Search Results (65)

Endoscopic retrograde cholangiopancreatography (ERCP) is the cornerstone in the management of choledocholithiasis. Despite continuous advancements in technique and safety, ERCP carries a risk of significant complications, underscoring the importance of avoiding unnecessary procedures. The principal contributor to potentially avoidable ERCPs in patients with known choledocholithiasis is the spontaneous passage of common bile duct stones. Small stone size and a long interval between diagnosis and the procedure have increasingly been found to favor this event. Moreover, despite the development of well-defined risk stratification scores for patients with suspected choledocholithiasis, the incidence of negative ERCPs within this patient population remains considerable, even when a high suspicion of choledocholithiasis is evident. This review summarizes current evidence on the incidence and predictors of avoidable ERCPs in these contexts, with particular emphasis on spontaneous stone passage. It also discusses the role of endoscopic ultrasound (EUS) as a diagnostic tool to reduce unnecessary procedures when initial imaging fails to confirm the presence of stones despite persistent high clinical suspicion. By integrating and critically appraising recent findings, we provide practical guidance for clinicians on decision-making regarding ERCP, particularly in situations where spontaneous stone passage is likely or imaging results are inconclusive. Full article

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is the primary treatment option for choledocholithiasis. However, this procedure carries an inherent non-negligible risk of complications, requiring precise indications and careful patient selection. Endoscopic ultrasonography (EUS) can verify the presence of bile duct stones prior to ERCP. The current ESGE recommendations permit ERCP in high-risk patients without confirmation; however, several individuals undergo ERCP without evident advantage, indicating a necessity for enhanced stratification. Objectives: We aim to evaluate the rate of EUS-validated choledocholithiasis in patients with suspected common bile duct (CBD) stones and to determine the predictors of residual stones. A secondary objective was to create and internally validate a streamlined scoring system to enhance risk assessment in ESGE high-risk patients. Methods: We conducted a retrospective analysis of patients who had endoscopic ultrasound for suspected choledocholithiasis from January 2023 to December 2024 at a tertiary center. Multivariate logistic regression determined independent predictors of retained calculi. A simplified score was derived from model coefficients and internally validated. Results: Among 438 examined patients, 186 were included and 87 had choledocholithiasis confirmed via EUS. ERCP was conducted in 81 patients and postponed for 6 patients due to contraindications. According to the ESGE criteria, 10 patients (5.4%) were classified as low risk, 92 (49.5%) as intermediate risk, and 84 (45.2%) as high risk for choledocholithiasis. For high-risk individuals, EUS identified stones in 45 (53.5%), while 39 (46.4%) experienced spontaneous clearance. Acute pancreatitis (aOR 0.075), cholangitis (aOR 6.939), and EUS CBD diameter (aOR 1.220 per mm) were independent predictors of stones. The resultant three-component score (−2 to +4 points) demonstrated effective discrimination (AUROC 0.788). A criterion of ≥2 resulted in 85.7% sensitivity and 59.0% specificity. Conclusions: Almost fifty percent of ESGE high-risk patients were not found to have CBD stones during EUS. Integrating EUS data with a straightforward predictive score may enhance risk classification and avert superfluous ERCP procedures. Full article

Background: Takotsubo cardiomyopathy (TTC), also known as stress-induced cardiomyopathy, is an acute but reversible form of left ventricular dysfunction, most commonly triggered by physical or emotional stress. Although well documented in cardiology practice, its occurrence following hepatobiliary surgery is rarely reported. Case presentation: We describe the case of a 67-year-old woman with a history of arterial hypertension and prior cholecystectomy who was admitted for elective hepatobiliary surgery due to choledocholithiasis complicated by a liver abscess. She underwent laparotomy with choledocholithotomy, hepaticojejunostomy, and abdominal drainage. The postoperative course was complicated by intra-abdominal bleeding, requiring reoperation, and subsequent intestinal leakage, necessitating a second re-laparotomy. On the tenth postoperative day after the second surgery, she developed chest discomfort and dyspnea upon minimal exertion. Electrocardiography revealed T-wave inversions in leads V3–V6, while echocardiography demonstrated a reduced ejection fraction of 45% with apical akinesis. Plasma levels of N-terminal pro-B-type natriuretic peptide (NT–proBNP) were elevated, whereas troponin remained within normal limits. Coronary angiography excluded obstructive coronary artery disease, and ventriculography confirmed apical ballooning consistent with Takotsubo cardiomyopathy. Conclusions: This case highlights Takotsubo cardiomyopathy as a rare but important postoperative complication of major hepatobiliary surgery. Awareness of this condition in surgical patients presenting with acute chest symptoms is essential, as timely recognition and differentiation from acute coronary syndrome directly influence management and prognosis. Full article

Background: Patients with type 2 diabetes mellitus (T2DM) and inflammatory bowel disease (IBD) face elevated risk of hepatobiliary complications. The biliary safety of GLP-1 and dual GLP-1/GIP receptor agonists in this population is uncertain. Methods: We conducted a retrospective cohort study using the TrinetX LIVE global health research network. Adults (≥18 years) with coexisting T2DM and IBD were assigned to exposure (semaglutide or tirzepatide) or comparator (no GLP-1/GIP therapy) cohorts. The index was first prescription (or matched date). Primary outcomes—cholelithiasis, cholecystitis, choledocholithiasis, and cholangitis—were identified by ICD-10 codes. Propensity score matching (1:1 greedy nearest neighbor; caliper 0.1 SD) balanced demographics, comorbidities, GI surgeries, and antidiabetic medications. Results: After propensity score matching, 32,052 patients were included (16,026 per cohort), achieving excellent covariate balance with standardized mean differences < 0.1 for nearly all variables. GLP-1/GIP agonist use was associated with significantly lower risks of multiple biliary complications. Cholelithiasis occurred in 3.5% of GLP-1/GIP users compared with 6.3% of nonusers (risk ratio [RR] 1.81, 95% CI 1.64–2.00; hazard ratio [HR] 1.27, 95% CI 1.14–1.41; p < 0.001). Cholecystitis similarly occurred less frequently among users (0.8% vs. 2.2%; RR 2.74, 95% CI 2.24–3.34; HR 1.85, 95% CI 1.50–2.27; p < 0.001). Choledocholithiasis was also reduced in the GLP-1/GIP cohort (0.6% vs. 1.5%; RR 2.72, 95% CI 2.14–3.46; HR 1.90, 95% CI 1.48–2.44; p < 0.001). Cholangitis events were rare in both groups (0.1% vs. 0.2%) with no significant difference on survival analysis (HR 1.07, 95% CI 0.58–1.97; p = 0.08). Conclusions: In adults with T2DM and IBD, GLP-1 and dual GLP-1/GIP receptor agonists are associated with substantially reduced risks of gallstone-related complications. These real-world data support the gastrointestinal safety of GLP-1–based therapy in a high-risk population and suggest possible biliary protective effects warranting prospective, agent-specific studies. Full article

Background/Objectives: The diagnostic management of obstructive pancreatobiliary pathologies often leads to unnecessary invasive procedures and the overuse of costly imaging due to inherent diagnostic uncertainties. This dilemma highlights the need for a refined triaging strategy. This study aimed to compare the diagnostic competence and triage potential of Transabdominal Ultrasonography (TAUS)—a cost-effective, first-line method—with the efficacy of the invasive method, Endoscopic Ultrasonography (EUS). Our objective was to identify specific TAUS findings that could render EUS redundant or serve as a clinical guide for referral to EUS. Methods: This prospective study included patients evaluated for suspected pancreatobiliary lesions (December 2024–September 2025). Final diagnoses (gold standard) were established using pathology, tumor board decisions, other imaging, or ≥6 months clinical follow-up. TAUS was performed by one operator blinded to clinical data. EUS was immediately performed by a different operator, blinded to TAUS results and all other clinical data. Data were grouped into normal findings, solid masses, cystic lesions, chronic pancreatitis, distal cholangiocarcinoma/ampullary tumors, and choledocholithiasis. Results: A total of 204 patients were included. TAUS sensitivity (76.5%) was significantly lower than EUS (94.6%) (p < 0.001), but both showed high specificity (TAUS: 82.9%; EUS: 88.24%). TAUS performance varied greatly by lesion type: high for solid lesions (81.8%) and chronic pancreatitis (88.9%), but markedly lower for distal common bile duct lesions/ampullary tumors (57.1%; p = 0.006). In univariate analysis, BMI (p < 0.001), lesion size (p = 0.002), MPD dilation (p = 0.001), and localization (p < 0.001) were associated with TAUS success. Lesion size (OR = 1.049, p = 0.029) was the independent predictor in the multivariate analysis. TAUS detected common bile duct dilation in obstructive cases at a high rate (95.9%) but had statistically significantly lower success in reaching a definitive diagnosis (63.3%; p < 0.001). Conclusions: While TAUS lacks the overall sensitivity of EUS, its robust detection performance for solid lesions and chronic pancreatitis suggests that it can reduce the need for further investigation in selected cases. The TAUS detection success, associated with factors like BMI and lesion size, combined with its high rate of common bile duct dilation detection, establishes a reliable triage guideline for referring patients to advanced diagnostic procedures, primarily EUS, to confirm the definitive etiology. Full article

Background/Objectives: ERCP is an established method of treating cholelithiasis; however, data on its use in the pediatric population is limited. The aim of this study was to assess the prevalence of cholelithiasis among Polish children, the number of ERCP procedures performed on them, and the time between endoscopic and surgical procedures when both were necessary. Methods: We performed a retrospective data analysis on Polish children hospitalized due to biliary tract pathologies (ICD-10 K80–K83) in the period of 2010–2022. Results: In the years 2010–2022, 15,581 hospitalizations linked to the diagnosis of K80–K83 were reported. Of these, 40.71% involved patients undergoing a surgical procedure, and 4.28% involved patients undergoing ERCP (10.15% of unique patients underwent ERCP). Females accounted for 65.91% of hospitalizations, and patients in the age group of 14–17 represented 57.31% of hospitalizations. No significant yearly trends were observed in the number of hospitalizations and ERCP procedures performed. The median time between ERCP and surgical procedures was 32 days. Conclusions: Both the number of ERCP procedures performed in Poland and the demography of patients are consistent with data from the literature. Further research is needed to fully understand the treatment of cholelithiasis among Polish children. Full article

Introduction: ERCP with temporary biliary stenting followed by elective cholecystectomy and postoperative ERCP is commonly used to treat choledocholithiasis. While early stent removal (within 3–6 months) is generally recommended, some studies suggest that longer dwell time may not increase morbidity. This study aims to evaluate outcomes associated with prolonged stent dwell time of more than six months. Methods: We conducted a retrospective study of all patients who underwent ERCP with plastic biliary stent insertion, followed by elective cholecystectomy and postoperative ERCP at a single tertiary center between 2018–2024. Patients were divided into early-ERCP (≤6 months) and late-ERCP (>6 months) groups. The primary outcome was the rate of recurrent biliary episodes. Secondary outcomes included urgent postoperative ERCP, stent reinsertion, and the need for additional ERCP’s. Results: A total of 203 patients were included (mean age 58.3 ± 19.8 years). Thirty-one patients (15%) had a stent dwell time of more than six months. Demographic and presenting characteristics were comparable between groups, except for acute cholecystitis, which was more frequent in the early-ERCP group (18% vs. 3.2%, p = 0.034). Recurrent biliary episodes were significantly more frequent in the late-ERCP group (19.4% vs. 5.8%, p = 0.021), as were urgent postoperative ERCP (16.1% vs. 5.2%, p = 0.044), stent reinsertion (35.5% vs. 14.5%, p = 0.008), and additional ERCPs (38.7% vs. 15.7%, p = 0.006). Conclusions: Prolonged biliary stent dwell time beyond six months is associated with significantly higher rates of recurrent biliary episodes, urgent postoperative ERCP, postoperative stent reinsertion, and additional ERCP’s. Full article

Background and Objectives: Laparoscopic cholecystectomy is one of the most performed surgical procedures worldwide. In low-risk patients, routine postoperative blood tests are frequently ordered despite limited evidence supporting their necessity. The aim of the study was to evaluate the predictability of complications that may occur with routine postoperative blood tests. Materials and Methods: This retrospective study examined 538 patients who underwent surgery in Cam and Sakura City Hospital between May 2020 and May 2021. Patients were divided into two groups: no postoperative complications (Group NC, n = 521) and postoperative complications (Group C, n = 17). Demographic characteristics, including age and gender, duration of surgery, cystic duct closure method, drain use, complications, preoperative and postoperative blood tests, and the mean time of hospital stay, were the collected data throughout the study. Results: The analysis of the post-operative blood test values revealed that the total bilirubin (p = 0.005), ALT (p = 0.002), AST (p = 0.002), GGT (p = 0.02) and amylase (p = 0.034) values were statistically significantly higher in Group C than in Group NC, but these values did not exceed the normal range except for ALT, AST and GGT, which were slightly higher than the normal parameters. Seventeen patients (3.15%) developed postoperative complications, including biliary leakage (n = 1); choledocholithiasis (n = 2); cardiac (n = 2), pulmonary (n = 9), and hemorrhagic (n = 2) complications; and a superficial wound infection (n = 1). Most complications were identified by symptoms and clinical observation. Conclusions: Routine postoperative blood tests in low-risk laparoscopic cholecystectomy patients do not significantly contribute to the early detection of complications. Clinical observation and targeted use of laboratory or imaging tests in selected high-risk cases might be more efficient. This approach can help reduce unnecessary workload, hospital costs, and healthcare expenditures without compromising patient safety. Full article

Background/Objectives: The combined techniques of endoscopic sphincterotomy followed by endoscopic papillary balloon dilation (ESBD) and endoscopic sphincterotomy followed by endoscopic papillary large balloon dilation (ESLBD) have gained popularity for the endoscopic treatment of choledocholithiasis. However, the conventional approach to these procedures requires two separate devices, a sphincterotome and a balloon catheter, which can complicate and prolong the procedure. We herein evaluated a novel integrated device combining a sphincterotome and balloon catheter developed to improve the efficiency of ESBD and ESLBD. Methods: This retrospective study compared the clinical outcomes of patients with choledocholithiasis who were treated using conventional sphincterotome and balloon catheters (n = 106) and those who were treated using the integrated device (n = 54). Results: Overall complete stone removal rates (99.1% vs. 100%) and adverse event incidence (12.3% vs. 13.0%) were comparable between the two groups. However, the integrated device significantly reduced total procedure time (40 vs. 27 min, p = 0.01), use of mechanical lithotripter (50.0% vs. 22.2%, p < 0.01), total number of procedures required. Conclusions: Complete stone removal rates and safety were comparable between the two groups. However, the novel integrated device may enhance the efficiency of common bile duct stone removal through ESBD and ESLBD because it eliminates the need to prepare and exchange separate devices. Full article

Background/Objectives: Endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction is the standard treatment for common bile duct (CBD) stones. However, when complete removal is not feasible, the temporary placement of a plastic stent (PS) is commonly used. This study aimed to assess 12-month stent patency in elderly patients with CBD stones. Methods: This prospective study included patients aged 70 years or older who underwent ERCP with PS placement for CBD stones at Daegu Catholic University Medical Center from March to December 2023. Patients were followed every three months with laboratory tests and abdominal radiographs. Stent dysfunction was defined as either cholangitis or cholecystitis due to stent migration or occlusion. Results: Of 12 enrolled patients, 2 were lost to follow-up. The remaining 10 had a median age of 85 years. The median stone diameter and number were 16.5 mm and 3, respectively. Two patients (20%) experienced stent dysfunction at 1.4 and 2.7 months and underwent successful stent exchange. Of the remaining eight, one declined further ERCP, while seven underwent elective ERCP at 12 months. Among them, five achieved successful stone removal and two required stent exchange. Kaplan–Meier analysis showed 90% patency at 1.4 months and 80% at 2.7 months, maintained through 12 months. Conclusions: Plastic stents showed an acceptable 12-month patency in most elderly patients. Early complications suggest the need for close monitoring during the first three months, after which long-term stent maintenance may be feasible in selected cases. Larger studies are needed to validate these findings. Full article

Background: Pediatric cholelithiasis has become increasingly diagnosed, partly due to enhanced imaging accessibility and rising obesity rates. Despite laparoscopic cholecystectomy being the standard treatment, the optimal timing for surgery remains debated, especially in complicated cases. The aim of our study is to analyze the demographic, clinical, and surgical characteristics of pediatric patients undergoing cholecystectomy and to identify the most favorable timing for surgery in terms of outcomes and complications. Material and methods: A retrospective study was conducted on 101 pediatric patients who underwent cholecystectomy between 2015 and 2024 at a tertiary children’s hospital. Patients were categorized based on surgical timing: elective, early (day 1–4), intermediate (day 5–14), and delayed (after day 14). Demographic data, clinical presentation, laboratory values, imaging, operative time, intraoperative findings, and postoperative complications were analyzed. Results: The median age was 15 years, with 64.35% female. Obesity was highly prevalent and significantly associated with choledocholithiasis and pancreatitis. Elective and delayed surgeries (after 14 days) had the shortest operative times (median: 2 h) and the lowest complication rates. Early surgeries (within 4 days) showed longer operative times and a higher incidence of intraoperative difficulties and complications. Histopathological findings did not influence clinical management, suggesting potential for selective examination. Conclusions: Elective or delayed cholecystectomy after a “cool-down” period of 5–14 days provides the most favorable outcomes in pediatric patients with complicated cholelithiasis. Conservative management remains appropriate for asymptomatic cases. A standardized approach to surgical timing may reduce complications and hospital costs Full article

Objectives: To analyze the factors associated with recurrent choledocholithiasis following endoscopic retrograde cholangiopancreatography (ERCP) with biliary sphincterotomy (BS). Methods: A retrospective, observational, and analytical cohort study was conducted. Patients who underwent ERCP with BS for benign biliary pathology and were followed for a minimum of two years were included. Demographic and clinical data were collected, including the indication for the procedure, endoscopic findings, performance and timing of cholecystectomy (before or after ERCP), and the need for repeat procedures. Episodes of choledocholithiasis were defined as those occurring at least six months after the initial ERCP. Follow-up continued until patient death, loss of follow-up, or the conclusion of the study. Results: A total of 576 patients were included, with a mean age of 71 years and an average follow-up duration of 131 months. Sixty-nine cases of recurrent choledocholithiasis were documented (11.96%). Multivariate analysis identified the following predictive factors for recurrence: age over 50 years, bile duct dilation upon initial evaluation, history of biliary surgery, cytology sampling, placement of biliary stents, repeated ERCP, biliary diversion procedures, and cholecystectomy prior to the index ERCP. Conclusions: Biliary duct dilation, advanced age, and any previous manipulation of the biliary tree are associated with an increased risk of recurrent choledocholithiasis. Cholecystectomy performed after the initial ERCP was not associated with a reduced recurrence risk. Full article

Background: Alcohol use and hypertriglyceridemia are the second and third common causes of acute pancreatitis after choledocholithiasis. Still, few studies directly compare the severity and outcomes of these two groups, which share pathophysiology pathways. Methods: In our study, we compared the biologic profile, severity according to the Atlanta classification and Balthazar index, intensive care unit admissions, and mortality between patients with hypertriglyceridemia-induced pancreatitis (HTGP) and alcohol-induced acute pancreatitis (AAP). A total of 78 patients were included in this study, 37.17% of which had HTGP, and 62.82% had AAP. Results: HTGP was more severe in terms of the Atlanta revised classification severity assessment (82.76% vs. 46%, p = 0.014), led to more extended hospitalizations (p = 0.024), and resulted in similar serum CRP levels among patients, with a significant difference regarding median serum fibrinogen values (739 vs. 563 mg/dL, p = 0.030) and necrotizing forms (24.13% vs. 10.20%). Hyponatremia was more significant in HTGP patients compared with AAP patients (130 vs. 137 mmol/L, p < 0.000). No differences were found in other inflammation indexes such as NLR (neutrophil count/lymphocyte count), PLR (platelet count/lymphocyte count), MLR (monocyte/lymphocyte count), SII (systemic immune-inflammation index), or SIRI (systemic inflammation response index). Conclusions: The pattern of acute pancreatitis is related to its etiology and may have different grades of severity. In our study, we found that hypertriglyceridemia-induced pancreatitis required twice as many admissions to the intensive care unit and was associated with lower serum sodium levels, and almost twice as many patients with HTGP had moderate or severe forms of acute pancreatitis compared to alcohol-induced pancreatitis cases. Full article

Background: Different techniques have been proposed to manage Cholecysto-choledocholithiasis (CCL) advantageously in one stage. Among these, Laparoendoscopic Rendezvous (LERV) addresses the CCL issue with a laparoscopic cholecystectomy, with insertion of a guide wire into the common bile duct through an incision of the cystic duct, followed by the clearance of the bile duct carried out by the endoscopists. The aim of this study was to evaluate the safety and the efficacy of the one-stage vs. a two-stage approach (pre-operative ERCP followed by cholecystectomy), and to compare our results with data from the current literature. Methods: All patients that underwent LERV in our facilities between January 2018 and December 2023 were evaluated. As a control group, we included patients that underwent a two-stage technique called the “sequential approach”. The primary outcome was to evaluate the efficacy in obtaining complete clearance of the common bile duct (CBD). The secondary outcomes included morbidity, mortality, operative time, conversion rate, hospital stay and CDB stone recurrence. Results: 120 patients in the LERV group were included; meanwhile, 70 patients underwent pre-operative ERCP plus cholecystectomy. A 97% bile duct clearance success rate in the LERV group and 93% in the ERCP group was observed, respectively. The median intraoperative time for the one-stage technique was 122 min (p < 0.001) and the median hospital stay was 4 days (p < 0.001). In the LERV group, an overall morbidity of 15% was reported (18/120): 15 Clavien–Dindo type 1, one type 3a and two type 3b (p < 0.001). At a median follow-up of 14 months, five patients experienced stone recurrence. In the ERCP group, we had a 93% success rate; meanwhile, we had longer hospitalization (p < 0.001), 27% post-ERCP pancreatitis (p < 0.001) and a cumulative morbidity of 30%. Conclusions: LERV offers the advantages of a being single-stage procedure and shorter hospitalization, with a lower risk of clinically relevant post-ERCP pancreatitis and failed CBD cannulation. Full article

Endoscopic management of benign pancreaticobiliary disorders encompasses a range of procedures designed to address complications in gallstone disease, choledocholithiasis, and pancreatic disorders. Acute cholecystitis is typically treated with cholecystectomy or percutaneous drainage (PT-GBD), but for high-risk or future surgical candidates, alternative decompression methods, such as endoscopic transpapillary gallbladder drainage (ETP-GBD), and endoscopic ultrasound (EUS)-guided gallbladder drainage (EUS-GBD), are effective. PT-GBD is associated with significant discomfort as well as variable adverse event rates. EUS-GBD leverages lumen-apposing metal stents (LAMS) for direct access to the gallbladder, providing the ability to treat an inflamed GB internally. Choledocholithiasis is primarily managed with ERCP, utilizing techniques to include balloon extraction, mechanical lithotripsy, or advanced methods such as electrohydraulic or laser lithotripsy in cases of complex stones. Altered anatomy from bariatric procedures like Roux-en-Y gastric bypass may necessitate specialized approaches, including balloon-assisted ERCP or EUS-directed transgastric ERCP (EDGE). Post-operative complications, including bile leaks and strictures, are managed endoscopically using sphincterotomy and stenting. Post-liver transplant anastomotic and non-anastomotic strictures often require repeated stent placements or advanced techniques like magnetic compression anastomosis in refractory cases. In chronic pancreatitis (CP), endoscopic approaches aim to relieve pain and address structural complications like pancreatic duct (PD) strictures and calculi. ERCP with sphincterotomy and stenting, along with extracorporeal shock wave lithotripsy (ESWL), achieves effective ductal clearance for PD stones. When traditional approaches are insufficient, direct visualization with peroral pancreatoscopy-assisted lithotripsy is utilized. EUS-guided interventions, such as cystgastrostomy, pancreaticogastrostomy, and celiac plexus blockade, offer alternative therapeutic options for pain management and drainage of peripancreatic fluid collections. EUS plays a diagnostic and therapeutic role in CP, with procedures tailored for high-risk patients or those with complex anatomy. As techniques evolve, endoscopic management provides minimally invasive alternatives for patients with complex benign pancreaticobiliary conditions, offering high clinical success and fewer complications. Full article