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Background and Aim: The association between biliary disorders with weight reduction enhanced by GLP-1RAs was observed frequently, nevertheless, the relative risk of the clinically relevant cholelithiasis was not specified clearly among different GLP-1RAs. Methods: 308 patients with type 2 diabetes mellitus (T2D) were recruited and divided into 4 groups; liraglutide, dulaglutide, semaglutide, versus control group; comprised of 69, 76, 71, and 92, respectively. Clinical history, examination, laboratory, and radiology tests were implemented. Results: Cholelithiasis significantly associates GLP1-RAs (p = 0.033). Overall cholelithiasis was evident in 31.2% of our participants. Symptomatic cholelithiasis prevails in 60.4% of patients with cholelithiasis. Symptomatic complicated cholelithiasis prevailed in 33.3%; distributed in 28.1%, 28.1%, 21.9%, and 21.9% in liraglutide, semaglutide, dulaglutide, and control groups, respectively. Meanwhile, symptomatic uncomplicated cholelithiasis was observed in 27.1%; distributed in 34.6%, 30.8%, 15.4%, and 19.2% in Liraglutide, semaglutide, dulaglutide, and control groups, respectively. Asymptomatic cholelithiasis was noted in 36.8%, 21.1%, 10.5%, and 31.6% of patients with dulaglutide, semaglutide, liraglutide, and control groups, respectively. Specifically, 81.1%, 68%, and 44% of patients with liraglutide, semaglutide, and dulaglutide experienced symptomatic cholelithiasis. The relative risk of cholelithiasis was 1.2, 1.3, and 1.4 in liraglutide, dulaglutide, and semaglutide with number needed to harm of 17.25, 14.69, and 10.96, respectively. The relative risk of symptomatic cholelithiasis was 1.6, 0.9, and 1.4 in liraglutide, dulaglutide, and semaglutide with number needed to harm of 3.14, 16.67, and 5.56, respectively. Conclusion: Liraglutide was associated with the highest risk of clinically relevant cholelithiasis than semaglutide, and dulaglutide in patients with T2D. [ABSTRACT FROM AUTHOR]

A 1‐year‐old, female, spayed dachshund presenting with clinical signs associated with cholangiohepatitis and cholangitis was found to have synthetic linear foreign material causing a common bile duct obstruction. The patient underwent a cholecystectomy, and foreign material was removed from the common bile duct via retrograde flushing into the duodenal papilla and manual retrieval. At the 6‐month post‐operative follow up visit, the patient had an improved cholestatic hepatopathy, with only a mild alkaline phosphatase elevation, moderate dilation of the common bile duct on ultrasonography, and was doing clinically well at home. 8 months post‐operatively, the patient re‐presented for an episode of septic cholangiohepatitis, with linear foreign material visualised within a dilated common bile duct on ultrasound. This episode was medically managed and was resolved with a 2‐week course of antibiotics. 1.5 years post‐operatively, the patient is doing clinically well, but continues to have persistent, moderate elevations of alanine transaminase and alkaline phosphatase. [ABSTRACT FROM AUTHOR]

Background: Intrahepatic cholangiocarcinoma is a biliary neoplasm usually showing a dismal prognosis. In early stages, surgical resection is the best treatment option, significantly increasing the overall survival. This approach is also recommended in the case of relapsing disease. In this study, we report the case of a patient affected by intrahepatic cholangiocarcinoma with multiple relapses and still alive for over 18 years. We also provide a systematic review regarding long-survivor (> 60 months) of intrahepatic cholangiocarcinoma. Case Presentation: A 41-year-old woman with no pathological history was diagnosed with localized intrahepatic cholangiocarcinoma and surgically treated with left hepatectomy. After the first intervention, the patients underwent three further surgical resections because of locoregional recurrences. Histologically, there were some significant similarities among all neoplasms, including the tubule-glandular architecture, but also morphological heterogeneity. The tumor immune microenvironment remained stable across the different lesions. The molecular analysis with next-generation sequencing demonstrated that all neoplasms shared the same genomic profile, including NBN and NOTCH3 mutations and chromosomes 1 and 3 alterations. Conclusions: This case study highlights the essential role of a stringent follow-up after resection of intrahepatic cholangiocarcinoma for detecting early relapsing tumors. Moreover, it shows the importance of the molecular characterization of multiple tumors for understanding their real nature. The accurate study of long-surviving patients highlights the features that are critical for outcome improvement. [ABSTRACT FROM AUTHOR]

Background: Gallstone pancreatitis (GSP) is common in elderly patients and carries worse outcomes. Laparoscopic cholecystectomy (LC) is recommended for prevention of recurrent GSP. In frail populations, an endoscopic retrograde cholangiopancreatography with sphincterotomy (ERCP-s) is an alternative. Management guidelines of GSP in the elderly are lacking. This study aimed to investigate and compare management strategies for GSP in the elderly. Materials and methods: A retrospective comparison of outcome of patients aged ≥65 years with first presentation of GSP treated either with (1) LC only, (2) ERCP-s, (3) ERCP-S followed by LC, or (4) no intervention. Results: 216 patients were included. Median age was 76 years (interquartile range 70-83). Most (80%, n = 172) had mild pancreatitis, whilst 12% (n = 26) had severe disease. 24% (n = 55) were treated with ERCP-s; 40% (n = 87) underwent LC alone; 11% (n = 23) had ERCP-s followed by LC; and 25% (n = 55) received no intervention. Patients without intervention were older (P < .001) and frailer (P < .001). The LC-only group had lower post-procedure re-admission rates of 6% (n = 5) compared to 27% (n = 14) for ERCP-s, 33% (n = 7) for ERCP-S + LC, and 31% (n = 17) for the no intervention group (P = .0001). Biliary cause mortality was highest in the no intervention group (n = 11, 20%). Conclusion: Laparoscopic cholecystectomy represents the gold standard for elderly patients with GSP. [ABSTRACT FROM AUTHOR]

Background: Patients with low socioeconomic status (SES) are disadvantaged in terms of access to health care. A novel metric for SES is the Distressed Communities Index (DCI). This study evaluates the effect of DCI on hospital choice and distance traveled for surgery. Methods: A Florida database was queried for patients with symptomatic cholelithiasis or chronic cholecystitis who underwent an outpatient cholecystectomy between 2016 and 2019. Patients' DCI was compared with hospital ratings, comorbidities, Charlson Comorbidity Index, and distance traveled for surgery. Stepwise logistic regression was used to determine which factors most influenced distance traveled for surgery. Results: There were 54,649 cases-81 open, 52,488 laparoscopic, and 2,080 robotic. There was no difference between surgical approach and patient's DCI group (p = 0.12). Rural patients traveled the farthest for surgery (avg 21.29 miles); urban patients traveled the least (avg 5.84 miles). Patients from distressed areas more often had surgery at one- or two-star hospitals than prosperous patients (61% vs 36.3%). Regression indicated distressed or at-risk areas predicted further travel for rural/small-town patients, while higher hospital ratings predicted further travel for suburban/urban patients. Discussion: Compared to prosperous areas, patients from distressed areas have surgery at lower-rated hospitals, travel further if they live in rural/small-town areas, but travel less if they live in suburban areas. We postulate that farther travel in rural areas may be explained by a lack of health care resources in poor, rural areas, while traveling less in suburban areas may be explained by personal lack of resources for patients with low SES. [ABSTRACT FROM AUTHOR]

Introduction: The role of robotic surgery in the nonelective setting remains poorly defined. Accessibility, patient acuity, and high turn-over may limit its applicability and utilization. The goal is to characterize the role of robotic cholecystectomy (CCY) in a busy acute care surgery (ACS) practice at a quaternary medical center, and compare surgical outcomes and resource utilization between robotic and laparoscopic CCY. Methods: Adult patients who underwent robotic (Da Vinci Xi) or laparoscopic CCY between 01/2021-12/2022 by an ACS attending within 1 week of admission were included. Primary outcomes included time from admission to surgery, off hour (weekend and 6p-6a) cases, operation time, and hospital costs, to reflect "feasibility" of robotic compared to laparoscopic CCY. Secondary outcomes encompassed surgery-related outcomes and complications. Results: The proportion of robotic CCY increased from 5% to 32% within 2 years. In total 361 laparoscopic and 89 robotic CCY were performed. Demographics and gallbladder disease severity were similar. Feasibility measures--operation time, case start time, time from admission to surgery, proportion of off-hour cases, and cost--were comparable between robotic and laparoscopic CCY. There were no differences in surgical complications, common bile duct injury, readmission, or mortality. Conversion to open surgery occurred more often in laparoscopic cases (5% vs 0%, P = .02, OR = 1.05). Discussion: Robotic CCY is associated with fewer open conversions and otherwise similar outcomes compared to laparoscopic CCY in the non-elective setting. Incorporation of robotic CCY in a busy ACS practice model is feasible with available resources. [ABSTRACT FROM AUTHOR]

Introduction: Preoperative Coronavirus Disease 2019 (COVID-19) infections are associated with postoperative adverse outcomes. However, there is limited data on the impact of postoperative COVID-19 infection on postoperative outcomes of common general surgery procedures. Objective: To evaluate the impact of postoperative COVID-19 diagnosis on laparoscopic cholecystectomy outcomes. Methods: Patients with symptomatic cholelithiasis, acute cholecystitis, or gallstone pancreatitis who underwent laparoscopic cholecystectomy with or without intraoperative cholangiogram were identified using the 2021 National Surgical Quality Improvement Program (NSQIP) database. Patients were categorized into two groups: patients with and without a postoperative COVID-19 diagnosis. Coarsened Exact Matching was used to match the groups based on preoperative risk factors, and outcomes were compared. Results: A total of 47,948 patients were included. In the aggregate cohort, 31% were male, and mean age was 50 years. Age, BMI, smoking, COPD, CHF, preoperative sepsis, and ASA class were significantly different between the two groups. After matching, there were no differences in characteristics. 30-day morbidity (OR = 2.7, 95% CI 1.4-5.1), pneumonia (OR = 5.0, 95% CI 1.7-15.0), DVT (OR = 8.22, 95% CI 1.0-66), reoperation (OR = 9.3, 95% CI 1.2-73.8), and readmission (OR = 4.8, 95% CI 2.3-10.1) continued to be significantly worse in the matched cohort. Conclusion: Postoperative COVID-19 infection was associated with worse outcomes after laparoscopic cholecystectomy. These findings suggest that even postoperative COVID-19 diagnosis increases the risk for adverse outcomes in patients recovering from laparoscopic cholecystectomy and may indicate that precautions should be taken and new COVID-19 infections even after surgery should be closely monitored. [ABSTRACT FROM AUTHOR]

Introduction: There is sparse data from India on indications, technical success, safety and outcomes of endoscopic retrograde cholangiopancreatography (ERCP) using standard adult duodenoscope in the pediatric population. Methods: Retrospective analysis of prospectively maintained electronic endoscopy and clinical database was performed to identify pediatric patients (age ≤ 18 years) who underwent ERCP between January 2017 and December 2022. Demographics and procedural details including indications, cholangio-pancreatogram findings, endotherapy type performed, technical and clinical success and complications were noted. Results: As many as 150 pediatric patients were included of whom 88 had pancreatic (mean age-13.7 years) and 62 had biliary disease (mean age- 14.9 years). Common pancreatic ERCP indications were chronic pancreatitis (n = 45 [51.1%]), pancreatic duct disruption fistula (n = 21 [23.9%]) and recurrent acute pancreatitis (n = 16 [18.2%]). Among biliary indications were choledocholithiasis (n = 29 [46.8%]), benign bile duct strictures (n = 13 [21%]), bile duct injury/leak and biliary stent removal (n = 7 [11.3%]) , choledochal cyst (n = 5 [8.1%]) and pancreatic mass causing biliary compression (n = 1 [1.6%]). Technical success in pancreatic and biliary ERCP was 94.3% and 95.2%, respectively, and clinical success was 84.1% and 93.5%, respectively. Most common complications following pancreatic ERCPs were acute pancreatitis (n = 9 [10.2%]) (mild = 5, moderate = 4) patients and post sphincterotomy bleed in one (1.1%). Among biliary ERCPs, post ERCP pancreatitis was seen in (n = 3 [4.8%]) (mild = 2, moderate = 1). Conclusion: ERCP can be safely and effectively performed in children using standard duodenoscope. Chronic pancreatitis, choledocholithiasis and pancreatic divisum are common pediatric ERCP indications. [ABSTRACT FROM AUTHOR]

Background: The detailed mechanisms underlying the development of ischemia‐type biliary lesions (ITBLs) in aged donor grafts remain unclear. In the present study we aimed to investigate the impact of aging on the response of the peribiliary gland (PBG) to ischemia–reperfusion injury (IRI) and its temporal changes. Methods: Experiments were performed using a 90‐min partial warm liver ischemia model in male Wistar rats of two age groups: young (7–8 weeks old) and old (52–60 weeks old). Liver tissues were obtained 24, 72, and 168 h after IRI. Histopathological and immunohistochemical assessments of the perihilar bile duct (PHBD), including the PBG, distal to the clip‐clamped site were performed. Results: Young rats showed little change in the bile duct tissues after IRI. However, old rats showed an increased PBG volume in the PHBD and marked PBG cell proliferation 24 h after IRI. Bile duct wall thickening with narrowing of the lumen peaked 72 h after IRI. Mucus production and oxidative stress in the PBG were significantly higher in old than in young rats after IRI. These findings showed a trend toward improvement 168 h after IRI. Conclusion: Age‐dependent differences in the response of the PBG to IRI may be related to differences in ITBL frequency. [ABSTRACT FROM AUTHOR]

Abstract Background and Aim The association between biliary disorders with weight reduction enhanced by GLP-1RAs was observed frequently, nevertheless, the relative risk of the clinically relevant cholelithiasis was not specified clearly among different GLP-1RAs. Methods 308 patients with type 2 diabetes mellitus (T2D) were recruited and divided into 4 groups; liraglutide, dulaglutide, semaglutide, versus control group; comprised of 69, 76, 71, and 92, respectively. Clinical history, examination, laboratory, and radiology tests were implemented. Results Cholelithiasis significantly associates GLP1-RAs (p = 0.033). Overall cholelithiasis was evident in 31.2% of our participants. Symptomatic cholelithiasis prevails in 60.4% of patients with cholelithiasis. Symptomatic complicated cholelithiasis prevailed in 33.3%; distributed in 28.1%, 28.1%, 21.9%, and 21.9% in liraglutide, semaglutide, dulaglutide, and control groups, respectively. Meanwhile, symptomatic uncomplicated cholelithiasis was observed in 27.1%; distributed in 34.6%, 30.8%, 15.4%, and 19.2% in Liraglutide, semaglutide, dulaglutide, and control groups, respectively. Asymptomatic cholelithiasis was noted in 36.8%, 21.1%, 10.5%, and 31.6% of patients with dulaglutide, semaglutide, liraglutide, and control groups, respectively. Specifically, 81.1%, 68%, and 44% of patients with liraglutide, semaglutide, and dulaglutide experienced symptomatic cholelithiasis. The relative risk of cholelithiasis was 1.2, 1.3, and 1.4 in liraglutide, dulaglutide, and semaglutide with number needed to harm of 17.25, 14.69, and 10.96, respectively. The relative risk of symptomatic cholelithiasis was 1.6, 0.9, and 1.4 in liraglutide, dulaglutide, and semaglutide with number needed to harm of 3.14, 16.67, and 5.56, respectively. Conclusion Liraglutide was associated with the highest risk of clinically relevant cholelithiasis than semaglutide, and dulaglutide in patients with T2D.

Christopher Thom, Justin Yaworsky, Kevin Livingstone, David Han, Jakob Ottenhoff Department of Emergency Medicine, University of Virginia Health System, Charlottesville, Virginia, USACorrespondence: Christopher Thom, University of Virginia Health System, 1215 Lee Street, Charlottesville, Virginia, 22903, USA, Email ct9k@hscmail.mcc.virginia.eduBackground: Biliary ultrasound is often utilized in the evaluation of abdominal pain in the Emergency Department (ED). Common bile duct (CBD) identification is traditionally a standard component of the biliary ultrasound examination but can be challenging to perform for the novice sonographer. Previous work has demonstrated that CBD dilatation is rare in cases of cholecystitis with normal liver function tests (LFTs). We sought to assess the frequency of CBD dilatation in the subset of ED patients undergoing hepatobiliary ultrasound who have normal LFTs and an absence of gallstones or biliary sludge on ultrasound. We also performed an assessment of changes in CBD diameter by age and cholecystectomy status.Methods: This was a retrospective chart review at a single academic ED. Patients were enrolled in the study if they underwent a radiology performed (RP) hepatobiliary ultrasound within the 2 year study period. Records were reviewed for the presence of gallstones or sludge, CBD diameter, age, clinical indication for the ultrasound, and LFTs. Descriptive analyses were performed, and interobserver agreement among data abstractors was assessed by K analysis for the presence of CBD dilatation. The Mann–Whitney test was utilized to assess statistical significance in the comparison of differences between CBD diameters amongst age groups.Results: Of 1929 RP hepatobiliary ultrasounds performed in the study period, 312 were excluded and 1617 met inclusion criteria. Amongst these, there were 506 patients who had normal LFTs and an ultrasound with no stones or sludge. Ten patients within this group had a dilated CBD > 7 mm (1.98%, 95% CI of 1.08% to 3.6%). We also noted a statistically significant increase in CBD size in the older age cohort and in those individuals with a history of cholecystectomy.Conclusion: CBD dilation in ED patients who present with normal LFTs and an absence of gallstones and biliary sludge is rare. Physicians should be reassured that the routine identification of the CBD on ultrasound in this setting is of low yield and need not be pursued.Plain Language Summary: The common bile duct is often taught as part of the biliary point-of-care ultrasound examination. However, it is more challenging to identify than the gallbladder and thus may limit adoption of POCUS by ED physicians. Our study adds to the body of work demonstrating that omitting the common bile duct from an ultrasound evaluation is likely reasonable when both the gallbladder and liver function tests are normal. Our study also adds to the literature regarding the increase in common bile duct size with age and with post-cholecystectomy status.Keywords: biliary, common bile duct, ultrasound, gallstones, cholelithiasis, point-of-care ultrasound

Background: Gallstone is a common problem in patients with sickle cell disease. Prevalence of this problem among sickle cell disease (SCD) children may vary with age, and geographic location. Studies on gallstone prevalence in SCD children are scanty in the South-South zone of Nigeria. Aim: To determine by ultrasonography the prevalence of gallstones among steady state sickle cell disease children attending the Paediatric Outpatient Clinic of the University of Benin Teaching Hospital, Benin-City, south south Nigeria. Methodology: The study was a descriptive cross sectional study. The prevalence of gall stones was studied prospectively on 101 sickle cell disease patients who attended the Paediatric Outpatient clinic of the University of Benin Teaching Hospital by means of ultrasonography. They were aged 1-18 years. All except three patients were Haemoglobin (Hb) SS while the remaining three were bSC. Statistical analysis was done by means, percentages and tests of significance was done using students t- test. Results: Five of the 101 children studied had gallstones and one had biliary sludge. The prevalence of gallstone was 5%. All patients with gallstones were HbSS, none with HbSC had stone although only three were studied.Only one child was symptomatic for the presence of gallstones. One patient had biliary sludge. The male: female ratio was 4:1. Prevalence increased with age; 2.9% 4.5% and 9.1% in patients aged less than 5,6-10 and 11-18 years respectively. Body weight was significantly associated with the presence of gallstones. Conclusion: Gallstone was found in 5% of the SCD children aged 1- 18years. This value is low compared to those from Europe and North America. It however confirmed the relative low prevalence in the general population of Nigerians.The clinical significance of gallstones in these SCD children is that it may contribute significantly to the morbidity and mortality seen in these children. Recommendation: Routine abdominal scan is recommended for sickle cell disease children to detect gallstone whose presence can mimic abdominal crisis. The option of elective cholecystectomy with reduced morbidity compared to emergency cholecystectomy can thus be exploited.

Primary biliary cholangitis (PBC) is a chronic autoimmune liver disease. In recent years, related studies in China and globally have provided some evidence-based medical evidence for the integrated traditional Chinese and Western medicine treatment of PBC. Based on the latest diagnosis and treatment experience and guidelines in China and globally, Expert Committee on Hepatology, Doctor Society of Integrative Medicine, Chinese Medical Doctor Association, organized related experts in China to formulate this consensus, in order to provide guidance and reference for clinicians in the diagnosis, TCM syndrome differentiation, and integrated traditional Chinese and Western medicine treatment of PBC. [ABSTRACT FROM AUTHOR]

Background: The cornerstone treatment for primary biliary cholangitis (PBC) is ursodeoxycholic acid (UDCA), but many patients exhibit an incomplete response, leading to disease progression. Risk prediction models like the GLOBE and UK-PBC scores hold promise for patient stratification and management. We aimed to independently assess the predictive accuracy of these risk scores for UDCA response in a prospective U.S. cohort. Methods: We conducted a prospective cohort study at a U.S. liver center, monitoring UDCA-treated PBC patients over a one-year follow-up. We evaluated the predictive efficacy of the GLOBE and UK-PBC scores for UDCA treatment response, comparing them to the Paris II criteria. Efficacy was assessed using univariate and multivariate analyses, followed by prognostic performance evaluation via receiver operating characteristic (ROC) curve analysis. Results: We evaluated 136 PBC patients undergoing UDCA therapy. Based on the Paris II criteria, patients were categorized into UDCA full-response and non-response groups. The GLOBE score identified a non-responder rate of 18% (p = 0.205), compared to 20% (p = 0.014) with the Paris II criteria. Multivariate analysis, adjusted for age and biochemical markers, showed that both the GLOBE and UK-PBC scores were strongly associated with treatment response (p < 0.001). The area under the ROC curve was 0.87 (95% CI 0.83−0.95) for the GLOBE score and 0.94 (95% CI 0.86−0.99) for the UK-PBC risk score. Conclusions: Our study demonstrates that GLOBE and UK-PBC scores effectively predict UDCA treatment response in PBC patients. The early identification of patients at risk of an incomplete response could improve treatment strategies and identify patients who may need second-line therapies. [ABSTRACT FROM AUTHOR]

Introduction: Fibrosis and cirrhosis are associated with worse outcomes after hepatectomy. Aspartate transaminase to platelet ratio index (APRI) is associated with fibrosis and cirrhosis in hepatitis C patients. However, APRI has not been studied to predict outcomes after hepatectomy in patients without viral hepatitis. Methods: We reviewed the ACS-NSQIP dataset to identify patients who underwent a minor hepatectomy between 2014 and 2021. We excluded patients with viral hepatitis or ascites as well as patients who underwent emergent operations or biliary reconstruction. APRI was calculated using the following equation: (AST/40)/(platelet count) × 100. APRI ≥0.7 was used to identify significant fibrosis. Univariable analysis was performed to identify factors associated with APRI ≥0.7, transfusion, serious morbidity, overall morbidity, and 30-day mortality. Multivariable logistic regression was performed to identify adjusted predictors of these outcomes. Results: Of the 18,069 patients who met inclusion criteria, 1630 (9.0%) patients had an APRI ≥0.7. A perioperative blood transfusion was administered to 2139 (11.8%). Overall morbidity, serious morbidity, and mortality were experienced by 3162 (17.5%), 2475 (13.7%), and 131 (.7%) patients, respectively. APRI ≥0.7 was an independent predictor of transfusion (adjusted OR: 1.48 [1.26-1.74], P <.001), overall morbidity (1.17 [1.02-1.33], P =.022), and mortality (1.97 [1.22-3.06], P =.004). Transfusion was an independent predictor of overall morbidity (3.31 [2.99-3.65], P <.001), serious morbidity (3.70 [3.33-4.11], P <.001), and mortality (5.73 [4.01-8.14], P <.001). Conclusions: APRI ≥0.7 is associated with perioperative transfusion, overall morbidity, and 30-day mortality. APRI may serve as a noninvasive tool to risk stratify patients prior to elective minor hepatectomy. [ABSTRACT FROM AUTHOR]

E. innesii is a recently described Enterococcus species which may be difficult to differentiate from the more common E. casseliflavus. We present the first clinical report of invasive E. innesii infection, featuring two cases of biliary sepsis. Whole genome sequencing confirmed the taxonomic assignment and the presence of vanC-4. Analysis of public genomes identified 13 deposited E. innesii and 13 deposited E. casselifalvus/E.gallinarum genomes which could be reassigned as E. innesii. Improved laboratory diagnosis of E. innesii is expected to generate additional data concerning its clinical relevance and support the future diagnosis and treatment of this uncommon pathogen. [ABSTRACT FROM AUTHOR]

Background and Objectives: Prolonged biliary stenting may lead to complications such as cholangitis, stentolith and stent migration. There is limited data on forgotten biliary stents for more than five years in literature. The aim of this retrospective study was to analyze the complications and outcomes in patients who forgot to get their biliary stents removed or exchanged for more than five years. Methods: The study population included patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) and plastic biliary stent placements in a tertiary care center from 1990 to 2022 for benign biliary diseases. Loss to follow-up and subsequent forgotten stent for more than five years were observed in 40 patients who underwent ERCP during this study period. We retrospectively analyzed the indications of stenting, present status of stent, complications and outcomes in the study patients. Results: The mean age of the study patients was 51.5 ± 11.5 years with 27 females. Indications of biliary stent placement were choledocholithiasis (33, 82.5%), bile leak (3, 7.5%), benign biliary stricture (2, 5%) and choledochal cyst (2, 5%). The mean duration of forgotten stent was 5.9 ± 3.6 years. Presenting symptoms were abdominal pain (37, 92.5%), fever (26, 65%) and jaundice (32, 80%). Most commonly placed stent was 7 French double pigtail of 10 cm length. Complications in the study patients were cholangitis (35, 87.5%), internal migration (2, 5%), pancreatitis (1, 2.5%) and portal hypertension (1, 2.5%). The outcomes were stone removal (30, 90.9%), stent removal (31, 77.5%), stent reinsertion (19, 47.5%), broken stent (3, 7.5%) and surgery (2, 5%). Conclusions: Prolonged duration (> 5 years) of forgotten stent is uncommon and is observed most commonly in patients with choledocholithiasis. The most common complication of long duration of forgotten stents was cholangitis followed by internal migration, pancreatitis and portal hypertension. Stone and stent removal was successful in a majority of patents, while surgery was required in less number of patients. [ABSTRACT FROM AUTHOR]

Purpose: This retrospective analysis aimed to assess the feasibility and safety of endoscopic retrograde cholangiopancreatography (ERCP) in pediatric patients by examining ERCP-related adverse events (AEs) occurring over a decade at a single center. Methods: Pediatric patients under 18 years old who underwent ERCP at the Second Hospital of Hebei Medical University from 1/2013 to 11/2023 were included. ERCP-related AEs were defined according to ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Clinical data of patients experiencing ERCP-related AEs were obtained from electronic medical records for analysis. Results: Over the past decade, a total of 76 pediatric patients underwent 113 ERCP procedures, including 26 patients who underwent repeat ERCP, totaling 63 procedures. There were 32 males and 44 females, with a median age of 13 years (range 3 years and 5 months–17 years and 9 months). Among all ERCP procedures, 14 (12.4%) were diagnostic and 99 (87.6%) were therapeutic, with a 100% success rate. 16 cases (14.2%) of ERCP-related AEs, all post-ERCP pancreatitis (PEP), were observed, while no other AEs defined by ESGE such as bleeding, perforation, cholangitis, cholecystitis, or sedation-related events were noted. Additionally, 23 cases (20.4%) of ERCP-related AEs not included in the ESGE definition were observed, including post-ERCP abdominal pain in 20 cases (17.7%), post-ERCP nausea and vomiting in 2 cases (1.8%), and unplanned reoperation in 1 case (0.9%). In the 26 cases of pediatric patients who underwent repeat ERCP, we observed that AEs occurred in 15 cases (57.7%) during their initial ERCP, which was much higher than the overall average level. Conclusions: Post-ERCP abdominal pain and PEP are the most common ERCP-related AEs in pediatric patients, while severe AEs such as bleeding and perforation are rare. The incidence of AEs after initial ERCP in pediatric patients who received repeat ERCP is higher than the overall average level. Based on our center's experience, we believe that ERCP can be safely performed in children over 3 years old with biliary and pancreatic diseases and obtain reliable clinical benefits. However, active monitoring and management of ERCP-related AEs are essential to improve the clinical outcomes of pediatric ERCP. [ABSTRACT FROM AUTHOR]

Artificial Intelligence (AI) is poised or has already begun to influence absorption, distribution, metabolism and excretion (ADME) science. It is not in the area expected – that of superior modelling of ADME data to increase its predictive power. It is influencing traditional exhaustive and careful literature research by providing almost perfect summaries of existing information. This will highly influence how people study, graduate and progress in the ADME sciences. The literature contains many flaws (protein binding influence on unbound drug concentration is one of the examples cited) and without direction AI may help to popularise them. ADME science has a relatively small number of key assays and values, but these are produced under widely varying conditions so large data sets, the best substrate for artificial intelligence, are not readily available to produce new more predictive systems. The use of AI to enrich the databases may be a near term goal. AI is already contributing in other areas such as technical skill assimilation, maintenance of complex instruments (combined with virtual reality) and the processing of pharmacovigilance. [ABSTRACT FROM AUTHOR]

Introduction. Biliary obstruction is a common manifestation of biliopancreatic malignancies, and its relief is an essential part of the treatment algorithm. Currently, there are three techniques to manage malignant biliary obstruction—endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic biliary drainage (PTBD), and endoscopic ultrasound-guided biliary drainage (EUS-BD). ERCP has been adopted as a first-line treatment modality but EUS-BD is gradually emerging as a viable alternative. The aim of the current article is to assess the clinical outcomes of the three nonsurgical biliary drainage procedures. Materials and methods. A total of 102 consecutive patients with unresectable biliopancreatic malignancy inducing biliary obstruction and subjected to palliative treatment by means of ERCP, EUS-BD, or PTBD were retrospectively included in the study. Results. No difference in clinical and technical success of the procedures was found: ERCP—97.2% technical; 88.9% clinical; PTBD—94.4% technical, 72.2% clinical; EUS-BD—90% technical; 83.3% clinical. Adverse events (AEs) and reinterventions were significantly more common in PTBD (38.9% and 52.8%) and ERCP (27.9% and 25%) compared to EUS-BD (10% and 3.3%). Total duration of hospital stay and number of hospitalizations were lower in the EUS-BD compared to PTBD and ERCP groups. Conclusions. In the presence of adequate expertise, EUS-BD may be superior to PTBD and ERCP in achieving and sustaining biliary drainage in the setting of unresectable malignancy.

Introduction. Biliary obstruction is a common manifestation of biliopancreatic malignancies, and its relief is an essential part of the treatment algorithm. Currently, there are three techniques to manage malignant biliary obstruction—endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic biliary drainage (PTBD), and endoscopic ultrasound-guided biliary drainage (EUS-BD). ERCP has been adopted as a first-line treatment modality but EUS-BD is gradually emerging as a viable alternative. The aim of the current article is to assess the clinical outcomes of the three nonsurgical biliary drainage procedures. Materials and methods. A total of 102 consecutive patients with unresectable biliopancreatic malignancy inducing biliary obstruction and subjected to palliative treatment by means of ERCP, EUS-BD, or PTBD were retrospectively included in the study. Results. No difference in clinical and technical success of the procedures was found: ERCP—97.2% technical; 88.9% clinical; PTBD—94.4% technical, 72.2% clinical; EUS-BD—90% technical; 83.3% clinical. Adverse events (AEs) and reinterventions were significantly more common in PTBD (38.9% and 52.8%) and ERCP (27.9% and 25%) compared to EUS-BD (10% and 3.3%). Total duration of hospital stay and number of hospitalizations were lower in the EUS-BD compared to PTBD and ERCP groups. Conclusions. In the presence of adequate expertise, EUS-BD may be superior to PTBD and ERCP in achieving and sustaining biliary drainage in the setting of unresectable malignancy. [ABSTRACT FROM AUTHOR]

Introduction: Uganda has until recently mostly referred patients for complex hepato‐pancreato‐biliary (HPB) surgery abroad due to lack of local expertize. We report indications and a spectrum of surgeries performed in the first 4 years following the establishment of a routine HPB service at Lubaga Hospital (LH), Kampala, Uganda. We also detailed the challenges encountered in setting up this service. Methods: Demographic, clinical parameters, surgery indications, procedures performed, and outcomes of consecutive patients that underwent HPB surgeries at LH from December 2018 to October 2022 were analyzed. Results: Majority were females 72 (57.6%) with a median age of 50 (6–88) years. Forty‐one (32.8%) underwent surgery on the pancreas (PS), 34 (27.2%) on the liver (LS), and 50 (40.0%) on the bile ducts (CBS). The most common symptom was abdominal pain. Benign disease was present in 37 patients (29.6%) while 88 (70.4%) had malignancy. A total of 34 patients (27.2%) had unresectable pancreatic head cancer and distal cholangiocarcinoma missed at preoperative imaging and discovered intraoperatively thus underwent palliative hepaticojejunostomy. Only 34 (27.2%) patients received postoperative ICU care. In‐hospital mortality for this heterogenous group of patients was 6 (4.8%) for PS, 3 (2.4%) for LS, and 8 (6.4%) for CBS. Conclusion: Despite many challenges like limited access to ERCP accessories, lack of endoscopic ultrasound scans and PET–CT scans in the whole country, late presentation, and low quality imaging especially in preoperative determination of resectability of hepato‐pancreato‐biliary cancers, we managed to establish a functional HPB service. Patient results achieved were good in spite of these limitations. [ABSTRACT FROM AUTHOR]

This article discusses a retrospective study conducted in Kolkata, India, which examined the burden and outcome of acute pancreatitis (AP). The study found that the most common causes of AP were alcohol, gallstones, and post-endoscopic retrograde cholangiopancreatography (ERCP). Local complications such as peripancreatic collections and pseudocysts were observed in many cases, and organ failure, particularly respiratory failure, was the most common complication. The mortality rate was 6.6%, primarily due to respiratory failure in severe AP cases. The study emphasizes the importance of early diagnosis and management of AP to improve outcomes. [Extracted from the article]

Ultrasound (US) is a fundamental and inexpensive tool both for the prompt diagnosis and for the study of diverse medical conditions. Its widespread use is partly due to the availability of US devices in the daily practice of physicians. US can be performed in real-time and is instrumental in the generation of clinical algorithms for the management of situations like trauma. It also constitutes a primary approach for the study of oncological diseases, and a guidance tool for interventions such as percutaneous drainages. In addition, and specifically for HPB surgeons, US is an essential tool in the operating room: intraoperative (either open or laparoscopic) US is necessary for the accurate determination of the stage, location, number, and margins of tumors within the liver, pancreas, or biliary tree. On another note, reading and understanding US images are skills that require time and training, which should be taught during surgical residencies. However, this is not customary in most residencies globally. This chapter offers a concise yet comprehensive elucidation of the basic principles of ultrasonography, the instruments required to perform an ultrasonic assessment of a patient, and the basic ultrasound controls.

Abstract Background Total serum bilirubin concentration (TBIL) can provide useful information on several pathophysiological conditions in cats. Nevertheless, whether the variable severity classification of hyperbilirubinemia can reliably indicate certain disease processes or predict a biliary obstruction (BO) has not been investigated. Hypothesis/Objective Determine if hyperbilirubinemia of variable severity can assist clinicians to identify BO, which often is considered a surgical emergency. Animals Two‐hundred sixteen client‐owned cats. Methods Data were retrospectively collected from all cats (January 2015‐August 2022) with an increased TBIL (>0.58 mg/dL [>10 μmol/L]) presented to 3 referral centers in the United Kingdom (UK). Presenting clinical features and diagnostic outcomes were collected. The predictive ability of TBIL to indicate BO was evaluated by multivariable binary logistic regression modeling and receiver operating characteristic (ROC) curves. Results Median TBIL was 1.73 mg/dL (range, 0.59‐26.15; 29.5 μmol/L; range, 10.1‐447.1) with severity classification of hyperbilirubinemia categorized as mild (>0.58‐2.92 mg/dL; >10‐50 μmol/L; 68.1%), moderate (>2.92‐5.85 mg/dL; >50‐100 μmol/L; 17.6%), severe (>5.85‐11.70 mg/dL; >100‐200 μmol/L; 9.7%) and very severe (>11.70 mg/dL; >200 μmol/L; 4.6%). Biliary obstruction was present in 17 (7.9%) cats, all of which received recommendation for emergency surgery. Median TBIL in cats with BO (9.69 mg/dL; 165.7 μmol/L) differed significantly from those without obstruction (1.51 mg/dL; 25.8 μmol/L; P

Gallbladder cancers are the most common biliary tract malignancies in the world. Adenocarcinoma constitutes the most common histology in gallbladder cancer. Neuroendocrine neoplasms of the gallbladder account for about 0.5% of all neuroendocrine neoplasms and 2.1% of all gallbladder tumors. They are rare tumors and present with non-specific symptoms such as abdominal pain, weight loss, anorexia, and obstructive jaundice, and, therefore, are often challenging to diagnose and treat. Mixed neuroendocrine-non-neuroendocrine neoplasm is a subtype of neuroendocrine neoplasm. To add to the literature, we report a rare case of a patient who presented with pain in the abdomen and non-bilious vomiting and was diagnosed with mixed neuroendocrine-non-neuroendocrine gallbladder cancer, identified by immunohistochemistry, and treated with palliative chemotherapy. Due to non-specific symptoms, patients may present at an advanced stage. Further, immunohistochemistry may assist in clinching the diagnosis.

Left-sided gallbladder positioning, or sinistroposition, is a rare anatomical variation that poses challenges during surgical intervention due to associated vascular and biliary anomalies. While existing literature suggests an incidence of approximately 0.04-1.1%, it remains an underreported phenomenon that falls well outside the realm of "expected" anatomical variation and are rarely identified on preoperative imaging. Here, we present a case of acute cholecystitis in a patient with unexpected left-sided gallbladder, highlighting the associated challenges and outlining both preoperative and intraoperative strategies for managing this rare but consequential anatomical variant. In this case, a 49-year-old woman with a prior history of bilateral ovarian cysts presented with clinical, laboratory, and imaging findings consistent with acute cholecystitis. She underwent laparoscopic cholecystectomy and was found to have a severely inflamed left-sided gallbladder that was obscured by omentum. Her gallbladder was found in the midline immediately beneath the falciform ligament, with most of the gallbladder body and fundus attached to liver segment III, situated to the left of the midline. An additional left-sided mid-abdominal port was required to enhance retraction, and an intraoperative cholangiogram (IOC) was performed given the elevated risk of structural injury. This case underscores the heightened intraoperative risk associated with deviations in vascular and biliary anatomy and provides recommendations for intraoperative adaptations to mitigate these risks. [ABSTRACT FROM AUTHOR]

Background: Total serum bilirubin concentration (TBIL) can provide useful information on several pathophysiological conditions in cats. Nevertheless, whether the variable severity classification of hyperbilirubinemia can reliably indicate certain disease processes or predict a biliary obstruction (BO) has not been investigated. Hypothesis/Objective: Determine if hyperbilirubinemia of variable severity can assist clinicians to identify BO, which often is considered a surgical emergency. Animals: Two‐hundred sixteen client‐owned cats. Methods: Data were retrospectively collected from all cats (January 2015‐August 2022) with an increased TBIL (>0.58 mg/dL [>10 μmol/L]) presented to 3 referral centers in the United Kingdom (UK). Presenting clinical features and diagnostic outcomes were collected. The predictive ability of TBIL to indicate BO was evaluated by multivariable binary logistic regression modeling and receiver operating characteristic (ROC) curves. Results: Median TBIL was 1.73 mg/dL (range, 0.59‐26.15; 29.5 μmol/L; range, 10.1‐447.1) with severity classification of hyperbilirubinemia categorized as mild (>0.58‐2.92 mg/dL; >10‐50 μmol/L; 68.1%), moderate (>2.92‐5.85 mg/dL; >50‐100 μmol/L; 17.6%), severe (>5.85‐11.70 mg/dL; >100‐200 μmol/L; 9.7%) and very severe (>11.70 mg/dL; >200 μmol/L; 4.6%). Biliary obstruction was present in 17 (7.9%) cats, all of which received recommendation for emergency surgery. Median TBIL in cats with BO (9.69 mg/dL; 165.7 μmol/L) differed significantly from those without obstruction (1.51 mg/dL; 25.8 μmol/L; P <.01). The optimal TBIL cut‐off to discriminate between cats with and without BO was ≥3.86 mg/dL (≥66 μmol/L) with a sensitivity of 94.1% and specificity of 82.4%. Using multivariable logistic regression, as age increased, the odds of BO increased significantly (odds ratio, 1.20; 95% confidence interval, 1.01‐1.42; P =.04). Conclusions and Clinical Importance: As part of a thorough clinical assessment, the severity classification of hyperbilirubinemia has the potential to predict the likelihood of a BO and to discriminate between cats that may or may not require surgery for BO at a suggested cut‐off of ≥3.86 mg/dL (≥66 μmol/L). Alongside TBIL, age is also useful when assessing for the likelihood of BO in a cat presented with hyperbilirubinemia. [ABSTRACT FROM AUTHOR]

Metastatic gastrointestinal cancer is not an uncommon situation, especially for pancreatic, gastric, and colorectal cancers. In this setting, few data are available on the impact of the treatment of the primary tumour. Oligometastatic disease is associated with longer survival in comparison with more advanced disease. Metastasis-directed therapy, such as stereotactic body radiotherapy, seems related to better outcomes, but the level of evidence is low. In most tumour locations, prospective data are very scarce and inclusion in ongoing trials is strongly recommended. [ABSTRACT FROM AUTHOR]

Key Clinical Message: This case demonstrates an atypical presentation of choledochal cysts (CDCs) and elaborates on the diagnostic challenges encountered when presented with CDCs in adulthood, as it principally presents in children. A choledochal cyst is a rare congenital anomaly characterized by cystic dilations in the extrahepatic and intrahepatic biliary trees. These cysts are classified according to their location and characteristics. This case study aims to demonstrate how nonspecific clinical features can pose a diagnostic dilemma when presented in adults. Additionally, the case report provides an overview of diagnostic methods and treatment options. In this case, we discuss a 50‐year‐old female who presented with a 2‐ to 3‐day history of severe colicky pain in the right upper quadrant of her abdomen without any other symptoms or abnormal laboratory tests. In addition to ultrasonography evidence of CBD dilation and cholelithiasis, MRCP results confirmed the diagnosis. She underwent surgical intervention involving cyst excision, a Roux‐en‐Y hepatojejunostomy, and a cholecystectomy. The postoperative period was without significant complications. The case presented here illustrates the potential outcomes for individuals who present with choledochal cysts during adulthood. Often, these cases present with vague symptoms or as the underlying cause of a more severe condition. This case contributes to the existing knowledge of choledochal cysts by providing insight into the clinical presentation, diagnostic methods, and treatment options. [ABSTRACT FROM AUTHOR]

Acute biliary pancreatitis (ABP) poses significant challenges in determining the optimal timing and approach for cholecystectomy, particularly in mild, moderately severe, and severe forms. This article reviews the existing literature on cholecystectomy timing and its impact on outcomes in ABP. A systematic literature search yielded 41 relevant articles from PubMed and Scopus databases. In mild ABP, early cholecystectomy within 72 hours of onset is increasingly favoured due to reduced technical difficulty and lower risk of recurrent pancreatitis. Conversely, delayed cholecystectomy, although traditionally practiced, may lead to higher recurrence rates and prolonged hospital stays. For moderate severe ABP, evidence remains limited, but early cholecystectomy appears to decrease hospital stay without increasing perioperative complications. In severe ABP, consensus suggests delaying cholecystectomy until peripancreatic collections resolve, typically 6 to 10 weeks post-onset, to minimize surgical morbidity. The role of endoscopic retrograde cholangiopancreatography (ERCP) alongside cholecystectomy remains contentious, with guidelines recommending its use in specific scenarios such as cholangitis or biliary obstruction. However, routine ERCP in mild ABP lacks robust evidence and may increase complications. Challenges persist regarding the management of residual choledocholithiasis post-ABP, highlighting the need for improved diagnostic criteria and management protocols. Overall, this review underscores the evolving landscape of cholecystectomy timing in ABP and provides insights into current best practices and areas for future research. [ABSTRACT FROM AUTHOR]

Cholangiocarcinoma (CCA) is a group of malignant heterogeneous cancer arising from the biliary tree. The tumor is characterized by insidious onset, high degree of malignancy, poor prognosis, and high recurrence rate. Immortalized cancer cell lines are the best and easiest models for in vitro cancer research. Here, we established a naturally immortalized highly tumorigenic hilar cholangiocarcinoma (hCCA) cell line, CBC3T-1. The CBC3T-1 cell line was cultured for over 60 passages. Thorough analysis showed that CBC3T-1 cells share characteristics similar to original tumor cells from patients with cholangiocarcinoma and display a stable phenotype, including features of epithelial origin, stem cell-like properties, as well as a high invasive and migratory capability and tumorigenicity in mice. Furthermore, this cell line showed the best sensitivity to paclitaxel, followed by gemcitabine. RNA sequencing and whole‑exome sequencing showed that cancer-associated pathways and somatic mutations played a dominant role in the development of CCA. We established and characterized a new hCCA cell line, CBC3T-1, which contributes to a better understanding of bile duct cancer, and can be used to study tumorigenesis and progression and the role of anticancer drugs. [ABSTRACT FROM AUTHOR]

Choledochal Cysts (CC), cystic dilatation of biliary tree are an uncommon finding. Generally found in pediatric age group are rarer in adults and commoner in females. They have a relatively greater incidence in a few parts of Asia as compared to the West. Even rarer are Giant Choledochal Cysts (GCC). We successfully treated an adult patient of GCC with an uncommon presentation which is the largest from the Indian subcontinent. [ABSTRACT FROM AUTHOR]

Background: Individual host susceptibility is believed to be a risk factor in the interaction between the host and the parasite. Since studying time series in humans is limited, animal models are replaced. Aim: This study aims to explore and compare the pattern of inflammatory cell types along the biliary tract and their association with proliferative lesions in the early development of CCA from susceptible and non-susceptible animal models. Methods: Thirty male Syrian golden hamsters and 30 BALB/c mice, serving as the susceptible and non-susceptible animal models, were used in this comparative study. The animals were infected with 50 O. viverrini metacercariae via gastric intubation. At days 1, 2, 7, 14, 28, and 56 post-infection (p.i.), five animals were randomly selected from each group and humanely sacrificed. The hepatobiliary tissues were collected and processed for histopathological study. Histochemical and immunohistochemical staining were applied to differentiate the inflammatory cell types. Kruskal-Wallis and Mann-Whitney tests were applied to assess all semi-quantitative and quantitative variables. The correlation between each variable was also analyzed using Spearman rank at a p-value [Open Vet J 2023; 13(9.000): 1150-1166]

Key Clinical Message This case demonstrates an atypical presentation of choledochal cysts (CDCs) and elaborates on the diagnostic challenges encountered when presented with CDCs in adulthood, as it principally presents in children. Abstract A choledochal cyst is a rare congenital anomaly characterized by cystic dilations in the extrahepatic and intrahepatic biliary trees. These cysts are classified according to their location and characteristics. This case study aims to demonstrate how nonspecific clinical features can pose a diagnostic dilemma when presented in adults. Additionally, the case report provides an overview of diagnostic methods and treatment options. In this case, we discuss a 50‐year‐old female who presented with a 2‐ to 3‐day history of severe colicky pain in the right upper quadrant of her abdomen without any other symptoms or abnormal laboratory tests. In addition to ultrasonography evidence of CBD dilation and cholelithiasis, MRCP results confirmed the diagnosis. She underwent surgical intervention involving cyst excision, a Roux‐en‐Y hepatojejunostomy, and a cholecystectomy. The postoperative period was without significant complications. The case presented here illustrates the potential outcomes for individuals who present with choledochal cysts during adulthood. Often, these cases present with vague symptoms or as the underlying cause of a more severe condition. This case contributes to the existing knowledge of choledochal cysts by providing insight into the clinical presentation, diagnostic methods, and treatment options.

Purpose: Identify risk factors for biliary toxicity in patients with colorectal liver metastases who received floxuridine (FUDR) via a surgically implanted hepatic artery infusion pump (HAIP). Describe the incidence of biliary toxicity and evaluate relevant patterns in the biliary toxicity cohort. Methods: A single center, retrospective, case-control study included adult colorectal cancer patients with liver metastases who received at least one cycle of FUDR via a surgically implanted HAIP from 1 January 2017, to 1 October 2021. Patients were excluded if they had incomplete records, cholangiocarcinoma diagnosis, or received concurrent mitomycin and FUDR. Biliary toxicity criteria derived from existing HAIP literature were utilized to determine whether patients experienced biliary toxicity. Multiple variables were compared by univariate statistical analysis between the biliary toxicity and non-biliary toxicity cohorts to identify potential risk factors for development of FUDR-induced biliary toxicity. Results: Out of 50 patients who had a HAIP implanted, 39 met the inclusion criteria. Five of the 39 patients (12.7%) included in the analysis met the pre-specified biliary toxicity criteria. No risk factors for biliary toxicity were identified. All five patients who developed biliary toxicity demonstrated elevations in alkaline phosphatase (ALP) prior to meeting the toxicity criteria. Conclusion: Biliary toxicity remains a significant and therapy-limiting consequence of FUDR administration. Rising ALP may be an early indicator of subsequent biliary toxicity. Future studies with more patients may identify risk factors that can facilitate risk mitigation strategies. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic cholecystectomy is the most common laparoscopic procedure performed in the United States. Our aim was to determine if increased operative time (OT) is associated with increased morbidity following laparoscopic cholecystectomy. Methods: Using ACS NSQIP from 2006 to 2015, we identified all adult (≥18 years) patients that underwent laparoscopic cholecystectomy for cholecystitis performed within 3 days of admission. Our analysis was limited to cases with OT ≥15 minutes and ≤360 minutes. Outcome variables included postoperative surgical site infections (SSI), dehiscence, pneumonia, reintubation, failure to wean from ventilator, pulmonary embolism, renal failure, urinary tract infection, cardiac arrest, myocardial infarct, bleeding, deep vein thrombosis, sepsis, septic shock, return to the operating room, and death. Results: 7,031 cases met inclusion criteria. Median OT was 63 minutes, first quartile was 46 minutes and third quartile was 87 minutes. Logistic regression analysis showed that increased OT (third vs first quartile) was an independent risk factor for superficial SSI (OR 1.75, 95% CI 1.36-2.25, P <.0001), organ-space SSI (OR 1.77, 95% CI 1.33-2.35, P <.0001), dehiscence (OR 2.03, 95% CI 1.01-4.07, P = 0.0470), and septic shock (OR 1.81, 95% CI 1.06-3.09, P = 0.0286). Increased OT was independently associated with increased LOS (fourth vs 1st quartile: IRR 1.53, P < 0.0001; third vs 1st quartile: IRR 1.29, P <.0001; 2nd vs 1st quartile: IRR 1.16, P < 0.0001). Conclusion: Increased OT is independently associated with morbidity and increased LOS following laparoscopic cholecystectomy for cholecystitis. Prospective studies are warranted to determine which factors contribute to increased OT and why. [ABSTRACT FROM AUTHOR]

Background: An increasing body of literature supports subtotal cholecystectomy (STC) in the management of patients with difficult gallbladder anatomy; however, large-scale studies examining outcomes of total cholecystectomy and STC are lacking. Methods: All adults undergoing total cholecystectomy or STC were tabulated from the 2016-2019 Nationwide Readmissions Database. Entropy balancing was performed to adjust for patient differences based on extent of resection. Subsequent multivariable regression models were used to assess the association of STC with major adverse events, postoperative length of stay (pLOS), hospitalization costs, and 30-day non-elective readmission rates. Results: Of an estimated 854 357 patients, 7089 (.8%) underwent STC. Compared to total, STC patients were significantly older, less commonly female, and had a higher Elixhauser Index (all P <.001). Both cohorts had similar rates of postoperative ERCP (1.7% vs 1.5%, P =.33); however, the STC cohort had significantly higher utilization of subsequent drainage procedures (1.8% vs.5%, P <.001). After entropy balancing and multivariable risk-adjustment, STC was not associated with greater odds of MAE (AOR 1.11, 95% CI.99-1.23, P =.06). Notably, relative to total, STC was associated with longer pLOS (β.14, 95% CI.11-.17, P <.001) and greater hospitalization costs (β + $1,900, 95% CI 1300-2,500, P <.001). However, the extent of resection was not associated with the likelihood of 30-day non-elective readmission (AOR 1.01, 95% CI.91-1.13, P =.86). Discussion: Our findings suggest that STC is a viable, yet resource intensive, option in the management of complex cholecystitis. [ABSTRACT FROM AUTHOR]

Neuroendocrine tumours (NETs) are a rare type of tumours that arise from the neuroendocrine cells which are distributed throughout the body. Of all the gastrointestinal tumours only 1–2% account for NETs. They have an extremely low incidence of 0.17% arising in the intrahepatic bile duct epithelium. Majority of hepatic NETs occur as a result of metastases from the primary NETs. Most cases of primary hepatic NET (PHNET) present as a solid nodular mass. However, predominantly cystic PHNET is extremely rare which mimics other cystic space-occupying lesions clinically and radiologically as seen in this case.

Perforations after endoscopic retrograde colangiopancreatography (ERCP) are divided into four types. Type 1 refers to the duodenum, type 2 the periampullary region, type 3 the bile duct itself, and type 4 the observation of retroperitoneal free air on cross-sectional imaging. The treatment of type 2 biliary perforations remains debatable. We present a patient who was successfully treated with a self-expandable metal stent (SEMS) without the need for surgery or any complications. [ABSTRACT FROM AUTHOR]

An aberrant right hepatic duct is a rare congenital anomaly of the biliary system. Failure to recognize these anomalies can result in serious complications. In this case, we present a patient who underwent laparoscopic cholecystectomy for chronic cholecystitis. Post-operatively she developed a bile leak for which she underwent reoperation. On reexploration, she was discovered to have a cystic stump leak and a rare Hisatsugu type V anatomic anomaly of the right hepatic duct originating from the cystic duct. She was subsequently managed with oversewing of the cystic duct stump and drainage. This case demonstrates the importance of recognizing these rare anomalies and the challenges of management in a rural, resource-limited setting. [ABSTRACT FROM AUTHOR]

ABSTRACT BACKGROUND: The prevalence of primary sclerosing cholangitis (PSC) in the general population has not yet been clearly established. The management of PSC should focus on delaying the progression of the disease and restraining its complications. The only curative therapy for the disease remains liver transplantation (LT). PSC is currently the fifth most common indication for LT and corresponds to 5% of all LT indications in adults. AIMS: Our objective is to evaluate the indications and outcomes of PSC patients undergoing LT in three liver transplantation centers in southern Brazil – Hospital Santa Isabel in Blumenau, Santa Catarina state, and Hospital das Clínicas and Hospital Nossa Senhora das Graças, in Curitiba, Parana state). METHODS: This is a longitudinal observational study of patients with PSC who underwent LT in three major Brazilian medical centers. Electronic medical records and study protocols of all patients subjected to LT from January 2011 to December 2021 were retrospectively reviewed. RESULTS: Of the 1,362 transplants performed in the three medical centers, 37 were due to PSC. Recurrence of PSC occurred in three patients (8.1%) in 3.0±2.4 years (range, 1–4 years). The 1-year and 5-year survival rates after the first LT were 83.8 and 80.6%, respectively. The 1-year and 5-year graft survival rates were, respectively, 83.8 and 74.8%. CONCLUSIONS: Our experience with LT in patients with PSC demonstrated good patient and graft survival results. Most deaths were due to common factors in patients undergoing LT.

BackgroundHereditary Spherocytosis (HS) is a rare, congenital red blood cell disorder presenting with variable clinical manifestations ranging from mild hemolytic anemia to severe anemia with hypersplenism and hepatobiliary complications.MethodsThe objectives of the study were to evaluate the diagnostic pathway of HS, the presence and management of hepatobiliary complications in pediatric patients with HS followed in a tertiary care center. The demographic, clinical, hematological information were retrieved from medical records of patients having at least 1 hematology visit between 2010 and 2020.ResultsForty-two patients were enrolled, 23 M. Mean age at onset of symptoms was 2.8 years, at diagnosis was 3.5 years. Anemia was the first manifestation in 73%; suspect of HS arose for all patients in first or second level outpatient clinics. Only 64% of patients performed two confirmation tests in the reference center. 28/42 had familiarity for HS; of the 13/42 who did not, only 47% performed further analysis. Sixteen patients developed gallbladder stones (40%), visible at the first ultrasound (5.6 years). Hemolytic crises and parvovirus infections were more frequent in patients with stones (53.6% vs. 26.1% and 63.6% vs. 28.6%, respectively). 10/16 (62.5%) underwent elective cholecystectomy: 8 had concomitant splenectomy.Conclusionsour study highlights the need to optimize the diagnostic pathway in networks of care involving general and specialized centers in order to reduce time to diagnosis and ensure that all patients receive confirmatory tests. A high frequency of hepatobiliary complications since young age was observed suggesting that screening with ultrasound should begin earlier

Background: Mucinous cystic neoplasms of the liver (MCN-L) including biliary cystadenomas (BCA) and biliary cystadenocarcinomas (BCAC) are rare cystic lesions that comprise less than 5% of all liver cysts and affect only a small subset of individuals. We herein review the current evidence regarding the clinical presentation, imaging characteristics, tumor markers, pathological findings, clinical management, and prognosis of MCN-L. Methods: A comprehensive review of the literature was performed using MEDLINE/Pubmed and Web of Science databases. In PubMed, the terms "biliary cystadenoma," "biliary cystadenocarcinoma," and "non parasitic hepatic cysts" were queried to identify the most recent data on MCN-L. Results: US imaging, CT, and MRI, as well as consideration of clinicopathological features, are required to appropriately characterize and diagnose hepatic cystic tumors. BCA are premalignant lesions and cannot be reliably differentiated from BCAC based on imaging alone. As such, both types of lesions should be treated with margin-negative surgical resection. Following surgical resection, recurrence is fairly low among patients with BCA and BCAC. Despite having worse long-term outcomes than BCA, the prognosis following surgical resection of BCAC still remains more favorable than other primary malignant liver tumors. Conclusion: MCN-L are rare cystic liver tumors that include BCA and BCAC, which can be difficult to differentiate based on imaging alone. Surgical resection remains the mainstay of management for MCN-L with recurrence being generally uncommon. Future multi-institutional studies are still required to better understand the biology behind BCA and BCAC to improve the care of patients with MCN-L. [ABSTRACT FROM AUTHOR]

Background: During a laparoscopic cholecystectomy, the critical view of safety is obtained through dissection of the gallbladder from the liver until there is anterior and posterior visualization of the cystic duct and cystic artery. This view is used to allow for proper identification of the cystic duct and artery that will be clipped and incised during the operation. Indocyanine green (ICG) can be used during the operation to directly visualize the biliary tract because of its excretion through the biliary system and elimination via the GI tract. Using a laparoscope capable of visualizing ICG allows for identification of bile duct anatomy to include: common hepatic bile duct, cystic duct, and aberrant, or accessory bile ducts. Additionally, visualization of the biliary structures using ICG prior to clipping and incision will allow for identification and prevention of missed biliary anatomy which could reduce incidence of bile leak, a known complication of cholecystectomies. We propose that visualization of the critical view of safety with ICG fluoroscopy be termed the critical view of safety plus. Purpose: We hypothesized that using the critical view of safety plus method for laparoscopic cholecystectomy will yield better scores and increase the decision of the control surgeon to choose to cut and proceed with the operation when compared with the traditional critical view of safety. Research Design: Comparision of operative photos of critical view of safety and critical view of safety plus which were randomized, double blinded, and graded by a single control surgeon. Study Sample: Our study consisted of fifty patients of which 72% female (n = 36) and 28% male (n = 14). The ethnic background included 76% non-Hispanic (n = 38) and 24% Hispanic or of Latino/a origin (n = 12). The average age of our patient was 49 years old (range 20 to 93 years old). Inclusion criteria consisted of patients undergoing laparoscopic cholecystectomy greater than or equal to 18 years old. Exclusion criteria included allergy to indocyanine dye or iodine and pregnancy. Analysis: The scores were evaluated using Chi-squared and paired T-test analysis using MedCalc, MedCalc Sofware Ltd, Belgium. Results: The decision to cut and proceed with the operation was chosen 29 times (58%) when viewing the critical view of safety plus vs 22 times (44%) with the critical view of safety (χ2 = 65.822, p < 0.0001). The decision to proceed with further dissection to isolate the cystic duct viewing the critical view of safety plus was chosen 8 times (16%) vs 11 times (22%) with critical view of safety (χ2 = 65.822, p < 0.0001) as shown in Fig. 2. The comparison of total scores with critical view of safety plus vs critical view of safety showed an average of 4.36 vs 4.04, p = 0.0733. The critical view of safety plus and critical view of safety individual criteria scores are: "two structures connected to the gallbladder" (average 1.54 vs 1.50, p = 0.598), "cystic plate clearance" (average 1.42 vs 1.28, p = 0.018), and "hepatocystic triangle clearance" (average 1.4 vs 1.26, p =0.0334). Conclusion: We recommend routine use of ICG fluoroscopy to obtain the critical view of safety plus to allow for improved visualization of the biliary tree, identification of aberrant biliary anatomy, and the potential to reduce risk of bile duct injury. [ABSTRACT FROM AUTHOR]

Autoimmune liver disease is an important immune-mediated pathologic entity involving the liver and intrahepatic bile duct, including autoimmune hepatitis, primary biliary cholangitis, and primary sclerosing cholangitis. Although it is necessary to ascertain its presence in acute or chronic liver disease without common causes, it is not easy to diagnose this disease straightforwardly because of its rarity. Recently, the incidence and prevalence of autoimmune hepatitis and primary biliary cholangitis have increased in several regions. In contrast, there is limited data dealing with the trend of the epidemiology of primary sclerosing cholangitis worldwide. Physicians should consider the epidemiologic characteristics of autoimmune liver disease because early diagnosis and proper treatment might prevent the progression of advanced liver disease. In addition, more sophisticated epidemiologic studies will be needed to elucidate the trend of these rare diseases nationwide.

Primary biliary cholangitis (PBC) is an autoimmune disease prevalent in middle-aged women and characterized by chronic cholestasis. PBC is diagnosed when at least two of the following three criteria are met: elevated alkaline phosphatase, presence of PBC-specific autoantibodies such as the anti-mitochondrial antibody or PBC-specific anti-nuclear antibodies, and non-suppurative inflammation of the interlobular bile duct after excluding other causes including drugs and biliary obstruction. The first-line treatment for PBC is ursodeoxycholic acid (UDCA, 13-15 mg/kg/day). The response to UDCA is predictive of long-term prognosis and should be evaluated 6-12 months after the UDCA treatment. The second-line treatments for PBC recommended due to an inadequate response to UDCA include obeticholic acid and fibrates. Symptoms and complications, including pruritus, sicca syndrome, and osteoporosis, should be evaluated and appropriately managed.

Background: In surgically high-risk patients with acute cholecystitis (AC), percutaneous cholecystostomy (PC) is an effective procedure. This study aimed to study the clinical outcomes of PC and to assess predictors for recurrence following PC placement. Methodology: A retrospective data review of all patients who underwent a PC for AC between 2010 and 2020 was performed. Results: Seventy-one patients underwent a PC with a mean age of 61.35 years (standard deviation: 14.11); 59 (83.1%) were male; 32 (45.1%) were the American Society of Anesthesiologists III and IV. Forty (56.3%) patients had multiple comorbid illnesses; 70 (98.6%) patients had Grade 2, 3 cholecystitis. All patients had ultrasound-guided drainage; 63 (88.7%) had transhepatic route. The mean duration till PC removal was 51.58 (1–313) days. Eleven (15.5%) patients developed recurrence after PC placement over a median of 40 (29–102) days; 6 (54.5%) were managed nonoperatively, 3 (27%) underwent laparoscopic cholecystectomy, and 2 (18%) developed cholangitis. After index admission with AC managed by PC, thirty-nine (54.9%) patients underwent cholecystectomy; 4(5.6%) at the index admission, 35 (49.3%) elective interval cholecystectomies. The rate of conversion to open at interval cholecystectomy among patients with no recurrence in the interval period was 31.88% (7/22), and 50% for patients with recurrent AC. Five (7.04%) patients had mortality at the index admission, and the overall 1-year mortality was 8.45% (6/71). Conclusion: A high clinical success rate and less procedure-related morbidity make PC a favorable procedure in surgically high-risk patients. Patients with a recurrent episode of AC were found to have higher rates of conversion at interval cholecystectomy. No specific predictor for recurrence was identified.

Abstract Background Aberrant cytokeratin 7 expression by hepatocytes (CK7+Hs) is the hallmark characteristic of cholestasis diseases, especially in ductopenia diseases such as primary biliary cholangitis (PBC). This study attempted to evaluate the differences and relationships between the clinical and histological features of aberrant cytokeratin 7 (CK7) expression by hepatocytes in PBC patients. Methods The clinicopathological data of patients diagnosed with PBC at the Second Hospital of Nanjing between January 2016 and September 2018 were analysed with SPSS 20.0. Results Eighty-nine PBC patients who underwent liver biopsy were enrolled in this study, and 15, 29 and 45 patients had aberrant CK7 expression by hepatocytes (CK7+Hs (2 +), CK7+Hs (1 +), and CK7−Hs, respectively). There were significant differences in TB, DB, ALP, TA, IgM, interface activity, and ductopenia grade between patients with CK7−Hs and CK7+Hs (2 +) (P