Common Bile Duct Obstruction Research Articles

ERCP treatment for intrabiliary rupture of hepatic hydatid cyst in a child

In this report, we present a patient with intrabiliary rupture of a hydatid cyst, which caused choledochal obstruction and treated with endoscopic retrograde cholangiopancreatography (ERCP). It is an emergency and treated with mini - mally invasive surgery. A twelve-year-old female patient with acute upper ab - dominal pain, nausea, and vomiting was admitted to pediatric surgery clinic with the preliminary diagnosis of cholestasis. There were localized right upper abdominal rebound and tenderness. Contrast-enhanced axial computed tomog - raphy images through the liver showed that there was a cystic lesion in segment 4 communicating with the biliary system. The main hepatic duct was obliterat - ed and dilated by curvilinear densities consistent with germinative membranes expelled from the cyst into the biliary system. ERCP and sphincterotomy were performed. Germinative membrane and daughter cysts were cleaned with the use of balloon and basket. The patient is doing well without any other complica - tion 20 months after ERCP. There have been few case reports documenting the successful use of ERCP treatment of hydatid cyst. ERCP may be a useful pro - cedure in selected children with suspected intrabiliary rupture or common bile duct obstruction, which occurs due to daughter cyst and germinative membrane.

Outcomes of Percutaneous Cholecystostomy in the Presence of Ascites

PurposeTo evaluate whether the presence of ascites increases complications following placement of percutaneous cholecystostomy tubes (PCTs). Materials and MethodsRetrospective review of all transhepatic PCTs placed between January 2005 and June 2014 was performed: 255 patients were included (median age of 65 y; range, 20–95 y). Of these patients, 97 had ascites and 158 had no ascites or only pelvic fluid. In all, 115 patients had calculous cholecystitis (45%), 127 had acalculous cholecystitis (50%), and 13 had common bile duct obstruction (5%). The primary outcome of interest was all complications, including bile peritonitis, pericatheter leakage requiring PCT change, pericholecystic abscess formation, drain dislodgment, or death from biliary sepsis within 14 days of initial PCT insertion. ResultsThe overall complication rate was 11% among patients with ascites (n = 11), compared with 10% in those without (n = 16; P = .834). No difference was found between the two groups in any one complication. The overall outcome of PCT drainage differed between groups, with significantly shorter survival times in patients with ascites. Patients with ascites underwent cholecystectomy less often than patients without ascites (21% vs 39%; P = .002). Likewise, patients with ascites were more likely than those without ascites to die with the PCT in place (49% vs 25%; P = .001). ConclusionsFrequencies of complications following PCT insertion were similar in patients with and without ascites. Additionally, the overall complication rate was low and not significantly different between the two groups. These observations support the use of PCT placement in patients with ascites.

Emphysematous Pyelitis Disguised as Cholestasis and Jaundice

Emphysematous pyelitis is a rare infection of the renal pelvis occurring alone or in association with pyelonephritis. The most common cause is E. coli and diabetes is the strongest risk factor. In a retrospective review including 48 patients who were diagnosed with either emphysematous pyelitis or pyelonephritis, the mean patient age was 60 years old and women outnumbered men 6:12. The most common initial symptoms include fever, dysuria, abdominal pain, and flank pain. The most frequent organ system involvement is hematologic and renal. Our patient, a 76 year old female, with no past medical history, presented with progressive weakness followed by the onset of jaundice. Her exam was notable for hypertension but no fever, jaundice, epigastric/right upper quadrant abdominal tenderness or peritoneal signs. Labs were remarkable for a profound leukocytosis, anemia, cholestasis, and an elevated creatinine. An abdominal ultrasound did not reveal cholecystitis or a common bile duct obstruction. Empiric antibiotics to include Ceftriaxone and Flagyl were started for possible cholangitis. On hospital day two, an abdominal endoscopic ultrasound was performed in lieu of a contrast study as renal function had worsened. This examination was normal. A non-contrasted CT scan of the abdomen and pelvis demonstrated the unusual findings of emphysematous pyelitis with a surrounding fluid collection concerning for a perinephric abscess. Subsequent management included placement of a percutaneous nephrostomy tube and antibiotics. Emphysematous pyelitis presenting as cholestasis is a novel clinical presentation of a rare illness.

Endoscopic retrograde cholangiopancreatography in periampullary diverticulum: The challenge of cannulation.

Periampullary diverticulum (PAD) is duodenal outpunching defined as herniation of the mucosa or submucosa that occurs via a defect in the muscle layer within an area of 2 to 3 cm around the papilla. Although PAD is usually asymptomatic and discovered incidentally during endoscopic retrograde cholangiopancreatography (ERCP), it is associated with different pathological conditions such as common bile duct obstruction, pancreatitis, perforation, bleeding, and rarely carcinoma. ERCP has a low rate of success in patients with PAD, suggesting that this condition may complicate the technical application of the ERCP procedure. Moreover, cannulation of PAD can be challenging, time consuming, and require the higher level of skill of more experienced endoscopists. A large portion of the failures of cannulation in patients with PAD can be attributed to inability of the endoscopist to detect the papilla. In cases where the papilla is identified but does not point in a suitable direction for cannulation, different techniques have been described. Endoscopists must be aware of papilla identification in the presence of PAD and of different cannulation techniques, including their technical feasibility and safety, to allow for an informed decision and ensure the best outcome. Herein, we review the literature on this practical topic and propose an algorithm to increase the success rate of biliary cannulation.

Combined Endoscopic and Laparoscopic Management of Postcholecystectomy Mirizzi Syndrome from a Remnant Cystic Duct Stone: Case Report and Review of the Literature.

Mirizzi syndrome has been defined in the literature as common bile duct obstruction resulting from calculi within Hartmann's pouch or cystic duct. We present a case of a 78-year-old female, who developed postcholecystectomy Mirizzi syndrome from a remnant cystic duct stone. Diagnosis of postcholecystectomy Mirizzi syndrome was made on endoscopic retrograde cholangiography (ERCP) performed postoperatively. The patient was treated with a novel strategy by combining advanced endoscopic and laparoscopic techniques in three stages as follows: Stage 1 (initial presentation): endoscopic sphincterotomy with common bile duct stent placement; Stage 2 (6 weeks after Stage 1): laparoscopic ultrasonography to locate the remnant cystic duct calculi followed by laparoscopic retrieval of the calculi and intracorporeal closure of cystic duct stump; Stage 3 (6 weeks after Stage 2): endoscopic removal of common bile duct stent along with performance of completion endoscopic retrograde cholangiogram. In addition, we have performed an extensive review of the various endoscopic and laparoscopic management techniques described in the literature for the treatment of postcholecystectomy syndrome occurring from retained cystic duct stones.

Early Cholecystectomy for Acute Cholecystitis Offers the Best Outcomes at the Least Cost: A Model-Based Cost-Utility Analysis

The application of early cholecystectomy for acute cholecystitis remains inconsistent across hospitals worldwide. Given the constrained nature of health care spending, careful consideration of costs relative to the clinical consequences of alternative treatments should support decision making. We present a cost-utility analysis comparing alternative time frames of cholecystectomy for acute cholecystitis. A Markov model with a 5-year time horizon was developed to compare costs and quality-adjusted life-years (QALY) gained from 3 alternative management strategies for the treatment of acute cholecystitis: early cholecystectomy (within 7 days of presentation), delayed elective cholecystectomy (8 to 12 weeks from presentation), and watchful waiting, where cholecystectomy is performed urgently only if recurrent symptoms arise. Model inputs were selected to reflect patients with uncomplicated acute cholecystitis-without concurrent common bile duct obstruction, pancreatitis, or severe sepsis. Real-world outcome probability and cost estimates included in the model were derived from analysis of population-based administrative databases for the province of Ontario, Canada. The QALY values were derived from utilities identified in published literature. Parameter uncertainty was evaluated through probabilistic sensitivity analyses. Early cholecystectomy was less costly (C$6,905 per person) and more effective (4.20 QALYs per person) than delayed cholecystectomy (C$8,511; 4.18 QALYs per person) or watchful waiting (C$7,274; 3.99 QALYs per person). Probabilistic sensitivity analysis showed early cholecystectomy was the preferred management in 72% of model iterations, given a cost-effectiveness threshold of C$50,000 per QALY. This cost-utility analysis suggests early cholecystectomy is the optimal management of uncomplicated acute cholecystitis. Furthermore, deferring surgery until recurrent symptoms arise is associated with the worst clinical outcomes.

Spontaneous Rupture of an Intrahepatic Biliary Duct Causing a Right Pleural and Retroperitoneal Biloma

Bilomas are encapsulated collections of bile outside of the biliary tree and are mainly caused by iatrogenic injury or abdominal trauma. Spontaneous rupture of the biliary tree is not common. We report a case of a patient with spontaneous rupture biloma treated with percutaneous and internal-external biliary drainage. A 68-year-old man with significant history of amyloidosis and monoclonal paraproteinemia was admitted for progressively worsening right upper quadrant abdominal pain and nausea for the last week. Vital signs were unremarkable and physical exam revealed mild jaundice and a positive Murphy sign. No rebound or guarding. Laboratory results revealed total bilirubin of 1.7 mg/dL, direct bilirubin of 0.8 mg/dL, alkaline phosphatase of 328 IU/L, AST of 190 IU/L, ALT 154 IU/L. Pancreatic enzymes and Ca 19-9 were within normal limits. Right upper quadrant ultrasound showed a distended gallbladder with biliary sludge and a dilated common bile duct (CBD) measuring 11mm. MRCP suggested a pancreatic head mass. Subsequent ERCP showed narrowing at the CBD making it difficult for cannulation. However fine needle aspiration samples were obtained and came back positive for malignancy. Over the next few days, the patient became febrile, continued having the abdominal pain and developed worsening liver function tests. CT of the abdomen revealed a large retroperitoneal fluid collection, intra and extrahepatic biliary duct dilation and a right pleural effusion. Patient underwent right chest tube placement, which drained 2 L of bilious pleural fluid. She also underwent percutaneous transhepatic cholangiogram, which showed bilious leakage from third order branch of the right hepatic duct at the level of the superior aspect of the right lobe of the liver, which was causing complete obstruction of the distal CBD. Subsequent internal-external biliary drain was placed without complications, followed by resolution of the patient's jaundice over the next days. Follow up CT of the abdomen confirmed resolution of the retroperitoneal and right pleural bilomas. After discharge, patient underwent Whipple procedure for resection of what was found to be a well differentiated cholangiocarcinoma of the CBD. He has been following with general surgery and hematology/oncology since then. Spontaneous biloma is a rare occurrence which needs to be promptly assessed and treated. Percutaneous biliary drainage with placement of an internal-external drain is an effective procedure which can be used, especially if endoscopic sphincterotomy is not feasible.

Year of the Dragon: A Remarkable CT Scan From a Chronically Obstructed Bile Duct

We present a remarkable case of chronic common bile duct (CBD) obstruction resulting in massive dilatation with a dragon like appearance (picture 1). This was a 78 year-old female with a history of cholecystectomy and sphincterotomy over 20 years ago. She had been asymptomatic until recently and presented with jaundice. CT scan findings are shown in pictures 1 and 3. ERCP was performed confirming the CT findings of a large CBD stone with this remarkable upstream dilatation. Due to comorbidities, the stone was bypassed with a stent with resolution of jaundice (picture 2 and 4). Abbreviation, CBD: Common Bile Duct, S: CBD stone, IHD: Intrahepatic ducts.Figure 1Figure 2

Blood Glucose Homeostasis in the Course of Partial Pancreatectomy--Evidence for Surgically Reversible Diabetes Induced by Cholestasis.

Background and AimPartial pancreatic resection is accompanied not only by a reduction in the islet cell mass but also by a variety of other factors that are likely to interfere with glucose metabolism. The aim of this work was to characterize the patient dynamics of blood glucose homeostasis during the course of partial pancreatic resection and to specify the associated clinico-pathological variables.MethodsIn total, 84 individuals undergoing elective partial pancreatic resection were consecutively recruited into this observational trial. The individuals were assigned based on their fasting glucose or oral glucose tolerance testing results into one of the following groups: (I) deteriorated, (II) stable or (III) improved glucose homeostasis three months after surgery. Co-variables associated with blood glucose dynamics were identified.ResultsOf the 84 participants, 25 (30%) displayed a normal oGTT, 17 (20%) showed impaired glucose tolerance, and 10 (12%) exhibited pathological glucose tolerance. Elevated fasting glucose was present in 32 (38%) individuals before partial pancreatic resection. Three months after partial pancreatic resection, 14 (17%) patients deteriorated, 16 (19%) improved, and 54 (64%) retained stable glucose homeostasis.Stability and improvement was associated with tumor resection and postoperative normalization of recently diagnosed glucose dysregulation, preoperatively elevated tumor markers and markers for common bile duct obstruction, acute pancreatitis and liver cell damage. Improvement was linked to preoperatively elevated insulin resistance, which normalized after resection and was accompanied by a decrease in fasting- and glucose-stimulated insulin secretion.ConclusionsSurgically reversible blood glucose dysregulation diagnosed concomitantly with a (peri-) pancreatic tumor appears secondary to compromised liver function due to tumor compression of the common bile duct and the subsequent increase in insulin resistance. It can be categorized as “cholestasis-induced diabetes” and thereby distinguished from other forms of hyperglycemic disorders.

PTH-038 Diagnostic utility of further assessment with endoscopic ultrasound in patients with unexplained common bile duct obstruction with and without abnormal liver enzymes: Abstract PTH-038 Table 1

Introduction Patients who undergo endoscopic ultrasound (EUS) are often referred because of a dilated common bile duct (CBD) of unknown cause and/or abnormal liver enzymes (LFT). We aimed to determine the diagnostic yield when such patients are referred for an EUS for further assessment. Method All patients who underwent an EUS in 2010 were included. Patients who had an identifiable cause of pathology on prior imaging were excluded. We retrospectively analysed our electronic database for radiological evidence of CBD dilatation, laboratory values of LFT and results of the EUS. Results 184 patients were identified. 60 (32.6%) had a dilated CBD with normal LFT (group A), 65 (35.3%) had dilated CBD with abnormal LFT (group B), 36 (19.6%) had abnormal LFT with a normal CBD (group C), and 23 (12.5%) had normal LFT with a normal CBD (group D). Out of 184 patients, 78 (42.4%) received a diagnosis at EUS. The diagnostic yield of EUS when divided into groups were: A = 23.3% (14/60), B = 55.4% (36/65), C = 55.6% (20/36), D = 34.8% (8/23). There was a significant difference in diagnostic yield between groups A vs B and A vs C (p = Conclusion Patients with abnormal LFT were more likely to have a positive diagnosis at EUS than those with a dilated CBD. However there were substantive positive findings in all groups justifying further assessment with EUS even if prior imaging tests were normal. Disclosure of interest None Declared.

Single-session EUS-guided FNA and biliary drainage with use of a biflanged lumen apposing stent on an electrocautery enhanced delivery system: one-stop shop for unresectable pancreatic mass with duodenal obstruction

Endoscopic palliation of unresectable pancreatic cancer with obstruction of both the duodenum and the common bile duct (CBD) is cumbersome, with successful biliary drainage achieved in only 30% of the cases. In most of them, percutaneous biliary drainage is necessary. We present a patient with an unresectable mass of the pancreatic head causing both CBD and duodenal obstruction who, after an EUS-FNA with rapid onsite cytopathologic evaluation, which revealed pancreatic adenocarcinoma, underwent same-session EUS-guided biliary drainage with use of a newly developed biflanged lumenapposing fully covered metal stent (LAFCMS) mounted on an electrocautery-enhanced delivery system (Hot-AX

Continuing Medical Education Exam: April 2015

Instructions: The GIE: Gastroinintestinal Endoscopy CME Activity can now be completed entirely online. To complete do the following: 1. Read the CME articles in this issue carefully and complete the activity: Holt BA, Jayasekeran V, Williams SJ, et al. Early metal stent insertion fails to prevent stricturing after single-stage complete Barrett’s excision for high-grade dysplasia and early cancer. Gastrointest Endosc 2015;81:857-64. Abougergi MS, Travis AC, Saltzman JR. The in-hospital mortality rate for upper GI hemorrhage has decreased over 2 decades in the United States: a nationwide analysis. Gastrointest Endosc 2015;81:882-8. Schlag C, Menzel C, Nennstiel S, et al. Emergency video capsule endoscopy in patients with acute severe GI bleeding and negative upper endoscopy results. Gastrointest Endosc 2015;81:889-95. Dhir V, Itoi T, Khashab MA, et al. Multicenter comparative evaluation of endoscopic placement of expandable metal stents for malignant distal common bile duct obstruction by ERCP or EUS-guided approach. Gastrointest Endosc 2015;81:913-23. 2. Log in online to complete a single examination with multiple choice questions followed by a brief post-test evaluation. Visit the Journal’s Web site at www.asge.org (members) or www.giejournal.org (nonmembers). 3. Persons scoring greater than or equal to 75% pass the examination and can print a CME certificate. Persons scoring less than 75% cannot print a CME certificate; however, they can retake the exam. Exams can be saved to be accessed at a later date. You may create a free personal account to save and return to your work in progress, as well as save and track your completed activities so that you may print a certificate at any time. The complete articles, detailed instructions for completion, as well as past Journal CME activities can also be found at this site.

Cannulation of the biliary tree under endoscopic control with an echoendoscope, without fluoroscopy: report of a case series.

Endoscopic ultrasonography (EUS) is a validated technique allowing precise diagnosis and staging of pancreatic, biliary and ampullary disease. Developments in instruments and accessories have led to a more extensive use of this technology to perform operations. The use of EUS as an operative technique, alone or in conjunction with other endoscopic procedures, has already been described in the literature in several reports. However, despite the use of EUS, fluoroscopy has always been required to perform these operations. There are no data in the literature describing the feasibility, safety and efficacy of operative EUS in the treatment of common bile duct (CBD) obstruction, following a malignant or benign disease, performed completely under EUS guidance without fluoroscopic assistance. In this series we describe three cases of EUS treatment of CBD diseases performed without fluoroscopic assistance. All the cases were treated by EUS without fluoroscopic assistance and no complications were encountered. Operative EUS without fluoroscopy appears to be a feasible technique. Its major advantages could be to shorten the examination time and to enable biliary or pancreatic operative endoscopy in patients in whom fluoroscopy could be dangerous, such as pregnant women. The endoscopist should have a good training both in EUS and endoscopic retrograde cholangiopancreatography. Prospective, larger studies are needed to confirm our preliminary data.

Comparison of Uncovered Stent Placement across versus above the Main Duodenal Papilla for Malignant Biliary Obstruction

PurposeTo evaluate the differences in efficiency and complications of metal stent insertion across versus above the main duodenal papilla (MDP) in patients with malignant obstruction of the common bile duct (CBD). Materials and MethodsRecords of 98 consecutive patients who underwent stent insertion for malignant CBD obstruction between 2004 and 2010 were retrospectively reviewed. Fifty-one patients (group 1) and 47 patients (group 2) were treated with stent insertion across and above the MDP, respectively. Primary stent patency, overall survival, complications, and changes in serum bilirubin level following stent insertion were assessed. ResultsInfection appeared in 12 and four patients, respectively, in groups 1 and 2. The respective mean primary stent patency times were 307.8 days ± 20.2 and 490.7 days ± 40.7, and mean survival times were 245.1 days ± 17.4 and 286.3 days ± 20.2. Bilirubin reduction rates were 55.7% ± 16.6 and 61.1% ± 13.7 at 1 week and 84.2% ± 5.7 and 86.2% ± 5.7 at 1 month in groups 1 and 2, respectively. In group 2, the rate of infection was significantly lower (P = .044) and primary stent patency was longer (P = .019). However, there was no significant difference between groups in survival time (P = .074) or bilirubin reduction rate at 1 week (P = .083) or 1 month (P = .082). ConclusionsBile stent insertion above the MDP may achieve longer stent patency and a lower infection rate compared with placement across the MDP. For patients with malignant CBD obstruction, biliary stents should be placed above the papilla if papillary lesions are not invaded.

Early Experience with Stapled Gastrointestinal Anastomoses in a Nigerian Hospital.

Background:Hand-sewn gastrointestinal anastomoses has been the traditional approach to gastrointestinal anastomosis in Nigeria while stapled anastomoses are infrequently performed in few centers.Objectives:To describe the outcome of our initial experience with stapled gastrointestinal anastomoses in a semi-urban patient population.Patients and Methods:Consecutive patients who had stapled gastrointestinal anastomoses between January 2011 and June 2014 in a Nigerian tertiary hospital were prospectively evaluated. Indications for operation, procedures performed and anastomoses constructed and postoperative outcome of each patient were documented.Results:Nineteen patients including seven males and 12 females had stapled anastomoses within the period. Their ages ranged between 41 and 68 (mean 52.5) years. Six (31.6%) Roux-en-Y gastrojejunostomies, 6 (31.6%) ileo-colic, 3 (15.8%) ileo-ileal, 2 (10.5%) colo-colic, and 2 (10.5%) colo-anal anastomoses were performed. Indications include antral gastric cancer in 4 (21.1%), right colon cancer 4 (21.1%), ileal perforations in 3 (15.8%) while 2 (10.5%) each had left colon cancer, common bile duct obstruction, rectal cancer and ruptured appendix. Mean duration of operation was 108 ± 46 min and mean duration of postoperative stay was 5 ± 2.6 days. No intraoperative complications were recorded and no anastomotic leakage occurred. At a median follow-up of 5 months no staple related stricture had occurred.Conclusions:Stapled gastrointestinal anastomoses are associated with a good outcome in our center. We propose a prospective, large-population randomized comparison of the technique with hand-sewn anastomoses.

Tube cholecystostomy before cholecystectomy for the treatment of acute cholecystitis.

Background and Objectives:Percutaneous cholecystostomy is currently indicated for patients with cholecystitis who might be poor candidates for operative cholecystectomy. We performed a study to evaluate the long-term outcome of patients undergoing emergent tube cholecystostomy.Methods:This study was a retrospective chart review of patients who underwent tube cholecystostomy from July 1, 2005, to July 1, 2012.Results:During the study period, 82 patients underwent 125 cholecystostomy tube placements. Four patients (5%) died during the year after tube placement. The mean hospital length of stay for survivors was 8.8 days (range, 1–59 days). Twenty-eight patients (34%) required at least 1 additional percutaneous procedure (range, 1–6) for gallbladder drainage. Twenty-nine patients (34%) ultimately underwent cholecystectomy. Surgery was performed a mean of 7 weeks after cholecystostomy tube placement. Laparoscopic cholecystectomy was attempted in 25 operative patients but required conversion to an open approach in 8 cases (32%). In another 4 cases, planned open cholecystectomy was performed. Major postoperative complications were limited to 2 patients with postoperative common bile duct obstruction requiring endoscopic retrograde cholangiopancreatography, 1 patient requiring a return to the operating room for hemoperitoneum, and 2 patients with bile leak from the cystic duct stump.Conclusions:In high-risk patients receiving cholecystostomy tubes for acute cholecystitis, only about one third will undergo surgical cholecystectomy. Laparoscopic cholecystectomy performed in this circumstance has a higher rate of conversion to open surgery and higher hepatobiliary morbidity rate.

Effect of probiotic supplementation on bacterial translocation in common bile duct obstruction.

To investigate the effects of probiotics on bacterial translocation in the obstructive common bile duct with comparison to an enteral product containing arginine and glutamine. In our study, 40 Sprague-Dawley rats each weighing 250-300g were used. Animals in Group 1 (sham) were laparatomized and fed standard chow supplemented with physiologic saline at daily doses of 2ml through orogastric tube for 7days. Common bile ducts of the animals in the other groups were ligated with 3/0 silk sutures. Group 2 (control group) was fed standard chow supplemented with daily doses of 2ml physiologic saline. Group 3 (probiotic group) was fed standard chow supplemented with a probiotic solution (Acidophilus plus) containing strains of Lactobacillus acidophilus, Bifidobacterium bifidum and Lactobacillus bulgaricus at a daily doses of 2×10(9) colony forming units (CFU). Group 4 (formula group) was fed only an enteral solution (Stresson Multi Fiber) containing glutamine, arginine and a medium-chain fatty acid at daily doses of 2g/kg. At the end of the 7th day, all animals were relaparatomized, and to determine bacterial translocation, aerobic, and anaerobic cultures were obtained from the specimens of mesenteric lymph nodes, intestinal mucosa, and blood samples. Smear cultures prepared from caecum were examined to determine the number of CFU. Finally, for histological examination specimens were excised from terminal ileum, and oxidative damage was assessed in liver tissues. Afterwards all animals were killed. Moderately lesser degrees of bacterial translocation, and mucosal damage were seen in Groups 3, and 4 relative to Group 2 (p<0.05). In Group 4, any difference was not seen in the number of cecal bacteria relative to baseline values, while in Group 3, significant decrease in cecal colonization was seen. Among all groups, a significant difference between levels of malondialdehyde, and glutathione was not observed. At the end of our study, we have concluded that both probiotics, and enteral diets which contain immunomodulators such as glutamine, and arginine alleviate bacterial translocation, and impairment of intestinal mucosa.

Multicenter comparative evaluation of endoscopic placement of expandable metal stents for malignant distal common bile duct obstruction by ERCP or EUS-guided approach

A single session of EUS-guided biliary drainage (EUS-BD) may be a viable alternative to ERCP in patients with malignant distal common bile duct (CBD) obstruction. There is no study comparing EUS-BD andERCP for the relief of distal malignant biliary obstruction. To compare the outcomes of self-expandable metal stent (SEMS) placement for malignant distal biliary obstruction by using ERCP and EUS-BD. Multicenter, retrospective analysis. Tertiary referral centers. Patients with malignant distal CBD obstruction requiring SEMS placement. Patients in the EUS-BD group underwent EUS-guided choledochoduodenostomy (EUS-CDS) or EUS-guided antegrade (EUS-AG) procedures after 1 or more failed ERCP attempts. Patients in the ERCP group underwent retrograde SEMS placement. Composite success (the ability to complete the intended therapeutic procedure in a single session and resulting in a greater than 50% decrease in bilirubin over 2 weeks). The study included 208 patients, 104 treated with ERCP and 104 treated with EUS-BD (68 EUS-CDS, 36EUS-AG). SEMS placement was successful in 98 patients in the ERCP group and 97 in the EUS-BD group (94.23% vs 93.26%, P= 1.00). The frequency of adverse events in the ERCP and EUS-BD groups was 8.65% and 8.65%, respectively. Postprocedure pancreatitis rates were higher in the ERCP group (4.8% vs 0, P= .059). The mean procedure times in the ERCP and EUS-BD groups were similar (30.10 and 35.95 minutes, P= .05). Retrospective analysis. In patients with malignant distal CBD obstruction requiring SEMS placement, the short-term outcome of EUS-BD is comparable to that of ERCP.

English

BACKGROUND: Cholecystitis is a common indication for major abdominal surgeries. It may occur with or without obstruction of common bile duct. Obstruction leads to secondary bacterial infection of bile. Bactibilia is an important predisposing factor for post-operative complications. Hence, this study was designed to determine the prevalence of bacteria in bile samples of cholecystitis patients and to correlate bactibilia and post-operative wound infection. MATERIALS AND METHODS: Bile samples collected intra-operatively were subjected to gram stain, culture, and antibiotic sensitivity testing. The patients were followed-up for post-operative complications. If postoperative wound infection was found, cultures were done and correlated with bacteria isolated from bile samples. RESULTS: Bactibilia was found in 43/100 (43%) of patients. Polymicrobial flora was found in 7% of bile samples. Escherichia coli, citrobacter, Klebsiella pneumoniae and pseudomonas were the predominant organisms isolated. Post-operative wound infection was found in ten (10%) patients who had bactibilia. Amikacin, gentamicin, ceftriaxone sulbatum, pipracillin tazobactum, imipenem were among most effective in prophylactic regimen. CONCLUSION: The organisms responsible for bactibilia were found to cause post-operative infections in the same patient warranting the use of prophylactic antibiotics in every patient undergoing cholecystectomy. All patients undergoing cholecystectomy should receive prophylactic antibiotic to prevent postoperative wound infections.

Covered Metallic Stents in Malignant Common Bile Duct Obstruction: To Use or Not to Use—That Is the Question!

Treatment of malignant common bile duct obstruction has remained controversial with respect to stent implantation, especially with regard to patency and adverse events (1–8). Recently, a randomized multicenter trial (9) showed that covered self-expanding metallic stents (SEMSs) with an antimigration system had a longer duration of patency than uncovered SEMSs. A similar result was reported in a metaanalysis of randomized trials comparing the patency of covered and uncovered SEMSs for palliation of distal malignant bile duct obstruction (10).