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Background. In patients with benign biliary strictures, the use of fully covered self-expandable metal stents (SEMS) has been proposed as an alternative to plastic stenting, but high quality prospective data are sparse. This study was performed to evaluate the long-term effectiveness and safety of a new fully covered SEMS for benign biliary strictures. Methods. All consecutive patients with benign biliary strictures were treated with placement of a fully covered SEMS (WallFlex) for 6 months. Short- and long-term stricture resolution, adverse events, and ease of stent removal were recorded. Results. 23 patients were enrolled. Stricture etiology was chronic pancreatitis (14), postorthotopic liver transplant (4), idiopathic (4), and biliary stones (1). All ERCPs were technically successful. All stents were successfully removed. Short-term stricture resolution was seen in 22/23 (96%) patients. Long-term success was 15/18 (83.3%). All 3 failures were patients with biliary strictures in the setting of chronic calcific pancreatitis. Conclusions. The use of the new SEMS for the treatment of benign biliary strictures led to short-term stricture resolution in the vast majority of patients. Over a long-term followup the success rate appears favorable compared to historical results achieved with multiple plastic stenting, particularly in patients with chronic pancreatitis. The study was registered with ClinicalTrials.gov (NCT01238900).

The development of biliary tract calculi after orthotopic liver transplantation presents a unique clinical problem. Previously described techniques for removing biliary stones by shock wave lithotripsy, litholytic therapy with oral bile acids, and endoscopic mechanical extraction may be ineffective or contraindicated in liver transplant patients. For this reason, percutaneous transhepatic electrohydraulic lithotripsy (EHL) was performed using an 11 French flexible ureteroscope in two pediatric patients who developed biliary tract calculi following orthotopic liver transplant. There were no complications and postoperative follow-up over 4 years has been uneventful. To our knowledge, these represent the first reported cases of percutaneous transhepatic endoscopic EHL to fragment biliary tract stones in a transplanted liver, which for us has been a safe and effective therapeutic option.

A patient with a cholecystocolic fistula, complicating cholecysto-choledocholithiasis, was treated endoscopically with gallbladder observation by peroral cholecystoscopy (POCCS). The patient was a 71-year-old female admitted to our hospital for investigation and treatment of biliary stones and a cholecystocolic fistula. Endoscopic lithotripsy and extracorporeal shock wave lithotripsy (ESWL) were performed after endoscopic sphincterotomy, and the gallbladder was subsequently investigated using a duodenoscope/ cholangioscope of the mother and baby type. Full distension of the gallbladder with saline solution allowed POCCS observation of the entire surface. The gallbladder mucosa was smooth, and neither stones nor tumors were observed. Though the cholecystocolic fistula itself could not be observed, we concluded that it had resulted from cholecystitis. Peroral cholecystoscopy is thus a useful method of investigating the gallbladder in such cases.

Background: Intrahepatic stones are characterized by high treatment failure and recurrence rates. In the past, surgery played a major role in the management of this disease, but surgical intervention may not be feasible in previously operated patients or those classified as poor surgical risks. The development of percutaneous trans-hepatic cholangioscopy and lithotripsy has played an important role in the treatment of these patients. Methods: We reviewed our results in 165 patients with intrahepatic stones treated by percutaneous trans-hepatic cholangioscopy and lithotripsy in the past 12 years. Results: The rate of complete stone removal was 80% (132 cases) and the rate of recurrent biliary stones after a mean 58 month follow-up interval was 32.6% (43 of 132 cases). There were 2 deaths during the treatment period and 10 deaths during follow-up. Conclusions: Percutaneous trans-hepatic cholangioscopy and lithotripsy are good alternatives in treating primary intrahepatic stones, especially for those patients unsuitable for surgery. (Gastrointest Endosc 1995;42:13-8.)

The majority of bile duct stones in Western patients originate in the gallbladder. Many patients with bile duct stones are asymptomatic. However, the acute complications of bile duct calculi—jaundice, cholangitis, and pancreatitis— may present in isolation or in combination with each other. Successful treatment of cholangitis and severe biliary pancreatitis requires urgent biliary decompression, which is best achieved by endoscopic sphincterotomy. Similarly, endoscopic sphincterotomy is the most appropriate method of relieving obstructive jaundice caused by biliary stones and, in some patients, may be the sole treatment required. Surgical intervention rarely is necessary in the acute stage, although definitive surgery may be required later, when the patient's clinical condition has improved.

Acute pancreatitis is a sudden swelling and inflammation of the pancreas. The two most common causes are alcohol use and biliary stones. Drug-induced acute pancreatitis are rare (1.4-2%). In this present study, we present a case of recurrent acute pancreatitis induced by a specific magnetic-resonance-imaging (MRI) contrast agent called gadobenate dimeglumine.

AIM: To assess the efficacy and safety of endoscopic papillary large balloon dilation after biliary sphincterotomy for difficult bile duct stones retrieval. METHODS: Retrospective review of consecutive patients submitted to the technique during 18 mo. The main outcomes considered were: efficacy of the procedure (complete stone clearance; number of sessions; need of lithotripsy) and complications. RESULTS: A total of 30 patients with a mean age of 68 ± 10 years, 23 female (77%) and 7 male (23%) were enrolled. In 10 patients, a single stone was found in the common bile duct (33%) and in 20 patients multiple stones (67%) were found. The median diameter of the stones was 17 mm (12-30 mm). Dilations were performed with progressive diameter Through-The-Scope balloons (up to 12, 15) or 18 mm. Complete retrieval of stones was achieved in a single session in 25 patients (84%) and in two sessions in 4 patients (13%). Failure occurred in 1 case (6%). Mechanical lithotripsy was performed in 6 cases (20%). No severe complications occurred. One patient (3%) had mild-grade post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. CONCLUSION: Endoscopic balloon dilatation with a large balloon after endoscopic sphincterotomy is a safe and effective technique that could be considered an alternative choice in therapeutic ERCP.

The first-line therapy for choledocholithiasis is endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction, which is successful in over 90% of cases. However, large biliary stones often require extracorporeal shockwave lithotripsy, electrohydraulic lithotripsy (EHL), or laser lithotripsy. The objective of our study was to assess the safety and efficacy of laser lithotripsy with choledochoscopy guidance.Between March 2001 and November 2009, laser lithotripsy with a holmium laser was used for complicated bile stones in 20 patients. All patients included had failed standard stone extraction techniques after a mean of 2.1 ± 1.1 ERCP sessions. Main outcome measures included complete stone clearance and complications post-procedure.Twenty patients (mean age 61.0 ± 22.3 years, six men) underwent laser lithotripsy with a mean stone size was 2.2 cm (range 1.1-3.5 cm) and a mean number of stones of 2.2 (range 1-6). A mean of 0.25 ± 0.20 kJ was applied during laser lithotripsy sessions with a mean procedure time of 85.3 ± 23.0 min. The majority (18/20, 90%) achieved final clearance after a mean of 1.4 ± 0.8 (29 total) laser sessions and a mean of 1.9 ± 0.8 (38 total) ERCP sessions. Five complications occurred: two patients required post-procedure admission for pain and three patients had bile leaks. All bile leaks were minor and resolved after biliary stenting.Laser lithotripsy using the holmium laser is safe and effective with direct cholangioscopic guidance. Further prospective studies are warranted.

Endoscopic retrograde cholangiopancreatography (ERCP) has emerged as the preferred option when direct visualization of the ampulla and direct access to the distal common bile duct are desired. This chapter describes facilities, equipment, and techniques for successful performance of ERCP in the patient with surgically unaltered gastroduodenal anatomy.

To assess the current status of extracorporeal shock wave lithotripsy (ESWL) for the treatment of gall-stones in Japan, we conducted a nationwide survey by sending a questionnaire to 251 institutions using this therapy. Replies were obtained from 50 institutions. The use ofESWL was investigated over the period from its introduction up to October 1992. ESWL was performed on 2, 760 of 10, 058 patients with gallstones (27. 4%). The stones were completely pulverized in 1, 021 of these 2, 760 patients (37. 0%). Complete disappearance was limited to single gallstones less than 20 mm in maximum diameter. A comparison in the number of ESWL sessions revealed no significant difference between the patients with and without a good response. Choledocholithiasis was resolved completely in 44. 0% of 157 patients who underwent ESWL for this condition and intrahepatic stones were cured in 18. 7% of 32 patients. Therefore, ESWL may be a useful form of conservative therapy for biliary calculi., 体外衝撃波結石破砕装置(ESWL)を用いた胆石治療の実態を把握するために, ESWL の設置された全国251施設を対象としたアンケート調査を行い, 50施設から回答を得た. 調査期聞は各施設の ESWL 導入時から1992年10月までで, 各施設の10, 058例の胆嚢結石に対し, ESWL 治療は27. 4% に行われた. その治療効果は ESWL 施行2, 760例中, 完全消失が1, 021例37. 0% もあり, 完全消失例を得るための必要条件は, 個数は1個で, 最大径は20 mm 以下であることが判明した. 肝内・総胆管結石に対する ESWL 治療では, 総胆管結石は157例中44. 0% が消失, 肝内結石32例に対しても18. 7% が完全消失し, 今後の保存的治療法の一つとして期待される.

Background Biliary stones are a common disease in western countries, and its management has changed dramatically over the past decade. Due to the increase of the middle-aged people, a larger number of elderly patients are affected by this disease. Laparoscopic cholecystectomy (LC) represents the gold standard for the treatment of gallbladder stones, and in cholecystectomized patients, the treatment of CBD stones remains the exclusive work of the endoscopist. But if the patient still has the gallbladder with stones, the ideal management of CBD stones remains controversial. There are two treatment options: the two time (LC and pre or postoperative ERCP), and the one time procedures (trans cystic approach and CBD exploration and laparoendoscopic procedure called “rendezvous”:RV). The aim of the work is to analyse our results of the mininvasive treatment of the cholecysto-choledocolithiasis in elderly patients.

Noninvasive or minimally invasive techniques for the treatment of biliary stones have been significantly advanced in the past two decades. The least invasive, extracorporeal shock-wave lithotripsy, continues to be used successfully, not only at its earliest reported site of use in Munich, Germany, but also in numerous other centers in the world. Lithotriptors that utilize a spark gap electrode or other sources of energy to generate sound waves and imaging by radiographic and ultrasonographic targeting of stones have proved to be effective in fragmenting biliary stones (90% to 95%) that are too large or otherwise inaccessible to removal by endoscopic papillotomy. Stone clearance (53% to 90%) may require successive treatments and the removal of debris by transendoscopic or surgical means. The mortality is low (0.5%), and the post-treatment course is relatively uncomplicated in an elderly, high-risk group of patients.

The CT findings of 23 patients with proven acute ascending cholangitis were retrospectively evaluated. Computed tomography confirmed the clinical diagnosis and detected the site and etiology of the obstructive process in the majority of patients. Biliary dilatation consistent with the clinical suspicion of acute cholangitis was present in 18 patients (78%), the level of the obstruction was detected in 15 patients, and the etiology of the obstructive process was visualized in 14 cases. Five patients presented with air in the biliary tree and three patients had liver abscesses. There was no good correlation established between jaundice, biliary infection, and the presence or degree of biliary dilatation. Biliary obstruction and acute cholangitis can develop before biliary dilatation is detected. In addition, CT showed limitations in establishing the etiology of the obstructive process, particularly in failing to detect 7 of 17 cases of cholesterol biliary stones.

Despite widely available technology for removal of bile duct stones, endoscopists currently encounter approximately 3% of patients with stones that defy extraction. After sphincterotomy and unsuccessful attempts at extraction of "defiant" stones, biliary stents were placed in 22 patients. Ten patients were treated with ursodeoxycholic acid, and 12 patients treated only with stent served as control subjects. Ductal strictures preventing stone extraction were present in eight control patients and in six patients treated with ursodeoxycholic acid. The number of total calculi in the ursodeoxycholic acid group was slightly higher (4.2 per patient) than the number in the control group (3.3 per patient). Stone and bile duct dimensions were similar in each group. Nine of 10 patients in the ursodeoxycholic acid group had complete stone clearance, and 41 of 42 stones were removed during a follow-up period of 9 +/- 2 months; in contrast, no patient in the control group had complete clearance and only 6 of 40 stones were removed after a follow-up period of 31 +/- 6 months. Oral ursodeoxycholic acid facilitates extraction of defiant bile duct stones. This treatment is an effective alternative to high-tech extraction methods for large biliary stones.

We report herein the case of a 46-year-old woman investigated for recurrent acute cholangitis. Ultrasound, endoscopic retrograde cholangiopancreatography, and computed tomography scan revealed dilatation and multiple images suggestive of intrahepatic biliary stones in the ducts that drained segments V and VI of the liver. Endoscopic treatment was attempted unsuccessfully, and based on the severity of the last crisis of cholangitis a laparotomy was performed. A right hepatic lobectomy including segments V and VI was carried out without any complications, resulting in complete relief of symptoms. Pathological examination of the liver demonstrated the presence of worm nests in the liver parenchyma with chronic granulomatous lesions.

Background: Cholestatic jaundice (CJ) in patients with sickle cell disease (SCD) poses diagnostic and therapeutic dilemmas. This is an evaluation of the role of ERCP in SCD. Methods: A total of 224 SCD patients with CJ had ERCP. The indications for ERCP were based on clinical and biochemical evidence of CJ and ultrasound findings. Results: The indications were: CJ only in79, CJ and dilated ducts in 103, and CJ and biliary stones in 42. The ERCP findings were: (A) For those with CJ only: ERCP was normal in 45, showed dilated ducts with no stones in 13, dilated ducts with stones in 16, normal CBD with a stone in 1; (B) For those with CJ, dilated ducts: ERCP was normal in 17, showed dilated ducts with stones in 47, dilated ducts without stones in 28, normal CBD with a stone in 1, a choledochoduodenal fistula in 2; (C) For those with CJ and duct stones: ERCP was normal in 2, showed dilated ducts with stones in 21, dilated ducts without stones in 14, normal CBD with a stone in 1. Conclusions: ERCP was unnecessary in a significant number (27%) of patients. This is especially so for those with CJ only (57%). These should be evaluated further prior to ERCP. There was also a significant number (19%) who had ES for duct dilatation without an obstruction. The reason for this dilatation is not known and the value of ES in this group needs to be investigated further.

Minimally invasive therapy is currently invaluable for the treatment of biliary stones. Clinicians should be familiar with the various endoscopic modalities that have been evolving. I reviewed the treatment of biliary stones from the common practice to pioneering procedures, and here I also briefly summarize the results of many related studies. Lithotripsy involves procedures that fragment large stones, and they can be roughly classified into two groups: intracorporeal modalities and extracorporeal shock-wave lithotripsy (ESWL). Intracorporeal modalities are further divided into mechanical lithotripsy (ML), electrohydraulic lithotripsy, and laser lithotripsy. ESWL can break stones by focusing high-pressure shock-wave energy at a designated target point. Balloon dilation after minimal endoscopic sphincterotomy (EST) is effective for retrieving large biliary stones without the use of ML. Peroral cholangioscopy provides direct visualization of the bile duct and permits diagnostic procedures or therapeutic interventions. Biliary stenting below an impacted stone is sometimes worth considering as an alternative treatment in elderly patients. This article focuses on specialized issues such as lithotripsy rather than simple EST with stone removal in order to provide important information on state-of-the-art procedures.

Laser lithotripsy is an excellent method of fragmenting those biliary stones that cannot be removed easily by less technically advanced methods such as basket extraction. The energy can be delivered through fine flexible fibers, around 200 to 320 microns in diameter, that can be passed through the channels of a variety of small endoscopes. Currently, the optimal laser seems to a pulsed system because of the conversion of light to acoustic energy with minimal heating of the surrounding tissues, thus avoiding the chance of tissue injury and perforation. The best wavelength seems to be 504 nm, because at this wavelength, there is maximum absorption of laser energy by pigment stones, resulting in fragmentation using low-energy pulses. With further research, optimal wavelengths and pulse durations may emerge.

Objective To assess the long-term evolution of elderly patients with large or impacted bile duct stones, treated by an endoscopic biliary endoprosthesis. Design Case series. Setting Tertiary care center. Patients Twenty-three patients with a mean (± SD) age of 86 ± 5 years (range, 77–97 years). On admission, 96% were highly symptomatic. These patients represent 8.4% of a group of 273 elderly patients (≧70 years old) with choledocholithiasis treated by endoscopic sphincterotomy between November 1984 and May 1989. Intervention Endoscopic insertion of a biliary endoprosthesis. Results Eighty-seven percent (20/23) remained completely free of biliary symptoms and died of unrelated illness (48%) after a mean follow-up of 23 months or are still alive (39%) with a mean follow-up of 52 months. In four cases, this asymptomatic evolution now extends for more than 5 years. Conclusion Insertion of a biliary endoprosthesis offers an effective method for long-term treatment of non-extractable biliary stones in elderly patients.

Biliary ascariasis is one of the most common types of ascaris infections. The current treatments are helminthic drug therapy, endoscopic extraction, and surgical extraction. A case of biliary ascariasis and cholecystocholedocholithiasis was successfully treated by laparoscopic extraction of the living worm and biliary stones. This procedure was found to be very effective for biliary ascariasis with biliary stones, and it holds promise for similar cases in the future.

OBJECTIVE Ascaris lumbricoides may obstruct bowel, biliary tree, pancreatic ducts, and appendix and induce biliary stones. The purpose of this article was to illustrate typical sonographic findings of A. lumbricoides in the gastrointestinal and biliary tracts. METHODS Clinical data of 57 patients undergoing sonographic examination with confirmed ascariasis were studied retrospectively, and features of sonographic characteristics of A. lumbricoides in gastrointestinal and biliary tracts were studied. RESULTS Sonographic characteristics of A. lumbricoides were single or multiple echogenic nonshadowing linear, tubular structures; curved strips or rodlike with or without echoic tubular central lines; and a spaghettilike appearance, a target sign, or a pseudotumor appearance in the transverse section. CONCLUSIONS Ascaris lumbricoides in the gastrointestinal and biliary tracts has various features. Sonographic examination in the diagnosis of ascaridiasis has a high value.

Background : Biliary stones are the leading cause of acute pancreatitis. Although cholecystectomy and selective endoscopic retrograde cholangiography (ERC) comprise the current treatment in patients with acute biliary pancreatitis (ABP), the time of intervention is still controversial. Objective : In this study the outcomes of cholecystectomy was evaluated. Methods : on first admission for ABP and in patients with recurrent biliary pancreatitis. A series of 45 patients with ABP between January 2003 and November 2008 were evaluated retrospectively. Patients were classified into two groups. Group I included 30 patients who underwent cholecystectomy on first admission before discharge from the hospital. Group II comprised of 15 patients who had recurrent biliary pancreatitis and then underwent cholecystectomy. The severity of the pancreatitis was determined by Ranson's criteria. Age, gender, length of hospital stay, severity of pancreatitis, amylase level, and complications of cholecystectomy were evaluated in both groups. Patients in group I underwent cholecystectomy during the first hospital admission and patients in group II during an admission for a recurrence. Results: there were 24 patients with a Ranson's score 3 in group I and 12 in group II. The mean hospital stays were 15.29 days (range 4-48 days) and 36.66 days (range 15-123 days) in groups I and II, respectively (p = 0.006). Morbidity was 11% without mortality in group I and 43% with one mortality in group II (p = 0.023). Conclusions: Definitive treatment of ABP can be accomplished effectively and safely by cholecystectomy following clinical improvement, with selective ERC performed during the first admission (delayed cholecystectomy). Waiting to perform cholecystectomy (interval cholecystectomy) may result in recurrent biliary pancreatitis, which may increase morbidity and the length of the hospital stay. Key words : Timing of cholecystectomy, acute biliary pancreatitisDOI: 10.3329/bsmmuj.v1i1.3690 BSMMU J 2008; 1(1): 11-14

연락처: 이상협, 463-707, 경기도 성남시 분당구 구미동 300 분당서울대학교병원 내과 Tel: (031) 787-7042, Fax: (031) 787-4051 E-mail: gidoctor@snubh.org Correspondence to: Sang Hyub Lee, M.D. Department of Internal Medicine, Seoul National University Bundang Hospital, 300, Gumi-dong, Bundang-gu, Seongnam 463-707, Korea Tel: +82-31-787-7042, Fax: +82-31-787-4051 E-mail: gidoctor@snubh.org Fig. 1. Pancreatico-bliliary CT and MRCP findings. (A) Non-contrast image. In segment IV/VIII of left lobe of liver, multiple high attenuated stones were found (arrowhead). (B) Contrast-enhanced image. This image showed focal low attenuated cystic dilatation of right intrahepatic duct (arrowhead). It also showed no definite dilatation of intrahepatic duct in other segments of the liver. 국소 Caroli병

Aims: To measure patients' satisfaction after endoscopic retrograde cholangiopancreatography (ERCP) for biliary stones in a large number of unselected endoscopy units. Methods: A prospective study using a questionnaire (Group Health Association of America—9 [GHAA-9], modified) was administered 24 h and 30 days after the procedure. Patients undergoing endoscopy for biliary stones for the first time were enrolled in a large number of endoscopy units, regardless of their size and workload. Results: In all, 700 patients were enrolled in 15 units. A high proportion of patients expressed satisfaction (80%). Satisfaction was less extensive for pain control and the quality of information provided before the procedure. There were no differences in the replies to questionnaires at 24 h and 30 days. Conclusion: It is feasible to record patients' satisfaction and in this series most patients were very satisfied. Criticisms concerned pain control and explanations provided before the procedure.

To evaluate risk factors for the recurrence of biliary stones after a percutaneous transhepatic biliary stone extraction.The procedures were performed on 339 patients between July 2004 and December 2008 (54 months). Medical records and images were retrospectively reviewed for 135 patients (mean age, 66.4 years; 83 men and 52 women) who had undergone follow-up for a mean of 13.2 months (range, 3-37 months). To evaluate risk factors for the recurrence of biliary stones, variables were evaluated with univariate and multivariate analyses. Variables included sex, age, stone location, number of stones, stone size, presence of a peripapillary diverticulum, application of antegrade sphincteroplasty, presence of a biliary stricture, largest biliary diameter before the procedure, and gallbladder status.Thirty-three of the 135 patients (24%) had recurrent symptomatic biliary stones and underwent an additional extraction. The mean time to recurrence was 17.2 months +/- 8.7. Univariate analysis of risk factors for recurrence of biliary stones demonstrated that location, number of stones, stone size, application of antegrade sphincteroplasty, presence of a biliary stricture, and biliary diameter were significant factors (P.05). With use of multivariate analysis, the number of stones (or =6; relative risk, 64.8; 95% confidence interval: 5.8, 717.6) and stone size (or =14 mm; relative risk, 3.8; 95% confidence interval: 1.138, 13.231) were determined to be significant risk factors.The independent risk factors for recurrence of symptomatic biliary stones after percutaneous transhepatic biliary stone extraction were a stone size of at least 14 mm and the presence of at least six stones.

Peroral cholangioscopy can allow direct visualization of the bile duct non-invasively. A major role of peroral cholangioscopy is the management of difficult biliary stones which are resistant to conventional endoscopic treatment, including mechanical lithotripsy. Electrohydraulic or laser lithotripsy under strict peroral cholangioscopic guidance may be a safe and effective alternative to surgery. Several clinical studies suggest the utility of peroral cholangioscopy for the management of various bile duct lesions. Cholangioscopic observation, with or without direct biopsy, may be a useful adjunct to endoscopic retrograde cholangiopancreatography (ERCP) for distinguishing malignant from benign bile duct lesions. However, an assessment of its diagnostic accuracy needs further clinical controlled studies. At present, the fragility of the equipment and technical difficulties lessen its popularity. Preliminary data obtained using newly designed cholangioscopes, which provide excellent quality images and improved maneuverability, are encouraging.

Endoscopic retrograde cholangiopancreatography (ERCP) is primarily aimed at the management of biliary stones and the treatment of jaundice, and is a procedure performed using endoscopic therapeutic devices with varied technical features and functions because they need to overcome clinical and anatomical variations. Therefore, it is necessary for physicians and nurses to acquire great skill and knowledge about how to use these various devices.

La perforación de la vesícula biliar ocurre con alguna frecuencia durante la colecistectomía laparoscópica (CL). El derrame de bilis y cálculos en la cavidad peritoneal es menos frecuente y la verdadera incidencia de cálculos abandonados en ésta cavidad es difícil de determinar. Éstos no son considerados un peligro; sin embargo, la exacta biología natural de estos cálculos extraviados no está bien dilucidada y parece ser que no son tan inocuos como se creía, ya que con frecuencia se están reportando variadas complicaciones tardías de esta condición. Presentamos 5 pacientes atendidos en nuestro servicio por fístula peritoneocutánea secundaria a litiasis biliar abandonada en la cavidad abdominal durante la CL practicada entre 1,5 y 10 años atrás. Concluimos que, si bien es cierto que las complicaciones secundarias a cálculos biliares abandonados en la cavidad peritoneal son poco frecuentes (0,08 -0,3%), cuando ocurren se traducen en alta morbilidad, por lo que debe evitarse esta condición retirando todos los cálculos derramados al ocurrir una rotura vesicular, e idealmente exteriorizarla en una bolsa. La conversión a cirugía abierta para aseo peritoneal exhaustivo pareciera no estar indicada, pero si la necesidad de entregar clara información al paciente acerca de las potenciales complicaciones tardías que la situación puede conllevar, evitando así problemas médico legales futuros. Gallbladder perforation may occur during laparoscopic cholecystectomy. The leakage of bile and stones to the peritoneal cavity is less common and the real incidence of abandoned stones is hard to ascertain. The possible complications of these abandoned stones are not well known. We report five patients (four females) aged 49 to 78 years, with a peritoneo-cutaneous fístula caused by biliary stones abandoned in the peritoneal cavity during laparoscopic cholecystectomy performed between 1.5 and 10 years before. We conclude that abandoned stones in the peritoneal cavity can be associated to important complications and those that leak to the peritoneal cavity during laparoscopic cholecystectomy, should be removed during the surgical procedure and the gallbladder should be excised in a bag. The conversión to open surgery for an exhaustive peritoneal lavage is apparently not indicated.

La perforación de la vesícula biliar ocurre con alguna frecuencia durante la colecistectomía laparoscópica (CL). El derrame de bilis y cálculos en la cavidad peritoneal es menos frecuente y la verdadera incidencia de cálculos abandonados en ésta cavidad es difícil de determinar. Éstos no son considerados un peligro; sin embargo, la exacta biología natural de estos cálculos extraviados no está bien dilucidada y parece ser que no son tan inocuos como se creía, ya que con frecuencia se están reportando variadas complicaciones tardías de esta condición. Presentamos 5 pacientes atendidos en nuestro servicio por fístula peritoneocutánea secundaria a litiasis biliar abandonada en la cavidad abdominal durante la CL practicada entre 1,5 y 10 años atrás. Concluimos que, si bien es cierto que las complicaciones secundarias a cálculos biliares abandonados en la cavidad peritoneal son poco frecuentes (0,08 -0,3%), cuando ocurren se traducen en alta morbilidad, por lo que debe evitarse esta condición retirando todos los cálculos derramados al ocurrir una rotura vesicular, e idealmente exteriorizarla en una bolsa. La conversión a cirugía abierta para aseo peritoneal exhaustivo pareciera no estar indicada, pero si la necesidad de entregar clara información al paciente acerca de las potenciales complicaciones tardías que la situación puede conllevar, evitando así problemas médico legales futuros.

Endoscopic sphincterotomy with stone extraction has been successful in the majority of patients with biliary stones; however, large biliary stones and pancreatic stones in the smaller pancreatic duct may require a new approach. Pulsed dye laser has proven effective in treating pancreatic duct calculi during ERCP. With an outpatient procedure to eliminate pancreatic duct calculi, patients can be treated safely and effectively without major surgery. The procedure is less invasive for the patient, thereby reducing morbidity and expense.

Different studies have suggested that the prevalence of gallstones is increased in patients with cirrhosis [1, 2, 3]. In the past, open cholecystectomy (OC) in cirrhotic patients was commonly accompanied by significant morbidity and mortality [4, 5]. Laparoscopic cholecystectomy (LC) has become the procedure of choice to treat symptomatic cholelithiasis in the general population. However, cirrhosis has been considered as a contraindication for LC due to the risk of bleeding and liver failure [6]. Currently, with the advances in laparoscopic technology, a range of increasingly complex procedures are performed, making traditional contraindications at best relative. Several studies have reported good results and suggested liberal use of LC in patients with early-stage cirrhosis and symptomatic cholelithiasis.

El íleo biliar es una complicación rara de la litiasis biliar que ocurre en apenas el 0,1% de estos pacientes y supone el 1-6% del total de las oclusiones intestinales mecánicas del adulto. Se presenta un caso clínico de íleo biliar de localización colónica en un paciente de 45 años de edad, colecistectomizado hace 4 años, que ingresa a nuestra institución con el diagnóstico de oclusión intestinal intermitente. Tras un tratamiento inicial conservador con buena evolución durante las primeras 48 h, presenta posteriormente un agravamiento de su cuadro clínico. Se decide laparotomía exploradora con resección de colon sigmoides y anastomosis término-terminal con colostomía transversa de derivación. En el examen de la pieza se objetiva cálculo biliar de 3 cm de diámetro impactado en el colon sigmoides. Debido a lo excepcional de esta patología y los pocos reportes internacionales existentes en pacientes colecistectomizados, nuestro objetivo es poner en consideración este caso clínico y su correspondiente revisión de la literatura Biliary ileus is an uncommon complication of biliary stones and accounts for 1 to 6% of all mechanical intestinal obstructions in the adult. We report a 45 years oíd male, subjected to a cholecystectomy four years earlier, admitted with the diagnosis of intermittent intestinal obstruction. Due to a bad evolution with medical treatment, he was subjected to an exploratory laparotomy and sigmoid colon was excised. A latero-terminal anastomosis and a transverse colostomy were done. The examination of the surgical piece showed the presence of a 3 cm diameter biliary stone impacted in the sigmoid colon

The paper studies the combined radiologic and endoscopic approach (rendez vous technique) to the treatment of the biliary complications following liver transplant. The “rendez-vous” technique was used with an electrokinetic lithotripter, in the treatment of a biliary anastomotic stricture with multiple biliary stones in a patient who underwent orthotopic liver transplant. In this patient, endoscopic or percutaneous transhepatic management of the biliary complication failed. The combined approach, percutaneous transhepatic and endoscopic treatment (rendez-vous technique) with the use of an electrokinetic lithotritor, was used to solve the biliary stenosis and to remove the stones. Technical success, defined as disappearance of the biliary stenosis and stone removal, was obtained in just one session, which definitively solved the complications. The combined approach of percutaneous transhepatic and endoscopic (rendez-vous technique) treatment, in association with an electrokinetic lithotritor, is a safe and feasible alternative treatment, especially after the failure of endoscopic and/or percutaneous trans-hepatic isolated procedures.

Aim: The ultrasonography is the first examining method to detect biliary problems. Biliary diseases are usually recognized as „side“ diagnosis and they are usually without complaints. The biliary disorders might be start as „acute“ or in other cases they are „silent“ problems. The aim of our study is to detect which type of diseases and how often lead to biliary problems. Methods: The patients suffering in different types of gastrointestinal diseases were examined by 2 D and 3 D abdominal ultrasonographic method. During the examining period the biliary system was detected as a „possible target system“. The gastrointestinal disorders were: hepatic disorders, sclerotising cholangitis, inflammatory bowel diseases, metastatic tumors during therapy eg. carcinoid tumor, GIST. The examinations were carried out with Kretz-Voluson 530 equipment 2D and 3D transducer. During the examination the gallbladder and the bile duct system were examined. The biliary system, the biliary stones and the gallbladder volume were measured by 3D method. Results: The biliary system is a main area of the occurrence of gastrointestinal disorders. The different types of the diseases affect the biliary system. Because of the forgoing it is very important to detect the „first sign“ and to compare it during the follow up. Different types of diseases cause different problems such as gallbladder wall thickening, sludge, cholelithiasis, functional disorders. In some cases they predict the „acute“ failure. Sometimes these problems originate from the diseases and in other cases from the treatment. Conclusion: The ultrasonographic methods are very important in the detection and prediction of biliary problems in gastrointestinal diseases.

A possible association of biliary stones and gastric surgery has been hypothesised since the clinical observations of Majoor in 1947 on a series of 147 gastric resections for peptic ulcer [1]. Although the pathophysiology of such an association was not completely understood, vagotomy and neuro-hormonal changes after gastric resections were advocated and an 18% prevalence of new gall-stones was reported at 5 years follow up, 13.5% of which required a surgical treatment [2, 3].

Extracorporeal shock wave lithotripsy is a noninvasive technique for treatment of patients with gallbladder and bile duct stones. Selected patients with gallbladder stones can be treated on an outpatient basis without general anesthesia and may return to full activity within 1 or 2 days. Stone-free rates of 40% to 60% at 6 months have been achieved in most reported series with minimal morbidity. Bile duct stone lithotripsy has achieved stone clearance in 80% of patients in whom conventional methods were unsuccessful and therefore constitutes a valuable second-line treatment for these patients.

A 67-year-old man was admitted with obstractive jaundice. Percutaneous transhepatic cholangiogram showed clots in the CBD, but we mistook them for biliary stones at first. As these clots disappeared by the cholangiography 4 days later, we could diagnose this case as hemobilia. After bleeding had stopped with biliary drainage, percutaneous transhepatic cholangioscopy (PTCS) and angiography were performed, but no bleeding lesion was revealed. He was discharged after benign course 2 months later. Hemobilia is a rare status, especially there are few cases of unknown origin. This case of idoopathic hemobilia is reported with reference to the literature. Diagnostic value of PTCS in hemobilia is also mentioned.

Historically, gallstone therapy has been surgery. Gastrointestinal endoscopists and radiologists are now becoming increasingly active in the definitive management of both cholelithiasis and choledocholithiasis. Today, for uncomplicated cholelithiasis and for many cases of choledocholithiasis in patients without increased surgical risk, biliary surgery remains the recommended treatment by internists and surgeons alike. However, with an increased battery of available therapeutic modalities, management decisions and strategies are becoming more complex and the treatment of biliary stone disease in the future will be different than it was in the past.

Correction: Pediatr Gastroenterol Hepatol Nutr 2015;18:73-84. http://dx.doi.org/10.5223/pghn.2015.18.2.73 This article was originally published on June 30, 2015. The following errors were discovered by the authors after publication: missing references and missing words. Firstly, the following new references have been added. 7. Kandula L, Lowe ME. Etiology and outcome of acute pancreatitis in infants and toddlers. J Pediatr 2008;152:106-10. 18. Choi IY, Jin SH, Choi KD, Kim KM. A Case of autoimmune chronic pancreatitis in a child. Korean J Pediatr Gastroenterol Nutr 2007;10:215-20. Accordingly, reference numbers "[7-16]" should be corrected as "[8-17]" and "[17-39]" should be corrected as "[19-41]" in main text and reference list, in order to maintain the sequential order of in-text citations. Secondly, the sentence on page 73 "It has been reported that the structural abnormalities of the pancreaticobiliary system, including biliary stones and sludge, are the leading causes of recurrent pediatric pancreatitis [6]." has been replaced with: "It has been reported that biliary diseases including the structural abnormalities of the pancreaticobiliary system are the leading causes of recurrent pediatric pancreatitis even for infants and toddlers [5-7]." The sentence on page 77 "Autoimmune pancreatitis is increasingly encountered in adults, but a few cases have been also reported in children and adolescents [16]." has been replaced with: "Autoimmune pancreatitis is increasingly encountered in adults, but a few cases have been also reported in children and adolescents [17,18]."

Introduction: Acute cholangitis (AC) is a clinical diagnosis entity. A high prevalence of acute inflammatory changes (AIC) are found in hepatic needle biopsies (HB) in these patients. The aim of our study is to determine the prevalence of AIC in HB performed on patients with AC due to biliary stones. Methods: Cross-sectional study. Surgery was performed at the Hospital Regional of Temuco. Patients with Charcot’s triad, over 15 years of age, and surgical exploration of common bile duct were included. There was exclusion if periampullary tumor or liver cirrhosis was suspected. Bile macroscopy and hepatic histopathology were determined. A hepatic needle biopsy was taken during surgery. Biopsies were analyzed by two independent pathologist groups and kappa statistics were applied. Results: From January to June, 2002, fifty-three patients (83% female) with a median age of 60.7 years with AC were operated on. We found 83% with pus in the biliary system and 17% with cloudy bile. Histopathology: minimal changes (32%), hepatic steatosis (25%), chronic periportal infiltration (17%), liver cirrhosis (11%), AIC (6%) and normal (9%). Kappa statistics were 0.77. In conclusion a low prevalence of AIC was found in the HB of patients with AC.

The purpose of this study was to assess the value of adding a T1-weighted image to MR cholangiopancreatography (MRCP) to detect bile duct stones.During a 30-month period, 148 patients suspected of having biliary stones and who underwent MRI including MRCP, a fat-suppressed T1-weighted fast low-angle shot (FLASH) sequence, and an axial HASTE sequence were enrolled in this study. The biliary stones were confirmed by ERCP, surgery, and percutaneous transhepatic cholangiography. Of these 148 patients, 73 had extrahepatic stones, 45 had intrahepatic stones, 20 had both extrahepatic and intrahepatic stones, and 10 had no biliary stones. Two separate sets of images, the MRCP set (composed of MRCP and axial HASTE) and the combined interpretion of the MRCP set and the T1-weighted image, were analyzed independently and separately by two observers. The diagnostic accuracy was evaluated using the receiver operating characteristic method. The sensitivity and specificity were also calculated.For common duct stones, the diagnostic accuracy and the sensitivity of both image sets showed similar values without any significant difference (0.998 [97.8%] for the combined interpretation; 0.988 [97.8%] for observer 1 and 0.995 [96.8%] for observer 2 for the MRCP set). However, for the intrahepatic stones, the diagnostic accuracy (0.993) and the sensitivity (98.5%) of the combined interpretation were significantly higher than those of the MRCP set for the two observers (0.926 [83.8%] for observer 1 and 0.922 [85.3%] for observer 2) (p0.05). No significant difference was seen in the specificity of the two image sets for both the intrahepatic and the common duct stones.Combining the axial T1-weighted image with MRCP is valuable for detecting intrahepatic stones.

BACKGROUND: Sphincter of Oddi manometry is the gold-standard method for sphincter of Oddi dysfunction. The prevalence of sphincter of Oddi dysfunction among patients referred to endoscopic retrograde cholangiopancreatography is largely unknown. AIM: To evaluate prospectively the prevalence of biliary sphincter of Oddi dysfunction (B-SOD) among Brazilian patients referred to endoscopic retrograde cholangiopancreatography and to study the safety of sphincter of Oddi manometry in this setting. METHODS: Biliary sphincter of Oddi manometry was intended in 110 patients referred to endoscopic retrograde cholangiopancreatography. The number of attempts to obtain deep cannulation with the manometry catheter was recorded and patients were divided into two groups: up to 5 (easy cannulation) and >5 attempts (difficult cannulation). RESULTS: Sphincter of Oddi manometry was successful in 71/110 patients (64.5%). Sphincter of Oddi dysfunction was found in 18/71 patients (25%). Endoscopic retrograde cholangiopancreatography findings were: normal in 16, biliary stones in 39, malignant biliary strictures in 9 and benign biliary strictures in 7. There was no statistical difference in sphincter of Oddi dysfunction prevalence regarding disease, gender or difficulty of cannulation. Only 2/71 patients developed post-procedure mild pancreatitis. CONCLUSIONS: We have found a high prevalence of sphincter of Oddi dysfunction in patients referred to endoscopic retrograde cholangiopancreatography. Gender, nature of disease or difficulty of cannulation did not influence the prevalence of sphincter of Oddi dysfunction among these patients. Sphincter of Oddi manometry is a safe procedure for the evaluation of sphincter of Oddi dysfunction in patients referred to endoscopic retrograde cholangiopancreatography. RACIONAL: Manometria do esfíncter de Oddi é o método padrão-ouro para o diagnóstico da disfunção do esfíncter de Oddi. Atualmente, a prevalência de disfunção do esfíncter de Oddi em pacientes encaminhados a colangiopancreatografia retrógrada endoscópica é desconhecida. OBJETIVOS: Avaliar prospectivamente a prevalência de disfunção do esfíncter de Oddi em pacientes encaminhados a colangiopancreatografia retrógrada endoscópica e estudar a segurança da manometria do esfíncter de Oddi nesses pacientes. MÉTODO: Neste estudo, 110 pacientes encaminhados à colangiopancreatografia retrógrada endoscópica foram submetidos a manometria do esfíncter de Oddi biliar. Com base no número de tentativas de canulação da papila os pacientes foram divididos em dois grupos: até cinco tentativas (canulação fácil) e mais de cinco tentativas (canulação difícil). RESULTADOS: Manometria do esfíncter de Oddi foi realizada com sucesso em 71/110 pacientes (64,5%). Disfunção do esfíncter de Oddi foi encontrada em 18/71 pacientes (25%). Os achados das colangiopancreatografia retrógrada endoscópica foram: estudo normal em 16, coledocolitíase em 39, estenose biliar maligna em 9 e estenose biliar benigna em 7. Não foi observada diferença estatística na prevalência de disfunção do esfíncter de Oddi considerando-se a natureza da doença, sexo ou a dificuldade de canulação. Somente 2/71 pacientes evoluíram com pancreatite pós-procedimento de leve intensidade. CONCLUSÃO: Encontrou-se alta prevalência de disfunção do esfíncter de Oddi em pacientes encaminhados a colangiopancreatografia retrógrada endoscópica. Sexo, natureza da doença ou dificuldade de canulação não mostraram influência na prevalência da disfunção nestes pacientes. Manometria do esfíncter de Oddi mostrou-se um procedimento seguro na pesquisa de disfunção do esfíncter de Oddi em pacientes encaminhados a colangiopancreatografia retrógrada endoscópica.

A 59-year-old man with non–insulin-dependent diabetes mellitus underwent laparoscopic cholecystectomy for biliary stones. He was able to return to work 8 days after surgery. The patient started to experience numbness and tingling in all four limbs 2–3 weeks later. The symptoms progressed to the point that he had difficulty driving, walking, and using his hands. Bladder function was intact. The patient was hospitalized for a complete neurologic evaluation 8 weeks after surgery. A cervical spine magnetic resonance (MR) imaging examination was performed at that time.