Biliary Pancreatitis Research Articles

Etiology of Pancreatitis in Patients at a Tertiary Care Center

Objective: To compare etiological frequencies in patients of acute pancreatitis presenting to our setup with international data.
 Study Design: Cross-sectional study
 Place and Duration of Study: Department of Gastroenterology, Pakistan Emirates Military Hospital & Combined Military Hospital, Rawalpindi Pakistan, from Aug 2020 to Jan 2022.
 Methodology: Patients over 12 years suffering from pancreatitis were recruited using a convenience sampling technique based upon predefined criteria for diagnosis of pancreatitis on a questionnaire. Relevant basic lab tests, including chemistries and imaging, including Ultrasound abdomen and CECT abdomen, were analyzed to establish aetiology. Data were continuously uploaded into an electronic data sheet. International Consensus Diagnostic Criteria (ICDC) algorithms were applied to diagnose autoimmune pancreatitis.
 Results: Out of 120 patients, 74(61.7%) were males, and 46(38.3%) were females. Biliary pancreatitis was the most common aetiology 50(41.7%), followed in descending order by idiopathic 36(30%), drug-induced pancreatitis (DIP) 9(7.5%), Post ERCP Pancreatitis (PEP) 8(6.7%), tumours 5(4%), Autoimmune pancreatitis (AIP), Hypertriglyceridemia and alcohol-induced pancreatitis each 2(1.7%).
 Conclusion: Biliary pancreatitis has the highest frequency, followed by idiopathic and drug-induced pancreatitis.

Epidemiological Features of Acute Pancreatitis (AP): Largest Single-Center, Cohort Study in the Western Region of Saudi Arabia.

Acute pancreatitis (AP) is a medical emergency which can range in severity from a mild, self-limiting condition to a catastrophic event that results in multiorgan failure. This study aimed to evaluate the epidemiological characteristics of AP. This study included all patients diagnosed with AP at King Abdulaziz University Hospital, a tertiary care hospital in Jeddah, Saudi Arabia, between 2017 and 2021. The main aim of this study was to investigate the frequency of AP in patients who present to the hospital with abdominal pain. Secondary objectives included analyzing the causes, complications, severity, and outcomes of the patients. A total of 67 patients were included. AP constituted 11.6% of all cases of patients presenting to the hospital with abdominal pain. Only seven patients presented with severe AP, which was significantly associated with advanced age (over 60 years old). The primary causes of AP were biliary and idiopathic pancreatitis, accounting for 80.6% of the cases. The most frequent complications observed were peripancreatic fluid collection and atelectasis, which occurred in 40.3% of cases. AP is a prevalent condition in patients with abdominal pain, with biliary pancreatitisbeing the leading cause of the disease. The majority of patients exhibited mild to moderate severity of symptoms and experienced positive outcomes when treated appropriately.

Initial values of skeletal muscle parameters in patients presenting with acute pancreatitis

Objective: Predicting the clinical course of acute pancreatitis has been discussed previously on the basis of visceral adipose tissue. This study was conducted to determine the relationship between clinical outcomes of acute pancreatitis and changes in skeletal muscle parameters.
 Method: This is a single-center, cross-sectional, retrospective study. Patients who were diagnosed with acute pancreatitis between 01-28 February 2019 and had abdominal computed tomography (CT) taken in the first week of their hospitalization were included in the study. L3 level of abdominal CT images were used to evaluate skeletal muscle parameters.
 Results: During the hospital database scanning, 127 patients newly diagnosed with acute pancreatitis were included in the study. The median age was 50 (18-88) years, 47% were male, and 53% were female. The median body mass index (BMI) was 26,42 (19.4-46.8) kg/m2. Fifty-one % of patients were diagnosed with biliary acute pancreatitis, and 48.8% were diagnosed with non-biliary acute pancreatitis. At the same time, acute pancreatitis severity was classified according to revised Atlanta criteria, 67.7% were mild (n = 86), 28.3% were moderate (n = 36) and 5 (3.9%) patients were severe. Skeletal muscle mass was evaluated using the total psoas index (TPI) and, skeletal muscle density calculated by HU. Median TPI was 6.3 (2.5-13.7). The median of Hounsfield Unit (HU) average calculation was 18.9 (3.8-28.5) (Table 1). There were no statistically significant differences on sex, age, BMI, skeletal muscle parameters, and acute pancreatitis clinical outcome (Table 2).
 Conclusion: Skeletal muscle parameters determined by TPI and HU were not a predictor of the clinical course, and viewing them always cannot effectively investigate their effect on acute pathologies. So, this way couldn't be proposed as a perfect method for predicting the clinical outcome of acute pancreatitis.

Multiple Choledochan Litiasison of a Case Presentation

Introduction: Choledocholithiasis is the most common cause of bile duct obstruction, occurring in 10-20% of patients with cholecystolithiasis, 7-14% of patients with cholecystectomy, and 18-33% of patients with acute biliary pancreatitis. Objective: To present a case with a giant multiple choledocholithiasis, with good evolution. Clinical Table: Female patient of 57 years of age, mixed race, smoker, hypertensive, with a history of vesicular lithiasis that was operated 28 years ago where initially it is treated by videolaparoscopy but in the transoperative it is determined its conversion to conventional cholecystectomy. The same goes to consultation of the area because it begins with pain in the epigastrium, dyspepsia, urine dark urine and sometimes gray stool for which they indicate a study and assess by the services of gastroenterology, general surgery where the surgical intervention is decided. Initially treated by ERCP and subsequently performed a Choledocholithotomy with placement of Kerh probe. Conclusions: The patient showed a favorable evolution.

Comparative Analysis of the Structure and Function of the Pancreas in Patients with a Combination of Chronic Pancreatitis and Metabolic Syndrome

Metabolic syndrome (MS) is the most urgent problem of modern medicine, which is associated with an unhealthy lifestyle. This is a complex metabolic disorder based on insulin resistance and compensatory hyperinsulinemia. MS is a risk factor for the development of a significant number of various diseases. The objective: to determine the structural and functional state of the liver and pancreatic gland (PG) in patients with chronic pancreatitis (CP) depending on the presence of MS. Materials and methods. 137 patients with CP of biliary genesis (CBP) were included in the study. Patients were divided into two groups: the 1st group – 22 persons with isolated CBP, the 2nd group – 115 patients with CBP+MS. The control group included 20 practically healthy subjects. The age of the study participants ranged from 30 to 71 years. The presence of MS was determined, the state and structure of the PG and liver were examined. Results. A statistically significant higher content of HbA1c was determined in patients with CBP and MS compared to the group of patients with only CBP (6.10±0.14% vs. 5.47±0.15%). A significantly higher blood glucose level was found in the patients with CBP+MS (5.99±0.29 mmol/l vs. 5.31±0.12 mmol/l) compared to patients with CBP. A significantly higher level of the HOMA index was also determined in the group of patients with CBP+MS compared to the CBP group (2.60±0.10 vs.1.84±0.09). A higher level of liver stiffness was found in patients with CBP compared to the control group. The indicator of fecal α-elastase in patients with CBP+MS was 114.52±2.79 mcg/g, which was significantly lower than that in the group of patients with CBP without MS (158.60±5.55 mcg/g). Conclusions. In the presence of MS in patients with chronic biliary pancreatitis, more significant structural disorders in the liver and pancreas were established in the direction of increased density according to shear wave elastometry. The results of the study demonstrated the aggravating effect of concomitant MS on the structural state of the liver and on the structural and functional state of the pancreas in patients with chronic biliary pancreatitis.

Low-phospholipid associated cholelithiasis (LPAC) syndrome: an unusual form in an elderly and overweight woman

BackgroundLow-phospholipid associated cholelithiasis (LPAC) remains an under-diagnosed condition. It can be revealed by complications such as acute cholecystitis, acute angiocholitis and acute pancreatitis. We report a case of acute pancreatitis secondary to LPAC syndrome.Case presentationA 58-year-old woman was hospitalized for recurrent biliary-type abdominal pain after cholecystectomies. The diagnosis of acute biliary pancreatitis revealing a low-phospholipid associated cholelithiasis syndrome was retained after explorations. An abdominal ultrasound performed by an expert radiologist allowed us to confirm the diagnosis of LPAC syndrome, showing a comet tail image along the intrahepatic bile ducts. Ursodeoxycholic acid was started without waiting for the result of the ABCB4 mutation. The outcome was spectacular with complete disappearance of the symptoms after the first week.ConclusionExpert ultrasound remains the key examination for the confirmation of the diagnosis of a low-phospholipid associated cholelithiasis syndrome. It should be requested at the slightest warning signs such as a young age less than 40 years and recurrence of biliary symptoms after cholecystectomy.

A CASE OF INTRAOPERATIVE DISCOVERY OF ABERENT SUBVESICAL BILE DUCT DURING LAPAROSCOPIC CHOLECYSTECTOMY

Introduction. Subvesical bile ducts (Lyushka ducts) are tubular aberrant anatomical anomalies of the biliary tree, in which the intrahepatic bile ducts drain into the lumen of the gallbladder at different levels.
 According to various sources, this variant of the anatomical architecture of the bile ducts occurs in 1.7 - 3% of clinical cases.
 The relevance of knowing the anatomical features of the biliary tree is due to the fact that routine preoperative methods of examination in most cases do not allow to verify them, and unnoticed damage to such courses at the stage of extraction of the bile duct can lead to intraoperative and postoperative complications.
 Therefore, knowledge of the presence of such anatomical options is a condition for safe laparoscopic cholecystectomy (LC).
 Goal. To represent a clinical case of aberrant subvesical bile duct during LC.
 Presentation of a clinical case. The 41-year-old patient was hospitalized for acute biliary pancreatitis of mild severity according to the Ranson scale against the background of gallstone disease. In cooperation with related specialists, the patient underwent complex conservative treatment according to the updated recommendations for the management of acute pancreatitis (AP). After the normalization of basic laboratory indicators, exclusion of local parapancreatic complications, the patient was prepared for LC. Intraoperatively, a subvesical aberrant bile duct with a diameter of 1 mm was found, connecting the lumen of the gallbladder with the intrahepatic ducts of the IV segment of the liver. Coagulation of the bilious source was performed. A diagnostic tubular drainage was installed. No complications were observed in the early and late postoperative period.
 Discussion. Subvesical bile ducts, or "Lyushka's ducts" - anatomical variants of biliary tracts that flow directly into the gallbladder, perforating its wall at different levels.
 The etiology of Lyushka's movements is a subject of debate. The first theory describes them as an embryological abnormality of development in the early stages of embryogenesis. In our clinical case, it is quite likely that subvesical bile ducts could have arisen according to the second theory - hypertrophy of parenchymal branches as a result of previous local inflammation against the background of chronic cholecystitis and periodic exacerbation of cryptogenic hepatitis.
 Due to their small size, these movements can go unnoticed, causing various postoperative complications. Therefore, such ducts are of great clinical importance for surgeons. Their preoperative identification is often impossible, so they can be damaged intraoperatively.
 Bile leakage due to damage to aberrant ducts usually manifests itself clinically within the first postoperative week. In severe cases, the development of biliary peritonitis with subsequent sepsis is possible.
 In our case, cholelithiasis from the subvesical course was eliminated by coagulation. In cases of postoperative complications, according to the literature, endoscopic methods are the main method of treatment. A repeat laparotomy is very rarely necessary.
 Conclusions. Aberrant subvesical bile ducts are extremely rare and may be overlooked during hepatobiliary operations. Their damage occurs at the stage of separation of the ZHM from its bed and is therefore inevitable. Knowledge of their existence, intraoperative vigilance and delicate surgical technique allow to identify and timely prevent the development of complications.

An unusual complication of acute biliary pancreatitis: an incidental discovery of hemobilia.

Hemobilia is a rare cause of upper gastrointestinal (GI) bleeding, which is often due to abdominal trauma; infectious or tumoral causes, and portal biliopathy or cholangiovascular fistulas (venous or arterial) have also been described [1]. Hemobilia is most often manifested by right hypochondrial pain, jaundice, and GI bleeding. Its management is mainly based on endoscopy and interventional radiology [2] [3], with surgical management used after failure of both techniques.

Predictive model of persistent choledocholithiasis in patients with acute biliary pancreatitis.

Choledocholithiasis causing acute biliary pancreatitis (ABP) may migrate to the duodenum or persist in the common bile duct (CBD). We developed a model for predicting persistent choledocholithiasis (PC) in patients with ABP. This retrospective cohort study included 204 patients, age ≥18 years (mean age: 73 years, 65.7% women), admitted for ABP in 2013-2018, with at least a magnetic resonance cholangiopancreatography (MRCP), endoscopic ultrasonography (EUS), and/or endoscopic retrograde cholangiopancreatography (ERCP). Epidemiological, analytical, imaging, and endoscopic variables were compared between patients with and without PC. Multivariate logistic regression analyses were performed to develop a predictive model of PC. Patients underwent MRCP (n=145, 71.1), MRCP and ERCP (n=44, 21.56%), EUS and ERCP (n=1, 0.49%), or ERCP (n=14, 6.86%). PC was detected in 49 patients (24%). PC was strongly associated with CBD dilation, detected in the emergency ultrasound (p<0.001; OR=27; 95% CI: 5.8-185.5), increased blood levels of gamma glutamyl transpeptidase, detected at 72h (p=0.008; OR=3.4; 95% CI: 1.5-8.9); and biliary sludge in the gallbladder (p=0.008; OR=0.03; 95% CI: 0.001-0.3). The predictive model showed a validated area under the curve (AUC) of 0.858 for detecting PC in patients with ABP. A nomogram was developed based on model results. The predictive model was highly effective in detecting PC in patients with ABP. Therefore, this model could be useful in clinical practice.

Predictive model of persistent choledocholithiasis in patients with acute biliary pancreatitis

Choledocholithiasis causing acute biliary pancreatitis (ABP) may migrate to the duodenum or persist in the common bile duct (CBD). We developed a model for predicting persistent choledocholithiasis (PC) in patients with ABP. This retrospective cohort study included 204 patients, age ≥18 years (mean age: 73 years, 65.7% women), admitted for ABP in 2013–2018, with at least a magnetic resonance cholangiopancreatography (MRCP), endoscopic ultrasonography (EUS), and/or endoscopic retrograde cholangiopancreatography (ERCP). Epidemiological, analytical, imaging, and endoscopic variables were compared between patients with and without PC. Multivariate logistic regression analyses were performed to develop a predictive model of PC. Patients underwent MRCP (n = 145, 71.1), MRCP and ERCP (n = 44, 21.56%), EUS and ERCP (n = 1, 0.49%), or ERCP (n = 14, 6.86%). PC was detected in 49 patients (24%). PC was strongly associated with CBD dilation, detected in the emergency ultrasound (p < 0.001; OR = 27; 95% CI: 5.8–185.5), increased blood levels of gamma glutamyl transpeptidase, detected at 72 h (p = 0.008; OR = 3.4; 95% CI: 1.5–8.9); and biliary sludge in the gallbladder (p = 0.008; OR = 0.03; 95% CI: 0.001–0.3). The predictive model showed a validated area under the curve (AUC) of 0.858 for detecting PC in patients with ABP. A nomogram was developed based on model results. The predictive model was highly effective in detecting PC in patients with ABP. Therefore, this model could be useful in clinical practice. La coledocolitiasis que provoca una pancreatitis aguda biliar (PAB) puede migrar al duodeno o persistir en el conducto biliar común (CBC). Desarrollamos un modelo para predecir la coledocolitiasis persistente (CP) en pacientes con PAB. Este estudio de cohortes retrospectivo incluyó a 204 pacientes, edad ≥ 18 años (edad media: 73 años, 65,7% mujeres), ingresados por PAB entre los años 2013 y 2018, a los que se les realizó al menos una colangiopancreatografía por resonancia magnética (CPRM), una ultrasonografía endoscópica (USE) o una colangiopancreatografía retrógrada endoscópica (CPRE). Se compararon variables epidemiológicas, analíticas, de imagen y endoscópicas entre pacientes con y sin CP. Se realizaron análisis de regresión logística multivariante para desarrollar un modelo predictivo de CP. Los pacientes se sometieron a CPRM (n = 145, 71,1%), CPRM y CPRE (n = 44, 21,56%), USE y CPRE (n = 1, 0,49%) o CPRE (n = 14, 6,86%). Se detectó CP en 49 pacientes (24%). La CP se asoció fuertemente con la dilatación del colédoco, detectada en la ecografía de urgencias (p < 0,001; OR = 27; IC del 95%: 5,8-185,5), aumento de los niveles sanguíneos de gamma glutamil transpeptidasa, detectados a las 72 h (p = 0,008; OR = 3,4, IC del 95%: 1,5-8,9), y barro biliar en la vesícula (p = 0,008; OR = 0,03; IC del 95%: 0,001-0,3). El modelo predictivo alcanzó un área bajo la curva validada de 0,858 para la detección de CP en pacientes con PAB. Se desarrolló un nomograma basado en los resultados del modelo. El modelo predictivo fue altamente efectivo en la detección de CP en pacientes con PAB. Por lo tanto, este modelo podría ser útil en la práctica clínica.

Retrospective Analysis of Characteristics, Indications and Outcomes of Endoscopic Retrograde Cholangiopancreatography (ERCP) in a Tertiary Referral Center in Saudi Arabia.

Endoscopic retrograde cholangiopancreatography (ERCP) is an advanced endoscopic procedure that is an essential tool in the management of pancreaticobiliary diseases. There is limited data available on the indications and outcomes of ERCP from this region. Therefore, we aim to report the characteristics of patients, indications and outcomes of ERCP in Saudi Arabia. Methods: We retrospectively looked at ERCP procedures done at a tertiary referral center covering the western region of Saudi Arabia from August 2018 until July 2020. Data were collected from the hospital's electronic patient record and endoscopy database. Of 1001 ERCPs performed, full data was available on 712 procedures on 581 patients that were included in the final analysis. Mean age was 53.1 years. Four hundred four (56.7%) were female. Board-certified consultants performed all ERCPs. The most common intervention was sphincterotomy, which was performed in 563(96.9%) patients who underwent first-ever ERCP, followed by dilatation and stenting. The commonest indication of ERCP was confirmed or suspected choledocholithiasis (52.6%), followed by replacement or removal of a biliary stent (15.7%), 55 (7.7%) for suspected ascending cholangitis, 54 (7.5%) for acute biliary pancreatitis and 15 (2%) for suspected sphincter of Oddi dysfunction. The commonest finding among all patients was choledocholithiasis in 57.9%, debris in 15.2% and biliary stricture in 14.8%. The commonest complication was pancreatitis in 22(3.1%) followed by post-sphincterotomy bleeding in 16(2.2%) and perforation in nine (1.2%). Bleeding was controlled by endoscopic intervention in four (25%) and one (6.2%) patient underwent surgery. One (0.14%) patienthad procedure-related mortalitysecondary to post-procedure pulmonary embolism and one had significant morbidity and prolonged hospitalization because of complicated perforation. The deeper common bile duct (CBD) cannulation rate was 97.3%. Our study results revealed that ERCP performed in the western region of Saudi Arabia has similar indications and findings as reported in theinternational literature. ERCP is successful in achieving the therapeutic objectives with complication rates consistent with published data.

The predictivity of serum biochemical markers in acute biliary pancreatitis

Acute pancreatitis (AP) is the most common gastrointestinal disease requiring hospital admission. Among the etiology of AP gallstones (45%) and alcohol abuse (20%) are the most frequent causes of AP. Sixty-nine patients of AP who met the inclusion criteria were evaluated from July 2021- June 2022. The predictivity of serum biochemical marker alanine transaminase (ALT) in acute biliary pancreatitis and the mean serum biochemical markers (ALT, aspartate transaminase, alkaline phosphatase, bilirubin, amylase and lipase level) in AP were evaluated. Total 69 patients with the diagnosis of AP were included. Forty-six (66.7%) were male and twenty-three (33.3%) were female out of which 12 (17.3%) were diagnosed as biliary pancreatitis and 57 (82.7%) had non-biliary pancreatitis. In non-biliary pancreatitis there were 41 male and 16 females. Non-biliary pancreatitis was more common in male and biliary pancreatitis was more common in female. There was no significant difference in mean levels of amylase in biliary and non-biliary pancreatitis (i.e. in non-biliary pancreatitis; mean ± SD = 387.14 ± 419.53, in biliary pancreatitis mean ± SD = 535.5 ± 533.51, p-value= 0.235 &gt;0.05), the mean lipase was not significantly different in biliary and non-biliary pancreatitis (i.e.in non biliary pancreatitis; mean ± SD=1287.75±894.37, in biliary pancreatitis mean ± SD =1666.41 ± 1150.47, p-value =0.289 &gt; 0.05). There was a significant difference seen among the mean levels of all other parameters (Bilirubin T&amp;D, ALT, AST and ALP) the mean was found to be significant in biliary and non-biliary pancreatitis (i.e. p-value=0.000&lt;0.05). Liver function test mainly ALT may predict biliary etiology of AP.

A291 CLINICAL OUTCOMES IN PATIENTS WITH MODERATE TO SEVERE PANCREATITIS AND PANCREATIC COLLECTIONS: A RETROSPECTIVE COHORT STUDY

Abstract Background Necrotizing pancreatitis occurs in approximately 20% of patients with pancreatitis and is associated with significant morbidity and mortality. Drainage of pancreatic collections is critical when there is associated infection but is also indicated in patients with biliary or gastric outlet obstruction or symptoms. Drainage strategies include percutaneous, endoscopic ultrasound (EUS) guided, and surgical. Data suggests that a step-up approach starting with EUS or percutaneous drainage is associated with lower mortality and morbidity at 3-6 months in comparison to surgery. Little is known about risk factors for pancreatic necrosis and long-term outcomes in patients with pancreatic collections, specifically those with necrotic collections. Purpose To improve knowledge about risk factors and long-term outcomes in patients with pancreatic collections. The primary objective was to compare mortality between patients with and without early necrotic collections. Secondary outcomes included ICU stay, recurrent collections and repeated interventions during follow-up. Method This was a retrospective cohort study of consecutive adults (&amp;gt; 18 years) with moderate to severe acute pancreatitis as per the Atlanta Criteria, admitted to a tertiary care centre in Ontario between January 2002 and January 2019 with radiological evidence of early pancreatic collections. Patients were identified using administrative codes and imaging reports from the Hospital’s data warehouse. Descriptive statistics were used. Comparisons between groups were made with chi-square and logistic regression for categorical variables. Result(s) 723 patients were identified and 276 were included in this report. The mean age was 54.5 years (SD 16) and 109 (39.5%) were females. The most common comorbidities were diabetes (33.3%), hypertension (38.4%) and obesity (14.8%). The most common pancreatitis etiologies were biliary (34.4%) alcohol misuse (17.0%) and post-ERCP pancreatitis (7.1%). Eighty-five (30.8%) patients were diagnosed with early necrotic collections and 53 (19.2%) with peri-pancreatic fluid collections during the initial 30 days of follow-up. Drainage was performed in 100 (36.2%) patients. Patients with necrotic collections were most likely to be obese (29.4% vs. 8.4%, P &amp;lt;0.001), have biliary pancreatitis (50.6% vs. 27.2%), require drainage of the collection (63.5% vs. 24.1%, P &amp;lt; 0.001), ICU stay (62.3% vs. 33.5%, P &amp;lt;0.001) and develop new collections during follow up (0% vs. 20.1%, P=0.04). Sixty-one (22.1%) patients died during a median follow up of 727 days (IQR 87-2042) and there were no differences between subgroups. Conclusion(s) Patients with pancreatic necrotic collections seem to have a more severe clinical course requiring ICU stay and interventions for drainage of the collection(s). Necrotic collections are more commonly seen in patient with biliary pancreatitis and obesity. No all-cause mortality differences were seen between groups during follow up. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

Patient selection for urgent endoscopic retrograde cholangio-pancreatography by endoscopic ultrasound in predicted severe acute biliary pancreatitis (APEC-2): a multicentre prospective study

ObjectiveRoutine urgent endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic biliary sphincterotomy (ES) does not improve outcome in patients with predicted severe acute biliary pancreatitis. Improved patient selection for ERCP by means...

Effect of Frailty on the Management of Suspected Choledocholithiasis.

The American Society for Gastrointestinal Endoscopy and The Society of American Gastrointestinal and Endoscopic Surgeons (ASGE-SAGES) guidelines for managing choledocholithiasis (CDL) omit patient-specific factors like frailty. We evaluated how frail patients with CDL undergoing same-admission cholecystectomy were managed within ASGE-SAGES guidelines. We analyzed patients undergoing same-admission cholecystectomy for CDL and/or acute biliary pancreatitis (ABP) from 2016 to 2019 at 12 US academic medical centers. Patients were grouped by Charlson comorbidity index into non-frail (NF), moderately frail (MF), and severely frail (SF). ASGE-SAGES guidelines stratified likelihood of CDL and were used to compare actual to suggested management. Rate of guideline deviation was our primary outcome. Secondary outcomes included rates of surgical site infections (SSIs), biliary leaks, and 30-day surgical readmissions. Rates are presented as NF, MF, and SF. Among 844 patients, 43.3% (n = 365) were NF, 25.4% (n = 214) were MF, and 31.4% (n = 265) were SF. Frail patients were older (33y vs 56.7y vs 73.5y, P < .0001) and more likely to have ABP (32.6% vs 47.7% vs 43.8%, P = .0005). As frailty increased, guideline deviation increased (41.1% vs 43.5% vs 53.6%, P < .006). Severe frailty was predictive of guideline deviation compared to MF (aOR 1.47, 95% CI 1.02-2.12, P = .04) and NF (aOR 1.46, 95% CI 1.01-2.12, P = .04). There was no difference in SSIs (P = .2), biliary leaks (P = .7), or 30-day surgical readmission (P = .7). Frail patients with common bile duct stones had more management deviating from guidelines yet no difference in complications. Future guidelines should consider including frailty to optimize detection and management of CDL in this population.

Establishment and validation of a predictive nomogram for the risk of premalignant lesions in children with choledochal cyst.

Choledochal cyst (CDC) increases the risk (2.5%-30%) of malignancy. Metaplasia and dysplasia have been recognized as premalignant lesions among CDCs. This study aimed to evaluate the risk factors of metaplasia and dysplasia in CDC children. Two hundred and ten CDC children who underwent cyst excision and Roux-en-Y hepaticojejunostomy at our institution between July 2020 and November 2021 were included and randomly divided into the training set andvalidation set. Univariate and multivariate logistic regression analysis were used to identify independent risk factors of premalignant lesions in the training set and build a predictive nomogram. The performance and discriminatory abilities of the nomogram were further assessed and validated in the validation set. Of the 210 CDC children, 78 (37.1%) patients developed premalignant lesions. Age (OR, 1.011, 95%CI, 1.000-1.022, P = 0.046), symptoms duration (OR, 1.021, 95%CI, 1.001-1.042, P = 0.036), cyst diameter (OR, 1.737, 95%CI, 1.328-2.273, P < 0.001), recurrent attacks of biliary pancreatitis (OR, 3.653, 95%CI, 1.205-11.076, P = 0.022), and biliary operation history (OR, 5.860, 95%CI, 1.268-27.084, P = 0.024) were identified as independent risk factors. Based on these predictors, a predictive nomogram was generated. The AUC of the nomogram was 0.873 in the training set and 0.793 in the validation set, indicating that it was robust and well calibrated. A novel nomogram to the individualized risk of premalignant lesions in CDC children was successfully built, on the basis of age, symptoms duration, cyst diameter, recurrent attacks of biliary pancreatitis, and biliary operation history. This nomogram, combined with the final pathological results, can help clinicians to develop more efficient follow-up strategies for the high-risk children with CDC.

Association between smoking status and inpatient outcomes of acute cholangitis in the United States: a propensity matched analysis.

Acute cholangitis (AC) is an infection of the biliary tract superimposed on stasis. This study aimed to investigate the effects of smoking on inpatient outcomes of AC. We identified primary AC hospitalizations using the National Inpatient Sample database (2017-2020). Using a 1:1 matching method, we created a matched comparison cohort of AC patients who were non-smokers, based on demographics, hospital characteristics and comorbidities. We matched 3960 smoker patients with 3960 non-smoker patients within the AC population. Non-smokers were older than smokers (70 vs. 59 years, P<0.001). Smokers had a stronger association with bile duct calculi (74.37% vs. 69.29%, P<0.001) and other bile duct disorders (clots, parasites, extrinsic compression and other rare disorders) (6.82% vs. 5.05%, P=0.011). No significant difference in inpatient mortality, median length of stay (LOS), or median inpatient cost (MIC) was found between the matched cohorts (P>0.05). However, smoking was associated with higher odds of complications, including sepsis without shock (0.88% vs. 0.51%, P=0.042), sepsis with shock (1.26% vs. 0.51%, P<0.001), biliary pancreatitis (6.57% vs. 4.42%, P<0.001) and myocardial infarction (6.19% vs. 3.54%, P<0.001), as well as a greater need for inpatient endoscopic retrograde cholangiopancreatography (ERCP) (72.85% vs. 63.76%, P<0.001) and early ERCP (50.76% vs. 42.32%, P<0.001) compared to non-smokers. This study found no difference in mortality, LOS, or MIC in acute cholangitis-related hospitalizations associated with smoking. However, smoking was associated with a higher risk of complications and a greater need for ERCP and early ERCP.

Outcomes of Early Vs. Delayed Laparoscopic Cholecystectomy in Acute Biliary Stone-Induced Pancreatitis a Prospective Observational Study

Objective: This study aims to compare the outcomes of early and delayed laparoscopic cholecystectomy in patients with acute biliary stone-induced pancreatitis Methods: this prospective observational stusy conducted in department of surgery hmc Peshawar From January 2015 to December 2019, 200 patients (100) (50%) male and 100(50%) female) with acute biliary stone-induced pancreatitis underwent laparoscopic cholecystectomy. Hospital E.M.R.s provided patient data. Laparoscopic cholecystectomy was performed early (before 72 hours) or delayed (beyond 72 hours). Complications and death were crucial outcomes. Recovery, hospitalization, and postoperative discomfort were secondary outcomes. Chi-square and t-tests analyzed data. Results: 200 patients were evaluated with a median age of 45 (IQR=35-56) years. 43 (21.5%) patients had difficult dissection. The median operative time was 46 (IQR=37-55) minutes, while the median hospital stay was 8 (IQR=5-8) days. 65(32.5%) patients had drain placement. Only minor complications were seen in 22 (11%) patients. Furthermore, most of the patients in the gallbladder group, i.e., 90.5%, had complete recovery, while the mortality rate was also meager, i.e., 0.45%. Early laparoscopic cholecystectomy had a reduced incidence of complications (p&lt;0.05), shorter inpatient time (p&lt;0.001), and quicker recovery time than delayed surgery. Both groups had similar death rates (p=0.070). Early laparoscopic cholecystectomy reduced discomfort (p&lt;0.001). Conclusion: This research suggests that early laparoscopic cholecystectomy for acute biliary stone-induced pancreatitis is safe and effective. Early laparoscopic cholecystectomy reduces postoperative discomfort, hospitalization, and complications. Keywords: Early Laparoscopic Cholecystectomy, Acute Biliary Stone, Delayed Laparoscopic Cholecystectomy, Pancreatitis, Biliary Tract Diseases.

Survey on initial management of acute pancreatitis in Latin America

ObjectiveThe population of Latin America harbors the highest incidence of gallstones and acute biliary pancreatitis, yet little is known about the initial management of acute pancreatitis in this large geographic region. Participants and methodsWe performed a post hoc analysis of responses from physicians based in Latin America to the international multidisciplinary survey on the initial management of acute pancreatitis. The questionnaire asked about management of patients during the first 72h after admission, related to fluid therapy, prescription of prophylactic antibiotics, feeding and nutrition, and timing of cholecystectomy. Adherence to clinical guidelines in this region was compared with the rest of the world. ResultsThe survey was completed by 358 participants from 19 Latin American countries (median age, 39 years [33–47]; women, 27.1%). The proportion of participants in Latin America vs. the rest of the world who chose non-compliant options with clinical guidelines were: prescription of fluid therapy rate other than moderate (42.2% vs 34.3%, P=.02); prescription of prophylactic antibiotics for severe (10.6% vs 18.0%, P=.002), necrotizing (28.5% vs 36.9%, P=.008), or systemic inflammatory response syndrome-associated (21.2% vs 30.6%, P=.002) acute pancreatitis; not starting an oral diet to patients with oral tolerance (77.9% vs 71.1%, P=.02); and delayed cholecystectomy (16.2% vs 33.8%, P<.001). ConclusionsSurveyed physicians in Latin America are less likely to prescribe antibiotics and to delay cholecystectomy when managing patients in the initial phase of acute pancreatitis compared to physicians in the rest of the world. Feeding and nutrition appear to require the greatest improvement.

Frailty Is Independently Associated with Higher Mortality and Readmissions in Patients with Acute Biliary Pancreatitis: A Nationwide Inpatient Study.

Acute pancreatitis is the most common gastrointestinal cause of hospital admissions in the United States of which biliary or gallstone disease is the most common inciting factor. Estimate the effects of frailty on burden, costs, and causes for hospitalization in patients with acute biliary pancreatitis. We analysed the Nationwide Readmission Database from 2016 to 2019 for patients with acute biliary pancreatitis. Patients were categorized into two groups, frail and non-frail, based on the Hospital Frailty Risk Score. Logistic and Cox regression were used to predict the impact of frailty on 30-day readmission, length of stay, mortality, and costs. 162,202 index hospitalizations with acute biliary pancreatitis without cholangitis were identified, of whom 59.2% (n = 96,045) were female and 22.49% (n = 36,475) were classified as frail. Readmissions within 30days were higher among frail patients (12.58% vs 7.09%, P < 0.001) compared to non-frail patients, respectively. Regression modeling showed that frail patients had higher odds of readmission (OR 1.32; 95% CI 1.24-1.42, P < 0.001), longer lengths of stay (8.18days vs 4.11days), and higher average costs of hospitalization ($21,511 vs $12,261) compared to non-frail patients, respectively. Cox regression showed that frail patients had a higher risk of mortality (HR 5.43; 95% Cl 4.06-7.29, P < 0.001) compared to non-frail patients, respectively. Frailty is independently associated with higher mortality and burden of healthcare utilization in patients with acute biliary pancreatitis. We suggest using the Hospital Frailty Risk Score as part of the treatment algorithm in patients with acute biliary pancreatitis.