Duct Stricture Research Articles

Characterizing Congenital Double Punctum Anomalies: Clinical, Endoscopic, and Imaging Findings.

To characterize the anatomical anomaly of congenital double puncta, identify factors contributing to epiphora and its treatment. Retrospective review of patients presenting with epiphora and a double lacrimal punctum over a 6-month period. Five consecutive patients (3 female) were identified. The median age was 50 years (range 34-76). Investigations included punctum optical coherence tomography, dacryocystography, and canalicular endoscopy. The medial punctum was more morphologically abnormal when compared with healthy puncta, with optical coherence tomography showing no vertical canalicular component in 80% (4/5) of patients, and a more superficial than usual horizontal canaliculus in 80% (4/5). Dacryocystography and canalicular endoscopy showed the junction of the 2 inferior canaliculi, which was very proximal in 1, mid canalicular in 2, and at the level of the common canaliculus in 2. In 1 patient, the only abnormality identified was the double lower punctum, with a high tear meniscus and delayed fluorescence dye disappearance test. They underwent endonasal dacryocystorhinostomy with improvement of epiphora. In the other 4 patients, causes of epiphora were nasolacrimal duct stenosis with mucocoele, punctal stenosis, common canalicular stenosis with nasolacrimal duct stenosis, upper canaliculitis, and blepharitis. Their treatments included endonasal dacryocystorhinostomy, punctoplasty, canaliculotomy, and blepharitis treatment. All had improvement of epiphora following treatment. These findings suggest that the underlying canalicular anomalies are varied and that the clinical manifestation is also heterogenous. Optical coherence tomography imaging suggests that the medial of the 2 puncta is the more morphologically abnormal one, with dacryocystography and canalicular endoscopy demonstrating different accessory canaliculi lengths.Double puncta coexist with a range of other nasolacrimal pathologies. OCT suggests that the medial of the 2 double puncta is the abnormal one, with DCG and endoscopy demonstrating a range of accessory canaliculus lengths.

231.2: Advantages of extrahepatic Glissonean approach in the donor operation in living donor liver transplantation.

Background: In the donor operation for living donor liver transplantation (LDLT), it is required to preserve the appropriate length and sufficient blood supply of bile ducts for both the remnant liver and the graft. We introduced the extrahepatic Glissonean approach combined with liver hanging maneuver in the living donor operation since 2016 to preserve blood supply of the hilar plate and secure the maximum length of the bile duct. We report the beneficial effect of the technique comparing the outcomes before and after the introduction. Methods: Surgical procedures are as follow. The first step is extrahepatic Glissonean pedicle isolation and the second one is liver transection with liver hanging maneuver. Prior to liver transection, we secure the extrahepatic Glissonean pedicle at the donation side approaching the gap between the Glissonean pedicle and Laennec’s capsule. Then, we introduce a hanging tape from the encircle point of Glissonean pedicle to the groove between the middle hepatic vein and right hepatic vein. Liver transection was initiated from the demarcation line and performed with the hanging maneuver. After the completion of transection, hepatic artery and portal vein of the donation side were isolated in the hilar part. The encircled pedicle without hepatic artery and portal vein was recognized as bile ducts. We compared surgical and clinical outcomes (operation time, intraoperative bleeding volume, postoperative stay, incidences of bile duct leakage and bile duct stenosis in donors and 1-year survival in recipients) of Glissonean approach group (2016-) with those of conventional technique group (2005-2015). Results: We performed 149 (lateral segment graft in 36, left lobe graft in 72, and right lobe graft in 41) and 42 (lat. seg. in 7, left in 24, and right in 11) of living donor operations before and after the introduction, respectively. There were no statistically significant differences in operation time, bleeding amount, postoperative stay between the groups. Bile duct stenosis was observed in 2 cases (1.3%) in conventional technique group but was not observed in Glissonean approach group. In conventional technique group, the incidence of bile leakage was higher in the left lobe graft than in right lobe graft (0.7% vs 6.0%). The incidence of bile leakage did not differ between the groups in lateral segment donor (0% vs 0%) and right lobe graft donor (0.7% vs 0%), but was markedly reduced in Glissonean approach group compared to conventional technique group in left lobe graft donor (4.2% vs 13.0%). One-year survival of recipients did not differ between the groups (90.6% vs 87.2%). Conclusions: The proposed procedures with extrahepatic Glissonean approach and pedicle guided liver transection enable minimum dissection of hilar part, preservation of blood supply for bile ducts, and dissection of bile ducts at the ideal point. The introduction was beneficial for reducing the incidence of bile duct complications.

Long-term outcomes of endoscopic treatment of aberrant hepatic duct injuries after cholecystectomy

Right aberrant hepatic ducts are an anatomic variant with clinical relevance because of the risk of injury during cholecystectomy. Treatment options for aberrant hepatic duct injuries are not standardized. This study aims to analyze the long-term results of endoscopic treatment of aberrant hepatic duct lesions. Patients who underwent ERCP for aberrant hepatic duct lesions were retrospectively identified. Demographic data, type of aberrant duct lesion according to the Strasberg classification, type of treatment (number of plastic stents inserted, treatment duration, and number of ERCPs), and adverse events were recorded. Follow-up was obtained by telephone contact or medical examinations. Between January 1996 and March 2019, 32 patients (78% women, mean age 51.7 years) with aberrant hepatic duct injuries underwent ERCP at our Endoscopy Unit. Six patients had Strasberg type B lesions, 11 patients had type C, and 8 patients had type E5, and 7 patients had a stenosis of the aberrant duct. A mean of 3.7 biliary plastic stents per patient were used; mean treatment duration was 6.3 months. All patients with isolated aberrant duct stenosis and 1 of 6 patients (17%) with type B Strasberg lesions achieved patency. Ten of 11 patients (91%) with type C Strasberg lesions achieved duct recanalization. After a mean follow-up of 109.3 ± 61.2 months, 29 of 32 patients (91%) were asymptomatic; 1 underwent surgery for recurrent cholangitis, 1 received a new endoscopic procedure because of cholangitis, and 1 reported episodic biliary colic without an increase in liver function test values and was successfully managed with a low-fat diet. An endoscopic approach to aberrant hepatic duct lesions after cholecystectomy can be considered an effective first-line therapy.

2141 “Knock Out” Pancreas: An Unusual Case of Isolated Pancreatic Duct Laceration in a Mixed Martial Arts Fighter

INTRODUCTION: Isolated Pancreatic duct laceration due to blunt trauma to the abdomen is very rare. Diagnosis requires a high level of suspicion as delay in diagnosis can lead to complications such as pseudocyst, abscess and duct stricture. We present an unusual case of pancreatic duct laceration complicated with pseudocyst formation due to blunt trauma to the abdomen during a Mixed Martial Arts fight. CASE DESCRIPTION/METHODS: 33-year-old MMA fighter with no past medical history sustained a blunt trauma to the abdomen during a fight resulting in a knockout. Patient was emergently transferred to the hospital for evaluation. Lab work revealed elevated lipase >2000 IU consistent with acute traumatic pancreatitis. CT of the abdomen revealed diffuse edema of the pancreas with suspicion for possible laceration of the pancreatic duct. Patient was conservatively managed and later discharged once pain improved. Patient continued to have abdominal pain and returned to the emergency room 3 months later with abdominal distention associated with nausea and vomiting. Repeat CT of the abdomen revealed a 13 cm × 12.5 cm cystic lesion around the body of the pancreas with communication with the pancreatic duct (Image 1,2). MRI revealed a large cystic lesion with potential communication with the pancreatic duct seen on T2 images (Image 3).An ERCP was attempted but due to the mechanical compression caused by the cyst, the ampulla could not be accessed. An Endoscopic Ultrasound guided placement of a 10 × 10 mm cyst gastrostomy stent resulted in successful drainage of the pancreatic pseudocyst. Patient was later discharged and followed up in 1 month with repeat imaging showing complete resolution of the cyst. Endoscopy was repeated 4 weeks later with removal of the cystgastrostomy stent. Patient has since been doing well and awaits ERCP to evaluate the anatomy of the pancreatic duct. DISCUSSION: Isolated laceration of the pancreatic duct due to blunt trauma to the abdomen is very rare. Sudden severe impact to the abdomen, such as a punch, compresses the pancreas against the vertebral column resulting in pancreatic laceration. Diagnosis requires a high degree of suspicion and imaging confirmation. Management can be challenging as most pancreatic duct lacerations are often missed resulting in complications such as in our patient. There have been case reports of successful management with early endoscopic pancreatic duct stent placement. Refractory cases often require complex abdominal surgeries such as pancreatico - jejunostomy.

Traumatic pancreatitis

Post-traumatic pancreatitis can develop secondary to blunt or penetrating abdominal trauma, post-endoscopic retrograde cholangiopancreatography, or following pancreatic surgery. Clinical findings are often nonspecific, and imaging findings can be subtle on presentation. Early diagnosis of pancreatic duct injury is critical and informs management strategy; imaging plays important role in diagnosis of ductal injury and identification of delayed complications such as retroperitoneal fluid collections, pancreatic fistula, ductal strictures, and recurrent pancreatitis. Delayed diagnosis of pancreatic injury is associated with high mortality and morbidity, and therefore, heightened clinical suspicion is important in order for the radiologist to effectively impact patient care. There are accepted scoring systems for classification of post-traumatic pancreatic injuries and these should be included in radiology reports. Pancreatitis following ERCP appears similar on imaging to other causes of acute pancreatitis unless concomitant perforation occurs. Postoperative pancreatitis may be difficult to diagnose given associated or overlapping expected postoperative findings. Postoperative pancreatic fistulas typically arise from either a leaking pancreatic resection surface or the pancreatoenteric anastomosis and are more common in patients with a "soft" pancreas. Preoperative imaging biomarkers like duct diameter, pancreatic glandular steatosis and parenchymal fibrosis can help predict risk of development of postoperative pancreatic fistula. This review will illustrate the imaging features and the most important imaging findings in patients with post-traumatic pancreatitis.

756P - Phase I/II trial of NBTXR3 activated by SBRT in patients with hepatocellular carcinoma or liver metastasis

BackgroundTreatment of hepatocellular carcinoma (HCC) and liver metastasis (mets) is challenging due to presence of underlying disease, e.g. cirrhosis. Stereotactic body radiation therapy (SBRT) is a well-tolerated alternative for inoperable patients (pts), yet maximal dose to the tumor is limited by potential toxicity to surrounding healthy tissues. Otherwise inert, NBTXR3 (hafnium oxide nanoparticles) when activated by ionizing radiation (RT) augments dose deposit within tumor cells, increasing tumor cell death compared to RT alone. A phase I/II clinical trial is underway to evaluate NBTXR3 activated by SBRT in pts with HCC or liver mets [NCT02721056]. MethodsA 3+3 dose escalation was utilized in the phase I. Pts received a single intralesional injection (ILI) of NBTXR3 followed by SBRT (45Gy/3 fractions/5-7 days), with tested NBTXR3 dose levels of 10, 15, 22 and 33% of baseline tumor volume. Primary endpoints included recommended phase II dose(s) identification and DLT. Secondary endpoints included global safety profile assessment, liver function by Child-Pugh score (CPS), AST to Platelet Ratio Index (APRI), and response rate (mRECIST/RECIST v1.1). ResultsFour dose escalation levels are finalized (n=17): 6 pts at 10% (2 SBRT doses tested due to organ constraints), 4 pts at 15 and 22% (due to fiducial displacement and ILI site shift) and 3 pts at 33%. No NBTXR3 related DLTs were observed. Related AEs observed: one malaise (G2, 10%); 2 abdominal pain, (G3, 15%); one bilateral pleural effusion (G1, 22%), one bile duct stenosis (G3, 22%) with associated disease recurrence and SBRT; one fatigue (G1, 33%). There were no clinically meaningful changes to CPS or APRI and CT-scan demonstrated absence of NBTXR3 in surrounding healthy tissues. In 7 evaluable HCC pts, best mRECIST target lesion responses were: 3 CR, 4 PR. In 5 evaluable mets pts, best target lesion responses were: 2 PR, 1 SD, 2 PD. ConclusionsNBTXR3 was well tolerated and showed preliminary anti-tumor activity, supporting a protocol amendment to evaluate an additional NBTXR3 dose level (42%). This innovative approach has the potential to address an unmet medical need in pts with unresectable primary or metastatic liver lesions. Clinical trial identificationNCT02721056. Legal entity responsible for the studyNanobiotix SA. FundingNanobiotix SA. DisclosureM. Pracht: Honoraria (self): Nanobiotix. E. Chajon: Honoraria (self): Nanobiotix. Y. Rolland: Honoraria (self): Nanobiotix. T. de Baere: Honoraria (self): Nanobiotix. F. Nguyen: Honoraria (self): Nanobiotix. J. Bronowicki: Honoraria (self): Nanobiotix. V. Vendrely: Honoraria (self): Nanobiotix. A. Sa Cunha: Honoraria (self): Nanobiotix. A. Baumann: Honoraria (self): Nanobiotix. V. Croisé-Laurent: Honoraria (self): Nanobiotix. E. Rio: Honoraria (self): Nanobiotix. P. Said: Full / Part-time employment: Nanobiotix. S. Le Sourd: Honoraria (self): Nanobiotix. P. Gustin: Honoraria (self): Nanobiotix. C. Perret: Honoraria (self): Nanobiotix. D. Peiffert: Honoraria (self): Nanobiotix. E. Deutsch: Honoraria (self): Nanobiotix.

Maskerade Tränenwegsstenose: Prävalenz von Tränensacktumoren

Tumors of the lacrimal sac are arare entity. Malignancies are often associated with ahigh mortality rate. Lacrimal sac tumors often present as lacrimal duct stenosis with dacryocystitis and are often only diagnosed after an intraoperative biopsy. The aim of this study was aretrospective analysis of all cases with lacrimal sac tumors, which presented with alacrimal duct stenosis at this medical center in the past 10years. All patients who were treated by external dacryocystorhinostomy (DCR) at the University Medical Center Münster during the period January 2009-December 2018 were retrospectively analyzed for the presence of alacrimal sac tumor. Symptoms, clinical and histopathological findings, diagnostic and therapeutic procedures as well as long-term follow-up were analyzed. Atotal number of 878 patients underwent an external DCR at the University Medical Center Münster during the study period. Of these patients 13were diagnosed with alacrimal sac tumor and included 9malignant lymphomas, 2squamous cell carcinomas, 1oncocytic adenoma and 1transitional cell papilloma. Neoplasms of the lacrimal sac can masquerade as lacrimal duct stenosis or dacryocystitis and must be considered as adifferential diagnosis in cases with an atypical clinical course. Alacrimal sac biopsy during an (external) DCR with subsequent histopathological examination is strongly recommended in such cases.

Recent innovations in therapeutic endoscopy for pancreatobiliary diseases.

The development of endoscopic treatment for pancreatobiliary diseases in recent years is remarkable. In addition to conventional transpapillary treatments under endoscopic retrograde cholangiopancreatography (ERCP), new endoscopic ultrasound-guided therapy is being developed and implemented. On the other hand, due to the development/improvement of various devices such as new metal stents, a new therapeutic strategy under ERCP is also advocated. The present review focuses on recent advances in the endoscopic treatment of pancreatic pseudocysts, walled-off necrosis, malignant biliary strictures, and benign biliary/pancreatic duct strictures.

Classification of the cystic duct patterns and endoscopic transpapillary cannulation of the gallbladder to prevent post-ERCP cholecystitis

BackgroundEndoscopic transpapillary cannulation of the gallbladder is useful but challenging. This study aimed to investigate cystic duct anatomy patterns, which may guide cystic duct cannulation.MethodsA total of 226 patients who underwent endoscopic transpapillary cannulation of the gallbladder were analyzed retrospectively.ResultsAccording to the cystic duct take-off, 226 cystic duct patterns were divided into 3 patterns: Type I (193, 85.4%), located on the right and angled up; Type II (7, 3.1%), located on the right and angled down; and Type III (26, 11.5%), located on the left and angled up. Type I was further divided into three subtypes: Line type, S type (S1, not surrounding the common bile duct; S2, surrounding the common bile duct), and α type (α1, forward α; α2, reverse α). Types I and III cystic ducts were easier to be cannulated with a higher success rate (85.1 and 86.4%, respectively) compared with Type II cystic duct (75%) despite no statistically significant difference. The reasons for the failure of gallbladder cannulation included invisible cyst duct take-off, severe cyst duct stenosis, impacted stones in cyst duct or neck of the gallbladder, sharply angled cyst duct, and markedly dilated cyst duct with the tortuous valves of Heister.ConclusionClassification of cystic duct patterns was helpful in guiding endoscopic transpapillary gallbladder cannulation.

Carbon-ion radiotherapy for cholangiocarcinoma: a multi-institutional study by and the Japan carbon-ion radiation oncology study group (J-CROS).

To evaluate the safety and efficacy of carbon-ion radiotherapy (CIRT) for cholangiocarcinoma via a multicenter retrospective study. Clinical data were collected from patients with cholangiocarcinoma who had received CIRT at one of four treating institutions in Japan. Of 56 eligible patients, none received surgery for cholangiocarcinoma before or after CIRT. The primary endpoint was overall survival (OS). Based on the tumor site, the 56 cases were categorized as intrahepatic cholangiocarcinoma (IHC) (n=27) or perihilar cholangiocarcinoma (PHC) (n=29). In all patients, the median tumor size was 37 (range, 15‒110) mm, and the most commonly prescribed dose was 76 Gy (relative biological effectiveness) in 20 fractions. The median survival was 14.8 (range, 2.1-129.2) months, and the 1- and 2-year OS rates were 69.7% and 40.9%, respectively. The median survival times of the patients with IHC and those with PHC were 23.8 and 12.6 months, respectively. Both univariate and multivariate analyses revealed that cholangitis pre-CIRT and Child‒Pugh class B were significant prognostic factors for an unfavorable OS. Of four patients who died of liver failure, one with IHC was suspected to have radiation-induced liver disease because of newly developed ascites, and died at 4.3 months post-CIRT. Grade 3 CIRT-related bile duct stenosis was observed in one IHC case. No other CIRT-related severe adverse events, including gastrointestinal events, were observed. These results suggest that CIRT yields relatively favorable treatment outcomes, especially for patients with IHC, and acceptable toxicities were observed in patients with cholangiocarcinoma who did not receive surgery.

Lymphatic Plastic Bronchitis Secondary to Thoracic Duct Stenosis

Lymphatic Plastic Bronchitis Secondary to Thoracic Duct Stenosis

Expressions and significance of transforming growth factor β1, Survivin and Caspase-3 in patients with intrahepatic bile duct stones and bile duct stenosis

Objective To investigate the expressions and the significance among the three markers TGF β1, Survivin and Caspase-3 in intrahepatic bile duct tissues in patients with intrahepatic bile duct stones. Method Total of 130 paraffin section of intrahepatic bile duct tissue were collected at Department of Pathology, The 904th Hospital of Joint Logistic Support Force of PLA from 2013 to 2018. Total of 50 patients with intrahepatic bile duct stones complicated with bile duct strictures (the stenosis group), 40 patients with intrahepatic bile duct stones with chronic inflammation (the inflammation group), and 40 patients with normal liver tissues (the normal control group) were included in this study. The expressions of TGF β1, Survivin and Caspase-3 in liver tissues were detected by immunohistochemistry and compared among the 3 groups to find their correlations with the clinicopathological features of the disease of the patients. Results TGF β1 was expressed in 72.0% of the patients in the stenosis group, 37.5% in the inflammatory group, and 15.0% in the normal control group. The differences among the groups were significant (P<0.05); Survivin was expressed in 78.0% of the patients in the stenosis group, 47.5% in the inflammatory group, and 25.0% in the normal control group. The differences among the groups were significant (P<0.05); Caspase-3 was expressed in 10.0% of the patients in the stenosis group, 42.5% in the inflammatory group, and 75.0% in the normal control group. The differences among the groups were significant (P<0.05). Within the stenosis group, TGF β1 was negatively correlated with Caspase-3 (r=-0.882, P<0.05), and positively correlated with Survivin (r=0.889, P<0.05). Survivin and Caspase-3 were also negatively correlated (r=-0.923, P<0.05). Conclusion Abnormal expressions of TGF β1, Survivin and Caspase-3 were involved in the formation of intrahepatic bile duct stones associated with bile duct strictures. Key words: Transforming growth factor beta 1; Caspase-3; Survivin; Intrahepatic bile duct stones; Bile duct stenosis

Transoral Ultrasound in the Diagnosis of Obstructive Salivary Gland Pathologies

Transcutaneous ultrasound (TCUS) is an accepted diagnostic method in salivary gland diseases. However, sparse data are available on the use of transoral ultrasound (TOUS) in sialadenopathies. One hundred five patients presenting with various obstructive sialadenopathies were examined using TOUS and TCUS. Ultrasound findings were validated by direct visualization in subsequent sialendoscopy examinations. By TOUS, but not by TCUS, all patients with sialolithiasis (70/105) could be identified and virtually all concrements, even very small ones, were detected and distinguished from artifacts. Ductal stenoses (16/105) could be correctly differentiated from sialoliths, and exceptional insights into the delicate anatomy of parotid duct stenoses were gained. TOUS provided detailed information on other space-occupying lesions (14/105) and circumvented the method-related diagnostic weaknesses of TCUS. As a valuable tool in the diagnosis of obstructive sialadenopathies, TOUS seems superior to TCUS in pathologies involving the distal parotid duct, the submandibular duct system and the floor of the mouth.

Surgical Outcomes After Pancreatic Resection of Screening-Detected Lesions in Individuals at High Risk for Developing Pancreatic Cancer

BackgroundScreening high-risk individuals (HRI) can detect potentially curable pancreatic ductal adenocarcinoma (PDAC) and its precursors. We describe the outcomes of high-risk individuals (HRI) after pancreatic resection of screen-detected neoplasms. MethodsAsymptomatic HRI enrolled in the prospective Cancer of the Pancreas Screening (CAPS) studies from 1998 to 2014 based on family history or germline mutations undergoing surveillance for at least 6 months were included. Pathologic diagnoses, hospital length of stay, incidence of diabetes mellitus, operative morbidity, need for repeat operation, and disease-specific mortality were determined. ResultsAmong 354 HRI, 48 (13.6%) had 57 operations (distal pancreatectomy (31), Whipple (20), and total pancreatectomy (6)) for suspected pancreatic neoplasms presenting as a solid mass (22), cystic lesion(s) (25), or duct stricture (1). The median length of stay was 7 days (IQR 5–11). Nine of the 42 HRI underwent completion pancreatectomy for a new lesion after a median of 3.8 years (IQR 2.5–7.6). Postoperative complications developed in 17 HRI (35%); there were no perioperative deaths. New-onset diabetes mellitus after partial resection developed in 20% of HRI. Fourteen PDACs were diagnosed, 11 were screen-detected, 10 were resectable, and 9 had an R0 resection. Metachronous PDAC developed in remnant pancreata of 2 HRI. PDAC-related mortality was 4/10 (40%), with 90% 1-year survival and 60% 5-year survival, respectively. ConclusionsScreening HRI can detect PDAC with a high resectability rate. Surgical treatment is associated with a relatively short length of stay and low readmission rate, acceptable morbidity, zero 90-day mortality, and significant long-term survival. Clinical Trial Registration NumberNCT2000089

Manejo endoscópico instrumental de la estenosis malignas de la vía biliar: ventajas de los nuevos stents.

Resumen Las estenosis neoplásicas de la vía biliar representan normalmente un grupo de tumores que se diagnostican en fases avanzadas y, por tanto, sin posibilidad de tratamiento quirúrgico con fines curativos de resecabilidad. El enfoque terapéutico paliativo endoscópico de las neoplasias biliares malignas persigue mejorar la calidad de vida de los pacientes en cuanto al dolor, prurito e ictericia, evitando así cuadros de colangitis o sepsis y engloba dos grandes procedimientos: el drenaje biliar mediante colangiopancreatografía retrógrada endoscópica (CPRE) y el drenaje mediante ecoendoscopia o ultrasonografía endoscópica (USE), que en los últimos años ha ido ganando importancia y se ha ido equiparando e incluso superando a otras técnicas complementarias como el drenaje percutáneo biliar. Ambos procedimientos son complementarias y permiten la colocación de prótesis o stents para permitir el adecuado drenaje del árbol biliar extra o intrahepático. El tipo de prótesis depende principalmente del tipo de paciente, de las características de la estenosis y el procedimiento endoscópico de drenaje a emplear, siendo generalmente las prótesis metálicas autoexpandibles las de mayor permeabilidad, durabilidad y las que presentan un menor número de efectos secundarios y reintervenciones. Habitualmente, las neoplasias malignas de la vía biliar requieren un abordaje mediante CPRE. Sin embargo, dicho procedimiento no siempre es posible por dificultad técnica, modificación anatómica quirúrgica previa o por infiltración neoplásica enteral, adoptando entonces el drenaje por ecoendoscopia un papel fundamental en el tratamiento paliativo de estos pacientes.

Botulinum toxin for ductal stenosis and fistulas of the main salivary glands

This study was performed to present the authors’ experience with botulinum toxin therapy for salivary stenosis and salivary fistula in terms of the procedure, dosage, effectiveness, and complications. A retrospective study of all patients treated in the maxillofacial surgery department for salivary stenosis or fistula from January 2014 to September 2018 was performed. Intraglandular injections of incobotulinumtoxinA (Xeomin) were utilized. The frequency of relapse and the pain recorded before injection and at 3 months after each injection or fistula resolution were assessed. Swallowing dysfunction or any diffusion of toxin into the facial muscles was recorded. This study included 22 patients (mean age 53 years). Botulinum therapy was indicated for parotid duct stenosis in 14 patients, submandibular duct stenosis in four patients, and parotid fistula in four patients. The frequency of relapse (P = 0.0001) and pain level (P = 0.0001) decreased after botulinum therapy. The average duration of the botulinum effect was 4.50±2.00 months after the first injection. No complication was observed. Botulinum therapy with 100 IU of Xeomin proved effective at resolving salivary fistula. Botulinum therapy is an effective treatment for symptoms of salivary duct stenosis in patients for whom minimally invasive procedures have failed. Botulinum therapy can also be used for the treatment of salivary fistulas.

SUN-LB088 Octreotide Induced Hypocalcemia in Case of Familial Hypocalciuric Hypercalcemia

Introduction: Octreotide is used for a wide arrange of disorders particularly with endocrinologic and gastrointestinal diseases. We present a case of an uncommon side effect of octreotide in a patient with Familial hypocalciuric hypercalcemia (FHH). Clinical case: 59 year old male presented in late 2011 for persistent hypercalcemia (age 52 at the time). He carried a diagnosis of suspected FHH. Medical records were available for review and demonstrated repeated, persistent hypercalcemia (~12.5-13.4 mg/dL) with no history of normo-calcemia, repeated low urine calciums (31 - 56 mg/24hr), PTH 74-130 pg/ml. Other testing included normal PTH-rp, 25 OH Vitamin D, 1,25 OH Vitamin D, and albumin. Hypercalcemia was confirmed with elevated ionized calcium. PMH also included recurrent pancreatitis since 2007 (admitted ~ 20 times for pancreatitis). No alcohol abuse. A cholecystectomy was completed but pancreatitis persisted. In 2010, triglycerides 1350 mg/dL during a hospitalization and he was treated with gemfibrozil. Despite follow up levels <200 mg/dL he continued to have episodes of pancreatitis. Due to persistent hypercalcemia without another etiology for pancreatitis, in early 2011 he underwent 3.5 gland parathyroidectomy with half a gland implanted in sternocleidomastoid muscle. PTH dropped immediately from ~150 to 30-40 pg/ml postoperatively with normal calcium levels. However, within 2 months calcium increased to 11-12.5 mg/dL with PTH 40-48 pg/ml. The patient continued to have episodes of pancreatitis. FH was limited due to both parents deceased but no report of calcium disorder. The patient had negative genetic testing for FHH. In April 2011, he was started on cinacalcet and titrated until calcium normalized. A few months later GI placed a biliary stent due to biliary/pancreatic duct strictures, initiated octreotide LR and titrated to 30mg monthly. In general, his episodes of pancreatitis decreased but did not resolve. In mid-2014 while he was still taking cinacalcet, he developed hypocalcemia and cinacalcet was stopped and calcium remained mostly WNL. Then in 6/2017 when admitted for liver phlegmon he had hypocalcemia and suspected symptomatic based on carpal symptoms. He also had new hyperglycemia. Discussion with GI led to a dose decrease in octreotide to 10mg. However patient developed pancreatitis and octreotide dose increased back to 20mg daily. Calcium remained in the low normal range on this dose. Conclusion: We believe this is the first published case of octreotide induced hypocalcemia in a patient with FHH. The occurrence of hypocalcemia in patient with a suspected inactivating mutation of the calcium sensing receptor (CASR) gene may assist in understanding the mechanism of octreotide induced hypocalcemia. Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. s presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

Acute therapy of newborns with critical congenital heart disease.

Critical congenital heart disease (cCHD) is the most common reason for acute cardiac failure in the neonatal period. cCHD, defined by systemic low cardiac output (LCO) and requiring surgery or catheter-based intervention in the first year of life, has an incidence of approximately 15% of CHD and is responsible for up to 25% fatalities of newborn infants. Clinical deterioration develops in most cases due to rapid closure of the ductus arteriosus (DA). Early diagnosis and immediate treatment determinate beneficial outcome. Critical CHD can be classified in duct-dependent systemic flow, duct-dependent pulmonary flow and transposition of the great arteries. The latter two manifest themselves in oxygen resistant cyanosis, whereas CHD with duct-dependent systemic flow may present itself with cardiogenic shock, which can be difficult to differentiate from other causes of shock such as sepsis. Besides prostaglandin therapy for reopening the arterial duct, a balanced parallel pulmonary and systemic circulation should be a therapeutic goal. In CHD with duct-dependent systemic flow a decrease of pulmonary resistance should be avoided; therefore inadequate oxygen therapy, hyperventilation and alkalosis due to excessive treatment of acidosis, should be averted. Volume therapy should be performed carefully. In CHD with duct-dependent pulmonary flow, pulmonary resistance can be decreased, in case of poor pulmonary flow systemic resistance should be increased, mild alkalosis is recommended. Intense volume therapy is in most cases necessary, except if a restrictive atrial communication is present. In addition to intensive care measures, an arsenal of catheter- and surgery-based procedures need to be hold available as back-up for emergency procedures. Transcatheter interventions are nowadays decisive. Atrial-septostomy was the first and still the most utilized high-urgency procedure; DA-stenting is used in prostaglandin-refractory duct stenosis. In the presence of critical aortic valve stenosis, palliation consists of balloon valvuloplasty. In critical aortic coarctation with myocardial failure and no response to prostaglandin, palliative balloon angioplasty may be the method of choice as bridging for corrective surgery.

Ultrasound in the Assessment of Parotid Duct Stenosis.

Parotid duct stenosis may occur with or without accompanying ductal anomalies, with associated differences in their pathogenesis and management. By identifying the characteristics of a stenosis, ultrasound (US) can assist in tailored management of parotid duct stenosis. The objective of this study was therefore to describe the US characteristics of parotid duct stenoses and to evaluate criteria for whether and in what ways these can be distinguished from each other by using US. A total of 108 patients who presented with parotid duct stenoses (130 parotid glands) were examined with high-resolution US between 2014 and 2017. The stenoses were assessed for duct dilatation, location, signs of ductal anomalies (circular encroachments/webs, duct bending/kinking, and presence of a megaduct) and the echogenicity of the gland parenchyma. Ultrasound was able to distinguish between stenoses associated with ductal anomalies and those without anomalies. Webs (82.5% versus 7.8%; P < .001), kinking (75.0% versus 3.3%; P < .001), and a megaduct (87.50% versus 15.63%; P < .001) and a tendency toward normal echogenicity in the gland parenchyma (77.5% versus 25.6%; P < .001) were significantly associated with ductal anomalies. Stenoses associated with ductal anomalies also had significantly larger duct diameters in comparison with those without anomalies (mean ± SD, 9.19 ± 3.65 versus 3.27 ± 2.17 mm; P < .001). This study describes US parameters that allow more detailed characterization of parotid stenoses with or without accompanying ductal anomalies. Differentiating between these at an early stage may be helpful for decision making on the further management in these patients.

Prophylactic pancreatic duct stenting in severe acute necrotizing pancreatitis: a prospective randomized study.

Pancreatic duct disruption is common and is associated with high morbidity in cases of acute necrotizing pancreatitis (ANP). In this study, we tested the feasibility and safety of prophylactic pancreatic duct stenting (PPDS) in ANP and compared PPDS with conservative treatment. We prospectively enrolled patients (aged 18 - 75 years) diagnosed with ANP between February 2011 and July 2015. These patients were prospectively randomized to receive PPDS or conservative treatment at two tertiary centers. PPDS was performed as soon as possible after randomization. Concern regarding iatrogenic infections with pancreatic necrosis in the PPDS group prompted interim analysis, which confirmed a highly elevated risk. Thus, the trial was terminated prematurely for ethical reasons. Of the 11 patients in the PPDS group, all patients with successful pancreatic duct placement (5/5, 100 %) presented with infection, compared with only 3 of the 13 patients (23.1 %) in the conservative treatment group (P = 0.01). Analysis revealed success rates of 63.6 % for pancreatic duct cannulation, 45.5 % for pancreatic duct stenting, and 18.2 % for placement of a stent bridging the necrosis. Cannulation and stenting failures were due to duodenal edema and pancreatic duct stenosis. PPDS in ANP is associated with an unacceptably high risk of pancreatic necrosis infection. In addition, the procedure is technically challenging due to duodenal edema and ductal stenosis.