Role of advanced endoscopy in the management of inflammatory digestive diseases (pancreas and biliary tract).

The progress of endoscopic diagnosis and treatment for inflammatory diseases of the biliary tract and pancreas have been remarkable. Endoscopic ultrasonography (EUS) and EUS-elastography are used for the diagnosis of early chronic pancreatitis and evaluation of endocrine and exocrine function in chronic pancreatitis. Notably, extracorporeal shock wave lithotripsy and electrohydraulic shock wave lithotripsy have improved the endoscopic stone removal rate in patients for whom pancreatic stone removal is difficult. Studies have reported the use of self-expanding metal stents for stent placement for pancreatic duct stenosis and EUS-guided pancreatic drainage for refractory pancreatic duct strictures. Furthermore, EUS-guided drainage using a double-pigtailed plastic stent has been performed for the management of symptomatic pancreatic fluid collection after acute pancreatitis. Recently, lumen-apposing metal stents have led to advances in the treatment of walled-off necrosis after acute pancreatitis. EUS-guided biliary drainage is an alternative to refractory endoscopic biliary drainage and percutaneous transhepatic biliary drainage for the treatment of acute cholangitis. The placement of an inside stent followed by switching to uncovered self-expanding metal stents in difficult-to-treat cases has been proposed for acute cholangitis by malignant biliary obstruction. Endoscopic transpapillary gallbladder drainage is an alternative to percutaneous transhepatic gallbladder drainage for severe and some cases of moderate acute cholecystitis. EUS-guided gallbladder drainage has been reported as an alternative to percutaneous transhepatic gallbladder drainage and endoscopic transpapillary gallbladder drainage. However, it is important to understand the advantages and disadvantages of each drainage method and select the optimal drainage method for each case.

[Endoscopic intraluminal treatment of early biliary complications after orthotopic liver transplantation]. / Opyt endoskopicheskogo vnutriprosvetnogo lecheniya rannikh biliarnykh oslozhnenii posle ortotopicheskoi transplantatsii pecheni.

OBJECTIVE: To improve the outcomes after orthotopic liver transplantation (OLT) followed by early biliary complications via endoscopic bilioduodenal stenting. MATERIAL AND METHODS: The study enrolled 41 patients with early biliary complications within 90 days after OLT. All patients underwent endoscopic treatment between 2001 and 2021. There were 34 (82.9%) men and 7 (17.1%) women aged 48.5±12.5 years. Strictures and failure of biliary anastomosis occurred in 33 (80.5%) and 8 (19.5%) patients, respectively. RESULTS: After endoscopic treatment, serum bilirubin normalized in 3.3±0.86 days in patients with strictures (23.7 (16.4; 34.5) mmol/l, p<0.001). Diameter of lobar ducts as a criterion of biliary hypertension was normalized after 4 (2.5; 5.5) days (p<0.001). Bile leakage after stenting with a covered self-expanding stent regressed in all 7 patients after 3 (2; 5) days. In 1 patient, bile output through the drainage stopped in 8 days after bilioduodenal stenting with a plastic stent. CONCLUSION: Endoscopic bilioduodenal stenting is always effective and minimally invasive treatment after liver transplantation followed by early biliary complications (failure or stricture of anastomosis). This approach minimizes postoperative complications (9.8%) that do not require surgical intervention (Clavien-Dindo grade I).

Biliary ascariasis misidentified as a biliary stent in a patient undergoing liver resection.

Ascaris lumbricoides causes one of the most common soil-transmitted helminthiases globally. The worms mostly infect the human small intestine and elicit negligible or nonspecific symptoms, but there are reports of extraintestinal ectopic ascariasis. We describe a rare case of biliary ascariasis mistaken for biliary stent in a 72-year-old female patient with a history of liver resection. She visited our outpatient clinic complaining of right upper quadrant pain and fever for the past week. She had previously undergone left lateral sectionectomy for recurrent biliary and intrahepatic duct stones 2 years ago. Besides mildly elevated gamma-glutamyl transferase levels, her liver function tests were normal. Magnetic resonance cholangiopancreatography revealed a linear filling defect closely resembling an internal stent from the common bile duct to the right intrahepatic bile duct. A live female A. lumbricoides adult worm was removed by endoscopic retrograde cholangiopancreatography (ERCP). Despite a significant decrease of the ascariasis prevalence in Korea, cases of biliary ascariasis are still occasionally reported. In this study, a additional case of biliary ascariasis, which was radiologically misdiagnosed as the biliary stent, was described in a hepatic resection patient by the worm recovery with ERCP in Korea.

Radiologic Reporting of Simple Hepatic Cyst Versus Biliary Cystadenoma May Lead to Unnecessary Surgery.

BACKGROUND AND AIMS: Simple liver cyst (SHC) is a benign condition with no malignant potential. They are typically discovered incidentally due to the increased use of abdominal imaging, but some patients may present with abdominal pain. A radiologist's differential diagnosis in cases of SHC will often include "rule out biliary cystadenoma." Under these circumstances, patients and surgeons are more likely to pursue surgical options even in asymptomatic cases. The aim of this study is to conduct a retrospective analysis of presentation, radiologic reporting, management plan, and histopathology of patients referred to a tertiary hospital in order to determine the correlation between radiology and histology. METHODS: We retrospectively analyzed the clinical, radiological, and histopathological data of 20 patients operated for a diagnosis of a cystic lesion in the liver. RESULT: The CT/MRI of 6 (30%) patients was reported as a biliary cystadenoma, 13 (65%) were reported as a simple hepatic cyst and 1 patient (5%) had hepatocellular carcinoma (HCC) with the additional diagnosis of multiple hepatic cysts. The lesion reported as HCC on the scan was separate from the cystic lesions. The modality of imaging for these cysts was evenly split, 50% of patients had a CT scan, and 50% had an MRI performed. All imaging studies were interpreted by an attending radiologist and most of them were discussed in multidisciplinary meetings. Nineteen patients (95%) had an intraoperative diagnosis of a simple liver cyst based on its visual appearance and clear fluid within the cyst. These patients underwent cyst wall fenestration and de-roofing with the cyst wall sent for histopathology. One patient (5%) with HCC underwent a non-anatomical liver resection. Histopathology was conclusive for a benign hepatic cystic lesion from the cyst wall biopsy. All 20 patients in this study underwent surgery, either due to symptoms or due to radiologic diagnosis of BCA. Four of the 20 cases (20%) were asymptomatic and out of these four cases, 3 (75%) were diagnosed as cystadenoma on the preoperative imaging studies. All 19 cases were diagnosed as a simple liver cyst on pathology. CONCLUSION: In summary, there is a growing trend of "ruling-out the diagnosis of biliary cystadenoma" in patients who present with liver cysts. Patients are appropriately more anxious after this preoperative diagnosis and the treating surgeons have medico-legal concerns regarding conservative management in asymptomatic patients diagnosed as BCA. This single center experience draws attention to the radiology criteria utilized for diagnosing a biliary cystadenoma and suggests that it is time to revisit the imaging interpretation and differential diagnosis.

Post-transplant biliary complications: advances in pathophysiology, diagnosis, and treatment.

Liver transplantation (LT) is the only curative therapy in patients with end-stage liver disease. Long-term survival is excellent, yet LT recipients are at risk of significant complications. Biliary complications are an important source of morbidity after LT, with an estimated incidence of 5%-32%. Post-LT biliary complications include strictures (anastomotic and non-anastomotic), bile leaks, stones, and sphincter of Oddi dysfunction. Prompt recognition and management is critical as these complications are associated with mortality rates up to 20% and retransplantation rates up to 13%. This review aims to summarise our current understanding of risk factors, natural history, diagnostic testing, and treatment options for post-transplant biliary complications.

Management of Biliary Complications in Liver Transplant Recipients.

Biliary complications are often referred to as the Achilles' heel of liver transplantation (LT). The most common of these complications include strictures, and leaks. Prompt diagnosis and management is key for preservation of the transplanted organ. Unfortunately, a number of factors can lead to delays in diagnosis and make adequate treatment a challenge. Innovations in advanced endoscopic techniques have increased non-surgical options for these complications and in many cases is the preferred approach.

Postoperative bile leakage caused by intrahepatic duct injury during right hemicolectomy: A case report.

INTRODUCTION: Bile peritonitis is one of the rare complications that can occur after cholecystectomy or hepatectomy. It is associated with high mortality, prolonged hospital stay, and increased cost. We herein report 2 cases of bile leakage as a postoperative complication of right hemicolectomy. PATIENT CONCERNS: Two patients underwent a right hemicolectomy for colon cancer. Both patients had a history of cholecystectomy, and intrahepatic bile duct dilatation was observed in preoperative imaging study. During surgery, adhesiolysis was performed between the liver and the hepatic flexure of the colon due to adhesion in that area. DIAGNOSIS: Postoperatively, bile fluid was drained via an intraabdominal drainage tube. Both cases required surgical intervention to explore the origin of the leakage. In both cases, the anastomosis was intact, and the injury of the intrahepatic bile duct just beneath the liver surface was the origin of bile leakage. INTERVENTIONS: Suture ligation, irrigation, and drainage were performed in both patients. OUTCOMES: There was no more bile leakage after reoperation, and both patients were discharged in good health after antibiotics treatment. CONCLUSION: Although very rare, bile leakage due to intrahepatic duct injury can occur after right hemicolectomy in patients with a history of cholecystectomy and intrahepatic duct dilatation. It is necessary to consider the possibility of bile duct injury and anastomotic leakage if bile leakage is suspected after right hemicolectomy.

Choledochal cyst and aberrant biliary configuration along with situs inversus totalis: a case report.

Situs inversus totalis is the complete transpositioning of thoracoabdominal viscera into a mirror image of the normal configuration. Choledochal cyst is the congenital cystic dilation of the biliary tract. Both these conditions coexisting in a patient is extremely rare. We hereby present a case of type IC choledochal cyst in a patient with situs inversus totalis presenting with biliary sepsis secondary to choledocholithiasis. Also detailed are the management and operative strategies employed to deal with this rare entity.

High presepsin concentrations in bile and its marked elevation in biliary tract diseases: A retrospective analysis.

BACKGROUND: Presepsin is a diagnostic and prognostic biomarker of both bacterial infection and sepsis; however, elevated presepsin levels have also been observed without sepsis. We conducted several analyses to evaluate the clinical laboratory parameters affecting presepsin levels. METHOD: We analyzed the association between sequential organ failure assessment (SOFA) scores and plasma presepsin levels and then analyzed clinical laboratory parameters in 567 patients with univariate and multivariate regression analysis and analysis of covariance (ANCOVA). We also determined presepsin in the bile of 11 patients and examined the presepsin immunostaining in liver. RESULTS: Spearman's rank correlation analysis with loge change revealed that presepsin levels were closely associated with loge-transformed SOFA score (ρ = 0.541), alkaline phosphatase (ALP); (ρ = 0.454) and gamma-glutamyl transferase; (ρ = 0.505). Multivariate regression analysis revealed that loge-transformed SOFA score (ß-coefficient = 0.316), ALP level (ß-coefficient = 0.380), and creatinine level (ß-coefficient = 0.290) independently and significantly affected loge presepsin levels. ANCOVA revealed that presepsin levels were significantly higher in patients with hepatobiliary disease. Patients who presented with dilatation of the bile ducts and elevated ALP levels or total bilirubin levels exhibited high presepsin levels in the bile. Presepsin production in liver Kupffer cells was also confirmed by immunostaining. CONCLUSION: Presepsin levels is correlated with the elevation of biliary enzymes in patients without renal dysfunction or sepsis. Additionally, presepsin exists with high concentrations in the bile and is positive in Kupffer cells.

Sequential Liver-Kidney Transplantation for Recurrent Liver Cysts Infection in a Patient With Autosomal Dominant Polycystic Kidney Disease: A Case Report.

Autosomal dominant polycystic kidney disease (ADPKD) is the most prevalent hereditary kidney disorder. Liver cysts are the most common extrarenal manifestation of the disease and usually remain asymptomatic. Liver cyst infection is rare, and its treatment is challenging. Liver transplantation (LT) is the only curative therapeutic option in symptomatic polycystic liver disease associated with ADPKD. Only a few cases of LT for recurrent liver cyst infection have been published. To our knowledge, we report the first case of sequential liver-kidney transplantation for recurrent liver cysts infection in a patient with ADPKD. A 55-year-old woman with ADPKD who had a kidney transplantation (KT) presented with multiple liver cysts infection 9 months after her KT. These episodes started after biliary tract complications due to an ampullary adenoma necessitating multiple endoscopic interventions. Her general status gradually degraded because antibiotic treatment was not effective, and she underwent LT for recurrent liver cysts infection 1 year and 9 months after her KT. LT in this setting turned out to be challenging but was possible. We think that better biliary tract workup before KT may prompt better care in these patients.

Applications of artificial intelligence in pancreatic and biliary diseases.

The application of artificial intelligence (AI) in medicine has increased rapidly with respect to tasks including disease detection/diagnosis, risk stratification, and prognosis prediction. With recent advances in computing power and algorithms, AI has shown promise in taking advantage of vast electronic health data and imaging studies to supplement clinicians. Machine learning and deep learning are the most widely used AI methodologies for medical research and have been applied in pancreatobiliary diseases for which diagnosis and treatment selection are often complicated and require joint consideration of data from multiple sources. The aim of this review is to provide a concise introduction of the major AI methodologies and the current landscape of AI research in pancreatobiliary diseases.

Artificial intelligence in pancreaticobiliary endoscopy.

Artificial intelligence (AI) applications in health care have exponentially increased in recent years, and a few of these are related to pancreatobiliary disorders. AI-based methods were applied to extract information, in prognostication, to guide clinical treatment decisions and in pancreatobiliary endoscopy to characterize lesions. AI applications in endoscopy are expected to reduce inter-operator variability, improve the accuracy of diagnosis, and assist in therapeutic decision-making in real time. AI-based literature must however be interpreted with caution given the limited external validation. A multidisciplinary approach combining clinical and imaging or endoscopy data will better utilize AI-based technologies to further improve patient care.

The Challenges of Implementing Artificial Intelligence into Surgical Practice.

BACKGROUND: Artificial intelligence is touted as the future of medicine. Classical algorithms for the detection of common bile duct stones (CBD) have had poor clinical uptake due to low accuracy. This study explores the challenges of developing and implementing a machine-learning model for the prediction of CBD stones in patients presenting with acute biliary disease (ABD). METHODS: All patients presenting acutely to Christchurch Hospital over a two-year period with ABD were retrospectively identified. Clinical data points including lab test results, demographics and ethnicity were recorded. Several statistical techniques were utilised to develop a machine-learning model. Issues with data collection, quality, interpretation and barriers to implementation were identified and highlighted. RESULTS: Issues with patient identification, coding accuracy, and implementation were encountered. In total, 1315 patients met inclusion criteria. Incorrect international classification of disease 10 (ICD-10) coding was noted in 36% (137/382) of patients recorded as having CBD stones. Patients with CBD stones were significantly older and had higher aspartate aminotransferase (AST), alanine aminotransferase (ALT), bilirubin and gamma-glutamyl transferase (GGT) levels (p < 0.001). The no information rate was 81% (1070/1315 patients). The optimum model developed was the gradient boosted model with a PPV of 67%, NPV of 87%, sensitivity of 37% and a specificity of 96% for common bile duct stones. CONCLUSION: This paper highlights the utility of machine learning in predicting CBD stones. Accuracy is limited by current data and issues do exist around both the ethics and practicality of implementation. Regardless, machine learning represents a promising new paradigm for surgical practice.