Biliary Stone Disease Research Articles

Prophylactic cholecystectomy is not mandatory in patients candidate to the resection for small intestine neuroendocrine neoplasms: a propensity score-matched and cost-minimization analysis

To evaluate two competitive strategies in patients undergoing resection of Small-intestine neuroendocrine neoplasms (Si-NEN): prophylactic cholecystectomy (PC) versus On-demand delayed (OC) cholecystectomy. None comparative studies are available. This is a retrospective study based on 247 Si-NENs candidates for the primary tumor resection. Patients were divided into two arms: PC and OC. Propensity score matching was performed, reporting the d value. The primary outcome was the rehospitalization rate for any cause. The secondary endpoints were: the rehospitalization rate for biliary stone disease (BSD), the mean number of rehospitalization (any cause and BSD), the complication rate (all and severe). A P value < 0.05 was considered significant, and the number needed to treat (NNT) < 10 was considered clinically relevant. Before matching, 52 (21.1%) were in the PC arm and 195 (78.9%) in the OC group. The two arms have a sub-optimal balance for age (d = 0.575), symptoms (d = 0.661), ENETS TNM stage (d = 0.661). After matching, we included 52 patients in PC and 104 in OC one. The two groups are well balanced (all d values < 0.5). The rehospitalization rate was similar in the two groups (36% vs 31; P = 0.594; NNT = 21). The rehospitalization rate for BSD was lower in the PC arm than OC one (0% vs 7%) without statistical significance (P = 0.096) and relevance (NNT = 15). The mean number of readmission (any cause and BSD) and the complication rate (all and severe) were similar. PC was not mandatory in patients having Si-NEN and candidates to the resection of primary tumors.

Superficial surgical site infections following stone and non-stone bile duct surgery- A comparative analysis

Background : Superficial surgical site infection (SSSI) is a vital issue after biliary surgery. Surgical site infections remain a major cause of illness in the post-operative period.&#x0D; Objectives : The purpose of the present study was to compare the number of wound infection and the causative organism of surgical site infection of patient of stone and non-stone bile duct surgery.&#x0D; Methodology : This cross-sectional study was carried out in the Department of Surgery at Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka from May 2017 to April 2018 for a period of 12 months. Patients presented with biliary disease of stone and non-stone variety were selected as study population. Patients were divided into 2 groups designated as group A and group B. Patients with the biliary stone disease were enrolled in group A and the biliary nonstone disease patients were in the group B. Patients were followed up in the postoperative period up to 2 weeks to find out the incidence of wound infection and its risk factors, causative agents, and some other variables. Certain variables were closely monitored to find the postoperative outcome as these variables were standard parameters in assessment of the outcome of the study.&#x0D; Results : A total number of 50 patients were recruited for this study of which 25 patients were enrolled in group A and the 25 patients were enrolled in group B. Mean age was 42.48 ± 17.21 years in group A and 40.04 ± 21.37 years in group B. The difference was not statistically significant ( p=0.659). Males were predominant in both groups. Male female ratio was 1.77:1 and 1.08:1 in group A and group B respectively. Inflammatory evidence of gall bladder with pericholecystic collection was found in 5 (20%) and 6 (24%) patients in group A and group B. There was evidence of cholangitis in 8 (32%) and 4 (16%) patients in group A and group B respectively. Evidence of inflammation at the wound site, was found in 14 (56%) patients in group A and 7 (28%) patients in group B. There was statistically significant difference between these 2 groups in the incidence of superficial surgical site infection, ( p value is 0.045). Regarding per operative collected bile, we found E. Coli in 4 cases in group A and 3 cases in group B ( p value is 0.408). Klebsiella spp. was found in 1 patient in group A. Wound swab C/S identified E. Coli in 1 patient in group A. Staph aureus was found in 1 and 2 patients in group A and group B respectively ( p value is nonsignificant).&#x0D; Conclusion : In conclusion, there is a difference in the incidence of occurrence of surgical site infection and causative agents after stone and non-stone bile duct surgery. Stone disease has increased chance of wound infection than nonstone disease of bile ducts.&#x0D; Northern International Medical College Journal Vol.11 (2) Jan 2020: 458-462

Demographics and risk factors for pediatric recurrent acute pancreatitis.

Approximately 20-30% of children who experience one episode of acute pancreatitis will have at least one additional episode. For some children, pancreatitis recurs multiple times and in a few years is followed by the diagnosis of chronic pancreatitis. Identifying risk factors for recurrent episodes and disease progression is critical to developing therapeutic interventions. Obesity is driving an increase in biliary stone disease and severe acute pancreatitis. Recurrent acute pancreatitis (RAP) may lead to the development of diabetes through autoimmune mechanisms. Cystic fibrosis or CFTR-related disorders may present as RAP and CFTR modulator therapy can increase or decrease the risk of acute pancreatitis in these populations. Children with Crohn disease have a three-fold risk of acute pancreatitis over the general population while children with ulcerative colitis are at increased risk for pediatric autoimmune pancreatitis, a disorder that may be distinct from autoimmune pancreatitis described in adults. Obstructive jaundice in the absence of identified mechanical factors may be a presenting sign of pediatric autoimmune pancreatitis. Pediatric RAP is a painful condition that leads to gland destruction and functional insufficiency. Risk factors are being clarified but preventive treatments remain elusive.

ID: 3522841 THE ROLE OF DIGITAL SINGLE-OPERATOR CHOLANGIOSCOPY-GUIDED HOLMIUM LASER LITHOTRIPSY TO MANAGE COMPLEX INTRA- AND EXTRA-HEPATIC BILIARY STONE DISEASE

Digital single-operator cholangioscopy (D-SOC) aids the access and management of complex biliary stones and strictures. We aimed to evaluate the efficacy and safety of D-SOC-guided Holmium laser lithotripsy (LL) to manage complex intra- and extra-hepatic biliary stone disease.

Treatment of acute cholecystitis in high-risk surgical patients.

Acute cholecystitis (AC) is the most common biliary stone disease complication. While there is consensus regarding cholecystectomy for AC, gallbladder drainage is indicated in elderly or high-risk surgical patients. We systematically reviewed available evidence in the field of EUS-guided gallbladder drainage (EUS-GBD) for AC in high-risk surgical patients. The studies were classified according to their level of evidence (LE) according to the Oxford Centre for Evidence Based Medicine classification. Literature search retrieved 175 manuscripts; most of them were expert opinions (LE V, N.=53) or case-series (LE IV, N.=29). There was no meta-analysis of RCT (LE Ia), while two randomized controlled trials (LE Ib) demonstrated that EUS-GBD was superior to percutaneous transhepatic-GBD (PT-GBD) regarding long-term outcomes (adverse events, recurrent cholecystitis, and reintervention). Several meta-analyses of cohort studies (LE IIa, N.=11) were designed to compare the three available drainage strategies (endoscopic, echoendoscopic and percutaneous) and to assess the pooled risk of adverse events. Comparison between surgery and EUS-GBD was done in a single retrospective study with a propensity score analysis (LE III). The outcomes of conversion from PT-GBD to EUS-GBD were covered by few retrospective studies (LE III). Several manuscripts (N.=69) were published on EUS-GBD as a rescue strategy in case of malignant biliary obstruction. The levels of evidence of EUS-GBD in the literature have evolved from initial descriptive studies to recent randomized controlled trials and meta-analysis of cohort studies. While several articles addressed the comparison among different techniques for GBD, in our opinion some topics and questions have not been adequately investigated. are still debated.

The role of routine thyroid assay in the management of gallstones

Cholelithiasis is a type of biliary stone disease, with a high prevalence. Along with classic risk factors like obesity, weight loss, female sex hormones, age, an association with thyroid dysfunction has been established.To evaluate the importance of thyroid profile as a diagnostic/therapeutic workup of gallstones.The study included 200 subjects, above 18 years. 100 subjects (50 males+50 females) had cholelithiasis confirmed by ultrasonography and remaining as 100 subjects(50males+50females) control group without gallstones. After a detailed history and clinical examination, blood samples were analyzed for TSH, T3 and T4, using Chemiluminescence-Immunoassay. Subjects with history of thyroid dysfunction or on thyroid replacement therapy, diabetes mellitus, pregnancy, drugs affecting thyroid hormone levels were excluded.Computing descriptive statistics was used. Any significant difference were tested using the unpaired sample student t-test.The case group had a mean age of 45.70 ± 13.76 and the controls, a mean age of 38.78 ± 15.63. There was a significant increase in the prevalence of gallstones after the age of 40years, especially in females. 20% of cases were hypothyroid and 12% were hyperthyroid when compared to the controls which were 10% hypothyroid and 6% hyperthyroid. The higher prevalence of hypothyroid among cases was statistically significant. Among the hypothyroid cases, 80% had subclinical hypothyroidism.Our study concludes by saying that thyroid assay could be made a part of the diagnostic work up of gallstone management thus providing early detection for thyroid dysfunction and thus reducing the surgical/anesthetic complications.

Complications of Endoscopic Retrograde Cholangiopancreatography in Patients With Previous Bariatric Surgery: A National Inpatient Sample Analysis, 2007-2013.

Bariatric surgery (BS) has been proven to be effective in the treatment of obesity and weight-related diseases, but the anatomic changes after BS make endoscopic retrograde cholangiopancreatography (ERCP) technically challenging. This study aims to assess the safety and clinical outcomes of ERCP in patients with previous BS. The National Inpatient Sample from 2007 to 2013 was queried for hospitalizations of adults over 18 years of age with procedure diagnoses of ERCP. Those with prior BS were selected as cases and those without BS as controls. Case-control matching at a ratio of 1 case to 2 controls was performed based on sex, age, race, comorbidities, and obesity. The primary outcomes were inpatient mortality and ERCP-related complications. Multivariate regression analysis was used to identify independent risk factors associated to the primary outcomes. A total of 1,068,862 weighted hospitalizations with ERCP procedure codes were identified. Of these, 6689 with BS were selected as cases, and 13,246 were matched as controls. The reason for hospital admission was most often biliary stone disease (60.7% vs. 55.5%), followed by malignancy (3.5% vs. 12.1%) and cholangitis (7.7% vs. 4.5%) with and without BS, P<0.05. The BS group had lower rates of post-ERCP pancreatitis (0.1% vs. 1.3%), cholecystitis (0.1% vs. 0.3%), bleeding (1.0% vs. 1.4%), and inpatient mortality (0.2% vs. 0.5%), but had higher rates of cholangitis (5.0% vs. 3.7%) and systemic infections (6.2% vs. 4.8%), all P<0.05. BS group had lower post-ERCP pancreatitis, cholecystitis and bleeding while had more cholangitis, and systemic infection compared with those without BS. Also, BS was independently associated with reduced inpatient mortality after adjusted for age, race, and comorbidity.

Long-term Follow-up of Patients Undergoing Endoscopic Intervention for Abdominal Pain with Minimal Biliary Ductal Dilation, Stone Disease, or Malignancy.

Safety and efficacy of endoscopic methods in management of biliary colic after cholecystectomy in patients with minimal biliary ductal dilation and no evidence of biliary stones or malignancy have not been clearly demonstrated. This study aimed to assess the efficacy of endoscopic management of such patients. The University of Louisville database was queried for patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) for colicky abdominal pain between 1996 and 2016 who had a common bile duct (CBD) diameter of ≤12mm. All patients had undergone prior cholecystectomy and were free of malignancy. Demographic, serologic, procedural, and outcome variables were assessed. A total of 35 patients underwent a total of 99 ERCPs. Median CBD diameter was 10 (range 4-12) mm. A total of 31 patients (89%) underwent sphincterotomy, 28 (80%) underwent stent placement, and 5 (14%) underwent balloon dilation. The median number of ERCPs performed was 2 (range 1-10). Three of the 35 patients (9%) developed post-ERCP pancreatitis at some point during their treatment. At last follow-up since initial ERCP (median 16 months, range 2.4-184 months), 12 (34%) patients endorsed abdominal pain and 11 (31%) reported experiencing nausea. For select patients with abdominal pain in the setting of minimal CBD dilation and no evidence of stone disease or malignancy, ERCP can safely and effectively be used to manage symptoms. While patients may require multiple interventions, they can derive long-term relief from these procedures.

Current Epidemiology of Periampullary Malignancies in a Tertiary Referral Center in the Philippines: A Five-Year Review

Background. Periampullary malignancies traditionally occur during the later decades of life, but casual observations at the Philippine General Hospital (PGH) have shown more patients presenting at younger ages. Updates on the epidemiology and clinical features of these uncommon cancers may improve detection and result in better outcomes. Objective. The study aimed to describe the current epidemiology of adult patients diagnosed with periampullary malignancies seen in the past five years at the PGH Department of Surgery. Methods. Demographic and clinical data were obtained on patients with either pancreatic head, ampullary, distal bile duct, or duodenal cancer diagnosed from 2015 to 2019. Age and sex distributions, rates of symptom presentation, utilization of diagnostic modalities, and prevalence of comorbid conditions were analyzed per individual primary site and for the entire study population. Results. Two hundred seventy-seven patients were included in the study, comprised mostly of pancreatic head cancers (56.32%) followed by ampullary (19.86%), duodenal (9.75%), and distal CBD cancers (7.58%). The mean age of presentation was 59.30 years. 33.94% of cases occurred in the 6th decade of life, while 24.91% of patients were aged 50 years and below. There was a nearly equal distribution by sex (50.90% female, 49.10% male). Majority of patients presented with jaundice (89.65%) and abdominal pain (71.64%). CT scan was used to diagnose 71.48% of patients. We observed a higher prevalence of diabetes mellitus (21.32%), biliary stone disease (19.12%), and smoking history (36.88%) in the study group compared to the general Philippine population. Conclusion. The epidemiology of periampullary malignancies at UP-PGH showed a younger age at presentation and an equal sex ratio compared to published data. Distributions of the primary sites, symptom frequency, and rate of associated comorbidities were consistent with previous findings from the literature.

The impact of COVID-19 pandemic on gastrointestinal diseases: a single-center cross-sectional study in central Greece.

BackgroundThe current COVID-19 pandemic induced a suppressive environment for healthcare professionals and patients, especially during the lockdown period. Except for the direct burden of the COVID-19, collateral damage has been identified concerning other diseases. The aim of this study was to evaluate the potential impact of the lockdown on the non-COVID-19 patients’ outcome in a tertiary gastroenterology department.MethodsPatients admitted to our department during the lockdown period (23 March- 4 May 2020) and during the respective previous year’s timeframe were recruited. Sex, age, comorbidities, presenting symptoms, final diagnosis, therapeutic management, duration of hospitalization, and outcome were evaluated. A direct comparison was performed to investigate the potential impact of the lockdown on the duration of hospitalization and the final outcome.ResultsA total of 161 patients were included to our analysis with 1:1 male:female ratio and mean age 70.86 years. Most of the cases experienced gastrointestinal tract bleeding, biliary stone disease manifestations, or gastrointestinal malignancy complications, and 85.1% were discharged. Fewer patients were hospitalized during the lockdown period (40%), whereas the duration of hospitalization was significantly longer (7.69±4.55 vs. 5.76±4.36 days). Binary logistic regression analysis and sensitivity analysis demonstrated that the quarantine was associated with increased prevalence of negative outcomes (odds ratio 5.21, 95% confidence interval 1.66-16.34; P=0.005), especially in cases with gastrointestinal malignancy and acute pancreatitis (P=0.045 and P=0.041, respectively).ConclusionThe increase in the negative outcomes of common gastrointestinal diseases and the duration of hospitalization during the lockdown raise reasonable concerns regarding healthcare policies against further outbreaks.

Clinical Management of Bile Duct Diseases: Role of Endoscopic Ultrasound in a Personalized Approach

Biliary diseases are common, but clinical symptoms are often unspecific and direct access and visualization of the biliopancreatic system for diagnostic purpose is difficult. In the last decades endoscopic ultrasound (EUS) has become a primary method in the gastrointestinal tract. It significantly changed the role of endoscopy in diagnostic imaging in the gastrointestinal tract and adjacent organs. EUS has become an effective diagnostic tool in biliary stone disease as well as in the diagnosis of indeterminate biliary strictures. Furthermore, an EUS-directed transmural approach emerged as a safe and effective alternative to ERCP in patients requiring biliary drainage, in particular as a backup method if standard ERCP-approach fails. Development of new techniques, specific accessories and stents during the last decade led to an enormous step forward in terms of efficacy and safety of an EUS-directed approach. In the current article technical and clinical aspects of EUS-guided diagnostic and therapeutic approaches in different clinical indications will be discussed together with a review of the available data.

Effect of Statins on the Risk of Extrahepatic Cholangiocarcinoma.

Statins have been proven to be cytotoxic to human cholangiocarcinoma cells by inhibiting cell division and inducing apoptosis. We aimed to determine the effect of statin use on the risk of cancer development and survival in patients with extrahepatic cholangiocarcinoma (ECC), including perihilar cholangiocarcinoma (pCCA) and distal cholangiocarcinoma (dCCA). A total of 394 patients with ECC and hyperlipidemia who received care at Mayo Clinic Rochester between 2005 and 2015 were matched by age, sex, race, ethnicity, and residency to 788 controls with hyperlipidemia. Clinical and outcome data were abstracted. The odds ratios (ORs) for risk and hazard ratios for outcomes were calculated. The mean age and standard deviation (SD) for cases and controls was 65.6years (13.8). The number of statin users in cases and controls was 73 (19%) and 403 (51%), respectively. Hepatitis C virus infection (OR,15.84; 95% confidence interval [CI], 4.06-61.87; P<0.001) was the most significant risk factor for pCCA followed by inflammatory bowel disease and cirrhosis, whereas other liver disease, including biliary stone disease (OR,4.06; CI, 2.24-7.36; P<0.001), was the only significant risk factor for dCCA. Statin use was associated with significantly reduced risk for all ECC (OR,0.22; CI, 0.16-0.29) as well as for the subtypes pCCA (OR,0.3; CI, 0.21-0.41) and dCCA (OR,0.06; CI, 0.03-0.14), all P<0.0001. Moderate-intensity dosage was found to decrease the risk of ECC (OR,0.48; CI, 0.34-0.67; P<0.001). Comparing statin ever users to nonusers, patients with dCCA who used statins had significantly overall better survival (hazard ratio=0.53; CI, 0.29-0.97; P=0.04). This case-control study suggests that statins decrease the risk of ECC and may improve survival in patients with dCCA. Additional validation studies are warranted.

Evaluation of the biochemical changes in bile under the influence of compound indigenous drug in biliary stone diseases

Evaluation of the biochemical changes in bile under the influence of compound indigenous drug in biliary stone diseases

Biliary stone disease in acromegaly under somatostatinanalogues: A longterm safety study

Biliary stone disease in acromegaly under somatostatinanalogues: A longterm safety study

Role of Prophylactic Cholecystectomy After Endoscopic Sphincterotomy for Biliary Stone Disease: A Systematic Review and Meta-analysis.

The aim of this study was to perform a structured systematic review and meta-analysis to evaluate the effectiveness and complication rate of cholecystectomy deferral versus prophylactic cholecystectomy among patients post-endoscopic biliary sphincterotomy for common bile duct stones. Although previous reports suggest a decreased risk of biliary complications with prophylactic cholecystectomy, biliary endoscopic cholangiopancreatography (ERCP) with sphincterotomy may provide a role for deferring cholecystectomy with the gallbladder left in situ. Searches of PubMed, EMBASE, Web of Science, and Cochrane Library databases were performed through August 2019 in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-Analysis of Observational Studies in Epidemiology guidelines. Measured outcomes included: mortality, recurrent biliary pain or cholecystitis, pancreatitis, cholangitis, and eventual need for cholecystectomy. Random effects models were used to determine pooled effect size and corresponding 95% confidence intervals (CIs). Nine studies (n = 1605) were included. A total of 53.8% (n = 864) patients had deferred cholecystectomy post-sphincterotomy. Deferral cholecystectomy as compared to prophylactic cholecystectomy resulted in a significant increased risk of mortality [odds raio (OR) 2.56 (95% confidence interval, CI 1.54-4.23); P < 0.0001; I2 = 18.49]. Patients who did not undergo prophylactic cholecystectomy developed more recurrent biliary pain or cholecystitis [OR 5.10 (95% CI 3.39-7.67); P < 0.0001; I2 = 0.00]. Rate of pancreatitis [OR 3.11 (95% CI 0.99-9.83); P = 0.053; I2 = 0.00] and cholangitis [OR 1.49 (95% CI 0.74-2.98); P = 0.264; I2 = 0.00] was unaffected. Overall, 26.00% (95% CI 14.00-40.00) of patients with deferred prophylactic cholecystectomy required eventual cholecystectomy. Prophylactic cholecystectomy remains the preferred strategy compared to a deferral approach with gallbladder in situ post-sphincterotomy for patients with bile duct stones. Future studies may highlight a subset of patients (ie, those with large balloon biliary dilation) that may not require cholecystectomy.

Su1289 COMPARISON OF EUS-GUIDED RENDEZVOUS AND PERCUTANEOUS BILIARY DRAINAGE IN PATIENTS FAILED STANDARD ERCP

Endoscopic retrograde cholangiography (ERCP) is the procedure of choice for biliary decompression in patients with obstructive jaundice. In cases of failed procedure, percutaneous biliary drainage (PBD) is currently the mainstream of alternative care. On the other hand, EUS-guided rendezvous (EUS-RV) drainage is gaining popularity of reported high technical success. Current literature mostly focuses on EUS-guided transluminal drainage, while only few studied on the role of EUS-RV. We aimed to compare the success rate, efficacy and safety of EUS-RV drainage over standard care as the rescue therapy. This is a retrospective cohort study reviewing cases underwent ERCP for both malignant and benign biliary obstruction at Prince of Wales Hospital in Hong Kong, an university-affiliated tertiary referral center. From January 2013 to October 2019, a total of 6294 ERCPs were performed with 179 (2.84%) failed. 32 cases underwent EUS-RV drainage while 23 cases were referred to intervention radiologists for either urgent percutaneous cholecystostomy (PTC) or percutaneous transhepatic biliary drainage (PTBD). Comparisons were made between the two groups regarding technical success, clinical achievement of biliary drainage, duration of hospital stay and adverse outcomes after procedure. Majority (71.8%) of EUS-RV cases suffered from biliary stone diseases. About half (53.1%) failed ERCP despite prior attempt of precut sphincterotomy. Over 70% of patients managed to access biliary tree with one single puncture only. In total, four cases failed EUS-RV drainage, while two succeeded after switching puncture site from transduodenal to transgastric. Patients in the EUS-RV drainage group were significantly older than the PBD arm (81 years-old vs 71 years-old, p = 0.012). In terms of technical success of biliary drainage, EUS-RV drainage was comparable to PBD (87.5% vs 87%, p=0.952) with similar degree of bilirubin drop by greater than 50% in 1 week (51.9% vs 44.4%, p=0.63). Fewer patients required repeated biliary intervention within 2 weeks after EUS-RV drainage than PBD (1/32 vs 5/23, p = 0.006). The mean length of hospital stay after procedure was 8 days shorter in the EUS-RV than the PBD group (9.6 days vs 17.7 days, p=0.076). Although overall complication rate of EUS-RV (21.9%) was slightly higher than that of PBD (13.7%), most were due to post-ERCP pancreatitis and the difference was not clinically significant (p=0.40). Only one procedure-related death due to bleeding was reported in the PBD group, while none from the EUS-RV group. EUS-RV drainage is a feasible alternative to PBD in patients with biliary obstruction after failing ERCP with precut. It showed a promising success rate up to 87.5% when expertise available, lower rate of re-intervention and shorter post-procedural hospital stay.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Enfermedad litiásica biliar

Five to 15% of the western population presents cholelithiasis. Most calculi are formed from cholesterol and are created inside the gallbladder, where they can migrate to the bile duct, eventually causing obstructive conditions and other complications. The diagnosis of biliary stone disease is based on clinical, laboratory and imaging data. The first diagnostic test is abdominal ultrasonography, which is highly sensitive for diagnosing cholelithiasis. In most cases, the cholelithiasis is asymptomatic and requires no specific treatment. When the disease causes symptoms or complications, cholecystectomy is indicated. The recommendation is to extract any diagnosed choledocholithiasis, even if it is asymptomatic, given the severity of its potential complications (cholangitis and acute pancreatitis). The method of choice is endoscopic retrograde cholangiopancreatography.

Chronobiology of acute pancreatitis in a single Italian centre.

Seasonal variation may occur in many different diseases hence influencing awareness in clinical practice. This study aimed to establish seasonal variations of acute pancreatitis by using a validated chronobiological analysis. All cases of acute pancreatitis consecutively observed in fifteen years, i.e., from January 2003 to December 2017, at St. Anna University Hospital of Ferrara, Italy, were included in this study. Accurate statistical and logistic regression analyses were applied to our database. A total number of 1883 consecutive cases of acute pancreatitis were observed. A significant peak was identified in the summer period (p=0.014). Patient stratification, according to age, showed that elderly people had an increased incidence of acute pancreatitis in autumn and summer (being the biliary stone disease the main cause, p=0.011) vs. other seasons (p=0.003). Mortality occurred more prominently in males vs. females, although the latter gender was more prone to acute pancreatitis (p=0.017). In a single centre of Northern East of Italy, we demonstrated that acute pancreatitis had a clear seasonal variation with a prominent incidence during summer. Various associated factors could contribute to this chronobiological pattern, including gender, age, and biliary stone disease.

Serum lipase amylase ratio in predicting the etiology of acute pancreatitis

Background: Acute pancreatitis remains a major cause of significant morbidity and mortality. Alcoholism and biliary tract stone disease are the main causes in up to 80% of cases. The diagnosis of acute pancreatitis is based on the correlation of clinical, biochemical, and radiological criteria. Serum lipase and amylase have been used to diagnose acute pancreatitis with values greater than three times the upper limit of normal being diagnostic. Objective: The aim is to study the value of serum lipase: amylase ratio in predicting the etiology of acute pancreatitis. Materials and Methods: This prospective study was conducted in a tertiary care hospital in North-East India during a 2-year period. The serum lipase/amylase ratio has been evaluated in 52 patients (31 acute alcoholic pancreatitis, 19 acute gallstone pancreatitis, 2 idiopathic). Results: Analysis of data showed that patients with acute alcoholic pancreatitis had higher serum lipase levels (2722.5 ± 285.7, mean ± standard deviation) compared to acute gallstone pancreatitis (1565.21 ± 198.2). On the other hand, acute gallstone pancreatitis patients had higher serum amylase (862.3 ± 105.5) compared to acute alcoholic pancreatitis patients (683.03 ± 618.31). Determination of lipase: amylase ratio showed that out of 31 patients of acute alcoholic pancreatitis 22 patients (71%) had lipase: amylase ratio ≥3. Out of 19 patients of acute gallstone pancreatitis, 17 patients (89.5%) had lipase: amylase ratio Conclusion: Serum lipase: amylase ratio fixed at 3.0 can assist in differentiating acute biliary pancreatitis from acute alcoholic pancreatitis. The lipase: amylase ratio ≥3 is observed in alcoholic acute pancreatitis while biliary pancreatitis has ratio

Percutaneous endoscopic biliary exploration in complex biliary stone disease: Case series study

Background and aimPatients with complex biliary stone disease are challenging to treat. We present our experience using urological interventions to treat challenging biliary stones. MethodsFifteen patients with biliary calculi underwent 21 interventions using either extracorporeal shock wave lithotripsy (ESWL), percutaneous transhepatic choledochoscopy, percutaneous transcystic choledochoscopy, or a combination of these. ResultsMost patients were elderly (median age, 60 years). The male-to-female ratio was higher than the norm for biliary stones (1:1.4). The most common reasons for failure of conventional endoscopic retrograde cholangiopancreatography (ERCP) were high American Society of Anesthesia (ASA) score (8 patients 53%), technical failure of ERCP (4 patients, 27%), previous Roux-en-Y gastric bypass (two patients, 13%), and post-common bile duct (CBD) injury with T-tube insertion (one patient, 7%). The stone sites were the CBD, gallbladder, and intrahepatic bile duct in nine (60%), three (20%), and three (20%) patients, respectively. All patients underwent minimally invasive interventions. This included ESWL in seven cases and endoscopic laser lithotripsy and stone manipulation through an access tube in eight patients (transhepatic in four patients, transcholecystic in three patients, and using a T-tube in one patient). Complete stone clearance was achieved in 12 patients (80%), whereas four patients required a second session and one patient required a third. The remaining three patients, two had residual asymptomatic debris and one failed procedure. ConclusionsComplicated and high-risk patients with biliary stones could be managed with minimally invasive intervention without subjecting them to a major risky procedure.