Endoscopic Retrograde Cholangio Research Articles

Endoscopic ultrasound-guided biliary interventions.

Endoscopic ultrasound (EUS)-guided biliary drainage (EUS-BD) includes EUS-guided hepaticogastrostomy (EUS-HGS), EUS-guided choledochoduodenostomy (EUS-CDS), EUS-guided gallbladder drainage (EUS-GBD), EUS-guided antegrade stenting (EUS-AG) and EUS-guided rendezvous (EUS-RV). While EUS-HGS, EUS-CDS and EUS-GBD are transluminal drainage procedures, EUS-AG is a traspapillary drainage procedure and EUS-RV is a procedure intended to facilitate endoscopic retrograde cholangio pancreatography (ERCP) in instances of failed cannulation. These procedures were initially developed as options for endoscopic salvage of failed ERCP, but have evolved to become first-line interventions also for select indications over time as the technique and expertise improved. Several randomised controlled trials have demonstrated EUS-BD, especially EUS-CDS has similar or even better outcomes as compared to ERCP in malignant biliary obstruction. However, widespread adoption of these modalities is limited by the availability of expertise, steep learning curve, lack of standardization of techniques and cost. In this review, we aim to provide an overview of various EUS-BD procedures including the indications, accessories, technique, outcomes and follow-up of each of these procedures.

435 Post ERCP Pancreatitis at a Tertiary Centre - a Retrospective Incidence and Causal Analysis

Abstract Background Post Endoscopic Retrograde Cholangio Pancreatography (ERCP) pancreatitis (PEP) is a serious and potentially life-threatening complication of ERCP. The overall incidence of PEP varies between 3.5% and 9.7% as per the recent meta-analyses in 2014. We aim to evaluate the incidence of PEP, conduct a causal analysis and financial implications at our hospital for general surgical patients. Method All General Surgical patients who had ERCP done between 01/10/2022 and 31/03/2023 were included in the analysis. The patient records on TrakCare® were analysed for demographic details, admission records, ERCP details, pre-procedural laboratory values and length of stay. The successful ERCPs defined as cannulation of the common bile duct were divided into the PEP and the non-PEP groups. Results A total of 155 patients had ERCP attempted but only 131 were successful. Of these 131, 13 (9.92%) developed PEP. Females in their 60s were predominantly affected. Three out of six patients undergoing ERCP for malignant biliary obstructions were affected (50%). Patients with grossly deranged Liver Function Tests (mean bilirubin levels >=134.92µmol/L) had a higher risk of developing PEP (p-value=0.021). The mean overall hospital stay was 3.5 days longer (2-49 days) for patients who developed PEP costing an extra £20,475 - £35,763 over 6 months to the NHS. There were no mortalities recorded. Conclusions Patients with gallstone disease should receive prompt cholecystectomy adhering to NICE guidelines to reduce the risk of developing gallstone-related complications. This in turn would lead to a reduction in PEP and positively affect the financial implications for the NHS.

Laparoscopic Common Bile Duct Exploration for Multiple Large Common Bile Duct Stones: A Case Report with Review of Literature

Endoscopic retrograde cholangio pancreatography (ERCP) followed by laparoscopic cholecystectomy (LC) in 2 different sessions, is the widely followed standard sequence of surgical procedures for concurrent gall bladder and common bile duct (CBD) stone disease, across the world. However, being highly technical, skillful and technology dependant, ERCP, sometimes, does not succeed even in the best of hands. This can happen due to abnormal local anatomy (eg. Previous Billroth II gastrectomy, previous surgical scars which distort the duodenum etc.) and unfriendly stone morphology such as a very large stone or a large number of stones. Failure to extract/retrieve bile duct stones at ERCP is an indication for CBD exploration (open or laparoscopic) at surgery. Herein, we present one such case of a 67 year old woman who had previously undergone surgery – laparoscopic cholecystectomy for gall stone disease 3 years back. She presented to us with a common bile duct loaded with multiple large stones. Inspite of undergoing ERCP (2 attempts over 48 hours), a common bile duct access could not be achieved endoscopically, thereby rendering endotherapy unsuccessful. She then underwent a successful totally laparoscopic CBD exploration, using standard laparoscopy instruments, some endoscopy accessories like endo-balloon & dormia basket and intraoperative fluoroscopy.

Our experience with ERCP (endoscopic retrograde cholangio pancreatography) as the first line treatment for simple bile duct leakage

Our experience with ERCP (endoscopic retrograde cholangio pancreatography) as the first line treatment for simple bile duct leakage

Choledocholithiasis Patient Applied to Endoscopic Retrograde Cholangio Pancreatography (ERCP) and Nursing Care: A Case Report

Koledokolitiazis, ortak safra kanalı içinde safra taşı varlığını ifade etmektedir. Yaşla birlikte fizyolojik olarak ortak safra kanalının genişlemesi nedeniyle koledokolitiazis, yaşlılarda daha sık görülmektedir. Koledokolitiazis genellikle biliyer kolik olarak tanımlanan karın ağrısına neden olmaktadır. Beraberinde bulantı ve kusma eşlik etmektedir. Koledokolitiazisli hastalarda Akut kolanjit, Akut Bilier Pankreatit gibi pek çok komplikasyon gelişebilmektedir. Komplikasyon gelişmiş koledokolitiazisli hastada hemşirelik bakımının amaçları; belirti ve bulguları erken tespit etmek, bireylerin öz bakımlarını sağlamak, yaşam kalitelerini yükseltmek ve iyilik hali kazandırmak, Endoskopik Retrograd Kolanjiyo Pankreatografi (ERCP) işlemi öncesinde, esnasında, sonrasında uygun hemşirelik girişimlerini planlamak, ERCP işlemi sırasında ve sonrasında gelişebilecek komplikasyonları takip etmek ve gerekli hemşirelik girişimlerini uygulamak, hasta ve ailesini eğitmektir. 56 yaşında olduğu bilinen ülseratif kolit (27 yıldır), ritim bozukluğu, DM tanıları olan hastanın 12 gündür epigastrik bölgede dolgunluk ve ağrısı nedeniyle acile başvurmuştur ve koledokolitiazis tanısı ile servise kabul edilmiştir. Olgu Marjory Gordon’un Fonksiyonel Sağlık Örüntüleri Hemşirelik Bakım Modeli ile değerlendirilerek, hemşirelik bakımı verilmiştir. Hastadan ve ailesinden çalışmanın yapılması ve yayınlanması için gerekli izin alınmıştır. Olguda akut ağrı, bulantı, hipertermi, iştahsızlığa bağlı vücut gereksiniminden az beslenme, yorgunluğa bağlı aktivite intoleransı, sarılık ve kaşıntıya bağlı cilt bütünlüğünde bozulma, sıvı elektrolit dengesizliği, bireysel başetmede yetersizlik, bilgi eksikliği hemşirelik tanıları belirlenmiştir.

Endoscopic retrograde cholangio pancreatography and endoscopic ultrasound: the pilot is only as good as the co-pilot – what do nurses need to know?

Endoscopy procedures require a collaborative team approach. Flight simulator training is an advanced method used to enhance the stress resilience and communication skills of nurses, which are crucial for successful execution. Novices need sufficient time to acquire expertise, so clear learning outcomes should be established for nurses in endoscopy. The European Society of Gastroenterology and Endoscopy Nurses and Associates has developed a job profile and core curriculum for endoscopy nursing. Various simulators, including those using tubes and virtual reality, are available for training, with the Erlangen active simulator for interventional endoscopy being the most suitable. Monitoring the frequency of procedures allows for individual competency assessment. Effective communication is essential for success and safety. Postgraduate training programmes should be provided for individuals lacking endoscopy education. National and international meetings should attract doctors and nurses to promote teamwork and knowledge exchange. Advancements in technology will shape the job profile of endoscopy professionals, including short wire systems, single-operator cholangiocytes, nurse endoscopists, nurse-assisted propofol sedation, artificial intelligence, endoscopy robots and hybrid procedures.

Effectiveness for Diagnosis of Malignancy of Bile Pyruvate Kinase M2 in Patients with Indeterminate Biliary Stricture.

Up to 70% of the cases of biliary strictures are cholangiocarcinoma. Cholangiocarcinoma has a late diagnosis and poor outcomes; therefore, effective biomarkers are needed for malignant lesions detection at earlier stages. The aim was to assess the diagnostic utility of bile pyruvate kinase M2 (PKM2) as a biomarker for the detection of malignant biliary strictures in patients with an indeterminate biliary stricture. This is a prospective study to evaluate the diagnostic value of bile PKM2 for the diagnosis of malignant biliary strictures. Bile samples were collected during Endoscopic Retrograde Cholangio Pancreatography to quantify PKM2 levels and were used to compare their diagnostic value with biliary brush cytology, endoscopic ultrasound-guided fine needle biopsy, or clinical follow-up. Forty-six patients were recruited for the study; 19 patients with malignant strictures and 27 with benign biliary strictures. The bile PKM2 levels were elevated in patients with malignant biliary strictures [median 0.045ng/mL (IQR 0.014 to 0.092)] compared with those with benign strictures [median 0.019ng/mL (IQR 0.00 to 0.047)]. Bile PKM2 had a receiver-operating characteristic curve of 0.66 (0.49 to 0.83) with a cutoff value of bile PKM2 of 0.0017ng/mL. The sensitivity and specificity of bile PKM2 for the diagnosis of cholangiocarcinoma were 89% and 26%; the positive and negative predictive values were 46% and 78%, respectively. In patients with indeterminate biliary strictures, bile PKM2 may be a potential biomarker for the diagnosis of malignancy.

Risk Factors for Post Endoscopic Retrograde Cholangio Pancreatography(ERCP) Pancreatitis (PEP) and Efficacy of Octreotide in its Prevention

Background: Pancreatitis is a potentially fatal complication of ERCP, seen in 5-15% procedures. Factors precipitating its risk and effective pharmacological intervention for its prevention need exploration to improve patient safety. Objective: To identify risk factors for post-ERCP pancreatitis (PEP) and to determine efficacy of intravenous octreotide in preventing PEP. Methodology: A quasi-experimental triple blind placebo-based study included patients undergoing ERCP and randomize them in two groups through simple random sampling. Group A to receive intravenous Octreotide 4μg/kg before attempting cannulation during ERCP and 1cc N/S as placebo for group B. Patients were followed for PEP and data were analyzed using chi square (x2) and logistic regression analysis. Results: Of 203 included patients, 101 (49.3%) received octreotide while 102 (50.7%) were in control group. Post ERCP pancreatitis developed in 32 (15.8%) patients, in 8 (7.9%) patients of octreotide group while in 24 (23.8%) patients of control group (p value 0.002 with odds ratio (OR) for octreotide of 0.33 (95% CI 0.15- 0.71). We identified biliary surgery (p value 0.005), serum bilirubin ≥ 3 mg/dl (p value 0.03), cannulation
 time > 5 minutes (p value 5 minutes, use of needle knife, PD cannulation and procedure time > 30 minutes are associated with increased risk of PEP. Intravenous octreotide before cannulation reduces risk of post ERCP pancreatitis.

HPB O07 Complication profile of laparoscopic common bile duct exploration: Results from R-ALiCE Study

Abstract Background There are two ways of managing common bile duct stones (CBDS); a two-stage and a single-stage approach. The two-stage procedure is the most common way of managing CBDS in the UK. In the two-stage approach, patients have pre-operative confirmation of CBDS followed by endoscopic retrograde cholangio pancreatography (ERCP) and delayed cholecystectomy. The single-stage approach is an equally effective but less favoured approach, which involves simultaneous intra-operative imaging followed by laparoscopic CBD exploration and cholecystectomy. Evidence supports that the single-stage approach is associated with reduced costs, length of stay, and better stone-free survival compared to the two-stage approach. Despite the evidence favouring the single-stage approach, it is still not widely used, and one of the reasons for this could be the lack of complication profile data from extensive multi-centre studies. We undertook a large multi-centre study called R-ALiCE (Retrospective- Audit of Laparoscopic Common Bile duct Exploration). One of the study's aims was to evaluate the outcome profile of LCBDE in the UK. Methods R-ALiCE Study was a multi-centre collaborative cohort study that collected data on all LCBDEs performed over five years (2015–2019) in 18 centres across the UK. A total of 1796 patients were enrolled on the study, and 1689 patients were included in the final analysis. The reasons for exclusion of 107 patients were: incomplete data: 13, open surgery: 11, LCBDE was not performed: 55, young adult=1, and 27 patients outside the time frame. Results The median age of patients (68.2% females) was 59 years (interquartile range: 43–71). One-third of patients had underlying cardiovascular co-morbidities, 14.6% had respiratory co-morbidities, and 3.1% had underlying liver disease. Almost 50% were obese (body mass index), and 28.2% were overweight. Fifty-six percent of (945) patients had an emergency/semi-elective procedure, while 44% (743) had an elective procedure. The median surgery duration was 123.9 minutes (range: 29–420). Laparoscopic to open conversion rate was 5%. Transcystic-exploration (TC-LCBDE) was attempted in 71.6% of all cases with a success rate of 77.6%. Transcholedochal-exploration (TD-LCBDE) was attempted in 41.1% of all cases: 12.5% were TC-LCBDE progressed to TD-LCBDE and 28.3% were direct TD-LCBDE. Overall, 30-day all-cause complication rate was 18.9% (319). Complication rate between TC and TD were: bile leak rate was 1.4% vs. 8.8% (p=0.000), retained stones 4.9% vs 5.6%(p=0.527), pancreatitis (0.9% vs 1% (p=0.828) and intrabdominal collections 1.8% vs 7.2%. Thirty-five percent of bile leaks were Grade A and 39% Grade B. The overall complication rate was 12.8% for TC and 27.7% for TD. Overall 30-day mortality was zero. Conclusions This is the largest LCBDE cohort study in the world and confirms that overall complications of LCBDE are low, and LCBDE can be safely performed for patients with simultaneous gallstones and bile duct stones. Transcystic approach should always be attempted as first line in selected patients to reduce the risk of complications.

A Retrospective Comparative Study Between Early (≤ 72 hrs) and Late (> 72 hrs) Laparoscopic Cholecystectomy after ERCP in St. Paul’s Hospital Iloilo

Objective: The study was performed to assess and compare the effect of early (≤ 72 hours) and late (>72 hours) laparoscopic cholecystectomy after Endoscopic retrograde cholangio pancreatography (ERCP) in terms of duration of operation, conversion to open cholecystectomy, intraoperative complicating factors, duration of hospital stay from the date of ERCP, hospital expenses, and presence of postoperative complications. Methods: This is a retrospective study from 2010 up to July 2019. Outcomes (duration of operation, rate of conversion, intraoperative complicating factors, length of hospital stay, hospital expenses and post-operative complications) were compared between patients who had ERCP then cholecystectomy within 72 hours (Early Group) and those who had ERCP then cholecystectomy after more than 72 hours (Late Group). Results: A total of 19 patients were included in this study. There were 10 patients in the Early Group and 9 in the Late Group. Early laparoscopic cholecystectomy after ERCP had a shorter statistically significant duration of hospital. Shorter operative time, fewer intraoperative complicating factors, no conversion to open cholecystectomy, cheaper hospital expenses and no post-operative complications were also noted in the Early Group as compared to the Late Group. Conclusion: Early laparoscopic cholecystectomy is safe and results in a shorter hospital stay compared to late laparoscopic cholecystectomy. Key words: early laparoscopic cholecystectomy, cholecystectomy after ERCP, choledocholithiasis, cholecystolithiasis

Primary sclerosing cholangitis-A long night's journey into day.

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S2890 A Case for Endoscopic Ultrasound-Directed TransGastric ERCP (EDGE) Procedure: Removal of Choledocholithiasis in Gastric Bypass Patient

Introduction: Due to rise in obesity, there has been an increased number of gastric bypass surgeries. Around 36% morbidly obese patient develop cholelithiasis or choledocholithiasis (CDL) in their lifetime. Due to the anatomy, a conventional Endoscopic Retrograde Cholangio Pancreatography (ERCP) is often challenging and not possible. We present a case of an altered anatomy ERCP in a patient with CDL and Roux-en-Y gastric bypass (RYGB) who underwent Endoscopic ultrasound Directed trans-Gastric ERCP(EDGE) procedure. Case Description/Methods: A 69-year-old female with a history of RYGB admitted for Hartmann’s procedure. During the hospitalization, she complained of RUQ pain and CT abdomen showed a distended gallbladder with cholelithiasis and CBD dilation of 8.3mm; MRCP confirmed five or more CDL. A traditional attempt at an ERCP using a pediatric colonoscope was unsuccessful in reaching the papilla. She underwent cholecystectomy with an intraoperative cholangiogram re-demonstrating the CDL. Options were to do a laparoscopy assisted ERCP v/s double balloon assisted ERCP v/s EDGE. Due to already multiple surgeries patient opted for EDGE procedure. For stage 1 of the EDGE, the excluded stomach was identified under EUS and punctured using a 19-gauge-needle followed by a radiocontrast dye injection into the excluded stomach confirmed under fluoroscopy. Subsequently, a guidewire was advanced through the needle into the pylorus and duodenum to verify the patency of pylorus. After confirming access to the excluded stomach, a 20 x 10 mm (AXIOSTM) lumen apposing metal stent (LAMS) was placed and a gastro-gastric fistula between the gastric pouch and the excluded stomach was formed. The lumen of the stent was subsequently dilated using a CRE balloon confirming the direct visualization of the gastric rugae. (Figure). The LAMS was left for 4 weeks for the tract to mature. Stage 2 of the EDGE procedure was then completed by passing the duodenoscope through the LAMS and completion of the traditional ERCP followed by removal of the LAMS. Overall patient did well. Discussion: EDGE is a minimally invasive EUS guided technique for doing an ERCP in patients with RYGB. Comparison studies have shown EDGE to have similar or better technical success when compared to laparoscopy-assisted ERCP and balloon Enteroscopy-assisted ERCP. Due to the high technical skill required in doing an EDGE, it is best advisable to offer this at institutions where a trained advanced endoscopist well versed with a therapeutic EUS is available.Figure 1.: A: EGD showing gastric pouch post-RYGB B: EUS suggests decompressed excluded stomach C: Injecting contrast into the excluded stomach - to make cystic cavity D: 20 x 10 mm(AXIOS) lumen apposing metal stent placement E: CRE Baloon dilation of LAMS F: Confirmed visualization of excluded gastric mucosa - gastrogastric fistula

Management of pancreatic trauma-a single center experience

Background: Traumatic injury to the pancreas is rare and frequently overlooked. High index of suspicion is required in diagnosing pancreatic injury and management is challenging even with experienced trauma surgeons. The aim of this study was to report our experience in the management of pancreatic injuries.Methods: We analyzed 39 patients with pancreatic injury managed in our center from January 2016- December 2021. Data regarding patients’ demographics, mode of injury, American association for the surgery of trauma-organ injury scale (AAST-OIS) grade of pancreatic injury, associated injuries, management, morbidity and mortality were collected for analysis.Results: The study included 39 patients who presented with blunt injury abdomen (AAST-OIS grading: grade 2 (n=6), grade 3 (n=29), grade 4 (n=4)) with mean age 28.9 years. Associated injuries were present in 41% of patients (n=16). Thirteen patients had non-operative management-5 of them were managed conservatively without any intervention; 8 of them had non-surgical intervention in the form of Percutaneous Drainage or Endoscopic Retrograde Cholangio Pancreatography with Pancreatic duct stent for peri-pancreatic collection or ductal injury. But the rate of readmission for recurrent pancreatitis and reintervention for peri-pancreatic collection was 46% and 38% respectively in these patients. Twenty-six patients underwent surgery-distal pancreato splenectomy, laparotomy and external drainage, Roux-en Y pancreaticojejunostomy.Conclusions: Management of high-grade pancreatic injuries needs technical expertise. Early diagnosis and appropriate surgical management in high-grade pancreatic injuries carries favorable outcomes. Delayed presentation with sepsis is associated with high mortality.

Application of one-stage surgical tactics treatment of acute cholecystitis in combination with choledocholithiasis

Introduction: Concrements of the common bile duct (choledocholithiasis) occur from 8% to 20% in patients with acute cholecystitis. This pathology requires simultaneous correction of the pathology of the gallbladder and the common bile duct. Methods: We retrospectively analyzed the case histories of 135 patients who underwent endoscopic retrograde cholangio pancreatography, endoscopic papillosphincterotomy, choledocholithoextraction followed by laparoscopic cholecystectomy + CHEST + LCE) for acute cholecystitis in combination with choledocholithiasis in the period from January 2016 to March 2021. Patients who underwent simultaneous treatment (ERCP + EPST + CLE + LCE under one anesthesia) were assigned to the OS group (n = 63), patients who underwent two-stage treatment (ERCP + EPST + CLE and LCE on the 3-4th day during one hospitalization) were assigned to the TS group (n = 72). All endoscopic procedures in both groups were performed by the same endoscopist using the same technique. Result: There were significant differences between the groups in terms of the duration of anesthesia, the dynamics of the decrease in the blood serum of the total bilirubin and the leukocytes range at the postoperative period, the frequency of postoperative complications and the duration of the average hospitalization in favor of one-stage treatment. 

Instruments Segmentation in X-ray Fluoroscopic Images for Endoscopic Retrograde Cholangio Pancreatography.

In this work, we propose a method to segment endoscope and guidewire from 2D X-ray fluoroscopic images of an endoscopic retrograde cholangiopancreatography (ERCP). We used an improved U-Net model. We obtained a Dice score of 0.94±0.05 for endoscope segmentation and a Hausdorff distance of 24.26 pixels for the guidewire segmentation. These preliminary results pave the way for further applications aiming at aiding the medical procedure.

Spontaneous choledoco-enteric fistula formation after bile duct injury due to laparoscopic cholecystectomy: A case report

In situations like peritonitis due to bile-duct injuries drains insertion give an opportunity for healing. However in presented case the bile leakage from drains spontaneously stopped. Only constipation leads to icterus. A spontaneous choledoco-enteric fistula explains these conditions, discovered later. It could be the result of inflammation causing adhesion. Keywords: bile duct injury; choledoco-enteric fistula; laparoscopic cholecystectomy. Abbreviations: MRCP: Magnetic Resonance Cholangio Pancreatoraphy; ERCP: Endoscopic Retrograde Cholangio Pancreatography; BDI: Bile Duct Injury; CBD: Common Bile Duct; MR: Magnetic Resonance.

EP.FRI.530 ‘Emergency’ Laparoscopic Common Bile Duct (CBD) Exploration: Is this the right time to change?

Abstract Aims Common Bile Duct (CBD) stones are becoming more common on surgical emergency take and accounts for up to 20 % of patients presenting with acute biliary pathologies. The hospital stay is prolonged whilst waiting for Endoscopic Retrograde Cholangio Pancreatography (ERCP). We aim to evaluate the feasibility, safety and cost-effectiveness of emergency laparoscopic CBD exploration (LCBDE) in these patients. Methods A cohort of patients with CBD stones underwent emergency LCBDE between January 2016 and December 2020 at a regional hospital in the United Kingdom was retrospectively reviewed. Results In total, 11 LCBDE were performed on emergency list. All patients were admitted with acute symptoms of either obstructive jaundice cholangitis or pancreatitis. All procedures were performed with choledochotomy. The mean patient age was 58 years and male-to-female ratio was 2:9. 3 patients (27%) had T- tube otherwise all ducts were primarily closed. Average hospital stay was 8.5 days. 1 patient returned to theatre for retained stone of 11mm. There was no 30 days mortality. There were no readmissions. Initial analysis with small number of patients showed, performing these procedures on emergency basis not only improved patient’s overall experience but also benefitted NHS Trust by approximately £18,500 as per the National Tariff System 2020/21. Conclusions Emergency LCBDE is safe, feasible and cost effective. We can safely aim to increase the proportion of LCBDE performed as an emergency case, where clinically appropriate, to reduce the financial burden and improve patient’s outcome with overwhelming NHS Trust funds.

Management of our endoscopic retrograde cholangio pancreatography cases during the pandemic process.

Endoscopic retrograde cholangio pancreatography (ERCP) is a technique in which endoscope and radiological imaging are used in combination in the diagnosis and treatment of diseases related to the pancreaticobiliary system. Our aim in this study is to discuss all aspects of approach strategies to ERCP patients whose operation is mandatory during the pandemic period, to draw the future perspective and to summarize the measures that the surgical team should take in terms of their own health and public health. During the pandemic period between 14 March and 31 December 2020, we accepted 270 patients to our ERCP unit. We made our analysis regarding the management of these cases under COVID-19 pandemic conditions. We presented our patients' form of application, application complaints, COVID- 19 contact stories, pre-procedure preparations, and our prevention methods to prevent COVID-19 transmission of the patient and healthcare team during the procedure, and post-procedure patient follow-up methods, and the management of our COVID-19-positive patients before the procedure. ERCP was applied to 270 patients. The COVID-19 test of 13 patients was positive before the procedure and they were taken to our COVID-19 isolated service. There was no problem in the anesthesia of patients who had positive COVID-19 PCR test and subsequently underwent ERCP. There was no difference in the discharge time after the ERCP procedure. COVID-19 pandemic has significantly affected the management and safety of ERCP units. ERCP procedures should be performed by determining the urgency of patients so that their treatment needs are not delayed. Postponing cases without planning can develop an increased workload in centers offering ERCP, and this situation can lead to further delays or negative consequences.

Laparoscopic Common Bile Duct Exploration as a Rescue Procedure for Failed Endoscopic Retrograde Cholangio-Pancreatography: A Case Report

Across the world, choledocholithiasis is presently treated by a two staged approach of Endoscopic Retrograde Cholangio- Pancreatography (ERCP) followed by Laparoscopic Cholecystectomy (LC); in a vast majority of the situations. Modern day literature abounds with comparative outcomes studies between ERCP and Laparoscopic Common Bile Duct Exploration (LCBDE), as therapeutic modalities for Common Bile Duct (CBD) stones. There are strong arguments both in favour and against both these treatment options, in literature. As per literature, the advantage of LCBDE is that it is a single stage procedure, but requires advanced laparoscopic expertise and a choledochoscope in the setup. The advantage of ERCP is that it is a highly standardised procedure. In expert hands and well equipped setups, it rarely ever fails to deliver. However, ERCP is also a highly operator dependant procedure. Also, in the best of hands, sometimes, local factors such as abnormal anatomy, stone morphology can lead to failures or suboptimal results. As per literature, ERCP to extract CBD stones can fail for various reasons such as failed cannulation, previous Billroth II gastrectomy, large CBD stones, large number of CBD stones etc. The failure in retrieving CBD stones by ERCP is an absolute indication for performing CBDE. Here, authors present a case report of a 73-year-old male with failed ERCP (inspite of two attempts) due to a large, solitary but tightly impacted terminal CBD stone. It hopes to convey the message that in similar situations, LCBDE, tactically using some endoscopy accessories, is a sound backup therapeautic option, inspite of non availability of a choledochoscope in the setup. The novelty of this case was that instead of the standard use of choledochoscope to directly visually confirm the completeness of stone clearance during the LCBDE, intraoperative fluoroscopy has been used effectively for the same; by obtaining good quality proximal and distal occlusion cholangiograms at the end of the procedure.

Study on 60 cases of common bile duct stone, there different modality of management and its inference

Background: The aim of the study was to determine the best treatment modality for common bile duct stone become more challenging as large number of options available such as endoscopic, laparoscopic or open surgical methods, we need to choose specific therapy according to patient’s clinical conditions, and individual expertise.Methods: It is prospective study including 60 patient having common bile duct stone along with gall bladder stone, its different modality of management and its inference, conducted in Bhopal Memorial Hospital and Research Centre, Bhopal, during period of January 2017 to January 2020.Results: In 60 cases 41 patients undergoes to endoscopic retrograde cholangio pancreatography (ERCP) first, stone successfully removed in 34 patients and stent placed, one patients developed pancreatitis after ERCP, managed conservatively, In 6 patients retained stone after ERCP procedure, one patients developed surgical emphysema after procedure, managed with ICD and conservatively, and one patient had bleeding during sphincterotomy so its procedure abandoned and one of the patient failed to cannulate common bile duct (CBD). 21 patients undergo laparoscopic common bile duct explorations, 2 lap CBD exploration converted to open CBD exploration with cholecystectomy, due to adhesion at hepatocystic triangle. Five patients undergoes open CBD exploration, in one patient hepaticojejunostomy was done as patient was having CBD stone with stricture. No mortality during and after procedure.Conclusions: Management of CBD stone is depends upon individual expertise and available modality. If surgeons are expertise then lap CBD exploration with cholecystectomy without attempting to ERCP guide stone removal is best approach in majority of patients.