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

Transductal versus transcystic laparoscopic common bile duct exploration: an institutional review of over four hundred cases

BACKGROUND

Many studies have failed to demonstrate significant differences between single- and two-staged approaches for the management of choledocholithiasis with concomitant gallstones in terms of post-operative morbidity. However, none of these studies paid specific attention to the differences between the methods of accessing the bile duct during laparoscopy. The aim of this study was to report outcomes of transcystic versus transductal laparoscopic common bile duct exploration (LCBDE) from our experience of over four hundred cases.

METHODS

Retrospective review of 416 consecutive patients who underwent LCBDE at a single-centre between 1998 and 2018 was performed. Data collected included pre-operative demographic information, medical co-morbidity, pre-operative investigations, intra-operative findings (including negative choledochoscopy rates, use of holmium laser lithotripsy and operative time) and post-operative outcomes.

RESULTS

Transductal LCBDE via choledochotomy was achieved in 242 patients (58.2%), whereas 174 patients (41.8%) underwent transcystic LCBDE. Stone clearance rates, conversion to open surgery and mortality were similar between the two groups. Overall morbidity as well as minor and major post-operative complications were significantly higher in the transductal group. The main surgery-related complications were bile leak (5.8% vs 1.1%, p = 0.0181) and pancreatitis (7.4% vs 0.6%, p = 0.0005). Median length of post-operative stay was also significantly greater in the transductal group.

CONCLUSION

This study represents the largest single study to date comparing outcomes from transcystic and transductal LCBDE. Where possibly, the transcystic route should be used for LCBDE and this approach can be augmented with various techniques to increase successful stone clearance and reduce the need for choledochotomy.

Laparoscopic common bile duct exploration for elderly patients with choledocholithiasis: a systematic review and meta-analysis

BACKGROUND

Laparoscopic common bile duct exploration (LCBDE) has been becoming more and more popular in patients with symptomatic choledocholithiasis. However, the safety and effectiveness of LCBDE in elderly patients with choledocholithiasis is still uncertain. This meta-analysis is aimed to appraise the safety and feasibility of LCBDE for elderly patients with choledocholithiasis.

MATERIALS AND METHODS

Studies comparing elderly patients and younger patients who underwent LCBDE for common bile duct stone were reviewed and collected from the PubMed, Medline, EMBASE, and Cochrane Library. Primary outcomes were stone clearance rate, overall complication rate, and mortality rate. Secondary outcomes were operative time, conversion rate, pulmonary complication, bile leakage, reoperation, residual stone rate, and recurrent stone rate.

RESULTS

Nine studies, including two prospective studies and seven retrospective studies, met the inclusion criteria. There were 2004 patients in this meta-analysis, including 693 elderly patients and 1311 younger patients. There was no statistically significant difference between elderly patients and younger patients regarding stone clearance rate (OR 0.73; 95% CI 0.42-1.26; p = 0.25), overall complication rate (OR 1.31; 95% CI 0.94-1.82; p = 0.12), and mortality rate (OR 2.80; 95% CI 0.82-9.53; p = 0.10). Similarly, the operative time, conversion rate, bile leakage, reoperation, residual stone rate, and recurrent stone rate showed no significant difference between two groups (p > 0.05). While elderly patients showed high risk for pulmonary complication (OR 4.41; 95% CI 1.78-10.93; p = 0.001) compared with younger patients.

CONCLUSION

Although there is associated with higher pulmonary complication, LCBDE is still considered as a safe and effective treatment for elderly patients with choledocholithiasis.

Safety and long-term outcomes of endoscopic papillary balloon dilation for removal of common bile duct stones

BACKGROUND

Endoscopic papillary balloon dilation (EPBD) is an effective treatment for common bile duct stones (CBDSs), but there have been few evaluations on its safety and long-term outcomes.

AIM

To assess the safety and long-term outcomes of EPBD in the treatment of CBDSs.

METHODS

The clinical data of patients who underwent CBDSs removal by EPBD from January 2014 to December 2015 at our hospital were reviewed. The main outcomes were stone clearance, endoscopic retrograde cholangiopancreatography (ERCP)-related complications, and stone recurrence.

RESULTS

A total of 42 patients with CBDSs who underwent EPBD at our hospital were reviewed. The overall successful CBDSs clearance was 100%. ERCP-related complications occurred in four ERCP procedures, all of which were pancreatitis. There was no perforation, bleeding, or cholangitis. Ten (23.8%) of forty-two patients had CBDSs recurrence after a mean period of 51.8 mo (18-66 mo) from the end of EPBD. Female gender (odds ratio = 22.891, 95% confidence interval: 1.544-339.362, P = 0.023) was significantly related to stone recurrence.

CONCLUSION

EPBD is safe and effective in the removal of CBDSs. Female gender may be a risk factor for stone recurrence in a long term.

Emergent Treatment of Acute Cholangitis and Acute Cholecystitis

Acute pathology of the biliary tract including cholangitis and cholecystitis can lead to biliary sepsis if early decompression is not performed. This article provides an overview of the presenting signs and symptoms and role of interventional radiology in the management of patients with acute cholangitis or acute cholecystitis. It is especially important to understand the role of IR in the context of other treatment options including medical management, endoscopy, and surgery.

Biliary spontaneous dislodgement spiral stent for patients who underwent mechanical lithotripsy

BACKGROUND

The incidence of post-endoscopic retrograde cholangiopancreatography (ERCP) cholangitis (PEC) in patients who underwent mechanical lithotripsy (ML) for large stone removal is high (up to 13.3%). One of the main causes is remaining small fragments or sludge that can impair normal biliary drainage. Endoscopic placement of a nasobiliary tube or a conventional plastic biliary stent has been commonly used under such conditions, but the patient may suffer from significant discomfort after the placement of a nasobiliary tube, while additional endoscopy is required for stent removal. We developed a biliary spontaneous dislodgement spiral stent (BSDSS) to overcome those shortcomings.

AIM

To evaluate the feasibility, safety, and effectiveness of inserting a BSDSS for patients who underwent ML for large stone removal.

METHODS

We conducted a single-center, retrospective, cohort study at West China Hospital, Sichuan University. A total of 91 consecutive patients with large biliary stones (≥ 10 mm) in the common bile duct who underwent ML between November 2017 and July 2018 were included. The 49 eligible patients were divided into the BSDSS group and the nasobiliary tube group. Technical success, post-ERCP adverse events (including PEC, post-ERCP pancreatitis, stone recurrence, BSDSS retention, self-extraction and dislocation of the nasobiliary tube), drainage time, and postoperative stay were measured and compared.

RESULTS

Twenty-one patients in the BSDSS group and 28 patients in the nasobiliary tube group were included in the analyses. The baseline characteristics and clinical information were similar in the two groups. Insertions of BSDSS and nasobiliary tube were technically successful in all 49 patients. There was no significant difference in the incidence of overall post-ERCP adverse events between the two groups (4.8% in the BSDSS group vs 17.9% in the nasobiliary tube group, P = 0.219). The median duration of drainage time (3 d in the BSDSS group vs 4 d in the nasobiliary tube group) and length of postoperative stay (4 d in the BSDSS group vs 5 d in the nasobiliary tube group) also did not differ (P = 0.934, and P = 0.223, respectively).

CONCLUSION

Endoscopic placement of a BSDSS appears to be feasible, safe and effective for patients who underwent ML for large stone removal.

Endoscopic treatment for choledocholithiasis in asymptomatic patients

BACKGROUND AND AIM

A few small retrospective studies recently found that endoscopic retrograde cholangiopancreatography (ERCP) in asymptomatic compared with symptomatic common bile duct stones (CBDSs) patients appeared to increase the risk of post-ERCP pancreatitis (PEP). This study aimed to determine the risk of ERCP in asymptomatic CBDS patients.

METHODS

A total of 327 consecutive patients with native papilla were invited to participate into the study and divided into two groups: 53 in the asymptomatic group and 274 in the symptomatic group, who underwent CBDS removal by ERCP. Patient's characteristics and outcomes were analyzed.

RESULTS

A total of 46 (14.1%) patients had ERCP-related complications, including PEP, cholangitis, perforation, and bleeding. The overall complication rate in the asymptomatic group was higher than in the control group (26.4% vs 11.7%, P < 0.01). PEP was the most common complication (30/327, 9.2%). Of the 30 cases of PEP, 25 (83.3%) were mild, and the severity in both groups was similar (9/1/1 vs 16/2/1, P > 0.05). The incidence rate of PEP in the asymptomatic group was higher than in the symptomatic group (20.8% vs 6.9%, P < 0.01). Multivariate regression analysis identified asymptomatic CBDSs (odds ratio = 0.241, 95% confidence interval: 0.092-0.628) as being independently associated with PEP occurrence.

CONCLUSION

Asymptomatic CBDSs were associated with increased incidence of PEP compared with symptomatic CBDSs.

Efficacy and safety of therapeutic ERCP in patients with ectopic papilla of Vater

It remains challenging for endoscopists to manage pancreaticobiliary diseases in patients with ectopic papilla of Vater by endoscopic retrograde cholangiopancreatography (ERCP). The present study sought to evaluate the efficacy and safety of ERCP for this issue.Consecutive patients with ectopic papilla of Vater who underwent initial ERCP due to pancreaticobiliary diseases were retrospectively analyzed.One hundred seven patients with ectopic papilla of Vater were included. The success rate of cannulation was 83.2%. Endoscopic sphincterotomy, endoscopic papillary balloon dilation, and mechanical lithotripsy were performed in 12 (11.2%), 25 (23.4%), and 1 (0.9%) patients, respectively. The technical success rate was 83.2%; of these, endoscopic nasobiliary drainage, endoscopic retrograde biliary drainage, endoscopic retrograde pancreatic drainage, and stone extraction was conducted in 61 (57.0%), 17 (15.9%), 5 (4.7%), and 45 (42.1%) patients, respectively. Bile duct stone size ≥1 cm, number ≥2, and duodenum stenosis were risk factors for stone extraction inability. Adverse events occurred in 20 (18.7%) patients, including post-ERCP pancreatitis (3.7%), hyperamylasemia (12.1%), and infection of biliary tract (2.8%); all of the adverse events were mild and alleviated by conventional therapies.ERCP is an appropriate choice for pancreaticobiliary diseases in patients with ectopic papilla of Vater due to its high efficacy and safety. Bile duct stone size ≥1 cm, number ≥2, and duodenum stenosis increase difficulties for stone extraction.

Natural history of asymptomatic bile duct stones and association of endoscopic treatment with clinical outcomes

BACKGROUND

Due to increasing opportunities for abdominal imaging studies, bile duct stones are occasionally diagnosed without any symptoms. However, there has been no consensus on the management of asymptomatic bile duct stones. We conducted a retrospective longitudinal cohort study to investigate the natural history of asymptomatic bile duct stones and clinical outcomes according to the timing of endoscopic removal.

METHODS

We identified consecutive patients who were diagnosed with asymptomatic common bile duct stones and categorized into those who were followed up with stones in situ (wait-and-see group) and those who received early endoscopic stone removal (intervention group). Cumulative incidence functions of biliary complications were estimated and compared between the groups.

RESULTS

We included 191 patients (114 patients in the wait-and-see group and 77 patients in the intervention group). In the wait-and-see group, the cumulative incidence of biliary complications was 6.1% at 1 year, 11% at 3 years, and 17% at 5 years. Asymptomatic disappearance of stones was observed in 22 patients (19%). Procedure-related adverse events of early endoscopic stone removal of asymptomatic stones were observed in 25 (32%) patients including 4 (5.2%) with severe pancreatitis. The cumulative incidence function of biliary complications did not differ by treatment strategies (P = 0.55).

CONCLUSIONS

Biliary complications occurred in a substantial proportion of patients with asymptomatic bile duct stones, but early endoscopic removal appeared to have little effect on the prevention of further biliary complications. Given the risk of procedure-related pancreatitis, the wait-and-see strategy may become a management option of asymptomatic stones.

Needle-knife fistulotomy vs. standard biliary sphincterotomy for choledocholithiasis: common bile duct stone recurrence and complication rate

Background and study aims  With common bile duct (CBD) stones, access to the CBD can be achieved through the papilla orifice followed by standard biliary sphincterotomy (SBS), or through precut fistulotomy (PF) in case of difficult cannulation. The two methods alter papilla anatomy differently, potentially leading to a different rate of stone recurrence. No data have been published on stone recurrence after PF in patients with CBD stones. The aim of this study was to evaluate CBD stone recurrence, reintervention rate after PF versus SBS, and complications. Patients and methods  This was a retrospective single-center cohort study including patients undergoing for the first time endoscopic retrograde cholangiopancreatography (ERCP) for CBD stones with PF in case of failed repeated cannulation attempts, matched for sex/age to patients with SBS randomly extracted from our database. T -test and Fisher's tests were used for continuous and categorical variable comparison. Recurrence probability was calculated with Kaplan-Meier curve. Factors associated with ERCP repetition were evaluated with logistic regression through a Cox's proportional hazards model. Results  Eighty-five patients with PF were included, with 85 matched controls (mean age 68.7 years, 45.9 % males). Overall, patients with PF had the same reintervention rate as those with SBS (14.1 % vs. 12.9 %) with a hazard ratio (HR) of 1.11 (95 % CI 0.49 - 2.50; P  = 0.81), but mean time to reintervention was significantly lower (74.9 ± 74.6 vs. 765.6 ± 961.3 days; P  < 0.0001), with 100 % of stones recurring within the first year in the PF group vs. 54.5 % in the SBS group ( P  = 0.01). The only factor associated with ERCP repetition risk was incomplete CBD clearing. Complications, including pancreatitis, did not differ significantly. Conclusions  The reintervention rate was significantly higher in the short term after PF. Therefore, closer follow-up in the first 6 to 12 months after ERCP might be appropriate for patients underoing PF.

Protocol for the CREST Choles (Chinese REgistry Study on Treatment of Cholecysto-Choledocholithiasis) study: an ambispective, multicenter, observational, open-cohort study

INTRODUCTION

The best approach for choledocholithiasis remains a matter of debate. Choledocholithiasis is usually treated with endoscopic sphincterotomy (EST), laparoscopic common bile duct exploration (LCBDE) or laparoscopic transcystic common bile duct exploration (LTCBDE). Data pertaining to the clinical outcomes of these approaches in the management of patients with cholecysto-choledocholithiasis in China are limited. An analysis of the economic burden associated with these treatments is lacking. The Chinese REgistry Study on the Treatment of Cholecysto-Choledocholithiasis (CREST Choles) was designed to address these issues in a real-world setting.

METHODS AND ANALYSIS

CREST Choles was an ambispective, multicenter, observational, open-cohort study. A total of 2700 patients undergoing one of the three treatments (EST+laparoscopic cholecystectomy (LC), LCBDE+LC and LTCBDE+LC) during the period from 1 January 2013 to 1 December 2018 at participating centres were enrolled in the study. Patients with gallstones and confirmed common bile duct stones were included. Data pertaining to demographics, disease history, procedural details, imaging features and follow-up were collected. Follow-up was conducted at least 6 months after enrolment in the study and annual follow-up will be conducted until December 2020. The primary outcome is the rate of adverse outcomes within 3 years postoperatively. Economic analysis (eg, incremental cost-effectiveness ratio) would be performed to compare expense across treatments.

ETHICS AND DISSEMINATION

Ethical approval was obtained at all participating centres. The registry presented is the first attempt to comprehensively evaluate the cost of treatment for cholecysto-choledocholithiasis in China. Findings are expected to be available in 2020 and will facilitate clinical decision making in such cases.

TRIAL REGISTRATION NUMBER

NCT02554097.

Risk factors for the development of post-endoscopic retrograde cholangiopancreatography pancreatitis in patients with asymptomatic common bile duct stones

BACKGROUND

Previous studies have revealed that patients with asymptomatic common bile duct (CBD) stones are at a high risk of developing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). However, no studies to date have addressed the risk factors for PEP in patients with asymptomatic CBD stones.

AIM

To examine the risk factors for PEP in patients with asymptomatic CBD stones.

METHODS

Using medical records of three institutions in Japan for 6 years, we identified a total of 1135 patients with choledocholithiasis including 967 symptomatic patients and 168 asymptomatic patients with native papilla who underwent therapeutic ERCP. We performed univariate and multivariate analyses to examine the risk factors for PEP in the 168 patients with asymptomatic CBD stones.

RESULTS

The overall incidence rate of PEP in all the patients with during study period was 4.7% (53/1135). Of the 168 patients with asymptomatic CBD stones, 24 (14.3%) developed PEP. In univariate analysis, precut sphincterotomy (P = 0.009) and biliary balloon sphincter dilation (P = 0.043) were significant risk factors for PEP. In multivariate analysis, precut sphincterotomy (P = 0.002, 95%CI: 2.2-27.8, odds ratio = 7.7), biliary balloon sphincter dilation (P = 0.015, 95%CI: 1.4-17.3, odds ratio = 4.9), and trainee endoscopists (P = 0.048, 95%CI: 1.01-8.1, odds ratio = 2.9) were significant risk factors for PEP.

CONCLUSION

ERCP for asymptomatic CBD stones should be performed by experienced endoscopists. When performing precut sphincterotomy or biliary balloon sphincter dilation in patients with asymptomatic CBD stones, the placement of a prophylactic pancreatic stent is strongly recommended to prevent PEP.

Post-endoscopic retrograde cholangiopancreatography pancreatitis in single-stage endoscopic common bile duct stone removal

Background and Aims

Papillary treatment, such as endoscopic sphincterotomy or endoscopic papillary balloon dilation, and subsequent single-stage endoscopic stone removal are often performed for choledocholithiasis; however, the incidence of postendoscopic retrograde cholangiopancreatography pancreatitis (PEP) is unclear. This study aimed to compare the overall incidence of PEP between single- and two-stage stone removal groups and the incidence of PEP between these two groups based on cannulation time.

Methods

We included 897 patients with native papilla who underwent papillary treatment and stone removal for choledocholithiasis with no inflammation or mild-to-moderate acute cholangitis at three institutions between April 2012 and March 2018 in Japan. We performed a propensity-matched analysis and regression adjustment by propensity score to adjust for potential confounding factors.

Results

In the propensity-matched analysis with 234 pairs, there was no significant difference in the overall incidence of PEP between single- and two-stage stone removal procedures (15/234, 6.4% vs 6/234, 2.6%, P = 0.072, respectively). Although single-stage stone removal after a cannulation time of ≤15 min was not a significant risk factor of PEP, the procedure after a cannulation time of >15 min was a significant risk factor of PEP as estimated by regression adjustment by propensity score (P = 0.014, 95% CI = 1.4-19.4, odds ratio = 5.2).

Conclusions

Single-stage endoscopic stone removal after a long cannulation time of >15 min increased the incidence of PEP compared with the two-stage stone removal procedure. Thus, single-stage stone removal should be performed in patients with a cannulation time ≤ 15 min.

Multiple recurrences after endoscopic removal of common bile duct stones: A retrospective analysis of 976 cases

BACKGROUND AND AIM

Recurrences after endoscopic treatment of common bile duct stones (CBDS) are common. The aims of this study were to identify risk factors for recurrences of CBDS and to evaluate the effect of interventions for prevention of further recurrences.

METHODS

A total of 976 patients who underwent endoscopic treatment of CBDS were retrospectively studied. Risk factors for single and multiple recurrent CBDS were evaluated using a Cox hazard regression model. The incidences of further recurrences were evaluated according to the additional interventions.

RESULTS

The mean age was 69.3 years, and 39.3% were female. Endoscopic papillary balloon dilation, endoscopic sphincterotomy, and endoscopic papillary large balloon dilation were performed in 858, 77, and 41 patients, respectively. The rates of one or more recurrence and multiple recurrences of CBDS were 12.4% and 2.7%, respectively. In the multivariate analyses, the significant risk factors were the bile duct size (hazard ratio [HR] 1.07, P = 0.012), gallbladder left in situ with stones (HR 1.91, P = 0.046), and pneumobilia after treatment (HR 2.10, P = 0.047) for single recurrence and the number of stones at the first recurrence (HR 1.16, P = 0.021) for multiple recurrences. In five out of nine cases with multiple recurrences, further recurrence was not observed after additional sphincteroplasty in addition to cholecystectomy.

CONCLUSIONS

The incidence of multiple recurrences was not uncommon after the first recurrence of CBDS.

Acute Pancreatitis Task Force on Quality: Development of Quality Indicators for Acute Pancreatitis Management

INTRODUCTION

Detailed recommendations and guidelines for acute pancreatitis (AP) management currently exist. However, quality indicators (QIs) are required to measure performance in health care. The goal of the Acute Pancreatitis Task Force on Quality was to formally develop QIs for the management of patients with known or suspected AP using a modified version of the RAND/UCLA Appropriateness Methodology.

METHODS

A multidisciplinary expert panel composed of physicians (gastroenterologists, hospitalists, and surgeons) who are acknowledged leaders in their specialties and who represent geographic and practice setting diversity was convened. A literature review was conducted, and a list of proposed QIs was developed. In 3 rounds, panelists reviewed literature, modified QIs, and rated them on the basis of scientific evidence, bias, interpretability, validity, necessity, and proposed performance targets.

RESULTS

Supporting literature and a list of 71 proposed QIs across 10 AP domains (Diagnosis, Etiology, Initial Assessment and Risk Stratification, etc.) were sent to the expert panel to review and independently rate in round 1 (95% of panelists participated). Based on a round 2 face-to-face discussion of QIs (75% participation), 41 QIs were classified as valid. During round 3 (90% participation), panelists rated the 41 valid QIs for necessity and proposed performance thresholds. The final classification determined that 40 QIs were both valid and necessary.

DISCUSSION

Hospitals and providers managing patients with known or suspected AP should ensure that patients receive high-quality care and desired outcomes according to current evidence-based best practices. This physician-led initiative formally developed 40 QIs and performance threshold targets for AP management. Validated QIs provide a dependable quantitative framework for health systems to monitor the quality of care provided to patients with known or suspected AP.

How to choose the most appropriate technique for the single-stage treatment of cholecysto-choledocolithiasis?

BACKGROUND

We utilized transcystic clearance and intra-operative papillotomy through a rendezvous technique for the treatment of cholecysto-choledocolithiasis. The goal of this study was to evaluate the reliability of pre-operative parameters to address the most suitable surgical procedure.

METHODS

A total of 180 patients affected by calculi of the gallbladder and bile duct underwent the single-stage treatment. According to several pre-operative parameters, 141 patients had to supposedly undergo transcystic clearance of the bile duct, while 39 patients had to be treated with the rendezvous technique. All patients were treated with the sequential procedure: first, we tried the transcystic procedure and, if there was a failure, we used a rendezvous technique. We prospectively analysed each group based on a series of variables such as sex, age, operative time, success rate of proposed treatment, conversion rate, post-operative complications and hospital stay.

RESULTS

Transcystic clearance was successful in 134 out of 141 patients (95.0%), while 2 patients needed to undergo a laparo-endoscopy procedure (failure). Thirty-five out of 39 patients (89.7%) obtained common bile-duct (CBD) clearance through the rendezvous technique, while 1 patient obtained clean-up through the simple transcystic procedure (failure). Five out of 141 patients with transcystic clearance and 3 out of 39 patients with the rendezvous technique underwent laparotomy CBD clearance with conversion rates of 3.5% and 7.7%, respectively. Post-operative complications showed similar percentages for both procedures. However, the surgical time turned out to be longer for the rendezvous technique.

CONCLUSIONS

The one-stage procedure for the treatment of cholecysto-choledocolithiasis was possible in 94% of the cases utilizing a surgical technique selected according to the patient's case history. The pre-operative parameters, such as jaundice, CBD diameters and stone diameters, have certified their reliability as good predictors of the most suitable procedure to follow.

A novel gallbladder umbrella stent (the Shai™ Stent) for prevention of stone migration and impaction: results on feasibility and short-term safety in a porcine model

BACKGROUND AND AIMS

Cholelithiasis is the most common biliary tract disorder. Surgery is the treatment of choice for symptomatic gallstones. Aims of this study were to investigate the feasibility and short-term safety of a new endoscopic procedure with a specially designed Nitinol gallbladder stent for blockage of gallstone migration, the Shai™ Stent. The Shai stent is designed to enable free bile flow, which will be supposed to prevent recurrent attacks.

METHODS

The Shai™ Stent was inserted into the gallbladder during a standard ERCP procedure using a conventional metal stent delivery system. The aim of the present study was to investigate the feasibility and safety of insertion and deployment and removal of the stent into the gallbladder of pigs. In addition, the short-term safety of the stent was evaluated.

RESULTS

Fifteen stents were placed in the gallbladder of 15 pigs. Mean procedure time was 25 min (15-37). The maximum follow-up before sacrifice was 42 days. The stent in 1 pig had migrated at the 42 days follow-up but there were no macroscopic changes in its gallbladder or other organs. The stent remained in place in the remaining 12 pigs at autopsy, and the gallbladder and bile ducts were macroscopically normal. Stent removal was easily done in two pigs immediately after placement.

CONCLUSIONS

Correct placement and removal of the Shai™ Stent in the gallbladder is safe and feasible in pigs. Further clinical trials are warranted to confirm these results and to effectively evaluate the capability of this stent as an innovative biotechnology to block gallstones from migration and impaction.

T-tube-free single-incision laparoscopic common bile duct exploration plus cholecystectomy: a single centre experience

BACKGROUND

The present study aimed to explore the indications and feasibility of T-tube-free trans-umbilical single-incision laparoscopic common bile duct exploration (SILCBDE) plus laparoscopic cholecystectomy (LC) for treating choledocholithiasis.

METHODS

Patients hospitalized in the Second Affiliated Hospital (Shengjing Hospital) of China Medical University from January 2010 to January 2017 with the diagnosis of common bile duct stones and treated with T-tube-free trans-umbilical single-incision LC plus common bile duct exploration were retrospectively analysed.

RESULTS

A total of 37 male/female choledocholithiasis patients (mean age 65 years, range 29-86) were treated with T-tube-free trans-umbilical SILCBDE plus LC. No intraoperative complication or conversion to open surgery occurred in any of the cases. The mean operative time was 99.8 min (range 84-125) for endoscopic nasobiliary drainage group (n = 6), 113.8 min (range 70-150) for endoscopic retrogradebiliary drainage group (n = 2), 131.1 min (range 75-161) for pigtail J-tube group (n = 24), 113.7 min (range 100-150) for primary closure group (n = 5). The mean post-operative hospital stay length was 5.5 days (range 4-7) for endoscopic nasobiliary drainage group, 12.5 days (range 10-15) for endoscopic retrogradebiliary drainage group, 6.5 days (range 4-10) for J-tube group, 5.8 days (range 4-9) for primary closure group. Pancreatitis, bile leakage and peritonitis were not presented in any of the group. After 17-101 months follow-up, three patients presented recurrent common bile duct stones.

CONCLUSION

In selected cases, T-tube-free trans-umbilical SILCBDE plus LC is feasible and safe for experienced surgeons, and can achieve similar therapeutic effects as common LC plus common bile duct exploration procedures.

Post-endoscopic retrograde cholangiopancreatography pancreatitis in patients with asymptomatic common bile duct stones

BACKGROUND AND AIM

For asymptomatic common bile duct (CBD) stones, removal by endoscopic retrograde cholangiopancreatography (ERCP) is recommended in available guidelines. However, few studies have reported the risk of post-ERCP pancreatitis (PEP), which is the most common and serious ERCP-related complication for asymptomatic CBD stones. We performed a propensity score matching analysis to examine the risk of PEP in therapeutic ERCP for asymptomatic CBD stones.

METHODS

Information from medical databases of three institutions in Japan was collected over 6 years to identify 1113 patients with native papilla who underwent therapeutic ERCP for choledocholithiasis (excluding biliary pancreatitis). We compared the risk of PEP between asymptomatic and symptomatic groups by performing one-to-one propensity score matching.

RESULTS

PEP was present in 52 (4.7%) of the 1113 patients overall. Of the 949 symptomatic patients, 28 (3.0%) had PEP, and of the 164 asymptomatic patients, 24 (14.6%) had PEP. The incidence of PEP was significantly higher in the asymptomatic group than in the symptomatic group (3.0% vs 14.6%; P < 0.001, odds ratio = 5.6). Of the 158 propensity score-matched symptomatic patients, five (3.2%) had PEP. In contrast, of the 158 propensity score-matched asymptomatic patients, 24 (15.2%) had PEP. Propensity score matching analysis revealed that the risk of PEP increased significantly in the asymptomatic group compared with the symptomatic group (3.2% vs 15.2%; P < 0.001, odds ratio = 5.5).

CONCLUSIONS

ERCP for asymptomatic CBD stones had a high risk of PEP. Endoscopists should explain in detail the risk of PEP to patients, especially those with asymptomatic CBD stones.

Single-operator cholangioscopy for the treatment of concomitant gallbladder stones and secondary common bile duct stones

BACKGROUND AND AIM

This study aims to assess the clinical validity and safety of single-operator cholangioscopy system (SOCS) for the treatment of concomitant gallbladder stones and secondary common bile duct (CBD) stones.

METHODS

This retrospective study included 10 consecutive patients who had small-sized stones (< 1 cm) in both the gallbladder and CBD; the patients underwent SOCS treatment from June 2016 to December 2016. The clinical validity of this minimally invasive surgery was determined by the operation success rate, stone removal rate, postoperative hospital stay, hospitalization cost, and contrast images before and after the operation. The clinical safety was evaluated by perioperative complications and outcomes, gallbladder stone recurrence, and gallbladder contractility function.

RESULTS

Both the technique success rate and the stone removal rate when using SOCS was 100%. There were no serious complications that occurred during the operation; three patients developed acute cholecystitis, and four patients underwent hyperamylasemia after the surgery. The average postoperative hospital stay was 5.8 ± 1.32 days, and the average hospitalization cost was 7466 ± 566.1 dollars. In the follow-up period, which ranged from 3 to 8 months, there was no stone residuals or recurrences in the gallbladder and CBD, and no patient showed a recurrence of biliary colic. In addition, the gallbladder contractility function was proven to be normal within 3 to 6 months after the operation.

CONCLUSIONS

SOCS could successfully manage concomitant gallbladder stones and secondary CBD stones and precisely protect normal biliary function.

Endoscopic papillary large balloon dilation without sphincterotomy for users of antithrombotic agents: A multicenter retrospective study

BACKGROUND AND AIM

With an aging population, an increasing number of individuals on antithrombotic agents are diagnosed with large bile duct stones. Studies have shown the effectiveness of endoscopic papillary large balloon dilation (EPLBD) for removal of large bile duct stones. EPLBD without endoscopic sphincterotomy (EST) may reduce the risk of procedure-related bleeding, but the safety of this procedure for users of antithrombotic agents remains unclear.

METHODS

In this multicenter retrospective study, we included patients who underwent EPLBD without EST for bile duct stones between March 2008 and December 2017. We compared adverse events and other clinical outcomes between users and non-users of antithrombotic agents (antiplatelet agents and anticoagulants).

RESULTS

We analyzed a total of 144 patients (47 users and 97 non-users of antithrombotic agents). Among the users, the agents were continued in 13% and were replaced with heparin in 62% during the periprocedural period. We did not observe clinically significant bleeding and thrombotic events irrespective of the use of antithrombotic agents. Overall rate of early adverse events did not differ between users and non-users (6.4% and 7.2%, P = 0.99). Procedural outcomes did not differ between the groups (necessity for lithotripsy, 28% vs. 29%; and complete stone removal in a single session, 72% vs. 71%, for users and non-users, respectively).

CONCLUSIONS

Endoscopic papillary large balloon dilation without EST may be done without a substantial increase in procedure-related bleeding for users of antithrombotic agents. A larger study is required to refine the management strategy for those agents during the periprocedural period.

Safety and efficacy of percutaneous transhepatic balloon dilation in removing common bile duct stones: A systematic review

BACKGROUND

Endoscopic sphincterotomy (EST) is widely regarded as the first choice in the management of common bile duct (CBD) stones. However, for some patients, this treatment is not possible. The percutaneous transhepatic balloon dilation (PTBD) technique has been suggested as an alternative but has yet to gain wide acceptance.

AIM

To review cases of PTBD for removing CBD stones and explore the safety and efficacy of this treatment.

METHODS

We conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched EMBASE, PubMed, and Web of Science for cases of PTBD that underwent CBD stone removal from 1981 to January 2019. We analyzed all relevant articles available in full text. We extracted data on patient’s age, gender, overall technique success rate, reasons for technique failure, and the presence and type of major and minor complications. We analyzed the data and reported the results in a table and text. Altogether, we retrieved 12 case series and 6 case reports, for a total of 1347 patients. Thirty cases were excluded due to a lack of patient data.

RESULTS

The overall technique success rate for removing a CBD stone was 98.5% (1327/1347) and 98.1% (109/111) for removing concurrent CBD and gallbladder stones. Based on available data (n = 1312), mean age of all patients (687 males and 625 females) was 68.9 years. The total number of procedures in the remaining 1317 patients (after exclusion) was 3237 (average 2.4 procedures per patient). The total number of failures for eliminating a CBD stone was 20, and the reasons for failure included: Stone impaction (n = 10), intrahepatic bile duct stricture (n = 5), large stone (n = 2), severe CBD dilation (n = 1), multiple stones (n = 1), and duodenal perforation (n = 1). Various major complications related to the procedure were reported, but the incidence rate was low (1.4%). No pancreatitis or procedure related mortality was reported. Minor complications including transient hyperamylasemia, nausea, vomiting, abdominal pain, fever, and mild hemobilia were reported. For 218 patients (88 patients with unsuccessful endoscopic removal due to anatomical change and large or impacted stone and 130 cases who refused endoscopic procedure due to poor general condition or other additional disease), the CBD stones were successfully pushed into the duodenum by performing the PTBD procedure.

CONCLUSION

PTBD is a safe and effective approach in the nonoperative management of CBD stones. PTBD provides an alternative treatment when endoscopic procedures fail or are unsuitable for the patient.

Percutaneous transhepatic cholangioscopy and lithotripsy in treating difficult biliary ductal stones: Two case reports

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is preferred for managing biliary obstruction in patients with bilio-enteric anastomotic strictures (BEAS) and calculi. In patients whose duodenal anatomy is altered following upper gastrointestinal (UGI) tract surgery, ERCP is technically challenging because the biliary tree becomes difficult to access by per-oral endoscopy. Advanced endoscopic therapies like balloon-enteroscopy or rendevous-ERCP may be considered but are not always feasible. Biliary sepsis and comorbidities may also make these patients poor candidates for surgical management of their biliary obstruction.

CASE SUMMARY

We present two 70-year-old caucasian patients admitted as emergencies with obstructive cholangitis. Both patients had BEAS associated with calculi that were predominantly extrahepatic in Patient 1 and intrahepatic in Patient 2. Both patients were unsuitable for conventional ERCP due to surgically-altered UGl anatomy. Emergency biliary drainage was by percutaneous transhepatic cholangiography (PTC) in both cases and after 6-weeks’ maturation, PTC tracts were dilated to perform percutaneous transhepatic cholangioscopy and lithotripsy (PTCSL) for duct clearance. BEAS were firstly dilated fluoroscopically, and then biliary stones were flushed into the small bowel or basket-retrieved under visualization provided by the percutaneously-inserted video cholangioscope. Lithotripsy was used to fragment impacted calculi, also under visualization by video cholangioscopy. Satisfactory duct clearance was achieved in Patient 1 after one PTCSL procedure, but Patient 2 required a further procedure to clear persisting intrahepatic calculi. Ultimately both patients had successful stone clearance confirmed by check cholangiograms.

CONCLUSION

PTCSL offers a pragmatic, feasible and safe method for biliary tract clearance when neither ERCP nor surgical exploration is suitable.

T-Tube Use After Laparoscopic Common Bile Duct Exploration

Background and Objectives:

Laparoscopic common bile duct exploration (LCBDE) has been verified to be an effective technique in treating choledocholithiasis, and T-tube insertion has been widely performed after LCBDE. With growing doubts regarding the effectiveness and safety of T-tube drainage (TTD), it has been suggested to replace such with primary duct closure (PDC). This meta-analysis aimed to evaluate the short- and long-term effectiveness and safety of PDC compared with TTD after LCBDE.

Methods:

The PubMed, Science Citation Index, and Cochrane Central Register of Controlled Trials databases were used to accomplish a systematic literature search for randomized controlled trials and pro-/retrospective cohort studies that compared PDC alone or PDC combined with biliary drainage stenting (PDC+BD) with TTD after LCBDE. A subgroup analysis was established to compare PDC+BD with TTD. RevMan 5.3 was used for the statistical analysis.

Results:

A total of 2552 patients from 26 studies were included. The pooled odds ratio supported PDC, which yielded lower postoperative overall morbidity and incidence of bile leak and bile peritonitis and shorter surgical time and postoperative hospital stay when compared with TTD. In the subgroup analysis, PDC+BD showed significantly better results in terms of postoperative overall morbidity, incidence of bile leak and bile peritonitis, surgical time, and postoperative hospital stay than did TTD. PDC and PDC+BD showed no difference in the incidence of recurrent stones and biliary stricture during the long-term follow-up period compared with TTD.

Conclusion:

PDC alone or PDC+BD is superior to TTD as a duct-closure method after LCBDE.

Technical Aspects of Bile Duct Evaluation and Exploration: An Update

Consensus guidelines recommend patients with symptomatic cholelithiasis and suspected choledocholithiasis have common bile duct exploration (CBDE) at the time of cholecystectomy to prevent downstream problems. Despite superiority of single-stage cholecystectomy with CBDE, 2-stage precholecystectomy/postcholecystectomy with endoscopic clearance of the duct is commonly practiced. This is related to inadequate training in minimally invasive techniques, lack of technical support for efficient and safe CBDE, and surgeons' inexperience with complex biliary pathologic condition. This article provides a framework for evaluating and treating patients with CBD pathologic condition with an emphasis on technical aspects of CBDE and preoperative planning and preparation.

Percutaneous extraction of residual post-cholecystectomy gallstones through the T-tube tract

Purpose

In the present study, the effectiveness and safety of minimally invasive percutaneous extraction of residual post-cholecystectomy gallstones through the T-tube tract were assessed.

Material and methods

Between 2000 and 2015, 12 patients (seven women and five men, mean age 78 ± 8 years) after open cholecystectomy with common bile duct exploration and T-tube drainage underwent percutaneous extraction of residual gallstones through the T-tube tract.

Results

The intervention was successful in 92% (11/12). In seven patients complete extraction of the retained gallstones was achieved, and in four cases partial extraction combined with passage of small residual fragments to the duodenum was obtained. In one case the extraction attempt was ineffective. Mild haemobilia was observed in two patients. No mortality or major complications were observed.

Conclusions

Our findings are consistent with literature data and confirm that percutaneous extraction of residual post-cholecystectomy gallstones through the T-tube tract is an effective and safe treatment method. Although the presented technique is not a novel approach, it can be beneficial in patients unsuitable for open surgery or laparoscopic intervention when ERCP attempt occurs ineffective or there exist contraindications to ERCP.

What should be known prior to performing EUS?

Direct referral of patients for EUS - instead of preprocedural consultation with the endosonographer - has become standard practice (like for other endoscopic procedures) as it is time- and cost-effective. To ensure appropriate indications and safe examinations, the endosonographer should carefully consider what information is needed before accepting the referral. This includes important clinical data regarding relevant comorbidities, the fitness of the patient to consent and undergo the procedure, and the anticoagulation status. In addition, relevant findings from other imaging methods to clarify the clinical question may be necessary. Appropriate knowledge and management of the patients' anticoagulation and antiplatelet therapy, antibiotic prophylaxis, and sedation issues can avoid unnecessary delays and unsafe procedures. Insisting on optimal preparation, appropriate indications, and clear clinical referral questions will increase the quality of the outcomes of EUS. In this paper, important practical issues regarding EUS preparations are raised and discussed from different points of view.

Efficacy and safety of laparoscopic holmium laser lithotripsy in the treatment of complicated biliary calculus: A PRISMA-compliant systematic reviews and meta-analysis

BACKGROUD

The aim of this study was to assess the efficacy and safety of laparoscopic holmium laser lithotripsy (LHLL) in the treatment of complicated biliary calculus.

METHODS

We systematically searched the electronic database (PubMed, EMBASE, Cochrane library, Web of science, and Chinese Biomedical Literature Database) up to May 2018 to identify case-controlled studies that compared LHLL with laparoscopic bile duct exploration (LBDE) for complicated biliary calculus.

RESULTS

Five case-controlled studies were included, with 541 patients (273 in the LHLL group and 268 in the LBDE group). Compared with LBDE, LHLL was associated with shorter operative time (weighted mean difference [WMD] = -40.04, P < .001) and lower estimated blood loss (EBL) (WMD = -56.42, P < .001), lesser duration of hospitalization (WMD = -3.93, P < .001) and lower rate of residual stone (OR = 0.13, P < .001). There was no statistically significant differences in bile leakage (OR = 0.48, P = .23) and hemobilia (OR = 0.49, 0.41).

CONCLUSION

Current evidence suggests that the efficacy of LHLL is superior to that of LBDE but they are similarly safe for the treatment of complicated biliary calculus. Limited by the quantity and quality of the studies included, these conclusions need to be verified by more high-quality studies.

[Outcomes of minimally invasive biliary decompression in obstructive jaundice]

AIM

To study postoperative complications and mortality after minimally invasive biliary decompression in patients with mechanical jaundice.

MATERIAL AND METHODS

Prospective analysis included 2.072 patients with mechanical jaundice who underwent differential biliary decompression depending on the cause, level of obstruction, severity of jaundice and patient's condition.

RESULTS

Relief of bilirubinemia and stabilization of the state were achieved in 1696 patients of the main group (98,6%) and in 328 (93.18%) patients of the control group. Mortality was similar in both groups: 8 (0.46%) and 2 (0.56%) patients. The best results were obtained in the main group for in-hospital and post-hospital complications after retrograde interventions (χ²=4.440821; df=0.891435; p<0.05) and post-hospital complications after antegrade interventions (χ²=35.52869; df= 1; p<0.05).

CONCLUSION

Differentiated approach to minimally invasive biliary decompression is followed by reduced postoperative morbidity.

Single-Stage Endoscopic Stone Extraction and Cholecystectomy during the Same Hospitalization

BACKGROUND/AIMS

The clinical impact of single-stage endoscopic stone extraction by endoscopic retrograde cholangiopancreatography (ERCP) and cholecystectomy during the same hospitalization remains elusive. This study aimed to determine the efficacy and safety of single-stage ERCP and cholecystectomy during the same hospitalization in patients with cholangitis.

METHODS

We retrospectively reviewed the medical records of 166 patients who underwent ERCP for mild to moderate cholangitis due to choledocholithiasis secondary to cholecystolithiasis from 2012 to 2016.

RESULTS

Complete stone extraction was accomplished in 92% of patients (152/166) at the first ERCP. Among 152 patients who underwent complete stone extraction, cholecystectomy was scheduled for 119 patients (78%). Cholecystectomy was performed during the same hospitalization in 89% of patients (106/119). We compared two groups of patients: those who underwent cholecystectomy during the same hospitalization (n=106) and those who underwent cholecystectomy during a subsequent hospitalization (n=13). In the delayed group, cholecystectomy was performed about three months after the first ERCP. There were no significant differences between the groups in terms of operative time, rate of postoperative complications, and interval from cholecystectomy to discharge.

CONCLUSION

Single-stage endoscopic stone extraction is recommended in patients with mild to moderate acute cholangitis due to choledocholithiasis. The combination of endoscopic stone extraction and cholecystectomy during the same hospitalization is safe and feasible.

Comparison of Efficacy and Safety of 4 Combinations of Laparoscopic and Intraoperative Techniques for Management of Gallstone Disease With Biliary Duct Calculi: A Systematic Review and Network Meta-analysis

Importance

Several techniques are used for surgical treatment of gallstone disease with biliary duct calculi, but the safety and efficacy of these approaches have not been compared.

Objectives

To compare the efficacy and safety of 4 surgical approaches to gallstone disease with biliary duct calculi.

Data Sources

MEDLINE, Scopus, and ISI-Web of Science databases, articles published between 1950 and 2017 and searched from August 12, 2017, to September 14, 2017. Search terms used were LCBDE, LC, preoperative, ERCP, postoperative, period, cholangiopancreatography, endoscopic, retrograde, rendezvous, intraoperative, one-stage, two-stage, single-stage, gallstone, gallstones, calculi, stone, therapy, treatment, therapeutics, surgery, surgical, procedures, clinical trials as topic, random, and allocation in several logical combinations.

Study Selection

Randomized clinical trials comparing at least 2 of the following strategies: preoperative endoscopic retrograde cholangiopancreatography (PreERCP) plus laparoscopic cholecystectomy (LC); LC with laparoscopic common bile duct exploration (LCDBE); LC plus intraoperative endoscopic retrograde cholangiopancreatography (IntraERCP); and LC plus postoperative ERCP (PostERCP).

Data Extraction and Synthesis

A frequentist random-effects network meta-analysis was performed. The surface under the cumulative ranking curve (SUCRA) was used to show the probability that each approach would be the best for each outcome.

Main Outcomes and Measures

Primary outcomes were the safety to efficacy ratio using overall mortality and morbidity rates as the main indicators of safety and the success rate as an indicator of efficacy. Secondary outcomes were acute pancreatitis, biliary leak, overall bleeding, operative time, length of hospital stay, total cost, and readmission rate.

Results

The 20 trials comprised 2489 patients (and 2489 procedures). Laparoscopic cholecystectomy plus IntraERCP had the highest probability of being the most successful (SUCRA, 87.2%) and safest (SUCRA, 69.7%) with respect to morbidity. All approaches had similar results regarding overall mortality. Laparoscopic cholecystectomy plus LCBDE was the most successful for avoiding overall bleeding (SUCRA, 83.3%) and for the shortest operative time (SUCRA, 90.2%) and least total cost (SUCRA, 98.9%). Laparoscopic cholecystectomy plus IntraERCP was the best approach for length of hospital stay (SUCRA, 92.7%). Inconsistency was found in operative time (indirect estimate, 19.05; 95% CI, 2.44-35.66; P = .02) and total cost (indirect estimate, 17.06; 95% CI, 3.56-107.21; P = .04). Heterogeneity was observed for success rate (τ, 0.8), operative time (τ, >1), length of stay (τ, >1), and total cost (τ, >1).

Conclusions and Relevance

The combined LC and IntraERCP approach had the greatest odds to be the safest and appears to be the most successful. Laparoscopic cholecystectomy plus LBCDE appears to reduce the risk of acute pancreatitis but may be associated with a higher risk of biliary leak.

Key techniques and procedure optimization of laparoscopic hepatectomy for hepatolithiasis

Hepatolithiasis is a common and refractory benign biliary tract disease in China. Meta-analyses show that laparoscopic hepatectomy (LH) is safe and effective for this disease. LH for hepatolithiasis has its distinctive techniques and procedures due to its unique clinicopathological characteristic in the era of precise hepatecomy and enhanced recovery after surgery. The key techniques include individualized selection of operating hole, hepatic inflow occlusion, anatomical hepatectomy, fine dissection, and other combined techniques. As for procedures, hepatecomy should be completed before extrahepatic bile duct choledocholithotomy is performed, and the portal hepatis should be preferentially dissected before the perihepatic ligaments are separated.

Frequency of symptoms associated with gallstone disease: a hospital-based cross sectional study

This study investigated the likely outcomes of gallstone disease and frequency of symptoms associated with this. This cross sectional study was performed at the Aliebn Abitaleb hospital in Rafsanjan over a period of twelve months from 2000 to 2001. A total sample of 70 individuals were included in the study, interviewing them using of a questionnaire covering data in terms of demographic features and medical history.The majority of patients belonged to the age group of 41 to 60 years (44.3% of all patients), while the lowest frequency was in the age group of 20 years or less. Frequency of females was higher than males. The frequency of female patients increased with the number of child birth, the highest being in women who had more than 5 child births. The most common complaint of pain was revealed as upper right abdominal quadrant (RUQ), which accounted for 95.7% of cases. Vomiting was observed in 52.9% of patients. In addition, the frequency of patients with chronic pain initiation was more than those with acute pain initiation. Among women, 17.5% had oral contraceptive pill constipation. It is worth noting that ultrasonography was the best diagnostic tool for evaluating patients. It is noteworthy that the most common symptom was right upper quadrant tenderness. Our data indicate that diabetes was the most common illness associated with gallstone disease and that 8.6% of patients had a family history of gallstone disease.

Current endoscopic strategies for managing large bile duct stones

Common bile duct stones are a relatively common occurrence and can often lead to devastating complications. Endoscopic retrograde cholangiopancreatography was introduced in the 1970s for management of common bile duct stones. Most common bile duct stones can be removed with simple techniques such as endoscopic sphincterotomy and balloon trawling. However, large bile duct stones continue to pose some difficulty in achieving complete extraction. In this article, we will review some of the established techniques such as the use of endoscopic papillary large balloon dilatation, mechanical lithotripsy, and cholangioscopy-assisted techniques. We will look at the recent literature to help clarify the particular methods and answer some of the questions surrounding these methods.

Single-stage laparoscopic common bile duct exploration and cholecystectomy versus two-stage endoscopic stone extraction followed by laparoscopic cholecystectomy for patients with gallbladder stones with common bile duct stones: systematic review and meta-analysis of randomized trials with trial sequential analysis

BACKGROUND

The ideal management of common bile duct (CBD) stones associated with gall stones is a matter of debate. We planned a meta-analysis of randomized trials comparing single-stage laparoscopic CBD exploration and cholecystectomy (LCBDE) with two-stage preoperative endoscopic stone extraction followed by cholecystectomy (ERCP + LC).

METHODS

We searched the Pubmed/Medline, Web of science, Science citation index, Google scholar and Cochrane Central Register of Controlled trials electronic databases till June 2017 for all English language randomized trials comparing the two approaches. Statistical analysis was performed using Review Manager (RevMan) [Computer program], Version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014 and results were expressed as odds ratio for dichotomous variables and mean difference for continuous. p value ≤ 0.05 was considered significant. Trial sequential analysis (TSA) was performed using TSA version 0.9.5.5 (Copenhagen: The Copenhagen Trial Unit, Centre for Clinical Intervention Research, 2016). PROSPERO trial registration number is CRD42017074673.

RESULTS

A total of 11 trials were included in the analysis, with a total of 1513 patients (751-LCBDE; 762-ERCP + LC). LCBDE was found to have significantly lower rates of technical failure [OR 0.59, 95% CI (0.38, 0.93), p = 0.02] and shorter hospital stay [MD - 1.63, 95% CI (- 3.23, - 0.03), p = 0.05]. There was no significant difference in mortality [OR 0.37, 95% CI (0.09, 1.51), p = 0.17], morbidity [OR 0.97, 95% CI (0.70, 1.33), p = 0.84], cost [MD - 379.13, 95% CI (- 784.80, 111.2), p = 0.13] or recurrent/retained stones [OR 1.01, 95% CI (0.38, 2.73), p = 0.98]. TSA showed that although the Z-curve crossed the boundaries of conventional significance, the estimated information size is yet to be achieved.

CONCLUSIONS

Single-stage LCBDE is superior to ERCP + LC in terms of technical success and shorter hospital stay in good-risk patients with gallstones and CBD stones, where expertise, operative time and instruments are available.

Familial risks for gallstones in the population of Sweden

Objectives

Gallstone disease (cholelithiasis) has a familial component, but detailed data on the modification of familial risk are lacking. Using nationwide hospital and population records, we aimed to determine detailed familial risks for medically diagnosed gallstone disease.

Design

Subjects were obtained from the Multigeneration Register, which contains family data on the Swedish population, and patients with gallstone disease were identified from the Hospital Discharge Register (1964-2015) and the Outpatient Register (2001-2015). Standardised incidence ratios (SIRs) were calculated as the ratio of observed to expected number of cases.

Results

Gallstone disease was diagnosed in 660 732 patients, with an overall incidence of 131 per 100 000 person-years. Familial cases accounted for 36.0% of all patients with gallstone disease. Of these, 50.9% had a parental family history (SIR 1.62), 35.1% had a sibling history (SIR 1.75) and 14.0% had a parental+sibling history (SIR 2.58). Among a total of 54 630 affected siblings, 84.4% were sibling pairs (SIR 1.55). However, the remaining 15.6% of the affected siblings constituted the high-risk group of multiple affected siblings and an SIR >10; these persons accounted for 7.7% of all familial cases. The spousal risk was only slightly increased to 1.18.

Conclusions

Overall, the results point to the underlying genetic causes for the observed familial clustering, which may involve polygenic gene-environmental interactions for most familial cases but high-risk genes in close to 10% of cases. Family histories should be taken into account in the medical setting and used for counselling of at-risk individuals.

Step-by-step strategy in the management of residual hepatolithiasis using post-operative cholangioscopy

Hepatolithiasis is the presence of calculi within the intrahepatic bile duct specifically located proximal to the confluence of the left and right hepatic ducts. The ultimate goal of hepatolithiasis treatment is the complete removal of the stone, the correction of the associated strictures and the prevention of recurrent cholangitis. Although hepatectomy could effectively achieve the above goals, it can be restricted by the risk of insufficient residual liver volume, and has a 15.6% rate of residual hepatolithiasis. With improvements in minimally invasive surgery, post-operative cholangioscopy (POC), provides an additional option for hepatolithiasis treatment with higher clearance rate and fewer severe complications. POC is very safe, and can be performed repeatedly until full patient benefit is achieved. During POC three main steps are accomplished: first, the analysis of the residual hepatolithiasis distribution indirectly by imaging methods or directly endoscopic observation; second, the establishment of the surgical pathway to relieve the strictures; and third, the removal of the stone by a combination of different techniques such as simple basket extraction, mechanical fragmentation, electrohydraulic lithotripsy or laser lithotripsy, among others. In summary, a step-by-step strategy of POC should be put forward to standardize the procedures, especially when dealing with complicated residual hepatolithiasis. This review briefly summarizes the classification, management and complications of hepatolithiasis during the POC process.