Risk Of Choledocholithiasis Research Articles

The Safety and Cost Analysis of Outpatient Laparoendoscopy in the Treatment of Cholecystocholedocholithiasis: A Retrospective Study.

The advantages of single-stage treatment of cholecystocholedocholithiasis are well established, but the conditions for carrying out treatment on an outpatient basis require a review of concepts and practices of medical corporations. To evaluate the practice of treating cholecystocholedocholithiasis by laparoendoscopy on an outpatient basis with cost analysis. A retrospective study was conducted on patients with cholecystocholedocholithiasis treated by combined laparoscopic cholecystectomy and endoscopic choledocholithotomy from January 2015 to January 2019. After collecting data from physical and digital medical records, the patients were divided into two groups-AR (n = 42)-ambulatory regimen and HR (n = 28)-hospitalization regimen-which were compared in terms of demographic, clinical and treatment variables and their results, as well as in terms of costs. The mean age of the AR group was lower than that of the HR group and the physical status of the AR patients was better when assessed according to the American Society of Anesthesiologists (ASA) (p = 0.01). There was no difference between groups regarding the risk of choledocholithiasis (p = 0.99). For the AR group, the length of stay was shorter: 11.29 h × 65.21 h (p = 0.02), as was the incidence of postoperative complications assessed by applying the Clavien-Dindo classification: 3 (7.1%) × 11 (39.2%) (p < 0.01). The total mean costs were higher for the HR group (USD 2489.93) than the AR group (USD 1650.98) (p = 0.02). Outpatient treatment of cholecystocholedocholithiasis by laparoendoscopy is safe and viable for most cases, has a lower cost and can support the reorientation of training and practice of hepatobiliary surgeons.

The significance of isolated hyperbilirubinemia in detecting asymptomatic common bile duct stones in patients undergoing laparoscopic cholecystectomy

AimThe aim of this study was to evaluate the role of isolated hyperbilirubinemia in the detection of choledocholithiasis. MethodsA retrospective cohort study focused on adult patients diagnosed with gallstone disease, and undergoing intra-operative cholangiogram for suspected choledocholithiasis. Those presenting with isolated hyperbilirubinemia were investigated for their risk of choledocholithiasis, and were compared with those with normal liver function tests. ResultsOut of the total 1274 patients undergoing intra-operative cholangiogram in the study period, only 18 exhibited isolated hyperbilirubinemia. Among these, four patients were found to have common bile duct (CBD) stones. This indicates that in approximately 22 % of patients, isolated hyperbilirubinemia may be associated with CBD stones. However, it is essential to note that the number of patients in the study with isolated hyperbilirubinemia was relatively small. ConclusionAlthough the incidence of isolated hyperbilirubinemia was limited in our study, the presence of CBD stones in some of these patients suggests a potential association. Isolated hyperbilirubinaemia should not be overlooked as a risk factor for CBD stones. Nonetheless, additional investigations with a larger sample size are needed to establish a more definitive understanding of the relationship between isolated hyperbilirubinemia and choledocholithiasis.

Postoperative Surveillance of Bile Duct Cysts through Modified "Roux en Y" Hepaticojejunostomy by Transgastric Endoscopic Access

Background: Choledochal cyst is a congenital dilatation of extra or intrahepatic bile ducts and is usually associated with pancreaticobiliary malformation, risk of choledocholithiasis, and biliary tract cancer. The standard treatment consists of complete cystic resection with biliodigestive anastomosis; the hepaticojejunostomy is the preferred type of reconstruction. Methods: A survey of all choledochal cyst cases operated by the Pancreas Group of our service was carried out from July 1984 to March 2020, and 27 patients who underwent surgical treatment were identified. Based on the need for subsequent access to biliodigestive anastomosis for intrahepatic lithiasis treatment, biliary stricture, and further cancer surveillance on remnant intrahepatic cysts, a modified "Roux-en-Y" hepaticojejunostomy was proposed providing surveillance of remnant choledochal cyst and treatment for postoperative anastomotic or intra-hepatic complications by less invasive strategy. Results: A surveillance strategy must be considered. All the current procedures depend on advanced radiology, generate discomfort to the patient in ostomy cases, or rely on more invasive and repeated biliary surgical procedures. The new technique proposes a jejunal segment of approximately 10,0 to 15,0 cm kept far from the anastomosis allowing its placement, without tension, in the anterior gastric wall below the small curvature between the body the stomach antrum, which enables access to the bile ducts through Endoscopy (ERCP), guided by Endoscopic Ultrasound (EUS). Conclusion: The modified "Roux en Y" hepaticojejunostomy is a new and straightforward technique that allows surveillance of patients submitted to the biliodigestive anastomosis of any kind and are useful in patients submitted to choledochal cyst resection.

S24 MRCP vs ERCP: Evaluation of ASGE Guidelines in Acute Gallstone Pancreatitis with Predicted Intermediate/High Risk for Choledocholithiasis

S24 MRCP vs ERCP: Evaluation of ASGE Guidelines in Acute Gallstone Pancreatitis with Predicted Intermediate/High Risk for Choledocholithiasis

Development of a risk score for choledocholithiasis in pediatric patients.

The prevalence of gallstones in children has increased over the last years. Choledocholithiasis (CD) is present in up to 30% of the cases. There is a scarcity of studies on the management of choledocholithiasis in children. The aim of this study was to develop a score that would allow predicting accurately the risk of CD in children with gallstones and reduce the number of non-therapeutic ERCP. We conducted a retrospective study in children with gallstones and suspected CD seen between January 2010 and December 2019. The main outcome was the presence of CD confirmed by at least one of the following diagnostic tests: magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP), and/or intraoperative cholangiography (IOC). We developed a risk score based on the presence or absence of the following risk factors: acute biliary pancreatitis, ascending cholangitis, elevated liver function tests (AST, ALT, total bilirubin [TB, ≥ 2mg/dl], conjugated bilirubin, gamma-glutamyl transpeptidase, and alkaline phosphatase), CD on ultrasound (US; this was considered predictive but not confirmatory of CD), and dilation of the common bile duct (> 6mm) by US. The score was divided into three different categories: low risk (no risk factors), intermediate risk (one risk factor present), high risk (≥ 2 risk factors present or ascending cholangitis). Given the main goal of reducing the number of diagnostic ERCPs, a very-high-risk subgroup (3 risk factors present or ascending cholangitis) was identified. We reviewed 133 patients with gallstones and suspected CD. In 56 (42.1%) patients, the presence of CD was confirmed by one or more of the definitive diagnostic tests (MRCP, ERCP, and IOC). The following variables were found to be the strongest predictors of CD: ascending cholangitis, TB ≥ 2mg/dl, common bile duct > 6mm, and the presence of CD by US. The positive predictive value for CD was 7.5% in the low-risk group (OR 0.06, P = < 0.001); 22.9% in the intermediate-risk group (OR 0.31, P = 0.007); 77.6% in the high-risk group (OR 20.14, P = < 0.001); and 95.7% in very-high-risk subgroup (OR 49.18, P = < 0.001). The risk score proposed in this study predicts accurately the presence of CD in children with gallstones. It can serve as a helpful tool to triage the need for costly and complex studies in the workup of CD, particularly in centers with limited resources. Finally, due to its high specificity and positive predictive value (PPV), the use of the very-high-risk criteria would allow for an important decrease in the number of non-therapeutic ERCP.

Routine intraoperative cholangiography during laparoscopic cholecystectomy: application of the 2016 WSES guidelines for predicting choledocholithiasis

BackgroundRoutine use of intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) for detecting common bile duct stones remains controversial. The 2016 World Society of Emergency Surgery (WSES) guidelines on acute calculous cholecystitis proposed a risk stratification for choledocholithiasis. Our present study aimed to (1) examine the findings of common bile duct (CBD) stones in patients underwent LC with routine use of IOC, and (2) validate the 2016 WSES risk classes for predicting choledocholithiasis.MethodsAll patients had LC with IOC routinely performed from November 2012 to December 2017 were reviewed retrospectively. Patients were classified into high-, intermediate-, and low-risk groups based on the 2016 WSES risk classes with modification.ResultsA total of 990 patients with LC and routine IOC were enrolled. CBD stones were detected in 197 (19.9%) patients. The rate of CBD stone detected in low-, intermediate-, high-risk groups were 0%, 14.2%, and 89.6%, respectively. Predictors as following: evidence of CBD stones on abdominal ultrasound or computed tomography, CBD diameter > 6 mm, total bilirubin > 4 mg/dL, bilirubin level = 1.8–4 mg/dL, abnormal liver biochemical test result other than bilirubin, presence of clinical gallstone pancreatitis had statistical significance between patients with and without CBD stones. Major bile duct injury was found in 4 patients (0.4%). All 4 patients had uneventful recovery after repair surgery.ConclusionsBased on our study results, the 2016 WSES risk classes for choledocholithiasis could be an effective approach for predicting the risk of choledocholithiasis. Considering its advantages for detecting CBD stones and biliary injuries, the routine use of IOC is still suggested.

Postoperative surveillance of bile duct cysts through modified “Roux en Y” hepaticojejunostomy by transgastric endoscopic access

Presenter: André de Moricz MD | Irmandade Santa Casa de Misericórdia de São Paulo Background: Choledochal cyst (CC) is a congenital dilatation of extra or intrahepatic bile ducts and is usually associated with pancreaticobiliary malformation, risk of choledocholithiasis, and biliary tract cancer. The standard treatment for CC consists of complete cystic resection with biliodigestive anastomosis; the hepaticojejunostomy is the preferred type of reconstruction due to lower complication rates. Methods: A survey of all choledochal cyst cases operated by the Pancreas group of our service was carried out from July 1984 to March 2020, and 22 patients who underwent surgical treatment were identified. Based on the need for subsequent access to biliodigestive anastomosis for intrahepatic lithiasis treatment, biliary stricture, and further cancer surveillance on remnant intrahepatic cysts, a modified “Roux-en-Y” was proposed hepaticojejunostomy providing surveillance of remnant choledochal cyst and treatment for postoperative hepaticojejunostomy complications by less invasive strategy. Results: Considering the possibility of late complications such as stenosis or incomplete resection of the cyst, a surveillance strategy must be considered. All the current procedures depend on advanced radiology, generate discomfort to the patient in ostomy cases, or rely on more invasive and repeated biliary surgical procedures. The new technique proposes a jejunal segment of approximately 10,0 to 15,0 cm kept far from the anastomosis allowing its placement, without tension, in the anterior gastric wall below the small curvature between the body the stomach antrum, which enables access to the bile ducts through Endoscopic Retrograde Cholangiopancreatography (ERCP) guided by Endoscopic Ultrasound (EUS) and therefore less invasive access than the ones described in the literature. Conclusion: The modified “Roux en Y” hepaticojejunostomy is a new and straightforward technique that allows surveillance of patients submitted to the biliodigestive anastomosis of any kind and are useful in patients submitted to choledochal cyst resection once it enables vigilance of the remnant bile duct and makes interventions possible when needed.

Evaluating the Revised American Society for Gastrointestinal Endoscopy Guidelines for Common Bile Duct Stone Diagnosis.

Background/AimsThe American Society for Gastrointestinal Endoscopy (ASGE) revised its guidelines for risk stratification of patients with suspected choledocholithiasis. This study aimed to assess the diagnostic performance of the revision and to compare it to the previous guidelines. MethodsWe conducted a retrospective cohort study of 267 patients with suspected choledocholithiasis. We identified high-risk patients according to the original and revised guidelines and examined the diagnostic accuracy of both guidelines. We measured the association between individual criteria and choledocholithiasis.ResultsUnder the original guidelines, 165 (62%) patients met the criteria for high risk, of whom 79% had confirmed choledocholithiasis. The categorization had a sensitivity and specificity of 68% and 55%, respectively, for the detection of choledocholithiasis. Under the revised guidelines, 86 (32%) patients met the criteria for high risk, of whom 83% had choledocholithiasis. The revised categorization had a lower sensitivity and higher specificity of 37% and 80%, respectively. The positive predictive value of the high-risk categorization increased with the revision, reflecting a potential decrease in diagnostic endoscopic retrograde cholangiopancreatograpies (ERCPs). Stone visualized on imaging had the greatest specificity for choledocholithiasis. Gallstone pancreatitis was not associated with the risk for choledocholithiasis. ConclusionsThe 2019 revision of the ASGE guidelines decreases the utilization of ERCP as a diagnostic modality and offers an improved risk stratification tool.

Su1537 TREATMENT OF CHOLELITHIASIS WITH CHOLEDOCHOLITHIASIS THROUGH THE ASSOCIATION OF LAPAROSCOPIC AND ENDOSCOPIC ACCESS, IN ONE-TIME AND OUTPATIENT BASIS, WITH COST ANALYSIS

The advantages of the treatment of choledocholithiasis and cholelithiasis in a single surgical time have been well established, but the types of access used and their combinations, the assistance processes and the assessment of cost effectiveness are still being studied. To evaluate the profile of patients with choledocholithiasis plus cholelithiasis treated by combined laparoscopic and endoscopic access in a single time on an outpatient basis and to determine the treatment costs. A retrospective study was conducted on patients with choledocholithiasis plus cholelithiasis treated by combined laparoscopic cholecystectomy and endoscopic choledocholithotomy from January 2015 to January 2019. The patients were divided into two groups: AR (n=42) – ambulatory regimen and HR (n=28) – hospitalization regimen – which were compared in terms of demographic, clinical and treatment variables and their results, as well as in terms of costs. The mean age of the AR group was lower than that of the HR group (43.52 x 53.46 years, p=0.03) and the physical status of the AR patients was better when assessed according to the American Society of Anesthesiologists (ASA) (p=0.01). There was no difference between groups regarding the risk of choledocholithiasis (p=0.99). For the AR group, the length of stay was shorter: 11.29 hours (6.15) x 65.21 hours (71.72) (p=0.02), as was the incidence of postoperative complications assessed by applying the Clavien-Dindo classification: 3.0 (7.1%) X 11 (39.2%) (p<0.01). The total mean costs were higher for the HR group ($2,489.93) than the AR group ($1,650.98) (p=0.02) (Figures 1 and 2). The combination of laparoscopic cholecystectomy and endoscopic choledocholithotomy, in a single time, on an outpatient basis, is safe and feasible for patients in good health, has a lower cost and may support the reorientation of hepatobiliary surgeon training with the integrated use of technological resources and the adoption of care protocols aimed at better clinical management of the choledocholithiasis approach.

To Compare EUS and MRCP in Detecting Choledocholithiasis in Patients of Intermediate Risk of Choledocholithiasis

To Compare EUS and MRCP in Detecting Choledocholithiasis in Patients of Intermediate Risk of Choledocholithiasis

An assessment of the yield of EUS in patients referred for dilated common bile duct and normal liver function tests.

Objective:This study aims to determine the yield of EUS in patients with common bile duct (CBD) dilation and normal liver function tests (LFTs).Materials and Methods:Between October 2000 and December 2016, all patients referred for EUS for unexplained CBD dilatation (CBD ≥7 mm), with normal aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, and bilirubin and no history of sphincterotomy, were eligible. Linear-array EUS was performed by one of the two experienced endosonographers. Data were extracted from a prospectively maintained database.Results:Of 29,920 upper gastrointestinal EUS procedures performed, 840/29,920 (3%) were for unexplained CBD dilation. Of 840 patients, 199 (24%) had normal LFTs, 99% were Caucasian, 46% had biliary-type abdominal pain, and 41% were postcholecystectomy. EUS diagnosed choledocholithiasis (CDL) or sludge in 18/199 (9%) patients (7/18 had CBD sludge only). No other pathology was diagnosed. Of 18 CDL patients, 15 (83%) had an intact gallbladder, and all 15 patients had cholelithiasis. The frequency of CDL or sludge in postcholecystectomy patients was only 3.7% (3/82); none of these patients were younger than 69 years of age. Regression analyses showed no associations between EUS diagnosis of CDL or sludge and biliary-type abdominal pain, other symptoms, sex, or race. Each additional year of age was associated with an increase in the risk of CDL or sludge by a factor of 1.05 (odds ratio: 1.05; P = 0.034).Summary:In patients with CBD dilation and normal LFTs, the only significant pathology identified is CBD stones or sludge (almost exclusively in elderly patients with cholelithiasis).Conclusion:EUS should be avoided in patients with dilated bile ducts and normal LFTs, especially if under 65 years of age and postcholecystectomy.

Comparison of Endoscopic Ultrasonography with Secretin-enhanced MR cholangiopancreatography for etiologic diagnosis in idiopathic acute pancreatitis

s / Pancreatology 15 (2015) S1eS141 S53 remains a challenge to assess the accurate indications for ERCP in patients with suspected choledocholithiasis and to select high risk PEP patients for appropriate prevention. Aims: The aim was to evaluate PEP prevalence and analyse patient's predictive factors of PEP in suspected choledocholithiasis prior ERCP. Patients & methods: 270 patients undergone ERCP due to suspected choledocholithiasis from 2012-2014y. Mean age was 65y (range 21-96y), 66% were females. The PEP prevalence were analysed. Patients were grouped using American Society of Gastrointestinal Endoscopy (ASGE,2010) outlined predictive factors, risk groups of choledocholithiasis prior ERCP. Univariate, multivariate analysis of choledocholithiasis and PEP risk factors were made. Results: Overall 16 patient's(6%) had PEP, 2(0,7%) hyperamylasemia. 2 cases were severe PEP with one lethal outcome. Choledocholithiasis was confirmed in 139(51%) patients, 10 occured PEP. All patients were in high risk group of PEP (according to ESGE,2014). 195(72%) patients had high risk, 75 intermediate risk of choledocholithiasis according to ASGE guidelines. PEP occured in 13 cases of high(p1⁄40,067), 3 intermediate group(p1⁄40,04). No risk factor significantly increased risk of PEP by univariate analysis. Abnormal liver biochemical test other than bilirubin (OR 0,857, p1⁄40,0001) and age>55y (OR 0,664, p1⁄40,020) increased risk by multivariate analysis. PEP was in 19% of age 18-45y, 17% 46-65y, 25% 66-85y. Choledocholithiasis mostly was in age 66-85y(28%). Conclusion: Patients with high risk of choledocholithiasis have higher risk of PEP comparing to intermediated risk. Patient's age >55y in suspected choledocholithiasis is additional predictive factor of PEP.

Do Cholecystectomy First in Patients with Intermediate Risk for Choledocholithiasis

Current guidelines recommend preoperative endoscopic retrograde cholangiopancreatography (ERCP) or endoscopic ultrasound (EUS) prior to cholecystectomy

Single-stage treatment with intraoperative ERCP: management of patients with possible choledocholithiasis and gallbladder in situ in a non-tertiary Spanish hospital

The best way to reduce endoscopic retrograde cholangiopancreatography (ERCP) complications is not to perform it if it is unnecessary. Both intraoperative and postoperative ERCP rely on use of intraoperative cholangiography as a final diagnostic test for choledocholithiasis (CLD) whenever clinical data are unable to rule out CLD. Intraoperative ERCP could become a therapeutic option when a previous preoperative ERCP fails. We present our experience with intraoperative ERCP. This is a descriptive and prospective study of a cohort of 82 patients with moderate risk of CLD. They were operated on by laparoscopic cholecystectomy with intraoperative cholangiography (IOC). We performed intraoperative ERCP using the rendezvous technique. Thirty-six out of 82 patients had an abnormal IOC study. Mean age was 58.7 years (standard deviation, SD 16.6, 25-83 years), and 60.6% were females. Ultrasound study showed that 51.4% of patients had a dilated bile duct. Magnetic resonance cholangiography (MRC) was performed on three patients (8.3%). The success rate of intraoperative ERCP was 88.2%. Three out of the 36 patients (8.8%) had ERCP complications [2 mild papillary bleeding (5.8%), 1 acute pancreatitis (2.9%)]. The rate of conversion to open surgery was 5% with a surgical complications rate of 4% [one injured duct and two surgical bleeding which required re-operation (2.5%)]. There were no mortalities. Four patients (11.1%) needed post-surgical ERCP, with a residual CLD rate of 5.6% (two patients) in the postoperative period. Mean surgical time was 181 min (SD 60, 75-345 min). Mean hospital stay was 6.2 days (SD 4.7, 2-24 days). Intraoperative ERCP is an option to prevent performing ERCP unnecessarily on patients with moderate risk of CLD not confirmed using appropriate radiological studies. It can resolve the biliary disease in a single step with a similar success rate to standard ERCP, but with low morbidity, especially of acute pancreatitis. The residual CLD rate is also very low.

Mo1582 Patterns of MRCP Utilization Prior to ERCP Among Patients at High Risk for Choledocholithiasis

Mo1582 Patterns of MRCP Utilization Prior to ERCP Among Patients at High Risk for Choledocholithiasis

Analysis Of Operative Characteristics And Economic Impact Of ERCP Versus MRCP In Patients With Acute Cholecystitis According To Levels Of Risk For Choledocholithiasis

Analysis Of Operative Characteristics And Economic Impact Of ERCP Versus MRCP In Patients With Acute Cholecystitis According To Levels Of Risk For Choledocholithiasis

Utility of Choledochoscopy/EUS to Diagnose and Treat Choledocholithiasis in Pregnancy

Purpose: The risk of choledocholithiasis is higher during pregnancy due to alteration in bile composition and biliary stasis that occurs during gestation. Treatment of these patients during pregnancy is challenging due to the risks from sedation and fluoroscopy. This is an interesting case of application of new technique to diagnose and treat choledocholithiasis. A twenty-six year old pregnant female at 28 weeks gestation presented with right upper quadrant pain, progressive jaundice, and low-grade fever. Her past medical history was significant for sickle cell disease, preeclampsia and choledocholithiasis. She had undergone a previous ERCP for stone removal after her last pregnancy. Upon presentation to the hospital, her total bilirubin was 6.8, AST 139, ALT 113, ALP 128 and WBC count was 16,500. Transabdominal ultrasound revealed a 9-mm common bile duct with possible filling defect. In order to avoid radiation exposure to fetus by fluoroscopy, EUS and choledochoscopy were used to examined the bile duct and achieve complete clearance. The linear echoendoscope revealed multiple hyperechoic well-rounded stones throughout the common bile duct. A prior sphincterotomy had been performed, so deep cannulation of the bile duct using the SpyGlass choledochoscope (Boston Scientific) was easily achieved. The SpyScope was useful in determining the exact location of the stones. A guidewire was advanced through the SpyScope into the left intrahepatic system. A 10 mm extraction balloon was used to extract multiple yellow pigment stones from CBD. The SpyScope was then reinserted and complete clearance of the CBD was seen. A 10 Fr 5-cm plastic biliary stent was placed to ensure drainage and prevent recurrent cholangitis during the remainder of her pregnancy. The linear echoendoscope was used to confirm adequate placement of the biliary stent. Subsequently, the patient had complete resolution of her symptoms and improvement in her LFT. The incidence of gallstones during pregnancy is estimated to be between 3% and 12%. Symptomatic gallstone disease is the second most common abdominal emergency in pregnant women and may require surgical intervention. In addition to the baseline risks of ERCP, fluoroscopy poses additional risk to the fetus. Various publications have reported using ERCP during pregnancy without fluoroscopy by using bile aspiration for confirmation of CBD cannulation, sphincterotomy and balloon extraction of stones. All these approaches are not perfect with regard to ensuring complete CBD clearance. This case highlights how choledochoscopy and endoscopic ultrasound are safe alternatives to fluoroscopy for evaluation of biliary disorders during pregnancy.

Safety of endoscopic retrograde cholangiopancreatography during pregnancy

The risk of choledocholithiasis is expected to be higher during pregnancy. This is attributed to alteration in bile composition as well as biliary stasis that take place during gestation. There is significant concern regarding application of endoscopic procedures especially the more invasive ones for treatment of choledocholithiasis during pregnancy. Our aim was to provide an additional support to the efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) in the management of biliary diseases during pregnancy. The medical records of 10 pregnant patients who underwent ERCP at King Abdullah University Hospital, during the period from 2002 to 2007 were reviewed. Pregnancy course and outcomes were followed up in all cases. Results were analysed and compared with published data on safety and efficacy of this procedure. The mean age for mothers was 24.3 years. The mean duration of gestation was 18.4 weeks. Two patients were in the first trimester, five were in their second trimester and another three in the third trimester. The main indication for ERCP was obstructive choledocholithiasis on ultrasound and liver function tests. Fetal radiation exposure was not routinely measured. During, or after, the procedure there was no need for tocolytic agents. Also there was no intrauterine fetal distress. Screening for congenital anomalies was negative in all cases. Major complications of biliary obstruction have been prevented through this procedure. Short-term follow up for all neonates whom mothers underwent ERCP during pregnancy supports its safety. However, specific long-term fetal complications of radiation exposure have not been investigated yet.

Usefulness of Endoscopic Ultrasound in Patients at High Risk of Choledocholithiasis

BackgroundEndoscopic retrograde cholangiopancreatography (ERCP) has been considered the nonsurgical gold standard for the diagnosis and treatment of choledocholithiasis (CDL). Complications include a 0.1% to 1.3% mortality rate and a 5% to 19% morbidity rate, including a reported 1.8% to 6.7% incidence of postprocedure pancreatitis. Twenty-seven percent to 67% of ERCPs done for suspected choledocholithiasis ultimately have negative results. Endoscopic ultrasound (EUS) has been proposed as an alternate means of diagnosing choledocholithiasis that may eliminate the need for ERCP and its associated morbidities in certain patients.MethodsRetrospective chart review identified 30 patients who underwent EUS with or without ERCP for suspected choledocholithiasis. Reports of all procedures performed were obtained and data were collected on all biliary abnormalities identified on both EUS and ERCP. Results: Pancreaticobiliary abnormalities were identified in 27 of 30 patients (90%) at EUS. Most common diagnoses included CDL (n = 9, 30%), biliary sludge (n = 11, 37%), pancreatitis (n = 8, 27%), and cholelithiasis (n = 7, 23%). Subsequent ERCP was performed in 14 patients (47%). Indications included a diagnosis of CDL by EUS (n = 9) and abnormal liver function tests (n = 5). CDL was identified in 5 of 14 patients (36%), and microlithiasis/biliary sludge was identified in an additional 5 patients (36%). In 4 patients, CDL was identified by EUS but not by ERCP. ERCP did not identify any new cases of CDL after EUS: of 21 patients without evidence of CDL on EUS, none were subsequently shown to have CDL or to develop any complications related to common duct stones.ConclusionsEUS is an effective method of diagnosing CDL. It demonstrates both a high sensitivity and specificity for identifying common bile duct stones. Its use as a screening modality in patients suspected of having CDL may allow more selective use of ERCP.

Common bile duct exploration and laparoscopic cholecystectomy: role of intraoperative ultrasonography.

In October 1993, to detect associated common bile duct (CBD) stones, we started an evaluation program of patients with symptomatic cholelithiasis who were candidates for laparoscopic cholecystectomy. We used a standard preoperative algorithm and a laparoscopic ultrasonographic (LUS) examination. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) was reserved for high-risk patients for CBD stones. Laparoscopic ultrasonographic examination during cholecystectomy was routinely performed to identify stones unsuspected preoperatively. Two-hundred-sixteen patients with symptomatic cholelithiasis were included in the study; 177 patients (82%) were at low risk for choledocholithiasis and 39 patients (18%) were at high risk and had preoperative ERCP. In 17 patients (43.5%) CBD stones were found, and in 16 patients (41%) they were removed by endoscopic sphincterotomy. In all patients, the main intra- and extrahepatic ducts were well documented by LUS, but in eight cases the distal tract of the CBD was not well-visualized. In eight patients, small stones were found in the CBD. A subsequent peroperative cholangiography or CBD exploration confirmed the diagnosis. In one patient, both LUS and cholangiography suspected a small stone; the CBD exploration did not confirm it (false positive). In two patients a small stone in the CBD was found during the followup period (two false negatives). An endoscopic sphincterotomy solved the problem. Laparoscopic ultrasonographic examination may be a real alternative to cholangiography during laparoscopic cholecystectomy: this may be reserved for selected instances on the basis of LUS findings. On the other hand, considerable ultrasonographic experience is required for LUS to be performed successfully.