Suspected Bile Duct Stones Research Articles

Suspected common bile duct stones: reduction of unnecessary ERCP by pre-procedural imaging and timing of ERCP

BackgroundEndoscopic retrograde cholangiopancreatography (ERCP) is the procedure of choice to remove sludge/stones from the common bile duct (CBD). In a small but clinically important proportion of patients with suspected choledocholithiasis ERCP is negative. This is undesirable because of ERCP associated morbidity. We aimed to map the diagnostic pathway leading up to ERCP and evaluate ERCP outcome.MethodsWe established a prospective multicenter cohort of patients with suspected CBD stones. We assessed the determinants that were associated with CBD sludge or stone detection upon ERCP.ResultsWe established a cohort of 707 patients with suspected CBD sludge or stones (62% female, median age 59 years). ERCP was negative for CBD sludge or stones in 155 patients (22%). Patients with positive ERCPs frequently had pre-procedural endoscopic ultrasonography (EUS) or magnetic resonance cholangiopancreatography (MRCP) imaging (44% vs. 35%; P = 0.045). The likelihood of ERCP sludge and stones detection was higher when the time interval between EUS or MRCP and ERCP was less than 2 days (odds ratio 2.35; 95% CI 1.25–4.44; P = 0.008; number needed to harm 7.7).ConclusionsEven in the current era of society guidelines and use of advanced imaging CBD sludge or stones are absent in one out of five ERCPs performed for suspected CBD stones. The proportion of unnecessary ERCPs is lower in case of pre-procedural EUS or MRCP. A shorter time interval between EUS or MRCP increases the yield of ERCP for suspected CBD stones and should, therefore, preferably be performed within 2 days before ERCP.Graphical abstract

WE2.11 Optimal Utilisation of Cross-Sectional Imaging in Patients with Painful Jaundice Undergoing Bile Duct Exploration or Conservative Management for Suspected Bile Duct Stones on a Specialist Unit

Abstract Aim Laparoscopic management of bile duct stones relies on intraoperative cholangiography, optimising utilisation of preopertative imaging. This study aims to determine whether such a policy is justifiable in jaundiced patients over 50 years of age with no risk factors for malignancy. Methods Prospectively collected data of patients presenting with gall stones and painful jaundice undergoing biliary surgery or treated conservatively was analysed. The presentation, preoperative imaging, cholangiography/ choledochoscopy findings and postoperative outcomes were recorded. Patients with risk factors for malignancy were excluded. Results 1220 jaundiced patients over 50 years were referred over 24 years. 684 underwent surgery having had CT in 15.3%, MRCP 10% and ERCP 2.5%. 536 unfit patients were managed conservatively (CT 15.7%, MRCP 27.8% and ERCP 29.5%). Most had these investigations under the care of other departments prior to referral. 21/684 (3%) presenting with painful jaundice associated with acute cholecystitis or bile duct stones and no risk factors for malignancy were diagnosed with malignancy on IOC and choledochoscopy. 7 patients had preoperative cross sectional imaging, one with ERCP showing no evidence of malignancy. The remaining 14 patients underwent postoperative imaging; 7 had radiologically undetectable disease, 6 had advanced disease and only one was suitable for a “curative resection”. 21/536 (3.9%) cancers were diagnosed in patients who were treated conservatively. Conclusion Based on the little diagnostic yield of curable biliary malignancies, a policy of no cross sectional imaging in patients with obstructive jaundice and no risk of malignancy is justifiable in units adopting single session management of bile duct stones.

O-EGS05 The Prevalence of Bile Duct Stones in Patients Presenting with Acute Pancreatitis vs. Jaundice in a 5774 patient series. The Case for Single Session Surgical Management

Abstract Background There is increasing evidence that single session laparoscopic cholecystectomy with cholangiography and, when necessary and available, bile duct exploration offers optimal clinical outcomes and superior cost benefits to patients with suspected bile duct stones. There is a perception that preoperative endoscopic clearance of bile duct stones is necessary in patients presenting with pancreatitis and jaundice. However, most patients do not have severe disease and are fit for index admission surgical management. We aim to study the prevalence of bile duct stones in pancreatitis vs. jaundice and evaluate this management approach with regards to preoperative and operative parameters and postoperative outcomes. Methods Analysis of prospectively maintained database of 5774 consecutive laparoscopic cholecystectomies, cholangiography(IOC) with or without bile duct exploration was undertaken. Patients with suspected bile duct stones are referred to one firm with an intention of single surgical treatment in the index admission. Data of patients presenting with acute pancreatitis and obstructive jaundice was extracted. In the absence of suspected malignancy there was a limited role for preoperative MRCP and ERCP. The incidence of confirmed CBD stones requiring exploration, type of exploration, morbidity, re-operations and readmissions, hospital stay, number of episodes, and presentation to resolution intervals were compared in the two groups. Results Conclusions Single session surgical treatment of patients with acute pancreatitis and jaundice by specialist firms in the index admission (89% and 86% if previous admissions by other units is excluded) offers many advantages. MRCP and ERCP utilisation is minimised in favour of IOC; two thirds of pancreatitis patients and one third of jaundiced patients have no CBD stones. Simple transcystic explorations deals with most stones in both groups. The morbidity, open conversion, readmissions, retained stones and re-operations are low. Total hospital stay, number of treatment episodes and presentation to resolution are optimised and should persuade surgeons to avoid subjecting patients to multiple treatments.

Moy.03Evaluation of the Basket in Catheter Technique for Transcystic Bile Duct Exploration and Suspected Ductal Stones

Abstract Aims The ‘Basket-in-catheter’ (BIC) technique facilitates laparoscopic transcystic ductal exploration (LTCE) and increases its success rate, being easier and safer than inserting the basket alone. This study evaluates the benefits in confirmed and suspected ductal stones. Methods Prospective preoperative, operative and postoperative data on consecutive single session ductal explorations was collected over 28 years and analysed. BIC became our default technique for the transcystic approach to confirmed or suspected bile duct stones. Results 741 of 1225 (60.5%) attempted LTCE were performed using retrieval baskets without dilating the cystic duct (CD). BIC was used in 646 (87.2%). Of 386 (52.1%) patients undergoing successful stone retrieval 62.7% had clinical and radiological risk factors for ductal stones and 92.0% had positive intraoperative cholangiography. 355 (47.9%) patients had preoperative or operative risk factors for CBD stones and equivocal cholangiography in 25%. Basket trawling was negative and repeat cholangiography confirmed resolution of abnormalities. Choledochoscopy was utilised in 484/1225 (39.5%), either primarily or when blind trawling failed to extract stones. Retained stones occurred in 7 patients, six requiring ERCP. Bile leakage occurred in 6 patients. There were two open conversions, no biliary injuries and no mortality. Post-operative pancreatitis occurred in 7 and recurrent stones in 8 patients. Conclusions The BIC technique achieves successful LTCE without CD dilatation in 40%, reducing the need for choledochoscopy and choledochotomy. It facilitates safe and speedy CBD trawling when stones are suspected due to preoperative or operative risk factors or equivocal cholangiography and helps surgeons acquire and consolidate ductal exploration skills.

1282 Evaluation of the Basket in Catheter Technique for Transcystic Bile Duct Exploration and Suspected Ductal Stones

Abstract Aim The ‘Basket-in-catheter’ (BIC) technique facilitates laparoscopic transcystic ductal exploration (LTCE) and increases its success rate, being easier and safer than inserting the basket alone. This study evaluates the benefits in confirmed and suspected ductal stones. Method Prospective preoperative, operative and postoperative data on consecutive single session ductal explorations was collected over 28 years and analysed. BIC became our default technique for the transcystic approach to confirmed or suspected bile duct stones. Results 741 of 1225 (60.5%) attempted LTCE were performed using retrieval baskets without dilating the cystic duct (CD). BIC was used in 646 (87.2%). Of 386 (52.1%) patients undergoing successful stone retrieval 62.7% had clinical and radiological risk factors for ductal stones and 92.0% had positive intraoperative cholangiography. 355 (47.9%) patients had preoperative or operative risk factors for CBD stones and equivocal cholangiography in 25%. Basket trawling was negative and repeat cholangiography confirmed resolution of abnormalities. Choledochoscopy was utilised in 484/1225 (39.5%), either primarily or when blind trawling failed to extract stones. Retained stones occurred in 7 patients, six requiring ERCP. Bile leakage occurred in 6 patients. There were two open conversions, no biliary injuries and no mortality. Post-operative pancreatitis occurred in 7 and recurrent stones in 8 patients. Conclusions The BIC technique achieves successful LTCE without CD dilatation in 40%, reducing the need for choledochoscopy and choledochotomy. It facilitates safe and speedy CBD trawling when stones are suspected due to preoperative or operative risk factors or equivocal cholangiography and helps surgeons acquire and consolidate ductal exploration skills.

Serum Amylase Levels is a Predictor for Negative Endoscopic Retrograde Cholangiopancreatography for Suspected Common Bile Duct Stones.

Negative endoscopic retrograde cholangiopancreatography (ERCP) for suspected common bile duct stones (CBDS) may be associated with significant morbidity and should be avoided. Between 2010 and 2018, 85 patients who have undergone negative ERCP for suspected CBDS were retrospectively evaluated and compared with 318 patients with positive findings. Predictors for negative ERCP were assessed. Patients with negative ERCP were younger; had increased levels of serum amylase, alanine transaminase, and lactate dehydrogenase; and increased hemoglobin. Even though preprocedure computed tomography (CT) or ultrasonography demonstrating CBDS were highly predictive of positive findings on ERCP, of the 212 patients with CBDS on computed tomography or ultrasonography, 17 (8%) eventually had a negative ERCP, suggesting spontaneous stone passage. An increased serum amylase level was the only predictor for negative ERCP in multivariate analysis, including in patients with preprocedure CBDS on imaging. The data suggest that assessing serum amylase may assist in avoiding unnecessary examinations.

The Prevalence of Bile Duct Sludge in Patients With Suspected Bile Duct Stones

Endoscopic Ultrasonography (EUS) in patients with suspected bile duct stones rules out the presence of stones in up to 65% of patients, thus preventing unnecessary Endoscopic Retrograde Cholangiography with Endoscopic Sphincterotomy (ERC with ES) and its complications in the majority of cases.1 Increased use of EUS for ruling out bile duct stones has led to more cases in which bile duct sludge is detected. Sludge is an ultrasound diagnosis usually described as layered, mobile, low-amplitude echoes without shadowing, representing bile precipitate out of solution.

Comparison of the accuracy of two T2-weighted MRCP sequences for suspected bile duct stones to optimise imaging protocols

Comparison of the accuracy of two T2-weighted MRCP sequences for suspected bile duct stones to optimise imaging protocols

Optimising the outcomes of index admission laparoscopic cholecystectomy and bile duct exploration for biliary emergencies: a service model

AimsThe rate of acute laparoscopic cholecystectomy remains low due to operational constraints. The purpose of this study is to evaluate a service model of index admission cholecystectomy with referral protocols, refined logistics and targeted job planning.MethodsA prospectively maintained dataset was evaluated to determine the processes of care and outcomes of patients undergoing emergency biliary surgery. The lead author has maintained a 28 years prospective database capturing standard demographic data, intraoperative details including the difficulty of cholecystectomy as well as postoperative outcome parameters and follow up data.ResultsOver five thousand (5555) consecutive laparoscopic cholecystectomies were performed. Only patients undergoing emergency procedures (2399,43.2% of entire group) were analysed for this study. The median age was 52 years with 70% being female. The majority were admitted with biliary pain (34%), obstructive jaundice (26%) and acute cholecystitis (16%). 63% were referred by other surgeons. 80% underwent surgery within 5 days (40% within 24 h). Cholecystectomies were performed on scheduled lists (44%) or dedicated emergency lists (29%). Two thirds had suspected bile duct stones and 38.1% underwent bile duct exploration. The median operating time was 75 min, median hospital stay 7 days, conversion rate 0.8%, morbidity 8.9% and mortality rate 0.2%.ConclusionIndex admission cholecystectomy for biliary emergencies can have low rates of morbidity and mortality. Timely referral and flexible theatre lists facilitate the service, optimising clinical results, number of biliary episodes, hospital stay and presentation to resolution intervals. Cost benefits and reduced interval readmissions need to be weighed against the length of hospital stay per episode.

Management of bile duct stones at cholecystectomy: an Australian single-centre experience over 2years.

Bile duct stones with an intact gallbladder can be treated with either bile duct exploration at cholecystectomy or endoscopic retrograde cholangiopancreatography (ERCP) before or after cholecystectomy. The aim of this study was to evaluate the management of bile duct stones at cholecystectomy at our institution. We also aimed to identify risk factors for failure of ductal clearance in our series. A retrospective review of 690 laparoscopic cholecystectomies over a 2-year period was performed. Patients who underwent laparoscopic bile duct exploration formed the study population. Of 69 patients with suspected bile duct stones at cholecystectomy 67 (97%) patients underwent laparoscopic bile duct exploration upfront. Complete ductal clearance was achieved in 52 (78%) patients. Postoperative complications (10/67, 15%) included postoperative bleeding (2/67, 3%), bile leak (1/67, 1%), and superficial wound infection (1/67, 1%). There was no mortality. The mean operative time was 126min and the median length of stay was 2 (1-4) days. A wider common bile duct (CBD) (≥ 8mm) increased the risk of failed ductal clearance (OR 4.50; 95% confidence interval (CI) 1.15-19.23). This study found that laparoscopic bile duct exploration can effectively and safely treat bile duct stones suspected at cholecystectomy.

Optimising the outcomes of index admission laparoscopic cholecystectomy and bile duct exploration for benign biliary emergencies: A service model

Presenter: Zubir Ahmed MD, PhD | University of Glasgow Background: Despite overwhelming evidence of its clear benefit, the rate of early laparoscopic cholecystectomy +/- bile duct exploration for acute biliary presentations such as cholecystitis and choledocholithiasis remains low mainly due to logistical and operational constraints. The aim of this study is to describe a service model that has been implemented to optimise the outcome of index admission laparoscopic cholecystectomy and bile duct exploration. In this study we demonstrated how a clear referral protocol, a refined logistical set-up and targeted job planning support the delivery of a service for all benign biliary emergencies in the United Kingdom. Methods: Patients undergoing emergency biliary surgery were identified and analysed from a prospectively maintained database containing 5555 consecutive laparoscopic cholecystectomy. The majority of biliary emergencies are referred to a dedicated biliary firm according to a clear protocol. The workload is recognised in job planning with an agreed target of 60% emergency surgery. Preoperative imaging is limited to ultrasound scanning with very small numbers of patients with suspected bile duct stones undergoing MRCP or ERCP. Maximum utilisation of theatre for biliary emergencies is achieved through scheduled lists, rapid access and emergency lists. Results: There were 2399 (43.2%) emergency cases in the database. The median age was 52 years with 70% female. The majority of cases were admitted with biliary colic (34%), obstructive jaundice (26%) and acute cholecystitis (16%). 63% were referred by other surgical team, 8% from other hospitals and 6% from physicians. 80% underwent surgery within 5 days of referral with 19% operated on same day of referral and 21% within 1 day of referral. 44% of laparoscopic cholecystectomies were performed on elective lists, 29% on semi elective “CEPOD” lists and 26% while on-call. The median operating time was 75 minutes, median total hospital stay was 7 days. The conversion rate was 0.7%, complication rate of 4.8% and a mortality rate of 0.1%. Conclusion: Early index admission laparoscopic cholecystectomy for all benign gallstone disease has been shown in this study to have low rates of morbidity and mortality. This was due to an established service model made possible with timely referral, flexibility of open lists and access to emergency theatre. In addition to optimal clinical results there are also clear advantages to other important outcome parameters such as number of episodes, hospital stay and presentation to resolution time.

Re-interventions and re-admissions in a 13-year series following use of laparoscopic subtotal cholecystectomy.

Background:Laparoscopic subtotal cholecystectomy (LSTC) without cystic duct ligation is an alternative to conversion to open surgery in a difficult cholecystectomy, thus avoiding a potentially hazardous dissection in Calot's triangle. The long-term outcomes of this procedure are not well reported. The aim of this study is to assess the rates of re-presentation, re-admissions, endoscopic interventions and completion cholecystectomy in patients who have undergone LSTC.Methods:Details of all patients undergoing cholecystectomy over a 13-year period (2003–2015) were entered on a prospective database. Further information on subsequent hospital attendances, biliary imaging, endoscopic interventions and re-operations following the index LSTC was collected retrospectively from hospital database.Results:Overall, 2313 patients underwent laparoscopic cholecystectomy. Eighty-five patients (3.7%) underwent LSTC and the rest had standard laparoscopic cholecystectomy. A controlled bile leak was observed in 16 (19%) patients post-operatively, of which 3 resolved spontaneously. The remaining 13 were managed with an early endoscopic retrograde cholangiopancreatography (ERCP) and biliary stent. Twenty-seven patients (32%), who underwent LSTC, were re-investigated for the upper abdominal symptoms. The time range for re-investigation was 21 days–124 months. Eight patients underwent ERCP post-discharge, for suspected bile duct stones on radiological imaging. Two patients required open completion cholecystectomy for symptomatic stones in the gallbladder remnant.Conclusion:LSTC is a feasible and safe alternative to open surgery with acceptable long-term consequences and re-interventions.

Dynamic liver test patterns do not predict bile duct stones.

Numerous models have been developed to predict choledocholithiasis. Recent work has shown that these algorithms perform suboptimally. Identification of clinical predictors with high positive and negative predictive value would minimize adverse events associated with unnecessary diagnostic endoscopic retrograde cholangiopancreatography (ERCP) while limiting the use of expensive tests including magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasound (EUS) for indeterminate cases. Consecutive unique inpatients who received their first ERCP at Los Angeles County Medical Center between January 2010 and November 2016 for suspected bile duct stones were reviewed. The primary outcome was the proportion of patients with specific combinations of liver enzyme patterns, transabdominal ultrasound, and clinical features who had stones confirmed on ERCP. As a secondary outcome, we assessed the performance of the American Society for Gastrointestinal Endoscopy (ASGE) risk stratification algorithm in our population. Of the 604 included patients, bile duct stones were confirmed in 410 (67.9%). Detailed assessment of liver enzyme patterns alone and in combination with clinical features and imaging findings yielded no highly predictive algorithms. Additionally, the ASGE high-risk criterion had a positive predictive value of only 68% for stones. For the 236 patients for whom MRCP was performed, this imaging modality was shown to have highest predictive value for the presence of stones on ERCP. Exhaustive exploration of various threshold values and dynamic patterns of liver enzymes combined with clinical features and basic imaging findings did not reveal an algorithm to accurately predict the presence of stones on ERCP. The ASGE risk stratification criteria were also insensitive in our population. Though desirable, there may be no "perfect" combination of clinical features that correlate with persistent bile duct stones. MRCP or EUS may be considered to avoid unnecessary ERCP and associated complications.

The majority of suspected bile duct stones can be managed at time of laparoscopic cholecystectomy

Introduction: Choledocholithiasis can be cleared by either endoscopic retrograde cholangiopancreatography (ERCP) with cholecystectomy as a two-stage procedure or operative bile duct exploration at time of laparoscopic cholecystectomy. The objective of this study is to evaluate the management of choledocholithiasis at our surgical unit where bile duct stones are managed preferentially at time of laparoscopic cholecystectomy. Method: A retrospective review of all laparoscopic cholecystectomies at the Prince Charles Hospital (Brisbane, Australia) between 1 September 2015 and 30 September 2017 was performed. Patients with suspected choledocholithiasis were identified and their management was described. Result: A total of 690 laparoscopic cholecystectomies were performed during the study period. 674/690 (98%) had a successful cholangiogram performed. Of these patients, 69/674 (10%) had suspected choledocholithiasis on operative cholangiogram. Two patients had biliary stents from prior endoscopic retrograde cholangiopancreatography (ERCP) and had no further attempts at bile duct exploration. Saline flushing of the duct +/- intravenous buscopan or glucagon was successful in attaining a clear operative cholangiogram in 21/69 (30%) of cases. Transcystic catheter passage into the duodenum without the use of a basket was successful in 13/69 (19%) of cases. Transcystic catheter with the use of basket was successful in 18/69 (26%) of cases. The choledochoscope was used with a basket in 3 cases. There was one choledochotomy performed amongst these, and this patient had a transpapillary antegrade biliary stent placed. Sixteen patients had post-operative ERCP referrals made. 12/69 (17%) were due to failure to clear their bile ducts at surgery, two were for removal of pre-existing stents and another two were for removal of antegrade transpapillary stents placed at surgery. Conclusion: The majority of patients had their suspected choledocholithiasis managed at time of laparoscopic cholecystectomy.

Sa1335 DYNAMIC LIVER TEST PATTERNS DO NOT PREDICT BILE DUCT STONES

Numerous models have been developed to predict the presence of choledocholithiasis. Recent work has shown that these algorithms, which focus on a single set of liver tests and imaging findings, perform suboptimally. We aimed to develop a dynamic model using fluctuations in liver enzyme values combined with imaging and clinical history to more accurately forecast persistent bile duct stones. Consecutive unique hospitalized patients who received their first endoscopic retrograde cholangiopancreatography (ERCP) at Los Angeles County Medical Center between January 2010 and November 2016 for suspected bile duct stones were reviewed. We categorized the liver enzyme patterns prior to ERCP as increasing, decreasing, or alternating values. The primary outcome of this study was the proportion of patients with these liver enzyme patterns who had stones confirmed on ERCP. As a secondary outcome, we determined whether the American Society of Gastroenterology (ASGE) risk stratification algorithm was predictive of stones. Of the 604 hospitalized patients who underwent initial ERCP at our medical center, 82.3% were considered high risk, 17.4% intermediate risk, and 0.3% low risk for choledocholithiasis based on ASGE guidelines. Bile duct stones were confirmed in 410 (67.9%) patients. Detailed assessment of liver enzyme patterns yielded no consistent predictive dynamic patterns. Additionally, the ASGE risk stratification algorithm was not predictive of stones. For the 236 patients for whom magnetic resonance cholangiopancreatography (MRCP) was performed, this imaging modality was shown to have high predictive value for presence of stones on ERCP (OR 6.73 [95% confidence interval: 3.50-12.92]). Based on our exploration of predominantly intermediate and high risk patients, there is no dynamic pattern of liver enzyme tests that accurately predicts the presence of stones on ERCP. The ASGE risk stratification algorithm was also insensitive in this population. MRCP or endoscopic ultrasound may be considered to avoid unnecessary ERCP and associated complications.Table 1Multivariate associations between dynamic liver enzyme fluctuations and ERCP findings.Trends (with at least 20% difference):FrequencyStonesStones/SludgeOR95% CIOR95% CIT. BiliSingle value110 (18.2%)1.001.00Two values, increasing (or equal)148 (24.5%)0.590.34-1.030.480.23-1.03Two values, decreasing61 (10.1%)1.410.65-3.040.690.26-1.85Three values, increasing (or equal)160 (26.5%)0.590.35-1.020.580.27-1.24Three values, decreased then increased15 (2.5%)2.840.59-13.791.870.22-16.03Three values, increased then decreased24 (4.0%)0.990.37-2.640.780.22-2.78Three values, decreasing86 (14.2%)0.960.51-1.840.580.25-1.35ALKPSingle value110 (18.2%)1.001.00Two values, increasing (or equal)191 (31.6%)0.690.41-1.180.490.24-1.02Two values, decreasing19 (3.2%)1.870.50-7.001.930.23-16.09Three values, increasing (or equal)260 (43.1%)0.710.43-1.170.620.30-1.26Three values, decreased then increased2 (0.3%)NANANANAThree values, increased then decreased0 (0.0%)NANANANAThree values, decreasing22 (3.6%)1.560.53-4.580.590.17-1.99ASTSingle value112 (18.6%)1.001.00Two values, increasing (or equal)94 (15.6%)0.610.33-1.140.500.22-1.15Two values, decreasing123 (20.4%)0.780.43-1.400.490.23-1.08Three values, increasing (or equal)95 (15.8%)0.50*0.27-0.910.670.29-1.58Three values, decreased then increased17 (2.8%)0.450.15-1.330.19*0.06-0.61Three values, increased then decreased19 (3.2%)1.500.44-5.041.110.22-5.61Three values, decreasing143 (23.7%)0.840.47-1.480.700.32-1.54ALTSingle value110 (18.2%)1.001.00Two values, increasing (or equal)124 (20.5%)0.670.38-1.190.520.23-1.14Two values, decreasing86 (14.2%)0.870.46-1.660.550.24-1.30Three values, increasing (or equal)139 (23.0%)0.620.35-1.080.590.27-1.28Three values, decreased then increased7 (1.2%)0.220.05-1.060.12*0.02-0.60Three values, increased then decreased13 (2.2%)1.510.37-6.121.720.20-14.93Three values, decreasing125 (20.7%)0.980.54-1.760.700.31-1.57This table documents the frequency and multivariate associations of the six different liver enzyme fluctuation patterns with ERCP findings based on at least 20% difference among sequential enzyme values. Odds ratio and confidence interval of each pattern of total bilirubin, alkaline phosphatase, aspartate aminotransferase, and alanine aminotransferase were recorded. Abbreviations: ERCP = endoscopic retrograde cholangiopancreatography; T. Bili = total bilirubin; ALKP = alkaline phosphatase; AST = aspartate aminotransferase; ALT = alanine aminotransferase; OR = odds ratio; CI = confidence interval. NA: due to only 2 datapoints available. * = statistically significant with p < 0.05. Open table in a new tab Table 2Univariate associations between ASGE predictors and ERCP findings.FrequencyStonesStones/SludgeOR95% CIOR95% CI“Very strong” predictors:Bile duct stone seen on US326 (54.0%)1.340.95-1.891.210.78-1.88T. Bili >4 mg/dL203 (33.6%)0.880.61-1.260.920.58-1.47Clinical ascending cholangitis(excluded)NANANANA“Strong” predictors:CBD dilation >6 mm on US437 (72.5%)1.100.75-1.611.010.62-1.65T. Bili 1.8-4 mg/dL245 (40.6%)0.820.58-1.160.960.61-1.49“Moderate” predictors:Abnormal ALKP, AST, or ALT197 (32.6%)1.250.86-1.801.040.65-1.66Age >55 years106 (17.6%)0.670.43-1.030.810.47-1.41Clinical gallstone pancreatitis109 (18.1%)0.350.22-0.530.340.21-0.56Likelihood of choledocholithiasis per ASGE guidelines:High risk497 (82.3%)0.980.63-1.540.940.53-1.69Intermediate risk105 (17.4%)0.990.63-1.551.040.58-1.85Low risk2 (0.3%)NA*NA*NA*NA*This table records univariate association findings of ASGE risk categories and their individual predictors with ERCP findings, as well as their associated odds ratios and 95% confidence intervals. Abbreviations: ERCP = endoscopic retrograde cholangiopancreatography; T. Bili = total bilirubin; ALKP = alkaline phosphatase; AST = aspartate aminotransferase; ALT = alanine aminotransferase; CBD = common bile duct; US = ultrasound; ASGE = American Society of Gastrointestinal Endoscopy; OR = odds ratio; CI = confidence interval; NA = not available. High risk = any very strong predictor or both strong predictors; Low risk = no predictors present; Intermediate risk = all other patients. * Result is not available as the 2 low risk patients predicted the presence of stones perfectly. Open table in a new tab

Evaluation of patients with abnormalities on intraoperative cholangiogram: time to abandon endoscopic retrograde cholangiopancreatography as the initial follow-up study

BackgroundEndoscopic retrograde cholangiopancreatography (ERCP) is currently the method of choice for the postoperative evaluation of suspected bile duct stones seen on intraoperative cholangiogram (IOC); however, the sensitivity of IOC for...

Su1645 Evaluation of Patients With Suspected Bile Duct Stone on Intraoperative Cholangiogram (IOC): Should Endoscopic Retrograde Cholangiopancreatography (ERCP) Be the Initial Study of Choice?

ERCP is currently the method of choice for the postoperative evaluation of suspected bile duct stones seen on IOC. The false positive rate of IOC has ranged widely in prior studies, from 2-60% and it is unclear whether there are specific predictors that could be used risk stratify patients to undergo postoperative ERCP vs. less invasive diagnostic testing.

Su1618 Predictors of Fluoroscopy Time During Endoscopic Retrograde Cholangiopancreatography (ERCP) Performed for the Treatment of Suspected Bile Duct Stones (Bds)

The minimization of fluoroscopy exposure during ERCP is an important goal. Prolonged exposure time, impacts patient and physician safety, and fluoroscopy exposure time (FT) has been proposed as a quality metric in ERCP. To date, limited data exists on patient and procedure level variables which contribute to increased FT.

Direct peroral cholangioscopy using an ultrathin endoscope: making technique easier

Cholangioscopy is a useful tool for the study and treatment of biliary pathology. Ultrathin upper endoscopes allow direct peroral cholangioscopy (DPC) but have some drawbacks. The aim of the study was to evaluate the success rate of DPC with an ultrathin endoscope using a balloon catheter to reach the biliary confluence. Prospective observational study. An ultrathin endoscope (Olympus XP180N, outer diameter 5.5 mm, working channel 2 mm) was used. To access the biliary tree, free-hand technique was used. To reach the biliary confluence an intraductal balloon catheter (Olympus B5-2Q diameter 1.9 mm) and a 0.025 inch guide wire was used. In all cases sphincterotomy and/or sphincteroplasty was performed. The success rate was defined as the percentage of cases in which the biliary confluence could be reached with the ultrathin endoscope. Fifteen patients (8 men/7 women) were included. Mean age was 77.7 + or - 10.8 years (range 45-91). The indications for cholangioscopy were suspected bile duct stones (n = 9), electrohydraulic lithotripsy for the treatment of difficult choledocholithiasis (n = 5) and evaluation of biliary stricture (n = 1). Access to the bile duct was achieved in 14/15 cases (93.3%). Biliary confluence was reached in 13/15 cases (86.7%). One complication was observed in one patient (oxigen desaturation). DPC with an ultrathin endoscope can be done with the free-hand technique. Intraductal balloon-guided DPC allows full examination of the common bile duct in most cases.

PTH-127 Appropriateness of use of MRCP (Magnetic Resonance Cholangio-Pancreaticgraphy) in Patients with Suspected CBD Stones – a District General Hospital Experience

IntroductionPatients with CBD (Common Bile Duct) stones require high risk interventions. Around 10–20% patients with symptomatic gallstones have CBD stones. Where the initial clinical, biochemical and ultrasound examinations failed to...