Does the bile duct angulation affect recurrence of choledocholithiasis?

AIM:To investigate whether bile duct angulation and T-tube choledochostomy influence the recurrence of choledocholithiasis.METHODS:We conducted a retrospective study including 259 patients who underwent endoscopic sphincterotomy and cholecystectomy for choledocholithiasis between 2000 and 2007.The imaginary line was drawn along the center of the bile duct and each internal angle was measured at the two angulation sites ofthe bile duct respectively.The values of both angles were added together.We then tested our hypothesis by examining whether T-tube choledochostomy was performed and stone recurrence occurred by reviewing each subject's medical records.RESULTS:The overall recurrence rate was 9.3% (24 of 259 patients).The mean value of sums of angles in the recurrence group was 268.3°± 29.6°,while that in the non-recurrence group was 314.8°± 19.9° (P < 0.05).Recurrence rate of the T-tube group was 15.9% (17 of 107),while that of the non T-tube group was 4.6% (7 of 152) (P < 0.05).Mean value of sums of angles after T-tube drainage was 262.5°± 24.6° and that before T-tube drainage was 298.0°± 23.9° in 22 patients (P < 0.05).CONCLUSION:The bile duct angulation and T-tube choledochostomy may be risk factors of recurrence of bile duct stones.

Primary endoscopic approximation suture under cap-assisted endoscopy of an ERCP-induced duodenal perforation

Duodenal perforation during endoscopic retrograde cholangiopancreatography(ERCP) is a rare complication,but it has a relatively high mortality risk.Early diagnosis and prompt management are key factors for the successful treatment of ERCP-related perforation.The management of perforation can initially be conservative in cases resulting from sphincterotomy or guide wire trauma.However,the current standard treatment for duodenal free wall perforation is surgical repair.Recently,several case reports of endoscopic closure techniques using endoclips,endoloops,or fully covered metal stents have been described.We describe four cases of iatrogenic duodenal bulb or lateral wall perforation caused by the scope tip that occurred during ERCP in tertiary referral centers.All the cases were simply managed by endoclips under transparent capassisted endoscopy.Based on the available evidence and our experience,endoscopic closure was a safe and feasible method even for duodenoscope-induced perforations.Our results suggest that endoscopists may be more willing to use this treatment.

Giant choledocholithiasis treated by mechanical lithotripsy using a gastric bezoar basket

Mechanical lithotripsy （ML） is usually considered as a standard treatment option for large bile duct stones. However, it is impossible to retrieve oversized stones because the conventional lithotripsy basket may not be able to grasp the stone. However, there is no es- tablished endoscopic extraction method for such gi- ant stone removal. We describe a case of successful extraction of a 4-cm large stone using a gastric bezoar basket. A 78-year-old woman had suffered from upper abdominal pain for 20 d. Contrast-enhanced computed tomogram revealed a 4-cm single stone in the distal common bile duct （CBD）. Endoscopic stone retraction was decided upon and endoscopic papillary balloon dilation was performed using a large balloon. An at- tempt to capture the stone using a standard lithotripsy basket failed due to the large stone size. Subsequently, we used a gastric bezoar basket to successfully capturethe stone. The stone was fragmented into small pieces and extracted. The stone was completely removed after two sessions of endoscopic retrograde cholangio- pancreatography; each of which took 30 rain. No com- plications occurred during or after the procedure. The patient was fully recovered and discharged on day 11 of hospitalization. ML using a gastric bezoar basket is a safe and effective retrieval method in select cases, and is considered as an alternative nonoperative option for the management of difficult CBD stones.

Effectiveness of contrast-enhanced harmonic endoscopic ultrasound for the evaluation of solid pancreatic masses

AIM:To evaluate the usefulness of contrast-enhanced harmonic endoscopic ultrasound(CH-EUS)in differentiating between pancreatic adenocarcinomas and other pancreatic disease.METHODS:This retrospective cohort study evaluated90 patients who were seen between November 2010and May 2013.All these patients had solid pancreatic masses that had a hypoechoic appearance on EUS.All patients underwent CH-EUS to evaluate this diagnostic method’s usefulness.The mass lesions observed on CH-EUS were classified into three categories based on their echo intensity:hypoenhanced,isoenhanced,and hyperenhanced lesions.We adjusted the sensitivity and the specificity of each category for detecting malignancies.We also estimated the accuracy of CH-EUS by comparing it to a pathological diagnosis.RESULTS:Of the 90 patients,62 had a pancreatic adenocarcinoma.Fifty-seven out of 62 pancreatic adenocarcinomas showed a hypoenhanced pattern on CHEUS.The sensitivity was 92%,the specificity 68%and the accuracy approximately 82%.The area under the curve of the receiver operating characteristic analysis for CH-EUS was 0.799.There is a significant association between the hypoenhanced pattern on CH-EUS and pancreatic duct adenocarcinoma(χ2=35.264,P<0.001).In pathological examinations,the number of specimens for EUS-fine needle aspiration(EUS-FNA)was considered insufficient for diagnosis in three patients,and in two patients,the results were reported to be negative for malignancy.Pancreatic masses in all five patients revealed a hypoenhanced pattern with CH-EUS.Three patients were diagnosed with pancreatic adenocarcinoma based on the pathology results of a biopsy,and the remaining two patients were clinically diagnosed with malignancy.CONCLUSION:CH-EUS is useful for distinguishing between pancreatic adenocarcinoma and other pancreatic disease.When a pancreatic mass shows a hypoenhanced pattern on CH-EUS but involves either insufficient samples or negative results with EUS-FNA,clinicians might consider performing another pathologic diagnosis on the basis of an EUS-FNA sample or a biopsy.