Recurrence of common bile duct stones following laparoscopic common bile duct exploration: a multicenter study

Tauroursodeoxycholic acid suppresses biliary epithelial cell apoptosis and endoplasmic reticulum stress by miR-107/NCK1 axis in a FXR-dependent manner

Tauroursodeoxycholic acid (TUDCA) can activate farnesoid X receptor (FXR) to involve in the formation of gallstones. Here, this study aimed to probe the potential mechanism of TUDCA-FXR network in the formation of bile duct stone. The levels of TUDCA, FXR and NCK1 were decreased, while the level of miR-107 was increased in the serum of bile duct stone patients. FXR expression was positively correlated with TUDCA or NCK1 expression in patients, moreover, TUDCA pretreatment in biliary epithelial cells increased the levels of FXR and NCK1, and rescued the decrease of NCK1 caused by FXR knockdown in cells. Then functional analysis showed FXR knockdown caused apoptosis and endoplasmic reticulum stress (ERS) as well as suppressed proliferation in biliary epithelial cells in vitro, which were attenuated by TUDCA pretreatment or NCK1 overexpression Mechanistically, NCK1 was a target of miR-107, which was up-regulated by FXR silencing, and FXR knockdown-induced decrease of NCK1 was rescued by miR-107 inhibition. Additionally, miR-107 expression was negatively correlated with TUDCA expression in bile duct stone patients, and TUDCA pretreatment in biliary epithelial cells decreased miR-107 expression by FXR. Functionally, the pretreatment of TUDCA or FXR agonist suppressed miR-107-evoked apoptosis and ERS in biliary epithelial cells. In conclusion, TUDCA up-regulates FXR expression to activate NCK1 through absorbing miR-107, thus suppressing the apoptosis and ERS in biliary epithelial cells, these results provided a theoretical basis for elucidating the mechanism of bile duct stone formation.

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.

Laparoscopic common bile duct exploration with primary closure could be safely performed among elderly patients with choledocholithiasis

BACKGROUND

For patients with choledocholithiasis, laparoscopic common bile duct exploration (LCBDE) is preferred over open surgery. Whether primary closure of the common bile duct (CBD) should be performed upon completion of choledochotomy remains unclear, and the corresponding indications for primary closure of the common bile duct have yet to be fully identified. This study was performed to evaluate the safety and feasibility of primary closure of CBD among elderly patients (≥ 70 years) after LCBDE.

METHODS

Patients with choledocholithiasis who had undergone LCBDE with primary closure of the CBD between July 2014 and December 2020 were retrospectively reviewed. Included patients were assigned into two groups (Group A: ≥70 years and Group B: <70 years) according to age. Group A was compared with Group B in terms of preoperative characteristics, intraoperative results and postoperative outcomes.

RESULTS

The mean operative time for Group A was 176.59 min (± 68.950), while the mean operative time for Group B was 167.64 min (± 69.635) (P = 0.324). The mean hospital stay after surgery for Group A was 8.43 days (± 4.440), while that for Group B was 8.30 days (± 5.203) (P = 0.849). Three patients in Group A experienced bile leakage, while bile leakage occurred in 10 patients in Group B (3.8% vs. 4.5%, P = 0.781). Group A was not significantly different from Group B in terms of postoperative complications and 30-day mortality except pneumonia (P = 0.016), acute cardiovascular event (P = 0.005) and ICU observation (P = 0.037). After a median follow-up time of 60 months, 2 patients in Group A and 2 patients in Group B experienced stone recurrence (2.5% vs. 0.9%, P = 0.612). One patient in Group A experienced stenosis of the CBD, while stenosis of the CBD occurred in 5 patients in Group B (1.3% vs. 2.2%, P = 0.937).

CONCLUSIONS

Primary closure of CBD upon completion of LCBDE could be safely performed among patients ≥ 70 years.

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.

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.

Predicting the Recurrence of Common Bile Duct Stones After ERCP Treatment with Automated Machine Learning Algorithms

BACKGROUND

Recurrence of common bile duct stones (CBDs) commonly happens after endoscopic retrograde cholangiopancreatography (ERCP). The clinical prediction models for the recurrence of CBDs after ERCP are lacking.

AIMS

We aim to develop high-performance prediction models for the recurrence of CBDS after ERCP treatment using automated machine learning (AutoML) and to assess the AutoML models versus the traditional regression models.

METHODS

473 patients with CBDs undergoing ERCP were recruited in the single-center retrospective cohort study. Samples were divided into Training Set (65%) and Validation Set (35%) randomly. Three modeling approaches, including fully automated machine learning (Fully automated), semi-automated machine learning (Semi-automated), and traditional regression were applied to fit prediction models. Models' discrimination, calibration, and clinical benefits were examined. The Shapley additive explanations (SHAP), partial dependence plot (PDP), and SHAP local explanation (SHAPLE) were proposed for the interpretation of the best model.

RESULTS

The area under roc curve (AUROC) of semi-automated gradient boost machine (GBM) model was 0.749 in Validation Set, better than the other fully/semi-automated models and the traditional regression models (highest AUROC = 0.736). The calibration and clinical application of AutoML models were adequate. Through the SHAP-PDP-SHAPLE pipeline, the roles of key variables of the semi-automated GBM model were visualized. Lastly, the best model was deployed online for clinical practitioners.

CONCLUSION

The GBM model based on semi-AutoML is an optimal model to predict the recurrence of CBDs after ERCP treatment. In comparison with traditional regressions, AutoML algorithms present significant strengths in modeling, which show promise in future clinical practices.

Comparison of Repeated Recurrence of Common Bile Duct Stones and Occurrence of Hepatolithiasis After Synchronous Laparoscopic Cholecystectomy Combined with Laparoscopic Common Bile Duct Exploration or with Endoscopic Sphincterotomy: a 10-Year Retrospective Study

BACKGROUND

The optimal treatment options for gallstones together with common bile duct stones (CBDS) remain controversial. The aim of this study was to further compare the recurrence rate of stones after synchronous laparoscopic cholecystectomy combined with laparoscopic common bile duct exploration (SLCL) and synchronous laparoscopic cholecystectomy combined with intraoperative endoscopic sphincterotomy (SLCE) and to determine which option is more effective in reducing the rate of repeated recurrence of CBDS and the incidence rate of hepatolithiasis.

METHODS

We retrospectively investigated the clinical data of patients who underwent SLCL or SLCE at our hepatobiliary center between August 2012 and August 2020. The primary and secondary endpoints of this study were the recurrence of CBDS and the occurrence of hepatolithiasis, respectively.

RESULTS

In total, 1005 patients were enrolled in this study, including 431 patients in the SLCL group and 574 patients in the SLCE group. SLCL was associated with a significantly decreased rate of CBDS recurrence (4.18% vs. 7.84%, P = 0.018), repeated CBDS recurrence (0.70% vs. 3.00%, P = 0.010), and incidence of hepatolithiasis (0.00% vs. 1.05%, P = 0.040). Compared with SLCE, SLCL was an independent protective predictor of the recurrence of CBDS (relative risk, 0.505; 95% confidence interval, 0.286-0.891; P = 0.018) and repeated recurrence of CBDS (relative risk, 0.226; 95% confidence interval, 0.066-0.777; P = 0.018).

CONCLUSIONS

SLCL is an optimal treatment option to SLCE for patients with gallstones combined with CBDS.

Comparing Stone Recurrence Following Surgical Common Bile Duct Exploration or Endoscopic Stone Extraction 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. Aspects of CBD stone management, such as sphincterotomy, have been implicated as risks for CBD stone recurrence although evidence is weak. The aim of this study was to compare stone recurrence following LCBDE and/or ERCP. Methods: Data were collected retrospectively for patients undergoing LCBDE and/or ERCP for CBD stones at a single center from 2008 to 2018. Primary outcome was stone recurrence (>6 months after duct clearance). Risk factors for recurrence were assessed using univariate and multivariate analyses. Results: A total of 445 patients underwent LCBDE-only, 79 patients underwent ERCP-only and 80 patients underwent LCBDE-ERCP. LCBDE-only patients were younger and preoperatively less morbid than ERCP-only patients. Although there was no significant difference for recurrence, there was a trend toward higher recurrence with ERCP-only compared with LCBDE-only and LCBDE-ERCP (5.1% versus 2.0% and 2.5%, P = .280). On univariate comparison, patients with a recurrence were significantly older, had a higher admission white cell count, higher number of ERCPs, increased transampullary stent use, and higher maximum CBD diameter. Total number of ERCP was the only independent predictor of stone recurrence (odds ratio 6.85 [2.55-18.42], P < .001) following multivariate regression. Conclusion: Management plan was not associated with stone recurrence. The total number of ERCP was the only independent predictor of recurrence. Within the limitations of case selection and bias toward LCBDE, this study suggests that limiting repeated ERCP may reduce CBD stone recurrence.

An artificial intelligence difficulty scoring system for stone removal during ERCP: a prospective validation

BACKGROUND

A computer-assisted (CAD) system was developed to assess, score, and classify the technical difficulty of common bile duct (CBD) stone removal during endoscopic retrograde cholangiopancreatography (ERCP). The efficacy of the CAD system was subsequently assessed through a multicenter, prospective, observational study.

METHOD

All patients who met the inclusion criteria were included. Based on cholangiogram images, the CAD system analyzed the level of difficulty of stone removal and classified it into "difficult" and "easy" groups. Subsequently, differences in clinical endpoints, including attempts at stone extraction, stone extraction time, total operation time, and stone clearance rates were compared between the two groups.

RESULTS

173 patients with CBD stones from three hospitals were included in the study. The group classified as difficult by CAD had more extraction attempts (7.20 vs. 4.20, P < 0.001), more frequent machine lithotripsy (30.4 % vs. 7.1 %, P < 0.001), longer stone extraction time (16.59 vs. 7.69 minutes, P < 0.001), lower single-session stone clearance rate (73.9 % vs. 94.5 %, P < 0.001), and lower total stone clearance rate (89.1 % vs. 97.6 %, P = 0.019) compared with the group classified as easy by CAD.

CONCLUSION

The CAD system effectively assessed and classified the degree of technical difficulty in endoscopic stone extraction during ERCP. In addition, it automatically provided a quantitative evaluation of CBD and stones, which in turn could help endoscopists to apply suitable procedures and interventional methods to minimize the possible risks associated with endoscopic stone removal.

Primary Recurrent Common Bile Duct Stones: Timing of Surgical Intervention

Cholelithiasis (gallstones) is a very common medical problem worldwide, with 5-30% of patients demonstrating a combined condition of cholelithiasis and choledocholithiasis (common bile duct stones (CBDS)). CBDS are usually classified as primary or secondary stones. Primary CBDS are defined as stones detected 2 years or more following cholecystectomy, while secondary stones, the most common type, usually migrate from the gallbladder to the bile ducts. Recurrent CBDS are defined as stones detected 6 months or more following endoscopic retrograde cholangiopancreatography (ERCP) with complete duct clearance. Although ERCP with endoscopic sphincterotomy has emerged as the main therapeutic option for CBDS, with up to 95% bile duct clearance rate, up to 25% of said patients develop recurrent bile duct stones. Thus far, several issues related to recurrent CBDS are still unclear and questions regarding this specific pathology have no precise answers: how many trials of ERCP and endoscopic sphincterotomy should be attempted before referring the patient for surgical management? Is there an association between risk factors and early surgical intervention? Thus, currently, there is no worldwide scientific-based consensus regarding the best management of this specific group of patients. The main issue for this article is to review the relevant English literature and find out the main high risk factors for recurrent CBDS, and form a diagnostic and treatment plan, hence, identifying the subgroup of patients that will benefit from early surgical management, preventing further ERCP-associated complications.

Predictors for stone recurrence after a successful common bile duct surgical exploration for choledocholithiasis

BACKGROUND

Recurrence after common bile duct stone (CBDS) clearance is the major long-term drawback of their management. Its prevalence is significant, and it occurs after all primary therapeutic alternatives. The aim of this study was to determine the predictive factors associated with stone recurrence after surgical common bile duct exploration (CBDE).

METHODS

A retrospective cohort study based on patients undergoing CBDE between 2000 and 2018 was conducted. Uni- and multivariate hierarchical regression analyses were performed to assess the independent predictive factors associated with recurrent CBDS in patients with initially successful surgery.

RESULTS

A total of 365 patients underwent successful surgical procedures. After a median follow-up of 43.2 (IQR 84) months, 31 (8.4%) patients were diagnosed with CBD stone recurrence. The median time to recurrence was 30.3 (IQR 38) months. The only variable associated with CBDS recurrence was preoperative endoscopic sphincterotomy (HR 2.436, 95% CI: 1.031-5.751, P = 0.042)).

CONCLUSION

Patients who undergo preoperative endoscopic sphincterotomy and then cholecystectomy with successful common bile duct clearance may be at increased risk for recurrent stone disease compared to those who go straight to surgery.

Novel elbow basket mechanical lithotripter for large common bile duct stone removal

BACKGROUND

Large common bile duct (CBD) stones often require lithotripsy. In this study, we aimed to introduce a novel device-elbow basket catheter for mechanical lithotripsy (ML) of CBD stones and assess the efficacy and safety of the novel device.

METHODS

This was a retrospective study. A total of 139 patients with large CBD stones who underwent lithotripsy using the elbow basket mechanical lithotripter (EBML) or conventional basket mechanical lithotripter (CBML) during endoscopic retrograde cholangiopancreatography (ERCP) from June 2016 to September 2021 in our center were enrolled in the study. The stone clearance rate, intubation time, overall procedure time, and adverse event rate were compared between the two groups.

RESULTS

The stone clearance rate in the first ERCP program in the EBML (n = 71) group was significantly higher than that in the CBML (n = 68) group (98.6% vs. 88.2%; P< 0.05). The intubation time in the EBML group was significantly shorter than that in the CBML group (median time; 12s vs. 78s; P< 0.001). The overall procedure time in the EBML group was significantly shorter than that in the CBML group (median time; 51 min vs. 63 min; P< 0.001). The adverse event rate (7.4% vs. 1.4%: P> 0.05) was similar between the two groups.

CONCLUSIONS

ML using EBML in patients with large CBD stones is feasible and safe. Compared with the CBML, the stone clearance rate of the EBML is higher in a single procedure and decreases the time of intubation and the overall procedure.

Single-stage intraoperative ERCP combined with laparoscopic cholecystectomy versus preoperative ERCP Followed by laparoscopic cholecystectomy in the management of cholecystocholedocholithiasis: A meta-analysis of randomized trials

OBJECTIVES

The optimal treatment strategy for cholecystocholedocholithiasis is still controversial. We conducted an up-to-date meta-analysis to compare the efficacy and safety of the intra- endoscopic retrograde cholangiopancreatography (ERCP) + LC procedure with the traditional pre-ERCP +  laparoscopic cholecystectomy (LC) procedure in the management of cholecystocholedocholithiasis.

METHODS

We searched the PubMed, Embase, Cochrane Library, and Web of Science databases up to September 2020. Published randomized controlled trials comparing intra-ERCP + LC and pre-ERCP + LC were considered. This meta-analysis was performed by Review Manager Version 5.3, and outcomes were documented by pooled risk ratio (RR) and mean difference (MD) with 95% confidence intervals.

RESULTS

Eight studies with a total of 977 patients were included in this meta-analysis. There was no significant difference between the two groups regarding CBD stone clearance (RR = 1.03, P = .27), postoperative papilla bleeding (RR = 0.41, P = .13), postoperative cholangitis (RR = 0.87, P = .79), and operation conversion rate (RR = 0.71, P = .26). The length of hospital stay was shorter in the intra-ERCP + LC group (MD = -2.75, P < .05), and intra-ERCP + LC was associated with lower overall morbidity (RR = 0.54, P < .05), postoperative pancreatitis (RR = 0.29, P < .05) and cannulation failure rate (RR = 0.22, P < .05).

CONCLUSIONS

Intra-ERCP + LC was a safer approach for patients with cholecystocholedocholithiasis. It could facilitate intubation, shorten hospital stay, and lower postoperative complications, especially postoperative pancreatitis, and reduce stone residue and reduce the possibility of reoperation for stone removal.

Identification of risk factors involved in recurrence after common bile duct stone removal with ERCP: A retrospective observational study

Recurrent stone detection is common after endoscopic treatment of common bile duct stones (CBDS). This study aimed to identify the risk factors for recurrence of CBDS.We retrospectively evaluated 14 patients who underwent endoscopic treatment for CBDS. Risk factors for single and multiple recurrent CBDSs were evaluated using logistic regression analysis.Endoscopic and needle-knife precut sphincterotomy was performed in 506 and 112 patients, respectively. There was 1 recurrence in 85 patients (13.8%), 2 recurrences in 23 patients (3.7%), and 3 recurrences in 9 patients (1.5%). According to the multivariate analyses, being older than 65 years (odds ratio [OR] 1.084, P = .000), concomitant heart disease (OR 2.528, P = .002), concomitant lung disease (OR 1.766, P = .035), a large common bile duct diameter (OR 1.347, P = .000), presence of cholelithiasis (OR 1.752, P = .018), stent (OR 1.794, P = .023), or T-tube placement in the common bile duct (OR 47.385, P = .000), and prolongation of the procedure (OR 1.037, P = .000) increased the risk of recurrence, while having undergone cholecystectomy due to gallstones (OR 1.645, P = .042). The mean stone diameter (P = .059), nitroglycerin use (P = .129), and periampullary diverticulum (P = .891) did not increase the risk of recurrent CBDS.The probability of multiple recurrences after the first recurrence of CBDS increased with age >65 years, concomitant heart/lung diseases, stent/T-tube placement in the common bile duct, a wide common bile duct (≥10 mm), and cholelithiasis.

A nomogram for predicting stones recurrence in patients with bile duct stones undergoing laparoscopic common bile duct exploration

Background

Methods

Results

Conclusions

Differences in Outcome and Comparison of Stress and Immune Status in Patients with Recurrent Common Bile Duct Stones after Biliary Tract Surgery Choosing Three Procedures (ERCP, OCBDE, and LCBDE) for Treatment

OBJECTIVE

To compare the effect of choosing ERCP, OCBDE, and LCBDE for the treatment of patients with recurrent common bile duct stones after biliary tract surgery.

METHOD

115 patients with recurrent common bile duct stones after biliary surgery in our hospital were retrospectively analyzed and divided into three groups according to the procedure, 36 patients in the ERCP group, 38 patients in the OCBDE group, and 41 patients in the LCBDE group, and compared the efficacy, stress status, and immune status of the three groups.

RESULT

The stone removal rates were 91.67%, 97.37%, and 97.56% in the ERCP, OCBDE, and LCBDE groups, respectively (P > 0.05). There were statistical differences between the ERCP, OCBDE, and LCBDE groups in terms of operative time, postoperative recovery time of exhaustion, recovery time of defecation, recovery time of feeding, and hospitalization time (P < 0.05). The postoperative complication rates were 8.33%, 10.53%, and 7.32% in the ERCP, OCBDE, and LCBDE groups, respectively (P > 0.05). The recurrence rates within 1 year after surgery were 2.78%, 7.89%, and 2.44% in the ERCP, OCBDE, and LCBDE groups, respectively (P > 0.05).

CONCLUSION

ERCP has short operative time, short hospital stay, and rapid postoperative recovery. LCBDE has mild trauma, and OCBDE has a wide range of application. Each of the three procedures has its own advantages and shortcomings, and the most appropriate procedure should be selected on the basis of comprehensive evaluation.

Conversion to open surgery during laparoscopic common bile duct exploration: predictive factors and impact on the perioperative outcomes

BACKGROUND

Laparoscopic common bile duct exploration (LCBDE) is an effective treatment for choledocholithiasis. The aim of this study was to determine the predictive factors associated with conversion during LCBDE and to assess the implications of conversion on the patients' postoperative course.

METHODS

A retrospective cohort study based on patients undergoing LCBDE between 2000 and 2018 was conducted. Uni- and multivariate regression analyses were performed.

RESULTS

A total of 357 patients underwent LCBDE, and the conversion rate was 14.2%. The main reasons for conversion were lithiasis extraction (21; 41%) and difficult dissection (13; 26%). Independent predictors for conversion were increasing levels of serum bilirubin prior to surgery (OR=4.745, 95% CI: 1.390-16.198; p=0.013), and emergency setting (OR=4.144, 95% CI: 1.449-11.846; p=0.008). Age was independently associated with lower odds of conversion (OR=0.979, 95% CI: 0.960-0.999; p=0.036). Conversion had a negative impact on the patients' postoperative course, including severe complication (21.6% vs. 5.2% p<0.001) and surgical reintervention (11.8% vs. 2.6% p=0.002) rates.

CONCLUSION

Conversion to open surgery during LCBDE was associated with increased postoperative morbidity. Emergency surgery and increasing levels of serum bilirubin previous to surgery independently increase the probability of conversion; however age was independently associated with lower odds of conversion.

Optimal treatment for concomitant gallbladder stones with common bile duct stones and predictors for recurrence of common bile duct stones

BACKGROUND

The optimal treatment for concomitant gallbladder (GB) stones with common bile duct (CBD) stones and predictors for recurrence of CBD stones are not established.

METHODS

This single-center, retrospective study reviewed 466 patients diagnosed with a first event of concomitant GB stones with CBD stones from January 2010 to December 2018.

RESULTS

92 patients underwent single-stage laparoscopic CBD exploration (LCBDE) and laparoscopic cholecystectomy (LC) (group1), 108 underwent LCBDE + LC after endoscopic stone extraction (ESE) failure (group2), and 266 underwent ESE + LC (group3). Clearance (95.7 vs. 99.1 vs. 97.0%, p = 0.324) and recurrence rates (5.4 vs. 13.0 vs. 7.9%, p = 0.138) did not differ between groups. Group1 had fewer procedures (p < 0.001), lower post-treatment complication rates (7.6 vs. 18.5 vs. 13.9%, p = 0.082), and shorter hospital stay after the first procedure (5.7 vs 13.0 vs 9.8 days, p < 0.001). 40 patients (8.6%) had recurrence of CBD stones at mean follow-up of 17.1 months, of which 29 (72.5%) occurred within 24 months. In multivariate analysis, a CBD diameter > 8 mm, combined type-1 periampullary diverticulum, and age > 70 years were significant predictors of recurrence.

CONCLUSION

Single-stage LCBDE + LC is a safe and effective treatment for concomitant GB stones with CBD stones compared to ESE + LC. LCBDE should be considered in patients with a high risk of ESE failure. Careful follow-up is recommended for patients at high risk of recurrence of CBD stones, especially within 24 months after surgical or endoscopic treatment.

Percutaneous Transhepatic Papillary Balloon Dilation versus Endoscopic Retrograde Cholangiopancreatography for Common Bile Duct Stones: A Multicenter Prospective Study

Background Endoscopic retrograde cholangiopancreatography (ERCP) is recommended by major guidelines for the removal of common bile duct (CBD) stones but is technically challenging in patients with low cardiopulmonary reserve and anatomic abnormalities of the upper gastrointestinal (GI) tract. Purpose To compare percutaneous transhepatic papillary balloon dilation (PTPBD) with ERCP for CBD stone removal. Materials and Methods Participants with one to three CBD stones (largest stone ≤30 mm) and without intrahepatic bile duct or gallbladder stones were eligible for this prospective cohort study. PTPBD was recommended in participants with low cardiopulmonary reserve or definitive anatomic abnormalities of the upper GI tract. Otherwise, both procedures were offered without preference. Follow-up, including abdominal CT, was conducted at 1-week and 1-, 3- and 6-month follow-up, and every 6 months thereafter. US and MR cholangiopancreatography were conducted if recurrence could not be confirmed with CT. Technical success rate was the primary outcome. Results A total of 531 participants were analyzed: there were 360 undergoing PTPBD (median age, 76 years; interquartile range [IQR], 64-82 years; 163 men) and 171 undergoing ERCP (median age, 66 years; IQR, 57-74 years; 94 men). The technical success rate was 99% (355 of 360) in the PTPBD group and 98% (167 of 171) in the ERCP group (relative risk, 1.02; P = .12). The incidence of overall complications was 4% (13 of 360) for PTPBD and 8% (13 of 171) for ERCP (relative risk, 0.27; 95% CI: 0.12, 0.61; P < .001). The PTPBD group showed a longer fluoroscopy time and a higher radiation exposure, with adjusted differences of 28.7 minutes (95% CI: 22.2, 35.2) and 384.3 mGy (95% CI: 296.5, 472), respectively. A propensity score-matching analysis (n = 123 per group) indicated that PTPBD had a slightly higher technical success rate and significantly fewer complications. Conclusion When compared with endoscopic retrograde cholangiopancreatography, percutaneous transhepatic papillary balloon dilation has a similar technical success rate and fewer perioperative complications but a higher radiation exposure. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by van Sonnenberg and Mueller in this issue.

Advances in Risk Factors for Recurrence of Common Bile Duct Stones

Choledocholithiasis is a chronic common disease. The incidence of cholelithiasis is 5%-15%, of which 5%-30% are combined with Choledocholithiasis. Although endoscopic cholangiopancreatography (ERCP) + endoscopic sphincterotomy (EST) is the most common treatment procedure, which clearance rate is up to 95%, the incidence of recurrent choledocholithiasis was 4%-25%. The risk factors of recurrence after choledocholithiasis clearance are the focuses of current researches, which are caused by multiple factors. We first systematically summarize the risk factors of common bile duct stones (CBDS) recurrence into five aspects: first-episode stone related factors, congenital factors, biological factors, behavioral intervention factors, and the numbers of stone recurrence.

Lessons learnt from the first 200 unselected consecutive cases of laparoscopic exploration of common bile duct stones at a district general hospital

BACKGROUND

The management of choledocholithiasis evolves with diagnostic imaging and therapeutic technology, facilitating a laparoscopic approach. We review our first 200 cases of laparoscopic exploration of the common bile duct, highlighting challenges and lessons learnt.

METHODS

We retrospectively studied the first 200 cases of laparoscopic cholecystectomy with common bile duct exploration between 2006 and 2019. The database contains demographics, clinicopathological characteristics, diagnostic modalities, operative techniques, duration and outcomes.

RESULTS

We compared two approaches: transcystic vs. transcholedochal in our 200 cases. Choledocholithiasis was suspected preoperatively in 163 patients. 21 cases found no stones. Of the remainder, 111/179 cases were completed via the transcystic route and the remaining were completed transcholedochally (68/179); 25% of the transcholedochal cases were converted from a transcystic approach. CBD diameter for transcystic route was 8.2 vs. 11.0 mm for transcholedochal. Total clearance rate was 84%. Retained or recurrent stones were noted in 7 patients. Length of stay was 5.8 days, 3.5 days in the transcystic route vs. 9.4 days after transcholedochal clearance. Eight patients required re-operation for bleeding or bile leak. No mortalities were recorded in this cohort, but 2 cases (1%) developed a subsequent CBD stricture.

CONCLUSION

Concomitant laparoscopic common bile duct clearance with cholecystectomy is feasible, safe and effective in a district general hospital, despite constraints of time and resources. The transcystic route has a lower complication rate and shorter hospital stay, and hence our preference of this route for all cases. Advancements in stone management technology will allow wider adoption of this technique, benefitting more patients.