The influence of periampullary diverticula on ERCP for treatment of common bile duct stones.

In order to evaluate the effectiveness of various methods we applied to decrease the influence of periampullary diverticula (PAD) on the success rate and complications of endoscopic retrograde cholangiopancreatography (ERCP) in the treatment of common bile duct (CBD) stones, we enrolled patients with CBD stones who had been treated by ERCP in our hospital between January 2015 and December 2018. According to the presence of PAD, the patients were divided into a PAD group and a non-PAD group. The rate of complete stone removal in the first session, the rate of overall stone removal, the frequency of application of mechanical lithotripsy, and procedure-related complications, including bleeding, hyperamylasemia, pancreatitis, perforation, and infection of biliary tract were recorded. A total of 183 cases, including 72 cases in the PAD group and 111 cases in the non-PAD group were enrolled. There was no statistical difference between the two groups regarding gender (P = 0.354). However, regarding age, there was a statistical difference (P = 0.002), and the incidence of PAD increased with age. There were 5 (6.9%) cases in the PAD group and 14 (12.6%) cases in the non-PAD group where mechanical lithotripsy was applied. There were 59 (81.9%) cases in the PAD group and 102 (91.9%) cases in the non-PAD group where there was complete removal of CBD stones in the first session, and there were 68 (94.4%) cases in the PAD group and 107 (96.4%) cases in the non-PAD group where there was complete removal of all stones. In the PAD group, there were 0 cases (0%) with gastrointestinal bleeding, 0 cases (0%) with gastrointestinal perforation, 13 cases (18.1%) with post-ERCP hyperamylasemia, 3 cases (4.2%) with post-ERCP pancreatitis, and 4 cases (5.6%) with biliary tract infection. In the non-PAD group, 1 case (0.9%) had gastrointestinal bleeding, 0 cases had gastrointestinal perforation, 18 cases (16.2%) had post-ERCP hyperamylasemia, 5 cases (4.5%) had post-ERCP pancreatitis, and 11 cases (9.9%) had biliary tract infection. This retrospective study showed that there was a statistical difference between the two groups regarding complete removal of CBD stones in the first session and application of mechanical lithotripsy (both P < 0.05), but no statistical difference according to the rates of overall stone removal and the complications (P > 0.05), which means that we can reduce the influence of PAD on ERCP for treatment of common bile duct stones.

Biodegradable Biliary Stents for Percutaneous Treatment of Post-liver Transplantation Refractory Benign Biliary Anastomotic Strictures.

PURPOSE: The aim of this study was to evaluate the safety and the effectiveness of polydioxanone-made biodegradable biliary stent placement for the treatment of post-transplant benign, refractory biliary anastomotic strictures. MATERIALS AND METHODS: This was a retrospective observational study on all adult liver transplant recipients who developed a clinically significant anastomotic stricture between January 2014 and June 2017. Percutaneous transhepatic cholangioplasty with balloon dilation was performed as therapeutic approach in selected patients after multidisciplinary evaluation. Refractory strictures (defined as stricture persistence after two interventional procedures) were managed with placement of polydioxanone-made biodegradable biliary stent (SX-Ella biliary stent, Czech Republic). Patency of the common bile duct was calculated using Kaplan-Meier analysis. RESULTS: Eighteen adult liver transplant recipients who developed a refractory biliary anastomotic stricture [males/females 13/5, median (IQR) 58.2 (9.3) years] underwent biodegradable biliary stent placement after 10.4 (32) months from liver transplantation. All procedures except one were uneventful. After a median (IQR) follow-up time of 27.2 (22) months, complete resolution of anastomotic stricture was achieved in 72% of patients, with significant improvement on liver enzymes. CONCLUSIONS: Polydioxanone-made biodegradable biliary stent might be a safe and effective therapeutic option for the difficult-to-treat benign biliary anastomotic stricture after liver transplantation.

Feasibility of bile duct as venous graft for venous reconstruction in pancreatic surgery: An animal experimental study.

OBJECTIVE: Pancreatic cancer is a kind of high malignant tumor with a poor prognosis. The aim is to determine whether the dilated bile duct can be used to reconstruct the vessels. METHODS: An animal model of jugular vein and portal vein reconstruction was established using the bile duct. A total of 20 landrace pigs were selected to undergo jugular vein reconstruction or portal vein reconstruction using the bile duct as a patch or bridge. The patency was evaluated by color Doppler, the reconstructed segments were removed and examined macroscopically and histologically at specified intervals, and the results were compared with synthetic vessels (IMPRA straight, 10s03-19). RESULTS: The lumen was patent, although a low level thrombosis was observed when jugular or portal vein patching was used. For bridging, stenosis of the lumen was observed, and necrosis appeared when the bile duct was used for bridging, indicating that it is feasible to reconstruct the jugular vein and portal vein with a bile duct patch. However, the bridge was not feasible possibly due to loss of blood supply, and consequent necrosis and fibrosis. CONCLUSION: The bile duct is technically feasible, but the outcomes are unsatisfactory.

Mechanism of pancreatic juice reflux in pancreaticobiliary maljunction: A fluid dynamics model experiment.

BACKGROUND: Pancreatic juice reflux to the common bile duct and gallbladder is observed in the pancreaticobiliary maljunction (PBM), and various pathological conditions occur in the biliary tract. However, the mechanism of pancreatic juice reflux has not been discussed yet. This study aimed to investigate the mechanism of this phenomenon from the perspective of the fluid dynamics theory. METHODS: A fluid dynamics model of PBM without biliary dilatation having gallbladder function and of the pressure of sphincter of Oddi was developed. Water (as bile juice and pancreatic juice) was flowed to these models with a flow rate similar to that in humans. Pancreatic and bile juice flow and bile duct pressure were observed in three phases of gallbladder function. Moreover, the same experiment was performed in the PBM without biliary dilatation model without gallbladder. RESULTS: Pancreatic juice reflux could be observed when the gallbladder was passively expanded with the pressure in the bile duct lower than that in the sphincter of Oddi. However, pancreatic juice reflux was not observed in the model without gallbladder. CONCLUSIONS: Gallbladder function may be strongly involved in pancreatic juice reflux in PBM without biliary dilatation. Cholecystectomy may be able to stop the reflux of pancreatic juice.

Polypoid Undifferentiated Carcinoma With Osteoclast-like Giant Cells Arising in the Distal Common Bile Duct: A Rare Case Report.

BACKGROUND: Undifferentiated carcinoma with osteoclast-like giant cells (UC-OGC) in distal common bile duct (CBD) is a rare entity. CASE REPORT: This case report describes a 45-year-old male with a history of a choledochal cyst status post partial excision and cholecystectomy who presented with a mass in the remaining distal/intrapancreatic common bile duct. It was initially mistaken for post-surgery hematoma; however, the rapid growth raised concern for malignancy, and prompted a pancreaticoduodenectomy (Whipple) procedure. Macroscopic examination revealed a 5.5 cm polypoid mass grossly confined in the lumen of the distal CBD. Histology was consistent with UC-OGC, with minimal invasion into the polyp stalk and adjacent CBD wall. Immunohistochemistry demonstrated co-expression of CK7 and p40, normal/wild-type p53, and retained SMAD4 expression in tumor cells. Next-generation sequencing detected mutations at p.Q61H (c.183A>C) of KRAS and p.E545K (c.1633G>A) of PIK3CA, keeping in line with similarity to conventional cholangiocarcinoma. The patient remained disease-free after two years of follow-up without chemotherapy. CONCLUSION: To our knowledge, this is the first case report of UC-OGC presented as a polypoid mass in the distal CBD. It highlights the complex dynamism and controversial pathogenesis of this unique entity, which should be made aware to avoid diagnostic pitfalls.

Unusual presentation of silently growing abdominal aortic aneurysm causing biliary obstruction.

Biliary obstruction is a rare presentation of abdominal aortic aneurysm (AAA). The most common symptoms of AAA are abdominal or back pain and limb ischaemia from thromboembolism. We report a case of a 67-year-old male who was diagnosed with obstructive jaundice secondary to an AAA. CT angiogram revealed compression of the common bile duct by the large AAA, causing diffuse intrahepatic and extrahepatic ductal dilatation. Surgical repair of the aortic aneurysm was successful, and patient's symptoms improved.

Pancreaticobiliary maljunction and congenital biliary dilatation.

Pancreaticobiliary maljunction is a congenital malformation in which the pancreatic and bile ducts join outside the duodenal wall, usually forming a long common channel. Because the action of the sphincter of Oddi does not regulate the function of the pancreaticobiliary junction in patients with pancreaticobiliary maljunction, two-way regurgitation occurs. Reflux of pancreatic juice into the biliary tract is associated with a high incidence of biliary cancer. Biliary carcinogenesis in patients with pancreaticobiliary maljunction is thought to follow the hyperplasia, dysplasia, then carcinoma sequence due to chronic inflammation caused by pancreatobiliary reflux. Pancreaticobiliary maljunction is diagnosed when an abnormally long common channel is evident on imaging studies. Congenital biliary dilatation involves both local dilatation of the extrahepatic bile duct, including the common bile duct, and pancreaticobiliary maljunction. Extrahepatic bile duct resection is the standard surgery for congenital biliary dilatation. However, complete excision of the intrapancreatic bile duct and removal of stenoses of the hepatic ducts are necessary to prevent serious complications after surgery.

Five hundred consecutive laparoscopic common bile duct explorations: 5-year experience at a single institution.

BACKGROUND: Laparoscopic common bile duct exploration (LCBDE) has gained wide popularity in the treatment of choledocholithiasis. Bile leakage remains a major cause of postoperative morbidity. The aim of this study was to report 5-year results of 500 LCBDEs and identify risk factors associated with bile leakage. METHODS: Five hundred consecutive LCBDEs performed in one institution from September 2011 to June 2016 were reviewed. Patients' clinical data were retrospectively collected and analyzed. Univariable and multivariable analysis of bile leakage was performed by logistic regression. RESULTS: We found stones (n = 388) or bile sludge (n = 71) in 459 patients (92%) on exploration, leaving 41 patients (8%) without stones. Operative time was 128 min in the first 250 LCBDEs, and this decreased to 103 min in the second 250 LCBDEs (P = 0.0004). Four hundred and eight (82%) procedures were completed with primary closure after choledochotomy; the rate of primary closure increased significantly in the second 250 patients compared with the first (88 vs 76%; P = 0.0005), whereas T-tube placement (2 vs 6%; P = 0.0225) and transcystic approach (7 vs 12%; P = 0.0464) decreased, respectively. Stone clearance was successful in 495 patients (99%). Overall morbidity was 5%, and bile leakage occurred in 17 patients (3.4%). Two patients died from bile leakage. The median follow-up was 24 months with stone recurrence occurred in two patients and bile duct stricture in one patient. Univariable analysis identified diameter of the common bile duct (CBD), stone clearance, and T-tube insertion as risk factors related to bile leakage. Multivariable analysis taking these three factors into account identified non-dilated CBD (risk ratio (RR) = 9.87; P = 0.007) and failure in stone clearance (RR = 11.88; P = 0.024) as significant risk factors. CONCLUSIONS: Bile leakage following LCBDE is associated with diameter of the CBD and stone clearance. LCBDE would be safer in proficient laparoscopic surgeons with a careful selection of patients.

Clinical Significance of Biliary Dilatation and Cholelithiasis after Subtotal Gastrectomy.

BACKGROUND/AIMS: The well-organized study to support that increased cholelithiasis and bile duct dilatation can occur after gastrectomy has not been reported. The aim of this study was to determine the incidence of cholelithiasis and the degree of common bile duct (CBD) dilatation in patients undergoing subtotal gastrectomy, compared to those undergoing endoscopic treatment for gastric cancer. METHODS: Patients who diagnosed with gastric cancer and received treatment at six academic referral centers were investigated for the incidence and time of cholelithiasis and the degree of CBD dilatation after treatment by analysis of 5-year follow-up CTs. The operation group underwent subtotal gastrectomy without vagotomy, while in the control group endoscopic treatment was administered for gastric cancer. RESULTS: A total of 802 patients were enrolled in 5-year analysis (735 patients in the operation group and 67 patients in the control group). Cholelithiasis occurred in 47 patients (6.39%) in the operation group and 3 patients (4.48%) in the control group (p=0.7909). The incidences of cholelithiasis were 4.28% in Billoth-I and 7.89% in Billoth-II (p=0.0487). The diameter of proximal CBD and distal CBD increased by 1.11 mm and 1.41 mm, respectively, in the operation group, compared to 0.4 mm and 0.38 mm, respectively, in the control group (pœ0.05). Patients with increased CBD dilatation more than 5 mm showed statistically significant increases in alkaline phosphatase and gamma-glutamyltransferase. CONCLUSIONS: The incidence of cholelithiasis was not increased due to subtotal gastrectomy without vagotomy, but the incidence was higher after Billoth-II compared to Billoth-I. In addition, significant change in the CBD diameter was observed after subtotal gastrectomy.

Endosonography for suspected obstructive jaundice with no definite pathology on ultrasonography.

BACKGROUND/PURPOSE: Ultrasonography (US) cannot demonstrate all the etiologies of biliary tract dilatation in patients with jaundice. Thus, we evaluated the etiologic yield of endosonography (EUS) for suspected obstructive jaundice when no definite pathology was found on US. Additionally, we sought to identify the predictors of the most common etiologies. METHODS: We performed a retrospective review of 123 consecutive patients who had undergone EUS for suspected obstructive jaundice when no definite pathology was identified on US. RESULTS: The most common diagnoses included no pathological obstruction (n = 43), pancreatobiliary malignancy (n = 41), and choledocholithiasis (n = 28). Pancreatobiliary malignancy was associated with common bile duct (CBD) dilatation, and fever and elevated alanine aminotransferase were predictors of choledocholithiasis (p < 0.05). The accuracy of EUS was 95.9% (118/123) for overall cause of suspected obstructive jaundice, 100% (40/40) for no pathological finding, 100% (23/23) for ampullary cancer, 100% (13/13) for pancreatic cancer, 75% (3/4) for CBD cancer, and 92.9% (26/28) for choledocholithiasis, respectively. Besides the two patients with focal chronic pancreatitis misdiagnosed as with pancreatic cancer, EUS missed the lesions in one CBD cancer patient and two patients with choledocholithiasis. The overall accuracy of EUS in ascertaining pancreatobiliary malignancy and choledocholithiasis was comparable (97.6%, 40/41 vs. 92.9%, 26/28; p > 0.05). CONCLUSION: Marked CBD dilatation (≥12 mm) should remind us of the high risk of malignancy, and the presence of CBD dilatation and fever is suggestive of choledocholithiasis. Negative EUS findings cannot assure any pathological obstruction in patients with clinically suspected obstructive jaundice.

[Contact lithotripsy in treatment of choledocholithiasis].

It was suggested to use contact ultrasonic lithotripsy in lumen of common bile duct during laparoscopic surgery in order to preserve the sphincter apparatus of major duodenal papilla. Waveguide with original structure was used for lithotripsy performing. Waveguide's total length is 400 mm. It has a radially curved 40 degrees broken part with diameter of 6 mm cone rolling in working portion with diameter of 4 mm and length of 60 mm for introduction in common bile duct. There is concave lens on waveguide working portion end with diameter of 1 mm. A lens permits concentrating the waves beam in longitudinal direction avoiding its scattering and minimizing the impact on surrounding tissues. Lithotripsy efficiency was proved in the in vitro (n=68) and in vivo (n=20) experiments. Such structure of waveguide permits to penetrate in lumen of common bile duct through dilated cystic duct or choledochendysis for calculi fragmentation.

Dynamic changes of common bile duct diameter during an episode of biliary colic, documented by ultrasonography.

Common bile duct stones frequently accompany gallstones and can be identified by a variety of imaging modalities. Little is known about the time course of dilatation of the common bile duct after acute obstruction or of normalization after spontaneous passage of an obstructing stone. We describe a case showing rapid fluctuations in common bile duct diameter during 72 hours in a patient presenting with epigastric pain and vomiting. Initial emergency bedside ultrasonography revealed a distended gallbladder, a dilated common bile duct (17 mm), and an obstructing stone. Five hours later, ultrasonography performed in the radiology suite showed a normal common bile duct diameter (4 mm) and no obstructing stone. The patient was admitted, and during the course of hospitalization different imaging modalities reported fluctuations in common bile duct measurements, ranging from 4 mm on computed tomography to 14 mm on endoscopic retrograde cholangiopancreatography. This case demonstrates disappearance of an obstructing stone with normalization of a highly distended common bile duct during 5 hours, highlighting that gallstone disease may be highly dynamic, with the possibility of rapid changes of common bile duct diameter. Emergency physicians, who frequently depend on ultrasonography to diagnose biliary disease, should be wary of the potential for rapid changes of sonographic findings in these patients.

Zolmitriptan: a novel portal hypotensive agent which synergizes with propranolol in lowering portal pressure.

OBJECTIVE: Only a limited proportion of patients needing pharmacological control of portal hypertension are hemodynamic responders to propranolol. Here we analyzed the effects of zolmitriptan on portal pressure and its potential interaction with propranolol. METHODS: ZOLMITRIPTAN, PROPRANOLOL OR BOTH WERE TESTED IN TWO RAT MODELS OF PORTAL HYPERTENSION: common bile duct ligation (CBDL) and CCl4-induced cirrhosis. In these animals we measured different hemodynamic parameters including portal venous pressure, arterial renal flow, portal blood flow and cardiac output. We also studied the changes in superior mesenteric artery perfusion pressure and in arterial wall cAMP levels induced by zolmitriptan, propranolol or both. Moreover, we determined the effect of splanchnic sympathectomy on the response of PVP to zolmitriptan. RESULTS: In both models of portal hypertension zolmitriptan induced a dose-dependent transient descent of portal pressure accompanied by reduction of portal flow with only slight decrease in renal flow. In cirrhotic rats, splanchnic sympathectomy intensified and prolonged zolmitriptan-induced portal pressure descent. Also, propranolol caused more intense and durable portal pressure fall when combined with zolmitriptan. Mesenteric artery perfusion pressure peaked for about 1 min upon zolmitriptan administration but showed no change with propranolol. However propranolol enhanced and prolonged the elevation in mesenteric artery perfusion pressure induced by zolmitriptan. In vitro studies showed that propranolol prevented the inhibitory effects of ß2-agonists on zolmitriptan-induced vasoconstriction and the combination of propranolol and zolmitriptan significantly reduced the elevation of cAMP caused by ß2-agonists. CONCLUSION: Zolmitriptan reduces portal hypertension and non-selective beta-blockers can improve this effect. Combination therapy deserves consideration for patients with portal hypertension failing to respond to non-selective beta-blockers.

Does heparin coating reduce encrustation of biliary plastic endoprostheses? A prospective randomized trial.

OBJECTIVE: Common bile duct stenting is widely performed for bridging benign and malignant obstructions. A major limitation is early stent occlusion making regular stent exchange necessary. Covalent binding of glycosaminoglycanes to polyethylene stents proved to reduce encrustation in urological implants. Since development of urological and biliary stent occlusion shows parallels, the aim of the study was to evaluate the efficacy of heparin coating of biliary endoprostheses in preventing encrustation. MATERIAL AND METHODS: In a prospective randomized trial, heparin-coated and native stents were endoscopically placed for almost 90 days on average. After removal, all stents were dried (50°C, 24 h), weighed and after longitudinal incision visible encrustation and discoloration recorded. Fifty-three patients (21 females/32 males, 70 ± 12 (42-87) years) were included; 13 patients (4 females/9 males, 58-79 years) completed the study according to the protocol. RESULTS: After removal, mean weight of encrustation in native stents was more than double as high as of covered stents (native: 37.9 ± 19.8 (16-93) mg; covered: 17.6 ± 6.7 (9-33) mg). In 12 of 13 cases, the encrustation weight of the native stent was higher than that of the corresponding covered stent in the same patient. Premature stent explantation became necessary in 3 of 13 native stents, because of recurrent jaundice or cholangitis but only in 1 of 13 covered stents. After longitudinal incision, the three uncovered stents showed excessive encrustation whereas no significant encrustation was found in the covered prosthesis. Altogether, covered stents showed less visible accumulation of clogging material and discoloration than native stents. CONCLUSIONS: Covalent bound heparin is highly effective in preventing encrustation of biliary polyethylene endoprostheses.

[Ultrasonography in the diagnosis of cholelithiasis and its complications].

The author presents the results of ultrasound investigation (USI) of 419 patients with cholecystocholedocholithiasis. The diagnostic accuracy of USI methods in patients with calculous cholecystitis was 98.8%. Direct signs of visualization of concrements in the common bile duct (CBD) were found but in 68.5% of patients. On the basis of USI results the common bile stones were found in 287 (68.5%) patients. The concrements omitted in transabdominal USI were diagnosed using endoscopic retrograde cholangiopancreaticography, magnetic resonance cholangio-pancreaticography, endoscopic ultrasonography as well as in operative intervention.