Emergency Endoscopic Retrograde Cholangiopancreatography Research Articles

Biliary Taeniasis: Case Series and Literature Review.

Biliary taeniasis is uncommon in clinical practice. We report two cases in our hospital. The first patient was diagnosed with acute biliary pancreatitis. Endoscopic retrograde cholangiopancreatography (ERCP) showed a white, flat, segmented 1-cm-wide tapeworm drilling into the duodenal papilla that was identified as Taenia saginata. After tapeworm removal, bile duct sweeping, and anthelmintic therapy, the patient recovered uneventfully. The second patient was diagnosed with acute cholangitis and multiple stones in the common bile duct and gallbladder. Emergency ERCP showed no tapeworm in the duodenum. During a subsequent ERCP 6 days later, a flat tapeworm, also T. saginata, was identified drilling into the duodenal papilla. We review five patients cases with acute acalculous cholecystitis or cholangitis caused by T. saginata or Taenia solium, and 1 patient with T. saginata drilling into the T-tube. Taeniasis should be taken into consideration when dealing with biliary and pancreatic disease.

Urgent one-stage endoscopic treatment for choledocholithiasis related moderate to severe acute cholangitis: A propensity score-matched analysis.

During emergency endoscopic retrograde cholangiopancreatography (ERCP), the safety and feasibility of performing one-stage endoscopic treatment for patients with acute cholangitis (AC) due to choledocholithiasis are unclear. To investigate the safety and feasibility of one-stage endoscopic treatment for moderate to severe AC. We enrolled all patients diagnosed with moderate to severe cholangitis due to common bile duct stones from January 2019 to July 2023. The outcomes were compared in this study between patients who underwent ERCP within 24 h and those who underwent ERCP 24 h later, employing a propensity score (PS) framework. Our primary outcomes were intensive care unit (ICU) admission rates, ICU length of stay, and duration of antibiotic use. In total, we included 254 patients and categorized them into two groups based on the time elapsed between admission and intervention: The urgent group (≤ 24 h, n = 102) and the elective group (> 24 h, n = 152). Ninety-three pairs of patients with similar characteristics were selected by PS matching. The urgent ERCP group had more ICU admissions (34.4% vs 21.5%, P = 0.05), shorter ICU stays (3 d vs 9 d, P < 0.001), fewer antibiotic use (6 d vs 9 d, P < 0.001), and shorter hospital stays (9 d vs 18.5 d, P < 0.001). There were no significant differences observed in adverse events, in-hospital mortality, recurrent cholangitis occurrence, 30-d readmission rate or 30-d mortality. Urgent one-stage ERCP provides the advantages of a shorter ICU stay, a shorter duration of antibiotic use, and a shorter hospital stay.

Pyogenic liver abscess following endoscopic retrograde cholangiopancreatography procedure for choledocholithiasis

Pyogenic liver abscess (PLA) is a condition in which there is pus accumulation in the liver. It usually develops in the context of portal pyemia, through hematogenous seeding as well as via biliary disease. PLA is a rare, but important complication following biliary instrumentation such as endoscopic retrograde cholangiopancreatography (ERCP). We report a case of a 44-year-old man who initially presented with clinical features of ascending cholangitis. Laboratory investigations revealed leukocytosis as well as hyperbilirubinemia. Diagnosis of choledocholithiasis was then confirmed with an ultrasound examination, showing a 1×1 cm stone in the common bile duct. ERCP was performed and achieved stone clearance. However, the patient returned 1 month later with similar symptoms of right upper quadrant pain, fever and jaundice. Suspecting recurrent choledocholithiasis, an emergency ERCP was performed and showed pooling of radio-opaque contrast in the extra-biliary space. There were also multiple CBD stones seen. An urgent CT Abdomen was done and revealed multiple liver abscesses in bilateral liver lobes, with the largest measuring 4.5x5.9x2.1cm. The patient was treated conservatively with Augmentin and repeat ultrasound at 4 weeks interval showed no residual liver abscess.

Single-use duodenoscopes are an efficient tool for emergency ERCP in real life.

Background Biliary tract emergencies are managed with endoscopic retrograde cholangiopancreatography (ERCP) using duodenoscopes, which are reusable devices that require high-level disinfection to minimize risk of cross-contamination. Recent reports about newly developed single-use duodenoscopes (SUDs) suggest equivalent performance with reusable duodenoscopes, but the effectiveness of SUDs in emergency ERCP has not yet been studied. Patients and methods We conducted a prospective case series of emergency ERCP procedures using SUDs (EXALT model D-Boston Scientific, United States) in a real-life, tertiary care setting without any possibility of using a back-up reusable duodenoscope. Results Twenty-one emergent ERCPs (acute cholangitis 48%, severe jaundice 38 %, others 14 %) were performed in 19 patients (mean age 49.5±15 years). Almost all procedures (20 of 21; 95 %) were technically and clinically successful, whereas selective cannulation failed in one case. Among the successful ERCPs, five (24 %) were achieved by a novice operator. The image was often considered skewed toward yellow tones (48 %), whereas stiffness and pushability for stent insertion were found suboptimal in 5 % of the procedures, without any impact on procedure success. Conclusions SUDs are effective and appropriate devices for emergent situations in real life even in non-expert hands and even if a regular duodenoscope is unavailable as a backup.

Urgent and emergency endoscopic retrograde cholangiopancreatography for gallstone-induced acute cholangitis and pancreatitis.

Urgent or emergency endoscopic retrograde cholangiopancreatography (ERCP) is indicated for gallstone-induced acute cholangitis and pancreatitis. The technique and optimal timing of ERCP depend on the disease state, its severity, anatomy, patient background, and the institutional situation. Endoscopic transpapillary biliary drainage within 24 h is recommended for moderate to severe acute cholangitis. The clinical outcomes of biliary drainage with nasobiliary drainage tube placement and plastic stent placement are comparable, and the choice is made on a case-by-case basis considering the advantages and disadvantages of each. The addition of endoscopic sphincterotomy (EST) is basically not necessary when performing drainage alone, but single-session stone removal following EST is acceptable in mild to moderate cholangitis cases without antithrombotic therapy or coagulopathy. For gallstone pancreatitis, early ERCP/EST are recommended in cases with impacted gallstones in the papilla. In some cases of gallstone pancreatitis, a gallstone impacted in the papilla has already spontaneously passed into the duodenum, and early ERCP/EST lacks efficacy in such cases, with unfavorable findings of cholangitis or cholestasis. If it is difficult to diagnose the presence of gallstones impacted in the papilla on imaging, endoscopic ultrasonography can be useful in determining the indication for ERCP.

A Year of Endoscopic Retrograde Cholangiopancreatography (ERCP) At a Glance. Indications, Interventions, Complications

Objective: To determine the demographics, indications and frequency of interventions and complications endoscopic retrograde cholangiopancreatography (ERCP).&#x0D; Study Design: Cross-sectional study.&#x0D; Place and Duration of Study: Department of Gastroenterology, Pak Emirates Military Hospital, Rawalpindi Pakistan, from Jan to Dec 2019.&#x0D; Methodology: The study included all the elective and emergency ERCP procedures from January 2019 to December 2019.&#x0D; Results: Out of 1030 patients who underwent endoscopic retrograde cholangio-pancreaticography, 903 were enrolled. Sixtyone percent of the participants were males. The mean age was 56 ± 16 years, with the majority of the patients lying in the age range of 41-65 years. The most common indication for ERCP in this study was choledocholithiasis (47%), the most common complication encountered was acute pancreatitis (2.1%), and a mortality rate of 0.2% was reported. The complication rate was statistically related to the intervention rather than the age and gender of the patients.&#x0D; Conclusion: The most common indication for ERCP remains choledocholithiasis, with the most common ERCP complication being acute pancreatitis followed by stent migration. Biliary fistulae, post-surgical biliary leaks and strictures, pancreatic pseudo cysts, acute cholangitis, choledocholithiasis and cholestasis secondary to as cariasis were found in a relatively younger group. The success rate was above 95% for high volume centres.

ERCP in critically ill patients is safe and does not increase mortality.

Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard for minimally-invasive treatment of biliary or pancreatic tract disease. When treating patients on intensive care units (ICU) with ERCP, interventionalists are faced with considerably higher morbidity compared to patients in ambulatory settings. However, data on complications and outcome of critical ill patients undergoing emergency ERCP are limited.A retrospective analysis of 102 patients treated on ICUs undergoing 121 ERCP procedures at the University Hospital of Essen, Germany between 2002 and 2016 was performed. Indications, interventional success, outcome including survival and procedure-related complications were analyzed. Patients’ condition pre-ERCP was categorized by using the “Simplified Acute Physiology Score” (SAPS 3).66/102 patients (64.7%) were referred to ERCP from surgical ICU, 36/102 (35.3%) from nonsurgical ICU. The majority of patients were male (63.7%), the mean age was 54.1 ± 14.9 [21–88] years. Indications for ERCP were biliary complications after liver transplantation (n = 34, 33.3%), biliary leakage after hepatobiliary surgery (n = 32, 31.4%), and cholangitis/biliary sepsis (n = 36; 35.3%), respectively. 117/121 (96.7%) ERCPs were successful, 1 patient (1.0%) died during ERCP. Post-ERCP pancreatitis occurred in 11.8% of interventions. The median simplified acute physiology score 3 was 65 points, predicting a risk-adjusted estimated mortality of 48.8%, corresponding to an observed mortality of 52.2% (P = n.s.).ERCP is safe in critically ill patients on ICU, it does not increase overall mortality rate and has a relatively low rate of procedure-associated complications.

Emergency Endoscopic Retrograde Cholangiopancreatography Did Not Increase the Incidence of Postprocedural Pancreatitis Compared With Elective Cases: A Prospective Multicenter Observational Study.

ObjectiveThe aim of this study was to identify the incidence of and risk factors for post–endoscopic retrograde cholangiopancreatography pancreatitis (PEP) after emergency endoscopic retrograde cholangiopancreatography (ERCP).MethodsWe performed a prospective multicenter observational study of 3914 patients who underwent ERCP. We compared the incidence of PEP after emergency and elective ERCP.ResultsA total of 3410 patients were enrolled in this study. Post-ERCP pancreatitis occurred in 44 of 800 patients (5.5%) and in 190 of 2418 patients (7.9%) in the emergency and elective groups, respectively. No significant difference was noted between the groups (odds ratio [OR], 0.73; 95% confidence interval [CI], 0.52–1.03; P = 0.07). Multivariate analysis showed that the following factors increased the risk for PEP after emergency ERCP: contrast medium injection into the pancreatic duct (OR, 2.56; 95% CI, 1.30–5.03; P = 0.005), >4 cannulation attempts (OR, 5.72; 95% CI, 2.61–12.50; P < 0.001), and endoscopic papillary balloon dilatation (OR, 9.24; 95% CI, 2.13–40.10; P < 0.001).ConclusionsNo significant difference was noted in the incidence of PEP in patients after emergency and elective ERCP. We may prevent PEP even after emergency ERCP by avoiding contrast injection into the pancreatic duct, multiple cannulation attempts, and endoscopic papillary balloon dilatation.

Is Immediate Laparoscopic Cholecystectomy after ERCP a Safe Treatment for Gallstone Complications?

Background: Laparoscopic cholecystectomy (LC) after endoscopic retrograde cholangiopancreatography (ERCP) is a standard treatment for patients with complicated cholelithiasis. Currently, there is no conclusion about the optimal interval between LC and ERCP, especially in the case of emergent ERCP. Objective: The purpose of this study is to compare the outcome of patients treated with immediate, early, and delayed LC after ERCP. Materials and Methods: A total of 198 patients who received LC and ERCP between July 2017 and June 2019 were retrospectively reviewed. Patients were divided into 3 groups: immediate (single-staged LC with ERCP &ndash; 109 patients), early (LC &lt;72 hr after ERCP &ndash; 20 patients) and delayed (LC &gt;72 hr after ERCP &ndash; 69 patients). Patient demographics and primary endpoints (conversion rate to open cholecystectomy (OC), blood loss, operative time, complications, mortality and length of hospital stay) were recorded. The secondary endpoint was to analyze factors that influence the conversion to OC. Results: There were no statistical differences in the conversion rate (p=0.921) and major complications (p=0.548) between all three groups. However, the immediate group demonstrated shorter length of post-ERCP hospital stay than other groups (p=0.0001). The analysis of emergent ERCP cases showed no difference in the conversion rate and major complications (p=0.999 and 0.329). Patients with a history of previous ERCP tend to convert to OC but the difference was not statistically significant in the multivariate analysis (p=0.106). Conclusion: Performing LC immediately after ERCP is safe, does not increase the conversion rate, and results in shorter hospital stays even in emergent ERCP cases. Keywords: Laparoscopic cholecystectomy; Endoscopic retrograde cholangiopancreatography; LC; ERCP; Minimally invasive surgery

Is emergency endoscopic retrograde cholangiopancreatography safe in COVID-19 pandemic?

Is emergency endoscopic retrograde cholangiopancreatography safe in COVID-19 pandemic?

Comparison of the impact of endoscopic retrograde cholangiopancreatography between pre-COVID-19 and current COVID-19 outbreaks in South Korea: Retrospective survey.

BACKGROUNDThe coronavirus disease 2019 (COVID-19) outbreak has markedly influenced the endoscopic patterns. Endoscopic retrograde cholangiopancreatography (ERCP) is an essential technique for pancreatobiliary disease but increases the risk of exposure to the virus-containing body fluid; however, the impact of COVID-19 on ERCP is unknown. AIMTo compare the number of endoscopic activities and to analyze the clinical outcomes of ERCPs before and during the COVID-19 outbreak in Daegu, South Kore.METHODSThis retrospective cohort study included patients aged ≥ 18 years who underwent ERCP between February 18 and March 28, 2020, at a tertiary hospital. ERCP indications and endoscopic details were compared with those from the same period in 2018 and 2019 as control groups.RESULTSOf the 269 ERCP procedures, 113 (42.0%) cases were performed as emergency procedures. The number of ERCP procedures in 2018 and 2019 decreased by 20.2% and 56.6%, respectively, compared with that in 2020 (P < 0.01); among the 113 emergency ERCPs, the observed numbers in 2018 (n = 42) and 2019 (n = 55) dramatically dropped by 61.9% and 70.9%, respectively, compared with that in 2020 (n = 16). Of the 16 cases in 2020, stone removal was performed in five, biliary stenting in five, sphincterotomy in five, and nasobiliary drainage in one. No case of ERCP-related infection in medical workers or other patients has been reported.CONCLUSIONThe COVID-19 outbreak significantly reduced the number of ERCPs; however, there is no difference in the indications and endoscopic interventions before and during the COVID-19 outbreak.

An unusual case of acute cholecystitis following anterior lumbar interbody fusion

Abstract Introduction: Acute acalculous cholecystitis is also likely to occur in critical systemic conditions, such as trauma, burns, and postoperative situations. Here, we report a rare case of acute cholecystitis after anterior lumbar interbody fusion (ALIF). Patient concerns: A 75-year-old female experienced low-grade fever (&lt; 38.3°C), following ALIF of L4–5. On postoperative day 3, the patient exhibited acute jaundice without abdominal discomfort. Diagnosis: Laboratory investigations revealed elevated values for liver function tests and bilirubin levels (aspartate aminotransferase, 79 IU/L; alanine aminotransferase, 56 IU/L; total bilirubin, 7.6 mg/dL; and direct bilirubin 4.1 mg/dL), with no prominent abnormalities, such as stones or dilatation of the hepatobiliary tract, on abdominal computed tomography. However, endoscopic ultrasound revealed diffuse thickening of the gallbladder (GB) wall and large amounts of echogenic material in the GB lumen, suggesting acute cholecystitis with GB sludge. Interventions: Emergency endoscopic retrograde cholangiopancreatography and biliary drainage were performed by inserting a single-tail catheter through the biliary tract. Outcomes: Clinical symptoms, including skin jaundice and icteric sclera, gradually improved, and the patient was discharged 13 days after the surgery. Liver function tests and bilirubin levels were normalized in the final laboratory investigations during the hospitalization period (aspartate aminotransferase. 26 IU/L; alanine aminotransferase. 16 IU/L; total bilirubin, 2.1 mg/dL; direct bilirubin, 0.9 mg/dL; and C-reactive protein, 0.21 mg/dL). Conclusion: Spinal surgeons should be aware of the possibility of biliary complications after ALIF. In particular, postoperative cholecystitis in elderly patients has a poor prognosis; therefore, early diagnosis and intervention are the only ways to improve the prognosis.

Clinical efficacy, timing, and outcomes of ERCP for management of bile duct leaks: a nationwide cohort study.

Background and study aims Endoscopic retrograde cholangiopancreatography (ERCP) can safely and effectively manage postsurgical or traumatic bile duct leaks (BDLs). Standardized guidelines are lacking regarding effective management of BDLs. Our aim was to evaluate the efficacy, clinical outcomes, and complications of different ERCP techniques and intervention timing using a nationwide database. Patients and methods We performed a retrospective analysis of the IBM Explorys database (1999–2019), a pooled, national, de-identified clinical database of over 64 million unique patients across the United States. ERCP timing after BDL was classified as emergent (< 1 day), urgent (1–3 days) or expectant (> 3 days). ERCP technique was classified into sphincterotomy, stent or combination therapy. ERCP complications were defined as pancreatitis, duodenal perforation, duodenal hemorrhage, and ascending cholangitis within 7 days of the procedure. Results Expectant ERCP had a decreased risk of adverse events (AEs) compared to emergent and urgent ERCP ( P = 0.004). Rehospitalization rates also were lower in expectant ERCP ( P < 0.001). Patients with COPD were more likely to have an AE if the ERCP was performed emergently compared to expectantly ( P = 0.002). Combination therapy had a lower rate of ERCP failure compared to placement of a biliary stent ( P = 0.02). There was no statistically significant difference in rates of ERCP failure between biliary stent and sphincterotomy ( P = 0.06) or sphincterotomy and combination therapy ( P = 0.74). Conclusion Our study suggests that ERCP does not need to be performed emergently or urgently for management of BDLs. Combination therapy is superior to stenting but not sphincterotomy; however, future prospective studies are needed to validate these findings.

S2698 A Rare Liver Mass:Hepatic Epithelioid Hemangioepithelioma

INTRODUCTION: Hepatocellular carcinoma (HCC) is the most common liver malignancy and diagnosed when the Liver Imaging Reporting and Data System (LIRADs) criteria are applied to an imaging study. When detected lesions do not meet LIRADS criteria, it is essential to pursue further workup, including liver biopsy. We present a rare vascular tumor hepatic epithelioid hemangioepithelioma (HEHE) masquerading as metastatic HCC to highlight the importance of confirming the imaging diagnosis. CASE DESCRIPTION/METHODS: A 63-year-old male with a past medical history of untreated hepatitis B and hepatitis C, compensated cirrhosis who presented with ascending cholangitis and persistent transaminitis despite Endoscopic retrograde cholangiopancreatography (ERCP). He underwent an emergency ERCP with stone removal and stent placement, but his total bilirubin 2.5, AST 320, and ALT 260 continued to be elevated. An MRI liver and MRCP was significant for an enhancing lesion measuring 2.9 × 3.3 cm within segment 2 without arterial enhancement, LIRADS-M (Figures 1 and 2). Chest CT showed multiple bilateral lung nodules concerning for possible metastases. The team was concerned for metastatic HCC, but the liver lesion did not meet diagnostic criteria. In the setting of uncertainty, a liver and lung biopsy was performed, which was consistent with a HEHE and septic emboli, respectively. After medical optimization, the patient will proceed with surgical resection of the tumor. DISCUSSION: The LIRADS criteria is a reporting system that describes hepatic masses. LI-RADS 5 lesions have a specificity of 86.2% for HCC, while LIRADS M, such as our patient, suggests a malignant lesion with a specificity of 93%. LIRADS M lesions should be biopsied because of diagnostic uncertainty, as highlighted in this case. Our patient was diagnosed with HEHE, which has an incidence is 1:1000.000 and is a tumor found in multiple organs such as the liver and lung. HEHE can mimic other radiological findings, for example, targertoid and lollipop lesions, which make a biopsy necessary for diagnosis. HEHE epithelioid cells surround the sinusoids, and there are atypical nuclei with prominent nucleoli in the peripheral zone. Also, it is associated with CD 34 and CD 31 immunohistochemical stain. This case highlights a rare malignant liver neoplasm masquerading as metastatic HCC, which highlights the importance of performing a liver biopsy in patients where there is diagnostic uncertainty.Figure 1.: The lesion is not seen on the arterial enhancement phase.Figure 2.: T2 hypointense enhancement within liver segment 2 of 2.9 × 3.3 cm.

S3493 Suspected Pneumoperitoneum After an ERCP

INTRODUCTION: Endoscopic retrograde cholangiopancreatography (ERCP) continues to evolve as a diagnostic and therapeutic intervention for numerous pancreaticobiliary disorders. The incidence rate of duodenal perforation (DP) is rare (0.5 to 1%) but with high mortality (9-18%). DP is often recognized radiographically with the presence of extrabiliary free air, but it is important to differentiate from pneumobilia, the free air of no clinical significance following an ERCP. CASE DESCRIPTION/METHODS: A 73-year-old female with past medical history of hypertension, hyperlipidemia, and diabetes presented to the emergency department due to fever, weakness, and confusion for which broad spectrum intravenous antibiotics were initiated. Labs demonstrated an ALT predominated transaminitis and hyperbilirubinemia. Computed tomography (CT) scan revealed dilated biliary tree with probable common bile duct stone. Subsequent septic shock led to an emergent ERCP for suspected ascending cholangitis. Sphincterotomy released a large amount of purulent material, a 1 cm stone, and several smaller stones. Post-procedural chest x-ray was concerning for free air. A nasogastric tube was placed and chest radiograph showed signs of pneumoperitoneum re-demonstrated. Finally, abdominal CT confirmed that there was no air under the diaphragm but pneumobilia was visualized. The patient continued to improve without complications and was subsequently discharged. DISCUSSION: ERCP is a safe and effective procedure for treating many diseases of the pancreatobiliary system but is attributed to subsequent morbidity in some cases. The complications of ERCP include hemorrhage, pancreatitis, cholangitis, and duodenal perforation. After an ERCP with sphincterotomy, clinically insignificant air in the biliary tree can be apparent on CT for months or even years.Although rare, perforation of the duodenum or bile duct can occur in about 1% of ERCP and most cases demonstrate pneumoperitoneum or retropneumoperitoneum. Once radiographic imaging shows free air under the diaphragm, CT imaging should be utilized to confirm the diagnosis.If DP is suspected, management should be individualized according to the imaging findings and overall clinical picture. Patients without peritonitis, sepsis, significant contrast leak during ERCP or follow-up upper GI study, and retro- or intraperitoneal fluid collections during CT, can be successfully managed conservatively with nothing by mouth, intravenous hydration, antibiotics and nasogastric tube for decompression.Figure 1.: Apparent free air under the diaphragm.Figure 2.: Pneumobilia on Abdominal CT. No pneumoperitoneum.

Perioperative outcomes of the patients treated using laparoscopic cholecystectomy after emergent endoscopic retrograde cholangiopancreatography for bile duct stones: Does timing matter?

There is no consensus on the optimal timing for laparoscopic cholecystectomy (LC) after emergent endoscopic retrograde cholangiopancreatography (ERCP) for suspected choledocholithiasis. Although certain data suggest that an early interval or single-stage treatment by LC, together with laparoscopic bile duct exploration, has more favorable outcomes, delayed LC is most often preferred as the standard treatment of patients with gallstones and choledocholithiasis following ERCP due to lack of experience, necessary instrumentation, or organizational restrictions. This study aims to compare the effects of different time intervals between ERCP and LC on perioperative outcomes. In this paper, preoperative and postoperative data from consecutive patients who were treated for common bile duct stones with emergent ERCP and then underwent LC were reviewed retrospectively. To evaluate the impacts of different time intervals on outcomes, patients were classified into three groups according to the duration from the last ERCP to LC: within two weeks (Group 1), between 2-6 weeks (Group 2), and over six weeks (Group 3). This study involved an analysis of 67 patients with a mean age of 52.8 years. Overall conversion rate was 20.0% in Group 1, 25.0% in Group 2, and 13.6% in Group 3 (p=0.646). The rate of conversion to open surgery was 25.0% in male patients and 14.2% in females. In addition, no significant difference was found between the groups concerning gender, comorbidities, laboratory and gallbladder features, operation time, and length of the hospital stay. The perioperative complication rate was found to be 17.9%; however, there was no significant difference between the three groups. Our results support that LC after ERCP is more complex and has higher conversion rates than LC for uncomplicated cholelithiasis. Although no significant effect of different time intervals between ERCP and LC on perioperative outcomes was demonstrated in patients with common bile duct stones concomitant with cholelithiasis, the 2-6 weeks after ERCP is a critical period for conversion to open surgery. It is recommended that LC after ERCP should be performed in the early period, considering that serious complications may occur in the late period and recurrent biliary attacks may occur.

The efficacy and safety of one-stage endoscopic treatment for ascending acute cholangitis caused by choledocholithiasis with severe comorbidities.

Emergency endoscopic retrograde cholangiopancreatography (ERCP) for ascending acute cholangitis in patients with severe comorbidities is challenging. Here, we evaluated the efficacy and safety of one-stage ERCP in such patients by performing a retrospective study. We included all patients with ascending acute cholangitis and undergoing ERCP between January 2017 and March 2019. In total, we recruited 212 patients: 74 and 138 with and without severe comorbidities, respectively. We collected and analyzed data related to basal characteristics, ERCP, and clinical outcomes. Elderly age (76.20 ± 9.99years vs. 66.52 ± 8.16years, P = 0.000), higher levels of leukocyte count (15.86 ± 2.47 × 109/ml vs. 13.49 ± 1.65 × 109/ml, P = 0.000), and serum bilirubin (3.11 ± 1.29mg/dl vs. 1.94 ± 0.90mg/dl, P = 0.000) were present in patients with severe comorbidities. A significantly higher proportion of these patients were severe cases (32.4% vs. 6.5%, P = 0.000), American Society of Anesthesiologists (ASA) stage V status (37.8% vs. 10.1%, P = 0.000) and had undergone general anesthesia (56.8% vs. 18.8%, P = 0.000). Successful biliary cannulation and complete stone clearance in one session were achieved in 207 and 202 patients, respectively. Mean length of hospital stay was 8.02 ± 2.71days. Forty-three patients required ICU stay with the mean length of 3.26 ± 3.51days. In-hospital mortality occurred in seven patients; all these patients had severe comorbidities. ERCP details, including urgent and early ERCP, biliary cannulation, complete stone clearance in one session, stent insertion, and complications were not significantly different between the two groups. Patients with severe comorbidities had a longer in-hospital stay (9.39 ± 3.15days vs. 7.29 ± 2.11days, P = 0.000), a higher proportion of ICU admission (45.9% vs. 6.5%, P = 0.000), and a longer ICU stay length (4.88 ± 4.37days vs. 1.44 ± 0.52days, P = 0.000). Our data also revealed that early diagnosis is an important predictor associated with clinical outcomes. One-stage ERCP is safe and effective for ascending acute cholangitis caused by choledocholithiasis. Early diagnosis is a significant predictor of clinical outcomes.

Timing of Cholecystectomy after Emergent Endoscopic Retrograde Cholangiopancreatography for Cholangitis

Debate remains regarding the timing of laparoscopic cholecystectomy after emergent endoscopic retrograde cholangiopancreatography (ERCP) for acute cholangitis. We hypothesized that patients undergoing early laparoscopic cholecystectomy would have fewer operative complications and a lower conversion rate. This study is a retrospective review of an ERCP database from 2012 to 2016 of adults with a diagnosis of cholangitis secondary to choledocholithiasis who underwent ERCP followed by a laparoscopic cholecystectomy. Patient demographics, ERCP details, timing of operation (<72 hours vs >72 hours after ERCP), complications, and mortality were recorded. Analysis included chi-square, Fisher's exact, and Wilcoxon rank-sum tests, where appropriate. In the 127 patients (65 per cent male; median age, 67 years; 48 (38%) early surgery), there were no differences in demographics, BMI, vital signs, or laboratory values. Patients in the late surgery group were more likely to have a Charlson Comorbidity Index > 3 (P = 0.002), require pre-operative endoscopic sphincterotomy (P < 0.002), need pre-operative insertion of a ductal stent (P < 0.03), and had more postoperative complications (P = 0.04). Patients in the late laparoscopic cholecystectomy group had more comorbidities and suffered more complications.

How I do it: laparoscopic treatment of common bile duct stones

The standard treatment for patients with symptomatic gallstones is laparoscopic cholecystectomy (LC). In patients undergoing LC the prevalence of common bile duct (CBD) stones ranges between 8% and 15% and it increases with advancing age, reaching up to 60% in elderly patients. Every patient who is candidate for LC should be evaluated for the presence of CBD stones and these should be treated if the diagnosis is confirmed. In the literature, the procedure of choice for CBD stones treatment is still debated. In many centers, pre- or postoperative endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (ES) and LC (two-stage endo-laparoscopic management) is considered standard practice instead of open choledocholithotomy and cholecystectomy. Laparoscopic single-stage management of gallstones and CBD stones has demonstrated equivalent outcomes to the two-stage endo-laparoscopic approach in randomized controlled trials but with shorter hospital stay and fewer interventions. Moreover, the two-stage endo-laparoscopic management of CBD stones and gallstones may be associated with a higher additional procedures rate, and possibly increased costs, as compared to single-stage laparoscopic management. Another option is single-stage endo-laparoscopic management of gallstones and CBD stones, performing ERCP/ES during the same LC anesthesia (so called, “Rendez-Vous” procedure). Excluding patients with cholangitis, who should be managed by emergency ERCP with ES and stones removal, in the elective setting the ultimate choice for one procedure or the other largely depends on the local resources and expertise that are available in the individual center, notwithstanding the scientific evidence in favour of single-stage laparoscopic management. The authors report the surgical techniques that they follow during LC for CBD exploration and stones’ removal by laparoscopic trans-cystic or choledochotomy approach.

Comparison between endoscopic retrograde biliary drainage and endoscopic nasobiliary drainage in treatment of acute cholangitis

Objective To compare the safety and effectiveness of endoscopic retrograde biliary drainage (ERBD) and endoscopic nasobiliary drainage (ENBD) in treatment of acute cholangitis. Methods A retrospective analysis was performed on data of 272 patients with acute cholangitis who underwent emergent endoscopic retrograde cholangiopancreatography (ERCP) in Beijing Chaoyang Hospital from January 2009 to June 2017. Patients were divided into ERBD group (n=143) and ENBD group (n=129) according to the drainage measures. In the ERBD group, there were 63 cases of grade Ⅰ (mild) acute cholangitis, 51 of grade Ⅱ (moderate), and 29 of grade Ⅲ (severe), and the corresponding cases in the ENBD group were 54, 37 and 38, respectively. The rate of improvement of inflammation, ERCP-related complications and interventions to drainage were compared between the two groups in all patients and each grade. Results The rates of improvement of inflammation in the ERBD group and the ENBD group were 89.5% (128/143) and 94.6% (122/129), respectively, in overall patients (χ2=2.399, P=0.126), 93.7% (59/63) and 98.1% (53/54), respectively, in grade Ⅰ patients (χ2=0.548, P=0.459), 90.2% (46/51) and 94.6% (35/37), respectively, in grade Ⅱ patients (χ2=0.125, P=0.724), and 79.3% (23/29) and 89.5% (34/38), respectively, in grade Ⅲ patients (χ2=0.657, P=0.418). The incidence of ERCP-related complications in the ERBD group and the ENBD group were 11.9% (17/143) and 7.8% (10/129), respectively, in overall patients (χ2=1.298, P=0.225), 9.5% (6/63) and 7.4% (4/54), respectively, in grade Ⅰ patients (χ2=0.006, P=0.939), 13.7% (7/51) and 8.1% (3/37), respectively, in grade Ⅱ patients (χ2=0.230, P=0.632), and 13.8% (4/29) and 7.9% (3/38), respectively, in grade Ⅲ patients (χ2=0.144, P=0.705). There were no significant differences in the rate of improvement of inflammation and ERCP-related complications between the two groups. The incidences of interventions to drainage in the ERBD group and the ENBD group were 10.5% (15/143) and 3.1% (4/129), respectively, in overall patients (χ2=5.699, P=0.017), 6.3% (4/63) and 1.9% (1/54), respectively, in grade Ⅰ patients (χ2=0.548, P=0.495), 9.8% (5/51) and 5.4% (2/37), respectively, in grade Ⅱ patients (χ2=0.125, P=0.724), and 20.7% (6/29) and 2.6% (1/38), respectively, in grade Ⅲ patients (χ2=3.965, P=0.046). There were significant differences in the incidence of interventions to drainage between the two groups in overall and grade Ⅲ patents. Conclusion ERBD and ENBD are equally safe and effective in treatment of different grades of acute cholangitis, but ENBD can reduce the incidence of interventions to drainage. Key words: Cholangiopancreatography, endoscopic retrograde; Stent; Nasobiliary drainage; Acute cholangitis