[A meta-analysis of preoperative versus intraoperative endoscopic sphincterotomy in patients with gallbladder and suspected common bile duct stones]

OBJECTIVE

To compare the safety and efficiency of preoperative endoscopic sphincterotomy (POES) versus intraoperative endoscopic sphincterotomy (IOES) in patients with gallbladder and common bile duct stones.

METHODS

Multiple electronic databases were searched for prospective, randomized, controlled trials on the safety and effectiveness of POES versus IOES. And the outcome parameters of clearance rate, post-procedural complications and hospital stay were analyzed.

RESULTS

Five trials with 631 patients (POES, n=318; IOES, n=313) were analyzed. Although the overall rates of common bile duct stone clearance were similar between POES and IOES (RR 0.96, 95% CI: 0.91-1.01; P=0.13), the failure rate of CBD cannulation was significantly higher for IOES (RR 2.54, 95% CI: 1.23-5.26; P=0.01) during endoscopic retrograde cholangiopancreatography (ERCP). The pooled RR after POES for overall complication rates was similar to that for IOES (RR 1.56, 95% CI: 0.94-2.59; P=0.09). However, as compared with IOES, the RR risk of ERCP-related complications was significantly higher for POES (RR 2.27, 95% CI: 1.18-4.40, P=0.01). No significant inter-group differences existed in morbidity after laparoscopic cholecystectomy or subsequent conversion into open surgery. In subgroup analyses, the rates of hemorrhage, perforation, cholangitis, cholecystitis, and gastric ulceration showed no significant inter-group differences.

CONCLUSION

With regards to stone clearance and overall complication rate, POES is comparable to IOES in patients with gallbladder and common bile duct stones. However, IOES has a lowered incidence of ERCP-related pancreatitis and a shorter hospital stay.

Nasobiliary drainage after endoscopic papillary balloon dilatation may prevent postoperative pancreatitis

AIM: To evaluate the necessity of endoscopic nasobiliary drainage (ENBD) catheter placement after clearance of common bile duct (CBD) stones.

METHODS: Patients enrolled in this study were randomly divided into two groups, according to whether or not they received ENBD after the removal of CBD stones. Group 1 (ENBD group) was then subdivided into three groups: G1a patients received an endoscopic papillary balloon dilatation (EPBD), G1b patients received an endoscopic sphincterotomy (EST), and G1c patients received neither. Group 2 (non-ENBD group) patients were also subdivided into three groups (G2a, G2b, and G2c), similar to Group 1. The maximum CBD diameter, the time for C-reactive protein (CRP) to normalize, levels of serum amylase, total serum bilirubin (TB) and alanine aminotransferase (ALT), and postoperative hospitalization duration (PHD) were measured.

RESULTS: A total of 218 patients (139 males, 79 females), with an average age of 60.1 ± 10.8 years, were enrolled in this study. One hundred and thirteen patients who received ENBD were included in Group 1, and 105 patients who did not receive ENBD were included in Group 2. The baseline clinical characteristics were similar in both groups. There were no significant differences in post-endoscopic retrograde cholangiopancreatography (ERCP)-related complications when Groups 1 and 2 were compared. Seventy-seven patients underwent EPBD, and 41 received an ENBD tube (G1a) and 36 did not (G2a). Seventy-three patients underwent EST, and 34 patients received an ENBD tube (G1b) and 39 did not (G2b). The remaining 68 patients underwent neither EPBD nor EST; of these patients, 38 received an ENBD tube (G1c) and 30 did not (G2c). For each of the three pairs of subgroups (G1a vs G2a, G1b vs G2b, G1c vs G2c), there were no significant differences detected in the PHD or the time to normalization of CRP, TB and ALT. In the EPBD group, the incidence of post-ERCP pancreatitis, hyperamylasemia and overall patient complications was significantly higher for G2a (post-ERCP pancreatitis: 6/36 vs 0/41, P = 0.0217; hyperamylasemia: 11/36 vs 4/41, P = 0.0215; overall patient complications: 18/36 vs 7/41, P = 0.0029).

CONCLUSION: After successful CBD stone clearance, ENBD is only beneficial when an EPBD procedure has been performed.

Role of endoscopic papillary balloon dilation in patients with recurrent bile duct stones after endoscopic sphincterotomy

BACKGROUND

Endoscopic sphincterotomy (ES) is an established treatment for patients with choledocholithiasis or common bile duct stones (CBDS), but further management of patients after ES with recurrent CBDS remains controversial. Endoscopic papillary large balloon dilation (EPLBD) has been used safely and effectively for stone removal in patients after ES with recurrent CBDS. The aim of this study was to evaluate the clinical efficacy of EPLBD in patients after complete ES with recurrent CBDS.

METHODS

Records of 891 patients with CBDS after complete ES from January 1991 to December 2008 were reviewed. Of 133 patients with recurrent CBDS, 122 had complete endoscopic bile duct clearance. Twenty-three patients (Group 1) underwent EPLBD and 99 (Group 2) underwent stone extraction without dilatation. Basic demographics and endoscopic findings at the first recurrence were recorded and analyzed. The primary end point was the second CBDS recurrence.

RESULTS

No statistical differences were observed between the two groups, except for larger CBDS size in Group 1. The bile duct clearance rate was 96% in Group 1 and 91% in Group 2. No complications such as pancreatitis, perforation, and bleeding were noted in Group 1, and one patient in Group 2 suffered from bleeding after stone extraction. The rate of second recurrent CBDS after endoscopic clearance for the first recurrent CBDS was 17% in Group 1 and 60% in Group 2 (p < 0.001). There were two independent factors for the second recurrence, including cirrhosis (odds ratio 4.734, p = 0.023) and stone extraction directly without major papilla expansion (odds ratio 6.050, p = 0.003).

CONCLUSION

EPLBD is a safe and effective endoscopic treatment for recurrent CBDS in patients after ES. It can also facilitate complete clearance of CBDS and prevent further CBDS recurrence.

Biliary tract infection or colonization with Elizabethkingia meningoseptica after endoscopic procedures involving the biliary tract

OBJECTIVE

This study was performed to investigate the clinical significance of detecting Elizabethkingia meningoseptica in the bile.

METHODS

We herein report a case series of biliary colonization or infection with E. meningoseptica. Twenty patients with E. meningoseptica recovered from the bile were treated at a 4,300-bed teaching hospital in China between January 2009 and December 2012. The clinical information for the cases of E. meningoseptica recovered from the bile and the microbiological data of the E. meningoseptica isolates were examined.

RESULTS

Most of the 20 patients were not immunocompromised, although they had cholelithiasis and had recently received antimicrobial agents. All cases were treated with indwelling nasobiliary tubes and endoscopic retrograde cholangiopancreatography and/or endoscopic sphincterotomy prior to the detection of E. meningoseptica in the bile. The average time between the placement of the nasobiliary tube and the detection of E. meningoseptica in the bile was 6.6 days. E. meningoseptica caused cholangitis in five cases, one of which also involved secondary septicemia, and colonized the nasobiliary tubes or biliary tract in the remaining 15 cases. All but two patients recovered and were discharged. Two patients died of septicemia; E. meningoseptica and Escherichia coli were the causative pathogens in one case and other organisms were the causative pathogens in the other.

CONCLUSION

E. meningoseptica is an unusual causative pathogen of healthcare-associated cholangitis. Cholangitis resulting from this bacterium is generally associated with good outcomes, although secondary septicemia can be life-threatening.

Endoscopic papillary large balloon dilation for removal of bile duct stones

AIM: To investigate the efficacy and outcomes of endoscopic papillary large balloon dilation (EPLBD) for bile duct stones in a multicenter prospective study.

METHODS: Lithotomy by EPLBD was conducted in 124 patients with bile duct stones ≥ 13 mm in size or with three or more bile duct stones ≥ 10 mm. After endoscopic sphincterotomy, the papilla was dilated using balloons 12-20 mm in diameter fitting the bile duct diameter.

RESULTS: The success rate of first-time lithotomy was 86.3% (107/124) and the final lithotomy success rate was 100% (124/124). Lithotripsy was needed in 10 of the 124 (13.6%) patients. Adverse events due to the treatment procedure occurred in 6 (4.8%) patients, all of which were mild. Performing large balloon dilation after endoscopic sphincterotomy in patients with large stones or multiple stones in the bile duct is considered to ensure the safety of treatment and to reduce the need for lithotripsy.

CONCLUSION: It is suggested that treatment by EPLBD for large bile duct stones may be safe and useful.

Development of a novel and simple ex vivo biologic ERCP training model

BACKGROUND

Training and teaching of ERCP in biologic models has gained importance over the past decade. However, many existing models are expensive, are not widely available, or rely on live animals.

OBJECTIVE

We describe a novel and simple ex vivo, biologic model for hands-on teaching.

DESIGN

Ex vivo porcine study.

SETTING

Experimental endoscopy unit.

METHODS

Experimental study using a custom-made ex vivo biologic ERCP simulation model. This model contains 2 new key concepts: (1) formation of a duodenal sweep by using the porcine stomach and (2) use of multiple neo-papillae for endoscopic sphincterotomy and biliary stent placement. The papilla was re-created with chicken heart, and the bile ducts were built from chicken trachea. Endoscopic sphincterotomy was performed by using a pull-type sphincterotome. Stenting was performed with Amsterdam-type plastic stents and guidewires.

MAIN OUTCOME MEASUREMENTS

The following definitions were used to evaluate the model: successful implantation of the neo-papilla, stability of the neo-papilla to the neo-duodenum, successful removal of the neo-papilla, and damage to the model. The following endoscopic endpoints were evaluated: successful cannulation, cannulation time, difficulties in positioning the papilla, quality of the biliary sphincterotomy, and prosthesis placement. Procedure-related adverse events such as perforation were also assessed.

RESULTS

Ten neo-papillae were consecutively used in 1 duodenalized stomach. The implantation and removal of the neo-papillae were easily and successfully accomplished in all 10 cases without any damage to the duodenalized stomach. The stability of the neo-papilla on the duodenal sweep was excellent in all cases. Cannulation, biliary sphincterotomy, and stent placement could be successfully performed in 100% of cases. There was no damage and were no technical problems with the model. There were no adverse events during endoscopy (ie, perforations, stent misplacement).

LIMITATIONS

Pilot study.

CONCLUSION

Although further studies are necessary, this simple, novel ex vivo model appears useful for training in sphincterotomy and bile duct cannulation. Because the neo-papillae are interchangeable, repetitive sphincterotomies and other interventions can be performed using a single porcine model.

Acute pancreatitis in pregnancy: a comparison of associated conditions, treatments and complications

OBJECTIVE

Acute pancreatitis is a rare condition in pregnancy. The aim of this study is to compare associated conditions, treatments and complications of pancreatitis in pregnant and age-matched non-pregnant controls.

METHODS

We carried out a population-based retrospective cohort study using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP-NIS) from 2003 to 2010. A cohort of pregnant women with acute pancreatitis was created and compared to a created age-matched cohort of non-pregnant women with acute pancreatitis at a 1:4 ratio. Comparisons of associated conditions, treatment types, and complications were carried out using unconditional logistic regression.

RESULTS

We identified 7725 cases of acute pancreatitis in pregnancy. As compared to non-pregnant controls, pancreatitis in pregnancy was more likely to be associated with cholelithiasis and less likely with hyperlipidemia and alcohol abuse. Pancreatitis in pregnancy was more likely to be treated with parenteral nutrition and less likely to undergo endoscopic sphincterotomy. As compared to non-pregnant controls, pregnant women with pancreatitis were less likely to have pancreatic pseudocysts/hemorrhage/necrosis, generalized peritonitis, adult respiratory distress syndrome, disseminated intravascular coagulation, and death.

CONCLUSION

Pancreatitis in pregnancy is predominantly caused by cholelithiasis, and unlike in the non-pregnant state, usually has a milder course.

Biliary stenting as alternative therapy to stone clearance in elderly patients with bile duct stones

BACKGROUND AND STUDY AIMS

Endoscopic retrograde cholangio- pancreatography with stone retrieval following endoscopic sphinc- terotomy (ES) is the standard method for the management of cho- ledocholithiasis. However, biliary stenting is used to treat patients with endoscopically irretrievable bile duct stones, especially elderly and high-risk patients. The aim of this study was to evaluate the benefits and risks of biliary stenting versus stone clearance follow- ing ES in the management of choledocholithiasis.

PATIENTS AND METHODS

Between January 2010 and December 2012, 165 patients with common bile duct stones who underwent biliary stenting or stone clearance following ES were enrolled. One 7 Fr. double-pigtail plastic stent was placed without ES or stone extraction. The procedure time, hospitalization period, adverse events, additional endoscopic interventions required and one-year mortality were evaluated retrospectively.

RESULTS

Ninety-nine and 66 patients were included in stenting group and in stone clearance group, respectively. Except for age, number of stones, and use of antithrombotic agents in the stent group, there were no statistically significant difference between groups. The average procedure time and hospitalization period in the stenting group were significantly shorter than those in stone clearance group (mean 21 min vs. 43.9 min, P < 0.0001; 3.8 days vs. 6.5 days, P < 0.0001). No significant differences were seen in ad- verse events and additional endoscopic interventions required be- tween both groups for at least a 1.5-year follow-up. No one-year mortality occurred.

CONCLUSIONS

Biliary stenting using a double-pigtail stent proved to be a useful alternative therapy to stone clearance following ES in the management of choledocholithiasis in elderly patients.

[Changes of the hemostasis system in patients with obturation jaundice caused by choledocholithiasis, and possibilities of their correction with the help of miniinvasive operative interventions]

Changes in the hemostasis system in choledocholithiasis, taking into account the obturation jaundice severity and possibility of the correction conduction, using miniinvasive operative interventions, were studied. Dynamic of changes in the hemostasis system in patients preoperatively, in 1 and 3 days after endoscopic papillosphincterotomy were monitored, using the method of a low--rate piezoelectric thromboelastography. Basing on analysis of the results, the changes in hemostasis in obturation jaundice were classified, taking into account its degree of severity, what have permitted to select a correct tactics for prophylaxis of hemorrhagic complications intraoperatively and postoperatively.

Management of bile duct injuries following laparoscopic cholecystectomy: long-term outcome and risk factors infuencing biliary reconstruction

BACKGROUND

Bile duct injury following cholecystectomy remains a severe complication with major implications for the patient outcome.

AIM

To assess the outcome of surgical treatment and study the risk factor infuencing biliary reconstruction in patients with bile duct injuries following laparoscopic cholecystectomy.

METHODS

Between January 2005 and December 2010, 43 patients with bile duct injuries following laparoscopic cholecystectomy were treated to our center. According to Strasberg classification, the types of injuries were as follows: type A in 7 patients (16.28%), type D in 4 (9.3%), type E1 in 9 (20.93%), type E2 in 11 (25.58%), type E3 in 10 (23.25%),and type E4 in 2 (4.65%) patients respectively. Management after referral included endoscopic sphincterotomy in patients with minor lesions (Strasberg type A) and Roux-en-Y hepaticojejunostomy in 36 patients with major duct injuries(Strasberg type D and E). 55.55% of patients with major bile duct injuries have endoscopic or surgical attempts of repair sprior to referral. In case of biliary peritonitis or acute cholangitis, the reconstruction was preceded by prolonged external biliary drainage.

RESULTS

All minor lesions were successfully treated endoscopically,with outstanding long term results. For patients with major duct injuries, the postoperative mortality and morbidity rate were 5.55% and 25%, respectively. After a median follow-up period of 34.1 (range, 12-68) months, 30 patients(88.23%) remain in good general condition (using McDonald classification) and 4 patients (11.77%) developed a late anastomotic stricture. Multivariate analyses have identified postoperative biliary leak (p=0.012) as an independent predictor factor for the occurrence of late anastomotic stricture.

CONCLUSIONS

Minor bile duct injuries can be successfully treated endoscopically if proper abdominal drainage is maintained. Roux-en-Y hepaticojejunostomy is feasible and safe with contained morbidity and durable results even when previous surgery has failed. Postoperative biliary leak is a significant predictor for poor long term outcome.

The Loop-Tip Wire for Selective Cannulation during ERCP in Patients with Billroth II Anastomosis: A Preliminary Feasibility Study

BACKGROUND/AIMS

Selective cannulation of common bile duct remains technically challenging in patients with Billroth II anastomosis due to an altered anatomy. We aimed to determine the feasibility of performing wire-assisted cannulation using a loop-tip wire during ERCP in patients with Billroth II anastomosis.

METHODOLOGY

We retrospectively analyzed a database of nine patients with Billroth II anastomosis who underwent ERCP using a loop-tip wire from January 2009 to July 2013 in the Hallym University Sacred Heart Hospital. Clinical characteristics and procedure-associated clinical outcomes were analyzed.

RESULTS

The mean age of the patients was 73.7 years, and the male/female ratio was 2:1. The success rate of selective biliary cannulation was 77.8%. The mean cannulation time was 3.6 minutes (range, 1-9 minutes). Two patients who had failed in selective cannulation underwent infundibulotomy using a needle-knife papillotome, but one of the two patients had failed in biliary stone removal and finally underwent surgery. Six patients underwent endoscopic sphincterotomy. Complete clearance of bile duct stones was achieved in seven patients in one session. There was one case of mild post-ERCP pancreatitis (11.1%).

CONCLUSIONS

The loop-tip wire can be an alternative instrument for wire-assisted selective cannulation in patients with Billroth II anastomosis.

Percutaneous video choledochoscopic treatment of retained biliary stones via dilated T-tube tract

BACKGROUND

Retained biliary stones is a common clinical problem in patients after surgery for complicated gallstone disease. When postoperative endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy are unsuccessful, several percutaneous procedures for stone removal can be applied as alternatives to relaparotomy. These procedures are performed either under fluoroscopic control or with the use of choledochoscopy, but it is also possible to combine these methods.

METHODS

Since 1994, we have used the percutaneous video choledochoscopic technique for the removal of difficult retained biliary stones via dilated T-tube tract in 17 patients, applying the technique of percutaneous stone extraction used in urology. While waiting for the T-tube tract to mature and after the removal of the T-tube, the dilatation of its tract was 26-30 Fr. Stone removal was carried out using a flexible video choledochoscope and a rigid renoscope under fluoroscopic control, with the aid of Dormia baskets, rigid forceps, and high-pressure irrigation.

RESULTS

We performed 23 operative procedures, and the clearance of the biliary ducts was successful in all cases. There were no major complications or deaths.

CONCLUSION

Percutaneous video choledochoscopic-assisted removal of large retained biliary stones via the T-tube tract is a highly effective and safe procedure. Its advantages over other procedures include the ability to visualize the stones and noncalculous filling defects; it also guarantees that the stones can be removed under visual video endoscopic control. It has no problems related to tract or stone size.

Biliary sphincterotomy is not required for bile duct stent placement

BACKGROUND

The aim of the present study was to assess the success and outcome of bile duct stent placement without the use of endoscopic biliary sphincterotomy (EBS).

PATIENTS AND METHODS

Over a period of 10 years and 9 months, all patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) were prospectively identified. Bile duct stent placement was routinely done without EBS unless additional therapy (stone removal, multiple stenting) was anticipated.

RESULTS

Of 5020 patients who underwent ERCP, bile duct stents were placed in 1668 patients. After excluding those requiring additional endoscopic therapy, 1112 patients (89.5%) had ERCP and stent placement without a sphincterotomy and 130 patients (10.5%) had ERCP and stent placement with asphincterotomy. Deployed endoprostheses were self-expandable metallic stents in 15.7% and plastic in 77.5%. Caliber of plastic stents was 10 Fr in 78.9% and <10 Fr in 21.1%. All stents were successfully placed in these 1112 patients without the need for EBS. Comparing patients undergoing bile duct stenting with and without sphincterotomy, no difference was seen in rates of pancreatitis (1.54% vs 2.07%, P > 0.9999).

CONCLUSION

Single bile duct stents, both plastic and metal, can be deployed without EBS.

[Endosonography in diagnosis of choledocholithiasis]

BACKGROUND AND STUDY AIMS

In 38-80% patients with suspicion to choledocholithiasis were no stones in common bile duct (CBD) after endoscopic retrograde cholangiopancreatography (ERCP). ERCP is not safe procedure and has a risk of complications ranging 4-15%. The aim of our study was to estimate the diagnostic value and safety of endoscopic ultrasound (EUS) in CBD stones diagnosis.

PATIENTS AND METHODS

In patients with medium probability of CBD stones (i.e. CBD ≤ 10 mm and/or bilirubin ≤ 2 times upper normal) was performed BUS with Pentax EG-3870UTK and Hitachi EUB-7000HV. From September 2012 till December 2013 it were done 72 investigations in patients with suspicion of CBD stones.

RESULTS

After EUS suspicion for CBD stones were in 21 patients. Average size of hyperechoic defects was 5.6 ± 3.3 (2-12) mm. ERCP was performed in 20 of them. Stones were confirmed and removed in 18 patients, in 2 patients without stones it was found a stricture of terminal part of CBD. In 9 patients absence of stones was confirmed during laparoscopic cholecystectomy with IOC. Patients without indications to cholecystectomy were followed for six months and there were no additional investigations. It were no complications after EUS. EUS sensitivity was 100%, specificity--96.2%, PPV--90%, NPV--100%.

CONCLUSION

EUS is effective tool for diagnosis of CBD stones in patients with medium probability of choledocholithiasis. It could be recommended as a first diagnostic step in these patients because the risk of complications is negligible.

Endoscopic papillary large balloon dilation for the removal of bile duct stones

Endoscopic papillary large balloon dilation (EPLBD) with endoscopic sphincterotomy (EST) has been widely used as the alternative to EST along with endoscopic mechanical lithotripsy (EML) for the removal of large or difficult bile duct stones. Furthermore, EPLBD without EST was recently introduced as its simplified alternative technique. Thus, we systematically searched PubMed, Medline, the Cochrane Library and EMBASE, and analyzed all gathered data of EPLBD with and without EST, respectively, by using a single standardized definition, reviewing relevant literatures, published between 2003 and June 2013, where it was performed with large-diameter balloons (12-20 mm). The outcomes, including the initial success rate, the rate of needs for EML, and the overall success rate, and adverse events were assessed in each and compared between both of two procedures: “EPLBD with EST” and “EPLBD without EST”. A total of 2511 procedures from 30 published articles were included in EPLBD with EST, while a total of 413 procedures from 3 published articles were included in EPLBD without EST. In the results of outcomes, the overall success rate was 96.5% in EPLBD with EST and 97.2% in EPLBD without EST, showing no significant difference between both of them. The initial success rate (84.0% vs 76.2%, P < 0.001) and the success rate of EPLBD without EML (83.2% vs 76.7%, P = 0.001) was significantly higher, while the rate of use of EML was significantly lower (14.1% vs 21.6%, P < 0.001), in EPLBD with EST. The rate of overall adverse events, pancreatitis, bleeding, perforation, other adverse events, surgery for adverse events, and fatal adverse events were 8.3%, 2.4%, 3.6%, 0.6%, 1.7%, 0.2% and 0.2% in EPLBD with EST and 7.0%, 3.9%, 1.9%, 0.5%, 0.7%, 0% and 0% in EPLBD without EST, respectively, showing no significant difference between both of them. In conclusion, recent accumulated results of EPLBD with or even without EST suggest that it is a safe and effective procedure for the removal of large or difficult bile duct stones without any additional risk of severe adverse events, when performed under appropriate guidelines.

[Acute, severe pancreatitis in a 13-year-old girl]

Acute pancreatitis is uncommon in children and the spectrum of etiologies is broader than in adults. Here we describe a case of acute, severe gallstone pancreatitis in an obese, 13-year-old girl presenting with upper abdominal pain and markedly elevated levels of amylase and transaminases. Abdominal ultrasound showed cholelithiasis and dilatation of the common bile duct; and an endoscopic retrograde cholangiopancreatography with papillotomy was performed. The girl was discharged for elective laparoscopic cholecystectomy.

Endoscopic papillary balloon dilation: Revival of the old technique

Radiologists first described the removal of bile duct stones using balloon dilation in the early 1980s. Recently, there has been renewed interest in endoscopic balloon dilation with a small balloon to avoid the complications of endoscopic sphincterotomy (EST) in young patients undergoing laparoscopic cholecystectomy. However, there is a disparity in using endoscopic balloon papillary dilation (EPBD) between the East and the West, depending on the origin of the studies. In the early 2000s, EST followed by endoscopic balloon dilation with a large balloon was introduced to treat large or difficult biliary stones. Endoscopic balloon dilation with a large balloon has generally been recognized as an effective and safe method, unlike EPBD. However, fatal complications have occurred in patients with endoscopic papillary large balloon dilation (EPLBD). The safety of endoscopic balloon dilation is still a debatable issue. Moreover, guidelines of indications and techniques have not been established in performing endoscopic balloon dilation with a small balloon or a large balloon. In this article, we discuss the issue of conventional and large balloon endoscopic dilation. We also suggest the indications and optimal techniques of EPBD and EPLBD.

Double-duct sign: do not forget the gallstones

A double-duct sign is the combined dilatation of the common bile duct and pancreatic duct, often caused by cancer of the pancreas. We present a patient with colicky pain in the right upper quadrant of her abdomen. On radiological imaging and endosonography, she had a double-duct sign due to choledocholithiasis and no mass in the pancreatic head. A literature search was performed, which indicated that in selected patients with a higher likelihood of pancreas cancer (for example jaundice or pancreatic mass on radiological imaging) up to 85% of patients do indeed have a pancreatic cancer. In an unselected population, regardless of presenting symptoms, a double-duct sign on endoscopic retrograde cholangiopancreatography (ERCP) was caused by a pancreas malignancy in 58% of patients. In selected patients without jaundice but with a double duct sign, pancreas cancer was only seen in 6% of patients. The sensitivity and specificity of the double-duct sign observed by ERCP for pancreatic cancer varies between 50-76% and 63-80%, respectively. Our patient with symptomatic choledocholithiasis underwent an uncomplicated ERCP with stone extraction and papillotomy and was referred for a cholecystectomy.

One-step laparoscopic and endoscopic treatment of gallbladder and common bile duct stones: our experience of the last 9 years in a retrospective study

The optimal timing and best method for removal of common bile duct stones (CBDS) associated with gallbladder stones (GBS) is still controversial. The aim of this study is to investigate the outcomes of a single-step procedure combining laparoscopic cholecystectomy (LC), intraoperative cholangiography (IOC), and endoscopic retrograde cholangiopancreatography (ERCP). Between January 2003 and January 2012, 1972 patients underwent cholecystectomy at our hospital. Of those, 162 patients (8.2%; male/female 72/90) presented with GBS and suspected CBDS. We treated 54 cases (Group 1) with ERCP and LC within 48 to 72 hours. In 108 patients (Group 2) we performed LC with IOC and, if positive, was associated with IO-ERCP and sphincterotomy. In Group 1, a preoperative ERCP and LC were completed in 50 patients (30%). In four cases (2%), an ERCP and endobiliary stents were performed without cholecystectomy and then patients were discharged because of the severity of clinical conditions and advanced American Society of Anesthesiologists score (III to IV). Two months later a preoperative ERCP and removal of biliary stents were performed followed by LC 48 to 72 hours later. In Group 2, the IOC was performed in all cases and CBDS were extracted in 94 patients (87%). In two cases, the laparoscopic choledochotomy was necessary to remove large stones. In another two cases, an open choledochotomy was performed to remove safely the stones with T-tube drainage. In three cases, conversion was necessary to safely complete the procedure. The mean operative time was 95 minutes (range, 45 to 150 minutes) in Group 1 and 130 minutes (range, 50 to 300 minutes) in Group 2. The mean hospital stay was 6.5 days (range, 4 to 21 days) in Group 1 and 4.7 days (range, 3 to 14 days) in Group 2. Five cases (two in Group 2 and three in Group 1) presented with CBDS at 12 to 18 months after surgery. They were treated successfully with a second ERCP. There was no perioperative mortality. Our experience suggests that when clinically and technically feasible, a single-stage approach combining LC, IOC, and ERCP to the patients diagnosed with chole-choledocholithiasis is indicated. The IO-ERCP with CBDS extraction is a safe and effective method with low risk of postoperative pancreatitis. One-step treatment is more comfortable for the patient and also reduces the mean hospital stay.

[Progress of intersphincter resection with direct coloanal anastomosis for ultra-low rectal cancer]

In recent years, sphincter preservation and improvement of quality of life have become the primary goals in the management of low-lying rectal cancer. For lesions within 2 cm from the dentate line or more than 5 cm from the anal margin, abdominoperineal resection results in permanent stoma creation while intersphincteric resection (ISR) provides solution to sphincter function preservation and improved quality of life. This review was to summarize the current literature pertaining to this procedure, including current research progress, indications, development of ISR procedure, oncological and functional outcomes.

Endoscopic papillary large balloon dilation in patients with periampullary diverticula

AIM: To evaluate the safety and effectiveness of endoscopic papillary large balloon dilation (EPLBD) for bile duct stone extraction in patients with periampullary diverticula.

METHODS: The records of 223 patients with large common bile duct stones (≥ 10 mm) who underwent EPLBD (12-20 mm balloon diameter) with or without limited endoscopic sphincterotomy (ES) from July 2006 to April 2011 were retrospectively reviewed. Of these patients, 93 (41.7%) had periampullary diverticula (PAD), which was categorized into three types. The clinical variables of EPLBD with limited ES (EPLBD + ES) and EPLBD alone were analyzed according to the presence of PAD.

RESULTS: Patients with PAD were significantly older than those without (75.2 ± 8.8 years vs 69.7 ± 10.9 years, P = 0.000). The rates of overall stone removal and complete stone removal in the first session were not significantly different between the PAD and non-PAD groups, however, there was significantly less need for mechanical lithotripsy in the PAD group (3.2% vs 11.5%, P = 0.026). Overall stone removal rates, complete stone removal rates in the first session and the use of mechanical lithotripsy were not significantly different between EPLBD + ES and EPLBD alone in patients with PAD (96.6% vs 97.1%; 72.9% vs 88.2%; and 5.1% vs 0%, respectively). No significant differences with respect to the rates of pancreatitis, perforation, and bleeding were observed between EPLBD + ES and EPLBD alone in the PAD group (3.4% vs 14.7%, P = 0.095; 0% vs 0%; and 3.4% vs 8.8%, P = 0.351, respectively).

CONCLUSION: EPLBD with limited ES and EPLBD alone are safe and effective modalities for common bile duct stone removal in patients with PAD, regardless of PAD subtypes.

One-stage versus two-stage management for concomitant gallbladder stones and common bile duct stones in patients with obstructive jaundice

No consensus exists regarding the optimal management of concomitant gallbladder stones and common bile duct stones (CBDS). Previous studies showed a significant association between the presence of obstructive jaundice and increased risk of postoperative complications and conversion to open surgery. This retrospective study evaluated the effectiveness and safety of one-stage (laparoscopic cholecystectomy [LC] plus laparoscopic common bile duct exploration) management versus two-stage (preoperative endoscopic retrograde cholangiopancreatography/endoscopic sphincterotomy + LC) management for patients with obstructive jaundice, concomitant gallbladder stones, and CBDS. One-stage management (n = 88) or two-stage management (n = 122) was used for 210 eligible patients between January 2009 and March 2011. Both types of management proved to be effective and safe. No significant difference was observed in terms of stone clearance from the common bile duct (CBD), postoperative morbidity, mortality, or conversion to open surgery. However, one-stage management was more cost-effective and decreased the number of procedures. In addition, postoperative hospital stay and operative time were shorter for patients who received one-stage management. Especially for patients with CBD greater than 1 cm in diameter, one-stage management is a better choice.

Endotherapy in chronic pancreatitis

Chronic pancreatitis (CP) is a progressive disease with irreversible changes in the pancreas. Patients commonly present with pain and with exocrine or endocrine insufficiency. All therapeutic efforts in CP are directed towards relief of pain as well as the management of associated complications. Endoscopic therapy offers many advantages in patients with CP who present with ductal calculi, strictures, ductal leaks, pseudocyst or associated biliary strictures. Endotherapy offers a high rate of success with low morbidity in properly selected patients. The procedure can be repeated and failed endotherapy is not a hindrance to subsequent surgery. Endoscopic pancreatic sphincterotomy is helpful in patients with CP with minimal ductal changes while minor papilla sphincterotomy provides relief in patients with pancreas divisum and chronic pancreatitis. Extracorporeal shock wave lithotripsy is the standard of care in patients with large pancreatic ductal calculi. Long term follow up has shown pain relief in over 60% of patients. A transpapillary stent placed across the disruption provides relief in over 90% of patients with ductal leaks. Pancreatic ductal strictures are managed by single large bore stents. Multiple stents are placed for refractory strictures. CP associated benign biliary strictures (BBS) are best treated with multiple plastic stents, as the response to a single plastic stent is poor. Covered self expanding metal stents are increasingly being used in the management of BBS though further long term studies are needed. Pseudocysts are best drained endoscopically with a success rate of 80%-95% at most centers. Endosonography (EUS) has added to the therapeutic armamentarium in the management of patients with CP. Drainage of pseudcysts, cannulation of inaccessible pancreatic ducts and celiac ganglion block in patients with intractable pain are all performed using EUS. Endotherapy should be offered as the first line of therapy in properly selected patients with CP who have failed to respond to medical therapy and require intervention.

[Endoscopic contact lithotripsy--modern alternative in the therapy of patients with large stones of the common bile duct]

The peculiarities of therapeutic ERCP and contact lithotripsy in patients with choledocholithiasis were studied. 6516 patients (age from 11 to 94 years old) with choledocholithiasis were examined Endoscopic sphincterotomy/balloon dilation with stone extraction was effective in 5507 (84.5%), in 539 (8.8%)--we achieved bile ducts clearance by using mechanical or electrohydraulic lithotripsy. Additional usage of contact lithotripsy increased the effectiveness of therapeutic ERCP to 93.2%. Contact lithotripsy decreased number of specific for ERCP complication from 7.83% to 1.57% in patients with large (> 25mm) stones. Electrohydraulic lithotripsy was successful in destruction of hard bile stones, when mechanical lithotripsy failed.

Primary sclerosing cholangitis in patient with celiac disease complicated by cholecystic empyema and acute pancreatitis

BACKGROUND

The association of celiac disease and sclerosing cholangitis is a well known, although unusual, pathologic feature of autoimmunity.

METHODS

A 64 year old patient presenting with sub-acute cholangitis and pancreatitis, treated with cholecystectomy and endoscopic sphincterotomy. The post-operative course, complicated by cholestatic jaundice, and subsequent clinical complications are described, showing how the diagnosis of sclerosing cholangitis was outlined after the Endoscopic Retrograde Cholangio-Pancreatography (ERCP) and confirmed by liver biopsy. Long term treatment with Ursodeoxycholic acid has gradually normalized bilirubin values, while cholestasis enzymes are gradually decreasing. After 18 months bleeding from oesophageal varices ensued, which was controlled through endoscopic ligation.

CONCLUSIONS

The diagnosis of primary sclerosing cholangitis should be taken into account when cholangitis is associated with other immunity derangements and segmentary dilatations of the intra-hepatic bile ducts, but no dilatation of the main bile duct is noticed at imaging or endoscopy. Recovery of hepatic function should be always attempted before bringing the patient to surgery, in order to avoid postoperative hepatic decompensation.

[Typing and surgical treatment choice for pancreatic ductal stone]

OBJECTIVE

To explore the improvement of typing and reasonable surgical treatment for pancreatic ductal stone (PDS).

METHODS

Totally 89 patients with pancreatic ductul stone treated underwent surgeries from January 2000 to December 2012 were involved into this study. There were 57 male and 32 female patients, the average age was (52 ± 23) years. According to the magnetic resonance cholangiopancreatography imaging and finding during surgery, pancreatolithiasis was classified into three types: type I, the stones were located in the main pancreatic duct; type II, the stones were located both in main and branch pancreatic duct; type III, the stones were diffusely scattered in the branch pancreatic duct; the position of PDS within pancreatic parenchyma were subtitled. In this group, 43 type I PDS were extracted with endoscopic papillotomy or endoscopic pancreatic sphincterotomy, or pancreatolithotomy plus pancreato-jejunal lateral anastomosis with wide anastomotic stoma; 39 type II cases were treated by pancreatolithotomy plus pancreato-jejunal lateral anastomosis or/and resection of pancreatic section; 7 type III PDS were managed with resection of pancreatic section.

RESULTS

All surgeries were performed successfully. Among complications, 6 cases (6.7%) were pancreatic leakage which recovered after systematic non-surgical treatment, 2 cases (2.2%) were anastomotic bleeding which led to 1 death, 6 cases (6.7%) were residual pancreatolithiasis in branch pancreatic duct type. Seventy-eight patients were followed up for 6 to 131 months, 57 cases were still alive so far. Five cases were intermittent abdominal pain, 7 cases were diabetes resulted from 2 subtotal pancreatectomy and 5 distal pancreatectomy, 5 cases occurred pancreatolithiasis recurrence and 3 underwent secondary surgeries.

CONCLUSIONS

The basis of this modified typing of pancreatolithiasis is the position of stone in pancreatic duct rather than pancreas parenchyma. It is more important and valuable for surgical principle of taking stones out completely and maintaining pancreatic function.

ERCP on a cohort of 2,986 patients with cholelitiasis: a 10-year experience of a single center

BACKGROUND & AIMS

Endoscopic Retrograde Cholangio-Pancreatography (ERCP) is the standard method of treatment for choledocholithiasis. We evaluated the diagnostic success rate and the outcomes of therapeutic ERCP for bile duct stones, in relation to the anatomical variants.

METHOD

A total of 3,097 consecutive ERCPs were performed in 2,986 patients during a 10-year period (2002-2011) in our endoscopy department. The analysis of the results of therapy was performed in relation to the anatomical variants, patients' age, opacification of the Wirsung duct and recurrent lithiasis.

RESULTS

The rate of successful cannulation was 98%. The patient's age and the diameter of the common bile duct were the factors influencing the probability of finding a gallstone: age over 74 years, AUC=0.547 (p<0.001) and a CBD diameter larger than 12 mm (AUC=0.735, p<0.001). The number of cases with opacification of the Wirsung duct, the use of precut papillotomy and the inability of finding a stone significantly decreased with the increasing experience of the operator (p<0.001). The stone removal was unsuccessful in 2.3%. Factors associated independently with unsuccessful extraction were previous surgical sphincteroplasty, stone size and Billroth I anastomosis. Ninety two patients (4.3%) were diagnosed with recurrent lithiasis. Factors associated independently with recurrence were stone size (p=0.002, OR=0.35), dilation of infundibulum (p=0.04, OR=0.13) and the presence of periampullary diverticula (p=0.004, OR=0.28).

CONCLUSIONS

The endoscopic treatment of choledocholithiasis is highly effective. It is influenced partly by the experience of the operator. In experienced hands, the success rate is high even in cases of anatomical variants and difficult calculi.

[Endoscopic papillary balloon dilatation vs. endoscopic sphincteropapillotomy for common bile duct stones: a meta analysis]

OBJECTIVE

To evaluate the safety and efficacy between endoscopic papillary balloon dilatation (EPBD) and endoscopic sphincteropapillotomy ( EST) for common bile duct stones using meta-analysis method.

METHODS

Randomizd controlled trials comparing EPBD with EST for common bile duct stones and published from January 1990 to July 2012 were recruited. This meta-analysis was conducted to estimate short-term and long-term complications. Fixed random effect model or random effect model was established to analyze the data.

RESULTS

Twelve randomizd controlled trials were included in this analysis. These studies included 1865 patients, 925 of them were treated with EPBD and 940 were treated with EST. The analysis of basic characteristics of these included studies showed that: compared to EST, patients in the EPBD group were younger (OR = -1.16, 95% CI: -1.49 to -0.84, P = 0.00), while in two groups, there were no significant difference (P > 0.05) in gender proportion, average size of stones, number of gallstones, previous cholecystectomy, the number of merged duodenal diverticulum, common bile duct diameter, the total follow-up time. Also, compared to EST, the overall stone clearance in the EPBD group was lower (OR = 0.64, 95% CI: 0.42 to 0.96, P = 0.03), pancreatitis incidence was higher (OR = 2.67, 95% CI: 1.61 to 4.43, P = 0.00), incidence of bleeding (OR = 0.12, 95% CI: 0.04 to 0.34, P = 0.00), acute cholecystitis (OR= 0.39, 95% CI: 0.18 to 0.84, P = 0.02), total long-term complication rate (OR = 0.53, 95% CI: 0.36 to 0.77, P = 0.01), stone recurrence rate more than a year were lower (OR= 0.48, 95% CI: 0.26 to 0.90, P = 0.02). While in two groups, there were no significant difference (P > 0.05) in the stone removal on 1 '' attempt, the total near-term complications and acute cholangitis.

CONCLUSIONS

On the basis of lower rates of bleeding, EPBD seems to be preferred strategy over EST for endoscopic remove of common bile duct stones in patients who have coagulopathy. Although stone recurrence rate more than a year of EPBD is lower, but the overall stone clearance rate is lower and the risk of pancreatitis is higher than that of EST.

[Analysis of clinical application of endoscopic retrograde cholangiopancreatography for the pancreatic diseases in children]

OBJECTIVE

To study the feasibility and risk of endoscopic retrograde cholangiopancreatography (ERCP) for children in clinic, and to evaluate the effects of ERCP in diagnosis and treatment of the pancreatic diseases in children.

METHOD

Totally 98 patients under 14 years of age who underwent ERCP from 1994 to 2011 were enrolled in the study. The data of diagnosis, anesthesia type, treatments, and postoperative complications were collected.

RESULT

The 98 patients were 4 to 14 years old, of whom 32 cases suffered from acute pancreatitis (30 cases with biliary disease and 2 with hyperlipidemia); 42 cases had chronic pancreatitis, of whom 36 had calculus of pancreatic duct, pancreatic pseudocyst was seen in 6 cases. Pancreas divisum was found in 20 cases, choledochopancreatic junction anomaly in 6 cases,and annular pancreas in 1 case. The operations of dissection of pancreatic duct and biliary duct, calculus removal, insertion of endoprosthesis and draining tube in pancreatic duct or biliary duct were performed. No patients died from ERCP complications. In observation of postoperative complications, acute pancreatitis after ERCP occurred in 1 case, with the incidence rate of 1%, 1 case had bleeding (1%), and 5 cases had hyperamylasemia (5%). All the complications were cured within 1 week. The average hospital stay was 5.51 d.

CONCLUSION

ERCP is useful and safe in children under suitable condition of doctors and equipments, and no high rates of complications were observed.

Ampulla dilation with different sized balloons to remove common bile duct stones

AIM: To assess the outcomes of ampulla dilation with different sized balloons to remove common bile duct (CBD) stones.

METHODS: Patients (n = 208) were divided into five groups based on the largest CBD stone size of < 5, 6-8, 8-12, 12-14, and > 14 mm. Patients underwent limited endoscopic sphincterotomy (EST) alone or limited EST followed by endoscopic papillary balloon dilation with 8, 10, 12 and 14 mm balloons, such that the size of each balloon did not exceed the size of the CBD. Short- and long-term outcomes, such as post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis, perforation, bleeding, and pneumobilia were compared among the five groups.

RESULTS: The overall rate of successful stone removal in all groups was 100%, and all patients were cured. Eight (3.85%) patients had post-ERCP pancreatitis, none had perforations, and 6 (2.9%) had bleeding requiring transfusion. There were no significant differences in early complication rates among the five groups. We observed significant correlations between increased balloon size and the short- and long-term rates of post-ERCP pneumobilia. Post-ERCP pancreatitis and bleeding correlated significantly with age, with post-ERCP pancreatitis occurring more frequently in patients aged < 60 years, and bleeding occurring more frequently in patients aged > 70 years. We observed a significant correlation between patient age and the diameter of the largest CBD stone, with stones > 12 mm occurring more frequently in patients > 60 years old.

CONCLUSION: Choosing a balloon size based on the largest stone diameter is safe and effective for removing CBD stones. Balloon size should not exceed 15 mm.

Endoscopic stent therapy in patients with chronic pancreatitis: A 5-year follow-up study

AIM: This study analyzed clinical long-term outcomes after endoscopic therapy, including the incidence and treatment of relapse.

METHODS: This study included 19 consecutive patients (12 male, 7 female, median age 54 years) with obstructive chronic pancreatitis who were admitted to the 2^nd Medical Department of the Technical University of Munich. All patients presented severe chronic pancreatitis (stage III°) according to the Cambridge classification. The majority of the patients suffered intermittent pain attacks. 6 of 19 patients had strictures of the pancreatic duct; 13 of 19 patients had strictures and stones. The first endoscopic retrograde pancreatography (ERP) included an endoscopic sphincterotomy, dilatation of the pancreatic duct, and stent placement. The first control ERP was performed 4 wk after the initial intervention, and the subsequent control ERP was performed after 3 mo to re-evaluate the clinical and morphological conditions. Clinical follow-up was performed annually to document the course of pain and the management of relapse. The course of pain was assessed by a pain scale from 0 to 10. The date and choice of the therapeutic procedure were documented in case of relapse.

RESULTS: Initial endoscopic intervention was successfully completed in 17 of 19 patients. All 17 patients reported partial or complete pain relief after endoscopic intervention. Endoscopic therapy failed in 2 patients. Both patients were excluded from further analysis. One failed patient underwent surgery, and the other patient was treated conservatively with pain medication. Seventeen of 19 patients were followed after the successful completion of endoscopic stent therapy. Three of 17 patients were lost to follow-up. One patient was not available for interviews after the 1^st year of follow-up. Two patients died during the 3^rd year of follow-up. In both patients chronic pancreatitis was excluded as the cause of death. One patient died of myocardial infarction, and one patient succumbed to pneumonia. All three patients were excluded from follow-up analysis. Follow-up was successfully completed in 14 of 17 patients. 4 patients at time point 3, 2 patients at time point 4, 3 patients at time point 5 and 2 patients at time point 6 and time point 7 used continuous pain medication after endoscopic therapy. No relapse occurred in 57% (8/14) of patients. All 8 patients exhibited significantly reduced or no pain complaints during the 5-year follow-up. Seven of 8 patients were completely pain free 5 years after endoscopic therapy. Only 1 patient reported continuous moderate pain. In contrast, 7 relapses occurred in 6 of the 14 patients. Two relapses were observed during the 1^st year, 2 relapses occurred during the 2^nd year, one relapse was observed during the 3^rd year, one relapse occurred during the 4^th year, and one relapse occurred during the 5^th follow-up year. Four of these six patients received conservative treatment with endoscopic therapy or analgesics. Relapse was conservatively treated using repeated stent therapy in 2 patients. Analgesic treatment was successful in the other 2 patients.

CONCLUSION: 57% of patients exhibited long-term benefits after endoscopic therapy. Therefore, endoscopic therapy should be the treatment of choice in patients being inoperable or refusing surgical treatment.

Comparison of endoscopic retrograde cholangiopancreatography between elderly and younger patients for common bile duct stones

BACKGROUND

Choledocholithiasis is increasing in elderly subjects. The introduction of endoscopic retrograde cholangiopancreatography with biliary sphincterotomy has almost replaced surgery in the treatment of this condition. The aim of the present study was to evaluate the rates of successful clearance of common bile duct stones and the endoscopic techniques used in a population aged 75 years or older compared with those in a younger age group.

MATERIALS AND METHODS

A retrospective analysis was made of data related patients who underwent endoscopic retrograde cholangiopancreatography for choledocolithiasis in the period 2010-2011. For all patients, factors such as sex, age at diagnosis, endoscopic treatment (stone extraction using baskets and balloon, mechanical lithotripsy and balloon dilatation of the ampulla, placement of a stent or a naso-biliary tube) and need of surgery were analysed. Two groups of patients were identified: patients aged <75 years (Group A) and patients aged ≥75 years (Group B). For the statistical analysis Mann-Whitney test and Fischer's Exact test were used.

RESULTS

A total of 234 patients were enrolled in the study (94 in Group A, 140 in Group B). No statistically significant differences were observed as far concerns sex, previous cholecystectomy, gallbladder stones and periampullary diverticula, but only for common bile duct dilatation. Complete clearance of common bile duct stones was achieved in 230 patients (97.5%).

CONCLUSIONS

The present data are in keeping with those presented in the literature, which confirm that endoscopic retrograde cholangiopancreatography is a safe and effective procedure also in older patients.

Juxtapapillary duodenal diverticula risk development and recurrence of biliary stone

We assessed whether the presence of juxtapapillary duodenal diverticula (JPDD) risks biliary stone disease and recurrence. In total, 695 patients who underwent ERCP were divided into two groups: biliary stone disease (group I, n = 523) and non-stone biliary diseases (group II, n = 172). Additionally, for a control group (group III), 80 age-matched healthy subjects underwent side-view duodenoscopy. In group I, rates of post-ERCP pancreatitis, cannulation failure, and disease recurrence in two-year follow up were compared according to the presence of JPDD. In results, the incidence of JPDD in group I (42.4%) was significantly higher than in group II (16.3%) and III (18.8%). The frequencies of JPDD were increased with age in all groups, and reached statistical significance in group I. In group I, rates of post-ERCP pancreatitis were significantly higher in patients with JPDD (18.5%) compared to JPDD negative (12.6%). The cannulation failure rate was also higher in patients with JPDD (9.9%) compared to JPDD negative (5.3%). Recurrence rate was higher in patients with JPDD (25.3%) compared to JPDD negative (9.2%). In conclusion, JPDD develops with aging and risks biliary stone formation. JPDD also seems to be associated with post-ERCP pancreatitis, cannulation failure and biliary stone recurrence.

Endoscopic treatment of difficult choledocholithiasis

Common bile duct stones can be treated with normal endoscopic techniques. Where stones cannot be removed due to their size or number or due to stenosis of the common bile duct, a plastic stent can be inserted, enabling rapid drainage of bile. At the three-month check-up complete removal of the stones was found in 41 (85.4%) of the 48 patients with difficult choledocholithiasis. In the remaining 7 patients (14.6%), the stent in any case resulted in clinical improvement. A permanent stent was necessary in 4 patients, enabling safe drainage with no complications. The use of endoscopy for stent placement was effective in all our cases of difficult coledocholithiasis without any complications.

Update on endoscopic management of main pancreatic duct stones in chronic calcific pancreatitis

Pancreatic duct stones are a common complication during the natural course of chronic pancreatitis and often contribute to additional pain and pancreatitis. Abdominal pain, one of the major symptoms of chronic pancreatitis, is believed to be caused in part by obstruction of the pancreatic duct system (by stones or strictures) resulting in increasing intraductal pressure and parenchymal ischemia. Pancreatic stones can be managed by surgery, endoscopy, or extracorporeal shock wave lithotripsy. In this review, updated management of pancreatic duct stones is discussed.

[Hydatid cysts with hepatic and pelvic synchronous location--clinical case]

About 75% of all hydatid cysts are located in the liver and they are singular. Extrahepatic hydatid cysts are rare pre- and intra-operative findings. The majority of such locations are consecutive from a hepatic primary. We present the clinical case of a 28-years woman, clinically diagnosed with a pelvic tumor. Ultrasonography and CT-scan showed two large tumors: a 17/10 cm left liver cyst, that contained free floating hyperechogenic hydatid sand and a 12/11 cm pelvic cyst, that displaced the urinary bladder, the uterus, the sigmoid colon and the rectum. The diagnosis of synchronous hepatic and pelvic hydatid cysts was suggested. Explorative laparotomy revealed a large cystic tumor of the left liver, 20/15 cm, with many daughter cysts. The cysts were aspirated through a closed suction system and flushed with hypertonic saline, then its cavity was unroofed and drained. We also found a voluminous hydatid cyst of the pelvis, which was treated in the same manner. After 2 days, a bile duct communication was diagnosed, with a medium biliary output--300-400 ml/day. The fistulography confirmed the connection with the biliary ducts. An endoscopic sphincterotomy was then performed, followed by a favourable evolution. According to the scientific criterias from the literature, we discussed the treatment and the outcome of these extrahepatic locations.

[Current therapy of the pancreato-pleural fistula]

This case report summarizes therapeutic options for the management of pancreato-pleural fistula (PPF) following a successful conservative treatment of one of our patients. PPF is a rare complication of chronic pancreatitis. The main aetiological factor is alcohol, which causes relapse of chronic pancreatitis associated with dyspnoea. Diagnosis is confirmed by physical examinations, laboratory tests of pleural fluid as well as ERCP being the most important diagnostic procedure. Conservative treatment of PPF consists of endoscopic therapy (endoscopic sphincterotomy with stenting of the pancreatic duct), octreotid combined with continuous enteral nutrition (jejunal feeding). If the above complex therapy fails, surgical treatment of PPF is advised.

[Factors related to therapeutic failure in the extraction of bile duct stones for endoscopic retrograde colangiopancreatography ERCP]

OBJECTIVE

Determine the factors that contribute to the technical difficulty of endoscopic clearance of common bile duct (CBD) stones in patients that underwent endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

Prospective study included 90 patients, who underwent ERCP and an endoscopic sphincterotomy for the extraction of CBD stone. Between April 2009 and March 2010 at Arzobispo Loayza National Hospital. The technical difficult of CBD stone removal was graded in: easy (1 to 8 attempts) and difficult ( more than 8 attempts or failed).

RESULTS

In the bivariate analysis, we found that factors which are related to the degree of difficulty were: stone greater than or equal to 15 mm, OR = 19.8, CI (5.7 - 68.6); common bile duct greater than or equal to 15 mm, OR= 12.8, CI (3.7 - 44.3) and the use of mechanical lithotripsy, OR= 18.6, CI (1.9 -179). No association was found between the difficulty of the clearance of stone with: age, previous cholecystectomy, number of stones, stone impaction, periampullary diverticulum, sharper distal common bile duct angulation and shorter arm of common bile duct angulation.

CONCLUSIONS

Complete clearance of common bile duct stone was technically more difficult in patients with: stone greater than or equal to 15 mm, diameter of common bile duct greater than or equal to 15 mm and with the use of mechanical lithotripsy.

Therapeutic effects of endoscopic therapy combined with enteral nutrition on acute severe biliary pancreatitis

BACKGROUND

Acute severe biliary pancreatitis (ASBP) is a severe and fatal disease, and the expenditure is huge and therapeutic effects are still not satisfactory. This study aimed to improve the therapeutic effects and reduce the expenditure of ASBP treatment.

METHODS

One hundred and five patients diagnosed with ASBP were referred to our department from January 2004 to July 2009. Diagnosis was based on the 2007 criteria of the Chinese Society of Surgery. Patients were divided into two groups; the E group: 50 patients who underwent endoscopic retrograde choledochopancreatography (ERCP) + endoscopic sphincterotomy (EST) + endoscopic lithotripsy basket (ESR) + endoscopic retrograde biliary drainage (ERBD) and enteral nutrition (EN), and the R group: 55 patients who underwent traditional treatment without ERCP. Subsequently, subjective symptoms, signs, biochemical analysis, serum endotoxin, tumor necrosis factor a, grades by computed tomography (CT), cost of hospitalization and length of stay were compared between the two groups.

RESULTS

All enrolled patients complied well with all therapeutic regimens. Endoscopic therapy that combined EN could significantly improve symptoms, clinical signs, laboratory values, tumor necrosis factor a and endotoxin while significantly reducing hospital expenditure and length of hospital stay. The experimental findings revealed that there were obvious advantages in the E group compared with the R group.

CONCLUSIONS

Endoscopic therapy combined with EN is an effective, safe and economic therapeutic regimen of ASBP.

Different clinical aspects of Wirsungocele: case series of three patients and review of literature

The association of Santorinicele with pancreas divisum has been described. This anatomic condition creates ideal conditions for acute pancreatitis episodes and chronic abdominal pain. Saccular dilation of main pancreatic duct has also been described as incidental finding and causing episodes of acute pancreatitis. However, there is no description of associated chronic abdominal pain. Three detailed cases of Wirsungocele demonstrated by endoscopic retrograde cholangiopancretography are presented. Two of them had episodes of acute pancreatitis and one had chronic abdominal pain. All patients were treated by endoscopic biliopancreatic sphincterotomy. After a follow-up for more than two years, none presents clinical recurrence. Endoscopic biliopancreatic sphincterotomy for symptomatic patients with this anatomic condition seems safe and effective.

Biliary ascariasis--role of endoscopic intervention

AIM

This study was undertaken to review the predisposing factors, presentation and management of patients diagnosed with biliary ascariasis while specifically emphasizing the role played by endoscopy.

METHODS

We performed a retrospective analysis of nine patients diagnosed and admitted with biliary ascariasis at our center. The diagnosis was based on ultrasound findings and confirmed by detection of round worms in the biliary tract or the descending duodenum. The clinical presentation and management were reviewed.

RESULTS

Five of the nine patients had prior biliary sphincter ablative/bypass procedures for choledocholithiasis; including endoscopic sphincterotomy in four and lateral choledochoduodenostomy in one patient. All but one patient presented with acute onset pain abdomen radiating to the back. One patient presented with features of acute cholecystitis. Ultrasound detected the presence of round worms in all the patients. Endoscopic retrograde cholangio-pancreatogram confirmed presence of worm in the biliary tree. Endoscopic extraction of the worm from the biliary tree or duodenum was successfully undertaken in all the patients and provided prompt relief. One patient had recurrence of infection after eight months which was re-treated by endoscopic extraction. Antihelminthics were instituted in all patients.

CONCLUSION

Biliary ascariasis, should be considered in the differential diagnosis of acute abdomen, particularly in patients who have undergone prior biliary sphincter ablation/bypass procedures like sphincterotomy or choledochoduodenostomy. Ultrasonography is a reliable diagnostic modality. Endoscopic retrograde cholangiogram confirms the diagnosis and precedes endoscopic extraction of the worm. This offers prompt relief from symptoms.