ABS
What was the sample size of the Bosley et al. study that looked at Antegrade Balloon Sphincteroplasty?
N=28
What was the stone clearance rate in the 2018 Pan et al. meta analysis?
94.1%
What is one benefit of performing CASE versus ABS?
Eliminate the risk of pancreatitis
Visually confirm ductal clearance
Use DV to guide stone extraction (vs blind)
Eliminate radiation (no-fluoro needed)
The scope is more expensive than a balloon.
What is the cost of a retained stone? What is the cost of managing a patient with pancreatitis? Reimbursement more than covers the cost of the scope.
What is the diameter of the Earth?
A) 40,070 km
B) 13,822 mi
C) 22,016 km
D) 7,926 mi
D) 7,926 mi
What was the rate of stone clearance (%) in the Bosley et al. ABS study?
75%
How long was the patient follow up period in the 2018 Pan et al. meta analysis?
10 years
Break down the findings of Bosley et al. to a surgeon who tells you they have heard of ABS and might want to try it.
(Group judge)
It is faster/more efficient to do ABS than LTCBDE.
Studies (Rojas-Ortega) indicate mean operative time for LC+IOC+LCBDE to be 120 +/- 40 mins, with skilled users averaging 90 mins. What is faster, 120 minutes, or recovering the patient from the LC then sedating them again for a follow-up ERCP when they come back with retained stones?
Faster doesn't mean better for the patient - the goal is stone clearance without increased risk to the patient, not shaving off 30 minutes during their procedure.
Why are you so concerned about how quickly you can finish and not what's best for your patient?
Octopus and cuttlefish are members of what class of marine animal?
[Hint: it comes from two Greek words, one meaning "head" and one meaning "foot".]
Cephalopods
What was the rate of pancreatitis found in the 1993 Carroll et al. ABS study?
15%
[Daily Double!!!!]
After 24 months of follow up, in the 2010 Rogers et al. study, what was the rate of pancreatitis in their 122 patients?
0%
You have a cost conscious surgeon who has always been iffy on opening Discover and now, having heard about ABS from a SAGES talk, wants to try ABS before scoping. How do you handle this with them?
(Group judge)
"If ABS doesn't work, I have no problem opening the scope next."
ABS should be considered an adjunct to follow attempts at choledochoscopy, not to precede it, because of the risk it carries for pancreatitis.
Not only is there more risk to the patient, but ABS relies on fluoroscopy to show whether or not the duct is clear, and fluoro misses stones 30% of the time (Sejpal).
When threatened, a turkey vulture can projectile vomit up to how far (answer in # of feet)?
10 feet
According to the Bosley et al. study, what is the other (non-pancreatitis) complication that may arise following ABS?
[Hint* they did not report on this due to the short patient follow up period.]
Biliary stricture.
According to Rojas-Ortega et al., what are considered risk factors for patients having stones in the common bile duct? (name 3 of the 4)
-Elevated bilirubin (0.1 and 1.2 mg/dL), aspartate aminotransferase ( 8–33 U/L), alanine aminotransferase 4 to 36 U/L), and alkaline phosphatase (30–120 IU/L) levels
-A history of pancreatitis or jaundice
-The presence of a dilated common bile duct (>6mm)
-Common bile duct stones on preoperative ultrasound examination
How would you communicate the important findings of Rojas-Ortega to a surgeon interested in LTCBDE?
2003 Study
–N= 40 patients underwent LTCBDE (after + IOC)
–94% stone clearance rate
–Mean operative time 120 +/- 40 mins (down to 90 minutes at time of publication)
–10 year follow up, 0 incidents of pancreatitis
I'll do power flushing and balloon sweep for small stones and sludge and will do choledochoscopy when the stone is large.
How can you be sure that your flushing/sweep clears all the small stones? Isn't there a possibility of debris floating into the proximal CBD/common hepatic duct?
How many sides does a circle have?
Two. [The inside and the outside]
What are the 4 steps of the LCBDE Intervention progression (in order)?
1. Diagnostic cholangiogram and glucagon / power flushing from cystic duct
2. Wire/catheter based transcystic CBDE with power flushing in the distal CBD
3. Wire based balloon sphincteroplasty with power flushing in the distal CBD
4. Choledochoscopy with nitinol stone retrieval baskets
What were the complications in Rojas-Ortega that led to the 8.8% complication rate in the LTCBDE group?
They had complications related to pulmonary atelectasis in two elderly patients and urosepsis in one.
How would you communicate the important results of the Pan meta analysis to a group of surgeons?
2018 meta analysis of LCBD vs pre-LC EST results over 11 years looked at 13 studies involving 1757 (872 vs 885) patients.
The stones clearance rate was significantly higher in LCBDE than pre-EST+LC.
Perioperative complications, conversion to other procedure, retained stones rate, lithiasis recurrence rate, operative time, length of hospital stay, and total charges were significantly lower in LCBDE group.
IR dilates the sphincter all the time, how come they never have pancreatitis rates?
The specialty that has the most experience dilating the Sphincter of Oddi is GI and in their literature, the rates of pancreatitis are well documented. This is something that is even mentioned in the Bosley et al. paper on ABS.
"A meta-analysis of balloon dilation during ERCP reports increased rates of pancreatitis but decreased rates of bleeding when compared to sphincterotomy during ERCP [15]. Due to the significant potential complications associated pancreatitis, some may find the increased risk elucidated in the ERCP literature too distressing to consider utilization of the transcystic balloon dilation technique."
Why is the sky blue?
Because of a process called Rayleigh scattering, which occurs when sunlight passes through the Earth's atmosphere and is scattered by tiny air molecules
The sun emits white light, which is made up of all the colors of the rainbow. When this light passes through the atmosphere, the blue and violet light waves are scattered more than the other colors because they have shorter wavelengths. This means that more blue light reaches our eyes, making the sky appear blue.
[The sky appears blue because our eyes are more sensitive to blue light, and the sun emits more energy as blue light than violet.]