Suspected Choledocholithiasis Research Articles

Effect of Frailty on the Management of Suspected Choledocholithiasis.

The American Society for Gastrointestinal Endoscopy and The Society of American Gastrointestinal and Endoscopic Surgeons (ASGE-SAGES) guidelines for managing choledocholithiasis (CDL) omit patient-specific factors like frailty. We evaluated how frail patients with CDL undergoing same-admission cholecystectomy were managed within ASGE-SAGES guidelines. We analyzed patients undergoing same-admission cholecystectomy for CDL and/or acute biliary pancreatitis (ABP) from 2016 to 2019 at 12 US academic medical centers. Patients were grouped by Charlson comorbidity index into non-frail (NF), moderately frail (MF), and severely frail (SF). ASGE-SAGES guidelines stratified likelihood of CDL and were used to compare actual to suggested management. Rate of guideline deviation was our primary outcome. Secondary outcomes included rates of surgical site infections (SSIs), biliary leaks, and 30-day surgical readmissions. Rates are presented as NF, MF, and SF. Among 844 patients, 43.3% (n = 365) were NF, 25.4% (n = 214) were MF, and 31.4% (n = 265) were SF. Frail patients were older (33y vs 56.7y vs 73.5y, P < .0001) and more likely to have ABP (32.6% vs 47.7% vs 43.8%, P = .0005). As frailty increased, guideline deviation increased (41.1% vs 43.5% vs 53.6%, P < .006). Severe frailty was predictive of guideline deviation compared to MF (aOR 1.47, 95% CI 1.02-2.12, P = .04) and NF (aOR 1.46, 95% CI 1.01-2.12, P = .04). There was no difference in SSIs (P = .2), biliary leaks (P = .7), or 30-day surgical readmission (P = .7). Frail patients with common bile duct stones had more management deviating from guidelines yet no difference in complications. Future guidelines should consider including frailty to optimize detection and management of CDL in this population.

Liver Blood Tests in the Management of Suspected Choledocholithiasis

The likelihood of common bile duct (CBD) stones considers liver blood tests (LBTs) if they are markedly altered only. The aim of our study was to find a reliable tool based on LBTs to predict the presence of CBD stones. We retrospectively considered all patients who underwent magnetic resonance cholangiopancreatography (MRCP) because of suspected CBD stones from January 2014 to June 2019. Demographic, clinical data, and LBT values were collected and analyzed. We selected 191 patients, 64 (33.5%) with positive MRCP and 127 (66.5%) with negative MRCP. The analysis showed that our compound LBT-based score had 83.6%, 90.7%, and 90.6% sensitivity, specificity, and negative predictive values, respectively, in determining MRCP results. We designed a weighted score with high diagnostic power in determining MRCP results that could help in differentiating between candidates for primary cholecystectomy and patients who benefit from preoperative MRCP.

Comparison of Radial Echoendoscopy and Predictive Factors in the Evaluation of Patients with Suspected Choledocholithiasis

Objective: The aim of this study was to compare predictive factors and Radial Echoendoscopy (EUS) in the diagnosis of choledocholithiasis.Materials and Methods: Patients with suspected choledocholithiasis were recruited from April 2011 to January 2018. All patient characteristics, findings of EUS and findings of ERCP were recorded and analyzed.Results: Eighty patients were enrolled in this study. Clinical symptoms, blood chemistry and liver function test were similar in patients with and without choledocholithiasis. Using the findings of ERCP as the gold standard, Radial EUS had sensitivity and specificity for the detection of choledocholithiasis at 90.2% and 97.4%, and for choledocholithiasis and/or common bile duct sludge at 92.7% and 100%, respectively. For patients with intermediate likelihood and high likelihood from predictive factors (33 and 45), Radial EUS was positive for choledocholithiasis in 51.5% (17/33) and 46.7% (21/45), and ERCP was positive for choledocholithiasis in 54.5% (18/33) and 48.9% (22/45), respectively.Conclusion: Predictive factors, for both intermediate and high likelihood groups, were not accurate to diagnose these patients. Radial EUS is a good diagnostic tool and should done in both groups of patients to avoid unnecessary ERCP.

Characteristics and Outcomes of ERCP at a Canadian Tertiary Centre: Initial Results from a Prospective High-Fidelity Biliary Endoscopy Registry.

BackgroundEndoscopic retrograde cholangiopancreatography (ERCP) is an essential procedure in the management of pancreatic and biliary disease. While its role is firmly established, further well-designed prospective ERCP research is required, as a large portion of previous work has employed retrospective or administrative methodologies, both prone to potential biases. The aim of the Calgary Registry for Advanced and Therapeutic Endoscopy (CReATE) is to be a high-fidelity prospective multicentre registry.MethodsThe study population consisted of consecutive adult ERCP patients from September 2018 to September 2019. Informed consent was acquired for each patient. All relevant preprocedural, procedural, peri-procedural and postprocedural data were captured in real time by a full-time third-party research assistant directly observing procedures. Outcomes were ascertained by comprehensive medical record review and patient phone interview 30 days after the index procedure.ResultsFive endoscopists performed 895 ERCP procedures, 90.1% of which were deemed successful. Suspected choledocholithiasis was the most common indication for ERCP, followed by suspected or confirmed stricture(s), at 61.0% and 29.5%, respectively. 61.0% of procedures were performed on ERCP-naive patients. Post-ERCP pancreatitis occurred following 4.9% of procedures, with clinically significant bleeding or perforation occurring following 1.8% and 0.1% of procedures, respectively.DiscussionThrough 12 months, CReATE captured 895 procedures prospectively, with each entry containing over 300 data fields. Active expansion to additional tertiary centres is underway, and this will enhance the existing data pool. CReATE has the potential to improve multiple facets of ERCP, including training, optimal procedural techniques, mitigation of adverse events and personalized patient care.

Practice Patterns and Outcomes Related to Magnetic Resonance Cholangiopancreatography Use in Suspected Choledocholithiasis: A 3-Year Single Center Retrospective Review

Practice Patterns and Outcomes Related to Magnetic Resonance Cholangiopancreatography Use in Suspected Choledocholithiasis: A 3-Year Single Center Retrospective Review

External Validation of Different Scoring Systems for Suspected Choledocholithiasis

Aim of the Study: The diagnosis of choledocholithiasis is challenging. Previously published scoring systems designed to calculate the risk of choledocholithiasis were evaluated to appraise the diagnostic performance. Patients and Methods: Data of patients who were admitted between 2013 and 2015 with the following characteristics were retrieved: bile stone-related symptoms and signs, and indication to laparoscopic cholecystectomy. To validate and appraise the performance of the 6 scoring systems, the acknowledged domains of each metrics were applied to the present cohort. Sensitivity, specificity, positive, negative predictive, Youden index, and receiver operating characteristic curve with the area under the curve (AUC) values of the scores were calculated. Results: Two-hundred patients were analyzed. The highest sensitivity and specificity were obtained from the Menezes’ (96.6%) and Telem’s (99.3%) metrics respectively. The Telem’s and Menezes’ scores had the best positive (75.0%) and negative (96.4%) predictive values respectively. The best accuracy, as computed by the Youden index and AUC, was found for the Soltan’s scoring system (0.628 and 0.88, respectively). Conclusion: The available scoring systems are precise only in identifying patients with a negligible risk of common bile duct stone, but overall insufficiently accurate to suggest the routine use in clinical practice.

Optimal Evaluation of Suspected Choledocholithiasis: Does This Patient Really Have Choledocholithiasis?

Optimal Evaluation of Suspected Choledocholithiasis: Does This Patient Really Have Choledocholithiasis?

The Relationship between Age, Common Bile Duct Diameter and Diagnostic Probability in Suspected Choledocholithiasis

Background: Aging has been associated with increasing common bile duct (CBD) diameter and reported as independently predictive of the likelihood of choledocolithiasis. These associations are controversial with uncertain diagnostic utility in patients presenting with symptomatic disease. The current study examined the relationship between age, CBD size, and the diagnostic probability of choledocolithiasis. Methods: Symptomatic patients undergoing evaluation for suspected choledocolithiasis from January 2008 to February 2011 were reviewed. In the cohort without choledocolithiasis, the relationship between aging and CBD size was examined as a continuous variable and by comparing mean CBD size across stratified age groups. Multivariate analysis examined the relationship between increasing age and diagnostic probability of choledocolithiasis in all patients. Results: Choledocolithasis was diagnosed by MR cholangiopancreatography (MRCP) or endoscopic retrograde (ERCP) in 496 of 1,000 patients reviewed. Mean CBD was 6.0 mm (±2.8 mm) in the 504 of 1,000 patients without choledocolithiasis on ERCP/MRCP. Increasing age had no correlation with CBD size as a continuous variable (r² = 0.011, p = 0.811). No difference occurred across age groups (Kruskal-Wallis, p = 0.157). Age had no association with diagnostic likelihood of choledocolithiasis (AOR [95% CI] 0.99 [0.98-1.01], adjusted-p = 0.335). Conclusion: In a large population undergoing investigation for biliary disease, increasing age was neither associated with increasing CBD diameter nor predictive of the likelihood of choledocolithiasis.

625 Validation of ASGE Risk Stratification and EUS-Based Strategy for Suspected Choledocholithiasis but Negative CT Finding

625 Validation of ASGE Risk Stratification and EUS-Based Strategy for Suspected Choledocholithiasis but Negative CT Finding

Management of Suspected Choledocholithiasis: A Decision Analysis

Introduction: Magnetic resonance cholangiography (MRC), endoscopic ultrasound (EUS), and endoscopic retrograde cholangio-pancreatography (ERCP) all represent viable options to establish the diagnosis of common bile duct (CBD) stones. The aim of the study was toassess how the three imaging modalities perform in head-to-head comparisons and in what order to apply them when using these procedures sequentially. Methods: A threshold analysis using a decision tree was modeled to compare the costs associated with different imaging techniques of the biliary system in a patient with cholestasis secondary to suspected choledocholithiasis. Test characteristics of MRC, EUS, and ERCP are taken from the literature. Cost data are based on average reimbursements at Oregon Health & Science University Hospitals in 2014. The main outcome parameter was the pre-test probability of CBD stones that would guide the physician towards starting the work-up with MRC or EUS versus going straight to ERCP as the primary procedure. Results: In patients with commercial insurance, the averagereimbursements for MRC, EUS, and ERCP are $3,355, $4,783, and $15,631, respectively. In instances of low pre-test probabilities (ranging between 0 and 40%) for choledocholithiasis, MRC represents the procedure of choice. For pre-test probabilities ranging between 40% and 91%, EUS is the preferred imaging modality. If CBD stones are suspected with an even higher pre-test probability, patients could go straight to ERCP as their first procedure. In patients with Medicare insurance, the averagereimbursements for MRC, EUS, and ERCP are $898, $2,499, and $4,619, respectively. For pre-test probabilities ranging between 0 and 82%, MRC represents the imaging procedure of choice. At all higher pre-test probabilities, Medicare patients could go straight to ERCP as their first procedure. The threshold probability for switching from MRC to EUS (87%) lies above the MRC-ERCP threshold. The threshold probability for switching from EUS to ERCP (80%) lies below the MRC-ERCP threshold. In a variety of sensitivity analyses, low costs associated with any of the three procedures increase its range of applicability at the expense of the other competing imaging modalities. Conclusion: MRC, EUS, and ERCP should be used in sequence and dependent on the pre-test probability of choledocholithiasis. In cost environments with relatively low MRC cost and high EUS cost, the range of applicability for EUS may become squeezed out.

Management of Suspected Choledocholithiasis: A Decision Analysis for Choosing the Optimal Imaging Modality.

Magnetic resonance cholangiography (MRC), endoscopic ultrasound (EUS), and endoscopic retrograde cholangio-pancreatography (ERCP) all represent viable options to establish the diagnosis of choledocholithiasis. The aim of the study was to assess how the three imaging modalities perform in head-to-head comparisons and in what order to apply them when using these procedures sequentially. A threshold analysis using a decision tree was modeled to compare the costs associated with different imaging techniques of the biliary system in a patient with suspected cholestasis secondary to choledocholithiasis. The main outcome parameter was the pre-test probability of common bile duct (CBD) stones that would guide the physician towards starting the work-up with MRC or EUS versus going straight to ERCP as the primary procedure. For low pre-test probabilities of CBD stones in the common bile duct, MRC represents the procedure of choice. For pre-test probabilities ranging between 40 and 91 %, EUS should be the preferred imaging modality. If CBD stones are suspected with an even higher pre-test probability, patients could go straight to ERCP as their first procedure. Low costs associated with any of the three procedures increase its range of applicability at the expense of the other competing imaging modalities. MRC, EUS, and ERCP should be used in sequence and dependent on the pre-test probability of choledocholithiasis.

Mo1440 The Pure Endoscopic Drainage of Pancreatic Pseudocysts in Children - a Safe and Eficient Method - Case Series

Mo1440 The Pure Endoscopic Drainage of Pancreatic Pseudocysts in Children - a Safe and Eficient Method - Case Series

Sa1404 Non-Indicated Endoscopic Retrograde Cholangiopancreatography in Suspected Choledocholithiasis: Prevalence, Complication, and Diagnostic Yield

Gallstone diseases affect more than 20 million people in the United States. Endoscopic retrograde cholangiopancreatography (ERCP) is the diagnostic and therapeutic intervention of choice for patients at high risk for choledocholithiasis however, it is recommended to be deferred to less invasive modalities when the risk for choledocholithiasis is intermediate due to its high complication rate. This study aims to evaluate diagnostic yield and risk associated with the procedure when it is performed outside of the current guideline's recommendation.

Mo1439 Safety and Efficacy of Moderate Sedation in Obese Patients Undergoing EndoScopic Retrograde Cholangiopancreatography for Suspected Choledocholithiasis

Mo1439 Safety and Efficacy of Moderate Sedation in Obese Patients Undergoing EndoScopic Retrograde Cholangiopancreatography for Suspected Choledocholithiasis

Working Smarter, Not Harder: A Clinical Index Score to Reduce Negative Cholangiograms in Patients with Suspected Choledocholithiasis

Nguyen, Andrew MD; Gifford, Edward MD; Plurad, David S. MD, FACS; de Virgilio, Christian M. MD, FACS; Kaji, Amy H. MD, PhD; Bricker, Scott D. MD; Bongard, Fred S. MD, FACS; Neville, Angela L. MD, FACS; Putnam, Brant A. MD, FACS; Kim, Dennis Y. MD Author Information

Su1603 ASGE Current Guidelines Performance for Suspected Choledocholithiasis in Hispanic Population

Su1603 ASGE Current Guidelines Performance for Suspected Choledocholithiasis in Hispanic Population

Management and Outcomes of Patients with Suspected Choledocholithiasis within a Safety Net System

Management and Outcomes of Patients with Suspected Choledocholithiasis within a Safety Net System

The Performance of ASGE Criteria in Risk-Stratifying Octogenarian Patients with Suspected Choledocholithiasis in Comparison with Younger Patients

Purpose: The American Society of Gastrointestinal Endoscopy (ASGE) guidelines for the management of choledocholithiasis propose use of 8 variables for stratifying patients with suspicion of choledocholithiasis, into low (<10%), intermediate (10-50%) and high (>50%) risk categories. We recently prospectively validated the ASGE criteria for the evaluation of suspected choledocholithiasis in all patients referred to our center. However, till date, there have been no studies to suggest if the ASGE criteria can be used effectively to risk-stratify very elderly patients with suspected choledocholithiasis. The aim of our study was to evaluate the performance of proposed ASGE criteria in risk-stratifying Octogenarian patients with suspected choledocholithiasis as compared to the younger patients. Methods: From September, 2011 to January, 2013, we evaluated 402 patients referred to our center for suspected choledocholithiasis. All the patients were categorized into high, intermediate and low risk for choledocholithiasis based on ASGE criteria. This category was not revealed to the endoscopist. We determined the presence of choledocholithiasis based on ERCP. Results: Of the 336 patients in the final analysis, 85 patients constituted the Octogenarian group and the remaining 251 constituted the younger group. Females constituted 60.5 % in the Octogenarian group and 57.6 % in the younger group. Out of 85 patients in the Octogenarian group, 66 met criteria for high risk of choledocholithiasis and 19 met criteria for intermediate risk of choledocholithiasis. Out of 251 patients in the younger group, 178 met criteria for high risk of choledocholithiasis and 73 met criteria for intermediate risk of choledocholithiasis. There were only two patients in the low risk group in the patient sample and therefore, excluded in the final analysis. Based on the eventual finding of choledocholithiasis on ERC, the high risk category based on the ASGE criteria predicted choledocholithiasis with a positive predictive value of 75.76% (95% CI 63.64-85.46%), sensitivity of 84.75% (95% CI 73.00-92.76%), and specificity of 38.46% (95% CI 20.25-59.42 %) in the octogenarian group. The high risk category predicted choledocholithiasis with a positive predictive value of 75.84% (95% CI 68.87-81.93%), sensitivity of 78.95% (95% CI 72.06-84.80%), and specificity of 46.25% (95% CI 35.03-57.76 %) in the younger group. There was no statistically significant difference between the PPV of the high risk category for the octogenarian and the younger group. Conclusion: The ASGE criteria adequately stratify Octogenarian patients at high and intermediate risk of choledocholithiasis and can be used for clinical decision making.

Su1413 Usefullness of Intraductal US in Patients With Highly Suspected Choledocholithiasis Without Definite Bile Duct Stone on ERCP

ERCP has been a first-line management strategy for choledocholithiasis. However, small bile duct stones can be missed to diagnose during ERCP. The aim of this study was to prospectively evaluate the accuracy of intraductal US (IDUS) for detecting small choledocholithiasis in patients with highly suspected bile duct stones without definite bile duct stone on ERC.

Mo1327 Evaluating the ASGE Guidelines on the Role of Endoscopy in Suspected Choledocholithiasis

Mo1327 Evaluating the ASGE Guidelines on the Role of Endoscopy in Suspected Choledocholithiasis