Two institutes' experience in laparoendoscopic "rendezvous" technique for patients undergoing laparoscopic cholecystectomy for stones in the gallbladder and bile duct: a prospective randomized comparative clinical trial.

There is still disagreement on the best treatment option for cholecystocholedocholithiasis. Although there are some benefits to the single-step procedure, the "laparoendoscopic rendezvous" (LERV) technique that include a lower risk of post-ERCP pancreatitis and a shorter hospital stay, the standard technique is still the two-step approach for clearing the common bile duct (CBD) using ERCP and then performing a laparoscopic cholecystectomy. The purpose of this study was to assess the effectiveness and safety of the LERV technique vs. the standard two-step approach. Four hundred thirty-six patients with symptomatized concomitant stones at both the gall bladder (GB) and the (CBD), at two gastroenterology centers in Zagazig city, Egypt, from January 2010 till April 2022, were analyzed. Patients were randomly divided into two equally groups. The overall length of hospital stay was the primary outcome, and the success of CBD clearance and morbidity, particularly post-ERCP pancreatitis, were the secondary endpoints. The LERV group experienced a significantly shorter hospital stay (median 2(2-8) days compared to 4.5 (4-11) days for the two-stage approach (p < 0.001)). The two groups did not differ in terms of CBD clearing success. Also, there was no significant difference in the number of patients with post-ERCP pancreatitis between the LERV group [14 patients (6.4%)] and the two-stage approach [26 patients (11.9%)] with p value = 0.703. For patients with cholecystocholedocholithiasis, the optimal treatment must be determined by the knowledge and resources that are accessible locally. Our data further supported the idea that treating patients with cholecystocholedocholithiasis in one stage is a safe and successful strategy.

Sphincterotomy for biliary sphincter of Oddi disorder and idiopathic acute recurrent pancreatitis: the RESPOnD longitudinal cohort.

OBJECTIVE: Sphincter of Oddi disorders (SOD) are contentious conditions in patients whose abdominal pain, idiopathic acute pancreatitis (iAP) might arise from pressurisation at the sphincter of Oddi. The present study aimed to measure the benefit of sphincterotomy for suspected SOD. DESIGN: Prospective cohort conducted at 14 US centres with 12 months follow-up. Patients undergoing first-time endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy for suspected SOD were eligible: pancreatobiliary-type pain with or without iAP. The primary outcome was defined as the composite of improvement by Patient Global Impression of Change (PGIC), no new or increased opioids and no repeat intervention. Missing data were addressed by hierarchal, multiple imputation scheme. RESULTS: Of 316 screened, 213 were enrolled with 190 (89.2%) of these having a dilated bile duct, abnormal labs, iAP or some combination. By imputation, an average of 122/213 (57.4% (95% CI 50.4% to 64.4%)) improved; response rate was similar for those with complete follow-up (99/161, 61.5% (54.0% to 69.0%)); of these, 118 (73.3%) improved by PGIC alone. Duct size, elevated labs and patient characteristics were not associated with response. AP occurred in 37/213 (17.4%) at a median of 6 months post ERCP and was more likely in those with a history of AP (30.9% vs 2.9%, p<0.0001). CONCLUSION: Nearly 60% of patients undergoing ERCP for suspected SOD improve, although the contribution of a placebo response is unknown. Contrary to prevailing belief, duct size and labs are poor response predictors. AP recurrence was common and like observations from prior non-intervention cohorts, suggesting no benefit of sphincterotomy in mitigating future AP episodes.

Indications and added value of videourodynamics in men with spinal cord injury.

Purpose: The primary aim of this study was to evaluate the indications and additional information provided by videourodynamic study (VUDS) over urodynamic studies (UDS) in men with spinal cord injury (SCI) and neurogenic lower urinary tract dysfunction (NLUTD). The secondary aim was to determine the added value of VUDS and its impact on bladder management. Materials and Methods: Single-centre retrospective study of all men with SCI who underwent VUDS between 2011 and 2021. Participant characteristics, clinical data and indications for UDS and VUDS as well as bladder management were recorded. The added value of VUDS was defined as additional information not provided by standard UDS that impacted on bladder management (choice of voiding mode, surgical indication or type of surgery). Results: Eighty-eight men with a median age of 52 years were included. In 20 men who were unable to perform self-catheterisation, the VUDS clarified the nature and extent of the obstruction and enabled targeted surgery to achieve reflex bladder emptying in all of them. VUDS also clarified the type and level of obstruction in 28 patients, enabling targeted surgery in 24. In 11 men, VUDS was performed as part of the preoperative assessment for a Brindley procedure or after this operation if a complication occurred during follow-up to confirm the need for further surgery or to target surgical revision. Overall, VUDS had added value in 59 patients (67%). Conclusions: VUDS had added value over UDS in specific situations; the additional information provided impacted on bladder management in men with SCI and NLUTD.

Usefulness of Endoscopic Retrograde Cholangiopancreatography (ERCP)-Related Procedures for Gallstone Pancreatitis.

INTRODUCTION: Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (EST) are said to be useful procedures for gallstone pancreatitis. However, there have been few reports on a large number of patients to whom they were used. The clinical usefulness of ERCP and EST is herein examined retrospectively. METHODS: ERCP and EST were performed to evaluate their clinical usefulness and safety in 108 patients who had gallbladder stones from December 1985 to October 2017 and were diagnosed as having gallstone pancreatitis. Of 108 patients, 83 were mild, and 25 were severe. Following the procedures, clinical courses were observed for three years in 108 patients who underwent the treatments. RESULTS: Cholangiogram was successfully conducted in 108 patients. Bile duct stones were noted in 90 patients, and the stones were removed after EST. Of 18 patients who did not show bile duct stone in cholangiogram, 13 patients underwent EST, while five patients taking anticoagulants completed procedures only with cholangiogram. Accidental symptom was hemorrhage in three patients (2.7%; 3/108), but it was mild and conservatively resolving. During the three-year observation period, acute cholangitis was noted in three patients (2.7%; 3/108), but no relapsing pancreatitis was noted. CONCLUSIONS: It was suggested that ERCP and EST could be useful therapies for gallstone pancreatitis.

Effect of endoscopic sphincterotomy and endoscopic papillary balloon dilation endoscopic retrograde cholangiopancreatographies on the sphincter of Oddi.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP), with its clinical ad-vantages of less trauma and faster recovery, has become the primary treatment for choledocholithiasis. AIM: To investigate the effects of different ERCP procedures on the sphincter of Oddi. METHODS: The clinical data of 91 patients who underwent ERCP at Yixing Hospital of Traditional Chinese Medicine between February 2018 and February 2021 were analyzed retrospectively. The patients were divided into endoscopic sphincterotomy (EST, n = 24) and endoscopic papillary balloon dilation (EPBD, n = 67) groups. The duration of operation, pancreatic development, pancreatic sphincterotomy, intubation difficulties, stone recurrence, and incidence of reflux cholangitis and cholecystitis were statistically analyzed in patients with a history of choledocholithiasis, pancreatitis, and Oddi sphincter dysfunction in the EST and EPBD groups. RESULTS: Differences in hypertension, diabetes, increased bilirubin, small diameter of the common bile duct, or ampullary diverticulum between the two groups were not significant. Statistically significant differences were observed between the two groups concerning sex and age (< 60 years). Patients with a history of choledocholithiasis, pancreatitis, and Oddi sphincter dysfunction were higher in the EST group than in the EPBD group. The number of cases of pancreatic development, pancreatic duct sphincterotomy, and difficult intubation were higher in the EST group than in the EPBD group. The number of Oddi's sphincter manometries, ERCP surgical outcomes, and guidewires entering the pancreatic duct several times in EST group were lower than those in the EPBD group. The numbers of stone recurrences, reflux cholangitis, and cholecystitis were higher in the EST group than in the EPBD group. CONCLUSION: In summary, common bile duct stones, pancreatitis history, and multiple guided wire introductions into the pancreatic duct are independent risk factors for EST and EPBD. Based on this evidence, this study can provide actionable insights for clinicians and researchers.

Clinical efficacy of laparoscopic cholecystectomy combined with endoscopic papillary balloon dilation in treatment of gallbladder stones with common bile duct stones: A retrospective study.

BACKGROUND: The incidence of cholelithiasis has been on the rise in recent years, but the choice of procedure is controversial. AIM: To investigate the efficacy of laparoscopic cholecystectomy (LC) combined with endoscopic papillary balloon dilation (EPBD) in patients with gallbladder stones (GS) with common bile duct stones (CBDS). METHODS: The clinical data of 102 patients with GS combined with CBDS were selected for retrospective analysis and divided into either an LC + EPBD group (n = 50) or an LC + endoscopic sphincterotomy (EST) group (n = 52) according to surgical methods. Surgery-related indexes, postoperative recovery, postoperative complications, and expression levels of inflammatory response indexes were compared between the two groups. RESULTS: Total surgical time, stone free rate, rate of conversion to laparotomy, and successful stone extraction rate did not differ significantly between the LC + EPBD group and LC + EST group. Intraoperative hemorrhage, time to ambulation, and length of hospitalization in the LC + EPBD group were lower than those of the LC + EST group (P < 0.05). The rate of total complications of the two groups was 9.80% and 17.65%, respectively, and the difference was not statistically significant. No serious complications occurred in either group. At 48 h postoperatively, the expression levels of interleukin-6, tumor necrosis factor-α, high-sensitivity C-reactive protein, and procalcitonin were lower in the LC + EPBD group than in the LC + EST group (P < 0.05). At 3 d postoperatively, the expression levels of aspartate transaminase, alanine transaminase, and total bilirubin were lower in the LC + EPBD group than in the LC + EST group (P < 0.05). CONCLUSION: LC combined with EPBD and LC combined with EST are both effective procedures for the treatment of GS with CBDS, in which LC combined with EPBD is beneficial to shorten the patient's hospitalization time, reduce the magnitude of elevated inflammatory response indexes, and promote postoperative recovery.

Current treatment of biliary Sphincter of Oddi Dysfunction.

The sphincter of Oddi is a delicate neuromuscular structure located at the junction of the biliary-pancreatic system and the duodenum. Sphincter of Oddi Dysfunction (SOD) can result in various clinical manifestations, including biliary-type pain and recurrent idiopathic pancreatitis. The management of SOD has been challenging. With the publication of the landmark Evaluating Predictors and Interventions in Sphincter of Oddi Dysfunction (EPISOD) trial and the Rome IV consensus, our clinical practice in the treatment of SOD has changed significantly in recent years. Currently, the management of type II SOD remains controversial and there is a lack of non-invasive therapy options, particularly for patients not responding to endoscopic treatment. In this mini review, we aimed to discuss the current knowledge on the treatment of biliary SOD.

Beyond the Usual Suspects: A Pictorial Case Report of Lemmel Syndrome Emphasizing the Role of Multimodality Imaging.

Lemmel syndrome, characterized by biliary and pancreatic duct obstruction secondary to a periampullary duodenal diverticulum (PAD), remains a rare and often overlooked diagnosis. Although duodenal diverticula are found in approximately 23% of the population, only about 5% of these cases lead to complications such as obstructions. A new case of Lemmel syndrome is demonstrated in the article about a middle-aged woman with chronic epigastric pain and right upper abdominal quadrant initially misdiagnosed as cholelithiasis. The accuracy of diagnosis was made possible by multimodal imaging methods, such as ultrasound, magnetic resonance cholangiopancreatography (MRCP), and computed tomography (CT) with oral contrast when a diffuse common bile duct was compressed by a PAD. Additionally, it highlights the necessity of including Lemmel syndrome in cases where patients have dilated bile ducts without calculi or mass lesions while emphasizing advanced imaging techniques for the revelation of structural malformations that underlay these conditions. The endoscopic intervention was minimally invasive but effective in relieving symptoms through sphincterotomy followed by laparoscopic cholecystectomy and biliary stent placement, thus making a point of the need for multiple disciplinary approaches toward treatment rare phenomenon like this one. This case report not only sheds light on the diagnostic and therapeutic avenues for Lemmel syndrome but also serves as a valuable educational resource for healthcare professionals. It emphasizes the need for heightened clinical vigilance and the adept use of imaging modalities in cases of biliary obstruction with obscure etiology. By contributing to the growing knowledge of this rare condition, we aim to facilitate timely diagnosis and optimize patient outcomes.

Prophylactic use of a self-assembling peptide hydrogel for preventing delayed bleeding after endoscopic sphincterotomy: A propensity score-matched analysis.

BACKGROUND AND AIM: Delayed endoscopic sphincterotomy-related bleeding (ES bleeding) is an unavoidable adverse event (AE) that can have serious ramifications. Intraoperative ES bleeding, which stops spontaneously in most cases, is a known risk factor for delayed bleeding. This study aimed to examine the preventive effect of a novel self-assembling peptide (SAP) for delayed ES bleeding in patients who attained spontaneous hemostasis after intraoperative ES bleeding. METHODS: A total of 1507 patients met the eligibility criteria for inclusion in this study. The rates of delayed ES bleeding and AE besides bleeding were compared between patients administered the SAP (SAP group) and those who were simply observed after spontaneous hemostasis of intraoperative ES bleeding (control group). Propensity score matching was performed to adjust for differences between the groups. RESULTS: The rate of delayed ES bleeding was significantly lower in the SAP group than that in the control group (0.9% vs 3.8%, P = 0.044). The rates of AEs other than bleeding were 2.4% and 3.8% in the SAP and control groups, respectively, and the difference lacked statistical significance (P = 0.481). Multivariate analysis revealed that the use of SAP was significantly associated with a lower frequency of delayed ES bleeding (odds ratio, 0.35; 95% confidence interval, 0.13-0.98; P = 0.047). CONCLUSIONS: Self-assembling peptide may be a simple, safe, and useful way to reduce the risk of delayed ES bleeding in patients who experienced intraoperative ES bleeding and obtained subsequent spontaneous hemostasis.

Challenges in the management of acute lithiasic cholangitis due to a long-retained plastic biliary stent: A case report.

BACKGROUND AND IMPORTANCE: This case report focuses on a rare cause of acute lithiasis cholangitis, which is residual choledocholithiasis on a plastic biliary stent that was placed nine years prior. CASE PRESENTATION: An 87-year-old male, with a history of hypertension and previous surgery for gallstone disease including cholecystectomy and placement of a Kehr drain in 2006, was diagnosed with residual stones in 2008 and received a plastic biliary stent after endoscopic sphincterotomy. Lost to follow-up for nine years, he presented with acute lithiasis cholangitis characterized by fever, conjunctival jaundice, leukocytosis, CRP elevation, and biochemical signs of cholestasis. CT imaging revealed choledocholithiasis on the biliary stent. The patient underwent surgical intervention, during which a dilated bile duct was discovered, a complete tangential choledocotomy was performed, and the stent/stone complex along with additional choledocholithiasis was removed. A choledochoduodenal anastomosis was subsequently performed. DISCUSSION: The use of plastic biliary stents can paradoxically lead to the formation of biliary stones, a condition termed "stentolith". Such scenarios emphasize the complications arising from prolonged stent presence, including bacterial proliferation and the consequent formation of calcium bilirubin stones. While endoscopic removal of these stent-stone complexes has been successful in a few cases, surgical intervention is often required due to the risks associated with endoscopic extraction, such as potential duodenal perforation. The choice of lithotripsy technique for endotherapy depends on availability and patient-specific factors. CONCLUSION: This complication highlights the importance of patient education, meticulous record-keeping, and regular follow-up to prevent such outcomes.