Endoscopic Retrograde Cholangiography In Patients Research Articles

Antegrade balloon dilatation of the duodenal papilla during laparoscopic cholecystectomy versus endoscopic retrograde cholangiography in patients with acute choledocholithiasis: a case control matched study

IntroductionIn acute obstructive common bile duct (CBD) stones endoscopic retrograde cholangiography for CBD stone removal before cholecystectomy (ChE) (‘ERC-first’) is the gold standard of treatment. Intraoperative antegrade balloon dilatation of the duodenal papilla during ChE with flushing of CBD stones to the duodenum (‘ABD-during-ChE’) may be an alternative ‘one-stop-shop’ treatment option. However, a comparison of outcomes of the ‘ABD-during-ChE’ technique and the’ERC-first’ approach has never been performed.MethodsRetrospective case control matched study of patients suffering from obstructive CBD stones (< 8 mm) without severe pancreatitis or cholangitis that underwent the traditional ‘ERC-first’ approach versus the ‘ABD-during-ChE’ technique. Primary endpoint was the overall Comprehensive Complication Index (CCI®) from diagnosis to complete CBD stone removal and performed ChE.ResultsA total of 70 patients were included (35 patients each in the ‘ERC first’- and ‘ABD-during-ChE’-group). There were no statistical significant differences in terms of demographics and disease specific characteristics between the two study groups. However, there was a not significant difference towards an increased overall CCI® in the ‘ERC-first’ group versus the ‘ABD-during-ChE’ group (14.4 ± 15.4 versus 9.8 ± 11.1, p = 0.225). Of note, six major complications (Clavien-Dindo classification ≥ IIIa) occurred in the ‘ERC-first’ group versus two in the ‘ABD-during-ChE’ group (17% versus 6%, p = 0.136). In addition, significantly more interventions and a longer overall time from diagnosis to complete clearance of bile ducts and performed ChE was found, when comparing the ‘ERC-first’ group and the ‘ABD-during-ChE’ group (3.7 ± 0.8 versus 1.1 ± 0.4, p < 0.001; 160.5 ± 228.6 days versus 12.0 ± 18.0 days, p < 0.001).ConclusionIn patients suffering from acute obstructive CBD stones smaller than 8 mm, compared to the ‘ERC-first’ approach, the ‘ABD-during-ChE’ technique resulted in significantly less interventions and reduced overall treatment time from diagnosis to complete clearance of bile ducts and performed ChE. This comes together with a strong trend of less intervention related complications in the ‘ABD-during-ChE’ group.

Factors affecting complete stone extraction in the initial procedure in short type single-balloon enteroscopy-assisted endoscopic retrograde cholangiography for patients with Roux-en-Y gastrectomy

Objectives This study aimed to evaluate the efficacy and safety of stone extraction in patients who underwent Roux-en-Y gastrectomy using short-type single-balloon enteroscopy (SBE) and to clarify the factors affecting complete stone extraction in the initial procedure. Methods The data of patients with Roux-en-Y gastrectomy who underwent endoscopic stone extraction using short SBE between September 2011 and January 2022 was analyzed. Results Overall, 85 patients were scheduled to undergo stone extraction. 77 patients were intended stone extraction after successful biliary cannulation. The complete stone extraction success in the initial procedure, overall complete stone extraction success including repeated procedures, and adverse event rates were 68.2% (95% confidence interval [CI], 57.2%–77.9%), 87.1% (95% CI, 78.0%–93.4%), and 8.2% (95% CI, 3.4%–16.2%), respectively. Multiple logistic regression analysis indicated that bile duct diameter affected the success of complete stone extraction after successful biliary cannulation in the initial procedure (odds ratio 0.53, 95% CI, 0.30–0.94, p = .03). Conclusions Stone extraction in patients with Roux-en-Y gastrectomy using short SBE was effective. Patients with a large diameter bile duct required several sessions for complete stone extraction, suggesting that more dedicated devices are warranted for patients with surgically altered anatomy.

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.

Tu1602 Feasibility of Endoscopic Papillary Large Balloon Dilatation With Double-Balloon Endoscopic Retrograde Cholangiography for Patients With Choleductolithiasis and Surgically Altered Anatomy

Recently, endoscopic papillary large balloon dilatation (EPLBD, balloon size: 12–20 mm) has been used to treat large bile duct stones. Double-balloon endoscopic retrograde cholangiography (DB-ERC) has been used for patients with choleductolithiasis who have surgically altered upper gastrointestinal tracts, whereas classical endoscopic papillary balloon dilatation (EPBD, balloon size: 8mm) has been used with DB-ERC in the past. We recently introduced EPLBD with DB-ERC in patients with surgically altered anatomy. We evaluated the feasibility, safety, and efficacy of EPLBD compared to EPBD with DB-ERC.

Endoscopic retrograde cholangiography in patients with predicted mild biliary pancreatitis: Used too frequently?

Endoscopic retrograde cholangiography in patients with predicted mild biliary pancreatitis: Used too frequently?

Single balloon enteroscopy for endoscopic retrograde cholangiography in patients with Roux-en-Y hepaticojejunoanastomosis

To evaluate single balloon enteroscopy in diagnostic and therapeutic endoscopic retrograde cholangiography (ERC) in patients with Roux-en-Y hepaticojejunoanastomosis (HJA). The study took place from January 2009 to December 2011 and we retrospectively assessed 15 patients with Roux-en-Y HJA who had signs of biliary obstruction. In total, 23 ERC procedures were performed in these patients and a single balloon videoenteroscope (Olympus SIF Q 180) was used in all of the cases. A transparent overtube was drawn over the videoenteroscope and it freely moved on the working part of the enteroscope. Its distal end was equipped with a silicone balloon that was inflated by air from an external pump at a pressure of ≤ 5.4 kPa. The technical limitations or rather the parameters of the single balloon enteroscope (working length - 200 cm, diameter of the working channel - 2.8 mm, absence of Albarran bridge) showed the need for special endoscopic instrumentation. Cannulation success was reached in diagnostic ERC in 12 of 15 patients. ERC findings were normal in 1 of 12 patients. ERC in the remaining 11 patients showed some pathological changes. One of these (cystic bile duct dilation) was subsequently resolved surgically. Endoscopic treatment was initialized in the remaining 10 patients (5 with HJA stenosis, 2 with choledocholithiasis, and 3 with both). This treatment was successful in 9 of 10 patients. The endoscopic therapeutic procedures included: balloon dilatation of HJA stenosis - 11 times (7 patients); choledocholitiasis extraction - five times (5 patients); biliary plastic stent placement - six times (4 patients); and removal of biliary stents placed by us - six times (4 patients). The mean time of performing a single ERC was 72 min. The longest procedure took 110 min and the shortest took 34 min. This shows that it is necessary to allow for more time in individual procedures. Furthermore, these procedures require the presence of an anesthesiologist. We did not observe any complications in these 15 patients. This method is more demanding than standard endoscopic retrograde cholangiopancreatography due to altered postsurgical anatomy. However, it is effective, safe, and widens the possibilities of resolving biliary pathology.

The role of endoscopy in the management of choledocholithiasis

The role of endoscopy in the management of choledocholithiasis

Spiral Enteroscopy ERC in Patients with Surgically Altered Hepatobiliary Anatomy

Purpose: Endoscopic access of the pancreaticobiliary tree in patients after hepatobiliary reconstructive surgery is challenging. Spiral enteroscopy is a technique in small bowel enteroscopy, which utilizes an overtube that pleats the small bowel, allowing advancement of the endoscope. This technique allows for access to the afferent limb and the pancreaticobiliary tree. Here we describe our experience with spiral enteroscopy for Endoscopic Retrograde Cholangiography (ERC) in patients with surgically altered hepatobiliary anatomy (hepaticojejunostomy (HJ) or orthotopic liver transplant (OLT)). Methods: Spiral ERC procedures done by a single physician in a tertiary care institution were reviewed. Three procedures were chosen for this abstract. Two patients had previously undergone HJ, and one patient had an OLT. All three procedures utilized a forward viewing Olympus SIFQ180 enteroscope with a 2.8 mm working channel and the Endo-Ease Discovery SB overtube (Spirus Medical, Inc, Stoughton, MA). Indications for the procedures included abnormal liver chemistries or Magnetic Resonance Cholangiopancreatography (MRCP). All procedures were done under monitored anesthesia care. Results: All patients were women, mean age 53 years (range 45-68). Successful intubation of the afferent limb and cannulation of the biliary tree was achieved in all three patients. Findings included a beaded but patent hepatic duct in the OLT patient, in whom the scope was advanced into the hepatic duct; and anastomotic stenoses in the other two patients. Therapeutic interventions performed were dilation of the choledochoenterostomy via balloon sphincteroplasty in one patient and using the cannulotome as a dilator in the other. There were no complications in any of the procedures. Conclusion: Spiral enteroscopy ERC is a new technique that allows for easier access to the pancreaticobiliary tree in patients with surgically altered hepatobiliary anatomy. Spiral enteroscopy ERC seems to be a safe and effective method for diagnostic and therapeutic maneuvers in this group of patients and can potentially avoid more invasive percutaneous or surgical intervention.

T1545: Efficacy and Outcome of Endoscopic Retrograde Cholangiography in Patients With Metastatic Colorectal Cancer

Colorectal cancer (CRC) frequently metastasizes to the liver and porta hepatis, which may result in biliary obstruction. The clinical scenarios when endoscopic retrograde cholangiography (ERC) may prove successful and therapeutic have not been well studied.

Single-balloon enteroscopy effectively enables diagnostic and therapeutic retrograde cholangiography in patients with surgically altered anatomy

In patients with surgically altered anatomy, ERCP is often unsuccessful. Single-balloon enteroscopy (SBE) enables deep intubation of the small bowel, permitting diagnostic and therapeutic ERCP in this subset of patients. To determine the effectiveness of SBE in performing endoscopic retrograde cholangiography (ERC) in patients with surgically altered anatomy. Case series. Large quaternary-care center. Thirteen patients (11 women) underwent 16 SBE procedures with ERCP. Patient anatomy consisted of Whipple (n = 3), hepaticojejunostomy (n = 3), Billroth II (n = 1), and Roux-en-Y (n = 9). Patients with surgically altered anatomy in whom standard ERCP techniques had failed or were not possible underwent ERC by using SBE with initial therapeutic intent. Success rates of diagnostic ERC and therapeutic ERC in those patients who required biliary intervention. Procedure-related complications were also assessed. Diagnostic ERC was successful 12 (92.3%) of 13 patients and in 13 (81.3%) of 16 cases. Therapeutic ERC was required in 10 patients in whom diagnostic ERC was first accomplished, and therapeutic ERC was successful in 9 (90%) of 10 patients. Biliary interventions included balloon dilation (n = 4), stone extraction (n = 2), sphincterotomy (n = 4), removal of a surgically placed stent (n = 3), and stenting (n = 2). Two patients developed pancreatitis after therapeutic ERC. Median follow-up was 53 days (range 22-522 days). Overall procedural success in an intent-to-treat analysis by case was 75%. Single-center experience. SBE enables diagnostic and therapeutic ERC in most patients with altered anatomy. SBE-assisted therapeutic ERC may be associated with an increased risk of pancreatitis. Improvement of the available equipment is necessary to perform more efficient and effective biliary interventions.

Single session versus separate session endoscopic ultrasonography plus endoscopic retrograde cholangiography in patients with low to moderate risk for choledocholithiasis

Endoscopic ultrasonography (EUS) is a minimally invasive diagnostic tool for common bile duct stones (CBDS) and may be used to select patients for therapeutic endoscopic retrograde cholangiography (ERC). The aim of this trial is to compare, in patients with non-high-risk for CDBS, the clinical and economic impact of EUS plus ERC performed in a single endoscopic session versus EUS plus ERC in two separate sessions. During an 11-month period, all adult patients admitted to the emergency department with suspicion of CBDS were categorized into either high-risk or non-high-risk groups, on the basis of clinical, biochemical, or transabdominal ultrasound findings. Patients in the non-high-risk group were randomized to receive EUS plus ERC in one single or in two separate sessions. Eighty patients were recruited and randomized. Forty patients underwent EUS plus ERC in a single session and 40 patients underwent EUS plus ERC in two separate sessions. Negative EUS examination for CBDS avoided unnecessary ERC to 33 patients. Out of 47 patients with positive EUS (25 from the single session group and 22 from the double session), ERC confirmed the presence of CBDS in 46 cases (EUS sensitivity 100% and specificity 98%). Average time of procedure and hospitalization were significantly shorter in the single session group compared to the two session group. The single session strategy was also less expensive. Endoscopic ultrasonography plus ERC with sphincterotomy and stone extraction performed during the same endoscopic session was safe and efficacious with a reduction of procedure time, hospitalization and costs.

Double-balloon Endoscopy for Retrograde Cholangiography in Patients with Choledochojejunostomy and Roux-en-Y Reconstruction

Choledochojejunal anastomoses with Roux-en-Y reconstruction excludes the biliary tract from conventional endoscopic retrograde cholangiography (ERC) with standard endoscopes due to the length of the interposed small bowel segment. Double-balloon enteroscopy (DBE) facilitates deep insertion into the small bowel and may be used to perform ERC in these patients. In the present case series we report our experience with diagnostic and therapeutic double-balloon ERC in patients with choledochojejunostomy to a long Roux-en-Y loop previously unavailable for standard length endoscopes. Between December 2004 and May 2008 15 patients (mean age: 60.2 years) with choledochojejunal anastomosis underwent a total of 25 DBE-ERC procedures. Cannulation of the bile ducts was achieved in 22 / 25 procedures (84 %). Twenty-one therapeutic interventions, including stone removal, biliary duct dilation, stent placement and removal of previously placed stents were performed during 16 procedures in 8 patients. The mean total duration time of the procedures was 74.6 +/- 25.0 minutes. Postinterventional self-limiting fever occurred after 4 procedures in 3 patients with cholangitis. After therapeutic interventions all patients had a significant drop of bilirubin levels and all except one patient were free of complaints (follow-up 10.4 +/- 8.6 months). The DBE system permits diagnostic and therapeutic ERC in surgically modified anatomy, previously unavailable for endoluminal access. In our experience this procedure is safe and has a high success rate with a favourable patient outcome.

EUS versus endoscopic retrograde cholangiography for patients with intermediate probability of bile duct stones: a prospective randomized trial

Factors affecting diagnostic accuracy and comparison of patients in the follow-up period for negative outcomes are not thoroughly investigated in a randomized trial. Our purpose was to compare diagnostic accuracy, complications, and number of interventions. Prospective, unicentric, single-blind, randomized study. Single tertiary referral university hospital. One hundred twenty patients with intermediate risk for common bile duct (CBD) stones were randomized to either an EUS-first, endoscopic retrograde cholangiography (ERC)-second (n = 60) versus an ERC-only (n = 60) procedure. EUS, ERC, sphincterotomy, and balloon sweeping of CBD when needed. Sensitivity of EUS versus ERC, factors affecting diagnostic capability, complications, total number of endoscopic procedures. The sensitivity and specificity of ERC were 75% (95% CI, 42%-93%) and 100% (95% CI, 95%-100%), respectively. The sensitivity and specificity of EUS were 91% (95% CI, 59%-99%) and 100% (95% CI, 95%-100%), respectively. EUS is more sensitive than ERC in detecting stones smaller than 4 mm (90% vs 23%, P < .01). Although not significant, there was a trend for an increased number of endoscopic procedures in the ERC group compared with the EUS group (98 vs 83). The post-ERC pancreatitis rate was 6 in 120 (5%) in all study patients, and the post-ERC pancreatitis rate in patients with an undilated CBD was 5 of 53 (9.43%). The independent factors for post-ERC pancreatitis are undilated CBD (risk ratio [RR] 6.320; 95% CI, 1.703-11.524, P = .009), allocation into the ERC group (RR 2.107; 95% CI, 1.330-3.339, P = .02), female sex (RR 1.803; 95% CI, 1.155-2.813, P = .03), and age less than 40 years (RR 1.888; 95% CI, 1.245-2.863, P = .01). Kaplan-Meier analysis revealed higher rate of negative outcome in the ERC group than in the EUS group (P = .049, log-rank test). The EUS-first approach is not associated with further risk for subsequent endoscopic procedures. Patients with an undilated CBD should be investigated by the EUS-first approach to prevent post-ERC pancreatitis.

Double-balloon enteroscopy for endoscopic retrograde cholangiography in patients with a Roux-en-Y anastomosis

Double-balloon enteroscopy (DBE) has been proved to be effective for deep intubation of the small bowel. Patients with a Roux-en-Y enteroanastomosis and biliary problems have been a challenge in gastrointestinal practice because of the lack of endoscopic access to the biliary anastomosis. We report on the first case series of patients with Roux-en-Y anatomy who have been examined using DBE. Between September 2005 and May 2006, 18 endoscopic retrograde cholangiography procedures were performed in 13 patients (median age 53, range 2 - 81 years) using the DBE technique at our hospital. Most of the cases (10/13) had had a liver transplant for primary sclerosing cholangitis. The Fujinon T-series DBE system was used in all cases. The entero-enteric anastomosis was reached easily in all 18 procedures, and the end of the Roux limb was reached in 17/18 procedures. The mean intubation time was 40 minutes (range 5 - 120 minutes). Adequate imaging was achieved in all but two cases, one of whom had a native papilla. Biliary stenting was performed in two patients, stent removal in three patients, and removal of a small stone in one patient. Endoscopic access and biliary cannulation in the setting of Roux-en-Y anatomy is safe and feasible using the new DBE system for enteral intubation. Adaptation of accessories would further improve the utility of the procedure.

Endoscopic ultrasound versus endoscopic retrograde cholangiography for patients with intermediate probability of bile duct stones: a randomized trial comparing two management strategies

Diagnostic endoscopic retrograde cholangiography (ERC) is being replaced by endoscopic ultrasonography (EUS) in patients with suspected bile duct stones. The assumption that such an approach is advantageous, however, has never been tested in a randomized trial. 100 patients with intermediate probability of bile duct stones were randomly allocated to EUS or ERC. Two patients in the ERC group were excluded; the remaining 98 patients received the allocated intervention and were entered into the analysis (EUS, 50 patients; ERC, 48 patients). Detected stones were removed endoscopically; patients without stones were followed for 1 year. The primary end point was the proportion of patients with a negative outcome, related to either endoscopic procedures (complications) or to false-negative diagnosis of stones. Investigators assessing the negative outcomes were not blinded to group assignment. The secondary end point was the total number of endoscopic procedures (EUS and ERC) performed in each group to diagnose and treat stones. Bile duct stone prevalence was 28% and 25% in the EUS and ERC groups, respectively (P > 0.05). In the EUS group, 71 endoscopic procedures were performed, and 63 in the ERC group (mean per patient, 1.42 +/- 0.76, and 1.31 +/- 0.55, respectively; P > 0.05). In the EUS group, these included 49 successful and one failed initial EUS, 15 ERCs for bile duct stone treatment, and six procedures required during follow-up. In the ERC group there were 36 successful and 12 failed initial ERCs, 13 repeat procedures (EUS or ERC) performed after failed or equivocal initial ERC, and two procedures during follow-up. Five patients in the EUS group (10%, 95% CI 4-22) and 19 patients in the ERC group (40%, 95% CI 27-54) experienced a negative outcome (P < 0.001). No difference was observed when only moderate to severe complications were considered (6%, 95% CI 1-17, and 10%, 95% CI 4-23, respectively). In patients with intermediate probability of bile duct stones, the management strategy based on EUS (with selective ERC in patients with confirmed stones) is safer and not associated with an excess of endoscopic procedures compared with a strategy based on ERC alone.

A New Method of Biliary Sampling for Cytopathological Examination During Endoscopic Retrograde Cholangiography

Biliary brushing during endoscopic retrograde cholangiography (ERC) may allow the diagnosis of cancer, but this technique is limited by a low (18-57%) sensitivity. We compared the cellular and diagnostic yields of a new sampling method (using stricture dilation and a grasping basket) with those of brushing. Sixty consecutive patients with a suspected malignant obstruction of the common bile duct were included in a consecutive, nonrandomized order. They underwent sampling during ERC using the new method (study patients, N = 30) or a brush (control patients, N = 30). A final diagnosis of cancer was made in 22/30 (73%) study patients and 21/30 (70%) control patients. At the end of the study period, all smears were interpreted at cytopathological examination in a blind and random fashion for cellularity (insufficient, low, moderate, or high) and diagnosis (normal, atypical considered reactive, highly atypical suspicious for cancer, or malignant). "Highly atypical" and "malignant" diagnoses were considered as indicative of cancer. Compared with biliary brushing, the new method provided a high cellular yield in more cases (19/30 vs 10/30, P= 0.020), a higher sensitivity for the detection of cancer (19/22 [86%] vs 11/21 [52%], P= 0.015), and a higher diagnostic accuracy (27/30 [90%] vs 20/30 [67%], P= 0.028). Specificity for the detection of cancer was 100%. The 30-d complication rate observed with the new method was 3%. Significantly higher cellular and diagnostic yields can be obtained at ERC in patients with suspected malignant biliary stricture by combining stricture dilation and a grasping basket compared with brushing.

Prospective evaluation in 121 consecutive unselected patients undergoing laparoscopic treatment of choledocholithiasis.

Laparoscopic common bile duct (CBD) exploration was attempted in 115 of 121 consecutive unselected patients with choledocholithiasis (mean age 69 (range 21-92) years) found during routine intraoperative cholangiography. The CBD was successfully cleared of all stones in 100 patients (87 per cent). Ten of 11 patients referred for surgery after failure of endoscopic sphincterotomy had complete laparoscopic choledocholithiasis. Eleven patients (10 per cent) required conversion to open CBD exploration, and laparoscopic exploration was not attempted in six (5 per cent) because of inflammation or fibrosis. Postoperative endoscopic sphincterotomy was required in four patients (4 per cent) for retained stones after laparoscopic exploration. There were no postoperative deaths (39 per cent of patients were aged 75 years or more). Routine intraoperative cholangiography, and when required laparoscopic CBD exploration, should be compared in randomized trials with preoperative endoscopic retrograde cholangiography in patients with suspected choledocholithiasis.

Efficacy and Outcome of Endoscopic Retrograde Cholangiography in Patients with Metastatic Colorectal Cancer Resulting in Biliary Obstruction

Background: Colorectal cancer (CRC) frequently metastasizes to the liver and porta hepatis. Metastatic disease may result in biliary obstruction and jaundice. The role of endoscopic drainage and outcome in these patients is unknown. Aim: To determine the success of endoscopic retrograde chaolngiography (ERC) in relieving malignant biliary obstruction secondary to CRC and to identify predictors of successful drainage and survival in this cohort of patients. Methods: Retrospective review at three major medical centers of patients who developed biliary obstruction secondary to metastatic CRC and underwent ERC over a 5 year period.

Pre-operative endoscopic ultrasonography can optimise the management of patients undergoing laparoscopic cholecystectomy with abnormal liver function tests as the sole risk factor for choledocholithiasis: a prospective study

Background. Pre-operative endosonography has been proposed as a cost-effective procedure in the management of patients who undergo laparoscopic cholecystectomy having an intermediate risk of common bile duct stones. We prospectively evaluated the impact of pre-operative endosonography on the management of patients facing laparoscopic cholecystectomy with abnormal liver function tests as the sole risk factor for choledocolithiasis. Methods. Among 587 consecutive patients scheduled for laparoscopic cholecystectomy, 47 (8%) patients having one or more abnormal liver function tests but a normal appearance of common bile duct at abdominal ultrasound, underwent pre-operative endosonography. In patients with endosonography-detected common bile duct stones, a pre-operative endoscopic retrograde cholangiography was performed, or an intra-operative endoscopic retrograde cholangiography was scheduled. In all endosonography-negative patients, an intra-operative trans-cystic cholangiography was performed. Results. Endosonography detected common bile duct stones in nine patients (19%) but only in five of them stones were radiologically confirmed (PPV 0.55). Endosonography-detected stones were confirmed in four of four (100%) patients in whom cholangiography was performed within 1 week, but only in one of five (20%) patients in whom radiology was further delayed ( P<0.05). In three of four cases (75%), stones detected at endosonography but not confirmed at X-rays, were smaller than 2.0 mm. Among 38 patients with negative endosonography, common bile duct stones were found in two patients (NPV 0.95), whereas unplanned endoscopic stone extraction was needed only in one patient (NPV 0.97). Conclusions. Pre-operative endosonography can spare unnecessary pre-operative endoscopic retrograde cholangiography as well as inappropriate scheduling of intra-operative endoscopic retrograde cholangiography in patients undergoing laparoscopic cholecystectomy with abnormal liver function tests. To maximise the impact of endosonography on the management of these patients, the procedure should be performed immediately before laparoscopic cholecystectomy.

EUS for suspected choledocholithiasis: Do benefits outweigh costs? A prospective, controlled study

This prospective study of the use of EUS to prevent unnecessary endoscopic retrograde cholangiography in patients with suspected choledocholithiasis has two aims: to evaluate the effectiveness, based on patient outcome, and the potential clinical and economic benefits of EUS. A prospective series of 485 patients (202 men, 283 women; mean age 66.2 years, range 20-94 years) suspected to have choledocholithiasis based on clinical, biochemical, and cross-sectional imaging (US or CT) data underwent EUS. Positive EUS findings were confirmed by endoscopic retrograde cholangiography with sphincterotomy and/or by surgery; negative findings were confirmed by clinical follow-up. An EUS result was considered a true negative if the patient was confirmed symptom-free with normal tests on follow-up of at least 6 months. The costs of EUS (procedure, days of hospitalization, any morbidity) were compared with the estimated costs of the endoscopic retrograde cholangiography avoided in patients with true-negative EUS findings. EUS findings were verified in 463 patients: EUS diagnosed choledocholithiasis in 239 (51.6%) and the absence of stones in 220 patients. In 4 patients (0.8%), EUS was incomplete. By sphincterotomy (209 patients), surgical bile duct exploration (39), percutaneous cholangiography (1 case in which EUS demonstrated a bile duct tumor), and follow-up (214), EUS diagnoses were confirmed as follows: 237 true-positive, 216 true-negative, 2 false-positive, 4 false-negative, 4 incomplete (sensitivity 98%, specificity 99%, positive predictive value 99%, negative predictive value 98%, accuracy 97%). In 214 (46%) patients, more invasive investigations of the bile duct were avoided. The mean cost for patients managed by the EUS-based strategy was ' 374.50 (-284.72), which was significantly less than the theoretical mean cost of ' 443.80 (p < 0.001) for patients undergoing endoscopic retrograde cholangiography. The results of this study confirm that EUS is highly reliable for the diagnosis of choledocholithiasis. Its use offers considerable clinical and economic advantages by preventing inappropriate and more invasive evaluation of the bile duct.