Updated guideline on the management of common bile duct stones (CBDS)

Characteristics and metabolic potential of biliary microbiota in patients with giant common bile duct stones

Background

Endoscopic retrograde cholangiopancreatography (ERCP) is an effective minimally invasive operation for the management of choledocholithiasis, while successful extraction is hampered by large diameter of stones. Emerging studies have revealed the close correlation between biliary microbiota and common bile duct stones (CBDS). In this study, we aimed to investigate the community characteristics and metabolic functions of biliary microbiota in patients with giant CBDS.

Methods

Eligible patients were prospectively enrolled in this study in First Affiliated Hospital of Soochow University from February 2022 to October 2022. Bile samples were collected through ERCP. The microbiota was analyzed using 16S rRNA sequencing. Metabolic functions were predicted by PICRUSTs 2.0 calculation based on MetaCyc database. Bile acids were tested and identified using ultra performance liquid chromatography-tandem mass spectrometry.

Results

A total of 26 patients were successfully included into final analysis, 8 in giant stone (GS) group and 18 in control group. Distinct biliary microbial composition was identified in patients with giant CBDS, with a significantly higher abundance of Firmicutes at phylum level. The unique composition at genus level mainly consisted of Enterococcus, Citrobacter, Lactobacillus, Pyramidobacter, Bifidobacterium and Shewanella. Pyramidobacter was exclusively found in GS group, along with the absence of Robinsoniella and Coprococcus. The contents of free bile acids were significantly higher in GS group, including cholic acid (98.39μmol/mL vs. 26.15μmol/mL, p=0.035), chenodesoxycholic acid (54.69μmol/mL vs. 5.86μmol/mL, p=0.022) and ursodeoxycholic acid (2.70μmol/mL vs. 0.17μmol/mL, p=0.047). Decreasing tendency of conjugated bile acids were also observed. Metabolic pathways concerning cholelithiasis were abundant in GS group, including geranylgeranyl diphosphate biosynthesis, gluconeogenesis, glycolysis and L-methionine biosynthesis.

Conclusions

This study demonstrated the community structure and metabolic potential of biliary microbiota in patients with giant CBDS. The unique biliary microbial composition holds valuable predictive potential for clinical conditions. These findings provide new insights into the etiology of giant CBDS from the perspective of biliary microbiota.

Effectiveness and complication rates of percutaneous transhepatic fluoroscopy-guided management of common bile duct stones: a single-arm meta-analysis

OBJECTIVES

To perform a systematic review and meta-analysis to determine the success and complication rate of percutaneous transhepatic fluoroscopy-guided management (PTFM) for the removal of common bile duct stones (CBDS).

METHODS

A comprehensive literature search of multiple databases was conducted to identify original articles published between January 2010 and June 2022, reporting the success rate of PTFM for the removal of CBDS. A random-effect model was used to summarize the pooled rates of success and complications with 95% confidence intervals (CIs).

RESULTS

Eighteen studies involving 2554 patients met the inclusion criteria and were included in the meta-analysis. Failed or infeasible endoscopic management was the most common indication of PTFM. The meta-analytic summary estimates of PTFM for the removal of CBDS were as follows: rate of overall stone clearance 97.1% (95% CI, 95.7-98.5%); stone clearance at first attempt 80.5% (95% CI, 72.3-88.6%); overall complications 13.8% (95% CI, 9.7-18.0%); major complications 2.8% (95% CI, 1.4-4.2%); and minor complications 9.3% (95% CI, 5.7-12.8%). Egger's tests showed the presence of publication bias with respect to the overall complications (p = 0.049). Transcholecystic management of CBDS had an 88.5% pooled rate for overall stone clearance (95% CI, 81.2-95.7%), with a 23.0% rate for complications (95% CI, 5.7-40.4%).

CONCLUSION

The systematic review and meta-analysis answer the questions of the overall stone clearance, clearance at first attempt, and complication rate of PTFM by summarizing the available literature. Percutaneous management could be considered in cases with failed or infeasible endoscopic management of CBDS.

CLINICAL RELEVANCE STATEMENT

This meta-analysis highlights the excellent stone clearance rate achieved through percutaneous transhepatic fluoroscopy-guided removal of common bile duct stones, potentially influencing clinical decision-making when endoscopic treatment is not feasible.

KEY POINTS

• Percutaneous transhepatic fluoroscopy-guided management of common bile duct stones had a pooled rate of 97.1% for overall stone clearance and 80.5% for clearance at the first attempt. • Percutaneous transhepatic management of common bile duct stones had an overall complication rate of 13.8%, including a major complication rate of 2.8%. • Percutaneous transcholecystic management of common bile duct stones had an overall stone clearance rate of 88.5% and a complication rate of 23.0%.

Risk Factors for Single and Multiple Recurrences for Endoscopic Retrograde Cholangiopancreatography and Open Choledochotomy in Treating Choledocholithiasis

Background

There are few studies comparing recurrences between endoscopic retrograde cholangiopancreatography (ERCP) and open choledochotomy (OCT).

Aims

To compare the effect of different surgical methods on single and multiple recurrences of choledocholithiasis.

Methods

A total of 1255 patients with choledocholithiasis who underwent ERCP or OCT were retrospectively studied. The recurrence of choledocholithiasis was calculated by the Kaplan-Meier method with the log-rank test. Multivariate analyses of recurrent choledocholithiasis were performed by introducing variables with P < 0.20 in univariate analysis into the logistic regression model.

Results

A total of 204 (16.7%, 204/1225) patients relapsed. Among the 204 patients, 74.5% relapsed within three years after surgery, of whom 39.7% (81/204) had multiple relapses (≥ 2). The recurrence rate of ERCP (17.2%, 119/692) was higher than that of OCT (15.1%, 85/563), but the difference was not statistically significant. The independent risk factors for a single recurrence of choledocholithiasis were diabetes, stone number ≥ 2, maximum stone diameter ≥ 15 mm, sedentary occupation, the approach of ERCP (EST or EPBD), periampullary diverticulum, primary suture, high-fat diet (postoperative), frequency of weekly vegetable intake (< 4, postoperative), and drinking (postoperative). However, the ERCP approach (EST or EPBD), OCT approach (LCBDE), primary suture, high-fat diet (postoperative), and frequency of weekly vegetable intake (< 4, postoperative) were independent risk factors for multiple recurrences of choledocholithiasis.

Conclusion

Patients with choledocholithiasis should be followed up regularly for one to three years after treatment. Stone number ≥ 2, diabetes mellitus, periampullary diverticulum, surgical methods, and lifestyle are all risk factors for the recurrence of choledocholithiasis. ERCP is still the preferred surgical method based on the advantages of low risk of cholangitis recurrence, less hospital stay, minimally invasive surgery, fewer postoperative complications, and easier acceptance by elderly patients. In addition to optimizing the treatment plans, postoperative lifestyle management is also vital.

Recurrence of common bile duct stones after choledocholithotomy in elderly patients: risk factor analysis and clinical prediction model development

Background

The reasons for the recurrence of common bile duct stones (CBDS) in elderly patients after choledocholithotomy are still unclear. This study aims to establish a prediction model for CBDS recurrence by identifying risk factors.

Methods

We conducted a retrospective analysis of 1804 elderly patients aged 65 years and above who were diagnosed to have CBDS and were admitted to Nanjing First Hospital between January 1, 2010, and January 1, 2021. According to inclusion and exclusion criteria, 706 patients were selected for the final analysis. The patients were assigned to two groups according to the presence or absence of CBDS recurrence, and their clinical data were then statistically analyzed. Subsequently, a prediction model and nomogram were developed, evaluating effectiveness using the concordance index (C-index).

Results

Of the 706 elderly patients, 62 patients experienced CBDS recurrence after surgery, resulting in a recurrence rate of 8.8%. The multivariate Cox analysis showed that prior history of cholecystectomy (hazard ratio [HR] = 1.931, 95% confidence interval [CI]: 1.051-3.547, p = 0.034), white blood cell (WBC) count ≥11.0 × 109/L (HR = 2.923, 95% CI: 1.723-4.957, p < 0.001), preoperative total bilirubin (TBIL) level ≥ 36.5 mmol/L (HR = 2.172, 95% CI: 1.296-3.639, p = 0.003), number of stones ≥2 (HR = 2.093, 95% CI: 1.592-5.294, p = 0.001), maximum stone diameter ≥ 0.85 cm (HR = 1.940, 95% CI: 1.090-3.452, p = 0.024), and T-tube drainage (HR = 2.718, 95% CI: 1.230-6.010, p = 0.013) were independent risk factors of CBDS recurrence in elderly patients after choledocholithotomy. A postoperative CBDS recurrence prediction model was constructed with a C-index value of 0.758 (95% CI: 0.698-0.818) and internal validation value of 0.758 (95% CI: 0.641-0.875).

Conclusion

A history of cholecystectomy, WBC count ≥11.0 × 109/L, preoperative TBIL level ≥ 36.5 mmol/L, number of stones ≥2, maximum stone diameter ≥ 0.85 cm, and T-tube drainage are the independent risk factors of CBDS recurrence after choledocholithotomy in elderly patients. Our developed prediction model for CBDS recurrence has good predictive ability and can help predict the prognosis of patients with CBDS.

Primary choledocholithiasis occurrence and recurrence is synergetcally modulated by the bile microbiome and metabolome alternations

AIMS

Primary choledocholithiasis is a common digestive disease with high morbidity and relapse. However, the compositions and functions of the bile microbial ecosystem and the pathogenesis of microfloral regulation of host metabolism resulting in stone formation are poorly understood.

MAIN METHODS

Biliary samples collected from patients with acute cholangitis induced by benign biliary stricture (nonlithiasis group, n = 17) and primary choledocholithiasis (lithiasis group, n = 33) were subjected to multiomics analyses. Furthermore, clinicopathological features collected over a 24-month follow-up period were examined to evaluate the predictive value of candidate microbes.

KEY FINDINGS

Five alpha diversity indices of the bile microbiome were significantly decreased in the lithiasis group. Furthermore, we identified 49 differential bile flora between the two groups, and the relative abundances of 6 bacteria, Actinobacteria, Actinobacteriota, Staphylococcales, Micrococcales, Altererythrobacter and Carnobacteriaceae, were associated with primary choledocholithiasis relapse conditions. Multiomics analyses showed that specific changes in disease-related bacterial taxa were closely related to metabolite variation (low-molecular weight carboxylic acids, sterol liquid and acylcarnitine), which might reflect disease prognosis. According to microbiomic and metabolomic pathway analyses, we revealed that bacterial infections, microbiota-derived amino acid metabolites and secondary bile acid-related pathways were significantly enriched in the stone-formation group, suggesting a novel host-microbial metabolic mechanism of primary choledocholithiasis.

SIGNIFICANCE

Our study first indicates bile host-microbial dysbiosis modulates the abnormal accumulation of metabolites might further disrupt calcium homeostasis and generate insoluble saponification. Additionally, we determined the predictive value of Actinomycetes phylum reduction for recurrence in primary common bile duct stone patients.

The Impact of Metabolic Factors and Lipid-Lowering Drugs on Common Bile Duct Stone Recurrence after Endoscopic Sphincterotomy with Following Cholecystectomy

BACKGROUND

Recurrent common bile duct stone after endoscopic retrograde cholangiopancreatography is an undesirable problem, even when a following cholecystectomy is carried out. Important factors are the composition and properties of stones; the most significant etiology among these is the lipid level. While numerous studies have established the association between serum lipid levels and gallstones, no study has previously reported on recurrent common bile duct stones after endoscopic sphincterotomy with following cholecystectomy.

MATERIALS AND METHODS

We retrospectively collected 2016 patients underwent endoscopic sphincterotomy from 1 January 2015 to 31 December 2017 in Linkou Chang Gung Memorial Hospital. Finally, 303 patients whose serum lipid levels had been checked following a cholecystectomy after ERCP were included for analysis. We evaluated if metabolic factors including body weight, BMI, HbA1C, serum lipid profile, and lipid-lowering drugs may impact the rate of common bile duct stone recurrence. Furthermore, we tried to find if there is any factor that may impact time to recurrence.

RESULTS

A serum HDL level ≥ 40 (p = 0.000, OR = 0.207, 95% CI = 0.114-0.376) is a protective factor, and a total cholesterol level ≥ 200 (p = 0.004, OR = 4.558, 95% CI = 1.625-12.787) is a risk factor of recurrent common bile duct stones after endoscopic sphincterotomy with cholecystectomy. Lipid-lowering drugs, specifically statins, have been shown to reduce the risk of recurrence significantly (p = 0.003, OR = 0.297, 95% CI = 0.132-0.665). No factors were found to impact the time to recurrence in this study.

CONCLUSIONS

The serum lipid level could influence the recurrence of common bile duct stones after endoscopic sphincterotomy followed by cholecystectomy, and it appears that statins can reduce the risk of recurrence.

Comparison of Outcomes between a Basket Catheter and a Balloon Catheter for Endoscopic Common Bile Duct Stone Removal

INTRODUCTION

Evidence for the outcomes of endoscopic retrograde cholangiopancreatography (ERCP) between a basket catheter and a balloon catheter for endoscopic common bile duct stone (CBDS) removal is lacking. This study aimed to compare ERCP outcomes using a basket catheter and a balloon catheter for endoscopic CBDS removal.

METHODS

This multicenter retrospective study included 904 consecutive patients with native papilla who underwent endoscopic stone removal for CBDS ≤10 mm using a basket catheter and/or a balloon catheter at three institutions in Japan. ERCP outcomes between the basket and balloon groups were compared using inverse probability of treatment weighting (IPTW) method.

RESULTS

ERCP-related adverse events occurred in 6.5% (29/449) and 7.7% (35/455) of patients in the basket and balloon groups, respectively (IPTW-adjusted p = 0.52). The incidences of post-ERCP pancreatitis, cholangitis, and perforation were similar in the basket and balloon groups (3.8% vs. 2.9%, 1.3% vs. 0.9%, and 0.7% vs. 0.7%, respectively). However, bleeding incidences were significantly higher in the balloon group than in the basket group (3.3% vs. 0.7%, IPTW-adjusted p = 0.012). Successful complete stone removal at one ERCP session using a single catheter was achieved in 17.8% (80/449) in the basket group and in 81.3% (370/455) in the balloon group (IPTW-adjusted p < 0.001).

DISCUSSION

A balloon catheter is more likely to complete stone extraction for CBDS ≤10 mm with a single catheter at one endoscopic stone removal session. However, the risk for post-ERCP bleeding is higher in the balloon group than in the basket group.

Diagnostic performance of laparoscopic transcystic common bile duct exploration for the detection of choledocholithiasis in patients with negative MRCP

There is little research to evaluate laparoscopic transcystic common bile duct (CBD) exploration (LTCBDE) as a diagnostic test to identify choledocholithiasis undergoing laparoscopic cholecystectomy (LC). This study aimed to assess the technical success and safety of LTCBDE in patients with suspected choledocholithiasis but negative magnetic resonance cholangiopancreatography (MRCP) undergoing LC. We did an ambispective cohort study in patients with gallstones and suspected CBD stones but negative MRCP undergoing LC. The primary outcomes were the rate of complications in the hospital. Between January 2010 and December 2018, 620 patients (median age, 58 years; 58.4% female) were eligible for the study. The success rate of LTCBDE was 91.8% and CBD stones were observed in 53.3% with a stone clearance rate of 99.3%. The overall postoperative complication rate was 0.65% and no death was recorded in the total cohort. Notably, the morbidity in LTCBDE is 0.53%. Retained CBD stones were diagnosed in 2 patients and managed by ERCP successfully. In the LTCBDE cohort, the median duration of operation was 78 (60-100) min and the median postoperative hospital stay was 1 (1-2) days. Overall, at a mean follow-up of 4.1 (2.3-6.1) years, recurrent CBD stones occurred in 1.1% and all-cause mortality in 0.6%. LTCBDE should be considered the favored choice in the diagnostic algorithm for patients with suspected choledocholithiasis but negative MRCP undergoing LC.

Nomogram predicting surgical risk of laparoscopic left-sided hepatectomy for hepatolithiasis

OBJECTIVE

To explore the surgical risk factors of laparoscopic left-sided hepatectomy for hepatolithiasis and establish and validate a nomogram to estimate the corresponding surgical risks.

METHODS

Patients with hepatolithiasis who underwent laparoscopic left-sided hepatectomy were retrospectively enrolled. Demographic data, clinicopathological parameters, and surgical factors were collected. Three hundred fifty-three patients were enrolled and randomly divided into training set (n=267) and validation set (n=86) by 3:1. Conversion to laparotomy was used as a surrogate index to evaluate the surgical risk. Univariate analysis was used to screen potential surgical risk factors, and multivariate analysis using logistic regression model was used to screen independent surgical risk factors. Nomogram predicting the surgical risks was established based on the independent risk factors. Discrimination, calibration, decision curve, and clinical impact analyses were used to evaluate the performance of the nomogram on the statistical and clinical aspects both in the training and validation sets.

RESULTS

Five independent surgical risk factors were identified in the training set, including recurrent abdominal pain, bile duct stricture, ASA classification ≥2, extent of liver resection, and biliary tract T tube drainage. No collinearity was found among these five factors, and a nomogram was established. Performance analyses of the nomogram showed good discrimination (AUC=0.850 and 0.817) and calibration (Hosmer-Lemeshow test, p=0.530 and 0.930) capabilities both in the training and validation sets. Decision curve and clinical impact analyses also showed that the prediction performance was clinically valuable.

CONCLUSIONS

A nomogram was established and validated to be effective in evaluating and predicting the surgical risk of patients undergoing laparoscopic left-sided hepatectomies for hepatolithiasis.

A clinician's guide to gallstones and common bile duct (CBD): A study protocol for a systematic review and evidence-based recommendations

Background and Aims

Gallstones are one of the most common and costly diseases of the gastrointestinal tract and occur when a combination of deposits consisting of fat or minerals accumulate in the gallbladder or common bile duct (CBD). This paper provides a comprehensive review of gallstone epidemiology, diagnosis, and management, focusing on current clinical guidelines and evidence-based approaches.

Methods

A systematic literature review gathered information from various sources, including PubMed, Trip, Google Scholar, Clinical Key, and reputable medical association websites. Keywords related to gallstones, CBD stones, cholelithiasis, choledocholithiasis, and guidelines were used to extract relevant recommendations. Expert consultations and consensus meetings localized the recommendations based on the target population and available resources.

Results

The paper discusses demographic factors, dietary habits, and lifestyle influences contributing to gallstone formation. Gallstones are categorized into cholesterol and pigment types, with varying prevalences across regions. Many individuals with gallstones remain asymptomatic, but complications can lead to serious and potentially life-threatening conditions. Diagnosis relies on history, physical examination, laboratory tests, and transabdominal ultrasound. Specific predictive factors help categorize patients into high, moderate, or low probability groups for CBD stones.

Conclusion

Evidence-based recommendations for gallstone diagnosis and management are presented, emphasizing individualized treatment plans. Surgical interventions, nonsurgical treatments like oral litholysis with UDCA, and stenting are discussed. The management of gallstones in pregnant women is also addressed, considering the potential risks and appropriate treatment options during pregnancy.

Diagnostic accuracy of updated risk assessment criteria and development of novel computational prediction models for patients with suspected choledocholithiasis

BACKGROUND

There are risks of choledocholithiasis in symptomatic gallstones, and some surgeons have proposed the identification of choledocholithiasis before cholecystectomy. Our goal was to evaluate the diagnostic accuracy of the latest guidelines and create computational prediction models for the accurate prediction of choledocholithiasis.

METHODS

We retrospectively reviewed symptomatic gallstone patients hospitalized with suspected choledocholithiasis. The diagnostic performance of 2019 and 2010 guidelines of the American Society for Gastrointestinal Endoscopy (ASGE) and 2019 guideline of the European Society of Gastrointestinal Endoscopy (ESGE) in different risks. Lastly, we developed novel prediction models based on the preoperative predictors.

RESULTS

A total of 1199 patients were identified and 681 (56.8%) had concurrent choledocholithiasis and were included in the analysis. The specificity of the 2019 ASGE, 2010 ASGE, and 2019 ESGE high-risk criteria was 85.91%, 72.2%, and 88.42%, respectively, and their positive predictive values were 85.5%, 77.4%, and 87.3%, respectively. For Mid-risk patients who followed 2019 ASGE about 61.8% of them did not have CBD stones in our study. On the choice of surgical procedure, laparoscopic cholecystectomy + laparoscopic transcystic common bile duct exploration can be considered the optimal treatment choice for cholecysto-choledocholithiasis instead of Endoscopic Retrograde Cholangio-Pancreatography (ERCP). We build seven machine learning models and an AI diagnosis prediction model (ModelArts). The area under the receiver operating curve of the machine learning models was from 0.77 to 0.81. ModelArts AI model showed predictive accuracy of 0.97, recall of 0.97, precision of 0.971, and F1 score of 0.97, surpassing any other available methods.

CONCLUSION

The 2019 ASGE guideline and 2019 ESGE guideline have demonstrated higher specificity and positive predictive value for high-risk criteria compared to the 2010 ASGE guideline. The excellent diagnostic performance of the new artificial intelligence prediction model may make it a better choice than traditional guidelines for managing patients with suspected choledocholithiasis in future.

Laparoscopic common bile duct exploration with primary closure is preferred for selected elderly individuals with choledocholithiasis

Background

Laparoscopic common bile duct exploration with primary closure (LCBDE-PC) exhibits more benefits than other surgeries for patients with choledocholithiasis. It remains unclear whether it is feasible for and beneficial to elderly individuals. This study aimed to clarify and stratify elderly patients who would benefit from LCBDE-PC.

Methods

A retrospective study of 1240 patients with choledocholithiasis who underwent laparoscopic procedures between 2011 and 2019 was conducted. Patients were divided into the young group (<65 years old, n = 708) and the elderly group (≥65 years old, n = 532). Perioperative outcomes were compared between the two groups.

Results

Laparoscopic common bile duct exploration with primary closure was successfully performed in 90.20% of the elderly and 94.20% of the young. No significant differences were observed between the two groups regarding reoperation, postoperative bile leakage, residual stones, drainage removal, and postoperative mortality. Compared with the young, the elderly had longer postoperative hospital stay (p = 0.035) and delayed postoperative eating time (p = 0.036) in the matched cohort. Independent risk factors for failed LCBDE-PC were preoperative pancreatitis (p = 0.018), year of the surgeon's experience (p = 0.008), preoperative C-reactive protein level (p = 0.034), preoperative total bilirubin (p = 0.021), impacted common bile duct (CBD) stones (p = 0.006), blood loss (p = 0.001), and edema of the CBD (p = 0.001). A novel nomogram for predicting failed LCBDE-PC in elderly individuals exhibited a sufficient discriminative ability according to the estimated area under the curve (AUC) of 0.869 (95% CI: 0.817-0.921, p < 0.01).

Conclusion

Laparoscopic common bile duct exploration with primary closure is safe, feasible, and effective for elderly individuals with choledocholithiasis. Elderly patients with a high risk of failed LCBDE-PC should be cautious of undergoing LCBDE-PC.

A Retrospective Study on the Three-Port Technique of Laparoscopic Common Bile Duct Exploration for the Management of Cholelithiasis and Choledocholithiasis

BACKGROUND

Laparoscopic cholecystectomy (LC) with laparoscopic common bile duct exploration (LCBDE) is convenient in treating cholelithiasis and choledocholithiasis due to its advantage of accelerated recovery. This retrospective study aimed to summarize the experience of cholelithiasis and choledocholithiasis treatment via three-port approach of LCBDE in Eastern China.

METHODS

Patients diagnosed with cholelithiasis and choledocholithiasis between July 2019 and October 2021 were included. Patients who received LC+LCBDE+primary suturing of the common bile duct (CBD) via a three-port approach were assigned to the LCBDE-P group, and those who received LC+LCBDE+T-tube drainage of CBD comprised the LCBDE-T group. The measurement data were compared between the two groups. P-values <0.05 indicated statistical significance.

RESULTS

A total of 88 patients were divided into two groups: LCBDE-P (n=50) and LCBDE-T (n=38). Multiple logistic regression analysis showed that LCBDE-P is associated with a shorter length of stay (OR=0.115, 95% CI: 0.040-0.329, P<0.001) and lower hospitalization costs (OR=0.120, 95% CI: 0.041-0.357, P<0.001). No significant differences between the two groups were detected in the operation time, intraoperative hemorrhage, clearance rate of CBD stones, postoperative liver function, and postoperative complications (P>0.05).

CONCLUSION

The three-port approach of LCBDE is a safe and feasible strategy for managing cholelithiasis and choledocholithiasis. Compared to LCBDE-T, LCBDE-P reduces the length of hospital stay and medical costs during hospitalization.

The Conservative Management of Choledocholithiasis With Ursodeoxycholic Acid

Choledocholithiasis has been defined as the presence of stones within the common bile duct (CBD) with up to one-half of the cases remaining asymptomatic. We report a case of an 84-year-old frail male admitted for the treatment of pneumonia, pleural effusion, and bacteraemia with co-incidental deranged liver function tests (LFTs). Ensuing magnetic resonance cholangiopancreatography (MRCP) noted three CBD stones; however, the patient remained asymptomatic. After discussing the benefits and risks of treatment options with the gastroenterology team, the patient refused endoscopic retrograde cholangiopancreatography (ERCP) and opted for close monitoring in the community whilst taking ursodeoxycholic acid (UDCA). In the months following, his LFTs normalised, and repeat MRCP no longer showed stones. This case demonstrates that UDCA with close monitoring may be considered a non-invasive alternative treatment of CBD stones, particularly in elderly or frail patients with multiple comorbidities.

The short- and long-term outcome after the surgical management of common bile duct stones in a tertiary referral hospital

BACKGROUND

The removal of common bile duct stones by endoscopic retrograde cholangiopancreatography (ERCP) shows excellent results with low complication rates and is therefore considered a gold standard. However, in case of stones non-removable by ERCP, surgical extraction is needed. The surgical approach is still controversial and clinical guidelines are missing. This study aims to analyze the outcomes of patients treated with choledochotomy or hepaticojejunostomy for common bile duct stones.

METHODS

All patients who underwent choledochotomy or hepaticojejunostomy for common bile duct stones at a tertiary referral hospital over 11 years were included. The analyzed data contains basic demographics, diagnostics, surgical parameters, length of hospitalization, and morbidity and mortality.

RESULTS

Over the study period, 4375 patients underwent cholecystectomy, and 655 received an ERCP with stone extraction, with 48 of these patients receiving subsequent surgical treatment. ERCP was attempted in 23/30 (77%) of the choledochotomy patients pre/intraoperatively and 11/18 (56%) in hepaticojejunostomy patients. The 30-day major complication rate (Clavien-Dindo > II) was 1/30 (3%) in the choledochotomy group and 2/18 (11%) in the hepaticojejunostomy group. Complications after 30 days occurred in 3/30 (10%) patients and 2/18 (11%), respectively, and no mortality occurred.

CONCLUSION

ERCP should still be considered the gold standard, although due to low short- and long-term morbidity rates, choledochotomy and hepaticojejunostomy represent effective surgical solutions for common bile duct stones.

The Role of the Bile Microbiome in Common Bile Duct Stone Development

INTRODUCTION

Common bile duct (CBD) stones are a health concern for 10-20% of individuals with symptomatic gallstones, leading to health complications and placing a burden on healthcare systems. This study was initiated to investigate the changes in microbiome compositions and the metabolic signature associated with CBD stones. The research approach integrated taxonomic and functional data with metabolomics data, complemented by in vivo experiments.

METHODS

In a single tertiary healthcare institution, a total of 25 patients were enrolled who had undergone endoscopic retrograde cholangiopancreatography (ERCP) between February 2019 and January 2021. We harvested DNA from bile samples acquired from these individuals. The amplification of the bacterial 16S rRNA gene V3-V4 region was conducted through polymerase chain reaction (PCR), followed by sequencing. We utilized QIIME2 for a comprehensive data analysis. Furthermore, we performed a metabolomic analysis of the bile samples using nuclear magnetic resonance (NMR) spectroscopy. For the assessment of functional gene enrichment, we employed MetaboAnalyst 5.0. Lastly, we executed in vivo experiments on C57BL/6 mice and undertook histological examinations of tissue samples.

RESULTS

Out of the 25 study subjects, 17 underwent ERCP due to CBD stones (the CBD stone group), while the remaining 8 had the procedure for different reasons (the non-CBD stone group). An alpha diversity analysis showed a significantly greater microbial diversity in the bile samples of the non-CBD stone group (p < 0.01), and a beta diversity analysis confirmed the greater microbial compositional abundance in the gut microbiomes in this group (p = 0.01). A taxonomic analysis revealed that the abundances of Enterococcaceae and Enterococcus were higher in the bile microbiomes of the CBD stone group. A metabolic profile analysis showed that the acetate, formate, and asparagine levels were higher in the CBD stone group. A pathway enrichment analysis showed the metabolic pathways (Arginine and Proline Metabolism, Aspartate Metabolism, Glycine, and Serine Metabolism, and Ammonia Recycling pathways) that were associated with these differences. Preclinical experiments demonstrated systemic inflammation and extracellular trap formation in the CBD stone group.

CONCLUSIONS

Our study highlights the importance of biliary dysbiosis and bile metabolites, specifically acetate and formate, in CBD stone development and progression. These findings have implications for the development of diagnostic and therapeutic strategies using microbiomes for CBD stones.

Risk factors for recurrent common bile duct stones: a systematic review and meta-analysis

BACKGROUND

Common bile duct stones (CBDS) have a reported recurrence rate of 4%-24% after stone extraction. The most commonly applied stone extraction method is endoscopic cholangiopancreatography (ERCP). We conducted a systematic review and meta-analysis to identify all available risk factors for recurrent CBDS following stone retraction.

RESEARCH DESIGN AND METHODS

A literature search of studies with case-control design was performed to identify potential risk factors for recurrent CBDS. The impact of different risk factors on stone recurrence was analyzed. Pooled odds ratios (ORs) with 95% CIs and heterogeneity were calculated. Identified risk factors were graded as 'strong,' 'moderate,' or 'weak' after quality assessment.

RESULTS

A total of 46 studies discussing stone recurrence following ERCP treatment were included. CBD diameter≥ 1.5 cm, sharp CBD angulation, multiple ERCP sessions, postoperative pneumobilia, history of CBD incision, and biliary stent placement were identified as strong risk factors; larger CBD diameter, periampullary diverticulum, mechanical lithotripsy, and history of cholecystectomy were identified as moderate. Other weak risk factors were also listed.

CONCLUSIONS

In this comprehensive study, we identified 14 risk/protective factors for recurrent CBDS following ERCP. Pooled odds ratios were calculated and evaluated the quality of evidence. These findings may shed light on the assessment and management of CBDS.

Observation versus intervention for incidental common bile duct stones at intraoperative cholangiogram: a systematic review

BACKGROUND

The natural history of incidental common bile duct stones (CBDS) is poorly understood. Current evidence is conflicting, with several studies suggesting the majority may pass spontaneously. Despite this, guidelines recommend routine removal even if asymptomatic. This study aimed to systematically review the outcomes of expectant management for CBDS detected on operative cholangiography during cholecystectomy.

METHODS

MEDLINE, Embase and CINAHL databases were systematically searched. Participants were adult patients with CBDS identified by intraoperative cholangiography. Intervention was regarded as any perioperative effort to remove common bile duct stones, including endoscopic retrograde cholangiopancreatography (ERCP), laparoscopic and open bile duct exploration. This was compared to observation. Outcomes of interest included rates of spontaneous stone passage, success of duct clearance and complications. Risk of bias was assessed using the ROBINS-I tool.

RESULTS

Eight studies were included. All studies were non-randomized, heterogeneous and at serious risk of bias. In patients observed after a positive IOC, 20.9% went on to have symptomatic retained stones. In patients directed to ERCP for positive IOC, persistent CBDS were found in 50.6%. Spontaneous passage was not associated with stone size. Meta-analysis is dominated by the results from one large database, which recommends intervention for incidental stones, despite low rates of persistent stones seen at postoperative ERCP.

CONCLUSIONS

Further evidence is required before a definitive recommendation on observation can be made. There is some evidence that asymptomatic stones may be safely observed. In clinical scenarios where the risks of biliary intervention are considered high, a conservative strategy could be more widely considered.

Gallstone and Gallbladder Disease: Biliary Tract and Cholangiopathies

Cholestatic liver diseases are named primarily due to the blockage of bile flow and buildup of bile acids in the liver. Cholestasis can occur in cholangiopathies, fatty liver diseases, and during COVID-19 infection. Most literature evaluates damage occurring to the intrahepatic biliary tree during cholestasis; however, there may be associations between liver damage and gallbladder damage. Gallbladder damage can manifest as acute or chronic inflammation, perforation, polyps, cancer, and most commonly gallstones. Considering the gallbladder is an extension of the intrahepatic biliary network, and both tissues are lined by biliary epithelial cells that share common mechanisms and properties, it is worth further evaluation to understand the association between bile duct and gallbladder damage. In this comprehensive article, we discuss background information of the biliary tree and gallbladder, from function, damage, and therapeutic approaches. We then discuss published findings that identify gallbladder disorders in various liver diseases. Lastly, we provide the clinical aspect of gallbladder disorders in liver diseases and ways to enhance diagnostic and therapeutic approaches for congruent diagnosis. © 2023 American Physiological Society. Compr Physiol 13:4909-4943, 2023.

Meta-analysis of the timing of laparoscopic cholecystectomy after endoscopic retrograde cholangiopancreatography in patients with cholecystolithiasis and choledocholithiasis

Endoscopic retrograde cholangiopancreatography (ERCP) combined with laparoscopic cholecystectomy plays an important role in the treatment of cholecystolithiasis combined with choledocholithiasis; however, there is no unified standard for the interval of ERCP before laparoscopic cholecystectomy. We conducted a literature search, data extraction and meta-analysis on this topic. Twelve articles with 1142 patients were included, including 567 patients in the E-laparoscopic cholecystectomy group (laparoscopic cholecystectomy performed within 72 h after ERCP) and 575 patients in the D-laparoscopic cholecystectomy group (laparoscopic cholecystectomy performed 72 h after ERCP). The results showed that: compared with the D-laparoscopic cholecystectomy group, the duration of cholecystectomy was shorter in the E-laparoscopic cholecystectomy group [weighted mean difference (WMD) = -16.18, 95% confidence interval (CI) (-22.27 to -10.08), P  < 0.00001], and the postoperative hospitalization was shorter [WMD = -1.24, 95% CI (-1.98 to -0.50), P  < 0.0001]. There were fewer complications [odds ratio (OR) = 0.25, 95% CI (0.39-0.62), P  < 0.0001], lower conversion rate [OR = 0.39, 95% CI (0.21-0.71), P  = 0.002], lower high sensitivity C-reactive protein at 3 days after surgery [WMD = -8.76, 95% CI (-12.59 to -4.93), P  < 0.00001], and fewer neutrophils in the ampulla of gallbladder specimen [WMD = -4.21, 95% CI (-4.55 to -3.88), P < 0.00001]. Therefore, in the treatment of cholecystolithiasis combined with choledocholithiasis by laparoscopic cholecystectomy within 72 h after ERCP, the degree of inflammation before and after surgery is less, the operation time and hospital stay are shortened, the postoperative complications and the conversion rate are reduced, which is a more appropriate time for surgery.

Prevention of acute post-manipulation pancreatitis

Endoscopic retrograde cholangiopancreatography (ERCP) is one of the most informative and often in-demand methods for the detection and treatment of pathology of the biliary tract, its diagnostic value is 79-98%. A significant disadvantage of the method are side effects and various complications (acute pancreatitis, bleeding, retroduodenal perforation, cholangitis, acute cholecystitis, etc.). Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is a common and severe complication of intraluminal endoscopic operations on the large duodenal papilla, its etiology is multifactorial, and the pathophysiology has not yet been fully studied. According to many randomized, controlled studies, the incidence of PEP ranges from 2.7 to 37%. Despite all the possibilities of modern medicine and the introduction of new methods, mortality with the development of PEP remains at a very high level: it reaches 7-15%, and with the development of destructive forms - 40-70%. The problems of prevention of PEP are still the subject of discussions and numerous studies by leading clinics around the world. In this paper, we conducted a review of the literature over the past decade using the sources of major medical libraries Medline, eLibrary, PubMed. The article discusses current modern pathogenetic mechanisms and the main risk factors for the development of PEP, related to both the characteristics of the patient and the procedure being performed, technical options for performing ERCP. The article also presents currently used and recommended by most authors methods of drug prevention of PEP and various technical solutions related to this complication. Thus, the not entirely satisfactory results of the proposed methods of prevention of PEP force the authors to search for safer and more effective solutions to this urgent problem at the present time.

The efficacy and safety of laparoscopic common bile duct exploration and cholecystectomy for the treatment of difficult common bile duct stones combined with gallstones: a multicenter retrospective study

PURPOSE

To analyze the benefits of laparoscopic common bile duct exploration and laparoscopic cholecystectomy (LCBDE + LC) versus endoscopic retrograde cholangiopancreatography and/or endoscopic sphincterotomy following laparoscopic cholecystectomy (ERCP/EST + LC) for difficult common bile duct stones combined with gallstones.

METHODS

A retrospective analysis of consecutive patients with difficult common bile duct stones combined with gallstones in three hospitals from January 2016 to January 2021 was performed.

RESULTS

ERCP/EST + LC contributed to reducing postoperative drainage time. However, LCBDE + LC showed a higher rate of complete clearance, along with lower postoperative hospital stays, expenses and incidence of postoperative hyperamylasemia, pancreatitis, re-operation and recurrence. In addition, LCBDE + LC showed safe and feasible performance in the elderly and patients with previous upper abdominal surgery.

CONCLUSION

It is an effective and safe method for LCBDE + LC for difficult common bile duct stones combined with gallstones.

Saline irrigation for reducing the recurrence of common bile duct stones after lithotripsy: a randomized controlled trial

Background

Mechanical lithotripsy produces stone fragments that are not easily detected by cholangiography and is a potential cause of recurrence of common bile duct stones (CBDS). This study aims to clarify whether 100 ml saline irrigation after mechanical lithotripsy reduces the recurrent rate of CBDS.

Methods

In this randomized controlled trial performed at the Surgical Endoscopy Center, the First Hospital of Lanzhou University between May 10, 2019, and Dec 31, 2020, patients undergoing endoscopic mechanical lithotripsy were randomly assigned to receive saline irrigation (study group) or no irrigation (control group). The saline irrigation was given 100 ml saline pulse irrigation after cholangiography showed no residual stones. Patients were followed up for at least 24 months after endoscopic stone removal to assess the recurrence of CBDS. This study was registered with ClinicalTrials.gov (NCT03937037).

Findings

During the median follow-up period of 35.6 months (interquartile range, 26.0-40.7), 43 of the 180 patients had stone recurrence (24%). The frequency of recurrence of CBD stones was 12.22% in the saline irrigation group and 35.56% in the control group, with a difference of 23.33% between the two groups (95% confidence interval [CI], 11.35%-35.32%, p < 0.001). Multivariable Cox proportional hazards analyses showed that constipation (hazard risk [HR] 2.42; 95% CI, 1.22-4.80, p = 0.012), periampullary diverticulum (PAD) (HR 3.06; 95% CI, 1.62-5.79, p < 0.001), and total to direct bilirubin ratio (HR 1.48; 95% CI, 1.21-1.81, p < 0.001) were independent risk factors for the recurrence of CBDS. Saline irrigation was the only preventive factor for the recurrence of CBDS (HR 0.22; 95% CI, 0.11-0.44, p < 0.001).

Interpretation

For patients with CBDS requiring mechanical lithotripsy, 100 ml saline irrigation effectively reduces the recurrent rate of CBDS after endoscopic stone removal.

Funding

This work was supported by National Natural Science Foundation of China (32160255); Natural Science Foundation of Gansu Province (22JR5RA898, 20JR10RA676); Science and Technology Planning Project of Chengguan District in Lanzhou (2020JSCX0043).

Comparison of different time intervals between laparoscopic cholecystectomy to endoscopic retrograde cholangiopancreatography for patients with cholecystolithiasis complicated by choledocholithiasis

Background

Endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC) is a common strategy for treatment of patients with gallstones with co-existing stones in the common bile duct (CBD). We conducted this study to compare the effect of different time intervals between ERCP and LC.

Methods

A total of 214 patients who underwent elective LC after ERCP for gallstones and CBD stones between January 2015 and May 2021 were retrospectively reviewed. We compared the hospital stay, operation time, perioperative morbidity, and conversion rate to open cholecystectomy, according to the interval between ERCP and ERCP and LC, namely, one day, 2–3 days, and 4 days or more. A generalized linear model was used to analyze the differences among the groups for outcomes.

Results

There were a total of 214 patients with 52, 80, and 82 patients in group 1, group 2, and group 3 respectively. These groups did not differ significantly in terms of major complications or conversion to open surgery (p = 0.503 and p = 0.358, respectively). The generalized linear model showed that operation times in group 1 and group 2 were similar (odds ratio (OR) 0.144, 95% confidence interval (CI) 12.597, 8.511, p = 0.704), while operation time was significantly longer in group 3 than in group 1 (OR 4.005, 95% CI, 0.217, 20.837, p = 0.045). Post-cholecystectomy hospital stay was similar among the three groups, while post-ERCP hospital stay was significantly longer in group 3 compared with group 1.

Conclusion

We recommend that LC be performed within three days after ERCP to reduce operating time and hospital stay.

A novel non-slip banded balloon catheter for endoscopic sphincteroplasty: an ex vivo and in vivo pilot study

Endoscopic balloon sphincteroplasty is an established procedure for the extraction of bile duct stones. However, the balloon often slips during the inflation process, and its length is an impediment if the distance between the papilla and scope is limited and/or the stone is located close to the papilla. This animal experimental study aimed to evaluate the feasibility of a novel short non-slip banded balloon measuring 15-20 mm in length for sphincteroplasty. The ex vivo component of this study was conducted using porcine duodenal papilla. Miniature pigs were subjected to endoscopic retrograde cholangiography in the in vivo component. The technical success of sphincteroplasty without any slippage was the primary outcome of the study and was compared between cases managed with the non-slip banded balloon (non-slip balloon group) and conventional balloon (conventional balloon group). The technical success rate of the ex vivo component, i.e., absence of any slippage, was significantly higher in the non-slip balloon group than in the conventional balloon group with the 8-mm (96.0% vs. 16.0%, P < 0.001) and 12-mm diameter balloons (96.0% vs. 0%, P < 0.001). The technical success rate of endoscopic sphincteroplasty without slippage in the in vivo component was significantly higher in the non-slip balloon group than in the conventional balloon group (100% vs. 40%, P = 0.011). No immediate adverse events were observed in either group. The slippage rate was significantly lower with sphincteroplasty using a non-slip balloon, despite the balloon length being considerably shorter than that of conventional balloons, demonstrating its potential utility in difficult cases.

Minimally invasive management of concomitant gallstones and common bile duct stones: an updated network meta-analysis of randomized controlled trials

BACKGROUND

To update a 2018 meta-analysis on the comparative efficacy and safety of four surgical techniques in patients with concomitant gallstones and common bile duct (CBD) stones.

METHODS

Randomized controlled trials (RCTs) comparing laparoscopic cholecystectomy (LC) plus laparoscopic common bile duct exploration (LCBDE), LC plus preoperative endoscopic retrograde cholangiopancreatography (PreERCP), LC plus intraoperative ERCP (IntraERCP), and LC plus postoperative ERCP (PostERCP) were included. Primary and secondary outcomes were compared using odds ratio, weighted mean difference, and 95% confidence intervals.

RESULTS

Twenty-five RCTs involved 3145 patients were included. Of these, 1188 (37.8%) underwent LC + PreERCP, 1183 (37.6%) LC + LCBDE, 689 (21.9%) LC + IntraERCP, and 85 (2.7%) LC + PostERCP. This analysis demonstrated that LC plus IntraERCP was the most likely approach to achieve technical success and reduce morbidity. No significant differences were observed between the four treatments concerning major morbidity, mortality, and operative time. LC plus LCBDE was effective for increasing biliary leak and conversion as well as decreasing postoperative hemorrhage and total costs. Additionally, LC plus PreERCP was associated with higher postoperative pancreatitis, while LC plus IntraERCP was associated with a shorter length of hospital stay. There was significant heterogeneity in operative time, hospital stay, and total costs (τ2 > 1).

CONCLUSIONS

This analysis provides evidence that LC plus IntraERCP appears to be the optimal strategy for patients with concomitant gallstones and CBD stones owing to its advantage in technical success and morbidity. LC plus LCBDE is associated with higher biliary leak and lower postoperative hemorrhage, whereas LC plus PreERCP is associated with higher postoperative pancreatitis.

Unnecessary endoscopic retrograde cholangiopancreatography associated with the spontaneous passage of common bile duct stones into the duodenum: a multicenter retrospective study

BACKGROUND

Unnecessary endoscopic retrograde cholangiopancreatography (ERCP) after spontaneous passage of common bile duct stones (CBDSs) should be avoided. This study aimed to examine the cumulative diagnosis rate and the predictive factors of spontaneous CBDS passage during the interval between the imaging diagnosis and ERCP.

METHODS

This multicenter retrospective study included 1260 consecutive patients with native papilla diagnosed with CBDSs using imaging modalities. Predictive factors and cumulative diagnosis rate of spontaneously passed CBDSs during the interval between imaging diagnosis and ERCP were analyzed.

RESULTS

The overall cumulative diagnosis rate of spontaneous CBDS passage was 6.2% (78/1260) during a mean interval of 5.0 days. In the multivariate analysis, CBDS sized < 6 mm on diagnostic imaging, solitary CBDS on diagnostic imaging, intervals between the imaging diagnosis and ERCP, and nondilated common bile duct (< 10 mm) were the significant factors associated with spontaneous CBDS passage. Specifically, the cumulative diagnosis rate of spontaneous passage was significantly higher in patients with solitary and CBDSs sized < 6 mm than in those with other CBDSs (14.4% [54/376] vs. 2.7% [24/884], P < 0.001). In both the asymptomatic and symptomatic groups, the cumulative diagnosis rate of the spontaneous passage of CBDSs was significantly higher in patients with solitary and CBDSs sized < 6 mm on diagnostic imaging than in those with multiple and/or CBDSs sized ≥ 6 mm on diagnostic imaging during a mean interval of 20.5 and 2.4 days, respectively (asymptomatic group: 22.4% [15/67] vs. 3.5% [4/113], P < 0.001, symptomatic group: 12.6% [39/309] vs. 2.6% [20/771], P < 0.001).

CONCLUSIONS

Solitary and CBDSs sized < 6 mm on diagnostic imaging can often lead unnecessary ERCP due to spontaneous passage. Preliminary endoscopic ultrasonography immediately before ERCP is recommended, especially in patients with solitary and small CBDSs on diagnostic imaging.

How to perform laparoscopic common bile duct exploration through a transverse choledochotomy

This article reviews common bile duct stones and describes our technique of laparoscopic common bile duct exploration (LCBDE) through a transverse choledochotomy at Hawke's Bay Hospital, New Zealand.

The Outcome and Safety in Laparoscopic Common Bile Duct Exploration with Primary Suture versus T-Tube Drainage: A Meta-Analysis

Background

Sometimes, after choledochotomy, the common bile duct is closed with T-tube drainage for several weeks to prevent postoperative complications such as biliary fistula and stricture. But there has been controversy over the advantages of primary suture versus T-tube drainage. The purpose of our meta-analysis in laparoscopic common bile duct exploration is to appraise the efficacy and safety of T-tube drainage and primary suture.

Methods

The literatures were searched by Web of Science, PubMed, Cochrane Library, OVID, and EMBASE between the year January 1, 2001 and February 28, 2021. Meta-analysis was performed by Stata 12.

Results

Fourteen studies with 1,549 patients (827 vs. 722) were included in our study. The primary suture group had significant lesser operative time (P ≤ 0.001), postoperative hospital stay (P ≤ 0.001), hospital expenses (P ≤ 0.001), intraoperative bleeding (P=0.001), and postoperative complications (P=0.006) than the T-tube drainage group. In postoperative bleeding (P=0.289), bile leakage (P=0.326), and bile duct stricture (P=0.750), there was no statistical difference. In the primary suture group, using single-arm synthesis, the bile leakage rate and the bile duct stricture rate were 0.07 vs. 0.04 and 0.00 vs. 0.00 in interrupted suture and continuous suture groups. The bile duct stricture rate was same in both groups, and the bile leakage rate was lower in the interrupted suture group. But the difference was not significant.

Conclusion

The primary suture group had several advantages, including lesser operative time, postoperative complications, intraoperative bleeding, postoperative hospital stay, and hospital expenses. In bile leakage and bile duct stricture, the difference between the two groups was not significant. In the primary suture group, interrupted suture and continuous suture groups had similar bile leakage rate and bile duct stricture rate.

ERCP for bile duct stones across a national service, demonstrating a high requirement for repeat procedures

Background and study aims  Bile duct stones (BDS) represent approximately 50 % of the requirement for endoscopic retrograde cholangiopancreatography (ERCP) within most services. Significant variation in outcome rates for BDS clearance at ERCP has been reported, and endoscopy societies have set standards for expected clearance rates. The aim of this study was to analyze procedure outcomes across a national service. Patients and methods  Using verified hospital episode statistics (HES) data for the National Health Service (NHS) in England, we analyzed all patients having first ERCPs for BDS from 2015 to 2017, and followed these patients for at least 2 years. Results  In total 37,468 patients underwent a first ERCP for BDS, with 69.8 % undergoing only one procedure. This figure of less than 70 % of BDS cleared at first ERCP is below the Key Performance Indicators as set by the British Society of Gastroenterology (> 75 %) and the European Society of Gastrointestinal Endoscopy (> 90 %). Of 55,556 ERCPs done for BDS, 52.9 % were repeat procedures, with 11,322 patients needing multiple procedures. For hospitals performing significant numbers of ERCPs (more than 600 for BDS during the study period) patients undergoing repeat ERCPs for BDS ranged from 9 % to 50 %. Conclusions  In this nationwide study, the performance at clearing BDS at first ERCP was suboptimal, with high numbers of repeat procedures required. This may have a negative impact on both patient outcomes and experience, and increase pressure on endoscopy services. Apparent variation of outcome between acute hospital care providers requires further analysis.

Surgical Management of Recurrence of Primary Intrahepatic Bile Duct Stones

BACKGROUND

The surgical treatment of primary intrahepatic bile duct stones is associated with high rates of postoperative complications, stone recurrence, and reoperation. This study aimed to report an 11-year experience in the management of postoperative recurrence of intrahepatic bile duct stones, analyze the causes of the reoperation, and establish appropriate surgical procedures.

MATERIALS AND METHODS

The records of 148 patients with postoperative recurrence of primary intrahepatic bile duct stones treated from January 2005 to December 2015 were retrospectively reviewed. Prior surgical treatment and postoperative data were analyzed to investigate possible causes of recurrence and reoperation.

RESULTS

All patients with a prior cholangiojejunostomy (n = 61) developed biliary stenosis (100%). Of the 86 patients without cholangiojejunostomy, 71 (82.56%) had abnormalities in the structure and function of the lower end of the common bile duct, and 86 had hilar and intrahepatic bile duct stenosis. Of all 148 patients, 136 (91.89%) had positive intraoperative bile cultures. Patients were treated with a modified surgical procedure, and the combined excellent and good rate of long-term outcomes reached 85.48% (106/124). The stone recurrence rate of the 124 patients decreased from 100% (124/124) of the prior operation to 5.65% (7/124) during the reoperation.

CONCLUSIONS

The pathogenesis of primary intrahepatic bile duct stones is associated with biliary infection and intrahepatic bile duct cholestasis. According to the etiology and pathogenic mechanism, surgical procedures that improve long-term outcomes and reduce postoperative recurrence include bile duct exploration with stone extraction, partial hepatectomy, hilar ductoplasty, and Roux-en-Y hepaticojejunostomy.

Endoscopic removal of common bile duct stones in nonagenarians: a tertiary centre experience

BACKGROUND/AIMS

There are few studies assessed the efficacy and mortality of endoscopic retrograde cholangiopancreatography (ERCP) for the removal of common bile duct (CBD) stones in the elderly aged ≥90 years. We aimed to assess the safety and efficacy of endoscopic removal of CBD stones in nonagenarians.

METHODS

We retrospectively reviewed ERCP reports for CBD stone removal. The endoscopic and therapeutic outcomes were collected. The length of stay (LOS), the total number of adverse events, and mortality rate were compared between groups.

RESULTS

A total of 125 nonagenarians were compared with 1,370 controls (65-89 years old individuals). The mean LOS for nonagenarians was significantly higher than in controls (13.6 days vs. 6.5 days). Completed intended treatment was similar in the nonagenarians and controls (89.8% and 89.5%, respectively). The overall complication rate did not differ between the groups. However, nonagenarians had a higher incidence of post-ERCP pneumonia (3.9%). None of the nonagenarians were readmitted to the hospital within 7 days. Four nonagenarians (3.2%) and 25 (1.8%) controls died within 30 days.

CONCLUSION

Advanced age alone did not affect the decision to perform the procedure. However, prompt diagnosis and treatment of post-ERCP pneumonia in nonagenarians could improve the outcomes and reduce mortality.

Bile Duct Stone Size May Influence the Efficacy of Endoscopic Sphincterotomy With or Without Large-Balloon Dilation: A Meta-Analysis

Purpose: Endoscopic sphincterotomy (EPT) combined with endoscopic papillary large balloon dilatation (EPBD) are used to remove large common bile duct (CBD) stones. This meta-analysis compared the efficacy and safety of EPT+EPBD versus EPT alone in the removal of stones based on stone size. Materials and Methods: Twenty-two studies (11 randomized control trials [RCTs] and 11 non-RCTs) were identified and reviewed based on searches of Embase, PubMed, and Web of Science. CBD stone's size was measured with reference to diameter of the duodenoscope (13 mm) and size of the large dilatation balloon (17 mm) seen on cholangiogram. The stone clearance rate, required mechanical lithotripsy (ML), procedure time, and pancreatitis were compared according to the mean stone size, and further divided into Groups A (small) 10-13 mm, B (medium) 13-17 mm, and C (large) >17 mm. Results: Subgroup analysis according to CBD stone size showed EPT + EPBD had a significantly better initial stone clearance rate than EPT in Groups B (odds ratio [OR] = 2.39, 95% confidence interval [CI]: 1.20-4.77) and C (OR = 3.05, 95% CI: 1.86-5.03), but not for Group A (OR = 1.41, 95% CI: 0.90-2.21). EPT+EPBD also required significantly less ML than EPT in Groups B (OR = 0.34, 95% CI: 0.15-0.77) and C (OR = 0.31, 95% CI: 0.13-0.73). EPT+EPBD had significantly shorter procedure time than EPT in Group B (standardized mean difference = -1.20, 95% CI: -2.08 to 0.32). In meta-regression analysis, Group B had a better OR in initial stone clearance rate and less ML usage rate correlation with the size of CBD stone, but not for Group C with larger stones. Conclusions: EPT+EPBD had a significantly better initial stone clearance rate, and required less ML with shorter procedure time than EPT for removing medium-sized CBD stones, but the efficacy was limited to large CBD stones. The study protocol and trial registration had been registered in PROSPERO (Registration No. CRD42020171689).

Morphological substantiation of ultrasonographic criteria of an acute cholecystitis and its paravesical complications

Objective. To improve quality of diagnosis of paravesical complications in patients, suffering an acute cholecystitis, using demonstration of interrelationship of changes in the gallbladder wall histostructure and its echogram data. Materials and methods. Comparative analysis of the gallbladder wall echogram and results of the gallbladder wall morphological investigation was conducted in 520 patients with an acute cholecystitis to determine the kind of paravesical complications. Results. Morphological investigation of the gallbladder wall have shown that the gallbladder dimensions and the wall thickness enhancement are not universal characteristic features for an acute cholecystitis. To determine the kind of its inflammation (phlegmonous, gangrenous or catarral) is also impossible. In accordance to ultrasonographic criteria an acute cholecystitis diagnosis is established, аnd patho-morphologist determines the inflammation form. Sclerotic processes with overgrowth of dense connective tissue were revealed in the gallbladder wall while presence of a long-term inflammatory process. That's why in the patients, suffering an acute cholecystitis, the gallbladder wall echograms may show excessively white signal with delineated contours, but at the same time the gallbladder volume may be not changed or even reduced. This data may impact the choice of operative procedure. Ultrasonographic signs of presence of paravesical infiltrate and abscess were established as well. Conclusion. Echographic changes of the gallbladder wall indicates its inflammation, but do not give possibility to find which form it has. The gallbladder volume may be reduced in an acute cholecystitis, if inflammation occurs on background of recurrent process. The gallbladder wall demonstrates excessively white positive echographic signal, if in its structure connective tissue and collagen fibers prevail.

Outcomes following common bile duct exploration versus endoscopic stone extraction before, during and after laparoscopic cholecystectomy for patients with common bile duct stones

BACKGROUND

Laparoscopic common bile duct exploration (LCBDE) and endoscopic retrograde cholangiopancreatography (ERCP) are two methods of retrieving common bile duct (CBD) stones. The best method for CBD stone removal is debatable. The aim of this study was to compare outcomes following LCBDE and/or ERCP, including laparoscopic cholecystectomy.

METHODS

Data were collected retrospectively for patients undergoing LCBDE and/or ERCP at a single centre from 2008 to 2018. Patients were grouped by intention-to-treat (single-stage LCBDE, pre-operative-, intra-operative-, or post-operative ERCP) and eventual plan (surgical or endoscopic). Outcomes included complication rates (minor Clavien-Dindo 1/2, major Clavien-Dindo 3/4, non-biliary complications) and mortality.

RESULTS

Of 671 patients, 578 patients received LCBDE and 93 patients received ERCP as primary care. Endoscopic clearance had significantly higher complications and mortality compared to surgical clearance. On an intention-to-treat basis LCBDE had the lowest minor-, major- and non-biliary complications, and mortality (5.2%, 6.1%, 2.9% and 0.5%, respectively), whilst pre-operative ERCP the worst (39.6%, 27.1%, 29.2% and 8.3%, respectively) (p=<0.001). LCBDE and postERCP had similar major complications and mortality.

CONCLUSION

Surgical clearance of CBD stones was potentially safer than endoscopic clearance. Pre-operative ERCP had the worst outcomes. LCBDE and postERCP are likely to have similar short-term patient outcomes.

Utilizing CT to identify clinically significant biliary dilatation in symptomatic post-cholecystectomy patients: when should we be worried?

PURPOSE

To determine a reliable threshold common duct diameter on CT, in combination with other ancillary CT and clinical parameters, at which the likelihood of pathology requiring further imaging or intervention is increased in post-cholecystectomy patients.

METHODS

In this IRB approved retrospective study, two attending radiologists independently reviewed CT imaging for 118 post-cholecystectomy patients, who were subsequently evaluated with MRCP, ERCP, or EUS, prompted by findings on the CT and clinical status. Measurements of the common duct (CD) were obtained at the porta hepatis, distal duct, and point of maximal dilation on axial and coronal CT scans. Patients were grouped by whether they required intervention after follow-up imaging. Pertinent baseline lab values and patient demographics were reviewed.

RESULTS

Of the 118 post-cholecystectomy patients, 38 patients (31%) required intervention, and 80 patients (69%) did not require intervention after follow-up imaging. For both readers, axial and coronal CD diameters were significantly higher in the 'intervention required' vs 'no intervention' groups at all locations (p value < 0.05). There was good to excellent inter-reader agreement at all locations (ICC 0.68-0.92). Pertinent baseline lab values including AST (p = 0.043), ALT (p = 0.001), alkaline phosphatase (p = 0.0001), direct bilirubin (p = 0.011), total bilirubin (p = 0.028), and WBC (p = 0.043) were significantly higher in the 'intervention required' group. CD thresholds of 8 mm yielded the highest sensitivities (76-95%), and CD thresholds of 12 mm yielded the highest specificities (65-78%). CD combined with bilirubin levels increased sensitivity and specificity, compared to using either feature alone.

CONCLUSION

Dilated CD on CT combined with bilirubin levels increases the sensitivity and specificity for identifying patients needing intervention. We recommend that a post-cholecystectomy patient who presents with a CD diameter > 10 mm on CT and elevated bilirubin levels should undergo further clinical and imaging follow-up.

The impact of endoscopic sphincterotomy incision size on common bile duct stone recurrence: A propensity score matching analysis

BACKGROUND/PURPOSE

The aim of this study is to clarify the relation between the incision size for endoscopic sphincterotomy (EST) and common bile duct stone (CBDS) recurrence.

METHODS

Patients who underwent elective endoscopic treatment for CBDS between January 2013 and December 2017 were enrolled, excluding those who met the exclusion criteria. The clinical characteristics were investigated using propensity score matching analysis.

RESULTS

A total of 243 patients were investigated. Propensity scores were calculated using multinomial logistic regression with five relevant variables (age, gender, follow-up time, maximum stone size, and bile duct diameter), which led to extraction of 188 cases to compose cohorts of the small and medium EST incision groups. The CBDS recurrence rate was 17.0% in the small incision group and 6.4% in the medium incision group. Multivariate analysis identified the medium incision as an independent predictor of CBDS recurrence (hazard ratio 0.350, 95% confidence interval 0.133-0.922, P = .034). The CBDS non-recurrence rate of the medium incision group was significantly higher than that of the small incision group (log-rank test P = .019).

CONCLUSIONS

Our findings suggest that the CBDS recurrence rate was lower in EST with medium incision size than with small incision size.

Combined surgical and intraoperative endoscopic rescue of a biliary incarcerated balloon dilator: a successful rescue in a fortunate patient

Background

Endoscopic papillary balloon dilatation (EPBD) is the second proposed maneuver for the endoscopic retrieval of common bile duct stones after endoscopic sphincterotomy (EST). Being less traumatic, EPBD is acknowledged for fewer procedure-related complications compared to (EST).

Case presentation

We present a 55-year-old lady, who was referred to the pancreato-biliary division, Gastrointestinal Endoscopy Unit, National Liver Institute, Menoufia University, for endoscopic management of a high likelihood of choledocholithiasis. Unfortunately, during the procedure, the balloon dilator was incarcerated inside the common bile duct (CBD) with failure of all endoscopic extraction trials. Because of the resultant cholangio-pancreatitis, the incarcerated inflated balloon had to be removed immediately. Open surgical rescue of the case in conjunction with the intraoperative endoscopic biliary stent deployment had made it possible to save the patient.

Conclusion

This case is one of the few reports of incarcerated balloon dilator during EPBD and failure of endoscopic retrieval, with subsequent acute pancreatitis/hepato-cholangitis, and gall bladder mucocele. Despite being a critical surgical candidate and owing to the attentive timely surgical intervention collaborated with the intra-operative endoscopic management, the case was fortunate.

The single-stage management of bile duct stones is underutilised: A prospective multicentre cohort study with a literature review

Backgrounds/Aims

Bile duct stones (BDS) can be managed either prior to laparoscopic cholecystectomy (LC) using endoscopic retrograde cholangiopancreatography (ERCP) or with laparoscopic bile duct exploration (LBDE) at the time of LC. The latter is underutilised. The aim of this study was to use the dataset of the previously performed CholeS study to investigate LBDE hospital volumes, LBDE-to-LC rates, and LBDE outcomes.

Methods

Data from 166 United Kingdom/Republic of Ireland hospitals were used to study the utilisation of LBDE in LC patients.

Results

Of 8,820 LCs performed, 932 patients (10.6%) underwent preoperative ERCP and 256 patients (2.9%) underwent LBDE. Of the 256 patients who underwent LBDE, 73 patients (28.5%) had undergone prior ERCP and 112 patients (43.8%) had undergone prior magnetic resonance cholangiopancreatography. Fifteen (9.0%) of the 166 included hospitals performed less than five LBDEs in the two-month study period. LBDEs were mainly performed by upper gastrointestinal surgeons (84.4%) and colorectal surgeons (10.0%). Eighty-seven percent of the LBDEs were performed by consultants and 13.0% were performed by trainees. The laparoscopic-to-open conversion rate was 12.5%. The median operation time was 111 minutes (range: 75-155 minutes). Median hospital stay was 6 days (range: 4-11 days) for emergency LBDEs and 1 day (range: 1-4 days) for elective LBDEs. Overall morbidity was 21.5%. Bile leak rate was 5.3%. Thirty-day readmission and mortality rates were 12.1% and 0.4%, respectively.

Conclusions

The single-stage approach to managing BDS was underutilised. An additional prospective study with a longer study period is needed to verify this finding.

Low Detection Rates of Bile Duct Stones During Endoscopic Treatment for Highly Suspected Bile Duct Stones with No Imaging Evidence of Stones

BACKGROUND

The revised American Society for Gastrointestinal Endoscopy (ASGE) guideline 2019 provides the high-risk criteria for suspected common bile duct stones (CBDSs).

AIMS

To evaluate CBDS detection rates during endoscopic retrograde cholangiopancreatography (ERCP) in high-risk patients with suspected CBDSs based on the ASGE guideline 2019.

METHODS

This multicenter retrospective study included 1100 consecutive patients who underwent ERCP for suspected CBDSs with any high-risk criteria based on the revised ASGE guideline 2019: Criterion 1, CBDSs on imaging; Criterion 2, clinical ascending cholangitis; and Criterion 3, total bilirubin exceeding 4 mg/dL and dilated common bile duct on imaging. We compared CBDS detection rates during ERCP based on individual and combined high-risk criteria.

RESULTS

The CBDS detection rates of patients who met any of the criteria, only Criterion 1, and Criteria 2 or 3 were 86.0% (946/1100), 93.4% (113/121), and 50.0% (106/212), respectively. In patients who met Criteria 1 and 2, 1 and 3, 2 and 3, and all criteria, CBDSs were confirmed during ERCP in 95.1% (490/515), 96.2% (25/26), 55.3% (26/47), and 98.4% (186/189), respectively. The CBDS detection rate during ERCP of patients with at least Criterion 1 significantly exceeded that of patients without at least Criterion 1 [95.7% (814/851) vs. 51.0% (132/259), respectively, P < 0.001].

CONCLUSIONS

Patients with CBDS visualization on imaging have very high CBDS detection rates during ERCP. However, performing ERCP on patients with only clinical predictors, such as cholangitis and dilated CBD with total bilirubin exceeding 4 mg/dL, often results in unnecessary ERCP.

Current approaches and questions yet to be resolved for the prophylaxis of post-endoscopic retrograde cholangiopancreatography pancreatitis

Prophylaxis is important for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP), which is the most common and serious complication of ERCP. Although the current guidelines include independent patient- and procedure-related risk factors for PEP and available PEP prophylactic measures, the synergistic effect of these risk factors on PEP should also be considered, given that patients often harbor multiple risk factors. Furthermore, a combination of prophylactic measures is often selected in clinical practice. However, established methods estimating the synergistic effect of independent risk factors on PEP incidence are lacking, and evidence on the impact of combining prophylactic measures on PEP should be discussed. Selection of appropriate candidate patients for ERCP is also important to reduce the incidence of PEP associated with unnecessary ERCP. ERCP indications in patients with asymptomatic common bile duct stones (CBDSs) and in those with suspected CBDSs with no imaging-based evidence of stones are controversial. Further studies are warranted to predict the synergistic effect of independent risk factors on PEP, determine the best prophylactic PEP measures, and identify appropriate candidates for ERCP in patients with asymptomatic CBDSs and those with suspected CBDSs.

Efficacy of intraoperative cholangiography versus preoperative magnetic resonance cholangiography in patients with intermediate risk for common bile duct stones

BACKGROUND

This is the first randomized trial to evaluate the efficacy of intraoperative cholangiography (IOC) and magnetic resonance cholangiopancreatography (MRCP) in patients with suspected CBDS.

METHODS

This unblinded, multicenter RCT was conducted at five swiss hospitals. Eligibility criteria were suspected CBDS. Patients were randomized to IOC and laparoscopic cholecystectomy (LC), followed by endoscopic retrograde cholangiopancreatography (ERCP) if needed, or MRCP followed by ERCP if needed, and LC. Primary outcome was length of stay (LOS), secondary outcomes were cost, stone detection, and complication rates.

RESULTS

122 Patients were randomised to the IOC Group (63) or the MRCP group (59). Median LOS for the IOC and the MRCP groups were 4 days IQR [3, 6] and [4, 6], with an estimated increase of LOS of 1.2 days in the MRCP group (p = 0.0799) in the linear model. Median cost in the IOC and MRCP groups were 10 473 Swiss Francs (CHF) and 10 801 CHF, respectively (p = 0.694). CBDS were found in 24 and 12 patients in the IOC and the MRCP groups, respectively (p = 0.0387). The complication rate did not differ between both groups.

CONCLUSION

There is equipoise between both pathways. IOC has a significantly higher diagnostic yield than MRCP.

TRIAL REGISTRATION

Clinicaltrials.gov identifier NCT02351492: Radiological Investigation of Bile Duct Obstruction (RIBO).

Primary closure combined with C-tube drainage through cystic duct after laparoscopic common bile duct exploration is safe and feasible for patients

OBJECTIVE

Biliary duct management is of great significance after laparoscopic cholecystectomy (LC) combined with laparoscopic common bile duct exploration (LCBDE) in the treatment of cholecystolithiasis accompanied with common bile duct (CBD) stones. This study is to evaluate the safety and effectiveness of primary closure with C-tube drainage through cystic duct after LC + LCBDE.

METHODS

Through a retrospective study, 290 patients who underwent LC + LCBDE in our hospital from January 2019 to April 2022 were enrolled and divided into 2 groups. 143 patients underwent primary closure with C-tube drainage through cystic duct (C-tube group) and the other 147 patients underwent traditional T-tube drainage (T-tube group). Personal information, perioperative examinations, surgical results, and follow-up results were collected and analyzed.

RESULTS

There were no significant differences in the average age, gender, the mean of CBD diameters and the rate of comorbidities (acute cholecystitis, obstructive jaundice, acute pancreatitis and acute cholangitis) between the two groups (P > 0.05). Hospital stay, postoperative hospital stay were significantly shorter in the C-tube group than T-tube group (P < 0.05). In addition, the average time of placing and removal the drainage tubes was significantly less than those of the T-tube group (P < 0.05). This study also showed significant differences in the incidence of postoperative abdominal infection and soft tissue infection in the two groups (P < 0.05). There were no significant differences in the incidence of postoperative complications including cholangitis, bile duct stenosis, mortality in two groups. There were also no significant differences between the two groups of the recurrence of CBD stones, reoperation and readmition in 30 days during the median follow-up of 6 months.

CONCLUSIONS

Compared with T tube drainage, patients with C-tube drainage after LC + LCBDE with primary closure of cystic duct recovered faster and had fewer complications. C-tube drainage is a safe and feasible treatment option for patients with cholecystolithiasis and choledocholithiasis.

The clinical effect of primary duct closure and T-tube drainage: A propensity score matched study

BACKGROUND

Although laparoscopic common bile duct exploration (LCBDE) is considered a safe and effective method for the removal of bile duct stones, selecting primary duct closure (PDC) or T-tube drainage (TTD) following choledochotomy remains controversial. This study aims to explore the clinical effects of PDC and TTD after LCBDE.

METHODS

We retrospectively analyzed clinical data of 348 patients with choledocholithiasis treated with LCBDE from January 2016 to October 2020. All patients were divided into PDC (225 cases) and TTD (123 cases) groups. Propensity score matching (PSM) was performed. We compared operative parameters and outcomes.

RESULTS

After matching (n = 116/group), no significant difference was observed between the two groups (P > 0.05) regarding intra-abdominal infection, incision infection, bile leakage, and retained stones. In terms of operation time, intraoperative blood loss, postoperative hospital stay, postoperative exhaust time, postoperative antibiotic use time, and postoperative abdominal drainage time, PDC group was obviously superior to TTD group (P < 0.05).

CONCLUSION

Primary closure following LCBDE is considered a safe and effective alternative to T-tube drainage.