Endoscopic Retrograde Cholangiopancreatography Group Research Articles

Efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) vs percutaneous transhepatic biliary drainage (PTBD) for cholangiocarcinoma biliary obstruction: An updated systematic review and meta analysis.

557 Background: Perioperative and/or palliative biliary drainage for the management of cholangiocarcinoma biliary obstruction has been part of the backbone of the multidisciplinary approach that this condition requires. For both intrahepatic and perihilar cholangiocarcinoma, ERCP and PTBD are the two main techniques available. There has yet to be consensus favoring one approach over the other. Methods: Following the PRISMA guidelines, a systematic review and meta-analysis were performed to determine if there was a difference in efficacy and safety of ERCP compared to PTBD for Cholangiocarcinoma Biliary Obstruction. Primary outcomes were successful biliary drainage, mean number of needed procedures, length of stay and overall adverse events rate. Data were analyzed using R version 4.2.2. The risk of bias was assessed by the Robins-I and RoB 2 tool. The quality of evidence was graded using the GRADE scale and Newcastle-Ottawa guidelines. Results: Three randomized clinical trials and two observational studies described the successful biliary drainage rate of ERCP vs PTBD for cholangiocarcinoma associated biliary obstruction, totaling 340 patients. Meta-analysis test for overall effect, showed no statistical difference between groups (RR = 0.88; 95% CI = [0.69; 1.13]; p = 0.23; Fig. 1). Similarly, in terms of the mean number of needed procedures per patient, a total of three randomized clinical trials and two observational studies, totaling 340 patients were included, no statistically significant difference was found (SMD = 0.64; 95% CI = [- 9.36; 10.63]; p = 0.57; Fig. 2). Likewise, one randomized clinical trial and two observational studies showed no statistically significant difference on the length of stay (days) mean between groups (SMD = 0.06; 95% CI = [- 1.57; 1.68]; p = 0.73; Fig. 3). Although, the three clinical trials and three observational studies showed a mild decreased adverse event and death (within 3 months) rate in the ERCP group, after undergoing statistical analysis, meta-analysis test for overall effect, showed no statistical difference (RR = 0.99; 95% CI = [0.55; 1.77]; p = 0.97; Fig. 4 and RR = 0.61; 95% CI = [0.10; 3.87]; p = 0.22; Fig. 5, respectively). The risk of bias was low with moderate-to-high quality of evidence amongst the included studies. Conclusions: Our updated systematic review and meta-analysis demonstrated no statistically significant difference in the successful biliary drainage rate, mean number of needed procedures, length of stay, death within 3 months and adverse event rate between ERCP vs PTBD for management of cholangiocarcinoma biliary obstruction. Further randomized studies are needed to confirm these findings.

Analysis of the efficacy of Percutaneous Transhepatic Cholangiography Drainage (PTCD) and Endoscopic Retrograde Cholangiopancreatography (ERCP) in the treatment of Malignant Obstructive Jaundice (MOJ) in palliative drainage and preoperative biliary drainage: a single-center retrospective study

PurposeThis study aimed to assess the safety and efficacy of percutaneous transhepatic cholangiography drainage (PTCD) and endoscopic retrograde cholangiopancreatography (ERCP) in palliative drainage and preoperative biliary drainage for treating malignant obstructive jaundice (MOJ).MethodsA total of 520 patients with MOJ who underwent PTCD or ERCP were enrolled and classified into palliative drainage group and preoperative biliary drainage group. Baseline characteristics, liver function, blood routine, complications were compared among the groups.ResultsThe technical success rates for PTCD and ERCP in palliative group were 97.1% and 85.9%. In palliative drainage group, PTCD had higher levels of total bilirubin (TB) reduction (53.0 (30.0,97.0) vs. 36.8 (17.9,65.0), p < 0.001) and direct bilirubin (DB) reduction (42.0 (22.0,78.5) vs. 28.0 (12.0,50.8), p = 0.001) than ERCP. However, PTCD was associated with higher rates of drainage tube displacement (20 cases, 11.8%), while ERCP had a higher incidence of biliary infection (39 cases, 22.8%) and pancreatitis (7 cases, 4.1%). In preoperative drainage group, PTCD achieved a 50% reduction in total bilirubin faster than ERCP (7.1 days vs. 10.5 days). And the time from palliation of jaundice to surgery was 24.2 days in PTCD group and 35.7 days in ERCP group, a statistically significant difference (Student’s t test, p = 0.017).ConclusionBoth PTCD and ERCP could improve liver function for MOJ patients. PTCD seems to offer better outcomes in jaundice reduction and liver function improvement in palliative drainage, but requires careful postoperative management. In preoperative biliary drainage, PTCD may be a better preoperative bridge to improve liver function and control infection.

Comparison of radiation exposure and fluoroscopy time between minimally invasive common bile duct exploration and endoscopic retrograde cholangiopancreatography for choledocholithiasis

Radiation exposure (RE) causes dose-dependent deleterious effects, and efforts should be made to decrease patient exposure to ionizing radiation. Patients with choledocholithiasis are commonly exposed to ionizing radiation as fluoroscopy-guided interventions including minimally invasive common bile duct (CBD) exploration (MICBDE) and endoscopic retrograde cholangiopancreatography (ERCP) are the preferred treatment modalities for CBD stone clearance. However, RE and fluoroscopy times (FTs) have not been compared between these 2 treatment modalities. Thus, this study aimed to compare FT and RE between MICBDE and ERCP in patients with choledocholithiasis. This is a retrospective analysis of a prospectively maintained database of a single surgeon performing MICBDE at an academic referral center between May 2021 and June 2023 compared with a retrospective analysis of all ERCPs performed between January 2020 and February 2021. Patient demographics, procedural details, fluoroscopic details, and postoperative outcomes were compared between the MICBDE and ERCP. The study was conducted as a single institution academic referral center located in the American Southwest. A total of 109 patients with choledocholithiasis were divided into 2 groups. A total of 53 (48.62%) patients underwent ERCP, and 56 (51.38%) patients underwent MICBDE. Inclusion criterion was all patients presenting with choledocholithiasis and subsequently undergoing ERCP or MICBDE. Patients who underwent ERCP for non-choledocholithiasis-related reasons were excluded. Primary outcomes include FT measured in minutes and RE measured in milligray (mGy). Secondary outcomes were successful clearance of the CBD, complications, procedural time, and reinterventions. A significant difference (P<.001) between FTs was identified between ERCP (3.1min) and MICBDE (1.54min). Median RE doses between the ERCP group (38mGy) and the MICBDE group (38.41mGy) were not statistically different (P= .88). Technical success of CBD clearance was similar in both groups (91% in the MICBDE group vs 93% in ERCP group; P= .711). Advantages of MICBDE over ERCP include the treatment of choledocholithiasis at the time of cholecystectomy, which reduces the risk of additional anesthesia episodes and introduces the potential for shorter hospital length of stay. This study showed that MICDBE had lower FT than had ERCP, and comparable RE. Given the advantages of MICBDE, it should be strongly considered at the time of laparoscopic cholecystectomy.

Multicenter study comparing EUS-guided hepaticogastrostomy and ERCP for malignant biliary obstruction in patients with accessible papillae.

One advantage of endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is that it is difficult for reflux cholangitis, caused by duodenal pressure increasing due to duodenal obstruction, to occur. In addition, since stent deployment is performed away from the malignant stricture site, longer stent patency than with endoscopic retrograde cholangiopancreatography (ERCP) may be obtained. However, no study has previously compared EUS-HGS and ERCP for patients without duodenal obstruction or surgically altered anatomy. The aim of the present study was to compare clinical outcomes between EUS-HGS and ERCP in normal anatomy patients without duodenal obstruction. In the ERCP group, patients who initially underwent biliary drainage were included. In the EUS-HGS group, patients who underwent EUS-HGS due to failed biliary cannulation were included. Patients with an inaccessible papilla, such as with surgically altered anatomy or duodenal obstruction, were excluded. A total of 314 patients who underwent ERCP and EUS-HGS were enrolled in this study. Of the 314 patients, 289 underwent biliary stenting under ERCP guidance, and 25 patients underwent biliary stenting under EUS-HGS. After propensity score-matching analysis, the adverse event rate tended to be lower in the EUS-HGS group than in the ERCP group. Although overall survival was not significantly different between the EUS-HGS and ERCP groups (p = .228), stent patency was significantly longer in the EUS-HGS group (median 366.0 days) than in the ERCP group (median 76.5 days). EUS-HGS had a lower adverse event rate, shorter procedure time, and longer stent patency than ERCP in cases of normal anatomy without duodenal obstruction.

A meta-analysis of the effects of transnasal high-flow oxygen therapy in gastrointestinal endoscopy.

This study aimed to systematically evaluate the clinical effects of using transnasal high-flow nasal cannula (HFNC) and conventional oxygen therapy (COT) in patients undergoing gastrointestinal endoscopy. A comprehensive literature search was conducted from 2004 to April 2024 to collect relevant studies on the application of HFNC in patients undergoing gastrointestinal endoscopy. Multiple Chinese and English databases, including China National Knowledge Infrastructure (CNKI), Wanfang Data, Web of Science, PubMed, and Cochrane Library, were searched systematically for randomized controlled trials (RCTs). Two researchers independently screened the literature, extracted data, and assessed the risk of bias in the included studies. RevMan 5.4 software was utilized for conducting the network meta-analysis. A total of 12 RCTs involving 3,726 patients were included. Meta-analysis results showed that HFNC reduced the incidence of hypoxemia and improved the minimum oxygen saturation (SpO2) compared with COT [odds ratio (OR) = 0.39, 95% confidence interval (CI): 0.29-0.53], [mean difference (MD) = 4.07, 95% CI: 3.14-5.01], and the difference was statistically significant. However, the baseline SpO2 levels and incidence of hypercapnia were not statistically significantly different between the HFNC and COT groups [MD = -0.21, 95% CI: -0.49-0.07]; [OR = 1.43, 95% CI: 0.95-2.15]. In terms of procedure time, the difference between HFNC and COT was not statistically significant, and subgroup analyses were performed for the different types of studies, with standard deviation in the gastroscopy group (MD = 0.09, 95% CI: -0.07-0.24) and the endoscopic retrograde cholangiopancreatography group (MD = 0.36, 95% CI: -0.50-1.23). The results demonstrated a significant reduction in the adoption of airway interventions in the HFNC group compared to the COT group (OR = 0.16, 95% CI: 0.05-0.53), with a statistically significant difference; this result was consistent with those of the included studies. The application of HFNC improves the incidence of hypoxemia, enhances oxygenation, and reduces airway interventions during gastrointestinal endoscopy. However, HFNC does not significantly affect baseline SpO2, hypercapnia, or procedure time. The limitations of this study must be acknowledged, and further high-quality studies should be conducted to validate these findings.

Comparison of the results of early and elective endoscopic retrograde cholangiopancreatography in patients with mild cholangitis

Aims: The optimal duration of endoscopic retrograde cholangiopancreatography (ERCP) in patients with mild cholangitis and when it should be performed is unclear. This study aimed to compare the results of patients with mild cholangitis who underwent early and elective ERCP. Methods: This study was designed as a retrospective study to compare the results of elective (time from admission to ERCP&gt;72 h) and early (time from admission to ERCP≤72 h) ERCP in patients with mild cholangitis according to the Tocyo 18 (TC18) guideline. The study included patients with naive papillae and mild cholangitis who underwent ERCP between February 2019 and 2023 at a single tertiary center’s gastroenterology clinic. Results: A total of 432 mild cholangitis patients were included in our study. The mean age and ASA score of the elective ERCP group was slightly higher than the other group (respectively, p=0.039 and p=0.025). No significant difference was found between the two groups in terms of technical and clinical success, mortality, ERCP-related adverse events, organ failure and intensive care unit admission. Length of hospital stay (LHS) was significantly (p

Interventional Treatment of Malignant Biliary Obstruction: Is It Time to Change the Paradigm?

Introduction. Biliary obstruction is a common manifestation of biliopancreatic malignancies, and its relief is an essential part of the treatment algorithm. Currently, there are three techniques to manage malignant biliary obstruction—endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic biliary drainage (PTBD), and endoscopic ultrasound-guided biliary drainage (EUS-BD). ERCP has been adopted as a first-line treatment modality but EUS-BD is gradually emerging as a viable alternative. The aim of the current article is to assess the clinical outcomes of the three nonsurgical biliary drainage procedures. Materials and methods. A total of 102 consecutive patients with unresectable biliopancreatic malignancy inducing biliary obstruction and subjected to palliative treatment by means of ERCP, EUS-BD, or PTBD were retrospectively included in the study. Results. No difference in clinical and technical success of the procedures was found: ERCP—97.2% technical; 88.9% clinical; PTBD—94.4% technical, 72.2% clinical; EUS-BD—90% technical; 83.3% clinical. Adverse events (AEs) and reinterventions were significantly more common in PTBD (38.9% and 52.8%) and ERCP (27.9% and 25%) compared to EUS-BD (10% and 3.3%). Total duration of hospital stay and number of hospitalizations were lower in the EUS-BD compared to PTBD and ERCP groups. Conclusions. In the presence of adequate expertise, EUS-BD may be superior to PTBD and ERCP in achieving and sustaining biliary drainage in the setting of unresectable malignancy.

Efficacy and Safety of Endoscopic Retrograde Cholangiopancreatography in Children of Pancreaticobiliary Maljunction Without Obvious Biliary Dilatation

There is no standard surgical approach for pancreaticobiliary maljunction (PBM) without congenital biliary dilatation (CBD). This study aimed to compare outcomes between therapeutic endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic hepaticojejunostomy (LH) for pediatric patients of PBM without obvious biliary dilatation (PBM-nonOBD). We retrospectively reviewed demographic and clinical data of pediatric patients with PBM-nonOBD from 2015 to 2021. There were 33 patients in ERCP group and 35 patients in LH group. Primary outcomes included treatment efficiency, postoperative recovery, and postoperative complications. Univariate analysis was further used to explore prognostic factors for ERCP. The mean diameter of the common bile duct in LH group was larger than that in ERCP group (8.6±1.3mm vs. 6.9±2.1 mm, p=0.003), while there were no significant differences between the two groups in age, gender, clinical manifestations, complications, and other imaging findings. Compared with LH group, ERCP group had a shorter operation time and postoperative recovery time. The treatment effective rate of ERCP was inferior to that of LH (45.4% vs. 85.7%, p＜0.001). For postoperative adverse events, post-ERCP pancreatitis (15.1%) was most common in the ERCP group. 30.3% of patients eventually required LH. Intestinal obstruction (5.7%), recurrent cholangitis (5.7%), gastrointestinal bleeding (2.8%), and anastomotic stenosis (2.8%) were observed in LH group and 8.6% of patients required a reoperation. A long common channel may be associated with poor prognosis after ERCP. ERCP is associated with less surgical trauma, shorter recovery time, and fewer serious complications than LH, while the treatment effective rate of ERCP is inferior to LH. The indications for endoscopic sphincterotomy and the timing of radical surgery need to be further explored. Ⅲ STUDY TYPE: Retrospective Comparative Study.

Impact of preoperative endoscopic procedures on adverse event rates after surgical resection for main-duct and mixed-type intraductal papillary mucinous neoplasms (IPMNs)

Main-duct (MD-) and mixed-type (MT-) IPMNs harbor an increased risk of pancreatic cancer and warrant surgical resection. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) are important in the diagnosis of IPMNs. The aim of this study was to investigate whether endoscopic procedures manipulating the MD impact postoperative adverse events in patients with MD- and MT-IPMNs. We performed a retrospective study of 369 patients who underwent resections for MD- or MT-IPMN at two tertiary centers (2000-2019). Multivariable logistic regression analyses were performed for postoperative adverse events to compare the risks between intervention (ERCP, EUS-FNA with branch duct (BD) aspirated, EUS-FNA with MD aspirated from the duct directly or cyst/mass arising from MD) versus no-intervention group. 33.1% of patients had a preoperative ERCP and 69.4% had EUS-FNA. Postoperative adverse events included: 30-day readmission (12.7%), delayed gastric emptying (13.8%), pancreatic fistula (10.3%), abdominal abscess (5.7%), cardiopulmonary adverse events (11.4%), and mortality (1.4%). The model was adjusted for potential confounders. There were no significant differences between the ERCP and no-ERCP groups for specific adverse events. Compared to no-EUS-FNA groups, groups of EUS-FNA with BD aspiration and EUS-FNA with MD aspiration from the main pancreatic duct directly or cyst/mass arising from MD did not show a significant increase in specific adverse events. Postoperative adverse events were not significantly increased among patients who had ERCP or EUS-FNA before surgical resection for MD- or MT-IPMNs. Endoscopic procedures directly sampling the MD can be safely pursued for diagnostic purposes in selected cases.

Ultrasound-Guided Percutaneous Transhepatic Cholangioscopic Lithotripsy for the Treatment of Common Bile Duct Stones and Analysis of Risk Factors for Recurrence.

As a minimally invasive treatment for common bile duct (CBD) stones, ultrasound-guided percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) is gaining attention and recognition from the medical community. A retrospective analysis was conducted on patients with CBD stones treated in our hospital from January 2016 to April 2022. Patients were divided into three groups: 77 treated with PTCSL, 93 with endoscopic retrograde cholangiopancreatography (ERCP), and 103 with laparoscopic common bile duct exploration (LCBDE). Their clinical data, perioperative indicators, and complications were analyzed comparatively. Then, risk factors for the post-PTCSL recurrence of CBD stones were analyzed by logistic regressions. Finally, the receiver operating characteristic curve was drawn. All perioperative indicators of the PTCSL group were better than the LCBDE group (P < 0.001). The incidences of cholangitis, hemobilia, and incisional infection after surgery were lower in the PTCSL group than in the LCBDE group (P < 0.05). Pancreatitis, reflux esophagitis, and papillary stenosis occurred less frequently in the PTCSL group than in the ERCP group (P < 0.05). Logistic regression analysis indicated that gallstones and family history were independent risk factors. The AUC for recurrent CBD stones predicted by multi-indicators was 0.895 (95% CI 0.792-0.999, P < 0.001) with a sensitivity of 96.7% and specificity of 68.8%. Ultrasound-guided PTCSL is a safe and effective treatment for CBD stones. Patients recovered quickly with fewer postoperative complications. It can be a first-line treatment for CBD stones. Gallstones and family history are independent risk factors for recurrent CBD stones, which provide a reference for clinicians in identifying the high-risk population needing close follow-up.

Comparative analysis of laparoscopic choledocholithiasis and ERCP treatment after cholecystectomy

ObjectiveTo compare the overall efficacy of laparoscopic common bile duct exploration(LCBDE) with endoscopic retrograde cholangiopancreatography (ERCP ) after cholecystectomy.MethodsFrom January 2017 to July 2021, Seventy patients with Choledocholithiasis after cholecystectomy who were admitted to our hospital were selected and divided into ERCP and LCBDE groups. comparison of baseline characteristics, clinical efficacy and postoperative complications between the ERCP and LCBDE.Results①The overall efficacy rate of LCBDE was 97.1%, while the overall efficacy rate in the ERCP group was 76.6%. The LCBDE group demonstrated a significantly higher overall effective rate compared to the ERCP group, with a statistically significant difference (p < 0.05). ②The preoperative and postoperative complications of the LCBDE group were visibly lower than the other group (P < 0.05). The postoperative time to oral intake, postoperative ventilation time, length of hospital stay, and hospital costs were higher in the ERCP group compared to the LCBDE group, with a statistically significant difference (P < 0.05).ConclusionIn the treatment of common bile duct stones after cholecystectomy, LCBDE is a superior choice compared to ERCP in terms of stone diameter, quantity, clearance rate, and hospital costs.

Management of borderline common bile duct stones: Retrospective comparative study

Background Borderline Size common bile duct stones (BLS-CBDS) are associated with hepato-pancreato-biliary morbidity and complications. Its optimum management is still controversial till now. Aim Is to compare conservative treatment versus endoscopic retrograde cholangiopancreatography (ERCP) for the treatment of BLS-CBDS. Material and methods This retrospective study included patients with BLS-CBDS less than or equal to 10 mm who were treated conservatively or by ERCP endoscopic stone extraction followed by laparoscopic cholecystectomy (LC). The primary outcome was successful common bile duct (CBD) clearance, and the secondary outcomes were complications, impact on laparoscopic cholecystectomy, and hospital stay. Results Out of 270 patients, 150 were treated by ERCP and 120 by the Conservative approach. There was complete clearance of CBDS in 75 (50%) patients out of 150 patients in the ERCP group and useless procedure in the remaining 75 (50%) patients. In the conservative group, there was complete clearance of CBDS in 99 (82.5%) cases, and useless in the remaining 21 (17.5%) patients. Post-ERCP pancreatitis occurred in 33 (22%) patients. Conclusion BLS-CBDS increases the technical difficulty of ERCP and the risk of post-ERCP pancreatitis. Conservative management of CBDS is effective in clearing CBDS, it should be considered to avoid unnecessary ERCP and its complications.

Evaluation of Clinical Indications of Three Treatments for Choledocholithiasis with Acute Cholangitis.

This study aimed to assess the efficacy of Endoscopic Retrograde Cholangiopancreatography (ERCP), common bile duct exploration, and percutaneous transhepatic cholangiography combined with common bile duct exploration for treating choledocholithiasis with acute cholangitis, to guide management strategies. A retrospective evaluation was conducted on a cohort of 283 inpatients diagnosed with choledocholithiasis and acute cholangitis at the affiliated hospital. Patients were categorized into three groups: Group A (ERCP group), Group B(common bile duct exploration group), and Group C(PTCD combine common bile duct exploration group.) Parameters such as hepatic function recovery, inflammation level control, blood loss, postoperative hospital duration, and postoperative complications were compared. All groups exhibited notable reductions in postoperative biochemical parameters including alanine aminotransferase (ALT), aspartate aminotransferase (AST), gamma-glutamyl transferase (GGT), total bilirubin (TBIL), and WBC (P < 0.05). Group A had the least blood loss(P < 0.05), and shortest hospital stay(P < 0.05), but a higher incidence of pancreatitis(P < 0.05), with a total of 8 cases occurred(7.3%). Group C had a shorter hospital stay compared to Group B(P < 0.05). For patients with fewer and smaller common bile duct stones and milder symptoms, it is recommended to primarily choose endoscopic retrograde cholangiopancreatography (ERCP), endoscopic sphincterotomy (EST), and endoscopic nasobiliary drainage (ENBD), it procedures offer quicker recovery and cause minimal trauma. For patients with numerous, larger common bile duct stones but stable conditions, bile duct exploration is recommended. For those with severe conditions and significant inflammation, PTCD and common bile duct exploration are advised.

Utility of Urgent Endoscopic Retrograde Cholangiopancreatography in Patients with Predicted Mild Acute Pancreatitis and Cholestasis.

Endoscopic retrograde cholangiopancreatography (ERCP) within 72h is suggested for patients presenting with acute biliary pancreatitis (ABP) and biliary obstruction without cholangitis. This study aimed to identify if urgent ERCP (within 24h) improved outcomes compared to early ERCP (24-72h) in patients admitted with predicted mild ABP. Patients admitted for predicted mild ABP defined as a bedside index of severity in acute pancreatitis score < 3 and underwent ERCP for biliary obstruction within 72h of presentation during the study period were included. Patients with prior biliary sphincterotomy or surgically altered anatomy preventing conventional ERCP were excluded. The primary outcome was the development of moderately severe or severe pancreatitis based on the revised Atlanta classification. Secondary outcomes were the length of hospital stay, the need for ICU admission, and ERCP-related adverse events (AEs). Of the identified 166 patients, baseline characteristics were similar between both the groups except for the WBC count (9.4 vs. 8.3/µL; p < 0.044) and serum bilirubin level (3.0 vs. 1.6mg/dL; p < 0.0039). Biliary cannulation rate and technical success were both high in the overall cohort (98.8%). Urgent ERCP was not associated with increased development of moderately severe pancreatitis (10.4% vs. 15.7%; p = 0.3115). The urgent ERCP group had a significantly shorter length of hospital stay [median 3 (IQR 2-3) vs. 3days (IQR 3-4), p < 0.01]. Urgent ERCP did not impact the rate of developing more severe pancreatitis in patients with predicted mild ABP but was associated with a shorter length of hospital stay and a lower rate of hospital readmission.

Comparison Study between ERCP and PTBD for Recurrent Choledocholithiasis in Patients Following Gastrectomy.

The recurrence rate of choledocholithiasis in the general population has been reported to exceed 10%. The incidence of cholelithiasis was reported to be higher in patients following gastrectomy than that in the general population. However, there is no study for recurrent choledocholithiasis incidence in patients following gastrectomy. This study aimed to evaluate the recurrence rate of choledocholithiasis and identify risk factors for recurrent choledocholithiasis in patients following gastrectomy. A retrospective analysis was performed on patients with gastrectomy history who underwent choledocholithiasis removal in Kyungpook National University Hospital between January 2011 and December 2019. Choledocholithiases were treated by endoscopic retrograde cholangiopancreatography (ERCP) (n = 41) or percutaneous transhepatic biliary drainage (PTBD) (n = 90). The gastrectomy type was classified as subtotal gastrectomy with Billroth I (18.3%), Billroth II (45.0%), and total gastrectomy with Roux-en-Y (36.6%). During a median follow-up period of 31.5 (range, 6-105) months, choledocholithiasis recurrence was noted in 19 of 131 patients (14.5%). In subgroup analysis, the ERCP group (24.4%) had higher choledocholithiasis recurrence than the PTBD group (10.0%). Stone removal modality (ERCP), no use of balloon sphincteroplasty, and the presence of periampullary diverticulum were significant risk factors for recurrent choledocholithiasis. In multivariate analysis, ERCP (hazard ratio (HR), 3.597; 95% confidence interval (CI): 1.264-10.204) CBD stricture (HR, 3.823; 95% CI: 1.118-13.080) and no use of balloon sphincteroplasty (HR, 4.830; 95% CI: 1.669-13.889) were risk factors for recurrent choledocholithiasis following stone removal. The incidence of CBD stones in patients who underwent gastrectomy is similar to that of the general population. ERCP, CBD stricture, and no use of balloon sphincteroplasty are potential risk factors for recurrent CBD stones following gastrectomy. When we consider PTBD disadvantages, the ERCP procedure with active use of balloon sphincteroplasty is recommended to decrease recurrent CBD stones.

RECLAIMING THE MANAGEMENT OF COMMON DUCT STONES IN ACUTE CARE SURGERY.

Acute care surgery (ACS) is well positioned to manage choledocholithiasis at the time of laparoscopic cholecystectomy, but barriers to laparoscopic common bile duct exploration (LCBDE) include experience and the perceived need for specialized equipment. The technical complexity of this pathway is generally seen as challenging. As such, LCBDE is historically relegated to the "enthusiast." However, a simplified, effective LCBDE technique as part of a "surgery first" strategy could drive wider adoption in the specialty most often managing these patients. To determine efficacy and safety, we sought to compare our initial ACS-driven experience with a simple, fluoroscopy-guided, catheter-based LCBDE approach during laparoscopic cholecystectomy (LC) to LC with endoscopic retrograde cholangiopancreatography (ERCP). We reviewed ACS patients who underwent LCBDE or LC + ERCP (pre-/postoperative) at a tertiary care center in the four years since starting this surgery first approach. Demographics, outcomes, and length of stay (LOS) were compared on an intention to treat basis. LCBDE was performed via using wire/catheter Seldinger techniques under fluoroscopic guidance with flushing or balloon dilation of the sphincter as needed. Our primary outcomes were LOS and successful duct clearance. 180 patients were treated for choledocholithiasis with 71 undergoing LCBDE. The success rate of catheter-based LCBDE was 70.4%. LOS was significantly reduced for the LCBDE group compared to the LC + ERCP group (48.8 vs 84.3 hrs, p < 0.01). Of note there were no intra- or postoperative complications in the LCBDE group. A simplified catheter-based approach to LCBDE is safe and associated with decreased LOS when compared to LC + ERCP. This simplified step-up approach may help facilitate wider LCBDE utilization by ACS providers who are well positioned for a timely surgery first approach in the management of uncomplicated choledocholithiasis. Level III, Therapeutic/Care Management.

MANAGEMENT OF CHOLEDOCHOLITHIASIS IN PAKISTAN: A COMPARISON OF ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY AND LAPAROSCOPIC COMMON BILE DUCT EXPLORATION

The objective of this study was to compare the management outcomes of endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis in Pakistan, based on a sample size of 150 patients. A retrospective analysis was conducted on 150 patients diagnosed with choledocholithiasis who underwent either ERCP (n=75) or LCBDE (n=75) at a tertiary care hospital in Pakistan. Patient demographics, procedure-related variables, postoperative outcomes, and complications were collected and analyzed. Primary outcome measures included stone clearance rates, procedure-related complications, length of hospital stay, and cost-effectiveness. The study included 150 patients, with 75 in each group. The stone clearance rate was significantly higher in the LCBDE group (82.7%) compared to the ERCP group (68.0%). However, the ERCP group had a lower incidence of procedure-related complications (12.0%) than the LCBDE group (24.0%). The mean length of hospital stay was shorter in the ERCP group (4.2 days) compared to the LCBDE group (6.1 days). Cost analysis revealed that ERCP was more cost-effective than LCBDE. In managing choledocholithiasis, ERCP and LCBDE are effective treatment options in Pakistan. LCBDE demonstrated a higher stone clearance rate (82.7%), while ERCP had a lower incidence of procedure-related complications (12.0%) and a shorter length of hospital stay (4.2 days). In terms of cost-effectiveness, ERCP was found to be more favorable.

Usefulness of Endoscopic Retrograde Cholangiopancreatography in the Diagnosis and Treatment of Traumatic Pancreatic Injury in Children.

Pediatric trauma patients are increasing, and trauma is the leading cause of death in children. Pancreatic injury is known as the fourth most common solid organ injury, but the diagnosis of pancreatic injury is often delayed due to the retroperitoneal location of the pancreas and the low sensitivity and specificity of diagnostic tests. Endoscopic retrograde cholangiopancreatography (ERCP) is an important test for the diagnosis and treatment of various biliary tract and pancreatic diseases. However, cases of performing ERCP in traumatic pancreatic injury in children have been rarely reported. Thus, we aimed to evaluate the usefulness of ERCP in traumatic pancreatic injury in children. Between January 1983 and December 2022, pediatric patients under the age of 18 who were treated for traumatic pancreatic injury at a single institution were recruited and retrospectively analyzed. Patient characteristics and clinical outcomes were assessed. Thirty-one patients were enrolled in this study. Among them, 15 (48.4%) patients underwent ERCP. The time to diet was significantly longer in the ERCP group. There were no statistically significant differences in other characteristics between the ERCP and the non-ERCP group. In nine (60%) patients of the ERCP group, ERCP was used for therapeutic intervention or as a decision-making tool for surgery, and was used to resolve pancreas-related complications. ERCP may be useful for the diagnosis and treatment of traumatic pancreatic injury in children. In addition, ERCP can be safely applied in children, and complications related to ERCP also may not increase. When obscure pancreatic injury is suspected, it is necessary to consider performing ERCP.

ERCP management of acute cholangitis caused by rupture of Echinococcus hepaticus into the biliary tract.

Hepatic cystic echinococcosis (HCE) rupture into the biliary tract, one of the most common and refractory complications, is treated by laparotomy to remove hydatid lesions. The aim of this article was to investigate the role of endoscopic retrograde cholangiopancreatography (ERCP) in the treatment of this particular disease. This was is a retrospective analysis of 40 patients with HCE ruptured into the biliary tract in our hospital from September 2014 to October 2019. They were divided into two groups, ERCP group (group A, n = 14) and conventional surgery group (group B, n = 26). Group A was treated with ERCP first to control infection and improve the general condition before undergoing laparotomy at an optional stage while group B was treated with laparotomy directly. First, the infection parameters and liver, kidney and coagulation functions of group A patients before and after ERCP were compared to evaluate treatment effectiveness. Second, the intraoperative and post-operative parameters during the laparotomy of group A were compared with group B to evaluate the impact of ERCP treatment on laparotomy. White blood cell, NE%, platelet, procalcitonin, C-reactive protein, interleukin-6, Total bilirubin (TBIL), alkaline phosphatase, gamma-glutamyl transpeptidase, aspartate transaminase, alanine transaminase (ALT), ALT and Cr in group A significantly improved by ERCP (P < 0.05); during laparotomy, the bleeding amount and hospital stay in group A were better (P < 0.05); moreover, concerning the post-operative complications, the incidence of acute renal failure and coagulation dysfunction in group A was significantly less (P < 0.05). ERCP, which not only quickly and effectively controls infection and improves the patient's systemic condition but also provides good support for subsequent radical surgery, enjoys good prospects for clinical application.

A81 OPTIMIZING THE INDICATIONS FOR BILIARY STENT PLACEMENT IN PATIENTS WITH CBD STONES: A QUALITY IMPROVEMENT INITIATIVE TO ENHANCE PATIENT CARE AND REDUCE HEALTHCARE RESOURCE UTILIZATION

Abstract Background A retrospective chart audit was performed to review biliary stent utilization from January 2020 to 2021 at the University of Alberta Hospital (UAH). Inappropriate stent usage was identified in 16% of patients with common bile duct (CBD) stones presenting for endoscopic retrograde cholangiopancreatography (ERCP). To improve this clinical practice, a quality improvement (QI) initiative was developed and completed. Purpose To reduce the number of inappropriately inserted biliary stents in patients with CBD stones. Method The results of the chart audit (pre-intervention) were shared with the ERCP group. The QI intervention was to align biliary stent insertion in accordance with published guidelines. A chart audit (post-intervention) was then performed on all ERCPs from July, 2021 to June, 2022. The indication for biliary stent insertion was assessed independently by two blinded reviewers. Result(s) A total of 661 patients (337 F) with mean age of 59±19 years (range 12-98 years) underwent 885 ERCPs during this post-intervention period. Of the 661 patients, 384 (58%) were referred for CBD stones. A total of 192 biliary stents (105 plastic, 85 metal) were placed during the first ERCP (192/661, 29%), as compared to the pre-intervention year (223/598, 37%, p=ns). However, only 13/192 stents (7%) were placed not in accordance with published guidelines (kappa=0.53), compared with 63/223 (28%) in the pre-intervention year (p&amp;lt;0.0001). This accounts for a 75% reduction in overall unnecessary stent placement. This reduction was mainly seen in the CBD stone subgroup, where there was an 88% reduction in inappropriate biliary stent placement compared to the pre-intervention year (8/384, 2% vs. 61/376, 16%, p&amp;lt;0.0001). Image Conclusion(s) Education to align practice in accordance with published guidelines has demonstrated a significant improvement in biliary stent insertion during ERCP in patients with CBD stones. This has resulted in significantly fewer inappropriate stent placements, a reduction in unnecessary follow-up ERCPs, and an overall saving of healthcare resources. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared