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.

A Circular RNA, Cholangiocarcinoma-Associated Circular RNA 1, Contributes to Cholangiocarcinoma Progression, Induces Angiogenesis, and Disrupts Vascular Endothelial Barriers.

BACKGROUND AND AIMS: Circular RNAs (circRNAs) and extracellular vesicles (EVs) are involved in various malignancies. We aimed to clarify the functions and mechanisms of dysregulated circRNAs in the cells and EVs of cholangiocarcinoma (CCA). APPROACH AND RESULTS: CircRNA microarray was used to identify circRNA expression profiles in CCA tissues and bile-derived EVs (BEVs). CCA-associated circRNA 1 (circ-CCAC1) expression was measured by quantitative real-time PCR. The clinical importance of circ-CCAC1 was analyzed by receiver operating characteristic curves, Fisher's exact test, Kaplan-Meier plots, and Cox regression model. The functions of circ-CCAC1 and exosomal circ-CCAC1 were explored in CCA cells and human umbilical vein endothelial cells (HUVECs), respectively. Different animal models were used to verify the in vitro results. RNA sequencing, bioinformatics, RNA immunoprecipitation, RNA pulldown, chromatin immunoprecipitation followed by sequencing, and luciferase reporter assays were used to determine the regulatory networks of circ-CCAC1 in CCA cells and HUVECs. Circ-CCAC1 levels were increased in cancerous bile-resident EVs and tissues. The diagnostic and prognostic values of circ-CCAC1 were identified in patients with CCA. For CCA cells, circ-CCAC1 increased cell progression by sponging miR-514a-5p to up-regulate Yin Yang 1 (YY1). Meanwhile, YY1 directly bound to the promoter of calcium modulating ligand to activate its transcription. Moreover, circ-CCAC1 from CCA-derived EVs was transferred to endothelial monolayer cells, disrupting endothelial barrier integrity and inducing angiogenesis. Mechanistically, circ-CCAC1 increased cell leakiness by sequestering enhancer of zeste homolog 2 in the cytoplasm, thus elevating SH3 domain-containing GRB2-like protein 2 expression to reduce the levels of intercellular junction proteins. In vivo studies further showed that increased circ-CCAC1 levels in circulating EVs and cells accelerated both CCA tumorigenesis and metastasis. CONCLUSIONS: Circ-CCAC1 plays a vital role in CCA tumorigenesis and metastasis and may be an important biomarker/therapeutic target for CCA.

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.

A significant proportion of patients with choledocholithiasis have markedly elevated alanine aminotransferase.

Objective: To determine the frequency and nature of liver enzyme elevations among patients presenting with choledocholithiasis (CDL). Methods: A prospective study identified all patients with serum level of alanine aminotransferase (ALT) ≥500 U/L (normal levels: <70 U/L in men, <45 U/L in women) over 1 year. Additionally, other patients with CDL were identified during the same period retrospectively by diagnostic codes and ERCP procedures, providing data on all CDL patients. Symptoms, liver tests, history of cholecystectomy, and radiological imaging were analyzed. Patients with radiologically confirmed CDL or a clinical diagnosis of CDL were included. Results: During the study period, 110 patients had CDL, 60% women, mean age 65 years. Overall 86/110 (78%) had confirmed CDL on imaging and 24/110 (22%) clinically diagnosed. Overall 26% had undergone cholecystectomy, median bile duct diameter 10.0 mm, median maximal liver tests: ALT 436, ALP 226, bilirubin 60 µmol/L (<25). Overall 9/110 (8%) had ALT ≥1000, 43/110 (39%) ALT levels between 500 and 1000 IU/L and 58/110 (53%) had ALT <500 IU/L. Patients with ALT ≥1000 had smaller bile duct diameter of 7 versus 10 mm (p < .001) but similar proportions of cholecystectomies. In the multivariate analysis age, maximal AST and maximal bilirubin were independent predictors of ALT >500. Maximal AST and bile duct diameter were independent predictors of ALT >1000. Conclusions: Approximately 8% of patients with CDL had markedly elevated ALT. These patients had smaller bile duct diameter. Pronounced ALT elevation is a part of the clinical spectrum of CDL.

External Validation of Different Scoring Systems for Suspected Choledocholithiasis.

AIM OF THE STUDY: The diagnosis of choledocholithiasis is challenging. Previously published scoring systems designed to calculate the risk of choledocholithiasis were evaluated to appraise the diagnostic performance. PATIENTS AND METHODS: Data of patients who were admitted between 2013 and 2015 with the following characteristics were retrieved: bile stone-related symptoms and signs, and indication to laparoscopic cholecystectomy. To validate and appraise the performance of the 6 scoring systems, the acknowledged domains of each metrics were applied to the present cohort. Sensitivity, specificity, positive, negative predictive, Youden index, and receiver operating characteristic curve with the area under the curve (AUC) values of the scores were calculated. RESULTS: Two-hundred patients were analyzed. The highest sensitivity and specificity were obtained from the Menezes' (96.6%) and Telem's (99.3%) metrics respectively. The Telem's and Menezes' scores had the best positive (75.0%) and negative (96.4%) predictive values respectively. The best accuracy, as computed by the Youden index and AUC, was found for the Soltan's scoring system (0.628 and 0.88, respectively). CONCLUSION: The available scoring systems are precise only in identifying patients with a negligible risk of common bile duct stone, but overall insufficiently accurate to suggest the routine use in clinical practice.

Clinical Observation of the Efficacy of Endoscopic Retrograde Cholangiopancreatography on Elder Choledocholithiasis and Its Effects on the Levels of TNF-α, IL-1, and IL-6.

OBJECTIVE: We conducted this study to investigate the clinical efficacy of endoscopic retrograde cholangiopancreatography (ERCP) on elder choledocholithiasis and its effects on the levels of TNF-α, IL-1, and IL-6. METHODS: Elder patients with choledocholithiasis were enrolled in this study, and according to the surgical methods, they were divided into the ERCP group and the surgical group. After treatment, we compared the efficacy of these two methods on patients, inflammatory responses indicated by the levels of TNF-α, IL-1, and IL-6, and the complications. RESULTS: No statistical significance was identified in the difference of the success rate in removal between the two groups (98% vs. 94%), but indicators of the ERCP group, including the surgical duration (28.5±12.8) min, remission duration of abdominal pain (1.2±0.2) d, recession time of jaundice (2.0±0.3) d, postoperative bedridden time (1.4±0.2) d, treatment time of the anti-infection (1.5±0.2) d, length of stay in hospital (6.5±0.3) d, levels of TNF-α (2.1±0.2) µg/L, IL-1 (6.3±0.8) µg/L, IL-6 (2.8±0.3) µg/L, and the incidence rate of complications (1.8%), were all significantly lower than those in the surgical group (p<0.05). CONCLUSION: In the treatment of choledocholithiasis, ERCP is excellent in controlling the trauma, accelerating the recovery duration, reducing the occurrence of complications and ameliorating the inflammatory responses. Thus, it is an ideal choice for choledocholithiasis.

Clinical Observation of the Efficacy of Endoscopic Retrograde Cholangiopancreatography on Elder Choledocholithiasis and Its Effects on the Levels of TNF-α, IL-1, and IL-6

SUMMARY OBJECTIVE: We conducted this study to investigate the clinical efficacy of endoscopic retrograde cholangiopancreatography (ERCP) on elder choledocholithiasis and its effects on the levels of TNF-α, IL-1, and IL-6. METHODS: Elder patients with choledocholithiasis were enrolled in this study, and according to the surgical methods, they were divided into the ERCP group and the surgical group. After treatment, we compared the efficacy of these two methods on patients, inflammatory responses indicated by the levels of TNF-α, IL-1, and IL-6, and the complications. RESULTS: No statistical significance was identified in the difference of the success rate in removal between the two groups (98% vs. 94%), but indicators of the ERCP group, including the surgical duration (28.5±12.8) min, remission duration of abdominal pain (1.2±0.2) d, recession time of jaundice (2.0±0.3) d, postoperative bedridden time (1.4±0.2) d, treatment time of the anti-infection (1.5±0.2) d, length of stay in hospital (6.5±0.3) d, levels of TNF-α (2.1±0.2) μg/L, IL-1 (6.3±0.8) μg/L, IL-6 (2.8±0.3) μg/L, and the incidence rate of complications (1.8%), were all significantly lower than those in the surgical group (p<0.05). CONCLUSION: In the treatment of choledocholithiasis, ERCP is excellent in controlling the trauma, accelerating the recovery duration, reducing the occurrence of complications and ameliorating the inflammatory responses. Thus, it is an ideal choice for choledocholithiasis.

RESUMO OBJETIVO: Realizamos este estudo para investigar a eficácia clínica da colangiopancreatografia retrógrada endoscópica (ERCP) na coledocolitíase idosa e seus efeitos nos níveis de TNF-α, IL-1 e IL-6. MÉTODOS: Pacientes idosos com coledocolitíase foram matriculados neste estudo. De acordo com os métodos cirúrgicos, eles foram divididos em grupo ERCP e grupo cirúrgico. Após o tratamento, comparamos a eficácia desses dois métodos em pacientes, respostas inflamatórias indicadas pelos níveis de TNF-α, IL-1 e IL-6 e as complicações. RESULTADOS: Não houve significância estatística na diferença da taxa de sucesso na remoção entre os dois grupos (98% versus 94%), mas indicadores do grupo ERCP, incluindo a duração cirúrgica (28,5 ± 12,8) min, duração da remissão da dor abdominal (1,2 ± 0,2) d, tempo de recessão de icterícia (2,0 ± 0,3) d, tempo pós-operatório (1,4 ± 0,2) d, tempo de tratamento da infecção (1,5 ± 0,2) d, duração da internação (6,5 ± 0,3) d, níveis de TNF-α (2,1 ± 0,2) μg / L, IL-1 (6,3 ± 0,8) μg / L, IL-6 (2,8 ± 0,3) μg / L e a taxa de incidência de complicações (1,8 %) foram todos significativamente inferiores aos do grupo cirúrgico (p<0,05). CONCLUSÃO: No tratamento da coledocolitíase, a ERCP é excelente no controle do trauma, acelerando a duração da recuperação, reduzindo a ocorrência de complicações e melhorando as respostas inflamatórias. Assim, é uma escolha ideal para a coledocolitíase.

Predictors for choledocholitiasis in patients undergoing endoscopic ultrasound.

AIM: Biliary lithiasis is common in most western countries. Symptomatic patients will also have choledocholithiasis in 10% of the cases. For patients with intermediate probability of CBD stones, the recommended imaging studies are endoscopic ultrasound (EUS) or MRCP. This study aims to identify early factors that can be used as predictors for the presence of CBD stones, and by that to find which patient should undergo ERCP without an early EUS. METHODS: This is a retrospective cohort study including all patients who underwent EUS for suspected choledocholithiasis at the Soroka University Medical Center (SUMC) in the years 2009-2014. Data collection was performed by manual surveillance of patients' computerized files and data gathering after approval by the Soroka Institutional Review Board Results: One hundred seventy-five (175) patients were included in the study. The average age was 57, and 111 patients were women (64.2%). Sixty-two patients (35%) had common bile duct stones by EUS and underwent an ERCP. Eighty-two percent of those 62 patients were found to have CBD stones at ERCP. Patients found positive for CBD stones by EUS were older than those who were negative (52 vs. 71 respectively, p < .001). These patients were also found to have a higher prevalence of ischemic heart disease and congestive heart failure. Common bile duct dilatation ≥8mm and gallstones presence in abdominal ultrasonography were more common in patients found positive for CBD stones by EUS than in those who were found negative (45% vs. 24% p < .05, and 81% vs. 66% p < .05, respectively). Alkaline phosphatase (ALP) serum levels higher than 300 IU/L were found to be the only independent predictor for the existence of CBD stones (OR = 2.98, p = .001(. When ALP serum levels lower than 150 IU/L or GGT lower than 150 IU/L were measured, the probability of having CBD stones was low (NPV of 90% and 87%, respectively). CONCLUSIONS: ALP serum levels higher than 300 IU/L are an independent predictor for the presence of CBD stones. EUS is an excellent screening tool for choledocholithiasis before performing ERCP. In most patients who undergo an early EUS, a subsequent diagnostic ERCP will not be needed.

Predictors of bile tree pathology in patients presenting with gallbladder disease.

BACKGROUND: Patients with gallstone disease can present with elevated liver function tests (LFTs). It is often challenging to differentiate those with a common bile duct (CBD) stone from those without a CBD stone on the basis of the LFTs levels. In this study, we aim to evaluate the predictors of a CBD stones among patients presenting with symptomatic gallbladder disease and elevated LFTs. PATIENTS AND METHODS: We retrospectively examined all patients who had undergone a cholecystectomy between January 2010 and December 2015. Patients with symptomatic cholelithiasis and increased LFTs were included. Patient characteristics, imaging findings, lab findings, endoscopic interventions, and operative report were recorded and evaluated. The diagnosis of CBD stones was made on the basis of ERCP and IOC findings. RESULTS: We included 354 patients in the final analysis. Of these, 113 (32%) had confirmed choledocholithiasis. The prevalence of CBD stones among biliary colic, acute cholecystitis, and pancreatitis patients was 47, 25, and 26%, respectively. γ-Glutamyl transferase and direct bilirubin had the highest sensitivities for CBD stones among these patients (83 vs. 79%). In the setting of biliary colic, total bilirubin was highly predictive of CBD stones with a positive predictive value of 85%. In the setting of acute cholecystitis, elevated LFTs were even less significant in predicting stones, with a positive predictive value of less than 40% for most. CONCLUSION: Although γ-glutamyl transferase and bilirubin levels showed a relatively higher sensitivity for CBDS compared with the other LFTs, these were not reliable enough because of high false-positive as well as false-negative values, especially in patients presenting with acute cholecystitis.

Accuracy of ASGE high-risk criteria in evaluation of patients with suspected common bile duct stones.

BACKGROUND AND AIMS: ERCP is recommended for patients considered high risk for choledocholithiasis after biochemical testing and abdominal US. Our aim was to determine whether the American Society for Gastrointestinal Endoscopy (ASGE) guidelines accurately select patients for whom the risk of ERCP is justified. METHODS: Consecutive patients hospitalized with suspected choledocholithiasis at Sir Run Run Shaw Hospital who received biochemical testing, abdominal US, and definitive testing for choledocholithiasis (MRCP, EUS, ERCP, intraoperative cholangiogram, and/or common bile duct [CBD] exploration) were identified. Patients with choledocholithiasis on abdominal US, with bilirubin levels >4 mg/dL (normal values <1.2 mg/dL), bilirubin levels ≥1.8 mg/dL plus a dilated CBD and/or clinical cholangitis were considered high risk per ASGE guidelines. RESULTS: Of 2724 patients with suspected choledocholithiasis, 1171 (43%) met high-risk criteria. Definitive testing (MRCP in 2442 [90%], EUS in 67 [2%], ERCP in 659 [24%], intraoperative cholangiogram in 229 [8%], and CBD exploration in 447 [16%]) revealed choledocholithiasis in 1076 [40%] patients. The specificity of the ASGE high-risk criteria was 74% (95% confidence interval [CI], 72%-77%) and positive predictive value was 64% (95% CI, 61%-67%). Using a more restrictive criteria (choledocholithiasis on abdominal US, bilirubin >4 mg/dL plus dilated CBD) improved the specificity to 94% (95% CI, 93%-95%) and positive predictive value to 85% (95% CI, 82%-88%). Doubling or more of bilirubin to >4 mg/dL and ≥1.8 mg/dL at second testing had specificities of 98% (95% CI, 96%-99%) and 95% (95% CI, 93%-96%), with positive predictive values of 62% (95% CI, 48%-76%) and 54% (95% CI, 44%-65%), respectively. CONCLUSIONS: Although ASGE high-risk criteria demonstrated >50% probability of the patient having choledocholithiasis, more than a third of the patients would receive diagnostic ERCPs. Criteria with choledocholithiasis on abdominal US and/or bilirubin levels >4 mg/dL plus a dilated CBD showed higher specificity and positive predictive value.

Severe Elevation of Liver Tests in Choledocholithiasis: An Uncommon Occurrence With Important Clinical Implications.

BACKGROUND AND AIMS: Choledocholithiasis is not commonly associated with dramatic elevations in aminotransferase or total serum bilirubin. Ours is the largest case series thus far studying the prevalence of dramatic elevations in liver tests associated with choledocholithiasis. MATERIALS AND METHODS: We performed a retrospective chart review of all patients with choledocholithiasis diagnosed on endoscopic retrograde pancreatocholangiogram at a tertiary referral hospital over 7 years. We identified 740 patients with available liver tests and determined the prevalence of aspartate aminotransferase (AST)/alanine aminotransferase (ALT) >1000 IU/L and of total serum bilirubin >10 mg/dL. We compared clinical characteristics of these 2 nonoverlapping groups. RESULTS: Of 740 patients, AST and/or ALT values >1000 IU/L were present in 45 (6.1%) patients. On average AST and ALT decreased 79% and 56%, respectively, at discharge 1 to 8 days later. Total serum bilirubin levels >10 mg/dL were present in 35 (4.7%) patients and decreased by an average of 64% at discharge 1 to 8 days later. When compared with the group with total serum bilirubin >10 mg/dL, the group with elevated aminotransferases had significantly more females (93% vs. 43%, P<0.001), had smaller common bile duct diameter (8.5 vs. 10.6 mm, P=0.04), and were more likely to have had a prior cholecystectomy (40% vs. 14%, P=0.01). These 80 patients had higher utilization of health resources: half had additional laboratory studies and one fourth had additional imaging studies performed. CONCLUSIONS: In patients with high AST and/or ALT and serum total bilirubin levels with known choledocholithiasis, elaborate work up to look for another etiology is not required. As long as the values decrease significantly, they do not need to be followed until they normalize in the same hospitalization.

Prospective validation of an initial cholecystectomy strategy for patients at intermediate-risk of common bile duct stone.

BACKGROUND AND AIMS: Initial cholecystectomy for patients at intermediate risk of common bile duct (CBD) stones (including increased liver function tests but bilirubin <4 mg/dL and no cholangitis) showed shorter length of stay and fewer CBD investigations without increased morbidity compared with sequential CBD endoscopic assessment and subsequent cholecystectomy in a randomized controlled trial. The objectives were to prospectively validate these results in daily clinical practice and discuss current guidelines. METHODS: Initial cholecystectomy has become the standard management strategy at Geneva University Hospitals since July 2013 for patients at intermediate risk of CBD stones admitted with acute gallstone-related conditions. Between July 2013 and December 2014, length of stay, number of CBD investigations, and number of adverse events were recorded for these patients and compared with the data of the patients in the randomized controlled trial. RESULTS: Data for 161 consecutive newly assessed patients at intermediate risk of CBD stones confirmed shorter length of stay (7.6 vs 9.8 days; P < .001), fewer CBD investigations (0.8 vs 1.4 investigations per patient; P < .001), and similar adverse event rates (5.6% vs 14%, P = .14 including all adverse events; 3.1% vs 8%, P = .22 including only grade ≥III adverse events, defined by endoscopic/surgical reintervention or intensive care unit admission) compared with the previously reported group of patients who underwent preoperative CBD investigations. CONCLUSIONS: These data confirm that initial cholecystectomy results in a shorter length of stay without increased morbidity among patients at intermediate risk of CBD stones compared with sequential CBD assessment and subsequent cholecystectomy. This approach may change current guidelines.

Investigation of liver dysfunction: who should we test for hepatitis E?

AIM: Hepatitis E virus (HEV) is endemic in developed countries, but unrecognized infection is common. Many national guidelines now recommend HEV testing in patients with acute hepatitis irrespective of travel history. The biochemical definition of 'hepatitis' that best predicts HEV infection has not been established. This study aimed to determine parameters of liver biochemistry that should prompt testing for acute HEV. METHODS: This was a retrospective study of serial liver function tests (LFTs) in cases of acute HEV (n=74) and three comparator groups: common bile duct stones (CBD, n=87), drug-induced liver injury (DILI, n=69) and patients testing negative for HEV (n=530). To identify the most discriminating parameters, LFTs from HEV cases, CBD and DILI were compared. Optimal LFT cutoffs for HEV testing were determined from HEV true positives and HEV true negatives using receiver operating characteristic curve analysis. RESULTS: Compared with CBD and DILI, HEV cases had a significantly higher maximum alanine aminotransferase (ALT) (P<0.001) and ALT/alkaline phosphatase (ALKP) ratio (P<0.001). For HEV cases/patients testing negative for HEV, area under receiver operating characteristic curve was 0.805 for ALT (P<0.001) and 0.749 for the ALT/ALKP ratio (P<0.001). Using an ALT of at least 300 IU/l to prompt HEV testing has a sensitivity of 98.6% and a specificity of 30.3% compared with an ALT/ALKP ratio higher than or equal to 2 (sensitivity 100%, specificity 9.4%). CONCLUSION: Patients with ALT higher than or equal to 300 IU/l should be tested for HEV. This is simple, detects nearly all cases and requires fewer samples to be tested than an ALT/ALKP ratio higher than or equal to 2. Where clinically indicated, patients with an ALT less than 300 IU/l should also be tested, particularly if HEV-associated neurological injury is suspected.

The Efficacy of Clinical Predictors for Patients with Intermediate Risk of Choledocholithiasis.

BACKGROUND/AIMS: For the suspected choledocholithiasis, the American Society for Gastrointestinal Endoscopy has proposed guidelines to assign risk based on clinical predictors. The study aimed to assess the usefulness of clinical predictors of choledocholithiasis set forth by the guidelines in patients with intermediate risk of choledocholithiasis. METHODS: In 2014, 109 patients with intermediate risk of choledocholithiasis underwent endoscopic ultrasound. Their medical records were retrospectively reviewed. The gold standard for choledocholithiasis was endoscopic retrograde cholangiopancreatography or clinical follow-up. RESULTS: Based on endoscopic ultrasound findings, choledocholithiasis was suspected in 18 patients, and it was removed in 17 patients. Choledocholithiasis was absent in the remaining 91 who did not show any signs from endoscopic ultrasound. Among the 2 strong (common bile duct (CBD) diameter >6 mm and bilirubin 1.8-4 mg/dl) and 3 moderate (abnormal liver biochemical test other than bilirubin, age >55 years and gallstone pancreatitis) clinical predictors, 28.8% of patients with one of the strong predictors had choledocholithiasis; however, only 3.5% of patients with any one of the moderate predictors had choledocholithiasis. As a result, only strong clinical predictors showed predictability: increased bilirubin level (OR 3.23; 90% CI 0.85-12.28) and dilated CBD diameter (OR 5.83; 90% CI 1.93-17.57). CONCLUSION: Only strong clinical predictors of choledocholithiasis showed predictability for patients with intermediate risk of choledocholithiasis.

Use of Liver Function Tests as First-line Diagnostic Tools for Predicting Common Bile Duct Stones in Acute Cholecystitis Patients.

BACKGROUND: Prior studies have examined the use of liver function tests (LFT) for predicting the presence of common bile duct (CBD) stones in chronic cholecystitis (CC) patients. It is currently unclear whether LFT are also useful for predicting CBD stones in patients with acute cholecystitis (AC). METHODS: Of 1059 patients who visited an emergency room with gallbladder-related symptoms between March 2004 and December 2009, 854 patients were analyzed, and were divided into three groups (556 AC patients without CBD stones (AC - CBD), 98 AC patients with CBD stones (AC + CBD), and 200 CC patients without CBD stones). We compared the LFT values at admission and the changes in LFT values over time following admission among the three groups. RESULTS: The LFT values were significantly greater in the AC + CBD group than in the AC - CBD groups. Of all the LFT variables analyzed, γ-glutamyl transpeptidase was the most reliable variable for predicting the presence of CBD stones, with a sensitivity of 80.6 % and a specificity of 75.3 % at the cut-off level of 224 IU/L. The elevated LFT values decreased significantly from the start of the follow-up assessment to before cholecystectomy in the AC - CBD group, but were unchanged before stone removal in the AC + CBD group. CONCLUSION: The LFT values on initial admission and the changes in LFT values over time are reliable predictors of CBD stones in patients with AC.

A scoring system for the prediction of choledocholithiasis: a prospective cohort study.

BACKGROUND: Techniques for diagnosing choledocholithiasis pose significant morbidity and mortality risks. OBJECTIVES: We aimed to develop and validate a clinical scoring system for predicting choledocholithiasis. DESIGN: Data from a prospectively maintained database of all patients with gallstones. SETTING: Patients were admitted to the general surgery department of a military hospital. PATIENTS AND METHODS: We enrolled consecutive patients with symptomatic gallstones, biliary pancreatitis, obstructive jaundice, or cholangitis, who subsequently underwent biochemical testing and ultrasonography. A predictive model was developed from a scoring system using their imaging and laboratory data. Endoscopic retrograde cholangiopancreatography (ERCP) or intraoperative cholangiography were used for confirmatory diagnoses. The predictive efficacy of the scoring system was validated using a retrospective cohort of 272 patients. MAIN OUTCOME MEASURES: Predictive accuracy of the scoring system. RESULTS: We enrolled 155 patients in the development group. The common bile duct diameter, alkaline phosphatase of >=200 IU, elevated bilirubin levels, alanine transaminase of >=220 IU, and male age of >=50 years were significantly associated with choledocholithiasis and were included in the scoring system. Ninety-six patients (35%) had scores of >=8 (high risk), 86 patients (32%) had scores of 4-7 (intermediate risk), and 27 patients (10%) had scores of 1-3 (low risk). In the validation cohort, the positive predictive value for a score of >=8 was 91.7%, and the scoring system had an area under the curve of 0.896. CONCLUSION: Scores of >=8 were strongly correlated with choledocholithiasis in the developmental and validation groups, which indicates that our scoring system may be useful for predicting the need for therapeutic ERCP. However, prospective validation in a large multicenter cohort is needed to fully understand the benefits of the system. LIMITATIONS: The retrospective validation cohort might have introduced selection and observational biases. The study may have been underpowered because of the sample size of the developmental cohort. The delay between admission and the time of ERCP theoretically may have increased the number of negative ERCP results, but our false negative rate for ERCP was consistent with the previously reported rates.

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.

Predictor factors for choledocholithiasis.

BACKGROUND: The choledocolithiasis has an incidence of 8-20% in patients with cholecystolithiasis. The preoperative diagnosis guides the interventional treatment on the bile duct AIM: To evaluate the sensitivity and specificity of the laboratory markers and imaging studies for choledocholithiasis preoperatively. METHODS: The study comprised 254 patients divided into two groups: the control group (207 patients), patients without choledocholithiasis intraoperatively and cases group (47 patients), that enrolled the patients with choledocholithiasis intra-operatively. Were evaluated the laboratory markers, image exams and intra-operative diagnostic aspects. RESULTS: The sample was homogeneous for age and gender. It was observed that 47% of the cases the patients did not show comorbidities. Hospitalization showes in cases group acute pancreatitis in12.8%, jaundice in 30%, fever in 30% and pain in the right hypochondrium in 95%. By comparing them, was observed that fever and jaundice were the signs and symptoms with statistical significance. Patients with choledocholithiasis had transaminases, alkaline phosphatase, gamma-glutamyl transferase and higher bilirubin with statistical significance (p<0.001). In regard to imaging studies, ultrasound was fairly accurate for cholelithiasis and choledocholithiasis (p<0.001). CONCLUSION: Changes in canalicular and transaminase enzymes are suggestive for preoperative choledocholithiasis; GGT showed better sensitivity and alkaline phosphatase greater specificity; ultrasonography and nuclear magnetic resonance cholangiopancreatography showed high specificity.

Double-Duct Sign in the Clinical Context.

OBJECTIVES: Double-duct sign (combined dilatation of the common bile duct and pancreatic duct) is an infrequently encountered finding in cross-sectional radiological imaging of the pancreatobiliary system. This sign is commonly deemed to signify on ominous pathology and suggests the presence of pancreatic or biliary malignancy. METHODS: We aim to correlate double-duct sign discovered on magnetic resonance cholangiopancreatogram (MRCP) in the clinical context. We retrospectively analyzed MRCP database over a period of 4 years, January 2010 to December 2013. Follow-up information was available for a median of 27 months (range, 12-42 months) RESULTS: The commonest cause of double-duct sign was choledocholithiasis followed closely by pancreatobiliary malignancy. Patients with jaundice in the context of double-duct sign had a higher incidence of malignancy (48%). None of the anicteric patients were found to have malignancy (P = 0.002). CONCLUSIONS: In patients with MRCP evidence of double-duct sign, the absence of jaundice makes a malignant etiology unlikely. Conversely, in jaundiced patients, a malignant cause is much more likely. Figures from larger series are needed to support this conclusion.