The role of endoscopy in the evaluation of suspected choledocholithiasis

New classification system for indications for endoscopic retrograde cholangiopancreatography predicts diagnoses and adverse events

BACKGROUND

Indications for endoscopic retrograde cholangiopancreatography (ERCP) have received little attention, especially in scientific or objective terms.

AIM

To review the prevailing ERCP indications in the literature, and to propose and evaluate a new ERCP indication system, which relies on more objective pre-procedure parameters.

METHODS

An analysis was conducted on 1758 consecutive ERCP procedures, in which contemporaneous use was made of an a-priori indication system. Indications were based on the objective pre-procedure parameters and divided into primary [cholangitis, clinical evidence of biliary leak, acute (biliary) pancreatitis, abnormal intraoperative cholangiogram (IOC), or change/removal of stent for benign/malignant disease] and secondary [combination of two or three of: pain attributable to biliary disease ('P'), imaging evidence of biliary disease ('I'), and abnormal liver function tests (LFTs) ('L')]. A secondary indication was only used if a primary indication was not present. The relationship between this newly developed classification system and ERCP findings and adverse events was examined.

RESULTS

The indications of cholangitis and positive IOC were predictive of choledocholithiasis at ERCP (101/154 and 74/141 procedures, respectively). With respect to secondary indications, only if all three of 'P', 'I', and 'L' were present there was a statistically significant association with choledocholithiasis (χ²(1) = 35.3, p < .001). Adverse events were associated with an unusual indication leading to greater risk of unplanned hospitalization (χ²(1) = 17.0, p < .001).

CONCLUSIONS

An a-priori-based indication system for ERCP, which relies on pre-ERCP objective parameters, provides a more useful and scientific classification system than is available currently.

Diagnostic accuracy of EUS compared with MRCP in detecting choledocholithiasis: a meta-analysis of diagnostic test accuracy in head-to-head studies

BACKGROUND AND AIMS

There is a wide range of reported sensitivity and specificity for EUS and MRCP in the diagnosis of choledocholithiasis, with lack of a proper meta-analysis of diagnostic test accuracy by using head-to-head comparison. Here, we aimed to compare the diagnostic accuracy of EUS and MRCP in detecting choledocholithiasis by using appropriate methodology recommended by the Cochrane Collaboration.

METHODS

A comprehensive electronic literature search up to January 2017 was done by 2 reviewers for prospective cohort studies comparing EUS and MRCP to a reference standard for detecting choledocholithiasis. The acceptable reference standards were considered ERCP, intraoperative cholangiography, or clinical follow-up >3 months for negative cases. Quality of the included studies was measured by using the QUADAS-2 tool. A bivariate hierarchical model was used to perform the meta-analysis of diagnostic test accuracy. Summary receiver operating characteristics were developed and the area under the curve was calculated.

RESULTS

A total of 5 of 32 studies were included. No study presented a high risk of bias. The pooled sensitivity and specificity were 0.97 (range, 0.91-0.99) and 0.90 (range, 0.83-0.94) for EUS and 0.87 (range, 0.80-0.93) and 0.92 (range, 0.87-0.96) for MRCP. The overall diagnostic odds ratio of EUS was significantly higher than the one with MRCP (162.5 vs 79.0, respectively; P = .008). Further analysis showed that this was mainly due to the significantly higher sensitivity of EUS as compared with that of MRCP (P = .006). The specificity was not significantly different between 2 modalities (P = .42).

CONCLUSION

Both EUS and MRCP provide good diagnostic accuracy, with EUS providing statically better diagnostic accuracy and sensitivity, with comparable specificity. EUS should be incorporated in the diagnostic algorithm in patients suspected of choledocholithiasis whenever appropriate.

Determinants of variability in management of acute calculous cholecystitis

BACKGROUND

While evidence supports early compared to delayed cholecystectomy as optimal management of acute calculous cholecystitis (ACC), significant variability in practice remains. The purpose of this study was to identify variables associated with early cholecystectomy, to target opportunities to improve adherence to best practices.

METHODS

Adult patients admitted to surgical units with ACC at two hospitals in a university hospital network between June 2010 and January 2015 were reviewed. Patients with concurrent pancreatitis, cholangitis or severe ACC (with organ system failure) were excluded. Early cholecystectomy was defined as surgery performed during same admission and within 7 days of presentation. Non-operative management was defined as admission for ACC treated conservatively, with or without eventual delayed cholecystectomy. The primary outcome was early cholecystectomy versus initial non-operative management; secondary outcomes included time to cholecystectomy, complications, and total hospital length of stay (LOS).

RESULTS

A total of 374 patients were included. Two hundred and forty six patients (66%) underwent early cholecystectomy, 60 (16%) were treated non-operatively and had delayed cholecystectomy, and 68 (18%) were only treated non-operatively. Median time to OR from initial presentation was 38 h [22-63] for early cholecystectomy patients and 69 days [29-116] for the non-operative patients who had delayed cholecystectomy. When comparing both groups, early cholecystectomy patients were younger and were treated more often at site 1. There were no differences in complications during hospitalization, but early cholecystectomy patients had a lower median total LOS (3 [2-5] vs. 5 [4-9], p < 0.001), and they had fewer gallstone-related events after discharge (1 vs. 18%, p < 0.001). On multiple logistic regression analysis, lower age, hospital site and lower risk of concurrent choledocholithiasis were all significantly associated with early cholecystectomy (p < 0.05).

CONCLUSION

Our data supports early cholecystectomy as best practice in management of ACC with no differences in complications during hospitalization, shorter median LOS and fewer gallstone-related events compared to non-operative management. We identified patient and institutional factors associated with early cholecystectomy. This suggests that multiple strategies will be necessary to promote adherence to best practices in the management of ACC within our institution.

Diagnostic Value of Endoscopic Ultrasonography in Symptomatic Patients with High and Intermediate Probabilities of Common Bile Duct Stones and a Negative Computed Tomography Scan

Background/Aims

When computed tomography (CT) does not indicate choledocholithiasis in highly suspicious patients, there is no definite consensus on the subsequent modality. Endoscopic ultrasonography (EUS) indicates fewer procedure-related complications than endoscopic retrograde cholangiopancreatography (ERCP) and has a lower cost than magnetic resonance cholangiopancreatography. Therefore, we aimed to investigate the diagnostic value of EUS in patients with suspected choledocholithiasis and negative CT findings.

Methods

Between March 2008 and November 2014, we retrospectively evaluated 200 patients with negative CT findings and high or intermediate probabilities of choledocholithiasis. All patients initially underwent EUS followed by ERCP as a confirmatory criterion standard. The primary outcome in these patients was the accuracy of EUS in the detection of choledocholithiasis. The secondary outcome was the clinical prediction of common bile duct (CBD) stones in this group.

Results

EUS indicated choledocholithiasis in 165 of the 200 patients, and ERCP confirmed choledocholithiasis in 161 patients (80.5%). The accuracy of EUS in the detection of choledocholithiasis was 94.0% (sensitivity, 97.5%; specificity, 79.5%; positive predictive value, 95.2%; negative predictive value, 88.6%). A multivariate analysis demonstrated that choledocholithiasis was strongly predicted by EUS detection of choledocholithiasis, an age >55 years and a clinical diagnosis of cholangitis.

Conclusions

An EUS-first approach is recommended for patients with suspected CBD stones and negative CT findings.

Predictors and outcomes of delayed plastic biliary stent removal following endoscopic retrograde cholangiopancreatography

OBJECTIVE

Plastic biliary stents are commonly placed during endoscopic retrograde cholangiopancreatography (ERCP) and should be removed or replaced within 3 months to reduce the risk of stent obstruction. The aim of the study was to identify predictors and outcomes of patients who had delayed plastic biliary stent removal following ERCP.

MATERIALS AND METHODS

Consecutive patients who received ERCP with plastic biliary stent placement at Loma Linda University Medical Center (10/2004-6/2013) were identified. Delayed removal was defined as presence of stent >3 months after index ERCP. Multivariable regression analysis to identify baseline characteristics associated with delayed removal was performed. Clinical outcomes of stent obstruction (e.g., cholangitis, hospitalization, intensive care) were also collected for those with delayed removal.

RESULTS

Among 374 patients undergoing ERCP with plastic biliary stent, 71 (19%) had delayed stent removal. Patients who had anesthesia assistance (AOR = 3.8, 95%CI 1.2-11.4), non-English primary language (AOR = 3.0, 95%CI 1.5-6.2), and outpatient ERCP (AOR = 2.0, 95%CI 1.1-3.4) had increased while choledocholithiasis (AOR = 0.5, 95%CI 0.3-0.99) had lower odds of delayed stent removal. Among those with delayed removal, 13 (18%) were hospitalized for stent obstruction (5 (7%) had cholangitis, 8 (11%) were hospitalized for more than a week, and 3 (4%) required intensive care).

CONCLUSIONS

Almost one-fifth of patients who underwent ERCP with plastic biliary stent placement had delayed removal with nearly one-fifth of these patients requiring hospitalization for stent obstruction. Targeting patients at risk by improving communication and ease of scheduling an ERCP may reduce preventable adverse events associated with delayed biliary stent removal.

Laparoscopic common bile duct exploration versus endoscopic retrograde cholangiopancreatography for choledocholithiasis found at time of laparoscopic cholecystectomy: Analysis of a large integrated health care system database

BACKGROUND

We compared endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic common bile duct exploration (LCBDE) for managing choledocholithiasis found at time of cholecystectomy.

METHODS

One hundred and five LCBDE (2005-2015) were compared to 195 LC/ERCP (2014-2015) from the Southern California Kaiser Permanente database.

RESULTS

LC/ERCP was more effective at clearing the CBD (98% vs. 88.6%, p = 0.01); but required more procedures per patient (mean ± standard deviation, 1.1 ± 0.4 vs. 2.0 ± 0.12, p < 0.001). Morbidity, hospital length of stay and readmission were not different (P > 0.05). Four patients failed ERCP, while 12 patients failed LCBDE and had subsequent ERCP (10) or CBD exploration (2). All patients with RYGB had successful LCBDE.

CONCLUSION

LC/ERCP is better than LCBDE in clearing CBD stones, but has similar morbidity and is an effective alternative for patients with RYGB.

Performance of the Choledocholithiasis Diagnostic Score in Patients with Acute Cholecystitis

Introduction

The prevalence of choledocholithiasis among patients with acute cholecystitis is estimated to be between 9 and 16.5%. There are no validated algorithms to predict choledocholithiasis in this group of patients.

Aim

The aim of this study was to evaluate the performance of the choledocholithiasis diagnostic score proposed by the American Society for Gastrointestinal Endoscopy, in patients with acute cholecystitis.

Material/Methods

A retrospective cross-sectional study, covering a 4-year period at a secondary care hospital, was performed. All patients with an encoded diagnosis of acute cholecystitis and with at least one of the following procedures were included: endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound, magnetic resonance cholangiopancreatography, and intraoperative cholangiography.

Results

Among 4,369 patients with the diagnosis of acute cholecystitis, 40 (0.92%) had clinical or sonographic suspicion of choledocholithiasis. Their mean age was 68.1 ± 15 years, and 22 (55%) were men. Thirty-one of the patients included (77.5%) had a high risk of choledocholithiasis, and 9 (22.5%) had an intermediate risk. In 16 (51.6%) of the 31 patients with a high risk, the diagnosis of choledocholithiasis was confirmed. In 2 (22.2%) of the 9 patients with an intermediate risk, the diagnosis of choledocholithiasis was also confirmed. The high risk score for choledocholithiasis had a positive predictive value of 52% and a sensitivity of 89%. The intermediate risk score for choledocholithiasis had a positive predictive value of 22% and a sensitivity of 11%.

Discussion and Conclusions

Suspicion of choledocholithiasis in patients with acute cholecystitis was a rare event (<1%). The sensitivity of the high risk score was approximately the same as found in published series with patients with suspected choledocholithiasis overall (86%), while the positive predictive value was substantially lower (52 vs. 79.8%). Therefore, in patients with acute cholecystitis and suspected choledocholithiasis, this score should not be used to screen for common bile duct stones, and a sensitive method should be used prior to ERCP.

Risk assessment of choledocholithiasis prior to laparoscopic cholecystectomy and its management options

Background

Accurate risk evaluation of choledocholithiasis prior to laparoscopic cholecystectomy is essential to determine optimal management strategy.

Objective

Our study aimed to evaluate the accuracy of separate predictors and Vilnius University Hospital Index (VUHI = A/30 + 0.4 × B; A = total bilirubin concentration (µmol/l), B = common bile duct (CBD) diameter (mm) measured by ultrasound) diagnosing choledocholithiasis and to assess different management strategies (cholecystectomy with intraoperative cholangiography and endoscopic retrograde cholangiopancreatography (ERCP)).

Methods

The retrospective study included 350 patients admitted to a tertiary care centre for laparoscopic cholecystectomy for cholecystolithiasis who were investigated for concomitant choledocholithiasis.

Results

Choledocholithiasis was diagnosed in 182 (76.2%) cases in the high-risk group (VUHI value ≥4.7) and 44 (39.6%) in the low, odds ratio is 4.86 (95% CI: 3.00-7.88). Its sensitivity was 80.5%, specificity 54.0%, accuracy 71.1%. Dilated CBD had the highest sensitivity (92.5%) of predictors.ERCP showed better diagnostic performance than intraoperative cholangiography. Complications of ERCP were more frequent for patients without stones. There was no significant difference of outcomes between the two management strategies.

Conclusion

The prognostic index has good diagnostic accuracy but dividing patients into two risk groups is insufficient. The suggested model allows determining an intermediate-risk group, which requires additional investigation. Both management approaches are appropriate.

Predictors of bile tree pathology in patients presenting with gallbladder disease

BACKGROUND

Patients with gallstone disease can present with elevated liver function tests (LFTs). It is often challenging to differentiate those with a common bile duct (CBD) stone from those without a CBD stone on the basis of the LFTs levels. In this study, we aim to evaluate the predictors of a CBD stones among patients presenting with symptomatic gallbladder disease and elevated LFTs.

PATIENTS AND METHODS

We retrospectively examined all patients who had undergone a cholecystectomy between January 2010 and December 2015. Patients with symptomatic cholelithiasis and increased LFTs were included. Patient characteristics, imaging findings, lab findings, endoscopic interventions, and operative report were recorded and evaluated. The diagnosis of CBD stones was made on the basis of ERCP and IOC findings.

RESULTS

We included 354 patients in the final analysis. Of these, 113 (32%) had confirmed choledocholithiasis. The prevalence of CBD stones among biliary colic, acute cholecystitis, and pancreatitis patients was 47, 25, and 26%, respectively. γ-Glutamyl transferase and direct bilirubin had the highest sensitivities for CBD stones among these patients (83 vs. 79%). In the setting of biliary colic, total bilirubin was highly predictive of CBD stones with a positive predictive value of 85%. In the setting of acute cholecystitis, elevated LFTs were even less significant in predicting stones, with a positive predictive value of less than 40% for most.

CONCLUSION

Although γ-glutamyl transferase and bilirubin levels showed a relatively higher sensitivity for CBDS compared with the other LFTs, these were not reliable enough because of high false-positive as well as false-negative values, especially in patients presenting with acute cholecystitis.

The efficacy and safety of the left lateral position for endoscopic retrograde cholangiopancreatography

BACKGROUND/AIM

Endoscopic retrograde cholangiopancreatography (ERCP) is typically performed in prone position. In cases of difficulty in prone position, ERCP can be performed in left lateral position. We aimed to evaluate the efficacy and safety of left lateral position for ERCP compared with those of prone position.

PATIENTS AND METHODS

Between August 2015 and March 2016, a total of 62 patients with native papilla who underwent ERCP were randomly assigned to undergo the procedure in left lateral position (n = 31) or prone position (n = 31). The outcomes of procedures were compared between the two groups.

RESULTS

There were no significant differences between the two groups in terms of the demographic data, indications for ERCP, comorbidities, anticoagulation agents, the types and doses of sedative agents, and procedural durations. The rates of technical success and adverse events were similar (96.8 and 40%, respectively, in left lateral group and 100 and 32.3%, respectively, in prone group). The rates of unintentional pancreatic duct (PD) cannulation and the acquisition of pancreatograms in left lateral group were significantly greater than those in prone group (9/30, 30.0% vs. 3/31, 9.7%, P = 0.046; 7/30, 23.3% vs. 1/31, 3.2%, P = 0.020, respectively). However, there was no significant difference in the rate of post-ERCP pancreatitis (6/30, 20% vs. 5/31, 16.1%, P = 0.694).

CONCLUSION

The left lateral position for ERCP can be as effective and safe as prone position. Due to increased rates of unintended PD cannulation and contrast injection, the initial use of left lateral position may be limited to cases that exhibit difficulty in prone position.

Accuracy of ASGE high-risk criteria in evaluation of patients with suspected common bile duct stones

BACKGROUND AND AIMS

ERCP is recommended for patients considered high risk for choledocholithiasis after biochemical testing and abdominal US. Our aim was to determine whether the American Society for Gastrointestinal Endoscopy (ASGE) guidelines accurately select patients for whom the risk of ERCP is justified.

METHODS

Consecutive patients hospitalized with suspected choledocholithiasis at Sir Run Run Shaw Hospital who received biochemical testing, abdominal US, and definitive testing for choledocholithiasis (MRCP, EUS, ERCP, intraoperative cholangiogram, and/or common bile duct [CBD] exploration) were identified. Patients with choledocholithiasis on abdominal US, with bilirubin levels >4 mg/dL (normal values <1.2 mg/dL), bilirubin levels ≥1.8 mg/dL plus a dilated CBD and/or clinical cholangitis were considered high risk per ASGE guidelines.

RESULTS

Of 2724 patients with suspected choledocholithiasis, 1171 (43%) met high-risk criteria. Definitive testing (MRCP in 2442 [90%], EUS in 67 [2%], ERCP in 659 [24%], intraoperative cholangiogram in 229 [8%], and CBD exploration in 447 [16%]) revealed choledocholithiasis in 1076 [40%] patients. The specificity of the ASGE high-risk criteria was 74% (95% confidence interval [CI], 72%-77%) and positive predictive value was 64% (95% CI, 61%-67%). Using a more restrictive criteria (choledocholithiasis on abdominal US, bilirubin >4 mg/dL plus dilated CBD) improved the specificity to 94% (95% CI, 93%-95%) and positive predictive value to 85% (95% CI, 82%-88%). Doubling or more of bilirubin to >4 mg/dL and ≥1.8 mg/dL at second testing had specificities of 98% (95% CI, 96%-99%) and 95% (95% CI, 93%-96%), with positive predictive values of 62% (95% CI, 48%-76%) and 54% (95% CI, 44%-65%), respectively.

CONCLUSIONS

Although ASGE high-risk criteria demonstrated >50% probability of the patient having choledocholithiasis, more than a third of the patients would receive diagnostic ERCPs. Criteria with choledocholithiasis on abdominal US and/or bilirubin levels >4 mg/dL plus a dilated CBD showed higher specificity and positive predictive value.

Sensitivity and Specificity of Magnetic Resonance Cholangiopancreatography versus Endoscopic Ultrasonography against Endoscopic Retrograde Cholangiopancreatography in Diagnosing Choledocholithiasis: The Indonesian Experience

BACKGROUND/AIMS

Biliary stone disease is one of the most common conditions leading to hospitalization. In addition to endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasonography (EUS) and magnetic resonance cholangiopancreatography (MRCP) are required in diagnosing choledocholithiasis. This study aimed to compare the sensitivity and specificity of EUS and MRCP against ERCP in diagnosing choledocholithiasis.

METHODS

This retrospective study was conducted after prospective collection of data involving 62 suspected choledocholithiasis patients who underwent ERCP from June 2013 to August 2014. Patients were divided into two groups. The first group (31 patients) underwent EUS and the second group (31 patients) underwent MRCP. Then, ERCP was performed in both groups. Sensitivity, specificity, and diagnostic accuracy of EUS and MRCP were determined by comparing them to ERCP, which is the gold standard.

RESULTS

The male to female ratio was 3:2. The mean ages were 47.25 years in the first group and 52.9 years in the second group. Sensitivity, specificity, accuracy, positive predictive value, and negative predictive value for EUS were 96%, 57%, 87%, 88%, and 80% respectively, and for MRCP were 81%, 40%, 68%, 74%, and 50%, respectively.

CONCLUSIONS

EUS is a better diagnostic tool than MRCP for diagnosing choledocholithiasis.

Endoscopic Ultrasonography Can Prevent Unnecessary Diagnostic Endoscopic Retrograde Cholangiopancreatography Even in Patients with High Likelihood of Choledocholithiasis and Inconclusive Ultrasonography: Results of a Prospective Study

Background/Aims

Endoscopic retrograde cholangiopancreatography (ERCP) is the initial therapy recommended for patients with high likelihood of choledocholithiasis. To determine whether endoscopic ultrasonography (EUS) can prevent diagnostic ERCPs in patients with high probability of choledocholithiasis and inconclusive ultrasonography (US).

Methods

All patients with high likelihood of choledocholithiasis and negative US underwent EUS. ERCP was performed for the patients who showed a definite stone/sludge on EUS. Patients without choledocholithiasis were followed up for 3 months. The primary outcome was avoidance of diagnostic ERCP.

Results

We included 78 patients (51 women; 27 men). Of these, 25 and 7 (total 41%) were diagnosed with choledocholithiasis and sludge, respectively; stone/sludge was removed in 96.9% of the patients. EUS ruled out choledocholithiasis in 38 patients (48.7%). Two of them were found to have choledocholithiasis on follow-up. The sensitivity, specificity, positive and negative predictive value of EUS for detecting choledocholithiasis were 93.9%, 97.3%, 96.9%, and 94.7%, respectively. Unnecessary ERCP was avoided in 57.7% of the patients by using the EUS-first approach.

Conclusions

EUS is a highly accurate and safe procedure. EUS can replace ERCP as the initial investigation in patients with a high probability of choledocholithiasis. It avoids unnecessary ERCP; hence, decreasing related costs and complications.

Routine Cysticotomy and Flushing of the Cystic Duct in Patients with Low Risk of Common Duct Stones: Can It Be Beneficial?

Background

Gallstone disease affects 15–20% of the general population and up to 20% of these patients present common bile duct stones.

Aim

This observational study reports our experience on routine cysticotomy and flushing of the cystic duct in patients with low risk of common duct stones.

Materials and Methods

We analyzed 731 patients who underwent laparoscopic cholecystectomy between September 2013 and September 2015.

Results

Patients were preoperatively stratified on the clinical risk; those presenting with low preoperative risk of common bile duct stones were referred to undergo laparoscopic cholecystectomy and routine cysticotomy with bile duct flushing. Patients presenting thick bile sludge, solid debrides, and/or increased tension of bile outflow underwent unplanned cholangiography. No intraoperative complications or conversion to open technique occurred. Average follow-up time was 22,8 months (range 12 to 37). Rate of retained ductal stones accounted for 0,3%.

Conclusions

Routine cysticotomy and bile flushing in our experience is a valid, simple, and not time consuming manoeuvre that can help decompressing and flushing CBD. Moreover, it is a valid tool for extending selective IOC approach in a focused manner. Further evaluations have to be conducted to evaluate risks and effectiveness of this manoeuvre.

Evolution in the utilization of biliary interventions in the United States: results of a nationwide longitudinal study from 1998 to 2013

BACKGROUND AND AIMS

Bile duct surgery (BDS), percutaneous transhepatic cholangiography (PTC), and ERCP are alternative interventions used to treat biliary disease. Our aim was to describe trends in ERCP, BDS, and PTC on a nationwide level in the United States.

METHODS

We used the National Inpatient Sample to estimate age-standardized utilization trends of inpatient diagnostic ERCP, therapeutic ERCP, BDS, and PTC between 1998 and 2013. We calculated average case fatality, length of stay, patient demographic profile (age, gender, payer), and hospital characteristics (hospital size and metropolitan status) for these procedures.

RESULTS

Total biliary interventions decreased over the study period from 119.8 to 100.1 per 100,000. Diagnostic ERCP utilization decreased by 76%, and therapeutic ERCP utilization increased by 35%. BDS rates decreased by 78% and PTC rates by 24%. ERCP has almost completely supplanted surgery for the management of choledocholithiasis. Fatality from ERCP, BDS, and PTC have all decreased, whereas mean length of stay has remained stable. The proportion of Medicare-insured, Medicaid-insured, and uninsured patients undergoing biliary procedures has increased over time. Most of the increase in therapeutic ERCP and decrease in BDS occurred in large, metropolitan hospitals.

CONCLUSIONS

Although therapeutic ERCP utilization has increased over time, the total volume of biliary interventions has decreased. BDS utilization has experienced the most dramatic decrease, possibly a consequence of the increased therapeutic capacity and safety of ERCP. ERCPs are now predominantly therapeutic in nature. Large urban hospitals are leading the shift from surgical to endoscopic therapy of the biliary system.

Comparative performance of non-contrast MRI with HASTE vs. contrast-enhanced MRI/3D-MRCP for possible choledocholithiasis in hospitalized patients

PURPOSE

To compare the performance of non-contrast MRI with half-Fourier acquisition single-shot turbo spin echo (HASTE) vs. contrast-enhanced MRI/3D-MRCP for assessment of suspected choledocholithiasis in hospitalized patients.

METHODS AND MATERIALS

123 contrast-enhanced abdominal MRI/MRCP scans in the hospital setting for possible choledocholithiasis were retrospectively evaluated. Endoscopic retrograde cholangiopancreatography, intraoperative cholangiogram or documented clinical resolution served as the reference standard. Readers first evaluated the biliary tree using coronal and axial HASTE and other non-contrast sequences, and later reviewed the entire exam with post-contrast sequences and 3D-MRCP. Test performance for the image sets was compared for choledocholithiasis, acute hepatitis, cholangitis, and acute cholecystitis. Reader agreement, MRCP image quality, and confidence levels were also assessed. Clinical predictors of age and fever were tested for association with perceived need for contrast in biliary assessment.

RESULTS

There were 27 cases of choledocholithiasis, 31 cases of acute hepatitis, 37 cases of acute cholecystitis, and 3 clinically diagnosed cases of acute cholangitis. Both the abbreviated and full contrast-enhanced/MRCP image sets resulted in high accuracy for choledocholithiasis (91.1-94.3% vs. 91.9-92.7%). There was no difference in sensitivity or specificity for either reader for any diagnosis between image sets (p > 0.40). 1 reader showed improved confidence (p < 0.001) with inclusion of MRCP and contrast-enhanced images, but neither confidence nor MRCP quality scores were associated with diagnostic accuracy. Patient age and fever did not predict the need for contrast-enhanced images.

CONCLUSION

In hospitalized patients with suspected choledocholithiasis, performance of non-contrast abdominal MRI with HASTE is similar to contrast-enhanced MRI with 3D-MRCP, offering potential for decreased scanning time and improved patient tolerability.

The Role of Endoscopic Biliary Drainage without Sphincterotomy in Gallstone Patients with Cholangitis and Suspected Common Bile Duct Stones Not Detected by Cholangiogram or Intraductal Ultrasonography

Background/Aims

Treatment for cholangitis without common bile duct (CBD) stones has not been established in patients with gallstones. We investigated the usefulness of endoscopic biliary drainage (EBD) without endoscopic sphincterotomy (EST) in patients diagnosed with gallstones and cholangitis without CBD stones by endoscopic retrograde cholangiopancreatography (ERCP) and intraductal ultrasonography (IDUS).

Methods

EBD using 5F plastic stents without EST was performed prospectively in patients with gallstones and cholangitis if CBD stones were not diagnosed by ERCP and IDUS. After ERCP, all patients underwent laparoscopic cholecystectomy. The primary outcomes were clinical and technical success. The secondary outcomes were recurrence rate of biliary events and procedure-related adverse events.

Results

Among 187 patients with gallstones and cholangitis, 27 patients without CBD stones according to ERCP and IDUS received EBD using 5F plastic stents without EST. The stents were maintained in all patients until laparoscopic cholecystectomy, and recurrence of cholangitis was not observed. After cholecystectomy, the stents were removed spontaneously in 12 patients and endoscopically in 15 patients. Recurrence of CBD stones was not detected during the follow-up period (median, 421 days).

Conclusions

EBD using 5F plastic stents without EST may be safe and effective for the management of cholangitis accompanied by gallstones in patients without CBD stones according to ERCP and IDUS.

Management of suspected common bile duct stones on cholangiogram during same-stay cholecystectomy for acute gallstone-related disease

BACKGROUND

Recent data have suggested that upfront cholecystectomy should be performed even in the presence of moderately abnormal liver function tests (LFTs). As a consequence, more common bile duct (CBD) stones are discovered on intra-operative cholangiogram. We assessed the presentation and management of such patients to refine their management plan.

METHODS

Adult patients (>16 years) with an acute gallstone-related disease who had undergone same-stay cholecystectomy from January 2013 to January 2015 were retrospectively assessed. We excluded patients with pre-operative endoscopic CBD exploration.

RESULTS

Among the 612 patients with same-stay cholecystectomy, 399 patients were included in the study, and 213 were excluded because of a pre-operative CBD exploration. Fifty patients (12.5%) presented an image of CBD stone on the intra-operative cholangiogram. Such patients were younger (47 vs. 55 years, P = .01) and less likely to present with fever (1 vs. 11.7%, P = .04) or signs of cholecystitis on ultrasound (66 vs. 83.7%, P = .003). Admission LFTs were higher in patients with an image of a stone. Among the 50 patients with an image on cholangiogram, a stone was confirmed in 26 (52%). Most patients (n = 32) underwent post-operative assessment with endoscopic ultrasound (EUS). LFTs did not predict the presence of a confirmed stone. However, the absence of contrast passage into the duodenum was negatively associated with a confirmed stone (P = .08), and a filling defect was positively associated with one (P = .11). Most confirmed stones were successfully extracted by endoscopic retrograde cholangiopancreatogram (ERCP) (25/26, 96%), except in one patient who needed a per-cutaneous approach because of duodenal diverticuli.

CONCLUSIONS

Same-stay cholecystectomy can (and should) be performed even in the presence of moderately abnormal liver function tests. The cholangiogram suspicion of a CBD stone is confirmed in only half of the patients (more often in the presence of a filling defect, and less often with the absence of contrast passage). All stones can be safely treated after surgery (most by ERCP).

Prospective validation of an initial cholecystectomy strategy for patients at intermediate-risk of common bile duct stone

BACKGROUND AND AIMS

Initial cholecystectomy for patients at intermediate risk of common bile duct (CBD) stones (including increased liver function tests but bilirubin <4 mg/dL and no cholangitis) showed shorter length of stay and fewer CBD investigations without increased morbidity compared with sequential CBD endoscopic assessment and subsequent cholecystectomy in a randomized controlled trial. The objectives were to prospectively validate these results in daily clinical practice and discuss current guidelines.

METHODS

Initial cholecystectomy has become the standard management strategy at Geneva University Hospitals since July 2013 for patients at intermediate risk of CBD stones admitted with acute gallstone-related conditions. Between July 2013 and December 2014, length of stay, number of CBD investigations, and number of adverse events were recorded for these patients and compared with the data of the patients in the randomized controlled trial.

RESULTS

Data for 161 consecutive newly assessed patients at intermediate risk of CBD stones confirmed shorter length of stay (7.6 vs 9.8 days; P < .001), fewer CBD investigations (0.8 vs 1.4 investigations per patient; P < .001), and similar adverse event rates (5.6% vs 14%, P = .14 including all adverse events; 3.1% vs 8%, P = .22 including only grade ≥III adverse events, defined by endoscopic/surgical reintervention or intensive care unit admission) compared with the previously reported group of patients who underwent preoperative CBD investigations.

CONCLUSIONS

These data confirm that initial cholecystectomy results in a shorter length of stay without increased morbidity among patients at intermediate risk of CBD stones compared with sequential CBD assessment and subsequent cholecystectomy. This approach may change current guidelines.

Assessment of available evidence in the management of gallbladder and bile duct stones: a systematic review of international guidelines

BACKGROUND

Gallstone disease is a frequent disorder in the Western world with a prevalence of 10-20%. Recommendations for the assessment and management of gallstones vary internationally. The aim of this systematic review was to assess quality of guideline recommendations for treatment of gallstones.

METHODS

PubMed, EMBASE and websites of relevant associations were systematically searched. Guidelines without a critical appraisal of literature were excluded. Quality of guidelines was determined using the AGREE II instrument. Recommendations without consensus or with low level of evidence were considered to define problem areas and clinical research gaps.

RESULTS

Fourteen guidelines were included. Overall quality of guidelines was low, with a mean score of 57/100 (standard deviation 19). Five of 14 guidelines were considered suitable for use in clinical practice without modifications. Ten recommendations from all included guidelines were based on low level of evidence and subject to controversy. These included major topics, such as definition of symptomatic gallstones, indications for cholecystectomy and intraoperative cholangiography.

CONCLUSION

Only five guidelines on gallstones are evidence-based and of a high quality, but even in these controversy exists on important topics. High quality evidence is needed in specific areas before an international guideline can be developed and endorsed worldwide.

Clinical outcomes of ERCP-related retroperitoneal perforations

Endoscopic retrograde cholangiopancreatography (ERCP)-related perforations represent rare but often severe conditions. While lesions with intraperitoneal perforation have an almost imperative indication to surgery, whether or not to manage retroperitoneal perforations surgically is still an area of debate. The aim of the present work was to review the available clinical evidence on the operatively and medically treated ERCP-related retroperitoneal perforations. From MEDLINE/PubMed databases 137 patients with retroperitoneal perforation were included from 12 studies that met the selection criteria for data investigation and analysis. Twenty-four patients were treated by prompt surgery; 113 were primarily managed conservatively and about 20% of these patients required surgery subsequently. Overall, the morbidity and mortality were 15.4% and 6.6%, respectively. Although most patients with retroperitoneal perforation may benefit from a non-operative management, a considerable number of patients fail to respond to medical treatment and require surgery afterwards. Identifying those patients who are at highest risk of poor outcome after conservative treatment should be considered a research priority.

Diagnosis and management of patients with an intermediate probability of choledocholithiasis

We thank Dr. Dib for his interest in our prospective study, in which we assessed the accuracy of the American Society for Gastrointestinal Endoscopy guidelines for the prediction of choledocholithiasis (CL). The guidelines suggest the option of using a less-invasive initial test including endoscopic ultrasonography (EUS) or magnetic resonance cholangiopancreatography (MRCP) in patients with intermediate probability of CL. However, there is a paucity of published literature supporting this recommendation. Furthermore, in the study by Adams et al. (3) such a recommendation is not supported by their data. Additionally, because the prevalence of CL varies among ethnic groups, we did not consider performing pre-ERCP (endoscopic retrograde cholangiopancreatography) imaging studies in our study.

Sphincterotomy with endoscopic biliary drainage for severe acute cholangitis: a meta-analysis

Aims To investigate the role of endoscopic sphincterotomy (ES) with endoscopic biliary drainage (EBD) in acute severe obstructive cholangitis management by performing a meta-analysis of controlled trials. Method We searched PubMed and Embase for controlled studies that compared endoscopic drainage with ES versus Non-ES in acute obstructive cholangitis. Two reviewers selected the studies and extracted the data. Disagreement was addressed by a third reviewer. Heterogeneity of the studies was analyzed by Cochran's Q statistics. A Mantel-Haenszel risk ratio was calculated utilizing a random effects model. Results Four controlled studies met our inclusion criteria with 392 participants (201 ES, 191 Non-ES). The outcomes were drainage insertion success rate, drainage effectiveness, post drainage pancreatitis, bleeding, procedure duration, perforation, cholecystitis, and 30-day mortality. Drainage insertion success rate was identical in both groups (RR: 1.00, 95 %CI% 0.96 - 1.04). Effective drainage was not significantly different (RR: 1.11, 95 %CI 0.73 - 1.7). There was no significant difference in the incidence of pancreatitis post EBD between the ES and Non-ES groups at 3 % and 4 %, respectively (RR: 0.73, 95 %CI 0.24 - 2.27). However, there was a significant increase in post EBD bleeding with ES compared to Non-ES (RR: 8.58, 95 %CI 2.03 - 36.34). Thirty-day mortality was similar between ES and Non-ES groups at 0.7 % and 1 %, respectively (RR: 0.5, 95 %CI 0.05 - 5.28). Conclusion Our findings show that EBD without ES is an effective drainage technique and carries less risk for post procedure bleeding. Patients who are critically ill and have coagulopathy should be spared from undergoing ES in the acute phase.

Management of suspected common bile duct stone: diagnostic yield of current guidelines

BACKGROUND

The American Society for Gastrointestinal Endoscopy (ASGE) has recently published a guideline for suspected CBDS with the intention of reducing unnecessary ERCP and thereby complications. The aim of this study was to assess the diagnostic efficacy of the ASGE guideline.

METHODS

Data of patients who underwent ERCP with suspected CBDS were analyzed retrospectively. Patients were classified into high, intermediate and low risk groups based on predictors that have been suggested by the ASGE. Very strong predictors of the presence of ductal stones included: CBDS on transabdominal ultrasonography (US), clinical ascending cholangitis or total bilirubin (TBIL) >4 mg/dL). Strong predictors included dilated CBD >6 mm on US with gallbladder in situ and TBIL level of 1.8-4.0 mg/dL whereas moderate predictor included abnormal liver biochemical test other than bilirubin, age more than 55 years and clinical findings of biliary pancreatitis.

RESULTS

Of 888 enrolled patients, 704 had CBDS demonstrated by ERCP and the remainder did not. All very strong and strong predictors were found to be significantly higher among patients who had CBDS. Detection of CBDS by ultrasonography and a dilated common biliary duct were observed to be independent risk factors associated with the existence of CBDS. The high risk group had a high (86.7%) positive predictive value (PPV), however, sensitivity and specificity were observed to be moderate (67.8% and 60.3% respectively). PPV was 67.9% in the intermediate risk group and the sensitivity and specificity were very low (31.9% and 42.3%).

DISCUSSION

The probability of CBDS was observed to be high in the intermediate and high risk groups. However due to low sensitivity and specificity values, the ASGE guideline needs additional or different predictors.

Accuracy of ASGE criteria for the prediction of choledocholithiasis

I read with interest the article "Accuracy of ASGE criteria for the prediction of choledocholithiasis" by Nárvaez et al. Patients with suspicion of choledocholithiasis (CL) were categorized according to the American Society for Gastrointestinal Endoscopy (ASGE) recommendations. Those patients classified into high or intermediate-probability for CL underwent an endoscopic retrograde cholangiopancreatography (ERCP) without any further non-endoscopic biliary imaging modalities. In the ASGE recommendations for intermediate risk CL patients, they mention options for the evaluation of these patients including endoscopic ultrasound (EUS) and magnetic resonance cholangiography (MRC).

[Efficiency of laparoscopic vs endoscopic management in cholelithiasis and choledocholithiasis. Is there any difference?]

BACKGROUND

Concomitant cholelithiasis and choledocholithiasis is a disease where incidence increases with age and can have serious complications such as pancreatitis, cholangitis and liver abscesses, but its management is controversial, because there are minimally invasive laparoscopic and endoscopic surgical procedures.

OBJECTIVE

To compare the efficiency in the management of cholelithiasis and choledocholithiasis with laparoscopic cholecystectomy with common bile duct exploration vs cholangiopancreatography endoscopic retrograde+laparoscopic cholecystectomy.

MATERIAL AND METHOD

Retrospective analysis of a five year observational, cross sectional multicenter study of patients with cholelithiasis and concomitant high risk of choledocholithiasis who were divided into two groups and the efficiency of both procedures was compared. Group 1 underwent laparoscopic cholecystectomy with common bile duct exploration and group 2 underwent cholangiopancreatography endoscopic retrograde+laparoscopic cholecystectomy.

RESULTS

40 patients, 20 were included in each group, we found p=0.10 in terms of operating time; when we compared hospital days we found p=0.63; the success of stone extraction by study group we obtained was p=0.15; the complications presented by group was p=0.1 and the number of hospitalizations by group was p ≤ 0.05 demonstrating statistical significance.

CONCLUSIONS

Both approaches have the same efficiency in the management of cholelithiasis and choledocholithiasis in terms of operating time, success in extracting stone, days of hospitalization, postoperative complications and conversion to open surgery. However the laparoscopic approach is favourable because it reduces the number of surgical anaesthetic events and the number of hospital admissions.

The utility and yield of endoscopic ultrasonography for suspected choledocholithiasis in common gastroenterology practice

BACKGROUND AND STUDY AIM

Endoscopic ultrasonography (EUS) is an established diagnostic modality for diagnosing common bile duct (CBD) stones. Its use has led to a reduction in the number of endoscopic retrograde cholangiopancreatography (ERCP) procedures performed for suspected choledocholithiasis. We aimed to explore the role of EUS in detecting CBD stones and/or sludge in common gastroenterology practice.

PATIENTS AND METHODS

We reviewed case records of 268 consecutive patients who underwent (EUS) procedures performed to confirm or rule out the presence of CBD stones and/or sludge between November 2006 and January 2011 in the Reinier de Graaf Hospital, Delft, The Netherlands, which is a nonacademic community hospital.

RESULTS

On the basis of EUS findings, 169 of 268 (63%) patients did not undergo ERCP and were therefore not exposed to its risk of complications. Patients with positive findings on EUS (n=99) all underwent ERCP and endoscopic sphincterotomy. Only 57 of 99 (58%) had positive findings at ERCP. The main contributing factors to this finding seem to be time interval between EUS and ERCP and the type of CBD content (i.e. sludge, one CBD stone or more than one CBD stone) described.

CONCLUSION

In our common gastroenterology practice, EUS plays an important role in selecting patients suspected to have CBD stones or sludge for ERCP. Much is to be learned about the probability of spontaneous passage of CBD stones and sludge into the duodenum.

Choledocholithiasis: Evaluation, Treatment, and Outcomes

Choledocholithiasis occurs in up to approximately 20% of patients with cholelithiasis. A majority of stones form in the gallbladder and then pass into the common bile duct, where they generate symptoms, due to biliary obstruction. Confirmatory diagnosis of choledocholithiasis is made with advanced imaging, including magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography (ERCP). Treatment varies locally; however, ERCP with sphincterotomy is most commonly employed with a high degree of success. Difficult anatomy and difficult stone burden require advanced surgical, endoscopic, and percutaneous techniques to extract or expel biliary stones. Knowledge of these treatment strategies will optimize outcomes.

Single-session laparoscopic cholecystectomy and ERCP: a valid option for the management of choledocholithiasis

BACKGROUND AND AIMS

The option for performing ERCP and laparoscopic cholecystectomy (LC) for the management of choledocholithiasis in the same operative session is often overlooked. We compared the success, safety, and cost of ERCP and LC when performed in either a single session or in separate sessions.

METHODS

We conducted a retrospective cohort study at a U.S. tertiary care hospital. We identified patients undergoing ERCP and LC between April 2011 and August 2014 in either a single operative session (n = 33) or in 2 separate sessions within a 30-day period (n = 80). Technical success, total anesthesia duration, operative time, length of hospitalization, cost of care, and morbidity and mortality were evaluated.

RESULTS

Bile duct clearance was achieved in all patients at ERCP in the same-session cohort. The separate versus single-session groups, respectively, did not differ in terms of total procedure times (mean ± SD = 142 ± 64 vs 142 ± 58 min; t test, P =.98), anesthesia duration (251 ± 64 vs 225 ± 69 min; P =.06), or overall cost (49.3 ± 24.5 vs 42.3 ± 23.2 ×1000 USD; P =.167), but hospitalization was longer in the separate-sessions group (6.2 ± 3.3 vs 4.8 ± 2.6 days; P =.03). The rates of adverse events were similarly low (7% vs 2%, P =.70).

CONCLUSIONS

Performing single-session ERCP and LC is safe, effective, economically viable, and reduces hospital stay compared with performing ERCP and LC during separate sessions.

Management of patients after recovering from acute severe biliary pancreatitis

Cholelithiasis is the most common cause of acute pancreatitis, accounting 35%-60% of cases. Around 15%-20% of patients suffer a severe attack with high morbidity and mortality rates. As far as treatment is concerned, the optimum method of late management of patients with severe acute biliary pancreatitis is still contentious and the main question is over the correct timing of every intervention. Patients after recovering from an acute episode of severe biliary pancreatitis can be offered alternative options in their management, including cholecystectomy, endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy, or no definitive treatment. Delaying cholecystectomy until after resolution of the inflammatory process, usually not earlier than 6 wk after onset of acute pancreatitis, seems to be a safe policy. ERCP and sphincterotomy on index admission prevent recurrent episodes of pancreatitis until cholecystectomy is performed, but if used for definitive treatment, they can be a valuable tool for patients unfit for surgery. Some patients who survive severe biliary pancreatitis may develop pseudocysts or walled-off necrosis. Management of pseudocysts with minimally invasive techniques, if not therapeutic, can be used as a bridge to definitive operative treatment, which includes delayed cholecystectomy and concurrent pseudocyst drainage in some patients. A management algorithm has been developed for patients surviving severe biliary pancreatitis according to the currently published data in the literature.

Is endoscopic treatment beneficial in patients with clinically suspicious of common bile duct stones but no obvious filling defects during the ERCP examination?

BACKGROUND

Sometimes, no definite filling defect could be found by cholangiogram (ERC) during the endoscopic retrograde cholangio-pancreatiographic (ERCP) exam; even prior images had evidence of common bile duct stones (CBDS). We aimed in estimating the positive rate of extraction of CBDS who had treated by endoscopic sphincterotomy/endoscopic papillary balloon dilation (EST/EPBD) with negative ERC finding.

METHODS

One hundred forty-one patients with clinically suspicious of CBDS but negative ERC, who had received EST/EPBD treatments was enrolled. Potential factors for predicting CBDS, as well as the treatment-related complications were analyzed.

RESULTS

Nearly half of the patients with negative ERC, had a positive stone extraction. Only patients with high probability of CBDS were significantly associated with positive stone extraction. Moreover, patients with intermediate probability of CBDS had higher rates of overall complications, including post-ERCP pancreatitis. In addition, no significant difference of post-ERCP pancreatitis was found between EST and EPBD groups in any one group of patients with the same probability of CBDS.

CONCLUSIONS

Regarding patients with negative ERC, therapeutic ERCP is beneficial and safe for patients present with high probability of CBDS. Moreover, under the same probability of CBDS, there was no significance difference in post-ERCP pancreatitis between EST and EPBD.

The Diagnostic Accuracy of Linear Endoscopic Ultrasound for Evaluating Symptoms Suggestive of Common Bile Duct Stones

Background. In order to assess the diagnostic accuracy of linear EUS for evaluating clinically suggestive CBD stones in high-risk groups. Methods. 202 patients with clinically suggestive CBD stones in high-risk groups who underwent linear EUS examination between January 2012 and January 2015 were retrospectively reviewed. Endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction or surgical choledochoscopy was only performed when a CBD stone was detected by linear EUS. Cases that were negative for CBD stones were followed up for at least 6 months. Results. Of 202 enrolled patients, 126 were positive for CBD stones according to linear EUS findings. 124 patients successfully underwent ERCP, and ERCP failed in 2 who were later successfully treated by surgical intervention. There were 2 false-positive cases with positive findings for CBD stones on ERCP. Among 76 patients without CBD stones, no false-negative cases were identified during the mean 6-month follow-up. Linear EUS had sensitivity, specificity, and positive and negative predictive values for the detection of CBD stones of 100%, 92.88%, 98.21%, and 100%, respectively. Conclusions. Linear EUS is a safe and efficacious diagnostic tool for evaluating clinically suggestive CBD stones with high risk of choledocholithiasis. Performing linear EUS prior to ERCP in patients with symptoms suggestive of CBD stones can reduce unnecessary ERCP procedures.

Effects of melatonin on the acute inflammatory response associated with endoscopic retrograde cholangiopancreatography: A randomized, double-blind, placebo-controlled trial

INTRODUCTION

Endoscopic retrograde cholangiopancreatography (ERCP) is associated with an acute inflammatory response and melatonin has a variety of immunomodulatory and antioxidant effects studied experimentally in pancreatobiliary pathology.

AIMS

The aim of our study was to evaluate the effects of peri-procedural administration of melatonin on the inflammatory response and lipid peroxidation associated with ERCP.

METHODS

In this proof-of-concept clinical trial, 37 patients with a high probability of choledocholithiasis were randomized to receive peri-procedure (ERCP) melatonin or placebo. We measured the serum concentration of tumor necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6), vascular endothelial growth factor (VEGF), lipid peroxidation, amylase, and liver function tests 24h before and after the procedure.

RESULTS

We found no pre-procedure or post-procedure differences between the melatonin group or the placebo group (P>.05) in the serum concentrations of TNF-alpha (melatonin: 153.8 vs. 149.4ng/m; placebo: 103.5 vs. 107.3ng/ml), IL-6 (melatonin: 131.8 vs. 133.3ng/ml; placebo: 177.8 vs. 197.8ng/ml), or VEGF (melatonin: 157.3 vs. 157.8pg/ml; placebo: 97.3 vs. 97.8pg/ml), or in relation to lipid peroxidation (melatonin: 39.2 vs. 72.3μg/ml; placebo: 66.4 vs. 90.5μg/ml). After ERCP, a significant decrease in the AST, ALT, and total bilirubin levels was found only in the melatonin group (P<.05). The administration of melatonin was safe and tolerable.

CONCLUSIONS

Melatonin is safe and tolerable in patients undergoing ERCP, but it does not appear to affect inflammatory cytokine concentrations or lipid peroxidation.

Endoscopic management of choledocholithiasis and cholelithiasis in patients with cirrhosis

Treatment of choledocholithiasis and cholelithiasis in patients with cirrhosis often requires diagnostic and therapeutic endoscopy such as endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP). Patients with underlying cirrhosis may have coagulopathy, hepatic encephalopathy, ascites and other comorbidities associated with cirrhosis that can make endoscopic therapy challenging and can be associated with a higher risk of adverse events. Given the unique derangements of physiologic parameters associated with cirrhosis this population requires a truly multifaceted and multidisciplinary understanding between therapeutic endoscopists, hepatologists and anesthesiologists. For therapeutic endoscopists, it is critical to be aware of the specific issues unique to this population of patients to optimize outcomes and avoid adverse events. The epidemiology of gallstone disease, the diagnostic and therapeutic approach to patients with varying degree of hepatic dysfunction, and a review of the available literature in this area are presented.

Comparing the Roles of EUS, ERCP and MRCP in Idiopathic Acute Recurrent Pancreatitis

Acute recurrent pancreatitis (ARP) is defined as more than two attacks of acute pancreatitis with complete or almost complete resolution of symptoms and signs of pancreatitis between episodes. The initial evaluation fails to detect the cause of ARP in 10%–30% of patients, whose condition is classified as idiopathic ARP. Endoscopic ultrasound (EUS) has gained increasing attention as a useful imaging modality for the pancreas and the extrahepatic biliary tree. The close proximity of the pancreas to the digestive tract allows EUS to obtain detailed images of this organ. This review aims to record pancreaticobiliary endoscopic ultrasound (EUS) and other imaging modalities in the clinical management of patients with idiopathic ARP.

Developing a clinical research career

The National Institute for Health Research helps to promote clinical research careers for health professionals working in clinical practice, and has developed a structure to support new researchers. This article explains how nurses can get involved in clinical research and the support available to them.

2016 WSES guidelines on acute calculous cholecystitis

Acute calculus cholecystitis is a very common disease with several area of uncertainty. The World Society of Emergency Surgery developed extensive guidelines in order to cover grey areas. The diagnostic criteria, the antimicrobial therapy, the evaluation of associated common bile duct stones, the identification of “high risk” patients, the surgical timing, the type of surgery, and the alternatives to surgery are discussed. Moreover the algorithm is proposed: as soon as diagnosis is made and after the evaluation of choledocholitiasis risk, laparoscopic cholecystectomy should be offered to all patients exception of those with high risk of morbidity or mortality. These Guidelines must be considered as an adjunctive tool for decision but they are not substitute of the clinical judgement for the individual patient.

Endoscopic retrograde cholangiography for pediatric choledocholithiasis: Assessing the need for endoscopic intervention

AIM: To assess pediatric patients for choledocholithiasis. We applied current adult guidelines to identify predictive factors in children.

METHODS: A single-center retrospective analysis was performed at a tertiary children’s hospital. We evaluated 44 consecutive pediatric patients who underwent endoscopic retrograde cholangiography (ERCP) for suspected choledocholithiasis. Patients were stratified into those with common bile duct stones (CBDS) at ERCP vs those that did not using the American Society of Gastrointestinal Endoscopy (ASGE) guidelines (Very Strong and Strong criteria) for suspected CBDS.

RESULTS: CBDS were identified in 84% at the time of ERCP. Abdominal ultrasound identified CBDS in 36% of patients. Conjugated bilirubin ≥ 0.5 mg/dL was an independent risk factor for CBDS (P = 0.003). The Very Strong (59.5%) and Strong (48.6%) ASGE criteria identified the majority of patients (P = 0.0001). A modified score using conjugated bilirubin had a higher sensitivity (81.2% vs 59.5%) and more likely to identify a stone than the standard criteria, odds ratio of 25.7 compared to 8.8. Alanine aminotransferase and gamma-glutamyl transferase values identified significant differences in a subset of patients with odds ratio of 4.1 and 3.25, respectively.

CONCLUSION: Current adult guidelines identified the majority of pediatric patients with CBDS, but specific pediatric guidelines may improve detection, thus decreasing risks and unnecessary procedures.

Accuracy of ASGE criteria for the prediction of choledocholithiasis

BACKGROUND/AIMS

Few studies have validated the performance of guidelines for the prediction of choledocholithiasis (CL). Our objective was to prospectively assess the accuracy of the American Society for Gastrointestinal Endoscopy (ASGE) guidelines for the identification of CL.

METHODS

A two-year prospective evaluation of patients with suspected CL was performed. We evaluated the ASGE guidelines and its component variables in predicting CL.

RESULTS

A total of 256 patients with suspected CL were analyzed. Of the 208 patients with high-probability criteria for CL, 124 (59.6%) were found to have a stone/sludge at endoscopic retrograde cholangiopancreatography (ERCP). Among 48 patients with intermediate-probability criteria, 21 (43.8%) had a stone/sludge. The performance of ASGE high- and intermediate-probability criteria in our population had an accuracy of 59.0% (85.5% sensitivity, 24.3% specificity) and 41.0% (14.4% sensitivity, 75.6% specificity), respectively. The mean ERCP delay time was 6.1 days in the CL group and 6.4 days in the group without CL, p = 0.638. The presence of a common bile duct (CBD) > 6 mm (OR 2.21; 95% CI, 1.20-4.10), ascending cholangitis (OR 2.37; 95% CI, 1.01-5.55) and a CBD stone visualized on transabdominal US (OR 3.33; 95% CI, 1.48-7.52) were stronger predictors of CL. The occurrence of biliary pancreatitis was a strong protective factor for the presence of a retained CBD stone (OR 0.30; 95% CI, 0.17-0.55).

CONCLUSIONS

Irrespective of a patient's ASGE probability for CL, the application of current guidelines in our population led to unnecessary performance of ERCPs in nearly half of cases.

Yield of magnetic resonance cholangiopancreatography for the investigation of bile duct dilatation in asymptomatic patients

BACKGROUND

Biliary dilatation in the asymptomatic patient is a frequent incidental finding in the work-up for which there are no current guidelines.

OBJECTIVES

The purpose of this study was to determine the yield of magnetic resonance cholangiopancreatography (MRCP) in asymptomatic patients with an incidental finding of biliary duct dilatation.

METHODS

The study included 68 consecutive patients for evaluation of biliary duct dilatation found incidentally on computed tomography (CT) or ultrasound (US). MRCP scans were reviewed, and data were retrospectively collected on demographics and laboratory work-up. Patients were divided by the presence of a significant or non-significant MRCP findings explaining the biliary duct dilatation and compared for normal or abnormal liver function.

RESULTS

Liver function was normal in 47 patients and abnormal in 21 patients. MRCP identified the cause of the bile duct dilatation in 41 patients (60.3%). Rates of insignificant causes were 51% in the normal-liver-function group and 7% in the abnormal-function group. Corresponding rates of significant causes were 27.7% and 61.9% (p = 0.007).

CONCLUSIONS

MRCP is a valuable tool in the work-up of biliary duct dilatation. Although significantly more significant causes of bile dilatation are identified in patients with abnormal liver function, almost one-third of patients with normal liver function need further work-up. This has important implications for establishing criteria for the use of MRCP in asymptomatic patients with biliary dilatation.