Endoscopic ultrasound versus magnetic resonance cholangiopancreatography for common bile duct stones

Might be over-evaluated: Predicting choledocholithiasis in patients with acute biliary pancreatitis

BACKGROUND

The increase in liver cholestasis enzyme and bilirubin levels, especially due to pancreatitis, mimics choledocholithiasis. This study aimed to examine the relationship between demographic and laboratory cut-off values and the presence of choledocholithiasis in patients with acute biliary pancreatitis (ABP).

METHODS

Patients diagnosed with ABP in the Department of General Surgery at Istanbul Faculty of Medicine between January 2010 and December 2022 were retrospectively analyzed. The presence of stones in the common bile duct was determined based on the results of magnetic resonance cholangiopancreatography (MRCP), endoscopic ultrasound (EUS), and endoscopic retrograde cholangiopancreatography (ERCP). Demographic and laboratory values of patients with and without bile duct stones were compared. Cut-off values were determined using receiver operating characteristic (ROC) curve analysis, and logistic regression analysis and modeling was performed for each variable.

RESULTS

A total of 1,026 ABP patients were evaluated. Patients whose enzyme levels were not elevated and those who did not undergo MRCP were excluded. A total of 584 patients were included in the study, and choledocholithiasis was detected in 188 (32.2%) patients. In multivariate analysis, age, gamma-glutamyl transferase (GGT), alkaline phosphatase (ALP), and direct bilirubin (DB) were found to be statistically associated with choledocholithiasis. The cut-off values were determined as 65 years for age, 394 U/L for GGT, 173 U/L for ALP, and 1.42 mg/dL for direct bilirubin. In the group where all four parameters were below these cut-off values, suggesting a clean common bile duct, it was observed that the negative predictive value was 97%.

CONCLUSION

Based on the demographic and laboratory data of patients with ABP, we were able to predict with more than 97% accuracy that the common bile duct was clean. Considering that our study only included patients who underwent MRCP due to elevated enzyme levels and suspicion of choledocholithiasis, the negative predictive value would be even higher if patients with acute biliary pancreatitis with normal enzyme levels were included. Additionally, no complications were observed in any of the patients during follow-up. This finding suggests that patients whose common bile duct is predicted to be clean can initially be monitored and supported with additional imaging methods if necessary. As a result, unnecessary imaging can be avoided, reducing costs and preventing the mortality and morbidity associated with unnecessary procedures.

Tauroursodeoxycholic acid suppresses biliary epithelial cell apoptosis and endoplasmic reticulum stress by miR-107/NCK1 axis in a FXR-dependent manner

Tauroursodeoxycholic acid (TUDCA) can activate farnesoid X receptor (FXR) to involve in the formation of gallstones. Here, this study aimed to probe the potential mechanism of TUDCA-FXR network in the formation of bile duct stone. The levels of TUDCA, FXR and NCK1 were decreased, while the level of miR-107 was increased in the serum of bile duct stone patients. FXR expression was positively correlated with TUDCA or NCK1 expression in patients, moreover, TUDCA pretreatment in biliary epithelial cells increased the levels of FXR and NCK1, and rescued the decrease of NCK1 caused by FXR knockdown in cells. Then functional analysis showed FXR knockdown caused apoptosis and endoplasmic reticulum stress (ERS) as well as suppressed proliferation in biliary epithelial cells in vitro, which were attenuated by TUDCA pretreatment or NCK1 overexpression Mechanistically, NCK1 was a target of miR-107, which was up-regulated by FXR silencing, and FXR knockdown-induced decrease of NCK1 was rescued by miR-107 inhibition. Additionally, miR-107 expression was negatively correlated with TUDCA expression in bile duct stone patients, and TUDCA pretreatment in biliary epithelial cells decreased miR-107 expression by FXR. Functionally, the pretreatment of TUDCA or FXR agonist suppressed miR-107-evoked apoptosis and ERS in biliary epithelial cells. In conclusion, TUDCA up-regulates FXR expression to activate NCK1 through absorbing miR-107, thus suppressing the apoptosis and ERS in biliary epithelial cells, these results provided a theoretical basis for elucidating the mechanism of bile duct stone formation.

Usefulness of Endoscopic Retrograde Cholangiopancreatography (ERCP)-Related Procedures for Gallstone Pancreatitis

INTRODUCTION

Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (EST) are said to be useful procedures for gallstone pancreatitis. However, there have been few reports on a large number of patients to whom they were used. The clinical usefulness of ERCP and EST is herein examined retrospectively.

METHODS

ERCP and EST were performed to evaluate their clinical usefulness and safety in 108 patients who had gallbladder stones from December 1985 to October 2017 and were diagnosed as having gallstone pancreatitis. Of 108 patients, 83 were mild, and 25 were severe. Following the procedures, clinical courses were observed for three years in 108 patients who underwent the treatments.

RESULTS

Cholangiogram was successfully conducted in 108 patients. Bile duct stones were noted in 90 patients, and the stones were removed after EST. Of 18 patients who did not show bile duct stone in cholangiogram, 13 patients underwent EST, while five patients taking anticoagulants completed procedures only with cholangiogram. Accidental symptom was hemorrhage in three patients (2.7%; 3/108), but it was mild and conservatively resolving. During the three-year observation period, acute cholangitis was noted in three patients (2.7%; 3/108), but no relapsing pancreatitis was noted.

CONCLUSIONS

It was suggested that ERCP and EST could be useful therapies for gallstone pancreatitis.

The association between the volume of the gallbladder based on sonographic findings and demographical data in the PERSIAN Guilan cohort study (PGCS)

BACKGROUND

Ultrasound is an important method to determine the volume of the gallbladder and check its structure. Considering the variation in the size and volume of the gallbladder in disease and physiological conditions, determining the volume of the gallbladder is clinically valuable. This study was carried out to evaluate the gallbladder volume and its association with patients' demographic data in the Prospective Epidemiological Research Studies of Iranian Adults (PERSIAN) Guilan cohort study (PGCS) population.

METHODS

In this cross-sectional study, 957 individuals aged 35-70 participated in determining the gallbladder volume by a radiologist based on the ultrasound method. The demographical data were collected using a questionnaire. After fasting for 12 h, the ultrasound was performed with an Ultrasonic device (Sonix SP series) with a 3.5 to 5 MHz probe.

RESULTS

The total frequency of gallbladder lesions was 2.2%. The results showed a significant association between marriage and gender with the presence or absence of lesions in the studied participants (P < 0.05). Also, significant differences were reported between the volume of gallbladder and gender, body mass index (BMI), social and economic status (SES), metabolic equivalent of task (MET), history of cardiovascular disease (CVD), and hypertension (P < 0.05). The results of a linear regression represented a significant association between gender, BMI, MET, and CVD and the mean volume of the gallbladder (P < 0.05). However, there was no significant association between the presence or absence of a lesion and the individuals' average gallbladder volume (P > 0.05).

CONCLUSION

According to our results, gender, BMI, MET, and CVD were significantly associated with gallbladder volume.

Preoperative MRCP Can Rule Out Choledocholithiasis in Acute Cholecystitis with a High Negative Predictive Value: Prospective Cohort Study with Intraoperative Cholangiography

BACKGROUND

Magnetic resonance cholangiopancreatography (MRCP) provides a noninvasive and fast modality for imaging the biliary tree when choledocholithiasis is suspected. Guidelines suggest that MRCP is recommended when strong or moderate signs of common bile duct (CBD) stones are present. Well-performed prospective studies are scarce regarding the sensitivity and specificity of preoperative MRCP in patients with acute cholecystitis in comparison with intraoperative cholangiography, ERCP, or choledochoscopy.

METHODS

We performed a prospective, observational population-based feasibility study in Central Finland Hospital Nova between January 2019 and December 2019. We examined the diagnostic performance of preoperative MRCP on consecutive patients with acute cholecystitis scheduled for index admission cholecystectomy. The accuracy of MRCP was verified with IOC, choledochoscopy, or ERCP. The interobserver reliability of the image quality of MRCP and the sensitivity and specificity of choledocholithiasis were observed independently by three experienced radiologists.

RESULTS

A total of 180 consecutive patients diagnosed with acute cholecystitis followed by index admission cholecystectomy were identified. MRCP was performed in 113/180 (62.8%) patients, and complementary perioperative imaging of the bile ducts was performed in 72/113 (63.7%) patients. The incidence of choledocholithiasis was high (29.2%). In acute cholecystitis, the sensitivity (76.2-85.7%) and specificity (84.3-92.2%) of MRCP were equally compared to the literature with unselected patient groups. The best visibility was observed in the common hepatic duct, the inferior CBD, and the central hepatic duct. The interobserver reliability was excellent for determining the size and quantity of CBD stones.

CONCLUSION

In acute cholecystitis, MRCP yields high negative predictive value regarding detection of choledocholithiasis. If CBD stones were discovered, the interobserver reliability was excellent when measuring the size and number of CBD stones. The best-visualized area was the distal part of the biliary tract, which provides good preoperative workup if choledocholithiasis is present.

Performance of the predictive criteria of the American Society for Gastrointestinal Endoscopy in the diagnosis of choledocholithiasis at a secondary care public hospital in the State of Nuevo León, Mexico

INTRODUCTION AND AIMS

Currently there is no ideal diagnostic/therapeutic approach for patients with suspected choledocholithiasis. The primary aim of our study was to evaluate the performance of the criteria for predicting choledocholithiasis proposed by the American Society for Gastrointestinal Endoscopy (ASGE) in 2019.

MATERIALS AND METHODS

A retrospective study was conducted that included 352 patients seen at a secondary care public healthcare institution in Monterrey, Nuevo León, that treats an open population and does not have endoscopic ultrasound or magnetic resonance cholangiopancreatography at its disposal.

RESULTS

The most frequent predictor presented by the patients was abnormal liver function tests (90.63%), and with their use alone, sensitivity was higher than that of all the predictors analyzed (91.41%). In addition, the finding of common bile duct stones on ultrasound imaging was the only predictor independently associated with the confirmatory diagnosis of choledocholithiasis. Regarding the general performance of the 2019 criteria, the high-risk category had 68.75% sensitivity, 52.08% specificity, a positive predictive value of 79.28%, a negative predictive value of 38.46%, diagnostic accuracy of 64.20%, and a confirmatory diagnosis of choledocholithiasis in 79.28% of the patients of that risk category.

CONCLUSIONS

The study corroborated that the presence of choledocholithiasis could be predicted using the choledocholithiasis predictors and risk categories proposed by the ASGE, with acceptable accuracy, in accordance with the standards suggested by those same guidelines.

Patient selection for urgent endoscopic retrograde cholangio-pancreatography by endoscopic ultrasound in predicted severe acute biliary pancreatitis (APEC-2): a multicentre prospective study

OBJECTIVE

Routine urgent endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic biliary sphincterotomy (ES) does not improve outcome in patients with predicted severe acute biliary pancreatitis. Improved patient selection for ERCP by means of endoscopic ultrasonography (EUS) for stone/sludge detection may challenge these findings.

DESIGN

A multicentre, prospective cohort study included patients with predicted severe acute biliary pancreatitis without cholangitis. Patients underwent urgent EUS, followed by ERCP with ES in case of common bile duct stones/sludge, within 24 hours after hospital presentation and within 72 hours after symptom onset. The primary endpoint was a composite of major complications or mortality within 6 months after inclusion. The historical control group was the conservative treatment arm (n=113) of the randomised APEC trial (Acute biliary Pancreatitis: urgent ERCP with sphincterotomy versus conservative treatment, patient inclusion 2013-2017) applying the same study design.

RESULTS

Overall, 83 patients underwent urgent EUS at a median of 21 hours (IQR 17-23) after hospital presentation and at a median of 29 hours (IQR 23-41) after start of symptoms. Gallstones/sludge in the bile ducts were detected by EUS in 48/83 patients (58%), all of whom underwent immediate ERCP with ES. The primary endpoint occurred in 34/83 patients (41%) in the urgent EUS-guided ERCP group. This was not different from the 44% rate (50/113 patients) in the historical conservative treatment group (risk ratio (RR) 0.93, 95% CI 0.67 to 1.29; p=0.65). Sensitivity analysis to correct for baseline differences using a logistic regression model also showed no significant beneficial effect of the intervention on the primary outcome (adjusted OR 1.03, 95% CI 0.56 to 1.90, p=0.92).

CONCLUSION

In patients with predicted severe acute biliary pancreatitis without cholangitis, urgent EUS-guided ERCP with ES did not reduce the composite endpoint of major complications or mortality, as compared with conservative treatment in a historical control group.

TRIAL REGISTRATION NUMBER

ISRCTN15545919.

Magnetic resonance cholangiopancreatography versus endoscopic ultrasound for diagnosis of choledocholithiasis: an updated systematic review and meta-analysis

INTRODUCTION

Both endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP) are used for the diagnosis of choledocholithiasis (CDL). Previous studies have shown conflicting results regarding the optimal diagnostic strategy for suspected CDL; hence, this meta-analysis was conducted.

METHODS

A comprehensive search of literature from 1990 till April 2022 was done of three databases for studies comparing EUS and MRCP to diagnose CDL.

RESULTS

A total of 12 studies were identified. The pooled sensitivity and specificity for EUS were 0.96 [95% confidence interval (CI) 0.92-0.98], and 0.92 (95% CI 0.85-0.96), respectively. The pooled sensitivity and specificity for MRCP were 0.85 (95% CI 0.78-0.90) and 0.90 (95% CI 0.79-0.96), respectively. EUS had a higher relative sensitivity [Relative risk (RR) 1.12, 95% CI 1.05-1.19], a higher diagnostic accuracy (Odds ratio 1.98, 95% CI 1.35-2.90) but comparable specificity (RR 1.02, 95% CI 0.96-1.08) with MRCP.

CONCLUSION

There is little difference concerning specificity, although EUS likely provides a higher sensitivity and accuracy for diagnosing CDL, compared to MRCP.

Unnecessary endoscopic retrograde cholangiopancreatography associated with the spontaneous passage of common bile duct stones into the duodenum: a multicenter retrospective study

BACKGROUND

Unnecessary endoscopic retrograde cholangiopancreatography (ERCP) after spontaneous passage of common bile duct stones (CBDSs) should be avoided. This study aimed to examine the cumulative diagnosis rate and the predictive factors of spontaneous CBDS passage during the interval between the imaging diagnosis and ERCP.

METHODS

This multicenter retrospective study included 1260 consecutive patients with native papilla diagnosed with CBDSs using imaging modalities. Predictive factors and cumulative diagnosis rate of spontaneously passed CBDSs during the interval between imaging diagnosis and ERCP were analyzed.

RESULTS

The overall cumulative diagnosis rate of spontaneous CBDS passage was 6.2% (78/1260) during a mean interval of 5.0 days. In the multivariate analysis, CBDS sized < 6 mm on diagnostic imaging, solitary CBDS on diagnostic imaging, intervals between the imaging diagnosis and ERCP, and nondilated common bile duct (< 10 mm) were the significant factors associated with spontaneous CBDS passage. Specifically, the cumulative diagnosis rate of spontaneous passage was significantly higher in patients with solitary and CBDSs sized < 6 mm than in those with other CBDSs (14.4% [54/376] vs. 2.7% [24/884], P < 0.001). In both the asymptomatic and symptomatic groups, the cumulative diagnosis rate of the spontaneous passage of CBDSs was significantly higher in patients with solitary and CBDSs sized < 6 mm on diagnostic imaging than in those with multiple and/or CBDSs sized ≥ 6 mm on diagnostic imaging during a mean interval of 20.5 and 2.4 days, respectively (asymptomatic group: 22.4% [15/67] vs. 3.5% [4/113], P < 0.001, symptomatic group: 12.6% [39/309] vs. 2.6% [20/771], P < 0.001).

CONCLUSIONS

Solitary and CBDSs sized < 6 mm on diagnostic imaging can often lead unnecessary ERCP due to spontaneous passage. Preliminary endoscopic ultrasonography immediately before ERCP is recommended, especially in patients with solitary and small CBDSs on diagnostic imaging.

Acute Gallstone Pancreatitis: If a Picture Is Worth a Thousand Words, How Many Images Do We Need?

Introduction Accurate diagnosis and prompt definitive management of choledocholithiasis are vital in acute gallstone pancreatitis. The sensitivity of detection of choledocholithiasis varies across imaging modalities. Magnetic resonance cholangiopancreatography (MRCP) is the most sensitive but may not be necessary, resulting in both delayed definitive management and increased costs. We aimed to evaluate the range of radiological investigations patients with acute gallstone pancreatitis underwent and the clinical appropriateness of MRCP when performed. Methods This was an observational study of patients diagnosed with acute gallstone pancreatitis between January 1, 2019 and November 30, 2021 in a district general hospital in London, UK. A detailed review of patient records, laboratory and radiological results, and endoscopic and/or operative intervention was undertaken. Results One hundred consecutive patients diagnosed with acute gallstone pancreatitis (median age 57 years) were included. Seventy-nine had a transabdominal ultrasound (USS), 46 had CT, and 40 patients had MRCP. The median waiting time for these investigations was 1, 0, and 4 days, respectively. Choledocholithiasis was identified in 21 patients (4 on USS, 5 on CT, and 12 on MRCP). As definitive management, 37% underwent endoscopic retrograde cholangiopancreatography, and 57% underwent laparoscopic cholecystectomy. A total of 19% of patients were readmitted with pancreatitis prior to definitive management. Conclusions First-line imaging investigations such as USS and CT can detect some cases of choledocholithiasis in patients with acute gallstone pancreatitis, but not all. Despite expenses in terms of cost and length of hospital stay, MRCP remains an essential resource to detect cases of choledocholithiasis not captured by USS or CT. We recommend establishing a guideline to streamline imaging in assessing acute gallstone pancreatitis.

Low Detection Rates of Bile Duct Stones During Endoscopic Treatment for Highly Suspected Bile Duct Stones with No Imaging Evidence of Stones

BACKGROUND

The revised American Society for Gastrointestinal Endoscopy (ASGE) guideline 2019 provides the high-risk criteria for suspected common bile duct stones (CBDSs).

AIMS

To evaluate CBDS detection rates during endoscopic retrograde cholangiopancreatography (ERCP) in high-risk patients with suspected CBDSs based on the ASGE guideline 2019.

METHODS

This multicenter retrospective study included 1100 consecutive patients who underwent ERCP for suspected CBDSs with any high-risk criteria based on the revised ASGE guideline 2019: Criterion 1, CBDSs on imaging; Criterion 2, clinical ascending cholangitis; and Criterion 3, total bilirubin exceeding 4 mg/dL and dilated common bile duct on imaging. We compared CBDS detection rates during ERCP based on individual and combined high-risk criteria.

RESULTS

The CBDS detection rates of patients who met any of the criteria, only Criterion 1, and Criteria 2 or 3 were 86.0% (946/1100), 93.4% (113/121), and 50.0% (106/212), respectively. In patients who met Criteria 1 and 2, 1 and 3, 2 and 3, and all criteria, CBDSs were confirmed during ERCP in 95.1% (490/515), 96.2% (25/26), 55.3% (26/47), and 98.4% (186/189), respectively. The CBDS detection rate during ERCP of patients with at least Criterion 1 significantly exceeded that of patients without at least Criterion 1 [95.7% (814/851) vs. 51.0% (132/259), respectively, P < 0.001].

CONCLUSIONS

Patients with CBDS visualization on imaging have very high CBDS detection rates during ERCP. However, performing ERCP on patients with only clinical predictors, such as cholangitis and dilated CBD with total bilirubin exceeding 4 mg/dL, often results in unnecessary ERCP.

Current approaches and questions yet to be resolved for the prophylaxis of post-endoscopic retrograde cholangiopancreatography pancreatitis

Prophylaxis is important for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP), which is the most common and serious complication of ERCP. Although the current guidelines include independent patient- and procedure-related risk factors for PEP and available PEP prophylactic measures, the synergistic effect of these risk factors on PEP should also be considered, given that patients often harbor multiple risk factors. Furthermore, a combination of prophylactic measures is often selected in clinical practice. However, established methods estimating the synergistic effect of independent risk factors on PEP incidence are lacking, and evidence on the impact of combining prophylactic measures on PEP should be discussed. Selection of appropriate candidate patients for ERCP is also important to reduce the incidence of PEP associated with unnecessary ERCP. ERCP indications in patients with asymptomatic common bile duct stones (CBDSs) and in those with suspected CBDSs with no imaging-based evidence of stones are controversial. Further studies are warranted to predict the synergistic effect of independent risk factors on PEP, determine the best prophylactic PEP measures, and identify appropriate candidates for ERCP in patients with asymptomatic CBDSs and those with suspected CBDSs.

Evaluating the role of endoscopic ultrasound in pancreatitis

INTRODUCTION

Endoscopic ultrasound (EUS) provides high-resolution images of both pancreatic parenchyma and duct and therefore is an integral component of evaluating and treating patients with pancreatitis and its complications. The development of enhanced EUS imaging techniques and newer EUS-specific accessories has expanded the diagnostic and therapeutic role of EUS in patients with acute and chronic pancreatitis (CP).

AREAS COVERED

This review discusses the current diagnostic and therapeutic role of EUS in acute pancreatitis (AP), CP, and autoimmune pancreatitis (AIP).

EXPERT OPINION

EUS plays a vital role in patients with AP by confirming the presence of common bile duct (CBD) stones in patients with acute biliary pancreatitis and intermediate probability of CBD stones. It plays an important role in the etiological evaluation of patients with idiopathic acute and recurrent pancreatitis. EUS is also an essential modality for diagnosing and managing pancreatico-biliary as well as gastroduodenal complications associated with CP. EUS-guided FNB using newer generation core biopsy needles has made possible accurate diagnosis of AIP by providing tissue samples with preserved architecture.

Role of endoscopic ultrasound in evaluation of patients with missed common bile duct stones

BACKGROUND

Choledocholithiasis develops in up to 20% of patients with gall bladder stones. The challenge in diagnosis usually occurs with small stones that may be missed by magnetic resonance cholangiopancreatography (MRCP). Endoscopic ultrasound (EUS) is accurate in detecting common bile duct (CBD) stones missed by MRCP, especially the small ones or those impacted at the distal CBD or the papillary region.

AIM

To evaluate the accuracy of EUS in detecting CBD stones missed by MRCP.

METHODS

Patients with an intermediate likelihood of choledocholithiasis according to ESGE guidelines and those with acute pancreatitis of undetermined cause were included. The presence of choledocholithiasis was evaluated by MRCP and EUS, and then results were confirmed by endoscopic retrograde cholangiopancreatography (ERCP). The sensitivity and specificity of EUS and MRCP were compared regarding the presence of stones, the size, and the number of detected stones.

RESULTS

Ninety out of 100 involved patients had choledocholithiasis, while ten patients were excluded as they had pancreatic or gall bladder masses during EUS examination. In choledocholithiasis patients, the mean age was 52.37 ± 14.64 years, and 52.2% were males. Most patients had biliary obstruction (74.4%), while only 23 (25.6%) patients had unexplained pancreatitis. The overall prevalence of choledocholithiasis was 83.3% by EUS, 41.1% by MRCP, and 74.4% by ERCP. Also, the number and size of CBD stones could be detected accurately in 78.2% and 75.6% by EUS and 41.1% and 70.3% by MRCP, respectively. The sensitivity of EUS was higher than that of MRCP (98.51% vs 55.22%), and their predictive value was statistically different (P < 0.001). Combination of both tools raised the sensitivity to 97.22% and specificity to 100%.

CONCLUSION

EUS could be a useful tool in assessing patients with suspected choledocholithiasis especially if combined with MRCP. However, its usefulness depends on its availability and the experience of the local centers.

Endoscopic ultrasound versus magnetic resonance cholangiopancreatography for the diagnosis of computed tomography-negative common bile duct stone: Prospective randomized controlled trial

OBJECTIVES

For suspected common bile duct stone (CBDS) missed on computed tomography (CT), there is no clear evidence on whether endoscopic ultrasound (EUS) or magnetic resonance cholangiopancreatography (MRCP) is the better diagnostic tool. We aimed to compare the diagnostic accuracy of EUS and MRCP for cases of missed CBDS on CT.

METHODS

Patients suspected of having CBDS were enrolled and randomly allocated to the EUS or MRCP group. Upon the initial examination, those having CBDS or sludge formation underwent endoscopic retrograde cholangiopancreatography (ERCP), while those who were CBDS-negative underwent a second examination with either MRCP or EUS, which was distinct from the initial diagnostic procedure. The primary outcome was diagnostic accuracy, and the secondary outcomes were diagnostic ability, detection rate and characteristics of CBDS in the second examination, and the frequency of adverse events.

RESULTS

Between April 2019 and January 2021, 50 patients were enrolled in the study. The accuracy was 92.3% for EUS and 68.4% for MRCP (P = 0.055). EUS showed 100% sensitivity, 88.2% specificity, 81.8% positive predictive value, and 100% negative predictive value, and MRCP showed 33.3% sensitivity, 84.6% specificity, 50% positive predictive value, and 73.3% negative predictive value. The CBDS detection rate in the second examination was 0% for MRCP after a negative EUS and 35.7% for EUS after a negative MRCP (P = 0.041). No adverse events occurred in any of the patients.

CONCLUSIONS

Endoscopic ultrasound may be a superior diagnostic tool compared to MRCP for the detection of CBDS that are undetected on CT. (UMIN000036357).

Predictors for stone recurrence after a successful common bile duct surgical exploration for choledocholithiasis

BACKGROUND

Recurrence after common bile duct stone (CBDS) clearance is the major long-term drawback of their management. Its prevalence is significant, and it occurs after all primary therapeutic alternatives. The aim of this study was to determine the predictive factors associated with stone recurrence after surgical common bile duct exploration (CBDE).

METHODS

A retrospective cohort study based on patients undergoing CBDE between 2000 and 2018 was conducted. Uni- and multivariate hierarchical regression analyses were performed to assess the independent predictive factors associated with recurrent CBDS in patients with initially successful surgery.

RESULTS

A total of 365 patients underwent successful surgical procedures. After a median follow-up of 43.2 (IQR 84) months, 31 (8.4%) patients were diagnosed with CBD stone recurrence. The median time to recurrence was 30.3 (IQR 38) months. The only variable associated with CBDS recurrence was preoperative endoscopic sphincterotomy (HR 2.436, 95% CI: 1.031-5.751, P = 0.042)).

CONCLUSION

Patients who undergo preoperative endoscopic sphincterotomy and then cholecystectomy with successful common bile duct clearance may be at increased risk for recurrent stone disease compared to those who go straight to surgery.

Artificial intelligence in the endoscopic approach of biliary tract diseases: A current review

In recent years there have been major developments in the field of artificial intelligence. The different areas of medicine have taken advantage of this tool to make various diagnostic and therapeutic methods more effective, safe, and user-friendly. In this way, artificial intelligence has been an increasingly present reality in medicine. In the field of Gastroenterology, the main application has been in the detection and characterization of colonic polyps, but an increasing number of studies have been published on the application of deep learning systems in other pathologies of the gastrointestinal tract. Evidence of the application of artificial intelligence in the assessment of biliary tract is still scarce. Some studies support the usefulness of these systems in the investigation and treatment of choledocholithiasis, demonstrating that they have the potential to be integrated into clinical practice and endoscopic procedures, such as endoscopic retrograde cholangiopancreatography. Its application in cholangioscopy for the investigation of undetermined biliary strictures also seems to be promising. Assessing the bile duct through endoscopic ultrasound can be challenging, especially for less experienced operators, thus becoming an area of potential interest for artificial intelligence. In this review, we summarize the state of the art of artificial intelligence in the endoscopic diagnosis and treatment of biliary diseases.

Accuracy of SAGES, ASGE, and ESGE criteria in predicting choledocholithiasis

BACKGROUND

Patients with suspected choledocholithiasis (CDL) are stratified as high-risk (HR), intermediate-risk (IR), and low-risk (LR) according to the guidelines of Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), American Society for Gastrointestinal Endoscopy (ASGE), and European Society of Gastrointestinal Endoscopy (ESGE). Although these approaches are invaluable, paucity of validation studies are currently available. This study aimed to evaluate the diagnostic accuracy of the above risk stratification criteria in predicting CDL.

METHODS

We conducted a retrospective cohort study of 280 patients with suspected CDL. All patients were stratified according to above professional societies as HR, IR, and LR, and diagnostic performance was evaluated.

RESULTS

In the HR group, area under the receiver operating characteristic curve (AUC) were 0.77 [95% confidence interval (CI), 0.70-0.84], 0.75 (95% CI, 0.68-0.81), and 0.74 (95% CI, 0.68-0.81) for SAGES, ASGE, and ESGE criteria, respectively. The diagnostic accuracy were 78.93% (81.13% sensitivity, 72.06% specificity), 75% (75.47% sensitivity, 73.53% specificity), and 70% (66.04% sensitivity, 82.35% specificity) for SAGES, ASGE, and ESGE criteria, respectively. Regarding the IR group, the diagnostic accuracy were 22.50% (16.98% sensitivity, 39.71% specificity), 25% (24.53% sensitivity, 26.47% specificity), and 30.00% (33.49% sensitivity, 19.12% specificity) for SAGES, ASGE, and ESGE criteria, respectively. The common bile duct stone (CBDS) visualized on imaging has the highest risk for CDL [odds ratio (OR), 13.59 (95% CI, 5.26-35.12)], followed by CBDS plus dilated common bile duct [OR, 13.33 (95% CI, 5.16-34.47)], CBDS plus cholangitis [OR, 13.33 (95% CI, 3.17-56.15)], and CBDS plus total bilirubin level > 1.7 mg/dL [OR, 9.89 (95% CI, 3.47-28.20)].

CONCLUSIONS

The current SAGES, ASGE, and ESGE criteria have acceptable diagnostic accuracy for CDL. The patients with visualized CBDS on imaging have the highest risk for CDL.

Improvement of the algorithm for diagnostics of postcholecystectomy syndrome taking into account functional and organic changes in the area of the large duodenal nipple

The aim. Improving the algorithm for diagnosing patients with postcholecystectomy syndrome (PCS), taking into account functional and organic changes in the major duodenal papilla (MDP). Materials and methods. 208 patients with PCS were examined. Laparoscopic cholecystectomy (CE) was performed in 172 patients in history, open CE was performed in 36 patients. 47 patients had obstructive jaundice, 84 had signs of biliary hypertension without an increase in bilirubin, 77 had no signs of biliary hypertension and an increase in bilirubin. The following instrumental research methods were used: abdominal organs ultrasound examination (AO USE), duodenoscopy, endoscopic retrograde cholangiopancreatography (ERCP), computed tomography (CT). In the main group, to study the morphofunctional changes in MDP, duodenoscopy with parietal impedancemetry, ultrasound of the hepatobiliary zone with a choleretic load were used. Results. In the main group, 34 patients underwent ultrasound of the hepatobiliary zone and Vater's nipple area with a choleretic breakfast according to Boyden according to the method of Grigoriev P.Ya. in our modification, 21 patients had an expansion of the choledochus by 2 mm. At the same time, taking meverin led to a decrease in the diameter of the choledochus, which indicated functional changes in the MDP. In 13 patients, the expansion of the choledochus, observed when taking a choleretic breakfast, persisted with the use of antispasmodics, which indicated the presence of an organic pathology of MDP. Duodenoscopy with impedancemetry was performed in 41 patients: 20 patients had 760–820 Ohm, which indicated the presence of functional changes, 12 patients had inflammatory changes in the MDP and 703–760 Ohm were detected, 9 patients with cicatricial fibrous changes had indicators impedance measurement 640–703 Ohm. The use of ultrasound with a choleretic breakfast and duodenoscopy with parietal impedancemetry in patients of the main group made it possible to identify functional and organic (inflammatory, fibrous) changes in the MDP, which made it possible to develop a therapeutic algorithm using both conservative therapy and the use of various options for transpapillary endoscopic interventions. Conclusions. Conducting an in-depth diagnosis of morpho-functional changes in MDP using parietal impedancemetry of MDP and ultrasound of the hepatobiliary zone with choleretic load allows us to identify both functional and morphological changes in MDP, which makes it possible to develop a therapeutic algorithm using drug therapy and transpapillary endoscopic techniques.

Accuracy of Ultrasound and Magnetic Resonance Cholangiopancreatography Findings in the Diagnosis of Biliary System Stones

This study aimed to evaluate the diagnostic accuracy of magnetic resonance cholangiopancreatography (MRCP) and Ultrasound (US) images for the diagnosis of biliary system stones, as well as to assess the consistency between MRCP and US findings. The study sample included 200 cases (90 males and 110 females) with symptomatic biliary system stones between 14 and 82 years. All cases underwent both the US and MRCP imaging for biliary system diagnosis. The study revealed that the most prominent age group with symptoms of biliary system stones was the 33-60-year-old group. It also found that the accuracy of US and MRCP in detecting gallbladder (GB) stones compared with the final diagnosis was 94% and 91%, respectively, with moderate conformity between their results. The accuracy of US and MRCP images in detecting common bile duct (CBD) stones was 61% and 98%, respectively, with fair conformity between their results. In addition, there is a significant agreement between the MRCP and US results in detecting the GB and CBD stones with an agreed percentage of 74% and 71%, respectively. The study concluded that US is the preferred imaging technique for patients with symptomatic gallbladder stones, whereas MRCP is a trustworthy investigation for common bile duct stones.

The Diagnostic Value of Endoscopic Ultrasonography for Common Bile Duct Dilatation without Identifiable Etiology Detected from Cross-Sectional Imaging

Background/Aims

Endoscopic ultrasonography (EUS) is warranted when cross-sectional imaging demonstrates common bile duct (CBD) dilatation without identifiable causes. This study aimed to assess the diagnostic performance of EUS in CBD dilatation of unknown etiology.

Methods

Retrospective review of patients with dilated CBD without definite causes undergoing EUS between 2012 and 2017.

Results

A total of 131 patients were recruited. The mean age was 63.2±14.1 years. The most common manifestation was abnormal liver chemistry (85.5%). The mean CBD diameter was 12.2±4.1 mm. The area under the receiver operating characteristic curve (AUROC) of EUS-identified pathologies, including malignancy, choledocholithiasis, and benign biliary stricture (BBS), was 0.98 (95% confidence interval [CI], 0.95-1.00). The AUROC of EUS for detecting malignancy, choledocholithiasis, and BBS was 0.91 (95% CI, 0.85-0.97), 1.00 (95% CI, 1.00-1.00), and 0.93 (95% CI, 0.87-0.99), respectively. Male sex, alanine aminotransferase ≥3× the upper limit of normal (ULN), alkaline phosphatase ≥3× the ULN, and intrahepatic duct dilatation were predictors for pathological obstruction, with odds ratios of 5.46 (95%CI, 1.74-17.1), 5.02 (95% CI, 1.48-17.0), 4.63 (95% CI, 1.1-19.6), and 4.03 (95% CI, 1.37-11.8), respectively.

Conclusions

EUS provides excellent diagnostic value in identifying the etiology of CBD dilatation detected by cross-sectional imaging.

Predicting common bile duct stones: Comparison of SAGES, ASGE and ESGE criteria for accuracy

OBJECTIVE

To determine accuracy of SAGES, ASGE and ESGE criteria for predicting presence of common bile duct (CBD) stones.

METHODS

In a prospective study at Jinnah Hospital Lahore from March 2021 to February 2022, patients with suspected CBD stone were stratified in High risk (HR), intermediate risk (IR) and low risk (LR) for SAGES, ASGE and ESGE criteria. All patients underwent ERCP and risk strata were analyzed using SPSS 22® for sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy.

RESULTS

In 90 patients with mean age 45.18(±14.87) and male/female ratio 0.64(35/55), area Under Curve (AUC) for predicting CBD stones was 0.75, 0.81and 0.83 for HR and 0.28, 0.52 and 0.52 for IR group while it was 0.53, 0.81 and 0.53 for absence of stone in LR group of SAGES, ASGE and ESGE criteria respectively. HR groups had accuracy of 81.1%, 86.7% and 87.8% in predicting CBD stone while LR criteria had 68.8%, 86.7% and 68.1% accuracy in predicting absence of CBD stone for SAGES, ASGE and ESGE respectively.

CONCLUSION

HR strata of SAGES, ASGE and ESGE scores have excellent accuracy in predicting CBD stones whereas IR and LR criteria are suboptimal for excluding CBD stones.

A Single Centre Experience With Routine Magnetic Resonance Cholangiopancreatography in the Management of Patients With Gall Stone Disease

AIM

To evaluate the role of preoperative magnetic resonance cholangiopancreatography (MRCP) in detection of common bile duct stone (CBDS) in cases of gall stone disease (GSD).

METHODS

This is a retrospective study with a prospectively maintained database, carried out in 116 patients who underwent laparoscopic cholecystectomy (LC) for GSD, from October 2017 to September 2020. Preoperative MRCP was performed in all cases.

RESULTS

MRCP detected CBDS in 23 out of 116 patients (19.8%) including silent CBDS in seven patients (6%). In situations of normal biochemical parameters and USG abdomen, 30.4% unnoticed CBDS out of all 23 CBDS, were discovered by MRCP. The sensitivity and specificity of aspartate aminotransferase (AST) or alanine aminotransferase (ALT) [positive predictive value (PPV): 24%; negative predictive value (NPV): 81.3%], alkaline phosphatase (ALP) (PPV: 63.2%; NPV: 88.7%), serum total bilirubin (PPV: 57.1%; NPV: 88.4%) and CBD diameter (PPV: 61.5%; NPV: 85.4%) were, respectively, 26.1% and 79.6%, 52.2% and 92.5%, 52.2% and 90.3%, and 34.8% and 94.6%. Cystic duct variations found in nine patients (7.75%). There was no bile duct injury (0%) noted in post operative patients.

CONCLUSION

With normal biochemical and USG parameters, MRCP is a valuable non-invasive investigation to detect the overlooked CBDS. After recognising the cystic duct variants, it may be possible to prevent bile duct injury. Before performing a laparoscopic cholecystectomy (LC) in GSD, a routine preoperative MRCP is highly recommended.

Factors related to the spontaneous passage of common bile duct stones through the papilla: a single-center retrospective cohort study

OBJECTIVE

Common bile duct (CBD) stones can spontaneously pass through the papilla. This study explored factors associated with stone passage by comparing differences in the clinical features of stones retained in the CBD and excreted stones.

METHODS

Data were retrospectively collected for all patients who were hospitalized in our center between March 2016 and May 2021 with clinical, laboratory, or imaging evidence of CBD stones. All patients underwent endoscopic retrograde cholangiopancreatography (ERCP) and were classified into two groups: group A (stones extracted by ERCP, n = 86) and group B (stones discharged before ERCP, n = 15). Demographic data, biochemical and radiological findings were compared between the groups.

RESULTS

Stone size (0.82 vs. 0.33 cm), and levels of total bilirubin (58.2 vs. 28.8 μmol/L), gamma-glutamyl transpeptidase (416.7 vs. 193.9 U/L), alkaline phosphatase (191.9 vs. 123.1 U/L), carbohydrate antigen 19-9 (603.7 vs. 37.2 U/mL), and α-L-fucosidase (37.4 vs. 22.6 U/L) were significantly higher in group A than in group B. Logistic regression analyses showed that stone size was the only factor significantly associated with spontaneous passage of CBD stones.

CONCLUSIONS

CBD stones less than 0.33 cm in size may be self-expelled through the papilla.

[Imaging diagnostics in acute pancreatitis]

Abdominal imaging is an important component of the diagnostics of acute pancreatitis. In addition to the clinical features and the laboratory constellation, it serves to establish the diagnosis or the exclusion of other diseases and also the identification and assessment of the course of local complications and vascular changes that can arise during the course of acute pancreatitis. Due to the numerous imaging examination methods that are available, their combination options and the different examination times, there are diverse application options that have to be taken into account, such as the severity and duration of the disease, concomitant diseases and complications of acute pancreatitis. A rational use of imaging is an important prerequisite for high quality and at the same time cost-effective patient care. This review summarizes the current importance of imaging in acute pancreatitis, with particular reference to the updated S3 guidelines on acute pancreatitis.

Management of cholelithiasis with choledocholithiasis: Endoscopic and surgical approaches

Gallstone disease and complications from gallstones are a common clinical problem. The clinical presentation ranges between being asymptomatic and recurrent attacks of biliary pain requiring elective or emergency treatment. Bile duct stones are a frequent condition associated with cholelithiasis. Amidst the total cholecystectomies performed every year for cholelithiasis, the presence of bile duct stones is 5%-15%; another small percentage of these will develop common bile duct stones after intervention. To avoid serious complications that can occur in choledocholithiasis, these stones should be removed. Unfortunately, there is no consensus on the ideal management strategy to perform such. For a long time, a direct open surgical approach to the bile duct was the only unique approach. With the advent of advanced endoscopic, radiologic, and minimally invasive surgical techniques, however, therapeutic choices have increased in number, and the management of this pathological situation has become multidisciplinary. To date, there is agreement on preoperative management and the need to treat cholelithiasis with choledocholithiasis, but a debate still exists on how to cure the two diseases at the same time. In the era of laparoscopy and mini-invasiveness, we can say that therapeutic approaches can be performed in two sessions or in one session. Comparison of these two approaches showed equivalent success rates, postoperative morbidity, stone clearance, mortality, conversion to other procedures, total surgery time, and failure rate, but the one-session treatment is characterized by a shorter hospital stay, and more cost benefits. The aim of this review article is to provide the reader with a general summary of gallbladder stone disease in association with the presence of common bile duct stones by discussing their epidemiology, clinical and diagnostic aspects, and possible treatments and their advantages and limitations.

The efficacy and safety of preoperative cholangiography via percutaneous transhepatic gallbladder drainage (PTGBD) for difficult laparoscopic cholecystectomy (LC)

BACKGROUND

Percutaneous transhepatic gallbladder drainage (PTGBD) is an important procedure for initial treatment of severe acute cholecystitis (AC) that is contraindicated for early laparoscopic cholecystectomy (LC). We presented our primary experience on a new approach of cholangiography via PTGBD (PTGBD-C) for preoperative delineation of biliary anatomy.

METHODS

A retrospective analysis was conducted on 93 patients who received PTGBD followed by LC for AC, with allocation into 2 groups that were PTGBD with (PTGBD-C group, 32 patients) or without (PTGBD-N group, 61 patients) cholangiography. All the clinical data, including demographics, cholangiography findings, operations, and complications, were collected and analyzed.

RESULTS

Cholangiography was attempted in 32 patients with a success of 31 cases, and the most common complication was transient fever in 3 patients. PTGBD-C group of patients showed significantly less operation time (83.2 ± 22.32 vs. 106.5 ± 40.25 min, P = 0.041) and conversion rate (0 vs. 2). There was no statistical difference in terms of postoperative hospitalization and complications.

CONCLUSIONS

PTGBD-C is a feasible and safe procedure for severe AC patients with delayed LC. It has advantages of direct cholangiography, being easy to perform and cost-effective, thus should be considered for clinical usage.

Remaining issues of recommended management in current guidelines for asymptomatic common bile duct stones

Current guidelines for treating asymptomatic common bile duct stones (CBDS) recommend stone removal, with endoscopic retrograde cholangiopancreatography (ERCP) being the first treatment choice. When deciding on ERCP treatment for asymptomatic CBDS, the risk of ERCP-related complications and outcome of natural history of asymptomatic CBDS should be compared. The incidence rate of ERCP-related complications, particularly of post-ERCP pancreatitis for asymptomatic CBDS, was reportedly higher than that of symptomatic CBDS, increasing the risk of ERCP-related complications for asymptomatic CBDS compared with that previously reported for biliopancreatic diseases. Although studies have reported short- to middle-term outcomes of natural history of asymptomatic CBDS, its long-term natural history is not well known. Till date, there are no prospective studies that determined whether ERCP has a better outcome than no treatment in patients with asymptomatic CBDS or not. No randomized controlled trial has evaluated the risk of early and late ERCP-related complications vs the risk of biliary complications in the wait-and-see approach, suggesting that a change is needed in our perspective on endoscopic treatment for asymptomatic CBDS. Further studies examining long-term complication risks of ERCP and wait-and-see groups for asymptomatic CBDS are warranted to discuss whether routine endoscopic treatment for asymptomatic CBDS is justified or not.

Comparison of Endoscopy First and Laparoscopic Cholecystectomy First Strategies for Patients With Gallstone Disease and Intermediate Risk of Choledocholithiasis: Protocol for a Clinical Randomized Controlled Trial

Background

The optimal approach for patients with gallbladder stones and intermediate risk of choledocholithiasis remains undetermined. The use of endoscopic retrograde cholangiopancreatography for diagnosis should be minimized as it carries considerable risk of postprocedural complications, and nowadays, less invasive and safer techniques are available.

Objective

This study compares the two management strategies of endoscopic ultrasound before laparoscopic cholecystectomy and intraoperative cholangiography for patients with symptomatic cholecystolithiasis and intermediate risk of choledocholithiasis.

Methods

This is a randomized, active-controlled, single-center clinical trial enrolling adult patients undergoing laparoscopic cholecystectomy for symptomatic gallbladder stones with intermediate risk of choledocholithiasis. The risk of choledocholithiasis is calculated using an original prognostic score (the Vilnius University Hospital Index). This index in a retrospective evaluation showed better prognostic performance than the score proposed by the American Society for Gastrointestinal Endoscopy in 2010. A total of 106 participants will be included and randomized into two groups. Evaluation of bile ducts using endoscopic ultrasound and endoscopic retrograde cholangiography on demand will be performed before laparoscopic cholecystectomy for one arm (“endoscopy first”). Intraoperative cholangiography during laparoscopic cholecystectomy and postoperative endoscopic retrograde cholangiopancreatography on demand will be performed in another arm (“cholecystectomy first”). Postoperative follow-up is 6 months. The primary endpoint is the length of hospital stay. The secondary endpoints are accuracy of the different management strategies, adverse events of the interventions, duct clearance and technical success of the interventions (intraoperative cholangiography, endoscopic ultrasound, and endoscopic retrograde cholangiography), and cost of treatment.

Results

The trial protocol was approved by the Vilnius Regional Biomedical Research Ethics Committee in December 2017. Enrollment of patients was started in January 2018. As of June 2020, 66 patients have been enrolled.

Conclusions

This trial is planned to determine the superior strategy for patients with intermediate risk of common bile duct stones and to define a simple and safe algorithm for managing choledocholithiasis.

Trial Registration

ClinicalTrials.gov NCT03658863; https://clinicaltrials.gov/ct2/show/NCT03658863.

International Registered Report Identifier (IRRID)

DERR1-10.2196/18837

Clinical Management of Bile Duct Diseases: Role of Endoscopic Ultrasound in a Personalized Approach

Biliary diseases are common, but clinical symptoms are often unspecific and direct access and visualization of the biliopancreatic system for diagnostic purpose is difficult. In the last decades endoscopic ultrasound (EUS) has become a primary method in the gastrointestinal tract. It significantly changed the role of endoscopy in diagnostic imaging in the gastrointestinal tract and adjacent organs. EUS has become an effective diagnostic tool in biliary stone disease as well as in the diagnosis of indeterminate biliary strictures. Furthermore, an EUS-directed transmural approach emerged as a safe and effective alternative to ERCP in patients requiring biliary drainage, in particular as a backup method if standard ERCP-approach fails. Development of new techniques, specific accessories and stents during the last decade led to an enormous step forward in terms of efficacy and safety of an EUS-directed approach. In the current article technical and clinical aspects of EUS-guided diagnostic and therapeutic approaches in different clinical indications will be discussed together with a review of the available data.

Diagnostic Accuracy of Endoscopic Ultrasonography Versus the Gold Standard Endoscopic Retrograde Cholangiopancreatography in Detecting Common Bile Duct Stones

Background and objectives Stone in the biliary tract is one of the most common causes of hospitalization. However, it is difficult to determine the prevalence of gallstones in the general population because they are often asymptomatic. Thus, management lies in the proper clearance of the common bile duct (CBD) along with the removal of the gallbladder, for which it must be diagnosed on time with proper accuracy. Imaging modalities including magnetic resonance cholangiopancreatography (MRCP), endoscopic ultrasound (EUS), and endoscopic retrograde cholangiopancreatography (ERCP) provide true visualization of choledocholithiasis with comparable sensitivities. The gold standard ERCP is an invasive procedure and may cause complications, such as pancreatitis, perforation, and bleeding. EUS is a minimally invasive procedure to assess the biliary tract using high-frequency sound waves. Until now the EUS has not been addressed much in our local tertiary care setups and this study was conducted to evaluate its accuracy in the diagnosis of choledocholithiasis. The objective of our study is to determine the diagnostic accuracy (specificity and sensitivity) of EUS versus ERCP for the diagnosis of choledocholithiasis. Materials and methods This retrospective study was conducted on patients suspected of having choledocholithiasis undergoing both EUS and ERCP based on their history, clinical symptoms, and laboratory test results including upper abdominal pain, deranged liver function enzymes, and a dilated CBD on radiology. EUS was initially performed for the diagnosis of extrahepatic biliary obstruction followed by one or more of the confirmatory criterion standard tests (including ERCP). In order to reduce the chances of passage of stone resulting in negative analysis, only those patients were included in which both procedures were conducted temporally close together (24-72 hours in most instances). The main outcome measures were diagnostic accuracy with the help of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) using a receiver operating characteristic curve. A total of 123 patients met the inclusion criteria via non-probability consecutive sampling methods. Results The mean age of our study population was 50.30 ± 13.91. We included 63 males (51.2%) and 60 females (48.8%). The most frequent indication for undergoing diagnostic procedures was deranged liver function tests (67.47%). The frequent comorbidities reported were hypertension (29.26%), diabetes (21.95%), chronic liver disease (16.26%), and ischemic heart disease (4.87%). Mean alkaline phosphatase and gamma-glutamyl transferase levels were markedly raised from the baseline in the study population. Post-ERCP complications were also reported in some of the study participants. About 85 patients (69.10%) were diagnosed with choledocholithiasis among the study participants. The diagnostic accuracy of EUS was compared with ERCP revealed an area under the curve (AUC) of 0.930, standard error of 0.031, 95% confidence interval of 0.868-0.991, the sensitivity of 89.5%, specificity of 96.5%, positive predictive value of 91.9%, and negative predictive value of 95.3%. Conclusion It is recommended that ERCP can be selectively conducted or excluded in patients with biliary obstruction in case of EUS negative, thus minimizing the complications and morbidity associated with an invasive procedure, with our results showing a comparative diagnostic accuracy of EUS.

2020 World Society of Emergency Surgery updated guidelines for the diagnosis and treatment of acute calculus cholecystitis

BACKGROUND

Acute calculus cholecystitis (ACC) has a high incidence in the general population. The presence of several areas of uncertainty, along with the availability of new evidence, prompted the current update of the 2016 WSES (World Society of Emergency Surgery) Guidelines on ACC.

MATERIALS AND METHODS

The WSES president appointed four members as a scientific secretariat, four members as an organization committee and four members as a scientific committee, choosing them from the expert affiliates of WSES. Relevant key questions were constructed, and the task force produced drafts of each section based on the best scientific evidence from PubMed and EMBASE Library; recommendations were developed in order to answer these key questions. The quality of evidence and strength of recommendations were reviewed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria (see https://www.gradeworkinggroup.org/ ). All the statements were presented, discussed and voted upon during the Consensus Conference at the 6th World Congress of the World Society of Emergency Surgery held in Nijmegen (NL) in May 2019. A revised version of the statements was voted upon via an online questionnaire until consensus was reached.

RESULTS

The pivotal role of surgery is confirmed, including in high-risk patients. When compared with the WSES 2016 guidelines, the role of gallbladder drainage is reduced, despite the considerable technical improvements available. Early laparoscopic cholecystectomy (ELC) should be the standard of care whenever possible, even in subgroups of patients who are considered fragile, such as the elderly; those with cardiac disease, renal disease and cirrhosis; or those who are generally at high risk for surgery. Subtotal cholecystectomy is safe and represents a valuable option in cases of difficult gallbladder removal.

CONCLUSIONS, KNOWLEDGE GAPS AND RESEARCH RECOMMENDATIONS

ELC has a central role in the management of patients with ACC. The value of surgical treatment for high-risk patients should lead to a distinction between high-risk patients and patients who are not suitable for surgery. Further evidence on the role of clinical judgement and the use of clinical scores as adjunctive tools to guide treatment of high-risk patients and patients who are not suitable for surgery is required. The development of local policies for safe laparoscopic cholecystectomy is recommended.

The Challenges of Implementing Artificial Intelligence into Surgical Practice

BACKGROUND

Artificial intelligence is touted as the future of medicine. Classical algorithms for the detection of common bile duct stones (CBD) have had poor clinical uptake due to low accuracy. This study explores the challenges of developing and implementing a machine-learning model for the prediction of CBD stones in patients presenting with acute biliary disease (ABD).

METHODS

All patients presenting acutely to Christchurch Hospital over a two-year period with ABD were retrospectively identified. Clinical data points including lab test results, demographics and ethnicity were recorded. Several statistical techniques were utilised to develop a machine-learning model. Issues with data collection, quality, interpretation and barriers to implementation were identified and highlighted.

RESULTS

Issues with patient identification, coding accuracy, and implementation were encountered. In total, 1315 patients met inclusion criteria. Incorrect international classification of disease 10 (ICD-10) coding was noted in 36% (137/382) of patients recorded as having CBD stones. Patients with CBD stones were significantly older and had higher aspartate aminotransferase (AST), alanine aminotransferase (ALT), bilirubin and gamma-glutamyl transferase (GGT) levels (p < 0.001). The no information rate was 81% (1070/1315 patients). The optimum model developed was the gradient boosted model with a PPV of 67%, NPV of 87%, sensitivity of 37% and a specificity of 96% for common bile duct stones.

CONCLUSION

This paper highlights the utility of machine learning in predicting CBD stones. Accuracy is limited by current data and issues do exist around both the ethics and practicality of implementation. Regardless, machine learning represents a promising new paradigm for surgical practice.

EUS assessment for intermediate risk of choledocholithiasis after a negative magnetic resonance cholangiopancreatography

Background and Aims

Guidelines recommend either EUS or magnetic resonance cholangiopancreatography (MRCP) for intermediate risk of choledocholithiasis. There is a lack of evidence that supports proceeding with EUS if the MRCP is negative and if clinical suspicion still exists.

Methods

This is a retrospective study of all patients who underwent EUS to assess for choledocholithiasis at a tertiary care referral center from July 2013 to October 2019.

Results

A total of 593 patients underwent EUS for evaluation for choledocholithiasis. Of the 593 patients, 35.2% (209/593) had an MRCP. 73.2% (153/209) had a negative MRCP while 26.8% (56/209) had a positive MRCP. Of the group of patients who underwent EUS with a negative MRCP, 15% (23/153) were positive for choledocholithiasis on EUS. Of these, 91% (21/23) were also positive for sludge or stones on endoscopic retrograde cholangiopancreatography and thus 14% (21/153) of the EUS were "true positives." There were no clinical or laboratory factors predictive of choledocholithiasis on univariate analysis in the EUS plus negative MRCP group. When further analyzing the MRCP negative group into MRCP-/EUS+ and MRCP-/EUS-subgroups, a total bilirubin >3 mg/dL predicted a bile duct stone (55% vs. 32%, P = 0.05).

Conclusion

The diagnostic yield of EUS for suspected choledocholithiasis in the setting of a negative MRCP is 14% in our cohort. EUS should be considered in patients with intermediate risk of choledocholithiasis with a negative MRCP if the clinical suspicion is still present, and especially if the total bilirubin is above 3 mg/dL.

Síndrome de Mirizzi que simulaba una neoplasia biliar maligna

El síndrome de Mirizzi puede cursar con manifestaciones clínicas y hallazgos imagenológicos y de laboratorio, similares a los encontrados en las neoplasias biliares malignas. Se describe el caso de un paciente cuyo enfoque clínico inicial y estudios de imágenes aportaron datos sugerentes de neoplasia de las vías biliares. Los marcadores tumorales (CA 19-9, CEA) resultaron elevados. Una nueva evaluación clínica y la exploración endoscópica por laparotomía de las vías biliares, permitieron establecer el diagnóstico de síndrome de Mirizzi. Después de la extracción del cálculo biliar y de la anastomosis entre el conducto hepático y el yeyuno, el paciente permaneció asintomático. En este caso, la reevaluación clínica y el uso del protocolo adecuado de estudio, contribuyeron a orientar y confirmar el diagnóstico de síndrome de Mirizzi, lo cual determinó la conducta terapéutica más acertada.

Intraoperative detection of the remnant cystic duct during robot-assisted surgery using near-infrared fluorescence imaging: a case report

Background

Post cholecystectomy syndrome is characterized as recurrence of symptoms as experienced before cholecystectomy. In rare cases, a remnant cystic duct is causing these symptoms and occasionally surgical resection is performed. During surgery, visualization of the biliary ducts could be difficult due to inflammation and dense adhesions.

Case presentation

In this article, we presented a 36-year old woman with post-cholecystectomy syndrome in which we evaluated the feasibility of near-infrared (NIR) fluorescence imaging using indocyanine green (ICG) for visualization of the remnant cystic and common bile duct during robot-assisted surgery. Intraoperative visualization of the remnant biliary duct and other important structures was feasible, and resection of the remnant cystic duct was successfully performed under fluorescence guidance, without any complications.

Conclusions

NIR fluorescence imaging of the biliary ducts using ICG does not prolong the operating time, and could potentially decrease the operation time in difficult procedures, because of easy and fast detection of the biliary tract. Furthermore, it is a non-hazardous and non-invasive technique, as it does not require use of radiation and cannot cause bile duct injury. This case illustrated that ICG NIR fluorescence imaging during difficult robot-assisted surgical procedures of the bile ducts is effective and therefore highly recommended.

Electronic supplementary material

The online version of this article (10.1186/s12893-019-0567-8) contains supplementary material, which is available to authorized users.

Post-endoscopic retrograde cholangiopancreatography pancreatitis: A systematic review for prevention and treatment

BACKGROUND

Post endoscopic retrograde cholangiopancreatography (ERCP) is comparatively complex application. Researchers has been investigated prevention of post-ERCP pancreatitis (PEP), since it has been considered to be the most common complication of ERCP. Although ERCP can lead various complications, it can also be avoided.

AIM

To study the published evidence and systematically review the literature on the prevention and treatment for PEP.

METHODS

A systematic literature review on the prevention of PEP was conducted using the electronic databases of ISI Web of Science, PubMed and Cochrane Library for relevant articles. The electronic search for the review was performed by using the search terms “Post endoscopic retrograde cholangiopancreatography pancreatitis” AND “prevention” through different criteria. The search was restricted to randomized controlled trials (RCTs) performed between January 2009 and February 2019. Duplicate studies were detected by using EndNote and deleted by the author. PRISMA checklist and flow diagram were adopted for evaluation and reporting. The reference lists of the selected papers were also scanned to find other relevant studies.

RESULTS

726 studies meeting the search criteria and 4 relevant articles found in the edited books about ERCP were identified. Duplicates and irrelevant studies were excluded by screening titles and abstracts and assessing full texts. 54 studies were evaluated for full text review. Prevention methods were categorized into three groups as (1) assessment of patient related factors; (2) pharmacoprevention; and (3) procedural techniques for prevention. Most of studies in the literature showed that young age, female gender, absence of chronic pancreatitis, suspected Sphincter of Oddi dysfunction, recurrent pancreatitis and history of previous PEP played a crucial role in posing high risks for PEP. 37 studies designed to assess the impact of 24 different pharmacologic agents to reduce the development of PEP delivered through various administration methods were reviewed. Nonsteroidal anti-inflammatory drugs are widely used to reduce risks for PEP. Rectal administration of indomethacin immediately prior to or after ERCP in all patients is recommended by European Society for Gastrointestinal Endoscopy guidelines to prevent the development of PEP. The majority of the studies reviewed revealed that rectally administered indomethacin had efficacy to prevent PEP. Results of the other studies on the other pharmacological interventions had both controversial and promising results. Thirteen studies conducted to evaluate the efficacy of 4 distinct procedural techniques to prevent the development of PEP were reviewed. Pancreatic Stent Placement has been frequently used in this sense and has potent and promising benefits in the prevention of PEP. Studies on the other procedural techniques have had inconsistent results.

CONCLUSION

Prevention of PEP involves multifactorial aspects, including assessment of patients with high risk factors for alternative therapeutic and diagnostic techniques, administration of pharmacological agents and procedural techniques with highly precise results in the literature.

The role of intraoperative cholangiography in patients undergoing laparoscopic cholecystectomy for acute gallstone pancreatitis: is magnetic resonance cholangiopancreatography needed?

INTRODUCTION

Intraoperative cholangiography is sporadically used in patients undergoing laparoscopic cholecystectomy to delineate common bile duct anatomy and exclude retained stones. In patients with acute gallstone pancreatitis, intraoperative cholangiography may reduce the need for preoperative magnetic resonance cholangiopancreatography.

MATERIALS AND METHODS

A retrospective review of a prospectively collected patient database was undertaken over a 15-year period. The primary objective was to evaluate intraoperative assessment of the common bile duct with intraoperative cholangiography in patients with acute gallstone pancreatitis.

RESULTS

A total of 2215 patients underwent laparoscopic cholecystectomy between October 1998 and December 2013; 113 patients (of whom 77 were women) with a mean age of 54 years (range 16-88 years) were diagnosed with acute gallstone pancreatitis. Of these, 102 patients (90%) underwent laparoscopic cholecystectomy with intraoperative cholangiography, which was normal in 89 cases. Thirteen patients had choledocholithiasis on intraoperative cholangiography, 11 of whom were managed with concomitant trans-cystic duct exploration and clearance. Two patients required postoperative endoscopic retrograde cholangiopancreatography.

CONCLUSIONS

In patients diagnosed with acute gallstone pancreatitis, it is reasonable to proceed directly to surgery using intraoperative cholangiography on the same admission as the definitive assessment of the common bile duct. This negates the need for magnetic resonance cholangiopancreatography and can translate into cost savings and reduced length of stay.

ASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasis

Each year choledocholithiasis results in biliary obstruction, cholangitis, and pancreatitis in a significant number of patients. The primary treatment, ERCP, is minimally invasive but associated with adverse events in 6% to 15%. This American Society for Gastrointestinal Endoscopy (ASGE) Standard of Practice (SOP) Guideline provides evidence-based recommendations for the endoscopic evaluation and treatment of choledocholithiasis. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework was used to rigorously review and synthesize the contemporary literature regarding the following topics: EUS versus MRCP for diagnosis, the role of early ERCP in gallstone pancreatitis, endoscopic papillary dilation after sphincterotomy versus sphincterotomy alone for large bile duct stones, and impact of ERCP-guided intraductal therapy for large and difficult choledocholithiasis. Comprehensive systematic reviews were also performed to assess the following: same-admission cholecystectomy for gallstone pancreatitis, clinical predictors of choledocholithiasis, optimal timing of ERCP vis-à-vis cholecystectomy, management of Mirizzi syndrome and hepatolithiasis, and biliary stent therapy for choledocholithiasis. Core clinical questions were derived using an iterative process by the ASGE SOP Committee. This body developed all recommendations founded on the certainty of the evidence, balance of risks and harms, consideration of stakeholder preferences, resource utilization, and cost-effectiveness.

Endoscopic Management of Acute Biliopancreatic Disorders

PURPOSE

Endoscopy is playing an ever-increasing role in the management of acute biliopancreatic disorders. With the management paradigm shifting away from more invasive surgical approaches, surgeons need to be aware of the treatment options available to improve patient care. Our manuscript serves to improve surgeons' knowledge and understanding of these emerging treatment modalities to expand their algorithmic approach to biliopancreatic disorders.

METHODS

Specific acute biliopancreatic disorders were identified from the literature and personal practice to create a structured review of common problems experienced by a surgeon of the gastrointestinal tract. An exhaustive literature review was performed to identify and analyze endoscopic treatment modalities for these disorders.

RESULTS

Endoscopic therapies continue to expand rapidly with a robust supportive literature. Data on endoscopic treatment strategies for acute biliopancreatic disorders demonstrate valuable improvements in outcomes in a number of these disorders.

DISCUSSION

Acute biliopancreatic disorders represent one of the most challenging pathophysiologies that a surgeon of the gastrointestinal tract may face. This manuscript represents a review of available endoscopic instrumentation as well as the author's interpretation of the current literature regarding indications and outcomes of endoscopic management for acute biliopancreatic disorders. Although this article does not supplant formal training in therapeutic endoscopy, surgeons reading this article should understand the role endoscopy plays in the management of acute biliopancreatic disorders.

Preoperative predictors of choledocholithiasis in patients presenting with acute calculous cholecystitis

BACKGROUND AND AIMS

Markedly increased liver chemistries in patients presenting with acute calculous cholecystitis (AC) often prompt an evaluation for concomitant choledocholithiasis (CDL). However, current guidelines directing the workup for CDL fail to address this unique population. The aims of this study are to define the range of presenting laboratory values and imaging findings in AC, develop a model to predict the presence of concurrent CDL, and develop a management algorithm that can be easily applied on presentation.

METHODS

We conducted a retrospective review of patients presenting with AC to a large tertiary hospital over a 3.5-year period. CDL was defined as common bile duct (CBD) stone(s), sludge, or debris seen on any of the following studies: US, CT, magnetic resonance imaging/MRCP, EUS, ERCP, or intraoperative cholangiogram. A multivariable model to predict CDL was developed on 70% of the patients and validated on the remaining 30%.

RESULTS

A total of 366 patients were identified and 65 (17.8%) had concurrent CDL. Univariable analysis was used to predict CDL and demonstrated statistically significant odds ratios for transaminases >3 times the upper limit of normal, alkaline phosphatase (AlkPhos) above normal, lipase >3 times the upper limit of normal, total bilirubin ≥1.8 mg/dL, and CBD diameter >6 mm. In the validation cohort, an optimal model containing alanine transaminase (ALT) >3 times the upper limit of normal, abnormal AlkPhos, and CBD diameter >6 mm was found to have an area under the receiver operating curve of 0.91. When 0 or 1 risk factors were present, 98.6% of patients did not have CDL. When all 3 risk factors were present, 77.8% were found to have CDL.

CONCLUSIONS

The prevalence of CDL is high among patients with AC. When a validated model is used, application of cutoffs for ALT, AlkPhos, and CBD diameter can effectively triage patients with low and high likelihood for CDL to surgery or ERCP, respectively.

2017 WSES and SICG guidelines on acute calcolous cholecystitis in elderly population

Background

Gallstone disease is very common afflicting 20 million people in the USA. In Europe, the overall incidence of gallstone disease is 18.8% in women and 9.5% in men. The frequency of gallstones related disease increases by age. The elderly population is increasing worldwide.

Aim

The present guidelines aims to report the results of the World Society of Emergency Surgery (WSES) and Italian Surgical Society for Elderly (SICG) consensus conference on acute calcolous cholecystitis (ACC) focused on elderly population.

Material and methods

The 2016 WSES guidelines on ACC were used as baseline; six questions have been used to investigate the particularities in elderly population; the answers have been developed in terms of differences compared to the general population and to statements of the 2016 WSES Guidelines. The Consensus Conference discusses, voted, and modified the statements. International experts contributed in the elaboration of final statements and evaluation of the level of scientific evidences.

Results

The quality of the studies available decreases when we approach ACC in elderly. Same admission laparoscopic cholecystectomy should be suggested for elderly people with ACC; frailty scores as well as clinical and surgical risk scores could be adopted but no general consensus exist. The role of cholecystostomy is uncertain.

Discussion and conclusions

The evaluation of pro and cons for surgery or for alternative treatments in elderly suffering of ACC is more complex than in young people; also, the oldest old age is not a contraindication for surgery; however, a larger use of frailty and surgical risk scores could contribute to reach the best clinical judgment by the surgeon. The present guidelines offer the opportunity to share with the scientific community a baseline for future researches and discussion.

Diagnostic Endoscopic Ultrasound: Technique, Current Status and Future Directions

Endoscopic ultrasound (EUS) is now well established as an important tool in clinical practice. From purely diagnostic imaging, it has progressed to include tissue acquisition, which provided the basis for therapeutic procedures. Even as interventional EUS developed, there has been ongoing progress in EUS diagnostic capabilities due to improved imaging systems, better needles for tissue acquisition and development of enhanced imaging functions such as contrast harmonic EUS (CHEUS) and EUS elastography. EUS is well established for differentiation of subepithelial lesions, for T-staging of luminal gastrointestinal and pancreaticobiliary malignancies, for differentiation of benign pancreaticobiliary disorders and for diagnostic tissue acquisition, which can be achieved by EUS-guided fine needle aspiration or by EUS-guided fine needle biopsy using dedicated biopsy needles. This review briefly describes the technique of performing EUS and then discusses its clinical utility in terms of gastrointestinal cancer staging, the evaluation of pancreaticobiliary disorders and tissue acquisition. Enhanced imaging techniques such as CHEUS and EUS elastography are briefly reviewed.

Combination of serum gamma-glutamyltransferase and alkaline phosphatase in predicting the diagnosis of asymptomatic choledocholithiasis secondary to cholecystolithiasis

BACKGROUND

Gamma-glutamyltransferase (GGT) is one of the most important laboratory tests for the evaluation of liver damage. Through a long-term clinical observation of patients with secondary asymptomatic choledocholithiasis, we found that most patients had abnormal GGT serum levels.

AIM

To investigate the combination of serum GGT and alkaline phosphatase (ALP) in predicting the diagnosis of asymptomatic choledocholithiasis secondary to cholecystolithiasis.

METHODS

In this retrospective cohort study, the clinical data of 829 patients with cholecystolithiasis admitted to the Third Affiliated Hospital of Zunyi Medical College from August 2014 to August 2017 were collected. Among these patients, 151 patients had secondary asymptomatic choledocholithiasis and served as the observation group, and the remaining 678 cholecystolithiasis patients served as the control group. Serum liver function indexes were detected in both groups, and the receiver operating characteristic (commonly known as ROC) curves were constructed for markers showing statistical significances. The cutoff value, sensitivity, and specificity of each marker were calculated according to the ROC curves.

RESULTS

The overall incidence of asymptomatic choledocholithiasis secondary to cholecystolithiasis was 18.2%. The results of liver function indexes including serum aspartate aminotransferase, alanine aminotransferase, direct bilirubin and total bilirubin levels showed no significant differences between the two groups (P > 0.05). However, the serum GGT and ALP levels were significantly higher in the observation group than in the control group (P < 0.05). The ROC curve analysis showed that the area under the curve was 0.881 (95%CI: 0.830-0.932), 0.647 (95%CI: 0.583-0.711) and 0.923 (95%CI: 0.892-0.953) for GGT, ALP, and GGT + ALP, respectively. The corresponding cut-off values of GGT and ALP were 95.5 U/L and 151.5 U/L, sensitivity were 90.8% and 65.1%, and specificity were 83.6% and 59.8%, respectively. The sensitivity and specificity of GGT + ALP were 93.5% and 85.1%, respectively.

CONCLUSION

An abnormally elevated serum GGT level has an important value in the diagnosis of asymptomatic choledocholithiasis secondary to cholecystolithiasis. The combination of serum GGT and ALP has better diagnostic performance. As a convenient, rapid and inexpensive test, it should be applied in secondary asymptomatic choledocholithiasis routine screening.

Selective Antegrade Biliary Stenting Aids Emergency Laparoscopic Cholecystectomy

Background: Symptomatic gall stone disease requires early emergency treatment to prevent complications. This early treatment is often delayed due to difficulty in the diagnosis and management of concomitant choledocholithiasis. Intervention with preoperative endoscopic retrograde cholangiopancreatography (ERCP) is associated with complications and known to be unnecessary in most cases. We follow a strategy of providing early cholecystectomy with selective utility of antegrade stent in cases of choledocholithiasis. Our main aim is to present our technique and results. Method: We conducted a 3-year (January 2014 to January 2017) review of a prospectively maintained database of our practice of performing routine intraoperative cholangiogram (IOC) during laparoscopic cholecystectomy (LC) and when choledocholithiasis is encountered on IOC; a transcystic antegrade biliary stent is inserted to decompress the common bile ducts (CBD) and facilitate postoperative ERCP at later date. Results: Of the 411 cholecystectomies performed, 77.3% were females with mean age of 48 years. Seventy-four patients were found to have CBD stones (CBDS) on IOC. Antegrade stents were successfully deployed in 69 cases. Even though Antegrade stents were done more frequently in emergency admissions (P = .001); this did not increase the length of hospital stay (LOHS) (P = .752) or the rate of complications (P = .171). However, doing a preoperative ERCP significantly increased LOHS (P = .001), and 67% of these needed two or more ERCP for complete clearance of CBD and had more complications. Nine (15.2%) out of 59 patients with pancreatitis had CBDS on IOC and were successfully managed with antegrade stent. Conclusion: This strategy can be followed by general surgeons, enabling them to perform LC in the presence of choledocholithiasis during acute admissions including pancreatitis. It does not require any specialist skills in CBD exploration and also eliminates unnecessary preoperative ERCP and avoids its potential complications.

Routine MRCP in the management of patients with gallbladder stones awaiting cholecystectomy: a single-centre experience

Objectives

To assess the frequency of choledocolithiasis and the role of preoperative laboratory findings, ultrasound (US) and magnetic resonance cholangio-pancreatography (MRCP) in the detection of choledocolithiasis in patients with gallbladder stones awaiting cholecystectomy.

Methods

A consecutive sample of 104 patients underwent MRCP prior to cholecystectomy. The patients were classified into different groups on the basis of the risk of choledocolithiasis. A specialised doctor with more 10 years of experience performed the US interpretation and a radiologist performed the MRCP interpretation blinded to US or aspartate aminotransferase (AST)/alanine aminotransferase (ALT)/alkaline phosphatase (ALP) results. A chi-square (χ²) test was performed to assess the statistical significance of differences in the frequency of choledocolithiasis based on laboratory findings, choledocal diameter on US and group risk.

Results

MRCP showed calculi in 7 out of 104 patients (6.7%), with no statistically significant differences between the high/moderate risk and low/no risk groups and between the patients with normal and altered laboratory findings or choledocal diameter on preoperative US. The sensitivity and specificity of AST/ALT [positive predictive value (PPV): 12%; negative predictive value (NPV): 94%], ALP (PPV: 7%; NPV: 94%), total serum bilirubin (PPV: 6%; NPV: 93%) and choledocal diameter (PPV: 20%; NPV: 94%) were, respectively, 28.6 and 94.8%, 85.7 and 17.5%, 14.3 and 93.8%, and 14.3 and 95.9%.

Conclusions

MRCP is a reliable evaluation for the detection of common bile duct (CBD) stones, reducing the misdiagnosis of retained choledocholithiasis with normal biochemical predictors and US examination.

Main messages

• MRCP is a non-invasive method for the detection of CBD stones.

• Preoperative MRCP reduces the misdiagnosis of retained choledocholithiasis.

• Detection of choledocholithiasis is mandatory prior to cholecystectomy to avoid surgical morbidity