Unilateral drainage and chemotherapy prolong the patency of a plastic stent placed above the sphincter of Oddi in patients with malignant hilar biliary obstruction.

Objectives: To evaluate the results of inside stent therapy for unresectable malignant hilar biliary obstruction and identify factors related to stent patency duration. Methods: Of 44 patients who underwent initial inside-stent placement above the sphincter of Oddi from April 2017 to December 2022, 42 with the resolution of jaundice (clinical success rate, 95.5%) were retrospectively analyzed. Univariate and multivariate logistic regression analysis identified factors associated with stent patency duration. Results: Univariate analysis revealed significant differences in the drainage method (406 days for unilateral drainage vs. 305 days for bilateral drainage of the right and left liver lobes, p = 0.022) with or without chemotherapy (406 days with vs. 154 days without, p = 0.038). Multivariate analysis (Cox proportional hazards analysis) revealed similar results, with unilateral drainage (p = 0.031) and chemotherapy (p = 0.048) identified as independent factors associated with prolonged stent patency. Early adverse events were observed in two patients (4.8%; one cholangitis, one pancreatitis). Conclusions: Inside-stent therapy was safely performed in patients with malignant hilar biliary obstruction. Simple unilateral drainage and chemotherapy may prolong stent patency.

Diagnostic yield of endoscopic ultrasound in dilated common bile duct with non-diagnostic cross-sectional imaging.

BACKGROUND: Biliary dilatation without obvious etiology on cross sectional imaging warrants further investigation. This study aimed to assess yield of endoscopic ultrasound in providing etiologic diagnosis in such situation. METHODS: Prospective cohort of consecutive patients with biliary dilatation & non diagnostic computed tomography (CT) and /or magnetic resonance imaging (MRI) underwent endoscopic ultrasound (EUS) with/without fine needle aspiration cytology (FNAC) and were followed clinically, biochemically with/without radiology for up to six months. The findings of EUS were corroborated with histopathology of surgical specimens and endoscopic retrograde cholangiography (ERCP) findings in relevant cases. RESULTS: Median age of 121 patients completing follow up was 55 years. 98.2% patients were symptomatic and median common bile duct (CBD) diameter was 13 mm. EUS was able to identify lesions attributable for biliary dilatation in (67 out of 121) 55.4% cases with ampullary neoplasm being the commonest (29 out of 67 i.e. 43%). Multivariate logistic regression analysis identified jaundice as the predictor of positive diagnosis on EUS, of finding ampullary lesion and pancreatic lesion on EUS. EUS had sensitivity, specificity, positive predictive value and diagnostic accuracy of 95.65%, 94.23%, 95.65% and 95.04% respectively in providing etiologic diagnosis. Threshold value for baseline bilirubin of 10 mg%, for baseline CA 19.9 of 225 u/L and for largest CBD diameter of 16 mm were determined to have specificity of 98%, 95%, 92.5% respectively of finding a positive diagnosis on EUS. CONCLUSION: EUS provides considerable diagnostic yield with high accuracy in biliary dilatation when cross sectional imaging fails to provide etiologic diagnosis.

Impact of timing of ERCP on long term outcomes of ERCP for acute cholangitis - A single center retrospective study.

INTRODUCTION: Acute cholangitis is a critical medical emergency. The association between the timing of ERCP and clinical outcomes of acute cholangitis is still debated. The current study aims to evaluate whether ERCP within 48 h (urgent) is associated with improved long term clinical outcomes. METHODS: This study is a single-center retrospective analysis of a prospectively maintained database. All patients admitted with acute cholangitis as per Tokyo guidelines at AIG Hospitals, Hyderabad between January 2022 to December 2022 were included. We evaluated the association between urgent ERCP and length of hospital stay, need for reintervention and readmissions, and mortality. RESULTS: A total of consecutive 301 patients underwent ERCP for acute cholangitis; of which 217 patients (31.3 % females; mean age 54.02 ± 14.9 years) underwent urgent ERCP. The remaining 84 (32.1 % females; mean age 56.56 ± 13.9 years) underwent routine ERCP. Fifty-eight (26.7 %) and 22 (26.2 %) patients with Grade III underwent urgent and routine ERCP respectively. The median (IQR) hospital stay for urgent ERCP was 8.00 (6.00 - 11.00) days and for routine ERCP was 11.00(8.00 - 15.00; p value 0.0001), with similar hospital stay post ERCP (p 0.26). There was no significant difference in mortality upto one year between patients who underwent urgent (22.1 %;48/217) or routine ERCP (31.0 %;26/84, p 0.135). The cox proportional hazard model showed that mortality is independently associated with older age (HR 1.034;95 %CI: 1.013 - 1.054; p 0.001) and malignancy (HR 8.64;95 %CI:4.728 - 15.790; p 0.0001). There was no significant difference between two groups in terms of need for reinterventions and readmissions. CONCLUSIONS: Urgent ERCP for acute cholangitis is associated comparable overall mortality, need for reinterventions, and readmissions with decreased total length of hospital stay. There is an unmet need to confirm these findings by randomized controlled studies.

Bile duct injury following laparoscopic cholecystectomy in a patient with a trifurcated hepatic duct: A case report.

INTRODUCTION AND IMPORTANCE: Iatrogenic bile duct injury is a serious complication of laparoscopic cholecystectomy, often due to misinterpretation of biliary tree anatomy. Anatomical variations, patient condition, gallbladder pathology, and surgeon-related factors are key risk factors for bile duct injury. CASE PRESENTATION: A 68-year-old male with a history of hypertension and type 2 diabetes mellitus underwent Laparoscopic cholecystectomy for symptomatic gallstones. One-month post-surgery, he developed right upper quadrant pain, jaundice, and elevated liver enzymes. Magnetic resonance cholangiopancreatography (MRCP) showed a hilar confluence stricture affecting the right posterior and left hepatic ducts, with mild-to-moderate dilation of upstream intrahepatic bile ducts. CLINICAL DISCUSSION: Trifurcation of the hepatic duct is a rare but clinically significant anatomical variation that can predispose patients to common bile duct injuries. Preoperative MRCP can identify such variations, aiding in surgical planning. However, intraoperative recognition and management of these anatomical differences are crucial to prevent bile duct injuries. This is particularly important in low-resource settings where routine preoperative imaging may not be feasible. CONCLUSION: Accurate intraoperative identification of biliary tree anatomical variations is essential to prevent iatrogenic injuries during surgery. Preoperative imaging, when available, can provide valuable information to assist in surgical planning. Additionally, the use of intra-operative cholangiogram (IOC) should be considered to help identify and manage anatomical variations, thereby reducing the risk of bile duct injuries.

Endoscopic assessment of minor papilla morphology: Predictors of successful cannulation and procedural pancreatitis risk in minor papilla endotherapy.

BACKGROUND: We evaluated for predictors of successful cannulation and post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in minor papilla endotherapy (MPE), emphasizing endoscopic minor papilla morphology. METHODS: We retrospectively analyzed 232 MPEs in 65 patients, assessing minor papilla morphology based on three features: bulge as "prominent" or "subtle," mucosal appearance as "papilla-like" resembling the main papilla or "SMT-like" akin to a gastrointestinal submucosal tumor, and orifice visibility as "clear" or "unclear." Cannulation success was evaluated in 65 enrolled patients, with PEP risk assessed in all 232 MPEs. RESULTS: Minor papilla morphology was categorized as prominent/subtle bulge in 42/23 patients, papilla-like/SMT-like mucosal appearance in 42/23, and clear/unclear orifice visibility in 24/41. Cannulation succeeded in 54/65 patients (83%). A papilla-like appearance and clear orifice visibility was significantly associated with cannulation success. PEP incidence was 5.2% and predominantly mild. A papilla-like appearance significantly decreased PEP incidence, while precutting technique and orifice dilation significantly increased PEP risk. CONCLUSION: Evaluating minor papilla morphology may help predict cannulation success and PEP risk in MPE. A papilla-like mucosal appearance prognosticates cannulation success and reduced PEP risk, with clear orifice visibility serving as a success predictor. These findings provide practical guidance for preprocedural planning by emphasizing the importance of minor papilla morphology evaluation.

Embryonal Rhabdomyosarcoma of the Bile Ducts Causing Obstructive Jaundice in a Child: A Case Report.

Jaundice in older children can occur when any obstruction is found within the bile ducts, either from bile stones, parasites, choledochal cysts and rarely, secondary to tumors. We present a previously well, 10-year-old Filipino boy with three-week history of progressive jaundice and tea-colored urine, and was initially assessed to have biliary ascariasis. Ultrasound showed a heterogeneous focus spanning the gallbladder neck and confirmed on endoscopic retrograde cholangiopancreatography as an exophytic mass at the ampulla of Vater. Tumor biopsy and immunohistochemical staining confirmed the diagnosis of Embryonal Rhabdomyosarcoma of the Bile Ducts. Chemotherapy was initiated to reduce the size of the tumor before any surgical intervention could be attempted. Despite chemotherapy, the tumor progressively grew. He acquired a respiratory infection which led to sepsis and his eventual demise. The disease should be considered in the differential diagnosis of a child with obstructive jaundice after exclusion of other more common causes.

Comparative efficacy of endoscopic ultrasound-guided biliary drainage versus endoscopic retrograde cholangiopancreatography as first-line palliation in malignant distal biliary obstruction: a systematic review and meta-analysis.

Background: Malignant distal biliary obstruction (MDBO) is a challenging clinical condition commonly managed with endoscopic retrograde cholangiopancreatography (ERCP). However, endoscopic ultrasound-guided biliary drainage (EUS-BD) has emerged as an alternative, especially in complex cases where ERCP fails or is deemed risky. This study aimed to compare the efficacy, safety and cost-effectiveness of EUS-BD vs. ERCP in the palliation of MDBO. Methods: We conducted a systematic review and meta-analysis, following PRISMA guidelines. Three databases were searched up to December 2023, including MEDLINE/PubMed, OVID and the Cochrane Central Register of Controlled Trials, for studies comparing EUS-BD with ERCP. Primary outcomes were technical and clinical success rates, while secondary outcomes included procedural times, hospital stay duration, 30-day mortality, reintervention rates, and adverse events such as pancreatitis. Results: Seven studies involving 1245 patients met the inclusion criteria. The meta-analysis revealed that EUS-BD had a technical success rate of 92%, compared to 85% for ERCP. Clinical success rates were similar for both EUS-BD and ERCP, at approximately 89%. EUS-BD was associated with a significantly lower incidence of pancreatitis (2% vs. 10% for ERCP). Conclusions: EUS-BD offers a viable and potentially superior alternative to ERCP for the primary palliation of MDBO, particularly in terms of technical success and a lower risk of pancreatitis. These findings support the adoption of EUS-BD in clinical settings equipped to perform this technique, though future research should focus on long-term outcomes and further economic analysis to solidify these recommendations.

Extraction Basket Entangled in Surgical Sutures in Common Bile Duct Forty-Five Years After Hepatobiliary Surgery: A Bizarre Adverse Event of Endoscopic Retrograde Cholangiopancreatography.

Endoscopic retrograde cholangiopancreatography (ERCP) is an important technique for treating biliary obstruction. A case report of a 75-year-old male with diagnosed choledocholithiasis and cholangitis was presented. He had a history of hepatic surgery 45 years ago, and during the ERCP, an unusual clinical scenario was encountered. Retained extraction basket during ERCP is a rare but known complication and there are no standard recommendations to manage it. To our knowledge, this is the first case report described in the literature with retention of an extraction basket in surgical sutures at ERCP and the longest period from surgery to stone formation in the biliary system. This case report aims to emphasize that in patients with a history of hepatobiliary surgery, postoperative material can cause complications during ERCP.

Comparison of radiation-shielding curtains for endoscopic retrograde cholangiopancreatography staff.

Occupational radiation exposure to the eye lens of medical staff during endoscopic retrograde cholangiopancreatography (ERCP) should be kept low so as not to exceed annual dose limits. Dose should be low to avoid tissue reactions and minimizing stochastic effects. It is known that the head and neck of the staff are exposed to more scattered radiation in an over-couch tube system than in a C-arm system (under-couch tube). However, this is only true when radiation-shielding curtains are not used. This study aimed to compare the protection radiation to the occupationally exposed worker between a lead curtain mounted on a C-arm system and an ERCP-specific lead curtain mounted on an over-couch tube system. A phantom study simulating a typical setting for ERCP procedures was conducted, and the scattered radiation dose at four staff positions were measured. It was found that scattered radiation doses were higher in the C-arm with a lead curtain than in the over-couch tube with an ERCP-specific lead curtain at all positions measured in this study. It was concluded that the over-couch tube system with an ERCP-specific lead curtain would reduce the staff eye dose by less than one-third compared to the C-arm system with a lead curtain. For the C-arm system, it is necessary to consider more effective radiation protection measures for the upper body of the staff, such as a ceiling-suspended lead screen or another novel shielding that do not interfere with procedures.

Establishment of predictive models and determinants of preoperative gastric retention in endoscopic retrograde cholangiopancreatography.

BACKGROUND: Study on influencing factors of gastric retention before endoscopic retrograde cholangiopancreatography (ERCP) background: With the wide application of ERCP, the risk of preoperative gastric retention affects the smooth progress of the operation. The study found that female, biliary and pancreatic malignant tumor, digestive tract obstruction and other factors are closely related to gastric retention, so the establishment of predictive model is very important to reduce the risk of operation. AIM: To analyze the factors influencing preoperative gastric retention in ERCP and establish a predictive model. METHODS: A retrospective analysis was conducted on 190 patients admitted to our hospital for ERCP preparation between January 2020 and February 2024. Patient baseline clinical data were collected using an electronic medical record system. Patients were randomly matched in a 1:4 ratio with data from 190 patients during the same period to establish a validation group (n = 38) and a modeling group (n = 152). Patients in the modeling group were divided into the gastric retention group (n = 52) and non-gastric retention group (n = 100) based on whether gastric retention occurred preoperatively. General data of patients in the validation group and modeling group were compared. Univariate and multivariate logistic regression analyses were performed to identify factors influencing preoperative gastric retention in ERCP patients. A predictive model for preoperative gastric retention in ERCP patients was constructed, and calibration curves were used for validation. The receiver operating characteristic (ROC) curve was analyzed to evaluate the predictive value of the model. RESULTS: We found no statistically significant difference in general data between the validation group and modeling group (P > 0.05). The comparison of age, body mass index, hypertension, and diabetes between the two groups showed no statistically significant difference (P > 0.05). However, we noted statistically significant differences in gender, primary disease, jaundice, opioid use, and gastrointestinal obstruction between the two groups (P < 0.05). Multivariate logistic regression analysis showed that gender, primary disease, jaundice, opioid use, and gastrointestinal obstruction were independent factors influencing preoperative gastric retention in ERCP patients (P < 0.05). The results of logistic regression analysis revealed that gender, primary disease, jaundice, opioid use, and gastrointestinal obstruction were included in the predictive model for preoperative gastric retention in ERCP patients. The calibration curves in the training set and validation set showed a slope close to 1, indicating good consistency between the predicted risk and actual risk. The ROC analysis results showed that the area under the curve (AUC) of the predictive model for preoperative gastric retention in ERCP patients in the training set was 0.901 with a standard error of 0.023 (95%CI: 0.8264-0.9567), and the optimal cutoff value was 0.71, with a sensitivity of 87.5 and specificity of 84.2. In the validation set, the AUC of the predictive model was 0.842 with a standard error of 0.013 (95%CI: 0.8061-0.9216), and the optimal cutoff value was 0.56, with a sensitivity of 56.2 and specificity of 100.0. CONCLUSION: Gender, primary disease, jaundice, opioid use, and gastrointestinal obstruction are factors influencing preoperative gastric retention in ERCP patients. A predictive model established based on these factors has high predictive value.

The safety of not implementing endoscopic nasobiliary drainage after elective clearance of choledocholithiasis: a systematic review and meta-analysis.

BACKGROUND: Endoscopic nasobiliary drainage (ENBD) is used as a drainage technique in patients with choledocholithiasis after stone removal. However, ENBD can cause discomfort, displacement, and other complications. This study aims to evaluate the safety of not using ENBD following elective clearance of choledocholithiasis. METHODS: Relevant studies were identified by searching PubMed, Web of Science, EMBASE, EBSCO, and Cochrane Library from their inception until August 2023. The main outcomes assessed were postoperative complications and postoperative outcomes. Subgroup analyses were conducted based on study design types and treatment procedures. RESULTS: Six studies, including three randomized controlled trials (RCTs) and three cohort studies, were analyzed. Among these, four studies utilized endoscopic techniques, and two employed surgical methods for choledocholithiasis clearance. The statistical analysis showed no significant difference in postoperative complications between the no-ENBD and ENBD groups, including pancreatitis (RR: 1.55, p = 0.36), cholangitis (RR: 1.81, p = 0.09), and overall complications (RR: 1.25, p = 0.38). Regarding postoperative outcomes, the subgroup analysis indicated that the bilirubin normalization time was longer in the no-ENBD group compared to the ENBD group in RCTs (WMD: 0.24, p = 0.07) and endoscopy studies (WMD: 0.23, p = 0.005), although the former did not reach statistical difference. There was also no significant difference in the length of postoperative hospital stay between the groups (WMD: -0.30, p = 0.60). CONCLUSION: It appears safe to no- ENBD after elective clearance of choledocholithiasis.

Clinical efficacy of laparoscopic cholecystectomy plus cholangioscopy for the treatment of cholecystolithiasis combined with choledocholithiasis.

BACKGROUND: Currently, endoscopic retrograde cholangiopancreatography (ERCP) plus laparoscopic cholecystectomy (LC) is the main treatment for cholecystolithiasis combined with choledocholithiasis. However, the treatment is unsatisfactory, and the development of better therapies is needed. AIM: To determine the clinical efficacy of LC plus cholangioscopy for cholecystolithiasis combined with choledocholithiasis. METHODS: Patients (n = 243) with cholecystolithiasis and choledocholithiasis admitted to The Affiliated Haixia Hospital of Huaqiao University (910th Hospital of Joint Logistic Support Force) between January 2019 and December 2023 were included in the study; 111 patients (control group) underwent ERCP + LC and 132 patients (observation group) underwent LC + laparoscopic common bile duct exploration (LCBDE). Surgical success rates, residual stone rates, complications (pancreatitis, hyperamylasemia, biliary tract infection, and bile leakage), surgical indicators [intraoperative blood loss (IBL) and operation time (OT)], recovery indices (postoperative exhaust/defecation time and hospital stay), and serum inflammatory markers [C-reactive protein (CRP), tumor necrosis factor-α (TNF-α), and interleukin-6 (IL-6) were compared. RESULTS: No significant differences in surgical success rates and residual stone rates were detected between the observation and control groups. However, the complication rate, IBL, OT, postoperative exhaust/defecation time, and hospital stays were significantly reduced in the observation group compared with the control group. Furthermore, CRP, TNF-α, and IL-6 Levels after treatment were reduced in the observation group compared with the levels in the control group. CONCLUSION: These results indicate that LC + LCBDE is safer than ERCP + LC for the treatment of cholecystolithiasis combined with choledocholithiasis. The surgical risks and postoperative complications were lower in the observation group compared with the control group. Thus, patients may recover quickly with less inflammation after LCBDE.

Revolutionizing palliative care: Electrocautery-enhanced lumen-apposing metal stents in endoscopic-ultrasound-guided biliary drainage for malignant obstructions.

Patients with malignant biliary obstruction, following endoscopic retrograde cholangiopancreatography (ERCP) failure could be referred for endoscopic-ultrasound-guided biliary drainage through electrocautery-enhanced (ECE) lumen-apposing metal stent (LAMS) placement. However, the efficacy and safety of ECE-LAMS in this scenario have remained debatable due to minimal scientific evidence. The current confirmed 91.0% clinical success, 96.7% technical success, 7.3% reintervention rate, and 17.5% adverse events, following the treatment of malignant biliary obstruction with ECE-LAMS delivery. Finally, ECE-LAMS proved to be a generalizable strategy for managing biliary obstruction for patients who were excluded from ERCP.

Unveiling the potential of electrocautery-enhanced lumen-apposing metal stents in endoscopic ultrasound-guided biliary drainage.

This editorial delves into Peng et al's article, published in the World Journal of Gastrointestinal Surgery. Peng et al's meta-analysis investigates the effectiveness of electrocautery-enhanced lumen-apposing metal stents (ECE-LAMS) in ultrasound-guided biliary drainage for alleviating malignant biliary obstruction. Examining 14 studies encompassing 620 participants, the research underscores a robust technical success rate of 96.7%, highlighting the efficacy of ECE-LAMS, particularly in challenging cases which have failed endoscopic retrograde cholangio pancreatography. A clinical success rate of 91.0% underscores its impact on symptom alleviation, while a reasonably tolerable adverse event rate of 17.5% is observed. However, the 7.3% re-intervention rate stresses the need for post-procedural monitoring. Subgroup analyses validate consistent outcomes, bolstering the applicability of ECE-LAMS. These findings advocate for the adoption of ECE-LAMS as an appropriate approach for biliary palliation, urging further exploration in real-world clinical contexts. They offer valuable insights for optimizing interventions targeting malignant biliary obstruction management.

Laparoscopic common bile duct exploration is an effective, safe, and less-costly method of treating choledocholithiasis.

BACKGROUND: Advancements in laparoscopic techniques led to the adoption of laparoscopic common bile duct exploration (LCBDE) as an alternative to endoscopic retrograde cholangiopancreatography (ERCP) for management of choledocholithiasis (CD). The goal of this study was to describe the initial experience at a safety net hospital with acute care surgeons performing LCBDE for suspected CD. We hypothesized LCBDE would reduce length of stay and hospital costs compared to laparoscopic cholecystectomy (LC) and ERCP performed in the same hospital admission. METHODS: This was a retrospective case-control study from 2019 to 2023 comparing LCBDE to LC/ERCP among patients diagnosed with CD. Statistical analyses were performed using Mann-Whitney U tests for continuous variables and Chi-square tests for categorical variables. Data reported as median [interquartile range] or research subjects with condition (percentage). RESULTS: A total of 110 LCBDE were performed, while 121 subjects underwent LC and ERCP. Patients in the LCBDE group were more likely to be female with a total of 87 female subjects (77.6%) compared to 76 male subjects (62.8%) (95% CI 1.14-3.74). Initial WBC was lower in the LCBDE group at 8.4 [6.9-11.8] compared to the LC/ERCP group at 10.9 [7.9-13.5] (p = 0.0013). Remaining demographics and lab values were similar between the two groups. Patients who underwent LCBDE had a significantly shorter length of stay at 2 days [1-3] compared to those in the LC/ERCP group at 4 days [3-6] (p < 0.001). Hospital charges for the LCBDE group were $46,685 [$38,687-$56,703] compared to $60,537 [$47,527-$71,739] for the LC/ERCP group (p < 0.001). CONCLUSION: LCBDE is associated with significantly lower hospital costs and shorter length of stay with similar post-operative complication and 30-day readmission rates. Our results show that LCBDE is safe and should be considered as a first-line approach in the management of CD.

Integrative Effects of Transcutaneous Electrical Acustimulation and Autonomic-Endocrine Mechanisms on Postprocedural Recovery in Patients With Endoscopic Retrograde Cholangio-Pancreatography.

OBJECTIVES: This study aimed to investigate the integrative effects and mechanisms of transcutaneous electrical acustimulation (TEA) on postprocedural recovery from endoscopic retrograde cholangio-pancreatography (ERCP). MATERIALS AND METHODS: A total of 86 patients for elective ERCP were randomly ordered to receive TEA (n = 43) at acupoints PC6 and ST36 or Sham-TEA (n = 43) at sham points from 24 hours before ERCP (pre-ERCP) to 24 hours after ERCP (PE24). Scores of gastrointestinal (GI) motility-related symptoms and abdominal pain, gastric slow waves, and autonomic functions were recorded through the spectral analysis of heart rate variability; meanwhile, circulatory levels of inflammation cytokines of tumor necrosis factor-α (TNF-α) and interleukin (IL)-10 and GI hormones of motilin, ghrelin, cholecystokinin (CCK), and vasoactive intestinal peptide (VIP) were assessed by enzyme-linked immunosorbent assay. RESULTS: 1) TEA, but not Sham-TEA, decreased the post-ERCP GI motility-related symptom score (2.4 ± 2.6 vs 7.9 ± 4.6, p < 0.001) and abdominal pain score (0.5 ± 0.7 vs 4.1 ± 2.7, p < 0.001) at PE24, and decreased the post-ERCP hospital day by 20.0% (p ＜0.05 vs Sham-TEA); 2) TEA improved the average gastric percentage of normal slow waves and dominant frequency by 34.6% and 33.3% at PE24, respectively (both p < 0.001 vs Sham-TEA); 3) TEA, but not Sham-TEA, reversed the ERCP-induced increase of TNF-α but not IL-10 at PE24, reflected as a significantly lower level of TNF-α in the TEA group than in the Sham-TEA group (1.6 ± 0.5 pg/mL vs 2.1 ± 0.9 pg/mL, p ＜ 0.01); 4) compared with Sham-TEA, TEA increased vagal activity by 37.5% (p ＜ 0.001); and 5) TEA caused a significantly higher plasma level of ghrelin (1.5 ± 0.8 ng/ml vs 1.1 ± 0.7 ng/ml, p ＜ 0.05) but not motilin, VIP, or CCK than did Sham-TEA at PE24. CONCLUSION: TEA at PC6 and ST36 accelerates the post-ERCP recovery, reflected as the improvement in GI motility and amelioration of abdominal pain, and suppression of the inflammatory cytokine TNF-α may mediate through both autonomic and ghrelin-related mechanisms.

Carbapenem-resistant Enterobacterales sepsis following endoscopic retrograde cholangiopancreatography: risk factors for 30-day all-cause mortality and the development of a nomogram based on a retrospective cohort.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) has become a routine endoscopic procedure that is essential for diagnosing and managing various conditions, including gallstone extraction and the treatment of bile duct and pancreatic tumors. Despite its efficacy, post-ERCP infections - particularly those caused by carbapenem-resistant Enterobacterales (CRE) - present significant risks. These risks highlight the need for accurate predictive models to enhance postprocedural care, reduce the mortality risk associated with post-ERCP CRE sepsis, and improve patient outcomes in the context of increasing antibiotic resistance. OBJECTIVE: This study aimed to examine the risk factors for 30-day mortality in patients with CRE sepsis following ERCP and to develop a nomogram for accurately predicting 30-day mortality risk. METHODS: Data from 195 patients who experienced post-ERCP CRE sepsis between January 2010 and December 2022 were analyzed. Variable selection was optimized via the least absolute shrinkage and selection operator (LASSO) regression model. Multivariate logistic regression analysis was then employed to develop a predictive model, which was evaluated in terms of discrimination, calibration, and clinical utility. Internal validation was achieved through bootstrapping. RESULTS: The nomogram included the following predictors: age > 80 years (hazard ratio [HR] 2.61), intensive care unit (ICU) admission within 90 days prior to ERCP (HR 2.64), hypoproteinemia (HR 4.55), quick Pitt bacteremia score ≥ 2 (HR 2.61), post-ERCP pancreatitis (HR 2.52), inappropriate empirical therapy (HR 3.48), delayed definitive therapy (HR 2.64), and short treatment duration (< 10 days) (HR 5.03). The model demonstrated strong discrimination and calibration. CONCLUSIONS: This study identified significant risk factors associated with 30-day mortality in patients with post-ERCP CRE sepsis and developed a nomogram to accurately predict this risk. This tool enables healthcare practitioners to provide personalized risk assessments and promptly administer appropriate therapies against CRE, thereby reducing mortality rates.

Post-cholecystectomy clip migration: an unusual nidus of choledocholithiasis: a case report.

Introduction and importance: Laparoscopic cholecystectomy is one of the common surgeries occurring worldwide and the gold standard for the management of gallstone disease. The non-absorbable surgical clips may slip and can migrate causing a variety of problems as such, choledocholithiasis. Case presentation: The authors report a case of 43-year-old female who presented with the complaint epigastric pain. She had undergone cholecystectomy 7 years back for symptomatic cholelithiasis. Ultrasonography of the abdomen showed a dilated common bile duct following which endoscopic retrograde cholangiopancreatography was done. A single black-colored stone with the metal clip was retrieved. Clinical discussion: Post-cholecystectomy clip migration should be considered as one of the differentials for choledocholithiasis. Ultrasonography of the abdomen shows the dilated common bile duct. Further management is done by endoscopic retrograde cholangiopancreatography. Conclusion: Surgical clips acting as nidus for choledocholithiasis is rare these days but should be considered as one of the differentials for pain abdomen.

Endoscopic Retrograde Cholangiopancreatography-Related Procedures for the Differential Diagnosis of Isolated Immunoglobin G4-Related Sclerosing Cholangitis and Perihilar Cholangiocarcinoma.

BACKGROUND/PURPOSE: Differential diagnosis of isolated immunoglobin (Ig)G4-related sclerosing cholangitis (IgG4-SC) and cholangiocarcinoma is challenging. We aimed to clarify the role of endoscopic retrograde cholangiography (ERCP)-related procedures in the differential diagnosis of isolated IgG4-SC and perihilar cholangiocarcinoma (PHCC). METHODS: Seven patients with hilar-type isolated IgG4-SC diagnosed at Hiroshima University Hospital and sixty-five patients with surgically resected invasive PHCC were enrolled, and the diagnostic yields of intraductal ultrasonography (IDUS), peroral cholangioscopy (POCS), and pathological examinations were determined. RESULTS: In six of seven (86%) patients with isolated IgG4-SC, the stricture was in the perihilar bile duct. IDUS showed that symmetrical wall thickening (40% vs. 5%, p = 0.04), homogeneous internal echo (80% vs. 5%, p < 0.001), and smooth outer margins (80% vs. 6%, p < 0.001) were more frequent in isolated IgG4-SC than in PHCC. POCS showed a smooth mucosal surface more frequent in isolated IgG4-SC (75% vs. 7%, p = 0.006). Only one patient had two pathological findings characteristic of IgG4-SC. The sensitivity for diagnosing PHCC was 81% using two or more combined sampling methods. CONCLUSIONS: Pathological examinations have limitations in the differential diagnosis of isolated-IgG4-SC and PHCC, and a diagnostic strategy that combines multiple ERCP-related procedures, including IDUS and POCS, is recommended.

Measurement of the distal bile duct density on computed tomography can differentiate choledocholithiasis from a control population.

PURPOSE: Hounsfield unit density of biliary fluid on CT may be a useful clinical marker that has not been described in the literature. This method has been used to differentiate pyonephrosis from hydronephrosis in obstructed collecting systems of the kidney. We aimed to create a user-friendly technique to measure the density of the distal bile duct using CT. The bile duct density of cases with proven choledocholithiasis at ERCP were compared with those of a control group (no biliary pathology). METHODS: A total of 106 patients with proven choledocholithiasis at ERCP and 50 control patients were analysed. The distal bile duct density was calculated using the 4-point and max ellipse methods. Two blinded, independent investigators calculated the bile duct density. RESULTS: The HU is significantly higher in the presence of choledocholithiasis (P < 0.0001). Using the Youden index a cut-off value of 28.6 HU for the 4-point technique is useful to predict the presence of choledocholithiasis (Sensitivity 58%, Specificity 86%). CONCLUSION: Calculation of the distal bile duct density can differentiate choledocholithiasis from a control population. It may be useful alone or as a component of a scoring system to select patients more effectively for intervention. The improved use of CT may also decrease use of MRCP and reduce time to ERCP, which have potential cost benefits.