Association between Cholecystectomy and the Incidence of Pancreaticobiliary Cancer after Endoscopic Choledocholithiasis Management.

(1) Background: Previous studies have raised concerns about a potential increase in pancreaticobiliary cancer risk after cholecystectomy, but few studies have focused on patients who undergo cholecystectomy after receiving endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis. This study aims to clarify cancer risks in these patients, who usually require cholecystectomy, to reduce recurrent biliary events. (2) Methods: We conducted a nationwide cohort study linked to the National Health Insurance Research Database, the Cancer Registry Database, and the Death Registry Records to evaluate the risk of pancreaticobiliary cancers. All patients who underwent first-time therapeutic ERCP for choledocholithiasis from 2011 to 2017 in Taiwan were included. We collected the data of 13,413 patients who received cholecystectomy after endoscopic retrograde cholangiopancreatography and used propensity score matching to obtain the data of 13,330 patients in both the cholecystectomy and non-cholecystectomy groups with similar age, gender, and known pancreaticobiliary cancer risk factors. Pancreaticobiliary cancer incidences were further compared. (3) Results: In the cholecystectomy group, 60 patients had cholangiocarcinoma, 61 patients had pancreatic cancer, and 15 patients had ampullary cancer. In the non-cholecystectomy group, 168 cases had cholangiocarcinoma, 101 patients had pancreatic cancer, and 49 patients had ampullary cancer. The incidence rates of cholangiocarcinoma, pancreatic cancer, and ampullary cancer were 1.19, 1.21, and 0.3 per 1000 person-years in the cholecystectomy group, all significantly lower than 3.52 (p < 0.0001), 2.11 (p = 0.0007), and 1.02 (p < 0.0001) per 1000 person-years, respectively, in the non-cholecystectomy group. (4) Conclusions: In patients receiving ERCP for choledocholithiasis, cholecystectomy is associated with a significantly lower risk of developing pancreaticobiliary cancer.

Postprocedure serum amylase or lipase levels predict postendoscopic retrograde cholangiopancreatography pancreatitis: Meta-analysis of diagnostic test accuracy studies and utility assessment.

OBJECTIVES: We aimed to clarify the clinical utility of measuring serum pancreatic enzymes after endoscopic retrograde cholangiopancreatography (ERCP) for the purpose of predicting post-ERCP pancreatitis (PEP) by a meta-analysis of diagnostic test accuracy studies. METHODS: Studies on the prediction accuracy of PEP by serum amylase or lipase measured at 2, 3, and 4 h after ERCP were collected. A literature search was performed in PubMed and the Cochrane Library database for studies published between January 1980 and March 2023. The quality of individual studies was evaluated using the Quality Assessment of Diagnostic Accuracy Studies-2. Data were analyzed using Meta-DiSc 2.0 software. RESULTS: We searched the databases and identified 20 observational studies (12,313 participants). PEPs were defined according to criteria by Cotton or modified Cotton, revised Atlanta criteria, or the Japanese criteria. Meta-analysis of eight studies (4389 participants) showed a pooled sensitivity of 71.1% (95% confidence interval [CI] 56.1-82.5) and pooled specificity of 91.2% (95% CI 85.9-94.6) for the serum amylase cut-off value at 3 times the upper limit of normal (ULN). Another meta-analysis of five studies (1970 participants) showed a pooled sensitivity of 85.8% (95% CI 61.9-95.7) and pooled specificity of 85.3% (95% CI 81.9-88.1) for the serum lipase cut-off value at 3 times ULN. CONCLUSION: Despite a high risk of bias due to various reference standards, this updated meta-analysis and the utility assessment by a decision tree showed the utility of serum amylase or lipase levels more than 3 times ULN measured 2-4 h after ERCP for predicting PEP.

Previously Untreated Ulcerative Colitis With Newly Diagnosed Primary Sclerosing Cholangitis: A Case Report.

Primary sclerosing cholangitis (PSC) is a rare type of autoimmune hepatic disease with unknown pathophysiology, often a sequela of ulcerative colitis (UC). Liver transplant, though curative, is inaccessible to many patients due to stringent organ availability and barriers to sufficient insurance coverage. Low health literacy and low socioeconomic class can significantly limit healthcare access and thus worsen overall healthcare outcomes. Here, we present the case of an uninsured 49-year-old man with untreated UC who was diagnosed with PSC and subsequently became lost to follow-up. It is critical for providers to identify barriers to acquiring appropriate medical care, such as financial instability and low health literacy, when identifying and treating conditions like PSC. Moreover, more research should be performed to investigate alternative treatments for PSC.

Comparison Between Contrast-Enhanced Computed Tomography and Contrast-Enhanced Magnetic Resonance Imaging With Magnetic Resonance Cholangiopancreatography for Resectability Assessment in Extrahepatic Cholangiocarcinoma.

OBJECTIVE: To compare the diagnostic performance and interobserver agreement between contrast-enhanced computed tomography (CECT) and contrast-enhanced magnetic resonance imaging (CE-MRI) with magnetic resonance cholangiopancreatography (MRCP) for evaluating the resectability in patients with extrahepatic cholangiocarcinoma (eCCA). MATERIALS AND METHODS: This retrospective study included treatment-naïve patients with pathologically confirmed eCCA, who underwent both CECT and CE-MRI with MRCP using extracellular contrast media between January 2015 and December 2020. Among the 214 patients (146 males; mean age ± standard deviation, 68 ± 9 years) included, 121 (56.5%) had perihilar cholangiocarcinoma. R0 resection was achieved in 108 of the 153 (70.6%) patients who underwent curative-intent surgery. Four fellowship-trained radiologists independently reviewed the findings of both CECT and CE-MRI with MRCP to assess the local tumor extent and distant metastasis for determining resectability. The pooled area under the receiver operating characteristic curve (AUC), sensitivity, and specificity of CECT and CE-MRI with MRCP were compared using clinical, surgical, and pathological findings as reference standards. The interobserver agreement of resectability was evaluated using Fleiss kappa (κ). RESULTS: No significant differences were observed between CECT and CE-MRI with MRCP in the pooled AUC (0.753 vs. 0.767), sensitivity (84.7% [366/432] vs. 90.3% [390/432]), and specificity (52.6% [223/424] vs. 51.4% [218/424]) (P > 0.05 for all). The AUC for determining resectability was higher when CECT and CE-MRI with MRCP were reviewed together than when CECT was reviewed alone in patients with discrepancies between the imaging modalities or with indeterminate resectability (0.798 [0.754-0.841] vs. 0.753 [0.697-0.808], P = 0.014). The interobserver agreement for overall resectability was fair for both CECT (κ = 0.323) and CE-MRI with MRCP (κ = 0.320), without a significant difference (P = 0.884). CONCLUSION: CECT and CE-MRI with MRCP showed no significant differences in the diagnostic performance and interobserver agreement in determining the resectability in patients with eCCA.

Case Series of MRI and CT Assessment of Acquired Hepato-Biliary and Pancreatic Transdiaphragmatic Fistulae.

Transdiaphragmatic fistulae are rare conditions characterized by pathological communication between two epithelium-lined surfaces. Hepato-thoracic fistula consists of abnormal communication between the liver and/or the biliary system and the thorax; while the pancreaticopleural fistula consists of abnormal communication between the pancreas and the thorax, the pleuro-biliary fistula represents the more common type. Clinical symptoms and laboratory findings are generally non-specific (e.g., thoracic and abdominal pain, dyspnea, cough, neutrophilia, elevated CPR, and bilirubin values) and initially, first-level investigations, such as chest RX and abdominal ultrasound, are generally inconclusive for the diagnosis. Contrast-enhanced CT represents the first two-level radiological imaging technique, usually performed to identify and evaluate the underlying pathology sustained by transdiaphragmatic fistulae, their complications, and the evaluation of the fistulous tract. When the CT remains inconclusive, other techniques such as MRI and MRCP can be performed. A prompt and accurate diagnosis is crucial because the recognition of fistulae and the precise definition of the fistulous tract have a major impact on the management acquisition process.

Racial disparities in endoscopic retrograde cholangiopancreatography (ERCP) utilization in the United States: are we getting better?

BACKGROUND: We identified trends of inpatient therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in the United States (US), focusing on outcomes related to specific patient demographics. METHODS: The National Inpatient Sample was utilized to identify all adult inpatient ERCP in the US between 2007-2018. Trends of utilization and adverse outcomes were highlighted. P-values ≤ 0.05 were considered statistically significant. RESULTS: We noted a rising trend for total inpatient ERCP in the US from 126,921 in 2007 to 165,555 in 2018 (p = 0.0004), with a significant increase in utilization for Blacks, Hispanics, and Asians. Despite an increasing comorbidity burden [Charlson Comorbidity Index (CCI) score ≥ 2], the overall inpatient mortality declined from 1.56% [2007] to 1.46% [2018] without a statistically significant trend (p = 0.14). Moreover, there was a rising trend of inpatient mortality for Black and Hispanic populations, while a decline was noted for Asians. After a comparative analysis, we noted higher rates of inpatient mortality for Blacks (2.4% vs 1.82%, p = 0.0112) and Hispanics (1.17% vs 0.83%, p = 0.0052) at urban teaching hospitals between July toand September compared to the October to June study period; however, we did not find a statistically significant difference for the Asian cohort (1.9% vs 2.10%, p = 0.56). The mean length of stay (LOS) decreased from 7 days in 2007 to 6 days in 2018 (p < 0.0001), while the mean total hospital charge (THC) increased from $48,883 in 2007 to $85,909 in 2018 (p < 0.0001) for inpatient ERCPs. Compared to the 2015-2018 study period, we noted higher rates of post-ERCP pancreatitis (27.76% vs 17.25%, p < 0.0001) from 2007-2014. CONCLUSION: Therapeutic ERCP utilization and inpatient mortality were on the rise for a subset of the American minority population, including Black and Hispanics.

The use of serum alkaline phosphatase as a choledocholithiasis marker to mitigate the cost of magnetic resonance cholangiography

ABSTRACT Objective To assess the predictive value of preoperative serum laboratory test results for identifying choledocholithiasis and reduce the use of cholangioresonance and its inherent costs. Methods Patients aged 21-69 years who underwent preoperative cholangioresonance examination at our institute were included. Patients with a history of fluctuating jaundice or biliary pancreatitis, bile duct dilatation on ultrasonography, and elevated levels of canalicular enzymes (alkaline phosphatase >100U/L and gamma-glutamyl transferase >50U/L) underwent cholangioresonance-guided surgery. Cases of choledocholithiasis confirmed by cholangioresonance were compared with those without choledocholithiasis. Serum laboratory data were evaluated and the diagnostic capabilities of these examinations were analyzed. Results A total of 104 patients were included. For detecting choledocholithiasis using alkaline phosphatase, the cut-off point was 78U/L, sensitivity was 97.6% (95%CI: 87.4-99.9), and specificity was 72.6% (95%CI: 59.8-83.1). In the binary logistic regression analysis, age (OR= 0.92; 95%CI: 0.86-0.98) and alkaline phosphatase level (OR= 1.02; 95%CI: 1.01-1.05) were selected for the final model. Conclusion Serum alkaline phosphatase levels may aid preoperative diagnosis of asymptomatic choledocholithiasis. After a global clinical assessment of the patient, serum laboratory findings may contribute to a reduction in cholangioresonance-related heathcare costs.

Clinical characteristics, predictors, and rates of hospitalized acute cholangitis patients in the United States.

Background: Acute cholangitis (AC) is a relatively uncommon condition, with a mortality rate of 50% without prompt treatment. Our study aimed to assess the impact of demographic and social factors on morbidity, mortality and healthcare utilization of patients with AC in the United States (US). Methods: We used data from the National Inpatient Sample (2016 and 2017). Our study population included all patients with a discharge diagnosis of AC, identified using the International Classification of Diseases, Tenth Revision (ICD-10) code K830. Results: A total of 18,649 patients were hospitalized with a diagnosis of AC, with rates higher among older persons. The incidence increased notably from 142.36 cases per million in 2016 to 144.3 in 2017. The majority (53%) of patients were on Medicare. Age >60 years was associated with greater mortality compared to 0-18 years (odds ratio [OR] 2.56, 95% confidence interval [CI] 1.21-5.43). Hispanic race (OR 1.4, 95%CI 1.15-1.76) and Black race (OR 1.3, 95%CI 1.04-1.63) had an increased mortality compared to White race. Among the factors analyzed, age >60 (OR 3.72, 95%CI 2.93-4.70) and male sex (OR 0.91, 95%CI 0.86-0.98) were found to be significantly associated with endoscopic retrograde cholangiopancreatography (ERCP) during hospitalization. The total charge for hospitalizations in 2016 was $766 million, increasing to $825 million in 2017. Conclusions: The incidence of AC in the US increased slightly year over year. In patients presenting with AC, age and race were associated with mortality while age and sex were associated with the need for ERCP.

Tokyo Guidelines (TG18) for Acute Cholangitis Provide Improved Specificity and Accuracy Compared to Fellow Assessment.

Background Acute cholangitis results in significant mortality unless treated promptly. The diagnostic grading criteria of the 2018 Tokyo Guidelines (TG18) are used worldwide as the standard for acute cholangitis (AC) management but validation in clinical practice is required. Aim Use of the Tokyo 2018 (TG18) guidelines in improving the diagnostic accuracy and early detection of AC compared to fellow clinical assessment. Methods A retrospective review of patient records from 1/2010-9/2019 seen at Augusta University - Medical College of Georgia with the International Classification of Diseases, Ninth Revision (ICD-9) code "cholangitis" and/or ICD-10 codes "acute cholangitis, other cholangitis, and calculus of bile duct with cholangitis" was performed. Inclusion criteria were gastroenterology inpatient consult fellow evaluation and clinical diagnosis of AC. A definitive diagnosis of AC was determined following endoscopic retrograde cholangiopancreatography (ERCP). TG18 scoring for AC was then performed, categorized as either diagnostic/non-diagnostic, and compared to fellow clinical assessments following definitive diagnosis post-ERCP. Data were analyzed with chi-square testing. Results Two hundred six patients were identified using ICD codes. Ninety-one met inclusion criteria and were analyzed. The mean patient age of the overall group was 67 years old (standard deviation of 13.3 years) with males comprising 69% and non-Hispanic white 56% of the study group. TG18 criteria assessment had a sensitivity of 86% and specificity of 63% for patients with AC post ERCP (p <0.05). TG18 accuracy was 81%. In comparison, fellow clinical suspicion had a sensitivity of 90.3% and specificity of 0% (NS). Fellow accuracy was 71%. No difference in fellows' diagnosis of suspected AC was noted based on the training year. Conclusion Application of the TG18 criteria for AC reduces the false positive rate and improves diagnostic accuracy, thus decreasing costs along with avoiding unnecessary ERCPs with associated complications.

Inpatient Choledocholithiasis Management: a Cost-Effectiveness Analysis of Management Algorithms.

BACKGROUND: Choledocholithiasis is commonly encountered. It is frequently managed with laparoscopic common bile duct exploration or endoscopic retrograde cholangiopancreatography (either preoperative, intraoperative, or postoperative relative to laparoscopic cholecystectomy). The purpose of this study is to determine the most cost-effective method to manage inpatient choledocholithiasis. METHODS: A decision tree model was created to evaluate the cost-effectiveness of laparoscopic common bile duct exploration and preoperative, intraoperative, and postoperative endoscopic retrograde cholangiopancreatography. The primary outcome was incremental cost-effectiveness ratio with a ceiling willingness to pay threshold assumed of $100,000 per quality-adjusted life year. Model parameters were determined through review of published literature and institutional data. Costs were from the perspective of the healthcare system with a time horizon of 1 year. Sensitivity analyses were performed on model parameters. RESULTS: In the base case analysis, laparoscopic common bile duct exploration was cost-effective, resulting in 0.9909 quality-adjusted life years at an expected cost of $18,357. Intraoperative endoscopic retrograde cholangiopancreatography yielded more quality-adjusted life years (0.9912) at a higher cost ($19,717) with an incremental cost-effectiveness ratio of $4,789,025, exceeding the willingness to pay threshold. Both preoperative and postoperative endoscopic retrograde cholangiopancreatographies were eliminated for being both more costly and less effective. Laparoscopic common bile duct exploration remained cost-effective if the probability of successful biliary clearance was above 0.79, holding all other variables constant. If its base cost remained below $18,400 and intraoperative endoscopic retrograde cholangiopancreatography base cost rose above $18,200, then laparoscopic common bile duct exploration remained cost-effective. CONCLUSION: Laparoscopic common bile duct exploration is the most cost-effective method to manage choledocholithiasis. Efforts to ensure availability of local expertise and resources for this procedure are warranted.

The assessment of the ASGE-grading system of ERCP: a large-sample retrospective study.

BACKGROUND AND AIMS: The American Society for Gastrointestinal Endoscopy (ASGE) has developed a complexity-grading system for endoscopic retrograde cholangiopancreatography (ERCP) to predict technical success and adverse events. This study aimed to assess the association between the degree of difficulty for ERCP and the rates of success and adverse event, in turn demonstrating the validity and practicality of this system. METHODS: ERCP procedures performed in the First Affiliated Hospital of Nanchang University from January 2011 to December 2020 were retrospectively reviewed. Procedural success and adverse events were recorded based on difficulty level according to the ASGE-grading system. RESULTS: A total of 20,652 ERCP procedures performed during the study period were analyzed, including 1908 procedures considered grade 1(9.2%), 10,170 procedures considered grade 2 (49.2%), 7764 procedures considered grade 3 (37.6%), 810 procedures considered grade 4 (3.9%). The overall success rate increased from 92.8% in 2011-2015 to 94.0% in 2016-2020, while the distribution of procedures and the incidence of complications showed little variation. The success rate revealed a significantly decreasing trend with increasing difficulty (ranging from 55.6 to 98.6%), mainly for biliary diseases. In addition, the difficulty scale was not associated with any differences in the rate of adverse event, except for the pancreatitis for grade 1 procedures, which had a low incidence. CONCLUSIONS: The ASGE-grading system can help predict the success rate of ERCP procedures but showed poor performance in predicting adverse events. Further exploration may be required to improve the grading system by adjusting or including certain clinical parameters, and to validate the system for extrapolation to other endoscopy units.

Endoscopic retrograde cholangiopancreatography-related adverse events in Korea: A nationwide assessment.

BACKGROUND: Although endoscopic retrograde cholangiopancreatography (ERCP) is a pivotal procedure for the diagnosis and treatment of a variety of pancreatobiliary diseases, it has been known that the risk of procedure-related adverse events (AEs) is significant. OBJECTIVE: We conducted this nationwide cohort study since there have been few reports on the real-world data regarding ERCP-related AEs. METHODS: Patients who underwent ERCP were identified between 2012 and 2015 using Health Insurance Review and Assessment database generated by the Korea government. Incidence, annual trends, demographics, characteristics according to the types of procedures, and the risk factors of AEs were assessed. RESULTS: A total of 114,757 patients with male gender of 54.2% and the mean age of 65.0 ± 15.2 years were included. The most common indication was choledocholithiasis (49.4%) and the second malignant biliary obstruction (22.8%). Biliary drainage (33.9%) was the most commonly performed procedure, followed by endoscopic sphincterotomy (27.4%), and stone removal (22.0%). The overall incidence of ERCP-related AEs was 4.7% consisting of post-ERCP pancreatitis (PEP; 4.6%), perforation (0.06%), and hemorrhage (0.02%), which gradually increased from 2012 to 2015. According to the type of procedures, ERCP-related AEs developed the most commonly after pancreatic stent insertion (11.4%), followed by diagnostic ERCP (5.9%) and endoscopic sphincterotomy (5.7%). Younger age and diagnostic ERCP turned out to be independent risk factors of PEP. CONCLUSIONS: ERCP-related AEs developed the most commonly after pancreatic stent insertion, diagnostic ERCP and endoscopic sphincterotomy. Special caution should be used for young patients receiving diagnostic ERCP due to increased risk of PEP.

Evaluation of socioeconomic and healthcare disparities on same admission cholecystectomy after endoscopic retrograde cholangiopancreatography among patients with acute gallstone pancreatitis.

BACKGROUND: Despite literature and guidelines recommending same admission cholecystectomy (CCY) after endoscopic retrograde cholangiopancreatography (ERCP) for patients with acute gallstone pancreatitis, clinical practice remains variable. The aim of this study was to investigate the role of clinical and socio-demographic factors in the management of acute gallstone pancreatitis. METHODS: Patients with acute gallstone pancreatitis who underwent ERCP during hospitalization were reviewed from the U.S. Nationwide Inpatient Sample database between 2008 and 2014. Patients were classified by treatment strategy: ERCP + same admission CCY (ERCP + CCY) versus ERCP alone. Measured variables including age, race/ethnicity, Charlson Comorbidity Index (CCI), hospital type/region, insurance payer, household income, length of hospital stay (LOS), hospitalization cost, and in-hospital mortality were compared between cohorts using χ2 and ANOVA. Multivariable logistic regression was performed to identify specific predictors of same admission CCY. RESULTS: A total of 205,012 patients (ERCP + CCY: n = 118,318 versus ERCP alone: n = 86,694) were analyzed. A majority (53.4%) of patients that did not receive same admission CCY were at urban-teaching hospitals. LOS was longer with higher associated costs for patients with same admission CCY [(6.8 ± 5.6 versus 6.4 ± 6.5 days; P < 0.001) and ($69,135 ± 65,913 versus $52,739 ± 66,681; P < 0.001)]. Mortality was decreased significantly for patients who underwent ERCP + CCY versus ERCP alone (0.4% vs 1.1%; P < 0.001). Multivariable regression demonstrated female gender, Black race, higher CCI, Medicare payer status, urban-teaching hospital location, and household income decreased the odds of undergoing same admission CCY + ERCP (all P < 0.001). CONCLUSION: Based upon this analysis, multiple socioeconomic and healthcare-related disparities influenced the surgical management of acute gallstone pancreatitis. Further studies to investigate these disparities are indicated.

Incidence and management of cystic duct perforation during endoscopic transpapillary gallbladder drainage for acute cholecystitis.

BACKGROUND AND AIM: Evidence regarding the incidence and clinical outcome of cystic duct perforation (CDP) during endoscopic transpapillary gallbladder drainage (ETGBD) is inadequate. The present study aimed to evaluate the incidence and management of CDP during ETGBD. METHODS: Between March 2011 and December 2019, 249 patients underwent initial ETGBD for acute cholecystitis. The incidence of CDP was retrospectively examined and the outcomes between the CDP and non-CDP groups were compared. RESULTS: CDP during ETGBD occurred in 23 (9.2%) of 249 patients (caused by guidewire in 15 and cannula in 8). ETGBD was successful in 10 patients following CDP. In 13 patients who failed ETGBD, 11 underwent bile duct drainage during the same session; nine patients underwent gallbladder decompression by other methods, such as percutaneous drainage. Clinical resolution for acute cholecystitis was achieved in 20 patients, and no bile peritonitis was noted. ETGBD technical success rates (45.3% vs. 91.2%, p < 0.001), ETGBD procedure times (66.5 vs. 54.8 min, p = 0.041), and hospitalization periods (24.5 vs. 18.7 days, p = 0.028) were significantly inferior in the CDP group (n = 23) compared with the non-CDP group (n = 216). There were no differences in clinical success and adverse events other than CDP between both groups. CONCLUSIONS: Cystic duct perforation reduced the ETGBD technical success rate. However, even in patients with cystic duct perforation, an improvement of acute cholecystitis was achieved by subsequent successful ETGBD or additional procedures, such as percutaneous drainage.

Early cholangioscopy-assisted electrohydraulic lithotripsy in difficult biliary stones is cost-effective.

BACKGROUND AND AIMS: Single-operator cholangioscopy-assisted electrohydraulic lithotripsy (SOC-EHL) is effective and safe in difficult choledocholithiasis. The optimal timing of SOC-EHL use, however, in refractory stones has not been elucidated. The following aims to determine the most cost-effective timing of SOC-EHL introduction in the management of choledocholithiasis. METHODS: A cost-effectiveness model was developed assessing three strategies with a progressively delayed introduction of SOC-EHL. Probability estimates of patient pathways were obtained from a systematic review. The unit of effectiveness is complete ductal clearance without need for surgery. Cost is expressed in 2018 US dollars and stem from outpatient US databases. RESULTS: The three strategies achieved comparable ductal clearance rates ranging from 97.3% to 99.7%. The least expensive strategy is to perform SOC-EHL during the first endoscopic retrograde cholangiography pancreatography (ERCP) (SOC-1: 18,506$). The strategy of postponing the use of SOC-EHL to the third ERCP (SOC-3) is more expensive (US$18,895) but is 2% more effective. (0.9967). SOC-EHL during the second ERCP in the model (SOC-2) is the least cost-effective. Sensitivity analyses show altered conclusions according to the cost of SOC-EHL, effectiveness of conventional ERCP, and altered willingness-to-pay (WTP) thresholds with early SOC-1 being the most optimal approach below a WTP cut-off of US$20,295. CONCLUSIONS: Early utilization of SOC-EHL (SOC-1) in difficult choledocholithiasis may be the least costly strategy with an effectiveness approximating those achieved with a delayed approach where one or more conventional ERCP(s) are reattempted prior to SOC-EHL introduction.

Endoscopic Treatment of Post-Cholecystectomy Biliary Leaks.

Postcholecystectomy leaks may occur in 0.3-2.7% of patients. Bile leaks associated with laparoscopy are often more complex and difficult to treat than those occurring after open cholecystectomy. Furthermore, their incidence has remained unchanged despite improvements in laparoscopic training and technological developments. The management of biliary leaks has evolved from surgery into a minimally invasive endoscopic procedural approach, namely, endoscopic retrograde cholangiopancreatography (ERCP), which decreases or eliminates the pressure gradient between the bile duct and the duodenum, thus creating a preferential transpapillary bile flow and allowing the leak to seal. For simple leaks, the success rate of endotherapy is remarkably high. However, there are more severe and complex leaks that require multiple endoscopic interventions, and clear strategies for endoscopic treatment have not emerged. Therefore, there is still some debate regarding the optimal time point at which to intervene, which technique to use (sphincterotomy alone or in association with the placement of stents, whether metallic or plastic stents should be used, and, if plastic stents are used, whether they should be single or multiple), how long the stents should remain in place, and when to consider treatment failure. Here, we review the types and classification of postoperative biliary injuries, particularly leaks, as well as the evidence for endoscopic treatment of the latter.

As fugas biliares pós colecistectomia podem ocorrer em 0,3 a 2,7% dos casos, sendo frequentemente mais complexas e difíceis de tratar quando comparamos as lesões provocadas pela abordagem laparoscópica versus cirurgia clássica. Associadamente a sua incidência não tem diminuído apesar da melhoria do treino em laparoscopia e do desenvolvimento tecnológico. O tratamento das fugas biliares evoluiu da cirurgia para a endoscopia permitindo, através da colangiopancreatografia retrógrada endoscópica (CPRE), executar vários procedimentos que têm como objetivo divergir preferencialmente o fluxo biliar através da papila para o duodeno e assim reduzir ou eliminar a pressão no sistema biliar, eliminando o fluxo de bílis através da perfuração e criando condições para o seu encerramento. Para fugas simples a taxa de sucesso da CPRE é muito elevada. Contudo, existem fugas mais graves e complexas com necessidade de múltiplas intervenções, não estando definidas estratégias claras para o tratamento endoscópico, persistindo alguma discussão em relação ao timing ideal para intervir, à melhor técnica a utilizar (esfincterotomia isolada ou associada à colocação de próteses biliares, se estas devem ser metálicas ou plásticas e, neste ultimo caso, se únicas ou múltiplas), ao período de tempo em que devem permanecer as próteses biliares, e quando assumir a falência do tratamento. Neste artigo iremos rever os tipos e a classificação das lesões pós-cirúrgicas das vias biliares, nomeadamente das fugas, assim como a evidência para o tratamento endoscópico destas últimas.

Valoración de la colangiopancreatografía retrógrada endoscópica como medio diagnóstico/terapéutico en pacientes con íctero obstructivo / Assessment of the endoscopic retrograde cholangiopancreatography as a diagnostic/therapeutic mean in patients with obstructive jaundice

RESUMEN Introducción: las enfermedades del eje pancreático/biliar son una consecuencia en la morbimortalidad del aparato digestivo, y es la causa en ocasiones de una obstrucción biliar. La colangiopancreatografía retrógrada endoscópica es un método preciso para el diagnóstico de la obstrucción biliar, y se asocia con una elevada tasa de sensibilidad y especificidad. Materiales y métodos: se realizó un estudio observacional descriptivo de corte transversal, con el objetivo de valorar el comportamiento de la colangiopancreatografía retrógrada endoscópica como medio diagnóstico y terapéutico en una muestra de 90 pacientes con dictamen presuntivo de íctero obstructivo. Resultados: predominaron las féminas en el grupo de edad superior a los 50 años. La coluria, la acolia y el íctero como representativos de una enfermedad obstructiva de las vías biliares, fueron las manifestaciones más frecuentes, corroboradas por el estudio endoscópico, donde la litiasis coledociana fue la principal causa de íctero. Conclusión: la esfinterotomía endoscópica fue el proceder terapéutico de elección, y la pancreatitis aguda postintervención fue la complicación más frecuente (AU).

ABSTRACT Introduction: the diseases of the pancreatic-biliary axis are a consequence in the digestive tract morbidity-mortality, and sometimes they are the cause of a biliary obstruction. The endoscopic retrograde cholangiopancreatography is a precise method for diagnosing the biliary obstruction, and is associated to high rates of sensitivity and specificity. Materials and methods: a cross-sectional, descriptive, observational study was carried out with the aim of assessing the behavior of endoscopic retrograde cholangiopancreatography as a therapeutic and diagnostic mean in a sample of 90 patients with presumptive report of obstructive jaundice. Results: women aged more than 50 years predominated. Choluria, acholia and jaundice, as representative of the biliary ducts obstructive disease, were the most frequent manifestations, corroborated by the endoscopic study, where choledocal lithiasis was the main cause of jaundice. Conclusions: endoscopic sphincterotomy was the elective therapeutic procedure, and post-intervention acute pancreatitis was the most frequent complication (AU).

Cost analysis of a long-term randomized controlled study in biliary duct-to-duct anastomotic stricture after liver transplantation.

Multiple plastic stent (MPS) for biliary anastomotic stricture (AS) after liver transplantation requires multiple procedures with consequent costs. To compare the success, adverse events and treatment-related costs of fully covered self-expandable metal stents (FCSEMS) versus MPS. Thirty liver transplant (LT) patients with clinically relevant naïve AS were prospectively randomized to FCSEMS or MPS, with stent numbers increased at 3-month intervals. Treatment costs per patient were calculated for endoscopic retrograde cholangiopancreatography (including all devices and stents) and overall hospital stay. Radiological success was achieved in 73% of FCSEMS (median indwelling period of 6 mos) and 93% of MPS patients (P = NS) (median period of 11 mos). AS recurrence occurred in 36% of FCSEMS and 7% of MPS patients (P = NS), and AS re-treatment was needed in 53% and 13% (P < 0.01), respectively, during follow-up of 60 (34-80) months. Stents migrated after 29% and 2.6% of FCSEMS and MPS procedures, respectively (P < 0.01). Including re-treatments, long-term clinical success was achieved in 28/30 (93%) patients. Overall treatment-related costs were similar between groups. In the subgroup of LT patients in clinical remission after first-line treatment, treatment costs were 41% lower per FCSEMS patient compared with MPS patients. FCSEMS did not perform better than MPS. FCSEMS migration increased the rate of re-treatment and costs.

Palliative endoscopic retrograde biliary drainage for malignant biliary obstruction in Korea: A nationwide assessment.

BACKGROUND: Malignant biliary obstruction (MBO) is usually caused by biliary tract cancer or pancreatic cancer. This study was performed to summarize the current situation regarding palliative endoscopic retrograde biliary drainage (ERBD) for MBO in Korea and to determine its clinical significance by analyzing representative nationwide data. METHODS: Patients that underwent palliative ERBD for MBO between 2012 and 2015 were identified using the Health Insurance Review and Assessment database, which covers the entire Korean population. We assessed clinical characteristics and complications and compared the clinical impacts of initial metal and plastic stenting in these patients. RESULTS: A total of 9,728 subjects (mean age, 65 ± 11.4 years; male, 61.4%) were identified and analyzed. The most common diagnosis was malignant neoplasm of liver and intrahepatic bile ducts (32.1%) and this was followed by extrahepatic or Ampulla of Vater cancer and pancreatic cancer. Initial plastic stent(s) placement was performed in 52.9% of the study subjects, and metal stent(s) placement was performed in 23.3%. The number of sessions of endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic biliary drainage (PTBD) was significantly higher in patients that underwent initial plastic stenting than in patients that underwent metal stenting (2.2 ± 1.7 vs 1.8 ± 1.4, P < 0.0001), but rates of post-ERCP pancreatitis, hospital days, and time to second ERCP or PTBD were not significantly different. CONCLUSION: This nationwide assessment study suggests that initial metal stenting is associated with fewer sessions of total ERCP or PTBD following the initial procedure, despite the preference for initial plastic stenting in Korea.

Training in endoscopic retrograde cholangio-pancreatography: a critical assessment of the broad scenario of training programs and models.

Introduction: Endoscopic Retrograde Cholangio-Pancreatography (ERCP) applications are rapidly evolving toward increasingly complex therapeutic approaches alongside with technological innovations. There are no globally agreed indications on the ERCP training path, which often requires too much time and does not always guarantee adequate skills.Areas covered: Frequency and difficulty of execution are the main objective criteria on which to draw up a training program: novel trainees should approach ERCP first through the simplest and most frequent procedures. An extensive use of training models would reduce the patient's performer-related risks. Amongst a wide variety of models, mechanical simulators have received large approval. In fact, they can be best-suited to each trainee's learning curve thanks to their precision and safety and by virtue of the unlimited repeatability of their use. However, more solid evidences are still needed.Expert opinion: Hands-on ERCP training should systematically employ mechanical simulators at least in the early stages of the learning process. An implementation of these models through sensors that objectively detect abnormalities in the movements would provide detailed feedbacks and deeper awareness. Simulators might also be useful for expert endoscopists to refine their skills. Rapid prototyping and 3D printing might be the way to create customized training models for successful training programs.