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Therapeutic endoscopic ultrasound (EUS) encompasses an array of procedures to manage pancreaticobiliary and luminal gastrointestinal disorders. Therapeutic EUS procedures include EUS-guided rendezvous of the pancreatic and biliary ducts, as well as direct drainage of the bile duct, pancreatic duct, and gallbladder, drainage of pancreatic fluid collections, and luminal anastomosis creation. These procedures have a range of required equipment, approaches, clinical outcomes, and adverse events dependent on both procedure-related and patient-related factors. In expert hands, these procedures provide patients with less invasive options and can achieve excellent clinical outcomes., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Interventional radiologists are an important part of a multidisciplinary team for the management of patients with biliary disease. Minimally invasive image-guided procedures can diagnose, temporize, and treat patients presenting with a broad spectrum of disease, including acute, chronic, benign, and malignant etiologies. In certain cases, interventional radiologists may provide definitive therapy for this often-difficult patient population. Effective treatment of patients with biliary disease is predicated on cooperation and collaboration of a multidisciplinary team working together providing optimal treatment to achieve positive outcomes., Competing Interests: Disclosure The author has nothing to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

PURPOSE OF REVIEW: In this review, we aim to summarize the existing literature and future directions on the use of artificial intelligence (AI) for the diagnosis and treatment of PB (pancreaticobiliary) disorders. RECENT FINDINGS: AI models have been developed to aid in the diagnosis and management of PB disorders such as pancreatic adenocarcinoma (PDAC), pancreatic neuroendocrine tumors (pNETs), acute pancreatitis, chronic pancreatitis, autoimmune pancreatitis, choledocholithiasis, indeterminate biliary strictures, cholangiocarcinoma and endoscopic procedures such as ERCP, EUS, and cholangioscopy. Recent studies have integrated radiological, endoscopic and pathological data to develop models to aid in better detection and prognostication of these disorders. AI is an indispensable proponent in the future practice of medicine. It has been extensively studied and approved for use in the detection of colonic polyps. AI models based on clinical, laboratory, and radiomics have been developed to aid in the diagnosis and management of various PB disorders and its application is ever expanding. Despite promising results, these AI-based models need further external validation to be clinically applicable., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background and Aim: Rapidly aging societies have become a major issue worldwide including Japan. This study aimed to elucidate relative changes in the characteristics of inpatients in Japan related to this issue., Methods: A total of 23 835 Japanese inpatients treated from 2010 to 2021 were enrolled (2010-2013, period I; 2014-2017, period II; 2018-2021, period III). Changes in clinical features were retrospectively analyzed based on ICD-10 diagnosis data., Results: The percentage of patients aged over 75 years increased over time (period I, 38.0%; II, 39.5%, III, 41.4%). Emergency admissions comprised 27.5% of all in period I, which increased to 43.2% in period II and again to 44.5% in period III (P < 0.001). In period I, gastrointestinal disease, liver disease, pancreatic-biliary disease, and other disease types were noted in 47.4%, 29.5%, 19.2%, and 3.9%, respectively, while those values were 44.0%, 18.0%, 33.9%, and 4.1%, respectively, in period III (P < 0.001). The frequency of liver disease decreased by approximately 0.6-fold from periods I to III, while that of biliary-pancreatic disease increased by approximately 1.8-fold during that time. Both percentage and actual numbers of patients with biliary-pancreatic disease increased during the examined periods. Analysis of changes in the proportion of organs affected by malignancy during periods I, II, and III showed a marked increase in cases of biliary-pancreatic malignancy (11.6%, 19.5%, 26.6%, respectively) (P < 0.001)., Conclusion: In association with the rapidly aging Japanese society, there has been an increasing frequency of biliary-pancreatic disease cases requiring hospitalization for treatment in the west Japan region of Shikoku., (© 2024 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Bile leaks arise from various causes such as trauma, complications after hepatobiliary surgery, and intrahepatic malignancies or their associated liver-directed treatments. Bile leaks can result in significant morbidity and mortality. Delayed diagnosis is not uncommon due to nonspecific manifestations; therefore, a high clinical suspicion is needed. A multidisciplinary approach for treatment of biliary leaks with prompt referral to tertiary care centers with experienced hepatobiliary surgeons, advanced endoscopists, and interventional radiologists is needed to address these challenging complications. Management of biliary leaks can range from conservative management to open surgical repair. Minimally invasive procedures play a crucial role in biliary leak treatment, and the interventional radiologist can help guide appropriate management on the basis of a clear understanding of the pathophysiology of biliary leaks and a current knowledge of the armamentarium of treatment options. In most cases, a simple diversion of bile to decompress the biliary system may prove effective. However, persistent and high-output biliary leaks require delineation of the source with tailored treatment options to control the leak. This may be done by additional diversions, occluding the source, reestablishing connections, or using a combination of therapies to bridge to more definitive surgical interventions. The authors describe the different treatment options and emphasize the role of interventional radiology. © RSNA, 2024.

Objectives: No study has explored whether availability of endoscopic retrograde cholangiopancreatography (ERCP) is adequate and equitable across US children's hospitals. We hypothesized that ERCP availability and utilization differs by geography and patient factors., Methods: Healthcare encounter data from 2009 to 2019 on children with pancreatic and biliary diseases from the Pediatric Health Information System were analyzed. ERCP availability was defined as treatment at a hospital that performed pediatric ERCP during the year of service., Results: From 2009 to 2019, 37,946 children (88,420 encounters) had a potential pancreatic or biliary indication for ERCP; 7066 ERCPs were performed. The commonest pancreatic diagnoses leading to ERCP were chronic (47.2%) and acute pancreatitis (43.2%); biliary diagnoses were calculus (68.3%) and obstruction (14.8%). No ERCP was available for 25.0% of pancreatic encounters and 8.1% of biliary encounters. In multivariable analysis, children with public insurance, rural residence, or of Black race were less likely to have pancreatic ERCP availability; those with rural residence or Asian race were less likely to have biliary ERCP availability. Black children or those with public insurance were less likely to undergo pancreatic ERCP where available. Among encounters for calculus or obstruction, those of Black race or admitted to hospitals in the West were less likely to undergo ERCP when available., Conclusions: One-in-four children with pancreatic disorders and one-in-12 with biliary disorders may have limited access to ERCP. We identified racial and geographic disparities in availability and utilization of ERCP. Further studies are needed to understand these differences to ensure equitable care., (© 2024 The Authors. Journal of Pediatric Gastroenterology and Nutrition published by Wiley Periodicals LLC on behalf of European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.)

The progress of endoscopic diagnosis and treatment for inflammatory diseases of the biliary tract and pancreas have been remarkable. Endoscopic ultrasonography (EUS) and EUS-elastography are used for the diagnosis of early chronic pancreatitis and evaluation of endocrine and exocrine function in chronic pancreatitis. Notably, extracorporeal shock wave lithotripsy and electrohydraulic shock wave lithotripsy have improved the endoscopic stone removal rate in patients for whom pancreatic stone removal is difficult. Studies have reported the use of self-expanding metal stents for stent placement for pancreatic duct stenosis and EUS-guided pancreatic drainage for refractory pancreatic duct strictures. Furthermore, EUS-guided drainage using a double-pigtailed plastic stent has been performed for the management of symptomatic pancreatic fluid collection after acute pancreatitis. Recently, lumen-apposing metal stents have led to advances in the treatment of walled-off necrosis after acute pancreatitis. EUS-guided biliary drainage is an alternative to refractory endoscopic biliary drainage and percutaneous transhepatic biliary drainage for the treatment of acute cholangitis. The placement of an inside stent followed by switching to uncovered self-expanding metal stents in difficult-to-treat cases has been proposed for acute cholangitis by malignant biliary obstruction. Endoscopic transpapillary gallbladder drainage is an alternative to percutaneous transhepatic gallbladder drainage for severe and some cases of moderate acute cholecystitis. EUS-guided gallbladder drainage has been reported as an alternative to percutaneous transhepatic gallbladder drainage and endoscopic transpapillary gallbladder drainage. However, it is important to understand the advantages and disadvantages of each drainage method and select the optimal drainage method for each case., (© 2024 Japan Gastroenterological Endoscopy Society.)

Liver transplantation is a technically demanding surgical procedure with known complications, and the optimal approach to addressing vascular and biliary complications requires a coordinated effort between surgical and interventional radiology teams. Vascular complications involving the hepatic artery, portal vein, or hepatic veins can be characterized by their mechanism, chronicity, and timing of presentation. These factors help determine whether the optimal therapeutic approach is surgical or endovascular. Very early presentation in the perioperative period favors surgical revision, while later presentation is best addressed endovascularly. Biliary complications can be categorized as leaks or strictures, and coordinated surgical, endoscopic, and percutaneous management is needed to address these types of complications. Through advances in technique and the management of complications, outcomes after liver transplantation continue to improve., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Liver transplantation (LT) is the only curative therapy in patients with end-stage liver disease. Long-term survival is excellent, yet LT recipients are at risk of significant complications. Biliary complications are an important source of morbidity after LT, with an estimated incidence of 5%-32%. Post-LT biliary complications include strictures (anastomotic and non-anastomotic), bile leaks, stones, and sphincter of Oddi dysfunction. Prompt recognition and management is critical as these complications are associated with mortality rates up to 20% and retransplantation rates up to 13%. This review aims to summarise our current understanding of risk factors, natural history, diagnostic testing, and treatment options for post-transplant biliary complications., Competing Interests: Competing interests: TS: CSA Medical research advisory board, Allergen research support, Research support Lucid., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Complementary to percutaneous intra-abdominal drainage, percutaneous transhepatic biliary drainage (PTBD) might ameliorate healing of pancreatic fistula and biliary leakage after pancreatoduodenectomy by diversion of bile from the site of leakage. This study evaluated technical and clinical outcomes of PTBD for this indication., Methods: All patients undergoing PTBD for leakage after pancreatoduodenectomy were retrospectively evaluated in two tertiary pancreatic centers (2014-2019). Technical success was defined as external biliary drainage. Clinical success was defined as discharge with a resolved leak, without additional surgical interventions for anastomotic leakage other than percutaneous intra-abdominal drainage., Results: Following 822 pancreatoduodenectomies, 65 patients (8%) underwent PTBD. Indications were leakage of the pancreaticojejunostomy (n = 25; 38%), hepaticojejunostomy (n = 15; 23%) and of both (n = 25; 38%). PTBD was technically successful in 64 patients (98%) with drain revision in 40 patients (63%). Clinical success occurred in 60 patients (94%). Leakage resolved after median 33 days (IQR 21-60). PTBD related complications occurred in 23 patients (35%), including cholangitis (n = 14; 21%), hemobilia (n = 7; 11%) and PTBD related bleeding requiring re-intervention (n = 4; 6%). In hospital mortality was 3% (n = 2)., Conclusion: Although drain revisions and complications are common, PTBD is highly feasible and appears to be effective in the treatment of biliopancreatic leakage after pancreatoduodenectomy., (Copyright © 2021 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

The history of ascariasis is very old. It is endemic in various parts of Bangladesh. Hepatobiliary ascariasis is a well-known complication of the intestinal ascariasis. Although cosmopolitan, it predominantly affects people in Asia, Africa, and South America. This was a prospective observational study conducted from July to December 2014 to explore the short term outcome of therapeutic ERCP in the treatment of biliary ascariasis in a tertiary care hospital of Bangladesh. A total of 60 cases of biliary ascariasis were selected conveniently in this study. Data were collected by face-to-face interviews and observation with the help of data sheet. Data were checked for quality control and analyzed by computer using SPSS software. The mean±SD age of the patients was 30.96±7.66 years. All the patients were aged between 17 and 55 years and predominantly affect women in the 3rd and 4th decades. The most common presentation was upper abdominal pain in 47(83.32%) of the patients. Ultrasound was the diagnostic tool of choice, where biliary ascariasis was found in 40(66.7%) of patients. ERCP is reserved mainly for therapeutic purposes and found successful in 57(95%) of the patients.

Rationale: Plastic endobiliary stents, after endoscopic retrograde cholangiopancreatography, can get spontaneously dislocated from the common bile duct and migrate intothe distal bowel. Most migrated biliary stents are removed with the passing of stool. However, migrated biliary stents can cause bowel perforation, albeit rarely, and surgical intervention may be required. Recently, we observed a colonic diverticular perforation caused by a migrated biliary stent, and we have reported this case with a review of the literature., Patients Concerns: A 74-year-old man presented with severe right lower quadrant pain after biliary stent insertion 1month ago., Diagnoses: Abdominal computed tomography revealed perforation of the proximal ascending colon by the migrated biliary stent, combined with localized peritonitis., Interventions: Emergency diagnostic laparoscopic examination revealed penetration of the proximal ascending colon by the plastic biliary stent, and right hemicolectomy was performed., Outcomes: On pathological examination, colonic diverticular perforation by the biliary stent was confirmed. The patient was discharged without any additional complications., Lessons: Endoscopic retrograde cholangiopancreatography endoscopists must always be cautious of the possibility of stent migration in patients with biliary stents in situ. In cases of biliary stent dislocation from the common bile duct in asymptomatic patients, follow-up with serial, plain abdominal radiographs, and physical examination is needed until confirmation of spontaneous passage through stool. In symptomatic cases suggesting peritonitis, abdominal computed tomography scan confirmation is needed, and early intervention should be considered., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Abstract: Biliary complications (BC) especially stenosis and strictures are the most common complications after orthotropic liver transplantation (OLT) procedure in adult recipients. The intention of this study was analyzed BC in 273 patients after OLT for the last 4 years in our department.Retrospective study of 273 patients underwent cadaveric donor liver transplantation between January 2014 and December 2017. Most of them (n = 268) have anastomosed bile duct in end to end, rest of them (n = 5) underwent hepaticojejunostomy. Statistical analysis was performed using Fischer exact test and Student t test. A P value <.05 was considered significant.BC were developed in 48/273 transplants (17.6%). The most frequent was biliary stricture (n = 42, 87.5%) followed by bile leak (n = 4, 8.3%) and choledocholitiasis (n = 2, 4.2%). Treatment was usually using endoscopic retrograde cholangiopancreatography. Recipients with hypotension during and after OLT treated by norepinephrine have a higher index of BC.Self-expanding metal stents implantation seems to be more effective than repeated balloon dilatation of anastomotic strictures with subsequent plastic biliary stent placement and associated with similar complication rate. Good fluid management against inotropic therapy may reduce risk of BC., Competing Interests: The authors have no conflicts of interests to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

The application of artificial intelligence (AI) in medicine has increased rapidly with respect to tasks including disease detection/diagnosis, risk stratification, and prognosis prediction. With recent advances in computing power and algorithms, AI has shown promise in taking advantage of vast electronic health data and imaging studies to supplement clinicians. Machine learning and deep learning are the most widely used AI methodologies for medical research and have been applied in pancreatobiliary diseases for which diagnosis and treatment selection are often complicated and require joint consideration of data from multiple sources. The aim of this review is to provide a concise introduction of the major AI methodologies and the current landscape of AI research in pancreatobiliary diseases., (© 2021 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Background and Objective: Acute pancreatitis is one of the most common gastrointestinal conditions requiring hospitalization. Even though its presentation during pregnancy is uncommon, it is a medical challenge. Currently, no studies compare the clinical outcomes between pregnant patients with acute pancreatitis and nonpregnant patients with acute pancreatitis. Our aim was to compare the characteristics and clinical outcomes of pregnant and nonpregnant women with acute pancreatitis., Methods: We conducted a retrospective study that included all patients admitted to our hospital with acute pancreatitis over a 10-year period. Demographics, general characteristics, and clinical outcomes were evaluated and compared between pregnant and nonpregnant women with acute pancreatitis, at a ratio of 1:5., Results: Over 10 years, 27 pregnant patients with acute pancreatitis were treated. Etiology was biliary in 96% and hypertriglyceridemia was the cause in 3.4% (1 patient). The mean patient age was 26.2 years (range 15-36 years). The main cause of acute pancreatitis was biliary disease (96%). Patients in the study group were in their first, second, or third trimester of pregnancy, at 7.4%, 33.3%, and 59.3%, respectively. In the comparison of pregnant versus nonpregnant patients with acute pancreatitis, there were no differences in age, hospital stay (7.37 vs. 10.8, P=.814), severity (severe 3.7% vs. 16.7%, P=.79), local complications (0% vs. 1.9%, P=.476), or mortality (0% vs. 1.9%, P=.476)., Conclusions: The clinical evolution of both groups with biliary acute pancreatitis was similar, with low morbidity and mortality., (Publicado por Masson Doyma México S.A.)

Besides the adverse effects associated with endoscopic retrograde cholangiopancreatography (ERCP), indirect visualization of the biliopancreatic system through fluoroscopy has limited its diagnostic and therapeutic efficacy. Direct visualization through cholangiopancreatoscopy may overcome this limitation and allow the resolution of many dilemmas related to the diagnostic and therapeutic drawbacks of ERCP. Herein, we discuss the current indications of single-operator cholangioscopy (SOC) concerning the diagnostic interventions within the biliopancreatic system. The current role of SOC in the diagnosis of pancreatobiliary stenosis, primary sclerosing cholangitis, intraductal papillary mucinous neoplasm, and pre-surgical mapping of neoplastic lesions were reviewed. There is growing data in the literature supporting the early implementation of SOC in the diagnostic algorithm of pancreatobiliary diseases. In selected cases, this could prevent diagnostic delay and reduce the risks and costs related to repeated ERCPs. This potential characterizes SOC as safety and cost-effective.

Liver and biliary pathology in the neonate are rare and include a broad range of structural, neoplastic, infectious, genetic, and metabolic diseases. While most conditions present postnatally, antenatal detection is increasing given recent advances in antenatal imaging capabilities. In certain structural or obstructive liver diseases, antenatal detection now proves essential to help guide treatment and prevent morbidity. We review the epidemiology, pathophysiology, common antenatal diagnostic findings, and recommendations for surgical liver and biliary pathology in the neonate., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Biliary diseases are common digestive system disorders which may combine with biliary tract infection such as cholecystitis or cholangitis. Thus, rapid identification of the bacteria and their antibiotic susceptibility profiles are crucial for reducing the mortality of patients with biliary tract infection., Aim: To identify bacterial species and antibiotic susceptibility for antibacterial therapy and analyze bile cultivation risk factors for increasing detection rates., Methods: This retrospective study was conducted from July 2008 to July 2017. In total, 1339 bile samples which were collected during therapeutic endoscopic retrograde cholangiopan-creatography or percutaneous transhepatic cholangiodrainage or other biliary surgeries or biliary drainage were obtained to characterize pathogen spectra, antibiotic susceptibility, and clinical features. Clinical data including age, sex, comorbidities, clinical symptoms, protopathies, and history of biliary tract diseases and surgeries were collated from hospital medical records. Species identification and initial drug susceptibility were further identified by biochemical characterization using the VITEK 2 Compact test., Results: Positive microbiological findings were observed in 738 samples. The most frequently encountered strains were gram-negative bacteria (74.94%), including Escherichia coli (37.78%), Pseudomonas aeruginosa (8.96%), and Klebsiella pneumoniae (10.29%). Bile bacteria were largely sensitive to carbapenems, piperacillin/tazobactam, and gentamicin. Gram-negative strains had low susceptibility to ceftriaxone, quinolones and ampicillin. Almost the same micro-organisms were present in patients with malignant and benign diseases. The number of samples with Klebsiella pneumoniae in the bile culture were significantly different between patients with malignant and benign diseases (55 vs 30; P = 0.019). Age ( P < 0.001), fever ( P < 0.001), history of biliary tract diseases and surgeries (both P < 0.001), benign disease ( P = 0.002), and the comorbidity chronic renal insufficiency ( P = 0.007) affected the positive rates of the bile samples., Conclusion: Gram-negative bacteria were the most commonly isolated biliary bacteria. We determined the major factors associated with positive detection rates. Microbiological analysis of bile samples allowed accurate antibiotic treatments., Competing Interests: Conflict-of-interest statement: The authors declare no conflicts of interest., (©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.)

Ischaemic cholangiopathy occurs as a consequence of deficient arterial blood flow to the bile duct wall. Bile duct ischaemia can lead to full-thickness necrosis, bile leakage, biloma formation, and sepsis. It is an important cause of graft failure post-orthotopic liver transplantation. In the native liver, the causes of biliary ischaemia are diverse and include vasculitis or a complication of endovascular procedures. The present review describes the pathology and radiological findings of ischaemic cholangiopathy and outlines the role of interventional radiology in its management., (Copyright © 2019 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Hepatobiliary complications are frequent in the context of allogeneic hematopoietic cell transplantation (allo-HCT) and contribute largely to the morbidity and mortality after transplantation. Within the framework of the ninth workshops of practice harmonization of the Francophone Society of Bone Marrow Transplantation and Cellular Therapy (SFGM-TC) held in Lille in September 2018, diagnostic approaches and treatments of hepatobiliary dysfunctions prior to and following transplantation were reviewed according to the analysis of published studies., (Copyright © 2019 Société Française du Cancer. Published by Elsevier Masson SAS. All rights reserved.)

Idiopathic portal hypertension (IPH) and extrahepatic portal venous obstruction (EHPVO) are prototype noncirrhotic causes of portal hypertension (PHT), characterized by normal hepatic venous pressure gradient, variceal bleeds, and moderate to massive splenomegaly with preserved liver synthetic functions. Infections, toxins, and immunologic, prothrombotic and genetic disorders are possible causes in IPH, whereas prothrombotic and local factors around the portal vein lead to EHPVO. Growth failure, portal biliopathy, and minimal hepatic encephalopathy are long-term concerns in EHPVO. Surgical shunts and transjugular intrahepatic portosystemic shunt resolve the complications secondary to PHT. Meso-Rex shunt is now the standard-of-care surgery in children with EHPVO., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose of Review: At present, balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography (ERCP) is the mainstay of therapy for benign biliary diseases in patients with surgically altered anatomy (SAA). Recently interventional endoscopic ultrasonography (EUS) techniques have been used for not only drainage procedure but also treatment procedure in such patients. This review aims to discuss details about interventional EUS techniques in such patients and published clinical data., Recent Findings: Antegrade treatment such as antegrade stone removal for bile duct stones or guidewire manipulation across the anastomotic stricture following antegrade balloon dilation and antegrade stenting for the stricture via the approach route created by EUS-bilioenterostomy, so-called EUS-guided antegrade intervention, have been developed. In difficult cases, per-oral cholangioscopy-assisted antegrade intervention has been reported as a useful technique. In addition, other novel alternative interventional EUS techniques have been also reported such as EUS-directed transgastric ERCP in patients with Roux-en-Y gastric bypass., Summary: Interventional EUS techniques appear to be feasible and safe alternative procedures for benign biliary diseases in patients with SAA after balloon enteroscopy-assisted ERCP failure.

Endoscopy is an underutilized technique in the practice of interventional radiology. The objectives of this article are to discuss potential uses of interventional radiology-operated endoscopy and to outline basic endoscopy setup and equipment uses. Endoscopy represents a new frontier to the fluoroscopically-guided procedures in biliary, gastrointestinal, and genitourinary disease that interventional radiologists commonly perform. It shows promise to improve interventional radiology procedure success rates and reduce procedure-associated risk for patients. Endoscopy has been traditionally performed by gastroenterologists and urologists and is relatively new in the practice of interventional radiology. The hand-eye coordination and manual dexterity required to perform standard image-guided procedures places interventional radiologists in a unique position to introduce endoscopy into standard practice. A focused and collaborative effort is needed by interventional radiologists to learn the techniques required to successfully integrate endoscopy into practice., (Published by Elsevier Inc.)

Purpose: There is a lack of experience with stenting for benign pancreaticobiliary disorders in children. Materials and Methods: Fifteen children (9 male and 6 female) with a median age of 7.1 years (range 0.7-14.2 years) who underwent treatment with a plastic stent for a benign disorder of the pancreaticobiliary system between May 2003 and September 2017 were recruited to this retrospective study. Results: Biliary and/or pancreatic plastic stents were inserted into 5 patients with congenital, 4 with post-traumatic, and 6 with idiopathic pathologies. Median duration of individual stent placement was 111 days (range 14-1569 days). Eleven children (73%) were treated with one stent only. In 4 cases, up to 22 stents were successively placed over time. There were no complications during stent insertion or stent removal. Seven patients (47%) experienced adverse effects during stenting, including choledocholithiasis, pancreaticolithiasis, cholangitis, acute pancreatitis, stent obstruction, and stent fracture. At follow-up, in 11 cases (73%), the underlying condition was resolved. In 4 children, all of whom suffered from congenital pancreaticobiliary disorders, stent therapy was considered as a temporary treatment before definite surgery. Conclusions: Patients with congenital anomalies of the pancreaticobiliary tree often require surgery for definitive management. However, temporary stent placement can be accomplished safely and successfully and this serves as a bridge to temporize their obstructive process while awaiting surgical intervention. Children with post-traumatic or idiopathic disorders can frequently be managed definitively by stenting alone and many of these require only one single stent insertion.

The management of autoimmune hepatobiliary disorders remains a challenging and emerging area of investigation. An awareness of cholestatic liver diseases is critical to appropriate recognition and management of these challenging diseases, because patients often present asymptomatically, and diagnosis is limited by the lack of disease-specific markers and diagnostic studies. Furthermore, there is a paucity of treatment options because the pathophysiology underlying autoimmune biliary diseases remains largely unknown. This article discusses the natural history, clinical presentation, diagnosis, and medical and surgical management strategies for three dominant autoimmune biliary diseases: primary biliary cirrhosis, primary sclerosing cholangitis, and immunoglobulin G4-related hepatobiliary disease., (Published by Elsevier Inc.)

Objective:: To evaluate the factors affecting the length of hospital stay (LOS) after percutaneous transhepatic biliary drainage (PTBD)., Methods:: A retrospective review of all patients who had undergone PTBD with or without stenting at a UK specialist centre between 2005 and 2016 was conducted., Results:: 692 patients underwent 1976 procedures over 731 clinical episodes for which, the median age was 65 (range 18-100) years, and the median Charlson Index was 3. PTBD was performed for malignant (n = 563) and benign strictures (n = 60), stones (n = 62), and bile leaks (n = 46). The median LOS was 13 (range 0-157) days, and the median interprocedure duration was 9 (range 0-304) days. The median number of procedures per patient was 2 and the median number of days required to complete a set of procedures for a patient (TBID) ranged from 0 to 557 days, with a median of 16 (interquartile range: 8-32) days. Patients with biliary leak had the highest LOS. Biliary stents were mostly placed at the second stage at a median of 6 (range 0-120) days from the first procedure day. Placement of a biliary stent in the first stage of the procedure was associated with shorter LOS (p < 0.001)., Conclusions:: Biliary stenting at index procedure reduces LOS, although it is not always technically possible. Patients with bile leak managed with PTBD have longer LOS., Advances in Knowledge:: This study provides data which can help in appropriate consenting, better planning, and efficient resource utilization for patients undergoing PTBD.

The most effective and fundamental treatment for end-stage liver disease is liver transplantation. Deceased-donor liver transplantation has been performed for many of these cases. However, living-donor liver transplantation (LDLT) has emerged as an alternative because it enables timely procurement of the donor organ. The success rate of LDLT has been improved by development of the surgical technique, use of immunosuppressant drugs, and accumulation of post-transplantation care experience. However, the occurrence of biliary stricture after LDLT remains a problem. This article reviews the pathogenesis, diagnosis, endoscopic management, and long-term outcomes of post-liver transplantation biliary stricture, with a focus on anastomotic stricture.

The two most relevant endoscopic treatable benign biliary diseases (BBD) are benign biliary strictures (BBSs) and biliary leaks (BLs), often associated with high morbidity. The most common endoscopic treatment for biliary strictures involves placement of multiple plastic stents (PSs), with or without balloon dilation, followed by planned exchange of the stents. Thus, there continues to be high interest in pursuing alternative endoscopic approaches that may achieve better results with fewer interventions. In this setting, the use of a fully-covered, self-expandable metal stent (FCSEMS) is an attractive alternative to single or multiple PSs for the treatment of BBDs. A single metal stent can remain in place for a longer period of time before removal; however, the maximum time the stent can be remain in place is still not well defined. The aim of this review is to determine the removal time of the TaeWoong® FCSEMS, placed for BBD. According to our data analysis, considering the absence of loss of the covering of the FCSEMS and of any adverse events during and after stent removal, leaving the TaeWoong medical FCSEMS in situ for an 8 months' period seems to be acceptable for benign biliary diseases. Further studies need to evaluate their removability at 1 year.

Background: Single-operator, per-oral cholangiopancreatoscopy (SOPCP) enables direct biliopancreatic ductal visualization, targeted tissue sampling, and therapeutic intervention. At Karolinska University Hospital, SOPCP was introduced early and has since been extensively utilized according to a standardized protocol. We analysed the clinical value of SOPCP in the diagnosis and treatment of biliopancreatic diseases in a single high volume center., Methods: All SOPCP procedures performed between March 2007 and December 2014 were retrospectively reviewed. Each procedure's diagnostic yield and therapeutic value was evaluated using a predefined 4 grade scale; 1 - no diagnostic or therapeutic value, 2 - information gained did not impact clinical decision-making and in case of a therapeutic intervention, did not alter the clinical course of the patient, 3 - information gained had an impact on clinical decision-making and in the case of a therapeutic intervention, assisted subsequent disease management, and finally, 4 - information gained was essential and critical for clinical decision-making and in case of a therapeutic intervention, solved the clinical problem requiring no further therapeutic actions. Descriptive statistics were used to analyse results, with uni- and multivariate analyses completed to assess risk of adverse events., Results: During the study period, 365 SOPCP procedures were performed. We found SOPCP of pivotal importance (grade 4) in 19% of cases, and of great clinical significance (grade 3) in 44% of cases. SOPCP did not affect clinical decision-making or alter clinical course (grade 1 and 2) in 37% of cases., Conclusion: SOPCP offers direct access to the biliopancreatic ducts for both diagnostic and therapeutic purposes, adding significant clinical value in 64% of cases., Trial Registration: As this is a purely observational and retrospectively registered study in which the assignment of the medical intervention was not at the discretion of the investigator, it has not been registered in a registry.

Background: Few studies investigated biliary leakage after pancreaticoduodenectomy (PD) especially when compared to postoperative pancreatic fistula (POPF). This study was to determine the incidence of biliary leakage after PD, predisposing factors of biliary leakage, and its management., Methods: We retrospectively studied all patients who underwent PD from January 2008 to December 2017 at Gastrointestinal Surgery Center, Mansoura University, Egypt. According to occurrence of postoperative biliary leakage, patients were divided into two groups. Group (1) included patients who developed biliary leakage and group (2) included patients without identified biliary leakage. The preoperative data, operative details, and postoperative morbidity and mortality were analyzed., Results: The study included 555 patients. Forty-four patients (7.9%) developed biliary leakage. Ten patients (1.8%) had concomitant POPF. Multivariate analysis identified obesity and time needed for hepaticojejunostomy reconstruction as independent risk factors of biliary leakage, and no history of preoperative endoscopic retrograde cholangiopancreatiography (ERCP) as protective factor. Biliary leakage from hepaticojejunostomy after PD leads to a significant increase in development of delayed gastric emptying, and wound infection. The median hospital stay and time to resume oral intake were significantly greater in the biliary leakage group. Non-surgical management was needed in 40 patients (90.9%). Only 4 patients (9.1%) required re-exploration due to biliary peritonitis and associated POPF. The mortality rate in the biliary leakage group was significantly higher than that of the non-biliary leakage group (6.8% vs 3.9%, P = 0.05)., Conclusions: Obesity and time needed for hepaticojejunostomy reconstruction are independent risk factors of biliary leakage, and no history of preoperative ERCP is protective factor. Biliary leakage increases the risk of morbidity and mortality especially if concomitant with POPF. However, biliary leakage can be conservatively managed in majority of cases., (Copyright © 2018. Published by Elsevier B.V.)

Background: Bile leak following liver resection can be associated with significant morbidity. This systematic review and meta-analysis aims to evaluate the effect of intraoperative bile leak testing on postoperative bile leak rate and other complications after liver resection without biliary reconstruction for any cause., Methods: PubMed, MEDLINE, Embase, Cochrane Library and grey literature databases were searched for articles between 1960 and 2017 comparing bile leak rates with or without bile leak testing. Standard meta-analysis methods were used. The primary outcome was bile leak rate, and secondary outcomes were overall morbidity, reintervention rate and length of stay., Results: 8 articles met inclusion criteria. Intraoperative bile leak testing after resection was associated with lower postoperative bile leak rate (4.1% vs 12.3%, OR 0.36, 95% CI 0.23-0.55, p < 0.001), overall morbidity (OR 0.67, 95% CI 0.47-0.96, p = 0.030), need for reintervention (OR 0.11, 95% CI 0.03-0.36, p < 0.001) and a shorter duration of hospital stay (2.21 days, 95% CI 0.69-3.73, p = 0.004)., Conclusion: The routine use of intraoperative bile leak testing during liver resection results in a significant reduction in postoperative bile leak rate, overall morbidity, length of hospital stay and need for re-intervention. Bile leak testing should be performed after liver resection without biliary reconstruction., (Copyright © 2018 International Hepato-Pancreato-Biliary Association Inc. All rights reserved.)

Purpose: To assess the effectiveness of percutaneous radiological treatment for complex biliary leaks compared to simple biliary leaks., Materials and Methods: We retrospectively analyzed 101 percutaneous treatments for bile leak performed from January 1994 to January 2012. Sixty (59%) bile leaks were classified as simple and 41 (41%) as complex based on a morphological classification that considered eight types of biliary wound on cholangiography images. The main treatment was percutaneous transhepatic biliary drainage (PTBD), and additional procedures were performed when required. The technical success of PTBD, leak healing, and recurrence, as well as complication rates were compared between the simple and complex leak groups., Results: Technical success of PTBP was achieved in 94/101 (93%) patients: 59/60 (98%) for simple leaks and 35/41 (85%) for complex leaks (p = 0.017). When PTBD internalization was achieved, leak healing was obtained in 80/94 (85%) patients: 52/59 (88%) for simple leaks and 28/35 (80%) for complex leaks (p = 0.37), with additional percutaneous procedures required in five patients with simple leaks and 13 patients with complex leaks (p = 0.001). There was no recurrence in 75/80 (94%) patients: 50/52 (96%) for simple leaks and 25/28 (89%) for complex leaks (p = 0.34). Major complications occurred in 28/101 (28%) patients: 16/59 (27%) for simple leaks and 12/41 (29%) for complex leaks (p = 0.82)., Conclusion: Once PTBD internalization is achieved, complex leaks heal as well as simple leaks.

Endosonography is an effective diagnostic procedure for intraluminal, parietal and extradigestive pathologies with superior resolution compared to other imaging modalities. The evolution of this technique permits targeted biopsies and offers new therapeutic approaches, initially for the drainage of abdominal collections, and now also for the drainage of bile ducts and the pancreas. These procedures offer a wide range of minimal invasive curative or palliative therapeutic options. The safety profile of these procedures is good and equivalent to a percutaneous approach. They provide a greater comfort and are associated with lower overall cost., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

Background: The patient-provider relationship (PPR) is an important element of health care delivery and may influence patient outcomes. The objective of the present study was to identify clinical predictors of PPR among patients with hepatopancreatobiliary (HPB) diseases and assess the association of PPR and health care utilization., Materials and Methods: The Medical Expenditure Panel Survey database from 2008-2014 was used to identify adult patients with HPB diagnoses. A PPR score of "poor," "average," and "optimal" was calculated from the Consumer Assessment of Healthcare Providers and Systems Survey. Predictors of poor PPR and the association of PPR and health care utilization were assessed., Results: Among 592 patients, PPR was optimal (210, 35.4%), average (270, 45.5%), or poor (114, 19.2%). Patients without insurance (36.3%) or with Medicaid (28.8%) were more likely to report poor PPR versus patients with private insurance (14.0%) or Medicare (15.4%) (P = 0.03). Poor (24.3%)- and low (21.5%)-income patients were more likely to report poor PPR versus middle (12.8%)- or high-income (14.0%) patients (P = 0.03). Poor mental health was also more common among patients with poor PPR (13.4%) versus average (5.4%) or optimal (3.7%) PPR (P = 0.02), and this association between poor PPR and poor mental health remained significant on multivariable analysis (odds ratio [OR] 2.43, 95% confidence interval [CI] 1.20-4.92). Poor PPR was associated with increased emergency room utilization on univariate (OR 2.50, 95% CI 1.21-5.14), but not multivariate (OR 2.18, 95% CI 0.92-5.15) analysis., Conclusions: Among patients with HPB diseases, PPR was associated with insurance type, socioeconomic status, and mental health scores. Patients reporting poor PPR were more likely to be high utilizers of the emergency room. Efforts to improve the PPR are needed and should be focused on these high-risk populations., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Competing Interests: None

Introduction: Single-operator cholangioscopy (SOC) is increasingly used for evaluation of the biliary tree following endoscopic retrograde cholangiopancreaticography (ERCP). This study aimed to determine the visual and histological success rates of SOC at a single Danish tertiary referral centre., Methods: All patients undergoing SOC between 2008 and 2015 were retrospectively included from a prospectively maintained database. Patient characteristics and proced-ure-related variables were obtained from medical records. A visual and a histological success rate were determined according to predefined criteria., Results: In total, 54 patients underwent SOC, most often due to suspicion of malignancy (n = 53; 98%). In one case, access to the common bile duct failed, and in six cases malignant disease was missed. Thus, the cholangioscopies were successful in 47 of 54 procedures corresponding to a visual success rate of 87%. Nine patients (17%) had a mean of 1.3 ± 1.0 SOC-guided biopsies taken. The extracted tissue was inadequate for histological evaluation in seven of nine cases, corres-pond-ing to a histological success rate of 22% (two out of nine tissue samples were eligible for histological diagnosis)., Conclusions: Considering the reasonable visual success rate, SOC seems to be a useful extension of ERCP during diagnostic work-up for detection of malignant disease in the biliary tree. However, one biopsy per patient is insufficient for histological verification of common bile duct malignancy., Trial Registration: The Danish Health Authority (3-3013-1299/1) and The Danish Data Protection Agency (RH-2015-229)., Funding: none., (Articles published in the DMJ are “open access”. This means that the articles are distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits any non-commercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.)

Background: Pancreatoduodenectomy sometimes causes late benign biliary complications, such as biliary stricture and/or hepaticolithiasis, which require intervention. The risk factors and timing of late biliary complications remain unclear. The purpose of this study was to clarify the incidence, timing of occurrence, and risk factors for late biliary complications after pancreatoduodenectomy., Methods: A total of 732 patients who underwent pancreatoduodenectomy between 2002 and 2016 were included in this retrospective study. Postoperative late biliary complications were defined as symptomatic benign biliary stricture and hepaticolithiasis, requiring radiologic or endoscopic intervention. Perioperative variables were collected to analyze the risk factors for late biliary complications. The treatment of late biliary complications was then evaluated., Results: A total of 28 patients (3.8%) developed late biliary complications with a median interval of 23.4 (0.7-98.9) months. Late biliary complications consisted of hepaticolithiasis (n = 11) and stricture (n = 27) (including overlap). The 5-year cumulative incidence of late biliary complications was 7.3%. A multivariate analysis showed that a common hepatic duct diameter of < 4 mm was an independent risk factor for late biliary complications. The 5-year cumulative incidence of late biliary complications in patients with a common hepatic duct diameter of < 4 mm was significantly higher than that of patients with a common hepatic duct diameter of ≥ 4 mm (27.6% vs 1.3%, P < .001). For initial treatment, endoscopic intervention (balloon dilation, lithotomy, and stenting) was successfully performed in 21 patients (75.0%), and percutaneous transhepatic intervention was performed in 7 (25.0%). No patients underwent surgery., Conclusion: The occurrence of late biliary complications was associated with a common hepatic duct diameter of < 4 mm. At the end of follow-up, high-risk patients should be adequately informed about late biliary complications and their symptoms., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Introduction: Biliary colic is a common diagnosis for patients presenting to the emergency department (ED). The purpose of this study is to examine the outcomes of patients coming to the ED with biliary colic., Methods: The NYS longitudinal SPARCS database was used to identify patients presenting to the ED with biliary colic from 2005 to 2014. Through the use of a unique identifier, patients were followed in NYS across multiple institutions. Patients who were lost to follow-up, with duplicated records, and those that underwent percutaneous cholecystectomy tubes were excluded from the analysis., Results: Between 2005 and 2014, there were 72,376 patients who presented to an ED with biliary colic. The admission rate was 20.7-26.02%. Overall, most patients who presented to the ED did not undergo surgery (39,567, 54.7%), of which 35,204 (89%) had only one ED visit, while 4,363(11%) returned to the ED (≥ 2 visits). Only 3.23-5.51% of patients underwent cholecystectomy at the time of initial presentation. Most subsequent cholecystectomies were performed electively (27.38-52.51%) (See Table 1 in this article). Average time to surgery among patients with elective cholecystectomy was 178.4 days. From the patients who underwent cholecystectomy, 10.35% had cholecystectomy at their first ED visit, 77.7% had cholecystectomy following the first ED visit, and 12% had multiple ED visits prior to surgery. Among patients who were discharged from the ED, 32% had their surgery at a different hospital than index presentation., Conclusion: A significant portion of patients (48.6%) who present to the ED with biliary colic will not return or have surgery within 5 years. A third of patients who eventually undergo cholecystectomy will go to another hospital for their surgery.

Background: In adults ERCP and endoscopic ultrasound (EUS) are standard methods of evaluating and treating many hepatopancreaticobiliary (HPB) conditions. HPB disease is being diagnosed with increasing frequency in children but information about role of ERCP and EUS and their outcomes in this population remain limited. Therefore the aims of this study were to describe the paediatric ERCP and EUS experience from a large tertiary referral HPB centre, and to systematically compare outcomes with those of other published series., Methods: All patients <18 years undergoing an ERCP or EUS between January 1992-December 2014 were included. Indications for the procedure, rates of technical success, procedural adverse events and reinterventions were recorded in all cases., Results: Ninety children underwent 111 procedures (87 ERCPs and 24 EUS). 53% (48) were female with a median age of 14 years (range: 3 months - 17 years). Procedures were performed under general anaesthesia (n = 48) or conscious sedation (n = 63). Common indications for ERCP included chronic or recurrent pancreatitis and biliary obstruction. Patients frequently had multiple comorbidities, with a median ASA grade of 2 (range 1-4). Therapeutic procedures performed included biliary or pancreatic sphincterotomy, common bile duct or pancreatic duct stone removal, biliary or pancreatic stent insertion, EUS-guided fine needle aspiration and endoscopic transmural drainage of pancreatic fluid collections. No adverse events were reported following ERCP but there was one complication requiring surgery following EUS guided cystenterostomy., Conclusion: ERCP and EUS in children and adolescents have high technical success rates and low rates of adverse events when performed in high volume HPB centres.