Detection Of Common Bile Duct Stones Research Articles

Laparoscopic Ultrasound-Guided Transcystic Approach for the Treatment of Common Bile Duct Stones.

Background: The treatment of choledocholithiasis with nondilated common bile duct (CBD) is a challenge for surgeons who often choose endoscopic retrograde cholangiopancreatography with laparoscopic cholecystectomy (LC) staging surgery instead of simultaneous laparoscopic CBD exploration with LC because of the small CBD diameter. This study aims to introduce and assess the clinical applicability of a technique we developed to identify and extract CBD stones using laparoscopic ultrasound (LUS). Methods: We retrospectively reviewed surgical procedures and clinical data of 13 patients who underwent LC and CBD exploration using LUS between May 2022 and August 2023. The cystic duct was used for CBD stone removal. Results: Ten patients were successfully treated; 2 patients with residual stones were treated with ursodeoxycholic acid, whereas 1 patient required a microincision near the CBD and choledochoscopy because of stone incarceration in the duodenal papilla. The CBD diameter was 6 mm (5-9 mm). There were less than three CBD stones, with diameters of 2-6 mm; the median operative time was 105 minutes (range, 52-155 minutes). One patient developed postoperative cholangitis. The median postoperative hospital stay was 6 days (3-8 days). The stone clearance rate was 76.9%, and the CBD stone detection rate was 100%. No intraoperative complications, postoperative bile leakage, and mortality occurred. Conclusions: CBD exploration and transcystic stone extraction under LUS guidance are safe and effective approaches for patients with choledocholithiasis; strict control over surgical indications is necessary. This study could provide new strategies for effectively treating choledocholithiasis.

The Use of Intraoperative Cholangiography During Cholecystectomy: A Systematic Review.

Cholecystectomy is a widespread surgical procedure for gallbladder diseases. Evolving techniques and technologies, such as intraoperative cholangiography (IOC), enhance safety and outcomes by providing real-time biliary system visualization during surgery. This systematic review explored available data on using IOC during cholecystectomy, highlighting its effectiveness, safety, and cost-effectiveness. To perform this systematic review, a thorough literature search was conducted using relevant keywords in electronic databases, such as PubMed, Medical Literature Analysis and Retrieval System Online (MEDLINE), Cochrane Library, Web of Science, and Google Scholar. We included studies published during the last 10 years exploring the use of IOC during cholecystectomy. The findings showed success rates of up to 90% with a median time of 21.9 minutes without complications. Most (90%) patients with acute gallstone pancreatitis underwent cholecystectomy with IOC, with unclear IOC results in 10.7% and failure in 14.7%. IOC failure factors included age, body mass index (BMI), male sex, concurrent acute cholecystitis, common bile duct (CBD) stone evidence on imaging, CBD diameter of >6 mm, total bilirubin of >4 mg/dL, abnormal liver tests, and gallstone pancreatitis. The detection of choledocholithiasis by IOC prompted trans-cystic duct exploration and endoscopic retrograde cholangiopancreatography (ERCP). Biliary abnormalities and stone identification were observed using IOC, and routine use increased bile duct stone detection while decreasing bile duct injury and readmission rates. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of IOC for common bile duct stone detection were reported at 77%, 98%, 97.2%, 63%, and 99%, respectively. Routine IOC was projected to provide substantial quality-adjusted life years (QALY) and cost-effectiveness gains compared to selective IOC. Regarding safety, IOC was generally associated with reduced complication and open surgery conversion risks, with similar rates of CBD injury and bile leaks. These findings indicate that IOC enhances cholecystectomy outcomes through precision and decreasing complications.

Using deep learning models in magnetic resonance cholangiopancreatography images to diagnose common bile duct stones

Backgrounds and aims Magnetic resonance cholangiopancreatography (MRCP) plays a significant role in diagnosing common bile duct stones (CBDS). Currently, there are no studies to detect CBDS by using the deep learning (DL) model in MRCP. This study aimed to use the DL model You Only Look Once version 5 (YOLOv5) to diagnose CBDS in MRCP images and verify its validity compared to the accuracy of radiologists. Methods By collecting the thick-slab MRCP images of patients diagnosed with CBDS, 4 submodels of YOLOv5 were used to train and validate the performance. Precision, recall rate, and mean average precision (mAP) were used to evaluate model performance. Analyze possible reasons that may affect detection accuracy by validating MRCP images in 63 CBDS patients and comparing them with radiologist detection accuracy. Calculate the correctness of YOLOv5 for detecting one CBDS and multiple CBDS separately. Results The precision of YOLOv5l (0.970) was higher than that of YOLOv5x (0.909), YOLOv5m (0.874), and YOLOv5s (0.939). The mAP did not differ significantly between the 4 submodels, with the following results: YOLOv5l (0.942), YOLOv5x (0.947), YOLO5s (0.927), and YOLOv5m (0.946). However, in terms of training time, YOLOv5s was the fastest (4.8 h), detecting CBDS in only 7.2 milliseconds per image. In 63 patients the YOLOv5l model detected CBDS with an accuracy of 90.5% compared to 92.1% for radiologists, analyzing the difference between the positive group successfully identified and the unidentified negative group not. The incorporated variables include common bile duct diameter > 1 cm (p = .560), combined gallbladder stones (p = .706), maximum stone diameter (p = .057), combined cholangitis (p = .846), and combined pancreatitis (p = .656), and the number of CBDS (p = .415). When only one CBDS was present, the accuracy rate reached 94%. When multiple CBDSs were present, the recognition rate dropped to 70%. Conclusion YOLOv5l is the model with the best results and is almost as accurate as the radiologist’s detection of CBDS and is also capable of detecting the number of CBDS. Although the accuracy of the test gradually decreases as the number of stones increases, it can still be useful for the clinician’s initial diagnosis.

Utility of the "BATS" Score in Predicting Choledocholithiasis in Patients With Gall Bladder Stones.

Background and aim The role of expensive, risky, and unnecessaryendoscopic interventions can be avoided by the use of non-invasive tests to predict common bile duct (CBD) stones. Therefore, our aim was to identify non-invasive predictors of choledocholithiasis (CL) in patients and further to predict a model and assess its diagnostic accuracy in predicting CL. Methods This cross-sectional study was carried out from June 1, 2020, to December 31, 2021. Patients having gall bladder stones on percutaneous transabdominal sonography and fulfilling intermediate probability criteria of CL were enrolled. These patients then underwent radial endoscopic ultrasound (EUS) followed by endoscopic retrograde cholangiopancreatography (ERCP) for detecting CBD stones. Univariate logistic regression analysis, followed by multivariate logistic regression analysis, was performed to ascertain the independent predictors of CBD stone in patients with intermediate probability. A model was proposed, and the diagnostic accuracy was calculated at an optimal cutoff. The model was then internally validated in the patients with intermediate probability and was also compared with the pre-existing score. Results Out of 131 patients included in the study, CBD stone was noted in 85 (66%) and 88 (67.2%) patients on EUS and ERCP, respectively. On multivariate analysis, high serum bilirubin (>2 mg/dL) and alkaline phosphatase (200 IU) and dilated CBD (>6 mm) on transabdominal sonography at baseline were significant predictors of CBD stone in these patients. Using these variables, a scoring system (BATS score) was developed, which had an area under the receiver operating curve (AUROC) of 0.98 in predicting the presence of CBD stone with a sensitivity of 93.18%, a specificity of 76.74%, and a diagnostic accuracy of 87.79%. In the validation cohort, a BATS score of ≥5 had a diagnostic accuracy of 95.91% in predicting CL. Conclusion TheBATS scoreshowed excellent sensitivity and good diagnostic accuracy in predicting the CBD stonewith excellent results on internal validation. However, external validation of our results is required to recommend this model on a larger scale.

THE SIGNIFICANCE OF MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY (MRCP) IN THE DETECTION OF SUSPECTED CHOLEDOCHOLITHIASIS.

Background: Magnetic resonance cholangiopancreatography (MRCP) is a radiation-free test that can be performed quickly and does not expose patients to ionizing radiation or iodinated contrast material. The present study is intended to evaluate the role of MRCP in the detection of Common Bile Duct (CBD) stones in patients with suspected choledocholithiasis. Thi Materials and Methods: s prospective study included 64 patients with suspected choledocholithiasis which was based on clinical evaluation and biochemical or ultrasonographic examination. MRCP was done in all patients. All presenting patients underwent open surgery after proper investigation. CBD exploration was performed in all patients, either due to the presence of palpable stones or due to the presence of dilated CBD (≥8 mm). Demonstration of CBD stones intra-operatively was considered the gold standard' for their presence, dened as stones visualized and extracted or attempted for extraction during surgical CBD exploration. Results: Intraoperatively, 45 (70.3%) out of 64 patients had cholelithiasis. 55 (85.93%) out of 64 patients had dilated CBDs. In 43 (67.18%) out of 64 patients, choledocholithiasis was detected intraoperatively. The sensitivity, specicity, and positive and negative predictive value of ultrasonography in detecting CBD stones in the present study were found to be 65.11%, 61.9%, 77.77% and 46.43% respectively. The sensitivity, specicity, positive predictive value and negative predictive value of MRCP in the diagnosis of CBD stones in the present study were 95.35%, 90.47%, 95.35% and 90.48% respectively. MRCP is a non–invasive and uncomplicated investigation w Conclusion: ith high sensitivity, specicity, and positive and negative predictive values for the detection of CBD stones. Hence MRCP is advised in all cases with a suspicion of CBD stones, where facilities and expertise are available.

Current management of concomitant cholelithiasis and common bile duct stones.

The management policy of concomitant cholelithiasis and choledocholithiasis is based on a one- or two-stage procedure. It basically includes either laparoscopic cholecystectomy (LC) with laparoscopic common bile duct (CBD) exploration (LCBDE) in the same operation or LC with preoperative, postoperative and even intraoperative endoscopic retrograde cholangiopancreatography-endoscopic sphincterotomy (ERCP-ES) for stone clearance. The most frequently used worldwide option is preoperative ERCP-ES and stone removal followed by LC, preferably on the next day. In cases where preoperative ERCP-ES is not feasible, the proposed alternative of intraoperative rendezvous ERCP-ES simultaneously with LC has been advocated. The intraoperative extraction of CBD stones is superior to postoperative rendezvous ERCP-ES. However, there is no consensus on the superiority of laparoendoscopic rendezvous. This is equivalent to a traditional two-stage procedure. Endoscopic papillary large balloon dilation reduces recurrence. LCBDE and intraoperative ERCP have similar good outcomes. The risk of recurrence after ERCP-ES is greater than that after LCBDE. Laparoscopic ultrasonography may delineate the anatomy and detect CBD stones. The majority of surgeons prefer the transcductal instead of the transcystic approach for CBDE with or without T-tube drainage, but the transcystic approach must be used where possible. LCBDE is a safe and effective choice when performed by an experienced surgeon. However, the requirement of specific equipment and advanced training are drawbacks. The percutaneous approach is an alternative when ERCP fails. Surgical or endoscopic reintervention for retained stones may be needed. For asymptomatic CBD stones, ERCP clearance is the first-choice method. Both one-stage and two-stage management are acceptable and can ensure improved quality of life.

Multiple Field-of-View Based Attention Driven Network for Weakly Supervised Common Bile Duct Stone Detection.

Common bile duct (CBD) stones caused diseases are life-threatening. Because CBD stones locate in the distal part of the CBD and have relatively small sizes, detecting CBD stones from CT scans is a challenging issue in the medical domain. We propose a deep learning based weakly-supervised method called multiple field-of-view based attention driven network (MFADNet) to detect CBD stones from CT scans based on image-level labels. Three dominant modules including a multiple field-of-view encoder, an attention driven decoder and a classification network are collaborated in the network. The encoder learns the feature of multi-scale contextual information while the decoder with the classification network is applied to locate the CBD stones based on spatial-channel attentions. To drive the learning of the whole network in a weakly-supervised and end-to-end trainable manner, four losses including the foreground loss, background loss, consistency loss and classification loss are proposed. Compared with state-of-the-art weakly-supervised methods in the experiments, the proposed method can accurately classify and locate CBD stones based on the quantitative and qualitative results. We propose a novel multiple field-of-view based attention driven network for a new medical application of CBD stone detection from CT scans while only image-levels are required to reduce the burdens of labeling and help physicians automatically diagnose CBD stones. The source code is available at https://github.com/nchucvml/MFADNet after acceptance. Our deep learning method can help physicians localize relatively small CBD stones for effectively diagnosing CBD stone caused diseases.

S1841 The Curious Case of CA 19-9 in Mirizzi Syndrome

Introduction: Mirizzi Syndrome (MS) is a rare complication of gallstone disease, caused by an obstructing stone in the cystic duct or the gallbladder neck, leading to obstruction of the common hepatic duct. This case discusses the utility of EUS in improving diagnostic yield of MS and the importance of cancer screening in these patients. Case Description/Methods: A 44-year-old male with a history of gastritis presented with right upper quadrant (RUQ) abdominal pain, jaundice, and scleral icterus for one week. On exam, the patient was afebrile with mild RUQ abdominal tenderness. Labs showed a total bilirubin of 5.4 mg/dL, AST of 66 U/L, ALT of 228 U/L, and a total alkaline phosphatase of 159 U/L. Ultrasound demonstrated intra- and extrahepatic biliary dilation with suggestion of a shadowing stone within the common bile duct (CBD). The gallbladder wall was thickened with trace pericholecystic fluid. MRCP showed a 15 mm calculus presumed to be in the CBD, with a 16 mm CBD dilation. ERCP showed a filling defect in the midportion of the CBD, and a CBD stent was placed. Due to these findings, a CA 19-9 antigen was drawn, measuring 3038 U/mL. EUS was then performed, which visualized a cystic duct stone partially extending into the CBD– a finding consistent with MS. An enlarged lymph node was visualized in the porta hepatis region. FNA of the lymph node as well as CBD brushings from the ERCP were both negative for malignant cells. The patient was discharged and underwent a cholecystectomy two weeks later. Surgical findings were consistent with MS and a 20 mm stone was removed with the gallbladder. The intraoperative frozen section of the gallbladder was negative for malignant cells. (Figure) Discussion: Initial evaluation for MS should include an ultrasound or CT scan, followed by MRCP. The pooled sensitivity of MRCP for detecting CBD stones is around 87%. While MRCP is often used to diagnose MS, the anatomy may not be well visualized due to the proximity of the cystic duct to the CBD. EUS has a pooled sensitivity of 97% in detecting a CBD stone and can better visualize the biliary tract anatomy, aiding in diagnosis. Diagnosis of MS prior to surgery can be helpful in avoiding biliary tract injuries. MS evaluation should also include screening for malignancy, as MS has an association with gallbladder cancer. While elevated CA 19-9 levels are concerning for malignancy, they can also be seen in chronic benign biliary obstruction. It is important to obtain a CA 19-9 level when suspecting MS, both before and after stone removal.Figure 1.: A. MRI: A T2-weighted image showing a 15 mm filling defect (white arrow) within the cystic duct, partially extending into the common bile duct, consistent with an obstructing stone. Intrahepatic and extrahepatic biliary dilation is also seen. B. Endoscopic ultrasound: An ovoid, hyperechoic structure, measuring 11 mm x 15 mm, with shadowing suggestive of a gallstone at the level of the cystic duct and compression of the common bile duct. C. Endoscopic ultrasound: An irregularly contracted gallbladder (black arrow) with adjacent dilated common bile duct. D. Endoscopic ultrasound: Fine needle aspiration of an enlarged lymph node with well defined margins in the porta hepatis region, measuring 20 mm x 15 mm in maximal cross-sectional diameter. Color Doppler imaging was utilized prior to needle puncture to confirm a lack of significant vascular structures within the needle path.

Development of a Predictive Model for Common Bile Duct Stones in Patients With Clinical Suspicion of Choledocholithiasis: A Cohort Study.

Current choledocholithiasis guidelines heavily focus on patients with low or no risk, they may be inappropriate for populations with high rates of choledocholithiasis. We aimed to develop a predictive scoring model for choledocholithiasis in patients with relevant clinical manifestations. A multivariable predictive model development study based on a retrospective cohort of patients with clinical suspicion of choledocholithiasis was used in this study. The setting was a 700-bed public tertiary hospital. Participants were patients who had completed three reference tests (endoscopic retrograde cholangiography, magnetic resonance cholangiopancreatography, and intraoperative cholangiography) from January 2019 to June 2021. The model was developed using logistic regression analysis. Predictor selection was conducted using a backward stepwise approach. Three risk groups were considered. Model performance was evaluated by area under the receiver operating characteristic curve, calibration, classification measures, and decision curve analyses. Six hundred twenty-one patients were included; the choledocholithiasis prevalence was 59.9%. The predictors were age > 55 years, pancreatitis, cholangitis, cirrhosis, alkaline phosphatase level of 125 - 250 or > 250 U/L, total bilirubin level > 4 mg/dL, common bile duct size > 6 mm, and common bile duct stone detection. Pancreatitis and cirrhosis each had a negative score. The sum of scores was -4.5 to 28.5. Patients were categorized into three risk groups: low-intermediate (score ≤ 5), intermediate (score 5.5 - 14.5), and high (score ≥ 15). Positive likelihood ratios were 0.16 and 3.47 in the low-intermediate and high-risk groups, respectively. The model had an area under the receiver operating characteristic curve of 0.80 (95% confidence interval: 0.76, 0.83) and was well-calibrated; it exhibited better statistical suitability to the high-prevalence population, compared to current guidelines. Our scoring model had good predictive ability for choledocholithiasis in patients with relevant clinical manifestations. Consideration of other factors is necessary for clinical application, particularly regarding the availability of expert physicians and specialized equipment.

Role of endoscopic ultrasound in evaluation of patients with missed common bile duct stones

BACKGROUNDCholedocholithiasis develops in up to 20% of patients with gall bladder stones. The challenge in diagnosis usually occurs with small stones that may be missed by magnetic resonance cholangiopancreatography (MRCP). Endoscopic ultrasound (EUS) is accurate in detecting common bile duct (CBD) stones missed by MRCP, especially the small ones or those impacted at the distal CBD or the papillary region. AIMTo evaluate the accuracy of EUS in detecting CBD stones missed by MRCP. METHODSPatients with an intermediate likelihood of choledocholithiasis according to ESGE guidelines and those with acute pancreatitis of undetermined cause were included. The presence of choledocholithiasis was evaluated by MRCP and EUS, and then results were confirmed by endoscopic retrograde cholangiopancreatography (ERCP). The sensitivity and specificity of EUS and MRCP were compared regarding the presence of stones, the size, and the number of detected stones. RESULTSNinety out of 100 involved patients had choledocholithiasis, while ten patients were excluded as they had pancreatic or gall bladder masses during EUS examination. In choledocholithiasis patients, the mean age was 52.37 ± 14.64 years, and 52.2% were males. Most patients had biliary obstruction (74.4%), while only 23 (25.6%) patients had unexplained pancreatitis. The overall prevalence of choledocholithiasis was 83.3% by EUS, 41.1% by MRCP, and 74.4% by ERCP. Also, the number and size of CBD stones could be detected accurately in 78.2% and 75.6% by EUS and 41.1% and 70.3% by MRCP, respectively. The sensitivity of EUS was higher than that of MRCP (98.51% vs 55.22%), and their predictive value was statistically different (P < 0.001). Combination of both tools raised the sensitivity to 97.22% and specificity to 100%. CONCLUSIONEUS could be a useful tool in assessing patients with suspected choledocholithiasis especially if combined with MRCP. However, its usefulness depends on its availability and the experience of the local centers.

Invisible or negligent—EUS detection for the negative CT or/and MRCP CBD stone

Invisible or negligent—<scp>EUS</scp> detection for the negative <scp>CT</scp> or/and <scp>MRCP CBD</scp> stone

Efficacy of an artificial neural network algorithm based on thick-slab magnetic resonance cholangiopancreatography images for the automated diagnosis of common bile duct stones.

Magnetic resonance cholangiopancreatography (MRCP) can accurately diagnose common bile duct (CBD) stones but is laborious to interpret. We developed an artificial neural network (ANN) capable of automatically assisting physicians with the diagnosis of CBD stones. This study aimed to evaluate the ANN's diagnostic performance for detecting CBD stones in thick-slab MRCP images and identify clinical factors predictive of accurate diagnosis. The presence of CBD stones was confirmed via direct visualization through endoscopic retrograde cholangiopancreatography (ERCP). The absence of CBD stones was confirmed by either a negative endoscopic ultrasound accompanied by clinical improvements or negative findings on ERCP. Our base networks were constructed using state-of-the-art EfficientNet-B5 neural network models, which are widely used for image classification. In total, 3156 images were collected from 789 patients. Of these, 2628 images from 657 patients were used for training. An additional 1924 images from 481 patients were prospectively collected for validation. Across the entire prospective validation cohort, the ANN achieved a sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of 93.03%, 97.05%, 97.01%, 93.12%, and 95.01%, respectively. Similarly, a radiologist achieved a sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy 91.16%, 93.25%, 93.22%, 90.20%, and 91.68%, respectively. In multivariate analysis, only bile duct diameter>10mm (odds ratio=2.45, 95% confidence interval [1.08-6.07], P=0.040) was related to ANN diagnostic accuracy. Our ANN algorithm automatically and quickly diagnoses CBD stones in thick-slab MRCP images, therein aiding physicians with optimizing clinical practice, such as whether to perform ERCP.

Routine intraoperative cholangiography during laparoscopic cholecystectomy: application of the 2016 WSES guidelines for predicting choledocholithiasis

BackgroundRoutine use of intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) for detecting common bile duct stones remains controversial. The 2016 World Society of Emergency Surgery (WSES) guidelines on acute calculous cholecystitis proposed a risk stratification for choledocholithiasis. Our present study aimed to (1) examine the findings of common bile duct (CBD) stones in patients underwent LC with routine use of IOC, and (2) validate the 2016 WSES risk classes for predicting choledocholithiasis.MethodsAll patients had LC with IOC routinely performed from November 2012 to December 2017 were reviewed retrospectively. Patients were classified into high-, intermediate-, and low-risk groups based on the 2016 WSES risk classes with modification.ResultsA total of 990 patients with LC and routine IOC were enrolled. CBD stones were detected in 197 (19.9%) patients. The rate of CBD stone detected in low-, intermediate-, high-risk groups were 0%, 14.2%, and 89.6%, respectively. Predictors as following: evidence of CBD stones on abdominal ultrasound or computed tomography, CBD diameter > 6 mm, total bilirubin > 4 mg/dL, bilirubin level = 1.8–4 mg/dL, abnormal liver biochemical test result other than bilirubin, presence of clinical gallstone pancreatitis had statistical significance between patients with and without CBD stones. Major bile duct injury was found in 4 patients (0.4%). All 4 patients had uneventful recovery after repair surgery.ConclusionsBased on our study results, the 2016 WSES risk classes for choledocholithiasis could be an effective approach for predicting the risk of choledocholithiasis. Considering its advantages for detecting CBD stones and biliary injuries, the routine use of IOC is still suggested.

The efficacy and accuracy of endoscopic ultrasound for detecting common bile duct stones in intermediate to high‐risk patients with non‐diagnostic CT or MRCP

AbstractCholedocholithiasis or common bile duct (CBD) stones are found in 15% to 20% of patients with symptomatic gallstone disease. Transabdominal ultrasound (TAUS), computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) are the most commonly used imaging studies for patients with suspected CBD stones. However, the sensitivity of these modalities may decline in patients with microlithiasis (CBD stones smaller than 5 to 6 mm). From literature reviewed, endoscopic ultrasound (EUS) was as effective as MRCP and endoscopic retrograde cholangiopancreatography (ERCP), with higher accuracy in small CBD stones than MRCP and less invasive than ERCP. However, there is not much evidence in the past regarding the diagnostic value of EUS for detecting CBD stones in intermediate to high probability patients based on the American Society for Gastrointestinal Endoscopy (ASGE) guidelines, after non‐diagnostic CT or MRCP. A total of 92 patients with intermediate to high probability of choledocholithiasis based on ASGE guidelines were recruited in this study. We calculated the sensitivity, specificity, positive and negative predictive value, and positive and negative likelihood ratios of EUS for detecting CBD stones after non‐diagnostic CT or MRCP. By using univariate and multivariate analysis, we described the significance of patients' baseline characteristics and predictors that imply for further EUS study after inconclusive CT or MRCP. 35 (38%) out of 92 patients were found to have CBD stones on EUS. Among them, 30 had stones removed by ERCP, and three patients received cholecystectomy and choledocholithotomy with stones removal. Two patients with positive findings of CBD stones on EUS initially, ended up with negative findings on subsequent ERCP procedure. 57 (62%) patients with negative findings of CBD stones on EUS received regular follow‐up with a period of 9 to 24 months and showed no significant change in subsequent imaging and biochemical studies. The diagnostic accuracy of EUS for choledocholithiasis after non‐diagnostic CT or MRCP was 94.3%, with a sensitivity of 100% and specificity of 96.6%. Among all predictors for choledocholithiasis, the presence of clinical cholangitis was the only significant predictor in our multivariate analysis. In patients with intermediate to high probability of choledocholithiasis based on ASGE guidelines, EUS has shown a favorable accuracy and efficacy for detecting CBD stones when CT or MRCP is inconclusive. And the presence of clinical cholangitis is a significant predictor that indicates the necessity for EUS in patients with suspected CBD stones after non‐diagnostic CT or MRCP.

Diagnostic Reliability of Ultrasound Compared to Magnetic Resonance Cholangiopancreatography and Endoscopic Retrograde Cholangiopancreatography in the Detection of Obstructive Jaundice: A Retrospective Medical Records Review.

BackgroundChallenges in the diagnosis of obstructive jaundice include locating the level of obstruction, knowing the cause of obstruction, and differentiating between benign and malignant causes. Imaging plays a significant role in detecting the causes of obstruction. Radiologists aim to diagnose biliary obstruction, its level, extent, and probable causes to determine the appropriate treatment for each case. MethodsOur study is a retrospective medical record review study. It included 150 patients who had ultrasound (US) diagnosis of biliary obstruction and underwent magnetic resonance cholangiopancreatography (MRCP) or endoscopic retrograde cholangiopancreatography (ERCP) in King Fahad Specialist Hospital, Buraidah. The patients’ medical records have been reviewed to measure the sensitivity and specificity of US, MRCP, and ERCP. ResultsStatistical analysis of the data showed that the sensitivity of US in detecting the most common cause of biliary obstruction, common bile duct (CBD) stone, was 26.6%, while the specificity was 100%. Comparing this sensitivity of US in detecting CBD stones to that of MRCP and ERCP, we obtained the following: US, 26.6%; MRCP, 62.9%; and ERCP, 62.4%. Although US was the least sensitive for detecting CBD stones, its specificity in this detection was 100%, while MRCP was 63.6%, and ERCP was 55.2%.Conclusion US is the best initial step for the diagnosis of biliary obstruction. However, MRCP and ERCP are more sensitive in detecting CBD stones compared to US. Also, compared to US, they have shown higher percentages in all aspects of detection: level, cause, and extent of biliary obstruction.

Additional Non-Contrast-Enhanced Computed Tomography (NCECT) of Abdomen to the Routine Magnetic Resonance Cholangiopancreatography (MRCP) Protocol, Increase the Accuracy of Common Bile Duct Stone Detection or Not

Objective: To compare the diagnostic accuracy of magnetic resonance cholangiopancreatography (MRCP) in addition to the non-contrast-enhanced computed tomography (NCECT), with MRCP alone, or NCECT alone for common bile duct (CBD) stone detection using endoscopic retrograde cholangiopancreatography (ERCP) as a gold standard. Materials and Methods: The medical records and image findings were retrospectively reviewed in all consecutive patients that underwent both MRCP and NCECT at Phramongkutklao Hospital between May 2012 and December 2015. The imaging data were reviewed using the consensus of two radiologists who were blind of the final diagnoses from ERCP. The accuracy of each modality in detecting CBD stone was reported as sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). The other associated findings were reported as the presence of gallstones aerobilia, pancreatic calcification, biliary stenting, intrahepatic duct (IHD) dilatation, and CBD dilatation using intermodality agreement and kappa statistics. Results: Two hundred forty-one patients underwent both MRCP and NCECT. The accuracy, sensitivity, specificity, PPV, and NPV of the combined modalities were 98%, 99%, 95%, 98%, and 95%, respectively, which was higher than MRCP alone but it did not reach a statistical significance (accuracy, sensitivity, specificity, PPV, and NPV of MRCP were 97%, 98%, 95%, 99%, and 91%, p=0.77 for accuracy). The other abnormalities found such as aerobilia, presence of gallstone, presence of IHD, and CBD dilatation were similar in both combined MRCP and NCECT as compared with MRCP alone. Conclusion: The accuracy of MRCP alone was good and acceptable for the detection of CBD stone. Adding NCECT to the routine MRCP did not result in a significantly higher accuracy. Thus, routinely adding the NCECT was no longer recommended to avoid unnecessary radiation exposure and increasing the cost of investigation. Keywords: Common bile duct stone, MRCP, NCECT, ERCP, Accuracy

Incidence and risk factors for postoperative common bile duct stones in patients undergoing endoscopic extraction and subsequent cholecystectomy

In patients who undergo cholecystectomy after endoscopic common bile duct (CBD) stone extraction, CBD stones found postoperatively could be problematic. This study aimed to investigate the incidence and risk factors of postoperative CBD stones after cholecystectomy. A total of 278 patients (mean age, 59.2 years; 71 men [51.1%]) who underwent endoscopic removal of CBD stones followed by cholecystectomy from January 2013 to December 2017 were included. An endoscopic nasobiliary drainage (ENBD) tube was placed immediately after endoscopic clearance of the CBD stones in all patients until cholecystectomy. An ENBD tubogram was obtained in all patients to determine the presence of postoperative CBD stones. Postoperative CBD stones were detected in 20.1% (56/278). An ENBD tubogram was obtained after an average of 2.42 days postoperatively. Based on univariate analysis, the statistically significant risk factors for postoperative CBD stone were CBD stones >2, CBD stone size >10mm, cholesterol stone, maximum diameter of CBD >15mm, treatment with endoscopic sphincterotomy alone, and use of endoscopic mechanical lithotripsy (EML). In multivariate analysis, cholesterol stone, CBD stones >2, CBD stone size >10mm, and EML were related to postoperative CBD stones after cholecystectomy. Based on the relatively high rate of postoperative CBD stones after cholecystectomy, careful follow-up should be considered in patients with high-risk factors to detect CBD stones early.

Impacts on outcomes and management of preoperative magnetic resonance cholangiopancreatography in patients scheduled for laparoscopic cholecystectomy: for whom it should be considered?

PurposeWe evaluated the impact of preoperative magnetic resonance cholangiopancreatography (MRCP) on patient outcomes, and found which patients should be considered for MRCP before cholecystectomy.MethodsWe performed retrospective analysis of 2,072 patients that underwent cholecystectomy for benign gallbladder disease from January 2014 to June 2017. Patients were grouped as CT only group (n = 737) and MRCP group (n = 1,335), including both CT and MRCP (n = 1,292) or MRCP only (n = 43). The main outcome measure was associated with complications after cholecystectomy, and the secondary outcomes were hospital stay, readmission, and events that could impact patient management due to addition of MRCP.ResultsThere were no statistical differences in occurrence of intraoperative or postoperative complications or readmission rate between the 2 groups. Hospital stay was about 0.6 days longer in the MRCP group. However, MRCP group was more susceptible to complications due to underlying patient demographics (older age, higher frequency of diabetes, and higher level of the inflammatory markers). MRCP diagnosed common bile duct (CBD) stones in 6.5% of patients (84/1,292) without CBD stones in CT, and bile duct anomalies were identified in 41 patients (3.2%). Elevated γ-GT was the only independent factor for additional detection of CBD stones (adjusted odds ratio [OR], 2.89; P = 0.029) and subsequent biliary procedures (adjusted OR, 3.34; P = 0.018) when additional MRCP was performed.ConclusionMRCP is valuable for identification of bile duct variation and CBD stones. Preoperative MRCP can be considered, particularly in patients with elevated γ-GT, for proper preoperative management and avoidance of complications.

349 Comparison of Common Bile Duct Measurement by Point-of-Care Ultrasound to Radiology-Performed Ultrasound

Exact incidence of common bile duct (CBD) stones is not known, but they have been found in 10-18% of patients undergoing cholecystectomies. They are associated with significant morbidity, resulting in pancreatitis or cholangitis if left untreated. Unfortunately, physical exam and lab tests are unreliable in detecting CBD stones. Limited data exists evaluating the use of point-of-care ultrasound (POCUS) in the emergency department (ED) to evaluate for CBD stones. Our objective was to evaluate the accuracy of CBD diameter measured on POCUS compared to radiology-performed ultrasound. In this retrospective chart review of one academic medical institution, we analyzed 4.5 years of POCUS data to find all cases where CBD dilation was measured and documented by an emergency physician in a POCUS report. We compared these results to radiology-performed ultrasound results of those same patients and compared the two values using paired Student’s T-test to test for significance, mean absolute error (MAE), and Pearson’s correlation coefficient. A total of 126 potential cases of CBD dilation were identified based on POCUS reports that had CBD dilation recorded. Of these, 53 (42%) had radiology imaging studies performed. Thirty-nine (74%) of those included were female. The mean CBD diameter measured on POCUS was 7.61mm (range: 1.3-16.8mm). The mean CBD diameter measured on formal radiology studies for these same patients was 7.34mm (range: 1.0-16.0mm). The two means were not significantly different by paired Student’s T-test (p = 0.63). However, mean absolute error between the two samples was 2.73mm. Pearson’s correlation coefficient was 0.27 (with +1/-1 indicating perfect correlation). While there was not a significant difference between the two samples’ means, there was poor agreement between POCUS and formal radiology US in the evaluation of CBD diameter. We cannot conclude that the two modalities are equivalent in their ability to accurately measure CBD diameter at this time. Limitations of this study include: retrospective chart review with small sample size and no standardization in the qualifications of the physicians performing the POCUS. Future work should include prospective cases and explore how ED providers who receive standardized POCUS training perform versus radiology-performed US for the measurement of CBD diameter.

Detection of Common Bile Duct Stones in Mild Acute Biliary Pancreatitis Using Magnetic Resonance Cholangiopancreatography.

Background All patients with mild acute biliary pancreatitis should undergo early cholecystectomy. Whether routine common bile duct (CBD) imaging should be employed before the surgical procedure in these patients is a matter of current controversy. The aim of this study was to investigate the rate of detection of CBD stones using magnetic resonance cholangiopancreatography (MRCP) at different time intervals from admission. Methods From January 1, 2011, through December 31, 2016, 72 patients with acute biliary pancreatitis underwent MRCP. Fifty-six (n=56) of them with mild biliary pancreatitis met the study criteria. The patients were divided into two groups. Group A did not have stones in the CBD (n=45), and Group B had stones in the CBD (n=11). The time from admission to MRCP was divided into several periods (day 1 through day 180), and the presence of the CBD stones on MRCP was weighted against remoteness from admission. Liver chemistry profiles were compared between the groups on admission and before the MRCP. Results The cumulative rate of choledocholithiasis was 19.7% (Group B, n=11). Forty-five patients (Group A, n=45, 80.3%) did not have gallstones in the CBD. Eight patients with choledocholithiasis (8/56, 14.2%) were detected during the first 10 days from admission out of 27 patients. In patients who underwent MRCP between days 11 and 20, choledocholithiasis was found in two patients (2/56, 3.5%) and in one patient between days 21 and 30 (1/56, 1.8%). No stones were found in patients who underwent MRCP beyond 30 days from admission. Liver chemistry profiles did not show a significant difference in both groups. CBD dilatation was observed at presentation in 11 patients (n=11/56), 6 in Group A (6/45, 13.3%) and 5 in Group B (5/11, 45.5%) (p=0.016). Conclusions Routine CBD evaluation should be encouraged after mild acute biliary pancreatitis. Early performance of MRCP gives high yield in selecting the patients for endoscopic retrograde cholangiopancreatography (ERCP) before cholecystectomy. A liver chemistry profile either on admission or before MRCP cannot predict the presence of CBD stones.