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Abstract Purpose To determine the causes of benign hepaticojejunostomy strictures (BHSs) after pancreaticoduodenectomy (PD) and the outcome of endoscopic retrograde cholangiography (ERC) treatment for BHSs. Methods A total of 175 patients who underwent PD between January 2013 and December 2020 and who were followed up for at least 1 year were included. Preoperative data, operative outcomes, and postoperative courses were compared between the BHS group and the group of patients who did not develop stenosis during follow-up (non-BHS group). The course of treatment in the BHS group was also examined. Results BHS occurred in 13 of 175 patients (7.4%). Multivariate analysis of the BHS and non-BHS groups revealed that male sex (OR; 3.753, 95% CI; 1.029–18.003, P = 0.0448) and a preoperative bile duct diameter less than 8.8 mm (OR; 7.51, 95% CI; 1.75–52.40, P = 0.0053) were independent risk factors for the development of BHS. In the BHS group, all patients underwent ERC using enteroscopy. The success rate of the ERC approach to the bile duct was 92.3%. Plastic stents were inserted in 6 patients, and metallic stents were inserted in 3 patients. The median observation period since the last ERC was 17.9 months, and there was no recurrence of stenosis in any of the 13 patients. Conclusions Patients with narrow bile ducts are at greater risk of BHS after PD. Recently, BHS after PD has been treated with ERC-related procedures, which may reduce the burden on patients.

Purpose: To determine the causes of benign hepaticojejunostomy strictures (BHSs) after pancreaticoduodenectomy (PD) and the outcome of endoscopic retrograde cholangiography (ERC) treatment for BHSs. Methods: A total of 175 patients who underwent PD between January 2013 and December 2020 and who were followed up for at least 1 year were included. Preoperative data, operative outcomes, and postoperative courses were compared between the BHS group and the group of patients who did not develop stenosis during follow-up (non-BHS group). The course of treatment in the BHS group was also examined. Results: BHS occurred in 13 of 175 patients (7.4%). Multivariate analysis of the BHS and non-BHS groups revealed that male sex (OR; 3.753, 95% CI; 1.029–18.003, P = 0.0448) and a preoperative bile duct diameter less than 8.8 mm (OR; 7.51, 95% CI; 1.75–52.40, P = 0.0053) were independent risk factors for the development of BHS. In the BHS group, all patients underwent ERC using enteroscopy. The success rate of the ERC approach to the bile duct was 92.3%. Plastic stents were inserted in 6 patients, and metallic stents were inserted in 3 patients. The median observation period since the last ERC was 17.9 months, and there was no recurrence of stenosis in any of the 13 patients. Conclusions: Patients with narrow bile ducts are at greater risk of BHS after PD. Recently, BHS after PD has been treated with ERC-related procedures, which may reduce the burden on patients. [ABSTRACT FROM AUTHOR]

Abstract Background Endoscopic retrograde cholangiography (ERC) with stone extraction and papillotomy with subsequent laparoscopic cholecystectomy—the two-step approach—is the standard treatment of common bile duct stones in many countries. However, ERC is associated with a high risk of complications and more than half of patients require multiple ERCs. Meta-analyses of randomised clinical trials find no major differences of the two-step approach in comparison with laparoscopic cholecystectomy with intraoperative laparoscopic stone clearance—the one-step approach. Currently, there are insufficient data to ascertain superiority. Methods The preGallstep trial is an investigator-initiated, multicentre randomised feasibility and pilot clinical trial with blinded outcome assessment. Eligible patients are patients with common bile duct stones (identified by magnetic resonance cholagiopancreatography), age 18 years or above with the possibility to perform both interventions within a reasonable time. We intent to randomise 150 participants allocated 1:1. The experimental intervention is the one-step approach. This consists of laparoscopic common bile duct exploration plus laparoscopic cholecystectomy. The control intervention is the two-step approach which consists of ERC plus sphincterotomy (first step) and subsequent laparoscopic cholecystectomy (second step). Feasibility outcomes include the proportion of eligible patients not wanting to participate, reasons for rejection to participate, difficulties during the informed consent procedure, difficulties with randomisation, difficulties with data management, difficulties with blinding patient charts and forms and difficulties with maintaining blinding for the outcome assessors. The primary pilot outcome is the proportion of participants with at least one postoperative complication according to the Clavien-Dindo score grade II and above until 90 days after randomisation. This outcome will be used for a future sample size calculation of a larger pragmatic trial. Further, a range of clinical explorative outcomes will be assessed. Discussion As no sample size is estimated in this trial, there is a risk of wrongly assessing the effect on the patient-related outcome. The surgical procedures cannot be blinded. However, blinding will be employed in all other aspects of the trial, including the establishment of a blinded outcome adjudication committee with three independent assessors. Heterogeneity in screening, randomisation, diagnostics, treatment procedures, interventions and follow-up across trial sites may cause challenges in conducting a larger pragmatic trial. To monitor inter-site differences, we have implemented a central data monitoring scheme. Trial registration ClinicalTrials.gov identification: NCT04801238 , Registered on 16 March 2021

Background: Endoscopic retrograde cholangiography (ERC) with stone extraction and papillotomy with subsequent laparoscopic cholecystectomy—the two-step approach—is the standard treatment of common bile duct stones in many countries. However, ERC is associated with a high risk of complications and more than half of patients require multiple ERCs. Meta-analyses of randomised clinical trials find no major differences of the two-step approach in comparison with laparoscopic cholecystectomy with intraoperative laparoscopic stone clearance—the one-step approach. Currently, there are insufficient data to ascertain superiority. Methods: The preGallstep trial is an investigator-initiated, multicentre randomised feasibility and pilot clinical trial with blinded outcome assessment. Eligible patients are patients with common bile duct stones (identified by magnetic resonance cholagiopancreatography), age 18 years or above with the possibility to perform both interventions within a reasonable time. We intent to randomise 150 participants allocated 1:1. The experimental intervention is the one-step approach. This consists of laparoscopic common bile duct exploration plus laparoscopic cholecystectomy. The control intervention is the two-step approach which consists of ERC plus sphincterotomy (first step) and subsequent laparoscopic cholecystectomy (second step). Feasibility outcomes include the proportion of eligible patients not wanting to participate, reasons for rejection to participate, difficulties during the informed consent procedure, difficulties with randomisation, difficulties with data management, difficulties with blinding patient charts and forms and difficulties with maintaining blinding for the outcome assessors. The primary pilot outcome is the proportion of participants with at least one postoperative complication according to the Clavien-Dindo score grade II and above until 90 days after randomisation. This outcome will be used for a future sample size calculation of a larger pragmatic trial. Further, a range of clinical explorative outcomes will be assessed. Discussion: As no sample size is estimated in this trial, there is a risk of wrongly assessing the effect on the patient-related outcome. The surgical procedures cannot be blinded. However, blinding will be employed in all other aspects of the trial, including the establishment of a blinded outcome adjudication committee with three independent assessors. Heterogeneity in screening, randomisation, diagnostics, treatment procedures, interventions and follow-up across trial sites may cause challenges in conducting a larger pragmatic trial. To monitor inter-site differences, we have implemented a central data monitoring scheme. Trial registration: ClinicalTrials.gov identification: NCT04801238, Registered on 16 March 2021 [ABSTRACT FROM AUTHOR]

Purpose: Endobiliary radiofrequency ablation (RFA) is a new endoscopic ablative technique. However, the ideal power setting for RFA has not yet been clarified. Therefore, we intended to evaluate the effects of endobiliary RFA according to time variations using novel RFA. Materials and methods: Nine female pigs were divided into three groups according to ablation time (60, 90, and 120 seconds) with the same setting (10 watts, 80 °C). All pigs underwent endoscopic retrograde cholangiography (ERC) and endobiliary RFA in the common bile duct. Gross and histologic examinations were performed after 24 hours. Results: The ERC and application of the endobiliary RFA were 100% successful, and the post-RFA cholangiogram did not show contrast leakage. The median depth of microscopic ablation was significantly different among the three groups (60 vs. 90 vs. 120 seconds = 1.90 (1.17–2.23) vs. 2.44 (2.31–2.60) vs. 2.52 (2.47–2.64) mm, p = 0.018). There was also a linear relationship between ablation time and microscopic ablation depth (r2 = 0.552, p = 0.002). However, no significant differences in macroscopic or microscopic ablation length were observed. In addition, there were focal ablation injuries in adjacent liver tissue in five of the nine pigs (2/3 in 60, 1/3 in 90, and 2/3 in 120 seconds). Conclusion: Endobiliary RFA using a novel RFA catheter resulted in controlled ablation with a linear relationship between microscopic ablation depth and ablation time in a swine model. Clinical studies are needed to validate the safe energy condition of endobiliary RFA in malignant biliary obstruction.

Purpose: Endobiliary radiofrequency ablation (RFA) is a new endoscopic ablative technique. However, the ideal power setting for RFA has not yet been clarified. Therefore, we intended to evaluate the effects of endobiliary RFA according to time variations using novel RFA. Materials and methods: Nine female pigs were divided into three groups according to ablation time (60, 90, and 120 seconds) with the same setting (10 watts, 80 °C). All pigs underwent endoscopic retrograde cholangiography (ERC) and endobiliary RFA in the common bile duct. Gross and histologic examinations were performed after 24 hours. Results: The ERC and application of the endobiliary RFA were 100% successful, and the post-RFA cholangiogram did not show contrast leakage. The median depth of microscopic ablation was significantly different among the three groups (60 vs. 90 vs. 120 seconds = 1.90 (1.17–2.23) vs. 2.44 (2.31–2.60) vs. 2.52 (2.47–2.64) mm, p = 0.018). There was also a linear relationship between ablation time and microscopic ablation depth (r2 = 0.552, p = 0.002). However, no significant differences in macroscopic or microscopic ablation length were observed. In addition, there were focal ablation injuries in adjacent liver tissue in five of the nine pigs (2/3 in 60, 1/3 in 90, and 2/3 in 120 seconds). Conclusion: Endobiliary RFA using a novel RFA catheter resulted in controlled ablation with a linear relationship between microscopic ablation depth and ablation time in a swine model. Clinical studies are needed to validate the safe energy condition of endobiliary RFA in malignant biliary obstruction. [ABSTRACT FROM AUTHOR]

Background and Aim The utility of conventional short-type double-balloon endoscopy (DBE) for pancreatobiliary disease in patients with postoperative anatomy had been widely acknowledged and accepted. However, some technical difficulties yet remained. In an attempt to solve these problems, the new short-type DBE (N-short DBE) was uniquely designed for therapeutic endoscopic retrograde cholangiography (ERC) in postoperative patients. The aim of this study was to evaluate the usefulness of N-short DBE for ERC in postoperative patients. Methods From August 2015 to April 2016, ERC using N-short DBE (DB-ERC) was performed in 100 postoperative patients (112 procedures). We retrospectively studied the success rate of reaching the blind end, the median time to reach the blind end, the diagnostic success rate, the therapeutic success rate, the median time to complete ERC-related interventions, the overall success rate, the median time to complete DB-ERC, and adverse events. Results The success rate of reaching the blind end was 99.1%. The median time to reach the blind end was 10 min (interquartile range [IQR], 6-19 min). The diagnostic success rate was 98.2%. The therapeutic success rate was 100%. The median time to complete ERC-related interventions was 36 min (IQR, 22-62 min). The overall DB-ERC success rate was 97.3%. The median time to complete DB-ERC was 54 min (IQR, 37-73 min). The occurrence of adverse events was 2.7%. Conclusions The N-short DBE for ERC in postoperative patients is useful and safe. DB-ERC is promising therapeutic modality in such patients and should be selected as the first-line policy. [ABSTRACT FROM AUTHOR]

Background: Patients with biliary obstruction are at high risk to develop septic complications after endoscopic retrograde cholangiography (ERC). We evaluated the benefits of local application of antimicrobial agents into ERC contrast media in preventing post-ERC infectious complications in a high-risk study population.Methods: Patients undergoing ERC at our tertiary referral center were retrospectively included. Addition of vancomycin, gentamicin and fluconazol into ERC contrast media was evaluated in a case-control design. Outcomes comprised infectious complications within 3 days after ERC.Results: In total, 84 ERC cases were analyzed. Primarily indications for ERC were sclerosing cholangitis (75%) and malignant stenosis (9.5%). Microbial testing of collected bile fluid in the treatment group was positive in 91.4%. Detected organisms were sensitive to the administered antimicrobials in 93%. The use of antimicrobials in contrast media was associated with a significant decrease in post-ERC infectious complications compared to non-use (14.3% vs. 33.3%; odds ratio [OR]: 0.33, 95% confidence interval [CI]: 0.114-0.978). After adjusting for the variables acute cholangitis prior to ERC and incomplete biliary drainage, the beneficial effect of intraductal antibiotic prophylaxis was even more evident (OR = 0.153; 95% CI: 0.039-0.598, p = 0.007). Patients profiting most obviously from intraductal antimicrobials were those with secondary sclerosing cholangitis.Conclusion: Local application of a combination of antibiotic and antimycotic agents to ERC contrast media efficiently reduced post-ERC infectious events in patients with biliary obstruction. This is the first study that evaluates ERC-related infectious complications in patients with secondary sclerosing cholangitis. Our first clinical results should now be prospectively evaluated in a larger patient cohort to improve the safety of ERC, especially in patients with secondary sclerosing cholangitis. [ABSTRACT FROM AUTHOR]

Tokyo Guideline 2013 (TG13) is an international guideline for the diagnosis, classification and treatment of acute cholangitis. Progress and controversy for the two years after TG13 was summarized. Endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP) are both effective imaging tests for common bile duct (CBD) stones. More factors e.g. obesity may be involved in severity assessment. Initiation of broad-spectrum antibiotics addressing the typical Gram-negative enteric bacteria spectrum and early biliary drainage are the mainstay therapeutic options. Early laparoscopic exploration is also an option for stone-related nonsevere acute cholangitis besides endoscopic retrograde cholangial or percutaneous transhepatic cholangial drainage. Surgical biliary drainage should be avoided in severe cholangitis. [ABSTRACT FROM AUTHOR]

Background: Direct cholangioscopy (DC) with ultraslim endoscopes and free-hand cannulation of the common bile duct (CBD) is a promising technique for evaluating and treating cholangiopathy. However, its safety and success rates are as yet unclear. Objective: To evaluate the overall success rates and adverse events with the procedure. Design: Single-center, prospective cohort study; 12 patients retrospectively enrolled. Setting: Academic tertiary referral center. Patients: A total of 100 DC procedures in 84 patients with biliary disease were evaluated prospectively. Interventions: DC performed with the patient under conscious sedation. Main Outcome Measurements: Overall success rates and adverse events with the procedure. Results: In 34 cases with small- or medium-sized sphincterotomies, sphincteroplasty was performed with a 10-mm dilating balloon before DC. The intraductal area of interest was successfully accessed in 87% of the procedures. The intended interventions were successfully carried out in 81 patients (93.1%), but failed in 6 (6.9%). In patients without significant strictures, intrahepatic exploration of the bile ducts beyond the level of the bifurcation was feasible in only 10.8%. The mean total procedure time was 38.6 ± 12.2 minutes. Adverse events occurred in 12 procedures (12%) and were managed conservatively. Limitations: All procedures were performed by 1 endoscopist. Conclusion: DC is safe and allows direct, high-resolution examination and a wide range of therapeutic options in the bile ducts in the majority of patients with biliary disease. However, the range of access is limited to the main bile duct. Suspected pathology restricted to the proximal intrahepatic ducts beyond the bifurcation is therefore not a good indication for DC. [Copyright &y& Elsevier]

Cholangiocarcinomas (CCAs) are hepatobiliary cancers with features of cholangiocyte differentiation; they can be classified anatomically as intrahepatic CCA (iCCA), perihilar CCA (pCCA), or distal CCA. These subtypes differ not only in their anatomic location, but in epidemiology, origin, etiology, pathogenesis, and treatment. The incidence and mortality of iCCA has been increasing over the past 3 decades, and only a low percentage of patients survive until 5 years after diagnosis. Geographic variations in the incidence of CCA are related to variations in risk factors. Changes in oncogene and inflammatory signaling pathways, as well as genetic and epigenetic alterations and chromosome aberrations, have been shown to contribute to the development of CCA. Furthermore, CCAs are surrounded by a dense stroma that contains many cancer-associated fibroblasts, which promotes their progression. We have gained a better understanding of the imaging characteristics of iCCAs and have developed advanced cytologic techniques to detect pCCAs. Patients with iCCAs usually are treated surgically, whereas liver transplantation after neoadjuvant chemoradiation is an option for a subset of patients with pCCAs. We review recent developments in our understanding of the epidemiology and pathogenesis of CCA, along with advances in classification, diagnosis, and treatment. [Copyright &y& Elsevier]

Background The aim of the present study was to evaluate the usefulness of a single-balloon enteroscope ( SBE) including a newly developed short SBE ( SIF- Y0004) for therapeutic endoscopic retrograde cholangiography ( ERC) in patients with Roux-en- Y ( R-Y) anastomosis. Patients and Methods Therapeutic ERC using a SBE was attempted in 19 cases (41 procedures) with R-Y anastomosis after gastrectomy. A standard SBE (working length of 200 cm, working channel of 2.8 mm) was used in 11 cases ( Group L), and a short SBE (working length of 152 cm, working channel of 3.2 mm) was used in eight cases ( Group S). Results Insertion of the scope up to the major papilla was achieved in 79% (15/19) of cases. Average insertion time was 37.0 ± 13.8 min (range, 19-62 min). Bile duct cannulation rate was 79% (11/14) after exclusion of the initial case in which scope exchange was unsuccessful. Average procedure time was78.8 ± 26.9 min (18-119 min). The scheduled therapeutic procedure was completed in 67% (10/15) of the cases (53% [10/19] on an intention-to-treat basis). Cardiorespiratory suppression due to sedative agents resulting in scope withdrawal developed in one procedure (2.4%; 1/41). Although there was no significant difference in therapeutic results between the two groups, the number of procedures was smaller (1.8 ± 1.3 vs 3.6 ± 3.1; P = 0.286) in Group S than in Group L. Conclusions Therapeutic ERC using a SBE for patients with R-Y anastomosis is considered to be safe and effective. A short SBE appears to be promising for further improvement in therapeutic results. [ABSTRACT FROM AUTHOR]

Background: EUS-guided biliary drainage (EGBD) can be performed via direct transluminal or rendezvous techniques. It is unknown how both techniques compare in terms of efficacy and adverse events. Objective: To describe outcomes of EGBD performed by using a standardized approach and compare outcomes of rendezvous and transluminal techniques. Design: Retrospective analysis of prospectively collected data. Setting: Two tertiary-care centers. Patients: Consecutive jaundiced patients with distal malignant biliary obstruction who underwent EGBD after failed ERCP between July 2006 and December 2012 were included. Intervention: EGBD by using a standardized algorithm. Main Outcome Measurements: Technical success, clinical success, and adverse events. Results: During the study period, 35 patients underwent EGBD (rendezvous n = 13, transluminal n = 20). Technical success was achieved in 33 patients (94%), and clinical success was attained in 32 of 33 patients (97.0%). The mean postprocedure bilirubin level was 1.38 mg/dL in the rendezvous group and 1.33 mg/dL in the transluminal group (P = .88). Similarly, length of hospital stay was not different between groups (P = .23). There was no significant difference in adverse event rate between rendezvous and transluminal groups (15.4% vs 10%; P = .64). Long-term outcomes were comparable between groups, with 1 stent migration in the rendezvous group at 62 days and 1 stent occlusion in the transluminal group at 42 days after EGBD. Limitations: Retrospective analysis, small number of patients, and selection bias. Conclusion: EGBD is safe and effective when the described standardized approach is used. Stent occlusion is not common during long-term follow-up. Both rendezvous and direct transluminal techniques seem to be equally effective and safe. The latter approach is a reasonable alternative to rendezvous EGBD. [Copyright &y& Elsevier]

Background: Mother-baby technologies, the criterion standard for cholangioscopy, have several limitations. A novel, short-access, mother-baby (SAMBA) system may improve this technique. Direct cholangioscopy (DC) was recently developed as an alternative to mother-baby cholangioscopy. Objective: Comparison of success rates with SAMBA and DC. Design: Single-center, randomized, controlled trial. Setting: Academic tertiary-care referral center. Patients: Sixty patients with suspected cholangiopathies randomized to either SAMBA (n = 30) or DC (n = 30). Intervention: Cholangioscopy under deep sedation. Main Outcome Measurements: Technical success rate of diagnostic or therapeutic procedure. Results: A total of 24 and 21 diagnostic procedures were performed in the SAMBA and DC groups, respectively. There were no significant differences in the overall technical success rates between SAMBA (90.0%) and DC (86.7%) (P = 1.0). There was better correlation between the endoscopic prediction and histologic findings in DC (P = .013). Procedure times were shorter in DC (P < .03). In patients without significant stenoses, SAMBA allowed intrahepatic bile duct exploration in all cases, compared with 10.5% of cases in DC (P < .01). No differences regarding adverse event rates between the groups occurred (10.0% both groups). Limitations: Small sample size. Heterogeneous indications for cholangioscopy. DC requires advanced skills of the endoscopist. The study is not replicable. Conclusion: SAMBA and DC offer high technical success rates for diagnostic and therapeutic interventions. The advantages of DC consist of superior imaging, shorter total procedure time, and a wider working channel for adequate tissue sampling. SAMBA is better than DC with regard to intraductal stability and accessibility of the intrahepatic bile ducts. [Copyright &y& Elsevier]

Background: Obtaining histological evidence of gallbladder carcinoma (GBC) is difficult due to its extraductal nature, and pathological confirmation remains challenging. We compared the diagnostic value and safety of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) with endoscopic retrograde cholangiography (ERC) in patients with suspected GBC. Patients: Eighty-three patients with GBC were evaluated. Prior to definitive management, pathological evidence of GBC was obtained through either ERC cytopathologic sampling ( n = 33), EUS-FNA ( n = 24) or both ( n = 26). Results: Among the 83 patients, 59 (71.0%) with biliary obstruction were sampled using ERC with 47.4% (28/59) sensitivity. In 19 of the remaining 31 cases, EUS-FNA sampling had 100% diagnostic sensitivity. Likewise, 50 (60.2%) of the 83 patients with suspected GBC underwent EUS-FNA of regional lymph nodes or the gallbladder (GB) mass itself with 94.8% sensitivity. The overall diagnostic sensitivity rates of ERC and EUS-FNA were 47.4 and 96%, respectively ( P < 0.001). Post-procedural complications were seen in 6.7% of the ERC group (4/59, all were mild pancreatitis), and in none of the EUS-FNA group ( P = 0.10). Conclusions: Gallbladder carcinoma sampling using ERC and EUS-FNA should be incorporated into the diagnostic workup of GB lesions as complementary tools, and EUS-FNA should be applied in the setting of failed or not indicated ERC. [ABSTRACT FROM AUTHOR]

Background: Preceding endoscopic retrograde cholangiography (ERC) in patients with choledochocystolithiasis impedes laparoscopic cholecystectomy (LC) and increases risk of conversion. We studied the influence of time interval between ERC and LC on the course of LC.Methods: All patients treated for choledochocystolithiasis with ERC and LC during 1996-2001 were studied retrospectively, comparing the course of LC in three time interval groups; LC < 2, 2-6, and > 6 weeks after ERC.Primary Outcomes: adhesions, bile duct injury, operating time, and conversion-rate.Results: Eighty-three patients were studied (group 1, n = 23; group 2, n = 15; group 3, n = 45). Adhesions, operation time, and bile duct damage did not significantly differ between the groups. The conversion rate in group 2 is significantly higher compared to group 1 (p = 0.027, OR 11 (1.13-106.8)) CONCLUSIONS: A higher conversion rate of LC is found 2-6 weeks after ERC compared to LC within 2 weeks. However, further research is needed to gain more reliable data on whether this is caused by timing. [ABSTRACT FROM AUTHOR]

Background: Radiofrequency ablation (RFA) of malignant liver lesions is considered a procedure with low morbidity. However, RFA performed close to hilar structures carries the risk of heat-induced biliary tract damage and subsequent septic episodes.Methods: We performed an analysis of complications in 42 patients with 211 liver lesions treated with a combined approach of liver resection and RFA.Results: One patient died due to postoperative liver failure. There was one case of temporary liver dysfunction, one vena cava thrombosis, and six febrile episodes. Four of the six febrile episodes were related to bile duct injuries. They became evident 3-5 weeks after the procedure. All four patients were treated successfully by the placement of stents within the biliary tract. None of the patients developed a hepatic abscess.Conclusion: Biliary tract damage is a complication that can occur weeks after RFA. Immediate endoscopic intervention can obviate the occurrence of prolonged septic complications. [ABSTRACT FROM AUTHOR]

Background: Intraoperative cholangiography (IOC) is frequently omitted in patients undergoing laparoscopic cholecystectomy (LC) if they have had successful preoperative endoscopic retrograde cholangiography (ERC).Methods: A prospectively maintained divisional laparoscopic cholecystectomy database was searched from 1991 to 1997 for patients who had IOC after preoperative ERC. The presence of recurrent or residual common duct stones seen on IOC and their impact on subsequent management were evaluated.Results: We identified a group of 127 patients who underwent preoperative ERC. Thirty-one patients (31/127, or 24%) went on to receive an IOC during cholecystectomy. In 15 patients whose preoperative ERC was reported normal, five (33%) had an abnormal IOC. In 16 patients whose ERC was reported as having cleared the duct, eight (50%) had an IOC abnormality. Eight of these 31 patients required a further procedure to clear the duct.Conclusion: Retained or recurrent common duct stones at cholecystectomy following diagnostic or therapeutic ERC were more common than expected. Therefore, IOC is recommended during LC regardless of the findings yielded by the preoperative ERC. [ABSTRACT FROM AUTHOR]

We attempted to clarify the surgical usefulness and limitation of endoscopic retrograde cholangiography (ERC) by comparing with drip infusion cholangiography (DIC). ERC was carried out on 144 patients with clinical symptoms of biliary tract diseases. The success rate was 71.5 per cent. Indications for surgery were found in 83.9 per cent of the patients with positive ERC findings and in 50.5 per cent of the patients in whom ERC was successful. The false positive rate in ERC, as revealed during the surgery was 2.3 per cent. Failure of ERC occurred in 41 patients. Failure of cannulation was attributed to para-vaterian diverticulum in 11, post-gastrectomy states in 5, the duodenal papilla covered by a polyp or a large fold in 2, and choledocho-duodenal fistula in 1. The failure of cannulation in 22 could not be clearly defined. As ERC was successful in 3 out of 9 patients in whom this approach was unsuccessful in the first trial, ERC should probably be repeated if such was indeed required pre-operatively. Diagnostic significance of DIC before ERC revealed that such plays a definite role in screening patients. [ABSTRACT FROM AUTHOR]

Background: Acute pancreatitis is an important complication of endoscopic retrograde cholangiography (ERC), occurring between 1-10% of patients. Several randomized controlled trials and meta-analyses have demonstrated the effectiveness of nonsteroidal anti-inflammatories (NSAIDs) such as diclofenac and indomethacin as a post-ERC pancreatitis (PEP) prophylaxis. The aim is to determine if the rectal diclofenac use reduces the PEP rate., Methods: Retrospective cohort study. Subjects were included who underwent ERC for different indications in a tertiary center between January 2015 and June 2016. Two groups were analyzed: group A (without diclofenac use) and group B (with use of diclofenac as PEP prophylaxis). Biodemographic, technical and mortality variables were measured., Results: The total cohort was 116 patients, 67 in group A and 49 in group B. The average age was 61.9±17.8 and 58.3±15.8 years, respectively (P=0.2606). Gender distribution showed a women predominance in both groups (P=0.933). Of the technical variables measured, the precut showed a statistically significant relationship to PEP (P=0.013). Of the total cohort, 8.6% developed acute pancreatitis after an ERC: four in group A and six in group B (P=0.196). In those who developed PEP (n=10), six patients developed severe acute pancreatitis (SAP). The average hospitalization for PEP was 32.2±34 days (P=0.881). No patients died, not were there any adverse reactions to the drug., Conclusions: Rectal diclofenac administered at the beginning of the ERC did not reduce the PEP rate in this patients cohort.

Because of the presence of portal cavernoma, paracholedochal and pericholedochal varices, portal cavernoma cholangiopathy (PCC) has become an entity unique to patients with extrahepatic portal venous obstruction (EHPVO). Majority of patients with these abnormalities are asymptomatic and are incidentally detected to have the presence of biliary abnormalities on cholangiography. Minority of patients present with symptoms of chronic cholestasis with or without biliary pain or acute cholangitis related most often to the presence of biliary strictures or stones. Other than the age of the patient and duration of EHPVO, presence of gall stones and common bile duct stones are other risk factors for the causation of symptoms in patients with PCC. This review summarizes the clinical characteristics of asymptomatic and symptomatic patients with PCC giving details of the prevalence of symptoms, their risk factors and overall burden of symptomatic PCC. [ABSTRACT FROM AUTHOR]

The pathogenesis of portal cavernoma cholangiopathy (PCC) is important as it can impact the choice of treatment modalities. PCC consists of a reversible component, which resolves by decompression of collaterals as well as a fixed component, which persists despite the decompression of collaterals. The reversible component is due to compression by large collaterals located adjacent to the bile duct as well as possibly intracholedochal varices. The fixed component is likely to be due to ischemia at the time of portal vein thrombosis, local ischemia by compression as well as encasement by a solid tumor-like cavernoma comprising of fibrous hilar mass containing multiple tiny collateral veins rather than markedly enlarged portal collaterals. Although cholangiographic abnormalities in portal hypertension are common, the prevalence of symptomatic PCC is low. This is likely to be related to the cause of portal hypertension, the duration of portal hypertension and possibly the pattern of occlusion of the splenoportal axis. There may possibly be higher prevalence of symptomatic PCC in extension of the thrombosis to the splenomesentric veins. [ABSTRACT FROM AUTHOR]

Biliary changes secondary to portal hypertension, especially in portal cavernoma secondary to extrahepatic portal vein obstruction have long been described in literature under different names by various authors. Most of the times these changes are asymptomatic and discovered on imaging, but can occasionally cause obstructive jaundice. There is no consensus on the appropriate nomenclature and definition of this entity. This article reviews the history of portal hypertensive biliopathy and the Indian Association for the Study of Liver Working Party consensus definition and nomenclature for it. [ABSTRACT FROM AUTHOR]

Portal cavernoma cholangiopathy (PCC) is defined as abnormalities in the extrahepatic biliary system including the cystic duct and gallbladder with or without abnormalities in the 1st and 2nd generation biliary ducts in a patient with portal cavernoma. Presence of a portal cavernoma, typical cholangiographic changes on endoscopic or magnetic resonance cholangiography and the absence of other causes of these biliary changes like bile duct injury, primary sclerosing cholangitis, cholangiocarcinoma etc are mandatory to arrive a diagnosis. Compression by porto-portal collateral veins involving the paracholedochal and epicholedochal venous plexuses and cholecystic veins and ischemic insult due to deficient portal blood supply or prolonged compression by collaterals bring about biliary changes. While the former are reversible after porto-systemic shunt surgery, the latter are not. Majority of the patients with PCC are asymptomatic and approximately 21% are symptomatic. Symptoms in PCC could be in the form of long standing jaundice due to chronic cholestasis, or biliary pain with or without cholangitis due to biliary stones. Endoscopic retrograde cholangiography has no diagnostic role because it is invasive and is associated with risk of complications, hence it is reserved for therapeutic procedures. Magnetic resonance cholangiography and portovenography is a noninvasive and comprehensive imaging technique, and is the modality of choice for mapping of the biliary and vascular abnormalities in these patients. PCC is a progressive condition and symptoms develop late in the course of portal hypertension only in patients with severe or advanced changes of cholangiopathy. Asymptomatic patients with PCC do not require any treatment. Treatment of symptomatic PCC can be approached in a phased manner, coping first with biliary clearance by nasobiliary or biliary stent placement for acute cholangitis and endoscopic biliary sphincterotomy for biliary stone removal; second, with portal decompression by creating portosystemic shunt; and third, with persistent biliary obstruction by performing second-stage biliary drainage surgery such as hepaticojejunostomy or choledochoduodenostomy. Patients with symptomatic PCC have good prognosis after successful endoscopic biliary drainage and after successful shunt surgery. [ABSTRACT FROM AUTHOR]