Conclusion
Creation of CPHT, in addition to the preservation of portal inflow from the native splanchnic system, should be considered in patients with diffuse splanchnic thrombosis, when sufficient physiological portal inflow cannot be restored at the time of LTx, but in whom the splanchnic circulation may reopen up later.
•There is no difference in perioperative mortality between patients selected for transplantation for NAFLD or for hepatitis C.•There is a high rate of NAFLD recurrence in patients who underwent ...transplant for NAFLD (43.5% after 5 years).•Patients who underwent transplant with recurrence of NAFLD have a higher BMI and a higher rate of myocardial infarction compared with patients without NAFLD recurrence.•The cardiovascular disease-free survival after transplantation is significantly lower in patients with NAFLD than in patients with hepatitis C, although there is no difference in survival after 5 years.
The increasing rate of liver transplantation (LT) for nonalcoholic fatty liver disease (NAFLD) raises concerns on cardiovascular morbidity and mortality after LT in these patients.
We collected variables regarding the presence of metabolic risk factors, NAFLD recurrence, cardiovascular morbidity, and overall survival at time of listing and after LT of 112 patients with NAFLD and a control group of 120 patients with hepatitis C (HCV).
Metabolic syndrome and cardiovascular morbidity component rates (24.1% vs 12.5%) at the time of LT listing were higher in patients with NAFLD compared with patients with HCV (for all, P < .0390). Median follow-up after LT was 5.6 years in patients with NAFLD vs 13.5 years in patients with HCV (P = .0009). There was no difference in 6-weeks postoperative mortality (1.7% vs 2.5%) (P =1.0000). Metabolic syndrome components after LT were more frequent in patients with NAFLD than in patients with HCV (for all, P < .0008). The incidence of NAFLD 5 years after LT was higher in patients transplanted for NAFLD compared with HCV (43.5% vs 4.2%) (P < .0001). Patients with recurrent NAFLD more often had myocardial infarction compared with those without recurrence (8.3% vs 0%) (P = .0313). Five years after LT, cardiovascular morbidity was more frequent in the NAFLD group than in the HCV group (12.8% vs 9.3%) (P = .0256), whereas no difference in overall survival was observed.
LT for NAFLD is associated with satisfactory 5-year outcomes; however, our data underscore the need for close monitoring and aggressive management of cardiovascular risk factors in these patients.
Endoscopic duodenal stenting is the current standard treatment for malignant gastric outlet obstruction (GOO) in patients with limited life expectancy. However, duodenal stenting is prone to stent ...dysfunction. Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is a novel technique with potentially superior stent patency. We compared clinical success, safety, and stent dysfunction of EUS-GE and duodenal stenting in patients with malignant GOO using propensity score matching.
This international, multicenter, retrospective study analyzed consecutive patients undergoing EUS-GE or duodenal stenting for GOO between 2015 and 2021 in three European centers. Primary outcomes were clinical success (GOO scoring system GOOSS ≥ 2) and stent dysfunction (GOOSS ≤ 1 after initial clinical success). A propensity score matching (1:1) analysis was performed using age, sex, underlying disease, disease stage, ascites, and peritoneal carcinomatosis as variables.
214 patients underwent EUS-GE (n = 107) or duodenal stenting (n = 107). After propensity score matching, 176 patients were matched and compared. Technical success rates for EUS-GE and duodenal stenting were 94 % (95 %CI 89 %-99 %) vs. 98 % (95 %CI 95 %-100 %), respectively (
= 0.44). Clinical success rates were 91 % (95 %CI 85 %-97 %) vs. 75 % (95 %CI 66 %-84 %;
= 0.008). Stent dysfunction occurred in 1 % (95 %CI 0-4 %) vs. 26 % (95 %CI 15 %-37 %) of patients (
< 0.001). Adverse event rate was 10 % (95 %CI 4 %-17 %) vs. 21 % (95 %CI 12 %-29 %;
= 0.09).
EUS-GE had higher clinical success and lower stent dysfunction, with similar safety, compared with duodenal stenting, suggesting that EUS-GE may be preferred over duodenal stenting in patients with malignant GOO.
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