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Background: Selective biliary cannulation (SBC) is a prerequisite for successful endoscopic retrograde cholangiopancreatography (ERCP). SBC has the potential to fail in as many as 20% of cases, even with skilled endoscopists. Precut incision techniques like needle-knife sphincterotomy (NKS) and transpancreatic septotomy (TPS) can be used in cases where standard cannulation techniques fail. However, these precut techniques may also fail in some cases. We aimed to evaluate the procedural success of the combined TPS + NKS technique in difficult biliary cannulation. Patients and methods: The study included 289 patients who underwent ERCP with precut techniques from 2017 to 2022. Patients were classified into the following three groups and evaluated retrospectively in terms of cannulation success, and ERCP-related adverse effects: Transpancreatic septotomy, NKS, and TPS + NKS; statistical package for the social sciences (SPSS), version 29.0, software was used to analyze the data. Results: The success rate of SBC was 69% in the TPS group, 75.3% in the NCS group, and 87% in the TPS + NCS group. There was no significant difference between the NKS and TPS + NKS groups. Cannulation success in both NKS group and NKS + TPS groups was significantly higher than in the TPS group (p < 0.001). Complication rates were similar. Conclusion: In cases where standard sphincterotomy and precut techniques fail, a second precut technique can be used. A previous TPS does not prevent NKS. How to cite this article: Abiyev A, Tuzcu B, Bilican G, et al. Combination of Precut Techniques in Difficult Biliary Cannulation. Euroasian J Hepato-Gastroenterol 2024;14(1):56-59.

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BACKGROUND: Transjugular intrahepatic portosystemic shunt (TIPS) is a common, effective and reliable treatment modality for portal hypertension. Migration of the TIPS stent into the right atrium is a rare and fatal complication. CASE PRESENTATION: We report a case of severe tricuspid regurgitation caused by a stent migrating into the right atrium in a patient hospitalized with refractory ascites due to cirrhosis. DISCUSSION: In this case, it is noteworthy that secondary stenting, which is necessary especially in cases of occlusion, significantly increases the risk of migration. CONCLUSION: Although a rare complication, intracardiac stent migration should be considered in patients with a history of TIPS in the presence of a new heart murmur and signs of arrhythmia.

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BACKGROUND AND AIMS: Currently malignancies of the liver are the sixth most frequently diagnosed cancers worldwide. The admission of patients to hospitals decreased due to the restriction of the Coronavirus disease 2019 (COVID-19) pandemic, especially patients suspected with cancer were delayed in their diagnosis and treatment. With this study, we aimed to investigate whether the Covid-19 pandemic caused a decrease in the number of hepatocellular cancers (HCC) or a delay in its diagnosis. METHODS: The study, which included newly diagnosed HCC patients, was conducted as a retrospective cross sectional study, in a single Turkey medical center. The patients were divided into pre-COVID-19 and post- COVID-19 two-year periods and compared in terms of tumor size, biochemical parameters, clinical and demographic features. RESULTS: A total of 63 HCC patients, 46 (73%) patients before the COVID-19 pandemic and 17 (27%) patients diagnosed during the COVID-19 pandemic were included. Maximum diameter of lesions and serum alpha- fetoprotein levels showed a statistically significant difference between the groups. Maximum tumor size in the pre-COVID-19 period was 4.58±3.77 mm, while in the COVID-19 period was 7.42±6.88 mm, the difference between two groups being statistically significant (p<0.05). HCC in the pre-COVID-19 period were detected mostly at Barcelona Clinic for Liver Cancer (BCLC) stage A (45.7%, n=21), while in the COVID-19 period most of HCC were detected at stage B (35.3%, n=6). CONCLUSIONS: The COVID-19 pandemic limited the access of patients to screening programs for HCC. The significant disruption in screening cirrhotic patients for HCC has led to a delay in diagnosis.

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We enrolled consecutive IBS-M patients (n = 25) according to Rome IV criteria. Fecal samples were obtained from all patients twice (pre-and post-intervention) and high-throughput 16S rRNA sequencing was performed. Six weeks of personalized nutrition diet (n = 14) for group 1 and a standard IBS diet (n = 11) for group 2 were followed. AI-based diet was designed based on optimizing a personalized nutritional strategy by an algorithm regarding individual gut microbiome features. The IBS-SSS evaluation for pre- and post-intervention exhibited significant improvement (p < .02 and p < .001 for the standard IBS diet and personalized nutrition groups, respectively). While the IBS-SSS evaluation changed to moderate from severe in 78% (11 out of 14) of the personalized nutrition group, no such change was observed in the standard IBS diet group. A statistically significant increase in the Faecalibacterium genus was observed in the personalized nutrition group (p = .04). Bacteroides and putatively probiotic genus Propionibacterium were increased in the personalized nutrition group. The change (delta) values in IBS-SSS scores (before-after) in personalized nutrition and standard IBS diet groups are significantly higher in the personalized nutrition group. AI-based personalized microbiome modulation through diet significantly improves IBS-related symptoms in patients with IBS-M. Further large-scale, randomized placebo-controlled trials with long-term follow-up (durability) are needed.

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The possible protective effect of betulinic acid on renal ischemia/reperfusion (I/R) injury was studied. Wistar Albino rats were unilaterally nephrectomized and subjected to 45 min of renal pedicle occlusion followed by 6 h of reperfusion. Betulinic acid (250 mg/kg, i.p.) or saline was administered at 30 min prior to ischemia and immediately before the reperfusion. Creatinine, blood urea nitrogen (BUN), lactate dehydrogenase (LDH) and TNF-alpha as well as the oxidative burst of neutrophil and leukocyte apoptosis were assayed in blood samples. Malondialdehyde (MDA), glutathione (GSH) levels, Na(+), K(+)-ATPase and myeloperoxidase (MPO) activities were determined in kidney tissue which was also analysed microscopically. I/R caused significant increases in blood creatinine, BUN, LDH and TNF-alpha. In the kidney samples of the I/R group, MDA levels and MPO activity were increased significantly, however, GSH levels and Na(+), K(+)-ATPase activity were decreased. Betulinic acid ameliorated the oxidative burst response to both formyl-methionyl-leucyl-phenylalanine (fMLP) and phorbol 12-myristate 13-acetate (PMA) stimuli, normalized the apoptotic response and most of the biochemical indices as well as histopathological alterations induced by I/R. In conclusion, these data suggest that betulinic acid attenuates I/R-induced oxidant responses, improved microscopic damage and renal function by regulating the apoptotic function of leukocytes and inhibiting neutrophil infiltration.

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