Periampullary Diverticulum Research Articles

Predictive Factors for Therapeutic Endoscopic Retrograde Cholangiopancreatography-Related Complications in the Treatment of Choledocholithiasis

Aims: Endoscopic retrograde cholangiopancreatography (ERCP) is now the exclusive endoscopic therapeutic modality for biliary as well as pancreatic diseases. The aim of our study is to evaluate the complication rate of ERCP in the treatment of choledocholithiasis and to assess the factors related to their occurrence. Methods: This is a retrospective descriptive and analytical study including 1048 patients who underwent ERCP for choledocholithiasis between January 2007 and August 2021. The factors associated with the occurrence of post-ERCP complications were studied by logistic regression analysis. Results: Among the patients studied, 60.5% had a simple lithiasis, 27.6% had multiple choledochal stones and 11.9% had large stones (> 15mm). Clinically, 18.7% of the patients presented with cholangitis and 9.4% with acute pancreatitis. A periampullary diverticulum was found in 9.4% of cases. A common bile duct stenosis was present in 6.5% of cases. The primary vacuity rate was 77.3%. However, additional manoeuvres were used in 20.5% of cases. Complications were reported in 5.8% of cases, including hemorrhage in 4.5%, pancreatitis in 0.8%, cholangitis in 0.2%, perforation in 0.1% and dormia impaction in 0.2%. No death was reported due to our procedures. In a multivariate analysis following adjustment of confounding factors, only the presence of a large stone (OR= 5.9, CI (1.460- 23.875), p=0.013) and female gender (OR= 1.867, CI (1.012-3.444), p=0.046) increased the risk of complications during ERCP. Conclusion: Our study suggests that female gender and the presence of à large gallstone are associated with a high risk of post-ERCP complications.

Síndrome de Lemmel: una causa infrecuente de colangitis aguda

Lemmel syndrome is a rare entity that causes biliary obstruction due to compression of the common bile duct by a periampullary diverticulum. It can manifest as acute cholangitis and is often underdiagnosed. However, once identified, it can be successfully treated with endoscopic retrograde cholangiopancreatography, being one of the most used methods. Lemmel syndrome should be considered in elderly patients with a diagnosis of periampullary duodenal diverticulum, once the presence of choledocholithiasis and pancreatobiliary neoplasms have been ruled out.

Predictive factors of needle-knife pre-cut papillotomy failure in patients with difficult biliary cannulation

Predictors of needle-knife pre-cut papillotomy (NKP) failure for patients with difficult biliary cannulation has not been reported. Between 2004 and 2016, 390 patients with difficult biliary cannulation undergoing NKP were included in this single-center study. Following NKP, deep biliary cannulation failed in 95 patients (24.4%, NKP-failure group) and succeeded in 295 patients (75.6%, NKP-success group). Patient and technique factors were used to identify the predictors of initial NKP failure. Compared with the NKP-success group, periampullary diverticulum (28.4% vs. 18%, p = 0.028), surgically altered anatomy (13.7% vs. 7.1%, p = 0.049), number of cases performed by less experienced endoscopists, and bleeding during NKP (38.9% vs. 3.4%, p < 0.001), were significantly more frequent in the NKP-failure group. On multivariate analysis, surgically altered anatomy (OR 2.374, p = 0.045), endoscopists’ experience (OR 3.593, p = 0.001), and bleeding during NKP (OR 21.18, p < 0.001) were significantly associated with initial failure of NKP. In conclusion, NKP is a highly technique-sensitive procedure, as endoscopists’ experience, bleeding during NKP, and surgically altered anatomy were predictors of initial NKP failure.

Identification of risk factors involved in recurrence after common bile duct stone removal with ERCP: A retrospective observational study.

Recurrent stone detection is common after endoscopic treatment of common bile duct stones (CBDS). This study aimed to identify the risk factors for recurrence of CBDS.We retrospectively evaluated 14 patients who underwent endoscopic treatment for CBDS. Risk factors for single and multiple recurrent CBDSs were evaluated using logistic regression analysis.Endoscopic and needle-knife precut sphincterotomy was performed in 506 and 112 patients, respectively. There was 1 recurrence in 85 patients (13.8%), 2 recurrences in 23 patients (3.7%), and 3 recurrences in 9 patients (1.5%). According to the multivariate analyses, being older than 65 years (odds ratio [OR] 1.084, P = .000), concomitant heart disease (OR 2.528, P = .002), concomitant lung disease (OR 1.766, P = .035), a large common bile duct diameter (OR 1.347, P = .000), presence of cholelithiasis (OR 1.752, P = .018), stent (OR 1.794, P = .023), or T-tube placement in the common bile duct (OR 47.385, P = .000), and prolongation of the procedure (OR 1.037, P = .000) increased the risk of recurrence, while having undergone cholecystectomy due to gallstones (OR 1.645, P = .042). The mean stone diameter (P = .059), nitroglycerin use (P = .129), and periampullary diverticulum (P = .891) did not increase the risk of recurrent CBDS.The probability of multiple recurrences after the first recurrence of CBDS increased with age >65 years, concomitant heart/lung diseases, stent/T-tube placement in the common bile duct, a wide common bile duct (≥10 mm), and cholelithiasis.

Choledocholithiasis characteristics with periampullary diverticulum and endoscopic retrograde cholangiopancreatography procedures: Comparison between two centers from Lanzhou and Kyoto.

BACKGROUNDMost of study regarding periampullary diverticulum (PAD) impact on endoscopic retrograde cholangiopancreatography (ERCP) therapy for choledocholithiasis based on data from one endoscopy center and lacked to compare the clinical characteristic of choledocholithiasis with PAD from different geographical patients.AIMTo compare the choledocholithiasis clinical characteristics between two regional endoscopy centers and analyze impacts of clinical characteristics on ERCP methods for choledocholithiasis patients with PAD.METHODSPatients seen in two endoscopy centers (The First Hospital of Lanzhou University, Lanzhou, Gansu Province, China, and Kyoto Second Red Cross Hospital, Kyoto, Japan) underwent ERCP treatment for the first time between January 2012 and December 2017. The characteristics of choledocholithiasis with PAD were compared between the two centers, and their ERCP procedures and therapeutic outcomes were analyzed.RESULTSA total of 829 out of 3608 patients in the Lanzhou center and 241 out of 1198 in the Kyoto center had choledocholithiasis with PAD. Lots of clinical characteristics were significantly different between the two centers. The common bile duct (CBD) diameter was wider, choledocholithiasis size was lager and multiple CBD stones were more in the Lanzhou center patients than those in the Kyoto center patients (14.8 ± 5.2 mm vs 11.6 ± 4.2 mm, 12.2 ± 6.5 mm vs 8.2 ± 5.3 mm, 45.3% vs 20.3%, P < 0.001 for all). In addition, concomitant diseases, such as acute cholangitis, gallbladder stones, obstructive jaundice, cholecystectomy, and acute pancreatitis, were significantly different between the two centers (P = 0.03 to < 0.001). In the Lanzhou center, CBD diameter and choledocholithiasis size were lower, and multiple CBD stones and acute cholangitis were less in non-PAD patients than those in PAD patients (13.4 ± 5.1 mm vs 14.8 ± 5.2 mm, 10.3 ± 5.4 mm vs 12.2 ± 6.5, 39% vs 45.3%, 13.9% vs 18.5%, P = 0.002 to < 0.001). But all these characteristics were not significantly different in the Kyoto center. The proportions of endoscopic sphincterotomy (EST), endoscopic balloon dilatation (EPBD), and EST+EPBD were 50.5%, 1.7%, and 42.5% in the Lanzhou center and 90.0%, 0.0%, and 0.4% in the Kyoto center, respectively. However, the overall post-ERCP complication rate was not significantly different between the two centers (8.9% in the Lanzhou and 5.8% in the Kyoto. P = 0.12). In the Lanzhou center, the difficulty rate in removing CBD stones in PAD was higher than in non-PAD group (35.3% vs 26.0%, P < 0.001). But the rate was no significant difference between the two groups in Kyoto center. The residual rates of choledocholithiasis were not significantly different between the two groups in both centers. Post-ERCP complications occurred in 8.9% of the PAD patients and 8.1% of the non-PAD patients in the Lanzhou Center, and it occurred in 5.8% in PAD patients and 10.0% in non-PAD patients in the Kyoto center, all P > 0.05.CONCLUSIONMany clinical characteristics of choledocholithiasis patients with PAD were significantly different between the Lanzhou and Kyoto centers. The patients had larger and multiple stones, wider CBD diameter, and more possibility of acute cholangitis and obstructive jaundice in the Lanzhou center than those in the Kyoto center. The ERCP procedures to manage native duodenal papilla were different depending on the different clinical characteristics while the overall post-ERCP complications were not significantly different between the two centers. The stone residual rate and post-ERCP complications were not significantly different between choledocholithiasis patients with PAD and without PAD in each center.

Analysis of the Relationship Between Periampullary Diverticulum and Recurrent Bile Duct Stones After Endoscopy on Magnetic Resonance Imaging of Magnetic Nanoparticles

The objective of this work was to investigate the effect of magnetic resonance cholangiopancreatography (MRCP) based on super-paramagnetic iron oxide nanoparticles (SPIONs) on the recurrence diagnosis of periampullary diverticulum (PAD) and bile duct stone (BDS), so as to provide a scientific research basis for the recidivation factors of bile duct stones in clinic. Patients with PAD diagnosed in hospital from July 2019 to March 2021 (who had undergone endoscopic gallstone surgery) were selected for study in this work. They were rolled into two groups, the parapapillary group (123 cases) and the cholangiopancreatic duct directly opening in the diverticulum group (97 cases), according to the clinical classification. Then, 100 patients without PAD who had undergone bile duct node therapy were selected as the control group. The recidivation of BDS, serological index, and biliary pressure index before and after treatment were compared. The relationship between PAD and recidivation of bile duct stones was analyzed. The results showed that the average particle size, hydration kinetic particle size, effective time, and duration of polyethylene glycol (PEG)/polyethyleneimine (PEI)/poly aspartic acid-super-paramagnetic iron oxide nanoparticles(PASP-SPIONs) were better than PEG/PEI-SPIONs and SPIONs. The recidivation rate of BDS in Groups R and X was remarkably higher than the rate in control group (P < 0.05). Before treatment, common bile duct pressure in the control group was lower obviously than that in Groups R and X (P < 0.05). After treatment, the indexes including total bilirubin, direct bilirubin, and alkaline phosphatase in control group were lower than those in Groups R and X (P < 0.05). The incidence of complications in Groups R and X was much higher than in contrast to the control group (P < 0.05). Therefore, PEG/PEI/PASP-SPIONs had good contrast effect and could be used as magnetic resonance imaging contrast agent. Complications such as common bile duct pressure and infection were increased by PAD, which may be the main factor for the recidivation of BDS.

A Novel Technique of Intradiverticular Papillary Canulation Aided by EVL Band Ligator in a Case of Lemmel's Syndrome

AbstractA duodenal periampullary diverticulum can cause changes in the local anatomy and pose a challenge for the cannulation of the bile duct. Cannulation may be much more difficult if the ampulla is located within the diverticula. We present the case of a 40-year-old man who developed obstructive jaundice and cholangitis because of the duodenal diverticula mechanically obstructing the common bile duct (Lemmel's syndrome). The papilla was located entirely within the duodenal diverticula and was brought out after placing endoscopic variceal ligation (EVL) bands. Biliary access and stenting could be done easily, after exposing the papilla. There were no complications during the procedure or the recovery period.

LEMMEL SYNDROME – RARE CAUSE OF CHOLANGITIS : A CASE REPORT

Introduction: Lemmel Syndrome is a rare cause of the biliary mechanical compression by the juxtapapillary pseudo-diverticulum, in the absence of gallstones or periampullary tumors. Most periampullary diverticula are asymptomatic. However, complications may occur in about 5%, including diverticulitis, pancreatitis, cholangitis, choledocholithiasis, enterolith, bezoar formation, intestinal obstruction, bleeding and perforation. Case report: A 60-year-old woman presented with abdominal pain,fever and jaundice of acute onset. She was hemodynamically stable except for a fever of 101 °F. Initial blood work revealed a WBC 14,500/mm3, ALT 118 IU/L, AST 189 IU/L, ALP 356 IU/L, T bilirubin 7.2 mg/dl. CT and MRI of abdomen revealed periampullary diverticulum compressing distal common bile duct causing proximal dilatation consistent with Lemmel syndrome. Patient was managed with broad spectrum antibiotics and other supportive measures in view of cholangitis. Patient underwent ERCP with CBD stenting. Patient’s lab parameters improved steadily and was asymptomatic in few days. Discussion: Our patient had abdominal pain associated with leukocytosis and cholangitis due to extrinsic compression of the distal CBD. Lemmel syndrome can be transient in nature as a result of a periampullary duodenal diverticulum causing extrinsic compression of the CBD. This can sometimes progress to cholangitis, as seen in our patient. Early diagnosis is necessary to avoid extensive and invasive workup. Management is often supportive, although in some cases with recurrent infection or persistent biliary obstruction, surgical diverticulectomy can be considered. Conclusion: Lemmel syndrome should be kept as a rare differential when evaluating patients with biliary obstruction.

OUR ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATICOGRAPHY EXPERIENCES: SINGLE CENTER, 688 PATIENTS

Abstract Introduction and Aim: Successful ERCP requires deep cannulation of the common bile duct and/or the main pancreatic duct through the major duodenal papilla (papilla of Vater). Complications have been reported in cases of selective biliary cannulation, but this diminishes in experienced hands. The aim of this topic is to evaluate the practices and results in our clinic on how to achieve successful cannulation and sphincterotomy at minimum risk for the patient. Methods: The results of 688 patients who underwent ERCP in the endoscopy unit of our clinic over a 6-year period (2015-2021) are evaluated. Demographic findings, co-morbidities, duration of the procedure, presence of periampullary diverticulum, difficult cannulation rate, stent use, complication rate and successful cannulation rates of the patients were evaluated. Results: 58.5% of the patients were female. Heart diseases were found in 44.6% of the patients, kidney diseases in 11.5%, lung diseases in 14.9%, central nervous system diseases in 7.8% and malignancy in 2.1%. The common bile duct diameter is 12.98 ± 3.44 mm, and the mean stone size is 8.70 ± 4.50 mm. Periampullary diverticulum was present in 110 (15.9%) of the patients, and stony gall bladder was present in 48.0% of the patients. Selective cannulation was performed in 77.9% and pre-cut sphincterotomy was performed in 18.2%. Periampullary malignancy was detected in 12.1% of patients, and stent was applied to 22.1% of patients. Failed in 3.1% of patients. Emergency laparotomy was performed in 4 patients (0.6%). Bleeding was found in 58 patients (8.5%), perforation in five patients (0.8%), pancreatitis in 25 patients (4.0%), and mortality in six patients (1.0%). Conclusions: Although endoscopic retrograde cholangiopancreatography is an effective diagnostic and therapeutic tool, it can lead to serious complications. ERCP indication should be put correctly, procedures should be done by experienced people. In experienced hands, the success rate is high even with anatomical variations and difficult stones.

Optimal treatment for concomitant gallbladder stones with common bile duct stones and predictors for recurrence of common bile duct stones.

The optimal treatment for concomitant gallbladder (GB) stones with common bile duct (CBD) stones and predictors for recurrence of CBD stones are not established. This single-center, retrospective study reviewed 466 patients diagnosed with a first event of concomitant GB stones with CBD stones from January 2010 to December 2018. 92 patients underwent single-stage laparoscopic CBD exploration (LCBDE) and laparoscopic cholecystectomy (LC) (group1), 108 underwent LCBDE + LC after endoscopic stone extraction (ESE) failure (group2), and 266 underwent ESE + LC (group3). Clearance (95.7 vs. 99.1 vs. 97.0%, p = 0.324) and recurrence rates (5.4 vs. 13.0 vs. 7.9%, p = 0.138) did not differ between groups. Group1 had fewer procedures (p < 0.001), lower post-treatment complication rates (7.6 vs. 18.5 vs. 13.9%, p = 0.082), and shorter hospital stay after the first procedure (5.7 vs 13.0 vs 9.8days, p < 0.001). 40 patients (8.6%) had recurrence of CBD stones at mean follow-up of 17.1months, of which 29 (72.5%) occurred within 24months. In multivariate analysis, a CBD diameter > 8mm, combined type-1 periampullary diverticulum, and age > 70years were significant predictors of recurrence. Single-stage LCBDE + LC is a safe and effective treatment for concomitant GB stones with CBD stones compared to ESE + LC. LCBDE should be considered in patients with a high risk of ESE failure. Careful follow-up is recommended for patients at high risk of recurrence of CBD stones, especially within 24months after surgical or endoscopic treatment.

S2498 Lemmel Syndrome: An Unusual Presentation with Gastric Outlet Obstruction

Introduction: Lemmel syndrome is a rare clinical entity characterized by a periampullary duodenal diverticulum causing compression and dilatation of the pancreatic and common bile ducts, classically accompanied by obstructive jaundice. Gastric outlet obstruction (GOO) is not a known complication of this syndrome, nor are there standardized approaches to its treatment. We present the first documented case of Lemmel syndrome presenting as GOO and its successful treatment with endoscopic diverticular lavage. Case Description/Methods: An 82-year-old woman presented with abdominal pain and non-bloody non-bilious emesis. On arrival, she was hemodynamically stable and anicteric. Computed tomography (CT) with contrast revealed a 2.7x3.7x5.2 cm complex pancreatic head mass containing air and debris, contiguous with the duodenum at the junction of the 2nd and 3rd segments with dilatation of the common bile (1 cm) and main pancreatic duct (0.6 cm), concerning for a pancreatic neoplasm. There was also GOO manifested as a markedly distended stomach with distal gastric and proximal duodenal wall thickening and hyperenhancement. Esophagogastroduodenoscopy (EGD) with endoscopic ultrasonography (EUS) showed no signs of significant abnormalities within the pancreas. However, a large non-bleeding periampullary diverticulum in the second portion of the duodenum containing a large amount of food debris was visualized and was found to be obstructing the common bile and main pancreatic ducts causing ductal dilatation. Endoscopic diverticular lavage with removal of food debris was performed. Her diet was quickly escalated, her symptoms resolved, and she was discharged the following afternoon. Repeat CT 11 days post-procedure showed resolution of GOO and reduced biliary ductal dilation and diverticular size. At 1-month follow-up, she remained asymptomatic and was tolerating high-fiber diet without clinical signs of gastric outlet or biliary obstruction. Discussion: Lemmel syndrome is a rare cause of GOO in the setting of pancreatic and common bile duct compression and dilatation with or without the presence of jaundice. Until now, there have been no reported cases of GOO secondary to Lemmel syndrome, nor its successful treatment with a simple diverticular lavage. It is important that physicians consider this diagnosis and treatment strategy in order to deliver cost-effective and appropriate care to patients presenting with GOO in the setting of a periampullary diverticulum with evidence of dilated biliary and pancreatic ducts.Figure 1.: CT abdomen pelvis demonstrating a 2.7 x 3.7 x 5.2 cm complex pancreatic head mass containing air and debris (A), contiguous with the duodenum at the junction of the second and third segments (B) with moderate 1.0 cm dilatation of the common bile duct (C) and 0.6 cm dilatation of the main pancreatic duct (D, E). CT abdomen pelvis demonstrating gastric outlet obstruction manifested as markedly distended stomach with distal gastric and proximal duodenal wall thickening and hyperenhancement (F).Figure 2.: Endoscopic ultrasonography (EUS) of the head (A), neck (B), and body (C) of the pancreas without signs of significant endosonographic abnormalities.Figure 3.: Large non-bleeding periampullary diverticulum in the second portion of the duodenum containing a large amount of food debris visualized and found to be obstructing the common bile and main pancreatic ducts causing ductal dilatation.Figure 4.: CT abdomen pelvis demonstrating improvement in common bile duct dilation (A) and diverticular size with resolution of radiographic evidence of gastric outlet obstruction (B, C) 10 days after endoscopic diverticular lavage. Bile duct measuring 0.7 cm, previously 1.0 cm. Diverticular dimensions measuring 1.9 x 3.6 x 3.7 cm (AP by transverse by craniocaudal), previously 2.7 x 3.7 x 5.2 cm. Pancreatic duct was poorly visualized, and comparison could not be made.

S1597 A Rare Presentation of Lemmel’s Syndrome as Acute Cholangitis With Acute Pancreatitis

Introduction: Duodenal diverticula are most commonly found in the second part of the duodenum adjacent to the ampulla of Vater. Periampullary diverticula (PAD) are extraluminal pseudo-diverticula lacking a mucosal layer. Although typically asymptomatic, they can rarely cause pancreaticobiliary obstruction. Obstructive jaundice can develop secondary to PAD without choledocholithiasis, a rare phenomenon called Lemmel’s Syndrome. We report a rare case of Lemmel’s syndrome presenting not only with acute cholangitis but also with concurrent pancreatitis, successfully treated with ERCP. Case Description/Methods: An 83-year-old female presented with upper abdominal pain, nausea, diarrhea, and rigors. She is s/p cholecystectomy and labs revealed AST 688 U/L, ALT 305 U/L, Alkaline Phosphatase 201 U/L, total bilirubin 3.4 mg/dL, lipase 968 U/L, and lactate 2.9 mmol/L. An abdominal CT scan showed severe dilation of the common bile duct of 2.1 cm with edematous appearance of the pancreatic head, findings of acute pancreatitis, and a large duodenal diverticulum adjacent to the pancreatic head (Fig 1). Her hospital course was complicated by gram negative bacteremia, concerning for acute cholangitis. MRCP confirmed marked dilation of the common bile duct extending to the Ampulla of Vater with a large periampullary diverticulum, without choledocholithiasis or mass lesions (Fig 2). The patient underwent ERCP which revealed a large duodenal diverticulum compressing the distal bile duct, treated with biliary sphincterotomy and stent placement (Fig 3-4). She showed gradual clinical improvement with this endoscopic approach and was discharged home with subsequent follow up for stent removal performed 6 weeks later. Discussion: Although common among duodenal diverticula, PAD are rarely symptomatic. The underlying pathogenesis remains unclear but is believed to be related to mechanical obstruction, inflammation, and fibrosis. Lemmel’s syndrome can be mistaken for pseudocysts, necrotic collections, periampullary tumors, and pancreatic head neoplasms. Physicians should have a high index of suspicion for Lemmel’s syndrome in patients with large symptomatic PAD, which although commonly presents as biliary obstruction causing acute cholangitis, can rarely also cause pancreatic obstruction leading to pancreatitis, as seen in our patient. Timely diagnosis and endoscopic treatment of Lemmel’s syndrome can be effective in the treatment of acute cholangitis and pancreatitis.Figure 1.: CT scan showing CBD dilation with large periampullary diverticulum.Figure 2.: MRI showing dilated CBD and PD with distal large periampullary diverticulum.Figure 3.: Endoscopic view of large periampullary diverticula with intradiverticular papilla seen on ERCP.Figure 4.: Fluoroscopic view of dilated CBD as a result of Lemmel’s syndrome.

S2322 Tighten Your Pantalones for This Pantaloon Bleed

Introduction: Diverticula can develop anywhere along the small bowel, most commonly in the duodenum. While most patients with duodenal diverticula are asymptomatic, some develop complications such as obstruction, diverticulitis, obstructive jaundice, and bleeding. Here, we present a unique manifestation of bleeding within a periampullary diverticulum. Case Description/Methods: A 66-year-old male with a history of hypertension, diabetes mellitus, end-stage renal disease, atrial fibrillation, and recent four-vessel coronary artery bypass grafting (CABG) presented with unstable angina and fatigue. Following his CABG 2 months ago, he was placed on warfarin and aspirin. His exam revealed hypotension, conjunctival pallor, active bowel sounds, and melena. His hemoglobin (Hb) was 5 g/dL compared to a baseline of 9.2 g/dL two months prior. Blood urea nitrogen was 154 mg/dL and creatinine was 3.47 mg/dL, elevated from his baseline. INR was 6.9 and troponin-I was 66.9 ng/mL. An electrocardiogram did not show ST-segment elevation. After medical management of his myocardial infarction, an upper endoscopy was only remarkable for a large periampullary diverticulum (PAD) containing a clot. Over the next 3 days, his Hb continued to downtrend despite transfusion. A repeat endoscopy showed blood in the gastric body and antrum, blood clots in the duodenal bulb, and oozing blood from the diverticulum. At this time, a side-viewing scope was utilized for better visualization and showed a large pantaloon diverticulum straddling a ridge overlying the common bile duct (CBD) with an ulcer and visible vessel (Figure 1). Hemostatic clip placement led to the cessation of the bleed. (Figure 2). His hemodynamics stabilized and he was maintained on twice-daily pantoprazole. There was a transient rise in his AST and ALT, which resolved spontaneously. The patient did not re-bleed. Discussion: Our patient had an ulcer within a pantaloon PAD that was only appreciated with a side-viewing duodenoscope. Thus, if there is any suspicion of blood within a large duodenal diverticulum such as a clot, the use of a side-viewing scope is warranted. Furthermore, treatment of this lesion was challenging as the ridge overlayed the CBD, raising concern for injuring the CBD or causing obstruction through endoclips or cautery, so the former was employed taking care not to grasp excess tissue other than the visible vessel. While the transient rise in the transaminases suggested a CBD obstruction, this was short-lived and no clinical sequelae ensued.

The role of periampullary diverticulum on the incidence of pancreaticobiliary diseases and the outcome of endoscopic retrograde cholangiopancreatography.

IntroductionPeriampullary diverticulum (PAD), although commonly discovered in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP), remains controversial regarding its role in pancreaticobiliary diseases and the failure rate of cannulation. The aim of this study was to evaluate the association of PAD with pancreaticobiliary diseases and its impact on the outcome of ERCP.Material and methodsA retrospective analysis was carried out on 1455 patients who underwent an ERCP. Patients were divided into a PAD group and a control group without PAD, and propensity score matching was performed to adjust for clinical differences. The comparison was focused on pancreaticobiliary diseases, technical success, and complications of ERCP.ResultsThe occurrence of PAD is associated significantly with increasing age (p < 0.001). Incidences of acute pancreatitis (AP), suppurative cholangitis, and pancreatic head cancer were significantly higher in the PAD group (p < 0.05). After propensity score matching, the PAD group exhibited a higher rate of post-ERCP complications including haemorrhage, post-ERCP pancreatitis (PEP), and hyperamylasaemia (p < 0.05). However, the prevalence of perforation and the success rate of ERCP did not differ between groups (p > 0.05).ConclusionsPeriampullary diverticulum develops with aging and seems to be associated with an increase in pancreaticobiliary diseases and post-ERCP complications except for perforation. Additionally, the presence of PAD does not affect the technical success of ERCP.

Peri-ampullary diverticulum was associated with a higher rate of acute cholangitis among patients with choledocholithiasis

Choledocholithiasis is a commonly encountered disease that is associated with various clinical presentations ranging from mild form of biliary colic to severe life-threatening acute cholangitis. Recently, peri-ampullary diverticulum (PAD) has been linked to the development of biliary diseases; however, data regarding its association with the development of acute cholangitis in the setting of choledocholithiasis are scarce. We aimed to identify predictors, specifically PAD, for the development of acute cholangitis in patients with choledocholithiasis. We performed a retrospective cross-sectional study of all patients admitted to Galilee Medical Center from 1 January 2010 to 31 December 2019 with different clinical presentations of documented choledocholithiasis including cholangitis, biliary pancreatitis, and biliary colic with abnormal liver enzymes. Overall, 651 patients were included in the final analysis. Among them, 88 patients (13.5%) had choledocholithiasis associated with acute cholangitis (group A), as compared to 563 patients (86.5%) without acute cholangitis (group B). The average ages in groups A and B were 77.8 ± 13.6 and 62.4 ± 20.4years, respectively (P < 0.0001). The rate of PAD was significantly higher in group A as compared to group B (35.2% vs. 19%, P = 0.0002). However, the rate of smoking, chronic liver diseases, hemolytic anemia, and post-cholecystectomy status were not different between the groups (P = 0.3, P = 0.3, P = 0.2, and P = 0.3), respectively. On univariate analysis, age (OR 1.05, P < 0.0001) and PAD (OR 2.32, P = 0.0006) were significantly associated with acute cholangitis. On multivariate logistic regression analysis, the effects of age and PAD were preserved (OR 1.05, 95% CI 1.03-1.07, P < 0.0001 and OR 1.64, 95% CI 1.02-2.72, P = 0.049), respectively. PAD showed a significant association with the development of acute cholangitis among patients with choledocholithiasis. Identification of gallbladder and biliary stones in patients with PAD is of paramount importance since early diagnosis and treatment might prevent further life-threatening complications.

Use of thiopurines is not a risk factor for post-ERC pancreatitis in patients with primary sclerosing cholangitis

IntroductionRisk of post-ERC pancreatitis (PEP) in patients with primary sclerosing cholangitis (PSC) is 1–7.8%. PSC is often associated with inflammatory bowel disease and autoimmune hepatitis, which are usually treated with thiopurines. The role of thiopurines in PEP risk is still unclear. Aims and methodsWe evaluated the thiopurine use in PEP. The data of 354 PSC patients who underwent 985 ERCs between 2009 and 2018 were collected. 177 patients treated with thiopurines (study group, SG) and 177 controls (CG) were matched with a propensity score (PSM). Odds ratios (ORs) with 95% confidence interval (95% CI) were calculated. Multivariable logistic regression analysis and generalized linear mixed model were performed. The P-value <0.05 was significant. ResultsIn matched data, 472 ERCs were performed in SG and 513 in CG. Thiopurines were used in 373/472 (79.0%) ERCs in SG. The PEP rate was 5.3% in SG and 5.7% in CG (p = 0.889). Unintentional pancreatic duct cannulation (OR 1.28, 95%CI 1.07–1.51, p = 0.004), and periampullary diverticulum (OR 4.87, 95%CI 1.72–11.98, p = 0.001) increased the risk of PEP. ConclusionPrior or present thiopurine use did not increase the risk of PEP.

Influence of periampullary diverticula on endoscopic retrograde cholangiopancreatography.

The present study aimed to explore the influence of the presence of periampullary diverticula (PAD) on the implementation of endoscopic retrograde cholangiopancreatography (ERCP). A total of 388 patients with pancreaticobiliary disease who underwent ERCP for the first time between January 2017 and December 2018 were included and they were divided into a PAD group (n=179) and non-PAD (N-PAD) group (n=209) according to the presence or absence of PAD. A logistic regression model was used to analyze the risk factors for PAD. The prevalence of PAD in males was higher than that in females [odds ratio (OR)=2.250, 95% CI: 1.670-3.801]. The prevalence of PAD in patients with bile duct stone was 57.92% and higher than that in patients without stone (OR=4.475, 95% CI: 2.932-7.679). The morbidity of PAD in elderly patients with bile duct stone was higher than in those without stone (OR=6.728, 95% CI: 3.790-11.943). Among the elderly patients, the constituent ratio of males in the PAD group was higher than that in the N-PAD group (χ2=13.543, P<0.001). The constituent ratio of patients who underwent endoscopic sphincterotomy (EST) was lower than that in the N-PAD group (χ2=10.800, P<0.001). In conclusion, the occurrence of PAD was high in elderly males and closely related to the occurrence of bile duct stones.

Could saline irrigation clear all residual common bile duct stones after lithotripsy? A self-controlled prospective cohort study

BACKGROUNDA previous study showed that irrigation with 100 mL saline reduced residual common bile duct (CBD) stones, which potentially cause recurrent stones after endoscopic retrograde cholangiopancreatography.AIMTo determine whether saline irrigation can improve CBD clearance after lithotripsy.METHODSThis prospective self-controlled study enrolled patients receiving mechanical lithotripsy for large (> 1.2 cm) CBD stones. After occlusion cholangiography confirmed CBD stone clearance, peroral cholangioscopy (POC) was performed to determine clearance scores based on the number of residual stones. The amounts of residual stones spotted via POC were graded on a 5-point scale (score 1, worst; score 5, best). Scores were documented after only stone removal (control) and after irrigation with 50 mL and 100 mL saline, respectively. The stone composition was analyzed using infrared spectroscopy.RESULTSBetween October 2018 and January 2020, 47 patients had CBD clearance scores of 2.4 ± 1.1 without saline irrigation, 3.5 ± 0.7 with 50 mL irrigation, and 4.6 ± 0.6 with 100 mL irrigation (P < 0.001). Multivariate analysis showed that CBD diameter > 15 mm [odds ratio (OR) = 0.08, 95% confidence interval (CI): 0.01-0.49; P = 0.007] and periampullary diverticula (PAD) (OR = 6.51, 95%CI: 1.08-39.21; P = 0.041) were independent risk factors for residual stones. Bilirubin pigment stones constituted the main residual stones found in patients with PAD (P = 0.004).CONCLUSIONIrrigation with 100 mL of saline may not clear all residual CBD stones after lithotripsy, especially in patients with PAD and/or a dilated (> 15 mm) CBD. Pigment residual stones are soft and commonly found in patients with PAD. Additional saline irrigation may be required to remove retained stones.

Difficult biliary stones in the elderly: Endoscopic retrograde cholangiography - A single surgical tertiary centre experience with follow-up.

Background:Pancreaticobiliary diseases and choledocholithiasis are common in elderly patients. Endoscopic treatment of biliary stones represents a well-established mini-invasive technique. However, limited data are available regarding the treatment of ‘difficult’ biliary stones, especially in the elderly population. The aim of our study is to evaluate the efficacy and safety of therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in patients ≥85 years of age with complex biliary stones.Materials and Methods:From January 2015 to January 2017, data from ERCP procedures performed for complex biliary stones were retrospectively collected. The patients were divided into two groups based on their age: Group A – aged 85 years or older (n = 110) and Group B – aged 65 years or younger (n = 62). Demographic data, success, complications and recurrence rates for both groups were reported.Results:Chronic comorbidities (86.3% vs. 24.2%; P < 0.001) and use of antithrombotic drugs (48.2% vs. 19.3%; P < 0.001) were more frequent in the elderly. The technical success rate (95.4% vs. 96.7%; P > 0.6) and complication rate (8.2% vs. 13%; P > 0.2) were not statistically different among the two groups. Periampullary diverticula (PAD) were observed more frequently in Group A (38.1% vs. 17.7%; P < 0.006). More patients from Group B underwent cholecystectomy during the same admission (8.2% vs. 42.3%; P < 0.001). The recurrence rate was not different among the groups (7.6% vs. 5%; P > 0.5). PAD was identified as the risk factor for recurrence (P < 0.02).Conclusion:ERCP in the elderly was found to be a safe procedure, carrying a high degree of success for the treatment of difficult biliary stones.

Lemmel's syndrome: an uncommon complication of periampullary duodenal diverticulum.

Lemmel's syndrome is an uncommon entity that causes obstructive jaundice due to a periampullary duodenal diverticulum in the absence of choledolithiasis or neoplasia. To date, there are few published cases and the etiopathogenesis remains unclear.