Diagnosis Of Choledocholithiasis Research Articles

Intraoperative cholangiography: Learning curve in a General Surgery residency

Background: The use of dynamic intra-operative cholangiography (dIOC) during laparoscopic cholecystectomy (Lap Chole) remains a topic under discussion. Objectives: This study aims to describe and evaluate the learning curve and findings in the dIOC during laparoscopic cholecystectomies performed by Residents of General Surgery, including it as a tool for a safe cholecystectomy, as well as training for the development of skills and abilities. Material and methods: Patients with indication of scheduled or emergency laparoscopic cholecystectomy were included. In the surgeries, traction was performed according to Hunter, critical safety vision and systematic dIOC, by a senior Resident and the dIOC by a less trained resident, tutored by a staff surgeon. Learning curve, operative times, dIOC time relationship with Lap Chole duration time (IOC/LC), repeated cystic dissection, cystic lithiasis and choledocholithiasis were evaluated. Results: 456 patients were operated for one year (2017-2018). It was observed that regardless of who performs the dIOC, they were able to improve their learning curve, objectifying shorter times for Lap Chole, dIOC and the IOC/LC relationship. The learning coefficients were better in complex surgeries in relation to the semester. 5.26 % had choledocholithiasis (n = 24), of these, 66.7% had cystic lithiasis (n = 16) and 25% associated cholecystitis (n = 6). All were resolved trancystically. There were no conversions and dIOC was performed in 100% of cases. Conclusion: The dIOC is an ideal procedure to be practiced systematically during residency. Because it gives the necessary training for the management of the transcystic pathway, allows avoiding an upper bile duct injury and the diagnosis of choledocholithiasis.

Comparison of pre-operative ultrasonography and magnetic resonance cholangiopancreatography with intra-operative surgical findings among patients suspicious to choledocholithiasis

Background: Choledocholithiasis with cholelithiasis is a common problem in the middle and older age group people. Aim of this study is to assess the usefulness of ultrasonography in the diagnosis of choledocholithiasis in resource poor set up.Methods: After matching the inclusion and exclusion criteria, all cases of diagnosed choledocholithiasis were taken for this prospective, single center, observational study.Results: Out of total 130 subjects, 41 were male and 89 were female. Increased incidence of choledocholithiasis was found in females (M:F=1:2.08). The mean age of presentation was 49.27±10.60 years. Ultrasonography was able to diagnose common bile duct (CBD) stones in 57 patients (43.84%) and ductal dilatation in 89 (68.46%). Whereas, magnetic resonance cholangiopancreatography (MRCP) detected CBD stones in 112 (86.15%). Cholelithiasis was associated with choledocholithiasis in 108 patients (83.07%).Conclusions: In the evaluation of choledocholithiasis, in our study particularly trans-abdominal ultrasonography (USG) seemed to have a lower yield than expected for accuracy in determining choledocholithiasis when compared to MRCP and Intra-operative findings. So, a negative USG in a particular may not exclude choledocholithiasis. So, MRCP is the ‘investigation of choice’ among the suspicious patients for CBD stone disease. That is why prior to cholecystectomy in symptomatic patients with deranged liver function test, MRCP always to be done, to detect the missed stone in CBD.

A significant proportion of patients with choledocholithiasis have markedly elevated alanine aminotransferase

Objective: To determine the frequency and nature of liver enzyme elevations among patients presenting with choledocholithiasis (CDL).Methods: A prospective study identified all patients with serum level of alanine aminotransferase (ALT) ≥500 U/L (normal levels: <70 U/L in men, <45 U/L in women) over 1 year. Additionally, other patients with CDL were identified during the same period retrospectively by diagnostic codes and ERCP procedures, providing data on all CDL patients. Symptoms, liver tests, history of cholecystectomy, and radiological imaging were analyzed. Patients with radiologically confirmed CDL or a clinical diagnosis of CDL were included.Results: During the study period, 110 patients had CDL, 60% women, mean age 65 years. Overall 86/110 (78%) had confirmed CDL on imaging and 24/110 (22%) clinically diagnosed. Overall 26% had undergone cholecystectomy, median bile duct diameter 10.0 mm, median maximal liver tests: ALT 436, ALP 226, bilirubin 60 μmol/L (<25). Overall 9/110 (8%) had ALT ≥1000, 43/110 (39%) ALT levels between 500 and 1000 IU/L and 58/110 (53%) had ALT <500 IU/L. Patients with ALT ≥1000 had smaller bile duct diameter of 7 versus 10 mm (p < .001) but similar proportions of cholecystectomies. In the multivariate analysis age, maximal AST and maximal bilirubin were independent predictors of ALT >500. Maximal AST and bile duct diameter were independent predictors of ALT >1000.Conclusions: Approximately 8% of patients with CDL had markedly elevated ALT. These patients had smaller bile duct diameter. Pronounced ALT elevation is a part of the clinical spectrum of CDL.

External Validation of Different Scoring Systems for Suspected Choledocholithiasis

Aim of the Study: The diagnosis of choledocholithiasis is challenging. Previously published scoring systems designed to calculate the risk of choledocholithiasis were evaluated to appraise the diagnostic performance. Patients and Methods: Data of patients who were admitted between 2013 and 2015 with the following characteristics were retrieved: bile stone-related symptoms and signs, and indication to laparoscopic cholecystectomy. To validate and appraise the performance of the 6 scoring systems, the acknowledged domains of each metrics were applied to the present cohort. Sensitivity, specificity, positive, negative predictive, Youden index, and receiver operating characteristic curve with the area under the curve (AUC) values of the scores were calculated. Results: Two-hundred patients were analyzed. The highest sensitivity and specificity were obtained from the Menezes’ (96.6%) and Telem’s (99.3%) metrics respectively. The Telem’s and Menezes’ scores had the best positive (75.0%) and negative (96.4%) predictive values respectively. The best accuracy, as computed by the Youden index and AUC, was found for the Soltan’s scoring system (0.628 and 0.88, respectively). Conclusion: The available scoring systems are precise only in identifying patients with a negligible risk of common bile duct stone, but overall insufficiently accurate to suggest the routine use in clinical practice.

Comparison of diagnostic efficacy of mrcp and ercp in the management of choledocholithiasis

Aim: We compared the accuracy of MRCP and ERCP findings in the management of suspected common bile duct stones. Material and Methods: Between September and December 2017, 104 patients underwent MRCP and then ERCP to explain the etiology of cholestasis and elevated liver enzymes and / or the bilirubin levels. Laboratory values and MRCP were compared with ERCP findings for the accuracy and reliability of laboratory and radiological findings. Results: The one-hundred four patients underwent MRCP and then ERCP. Of these, 49 (47.1%) were males. The mean age of the patients was 60.7 ± 16.4 years. When compared MRCP and ERCP findings, the sensitivity of MRCP was 71%, specificity was 35%, negative predictive value (NPV) was 31% and positive predictive value(PPV) was 75%. The accuracy rate was calculated as 61% Conclusion: The diagnosis of choledocholithiasis, should have been done with primarily MRCP and EUS should be used in cases when MRCP is inadequate. ERCP should be used for only in therapeutic procedures.

Effects of predictive nursing on the postoperative complications after endoscopic retrograde cholangio-pancreatography

Objective To analyze the complications after endoscopic retrograde cholangio-pancreatography (ERCP) and nursing countermeasures. Methods A total of 84 patients who were hospitalized in the General Surgery Department of the First People's Hospital of Neijiang with the diagnosis of choledocholithiasis from Octorber 2014 to October 2016 for ERCP were recruited in the study. All the subjects were randomly divided into control group (n=44) and experimental group (n=40) . The control group were given routine perioperative nursing, while the experimental group were given predictive nursing on the basis of routine nursing. Hospitalization time, postoperative complications and nursing satisfaction were compared between the two groups. Results The incidence rate of postoperative complication was 5.00% in the experimental group, which was lower than that of the control group (27.27%) (P<0.05) . The hospitalization time of the experimental group was lower than that of the control group, and the nursing satisfaction was higher. All the differences were statistically significant (P<0.05) . Conclusions Postoperative complications such as acute pancreatitis, hyperamylasemia, biliary tract infection, gastrointestinal bleeding and perforation are easy to occur after ERCP. Predictive nursing can effectively reduce the incidence of postoperative complications, shorten hospitalization time and improve patient satisfaction. Key words: Cholangiopancreatography, endoscopic retrograde; Postoperative complications; Predictive nursing

Laparoscopic Common Bile Duct Exploration for Choledocholithiasis: Analysis of Practice Patterns of Intermountain HealthCare

The ideal management of common bile duct (CBD) stones remains controversial, whether with single-stage management using laparoscopic CBD exploration (LCBDE) during laparoscopic cholecystectomy, or with 2-stage management using preoperative or postoperative ERCP. We wished to elucidate the practice patterns within our health system, which includes both large urban referral centers and small rural critical access hospitals. We conducted a retrospective data analysis from our 22-hospital, not-for-profit, integrated healthcare system. All patients with a diagnosis of choledocholithiasis who underwent laparoscopic cholecystectomy (LC) and either ERCP or LCBDE for duct clearance between 2008 and 2013 were included. Demographic data, along with disease-specific characteristics and outcomes, were collected and compared. During the study period, 37,301 patients underwent LC. Of these, 1,961 (5.3%) met inclusion criteria. Single-stage management with LC+LCBDE was performed in 28% of patients, and the remaining 72% underwent 2-stage management with ERCP (73% postoperative ERCP, 27% preoperative). Mean total number of procedures was lowest in the LC+LCBDE group vs the post-cholecystectomy ERCP group vs the preoperative ERCP group (mean 1.4 vs 2.1 vs 2.3; p < 0.05). Hospital charges were also lower in the LC+LCBDE group vs post-cholecystectomy ERCP vs preoperative ERCP groups ($9,000 vs $10,800 vs $14,200; p < 0.05). Single-stage vs two-stage management varied greatly between hospitals (from 0% to 93%). Single-stage management of CBD stones resulted in the fewest procedures and lower hospital charges without an increase in complications. Single-stage management (LC+LCBDE) of CBD stones is underused and can offer better value in today's cost-constrained environment.

Minimally-invasive and endovideosurgical technologies in diagnosis and treatment of choledocholithiasis.

. The paper presents the results of the use of minimally-invasive methods in the diagnosis and treatment of choledocholithiasis. The results of treatment of 595 patients aged from 24 to 92 years with the diagnosis of choledocholithiasis were evaluated. In 552 (93,0%) patients, clinical ma­nifestations of mechanical icterus were noted. In 508 (85,3%) patients, choledocholithiasis was combined with the presence of gallstones, in 15 (2,5%) cases – with calculous cholecystitis, in 69 (11,6%) cases - choledocholithiasis was residual. For the diagnosis of choledocholithiasis, ultrasound of the abdominal cavity, computed tomography, endoscopic retrograde cholangiopancreatogy, percutaneous fistulocholangiography, intraoperative cholangiography or cholangiography were used. Surgical treatment included both mini-invasive interventions and traditional operations. 227 (38,1%) patients underwent endoscopic papillosphincterotomy, which was effective in a size of concrement up to 7 mm in 83,7%. The percutaneous drainage of the bille ducts was performed in 88 (14,7%) patients, the efficacy was achieved in 82,9%. 313 (52,6%) patients subsequently underwent the second stage of surgical treatment of choledocholithiasis by laparoscopy – 263 (84,0%) and laparotomy – 50 (16,0%) with cholecystectomy with choledocholithoextraction and subsequent external or internal drainage of choledochus. Comparison of different methods of investigation showed that none of the diagnostic techniques had 100% of accuracy and informative value. The efficacy of transpapillary manipulation directly depended on the size of the stones.

Performance of the Choledocholithiasis Diagnostic Score in Patients with Acute Cholecystitis

Introduction: The prevalence of choledocholithiasis among patients with acute cholecystitis is estimated to be between 9 and 16.5%. There are no validated algorithms to predict choledocholithiasis in this group of patients. Aim: The aim of this study was to evaluate the performance of the choledocholithiasis diagnostic score proposed by the American Society for Gastrointestinal Endoscopy, in patients with acute cholecystitis. Material/Methods: A retrospective cross-sectional study, covering a 4-year period at a secondary care hospital, was performed. All patients with an encoded diagnosis of acute cholecystitis and with at least one of the following procedures were included: endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound, magnetic resonance cholangiopancreatography, and intraoperative cholangiography. Results: Among 4,369 patients with the diagnosis of acute cholecystitis, 40 (0.92%) had clinical or sonographic suspicion of choledocholithiasis. Their mean age was 68.1 ± 15 years, and 22 (55%) were men. Thirty-one of the patients included (77.5%) had a high risk of choledocholithiasis, and 9 (22.5%) had an intermediate risk. In 16 (51.6%) of the 31 patients with a high risk, the diagnosis of choledocholithiasis was confirmed. In 2 (22.2%) of the 9 patients with an intermediate risk, the diagnosis of choledocholithiasis was also confirmed. The high risk score for choledocholithiasis had a positive predictive value of 52% and a sensitivity of 89%. The intermediate risk score for choledocholithiasis had a positive predictive value of 22% and a sensitivity of 11%. Discussion and Conclusions: Suspicion of choledocholithiasis in patients with acute cholecystitis was a rare event (<1%). The sensitivity of the high risk score was approximately the same as found in published series with patients with suspected choledocholithiasis overall (86%), while the positive predictive value was substantially lower (52 vs. 79.8%). Therefore, in patients with acute cholecystitis and suspected choledocholithiasis, this score should not be used to screen for common bile duct stones, and a sensitive method should be used prior to ERCP.

The role of magnetic resonance cholangiopancreatography and diffusion-weighted imaging for the differential diagnosis of obstructive biliary disorders

Background: Although endoscopic retrograde cholangiopancreatography (ERCP) is accepted as the gold standard, there is a place for magnetic resonance cholangiopancreatography (MRCP) and diffusion-weighted imaging (DWI) in the diagnosis of obstructive biliary disorders.Aim: To compare the findings of MRCP with ERCP in patients with obstructive biliary disorders and to investigate the diagnostic efficacy of MRCP combined with DWI.Study design: Retrospective, analytic, cross-sectional study.Methods: The MRCP images of 126 patients who underwent both MRCP and ERCP owing to biliary obstruction were reviewed. Nine patients were excluded because of incomplete diagnostic workup or a long period (&gt;3 months) between MRCP and ERCP. Ninety-two patients underwent DWI, which was also evaluated. The sensitivity, specificity and accuracy of MRCP and DWI were analysed.Results: The sensitivity, specificity and accuracy of MRCP according to ERCP results as the gold standard was 97%, 71% and 93% for assessment of biliary dilatation; 100%, 94.7% and 97.5% for the diagnosis of choledocholithiasis; 93.7%, 100% and 99% for the identification of benign strictures; 100%, 100% and 100% for the diagnosis of malignant tumours; and 100%, 100% and 100% for the detection of complicated hydatid cysts; respectively. The sensitivity and specificity of DWI for the diagnosis of malignant tumour was 100%. In the detection of choledocholithiasis, the sensitivity and specificity of DWI was 70.8% and 100%.Conclusions: MRCP is an alternative, non-invasive, diagnostic modality, comparable with ERCP for the evaluation of pancreaticobiliary diseases. DWI can be helpful for diagnosis of choledocholithiasis and tumours.

Diagnostic value of biliopancreatic endosonography in the diagnosis of acute cholangitis secondary to biliary obstruction

Background and Objectives:The diagnosis of obstructive cholangiopathies by biliopancreatic endosonography has been extensively studied, and there is an extensive recognition of its role in the diagnosis of choledocholithiasis, biliopancreatic tumors, and extrinsic biliary compression syndromes. Cholangitis, a more frequent complication of biliary obstruction, which is responsible for much of its morbidity and mortality, has not been sufficiently linked to endosonographic findings.Methods:Our study attempted to define the diagnostic validity of endosonography in patients with acute cholangitis to limit the morbidity and mortality of the diagnostic delay and simultaneously achieve an etiological diagnosis and a primary management plan in patients at risk. A descriptive study was carried out to analyze the clinical histories of patients undergoing biliopancreatic endosonography for obstructive jaundice of any etiology and who were subsequently taken to endoscopic retrograde cholangiopancreatography (ERCP) to manage biliary obstruction, for which we compared the endosonographic findings compatible with acute cholangitis (thickening of the bile duct of 1.5 mm or more, presence of pericolangitic halo of at least 1.5 cm in length, and presence of mixed echogenicity content in the interior of the pathway biliar) with the presence of purulent drainage in ERCP.Results:A high frequency of these findings was found in patients with cholangitis, with biliary wall thickening being more common in 92.6% of cases. Moreover, to a lesser extent, the pericholangitic halo presence in 59.3% and ductal content in 66.7% of the cases. No differences were found in the demographic characteristics of patients such as age and sex. The etiology of biliary obstruction showed a behavior similar to that of historical controls.Conclusions:It is advisable to carry out studies with a greater statistical power, to validate our results, for a future inclusion of EUS in the diagnostic algorithm of clinical practice guidelines in acute cholangitis.

Role of Endoscopic Retrograde Cholangiopancreatography in the Diagnosis of Choledocholithiasis

Abstract Introduction. Retrograde cholangiopancreatography (ERCP) is a validated reference method for detection and treatment of choledocholithiasis. It can be performed at any stage of treatment. It allows for differentiation of bile retention causes, assessment of the level of bile ducts dilation, location of the obstruction level and establishment of recommendations for invasive bile ducts tests. Despite varied course of choledocholithiasis, swift detection and removal of stones from bile ducts should be striven for due to a potential risk of life-threatening complications. Aim. The aim of the study was to evaluate the diagnostic effectiveness of the retrograde cholangiopancreatography in patients with suspected bile ducts choledocholithiasis. Material and methods. Based on the literature review, the retrograde cholangiopancreatography in the diagnostics of bile ducts choledocholithiasis has been evaluated. Identification of choledocholithiasis, regardless of clinical symptoms, is associated with the decision to remove deposits from bile ducts. ERCP is the method of choice. Conclusions. As studies by numerous authors show, cholelithiasis can be the leading cause of cholangitis and pancreatitis. Diagnostic ERCP with evacuation deposits remains the most recommended diagnostic method in such cases.

Evaluación de la seguridad de la CPRE en pacientes de la tercera edad: experiencia de un hospital universitario en Bogotá

Antecedentes: la colangiopancreatografía retrógrada endoscópica (CPRE) es el método de elección en el manejo de la coledocolitiasis; sin embargo, existen controversias sobre su seguridad en el adulto mayor. Objetivo: determinar si hay mayor riesgo de complicaciones con la realización de la CPRE en el manejo de la coledocolitiasis en pacientes mayores de 70 años de edad valorados en el Hospital Universitario Clínica San Rafael (HUCSR). Metodología: se realizó un estudio analítico de corte transversal que incluyó pacientes que ingre- saron al servicio de urgencias del HUCSR durante el período de 1 año (2011-2012) con diagnóstico de coledocolitiasis. La información demográfica, clínica y paraclínica, así como los hallazgos del procedimiento, fueron analizados teniendo en cuenta dos grupos de pacientes (mayores y menores de 70 años de edad). Se llevó a cabo un análisis estadístico univariado y bivariado. Resultados: se incluyó un total de 171 pacientes. La presencia de comorbilidades (es decir, diabetes e hipertensión arterial), los niveles de bilirrubina directa y de transaminasas fueron variables asociadas sig- nificativamente con los pacientes con edad mayor o igual a los 70 años. Se presentaron complicaciones relacionadas con el procedimiento, siendo la más frecuente la pancreatitis pos-CPRE y la hemorragia pospa- pilotomía; sin embargo, no estuvieron relacionadas con la edad de los pacientes. Conclusión: la CPRE es segura en pacientes con coledocolitiasis. La edad mayor de 70 años no incre- menta la mortalidad relacionada con el procedimiento.

EFFICIENCY OF INSTRUMENTAL METHODS FOR DIFFERENTIAL DIAGNOSIS OF MECHANICAL JAUNDICE

Aim. The aim of the study was to investigate the efficiency of instrumental methods for differential diagnosis of mechanical jaundice. Materials and methods. Retrospective analysis of the results of mechanical jaundice diagnosis was carried out in 253 patients. Transabdominal ultrasonography (US), endoscopic retrograde cholangiography (ERCG), percutaneous transhepatic cholangiography (PTCG), intraoperative cholangiography (ICG), computed tomography (CT), magnetic resonance imaging (MRI) were used. Results. Calculous character of disease was revealed in 133 (53 %) patients, acalculous mechanical jaundice - in 120 (47 %). Ultrasonography has a sensitivity of 87 % when revealing cholelithiais, 13 % - diagnosis of choledocholithiasis, 43 % - tumors of pancreaticoduodenal zone (PDZ). ERCG is most effective for diagnosis of choledocholithiasis and big duodenal papilla stenosis (sensitivity, 91 % and 78 %, respectively). In case of benign and malignant biliary strictures, the study is also highly informative, but can be performed only in 21 % of cases. CT and MRI demonstrate a high sensitivity (75-100 %); they are most effective when determining the character of pathological process. PTCG sensitivity in choledocholithiasis is 100 %, in PDZ tumors - 75 %, in strictures - 65 %, in indurative pacreatitis - 50 %. Conclusions. When suspecting the calculous character of disease, ERCG is the most effective method for differential diagnosis of mechanical jaundice. Differential diagnosis of acalculous mechanical jaundice is most difficult. In the majority of cases, we have to use successively some diagnostic methods, that proves their insufficient effectiveness.

Chemerin: a new biomarker to predict postendoscopic retrograde cholangiopancreatography pancreatitis.

Individuals with increased visceral adiposity are considered to be more sensitive and more prone to severe acute pancreatitis because of the inflammatory microenvironment they have. We hypothesized that insulin resistance, adipokines, and proinflammatory cytokines that markedly affect the course of pancreatitis can contribute toward development of postendoscopic retrograde cholangiopancreatography (post-ERCP) pancreatitis (PEP) and aimed to investigate the association between PEP risk and preprocedural serum vaspin, chemerin, tumor necrosis factor α, interleukin-6 (IL-6) levels, and homeostasis model assessment of insulin resistance. Eighty-two patients with a diagnosis of choledocholithiasis and 30 controls were enrolled. Preprocedural chemerin, vaspin, IL-6, and well-known PEP risk factors were compared between PEP and non-PEP groups. The mean age of the patients was 56.3±14.4 years; 52 patients were women. Adipocytokine levels, BMIs, and waist circumferences of the patient group were found to be higher than those of the controls. Total cannulation success and the mean procedure time were 82.9% and 28.7±8.8 min, respectively. PEP developed in 12 (14.6%) patients. Chemerin levels in the PEP group were higher than those in the non-PEP group (580.2±172.5 vs. 392.2±168.2 ng/ml, P<0.01). Insulin resistance was higher in the PEP group than the non-PEP group (P=0.001), but there was no significant difference between PEP and non-PEP groups in terms of preprocedural vaspin, tumor necrosis factor α, IL-6, and C-reactive protein levels. According to logistic regression analysis, increased chemerin levels, homeostasis model assessment of insulin resistance 2.5 or greater, and pancreatic duct cannulation were found to be independent risk factors for PEP [odds ratio (OR)=1.006, P=0.006; OR=4.57, P=0.05; OR=6.54, P=0.02]. Elevated serum chemerin levels and insulin resistance are independent risk factors of PEP development.

Biliary/Pancreas.

Biliary/Pancreas.

Eleven years of primary closure of common bile duct after choledochotomy for choledocholithiasis.

The choice of surgical technique to extract stones from the common bile duct (CBD) depends on local experience, anatomical characteristics and also on the size, location and number of stones. Most authors consider choledochotomy an alternative to failed transcystic exploration, although some use it exclusively. Although the CBD is traditionally closed with T-tube drainage after choledochotomy, its use is associated with 11.3-27.5% morbidity. This study examined the efficacy of laparoscopic CBD exploration (LCBDE) with primary closure for the treatment of CBD stones using intraoperative cholangiography (IOC). Retrospective study of 160 patients who underwent LCBDE with primary closure after choledochotomy between January 2001 and December 2012. The diagnosis of choledocholithiasis was definitively made in all cases by IOC. The overall complication rate was 15% and the biliary complication rate was 7.5%. Bile leakage was reported in 11 patients (6.8%). In over half the cases (63.6%), no further action was required and the leak closed spontaneously. Six patients were reoperated (3.75%), two for bile peritonitis and four for haemoperitoneum. The success rate for stone clearance was 96.2%. The mortality rate and CBD stricture rate were 0%. Primary closure after choledochotomy to clear stones from the CBD is a safe technique that confers excellent results and allows one-stage treatment.

Mo1425 Utilization Trends of Endoscopic Retrograde Cholangiopancreatography (ERCP) From 2000-2014 in a Large US Endoscopic Database

patient tolerance of procedure, technical success, and recovery time, and most are limited to single centers with few patients. Our aim was to assess utilization of deep sedation with propofol among inpatients undergoing ERCP for choledocholithiasis and compare outcomes of mortality, complications, length of stay (LOS), and hospitalization cost between those who received deep sedation and those who did not. Methods: This cross-sectional study included hospitalized patients with a diagnosis of choledocholithiasis who underwent ERCP between 2006 and 2012. Data was obtained from the Perspective database, a validated dataset of inpatient admissions from O500 hospitals nationwide created to measure quality and health care utilization. Patient and hospital characteristics were compared by Chi-square and t-tests, and multivariable analysis was used to determine the effect of deep sedation on outcomes of in-hospital mortality, complications, LOS, and hospitalization cost. Results: We identified 60,342 eligible patients, of which 26,244 (43.5%) had deep sedation with propofol. The proportion of ERCP cases with propofol increased from 28.8% (2006) to 53.2% (2012). Mean age of the population was 63.8 20.1 years (62.3 with propofol, 65.1 without, p!0.0001). Patient characteristics inversely associated with propofol use were older age, Medicare insurance, and multiple comorbidities. Hospital characteristics inversely associated with propofol use were teaching status and larger hospital size. In-hospital mortality following ERCP was 1.2% (1.1% with propofol, 1.3% without, p!0.0001), rate of any complication was 38.2% (37.2% with propofol, 39.0% without, p!0.0001), LOS was 6.1 days (6.1 with propofol, 6.2 without, pZ0.13), and hospitalization cost was $13,127 7,463 ($13,414 with propofol, $12,905 without, p!0.0001). Adjusting for patient and hospital characteristics on multivariable analysis, hospitalization cost was $759 greater with propofol (p!0.0001) but there were no differences in in-hospital mortality (OR 0.97 95% CI 0.83-1.12), rate of any complication (OR 1.02 95% CI 0.991.06), and LOS (1.05 days more with propofol, 95% CI 0.96-1.14) between those who received propofol and those who did not. Conclusions: Utilization of propofol for ERCP in hospitalized patients with choledocholithiasis has increased. Selection of patients for deep sedation with propofol should be based on patient characteristics, irrespective of hospital characteristics and resources, as clinical outcomes are comparable and hospitalization cost differences are negligible.

Rationale for effectiveness of a new method of radial sphincterotomy during obstruction of extrahepatic bile ducts

Aim. Determination of the effectiveness of the improved method of sphincterotomy in choledocholithiasis, called radial sphincterotomy. Methods. Analyzed were results of 38 operations performed by endoscopic retrograde cholangiopancreatography in patients with a diagnosis of choledocholithiasis. In the first group (23 patients) performed a standard sphincterotomy, in the second group - radial sphincterotomy. 21 patients of the first group had gallstones up to 20 mm, 2 patients - more than 20 mm; in 6 patients (out of 15) of a second group gallstones sizes exceeded 20 mm, the other patients had stones sizes 15-20 mm. Results. The technique developed radial sphincterotomy allows multiple incisions towards 11, 12 and 13 hour clock directions. Thus, the main incision can be made to the transverse folds, and other radial incisions should be carried out below it, not going beyond the proposed location of the intramural common bile duct. Anatomical and mathematical justifications of the method of radial sphincterotomy were presented. Depending on the cut and shape of papillae, the severity of the upper transverse folds defining a safe distance from the hole until it papillae, performed lateral radial incisions, thereby achieving an increase of sphincterotomy cut altogether. Neither group registered death. In 2 (8.7%) patients of the first group bleeding occurred during the procedure, after the operation pancreatitis has developed in 1 (4.3%) patients in first group and in 1 (6.7%) patients in the second group. Conclusion. The proposed technique of radial sphincterotomy is a safe way to increase the area of dissected papillae to provide high efficiency for removal of large gallstones.

Randomised study on single stage laparo-endoscopic rendezvous (intra-operative ERCP) procedure versus two stage approach (Pre-operative ERCP followed by laparoscopic cholecystectomy) for the management of cholelithiasis with choledocholithiasis.

INTRODUCTION:The ‘Rendezvous’ technique consists of laparoscopic cholecystectomy (LC) standards with intra-operative cholangiography followed by endoscopic sphincterotomy. The sphincterotome is driven across the papilla through a guidewire inserted by the transcystic route. In this study, we intended to compare the two methods in a prospective randomised trial.MATERIALS AND METHODS:From 2005 to 2012, we enrolled 83 patients with a diagnosis of cholecysto-choledocolithiasis. They were randomised into two groups. In ‘group-A’,41 patients were treated with two stages management, first by pre-operative endoscopic retrograde cholangiopancreatography (ERCP) and common bile duct (CBD) clearance and second by LC. In ‘group-B’, 42 patients were treated with LC and intra-operative cholangiography; and when diagnosis of choledocholithiasis was confirmed, patients had undergone one stage management of by Laparo-endoscopic Rendezvous technique.RESULTS:In arm-A and arm-B groups, complete CBD clearance was achieved in 29 and 38 patients, respectively. Failure of the treatment in arm-A was 29% and in arm-B was 9.5%. In arm-A, selective CBD cannulation was achieved in 33 cases (80.5%) and in arm-B in 39 cases (93%). In arm-Agroup, post-ERCP hyperamylasia was presented in nine patients (22%) and severe pancreatitis in five patients (12%) versus none of the patients (0%) in arm-B group, respectively. Mean post-operative hospital stay in arm-A and arm-B groups are 10.9 and 6.8 days, respectively.CONCLUSION:One stage laparo-endoscopic rendezvous approach increases selective cannulation of CBD, reduces post-ERCP pancreatitis, reduces days of hospital stay, increases patient's compliance and prevents unnecessary intervention to CBD.