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A potbelly pig was evaluated for anorexia and icterus. Clinicopathologic abnormalities suggested an active inflammatory hepatobiliary process. Ultrasound and CT of the abdomen revealed an extrahepatic biliary obstruction of the common bile duct (CBD). Surgical exploration and choledochotomy revealed a markedly dilated CBD containing a large volume of intraluminal inspissated biliary material. This case report describes the imaging findings of an extrahepatic biliary obstruction secondary to abscessation within the CBD in a pig., (© 2024 The Authors. Veterinary Radiology & Ultrasound published by Wiley Periodicals LLC on behalf of American College of Veterinary Radiology.)

Endoscopic ultrasound-guided biliary drainage (EUS-BD) is being used increasingly as an alternative treatment for malignant biliary obstruction (MBO). However, few studies have compared EUS-BD and endoscopic retrograde cholangiopancreatography biliary drainage (ERCP-BD). We searched the PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov databases until 1 November 2020 for studies comparing EUS-BD versus ERCP-BD. The primary outcomes of interest in this study were technical and clinical success. Nine studies involving 634 patients were included in this meta-analysis. Regarding technical and clinical success, there were no significant differences between EUS-BD and ERCP-BD (odds ratio [OR], 0.76; 95% CI: 0.30-1.91; OR, 1.45, 95% confidence interval [CI], 0.66-3.16, respectively). EUS-BD was associated with significantly less reintervention vs ERCP-BD (OR, 0.36, 95% CI, 0.15-0.86). Regarding adverse events, the rates were similar for EUS-BD and ERCP-BD (OR: 0.75, 95% CI, 0.45-1.24). There were no significant differences in the types of adverse events (stent occlusion, stent migration, stent dysfunction, and duration of stent patency) between the two techniques. EUS-BD was associated with lower reintervention rates compared with ERCP-BD, with comparable safety and efficacy outcomes. However, more high-quality randomized trials are required., (Copyright © 2021 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Background: Transient elastography and acoustic radiation force impulse (ARFI) imaging are noninvasive tools for liver stiffness measurement (LSM), which may be influenced by cholestasis., Aim: The aim of the study was to evaluate the performance of transient elastography and ARFI in extrahepatic cholestasis and correlate changes in LSM with biochemical activity., Materials and Methods: A total of 38 patients with extrahepatic cholestasis prospectively underwent transient elastography and ARFI. Changes in LSM by transient elastography/ARFI were evaluated after 1 week of ERCP and correlated with biochemical parameters. The optimal ARFI cutoffs according to stages of clinical interest were analyzed., Results: Biliary obstruction was calcular in 21 (55.3%) and noncalcular in 17 (44.7%) (benign n = 15, malignant n = 2). After 1 week, adequate biliary drainage reduced total bilirubin from 7.7 to 2.2 mg/dL (P < 0.001) which significantly correlated with reduction of LSM by transient elastography from 12.38 ± 6.68 kPa to 8.08 ± 3.21 kPa (P < 0.001), and by ARFI from 1.73 ± 0.51 m/s to 1.56 ± 0.70 m/s (P = 0.014). The LSM percentage change showed a decrease (nonsignificant, P = 0.843) by 25.83% using transient elastography and a significant decrease (P < 0.001) by 18.42% using ARFI in the improved patients. At initial visit, transient elastography positively correlated with ARFI, bilirubin and platelets, also, transient elastography had a positive correlation with ARFI, bilirubin, alkaline phosphatase (ALP), γ-glutamyl transpeptidase (GGT) in follow-up visit. LSM by ARFI (visit 1) negatively correlated with ALT, while in (visit 2), ARFI positively correlated with bilirubin, ALP, GGT and negatively correlated with albumin., Conclusion: The increased LSM in patients with extrahepatic cholestasis is reduced after adequate biliary drainage, implying that increased values are not solely due to liver fibrosis, but due to biliary congestion leading temporarily to increased elasticity., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

The question of when and how to drain a malignant biliary obstruction (MBO), both intrinsic or extrinsic, remains a controversial point among endoscopists. An important factor that influences the decision to drain an MBO or not is if the patient is a surgical candidate or not and, in the former case, if the patients must undergo neoadiuvant chemotherapy or not. Other questions arising during biliary drainage in MBO patients is which type of stent should be chosen, plastic or metal, and if endoscopic biliary sphincterotomy must be performed or not when a stent is placed. The present review attempts to answer these questions and summarizes the optimal approach toward patients with MBO based on the available evidence.

Background/objectives: This paper is part of the international consensus guidelines on chronic pancreatitis, presenting for interventional endoscopy., Methods: An international working group with experts on interventional endoscopy evaluated 26 statements generated from evidence on 9 clinically relevant questions. The Grading of Recommendations Assessment, Development, and Evaluation approach was used to evaluate the level of evidence. To determine the level of agreement, a nine-point Likert scale was used for voting on the statements., Results: Strong consensus was obtained for 15 statements relating to nine questions including the recommendation that endoscopic intervention should be offered to patients with persistent severe pain but not to those without pain. Endoscopic decompression of the pancreatic duct could be used for immediate pain relief, and then offered surgery if this fails or needs repeated endoscopy. Endoscopic drainage is preferred for portal-splenic vein thrombosis and pancreatic fistula. A plastic stent should be placed and replaced 2-3 months later after insertion. Endoscopic extraction is indicated for stone fragments remaining after ESWL. Interventional treatment should be performed for symptomatic/complicated pancreatic pseudocysts. Endoscopic treatment is recommended for bile duct obstruction and afterwards surgery if this fails or needs repeated endoscopy. Surgery may be offered if there is significant calcification and/or mass of the pancreatic head. Percutaneous endovascular treatment is preferred for hemosuccus pancreaticus. Surgical treatment is recommended for duodenal stenosis due to chronic pancreatitis., Conclusions: This international expert consensus guideline provides evidenced-based statements concerning indications and key aspects for interventional endoscopy in the management of patients with chronic pancreatitis., Competing Interests: Declaration of competing interest All authors have no conflict of interest of these consensus guidelines., (Copyright © 2020 IAP and EPC. Published by Elsevier B.V. All rights reserved.)

Anatomical variations of the hepatic artery have been described as responsible for the onset of jaundice or stone formation. We present three cases of intrahepatic stones secondary to a compression of the proximal common bile duct (CBD) by the right hepatic artery (RHA). Three consecutive patients (males, mean age 65 years) with symptoms of cholangitis and intra-hepatic stones admitted between October 2017 and June 2018 with a final diagnosis of CBD compression from the RHA. The three patients underwent ERCP and biliary sphincterotomy with extraction of intra-hepatic stones; after stone removal cholangiograhy showed CBD compression just below the main hepatic confluence which was confirmed to be secondary to RHA compression on subsequent MRI. The patients remained asymptomatic after 12 months mean follow-up. Compression of the CBD by the RHA might be responsible for intra-hepatic stone formation. Endoscopic treatment is feasible and effective on short-term follow-up.

Background: Most patients with distal extrahepatic cholangiocarcinoma have developed jaundice or cholangitis at the time of initial diagnosis, which can delay surgery. We aim to evaluate the actual EB-RFA ablation volume and validated the clinical feasibility of preoperative endobiliary radiofrequency ablation (EB-RFA) for resectable distal extrahepatic cholangiocarcinoma., Methods: The medical records of patients who underwent EB-RFA from July 2016 to June 2017 at a single tertiary academic medical center were reviewed. Inclusion criteria were patients with resectable distal extrahepatic cholangiocarcinoma who required preoperative biliary decompression. Clinical outcomes of EB-RFA were reviewed retrospectively and the surgical specimens were reevaluated., Results: Of the eight patients who required a delayed operation, preoperative EB-RFA was successfully performed without serious complications including peritonitis, hemobilia, or perforation. Although curative resection was attempted in all patients, one patient underwent open and closure due to hepatic metastasis. Seven patients underwent curative surgical resection and the histology revealed that median maximal ablation depth was 4.0 mm (range, 1-6) and median effective ablation length (histological ablation length/fluorosocopic ablation length) was 72.0% (range, 42.1-95.3)., Conclusions: EB-RFA partially ablated human cancer tissue and preoperative EB-RFA might be a safe and feasible in patients with distal extrahepatic cholangiocarcinoma who require a delayed operation. Ablation of the target lesion longer than the estimated length by fluoroscopy may improve the efficacy of EB-RFA., Competing Interests: The authors have declared that no competing interests exist.

Background/aims: Endoscopic retrograde biliary drainage (ERBD) has become a standard procedure in patients with a biliary obstruction. Intraductal ultrasonography (IDUS) has emerged as a new tool for managing extrahepatic biliary diseases. IDUS-directed ERBD can be performed without conventional cholangiography (CC). The goal of this study was to assess the effectiveness and safety of IDUS-directed ERBD compared to CC-directed ERBD in patients with an extrahepatic biliary obstruction., Methods: A total of 210 patients who had undergone IDUS-directed ERBD (IDUS-ERBD, n = 105) and CC-directed ERBD (CC-ERBD, n = 105) between October 2013 and April 2014 were analyzed retrospectively. The primary outcome measure was the procedural success rate. Secondary outcome measures included clinical outcomes, total procedure time, radiation exposure time, and overall complication rates., Results: The total technical success rate of ERBD was 100% (105/105) in the IDUS-ERBD and CC-ERBD groups. Mean procedure time was slightly prolonged in the IDUS-ERBD group than that in the CC-ERBD group (32.1 ± 9.9 minutes vs. 28.4 ± 11.6 minutes, p = 0.023). Mean radiation exposure time was one-third less in the IDUS-ERBD group than that in the CC-ERBD group (28.0 ± 49.3 seconds vs. 94.2 ± 57.3 seconds, p < 0.001). No significant differences in complication rates were detected between the groups., Conclusions: IDUS-ERBD was equally effective and safe as CC-ERBD in patients with an extrahepatic biliary obstruction. Although IDUS-ERBD increased total procedure time, it significantly decreased radiation exposure., Competing Interests: No potential conflict of interest relevant to this article was reported.

Biliary MRI is a relatively new diagnostic test in the arsenal of exploration techniques in biliopancreatic pathology. This is a reproducible and reliable non invasive technique for direct visualization of biliary and pancreatic ducts. This study aims to evaluate the morphological features of major abnormalities and the role of biliary MRI in the etiological diagnosis of cholestatic icteruses. This is a retrospective study of 17 patients conducted in the Imaging Unit of the University Hospital of Fann and of the Principal hospital of Dakar over a period of 4 years and six months (January 2008 at July 2012). All patients underwent MRI (1.5T) according to the standardized protocols for the explored pathology. Only medical records of patients whose diagnosis was established based on laboratory tests and who underwent biliary MRI and surgical exploration were retained. The study involved 5 women and 12 men with a sex ratio of 2.4. The average age of patients was 58 years, ranging between 35 and 81 years. Klatskin tumors were found in 7 patients with infiltrative form in 71% of cases and exophytic form was found in 28% of cases. Cancers of the gallbladder were found in 28% of cases. Cancers in the head of the pancreas accounted for 28% of cases. Major bile duct lithiasis was detected in 5 patients, choledocholithiasis in 60% of cases and a single lithiasis in 40% of cases. All these lesions were responsible for an expansion of intrahepatic bile duct (IHBD). One case of intra and extrahepatic bile ducts dilatation was found without biliopancreatic cause. Biliary MRI is the test of choice for the exploration of cholestatic icteruses. It should be recommended as first-line examination when residual lithiasis is suspected and as second-line examination after ultrasound, when the latter shows a suspected bile ducts tumoral obstruction. Its association with CT scan is the best combination of screening tests for etiologic diagnosis and pre-operative assessment of tumoral biliary obstructions., Competing Interests: Conflits d’intérêts Les auteurs ne déclarent aucun conflit d'intérêt.

Introduction: Biliary obstruction in chronic calcific pancreatitis (CCP) is often caused by inflammatory or fibrotic strictures of the bile duct, carcinoma of head of pancreas or less commonly by compression from pseudocysts. Pancreatic calculi causing ampullary obstruction and leading to obstructive jaundice is extremely rare., Methods: The medical records of all patients with CCP or biliary obstruction who underwent endoscopic retrograde cholangiopancreatography (ERCP) over 4 years between 2010-2014 at Kasturba Medical College, Manipal were analyzed., Results: Five patients of CCP with impacted pancreatic calculi at the ampulla demonstrated during ERCP were identified. All 5 presented with biliary obstruction and were incidentally detected to have CCP when evaluated for the same; 3 patients had features of cholangitis. All the patients were managed successfully by endoscopic papillotomy and extraction of pancreatic calculi from the ampulla with resolution of biliary obstruction., Conclusion: Pancreatic calculus causing ampullary obstruction, though very rare, should be considered as a possibility in patients with CCP complicated by biliary obstruction. Endoscopic therapy is affective in the resolution of biliary obstruction in such patients.

Inspissated bile syndrome (IBS) is a rare neonatal disease. In the majority of cases, it resolves spontaneously and treatment is conservative. Follow-up is recommended with close monitoring of laboratory tests. When IBS does not resolve spontaneously, a catheter can be inserted into the gallbladder for cholangiography, which allows irrigation and drainage. Despite this treatment, some biliary tract obstruction may persist. We report on the case of a 3-month-old infant whose continuous biliary obstruction caused by IBS was successfully managed by interventional radiology with the association of N-acetylcysteine and glucagon. Even as first-line agents, these would allow more rapid clearance of gallstones and prevent infectious complications of indwelling catheters as well as decrease the need for surgery., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Endoscopic ultrasound (EUS)-guided biliary drainage (EUS-BD) is not normally indicated for an obstructed right intrahepatic bile duct (IHBD). The technical feasibility and clinical efficacy of a novel technique of EUS-BD for right IHBD obstruction were evaluated. A total of 11 patients underwent drainage using either a left or a right biliary access route. The causes of obstructive jaundice were cholangiocarcinoma (n = 6), pancreatic cancer (n = 3), gastric cancer (n = 1), and colon cancer (n = 1). After placement of an uncovered metal stent to bridge the obstruction, a hepaticogastrostomy was completed using a covered stent. Mean procedure time was 33.9 ± 10.0 minutes. Technical and functional success were achieved in all patients, and no adverse events occurred. This novel method appears to be safe and effective for right IHBD obstruction., (© Georg Thieme Verlag KG Stuttgart · New York.)

An elderly female was admitted with obstructive jaundice, secondary to an impacted 1.7 cm size stone in distal CBD. Cholangiogram obtained during ERCP revealed dilated biliary system with large, immobile stone at the lower end of CBD. A large size sphincterotomy was performed and stone extraction using biliary balloon / dormia basket attempted which was unsuccessful as the stone was impacted in distal CBD. Therefore, a plastic biliary stent of 9 cm/8.5 french size was inserted successfully to secure the biliary drainage. Patient improved clinically and discharged home on ursodeoxycholic acid. Four weeks later, she presented to emergency department with signs of cholangitis. An emergency ERCP was performed. The stent had migrated up completely into the left intra hepatic duct. In this session, the stone was extracted and biliary drainage secured. Migrated stent was removed later on by another ERCP procedure.

An 11-year-old, neutered female British Shorthair cat was referred with a 4-week history of abdominal pain and vomiting. Abdominal ultrasonography revealed a dilated common bile duct containing a spindle-shaped structure with several reflecting interfaces. Differentials that were considered included an intraluminal foreign body, or helminth parasites within the common bile duct. Surgical exploration of the abdominal cavity demonstrated the presence of two grass awns obstructing the common bile duct. Anomalies of the portal vasculature were noted during surgery and were considered an incidental finding. The clinical signs resolved following surgical removal of the grass awns., (© 2013 American College of Veterinary Radiology.)

Objective: This aim of this study is to determine the risk factors in failed endoscopic retrograde cholangiography (ERC)., Background: Endoscopic treatment is considered the first-line intervention for biliary anastomotic stricture (BAS) after right-lobe living donor liver transplantation with duct-to-duct anastomosis., Methods: A retrospective study was performed on 287 patients who received right-lobe living donor liver transplantation with duct-to-duct anastomosis. The morphology of BAS was defined according to the shape of the distal side of duct-to-duct anastomosis shown on cholangiogram and was categorized into 3 types: pouched, intermediately pouched, and triangular. All cases of ERC were performed by operating surgeons., Results: Fifty-nine patients (20.6%) had BAS and received ERC and balloon dilatation with or without stenting. The success rate was 73.2%. The median number of sessions needed for successful ERC was 3. In the 15 patients with failed ERC, 4 were successfully treated with percutaneous transhepatic biliary drainage and balloon dilatation and 11 underwent conversion hepaticojejunostomy (6 had external percutaneous transhepatic biliary drainage as a temporizing measure). On multivariate analysis, recipient age [odds ratio (OR): 0.922; 95% confidence interval (CI): 0.85-1.00; P = 0.049], operation time (OR: 1.007; 95% CI: 1.001-1.013; P = 0.025), and morphology of stricture (OR: 6.722; 95% CI: 1.31-34.48; P = 0.022) were independent risk factors associated with failed ERC. The success rates for the 3 types of BAS-pouched, intermediately pouched, and triangular-were 42.9%, 63.6%, and 88.9%, respectively (P = 0.021). Association was found between bile leak and pouched BAS (P = 0.008)., Conclusions: ERC is highly effective in treating BAS. A success rate of 73%, the highest ever reported, has been achieved. Morphology of stricture is associated with outcome of ERC. Radiological or surgical intervention should be considered for patients with pouched BAS after endoscopic treatment fails for the first time.

Objective: Endoscopic placement of covered self-expandable metal stent (SEMS) has gained popularity in the management of benign biliary strictures (BBS). The existing SEMS has been designed primarily to palliate malignant biliary obstruction and has a high frequency of stent migration, difficulty in retrieval and stricture recurrence after stent removal. This study aimed to design a novel retrievable SEMS dedicated to the treatment of extrahepatic BBS and evaluate its clinical efficacy and safety., Methods: A short fully covered SEMS (FCSEMS) with a retrieval lasso was designed for the specific treatment of BBS. A total of 45 patients with segmental extrahepatic BBS were included in this study. The stent was placed entirely inside the bile duct with only the retrieval lasso extending from the papilla. The stents were recommended to be in situ for 6 to 12 months before removal., Results: The FCSEMS was successfully placed in all 45 patients. In all, 33 patients had their FCSEMS successfully removed after a mean period of 8.6 ± 3.7 (range 2-15.5) months. Stent migration occurred in 9.1% of the patients. During a mean follow-up of 18.9 months after stent removal, recurrent stricture was found in 2 (6.1%) patients and was successfully treated with a second FCSEMS. Overall, the strictures resolved in 30/33 (90.9%) patients., Conclusions: Intraductal placement of a short FCSEMS is suitable for the treatment of segmental extrahepatic BBS. This new removable design offered prolonged stenting and drainage for BBS for up to one year with minimal complications., (© 2013 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd.)

Jaundice corresponds to elevated bilirubin- levels, whereat one has to distinguish between direct and indirect serum-bilirubin. In the present Mini Review causes and differential diagnosis of jaundice are outlined. Ultrasound-diagnostic plays a major role in identifying intrahepatic or extrahepatic jaundice. Attention is given to the differential diagnosis of elevated liver enzymes in presence of jaundice, pointing out the distinction between hepatocellular and cholestatic parameters as well as the differentiation in acute or chronic increase. Moreover, the consequences of liver enzyme elevations including further diagnostic procedures, are highlighted. Finally, possibilities and limitations of modern diagnostic tests for liver fibrosis are briefly overviewed.

Background: Extrahepatic bile duct injury from blunt abdominal trauma is severe and very rare. However, no definitive treatment has been proposed for biliary strictures caused by blunt abdominal trauma., Methods: Four cases of late biliary stricture following the initial repair of the liver rupture because of the blunt abdominal trauma are described. The diagnosis, treatment, and outcome of the complications are discussed., Results: One patient received bile drainage because of biliary peritonitis on admission. He underwent a right hepatectomy and a Roux-en-Y anastomosis on the left bile duct because of right lobar atrophy 3 months later. Cholangiojejunostomy was performed in the other three patients using the Hepp-Couinaud technique. The patients were followed for 5-37 months, yielding no recurrence of the biliary stricture or cholangitis., Conclusion: Surgical intervention should be used after the failure of repeating endoscopic stenting or percutaneous drainage. The Hepp-Couinaud technique could provide a wide and accurate leakproof mucosa-to-mucosa anastomosis that is responsible for excellent results.

Aim: To report the largest patient cohort study investigating the diagnostic yield of intraductal ultrasound (IDUS) in indeterminate strictures of the common bile duct., Methods: A patient cohort with bile duct strictures of unknown etiology was examined by IDUS. Sensitivity, specificity and accuracy rates of IDUS were calculated relating to the definite diagnoses proved by histopathology or long-term follow-up in those patients who did not undergo surgery. Analysis of the endosonographic report allowed drawing conclusions with respect to the T and N staging in 147 patients. IDUS staging was compared to the postoperative histopathological staging data allowing calculation of sensitivity, specificity and accuracy rates for T and N stages. The endoscopic retrograde cholangio-pancreatography and IDUS procedures were performed under fluoroscopic guidance using a side-viewing duodenoscope (Olympus TJF 160, Olympus, Ltd., Tokyo, Japan). All procedures were performed under conscious sedation (propofol combined with pethidine) according to the German guidelines. For IDUS, a 6 F or 8 F ultrasound miniprobe was employed with a radial scanner of 15-20 MHz at the tip of the probe (Aloka Co., Tokyo, Japan)., Results: A total of 397 patients (210 males, 187 females, mean age 61.43 ± 13 years) with indeterminate bile duct strictures were included. Two hundred and sixty-four patients were referred to the department of surgery for operative exploration, thus surgical histopathological correlation was available for those patients. Out of 264 patients, 174 had malignant disease proven by surgery, in 90 patients benign disease was found. In these patients decision for surgical exploration was made due to suspicion for malignant disease in multimodal diagnostics (computed tomography scan, endoscopic ultrasound or magnetic resonance imaging). Twenty benign bile duct strictures were misclassified by IDUS as malignant while 14 patients with malignant strictures were initially misdiagnosed by IDUS as benign resulting in sensitivity, specificity and accuracy rates of 93.2%, 89.5% and 91.4%, respectively. In the subgroup analysis of malignancy prediction, IDUS showed best performance in cholangiocellular carcinoma as underlying disease (sensitivity rate, 97.6%) followed by pancreatic carcinoma (93.8%), gallbladder cancer (88.9%) and ampullary cancer (80.8%). A total of 133 patients were not surgically explored. 32 patients had palliative therapy due to extended tumor disease in IDUS and other imaging modalities. Ninety-five patients had benign diagnosis by IDUS, forceps biopsy and radiographic imaging and were followed by a surveillance protocol with a follow-up of at least 12 mo; the mean follow-up was 39.7 mo. Tumor localization within the common bile duct did not have a significant influence on prediction of malignancy by IDUS. The accuracy rate for discriminating early T stage tumors (T1) was 84% while for T2 and T3 malignancies the accuracy rates were 73% and 71%, respectively. Relating to N0 and N1 staging, IDUS procedure achieved accuracy rates of 69% for N0 and N1, respectively., Limitations: Pre-test likelihood of 52% may not rule out bias and over-interpretation due to the clinical scenario or other prior performed imaging tests., Conclusion: IDUS shows good results for accurate diagnostics of bile duct strictures of uncertain etiology thus allowing for adequate further clinical management.

The aim of endoscopic therapy of chronic pancreatitis (CP) is to treat pain by draining the pancreatic duct or managing loco-regional complications. Recent decennia were characterized by continuous improvement of endoscopic techniques and devices, resulting in a better clinical outcome. Novel developments now also provide the opportunity to endoscopically treat refractory CP-related complications. Especially suboptimal surgical candidates could potentially benefit from these new developments, consequently avoiding invasive surgery. The use of fully covered self-expandable metal stents (SEMS) has been explored in pancreatic and CP-related biliary duct strictures, resistant to conventional treatment with plastic endoprotheses. Furthermore, endosonography-guided transmural drainage of the main pancreatic duct via duct-gastrostomy is an alternative treatment option in selected cases. Pancreatic pseudocysts represent an excellent indication for endoscopic therapy with some recent case series demonstrating effective drainage with the use of a fully covered SEMS. Although results of these new endoscopic developments are promising, high quality randomized trials are required to determine their definite role in the management of chronic pancreatitis.

We describe a 99-day old girl with inspissated bile syndrome (IBS) unresponsive to treatment with oral ursodeoxycholic acid. We performed a pure laparoscopic 2-stage procedure, consisting of cholecystostomy and insertion of an indwelling balloon catheter for local ursodeoxycholic acid flushing for 13 consecutive days. Subsequently, the cholecystostomy was removed, preserving the gallbladder using the same laparoscopical approach when bilirubin values returned to normal and bile duct obstruction was no longer detectable radiologically. This is the first report of an exclusively laparoscopic management of IBS., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Covered or uncovered self expandable metallic stents (SEMS) placed in patients with malignant biliary obstruction can occlude in 19-40 %, but optimal management is unclear., Aim: We sought to summarize current evidence regarding management of occluded SEMS in patients with malignant biliary obstruction., Methods: Two investigators independently searched Pubmed, Embase, and Web of Science using pre-defined search criteria, and reviewed bibliographies of included studies. Data were independently abstracted by two investigators, and analyzed using RevMan. We compared strategies of second SEMS versus plastic stents with respect to the following outcomes: rate of second stent re-occlusion, duration of second stent patency, and survival., Results: Ten retrospective studies met inclusion criteria for the systematic review. Management options described were placement of an uncovered SEMS (n = 125), covered SEMS (n = 106), plastic stent (n = 135), percutaneous biliary drain (n = 7), mechanical cleaning (n = 18), or microwave coagulation (n = 7). Relative risk of re-occlusion was not significantly different in patients with second SEMS compared to plastic stents (RR 1.24, 95 % CI 0.92, 1.67, I(2) = 0, p 0.16). Duration of second stent patency was not significantly different between patients who received second SEMS versus plastic stents (weighted mean difference 0.46, 95 % CI -0.30, 1.23, I(2) = 83 %). Survival was not significantly different among patients who received plastic stents versus SEMS (weighted mean difference -1.13, 95 % CI -2.33, 0.07, I(2) 86 %, p = 0.07)., Conclusions: Among patients with malignant biliary obstruction and occluded SEMS, available evidence suggests a strategy of placing a plastic stent may be as effective as second SEMS. Limitations of these findings were that all studies were retrospective and heterogeneity between studies was detected for two of the outcomes.

Background and Aim: Although reports on endosonography-guided biliary drainage (ESBD) have been increasing, only a few reports on deployment of a self-expandable metal stents (SEMS) have been reported. The aim of the present study was to evaluate the safety and efficacy of SEMS deployment in ESBD., Methods: Of 42 patients who underwent ESBD during the period from January 2007 to August 2011, 21 patients with unresectable malignant biliary obstruction in whom SEMS deployment had been attempted were included. In the first session, a plastic stent or SEMS was placed in a bilio-enteric anastomosis (BEA) method. SEMS was deployed with the one-step technique or with replacement of a plastic stent with a SEMS in the second session. The technical success, early and late complications, and stent patency of SEMS were evaluated., Results: One-step SEMS deployment was attempted in seven patients, and SEMS was deployed with stent exchange in 14. SEMS deployment was successful in all patients without any complications. Finally, SEMS was placed in a BEA method in 16 patients (extrahepatic bile duct, 13; intrahepatic bile duct, three), and with antegrade deployment in five. Late complications occurred in three patients who underwent deployment of SEMS in a BEA method (stent obstruction in two and reflux cholangitis in one). The mean stent patency period was 433 days., Conclusions: As SEMS deployment in ESBD is safe and provides long stent patency, a SEMS seems to be the stent of choice in ESBD for patients with unresectable malignant biliary obstruction in whom long survival is expected., (© 2012 The Authors. Digestive Endoscopy © 2012 Japan Gastroenterological Endoscopy Society.)

Portal biliopathy refers to biliary abnormalities secondary to extrahepatic portal vein obstruction and cavernous transformation and is caused by vascular compression from peribiliary collateral vessels, producing segmental stenoses of the common bile duct and abnormal liver function test (LFT) results. A review of imaging studies yielded 18 patients with abnormal LFT results, biliary tract dilatation, and extrahepatic portal vein obstruction with cavernous transformation. Multidetector computed tomography and magnetic resonance imaging showed biliary stenotic segments in 11 patients secondary to extrinsic compression from enlarged peribiliary collaterals. Clinical and imaging follow-up demonstrated improvement in LFT results with minimal decrease in bile duct dilatation, eliminating percutaneous or endoscopic biliary intervention., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Patient with giant rapidly growing liver hemangioma who carried out right hemihepatectomy is reported. The feature if this case is choledocholithiasis after liver resection followed by its rare complication (spontaneous biloma) in 6 years after surgery. Minimally invasive procedures (percutaneous drainage, endoscopic papillotomy and stenting) eliminated each of bile collection and cause of biliary obstruction without surgical intervention.

Background: Although reports on endosonography-guided biliary drainage (ESBD) have been increasing, only a few discuss deployment of a self-expandable metal stent (SEMS) in the first session., Objective: To evaluate the safety and efficacy of ESBD with the one-step placement of a newly designed fully-covered SEMS., Patient and Methods: Five patients with malignant biliary obstruction in whom one-step placement of an anti-migration designed SEMS in the first session of ESBD had been attempted between January 2007 and October 2009 were included in this study. Main outcome measurements were technical and clinical successes, early complications, and short-term results., Results: ESBD was attempted to bridge the extrahepatic bile duct and the duodenum and one-step SEMS placement was successful in all cases. There were no early complications related to ESBD and excellent biliary decompression was obtained in all cases. SEMS dysfunction such as stent migration and occlusion was not seen during the follow-up period (mean follow-up 138 days, range 102-184 days)., Conclusion: One-step placement of a fully-covered SEMS in ESBD is possibly a safe and effective treatment for biliary obstruction.

Purpose: This study compared the diagnostic accuracy of magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasonography (EUS) in evaluating the cause of extrahepatic bile duct dilatation., Materials and Methods: Forty-five patients (26 men, mean age 57 years) with extrahepatic biliary dilatation, as shown by transabdominal ultrasound, with or without elevated biliary and pancreatic serum indices, were prospectively studied with MRCP and EUS between September 2007 and October 2008. EUS and MRCP were performed within no more than 24 h of each other to reduce the possibility of changes due to stone migration. Image analysis was carried out in a double-blind fashion., Results: MRCP had 88.9% diagnostic accuracy, 91.9% sensitivity and 75% specificity, with 94.4% positive predictive value and 66.7% negative predictive value. EUS had 93.3% diagnostic accuracy, 97.3% sensitivity and 75% specificity; the positive and negative predictive values were 94.7% and 85.7%, respectively., Conclusions: MRCP and EUS do not show significant statistical differences in diagnostic accuracy. MRCP is an accurate, noninvasive modality in the study of extrahepatic biliary pathology. EUS is especially reliable in patients with extrahepatic biliary obstruction caused by endoluminal sludge.

We report the case of a 78-year-old male patient with obstructive jaundice due to a pancreatic head neoplasm. The patient's general condition did not permit an endoscopic approach and the presence of diffuse liver metastases prohibited hepatic puncture for percutaneous biliary drainage, therefore the transcolecystic transperitoneal approach was decided to be the safest decompression route. Through a gallbladder access, a Viabil-covered stent with a mesh extension was placed in the distal common bile duct, without complications. The patient died 8 months later without signs of stent dysfunction or necessity of reintervention. Transcholecystic transperitoneal access is a safe option when diffuse liver metastases prohibit the transhepatic approach, even in cases where placement of a covered stent is considered necessary.

Purpose: To evaluate the technical success and clinical effectiveness of percutaneous transcholecystic placement of self-expanding metallic stents for the treatment of malignant obstructions of the common bile duct., Materials and Methods: Fifteen patients with malignant obstruction at the lower level of the common bile duct not amenable to surgery were retrospectively reviewed in this study. In all patients, conventional biliary drainage via transhepatic peripheral duct access or endoscopic retrograde biliary drainage (ERBD) were technically difficult or deemed so at imaging evaluation. The causes of obstruction were cholangiocarcinoma (n = 7), pancreatic carcinoma (n = 6), and metastatic lymphadenopathy from gastric carcinoma in the hepatoduodenal ligament (n = 2). Following percutaneous cholecystostomy, a 5-F catheter was inserted into the common bile duct, duodenum, or the anastomosed jejunum through the cystic duct and the malignant obstruction and metallic stents were placed. The technical success was defined as the removal of the drainage tube after the stent placement for the obstruction. The mean follow-up period was 25.4 months., Results: Sixteen stents were placed in 15 patients. Technical success was achieved in all patients (100%) without major complications. Minor complications included controllable pain or self-limited hemobilia in six of the 15 patients (40%). Lower bilirubin levels compared with those before the procedure were achieved in 14 of the 15 patients (93%)., Conclusions: Percutaneous transcholecystic placement of metallic stents is a feasible and effective method to manage malignant obstruction at the lower level of the common bile duct not amenable to surgery when conventional biliary drainage via transhepatic peripheral duct access or ERBD were technically difficult or deemed so at imaging evaluation., (Copyright (c) 2010 SIR. Published by Elsevier Inc. All rights reserved.)

A radiofrequency (RF) wire puncture technique was used in the recanalization of biliary anastomotic occlusions in five patients. The technical success of recanalization, which was defined as successful puncture and crossing of the obstruction followed by balloon cholangioplasty and internal-external biliary drainage without evidence of complications, was 100%. The average follow-up was 13 months (range, 11-16 months). For biliary occlusion recanalization, the RF wire may allow the use of percutaneous therapy in the treatment of a subset of individuals who would otherwise have to undergo open surgical intervention., (Copyright (c) 2010 SIR. Published by Elsevier Inc. All rights reserved.)

Jejunal access loop is fashioned in patients who undergo Roux en Y hepaticojejunostomy and biliary intervention is anticipated on follow up. Post-operative study of the biliary tree through the access loop is usually done under fluoroscopic guidance. We present a series of 20 access loop cholangiograms performed in our institution between August 2004 and November 2008. We aimed to evaluate the safety and efficacy of the procedure and to highlight the role of CT guidance in procuring access. Access loop was accessed using CT (n = 13), ultrasound (n = 3) or fluoroscopic guidance (n = 4). Fluoroscopy was used for performing cholangiograms and interventions. Twelve studies had balloon plasty of the stricture at anastomotic site or high up in the hepatic ducts. Seven studies showed normal cholangiogram. Plasty was unsuccessful in one study. Technical success in accessing the jejunal access loop was 100%; in cannulation of anastomotic site and balloon plasty it was 95%. One case required two attempts. Procedure-related complications were not seen. All patients who underwent balloon plasty of the stricture were doing well for variable lengths of time. Access loop cholangiogram and interventions are safe and effective. CT guidance in locating/procuring the access loop is a good technique.

This study investigated the relative accuracy and roles of abdominal ultrasonography, hepatobiliary scintigraphy and liver biopsy in the diagnosis of infantile cholestasis. A total of 50 infants (27 females) aged 1 - 12 months were classified into those with intrahepatic causes of cholestasis (n = 22) and those with extrahepatic causes (n = 28). Cholestasis is caused by a wide range of conditions and diagnosis requires meticulous history taking, thorough clinical examination and many laboratory tests. The most common cause of intrahepatic cholestasis was found to be idiopathic neonatal hepatitis (54.5%), followed by infectious hepatitis (9.1%), metabolic liver diseases (9.1%), intrahepatic biliary atresia (9.1%) and Alagille syndrome (4.5%). The most common cause of extrahepatic cholestasis was extrahepatic biliary atresia (96.4%). The incidence of choledochal cyst was low (3.6%). The cornerstone of the diagnosis of infantile cholestasis was found to be liver biopsy, which was associated with a high degree of accuracy.

Background: Obstructive jaundice caused by an intraductal hepatocellular carcinoma is a rare initial symptom. We report a rare case of an extrahepatic icteric type hepatocellular carcinoma., Methods: A 75-year-old patient was admitted to our hospital because of obstructive jaundice 3 months after resection of multilocular hepatocellular carcinoma. A postoperative bile leakage was treated by placement of a decompressing stent in the common bile duct. Endoscopic retrograde choledochoscopy showed extended blood clots filling the bile duct system and computed tomography revealed a local swelling in the common extrahepatic bile duct. The level of alpha-fetoprotein (AFP) was only slightly elevated but that of CA19-9 was dramatically increased. Cholangiography showed an intraductal filling defect typical of a cholangiocellular carcinoma., Results: Bile duct brushing cytology showed no cholangiocellular carcinoma but hepatocellular carcinoma cells in the extrahepatic bile duct. An extrahepatic bile duct resection was performed. Histological examination confirmed the diagnosis of extrahepatic intraductal growth of hepatocellular carcinoma., Conclusion: Ectopic hepatocellular carcinoma is a rare but important differentially diagnosed of extrahepatic bile duct filling defect.

Background/aims: Timely diagnosis of biliary atresia (BA) requires key investigations that are less invasive but as accurate as possible. Non-invasive imaging preselects patients before explorative laparotomy is performed. The purpose of this prospective study was to evaluate the accuracy of endoscopic retrograde cholangiopancreaticography (ERCP) in these patients and to discuss its relevance to future diagnostic guidelines in neonatal jaundice., Methods: Over a 7-year period, ERCP was routinely performed in cholestatic patients less than 6 months of age suspected for an extrahepatic origin of cholestasis, most likely BA. Endoscopic diagnosis was correlated with intraoperative findings., Results: In 140 consecutive patients (mean age: 60 days; weight: 4 kg), ERCP excluded BA in 34 (25%) but failed in 18 newborns (13%) for technical reasons. The average procedure time was 23 min, and no severe complications occurred. Explorative laparotomy was performed in 106 patients and revealed BA in 80 cases. In this series, the sensitivity of ERCP for diagnosing biliary atresia was 92% and specificity was 73%., Conclusions: In preselected patients, ERCP is not an alternative to non-invasive imaging, but it avoids unnecessary surgical procedures in almost 25% of the cases. Hence, ERCP is recommended prior to explorative laparotomy in all patients suspected for BA.

Purpose: To evaluate the evolution of morphologic features of autoimmune pancreatitis (AIP) at computed tomography (CT) and to identify imaging features that can predict AIP response to corticosteroid therapy (CST)., Materials and Methods: This HIPAA-compliant retrospective study had institutional review board approval. From among a cohort of 63 patients with AIP, 15 patients (12 men, three women; mean age, 64.7 years; age range, 30-84 years) who underwent sequential CT examinations before treatment were included to assess the evolution of disease by reviewing pancreatic, peripancreatic, and ductal changes. Of these patients, 13 received CST and underwent posttreatment CT; these CT studies were evaluated to determine if there were imaging features that could predict response to CST., Results: The disease evolved from changes of diffuse (14 of 15 patients) or focal (one of 15 patients) parenchymal swelling, peripancreatic stranding (10 of 15 patients), "halo" (nine of 15 patients), pancreatic duct changes (15 of 15 patients), and distal common bile duct narrowing (12 of 15 patients) to either resolution or development of ductal strictures and/or focal masslike swelling. In 13 patients treated with CST, favorable response to treatment was seen in those with diffuse pancreatic and peripancreatic changes. Suboptimal response was seen in patients with ductal stricture formation (two of 13 patients) and in those in whom focal masslike swellings persisted after resolution of diffuse changes (seven of 13 patients)., Conclusion: CT features like diffuse swelling and halo respond favorably to CST and likely reflect an early inflammatory phase, whereas features like ductal strictures and focal masslike swelling are predictive of a suboptimal response and symbolize a late stage with predominance of fibrosis.