Clinical Assessment of Differential Diagnostic Methods in Infants with Cholestasis due to Biliary Atresia or Non-Biliary Atresia.

The different methods in differentiating biliary atresia (BA) from non-BA-related cholestasis were evaluated in order to provide a practical basis for a rapid, early and accurate differential diagnosis of the diseases. 396 infants with cholestatic jaundice were studied prospectively during the period of May 2007 to June 2011. The liver function in all subjects was tested. All cases underwent abdominal ultrasonography and duodenal fluid examination. Most cases were subjected to hepatobiliary scintigraphy, magnetic resonance cholangiopancreatography (MRCP) and a percutaneous liver biopsy. The diagnosis of BA was finally made by cholangiography or histopathologic examination. The accuracy, sensitivity, specificity and predictive values of these various methods were compared. 178 patients (108 males and 70 females with a mean age of 58±30 days) were diagnosed as having BA. 218 patients (136 males and 82 females with a mean age of 61 ±24 days) were diagnosed as having non-BA etiologies of cholestasis jaundice during the follow-up period in which jaundice faded after treatment with medical therapy. For diagnosis of BA, clinical evaluation, hepatomegaly, stool color, serum gamma-glutamyltranspeptidase (GGT), duodenal juice color, bile acid in duodenal juice, ultrasonography (gallbladder), ultrasonography (griangular cord or strip-apparent hyperechoic foci), hepatobiliary scintigraphy, MRCP, liver biopsy had an accuracy of 76.0%, 51.8%, 84.3%, 70.0%, 92.4%, 98.0%, 90.4%, 67.2%, 85.3%, 83.2% and 96.6%, a sensitivity of 83.1%, 87.6%, 96.1%, 73.7%, 90.4%, 100%, 92.7%, 27.5%, 100%, 89.0% and 97.4%, a specificity of 70.2%, 77.5%, 74.8%, 67.0%, 94.0%, 96.3%, 88.5%, 99.5%, 73.3%, 75.4% and 94.3%, a positive predictive value of 69.0%, 72.6%, 75.7%, 64.6%, 92.5%, 95.7%, 86.8%, 98.0%, 75.4%, 82.6% and 98.0%, and a negative predictive value of 83.6%, 8.5%, 95.9%, 75.7%, 92.3%, 100%, 84.2%, 93.7%, 100%, 84.0% and 92.6%, respectively. It was concluded that all the differential diagnosis methods are useful. The test for duodenal drainage and elements is fast and accurate. It is helpful in the differential diagnosis of BA and non-BA etiologies of cholestasis. It shows good practical value clinically.

Review article: Asia-Pacific consensus recommendations on endoscopic tissue acquisition for biliary strictures.

BACKGROUND: Pre-operative tissue diagnosis for suspected malignant biliary strictures remains challenging. AIM: To develop evidence-based consensus statements on endoscopic tissue acquisition for biliary strictures. METHODS: The initial draft of statements was prepared following a systematic literature review. A committee of 20 experts from Asia-Pacific region then reviewed, discussed, and modified the statements. Two rounds of independent voting were conducted to reach a final version. Consensus was considered to be achieved when 80% or more of voting members voted "agree completely" or "agree with some reservation." RESULTS: Eleven statements achieved consensus. The choice of tissue sampling modalities for biliary strictures depends on the clinical setting, the location of lesion, and availability of expertise. Detailed radiological and endoscopic evaluation is useful to guide the selection of appropriate tissue acquisition technique. Standard intraductal biliary brushing and/or forceps biopsy is the first option when endoscopic biliary drainage is required with an overall (range) sensitivity and specificity of 45% (26%-72%) and 99% (98%-100%), and 48% (15%-100%) and 99% (97%-100%), respectively, in diagnosing malignant biliary strictures. Probe-based confocal laser endomicroscopy and fluorescence in situ hybridisation using 4 fluorescent-labelled probes targeting chromosomes 3, 7, 17 and 9p21 locus may be added to improve the diagnostic yield. Cholangioscopy-guided biopsy and EUS-guided tissue acquisition can be considered after prior negative conventional tissue sampling with an overall (range) sensitivity and specificity of 60% (38%-88%) and 98% (83%-100%), and 80% (46%-100%) and 97% (92%-100%), respectively, in diagnosing malignant biliary strictures. CONCLUSION: These consensus statements provide evidence-based recommendations for endoscopic tissue acquisition of biliary strictures.

Role of intraoperative cholangiography for detecting residual stones after biliary pancreatitis: still useful? A retrospective study.

BACKGROUND: Intraoperative cholangiography (IOC) may detect residual stones in the common bile duct (CBD) after acute biliary pancreatitis (ABP). The aim of the present study is to analyze the utility of IOC in detecting residual stones in patients undergoing cholecystectomy for ABP and if complications are related with this procedure. METHODS: Demographic and clinical factors were assessed in patients with mild ABP who underwent IOC during laparoscopic cholecystectomy. Factors assessed included preoperative size of the CBD on ultrasonography, presence of stones in the gallbladder and the CBD, and IOC results. For the statistical analysis, χ2 or Fisher's exact tests to compare proportions and the nonparametric Mann-Whitney U test for analysis of values with abnormal distribution were used. RESULTS: The study included 113 patients, 82 males (72.6%) and 31 females (27.4%), of mean age 46.9 ± 14.7 years (range 18-86 years). All preoperative laboratory indicators were elevated. The group of the patients with stones in the CBD diagnosed by IOC was divided in patients with diameters <0.8 mm and with diameters ≥0.8 mm of the CBD diagnosed preoperatively with ultrasound. The laboratory tests do not demonstrate difference statistically significative between these two groups. The group of the patients without stones in the CBD diagnosed by IOC was also divided in patients with diameters <0.8 mm and with diameters ≥0.8 mm of the CBD. Also in these two groups, the statistical analysis of the laboratory tests does not demonstrate significative difference. Most procedures were performed by specialists (64.6%), and all patients underwent IOC. IOC showed stones in 84/113 patients (74.3%). A comparison of patients with and without stones at IOC showed similar mean times from hospitalization to surgery (5.9 days [range 2-12 days] vs. 6.1 days [range 2-23 days]), from surgery until hospital discharge (2.0 days [range 0-4 days] vs. 2.2 days [range 0-11 days]), and overall length of stay (7.9 days [range 3-19 days] vs. 8.3 days [range 3-23 days]) (P > 0.001). CONCLUSIONS: IOC is useful to diagnose residual CBD stones, without increasing complications related to the procedure itself.

Role of endoscopy in primary sclerosing cholangitis: European Society of Gastrointestinal Endoscopy (ESGE) and European Association for the Study of the Liver (EASL) Clinical Guideline.

1 ESGE/EASL recommend that, as the primary diagnostic modality for PSC, magnetic resonance cholangiography (MRC) should be preferred over endoscopic retrograde cholangiopancreatography (ERCP).Moderate quality evidence, strong recommendation. 2 ESGE/EASL suggest that ERCP can be considered if MRC plus liver biopsy is equivocal or contraindicated in patients with persisting clinical suspicion of PSC. The risks of ERCP have to be weighed against the potential benefit with regard to surveillance and treatment recommendations.Low quality evidence, weak recommendation. 6 ESGE/EASL suggest that, in patients with an established diagnosis of PSC, MRC should be considered before therapeutic ERCP.Weak recommendation, low quality evidence. 7 ESGE/EASL suggest performing endoscopic treatment with concomitant ductal sampling (brush cytology, endobiliary biopsies) of suspected significant strictures identified at MRC in PSC patients who present with symptoms likely to improve following endoscopic treatment.Strong recommendation, low quality evidence. 9 ESGE/EASL recommend weighing the anticipated benefits of biliary papillotomy/sphincterotomy against its risks on a case-by-case basis.Strong recommendation, moderate quality evidence.Biliary papillotomy/sphincterotomy should be considered especially after difficult cannulation.Strong recommendation, low quality evidence. 16 ESGE/EASL suggest routine administration of prophylactic antibiotics before ERCP in patients with PSC.Strong recommendation, low quality evidence. 17 EASL/ESGE recommend that cholangiocarcinoma (CCA) should be suspected in any patient with worsening cholestasis, weight loss, raised serum CA19-9, and/or new or progressive dominant stricture, particularly with an associated enhancing mass lesion.Strong recommendation, moderate quality evidence. 19 ESGE/EASL recommend ductal sampling (brush cytology, endobiliary biopsies) as part of the initial investigation for the diagnosis and staging of suspected CCA in patients with PSC.Strong recommendation, high quality evidence.

Optimization of near-infrared fluorescence cholangiography for open and laparoscopic surgery.

BACKGROUND: During laparoscopic cholecystectomy, common bile duct (CBD) injury is a rare but severe complication. To reduce the risk of injury, near-infrared (NIR) fluorescent cholangiography using indocyanine green (ICG) has recently been introduced as a novel method of visualizing the biliary system during surgery. To date, several studies have shown feasibility of this technique; however, liver background fluorescence remains a major problem during fluorescent cholangiography. The aim of the current study was to optimize ICG dose and timing for NIR cholangiography using a quantitative intraoperative camera system during open hepatopancreatobiliary (HPB) surgery. Subsequently, these results were validated during laparoscopic cholecystectomy using a laparoscopic fluorescence imaging system. METHODS: Twenty-seven patients who underwent NIR imaging using the Mini-FLARE image-guided surgery system during open HPB surgery were analyzed to assess optimal dosage and timing of ICG administration. ICG was intravenously injected preoperatively at doses of 5, 10, and 20 mg, and imaged at either 30 min (early) or 24 h (delayed) post-injection. Next, the optimal doses found for early and delayed imaging were applied to two groups of seven patients (n = 14) undergoing laparoscopic NIR fluorescent cholangiography during laparoscopic cholecystectomy. RESULTS: Median liver-to-background contrast was 23.5 (range 22.1­35.0), 16.8 (range 11.3­25.1), 1.3 (range 0.7­7.8), and 2.5 (range 1.3­3.6) for 5 mg/30 min, 10 mg/30 min, 10 mg/24 h, and 20 mg/24 h, respectively. Fluorescence intensity of the liver was significantly lower in the 10 mg delayed-imaging dose group compared with the early imaging 5 and 10 mg dose groups (p = 0.001), which resulted in a significant increase in CBD-to-liver contrast ratio compared with the early administration groups (p < 0.002). These findings were qualitatively confirmed during laparoscopic cholecystectomy. CONCLUSION: This study shows that a prolonged interval between ICG administration and surgery permits optimal NIR cholangiography with minimal liver background fluorescence.

Documenting correct assessment of biliary anatomy during laparoscopic cholecystectomy.

BACKGROUND: Correct assessment of biliary anatomy can be documented by photographs showing the "critical view of safety" (CVS) but also by intraoperative cholangiography (IOC). METHODS: Photographs of the CVS and IOC images for 63 patients were presented to three expert observers in a random and blinded fashion. The observers answered questions pertaining to whether the biliary anatomy had been conclusively documented. RESULTS: The CVS photographs were judged to be "conclusive" in 27%, "probable" in 35%, and "inconclusive" in 38% of the cases. The IOC images performed better and were judged to be "conclusive" in 57%, "probable" in 25%, and "inconclusive" in 18% of the cases (P < 0.001 compared with the photographs). The observers indicated that they would feel comfortable transecting the cystic duct based on the CVS photographs in 52% of the cases and based on the IOC images in 73% of the cases (P = 0.004). The interobserver agreement was moderate for both methods (kappa values, 0.4-0.5). For patients with a history of cholecystitis, both the CVS photographs and the IOC images were less frequently judged to be sufficient for transection of the cystic duct (P = 0.006 and 0.017, respectively). CONCLUSION: In this series, IOC was superior to photographs of the CVS for documentation of the biliary anatomy during laparoscopic cholecystectomy. However, both methods were judged to be conclusive only for a limited proportion of patients, especially in the case of cholecystitis. This study highlights that documenting assessment of the biliary anatomy is not as straightforward as it seems and that protocols are necessary, especially if the images may be used for medicolegal purposes. Documentation of the biliary anatomy should be addressed during training courses for laparoscopic surgery.

[Liability of surgeons with respect to injuries to the bile duct during laparoscopic cholecystectomy : Analyses of malpractice litigations in the years 1996-2009]. / Arzthaftung bei Gallengangsverletzungen nach laparoskopischer Cholezystektomie : Analyse der gerichtlichen Urteile der Jahre 1996 bis 2009.

BACKGROUND: Injuries to the bile duct during laparoscopic cholecystectomy are often a cause of malpractice litigations. METHODS: A total of 13 legal verdicts as a result of bile duct injury from 1996 to 2009 were reviewed. Comments on the verdicts and the opinions of expert witnesses were analyzed. RESULTS: Out of 13 claims, 7 were upheld and 6 were rejected. Most expert witnesses from 1996 to 2002 stated that not carrying out a cholangiography and insufficient preparation of the cystic duct constituted a performance below the standard of care expected. Expert witness testimonies from 2004 to 2009, however, regarded injury to the bile duct as predominantly inherent to treatment. CONCLUSION: With the expansion and acceptance of laparoscopic interventions, changes in the results of malpractice litigation have become evident. In contrast to the phase during establishment of the technology, an injury to the bile duct is nowadays judged predominantly as inherent to treatment.

Surgeon knowledge, behavior, and opinions regarding intraoperative cholangiography.

BACKGROUND: The risk of common bile duct injury during laparoscopic cholecystectomy (LC) is 50% to 70% lower when an intraoperative cholangiogram (IOC) is used, and this effect is exaggerated among less experienced surgeons. Routine IOC is not universal, and barriers to its use, including surgeon knowledge, behavior, and attitudes, should be understood in developing quality-improvement interventions aimed at increasing IOC use. STUDY DESIGN: There were 4,100 general surgeons randomly selected from the American College of Surgeons who were mailed a survey about IOC. Surveys with a valid exclusion (retired, no LC experience) were considered responsive but were excluded from data analysis. RESULTS: Forty-four percent responded, with 1,417 surveys analyzed (mean age 51.8+/-9.6 years; 89.2% men; 55.3% private practice). Twenty-seven percent of respondents defined themselves as routine IOC users and 91.3% of routine users reported IOC use in more than 75% of LCs performed. Academic surgeons were less often routine users compared with nonacademics (15% versus 30%; p < 0.001). Selective users were more often low-volume (less than 20 LC/year) surgeons (8% versus 15%) as compared with routine users, who were more often high-volume (more than 100 LC/year) surgeons (27% versus 20%). Routine users had more favorable and accurate opinions about IOC (less costly and more protective of injury) than did selective users. Thirty-nine percent of routine users thought IOC decreased the risk of common bile duct injury by at least half compared with 10% of selective users. CONCLUSIONS: Surgeons at greatest risk for causing common bile duct injury (inexperienced, low-volume surgeons) and those who have the greatest opportunity to train others are less likely to use IOC routinely. These represent target groups for quality-improvement interventions aimed at broader IOC use.

La colangiografía intraoperatoria selectiva en colecistitis aguda / The selective intraoperating colangiografía in acute colecistitis

Antecedentes: Está generalmente aceptado que la colecistitis aguda (CA) se asocia a un aumento de la incidencia de litiasis coledocina (LC) y de lesión quirúrgica de la vía biliar (LQVB), haciendo más necesaria la colangiografía intraoperatoria (CIO). No obstante, no existe suficiente información sobre la posibilidad de un eventual aumento de litiasis residual insospechada o LQVB asociados a la CIO selectiva en CA en servicios con experiencia en esta cirugía. Objetivo: Analizar la posibilidad de emplear la CIO selectiva en colecistectomías laparoscópica de pacientes con CA sin aumentar la morbilidad. Lugar de aplicación: Hospital Privado de Comunidad. Diseño: Análsis retrospectivo con datos registrados en forma prospectiva. Población: 345 pacientes consecutivos con coleccistectomías laparoscópicas por CA con CIO selectiva (pacientes sin evidencia clínica, de laboratorio o ecográfica de colestasis). período: junio/1993 - junio/2003. Método: Registro de incidencia de LC y LQVB en la serie. Registro de las conversaciones a cirugía abierta y de las CIO realizadas, y su indicación. Resultados: Ningún paciente tuvo litiasis biliar comparada ni LQVB, con un seguimiento del 92% de los mismos durante 23 meses promedio (rango: 19 a 30 meses). Se conviertieron a cirugía abierta por dificultades operatorias 5 operados (1,5%). Se realizó CIO en 46 casos por las dudas anatómicas (13,3%), que no evidenciaron LC. Conclusiones: la ausencia de CIO en 345 colecistectomías laparoscópicas consecutivas de pacientes con CA sin alteraciones del hepatograma ni dilatación ecográfica de la vía biliar no tuvo morbilidad, en términos de LQVB y litiasis coledociana insospechada, luego de un seguimiento de 23 meses promedio. La utilidad de la CIO se evidenció en las dudas anatómicas durante la intervención. Estos datos plantean la posibilidad de aplicar también la CIO selectiva en colecistectomías laparoscópicas de pacientes con colecistitis aguda en equipos quirúrgicos con experiencia...

Manometric and radiographic evaluation of transduodenal sphincteroplasty (papillary dilation) in dogs

OBJETIVO: Avaliar, em cães, a função da papila duodenal maior submetidas à dilatação por balão hidrostático sob o ponto de vista das alterações radiográficas e manométricas. MÉTODOS: Vinte cães foram submetidos a laparotomia, duodenotomia, dilatação da papila maior - GA(n=10) - com balão de 8mm insuflado com pressão de 0,5atm, durante 2 minutos ou ao procedimento simulado - GB(n=10). A manometria computadorizada e a colangiografia foram efetuadas antes e imediatamente após o procedimento inicial, uma e quatro semanas após a dilatação ou a simulação. Foram calculadas à partir das imagens radiográficas: a média, desvio-padrão, mediana, variação absoluta e porcentual das medidas do diâmetro da papila. Foram medidas: a pressão basal na região da papila, a amplitude das contrações e a pressão do colédoco em todos tempos de observação(t0, t7 e t28). RESULTADOS: Não houve diferença nas medidas do diâmetro da papila em t0 (GA=5,14 e DP=1,1) (GB=4,64 e DP=0,9), assim como nas variações absolutas (0,14mm) ou relativas (-2,7%). Nos animais do GA a medida da pressão basal da papila, mostrou-se menor no t28 (11,1) que nos tempos t0 (18,6) e T7 (16,2). As médias das amplitudes de contração foram significantemente inferiores nos tempos pós-operatórios (pós-t0, t7 e t28) em relação ao tempo inicial (pré-t0), nos animais dos grupos A e B. Os valores médios da pressão no colédoco também foram inferiores em t28 (7,5) que nos tempos t0 (17,8) e t7 (12,6) nos animais do GA.CONCLUSÃO: A função da papila duodenal está comprometida parcialmente com a dilatação, pois provocou diminuição da pressão basal e comprometimento da capacidade do esfíncter em suas contrações cíclicas até aos 28 dias de observação.

Manometric and radiographic evaluation of transduodenal sphincteroplasty (papillary dilation) in dogs.

PURPOSE: To evaluate, in dogs, the functions of biliary sphincter subjected to dilation hydrostatic balloon by the point of view of the radiographic and manometric alterations. METHODS: Twenty dogs were submitted to laparotomy, duodenotomy, and enlargement of the major duodenal papilla- GA(n=10) - with balloon of 8mm inflated with pressure of 0,5atm, during 2 minutes or to the sham procedure - GB(n=10). The computerized manometry and the cholangiography were done before and immediately after the initial procedure, one and four weeks after the dilation or the sham. It was calculated from the radiographic images: the mean, standard deviation, absolute and percentual variation of the diameter measures of the papilla. It was measured: the basal pressure in the papilla region, the contraction amplitudes and the choledoc pressure in all observation times (t0, t7 and t28). RESULTS: There was not differences in the diameter measures of the papilla in t0 (GA=5,14 +/- 1,1) (GB=4,64 +/-0,9), as well as in the absolute (0,14 mm) or relative (-2,7%) variations. In the animals of GA the papilla basal pressure measure was found to be smaller in t28 (11,1) than in t0 (18,6) and t7 (16,2). The contraction amplitudes measures were significantly smaller in the postoperatory times (post-t0, t7 and t28) when comparing to the initial time (pre-t0), in the animals of groups A and B. The average pressure values in the choledoc were also smaller in t28 (7,5) than in t0 (17,8) and t7 (12,6) in the animals of GA. CONCLUSION: the function of the major duodenal papilla is partially committed with the dilation, therefore it provoked the basal pressure decrease and compromising of the capacity of sphincter in its cyclical contractions up to the 28 days of observation.

[Multidetector CT and MRI of biliary diseases]. / Scanner multidétecteur face à l'IRM dans les maladies des voies biliaires.

Computed tomography (CT) retains an important clinical role for diagnostic imaging of intra- and extrahepatic biliary disorders, since access to MR cholangiography is limited in many settings. With regard to the recent technical innovations due to the advent of multidetector CT, it appears interesting to reappraise the respective role of CT and MR imaging and to define the situations in which MR imaging is clearly superior and those in which CT may be sufficient. MR cholangiography is the most reliable noninvasive technique for choledocho-lithiasis, and the current literature provides no evidence that multidetector CT could replace it for this indication. In the context of stenoses and cystic disorders, however, contrast--enhanced CT with 2D and 3D reconstructions can often provide sufficient information to answer the clinically relevant questions.

National survey on cholecystectomy related bile duct injury--public health and financial aspects in Belgian hospitals--1997.

Public health and financial aspects of cholecystectomy related bile duct injury (BDI) are highlighted in a National Cholecystectomy Survey carried out through 'datamining' the Federal State Medical Records Summaries and Financial Summaries of all Belgian hospitals in 1997. All cancer diagnoses, children < or = 10 years, cholecystectomies performed as an abdominal co-procedure or patients having undergone other non-related surgery were excluded from the study. 10.595 laparoscopic (LC) and 1.033 open cholecystectomies (OC) as well as 137 secondary BDI treatments (LC/OC) were included in the survey (total 11.765). Both LC and OC groups turned out to be significantly different as to distribution of patient's age and APR-DRG severity classes. Composite criteria in terms of ICD-9-CM and billing codes were elaborated to classify: 1) primary, intra-operatively detected and treated BDI (N = 30), 2) primary delayed BDI treatments (N = 38), 3) secondary BDI treatments (N = 137), 4) non-BDI abdomino-surgical complications (N = 119), 4) uneventful laparoscopic (N = 7.476) and 5) uneventful open cholecystectomy (N = 681). Complication rates, community costs of LC and OC groups, incidence of preoperative ERCP and/or intra-operative cholangiography as well as interventions for complications were studied. Incidence of cholecystectomy related BDI was 0.37% in LC, 2.81% in OC and 0.58% overall. Average costs amounted to [symbol: see text] 1.721 for uneventful LC, [symbol: see text] 2.924 for uneventful OC, [symbol: see text] 7.250 for primary, intra-operatively detected and immediately treated BDI [symbol: see text] 9.258 for primary delayed BDI treatments, [symbol: see text] 6.076 for secondary BDI treatments and [symbol: see text] 10.363 for non-BDI abdomino-surgical complications. In conclusion BDI with cholecystectomy reveals to be a serious complication increasing the overall average cost factor ninefold if not detected intra-operatively, in which case the raise is only fourfold. As a consequence BDI should be avoided by all means. In this respect 4 crucial surgical guidelines are emphasised.

Laparoscopic ultrasonography is a complement to cholangiography for the detection of choledocholithiasis at laparoscopic cholecystectomy.

BACKGROUND: Intraoperative cholangiography and laparoscopic ultrasonography are both used in the detection of common bile duct stones at laparoscopic cholecystectomy. The aim of this prospective study was to determine whether laparoscopic ultrasonography has an alternative or a complementary role with respect to cholangiography in achieving this end. METHODS: The biliary trees of 900 patients undergoing laparoscopic cholecystectomy were examined routinely by the two methods. The diagnostic power of each investigation and of the two techniques in combination was evaluated. The statistical non-random concordance between the two methods was also determined. RESULTS: Laparoscopic ultrasonography was performed in all 900 patients. Cholangiography was performed in 762 (85 per cent). The mean (range) duration was 9.8 (4-21) min for laparoscopic ultrasonography and 17.6 (7-42) min for cholangiography. For the detection of common bile duct stones, with a kappa coefficient of 0.57 (95 per cent confidence interval (c.i.) 0.43 to 0.71), the non-random concordance between the two methods was considered to be fair to good. The sensitivity of laparoscopic ultrasonography was 0.80 (95 per cent c.i. 0.65 to 0.91) and its specificity was 0.99 (95 per cent c.i. 0.98 to 1.00). The respective values for cholangiography were 0.75 (95 per cent c.i. 0.59 to 0.87) and 0.99 (95 per cent c.i. 0.98 to 1.00). The examinations combined had a sensitivity of 0.95 (95 per cent c.i. 0.86 to 0.99) and a specificity of 0.98 (95 per cent c.i. 0.96 to 1.00). CONCLUSION: Laparoscopic ultrasonography and intraoperative cholangiography are complementary, as the combination of both methods maximizes the intraoperative detection of choledocholithiasis.

Pattern of management of common bile duct stones in the laparoscopic era: a NSW survey.

BACKGROUND: The management of common bile duct (CBD) stones in the laparoscopic era remains controversial with various management strategies employed by surgeons. The aim of this study was to ascertain the common practice across a single Australian state, and to see if a 'best practice' for CBD stone management could be established. METHODS: A questionnaire was sent to 390 general surgeons in New South Wales in April 1999. Data collected included the type of practice, number of cholecystectomies performed, preoperative markers of CBD stones, indications for preoperative endoscopic retrograde cholangiopancreatography (ERCP), use of operative cholangiography (OC) and the management of CBD stones found on OC. RESULTS: The questionnaire was returned by 223 (57%) surgeons. Fifty-four (14%) of these respondents were excluded as they did not perform laparoscopic cholecystectomy, leaving 169 (43%) respondents for analysis. The preoperative indicators for CBD stones were ranked as: jaundice > dilated CBD on ultrasound > serum bilirubin > serum alkaline phosphatase/alanine aminotransferase > previous biliary pancreatitis. Preoperative ERCP would be performed by 88% for persistent jaundice or cholangitis, 33% for elevated liver function test, 25% for dilated CBD and 24% for biliary pancreatitis. Operative cholangiography is routinely performed by 67%, selectively by 29% and never by 4%. If CBD stones are encountered 47% would attempt laparoscopic clearance via the cystic duct or choledochotomy; however, 72% replied that they would use postoperative ERCP as part of their usual strategy for the management of CBD stones. CONCLUSIONS: There was no clear common pattern for the management of suspected or proven CBD stones. There were three management issues in which there was a 'common practice'. These were: (i) the use of preoperative ERCP for patients with persistent jaundice or cholangitis; and the routine use of (ii) OC and (iii) postoperative ERCP to clear the CBD, assuming other methods had failed.

NIH state-of-the-science statement on endoscopic retrograde cholangiopancreatography (ERCP) for diagnosis and therapy.

OBJECTIVE: To provide health care providers, patients, and the general public with a responsible assessment of currently available data regarding the use of endoscopic retrograde cholangiopancreatography (ERCP) for diagnosis and therapy. PARTICIPANTS: A non-Federal, non-advocate, 13-member panel representing the fields of gastroenterology, hepatology, clinical epidemiology, oncology, biostatistics, surgery, health services research, radiology, internal medicine, and the public. In addition, experts in these same fields presented data to the panel and to a conference audience of approximately 300. EVIDENCE: Presentations by experts; a systematic review of the medical literature provided by the Agency for Healthcare Research and Quality; and an extensive bibliography of ERCP research papers, prepared by the National Library of Medicine. Scientific evidence was given precedence over clinical anecdotal experience. CONFERENCE PROCESS: Answering predefined questions, the panel drafted a statement based on the scientific evidence presented in open forum and the scientific literature. The draft statement was read in its entirety on the final day of the conference and circulated to the experts and the audience for comment. The panel then met in executive session to consider these comments and released a revised statement at the end of the conference. The statement was made available on the World Wide Web at http://consensus.nih.gov immediately after the conference. This statement is an independent report of the panel and is not a policy statement of the NIH or the Federal Government. CONCLUSIONS: In the diagnosis of choledocholithiasis, magnetic resonance cholangiopancreatography (MRCP), endoscopic ultrasound (EUS), and ERCP have comparable sensitivity and specificity. Patients undergoing cholecystectomy do not require ERCP preoperatively if there is low probability of having choledocholithiasis. Laparoscopic common bile duct exploration and postoperative ERCP are both safe and reliable in clearing common bile duct stones. ERCP with endoscopic sphincterotomy (ES) and stone removal is a valuable therapeutic modality in choledocholithiasis with jaundice, dilated common bile duct, acute pancreatitis, or cholangitis. In patients with pancreatic or biliary cancer, the principal advantage of ERCP is palliation of biliary obstruction when surgery is not elected. In patients who have pancreatic or biliary cancer and who are surgical candidates, there is no established role for preoperative biliary drainage by ERCP. Tissue sampling for patients with pancreatic or biliary cancer not undergoing surgery may be achieved by ERCP, but this is not always diagnostic. ERCP is the best means to diagnose ampullary cancers. ERCP has no role in the diagnosis of acute pancreatitis except when biliary pancreatitis is suspected. In patients with severe biliary pancreatitis, early intervention with ERCP reduces morbidity and mortality compared with delayed ERCP. ERCP with appropriate therapy is beneficial in selected patients who have either recurrent pancreatitis or pancreatic pseudocysts. Patients with type I sphincter of Oddi dysfunction (SOD) respond to endoscopic sphincterotomy (ES). Patients with type II SOD should not undergo diagnostic ERCP alone. If sphincter of Oddi manometer pressures are >40 mmHg, ES is beneficial in some patients. Avoidance of unnecessary ERCP is the best way to reduce the number of complications. ERCP should be avoided if there is a low likelihood of biliary stone or stricture, especially in women with recurrent pain, a normal bilirubin, and no other objective sign of biliary disease. Endoscopists performing ERCP should have appropriate training and expertise before performing advanced procedures. With newer diagnostic imaging technologies emerging, ERCP is evolving into a predominantly therapeutic procedure.

The role of ERCP and pancreatoscopy in cystic and intraductal tumors.

ERCP and pancreatoscopy may establish a diagnosis of IPMT and differentiate it from a pseudocyst or cystic neoplasm of the pancreas. These techniques may also assess risk of malignancy, extent of disease, allow tissue sampling, and provide therapeutic intervention.