asge guidelines choledocholithiasis

The positive predictive value of the high-risk categorization increased with the revision, reflecting a potential decrease in diagnostic endoscopic retrograde cholangiopancreatograpies (ERCPs). 30(7):742-748. 0000102414 00000 n It is very important that you consult your doctor about your specific condition. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework was used to rigorously review and synthesize the contemporary literature regarding the following topics: EUS versus MRCP for diagnosis, the role of early ERCP in gallstone pancreatitis, endoscopic papillary dilation after sphincterotomy versus sphincterotomy alone for large bile duct stones, and impact of ERCP-guided intraductal therapy for large and difficult choledocholithiasis. The site is secure. The American Society for Gastrointestinal Endoscopy (ASGE) revised its guidelines for risk stratification of patients with suspected choledocholithiasis. Summary of Evidence. Epub 2022 Sep 26. National Library of Medicine A Cochrane review on the topic has shown that single-stage laparoscopic common bile duct exploration with cholecystectomy and two-stage ERCP followed by laparoscopic cholecystectomy have similar efficacy rates in clearing the CBD with no significant difference in patient morbidity and mortality [17]. This demonstrated that the use of the revised guidelines in assessing risk for choledocholithiasis in AGP patients can lead to a decrease in . 0000016291 00000 n government site. Papillary cannulation and sphincterotomy techniques at ERCP: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Articles pertaining to management strategies for choledocholithiasis and best clinical scenarios for the application of each strategy are summarized below under each question. Buxbaum JL, Abbas Fehmi SM, Sultan S. ASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasis . The choledochotomy can then be closed either primarily using absorbable 40 or 50 sutures or over a T-tube, an antegrade biliary stent or with an external biliary drain depending on the surgeons discretion and the clinical situation depending on the potential risk of post-operative CBD stricture, increased pressure within the CBD leading to bile leak or retained common bile duct stones [16]. eCollection 2023. 0000098091 00000 n This study aimed to assess the diagnostic performance of the revision and to compare it to the previous guidelines. Patients with choledocholithiasis on abdominal US, with bilirubin levels >4 mg/dL (normal values <1.2 mg/dL), bilirubin levels 1.8 mg/dL plus a dilated CBD and/or clinical cholangitis were considered high risk per ASGE guidelines. 4). 0000004204 00000 n 2023 Mar 16;18(3):e0282899. Technology evaluations provide a review of existing, new, or emerging endoscopic technologies that have an impact on the practice of GI endoscopy. There are also through the scope choledochoscopes (e.g., Spyglass) that are now available that can administer intracorporeal electrohydraulic or laser lithotripsy. 0000029131 00000 n Clipboard, Search History, and several other advanced features are temporarily unavailable. 2019 Oct;33(10):3300-3313. doi: 10.1007/s00464-018-06620-x. ASGE guideline on screening and surveillance of Barrett's esophagus. -, Tse F, Barkun JS, Romagnuolo J, Friedman G, Bornstein JD, Barkun AN. 2017 Sep;86(3):525-532. doi: 10.1016/j.gie.2017.01.039. 0000100613 00000 n 2020 ASGE. Scand J Gastroenterol 53:13881392, Hope WW, Fanelli R, Walsh DS, Narula VK, Price R, Stefanidis D, Richardson WS (2017) SAGES clinical spotlight review: intraoperative cholangiogram. Web Design and Development by Matrix Group International, Inc. Each year choledocholithiasis results in biliary obstruction, cholangitis, and pancreatitis in a significant number of patients. An official website of the United States government. To note, papillary balloon dilation, as an alternative to sphincterotomy, appears to be a feasible strategy for removal of choledocholithiasis during endoscopic retrograde cholangiopancreatography (ERCP) sphincterotomy [1]. Federal government websites often end in .gov or .mil. The excluded stomach is located endosonographically from the gastric pouch or afferent limb and accessed to deploy a lumen-apposing metal stent into the excluded gastric remnant to allow antegrade passage of a duodenoscope through the fistula where conventional ERCP can be performed to access and cannulate the ampulla and biliary tree. cholangiography (IOC) at elective cholecystectomy Bile duct dilation was documented in only 3.06% of cases. World J Gastroenterol 20:1338213401, Sauerbruch T, Stern M (1989) Fragmentation of bile duct stones by extracorporeal shock waves. Surg Endosc 32:26032612, Dasari BV, Tan CJ, Gurusamy KS, Martin DJ, Kirk G, McKie L, Diamond T, Taylor MA (2013) Surgical versus endoscopic treatment of bile duct stones. The primary treatment, ERCP, is minimally invasive but associated with adverse events in 6% to 15%. Reimagining surgical care for a healthier world. It is very important that you consult your doctor about your specific condition. 3,4,8,9 Not surprisingly, many practice patterns now exist to manage CBD stones, which has led to national debate regarding the optimal algorithm. Choledocholithiasis is a common presentation of symptomatic cholelithiasis that can result in biliary obstruction, cholangitis, and pancreatitis. Tel: (310) 437-0544, SAGES Guidelines, Statements, & Standards of Practice, Copyright 2023 Society of American Gastrointestinal and Endoscopic Surgeons. Guidelines for clinical practice are intended to indicate preferable approaches to medical problems as established by experts in the field. 3300 Woodcreek Dr., Downers Grove, IL 60515 Although data regarding the natural history of choledocholithiasis Choledocholithiasis is a common presentation of symptomatic cholelithiasis that can result in biliary obstruction, cholangitis, and pancreatitis. 0000100412 00000 n The clinical presentation of choledocholithiasis can range from completely asymptomatic to biliary colic and symptoms of obstructive jaundice, such as pruritus, dark urine and acholic stools. 2023 Society of American Gastrointestinal and Endoscopic Surgeons. The diagnostic performance of the ASGE and ESGE guidelines is summarized in Table 3. We identified high-risk patients according to the original and revised guidelines and examined the diagnostic accuracy of both guidelines. Dynamic liver test patterns do not predict bile duct stones. If the patient is undergoing a pre-operative ERCP and endoscopic attempts with balloon or basket sweeping are unsuccessful, mechanical lithotripsy by way of capturing and fragmenting stones with a reinforced basket with a spiral sheath can be successful in over 80% of cases [28,29]. If the stones cannot be cleared intraoperatively, laparoscopic transcystic biliary stent placement can be performed under fluoroscopic guidance which can facilitate biliary drainage and allows for post-operative ERCP to be performed electively and more successfully. 0000021047 00000 n 2010;71:19. Clin J Gastroenterol. Surg Endosc. Chandran A, Rashtak S, Patil P, et al. Dig Dis 26:324329, Kedia P, Tyberg A, Kumta NA, Gaidhane M, Karia K, Sharaiha RZ, Kahaleh M (2015) EUS-directed transgastric ERCP for Roux-en-Y gastric bypass anatomy: a minimally invasive approach. Accessibility HHS Vulnerability Disclosure, Help Under the revised guidelines, 86 (32%) patients met the criteria for high risk, of whom 83% had choledocholithiasis. 0000011146 00000 n All recommendations follow a rigorous process based on a systematic review of medical literature as outlined by the National Academy of Medicine (formerly Institute of Medicine) standards for guideline development. 2023 Feb 28;12(3):482. doi: 10.3390/antibiotics12030482. 0000004317 00000 n The effective dose of ursodeoxycholic acid is between 8 and 12mg/kg daily for several months. We measured the association between individual criteria and choledocholithiasis. This American Society for Gastrointestinal Endoscopy (ASGE) Standard of Practice (SOP) Guideline provides evidence-based recommendations for the endoscopic evaluation and treatment of choledocholithiasis. Forest plot of randomized trials comparing endoscopic sphincterotomy followed by large balloon dilation versus endoscopic sphincterotomy for stone clearance. 0000009480 00000 n Costanzo ML, D'Andrea V, Lauro A, Bellini MI. Patients without evidence of jaundice and a normal bile duct on ultrasound have a low probability of choledocholithiasis (<5%) [9]. Epub 2019 Mar 25. ASGE quality indicators are based on a rigorous review process which results in valid metrics for evaluating GI endoscopic procedures. However, a simulation-based mastery learning curriculum has been shown to increase the clinical utilization, skill acquisition and adoption of laparoscopic common bile duct exploration [20]. . Regardless, the surgeon must be familiar with all possible options at their disposal for managing the patient presenting with choledocholithiasis which are highlighted in this document. With great interest, we read the study analyzing the diagnostic accuracy of current practice guidelines in predicting choledocholithiasis.1 The authors showed that the 2019 guidelines provided higher specificity for detecting choledocholithiasis.2,3 With current practice guidelines, the risk to the patient receiving diagnostic ERCP can be reduced. trailer All Rights Reserved. If plans are made intraoperatively for post-operative ERCP for common bile duct stone clearance, additional measures, such as endoloops or additional laparoscopic clips on the cystic duct stump and an external drain in the gallbladder fossa, should be considered to protect against leakage of the cystic duct stump due to the higher pressures present in the biliary tree. Suspected common bile duct stones: reduction of unnecessary ERCP by pre-procedural imaging and timing of ERCP. Epub 2021 Mar 22. Exclusion criteria and risk stratification of included patients with suspected choledocholithiasis (CDL). The categorization had a sensitivity and specificity of 68% and 55%, respectively, for the detection of choledocholithiasis. The https:// ensures that you are connecting to the Endoscopic ultrasound-guided biliary drainage via choledochoduodenostomy is also another documented method of accessing the common bile duct in which the common bile duct is directly punctured via a transduodenal approach to both clear and stent the common bile duct but this does require advanced endoscopic expertise [27]. However, the main disadvantage of MRCP is that common bile duct stones identified require intervention by another method to be removed. Guidelines are not a substitute for physicians opinion on individual patients. A systematic English literature search was conducted in PubMed to determine the appropriate management strategies for choledocholithiasis.The following clinical spotlight review is meant to critically review the available evidence and provide recommendations for the work-up, investigations as well as the endoscopic, surgical and percutaneous techniques in the management of choledocholithiasis. The standard IOC method includes cannulation of the cystic duct or gallbladder with a fine catheter and direct injection of contrast to visualize the common bile duct and biliary tree [13]. J Laparoendosc Adv Surg Tech A. At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made. 0000099052 00000 n 0000006146 00000 n patients with known choledocholithiasis. 0000007012 00000 n pre-cholecystectomy.16 However, because biliary Quality documents define the indicators of high-quality endoscopy and how to measure it. Complications of common bile duct exploration include retained stones (05%), bile leak (2.326.7%), common bile duct stricture (00.8%) and pancreatitis (03%). Accuracy of SAGES, ASGE, and ESGE criteria in predicting choledocholithiasis. A new approach to biliary calculi after failure of routine endoscopic measures. The following information is intended only to provide general information and not as a definitive basis for diagnosis or treatment in any particular case. %PDF-1.4 % migrate,13,14 and migrating stones pose a moderate Surg Endosc 15:413, Bansal VK, Misra MC, Rajan K, Kilambi R, Kumar S, Krishna A, Kumar A, Pandav CS, Subramaniam R, Arora MK, Garg PK (2013) Single-stage laparoscopic common bile duct exploration and cholecystectomy versus two-stage endoscopic stone extraction followed by laparoscopic cholecystectomy for patients with concomitant gallbladder stones and common bile duct stones: A randomized controlled trial. Although studies show EDGE to be safe and effective, there are concerns regarding persistent gastrogastric fistula and weight gain following stent removal in which it is recommended that either an upper endoscopy or upper GI series be obtained in all patients post-stent removal to determine the presence of persistent fistula. However, the timely availability of alternative imaging and patient morbidity may drive diagnostic and therapeutic pathways in individual patients and environments. We evaluated and validated the clinical utility of these new risk stratification criteria for . ASGE strives to provide clinically relevant and practical recommendations, which can help standardize patient care and improve outcomes. Each year choledocholithiasis results in biliary obstruction, cholangitis, and pancreatitis in a significant number of patients. Optimal Predictive Criteria for Common Bile Duct Stones: The Search Continues. Incidence rates of post-ERCP complications: a systematic survey of prospective studies. Accuracy of ASGE high-risk criteria in evaluation of patients with suspected common bile duct stones. ASGE quality indicators are based on a rigorous review process which results in valid metrics for evaluating GI endoscopic procedures. 52(9):736-744. 2021 Mar;54(2):147-148. doi: 10.5946/ce.2021.080. Management algorithm for patients based on probability of choledocholithiasis. Following this, immediate antimicrobial therapy targeted to the biliary tract and biliary drainage are the key goals of the treatment of acute cholangitis [38]. 0000006698 00000 n Yousaf MN, Mahmud Y, Sarwar S, Ahmad MN, Ahmad M, Abbas G. Pak J Med Sci. Please enable it to take advantage of the complete set of features! 0000048268 00000 n However, the specificity and PPV would lead more than a third of these patients to receive diagnostic ERCPs. ASGE Guideline for the Management of Post-Liver Transplant Biliary Strictures, ASGE Guideline on the Role of Ergonomics to Prevent Injuries for the Endoscopist, ASGE guideline on the Role of Endoscopy in the Diagnosis of Biliary Strictures, ASGE Guideline on the Role of Endoscopic Submucosal Dissection in the Management of Esophageal and Gastric Mucosal Neoplasia. J Clin Gastroenterol 52:579589, Sousa M, Pinho R, Proenca L, Rodrigues J, Silva J, Gomes C, Carvalho J (2018) Choledocholithiasis in elderly patients with gallbladder in situ is ERCP sufficient? Questions. 2). 243 110 Maple JT, Ben-Menachem T, et al. We have a few concerns about the current study. 0000017746 00000 n Relative contraindications to the transcystic approach include a small, friable cystic duct, multiple stones in the common bile duct, stones larger than 1cm or stones in the proximal duct [16,22]. Bethesda, MD 20894, Web Policies This technique is particularly attractive in the setting of sepsis secondary to acute cholangitis in the patient that is hemodynamically unstable and thus, unfit for endoscopic or surgical intervention. Surgical drainage and management is generally rare and not advocated in these critically ill patients due to the increased morbidity and mortality compared to endoscopic treatment in this patient population [40]. removal of discovered CBD stones is generally BUEN ARTICULO guideline asge guideline on the role of endoscopy in the evaluation and management of choledocholithiasis prepared : asge standards of practice. Choledocholithiasis is a commonly encountered diagnosis for general surgeons. The aim of clinical guidelines is to help physicians make important decisions by summating the best evidence in a readily accessible format.1 In 2019, the American Society for Gastrointestinal Endoscopy (ASGE) revised the guidelines for suspected choledocholithiasis based on studies evaluating the performance of the 2010 recommendations.2-8 The definition of parameters to predict high . Ultrasound findings consistent with choledocholithiasis include visualization of a common bile duct stone and a dilated common bile duct greater than 8-mm [3]. . 2022 Aug 5;11(15):4575. doi: 10.3390/jcm11154575. (2020)Comparison of the Relative Safety and Efficacy of Laparoscopic Choledochotomy with Primary Closure and Endoscopic Treatment for Bile Duct Stones in Patients with Cholelithiasis. The stent is deployed across the ampulla such that the internal flap is within the common bile duct and the external flap is within the duodenum. Systematic review and meta-analysis of the 2010 ASGE non-invasive predictors of choledocholithiasis and comparison to the 2019 ASGE predictors. 0000006855 00000 n Background/aims: Phone: (630) 573-0600 | Fax: (630) 963-8332 | Email: info@asge.org 0000100142 00000 n Other strong predictors for choledocholithiasis include clinical evidence of acute cholangitis, a bilirubin greater than 1.7mg/dL and a dilated CBD; the presence of two or more of these factors has a pre-test probability of 50%-94% for choledocholithiasis (considered high) [7,8]. Sperna Weiland CJ, Verschoor EC, Poen AC, Smeets XJMN, Venneman NG, Bhalla A, Witteman BJM, Timmerhuis HC, Umans DS, van Hooft JE, Bruno MJ, Fockens P, Verdonk RC, Drenth JPH, van Geenen EJM; Dutch Pancreatitis Study Group. The energy setting and number of discharges delivered is dependent on the device used and patient tolerance as the main adverse effects include pain, local hematoma formation, cardiac arrhythmias, biliary obstruction, hemobilia and hematuria [31]. et al. Comprehensive systematic reviews were also performed to assess the following: same-admission cholecystectomy for gallstone pancreatitis, clinical predictors of choledocholithiasis, optimal timing of ERCP vis--vis cholecystectomy, management of Mirizzi syndrome and hepatolithiasis, and biliary stent therapy for choledocholithiasis. 0000101569 00000 n 243 0 obj <> endobj BExample of an internal biliary stents that can be placed percutaneously under fluoroscopic guidance. Gastrointest Endosc 2011;74:731-744. Bethesda, MD 20894, Web Policies If you have any questions or suggestions, please contact Customer Support at Info@asge.org. Elsevier, Philadelphia, pp 391395, Hazey JW, Conwell DL, Guy GE (eds) (2016) Multidisciplinary management of common bile duct stones. 0000007803 00000 n Bookshelf Definitive . The .gov means its official. 3. If the stones cannot be extracted concurrently with biliary drainage in these critically ill patients, two-session treatment can be pursued with endoscopic biliary stenting performed as initial treatment followed by endoscopic stone removal after improvement of cholangitis [39]. Role of Endoscopy in the Management of Choledocholithiasis - ASGE In this retrospective study, the authors compared the performance of two such guidelines published by the American Society for Gastrointestinal Endoscopy (ASGE) in 2010 and 2019. Please enable it to take advantage of the complete set of features! 0000007249 00000 n Tintara S, Shah I, Yakah W, Ahmed A, Sorrento CS, Kandasamy C, Freedman SD, Kothari DJ, Sheth SG. to 34% of common bile duct (CBD) stones will spontaneously 0000005106 00000 n 0000099851 00000 n Surg Endosc 25:25922596, Miura F, Okamoto K, Takada T, Strasberg SM, Asbun HJ, Pitt HA, Gomi H, Solomkin JS, Schlossberg D, Han HS, Kim MH, Hwang TL, Chen MF, Huang WS, Kiriyama S, Itoi T, Garden OJ, Liau KH, Horiguchi A, Liu KH, Su CH, Gouma DJ, Belli G, Dervenis C, Jagannath P, Chan ACW, Lau WY, Endo I, Suzuki K, Yoon YS, de Santibaes E, Gimnez ME, Jonas E, Singh H, Honda G, Asai K, Mori Y, Wada K, Higuchi R, Watanabe M, Rikiyama T, Sata N, Kano N, Umezawa A, Mukai S, Tokumura H, Hata J, Kozaka K, Iwashita Y, Hibi T, Yokoe M, Kimura T, Kitano S, Inomata M, Hirata K, Sumiyama Y, Inui K, Yamamoto M (2018) Tokyo Guidelines 2018: Initial management of acute biliary infection and flowchart for acute cholangitis. in a separate ASGE practice guideline.12 This guideline 0000008123 00000 n ASGE Guideline Recommendations | January 2021, ASGE Guideline Recommendations | January 2021 Course List, ASGE Esophagology General GI Practice Virtual Program (LIVE Virtual) | April 2021, ASGE Esophagology General GI Practice (On-Demand) | April 2021, Endoscopy 2020: Leaders in Endoscopy and Video Case Studies | June 2020, GERD & Esophageal Motility Disorders (On-Demand) | January 2019, Gastrointestinal Endoscopy 2021: New Frontiers in ERCP & EUS (On-Demand) | March 2021, ASGE Endo Hangout: Acute Management of GI Bleeding | January 2022, Screening and Surveillance Guidelines (Speaker: Marcia Cruz-Correa), Guidelines for Safety in the Gastrointestinal Endoscopy Unit, ASGE guideline on minimum staffing requirements for the performance of GI endoscopy, ASGE guideline on the management of achalasia, Multisociety guideline on reprocessing flexible GI endoscopes and accessories, ASGE guideline on screening and surveillance of Barretts esophagus, ASGE guideline on the role of endoscopy in the management of benign and malignant gastroduodenal obstruction, ASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasis. Endoscopy. 0000003352 00000 n 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. Choledocholithiasis, ERCP, Common bile duct exploration, Management, Diagnosis. Overall, there were no changes to the general recommendations of this clinical review based on an updated literature search [1-6]. The revised categorization had a lower sensitivity and higher specificity of 37% and 80%, respectively. Epub 2022 Jan 24. Core clinical questions were derived using an iterative process by the ASGE SOP Committee. Sci Rep. 2023 Mar 10;13(1):4032. doi: 10.1038/s41598-023-31206-6. We suggest that the reader also reviews the SAGES clinical spotlight review on laparoscopic common bile duct exploration for further details [16]. ASGE Standards of Practice Committee, Maple JT, Ikenberry SO, Anderson MA, Appalaneni V, Decker GA, et al: The role of endoscopy in the management of choledocholithiasis. 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. J Clin Med. Springer, Cham, pp 101111, TH Lee SH Park SH Lee CK Lee SH Lee IK Chung HS Kim SJ Kim (2010) Modified rendezvous intrahepatic bile duct cannulation technique to pass a PTBD catheter in ERCP. All Rights Reserved. When choledocholithiasis is confirmed intraoperatively, a decision should be made between common bile duct exploration at the time of cholecystectomy and post-operative ERCP, which is dependent on local availability of surgical and endoscopic expertise. . Add to your cart and watch on-demand on your own device, at a time convenient with your schedule. Each year choledocholithiasis results in biliary obstruction, cholangitis, and pancreatitis in a signicant number of patients. Background: Acute gallstone pancreatitis (AGP) is the most common cause of acute pancreatitis (AP) in the United States. are limited, available studies indicate that 21% As such, the EDGE procedure can be an alternative method of accessing the biliary tree in which an anastomosis is created typically with a lumen-apposing metal stent between the gastric pouch or jejunum to the excluded stomach under endoscopic ultrasound visualization which allows a duodenoscope to be passed to perform a conventional ERCP [35] (Fig. The role of endoscopy in the evaluation of suspected choledocholithiasis. See this image and copyright information in PMC. Disclaimer. All Rights Reserved. official website and that any information you provide is encrypted Overall specificity for stones was greater using the 2019 criteria (76% vs 46.5%;P<.001), yet the positive and negative predictive values were not significantly different between the two guidelines. 0000006068 00000 n 1may be helpful for managing patients with suspected choledocholithiasis dependent on their risk stratification. The visualization of a common bile duct stone on abdominal ultrasound carries approximately a 73% sensitivity and 91% specificity according to a meta-analysis of five studies [6]. The primary treatment, ERCP, is minimally invasive but associated with adverse events in 6% to 15%. Past studies have demonstrated greater safety and reduced costs when ERCP is reserved for therapeutic application in patients with a high likelihood of duct stones, as opposed to performance as a diagnostic and potentially therapeutic intervention among those with low to intermediate risk of stones. choledocholithiasis ranges from 5% to 10% in those patients Surg Endosc. HPB (Oxford) 2006;8:409425. However, there are a variety of other minimally invasive techniques that can be employed prior to surgical intervention. Epub 2022 Nov 30. Quality documents define the indicators of high-quality endoscopy and how to measure it. Here you will find ASGE guidelines for standards of practice. . Due to the difficulty in navigation and subsequent cannulation, balloon-assisted ERCP is not always technically feasible for biliary duct clearance in these patients. ASGE guidelines in patients with AGP. 0000005448 00000 n 0000000016 00000 n This is described in more detail in the SAGES clinical spotlight review on laparoscopic common bile duct exploration [16]. 2002 Jan 14-16;19(1):1-26. 0000004992 00000 n Br J Surg 84:14071409, DiSario J, Ram C, Croffie J, Liu J, Mishkin D, Shah R, Somogyi L, Tierney W, Song LM, Petersen BT (2007) Biliary and pancreatic lithotripsy devices. Keywords: Gastrointest Endosc 71:1-9, Khan MA, Khan Z, Tombazzi CR, Gadiparthi C, Lee W, Wilcox CM (2018) Role of cholecystectomy after endoscopic sphincterotomy in the management of choledocholithiasis in high-risk patients: a systematic review and meta-analysis. Conclusion: NIH Consens State Sci Statements. Each recommendation is based on consideration of the best medical literature, the balance between risks and benefits, cost-effectiveness, patients values, and equity. Methods: We conducted a retrospective cohort study of 267 patients with suspected choledocholithiasis. Nonoperative imaging techniques in suspected biliary tract obstruction. 0000101495 00000 n A total of 725 articles were found and reviewed by the working group; after exclusion of studies not relevant to our clinical questions 79 full manuscripts were reviewed in detail.

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