Biliary manometry, bacterial characteristics, bile composition, and histologic changes fifteen to seventeen years after endoscopic sphincterotomy

Incidental Intraoperatively Detected Choledocholithiasis: A General Surgeon's Approach to Management

Background Up to 15% of patients with cholelithiasis have choledocholithiasis, with almost 10% not detected pre-operatively. Our study aims to quantify the prevalence of incidental choledocholithiasis during routine intra-operative cholangiogram (IOC), identify the best management pathway, and identify reliable pre-operative factors to predict choledocholithiasis. Methods We conducted a single-centre, retrospective cohort study at St John of God Midland Hospital in Western Australia, Perth, on 880 consecutive patients who underwent cholecystectomies performed by 15 surgeons between January 2, 2020, and December 30, 2021.  Results The overall choledocholithiasis rates were 10.6% (93), with 4.0% (35) diagnosed pre-operatively and 6.6% (58) diagnosed during IOC. In all, 50% of incidental choledocholithiasis during IOC were managed with hyoscine butylbromide, with a 55.2% success rate; 22.4% of patients received octreotide, with a 61.5% success rate; and 8.6% of patients underwent trans-cystic bile duct exploration (TCBE) and 8.6% underwent postoperative endoscopic retrograde cholangiopancreatography (ERCP), both with 100% success rates. Choledocholithiasis most commonly presents with gallstone pancreatitis, with a median aspartate aminotransferase (AST) level 7.2 times and alanine transaminase (ALT) level 7.8 times higher than those of patients without choledocholithiasis. Magnetic resonance cholangiopancreatography (MRCP) was the most sensitive in identifying choledocholithiasis with a 66.7% pickup rate. The median common bile duct (CBD) diameter on ultrasound was 8 mm, computerised tomography scans were 11 mm, and MRCP was 9 mm. Conclusion One in 10 cholecystectomies will be complicated with choledocholithiasis, and over half will be incidentally diagnosed during routine IOC. We propose IOC in all cases and hyoscine butylbromide, octreotide, and saline flushes as first-line treatment; if unsuccessful, TCBE is performed. Gallstone pancreatitis, markedly elevated AST/ALT, and imaging showing CBD ≥8 mm may serve as early predictors of choledocholithiasis.

Endoclip papillaplasty (ECPP) versus limited EST plus EPLBD for a decrease in recurrent choledocholithiasis: a prospective cohort study

BACKGROUND AND AIMS

Limited EST plus EPLBD has been widely used for the therapy of large CBDS; however, long-term complication-relevant studies suggested that it damaged the function of the sphincter of Oddi (SO) and resulted in recurrent choledocholithiasis. Thus, we designed Endoclip papillaplasty (ECPP) and previous studies have shown that it successfully restored the function of SO. In this study, we designed a prospective cohort and aimed to verify the safety and effectiveness of ECPP.

METHODS

Eligible patients were divided into the ECPP group and the limited EST plus EPLBD group based on papillary morphology and the ratio of maximum size of stones to length of intramural segments of CBD. All participants in the ECPP group received endoscopy at 3 weeks to retrieve the biliary stent, perform SOM, and were divided into grade A and grade B based on the healing grade of SO. All patients were followed up every 6 months until recurrent choledocholithiasis, patient death, or at the 36-month follow-up end. The primary outcome was the incidence of recurrent choledocholithiasis. The secondary outcomes included mechanical lithotrip usage and adverse events.

RESULTS

The incidences of recurrent choledocholithiasis in the ECPP group and limited EST plus EPLBD group were 13.6 and 22.1%, respectively (P = 0.204). The ECPP-A group had a lower incidence of recurrent choledocholithiasis than the limited EST plus EPLBD groups (5.1 vs. 22.1%, P = 0.020*), and certified the function of SO successfully restored in the ECPP-A group.

CONCLUSION

The ECPP-A group had a decrease in recurrent choledocholithiasis, and ECPP was safe and effective for CBDS.

Evaluation of therapeutic efficacy, safety and economy of ERCP and LTCBDE in the treatment of common bile duct stones

Objectives: This study further compared the endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic transcystic common bile duct exploration (LTCBDE) approaches in the treatment of common bile duct stones (CBDS) from the perspective of efficacy, safety and economy.

Methods: The therapeutic efficacy and safety of ERCP and LTCBDE approaches were retrospectively compared. Cost-effectiveness analysis of clinical economics was performed to analyze and evaluate the two approaches.

Results: There was no significant difference in the success rate of surgery and bile stone residue between ERCP and LTCBDE group. The incidence of postoperative complications in ERCP group was significantly higher than that in the LTCBDE group; while the incidence of pancreatitis in the ERCP group was significantly higher than that in the LTCBDE group. There was no significant difference in biliary infection, bile leakage and sepsis between ERCP and LTCBDE groups. In terms of cost, the costs of surgery and nursing were significantly lower, the costs of treatment and sanitary materials were significantly higher in the ERCP group than that in the LTCBDE group. There was no significant difference in the costs of medical examination, laboratory test, medicine cost and total cost between ERCP group and LTCBDE group. The total length of hospital stay, length of hospital stay before surgery and duration of surgery in the ERCP group were significantly lower than that in the LTCBDE group; there was no significant difference in length of hospital stay after surgery between the ERCP and LTCBDE group. The cost-effectiveness ratio of ERCP group was 34171.25, and the cost-effectiveness of LTCBDE group was 34524.25. The incremental cost-effectiveness ratio (ICER) of the two groups was 51415.

Conclusion: ERCP and LTCBDE approaches had similar therapeutic efficacy in the treatment of CBDS. The safety of LTCBDE approach is superior to that of ERCP approach for the treatment of CBDS. ERCP approach is more economical in the treatment of CBDS than LTCBDE approach.

Development of upper gastrointestinal cancer in patients with symptomatic gallstones, cholecystectomy, and sphincterotomy: A nationwide cohort study

BACKGROUND AND OBJECTIVE

Exposures of gallstones and treatments thereof in relation to development of cancer have not been explored before in long-term follow-up studies. Our objective was to determine whether symptomatic gallstones, cholecystectomy, or sphincterotomy were associated with development of upper gastrointestinal cancers.

METHODS

This is a nationwide cohort study of persons born in Denmark 1930-1984 included from age 30 years with long-term follow-up (1977-2014). Exposures were hospital admissions with gallstones, cholecystectomy, and sphincterotomy. Time-varying covariates were included in analyses to allow the impact of exposures to change with time. Follow-up periods were 2-5 and > 5 years. Hazard ratios (HR) with 95% confidence intervals (CI) were reported.

RESULTS

A total of 4,465,962 persons were followed. We found positive associations between sphincterotomy and biliary (>5 years HR 4.34, CI [2.17-8.70]), gallbladder (2-5 years HR 20.7, CI [8.55-50.1]), and pancreatic cancer (2-5 years HR 3.68, CI [2.09-6.49]). Cholecystectomy was positively associated with duodenal (2-5 years HR 2.94, CI [1.31-6.58]) and small bowel cancer (2-5 years HR 2.75, CI [1.56-4.87]). Inverse associations were seen for cholecystectomy and biliary (>5 years HR 0.60, CI [0.41-0.87]), pancreatic (>5 years HR 0.45 CI [0.35-0.57]), esophageal (>5 years HR 0.57, CI [0.43-0.74]), and gastric cancer (>5 years HR 0.68, CI [0.55-0.86]) and for gallstones and pancreatic cancer (>5 years HR 0.66, CI [0.47-0.93]). Gallstones were positively associated with gallbladder (>5 years HR 3.51, CI [2.02-6.10]) and small bowel cancer (2-5 years HR 3.21, CI [1.60-6.45]).

CONCLUSIONS

A positive association between sphincterotomy and biliary cancer was identified. Cholecystectomy seems to be inversely associated with biliary, pancreatic, esophageal, and gastric cancer. Associations should be explored in similar large cohorts.

Paradoxical Stimulatory Response of Remanent Sphincter of Oddi to Buscapina After Endoscopic Sphincterotomy

Background/Aims

Endoscopic removal of bile duct stones has become the treatment of choice, which includes endoscopic sphincterotomy (EST) in the majority of cases, destroying at least partially the Oddi sphincter (OS). Loss of sphincter function in variable grade has been described, but changes in innervation are not known.

Methods

Endoscopic manometry of OS was performed in 14 patients after EST with specialized perfused catheter. Pressure values were registered before and after 10 mg Buscapina injected intravenously.

Results

Choledocho-duodenal pressure gradient was absent in all of 14 patients. Basal OS pressure was zero in 7 and conserved in normal range in the remaining 7. Phasic motor activity was registered in 11 patients and was absent in 3 patients. After 10 mg Buscapina intravenous injection, instead of habitual inhibition, increase in basal OS pressure and in frequency of phasic contractions was observed in 9 patients. This response was not related to age of patients, neither with time elapsed between the EST and manometry, nor the estimated size of papillotomy orifice. Duodenal peristalsis was invariably inhibited in all patients.

Conclusions

EST destroys not only the smooth muscle of OS, also alters the innervation interrupting the duodeno-sphincteric nerve circuit. This finding questions the use of Buscapina or other anticholinergic agent as spasmolytic in patients after EST.

Endoclip papillaplasty restores sphincter of Oddi function: Pilot study

OBJECTIVES

Endoscopic sphincterotomy (EST) damaged the sphincter of Oddi (SO) function. This study aimed to explore the feasibility and efficacy of endoclip papillaplasty in restoring SO function.

METHODS

This prospective pilot study included consecutive patients with choledocholithiasis (stone size ≥10 mm) who underwent large-EST for stone removal, followed by endoclip papillaplasty, between May 2018 and March 2019.

RESULTS

Thirty patients were enrolled in this trail. Overall, 80% of the patients had a SO basal pressure of >10 mmHg after endoclip papillaplasty. Manometric parameters, including SO basal pressure, phasic wave contraction amplitude, phasic waves per minute, recovered after endoclip papillaplasty (P > 0.05). There were no significant differences in the manometric parameters of SO between healing grades A and B. Six patients developed mild post-endoscopic retrograde cholangiopancreatography pancreatitis, including three that had pancreatic stenting. Bile duct stone recurrence developed in 3.3% of the patients (1/30) during an 18-month follow-up.

CONCLUSIONS

Endoclip papillaplasty might restore SO function and possibly prevented biliary stone and cholangitis recurrence.

Safety and long-term outcomes of endoscopic papillary balloon dilation for removal of common bile duct stones

BACKGROUND

Endoscopic papillary balloon dilation (EPBD) is an effective treatment for common bile duct stones (CBDSs), but there have been few evaluations on its safety and long-term outcomes.

AIM

To assess the safety and long-term outcomes of EPBD in the treatment of CBDSs.

METHODS

The clinical data of patients who underwent CBDSs removal by EPBD from January 2014 to December 2015 at our hospital were reviewed. The main outcomes were stone clearance, endoscopic retrograde cholangiopancreatography (ERCP)-related complications, and stone recurrence.

RESULTS

A total of 42 patients with CBDSs who underwent EPBD at our hospital were reviewed. The overall successful CBDSs clearance was 100%. ERCP-related complications occurred in four ERCP procedures, all of which were pancreatitis. There was no perforation, bleeding, or cholangitis. Ten (23.8%) of forty-two patients had CBDSs recurrence after a mean period of 51.8 mo (18-66 mo) from the end of EPBD. Female gender (odds ratio = 22.891, 95% confidence interval: 1.544-339.362, P = 0.023) was significantly related to stone recurrence.

CONCLUSION

EPBD is safe and effective in the removal of CBDSs. Female gender may be a risk factor for stone recurrence in a long term.

Microbial Contamination, Infection, and Antimicrobial Use During Total Pancreatectomy With Islet Autotransplantation

OBJECTIVES

Total pancreatectomy with islet autotransplantation can relieve pain associated with chronic pancreatitis while preserving islet function. Islet preparations are often contaminated by enteric flora. We assessed the impact of contaminated islet preparations on the prevalence of postoperative infection.

METHODS

Electronic health records for patients who underwent total pancreatectomy with islet autotransplantation from August 1, 2011, to November 15, 2017 were retrospectively reviewed to compare the prevalence of postoperative infection in patients with a positive islet culture and islet culture negative patients.

RESULTS

Sixty-one patients were included. Twenty-nine patients (47.5%) had a positive islet culture, and 23 (79.3%) of these patients received antimicrobial prophylaxis. The prevalence of postoperative infection did not differ between the islet culture positive and islet culture negative groups (41% vs 34%, P = 0.57). No infections occurred in the 6 islet culture positive patients who did not receive prophylaxis. No difference in intensive care unit or hospital length of stay or in 30-day or 90-day readmission rates were observed.

CONCLUSIONS

Despite the common use of postoperative systemic antimicrobials, we observed no difference in the prevalence of postoperative infection, length of stay, or hospital readmission in patients receiving a contaminated islet preparation. If prophylactic antimicrobials are used, the duration should be minimized.

Risk of cholangiocarcinoma in patients undergoing therapeutic endoscopic retrograde cholangiopancreatography or cholecystectomy: A population based study

BACKGROUND

Cholangiocarcinoma is a highly lethal disease that had been underestimated in the past two decades. Many risk factors are well documented for in cholangiocarcinoma, but the impacts of advanced biliary interventions, like endoscopic sphincterotomy (ES), endoscopic papillary balloon dilatation (EPBD), and cholecystectomy, are inconsistent in the previous literature.

AIM

To clarify the risks of cholangiocarcinoma after ES/EPBD, cholecystectomy or no intervention for cholelithiasis using the National Health Insurance Research Database (NHIRD).

METHODS

From data of NHIRD 2004-2011 in Taiwan, we selected 7938 cholelithiasis cases as well as 23814 control group cases (matched by sex and age in a 1:3 ratio). We compared the previous risk factors of cholangiocarcinoma and cholangiocarcinoma rate in the cholelithiasis and control groups. The incidences of total and subsequent cholangiocarcinoma were calculated in ES/EPBD patients, cholecystectomy patients, cholelithiasis patients without intervention, and groups from the normal population.

RESULTS

In total, 537 cases underwent ES/EPBD, 1743 cases underwent cholecystectomy, and 5658 cholelithiasis cases had no intervention. Eleven (2.05%), 37 (0.65%), and 7 (0.40%) subsequent cholangiocarcinoma cases were diagnosed in the ES/EPBD, no intervention, and cholecystectomy groups, respectively, and the odds ratio for subsequent cholangiocarcinoma was 3.13 in the ES/EPBD group and 0.61 in the cholecystectomy group when compared with the no intervention group.

CONCLUSION

In conclusion, symptomatic cholelithiasis patients who undergo cholecystectomy can reduce the incidence of subsequent cholangiocarcinoma, while cholelithiasis patients who undergo ES/EPBD are at a great risk of subsequent cholangiocarcinoma according to our findings.

Endoscopic management of anastomotic stricture after living-donor liver transplantation

The most effective and fundamental treatment for end-stage liver disease is liver transplantation. Deceased-donor liver transplantation has been performed for many of these cases. However, living-donor liver transplantation (LDLT) has emerged as an alternative because it enables timely procurement of the donor organ. The success rate of LDLT has been improved by development of the surgical technique, use of immunosuppressant drugs, and accumulation of post-transplantation care experience. However, the occurrence of biliary stricture after LDLT remains a problem. This article reviews the pathogenesis, diagnosis, endoscopic management, and long-term outcomes of post-liver transplantation biliary stricture, with a focus on anastomotic stricture.

Japan Gastroenterological Endoscopy Society guidelines for endoscopic sphincterotomy

The Japan Gastroenterological Endoscopy Society (JGES) has recently compiled guidelines for endoscopic sphincterotomy (EST) using evidence-based methods. Content regarding actual clinical practice, including detailed endoscopic procedures, instruments, device types and usage, has already been published by the JGES postgraduate education committee in May 2015 and, thus, in these guidelines we avoided duplicating such content as much as possible. The guidelines do not address pancreatic sphincterotomy, endoscopic papillary balloon dilation (EPBD), and endoscopic papillary large balloon dilation (EPLBD). The guidelines for EPLBD are planned to be developed separately. The evidence level in this field is often low and, in many instances, strong recommendation has to be determined on the basis of expert consensus. At this point in time, the guidelines are divided into six items including indications, techniques, specific cases, adverse events, outcomes, and postoperative follow up.

Comparable Long-term Outcomes of 1-Minute vs 5-Minute Endoscopic Papillary Balloon Dilation for Bile Duct Stones

BACKGROUND & AIMS

Endoscopic papillary balloon dilation (EPBD) is an alternative to endoscopic sphincterotomy for choledocholithiasis. Unlike endoscopic sphincterotomy, EPBD preserves biliary sphincter function, reducing long-term risk of recurrent choledocholithiasis by 50%. Guidelines recommend that duration of EPBD exceeds 2 minutes, to adequately loosen the sphincter and reduce risks of failed stone extraction and post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. However, it is unclear whether this long duration of EPBD impairs sphincter function and negates the long-term benefit of EPBD. We performed a randomized controlled trial to determine whether long-duration (>1 minute) EPBD increases the risk of subsequent choledocholithiasis and hepatobiliary complications compared with short-duration EPBD (<1 minute).

METHODS

We performed a prospective study of 170 adult patients who underwent ERCP for suspected choledocholithiasis from April 2007 through October 2008 at 2 centers in Taiwan. Patients were randomly assigned to groups that underwent 1-minute (n = 86) or 5-minute (n = 84) EPBD for choledocholithiasis; patients were followed through June 2015. One month after the initial ERCP, patients were examined and liver function tests and abdominal sonographies were performed. Patients were then examined every 3-6 months over a median follow-up period of approximately 7 years. The primary outcome was recurrent choledocholithiasis or acute cholangitis and the secondary outcome was overall hepatobiliary complications. We assessed the effects of EPBD duration by Cox regression.

RESULTS

Thirteen patients (15.1%) developed recurrent choledocholithiasis or acute cholangitis after 1-minute EPBD, and 10 patients (11.9%) developed recurrent choledocholithiasis or acute cholangitis after 5-minute EPBD (P = .352). There was no significant difference between groups in number of hepatobiliary complications (P = .154). Compared with 1-minute EPBD, 5-minute EPBD did not increase risk of the primary outcome (adjusted hazard ratio, 0.76; 95% confidence interval, 0.32-1.82) or the secondary outcome (adjusted hazard ratio, 0.65; 95% confidence interval, 0.31-1.40). Mechanical lithotripsy, performed for failed stone extraction with EPBD at initial ERCP, was a risk factor for primary and secondary outcomes.

CONCLUSIONS

In a randomized controlled trial, we found that the risk of recurrent choledocholithiasis and hepatobiliary complications did not increase with long-duration EPBD (>1 minute), but was increased with mechanical lithotripsy.

Endoscopic management of biliary strictures after living donor liver transplantation

Living donor liver transplantation (LDLT) is an effective alternative to deceased liver transplantation (DDLT) for end-stage liver disease. Although advances in surgical techniques, immunosuppressive management, and post-transplant care have improved the overall outcomes of LDLT, biliary strictures remain the major unsolved problem. Endoscopic retrograde cholangiopancreatography (ERCP) is currently considered the first-line therapy for biliary strictures following LDLT with duct-to-duct reconstruction, with percutaneous and surgical interventions reserved for patients with unsuccessful management via ERCP. Endoscopic management of biliary strictures is technically more challenging in LDLT than in DDLT because of the complexity of the biliary anastomosis, in addition to the tortuous and angulated biliary system. Placement of one or more plastic stents after balloon dilation has been the standard strategy for post-LDLT stricture, but this requires multiple stent exchange to prevent stent occlusion until stricture resolution. Inside stents might prevent duodenobiliary reflux and thus have longer stent patency, obviating the need for multiple ERCPs. Newly developed covered self-expandable metallic stents with anti-migration systems are alternatives to the placement of multiple plastic stents. With the advent of deep enteroscopy, biliary strictures in LDLT patients with Roux-en-Y hepaticojejunostomy are now treatable endoscopically. In this review, we discuss the short- and long-term outcomes of endoscopic management of post-LDLT strictures as well as recent advances in this field.

Biliary stone removal through the percutaneous transhepatic biliary drainage route, focusing on the balloon sphincteroplasty flushing technique: a single center study with 916 patients

PURPOSE

To present our experience in biliary stone removal (BSR) through the percutaneous transhepatic biliary drainage (PTBD) route in 916 patients, and discuss its clinical usefulness.

MATERIALS AND METHODS

From 2001 to 2015, 916 patients (479 male patients and 437 female patients; age range, 22-92 years; mean age, 67 years) with 52 recurring cases, so a total of 968 cases, were enrolled in this study and retrospectively reviewed. PTBD was performed in all patients. BSR was performed using a combination of a balloon sphincteroplasty flushing technique, a pushing technique after sphincteroplasty, and classical extraction technique, decided case by case.

RESULTS

A complete removal was achieved in 893 cases (92.3%) and the overall clinical success rate was 99.3%. Failure occurred in 7 cases (0.7%), and the causes of failure were stone impaction (n = 5) and intrahepatic bile duct stricture (n = 2). Sphincteroplasty was performed in 902 cases (93.2%). Balloon sphincteroplasty flushing technique was used in 829 (85.6%) cases. There was no major complication. Transient minor complications were seen in 86 cases (8.9%).

CONCLUSIONS

BSR through the PTBD route using a combination of techniques, including balloon sphincteroplasty flushing, is a safe and effective treatment modality to remove biliary stones.

Non-O1/non-O139 Vibrio cholerae septicaemia in a Saudi man: a case report

Background. The non-O1/non-O139 serogroups of Vibrio cholerae occur in diverse natural niches, and usually cause mild and self-limiting gastrointestinal illness. However, they have well-documented potential to cause invasive and extra-intestinal infections among immunocompromised patients. Furthermore, their ability to grow in low-salinity surface water, and the existence of asymptomatic human carriers, suggest novel acquisition routes for this unusual infection, even in people without obvious risk factors.

Case presentation. A 62-year-old man presented with epigastric pain, vomiting and fever. The patient had a history of diabetes and cholecystectomy, although our initial examination did not reveal any significant findings that might indicate V. cholerae infection. However, blood cultures subsequently revealed the presence of V. cholerae, which was positively identified using both conventional and modern non-conventional technologies. The identity of the V. cholerae isolate was confirmed using Vitek MS (matrix–assisted laser desorption ionization-time of flight MS) and the FilmArray system, in addition to its initial identification using the Vitek 2 system. The septicaemia was successfully treated using a 14 day course of ciprofloxacin.

Conclusion. The present case highlights the need to remain highly suspicious of non-O1/non-O139 V. cholerae infections in patients with known risk factors, as well as in healthy individuals with epidemiological exposure and compatible clinical symptoms. Special care should be taken to avoid false-positive results from confirmatory laboratory tests, as the organism can grow in fresh water, and the results should be verified using multiple methods.

Ultrathin choledochoscope improves outcomes in the treatment of gallstones and suspected choledocholithiasis

BACKGROUND

We aimed to compare laparoscopic cholecystectomy (LC) and simultaneous laparoscopic transcystic common bile duct exploration (LTCBDE) using an ultrathin choledochoscope with LC followed by endoscopic retrograde cholangiopancreatography (ERC) and endoscopic sphincterotomy (ES) when indicated.

METHODS

We retrospectively reviewed the records of patients seen between 2004 and 2014 and treated with LC+LTCBDE or LC for gallstones and suspected choledocholithiasis. Postoperative complications and surgical outcomes were compared using t-test, Mann-Whitney U test, or chi-square test.

RESULTS

115 patients underwent successful LC+LTCBDE and 112 LC; follow-up data was available for 103 and 106 patients, respectively. Seventeen patients (16.5%) in the LC+LTCBDE group and 10 (28.6%) in the LC+ERC+ES group developed complications (P = 0.114). The LC+LTCBDE group had a significantly higher rate of satisfactory biliary function outcomes than the LC+ERC+ES group (98.1% vs. 85.7%, respectively) (P = 0.017).

CONCLUSIONS

Single-step LC+LTCBDE using an ultrathin choledochoscope may provide better outcomes in patients with gallstones and suspected choledocholithiasis.

Clinical features of acute obstructive suppurative pancreatic ductitis: A retrospective review of 20 cases

BACKGROUND AND AIMS

The clinical features of acute obstructive suppurative pancreatic ductitis (AOSPD) have not been elucidated. We aimed to clarify the clinical features of AOSPD.

METHODS

We retrospectively reviewed the clinical features of 20 patients with AOSPD at two tertiary referral centers between 1993 and 2012. We compared 17 AOSPD patients with chronic pancreatitis (CP) and 42 patients with acute-on-CP in terms of clinical characteristics, presentation, and laboratory and imaging findings.

RESULTS

The etiology of AOSPD involved CP in 17 (85%) patients, pancreatic ductal adenocarcinoma in 2 (10%), and intraductal papillary mucinous neoplasm in 1 (5%). Endoscopic pancreatic drainage was effective in 19 (95%) patients. Body temperature was significantly higher in AOSPD with CP than acute-on-CP patients (median: 38.2 vs 36.9 °C; P < 0.001). Serum amylase levels at onset were significantly lower (median: 133 vs 364.5 U/L; P = 0.009), and C-reactive protein was significantly higher (median: 9.42 vs 1.06 mg/dL; P < 0.001) in AOSPD with CP patients. Enlargement of the pancreatic parenchyma (18 vs 93%; P < 0.001) and stranding of the surrounding fat (12 vs 93%; P < 0.001) on computed tomography were observed less frequently in patients with AOSPD with CP patients. The diameter of the main pancreatic duct was significantly greater in AOSPD with CP than acute-on-CP patients (median: 7 vs 5 mm; P = 0.006).

CONCLUSIONS

The major etiology of AOSPD involved CP, and endoscopic pancreatic drainage was effective. The clinical features differ between AOSPD with CP and acute-on-CP.

Comparison of endoscopic papillary balloon dilatation and endoscopic sphincterotomy for bile duct stones

Endoscopic treatment for bile duct stones is low-invasive and currently considered as the first choice of the treatment. For the treatment of bile duct stones, papillary treatment is necessary, and the treatments used at the time are broadly classified into two types; endoscopic papillary balloon dilatation where bile duct closing part is dilated with a balloon and endoscopic sphincterotomy (EST) where bile duct closing part is incised. Both procedures have advantages and disadvantages. Golden standard is EST, however, there are patients with difficulty for EST, thus we must select the procedure based on understanding of the characteristics of the procedure, and patient backgrounds.

Role of Balloon-Sheathed Intraductal Ultrasonography for Patients with Extensive Pneumobilia

Intraductal ultrasonography (IDUS) is one of the most useful diagnostic tools for various extrahepatic biliary diseases. However, conventional IDUS has some limitations in providing accurate cross-sectional imaging of the bile duct in patients with extensive pneumobilia. Using a balloon-sheathed catheter, the US system (balloon-sheathed IDUS) can overcome these limitations. Sixteen patients underwent balloon-sheathed IDUS during endoscopic retrograde cholangiography. The balloon-sheathed IDUS was inserted via a transpapillary route when visualization of the bile duct with conventional IDUS was distorted by extensive pneumobilia. The patient group had a mean age of 65.5 years, and 56.3% (9/16) were male. The balloon-sheathed IDUS permitted successful visualization of the bile duct in all patients, regardless of the extent of pneumobilia. Using this system, remnant common bile duct stones were detected in five patients (31.3%), and cholangiocarcinoma was detected in one patient (6.3%). The balloon-sheath IDUS aided in stone sweeping. No significant complications, including bleeding, perforation, or pancreatitis, occurred in any of the patients. The balloon-sheathed catheter US system was useful and safe for biliary IDUS in patients with extensive pneumobilia.

Long- and short-term outcomes of ERCP for bile duct stones in patients over 80 years old compared to younger patients: a propensity score analysis

Backgrounds and study aims: Endoscopic sphincterotomy (ES) is widely accepted as first-line therapy for bile duct stones (BDS). The major long-term pancreaticobiliary complication is BDS recurrence. Whether cholecystectomy should be performed after ES, especially in elderly patients, remains controversial. The aim of this study is to investigate the short-term and long-term outcomes after therapeutic endoscopic retrograde cholangiopancreatography (ERCP) for BDS and to analyze risk factors for pancreaticobiliary complications. We also compared long-term outcomes in patients older and younger than age 80.

PATIENTS AND METHODS

A total of 1210 patients who underwent therapeutic ERCP for BDS were retrospectively reviewed to identify risk factors for pancreaticobiliary complications. We divided these patients into two groups: Group Y (< 80 years; 960 patients) and Group O (≥ 80 years; 250 patients). There were 192 matched pairs in the propensity score analysis.

RESULTS

The incidence of pancreaticobiliary complications was 13.1 % (126/960) in Group Y and 20.4 % (51/250) in Group O (P < 0.00001). Multivariate analysis showed that a gallbladder left in situ with stones was a significant independent risk factor (hazard ratio, 2.81; 95 % confidence interval, 1.62 - 4,89; P = 0.0002). There were no significant differences in the incidence of pancreaticobiliary complications between the propensity score-matched groups.

CONCLUSIONS

A gallbladder in situ with stones was the only significant risk factor for pancreaticobiliary complications after treatment for BDS. Age per se should not be the major factor when deciding on treatment that minimizes the occurrence of pancreaticobiliary disease.

A Preliminary Comparison of Endoscopic Sphincterotomy, Endoscopic Papillary Large Balloon Dilation, and Combination of the Two in Endoscopic Choledocholithiasis Treatment

Background

Endoscopic retrograde cholangiopancreatography (ERCP) is commonly performed to remove bile duct stones. Endoscopic sphincterotomy (EST), endoscopic papillary large balloon dilation (EPLBD), and endoscopic sphincterotomy plus large balloon dilation (ESLBD) are 3 methods used to enlarge the papillary orifice, but their efficacy and safety remains controversial. This study aimed to compare these methods for treating common bile duct (CBD) stones.

Material/Methods

Between July 2011 and December 2013, 255 consecutive patients with proven CBD stones were randomly assigned to EST, EPLBD, or ESLBD (n=85/group). The stone clearance rate, cannulation time, procedural time, frequency of mechanical lithotripsy (ML) use, complications, mortality, and procedural costs were compared.

Results

A total of 92.9%, 91.8%, and 96.5% of the patients in the EST, EPBD, and ESBD groups had stones cleared at first ERCP (P=0.519), respectively. ML was used in 9.4%, 14.1%, and 8.2% of the patients in the EST, EPLBD, and ESLBD groups (P=0.419). The costs of EPLBD were higher than EST and lower than ESLBD (P<0.001). Complications occurred in 4.7%, 4.7%, and 5.9% of the patients in the EST, EPLBD, and ESLBD groups, respectively (P=1.000). The proportion in severity was similar (P=0.693). None of the patients died after the procedures. The rates of the post-ERCP pancreatitis, cholangitis, and bleeding were similar among all groups.

Conclusions

EST, EPLBD, and ESLBD might clear CBD stones with equal efficacy and safety. A non-inferiority trial might be necessary to confirm these results.

Determinants of long-term complications of endoscopic sphincterotomy are infections and high risk factors of bile duct and not sphincter of Oddi dysfunction

BACKGROUND

With the popularity of endoscopic sphincterotomy (EST), long-term complications of EST are receiving increasingly more attention, but the mechanisms have not been sufficiently elucidated.

AIM

This study aimed to investigate the relationship between long-term complications of EST and sphincter of Oddi (SO) function and other associated risk factors.

PATIENTS AND METHODS

A total of 139 patients with choledocholithiasis who had undergone EST were consecutively enrolled, and divided into two groups: patients with long-term complications (LC group) and patients without complications (control group). Before and 2 years after EST, sphincter of Oddi manometry and bacterial culture were performed to evaluate the functional change in SO and infection of the biliary duct.

RESULTS

With an average follow-up duration of 45.8 months, 25 (18.0%) patients developed long-term complications (LC group). Compared with before EST, contraction amplitude and frequency of SO in both groups were markedly reduced after EST, but the changes were not significantly different between the two groups (P>0.05). The rates of bacterial infection in the biliary tract increased significantly in the LC group compared with the control group after EST: 57.1% (12/21) versus 32.7% (35/107), respectively (P=0.034), although these were similar before EST in both the groups. Logistic regression analysis showed that cholecystolithiasis, common bile duct diameter 15 mm or more, and maximum stone diameter 15 mm or more were major risk factors for long-term complications.

CONCLUSION

Weakened SO function is not a decisive factor for long-term complications of EST, which were mainly influenced by biliary tract infection and high risk factors of the biliary tract.

Positive sterility cultures of transplant solutions during pancreatic islet autotransplantation are associated infrequently with clinical infection

BACKGROUND

Chronic pancreatitis is a painful and often debilitating disease. Total pancreatectomy with intra-portal islet autotransplantation (TP-IAT) is a treatment option that allows for pain relief and preservation of beta-cell mass, thereby minimizing the complication of diabetes mellitus. Cultures of harvested islets are often positive for bacteria, possibly due to frequent procedures prior to TP-IAT, such as endoscopic retrograde cholangiopancreatography (ERCP), stenting, or other operative drainage procedures. It is unclear if these positive cultures contribute to post-operative infections.

HYPOTHESIS

We hypothesized that positive cultures of transplant solutions will not be associated with increased infection risk.

METHODS

We reviewed retrospectively the sterility cultures from both the pancreas preservation solution used to transport the pancreas and the final islet preparation for intra-portal infusion of patients who underwent TP-IAT between April 2006 and November 2012. Two hundred fifty-one patients underwent total, near-total, or completion pancreatectomy with IAT and had complete sterility cultures. All patients received prophylactic peri-operative antibiotics. Patients with positive pancreas preservation solution or islet sterility cultures received further antibiotics for 5-7 d. Patients' medical records were reviewed for post-operative infections and causative organisms.

RESULTS

Of the 251 patients included, 151 (61%) had one or more positive bacterial cultures from the pancreas preservation solution or final islet product. Seventy-three of the 251 patients (29%) had an infectious complication. Thirty-four of the 73 (22%) patients with a post-operative infectious complication also had positive cultures. Only seven of 151 patients with positive cultures (4.7%) had an infectious complication caused by the same organism as that isolated from their pancreas or islet cell preparation.

CONCLUSIONS

In autologous islet preparations, isolation solutions frequently have positive cultures, but this finding is associated infrequently with clinical infection.

Endoscopic large balloon sphincteroplasty is a useful, safe adjunct for difficult to treat choledocholithiasis

BACKGROUND

The aim of this study was to assess the safety and efficacy of large balloon sphincteroplasty when used in conjunction with endoscopic biliary sphincterotomy during endoscopic retrograde cholangiopancreatography (ERCP) for therapy of choledocholithiasis.

METHODS

A retrospective audit of all ERCP's performed for choledocholithiasis between January 2012 and October 2013 at one institution was performed. Procedures that utilized large balloon sphincteroplasty were compared with those underwent standard endoscopic stone extraction. Outcomes including stone clearance rate for the individual procedure type, post-ERCP complications and need for surgical exploration of the bile duct were documented.

RESULTS

A total of 346 procedures on 306 patients that met the inclusion criteria were identified. Fifty-four (15.6%) procedures included large balloon sphincteroplasty and were compared with 292 (84.4%) procedures that used standard balloon extraction techniques. Despite those patients in the large balloon sphincteroplasty group having a higher rate of previous ERCP (33.3% versus 19.5%, P = 0.031) and a larger proportion of patients with stones greater than 10 mm (40.3% versus 11.3%, P < 0.001), the overall initial clearance rate was similar at 83%. Ultimately, only 14 out of 306 (4.6%) of all patients required surgical intervention. There was no significant difference in the rate of post-ERCP pancreatitis between the two groups (5.6% versus 3.8%, P = 0.466).

CONCLUSION

Large balloon sphincteroplasty of the sphincter of Oddi is a safe and effective adjunct to endoscopic biliary sphincterotomy in difficult to treat choledocholithiasis. The current study demonstrated large balloon sphincteroplasty did not result in more complications despite a tendency to being used for larger stones.

Recurrent common bile duct stones composed of ursodeoxycholic acid: a report of four cases

Ursodeoxycholic acid (UDCA) is often used to treat cholesterol gallstones. UDCA makes cholesterol stones soluble, thereby improving biliary emptying. Conversely, however, UDCA can also form stones via an unknown mechanism, as shown in a few previous reports of cholangitis caused by the formation of UDCA stones in the common bile duct (CBD). We herein report four cases of recurrent cholangitis resulting from UDCA stones. The withdrawal of UDCA administration was highly effective in these patients. The details of these four cases suggest that clinicians must rethink the indications for UDCA treatment in cases in which cholangitis caused by CBD stones frequently recurs over a short period of time.

Comparison of long-term outcomes after endoscopic sphincterotomy versus endoscopic papillary balloon dilation: a propensity score-based cohort analysis

BACKGROUND

Endoscopic sphincterotomy (ES) is widely performed in patients with common bile duct stones (CBDS). However, the long-term outcomes of patients following ES have not been sufficiently elucidated. Impaired papillary function following ES may result in additional late complications. In contrast, endoscopic papillary balloon dilation (EPBD)-another option for treating CBDS-is expected to preserve papillary function. This study aimed to compare the long-term outcomes of patients with CBDS treated with ES to those treated with EPBD in a large cohort. In addition, a subgroup analysis was performed, according to gallbladder (GB) status.

METHODS

A cohort study was performed using propensity score matching to reduce treatment selection bias. This involved the analysis of follow-up data for 1086 patients who underwent EPBD or ES for CBDS.

RESULTS

Propensity score matching extracted 246 pairs of patients. The median (interquartile range) follow-up period after EPBD or ES was 93.5 (46.8-129.2) months and 90 (42-139.3) months, respectively. The incidence of CBDS recurrence after EPBD and ES were 8.5 and 15.0 %, respectively. The hazard ratio (95 % CI) was 0.577 (0.338-0.986) (P = 0.044). Based on the status of the GB, the incidence of CBDS recurrence was significantly different between post-EPBD and post-ES in the group with cholecystectomy after EPBD/ES (P = 0.013).

CONCLUSIONS

The incidence of biliary complications was significantly lower in patients after EPBD than in those after ES, and this outcome appeared most markedly in patients who also underwent cholecystectomy.

Endoscopic papillary balloon intermittent dilatation and endoscopic sphincterotomy for bile duct stones

AIM: To compare the effectiveness and safety of endoscopic papillary balloon intermittent dilatation (EPBID) and endoscopic sphincterotomy (EST) in the treatment of common bile duct stones.

METHODS: From March 2011 to May 2012, endoscopic retrograde cholangiopancreatography was performed in 560 patients, 262 with common bile duct stones. A total of 206 patients with common bile duct stones were enrolled in the study and randomized to receive either EPBID with a 10-12 mm dilated balloon or EST (103 patients in each group). For both groups a conventional reticular basket or balloon was used to remove the stones. After the procedure, routine endoscopic nasobiliary drainage was performed.

RESULTS: First-time stone removal was successfully performed in 94 patients in the EPBID group (91.3%) and 75 patients in the EST group (72.8%). There was no statistically significant difference in terms of operation time between the two groups. The overall incidence of early complications in the EPBID and EST groups was 2.9% and 13.6%, respectively, with no deaths reported during the course of the study and follow-up. Multiple regression analysis showed that the success rate of stone removal was associated with stone removal method [odds ratio (OR): 5.35; 95%CI: 2.24-12.77; P = 0.00], the transverse diameter of the stone (OR: 2.63; 95%CI: 1.19-5.80; P = 0.02) and the presence or absence of diverticulum (OR: 2.35; 95%CI: 1.03-5.37; P = 0.04). Postoperative pancreatitis was associated with the EST method of stone removal (OR: 5.00; 95%CI: 1.23-20.28; P = 0.02) and whether or not pancreatography was performed (OR: 0.10; 95%CI: 0.03-0.35; P = 0.00).

CONCLUSION: The EPBID group had a higher success rate of stone removal with a lower incidence of pancreatitis compared with the EST group.

Endoscopic papillary balloon dilation for difficult common bile duct stones: Our experience

AIM: To evaluate the efficacy and safety of endoscopic balloon dilation (EBD) performed for common bile duct (CBD) stones.

METHODS: From a computer database, we retrospectively analyzed the data relating to EBD performed in patients at the gastrointestinal unit of the Sandro Pertini Hospital of Rome (small center with low case volume) who underwent endoscopic retrograde cholangiopancreatography (ERCP) for CBD from January 1, 2010 to February 29, 2012. All patients had a proven diagnosis of CBD stones studied with echography, RMN-cholangiography and, when necessary, with computed tomography of the abdomen (for example, in cases with pace-makers). Prophylactic therapies, with gabexate mesilate 24 h before the procedure and with an antibiotic (ceftriaxone 2 g) 1 h before, were administered in all patients. The duodenum was intubated with a side-viewing endoscope under deep sedation with intravenous midazolam and propofol. The patients were placed in the supine position in almost all cases. EBD of the ampulla was performed under endoscopic and fluoroscopic guidance with a balloon through the scope (Hercules, wireguided balloon^®, Cook Ireland Ltd. and CRE^®, Microvasive, Boston Scientific Co., Natick, MA, United States).

RESULTS: A total of 14 patients (9 female, 5 male; mean age of 73 years; range 57-82 years) were enrolled in the study, in whom a total of 15 EBDs were performed. All patients underwent minor endoscopic sphincterotomy (ES) prior to the EBD. The size of balloon insufflation depended on stone size and CBD dilation and this was performed until it reached 16 mm in diameter. EBD was performed under endoscopic and fluoroscopic guidance. The balloon was gradually filled with diluted contrast agent and was maintained inflated in position for 45 to 60 s before deflation and removal. The need for precutting the major papilla was 21.4%. In one patient (an 81-year-old), EBD was performed in a Billroth II. Periampullary diverticula were found only in a 74-year-old female. The adverse event related to the procedures (ERCP + ES) was only an intra procedural bleeding (6.6%) that occurred after ES and was treated immediately with adrenaline sclerotherapy. No postoperative complications were reported.

CONCLUSION: With the current endoscopic techniques, very few patients with choledocholithiasis require surgery. EBD is an efficacious and safe procedure.

Severe acute cholangitis after endoscopic sphincterotomy induced by barium examination: A case report

Endoscopic sphincterotomy (EST) is considered as a possible etiological factor for severe cholangitis. We herein report a case of severe cholangitis after endoscopic sphincterotomy induced by barium examination. An adult male patient presented with epigastric pain was diagnosed as having choledocholithiasis by ultrasonography. EST was performed and the stone was completely cleaned. Barium examination was done 3 d after EST and severe cholangitis appeared 4 h later. The patient was recovered after treated with tienam for 4 d. Barium examination may induce severe cholangitis in patients after EST, although rare, barium examination should be chosen cautiously. Cautions should be also used when EST is performed in patients younger than 50 years to avoid the damage to the sphincter of Oddi.

Balloon dilation with adequate duration is safer than sphincterotomy for extracting bile duct stones: a systematic review and meta-analyses

BACKGROUND & AIMS

Endoscopic sphincterotomy (EST) is the standard treatment for choledocholithiasis. Endoscopic papillary balloon dilation (EPBD) has a lower risk for bleeding than EST, but EPBD is reserved for patients with bleeding diathesis because some studies reported that it increases the risk for pancreatitis. A short dilation time (≤1 minute) is therefore recommended to reduce pancreatitis. However, there is evidence for an inverse relationship between EPBD duration and pancreatitis, prompting reevaluation of the optimal duration and relative safety of EPBD vs EST.

METHODS

We systematically reviewed randomized controlled trials to compare long EPBD (>1 minute), short EPBD (≤1 minute), and EST regarding pancreatitis and overall complications. In addition to pairwise meta-analyses, Bayesian network meta-analysis was undertaken to compare the 3 procedures together. Relation between duration and outcome was also analyzed by meta-regression.

RESULTS

Compared with EST, short EPBD had a higher risk for pancreatitis (odds ratio [OR] by traditional analysis, 3.87; 95% confidence interval, 1.08-13.84 and OR by network meta-analysis, 4.14; 95% credible interval, 1.58-12.56), but long EPBD did not pose a higher risk than EST (1.14, 0.56-2.35 and 1.07, 0.38-2.76). Long EPBD had a lower overall rate of complications than EST (0.61, 0.36-1.04 and 0.54, 0.20-1.36). In network meta-analysis, probabilities of being the safest treatment for long EPBD/short EPBD/EST regarding pancreatitis and overall complications were 43.9%/0.2%/55.9% and 90.3%/1.3%/8.4%, respectively.

CONCLUSIONS

Duration of EPBD is inversely associated with pancreatitis risk. Currently recommended ≤1-minute dilation actually increases pancreatitis. EPBD with adequate duration may be preferred over EST because of comparable pancreatitis but lower overall complication rates.

Two-stage vs single-stage management for concomitant gallstones and common bile duct stones

AIM: To evaluate the safety and effectiveness of two-stage vs single-stage management for concomitant gallstones and common bile duct stones.

METHODS: Four databases, including PubMed, Embase, the Cochrane Central Register of Controlled Trials and the Science Citation Index up to September 2011, were searched to identify all randomized controlled trials (RCTs). Data were extracted from the studies by two independent reviewers. The primary outcomes were stone clearance from the common bile duct, postoperative morbidity and mortality. The secondary outcomes were conversion to other procedures, number of procedures per patient, length of hospital stay, total operative time, hospitalization charges, patient acceptance and quality of life scores.

RESULTS: Seven eligible RCTs [five trials (n = 621) comparing preoperative endoscopic retrograde cholangiopancreatography (ERCP)/endoscopic sphincterotomy (EST) + laparoscopic cholecystectomy (LC) with LC + laparoscopic common bile duct exploration (LCBDE); two trials (n = 166) comparing postoperative ERCP/EST + LC with LC + LCBDE], composed of 787 patients in total, were included in the final analysis. The meta-analysis detected no statistically significant difference between the two groups in stone clearance from the common bile duct [risk ratios (RR) = -0.10, 95% confidence intervals (CI): -0.24 to 0.04, P = 0.17], postoperative morbidity (RR = 0.79, 95% CI: 0.58 to 1.10, P = 0.16), mortality (RR = 2.19, 95% CI: 0.33 to 14.67, P = 0.42), conversion to other procedures (RR = 1.21, 95% CI: 0.54 to 2.70, P = 0.39), length of hospital stay (MD = 0.99, 95% CI: -1.59 to 3.57, P = 0.45), total operative time (MD = 12.14, 95% CI: -1.83 to 26.10, P = 0.09). Two-stage (LC + ERCP/EST) management clearly required more procedures per patient than single-stage (LC + LCBDE) management.

CONCLUSION: Single-stage management is equivalent to two-stage management but requires fewer procedures. However, patient’s condition, operator’s expertise and local resources should be taken into account in making treatment decisions.

Endoscopic papillary balloon dilatation versus endoscopic sphincterotomy in the treatment for choledocholithiasis: a meta-analysis

BACKGROUND AND AIM

Endoscopic papillary balloon dilatation (EPBD) and endoscopic sphincterotomy (EST) are two common nonsurgical treatments endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis. The aim of this study was to compare the efficacy and safety of EPBD and EST in the treatment for choledocholithiasis, confining the analysis to work reported in the last decade.

METHODS

The rate of overall postoperative complications was chosen as the primary outcome, and 10 other outcomes were secondary outcomes. Relative risk (RR) or Peto odds ratio (OR) were computed as the measures of pooled effects. We planned sensitivity analyses a priori for examining the change in robustness of the sensitivity to excluding studies with some inappropriate objects, technique defects or without full-text acquisition.

RESULTS

For complete stone removal, EPBD was similar to EST (95% vs. 96%, P = 0.36) and overall postoperative complications (14.0% vs. 11.7%, P = 0.53). The incidence of post-ERCP cholangitis (2.5% vs. 1.8%, P = 0.40), basket impaction (0.9% vs. 0%, P = 0.16) and perforation (0.0% vs. 0.4%, P = 0.17) were equivalent between EPBD and EST. On the other hand, EPBD caused more post-ERCP pancreatitis (PEP) (9.4% vs. 3.3%, P < 0.00001), but less hemorrhage (0.1% vs. 4.2%, P < 0.00001). People undergoing EPBD required more use of endoscopic mechanical lithotripsy (35.0% vs. 26.2%, P = 0.0004). The results of sensitivity analyses showed no substantial change.

CONCLUSION

EPBD is comparable to EST for stone extraction, though it requires more endoscopic mechanical lithotripsy (EML). EPBD may outweigh EST for patients with coagulopathy; however, it may cause more PEP.

Effects of endoscopic sphincterotomy on biliary epithelium: A case-control study

AIM: To study the long-term effects of endoscopic sphincterotomy on biliary epithelium.

METHODS: This is a prospective case-control study. A total of 25 patients with a median age of 71 years (range 49-89 years) and prior endoscopic sphincterotomy (ES) for benign disease formed the first group. The median time from ES was 42 mo (range 8-144 mo). Another 25 patients with a median age of 76 years (range 44-94 mo) and similar characteristics who underwent current endoscopic retrograde cholangiopancreatography (ERCP) and ES for benign disease formed the second group (control group). Brush cytology of the biliary tree with p53 immunocytology was performed in all patients of both groups. ERCPs and recruitment were conducted at the Endoscopic Unit of Aretaieion University Hospital and Tzaneio Hospital, Athens, from October 2006 to June 2010.

RESULTS: No cases were positive or suspicious for malignancy. Epithelial atypia was higher in the first group (32% vs 8% in the second group, P = 0.034). Acute cholangitis and previous biliary operation rates were also higher in the first group (acute cholangitis, 60% vs 24% in the second group, P = 0.01; previous biliary operation, 76% vs 24% in the second group, P = 0.001). Subgroup analysis showed that previous ES was the main causal factor for atypia, which was not related to the time interval from the ES (P = 0.407). Two patients (8%) with atypia in the first group were p53-positive.

CONCLUSION: ES causes biliary epithelial atypia that represents mostly reactive/proliferative rather than premalignant changes. The role of p53 immunoreactivity in biliary atypia needs to be further studied.

Superinfection of focal liver lesions after bile duct procedures

OBJECTIVES

Pyogenic liver abscess is a rare condition in the general population. The source of infection is most often biliary, and more rarely gastrointestinal via the portal tract, or even hematogenic. Other than in special contexts (scarring after radiofrequency ablation), focal liver lesions are not a usual risk factor for hepatic abscesses in patients with a history of bile duct procedures (sphincterotomy, biliary stenting, biliary enteric anastomosis). MATERIALS AND METHOD - RESULTS: We report four cases of focal liver lesions (two patients with benign lesions of the biliary cyst type and two other patients with lesions due to pancreatic cancer) complicated by a superinfection in patients with a history of bile duct procedures. There were no predisposing factors other than a context of cancer or diabetes.

CONCLUSION

Superinfection of a focal liver lesion should be considered when there is a suggestive clinical picture and a change in the appearance of the lesion in patients with a history of bile duct procedures in a context of cancer or diabetes.

Recurrence of bile duct stones after endoscopic papillary large balloon dilation combined with limited sphincterotomy: long-term follow-up study

Background/Aims

Endoscopic papillary large-balloon dilation combined with limited endoscopic sphincterotomy (EPLBD+ES) is promising for the treatment of common bile duct (CBD) stones. The aim of this study was to clarify the recurrence rate and the risk factors for CBD stones after EPLBD+ES.

Methods

In total, 100 patients who underwent EPLBD+ES from 2006 to 2007 were evaluated retrospectively. One hundred and nine patients who were treated with endoscopic sphincterotomy (ES) from 2004 to 2005 were set as the historical control group. Various risk factors for the recurrence of bile duct stones were analyzed.

Results

Of the 209 patients, the duration of follow-up was 32.5±4.5 months in the EPLBD+ES group and 31.8±6.0 months in the ES group. The recurrence rate of CBD stones was 11.0% (11/100) in the EPLBD+ES group and 13.8% (15/109) in the ES group (p=0.546). The cumulative recurrence rate of stones was not significantly different between the EPLBD+ES and ES groups (log rank, p=0.537). Univariate analysis showed that the diameter of the CBD (≥22 mm) was the only predictive variable that could differentiate recurrence from nonrecurrence in the EPLBD+ES group. Multivariate analysis revealed that the diameter of the bile duct was the only risk factor for stone recurrence (p=0.022; odds ratio, 1.175; 95% confidence interval, 1.023 to 1.348).

Conclusions

The recurrence rate of CBD stones after EPLBD+ES is comparable to that of the ES group, and a dilated CBD appears to increase the risk of bile duct stone recurrence.

Effects of endoscopic papillary balloon dilation and endoscopic sphincterotomy on bacterial contamination of the biliary tract

BACKGROUND AND STUDY AIMS

Although endoscopic papillary balloon dilation (EPBD) has appeared with the expectation of better preserving sphincter of Oddi function than endoscopic sphincterotomy (EST), whether it can more effectively prevent bacterial contamination of the biliary tract than EST is controversial. To address this issue, we investigated the bacterial flora in the bile after the two procedures.

PATIENTS AND METHODS

Eighty-six patients were alternately allocated to EPBD or EST. Blood-liver function tests, ultrasonography, and endoscopic retrograde cholangiopancreatography were performed 6 months and 2 years after EPBD or EST, and the bile was sampled for bacterial culture during endoscopic retrograde cholangiopancreatography. Bactobilia and late complications were prospectively compared between the two procedures.

RESULTS

Overall, no significant difference was found in the incidence of bactobilia between EPBD and EST at the two examination points. Limiting stone diameter to 8 mm or less, there was a trend toward lower rate of bactobilia in the EPBD group 2 years later although the statistical significance disappeared after correction for multiple comparisons. The absence rate of late complications after EPBD was higher than that after EST, but there was no significant difference between the two procedures, both for the overall patients and for the patients with small stones.

CONCLUSION

EPBD has a possibility of suppressing bacterial contamination of the biliary tract compared with EST in patients with small stones. A large, long-term follow-up, randomized, controlled trial is necessary to clarify whether this benefit of EPBD reduces late complications.

Complications of the treatment of endoscopic biliary strictures developing after liver transplantation

BACKGROUND

Bile duct strictures remain a major source of morbidity after orthotopic liver transplantation (OLT). Endoscopic management by the conventional methods of biliary dilatation and/or stent placement has been successful, but sometimes severe complications occur, necessitating prolonged therapy. The aim of this study is to clarify the complications of the endoscopic approach for endoscopic dilatation and/or stent placement.

METHOD

Of 46 patients who underwent living-donor liver transplantation, 10 were diagnosed as having anatomic biliary strictures by endoscopic retrograde cholangiopancreatography (ERCP). Two patients developing biliary strictures after deceased-donor liver transplantation were also enrolled in the study. For the purpose of comparison, 302 patients with a total of 550 consecutive ERCP cases (including 115 patients with 250 malignant bile duct strictures) were recruited in this study. Success rate, number of endoscopy sessions, the median procedure time for ERCP, and incidence of complications including post-ERCP pancreatitis were compared in the OLT cases and other cases.

RESULTS

The following results were obtained in the OLT cases, malignant stricture cases, and all cases, respectively: mean number of endoscopy sessions was 3.62, 2.17, and 1.94 (P = 0.0216, P < 0.0001); post-ERCP pancreatitis occurred in 5 (12.5%), 10 (4.0%), and 19 cases (3.5%) (P = 0.0327, P = 0.0093); and severe pancreatitis occurred in 2 cases of OLT. In a univariate analysis for post-ERCP pancreatitis, OLT was extracted as the only significant risk factor.

CONCLUSIONS

Endoscopic maneuvering for biliary dilatation and/or stent placement following OLT was associated with a higher risk of post-ERCP pancreatitis than the use of the same technique for the treatment of malignant biliary stricture. Endoscopic treatment after OLT was a significant risk factor for post-ERCP pancreatitis.

Endoscopic sphincterotomy plus endoprostheses in the treatment of large or multiple common bile duct stones

BACKGROUND AND AIM

Little information is available on the outcomes of endoscopic sphincterotomy plus biliary stent placement without stone extraction as primary therapy at initial endoscopic retrograde cholangiopancreatography (ERCP) in the treatment of large or multiple common bile duct (CBD) stones. The aim of the present study was to study the effect of biliary stents and sphincterotomy as primary therapy for patients with choledocholithiasis.

METHODS

Patients with large (≥20 mm) or multiple (≥3) CBD stones were retrospectively studied. The patients underwent endoscopic sphincterotomy and placement of plastic stents in the bile duct without stone extraction at the initial ERCP. Three or more months later, a second ERCP was carried out and stone removal was attempted. Differences in stone size and the largest CBD diameter before and after stenting were compared. Stone clearance and complications were also evaluated.

RESULTS

52 patients were enrolled. After a median of 124 days of biliary plastic stent placement the mean maximal stone diameter decreased from 16.6 mm to 10.0 mm (P < 0.01). The mean CBD diameter also decreased from 15.3 mm to 11.5 mm (P < 0.01). The total stone clearance at second ERCP was 94.2%, only 5.7% of which needed mechanical lithotripsy.

COMPLICATIONS

pancreatitis in one (1.9%) at initial ERCP, cholangitis in two (3.8%) after 52 days and 84 days of placement of stent. No complications were recorded at second ERCP.

CONCLUSIONS

Biliary plastic stents plus endoscopic sphincterotomy without stone extraction as primary therapy at initial ERCP is a safe and effective method in the management of large or multiple CBD stones.

Endoscopic papillary balloon dilation for removal of choledocholithiasis: indications, advantages, complications, and long-term follow-up results

Endoscopic papillary balloon dilation (EPBD) is an alternative method of endoscopic sphincterotomy (EST). Although concerns regarding post-procedure pancreatitis have been expressed, EPBD has come to be recognized as an effective and safe method for stone removal in specific cases. To analyze the proper indications, ideal methods, complications, and long-term follow-up results for EPBD, we reviewed articles about EPBD located through a search of the PubMed data base. We analyzed the ballooning methods, indications, results and complications of EPBD among the articles found and compared the results with those of EST. We considered the authors' own clinical experience and knowledge in developing recommendations for EPBD. EPBD showed similar efficacy and safety for the removal of choledocholithiasis to that of EST. Although large or multiple stones were difficult to remove by EPBD, it was safer and easier to apply in patients with coagulopathy or abnormal anatomy. To prevent severe pancreatitis, excessive ballooning and impractical cannulation should be avoided, and precut sphincterotomy or adjuvant prophylaxis should be considered. Due to its preservation of the sphincter of Oddi, EPBD is expected to have fewer long-term complications, such as stone recurrence, cholangitis and cholecystitis. In conclusion, EPBD appears to be safe and effective for the treatment of choledocholithiasis with proper selection of ballooning methods and patients.

Safety and long-term outcomes of endoscopic papillary balloon dilation in children with bile duct stones

BACKGROUND

Although experience with diagnostic and therapeutic ERCP in children is growing, little is known about the safety and technical outcomes of endoscopic papillary balloon dilation (EPBD) in pediatric patients with bile duct stones (BDSs).

OBJECTIVE

To assess the safety and long-term outcomes of EPBD in pediatric patients with BDSs.

DESIGN

Case study.

SETTING

Tertiary referral center.

PATIENTS AND INTERVENTIONS

This study involved 5 children who had BDSs combined with gallstones who underwent EPBD.

MAIN OUTCOME MEASUREMENTS

Successful EPBD, successful stone removal, procedure-related complications, and long-term outcomes.

RESULTS

ERCP was successful in all cases, with cannulation and subsequent EPBD. Stone removal was performed in 1 session in all patients. No EPBD-related complications were observed in any patient. After EPBD, 1 patient subsequently underwent laparoscopic cholecystectomy for gallstones. The remaining 4 were followed without surgery. In 2 patients, gallstones were spontaneously passed from the bile duct into the duodenum. During the follow-up period, over a mean of 7.1 years (range 3.7-9.3 years), no recurrence of BDSs was observed in any patient.

LIMITATIONS

Small number of patients.

CONCLUSIONS

Although BDSs are rare in pediatric patients, EPBD may be a safe and effective technique for the management of such stones in some children.

Long-term outcomes after endoscopic sphincterotomy versus endoscopic papillary balloon dilation for bile duct stones

OBJECTIVE

Endoscopic sphincterotomy (ES) is a well-established standard method for treating common bile duct stones. However, biliary sphincter function is impaired after the treatment, and this may influence the long-term outcomes. In this study, we aimed to compare the long-term outcomes after ES with those after endoscopic papillary balloon dilation (EPBD) because the latter procedure is expected to preserve biliary sphincter function better than ES.

DESIGN

A prospective follow-up of the original cohort in a previously randomized, controlled trial to compare the early outcomes after ES and EPBD.

SETTING

Eleven centers, including 6 clinical practices and 5 academic institutions.

PATIENTS

A total of 282 patients with common bile duct stones were randomly selected to undergo ES (n = 144) or EPBD (n = 138) in the previous study.

INTERVENTIONS

ES or EPBD.

MAIN OUTCOME MEASUREMENTS

Complications after ES or EPBD occurring during long-term follow-up.

RESULTS

The patients were followed up annually after the treatment. The median duration of the follow-up was 6.7 years. Morbidity was observed in 36 (25.0%) and 14 (10.1%) of the patients who underwent ES and EPBD, respectively (P = .0016). Kaplan-Meier analysis revealed a significantly higher incidence of biliary complications in the ES group than in the EPBD group (P = .0011). Multivariate analysis showed that ES, periampullary diverticulum, and in situ gallbladder stones were independent risk factors for stone recurrence.

CONCLUSIONS

During long-term follow-up, patients who underwent ES had significantly more biliary complications than those who underwent EPBD. The biliary sphincter dysfunction after ES results in additional late complications.

Endoscopic papillary balloon dilation for bile duct stone removal in patients 60 years old or younger

BACKGROUND

The aim of this study was to evaluate short- and long-term outcomes in relatively young patients (≤ 60 years old) who underwent endoscopic papillary balloon dilation (EPBD) for bile duct stone removal.

METHODS

Immediate and long-term outcomes were evaluated in 311 patients who were 60 years old or younger at the time of EPBD. The stone recurrence rate was compared among four groups stratified according to gallbladder (GB) status before and after EPBD (cholecystectomy after EPBD, GB left in situ with stones, GB left in situ without stones, and cholecystectomy before EPBD).

RESULTS

Bile duct stones were completely removed via EPBD alone in 304 patients (97.7%). Post-EPBD pancreatitis occurred in 24 patients (7.7%), and was mild in 18 patients, moderate in 5 patients, and severe in 1 patient. The rate of pancreatitis was significantly higher in these patients than in patients aged more than 60 years who underwent EPBD during the same study period (4.7%). Long-term outcomes were evaluated in 217 patients who were followed for at least 1 year after complete stone removal via EPBD. During a mean follow-up period of 5.6 years (range, 1.0-13.4 years), stone recurrence was observed in 13 patients (6.0%). The cumulative stone recurrence rates at 5 and 10 years after EPBD were 5.9 and 7.1%, respectively. Patients in the cholecystectomy after EPBD group had the lowest risk of stone recurrence among the four groups (2.0%).

CONCLUSION

EPBD removes bile duct stones in the majority of younger patients without increasing the risk of severe pancreatitis. Post-EPBD pancreatitis is more likely to occur in younger patients as compared to older patients. The long-term outcomes of EPBD appear favorable, especially in patients who have undergone cholecystectomy after EPBD.

Risk factors for recurrent symptomatic pigmented biliary stones after percutaneous transhepatic biliary extraction

PURPOSE

To evaluate risk factors for the recurrence of biliary stones after a percutaneous transhepatic biliary stone extraction.

MATERIALS AND METHODS

The procedures were performed on 339 patients between July 2004 and December 2008 (54 months). Medical records and images were retrospectively reviewed for 135 patients (mean age, 66.4 years; 83 men and 52 women) who had undergone follow-up for a mean of 13.2 months (range, 3-37 months). To evaluate risk factors for the recurrence of biliary stones, variables were evaluated with univariate and multivariate analyses. Variables included sex, age, stone location, number of stones, stone size, presence of a peripapillary diverticulum, application of antegrade sphincteroplasty, presence of a biliary stricture, largest biliary diameter before the procedure, and gallbladder status.

RESULTS

Thirty-three of the 135 patients (24%) had recurrent symptomatic biliary stones and underwent an additional extraction. The mean time to recurrence was 17.2 months +/- 8.7. Univariate analysis of risk factors for recurrence of biliary stones demonstrated that location, number of stones, stone size, application of antegrade sphincteroplasty, presence of a biliary stricture, and biliary diameter were significant factors (P < .05). With use of multivariate analysis, the number of stones (> or =6; relative risk, 64.8; 95% confidence interval: 5.8, 717.6) and stone size (> or =14 mm; relative risk, 3.8; 95% confidence interval: 1.138, 13.231) were determined to be significant risk factors.

CONCLUSIONS

The independent risk factors for recurrence of symptomatic biliary stones after percutaneous transhepatic biliary stone extraction were a stone size of at least 14 mm and the presence of at least six stones.

Sequential endoscopic papillary balloon dilatation following limited sphincterotomy for common bile duct stones

Endoscopic papillary balloon dilatation (EPBD) has been recently used in conjunction with endoscopic sphincterotomy (EST) for the removal of common bile duct (CBD) stones. The present study was aimed at assessing the safety and outcome of sequential EPBD following EST for CBD stones. A total of 74 patients (43 females, mean age 41 years) with > or = 10-mm stone(s) in the CBD were selected for the procedure, which included limited EST followed by EPBD with balloon dilators of 10-18 mm in size. Eleven patients had undergone EST and unsuccessful stone removal earlier. Forty-nine patients had symptoms of CBD stones, while 25 were detected on imaging. Eleven patients had previous CBD stent in situ and four had T-tube in situ. The stone size was 10-12 mm in 34, 13-14 mm in 26, and > or = 15 mm in 14 patients. Thirty-one patients had a single stone, while 43 had > or = 2 stones. The successful removal of stones was achieved in 68 (91.9%) patients; 62 in the first attempt, five in the second, and one in the third. Six patients were deemed to be "failures." In two of them, the stones could be removed after mechanical lithotripsy. Complications were seen in 16 patients, with self-limiting pain in 13, self-limiting ooze in five, melaena in one, and mild pancreatitis in two. One patient had impaction of the dormia basket. We conclude that EPBD following EST is safe and effective in removing stones > or = 10 mm in size in over 90% of patients.

Long-term prognosis of patients after endoscopic sphincterotomy for choledocholithiasis

INTRODUCTION

The aims of the present study were to clarify the long-term prognosis of endoscopic sphincterotomy (EST) for choledocholithiasis and to evaluate the need for cholecystectomy after EST.

METHODS

Between 1993 and 2007, 262 patients who underwent successful EST for choledocholithiasis were followed up for more than 6 months). Eighteen patients had previously undergone cholecystectomy (Group A), 129 had a calculous gallbladder (GB) and underwent cholecystectomy after EST (Group B), 46 had a calculous GB in situ (Group C), and 69 had an acalculous GB in situ (Group D). Late complications, including recurrence of choledocholithiasis, acute cholecystitis and biliary carcinoma, were evaluated.

RESULTS

Of the 262 patients, late complications occurred in 34 patients (13.0%) and recurrence of choledocholithiasis occurred in 29 patients (11.1%). The rate of late complications was higher in Group C (23.9%) than in Group B (7.8%) (P < 0.001). The rate of recurrent choledocholithiasis was higher in Group C (17.4%) than in Group B (7.8%) (P < 0.05). Univariate analysis indicated that pneumobilia after EST was associated with the recurrence of choledocholithiasis (P < 0.001). Acute cholecystitis occurred in eight (7.0%) of 115 patients with intact GB. A gallbladder carcinoma was found after EST. Late complications were not serious and endoscopically or surgically manageable.

CONCLUSIONS

EST for choledocholithiasis is safe and effective. Cholecystectomy after EST is recommended in patients with calculous GB, but is not necessary in patients with acalculous GB. Pneumobilia was associated with the recurrence of choledocholithiasis.

Endoscopic sphincterotomy and long-term risk of cholangiocarcinoma: a population-based follow-up study

Sphincterotomy of the ampulla of Vater--a common diagnostic and therapeutic procedure that is sometimes done during endoscopic retrograde cholangiography (ERC)--allows reflux of intestinal content into the biliary tree. The resulting inflammation may contribute to malignant transformation of the biliary epithelium and therefore increase the risk of cholangiocarcinoma. We used data from population-based Danish health-care registries to examine the incidence of cholangiocarcinoma after ERC for 10 690 ERC patients who underwent sphincterotomy between 1977 and 2003 and 10,690 ERC patients who did not undergo sphincterotomy. Patients with sphincterotomy were matched to patients without sphincterotomy by sex and age at, calendar year of, and indication for ERC. The cholangiocarcinoma incidence rate for sphincterotomy patients was 404 per 100,000 person-years during the first year after ERC and decreased progressively at later times after ERC (79, 42, and 27 per 100,000 person-years during years 2, 3-5, and > 5, respectively). The corresponding rates for patients without sphincterotomy were 458, 12, 10, and 19 per 100,000 person-years, respectively. The gradual decrease in cholangiocarcinoma rate over time after ERC for sphincterotomy patients indicates that some of these patients had a cholangiocarcinoma that was present at the time of ERC but not diagnosed until 2-5 years later. The similar rates at the latest times after ERC suggest the lack of a causal association between sphincterotomy and cholangiocarcinoma.