Extracorporeal shock wave lithotripsy for difficult common bile duct stones: a comparison between 2 different lithotripters in a large cohort of patients.

BACKGROUND: Extracorporeal shock wave lithotripsy (ESWL) for difficult common bile duct (CBD) stones is a safe and effective treatment strategy allowing for bile duct clearance in approximately 90% of patients with a low incidence of mild adverse events. OBJECTIVE: To compare the CBD clearance rates achieved after ESWL performed with 2 different lithotripters (Siemens Lithostar Plus and Storz Modulith SLX-F2) in a large cohort of patients with difficult CBD stones. DESIGN: A retrospective analysis of a prospectively collected database. SETTING: Tertiary care center. PATIENTS: All of the consecutive patients who underwent ESWL because of difficult CBD stones between 1990 and 2012 were considered suitable for inclusion. INTERVENTIONS: ESWL with Lithostar Plus or with Modulith SLX-F2. MAIN OUTCOME MEASUREMENTS: CBD clearance. RESULTS: Three hundred ninety-two patients with difficult CBD stones were treated; 199 patients were treated with the Lithostar Plus and 193 patients with the Modulith SLX-F2. CBD clearance was achieved in 349 patients (89.0%) with no significant difference between the patients treated with Lithostar Plus and those treated with Modulith SLX-F2 (90.5% vs 87.6%; P = .45). Patients treated with Modulith SLX-F2 underwent a significantly lower number of ESWL sessions (3 [range, 2 to 4] vs 3 [range, 2 to 4]; P = .0015), had a lower incidence of ESWL-related adverse events (5.2% vs 13.6%; P = .009), and never required opioid analgesia (P < .001). LIMITATIONS: Retrospective design. CONCLUSIONS: The Modulith SLX-F2 allows the same clearance rate as the Lithostar Plus but has a significantly lower incidence of adverse events and requires fewer ESWL sessions.

Therapeutic management and clinical outcome of autoimmune pancreatitis.

BACKGROUND: Autoimmune pancreatitis, in comparison to other benign chronic pancreatic diseases, is characterized by the possibility of curing the illness with immunosuppressant drugs. The open question is whether to differentiate autoimmune pancreatitis as a primary or secondary disease based on the presence or absence of other autoimmune diseases or whether to consider autoimmune pancreatitis a clinical and pathological systemic entity, called IgG4-related sclerosing disease, since this aspect is also very important from a therapeutic point of view. METHODS: In this paper, we reviewed the conventional therapeutic approach used to treat autoimmune pancreatitis patients and the clinical outcome related to each treatment modality. We also reviewed some aspects which are important for the correct management of autoimmune pancreatitis, such as the surgical approach, the outcome of surgically treated autoimmune pancreatitis patients, whether medical treatment is always necessary, and, finally, when medical treatment should be initiated. CONCLUSIONS: Steroids are useful in alleviating the symptoms of the acute presentation of autoimmune pancreatitis, but some questions remain open such as the dosage of steroids in the acute phase and the duration of steroid therapy; finally, it should be assessed if other immunosuppressive non-steroidal drugs may become the first-line therapy in patients with AIP without jaundice and without atrophic pancreas.

Results of endoscopic retrograde cholangiopancreatography in the treatment of biliary tract complications after orthotopic liver transplantation: our experience.

BACKGROUND/AIMS: Biliary tract complications are a common cause of morbidity and mortality after orthotopic liver transplantation. We report our experience in the use of ERCP in the treatment of post liver transplantation biliary complications. METHODOLOGY: Retrospectively we evaluated 34 patients who had undergone ERCP out of 460 who received a liver transplantation between January 1999 and December 2004. Eighteen patients presented biliary strictures, anastomotic in 12 cases and hilar in 6 cases; seven patients presented a biliary fistula and fifteen presented biliary stones in 8 cases associated to stricture and in 1 case to a fistula. Finally three patients underwent ERCP do to jaundice. The 18 patients with biliary strictures underwent sphincterotomy, dilation and stenting; the seven cases with fistulas were treated with a plastic biliary stent without sphincterotomy and the patients with biliary stones underwent sphincterotomy and endoscopic toilette of the common bile duct. RESULTS: An ERCP success rate of 97.7% was achieved without any significant complications. We obtained the resolution of all the biliary anastomotic strictures; resolution of hilar strictures was obtained in 66.6%. Biliary leak healed in 85.7% of patients. Complete endoscopic toilette was achieved in all the patients with biliary stones. CONCLUSIONS: In our experience ERCP has proved to be safe and effective in the treatment of post liver transplant biliary complications.

Reliability of endoscopic ultrasound in predicting the number and size of common bile duct stones before endoscopic retrograde cholangiopancreatography.

BACKGROUND: Endoscopic ultrasound (EUS) is accurate for the diagnosis of choledocholithiasis; however, data are lacking regarding the prediction of stone number and size. AIMS: To evaluate the concordance between EUS and endoscopic retrograde cholangiopancreatography (ERCP) in stone number and size assessment. METHODS: We performed a retrospective analysis of consecutive patients undergoing ERCP due to detection of choledocholithiasis by EUS. Concordance between EUS and ERCP was defined as difference in stone diameter <30% and perfect match in stone number. RESULTS: Among 116 patients, 25% had sludge, 37.9% had single and 37.1% had multiple stones. Overall concordance was 62.9%. Sludge was correctly assessed in 85.7%, single stone in 81.3% and multiple stones in 45.1% (P=0.0001). EUS was accurate in 78.8% of patients who underwent both procedures in the same session, but only in 61.9% in those who underwent ERCP within 1 week. Multivariate analysis identified the single-session approach (odds ratio 2.894; P=0.035) and multiple stones (odds ratio 0.244; P=0.001) as independent predictors of concordance. CONCLUSIONS: Concordance between EUS and ERCP was correlated to the single session approach and inversely correlated to the presence of multiple stones. EUS may predict potentially difficult ERCP allowing to plan the best treatment strategy.