Duct Stones Research Articles

A retrospective analysis of magnetic resonance cholangiopancreatography investigating gallstones in a contemporary surgical setting.

BackgroundsThe New Zealand Public Health System operates in a resource limited environment. Pre‐operative investigation of choledocholithiasis (CDL) is variable. Protocol driven practice has improved patient outcomes and cost‐effectiveness. The aim is to explore risk stratification for CDL and specific thresholds for accessing magnetic resonance cholangiopancreatography (MRCP) in this contemporary setting.MethodsAll adult (16+ years) acute inpatient MRCP requests for gallstone work‐up between 1 Jan 2018 and 2031 Dec 2019 at Dunedin Hospital were included. Patients with characteristics not in fitting with an acute symptomatic examination were excluded. Receiver operating characteristic curves were estimated for bilirubin versus MRCP positive by the presence/absence of dilated ducts, indication and American Society of Gastrointestinal Endoscopy (ASGE) risk grouping.ResultsA 106 patients were included. Mean bilirubin at presentation and time of MRCP, 47 versus 28 μmol/L, respectively. MRCP confirmed CDL in 39 (37%) patients. 38 (97%) had biochemical changes with choledocholithiasis. 21 (40%) with CBD dilation had ductal stones versus 18 (34%) with normal ducts. ASGE risk stratification showed 36 (34%), 66 (62%) and 4 (4%) were high, intermediate and low risk, respectively. Of these groups 44%, 35% and 0% had CBD stones on MRCP, respectively. Combination thresholds involving duct size and bilirubin can yield negative predictive values >90%, substantially reducing MRCP load.ConclusionsMRCP requests can be triaged to maximize stones detected without overly increasing the rate of missed duct stones whilst protecting the limited MRI and ERCP resources. International thresholds and risk stratification alone may not be applicable in our resource limited environment.

Endoscopic nasobiliary drainage-based saline-injection ultrasound: an imaging technique for remnant stone detection after retrograde cholangiopancreatography

BackgroundThe purpose of this retrospective study aimed to assess the accuracy of detection of remnant common bile duct (CBD) stones by injecting saline through endoscopic nasobiliary drainage (ENBD) tubes under transabdominal ultrasound (US) guidance.MethodStone extraction and ENBD are regularly achieved through endoscopic retrograde cholangiopancreatography (ERCP) in patients with CBD stones. At 1–3 days thereafter, routine US studies were performed and repeated, using ENBD tubal saline injections (20–100 mL).ResultsA total of 302 patients underwent standard ERCP stone extractions in conjunction with occlusion cholangiograms, routine US testing, and ENBD-based saline-injection US exams. By occlusion cholangiogram, remnant stones were suspected in 31 (10.3%) patients in total of 302, and 26 (83.8%) were verified as true positives (sensitivity, 50.9%; specificity, 98.0%). Routine US studies proved suspicious in 13 (4.3%) patients in total of 302, and 12 (92.3%) were verified as true positives (sensitivity, 23.5%; specificity, 99.6%). Using ENBD-based saline-injection US, suspected stones were identified in 50 (16.6%) patients in total of 302, and 46 (92%) were verified as true positives (sensitivity, 90.1%; specificity, 98.4%). The sensitivity of ENBD-based saline-injection US significantly surpassed that of occlusion cholangiogram (p < 0.001) and routine US (p < 0.001).ConclusionDetection of remnant CBD stones via ENBD-based saline-injection US is a valid, inexpensive, and repeatable means of patient screening that is non-invasive, radiation-free, and dynamically informative. This may help improve the accuracy of detecting remnant CBD stones after ERCP.

Clinical Guidelines of the Russian Society of Surgeons, the Russian Gastroenterological Association, the Association of Surgeons-Hepatologists and the Endoscopic Society “REndO” on Diagnostics and Treatment of Chronic Pancreatitis

Aim:to present modern methods of diagnosis and treatment of chronic pancreatitis for gastroenterologists, general practitioners and physicians.Chronic pancreatitis (CP) is a long-term inflammatory disease of the pancreas, manifested by irreversible morphological changes in the parenchyma and pancreatic ducts, which cause pain and/or persistent impairment of function. Current concept on the etiology of CP is reflected by the TIGAR-O classification. The criteria for establishing the diagnosis of CP include typical attacks of abdominal pain and/or clinical and laboratory signs of exocrine, endocrine insufficiency with the mandatory detection of characteristic morphological changes (calcifications in the parenchyma and pancreatic ductal stones, dilatation of the main pancreatic duct and its branches). CT, MRCP, and pancreatobiliary endosonography are recommended as the methods of choice to verify the diagnosis of CP. Conservative treatment of patients with CP is provided for symptom relief and prevention of complications. Individual cases with severe non-interactable abdominal pain, as well as a complicated course of the disease (development of ductal hypertension due to main pancreatic duct stones or strictures, obstructive jaundice caused by compression of the common bile duct, symptomatic postnecrotic cysts, portal hypertension due to compression of the portal vein or thrombosis of the splenic vein, persistent duodenal obstruction, pseudoaneurysm of the celiac trunk basin and the superior mesenteric artery) serve as an indication for endoscopic or surgical treatment. The Guidelines set out modern approaches to the diagnosis, conservative, endoscopic and surgical treatment of CP, and the prevention of its complications.Conclusion.The implementation of clinical guidelines can contribute to the timely diagnosis and improve the quality of medical care for patients with chronic pancreatitis.

Compliance to endoscopic retrograde cholangiopancreatography according to current guidelines and adverse outcomes of suspected choledocholithiasis in an acute care setting.

Common bile duct (CBD) stones are common among patients who underwent cholecystectomy. However, few studies have investigated the compliance with the guidelines for the prediction of choledochlithiasis (CL). Therefore, we aim to study the compliance with the American Society for Gastrointestinal Endoscopy (ASGE) guidelines for the identification of CL in a major hospital in Saudi Arabia's capital. We conducted a retrospective chart review on adult patients admitted to emergency department at King Abdulaziz Medical City, Riyadh with gallstones between January 2016 and January 2019. Our data collection includes demographics and level of suspicion based on Transabdominal Ultrasound, liver function, amylase, and lipase tests. We then determined the likelihood of CL based on ASGE guidelines in order to assess the adherence to ASGE guidelines, the procedure's outcomes and adverse outcomes. We identified 826 patients who met the study's criteria: 384 (46.4%) were compliant, while 442 (53.6%) were non-compliant with ASGE guidelines. There was a significant association between compliance and the presence of stones on ERCP in high likelihood patients. 48 (21.3%) of total ERCP procedures among all the likelihoods had adverse outcomes. 13 (40.6%) of non-compliant ERCP performed in intermediate likelihood have experienced adverse outcomes. There was a significant association between having adverse outcomes and being non-complaint with ASGE guidelines. Despite ASGE guidelines' recommendations, a third of high likelihood cases and the majority of intermediate likelihood cases were non-compliant. Additionally, the current guidelines for the intermediate group are somewhat vague, giving ample leeway for patients to be placed in the intermediate group, which might subject them to unnecessary interventions. To conclude, there was a great lack of compliance with ASGE guidelines that is significantly associated with adverse outcomes. Hence, reassessing the current guidelines and monitoring healthcare facilities' compliance with the updated guidelines is highly recommended.

43 The Value of Endoscopic Ultrasound (EUS) in the Investigative Pathway of Acute Idiopathic Pancreatitis (AIP)

Abstract Introduction The British Society of Gastroenterology (BSG) guidelines on the management of acute idiopathic pancreatitis (AIP) state the incidence of idiopathic cases to be no more than 30%. However, before a firm diagnosis of AIP is made, Endoscopic Ultrasound (EUS) may be used to determine occult causes. This approach may help prevent recurrent attacks which may evolve into chronic pancreatitis. Method Retrospective analysis over a one-year period of cases of AIP in a tertiary referral centre was performed to see the incidence of AIP and the role of EUS. Patients with an identifiable cause for pancreatitis were excluded, leaving only those who had received a diagnosis of AIP and the diagnostic value of EUS was examined. Results Of the 101 patients diagnosed with AIP, 19% (n=19) underwent an EUS successfully. 79% (n=15) had no underlying cause of pancreatitis identified on EUS. In the remaining 21% of cases (n=4), microlithiasis, ductal stones, and pus requiring drainage were common findings. Of these patents, only 1 was referred for surgery. In the patient group with negative findings on EUS, 4% were unaffected, 2% were referred for surgery, 2% died and 7% had recurrent episodes of pancreatitis. Conclusions The results of this study show that EUS is a valuable modality in patients with suspected AIP, with a positive diagnostic rate of 21%. Therefore, we propose EUS needs to be included in the investigative pathway of all suspected AIP. Although EUS is a relatively scarce resource, further research is required to establish guidelines for the investigation of suspected AIP.

P-EUS02 The value of Endoscopic Ultrasound (EUS) in the investigative pathway of Acute Idiopathic Pancreatitis (AIP)

Abstract Background The British Society of Gastroenterology (BSG) guidelines on the management of acute idiopathic pancreatitis (AIP) state the incidence of idiopathic cases to be no more than 30%. However, before a firm diagnosis of AIP is made, Endoscopic Ultrasound (EUS) may be used to determine occult causes. This approach may help prevent recurrent attacks which may evolve into chronic pancreatitis. Methods Retrospective analysis over a one-year period of cases of AIP in a tertiary referral center was performed to see the incidence of AIP and the role of EUS. Patients with an identifiable cause for pancreatitis were excluded, leaving only those who had received a diagnosis of AIP and the diagnostic value of EUS was examined. Results Of the 101 patients diagnosed with AIP, 19% (n = 19) underwent an EUS succesfully. 79% (n = 15) had no underlying cause of pancreatitis identified on EUS. In the remaining 21% of cases (n = 4), microlithiasis, ductal stones, and pus requiring drainage were common findings. Of these patents, only 1 was referred for surgery. In the patient group with negative findings on EUS, 4% were unaffected, 2% were refered for surgery, 2% died and 7% had recurrent episodes of pancreatitis. Conclusions The results of this study show that EUS is a valuable modality in patients with suspected AIP, with a positive diagnostic rate of 21%. Therefore, we propose EUS needs to be included in the investigative pathway of all suspected AIP. Although EUS is a relatively scarce resource, further research is required to establish guidelines for the investigation of suspected AIP.

O-BN06 A Proposed Difficulty Grading System for Laparoscopic Bile Duct Exploration. Benefits to Practice and Research

Abstract Background A gap remains between the mounting evidence for single session management of bile duct stones and the obstacles to wider adoption of this approach. The practice of laparoscopic bile duct exploration (LCBDE) is limited not only by the availability of training opportunities and adequate equipment but also by the perception that the technique is difficult and requires a high skill-set. The aim of this analysis is to compare the preoperative and operative characteristics and the postoperative outcomes in easy vs. difficult LCBDE in a large consecutive series, according to a proposed 5 grade classification. Methods 1326 LCBDEs were graded according to the location, number and size of ductal stones, retrieval techniques used, utilisation of choledochoscopy and specific biliary pathologies encountered. The cohort was divided into two groups: easy (Grades I A&amp;B, and Grade II A&amp;B, requiring transcystic or transductal exploration for up to 15 stones the largest being 15mm) and difficult (Grades III A&amp;B, for over 15 stones or intrahepatic stones of any size needing transcystic choledochoscopy, IV and V with Mirizzi Syndrome, impacted stones, and ducts needing stenting, conversion or bilioenteric anastomosis). Various outcome parameters were compared. Results Age, sex, obesity and previous biliary admissions had no effect on operative difficulty. Emergency admission, obstructive jaundice, previous ERCP and dilated CBD were predictive of difficult explorations. 78.3% of patients with acute cholecystitis or pancreatitis, 37 % of jaundice and 46% of cholangitis had easy explorations. Transcystic stone retrieval was possible in 77.7% of easy explorations and choledochotomy required in 62.3% of difficult explorations (vs. 33.6% in the whole series). Choledochoscopy was utilised in 23.4% of Grades I&amp;II vs. 98% in difficult explorations. As expected more biliary drains, stenting, bilio-enteric anastomosis, conversions, operative time, biliary-related complications, hospital stay, readmissions and retained stones increased with difficulty. Grades I&amp;II patients had 2 or more hospital episodes in 26.5% vs. 41.2% for grades III to V, the median presentation to resolution interval increasing from 1 to 3 weeks. There were 2 deaths in difficulty Grade V and one in Grade IIB. Conclusions Difficulty grading of LCBDE is a useful tool of predicting outcomes. It facilitates comparison between studies and fair assessment of training. LCBDEs are easy in 72% and of these 77% can be completed transcystically. It is hoped this will encourage more units to adopt single session management of bile duct stones through establishing referral protocols, developing and refining the skills through training and acquiring the necessary equipment.

P-BN27 Novel technique for safe and efficient cannulation of the cystic and common bile duct

Abstract Background Concomitant stones in the common bile duct (CBD) at the time of laparoscopic cholecystectomy (LC) are present in up to 15% of patients. In conjunction with intra-operative cholangiogram (IOC), transcystic common bile duct exploration (TCBDE) enables diagnosis and management of ductal stones in a single stage procedure. However, cannulation of the cystic duct (CD) and CBD can be challenging. With repeated attempts at cannulation, there is increased risk of iatrogenic injury by creating a false passage or perforating the duct. We propose a novel technique for the safe cannulation of the CD and CBD. Methods Once critical view of safety is achieved, a clip is placed distally in the CD and opened with scissors. A flexible tip 80cm guidewire is then preloaded into 5-French ureteric catheter. The complex is then passed into the introducer through the lateral port. A grasper placed at Hartmann’s pouch is used to retract the gallbladder and straighting the CD. Only the guidewire is advanced out of the catheter, traversing the CD and CBD. Once safely advanced, the catheter can then be slid over the guidewire and the guidewire can be removed. IOC and TCBDE can then be performed if indicated. Results This technique was performed on 18 patients who failed CD cannulation during elective and emergency LC for symptomatic gallstone disease in a single center performed by the same surgical team. Median age was 46 years and there was 15 females. A total of 34 cannulations were attempted (in 18 patients) which 100% success rate. There was no added time required for the technique. In majority of cases it decreased the operative time due to quick intubation of CBD. None of the cases required conversion to open surgery. Conclusions The novel technique described for cannulation of the cystic duct uses a Seldinger ‘like’ approach. This is a safe an effective strategy for cannulation of the CD, making the skills more accessible and more time efficient. This should encourage more surgeons to perform IOC and TCBDE where indicated.

Moy.03Evaluation of the Basket in Catheter Technique for Transcystic Bile Duct Exploration and Suspected Ductal Stones

Abstract Aims The ‘Basket-in-catheter’ (BIC) technique facilitates laparoscopic transcystic ductal exploration (LTCE) and increases its success rate, being easier and safer than inserting the basket alone. This study evaluates the benefits in confirmed and suspected ductal stones. Methods Prospective preoperative, operative and postoperative data on consecutive single session ductal explorations was collected over 28 years and analysed. BIC became our default technique for the transcystic approach to confirmed or suspected bile duct stones. Results 741 of 1225 (60.5%) attempted LTCE were performed using retrieval baskets without dilating the cystic duct (CD). BIC was used in 646 (87.2%). Of 386 (52.1%) patients undergoing successful stone retrieval 62.7% had clinical and radiological risk factors for ductal stones and 92.0% had positive intraoperative cholangiography. 355 (47.9%) patients had preoperative or operative risk factors for CBD stones and equivocal cholangiography in 25%. Basket trawling was negative and repeat cholangiography confirmed resolution of abnormalities. Choledochoscopy was utilised in 484/1225 (39.5%), either primarily or when blind trawling failed to extract stones. Retained stones occurred in 7 patients, six requiring ERCP. Bile leakage occurred in 6 patients. There were two open conversions, no biliary injuries and no mortality. Post-operative pancreatitis occurred in 7 and recurrent stones in 8 patients. Conclusions The BIC technique achieves successful LTCE without CD dilatation in 40%, reducing the need for choledochoscopy and choledochotomy. It facilitates safe and speedy CBD trawling when stones are suspected due to preoperative or operative risk factors or equivocal cholangiography and helps surgeons acquire and consolidate ductal exploration skills.

1282 Evaluation of the Basket in Catheter Technique for Transcystic Bile Duct Exploration and Suspected Ductal Stones

Abstract Aim The ‘Basket-in-catheter’ (BIC) technique facilitates laparoscopic transcystic ductal exploration (LTCE) and increases its success rate, being easier and safer than inserting the basket alone. This study evaluates the benefits in confirmed and suspected ductal stones. Method Prospective preoperative, operative and postoperative data on consecutive single session ductal explorations was collected over 28 years and analysed. BIC became our default technique for the transcystic approach to confirmed or suspected bile duct stones. Results 741 of 1225 (60.5%) attempted LTCE were performed using retrieval baskets without dilating the cystic duct (CD). BIC was used in 646 (87.2%). Of 386 (52.1%) patients undergoing successful stone retrieval 62.7% had clinical and radiological risk factors for ductal stones and 92.0% had positive intraoperative cholangiography. 355 (47.9%) patients had preoperative or operative risk factors for CBD stones and equivocal cholangiography in 25%. Basket trawling was negative and repeat cholangiography confirmed resolution of abnormalities. Choledochoscopy was utilised in 484/1225 (39.5%), either primarily or when blind trawling failed to extract stones. Retained stones occurred in 7 patients, six requiring ERCP. Bile leakage occurred in 6 patients. There were two open conversions, no biliary injuries and no mortality. Post-operative pancreatitis occurred in 7 and recurrent stones in 8 patients. Conclusions The BIC technique achieves successful LTCE without CD dilatation in 40%, reducing the need for choledochoscopy and choledochotomy. It facilitates safe and speedy CBD trawling when stones are suspected due to preoperative or operative risk factors or equivocal cholangiography and helps surgeons acquire and consolidate ductal exploration skills.

A comparative study between single-operator pancreatoscopy with intraductal lithotripsy and extracorporeal shock wave lithotripsy for the management of large main pancreatic duct stones.

Endoscopic management of large main pancreatic ductal (MPD) stones often require treatment with lithotripsy. Extracorporeal shock wave lithotripsy (ESWL) has been the mainstay therapy, and single-operator pancreatoscopy with intraductal (intracorporeal) lithotripsy (SOPIL) is an emerging technique. However, no comparative studies between these techniques exist. We therefore aimed to compare ESWL to SOPIL for the treatment of large MPD stones. This is a retrospective cohort study comparing patients who were treated with ESWL or SOPIL from September 2013 to September 2019 at a single tertiary center. Logistic regression was performed to identify factors associated with technical success and efficient stone clearance (≤ 2 procedures to clear stones). There were 240 patients who were treated with ESWL and 18 treated with SOPIL. The overall technical success rate of stone clearance was 224/258 (86.8%), which was similar between the ESWL and SOPIL groups (86.7% vs 88.9%, p = 1.000). A SOPIL approach required fewer total procedures (1.6 ± 0.6 vs 3.1 ± 1.5, p < 0.001) and less aggregate procedure time (101.6 ± 68.2 vs 191.8 ± 111.6min, p = 0.001). Adverse event rates were similar between the groups (6.3% vs 5.6%, p = 1.000). The use of SOPIL was independently associated with greater efficiency compared to ESWL (OR 5.241 [1.348-20.369], p = 0.017). Stone size > 10mm was associated with less efficient stone clearance (OR 0.484 [0.256-0.912], p = 0.025). Both ESWL and SOPIL are safe and effective endoscopic adjunct modalities for treating large pancreatic duct stones. SOPIL is an emerging alternative to ESWL that is potentially more efficient for lithotripsy and MPD stone clearance.

Prognostic factors for successful outcome in sialendoscopy for sialolithiasis

ZusammenfassungHintergrund Der Erfolg der Sialendoskopie hängt von mehreren Faktoren ab. Im Jahr 2008 wurde die Lithiasis-Stenosis-Dilatation (LSD) -Klassifikation zur genaueren Beschreibung des Stein-Gang-Verhältnisses eingeführt. Neben dem Nutzen der LSD-Klassifikation untersuchten wir weitere prä- und intraoperativ erhobene Einflussfaktoren auf den Erfolg der Sialendoskopie bei Sialolithiasis. Methode PatientInnen mit Sialolithiasis der Glandula submandibularis und Glandula parotis, die zwischen September 2018 und März 2020 eine primäre Sialendoskopie erhielten, wurden retrospektiv untersucht. Die Steingröße, Steinlokalisation und LSD-Klassifikation wurden unter anderem als prognostische Einflussfaktoren untersucht. Ergebnisse Insgesamt wurden 37 PatientInnen retrospektiv untersucht. Eine erfolgreiche Steinextraktion wurde bei 12/37 (32 %) PatientInnen durchgeführt. Bei Erfolg betrug die mediane Steingröße 3,7 mm, verglichen mit 10 mm bei Misserfolg (Mann-Whitney-Test; p < 0,0001). Bei Erfolg waren 11/12 Steine distal lokalisiert, verglichen mit 13/25 proximal lokalisierten Steinen bei Misserfolg (Pearson-Chi-Quadrat-Test; p = 0,010). Bei Erfolg wurden 10/12 Steine als L1S0D0 klassifiziert, während 15/25 bei Misserfolg als L3aS0D0-Steine klassifiziert wurden (Pearson-Chi-Quadrat-Test; p = 0,001). Für distal lokalisierte Steine, die kleiner als 5 mm waren, lag die Erfolgsrate bei 100 %. Für proximal lokalisierte Steine, die größer als 4 mm waren, lag die Erfolgsrate bei 0 %. Für die als L1S0D0 klassifizierten Steine betrug die Erfolgsrate 60–100 %. Schlussfolgerung Distal lokalisierte Steine und Steine kleiner als 5 mm in einem ansonsten unauffälligen Gangsystem können als prognostisch günstige Faktoren angesehen werden. Zukünftige Studien sollten anhand größerer Datenmengen die LSD-Klassifikation, das Volumen der Steine und deren Gangorientierung bzw. deren Abstand von der Papille untersuchen.

Treatment of Complex Whole Liver Intrahepatic Ductal Stones Using a Patented Stone-Clearance Sheath Combined with Nephroscopic Holmium Laser Lithotripsy

Purpose: To investigate the clinical efficacy of nephroscopic laser lithotripsy with the aid of a patented suctioning sheath in treating complicated whole-liver dispersed intrahepatic ductal stones. Methods: From September 2013 to September 2017, 150 patients who were diagnosed with whole-liver dispersed intrahepatic ductal stones were included in this study and were divided into two groups randomly. The control group consists of 75 patients who were treated by traditional surgery combined with choledochoscopic laser lithotripsy. The observation group consists of the other 75 patients who were treated by traditional surgery combined with nephroscopic laser lithotripsy with the aid of the patented sheath. Related treatment outcome parameters were compared. Results: There were no significant differences in first surgery operative time, first surgery bleeding amount, complication and stone clearance rates (P&gt;0.05). However, the second surgery operative time was (63.58±9.84) min while the complication rate was 7.5% in the observation group, significantly less than that of control group (P&lt;0.05). There were significantly higher first-stage and second stage sinus ductal stone clearance rates and final stone clearance rate in the observation group compared to that of control group (P&lt;0.05), while operative times, hospitalization duration and cost, and one year stone recurrent rate were significantly lower (P&lt;0.05). Conclusion: The efficacy of using the patented stone-clearance sheath combined with nephroscopic holmium laser lithotripsy was significant, warrants more extensive clinical adoption.

Laparoscopic Choledochoduodenostomy in Bile Duct Stone Diseases

Common bile duct (CBD) stones are present in 5–15% of patients with gallstones. Some of these patients are candidates for a definitive biliary drainage procedure for prevention of stone recurrence. The aim of our study was to ascertain the outcome of laparoscopic choledochoduodenostomy in choledocholithiasis. After obtaining ethical clearance from the institutional ethical committee, the present prospective and observational study was conducted on 32 patients over a period from September 2017 to September 2020 in the tertiary care hospital. In our study, the total number of patients was 32, of whom 26 (81%) were females. The mean and range of age were 54.44 SD 10.827 and 24–70 years, respectively. The most common presenting feature was jaundice (53.125%). The mean CBD diameter was 24.59 SD 2.564 mm with multiple stones in CBD in 90.625% of our patients. The mean duration of surgery and intraoperative blood loss was 147.94 SD 9.732 and 76.25 SD 12.636 ml, respectively. The mean hospital stay was 6.34 SD 0.827 days with 90.6% of the patients returning to work in the 3rd week. In our study, there was no conversion to open and a single patient developed postoperative ileus which was managed conservatively. There was complete resolution of symptoms on follow-up. Laparoscopic choledochoduodenostomy is safe for benign bile duct diseases. It is physiological, with minimal intraoperative blood loss, less operative time, and fewer postoperative complications and is safe with faster recovery.

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

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

Conventional Surgical Management of Bile Duct Stones: A Service Model and Outcomes of 1318 Laparoscopic Explorations.

The primary aim of this study was to describe the service model of one-session management, with a limited role for preoperative endoscopic clearance. The secondary aim was to review the outcomes and long term follow up in comparison to available studies on LCBDE. The laparoscopic era brought about a decline in the conventional surgical management of common bile duct stones. Preoperative endoscopic removal became the primary method of managing choledocholithiasis. Although LCBDE deals with gallstones and ductal stones in onw session, the limited availability of such an advanced procedure perpetuated the reliance on the endoscopic approach. Prospective data was entered into a single surgeon's database containing 5739 laparoscopic cholecystectomy over 28 years and analyzed. One thousand eighteen consecutive LCBDE were included (23% of the series). Intraoperative cholangiography was performed in 1292 (98.0%). The median age was 60 years, male to female ratio 1:2 and 75% were emergency admissions. Most patients (43.4%) presented with jaundice. 66% had transcystic explorations and one third through a choledochotomy with 2.1% retained stones, 1.2% conversion, 18.7% morbidity, and 0.2% mortality. Postoperative ERCPs were needed in 3.1%. Recurrent stones occurred in 3%. One stage LCBDE is a safe and cost-effective treatment where the expertise and equipment are available. Endoscopic treatment has a role for specific indications but remains the first-line treatment in most units. This study demonstrates that establishing specialist services through training and logistic support can optimize the outcomes of managing common bile duct stones.

Clinical Evaluation of a Newly Developed Guidewire for Pancreatobiliary Endoscopy.

Background: The guidewire (GW) plays an important role in pancreatobiliary endoscopy. GW quality is a critical factor in the effectiveness and efficiency of pancreatobiliary endoscopy. In this study, we evaluate a new 0.025 inch multipurpose endoscopic GW: the M-Through. Methods: Our study was a multicenter retrospective analysis. We enrolled patients who underwent endoscopic procedures using the M-Through between May 2018 and April 2020. Patients receiving the following endoscopic treatments were enrolled: common bile duct (CBD) stone extraction, endoscopic drainage for distal and hilar malignant biliary obstruction (MBO), and endoscopic drainage for acute cholecystitis. For each procedure, we examined the rate of success without GW exchange. Results: A total of 170 patients (80 with CBD stones, 60 with MBO, and 30 with cholecystitis) were enrolled. The rate of completion without GW exchange was 100% for CBD stone extraction, 83.3% for endoscopic drainage for MBO, and 43.3% for endoscopic drainage for cholecystitis. In unsuccessful cholecystitis cases with the original GW manipulator, 1 of 8 cases succeeded in the manipulator exchange. Including 6 cases who changed GW after the manipulator exchange, 11 of 16 cases succeeded in changing GW. There was significant difference in the success rate between the manipulator exchange and GW exchange (p = 0.03). The insertion of devices and stent placement after biliary cannulation (regardless of type) were almost completed with M-through. We observed no intraoperative GW-related adverse events such as perforation and bleeding due to manipulation. Conclusion: The 0.025 inch M-Through can be used for endoscopic retrograde cholangiopancreatography-related procedures efficiently and safely. Our study found high rates of success without GW exchange in all procedures except for endoscopic drainage for cholecystitis. This GW is considered (1) excellent for supportability of device insertion to remove CBD stones; (2) good for seeking the biliary malignant stricture but sometimes need the help of a hydrophilic GW; (3) suboptimal for gallbladder drainage that require a high level of seeking ability.

Predictivity of Biochemical Markers on Aetiology and Length of Hospitalisation in Acute Pancreatitis.

BackgroundAcute pancreatitis (AP) is a common cause of emergency hospital admission. Predictive value of biochemical markers including alanine aminotransferase (ALT), alkaline phosphatase (ALP), bilirubin and lipase on pancreatitis has not been fully established. This study aimed to assess the role of ALT, ALP, bilirubin and lipase levels at admission on predicting the aetiology and length of hospital stay in AP. This study also assesses quantitative high lipase as a predictor of gallstone pancreatitis (GP).MethodsAll patients above the age of 18 with a diagnosis of AP between October 2016 - 2017 were included in our study. The exclusion criteria were patients with a known history of pancreatitis or biliary disease/bile duct stones and pregnancy. This is a retrospective study performed from a prospectively collected electronic patient database at our hospital.ResultsAmong the 143 patients with AP, 50 patients were diagnosed with gallstone pancreatitis (GP) and the remaining of 93 patients suffered non-gallstone pancreatitis (NGP). Mean ALT level was significantly higher in gallstone pancreatitis (237 ± 351 IU) compared to non-gallstone pancreatitis (107 ± 162 IU; P = 0.005). ALP level was numerically high in GP (151.5 ± 186) compared to NGP (138 ± 105 IU; P = 0.64). Similar results in bilirubin level also noted in GP (35.5 ± 24.5) comparing to NGP (20.7 ± 79.6 µmol/L; P = 0.09).Raised ALT (9.3 ± 8.2 versus 3 ± 2.19 days), bilirubin (8.5 ± 2.5 versus 6.9 ± 1.19 days) and ALP levels (6.26 ± 6.1 versus 3.5 ± 10 days respectively; P = 0.05) were associated with longer hospitalisation in GP comparing to NGP. The lipase level more than 10 times the upper reference level (10-URL) was found to be associated with GP (39/50) than NGP (54/93; P = 0.027).ConclusionRaised ALT, high lipase of 10 URL levels were associated with gallstone pancreatitis. In gallstone pancreatitis, patients with high ALT, bilirubin and ALP levels had longer hospital stay.

S3347 Proximal Migration of Pancreatic Stent in Pancreatic Divisum: Challenges in Retrieval and Review of Literature

INTRODUCTION: Pancreatic divisum is the commonest congenital malformation of pancreas. When patients get symptomatic with recurrent attacks of pancreatitis, they undergo ERCP with sphincterotomy and stent placement. Proximal migration of pancreatic stent in Pancreatic divisum is rare and is challenging to manage. We describe an interesting case of proximal migration of pancreatic stent in Pancreatic divisum and perform review of literature. CASE DESCRIPTION/METHODS: A 55-year-old female with past medical history of Pancreas Divisum, Recurrent Pancreatitis presented with sharp epigastric pain radiating to her back associated with nausea and vomiting. On physical exam, she appeared stable with moderate epigastric tenderness. Imaging revealed stones in the main pancreatic duct (PD) with Pancreas Divisum. ERCP was performed, which revealed stenosed minor papilla, which was selectively cannulated and sphincterotomy was performed, ductal stone was removed, and an 8.5 Fr x 9 cm straight plastic stent was placed (Figure 1). During repeat ERCP 3 weeks later, stent was found to have migrated deep into the main PD (Figure 2). The PD was explored endoscopically using SpyGlass Direct Visualization System (Boston Scientific, Natick, Massachusetts, USA). Proximally migrated PD stent was seen which was successfully retrieved using a SpyGlass Retrieval Snare and multiple PD stents were removed. A 5 Fr x 9 cm pigtail PD stent was placed to ensure adequate pancreatic drainage after intraductal intervention. DISCUSSION: Pancreatic stents can migrate both distally as well as proximally into the PD. Migrated stent can cause recurrent pancreatitis, infection, perforation as swell as stenosis of the duct. Incidence of stent migration has been reported at about 1.5% in medical literature.(1) Retrieval of migrated stent is challenging, especially in pancreatic divisum due to anatomical location of main pancreatic duct and the acute angle at which endoscope must be maneuvered. Use of SpyGlass Direct Visualization System enables direct and fluoroscopic visualization of the pancreatic duct. If endoscopic retrieval is not possible, surgical retrieval may be necessary. Risk factors for proximal migration of stent include cholangiocarcinoma, malignant strictures, longer stent use.(1,2).Figure 1.: Cannulation of minor papilla and stone in PD (as pointed by arrow), stent placement.Figure 2.: Migrated PD stent.

S1385 First Case of Risperidone-Associated Secondary Sclerosing Cholangitis

INTRODUCTION: Secondary sclerosing cholangitis is a rare form of sclerosing cholangitis, with cholangiography and biopsy findings that are similar to primary sclerosing cholangitis. Early recognition of secondary causes is important to delay disease progression. There has not been any report that identified antipsychotics as a potential cause of secondary sclerosing cholangitis. Herein, we present a unique case of risperidone-associated secondary sclerosing cholangitis. CASE DESCRIPTION/METHODS: A 72-year-old Caucasian female, who had been treated with risperidone for catatonic schizophrenia for six months, presented to the hospital with altered mental status and fever. Pertinent laboratory findings upon arrival were leukocytosis (white blood cell count - 11.5 × 109/L), bacteriuria, pyuria, and transaminitis (alanine aminotransferase - 597 units/L, aspartate aminotransferase - 467 units/L, gamma-glutamyl transferase - 775 units/L, and alkaline phosphatase - 535 units/L). Ultrasound of the abdomen did not show ductal dilation. Risperidone was held. The patient was treated with antibiotics for a urinary tract infection, with resolution of fever and leukocytosis. As transaminitis improved, risperidone was restarted on day 4; however, transaminitis subsequently worsened. Further work-up was negative for viral hepatitis A/B/C and CMV/EBV infection. Liver core biopsy revealed periductal inflammation with onion skinning-like pattern (Figure 1–3), consistent with secondary sclerosing cholangitis. Transaminitis improved following discontinuation of risperidone. Subsequent endoscopic retrograde cholangiopancreatography revealed three stones in the lower common bile duct, with moderate, diffuse duct dilation. DISCUSSION: Risperidone and other antipsychotics have been reported to induce cholestatic hepatitis. Previous case reports have suggested an association of risperidone with drug-induced hepatitis, as evidenced by transaminitis and inflammatory liver parenchymal changes. Our case is the first to suggest a link between risperidone and secondary sclerosing cholangitis. The fibrotic changes of biliary duct, as well as the temporal relationship between risperidone intake and elevation of hepatic enzymes, are suggestive of this diagnosis. The findings of multiple ductal stones and ductal dilation likely represent the chronic inflammatory process.Figure 1.: Hematoxylin & eosin stain demonstrates the characteristic onion-skinning changes in periductal area.Figure 2.: Trichrome stain reveals high collagen content (blue) in the onion-skinning pattern, predominantly in the periductal area, consistent with active fibroblastic proliferation.Figure 3.: Inflammatory cells infiltrate hepatic parenchyma, consistent with non-specific immune response seen in hepatitis.