Role and timing of endoscopy in acute biliary pancreatitis

The role and timing of endoscopy in the setting of acute biliary pancreatitis(ABP) is still being debated. Despite numerous randomized trials have been published,there is an obvious lack of consensus on the indications and timing of endoscopic retrograde cholangiopancreatography(ERCP) in ABP in metaanalyses and nationwide guidelines. The present editorial has been written to clarify the role of endoscopy in ABP. In clinical practice the decision to perform an ERCP is often based on biochemical and radiological criteria despite they already have been shown to be unreliable predictors of common bile duct stone presence. Endoscopic ultrasonography(EUS) is not currently a worldwide standard diagnostic procedure early in the course of acute biliary pancreatitis,but it has been shown to be accurate,safe and cost effective in diagnosing biliary obstructions compared with magnetic resonance cholangiopancreatography and ERCP and therefore in preventing unnecessary ERCP and its related complications. Early EUS in ABP allows,if appropriate,immediate endoscopic treatment and significant spare of unnecessary operative procedures thus reducing possible related complications.

Laparoscopic ultrasonography as an alternative to intraoperative cholangiography during laparoscopic cholecystectomy

To assess the role of laparoscopic ultrasound (LUS) as a substitute for intraoperative cholangiography (IOC) during cholecystectomy. METHODSWe present a MEDLINE and PubMed literature search, having used the key-words “laparoscopic intraoperative ultrasound” and “laparoscopic cholecystectomy”. All relevant English language publications from 2000 to 2016 were identified, with data extracted for the role of LUS in the anatomical delineation of the biliary tract, detection of common bile duct stones (CBDS), prevention or early detection of biliary duct injury (BDI), and incidental findings during laparoscopic cholecystectomy. Data for the role of LUS vs IOC in complex situations (i.e., inflammatory disease/fibrosis) were specifically analyzed. RESULTSWe report data from eighteen reports, 13 prospective non-randomized trials, 5 retrospective trials, and two meta-analyses assessing diagnostic accuracy, with one analysis also assessing costs, duration of the examination, and anatomical mapping. Overall, LUS was shown to provide highly sensitive mapping of the extra-pancreatic biliary anatomy in 92%-100% of patients, with more difficulty encountered in delineation of the intra-pancreatic segment of the biliary tract (73.8%-98%). Identification of vascular and biliary variations has been documented in two studies. Although inflammatory disease hampered accuracy, LUS was still advantageous vs IOC in patients with obscured anatomy. LUS can be performed before any dissection and repeated at will to guide the surgeon especially when hilar mapping is difficult due to fibrosis and inflammation. In two studies LUS prevented conversion in 91% of patients with difficult scenarios. Considering CBDS detection, LUS sensitivity and specificity were 76%-100% and 96.2%-100%, respectively. LUS allowed the diagnosis/treatment of incidental findings of adjacent organs. No valuable data for BDI prevention or detection could be retrieved, even if no BDI was documented in the reports analyzed. Literature analysis proved LUS as a safe, quick, non-irradiating, cost-effective technique, which is comparatively well known although largely under-utilized, probably due to the perception of a difficult learning curve. CONCLUSIONWe highlight the advantages and limitations of laparoscopic ultrasound during cholecystectomy, and underline its value in difficult scenarios when the anatomy is obscured.

Early endoscopic ultrasonography in acute biliary pancreatitis: A prospective pilot study

AIM: To investigate the clinical usefulness of early endoscopic ultrasonography(EUS) in the management of acute biliary pancreatitis(ABP).METHODS: All consecutive patients entering the emergency department between January 2010 and December 2012 due to acute abdominal pain and showing biochemical and/or radiological findings consistent with possible ABP were prospectively enrolled. Patients were classified as having a low,moderate,or high probability of common bile duct(CBD) stones,according to the established risk stratification. Exclusion criteria were: gastrectomy or patient in whom the cause of biliary obstruction was already identified by ultrasonography. All enrolled patients underwent EUS within 48 h of their admission. Endoscopic retrograde cholangiopancreatography was performed immediately after EUS only in those cases with proven CBD stones or sludge. The following parameters were investigated:(1) clinical: age,sex,fever;(2) radiological: dilated CBD; and(3) biochemical: bilirubin,AST,ALT,g GT,ALP,amylase,lipasis,PCR. Association between presence of CBD stone at EUS and the individual predictors wereassessed by univariate logistic regression. Predictors significantly associated with CBD stones(P < 0.05) were entered in a multivariate logistic regression model.RESULTS: A total of 181 patients with pancreatitis were admitted to the emergency department between January 2010 and December 2012. After exclusion criteria a total of 71 patients(38 females,53.5%,mean age 58 ± 20.12 years,range 27-89 years; 33 males,46.5%,mean age 65 ± 11.86 years,range 41-91 years) were included in the present study. The probability of CBD stones was considered low in 21 cases(29%),moderate in 26(37%),and high in the remaining 24(34%). The 71 patients included in the study underwent EUS,which allowed for a complete evaluation of the target sites in all the cases. The procedure was completed in a mean time of 14.7 min(range 9-34 min),without any notable complications.The overall CBD stone frequency was 44%(31 of 71),with a significant increase from the group at low pretest probability to that at moderate(OR = 5.79,P = 0.01) and high(OR = 4.25,P = 0.03) pretest probability.CONCLUSION: Early EUS in ABP allows,if appropriate,immediate endoscopic treatment and significant spare of unnecessary operative procedures thus reducing possible related complications.