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Mittal N, Ali FS, Machado AP, Ngo S, Shatila M, DaVee T, Thosani N, Wadhwa V. The Impact of Intraoperative Glucagon on the Diagnostic Accuracy of Intraoperative Cholangiogram for the Diagnosis of Choledocholithiasis: Experience from a Large Tertiary Care Center. Diagnostics (Basel) 2024; 14:1405. [PMID: 39001295 PMCID: PMC11241315 DOI: 10.3390/diagnostics14131405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 06/24/2024] [Accepted: 06/28/2024] [Indexed: 07/16/2024] Open
Abstract
A proportion of patients who undergo intraoperative cholangiogram (IOC) do not have bile duct stones at the time of endoscopic retrograde cholangiopancreatography (ERCP), either due to the spontaneous passage of stones or a false-positive IOC. Glucagon has been utilized as an inexpensive tool to allow the passage of micro-choledocholithiasis to the duodenum and resolve filling defects caused by stones or air bubbles. The purpose of our study is to understand the change in diagnostic accuracy of IOC to detect choledocholithiasis with intraoperative glucagon. We conducted a retrospective study at a tertiary care center on adult patients who underwent laparoscopic cholecystectomy with IOC. The diagnostic accuracy of IOC was assessed before and after the administration of intravenous glucagon. Of 1455 patients, 374 (25.7%) received intraoperative glucagon, and 103 of these 374 patients (27.5%) showed resolution of the filling defect with the passage of contrast to the duodenum. Pre- and post-glucagon administration comparison showed enhancement in specificity from 78% to 83%, an increase in positive predictive value from 67.3% to 72.4%, and an improvement in the diagnostic accuracy of IOC from 81.5% to 84.3%. Our findings suggest that intraoperative glucagon administration carries the potential to reduce the rate of false-positive IOCs, thereby reducing the performance of unnecessary ERCPs.
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Affiliation(s)
- Nitish Mittal
- Department of Internal Medicine, The University of Texas Health Sciences Center, Houston, TX 77054, USA; (N.M.); (A.P.M.)
| | - Faisal S. Ali
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas Health Sciences Center, Houston, TX 77054, USA; (F.S.A.); (T.D.)
| | - Antonio Pizuorno Machado
- Department of Internal Medicine, The University of Texas Health Sciences Center, Houston, TX 77054, USA; (N.M.); (A.P.M.)
| | - Sean Ngo
- School of Medicine, McGovern Medical School, Houston, TX 77054, USA;
| | - Malek Shatila
- Department of Gastroenterology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Tomas DaVee
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas Health Sciences Center, Houston, TX 77054, USA; (F.S.A.); (T.D.)
| | - Nirav Thosani
- Department of Surgery, Section of Endoluminal Surgery and Interventional Gastroenterology, McGovern Medical School at UTHealth, Houston, TX 77054, USA;
| | - Vaibhav Wadhwa
- Department of Surgery, Section of Endoluminal Surgery and Interventional Gastroenterology, McGovern Medical School at UTHealth, Houston, TX 77054, USA;
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Ul Hassan Khurshid K, Hinna RE, Khan RSA, Rauf Asghar A, Mushtaq Chaudhary A, Afzal M, Ali Khan U, Ali Khan Z, Ali Khan A, Ali Khan RZ. Comparison of Endoscopic Ultrasound and Transabdominal Ultrasound in the Detection of Gallbladder and Common Bile Duct Microlithiasis. Cureus 2024; 16:e58756. [PMID: 38779249 PMCID: PMC11111097 DOI: 10.7759/cureus.58756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2024] [Indexed: 05/25/2024] Open
Abstract
OBJECTIVE Endoscopic ultrasonography (EUS) is an emerging method with a wide range of potential uses in gastroenterology, including the detection of bile duct stones and the identification of early ductal alterations in suspected patients. This study was designed to compare the diagnostic yield of EUS and transabdominal ultrasound (TUS) in the detection of gallbladder and common bile duct (CBD) microlithiasis. METHOD Patients with biliary colic with normal initial TUS were the subjects of this prospective study. EUS scan was performed on all recruited patients and linear endoscopes were used for the EUS examination. Cholecystectomy and histological analysis were done in patients within two weeks after EUS revealing cholelithiasis whereas the cases of CBD stone/microlithiasis were confirmed by endoscopic retrograde cholangiopancreatography (ERCP). The mean values of all hematological characteristics were independently determined for males and females and then compared using Student's t-test. For statistical significance, a p-value of 0.05 or below was used. RESULTS A total of 131 patients, including 77 females and 54 males, with a mean age of 38.41 ± 14.78 years were examined. All 78 (59.5%) individuals who had cholecystectomy were found to have gallstones or microlithiasis as successfully diagnosed by EUS. The sensitivity and specificity of EUS were 92.9% and 100%, respectively, for CBD stones and 98.8% and 100%, respectively, for the detection of gallbladder microlithiasis. The agreement between EUS and TUS was fair for CBD stones (κ = 0.214) and very weak for microlithiasis (κ = -0.093). CONCLUSION EUS demonstrates a superior yield over TUS in detecting gallbladder stones and CBD microlithiasis, offering a more reliable diagnostic modality. LIMITATION This was a single-center study.
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Affiliation(s)
| | - Rashk E Hinna
- Gastroenterology, Pak Emirates Military Hospital, Rawalpindi, PAK
| | | | - Arshman Rauf Asghar
- Internal Medicine, Combined Military Hospital (CMH) Lahore Medical College and Institute of Dentistry, Lahore, PAK
| | | | - Muhammad Afzal
- Internal Medicine, Margalla Institute of Health Sciences, Rawalpindi, PAK
| | | | | | - Ayaan Ali Khan
- Health Sciences, International Community School, Kirkland, USA
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Sanin G, Cambronero G, Patterson J, Bosley M, Ganapathy A, Wescott C, Neff L. ERCP findings provide further justification for a "surgery-first" mindset in choledocholithiasis. Surg Endosc 2023; 37:8714-8719. [PMID: 37524916 DOI: 10.1007/s00464-023-10329-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 07/19/2023] [Indexed: 08/02/2023]
Abstract
INTRODUCTION Choledocholithiasis is most often managed in a two-procedure pathway including endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC). In contrast, a single-stage, surgery-first approach consisting of LC, cholangiogram, and laparoscopic common bile duct exploration (LCBDE) is associated with reduced hospital stays and equivalent morbidity. Despite this, nationwide referral patterns heavily favor ERCP, obscuring those undergoing ERCP with obstructions amenable to simple intraoperative interventions. We hypothesized that most patients had endoscopic findings consistent with simple sludge or small-to-medium stones, which could have been cleared by basic LCBDE maneuvers. METHODS We retrospectively reviewed 294 patients > 18 years old who underwent preoperative ERCP for the management of suspected choledocholithiasis. Exclusion criteria included: failed ERCP, cholangitis, prior cholecystectomy, patient refusal of surgery, or medical conditions precluding surgical candidacy. Stone size was categorized as small (0-4 mm), medium (5-7 mm), and large (≥ 8 mm). RESULTS At the time of ERCP, 37 (20.1%) patients had sludge only, 96 (52.2%) had stones only, 42 (22.8%) had sludge and stones, and 9 (4.8%) had no stones. Of the 138 patients with any stones, 37 (26.8%) had small stones, 41 (29.7%) medium, 43 (31.2%) large, and 17 (12.3%) had uncharacterizable stones. Overall, 74.3% of patients had findings of sludge, stones (0-7 mm), or negative ERCP. CONCLUSION The majority of patients who underwent preoperative ERCP for suspected choledocholithiasis had findings that are amenable to simple intraoperative interventions. In fact, over a quarter of the patients had a negative ERCP, sludge, or small stones which would likely be cleared by flushing/glucagon precluding any further instrumentation. While large stones may require more advanced techniques, this represents a small percentage of patients. Surgery-first management for suspected choledocholithiasis can offer an efficient alternative for the majority of patients.
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Affiliation(s)
- Gloria Sanin
- Wake Forest Baptist Medical Center, 1 Medical Center Blvd, Winston-Salem, NC, 27157, USA.
| | - Gabriel Cambronero
- Wake Forest Baptist Medical Center, 1 Medical Center Blvd, Winston-Salem, NC, 27157, USA
| | - James Patterson
- Wake Forest Baptist Medical Center, 1 Medical Center Blvd, Winston-Salem, NC, 27157, USA
| | - Maggie Bosley
- Wake Forest Baptist Medical Center, 1 Medical Center Blvd, Winston-Salem, NC, 27157, USA
| | - Aravindh Ganapathy
- Wake Forest Baptist Medical Center, 1 Medical Center Blvd, Winston-Salem, NC, 27157, USA
| | - Carl Wescott
- Wake Forest Baptist Medical Center, 1 Medical Center Blvd, Winston-Salem, NC, 27157, USA
| | - Lucas Neff
- Wake Forest Baptist Medical Center, 1 Medical Center Blvd, Winston-Salem, NC, 27157, USA
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Khan RSA, Alam L, Khan ZA, Khan UA. Comparing the efficacy of EUS versus MRCP with ERCP as gold standard in patients presenting with partial biliary obstruction - finding a better diagnostic tool. Pak J Med Sci 2023; 39:1275-1279. [PMID: 37680787 PMCID: PMC10480756 DOI: 10.12669/pjms.39.5.7280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 12/06/2022] [Indexed: 09/09/2023] Open
Abstract
Objective To evaluate the diagnostic accuracy of different imaging modalities in patients with partial biliary obstruction with no obvious aetiology on initial imaging. Methods This is a prospective single-centre cohort study carried out at Pak Emirates Military Hospital, Rawalpindi from June 2019 to June 2021 with non-probability consecutive sampling. Patients with ages 16 to 75 years, presenting with partial biliary obstruction and undetermined aetiology on initial imaging (TUS and MRCP) were enrolled. EUS was performed for each of these patients and the case was regarded as "true positive" or "true negative" if the findings of imaging modality correlated to those of ERCP. ROC curve, sensitivity, specificity, PPV, NPV and AUC (with 95% confidence interval) were drawn for all the diagnostic tools using SPSS V. 21. Results A total of 65 patients were enrolled over a period of two years with male to female ratio of 1.4:1. Forty-four patients had an intermediate risk of choledocholithiasis upon preliminary evaluation whereas, 48(74%) of the participants had CBD calculi or sludge confirmed upon subsequent ERCP. Trans-abdominal ultrasound showed the lowest sensitivity (29.2%), specificity (85%), NPV 12% and PPV 93% for diagnosing CBD calculi. This was followed by MRCP with a sensitivity of 37.5%, specificity of 100%, NPV of 36.2% and PPV of 100%. EUS showed the maximum diagnostic accuracy with AUC of 1.0 and a 100% sensitivity and specificity when compared with ERCP as gold standard. Conclusion EUS is superior to MRCP in terms of diagnostic accuracy as minimally invasive diagnostic tool and EUS superiority is particularly relevant in patients with intermediate risk of choledocholithiasis.
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Affiliation(s)
- Rao Saad Ali Khan
- Rao Saad Ali Khan, FCPS Med, FCPS Gastroenterology, FRCP Consultant Gastroenterology and Transplant Hepatologist, Pak Emirates Military Hospital, Rawalpindi Pakistan
| | - Laima Alam
- Laima Alam, FCPS Gastroenterology, MRCP (UK), CHPE Consultant Gastroenterology, Bahria International Hospital, Rawalpindi Pakistan
| | - Zoya Ali Khan
- Zoya Ali Khan, Research Assistant, Pak Emirates Military Hospital, Rawalpindi Pakistan
| | - Uzair Ali Khan
- Uzair Ali Khan, Research Assistant, Pak Emirates Military Hospital, Rawalpindi Pakistan
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Kashchenko VA, Emelyanov SI, Strizheletsky VV, Kossovich MA, Tariverdiev ML, Rutenburg GM, Bogatikov AA, Lodygin AV, Gornov SV, Sultanova FM. [Integration of ICG-fluorescence cholangiography into the safety system of laparoscopic cholecystectomy]. Khirurgiia (Mosk) 2023:89-98. [PMID: 38010022 DOI: 10.17116/hirurgia202311189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
THE AIM OF THE STUDY Is evaluating the possibility of integrating ICG-fluorescent cholangiography into the general safety system for laparoscopic cholecystectomy to prevent damage to the extrahepatic bile ducts by working out the methodological aspects of navigation technologies. MATERIALS AND METHODS The analysis of literature data on various approaches to improve the perioperative identification of anatomical structures during laparoscopic cholecystectomy, including the ICG-fluorescent cholangiography, was carried out. This program was implemented during the provision of elective surgical care to 24 patients with cholelithiasis who underwent laparoscopic cholecystectomy with ICG-fluorescent navigation. RESULTS AND DISCUSSION The developed program included: preoperative assessment of the anatomy of the biliary tree using MRCP; intraoperative technique of safe laparoscopic cholecystectomy with mandatory application of the concept of «critical view of safety» (CVS), which allows the most effective identification of the necessary anatomical structures; the use of ICG-fluorescent cholangiography, which allows to improve the control of anatomical structures at all stages of the operations. CONCLUSIONS The first experience of using ICG-fluorescent cholangiography testifies to the high informative value of the method, the possibility and prospects of integrating the technology into a comprehensive safety system during laparoscopic cholecystectomy.
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Affiliation(s)
- V A Kashchenko
- North-Western district scientific and clinical center named after L.G. Sokolov Federal Medical and Biological Agency, St. Petersburg, Russia
- Saint-Petersburg State University, St. Petersburg, Russia
| | - S I Emelyanov
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - V V Strizheletsky
- Saint-Petersburg State University, St. Petersburg, Russia
- St George Martyr Municipal Hospital, St. Petersburg, Russia
| | | | | | - G M Rutenburg
- St George Martyr Municipal Hospital, St. Petersburg, Russia
| | - A A Bogatikov
- North-Western district scientific and clinical center named after L.G. Sokolov Federal Medical and Biological Agency, St. Petersburg, Russia
- Saint-Petersburg State University, St. Petersburg, Russia
| | - A V Lodygin
- North-Western district scientific and clinical center named after L.G. Sokolov Federal Medical and Biological Agency, St. Petersburg, Russia
- Saint-Petersburg State University, St. Petersburg, Russia
| | - S V Gornov
- Russian Biotechnological University (BIOTECH University), Moscow, Russia
| | - F M Sultanova
- St George Martyr Municipal Hospital, St. Petersburg, Russia
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Ng J, Teng R, Izwan S, Chan E, Kumar M, Damodaran Prabha R, Puhalla H. Incidence and management of choledocholithiasis on routine intraoperative cholangiogram: a 5-year tertiary centre experience. ANZ J Surg 2023; 93:139-144. [PMID: 36562109 DOI: 10.1111/ans.18215] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 12/10/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND The incidence of choledocholithiasis on routine intraoperative cholangiogram (IOC) during cholecystectomy is approximately 12%. Cholecystectomy without IOC may lead to undiagnosed choledocholithiasis placing patients at risk of complications such as pancreatitis or cholangitis. This study aims to determine the incidence of choledocholithiasis intraoperatively as well as the associated risk factors and the methods of management. METHODS A retrospective observational analysis of all laparoscopic cholecystectomies with IOC at the Gold Coast Hospital and Health Service from 1 January 2016 to 2 December 2021 was carried out. Patient demographics, operative data and cholangiogram findings were collected from electronic medical systems. RESULTS A total of 3904 cholecystectomies were carried out over the study period. 3520 (90.1%) had an IOC, and 474 (13.4%) had positive IOC findings. 158 (33.3%) of the cases were managed intraoperatively with hyoscine butylbromide with or without intravenous glucagon followed by biliary tree flushing alone, 183 (38.6%) received transcystic bile duct exploration (TCBDE) with a success rate of 83% and 167 (35.2%) received endoscopic retrograde cholangiopancreatography (ERCP). Choledocholithiasis was incidental in 44 (9.28%) patients. CONCLUSION Incidental choledocholithiasis during routine IOC is not uncommon. Management predominantly includes intraoperative TCBDE or postoperatively via an ERCP. This study has not found reliable preoperative factors to predict choledocholithiasis based on preoperative clinical, radiological and biochemical factors. A small proportion of patients received preoperative endoscopic intervention, and the decision-making process requires further investigation.
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Affiliation(s)
- Justin Ng
- Department of General Surgery, Gold Coast University Hospital-Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia.,Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Roy Teng
- Department of General Surgery, Gold Coast University Hospital-Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia.,School of Medicine and Dentistry, Griffith University, Gold Coast, Queensland, Australia
| | - Sara Izwan
- Department of General Surgery, Gold Coast University Hospital-Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia.,School of Medicine and Dentistry, Griffith University, Gold Coast, Queensland, Australia
| | - Erick Chan
- Department of General Surgery, Gold Coast University Hospital-Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia.,School of Medicine and Dentistry, Griffith University, Gold Coast, Queensland, Australia
| | - Maarisha Kumar
- School of Medicine and Dentistry, Griffith University, Gold Coast, Queensland, Australia
| | - Ramesh Damodaran Prabha
- Department of General Surgery, Gold Coast University Hospital-Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia
| | - Harald Puhalla
- Department of General Surgery, Gold Coast University Hospital-Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia.,Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia.,School of Medicine and Dentistry, Griffith University, Gold Coast, Queensland, Australia
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Afzalpurkar S, Giri S, Kasturi S, Ingawale S, Sundaram S. Magnetic resonance cholangiopancreatography versus endoscopic ultrasound for diagnosis of choledocholithiasis: an updated systematic review and meta-analysis. Surg Endosc 2022; 37:2566-2573. [PMID: 36344899 DOI: 10.1007/s00464-022-09744-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 10/14/2022] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Both endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP) are used for the diagnosis of choledocholithiasis (CDL). Previous studies have shown conflicting results regarding the optimal diagnostic strategy for suspected CDL; hence, this meta-analysis was conducted. METHODS A comprehensive search of literature from 1990 till April 2022 was done of three databases for studies comparing EUS and MRCP to diagnose CDL. RESULTS A total of 12 studies were identified. The pooled sensitivity and specificity for EUS were 0.96 [95% confidence interval (CI) 0.92-0.98], and 0.92 (95% CI 0.85-0.96), respectively. The pooled sensitivity and specificity for MRCP were 0.85 (95% CI 0.78-0.90) and 0.90 (95% CI 0.79-0.96), respectively. EUS had a higher relative sensitivity [Relative risk (RR) 1.12, 95% CI 1.05-1.19], a higher diagnostic accuracy (Odds ratio 1.98, 95% CI 1.35-2.90) but comparable specificity (RR 1.02, 95% CI 0.96-1.08) with MRCP. CONCLUSION There is little difference concerning specificity, although EUS likely provides a higher sensitivity and accuracy for diagnosing CDL, compared to MRCP.
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Affiliation(s)
- Shivaraj Afzalpurkar
- Institute of Gastrosciences and Liver, Apollo Multispecialty Hospital, Kolkata, India
| | - Suprabhat Giri
- Department of Gastroenterology, Nizam's Institute of Medical Sciences, Hyderabad, India
| | - Sunil Kasturi
- Department of Gastroenterology, Gastrocare, Liver & Digestive Disease Center, Bhopal, India
| | - Sushrut Ingawale
- Department of General Medicine, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Sridhar Sundaram
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Homi Bhabha National Institute, Parel, Mumbai, 400012, Maharashtra, India.
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Jang DK, Kim J, Paik CN, Kim JW, Lee TH, Jang JY, Yoon SB, Lee JK. Endoscopic retrograde cholangiopancreatography-related adverse events in Korea: A nationwide assessment. United European Gastroenterol J 2021; 10:73-79. [PMID: 34953054 PMCID: PMC8830275 DOI: 10.1002/ueg2.12186] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 11/21/2021] [Indexed: 01/16/2023] Open
Abstract
Background Although endoscopic retrograde cholangiopancreatography (ERCP) is a pivotal procedure for the diagnosis and treatment of a variety of pancreatobiliary diseases, it has been known that the risk of procedure‐related adverse events (AEs) is significant. Objective We conducted this nationwide cohort study since there have been few reports on the real‐world data regarding ERCP‐related AEs. Methods Patients who underwent ERCP were identified between 2012 and 2015 using Health Insurance Review and Assessment database generated by the Korea government. Incidence, annual trends, demographics, characteristics according to the types of procedures, and the risk factors of AEs were assessed. Results A total of 114,757 patients with male gender of 54.2% and the mean age of 65.0 ± 15.2 years were included. The most common indication was choledocholithiasis (49.4%) and the second malignant biliary obstruction (22.8%). Biliary drainage (33.9%) was the most commonly performed procedure, followed by endoscopic sphincterotomy (27.4%), and stone removal (22.0%). The overall incidence of ERCP‐related AEs was 4.7% consisting of post‐ERCP pancreatitis (PEP; 4.6%), perforation (0.06%), and hemorrhage (0.02%), which gradually increased from 2012 to 2015. According to the type of procedures, ERCP‐related AEs developed the most commonly after pancreatic stent insertion (11.4%), followed by diagnostic ERCP (5.9%) and endoscopic sphincterotomy (5.7%). Younger age and diagnostic ERCP turned out to be independent risk factors of PEP. Conclusions ERCP‐related AEs developed the most commonly after pancreatic stent insertion, diagnostic ERCP and endoscopic sphincterotomy. Special caution should be used for young patients receiving diagnostic ERCP due to increased risk of PEP.
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Affiliation(s)
- Dong Kee Jang
- Department of Internal Medicine, Seoul Metropolitan Government Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Jungmee Kim
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Chang Nyol Paik
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jung-Wook Kim
- Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Korea
| | - Tae Hee Lee
- Institute for Digestive Research, Soonchunhyang University Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Jae-Young Jang
- Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Korea
| | - Seung Bae Yoon
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jun Kyu Lee
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
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Tran A, Hoff C, Polireddy K, Neymotin A, Maddu K. Beyond acute cholecystitis-gallstone-related complications and what the emergency radiologist should know. Emerg Radiol 2021; 29:173-186. [PMID: 34787758 DOI: 10.1007/s10140-021-01999-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 11/08/2021] [Indexed: 12/30/2022]
Abstract
The purpose of this study is to emphasize the imaging features of complications of gallstones beyond the cystic duct on ultrasound (US), enhanced and nonenhanced computed tomography (CECT and NECT), magnetic resonance imaging (MRI), magnetic resonance cholangiopancreatography (MRCP), and endoscopic retrograde cholangiopancreatography (ERCP). This article includes a brief overview of gallstone imaging and emerging trends in the detection of gallstones. This review article will highlight complications of gallstones, including choledocholithiasis, gallstone pancreatitis, acute cholangitis, Mirizzi syndrome, cholecystobiliary and cholecystoenteric fistulas, and gallstone ileus. Imaging findings and limitations of US, CT, MRI, and ERCP will be discussed. The review article will also briefly discuss the management of each disease. The presence of gallstones beyond the level of the cystic duct can lead to a spectrum of diseases, and emergency radiologists play a critical role in disease management by providing a timely diagnosis. Documenting the location of a gallstone within the common bile duct (CBD) in symptomatic cholelithiasis and the presence of acute interstitial edematous pancreatitis and/or ascending cholangitis plays a pivotal role in disease management. Establishing the presence of ectopic gallstones and biliary-enteric fistulae has a significant role in directing patient management.
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Affiliation(s)
- Andrew Tran
- Emory University School of Medicine, Atlanta, GA, USA.
| | - Carrie Hoff
- Div. Emergency and Trauma Imaging, Department of Radiology and Imaging Sciences, Emory University Hospital Midtown, Atlanta, USA
| | | | - Arie Neymotin
- Department of Radiology, MedStar Health, Washington, DC, USA
| | - Kiran Maddu
- Div. Emergency and Trauma Imaging, Department of Radiology and Imaging Sciences, Emory University Hospital Midtown, Atlanta, USA
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Yu B, Zhi X, Li Q, Xu B, Dong Z, Li T, Chen Z. The efficacy and safety of preoperative cholangiography via percutaneous transhepatic gallbladder drainage (PTGBD) for difficult laparoscopic cholecystectomy (LC). Surg Endosc 2021; 36:1355-1361. [PMID: 34013391 DOI: 10.1007/s00464-021-08414-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 02/23/2021] [Indexed: 12/07/2022]
Abstract
BACKGROUND Percutaneous transhepatic gallbladder drainage (PTGBD) is an important procedure for initial treatment of severe acute cholecystitis (AC) that is contraindicated for early laparoscopic cholecystectomy (LC). We presented our primary experience on a new approach of cholangiography via PTGBD (PTGBD-C) for preoperative delineation of biliary anatomy. METHODS A retrospective analysis was conducted on 93 patients who received PTGBD followed by LC for AC, with allocation into 2 groups that were PTGBD with (PTGBD-C group, 32 patients) or without (PTGBD-N group, 61 patients) cholangiography. All the clinical data, including demographics, cholangiography findings, operations, and complications, were collected and analyzed. RESULTS Cholangiography was attempted in 32 patients with a success of 31 cases, and the most common complication was transient fever in 3 patients. PTGBD-C group of patients showed significantly less operation time (83.2 ± 22.32 vs. 106.5 ± 40.25 min, P = 0.041) and conversion rate (0 vs. 2). There was no statistical difference in terms of postoperative hospitalization and complications. CONCLUSIONS PTGBD-C is a feasible and safe procedure for severe AC patients with delayed LC. It has advantages of direct cholangiography, being easy to perform and cost-effective, thus should be considered for clinical usage.
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Affiliation(s)
- Bingran Yu
- Department of Hepatobiliary Surgery, General Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, 107 West Wen Hua Road, Jinan, 250012, China
| | - Xuting Zhi
- Department of Hepatobiliary Surgery, General Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, 107 West Wen Hua Road, Jinan, 250012, China
| | - Qiong Li
- Department of Hepatobiliary Surgery, General Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, 107 West Wen Hua Road, Jinan, 250012, China
| | - Bowen Xu
- Department of Hepatobiliary Surgery, General Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, 107 West Wen Hua Road, Jinan, 250012, China
| | - Zhaoru Dong
- Department of Hepatobiliary Surgery, General Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, 107 West Wen Hua Road, Jinan, 250012, China
| | - Tao Li
- Department of Hepatobiliary Surgery, General Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, 107 West Wen Hua Road, Jinan, 250012, China.
| | - Zhiqiang Chen
- Department of Hepatobiliary Surgery, General Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, 107 West Wen Hua Road, Jinan, 250012, China.
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Anwer M, Asghar MS, Rahman S, Kadir S, Yasmin F, Mohsin D, Jawed R, Memon GM, Rasheed U, Hassan M. Diagnostic Accuracy of Endoscopic Ultrasonography Versus the Gold Standard Endoscopic Retrograde Cholangiopancreatography in Detecting Common Bile Duct Stones. Cureus 2020; 12:e12162. [PMID: 33489574 PMCID: PMC7813932 DOI: 10.7759/cureus.12162] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background and objectives Stone in the biliary tract is one of the most common causes of hospitalization. However, it is difficult to determine the prevalence of gallstones in the general population because they are often asymptomatic. Thus, management lies in the proper clearance of the common bile duct (CBD) along with the removal of the gallbladder, for which it must be diagnosed on time with proper accuracy. Imaging modalities including magnetic resonance cholangiopancreatography (MRCP), endoscopic ultrasound (EUS), and endoscopic retrograde cholangiopancreatography (ERCP) provide true visualization of choledocholithiasis with comparable sensitivities. The gold standard ERCP is an invasive procedure and may cause complications, such as pancreatitis, perforation, and bleeding. EUS is a minimally invasive procedure to assess the biliary tract using high-frequency sound waves. Until now the EUS has not been addressed much in our local tertiary care setups and this study was conducted to evaluate its accuracy in the diagnosis of choledocholithiasis. The objective of our study is to determine the diagnostic accuracy (specificity and sensitivity) of EUS versus ERCP for the diagnosis of choledocholithiasis. Materials and methods This retrospective study was conducted on patients suspected of having choledocholithiasis undergoing both EUS and ERCP based on their history, clinical symptoms, and laboratory test results including upper abdominal pain, deranged liver function enzymes, and a dilated CBD on radiology. EUS was initially performed for the diagnosis of extrahepatic biliary obstruction followed by one or more of the confirmatory criterion standard tests (including ERCP). In order to reduce the chances of passage of stone resulting in negative analysis, only those patients were included in which both procedures were conducted temporally close together (24-72 hours in most instances). The main outcome measures were diagnostic accuracy with the help of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) using a receiver operating characteristic curve. A total of 123 patients met the inclusion criteria via non-probability consecutive sampling methods. Results The mean age of our study population was 50.30 ± 13.91. We included 63 males (51.2%) and 60 females (48.8%). The most frequent indication for undergoing diagnostic procedures was deranged liver function tests (67.47%). The frequent comorbidities reported were hypertension (29.26%), diabetes (21.95%), chronic liver disease (16.26%), and ischemic heart disease (4.87%). Mean alkaline phosphatase and gamma-glutamyl transferase levels were markedly raised from the baseline in the study population. Post-ERCP complications were also reported in some of the study participants. About 85 patients (69.10%) were diagnosed with choledocholithiasis among the study participants. The diagnostic accuracy of EUS was compared with ERCP revealed an area under the curve (AUC) of 0.930, standard error of 0.031, 95% confidence interval of 0.868-0.991, the sensitivity of 89.5%, specificity of 96.5%, positive predictive value of 91.9%, and negative predictive value of 95.3%. Conclusion It is recommended that ERCP can be selectively conducted or excluded in patients with biliary obstruction in case of EUS negative, thus minimizing the complications and morbidity associated with an invasive procedure, with our results showing a comparative diagnostic accuracy of EUS.
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Affiliation(s)
- Mohsin Anwer
- General Surgery, Liaquat National Hospital, Karachi, PAK
| | | | - Sheeraz Rahman
- General Surgery, Liaquat National Hospital, Karachi, PAK
| | - Shanil Kadir
- Gastroenterology, Liaquat National Hospital, Karachi, PAK
| | - Farah Yasmin
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
| | - Dania Mohsin
- General Surgery, Liaquat National Hospital, Karachi, PAK
| | - Rumael Jawed
- Internal Medicine, Liaquat National Hospital, Karachi, PAK
| | | | - Uzma Rasheed
- Internal Medicine, Liaquat National Hospital, Karachi, PAK
| | - Maira Hassan
- Internal Medicine, Liaquat National Hospital, Karachi, PAK
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The accuracy of 3T magnetic resonance cholangiopancreatography in suspected choledocholithiasis. Pol J Radiol 2019; 84:e419-e423. [PMID: 31969960 PMCID: PMC6964331 DOI: 10.5114/pjr.2019.89689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 09/23/2019] [Indexed: 11/17/2022] Open
Abstract
Purpose The purpose of this study was to investigate interobserver agreement during magnetic resonance cholangio-pancreatography (MRCP) evaluation and the sensitivity and specificity of MRCP obtained with 3T scanners in cases of bile duct obstruction. Material and methods A total of 37 patients who had MRCP and endoscopic retrograde cholangiography (ERCP) were included. Choledochal pathology was divided into two groups regarding the presence of stones as "there is stone or not". MRCPs were performed with a 3-Tesla system using respiratory triggered HASTE technique in axial and coronal planes and with T2 SPACE sequence in the coronal plane. Sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) were calculated separately for each observer. The average of both observers was calculated for comparison with other studies. Results Thirty-seven patients were in the study population. Agreement between the observers was analysed, and Cohen's κ value was evaluated as 0.84. For two observers, the sensitivity of MRCP was 93%, whereas the specificity was 75% for the first observer and 62% for the second. Conclusions In this study we found a high level of interobserver agreement in evaluating MRCP. MRCP has a high sensitivity in detecting choledocholithiasis.
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Tso DK, Almeida RR, Prabhakar AM, Singh AK, Raja AS, Flores EJ. Accuracy and timeliness of an abbreviated emergency department MRCP protocol for choledocholithiasis. Emerg Radiol 2019; 26:427-432. [DOI: 10.1007/s10140-019-01689-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 03/28/2019] [Indexed: 12/13/2022]
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Lee TY. Optimal Evaluation of Suspected Choledocholithiasis: Does This Patient Really Have Choledocholithiasis? Clin Endosc 2017; 50:415-416. [PMID: 29017296 PMCID: PMC5642062 DOI: 10.5946/ce.2017.146] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 09/25/2017] [Indexed: 12/31/2022] Open
Affiliation(s)
- Tae Yoon Lee
- Division of Gastroenterology, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
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