Calculi, Biliary

A total of 3305 patients underwent ERCP in our hospital between October 2009 and September 2014 and 258 were diagnosed with difficult biliary cannulation. Of these 258 patients, 58 of them had their index ERCP with successful cannulations and underwent subsequent limited PS combined with EPBD for CBD stone removal. These 58 patients were analyzed in this retrospective study. On the other hand, two hundred of these patients encountered a first unsuccessful ERCP due to difficult biliary cannulation and then decided not to have a second one (none of them had received limited precut procedure). One hundred and fifty-five of them chose to receive surgery; 42 of them were treated by percutaneous biliary drainage and 3 received supportive treatments.
The definition of difficult biliary cannulation in our study was as follows: (1) failed cannulation within 10 min (2) 5 passages or injections of the pancreatic duct, or (3) 10 attempts at the papilla without a time limit (Fig. 1a). We stopped anticoagulant administration such as aspirin for 7 days before the procedures in those who were prescribed for primary prevention. For those who received anticoagulant for secondary prevention in low cardiovascular risk patients, we stopped clopidogrel, prasugrel, ticagrelor and coumadin 5 days before ERCP according to British Society of Gastroenterology and European Society of Gastrointestinal endoscopy [14 (link), 15 (link)]. For patients with high cardiovascular risks, the procedures were postponed if possible until anticoagulant could be discontinued safely (usually >12 months after insertion of drug-eluting coronary stents or >1 month after insertion of bare metal coronary stents). However, when an emergent or semi-emergent indication like an impacted stone or jaundice in need of immediate action was encountered, cardiologists were routinely consulted and replaced by other emergent non-endoscopic bilary driange procedures. Prophylactic NSAIDs were given to all patients to reduce risk of post-ERCP pancreatitis routinely in our department.Fig. 1

a Difficult biliary cannulation was due to failure of 10 attempts at duodenal papilla; (b) Limited precut sphincterotomy was performed with the extent of cutting was less than half the length of the papillary mound; (c) Common bile duct stone was found after successful biliary cannulation; (d) Endoscopic papillary balloon dilation was performed after limited precut sphincterotomy; (e and f) Common bile duct stone was extracted by retrieval balloon

The patients received pharyngeal anesthesia with xylocaine spray in the same manner as that for general endoscopy. Hyoscine-N-butylbromide (20 mg) was administered intramuscularly before the procedure, and meperidine (30 to 50 mg) was administered before EPBD. ERCP was performed using a side-view endoscope (JF 260v and TJF 240; Olympus, Tokyo, Japan) after selective cannulation of the CBD with a cholangiography catheter (PR-113Q, Olympus). We preferred a needle-knife sphincterotome (KD-V441, Olympus) in all cases. Two highly experienced endoscopists [the first and second authors], with experiences of more than 3000 ERCPs procedures each, and ongoing workloads of more than 250 ERCPs procedures each annually, performed all the limited PS combined with EPBD procedures. Diathermy was applied with a blended current (20 W cut and 20 W coagulation) using the ESG 100 system (Olympus). The incision started from the lip of the papillary orifice (at the 11-o’clock position) and proceeded upward over the papillary mound. The extent of cutting in limited PS is less than half the length of the papillary mound (Fig. 1b). To perform EPBD after cannulation of the bile duct with limited PS (Fig. 1c), a 0.035-inch guide-wire (Zebra Exchange Guide-wire; Microvasive Boston Scientific, Watertown, MA) was inserted into the bile duct through the catheter. After the guide-wire was inserted deeply into the bile duct, the catheter was removed with the guide-wire left in place. A balloon-tipped catheter (5.5 cm long and 8–20 mm wide; Microvasive Boston Scientific), was inserted over the guide-wire so that the balloon was extended across the papilla. The balloon was inflated to 8–20 mm in diameter with saline solution to dilate the papilla at progressively increasing pressures of 3 to 8 atm for 2 min, according to the size of the CBD stones (Fig. 1d). After removing the dilation catheter, stones were extracted with a basket catheter or retrieval balloon (Fig. 1e, f). Endoscopic mechanical lithotripsy (EML) was used to crush stones >15 mm in diameter when extraction of these stones was difficult after EPBD. When stones were not extracted completely, a biliary stent was inserted and the residual stones were removed after 3–7 days without repeating EPBD. A prophylactic pancreatic stent was not used after EPBD. Complete stone removal was defined as the absence of bile duct stones on a balloon occlusion cholangiogram.

21. Irritable bowel syndrome
22. Inflammatory bowel disease
23. Coeliac disease
24. Chronic liver disease
25. Peptic ulcer
26. Gall stones

All consecutive patients aged 18 years or older with a confirmed diagnosis of HT after AIS between January 2012 and June 2022 were enrolled in this retrospective cohort study conducted at the Stroke Center of the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China.
This study was approved by the Institutional Review Board and Ethics Committee of the First Affiliated Hospital of Wenzhou Medical University. The requirement for informed consent was waived as this was a retrospective study and all data were anonymous.
The diagnosis of first-ever AIS was confirmed by computed tomography (CT) or magnetic resonance imaging (MRI) at admission. The exclusion criteria were: a diagnosis of hemorrhagic stroke or transient ischemic attacks; a previous history of biliary calculus, cholecystitis, or malignancy; serum transaminase concentration greater than twice the upper limit of the reference range within 6 months; hepatitis B or C virus positivity; chronic kidney disease (glomerular filtration rate < 60 mL min⁻¹ 1.73 m⁻²); ongoing infection or inflammation; alcoholism (consumption of at least 40 g alcohol/day for males and ≥ 20 g/day for females during the previous 3 months); having received intravenous thrombolytic therapy; failure to undergo a second CT/MRI scan; and incomplete medical records.
A final total of 408 consecutive patients diagnosed with HT after AIS, consisting of 247 with sHT and 161 with HT after thrombectomy (tHT), were included in this study. The same number of age- and sex-matched AIS inpatients without HT for each cohort were randomly selected from the Stroke Center of our institution between January 2017 and June 2022 as controls. All patients met the inclusion criteria.

All CT scans were performed using the picture archiving and communication system (PACS; Pathspeed, Pathspeed, GE Medical Systems Integrated Imaging Solutions) and were independently evaluated by two radiologists imaging features. The two radiologists did not know the clinical indicators or pathological findings. A consensus was reached by joint discussion when there was disagreement between the two physicians. The main observations were the maximum length of the lesion; its location (divided into base, base + body, body, body + neck, and neck); the number of the lesion (single or multiple); the base status (the base width of GPs was as about Yamada’s classification: the angle between the protuberance of the GPs and the basement mucosa > 90° is referred to as the wide base, whereas the angle < 90°is defined narrow base [11 (link)]); gallbladder stones (absent or present); and lesions CT values in the plain and triphasic dynamic enhanced scan.