Variations of bile bacterial community alongside gallstone disease progression and key taxa involved in poor outcomes after endoscopic surgery

Gallstone disease is a prevalent biliary disease worldwide, and bacteria play vital roles in the disease development and progression, as well as the prognosis after endoscopic surgery. However, there have been limited studies to explore the key taxa involved. In this study, bile samples from healthy controls (HCs, liver donors without hepatobiliary disease) and three diseased groups, namely patients with gallbladder stones (GBS), patients with common bile duct stones (CBDS), and patients with stricture in the common bile duct (SCBD), were collected and analyzed. Bacterial community characterization based on 16S rRNA amplicon sequencing showed that bacterial diversities did not change significantly alongside gallstone disease development and progression. The predominant phyla in each group were Proteobacteria, Firmicutes, Bacteroidota, and Fusobacteriota, representing over 80% in abundance of the biliary bacteria community. Specifically, the abundance of Proteobacteria decreased greatly while that of Firmicutes and Bacteroidota increased greatly in the diseased groups when compared to that in HCs. Moreover, linear discriminant analysis identified several genera highly represented in the diseased groups. Among them, Klebsiella, Prevotella, Pseudomonas and Veillonella are persistent in both the HCs group and the diseased groups, indicating an enrichment of local bile bacteria in the diseased bile; while Lachnoanerobaculum, Atopobium, Oribacterium, and Stomatobaculum, those aligned to oral cavity taxa, are persistent in the diseased groups but are transient in the HCs group, and their abundances sequentially increased with the disease development and progression (HCs→GBS→CBDS→SCBD), implying a translocation and colonization of the oral cavity bacteria in the diseased bile. Moreover, co-occurrence network analysis revealed that bacterial infection (e.g., Photobacterium and Plesiomonas) from the intestine was developed during endoscopic surgery with reduced bile bacteria diversity. The results of this study revealed that the bile bacterial community is relatively stable and dominated by a few persistent taxa. Moreover, we hypothesized that translocation and colonization of specific bacteria from the oral cavity happens alongside gallstone disease development and progression, and bacterial infection from the intestinal tract results in poor outcomes after endoscopic surgery.

Biliary colic in the emergency department: A state-wide analysis of one-year costs and clinical outcomes

Importance

Approximately 335,000 cases of biliary colic present to US emergency departments (EDs) annually, and most patients without complications are discharged from the ED. It is unknown what are the subsequent surgery rates, subsequent complications of biliary disease, ED revisits, repeat hospitalizations and cost; and, how does the ED disposition decision (admission versus discharge) affect long-term outcomes.

Objective

To determine whether there is a difference in one-year surgery rates, complications of biliary disease, ED revisits, repeat hospitalizations, and cost in ED patients with uncomplicated biliary colic who are admitted to the hospital versus those that are discharged from the ED.

Design setting and participants

A retrospective observational study was conducted using records collected from the Maryland Healthcare Cost and Utilization Project (HCUP) in the Ambulatory Surgery, the Inpatient, and the ED setting between 2016 and 2018. After applying inclusion criteria, 7036 ED patients with uncomplicated biliary colic were followed for one year after their index ED visit for repeat healthcare utilization across multiple settings. A multivariable logistic regression study was performed to asses for risk factors for surgery allocation and hospital admission. Medicare Relative Value Units (RVUs) and HCUP Cost-Charge Ratio files were used to estimate direct costs.

Exposures

Episodes of biliary colic were ascertained using ICD-10 codes at the index ED visit.

Main outcomes and measures

The primary outcome was the one-year surgery rate, defined as a cholecystectomy. Secondary outcomes included the rate of new acute cholecystitis or other related complications, ED revisits, hospital admission and costs. Associations with hospital admission and surgeries were measured using adjusted odds ratios (ORs) with 95 % CIs.

Results

Of the 7036 patients analyzed, 793 (11.3 %) were admitted and 6243 (88.7 %) were discharged on their initial ED visit. When comparing the groups who were initially admitted versus discharged, we observed similar one-year cholecystectomy rates (42 % versus 43 %, mean difference 0.5 %, 95 % CI -3.1 %-4.2 %; P < 0.001), lower rates of new cholecystitis occurrences (18 % versus 41 %, mean difference 23 %, 95 % CI, 20 %-26 %; P < 0.001), lower rates of ED revisits (96 vs 198 per 1000 patients, mean difference 102, 95 % CI, 74-130; P < 0.001) and higher costs ($9880 versus $1832, mean difference 8048, 95 % CI, 7478-8618; P < 0.001). Initial ED hospital admission was associated with increased age (adjusted odds ratio [aOR], 1.44; 95 % CI, 1.35-1.53; P < 0.001), obesity (aOR, 1.38; 95 % CI, 1.32-1.44; P < 0.001), ischemic heart disease (aOR, 1.39; 95 % CI, 1.30-1.48; P < 0.001), mood disorders (aOR, 1.18; 95 % CI, 1.13-1.24; P < 0.001), alcohol-related disorders (aOR, 1.20; 95 % CI, 1.12-1.27; P < 0.001), hyperlipidemia (aOR, 1.16; 95 % CI, 1.09-1.23; P < 0.001), hypertension (aOR, 1.15; 95 % CI, 1.08-1.21; P < 0.001), and nicotine dependence (aOR, 1.09; 95 % CI, 1.03-1.15; P = 0.003) but not associated with race (P > 0.9), ethnicity (P > 0.9), or income-stratified zip code (aOR, 1.04; 95 % CI, 0.98-1.09; P = 0.17).

Conclusions and relevance

In our analysis of ED patients with uncomplicated biliary colic from a single state, the majority of patients do not receive a cholecystectomy within one year and hospital admission at the initial visit was not associated with an overall change in rates of cholecystectomy but was associated with increased costs. These findings inform our understanding of the long-term outcomes and are important considerations when communicating care options with ED patients with biliary colic.

Suppression of bile acid synthesis as a tipping point in the disease course of primary sclerosing cholangitis

Background & Aims

Farnesoid X receptor (FXR) agonists and fibroblast growth factor 19 (FGF19) analogues suppress bile acid synthesis and are being investigated for their potential therapeutic efficacy in cholestatic liver diseases. We investigated whether bile acid synthesis associated with outcomes in 2 independent populations of people with primary sclerosing cholangitis (PSC) not receiving such therapy.

Methods

Concentrations of individual bile acids and 7α-hydroxy-4-cholesten-3-one (C4) were measured in blood samples from 330 patients with PSC attending tertiary care hospitals in the discovery and validation cohorts and from 100 healthy donors. We used a predefined multivariable Cox proportional hazards model to evaluate the prognostic value of C4 to predict liver transplantation-free survival and evaluated its performance in the validation cohort.

Results

The bile acid synthesis marker C4 was negatively associated with total bile acids. Patients with fully suppressed bile acid synthesis had strongly elevated total bile acids and short liver transplantation-free survival. In multivariable models, a 50% reduction in C4 corresponded to increased hazards for liver transplantation or death in both the discovery (adjusted hazard ratio [HR] = 1.24, 95% CI 1.06–1.43) and validation (adjusted HR = 1.23, 95% CI 1.03–1.47) cohorts. Adding C4 to established risk scores added value to predict future events, and predicted survival probabilities were well calibrated externally. There was no discernible impact of ursodeoxycholic acid treatment on bile acid synthesis.

Conclusions

Bile acid accumulation-associated suppression of bile acid synthesis was apparent in patients with advanced PSC and associated with reduced transplantation-free survival. In a subset of the patients, bile acid synthesis was likely suppressed beyond a tipping point at which any further pharmacological suppression may be futile. Implications for patient stratification and inclusion criteria for clinical trials in PSC warrant further investigation.

Lay summary

We show, by measuring the level of the metabolite C4 in the blood from patients with primary sclerosing cholangitis (PSC), that low production of bile acids in the liver predicts a more rapid progression to severe disease. Many people with PSC appear to have fully suppressed bile acid production, and both established and new drugs that aim to reduce bile acid production may therefore be futile for them. We propose C4 as a test to find those likely to respond to these treatments.

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The bile acid synthesis marker C4 associated negatively with bile acid levels in patients with PSC.

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Suppression of bile acid synthesis was likely nearly complete in advanced PSC.

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UDCA treatment contributed significantly to total circulating bile acids but did not appear to affect bile acid synthesis.

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Attempts to inhibit bile acid synthesis in patients with low C4 may be futile, and such drugs may be contraindicated.

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Patients with PSC and low circulating C4 had shorter liver transplantation-free survival in two independent cohorts.

Patients with complicated gallstone disease in the emergency department: clinical impact and cost-effectiveness of emergency department disposition decision

Objective

The objective of this study was to assess the 1‐year outcomes of emergency department (ED) patients with complicated gallstone disease, including surgery rates, initial admission rates, ED revisits, repeat hospitalizations, and cost.

Methods

Using 3 linked statewide databases from the Maryland Healthcare Cost and Utilization Project, we identified patients with a primary diagnosis of complicated gallstone disease treated in an ED between 2016 and 2018. We measured the healthcare use and direct costs in the ambulatory surgery, inpatient, and ED settings for 1 year after the initial ED visit. Finally, we performed a multivariate logistic regression analysis comparing initially admitted versus discharged patients.

Results

Of the 8751 patients analyzed, 86.8% were admitted to the hospital and 13.2% were discharged on their initial ED visit. Of the admitted patients, 78.7% received a cholecystectomy during the initial hospitalization plus 6.1% at a later date; of the discharged patients, 41.5% received a cholecystectomy. Admitted patients demonstrated lower recurrent gallbladder complications compared with those discharged (7.5% vs 44.5%), fewer ED revisits (4% vs 20.3%), and fewer repeat hospitalizations (4.5% vs 16.7%). Despite this, the 1‐year cost in the admitted patients was higher ($9448 vs $2933). Obesity, age, and mood disorders but not race, ethnicity, or zip code were associated with admission at initial ED visit.

Conclusions

In our single‐state analysis of ED patients with complications of gallstone disease, most patients are admitted on the initial visit and receive a cholecystectomy during that hospitalization. The discharged group had higher rates of 1‐year complications, ED revisits, and repeat hospitalizations but lower cost.

Validation of Tokyo Guidelines 2007 and Tokyo Guidelines 2013/2018 Criteria for Acute Cholangitis and Predictors of In-Hospital Mortality

BACKGROUND

Acute cholangitis (AC) is a common emergency with a significant mortality risk. The Tokyo Guidelines (TG) provide recommendations for diagnosis, severity stratification, and management of AC. However, validation of the TG remains poor. This study aims to validate TG07, TG13, and TG18 criteria and identify predictors of in-hospital mortality in patients with AC.

METHODS

This is a retrospective audit of patients with a discharge diagnosis of AC in the year 2016. Demographic, clinical, investigation, management and mortality data were documented. We performed a multinomial logistic regression analysis with stepwise variable selection to identify severity predictors for in-hospital mortality.

RESULTS

Two hundred sixty-two patients with a median age of 75.9 years (IQR 64.8-82.8) years were included for analysis. TG13/TG18 diagnostic criteria were more sensitive than TG07 diagnostic criteria (85.1 vs. 75.2%; p < 0.006). The majority of the patients (n = 178; 67.9%) presented with abdominal pain, pyrexia (n = 156; 59.5%), and vomiting (n = 123; 46.9%). Blood cultures were positive in 95 (36.3%) patients, and 79 (83.2%) patients had monomicrobial growth. The 30-day, 90-day, and in-hospital mortality numbers were 3 (1.1%), 11 (4.2%), and 15 (5.7%), respectively. In multivariate analysis, type 2 diabetes mellitus (OR = 12.531; 95% CI 0.354-116.015; p = 0.026), systolic blood pressure <100 mm Hg (OR = 10.108; 95% CI 1.094-93.395; p = 0.041), Glasgow coma score <15 (OR = 38.16; 95% CI 1.804-807.191; p = 0.019), and malignancy (OR = 14.135; 95% CI 1.017-196.394; p = 0.049) predicted in-hospital mortality.

CONCLUSION

TG13/18 diagnostic criteria are more sensitive than TG07 diagnostic criteria. Type 2 diabetes mellitus, systolic blood pressure <100 mm Hg, Glasgow coma score <15, and malignant etiology predict in-hospital mortality in patients with AC. These predictors could be considered in acute stratification and treatment of patients with AC.

Epidemiology and risk factors for pyogenic liver abscess in the Calgary Health Zone revisited: a population-based study

Background

Pyogenic liver abscess (PLA), although uncommon in North America, is associated with significant morbidity and mortality. We sought to re-examine the epidemiology, risk factors, and outcomes of PLA in a large, diverse Canadian health zone.

Methods

All Calgary Health Zone (CHZ) residents aged ≥20 with PLA between 2015 and 2017 were identified. Incidence and mortality rates were calculated using census data. Risk factors for PLA were identified using a multivariate analysis. Data was compared to 1999–2003 data, also collected in the CHZ.

Results

There were 136 patients diagnosed with PLA between 2015 and 2017. Incidence rate during this period increased significantly relative to 1999–2003 (3.7 vs 2.3 cases/100,000 population, p < 0.01), however, mortality rates remained similar. The microbiological composition of PLA did not change over this 15-year time period but the number of antimicrobial resistant isolates did increase (8% vs 1%, p = 0.04). The greatest risk factors for PLA relative to general populations included current malignancy, liver-transplant, end-stage renal disease, and cirrhosis. Thirty-day mortality was 7.4% and independent risk factors included polymicrobial bacteremia, absence of abscess drainage, congestive-heart failure, a history of liver disease, and admission bilirubin.

Conclusions

Pyogenic liver abscess is a health concern with rising incidence rate. The increasing prevalence of comorbidities in our population and factors that are associated with risk of PLA suggests this will continue to be an emerging diagnosis of concern. Increasing prevalence of antibiotic resistant organisms compounding unclear optimal treatment regimens is an issue that requires urgent study.

Associations of neopterin and kynurenine-tryptophan ratio with survival in primary sclerosing cholangitis

BACKGROUND AND AIMS

Biomarkers of inflammation may be of clinical utility in primary sclerosing cholangitis (PSC). We aimed to investigate the interferon gamma-related biomarkers neopterin and kynurenine-tryptophanratio (KT-ratio) in PSC.

METHODS

Circulating neopterin, tryptophan and kynurenine were measured with LC-MS/MS in multiple cross-sectional cohorts comprising in total of 524 PSC patients and 100 healthy controls from Norway, Germany and Sweden.

RESULTS

Neopterin and KT-ratio were significantly increased in PSC patients compared with controls in both a discovery and a validation cohort from Norway. Furthermore, high neopterin and KT-ratio levels were associated with a shorter transplantation-free survival in the PSC patients in the Norwegian discovery cohort and the German validation cohort. However, in the validation PSC cohort from Sweden, no relationship between neopterin and KT-ratio and liver transplantation-free survival was observed. The correlations between neopterin and KT-ratio were moderate to strong and similar in all cohorts (rho 0.50-0.67). Neopterin and KT-ratio also correlated with C-reactive protein (rho 0.17-0.63) and revised Mayo risk score (rho 0.23-0.42) in all cohorts.

CONCLUSIONS

Neopterin and KT-ratio were elevated in PSC and associated with liver transplantation-free survival in two independent PSC cohorts, highlighting a possible role of interferon gamma-driven inflammation in the pathogenesis. However, the lack of association with survival in one of the cohorts reduces the potential clinical value of neopterin and KT-ratioas biomarkers and highlights the need to validate new biomarkers in PSC in multiple cohorts.

Applications of artificial intelligence in pancreatic and biliary diseases

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

Endoscopic and percutaneous biliary interventions in patients with altered upper gastrointestinal anatomy-the Munich Multicenter Experience

BACKGROUND

In patients with altered upper gastrointestinal anatomy, conventional endoscopic retrograde cholangiography is often not possible and different techniques, like enteroscopy-assisted or percutaneous approaches are required. Aim of this study was to analyze success and complication rates of these techniques in a large collective of patients in the daily clinical practice in a pre-endosonographic biliary drainage era.

PATIENTS AND METHODS

Patients with altered upper gastrointestinal anatomy with biliary interventions between March 1st, 2006, and June 30th, 2014 in four tertiary endoscopic centers in Munich, Germany were retrospectively analyzed.

RESULTS

At least one endoscopic-assisted biliary intervention was successful in 234/411 patients (56.9%)-in 192 patients in the first, in 34 patients in the second and in 8 patients in the third attempt. Success rates for Billroth-II/Whipple-/Roux-en-Y reconstruction were 70.5%/56.7%/49.5%. Complication rates for these reconstructions were 9.3%/6.5%/6.3%, the overall complication rate was 7.1%. Success rates were highest in patients with Billroth-II reconstruction where use of a duodenoscope was possible, complication rates were also highest in this scenario. Success rates were lowest in longer-limb anatomy like Roux-en-Y reconstruction. Percutaneous biliary drainages (PTBD) were inserted 268 times with substantially higher success (90.7%) as well as complication rates (11.6%) compared to the endoscopic approach. Compared to patients treated endoscopically, patients with PTBD had a lower performance status, more severe cholestasis and a significant higher rate of malignant underlying disease.

CONCLUSION

In patients with altered upper gastrointestinal anatomy, success rates of endoscopic-assisted biliary interventions are lower compared to PTBD. Still, due to the beneficial complication rates of the endoscopic approach, this technique should be preferred whenever possible and in selected patients who still need to be defined in detail, repeated endoscopic attempts are useful to help achieve the desired result.

Laparoscopic SpyGlass cholangioscopy evaluation during bilioenteric anastomosis for hepatolithiasis, a case report

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Diagnosis and management of benign hepatobiliary diseases are often challenging.

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SpyGlass cholangioscopy has enhanced the diagnosis of biliary diseases.

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A multidisciplinary approach can ensure diagnosis and treatment of patients with hepatobiliary diseases.

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Association of laparoscopic hepaticojejunostomy to SpyGlass cholangioscopy is a safe and minimal invasive procedure.

Introduction

Careful evaluation of intrahepatic injury of biliary tract diseases is crucial to assure proper management and estimate disease prognosis. Hepatholithiasis is a rare condition that can be associated to cholestatic liver diseases. Additional tools to improve diagnosis and patient care are of great interest specially if associated to decreased morbidity. Recently the spread of single-operator platforms of cholangioscopy brought this procedure back to scene. Our aim was to identify safety, feasibility and utility of SpyGlass cholangioscopy of biliary tract during laparoscopic hepaticojejunostomy.

Presentation of case

A 53 years-old man with hepatolithiasis associated to choledolithiasis under treatment with ursodeoxycholic acid and fenofibrate for 8 months, was submitted to laparoscopic hepaticojejunostomy with cholangioscopy for biliary duct evaluation. Spyscope was inserted through a right lateral laparoscopic trocar entering the common bile duct. Examination of intra-hepatic bile ducts showed injury of right biliary. Few microcalculi were visualized. Left biliary ducts presented normal mucosa. Histopathological examination showed a chronic inflammatory process. During the procedure contrasted radiologic images were performed to assure Spyscope location. Following cholangioscopy evaluation, a Roux-en-Y hepaticojejunostomy was performed. To enlarge hepatic duct, a small longitudinal incision was made, and a PDS-5.0 running suture was used for bilioenteric anastomosis. Patient was discharged on postoperative day 6, with drain removal on day 20.

Conclusion

SpyGlass cholangioscopy during laparoscopic hepaticojejunostomy is feasible leading to minimal additional invasion of the surgical. In this case the method was performed safely, providing detailed examination of injured biliary ducts, adding elements to determine disease prognosis and patient care.

Mirizzi syndrome from type I to Vb: a single center experience

OBJECTIVES

The present study describes a cohort of patients diagnosed with Mirizzi syndrome from type I to Vb, over a period of four years. It aimed to identify diagnostic and management pitfalls of Mirizzi syndrome, as well as their concomitant cholecystobiliary or cholecystoenteric fistulas.

MATERIAL AND METHODS

We retrospectively reviewed all electronic medical records of patients who underwent surgery for Mirizzi syndrome at a single institution.

RESULTS

Twenty-two patients (0.6%) were diagnosed with Mirizzi syndrome. Most of the patients were females (n=19, 86.3%). Mean age was 43.8 years (range: 21-71 years). Ultrasound was performed in all (100%) patients. Six (27.2%) patients had a CT scan and six (27.2%) patients had endoscopic retrograde cholangiopancreatography. Overall preoperative diagnosis was achieved on 36.6% (n=8) of the patients. There were the same total and partial cholecystectomies, accounting for ten (45.5%) cases each, one hepaticojejunostomy with cholecystectomy (4.5%), and one enterolithotomy (4.5%). Laparoscopic cholecystectomy was attempted in 15 (68.1%) patients, with conversion to open surgery in 93.3% (n=14) of the patients. An open approach was made in five (22.7%) cases. Four (18.1%) patients were reported as MS type I, both types II and III each account for 22.7% (n=5) of the cases, there was only one (4.5%) patient with type IV, and seven (31.8%) patients with type V.

CONCLUSION

There are limited studies of patients with Mirizzi syndrome, including type V classification, and when this syndrome is suspected, a preoperative diagnosis should be made to avoid bile duct injuries or lesions to adjacent organs.

Complicating factors in the management of advanced Bouveret syndrome in frail and medically complex patients: Case report and discussion of pathophysiology

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Bouveret’s syndrome results from biliary stones from cholecysto-duodenal fistula.

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Gastric outlet obstruction from duodenal stones has high morbidity and mortality.

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Duodenal gallstones may grow over time, increasing risks of management.

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Delay in diagnosis and stone extraction may result in needing higher risk surgery.

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Tertiary referral of at-risk elderly or frail patients may improve outcomes.

Introduction

Bouveret Syndrome is a rare but important variant of gallstone ileus with high potential for morbidity and mortality. Bouveret syndrome is a complication of gallstone disease resulting from chronic inflammation and subsequent fistulization between the gallbladder and duodenum or stomach with subsequent impaction of the stone in the proximal GI tract. Here we present a case in an elderly man with moderate medical comorbidities.

Presentation of case

An elderly man presented to the hospital with symptoms of gastrointestinal obstruction. Upon further diagnostic work-up, he was noted to have a 5.8 cm gallstone impacted in his proximal GI tract and thus diagnosed with a rare variant of gallstone ileus—Bouveret syndrome.

Discussion

The therapeutic goal in approaching Bouveret syndrome is removal of the stone and improvement in obstruction and cholangitis. This may be accomplished with surgery or endoscopic therapy—although this may be less effective. Bouveret syndrome may have high morbidity.

Conclusion

Bouveret syndrome is a rare but potentially serious syndrome that should be managed accordingly. It should remain on the differential diagnosis of an elderly patient presenting with gastrointestinal obstructions, particularly if there is a history of gallstone disease and concern for proximal GI obstruction.

A 3-Year MBSAQIP propensity-matched analysis of Roux-en-Y gastric bypass with concomitant cholecystectomy: Is the robotic or laparoscopic approach preferred?

BACKGROUND

The primary objective of this study was to compare outcomes of patients undergoing minimally invasive RYGB (MIS/RYGB) versus MIS/RYGB with concomitant Cholecystectomy (CCY). A secondary objective was to compare the outcomes for laparoscopic RYGB (LRYGB) and robotic RYGB (RRYGB) with concomitant CCY.

METHODS

Outcomes of 117,939 MIS/RYGB with and without CCY were propensity-matched (Age, Gender, BMI, Comorbidities), 10:1, using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database from 2015-2017. The MIS/RYGB with CCY were then separated into LRYGB and RRYGB cases for comparison. Exclusion criteria included emergency cases, conversions to open, and age less than 18.

RESULTS

The operative time and length of stay (LOS) was significantly increased with addition of concomitant CCY. There was no significant difference in readmission, reoperation, intervention, morbidity, or mortality. The RRYGB with CCY approach was associated with a significantly longer operative times compared to the LRYGB with CCY (177 vs. 135 min, p < 0.0001). The laparoscopic and robotic groups demonstrated no significant difference LOS, readmission, reoperation, intervention, morbidity, or mortality rates.

CONCLUSIONS

Our study demonstrates that concomitant cholecystectomy increased the operative time and length of stay. However, concomitant CCY was not associated with any increased morbidity. The study demonstrated no significant difference in morbidity between robotic and laparoscopic approach. The robotic approach, however, was associated with a significantly longer operative time compared to the laparoscopic approach. While the indications for CCY remain controversial, concomitant CCY does not convey additional risk regardless of operative approach.

Massive gallstone in an asymptomatic Indigenous Canadian male: Case report and literature review

INTRODUCTION

Gallstones are present in 10-15% of North Americans, but only 20% become symptomatic. This case report describes a patient with a 7.5 cm gallstone detected incidentally while being investigated for cardiac pathology. This is the first report in the English literature of a stone this size that has remained clinically asymptomatic. This work is reported in line with the SCARE criteria.

CASE REPORT

The patient was a 71-year-old Indigenous Canadian male, with atrial fibrillation. His cardiologist ordered a CT scan of his chest, which incidentally identified a large gallstone. He was referred to surgery for asymptomatic cholelithiasis. An uncomplicated laparoscopic cholecystectomy was performed. Final pathology showed a 7.5 cm gallstone with features of chronic cholecystitis.

DISCUSSION

The patient's ethnicity and gallstone size placed him at increased risk for gallbladder cancer, gallstone fistulization and perforation. We reviewed the literature for asymptomatic patients who may benefit from cholecystectomy: transplant recipients and those with hemolytic disorders. Laparoscopic cholecystectomy is not currently indicated in diabetics and bariatric surgery patients.

CONCLUSION

This case report shows that there are asymptomatic patients with massive gallstones. A review of their history, risk factors for malignancy and future gallstone related complications must be carefully weighed and discussed prior to deciding on surgical versus expectant management.

Hyponatremia is associated with more severe biliary disease

BACKGROUND

Sodium level is an important clinical predictor of complex biliary disease. Hyponatremia has been observed in conjunction with biliary disease, however the nature of this association remains unclear.

AIM

To investigate the association between serum sodium and severe biliary disease.

METHODS

Of 920 patients with gallstone disease treated at the SFVA Hospital from 1989-2019 were studied. We conducted multivariate analyses of correlation between sodium level and biliary disease severity, the presence/location of biliary bacteria, and other factors. Minimum sodium level pre-intervention was collected. Gallstones, bile, and blood (as relevant) were cultured. Illness severity was characterized: (1) None (no infectious manifestations); (2) Systemic inflammatory response syndrome; (3) Severe illness (gangrenous cholecystitis, cholangitis, necrotizing pancreatitis); and (4) Multiple organ dysfunction syndrome (bacteremia, hypotension, organ failure). Comorbidity was defined using the Charlson Comorbidity Index (CCI).

RESULTS

Decreased sodium level significantly correlated with worsening illness severity, ascending bacterial infection, gangrenous changes, elevated CCI score, increasing age, male sex, and glucose. On multivariate analysis, all factors, except age, gender and glucose, independently correlated with sodium level and factors were additive.

CONCLUSION

This unique study is the first to explore, with such granularity, the relationship between biliary disease and sodium. No prior studies have examined specific culture and clinical data. It illustrates an inverse, independent correlation between illness severity and sodium. Culture data demonstrate that sodium decreases as infection ascends from gallstone colonization to bactibilia to bacteremia. Patient comorbidity and gangrenous changes also independently correlate with sodium on multivariate analysis. Sodium level is an important clinical indicator of disease severity for patients with biliary disease.

Laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography for choledocholithiasis after Roux-en-Y gastric bypass: A case report

Background

Exclusion of the stomach after Roux-en-Y gastric bypass (RYGB) makes access to the biliary tree very challenging for the surgeon or the endoscopist. Different techniques have been described to overcome this downside, including laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography (ERCP), which is an outstanding method to access the remnant stomach in order to reach the duodenal papilla. The use of this technique is associated with a high success rate.

Presentation of case

Here we present the case of a 57-year-old patient with altered RYGB anatomy. The patient underwent laparoscopic cholecystectomy. Intraoperative cholangiography revealed the presence of a stone in the common bile duct. A laparoscopy-assisted transgastric ERCP was performed successfully. During the procedure, the duodenoscope was introduced through a gastrostomy, obviating the need for an intragastric trocar. The patient evolved favorably and was discharged on second postoperative day without any complications.

Discussion

Transgastric laparoscopy-assisted ERCP represents an effective approach for the management of biliary complications after RYGB, even if there is a long interval between the two interventions, as occurred in the present case. Other methods described for accessing the biliary tree in patients with altered RYGB anatomy are double-balloon ERCP and endoscopic ultrasound-directed transgastric ERCP. We elected to perform the laparoscopy-assisted approach because choledocholithiasis was diagnosed transoperatively, thus, avoiding the need for secondary procedures or interventions.

Conclusion

Transgastric laparoscopy-assisted ERCP is a feasible procedure with low complication rates and is used in treating patients with altered RYGB anatomy who present with biliary tract disorders. The use of transgastric laparoscopy-assisted ERCP allows endoscopic treatment and cholecystectomy to be performed in a single setting.

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Case report of a patient with altered RYGB anatomy, which presented choledocholithiasis.

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There are several ways to treat this disorder on patients with this condition.

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Laparoscopic Assisted Trans-gastric ERCP is a feasible and secure option.

Patient-specific 3D printed model of biliary ducts with congenital cyst

BACKGROUND

3D printing has shown great promise in medical applications, with increasing reports in liver diseases. However, research on 3D printing in biliary disease is limited with lack of studies on validation of model accuracy. In this study, we presented our experience of creating a realistic 3D printed model of biliary ducts with congenital cyst. Measurements of anatomical landmarks were compared at different stages of model generation to determine dimensional accuracy.

METHODS

Contrast-enhanced computed tomography (CT) images of a patient diagnosed with congenital cyst in the common bile duct with dilated hepatic ducts were used to create the 3D printed model. The 3D printed model was scanned on a 64-slice CT scanner using the similar abdominal CT protocol. Measurements of anatomical structures including common hepatic duct (CHD), right hepatic duct (RHD), left hepatic duct (LHD) and the cyst at left to right and anterior to posterior dimensions were performed and compared between original CT images, the standard tessellation language (STL) image and CT images of the 3D model.

RESULTS

The 3D printing model was successfully generated with replication of biliary ducts and cyst. Significant differences in measurements of these landmarks were found between the STL and the original CT images, and the CT images of the 3D printed model and the original CT images (P<0.05). Measurements of the RHD and LHD diameters from the original CT images were significantly larger than those from the CT images of 3D model or STL file (P<0.05), while measurements of the CHD diameters were significantly smaller than those of the other two datasets (P<0.05). No significant differences were reached in measurements of the CHD, RHD, LHD and the biliary cyst between CT images of the 3D printed model and STL file (P=0.08-0.98).

CONCLUSIONS

This study shows our experience in producing a realistic 3D printed model of biliary ducts and biliary cyst. The model was found to replicate anatomical structures and cyst with high accuracy between the STL file and the CT images of the 3D model. Large discrepancy in dimensional measurements was noted between the original CT and STL file images, and the original CT and CT images of the 3D model, highlighting the necessity of further research with inclusion of more cases of biliary disease to validate accuracy of 3D printed biliary models.

Identification of a xenobiotic as a potential environmental trigger in primary biliary cholangitis

BACKGROUND & AIMS

Primary biliary cholangitis (PBC) is an autoimmune-associated chronic liver disease triggered by environmental factors, such as exposure to xenobiotics, which leads to a loss of tolerance to the lipoic acid-conjugated regions of the mitochondrial pyruvate dehydrogenase complex, typically to the E2 component. We aimed to identify xenobiotics that might be involved in the environmental triggering of PBC.

METHODS

Urban landfill and control soil samples from a region with high PBC incidence were screened for xenobiotic activities using analytical, cell-based xenobiotic receptor activation assays and toxicity screens.

RESULTS

A variety of potential xenobiotic classes were ubiquitously present, as identified by their interaction with xenobiotic receptors - aryl hydrocarbon receptor, androgen receptor and peroxisome proliferator activated receptor alpha - in cell-based screens. In contrast, xenoestrogens were present at higher levels in soil extracts from around an urban landfill. Furthermore, two landfill sampling sites contained a chemical(s) that inhibited mitochondrial oxidative phosphorylation and induced the apoptosis of a hepatic progenitor cell. The mitochondrial effect was also demonstrated in human liver cholangiocytes from three separate donors. The chemical was identified as the ionic liquid [3-methyl-1-octyl-1H-imidazol-3-ium]+ (M8OI) and the toxic effects were recapitulated using authentic pure chemical. A carboxylate-containing human hepatocyte metabolite of M8OI, bearing structural similarity to lipoic acid, was also enzymatically incorporated into the E2 component of the pyruvate dehydrogenase complex via the exogenous lipoylation pathway in vitro.

CONCLUSIONS

These results identify, for the first time, a xenobiotic in the environment that may be related to and/or be a component of an environmental trigger for PBC. Therefore, further study in experimental animal models is warranted, to determine the risk of exposure to these ionic liquids.

LAY SUMMARY

Primary biliary cholangitis is a liver disease in which most patients have antibodies to mitochondrial proteins containing lipoic acid binding site(s). This paper identified a man-made chemical present in soils around a waste site. It was then shown that this chemical was metabolized into a product with structural similarity to lipoic acid, which was capable of replacing lipoic acid in mitochondrial proteins.

Primary Biliary Cholangitis and Autoimmune Hepatitis

Primary biliary cholangitis and autoimmune hepatitis are common autoimmune diseases of the liver. Both have typical clinical presentations, including certain autoantibodies on serologic testing. Histologic features are also often typical: primary biliary cholangitis shows bile duct destruction (sometimes with granulomas), and autoimmune hepatitis shows prominent portal and lobular lymphoplasmacytic inflammation. Both have a wide differential diagnosis, including one another; they may also simultaneously occur within the same patient. Careful use of clinical and histologic criteria may be necessary for diagnosis. First-line therapy is immunosuppression for autoimmune hepatitis and ursodeoxycholic acid for primary biliary cholangitis. Both diseases may progress to cirrhosis.

Utility of common bile duct measurement in ED point of care ultrasound: A prospective study

BACKGROUND

Measurement of the common bile duct (CBD) is considered a fundamental component of biliary point-of-care ultrasound (POCUS), but can be technically challenging.

OBJECTIVE

The primary objective of this study was to determine whether CBD diameter contributes to the diagnosis of complicated biliary pathology in emergency department (ED) patients with normal laboratory values and no abnormal biliary POCUS findings aside from cholelithiasis.

METHODS

We performed a prospective, observational study of adult ED patients undergoing POCUS of the right upper quadrant (RUQ) and serum laboratory studies for suspected biliary pathology. The primary outcome was complicated biliary pathology occurring in the setting of normal laboratory values and a POCUS demonstrating the absence of gallbladder wall thickening (GWT), pericholecystic fluid (PCF) and sonographic Murphy's sign (SMS). The association between CBD dilation and complicated biliary pathology was assessed using logistic regression to control for other factors, including laboratory findings, cholelithiasis and other sonographic abnormalities.

RESULTS

A total of 158 patients were included in the study. 76 (48.1%) received non-biliary diagnoses and 82 (51.9%) were diagnosed with biliary pathology. Complicated biliary pathology was diagnosed in 39 patients. Sensitivity of CBD dilation for complicated biliary pathology was 23.7% and specificity was 77.9%.

CONCLUSION

Of patients diagnosed with biliary pathology, none had isolated CBD dilatation. In the absence of abnormal laboratory values and GWT, PCF or SMS on POCUS, obtaining a CBD measurement is unlikely to contribute to the evaluation of this patient population.

Pediatric cholangiopathies: diseases of the gallbladder and biliary tract

Pediatric gallbladder and bile duct disease encompasses a broad spectrum of processes, from congenital to developmental to neoplastic. We describe normal pediatric biliary anatomy and summarize the most common pathologic entities, with a focus on non-invasive imaging techniques and findings. Ultrasound is the first-line imaging modality in children with suspected biliary pathology based on its widespread availability, cost effectiveness, and lack of ionizing radiation. MRI and MRCP are often used for further evaluation in cases of diagnostic uncertainty and for surgical planning.

Utility of MRCP in clinical decision making of suspected choledocholithiasis: An institutional analysis and literature review

BACKGROUND

The ideal treatment algorithm for suspected choledocholithiasis is not yet well defined. Imaging options include magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP), and intraoperative cholangiogram (IOC). MRCP is diagnostic, while the other two modalities can also be therapeutic. Each of these modalities for diagnosis and treatment carries its own set of risks, benefits, and institutional costs. We hypothesized that there would be a significant difference between the biochemical profiles and characteristics of patients who undergo ERCP vs. MRCP vs. operative intervention as the initial choice of treatment/imaging modality.

METHODS

We performed a retrospective review of the electronic medical records for all patients with a coded diagnosis of choledocholithiasis from 2011 to 2014. The initial diagnostic modality was assessed for each hospital encounter. The statistical characteristics of MRCP as compared to fluoroscopic imaging of the biliary tree (ERCP, IOC) were analyzed.

RESULTS

Overall, 527 hospital encounters were identified. Initial intervention included ERCP in 63%, MRCP in 12%, and cholecystectomy in 25% of patients. Patients undergoing cholecystectomy first, compared to MRCP or ERCP, tended to have lower values for alkaline phosphatase (P < 0.001) and AST (P = 0.002) as well as be of younger age (P < 0.0001). Of the patients that underwent MRCP as their initial procedure, 82% subsequently underwent either ERCP or laparoscopic cholecystectomy. In patients who underwent an initial MRCP followed by either ERCP or IOC, the predictive performance of MRCP was as follows: sensitivity = 0.90, specificity = 0.86, positive predictive value = 0.97, negative predictive value = 0.60, agreement (Cohen's Kappa) = 0.64.

CONCLUSIONS

There is a significant difference in the laboratory evaluation and demographics of patients undergoing ERCP, MRCP, and laparoscopic cholecystectomy. MRCP was followed with a more invasive test a majority of the time. Since MRCP did not change the management of patients with suspected choledocholithiasis, its utility in this patient population should be questioned. Further research is needed to better define the pretest characteristics which would predict which patients do not need further intervention after MRCP as well as defining the most cost-effective strategy.

Portal biliopathy

Portal biliopathy refers to cholangiographic abnormalities which occur in patients with portal cavernoma. These changes occur as a result of pressure on bile ducts from bridging tortuous paracholedochal, epicholedochal and cholecystic veins. Bile duct ischemia may occur due prolonged venous pressure effect or result from insufficient blood supply. In addition, encasement of ducts may occur due fibrotic cavernoma. Majority of patients are asymptomatic. Portal biliopathy is a progressive disease and patients who have long standing disease and more severe bile duct abnormalities present with recurrent episodes of biliary pain, cholangitis and cholestasis. Serum chemistry, ultrasound with color Doppler imaging, magnetic resonance imaging with magnetic resonance cholangiopancreatography and magnetic resonance portovenography are modalities of choice for evaluation of portal biliopathy. Endoscopic retrograde cholangiography being an invasive procedure is indicated for endotherapy only. Management of portal biliopathy is done in a stepwise manner. First, endotherapy is done for dilation of biliary strictures, placement of biliary stents to facilitate drainage and removal of bile duct calculi. Next portal venous pressure is reduced by formation of surgical porto-systemic shunt or transjugular intrahepatic portosystemic shunt. This causes significant resolution of biliary changes. Patients who persist with biliary symptoms and bile duct changes may benefit from surgical biliary drainage procedures (hepaticojejunostomy or choledechoduodenostomy).

Duloxetine for the Treatment of Patients with Suspected Sphincter of Oddi Dysfunction: A Pilot Study

OBJECTIVE

To examine the tolerability and efficacy of duloxetine in patients with suspected sphincter of Oddi dysfunction (SOD).

METHODS

An open-label, single-center, 12-week trial of duloxetine 60 mg once daily was conducted in 20 patients with suspected SOD. All patients were evaluated by expert pancreato-biliary specialists. The primary outcome measure was a Patient Global Impression of Change (PGIC) scale. Secondary measures included the pain burden, assessed by the Recurrent Abdominal Pain Intensity and Disability scale, the Short-Form Health Survey, and the Hospital Anxiety and Depression Scale. A positive clinical response was defined as a PGIC score of much or very much improved at 3 months and was estimated using a two-sided 90 % confidence interval. The primary outcome was analyzed using a one-sample binomial test at a significance level of 0.10.

RESULTS

Of the 20 screened patients, 18 were enrolled; 14 completed at least one post-baseline evaluation; and 10 patients completed the third month endpoint visit. Patients missing the third month visit were considered non-responders for the primary outcome. Response rates were 90 % for study completers (n = 10; 90 % CI 74-100; p = 0.02) and 64 % for patients who completed at least one post-baseline evaluation (n = 14; 90 % CI 43-85; p = 0.42). Seven patients did not complete the study due to adverse events (mostly fatigue and nausea).

CONCLUSIONS

Duloxetine showed an indication of efficacy in the treatment of pain in patients with suspected SOD, but adverse events limited its use. These preliminary, open-label results justify definitive placebo-controlled trials.

Minimally invasive techniques of biliary surgery in new era

With the rapid development of technology and improvement of surgical skills, many types of minimally invasive techniques have been developed, including laparoscopic technique, combined endoscopic-laparoscopic technique, robotic surgery, and percutaneous transhepatic cholangial drainage technique. Different techniques own their special advantages for different types of biliary diseases. In the current review, I discuss the progress in minimally invasive techniques dealing with biliary diseases in the new era.

Impact of previous cyst-enterostomy on patients’ outcome following resection of bile duct cysts

AIM: To analyze the impact of previous cyst-enterostomy of patients underwent congenital bile duct cysts (BDC) resection.

METHODS: A multicenter European retrospective study between 1974 and 2011 were conducted by the French Surgical Association. Only Todani subtypes I and IVb were included. Diagnostic imaging studies and operative and pathology reports underwent central revision. Patients with and without a previous history of cyst-enterostomy (CE) were compared.

RESULTS: Among 243 patients with Todani types I and IVb BDC, 16 had undergone previous CE (6.5%). Patients with a prior history of CE experienced a greater incidence of preoperative cholangitis (75% vs 22.9%, P < 0.0001), had more complicated presentations (75% vs 40.5%, P = 0.007), and were more likely to have synchronous biliary cancer (31.3% vs 6.2%, P = 0.004) than patients without a prior CE. Overall morbidity (75% vs 33.5%; P < 0.0008), severe complications (43.8% vs 11.9%; P = 0.0026) and reoperation rates (37.5% vs 8.8%; P = 0.0032) were also significantly greater in patients with previous CE, and their Mayo Risk Score, during a median follow-up of 37.5 mo (range: 4-372 mo) indicated significantly more patients with fair and poor results (46.1% vs 15.6%; P = 0.0136).

CONCLUSION: This is the large series to show that previous CE is associated with poorer short- and long-term results after Todani types I and IVb BDC resection.

Biliary Tumor Ablation with Photodynamic Therapy and Radiofrequency Ablation

Within the past two decades, major progress has been made in biliary endoscopy both with stenting and with ablative therapy. A primary goal in patients with malignant biliary lesions who are not candidates for surgery is to provide localized and efficient necrosis of the lesions. This article summarizes the current literature on biliary tumor ablation with photodynamic therapy and radiofrequency ablation. Prognosis, treatment technique, potential complications, treatment efficacy, and controversies are discussed.

Sex-Dependent Claudin-1 Expression in the Liver of Euthyroid and Hypothyroid Mice

BACKGROUND

In the liver the tight junction protein claudin-1 plays an important role in bile secretion by maintaining the paracellular barrier of bile canaliculi and the bile duct. A diminished bile excretion has been found in hypothyroid patients, and the prevalence of gallstones is increased in hypothyroidism. This association, however, only applies for men and is in contrast to the well-established female preponderance of biliary disease in the general population.

OBJECTIVES

We hypothesized that hypothyroidism could lead to altered claudin-1 expression in the liver, and that this effect may be sex specific.

METHODS

We characterized claudin-1 expression and localization in livers of euthyroid and hypothyroid male and female C57BL/6NTac mice by real-time PCR, Western blot and immunofluorescence.

RESULTS

Claudin-1 is expressed in canalicular regions and the bile ducts of the murine liver. Livers of female mice showed lower claudin-1 expression than male livers. In hypothyroid livers, female animals showed an elevated claudin-1 expression, whereas reduced claudin-1 expression was found in male animals compared to the euthyroid controls.

CONCLUSION

We demonstrate a correlation between claudin-1 expression and hypothyroidism in the murine liver. Furthermore, a sex-dependent alteration of claudin-1 expression was found.

[Acute pancreatitis: an overview of the management]

Over the past decades, the incidence and the number of hospital admissions for acute pancreatitis have increased in the Western countries. The two most common etiological factors of acute pancreatitis are gallstones (including small gallstones or microlithiasis) and alcohol abuse. Acute pancreatitis is associated with a significant mortality (4-10%) and 25% in case of pancreatic necrosis, especially. Edematous pancreatitis is benign and oral feeding can be restarted once abdominal pain is decreasing and inflammatory markers are improving. Enteral tube feeding should be the primary therapy in patients with predicted severe acute pancreatitis who require nutritional support. Enteral nutrition in acute pancreatitis can be administered via either the nasojejunal or nasogastric route. In case of necrosis, preventive antibiotics are not recommended. The single indication is infected necrosis confirmed by fine needle aspiration. The incidence trends of acute pancreatitis possibly reflect a change in the prevalence of main etiological factors (e.g. gallstones and alcohol consumption) and cofactors such as tobacco, obesity and genetic susceptibility. Priority is to search for associated causes, especially in cases with atypical symptoms. In case of first acute pancreatitis in patients older than 50 years, the presence of a tumor (benign or malignant) has to be specifically ruled out, using CT-scan, MRI and endoscopic ultrasound.

Evaluation of fully covered self-expanding metal stents in benign biliary strictures and bile leaks

AIM: To investigate the use of fully covered metal stents in benign biliary strictures (BBS) and bile leaks.

METHODS: We studied 17 patients, at Harbor-UCLA Medical center (Los Angeles), with BBS (n = 12) and bile leaks (n = 5) from July 2007 to February 2012 that had received placement of fully covered self-expanding metal stents (FCSEMs). Fourteen patients had endoscopic placement of VIABIL^® (Conmed, Utica, New York, United States) stents and three had Wallflex^® (Boston Scientific, Mass) stents. FCSEMS were 8 mm or 10 mm in diameter and 4 cm to 10 cm in length. Patients were followed at regular intervals to evaluate for symptoms and liver function tests. FCSEMS were removed after 4 or more weeks. Resolution of BBS and leak was documented cholangiographically following stent removal. Stent patency can be defined as adequate bile and contrast flow from the stent and into the ampulla during endoscopic retrograde cholangiopancreatography (ERCP) without clinical signs and/or symptoms of biliary obstruction. Criterion for bile leak resolution at ERCP is defined as absence of contrast extravasation from the common bile duct, cystic duct remanent, or gall bladder fossa. Rate of complications such as migration, and in-stent occlusion were recorded. Failure of endoscopic therapy was defined as persistent biliary stenosis or continuous biliary leakage after 12 mo of stent placement.

RESULTS: All 17 patients underwent successful FCSEMS placement and removal. Etiologies of BBS included: cholecystectomies (n = 8), cholelithiasis (n = 2), hepatic artery compression (n = 1), pancreatitis (n = 2), and Whipple procedure (n = 1). All bile leaks occurred following cholecystectomy. The anatomic location of BBS varied: distal common bile duct (n = 7), common hepatic duct (n = 1), hepaticojejunal anastomosis (n = 2), right intrahepatic duct (n = 1), and choledochoduodenal anastomatic junction (n = 1). All bile leaks were found to be at the cystic duct. Twelve of 17 patients had failed prior stent placement or exchange. Resolution of the biliary strictures and bile leaks was achieved in 16 of 17 patients (94%). The overall median stent time was 63 d (range 27-251 d). The median stent time for the BBS group and bile leak group was 62 ± 58 d (range 27-199 d) and 92 ± 81 d (range 48-251 d), respectively. All 17 patients underwent successful FCSEMS removal. Long term follow-up was obtained for a median of 575 d (range 28-1435 d). Complications occurred in 5 of 17 patients (29%) and included: migration (n = 2), stent clogging (n = 1), cholangitis (n = 1), and sepsis with hepatic abscess (n = 1).

CONCLUSION: Placement of fully covered self-expanding metal stents may be used in the management of benign biliary strictures and bile leaks with a low rate of complications.

Androgen-deprivation therapy and risk for biliary disease in men with prostate cancer

BACKGROUND

Androgen-deprivation therapy (ADT) by either a gonadotropin-releasing hormone (GnRH) agonist or bilateral orchiectomy improves disease-related outcomes of men with prostate cancer but has a variety of adverse metabolic effects including obesity, increased abdominal girth, increased triglycerides, and insulin resistance. Each is a risk factor for gallstone disease. Additionally, GnRH agonist treatment was recently shown in metabolomic analyses to increase plasma levels of some bile acids.

OBJECTIVE

To assess the relationship between ADT and the incidence of biliary disease in men with prostate cancer.

DESIGN, SETTING, AND PARTICIPANTS

We studied 183 842 men >65 yr of age living in Surveillance, Epidemiology, and End Results regions who were diagnosed with prostate cancer from 1992 to 2007 and followed through 2009.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

We calculated incidence rates for biliary disease during treatment with GnRH agonists, orchiectomy, or no therapy. We used Cox proportional hazard models to assess the association of ADT with biliary disease.

RESULTS AND LIMITATIONS

Among 183 842 men with locoregional prostate cancer, 48.4% received GnRH agonist treatment and 2.2% underwent bilateral orchiectomy during follow-up. GnRH agonist treatment was associated with a significantly higher incidence of biliary disease compared with no treatment (15.7 vs 13.4 cases per 1000 person-years; p<0.001). In adjusted analyses, GnRH agonist use was associated with the risk of biliary disease (adjusted hazard ratio: 1.10; 95% confidence interval, 1.05-1.15; p<0.001). Orchiectomy was not significantly associated with biliary disease.

CONCLUSIONS

GnRH agonist treatment may be associated with a greater risk of incident biliary disease.

Role of endoscopic ultrasound in gastrointestinal surgery

Endoscopic Ultrasound is an emerging diagnostic tool in the field of Gastrointestinal Surgery. Our review article focuses on role of EUS in staging cancers (esophageal, gastric, biliary and rectal), detection of bilio-pancreatic calculi and diagnosis of chronic pancreatitis. Potential for performing EUS based therapeutic interventions are been explored and looks promising from the initial reports.

Management of pancreaticobiliary disease using a new intra-ductal endoscope: The Texas experience

AIM: To evaluate a new single-operator mini-endoscope, Spyglass^®, for its performance, feasibility and safety in the management of pancreaticobiliary disease.

METHODS: In a multicenter retrospective analysis of patients undergoing intraductal endoscopy, we evaluated 128 patients (71 men, mean age 57.6 years). Indications were therapeutic (TX) in 72 (56%) and diagnostic (DX) in 56 (44%).

RESULTS: Peroral endoscopy was performed in 121 and percutaneous in seven. TX indications included CBD stones in 41, PD stones in six, and biliary strictures in 25. DX indications included abnormal LFT’s in 15, abnormal imaging in 38 and cholangiocarcinoma staging in three. Visualization of the stone(s) was considered good in 31, fair in six, and poor in four. Advancement of the electrohydraulic lithotripsy probe was not possible in three patients and proper targeting of the lesion was partial in four patients. A holmium laser was used successfully in three patients. Ductal clearance was achieved in 37 patients after one procedure and in four patients after two procedures. Diagnosis of biliary strictures was modified in 20/29 and confirmed to be malignant in 10/23. Of the modified patients, no diagnosis was available in 17. Spyglass^® demonstrated malignancy in 8/17 and non-malignancy in nine. Suspected pathology by imaging studies and abnormal LFT’s was modified in 43/63 (66%). Staging of cholangiocarcinoma demonstrated multicentric cholangiocarcinoma in 2/3. There was no morbidity associated with the use of Spyglass^®.

CONCLUSION: Spyglass Spyscope^® is a first generation, single operator miniature endoscope that can evaluate and treat various biliary and pancreatic tract diseases.