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Weiss T, Dreznik Y, Paran M, Kravarusic D. Approach to biliary tree clearance in pediatric patients undergoing cholecystectomy: insights from a tertiary hospital. Pediatr Surg Int 2025; 41:139. [PMID: 40392244 DOI: 10.1007/s00383-025-06037-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/04/2025] [Indexed: 05/22/2025]
Abstract
INTRODUCTION Despite the increasing rate of cholecystectomy in pediatric patients, no standardized protocols for perioperative biliary tree clearance in children exist and the applicability of adult guidelines to pediatric patients remains uncertain. AIM To identify predictors for CBD stones in pediatric patients undergoing cholecystectomy and to evaluate the applicability of adult guidelines for children. MATERIALS AND METHODS We conducted a retrospective study on pediatric patients who underwent cholecystectomy for cholelithiasis at a tertiary pediatric medical center from 2011 to 2024. Medical records were reviewed for demographic and clinical characteristics. Elevated bilirubin was defined as above 4 mg/dL with > 20% conjugated. The outcomes measured included the presence of CBD stones detected by ERCP or intraoperative cholangiography and post-cholecystectomy complications due to retained stones. RESULTS A total of 177 patients were included in the study, with a median age of 13.4 years (IQR 9, 16.4). Sixteen patients (9%) were diagnosed with CBD stones. Elevated bilirubin, dilated CBD, and filling defects on primary imaging were strongly associated with CBD stones (50.0% vs. 9.9%, p < 0.001, 62.5% vs. 9.3%, p < 0.001, 43.8% vs. 4.4%, p < 0.001). The 2019 ASGE guidelines had a sensitivity of 56.2% and a specificity of 91.1% for predicting CBD stones. Adjusting the guidelines to classify elevated bilirubin as an independent high-risk feature improved sensitivity to 68.8%, with a slight reduction in specificity to 87.6%. CONCLUSION Our study suggests that the 2019 ASGE guidelines are applicable to children. Based on our findings and previous data, it seems reasonable to classify bilirubin elevation as an independent high-risk feature.
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Affiliation(s)
- Tal Weiss
- Faculty of Medicine, Tel Aviv University, Kiryat HaUniversita, Ramat Aviv, Tel Aviv, Israel.
- Department of General Surgery, Hillel Yaffe Medical Center, The Rapaport School of Medicine, Technion, Haifa, Israel.
| | - Yael Dreznik
- Department of Pediatric and Adolescent Surgery, Schneider Children's Medical Center of Israel, Petah-Tiqwa, Israel
- Faculty of Medicine, Tel Aviv University, Kiryat HaUniversita, Ramat Aviv, Tel Aviv, Israel
| | - Maya Paran
- Department of Pediatric and Adolescent Surgery, Schneider Children's Medical Center of Israel, Petah-Tiqwa, Israel
- Faculty of Medicine, Tel Aviv University, Kiryat HaUniversita, Ramat Aviv, Tel Aviv, Israel
| | - Dragan Kravarusic
- Department of Pediatric and Adolescent Surgery, Schneider Children's Medical Center of Israel, Petah-Tiqwa, Israel
- Faculty of Medicine, Tel Aviv University, Kiryat HaUniversita, Ramat Aviv, Tel Aviv, Israel
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García-Villarreal F, Torres-Treviño LM, Herrera-Figueroa C, Jáquez-Quintana JO, Garza-Galindo AA, Cortez-Hernández CA, García-Compeán D, Jiménez-Castillo RA, Maldonado-Garza HJ, González-González JA. An App model that utilizes a logistic regression algorithm for predicting choledocholithiasis: A prospective clinical trial. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2025; 90:22-28. [PMID: 40274470 DOI: 10.1016/j.rgmxen.2024.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 05/23/2024] [Indexed: 04/26/2025]
Abstract
INTRODUCTION AND AIM The diagnostic yield of the current criteria for assigning the risk of choledocholithiasis (CL) is inaccurate. The aim of our work was to develop a logistic regression model for predicting CL diagnosis in patients catalogued as either intermediate or high risk for CL, according to the criteria of the American Society for Gastrointestinal Endoscopy (ASGE). MATERIAL AND METHODS We conducted an analytic, observational, cross-sectional study for evaluating the diagnostic yield of a logistic regression model in adults with intermediate or high risk for CL. A receiver operating characteristic (ROC) curve analysis was done to determine the best cutoff point for predicting the diagnosis of CL. Endoscopic retrograde cholangiopancreatography (ERCP) was utilized as the gold standard for diagnosing CL. RESULTS A total of 148 patients suspected of presenting with CL were studied. In our cohort, 71 had immediate risk and 77 had high risk. CL diagnosis was confirmed in 102 patients (69%). Our model showed an area under the curve (AUC) of 0.68. In patients with an intermediate risk for CL, the AUC value was 0.72 and the positive predictive value (PPV) was 70%. In patients with a high risk for CL, the AUC value was 0.78 and the PPV was 89%. CONCLUSION Our model appears to better predict the diagnosis of CL than the ASGE criteria for patients with an intermediate or high risk for the disease. Our model can guide clinical decisions in patients with suspected CL.
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Affiliation(s)
- F García-Villarreal
- Departamento de Medicina Interna, Servicio de Gastroenterología y Endoscopia Digestiva, Hospital Universitario "Dr. José E. González", Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, Mexico
| | - L M Torres-Treviño
- Facultad de Ingeniería Mecánica y Eléctrica, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, Mexico
| | - C Herrera-Figueroa
- Departamento de Medicina Interna, Servicio de Gastroenterología y Endoscopia Digestiva, Hospital Universitario "Dr. José E. González", Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, Mexico
| | - J O Jáquez-Quintana
- Departamento de Medicina Interna, Servicio de Gastroenterología y Endoscopia Digestiva, Hospital Universitario "Dr. José E. González", Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, Mexico
| | - A A Garza-Galindo
- Departamento de Medicina Interna, Servicio de Gastroenterología y Endoscopia Digestiva, Hospital Universitario "Dr. José E. González", Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, Mexico
| | - C A Cortez-Hernández
- Departamento de Medicina Interna, Servicio de Gastroenterología y Endoscopia Digestiva, Hospital Universitario "Dr. José E. González", Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, Mexico
| | - D García-Compeán
- Departamento de Medicina Interna, Servicio de Gastroenterología y Endoscopia Digestiva, Hospital Universitario "Dr. José E. González", Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, Mexico
| | - R A Jiménez-Castillo
- Departamento de Medicina Interna, Servicio de Gastroenterología y Endoscopia Digestiva, Hospital Universitario "Dr. José E. González", Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, Mexico
| | - H J Maldonado-Garza
- Departamento de Medicina Interna, Servicio de Gastroenterología y Endoscopia Digestiva, Hospital Universitario "Dr. José E. González", Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, Mexico
| | - J A González-González
- Departamento de Medicina Interna, Servicio de Gastroenterología y Endoscopia Digestiva, Hospital Universitario "Dr. José E. González", Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, Mexico.
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García-Villarreal F, Torres-Treviño L, Herrera-Figueroa C, Jáquez-Quintana J, Garza-Galindo A, Cortez-Hernández C, García-Compeán D, Jiménez-Castillo R, Maldonado-Garza H, González-González J. Un modelo tipo App que utiliza un algoritmo de regresión logística para predecir coledocolitiasis. Un ensayo clínico prospectivo. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2025; 90:22-28. [DOI: 10.1016/j.rgmx.2024.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/02/2025]
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Woo JH, Cho H, Ryu K, Choi YW, Lee S, Lee TH, Kim DS, Choi IS, Moon JI, Lee SJ. Predictors of Choledocholithiasis in Cholecystectomy Patients and Their Cutoff Values and Prediction Model in Korea in Comparison with the 2019 ASGE Guidelines. Gut Liver 2024; 18:1060-1068. [PMID: 38712399 PMCID: PMC11565007 DOI: 10.5009/gnl230534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 02/09/2024] [Accepted: 02/13/2024] [Indexed: 05/08/2024] Open
Abstract
Background/Aims : In 2019, the American Society for Gastrointestinal Endoscopy (ASGE) established clinical predictors for choledocholithiasis. Our study was designed to evaluate these predictors within the Korean clinical context, establish cutoff values, and develop a predictive model. Methods : This retrospective study analyzed patients who underwent laparoscopic cholecystectomy. The relationships between choledocholithiasis and predictors including age, blood tests, and imaging findings were assessed through univariate and multivariate logistic regression analyses. We established Korean cutoff values for these predictors and developed a scoring system for choledocholithiasis using a multivariate logistic regression. The performance of this scoring system was then compared with that of the 2019 ASGE guidelines through a receiver operating characteristic curve. Results : We established Korean cutoff values for age (>70 years), alanine aminotransferase (>26.5 U/L), aspartate aminotransferase (>28.5 U/L), gamma-glutamyl transferase (GGT; >82.5 U/L), alkaline phosphatase (ALP; >77.5 U/L), and total bilirubin (>0.95 mg/dL). In the multivariate analysis, only age >70 years, GGT >77.5 U/L, ALP >77.5 U/L, and common bile duct dilatation remained significant. We then developed a new Korean risk stratification model from the multivariate analysis, with an area under the curve of 0.777 (95% confidence interval, 0.75 to 0.81). Our model was stratified into the low-risk, intermediate-risk, and high-risk groups with the scores being <1.0, 1.0-5.5, and >5.5, respectively. Conclusions : Predictors of choledocholithiasis in cholecystectomy patients and their cutoff values in Korean should be adjusted and further studies are needed to develop appropriate guidelines.
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Affiliation(s)
- Jung Hun Woo
- Departments of Gastroenterology, Konyang University Myunggok Medical Research Institute, Daejeon, Korea
| | - Hwanhyi Cho
- Departments of Gastroenterology, Konyang University Myunggok Medical Research Institute, Daejeon, Korea
| | - Kihyun Ryu
- Departments of Gastroenterology, Konyang University Myunggok Medical Research Institute, Daejeon, Korea
| | - Young Woo Choi
- Departments of Gastroenterology, Konyang University Myunggok Medical Research Institute, Daejeon, Korea
| | - Sanghyuk Lee
- Departments of Gastroenterology, Konyang University Myunggok Medical Research Institute, Daejeon, Korea
| | - Tae Hee Lee
- Departments of Gastroenterology, Konyang University Myunggok Medical Research Institute, Daejeon, Korea
| | - Dae Sung Kim
- Departments of Gastroenterology, Konyang University Myunggok Medical Research Institute, Daejeon, Korea
| | - In Seok Choi
- Departments of General Surgery, Konyang University Myunggok Medical Research Institute, Daejeon, Korea
| | - Ju Ik Moon
- Departments of General Surgery, Konyang University Myunggok Medical Research Institute, Daejeon, Korea
| | - Seung Jae Lee
- Departments of General Surgery, Konyang University Myunggok Medical Research Institute, Daejeon, Korea
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Huerta-Reyna R, Guevara-Torres L, Martínez-Jiménez MA, Armas-Zarate F, Aguilar-García J, Waldo-Hernández LI, Martínez-Martínez MU. Development and validation of a predictive model for choledocholithiasis. World J Surg 2024; 48:1730-1738. [PMID: 38725097 DOI: 10.1002/wjs.12206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Accepted: 04/22/2024] [Indexed: 07/05/2024]
Abstract
BACKGROUND Gallstone-related conditions affect a significant portion of the population, with varying prevalence among different ethnic groups. Complications such as pancreatitis and cholangitis are associated with the presence of common bile duct (CBD) stones. Existing guidelines for diagnosing choledocholithiasis lack precision, leading to excessive use of invasive procedures like endoscopic retrograde cholangiopancreatography (ERCP). METHODS A prospective study was conducted at Hospital Central "Dr. Ignacio Morones Prieto," involving 374 patients in the development cohort and 154 patients in the validation cohort. Patients meeting inclusion criteria underwent biochemical testing and ultrasonography. A predictive scoring system was developed using logistic regression and validated in an independent cohort. Clinical and laboratory variables were collected, and model performance was assessed using receiver-operator characteristic (ROC) curves. RESULTS The predictive model incorporated variables such as age, pancreatitis, cholangitis, bilirubin levels, and CBD stone presence on ultrasound. The model demonstrated an area under the ROC curve (AUC) of 93.81% in the validation dataset. By adjusting the threshold defining high-risk probability to 40%, the model improved specificity and sensitivity compared to existing guidelines. Notably, the model reclassified patients, leading to a more accurate risk assessment. CONCLUSIONS The developed algorithm accurately predicts choledocholithiasis non-invasively in patients with symptomatic gallstones. This tool has the potential to reduce reliance on costly or invasive procedures like magnetic resonance cholangiopancreatography and ERCP, offering a more efficient and cost-effective approach to patient management. The user-friendly calculator developed in this study could streamline diagnostic procedures, particularly in resource-limited healthcare settings, ultimately improving patient care.
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Affiliation(s)
- Raúl Huerta-Reyna
- Department of Surgery, Hospital Central Dr. Ignacio Morones Prieto, San Luis Potosí, México
| | - Lorenzo Guevara-Torres
- Department of Surgery, Hospital Central Dr. Ignacio Morones Prieto, San Luis Potosí, México
| | | | - Francisco Armas-Zarate
- Department of Surgery, Hospital Central Dr. Ignacio Morones Prieto, San Luis Potosí, México
| | - Jorge Aguilar-García
- Department of Surgery, Hospital Central Dr. Ignacio Morones Prieto, San Luis Potosí, México
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Xiao CH, Liu P, Zhang HH, Yang F, Chen X, Huang F, Liu JB, Tan XZ. Incremental diagnostic value of virtual non-contrast dual-energy CT for the diagnosis of choledocholithiasis over conventional unenhanced CT. Diagn Interv Imaging 2024; 105:292-298. [PMID: 38378382 DOI: 10.1016/j.diii.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 02/04/2024] [Accepted: 02/06/2024] [Indexed: 02/22/2024]
Abstract
PURPOSE The purpose of this study was to evaluate the incremental diagnostic value of virtual non-contrast (VNC) images derived from unenhanced dual-energy computed tomography (CT) for the diagnosis of choledocholithiasis by comparison with conventional unenhanced CT. MATERIALS AND METHODS Eighty-nine patients with gallbladder stones who had undergone both abdominal unenhanced dual-energy CT and magnetic resonance cholangiopancreatography (MRCP) were retrospectively included. There were 53 men and 36 women, with a mean age of 54 ± 13 (standard deviation) years (age range: 41-67 years). VNC and conventional CT images were generated. Two independent radiologists evaluated the presence of choledocholithiasis in three reading sessions (session 1, conventional unenhanced CT images; session 2, VNC images; session 3, conventional unenhanced CT plus VNC images). The reading time to identify choledocholithiasis was recorded. Inter-reader agreement was measured by using the Cohen kappa (κ) test. Incremental diagnostic value of VNC imaging when combined with conventional unenhanced CT was assessed based on discrimination (area under the curve [AUC]) and clinical utility (decision curve analysis). The diagnostic performance of dual-energy CT and that of MRCP were compared using DeLong test. RESULTS Using the standard of reference, 39 patients (39/89; 44%) had choledocholithiasis. The diagnosis of choledocholithiasis was improved using VNC images in combination with conventional unenhanced CT (AUC, 0.877; 95% confidence interval [CI]: 0.808, 0.947) by comparison with conventional unenhanced CT alone (AUC, 0.789; 95% CI: 0.718, 0.877) (P = 0.033) and achieved almost perfect inter-reader agreement (κ = 0.88; 95% CI: 0.72, 1.00) for the diagnosis of choledocholithiasis, without lengthening the median reading time (16.2 s for the combination of conventional CT and VNC images vs. 14.7 s for conventional CT alone; P= 0.325). Based on decision curve analysis, adding VNC imaging to conventional unenhanced CT resulted in a higher net benefit among most of decision thresholds. No differences in diagnostic performance were found between the combination of conventional unenhanced CT and VNC imaging (AUC, 0.877; 95% CI: 0.808, 0.947) and MRCP (AUC, 0.913; 95% CI: 0.852, 0.974) (P= 0.458). CONCLUSIONS VNC images derived from dual-energy unenhanced CT have incremental diagnostic value for the diagnosis of choledocholithiasis. Unenhanced CT in a dual-energy mode may be a useful tool for the diagnosis of choledocholithiasis.
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Affiliation(s)
- Chang-Hui Xiao
- Department of Radiology, Hunan Provincial People's Hospital, the First Affiliated Hospital of Hunan Normal University, Changsha 410005, China; Department of Radiology, Changde Hospital, Xiangya School of Medicine, Central South University, Changde 415000, Hunan, China
| | - Peng Liu
- Department of Radiology, Hunan Provincial People's Hospital, the First Affiliated Hospital of Hunan Normal University, Changsha 410005, China
| | - Hui-Hui Zhang
- Department of Radiology, Hunan Provincial People's Hospital, the First Affiliated Hospital of Hunan Normal University, Changsha 410005, China
| | - Fan Yang
- Department of Radiology, Hunan Provincial People's Hospital, the First Affiliated Hospital of Hunan Normal University, Changsha 410005, China
| | - Xiang Chen
- Department of Radiology, Hunan Provincial People's Hospital, the First Affiliated Hospital of Hunan Normal University, Changsha 410005, China
| | - Feng Huang
- Department of Radiology, Hunan Provincial People's Hospital, the First Affiliated Hospital of Hunan Normal University, Changsha 410005, China
| | - Jian-Bin Liu
- Department of Radiology, Hunan Provincial People's Hospital, the First Affiliated Hospital of Hunan Normal University, Changsha 410005, China
| | - Xian-Zheng Tan
- Department of Radiology, Hunan Provincial People's Hospital, the First Affiliated Hospital of Hunan Normal University, Changsha 410005, China.
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Rigby MJ, Tawfiq RK, Szostek JH. 40-Year-Old Man With Epigastric Abdominal Pain and Nausea. Mayo Clin Proc 2024; 99:1167-1172. [PMID: 38829294 DOI: 10.1016/j.mayocp.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 09/06/2023] [Accepted: 09/07/2023] [Indexed: 06/05/2024]
Affiliation(s)
- Michael J Rigby
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Reema K Tawfiq
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Jason H Szostek
- Advisor to residents and Consultant in General Internal Medicine, Mayo Clinic, Rochester, MN.
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Steinway SN, Tang B, Telezing J, Ashok A, Kamal A, Yu CY, Jagtap N, Buxbaum JL, Elmunzer J, Wani SB, Khashab MA, Caffo BS, Akshintala VS. A machine learning-based choledocholithiasis prediction tool to improve ERCP decision making: a proof-of-concept study. Endoscopy 2024; 56:165-171. [PMID: 37699524 DOI: 10.1055/a-2174-0534] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/14/2023]
Abstract
BACKGROUND Previous studies demonstrated limited accuracy of existing guidelines for predicting choledocholithiasis, leading to overutilization of endoscopic retrograde cholangiopancreatography (ERCP). More accurate stratification may improve patient selection for ERCP and allow use of lower-risk modalities. METHODS A machine learning model was developed using patient information from two published cohort studies that evaluated performance of guidelines in predicting choledocholithiasis. Prediction models were developed using the gradient boosting model (GBM) machine learning method. GBM performance was evaluated using 10-fold cross-validation and area under the receiver operating characteristic curve (AUC). Important predictors of choledocholithiasis were identified based on relative importance in the GBM. RESULTS 1378 patients (mean age 43.3 years; 61.2% female) were included in the GBM and 59.4% had choledocholithiasis. Eight variables were identified as predictors of choledocholithiasis. The GBM had accuracy of 71.5% (SD 2.5%) (AUC 0.79 [SD 0.06]) and performed better than the 2019 American Society for Gastrointestinal Endoscopy (ASGE) guidelines (accuracy 62.4% [SD 2.6%]; AUC 0.63 [SD 0.03]) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines (accuracy 62.8% [SD 2.6%]; AUC 0.67 [SD 0.02]). The GBM correctly categorized 22% of patients directed to unnecessary ERCP by ASGE guidelines, and appropriately recommended as the next management step 48% of ERCPs incorrectly rejected by ESGE guidelines. CONCLUSIONS A machine learning-based tool was created, providing real-time, personalized, objective probability of choledocholithiasis and ERCP recommendations. This more accurately directed ERCP use than existing ASGE and ESGE guidelines, and has the potential to reduce morbidity associated with ERCP or missed choledocholithiasis.
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Affiliation(s)
- Steven N Steinway
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, United States
| | - Bohao Tang
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, United States
| | - Jeremy Telezing
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, United States
| | - Aditya Ashok
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, United States
| | - Ayesha Kamal
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, United States
| | - Chung Yao Yu
- Division of Gastroenterology, University of Southern California Keck School of Medicine, Los Angeles, United States
| | - Nitin Jagtap
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - James L Buxbaum
- Division of Gastroenterology, University of Southern California Keck School of Medicine, San Francisco, United States
| | - Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, United States
| | - Sachin B Wani
- Division of Gastroenterology, University of Colorado Anschutz Medical Campus, Aurora, United States
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, United States
| | - Brian S Caffo
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, United States
| | - Venkata S Akshintala
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, United States
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Wong WF, Kuo YT, Han ML, Wang HP. Endoscopic ultrasound avoids diagnostic ERCP among the ASGE high-risk group - Experience in an Asian population. J Formos Med Assoc 2024; 123:374-380. [PMID: 37673777 DOI: 10.1016/j.jfma.2023.08.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 08/18/2023] [Accepted: 08/23/2023] [Indexed: 09/08/2023] Open
Abstract
BACKGROUND A prediction system for common bile duct (CBD) stones was originally published by the American Society for Gastrointestinal Endoscopy (ASGE) in 2010 and was last revised in 2019. We wanted to investigate its application in an Asian population, who have different etiologies of bile duct stone formation and accessibility to medical service compared to the West. METHODS This is a single center retrospective study. Patients who received endoscopic ultrasound (EUS) for suspected CBD stones were collected from our endoscopic record system over a 10-year period. The accuracy of the revised ASGE criteria was estimated according to the results of EUS. A minimum follow-up of 6 months was required to detect false negative results. RESULTS 142 patients were enrolled, 87 (61%) patients had CBD stones. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of the revised ASGE criteria for high-risk patients were 69%, 38%, 64%, 44%, and 57%. 36% of the ASGE-defined high-risk patients negative for CBD stones on EUS. The two significant predictors for CBD stone were CBD dilatation (adjusted OR 3.06, 95% C.I. 1.31-7.17, p = 0.010) and ascending cholangitis (adjusted OR 2.28, 95% C.I. 1.01-5.15, p = 0.047). CONCLUSION ASGE recommends that patients defined as high-risk for choledocholithiasis be considered for direct ERCP without prior need for confirmation imaging. However, our findings indicate a high rate (36%) of patients in that group negative for CBD stones on EUS. Hence, EUS is still be suggested first in selective high-risk patients so that diagnostic ERCP can be avoided in our Asian society.
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Affiliation(s)
- Weng-Fai Wong
- Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan.
| | - Yu-Ting Kuo
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan.
| | - Ming-Lun Han
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan.
| | - Hsiu-Po Wang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.
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Dos Santos JS, Kemp R, Orquera AGM, Gaspar AF, Júnior JRL, Queiroz LTA, Avezum VAPAF, Ardengh JC, Sankarankutty AK, Lima LS. The Safety and Cost Analysis of Outpatient Laparoendoscopy in the Treatment of Cholecystocholedocholithiasis: A Retrospective Study. J Clin Med 2024; 13:460. [PMID: 38256593 PMCID: PMC10816273 DOI: 10.3390/jcm13020460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 01/04/2024] [Accepted: 01/11/2024] [Indexed: 01/24/2024] Open
Abstract
INTRODUCTION The advantages of single-stage treatment of cholecystocholedocholithiasis are well established, but the conditions for carrying out treatment on an outpatient basis require a review of concepts and practices of medical corporations. OBJECTIVE To evaluate the practice of treating cholecystocholedocholithiasis by laparoendoscopy on an outpatient basis with cost analysis. METHOD A retrospective study was conducted on patients with cholecystocholedocholithiasis treated by combined laparoscopic cholecystectomy and endoscopic choledocholithotomy from January 2015 to January 2019. After collecting data from physical and digital medical records, the patients were divided into two groups-AR (n = 42)-ambulatory regimen and HR (n = 28)-hospitalization regimen-which were compared in terms of demographic, clinical and treatment variables and their results, as well as in terms of costs. RESULTS The mean age of the AR group was lower than that of the HR group and the physical status of the AR patients was better when assessed according to the American Society of Anesthesiologists (ASA) (p = 0.01). There was no difference between groups regarding the risk of choledocholithiasis (p = 0.99). For the AR group, the length of stay was shorter: 11.29 h × 65.21 h (p = 0.02), as was the incidence of postoperative complications assessed by applying the Clavien-Dindo classification: 3 (7.1%) × 11 (39.2%) (p < 0.01). The total mean costs were higher for the HR group (USD 2489.93) than the AR group (USD 1650.98) (p = 0.02). CONCLUSION Outpatient treatment of cholecystocholedocholithiasis by laparoendoscopy is safe and viable for most cases, has a lower cost and can support the reorientation of training and practice of hepatobiliary surgeons.
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Affiliation(s)
- José Sebastião Dos Santos
- Department of Surgery and Anatomy, Faculty of Medicine of Ribeirão Preto, University of São Paulo (FMRP-USP), São Paulo 05508-220, Brazil
| | - Rafael Kemp
- Department of Surgery and Anatomy, Faculty of Medicine of Ribeirão Preto, University of São Paulo (FMRP-USP), São Paulo 05508-220, Brazil
| | - Alicia Guadalupe Mendoza Orquera
- Postgraduate Program, Department of Surgery and Anatomy, Faculty of Medicine of Ribeirão Preto, University of São Paulo (FMRP-USP), São Paulo 05508-220, Brazil
| | - Alberto Facury Gaspar
- Postgraduate Program, Department of Surgery and Anatomy, Faculty of Medicine of Ribeirão Preto, University of São Paulo (FMRP-USP), São Paulo 05508-220, Brazil
- University Hospital, Faculty of Medicine of Ribeirão Preto, University of São Paulo (FMRP-USP), São Paulo 05508-220, Brazil
| | - Jorge Resende Lopes Júnior
- University Hospital, Faculty of Medicine of Ribeirão Preto, University of São Paulo (FMRP-USP), São Paulo 05508-220, Brazil
| | - Lucas Tobias Almeida Queiroz
- Postgraduate Program, Department of Surgery and Anatomy, Faculty of Medicine of Ribeirão Preto, University of São Paulo (FMRP-USP), São Paulo 05508-220, Brazil
| | | | - José Celso Ardengh
- University Hospital, Faculty of Medicine of Ribeirão Preto, University of São Paulo (FMRP-USP), São Paulo 05508-220, Brazil
- Digestive Endoscopy Service, Hospital Moriah, São Paulo 04084-002, Brazil
- Department of Diagnostic Imaging, Federal University of São Paulo, São Paulo 04021-001, Brazil
| | - Ajith Kumar Sankarankutty
- Department of Surgery and Anatomy, Faculty of Medicine of Ribeirão Preto, University of São Paulo (FMRP-USP), São Paulo 05508-220, Brazil
| | - Leonardo Santos Lima
- Postgraduate Program, Department of Surgery and Anatomy, Faculty of Medicine of Ribeirão Preto, University of São Paulo (FMRP-USP), São Paulo 05508-220, Brazil
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11
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Černe ŽP, Sever N, Strniša L, Plut S, Drnovšek J, Hanžel J, Siuka D, Štabuc B, Drobne D. Performance of European and American Societies of Gastrointestinal Endoscopy Guidelines for Prediction of Choledocholithiasis in Patients with Acute Biliary Pancreatitis. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:2176. [PMID: 38138279 PMCID: PMC10744392 DOI: 10.3390/medicina59122176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 11/27/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023]
Abstract
Background and Objectives: Up to one-third of patients with acute biliary pancreatitis also present with choledocholithiasis. Guidelines from the European Society of Gastrointestinal Endoscopy (ESGE) and the American Society for Gastrointestinal Endoscopy (ASGE) for investigating suspected choledocholithiasis suggest endoscopic retrograde cholangiopancreatography in patients with high-likelihood (ESGE)/high-probability (ASGE) predictors and endoscopic ultrasound in those with intermediate-likelihood (ESGE)/intermediate-probability (ASGE) predictors. Although both guidelines are similar, they are not identical. Furthermore, these algorithms were mainly developed from cohorts of patients without pancreatitis and are therefore poorly validated in a subset of patients with acute pancreatitis. We aimed to assess the performance of the ESGE and ASGE algorithms for the prediction of choledocholithiasis in patients with acute biliary pancreatitis. Materials and Methods: This was a retrospective analysis of 86 consecutive patients admitted to a tertiary referral centre in the year 2020 due to acute biliary pancreatitis. Results: Choledocholithiasis was confirmed in 29/86 (33.7%) of patients (13 with endoscopic retrograde cholangiopancreatography and 16 with endoscopic ultrasound). All 10/10 (100%) ESGE high-likelihood and 14/19 (73.7%) ASGE high-probability patients had choledocholithiasis. Only 19/71 (26.8%) patients with ESGE intermediate likelihood and 15/67 (22.4%) with ASGE intermediate probability had choledocholithiasis. Only 8/13 (61.5%) patients with the ASGE high-probability predictor of dilated common bile duct plus bilirubin > 68.4 µmol/mL had choledocholithiasis. Since this predictor is not considered high likelihood by ESGE, this resulted in a superior specificity of the European compared to the American guideline (100% vs. 91.2%). Following the American instead of the European guidelines would have resulted in five unnecessary endoscopic retrograde cholangiopancreatographies and five unnecessary endoscopic ultrasound examinations. Conclusions: This retrospective analysis suggests that the European guidelines may perform better than the American guidelines at predicting choledocholithiasis in the setting of acute pancreatitis. This was because dilated common bile duct plus bilirubin > 68.4 µmol/mL was not a reliable predictor for persistent bile duct stones.
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Affiliation(s)
- Žan Peter Černe
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia; (Ž.P.Č.); (J.D.); (B.Š.)
| | - Nejc Sever
- Department of Gastroenterology, University Medical Centre Ljubljana, Japljeva 2, 1000 Ljubljana, Slovenia; (N.S.); (L.S.); (S.P.); (J.H.); (D.S.)
| | - Luka Strniša
- Department of Gastroenterology, University Medical Centre Ljubljana, Japljeva 2, 1000 Ljubljana, Slovenia; (N.S.); (L.S.); (S.P.); (J.H.); (D.S.)
| | - Samo Plut
- Department of Gastroenterology, University Medical Centre Ljubljana, Japljeva 2, 1000 Ljubljana, Slovenia; (N.S.); (L.S.); (S.P.); (J.H.); (D.S.)
| | - Jan Drnovšek
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia; (Ž.P.Č.); (J.D.); (B.Š.)
- Department of Gastroenterology, University Medical Centre Ljubljana, Japljeva 2, 1000 Ljubljana, Slovenia; (N.S.); (L.S.); (S.P.); (J.H.); (D.S.)
| | - Jurij Hanžel
- Department of Gastroenterology, University Medical Centre Ljubljana, Japljeva 2, 1000 Ljubljana, Slovenia; (N.S.); (L.S.); (S.P.); (J.H.); (D.S.)
| | - Darko Siuka
- Department of Gastroenterology, University Medical Centre Ljubljana, Japljeva 2, 1000 Ljubljana, Slovenia; (N.S.); (L.S.); (S.P.); (J.H.); (D.S.)
| | - Borut Štabuc
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia; (Ž.P.Č.); (J.D.); (B.Š.)
- Department of Gastroenterology, University Medical Centre Ljubljana, Japljeva 2, 1000 Ljubljana, Slovenia; (N.S.); (L.S.); (S.P.); (J.H.); (D.S.)
| | - David Drobne
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia; (Ž.P.Č.); (J.D.); (B.Š.)
- Department of Gastroenterology, University Medical Centre Ljubljana, Japljeva 2, 1000 Ljubljana, Slovenia; (N.S.); (L.S.); (S.P.); (J.H.); (D.S.)
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12
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Capparelli MA, Cotignola L, Domínguez MV, D'Alessandro PD, Ayarzabal VH, Barrenechea ME. Clinical Utility of Definitive Diagnostic Tests for Choledocholithiasis in Pediatric Patients with Mild Gallstone Pancreatitis. J Pediatr Surg 2023; 58:2352-2355. [PMID: 37460346 DOI: 10.1016/j.jpedsurg.2023.06.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 06/14/2023] [Accepted: 06/17/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND Gallstone pancreatitis was historically considered a risk factor for choledocholithiasis (CD). However, recent studies of adult patients evidenced a weak association between gallstone pancreatitis and CD. The aim of this study was to analyze this association in pediatric patients. METHODS We conducted a retrospective study on patients with mild gallstone pancreatitis who underwent any definitive testing for CD (MRCP, ERCP, IOC), managed between March 2010 and September 2022. Patients were classified according to the presence or absence of risk factors for CD (total bilirubin ≥2 mg/dl; common bile duct >6 mm on ultrasound; and/or CD on ultrasound). We evaluated the diagnosis of CD on definitive testing in both groups and analyzed the predictive capacity of the presence of risk factors. RESULTS Eighty-four patients were included in the final analysis. Seventy-nine percent were females. The median age was 13 (4-17) years. Forty-seven (55.9%) patients had one or more risk factors. The definitive testing confirmed 13 (15.5%) cases of CD, 12 (25.5%) in the group of patients with risk factors and 1 (2.7%) in those without risk factors. The sensitivity, specificity, positive predictive value and negative predictive value of the presence of associated risk factors were 92.3, 50.7, 25.5 and 97.3%, respectively. CONCLUSION Pediatric patients with gallstone pancreatitis without associated risk factors have a very low incidence of CD. In these patients we suggest performing a laparoscopic cholecystectomy without intraoperative cholangiography or any other definitive test for CD. LEVEL OF EVIDENCE Level II, retrospective study.
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Affiliation(s)
| | - Luciana Cotignola
- Division of General Surgery, J.P. Garrahan Hospital, Buenos Aires, Argentina
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13
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Lattanzi B, Ramai D, Gkolfakis P, Facciorusso A. Predictive models in EUS/ERCP. Best Pract Res Clin Gastroenterol 2023; 67:101856. [PMID: 38103924 DOI: 10.1016/j.bpg.2023.101856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 07/30/2023] [Indexed: 12/19/2023]
Abstract
Predictive models (PMs) in endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) have the potential to improve patient outcomes, enhance diagnostic accuracy, and guide therapeutic interventions. This review aims to summarize the current state of predictive models in ERCP and EUS and their clinical implications. To be considered useful in clinical practice a PM should be accurate, easy to perform, and may consider objective variables. PMs in ERCP estimate correct indication, probability of success, and the risk of developing adverse events. These models incorporate patient-related factors and technical aspects of the procedure. In the field of EUS, these models utilize clinical and imaging data to predict the likelihood of malignancy, presence of specific lesions, or risk of complications related to therapeutic interventions. Further research, validation, and refinement are necessary to maximize the utility and impact of these models in routine clinical practice.
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Affiliation(s)
- Barbara Lattanzi
- Gastroenterology and Emergency Endoscopy Unit, Sandro Pertini Hospital of Rome, Italy.
| | - Daryl Ramai
- Gastroenterology and Hepatology, University of Utah Hospital, Utah, USA.
| | - Paraskevas Gkolfakis
- Department of Gastroenterology, General Hospital of Nea Ionia "Konstantopoulio-Patision", 14233, Athens, Greece.
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Medical Sciences, University of Foggia, Via Pinto 1, 71122, Foggia, Italy.
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14
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Aljorfi A, Abdelkarim M, Elaraby M, Kotb A, Morgan R. The significance of isolated hyperbilirubinemia in detecting asymptomatic common bile duct stones in patients undergoing laparoscopic cholecystectomy. SURGERY IN PRACTICE AND SCIENCE 2023; 15:100223. [PMID: 39844805 PMCID: PMC11749414 DOI: 10.1016/j.sipas.2023.100223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/06/2023] [Accepted: 11/06/2023] [Indexed: 01/24/2025] Open
Abstract
Aim The aim of this study was to evaluate the role of isolated hyperbilirubinemia in the detection of choledocholithiasis. Methods A retrospective cohort study focused on adult patients diagnosed with gallstone disease, and undergoing intra-operative cholangiogram for suspected choledocholithiasis. Those presenting with isolated hyperbilirubinemia were investigated for their risk of choledocholithiasis, and were compared with those with normal liver function tests. Results Out of the total 1274 patients undergoing intra-operative cholangiogram in the study period, only 18 exhibited isolated hyperbilirubinemia. Among these, four patients were found to have common bile duct (CBD) stones. This indicates that in approximately 22 % of patients, isolated hyperbilirubinemia may be associated with CBD stones. However, it is essential to note that the number of patients in the study with isolated hyperbilirubinemia was relatively small. Conclusion Although the incidence of isolated hyperbilirubinemia was limited in our study, the presence of CBD stones in some of these patients suggests a potential association. Isolated hyperbilirubinaemia should not be overlooked as a risk factor for CBD stones. Nonetheless, additional investigations with a larger sample size are needed to establish a more definitive understanding of the relationship between isolated hyperbilirubinemia and choledocholithiasis.
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Affiliation(s)
- A. Aljorfi
- Department of General Surgery, Glan Clwyd Hospital, Betsi Cadwallader University Health Board, Wales, United Kingdom
| | - M. Abdelkarim
- Department of General Surgery, Glan Clwyd Hospital, Betsi Cadwallader University Health Board, Wales, United Kingdom
| | - M. Elaraby
- Department of General Surgery, Glan Clwyd Hospital, Betsi Cadwallader University Health Board, Wales, United Kingdom
| | - A. Kotb
- Department of General Surgery, Glan Clwyd Hospital, Betsi Cadwallader University Health Board, Wales, United Kingdom
| | - R. Morgan
- Department of General Surgery, Glan Clwyd Hospital, Betsi Cadwallader University Health Board, Wales, United Kingdom
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Ovalle-Chao C, Guajardo-Nieto DA, Elizondo-Pereo RA. Performance of the predictive criteria of the American Society for Gastrointestinal Endoscopy in the diagnosis of choledocholithiasis at a secondary care public hospital in the State of Nuevo León, Mexico. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2023; 88:322-332. [PMID: 35810095 DOI: 10.1016/j.rgmxen.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 11/03/2021] [Indexed: 11/22/2022]
Abstract
INTRODUCTION AND AIMS Currently there is no ideal diagnostic/therapeutic approach for patients with suspected choledocholithiasis. The primary aim of our study was to evaluate the performance of the criteria for predicting choledocholithiasis proposed by the American Society for Gastrointestinal Endoscopy (ASGE) in 2019. MATERIALS AND METHODS A retrospective study was conducted that included 352 patients seen at a secondary care public healthcare institution in Monterrey, Nuevo León, that treats an open population and does not have endoscopic ultrasound or magnetic resonance cholangiopancreatography at its disposal. RESULTS The most frequent predictor presented by the patients was abnormal liver function tests (90.63%), and with their use alone, sensitivity was higher than that of all the predictors analyzed (91.41%). In addition, the finding of common bile duct stones on ultrasound imaging was the only predictor independently associated with the confirmatory diagnosis of choledocholithiasis. Regarding the general performance of the 2019 criteria, the high-risk category had 68.75% sensitivity, 52.08% specificity, a positive predictive value of 79.28%, a negative predictive value of 38.46%, diagnostic accuracy of 64.20%, and a confirmatory diagnosis of choledocholithiasis in 79.28% of the patients of that risk category. CONCLUSIONS The study corroborated that the presence of choledocholithiasis could be predicted using the choledocholithiasis predictors and risk categories proposed by the ASGE, with acceptable accuracy, in accordance with the standards suggested by those same guidelines.
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Affiliation(s)
- C Ovalle-Chao
- Departamento de Cirugía General, Hospital Metropolitano "Dr. Bernardo Sepúlveda", Monterrey, Nuevo León, Mexico.
| | - D A Guajardo-Nieto
- Departamento de Cirugía General, Hospital Metropolitano "Dr. Bernardo Sepúlveda", Monterrey, Nuevo León, Mexico
| | - R A Elizondo-Pereo
- Departamento de Enseñanza e Investigación en Salud, Christus Muguerza Hospital Alta Especialidad, Monterrey, Nuevo León, Mexico
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Zhang H, Gao J, Sun Z, Zhang Q, Qi B, Jiang X, Li S, Shang D. Diagnostic accuracy of updated risk assessment criteria and development of novel computational prediction models for patients with suspected choledocholithiasis. Surg Endosc 2023; 37:7348-7357. [PMID: 37474825 DOI: 10.1007/s00464-023-10087-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Accepted: 04/17/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND There are risks of choledocholithiasis in symptomatic gallstones, and some surgeons have proposed the identification of choledocholithiasis before cholecystectomy. Our goal was to evaluate the diagnostic accuracy of the latest guidelines and create computational prediction models for the accurate prediction of choledocholithiasis. METHODS We retrospectively reviewed symptomatic gallstone patients hospitalized with suspected choledocholithiasis. The diagnostic performance of 2019 and 2010 guidelines of the American Society for Gastrointestinal Endoscopy (ASGE) and 2019 guideline of the European Society of Gastrointestinal Endoscopy (ESGE) in different risks. Lastly, we developed novel prediction models based on the preoperative predictors. RESULTS A total of 1199 patients were identified and 681 (56.8%) had concurrent choledocholithiasis and were included in the analysis. The specificity of the 2019 ASGE, 2010 ASGE, and 2019 ESGE high-risk criteria was 85.91%, 72.2%, and 88.42%, respectively, and their positive predictive values were 85.5%, 77.4%, and 87.3%, respectively. For Mid-risk patients who followed 2019 ASGE about 61.8% of them did not have CBD stones in our study. On the choice of surgical procedure, laparoscopic cholecystectomy + laparoscopic transcystic common bile duct exploration can be considered the optimal treatment choice for cholecysto-choledocholithiasis instead of Endoscopic Retrograde Cholangio-Pancreatography (ERCP). We build seven machine learning models and an AI diagnosis prediction model (ModelArts). The area under the receiver operating curve of the machine learning models was from 0.77 to 0.81. ModelArts AI model showed predictive accuracy of 0.97, recall of 0.97, precision of 0.971, and F1 score of 0.97, surpassing any other available methods. CONCLUSION The 2019 ASGE guideline and 2019 ESGE guideline have demonstrated higher specificity and positive predictive value for high-risk criteria compared to the 2010 ASGE guideline. The excellent diagnostic performance of the new artificial intelligence prediction model may make it a better choice than traditional guidelines for managing patients with suspected choledocholithiasis in future.
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Affiliation(s)
- Haoxiang Zhang
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
- Department of Hepatopancreatobiliary Surgery, Fujian Provincial Hospital, Fuzhou, Fujian, China
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Jiangping Gao
- Department of Surgical Oncology, Gansu Provincial Hospital, Lanzhou, China
| | - Zhen Sun
- Department of Gastrointestinal Surgery, The Second Hospital of Jilin University, Changchun, China
| | - Qingkai Zhang
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
- Institute (College) of Integrative Medicine, Dalian Medical University, Dalian, Liaoning, China
| | - Bing Qi
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
- Institute (College) of Integrative Medicine, Dalian Medical University, Dalian, Liaoning, China
| | - Xingchi Jiang
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
- Institute (College) of Integrative Medicine, Dalian Medical University, Dalian, Liaoning, China
| | - Shuang Li
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
- Institute (College) of Integrative Medicine, Dalian Medical University, Dalian, Liaoning, China
| | - Dong Shang
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China.
- Institute (College) of Integrative Medicine, Dalian Medical University, Dalian, Liaoning, China.
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Chang YH, Lin MY, Hsieh MT, Ou MC, Huang CR, Sheu BS. Multiple Field-of-View Based Attention Driven Network for Weakly Supervised Common Bile Duct Stone Detection. IEEE JOURNAL OF TRANSLATIONAL ENGINEERING IN HEALTH AND MEDICINE 2023; 11:394-404. [PMID: 37465459 PMCID: PMC10351611 DOI: 10.1109/jtehm.2023.3286423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 03/14/2023] [Accepted: 06/08/2023] [Indexed: 07/20/2023]
Abstract
OBJECTIVE Common bile duct (CBD) stones caused diseases are life-threatening. Because CBD stones locate in the distal part of the CBD and have relatively small sizes, detecting CBD stones from CT scans is a challenging issue in the medical domain. METHODS AND PROCEDURES We propose a deep learning based weakly-supervised method called multiple field-of-view based attention driven network (MFADNet) to detect CBD stones from CT scans based on image-level labels. Three dominant modules including a multiple field-of-view encoder, an attention driven decoder and a classification network are collaborated in the network. The encoder learns the feature of multi-scale contextual information while the decoder with the classification network is applied to locate the CBD stones based on spatial-channel attentions. To drive the learning of the whole network in a weakly-supervised and end-to-end trainable manner, four losses including the foreground loss, background loss, consistency loss and classification loss are proposed. RESULTS Compared with state-of-the-art weakly-supervised methods in the experiments, the proposed method can accurately classify and locate CBD stones based on the quantitative and qualitative results. CONCLUSION We propose a novel multiple field-of-view based attention driven network for a new medical application of CBD stone detection from CT scans while only image-levels are required to reduce the burdens of labeling and help physicians automatically diagnose CBD stones. The source code is available at https://github.com/nchucvml/MFADNet after acceptance. CLINICAL IMPACT Our deep learning method can help physicians localize relatively small CBD stones for effectively diagnosing CBD stone caused diseases.
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Affiliation(s)
- Ya-Han Chang
- Department of Computer Science and EngineeringNational Chung Hsing UniversityTaichung402202Taiwan
| | - Meng-Ying Lin
- Department of Internal MedicineNational Cheng Kung University Hospital, College of Medicine, National Cheng Kung UniversityTainan701401Taiwan
| | - Ming-Tsung Hsieh
- Department of Internal MedicineNational Cheng Kung University Hospital, College of Medicine, National Cheng Kung UniversityTainan701401Taiwan
| | - Ming-Ching Ou
- Department of Medical ImageNational Cheng Kung University Hospital, College of Medicine, National Cheng Kung UniversityTainan701401Taiwan
| | - Chun-Rong Huang
- Department of Computer Science and EngineeringNational Chung Hsing UniversityTaichung402202Taiwan
- Cross College Elite Program, and Academy of Innovative Semiconductor and Sustainable ManufacturingNational Cheng Kung UniversityTainan701401Taiwan
| | - Bor-Shyang Sheu
- Department of Internal MedicineNational Cheng Kung University Hospital, College of Medicine, National Cheng Kung UniversityTainan701401Taiwan
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Durán M, Silvestre J, Hernández J, Briceño J, Martínez-Isla A, Martínez-Cecilia D. Learning curve for performing laparoscopic common bile duct exploration in biliary surgery 2.0 era. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2023; 30:374-382. [PMID: 35947065 DOI: 10.1002/jhbp.1228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 06/27/2022] [Accepted: 08/07/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Recent trials and metanalysis have demonstrated the favorable results of laparoscopic cholecystectomy (LC) and laparoscopic common bile duct exploration (LCBDE) for the treatment of cholecysto-choledocholithiasis. The aim of this study was to evaluate the LC + LCBDE learning curve including transcystic and transductal approaches and its effect on the outcomes. METHODS We identified all unselected patients who underwent LC + LCBDE by a single surgeon between May 2017 and July 2021. Pre-, intra-, and postoperative data were analyzed using the cumulative sum (CUSUM) analysis to evaluate the learning curve. RESULTS A total of 110 patients were included. Total postoperative complications rate was 12.7%, including bile leakage in six (5.5%) patients. Mean length of hospital stay was 2.7 (1-14) days. No patient had conversion to open surgery. The CUSUM graph divided the learning curve into three distinct phases: (1) Learning (1-38), (2) Competence (39-61) and (3) Proficiency (62-110). There was a significant increase in the transcystic approach rate with each phase (44.7% vs 73.9% vs 98%; P < .001). A significant decrease in the operative time (150.9 vs 117.6 vs 99.9 min; P < .001) and complication rate (21.1% vs 21.7% vs 2%; P = .01) were observed across the three phases. CONCLUSION Our data suggest that the learning curve for complete competence in LC + LCBDE is approximately 60 cases, provided that proper training is available. The initial learning phase can be carried out safely and efficiently with acceptable results.
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Affiliation(s)
- Manuel Durán
- Department of Hepatobiliary Surgery and Liver Transplantation, Reina Sofia University Hospital, Cordoba, Spain
| | - José Silvestre
- Department of Hepatobiliary Surgery, Hospital Universitario de Toledo, Toledo, Spain
| | - Jara Hernández
- Department of Hepatobiliary Surgery, Hospital Universitario de Toledo, Toledo, Spain
| | - Javier Briceño
- Department of Hepatobiliary Surgery and Liver Transplantation, Reina Sofia University Hospital, Cordoba, Spain
| | - Alberto Martínez-Isla
- Department of Upper GI Surgery, Northwick Park Hospital & St Marks Hospitals, London, UK
| | - David Martínez-Cecilia
- Department of Hepatobiliary Surgery, Hospital Universitario de Toledo, Toledo, Spain
- Department of Hepatobiliary and Pancreatic Surgery, Hospital Universitario La Princesa, Madrid, Spain
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Ramírez-Peña T, Vargas-Rubio RD, Lombo CE, Rodríguez-Hortua LM, Muñoz-Velandia OM. Dynamic changes in liver function tests do not correctly reclassify patients at risk of choledocholithiasis beyond ASGE 2019 criteria. Ther Adv Gastrointest Endosc 2023; 16:26317745231202869. [PMID: 37790921 PMCID: PMC10542322 DOI: 10.1177/26317745231202869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 09/04/2023] [Indexed: 10/05/2023] Open
Abstract
Introduction Dynamic changes in liver function tests have been proposed to correctly reclassify the risk of choledocholithiasis; however, information is scarce and insufficient to recommend its use. Methods Retrospective cohort of patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) due to moderate and high risk of choledocholithiasis according to the 2019 American Society of Gastrointestinal Endoscopy (ASGE) guidelines. We evaluated whether significant changes in liver function tests (bilirubin, transaminases, or alkaline phosphatase), defined as an increase or a reduction ⩾30 or ⩾50% between two measurements taken with a difference of 24-72 h can correctly reclassify the risk of choledocholithiasis beyond the ASGE guidelines. The net reclassification index (NRI) was calculated for patients with and without choledocholithiasis. Results Among 1175 patients who underwent ERCP, 170 patients were included in the analysis (59.4% women, median 59.5 years). Among patients without a diagnosis of choledocholithiasis, the number of patients correctly reclassified by transaminases was slightly higher than those incorrectly reclassified (NRI = 0.24 for aspartate amino transaminase and 0.20 for alanine amino transaminase). However, among patients with a diagnosis of choledocholithiasis, it led to incorrect reclassification in a greater number of cases (NRI = -0.21 and -0.14, respectively). The benefits of reclassification were minimal for bilirubin and alkaline phosphatase, or for value changes >50%. A subgroup analysis showed similar findings in patients without a history of cholecystectomy and in those with normal bile duct. Conclusion Dynamic changes in liver function tests do not improve choledocholithiasis risk classification beyond the 2019 ASGE criteria. New criteria should continue to be sought to optimize risk stratification.
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Affiliation(s)
- Tatiana Ramírez-Peña
- Department of Internal Medicine, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Rómulo Darío Vargas-Rubio
- Department of Internal Medicine, Pontificia Universidad Javeriana, Bogotá, Colombia
- Unit of Gastroenterology, Hospital Universitario San Ignacio, Bogotá, Colombia
| | - Carlos Ernesto Lombo
- Department of Internal Medicine, Pontificia Universidad Javeriana, Bogotá, Colombia
| | | | - Oscar Mauricio Muñoz-Velandia
- Department of Internal Medicine, Pontificia Universidad Javeriana, Cra. 7 #40-62, Bogotá 1111, Colombia
- Department of Internal Medicine, Hospital Universitario San Ignacio, Bogotá, Colombia
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20
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Saito H, Iwasaki H, Itoshima H, Kadono Y, Shono T, Kamikawa K, Urata A, Nasu J, Uehara M, Matsushita I, Kakuma T, Tada S. Low Detection Rates of Bile Duct Stones During Endoscopic Treatment for Highly Suspected Bile Duct Stones with No Imaging Evidence of Stones. Dig Dis Sci 2022; 68:2061-2068. [PMID: 36450977 DOI: 10.1007/s10620-022-07773-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 11/14/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND The revised American Society for Gastrointestinal Endoscopy (ASGE) guideline 2019 provides the high-risk criteria for suspected common bile duct stones (CBDSs). AIMS To evaluate CBDS detection rates during endoscopic retrograde cholangiopancreatography (ERCP) in high-risk patients with suspected CBDSs based on the ASGE guideline 2019. METHODS This multicenter retrospective study included 1100 consecutive patients who underwent ERCP for suspected CBDSs with any high-risk criteria based on the revised ASGE guideline 2019: Criterion 1, CBDSs on imaging; Criterion 2, clinical ascending cholangitis; and Criterion 3, total bilirubin exceeding 4 mg/dL and dilated common bile duct on imaging. We compared CBDS detection rates during ERCP based on individual and combined high-risk criteria. RESULTS The CBDS detection rates of patients who met any of the criteria, only Criterion 1, and Criteria 2 or 3 were 86.0% (946/1100), 93.4% (113/121), and 50.0% (106/212), respectively. In patients who met Criteria 1 and 2, 1 and 3, 2 and 3, and all criteria, CBDSs were confirmed during ERCP in 95.1% (490/515), 96.2% (25/26), 55.3% (26/47), and 98.4% (186/189), respectively. The CBDS detection rate during ERCP of patients with at least Criterion 1 significantly exceeded that of patients without at least Criterion 1 [95.7% (814/851) vs. 51.0% (132/259), respectively, P < 0.001]. CONCLUSIONS Patients with CBDS visualization on imaging have very high CBDS detection rates during ERCP. However, performing ERCP on patients with only clinical predictors, such as cholangitis and dilated CBD with total bilirubin exceeding 4 mg/dL, often results in unnecessary ERCP.
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Affiliation(s)
- Hirokazu Saito
- Department of Gastroenterology, Kumamoto City Hospital, 4-1-60, Higashimachi, Higashi-ku, Kumamoto City, Kumamoto, 862-8505, Japan.
| | - Hajime Iwasaki
- Department of Gastroenterology, Kumamoto Chuo Hospital, 1-5-1, Tainoshima, Minami-ku, Kumamoto City, Kumamoto, 862-0965, Japan
| | - Hisashi Itoshima
- Department of Gastroenterology, Saiseikai Kumamoto Hospital, 5-3-1, Chikami, Minami-ku, Kumamoto City, Kumamoto, 861-4193, Japan
| | - Yoshihiro Kadono
- Department of Gastroenterology, Tsuruta Hospital, 10-112, Hotakubohonmachi, Higashi-ku, Kumamoto City, Kumamoto, 862-0925, Japan
| | - Takashi Shono
- Department of Gastroenterology, Kumamoto Chuo Hospital, 1-5-1, Tainoshima, Minami-ku, Kumamoto City, Kumamoto, 862-0965, Japan
| | - Kentaro Kamikawa
- Department of Gastroenterology, Saiseikai Kumamoto Hospital, 5-3-1, Chikami, Minami-ku, Kumamoto City, Kumamoto, 861-4193, Japan
| | - Atsushi Urata
- Department of Gastroenterology, Saiseikai Kumamoto Hospital, 5-3-1, Chikami, Minami-ku, Kumamoto City, Kumamoto, 861-4193, Japan
| | - Jiro Nasu
- Department of Gastroenterological Surgery, Kumamoto Chuo Hospital, 1-5-1, Tainoshima, Minami-ku, Kumamoto City, Kumamoto, 862-0965, Japan
| | - Masayoshi Uehara
- Department of Gastroenterology, Saiseikai Kumamoto Hospital, 5-3-1, Chikami, Minami-ku, Kumamoto City, Kumamoto, 861-4193, Japan
| | - Ikuo Matsushita
- Department of Gastroenterology, Kumamoto Chuo Hospital, 1-5-1, Tainoshima, Minami-ku, Kumamoto City, Kumamoto, 862-0965, Japan
| | - Tatsuyuki Kakuma
- Department of Biostatics Center, Medical School, Kurume University, 67, Asahimachi, Kurume City, Fukuoka, 830-0011, Japan
| | - Shuji Tada
- Department of Gastroenterology, Kumamoto City Hospital, 4-1-60, Higashimachi, Higashi-ku, Kumamoto City, Kumamoto, 862-8505, Japan
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21
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Saito H, Fujimoto A, Oomoto K, Kadowaki Y, Tada S. Current approaches and questions yet to be resolved for the prophylaxis of post-endoscopic retrograde cholangiopancreatography pancreatitis. World J Gastrointest Endosc 2022; 14:657-666. [PMID: 36438884 PMCID: PMC9693687 DOI: 10.4253/wjge.v14.i11.657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 10/06/2022] [Accepted: 10/26/2022] [Indexed: 11/14/2022] Open
Abstract
Prophylaxis is important for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP), which is the most common and serious complication of ERCP. Although the current guidelines include independent patient- and procedure-related risk factors for PEP and available PEP prophylactic measures, the synergistic effect of these risk factors on PEP should also be considered, given that patients often harbor multiple risk factors. Furthermore, a combination of prophylactic measures is often selected in clinical practice. However, established methods estimating the synergistic effect of independent risk factors on PEP incidence are lacking, and evidence on the impact of combining prophylactic measures on PEP should be discussed. Selection of appropriate candidate patients for ERCP is also important to reduce the incidence of PEP associated with unnecessary ERCP. ERCP indications in patients with asymptomatic common bile duct stones (CBDSs) and in those with suspected CBDSs with no imaging-based evidence of stones are controversial. Further studies are warranted to predict the synergistic effect of independent risk factors on PEP, determine the best prophylactic PEP measures, and identify appropriate candidates for ERCP in patients with asymptomatic CBDSs and those with suspected CBDSs.
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Affiliation(s)
- Hirokazu Saito
- Department of Gastroenterology, Kumamoto City Hospital, Kumamoto City 862-8505, Kumamoto, Japan
| | - Atsushi Fujimoto
- Department of Gastroenterology, Kumamoto City Hospital, Kumamoto City 862-8505, Kumamoto, Japan
| | - Kana Oomoto
- Department of Gastroenterology, Kumamoto City Hospital, Kumamoto City 862-8505, Kumamoto, Japan
| | - Yoshitaka Kadowaki
- Department of Gastroenterology, Kumamoto City Hospital, Kumamoto City 862-8505, Kumamoto, Japan
| | - Shuji Tada
- Department of Gastroenterology, Kumamoto City Hospital, Kumamoto City 862-8505, Kumamoto, Japan
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22
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Tunruttanakul S, Verasmith K, Patumanond J, Mingmalairak C. Development of a Predictive Model for Common Bile Duct Stones in Patients With Clinical Suspicion of Choledocholithiasis: A Cohort Study. Gastroenterology Res 2022; 15:240-252. [PMID: 36407811 PMCID: PMC9635785 DOI: 10.14740/gr1560] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 09/14/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Current choledocholithiasis guidelines heavily focus on patients with low or no risk, they may be inappropriate for populations with high rates of choledocholithiasis. We aimed to develop a predictive scoring model for choledocholithiasis in patients with relevant clinical manifestations. METHODS A multivariable predictive model development study based on a retrospective cohort of patients with clinical suspicion of choledocholithiasis was used in this study. The setting was a 700-bed public tertiary hospital. Participants were patients who had completed three reference tests (endoscopic retrograde cholangiography, magnetic resonance cholangiopancreatography, and intraoperative cholangiography) from January 2019 to June 2021. The model was developed using logistic regression analysis. Predictor selection was conducted using a backward stepwise approach. Three risk groups were considered. Model performance was evaluated by area under the receiver operating characteristic curve, calibration, classification measures, and decision curve analyses. RESULTS Six hundred twenty-one patients were included; the choledocholithiasis prevalence was 59.9%. The predictors were age > 55 years, pancreatitis, cholangitis, cirrhosis, alkaline phosphatase level of 125 - 250 or > 250 U/L, total bilirubin level > 4 mg/dL, common bile duct size > 6 mm, and common bile duct stone detection. Pancreatitis and cirrhosis each had a negative score. The sum of scores was -4.5 to 28.5. Patients were categorized into three risk groups: low-intermediate (score ≤ 5), intermediate (score 5.5 - 14.5), and high (score ≥ 15). Positive likelihood ratios were 0.16 and 3.47 in the low-intermediate and high-risk groups, respectively. The model had an area under the receiver operating characteristic curve of 0.80 (95% confidence interval: 0.76, 0.83) and was well-calibrated; it exhibited better statistical suitability to the high-prevalence population, compared to current guidelines. CONCLUSIONS Our scoring model had good predictive ability for choledocholithiasis in patients with relevant clinical manifestations. Consideration of other factors is necessary for clinical application, particularly regarding the availability of expert physicians and specialized equipment.
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Affiliation(s)
- Suppadech Tunruttanakul
- Department of Surgery, Sawanpracharak Hospital, Nakhon Sawan 60000, Thailand,Corresponding Author: Suppadech Tunruttanakul, Department of Surgery, Sawanpracharak Hospital, Muang, Nakhon Sawan 60000, Thailand.
| | | | - Jayanton Patumanond
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Chatchai Mingmalairak
- Department of Surgery, Faculty of Medicine, Thammasat University, Pathum Thani 10120, Thailand
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23
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Lei Y, Lethebe BC, Wishart E, Bazerbachi F, Elmunzer BJ, Thosani N, Buxbaum JL, Chen YI, Bass S, Cole MJ, Turbide C, Brenner DR, Heitman SJ, Mohamed R, Forbes N. Test Performance Characteristics of Dynamic Liver Enzyme Trends in the Prediction of Choledocholithiasis. J Clin Med 2022; 11:4575. [PMID: 35956191 PMCID: PMC9369577 DOI: 10.3390/jcm11154575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/18/2022] [Accepted: 08/02/2022] [Indexed: 11/17/2022] Open
Abstract
(1) Background: Various methods to predict the presence or absence of choledocholithiasis (CDL) have been proposed. We aimed to assess the performance characteristics of dynamic liver enzyme trends in the prediction of CDL. (2) Methods: This was a single-center retrospective cohort study. All adult in-patients undergoing endoscopy for suspected CDL between 1 January 2012 and 7 October 2018 were identified, with patients with prior cholecystectomy, prior sphincterotomy, or indwelling biliary prostheses were excluded. Available laboratory parameters within 72 h preceding the procedure were recorded, allowing for the assessment of trends. Dynamic enzyme trends were defined as any increase or decrease by 30% and 50% within 72 h of the index procedure. (3) Results: A total of 878 patients were included. Mean age was 61.8 years, with 58.6% female. Increases in alkaline phosphatase (ALP) of at least 30% or 50% were both specific for the presence of CDL, with specificities of 82.7% (95% CI 69.7-91.8%) and 88.5% (95% CI 76.6-95.6%), respectively. Decreases in bilirubin or ALP of at least 50% were highly specific for the absence of CDL, with specificities of 91.7% (95% CI 85.7-95.8%) and 100.0% (97.2-100.0%), respectively. (4) Conclusions: Several liver enzyme trends appear to be specific for the absence or presence of stones; in particular, significant decreases in total bilirubin or ALP of at least 30-50% over the prior 72 h appear to be especially predictive of an absence of intraductal findings during endoscopy.
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Affiliation(s)
- Yang Lei
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1, Canada
| | - B. Cord Lethebe
- Clinical Research Unit, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1, Canada
| | - Erin Wishart
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1, Canada
| | - Fateh Bazerbachi
- CentraCare, Interventional Endoscopy Program, St. Cloud Hospital, St. Cloud, MN 56303, USA
| | - B. Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Nirav Thosani
- Center for Interventional Gastroenterology (iGUT), McGovern Medical School, UTHealth, Houston, TX 77030, USA
| | - James L. Buxbaum
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
| | - Yen-I Chen
- Department of Medicine, McGill University, Montreal, QC H3A 1A1, Canada
| | - Sydney Bass
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1, Canada
| | - Martin J. Cole
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1, Canada
| | - Christian Turbide
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1, Canada
| | - Darren R. Brenner
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
- Department of Cancer Epidemiology and Prevention Research, Cancer Control Alberta, Alberta Health Services, Calgary, AB T2S 3C3, Canada
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Steven J. Heitman
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Rachid Mohamed
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1, Canada
| | - Nauzer Forbes
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
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24
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Robinson C, Turner RM, Potter J. A retrospective analysis of magnetic resonance cholangiopancreatography investigating gallstones in a contemporary surgical setting. ANZ J Surg 2022; 92:2174-2179. [PMID: 35766431 PMCID: PMC9544053 DOI: 10.1111/ans.17875] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 04/03/2022] [Accepted: 06/09/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUNDS The New Zealand Public Health System operates in a resource limited environment. Pre-operative investigation of choledocholithiasis (CDL) is variable. Protocol driven practice has improved patient outcomes and cost-effectiveness. The aim is to explore risk stratification for CDL and specific thresholds for accessing magnetic resonance cholangiopancreatography (MRCP) in this contemporary setting. METHODS All adult (16+ years) acute inpatient MRCP requests for gallstone work-up between 1 Jan 2018 and 2031 Dec 2019 at Dunedin Hospital were included. Patients with characteristics not in fitting with an acute symptomatic examination were excluded. Receiver operating characteristic curves were estimated for bilirubin versus MRCP positive by the presence/absence of dilated ducts, indication and American Society of Gastrointestinal Endoscopy (ASGE) risk grouping. RESULTS A 106 patients were included. Mean bilirubin at presentation and time of MRCP, 47 versus 28 μmol/L, respectively. MRCP confirmed CDL in 39 (37%) patients. 38 (97%) had biochemical changes with choledocholithiasis. 21 (40%) with CBD dilation had ductal stones versus 18 (34%) with normal ducts. ASGE risk stratification showed 36 (34%), 66 (62%) and 4 (4%) were high, intermediate and low risk, respectively. Of these groups 44%, 35% and 0% had CBD stones on MRCP, respectively. Combination thresholds involving duct size and bilirubin can yield negative predictive values >90%, substantially reducing MRCP load. CONCLUSIONS MRCP requests can be triaged to maximize stones detected without overly increasing the rate of missed duct stones whilst protecting the limited MRI and ERCP resources. International thresholds and risk stratification alone may not be applicable in our resource limited environment.
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Affiliation(s)
| | - Robin M Turner
- Biostatistics Centre, University of Otago, Dunedin, New Zealand
| | - Jon Potter
- Surgical Department, Dunedin Hospital, Dunedin, New Zealand
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25
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Tunruttanakul S, Chareonsil B, Verasmith K, Patumanond J, Mingmalairak C. Evaluation of the American Society of Gastrointestinal Endoscopy 2019 and the European Society of Gastrointestinal Endoscopy guidelines' performances for choledocholithiasis prediction in clinically suspected patients: A retrospective cohort study. JGH Open 2022; 6:434-440. [PMID: 35774349 PMCID: PMC9218518 DOI: 10.1002/jgh3.12773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 04/06/2022] [Accepted: 05/12/2022] [Indexed: 12/07/2022]
Abstract
Background and Aim The American Society of Gastrointestinal Endoscopy (ASGE) and the European Society of Gastrointestinal Endoscopy (ESGE) have published guidelines for choledocholithiasis. However, the guidelines were formulated using data from a large number of patients with no to low risk of common bile duct (CBD) stones. This study aimed to assess the guidelines' predictive performance in a population with a high frequency of stones. Methods Data for three choledocholithiasis standard reference tests were retrospectively reviewed from January 2019 to June 2021. Clinical parameters were used to categorize patients into risk groups according to the guidelines, and then the guidelines' predictive abilities were calculated. Results Among 1185 patients, 521 were included. The stone prevalence was 61.0% (n = 318). Twelve (2.3%), 146 (28.0%), and 363 (69.7%) patients were classified into low‐, intermediate‐, and high‐risk groups according to the ASGE guidelines, and 30 (5.8%), 149 (28.6%), and 342 (65.6%) according to the ESGE guidelines. Focusing on the high‐risk group, the ASGE guidelines had a positive predictive value of 73.6 and a positive likelihood ratio of 1.78. The ESGE guidelines had a positive predictive value of 73.7 and positive likelihood ratio of 1.79. Both guidelines had equivalent areas under the receiver operating characteristic curve of 0.69 (95% confidence interval [CI]: 0.65–0.73) and 0.68 (95% CI: 0.64–0.72), respectively. Conclusion In the high‐risk group, the guidelines increased the chance of detecting choledocholithiasis by approximately 10% (61.0% prevalence to 73.6 and 73.7% positive predictive value). However, statistically, the guidelines had marginal discriminative performance in a population with high stone prevalence.
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Affiliation(s)
| | | | | | - Jayanton Patumanond
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine Chiang Mai University Chiang Mai Thailand
| | - Chatchai Mingmalairak
- Department of Surgery, Faculty of Medicine Thammasat University Pathum Thani Thailand
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Wang L, Mirzaie S, Dunnsiri T, Chen F, Wilhalme H, MacQueen IT, Cryer H, Eastoak-Siletz A, Guan M, Cuff C, Tabibian JH. Systematic review and meta-analysis of the 2010 ASGE non-invasive predictors of choledocholithiasis and comparison to the 2019 ASGE predictors. Clin J Gastroenterol 2022; 15:286-300. [PMID: 35072902 PMCID: PMC8956528 DOI: 10.1007/s12328-021-01575-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 12/10/2021] [Indexed: 11/21/2022]
Abstract
In 2019, the American Society for Gastrointestinal Endoscopy (ASGE) guideline on the endoscopic management of choledocholithiasis modified the individual predictors of choledocholithiasis proposed in the widely referenced 2010 guideline to improve predictive performance. Nevertheless, the primary literature, especially for the 2019 iteration, is limited. We performed a systematic review with meta-analysis to examine the diagnostic performance of the 2010, and where possible the 2019, predictors. PROSPERO protocol CRD42020194226. A comprehensive literature search from 2001 to 2020 was performed to identify studies on the diagnostic performance of any of the 2010 and 2019 ASGE choledocholithiasis predictors. Identified studies underwent keyword screening, abstract review, and full-text review. The primary outcomes included multivariate odds ratios (ORs) and 95% confidence intervals for each criterion. Secondary outcomes were reported sensitivities, specificities, and positive and negative predictive value. A total of 20 studies met inclusion criteria. Based on reported ORs, of the 2010 guideline "very strong" predictors, ultrasound with stone had the strongest performance. Of the "strong" predictors, CBD > 6 mm demonstrated the strongest performance. "Moderate" predictors had inconsistent and/or weak performance; moreover, all studies reported gallstone pancreatitis as non-predictive of choledocholithiasis. Only one study examined the new predictor (bilirubin > 4 mg/dL and CBD > 6 mm) proposed in the 2019 guideline. Based on this review, aside from CBD stone on ultrasound, there is discordance between the proposed strength of 2010 choledocholithiasis predictors and their published diagnostic performance. The 2019 guideline appears to do away with the weakest 2010 predictors.
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Affiliation(s)
- Louie Wang
- David Geffen School of Medicine, University of California, 10833 Le Conte Ave, Los Angeles, CA, 90095, USA.
| | - Sarah Mirzaie
- David Geffen School of Medicine, University of California, 10833 Le Conte Ave, Los Angeles, CA, 90095, USA
| | - Tavit Dunnsiri
- Department of Internal Medicine, University of California, Los Angeles, CA, USA
| | - Formosa Chen
- David Geffen School of Medicine, University of California, 10833 Le Conte Ave, Los Angeles, CA, 90095, USA
- Division of Gastroenterology, Department of Surgery, Olive View-UCLA Medical Center, Sylmar, CA, USA
| | - Holly Wilhalme
- Statistics Core, Department of Medicine, University of California, Los Angeles, CA, USA
| | - Ian T MacQueen
- David Geffen School of Medicine, University of California, 10833 Le Conte Ave, Los Angeles, CA, 90095, USA
- Department of Surgery, University of California, Los Angeles, CA, USA
| | - Henry Cryer
- David Geffen School of Medicine, University of California, 10833 Le Conte Ave, Los Angeles, CA, 90095, USA
- Department of Surgery, University of California, Los Angeles, CA, USA
| | - Anaar Eastoak-Siletz
- David Geffen School of Medicine, University of California, 10833 Le Conte Ave, Los Angeles, CA, 90095, USA
- Department of Surgery, University of California, Los Angeles, CA, USA
| | - Michelle Guan
- David Geffen School of Medicine, University of California, 10833 Le Conte Ave, Los Angeles, CA, 90095, USA
| | - Callie Cuff
- David Geffen School of Medicine, University of California, 10833 Le Conte Ave, Los Angeles, CA, 90095, USA
| | - James H Tabibian
- David Geffen School of Medicine, University of California, 10833 Le Conte Ave, Los Angeles, CA, 90095, USA
- Division of Gastroenterology, Department of Medicine, Olive View-UCLA Medical Center, Sylmar, CA, USA
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Almaslamani A, Aldusari R, Arishi H, Alaamri A, Almudaiheem F, Almutairi S, Alshuraymi A, El-Boghdadly S. Compliance to endoscopic retrograde cholangiopancreatography according to current guidelines and adverse outcomes of suspected choledocholithiasis in an acute care setting. Surg Endosc 2022; 36:5602-5609. [PMID: 35277770 DOI: 10.1007/s00464-022-09113-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 02/07/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Common bile duct (CBD) stones are common among patients who underwent cholecystectomy. However, few studies have investigated the compliance with the guidelines for the prediction of choledochlithiasis (CL). Therefore, we aim to study the compliance with the American Society for Gastrointestinal Endoscopy (ASGE) guidelines for the identification of CL in a major hospital in Saudi Arabia's capital. METHODS We conducted a retrospective chart review on adult patients admitted to emergency department at King Abdulaziz Medical City, Riyadh with gallstones between January 2016 and January 2019. Our data collection includes demographics and level of suspicion based on Transabdominal Ultrasound, liver function, amylase, and lipase tests. We then determined the likelihood of CL based on ASGE guidelines in order to assess the adherence to ASGE guidelines, the procedure's outcomes and adverse outcomes. RESULTS We identified 826 patients who met the study's criteria: 384 (46.4%) were compliant, while 442 (53.6%) were non-compliant with ASGE guidelines. There was a significant association between compliance and the presence of stones on ERCP in high likelihood patients. 48 (21.3%) of total ERCP procedures among all the likelihoods had adverse outcomes. 13 (40.6%) of non-compliant ERCP performed in intermediate likelihood have experienced adverse outcomes. There was a significant association between having adverse outcomes and being non-complaint with ASGE guidelines. CONCLUSION Despite ASGE guidelines' recommendations, a third of high likelihood cases and the majority of intermediate likelihood cases were non-compliant. Additionally, the current guidelines for the intermediate group are somewhat vague, giving ample leeway for patients to be placed in the intermediate group, which might subject them to unnecessary interventions. To conclude, there was a great lack of compliance with ASGE guidelines that is significantly associated with adverse outcomes. Hence, reassessing the current guidelines and monitoring healthcare facilities' compliance with the updated guidelines is highly recommended.
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Affiliation(s)
- Abdulrahman Almaslamani
- College of Medicine, AlMaarefa University, 7265 Alnahdah District, Shabwah street, Riyadh, 13221-3122, Saudi Arabia.
| | - Rakan Aldusari
- College of Medicine, King Saud Bin Abdulaziz University for Health Science, Riyadh, Saudi Arabia
| | - Hassan Arishi
- King Abdulaziz Medical City, National Guard, Riyadh, Saudi Arabia
| | - Ahmed Alaamri
- College of Medicine, King Khalid University, Abha, Saudi Arabia
| | | | - Sami Almutairi
- College of Medicine, Qassim University, Buraydah, Saudi Arabia
| | - Abdulhakim Alshuraymi
- College of Medicine, AlMaarefa University, 7265 Alnahdah District, Shabwah street, Riyadh, 13221-3122, Saudi Arabia
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Lin MY, Lee CT, Hsieh MT, Ou MC, Wang YS, Lee MC, Chang WL, Sheu BS. Endoscopic ultrasound avoids adverse events in high probability choledocholithiasis patients with a negative computed tomography. BMC Gastroenterol 2022; 22:94. [PMID: 35241000 PMCID: PMC8895914 DOI: 10.1186/s12876-022-02162-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 02/15/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The current guideline recommends patients who meet high probability criteria for choledocholithiasis to receive endoscopic retrograde cholangiopancreatography (ERCP). However, adverse events can occur during ERCP. Our goal is to determine whether endoscopic ultrasound (EUS) before ERCP can avoid unnecessary ERCP complications, especially in patients with a negative CT scan. METHODS A total of 604 patients with high probability of choledocholithiasis were screened and 104 patients were prospectively enrolled. Patients with malignant biliary obstruction, altered GI anatomy, and choledocholithiasis on CT scan were excluded. Among them, 44 patients received EUS first, and ERCP if choledocholithiasis present (EUS-first group). The other 60 patients received ERCP directly (ERCP-first group). The baseline characteristics, presence of choledocholithiasis, and complications were compared between groups. All patients were followed for 3 months to determine the difference in recurrent biliary event rate. Cost-effectiveness was compared between the two strategies. RESULTS There was no marked difference in age, sex, laboratory data, presenting with pancreatitis, and risk factors for choledocholithiasis. Overall, 51 patients (49.0%) had choledocholithiasis, which did not justify the risk of direct ERCP. In the EUS-first group, 27 (61.4%) ERCP procedures were prevented. The overall complication rate was significantly lower in the EUS-first group compared to the ERCP-fist group (6.8% vs. 21.7%, P = 0.04). The number-needed-to-treat to avoid one unnecessary adverse event was 6.71. After a 3-month follow-up, the cumulative recurrence biliary event rates were similar (13.6% vs. 15.0%, P = 0.803). EUS-first strategy was more cost-effective than the ERCP-first strategy (mean cost 2322.89$ vs. 3175.63$, P = 0.002). CONCLUSIONS In high-probability choledocholithiasis patients with a negative CT, the EUS-first strategy is cost-effective, which can prevent unnecessary ERCP procedures and their complications.
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Affiliation(s)
- Meng-Ying Lin
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan, R.O.C
| | - Chun-Te Lee
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan, R.O.C
| | - Ming-Tsung Hsieh
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan, R.O.C
| | - Ming-Ching Ou
- Department of Medical Image, National Cheng Kung University Hospital, Tainan, Taiwan, R.O.C
| | - Yao-Shen Wang
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan, R.O.C
| | - Meng-Chieh Lee
- Department of Emergent Medicine, National Cheng Kung University Hospital, Tainan, Taiwan, R.O.C
| | - Wei-Lun Chang
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan, R.O.C..
| | - Bor-Shyang Sheu
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan, R.O.C..
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Wangchuk K, Srichan P. Accuracy of SAGES, ASGE, and ESGE criteria in predicting choledocholithiasis. Surg Endosc 2022; 36:7233-7239. [PMID: 35146555 DOI: 10.1007/s00464-022-09089-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 01/29/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Patients with suspected choledocholithiasis (CDL) are stratified as high-risk (HR), intermediate-risk (IR), and low-risk (LR) according to the guidelines of Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), American Society for Gastrointestinal Endoscopy (ASGE), and European Society of Gastrointestinal Endoscopy (ESGE). Although these approaches are invaluable, paucity of validation studies are currently available. This study aimed to evaluate the diagnostic accuracy of the above risk stratification criteria in predicting CDL. METHODS We conducted a retrospective cohort study of 280 patients with suspected CDL. All patients were stratified according to above professional societies as HR, IR, and LR, and diagnostic performance was evaluated. RESULTS In the HR group, area under the receiver operating characteristic curve (AUC) were 0.77 [95% confidence interval (CI), 0.70-0.84], 0.75 (95% CI, 0.68-0.81), and 0.74 (95% CI, 0.68-0.81) for SAGES, ASGE, and ESGE criteria, respectively. The diagnostic accuracy were 78.93% (81.13% sensitivity, 72.06% specificity), 75% (75.47% sensitivity, 73.53% specificity), and 70% (66.04% sensitivity, 82.35% specificity) for SAGES, ASGE, and ESGE criteria, respectively. Regarding the IR group, the diagnostic accuracy were 22.50% (16.98% sensitivity, 39.71% specificity), 25% (24.53% sensitivity, 26.47% specificity), and 30.00% (33.49% sensitivity, 19.12% specificity) for SAGES, ASGE, and ESGE criteria, respectively. The common bile duct stone (CBDS) visualized on imaging has the highest risk for CDL [odds ratio (OR), 13.59 (95% CI, 5.26-35.12)], followed by CBDS plus dilated common bile duct [OR, 13.33 (95% CI, 5.16-34.47)], CBDS plus cholangitis [OR, 13.33 (95% CI, 3.17-56.15)], and CBDS plus total bilirubin level > 1.7 mg/dL [OR, 9.89 (95% CI, 3.47-28.20)]. CONCLUSIONS The current SAGES, ASGE, and ESGE criteria have acceptable diagnostic accuracy for CDL. The patients with visualized CBDS on imaging have the highest risk for CDL.
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Ali FS, DaVee T, Bernstam EV, Kao LS, Wandling M, Hussain MR, Rashtak S, Ramireddy S, Guha S, Thosani N. Cost-effectiveness analysis of optimal diagnostic strategy for patients with symptomatic cholelithiasis with intermediate probability for choledocholithiasis. Gastrointest Endosc 2022; 95:327-338. [PMID: 34499905 DOI: 10.1016/j.gie.2021.08.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 08/14/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS EUS, MRCP, and intraoperative cholangiogram (IOC) are the recommended diagnostic modalities for patients with intermediate probability for choledocholithiasis (IPC). The relative cost-effectiveness of these modalities in patients with cholelithiasis and IPC is understudied. METHODS We developed a decision tree for diagnosing IPC (base-case probability, 50%; range, 10%-70%); patients with a positive test were modeled to undergo therapeutic ERCP. The strategies tested were laparoscopic cholecystectomy with IOC (LC-IOC), MRCP, single-session EUS + ERCP, and separate-session EUS + ERCP. Costs and probabilities were extracted from the published literature. Effectiveness was assessed by assigning utility scores to health states, average proportion of true-positive diagnosis of IPC, and the mean length of stay (LOS) per strategy. Cost-effectiveness was assessed by extrapolating a net-monetary benefit (NMB) and average cost per true-positive diagnosis. RESULTS LC-IOC was the most cost-effective strategy to diagnose IPC (base-case probability of 50%) among patients with cholelithiasis in health state-based effectiveness analysis (NMB of $34,612), diagnostic test accuracy-based effectiveness analysis (average cost of $13,260 per true-positive diagnosis), and LOS-based effectiveness analysis (mean LOS of 4.13) compared with strategies 2 (MRCP), 3 (single-session EUS + ERCP), and 4 (separate-session EUS + ERCP). These findings were robust on deterministic and probabilistic sensitivity analyses. CONCLUSIONS For patients with cholelithiasis with IPC, LC-IOC is a cost-effective approach that should limit preoperative testing and may shorten hospital LOS. Our findings may be used to design institutional and organizational management protocols.
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Affiliation(s)
- Faisal S Ali
- Center for interventional Gastroenterology at UTHealth (iGUT), University of Texas Health Science Center at Houston, Houston, Texas, USA; Department of Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Tomas DaVee
- Center for interventional Gastroenterology at UTHealth (iGUT), University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Elmer V Bernstam
- Department of General Internal Medicine, McGovern Medical School, and School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Lillian S Kao
- Department of Internal Medicine, Saint Joseph Hospital, Chicago, Illinois, USA
| | - Mike Wandling
- Department of Internal Medicine, Saint Joseph Hospital, Chicago, Illinois, USA
| | - Maryam R Hussain
- Department of Public Health, Mount Sinai Icahn School of Medicine, New York, New York, USA
| | - Shahrooz Rashtak
- Center for interventional Gastroenterology at UTHealth (iGUT), University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Srinivas Ramireddy
- Center for interventional Gastroenterology at UTHealth (iGUT), University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Sushovan Guha
- Center for interventional Gastroenterology at UTHealth (iGUT), University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Nirav Thosani
- Center for interventional Gastroenterology at UTHealth (iGUT), University of Texas Health Science Center at Houston, Houston, Texas, USA
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Tracy BM, Poulose BK, Paterson CW, Mendoza AE, Gaitanidis A, Saxe JM, Young AJ, Zielinski MD, Sims CA, Gelbard RB. National adherence to the ASGE-SAGES guidelines for managing suspected choledocholithiasis: An EAST multicenter study. J Trauma Acute Care Surg 2022; 92:305-312. [PMID: 34813581 DOI: 10.1097/ta.0000000000003466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The American Society for Gastrointestinal Endoscopy and Society of American Gastrointestinal and Endoscopic Surgeons provide guidelines for managing suspected common bile duct (CBD) stones. We sought to evaluate adherence to the guidelines among patients with choledocholithiasis and/or acute biliary pancreatitis (ABP) and to evaluate the ability of these guidelines to predict choledocholithiasis. METHODS We prospectively identified patients undergoing same-admission cholecystectomy for choledocholithiasis and/or ABP from 2016 to 2019 at 12 United States medical centers. Predictors of suspected CBD stones were very strong (CBD stone on ultrasound; bilirubin >4 mg/dL), strong (CBD > 6 mm; bilirubin ≥1.8 to ≤4 mg/dL), or moderate (abnormal liver function tests other than bilirubin; age >55 years; ABP). Patients were grouped by probability of CBD stones: high (any very strong or both strong predictors), low (no predictors), or intermediate (any other predictor combination). The management of each probability group was compared with the recommended management in the guidelines. RESULTS The cohort was comprised of 844 patients. High-probability patients had 64.3% (n = 238/370) deviation from guidelines, intermediate-probability patients had 29% (n = 132/455) deviation, and low-probability patients had 78.9% (n = 15/19) deviation. Acute biliary pancreatitis increased the odds of deviation for the high- (odds ratio [OR], 1.71; 95% confidence interval [CI], 1.06-2.8; p = 0.03) and intermediate-probability groups (OR, 1.6; 95% CI, 1.07-2.42; p = 0.02). Age older than 55 years (OR, 2.19; 95% CI, 1.4-3.43; p < 0.001) also increased the odds of deviation for the intermediate group. A CBD greater than 6 mm predicted choledocholithiasis in the high (adjusted OR (aOR), 2.16; 95% CI, 1.17-3.97; p = 0.01) and intermediate group (aOR, 2.78; 95% CI, 1.59-4.86; p < 0.001). Any very strong predictor (aOR, 2.43; 95% CI, 1.76-3.37; p < 0.0001) and both strong predictors predicted choledocholithiasis (aOR, 2; 95% CI, 1.35-2.96; p < 0.001). CONCLUSION Almost 45% of patients with suspected CBD stones were managed discordantly from the American Society for Gastrointestinal Endoscopy and Society of American Gastrointestinal and Endoscopic Surgeons guidelines. We believe these guidelines warrant revision to better reflect the ability of the clinical variables at predicting choledocholithiasis. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Brett M Tracy
- From the Division of Trauma, Critical Care & Burn Surgery (B.M.T., B.K.P., A.J.Y., C.A.S.), The Ohio State University, Columbus, Ohio; Department of Surgery (C.W.P.), Emory University School of Medicine; Division of Acute Care Surgery (C.W.P., R.B.G.), Grady Memorial Hospital, Atlanta, Georgia; Division of Trauma, Emergency Surgery & Surgical Critical Care (A.E.M., A.G.), Massachusetts General Hospital, Boston, Massachusetts; Department of Surgery (J.M.S.), Ascension St. Vincent Hospital, Indianapolis, Indiana; Division of Trauma (M.D.Z.), Critical Care & Emergency General Surgery, Mayo Clinic, Rochester, Minnesota; and Division of Acute Care Surgery (R.B.G.), University of Alabama at Birmingham, Birmingham, Alabama
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Dalai C, Azizian JM, Trieu H, Rajan A, Chen FC, Dong T, Beaven SW, Tabibian JH. Machine learning models compared to existing criteria for noninvasive prediction of endoscopic retrograde cholangiopancreatography-confirmed choledocholithiasis. LIVER RESEARCH (BEIJING, CHINA) 2021; 5:224-231. [PMID: 35186364 PMCID: PMC8855981 DOI: 10.1016/j.livres.2021.10.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 08/05/2021] [Accepted: 10/20/2021] [Indexed: 02/09/2023]
Abstract
BACKGROUND AND AIMS Noninvasive predictors of choledocholithiasis have generally exhibited marginal performance characteristics. We aimed to identify noninvasive independent predictors of endoscopic retrograde cholangiopancreatography (ERCP)-confirmed choledocholithiasis and accordingly developed predictive machine learning models (MLMs). METHODS Clinical data of consecutive patients undergoing first-ever ERCP for suspected choledocholithiasis from 2015-2019 were abstracted from a prospectively-maintained database. Multiple logistic regression was used to identify predictors of ERCP-confirmed choledocholithiasis. MLMs were then trained to predict ERCP-confirmed choledocholithiasis using pre-ERCP ultrasound (US) imaging only and separately using all available noninvasive imaging (US/CT/magnetic resonance cholangiopancreatography). The diagnostic performance of American Society for Gastrointestinal Endoscopy (ASGE) "high-likelihood" criteria was compared to MLMs. RESULTS We identified 270 patients (mean age 46 years, 62.2% female, 73.7% Hispanic/Latino, 59% with noninvasive imaging positive for choledocholithiasis) with native papilla who underwent ERCP for suspected choledocholithiasis, of whom 230 (85.2%) were found to have ERCP-confirmed choledocholithiasis. Logistic regression identified choledocholithiasis on noninvasive imaging (odds ratio (OR) = 3.045, P = 0.004) and common bile duct (CBD) diameter on noninvasive imaging (OR=1.157, P = 0.011) as predictors of ERCP-confirmed choledocholithiasis. Among the various MLMs trained, the random forest-based MLM performed best; sensitivity was 61.4% and 77.3% and specificity was 100% and 75.0%, using US-only and using all available imaging, respectively. ASGE high-likelihood criteria demonstrated sensitivity of 90.9% and specificity of 25.0%; using cut-points achieving this specificity, MLMs achieved sensitivity up to 97.7%. CONCLUSIONS MLMs using age, sex, race, presence of diabetes, fever, body mass index (BMI), total bilirubin, maximum CBD diameter, and choledocholithiasis on pre-ERCP noninvasive imaging predict ERCP-confirmed choledocholithiasis with good sensitivity and specificity and outperform the ASGE criteria for patients with suspected choledocholithiasis.
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Affiliation(s)
- Camellia Dalai
- UCLA-Olive View Internal Medicine Residency Program, Department of Medicine, Olive View-UCLA Medical Center, Sylmar, CA, USA
| | - John M Azizian
- UCLA-Olive View Internal Medicine Residency Program, Department of Medicine, Olive View-UCLA Medical Center, Sylmar, CA, USA
| | - Harry Trieu
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Anand Rajan
- UCLA-Olive View Internal Medicine Residency Program, Department of Medicine, Olive View-UCLA Medical Center, Sylmar, CA, USA
| | - Formosa C Chen
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Tien Dong
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Simon W Beaven
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Division of Gastroenterology, Department of Medicine, Olive View-UCLA Medical Center, Sylmar, CA, USA
| | - James H. Tabibian
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Division of Gastroenterology, Department of Medicine, Olive View-UCLA Medical Center, Sylmar, CA, USA
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Choi YH, Lee YS, Lee SH, Son JH, Ryu JK, Kim YT, Paik WH. Role of EUS at high risk for choledocholithiasis without severe cholangitis and visible stone on cross-sectional imaging: A multicenter randomized clinical trial. Endosc Ultrasound 2021; 10:455-462. [PMID: 34755702 PMCID: PMC8785677 DOI: 10.4103/eus-d-20-00229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background and Objectives: The prevalence of choledocholithiasis in the high-risk group of choledocholithiasis has been reported to be slightly more than 50% when there is no definite cholangitis. Replacement of diagnostic endoscopic retrograde cholangiography (ERC) with an EUS-first approach may be beneficial in these patients. Materials and Methods: In this prospective, multicenter study, patients with dilated common bile duct and serum total bilirubin levels of 1.8–4 mg/dL were randomly allocated to undergo either EUS first, followed by subsequent ERC if necessary (EUS group) or ERC only (ERC group). The primary endpoint was the incidence of negative outcomes associated with a false-negative diagnosis of the choledocholithiasis or the endoscopic procedure. The secondary endpoints were the rate of diagnostic ERC and hospital stay length related to the endoscopic procedure. Results: Of 90 patients who were randomly assigned, the final analysis involved 42 in the EUS group and 44 in the ERC group. The negative outcomes were not significantly different between the EUS and ERC groups (2.4% vs. 6.8%; P = 0.62). The rate of diagnostic ERC was significantly lower in the EUS group (2.4% vs. 47.7%; P < 0.001). The hospital stay length related to the endoscopic procedure was significantly shorter in the EUS group (1.8 ± 1.0 vs. 2.5 ± 1.2 days; P = 0.001). Conclusion: In selected high-risk choledocholithiasis patients, an EUS-first strategy significantly decreased the rate of diagnostic ERC and hospital stay but did not achieve a significant reduction in negative endoscopic procedure outcomes.
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Affiliation(s)
- Young Hoon Choi
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine; Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Yoon Suk Lee
- Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, South Korea
| | - Sang Hyub Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Jun Hyuk Son
- Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, South Korea
| | - Ji Kon Ryu
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Yong-Tae Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Woo Hyun Paik
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
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Cohen RZ, Tian H, Sauer CG, Willingham FF, Santore MT, Mei Y, Freeman AJ. Creation of a Pediatric Choledocholithiasis Prediction Model. J Pediatr Gastroenterol Nutr 2021; 73:636-641. [PMID: 34224492 DOI: 10.1097/mpg.0000000000003219] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Definitive non-invasive detection of pediatric choledocholithiasis could allow more efficient identification of those patients who are most likely to benefit from therapeutic endoscopic retrograde cholangiopancreatography (ERCP) for stone extraction. OBJECTIVE To craft a pediatric choledocholithiasis prediction model using a combination of commonly available serum laboratory values and ultrasound results. METHODS A retrospective review of laboratory and imaging results from 316 pediatric patients who underwent intraoperative cholangiogram or ERCP due to suspicion of choledocholithiasis were collected and compared to presence of common bile duct stones on cholangiography. Multivariate logistic regression with supervised machine learning was used to create a predictive scoring model. Monte-Carlo cross-validation was used to validate the scoring model and a score threshold that would provide at least 90% specificity for choledocholithiasis was determined in an effort to minimize non-therapeutic ERCP. RESULTS Alanine aminotransferase (ALT), total bilirubin, alkaline phosphatase, and common bile duct diameter via ultrasound were found to be the key clinical variables to determine the likelihood of choledocholithiasis. The dictated specificity threshold of 90.3% yielded a sensitivity of 40.8% and overall accuracy of 71.5% in detecting choledocholithiasis. Positive predictive value was 71.4% and negative predictive value was 72.1%. CONCLUSION Our novel pediatric choledocholithiasis predictive model is a highly specific tool to suggest ERCP in the setting of likely choledocholithiasis.
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Affiliation(s)
- Reuven Zev Cohen
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Emory University School of Medicine, Children's Healthcare of Atlanta
| | - Hongzhen Tian
- H. Milton School of Industrial and Systems Engineering, Georgia Institute of Technology
| | - Cary G Sauer
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Emory University School of Medicine, Children's Healthcare of Atlanta
| | - Field F Willingham
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine
| | - Matthew T Santore
- Section of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA
| | - Yajun Mei
- H. Milton School of Industrial and Systems Engineering, Georgia Institute of Technology
| | - A Jay Freeman
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Emory University School of Medicine, Children's Healthcare of Atlanta
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Abstract
PURPOSE The prevalence of gallstones in children has increased over the last years. Choledocholithiasis (CD) is present in up to 30% of the cases. There is a scarcity of studies on the management of choledocholithiasis in children. The aim of this study was to develop a score that would allow predicting accurately the risk of CD in children with gallstones and reduce the number of non-therapeutic ERCP. MATERIALS AND METHODS We conducted a retrospective study in children with gallstones and suspected CD seen between January 2010 and December 2019. The main outcome was the presence of CD confirmed by at least one of the following diagnostic tests: magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP), and/or intraoperative cholangiography (IOC). We developed a risk score based on the presence or absence of the following risk factors: acute biliary pancreatitis, ascending cholangitis, elevated liver function tests (AST, ALT, total bilirubin [TB, ≥ 2 mg/dl], conjugated bilirubin, gamma-glutamyl transpeptidase, and alkaline phosphatase), CD on ultrasound (US; this was considered predictive but not confirmatory of CD), and dilation of the common bile duct (> 6 mm) by US. The score was divided into three different categories: low risk (no risk factors), intermediate risk (one risk factor present), high risk (≥ 2 risk factors present or ascending cholangitis). Given the main goal of reducing the number of diagnostic ERCPs, a very-high-risk subgroup (3 risk factors present or ascending cholangitis) was identified. RESULTS We reviewed 133 patients with gallstones and suspected CD. In 56 (42.1%) patients, the presence of CD was confirmed by one or more of the definitive diagnostic tests (MRCP, ERCP, and IOC). The following variables were found to be the strongest predictors of CD: ascending cholangitis, TB ≥ 2 mg/dl, common bile duct > 6 mm, and the presence of CD by US. The positive predictive value for CD was 7.5% in the low-risk group (OR 0.06, P = < 0.001); 22.9% in the intermediate-risk group (OR 0.31, P = 0.007); 77.6% in the high-risk group (OR 20.14, P = < 0.001); and 95.7% in very-high-risk subgroup (OR 49.18, P = < 0.001). CONCLUSION The risk score proposed in this study predicts accurately the presence of CD in children with gallstones. It can serve as a helpful tool to triage the need for costly and complex studies in the workup of CD, particularly in centers with limited resources. Finally, due to its high specificity and positive predictive value (PPV), the use of the very-high-risk criteria would allow for an important decrease in the number of non-therapeutic ERCP.
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Abstract
Cholecystectomy is one of the most common general surgery procedures performed worldwide. Complications include bile duct injury, strictures, bleeding, infection/abscess, retained gallstones, hernias, and postcholecystectomy syndrome. Obtaining a critical view of safety and following the other tenets of the Safe Cholecystectomy Task Force will aid in the prevention of bile duct injury and other morbidity associated with cholecystectomy.
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Affiliation(s)
- Xiaoxi Chelsea Feng
- Department of Surgery, Cedars Sinai Medical Center, 8635 W Third Street, West Medical Office Tower, Suite 795, Los Angeles, CA 90048, USA
| | - Edward Phillips
- Department of Surgery, Cedars Sinai Medical Center, 8635 W Third Street, West Medical Office Tower, Suite 795, Los Angeles, CA 90048, USA
| | - Daniel Shouhed
- Department of Surgery, Cedars Sinai Medical Center, 459 North Croft Avenue, Los Angeles, CA 90048, USA.
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Fishman DS, Barth B, Man-Wai Tsai C, Giefer MJ, Martinez M, Wilsey M, Khalaf RT, Liu QY, DeAngelis P, Torroni F, Faraci S, Troendle DM. A prospective multicenter analysis from the Pediatric ERCP Database Initiative: predictors of choledocholithiasis at ERCP in pediatric patients. Gastrointest Endosc 2021; 94:311-317.e1. [PMID: 33539907 DOI: 10.1016/j.gie.2021.01.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 01/24/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The management of suspected choledocholithiasis remains a challenge in pediatric endoscopy. Several recommendations are available for adult patients; however, it is unknown which pediatric patients are most likely to benefit from ERCP for evaluation of choledocholithiasis. The primary aim of this study was to evaluate adult-based criteria in the evaluation of pediatric patients with choledocholithiasis. A secondary aim was to evaluate the role of conjugated (or direct) bilirubin to improve the sensitivity of detecting choledocholithiasis. METHODS This was a prospective multicenter study in pediatric patients as part of the Pediatric ERCP Database Initiative (PEDI) with additional post-hoc analysis of updated guidelines. Patients <19 years of age undergoing ERCP for suspected choledocholithiasis or gallstone pancreatitis were enrolled at participating sites. RESULTS Ninety-five patients were enrolled (69 with choledocholithiasis confirmed at ERCP and 26 with no stones at ERCP). Adverse event rates were similar in both groups. Specificity ranged from 27% to 91% using adult guidelines, but a sensitivity of only 20% to 69%. The were no significant differences between the 2 groups using preprocedure transabdominal US (P = 1.0). Significant differences between groups were identified using either the total or conjugated bilirubin (P = .02). There was also a significant difference between the stone and no-stone groups when conjugated bilirubin was dichotomized to >2 mg/dL (P = .03). CONCLUSIONS Abdominal imaging and laboratory indices may be used to predict pediatric choledocholithiasis with varying sensitivity and specificity. Pediatric-specific guidelines may allow for improved stone prediction compared with existing adult recommendations.
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Affiliation(s)
- Douglas S Fishman
- Section of Pediatric Gastroenterology, Hepatology and Nutrition; Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Brad Barth
- UT Southwestern Department of Pediatrics, Division of Pediatric Gastroenterology Children's Health-Children's Medical Center, Dallas, Texas, USA
| | - Cynthia Man-Wai Tsai
- Section of Pediatric Gastroenterology, Hepatology and Nutrition; Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Matthew J Giefer
- The University of Queensland, Brisbane, Australia; Ochsner Health, New Orleans, Louisianna, USA
| | - Mercedes Martinez
- Department of Pediatrics, Columbia University Medical Center, New York, New York, USA
| | - Michael Wilsey
- Division of Pediatric Gastroenterology, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Racha T Khalaf
- University of South Florida Morsani College of Medicine, Department of Pediatrics, Tampa, Florida, USA
| | - Quin Y Liu
- Cedars-Sinai Medical Center, and David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Paola DeAngelis
- Digestive Surgery and Endoscopy Unit, Bambino Gesu Children's Hospital, Rome, Italy
| | - Filippo Torroni
- Digestive Surgery and Endoscopy Unit, Bambino Gesu Children's Hospital, Rome, Italy
| | - Simona Faraci
- Digestive Surgery and Endoscopy Unit, Bambino Gesu Children's Hospital, Rome, Italy
| | - David M Troendle
- UT Southwestern Department of Pediatrics, Division of Pediatric Gastroenterology Children's Health-Children's Medical Center, Dallas, Texas, USA
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Chandran A, Rashtak S, Patil P, Gottlieb A, Bernstam E, Guha S, Ramireddy S, Badillo R, DaVee RT, Kao LS, Thosani N. Comparing diagnostic accuracy of current practice guidelines in predicting choledocholithiasis: outcomes from a large healthcare system comprising both academic and community settings. Gastrointest Endosc 2021; 93:1351-1359. [PMID: 33160977 DOI: 10.1016/j.gie.2020.10.033] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 10/20/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The American Society for Gastrointestinal Endoscopy (ASGE) 2010 guidelines for suspected choledocholithiasis were recently updated by proposing more specific criteria for selection of high-risk patients to undergo direct ERCP while advocating the use of additional imaging studies for intermediate- and low-risk individuals. We aim to compare the performance and diagnostic accuracy of 2019 versus 2010 ASGE criteria for suspected choledocholithiasis. METHODS We performed a retrospective chart review of a prospectively maintained database (2013-2019) of over 10,000 ERCPs performed by 70 gastroenterologists in our 14-hospital system. We randomly selected 744 ERCPs in which the primary indication was suspected choledocholithiasis. Patients with a history of cholecystectomy or prior sphincterotomy were excluded. The same patient cohort was assigned as low, intermediate, or high risk according to the 2010 and 2019 guideline criteria. Overall accuracy of both guidelines was compared against the presence of stones and/or sludge on ERCP. RESULTS Of 744 patients who underwent ERCP, 544 patients (73.1%) had definite stones during ERCP and 696 patients (93.5%) had stones and/or sludge during ERCP. When classified according to the 2019 guidelines, fewer patients were high risk (274/744, 36.8%) compared with 2010 guidelines (449/744, 60.4%; P < .001). Within the high-risk group per both guidelines, definitive stone was found during ERCP more frequently in the 2019 guideline cohort (226/274, 82.5%) compared with the 2010 guideline cohort (342/449, 76.2%; P < .001). In our patient cohort, overall specificity of the 2010 guideline was 46.5%, which improved to 76.0% as per 2019 guideline criteria (P < .001). However, no significant change was noted for either positive predictive value or negative predictive value between 2019 and 2010 guidelines. CONCLUSIONS The 2019 ASGE guidelines are more specific for detection of choledocholithiasis during ERCP when compared with the 2010 guidelines. However, a large number of patients are categorized as intermediate risk per 2019 guidelines and will require an additional confirmatory imaging study.
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Affiliation(s)
- Aswathi Chandran
- Center for Interventional Gastroenterology at UTHealth (iGUT), McGovern Medical School, UTHealth, Houston, Texas, USA
| | - Shahrooz Rashtak
- Center for Interventional Gastroenterology at UTHealth (iGUT), McGovern Medical School, UTHealth, Houston, Texas, USA
| | - Prithvi Patil
- Center for Interventional Gastroenterology at UTHealth (iGUT), McGovern Medical School, UTHealth, Houston, Texas, USA
| | - Assaf Gottlieb
- School of Biomedical Informatics, UTHealth, Houston, Texas, USA
| | - Elmer Bernstam
- School of Biomedical Informatics, UTHealth, Houston, Texas, USA
| | - Sushovan Guha
- Center for Interventional Gastroenterology at UTHealth (iGUT), McGovern Medical School, UTHealth, Houston, Texas, USA
| | - Srinivas Ramireddy
- Center for Interventional Gastroenterology at UTHealth (iGUT), McGovern Medical School, UTHealth, Houston, Texas, USA
| | - Ricardo Badillo
- Center for Interventional Gastroenterology at UTHealth (iGUT), McGovern Medical School, UTHealth, Houston, Texas, USA
| | - Roy Tomas DaVee
- Center for Interventional Gastroenterology at UTHealth (iGUT), McGovern Medical School, UTHealth, Houston, Texas, USA
| | | | - Nirav Thosani
- Center for Interventional Gastroenterology at UTHealth (iGUT), McGovern Medical School, UTHealth, Houston, Texas, USA
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Ko C, Buxbaum J. Do the 2019 ASGE choledocholithiasis guidelines reduce diagnostic ERCP? Gastrointest Endosc 2021; 93:1360-1361. [PMID: 33712227 DOI: 10.1016/j.gie.2020.12.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 12/31/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Christopher Ko
- Division of Gastroenterology, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - James Buxbaum
- Division of Gastroenterology, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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Jagtap N, Karyampudi A, Yashavanth HS, Ramchandani M, Lakhtakia S, Kalapala R, Tandan M, Basha J, Nabi Z, Gupta R, Reddy DN. Intermediate Likelihood of Choledocholithiasis: Do All Need EUS or MRCP? JOURNAL OF DIGESTIVE ENDOSCOPY 2021. [DOI: 10.1055/s-0041-1728233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Abstract
Background Recently updated guidelines for choledocholithiasis stratify suspected patients into high, intermediate, and low likelihood, with the aim to reduce risk of diagnostic endoscopic retrograde cholangiopancreatography. This approach has increased proportion of patients in intermediate likelihood making it heterogenous. We aim to substratify intermediate group so that diagnostic tests (endoscopic ultrasound/magnetic resonance cholangiopancreatography) are judicially used.
Methods This is a single-center retrospective analysis of prospectively maintained data. We used subset of patients who met intermediate likelihood of American Society of Gastrointestinal Endoscopy (ASGE) criteria from previously published data (PMID:32106321) as derivation cohort. Binominal logistic regression analysis was used to define independent predictors of choledocholithiasis. A composite score was derived by allotting 1 point for presence of each independent predictor. The diagnostic performance of a composite score of ≥ 1 was evaluated in validation cohort.
Results A total of 678 (mean age [standard deviation]: 47.0 [15.9] years; 48.1% men) and 162 (mean age 47.8 [14.8] years; 47.4% men) patients in ASGE intermediate-likelihood group were included as derivation cohort and validation cohort, respectively. Binominal logistic regression analysis showed that male gender (p = 0.024; odds ratio [OR] = 1.92), raised bilirubin (p = 0.001; OR = 2.40), and acute calculus cholecystitis (p = 0.010; OR = 2.04) were independent predictors for choledocholithiasis. A composite score was derived by allotting 1 point for presence of independent predictors Using ≥ 1 as cutoff, sensitivity and specificity for detection of choledocholithiasis were 80% (95% confidence interval [CI]: 68.2–88.9) and 36.2% (95% CI: 32.2–40.0), respectively, in derivation cohort. Applying composite score in independent validation cohort showed sensitivity and specificity of 73.3% (95% CI: 44.9–92.2) and 40.1% (95% CI: 30.1–48.5), respectively.
Conclusion Substratification of intermediate-likelihood group of ASGE criteria is feasible. It may be useful in deciding in whom confirmatory tests should be performed with priority and in whom watchful waiting may be sufficient.
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Affiliation(s)
- Nitin Jagtap
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Arun Karyampudi
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - HS Yashavanth
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Mohan Ramchandani
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Sundeep Lakhtakia
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Rakesh Kalapala
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Manu Tandan
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Jahangeer Basha
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Zaheer Nabi
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Rajesh Gupta
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - DNageshwar Reddy
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
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Lee YN, Moon JH. Optimal Predictive Criteria for Common Bile Duct Stones: The Search Continues. Clin Endosc 2021; 54:147-148. [PMID: 33745267 PMCID: PMC8039746 DOI: 10.5946/ce.2021.080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 03/05/2021] [Indexed: 11/23/2022] Open
Affiliation(s)
- Yun Nah Lee
- Digestive Disease Center and Research Institute, Department of Internal Medicine, Soonchunhyang University School of Medicine, Bucheon, Korea
| | - Jong Ho Moon
- Digestive Disease Center and Research Institute, Department of Internal Medicine, Soonchunhyang University School of Medicine, Bucheon, Korea
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Kokoroskos N, Peponis T, Lee JM, El Hechi M, Naar L, Nederpelt C, Gaitanidis A, Mendoza AE, Saillant N, Kaafarani H, King D, Velmahos G, Fagenholz P. The Role of Transaminases in Predicting Choledocholithiasis. A Novel Predictive Composite Score Development in a Cohort of 1089 Patients Undergoing Laparoscopic Cholecystectomy. Am Surg 2021; 88:1631-1637. [PMID: 33710916 DOI: 10.1177/0003134821998664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Optimal use of interventional procedures and diagnostic tests for patients with suspected choledocholithiasis depends on accurate pretest risk estimation. We sought to define sensitivity/specificity of transaminases in identifying choledocholithiasis and to incorporate them into a biochemical marker composite score that could accurately predict choledocholithiasis. METHODS All adult patients who underwent laparoscopic cholecystectomy by our Emergency Surgery Service between 2010 and 2018 were reviewed. Admission total bilirubin (TB), aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase (ALP) was captured. Choledocholithiasis was confirmed via intraoperative cholangiogram, endoscopic retrograde cholangiopancreatography, or magnetic resonance cholangiopancreatography. Area under receiver operating characteristic curve (AUC) or C-statistic for AST, ALT, ALP, and TB as a measure of detecting choledocholithiasis was calculated. For score development, our database was randomly dichotomized to derivation and validation cohort and a score was derived. The score was validated by calculating its C-statistic. RESULTS 1089 patients were included; 210 (20.3%) had confirmed choledocholithiasis. The AUC was .78 for TB, .77 for ALP and AST, and .76 for ALT. 545 and 544 patients were included in the derivation and the validation cohort, respectively. The elements of the derived score were TB, AST, and ALP. The score ranged from 0 to 4. The AUC was .82 in the derivation and .77 in the validation cohort. The probability of choledocholithiasis increased from 8% to 89% at scores 0 to 4, respectively. CONCLUSIONS Aspartate aminotransferase predicted choledocholithiasis adequately and should be featured in choledocholithiasis screening algorithms. We developed a biochemical composite score, shown to be accurate in preoperative choledocholithiasis risk assessment in an emergency surgery setting.
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Affiliation(s)
- Nikolaos Kokoroskos
- Department of Surgery, Harvard Medical School, 548305Massachusetts General Hospital, Boston, MA, USA
| | - Thomas Peponis
- Department of Surgery, Harvard Medical School, 548305Massachusetts General Hospital, Boston, MA, USA
| | - Jae Moo Lee
- Department of Surgery, Harvard Medical School, 548305Massachusetts General Hospital, Boston, MA, USA
| | - Majed El Hechi
- Department of Surgery, Harvard Medical School, 548305Massachusetts General Hospital, Boston, MA, USA
| | - Leon Naar
- Department of Surgery, Harvard Medical School, 548305Massachusetts General Hospital, Boston, MA, USA
| | - Charlie Nederpelt
- Department of Surgery, Harvard Medical School, 548305Massachusetts General Hospital, Boston, MA, USA
| | - Apostolos Gaitanidis
- Department of Surgery, Harvard Medical School, 548305Massachusetts General Hospital, Boston, MA, USA
| | - April E Mendoza
- Department of Surgery, Harvard Medical School, 548305Massachusetts General Hospital, Boston, MA, USA
| | - Noelle Saillant
- Department of Surgery, Harvard Medical School, 548305Massachusetts General Hospital, Boston, MA, USA
| | - Haytham Kaafarani
- Department of Surgery, Harvard Medical School, 548305Massachusetts General Hospital, Boston, MA, USA
| | - David King
- Department of Surgery, Harvard Medical School, 548305Massachusetts General Hospital, Boston, MA, USA
| | - George Velmahos
- Department of Surgery, Harvard Medical School, 548305Massachusetts General Hospital, Boston, MA, USA
| | - Peter Fagenholz
- Department of Surgery, Harvard Medical School, 548305Massachusetts General Hospital, Boston, MA, USA
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Reddy S, Jagtap N, Kalapala R, Ramchandani M, Lakhtakia S, Basha J, Nabi Z, Karyampudi A, Chavan R, Tandan M, Gupta R, Reddy DN. Choledocholithiasis in acute calculous cholecystitis: guidelines and beyond. Ann Gastroenterol 2021; 34:247-252. [PMID: 33654367 PMCID: PMC7903571 DOI: 10.20524/aog.2020.0562] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 09/09/2020] [Indexed: 12/15/2022] Open
Abstract
Background Acute calculous cholecystitis (ACC) is the most frequent complication of gallstones requiring cholecystectomy. These patients may have coexisting choledocholithiasis. We aimed to evaluate the role of current guidelines for choledocholithiasis in patients with ACC. Methods In this retrospective study, we included all patients diagnosed with ACC between December 2018 and May 2019. These patients were substratified according to the guidelines of the American and European Societies of Gastrointestinal Endoscopy (ASGE and ESGE) as having high, intermediate, or low likelihood of choledocholithiasis, and the diagnostic performance was measured. Binomial logistic regression analysis was applied to ascertain independent risk factors for choledocholithiasis. Results A total of 173 patients with ACC, mean age (±standard deviation) 49.89±15.74 years and 60.1% male, were included. Sixty-three (36.4%) had confirmed choledocholithiasis. ASGE high likelihood criteria had sensitivity and specificity of 61.9% (95% confidence interval [CI] 48.8-73.9) and 83.4% (95%CI 75.4-90.0) for predicting choledocholithiasis. ESGE high likelihood criteria had sensitivity and specificity of 49.2% (95%CI 36.4-62.1) and 87.3% (95%CI 79.6-92.9). On logistic regression analysis, an alkaline phosphatase level above the upper limit of normal (P=0.003; odds ratio [OR] 4.26, 95%CI 1.66-10.96) and a dilated common bile duct on ultrasound (P=0.001; OR 9.97, 95%CI 4.65-21.36) were independent positive predictors for choledocholithiasis, while acute biliary pancreatitis was an independent negative predictor (P=0.030; OR 0.36, 95%CI 0.14-0.91). Conclusions The performance of the ASGE and ESGE guidelines’ risk stratification criteria is inadequate in patients with ACC. We suggest the utilization of a separate predictive model for suspected choledocholithiasis in these patients.
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Affiliation(s)
- Siddhartha Reddy
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India (Siddhartha Reddy, Nitin Jagtap, Rakesh Kalapala, Mohan Ramchandani, Sundeep Lakhtakia, Jahangeer Basha, Zaheer Nabi, Arun Karyampudi, Radhika Chavan, Manu Tandan, Rajesh Gupta, D. Nageshwar Reddy)
| | - Nitin Jagtap
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India (Siddhartha Reddy, Nitin Jagtap, Rakesh Kalapala, Mohan Ramchandani, Sundeep Lakhtakia, Jahangeer Basha, Zaheer Nabi, Arun Karyampudi, Radhika Chavan, Manu Tandan, Rajesh Gupta, D. Nageshwar Reddy)
| | - Rakesh Kalapala
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India (Siddhartha Reddy, Nitin Jagtap, Rakesh Kalapala, Mohan Ramchandani, Sundeep Lakhtakia, Jahangeer Basha, Zaheer Nabi, Arun Karyampudi, Radhika Chavan, Manu Tandan, Rajesh Gupta, D. Nageshwar Reddy)
| | - Mohan Ramchandani
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India (Siddhartha Reddy, Nitin Jagtap, Rakesh Kalapala, Mohan Ramchandani, Sundeep Lakhtakia, Jahangeer Basha, Zaheer Nabi, Arun Karyampudi, Radhika Chavan, Manu Tandan, Rajesh Gupta, D. Nageshwar Reddy)
| | - Sundeep Lakhtakia
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India (Siddhartha Reddy, Nitin Jagtap, Rakesh Kalapala, Mohan Ramchandani, Sundeep Lakhtakia, Jahangeer Basha, Zaheer Nabi, Arun Karyampudi, Radhika Chavan, Manu Tandan, Rajesh Gupta, D. Nageshwar Reddy)
| | - Jahangeer Basha
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India (Siddhartha Reddy, Nitin Jagtap, Rakesh Kalapala, Mohan Ramchandani, Sundeep Lakhtakia, Jahangeer Basha, Zaheer Nabi, Arun Karyampudi, Radhika Chavan, Manu Tandan, Rajesh Gupta, D. Nageshwar Reddy)
| | - Zaheer Nabi
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India (Siddhartha Reddy, Nitin Jagtap, Rakesh Kalapala, Mohan Ramchandani, Sundeep Lakhtakia, Jahangeer Basha, Zaheer Nabi, Arun Karyampudi, Radhika Chavan, Manu Tandan, Rajesh Gupta, D. Nageshwar Reddy)
| | - Arun Karyampudi
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India (Siddhartha Reddy, Nitin Jagtap, Rakesh Kalapala, Mohan Ramchandani, Sundeep Lakhtakia, Jahangeer Basha, Zaheer Nabi, Arun Karyampudi, Radhika Chavan, Manu Tandan, Rajesh Gupta, D. Nageshwar Reddy)
| | - Radhika Chavan
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India (Siddhartha Reddy, Nitin Jagtap, Rakesh Kalapala, Mohan Ramchandani, Sundeep Lakhtakia, Jahangeer Basha, Zaheer Nabi, Arun Karyampudi, Radhika Chavan, Manu Tandan, Rajesh Gupta, D. Nageshwar Reddy)
| | - Manu Tandan
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India (Siddhartha Reddy, Nitin Jagtap, Rakesh Kalapala, Mohan Ramchandani, Sundeep Lakhtakia, Jahangeer Basha, Zaheer Nabi, Arun Karyampudi, Radhika Chavan, Manu Tandan, Rajesh Gupta, D. Nageshwar Reddy)
| | - Rajesh Gupta
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India (Siddhartha Reddy, Nitin Jagtap, Rakesh Kalapala, Mohan Ramchandani, Sundeep Lakhtakia, Jahangeer Basha, Zaheer Nabi, Arun Karyampudi, Radhika Chavan, Manu Tandan, Rajesh Gupta, D. Nageshwar Reddy)
| | - D Nageshwar Reddy
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India (Siddhartha Reddy, Nitin Jagtap, Rakesh Kalapala, Mohan Ramchandani, Sundeep Lakhtakia, Jahangeer Basha, Zaheer Nabi, Arun Karyampudi, Radhika Chavan, Manu Tandan, Rajesh Gupta, D. Nageshwar Reddy)
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Jacob JS, Lee ME, Chew EY, Thrift AP, Sealock RJ. Evaluating the Revised American Society for Gastrointestinal Endoscopy Guidelines for Common Bile Duct Stone Diagnosis. Clin Endosc 2020; 54:269-274. [PMID: 33153247 PMCID: PMC8039731 DOI: 10.5946/ce.2020.100] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 08/10/2020] [Indexed: 01/21/2023] Open
Abstract
Background/Aims The American Society for Gastrointestinal Endoscopy (ASGE) revised its guidelines for risk stratification of patients with suspected choledocholithiasis. This study aimed to assess the diagnostic performance of the revision and to compare it to the previous guidelines.
Methods We conducted a retrospective cohort study of 267 patients with suspected choledocholithiasis. We identified high-risk patients according to the original and revised guidelines and examined the diagnostic accuracy of both guidelines. We measured the association between individual criteria and choledocholithiasis. Results Under the original guidelines, 165 (62%) patients met the criteria for high risk, of whom 79% had confirmed choledocholithiasis. The categorization had a sensitivity and specificity of 68% and 55%, respectively, for the detection of choledocholithiasis. Under the revised guidelines, 86 (32%) patients met the criteria for high risk, of whom 83% had choledocholithiasis. The revised categorization had a lower sensitivity and higher specificity of 37% and 80%, respectively. The positive predictive value of the high-risk categorization increased with the revision, reflecting a potential decrease in diagnostic endoscopic retrograde cholangiopancreatograpies (ERCPs). Stone visualized on imaging had the greatest specificity for choledocholithiasis. 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 an improved risk stratification tool.
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Affiliation(s)
- Jake S Jacob
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Michelle E Lee
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Erin Y Chew
- Department of Internal Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Aaron P Thrift
- Section of Epidemiology and Population Sciences, Department of Medicine, Baylor College of Medicine, Houston, TX, USA.,Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX, USA
| | - Robert J Sealock
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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The Challenges of Implementing Artificial Intelligence into Surgical Practice. World J Surg 2020; 45:420-428. [PMID: 33051700 DOI: 10.1007/s00268-020-05820-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND Artificial intelligence is touted as the future of medicine. Classical algorithms for the detection of common bile duct stones (CBD) have had poor clinical uptake due to low accuracy. This study explores the challenges of developing and implementing a machine-learning model for the prediction of CBD stones in patients presenting with acute biliary disease (ABD). METHODS All patients presenting acutely to Christchurch Hospital over a two-year period with ABD were retrospectively identified. Clinical data points including lab test results, demographics and ethnicity were recorded. Several statistical techniques were utilised to develop a machine-learning model. Issues with data collection, quality, interpretation and barriers to implementation were identified and highlighted. RESULTS Issues with patient identification, coding accuracy, and implementation were encountered. In total, 1315 patients met inclusion criteria. Incorrect international classification of disease 10 (ICD-10) coding was noted in 36% (137/382) of patients recorded as having CBD stones. Patients with CBD stones were significantly older and had higher aspartate aminotransferase (AST), alanine aminotransferase (ALT), bilirubin and gamma-glutamyl transferase (GGT) levels (p < 0.001). The no information rate was 81% (1070/1315 patients). The optimum model developed was the gradient boosted model with a PPV of 67%, NPV of 87%, sensitivity of 37% and a specificity of 96% for common bile duct stones. CONCLUSION This paper highlights the utility of machine learning in predicting CBD stones. Accuracy is limited by current data and issues do exist around both the ethics and practicality of implementation. Regardless, machine learning represents a promising new paradigm for surgical practice.
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Chen H, Zeng WK, Shi GZ, Gao M, Wang MZ, Shen J. Liver fat accumulation measured by high-speed T2-corrected multi-echo magnetic resonance spectroscopy can predict risk of cholelithiasis. World J Gastroenterol 2020; 26:4996-5007. [PMID: 32952345 PMCID: PMC7476179 DOI: 10.3748/wjg.v26.i33.4996] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 06/14/2020] [Accepted: 08/01/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Liver fat accumulation is associated with increased cholesterol synthesis and hypersecretion of biliary cholesterol, which may be related to the development of cholelithiasis. AIM To investigate whether liver fat accumulation measured by high-speed T2-corrected multi-echo magnetic resonance spectroscopy (MRS) is a risk factor for cholelithiasis. METHODS Forty patients with cholelithiasis and thirty-one healthy controls were retrospectively enrolled. The participants underwent high-speed T2-corrected multi-echo single-voxel MRS of the liver at a 3T MR scanner. The proton density fat fraction (PDFF) and R2 value were calculated. Serum parameters and waist circumference (WC) were recorded. Spearman's correlation analysis was used to analyze the relationship between PDFF, R2, and WC values. Multivariate logistic regression analysis was carried out to determine the significant predictors of the risk of cholelithiasis. Receiver operating characteristic curve (ROC) analysis was used to evaluate the discriminative performance of significant predictors. RESULTS Patients with cholelithiasis had higher PDFF, R2, and WC values compared with healthy controls (5.8% ± 4.2% vs 3.3% ± 2.4%, P = 0.001; 50.4 ± 24.8/s vs 38.3 ± 8.8/s, P = 0.034; 85.3 ± 9.0 cm vs 81.0 ± 6.9 cm, P = 0.030; respectively). Liver iron concentration extrapolated from R2 values was significantly higher in the cholelithiasis group (2.21 ± 2.17 mg/g dry tissue vs 1.22 ± 0.49 mg/g dry tissue, P = 0.034) than in the healthy group. PDFF was positively correlated with WC (r = 0.502, P < 0.001) and R2 (r = 0.425, P < 0.001). Multivariate logistic regression analysis showed that only PDFF was an independent risk factor for cholelithiasis (odds ratio = 1.79, 95%CI: 1.22-2.62, P = 0.003). ROC analysis showed that the area under the curve of PDFF was 0.723 for discriminating cholelithiasis from healthy controls, with a sensitivity of 55.0% and specificity of 83.9% when the cut-off value of PDFF was 4.4%. CONCLUSION PDFF derived from high speed T2-corrected multi-echo MRS can predict the risk of cholelithiasis.
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Affiliation(s)
- Hong Chen
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510120, Guangdong Province, China
| | - Wei-Ke Zeng
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510120, Guangdong Province, China
| | - Guang-Zi Shi
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510120, Guangdong Province, China
| | - Ming Gao
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510120, Guangdong Province, China
| | - Meng-Zhu Wang
- Department of MR Scientific Marketing, Siemens Healthineers, Guangzhou 510120, Guangdong Province, China
| | - Jun Shen
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510120, Guangdong Province, China
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Khoury T, Kadah A, Mahamid M, Mari A, Sbeit W. Bedside score predicting retained common bile duct stone in acute biliary pancreatitis. World J Clin Cases 2020; 8:1414-1423. [PMID: 32368534 PMCID: PMC7190963 DOI: 10.12998/wjcc.v8.i8.1414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 03/03/2020] [Accepted: 04/15/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Retained common bile duct (CBD) stone after an acute episode of biliary pancreatitis is of paramount importance since stone extraction is mandatory. AIM To generate a simple non-invasive score to predict the presence of CBD stone in patients with biliary pancreatitis. METHODS We performed a retrospective study including patients with a diagnosis of biliary pancreatitis. One hundred and fifty-four patients were included. Thirty-three patients (21.5%) were diagnosed with CBD stone by endoscopic ultrasound (US). RESULTS In univariate analysis, age (OR: 1.048, P = 0.0004), aspartate transaminase (OR: 1.002, P = 0.0015), alkaline phosphatase (OR: 1.005, P = 0.0005), gamma-glutamyl transferase (OR: 1.003, P = 0.0002) and CBD width by US (OR: 1.187, P = 0.0445) were associated with CBD stone. In multivariate analysis, three parameters were identified to predict CBD stone; age (OR: 1.062, P = 0.0005), gamma-glutamyl transferase level (OR: 1.003, P = 0.0003) and dilated CBD (OR: 3.685, P = 0.027), with area under the curve of 0.8433. We developed a diagnostic score that included the three significant parameters on multivariate analysis, with assignment of weights for each variable according to the co-efficient estimate. A score that ranges from 51.28 to 73.7 has a very high specificity (90%-100%) for CBD stones, while a low score that ranges from 9.16 to 41.04 has a high sensitivity (82%-100%). By performing internal validation, the negative predictive value of the low score group was 93%. CONCLUSION We recommend incorporating this score as an aid for stratifying patients with acute biliary pancreatitis into low or high probability for the presence of CBD stone.
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Affiliation(s)
- Tawfik Khoury
- Faculty of Medicine in the Galilee, Bar-Ilan University, Safed 1311502, Israel
- Department of Gastroenterology, Galilee Medical Center, Nahariya 22100, Israel
- Gastroenterology and endoscopy units, The Nazareth Hospital EMMS, Nazareth 16100, Israel
| | - Anas Kadah
- Faculty of Medicine in the Galilee, Bar-Ilan University, Safed 1311502, Israel
- Department of Gastroenterology, Galilee Medical Center, Nahariya 22100, Israel
| | - Mahmud Mahamid
- Faculty of Medicine in the Galilee, Bar-Ilan University, Safed 1311502, Israel
- Gastroenterology and endoscopy units, The Nazareth Hospital EMMS, Nazareth 16100, Israel
| | - Amir Mari
- Faculty of Medicine in the Galilee, Bar-Ilan University, Safed 1311502, Israel
- Gastroenterology and endoscopy units, The Nazareth Hospital EMMS, Nazareth 16100, Israel
| | - Wisam Sbeit
- Faculty of Medicine in the Galilee, Bar-Ilan University, Safed 1311502, Israel
- Department of Gastroenterology, Galilee Medical Center, Nahariya 22100, Israel
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48
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Hall C, Regner JL, Schroeppel T, Rodriguez J, McIntyre R, Wright F, Dissanaike S, Richmond R, Santos A, Frazee RC. Protocol driven management of suspected common duct stones: A Southwestern Surgical Congress multi-centered trial. Am J Surg 2019; 218:1152-1155. [PMID: 31558305 DOI: 10.1016/j.amjsurg.2019.09.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 09/04/2019] [Accepted: 09/10/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Several options exist for the diagnosis and management of suspected common duct stones. We hypothesized that a protocol-directed approach would shorten length of stay in this patient population. METHODS Patients from four participating institutions with a peak bilirubin <4 mg/dL underwent surgery as the initial procedure, whereas patients with a bilirubin ≥4 mg/dL underwent endoscopy. The primary endpoint was length of stay. Analysis involved chi square and Wilcoxon-Mann-Whitney test with significance at p < 0.05. RESULTS 214 patients were managed under the protocol during six-month study period. 111 patients (52%) required endoscopy and surgery. Length of stay and the number of MRCPs performed pre-operatively significantly decreased following protocol implementation (p < 0.05). CONCLUSIONS "Surgery first" approach in patients with bilirubin <4 ml/dL resulted in low morbidity and mortality, reduced MRCP, and length of stay.
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Affiliation(s)
- Chad Hall
- Baylor Scott & White Health, Department of Surgery, Temple, TX, USA
| | - Justin L Regner
- Baylor Scott & White Health, Department of Surgery, Temple, TX, USA
| | | | - Joe Rodriguez
- UCHealth, Department of Surgery, Colorado Springs, CO, USA
| | - Robert McIntyre
- University of Colorado, Department of Surgery, Denver, CO, USA
| | - Franklin Wright
- University of Colorado, Department of Surgery, Denver, CO, USA
| | - Sharmila Dissanaike
- Texas Tech University Health Science Center, Department of Surgery, Lubbock, TX, USA
| | - Robyn Richmond
- Texas Tech University Health Science Center, Department of Surgery, Lubbock, TX, USA
| | - Ariel Santos
- Texas Tech University Health Science Center, Department of Surgery, Lubbock, TX, USA
| | - Richard C Frazee
- Baylor Scott & White Health, Department of Surgery, Temple, TX, USA.
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49
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Lee HW, Park DH, Lee JH, Oh DW, Song TJ, Lee SS, Seo DW, Lee SK, Kim MH, Moon JE. Prevalence and Predictors of Unnecessary Endoscopic Retrograde Cholangiopancreatography in the Two-Stage Endoscopic Stone Extraction Followed by Laparoscopic Cholecystectomy. J Gastrointest Surg 2019; 23:1578-1588. [PMID: 30671794 DOI: 10.1007/s11605-018-04090-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 12/18/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUNDS A two-stage procedure involving endoscopic retrograde cholangiopancreatography (ERCP), followed by cholecystectomy, is one of the primary treatments of concomitant gallstones and choledocholithiasis. However, negative findings on ERCP and migrating gallstones after cholecystectomy are major concerns. This study aimed to identify the prevalence of unnecessary ERCP and to develop and validate a predictive nomogram using preoperative factors in patients who underwent a two-stage procedure. METHODS Consecutive 931 patients were treated with the two-stage procedure for evident gallstones and suspected choledocholithiasis. After the cholecystectomy, a cholangiogram was performed to confirm the absence of the migrating gallstones. The patients were divided into derivation (n = 652) and validation (n = 279) cohorts. RESULTS A total of 26.5% (247/931) patients had unnecessary ERCP (negative choledocholithiasis, 14.6%; migrating gallstones, 11.9%). No stones on images (P < 0.001), total bilirubin < 1.2 mg/dL (P = 0.006), and common bile duct diameter < 8.0 mm (P = 0.004) were independent factors associated with negative finding on ERCP with a validated nomogram area under the curve (AUC) of 0.72 (95% confidence interval [CI] 0.64-0.80). For migrating gallstones after cholecystectomy, radiolucent gallstones (P < 0.001), gallstone size ≤ 6.4 mm (P = 0.001), cystic duct stones (P < 0.001), gallbladder wall thickness ≥ 3.2 mm (P = 0.003), and low-lying cystic duct (P < 0.001) were independent factors with a validated nomogram AUC of 0.77 (95% CI 0.68-0.87). CONCLUSIONS About one fourth of the patients may have unnecessary ERCP in the two-stage procedure. Based on our nomogram using preoperative factors, high-risk patients who are more likely to perform unnecessary ERCP could be considered for the one-stage procedure.
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Affiliation(s)
- Hyun Woo Lee
- Digestive Disease Center and Research Institute, Department of Internal Medicine, Soonchunhyang University school of Medicine, Bucheon, South Korea
| | - Do Hyun Park
- Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea.
| | - Jae Hoon Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Dong Wook Oh
- Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Tae Jun Song
- Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Sang Soo Lee
- Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Dong-Wan Seo
- Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Sung Koo Lee
- Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Myung-Hwan Kim
- Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Ji Eun Moon
- Department of Biostatistics, Clinical Trial Center, Soonchunhyang University Bucheon Hospital, Bucheon, South Korea
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50
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Lee HW, Song TJ, Park DH, Lee SS, Seo DW, Lee SK, Kim MH, Jun JH, Moon JE, Song YH. Diagnostic performance of the current risk-stratified approach with computed tomography for suspected choledocholithiasis and its options when negative finding. Hepatobiliary Pancreat Dis Int 2019; 18:366-372. [PMID: 31266728 DOI: 10.1016/j.hbpd.2019.06.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Accepted: 06/13/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Several studies evaluated the current guideline of the American Society for Gastrointestinal Endoscopy (ASGE) and reported only suboptimal accuracy. This study evaluated the diagnostic performance of the ASGE guideline based on computed tomography (CT) and role of endoscopic ultrasonography (EUS) and magnetic resonance cholangiopancreatography (MRCP) in patients with suspected choledocholithiasis but negative CT finding. METHODS Patients with suspected choledocholithiasis undergoing ERCP between January 2016 and January 2017 were retrospectively analyzed. All patients underwent CT to detect choledocholithiasis. EUS or MRCP was performed when the CT scan showed negative findings. Patients were classified into the high and intermediate-risk groups, based on predictors from the ASGE criteria. RESULTS Of 583 patients with suspected choledocholithiasis, 340 (58.3%) had stones on ERCP (65.9% in the high-risk group and 40.6% in the intermediate-risk group). The accuracy of ASGE guideline for CT was 63.98% (79.12% sensitivity, 42.80% specificity) and 36.02% (20.88% sensitivity, 57.20% specificity) in the high-risk and intermediate-risk groups, respectively. In 103 patients in the high-risk group underwent both CT and US, the accuracy of CT was higher than that of US for detecting choledocholithiasis (78.64% vs. 53.40%), with a significant difference in area under the curve (AUC) (0.78 vs. 0.59, P < 0.001). Of 339 with negative CT finding, the accuracy of EUS was higher than that of MRCP (90.91% vs. 82.76%), but with no significant difference in AUC (0.91 vs. 0.83, P = 0.347). CONCLUSIONS CT-based ASGE guideline showed superior diagnostic performance than US for predicting choledocholithiasis. The diagnostic options, EUS or MRCP, with negative CT finding showed comparable performance. Therefore, the diagnostic modality should be selected based on availability, experience, cost, and contraindications.
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Affiliation(s)
- Hyun Woo Lee
- Digestive Disease Center and Research Institute, Department of Internal Medicine, Soonchunhyang University School of Medicine, Bucheon, Korea.
| | - Tae Jun Song
- Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Do Hyun Park
- Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Sang Soo Lee
- Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Dong-Wan Seo
- Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Sung Koo Lee
- Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Myung-Hwan Kim
- Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jae Hyuck Jun
- Division of Gastroenterology, Department of Internal Medicine, University of Eulji College of Medicine, Eulji Medical Center, Daejeon, Korea
| | - Ji Eun Moon
- Department of Biostatistics, Clinical trial center, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Yeon Han Song
- Digestive Disease Center and Research Institute, Department of Internal Medicine, Soonchunhyang University School of Medicine, Bucheon, Korea
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