Endoscopic Retrograde Cholangiography Research Articles

S2829 ERCP via EUS Guided Duodenojejunostomy for a Biliary Stricture After Roux-en-Y Hepaticojejunostomy

Introduction: Patients with a Roux-en-Y hepaticojejunostomy (RYHJ) present a unique challenge when endoscopic retrograde cholangiography (ERC) is required. Standard approaches range from a surgical approach involving laparoscopic assistance to device assisted enteroscopy, with transoral approaches generally being variably successful, due to anatomy, length of intestinal limbs after surgery, and limitations in available accessories for use in device assisted enteroscopy. Here, we report the endoscopic use of a LAMS to create a duodenojejunostomy (DJ), thereby enabling ERC in a patient with RYHJ. Case Description/Methods: A 46-year-old woman status post cholecystectomy complicated by common bile duct injury necessitating RHYJ and prior anastamotic strictures, presented with recurrent self-limited cholangitis. She presented to clinic with intermittent episodes right upper quadrant pain, and fever which were treated conservatively with antibiotics. MRCP demonstrated stricture of the hepatic duct near the anastomosis [1]. Device assisted endoscopy was performed, but the anastomosis was unable to be reached. After discussing endoscopic, IR, and surigcal options we proceeded with EUS guided interventions given the anticipated need for recurrent interventions for a biliary stricture. EUS demonstrated mild intrahepatic dilation with limited access points for hepaticogastrostomy. The bile duct and hepaticojejunostomy were visualized from the bulb with small bowel adjacent to the anastomosis [2]. The jejunum was accessed using a 19 G FNA needle, and bile was aspirated to confirm intraluminal location. The jejunum was filled with 200 mL of sterile water and contrast [3]. A 15 mm x 10 mm AXIOS was then deployed in good position, creating a DJ, which was confirmed fluoroscopically and endoscopically [4]. Contrast was then injected through the stent to exclude a leak. 4 weeks later, ERCP was performed via the DJ [5]. Cholangioscopy was performed which showed some edematous bile duct mucosa without findings concerning for malignancy [6]. Biopsies and brushings were performed and three plastic stents were placed. The patient tolerated the procedure well, the tissue was benign and the patient has had resolution of her cholangitis symptoms. Discussion: In conclusion, we report a novel use of LAMS enabling ERC in patient’s status post RHYJ which allows easy access for repeat interventions and avoids the difficulties and limitations of device assisted enteroscopy ERCP.Figure 1.: Image 1. MRCP showing hepatic duct stricture near the anastomosis Image 2. EUS with bile duct adjacent to fluid filled jejunum Image 3. EUS with FNA needle accessing hepaticojejunostomy Image 4. EUS with LAMS deployed from duodenum to jejunum Image 5. Matured duodenojejunostomy Image 6. Cholangioscopy demonstrating edematous mucosa.

A Rare Adverse Event after Endoscopic Retrograde Cholangiography.

A Rare Adverse Event after Endoscopic Retrograde Cholangiography.

Development of a Predictive Model for Common Bile Duct Stones in Patients With Clinical Suspicion of Choledocholithiasis: A Cohort Study.

Current choledocholithiasis guidelines heavily focus on patients with low or no risk, they may be inappropriate for populations with high rates of choledocholithiasis. We aimed to develop a predictive scoring model for choledocholithiasis in patients with relevant clinical manifestations. A multivariable predictive model development study based on a retrospective cohort of patients with clinical suspicion of choledocholithiasis was used in this study. The setting was a 700-bed public tertiary hospital. Participants were patients who had completed three reference tests (endoscopic retrograde cholangiography, magnetic resonance cholangiopancreatography, and intraoperative cholangiography) from January 2019 to June 2021. The model was developed using logistic regression analysis. Predictor selection was conducted using a backward stepwise approach. Three risk groups were considered. Model performance was evaluated by area under the receiver operating characteristic curve, calibration, classification measures, and decision curve analyses. Six hundred twenty-one patients were included; the choledocholithiasis prevalence was 59.9%. The predictors were age > 55 years, pancreatitis, cholangitis, cirrhosis, alkaline phosphatase level of 125 - 250 or > 250 U/L, total bilirubin level > 4 mg/dL, common bile duct size > 6 mm, and common bile duct stone detection. Pancreatitis and cirrhosis each had a negative score. The sum of scores was -4.5 to 28.5. Patients were categorized into three risk groups: low-intermediate (score ≤ 5), intermediate (score 5.5 - 14.5), and high (score ≥ 15). Positive likelihood ratios were 0.16 and 3.47 in the low-intermediate and high-risk groups, respectively. The model had an area under the receiver operating characteristic curve of 0.80 (95% confidence interval: 0.76, 0.83) and was well-calibrated; it exhibited better statistical suitability to the high-prevalence population, compared to current guidelines. Our scoring model had good predictive ability for choledocholithiasis in patients with relevant clinical manifestations. Consideration of other factors is necessary for clinical application, particularly regarding the availability of expert physicians and specialized equipment.

S2835 Gastro-Cholecysto-Colonic Fistula Following Endoscopic Ultrasound-Guided Gallbladder Drainage for Stump Cholecystitis: A Case Report

Introduction: Cholecystocolonic fistulas (CCF) usually occur as a complication of gallstones but cases due to malignancy, peptic ulcers, and Crohn’s disease have been reported. We present a case of a gastro-cholecysto-colonic fistula after endoscopic ultrasound guided-gallbladder drainage (EUS-GBD) for stump cholecystitis. Case Description/Methods: A 50 year old male presented with abdominal pain. CT scan noted acute cholecystitis. He underwent laparoscopic converted to open subtotal cholecystectomy due to significant inflammation around the gallbladder. He represented 3 weeks later for abdominal pain. CT showed stump cholecystitis. Gastroenterology was consulted for EUS-GBD given his poor surgical candidacy. Diagnostic EUS revealed choledocholithiasis. Endoscopic retrograde cholangiography (ERC) with cholangioscopy, electrohydraulic lithotripsy, and stone removal was completed. Transgastric EUS-GBD with a 10 x 10 mm electrocautery enhanced lumen apposing metal stent (LAMS) was then performed followed by double pigtail stent (DPT) placement within the LAMS. At a follow up visit, abdominal pain resolved but he developed debilitating diarrhea and was started on cholestyramine. Upper endoscopy 4 weeks after EUS-GBD revealed a gastro-cholecysto-colonic fistula with the proximal end of the DPT in the colon. Cholecystoscopy confirmed absence of gallstones so the LAMS and DPT were removed. Clips were used to close the cholecystogastric tract. Oral contrasted CT with delayed images showed tethering of the gallbladder to the hepatic flexure but no extravasation of contrast into the gallbladder from either the stomach or colon. Given this, clinical observation was pursued. Six weeks later, CT noted similar tethering without contrast leak. On colonoscopy, an area of inflamed mucosa at the hepatic flexure was seen without a patent fistula tract. Biopsies showed chronic colitis. Diarrhea subsequently resolved. (Figure) Discussion: CCFs are a rare complication of gallstone disease. If untreated, biliary sepsis can occur. Surgery is the standard treatment but endoscopic transpapillary gallbladder drainage with a DPT can promote fistula healing in non-surgical patients. We present a case of a gastro-cholecysto-colonic fistula in a poor surgical candidate after EUS-GBD for stump cholecystitis. This was managed with closure of the cholecystogastric tract. CCF closure occurred spontaneously. In cases of persistent CCF, transpapillary gallbladder drainage should be considered.Figure 1.: A. Double pigtail stent migrated into transverse colon with gastro-cholecysto-colonic fistula as viewed from the gallbladder lumen. B. CT scan showing tethering of hepatic flexure to remnant gallbladder (red arrow) without contrast extravasation into the gallbladder from the stomach or colon. C. Closed cholecystocolonic fistula (black arrow) viewed from the hepatic flexure.

S1727 Endoscopic Ultrasound-Guided Transgastric Drainage of an Infected Biloma After Cholecystectomy: A Case Report

Introduction: A biloma is a well-defined collection of bile outside the biliary tree typically caused by iatrogenic disruption of a bile duct. Percutaneous drainage is the traditional treatment modality with surgery reserved for refractory cases. Endoscopic ultrasound (EUS) guided transenteric drainage has emerged as a suitable alternative. We present a case of an infected post-cholecystectomy biloma treated using EUS-guided drainage with a transgastric LAMS. Case Description/Methods: A 57-year-old female presented with fevers, abdominal pain, nausea, and vomiting following a laparoscopic cholecystectomy for acute cholecystitis 12 days prior. Labs noted a leukocytosis with normal liver chemistries. CT scan of the abdomen showed a peripherally enhancing gas and fluid collection in the subhepatic space measuring 14.5 x 7 x 8 cm, resulting in a mass effect on the antrum and proximal duodenum. Gastroenterology was consulted for the management of suspected bile leak and infected biloma. Endoscopic retrograde cholangiography (ERC) revealed a bile leak with contrast extravasation from the cystic duct stump. This was treated with biliary sphincterotomy and placement of a 10 Fr x 7 cm plastic biliary stent. Same session EUS demonstrated a large fluid collection abutting the antrum with a well-defined wall. EUS-guided drainage of the biloma was performed using a 15 x 10 mm electrocautery enhanced LAMS via a transgastric approach. Approximately 1 L of purulent fluid was evacuated from the cavity. A subsequent CT scan confirmed the correct positioning of the LAMS with marked cavity decompression (Figure). The patient’s symptoms resolved. Endoscopy with LAMS removal and placement of 2 10 Fr x 4 cm double pigtail stents (DPT) was performed 1 week later. CT 1 week after DPT placement noted near-complete resolution of the fluid collection. Six weeks after the index procedure, ERC showed resolution of the cystic duct leak and the biliary stent was removed. Both DPTs were removed 2 weeks later. The patient has remained well clinically. Discussion: EUS-guided transenteric biloma drainage is a safe and effective alternative to percutaneous drainage. Initial cases were performed using plastic stents but more recently, transduodenal drainage with a LAMS was reported. Endoscopic drainage also enables same session identification and treatment of the culprit bile leak which is essential to prevent biloma recurrence. Our case is the first reported EUS-guided transgastric drainage of an infected biloma using a LAMS.Figure 1.: A. CT scan illustrating a large subhepatic fluid and gas-containing collection (Black arrow) with resultant gastric outlet obstruction (red arrow). B. Successful placement of a transgastric lumen apposing metal stent (LAMS) into the biloma cavity with immediate drainage of purulent fluid. C. Post-drainage CT scan demonstrating biloma cavity decompression and appropriate positioning of the LAMS (green arrow).

S1944 An Extraordinary Case of Gallbladder Small Cell Carcinoma

Introduction: We present a case of a patient diagnosed with Gallbladder Small Cell Carcinoma (SCC). Case Description/Methods: This is a 58-year-old gentleman who presented to the emergency department complaining of pruritis. Associated with fatigue, appetite loss, and a 20-pound weight loss for three months. The physical exam was remarkable for scleral icterus and jaundice. Labs were remarkable for Total Bilirubin of 23.4 and Direct Bilirubin of 16.5. CT abdomen with IV contrast showed wall thickening of the gallbladder and infiltrates to his liver (Figure a). The patient had an Endoscopic retrograde cholangiography (ERCP) where the common hepatic duct contained single severe stenosis. One stent was placed into the common bile duct. A solid mass was found in the gallbladder, a biopsy was retrieved, and pathology confirmed Gallbladder SCC (Figures b and c). The patient was started on chemotherapy with carbo-etoposide. Another interval CT abdomen was obtained three months later which showed further invasion into segment four of the liver, new peritoneal metastasis, and increased biliary ductal dilation. The patient was subsequently started on FOLFIRINOX. Follow-up CT two months later after three rounds of chemotherapy showed stable hepatic lesions but increased intrahepatic ductal dilation. Interval CT abdomen two months later showed enlargement of hepatic segment four mass with involvement of segment five, peritoneal carcinomatosis, and new tumor implants along the anterior margin of the pancreas. The patient is currently on CAPTEM. Discussion: Gallbladder SCC is an extraordinary finding as it has an incidence of .2% of all neuroendocrine tumors (1) with almost all cases either locally advanced or metastatic at the time of diagnosis. In Fuji et al’s case series review, it was found that the one-and two-year survival rates of the 53 cases were 28% and 0% respectively (2). In patients with localized disease, surgical resection may result in prolonged survival. Chemotherapy is used to treat disseminated disease, although there are no clinical trials of a specific regimen given the scarcity of cases. Although incredibly rare, SCC of the gallbladder should be part of the differential diagnosis for gallbladder cancer.Figure 1.: A: CT abdomen with IV contrast showing gallbladder wall thickening (black arrow) and infiltrates into the liver (red arrow). B: Hematoxylin and eosin image of the gallbladder core needle biopsy showing high-grade neuroendocrine carcinoma involving fibrous stroma. Tumor cells are hyperchromatic with a high nucleus to cytoplasmic ratios and show evidence of molding and crush artifact. C: Core needle biopsy of the gallbladder immunohistochemical stain for RB1 shows loss of tumor cell nuclear expression of the Rb protein, characteristic for small cell carcinomaREFERENCES 1. Kanthan R, Senger JL, Ahmed S, Kanthan SC. Gallbladder cancer in the 21st century. J Oncol 2015; 967472. 2. Fujii H, Aotake T, Horiuchi T, Chiba Y, Imamura Y, Tanaka K. Small cell carcinoma of the gallbladder: a case report and review of 53 cases in the literature. Hepatogastroenterology 2001;48(42):1588-93.

Mucinous cystic neoplasm of the liver with polypoid nodule prolapsing into the bile duct: a case report and review of literature

BackgroundMucinous cystic neoplasm of the liver (MCN-L) is a rare cystic tumor as defined by the 2010 World Health Organization classification. MCN-L usually does not communicate with or grow into the bile duct. Herein, we present a rare case of MCN-L with a polypoid nodule protruding into the bile duct.Case presentationA 69-year-old woman was referred to our hospital for elevated serum liver enzyme levels and obstructive jaundice. The patient also complained of abdominal pain in the right hypochondriac region. Abdominal ultrasonography showed a cystic lesion in segment 4 (S4) of the liver. Computed tomography revealed a 4-cm multilocular cystic lesion with a thick wall and multiple septal formations, showing a cyst-in-cyst appearance in S4. Endoscopic retrograde cholangiography showed a contrast defect between the left hepatic duct and the common bile duct, which was suspected to be a nodular lesion in the bile duct. Bile cytology and biopsy of the nodular lesion showed no malignant findings. Based on these findings, the differential diagnosis in this patient included intraductal papillary neoplasm of the bile duct and MCN-L, which had malignant potential. The patient underwent left hemihepatectomy, including caudate lobe excision with bile duct resection and right hepatocholangiojejunostomy. Macroscopic findings showed a 40 × 29 mm multilocular cystic lesion with a polypoid nodule that protruded into the left intrahepatic bile duct. As an ovarian-like stroma was observed in both cystic and polypoid lesions microscopically, the histopathological diagnosis was MCN-L. The postoperative course was uneventful, and the patient was discharged 24 days after surgery. The patient is currently alive without recurrence 22 months after the surgery.ConclusionAlthough MCN-L rarely communicates with the bile duct, it is necessary to consider that MCN-L could grow into the bile duct, occasionally causing obstructive jaundice.

Endoscopic versus percutaneous intervention for palliation in malignant hilar bile duct obstruction – A comparative cohort study

BackgroundBiliary drainage in patients managed palliatively for malignant hilar obstruction can be achieved by endoscopic transpapillary stenting using endoscopic retrograde cholangiography (ERC) or percutaneous transhepatic stent or catheter placement using percutaneous transhepatic cholangiography (PTC). This study compares ERC and PTC drainage for malignant hilar bile duct obstruction. MethodsA retrospective study of drainage procedures at two academic hospitals was conducted from 2015 to 2020. Procedural success (divided into access-, bridging-, and technical success), therapeutic success, duration of therapeutic success and complications were analysed for different Bismuth-Corlette stricture types. ResultsA total of 293 patients were included, 153 (52.2%) in the ERC group and 140 (47.8%) in the PTC group. Access and bridging success in the ERC and PTC groups were 83.5% vs. 97.2% (p < 0.001) and 90.2% vs. 84.5% (p = 0.119), respectively. Technical and therapeutic success were equivalent between the two groups (98.3% vs. 99.3%, p = 0.854 and 81.7% vs. 73.3%, p = 0.242). Duration of therapeutic success was longer after ERC drainage compared to PTC drainage (p = 0.009) with a 3-month gain in duration of therapeutic success after ERC drainage (p = 0.006, 95% CI [26–160]). Cholangitis rates were equivalent (21.4% vs. 24.7%, p = 0.530), pancreatitis was more common in the ERC group (9.4% vs. 0%, p < 0.001) and procedure-related deaths more common in the PTC group (6.0% vs. 15.8%, p < 0.001). ConclusionAlthough ERC and PTC drainage of malignant hilar obstruction were similar regarding technical and therapeutic success, ERC drainage was more durable. Outcome differences for B–C stricture types should be explored in future studies.

Screening for hilar biliary invasion in ampullary cancer patients.

BACKGROUNDThe treatment for ampullary cancer is pancreatoduodenectomy or local ampullectomy. However, effective methods for the preoperative investigation of hilar biliary invasion in ampullary cancer patients have not yet been identified.AIMTo determine the necessity of and an appropriate method for investigating hilar biliary invasion of ampullary cancer.METHODSAmong 43 ampullary cancer patients, 34 underwent endoscopic treatment (n = 9) or surgery (n = 25). The use of imaging findings (thickening and enhancement of the bile duct wall on contrast-enhanced computed tomography, irregularity on endoscopic retrograde cholangiography, thickening of the entire bile duct wall on intraductal ultrasonography (IDUS), and partial thickening of the bile duct wall on IDUS) and biliary biopsy results for diagnosing hilar biliary invasion of ampullary cancer was compared.RESULTSHilar invasion was not observed in every patient. Among the patients who did not undergo biliary stent insertion, the combination of partial thickening of the bile duct wall on IDUS and biliary biopsy results showed the highest accuracy (100%) for diagnosing hilar biliary invasion. However, each imaging method and biliary biopsy yielded some false-positive results.CONCLUSIONAlthough some false-positive results were obtained with each method, the combination of partial thickening of the bile duct wall on IDUS and biliary biopsy results was useful for diagnosing hilar biliary invasion of ampullary cancer. However, hilar invasion of ampullary cancer is rare; therefore, the investigation of hilar biliary invasion of ampullary cancer might be unnecessary.

Effect of endoscopic treatment in patients with secondary sclerosing cholangitis.

Secondary sclerosing cholangitis (SSC) is a progressive disease with high mortality and characterized by chronic inflammation and biliary obstruction. Therapeutic options are limited. The aim of this retrospective study was to evaluate the effects of endoscopic treatment in patients with SSC, the outcome, and association with potential risk factors. Data from all patients with SSC from 1996 to April 2021 were included. Eighty patients with SSC were included. Seventy-five patients (93.8%) underwent diagnostic endoscopic retrograde cholangiography; 46 patients (57.5%) could be treated endoscopically. Endoscopic treatment comprised removal of biliary casts (n=36/75), dilatation of bile ducts (n=17/75), and intermittent stenting (n=11/75). Twenty patients underwent orthotopic liver transplantation (25%); 27 patients died (33.8%). Transplantation-free survival was affected neither by endoscopic treatment nor by presence of biliary strictures, but bacteria positive bile culture was associated with better and increased levels of serum alkaline phosphatase and bilirubin levels with poor outcome. Secondary sclerosing cholangitis is a progressive disease with poor long-term prognosis. Endoscopic treatment options seem to be limited regarding transplantation-free survival but might improve quality of life and prevent local complications such as cholangitis. The observed limited effect of endoscopic treatment might be attributed to the rapid progression of this disease.

Endoscopic Management of Biliary Complications Following Hepatobiliary Surgery

Biliary complications are frequent after hepatic surgery and may greatly influence postoperative morbidity and mortality. Most of these are leaks or strictures to the bile duct, most frequently leaks after cholecystectomy and liver resection. Strictures are an important problem after liver transplantation. Patients after orthotopic liver transplantation are particularly vulnerable, as they are different from biliary complications after liver resection and must be treated very sensitively and carefully. Endoscopic retrograde cholangiography is an excellent procedure for treating these complications. The therapeutic properties include endoscopic sphincterotomy, insertion of prostheses and dilatations. These procedures can give success rates of up to 90% of cases. For hepatico-jejunostomies, there are alternative possibilities of intervention, such as balloon- or motor-supported antegrade enteroscopy, percutaneous transhepatic cholangio drainage or the increasing use of endosonographically supported procedures.

Comparison of an Inside Stent and a Fully Covered Self-Expandable Metallic Stent as Preoperative Biliary Drainage for Patients with Resectable Perihilar Cholangiocarcinoma.

Background There is a need for a more tolerable preoperative biliary drainage (PBD) method for perihilar cholangiocarcinoma (PHCC). In recent years, inside stents (ISs) have attracted attention as a less suffering PBD method. Few studies have compared IS with a fully covered self-expandable metallic stent (FCSEMS) as PBD for resectable PHCC. The aim of this study is to compare them. Methods This study involved 86 consecutive patients (IS: 51; FCSEMS: 35). The recurrent biliary obstruction (RBO) rate until undergoing surgery or being diagnosed as unresectable, time to RBO, factors related to RBO, incidence of adverse events related to endoscopic retrograde cholangiography, and postoperative complications associated with each stent were evaluated retrospectively. Results There was no significant difference between the two groups in the incidence of adverse events after stent insertion. After propensity score matching, the mean (SD) time to RBO was 37.9 (30.2) days in the IS group and 45.1 (35.1) days in the FCSEMS group, with no significant difference (P=0.912, log-rank test). A total of 7/51 patients in the IS group and 3/35 patients in the FCSEMS group developed RBO. The only risk factor for RBO was bile duct obstruction of the future excisional liver lobe(s) due to stenting (HR 29.8, P=0.008) in the FCSEMS group, but risk factors could not be indicated in the IS group. There was no significant difference in the incidence of bile leakage or liver failure. In contrast, pancreatic fistula was significantly more common in the FCSEMS group (13/23 patients) than in the IS group (3/28 patients) (P < 0.001), especially in patients who did not undergo pancreatectomy (P=0.001). Conclusions As PBD, both IS and FCSEMS achieved low RBO rates. Compared with FCSEMS, IS shows no difference in RBO rate, is associated with fewer postoperative complications, and is considered an appropriate means of PBD for resectable PHCC. This trail is registered with UMIN000025631.

Long-term Clinical Outcomes and Predictive Factors for Living-donor Liver Transplant Recipients With Biliary Strictures.

Biliary strictures frequently occur in living-donor liver transplant (LDLT) recipients. However, long-term clinical outcomes and their associated factors are unclear. We analyzed an historical cohort of 228 recipients who underwent LDLT with post-liver transplantation biliary strictures. Endoscopic retrograde cholangiography or percutaneous transhepatic biliary drainage were performed to treat biliary strictures. Patients that experienced persistent jaundice over 3 mo after the initial treatment were defined as a remission-failure group. Median observation period was 8.5 y after the diagnosis of biliary stricture. The 15-y graft survival (GS) rate was 70.6%, and 15-y rate of developing portal hypertension (PH) was 26.1%. Remission failure occurred in 25.0% of study participants. In the multivariate analysis, biopsy-proven acute rejection, and portal vein/hepatic artery abnormalities were risk factors for remission failure. Development of PH, retransplantation, and death were significantly more frequent in the remission-failure group. Remission failure and PH were associated with poor GS. In multivariate analyses, hepatic artery abnormality and biloma were common significant factors that were associated with a poor GS and development of PH. The insufficient blood supply reflected by hepatic artery abnormality and biloma might be the most important factor that can predict poor long-term survival in LDLT patients with biliary strictures. Future large-scale prospective studies are needed to validate our observations.

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.

Comparison of short-course antibiotic therapy of 6 or less days with a longer treatment in patients with cholangitis after liver transplantation.

Stenosis of the biliary anastomosis predisposes liver graft recipients to bacterial cholangitis. Antibiotic therapy (AT) is performed according to individual clinical judgment, but duration of AT remains unclear. All liver graft recipients with acute cholangitis according to the Tokyo criteria grade 1 and 2 after endoscopic retrograde cholangiography (ERC) were included. Outcome of patients treated with short AT (<7 days) was compared to long AT (>6 days). Recurrent cholangitis (RC) within 28 days was the primary end point. In total, 30 patients were included with a median of 313 (range 34-9849) days after liver transplantation until first proven cholangitis. Among 62 cases in total, 51/62 (82%) were graded as Tokyo-1 and 11/62 (18%) as Tokyo-2. Overall median duration of AT was 6 days (1-14) with 36 cases (58%) receiving short AT and 26 (42%) receiving long AT. RC was observed in 10 (16%) cases, without significant difference in occurrence of RC in short versus long AT cases. CRP and bilirubin were significantly higher in patients with long AT, while low serum albumin and low platelets were associated with risk of RC. A shorter antibiotic course than 7 days shows good results in selected, ERC-treated patients for post-transplantation biliary strictures.

P-67 Comparison of the malignant predictors in intrahepatic and extrahepatic intraductal papillary neoplasm of bile duct

Intraductal papillary neoplasm of the bile duct (IPNB) is a precancerous lesion of cholangiocarcinoma, for which surgical resection is the most effective treatment. We evaluated the predictors of malignancy in IPNB according to anatomical location and the prognosis without surgery. A total of 196 IPNB patients who underwent pathologic confirmation by surgical resection or endoscopic retrograde cholangiography or percutaneous transhepatic cholangioscopic biopsy were included. Clinicopathological findings of IPNB with invasive carcinoma or mucosal dysplasia were analyzed according to anatomical location. Of the 116 patients with intrahepatic IPNB (I-IPNB) and 80 patients with extrahepatic IPNB (E-IPNB), 62 (53.4%) and 61 (76.3%) were diagnosed with invasive carcinoma, respectively. Multivariate analysis revealed that mural nodule > 12 mm (p=0.043) in I-IPNB and enhancement of mural nodule (p=0.044) in E-IPNB were predictive factors for malignancy. Pathology discrepancy before and after surgery, IPNB has 71.2% of sensitivity and 82.3% of specificity. In the non-surgical IPNB group, composed of nine I-IPNB and seven E-IPNB, 43.7% progressed to IPNB with invasive carcinoma within 876 days. E-IPNB has a higher rate of malignancy than I-IPNB. The predictive factor for malignancy is mural nodule > 12 mm in I-IPNB and mural nodule enhancement in E-IPNB.

Intraductal Radiofrequency Ablation as a Palliative Treatment for Advanced Malignant Hilar Biliary Obstruction

Malignant hilar biliary obstruction (MHBO) frequently accompanies cholestasis and cholangitis, and requires biliary stent placement. To prevent stent occlusion and prolong survival, local ablation therapy can be considered adjunctive to stent placement. Intraductal radiofrequency ablation (ID-RFA) is a recently developed local therapy for malignant biliary obstruction that can be easily performed employing endoscopic retrograde cholangiography. The use of ID-RFA to treat MHBO (as distinct from distal biliary obstruction) was suggested to be associated with severe adverse events. However, recent comparative studies have shown that ID-RFA is feasible and safe, and acceptably efficacious, in patients with advanced MHBO; newer temperature-controlled ID-RFA devices may enhance safety further. Regularly repeated ID-RFA with stent exchange affords better survival than stenting alone. However, the optimal ID-RFA strategy for MHBO remains inconclusive given the lack of data. Further large-scale clinical trials are needed.

Novel histological scoring for predicting disease outcome in primary sclerosing cholangitis.

BackgroundPrimary sclerosing cholangitis (PSC) is a progressive cholestatic liver disease that may lead to liver cirrhosis or cholangiocarcinoma. Liver histology and fibrosis stage are predictive markers of disease progression, and histological cirrhosis is defined as a significant endpoint. PSC‐specific histological scoring methods are lacking at present. We aimed to develop a tailored classification system for PSC, the PSC histoscore, based on histological features associated with disease progression.MethodsIn total, 300 PSC patients diagnosed between 1988 and 2018 were enrolled; their data were collected from the PSC registry (Helsinki University Hospital), and liver specimens were obtained from the Biobank of Helsinki. Five histological features included in the adapted Nakanuma scoring system and three additional parameters typical for PSC histology were evaluated and compared with the clinical and laboratory data. A compound endpoint consisting of liver transplantation, development of cholangiocarcinoma, or death was used as outcome measurement.ResultsStage (fibrosis, bile duct loss, ductular reaction, and chronic cholestasis) and grade (portal inflammation, portal edema, hepatitis activity, and cholangitis activity) parameters were found to be independent predictive risk factors for the compound endpoint (P < 0.001). High disease grade (2–6) and stage (2–4) better correlated with clinical endpoints when evaluated with the PSC histoscore system compared to the adapted Nakanuma classification. The risk for disease progression in sequential endoscopic retrograde cholangiography (ERC) examinations was increased with elevated total PSC histoscores.ConclusionThe PSC histoscore is a novel histological classification system for PSC. Our findings support the applicability of liver histology as a marker for disease progression.

Diagnostic value of endoscopic retrograde cholangiopancreatography and therapeutic value of endoscopic sphincterotomy in dogs with suspected hepatobiliary disorders

BackgroundConventional diagnostic methods have some limitations in diagnosing specific causes of canine hepatobiliary disorders. In the evaluation of the hepatobiliary system in dogs, ultrasonography (US) is the first imaging method of choice. Nonetheless, endoscopic retrograde cholangiopancreatography (ERCP) has also been proven to be a practicable technique for evaluating canine hepatobiliary (endoscopic retrograde cholangiography, ERC) and pancreatic duct (endoscopic retrograde pancreatography, ERP) disorders, providing additional therapeutic options by sphincterotomy (EST). To date, the efficacy and safety of diagnostic and therapeutic ERCP has not been evaluated in veterinary medicine literature. The present study sought to report complications and outcomes of dogs undergoing ERCP and EST, and to assess the usefulness of diagnostic ERCP by comparing the findings of US, ERCP and histopathological findings in liver and pancreas.ResultsThis retrospective case series comprises data collected from 15 dogs that underwent successful ERC/ERCP. Nine dogs underwent EST following ERC. US and ERC were best in agreement when assessing the common bile duct. In case of disagreement between the modalities, the ERC findings of the ductal structures were in line with the available pathology findings more often than the US findings, whereas the opposite was noted for the gallbladder. The technical success rates were 88.2% for ERC, 66.7% for ERP, and 81.8% for EST, with no major complications during or immediately after the procedure. Immediate bile flow after EST was recorded in 7/9 dogs but only four showed coinciding clinical and laboratory improvement and four dogs were euthanized within 1-6 days after EST.ConclusionsUS remains a valuable initial diagnostic imaging method for hepatobiliary disorders and allows good assessment of the gallbladder. ERC can serve as a complementary procedure for diagnostic assessment of the hepatobiliary duct disorders. However, in order to improve the outcomes of EST, careful selection of patients for the procedure would require more advanced diagnostic imaging of the hepatobiliary area.

Long-Term Outcomes of Endoscopic Management of Patients with Symptomatic Portal Cavernoma Cholangiopathy with No Shuntable Veins for Surgery or Failed Surgery

Shunt surgery is the definitive treatment for symptomatic patients with portal cavernoma cholangiopathy (PCC), but few patients are non-surgical candidates or fail to improve even after surgery. This study aims to analyze the long-term outcomes of endoscopic therapy in these patients. Retrospective review of a prospectively maintained database of all patients with symptomatic PCC managed with endoscopic retrograde cholangiography (ERC) followed by stent placement. Outcomes studied included number of biliary interventions, complications, resolution of stricture, development of decompensation and mortality. Thirty-five patients (68.6% males, median age = 35 years) with a median follow-up duration of 46 months (12-112) were included in the analysis. Presentation was only jaundice in 51.4% cases while one-third (37.1%) of the patients presented with cholangitis. Patients underwent a total of 363 endoscopic sessions with a median of 9 procedures (3-29) per patient. Hemobilia was the most common complication of the procedure (6.06%). Ten (28.5%) patients required frequent stent exchanges. Patients who required frequent stent exchanges had higher number of cholangitis episodes and hospitalization. Secondary biliary cirrhosis developed in 4 (11.4%) patients and 2 (5.7%) patients had mortality. Of the 5 (14.3%) patients who were given a stent free trial, 3 patients required restenting due to redevelopment of symptoms. Patients with PCC without shuntable veins for surgery or those who failed to improve after surgery can be managed long-term with repeated endoscopic intervention with a slightly increased risk of non-fatal hemobilia.