Gallstone ileus presenting in an elderly patient: A case report.

INTRODUCTION AND IMPORTANCE: Biliary ileus is a rare yet significant cause of mechanical intestinal obstruction, which occurs when a gallstone enters the gastrointestinal tract through a bilioenteric fistula, leading to intestinal blockage. This condition primarily affects elderly patients and is associated with high morbidity and mortality if not diagnosed and treated promptly. CASE PRESENTATION: We present the case of a 94-year-old female with a history of hypertension and chronic venous insufficiency. The patient was admitted with severe abdominal pain, nausea, and vomiting, with clinical findings suggestive of intestinal obstruction. Computed tomography revealed Rigler's triad, confirming the diagnosis of biliary ileus. An exploratory laparotomy was performed, identifying three gallstones in the small intestine. The patient underwent enterotomy for stone extraction and had a favorable immediate postoperative outcome. CLINICAL DISCUSSION: Biliary ileus presents a diagnostic challenge due to its nonspecific symptoms. While Rigler's triad (pneumobilia, intestinal obstruction, and ectopic gallstone) is diagnostic, it is not always apparent in imaging. Surgical intervention remains the standard of care for resolving the obstruction, though appropriate preoperative management and timely surgery are crucial for improving outcomes. CONCLUSION: This case emphasizes the importance of considering biliary ileus in the differential diagnosis of intestinal obstruction, particularly in elderly patients. Early surgical intervention is essential to prevent severe complications. Evidence based medicine ranking: Level IV.

The HALP score as a prognostic factor in metastatic biliary cancer.

BACKGROUND: Biliary tract cancers are serious diseases and new biomarkers may be useful for the optimal management and prediction of these cases. This study aimed to evaluate the prognostic significance of the hemoglobin, albumin, lymphocyte, and platelet (HALP) score, a novel composite marker, in patients with metastatic biliary tract cancer. METHODS: Patients with biliary tract cancers were analyzed retrospectively. Laboratory values, patient and disease characteristics, and survival rates were evaluated. The diagnostic impact of the HALP score was assessed with regression analyses. RESULTS: The study included 106 individuals with metastatic biliary tract cancer. Based on the median HALP score, ≥ 2.22 was considered a high score and < 2.22 was considered low. The overall average survival time was found to be 11.4 months. Patients with low HALP scores had median overall survival of 9.5 months, while those with high HALP scores had median overall survival of 15.9 months. In multivariate analysis, Eastern Cooperative Oncology Group performance status, CA19-9 level, and HALP score remained significant predictors of overall survival. CONCLUSION: The HALP score appears to be a useful prognostic marker in patients with metastatic biliary tract cancer.

Efficacy and safety of camrelizumab combined with chemotherapy in the treatment of advanced biliary malignancy and associations between peripheral blood lymphocyte subsets and clinical outcomes.

BACKGROUND: Biliary tract cancer (BTC) is a highly heterogeneous aggressive tumor, and advanced patients have poor prognosis. This work aimed to evaluate the efficacy and safety of camrelizumab combined with chemotherapy in treating advanced BTC, and to explore predictive biomarkers for distinguishing effective population. METHODS: 183 advanced BTC patients admitted from September 2018 to September 2021 were retrospectively selected. 93 patients were treated with camrelizumab combined with chemotherapy (C+C group) and 90 patients were treated with chemotherapy alone (C group). Objective response rate (ORR), disease control rate (DCR), median progression-free survival (mPFS), and median overall survival (mOS) were analyzed between two groups. Peripheral blood lymphocyte subsets were assessed by flow cytometry pre- and post-treatment. RESULTS: The mPFS (6.9 months) and mOS (12.1 months) in the C+C group were significantly longer than those in the C group, which were 5.2 months and 9.8 months respectively (HR 0.46, 95% CI 0.38-0.54, p=0.017; HR 0.39, 95% CI 0.32-0.47, p=0.033). The percentage of Total T, CD4+T, natural killer (NK) cells, lymphocyte, and CD4+/CD8+ cell ratios were significantly increased in effective patients after C+C treatment, but didn't increase in progressive disease (PD) patients. Higher percentage of Total T, CD4+T, and higher CD4+/CD8+ cell ratios post-treatment were associated with longer OS. CONCLUSIONS: Camrelizumab combining chemotherapy significantly prolonged the mPFS and mOS of advanced BTC patients. Immunotherapy may improve the immune status of advanced patients, and immunotherapy efficacy might be predicted based on the peripheral blood lymphocyte subsets.

Clinically significant portal hypertension in patients with primary biliary cholangitis: Clinicopathological features and prognostic value.

INTRODUCTION AND OBJECTIVES: Primary biliary cholangitis (PBC) may progress to clinically significant portal hypertension (CSPH) before the development of cirrhosis. This study aimed to investigate CSPH incidence as well as the clinicopathological characteristics and predictive value of these features for the prognosis of patients with PBC, especially at early histologic stage. PATIENTS AND METHODS: Patients diagnosed with PBC between January 2013 and April 2022 were retrospectively enrolled. The prognostic value of baseline clinicopathological characteristics for long-term outcomes in PBC patients with CSPH was assessed using Kaplan-Meier survival analysis and COX regression analysis. RESULTS: Among 280 patients with PBC, 104 underwent liver biopsy and 68 were at early histologic stage. CSPH was present in 47.2 % of participants with 20.6 % at early histologic stage. CSPH was a risk factor for predicting the liver transplant-free survival in PBC patients (hazard ratio [HR], 6.78; 95 % CI, 2.94-15.63), especially those at early stage. Perisinusoidal fibrosis and nodular regenerative hyperplasia (NRH) were common histopathological features in PBC patients with CSPH at the early stages. Fibrous septa formation in the hepatic lobules (HR, 4.85; 95 % CI, 1.51-15.52) and cholestasis (HR, 7.70; 95 % CI, 2.56-23.18) were independent predictors of adverse outcomes. CONCLUSIONS: CSPH indicates an increased risk of adverse outcomes in PBC patients, especially those in early histologic stage. Perisinusoidal fibrosis and NRH are valuable histological features of CSPH in patients with early-stage PBC. Identification of clinicopathological features and assessment of portal hypertension (especially at early stage), contribute to the development of personalized strategies.

Biliary stenosis after liver transplant is not associated with cytomegalovirus infection.

Background: Liver transplantation (LT) is the best treatment for end-stage liver disease; however, biliary complications (BCs) still pose a significant challenge. Among the post-transplant BC, strictures and biliary fistulas are the most common. Biliary strictures are classified as anastomotic and non-anastomotic. Some previous studies suggest an association between post-transplant biliary strictures and cytomegalovirus (CMV) infection. In this study, we aimed to identify whether there is an association between CMV infection and biliary strictures in patients undergoing LT. Methods: A retrospective study of 175 patients aged ≥18 years undergoing LT at Felicio Rocho Hospital between 2011 and 2017 was conducted. All included patients received grafts perfused with Institut Georges Lopez-1 (IGL-1) solution from brain-dead donors, survived post-transplantation for more than 120 days, and had a minimum follow-up of 12 months after LT. The diagnosis of CMV was made by antigenemia and biliary strictures by magnetic resonance cholangiopancreatography (MRCP). Results: The average age of the recipients was 54 years. Postoperative BCs occurred in 12% of transplants. The most common BC was stricture (9.1%), with a predominance of anastomotic strictures (AS) over non-AS (NAS) (87.5% vs. 12.5%, respectively). CMV infection was confirmed in 22.9% of patients. In the univariate analysis, post-transplant CMV infection correlated with the development of BCs (P=0.01), as well as biliary strictures (P=0.008). In the multivariate analysis, however, only model for end-stage liver disease (MELD) >21 was a risk factor for the development of BCs in general (P=0.02) and biliary strictures (P=0.01). Conclusions: CMV infection was not an independent risk factor for the development of non-anastomotic post-transplant biliary strictures in this study.

Influence of biliary and vascular resection types on morbidity in hepatectomies with vascular involvement.

INTRODUCTION: Hepatectomies associated with vascular resections pose a technical challenge for surgeons, involving multiple reconstruction techniques. Moreover, adding clinical and surgical risks in the postoperative setting of these complex procedures are mainly due to prolonged surgical periods and potential complications inherent to vascular manipulation. Leveraging the expertise of a Cancer Center, we propose an institutional assessment utilizing the case series from A. C. Camargo Cancer Center in hepatectomies associated with vascular resection, evaluating postoperative complications and outcomes while highlighting clinical, laboratory, pathological, and surgical factors that may influence results. OBJECTIVE: To assess mortality and morbidity associated with hepatectomies involving vascular resection. MATERIALS AND METHODS: From a prospective database, a study was performed evaluating postoperative survival and morbidity using scoring systems such as Clavien-Dindo through a cohort analysis. RESULTS: From a total of 1021 liver resections for a period of 10 years, 31 cases were evaluated from a unique cancer center in Brazil! Factors such as the performance of major hepatectomies, the need for blood transfusion, and the administration of neoadjuvant or adjuvant systemic therapy did not appear to influence the outcome of morbidity or mortality. However, the resection of the associated bile duct and the type of vascular resection seemed to influence morbidity outcomes with statistical significance (p = 0.006+ …). CONCLUSION: Hepatectomies associated with vascular resections are safe in selected cases and when performed in referral centers. Factors such as associated bile duct resection and type of vascular resection should be considered for procedure indication.

El cirujano general en las urgencias hepatobiliares en Colombia desde la visión de los expertos: un estudio cualitativo / The general surgeon in hepatobiliary emergencies in Colombia from the experts' perspective: A qualitative study

Introducción. El manejo perioperatorio de las urgencias hepatobiliares por parte del cirujano general es una competencia esperada y se considera un reto por su relativa frecuencia, impacto en la salud del individuo y la economía, así como las implicaciones en el ejercicio clínico confiable y de alta calidad. Se desconocen los aspectos formales de la educación en cirugía hepatobiliar para el cirujano general en Colombia. El objetivo del presente estudio fue explorar la perspectiva de los cirujanos hepatobiliares sobre esta problemática. Métodos. Se realizó un estudio cualitativo, mediante entrevistas semiestructuradas con 14 especialistas en cirugía hepatobiliar colombianos, en donde se exploraron los desafíos del entrenamiento, el tiempo y las características de una rotación, la evaluación de la confiabilidad, el número de procedimientos y el rol de la simulación. Se hizo un análisis temático de la información. Resultados. Los expertos mencionaron la importancia de la rotación obligatoria por cirugía hepatobiliar para los cirujanos en formación. El tiempo ideal es de tres meses, en el último año de residencia, en centros especializados, con exposición activa y bajo supervisión. Conclusiones. Por las características epidemiológicas del país y la frecuencia de enfermedades hepatobiliares que requieren tratamiento quirúrgico, es necesario que el cirujano general cuente con una formación sólida en este campo durante la residencia. El presente estudio informa sobre las características ideales del entrenamiento en este campo desde la visión de los expertos colombianos.

Introduction. The perioperative management of hepatobiliary emergencies by the general surgeon is an expected competence and is considered a challenge due to its relative frequency, impact on the individual health and the economy, as well as the implications for reliable and high-quality clinical practice. The formal aspects of education in hepatobiliary surgery for the general surgeon in Colombia are unknown. The objective of the present study was to explore the perspective of hepatobiliary surgeons on this problem. Methods. A qualitative study was carried out through semi-structured interviews with 14 Colombian hepatobiliary surgery specialists, where the challenges of training, time and characteristics of the rotation, evaluation of reliability, number of procedures and role of simulation. A thematic analysis of the information was carried out. Results. The experts mentioned the importance of mandatory rotation for hepatobiliary surgery for surgeons in training. The ideal duration was three months, during the last year of residency, in specialized centers with active exposure and under supervision. Conclusions. Due to the epidemiological characteristics of the country and the frequency of hepatobiliary diseases that require surgical treatment, it is necessary for the general surgeon to have solid training in this field during residency. The present study reports on the ideal characteristics of training in this field from the perspective of Colombian experts.

The effect of pre-operative biliary drainage in resectable periampullary lesions: a systematic review and meta-analysis.

OBJECTIVE: The effect of a pre-operative biliary stent on complications after pancreaticoduodenectomy (PD) remains controversial. MATERIALS AND METHOD: We conducted a meta-analysis according to the preferred reporting items for systematic reviews and meta-analyses guidelines, and PubMed, Web of Science Knowledge, and Ovid's databases were searched by the end of February 2023. 35 retrospective studies and 2 randomized controlled trials with a total of 12641 patients were included. RESULTS: The overall complication rate of the pre-operative biliary drainage (PBD) group was significantly higher than the no-PBD group (odds ratio [OR] 1.46, 95% confidence interval [CI] 1.22-1.74; p < 0.0001), the incidence of post-operative delayed gastric emptying was increased in patients with PBD compared those with early surgery (OR 1.21, 95% CI: 1.02-1.43; p = 0.03), and there was a significant increase in post-operative wound infections in patients receiving PBD with an OR of 2.2 (95% CI: 1.76-2.76; p < 0.00001). CONCLUSIONS: PBD has no beneficial effect on post-operative outcomes. The increase in post-operative overall complications and wound infections urges the exact indications for PBD and against routine pre-operative biliary decompression, especially for patients with total bilirubin < 250 umol/L waiting for PD.

OBJETIVO: El efecto de una endoprótesis biliar pre-operatoria sobre las complicaciones después de la pancreaticoduodenectomía sigue siendo controvertido. MATERIALES Y MÉTODO: Se llevó a cabo un metaanálisis siguiendo las directrices PRISMA y se realizaron búsquedas en PubMed, Web of Science Knowledge y la base de datos de Ovid hasta finales de febrero de 2023. Se incluyeron 35 estudios retrospectivos y 2 ensayos controlados aleatorizados, con un total de 12,641 pacientes. RESULTADOS: La tasa global de complicaciones del grupo drenaje biliar pre-operatorio (PBD) fue significativamente mayor que la del grupo no-PBD (odds ratio [OR]: 1.46; intervalo de confianza del 95% [IC 95%]: 1.22-1.74; p < 0.0001), la incidencia de vaciado gástrico retardado posoperatorio fue mayor en los pacientes con PBD en comparación con los de cirugía precoz (OR: 1.21; IC95%: 1.02-1.43; p = 0.03), y hubo un aumento significativo de las infecciones posoperatorias de la herida en los pacientes que recibieron PBD (OR: 2.2; IC 95%: 1.76-2.76; p < 0.00001). CONCLUSIONES: El drenaje biliar pre-operatorio no tiene ningún efecto beneficioso sobre el resultado posoperatorio. El aumento de las complicaciones posoperatorias globales y de las infecciones de la herida urge a precisar las indicaciones de PBD y a desaconsejar la descompresión biliar pre-operatoria sistemática, en especial en pacientes con bilirrubina total inferior a 250 µmol/l en espera de pancreaticoduodenectomía.

Complications in Patients with Surgically Altered Gastrointestinal Anatomy Undergoing Endoscopic Retrograde Cholangiopancreatography: 15-Year Experience at a Tertiary Care Center in Latin America.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is a common procedure, but it poses challenges in patients with surgically altered gastrointestinal anatomy (SAGA). Alternative techniques like single-balloon enteroscopy (SBE), double-balloon enteroscopy (DBE), or push enteroscopy (PE) have been used, albeit with potential complications. Limited Latin American data exists on ERCP complications in SAGA patients. Our goal is to describe complications of ERCP in SAGA at a national referral institution. METHODS: Retrospective, single-center cohort study. All SAGA ERCP procedures performed at the Gastrointestinal Endoscopy Department of the National Institute of Medical Sciences and Nutrition Salvador Zubirán from January 2008 to May 2023 were included. Extracted data from records included procedure specifics, endoscope type, success, and complications. Complications were evaluated during procedure and 28-day post-procedure and classified using the AGREE system. RESULTS: A total of 266 procedures in 174 patients were included, 74% were women, and the median age was 44 years. Predominant modified anatomy was Roux-en-Y biliary reconstruction (79%), followed by Whipple procedure (13%) and subtotal gastrectomy with Roux-en-Y reconstruction (6.0%). The main indications were cholangitis with stricture (31%), stricture (19%), and cholangitis (19%). DBE was used in 89%, PE in 7.5%, and SBE in 3.4%. Success rates were 77% endoscopic, 72% technical, and 69% therapeutic; in 30%, the procedure was unsuccessful. Complications happened in 18% of cases, most commonly cholangitis (7.5%), followed by perforation (2.6%) and hemorrhage (1.9%). According to the AGREE classification, 10.9% were grades 1 and 2, 6.4% were grade 3, and 0.4% were grade 4 complications. No significant differences emerged between groups with and without complications. Procedures increased over time, but complications and unsuccessful procedures remained stable. CONCLUSION: ERCP complications align with international data, often not requiring invasive treatment. Enhanced exposure to such cases correlates with fewer complications and failures. Prospective studies are essential to identify complication and failure predictors.

Experience of a reference center on ventriculo-gallbladder shunt as an alternative treatment for peritoneal failure in children.

PURPOSE: Ventriculo-peritoneal shunt is the gold standard for non-obstructive hydrocephalus. Despite advances in material, infection prevention, and valve technologies, failure can still occur. The aim of this article is to present a comprehensive study based on the experience of a reference center in pediatric neurosurgery in Rio de Janeiro with the use of the ventriculo-gallbladder shunt as an alternative to peritoneal failure. METHODS: A retrospective study was conducted from January 2018 to December 2023 of patients diagnosed with cerebrospinal fluid shunt dysfunction due to peritoneal failure and submitted to ventriculo-gallbladder shunt as an alternative in a reference center of Rio de Janeiro. RESULTS: From 2018 to 2023, 18 peritoneal failures were diagnosed. Among them, 10 patients (55.5%) were selected for ventriculo-gallbladder shunt (VGS). Different causes were responsible for the hydrocephalus in these patients. VGS was placed at a mean age of 35.4 months. Four patients had temporary complications: 2 self-limited diarrheas in the first month and 2 shunt infections. After the resolution of the infection, a new VGS was placed successfully. The average follow-up was 18.8 months (follow-up 9-68 months) without further issues. CONCLUSION: VGS is a viable option for patients facing peritoneal failure. This paper provides valuable insights into the surgical technique and outcomes associated with this alternative.

Imaging features of malignant vs stone-induced biliary obstruction: Aspects to consider.

Radiological studies play a crucial role in the evaluation of patients with biliary duct obstruction, allowing for the guidance of clinical diagnosis towards a malignant or stone-induced etiology through the recognition of relevant imaging features, which must be continuously revisited given their prognostic significance. This article aims to emphasize the importance of recognizing crucial imaging aspects of malignant and stone-induced biliary obstruction.

Choledocoduodenal Biliary Bypass for Recurrent Choledocholithiasis in a Patient with Gastric Bypass: An Old Trick to Solve a Modern Problem.

Bariatric patients are at risk for developing biliary stones. Choledocholithiasis poses a significant challenge in Roux-en-Y gastric bypass patients due to anatomical changes, complicating the treatment. We present a case of a 71-year-old female with recurrent choledocholithiasis post-bariatric surgery. After failed endoscopic attempts, a biliodigestive bypass with choledocoduodenal anastomosis was performed successfully using the Da Vinci robotic platform. This technique offers a single anastomosis, excluding the duodenum from transit, preventing food reflux. The patient had an uneventful recovery with no recurrence after 1 year. The choledocoduodenal anastomosis is a viable option for biliary diversion in patients with challenging endoscopic access post-gastric bypass, offering favorable outcomes.

Hyaline cartilage at the portal plate and gallbladder in biliary atresia.

Biliary atresia (BA) is a fibro-obliterative cholestatic disease of infancy. The presence of cartilage in the resected tissue is an uncommon finding. We documented the presence of both mature and immature hyaline cartilage in the portal plate and the wall of the gallbladder in a 2-month-old girl infant with BA who had undergone Kasai portoenterostomy. The presence of cartilage could be part of a heterotopia or an uncommon connective tissue metaplasia. The presence of immature cartilage with the merging of the perichondrium with the soft tissue highlights a metaplastic etiology in the index case.

Autoimmune Liver Disease Associated Uveitis: An Extrahepatic Manifestation or a Polyautoimmunity Phenomenon? Case Reports.

PURPOSE: To report two cases of non-granulomatous unilateral anterior uveitis in two female patients associated with autoimmune liver diseases (ALD), emphasizing the possibility of this rare coexistence as a polyautoimmunity phenomenon. CASE DESCRIPTIONS: Case 1: An 18-year-old female with a history of congenital renal hypoplasia and metabolic syndrome presented with anterior uveitis in OS and a history of jaundice, blood elevated hepatic enzymes, and cholangioresonance compatible with primary sclerosing cholangitis (PSC). Laboratory work-up for additional autoimmune and infective causes were within normal limits. Case 2: An 58-year-old female presented an episode of anterior uveitis in OD and a history of Sjögren syndrome diagnosed at the age of 53, primary biliary cholangitis (PBC), systemic sclerosis, Raynaud's phenomenon, bilateral sacroiliitis, and vitiligo, consistent with polyautoimmunity and multiple autoimmune syndrome. CONCLUSIONS: Uveitis rarely coexists with ALD. However, it is essential to recognize the possibility of polyautoimmunity in patients presenting with ophthalmic manifestations and a previous diagnosis of ALD, such as PSC or PBC.

Primary liver transplantation vs transplant after Kasai portoenterostomy in children with biliary atresia: A retrospective Brazilian single-center cohort.

BACKGROUND: Biliary atresia (BA) is the most common indication for pediatric liver trans plantation, although portoenterostomy is usually performed first. However, due to the high failure rate of portoenterostomy, liver transplantation has been advocated as the primary procedure for patients with BA. It is still unclear if a previous portoenterostomy has a negative impact on liver transplantation outcomes. AIM: To investigate the effect of prior portoenterostomy in infants un dergoing liver transplantation for BA. METHODS: This was a retrospective cohort study of 42 pediatric patients with BA who underwent primary liver transplantation from 2013 to 2023 at a single tertiary center in Brazil. Patients with BA were divided into two groups: Those under going primary liver transplantation without portoenterostomy and those undergoing liver transplantation with prior portoenterostomy. Continuous variables were compared using the Student's t-test or the Kruskal-Wallis test, and categorical variables were compared using the χ2 or Fisher's exact test, as appropriate. Multivariable Cox regression analysis was performed to determine risk factors for portal vein thrombosis. Patient and graft survival analyses were conducted with the Kaplan-Meier product-limit estimator, and patient subgroups were compared using the two-sided log-rank test. RESULTS: Forty-two patients were included in the study (25 [60%] girls), 23 undergoing liver transplantation without prior portoenterostomy, and 19 undergoing liver transplantation with prior portoenterostomy. Patients with prior portoenterostomy were older (12 vs 8 months; P = 0.02) at the time of liver transplantation and had lower Pediatric End-Stage Liver Disease scores (13.2 vs 21.4; P = 0.01). The majority of the patients (35/42, 83%) underwent living-donor liver transplantation. The group of patients without prior portoenterostomy appeared to have a higher incidence of portal vein thrombosis (39 vs 11%), but this result did not reach statistical significance. Prior portoenterostomy was not a protective factor against portal vein thrombosis in the multivariable analysis after adjusting for age at liver transplantation, graft-to-recipient weight ratio, and use of vascular grafts. Finally, the groups did not significantly differ in terms of post-transplant survival. CONCLUSION: In our study, prior portoenterostomy did not significantly affect the outcomes of liver transplantation.

Ultrasound principles and instrumentation.

Ultrasound (US) is a fundamental and inexpensive tool both for the prompt diagnosis and for the study of diverse medical conditions. Its widespread use is partly due to the availability of US devices in the daily practice of physicians. US can be performed in real-time and is instrumental in the generation of clinical algorithms for the management of situations like trauma. It also constitutes a primary approach for the study of oncological diseases, and a guidance tool for interventions such as percutaneous drainages. In addition, and specifically for HPB surgeons, US is an essential tool in the operating room: intraoperative (either open or laparoscopic) US is necessary for the accurate determination of the stage, location, number, and margins of tumors within the liver, pancreas, or biliary tree. On another note, reading and understanding US images are skills that require time and training, which should be taught during surgical residencies. However, this is not customary in most residencies globally. This chapter offers a concise yet comprehensive elucidation of the basic principles of ultrasonography, the instruments required to perform an ultrasonic assessment of a patient, and the basic ultrasound controls.

Procedimiento endoscópico-percutáneo de rendezvous para el manejo de vía biliar difícil: experiencia en un centro endoscópico de Lima-Perú / Endoscopic-percutaneous rendezvous procedure for the management of difficult biliary tract: experience in an endoscopic center in Lima-Peru

RESUMEN Objetivos: El acceso biliar refractario a las técnicas convencionales de canulación es un escenario clínico desafiante para la mayoría de endoscopistas, la técnica de rendezvous endoscópico-percutáneo es una óptima alternativa con altas tasas de éxito y bajas tasas de complicaciones en manos expertas, sin embargo, su uso rutinario en Occidente principalmente Latinoamérica es aún limitado. El objetivo de nuestro estudio fue evaluar la factibilidad, eficacia y seguridad del rendezvous endoscópico-percutáneo en el manejo de la vía biliar difícil en un centro endoscópico en Perú. Materiales y métodos: Estudio descriptivo - tipo serie de casos que incluyó 21 pacientes, con diagnóstico de vía biliar difícil, todos tratados mediante rendezvous endoscópico-percutáneo entre Julio 2017 a Julio 2020. Se evaluó: edad, género, número de colangiopancreatografias retrógradas endoscópicas fallidas previas, hallazgos endoscópicos asociados, tasa de canulación exitosa, tasa de resolución exitosa de coledocolitiasis difícil, eventos adversos y mortalidad relacionada con el procedimiento. Resultados: La tasa de canulación exitosa fue del 100% (21/21). Se presentaron 12 casos (57,1%) de coledocolitiasis difícil de los cuales se obtuvo una tasa de resolución exitosa del 91,6% (11/12). La tasa global de eventos adversos fue de 4,7% (1/21), la cual fue un caso de hemorragia digestiva post-esfinteroplastía que fue resuelta exitosamente solo por vía endoscópica. Conclusiones: El rendezvous endoscópico-percutáneo realizado por manos expertas es factible, seguro y clínicamente efectivo para el manejo de la vía biliar difícil en Latinoamérica.

ABSTRACT Objectives: Biliary access refractory to conventional cannulation techniques is a challenging clinical scenario for most endoscopists. The endoscopic-percutaneous rendezvous technique is an optimal alternative with high success rates and low complication rates in expert hands, however its routine use in the West, mainly in Latin America, is still limited. The aim of our study was to evaluate the feasibility, efficacy and safety of endoscopic-percutaneous rendezvous in the management of difficult biliary tract in an endoscopic center in Peru. Materials and methods: Descriptive study - case series type that included 21 patients, with diagnosis of difficult bile duct, all treated by endoscopic-percutaneous rendezvous between July 2017 to July 2020. We evaluated: age, gender, number of previous failed endoscopic retrograde cholangiopancreatography, associated endoscopic findings, rate of successful cannulation, rate of successful resolution of difficult choledocholithiasis, adverse events and procedure-related mortality. Results: The rate of successful cannulation was 100% (21/21). There were 12 cases (57.1%) of difficult choledocholithiasis of which there was a successful resolution rate of 91.6% (11/12). The overall adverse event rate was 4.7% (1/21), which was one case of post-sphincteroplasty gastrointestinal bleeding that was successfully resolved endoscopically only. Conclusions: Endoscopic-percutaneous rendezvous performed by expert hands is feasible, safe and clinically effective for the management of the difficult bile duct in Latin America.

Seis meses de entrenamiento en Colangiografía Endoscópica Retrograda en centro formador de alto volumen ¿es suficiente? Experiencia inicial en un hospital de la Araucanía

Introducción: La colangiopancreatografía endoscópica retrógrada (CPRE) es un procedimiento terapéutico para diversas patologías biliopancreáticas. Existen diversos centros de formación con una variedad de tiempos de práctica para la realización de CPRE. Objetivo: Evaluar resultados iniciales post entrenamiento en endoscopia terapéutica en el Instituto Chileno-Japonés del Hospital San Borja Arriarán, analizando 150 CPRE consecutivas, describiendo aspectos técnicos, morbilidad y mortalidad, realizadas entre noviembre de 2017 a enero de 2019 por un único operador en un hospital de la Araucanía. Método: Análisis retrospectivo del registro prospectivo de los 150 primeros casos consecutivos de CPRE realizados en el hospital San José de Victoria (HSJV). Se midieron variables clínicas, técnicas y de laboratorio. Se utilizó estadística descriptiva con medidas de tendencia central, dispersión y tendencia extrema. Resultados: Serie de 150 pacientes sometidos a CPRE: Edad promedio 60,1 años, mediana de 65 y edades extremas 16-98 años. Sexo femenino 69,3%. Indicaciones CPRE: 67,3% coledocolitiasis sin colangitis, 16,7% colangitis aguda, 6% estenosis de vía biliar benigna, 3.3% tumor periampular. Todos apoyados por anestesista, 50,7% propofol y 49.3% anestesia general. Tasa de canulación biliar 96,7%. Precorte 19,3%. Complicaciones reportadas alcanzaron el 4,67%, sin mortalidad por el procedimiento en la serie. Conclusiones: Los resultados de esta serie muestran que la formación obtenida por el profesional logró los estándares sugeridos para un procedimiento efectivo y seguro, destacando una tasa de canulación del 96,7%, siendo superior a lo que las guías internacionales describen como exitosa. La morbilidad asociada a CPER es comparable a cifras nacionales e internacionales.

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) is a therapeutic procedure for various biliopancreatic pathologies. There are different training centers with a variety of practice times for performing ERCP. Objective: This study aims to evaluate the initial post-training results in therapeutic endoscopy at the Chilean-Japanese Institute of San Borja Arriarán Hospital, analyzing 150 consecutive ERCP procedures performed between November 2017 and January 2019 by a single operator at a hospital in La Araucanía, describing technical aspects, morbidity, and mortality. Method: Retrospective analysis of the prospective registry of the first 150 consecutive ERCP cases performed at the San José de Victoria Hospital (HSJV). Clinical, technical and laboratory variables were measured. Descriptive statistics were produced with measures of central tendency, dispersion and extreme tendency. Results: Series of 150 patients undergoing ERCP: mean age 60.1 years, median 65 and extreme ages 16-98 years. Female sex 69.3%. ERCP indications: 67.3% choledocholithiasis without cholangitis, 16.7% acute cholangitis, 6% benign bile duct stenosis, 3.3% periampullary tumor. All supported by an anesthetist, 50.7% propofol and 49.3% general anesthesia. Biliary cannulation rate 96.7%. Precut 19.3%. Reported complications reached 4.67%, with no mortality from the procedure in the series. Conclusions: The results of this series show that the training obtained by the professional improves the standards proposed for an effective and safe procedure, highlighting a cannulation rate of 96.7%, higher than what international guidelines describe as successful. The morbidity associated with ERCP in our series is comparable to national and international figures.

Efficacy and safety of anlotinib plus anti-PD-1 agents in patients with refractory advanced biliary tract cancers.

BACKGROUND: Anlotinib has demonstrated promising anti-tumor efficacy in various solid tumors. Additionally, there is evidence suggesting that immune therapy can enhance the systemic responses of anlotinib. This study aimed to assess the effectiveness and safety of combining anlotinib with PD-1 inhibitors compared to fluoropyrimidine-based chemotherapy as a second-line treatment option for advanced biliary tract cancers (BTCs). METHODS: A total of 242 patients with BTCs were screened at the First Affiliated Hospital of Zhengzhou University from October 2015 to October 2022. Among them, 78 patients who received either anlotinib plus PD-1 inhibitors (AP) or fluoropyrimidine-based chemotherapy (FB) as second-line treatment were included in the study. The primary endpoint was progression-free survival (PFS), and the secondary endpoints included objective response rate (ORR), disease control rate (DCR), overall survival (OS), safety, and predictive tumor biomarkers. RESULTS: Among the 78 patients with BTCs, 39 patients received AP, while 39 patients were administered FB. The ORR in the AP group was 20.5%, compared to 5.1% in the FB group. The DCR was 87.2% in the AP group and 66.7% in the FB group. The AP group demonstrated significantly better ORR and DCR compared to the FB group (p = 0.042, p = 0.032). The median PFS and OS in the AP group were 7.9 months (95% CI: 4.35-11.45) and 13.9 months (95% CI: 5.39-22.41), respectively. In the FB group, the median PFS and OS were 4.1 months (95% CI: 3.17-5.03) and 13.2 months (95% CI: 8.72-17.68), respectively. The AP group exhibited significantly better median PFS than the FB group (p = 0.027). In the subgroup analysis, patients without liver metastasis had a much longer PFS in the AP group compared to the FB group (14.3 vs. 5.5 months, p = 0.016). Similarly, patients with CEA ≤ 5 µg/L also demonstrated a longer PFS in the AP group compared to the FB group (8.7 vs. 3.9 months, p = 0.008). CONCLUSIONS: The combination of anlotinib and PD-1 inhibitors demonstrated a promising clinical effect compared to fluoropyrimidine-based chemotherapy in the second-line treatment of refractory advanced BTCs. Liver metastases and CEA levels may serve as predictive factors for identifying patients who may benefit from AP therapy.

The value of endoscopic duodenal papilloplasty with titanium clip in improving post-operative complications of choledocholithiasis.

OBJECTIVE: To investigate the value of endoscopic duodenal papillary sphincterotomy combined with balloon dilatation in the treatment of duodenal papilloplasty with titanium clip after choledocholithiasis in post-operative complications. MATERIALS AND METHODS: One hundred and twenty-five patients (69 males and 56 females) with a median age of 65 (32-81) years were included. The treatment plan was randomly divided into Group A (n = 59) and Group B (n = 66) according to the random number table. Patients in Group A were treated with endoscopic sphincterotomy (EST) combined with endoscopic papillary large balloon dilation (EPLBD), followed by a titanium clip for duodenal papilloplasty and then indwelling nasobiliary drainage, whereas those in Group B were treated with EST combined EPLBD to remove stones and then indwelling nasobiliary drainage. RESULTS: In patients with choledocholithiasis or with anatomical changes that make stone extraction difficult, this prospective study attempted to perform duodenal papilloplasty with titanium clips after EST and EPLBD lithotripsy to compare and observe post-operative papillary healing, biliary reflux, and complication rates. CONCLUSIONS: The use of endoscopic duodenal papilloplasty with a titanium clip can improve biliary reflux after lithotripsy and reduce the incidence of post-operative cholangitis complications.

OBJETIVO: Investigar el valor de la esfinterotomía papilar duodenal endoscópica combinada con dilatación con balón en el tratamiento de la papiloplastia duodenal con clip de titanio después de coledocolitiasis en complicaciones postoperatorias. MATERIALES Y MÉTODOS: Se incluyeron un total de 125 pacientes (69 hombres y 56 mujeres) con una mediana de edad de 65 (32-81) años. Los pacientes del Grupo A se trataron con esfinterotomía endoscópica (EST) combinada con dilatación papilar endoscópica con balón grande (EPLBD), seguida de clip de titanio para papiloplastia duodenal y luego drenaje nasobiliar permanente, mientras que los del Grupo B se trataron con EPLBD combinado con EST para eliminar cálculos y luego drenaje nasobiliar permanente. RESULTADOS: En pacientes con coledocolitiasis o con cambios anatómicos que dificultan la extracción de cálculos, este estudio prospectivo intentó realizar papiloplastia duodenal con clips de titanio después de litotricia EST y EPLBD para comparar y observar la cicatrización papilar postoperatoria, el reflujo biliar y las tasas de complicaciones. CONCLUSIÓN: El uso de papiloplastia duodenal endoscópica con clips de titanio puede mejorar el reflujo biliar después de la litotricia y reducir la incidencia de complicaciones de colangitis postoperatorias.