Amy Hosmer

Predicting the likelihood of a persistent bile duct stone in patients with suspected choledocholithiasis: accuracy of existing guidelines and the impact of laboratory trends

BACKGROUND Existing guidelines aim to stratify the likelihood of choledocholithiasis to guide the use of ERCP versus a lower-risk diagnostic study such as EUS, MRCP, or intraoperative cholangiography. OBJECTIVE To assess the performance of existing guidelines in predicting choledocholithiasis and to determine whether trends in laboratory parameters improve diagnostic accuracy. DESIGN Retrospective cohort study. SETTING Tertiary-care hospital. PATIENTS Hospitalized patients presenting with suspected choledocholithiasis over a 6-year period. INTERVENTIONS Assessment of the American Society for Gastrointestinal Endoscopy (ASGE) guidelines, its component variables, and laboratory trends in predicting choledocholithiasis. MAIN OUTCOME MEASUREMENTS The presence of choledocholithiasis confirmed by EUS, MRCP, or ERCP. RESULTS A total of 179 (35.9%) of the 498 eligible patients met ASGE high-probability criteria for choledocholithiasis on initial presentation. Of those, 99 patients (56.3%) had a stone/sludge on subsequent confirmatory test. Of patients not meeting high-probability criteria on presentation, 111 (34.8%) had a stone/sludge. The overall accuracy of the guidelines in detecting choledocholithiasis was 62.1% (47.4% sensitivity, 73% specificity) based on data available at presentation. The accuracy was unchanged when incorporating the second set of liver chemistries obtained after admission (63.2%), suggesting that laboratory trends do not improve performance. LIMITATIONS Retrospective study, inconsistent timing of the second set of biochemical markers. CONCLUSION In our cohort of patients, existing choledocholithiasis guidelines lacked diagnostic accuracy, likely resulting in overuse of ERCP. Incorporation of laboratory trends did not improve performance. Additional research focused on risk stratification is necessary to meet the goal of eliminating unnecessary diagnostic ERCP.

Efficacy and Safety of Digital Single-Operator Cholangioscopy for Difficult Biliary Stones

BACKGROUND & AIMS: It is not clear whether digital single‐operator cholangioscopy (D‐SOC) with electrohydraulic and laser lithotripsy is effective in removal of difficult biliary stones. We investigated the safety and efficacy of D‐SOC with electrohydraulic and laser lithotripsy in an international, multicenter study of patients with difficult biliary stones. METHODS: We performed a retrospective analysis of 407 patients (60.4% female; mean age, 64.2 years) who underwent D‐SOC for difficult biliary stones at 22 tertiary centers in the United States, United Kingdom, or Korea from February 2015 through December 2016; 306 patients underwent electrohydraulic lithotripsy and 101 (24.8%) underwent laser lithotripsy. Univariate and multivariable analyses were performed to identify factors associated with technical failure and the need for more than 1 D‐SOC electrohydraulic or laser lithotripsy session to clear the bile duct. RESULTS: The mean procedure time was longer in the electrohydraulic lithotripsy group (73.9 minutes) than in the laser lithotripsy group (49.9 minutes; P < .001). Ducts were completely cleared (technical success) in 97.3% of patients (96.7% of patients with electrohydraulic lithotripsy vs 99% patients with laser lithotripsy; P = .31). Ducts were cleared in a single session in 77.4% of patients (74.5% by electrohydraulic lithotripsy and 86.1% by laser lithotripsy; P = .20). Electrohydraulic or laser lithotripsy failed in 11 patients (2.7%); 8 patients were treated by surgery. Adverse events occurred in 3.7% patients and the stone was incompletely removed from 6.6% of patients. On multivariable analysis, difficult anatomy or cannulation (duodenal diverticula or altered anatomy) correlated with technical failure (odds ratio, 5.18; 95% confidence interval, 1.26–21.2; P = .02). Procedure time increased odds of more than 1 session of D‐SOC electrohydraulic or laser lithotripsy (odds ratio, 1.02; 95% confidence interval, 1.01–1.03; P < .001). CONCLUSIONS: In a multicenter, international, retrospective analysis, we found D‐SOC with electrohydraulic or laser lithotripsy to be effective and safe in more than 95% of patients with difficult biliary stones. Fewer than 5% of patients require additional treatment with surgery and/or extracorporeal shockwave lithotripsy to clear the duct.

Endoscopic ultrasound-guided hepaticogastrostomy and antegrade clearance of biliary lithiasis in patients with surgically-altered anatomy

Background and study aims  Endoscopic retrograde cholangiography (ERC) in patients with complex surgically-altered anatomy (SAA) is technically demanding and has limitations. Developments in EUS-guided procedures allow alternative approaches for patients with altered gastrointestinal anatomy and biliary lithiasis. Patients and methods  Single-center, retrospective review of prospectively entered patients with SAA who underwent EUS-guided hepaticogastrostomy (HGS) followed by an interval antegrade endoscopic clearance of biliary lithiasis. Results  9 patients with Roux-en-Y anatomy underwent HGS to allow clearance of biliary lithiasis after a mean of 2.5 procedures. Technical success was achieved in 100 % of patients utilizing subsequent antegrade endoscopic techniques after HGS including: balloon sweep (9), transpapillary balloon dilation (8), cholangioscopy with electrohydraulic lithotripsy (4), and mechanical lithotripsy (1). HGS stents were removed in all patients. 1 adverse event (cholangitis) occurred after cholangioscopy and prolonged intraductal electrohydraulic lithotripsy. Conclusion  EUS-guided antegrade therapy for the management of biliary lithiasis in patients with altered gastrointestinal anatomy appears efficacious with a low risk of adverse events. These preliminary results suggest this approach should be considered at centers with available expertise.

Management of an esophagojejunal anastomotic stricture using a lumen-apposing metal stent

re 1. A, Esophagram demonstrating the esophagojejunal anastomotic stricture. B, Endoscopic view of the esophagojejunal stricture before serial on dilation. C, Endoscopic view of the esophagojejunal stricture immediately before the second balloon dilation procedure. D, Deep submucosal g at 5 o’clock position after 12-mm balloon dilation, precluding safe dilation with larger-diameter balloons. E, Placement of a lumen-apposing metal across the esophagojejunal anastomotic stricture. F, Esophagojejunostomy after removal of lumen-apposing metal stent after a 4-week dwell.