An assessment of existing risk stratification guidelines for the evaluation of patients with suspected choledocholithiasis.

BACKGROUND: Prior studies have demonstrated that existing risk stratification guidelines for the evaluation of suspected choledocholithiasis lack accuracy, leading to the overutilization of endoscopic retrograde cholangiopancreatography (ERCP). The aim of our study was to evaluate the performance characteristics of published guidelines in predicting choledocholithiasis and to determine the impact of laboratory trends on diagnostic accuracy. METHODS: We identified patients with suspected choledocholithiasis hospitalized over a 5-year period (2009-2014) at a tertiary care academic medical center. Among eligible patients, we assessed the performance characteristics of the American Society for Gastrointestinal Endoscopy (ASGE) guidelines predicting the presence of choledocholithiasis, confirmed by endoscopic ultrasound, magnetic resonance cholangiography, ERCP, or intra-operative cholangiography. We also evaluated whether a second set of liver function tests improved the accuracy of the guidelines. RESULTS: On presentation, 71 of the 173 eligible patients (41.4 %) met ASGE high-probability criteria for choledocholithiasis. Of these, only 39 (54.9 %) were found to have a choledocholithiasis on confirmatory testing. Conversely, of the 102 patients (58.6 %) who were classified as low or intermediate probability, 32 (31.4 %) had choledocholithiasis. Overall, the accuracy of the guidelines was 63 % (sensitivity 54.9 %; specificity 68.6 %). Incorporating a second set of laboratory tests did not improve accuracy (62.7 %), and a significant decline in liver function tests did not reliably predict spontaneous stone passage. CONCLUSIONS: Existing guidelines performed suboptimally for predicting choledocholithiasis in our patient population, similar to other validation studies. These findings further underscore the importance of developing alternate risk stratification tools for choledocholithiasis, aiming to minimize unnecessary diagnostic ERCP.

Low symptomatic premature stent occlusion of multiple plastic stents for benign biliary strictures: comparing standard and prolonged stent change intervals.

BACKGROUND: Benign biliary strictures are typically managed endoscopically whereby an increasing size or number of plastic stents is placed at ERCP. Stents are often changed every 3 to 4 months based on the known median patency of a single biliary stent, but patency data for multiple biliary stents are lacking. OBJECTIVE: To assess the incidence of occlusion-free survival of multiple plastic biliary stents and the rate of premature occlusion if left in longer than 6 months. DESIGN: Retrospective. SETTING: Tertiary-care medical center (Charleston, SC). PATIENTS: Consecutive patients who received multiple plastic stents for benign nonhilar biliary strictures from 1994 to 2008 were identified. INTERVENTIONS: Exchange of multiple plastic biliary stents within 6 months (group 1) or 6 months or longer (group 2) after placement. MAIN OUTCOME MEASUREMENTS: Symptomatic stent occlusion. RESULTS: Seventy-nine patients with nonhilar extrahepatic benign biliary stricture underwent 125 ERCPs with multiple plastic biliary stents. Stents were scheduled for removal/exchange within 6 months in 52 patients (86 ERCPs) compared with after 6 months in 22 patients (26 ERCPs). The median interval between multiple stent placement and removal/exchange was 90 days for group 1 and 242 days for group 2. Premature stent occlusion occurred in 4 of 52 (7.7%) patients in group 1 versus 1 of 22 (4.5%) in group 2, with significantly longer occlusion-free survival in group 2 (log-rank P < .0001). LIMITATIONS: Retrospective study at a single tertiary referral center. CONCLUSION: Multiple plastic biliary stents for benign nonhilar strictures were associated with a low rate of premature symptomatic stent occlusion at more than 6 months and a longer occlusion-free survival.

Post-ERCP pancreatitis rates do not differ between needle-knife and pull-type pancreatic sphincterotomy techniques: a multiendoscopist 13-year experience.

BACKGROUND: Pancreatic sphincterotomy is one of several factors associated with an increased risk of post-ERCP pancreatitis (PEP). The needle-knife pancreatic sphincterotomy technique (NKS) is purported to result in less-frequent post-ERCP pancreatitis compared with a standard pull-type sphincterotomy (PTS). OBJECTIVE: Our purpose was to analyze the experience with both endoscopic pancreatic sphincterotomy (EPS) techniques with respect to post-ERCP pancreatitis at a single tertiary-level referral center. DESIGN: Retrospective analysis. SETTING: Tertiary-care medical center (Charleston, South Carolina). PATIENTS: Patients without chronic pancreatitis and with normal retrograde pancreatogram who underwent EPS between 1994 and 2007 were identified. Patients were excluded for the following reasons: pancreatic stent not placed, both sphincterotomy techniques used, any balloon dilation of the ampullary orifice, precut or access papillotomy, pancreas divisum. RESULTS: A total of 481 patients were identified and underwent 510 ERCPs. Indications for ERCP were recurrent pancreatic-type pain (n = 353) or pancreatitis (n = 157). NKS was used for 395 of 510 (77.5%) cases versus 115 of 510 (22.5%) in which PTS was used. The incidence of post-ERCP pancreatitis was no different between NKS (25/395, 6.4%) and PTS (9/115, 7.8%). Most cases were mild pancreatitis; a single episode of severe PEP occurred in each group. CONCLUSIONS: The risk of post-ERCP pancreatitis does not differ between EPS techniques when performed at a high-volume pancreaticobiliary referral center when using routine prophylactic pancreatic duct stent placement.