Intrabiliary pressure in the pathophysiology of extra hepatic biliary obstruction.

Background and Aim: The aim of this study was to evaluate the role of intrabiliary pressure (IBP) in the pathophysiology of extrahepatic biliary obstruction (EHBO) during percutaneous transhepatic biliary drainage (PTBD). Materials and Methods: Adult patients with EHBO who underwent PTBD were prospectively enrolled. IBP was recorded during primary PTBD. The parameters of interest were age, gender, etiology of EHBO, baseline and post-PTBD liver function tests, duration for resolution of jaundice (decrease in total serum bilirubin ≥30% of baseline or <2 mg/dL), cholangitis, bile cultures, and serum albumin levels. The level of EHBO was divided into three types: Type 1 - secondary biliary confluence involved; Type 2 - primary biliary confluence involved; Type 3 - mid and distal common bile duct obstruction. Results: IBP was measured in 102 patients, and finally, 87 patients, including 52 (59.77%) females, were analyzed. The mean age of the patients was 56.1±11.6 years. The most common etiology of EHBO was carcinoma of the gallbladder in 44 (50.6%) patients. The mean IBP was 18.41±3.91 mmHg. IBP was significantly higher in Type 3 EHBO compared to Type 1 and 2 (p=0.012). A significant correlation was seen between IBP and baseline total serum bilirubin (p<0.01). There was a negative correlation between IBP and baseline serum albumin (p=0.017). In 56.3% of patients, resolution of jaundice was observed by day 3, but this was not significantly associated with IBP (p=0.19). There was no correlation between IBP and cholangitis (p=0.97) or bacterial cultures (p=0.21). Conclusion: IBP was significantly associated with the type of EHBO, baseline serum bilirubin, and albumin levels. IBP could not predict cholangitis or the resolution of jaundice after PTBD.

Gastric Injury in Percutaneous Transhepatic Liver Biopsy After Living Donor Liver Transplantation: A Report of Two Cases.

Percutaneous transhepatic liver biopsy (PTLB) is essential for assessing liver function but carries risks such as bleeding, cholangitis, bowel injuries, and rare fatal complications. Gastric injury following PTLB is rare and not widely reported. This report describes two cases of gastric injury during ultrasound (US)-guided PTLB in patients following living donor liver transplantation. Gastric injury is uncommon, particularly when sampling from the left lobe due to its proximity to the stomach. Ensuring a clear field of vision, meticulous equipment preparation, and skilled technique are crucial for safe PTLB. When there is a risk of gastric injury, using smaller and shorter needles or alternative methods to US-guided PTLB is essential. Gastric injury should be promptly considered and treated if multiple punctures are required and if abdominal symptoms or gastrointestinal bleeding occur after PTLB.

Transhepatic Antegrade Gastric Variceal Sclerotherapy: Comparing Outcomes with and without Initial Efferent Vein Embolization.

PURPOSE: To compare the efficacies of percutaneous transhepatic obliteration (PTO) with initial afferent vein embolization (PTO-A) and with initial efferent vein embolization (PTO-E) for gastric varices (GVs). MATERIALS AND METHODS: Consecutive patients undergoing PTO-A or PTO-E for type 1 isolated gastric varices or type 2 gastroesophageal varices between June 2007 and February 2023 were included. PTO-A or PTO-E was indicated when balloon-occluded retrograde transvenous obliteration failed, or there was no portosystemic shunt for the retrograde transvenous approach. PTO-A was performed for patients before March 2009 and for patients with multiple efferent channels from the GVs. PTO-E was attempted for patients after April 2009. Twenty-six patients were included, of whom 18 underwent PTO-A, and 8 underwent PTO-E. In 12 patients, PTO-E was attempted without success, and they underwent PTO-A instead. The primary outcome was successful complete eradication of GVs within 1 week after the procedure. Secondary outcomes were the GV recurrence-free period and overall survival after the procedure. RESULTS: Technical success was achieved in all 26 patients, with a complete GV eradication rate of 33.3% in PTO-A and 100% in PTO-E, significantly higher in PTO-E (p = 0.002). The median recurrence-free period was 8.7 months with PTO-A and 75.1 months with PTO-E; PTO-E had a significantly longer recurrence-free period (p = 0.042). Median overall survival was 37.2 months with PTO-A and 49.9 months with PTO-E, with no significant difference (p = 0.955). CONCLUSION: PTO-E had a better complete eradication rate and longer recurrence-free period than PTO-A for GVs.

Evaluating the yield of digital single operator cholangioscopy in posttransplant biliary strictures after unsuccessful guidewire placement with ERCP.

Background and Aims: Strictures are the most common biliary complication after liver transplantation, and endoscopic retrograde cholangiopancreatography (ERCP) is considered the gold standard in its management. Failure to cross the biliary anastomosis requires a repeated attempt with ERCP, referral for percutaneous transhepatic cholangiography (PTC) or surgery. We present our experience with the digital single operator cholangioscope (D-SOC) in achieving guidewire access in a liver transplant cohort with difficult biliary strictures who have failed conventional ERCP methods. Methods: This was a retrospective study involving two adult liver transplant centers servicing the two most populated states in Australia. Deceased-donor liver transplant recipients undergoing D-SOC for biliary strictures who have failed conventional methods to achieve biliary access were included. Results: Between July 2017 to April 2022, eighteen patients underwent D-SOC after failing to achieve guidewire placement through standard ERCP techniques. Thirteen out of eighteen (72%) had successful guidewire placement with index D-SOC. Five of eighteen patients (28%) had unsuccessful guidewire placement with D-SOC. In two of these patients, use of D-SOC informed further endoscopic management, with one avoiding PTC and the other avoiding surgery. Two of the five patients required PTC and one patient was left unstented. Three patients developed post D-SOC cholangitis. Conclusions: D-SOC is effective at achieving guidewire access in post-liver transplant patients who fail conventional ERCP techniques and should be considered in the treatment algorithm as a step before PTC and surgery.

Contrast-enhanced ultrasound-guided percutaneous transhepatic cholangiodrainage is a safe and effective procedure for patients with malignant biliary obstruction and stage 3 chronic kidney disease.

OBJECTIVES: This study aimed to validate the efficacy and safety of contrast-enhanced ultrasound-guided percutaneous transhepatic cholangiodrainage (CEUS-PTCD) as a biliary drainage procedure in patients with malignant biliary obstruction and stage 3 chronic kidney disease (CKD3). MATERIALS AND METHODS: Between January 2019 and December 2023, 634 patients who underwent CEUS-PTCD were retrospectively enrolled in this study. During the procedure, imaging parameters such as the maximum diameter of the dilated bile duct, presence of ascites, detailed findings from CEUS, and clinical outcomes were meticulously recorded. Laboratory results, including serum bilirubin levels, liver function tests, and estimated glomerular filtration rate (eGFR), were evaluated in one day before and three days after procedure. The aforementioned parameters were compared using the paired-sample t test and the Wilcoxon test. RESULTS: A total of 66 (10.41 %) patients with malignant biliary obstruction and CKD3 were included in the final analysis (median age: 66, range: 30-89 years, 46 males and 20 females). Procedure records indicated that 23 patients (34.8 %) had a maximum biliary duct dilation diameter of ≤ 4 mm, while 5 patients (7.6 %) exhibited mild ascites. Additionally, 24 patients (36.4 %) had ultrasound contrast agent entry into both the biliary duct and bloodstream. All patients successfully achieved external bile drainage following CEUS-PTCD, with no significant complications observed during or after the intervention. Post-procedure, there was a statistically significant reduction in all previously elevated serum bilirubin and liver enzyme levels (P-values were less than 0.05). Furthermore, no statistically significant alterations in eGFR were observed prior to or following CEUS-PTCD across all patients (P = 0.295), including comparisons between groups with and without the ultrasound contrast agent into the bloodstream (P = 0.254). CONCLUSION: CEUS-PTCD is a safe and effective biliary drainage procedure for patients with malignant biliary obstruction and CKD3.

Technical feasibility of endoscopic ultrasound-guided liver abscess drainage for the right hepatic lobe using a novel metal stent as first-line treatment (with video).

BACKGROUND AND AIM: Although Endoscopic ultrasound-guided liver abscess drainage (EUS-LAD) has been developed, only the left hepatic or caudate lobe can traditionally be drained by EUS. However, there is no evidence for the technical feasibility of EUS-LAD for the right hepatic lobe. In this retrospective study, the technical feasibility of EUS-LAD using a novel partially covered self-expandable metal stent (PCSEMS) with an anti-migration system was evaluated as a first-line drainage technique for right hepatic lobe abscesses. METHOD: This study included consecutive patients with right liver abscesses between December 2020 and February 2024. The primary outcome in this study was the technical success rate of EUS-LAD. Technical success of EUS-LAD was defined as successful stent deployment from the liver abscess to the duodenum. Clinical success, procedure time, duration of hospital stay, recurrence of liver abscess, and adverse events were evaluated as secondary outcomes. RESULT: 19 patients were enrolled in this study. The location of the liver abscesses was mainly at segment 6. The mean size of the liver abscesses was 91.8 mm. The liver abscess could be identified under EUS guidance from the duodenum in 16 patients. Puncture using a 19-G needle was attempted, but the needle could not reach the liver abscess in one patient. The novel PCSEMS was successfully deployed in all patients. Technical success rate of EUS-LAD was 78.9% (15/19). Adverse events associated with the procedure were observed in 3 patients, but conservative treatment was successful. Clinical success was obtained in 14 patients (93.3%). The median duration of stent placement was 19 days (range, 7 to 41 days). The median follow-up period was 556 days, and recurrence of liver abscess was not observed in any patients. CONCLUSIONS: In conclusion, EUS-LAD for the right liver lobe using a novel PCSEMS can be feasible and safe.

Efficacy and safety of endoscopic nasobiliary drainage versus percutaneous transhepatic cholangial drainage in the treatment of advanced hilar cholangiocarcinoma: a systematic review and meta-analysis.

OBJECTIVE: To evaluate and compare the efficacy and safety of Endoscopic Nasobiliary Drainage (ENBD) and Percutaneous Transhepatic Cholangiography Drainage (PTCD) in patients with advanced Hilar Cholangiocarcinoma (HCCA) through a meta-analysis of clinical studies. METHODS: We searched Chinese and English databases, including China National Knowledge Infrastructure (CNKI), Wanfang database, PubMed, Embase, Scopus, and Web of Science, for relevant literatures on PTCD and ENBD for advanced HCCA clinical trials. Two investigators independently screened the literatures, and the quality of the included studies was evaluated using the Newcastle-Ottawa Scale (NOS). The primary endpoint was the success rate of biliary drainage operation, while secondary endpoints included Total Bilirubin (TBIL) change, acute pancreatitis, biliary tract infection, hemobilia, and other complications. R software was used for data analysis. RESULTS: A comprehensive database search, based on predefined inclusion and exclusion criteria, yielded 26 articles for this study. Analysis revealed that PTCD had a significantly higher success rate than ENBD [OR (95% CI) = 2.63 (1.98, 3.49), Z=6.70, P<0.05]. PTCD was also more effective in reducing TBIL levels post-drainage [SMD (95%CI) =-0.13 (-0.23, -0.03), Z=-2.61, P<0.05]. While ENBD demonstrated a lower overall complication rate [OR (95%CI) = 0.60 (0.43, 0.84), Z=-2.99, P<0.05], it was associated with a significantly lower incidence of post-drainage biliary hemorrhage compared to PTCD [OR=3.02, 95%CI: (1.94-4.71), Z= 4.89, P<0.01]. CONCLUSIONS: This meta-analysis compares the efficacy and safety of ENBD and PTCD for palliative treatment of advanced HCCA. While both are effective, PTCD showed superiority in achieving successful drainage, reducing TBIL, and lowering the incidence of acute pancreatitis and biliary infections. However, ENBD had a lower risk of post-drainage bleeding. Clinicians should weigh these risks and benefits when choosing between ENBD and PTCD for individual patients. Further research is needed to confirm these findings and explore long-term outcomes.

A case of an intraabdominal, but extrahepatic ruptured percutaneous transhepatic biliary drainage and its following rescue. A case report and literature review.

Percutaneous transhepatic biliary drainage is a well-established technique for the treatment of biliary obstruction in patients with failed endoscopic approaches. We report on an 82-year-old man with a history of cholangiocarcinoma treated with pancreaticoduodenectomy who presented with recurrent cholangitis and sepsis. Percutaneous transhepatic biliary drainage was performed after unsuccessful endoscopic retrograde cholangiography, which initially improved his condition. However, due to an accidental dislodgement, there was an intra-abdominal fracture of the drain which led to biliary peritonitis and clinical deterioration. The fractured intrahepatic drain was successfully extracted in our angio suite, and a novel subcutaneous fixation technique was introduced to prevent similar occurrences in the future. This case study signifies the role of interventional radiology in the management of percutaneous transhepatic biliary drainage complications and the importance of preventative measures to avoid dislodgement.

Endoscopic ultrasound-guided biliary drainage using electrocautery-enhanced lumen-apposing metal stent for malignant biliary obstruction: A promising procedure.

In this editorial, we comment on the article by Peng et al. Palliative drainage for biliary obstruction resulting from unresectable malignant lesions includes internal and external drainage. The procedures of biliary drainage are usually guided by fluoroscopy or transcutaneous ultrasound, endoscopic ultrasound (EUS), or both. Endoscopic retrograde cholangiopancreatography (ERCP) has been primarily recommended for the management of biliary obstruction, while EUS-guided biliary drainage and percutaneous transhepatic biliary drainage (PTBD) are alternative choices for cases where ERCP has failed or is impossible. PTBD is limited by shortcomings of a higher rate of adverse events, more reinterventions, and severe complications. EUS-guided biliary drainage has a lower rate of adverse events than PTBD. EUS-guided biliary drainage with electrocautery-enhanced lumen-apposing metal stent (ECE-LAMS) enables EUS-guided biliary-enteric anastomosis to be performed in a single step and does not require prior bile duct puncture or a guidewire. The present meta-analysis showed that ECE-LAMS has a high efficacy and safety in relieving biliary obstruction in general, although the results of LAMS depending on the site of biliary obstruction. This study has highlighted the latest advances with a larger sample-based comprehensive analysis.

Management of biliary complications after LDLT.

Biliary complications (BC) in the recipient continue to be an as yet, unresolved issue following living donor liver transplantation (LDLT). Bile leaks (BL) and biliary anastomotic strictures (BAS) are the most common BCs, with the latter contributing to close to 80%. With increasing expertise, endoscopic treatment with endoscopic retrograde cholangiography (ERC) [the first-line treatment] and percutaneous transhepatic cholangiography (PTC) with percutaneous transhepatic biliary drainage (PTBD) alone or in combination with ERC lead to successful management in a majority of these cases. However, prediction of difficulty of endoscopic success in biliary strictures, optimal duration of indwelling stents and their planned removal, management options in high-grade strictures (HGS) and the long-term outcome of patients requiring intervention for BC's are still unanswered questions in this setting. This review will try to summarise pertinent issues, novel insights and finally propose basic principles to be adhered to when dealing with the gamut of possible biliary complications after LDLT.

Early Versus Delayed Laparoscopic Cholecystectomy, after Percutaneous Gall Bladder Drainage, for Grade II Acute Cholecystitis TG18 in Patients with Concomitant Cardiopulmonary Disease.

Background: The advancement in medical care has led to an increase in patients with acute cholecystitis (AC) and cardiopulmonary comorbidities referred for surgery. Grade II AC, according to Tokyo Guidelines in 2018 (TG18), is characterized by severe local inflammation with no systemic affection. The optimal treatment for patients with high-risk grade II AC has not yet been clearly established, which is still a dilemma. For these patients, laparoscopic cholecystectomy (LC), despite being the only definitive treatment, is still a challenge. The introduction of percutaneous cholecystostomy as a temporary minimally invasive alternative technique allows an immediate gallbladder decompression with a rapid clinical improvement. However, the next step after percutaneous transhepatic gall bladder drainage (PTGBD) in these high-risk patients is still a debate, with no definitive consensus about the ideal treatment of choice as well as its optimal timing. In our study, we followed a treatment algorithm for high-risk patients that involved early gallbladder decompression by PTGBD, followed by LC at different intervals once the patient is considered fit for surgery. Method: A retrospective study of 58 patients with high-risk grade II AC with cardiopulmonary comorbidity from our medical records was included. They were managed initially with PTGBD, an LC was then performed either within 7 days after drain insertion (early group, 26 patients), while an LC was performed later for the remaining patients within 6-8 weeks after PTGBD (late group, 32 patients). The results of the two groups were analyzed. Result: Procalcitonin and C-reactive protein were significantly higher in the late group. No significant difference was found between both groups with regard to operative time, PTGBD-related complications, and major perioperative complications. Timing after PTGBD did not affect the incidence of operative complications. Total hospital stay was significantly shorter in the early group. Conclusion: PTGBD is a safe initial intervention for high-risk patients with AC with a low morbidity and high success rate. Urgent LC after PTGBD can be performed safely for well-selected high-risk patients with the timing of surgery is personalized according to each patient's clinical situation. Early LC (after PTGBD) has the advantage of shorter hospital stay, low cost, as well as avoiding the risk of biliary complications and mortality if waiting a delayed surgery with no significant difference in morbidity compared with late LC.

Preoperative systemic and local inflammation are independent risk factors for difficult laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage.

Background: Laparoscopic cholecystectomy (LC) is required for acute cholecystitis patient with percutaneous transhepatic gallbladder drainage (PTGBD). However, it's unknown how to distinguishing the surgical difficulty for these patients. Methods: Data of patients who underwent LC after PTGBD between 2016 and 2022 were collected. Patients were categorized into difficult and non-difficult operations based on operative time, blood loss, and surgical conversion. Performance of prediction model was evaluated by ROC, calibration, and decision curves. Results: A total of 127 patients were analyzed, including 91 in non-difficult operation group and 36 in difficult operation group. Elevated CRP (P = 0.011), pericholecystic effusion (P < 0.001), and contact with stomach or duodenal (P = 0.015) were independent risk factors for difficult LC after PTGBD. A nomogram was developed according to these risk factors, and was well-calibrated and good at distinguishing difficult LC after PTGBD. Conclusion: Preoperative elevated systemic and local inflammation indictors are predictors for difficult LC after PTGBD.

Current Gallstone Treatment Methods, State of the Art.

This study aims to provide valuable references for clinicians in selecting appropriate surgical methods for biliary tract stones based on patient conditions. In this paper, the advantages and disadvantages of various minimally invasive cholelithiasis surgical techniques are systematically summarized and innovative surgical approaches and intelligent stone removal technologies are introduced. The goal is to evaluate and predict future research priorities and development trends in the field of gallstone surgery. In recent years, the incidence of gallstone-related diseases, including cholecystolithiasis and choledocholithiasis, has significantly increased. This surge in cases has prompted the development of several innovative methods for gallstone extraction, with minimally invasive procedures gaining the most popularity. Among these techniques, PTCS, ERCP, and LCBDE have garnered considerable attention, leading to new surgical techniques; however, it must be acknowledged that each surgical method has its unique indications and potential complications. The primary challenge for clinicians is selecting a surgical approach that minimizes patient trauma while reducing the incidence of complications such as pancreatitis and gallbladder cancer and preventing the recurrence of gallstones. The integration of artificial intelligence with stone extraction surgeries offers new opportunities to address this issue. Regarding the need for preoperative preparation for PTCS surgery, we recommend a combined approach of PTBD and PTOBF. For ERCP-based stone extraction, we recommend a small incision of the Oddi sphincter followed by 30 s of balloon dilation as the optimal procedure. If conditions permit, a biliary stent can be placed post-extraction. For the surgical approach of LCBDE, we recommend the transduodenal (TD) approach. Artificial intelligence is involved throughout the entire process of gallstone detection, treatment, and prognosis, and more AI-integrated medical technologies are expected to be applied in the future.

Comparative Efficacy of Magnetic Resonance Cholangiopancreatography vs. Percutaneous Transhepatic Cholangiography With Percutaneous Transhepatic Biliary Drainage Stenting in Evaluating Obstructive Jaundice: A Prospective Study in South India.

Introduction Obstructive jaundice due to proximal biliary obstruction presents significant diagnostic and therapeutic challenges. Accurate and timely diagnosis is essential for effective management. Objective/aim This study aimed to evaluate and compare the diagnostic accuracy of magnetic resonance cholangiopancreatography (MRCP) and percutaneous transhepatic cholangiography (PTC) along with percutaneous transhepatic biliary drainage (PTBD) stenting in obstructive jaundice, while also incorporating the comparison of ultrasonography (USG) and computed tomography (CT) findings. Materials and methods A prospective study was conducted at a tertiary healthcare center in South India from January 2020 to June 2022. Comprehensive diagnostic evaluations were performed using USG, contrast-enhanced computed tomography (CECT), MRCP, and PTC. The diagnostic outcomes from USG and CECT were initially assessed, followed by MRCP for every patient. These results were then compared with PTC, focusing on identifying the causes and levels of biliary obstruction. Results Fifty patients with suspected obstructive jaundice were included in the study. The study predominantly involved patients aged between the fourth and eighth decades (80%). Choledocholithiasis was identified as the leading cause (30%). MRCP demonstrated superior sensitivity in identifying both the cause (80%) and level (88%) of obstruction. It was particularly effective in detecting hilar masses with 100% sensitivity. Conversely, PTC, while less sensitive in detection, offered the advantage of simultaneous therapeutic intervention through stenting, with a sensitivity rate of 93% in detecting hilar masses. Conclusion MRCP outperforms PTC in diagnostic sensitivity for obstructive jaundice caused by proximal biliary obstruction. However, the advantage of PTC lies in its capacity for immediate therapeutic intervention via stent placement, addressing both diagnostic and treatment needs.

Bile Duct Injuries after Cholecystectomy: An Individual Patient Data Systematic Review.

Background: Post-cholecystectomy bile duct injuries (BDIs) represent a challenging complication, with negative impacts on clinical outcomes. Several surgical and endoscopic/interventional radiologist (IR) approaches have been proposed to manage these damages, though with high failure rates. This individual patient data (IPD) systematic review analyzes the potential risk factors for failure after treatment interventions for BDIs, both surgical and endoscopic/IR. Methods: An extensive literature search was conducted on MEDLINE and Scopus for relevant articles published in English on the management of BDIs after cholecystectomy, between 1 January 2010 and 31 December 2023. Our series of BDIs was included. BDIs were always categorized according to the Strasberg's classification. The composite primary endpoints evaluated were the failure of treatment interventions, defined as patient death or the requirement of any other procedure, whatever surgical and/or endoscopic/IR, after the primary treatment. Results: A total of 342 cases were retrieved from our literature analysis, including our series of 19 patients. Among these, three groups were identified: "upfront surgery", "upfront endoscopy and/or IR" and "no upfront treatment", consisting of 224, 109 and 9 patients, respectively. After eliminating the third group, treatment intervention failure was observed overall in 34.2% (114/333) of patients, of whom 80.7% (92/114) and 19.3% (22/114) in the "upfront surgery" and in the "upfront endoscopy/IR" groups, respectively. At multivariable analysis, injury type D and E, and repair in a non-specialized center represented independent predictors of treatment failure in both groups, whereas laparoscopic cholecystectomy (LC) converted to open and immediate attempt of surgical repair exclusively in the first group. Conclusions: Significant treatment failure rates are responsible for remarkable negative effects on immediate and longer-term clinical outcomes of post-cholecystectomy BDIs. Understanding the important risk factors for this outcome may better guide the most appropriate therapeutical approach and improve clinical decisions in case this serious complication occurs.

Three-dimensional visualization technology for guiding one-step percutaneous transhepatic cholangioscopic lithotripsy for the treatment of complex hepatolithiasis.

BACKGROUND: Biliary stone disease is a highly prevalent condition and a leading cause of hospitalization worldwide. Hepatolithiasis with associated strictures has high residual and recurrence rates after traditional multisession percutaneous transhepatic cholangioscopic lithotripsy (PTCSL). AIM: To study one-step PTCSL using the percutaneous transhepatic one-step biliary fistulation (PTOBF) technique guided by three-dimensional (3D) visualization. METHODS: This was a retrospective, single-center study analyzing, 140 patients who, between October 2016 and October 2023, underwent one-step PTCSL for hepatolithiasis. The patients were divided into two groups: The 3D-PTOBF group and the PTOBF group. Stone clearance on choledochoscopy, complications, and long-term clearance and recurrence rates were assessed. RESULTS: Age, total bilirubin, direct bilirubin, Child-Pugh class, and stone location were similar between the 2 groups, but there was a significant difference in bile duct strictures, with biliary strictures more common in the 3D-PTOBF group (P = 0.001). The median follow-up time was 55.0 (55.0, 512.0) days. The immediate stone clearance ratio (88.6% vs 27.1%, P = 0.000) and stricture resolution ratio (97.1% vs 78.6%, P = 0.001) in the 3D-PTOBF group were significantly greater than those in the PTOBF group. Postoperative complication (8.6% vs 41.4%, P = 0.000) and stone recurrence rates (7.1% vs 38.6%, P = 0.000) were significantly lower in the 3D-PTOBF group. CONCLUSION: Three-dimensional visualization helps make one-step PTCSL a safe, effective, and promising treatment for patients with complicated primary hepatolithiasis. The perioperative and long-term outcomes are satisfactory for patients with complicated primary hepatolithiasis. This minimally invasive method has the potential to be used as a substitute for hepatobiliary surgery.

Percutaneous transhepatic cholangioscopy in the management of hepatolithiasis.

The treatment of lithiasis in patients with biliodigestive bypass can be controversial. The combination of percutaneous access together with cholangioscopy is an alternative to surgical treatment for the management of this pathology. In recent years, the appearance of smaller and more flexible fiber-optic cholangioscopes as well as the possibility to perform lithotripsy have changed the treatment of this pathology, providing good results. After our experience, we believe that cholangioscopy assisted by a percutaneous approach is a safe technique, with few complications and early recovery for patients in whom it is not possible to perform endoscopic management.

Interval cholecystectomy following drainage procedures for acute cholecystitis: percutaneous transhepatic vs endoscopic transpapillary gallbladder drainage.

BACKGROUND: Gallbladder drainage procedures are often considered for acute cholecystitis (AC) patients with significant peri-operative risks. While percutaneous transhepatic gallbladder drainage (PTGBD) has been evaluated in previous studies, there is scarce data on the feasibility and efficacy of endoscopic transpapillary gallbladder stenting (ETGBS) in patients with AC. This study aimed to compare the characteristics of interval cholecystectomy following ETGBS and PTGBD. METHODS: This retrospective descriptive study included patients who underwent ETGBS and/or PTGBD for AC and subsequently underwent interval cholecystectomy between 2018 and 2023. Demographics, operative technique, and postoperative complications of patients with ETGBS and PTGBD were compared. RESULTS: A total of 59 patients were included (14 ETGBS and 45 PTGBD). The median days between ETGBS and cholecystectomy were significantly longer than the PTGBD group (64 [45-150] days vs. 16 [10-42] days, p=0.045). The median operation time was significantly longer in the ETGBS group.　Among 33 patients who underwent subtotal cholecystectomy, the ERGBS group more frequently required closure of the gallbladder stump due to the difficulty in ligating the cystic duct compared to the PTGBD group (75.0% vs. 28.0%, p=0.035). Similarly, the fundus-first approach was more commonly selected in the ERGBS group (62.5% vs. 28.0%, p=0.01). No significant differences in the incidence of postoperative complications were observed between the two groups. CONCLUSIONS: Interval cholecystectomy following ETGBS is more technically demanding compared to PTGBD. Laparoscopic subtotal cholecystectomy following ETGBS could be a potential treatment option for patients who are unfit for early surgery, with the recognition of the difficulty in ligating the cystic duct.