Biliary Tract Stones Research Articles

Current Gallstone Treatment Methods, State of the Art.

This study aims to provide valuable references for clinicians in selecting appropriate surgical methods for biliary tract stones based on patient conditions. In this paper, the advantages and disadvantages of various minimally invasive cholelithiasis surgical techniques are systematically summarized and innovative surgical approaches and intelligent stone removal technologies are introduced. The goal is to evaluate and predict future research priorities and development trends in the field of gallstone surgery. In recent years, the incidence of gallstone-related diseases, including cholecystolithiasis and choledocholithiasis, has significantly increased. This surge in cases has prompted the development of several innovative methods for gallstone extraction, with minimally invasive procedures gaining the most popularity. Among these techniques, PTCS, ERCP, and LCBDE have garnered considerable attention, leading to new surgical techniques; however, it must be acknowledged that each surgical method has its unique indications and potential complications. The primary challenge for clinicians is selecting a surgical approach that minimizes patient trauma while reducing the incidence of complications such as pancreatitis and gallbladder cancer and preventing the recurrence of gallstones. The integration of artificial intelligence with stone extraction surgeries offers new opportunities to address this issue. Regarding the need for preoperative preparation for PTCS surgery, we recommend a combined approach of PTBD and PTOBF. For ERCP-based stone extraction, we recommend a small incision of the Oddi sphincter followed by 30 s of balloon dilation as the optimal procedure. If conditions permit, a biliary stent can be placed post-extraction. For the surgical approach of LCBDE, we recommend the transduodenal (TD) approach. Artificial intelligence is involved throughout the entire process of gallstone detection, treatment, and prognosis, and more AI-integrated medical technologies are expected to be applied in the future.

Treatment efficacy and early complications of Percutaneous Transhepatic Holmium Laser Lithotripsy for biliary stones under Digital Subtraction Angiography guidance

Background: Intrahepatic stones and common bile duct stones are common diseases in Vietnam. Surgical treatments have a high rate of remaining intrahepatic bile duct stones and are ineffective with intrahepatic stones and cases with biliary strictures, while endoscopic retrograde cholangiopancreatography stone removal (ERCP) is usually indicated for small common bile duct stones and has disadvantages such as having to performe sphincterectomie of Oddi, 5% causing acute pancreatitis. Nowadays, minimally invasive treatment techniques are more and more developed. Percutaneous transhepatic lithotripsy under fluoroscopy guidance (TSQD) is an improved method using Holmium laser with small sized trocart (16F) help avoid open surgery and increase the rate of stone clearance, especially with stones located in the intrahepatic duct branches. For that reason, we conducted research to evaluate the treatment effectiveness and early complications of this method. Materials and method: This study was conducted on a group of 38 patients with main biliary tract stones, diagnosed and treated using PTHLL under fluoroscopy guidance at Hanoi Medical University Hospital from July 2018 to December 2019. Results: The PTHLL procedures was performed on patients with main extrahepatic biliary stones (28.9%) and those with intrahepatic stones, either isolated or combined (71.1%). One-step lithotripsy was applied in 26.3% of cases without cholangitis, simple stones. In another hand, Two-steps procedure were indicated in 73.7% of cases with cholangitis, multiple stones, and poor patient health. Stand-alone laser lithotripsy (23.7%) was suitable for simpler cases, while combination with baskets and balloons (76.3%) was used for complex situations. The overall complete stone clearance rate was 84.2%. Complications included septicemie (7.8%) and biloma (2.6%). No major complications like bleeding or deaths were encountered in this study. Conclusion: PTHLL under fluoroscopy guidance is a minimally invasive method that achieves a high rate of complete stone clearance in both intra- and extrahepatic biliary stones, with a low early complication rate. Key words: intervention, biliary stone, percutaneous transhepatic holmium laser lithotripsy.

A COMPARATIVE STUDY BETWEEN APACHE II AND RANSON’S SCORING SYSTEMS IN PREDICTING THE SEVERITY OF ACUTE PANCREATITIS

Aims and Objectives: The aims and objectives of the study are to compare the Ranson’s scoring system with APACHE II score in predicting the severity of acute pancreatitis. Methods: 50 cases having acute pancreatitis were included in this study on the basis of a predefined inclusion and exclusion criteria. Institutional ethical committee was approved the study. The duration of study was 2 years. Informed consent was obtained from the patients. Assessment of severity of pancreatitis was done on the basis of Ranson’s scoring as well as APACHE II score. Final severity score of the patients on the basis of both the scoring systems was assessed to determine the efficacy of each scoring system in predicting the severity. Results: Out of these 50 cases, there were 37 (74%) males and 13 (26%) females. The mean age of affected cases was found to be 36.86±7.91 years. The most common etiological factor was chronic alcoholism which was seen in 22 (44%) patients followed by biliary tract disease or stones (24%), hypertriglyceridemia (14%), post ERCP (2%), idiopathic (14%), and autoimmune pancreatitis (2%). Mild and severe pancreatitis was seen in 35 (70%) and 15 (30%), respectively. APACHE II score was found to be having more sensitivity and positive predictive value for the diagnosis of severe pancreatitis as compared to Ranson’s score. There was no significant difference in specificity, negative predictive value, and accuracy as determined by Ranson’s and APACHE II Score. Conclusion: APACHE II score is better in predicting severity of acute pancreatitis as it is found to have a better sensitivity and positive predictive value for the diagnosis of severe pancreatitis as compared to Ranson’s score.

Evaluating prognostic value of biliary stone in intrahepatic cholangiocarcinoma by propensity score matching analysis.

Background: To explore biliary tract stone (BTS) as prognostic factors of intrahepatic cholangiocarcinoma (ICC). Methods: Clinical data of 985 ICC patients were classified into no BTS group and BTS group-subgrouped into hepatolithiasis (HL) and non-hepatolithiasis (NHL) group. Propensity score matching was utilized to mitigate baseline characteristics. Preoperative peripheral inflammation parameters (PPIP) were further investigated. Immunostaining of CD3, CD4, CD8, CD68, PD1 and PD-L1 were conducted. Results: Overall survival (OS) of patients without BTS surpassed BTS group (P = 0.040) while no difference of time to recurrence (TTR) was observed (P = 0.146). HL group had shorter OS and TTR than HL-matched group (P < 0.001 and P = 0.017, respectively) and survival time of NHL group differed not with NHL-matched group (P > 0.05). PPIP like neutrophils to lymphocytes ratio (NLR), platelet to lymphocyte ratio (PLR) and systemic immune inflammation (SII) of HL group exceeded no BTS group or NHL group (all P < 0.05). Associations of PPIP and tumorous immunocytes differed vastly among HL group, NHL group and no BTS group. Tumorous CD4+/CD3+ ratio and PD1+/CD3+ ratio of HL group surpassed those in no BTS group (P = 0.036 and P < 0.001, respectively) and NHL group (P = 0.015 and 0.002, respectively). Para-tumorous CD68+ macrophages exceeded that in tumor samples of HL group (P < 0.001). No difference of CD8+/CD3+ lymphocyte ratio and PD-L1 rank were detected. Conclusions: Hepatolithiasis, rather than extra-hepatic biliary stone, is a poor prognostic indicator of ICC. Immunotherapy is promising in treating HL-related ICC.

Value of enhanced recovery after surgery in patients undergoing endoscopic retrograde cholangiopancreatography with intravenous anaesthesia for choledocholithiasis: a retrospective observational study.

Enhanced recovery after surgery (ERAS) is rarely used in minimally invasive endoscopic surgery, especially in endoscopic retrograde cholangiopancreatography (ERCP). This study evaluated the safety and efficacy of the ERAS protocol in patients undergoing ERCP for choledocholithiasis. The study had a retrospective design and included patients with biliary tract stones who underwent ERCP between June 2019 and November 2022. Patients who received the ERAS protocol between June 2021 and November 2022 were enrolled as an ERAS group, and those who received traditional perioperative treatment between December 2019 and May 2021 were enrolled as a control group. A total of 349 patients were enrolled (ERAS group, n = 185; control group, n = 164). The cannulation and stone extraction success rates were significantly higher in the ERAS group than in the control group (p < 0.05). The incidence of postoperative pancreatitis was significantly lower in the ERAS group (p = 0.02), but there were no significant differences in other complications. The postoperative hospital stay was significantly shorter in the ERAS group than in the control group (p < 0.001), with no statistically significant differences in costs according to surgical period, or in total costs, between the 2 groups. Application of the ERAS protocol is safe and feasible in patients undergoing ERCP for choledocholithiasis. The ERAS protocol can accelerate recovery, reduce postoperative pain, and shorten the hospital stay without increasing the cost of treatment.

TO STUDY THE RISK FACTORS ETIOLOGY OF ACUTE PANCREATITIS

Background: The most important aetiological factors for acute pancreatitis are either biliary tract stone disease or alcohol, which account for approximately 75-80% of all cases of acute pancreatitis&#x0D; Methods: This study was conducted in the department of surgery, RNT Medical College and Maharana Bhupal Govt. Hospital, Udaipur. A total of 35 cases of acute pancreatitis were studied&#x0D; Results: In our study of 35 cases of acute pancreatitis, 14(40%) patient had alcoholic pancreatitis, while 13(37.2%) patient had gall stone pancreatitis. In 8(22.8%) patient cause was undetected.&#x0D; Conclusion: Alcohol abuse and gall stones were main etiological factors with almost equal frequency.&#x0D; Keywords: Risk factor, Pancreatitis, Gall sone

TO STUDY THE INCIDENCE OF GALL STONE PANCREATITIS AND ALCOHOLIC PANCREATITIS OUR INSTITUTION

Background: The most important aetiological factors for acute pancreatitis are either biliary tract stone disease or alcohol, which account for approximately 75-80% of all cases of acute pancreatitis&#x0D; Methods: This study was conducted in the department of surgery, RNT Medical College and Maharana Bhupal Govt. Hospital, Udaipur. A total of 35 cases of acute pancreatitis were studied&#x0D; Results: In our study of 35 cases of acute pancreatitis, 14(40%) patient had alcoholic pancreatitis, and 13(37.2%) patient had gall stone pancreatitis.&#x0D; Conclusion: Prevalence of Alcohol abuse and gall stones were almost equal frequency.&#x0D; Keywords: Risk factor, Pancreatitis, Gall sone

Ultrasonography (USG) diagnostic test compared to magnetic resonance cholangio pancreatografy (MRCP) in patients with obstructive jaundice in Dr. Moewardi Public Hospital

Background: Ultrasonography (USG) is still the first imaging modality for initial examination in patients with obstructive jaundice. Abdominal ultrasonography is quite good in seeing the morphology of the biliary tract, although the diagnostic etiological sensitivity of various causes of obstruction is very low. Magnetic resonance cholangio pancreatography (MRCP) is a new technique and can show the same picture as ERCP examination and no contrast media is needed. Aim: Aim for this study is knowing the results of ultrasound diagnostic tests in detecting Obstruction jaundice which was confirmed by the results of MRCP examination at Dr. Moewardi public hospital. Method: This study uses a diagnostic test that assesses sensitivity, big specifications, negative predictive value and positive predictive value of ultrasound in detecting jaundice obstruction confirmed by the results of the MRCP examination. Sampling was done by purposive sampling, on 68 research subjects. Results: This study show the characteristics of jaundice in the form of stones with sensitivity and specificity values ​​of 84% and 83%, positive predictive value 75% and negative predictive value 90% and in biliary tract tumors 83% and 84%, positive predictive value 75% and predictive value negative 90%. Conclusions: Ultrasound has a high sensitivity and specificity value in diagnosing obstructive jaundice in the case of biliary tract stones and biliary tract tumors

Comparison of the Long-term Outcome Between Billroth-I and Roux-en-Y Reconstruction Following Distal Gastrectomy for Gastric Cancer

BackgroundVarious reconstruction methods have been performed following distal gastrectomy; however, each reconstruction method has its own advantages and disadvantages. This study aims to compare the long-term outcomes between Billroth-I (B-I) and Roux-en-Y (RY) reconstruction after distal gastrectomy for gastric cancer. MethodsA total of 459 patients who underwent distal gastrectomy (B-I: 166, RY: 293) were included. Postoperative endoscopic findings and biliary tract stone formation were compared between the two groups. ResultsAt 1 year and 2 years postoperatively, gastric residue was more common in the RY group, gastritis was similar between groups, and bile reflux was more common in the B-I group. At 5 years postoperatively, gastric residue was similar between the groups, while gastritis and bile reflux were more common in the B-I group. Gastroesophageal reflux was more common in the B-I group at 1 year postoperatively, but gastroesophageal reflux became not significantly different between the groups at 2 and 5 years postoperatively. Gallstone formation was more common in the RY group and in patients aged ≥ 65 years. ConclusionDuring long-term follow-up, RY reconstruction was associated with lower incidence of bile reflux and gastritis, and higher incidence of gallstone formation than B-I reconstruction. The incidence of gastric residue was more common in the RY reconstruction group in the early postoperative period and became not significantly different between the two groups over time. For aged patients with RY reconstruction, cholecystectomy is recommended concurrently as gastrectomy.

Cholangioscopy and its Primary Sclerosing Cholangitis

Primary sclerosing cholangitis (PSC) is a cholestatic liver disease characterised by chronic inflammation and fibro-obliteration of the intrahepatic and/or extrahepatic bile ducts. It is associated with numerous hepatobiliary complications including an increased risk of malignancy (in particular, cholangiocarcinoma) and biliary tract stone formation. The evaluation of biliary strictures in patients with PSC is especially challenging, with imaging and endoscopic methods having only modest sensitivity for the diagnosis of cholangiocarcinoma, and treatment of biliary strictures poses a similarly significant clinical challenge. In recent years, peroral cholangioscopy has evolved technologically and increased in popularity as an endoscopic tool that can provide direct intraductal visualisation and facilitate therapeutic manipulation of the biliary tract. However, the indications for and effectiveness of its use in patients with PSC remain uncertain, with only a few studies performed on this small but important subset of patients. In this review, the authors discuss the available data regarding the use of peroral cholangioscopy in patients with PSC, with a focus on its use in the evaluation and management of biliary strictures and stones.

Hepatolithiasis; case series, review and current management strategy

Background: Intrahepatic biliary tract stone formation is referred to as hepatolithiasis (HL). Hepatolithiasis causes local and systemic complications and insufficient treatment Methods with increased risk of reoccurrence makes it an important health problem. Surgical interventions ranges from endoscopic attempts to small segment resection and finally to liver transplant. Here in, we evaluated the patients who are diagnosed with HL and the treatment strategies in light of the current literature. Materials and Methods: Patients who are diagnosed with HL between the years of 2014 to 2018 and the applied treatment strategies were retrospectively examined. Patient demographics, causes of disease, complications and the treatment options of the patients were evaluated. Results: Totaly 16 patients were admitted to the study. Mean age of the patients was 64.3. We determined that 7 patients had been received cholecystectomy before. Out of these 7 patients, three patients, because they had been operated for main bile duct trauma during laparoscopic cholecystectomy, had been suffered from anastomotic stenosis in which has 2 hepaticojejunostomy (HJ) stenosis and 1 hepaticoduodenostomy stenosis with metal stent. Also, HJ stenosis and then HL developed in one patient after Whipple procedure. Ultrasonography, EUS, MRCP, CT, ERCP, PTC Methods are applied for diagnostic purposes. Eight patients were operated for HL; left hepatectomy for 2 patients and lateral sector resection in one patient. HJ revised in two patients. Stenotic region including stent ingrowth and fibrotic stricture resected and neo-hepaticojejunostomy performed in 2 patients. Anastomotic resection and portojejunostomy (Kasai) performed in one patient. All of HJ were done in Roux-en-Y style. The remaining 8 patients were observed with medical and endoscopic approaches. Discussion and Conclusions: Hepatolithiasis is a serious condition that requires multimodal treatment approaches. Anastomosis stenosis and stent implementation promote hepatolithiasis formation and increase recurrence. Functional HJ procedures will especially decrease the formation of this complication.

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

Immune thrombocytopenic purpura increased risk of subsequent pancreatitis: A Nationwide population cohort study

Immune thrombocytopenic purpura (ITP) is characterized by thrombocytopenia and bleeding diathesis. Pancreatitis is a very rare complication but may be fatal. We analyzed data of newly diagnosed ITP patients, excluding those with a history of splenectomy, unknown sex or date of birth, or preexisting pancreatitis at the time of ITP diagnosis, and compared these with selected age-, gender-, and index-year-matched controls, using the Taiwan National Health Insurance Research Database from 1996 to 2013. The study enrolled 100,177 ITP patients and 100,177 controls. We found that pancreatitis risk was higher in secondary ITP patients, regardless of age group, gender, baseline Charlson comorbidity index (CCI) score, history of biliary stone, hyperlipidemia, or alcoholism, than in the control population. Primary ITP patients with CCI score 1 and without biliary tract stone history also showed a higher pancreatitis risk than the controls. The incidence rate and cumulative incidence of pancreatitis were increased in primary, secondary, and unspecified ITP cases. These phenomena may be related to the presence of autoantibodies against glycoprotein IIb/IIIa, or to IgG4, microparticle obstruction, or sclerosis. We noted a direct association between ITP and the development of pancreatitis in Taiwan population.

1321 A Choledochodoudenal Fistula Without Gallstones: A Case Report

INTRODUCTION: Choledochoduodenal fistulas (CDFs) are abnormal connections that form between the common bile duct and the duodenum. CDFs are rare and result from biliary tract diseases like biliary tract stones and/or infections, peptic ulcer disease, Crohn's disease and surgery. They are more common in elderly patients. CDFs may present with cholangitis-like symptoms and the diagnosis is confirmed with endoscopic retrograde cholangiopancreatography (ERCP). Treatment include therapeutic ERCP or surgery. CASE DESCRIPTION/METHODS: Our patient was a 31 year-old Hispanic female who immigrated recently from El Salvador. The patient presented with symptoms of right upper quadrant pain along with nausea/vomiting and low grade fever. Initial laboratories results were remarkable for white blood cell count (WBC) 14.3 × 109 L, acetate aminotransferase (AST) 493 U/L, alanine aminotransferase (ALT) 438 U/L, total bilirubin 2.4 mg/dl, direct bilirubin 0.56 mg/dl, and Alkaline phosphatase 192 U/L. Abdominal ultrasonography showed non-specific gallbladder wall thickening with dilation of the intrahepatic and extrahepatic bile duct (common bile duct diameter of 1.2 cm), and no gallbladder stones (Figure 1). The patient was admitted to the floor and started on broad-spectrum intravenous antibiotics. An urgent ERCP demonstrated a 3 mm choledochoduodenal fistula seen superior to the major papilla. The fistula was draining purulent materials (Figure 2). The common bile duct (CBD) was dilated to 12 mm with no filling defects (Figure 3). The biliary tree was drained and no stones were found (Figure 3). To ensure adequate biliary drainage, a 10 Fr × 5 cm plastic stent was placed into the CBD (Figure 3). Soon, patient clinical and laboratory profile dramatically improved and was discharged two days later with plan for outpatient follow-up. DISCUSSION: We are reporting a unique case of CDF that developed spontaneously in a patient who has no significant past medical history. No underlying pathology like biliary tract stones was found during the ERCP. This case may raise a question that CDFs could be sometimes idiopathic with no predisposing factors. Spontaneous CDFs are uncommon especially in young population. Only few cases in young patients had been reported in literature. The youngest patient reported in literature was a 6-year-old female who had an unusual case of recurrent cholangitis due to CDF.

A systematic review of advanced endoscopy-assisted lithotripsy for retained biliary tract stones: laser, electrohydraulic or extracorporeal shock wave.

When conventional endoscopic treatment of bile duct stones is impossible or fails, advanced endoscopy-assisted lithotripsy can be performed by electrohydraulic lithotripsy (EHL), laser lithotripsy, or extracorporeal shock wave lithotripsy (ESWL). No systematic review has compared efficacy and safety between these techniques. A systematic search was performed in PubMed, the Cochrane Library, and EMBASE for studies investigating EHL, laser lithotripsy, and ESWL in patients with retained biliary tract stones. After screening 795 studies, 32 studies with 1969 patients undergoing EHL (n = 277), laser lithotripsy (n = 426) or ESWL (n = 1266) were included. No randomized studies were available. Although each advanced lithotripsy technique appeared to be highly effective, laser lithotripsy had a higher complete ductal clearance rate (95.1 %) than EHL (88.4 %) and ESWL (84.5 %; P < 0.001). In addition, a higher stone fragmentation rate was reported for laser lithotripsy (92.5 %) than for EHL (75.5 %) and ESWL (89.3 %; P < 0.001). The post-procedural complication rate was significantly higher for patients treated with EHL (13.8 %) than for patients treated with ESWL (8.4 %) or laser lithotripsy (9.6 %; P = 0.04). Data on the recurrence rate of the biliary tract stones were lacking. This systematic review revealed that laser lithotripsy appeared to be the most successful advanced endoscopy-assisted lithotripsy technique for retained biliary tract stones, although randomized studies are lacking.

Rare causes of hyperbilirubinemia after lung transplantation: our experience at a single center.

Lung transplantation is the last treatment option for end-stage lung disease, and the number of lung transplantations has been steadily increasing. Hyperbilirubinemia is a rare complication after lung transplantation. The aim of this study was to review rare causes of hyperbilirubinemia after lung transplantation at our center. In this single-center study, we retrospectively reviewed the records of 116 consecutive lung transplantation patients who underwent lung transplantation at Severance Hospital and Gangnam Severance Hospital of Yonsei University College of Medicine in South Korea between December 22, 2010 and January 1, 2016. Hyperbilirubinemia was defined as a total bilirubin level exceeding 5 mg/dL for at least 3 days after lung transplantation. Hyperbilirubinemia occurred in 33 patients (28.4%) who received lung transplants at our institution. Twenty-four cases involved common causes such as drug toxicity, biliary tract stone, sepsis, and bleeding. However, rare causes of hyperbilirubinemia including hemophagocytic lymphohistiocytosis (HLH), thrombotic microangiopathy (TMA), and ischemic cholangiopathy were observed in 9 (7.8%) patients during the study period. All patients with hyperbilirubinemia due to a rare cause died despite aggressive treatment. Causes of hyperbilirubinemia after lung transplantation are varied, and the prognosis of patients with hyperbilirubinemia arising from rare causes was poor. Therefore, early evaluation and management of hyperbilirubinemia after lung transplantation is important to improve patient outcomes.

Use of Acoustic Radiation Force Impulse Elastography to Predict Acute Pancreatitis: A Case-Control Study

Diagnosis of uncomplicated acute pancreatitis (AP) by trans-abdominal ultrasonography is not sensitive. We try to demonstrate the potential value of acoustic radiation force impulse (ARFI) elastography on prediction of AP. We performed ARFI elastography (Siemens Acuson S2000™ ultrasound system: median value of 3 valid measurements and median value, meters/second (m/s)) on 20 AP patients and 43 control patients who received ultrasonography for indications other than AP (non-AP group) between March 2016 and March 2017. Measurement of ARFI at pancreatic body was carried out via transhepatic route. The ARFI mean values, clinical and laboratory data of two groups were analyzed. More male patients was noted in AP group (male 80.0% vs. 37.2%, p=0.002).The mean age of AP and non-AP groups were 42.80 ± 10.67 years and 49.70 ± 15.79 years (p=0.08), respectively. Etiologies for AP were alcohol (13/20, 65%), followed by biliary tract stones (3/20, 15%), hypertriglyceridemia (2/20, 10%), and unknown cause (2/20, 10%). Most (18/20, 90%) of ARFI elastography in AP group were performed within 24 hours after the hospitalization. The mean values of ARFI in AP and non-AP groups were 1.88 ± 0.72 m/s and 1.13 ± 0.29 m/s (p<0.001), respectively. Higher ARFI values were found in alcohol (2.08 ± 0.80, p<0.001) and hypertriglyceridemia (1.66 ± 0.10, p=0.003) related AP than controls. Using cut-off value of ARFI 1.32 m/s for diagnosis of AP had sensitivity and specificity of 85.0% and 79.1%, respectively (AUC ROC 0.86). ARFI elastography had no value in prediction of serum lipase level (P=0.412), BISAP score (P=0.936) and the length of hospitalization days (P=0.831). Higher ARFI was found in AP patients, especially for alcohol and hypertriglyceridemia related causes. However, the value of ARFI was not associated with clinical severity. Further study with larger number of study subjects is warranted to demonstrate the diagnostic and prognostic role of ARFI elastography in AP patients.

ERCP for biliary stones in the elderly: should we stop ducking the cholecystectomy?

ERCP for biliary stones in the elderly: should we stop ducking the cholecystectomy?

Laparoscopic Technique and Initial Experiences of Choledocholithotomy Closure With Knotless Unidirectional Barbed Sutures After Surgery for Biliary Stone Disease.

Between January 2012 and June 2013, we performed laparoscopic choledocholithotomy on 10 cases of common bile duct stone disease. Laparoscopic surgery for common duct stone disease is technically demanding. Particularly, laparoscopic intracorporeal suturing and knot tying for repair of choledochotomy are the most difficult skills in this operative procedures. Barbed sutures has recently been proposed to facilitate laparoscopic suturing. This is the first report demonstrating that the barbed suture could potentially improve the efficacy of the intracorporeal repair of choledochotomy following extirpation of biliary tract stones with less time needed to suture. Consecutive 10 patients with common bile duct stones who underwent laparoscopic choledocholithotomy were enrolled in this study. Choledochotomy was closed with V-Loc sutures (15 cm V-Loc 180 sutures) for 7 patients, and a V-20 needle (26 mm, tapered) for 3 patients. The mean choledochotomy closure time was significantly shorter in the V-Loc group (15.2 ± 1.6 min) than in the Vicryl group (23.5 ± 1.5 min). The unidirectional barbed sutures allowed surgeons to use both their hands effectively and to focus exclusively on the placement of the subsequent stitches, without the need to maintain tension on preceding stitches to prevent slippage. And also the unidirectional barbed sutures were able to distribute tension evenly along the suture line, allowing good tissue apposition. The knotless unidirectional barbed sutures are a safe and effective tool for choledochotomy repair during surgery for common bile duct stones.

Evaluation of thyroid profile in biliary tract stones

Background: In the course of clinical practice it has been observed that a no. of patients with biliary tract stones have hypothyroidism in their medical history. The prevalence of hypothyroidism is increased in patients of choledocholithiasis than in cholelithiasis patients. Aims and objectives: To find the prevalence of hypothyroidism in patients of cholelithiasis and choledocholithiasis. Methods: This study was conducted in post graduate dept. of surgery, SMHS over a period of 2 years on a total of 100 patients, 50 diagnosed as having cholelithiasis and 50 having choledocholithiasis. A complete history, detailed clinical examination followed by evaluation as per protocol was done. Results: There was an increased prevalence of choledocholithiasis with increasing age (max. pts. in age group 51-60) with female predominance in patients diagnosed as choledocholithiasis, thereby implying increasing age and female gender as risk factors for choledocholithiasis. There was a prevalence of 16% of hypothyroidism in patients of choledocholithiasis in comparison to 8% in cholelithiasis group with subclinical hypothyroidism present in maximum no. of patients (75%). Conclusions: Hypothyroidism is more common in the choledocholithiasis patients as compared to cholelithiasis group, with female predominance and with subclinical variant in maximum No. of patients which support the hypothesis that hypothyroidism might play a role in the formation of CBD stones.