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Introduction: There is sparse data from India on indications, technical success, safety and outcomes of endoscopic retrograde cholangiopancreatography (ERCP) using standard adult duodenoscope in the pediatric population. Methods: Retrospective analysis of prospectively maintained electronic endoscopy and clinical database was performed to identify pediatric patients (age ≤ 18 years) who underwent ERCP between January 2017 and December 2022. Demographics and procedural details including indications, cholangio-pancreatogram findings, endotherapy type performed, technical and clinical success and complications were noted. Results: As many as 150 pediatric patients were included of whom 88 had pancreatic (mean age-13.7 years) and 62 had biliary disease (mean age- 14.9 years). Common pancreatic ERCP indications were chronic pancreatitis (n = 45 [51.1%]), pancreatic duct disruption fistula (n = 21 [23.9%]) and recurrent acute pancreatitis (n = 16 [18.2%]). Among biliary indications were choledocholithiasis (n = 29 [46.8%]), benign bile duct strictures (n = 13 [21%]), bile duct injury/leak and biliary stent removal (n = 7 [11.3%]) , choledochal cyst (n = 5 [8.1%]) and pancreatic mass causing biliary compression (n = 1 [1.6%]). Technical success in pancreatic and biliary ERCP was 94.3% and 95.2%, respectively, and clinical success was 84.1% and 93.5%, respectively. Most common complications following pancreatic ERCPs were acute pancreatitis (n = 9 [10.2%]) (mild = 5, moderate = 4) patients and post sphincterotomy bleed in one (1.1%). Among biliary ERCPs, post ERCP pancreatitis was seen in (n = 3 [4.8%]) (mild = 2, moderate = 1). Conclusion: ERCP can be safely and effectively performed in children using standard duodenoscope. Chronic pancreatitis, choledocholithiasis and pancreatic divisum are common pediatric ERCP indications. [ABSTRACT FROM AUTHOR]

E. innesii is a recently described Enterococcus species which may be difficult to differentiate from the more common E. casseliflavus. We present the first clinical report of invasive E. innesii infection, featuring two cases of biliary sepsis. Whole genome sequencing confirmed the taxonomic assignment and the presence of vanC-4. Analysis of public genomes identified 13 deposited E. innesii and 13 deposited E. casselifalvus/E.gallinarum genomes which could be reassigned as E. innesii. Improved laboratory diagnosis of E. innesii is expected to generate additional data concerning its clinical relevance and support the future diagnosis and treatment of this uncommon pathogen. [ABSTRACT FROM AUTHOR]

Background and Objectives: Prolonged biliary stenting may lead to complications such as cholangitis, stentolith and stent migration. There is limited data on forgotten biliary stents for more than five years in literature. The aim of this retrospective study was to analyze the complications and outcomes in patients who forgot to get their biliary stents removed or exchanged for more than five years. Methods: The study population included patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) and plastic biliary stent placements in a tertiary care center from 1990 to 2022 for benign biliary diseases. Loss to follow-up and subsequent forgotten stent for more than five years were observed in 40 patients who underwent ERCP during this study period. We retrospectively analyzed the indications of stenting, present status of stent, complications and outcomes in the study patients. Results: The mean age of the study patients was 51.5 ± 11.5 years with 27 females. Indications of biliary stent placement were choledocholithiasis (33, 82.5%), bile leak (3, 7.5%), benign biliary stricture (2, 5%) and choledochal cyst (2, 5%). The mean duration of forgotten stent was 5.9 ± 3.6 years. Presenting symptoms were abdominal pain (37, 92.5%), fever (26, 65%) and jaundice (32, 80%). Most commonly placed stent was 7 French double pigtail of 10 cm length. Complications in the study patients were cholangitis (35, 87.5%), internal migration (2, 5%), pancreatitis (1, 2.5%) and portal hypertension (1, 2.5%). The outcomes were stone removal (30, 90.9%), stent removal (31, 77.5%), stent reinsertion (19, 47.5%), broken stent (3, 7.5%) and surgery (2, 5%). Conclusions: Prolonged duration (> 5 years) of forgotten stent is uncommon and is observed most commonly in patients with choledocholithiasis. The most common complication of long duration of forgotten stents was cholangitis followed by internal migration, pancreatitis and portal hypertension. Stone and stent removal was successful in a majority of patents, while surgery was required in less number of patients. [ABSTRACT FROM AUTHOR]

Background: Intrahepatic cholangiocarcinoma is a biliary neoplasm usually showing a dismal prognosis. In early stages, surgical resection is the best treatment option, significantly increasing the overall survival. This approach is also recommended in the case of relapsing disease. In this study, we report the case of a patient affected by intrahepatic cholangiocarcinoma with multiple relapses and still alive for over 18 years. We also provide a systematic review regarding long-survivor (> 60 months) of intrahepatic cholangiocarcinoma. Case Presentation: A 41-year-old woman with no pathological history was diagnosed with localized intrahepatic cholangiocarcinoma and surgically treated with left hepatectomy. After the first intervention, the patients underwent three further surgical resections because of locoregional recurrences. Histologically, there were some significant similarities among all neoplasms, including the tubule-glandular architecture, but also morphological heterogeneity. The tumor immune microenvironment remained stable across the different lesions. The molecular analysis with next-generation sequencing demonstrated that all neoplasms shared the same genomic profile, including NBN and NOTCH3 mutations and chromosomes 1 and 3 alterations. Conclusions: This case study highlights the essential role of a stringent follow-up after resection of intrahepatic cholangiocarcinoma for detecting early relapsing tumors. Moreover, it shows the importance of the molecular characterization of multiple tumors for understanding their real nature. The accurate study of long-surviving patients highlights the features that are critical for outcome improvement. [ABSTRACT FROM AUTHOR]

Purpose: This retrospective analysis aimed to assess the feasibility and safety of endoscopic retrograde cholangiopancreatography (ERCP) in pediatric patients by examining ERCP-related adverse events (AEs) occurring over a decade at a single center. Methods: Pediatric patients under 18 years old who underwent ERCP at the Second Hospital of Hebei Medical University from 1/2013 to 11/2023 were included. ERCP-related AEs were defined according to ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Clinical data of patients experiencing ERCP-related AEs were obtained from electronic medical records for analysis. Results: Over the past decade, a total of 76 pediatric patients underwent 113 ERCP procedures, including 26 patients who underwent repeat ERCP, totaling 63 procedures. There were 32 males and 44 females, with a median age of 13 years (range 3 years and 5 months–17 years and 9 months). Among all ERCP procedures, 14 (12.4%) were diagnostic and 99 (87.6%) were therapeutic, with a 100% success rate. 16 cases (14.2%) of ERCP-related AEs, all post-ERCP pancreatitis (PEP), were observed, while no other AEs defined by ESGE such as bleeding, perforation, cholangitis, cholecystitis, or sedation-related events were noted. Additionally, 23 cases (20.4%) of ERCP-related AEs not included in the ESGE definition were observed, including post-ERCP abdominal pain in 20 cases (17.7%), post-ERCP nausea and vomiting in 2 cases (1.8%), and unplanned reoperation in 1 case (0.9%). In the 26 cases of pediatric patients who underwent repeat ERCP, we observed that AEs occurred in 15 cases (57.7%) during their initial ERCP, which was much higher than the overall average level. Conclusions: Post-ERCP abdominal pain and PEP are the most common ERCP-related AEs in pediatric patients, while severe AEs such as bleeding and perforation are rare. The incidence of AEs after initial ERCP in pediatric patients who received repeat ERCP is higher than the overall average level. Based on our center's experience, we believe that ERCP can be safely performed in children over 3 years old with biliary and pancreatic diseases and obtain reliable clinical benefits. However, active monitoring and management of ERCP-related AEs are essential to improve the clinical outcomes of pediatric ERCP. [ABSTRACT FROM AUTHOR]

Cholangiocarcinoma (CCA) is a group of malignant heterogeneous cancer arising from the biliary tree. The tumor is characterized by insidious onset, high degree of malignancy, poor prognosis, and high recurrence rate. Immortalized cancer cell lines are the best and easiest models for in vitro cancer research. Here, we established a naturally immortalized highly tumorigenic hilar cholangiocarcinoma (hCCA) cell line, CBC3T-1. The CBC3T-1 cell line was cultured for over 60 passages. Thorough analysis showed that CBC3T-1 cells share characteristics similar to original tumor cells from patients with cholangiocarcinoma and display a stable phenotype, including features of epithelial origin, stem cell-like properties, as well as a high invasive and migratory capability and tumorigenicity in mice. Furthermore, this cell line showed the best sensitivity to paclitaxel, followed by gemcitabine. RNA sequencing and whole‑exome sequencing showed that cancer-associated pathways and somatic mutations played a dominant role in the development of CCA. We established and characterized a new hCCA cell line, CBC3T-1, which contributes to a better understanding of bile duct cancer, and can be used to study tumorigenesis and progression and the role of anticancer drugs. [ABSTRACT FROM AUTHOR]

Choledochal Cysts (CC), cystic dilatation of biliary tree are an uncommon finding. Generally found in pediatric age group are rarer in adults and commoner in females. They have a relatively greater incidence in a few parts of Asia as compared to the West. Even rarer are Giant Choledochal Cysts (GCC). We successfully treated an adult patient of GCC with an uncommon presentation which is the largest from the Indian subcontinent. [ABSTRACT FROM AUTHOR]

The rising incidence combined with pregnancy-related physiological changes make gallbladder and biliary pathology high on the differential for pregnant patients presenting with right upper abdominal pain. Imaging plays a crucial role in determining surgical versus non-surgical management in pregnant patients with biliary or gallbladder pathology. Ultrasound (first-line) and magnetic resonance with magnetic resonance cholangiopancreatography (second-line) are the imaging techniques of choice in pregnant patients with suspected biliary pathology due to their lack of ionizing radiation. MRI/MRCP offers an excellent non-invasive imaging option, providing detailed anatomical detail without known harmful fetal side effects. This article reviews physiological changes in pregnancy that lead to gallstone and biliary pathology, key imaging findings on US and MRI/MRCP, and management pathways. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study is to understand factors associated with timing of adjuvant therapy for cholangiocarcinoma and the impact of delays on overall survival (OS). Methods: Data from the National Cancer Database (NCDB) for patients with non-metastatic bile duct cancer from 2004 to 2015 were analyzed. Patients were included only if they underwent surgery and adjuvant chemotherapy and/or radiotherapy (RT). Patients who underwent neoadjuvant or palliative treatments were excluded. Pearson's chi-squared test and multivariate logistic regression analyses were used to assess the distribution of demographic, clinical, and treatment factors. After propensity score matching with inverse probability of treatment weighting, OS was compared between patients initiating therapy past various time points using Kaplan Meier analyses and doubly robust estimation with multivariate Cox proportional hazards modeling. Results: In total, 7,733 of 17,363 (45%) patients underwent adjuvant treatment. The median time to adjuvant therapy initiation was 59 days (interquartile range 45–78 days). Age over 65, black and Hispanic race, and treatment with RT alone were associated with later initiation of adjuvant treatment. Patients with larger tumors and high-grade disease were more likely to initiate treatment early. After propensity score weighting, there was an OS decrement to initiation of treatment beyond the median of 59 days after surgery. Conclusions: We identified characteristics that are related to the timing of adjuvant therapy in patients with biliary cancers. There was an OS decrement associated with delays beyond the median time point of 59 days. This finding may be especially relevant given the treatment delays seen as a result of COVID-19. [ABSTRACT FROM AUTHOR]

Background and aim: Surgical cholecystectomy is the gold standard strategy for the management of acute cholecystitis (AC). However, some patients are considered unfit for surgery due to certain comorbid conditions. As such, we aimed to compare less invasive treatment strategies such as endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) and percutaneous gallbladder drainage (PT-GBD) for the management of patients with AC who are suboptimal candidates for surgical cholecystectomy. Methods: A comprehensive search of multiple electronic databases was performed to identify all the studies comparing EUS-GBD versus PT-GBD for patients with AC who were unfit for surgery. A subgroup analysis was also performed for comparison of the group undergoing drainage via cautery-enhanced lumen-apposing metal stents (LAMS) versus PT-GBD. The outcomes included technical and clinical success, adverse events (AEs), recurrent cholecystitis, reintervention, and hospital readmission. Results: Eleven studies including 1155 patients were included in the statistical analysis. There was no difference between PT-GBD and EUS-GBD in all the evaluated outcomes. On the subgroup analysis, the endoscopic approach with cautery-enhanced LAMS was associated with lower rates of adverse events (RD = − 0.33 (95% CI − 0.52 to − 0.14; p = 0.0006), recurrent cholecystitis (− 0.05 RD (95% CI − 0.09 to − 0.02; p = 0.02), and hospital readmission (− 0.36 RD (95% CI–0.70 to – 0.03; p = 0.03) when compared to PT-GBD. All other outcomes were similar in the subgroup analyses. Conclusions: EUS-GBD using cautery-enhanced LAMS is superior to PT-GBD in terms of safety profile, recurrent cholecystitis, and hospital readmission rates in the management of patients with acute cholecystitis who are suboptimal candidates for cholecystectomy. However, when cautery-enhanced LAMS are not used, the outcomes of EUS-GBD and PT-GBD are similar. Thus, EUS-GBD with cautery-enhanced LAMS should be considered the preferable approach for gallbladder drainage for this challenging population. [ABSTRACT FROM AUTHOR]

Background: The SAGES International Proctoring Course for Laparoscopic Cholecystecomy accepts applications from low to middle-income countries for SAGES faculty to train local surgeons. A regional public hospital in the 10th most populous city in the Philippines was one of the chosen sites for the 1-week course in 2010. Two SAGES surgeons and one nurse trained two local surgeons and four nurses identified by the hospital director. Methods: All patients seen in the out-patient clinic at the Zamboanga City Medical Center in the Philippines and scheduled for elective laparoscopic cholecystectomy from the first day of the course in August 2010 until December 2018 were entered into a prospectively collected database including demographics, pre-op diagnosis, operative findings, histopathologic diagnosis, conversion rates and 30-day complications including re-operations. Results: 521 patients underwent laparoscopic cholecystectomy. Majority were female (63.7%) with a mean age of 45.9 years. Most procedures were completed laparoscopically with an open conversion rate of 3.3%. Three patients underwent laparoscopic subtotal cholecystectomy. Reported complications requiring reoperation included one stump necrosis, two incisional hernias and one retained stone. One serosal injury and one surgical site infection were also reported for an overall morbidity rate of 4.6%. Pathology showed chronic calculous cholecystitis in 92.8% of specimens. No 30-day mortality was recorded. Conclusion: The SAGES International Proctoring Course for Laparoscopic Cholecystectomy has been shown to be a successful method for global surgery training. A focused 1-week direct proctoring model in the Philippines showed a sustained culture of safety in cholecystectomy with low 30-day morbidity, complication and conversion rates over a decade following participation in this program. [ABSTRACT FROM AUTHOR]

Primary sclerosing cholangitis is a rare chronic inflammatory disease affecting the bile ducts, which can eventually result in bile duct strictures, cholestasis and cirrhosis. Patients are often asymptomatic but may present with clinical features of cholestasis. Imaging plays an important role in the diagnosis and management. This review covers the pathophysiology, clinical features, imaging findings as well as methods of surveillance and post-transplant appearance. [ABSTRACT FROM AUTHOR]

Pathologies of the biliary tree include a wide-spectrum of benign and malignant processes. The differential for benign disease includes congenital and acquired disease with variable prognosis and management pathways. Given the ability to mimic malignancy, benign processes are difficult to diagnose by imaging. Direct cholangiography techniques with tissue sampling are the gold standards for the diagnosis of benign and malignant biliary pathologies. Non-invasive imaging with ultrasound offers a first-line diagnostic tool while MRI/MRCP offers higher specificity for identifying underlying pathology and distinguishing from malignant disease. In this review, we focus on the imaging appearance of dilatation, cystic anomalies obstruction, inflammation, ischemia, strictures, pneumobilia, and hemobilia to help construct a differential for benign processes. [ABSTRACT FROM AUTHOR]

Primary biliary cholangitis is a rare progressive chronic inflammation of the medium and small bile ducts that abdominal radiologists may encounter, particularly if working in a tertiary setting or at a transplant center. This brief review covers current thinking about the pathophysiology and presentation of the disease, as well as the current diagnostic criteria in use by hepatologists. Imaging strategies for diagnosis will be reviewed as well as current treatment strategies and the use of imaging in monitoring response to treatment, including image-guided elastography. [ABSTRACT FROM AUTHOR]

The radiologic diagnosis of biliary disease can be challenging due to atypical or delayed presentation, rare or less common entities, and imaging overlap of benign and malignant processes. Establishing a specific diagnosis, when possible, is important to avoid progression of infections to sepsis and multiorgan failure, and for appropriate staging and management in cases of malignancy. Gallstones are the most common biliary disease, and along with stone-related complications, including cholecystitis and choledocholithiasis, constitute the majority of acute biliary pathology. Late and atypical manifestations of acute cholecystitis demonstrate imaging overlap with primary gallbladder cholangiocarcinoma, especially with cases of exuberant inflammatory reaction such as xanthogranulomatous cholecystitis. Additional challenging scenarios related to gallbladder disease, that may be benign or malignant, include adjacent fistulas and lymphadenopathy. Dropped gallstones, especially in atypical locations, may be misdiagnosed as neoplastic. Recurrent cholecystitis after cholecystectomy, whether related to subtotal cholecystectomy or to stumpitis, is another entity that can be confusing to the radiologist with a documented history of cholecystectomy. Inflammatory and autoimmune conditions, such as pseudotumors and IgG4 disease, are a less common but not infrequent cause of diagnostic dilemma. Furthermore, biliary strictures and hepatobiliary cystic lesions can be benign or malignant and could constitute a diagnostic and management challenge. The goal of this manuscript is to present the lessons learned from multidisciplinary conferences on the above entities and suggest tips and pearls to maximize the value of radiologists’ contribution to patient management. [ABSTRACT FROM AUTHOR]

Introduction: The aim of this paper was to report the experience of one-stage LC and LCBDE service within a medium sized acute NHS healthcare trust to demonstrate the feasibility of this treatment modality in terms of safety, quality and effectiveness inside the limitations of the UK's nationalised healthcare system. Methods: All patients undergoing LCBDE at our institution from November 2013 – July 2021 were included in the study. Data were collected from a prospectively maintained institutional database and data points corroborated by electronic patient data on hospital systems. Results: Three hundred and eleven patients underwent LCBDE. Median age was 68 (range 21–95). Most cases were performed as urgent/emergency (n = 206, 66% vs n = 105, 34% elective). Bile duct stones were diagnosed pre-operatively in 23% of cases (n = 73). Intra-operative diagnosis was made using laparoscopic ultrasound (n = 228, 73%), cholangiogram (n = 44, 14%) or combination of both (n = 31, 10%). Laparoscopic completion rate was 94%. 56% were via choledochotomy and 44% trans-cystic. Incidence of bile leak was 4.2% (n = 13) and the incidence of retained stone within 90 days was 3.9%. Median length of stay was 2 days post-operatively (range 0–62). The rate of mortality was 0.66%. Conclusion: The data from our study shows that LC and LCBDE is a safe, effective service that can be successfully delivered in the NHS. With the developing specialisation of benign biliary units, we believe that this approach to choledocholithiasis is reproducible and achievable nationally and should be considered first-line in the management of this condition. [ABSTRACT FROM AUTHOR]

Background: The management of difficult lithiasis of common bile duct (CBD) often requires a multimodal approach. Fully Covered Metal Stents (FCSEMS) could fragment the stones, dilate strictures of the CBD and progressively enlarge the papillary orifice. The aim of the study was to evaluate the efficacy of FCSEMS in the treatment of difficult lithiasis of CBD. Methods: All consecutive cases of difficult lithiasis of CBD after an attempt of clearance with complete sphincterotomy were retrospectively considered from 2009 to 2019. Intrahepatic lithiasis cases were excluded. Multivariable analysis (stepwise logistic regression if p value < 0.1 at univariable analysis) was made to understand factors associated with efficacy of FCSEMS in difficult lithiasis of CBD. Results: 163 cases of difficult lithiasis over 1516 cases of lithiasis of CBD (incidence of 11%) were considered. Among eligible patients, 96 (mean age 78 ± 11.9 years, 43% males) placed a FCSEMS during the first ERCP. Mean diameter of stone was 17.5 ± 5.5 mm. An attempt of dilation during the same procedure was made in 18% cases. After removal of the stent, 52 (54%) patients had complete clearance of CBD at cholangiography. The rest of patients (44), subsequently underwent multimodal treatment (final success of 95%). After logistic regression, variables positively associated with clearance of CBD were sex male (OR 3.5) and stent permanence ≥ 30 days (OR 3.2). Diameter of the stone ≥ 2 cm was associated with failure (OR 0.2). 7 post-ERCP pancreatitis, 6 post-sphincterotomy bleeding and 3 cholangitis occurred. Conclusions: FCSEMS are useful in the approach of difficult lithiasis of CBD with no significant adverse events associated. [ABSTRACT FROM AUTHOR]

In pediatric liver transplantation, bile duct complications occur with a greater incidence than vascular anastomotic dysfunction and represent a major source of morbidity and mortality. While surgical re-anastomosis can reduce the need for retransplantation, interventional radiology offers minimally invasive and graft-saving therapies. The combination of small patient size and prevailing Roux-en-Y biliary enteric anastomotic techniques makes endoscopic retrograde cholangiopancreatography difficult if not impossible. Expertise in percutaneous management is therefore imperative. This article describes post-surgical anatomy, pathophysiology and noninvasive imaging of biliary complications. We review percutaneous techniques, focusing heavily on biliary access and interventions for reduced liver grafts. Subsequently we review the results and adverse events of these procedures and describe conditions that masquerade as biliary obstruction. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to evaluate the predictive value of a 'Modified Karnofsky Scoring System' on outcomes and provide real-world data regarding the UK practice of biliary interventions. Materials and Methods: A prospective multi-centred cohort study was performed. The pre-procedure modified Karnofsky score, the incidence of sepsis, complications, biochemical improvement and mortality were recorded out to 30 days post procedure. Results: A total of 292 patients (248 with malignant lesions) were suitable for inclusion in the study. The overall 7 and 30 day mortality was 3.1% and 16.1%, respectively. The 30 day sepsis rate was 10.3%. In the modified Karnofsky 'high risk' group the 7 day mortality was 9.7% versus 0% for the 'low risk' group (p = 0.002), whereas the 30 day mortality was 28.8% versus 13.3% (p = 0.003). The incidence of sepsis at 30 days was 19% in the high risk group versus 3.3% at the low risk group (p = 0.001) Conclusion: Percutaneous biliary interventions in the UK are safe and effective. Scoring systems such as the Karnofsky or the modified Karnofsky score hold promise in allowing us to identify high risk groups that will need more careful consideration and enhanced patient informed consent but further research with larger studies is warranted in order to identify their true impact on patient selection and outcomes post biliary interventions. [ABSTRACT FROM AUTHOR]

Purpose: Gallbladder cancer (GBC) is the most common malignancy of the biliary tract. The median survival of the disease is around 6 months. In this study, we explore clinical trials related to non-resectable GBC, determine the shortcomings leading to the lack of development of new treatment, and shed light on possible areas of improvement. Methods: On April 20, 2019 the authors completed a search on ClinicalTrials.gov for all therapeutic and interventional clinical trials involving non-resectable GBC, without any limits on date or location. Trial characteristics such as duration, phase, sample size, and whether a publication was produced were collected and analyzed. Results: Sixty-two trials met our selection criteria. The average duration of trials was 5 years. Trials were conducted in 8 different countries: most of them in North America (USA and Canada). About 88% of trials were in early phases (I, I/II, and II) and 85% of trials were completed. Only 4 relevant publications were produced from all the trials in our study. Gemcitabine was the most common drug used. Use of gemcitabine alone or in combination with either capecitabine or cisplatin showed significant increase mean progression-free survival. Conclusion: This study revealed a low number of trials, lack of geographic diversity, and scarcity of publications concerning non-resectable GBC. Adequate management of is of great importance to reach effective therapies for this disease. [ABSTRACT FROM AUTHOR]

Purpose: Currently, there is little consensus on management of the in situ gallbladder of patients undergoing gastric bypass. Our aim was to evaluate outcomes of selective concomitant cholecystectomy (CCY) and long-term biliary outcomes after Roux-en-Y gastric bypass (RYGB). Materials and Methods: We performed a retrospective analysis of patients undergoing laparoscopic RYGB (LRYGB) between 2008 and 2018. Chi-square, Fisher's exact, or Wilcoxon rank-sum tests were used to compare outcomes. Concomitant CCY was performed on a selective basis. Results: Three thousand and four patients underwent a RYGB (LRYGB n = 2458, open RYGB n = 546). Fifty-two percent (n = 1670) of patients had undergone CCY at any stage. Thirty-one percent of patients (n = 933) had CCY prior to RYGB, 13% (n = 403) had a concomitant CCY and 13% (n = 214) of the remainder required interval CCY. In the LRYGB subgroup, 29.9% (n = 735) had a prior CCY; 12.9% (n = 202) of those with an in situ gallbladder required interval CCY. Those who underwent concomitant CCY/LRYGB (n = 328) were compared with LRYGB alone (n = 1231). The concomitant CCY group was significantly older and had higher percentage of females, higher preoperative BMI, higher Charlson Comorbidity Index, and a higher medication count. There was no significant difference in BMI nadir, length of stay, complications, or mortality. Interval CCY had a higher incidence of CCY-related complications. Conclusion: Our study suggests a higher percentage of bariatric patients with in situ gallbladders will undergo interval CCY than documented in recently published guidelines. Concomitant CCY can be performed without an increase in length of stay or complications. Interval CCY may be associated with a higher complication rate. [ABSTRACT FROM AUTHOR]

Spontaneous biliary perforation (SBP) in pediatrics is rare and historically has been treated with laparotomy for attempted repair and cholecystectomy. In recent years, management has evolved into a conservative approach, opting for cholecystostomy and peritoneal drainage over cholecystectomy. In this case, we report the first successful conservative management of SBP using an exclusively laparoscopic approach without cholecystectomy in a pediatric patient. [ABSTRACT FROM AUTHOR]

Background: Gallbladder cancer remains a rare cancer with a poor prognosis. National guidelines recommend radical resection in the absence of metastatic disease. This often requires extensive dissection around the extrahepatic bile ducts. We report our experience of real-time near-infrared fluorescence imaging using indocyanine green during robotic radical resection of gallbladder adenocarcinomas.Methods: Ten patients with gallbladder adenocarcinoma underwent robotic radical resection entailing central hepatectomy (segments IV-B and V) with regional lymphadenectomy. Real-time NIRF imaging was performed using the da Vinci® Firefly system after intravenous administration of ICG 30 to 60 min preoperatively. Primary objective was to determine safety of this technique.Results: Procedure was successfully completed in all patients. Seven patients (70%) had incidentally discovered gallbladder cancer after laparoscopic cholecystectomy and five patients had preoperatively known positive margins. Mean operative time was 173 min. Mean intraoperative blood loss was 88 mL (30-200 mL). Median number of lymph nodes retrieved was 5 (2-8). High ligation of cystic duct was performed close to the common bile duct (CBD) junction with the assist of NIRF and negative margins were achieved in all patients. No major complications (Grade III-IV) or mortality was seen at 30 days post-op.Conclusions: Results from our limited experience demonstrate procedural safety and beneficial use of NIRF using ICG during robotic radical resection of gallbladder adenocarcinomas. It may assist in attainment of negative cystic duct margin and lymphatic clearance around the biliary tree especially in complex re-explorative biliary surgery. [ABSTRACT FROM AUTHOR]

Gallstone-related disease can have significant associated morbidity and mortality worldwide. The incidence of gallstone-related disease in the Western world is on the increase. There are multiple different pathological manifestations of gallstone disease: the presentation, diagnosis and associated complications of which vary significantly depending on anatomical location. The role of imaging in gallstone-related disease is broad with radiology playing an essential role in the diagnosis, management and follow-up of gallstone-related pathologies. This paper distills the broad range of gallstone-related pathologies into an anatomical map, discussing the disease processes involved at each point along the biliary tree and reviewing the strengths and weaknesses of different imaging modalities for each distinct disease process. [ABSTRACT FROM AUTHOR]

Objective: To investigate whether covered stents show a higher efficacy than uncovered stents in percutaneous treatment of malignant hilar biliary obstruction.Methods: Patients with obstructive jaundice caused by an unresectable hilar malignancy were included after failed endoscopic intervention in a prospective randomized trial comparing expanded polytetrafluoroethylene and fluorinated ethylene propylene (ePTFE-FEP)-covered nitinol stents with uncovered nitinol stents. Exclusion criteria were as follows: primary tumors existing more than 3 months, a biliodigestive anastomosis, previous stenting, and a Karnofsky score of less than 50. Safety, clinical success, and adjuvant chemotherapy were compared as well as occlusion rate, patency, and survival.Results: A total of 120 patients were included. One patient was post hoc excluded. Fourteen patients who died within 7 days and one patient without patency data were excluded from patency analysis. Serious adverse events (p = 0.4), 30-day mortality (p = 0.5), and clinical success (p = 0.8) were equivalent for both stent groups. Twenty-one out of 61 (34%) patients in the covered and 24/58 (41%) in the uncovered stent groups received adjuvant chemotherapy (p = 0.5). Occlusion rate was 54% (27/50) in the covered stent group and 57% (31/54) in the uncovered stent group (p = 0.8). Median patency was 229 days (95% CI 113-345) for covered stents and 130 days (95% CI 75-185) for uncovered stents (p = 0.1). Median survival in patients with covered stents was 79 days (95% CI 52-106) and with uncovered stents 92 days (95% CI 60-124) (p = 0.3).Conclusion: In malignant hilar biliary obstruction, there is no evidence that ePTFE-FEP-covered stents are superior to uncovered stents in terms of safety, clinical success, adjuvant chemotherapy, patency, or survival.Key Points: • Percutaneous palliation of hilar biliary obstruction is feasible with both uncovered and covered stents. • Clinical success in terms of bilirubin decrease and adjuvant chemotherapy is achievable with both stents. • Thirty-day mortality is considerable when stenting is also offered to patients with a low performance status. [ABSTRACT FROM AUTHOR]

Purpose of review: The goal of this manuscript is to review the current literature related to fibrogenesis in the pancreatobiliary system and how this process contributes to pancreatic and biliary diseases. In particular, we seek to define the current state of knowledge regarding the epigenetic mechanisms that govern and regulate tissue fibrosis in these organs. A better understanding of these underlying molecular events will set the stage for future epigenetic therapeutics. Recent findings: We highlight the significant advances that have been made in defining the pathogenesis of pancreatobiliary fibrosis as it relates to chronic pancreatitis, pancreatic cancer, and the fibro-obliterative cholangiopathies. We also review the cell types involved as well as concepts related to epithelial-mesenchymal crosstalk. Furthermore, we outline important signaling pathways (e.g., TGFβ) and diverse epigenetic processes (i.e., DNA methylation, non-coding RNAs, histone modifications, and 3D chromatin remodeling) that regulate fibrogenic gene networks in these conditions. Summary: We review a growing body of scientific evidence linking epigenetic regulatory events to fibrotic disease states in the pancreas and biliary system. Advances in this understudied area will be critical toward developing epigenetic pharmacological approaches that may lead to more effective treatments for these devastating and difficult to treat disorders. [ABSTRACT FROM AUTHOR]

Purpose: Pediatric experience with biliary tract injuries (BTI) is limited and mostly consists of case presentations. The purpose of this study is to evaluate clinical and radiological findings of possible BTI, treatment strategies, and results.Methods: The records of nine patients with the diagnosis of BTI between July 2009 and November 2017 were reviewed retrospectively.Results: There were seven boys and two girls (mean 8.05 ± 4.39 years). The mechanisms were motor vehicle occupant, fall, crush and gunshot wound. Hepatic laceration routes that extended into the porta hepatis and contracted the gall bladder were demonstrated on computerized tomography (CT). Bile duct injury was diagnosed with bile leakage from the thoracic tube (n = 2), from the abdominal drain (n = 2) and by paracentesis (n = 5). Extrahepatic (n = 8) and intrahepatic (n = 1) bile duct injuries were diagnosed by cholangiography. Endoscopic retrograde cholangiography, sphincterotomy, and stent placement were successfully completed in five patients. Peritoneal drainage stopped after 3-17 days of procedure in four patients. The fifth patient was operated with the diagnosis of cystic duct avulsion. Cholecystectomies, primary repair of laceration, cystic duct ligation, and Roux-en-Y hepatoportoenterostomy were performed in the remaining four patients. All patients presented with clinically normal findings, normal liver functions, and normal ultrasonographic findings in the follow-up period.Conclusions: The presentation of the parenchymal injury extending to the porta hepatis with contracted gall bladder on CT and diffuse homogenous abdominal fluid should be considered as signs of BTI. We suggest a multi-disciplinary approach for the diagnosis and treatment of BTIs. Surgery may be indicated according to the patient's clinical condition, radiological findings and failure of non-operative treatment. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study is to evaluate the prevalence of intra- and extrahepatic ductal dilatation in asymptomatic individuals after cholecystectomy. Methods and materials: This IRB-approved retrospective cohort study evaluated the prevalence of intra- and extrahepatic biliary dilation in 77 consecutive post cholecystectomy patients who had CT obtained in the portal venous phase. These were then compared to age and sex matched control patients. Two radiologists in consensus blinded to surgical history evaluated the intrahepatic ducts qualitatively for dilatation. A single radiologist using the best of three orthogonal planes measured the extrahepatic ducts. Extrahepatic ducts were considered dilated if >7 mm plus 1 mm/decade after 60 years. T tests and chi-squared tests were performed. Results: Cholecystectomy patient duct patterns: normal ducts 26% (20/77); intra- and extrahepatic dilation 31.2% (24/77); intrahepatic dilation only 18.2% (14/77); extrahepatic dilation only 24.7% (19/77). Control patient duct patterns: normal ducts 88.3% (68/77); intra- and extrahepatic dilation 2.6% (2/77); intrahepatic dilation only 2.6% (2/77); extrahepatic dilation only 6.5% (5/77). All intrahepatic ductal dilatation was mild. Total intrahepatic dilation: 49.4% (cholecystectomy); 5.2% (control patients). The relative risk of intrahepatic ductal dilation in cholecystectomy patients was 9.5:1. Increased prevalence of intra- and extrahepatic dilation in cholecystectomy patients was statistically significant ( p < 0.0001). Average extrahepatic duct was 7.8 mm (cholecystectomy) and 5.3 mm (control patients) ( p < 0.001). Conclusion: Mild intrahepatic biliary dilation in the setting of cholecystectomy is very common, and if not associated with clinical or biochemical evidence of obstruction is likely of no clinical significance. [ABSTRACT FROM AUTHOR]

Purpose of Review: Biliary atresia is the most common indication for liver transplantation among children. In recent years, prospective, multi-centre collaboration has been underway with the aim of providing high-quality data on the natural history of the condition, prior to and following hepatic portoenterostomy. Recent Findings: There is increasing evidence that specific histological findings, and age, at the time of portoenterostomy have relevance as prognostic indicators. Recent data suggest that the sub-type of biliary atresia, its co-existence with other anomalies and concurrent infection may also be important variables. Summary: This review provides a comprehensive summary of the histological predictors of outcome following portoenterostomy. Later age at portoenterostomy, advanced degree of hepatic fibrosis and co-existence with other congenital anomalies are strongly correlated with poor outcomes following portoenterostomy. There is increasing evidence to suggest that common serological indices and the presence or absence of cytomegalovirus (CMV) co-infection may have utility as early prognostic indicators. [ABSTRACT FROM AUTHOR]

Purpose: We describe the design and preliminary characterization of a stent incorporating light-emitting diodes (LEDs) for photodynamic therapy (PDT) of malignant biliary obstruction.Methods: A prototype was constructed with red (640 nm) LEDs embedded in a 14.5 French polyurethane tube. The device was evaluated for optical power and subjected to physical and electrical tests. PDT-induced reactive oxygen species were imaged in a gel phantom.Results: The stent functioned at a 2.5-cm bend radius and illuminated for 6 months in saline. No stray currents were detected, and it was cool after 30 minutes of operation. Optical power of 5-15 mW is applicable to PDT. Imaging of a reactive oxygen indicator showed LED-stent activation of photosensitizer.Conclusions: The results motivate biological testing and design optimization. [ABSTRACT FROM AUTHOR]

Purpose To assess the role of breath-held 3D-SSFP MRCP in evaluation of post-laparoscopic cholecystectomy biliary complications. Patients and methods This study included 29 patients with post-laparoscopic cholecystectomy symptoms like abdominal pain, vomiting or jaundice during period from March 2013 to March 2015. The ages of patients ranged from 28 to 70 years (mean 49 ± 16 year). MRCP was performed for all patients on 1.5 tesla MRI machine with breath-held multi-slice acquisition. Both 2D and 3D MRCP were done. Results The encountered post laparoscopic biliary complications were either major injuries like complete bile duct transection in 8 cases and bile duct ligation in 4 cases or minor injuries like partial thermal tear in 4 cases, slipped clips in 2 cases and benign strictures in 5 cases. The retained biliary stones were another complication and located either intrahepatic in 2 cases or extra-hepatic in 4 cases. 13 cases were managed by ERCP with sphincterotomy, dilatation and/or T-tube insertion. Other 13 patients were managed operatively with removal of ligature or hepaticojujenostomy and the remaining 3 patients were managed conservatively. Conclusion The use of breath-held 3D-SSFP MRCP is essential in evaluation of post-laparoscopic cholecystectomy biliary complications and in planning for management regimens. [ABSTRACT FROM AUTHOR]

Purpose: There are conflicting views regarding preoperative biliary drainage in patients undergoing pancreatectomy. The aim of this study was to evaluate the effect of jaundice resolution on postoperative outcomes. Methods: Patients who underwent pancreatectomy in a single institution since 2010 were retrospectively analyzed. They were divided into two groups, depending on the presence or not of preoperative biliary drainage. Postoperative morbidity and mortality were evaluated. Results: Ninety-nine patients underwent biliary drainage by endoscopic retrograde cholangiopancreatography (ERCP) (PBD group), while 105 patients had no biliary drainage (non-PBD group). No significant difference between the two groups could be identified in terms of overall complications ( p = 0.121) or mortality ( p = 1). There was no significant difference regarding pancreatic fistula ( p = 0.554), delayed gastric emptying ( p = 0.127), hemorrhage ( p = 0.426), number of reoperations ( p = 1.000) or readmissions ( p = 1.000). The only significant difference was found in the hospital stay, where patients who underwent preoperative biliary drainage had a prolonged length of stay of more 3 days (15.52 vs. 11.31) ( p < 0.001). Conclusion: Preoperative biliary drainage in patients undergoing pancreatectomy does not increase the rates of postoperative morbidity or mortality, but has a negative effect on hospital stay. [ABSTRACT FROM AUTHOR]

Biliary strictures and masses are commonly a result of cholangiocarcinoma. However, there are several congenital, infectious, inflammatory, autoimmune, iatrogenic, and neoplastic etiologies that should also be considered in the differential diagnosis. Knowledge of the key imaging and clinical findings will aid in facilitating the diagnosis and treatment. [ABSTRACT FROM AUTHOR]

Background: Different factors have been associated with prolonged fluoroscopy time (FT) during endoscopic retrograde cholangiopancreatography (ERCP). Aim: We hypothesize that FT depends on both the anatomical location of the pathology managed during ERCP and the complexity of the ERCP. Methods: Three centers participated in a retrospective multi-center cohort study. Data on patient demographics, ERCP complexity, and the location of pathology were collected. The relationships between FT and the location of pathology, ERCP complexity, patient demographics, and ERCP maneuvers, respectively, were analyzed. Prolonged FT was defined as a FT > 10 min. Results: A total of 442 cases underwent ERCP in three different centers (301 cases, 76 cases, and 65 cases in centers A, B, and C, respectively) by six endoscopists. The median FT for all cases was 282 (range 8-3,516) s. Mean FT increased progressively according to anatomical location in the order extrahepatic cases { n = 298; mean FT 292 [95 % confidence interval (CI) 263-322] s}, pancreatic cases [ n = 27; mean FT 359 (95 % CI 200-517) s], and intrahepatic cases [ n = 117; mean FT 736 s (95 % CI 635-836) s]. Mean FT increased progressively with the complexity scale, with mean FT for Grade I, 218 (95 % CI 138-299) s; Grade II, 295 (95 % 261-329) s; Grade III, 586 (95 % CI 508-663) s; Grade IV, 636 (95 % CI 437-834) s. Multivariable analysis confirmed that prolonged FT was independently associated with anatomical location of the targeted pathology during ERCP-but not with ERCP complexity and endoscopy center. Conclusion: Prolonged FT during ERCP is associated most strongly with intrahepatic cases. FT can be used most effectively as a quality measure if it is stratified according to presence or absence of intrahepatic cases. [ABSTRACT FROM AUTHOR]

Purpose: Gemcitabine/cisplatin combination therapy has been the standard palliative chemotherapy for patients with advanced biliary tract cancer (BTC). We aimed to evaluate the efficacy and safety of adding S-1 to gemcitabine/cisplatin combination therapy for patients with advanced BTC. Methods: Patients with histologically or cytologically confirmed unresectable or recurrent BTC were eligible for inclusion. The primary end point was overall survival. Based on the results of our preceding phase I study, gemcitabine and cisplatin were administered intravenously at doses of 1,000 or 25 mg/m, respectively, on day 1, and oral S-1 was administered daily at a dose of 80 mg/m on days 1-7 every 2 weeks. This study was registered with ClinicalTrials.gov (NCT01284413) and the UMIN Clinical Trials Registry (ID 000004468). Results: Fifty patients enrolled between October 2011 and August 2012 were evaluated. After a median follow-up of 15.1 months (range 2.4-24.4 months), the median overall survival time was 16.2 months [95 % confidence interval (CI) 10.2-22.2 months], and the one-year overall survival rate was 59.9 % (95 % CI 46.2-73.5 %). The grade 3-4 hematological toxicities were as follows: neutropenia (32 %), anemia (32 %), thrombocytopenia (10 %), and febrile neutropenia (4 %). The common grade 3-4 non-hematological toxicities were biliary tract infection (14 %), anorexia/nausea (10 %), and fatigue (8 %). Conclusions: Gemcitabine/cisplatin/S-1 combination chemotherapy offered a promising survival benefit with manageable toxicity in patients with advanced BTC. A randomized phase III trial to investigate the efficacy of this regimen compared to gemcitabine/cisplatin combination therapy in patients with advanced BTC is now underway (UMIN000014371/NCT02182778). [ABSTRACT FROM AUTHOR]

Background and Aim: There are scarce data regarding the impact of sphincterotome design on cannulation success. We aimed to compare two different 5.5 Fr standard sphincterotomes to determine initial cannulation success. Methods: Adult patients with naive papillae were enrolled in a prospective, randomized, crossover study. Two different 5.5 Fr sphincterotomes preloaded with guidewire (GW) were used in two groups with 140 patients included per group. A total of five papillary attempts and two pancreatic channel entries were allowed as maximum targets. In a case of more than two pancreatic entries, a double GW technique was attempted before crossover. If choledochal cannulation was not achieved within ten papillary attempts or more than four pancreatic entries despite crossover, access papillotomy was performed. Successful biliary cannulation was the primary outcome. Secondary outcomes were incidence of early complications and overall cannulation success. Results: Higher initial cannulation success was achieved in group I compared with group II (88.5 vs. 77.1 %, p = 0.011). The crossover and double GW techniques reduced the need for precut from 11.7 to 5.3 %. The overall cannulation success including precut for failed cases was 99.2 % (group I) and 98.5 % (group II). Sphincterotome type, presence of crossover, and number of cannulation attempts were predictors of successful cannulation in multivariate analysis. Conclusions: There was a significant difference in cannulation success between two different 5.5 Fr sphincterotomes. The cannulation success was mainly governed by sphincterotome design which serves a proper spatial orientation during the procedure. The combined use of crossover and double GW techniques may substantially decrease precut necessity. [ABSTRACT FROM AUTHOR]

Balanced steady state-free precession (b-SSFP) pulse sequences have a number of properties which can be useful in magnetic resonance cholangiopancreatography (MRCP), including short acquisition times, high signal-to-noise ratios, and T2/T1 contrast weighting. The utility and versatility of b-SSFP sequences for MRCP imaging are probably underappreciated, and this pictorial essay briefly discusses benefits and limitations of 2D and 3D b-SSFP techniques used in place of or in addition to conventional single-shot fast spin echo or 3D fast spin echo acquisitions and illustrates their appearance in several clinical cases. [ABSTRACT FROM AUTHOR]

Self-expandable metal stents (SEMS) are the current standard of care for the palliative management of malignant biliary strictures. Recently, endoscopic ablative techniques with direct affect to local tumor have been developed to improve SEMS patency. Several reports have demonstrated the technical feasibility and safety of intraductal radiofrequency ablation (RFA), by both endoscopic and percutaneous approaches, in palliation of malignant strictures of the bile duct. Intraductal RFA has also been used in the treatment of occlusion of both covered and uncovered SEMS occlusion from tumor ingrowth or overgrowth. This article provides a comprehensive review of intraductal RFA in the management of malignant biliary obstruction. [ABSTRACT FROM AUTHOR]

Evaluation of various methods of biliary enteric anastomosis in benign biliary diseases (BBD). A surgeon operating for BBD needs to improve the internal drainage of bile to prevent stasis and its back-pressure effects. This is best obtained by biliary enteric anastomosis. A total of 121 cases of biliary enteric anastomosis in BBD were included in this study. The postoperative course and long-term outcome were studied prospectively. In the choledochoduodenostomy group, there were no leaks, no restrictures, and no mortality. Five (10.41 %) patients had cholangitis attacks and 2 (4.17 %) patients had sump syndrome. The choledochojejunostomy group had no leaks, no restrictures. Two (7.14 %) patients had repeated cholangitis and 2 (7.14 %) patients had sump syndrome, no mortality. The hepaticojejunostomy group had 3 cases of anastomotic leak of which 2 healed spontaneously and 1 needed resurgery. There was restricture in 2 cases, in which resurgery was successful-one death, no cholangiocarcinoma. Biliary enteric anastomosis is a safe and effective method for the management of BBD. The method should be selected according to the disease pathology and patient characteristics. [ABSTRACT FROM AUTHOR]

Acute Biliary Pancreatitis is one of the commonest forms of pancreatitis in Nepal. Controversies exist as to the most appropriate way of management of these cases. The present study was carried out to evaluate the management and outcome of Acute Biliary Pancreatitis cases in a tertiary level hospital of Nepal. A retrospective analysis of the patients managed with Acute Biliary Pancreatits was done. All patients admitted with the diagnosis of Acute Biliary Pancreatitis over a period of 2 years were included in the study. The variables measured were age, sex, clinical presentation, laboratory investigations, mode of treatment and outcome. A total of 45 cases had Acute Biliary Pancreatitis suggesting a prevalence of 28 %. The mean age was 45 ± 10 year. 39 patients (86.6 %) were treated with conservative management. 23 patients (54 %) had an uneventful recovery without any complications. 21 patients (46 %) developed some form of complications but recovered successfully. Mortality was seen in only one patient in the conservatively treated group. In a resource poor setting such as Nepal, definitive management is not always possible. Conservative management of Acute Biliary Pancreatitis has a favorable outcome in the majority of our patients with acceptable morbidity and mortality. Definitive management can be safely performed during index admission where possible. [ABSTRACT FROM AUTHOR]

Background: Although biliary complications after orthotopic liver transplantation represent a common source of morbidity and mortality, decreasing graft survival, consensus is lacking on their management in the pediatric population.Objective: The aim of this study was to present the prevalence of such biliary complications and their interventional radiologic management with representative images.Materials and Methods: This retrospective study reports our experience with percutaneous transhepatic cholangiography in the management of biliary complications after orthotopic liver transplantation in pediatric patients. This study enrolled all pediatric patients (<18 years old) who underwent percutaneous transhepatic cholangiography for the management of biliary complications after orthotopic liver transplantation at a tertiary care center between January 2010 and December 2020. Diagnosis of biliary complications and indication to perform percutaneous transhepatic cholangiography were based on clinical, laboratory or radiologic data.Results: Among the 301 orthotopic liver transplantations, 78 (26%) developed biliary complications that were managed by interventional radiology: these included 52 (17.3%) biliary strictures, 19 (6.3%) bile leaks, 5 (1.7%) biliary stones, 1 (0.3%) iatrogenic biliary obstruction and 1 (0.3%) vanishing syndrome. The median time interval between orthotopic liver transplantation and the diagnosis of biliary complications was 6.0 years (interquartile range [IQR] 8.2 years). Percutaneous transhepatic cholangiography and biliary duct catheterization were successful in all cases, with low rates of complications that were variable among subgroups.Conclusion: A wide spectrum of biliary complications can occur after pediatric orthotopic liver transplantation. In this large single-center experience, we highlight the value of percutaneous transhepatic cholangiography in their diagnosis and management. Percutaneous treatments in pediatric patients are safe and effective, providing resolution or serving as a bridge to surgery, including re-transplantation. [ABSTRACT FROM AUTHOR]

Purpose: Previous clinical studies have shown the safety and efficacy of this novel radiofrequency ablation catheter when used for endoscopic palliative procedures. We report a retrospective study with the results of first in man percutaneous intraductal radiofrequency ablation in patients with malignant biliary obstruction. Methods: Thirty-nine patients with inoperable malignant biliary obstruction were included. These patients underwent intraductal biliary radiofrequency ablation of their malignant biliary strictures following external biliary decompression with an internal-external biliary drainage. Following ablation, they had a metal stent inserted. Results: Following this intervention, there were no 30-day mortality, hemorrhage, bile duct perforation, bile leak, or pancreatitis. Of the 39 patients, 28 are alive and 10 patients are dead with a median survival of 89.5 (range 14-260) days and median stent patency of 84.5 (range 14-260) days. One patient was lost to follow-up. All but one patient had their stent patent at the time of last follow-up or death. One patient with stent blockage at 42 days postprocedure underwent percutaneous transhepatic drain insertion and restenting. Among the patients who are alive ( n = 28) the median stent patency was 92 (range 14-260) days, whereas the patients who died ( n = 10) had a median stent patency of 62.5 (range 38-210) days. Conclusions: In this group of patients, it appears that this new approach is feasible and safe. Efficacy remains to be proven in future, randomized, prospective studies. [ABSTRACT FROM AUTHOR]

Hepatotoxicity of drug candidates is one of the major concerns in drug screening in early drug discovery. Detection of hepatic oxidative stress can be an early indicator of hepatotoxicity and benefits drug selection. The glutathione (GSH) and glutathione disulfide (GSSG) pair, as one of the major intracellular redox regulating couples, plays an important role in protecting cells from oxidative stress that is caused by imbalance between prooxidants and antioxidants. The quantitative determination of the GSSG/GSH ratios and the concentrations of GSH and GSSG have been used to indicate oxidative stress in cells and tissues. In this study, we tested the possibility of using the biliary GSSG/GSH ratios as a biomarker to reflect hepatic oxidative stress and drug toxicity. Four compounds that are known to alter GSH and GSSG levels were tested in this study. Diquat (diquat dibromide monohydrate) and acetaminophen were administered to rats. Paraquat and tert-butyl hydroperoxide were administered to mice to induce changes of biliary GSH and GSSG. The biliary GSH and GSSG were quantified using calibration curves prepared with artificial bile to account for any bile matrix effect in the LC-MS analysis and to avoid the interference of endogenous GSH and GSSG. With four examples (in rats and mice) of drug-induced changes in the kinetics of the biliary GSSG/GSH ratios, this study showed the potential for developing an exposure response index based on biliary GSSG/GSH ratios for predicting hepatic oxidative stress. [ABSTRACT FROM AUTHOR]

Objectives: While diabetes has been linked to several cancers in the gastrointestinal (GI) tract, findings have been mixed for sites other than colorectal and liver cancer. We used the Women's Health Initiative (WHI) data and conducted a comprehensive assessment of associations between diabetes and GI malignancy (esophagus, stomach, liver, biliary, pancreas, colon, and rectal). Methods: A total of 145,765 postmenopausal women aged 50-79 enrolled in the WHI were followed for a mean 10.3 years. Cox proportional hazard regression models were used to estimate hazard ratios (HRs) and 95 % confidence intervals (CIs) for the association between GI cancers and diagnosed diabetes, including its duration and treatment. Results: Diabetes at enrollment was associated with increased risk of liver (HR = 2.97; 95 % CI, 1.66-5.32), pancreatic (HR = 1.62; 95 % CI, 1.15-2.30), colon (HR = 1.38; 95 % CI, 1.14-1.66), and rectal (HR = 1.87, 95 % CI: 1.22-2.85) cancer. Diabetes severity, assessed by duration or need for pharmacotherapy, appeared to have stronger links to risk of liver, pancreatic, and rectal cancer, but not colon cancer. There was no statistically significant association of diabetes with biliary, esophageal, and stomach cancers. Conclusion: Type 2 diabetes is associated with a significantly increased risk of cancers of the liver, pancreas, colon, and rectum in postmenopausal women. The suggestion that diabetes severity further increases these cancer risks requires future studies. [ABSTRACT FROM AUTHOR]

Cholangiocarcinoma (CCA) is a tumor of the bile ducts that usually presents with biliary obstruction and has a poor prognosis. The treatment of CCA is challenging as the tumor is usually diagnosed late and the treatments are not very effective except when complete surgical resection is possible. In carefully selected patients, liver transplant can be a curative therapy. In the majority of cases, complete surgical resection is not possible and palliation is the mainstay of treatment. Stenting, using plastic or metallic stents, allows for biliary drainage. Photodynamic therapy plays a role in palliation and might play a role in adjuvant or neoadjuvant therapy. While radiation and chemotherapy can be beneficial, newer ablative techniques and targeted chemotherapies are promising. [ABSTRACT FROM AUTHOR]

Peroral choledochoscopy was first described in the 1970s, but the use of earlier generation choledochoscopes was significantly limited by complex equipment setup and fragility resulting in high repair costs. In late 2006, the SpyGlass Direct Visualization System (Boston Scientific Corp, Natick, MA, USA) was introduced to the market. It is a single-operator cholangioscopy platform and improves upon many shortcomings of the dual-operator systems. Currently, the two main indications for its use are evaluation of indeterminate biliary strictures and lithotripsy for difficult-to-remove biliary stones. Recently published prospective data reconfirm that the overall success rates for adequate tissue sampling and bile duct stone clearance are around 90 %, with an acceptable safety profile. The sensitivity for detecting cancer in intrinsic biliary strictures (e.g., cholangiocarcinoma) is superior to that of standard ERCP sampling modalities, but a limited yield has been noted when sampling extrinsic malignant biliary strictures (e.g., pancreatic cancer). The two main limitations of the SpyGlass system are image quality that is impeded by the use of fiberoptic technology and a relatively small accessory channel providing passage only for dedicated miniaccessories. Nevertheless, the SpyGlass platform has made single-operator cholangioscopy feasible and refined the technique in a number of important ways. This innovation has significantly expanded our diagnostic and therapeutic ERCP armamentarium. An upgraded digital imaging version is currently in development. [ABSTRACT FROM AUTHOR]

Background and Aims: Primary biliary cirrhosis (PBC) is a relatively uncommon liver disease, and information on the prognosis and survival of PBC patients in mainland China is lacking. We therefore conducted a retrospective study to investigate the prognostic factors and survival in Chinese PBC patients.Methods: Between October 2001 and May 2009, patients registered at Beijing You'an Hospital with abnormal liver function and serum positivity for antimitochondrial antibody (AMA) and/or AMA-M2 (n = 391) were screened. Patients diagnosed with PBC were identified, and their medical data were reviewed and analyzed for mortality predictors.Results: A total of 147 PBC patients were identified (mean age: 54 years, range: 28-81), of whom 126 (85.7%) were women. At the time of diagnosis, 119 patients (81.0%) were symptomatic, 28(19.0%) had hepatic decompensation, and no patients were asymptomatic. During a median follow-up period of 48 months (range: 2-312), 36 patients (24.5%) died or underwent liver transplantation, and 65 patients (44.2%) developed hepatic decompensation. The overall 5-year survival rate was 79%. Multivariate analysis indicated that Mayo risk score ≥6.11(P = 0.008), and serum IgG ≥ 17.20 g/l (P = 0.016) were associated with mortality.Conclusions: Most Chinese PBC patients in this study were symptomatic at diagnosis and had significant mortality. Mayo risk score, and serum IgG were independent prognostic factors for survival. [ABSTRACT FROM AUTHOR]

Cholangiocarcinoma (CCA) is a rare tumor arising from the epithelium of the intrahepatic or the extrahepatic bile ducts. It is rarely diagnosed before 40 years of age except in patients with primary sclerosing cholangitis. CCA is usually clinically silent until the tumor obstructs the bile ducts. Carbohydrate antigen 19-9 is the most commonly used tumor marker, and magnetic resonance cholangiopancreatography is the best available imaging modality for CCA. Endoscopic retrograde cholangiopancreatography and cholangioscopy allow tissue acquisition. Positron emission tomography may play a role in identifying occult metastases. Tissue diagnosis is obtained by brush cytology or bile duct biopsy. [ABSTRACT FROM AUTHOR]

Introduction: The peroxisome proliferator-activated receptors (PPARs) are well established to be important in modulating the fibrogenic response to liver injury. PPARγ plays a role in hepatic fibrosis, presumably by virtue of its expression in hepatic stellate cells, which are key effectors of fibrosis. In this study, we evaluated whether the potent nonthiozolidinedione PPARγ agonist, GW570, had effects on isolated stellate cells and hepatic fibrosis in vivo. Methods: Liver fibrosis and stellate cell activation were induced in vivo by either bile duct ligation (BDL) or administration of carbon tetrachloride (CCl). Primary cultures of stellate cells isolated from normal rats were exposed to GW570. The PPARγ agonist was also given to male Sprague-Dawley rats before or during injury to test its ability to ameliorate fibrosis. Fibrosis biomarkers including total collagen, hydroxyproline, collagen I α1 and smooth muscle α actin were measured. Results: GW570 had potent effects on isolated stellate cells, both simulating PPARγ mediated gene transcription, as well as inhibiting collagen I α1 mRNA and protein expression and smooth muscle α actin protein abundance, consistent with suppression of stellate cell activation. In BDL liver injury, a daily dose of 10 mg/kg per day of GW570 inhibited collagen I α1 mRNA, while concentrations of 1 also inhibited fibrosis as measured by hydroxyproline and total collagen content. Lower doses of GW570 (0.1-1.0 mg/kg per day) did not significantly abrogate whole liver collagen or hydroxyproline content in this model. In a CCl model, 0.1-1.0 mg/kg per day GW570 reduced expression of smooth muscle α actin, but did not affect whole liver collagen or hydroxyproline content. Finally, we found that GW570 had anti-inflammatory effects on Kupffer cells as well as in vivo during CCl injury. Conclusion: PPARγ receptor agonism with the nonthiozolidinedione, GW570, inhibited stellate cell activation in vitro and in vivo, and abrogated the fibrogenic response to injury in a dose responsive fashion. [ABSTRACT FROM AUTHOR]