Endoscopic Ultrasonography Can Prevent Unnecessary Diagnostic Endoscopic Retrograde Cholangiopancreatography Even in Patients with High Likelihood of Choledocholithiasis and Inconclusive Ultrasonography: Results of a Prospective Study

Ruchir Patel,Meghraj Ingle,Dhaval Choksi,Prateik Poddar,Vikas Pandey,Prabha Sawant 대한소화기내시경학회 2017 Clinical Endoscopy Vol.50 No.6

Background/Aims: Endoscopic retrograde cholangiopancreatography (ERCP) is the initial therapy recommended for patients with high likelihood of choledocholithiasis. To determine whether endoscopic ultrasonography (EUS) can prevent diagnostic ERCPs in patients with high probability of choledocholithiasis and inconclusive ultrasonography (US). Methods: All patients with high likelihood of choledocholithiasis and negative US underwent EUS. ERCP was performed for the patients who showed a definite stone/sludge on EUS. Patients without choledocholithiasis were followed up for 3 months. The primary outcome was avoidance of diagnostic ERCP. Results: We included 78 patients (51 women; 27 men). Of these, 25 and 7 (total 41%) were diagnosed with choledocholithiasis and sludge, respectively; stone/sludge was removed in 96.9% of the patients. EUS ruled out choledocholithiasis in 38 patients (48.7%). Two of them were found to have choledocholithiasis on follow-up. The sensitivity, specificity, positive and negative predictive value of EUS for detecting choledocholithiasis were 93.9%, 97.3%, 96.9%, and 94.7%, respectively. Unnecessary ERCP was avoided in 57.7% of the patients by using the EUS-first approach. Conclusions: EUS is a highly accurate and safe procedure. EUS can replace ERCP as the initial investigation in patients with a high probability of choledocholithiasis. It avoids unnecessary ERCP; hence, decreasing related costs and complications.

Diagnostic Value of Endoscopic Ultrasonography in Symptomatic Patients with High and Intermediate Probabilities of Common Bile Duct Stones and a Negative Computed Tomography Scan

( Tae Joo Jeon ),( Jae Hee Cho ),( Yeon Suk Kim ),( Si Young Song ),( Ji Young Park ) 대한소화기학회 2017 Gut and Liver Vol.11 No.2

Background/Aims: When computed tomography (CT) does not indicate choledocholithiasis in highly suspicious patients, there is no definite consensus on the subsequent modality. Endoscopic ultrasonography (EUS) indicates fewer procedure-related complications than endoscopic retrograde cholangio-pancreatography (ERCP) and has a lower cost than magnetic resonance cholangiopancreatography. Therefore, we aimed to investigate the diagnostic value of EUS in patients with suspected choledocholithiasis and negative CT findings. Methods: Between March 2008 and November 2014, we retrospectively evaluated 200 patients with negative CT find-ings and high or intermediate probabilities of choledocholi-thiasis. All patients initially underwent EUS followed by ERCP as a confirmatory criterion standard. The primary outcome in these patients was the accuracy of EUS in the detection of choledocholithiasis. The secondary outcome was the clinical prediction of common bile duct (CBD) stones in this group. Results: EUS indicated choledocholithiasis in 165 of the 200 patients, and ERCP confirmed choledocholithiasis in 161 patients (80.5%). The accuracy of EUS in the detection of choledocholithiasis was 94.0% (sensitivity, 97.5%; specificity, 79.5%; positive predictive value, 95.2%; negative predictive value, 88.6%). A multivariate analysis demonstrated that choledocholithiasis was strongly predicted by EUS detection of choledocholithiasis, an age >55 years and a clinical diag-nosis of cholangitis. Conclusions: An EUS-first approach is recommended for patients with suspected CBD stones and negative CT findings. (Gut Liver 2017;11:290-297)

확장이 없는 총담관 결석의 진단에서 내시경초음파검사의 유용성

이정환 ( Jung Hwan Lee ),김유선 ( You Sun Kim ),류수형 ( Soo Hyung Ryu ),이상렬 ( Sang Ryul Lee ),이수연 ( Su Yeon Lee ),박종혁 ( Jong Hyeok Park ),문정섭 ( Jeong Seop Moon ),김형훈 ( Hyung Hun Kim ) 대한소화기학회 2010 대한소화기학회지 Vol.56 No.2

Background/Aims: Endoscopic retrograde cholangiopancreatography (ERCP) is the most accurate modality in diagnosis of choledocholithiasis. However, it carries some complications. Endoscopic Ultrasonography (EUS) is less invasive than ERCP and used for the diagnosis of choledocholithiasis. Recent studies showed that a usefulness of EUS for the diagnosis of small choledocholithiasis without common bile duct (CBD) dilatation. For such a reason, ERCP is being replaced by EUS in the diagnosis of bile duct stones. The aim of this study was to investigate the accuracy of EUS for the diagnosis of choledocholithiasis without CBD dilatation. Methods: A total of 66 patients with suspected choledocholithiasis without CBD dilatation were enrolled. EUS were performed in all cases within 48 hours after computed tomography (CT) or ultrasonography (US). Final diagnosis was obtained by ERCP or clinical course (minimum 6 months follow-up). We analyzed the accuracy of US, CT, and EUS, respectively. Results: CT and US were performed in 51 and 15 cases, respectively. CBD stones were detected in 23 (35%) patients by ERCP. EUS showed 100% sensitivity, 95% specificity, 92% positive predictive value, and 100% negative predictive value for identifying CBD stones. CT or US showed 26%, 93%, 67%, and 70%, respectively. There were no EUS-related complications. Conclusions: EUS was more effective than CT or US and as accurate as ERCP for the diagnosis of small choledocholithiasis without CBD dilatation. Thus, EUS may help to avoid unnecessary diagnostic ERCP and its complication. (Korean J Gastroenterol 2010;56:97-102)

간외담관 담석증의 진단에 있어서 초음파내시경과 내시경적 역행성 담관조영술의 유용성의 비교

박현신,김명식,강효승,정석,이진우,권계숙,이돈행,김범수,김형길,신용운,김영수 대한내과학회 2004 대한내과학회지 Vol.66 No.5

목적 : 간외담관 담석증을 진단하는데 있어 내시경적역행성 담관조영술과 초음파내시경은 보편적인 진단법으로 인정되고 있다. 담관담석증이 의심되는 환자의 20~80%에서 담석이 없는 경우로 많은 경우에서 내시경적 역행성 담관조영술과 유두절개술이 불필요한 검사가 될 수 있다. 초음파내시경은 내시경적 역행성 담관조영술에 비해 비침습적이며 합병증이 거의 없는 장점이 있다. 간외담관 담석증의 진단에 있어 초음파내사경의 진단율을 내시경적 역행성 담관조영술과 전향적으로 비교하여 초음파내시경의 유용성을 검토하고자 하였다. 방법 : 간외담관 담석증의 의심되는 환자 73명을 대상으로 48시간이내에 초음파내시경과 내시경적 역행성 담관조영술을 순차적으로 시행하였다. 결과 : 초음파내시경과 내시경적 역행성 담관조영술을 모두 시행한 69명 중 53명(76.8%)에서 담관담석증을 확진하였고, 이 중 7예는 초음파내시경에서만 진단되었고, 모두 0.5 cm 이하의 소담석이었다 초음파내시경과 내시경적 역행성 담관조영술에서 음성ㅇ르 보인 16명(23.2%)에서는 유듀절개술을 시행하지 않고 1년 이상 추적관찰한 결과 증상재발과 담즙정체 증후가 모두 없었다. 내시경적 역행성 담관조영술 시행 후 1예에서 췌장염이 발생되었다고 금식 등의 보존적인 치료로 회복되었으며 초음파내시경으로 인한 합병증은 없었다. 결론 : 간외담관 담석증이 의심이 되는 환자에서 초음파내시경은 내시경적 역행성 담관조영술에 비해 진단적 예민도가 높고 필요 없을 수도 있는 침습적인 담관조영술과 유두절재술을 줄일 수 있다고 생각된다. Background : Endoscopic ultrasonography (EUS) and endoscopic retrograde cholangiography (ERC) are accurate for the diagnosis of common bile duct stone. But sometimes, endoscopic sphinctertomy is done unnecessarily in patients with suspected choledocholithiasis. Endoscopic ultrasonography is a promising procedure for the diagnosis of extrahepatic cholestasis due to noninvasiveness and accuracy. We comlared the effectiveness of endoscopic ultrasonography with endoscopic retrograde cholangiography in detecting the extrahepatic choledocholithiasis. Methods : sixty nine patients suspected choledocholithiasis. were evaluated using endoscopic ultrasonography (EUS) and endoscopic retrograde cholangiography (ERC). endoscopic sphinctertomy with instrumental exploration was then done when EUS or ERCP image showed the stones. Results : Choledocholithiasis was confirmed in 53 (76.8%) patients. Seven patients were false negative on ERC, of whom all were true positive on endoscopic ultrasonography. Six patients false negative on ERC had small stone (<5 min in diameter) in dilated bileduct one patients had impacted stone on the ampulla of Vater. Conclusion : EUS could be an accurate for the diagnosis of choledocholithiasis and may prevent inappropriate invasive exploration of the common bile duct.

Outcomes of laparoscopic choledochotomy using cholangioscopy via percutaneous-choledochal tube for the treatment of hepatolithiasis and choledocholithiasis: A preliminary Vietnamese study

Loi Van Le,Quang Van Vu,Thanh Van Le,Hieu Trung Le,Khue Kim Dang,Tuan Ngoc Vu,Anh Hoang Ngoc Nguyen,Thang Manh Tran 한국간담췌외과학회 2024 Annals of hepato-biliary-pancreatic surgery Vol.28 No.1

Backgrounds/Aims: Hepatolithiasis and choledocholithiasis are frequent pathologies and unfortunately, with the current treatment strategies, the recurrence incidence is still high. This study aimed to assess the outcomes of laparoscopic choledochotomy using cholangioscopy via the percutaneous-choledochal tube for the treatment of hepatolithiasis and choledocholithiasis in Vietnamese patients. Methods: A cross-sectional study of patients with hepatolithiasis and/or choledocholithiasis who underwent laparoscopic choledochotomy using intraoperative cholangioscopy via percutaneous-choledochal tube at the Department of Hepatopancreatobiliary Surgery, 108 Military Central Hospital, from June 2017 to March 2020. Results: A total of 84 patients were analyzed. Most patients were females (56.0%) with a median age of 55.56 years. Among them, 41.8% of patients had previous abdominal operations, with 33.4% having choledochotomy. All patients underwent successful laparoscopic common bile duct exploration followed by T-tube drainage without needing to convert to open surgery. Most patients (64.3%) had both intrahepatic and extrahepatic stones. The rate of stones ≥ 10 mm in diameter was 64.3%. Biliary strictures were observed in 19.1% of patients during cholangioscopy. Complete removal of stones was achieved in 54.8% of patients. Intraoperative complications were encountered in two patients, but there was no need to change the strategy. The mean operating time was 121.85 ± 30.47 minutes. The early postoperative complication rate was 9.6%, and all patients were managed conservatively. The residual stones were removed through the T-tube tract by subsequent choledochoscopy in 34/38 patients, so the total success rate was 95.2%. Conclusions: Laparoscopic choledochotomy combined with cholangioscopy through the percutaneous-choledochal tube is a safe and effective strategy for hepatolithiasis and/or choledocholithiasis, even in patients with a previous choledochotomy.

복강경하 담낭절제술 시술예정 환자에서 총담관결석의 진단에 대한 내시경적 초음파단층촬영술의 유용성

주재학(Jae Hak Joo),박찬욱(Chan Wook Park),송동화(Dong Hwa Song),이준성(Joon Seong Lee),이문성(Moon Sung Lee),조성원(Sung Won Cho),심찬섭(Chan Sup Shim) 대한소화기학회 1994 대한소화기학회지 Vol.26 No.4

N/A One hundred thirty two patients with symptomatic cholelithiasis were evaluated using endo- scopic ultrasonography(EUS), standard abdominal ultrasonography(US) and endoscopic retro- grade cholangiopancreatography(ERCP) for the detection of choledocholithiasis prior to laparoscopic cholecystectomy. Twenty eight patients(21.2% ) had choledocholithiasis and 21.4 % of patients with common bile duct stones had normal sized ducts in US. Whole common bile duct was successfully examined in all patients by EUS, but only 65.9% of patients by US and 94.7% of patienCS by ERCP. EUS det,ect,ed choledocholithiasis in 22 of 28 patientS(89.3% ), compared to 19 of 28 patients(67.9%) detected by US and 26 of 28 patients(92.9%) detected by ERCP. While no compliactions as a result of EUS encountered, complications resulting from ERCP occurred in 7 patients (5.3%), including cholecystitis in 2 patients, cholangitis in 3 patients and pancreatitis in 2 patients. These results suggest that EUS is more sensitive than standard abdominal ultrasonog..aphy and as sensitive as ERCP in the detection of choledocholithiasis. In view of complication and failure rates, EUS appears to offer significant advantages over ERCP. We concluded that EUS is safe and effective imaging technique in the diagnosis of choledocholithiasis prior to laparoscopic cholecystectomy.(Korean J Qastroenterol 1994; 26: 690 696)

총수담관 결석에 있어서 총수담관 십이지장 문합술과 경십이지장 괄약근 성형술식 비교

김곤홍(Kon Hong Kim),전형천(Heoung Cheon Jeon),김우길(Woo Kil Kim) 대한소화기학회 1994 대한소화기학회지 Vol.26 No.4

N/A There were various reports that the occurrence rate of choledocholithiasis in Korea is higher than Occidental. Therefore, it is predicted that the frequency of retained or recurrent stone after biliary surgery for the choledocholithiasis may be high too, but it can be minimized if we apply more reliable operation method to various conditions of choledocholithiasis. A cornpara- tive retrospective clinical analysis was undertaken to assess the operative results in 100 con- secutive patients with choledocholithiasis who underwent choledochoduodenostomy(CDD group,' 51 cases) or transduodenal sphincteroplasty(TDS group,' 49 cases) during the period from May,1981 through October, 1992. Median duration of follow up was 45 rnonths(range 5 to 128 months) in CDD group and 38 months(range 7 to 98 months) in TDS group. The two groups were comparable with respect to age, operative urgency, associated disease and follow up duration except sex ratio. There was tendency of choice as first time operation in TDS group(82% vs 61%) rather than 2nd or 3rd time operation which were more frequently per- formed in CDD group(p<0.05). Main operative indication was CBD stone with combined IHD stones(61%) in CDD group and was impacted ampullary stone(49%) in TDS group. Mean di- ameter of CBD was greater in CDD group(2.3cm) cornpared to TDS group(1.6cm)(p<0.01). Median operative time and duration of hospital stay were shorter in CDD group compared to TDS group(139minutes vs 174minutes, p<0.001; 13days vs 17days, p<0.05 respectively). There was no difference in change of the postoperative liver function test between two groups. About 60 70% of patients with preoperatively elevated SGOT, SGPT, ALP and bilirubin value were returned to norrnal within 7 days following operations. Early postoperative evalua- tion revealed no differences between the CDD and TDS group with respect to retained stone (16% respectively), wound infection (4% vs 8%)(p=0.63) and operative mortality (2% vs 4 %)(p=0.97), but major and overall morbidity rate were higher in TDS group compared to CDD group (41% vs 20%, and 51% vs 25%, p<0.01, respectively). Late evaluation with long term follow up, showed no differences between the CDD and TDS group with respect to as- cending cholangitis(24% vs 12%, p=0.227), recurrent stone(12% vs 4%, p=0.295). These results lead to the conclusion that CDD is more safer, simpler, less time consuming procedure with short hospital stay and equal effectiveness compared to TDS, but TDS is primarily indicated in patients with impacted ampullary stone and srnall CBD diameter or biliary pancreatitis.(Korean J Gastroenterol 1994; 26: 683 689)

담낭 담석으로 인한 복강경 담낭절제술시 총수담관결석 동반 유무의 예측인자

김재선,권오상,최창원,임형준,정길만,변관수,최상용,박영태,김진호 大韓消化器病學會 1997 大韓消化器病學會誌 Vol.30 No.3

Evaluating the Revised American Society for Gastrointestinal Endoscopy Guidelines for Common Bile Duct Stone Diagnosis

Jake S. Jacob,Michelle E. Lee,Erin Y. Chew,Aaron P. Thrift,Robert J. Sealock 대한소화기내시경학회 2021 Clinical Endoscopy Vol.54 No.2

Background/Aims: The American Society for Gastrointestinal Endoscopy (ASGE) revised its guidelines for risk stratification ofpatients with suspected choledocholithiasis. This study aimed to assess the diagnostic performance of the revision and to compare itto the previous guidelines. Methods: We conducted a retrospective cohort study of 267 patients with suspected choledocholithiasis. We identified high-riskpatients according to the original and revised guidelines and examined the diagnostic accuracy of both guidelines. We measured theassociation between individual criteria and choledocholithiasis. Results: Under the original guidelines, 165 (62%) patients met the criteria for high risk, of whom 79% had confirmedcholedocholithiasis. The categorization had a sensitivity and specificity of 68% and 55%, respectively, for the detectionof choledocholithiasis. Under the revised guidelines, 86 (32%) patients met the criteria for high risk, of whom 83% hadcholedocholithiasis. The revised categorization had a lower sensitivity and higher specificity of 37% and 80%, respectively. Thepositive predictive value of the high-risk categorization increased with the revision, reflecting a potential decrease in diagnosticendoscopic retrograde cholangiopancreatograpies (ERCPs). Stone visualized on imaging had the greatest specificity forcholedocholithiasis. Gallstone pancreatitis was not associated with the risk for choledocholithiasis. Conclusions: The 2019 revision of the ASGE guidelines decreases the utilization of ERCP as a diagnostic modality and offers animproved risk stratification tool.

Sensitivity and Specificity of Magnetic Resonance Cholangiopancreatography versus Endoscopic Ultrasonography against Endoscopic Retrograde Cholangiopancreatography in Diagnosing Choledocholithiasis: The Indonesian Experience

Dadang Makmun,Achmad Fauzi,Hamzah Shatri 대한소화기내시경학회 2017 Clinical Endoscopy Vol.50 No.5

Background/Aims: Biliary stone disease is one of the most common conditions leading to hospitalization. In addition to endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasonography (EUS) and magnetic resonance cholangiopancreatography (MRCP) are required in diagnosing choledocholithiasis. This study aimed to compare the sensitivity and specificity of EUS and MRCP against ERCP in diagnosing choledocholithiasis. Methods: This retrospective study was conducted after prospective collection of data involving 62 suspected choledocholithiasis patients who underwent ERCP from June 2013 to August 2014. Patients were divided into two groups. The first group (31 patients) underwent EUS and the second group (31 patients) underwent MRCP. Then, ERCP was performed in both groups. Sensitivity, specificity, and diagnostic accuracy of EUS and MRCP were determined by comparing them to ERCP, which is the gold standard. Results: The male to female ratio was 3:2. The mean ages were 47.25 years in the first group and 52.9 years in the second group. Sensitivity, specificity, accuracy, positive predictive value, and negative predictive value for EUS were 96%, 57%, 87%, 88%, and 80% respectively, and for MRCP were 81%, 40%, 68%, 74%, and 50%, respectively. Conclusions: EUS is a better diagnostic tool than MRCP for diagnosing choledocholithiasis.