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To systematically evaluate the effects of a fast‐track recovery programme on perioperative wound infections and postoperative complications in patients undergoing biliary tone surgery, we conducted a comprehensive search of PubMed, Web of Science, Cochrane Library, Embase, China Biomedical Literature Database, Wanfang and China National Knowledge Infrastructure databases from inception to 29 September 2023 for randomised controlled trials (RCTs) focusing on the application of a fast‐track recovery programme in patients undergoing biliary stone surgery. Two researchers independently screened and evaluated the studies based on predefined inclusion and exclusion criteria, and data were subsequently extracted from the included studies. Stata software (version 17.0) was employed for data analysis. Overall, 19 RCTs involving 2363 patients were included, with 1178 patients allocated to the fast‐track recovery programme group and 1185 to the conventional care group. The results revealed a significantly lower occurrence of wound infection (3.74% vs. 9.45%, OR = 0.36, 95% CI: 0.25–0.51, p < 0.001) and postoperative complications (11.38% vs. 27.34%, OR = 0.31, 95% CI: 0.25–0.39, p < 0.001) in the fast‐track recovery programme group compared to the conventional care group. The available evidence supports the assertion that implementing a fast‐track recovery programme in the perioperative period of patients undergoing biliary stone surgery effectively reduces the incidence of wound infections and postoperative complications while facilitating postoperative recovery. [ABSTRACT FROM AUTHOR]

Endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) are both crucial for the endoscopic management of biliopancreatic diseases: the combination of their diagnostic and therapeutic potential is useful in many clinical scenarios, such as indeterminate biliary stenosis, biliary stones, chronic pancreatitis and biliary and pancreatic malignancies. This natural and evident convergence between EUS and ERCP, which by 2006 we were calling the "Endoscopic ultrasonography retrograde colangiopancreatography (EURCP) concept", has become a hot topic in the last years, together with the implementation of the therapeutic possibilities of EUS (from EUS-guided necrosectomy to gastro-entero anastomoses) and with the return of ERCP to its original diagnostic purpose thanks to ancillary techniques (extraductal ultrasound (EDUS), intraductal ultrasound (IDUS), cholangiopancreatoscopy with biopsies and probe-based confocal laser endomicroscopy (pCLE)). In this literary review, we retraced the recent history of EUS and ERCP, reported examples of the clinical applicability of the EURCP concept and explored the option of performing the two procedures in only one endoscopic session, with its positive implications for the patient, the endoscopist and the health care system. In the last few years, we also evaluated the possibility of combining EUS and ERCP into a single endoscopic instrument in a single step, but certain obstacles surrounding this approach remain. [ABSTRACT FROM AUTHOR]

Biliary lithiasis is relatively rare in the black African community with a very sparsely distribution. The management problems in our context is due to diagnostic and therapeutic means. We report our experience in the management of gallbladder stones and discuss the epidemiological, clinical, and therapeutic aspects in our context. This is a retrospective and descriptive study from January 2015 to May 2019. It included all the patients operated for simple or complicated gallbladder stones. The parameters evaluated included age, sex, geographic origin, history, symptoms, morphological data, type of surgery, postoperative morbidity and mortality. The serie included 16 men and 59 women. The average age was 46.59 years [range 10 - 85 years]. Three patients had type SS sickle cell disease. Moderate obesity was noted in 29 patients and severe obesity in 3 patients. The clinical and radiological findings revealed vesicular stones and a fine vesicular wall in 46 cases, acute cholecystitis in 23 cases, and sclero-atrophic lithiasis in 5 cases. Laparoscopy was performed in 71 cases (75,9%) for symptomatic gallbladder stone. Conversion to open surgery was performed in 3 cases (4%), due to equipement failure in 2 cases and surgical difficulties in 1 case (chronic cholecystitis with strong adhesions). The duration of laparoscopic in tervention was on average 58,65 minutes [range 30- 180 minutes]. The mortality rate was 1.3% (1case for hemorragies). The mean hospital duration was 2.51 days [range 2 to 10 days]. A relatively young and non obese population is noted in our series and reflects the heterogeneity of the etiological factors of biliary stones. Management is improved by laparoscopy in our context and difficulties encountered are associated to chronic cholecystitis. [ABSTRACT FROM AUTHOR]

Abstract Objectives Distally located small common bile duct stones are often difficult to treat or grasp endoscopically. Therefore, multiple devices, such as baskets or balloon catheters, are frequently used in such cases. However, it is desirable to use a single device for stone extraction from the perspective of cost‐effectiveness. In this multicenter study, we evaluated the efficacy of a new eight‐wire basket catheter for extracting small (≤10 mm) common bile duct stones. Methods We retrospectively analyzed the records of 144 patients who underwent stone extraction using the eight‐wire basket catheter for common bile duct stones ≤10 mm. The success rate of complete stone extraction and the risk factors for the difficulty in stone extraction with the eight‐wire catheter alone were mainly evaluated. Results The success rate of stone extraction with the eight‐wire catheter alone was 86.1%. The final rate of complete stone extraction was 98.0%. The mean of the maximum diameter of the common bile duct and the largest stone dimension were 10.5 ± 3.5, and 5.1 ± 2.1 mm, respectively. Common bile duct diameter ≥12 mm and stone diameter ≥6 mm were identified as independent risk factors for the difficulty in stone extraction with the eight‐wire catheter alone. Conclusions The success rate of the new eight‐wire basket for small common bile duct stone extraction was acceptable. The device is beneficial and could be used from the start for the extraction of small stones

Endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) are both crucial for the endoscopic management of biliopancreatic diseases: the combination of their diagnostic and therapeutic potential is useful in many clinical scenarios, such as indeterminate biliary stenosis, biliary stones, chronic pancreatitis and biliary and pancreatic malignancies. This natural and evident convergence between EUS and ERCP, which by 2006 we were calling the “Endoscopic ultrasonography retrograde colangiopancreatography (EURCP) concept”, has become a hot topic in the last years, together with the implementation of the therapeutic possibilities of EUS (from EUS-guided necrosectomy to gastro-entero anastomoses) and with the return of ERCP to its original diagnostic purpose thanks to ancillary techniques (extraductal ultrasound (EDUS), intraductal ultrasound (IDUS), cholangiopancreatoscopy with biopsies and probe-based confocal laser endomicroscopy (pCLE)). In this literary review, we retraced the recent history of EUS and ERCP, reported examples of the clinical applicability of the EURCP concept and explored the option of performing the two procedures in only one endoscopic session, with its positive implications for the patient, the endoscopist and the health care system. In the last few years, we also evaluated the possibility of combining EUS and ERCP into a single endoscopic instrument in a single step, but certain obstacles surrounding this approach remain.

Background: Temporary fully covered self‐expandable metal stent (FCSEMS) placement is performed for benign choledochojejunal anastomotic stenosis (bCJS). However, recurrence may develop after stricture resolution. We investigated endoscopic biliary stenting using FCSEMS for bCJS. Methods: Sixteen bCJS patients with FCSEMS placement were retrospectively analyzed. FCSEMS was removed endoscopically after 2 months. Technical success, stricture resolution, recurrence, and adverse events were evaluated. Results: The technical success rate for FCSEMS placement was 94% (15/16). Biliary stones were detected and extracted in four patients. FCSEMS removal was successfully performed on 14 patients, excluding one with stent migration. At FCSEMS removal, stricture resolution was noted in 14 patients; however, four had anastomotic ulcers. The median follow‐up was 319 days. Three patients with a history of repeated plastic stent placement had no recurrence. Four out of 15 patients (27%) had recurrence, and three had no recurrence after additional interventions. Biliary stones before first FCSEMS placement (P =.003) or anastomotic ulcers at FCSEMS removal (P =.018) were associated with recurrence. Conclusions: Although FCSEMS placement was useful for stricture resolution, recurrence was detected in patients with biliary stones before first FCSEMS placement or anastomotic ulcers at FCSEMS removal. Anastomotic ulcers are a risk factor for recurrence and only detected by endoscopy. [ABSTRACT FROM AUTHOR]

Endoscopic retrograde cholangiopancreatography (ERCP) is the current treatment of choice in bile duct stones. Several factors such as variant anatomy of ampulla and surgical procedures like hepaticojejunostomy limit the success of ERCP in treating bile duct stones. Percutaneous transhepatic laser lithotripsy using interventional radiologic and endourologic techniques, which is uncommon, is a reasonable treatment option in such difficult cases. It is a minimally invasive, safe procedure accompanied by a high success rate, minimal morbidity, and a short hospital stay. We report our technique and experience in a series of three patients who underwent percutaneous transhepatic biliary drainage (PTBD) followed by percutaneous transhepatic laser lithotripsy in an attempt to avoid open surgery when ERCP was technically difficult.

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INTRODUCTION Biliary cholesterol supersaturation is the main prerequisite for forming cholesterol biliary stones, and elevated unconjugated bilirubin in bile is considered the primary cause of pigment biliary stones.Thus, biliary stones are formed as a result of impaired metabolic regulation of the human body. Impaired lipid homeostasis can give rise to cholesterol hypersecretion from biliary canaliculi. Therefore, a high incidence of cholesterol biliary stones compared to pigment biliary stones can be expected in patients with impaired lipid homeostasis. MATERIAL AND METHODS This prospective study with 85 patients admitted to the tertiary health centre with diagnosis of biliary stones between 2018-2020. An observational analysis was done to assess the correlation between biliary stones and lipid profile level and establish a relationship between dyslipidaemia and the occurrence of biliary tract stones. RESULTS A total of 85 patients were included in the study of which majority of the patients were females. Majority of the patients were diagnosed with cholelithiasis (80%). Of 68 patients with cholelithiasis and 17 with choledocholithiasis, 58.82% (40) and 29.41% (5) had abnormal LDL cholesterol, respectively. The difference was significant, with a P-value of 0.029 suggesting a higher instance of LDL abnormality in patients with cholelithiasis. CONCLUSION As noted, a higher number of patients with cholelithiasis and choledocholithiasis have abnormal lipid profile. The incidence of raised LDL cholesterol was more pronounced in those with cholelithiasis. Mean levels of HDL-cholesterol were higher in the cholelithiasis group, whereas VLDL cholesterol levels were statistically higher in those with choledocholithiasis. [ABSTRACT FROM AUTHOR]

Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and stone extraction is the treatment of choice for choledocholithiasis, reaching a successful clearance of the common bile duct (CBD) in up to 90% of the cases. Endoscopic ultrasound (EUS) has the best diagnostic accuracy for CBD stones, its sensitivity and specificity range being 89–94% and 94–95%, respectively. Traditionally seen as two separate entities, the two worlds of EUS and ERCP have recently come together under the new discipline of bilio-pancreatic endoscopy. Nevertheless, the complexity of both EUS and ERCP led the European Society of Gastrointestinal Endoscopy to identify quality in endoscopy as a top priority in its recent EUS and ERCP curriculum recommendations. The clinical benefits of performing EUS and ERCP in the same session are several, such as benefiting from real-time information from EUS, having one single sedation for both the diagnosis and the treatment of biliary stones, reducing the risk of cholangitis/acute pancreatitis while waiting for ERCP after the EUS diagnosis, and ultimately shortening the hospital stay and costs while preserving patients’ outcomes. Potential candidates for the same session approach include patients at high risk for CBD stones, symptomatic individuals with status post-cholecystectomy, pregnant women, and those unfit for surgery. This narrative review discusses the main technical aspects and evidence from the literature about EUS and ERCP in the management of choledocholithiasis. [ABSTRACT FROM AUTHOR]

Biliary endoscopy is underutilized by interventional radiologists and has the potential to become an effective adjunctive tool to help both diagnose and treat a variety of biliary pathology. This is particularly true in cases where endoscopic retrograde cholangiopancreatography fails or is not feasible due to surgically altered anatomy. Both preoperative clinical and technical procedural factors must be taken into consideration prior to intervention. In this article, clinical evaluation, perioperative management, and procedural techniques for percutaneous biliary endoscopy are reviewed. [ABSTRACT FROM AUTHOR]

Intrahepatic and extrahepatic lithiasis, a condition characterized by the presence of stones in the liver and bile ducts, is a common disease in Asia, particularly in East and Southeast Asia. We report a case with laparoscopic exploration of the common bile duct using a flexible cholangioscope and modified trans-common bile duct tunnel for hepatolithiasis combined with the dilated common bile duct. A 35-year-old male patient has had chronic epigastric and right upper quadrant pain. The common bile duct was 11 mm dilated, and hepatolithiasis was also present, according to an upper abdomen MRI. The largest stone measured between 14 and 21 mm. A modified trans-common bile duct tunnel from the abdominal wall into the common bile duct was used in a laparoscopic procedure to examine the common bile duct. Complications during the procedure or following it were not present. The procedure took 120 min, and the blood loss was about 50 ml. The patient was discharged on the sixth postoperative day, and a follow-up visit one month later revealed that single-session stone clearance had been accomplished. Laparoscopic exploration of the common bile duct using a cholangioscope and modified trans-choledochal tube is applicable in selected patients and can be effectively and safely used to treat hepatolithiasis combined with the dilated common bile duct. In this case, we present an innovative approach for hepatolithiasis when combined with dilated common bile duct. • Intrahepatic and extrahepatic lithiasis are common in East and Southeast Asia. • Modified trans-choledochal tube utilizing ShileyTM Hi-Lo Cuffed endotracheal tube • Lap CBD exploration is suitable for treating hepatolithiasis with dilated CBD. [ABSTRACT FROM AUTHOR]

Background/Aims: The aim of this study is to predict cases where the clearance of the biliary system from stones at the initial endoscopic retrograde cholangiopancreatography (ERCP) might be of value for better risk-stratifying patients. We attempted to identify factors that are associated with a higher failure rate of clearing the biliary system on the index ERCP. Patients and Methods: This is a retrospective study from January 2008 to January 2015. All patients with bile duct stones confirmed on ERCP were included in this study. Patients who had prior attempts of bile duct stone extraction were excluded. Results: A total of 554 ERCPs were performed to extract biliary duct stones from 426 patients. The mean age was 46.3 years and 41.7% were males. The group where the index ERCP did not clear the biliary system tended to be older (50.4 vs. 45.2 years, P = 0.03). On multivariate analysis, the presence of fever (OR 4.64; 95% CI, 1.66–12.79), a larger number of filling defects (OR 1.34; 95% CI, 1.13–1.93), presence of a stricture distal to a stone (OR 4.63; 95% CI, 1.36–15.78), the use of an extraction basket (OR 3.23; 95% CI, 1.56–6.74), and/or mechanical lithotripsy (OR 3.05; 95% CI, 1.10–8.49) were all associated with a lower odds of clearing the biliary system. The use of an extraction balloon was associated with the success of clearing the biliary system (99.7% vs. 77.4%, P < 0.01) and a lower odds of failing (OR 0.01; 95% CI, 0.00–0.08) on multivariate analysis. Conclusion: A few of the characteristics that are found on cholangiography at the index ERCP could be used to identify patients that might require more than one ERCP to clear the biliary system from stones.

Purpose: To evaluate the efficacy and safety of percutaneous transhepatic endoscopic holmium laser biliary lithotripsy (PTBL) to treat recurrent cholangitis due to intra/extrahepatic stones, in patients not candidate for traditional endoscopic treatment. Materials and methods: We retrospectively evaluated 28 patients (M:F = 19:9, mean age = 65 years, SD = 14) undergoing 43 PTBL for stone-related recurrent cholangitis from January 1, 2012 to January 31, 2019 in a single academic center. Data collected included demographics, location and number of stones, clinical success after one (primary) or more than one (secondary) PTBL, procedure time, duration of hospital stay, number of retreatments and post-procedural complications. Clinical success was defined as the resolution of cholangitis at 30-day follow-up. Results: PTBL were successful for 23/28 (82%) patients, 16 (57%) with one and 7 (88%) with repeat procedures. The remaining 5 (18%) patients were finally treated with surgery (3, 11%) or further antibiotics (2, 7%). PTBL were performed to treat intrahepatic stones (22 treatments, 51%), extrahepatic (14, 33%), and both intra/extrahepatic (7, 16%). One to three stones were found in 12/43 (28%) PTBL, more than three in 31/43 (72%). Single PTBL was performed in 20/28 (71%) patients, two in 3/28 (11%), three in 3/28 (11%), and four in 2/28 (7%). Median procedure duration was 115 (29–210, 95% CI 101–129) minutes; median hospital stay was 5.5 (2–42) days. The only major complication was the breakage of a guidewire tip, surgically retrieved; minor complications included one aspiration pneumonia and three instances of intrahepatic hemorrhage, treated conservatively. Conclusions: PTBL was clinically successful in the 82% of patients not candidate for endoscopic treatment, with a low complication rate. [ABSTRACT FROM AUTHOR]

This case report describes an 8‐year‐old girl who underwent a segmental LT for a primary diagnosis of citrullinemia at the age of 12 months. She presented with cholangitis secondary to stenosis of the biliary‐enteric anastomosis. MRI revealed dilatation of intrahepatic bile ducts associated with multiple stones. An endoscopic approach failed to decompress the bile ducts and remove the stones. A percutaneous approach was then undertaken. After placement of a temporary external biliary drain for 12 days, a 26 French sheath was placed to access the bile ducts. Using a 14Fr flexible cystoscope, 80%‐90% of the biliary stones were removed. This was followed by antegrade balloon dilatation of the biliary‐enteric anastomosis. Two months later, the procedure was repeated, resulting in complete clearance of the biliary stones. An internal‐external biliary drain was maintained in placed for 10 months. The patient has been asymptomatic, with no evidence of stone recurrence for 13 months after drain removal. Percutaneous biliary stone removal is commonly performed in adults with non‐transplanted livers, especially in complex cases, and has also been shown to be successful in the pediatric population. However, it is rarely reported in transplanted livers in adults, and to the best of our knowledge, no pediatric cases have been reported. This case illustrates that this technique can be successfully utilized in pediatric LT patients. [ABSTRACT FROM AUTHOR]

Background: Standard endoscopic treatment might fail to treat biliary stone disease. Here, we investigated the efficacy and safety of recently introduced digital single-operator video cholangioscopy (SOVC) for the treatment of difficult biliary stones.Methods: Digital SOVC procedures, performed in two tertiary referral centers between 2015 and 2018, were retrospectively analyzed. Only patients with a previous failure of endoscopic standard treatment and a SOVC-based biliary stone treatment using electrohydraulic lithotripsy (EHL) or laser lithotripsy (LL) were included. The primary endpoint was to evaluate the stone removal rate per procedure and per patient.Results: In total, 75 examinations with a digital SOVC-assisted biliary stone treatment, performed in 60 patients, were identified. Biliary stones were mainly located extrahepatic (64%) and less frequently intrahepatic (36%). The median stone size was 20 mm (interquartile range [IQR]: 10-25 mm) and the median stone number was 1 (IQR: 1-2). Digital SOVC-based treatment of biliary stone disease was successful in 95% of patients and 15% needed at least two treatment sessions. Evaluated per procedure, a complete stone removal was accomplished in 67% of all examinations (including initial and repeated procedures), while an incomplete stone removal was observed in 33% of cases. The per procedure analyzes revealed that the success rates for a complete stone removal were similar between LL and EHL (66% vs. 68%; p = 0.87). Complications, such as postinterventional cholangitis and pancreatitis occurred in 16% of examinations; however, except from one case, all were mild or moderate and no procedure-associated mortality occurred.Conclusions: Digital SOVC-assisted biliary stone treatment is highly effective even in cases with difficult biliary stones and might be considered the new standard of care for these patients. Furthermore, mild up to moderate complications were intermittently observed which might document the complexity of our included cases. [ABSTRACT FROM AUTHOR]

Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and stone extraction is the treatment of choice for choledocholithiasis, reaching a successful clearance of the common bile duct (CBD) in up to 90% of the cases. Endoscopic ultrasound (EUS) has the best diagnostic accuracy for CBD stones, its sensitivity and specificity range being 89–94% and 94–95%, respectively. Traditionally seen as two separate entities, the two worlds of EUS and ERCP have recently come together under the new discipline of bilio-pancreatic endoscopy. Nevertheless, the complexity of both EUS and ERCP led the European Society of Gastrointestinal Endoscopy to identify quality in endoscopy as a top priority in its recent EUS and ERCP curriculum recommendations. The clinical benefits of performing EUS and ERCP in the same session are several, such as benefiting from real-time information from EUS, having one single sedation for both the diagnosis and the treatment of biliary stones, reducing the risk of cholangitis/acute pancreatitis while waiting for ERCP after the EUS diagnosis, and ultimately shortening the hospital stay and costs while preserving patients’ outcomes. Potential candidates for the same session approach include patients at high risk for CBD stones, symptomatic individuals with status post-cholecystectomy, pregnant women, and those unfit for surgery. This narrative review discusses the main technical aspects and evidence from the literature about EUS and ERCP in the management of choledocholithiasis.

Background Sickle cell disease (SCD) is a prevalent genetic disorder in the Middle East, particularly in Oman, leading to significant morbidity. It is caused by a mutation in the gene encoding hemoglobin (Hb) molecules, resulting in the formation and polymerization of hemoglobin S (HbS), which subsequently leads to hemolysis. Chronic hemolysis in SCD patients often results in various complications, including increased bilirubin levels in the gallbladder and the formation of pigmented biliary stones, which may obstruct the biliary tract system. In such cases, endoscopic retrograde cholangiopancreatography (ERCP) is often employed as a diagnostic and therapeutic tool to manage biliary complications. Objectives and rationale Considering the lack of studies on the Omani population with SCD, our study aims to determine the incidence of biliary stone formation in SCD patients undergoing ERCP and identify associated risk factors. Subjects and methods This retrospective study included 79 SCD patients aged over 12 years who underwent ERCP at Sultan Qaboos University Hospital, Muscat, Oman, between January 2010 and January 2023. Patient data were extracted from medical records. Continuous variables were analyzed using mean and standard deviation calculations, with independent sample t-tests for mean comparisons. The chi-square test assessed associations between categorized variables, with a p-value of ≤0.05 denoting statistical significance. Results The prevalence of choledocholithiasis in SCD patients undergoing ERCP was 67.1%. The incidence was higher in females (68.9%) than males (65.9%), in patients aged 12-29 (71.2%) compared to those aged ≥29 (59.3%), in patients with SCD (70.6%) versus sickle cell thalassemia (66.1%), and in those who had undergone gallbladder removal (80.0%) compared to those who did not (61.3%). Prevalence was also higher in patients not using hydroxyurea and folic acid (70.6% and 84.6%, respectively); however, chi-square analysis showed no significant association (p-value > 0.05). Additionally, t-test comparisons of HbS and HbF levels showed no significant differences. Conclusion This study documents a high prevalence of choledocholithiasis (67.1%) in SCD patients undergoing ERCP. Although the prevalence is notable, the examined risk factors did not show a significant association with stone formation., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Al Shamousi et al.)

Background/Aims: The aim of this study is to predict cases where the clearance of the biliary system from stones at the initial endoscopic retrograde cholangiopancreatography (ERCP) might be of value for better risk-stratifying patients. We attempted to identify factors that are associated with a higher failure rate of clearing the biliary system on the index ERCP. Patients and Methods: This is a retrospective study from January 2008 to January 2015. All patients with bile duct stones confirmed on ERCP were included in this study. Patients who had prior attempts of bile duct stone extraction were excluded. Results: A total of 554 ERCPs were performed to extract biliary duct stones from 426 patients. The mean age was 46.3 years and 41.7% were males. The group where the index ERCP did not clear the biliary system tended to be older (50.4 vs. 45.2 years, P = 0.03). On multivariate analysis, the presence of fever (OR 4.64; 95% CI, 1.66–12.79), a larger number of filling defects (OR 1.34; 95% CI, 1.13–1.93), presence of a stricture distal to a stone (OR 4.63; 95% CI, 1.36–15.78), the use of an extraction basket (OR 3.23; 95% CI, 1.56–6.74), and/or mechanical lithotripsy (OR 3.05; 95% CI, 1.10–8.49) were all associated with a lower odds of clearing the biliary system. The use of an extraction balloon was associated with the success of clearing the biliary system (99.7% vs. 77.4%, P < 0.01) and a lower odds of failing (OR 0.01; 95% CI, 0.00–0.08) on multivariate analysis. Conclusion: A few of the characteristics that are found on cholangiography at the index ERCP could be used to identify patients that might require more than one ERCP to clear the biliary system from stones. [ABSTRACT FROM AUTHOR]

Background and study aims As life expectancy increases worldwide, so does the prevalence of biliary tract and pancreatic disorders, resulting in rising demand for invasive procedures such as endoscopic retrograde cholangiopancreatography (ERCP) in the elderly. Few studies have assessed the safety of ERCP in patients 90 years and older, particularly among the Hispanic population. The primary aim of this study was to determine the technical success and adverse events (AEs) associated with ERCP in patients 90 years of age or older in comparison to a younger cohort of patients. Patients and methods A retrospective analysis of all ERCPs done at our institution from 2012 to 2018 was performed. Three hundred ERCPs in patients < 90 years old and all 28 ERCPs done in patients ≥ 90 years old were included in the analysis. Results ERCPs were successfully completed in 96.4% of patients > 90 years old and 96.3% of the < 90-year-old cohort (realtive risk [RR] 1.00, confidence interval 0.92-1.07). There was no difference in the rate of periprocedural AEs. Post-ERCP AEs occurred in 7.1% and 3.0% in patients aged < 90 and > 90 years, respectively (RR 2.38, 0.54-10.48). No deaths were directly attributed to the procedure; however, inpatient mortality was higher in the group aged > 90 years. Conclusions ERCP is safe and effective in nonagenarian patients, and advanced age should not be considered an independent risk factor for AEs nor a contraindication for the procedure., Competing Interests: Conflict of Interest The authors declare that they have no conflict of interest., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Other than rejection, hepatic artery and portal vein thrombosis are the most common complications in the immediate postoperative period with hepatic arterial thrombosis more common and more devastating. Hepatic artery stenosis is more common 1 month after transplantation, whereas portal and hepatic vein stenosis is more often seen as a late complication. Ultrasound is the first-line imaging examination to diagnose vascular complications with contrast-enhanced CT useful if ultrasound findings are equivocal. MR cholangiography is often most helpful in diagnosing bile leaks, biliary strictures, and biliary stones., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objectives: Advanced ERCP techniques (AETs) for difficult biliary stones include peroral cholangioscopy (POC) with electrohydraulic/laser lithotripsy (EHL/LL), endoscopic papillary large balloon dilation (EPLBD) and mechanical lithotripsy (ML). We assess the efficacy of AETs. Methods: A retrospective query for AETs. Primary outcome: Complete duct clearance. Secondary outcome: Complete duct clearance by technique. Statistical Analysis version 9.3 (SAS Inc., Cary, NC). Results: From 1/00 to 10/12, 349 patients were identified of which 222 (80% had prior ERCPs) had AETs. 211 with sufficient follow-up underwent 295 ERCPs; 280 of which were AET’s. Index AETs: POC with EHL/LL (n = 46/211, 22%), ML (n = 84/211, 40%), EPLBD with mean balloon size of 11.5 ± 1.7 mm (n = 39/211, 18%) and combination AETs (n = 42/211, 20%). Stone characteristics: 76% had ≥1 stone, 81% extrahepatic and 32% had strictures. Number of stones (mean 2.5 and range 1-20) did not differ among groups. EPLBD had higher percentage (95%) of extrahepatic stones (p = .0003). The ‘Combination’ and ‘POC’ groups had larger stones (mean 17.7 mm ±6.4 and 16.8 mm ±6.1, respectively; p < .001). Complete clearance: 209/211 (99%) at index AET 167/211 (79%) or after mean of 2.5 ± 0.7 AETs in 42/211 (20%). Partial clearance: 2/211 (1%). Clearance at index AETs was higher with EPLBD (90%, p = .014). Adverse Events: 7/280 (2.5%). Conclusions: AETs achieved clearance in 99%. EPLBD had higher clearance at index AET likely owing to higher extrahepatic stones. Larger stones, but not number, were associated with increased combination AETs and total ERCPs. [ABSTRACT FROM AUTHOR]

Background/Aims: We aimed to evaluate the efficacy and safety of Spyglass-guided electrohydraulic lithotripsy (EHL) for difficult common bile duct stones (CBD) not amenable to conventional endoscopic therapy. Design: A retrospective study evaluating the efficacy of Spyglass-guided EHL in treating difficult CBD stones, in a single tertiary care center. Patients and Methods: All patients who underwent Spyglass-guided EHL from 2012 to 2013 were compared with a historical cohort who had ECSWL. Results: A total number of 13 patients underwent Spyglass-guided EHL, 8 (61.5%) of them were males. The mean age was 46.5 ± 5.6 years. Bile duct clearance was achieved in 13 (100%) of them. Seventy-six percent required only one Endoscopic Retrograde Cholangiopancreatography (ERCP) to clear the CBD, 7.7% required two ERCPs, and 15.4% required three ERCPs. Adverse effects (cholangitis) occurred in one patient (10%), whereas only 30 patients (64.4%) of the ESWL group had complete CBD stone clearance. Thirty-seven percent required one ERCP to clear the CBD, 35.6% required two ERCPs, and 20% required three ERCPs. Adverse effects happened in seven (15.5%) patients, where five (11%) had cholangitis and two (4.4%) had pancreatitis. Conclusion: Although a retrospective design with a small sample size, we concluded that Spyglass-guided EHL is an effective procedure in treating difficult CBD stones.

Objectives: Clinical evidence regarding radiological–endoscopic management of intrahepatic bile duct stones is currently lacking. Our aim is to report our 18-year experience in combined radiological–endoscopic management of intrahepatic difficult bile duct stones. Methods: From June 1994 to June 2012, 299 symptomatic patients with difficult bile duct stones were admitted to our institution. Percutaneous transhepatic cholangiography (PTC)/biliary drainage/s was performed, dilating the PTC track to 10 or 16 French within 3–7 days. Afterward we carried out percutaneous transhepatic cholangioscopy (PTCS) with electrohydraulic lithotripsy (EHL) and/or interventional radiology techniques. Follow up was made with clinical/laboratory tests and ultrasound (US). We retrospectively analyzed our radiological–endoscopic approach and reported our technical and clinical outcomes. Results: Complete stone clearance was achieved in 298 patients after a maximum of 4 consecutive sessions. Most patients (64.6%) were treated with PTCS/EHL alone, while the remaining with radiological techniques alone (26%) or a combination of both techniques (13.3%). Recurrence of stones occurred in 45 cases (15%, Tsunoda class III and class IV) within 2 years and were successfully retreated. Major adverse events were: 5 (1.6%) cases of massive bleeding that required embolisation, 2 (0.66%) perforations of the common bile duct and 31 cases (10.3%) of acute cholangitis managed with medical therapy or intervention. Conclusion: After 18 years of experience we demonstrated that our combined radiological–endoscopic approach to ‘difficult bile duct stones‘ may result in both immediate and long-term clearance of stones with a low rate of adverse events. [ABSTRACT FROM AUTHOR]