Biliary Events Research Articles

BN SO56 - Post-ERCP clearance of bile duct stones: Should the gallbladder be left in-situ?

Abstract Background Laparoscopic cholecystectomy (LC) has become the gold standard treatment for patients with cholelithiasis and co-existing common bile duct stones (CBSD) with the ultimate goal to prevent further biliary complications. Despite the procurement of ERCP and LC skills, there still remain a significant proportion of patients who are treated non-operatively. There has been debate on the safety of a ‘watch-and-wait’ policy post ERCP for clearance of CBDS alone. The objective of our study was to review our current practice and compare the outcomes of expectant management (EM) versus LC with an aim to evaluate the necessity of LC after ERCP. Method A retrospective review of patients who underwent ERCP for choledocholithiasis from 1st January 2017 to 31st December 2019 was performed. Exclusion criteria applied to patients with previous cholecystectomy, absence of CBDS, gallbladder/pancreatic malignancy, biliary stricture and patients lost to follow-up. Patient characteristics, details of ERCP, initial plan for EM or LC, details of LC and further changes in treatment plan were extracted from the prospectively maintained database of a single institution. Age 70 years is used as cut-off to define elderly group. Primary outcomes measured were biliary-related morbidity and mortality. Secondary outcomes included all-cause mortality, operation-related morbidity and mortality. Results 265 patients were identified, with 136 patients primarily planned for EM and 129 patients initially booked for LC. The median age of patients in the EM group was greater than LC group (80 vs 62 years). 20.6% patients in the EM group re-presented with biliary events compared to 3.9% in the LC group. The median time from first ERCP to recurrence of biliary events in the EM group was 14 months. There was no significant correlation between age and complications from LC. However, 51.4% of our EM group died during follow up with a median survival of 29.5 months. Conclusion Prophylactic cholecystectomy should be performed for patients with concomitant cholelithiasis and choledocholithiasis. A conservative approach should be reserved for the elderly population who are not ideal surgical candidates. A follow-up of up to 2 years is recommended for patients who opt for a ‘watch-and-wait’ approach. Early LC is preferrable due to the risk of recurrence of biliary events and the higher risks of surgery if patients require emergency surgery. Further study is warranted to determine the optimal timing for LC. Patients should be informed about the potential recurrence of symptoms if the waiting time to surgery is longer than expected.

8418 Association of GLP-1 Receptor Agonists and SGLT-2 Inhibitors with Major Adverse Cardiovascular Events and Serious Liver Events among Patients with Type 2 Diabetes and MASLD

Abstract Disclosure: A. Kutz: None. D.J. Wexler: None. J. Liu: None. J.M. Paik: None. E. Patorno: None. Introduction and study question Little is known about the cardiovascular (CV) and hepatic effectiveness of glucagon-like peptide 1 receptor agonists (GLP-1 RA) and sodium–glucose cotransporter 2 inhibitors (SGLT-2i) in people with type 2 diabetes (T2D) and known metabolic dysfunction-associated steatotic liver disease (MASLD) in clinical practice. We assessed the comparative CV and hepatic effectiveness and the safety of GLP-1 RA and SGLT-2i in people with T2D and prevalent MASLD. Methodology Using pooled data from Medicare fee-for-service (2013–2020) and a large U.S. health insurance database (2013-June 2022), we conducted two propensity-score fine stratification weighted cohort studies including adults with T2D and a diagnosis of MASLD who initiated GLP-1RA, SGLT-2i, or dipeptidyl peptidase 4 inhibitors (DPP-4i, reference). Using Cox proportional hazards models, we assessed the primary CV effectiveness composite outcome of acute myocardial infarction, ischemic stroke, hospitalization for heart failure, or all-cause mortality. The primary hepatic effectiveness outcome was a composite of serious liver events (hospitalization for ascites, spontaneous bacterial peritonitis, hepatorenal syndrome, bleeding esophageal varices, hepatic encephalopathy, or liver transplantation). The safety outcome was a composite of severe adverse events (lower limb amputation, non-vertebral fracture, emergency admission for hypoglycemia, or hospitalization for acute kidney injury, diabetic ketoacidosis [DKA], severe genital or urinary tract infection, acute pancreatitis, or biliary event). Major results Compared with DPP-4i (n=17,084 initiators), the hazard ratio (HR) for the primary CV outcome associated with GLP-1 RA (n=13,666 initiators) was 0.67 (95% CI, 0.56 to 0.81), corresponding to an incidence rate difference (IRD) per 1,000 person-years of -21.6 (95% CI, -26.7 to -16.6). The HR for the primary hepatic outcome was 0.47 (95% CI, 0.25 to 0.90), the IRD -2.1 (95% CI -3.4 to -0.9). Similar CV benefits were observed for SGLT-2i (n=11,108) vs DPP-4i (n=16,979), with a HR for the primary CV outcome of 0.82 (95% CI 0.70–0.96) and an IRD of -11.0 (95% CI -16.2 to -5.8). For the primary hepatic outcome, the HR was 0.81 (95% CI 0.45 to 1.44) and the IRD -1.1 (95% CI -2.4 to 0.3). Severe adverse events were not more frequent with GLP-1RA or SGLT-2i compared with DPP-4i. Interpretation and conclusion Among people with T2D and MASLD, the use of GLP-1 RA or SGLT-2i was associated with fewer CV events, vs DPP-4i, while GLP-1 RA also reduced serious liver events. Compared with DPP-4i, GLP-1RA or SGLT-2i were not associated with higher safety adverse event rates. Presentation: 6/2/2024

Optimal Timing to Perform Cholecystectomy in Patients with Acute Biliary Pancreatitis

Background: Acute biliary pancreatitis accounts for nearly 50% of acute pancreatitis cases, primarily caused by gallstones and biliary sludge. Cholecystectomy remains the definitive treatment to prevent recurrent biliary events, but the optimal timing of surgery remains debated.Objective: This study aimed to evaluate the optimal timing of cholecystectomy in patients with mild to moderate acute biliary pancreatitis, comparing early cholecystectomy during index admission to delayed cholecystectomy.Methods: A prospective cohort study was conducted over 24 months at Combined Military Hospital, Kohat, Pakistan. A total of 126 patients aged 18 years and older, diagnosed with mild to moderate acute biliary pancreatitis, were included. Patients with severe pancreatitis, ICU admissions, or requiring ERCP were excluded. Patients were divided into two groups: index admission cholecystectomy and delayed cholecystectomy. Data were analyzed using SPSS 25 with chi-square tests applied. A p-value of <0.05 was considered statistically significant.Results: Recurrent pancreatitis occurred in 0 patients in the early group versus 41 patients in the delayed group (p < 0.001). The mean hospital stay was significantly shorter in the early group (5.92 vs 12.31 days, p < 0.001).Conclusion: Early cholecystectomy significantly reduced recurrent biliary events and shortened hospital stay in patients with mild to moderate acute biliary pancreatitis without increasing complications.

Benefits of endoscopic gallbladder stenting following percutaneous transhepatic gallbladder drainage.

Endoscopic transpapillary gallbladder drainage is challenging because of the complexity of the procedure and high incidence of adverse events (AEs). To overcome these problems, endoscopic gallbladder stenting (EGBS) after percutaneous transhepatic gallbladder drainage (PTGBD) can be effective, as it mitigates inflammation and adhesion. To examine the benefits of EGBS after PTGBD to assess its efficacy and impact on AEs. We retrospectively analyzed data from 35 patients who underwent EGBS after PTGBD at a single center between January 2016 and December 2023. The primary outcomes were technical success and AEs, and the rate of recurrent cholecystitis was evaluated. In addition, the reasons for the failure of the procedure were identified. Among the 35 patients, the technical success rate was 77.1% and the final contrast of the cystic duct was successful in 97.1% of patients. The incidence of early AEs was relatively low (11.4%), with no instances of cystic duct perforation. The rate of recurrent cholecystitis was 3.7%, and no other biliary events were observed. EGBS after PTGBD may be significantly beneficial, with a substantial success rate and minimal AEs in both short- and long-term follow-ups.

Risk factors for biliary tract events during elective cholecystectomy waiting time after endoscopic retrograde cholangiopancreatography for choledocholithiasis.

Endoscopic lithotripsy and elective cholecystectomy, followed by endoscopic retrograde cholangiopancreatography, are the first-line treatments for patients with common bile duct (CBD) stones (CBDS) and gallstones. However, this approach entails acute cholecystitis and recurrent cholangitis risk while patients await surgery. We aimed to identify acute cholecystitis and cholangitis risk factors during the waiting time for elective cholecystectomy. This study comprised 151 patients with CBDS combined with gallstones who underwent cholecystectomy within 90 days of the first endoscopic retrograde cholangiopancreatographyat two tertiary care centers between January 2019 and October 2021. The incidence of biliary tract events (acute cholecystitis, acute cholangitis, or any complications requiring unplanned cholangiopancreatography) was 28% (43 cases). In univariate and multivariate analyses, plastic stent placement as a bridge to surgery for the first treatment of CBDS was an independent risk factor for biliary tract events during the waiting time for surgery (odds ratio 4.25, p = 0.002). A subgroup analysis among those with plastic stent placement revealed a CBD diameter of ≤ 10 mm as an independent risk factor for acute cholecystitis (odds ratio 4.32; p = 0.027); a CBD diameter ≥ 11 mm was an independent risk factor for acute cholangitis and unplanned re-endoscopic retrograde cholangiopancreatography (odds ratio 5.66; p = 0.01). Plastic stent placement for CBDS before elective cholecystectomy increases the risk of acute cholecystitis or acute cholangitis during the waiting time for elective cholecystectomy.

Role of Biliary Stent in Recurrence Recurrent Biliary Events Postendoscopic Retrograde Cholangiopancreatography: A Comment.

Role of Biliary Stent in Recurrence Recurrent Biliary Events Postendoscopic Retrograde Cholangiopancreatography: A Comment.

Is Cholecystectomy Necessary after Choledocholithiasis Treatment for the Elderly or Patients with Many Comorbidities?

We evaluated the prognosis after endoscopic treatment for choledocholithiasis, particularly in patients with borderline tolerance to surgery. Stone removal and cholecystectomy are generally recommended for patients with choledocholithiasis combined with gallstones to prevent recurrent biliary events. However, the prognosis after choledocholithiasis treatment in patients with borderline tolerance to surgery, such as the elderly or those with many comorbidities, remains controversial. We retrospectively analyzed data from patients with choledocholithiasis treated at our facility between January 2012 and December 2021. Patients who underwent endoscopic sphincterotomy were dichotomized into the cholecystectomy (CHOLE) and conservation (CONS) groups depending on whether cholecystectomy was performed, and their prognoses were subsequently compared. Furthermore, we performed a logistic regression analysis of the factors contributing to recurrent biliary events in patients with high age-adjusted Charlson Comorbidity Index (aCCI) scores. Of 169 participants, 110 had gallstones and were divided into the CHOLE (n = 56) and CONS (n = 54) groups. The CONS group was significantly ordered, had more comorbidities, and higher aCCI scores, whereas the CHOLE group had fewer recurrent biliary events, although not significant (p = 0.122). No difference was observed in the recurrent incidence of grade ≥2 biliary infections and mortality related to biliary events between the groups. In patients with aCCI scores ≥5, conservation without cholecystectomy was not an independent risk factor for recurrent biliary events. Cholecystectomy after choledocholithiasis treatment prevents recurrent biliary events, but conservation without cholecystectomy is a feasible option for patients with high aCCI scores.

Radiofrequency ablation via catheter and transpapillary access in patients with cholangiocarcinoma (ACTICCA-2 trial) – a multicenter, randomized, controlled, open-label investigator-initiated trial

BackgroundDespite the recent advances in cancer treatment, the therapeutic options for patients with biliary tract cancer are still very limited and the prognosis very poor. More than 50% of newly diagnosed patients with biliary tract cancer are not amenable to curative surgical treatment and thus treated with palliative systemic treatment. Malignant bile duct obstructions in patients with perihilar and/or ductal cholangiocarcinoma (CCA) represents one of the most important challenges in the management of these patients, owning to the risk represented by developing life-threatening cholangitis which, in turn, limits the use of systemic treatment. For this reason, endoscopic stenting and/or bile duct decompression is the mainstay of treatment of these patients. Data on efficacy and safety of adding radiofrequency ablation (RFA) to biliary stenting is not conclusive. The aim of this multicenter, randomized trial is to evaluate the effect of intraductal RFA prior to bile duct stenting in patients with unresectable perihilar or ductal CCA undergoing palliative systemic therapy.Methods/DesignACTICCA-2 is a multicenter, randomized, controlled, open-label, investigator-initiated trial. 120 patients with perihilar or ductal CCA with indication for biliary stenting and systemic therapy will be randomized 1:1 to receive either RFA plus bile duct stenting (interventional arm) or bile duct stenting alone (control arm). Patients will be stratified by trial site and tumor location (perihilar vs. ductal). Both arms receive palliative systemic treatment according to the local standard of care determined by a multidisciplinary tumorboard. The primary endpoint is time to first biliary event, which is determined by an increase of bilirubin to > 5 mg/dl and/or the occurrence of cholangitis leading to premature stent replacement and/or disruption of chemotherapy. Secondary endpoints include overall survival, safety according to NCI CTCAE v5, quality of life assessed by questionnaires (EORTC QLQ-C30 and QLQ-BIL21), clinical event rate at 6 months after RFA and total days of over-night stays in hospital. Follow-up for the primary endpoint will be 6 months, while survival assessment will be continued until end of study (maximum follow-up 30 month). All patients who are randomized and who underwent endoscopic stenting will be used for the primary endpoint analysis which will be conducted using a cause-specific Cox proportional hazards model with a frailty for trial site and fixed effects for the treatment group, tumor location, and stent material.DiscussionACTICCA-2 is a multicenter, randomized, controlled trial to assess efficacy and safety of adding biliary RFA to bile duct stenting in patients with CCA receiving palliative systemic treatment.Trial registrationThe study is registered with ClinicalTrials.gov (NCT06175845) and approved by the local ethics committee in Hamburg, Germany (2024-101232-BO-ff). This manuscript reflects protocol version 1 as of January 9th, 2024.Graphical

Comorbidities and complications in adult and paediatric patients with pyruvate kinase deficiency: Analysis from the Peak Registry.

Pyruvate kinase (PK) deficiency, a rare, congenital haemolytic anaemia caused by mutations in the PKLR gene, is associated with many clinical manifestations, but the full disease burden has yet to be characterised. The Peak Registry (NCT03481738) is an observational, longitudinal registry of adult and paediatric patients with PK deficiency. Here, we described comorbidities and complications in these patients by age at most recent visit and PKLR genotype. As of 13 May 2022, 241 patients were included in the analysis. In total, 48.3% had undergone splenectomy and 50.5% had received chelation therapy. History of iron overload (before enrolment/during follow-up) was common (52.5%), even in never-transfused patients (20.7%). Neonatal complications and symptoms included jaundice, splenomegaly and hepatomegaly, with treatment interventions required in 41.5%. Among adults, osteopenia/osteoporosis occurred in 19.0% and pulmonary hypertension in 6.7%, with median onset ages of 37, 33 and 22 years, respectively. Biliary events and bone health problems were common across PKLR genotypes. Among 11 patients who had thromboembolic events, eight had undergone prior splenectomy. Patients with PK deficiency may have many complications, which can occur early in and throughout life. Awareness of their high disease burden may help clinicians better provide appropriate monitoring and management of these patients.

Impact of index admission cholecystectomy vs interval cholecystectomy on readmission rate in acute cholangitis: National Readmission Database survey.

Elective cholecystectomy (CCY) is recommended for patients with gallstone-related acute cholangitis (AC) following endoscopic decompression to prevent recurrent biliary events. However, the optimal timing and implications of CCY remain unclear. To examine the impact of same-admission CCY compared to interval CCY on patients with gallstone-related AC using the National Readmission Database (NRD). We queried the NRD to identify all gallstone-related AC hospitalizations in adult patients with and without the same admission CCY between 2016 and 2020. Our primary outcome was all-cause 30-d readmission rates, and secondary outcomes included in-hospital mortality, length of stay (LOS), and hospitalization cost. Among the 124964 gallstone-related AC hospitalizations, only 14.67% underwent the same admission CCY. The all-cause 30-d readmissions in the same admission CCY group were almost half that of the non-CCY group (5.56% vs 11.50%). Patients in the same admission CCY group had a longer mean LOS and higher hospitalization costs attributable to surgery. Although the most common reason for readmission was sepsis in both groups, the second most common reason was AC in the interval CCY group. Our study suggests that patients with gallstone-related AC who do not undergo the same admission CCY have twice the risk of readmission compared to those who undergo CCY during the same admission. These readmissions can potentially be prevented by performing same-admission CCY in appropriate patients, which may reduce subsequent hospitalization costs secondary to readmissions.

Hepatic artery stenosis following adult liver transplantation: evaluation of different endovascular treatment approaches

PurposeTo evaluate the efficacy and safety of hepatic artery interventions (HAI) versus extra-hepatic arterial interventions (EHAI) when managing clinically significant hepatic artery stenosis (HAS) after adult orthotopic liver transplantation.Materials and methodsA single-center retrospective cohort analysis was conducted on liver transplant patients who underwent intervention for clinically significant HAS from September 2012 to September 2021. The HAI treatment arm included hepatic artery angioplasty and/or stent placement while the EHAI treatment arm comprised of non-hepatic visceral artery embolization. Primary outcomes included peri-procedural complications and 1-year liver-related deaths. Secondary outcomes included biliary ischemic events, longitudinal trends in liver enzymes and ultrasound parameters pre-and post-intervention.ResultsThe HAI arm included 21 procedures in 18 patients and the EHAI arm included 27 procedures in 22 patients. There were increased 1-year liver-related deaths (10% [2/21] vs 0% [0/27], p = 0.10) and complications (29% [6/21] vs 4% [1/27], p = 0.015) in the HAI group compared to the EHAI group. Both HAI and EHAI groups exhibited similar improvements in transaminitis including changes of ALT (-72 U/L vs -112.5 U/L, p = 0.60) and AST (-58 U/L vs -48 U/L, p = 0.56) at 1-month post-procedure. Both treatment arms demonstrated increases in post-procedural peak systolic velocity of the hepatic artery distal to the stenosis, while the HAI group also showed significant improvement in resistive indices following the intervention.ConclusionDirect hepatic artery interventions remain the definitive treatment for clinically significant hepatic artery stenosis; however, non-hepatic visceral artery embolization can be considered a safe alternative intervention in cases of unfavorable hepatic anatomy.Graphical

Intraoperative transcystic laparoscopic common bile duct stone clearance with SpyGlass™ discover during emergency and elective cholecystectomy: a single-center case series

Background and study aimThe development of a new cholangioscope, the SpyGlass™ Discover (Boston Scientific), has allowed the laparoscopic transcystic common bile duct exploration and stone clearance. The possibility of simultaneous treatment of choledocholithiasis during early laparoscopic cholecystectomy offers the opportunity to enormously reduce the time between acute cholecystitis diagnosis and the execution of cholecystectomy with better outcomes for patients. Furthermore, an altered anatomy of the gastrointestinal tract is not an obstacle to this technique. The aim of the study was to determine whether this new procedure is feasible, safe, and effective.Patients and methodsThe investigation employs a retrospective case series study including all consecutive patients with a diagnosis of common bile duct stones undergoing cholecystectomy and intraoperative laparoscopic common bile duct clearance using SpyGlass™ Discover at IRCCS Policlinico San Matteo in Pavia (Italy). Eighteen patients were included from May 2022 to May 2023.ResultsA complete clearance of the common bile duct was obtained in 88.9% of patients. The mean postoperative length of stay was 3 days. No major complications occurred. After a median follow-up of 8 months, no recurrence of biliary events or readmissions occurred.ConclusionThis procedure has proven to be feasible, safe, and effective.

Association between Cholecystectomy and the Incidence of Pancreaticobiliary Cancer after Endoscopic Choledocholithiasis Management.

(1) Background: Previous studies have raised concerns about a potential increase in pancreaticobiliary cancer risk after cholecystectomy, but few studies have focused on patients who undergo cholecystectomy after receiving endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis. This study aims to clarify cancer risks in these patients, who usually require cholecystectomy, to reduce recurrent biliary events. (2) Methods: We conducted a nationwide cohort study linked to the National Health Insurance Research Database, the Cancer Registry Database, and the Death Registry Records to evaluate the risk of pancreaticobiliary cancers. All patients who underwent first-time therapeutic ERCP for choledocholithiasis from 2011 to 2017 in Taiwan were included. We collected the data of 13,413 patients who received cholecystectomy after endoscopic retrograde cholangiopancreatography and used propensity score matching to obtain the data of 13,330 patients in both the cholecystectomy and non-cholecystectomy groups with similar age, gender, and known pancreaticobiliary cancer risk factors. Pancreaticobiliary cancer incidences were further compared. (3) Results: In the cholecystectomy group, 60 patients had cholangiocarcinoma, 61 patients had pancreatic cancer, and 15 patients had ampullary cancer. In the non-cholecystectomy group, 168 cases had cholangiocarcinoma, 101 patients had pancreatic cancer, and 49 patients had ampullary cancer. The incidence rates of cholangiocarcinoma, pancreatic cancer, and ampullary cancer were 1.19, 1.21, and 0.3 per 1000 person-years in the cholecystectomy group, all significantly lower than 3.52 (p < 0.0001), 2.11 (p = 0.0007), and 1.02 (p < 0.0001) per 1000 person-years, respectively, in the non-cholecystectomy group. (4) Conclusions: In patients receiving ERCP for choledocholithiasis, cholecystectomy is associated with a significantly lower risk of developing pancreaticobiliary cancer.

Clinical outcomes after transplantation of domino grafts or standard deceased donor livers: a systematic review and meta-analysis.

Domino liver transplantation (DLT) utilizes otherwise discarded livers as donor grafts for another recipients. It is unclear whether DLT has less favorable outcomes compared to deceased donor liver transplantation (DDLT). We aimed to assess the outcomes of DLT compared to DDLT. MEDLINE, Embase, and Web of Science database were searched to identify studies comparing outcomes after DLT with DDLT. Data were pooled using random-effects modeling, evaluating odds ratios (OR) or mean difference (MD) for outcomes including waiting list time, severe hemorrhage, intensive care unit (ICU), length hospital stay (LOS), rejection, renal, vascular, and biliary events, and recipient survival at 1, 3, 5, and 10years. Five studies were identified including 945 patients (DLT=409, DDLT=536). The DLT recipients were older compared to the DDLT group (P=0.04), and both cohorts were comparable regarding lab MELD, hepatocellular carcinoma, and waitlist time. There were no differences in vascular (OR: 1.60, P=0.39), renal (OR: 0.62, P=0.24), biliary (OR: 1.51, P=0.21), severe hemorrhage (OR: 1.09, P=0.86), rejection (OR: 0.78, P=0.51), ICU stay (MD: 0.50, P=0.21), or LOS (MD: 1.68, P=0.46) between DLT and DDLT. DLT and DDLT were associated with comparable 1-year (78.9% vs 80.4%; OR: 1.03, P=0.89), 3-year (56.2% vs 54.1%; OR: 1.35, P=0.07), and 10-year survival (6.5% vs 8.5%; OR: 0.8, P=0.67) rates. DLT was associated with higher 5-year survival (41.6% vs 36.4%; OR: 1.70; P=0.003) compared to DDLT, which was not confirmed at sensitivity analysis. This meta-analysis of the best available evidence (Level 2a) demonstrated that DLT and DDLT have comparable outcomes. As indications for liver transplantation expand, future high-quality research is encouraged to increase the DLT numbers in clinical practice, serving the growing waiting list candidates, with the caveat of uncertain de novo disease transmission risks.

A study of early laparoscopic cholecystectomy in mild acute gallstone pancreatitis

Abstract Background: Acute pancreatitis, secondary to gallstones, is a challenging situation in terms of decision regarding the timing of surgical intervention. There are studies which show no difference in terms of conversion rate, complication rate, and technical difficulty when timings of laparoscopic cholecystectomy (LC) are performed in acute biliary pancreatitis. The present study is done to evaluate the efficacy, safety, and outcome of early LC in patients of mild gallstone pancreatitis (GP) in index hospital admission. Patients and Methods: A total of 107 patients were included in the study. The patients having mild GP were classified as per Glasgow’s modification of Ranson’s criteria underwent LC in index admission, control group A, in which LC was carried out after interval of 6–8 weeks of discharge and control B group comprised patients of gallstones who do not have pancreatitis. Results: The adhesions were mostly fibrinous in the study group and fibrous in the control A group amounting to increased operating time in the control A group.A2- Increased GB thickness and GB wall edema found in patients of acute cholecystitis in study group amounted lesser chances of GB perforation and spillage of bile, better planes of dissection because of surrounding oedematous tissue and subsequently lesser operating time. No increased intraoperative complications were noted in the study group. The total duration of hospital stay was significantly reduced in the study group. Recurrent hospital admission was observed in the control A group due to other biliary events. Conclusion: LC in the index admission decreases hospital stay and prevents further attacks of pancreatitis in future. Proper selection, categorization of patients, and early operation are not associated with any increased anesthetic and surgical hazard.

Usefulness of intraoperative bile culture in patients with acute calculous cholecystitis with previous biliary events: does the postoperative management change?

The aim of our study wasto determine the usefulness of intraoperative gallbladder cultures in the postoperative course in surgically treated patients with acute calculous cholecystitis and previous biliary events (ACC-PBE). Retrospective unicenter study on surgically treated ACC-patients between January 2014 and December 2018. Clinical benefit was defined as a > 20% change in postoperative antibiotic treatment.Secondary endpoints: postoperative morbidity and length-of-stay (LOS) in ACC-PBE patients with positive intraoperative biliary culture (IBC). Statistical significance was defined as p < 0.05. Out of the initial 711 patients, 203 met the study's inclusion criteria, with 139 of them having IBC results (72 positive, 67 negative). Our analysis revealed no significant difference in the incidence of positive-IBC between patients with ACC-PBE. Among this group, only 6% changed postoperative antibiotic treatment based on IBC results. There were no statistically significant differences in postoperative complications (p: 0.21) or LOS (p: 0.23) in the ACC-PBE group. In multivariate analysis, age > 70years old (p: 0.00; HR 3.1, 95% IC [1.6-6.4]), prior ERCP (p: 0.02; HR 5.9, 95% IC [1.25-27.5]) and prior antibiotic treatment (p: 0.01; HR 3.6, 95% IC [1.32-9.86]) were identified as independent factors that influenced PBC. IBC in operated ACC-PBE do not alter postoperative management. While positive-IBC was associated with age, prior ERCP, and prior antibiotic treatment, these findings did not have a significant impact on postoperative morbidity or LOS.

The rate of biliary adverse events in duct-to-duct living donor liver transplant compared with deceased donor liver transplant

Background and AimsLiving donor liver transplantation (LDLT) allows for decreased listing-to-transplant time in patients with end-stage liver disease (ESLD) but has been noted to be associated with higher rates of biliary adverse events. We aim to assess the adverse events of LDLT and compare to deceased donor liver transplant (DDLT) patients. MethodsWe retrospectively reviewed patients having undergone duct-to-duct anastomosis LDLT at a single center from 2011-2020. Exclusion criteria included pediatric patients and LDLT with Roux-en-Y hepaticojejunostomy. Patients were then matched 1:1 with DDLT. Matching was performed by age, gender, etiology of liver disease, and MELD. Outcomes of interest included incidence of biliary strictures, bile leak, stricture recurrence rate and the number of interventions required for stricture resolution. ResultsFifty patients with LDLT were matched to 50 patients with DDLT. Bile leak occurred in 14 (38%) vs 5 (10%) patients in LDLT and DDLT groups, respectively (p-value 0.001). Biliary strictures occurred in 14(28%) vs 15(30%) patients in LDLT and DDLT groups, respectively (p-value 0.68). There was no difference in the median number of interventions required to resolve the strictures [3 (2-6) vs 4 (3-5), respectively; p-value 0.79]. Three patients in each group had recurrence of strictures after documented resolution. Mortality in both groups were similar [5 (10%) patients in LDLT vs 6(12%) in DDLT (P-value 0.75)]. ConclusionPatients who undergo LDLT were equally as likely to develop anastomotic strictures compared to DDLT. Duct-to-duct anastomosis LDLT should be frequently considered in patients with ESLD with favorable anatomy.

Non-interventional Management of Asymptomatic Diminutive Choledocholithiasis Versus Endoscopic Extraction in Consecutive Patients.

Current guidelines recommend treating choledocholithiasis, regardless of symptoms or stone size, with endoscopic retrograde cholangiopancreatography (ERCP). However, asymptomatic choledocholithiasis, discovered incidentally on imaging, may carry a higher risk of ERCP-related adverse events, and some asymptomatic and diminutive stones may not cause biliary adverse events during extended follow-up. Therefore, we aimed to clarify the best treatment strategies for asymptomatic choledocholithiasis based on stone size. We retrospectively identified patients with incidental imaging-found asymptomatic diminutive (≤ 4mm) or non-diminutive (> 4mm) choledocholithiasis and divided them into two groups: those who did not undergo ERCP and were treated when complications arose (on-demand group) and those who underwent ERCP before being symptomatic (intervention group). Adverse events were defined as any biliary or pancreatic complication related to ERCP or arising during observation or after intervention. The primary outcome was the adjusted overall adverse event-free survival using the propensity score-based matching weights method comparing the two groups of stone size. Among 148 patients identified (median follow-up period, 969days), 68 had diminutive stones and 80 had non-diminutive stones. Of the 68 patients with diminutive stones, 51 were in the on-demand group and 17 in the intervention group. The overall adjusted adverse event-free survival was significantly higher in the on-demand group for diminutive stones (97.4% and 70.1%, respectively, at 3years; p = 0.01). Patients with incidental imaging-detected asymptomatic diminutive choledocholithiasis may benefit from clinical observation, pursuing ERCP when symptoms develop.

Delay for cholecystectomy after common bile duct clearance with ERCP is just running after recurrent biliary event

BackgroundGallstone disease will affect 15% of the adult population with concomitant common bile duct stone (CBDS) occurring in up to 30%. Endoscopic retrograde cholangiopancreatography (ERCP) is the mainstay of management for removal of CBDS, as cholecystectomy for the prevention of recurrent biliary event (RBE). RBE occurs in up to 47% if cholecystectomy is not done. The goal of this study was to evaluate the timing of occurrence of RBE after common bile duct clearance with ERCP and associated outcomes.MethodsThe records of all patients who underwent ERCP for gallstone disease followed by cholecystectomy, in a single center from 2010 to 2022, were reviewed. All RBE were identified. Actuarial incidence of RBE was built. Patients with and without RBE were compared.ResultsThe study population is composed of 529 patients. Mean age was 58.0 (18–95). There were 221 RBE in 151 patients (28.5%), 39/151 (25.8%) having more than one episode. The most frequent RBE was acute cholecystitis (n = 104) followed by recurrent CBDS (n = 95). Median time for first RBE was 34 days. Actuarial incidence of RBE started from 2.5% at 7 days to reach 53.3% at 1 year. Incidence-rate of RBE was 2.9 per 100 person-months. Patients with RBE had significant longer hospitalisation time (11.7 vs 6.4 days; P < 0.0001), longer operative time (66 vs 48 min; P < 0.0001), longer postoperative stay (2.9 vs 0.9 days; P < 0.0001), higher open surgery rate (7.9% vs 1.3%; P < 0.0001), and more complicated pathology (23.8% vs 5.8%; P < 0.0001) and cholecystitis (64.2% vs 25.9%; P < 0.0001) as final diagnoses.ConclusionsRBE occurred in 28.5% of the subjects at a median time of 34 days, with an incidence of 2.5% as early as 1 week. Cholecystectomy should be done preferably within 7 days after common bile duct clearance in order to prevent RBE and adverse outcomes.

Endoscopic Ultrasound-Guided Gastrojejunostomy for Malignant Afferent Loop Syndrome Using a Fully Covered Metal Stent: A Multicenter Experience.

Endoscopic-ultrasound-guided gastrojejunostomy (EUS-GJ) can be a new alternative for patients with malignant afferent loop syndrome (MALS). However, a fully covered self-expandable metal stent (FCSEMS) has not been well investigated in this setting. This is a multicenter retrospective cohort study. Consecutive patients that underwent EUS-GJ using a FCSEMS for MALS between April 2017 and November 2022 were enrolled. Primary outcomes were technical and clinical success rates. Secondary outcomes were adverse events, recurrent symptoms, and overall survival. Twelve patients (median age: 67.5 years (interquartile range: 58-74.8); 50% male) were included. The most common primary disease and type of previous surgery were pancreatic cancer (67%) and pancreatoduodenectomy (75%), respectively. Technical success and clinical success were achieved in all patients. Procedure-related adverse events occurred in one patient (8%) with mild peritonitis. During a median follow-up of 96.5 days, one patient (8%) had recurrent symptoms due to the EUS-GJ stent dysfunction; including biliary events unrelated to the EUS-GJ stent, five patients (42%) had recurrent events. The median overall survival was 137 days. Nine patients (75%) died due to disease progression. EUS-GJ with a FCSEMS seems safe and effective for MALS with high technical and clinical success rates and an acceptable recurrence rate.