• endoscopic retrograde cholangiopancreatography
• intradiverticular papilla
• meta‐analysis
• periampullary diverticulum
• successful cannulation rate

• Humans
• Ampulla of Vater/pathology
• Ampulla of Vater/surgery
• Catheterization/adverse effects
• Catheterization/methods
• Cholangiopancreatography, Endoscopic Retrograde/adverse effects
• Cholangiopancreatography, Endoscopic Retrograde/methods
• Common Bile Duct Diseases/complications
• Common Bile Duct Diseases/surgery
• Diverticulum/complications
• Diverticulum/diagnosis
• Diverticulum/pathology
• Pancreatitis/epidemiology
• Pancreatitis/etiology
• Postoperative Complications/etiology
• Postoperative Complications/epidemiology

• ampulla of the vater
• double duct sign
• lemmel syndrome
• periampullary diverticulum
• transaminitis

• ERCP
• bile duct stone
• cholecystectomy
• gallstone disease
• meta‐analysis

• Duodenobiliary reflux
• Endoclip papillaplasty
• Endoscpoic treatment
• Recurrent choledocholithiasis

• Humans
• Cholangiopancreatography, Endoscopic Retrograde/methods
• Choledocholithiasis/surgery
• Sphincterotomy, Endoscopic/methods
• Prospective Studies
• Treatment Outcome
• Dilatation/methods

• choledocholithiasi
• endoscopic papillary balloon dilation
• endoscopic sphincterotomy
• prognostic factors
• recurrent choledocholithiasis

• Humans
• Cholangiopancreatography, Endoscopic Retrograde/adverse effects
• Cholangiopancreatography, Endoscopic Retrograde/methods
• Sphincterotomy, Endoscopic/adverse effects
• Gallstones/diagnostic imaging
• Gallstones/surgery
• Risk Factors
• Common Bile Duct/surgery
• Choledocholithiasis/etiology
• Choledocholithiasis/surgery
• Retrospective Studies
• Treatment Outcome

• acute pancreatitis
• diverticulum
• esophagastroduodenoscopy scope
• magnetic resonance cholangiopancreatography (mrcp)
• pancreatitis causes
• periampullary diverticulum

• Common bile duct stones
• Endoscopic retrograde cholangiopancreatography
• Lithotripsy
• Recurrence
• Saline irrigation

• Bile duct stone
• Cholecystectomy
• Cholelithiasis
• Cystic duct

• ERCP
• Endoscopic sphincterotomy
• Recurrent CBDS
• Risk factors
• Surgical intervention

• Choledocholithiasis
• Common bile duct exploration
• Recurrence
• Surgery

• Cholangiopancreatography, Endoscopic Retrograde/methods
• Cholecystectomy, Laparoscopic/methods
• Choledocholithiasis/surgery
• Common Bile Duct/surgery
• Gallstones/surgery
• Humans
• Recurrence
• Retrospective Studies

Most of study regarding periampullary diverticulum (PAD) impact on endoscopic retrograde cholangiopancreatography (ERCP) therapy for choledocholithiasis based on data from one endoscopy center and lacked to compare the clinical characteristic of choledocholithiasis with PAD from different geographical patients.

To compare the choledocholithiasis clinical characteristics between two regional endoscopy centers and analyze impacts of clinical characteristics on ERCP methods for choledocholithiasis patients with PAD.

Patients seen in two endoscopy centers (The First Hospital of Lanzhou University, Lanzhou, Gansu Province, China, and Kyoto Second Red Cross Hospital, Kyoto, Japan) underwent ERCP treatment for the first time between January 2012 and December 2017. The characteristics of choledocholithiasis with PAD were compared between the two centers, and their ERCP procedures and therapeutic outcomes were analyzed.

A total of 829 out of 3608 patients in the Lanzhou center and 241 out of 1198 in the Kyoto center had choledocholithiasis with PAD. Lots of clinical characteristics were significantly different between the two centers. The common bile duct (CBD) diameter was wider, choledocholithiasis size was lager and multiple CBD stones were more in the Lanzhou center patients than those in the Kyoto center patients (14.8 ± 5.2 mm vs 11.6 ± 4.2 mm, 12.2 ± 6.5 mm vs 8.2 ± 5.3 mm, 45.3% vs 20.3%, P < 0.001 for all). In addition, concomitant diseases, such as acute cholangitis, gallbladder stones, obstructive jaundice, cholecystectomy, and acute pancreatitis, were significantly different between the two centers (P = 0.03 to < 0.001). In the Lanzhou center, CBD diameter and choledocholithiasis size were lower, and multiple CBD stones and acute cholangitis were less in non-PAD patients than those in PAD patients (13.4 ± 5.1 mm vs 14.8 ± 5.2 mm, 10.3 ± 5.4 mm vs 12.2 ± 6.5, 39% vs 45.3%, 13.9% vs 18.5%, P = 0.002 to < 0.001). But all these characteristics were not significantly different in the Kyoto center. The proportions of endoscopic sphincterotomy (EST), endoscopic balloon dilatation (EPBD), and EST+EPBD were 50.5%, 1.7%, and 42.5% in the Lanzhou center and 90.0%, 0.0%, and 0.4% in the Kyoto center, respectively. However, the overall post-ERCP complication rate was not significantly different between the two centers (8.9% in the Lanzhou and 5.8% in the Kyoto. P = 0.12). In the Lanzhou center, the difficulty rate in removing CBD stones in PAD was higher than in non-PAD group (35.3% vs 26.0%, P < 0.001). But the rate was no significant difference between the two groups in Kyoto center. The residual rates of choledocholithiasis were not significantly different between the two groups in both centers. Post-ERCP complications occurred in 8.9% of the PAD patients and 8.1% of the non-PAD patients in the Lanzhou Center, and it occurred in 5.8% in PAD patients and 10.0% in non-PAD patients in the Kyoto center, all P > 0.05.

Many clinical characteristics of choledocholithiasis patients with PAD were significantly different between the Lanzhou and Kyoto centers. The patients had larger and multiple stones, wider CBD diameter, and more possibility of acute cholangitis and obstructive jaundice in the Lanzhou center than those in the Kyoto center. The ERCP procedures to manage native duodenal papilla were different depending on the different clinical characteristics while the overall post-ERCP complications were not significantly different between the two centers. The stone residual rate and post-ERCP complications were not significantly different between choledocholithiasis patients with PAD and without PAD in each center.

• Clinical characteristics
• Periampullary diverticulum
• Endoscopic retrograde cholangiopancreatography
• Choledocholithisasis

• Choledocholithiasis
• Endoscopic retrograde cholangiopancreatography
• Recurrence

To evaluate the efficacy and safety of our new surgical procedures for primary intra- and extrahepatic hepatolithiasis. Hepatolithiasis is an intractable disease with frequent recurrences.

From 1996 to 2005, 142 patients with intrahepatic and/or extrahepatic hepatolithiasis treated with the conventional surgical methods were included as the control group, while 128 consecutive patients treated with new surgical methods from 2006 to 2015 were included as the observation group. The new surgical procedures included a comprehensive intraoperative exploration of the bile ducts, focusing on the structure and function of the hilar bile duct and duodenal papilla, exploration of the affected liver, and bile culture.

The observation group had a significantly higher complete stone clearance rate than the control group (100% vs. 65.96%). The observation group had significantly lower incidences of cholangitis and bile duct stones, as well as a higher excellent and good long-term surgical efficacy rate (86.24% vs. 52.73%). Multivariate Cox analysis showed that the control group had a higher risk for fair + poor efficacy than the observation group (HR: 8.47).

Our new surgical procedures are safe and can provide a good long-term efficacy for treating primary hepatolithiasis intra- and extrahepatic hepatolithiasis.

• Abnormality of the duodenal papilla
• Hepatolithiasis
• Hilar bile duct stenosis
• Oddis sphincter
• Partial hepatectomy

• bile duct stone
• elderly
• endoscopic retrograde cholangiopancreatography
• periampullary diverticula

• Difficult biliary stones
• elderly
• endoscopic treatment
• recurrence
• therapeutic endoscopic retrograde cholangiopancreatography

• ERCP
• common bile duct stones
• recurrence
• risk factors

• Duodenal diverticula
• cholelithiasis
• colon diverticula
• computed tomography
• pathologies
• periampullary diverticula

• cholestasis
• management
• primary choledocholithiasis
• risk factor

Different types of periampullary diverticulum (PAD) may differentially affect the success of endoscopic retrograde cholangiopancreatography (ERCP) cannulation, but the clinical significance of the two current PAD classifications for cannulation is limited.

To verify the clinical value of our newly proposed PAD classification.

A new PAD classification (Li-Tanaka classification) was proposed at our center. All PAD patients with native papillae who underwent ERCP from January 2012 to December 2017 were classified according to three classification systems, and the effects of various types of PAD on ERCP cannulation were compared.

A total of 3564 patients with native papillae were enrolled, including 967 (27.13%) PAD patients and 2597 (72.87%) non-PAD patients. In the Li-Tanaka classification, type I PAD patients exhibited the highest difficult cannulation rate (23.1%, P = 0.01), and type II and IV patients had the highest cannulation success rates (99.4% in type II and 99.3% in type IV, P < 0.001). In a multivariable-adjusted logistic model, the overall successful cannulation rate in PAD patients was higher than that in non-PAD patients [odds ratio (OR) = 1.87, 95% confidence interval (CI): 1.04-3037, P = 0.037]. In addition, compared to the non-PAD group, the difficulty of cannulation in the type I PAD group according to the Li-Tanaka classification was greater (OR = 2.04, 95%CI: 1.13-3.68, P = 0.004), and the successful cannulation rate was lower (OR = 0.27, 95%CI: 0.11-0.66, P < 0.001), while it was higher in the type II PAD group (OR = 4.44, 95%CI: 1.61-12.29, P < 0.01).

Among the three PAD classifications, the Li-Tanaka classification has an obvious clinical advantage for ERCP cannulation, and it is helpful for evaluating potentially difficult and successful cannulation cases among different types of PAD patients.

• Endoscopic retrograde cholangiopancreatography
• Periampullary diverticulum
• Classification
• Difficult cannulation
• Successful cannulation

• Adult
• Aged
• Ampulla of Vater/pathology
• Ampulla of Vater/surgery
• Catheterization/adverse effects
• Catheterization/methods
• Cholangiopancreatography, Endoscopic Retrograde/adverse effects
• Cholangiopancreatography, Endoscopic Retrograde/methods
• Diverticulum/diagnosis
• Diverticulum/pathology
• Diverticulum/surgery
• Duodenal Diseases/diagnosis
• Duodenal Diseases/pathology
• Duodenal Diseases/surgery
• Female
• Follow-Up Studies
• Humans
• Male
• Middle Aged
• Postoperative Complications/epidemiology
• Postoperative Complications/etiology
• Retrospective Studies
• Risk Factors
• Treatment Outcome

• ERCP
• biliary stricture
• cannulation success
• risk factor
• trainee

Recurrence of primary choledocholithiasis commonly occurs after complete removal of stones by therapeutic endoscopic retrograde cholangiopancreatography (ERCP). The potential causes of the recurrence of choledocholithiasis after ERCP are unclear.

To analyze the potential causes of the recurrence of choledocholithiasis after ERCP.

The ERCP database of our medical center for the period between January 2007 and January 2016 was retrospectively reviewed, and information regarding eligible patients who had choledocholithiasis recurrence was collected. A 1:1 case-control study was performed for this investigation. Data including general characteristics of the patients, past medical history, ERCP-related factors, common bile duct (CBD)-related factors, laboratory indicators, and treatment was analyzed by univariate and multivariate logistic regression analysis and Kaplan-Meier analysisly.

First recurrence of choledocholithiasis occurred in 477 patients; among these patients, the second and several instance (≥ 3 times) recurrence rates were 19.5% and 44.07%, respectively. The average time to first choledocholithiasis recurrence was 21.65 mo. A total of 477 patients who did not have recurrence were selected as a control group. Multivariate logistic regression analysis showed that age > 65 years (odds ratio [OR] = 1.556; P = 0.018), combined history of choledocholithotomy (OR = 2.458; P < 0.01), endoscopic papillary balloon dilation (OR = 5.679; P = 0.000), endoscopic sphincterotomy (OR = 3.463; P = 0.000), CBD stent implantation (OR = 5.780; P = 0.000), multiple ERCP procedures (≥2; OR = 2.75; P = 0.000), stones in the intrahepatic bile duct (OR = 2.308; P = 0.000), periampullary diverticula (OR = 1.627; P < 0.01), choledocholithiasis diameter ≥ 10 mm (OR = 1.599; P < 0.01), bile duct-duodenal fistula (OR = 2.69; P < 0.05), combined biliary tract infections (OR = 1.057; P < 0.01), and no preoperative antibiotic use (OR = 0.528; P < 0.01) were independent risk factors for the recurrence of choledocholithiasis after ERCP.

Patient age greater than 65 years is an independent risk factor for the development of recurrent choledocholithiasis following ERCP, as is history of biliary surgeries, measures during ERCP, and prevention of postoperative complications.

• Choledocholithiasis
• Endoscopic retrograde cholangiopancreatography
• Recurrence
• Common bile duct

• Cap-assisted endoscopy
• Diverticulum
• Endoscopic retrograde cholangiopancreatography

• Choledocholithiasis
• Common bile duct stone
• Duodenal diverticulum
• Meta-analysis
• Periampullary diverticulum

• Cholangitis
• Choledocholithiasis
• Endosonography
• Pancreas

• Aged
• Biliary Tract Diseases/complications
• Biliary Tract Diseases/diagnostic imaging
• Case-Control Studies
• Diverticulum/complications
• Diverticulum/diagnostic imaging
• Duodenal Diseases/complications
• Duodenal Diseases/diagnostic imaging
• Endosonography/methods
• Female
• Humans
• Male
• Middle Aged
• Pancreatic Diseases/complications
• Pancreatic Diseases/diagnostic imaging
• Retrospective Studies
• Sensitivity and Specificity

Predictors for bile duct stone recurrence after endoscopic stone extraction have not yet been clearly defined and a study investigating naïve major duodenal papilla is warranted because studies focusing only on naïve major duodenal papilla are rare. The aim of this study was to observe the long-term outcomes of endoscopic bile duct stone extraction for naïve major duodenal papilla and to assess the predictors for recurrence.

This was a retrospective cohort study that consisted of 384 patients with naïve papilla who underwent initial endoscopic bile duct stone extraction. Patients were followed up in outpatient department subsequent to complete stone clearance. Recurrence was defined as symptomatic repeated stone formation observed at least three months after the procedure. Stone recurrence, predictors of recurrence, and the recurrence rate, depending on each endoscopic treatment for major duodenal papilla, were examined.

In this study, 34 patients (8.9%) developed stone recurrence. The median time to recurrence was 439 days. Periampullary diverticulum and multiple stones were strong predictors of bile duct stone recurrence (RR, 5.065; 95% CI, 2.435–10.539 and RR: 2.4401; 95% CI: 1.0946–5.4396, respectively). The above two factors were independent predictors of stone recurrence as per logistic regression analysis adjusted for confounders (Periampullary diverticulum: OR, 7.768; 95% CI, 3.27–18.471; multiple stones: OR, 4.144; 95% CI, 1.33–12.915). No recurrence was observed after endoscopic papillary large balloon dilatation (0/20), whereas recurrence was observed in 7 patients after endoscopic papillary balloon dilatation (7/45) and in 27 patients after endoscopic sphincterotomy (27/319). However, these differences were not statistically significant (p = 0.105).

We determined that the presence of periampullary diverticulum and multiple stones are strong predictors for recurrence after endoscopic stone extraction. Moreover, endoscopic papillary large balloon dilatation tended to be correlated with non-recurrence of bile duct stone.

• Choledocholithiasis
• management
• recurrence

Introduction. Duodenal diverticuli alter the anatomy of the papillary region and can make an ERCP difficult. Aim. To study the outcome of ERCP in cases of duodenal diverticuli. Patients and Methods. Consecutive ERCPs in a period of 24 years were included. Endoscopy reports were studied for presence of diverticuli. Success of the procedure and findings were noted. Clinical records were searched for clinical presentation of the patient. Patients without duodenal diverticuli were used as comparison. Results. 2795 procedures were done in 2092 patients. Of these, 211 (10%) had diverticuli. Diverticuli occurred significantly more often in women (p < 0.001). ERCP was significantly more often inconclusive in cases of a diverticulum, 12.8% versus 6.3%, p < 0.001. In cases of a successful ERCP, patients with diverticuli showed more often no abnormalities in the bile duct, 26% versus 17%, p < 0.001. In 64% of cases, the reason for ERCP was cholestasis. There was no significant difference in presence of stones or cholangitis. Biliary pancreatitis was seen more often in patients without diverticuli, 4.4% versus 1.4%, p = 0.04. This was also the case for malignancies, 18.5% versus 6.6%, p < 0.001. Conclusion. It is concluded that duodenal diverticuli can be responsible for cholestasis. Presence of a diverticulum in the duodenum makes the ERCP procedure more complex.

Periampullary diverticula (PD) is caused by extraluminal pouching of duodenal mucosa. Using a very common endoscopic procedure to diagnose or treat gastrointestinal disorders, we encountered duodenal diverticulum.

This is a retrospective, single-center study. Three thousand and sixteen patients on whom endoscopic retrograde cholangiopancreatography (ERCP) was performed at Ankara University Medical School, Department of Gastroenterology, from June 2009 to June 2014 were included to the study.

Hundred and thirty patients (males 65, females 65) among the 3,016 had PD. Two hundred and sixty patients without diverticulum were randomly chosen from the 3,016 patients, as a control group [121 (47%) females, 139 (53%) males]. There was no statistical difference between the two groups. The mean age of the patients with PD was 69.9 years, while the mean age was 62.3 years for patients without PD (p < 0.001). Incidence for PD was 4.6%. The papilla of Vater was located in the inter-diverticular area (Type 1) in 9 patients (8.3%), at the edge of the diverticulum (Type 2) in 31 patients (28.4%), and at a distance of 2 to 3 cm from the papilla (Type 3) in 69 patients (63.3%).

Although numerically more common bile duct stones occurred in patients with PD compared to those without PD, there was no statistical difference between the two groups. The rate of pancreato-biliary carcinomas was higher in patients without diverticulum. Cannulation was successful in both groups at the rate of 97.6 and 92% respectively, but cannulation failed more often in patients without PD. Duodenal perforation occurred in one patient with PD. Bleeding after sphincterotomy occurred in two patients without PD.

Örmeci N, Deda X, Kalkan Ç, Tüzün AE, Karakaya F, Dökmeci A, Bahar DK, Özkan H, İdilman R, Çınar K. Impact of Periampullary Diverticula on Bile Duct Stones and Ampullary Carcinoma. Euroasian J Hepato-Gastroenterol 2016;6(1):31-34.

• Ampullary carcinoma
• Bile duct stones
• ERCP
• Periampullary diverticula.

AIM: To assess the efficacy of emergency duodenoscopy in the diagnosis and treatment of acute cholangitis with common bile duct stones in elderly patients.

METHODS: A retrospective analysis was performed of 291 patients aged over 80 years with acute cholangitis and common bile duct stones from May 2013 to August 2014, including 210 cases who underwent early conservative treatment (conservative group) and 81 cases who underwent emergency duodenoscopic treatment within 12 h of hospitalization (endoscopic group). White blood cell (WBC), serum total bilirubin (STB), conjugated bilirubin (CB), alkaline phosphatase (ALP), γ-glutamyl transferase (GGT), and C-reactive protein (CRP) before treatment and 1, 4 d after treatment, the time required for body temperature to return to normal, the time to disappearance of abdominal tenderness and the total number of days of hospitalization were compared between the two groups.

RESULTS: Compared with the conservative group, STB, CB, ALP and GGT levels on 1 d after treatment decreased more significantly in the endoscopic group (66.81 μmol/L ± 36.96 μmol/L vs 18.36 μmol/L ± 31.39 μmol/L, 49.06 μmol/L ± 23.24 μmol/L vs 14.41 μmol/L ± 19.69 μmol/L, 40.57 U/L ± 29.43 U/L vs 16.21 U/L ± 34.47 U/L, 36.44 U/L ± 27.01 U/L vs 14.97 U/L ± 29.70 U/L; P < 0.05 for all). On 4 d, WBC, STB, CB, ALP, GGT and CRP levels decreased more significantly in the endoscopic group than in the conservative group (5.77 × 10⁹/L ± 1.74 × 10⁹/L vs 3.58 × 10⁹/L ± 1.33 × 10⁹/L, 90.78 μmol/L ± 55.93 μmol/L vs 55.75 μmol/L ± 86.94 μmol/L, 60.61 μmol/L ± 31.27 μmol/L vs 53.07 μmol/L ± 63.55 μmol/L, 88.91 U/L ± 40.26 U/L vs 21.59 U/L ± 39.76 U/L, 96.53 U/L ± 76.62 U/L vs 33.34 U/L ± 59.47 U/L, 10.67 mg/L ± 17.19 mg/L vs 5.43 mg/L ± 10.21 mg/L; P < 0.05 for all). The time required for body temperature to return to normal, time to disappearance of abdominal tenderness and the total number of days of hospitalization in the endoscopic group were significantly shorter than those in the conservative group (3.65 d ± 1.21 d vs 4.14 d ± 1.58 d, 1.67 d ± 0.86 d vs 2.40 d ± 1.17 d, 11.41 d ± 4.90 d vs 14.65 d ± 6.68 d; P < 0.05 for all).

CONCLUSION: Emergency duodenoscopic retrograde cholangiopancreatography (ERCP) and endoscopic nasobiliary drainage (ENBD) within 12 h of admission, compared with drug therapy alone, relieve symptoms more significantly and shorten treatment cycles.

• Emergency
• Duodenoscopy
• Elderly patients
• Acute cholangitis
• Choledocholithiasis