Usefulness of intraductal ultrasonography in icteric patients with highly suspected choledocholithiasis showing normal endoscopic retrograde cholangiopancreatography

Evidence-based clinical practice guidelines for cholelithiasis 2021

The Japanese Society of Gastroenterology first published evidence-based clinical practice guidelines for cholelithiasis in 2010, followed by a revision in 2016. Currently, the revised third edition was published to reflect recent evidence on the diagnosis, treatment, and prognosis of cholelithiasis conforming to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Following this revision, the present English version of the guidelines was updated and published herein. The clinical questions (CQ) in the previous version were reviewed and rearranged into three newly divided categories: background questions (BQ) dealing with basic background knowledge, CQ, and future research questions (FRQ), which refer to issues that require further accumulation of evidence. Finally, 52 questions (29 BQs, 19 CQs, and 4 FRQs) were adopted to cover the epidemiology, pathogenesis, diagnosis, treatment, complications, and prognosis. Based on a literature search using MEDLINE, Cochrane Library, and Igaku Chuo Zasshi databases for the period between 1983 and August 2019, along with a manual search of new information reported over the past 5 years, the level of evidence was evaluated for each CQ. The strengths of recommendations were determined using the Delphi method by the committee members considering the body of evidence, including benefits and harms, patient preference, and cost-benefit balance. A comprehensive flowchart was prepared for the diagnosis and treatment of gallbladder stones, common bile duct stones, and intrahepatic stones, respectively. The current revised guidelines are expected to be of great assistance to gastroenterologists and general physicians in making decisions on contemporary clinical management for cholelithiasis patients.

Preferable timing of intraductal ultrasonography during endoscopic retrograde cholangiopancreatography lithotomy: A prospective cohort study

Aim

Intraductal ultrasonography (IDUS) is a highly sensitive and non-invasive detective method that can be used to detect complete calculus clearance during endoscopic retrograde cholangiopancreatography (ERCP). In this study, we examined the preferable timing of IDUS during ERCP lithotomy.

Methods

From 2017 to 2020, patients with choledocholithiasis were randomized into IDUS-BL (IDUS performed before lithotomy) group, IDUS-ALC (cholangiography and IDUS performed after lithotomy) group, and IDUS-AL group (IDUS performed after lithotomy) group. The influence of IDUS on the accuracy of prejudgment, the incidence of residual stones, the need for repeated lithotomy (RL), and fluoroscopy time were analyzed.

Results

A total of 184 patients were enrolled. No residual stones were found during follow-up in any of the three groups. There was no difference in prejudgment accuracy rate on size and number of stones between different groups (all P > 0.05). RL were performed in 5, 9, and 9 cases of IDUS-BL, IDUS-ALC, and IDUS-AL group, respectively (P > 0.05). IDUS-AL group had a shorter fluoroscopy time than the other two groups (1.5 ± 0.6 vs. 2.8 ± 1.2, 2.5 ± 1.0 min, P < 0.05). Incidence of RL was related to the location of calculus [middle or lower part of common bile duct (CBD)], lithotripsy, dilated CBD (2.12 ± 0.46 vs. 1.78 ± 0.40 cm, P < 0.01), and inaccuracy prejudgment.

Conclusion

IDUS performed after lithotomy is preferable for shorten fluoroscopy time during ERCP. IDUS is a reliable solution for the stone omission, which may be more valuable for patients with high-risk factors of RL.

Various innovative roles for 3-Fr microcatheters in pancreaticobiliary endoscopy

With the development of newer devices and technical innovations, pancreaticobiliary endoscopy is expanding to assume more advanced therapeutic roles. As with other devices, slimmed-down "3-Fr microcatheters" are considered to be opening new windows toward entirely new therapeutic techniques for various purposes. Our practical experience with a total of 34 consecutive patients in whom 3-Fr microcatheters were applied during pancreaticobiliary endoscopic procedures clarified the potential roles of this instrument in pancreaticobiliary endoscopy. The major benefits of 3-Fr microcatheters involve their slimness and flexibility. Applications of 3-Fr microcatheters could be categorized into three groups according to the characteristics of usage: (1) utilization as a cannulation catheter for peroral digital cholangioscopy (n = 15); (2) selective advancement through deep flexures or severely stenotic ducts (n = 11); or (3) two-devices-in-one-channel technique (n = 8). The microcatheter worked successfully for cannulation of cholangioscopy in all but one case (14/15, 93.3%). For selective advancement, the microcatheter worked for troubleshooting in 9 of 11 cases (81.8%). With the two-devices-in-one-channel technique, the microcatheter proved satisfactory in all cases (8/8, 100%). In total, the microcatheter was successfully maneuvered in 31 of 34 cases (91.1%), following the failure of procedures using conventional endoscopic techniques. In terms of adverse events, cystic duct injury was only observed in two cases (5.8%), who recovered under conservative observation, because its slimness could minimize the damage. We believe that 3-Fr microcatheters offer effective and safe salvage troubleshooting during various endoscopic pancreaticobiliary procedures that face troublesome situations with conventional strategies.

Effects of Saline Irrigation of the Bile Duct to Reduce the Rate of Residual Common Bile Duct Stones: A Multicenter, Prospective, Randomized Study

OBJECTIVES

In clinical practice, recurrent cholangitis due to residual common bile duct (CBD) stone occurs frequently even after endoscopic stone removal. This study aimed to determine whether preventive saline irrigation of the bile duct (PSIB) after endoscopic removal of CBD stones would decrease the residual CBD stones.

METHODS

In this multicenter, prospective, randomized study, patients who received endoscopic retrograde cholangiopancreatography for removal of CBD stone were randomized to either receiving PSIB after stone removal (PSIB group) or not receiving PSIB (non-PSIB group). Patients were prospectively followed up and the presence of residual CBD stones was evaluated within 6 months after endoscopic stone removal.

RESULTS

A total of 148 patients were enrolled and completed follow-up (73 in PSIB group and 75 in non-PSIB group). The two groups were similar with regard to baseline characteristics. Residual CBD stones were detected in 22 patients (14.9%). The incidences of residual CBD stones were 6.8% in PSIB group and 22.7% in non-PSIB group (P=0.010). Multivariate analysis revealed that the performance of PSIB and the presence of only a single-CBD stone were the significant factors for the decrease of the occurrence of the residual CBD stones. Although, procedure time was slightly longer in PSIB group (22.0 vs 19.2 min, P=0.037), no significant difference was observed in the procedure-related complications between the two groups.

CONCLUSIONS

PSIB could reduce the residual CBD stones without increasing complications. Considering the efficacy and safety, routine PSIB after endoscopic CBD stone removal seems to be preferred (ClinicalTrials.gov identifier: NCT01425177).

Comparing cost-effectiveness between endoscopic ultrasound and endoscopic retrograde cholangiopancreatography in diagnosis of common bile duct stone in patients with predefined risks: A study from a developing country

Background and Objectives:

Endoscopic ultrasound (EUS) achieves results comparable to endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis of common bile duct (CBD) stone, but studies from the western have shown EUS to be less expensive in patients with intermediate risk for CBD stones. The aim of this study was to compare the costs of EUS and ERCP in the diagnosis of CBD stones in a developing country.

Materials and Methods:

A prospective study was done with 141 patients with suspected CBD stones, categorized as having high or intermediate risk for CBD stone. All underwent EUS, and the high-risk patients had ERCP after the EUS. For intermediate-risk patients, an ERCP was done at the discretion of the attending physician. The CBD stone was confirmed by ERCP in patients who underwent both EUS and ERCP. Patients who received EUS only were followed up every 3 months for 1 year. The false negative rate in patients with EUS and ERCP was estimated in the clinical follow-up.

Result:

One hundred and forty-one patients (141: 83 females, 58 males) with a mean age ± standard deviation (SD) of 55.71 ±18.68 years were recruited. Ninety-four (94) patients underwent both EUS and ERCP. ERCP confirmed the diagnosis in 83 of 85 patients (97.6%) with CBD stone detected by EUS. Forty-seven (47) patients with a negative EUS and no ERCP done were symptom-free during the follow-up. The overall sensitivity, specificity, positive predictive value, and negative predictive value of EUS were 97.6%, 80%, 97.6%, and 80% respectively. An EUS-based strategy for high-risk patients was 15% more expensive than an ERCP-based strategy, but the EUS-based strategy reduced the cost to 37.78% less than the ERCP-based strategy in intermediate-risk patients. The EUS-based strategy was cost-saving when the CBD stone prevalence was less than 52.5%.

Conclusion:

EUS is safer and less costly than ERCP for CBD stone diagnosis in patients with intermediate risk.

The role of intraductal ultrasonography in pancreatobiliary diseases

Intraductal ultrasonography (IDUS) provides real-time, cross-sectional imaging of pancreatobiliary ducts and surrounding structures during endoscopic retrograde cholangiopancreatography using a high-frequency ultrasound (US) transducer. Hence, IDUS has been considered a sensitive tool in the evaluation of suspicious choledocholithiasis and neoplasms, to help distinguish between benign and malignant bile duct strictures or wall thickness, and to assess tumor extension and invasion depth. With the rapid development and enriched choices of sensitive diagnostic modalities include but are not limited to endoscopic US, peroral cholangioscopy, and confocal laser endomicroscopy, it is needed to systematically assess the role of IDUS in the investigation of pancreatobiliary diseases. Some new developments and innovative use of IDUS techniques will be discussed in this paper with the review of literature.

Endoscopic Extraction of Biliary Fascioliasis Diagnosed Using Intraductal Ultrasonography in a Patient with Acute Cholangitis

Fasciola hepatica infection may result in biliary obstruction with or without cholangitis in the chronic biliary phase. Because clinical symptoms and signs of F. hepatica are similar to other biliary diseases that cause bile duct obstruction, such as stones or bile duct malignancies, that are, in fact, more common, this condition may not be suspected and diagnosis may be overlooked and delayed. Patients undergoing endoscopic retrograde cholangiopancreatography or endoscopic ultrasonography for the evaluation of bile duct obstruction may be incidentally detected with the worm, and diagnosis can be confirmed by extraction of the leaf-like trematode from the bile duct. Intraductal ultrasonography (IDUS) can provide high-resolution cross-sectional images of the bile duct, and is useful in evaluating indeterminate biliary diseases. We present a case of biliary fascioliasis that was diagnosed using IDUS and managed endoscopically in a patient with acute cholangitis.