A new classification of periampullary diverticulum: cannulation of papilla on the inner margins of the diverticulum (Type IIa) is more challenging.

BACKGROUND: Periampullary diverticulum (PAD) may make the performance of endoscopic retrograde cholangiopancreatography (ERCP) in patients with choledocholithiasis more difficult and may increase complication rates. The present study evaluated the effects of PAD on first-time ERCP in patients with choledocholithiasis. METHODS: Outcomes were compared in patients with and without PAD and in those with four types of PAD: papilla located completely inside the diverticulum (type I), papilla located in the inner (type II a) and outer (type II b) margins of the diverticulum; and papilla located outside the diverticulum (type III). Parameters compared included cannulation time and rates of difficult cannulation, post-ERCP pancreatitis (PEP) and perforation. RESULTS: The median cannulation times in patients with types I, II a, II b, III PAD and in those without PAD were 2.0 min, 5.0 min, 0.67 min, 3.5 min, and 3.5 min, respectively, with difficult cannulation rates in these groups of 7.4%, 31.4%, 8.3%, 18.9%, and 23.2%, respectively. The rates of PEP in patients with and without PAD were 5.3% and 5.1%, respectively. Four patients with and one without PAD experienced perforation. CONCLUSIONS: The division of PAD into four types may be more appropriate than the traditional division into three types. Cannulation of type I and II b PAD was easier than cannulation of patients without PAD, whereas cannulation of type II a PAD was more challenging. PAD may not increase the rates of PEP.

Large common bile duct stones in high-risk elderly patients: Immediate endoscopic stone removal or elective stone removal? A single-center retrospective study.

BACKGROUND AND OBJECTIVE: For high-risk elderly patients with chronic diseases, endoscopic stone removal for large common bile duct stones is associated with a high risk of adverse events and incomplete stone removal. The aim of this study was to investigate whether the treatment strategy of short-term biliary plastic stent placement followed by elective endoscopic stone removal is more effective and safer than immediate endoscopic stone removal. METHODS: The data of 262 high-risk elderly patients who received endoscopic retrograde cholangiopancreatography (ERCP) for large common bile duct (CBD) stones from 2017 to 2022 were retrospectively analyzed. The patients were divided into group A (immediate stone removal) and group B (stent drainage + elective stone removal). The baseline data of the 2 groups were matched 1:1 by propensity score matching. The stone clearance rate, ERCP procedure time, total hospital stay, and procedure-related adverse events were compared between the matched groups. In group B, stone size before and after stent placement, hospital stay, procedure time and adverse events of two ERCPs were compared. RESULTS: A total of 57 pairs of patients were successfully matched between the 2 groups. The stone clearance rate in group B was higher than that in group A (89.5% vs. 75.3, P = 0.049). The total hospital stay in group B was longer than that in group A (11.86 ± 3.912 d vs. 19.14 ± 3.176 d, P<0.001). The total adverse event rate in group A was higher than that in group B (29.8% vs. 12.3%, P = 0.005). The incidence of cholangitis/cholecystitis after ERCP was significantly higher in group A than in group B (7.0% vs. 0.9% P = 0.029). There was no significant difference in the incidence of post-ERCP pancreatitis, bleeding, pneumonia, and cardio-cerebrovascular events between the 2 groups. There were no perforation cases in either group. After plastic biliary stent placement in group B, the stone size was significantly smaller than before stent placement (1.59 ± 0.544 cm vs. 1.95 ± 0.543 cm, P < 0.001), and there was no significant difference in the total adverse event incidence between the two ERCP procedures (18.8% vs. 10.9%, P = 0.214). CONCLUSION: For high-risk elderly patients with large CBD stones, the treatment strategy involving temporary placement of plastic stent and elective endoscopic stone removal is safer and more effective than immediate stone removal.

Endoscopic ultrasound avoids adverse events in high probability choledocholithiasis patients with a negative computed tomography.

BACKGROUND: The current guideline recommends patients who meet high probability criteria for choledocholithiasis to receive endoscopic retrograde cholangiopancreatography (ERCP). However, adverse events can occur during ERCP. Our goal is to determine whether endoscopic ultrasound (EUS) before ERCP can avoid unnecessary ERCP complications, especially in patients with a negative CT scan. METHODS: A total of 604 patients with high probability of choledocholithiasis were screened and 104 patients were prospectively enrolled. Patients with malignant biliary obstruction, altered GI anatomy, and choledocholithiasis on CT scan were excluded. Among them, 44 patients received EUS first, and ERCP if choledocholithiasis present (EUS-first group). The other 60 patients received ERCP directly (ERCP-first group). The baseline characteristics, presence of choledocholithiasis, and complications were compared between groups. All patients were followed for 3 months to determine the difference in recurrent biliary event rate. Cost-effectiveness was compared between the two strategies. RESULTS: There was no marked difference in age, sex, laboratory data, presenting with pancreatitis, and risk factors for choledocholithiasis. Overall, 51 patients (49.0%) had choledocholithiasis, which did not justify the risk of direct ERCP. In the EUS-first group, 27 (61.4%) ERCP procedures were prevented. The overall complication rate was significantly lower in the EUS-first group compared to the ERCP-fist group (6.8% vs. 21.7%, P = 0.04). The number-needed-to-treat to avoid one unnecessary adverse event was 6.71. After a 3-month follow-up, the cumulative recurrence biliary event rates were similar (13.6% vs. 15.0%, P = 0.803). EUS-first strategy was more cost-effective than the ERCP-first strategy (mean cost 2322.89$ vs. 3175.63$, P = 0.002). CONCLUSIONS: In high-probability choledocholithiasis patients with a negative CT, the EUS-first strategy is cost-effective, which can prevent unnecessary ERCP procedures and their complications.

Obstructive Jaundice Secondary to Clip Migration in the Common Bile Duct 9 Years after Laparoscopic Cholecystectomy.

Surgical clip migration in the common bile duct with consecutive stone formation is a rare occurrence after laparoscopic cholecystectomy, less than 100 cases being reported so far. We report a case of a 55-year-old woman with obstructive jaundice due to bile duct stone formed around a migrated surgical clip 9 years after laparoscopic cholecystectomy. The patient presented with pain in the upper abdomen and jaundice. Abdominal ultrasound diagnosed dilation of the common bile duct and intrahepatic bile ducts. The diagnosis was confirmed by computed tomography which revealed a metal clip in the distal part of the common bile duct. The patient was managed successfully by endoscopic retrograde cholangiopancreatography (ERCP) and the surgical clip was retrieved using the Dormia basket. The exact mechanism of clip migration is not fully understood but may be explained by local inflammation and ineffective clipping. Although a rare occurrence, clip migration should not be excluded when considering the differential diagnosis of patients presenting with obstructive jaundice or cholangitis after laparoscopic cholecystectomy. Minimally invasive management by ERCP is the procedure of choice for migrated clips related complications but surgical common bile duct exploration may be necessary.

Acute obstructive cholangitis due to fishbone in the common bile duct: a case report and review of the literature.

BACKGROUND: Choledocholithiasis is an endemic condition in the world. Although rare, foreign body migration with biliary complications needs to be considered in the differential diagnosis for patients presenting with typical symptoms even many years after cholecystectomy, EPCP, war-wound, foreign body ingestion or any other particular history before. It is of great clinical value as the present review may offer some help when dealing with choledocholithiasis caused by foreign bodies. CASE PRESENTATION: We reported a case of choledocholithiasis caused by fishbone from choledochoduodenal anastomosis regurgitation. Moreover, we showed up all the instances of choledocholithiasis caused by foreign bodies published until June 2018 and wrote the world's first literature review of foreign bodies in the bile duct of 144 cases. The findings from this case suggest that the migration of fishbone can cause various consequences, one of these, as we reported here, is as a core of gallstone and a cause of choledocholithiasis. CONCLUSION: The literature review declared the choledocholithiasis caused by foreign bodies prefer the wrinkly and mainly comes from three parts: postoperative complications, foreign body ingestion, and post-war complications such as bullet injury and shrapnel wound. The Jonckheere-Terpstra test indicated the ERCP was currently the treatment of choice. It is a very singular case of choledocholithiasis caused by fishbone, and the present review is the first one concerning choledocholithiasis caused by foreign bodies all over the world.

Loss of cellular FLICE-inhibitory protein promotes acute cholestatic liver injury and inflammation from bile duct ligation.

Cholestatic liver injury results from impaired bile flow or metabolism and promotes hepatic inflammation and fibrogenesis. Toxic bile acids that accumulate in cholestasis induce apoptosis and contribute to early cholestatic liver injury, which is amplified by accompanying inflammation. The aim of the current study was to evaluate the role of the antiapoptotic caspase 8-homolog cellular FLICE-inhibitory (cFLIP) protein during acute cholestatic liver injury. Transgenic mice exhibiting hepatocyte-specific deletion of cFLIP (cFLIP-/-) were used for in vivo and in vitro analysis of cholestatic liver injury using bile duct ligation (BDL) and the addition of bile acids ex vivo. Loss of cFLIP in hepatocytes promoted acute cholestatic liver injury early after BDL, which was characterized by a rapid release of proinflammatory and chemotactic cytokines (TNF, IL-6, IL-1ß, CCL2, CXCL1, and CXCL2), an increased presence of CD68+ macrophages and an influx of neutrophils in the liver, and resulting apoptotic and necrotic hepatocyte cell death. Mechanistically, liver injury in cFLIP-/- mice was aggravated by reactive oxygen species, and sustained activation of the JNK signaling pathway. In parallel, cytoprotective NF-κB p65, A20, and the MAPK p38 were inhibited. Increased injury in cFLIP-/- mice was accompanied by activation of hepatic stellate cells and profibrogenic regulators. The antagonistic caspase 8-homolog cFLIP is a critical regulator of acute, cholestatic liver injury. NEW & NOTEWORTHY The current paper explores the role of a classical modulator of hepatocellular apoptosis in early, cholestatic liver injury. These include activation of NF-κB and MAPK signaling, production of inflammatory cytokines, and recruitment of neutrophils in response to cholestasis. Because these signaling pathways are currently exploited in clinical trials for the treatment of nonalcoholic steatohepatitis and cirrhosis, the current data will help in the development of novel pharmacological options in these indications.

Early adverse events and long-term outcomes of endoscopic sphincterotomy in a pediatric population: a single-center experience.

Background and aims: The use of endoscopic sphincterotomy (EST) in the management of pancreaticobiliary disease in children is increasing. However, studies of long-term outcomes are limited in pediatric patients. Therefore, this study evaluated the early adverse events and long-term outcomes following EST in pediatric patients. Patients and methods: We retrospectively analyzed data from 198 pediatric patients who underwent ESTs at Asan Medical Center Children's Hospital between 1994 and 2013. The median age was 8.7 years (range 18 months to17 years). We evaluated the indications, success rates, early adverse events, and long-term outcomes. Results: Long-term information was available in 198 patients with a median follow-up duration of 42 months (range, 1.8 - 232.1 months). Early adverse events (< 30 days) following 294 ESTs among 198 patients included pancreatitis in 17 (5.7 %), hemorrhages in 6 (2.0 %), sepsis in 3 (1.0 %), and perforations in 2 (0.7 %). Long-term complications ( > 30 days) developed in 12 patients (6.1 %), including cholangitis with or without bile duct stone (n = 7), and minor papilla restenosis (n = 5). The cumulative incidence rates of long-term complications were 3.1 %, 6.1 %, 9.3 %, and 9.3 %, at 1, 5, 10, and 15 years. There were no procedure-related pancreaticobiliary malignancies or deaths. All adverse events and long-term complications improved with appropriate management. Conclusions: In pediatric patients with pancreaticobiliary disease, EST has a high level of technical success. In addition, pediatric EST showed low rates of early adverse events and long-term complications, which could be managed safely. Our results suggest that EST is a safe method for treating pancreaticobiliary disease, even in the pediatric population.

Endoscopic management of choledochocele complicated with choledocholithiasis and pancreatitis in an old patient.

Choledochocele, or type III choledochal cyst, is a rare congenital disease and is even less common among adults compared with children. In this case, a 75-year-old female was admitted to our hospital presented with epigastric pain and vomiting for one day. Abdominal computed tomography revealed dilated common bile duct, pancreatitis and peripancreatic effusion. The patient was treated with fasting, fluid resuscitation, anti-acid agents, somatostatin and antibiotics. Endoscopic retrograde cholangiopancreatography was employed for the further diagnosis of choledochocele, choledocholithiasis and biliary stenosis. Endoscopic sphincterotomy, stone extraction and plastic stent placement were performed for treatment. The patient recovered quickly after the treatment and no signs of recurrence and complications were observed during the first follow-up. Endoscopic management may be a promising and alternative therapy for choledochocele although long-term follow-up is necessary to confirm the efficacy and safety of this procedure in the future.

One-Step LC and ERCP Treatment of 40 Cases with Cholelithiasis Complicated with Common Bile Duct Stones.

BACKGROUND/AIMS: To discuss the clinical significance of combined application of laparoscopic cholecystectomy (LC) and endoscopic retrograde cholangiopancreatography (ERCP) for one-stage treatment of cholelithiasis complicated with common bile duct stones. METHODOLOGY: To retrospectively analyze 40 cases with cholelithiasis complicated with common bile duct stones treated with LC plus intraoperative ERCP between May 2005 and September 2012 and to evaluate the clinical efficacy in the treatment of cholelithiasis complicated with common bile duct stones. RESULTS: Among 40 cases, 36 successfully underwent LC plus intraoperative ERCP and 4 were transferred to open surgery. Eighteen patients with preoperative abnormal liver function showed declined indexes post-operatively. Compared with LC, more patients had abdominal distention and vomiting. Seven patients presented with transient increase in the levels of serum amylase with no incidence of acute pancreatitis. One had hematochezia and recovered after conservative treatment with no incidence of bile leakage and perforation and other severe complications. CONCLUSIONS: LC combined with intraoperative ERCP is safe and efficacious in the primary treatment of cholelithiasis complicated with common bile duct stones to avoid open surgery and double surgeries.

Artificial neural network predicts the need for therapeutic ERCP in patients with suspected choledocholithiasis.

BACKGROUND: Selection of patients with the highest probability for therapeutic ERCP remains an important task in a clinical workup of patients with suspected choledocholithiasis (CDL). OBJECTIVE: To determine whether an artificial neural network (ANN) model can improve the accuracy of selecting patients with a high probability of undergoing therapeutic ERCP among those with strong clinical suspicion of CDL and to compare it with our previously reported prediction model. DESIGN: Prospective, observational study. SETTING: Single, tertiary-care endoscopy center. PATIENTS: Between January 2010 and September 2012, we prospectively recruited 291 consecutive patients who underwent ERCP after being referred to our center with firm suspicion for CDL. INTERVENTIONS: Predictive scores for CDL based on a multivariate logistic regression model and ANN model. MAIN OUTCOME MEASUREMENTS: The presence of common bile duct stones confirmed by ERCP. RESULTS: There were 80.4% of patients with positive findings on ERCP. The area under the receiver-operating characteristic curve for our previously established multivariate logistic regression model was 0.787 (95% CI, 0.720-0.854; P < .001), whereas area under the curve for the ANN model was 0.884 (95% CI, 0.831-0.938; P < .001). The ANN model correctly classified 92.3% of patients with positive findings on ERCP and 69.6% patients with negative findings on ERCP. LIMITATIONS: Only those variables believed to be related to the outcome of interest were included. The majority of patients in our sample had positive findings on ERCP. CONCLUSIONS: An ANN model has better discriminant ability and accuracy than a multivariate logistic regression model in selecting patients for therapeutic ERCP.

Double common bile duct with choledochal cyst and cholelithiasis: report of a case.

Double common bile duct (DCBD) is a rare congenital anomaly of the biliary system, often associated with biliary lithiasis, choledochal cyst, pancreaticobiliary maljunction (PBM), and upper gastrointestinal tract malignancies. We report a case of type I DCBD with choledochal cyst and cholelithiasis in a 52-year-old Chinese man. We also reviewed 24 cases of DCBD reported in the Chinese literature between 1965 and 2012. Most (58.3%) of these cases were classified as type I DCBD, with accompanying choledocholithiasis in 79.2%, cholecystolithiasis in 37.5%, choledochal cyst in 33.3%, and PBM in 8.3%. There was no case of concomitant cancer. The type and coexistence of PBM with DCBD are clinically important because of its close implications with concomitant pathology. Most Chinese people with DCBD have type I. Moreover, the high incidences of choledochal cyst and biliary lithiasis and the extremely low incidences of PBM and biliary cancer are the major clinical characteristics of DCBD in China.

[Choledochal lithiasis and stenosis secondary to the migration of a surgical clip]. / Litiasis y estenosis del colédoco provocada por la migración de un clip quirúrgico.

The migration of a clip to the common bile duct after cholecystectomy is an uncommon, usually late, complication that can lead to diverse complications like stone formation, stenosis, and obstruction in the bile duct. We present the case of a patient who presented with signs and symptoms of cholangitis due to clip migration one year after laparoscopic cholecystectomy; endoscopic retrograde cholangiopancreatography and biliary tract stent placement resolved the problem.

Obesity and Risk for Incomplete Stone Clearance in Patients with Bile Duct Stones Undergoing ERCP.

INTRODUCTION: Obesity degrades fluoroscopic image quality and could impact on the endoscopic retrograde cholangiopancreatography (ERCP) outcomes. Our study aimed to compare the clinical outcomes and adverse events (AEs) between obese and non-obese patients undergoing ERCP for biliary stone-related conditions. METHODS: Patients who underwent ERCP for biliary-stone related conditions were included. The analyzed outcomes included the rates of successful bile duct cannulation, incomplete bile duct stone clearance, recurrent bile duct stones, and AEs. RESULTS: A total of 229 patients (116 obese patients and 113 non-obese patients) were included. All patients had successful bile duct cannulation. The rates of incomplete bile duct stone clearance (11.3% vs. 9.0%, P = 0.51), recurrent bile duct stones (1.9% vs. 4.2%, P = 0.24), and AEs (1.8% vs. 0.7%, P = 0.43) were not significantly different between the two groups, respectively. CONCLUSION: Our study demonstrates no associations between obesity and the rates of incomplete stone clearance, recurrent stones, successful cannulation, or AEs in patients undergoing ERCP for biliary stone-related disease.

Percutaneous transgallbladder rendezvous for enteroscopic management of choledocholithiasis in patients with surgically altered anatomy.

INTRODUCTION: Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered upper gastrointestinal anatomy (SAA) is generally challenging despite the use of enteroscopy. After failed biliary cannulation, rendezvous technique (RV) can be an option to assist the biliary access. However, proper needle puncture of biliary ducts, which is critical in the RV procedure, can be difficult because of insufficient biliary dilation. By contrast, the gallbladder can be punctured as a possible access route for RV. AIM: To evaluate the feasibility and safety of percutaneous transgallbladder (PTGB)-RV in patients with SAA. PATIENTS AND METHODS: Six patients who underwent PTGB-RV were included. PTGB drainage was performed in cases without sufficient biliary duct dilation. A guidewire was inserted through the PTGB route with antegrade passage through the cystic duct, common bile duct and duodenal papilla. An enteroscope was inserted up to the papilla, at the guidewire exit site. The guidewire was pulled out through the accessory channel followed by biliary cannulation over the guidewire and endoscopic papillary balloon dilation (EPBD) for stone removal. RESULTS: Six patients with SAA (Roux-en-Y in 4 and Billroth-II in 2) underwent PTGB-RV for removal of bile duct stones. In all patients, a guidewire was successfully inserted into the duodenum followed by insertion of the enteroscope and biliary cannulation. EPBD was then performed, but subsequent stone removal failed in 1 patient. Stone removal was successful in 5 patients without complication, except 1 case of mild pancreatitis. CONCLUSION: PTGB-RV seems to be a feasible and relatively safe salvage technique in patients with SAA.

Endoscopic papillary large balloon dilatation alone is safe and effective for the treatment of difficult choledocholithiasis in cases of Billroth II gastrectomy: a single center experience.

BACKGROUND: Endoscopic treatment of difficult common bile duct (CBD) stones (diameter ≥ 10 mm, or four or more) is difficult in patients who have undergone Billroth II (B-II) gastrectomy. Endoscopic sphincterotomy (EST) can be particularly troublesome due to anatomical changes effected by the gastrectomy. AIM: We evaluated the efficacy and safety of endoscopic papillary large balloon dilation (EPLBD) with large-diameter dilation balloons in the treatment of difficult CBD stones in patients who have undergone B-II gastrectomy. MATERIALS AND METHODS: From June 2006 to April 2011, patients with difficult CBD stones and who had undergone B-II gastrectomy previously were included in this study. EPLBD was performed with a 10-18 mm balloon catheter. When selective cannulation through the sphincter was possible, EPLBD was performed without EST. EPLBD was otherwise performed after fistulotomy with needle knife. RESULTS: A total of 40 patients (32 male) underwent EPLBD for the retrieval of CBD stones, and concurrent fistulotomy was performed in seven patients. The median diameter of CBD was 13 mm (range 10-20 mm) and the balloon was 12 mm (range 10-17 mm). CBD stones were successfully removed in all patients. In only three patients, repeated sessions of ERCP were required for complete removal of CBD stones. Mechanical lithotripsy was required in only one case. Acute complications from EPLBD included mild pancreatitis in two patients (5.0 %). Severe complications, including perforation and bleeding, were not observed. Late complications included stone recurrence in one patient (2.5 %) and cholecystitis in four patients (10.0 %). CONCLUSIONS: In cases of B-II gastrectomy, EPLBD without EST is a safe and highly effective technique for the retrieval of difficult CBD stones. EPLBD should be considered as an alternative tool to conventional EST.

Risk factors of choledocholithiasis formation after liver transplantation.

Systematic study of risk factors for biliary stone post-liver transplantation is rarely performed. To investigate the risk factor of choledocholithiasis formation after liver transplantation, we conducted a case-control study. Fourteen patients were selected into a study group. The stones of the bile duct of the patients were confirmed and treated successfully by endoscopic retrograde cholangiopancreatography. For univariate analysis, we selected carefully some potential risk factors such as cold ischemia time, warm ischemia time, and biliary stricture. The results revealed that cold ischemia time and biliary stenosis were significant predictors. But multivariate analysis revealed that only biliary stenosis was a significant risk factor. In conclusion, biliary stenosis is a risk factor of bile duct stones formation after liver transplantation. Endoscopic retrograde cholangiopancreatography is effective and safe in the diagnosis or treatment of bile duct stones after liver transplantation.