Common bile duct diameters after endoscopic sphincterotomy in patients with common bile duct stones: ultrasonographic evaluation

Background: One of the most reliable, frequently used imaging techniques in cholestasis is ultrasonography (US) for the diagnosis of common bile duct (CBD) stones. Methods: In this study, changes in diameters of CBD were determined ultrasonographically before and after endoscopic sphincterotomy (ES) in 46 patients with stone-induced dilated CBD. Results: There was a significant decrease in CBD diameter measured 1 week after ES and extraction of stone (p < 0.001). In 87% of cases, the difference was more significantly pronounced during the first 24 h of ES. The mean CBD diameters on US were 13.70 ± 3.00 mm (10–21 mm) before and 9.13 ± 2.90 mm (4.2–18 mm) 24 h after endoscopic treatment (p < 0.001). After ES, six patients (13%) with inadequate decreases in CBD diameters were found to have residual stones. Conclusion: US can show residual stones in the CBD with the same efficacy as endoscopic retrograde cholangiopancreatography.     

Difference of CBD width on US vs. ERCP

Purpose To investigate the relationship between US and ERCP in the measurement of common bile duct (CBD) width after application of Compound and Harmonic imaging on ultrasound. Methods We prospectively evaluated the CBD width as measured on endoscopic retrograde cholangiopancreatography (ERCP) and ultrasonography (US), applying Compound and Harmonic US techniques, on 100 patients. Furthermore, we retrospectively re-examined US and ERCP images of 48 patients who underwent ERCP and US during the same hospitalization period. Results The average difference in measurements by US compared to ERCP was 2.3 mm (P < 0.01) in the retrospective and 1.9 mm in the prospective study (P < 0.001). The average difference in measurements between US and ERCP in post-cholecystectomy patients was 4.0 mm in the retrospective study (10 patients), and 3.8 in the prospective study (25 patients). The difference between the measurements on both examinations decreased with increasing CBD width. There was a good correlation between ERCP and US measurements of CBD width (r = 0.73 for all patients and r = 0.88 for patients with intact gallbladder, P < 0.001). Conclusions There is a gap between measurement of CBD width on US and ERCP of about 2 mm. The application of Compound and Harmonic techniques in the prospective study probably enabled a more accurate sonographic measurement.     

Variations of common bile duct diameter after endoscopic sphincterotomy

Diameters of the common bile duct (CBD) and common hepatic duct (CHD) were measured before and after endoscopic sphincterotomy (EPT) in 100 patients. There was a significant reduction of the lumen diameter in both the CBD and CHD (p<0.01) after EPT. A comparison between 32 patients without symptoms (such as pain, residual stones, and elevated levels of liver enzymes) and 19 patients with remaining symptoms after EPT, showed a statistically significant reduction in both CBD and CHD diameters (p< 0.001) in the former group, and no statistically proven changes in the diameters in the latter group, since a change of <1.5 mm was not considered significant. Therefore, the absence of a reduction or a dilatation of the diameter of the CBD after EPT may suggest that these patients may have persisting complaints after EPT.Measurements on models (phantoms) show that body position of the patient during endoscopic retrograde cholangiopancreatography (ERCP) has little and negligible influence on the measured diameters of the CBD and CHD.     

Virtual CT cholangiography in patients with choledocholithiasis

Background: We evaluated the feasibility and accuracy of virtual computed tomographic cholangiography (VCTC) in detecting choledocholithiasis and imaging anatomic variations of the biliary tree. Methods: Thirty-three consecutive patients with clinical and biological signs of choledocholithiasis underwent spiral CT after intravenous infusion of iotroxindimeglumine. Patients with total serum bilirubin levels above 3 mg/dL were not included in this study. Spiral data sets were used to construct intralumenal images of the biliary tree. The images were reviewed by two abdominal radiologists. The biliary ducts were divided into three segments, so the analysis was based on 99 segments. The diagnosis obtained by VCTC was compared with the final diagnosis established by endoscopic retrograde cholangiography or intraoperative cholangiography. Results: VCTC correctly depicted biliary stones in nine of 10 patients and anatomic variations in all five patients, and no false-positive cases were observed. VCTC showed excellent endolumenal visualization of 87 of 99 segments of the biliary tree. The processing time (9.3 ± 2.1 min) was particularly short. Conclusion: VCTC with intravenous infusion of iotroxindimeglumine may be a feasible clinical tool, with acceptable accuracy in selected cases.     

Direct peroral cholangioscopy using an ultraslim upper endoscope for management of residual stones after mechanical lithotripsy for retained common bile duct stones

Background and study aims: The incidence of residual stones after mechanical lithotripsy for retained common bile duct (CBD) stones is relatively high. Peroral cholangioscopy using a mother - baby system may be useful for confirming complete extraction of stones, but has several limitations regarding routine use. We evaluated the role of direct peroral cholangioscopy (DPOC) using an ultraslim upper endoscope for the evaluation and removal of residual CBD stones after mechanical lithotripsy.Patients and methods: From August 2006 to November 2010, 48 patients who had undergone mechanical lithotripsy for retained CBD stones with no evidence of filling defects in balloon cholangiography were recruited. The bile duct was inspected by DPOC after balloon cholangiography. Detected residual CBD stones were directly retrieved with a basket or balloon catheter under DPOC. The incidence of residual stones detected by DPOC, and the success rate of residual stone retrieval under DPOC were investigated.Results: DPOC was successfully performed in 46 of the 48 patients (95.8 %). Of these, 13 patients (28.3 %) had residual CBD stones (mean number 1.4, range 1 - 3; mean diameter 4.5 mm, range 2.3 - 9.6). The residual stones were removed directly under DPOC in 11 of these patients (84.6 %). There were no complications associated with DPOC or stone removal. Conclusion: DPOC using an ultraslim upper endoscope is a useful endoscopic procedure for the evaluation and extraction of residual stones after mechanical lithotripsy for retained CBD stones.     

Dynamic MRI in indirect estimation of microvessel density,histologic grade,and prognosis in colorectal adenocarcinomas

The relations of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) parameters to microvessel density (MVD), histologic grade, and presence of metastasis were evaluated to establish new prognostic indicators in colorectal cancer (CRC). Fast-low angle shot DCE-MRI parameters (time-intensity curves, TICs; maximal relative enhancement within the first minute, E_max/1; maximal relative enhancement of the entire study, E_max; steepest slope of the contrast enhancement curve; and time to peak enhancement) of 21 CRCs (seven Duke stage B, 12 Duke stage C, and two Duke stage D) were retrospectively evaluated and correlated with corresponding postoperative MVD measurements, histologic grades, and presence of metastasis at 2 years. TICs were classified as type A in nine (43%), type B in seven (33%), and type C in five cases (24%). There was a significant difference between TIC types with regard to MVD (p < 0.05–0.001). Time to peak enhancement, steepest slope of TIC, and E_max/1 were strongly correlated with MVD (r = –0.765, p < 0.01; r = 0.681, p < 0.01; r = 0.634, p < 0.01; respectively). MVD, steepest slope of the enhancement curve, E_max/1, and E_max strongly correlated with histologic grade (r = 0.475, p < 0.05; r = 0.683, p < 0.01; r = 0.687, p < 0.01; r = 0.791, p < 0.01; respectively). There was a significant difference between groups of patients with and without metastasis with regard to histologic grade (p < 0.05) and two of the DCE-MRI parameters (p < 0.005 for E_max/1 and p < 0.05 for time to peak enhancement). Discriminant analysis correctly predicted the metastatic occurrence at 2 years in 90.5% of cases using E_max/1 (p < 0.001). Histologic grade resulted in lower rates of discrimination (66.7%; p < 0.05). DCE-MRI parameters may help in the prediction of MVD and histologic grade in CRC and may be used to predict therapeutic outcome.     

胆囊切除术后残留胆总管结石的内镜诊治

目的：探讨经内镜逆行胰胆管造影（ERCP）在胆囊切除术后残留胆总管结石诊治中的应用价值。方法：对胆囊切除术后腹痛、发热、黄疸或肝功能异常而经B超、CT或磁共振胰胆管造影（MRCP）证实或怀疑残留胆总管结石的患者进行ERCP检查，对发现胆总管结石的患者行EST或EPBD后取石。结果：ERCP检查的成功率为96．4％（108／112）。85例证实胆总管结石的患者行EST或EPBD后取石，79例（92．9％）取石治疗成功；6例因合并肝内胆管多发结石而行外科手术治疗。并发症发生率为4．5％，其中消化道出血2例，急性胰腺炎3例。结论；对于胆囊切除术后残留胆总管结石的患者，ERCP是理想的诊断方法，而且还可以同时进行治疗。     

Endoscopic papillary balloon dilation for difficult common bile duct stones: Our experience

AIM: To evaluate the efficacy and safety of endoscopic balloon dilation (EBD) performed for common bile duct (CBD) stones.METHODS: From a computer database, we retrospectively analyzed the data relating to EBD performed in patients at the gastrointestinal unit of the Sandro Pertini Hospital of Rome (small center with low case volume) who underwent endoscopic retrograde cholangiopancreatography (ERCP) for CBD from January 1, 2010 to February 29, 2012. All patients had a proven diagnosis of CBD stones studied with echography, RMN-cholangiography and, when necessary, with computed tomography of the abdomen (for example, in cases with pace-makers). Prophylactic therapies, with gabexate mesilate 24 h before the procedure and with an antibiotic (ceftriaxone 2 g) 1 h before, were administered in all patients. The duodenum was intubated with a side-viewing endoscope under deep sedation with intravenous midazolam and propofol. The patients were placed in the supine position in almost all cases. EBD of the ampulla was performed under endoscopic and fluoroscopic guidance with a balloon through the scope (Hercules, wireguided balloon^®, Cook Ireland Ltd. and CRE^®, Microvasive, Boston Scientific Co., Natick, MA, United States).RESULTS: A total of 14 patients (9 female, 5 male; mean age of 73 years; range 57-82 years) were enrolled in the study, in whom a total of 15 EBDs were performed. All patients underwent minor endoscopic sphincterotomy (ES) prior to the EBD. The size of balloon insufflation depended on stone size and CBD dilation and this was performed until it reached 16 mm in diameter. EBD was performed under endoscopic and fluoroscopic guidance. The balloon was gradually filled with diluted contrast agent and was maintained inflated in position for 45 to 60 s before deflation and removal. The need for precutting the major papilla was 21.4%. In one patient (an 81-year-old), EBD was performed in a Billroth II. Periampullary diverticula were found only in a 74-year-old female. The adverse event related to the procedures (ERCP + ES) was only an intra procedural bleeding (6.6%) that occurred after ES and was treated immediately with adrenaline sclerotherapy. No postoperative complications were reported.CONCLUSION: With the current endoscopic techniques, very few patients with choledocholithiasis require surgery. EBD is an efficacious and safe procedure.     

The normal retrograde cholangiogram: a definition of normal caliber

Purpose: To evaluate normal retrograde cholangiograms to determine a normal range of ductal calibers and identify its variation with age. Materials and methods: The retrograde cholangiograms of 136 patients (age range: 17–84 years; mean age 49.8 years ± 17.3 [standard deviation]) with clinical follow-up and subsequent studies suggesting normal biliary trees were evaluated. Patients with previous cholecystectomy, choledocholithiasis, or pancreatitis were excluded. Common bile duct (CBD) and common hepatic duct (CHD) sizes were measured. Results: Measurements uncorrected for radiographic magnification of CBD revealed a mean of 8.5 mm ± 2.7 mm [standard deviation] and CHD had a mean of 8.1 mm ± 2.6 mm. There was an increase in CBD caliber by 0.5 mm per decade of increasing age (p < 0.001) and an increase in CHD caliber by 0.35 mm per decade of age (p < 0.01). Conclusion: The range of normal cholangiographic bile duct caliber is wide and a CBD caliber of 13.9 mm occurs at the top of this range (mean plus two standard deviations). There is a small but statistically significant trend of ductal dilatation with advancing age. Received: 13 December 1995/Accepted after revision: 24 April 1996     

Use of the Bard Memotherm self-expanding metal stent in the palliation of colonic obstruction

Background: Self-expanding metal stents (SEMS) are a recognized means of palliating large bowel obstruction due to colonic neoplasia. The literature mainly relates to the use of modified esophageal stents (expanded diameter, 18–22 mm) in the colorectum. Stent migration has been a common complication and may be related to expanded stent diameter. This series reports our experience with the Memotherm Colorectal SEMS (expanded diameter, 25–30 mm). Methods: Prospective data were collected from February 1999 to September 2000. Sixteen patients (age range = 61–99 years) were considered for the Memotherm Colorectal SEMS. Stents were inserted radiologically under fluoroscopic control. Outcome was classified as a technical success (stent in correct position and expanded) and a clinical success (colon decompressed, symptoms relieved, and bowels working). Results: Thirteen cases (81%) underwent successful SEMS placement. These were technically and clinically successful. Two cases required insertion of two overlapping stents to traverse long strictures. Three unsuccessful cases were emergency presentations in which a guidewire could not be passed across the lesion. Two of these were due to benign strictures and the third to extrinsic compression by ovarian carcinoma. Conclusion: In our experience, the Memotherm Colorectal SEMS was easy to use, was effective in the palliation of obstructing colorectal carcinoma, and appeared to reduce the risk of stent migration.     

Percutaneous transhepatic sphincterotomy

Endoscopic sphincterotomy (ES) is a highly successful and preferred method for common bile duct (CBD) stone removal. In the rare instance when ES is unsuccessful and CBD stones are removed percutaneously, improved biliary drainage remains desirable to prevent stone recurrence. To this end, percutaneous transhepatic sphincterotomy (PTS) has been performed in nine patients. All patients presented with ascending cholangitis due to biliary obstruction from CBD stones. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy was unsuccessful due to previous upper Gl reconstructive surgery (n = 8) and technical failure (n = 1). Percutaneous biliary drainage (PBD), followed by transhepatic stone removal, was performed prior to the transhepatic sphincterotomy using a standard endoscopic papillotome. Fluoroscopic guidance was used in the first three patients and in the remainder both fluoroscopy and percutaneous choledochoscopy were used. Sphincterotomy was successfully performed in all nine patients; post-procedure cholangiograms showed improved biliary drainage. In two patients, the choledochoscope was passed through the sphincter with ease. One patient bled soon after the procedure (fluoroscopic control only) and responded quickly to treatment with blood transfusion. No complications have occurred since choledochoscopy was incorporated into the procedure. All patients remained free of biliary symptoms for an average follow-up of 19 months (range 12-45 months). Our early experience shows that PTS is efficacious in improving biliary drainage and that it offers a therapeutic alternative to surgery in highly-selected patients.     

Factors related to the spontaneous passage of common bile duct stones through the papilla: a single-center retrospective cohort study

ObjectiveCommon bile duct (CBD) stones can spontaneously pass through the papilla. This study explored factors associated with stone passage by comparing differences in the clinical features of stones retained in the CBD and excreted stones.MethodsData were retrospectively collected for all patients who were hospitalized in our center between March 2016 and May 2021 with clinical, laboratory, or imaging evidence of CBD stones. All patients underwent endoscopic retrograde cholangiopancreatography (ERCP) and were classified into two groups: group A (stones extracted by ERCP, n = 86) and group B (stones discharged before ERCP, n = 15). Demographic data, biochemical and radiological findings were compared between the groups.ResultsStone size (0.82 vs. 0.33 cm), and levels of total bilirubin (58.2 vs. 28.8 μmol/L), gamma-glutamyl transpeptidase (416.7 vs. 193.9 U/L), alkaline phosphatase (191.9 vs. 123.1 U/L), carbohydrate antigen 19-9 (603.7 vs. 37.2 U/mL), and α-L-fucosidase (37.4 vs. 22.6 U/L) were significantly higher in group A than in group B. Logistic regression analyses showed that stone size was the only factor significantly associated with spontaneous passage of CBD stones.ConclusionsCBD stones less than 0.33 cm in size may be self-expelled through the papilla.     

Dynamic right and left ventricular interactions in the rabbit: Simultaneous measurement of ventricular pressure-volume loops

: This study was performed to characterize the dynamic factors determining ventricular interdependence in an open-pericardium intact animal model. Materials and: Simultaneous measures of right ventricular (RV) and left ventricular (LV) pressures and volumes in 6 urethane-anesthetized openchested, open-pericardium rabbits. RV and LV V were calculated every 2 milliseconds. Measurements were made at initial baseline blood volume, and again after two infusions of 20 mL/kg isoconductive colloid solution. At each blood volume level, partial aortic (AO), pulmonary artery (PAO), and inferior vena caval (IVC) occlusions were performed. Biventricular diastolic compliance and end-systolic elastance were calculated from these data.: Baseline end-diastolic (ED) and end-systolic (ES) V were 3.29 ± 0.55 and 2.43 ± 0.33 mL (x ± SD) for the LV, and 3.38 ± 1.56 and 2.84 ± 1.36 mL for the RV, respectively. AO increased all LV pressure and volume (P < .05) but did not alter RV ED volume (2.85 ± 1.20 mL) or ED pressure (3.3 ± 2.0 to 3.6 ± 2.1 mm Hg). PAO increased RV ES pressure (P < .05) but did not alter RV ED volume, ED pressure, or ES volume, although it decreased LV ED volume (2.82 ± 0.59, P < .05). AO also immediately increased end-systolic RV elastance to a value greater than that defined by IVC (7.9 ± 4.4 to 10.9 ± 6.6 mm Hg/mL, P < .05). Intravascular volume expansion though increasing baseline pressure and volume, did not alter qualitatively biventricular responses to AO, PA, or IVC.: Ventricular interdependence has both systolic and diastolic components that have differing directional effects. In the pericardectomized rabbit, increases in RV ED volume decrease LV ED volume by decreasing LV diastolic compliance, but do not alter LV systolic function. Whereas, increases in LV ED volume decrease RV ES volume resulting in an increase in RV maximal elastance, but minimally alter RV diastolic function.     

Early invasive colorectal carcinomas with submucosal invasion: radiographic characteristics with barium double contrast images

Background: We assessed the radiographic characteristics of early colorectal carcinomas with submucosal invasion (CCSI) with the use of double-contrast images. Methods: From 1989 to 1997, 193 patients with 196 CCSI lesions underwent double-contrast barium enema examinations. Three gastrointestinal radiologists retrospectively reviewed the radiographic characteristics of the lesions and classified them as protruding and depressed types by consensus. Further, subclassifying the protruding into lobular and smooth types was accomplished on the basis of surface structure. Each type was compared with pathologic findings of resected specimens. Results: The incidence of the protruding type was 98.0%, and that of the depressed type was only 2.0%. The proportion of smooth lesions was 49.0% for the protruding type; these had a mean diameter of 17.9 mm, which was significantly smaller than the 23.1 mm mean observed for lobular lesions (p < 0.01). Of the smooth lesions, 44.7% demonstrated massive invasion, whereas 91.8% of lobular lesions exhibited only slight or moderate invasion into the submucosa (p < 0.01). The extent of invasion of the smooth lesions was greater than that for their lobular counterparts in terms of venous and lymph node involvement. Conclusion: Almost all CCSIs could be identified radiologically as protruding lesions; these had a smooth rather than a lobulated surface and demonstrated greater malignancy, despite the smaller size. It is clinically important to discriminate these from other polypoid lesions in establishing patient treatment. Double-contrast imaging is useful for evaluation of the surface characteristics of CCSIs in barium enema studies.     

The role of cholecystectomy in reducing recurrent gallstone pancreatitis

BACKGROUND AND STUDY AIM: Endoscopic sphincterotomy (ES) or cholecystectomy can prevent recurrent acute pancreatitis (RAP) in patients with gallstone-related pancreatitis. However, it is unknown whether cholecystectomy after ES offers additional benefit in preventing RAP in these patients. This is a retrospective study to assess whether cholecystectomy can decrease the incidence of RAP in patients with gallstone-related pancreatitis. PATIENTS AND METHODS: Records from 139 patients with gallstone-related pancreatitis were analyzed. Of these, 58 patients had gallbladder stones with concomitant common bile duct (CBD) stones and 81 patients had gallbladder stones without CBD stones. Of the 58 patients who had both gallbladder and CBD stones, 37 (63.8 %) did not undergo cholecystectomy after ES (group 1) and 21 patients (36.2 %) did undergo cholecystectomy after ES (group 2). Of the 81 patients who had gallbladder stones but who did not have CBD stones, 54 (66.7 %) did not undergo cholecystectomy (group 3) and 27 (33.3 %) did undergo cholecystectomy (group 4). RESULTS: At the time of analysis, three patients (8.1 %) in group 1 and three patients (14.3 %) in group 2 developed RAP. There was no significant difference in the estimated probability of occurrence of RAP over time between group 1 and group 2 ( P = 0.41). However, there was a significantly higher probability of patients developing RAP over time in group 3 compared with group 4 (6/54 vs. 0/27 respectively, P = 0.04). CONCLUSION: In patients with gallbladder stones without CBD stones, cholecystectomy can decrease the incidence of RAP. In patients with both gallbladder and CBD stones, however, the risk of RAP was not further reduced by cholecystectomy after ES and complete removal of CBD stones.     

Relationship between Cycle Length of Typical Atrial Flutter and Double Potential Interval after Achievement of Complete Isthmus Block

Background: There is some disagreement concerning the minimal value of the interval between components of double potentials (DPs interval) that allows distinguishing complete and incomplete block in the cavotricuspid isthmus (CTI). Objectives: To assess clinical utility of the relationship between atrial flutter cycle length (AFL CL) and the DPs interval. Methods: Ablation of the CTI was performed in 87 patients during AFL (245 ± 40 ms). Subsequently, DPs were recorded during proximal coronary sinus pacing at sites close to a gap in the ablation line and after achievement of complete isthmus block. Results: We noted strong correlation between AFL CL and the DPs interval after achievement of isthmus block (r = 0.73). The mean DPs interval was 95.3 ± 18.3 ms (range 60–136 ms) and 123.3 ± 24.3 ms (range 87–211 ms) during incomplete and complete isthmus block, respectively (P < 0.001). When expressed as a percentage of AFL CL, this interval was 35.7 ± 3.5% AFL CL (range 28–40.2%) and 50.4 ± 6.9% AFL CL (range 39–72%) during incomplete and complete isthmus block, respectively (P < 0.001). A cutoff value of 40% of AFL CL identified CTI block with 96.7% sensitivity and 100% specificity. Conclusions: The interval between DPs after achievement of block in the CTI correlates with AFL CL. The DPs interval expressed as a percentage of AFL CL allows better distinguishing between complete and incomplete isthmus block compared to standard method based on milliseconds. The DPs interval below 40% of AFL CL indicates sites close to a gap in the ablation line. (PACE 2010; 33:1518–1527)     

Magnetic resonance imaging of the main pulmonary artery: reliable assessment of dimensions in Marfan patients on a simple axial spin echo image

Objective: To investigate if a simple axial spin echo (SE) image can be used for reliable assessment of pulmonary artery dimensions in patients with Marfan syndrome. Methods: Fifty Marfan patients (mean age 33 ± 10 years; 34 men, 16 women) and 15 normal subjects (mean age 28 ± 4 years; nine men, six women) underwent cardiac magnetic resonance imaging (MRI). Pulmonary artery dimensions were obtained on axial SE images at two different levels: (1) the level of the pulmonary artery root, and (2) the level of the pulmonary artery bifurcation. To evaluate the accuracy of axial plane measurements 10 Marfan patients also underwent contrast-enhanced MR angiography (CE-MRA). Results: In the 10 Marfan patients who also underwent CE-MRA, the mean diameter at the pulmonary bifurcation assessed with CE-MRA (31.5 ± 3.6 mm) was almost equal to mean diameter assessed with axial SE (30.7 ± 3.6 mm). Agreement of methodology according to Bland and Altman analysis showed a 95% confidence interval ranging from –2.6 to +4.4 mm for all distances of the pulmonary artery root. In Marfan patients the mean right-left diameter measured on both axial SE images and CE-MRA was approximately 2.5 mm larger than the anterior-right and anterior-left diameters (p < 0.001). Conclusions: Axial SE MRI is a reliable and easy acquisition to measure pulmonary artery dimensions in patients with Marfan syndrome, and could be used for follow-up, especially in patients with severe involvement of the cardiovascular system. Not only the pulmonary artery trunk but also the asymmetric pulmonary root should be measured, although the clinical relevance of the asymmetric root is not yet known.     

Accuracy of linear endoscopic ultrasonography in the evaluation of patients with suspected common bile duct stones

BACKGROUND AND STUDY AIMS: Endoscopic ultrasonography (EUS) with radial scanning is an efficient diagnostic tool where there is suspicion of common bile duct (CBD) stones. Little is known about the use of linear EUS in this condition. The aim of this study was to evaluate the diagnostic efficiency of linear EUS in a large group of patients suspected to have bile duct stones, using endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy and exploration of the CBD using a Dormia basket, or surgical choledochotomy with choledochoscopy, as diagnostic "gold standards." PATIENTS AND METHODS: 134 patients with clinical suspicion of CBD stones were included in the study and prospectively evaluated, using EUS, and ERCP with endoscopic sphincterotomy (127 patients), or choledochotomy with choledochoscopy where ERCP was unsuccessful (seven patients). EUS was done before ERCP using an echo endoscope (Pentax FG 32 UA; 5 - 7.5 MHz) and Hitachi EUB 405 ultrasound machine. ERCP was done using the TFJ 100 or TJ 20 Olympus duodenoscope. ERCP was carried out within a mean of 2 days after EUS. The longest time between EUS and ERCP was 3 days. The examiners were blinded to the results of the other method used. RESULTS: CBD stones were found in 91 (68 %) patients at ERCP with ES or at surgery. The correct diagnosis was established by EUS in 85 patients. The remaining 43 patients without CBD stones were correctly diagnosed in 41 cases by means of EUS, giving an accuracy of 94 %, sensitivity of 93 %, specificity of 93 %, a positive predictive value of 98 %, a negative predictive value of 87 %, and a Youden's index of 89 %. CONCLUSIONS: Linear EUS is a fairly reliable method for the evaluation of patients with high suspicion for CBD stones. The usefulness of linear EUS in the evaluation of patients with low or moderate suspicion for CBD stones warrants further study.     

Effect of cholecystectomy on common bile duct diameters: a longitudinal prospective ultrasonographic study

The medium-term effect of cholecystectomy on common bile duct diameters (CBD) was investigated prospectively in 64 patients with gallstone disease examined by ultrasonography immediately before and 27 months to 39 months after the operation. In 32 patients with chronic cholecystitis and patent cystic ducts, CBD diameters increased slightly (median 4.6 mm pre- and 5.3 mm postoperatively; p less than 0.05). A group of 19 patients with acute cholecystitis or cystic duct occlusion showed a significant decrease (median 7.7 mm pre- and 5.5 mm postoperatively; p less than 0.05). In 13 patients with common bile duct stones, the CBD diameters also decreased significantly after surgical intervention (median 7.5 mm pre- and 5.0 mm postoperatively; p less than 0.05). The widest CBD diameter after cholecystectomy observed in this study was 10 mm. We conclude that either increases or decreases of the CBD diameters may occur after cholecystectomy in patients with calculous gallbladder disease, and that the postoperative evolution is governed by the exact nature of the underlying biliary disease at the time of the index operation.     

内镜逆行胰胆管造影术在不同类型困难胆管结石中的诊疗体会

目的 探讨内镜逆行胰胆管造影术（ERCP）在胆总管巨大结石、胆总管多发结石和消化道重建术后患者中的治疗效果，分析手术失败的原因及其影响因素。方法 回顾性分析2016年－2019年解放军联勤保障部队第九〇九医院收治的146例经ERCP治疗的困难胆管结石患者的临床资料。其中，A组（n = 43）结石直径 > 15 mm，B组（n = 21）结石数量 > 10枚，C组（n = 82）行上消化道重建。根据ERCP取石是否成功，分为取石成功组（n = 106）和取石失败组（n = 40），比较两组患者ERCP操作时间、插管次数、取石成功率、结石残余率、不良事件发生率、结石直径和消化道重建方式等，采用单因素和多因素分析困难胆管结石患者ERCP手术失败的原因。结果 3组患者操作时间、平均插管次数、结石直径、残余结石和激光碎石比较，差异均有统计学意义（P < 0.05）；单因素分析结果显示：困难胆管结石患者中，ERCP取石成功组与取石失败组ERCP操作时间、插管次数、结石数目、消化道重建和是否首次ERCP比较，差异均有统计学意义（P < 0.05）；多因素分析结果显示：ERCP操作时间、插管次数、多发结石和消化道重建是困难胆管结石患者ERCP取石失败的危险因素（P < 0.05）。结论 ERCP取石在困难胆管结石患者中安全、可行，但需根据个体情况制定合理的治疗方案。