BACKGROUND/AIMS: Periampullary diverticulum (PAD) is frequently encountered during endoscopic retrograde cholangiopancreatography (ERCP) and has been associated with stone formation in the bile duct. The effects of PAD on the ERCP procedure have been often debated. We aimed to compare the therapeutic success of ERCP between patients with PAD and matched controls. METHODS: We reviewed all ERCPs with findings of PAD in a national database (n=1,089) and compared them with age- and gendermatched controls in a 1:3 fashion (n=3,267). Demographics, endoscopic findings, visualization of main structures, and therapeutic success rates were compared between groups. Secondary analysis compared PAD cases and controls who had gallstone disease. RESULTS: The average cohort age was 68.4±14.3 years and 55.1% were male. ERCP success was similar in both groups, and no significant inter-group differences were found in the multivariate analysis. The presence of PAD did not affect the rates of sphincterotomy or visualization of main biliary structures. Secondary analysis showed similar success rates for gallstone removal between patients with PAD and controls. CONCLUSIONS: PAD may not be considered a hinderance to ERCP success. Further research is needed to determine the best approach to cannulate the ampulla and provide endoscopic therapy for different subtypes of PAD.
Bile Ducts ; Case-Control Studies ; Cholangiopancreatography, Endoscopic Retrograde ; Cohort Studies ; Demography ; Diverticulum ; Gallstones ; Humans ; Male ; Multivariate Analysis

Background/Aims: Endoscopic visualization of the microscopic anatomy can facilitate the real-time diagnosis of pancreatobiliary disorders and provide guidance for its treatment. This study aimed to review the technique, image classification, and diagnostic performance of confocal laser endomicroscopy (CLE). Methods: We conducted a systematic review of CLE in pancreatic and biliary ducts of humans, and have provided a narrative of the technique, image classification, diagnostic performance, ongoing research, and limitations. Results: Probe-based CLE differentiates malignant from benign biliary strictures (sensitivity, ≥89%; specificity, ≥61%). Needlebased CLE differentiates mucinous from non-mucinous pancreatic cysts (sensitivity, 59%; specificity, ≥94%) and identifies dysplasia. Pancreatitis may develop in 2-7% of pancreatic cyst cases. Needle-based CLE has potential applications in adenocarcinoma, neuroendocrine tumors, and pancreatitis (chronic or autoimmune). Costs, catheter lifespan, endoscopist training, and interobserver variability are challenges for routine utilization. Conclusions CLE reveals microscopic pancreatobiliary system anatomy with adequate specificity and sensitivity. Reducing costs and simplifying image interpretation will promote utilization by advanced endoscopists.

Purpose: Varicocele is a common problem among infertile men. Varicocele repair (VR) is frequently performed to improve semen parameters and the chances of pregnancy. However, there is a lack of consensus about the diagnosis, indications for VR and its outcomes. The aim of this study was to explore global practice patterns on the management of varicocele in the context of male infertility. Materials and Methods: Sixty practicing urologists/andrologists from 23 countries contributed 382 multiple-choice-questions pertaining to varicocele management. These were condensed into an online questionnaire that was forwarded to clinicians involved in male infertility management through direct invitation. The results were analyzed for disagreement and agreement in practice patterns and, compared with the latest guidelines of international professional societies (American Urological Association [AUA], American Society for Reproductive Medicine [ASRM], and European Association of Urology [EAU]), and with evidence emerging from recent systematic reviews and meta-analyses. Additionally, an expert opinion on each topic was provided based on the consensus of 16 experts in the field. Results: The questionnaire was answered by 574 clinicians from 59 countries. The majority of respondents were urologists/ uro-andrologists. A wide diversity of opinion was seen in every aspect of varicocele diagnosis, indications for repair, choice of technique, management of sub-clinical varicocele and the role of VR in azoospermia. A significant proportion of the responses were at odds with the recommendations of AUA, ASRM, and EAU. A large number of clinical situations were identified where no guidelines are available. Conclusions This study is the largest global survey performed to date on the clinical management of varicocele for male infertility. It demonstrates: 1) a wide disagreement in the approach to varicocele management, 2) large gaps in the clinical practice guidelines from professional societies, and 3) the need for further studies on several aspects of varicocele management in infertile men.