Hepatic subcapsular hematoma: A rare complication post-ERCP; a case report.

INTRODUCTION: Endoscopic retrograde cholangiopancreatography (ERCP) is commonly used in gastroenterology wards for both diagnostic and therapeutic purposes. It doesn't however come free of complications. As a matter of fact, complications are reported in up to 10% of patients undergoing ERCP. PATIENT CONCERNS: In this article, we report the case of a patient who underwent ERCP and sphincterotomy for choledocholithiasis. Twenty-four hours after the procedure, the patient developed sudden sharp abdominal pain and dropped her hemoglobin levels. DIAGNOSIS: An emergent gastroscopy was done and it ruled out bleeding from the sphincterotomy. Computed tomography of the abdomen showed a large hepatic subcapsular hematoma. INTERVENTIONS: Blood was urgently transfused and the patient was transferred to the intensive care unit for monitoring. OUTCOMES: The patient's condition quickly deteriorated despite extensive resuscitative measures, and eventually passed away on day 4 post ERCP. LESSONS: Hepatic subcapsular hematoma is a very rare but fatal complication after ERCP and should be ruled out in patients who underwent the procedure and develop sudden abdominal pain with hemodynamic and laboratory instability.

The value of endoscopic duodenal papilloplasty with titanium clip in improving post-operative complications of choledocholithiasis.

OBJECTIVE: To investigate the value of endoscopic duodenal papillary sphincterotomy combined with balloon dilatation in the treatment of duodenal papilloplasty with titanium clip after choledocholithiasis in post-operative complications. MATERIALS AND METHODS: One hundred and twenty-five patients (69 males and 56 females) with a median age of 65 (32-81) years were included. The treatment plan was randomly divided into Group A (n = 59) and Group B (n = 66) according to the random number table. Patients in Group A were treated with endoscopic sphincterotomy (EST) combined with endoscopic papillary large balloon dilation (EPLBD), followed by a titanium clip for duodenal papilloplasty and then indwelling nasobiliary drainage, whereas those in Group B were treated with EST combined EPLBD to remove stones and then indwelling nasobiliary drainage. RESULTS: In patients with choledocholithiasis or with anatomical changes that make stone extraction difficult, this prospective study attempted to perform duodenal papilloplasty with titanium clips after EST and EPLBD lithotripsy to compare and observe post-operative papillary healing, biliary reflux, and complication rates. CONCLUSIONS: The use of endoscopic duodenal papilloplasty with a titanium clip can improve biliary reflux after lithotripsy and reduce the incidence of post-operative cholangitis complications.

OBJETIVO: Investigar el valor de la esfinterotomía papilar duodenal endoscópica combinada con dilatación con balón en el tratamiento de la papiloplastia duodenal con clip de titanio después de coledocolitiasis en complicaciones postoperatorias. MATERIALES Y MÉTODOS: Se incluyeron un total de 125 pacientes (69 hombres y 56 mujeres) con una mediana de edad de 65 (32-81) años. Los pacientes del Grupo A se trataron con esfinterotomía endoscópica (EST) combinada con dilatación papilar endoscópica con balón grande (EPLBD), seguida de clip de titanio para papiloplastia duodenal y luego drenaje nasobiliar permanente, mientras que los del Grupo B se trataron con EPLBD combinado con EST para eliminar cálculos y luego drenaje nasobiliar permanente. RESULTADOS: En pacientes con coledocolitiasis o con cambios anatómicos que dificultan la extracción de cálculos, este estudio prospectivo intentó realizar papiloplastia duodenal con clips de titanio después de litotricia EST y EPLBD para comparar y observar la cicatrización papilar postoperatoria, el reflujo biliar y las tasas de complicaciones. CONCLUSIÓN: El uso de papiloplastia duodenal endoscópica con clips de titanio puede mejorar el reflujo biliar después de la litotricia y reducir la incidencia de complicaciones de colangitis postoperatorias.

Efficacy and safety of double endoscopy combined with exploration in the treatment of elderly patients with cholecystolithiasis complicated with choledocholithiasis.

OBJECTIVE: To investigate the efficacy and safety of laparoscopy combined with choledochoscopy in the treatment of elderly patients with cholecystolithiasis complicated with choledocholithiasis. METHODS: A retrospective analysis of 114 patients admitted to our hospital from January 2020 to January 2023 was conducted. These patients underwent laparoscopic cholecystectomy combined with choledocholithiasis and were divided into an elderly group (≥ 60 years old) of 63 cases and a young and middle-aged group (< 60 years old) of 51 cases according to age. The efficacy and safety indicators of the two groups of patients were observed, and complications were followed up by telephone within 6 months after surgery. The follow-up deadline was June 2023. RESULTS: Among the eligible patients (53 men, 61 women, average age 57 years), all were successfully operated, and 1 case was converted to laparotomy. The elderly and young and middle-aged groups were compared concerning hospitalisation time, bowel sound recovery time, and total postoperative complications, and the differences were statistically significant (P-values were 0.009, 0.006, and 0.039). However, there was no statistically significant difference between the two groups of patients in terms of hospitalisation costs, intraoperative blood loss, operation time, drainage tube removal time, conversion to laparotomy rate, and stone clearance rate (P-values > 0 0.05). CONCLUSION: Strict adherence to surgical standards and enhanced postoperative care resulted in similar efficacy and safety results for double endoscopy combined with the exploration of treatment for elderly and young patients with cholecystolithiasis and choledocholithiasis.

The Comparison of Clinical Outcomes in Elderly (≥75 Years) and Non-Elderly (<75 Years) Patients with Acute Cholangitis Due to Choledocholithiasis.

Background and Objectives: Acute cholangitis may be fatal, particularly in elderly patients. According to the Tokyo Guidelines 2018, those aged ≥75 years are classified as moderate (Grade II) severity. However, it has not been established whether age itself is the deciding factor of poor outcomes. We studied the impact of old age (≥75 years) on the mortality and morbidity of acute cholangitis due to choledocholithiasis. Materials and Methods: We retrospectively examined 260 patients with calculous acute cholangitis who had undergone biliary drainage. Patients were divided into two groups: elderly (≥75 years) and non-elderly (<75 years). We aimed to compare organ dysfunction, in-hospital mortality, intensive care unit (ICU) hospitalization, and the severity of acute cholangitis. Results: Of 260 patients, 134 (51.5%) were in the elderly group and 126 (48.5%) were in the non-elderly group. The mean age was 72.3 ± 14.4 years, and 152 (58.5%) were men. The elderly patients showed a higher incidence of shock (12.7% vs. 4.8%, p = 0.029), respiratory dysfunction (7.5% vs. 0%, p = 0.002), and renal dysfunction (8.2% vs. 0.8%, p = 0.006) than the non-elderly patients. The overall in-hospital mortality rate was 2.7%, with no significant differences between the elderly and the non-elderly (4.5% vs. 0.8%, p = 0.121). The incidence of severe acute cholangitis was significantly higher in the elderly group (26.9% vs. 9.5%, p < 0.001). However, there was no significant difference in the rates of ICU hospitalization (9.7% vs. 4%, p = 0.088) and lengths of hospital stay (LOS) (8.3 d vs. 7.1 d, p = 0.086). Conclusions: No difference was observed in the in-hospital mortality, ICU hospitalization, or LOS between the elderly (≥75 years) and the non-elderly (<75 years) with calculous acute cholangitis. However, severe acute cholangitis was significantly more frequent in elderly patients.

Performance of European and American Societies of Gastrointestinal Endoscopy Guidelines for Prediction of Choledocholithiasis in Patients with Acute Biliary Pancreatitis.

Background and Objectives: Up to one-third of patients with acute biliary pancreatitis also present with choledocholithiasis. Guidelines from the European Society of Gastrointestinal Endoscopy (ESGE) and the American Society for Gastrointestinal Endoscopy (ASGE) for investigating suspected choledocholithiasis suggest endoscopic retrograde cholangiopancreatography in patients with high-likelihood (ESGE)/high-probability (ASGE) predictors and endoscopic ultrasound in those with intermediate-likelihood (ESGE)/intermediate-probability (ASGE) predictors. Although both guidelines are similar, they are not identical. Furthermore, these algorithms were mainly developed from cohorts of patients without pancreatitis and are therefore poorly validated in a subset of patients with acute pancreatitis. We aimed to assess the performance of the ESGE and ASGE algorithms for the prediction of choledocholithiasis in patients with acute biliary pancreatitis. Materials and Methods: This was a retrospective analysis of 86 consecutive patients admitted to a tertiary referral centre in the year 2020 due to acute biliary pancreatitis. Results: Choledocholithiasis was confirmed in 29/86 (33.7%) of patients (13 with endoscopic retrograde cholangiopancreatography and 16 with endoscopic ultrasound). All 10/10 (100%) ESGE high-likelihood and 14/19 (73.7%) ASGE high-probability patients had choledocholithiasis. Only 19/71 (26.8%) patients with ESGE intermediate likelihood and 15/67 (22.4%) with ASGE intermediate probability had choledocholithiasis. Only 8/13 (61.5%) patients with the ASGE high-probability predictor of dilated common bile duct plus bilirubin > 68.4 µmol/mL had choledocholithiasis. Since this predictor is not considered high likelihood by ESGE, this resulted in a superior specificity of the European compared to the American guideline (100% vs. 91.2%). Following the American instead of the European guidelines would have resulted in five unnecessary endoscopic retrograde cholangiopancreatographies and five unnecessary endoscopic ultrasound examinations. Conclusions: This retrospective analysis suggests that the European guidelines may perform better than the American guidelines at predicting choledocholithiasis in the setting of acute pancreatitis. This was because dilated common bile duct plus bilirubin > 68.4 µmol/mL was not a reliable predictor for persistent bile duct stones.

Rendezvous procedure, a simultaneous endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy for choledocholithiasis, in a rural surgical program in Northwest Ontario.

Introduction: Northwest Ontario has a high prevalence of cholelithiasis, at 1.6 times the provincial norm. There is a concomitant 14% rate of choledocholithiasis. Accessing surgical services in the region often requires extensive travel by air. Choledocholithiasis management is typically with a 2-staged approach, an endoscopic retrograde cholangiopancreatography (ERCP) followed several days or weeks later by laparoscopic cholecystectomy (LC). Regional surgeons were concerned about the patient burden of travel and the loss to follow-up inherent in scheduling two independent procedures at separate hospital admissions. They adopted a 1-stage management, called the rendezvous procedure, which describes the simultaneous performance of an ERCP and LC. Methods: We accessed Sioux Lookout Meno Ya Win Health Centre hospital data for all patients receiving an ERCP and LC between 1 June 2019 and 1 December 2022. We documented patient demographics, operative outcomes, length of stay and transfer to other facilities. Results: There were 29 rendezvous procedures performed, with successful cannulation of the ampulla of Vater in 27 (93%) cases and stone removal in 23 (79%), with a complication rate of 7%. The operating time averaged 136 min, and two patients required transfer to a tertiary care centre and four were stented locally and required a return trip to Sioux Lookout for repeat ERCP and successful stone removal. The average length of stay was 2.1 ± 1.3 days. Patients who could not access a rendezvous procedure averaged 46.1 ± 78.1 days between procedures. Conclusion: Managing choledocholithiasis with a 1-stage approach was safe and effective and reduced patient travel, time to definitive care and hospital admissions.

Résumé Introduction: Le nord-ouest de l'Ontario présente une prévalence élevée de cholélithiase, soit 1,6 fois la norme provinciale. Le taux de cholédocholithiase concomitant est de 14%. L'accès aux services chirurgicaux de la région nécessite souvent de longs déplacements en avion. La prise en charge de la cholédocholithiase SE fait généralement en deux étapes: Une cholangiopancréatographie rétrograde endoscopique (CPRE) suivie, plusieurs jours ou semaines plus tard, d'une cholécystectomie laparoscopique (CL). Les chirurgiens régionaux étaient préoccupés par le fardeau que représentaient pour le patient les déplacements et la perte de suivi inhérents à la programmation de deux procédures indépendantes à des admissions hospitalières distinctes. Ils ont adopté une gestion en une étape appelée procédure de rendez-vous, qui décrit la réalisation simultanée d'une CPRE et d'une CL. Méthodes: Nous avons accédé aux données hospitalières du centre de santé Meno Ya Win de Sioux Lookout pour tous les patients ayant bénéficié d'une CPRE et d'une CL entre le 1er juin 2019 et le 1er décembre 2022. Nous avons documenté les données démographiques des patients, les résultats opératoires, la durée du séjour et le transfert vers d'autres établissements. Résultats: Vingt-neuf procédures de rendez-vous ont été réalisées, avec une canulation réussie de l'ampoule de Vater dans 27 cas (93%) et l'ablation des calculs dans 23 cas (79%), avec un taux de complication de 7%. Le temps d'opération a été en moyenne de 136 min. Two patients ont dû être transférés dans un centre de soins tertiaires et 4 ont été stentés localement et ont dû être ramenés à Sioux Lookout pour une nouvelle CPRE et une extraction réussie du calcul. La durée moyenne du séjour était de 2,1 ± 1,3 jours. Les patients qui n'ont pas pu accéder à une procédure de rendez-vous ont passé en moyenne 46.1 ± 78.1 jours entre les procédures. Conclusion: La prise en charge de la cholédocholithiase en une seule étape s'est avérée sûre et efficace et a permis de réduire les déplacements des patients, les délais de prise en charge définitive et les admissions à l'hôpital. Mots-clés: Rural, chirurgie, maladie de la vésicule biliaire.

Haemorrhagic cholecystitis in a young patient, complicated by gallbladder perforation and choledocholithiasis.

Haemorrhagic cholecystitis is a rare condition associated with a high risk of morbidity and mortality. Its pathophysiology is thought to be due to gallbladder wall erosion and infarction secondary to inflammation, which subsequently leads to haemorrhage into the gallbladder lumen or the peritoneal cavity. There is no current official guidance on optimal management of this condition. We describe a case of a female patient in her 40s who presented with right upper quadrant pain, followed by haematemesis. After CT scan, a diagnosis of haemorrhagic cholecystitis was made and initially managed conservatively. In this case, haemorrhagic cholecystitis was later complicated by gallbladder perforation and choledocholithiasis. Definitive management was with emergency open cholecystectomy. We believe this to be the first reported case of haemorrhagic cholecystitis complicated by gallbladder perforation and choledocholithiasis. This report highlights the need for early definitive management of haemorrhagic cholecystitis to prevent subsequent complications.

[Complex endoscopic treatment of a patient with a large adenoma of the major duodenal papilla, choledocholithiasis and stricture of the common bile duct]. / Kompleksnoe endoskopicheskoe lechenie patsientki s krupnoi adenomoi bol'shogo sosochka dvenadtsatiperstnoi kishki, kholedokholitiazom i strikturoi obshchego zhelchnogo protoka.

Incidence of adenomas of the major duodenal papilla has increased in recent years due to widespread endoscopic screening. These adenomas require resection due to high risk of malignant transformation. Currently, minimally invasive endoscopic interventions are often considered as an alternative to surgical treatment. Combination of major duodenal papilla neoplasms with choledocholithiasis and bile duct strictures are particularly difficult for endoscopic treatment. A 56-year-old patient underwent complex endoscopic treatment for a large adenoma of the major duodenal papilla spreading to duodenal walls and distal segment of the common bile duct combined with choledocholithiasis and stricture of the common bile duct. The patient underwent complex minimally invasive treatment with endoscopic lithoextraction, fragment-by-fragment removal of the neoplasm with intra-ductal ablation of residual adenomatous tissue and subsequent staged biliary stenting for the stricture of the common bile duct, as well as stenting of the main pancreatic duct for prevention of pancreatitis. An integrated approach to the treatment of a patient with a large adenoma of the major duodenal papilla, choledocholithiasis and stricture of the common bile duct provided clinical success without complications and the need for long-term rehabilitation.

Laparoscopic common bile duct exploration with primary closure could be safely performed among elderly patients with choledocholithiasis.

BACKGROUND: For patients with choledocholithiasis, laparoscopic common bile duct exploration (LCBDE) is preferred over open surgery. Whether primary closure of the common bile duct (CBD) should be performed upon completion of choledochotomy remains unclear, and the corresponding indications for primary closure of the common bile duct have yet to be fully identified. This study was performed to evaluate the safety and feasibility of primary closure of CBD among elderly patients (≥ 70 years) after LCBDE. METHODS: Patients with choledocholithiasis who had undergone LCBDE with primary closure of the CBD between July 2014 and December 2020 were retrospectively reviewed. Included patients were assigned into two groups (Group A: ≥70 years and Group B: <70 years) according to age. Group A was compared with Group B in terms of preoperative characteristics, intraoperative results and postoperative outcomes. RESULTS: The mean operative time for Group A was 176.59 min (± 68.950), while the mean operative time for Group B was 167.64 min (± 69.635) (P = 0.324). The mean hospital stay after surgery for Group A was 8.43 days (± 4.440), while that for Group B was 8.30 days (± 5.203) (P = 0.849). Three patients in Group A experienced bile leakage, while bile leakage occurred in 10 patients in Group B (3.8% vs. 4.5%, P = 0.781). Group A was not significantly different from Group B in terms of postoperative complications and 30-day mortality except pneumonia (P = 0.016), acute cardiovascular event (P = 0.005) and ICU observation (P = 0.037). After a median follow-up time of 60 months, 2 patients in Group A and 2 patients in Group B experienced stone recurrence (2.5% vs. 0.9%, P = 0.612). One patient in Group A experienced stenosis of the CBD, while stenosis of the CBD occurred in 5 patients in Group B (1.3% vs. 2.2%, P = 0.937). CONCLUSIONS: Primary closure of CBD upon completion of LCBDE could be safely performed among patients ≥ 70 years.

Comparison of laparoscopic common bile duct exploration and endoscopic retrograde cholangiopancreatography combined with laparoscopic cholecystectomy for patients with gallbladder and common bile duct stones a meta-analysis of randomized controlled trials.

OBJECTIVE: This study aimed to compare the efficacy and safety of laparoscopic common bile duct exploration (LCBDE) and endoscopic retrograde cholangiopancreatography (ERCP) combined with laparoscopic cholecystectomy (LC) to determine which one provides a better outcome for patients with gallbladder and common bile duct stones. MATERIALS AND METHODS: An electronic literature search was undertaken using Embase, Medline, PubMed, and Cochrane Library databases up to April 2022. For quality assessment of included studies, randomized controlled trials (RCTs) were assessed by utilizing the Jadad scale. The primary outcome includes surgical success rate, retained stone rate, stone clearance rate, major morbidity, and mortality. The second outcome includes conversion to open surgery rate, postoperative pancreatitis, bile leakage, cholangitis, hemorrhage, pneumonia, and surgical-site infection. RESULTS: 14 randomized controlled trials with 2,181 patients were included. No significant difference was seen between the two groups in terms of surgical success, stone clearance, retained stones, operation time, and total morbidity. LC-LCBDE had higher rate of bile leakage [relative risk (RR): 4.52; 95% confidence interval (CI): 2.19-9.31] and lower rate of postoperative pancreatitis (RR: 0.25; 95% CI: 0.13-0.46), cholangitis (RR: 0.17; 95% CI: 0.05-0.67), and hemorrhage (RR: 0.18; 95% CI: 0.07-0.42). CONCLUSIONS: Both LC+LCBDE and LC+ERCP are safe, effective, and minimal-invasive treatments for concomitant gallbladder and CBD stones. LC-LCBDE was associated with comparable effects compared with LC+ERCP in terms of surgical success rate, stone clearance rate, retained stones rate, operation time, and total morbidity. At the same time, LC-LCBDE had a higher rate of bile leakage and a lower rate of postoperative pancreatitis, cholangitis, and hemorrhage.

Gallstone Ileus With Persistent Cholelithiasis and Choledocholithiasis.

Gallstone ileus is an uncommon but well-described occurrence in general surgery. However, discrepancy regarding optimal surgical management with 1 or 2 stage operation is still debated. This case report presents a 73-year-old woman who presented to the emergency department (ED) with a small bowel obstruction due to a gallstone lodged in a portion of the proximal ileum. The patient was also noted to have persistent cholelithiasis and cholecystoduodenal fistula. A single-stage surgery involving enterolithotomy, cholecystectomy, fistula repair, and cholangioscopy was performed. The patient progressed well and was discharged home without recurrent symptoms. Therefore, in a hemodynamically stable patient with persistent cholelithiasis or choledocholithiasis, it is reasonable to perform a definitive single-stage operation.

Choledocholithiasis Can Present with Marked Transaminases Elevation: Systematic Review and Meta-Analysis.

BACKGROUND: Extreme transaminase elevation > 1000 international units per liter (IU/L) is typically caused by hepatocellular injury due to ischemia, drugs, or viral infection. Acute choledocholithiasis can also present with marked transaminase elevation mimicking severe hepatocellular injury, contrary to the presumed cholestatic pattern. METHODS: We searched PubMed/Medline, EMBASE, Cochrane Library, and Google Scholar for studies reporting the proportion of marked elevation of alanine aminotransferase (ALT) or aspartate aminotransferase (AST) > 1000 IU/L in patients with common bile duct (CBD) stones. A proportion meta-analysis with a corresponding 95% confidence interval (CI) was used to pool the proportion of patients with extreme transaminase elevation. I2 was used to examine heterogeneity. We used CMA software utilizing a random effect model for statistical analysis. RESULTS: Three studies (n = 1328 patients) were included in our analysis. The reported frequency of ALT or AST > 1000 IU/L in choledocholithiasis patients ranged between 6 and 9.6%, with pooled frequency of 7.8% (95% CI 5.5-10.8%, I2 61%). The frequency of patients with ALT or AST > 500 IU/L was higher, ranging between 28 and 47%, with pooled frequency of 33.1% (95% CI 25.3-42%, I2 88%). CONCLUSION: This is the first meta-analysis to study prevalence of severe hepatocellular injury in patients with CBD stones. Results revealed that approximately one-third of patients with choledocholithiasis present with ALT or AST > 500 IU/L. Furthermore, levels > 1000 IU/L are not uncommon. An elaborate work-up for alternative etiologies of severe transaminase elevation is likely unwarranted in cases with clear evidence of choledocholithiasis.

Observation versus intervention for incidental common bile duct stones at intraoperative cholangiogram: a systematic review.

BACKGROUND: The natural history of incidental common bile duct stones (CBDS) is poorly understood. Current evidence is conflicting, with several studies suggesting the majority may pass spontaneously. Despite this, guidelines recommend routine removal even if asymptomatic. This study aimed to systematically review the outcomes of expectant management for CBDS detected on operative cholangiography during cholecystectomy. METHODS: MEDLINE, Embase and CINAHL databases were systematically searched. Participants were adult patients with CBDS identified by intraoperative cholangiography. Intervention was regarded as any perioperative effort to remove common bile duct stones, including endoscopic retrograde cholangiopancreatography (ERCP), laparoscopic and open bile duct exploration. This was compared to observation. Outcomes of interest included rates of spontaneous stone passage, success of duct clearance and complications. Risk of bias was assessed using the ROBINS-I tool. RESULTS: Eight studies were included. All studies were non-randomized, heterogeneous and at serious risk of bias. In patients observed after a positive IOC, 20.9% went on to have symptomatic retained stones. In patients directed to ERCP for positive IOC, persistent CBDS were found in 50.6%. Spontaneous passage was not associated with stone size. Meta-analysis is dominated by the results from one large database, which recommends intervention for incidental stones, despite low rates of persistent stones seen at postoperative ERCP. CONCLUSIONS: Further evidence is required before a definitive recommendation on observation can be made. There is some evidence that asymptomatic stones may be safely observed. In clinical scenarios where the risks of biliary intervention are considered high, a conservative strategy could be more widely considered.

Clinical Analysis of Laparoscopic Common Bile Duct Primary Suture and T-Tube Drainage in the Treatment of Common Bile Duct Stones.

Background: At present, T-tube drainage or primary suture for common bile duct stones is common management. Methods: The clinical data of 100 patients who underwent laparoscopic common bile duct exploration and T-tube drainage or primary suture for common bile duct stones from 2019 to 2021 were analyzed retrospectively, including 50 cases of primary suture and 50 cases of T-tube drainage. Results: The operation time and postoperative hospital stay of patients with primary suture were lower than those in T-tube drainage group (P < .05). There was no significant difference in the incidence of postoperative complications and hospitalization expenses between the two groups (P > .05). Conclusions: It has been suggested that the therapeutic effect of laparoscopic primary suture is better than that of T-tube drainage; although they have different indications, they should be selected according to the specific individual situation of patients.

Ingesta-associated choledocholithiasis in horses: 2 cases and literature review.

Equine ingesta-associated choledocholithiasis is a rare cause of morbidity and mortality. We describe here the clinical, gross, histologic, and microbiologic features of this condition in 2 horses and compare the features to 2 previous cases. Case 1 was a 4-y-old Thoroughbred mare with colic. Case 2 was an 18-y-old American Paint Horse mare with colic, chronic weight loss, and inappropriate mentation. Both had elevated biochemical markers of hepatocellular injury and cholestasis and were euthanized given a poor prognosis. Case 1 had a well-formed 5-cm choledocholith surrounding a piece of hay, and had chronic neutrophilic cholangiohepatitis, bridging fibrosis, and extrahepatic obstruction. Case 2 had an ill-formed choledocholith with occasional hay fragments, wood stick, and twigs, and had regionally extensive hepatocellular necrosis with mild neutrophilic cholangiohepatitis and bridging fibrosis. Enterococcus casseliflavus and Escherichia coli were isolated in both cases; Clostridium spp. were also isolated from case 2. All 4 reported cases had increased activity of cholestatic enzymes, hyperbilirubinemia, portal inflammation, and bridging fibrosis. Colic, pyrexia, leukocytosis with neutrophilia, and elevated hepatocellular enzyme activity were documented in 3 cases. Foreign material in all 4 cases was plant origin (choledochophytolithiasis), including hay (n = 2), sticks/twigs (n = 2), and grass awns (n = 1). Ingesta-associated choledocholithiasis may be considered as a cause of colic, pyrexia, and elevated cholestatic biomarkers in horses.

The efficacy and safety of laparoscopic common bile duct exploration and cholecystectomy for the treatment of difficult common bile duct stones combined with gallstones: a multicenter retrospective study.

PURPOSE: To analyze the benefits of laparoscopic common bile duct exploration and laparoscopic cholecystectomy (LCBDE + LC) versus endoscopic retrograde cholangiopancreatography and/or endoscopic sphincterotomy following laparoscopic cholecystectomy (ERCP/EST + LC) for difficult common bile duct stones combined with gallstones. METHODS: A retrospective analysis of consecutive patients with difficult common bile duct stones combined with gallstones in three hospitals from January 2016 to January 2021 was performed. RESULTS: ERCP/EST + LC contributed to reducing postoperative drainage time. However, LCBDE + LC showed a higher rate of complete clearance, along with lower postoperative hospital stays, expenses and incidence of postoperative hyperamylasemia, pancreatitis, re-operation and recurrence. In addition, LCBDE + LC showed safe and feasible performance in the elderly and patients with previous upper abdominal surgery. CONCLUSION: It is an effective and safe method for LCBDE + LC for difficult common bile duct stones combined with gallstones.

Meta-analysis of the timing of laparoscopic cholecystectomy after endoscopic retrograde cholangiopancreatography in patients with cholecystolithiasis and choledocholithiasis.

Endoscopic retrograde cholangiopancreatography (ERCP) combined with laparoscopic cholecystectomy plays an important role in the treatment of cholecystolithiasis combined with choledocholithiasis; however, there is no unified standard for the interval of ERCP before laparoscopic cholecystectomy. We conducted a literature search, data extraction and meta-analysis on this topic. Twelve articles with 1142 patients were included, including 567 patients in the E-laparoscopic cholecystectomy group (laparoscopic cholecystectomy performed within 72 h after ERCP) and 575 patients in the D-laparoscopic cholecystectomy group (laparoscopic cholecystectomy performed 72 h after ERCP). The results showed that: compared with the D-laparoscopic cholecystectomy group, the duration of cholecystectomy was shorter in the E-laparoscopic cholecystectomy group [weighted mean difference (WMD) = -16.18, 95% confidence interval (CI) (-22.27 to -10.08), P  < 0.00001], and the postoperative hospitalization was shorter [WMD = -1.24, 95% CI (-1.98 to -0.50), P  < 0.0001]. There were fewer complications [odds ratio (OR) = 0.25, 95% CI (0.39-0.62), P  < 0.0001], lower conversion rate [OR = 0.39, 95% CI (0.21-0.71), P  = 0.002], lower high sensitivity C-reactive protein at 3 days after surgery [WMD = -8.76, 95% CI (-12.59 to -4.93), P  < 0.00001], and fewer neutrophils in the ampulla of gallbladder specimen [WMD = -4.21, 95% CI (-4.55 to -3.88), P < 0.00001]. Therefore, in the treatment of cholecystolithiasis combined with choledocholithiasis by laparoscopic cholecystectomy within 72 h after ERCP, the degree of inflammation before and after surgery is less, the operation time and hospital stay are shortened, the postoperative complications and the conversion rate are reduced, which is a more appropriate time for surgery.

Clinical and Microbiological Profile of Patients with Acute Cholangitis in a Tertiary Care Center.

INTRODUCTION: Acute cholangitis usually complicates biliary obstruction and antibiotic therapy plays a major role, as an adjunct to adequate biliary drainage in cholangitis. The knowledge of bacterial epidemiology in cholangitis will help to choose antibiotic wisely. The aim of the study was to analyze the clinical and bacteriological profile, in acute cholangitis. MATERIALS: We retrospectively analyzed the patients with acute cholangitis admitted under the Department of Gastroenterology, Kalinga Institute of Medical Sciences, Bhubaneswar August 2020 and July 2022. RESULT: 100 patients with mean age of 53.79 ± 14.96 years (male:female = 48:52) were included in the study. Choledocholithiasis (54%), carcinoma gallbladder (16%) and periampullary carcinoma (13%) were the main cause of biliary obstruction. The most common presenting complaints were fever followed by jaundice, the classically described Charcot's triad was present in only 33 (33%) patients. Most of the patients had moderate cholangitis (52%), followed by mild cholangitis (27%) and severe cholangitis (21%); based on Tokyo 2018 guidelines. Biliary drainage was done by endoscopic retrograde stenting in 92% and percutaneous trans-hepatic drainage in 8% of patients. Bile culture were positive on 86% of patients; gram-negative isolates were in 82.5% (71/86), gram-positive isolates were in 15.2% (13/86) and candida species in 2.3% (2/86). The commonest gram negative organisms isolated were Escherichia coli (34/86) followed by Klebsiella pneumonia (26/86) and Enterococcus faecalis (6/86) being the commonest gram-positive organism. The overall mortality rate was 11%; all had severe cholangitis. CONCLUSION: Choledocholithiasis is the commonest cause of biliary obstruction in patients presenting with acute cholangitis. Escherichia coli and Klebsiella pneumonia are the major contributors to acute cholangitis. References Reiter FP, Obermeier W, Jung J, et al. Prevalence, resistance rates, and risk factors of pathogens in routine bile cultures obtained during endoscopic retrograde cholangiography. Dig Dis 2021;39(1):42-51. Kaya M, Bestas R, Bacalan F, et al. Microbial profile and antibiotic sensitivity pattern in bile cultures from endoscopic retrograde cholangiography patients. World J Gastroenterol 2012;18(27):3585-3589.

Dolor torácico, un síntoma poco habitual de coledocolitiasis / Chest pain, an unusual symptom of choledocholithiasis

La litiasis biliar en Pediatría es una patología de baja incidencia. El diagnóstico se suele producir de forma casual debido a que cursa en la mayor parte de los casos de forma asintomática. En ocasiones, el síntoma de debut es en forma de dolor torácico, si bien esta circunstancia es poco frecuente. El método diagnóstico más utilizado es la ecografía abdominal debido a su alta especificidad y sensibilidad. El tratamiento depende de las características del paciente, pudiendo plantear opciones tanto médicas como quirúrgicas (AU)

Cholelithiasis in paediatrics is a pathology that has a low incidence. Diagnosis is usually made by chance as it is mostly asymptomatic. Chest pain as presenting symptom is rare. The most commonly used diagnostic method is abdominal ultrasound due to its high specificity and sensitivity. Treatment depends on the characteristics of the patient, and both medical and surgical options may be considered. (AU)