The clinical efficacy and safety of different biliary drainage in malignant obstructive jaundice: a meta-analysis.

Background: Currently, percutaneous transhepatic cholangial drainage (PTCD) and endoscopic retrograde cholangiopancreatography (ERCP) are commonly employed in clinical practice to alleviate malignant obstructive jaundice (MOJ). Nevertheless, there lacks a consensus regarding the superiority of either method in terms of efficacy and safety. Aim: To conduct a systematic evaluation of the effectiveness and safety of PTCD and ERCP in treating MOJ, and to compare the therapeutic outcomes and safety profiles of these two procedures. Methods: CNKI, VIP, Wanfang, CBM, PubMed, Web of Science, Embase, The Cochrane Library, and other databases were searched for randomized controlled trials (RCTs) on the use of PTCD or ERCP for MOJ. The search period was from the establishment of the databases to July 2023. After quality assessment and data extraction from the included studies, Meta-analysis was performed using RevMan5.3 software. Results: A total of 21 RCTs involving 1,693 patients were included. Meta-analysis revealed that there was no significant difference in the surgical success rate between the two groups for patients with low biliary obstruction (P=0.81). For patients with high biliary obstruction, the surgical success rate of the PTCD group was higher than that of the ERCP group (P < 0.0001), and the overall surgical success rate of the PTCD group was also higher than that of the ERCP group (P = 0.008). For patients with low biliary obstruction, the rate of jaundice relief (P < 0.00001) and the clinical efficacy (P = 0.0005) were better in the ERCP group, while for patients with high biliary obstruction, the rate of jaundice relief (P < 0.00001) and the clinical efficacy (P = 0.003) were better in the PTCD group. There was no significant difference in the overall jaundice remission rate and clinical efficacy between the two groups (P = 0.77, 0.53). There was no significant difference in the reduction of ALT, TBIL, and DBIL before and after surgery and the incidence of postoperative complications between the two groups (P > 0.05). Conclusion: Both PTCD and ERCP can efficiently alleviate biliary obstruction and enhance liver function. ERCP is effective in treating low biliary obstruction, while PTCD is more advantageous in treating high biliary obstruction.

Clinical Profiles and Outcomes of Patients Undergoing Endoscopic Retrograde Cholangiopancreatography in a Tertiary Care Center.

Introduction Endoscopic retrograde cholangiopancreatography (ERCP) is a lifesaving therapeutic procedure that carries its own complexities and risks. Clinicians use ERCP as a therapeutic tool for the treatment of biliary stones, malignant obstruction, and acute cholangitis.  Aim In our study, we aimed to analyze the clinical profile and outcome of patients who underwent ERCP in the Department of Medical Gastroenterology from August 2021 to February 2023 at Government Medical College Kottayam in India. Materials and methods We conducted a retrospective study using data from patients who underwent ERCP in the Department of Medical Gastroenterology from August 2021 to February 2023 at Government Medical College Kottayam. We used a semi-structured questionnaire, pro forma, laboratory investigation reports, and SPSS Statistics software (IBM Corp., Armonk, NY) for our data analysis. We included all patients older than 18 years. Results In our study 65% of the patients were female. The primary indication for ERCP was common bile duct stones. Of the 216 attempted ERCP cases, we performed successful cannulation in 201 patients, a success rate of 93%. The cannulation time was less than five minutes in the majority of the cases and more than five minutes in 30% of the cases. The commonest type of ampulla in our study was Type One. In our study patients with chronic obstructive pulmonary disease had an increased risk of developing post-ERCP pancreatitis. The most common complication in our study was pancreatitis, which occurred in 29 cases (14%). Only three cases had moderate to severe pancreatitis requiring a prolonged hospital stay of more than three days. There was one fatality immediately following ERCP probably owing to sepsis-induced myocarditis. Of the 201 cases, 15 (7.5%) required precut sphincterotomy. Conclusion Analysis of data from patients who underwent ERCP in our department showed that the procedure is safe and effective in treating biliary disorders. The successful cannulation rate and complication rate with ERCP in our tertiary care center are at par with other published data.

Post-embolization syndrome-like symptoms due to shedding of necrotic material of hepatocellular carcinoma into the bile duct following transcatheter arterial chemoembolization: an instructive case.

Fever, abdominal pain, and liver dysfunction are almost inevitable complications of transcatheter arterial chemo embolization (TACE) for hepatocellular carcinoma, but these symptoms may also be due to bile duct obstruction caused by shedding of necrotic tumor material into the bile duct. A 68-year-old man presented with persistent fever, liver dysfunction, and abdominal pain after TACE. Computed tomography revealed stone-like hyperdensities in the bile duct. Endoscopic retrograde cholangiopancreatography revealed these structures to be necrotic material from hepatocellular carcinoma. We believe this is an instructive case of an often overlooked situation.

Uncovering the spread of drug-resistant bacteria through next-generation sequencing based surveillance: transmission of extended-spectrum ß-lactamase-producing Enterobacterales by a contaminated duodenoscope.

Contamination of duodenoscopes is a significant concern due to the transmission of multidrug-resistant organisms (MDROs) among patients who undergo endoscopic retrograde cholangiopancreatography (ERCP), resulting in outbreaks worldwide. In July 2020, it was determined that three different patients, all had undergone ERCP with the same duodenoscope, were infected. Two patients were infected with blaCTX-M-15 encoding Citrobacter freundii, one experiencing a bloodstream infection and the other a urinary tract infection, while another patient had a bloodstream infection caused by blaSHV-12 encoding Klebsiella pneumoniae. Molecular characterization of isolates was available as every ESBL-producing isolate undergoes Next-Generation Sequencing (NGS) for comprehensive genomic analysis in our center. After withdrawing the suspected duodenoscope, we initiated comprehensive epidemiological research, encompassing case investigations, along with a thorough duodenoscope investigation. Screening of patients who had undergone ERCP with the implicated duodenoscope, as well as a selection of hospitalized patients who had ERCP with a different duodenoscope during the outbreak period, led to the discovery of three additional cases of colonization in addition to the three infections initially detected. No microorganisms were detected in eight routine culture samples retrieved from the suspected duodenoscope. Only after destructive dismantling of the duodenoscope, the forceps elevator was found to be positive for blaSHV-12 encoding K. pneumoniae which was identical to the isolates detected in three patients. This study highlights the importance of using NGS to monitor the transmission of MDROs and demonstrates that standard cultures may fail to detect contaminated medical equipment such as duodenoscopes.

Comparing sedation protocols for endoscopic retrograde cholangiopancreatography (ERCP): A retrospective study.

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is a widely used diagnostic and therapeutic procedure. Effective sedation is crucial to enhance patient comfort and optimize endoscopist performance. Various sedation protocols, including Propofol and Dexmedetomidine (Pro-Dex), Ketamine and Propofol (Keto-Fol), Propofol and Midazolam (Pro-Mid), and Propofol alone, have been utilized during ERCP. This retrospective study aims to compare the safety and efficacy of these four sedation protocols. Methods: A retrospective analysis was conducted on data from 600 patients who underwent ERCP between 2018 and 2021, with each patient receiving one of the four sedation protocols. Protocol assignment was based on the endoscopist's preference. Data on hemodynamic parameters, sedation level, recovery time, and procedure-related complications were collected. Results: Baseline data showed no significant differences among the groups pre-procedure. The Pro-Dex group exhibited significantly lower mean total propofol dose, shorter recovery time, and faster achievement of Ramsay Sedation Scale (RSS) score 3-4 compared to the other groups. The Pro-group demonstrated significantly longer hospital stay than the other three groups (median, 4.19 ± 1.1 vs. 3.48 ± 1.2 days in the KP groups, p = 0.042). There were no significant variations in the incidence of respiratory depression, hypotension, or bradycardia among the four groups. Additionally, notable trends were found for hemodynamic measures, total propofol dosage, time to reach the desired level of sedation (as measured by the Ramsay Sedation Scale), and hospital stay based on BMI categories, indicating that higher BMI is linked to more serious outcomes. Conclusion: Our retrospective study demonstrates that the Pro-Dex protocol offers superior sedation quality, faster recovery, and fewer complications compared to the other protocols during ERCP. However, the incidence of ERCP-related adverse events did not significantly differ among the four sedation protocols. These findings can aid clinicians in selecting the most appropriate sedation protocol for ERCP, considering patient and endoscopist preferences.

Index admission cholecystectomy for biliary acute pancreatitis or choledocholithiasis reduces 30-day readmission rates in children.

BACKGROUND: Adult patients with biliary acute pancreatitis (BAP) or choledocholithiasis who do not undergo cholecystectomy on index admission have worse outcomes. Given the paucity of data on the impact of cholecystectomy during index hospitalization in children, we examined readmission rates among pediatric patients with BAP or choledocholithiasis who underwent index cholecystectomy versus those who did not. METHODS: Retrospective study of children (< 18 years old) admitted with BAP, without infection or necrosis (ICD-10 K85.10), or choledocholithiasis (K80.3x-K80.7x) using the 2018 National Readmission Database (NRD). Exclusion criteria were necrotizing pancreatitis with or without infected necrosis and death during index admission. Multivariable logistic regression was performed to identify factors associated with 30-day readmission. RESULTS: In 2018, 1122 children were admitted for index BAP (n = 377, 33.6%) or choledocholithiasis (n = 745, 66.4%). Mean age at admission was 13 (SD 4.2) years; most patients were female (n = 792, 70.6%). Index cholecystectomy was performed in 663 (59.1%) of cases. Thirty-day readmission rate was 10.9% in patients who underwent cholecystectomy during that index admission and 48.8% in those who did not (p < 0.001). In multivariable analysis, patients who underwent index cholecystectomy had lower odds of 30-day readmission than those who did not (OR 0.16, 95% CI 0.11-0.24, p < 0.001). CONCLUSIONS: Index cholecystectomy was performed in only 59% of pediatric patients admitted with BAP or choledocholithiasis but was associated with 84% decreased odds of readmission within 30 days. Current guidelines should be updated to reflect these findings, and future studies should evaluate barriers to index cholecystectomy.

Acquired Bronchobiliary Fistula in a Young Adult Patient With Sepsis: A Case Report.

Bronchobiliary fistula (BBF) is a rare, highly morbid condition that results from an abnormal connection between biliary channels and the bronchial tree. In the past, this condition has been known to be caused by untreated hydatid cysts or hepatic abscesses that can erode through the diaphragm into the pleural cavity and bronchial tree, creating fistulation. However, the condition's spectrum has changed in recent years, and BBFs have also become associated with neoplasm, iatrogenic causes, and trauma. Cases of BBF are treated differently, either with simple conservative management or invasive surgery. We present a case of a 46-year-old male initially presenting with sepsis, who was found to have a BBF. The diagnosis was made after a hepatobiliary iminodiacetic acid scan showed the flow of a tracer in the lung fields. The condition was likely due to acute cholecystitis and prior biliary instrumentation. The patient was treated successfully with percutaneous cholecystostomy tube insertion followed by elective laparoscopic cholecystectomy several weeks after hospital discharge.

Pediatric ERCP: Evolving into an Outpatient Procedure.

BACKGROUND: While most adult ERCPs are performed on an outpatient basis, pediatric ERCPs are typically performed on an inpatient basis, or with ERCP followed by at least one night inpatient admission. We have begun performing a substantial proportion of our pediatric ERCPs on an outpatient basis, using our clinical judgment to guide the decision process. In the present study, we compare patient characteristics, indications, and adverse events associated with outpatient vs. inpatient ERCP. METHODS: Using our endoscopy database, we identified patients 18 years of age and under who underwent ERCP from 2019 to 2021. Demographics, hospitalization status, indications, findings, interventions, as well as available adverse event and clinical outcomes data were analyzed. RESULTS: 147 ERCP procedures were performed during the study period by one of two interventional endoscopists. A subset of 51 (34.7%) patients underwent outpatient ERCP. Comparison of the two groups (outpatient vs. inpatient ERCP) was notable for no statistically significant difference in patient age, range of indications, or proportion of index vs. subsequent ERCP. Overall rates of ERCP-associated adverse events were low and there was no statistically significant difference between adverse events in patients who underwent outpatient vs. inpatient ERCP. CONCLUSION: We analyzed outpatient and inpatient pediatric ERCP patient demographics and ERCP characteristics to identify factors that guide decision to determine whether pediatric ERCPs are performed on an outpatient vs. inpatient basis. There was no significant difference in adverse events associated with outpatient vs. inpatient pediatric ERCPs, attesting to the safety of outpatient ERCP for this subset of patients in the studied context. This is an area worthy of future prospective and multi-center study.

Innovative Water-Wire Cannulation Technique for Managing Near-Complete Obstruction Due to Post-orthotopic Liver Transplant Anastomotic Strictures: A Report of Two Cases.

This report presents an innovative water-wire cannulation technique for managing challenging anastomotic strictures in post-orthotopic liver transplant patients, highlighting its successful application in two distinct cases. Anastomotic strictures pose a significant hurdle in hepatobiliary medicine, often complicating the course post-liver transplantation. Standard endoscopic retrograde cholangiopancreatography (ERCP) methods frequently encounter limitations in severe stricture cases, necessitating alternative approaches. The water-wire cannulation technique, introduced in this report, innovatively utilizes water injection to gently dilate the stricture, enabling successful guidewire insertion and subsequent standard endoscopic interventions. This method was effectively applied in two patients with severe anastomotic strictures, where conventional ERCP techniques were unsuccessful. The technique's effectiveness, demonstrated in these cases, offers a less invasive and potentially safer alternative to traditional options like cholangioscopy, percutaneous transhepatic cholangiography (PTC), or surgical revision, which carry higher risks and complexities. The water-wire cannulation technique's success emphasizes the need for innovative and adaptable strategies in hepatobiliary medicine, especially for managing post-transplant complications. Its potential applicability in a broader spectrum of biliary strictures warrants further exploration. Overall, this technique represents a significant advancement in the endoscopic management of complex biliary strictures, promising to enhance patient care and outcomes in hepatobiliary medicine.

Combining brushing cytology with simultaneous vacuum aspiration in suspicious biliopancreatic malignancies: A multicenter propensity score-matched study (with video).

BACKGROUND: Brush cytology during endoscopic retrograde cholangiopancreatography (ERCP) is a standard approach in diagnosing biliopancreatic strictures, with yet unsatisfying sensitivity. AIMS: We brought additional simultaneous vacuum aspiration to brushing process and re-evaluate the diagnostic performance. METHODS: This multi-centered retrospective study was conducted in three tertiary centers. Consecutive patients with biliopancreatic strictures were identified. The patients were divided into two arms: the conventional arm (CA) receiving general brushing approach, and the modified arm (MA) being treated with additional vacuum aspiration when performing bushing. The 1:1 propensity-score matching was implemented to tackle the selective biases. RESULTS: A total of 555 patients were identified and 200 patient pairs (193 males, 207 females, with a mean age of 68.1 ± 13.1 years.) fell into the ultimate evaluation. A final diagnosis of malignant stricture was established in 243 patients. The diagnostic yield of the MA group was substantially better than that of the CA group, whether "suspicious malignancies" were considered malignancies or not. The rates of sensitivity, specificity and accuracy were 46.2%, 100%, 68.0% in the MA group, and 15.3%, 98.7%, and 47.0% in the CA group respectively. CONCLUSIONS: Brushing accompanied by simultaneous vacuum aspiration at ERCP improves the diagnostic yield in suspicious biliopancreatic malignancies.

ERCP for the initial management of malignant biliary obstruction - real world data on 596 procedures.

AIMS: To evaluate outcomes of ERCP as first-line management in patients with malignant biliary obstruction (MBO) of all causes and stages, reflecting a real-life setting. METHODS: Retrospective observational study of patients with ERCP as the first-line management of MBO at Oslo University Hospital between 2015 and 2021. Primary outcome measure was a ≥ 50% decrease from the pre-procedural bilirubin within 30 days after ERCP. Secondary outcome measures were technical success of ERCP, complications and overall mortality. RESULTS: A total of 596 patients were included, median age 70 years. ASA score was ≥ III in 67% of patients. The most common cancers causing MBO were pancreatic cancer (52%), metastatic lesions (20%) and cholangiocarcinoma (16%). The primary outcome measure was achieved in 62% of patients. With endoscopic access, overall technical success was 80% with 85% for the distal extrahepatic group, 71% for the perihilar, 40% for the intrahepatic and 53% for multiple level MBOs. Reinterventions were performed in 27% of the patients. Complications occurred in 15% of the patients, including post-ERCP pancreatitis in 9%. Most complications were of minor/moderate severity (81%). Overall mortality was 33% within the first 90 days. Patients deceased by the end of the study period (83%) had median survival of 146 days (range 1-2,582 days). CONCLUSIONS: ERCP has a high rate of clinical effect and technical success in the management of both distal extrahepatic and perihilar MBO. Our data indicate that ERCP is a valid option in the first-line management of MBO.

The hospital frailty risk score as a predictor of readmission after ERCP.

BACKGROUND AND AIMS: The 30-day readmission rate is a nationally recognized quality measure with nearly one-fifth of patients being readmitted. This study aims to evaluate frailty, as measured by the hospital frailty risk score (HFRS), as a prognostic indicator for 30-day readmission after inpatient ERCP. METHODS: We analyzed weighted discharge records from the 2017 Nationwide Readmissions Database (NRD) to identify patients undergoing ERCP between 01/01/2017 and 11/30/2017. Our primary outcome was the 30-day unplanned readmission rate in frail (defined as HFRS > 5) against non-frail (HFRS < 5) patients. A mixed effects multivariable logistic regression method was employed. RESULTS: Among 68,206 weighted hospitalized patients undergoing ERCP, 31.3% were frail. Frailty was associated with higher 30-day readmission (OR 1.23, 95% CI [1.16-1.30]). Multivariable analysis showed a greater risk of readmission with cirrhosis (OR 1.26, 95% CI [1.10-1.45]), liver transplantation (OR 1.36, 95% CI [1.08-1.71]), cancer (OR 1.58, 95% CI [1.48-1.69]), and male gender (OR 1.24, 95% CI [1.18-1.31]). Frail patients also had higher mortality rate (1.8% vs 0.6%, p < 0.01)], longer LOS during readmission (6.7 vs 5.6 days, p < 0.01), and incurred more charges from both hospitalizations ($175,620 vs $132,519, p < 0.01). Sepsis was the most common primary indication for both frail and non-frail readmissions but accounted for a greater percentage of frail readmissions (17.9% vs 12.4%, p < 0.01). CONCLUSIONS: Frailty is associated with higher readmission rates, mortality, LOS, and hospital charges for admitted patients undergoing ERCP. Sepsis is the leading cause for readmission. Independent risk factors for readmission include liver transplantation, cancer, cirrhosis, and male gender.

Validity of a virtual reality endoscopic retrograde cholangiopancreatography simulator: can it distinguish experts from novices?

Background: There is a lack of evidence regarding the effectiveness of virtual simulators as a means to acquire hands-on exposure to endoscopic retrograde cholangiopancreatography (ERCP). The present study aimed to assess the outcome and construct validity of virtual ERCP when training on the GI II Mentor simulator. Methods: A group of seven experienced endoscopists were compared with 31 novices. After a short introduction, they were requested to carry out three virtual ERCP procedures: diagnosing and removing a common bile duct (CBD) stone; diagnosing and taking brush cytology from a hilar stenosis; and, finally, diagnosing and treating a cystic leakage with a BD stent. For each task, the total time required to complete the task, time required to correctly view the papilla, total time of irradiation, time to deep cannulation, time to define diagnosis, time to complete sphincterotomy, and time to complete the respective intervention were measured. Cannulation of the BD, correct diagnosis, sphincterotomy, and time to complete intervention were assessed by an assessor blinded to the status of the endoscopist who performed the virtual ERCP. Results: The time required to visualize the papilla and to cannulate deeply when removing the BD stone was significantly shorter for the experts (both p < 0.05). The time to visualize the papilla, cannulate deeply, reach a diagnosis, complete sphincterotomy, and complete the intervention was significantly shorter for the experts when managing cystic leakage (all p < 0.05). In diagnosing and taking brush cytology from a hilar stenosis, there was only a trend toward the experts needing less time for the deep cannulation of the BD (p = 0.077). Conclusion: The performance differed between experts and novices, especially in the management of cystic leakage. This corroborates the construct validity of the GI II Mentor simulator.

Comparison of anesthetic effects of different doses of alfentanil combined with ciprofol in elderly patients undergoing ERCP: a randomized controlled trial.

BACKGROUND AND OBJECTS: Patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) are often old and poor in physical fitness. The purpose of this study was to investigate the anesthetic effect of different doses of alfentanil combined with ciprofol in elderly patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). METHODS: In this clinical trial, 137 patients, who were candidates for ERCP were randomly divided into three groups. Group A were given 0.15 µg/kg/min of alfentanil in maintenance stage, Group B were given 0.25 µg/kg/min and Group C were given 0.35 µg/kg/min. Mean arterial pressure (MAP), heart rate (HR), oxygen saturation (SpO2) of the patients at each time point including the entry into the operation room (T0), at the beginning of surgery(T1), 10 min after surgery(T2), 20 min after surgery(T3), 30 min after surgery(T4),endoscopy withdrawal (T5) were recorded. Adverse events(including respiratory depression, body movement and hypoxemia),the dosage of ciprofol, the time of operation time and awakening were recorded. RESULTS: Compared with Group A, MAP and HR in Group B and Group C was decreased during T1-T5 (P < 0.05). Compared with group B, MAP and HR in group C was decreased during T1-T5 (P < 0.05). Compared with Group A and Group C,the number of adverse reactions of Group B was decreased(P < 0.05). There was no statistical difference in surgical time among the three groups(P > 0.05),but a statistically significant difference in recovery time (P < 0.05). CONCLUSION: The adverse events of alfentanil 0.25µg/kg/min combined with ciprofol were low, and the anesthetic effect was the best.

Fundamental study on diagnostic reference level quantities for endoscopic retrograde cholangiopancreatography using a C-arm fluoroscopy system.

The diagnostic reference level (DRL) is an effective tool for optimising protection in medical exposures to patients. However regarding air kerma at the patient entrance reference point (Ka,r), one of the DRL quantities for endoscopic retrograde cholangiopancreatography (ERCP), manufacturers use a variety of the International Electrotechnical Commission and their own specific definitions of the reference point. The research question for this study was whetherKa,ris appropriate as a DRL quantity for ERCP. The purpose of this study was to evaluate the difference betweenKa,rand air kerma incident on the patient's skin surface (Ka,e) at the different height of the patient couch for a C-arm system. Fluoroscopy and radiography were performed using a C-arm system (Ultimax-i, Canon Medical Systems, Japan) and a over-couch tube system (CUREVISTA Open, Fujifilm Healthcare, Japan).Ka,ewas measured by an ion chamber placed on the entrance surface of the phantom. Kerma-area product (PKA) andKa,rwere measured by a built-inPKAmeter and displayed on the fluoroscopy system.Ka,edecreased whileKa,rincreased as the patient couch moved away from the focal spot. The uncertainty of theKa,e/Ka,rratio due to the different height of the patient couch was estimated to be 75%-94%.Ka,rmay not accurately representKa,e.PKAwas a robust DRL quantity that was independent of the patient couch height. We cautioned against optimising patient doses in ERCP with DRLs set in terms ofKa,rwithout considering the patient couch height of the C-arm system. Therefore, we recommend thatKa,ris an inappropriate DRL quantity in ERCP using the C-arm system.

Previously Untreated Ulcerative Colitis With Newly Diagnosed Primary Sclerosing Cholangitis: A Case Report.

Primary sclerosing cholangitis (PSC) is a rare type of autoimmune hepatic disease with unknown pathophysiology, often a sequela of ulcerative colitis (UC). Liver transplant, though curative, is inaccessible to many patients due to stringent organ availability and barriers to sufficient insurance coverage. Low health literacy and low socioeconomic class can significantly limit healthcare access and thus worsen overall healthcare outcomes. Here, we present the case of an uninsured 49-year-old man with untreated UC who was diagnosed with PSC and subsequently became lost to follow-up. It is critical for providers to identify barriers to acquiring appropriate medical care, such as financial instability and low health literacy, when identifying and treating conditions like PSC. Moreover, more research should be performed to investigate alternative treatments for PSC.

Complex Intrahepatic Lithiasis: A Case Report of Combined Treatment With Surgical Exploration of the Bilioenteric Anastomosis and Laser Lithotripsy by Cholangioscopy.

Intrahepatic lithiasis, or hepatolithiasis, is an endemic disease in southeast Asia, although, with immigration from Eastern countries, the incidence of this pathology is rising worldwide. The Latin American experience demonstrates morbidity and mortality compatible with other Western countries, but minimally invasive procedures are lacking. We demonstrate a case of a combined surgical and endoscopic approach for stone clearance. We present a case of a 47-year-old female patient with biliary enteric anastomosis to treat recurrent pyogenic cholangitis resulting from intrahepatic lithiasis. The patient was admitted to the emergency room, presented with a new episode of cholangitis, and submitted to transcutaneous hepatobiliary drainage. The multidisciplinary approach, including the endoscopic and surgical teams, successfully performed the stone clearance with laser lithotripsy and stone removal by open access. The postoperative period was uneventful, and the patient did not present any sign of recurrence after one year. A combined surgical and endoscopic approach achieved short-term clinical and technical success in this novel case. Moreover, individualizing cases requiring open surgical access is feasible, which allows a combined endoscopic approach with safety.

Time to interval cholecystectomy and associated outcomes in a population aged 50 and above with mild gallstone pancreatitis.

BACKGROUND: Cholecystectomy on index admission for mild gallstone pancreatitis (GSP) is recommended, although not always feasible. This study examined rates and outcomes of people aged ≥ 50 years who underwent interval (delayed) cholecystectomy at increasing time points. METHODS: Hospitalisation and death data were linked for individuals aged ≥ 50 years admitted to hospital in New South Wales, Australia with mild GSP between 2008-2018. Primary outcome was interval cholecystectomy timing. Secondary outcomes included mortality, emergency readmission for gallstone-related disease (GSRD) (28 and 180-day), and length of stay (LOS) (index admission and total six-month GSRD). RESULTS: 3,003 patients underwent interval cholecystectomy: 861 (28.6%) at 1-30, 1,221 (40.7%) at 31-90 and 921 (30.7%) at 91-365 days from index admission. There was no difference in 365-day mortality between groups. Longer delay to cholecystectomy was associated with increased 180-day emergency GSRD readmission (17.5% vs 15.8% vs 19.9%, p < 0.001) and total six-month LOS (5.9 vs 8.4 vs 8.3, p < 0.001). Endoscopic retrograde cholangiopancreatography (ERCP) was increasingly required with cholecystectomy delay (14.5% vs 16.9% vs 20.4%, p < 0.001), as were open cholecystectomy procedures (4.8% vs 7.6% vs 11.3%, p < 0.001). Extended delay was associated with patients of lower socioeconomic status, regional/rural backgrounds or who presented to a low volume or non-tertiary hospital (p < 0.001). CONCLUSION: Delay to interval cholecystectomy results in increased rates of emergency readmission, overall LOS, risks of conversion to open surgery and need for ERCP. Index admission cholecystectomy is still recommended, however when not possible, interval cholecystectomy should be performed within 30 days to minimise patient risk and healthcare burden.