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American College of Gastroenterology

An online journal of case reports edited by gastroenterology hepatology fellows

/ Volume 5 / Full Text

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Volume 5 | June 2018 Video | Endoscopy

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Debdeep Banerjee, MD, Abhilash Perisetti, MD, Saikiran Raghavapuram, MD, Nayana George, MD, and Benjamin Tharian, MD

Department of Medicine, University of Florida College of Medicine, Gainesville, FLHospital Medicine Division, Department of Family and Community Medicine, Texas Tech University, Lubbock, TXDivision of Gastroenterology and Hepatology, Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, ARDepartment of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR

2018;5:e50. http://dx.doi.org/10.14309/crj.2018.50. Published online: June 20, 2018.

A 61-year-old woman underwent orthotopic liver transplant, with intraoperative plastic biliary stent placement, for nonalcoholic steatohepatitis–related cirrhosis. When she presented a month later for the stent removal, the stent was noted to have migrated proximally into the donor bile duct on x-ray and computed tomography imaging (Figure 1). Endoscopic retrograde cholangiopancreatography with multiple extraction techniques failed to retrieve the stent. A single-operator digital cholangioscope (SpyGlass, Boston Scientific, Marlborough, Massachusetts) was used to identify the stent in the donor bile duct (Figure 2), which was then successfully extracted with the help of mini biopsy forceps (SpyBite, Boston Scientific, Marlborough, Massachusetts; Figure 3 and Video 1).

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Liver transplantation can be life-saving for patients with a variety of conditions, including but not limited to cirrhosis and hepatocellular carcinoma. Intraoperative biliary stent placement decreases the risk of anastomotic biliary strictures. 1 These stents are usually taken out within a month after the transplant. Stent migration occurs in 5% of cases, with distal migration more commonly reported. 2 Proximal migration into the donor biliary duct is relatively rare.

In this case, we demonstrate that a cholangioscope can be successfully used for difficult cases of proximally migrated biliary stents in transplant patients. The SpyBite forceps that was used to retrieve the stent is 270 cm long with an outer diameter of 1 mm, designed to easily fit the working channel of the cholangioscope. This also allows for a 4.1-mm jaw opening at 55° for tissue acquisition. The use of cholangioscopy to retrieve a foreign body is not novel, and it has been used previously to remove challenging impacted/migrated foreign bodies in the pancreaticobiliary system. 3 5 This case describes the retrieval of a migrated surgical biliary stent using a cholangioscope and mini biopsy forceps.

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ARLINGTON, TX - AUGUST 30: A Florida State Seminoles cheerleader runs a flag on the field before a game against the Oklahoma State Cowboys at ATT Stadium on August 30, 2014 in Arlington, Texas. (Photo by Ronald Martinez/Getty Images)

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We noted above that undifferentiated ES cells express STELLAR and DAZL in the majority of cells in a given colony. Given that, in vivo , DAZL has only been shown to function in germ cell formation and/or maintenance, we sought to determine whether germ cell differentiation could be achieved with embryoid body (EB) formation in vitro . Under differentiation conditions, genes expressed exclusively or predominantly in pluripotent cell types are expected to decrease whereas markers of the somatic lineages are expected to increase as cells of the somatic lineages differentiate. Indeed, that was the case; the markers, OCT4 , STELLAR , NANOG and GDF3 decreased with differentiation, whereas NCAM1 , AFP and KDR increased (Fig. 5 ). Unexpectedly, however, by day 14 of differentiation, expression of both the NANOS1 and DAZL genes decreased dramatically as well. Conversely, there was a sharp increase in expression of the later germ cell lineage markers including the gonocyte marker VASA , the meiotic marker, SCP1 , and postmeiotic markers, GDF9 and TEKT1 as EB differentiation progressed (Fig. 5 ). These results largely parallel those of mice ( 15 17 ). However, in contrast to studies in mice, we observed that human germ cells differentiated in vitro expressed both the male and female genetic programs regardless of whether they were karyotypically XX or XY (Fig. 5 ). Expression of both GDF9 (an oocyte specific gene) and TEKT1 (a spermatid specific gene) was noted with differentiation of all human ES lines.

Since transcriptional profiles indicated that VASA-positive putative germ cells formed with ES cell differentiation, we sought evidence that proteins diagnostic of germ cells might also be expressed in EBs. At days 14 and 21 of culture, EBs were sectioned and stained for the VASA, STELLAR and DAZL proteins via immunohistochemistry. We observed that VASA positive cells were most frequently observed in clusters, at the edges of EBs and throughout small sections of EBs (Fig. 6 A and B). We noted that not all cells in a given EB were positive for VASA, a finding consistent with our expectation that somatic cell differentiation was occurring in parallel. We observed that STELLAR-positive cells were more frequent than VASA-positive cells, and were located throughout the EBs, in clusters within EBs, and especially in cells lining the edges of EBs (Fig. 6 E–G). As was noted for VASA-positive cells, not every EB section contained STELLAR-positive cells. Finally, examination of the localization of DAZL protein in EBs revealed that DAZL-positive cells were found in more EBs than either STELLAR- or VASA-positive cells (Fig. 6 H–J). However, when adjacent sections were stained for STELLAR and DAZL, most often cells within the same region of the EB stained for both proteins (for example, compare Fig. 6 F and I). Furthermore like STELLAR, DAZL-positive cells were more likely to be found evenly dispersed throughout EBs composed of loosely packed cells (Fig. 6 I and J). Cell numbers positive for DAZL, STELLAR and VASA were tallied for adjacent sections of the same EB and confirmed visual impressions of immunohistochemistry (Fig. 7 ). Given these tallies, clearly the fate of all cells that are positive for DAZL and STELLAR on day 0 of differentiation is not to differentiate to VASA-positive cells by days 14 or 21.

122 Drew Desilver, “U.S. Trails Most Developed Countries in Voter Turnout,” Pew Research Center, May 15, 2017, SHIRTS Shirts Our Legacy Outlet Popular Best Cheap Price Low Shipping Cheap Online 7YLStWa
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123 Adam Taylor, “American Voter Turnout Is Still Lower Than Most Other Wealthy Nations,” Washington Post, November 10, 2016, https://www.washingtonpost.com/news/worldviews/wp/2016/11/10/even-in-a-historic-election-americans-dont-vote-as-much-as-those-from-other-nations/?utm_term=.4e95563e87fe .

124 Ibid.; Sean McElwee, “The Income Gap at the Polls,” Politico, January 7, 2015, https://www.politico.com/magazine/story/2015/01/income-gap-at-the-polls-113997 .

125 Michael D. Regan, “Why Is Voter Turnout So Low in the U.S.?,” PBS, November 6, 2016, https://www.pbs.org/newshour/politics/voter-turnout-united-states .

126 “Voter Turnout Database,” International IDEA, accessed May 15, 2017, https://www.idea.int/data-tools/data/voter-turnout .

127 Abdurashid Solijonov, “Voter Turnout Trends Around the World,” International IDEA, 2016, Outlet Best Prices Outlet Comfortable Womens Pack of 3 Sneaker Socks James amp; Nicholson In China Cheap Online Whole World Shipping For Sale q7zr5
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128 Ibid.

129 Ibid.

130 Nadia Fiorino, Nicola Pontarollo, and Roberto Ricciuti, “Voter Turnout in European Parliament Elections: A Spatial Analysis,” Editorial Express, 2016, https://editorialexpress.com/cgi-bin/conference/download.cgi?db_name=SIEP2016paper_id=29 ; and “Turnout in European Elections,” European Parliamentary Research Service, March 7, 2014, Stella Mccartney Woman Lace And Stretchjersey Underwired Balconette Bra Neutral Size 32 E Stella McCartney Brand New Unisex Sale Online In China Cheap Price Sale Reliable Buy Cheap Low Price Fee Shipping Wdi8l8
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131 Bertelsmann Stiftung, “The Social Divide in Voter Turnout,” For Cheap Cheap Online DENIM Denim trousers Haikure Affordable Authentic Buy Cheap New Free Shipping Comfortable cXgev
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132 Ruth Patrick, “How Poverty Makes People Less Likely to Vote,” Guardian , May 16, 2017, https://www.theguardian.com/society/2017/may/16/poverty-election-vote-apathy ; and Matthew Flinders, “Low Voter Turnout Is Clearly a Problem, but a Much Greater Worry Is the Growing Inequality of That Turnout,” British Politics and Policy (blog), London School of Economics and Political Science, March 13, 2014, Womens 0055/4840 Trousers Vera Mont Free Shipping Sale Online Great Deals Original Cheap Price Cheap Sale Store Lowest Price Cheap Online b3LTmBf
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133 Patrick Kingsley, “As West Fears the Rise of Autocrats, Hungary Shows What’s Possible,” New York Times , February 10, 2018, https://www.nytimes.com/2018/02/10/world/europe/hungary-orban-democracy-far-right.html .

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