Endoscopic Biliary Intervention Research Articles

Comparative Safety of Robotic-Assisted vs Laparoscopic Cholecystectomy

Robotic-assisted cholecystectomy is rapidly being adopted into practice, partly based on the belief that it offers specific technical and safety advantages over traditional laparoscopic surgery. Whether robotic-assisted cholecystectomy is safer than laparoscopic cholecystectomy remains unclear. To determine the uptake of robotic-assisted cholecystectomy and to analyze its comparative safety vs laparoscopic cholecystectomy. This retrospective cohort study used Medicare administrative claims data for nonfederal acute care hospitals from January 1, 2010, to December 31, 2019. Participants included 1 026 088 fee-for-service Medicare beneficiaries 66 to 99 years of age who underwent cholecystectomy with continuous Medicare coverage for 3 months before and 12 months after surgery. Data were analyzed August 17, 2022, to June 1, 2023. Surgical technique used to perform cholecystectomy: robotic-assisted vs laparoscopic approaches. The primary outcome was rate of bile duct injury requiring definitive surgical reconstruction within 1 year after cholecystectomy. Secondary outcomes were composite outcome of bile duct injury requiring less-invasive postoperative surgical or endoscopic biliary interventions, and overall incidence of 30-day complications. Multivariable logistic analysis was performed adjusting for patient factors and clustered within hospital referral regions. An instrumental variable analysis was performed, leveraging regional variation in the adoption of robotic-assisted cholecystectomy within hospital referral regions over time, to account for potential confounding from unmeasured differences between treatment groups. A total of 1 026 088 patients (mean [SD] age, 72 [12.0] years; 53.3% women) were included in the study. The use of robotic-assisted cholecystectomy increased 37-fold from 211 of 147 341 patients (0.1%) in 2010 to 6507 of 125 211 patients (5.2%) in 2019. Compared with laparoscopic cholecystectomy, robotic-assisted cholecystectomy was associated with a higher rate of bile duct injury necessitating a definitive operative repair within 1 year (0.7% vs 0.2%; relative risk [RR], 3.16 [95% CI, 2.57-3.75]). Robotic-assisted cholecystectomy was also associated with a higher rate of postoperative biliary interventions, such as endoscopic stenting (7.4% vs 6.0%; RR, 1.25 [95% CI, 1.16-1.33]). There was no significant difference in overall 30-day complication rates between the 2 procedures. The instrumental variable analysis, which was designed to account for potential unmeasured differences in treatment groups, also showed that robotic-assisted cholecystectomy was associated with a higher rate of bile duct injury (0.4% vs 0.2%; RR, 1.88 [95% CI, 1.14-2.63]). This cohort study's finding of significantly higher rates of bile duct injury with robotic-assisted cholecystectomy compared with laparoscopic cholecystectomy suggests that the utility of robotic-assisted cholecystectomy should be reconsidered, given the existence of an already minimally invasive, predictably safe laparoscopic approach.

Successful endoscopic biliary intervention using the multiloop traction device for periampullary diverticulum.

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Evaluation of Tofacitinib in Primary Sclerosing Cholangitis and Associated Colitis: A Multicenter, Retrospective Study

Evaluation of Tofacitinib in Primary Sclerosing Cholangitis and Associated Colitis: A Multicenter, Retrospective Study

Hepatic Abscess following Yttrium-90 Radioembolization in Patients with Surgical Bilioenteric Anastomosis or Compromised Sphincter of Oddi: A Tertiary Cancer Center Experience.

Purpose: We describe our experience with the development of hepatobiliary infection in patients with prior surgical, percutaneous, or endoscopic biliary interventions who are receiving transarterial radioembolization (TARE) with yttrium-90 (90Y) for primary or metastatic hepatobiliary lesions. Methods: Records of 15 patients with a history of prior biliary intervention and liver malignancy subsequently treated with TARE at the participating medical center from November 2009 to September 2015 were reviewed. The primary endpoint was the development of a hepatic abscess or cholangitis in a patient after radioembolization. Results: A total of 15 patients comprising 9 men and 6 women, with a median age of 49 years (range 30–73), underwent 17 TARE with 90Y procedures. Of the 15 patients, 2 (13.3%) of them developed a hepatobiliary infection. A single patient (6.6%) developed a hepatobiliary abscess. Conclusion: Our study shows a low incidence rate of hepatic abscess following TARE in patients with prior biliary intervention.

Management Strategies for Benign Biliary Strictures

AbstractBiliary stricture is the abnormal narrowing of the biliary ductal system, leading to bile stasis and eventual ductal obstruction and dilatation. Common etiologies of biliary strictures can be broadly classified based on benign or malignant causes. The pathogenesis of benign biliary strictures (BBSs) can be a sequela of several causes, including iatrogenic, inflammatory, ischemic, infectious, and immunologic etiologies. Among the common causes of BBS, an iatrogenic biliary ductal injury sustained during hepatobiliary surgeries is the most frequently reported cause of BBS. Clinically, patients with BBS can present with obstructive biliary symptoms, and urgent biliary decompressive interventions are frequently required to prevent fatal complications. Cross-sectional imaging such as MR cholangiopancreatography enables timely evaluation of the stricture and facilitates therapeutic planning. The primary objective in managing biliary strictures (both benign and malignant) is to achieve permanent ductal patency and minimize the need for repeated interventions. A multidisciplinary team of gastroenterologists, interventional radiologists, and hepatobiliary surgeons is generally involved in caring for patients with BBS. This review provides a summary of clinically available endoscopic, percutaneous, and surgical biliary interventions for the management of patients with BBS.

Duodenal perforation secondary to stent migration after ERCP for hepatobiliary tuberculosis: Case report of a lethal complication in a young patient.

IntroductionInterventional internal drainage of the biliary tract has become an established procedure for the temporary and definitive treatment of biliary obstruction due to malignant or benign disease. The complication rate is reported to be so low that when feasible, this technique is preferred over a surgical drainage procedure.Presentation of a caseA 26-year old woman was referred to the hepatopancreaticobiliary surgery service due to severe abdominal pain for 3 days after undergoing endoscopic retrograde cholangiopancreatography (ERCP). She underwent biliary dilatation and stent insertion for obstructive jaundice secondary to biliary stricture from hepatobiliary tuberculosis. The patient underwent exploratory laparotomy, peritoneal lavage, duodenorrhaphy and tube jejunostomy for bilious peritonitis and duodenal perforation from biliary stent migration. The patient died one day post-operation due to septic shock from secondary bacterial peritonitis.DiscussionERCP and other interventional endoscopic biliary interventions are increasingly being used for biliary obstruction. Despite the various complications which arise from these diagnostic and therapeutic modalities, complications are relatively uncommon. Duodenal perforation from biliary stent migration is a rare complication after undergoing ERCP and stenting. However, in patients presenting with severe pain and physical signs of acute abdomen after the procedure, it should always be a consideration.ConclusionsDespite the relative safety of interventional techniques for biliary obstruction, complications like pancreatitis, hemorrhage and perforation may occur. Early recognition and high index of suspicion allows for early intervention with good outcomes. Duodenal perforation from stent migration can occur and when intervention is delayed may lead to morbidity and mortality.

Advancements in Endoscopic Biliary Interventions by Gastroenterology.

Endoscopic retrograde cholangiopancreatography (ERCP) is an endoscopic technique in which a specialized side-viewing endoscope is guided into the duodenum, allowing for instruments to access the biliary and pancreatic ducts. ERCP was initially developed as a diagnostic tool as computed tomography was in its infancy during that time. ERCP has evolved since its inception in the 1960s to becoming not only a valuable diagnostic resource but now an effective therapeutic intervention in the treatment of various biliary disorders. The most common biliary interventions performed by ERCP include the management of biliary obstructions for benign and malignant indications. Additionally, endoscopic ultrasound (EUS) has been increasingly utilized in diagnosing and intervening on pancreaticobiliary lesion. This article will discuss the various methods currently available for various endoscopic biliary interventions and future interventional techniques. For the management of biliary strictures, EUS can be utilized with fine need aspiration, while ERCP can be used for the placement of various stents and diagnostic modalities. Another example is radiofrequency ablation, which can be used for the treatment of hilar strictures. Achieving bile duct access can be challenging in patients with complicated clinical scenarios; other techniques that can be used for bile duct access include EUS-guided rendezvous approach, transluminal approach, Choleodochoduodenostomy, and hepatogastrostomy, along with gaining access in complicated anatomy such as in patients with Rou-en-Y anatomy. Another useful endoscopic tool is nonsurgical drainage of the gallbladder, which can be a suitable option when patients are not optimal surgical candidates. There has also been an increase in outpatient utilization of ERCP, which was previously seen as a predominantly inpatient procedure in the past. Possible future evolutions of biliary interventions include robotic manipulation of a duodenoscope and direct infusion of chemotherapeutic or immunomodulatory agents into the pancreaticobiliary tree. These advancements will depend on parallel advancements in other imaging and laboratory as well as breakthrough technology or techniques by other disciplines including interventional radiology and minimally invasive surgery.

Endoscopic and Percutaneous Biliary Interventions after Liver Transplantation: Nationwide Data in Korea.

Background/AimsBiliary complications including biliary strictures and bile leaks are the most common complications that occur after liver transplantation (LT). Endoscopic treatment with endoscopic retrograde cholangiography (ERC) is considered the first-line treatment, and percutaneous transhepatic cholangiography (PTC) can serve as an alternative or rescue therapy. However, nationwide clinical data on the frequency of ERC and PTC following LT have not yet been investigated.MethodsUsing the nationwide claims database, we investigated patients who underwent LT between 2012 and 2014 in Korea and followed them until 2015. We analyzed the prevalence and characteristics of patients and biliary procedures, including ERC and PTC implemented after LT.ResultsA total of 3,481 patients underwent LT during the 3-year study period. Among them, 3.0% of patients underwent biliary intervention postoperatively during the same hospitalization period, and 21.4% of patients received biliary intervention later on after initially being discharged from the hospital following LT. A total of 16.9% and 12.1% of patients underwent ERC and PTC after LT, respectively. The median period from LT to the first biliary intervention was 7.8 months (interquartile range, 3.5 to 14.6 months), and these patients underwent an average of 3.2±2.8 biliary procedures during the follow-up period. Patients undergoing living donor LT were more than twice as likely to undergo biliary procedures as those undergoing deceased donor LT (25.5% vs 12.1%).ConclusionsApproximately one-fourth of patients in Korea who underwent LT subsequently underwent ERC or PTC. Compared with deceased donor LT patients, those undergoing living donor LT underwent more biliary interventions and were more difficult to treat.

ID: 3526852 TRANSPANCREATIC SPHINCTEROTOMY TECHNIQUE AND DOUBLE GUIDEWIRE PLACEMENT FOR DIFFICULT CANNULATION IN ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP). IS IT USEFUL IN THE PEDIATRIC PATIENT?

Selective bile duct cannulation is the prerequisite for all endoscopic biliary therapeutic interventions, but this cannot always be achieved easily. Despite advances and new developments in endoscopic accessories, selective biliary access fails in 5%-15% of cases, even in expert high-volume centers. Various techniques, such as double-guidewire induced cannulation, pre-cut papillotomy or trans pancreatic sphincterotomy with or without placement of a pancreatic stent, have been used to improve cannulation success rates. Repeated and prolonged attempts at cannulation increase the risk of pancreatitis. These techniques have been reported in adults, but there are no data on their use in children.

EUS-guided Anastomosis Complication in a Patient with Roux-en-Y Gastric Bypass: Dehiscence of the Surgical Anastomosis During Endoscopic Mucosal Resection Across EUS-guided Jejunum-gastric Anastomosis with Lumen Apposing Metal Stent

Roux-en-Y gastric bypass (RYGB) is one of the most common surgical procedures for the management of morbid obesity. However, RYGB poses technical difficulties in exploring the gastric remnant and in performing endoscopic biliary interventions due to altered anatomy. Recently, EUS guided gastro-gastric anastomosis to access the excluded stomach has been introduced in order to allow direct trans-gastric interventions. We report the case of a 38-year-old female referred to our unit to undergo EUS direct trans-gastric intervention (EDGI) for the management of a small stone in the biliary tract. Pre-procedural CT scan highlighted an abnormal distension of the gastric remnant. EUS guided jejuno-gastric anastomosis was carried out with the deployment of a 15 x 10 mm lumen apposing metal stent (LAMS). After 3 days, an upper GI endoscopy was performed, highlighting a mobile 25 mm polyp near the pylorus. Therefore endoscopic resection was planned before the performance of the ERCP. Piecemeal endoscopic mucosectomy was carried out with no evidence of any adverse event. However, endoscopic evaluation after specimen retrieval detected an almost complete dehiscence of the anastomosis. Emergency surgery was decided with restoration of the continuity of the gastric cavity to allow future endoscopic examinations/procedures. Here, we report the first case of dehiscence of the surgical gastro-jejunal anastomosis during EDGI procedure. Performing an ERCP during EDGI is probably safer than performing gastric interventions. When performing EDGI, it is paramount to carefully evaluate the type of planned gastric procedure and to adopt a tailored approach according the several variables involved.

Laparoscopic-Assisted Endoscopic Retrograde Cholangiopancreatography in Patients With Prior Gastric Bypass Surgery: A Case Series of Technical Challenges

ABSTRACT Accessing the biliary ducts for performing endoscopic retrograde cholangiopancreatography (ERCP) and relevant interventional procedures after gastric bypass surgery is technically difficult and frequently unsuccessful due to anatomical alterations. To overcome such technical challenges, laparoscopic-assisted ERCP (LA-ERCP) is used to approach the biliary ducts via nonperoral reliable access for performing different endoscopic biliary interventions. In this case series, we report a total of three patients with different anatomical alterations who underwent LA-ERCP.

Endoscopic and percutaneous biliary interventions in patients with altered upper gastrointestinal anatomy-the Munich Multicenter Experience.

In patients with altered upper gastrointestinal anatomy, conventional endoscopic retrograde cholangiography is often not possible and different techniques, like enteroscopy-assisted or percutaneous approaches are required. Aim of this study was to analyze success and complication rates of these techniques in a large collective of patients in the daily clinical practice in a pre-endosonographic biliary drainage era. Patients with altered upper gastrointestinal anatomy with biliary interventions between March 1st, 2006, and June 30th, 2014 in four tertiary endoscopic centers in Munich, Germany were retrospectively analyzed. At least one endoscopic-assisted biliary intervention was successful in 234/411 patients (56.9%)-in 192 patients in the first, in 34 patients in the second and in 8 patients in the third attempt. Success rates for Billroth-II/Whipple-/Roux-en-Y reconstruction were 70.5%/56.7%/49.5%. Complication rates for these reconstructions were 9.3%/6.5%/6.3%, the overall complication rate was 7.1%. Success rates were highest in patients with Billroth-II reconstruction where use of a duodenoscope was possible, complication rates were also highest in this scenario. Success rates were lowest in longer-limb anatomy like Roux-en-Y reconstruction. Percutaneous biliary drainages (PTBD) were inserted 268 times with substantially higher success (90.7%) as well as complication rates (11.6%) compared to the endoscopic approach. Compared to patients treated endoscopically, patients with PTBD had a lower performance status, more severe cholestasis and a significant higher rate of malignant underlying disease. In patients with altered upper gastrointestinal anatomy, success rates of endoscopic-assisted biliary interventions are lower compared to PTBD. Still, due to the beneficial complication rates of the endoscopic approach, this technique should be preferred whenever possible and in selected patients who still need to be defined in detail, repeated endoscopic attempts are useful to help achieve the desired result.

Risk Factors for Endoscopic Biliary Tract Interventions Following Orthotopic Liver Transplantation: An Analysis of 10,252 Patients over 15 Years Across the United States

Introduction: Endoscopic biliary tract interventions following orthotopic liver transplantation (OLT) are being utilized more commonly now with advancements in endoscopic technique and technology. This study assesses the risk factors for endoscopic procedures following OLT. Method: Data on 10,252 OLT patients from the National Inpatient Sample database who underwent post-transplant endoscopic biliary procedures (EBP) was analyzed over a 15-year period (2001-2016). Results: 581 patients who had EBP were identified. Of these, 467 (80.4%) had ERCP, sphincterotomy and stenting. The remainder had ERCP alone. EBP and non-EBP patients had a similar demographic and comorbidity profile. The strongest risk factors for EBP post-OLT on multivariate analysis were biliary anastomotic stricture (OR 6.1), bile leak/fistula (OR 5.4), choledocholithiasis (OR 5.0), cholangitis (OR 4.2), age>60 (OR 2.1), living donor graft (OR 1.9), and emergency admission status (OR 1.1), p< 0.05. Conversely, roux-en-y hepaticojejunostomy and age< 20 were associated with fewer EBP, p< 0.05. EBP was associated with a significantly longer length of stay (98.3% stayed over 1 week), and higher risk of post-procedure biliary sepsis (23.2% vs 11.8%), graft abscess (11.4% vs 6%), acute graft rejection (46.1% vs 18.4%), and inpatient mortality (7.2% vs 5.3%), p< 0.05. Conclusions: OLT recipients who develop postoperative biliary complications (especially anastomotic strictures), older than 60, have living donor grafts and have non-elective admissions are at highest risk of undergoing EBP. Although unavoidable in many situations, EBP is associated with significantly greater morbidity and mortality post-OLT. Clinicians must be cognizant of these risks when considering EBP in OLT recipients. Clinical Profile of 10,252 Liver Transplant Patients from the NIS Database (2001-2016)

Gallstone Ileus: An Unfortunate Complication after Endoscopic Biliary Drainage

BACKGROUND: Gallstone ileus is a misnomer of intestinal obstruction. This rare entity of gallstone disease happens after episodes of acute cholecystitis, Mirizzi’s syndrome, or even after endoscopic intervention.&#x0D; CASE REPORT: A 17-year-old lady with acute cholecystitis, hepatolithiasis, and choledocholithiasis was endoscopically managed through endoscopic retrograde cholangiopancreatography. She was initially well but complicated with intestinal obstruction the next day. The abdominal radiograph and computed tomography showed a dilated small bowel secondary to gallstone ileus. An emergency laparotomy was performed to relieve the obstruction.&#x0D; CONCLUSION: Gallstone ileus is a rare cause of intestinal obstruction. It must be suspected in a patient with underlying gallstone disease, especially after an endoscopic biliary intervention. Emergency enterotomy and stone extraction are the imperative surgical intervention if the stone is not able to pass out spontaneously.

Management of difficult or failed biliary access in initial ERCP: A review of current literature

Selective bile duct cannulation is the prerequisite for all endoscopic biliary therapeutic interventions, but this cannot always be achieved easily. Despite advances and new developments in endoscopic accessories, selective biliary access fails in 5%-15% of cases, even in expert high volume centers. Various techniques - such as double-guidewire induced cannulation, pre-cut papillotomy or transpancreatic sphincterotomy with or without placement of a pancreatic stent - have been used to improve cannulation success rates. Repeated and prolonged attempts at cannulation increase the risk of pancreatitis. Repeating the ERCP within a few days after initial failed pre-cut is a successful strategy and should be tried before contemplating more invasive, alternative interventions such as percutaneous-endoscopic or endoscopic ultrasound guided rendezvous procedure, percutaneous transhepatic or surgical intervention. However, standard guidelines or sequential protocol has not been existed up to now. In certain circumstances, there are unique clinical indications for which invasive, alternative interventions should be preferred. We present and discuss the methods that can be used in difficult or failed initial ERCP, therefore to provide practical advice for endoscopists, especially those who are inexperienced.

Risk of endoscopic biliary interventions in primary sclerosing cholangitis is similar between patients with and without cirrhosis.

BackgroundEndoscopic retrograde cholangiography (ERC) is a mainstay of therapy in patients with primary sclerosing cholangitis (PSC) and obstructive cholestasis. Patients with liver cirrhosis have an increased risk of surgical complications and are more susceptible to infections. Since PSC often progresses to cirrhosis, we aimed to assess whether ERC is associated with increased risk of complications in patients with PSC and cirrhosis.MethodsOut of 383 patients with PSC, 208 patients received endoscopic treatment between 2009–2017. Seventy patients had cirrhosis when ERC was performed and 138 patients had no signs of cirrhosis. Overall, 663 ERC procedures were analysed, with 250 ERC in patients with cirrhosis and 413 ERC in patients without cirrhosis. Data were analysed retrospectively from a prospectively acquired database using repeated measures logistic regression.ResultsOverall, 40 procedure-related complications were documented in 663 ERC interventions (6%). The rate of complications was similar between patients with and without cirrhosis (4.4% vs. 7.0%). First-time ERC was associated with a higher risk of complications (17.5% vs. 4.9%). Biliary sphincterotomy, stent placement and female sex, but not presence of liver cirrhosis, were identified as risk factors for overall complications in multivariate analysis. Patients without cirrhosis showed a significant decline of ALP and bilirubin levels after the first two interventions. In contrast, in patients with cirrhosis, ALP and bilirubin levels did not significantly decline after ERC.ConclusionsIn patients with PSC, cirrhosis was not a risk factor for post-ERC complications. Therefore, cirrhosis should not preclude endoscopic intervention in patients with clear clinical indication.

A comparison of endoscopic and non-endoscopic biliary intervention outcomes in patients with prior bariatric surgery.

Background and study aims Endoscopic biliary intervention (BI) is often difficult to perform in patients with prior bariatric surgery (BRS). We sought to analyze outcomes of patients with prior BRS undergoing endoscopic and non-endoscopic BI. Patients and methods The Nationwide Inpatient Sample (2007 – 2011) was reviewed to identify all adult inpatients (≥ 18 years) with a history of BRS undergoing BI. The clinical outcomes of interest were in-patient mortality, length of stay (LOS), and total hospital charges. Results There were 7,343 patients with prior BRS who underwent BIs where a majority were endoscopic (4,482 vs. 2,861, P < 0.01). The mean age was 50±30.8 years and the majority were females (80.5 %). Gallstone-related disease was the most common indication for BI and managed more often with primary endoscopic management (2,146 vs. 1,132, P < 0.01). Inpatient mortality was not significantly different between patients undergoing primary endoscopic versus non-endoscopic BI (0.2 % vs. 0.7 %, P = 0.2). Patients with sepsis were significantly more likely to incur failed primary endoscopic BI (OR 2.74, 95 % CI 1.15, 6.53) and were more likely to be managed with non-endoscopic BI (OR 2.13, 95 % CI 1.3, 3.5). Primary non-endoscopic BI and failed endoscopic BI were both associated with longer LOS (by 1.77 days, P < 0.01 and by 2.17 days, P < 0.01, respectively) and higher hospitals charges (by $11,400, P < 0.01 and by $ 14,200, P < 0.01, respectively). Conclusion Primary endoscopic management may be a safe and cost-effective approach for patients with prior BRS who need BI. While primary endoscopic biliary intervention is more common, primary non-endoscopic intervention may be used more often for sepsis.

Biliary Obstruction: Endoscopic Approaches.

Painless jaundice is a harbinger of malignant biliary obstruction, with the majority of cases due to pancreatic adenocarcinoma. Despite advances in treatment, including improved surgical techniques and neoadjuvant (preoperative) chemotherapy, long-term survival from pancreatic cancer is rare. This lack of significant improvement in outcomes is believed to be due to multiple reasons, including the advanced stage at diagnosis and lack of an adequate biomarker for screening and early detection, prior to the onset of jaundice or epigastric pain. Close attention is required to select appropriate patients for preoperative biliary decompression, and to prevent morbid complications from biliary drainage procedures, such as pancreatitis and cholangitis. Use of small caliber plastic biliary stents during endoscopic retrograde cholangiopancreatography should be minimized, as metal stents have increased area for improved bile flow and a reduced risk of adverse events during neoadjuvant therapy. Efforts are underway by translational scientists, radiologists, oncologists, surgeons, and gastroenterologists to augment lifespan for our patients and to more readily treat this deadly disease. In this review, the authors discuss the rationale and techniques of endoscopic biliary intervention, mainly focusing on malignant biliary obstruction by pancreatic cancer.

TEMPO OF BILIARY DECOMPRESSION AND DYNAMICS OF INDICES OF THE SYNTHETIC FUNCTION OF LIVER AFTER TRANSPAPILLARY ENDOSCOPIC BILLIARY INTERVENTION IN PATIENTS WITH OBSTRUCTIVE JAUNDICE DUE TO CHOLEDOCHOLITHIASIS

The purpose of the work was to study the dynamics of indicators of synthetic function of the liver, depending on the rate of decompression of the bile duct after endoscopic transpapillary biliary intervention in patients with choledocholithiasis complicated by obstructive jaundice. For this purpose, 59 patients with choledocholithiasis complicated by obstructive jaundice who had transpapillary endoscopic biliary decompression were examined. The distribution of patients was divided into three groups, depending on the level of jaundice. When choosing the terms of the second stage of radical surgery on the bile duct in patients with obstructive jaundice due to choledocholithiasis after the previous transpaculary endoscopic decompression, it should be based on an assessment of the baseline of liver dysfunction indices and their dynamics in the post-decompression period, but not only on the levels of cholestasis.

Tattoo of Scheepers

Introduction: Following pancreaticoduodenectomy (PD) up to 40% of patients experience a degree of delayed gastric emptying (DGE). The role of intra-operative jejunal tube placement and direct post-operative tube feeding to prevent [LL1] DGE remains controversial. However, enteral jejunal feeding is preferred to total parental feeding. Endoscopic biliary intervention of the ascending loop of the gastro- or duodenal-jejunostomy, as well as endoscopic tube placement of the descending jejunal loop, is a technical challenge. To improve the endoscopic procedures after PD, a new technique has been developed. Methods: A simple guide [LL2] for post-operative endoscopic interventions is to tattoo the afferent jejunal loop 5 cm following the gastro- or duodeno-jejunostomy intra-operatively. A short video and endoscopic pictures will be shown. Conclusion: Intra-operative tattooing of the afferent jejunal loop provides guidance for post-operative endoscopic procedures. This will fasten endoscopic interventions and prevent misplacement of jejunal tubes.