Obstructive jaundice treatment during the COVID-19 pandemic: retrospective cohort study at a single tertiary care center in Serbia.

OBJECTIVE: We aimed to compare mortality and complication rates in patients treated for obstructive jaundice before and during the COVID-19 pandemic in a tertiary care center in Serbia. METHODS: We conducted a retrospective cohort study among a first group of patients treated between 1 January 2017 and 1 January 2019. The second group was treated between 1 March 2020 and 1 March 2022. RESULTS: The first group comprised 35 patients, and the second group (in which all patients were SARS-CoV-2 positive) included 18 patients; 37 and 16 patients were treated for malignant and benign diseases, respectively. The groups did not differ significantly regarding the diagnoses and treatment received. The second group showed significantly higher aspartate aminotransferase levels and lower white blood cell, C-reactive protein, and interleukin 6 levels. Mortality and complication rates did not differ significantly between groups. All deceased patients in the second group had significant radiologic findings associated with COVID-19 pneumonia. CONCLUSIONS: COVID-19 infection is a risk factor in treating obstructive jaundice. This study illustrates the potential influence of COVID-19 on mortality after obstructive jaundice treatment. COVID-19 pneumonia may be a significant risk factor for mortality in patients treated for obstructive jaundice.

Disease-Based Risk Stratification of Postendoscopic Retrograde Cholangiopancreatography Pancreatitis for Common Bile Duct Stones.

BACKGROUND: Risk stratification of postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) for common bile duct (CBD) stones is needed for clinicians to adequately explain to patients regarding the risk of PEP in advance of ERCP and to proactively take preventive measures in high-risk patients. AIMS: To stratify the risk of PEP for CBD stones based on CBD-related diseases. METHODS: A total of 1551 patients with naïve papilla who underwent ERCP for CBD stones were divided into three groups: Group A: asymptomatic CBD stones, Group B: obstructive jaundice and elevated liver test values without cholangitis, and Group C: mild, moderate, and severe cholangitis. We stratified the risk of PEP by comparing its incidence among the three groups using the Holm's method. Furthermore, we performed one-to-one propensity score matching between Group A and the other groups to examine the risk of PEP in Group A. RESULTS: The incidence rates in Groups A, B, and C were 13.7%, 7.3%, and 1.8%, respectively. The Holm-adjusted p values between Groups A and B, Groups A and C, and Groups B and C were 0.023, < 0.001, and < 0.001, respectively. Propensity score matching revealed that the incidence of PEP was significantly more in Group A than in the other groups (13.3% vs. 1.5%; p < 0.001). CONCLUSIONS: The risk of PEP for CBD stones was stratified into low risk (Group C), intermediate risk (Group B), and high risk (Group A). This simple disease-based risk stratification may be useful to predict the risk of PEP in advance of ERCP.

A nomogram based on combining systemic and hepatic inflammation markers for predicting microscopic bile duct tumour thrombus in hepatocellular carcinoma.

BACKGROUND: Bile duct invasion is a relatively rare event and is not well characterised in hepatocellular carcinoma (HCC). It remains very difficult to diagnose HCC with bile duct tumour thrombus (BDTT) before surgery. Increasing evidence has revealed that inflammation plays a critical role in tumorigenesis. This study aimed to develop nomograms based on systemic and hepatic inflammation markers to predict microscopic BDTT (micro-BDTT) before surgery in HCC. METHODS: A total of 723 HCC patients who underwent hepatectomy as initial therapy between January 2012 and June 2020 were included in the study. Logistic regression analysis was used to identify independent risk factors for micro-BDTT. The nomograms were constructed using significant predictors, including α-fetoprotein (AFP), alkaline phosphatase (ALP), direct bilirubin (DB), prognostic nutritional index (PNI), and γ-glutamyl transferase (γ-GT)/alanine aminotransferase (ALT). The prediction accuracies of the nomograms were evaluated using the area under the receiver operating characteristic (ROC) curve. RESULTS: AFP, ALP, DB, PNI, and γ-GT/ALT were independent risk factors for predicting micro-BDTT (P = 0.036, P = 0.004, P = 0.013, P = 0.012, and P = 0.006, respectively), which were assembled into the nomograms. The area under the ROC curve of the nomograms combining PNI and γ-GT/ALT for predicting micro-BDTT was 0.804 (95% confidence interval [CI]: 0.730-0.878). The sensitivity and specificity values when used in predicting micro-BDTT before surgery were 0.739 (95% CI: 0.612-0.866) and 0.781 (95% CI: 0.750-0.813), respectively. CONCLUSIONS: The nomogram based on combining systemic and hepatic inflammation markers is suitable for predicting micro-BDTT before surgery in HCC patients, leading to a rational therapeutic choice for HCC.

Obstructive jaundice: Studies on predictors of biliary infection and microbiological analysis in an HIV setting.

BACKGROUND: Early diagnosis of biliary infection is critical for timely antimicrobial therapy and biliary drainage. HIV infection may influence the spectrum and severity of biliary infection in an environment with a high HIV prevalence. Charcot's triad has low sensitivity and higher specificity for biliary infection, and more sensitive markers are required. OBJECTIVES: To investigate possible predictors of biliary infection (bacteriobilia) and identify the microbiological spectrum in patients presenting with biliary obstruction to a tertiary institute in an environment with a high prevalence of HIV. METHODS: Bile was assessed for infection at endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography and surgery, and the roles of clinical/haematological factors, C-reactive protein (CRP) and procalcitonin (PCT) in determining biliary infection were evaluated. RESULTS: One hundred and six patients with obstructive jaundice had a mean age of 52 years (range 21 - 58); most were female (74%), and 36 (34%) were infected with HIV, with a mean CD4 count of 495 cells/µL. Choledocholithiasis (53%), biliary strictures (21%) and head of pancreas tumour (8%) were the main aetiopathologies. Bile was obtained for microbial culture from 104 patients (98%), and 56 (54%) were infected. Gram-negative bacteria were most frequent (58%), and 2 HIV-infected patients had fungal infections (Candida albicans and Aspergillus fumigatus). Screening for endoscopy-associated infections revealed Pseudomonas aeruginosa. PCT was a poor predictor of bacterial infection, whereas CRP was a fair predictor. CONCLUSIONS: The majority of bacteria cultured were sensitive to ciprofloxacin or amoxicillin-clavulanate. Duodenoscopes were a potential source of Pseudomonas infection.

Cholestatic jaundice in neonates: How common is biliary atresia? Experience at an Australian tertiary centre.

AIM: To (i) review the aetiologies of neonatal cholestasis among term and preterm neonates at a single tertiary centre in Australia; (ii) identify clinical variables associated with biliary atresia (BA) and non-BA aetiology of neonatal cholestasis; (iii) investigate the utility of hepatobiliary scintigraphy in predicting BA among term and preterm neonates. METHODS: A retrospective cohort study of neonates born and investigated for cholestasis at two co-located neonatal and children facilities from January 2013 to December 2017. RESULTS: Of the 139 neonates with cholestasis, BA and intestinal-failure-associated liver-disease was the most common cause of neonatal cholestasis in term (18%) and preterm (66%) cohorts, respectively. Incidence of BA was higher in term (1:6) than preterm (1:50) neonates (OR 10.29; 95% CI 2.06-49.97, P = 0.0024). Higher birthweight, acholic stool, absent or abnormal gallbladder on ultrasound was significantly associated with BA while gestational age ≤32 weeks, total parenteral nutrition ≥14 days and low albumin were associated with non-BA aetiology of cholestasis. In diagnosing BA, non-draining hepatobiliary scintigraphy demonstrated a lower specificity (73% vs. 90%) and lower positive predictive value (25% vs. 78%) in preterm compared to term neonates. CONCLUSION: Aetiology of cholestasis among preterm neonates differs from those in term neonates and currently existing diagnostic algorithm for neonatal cholestasis may need to be modified for preterm cohort, taking into account the prevalence for each aetiology, potential predictors and cost-efficiency.

Endoscopic management and clinical outcomes of obstructive jaundice.

BACKGROUND: This study aimed at evaluating the endoscopic management and clinical outcomes in patients with obstructive jaundice undergoing Endoscopic Retrograde Cholangiopancreatography (ERCP) within a newly established apprenticeship teaching model at an academic centre in a resource-limited setting. MATERIALS AND METHODS: We employed an apprenticeship-style model of ERCP training with graded responsibility, multidisciplinary group feedback and short-interval repetition. We collected sociodemographic and clinicopathologic data on consecutive patients who underwent ERCP from March 2018 to February 2020. RESULTS: A total of 177 patients were referred, of which 146 patients had an ERCP performed for obstructive jaundice and 31 excluded during the study period. The median age was 55 years, age range from 8 to 83 years. The most common referral diagnosis was pancreatic head cancer 56/146 (38.1%), followed by choledocholithiasis 29/146 (19.7%), cholangiocarcinoma 22/146 (15.0%) and gall bladder cancer 11/146 (7.5%). In all, 102 patients had a malignant indication for ERCP. The cannulation rate was 92%. The most common site for malignant biliary obstruction was proximal bile stricture in 31/102 (30.4%), followed by distal bile strictures in 30/102 (28.4%), periampullary cancer 20/102 (19.6%) and mid bile duct stricture in 9/102 (8.8%). The common benign obstructive etiology includes choledocholithiasis in 33/44 (75%) and mid duct obstruction from post-cholecystectomy bile duct injury in 3/44 (2.9%) while 2/44 (2.0%) patients had choledochal cyst. Overall complications were post-ERCP pancreatitis (8/146 patients), cholangitis (3/146 patients), stent migration and post-sphincterotomy bleeding (one patient each). Peri-procedural mortality was 5/146 (3.4%). CONCLUSION: ERCP is an effective and safe method of treatment of patients with benign and malignant biliary obstruction. The low morbidity and mortality and its immediate therapeutic benefits, together with the short duration of hospitalization, indicate that this procedure is an important asset in the management of such patients.

Incidence and risk factors of pancreatitis in obstructive jaundice patients after percutaneous placement of self-expandable metallic stents.

BACKGROUND: Percutaneous transhepatic biliary drainage is an alternative treatment for patients with malignant distal biliary obstruction. The aim of this study was to investigate the occurrence of pancreatitis in patients who had undergone percutaneous placement of a biliary stent and to assess the risk factors for pancreatitis and the treatment outcomes. METHODS: From January 2010 to October 2016, 980 patients in our hospital who underwent percutaneous placements of self-expandable metallic stents for obstructive jaundice were retrospectively analyzed. The incidence of pancreatitis and risk factors were assessed by univariate and multivariate logistic regression analysis. Therapeutics, such as somatostatin, which were also adminstrated to release the symptom and promote the restoration of normal function of pancreas, were also analyzed. RESULTS: Pancreatitis occurred in 45 (4.6%) patients. One patient died from severe acute pancreatitis. Multivariate logistic regression analysis showed that common bile duct stent placement was the only independent risk factor that related to pancreatitis (odds ratio = 2.096, 95% CI: 1.248-5.379; P = 0.002). By using somatostatin, the concentrations of serum amylase and lipase were decreased in 44 patients with pancreatitis. No major complications were found during the treatment. CONCLUSIONS: Pancreatitis is a relatively low complication of percutaneous placement of biliary stents. The common bile duct stent placement is the only independent risk factor that related to pancreatitis. In this case, the percutaneous transhepatic biliary drainage is a preferred method for treatment. Furthermore, somatostatin is a secure and efficacious method to release the symptom and promote the restoration of pancreatic function.

Epidemiological profile, referral routes and diagnostic accuracy of cases of acute cholangitis among individuals with obstructive jaundice admitted to a tertiary-level university hospital: a cross-sectional study

ABSTRACT BACKGROUND: Obstructive jaundice may lead to ominous complications and requires complex diagnostic evaluations and therapies that are not widely available. OBJECTIVE: To analyze the epidemiological profile, referral routes and diagnostic accuracy at admittance of cases of acute cholangitis among patients with obstructive jaundice treated at a referral unit. DESIGN AND SETTING: Cross-sectional study at a tertiary-level university hospital. METHODS: Patients with obstructive jaundice who were treated by means of endoscopic retrograde cholangiopancreatography, resection and/or surgical biliary drainage were evaluated. The main variables analyzed were epidemiological data, referral route, bilirubin levels and time elapsed between symptom onset and admittance and diagnosing of acute cholangitis at the referral unit. The accuracy of the clinical diagnosis of acute cholangitis was compared with a retrospective analysis on the medical records in accordance with the Tokyo criteria. RESULTS: Female patients predominated (58%), with an average age of 56 years. Acute cholangitis was detected in 9.9% of the individuals; application of the Tokyo criteria showed that the real prevalence was approximately 43%. The main referral route was direct contact (31.8%) and emergency care (29.7%); routing via official referral through the public healthcare system accounted for 17.6%, and internal referral from other specialties, 20%. The direct route with unofficial referral was the most important route for cases of neoplastic etiology (P < 0.01) and was the fastest route (P < 0.01). CONCLUSIONS: There is a deficiency in the official referral routes for patients with obstructive jaundice. The accuracy of the clinical diagnosis of acute cholangitis was poor. Wider dissemination of the Tokyo criteria is essential.

Type 2 Autoimmune Pancreatitis (Idiopathic Duct-Centric Pancreatitis) Highlighting Patients Presenting as Clinical Acute Pancreatitis: A Single-Center Experience.

Background/Aims: Type 2 autoimmune pancreatitis (AIP) has been considered extremely rare in East Asia. This study aimed to clarify the prevalence, clinical characteristics and radiological findings of type 2 AIP highlighting patients presenting as acute pancreatitis in a single center. Methods: Type 2 AIP patients were classified according to International Consensus Diagnostic Criteria. Radiological findings were compared between type 2 AIP presenting as acute pancreatitis and gallstone pancreatitis. Results: Among 244 patients with AIP, 27 (11.1%) had type 2 AIP (definite, 15 [55.5%] and probable 12 [44.5%]). The median age of patients with type 2 AIP was 29 years (interquartile range, 20 to 39 years). Acute pancreatitis was the most common initial presentation (n=17, 63%) while obstructive jaundice was present in only one patient. Ulcerative colitis (UC) was associated with type 2 AIP in 44.4% (12/27) of patients. Radiological pancreatic imaging such as delayed enhancement of diffusely enlarged pancreas, homogeneous enhancement of focal enlargement/mass, absent/minimal peripancreatic fat infiltration or fluid collection, and multifocal main pancreatic duct narrowings were helpful for differentiating type 2 AIP from gallstone pancreatitis. During follow-up (median, 32.3 months), two patients (2/25, 8%) experienced relapse. Conclusions: In South Korea, type 2 AIP is not as rare as previously thought. Overall, the clinical profile of type 2 AIP was similar to that of Western countries. Type 2 AIP should be considered in young UC patients with acute pancreatitis of uncertain etiology.

The prevalence of complications of pneumonia among adults admitted to a tertiary care center in Riyadh from 2010-2017.

BACKGROUND: Pneumonia, the commonest lower respiratory tract infection, can result in respiratory and non-respiratory complications. Few studies have reported on the prevalence of many complications. OBJECTIVES: Identify the prevalence of 18 complications of pneumonia and compare complication rates by age group and type of pneu.monia. Identify most prevalent comorbidities, the effect of the number of comorbidities on the presence of complications, and the association between specific comorbidities and specific complications. DESIGN: Retrospective, cross-sectional prevalence study. SETTING: Tertiary care center in Riyadh. PATIENTS AND METHODS: The target population were patients aged 17 years and older, of different nationalities and both genders, diagnosed with pneumonia during the period of 2010 to 2017. Selection was by stratified sampling by year of admission. MAIN OUTCOME MEASURES: Complications of pneumonia. SAMPLE SIZE: 800. RESULTS: Complications were observed in 427 patients (53.4%). The complications were respiratory in 258 patients (32%), sepsis and septic shock in 186 (23%), cardiac in 125 (16%), neurological in 5 (0.6%), and cholestatic jaundice in 2 (0.3%). Pleural effusion was the commonest complication, observed in 230 patients. There was a significant difference (P less than .001) between the complication rates in older patients compared to younger (60% as compared to 41%). For the type of pneumonia, there was a significant difference (P less than .001) between community-acquired pneumonia and hospital-acquired pneumonia in the presence of complications (OR=2.41, 95% CI for OR=1.66, 3.49). The number of comorbidities was significantly associated with the presence of complications (P=.001) for those with multiple comorbidities (46% for patients with no comorbid illnesses versus 68% in patients with three or more comorbidities). CONCLUSION: These results suggest that Saudi Arabia needs to establish better prevention and intervention programs, especially for the high-risk groups identified in this study: older patients, patients with hospital-acquired pneumonia and patients with two or more comorbidities. LIMITATIONS: Retrospective design and single-centered. CONFLICT OF INTEREST: None.

Epidemiological profile, referral routes and diagnostic accuracy of cases of acute cholangitis among individuals with obstructive jaundice admitted to a tertiary-level university hospital: a cross-sectional study.

BACKGROUND: Obstructive jaundice may lead to ominous complications and requires complex diagnostic evaluations and therapies that are not widely available. OBJECTIVE: To analyze the epidemiological profile, referral routes and diagnostic accuracy at admittance of cases of acute cholangitis among patients with obstructive jaundice treated at a referral unit. DESIGN AND SETTING: Cross-sectional study at a tertiary-level university hospital. METHODS: Patients with obstructive jaundice who were treated by means of endoscopic retrograde cholangiopancreatography, resection and/or surgical biliary drainage were evaluated. The main variables analyzed were epidemiological data, referral route, bilirubin levels and time elapsed between symptom onset and admittance and diagnosing of acute cholangitis at the referral unit. The accuracy of the clinical diagnosis of acute cholangitis was compared with a retrospective analysis on the medical records in accordance with the Tokyo criteria. RESULTS: Female patients predominated (58%), with an average age of 56 years. Acute cholangitis was detected in 9.9% of the individuals; application of the Tokyo criteria showed that the real prevalence was approximately 43%. The main referral route was direct contact (31.8%) and emergency care (29.7%); routing via official referral through the public healthcare system accounted for 17.6%, and internal referral from other specialties, 20%. The direct route with unofficial referral was the most important route for cases of neoplastic etiology (P < 0.01) and was the fastest route (P < 0.01). CONCLUSIONS: There is a deficiency in the official referral routes for patients with obstructive jaundice. The accuracy of the clinical diagnosis of acute cholangitis was poor. Wider dissemination of the Tokyo criteria is essential.

Nomogram to predict overall survival after gallbladder cancer resection in China.

AIM: To integrate clinically significant variables related to prognosis after curative resection for gallbladder carcinoma (GBC) into a predictive nomogram. METHODS: One hundred and forty-two GBC patients who underwent curative intent surgical resection at Peking Union Medical College Hospital (PUMCH) were included. This retrospective case study was conducted at PUMCH of the Chinese Academy of Medical Sciences and Peking Union Medical College (CAMS & PUMC) in China from January 1, 2003 to January 1, 2018. The continuous variable carbohydrate antigen 19-9 (CA19-9) was converted into a categorical variable (cCA19-9) based on the normal reference range. Stages 0 to IIIA were merged into one category, while the remaining stages were grouped into another category. Pathological grade X (GX) was treated as a missing value. A multivariate Cox proportional hazards model was used to select variables to construct a nomogram. Discrimination and calibration of the nomogram were performed via the concordance index (C-index) and calibration plots. The performance of the nomogram was estimated using the calibration curve. Receiver operating characteristic (ROC) curve analysis and decision curve analysis (DCA) were performed to evaluate the predictive accuracy and net benefit of the nomogram, respectively. RESULTS: Of these 142 GBC patients, 55 (38.7%) were male, and the median and mean age were 64 and 63.9 years, respectively. Forty-eight (33.8%) patients in this cohort were censored in the survival analysis. The median survival time was 20 months. A series of methods, including the likelihood ratio test and Akaike information criterion (AIC) as well as stepwise, forward, and backward analyses, were used to select the model, and all yielded identical results. Jaundice [hazard ratio (HR) = 2.9; 95% confidence interval (CI): 1.60-5.27], cCA19-9 (HR = 3.2; 95%CI: 1.91-5.39), stage (HR = 1.89; 95%CI: 1.16-3.09), and resection (R) (HR = 2.82; 95%CI: 1.54-5.16) were selected as significant predictors and combined into a survival time predictive nomogram (C-index = 0.803; 95%CI: 0.766-0.839). High prediction accuracy (adjusted C-index = 0.797) was further verified via bootstrap validation. The calibration plot demonstrated good performance of the nomogram. ROC curve analysis revealed a high sensitivity and specificity. A high net benefit was proven by DCA. CONCLUSION: A nomogram has been constructed to predict the overall survival of GBC patients who underwent radical surgery from a clinical database of GBC at PUMCH.

Value of percutaneous transhepatic cholangiobiopsy for pathologic diagnosis of obstructive jaundice: analysis of 826 cases.

BACKGROUND: Obstructive jaundice (OJ) is insensitive to radiation and chemotherapy, and a pathologic diagnosis is difficult to make clinically. Percutaneous transhepatic cholangiobiopsy (PTCB) is simple to perform and minimally invasive, and clinical practice has shown it to be an accurate and reliable new method for bile duct histopathologic diagnosis. PURPOSE: To investigate the value of PTCB for pathologic diagnosis of causes of OJ. MATERIAL AND METHODS: From April 2001 to December 2011, PTCB was performed in 826 consecutive patients. Data on pathologic diagnosis, true positive rate, and complications were analyzed retrospectively. Patients with negative pathologic findings were diagnosed using clinical, imaging, laboratory, and prognostic data. The feasibility and safety of PTCB for OJ were evaluated and true positive rates for biliary carcinoma and non-biliary carcinoma compared. RESULTS: PTCB was successful in all cases. Of 740 patients clinically diagnosed with malignant biliary stricture and 86 with benign biliary stricture, 727 received a positive pathologic diagnosis; in 99, the pathologic findings were considered false negative. The true positive rate for PTCB was 88.01% overall, differing significantly for biliary and non-biliary carcinoma (χ2 = 12.87, P < 0.05). Malignancy accounted for 89.59% of OJ cases; well, moderately, and poorly differentiated carcinoma represented 57.88%, 19.97%, and 22.15%. Biliary adenocarcinoma was the predominant malignant pathologic type (96.41%). Transient bilemia, bile leakage, and temporary hemobilia occurred in 47, 11, and 28 cases, respectively, with no serious complications. CONCLUSION: PTCB is safe, feasible, and simple, with a high true positive rate for definitive diagnosis of OJ causes. Well differentiated adenocarcinoma was the predominant pathologic type.

Long-term follow-up of children and adolescents with primary sclerosing cholangitis and autoimmune sclerosing cholangitis.

BACKGROUND: Sclerosing cholangitis (SC) is a chronic cholestatic hepatobiliary disease with uncertain long-term prognosis in pediatric patients. This study aimed to evaluate long-term results in children with SC according to the types of SC. METHODS: We retrospectively followed up 25 children with SC over a period of 4-17 years (median 12). The diagnosis of SC was based on biochemical, histological and cholangiographic findings. Patients fulfilling diagnostic criteria for probable or definite autoimmune hepatitis at the time of diagnosis were defined as having autoimmune sclerosing cholangitis (ASC); other patients were included in a group of primary sclerosing cholangitis (PSC). The incidence of the following complications was studied: obstructive cholangitis, portal hypertension, advanced liver disease and death associated with the primary disease. RESULTS: Fourteen (56%) patients had PSC and 11 (44%) had ASC. Patients with ASC were significantly younger at the time of diagnosis (12.3 vs 15.4 years, P=0.032) and had higher IgG levels (22.7 vs 17.2 g/L, P=0.003). The mentioned complications occurred in 4 (16%) patients with SC, exclusively in the PSC group: one patient died from colorectal cancer, one patient underwent liver transplantation and two patients, in whom severe bile duct stenosis was present at diagnosis, were endoscopically treated for acute cholangitis. Furthermore, two other children with ASC and 2 children with PSC had elevated aminotransferase levels. The 10-year overall survival was 95.8% in all patients, 100% in patients without complicated liver disease, and 75.0% in patients with complications. CONCLUSION: In children, ASC is a frequent type of SC, whose prognosis may be better than that in patients with PSC.

Early biliary complications following pancreaticoduodenectomy: prevalence and risk factors.

BACKGROUND: Early biliary complications (EBC) following pancreaticoduodenectomy (PD) are poorly known. This study aimed to assess incidence, predictive factors, and treatment of EBC including bilio-enteric stricture, transient jaundice, biliary leak, and cholangitis. METHOD: From 2007 to 2011, 352 patients underwent PD. Statistical analysis including logistic regression was performed to determine EBC predictive factors. RESULTS: 49 patients (14%) developed 51 EBC, including 7(2%) bilio-enteric strictures, 15(4%) transient jaundices, 9(3%) biliary leaks, and 20(6%) cholangitis with no mortality and a 18% reoperation rate. In multivariate analysis, male gender, benign disease, malignancy with preoperative chemoradiation, and common bile duct (CBD) diameter ≤ 5 mm were predictive of EBC. Of the 7 strictures, all were associated with CBD ≤ 5 mm and 5(71%) required reoperation. Transient jaundice resolved spontaneously in all 15 cases. Among 8 patients with serum bilirubin level > 50 µmol/L (3 mg/dL) at POD3, 7(88%) developed bilio-enteric stricture. Biliary leak resolved spontaneously in 5(56%); otherwise, it required reoperation. Cholangitis recurred after antibiotics discontinuation in 5(25%). CONCLUSIONS: EBC following PD do not increase mortality. EBC are more frequent with male gender, benign disease, malignancy with preoperative chemoradiation, and CBD ≤ 5 mm. Transient jaundice or cholangitis has a favorable outcome, whereas bilio-enteric stricture or biliary leak can require reintervention.

Amoxicillin-Clavulanate-Induced Liver Injury.

BACKGROUND AND AIMS: Amoxicillin-clavulanate (AC) is the most frequent cause of idiosyncratic drug-induced injury (DILI) in the US DILI Network (DILIN) registry. Here, we examined a large cohort of AC-DILI cases and compared features of AC-DILI to those of other drugs. METHODS: Subjects with suspected DILI were enrolled prospectively, and cases were adjudicated as previously described. Clinical variables and outcomes of patients with AC-DILI were compared to the overall DILIN cohort and to DILI caused by other antimicrobials. RESULTS: One hundred and seventeen subjects with AC-DILI were identified from the cohort (n = 1038) representing 11 % of all cases and 24 % of those due to antimicrobial agents (n = 479). Those with AC-DILI were older (60 vs. 48 years, P < 0.001). AC-DILI was more frequent in men than women (62 vs. 39 %) compared to the overall cohort (40 vs. 60 %, P < 0.001). The mean time to symptom onset was 31 days. The Tb, ALT, and ALP were 7 mg/dL, 478, and 325 U/L at onset. Nearly all liver biopsies showed prominent cholestatic features. Resolution of AC-DILI, defined by return of Tb to <2.5 mg/dL, occurred on average 55 days after the peak value. Three female subjects required liver transplantation, and none died due to DILI. CONCLUSION: AC-DILI causes a moderately severe, mixed hepatocellular-cholestatic injury, particularly in older men, unlike DILI in general, which predominates in women. Although often protracted, eventual apparent recovery is typical, particularly for men and usually in women, but three women required liver transplantation.

Elaboración de un score predictivo preoperatorio de coledocolitiasis / Design of a preoperative predictive score for choledocholithiasis

INTRODUCCIÓN: La coledocolitiasis es la causa más común de ictericia obstructiva y ocurre en un 5-10% de los pacientes que presentan colelitiasis. OBJETIVOS: Elaboración un modelo predictivo preoperatorio de coledocolitiasis. MATERIAL Y MÉTODOS: Estudio prospectivo de 556 pacientes ingresados en nuestros servicios por patología biliar. Análisis comparativo de variables preoperatorias clínicas, analíticas y ecográficas de los pacientes sin coledocolitiasis frente a las de los 65 pacientes con dicho hallazgo. Análisis multivariante de regresión logística para obtener un modelo predictivo de coledocolitiasis, determinando sensibilidad, especificidad, valores predictivos positivo (VPP) y negativo (VPN). RESULTADOS: Los factores predictivos de coledocolitiasis fueron la existencia de historia biliar previa (antecedentes de cólicos biliares, colecistitis, coledocolitiasis o pancreatitis aguda biliar) (p = 0,021; OR = 2.225; IC 95%: 1.130-4.381), las cifras de BT al ingreso superior a 4 mg/dl (p = 0,046; OR = 2.403; IC 95%: 1.106-5.685), el valor de la FA al ingreso superior a 150 mg/dl (p = 0.022; OR = 2.631; IC 95%: 1.386-6.231), cifras de la GGT superiores a 100 (p = 0,035; OR = 2,10; IC 95%: 1.345-5.850), y el hallazgo ecográfico de dilatación de la vía biliar (p = 0,034; OR = 3.063; IC 95%: 1.086-8.649). Un score superior a 5 conlleva una especificidad y VPP de 100% para detectar coledocolitiasis, y un score inferior a 3, una sensibilidad y un VPN del 100% para descartarla. CONCLUSIONES: El score obtenido descarta o confirma preoperatoriamente la existencia de coledocolitiasis, y permite al paciente beneficiarse directamente de la colecistectomía laparoscópica (CL) o de la realización previa de colangiopancreatografía retrógrada endoscópica (CPRE)

INTRODUCTION: Choledocholithiasis is the most common cause of obstructive jaundice and occurs in 5-10% of patients with cholelithiasis. OBJECTIVES: To design a preoperative predictive score for choledocholithiasis. MATERIAL AND METHODS: A prospective study was carried out in 556 patients admitted to our department for biliary disease. Preoperative clinical, laboratory, and ultrasound variables were compared between patients without choledocholithiasis and 65 patients with this diagnosis. A multivariate logistic analysis was performed to obtain a predictive model of choledocholithiasis, determining sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). RESULTS: Predictors of choledocholithiasis were the presence of a prior history of biliary disease (history of biliary colic, acute cholecystitis, choledocholithiasis or acute biliary pancreatitis) (p=0.021, OR=2.225, 95% CI: 1.130-4.381), total bilirubin values >4mg/dl (p=0.046, OR=2.403, 95% CI: 1.106-5.685), alkaline phosphatase values >150mg/dl (p=0.022 income, OR=2.631, 95%: 1.386-6.231), gamma-glutamyltransferase (GGT) values >100mg/dl (p=0.035, OR=2.10, 95% CI: 1.345-5.850), and an ultrasound finding of biliary duct >8mm (p=0.034, OR=3.063 95% CI: 1086-8649). A score superior to 5 had a specificity and PPV of 100% for detecting choledocholithiasis and a score less than 3 had a sensitivity and NPV of 100% for excluding this diagnosis. CONCLUSIONS: The preoperative score can exclude or confirm the presence of choledocholithiasis and allows patients to directly benefit from laparoscopic cholecystectomy (LC) or prior endoscopic retrograde cholangiopancreatography (ERCP)

Análisis de los factores pronósticos en la atresia de vías biliares / Analysis of prognostic factors in biliary atresia

Objetivo. La atresia de vías biliares presenta una incidencia de 1 de cada 9.000 a 12.000 recién nacidos vivos. Nuestro objetivo fue analizar las variables pronósticas que han tenido influencia en la evolución de nuestros pacientes con atresia de vías biliares. Material y métodos. Estudio retrospectivo, basado en la revisión de los pacientes intervenidos en nuestro centro mediante la técnica de Kasai desde marzo de 1983 a enero del 2012. Se analizaron 52 variables pronósticas tales como: antecedentes, sintomatología, pruebas diagnósticas, empleo de corticoides, complicaciones y evolución. Resultados. De 35 pacientes intervenidos mediante Kasai se incluyen 29, siendo el 58,82% del sexo masculino; agrupados de acuerdo con la edad de la cirugía: grupo A (<60 días) 14/29; grupo B (60-90) 14/29 y grupo C (>90) 1/29. La atresia tipo II fue más prevalente en el grupo A y la III en los grupos B y C. Existió predominio de fi brosis hepática en los grupos A y C, y de cirrosis en el B. La media de estancia hospitalaria fue de 24,66; 28,50 y 50,00 días para los grupos A, B y C, respectivamente. A partir del 2004 se instauró tratamiento con corticoides en el postoperatorio, observando complicaciones en el 40% de los tratados y 70 % de los no tratados. En 10 años, el 44,82% están asintomáticos y el 37,9% trasplantados. Conclusiones. Tanto el diagnóstico como la derivación porto entérica precoz mejoran el pronóstico. El tratamiento con corticoides podría beneficiar la evolución de los pacientes a corto plazo

Objective. Biliary atresia presents a worldwide incidence about 1 of every 9000-12000 live newborns. Our goal was to analyze the prognostic variables of our patients with biliary atresia. Material and methods. Retrospective study, based on the review of all patients who underwent surgery at our centre by the Kasai technique from March 1983 to January 2012. A total of 52 variables were analyzed such as: clinical history, symptoms, diagnostic tests, use of corticosteroids, complications and evolution. Results. From 35 patients operated by Kasai Technical we included 29, being 58,82 % male; grouped according to the age of surgery: Group A (<60 days) 14/29; Group B (60-90) 14/29 and Group C (>90) 1/29. We observed that atresia type II was more common in the Group A and III in group B and C. There was a predominance of hepatic fibrosis in patients from Group A and C, and cirrhosis in B. The mean hospital stay was 24,66; 28,50 and 50,00 days for Group A, B and C respectively. Since 2004 it is established a treatment with corticosteroids in the postoperative period; complications noted in 40% of the treated and in 70% of the untreated. In 10 years, 44,82 % are asymptomatic and transplanted 37.9%. Conclusions. In this study both the diagnosis and early Kasai technique improve prognosis. Treatment with corticoids could benefit short-term results

Predicting native papilla biliary cannulation success using a multinational Endoscopic Retrograde Cholangiopancreatography (ERCP) Quality Network.

BACKGROUND: Success in deep biliary cannulation via native ampullae of Vater is an accepted measure of competence in ERCP training and practice, yet prior studies focused on predicting adverse events alone, rather than success. Our aim is to determine factors associated with deep biliary cannulation success, with/ without precut sphincterotomy. METHODS: The ERCP Quality Network is a unique prospective database of over 10,000 procedures by over 80 endoscopists over several countries. After data cleaning, and eliminating previously stented or cut papillae, two multilevel fixed effect multivariate models were used to control for clustering within physicians, to predict biliary cannulation success, with and without allowing "precut" to assist an initially failed cannulation. RESULTS: 13018 ERCPs were performed by 85 endoscopists (March 2007 - May 2011). Conventional (without precut) and overall cannulation rates were 89.8% and 95.6%, respectively. Precut was performed in 876 (6.7%). Conventional success was more likely in outpatients (OR 1.21), but less likely in complex contexts (OR 0.59), sicker patients (ASA grade (II, III/V: OR 0.81, 0.77)), teaching cases (OR 0.53), and certain indications (strictures, active pancreatitis). Overall cannulation success (some precut-assisted) was more likely with higher volume endoscopists (> 239/year: OR 2.79), more efficient fluoroscopy practices (OR 1.72), and lower with moderate (versus deeper) sedation (OR 0.67). CONCLUSION: Biliary cannulation success appears influenced by both patient and practitioner factors. Patient- and case-specific factors have greater impact on conventional (precut-free) cannulation success, but volume influences ultimate success; both may be used to select appropriate cases and can help guide credentialing policies.