Choledocholithiasis-a new clinical pathway

Sequential comparison of single-stage laparoscopic common bile duct exploration combined with cholecystectomy

Laparoscopic cholecystectomy (LC) combined with laparoscopic common bile duct exploration (LCBDE) is used to treat gallbladder (GB) stones combined with common bile duct (CBD) stones. Patients with GB stones combined with CBD stones who underwent single-stage LC + LCBDE surgery in our center from January 2020 to November 2023 were retrospectively analyzed and divided into LC-BDE and BDE-LC groups. LC-BDE was performed in patients with cystic duct diameter ≥ 0.5 cm, and BDE-LC was performed in patients with cystic duct diameter < 0.5 cm. Baseline data, preoperative conditions, operative details, postoperative hospitalization, postoperative care, and complication rates were compared between patients in the two groups. A total of 240 patients were included, including 72 in the LC-BDE group and 168 in the BDE-LC group. There was a significant difference between the two groups in terms of intraoperative blood loss (5 (0, 16) mL vs. 16 (10, 20) mL, P < 0.001). There were no statistically significant differences between the two groups in terms of operative time (130.2 (110.0, 168.6) min vs. 125.0 (105.0, 150.0) min, P = 0.112), and postoperative complications such as bile leakage (8.3 vs. 11.9%, P = 0.415). Different operative sequences of cholecystectomy and common bile duct exploration in the single-stage surgical treatment of GB stones combined with CBD stones were acceptable in terms of bile duct stone clearance and postoperative complication rates.

Application effect of standardized nursing process of abdominal drainage tube in cholelithiasis: a single-center retrospective cohort study

BACKGROUND

and aims: Although abdominal drainage tubes have been widely used to treat cholelithiasis, complications still affect patients' prognoses. There is no Standardized Nursing Process (SNP) for abdominal drainage tubes after Laparoscopic cholecystectomy (LC). This study aims to observe the clinical efficacy and explore the feasibility of SNP intervention for abdominal drainage tubes in cholelithiasis patients after LC.

METHODS

This retrospective study included the patients with cholelithiasis admitted to Xishan People's Hospital of Wuxi City between Jan 2023 and Aug 2024. Patients were separated into Standardized Nursing Process (SNP) group and non-Standardized Nursing Process (non-SNP) group. The outcomes were compared between the two groups, and Univariate and multivariate analyses were performed to analyze the factors associated with SNP. P values less than 0.05 were considered statistically significant.

RESULTS

Among a total of 264 patients with cholelithiasis who were included in the study, 147 patients were treated with SNP, and the other 117 patients were treated without SNP. Compared with non-SNP, multivariate analysis suggested that SNP was an independent factor linked to alleviation of postoperative pain (OR = 0.22, 95%CI: 0.13-0.36) (P < 0.001), strongly associated with the activity rate of getting out of bed within 24 h (OR = 2.28, 95%CI:1.33-3.91), effectively associated with a lower incidence of drainage tube outlet leakage and post-extubation leakage. Importantly, SNP management correlated with higher patient satisfaction (p < 0.001).

CONCLUSIONS

SNP implementation correlated with improved activity rate of getting out of bed within 24 h after LC, fewer occurrence of post-extubation leakage, reduced postoperative pain and higher satisfaction rates.

Laparoscopic Common Bile Duct Exploration for Choledocholithiasis in the Elderly: A Systematic Review and Meta-Analysis

Introduction: Laparoscopic common bile duct exploration (LCBDE) is a well-established and effective minimally invasive surgical approach for managing choledocholithiasis. However, its safety in the elderly population is not well established. Therefore, this study compares surgery-related outcomes in elderly patients undergoing LCBDE. Methods: We systematically searched PubMed, Embase, and Cochrane Library for studies comparing elderly and young patients undergoing LCBDE. Binary outcomes were compared using odds ratios (ORs), with 95% confidence intervals (CIs). Heterogeneity was assessed with I2 statistics. Statistical analysis was performed using Software R, version 4.3.3. Results: Twelve studies comprising 3791 patients were included, of whom 1411 patients (37%) were from the elderly group. Elderly patients were associated with an increase in mortality (OR: 3.42; 95% CI: 1.08-10.85; P = .04; I2 = 0%), overall postoperative complications (OR: 1.60; 95% CI: 1.11-2.22; P = .01; I2 = 52%), and pneumonia (OR: 4.37; 95% CI: 2.00-9.55; P < .01; I2 = 0%) rates. However, there were no significant differences between groups in remnant stones (OR: 1.37; 95% CI: 0.70-2.68; P = .36; I2 = 0%) and recurrent stones (OR: 1.37; 95% CI: 0.64-2.95; P = .42; I2 = 0%) pancreatitis (OR: 0.98; 95% CI: 0.16-5.95; P = .98; I2 = 0%) and bile leakage (OR: 1.24; 95% CI: 0.75-2.07; P = .40; I2 = 0%). Conclusion: In this meta-analysis, elderly patients who underwent LCBDE experienced increased mortality, overall complications, and pneumonia rates compared with young patients. Furthermore, there were no significant differences between the groups in remnant and retained stones, pancreatitis, and bile leakage.

Pediatric Cholecystectomy Case Volume and Complexity Following the COVID-19 Pandemic

BACKGROUND AND OBJECTIVES

Historically, cholecystectomy was infrequently performed in children. Lifestyle changes, delays in health care access, and increases in childhood obesity occurred during the COVID-19 pandemic. The impact of these shifts on need for cholecystectomy are poorly understood. We evaluate trends in cholecystectomy case volume among children during the COVID-19 pandemic.

METHODS

A multi-institutional retrospective cohort study was conducted for children ages 18 years and younger who underwent cholecystectomy from January 1, 2016, to July 31, 2022, at 10 children's hospitals. Differences in cholecystectomy case mix and volume before and during the pandemic were identified using bivariate comparisons and interrupted time series analysis.

RESULTS

Overall, 4282 children were identified: 2122 before the pandemic and 2160 during the pandemic. Most were female (74.2%) with a median age of 15 years (IQR, 13.0-16.0 years). The proportion of Hispanic (55.0% vs 60.1%; P = .01) patients, body mass index (BMI) (26.0 vs 27.1; P < .001), and obesity (BMI > 30) (30.8% vs 37.4%; P < .001) increased during the pandemic. Predicted monthly case volume increased from 40 to 100 during the pandemic. Patients transferred from an outside hospital increased (21.3% vs 28.5%; P < .001). Significant increases in acute cholecystitis (12.2% vs 17.3%; P < .001), choledocholithiasis (12.8% vs 16.5%; P = .001), gallstone pancreatitis (10.6% vs 12.4%; P = .064), and chronic cholecystitis (1.4% vs 3.2%; P < .001) also occurred. On interrupted time series analysis, change in month-to-month case count significantly increased during the pandemic (Figure 1; P < .001), which persisted after exclusion of transferred patients.

CONCLUSIONS

Pediatric cholecystectomy case volume and complexity increased during the COVID-19 pandemic. These findings may be secondary to changes in childhood health, transfer patterns, and shifts in access, highlighting an increased health care burden on children's hospitals.

Laparoendoscopic Rendezvous: An Effective and Safe Approach in the Management of Cholecysto-Choledocholithiasis in Selected Patients

Background: Different techniques have been proposed to manage Cholecysto-choledocholithiasis (CCL) advantageously in one stage. Among these, Laparoendoscopic Rendezvous (LERV) addresses the CCL issue with a laparoscopic cholecystectomy, with insertion of a guide wire into the common bile duct through an incision of the cystic duct, followed by the clearance of the bile duct carried out by the endoscopists. The aim of this study was to evaluate the safety and the efficacy of the one-stage vs. a two-stage approach (pre-operative ERCP followed by cholecystectomy), and to compare our results with data from the current literature. Methods: All patients that underwent LERV in our facilities between January 2018 and December 2023 were evaluated. As a control group, we included patients that underwent a two-stage technique called the "sequential approach". The primary outcome was to evaluate the efficacy in obtaining complete clearance of the common bile duct (CBD). The secondary outcomes included morbidity, mortality, operative time, conversion rate, hospital stay and CDB stone recurrence. Results: 120 patients in the LERV group were included; meanwhile, 70 patients underwent pre-operative ERCP plus cholecystectomy. A 97% bile duct clearance success rate in the LERV group and 93% in the ERCP group was observed, respectively. The median intraoperative time for the one-stage technique was 122 min (p < 0.001) and the median hospital stay was 4 days (p < 0.001). In the LERV group, an overall morbidity of 15% was reported (18/120): 15 Clavien-Dindo type 1, one type 3a and two type 3b (p < 0.001). At a median follow-up of 14 months, five patients experienced stone recurrence. In the ERCP group, we had a 93% success rate; meanwhile, we had longer hospitalization (p < 0.001), 27% post-ERCP pancreatitis (p < 0.001) and a cumulative morbidity of 30%. Conclusions: LERV offers the advantages of a being single-stage procedure and shorter hospitalization, with a lower risk of clinically relevant post-ERCP pancreatitis and failed CBD cannulation.

A Novel Taxonomy of Intraoperative Cholangiograms in Suspected Choledocholithiasis: A Tool for Advancing Laparoscopic Common Bile Duct Exploration Outcomes Research

BACKGROUND

Cholangiography for visualization of the biliary tree during laparoscopic cholecystectomy is an important diagnostic roadmap in the context of suspected choledocholithiasis (CDL). The renewed interest in transcystic laparoscopic common bile duct exploration (LCBDE) necessitates a general description of the range of CDL presentations. Our aim was to establish a novel classification system of intraoperative cholangiograms (IOCs) to advance research efforts in this field.

METHODS

A novel cholangiogram classification system, featuring 8 distinct presentations of choledocholithiasis, was applied to a data set of 80 preintervention IOCs for suspected choledocholithiasis. The classification system is as follows: A (no common bile duct stones, duodenal filling present, and concern for air bubbles), B (no common bile duct stones, no duodenal filling, and concern for sludge), C1 (stone(s) < 2x size of cystic duct with duodenal filling), C2 (stone(s) < 2x size of cystic duct without duodenal filling), D1 (stone(s) ≥ 2x size of cystic duct with duodenal filling), D2 (stone(s) ≥ 2x size of cystic duct without duodenal filling), E1 (congenital anatomical variant and/or common duct stricture), and E2 (surgically altered biliary anatomy).

RESULTS

Cholangiogram review yielded preintervention classifications for 6 of 8 variants (A-E): A (7.5%), B (3.75%), C1 (23.75%), C2 (42.5%), D1 (15%), and D2 (7.5%). Analysis of cystic duct diameter yielded no significant differences among classification groups, indicating no predominant pattern of cystic duct anatomy within a given classification.

DISCUSSION

An IOC classification system for suspected choledocholithiasis is foundational to answering key clinical questions for transcystic laparoscopic common bile duct exploration.

Reducing MRCP Utilization Through a "Surgery First" Approach for Pediatric Choledocholithiasis: A CARES Working Group Retrospective Study

BACKGROUND

Choledocholithiasis in children is rising and frequently managed with an endoscopy-first (EF) approach that utilizes endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC). Magnetic resonance cholangiopancreatography (MRCP) is a resource intensive modality that often precedes ERCP to gain further assurance of choledocholithiasis prior to intervention. MRCP can lead to a longer length of stay (LOS) and strain healthcare resources. We hypothesized that the use of MRCP is decreased with a surgery-first (SF) approach.

METHODS

The Choledocholithiasis Alliance for Research, Education, and Surgery (CARES) Working Group conducted this retrospective study on pediatric patients with suspected choledocholithiasis. SF patients underwent LC + intraoperative cholangiogram (IOC) ± laparoscopic common bile duct exploration (LCBDE). Imaging studies included ultrasound (US), MRCP, and computed tomography (CT).

RESULTS

From seven institutions, 357 pediatric patients were identified. The SF (n = 220) group received fewer imaging studies then EF (n = 137) (1.29 vs. 1.62; p < 0.05). US was more commonly employed and the number of US and CT scans was similar. The SF group had lower MRCP utilization than EF (29% vs. 59%; p < 0.05). EF patients that received an MRCP had the longest LOS (4.0 d [2.4, 6.3]) compared to SF that did not (1.9 d [1.2, 3.2]) (p < 0.05).

CONCLUSION

Children with choledocholithiasis managed with an EF approach receive more diagnostic imaging, especially MRCP. While MRCP remains a powerful diagnostic tool, a surgery-first approach can minimize the resource utilization and LOS associated with magnetic resonance imaging.

LEVEL OF EVIDENCE

Level III.

Multi-Institutional Analysis of Choledocholithiasis in Pediatric vs Adult Patients

BACKGROUND

In adults, upfront intraoperative cholangiogram with laparoscopic common bile duct exploration (LCBDE) is well accepted for management of choledocholithiasis. Despite recent evidence supporting LCBDE utility in children, there has been hesitation to adopt this surgery first (SF) approach over ERCP first (EF) due to perceived technical challenges. We compared rates of successful stone clearance during LCBDE between adult and pediatric patients to evaluate if pediatric surgeons could anticipate similar rates of successful clearance.

METHODS

A multicenter, retrospective review of pediatric (<18 years) and adult patients with choledocholithiasis managed from 2018 to 2024 was performed. Demographic and clinical data were obtained. Rate of successful duct clearance with LCBDE was compared. Surgical and endoscopic complications (infections, bleeding, pancreatitis, bile leak) were also compared.

RESULTS

724 patients, 333 (45.9%) pediatric and 391 (54.0%) adults, were included. The median age of pediatric vs adult patients was 15.2 years [13.1, 16.6] vs 55.5 years [34.1, 70.5], respectively. Of these, 201 (60.4%) pediatric vs 169 (43.2%) adult patients underwent SF, p < 0.001. LCBDE was attempted in 84 (41.7%) pediatric vs 140 (82.8%) adults, p = 0.002. LCBDE success was higher in pediatric vs adult patients (82.1% vs 71.4%, p = 0.004). Complications rates were similar however, pediatric patients who underwent EF had higher endoscopic complications (9.1% vs 3.6%, p = 0.03).

CONCLUSION

LCBDE is highly successful in children vs adults with no increased surgical complications. This data, coupled with the limited ERCP access for children, supports that LCBDE is an equally effective tool for managing choledocholithiasis in children as is accepted in adults.

LEVEL OF EVIDENCE

Level III.

Moving the needle for laparoscopic common bile duct exploration: defining obstacles for the path forward

INTRODUCTION

Laparoscopic cholecystectomy is performed very commonly but laparoscopic common bile duct exploration (LCBDE) is performed infrequently. We aimed to determine the most significant barriers to performing LCBDE and to identify the highest yield interventions to facilitate adoption.

METHODS AND PROCEDURES

A national survey was designed by content experts, who regularly perform LCBDE. The survey was distributed by email to the Society of American Gastrointestinal and Endoscopic Surgeons and the American Association for the Surgery of Trauma memberships. Non-U.S. surgeon responses were excluded. Descriptive statistics were used to analyze the results.

RESULTS

Seven hundred twenty six practicing surgeons responded to the survey, 543 of which were US surgeons who perform laparoscopic cholecystectomy. Only 27% of respondents preferred to manage choledocholithiasis with LCBDE. Their technique of choice was choledochoscopy (70%). Despite this, 36% of surgeons did not have access to a choledochoscope or were unsure if they did. Seventy percent of surgeons who performed LCBDE did not have supplies readily available in a central stocking location. Only 8.5% of surgeons agreed that routine LCBDE would impact their referral relationship with gastroenterology. About half the respondents (47%) considered LCBDE worth the time, but only 25% knew about reimbursement for the procedure. Almost all (85%) of surgeons understood that LCBDE results in shorter length of stay compared to ERCP.

CONCLUSIONS

Only a quarter of the surgeons performing cholecystectomy perform LCBDE. Multiple barriers contribute to low LCBDE utilization. Increasing availability of appropriate equipment, a dedicated supply cart, and teaching fluoroscopic LCBDE interventions may address limitations and increase adoption. These efforts may also increase efficiency, minimizing perceived time and skill restraints. Although many surgeons understand LCBDE decreases length of stay, they are unaware of surgeon-specific LCBDE financial benefits. Systematically addressing these barriers may increase LCBDE adoption, improve patient care, and decrease healthcare costs.

Laparoscope combined with ureteroscope in the treatment of bile duct stones and cholecystolithiasis in a child: a case report and literature review

Cholecystolithiasis combined with bile duct stones is more and more common in children, but the surgical treatment is still controversial. We report on a 3-year-old boy, who underwent laparoscope combined with ureteroscope for choledocholithiasis with cholecystolithiasis. This combination therapy offers the possibility to treat pediatric patients with cholecystolithiasis and bile duct stones in low-resource settings where ERCP experience and child-specific surgical instruments are not available. Additionally, a comprehensive review of previous studies was conducted to summarize the surgical treatments. The surgical treatment of children should be made according to the specific situation to maximize the success of the operation and reduce the risk.

Laparoscopic cholecystectomy for symptomatic cholelithiasis in children and adolescents: analysis of 50 cases from a single institution

PURPOSE

To investigate the clinical characteristics of symptomatic cholecystolithiasis and laparoscopic cholecystectomy complications in pediatric patients.

METHODS

The medical records of 50 children and adolescents who underwent laparoscopic cholecystectomy were analyzed. We evaluated gender, age, body mass index, preoperative clinical aspects, perioperative complications, and gallstone composition.

RESULTS

Among the patients, 33 (66%) were female, and 17 (34%) were male. The mean age was 11.4 ± 3.6. All patients were diagnosed with cholecystolithiasis by abdominal ultrasonography. Twelve patients (24%) had hematological disease: eight (16%) with sickle cell anemia and four (8%) with hereditary spherocytosis. Thirteen patients (26%) were obese. Twelve patients (24%) had complicated biliary disease. During the intraoperative period, three patients (6%) had excessive bleeding in the hepatic hilum, and one had an accidental injury to the common bile duct. Three (6%) postoperative complications (acute pancreatitis, common bile duct stenosis, and intestinal obstruction) were observed. Among 28 patients (56%), 25 (50%) had cholesterol gallstones, and three (6%) had bile pigment gallstones.

CONCLUSIONS

The evolution of cholecystolithiasis in the pediatric population can present serious complications, emphasizing the need to avoid temporizing cholecystolithiasis in children and adolescents because laparoscopic cholecystectomy in this group is safe, with low complication rates.

Increases in pediatric cholecystectomy during the COVID-19 pandemic: An interrupted time series analysis

BACKGROUND

Historically, cholecystectomy is infrequently performed in children. Lifestyle changes, delays in healthcare access, and increases in childhood obesity occurred during the COVID-2019 pandemic. It is unclear whether these changes impacted pediatric gallbladder disease and the need for cholecystectomy.

METHODS

A retrospective study of children ≤18 years old undergoing cholecystectomy from January 1, 2016, to July 31, 2022, at a tertiary children's hospital was conducted. On March 19, 2020, a statewide mandatory coronavirus disease 2019 stay-at-home policy began. Differences in children undergoing cholecystectomy before and during the pandemic were identified using bivariate comparisons. An interrupted time series analysis identified differences in case volume trends.

RESULTS

Overall, 633 children were identified-293 pre-pandemic and 340 pandemic. A majority were female sex (76.3%) and Hispanic (67.5%), with a median age of 15 years (interquartile range: 13.0-16.0). Children who underwent cholecystectomy during the pandemic had significantly higher body mass index (28.4 versus 25.8, P = .002), and obesity (body mass index >30) was more common (45.3% versus 31.7%, P = .001). During the pandemic, significant increases in complicated biliary disease occurred-symptomatic cholelithiasis decreased (41.5% versus 61.8%, P < .001) and choledocholithiasis (17.9% versus 11.6%, P = .026), gallstone pancreatitis (17.4% versus 10.6%, P = .015), and chronic cholecystitis (4.7% versus 1.0%, P = .007) increased. The number of cholecystectomies performed per month increased during the pandemic, and on interrupted time series analysis, there was a significant increase in month-to-month case count during the pandemic (P = .003).

CONCLUSION

Cholecystectomy case volume significantly increased during the coronavirus disease 2019 pandemic, possibly secondary to increases in childhood obesity. Future studies are needed to determine whether this increased frequency of pediatric cholecystectomy is representative of broader shifts in pediatric health and healthcare use after coronavirus disease 2019.

The Laparoscopy in Biliary Exploration Research and Training Initiative (LIBERTI) trial: simulator-based training for laparoscopic management of choledocholithiasis

BACKGROUND

Laparoscopic cholecystectomy with common bile duct exploration (LCBDE) is equivalent in safety and efficacy to endoscopic retrograde cholangiopancreatography (ERCP) plus laparoscopic cholecystectomy (LC) while decreasing number of procedures and length of stay (LOS). Despite these advantages LCBDE is infrequently utilized. We hypothesized that formal, simulation-based training in LCBDE would result in increased utilization and improve patient outcomes across participating institutions.

METHODS

Data was obtained from an on-going multi-center study in which simulator-based transcystic LCBDE training curricula were instituted for attending surgeons and residents. A 2-year retrospective review of LCBDE utilization prior to LCBDE training was compared to utilization up to 2 years after initiation of training. Patient outcomes were analyzed between LCBDE strategy and ERCP strategy groups using χ2, t tests, and Wilcoxon rank tests.

RESULTS

A total of 50 attendings and 70 residents trained in LCBDE since November 2020. Initial LCBDE utilization rate ranged from 0.74 to 4.5%, and increased among all institutions after training, ranging from 9.3 to 41.4% of cases. There were 393 choledocholithiasis patients analyzed using LCBDE (N = 129) and ERCP (N = 264) strategies. The LCBDE group had shorter median LOS (3 days vs. 4 days, p < 0.0001). No significant differences in readmission rates between LCBDE and ERCP groups (4.7% vs. 7.2%, p = 0.33), or in post-procedure pancreatitis (0.8% v 0.8%, p > 0.98). In comparison to LCBDE, the ERCP group had higher rates of bile duct injury (0% v 3.8%, p = 0.034) and fluid collections requiring intervention (0.8% v 6.8%, p < 0.009) secondary to cholecystectomy complications. Laparoscopic antegrade balloon sphincteroplasty had the highest technical success rate (87%), followed by choledochoscopic techniques (64%).

CONCLUSION

Simulator-based training in LCBDE results in higher utilization rates, shorter LOS, and comparable safety to ERCP plus cholecystectomy. Therefore, implementation of LCBDE training is strongly recommended to optimize healthcare utilization and management of patients with choledocholithiasis.

Contemporary management of common bile duct stone: What you need to know

ABSTRACT

Choledocholithiasis is a common presentation of symptomatic cholelithiasis encountered by the acute care surgeon. There is a wide spectrum of variation in management of this disease due to evolutions in laparoscopic and endoscopic techniques. Intricacies in management are related to the timing of diagnosis as well as locally available imaging modalities, surgical expertise, and ancillary advanced endoscopy and interventional radiological support. While individual patient demographics and institutional characteristics will determine management of choledocholithiasis, it is incumbent for the treating surgeon to be well versed in all manners of therapy currently available. The objective of this review is to provide an evidence-based summary of the contemporary management of choledocholithiasis.

Enlarged fistulotomy of the papilla as access to the biliary tract during ERCP

BACKGROUND

Demonstration of access to the bile duct through Enlarged Papillary Fistulotomy, a method different from conventional fistulotomy.

AIMS

Demonstration of the EFP technique with dissection in layers of the papilla for accessing the common bile duct, its efficiency and safety, rescue of cases of failure in cannulation and cases of access failure by EFP in the first attempt, facilitating cannulation in the second attempt.

METHODS

Cross-sectional study, with retrospective data collection from 2233 ERCP exams with 528 EFP procedures, analysis of success and complications.

RESULTS

528 patients underwent EFP on the first attempt, with success in 465 cases (88.06%) and 63 failures (11.94%). Of these failures, 33 patients (52.38%) returned for a second EFP attempt, with success in 30 cases (90.9%) and failure in 3 cases (9.1%). Deep bile duct cannulation was achieved in 93.75% of EFP procedures, and cannulation failure occurred in 33 cases (6.25%).

CONCLUSION

EFP showed efficiency in CBD cannulation, did not induce post-ERCP pancreatitis, no cases of perforation or false tract, but resulted in higher rates of minor bleeding, rescued cases of access failure by EFP, facilitated the posterior approach on the second attempt, it is safe, effective, low risk and associated with few comorbidities.

ERCP findings provide further justification for a "surgery-first" mindset in choledocholithiasis

INTRODUCTION

Choledocholithiasis is most often managed in a two-procedure pathway including endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC). In contrast, a single-stage, surgery-first approach consisting of LC, cholangiogram, and laparoscopic common bile duct exploration (LCBDE) is associated with reduced hospital stays and equivalent morbidity. Despite this, nationwide referral patterns heavily favor ERCP, obscuring those undergoing ERCP with obstructions amenable to simple intraoperative interventions. We hypothesized that most patients had endoscopic findings consistent with simple sludge or small-to-medium stones, which could have been cleared by basic LCBDE maneuvers.

METHODS

We retrospectively reviewed 294 patients > 18 years old who underwent preoperative ERCP for the management of suspected choledocholithiasis. Exclusion criteria included: failed ERCP, cholangitis, prior cholecystectomy, patient refusal of surgery, or medical conditions precluding surgical candidacy. Stone size was categorized as small (0-4 mm), medium (5-7 mm), and large (≥ 8 mm).

RESULTS

At the time of ERCP, 37 (20.1%) patients had sludge only, 96 (52.2%) had stones only, 42 (22.8%) had sludge and stones, and 9 (4.8%) had no stones. Of the 138 patients with any stones, 37 (26.8%) had small stones, 41 (29.7%) medium, 43 (31.2%) large, and 17 (12.3%) had uncharacterizable stones. Overall, 74.3% of patients had findings of sludge, stones (0-7 mm), or negative ERCP.

CONCLUSION

The majority of patients who underwent preoperative ERCP for suspected choledocholithiasis had findings that are amenable to simple intraoperative interventions. In fact, over a quarter of the patients had a negative ERCP, sludge, or small stones which would likely be cleared by flushing/glucagon precluding any further instrumentation. While large stones may require more advanced techniques, this represents a small percentage of patients. Surgery-first management for suspected choledocholithiasis can offer an efficient alternative for the majority of patients.

Echo-Endoscopy Combined with Virtual Reality: A Whole Perspective of Laparoscopic Common Bile Duct Exploration in Children

Introduction: Endoscopic procedures are performed more frequently in children due to technological advances that can be safely performed in an adequate setting with a support of a multidisciplinary team. Pediatric indications for ERCP (endoscopic retrograde cholangiopancreatography) and EUS (endoscopic ultrasound) occur mainly due to congenital malformations. In a pediatric case series, we report the application of EUS combined with duodenoscopy, eventually associated with ERCP and minimally invasive surgery, highlighting the importance of defining a tailored dedicated management pathway for each patient. Patients and methods: A series of 12 patients, managed at our Center in the last three years, were evaluated, and their management was discussed. Results: EUS was performed in eight patients and permitted the differential diagnosis of duplication cysts and the visualization of the biliary tree and pancreatic anatomy. ERCP was attempted in five patients: in one case, it permitted the preservation of pancreatic tissue, postponing surgery and in three patients, it was technically unfeasible. MIS (minimally invasive surgery) was performed in seven patients, two with laparoscopic common bile duct exploration (LCBDE). Precise anatomical definition and the possibility of surgical simulation and team sharing were evaluated under VR HMD (Virtual Reality Head Mounted Display) in four cases. Conclusions: Exploration of the common bile duct in children differs from that of the adult population and combines echo-endoscopy and ERCP. The integrated use of minimally invasive surgery in the pediatric area is necessary for the whole management perspective in complex malformations and small patients. The introduction in the clinical practice of a preoperative study with Virtual Reality allows a better survey of the malformation and a tailored treatment.

Resolution of Liver Function Tests After Laparoscopic Common Bile Duct Exploration Versus Endoscopic Retrograde Cholangiopancreatography

Laparoscopic cholecystectomy (LC) with laparoscopic common bile duct exploration (LCBDE) is gaining traction for the management of choledocholithiasis. Liver function tests (LFTs) are often used to determine the success of ductal clearance, yet the impact of differing therapeutic interventions, endoscopic retrograde cholangiopancreatography (ERCP) or LCBDE, have on postprocedure LFT is insufficiently described. We hypothesize that these interventions have different postoperative LFT profiles. The preprocedural and postprocedural total bilirubin (Tbili), aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase (ALP) were analyzed of 167 patients who had successful ERCPs (117) or LCBDEs (50). Endoscopic retrograde cholangiopancreatography patients demonstrated a significant decrease in all LFTs postprocedure (n = 117; P = <0.001 for all) with a continued downtrend when a second set of LFTs was obtained (n = 102; P = <0.001 for all). For successful LC+LCBDEs, there was no significant change between preoperative and 1st postoperative Tbili, AST, ALT, and ALP and the 2nd postoperative labs.

Dual Balloon Catheter: A Novel Laparoscopic Common Bile Duct Exploration Device

Introduction: Choledocholithiasis is a disease process that can be managed by laparoscopic common bile duct exploration at the time of cholecystectomy. However, it can be negatively perceived by surgeons as lengthening procedure time and adding technical complexity. Materials and Methods: We have created a dual balloon biliary intervention catheter designed to make common duct exploration efficient, simple, and safe. The device consists of two balloons, one compliant and one noncompliant, to perform initial cholangiography, dilate the sphincter, and occlude the proximal duct for distal power flushing of stones. The catheter design facilitates a stepwise, over the wire progression of interventions with a singular device. Results: The catheter has been successfully deployed in a porcine feasibility model and the dual balloon concepts reduced to practice using currently available devices. Conclusion: Laparoscopic common bile duct exploration is a safe and effective way to treat choledocolithiasis. The Dual Balloon Catheter is a novel device that allows for duct occlusion for cholangiogram and power flushing in conjunction with duct and sphincter dilation.

Outcomes following balloon sphincteroplasty as an adjunct to laparoscopic common bile duct exploration

BACKGROUND

Laparoscopic common bile duct exploration (LCBDE) at the time of cholecystectomy is an efficient pathway for management of choledocholithiasis. Performing this safely under one anesthetic offers advantages over a two-step process with cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP). Despite the proven efficacy of LCBDE, endoscopy continues to be predominantly utilized. Simplifying the intervention may drive LCBDE adoption. To this end, we refined a stepwise intraoperative pathway that utilizes over the wire balloon catheters to dilate the Sphincter of Oddi to facilitate stone passage into the duodenum. To determine the efficacy during the initial adoption phase on a general surgery service, we reviewed our experience with LCBDE balloon sphincteroplasty as part of this pathway.

METHODS

We retrospectively reviewed the records of patients who underwent LCBDE with balloon sphincteroplasty at a single tertiary care center over a three-year period. Preoperative demographics, imaging/laboratory results, intra and postoperative outcomes were reviewed.

RESULTS

Choledocholithiasis was managed with transcystic balloon sphincteroplasty during LCBDE in 28 cases over a three-year period. The cohort included 16 women and 12 men with a mean age of 47 years (range = 19-89). Operative indications included cholecystitis (n = 11, 39%), choledocholithiasis (n = 13, 47%), cholelithiasis (n = 2, 7%), and gallstone pancreatitis (n = 2, 7%). The stones were successfully cleared by the balloon sphincteroplasty technique in 75% of the cases. The average fluoroscopy time during LCBDE was 338 s (± 214). The average operating room time was 173 min (± 35). Mean length of stay was 58 h (± 46). There were no intra- or postoperative complications.

CONCLUSION

Wire ready cholangiography followed by balloon sphincteroplasty with saline/contrast flush is a simple and safe way to clear the common bile duct. This technique is a gateway for further expansion and adoption of LCBDE.

MRI Evaluation of Indomethacin Suppositories in the Prevention of Complications of Pancreatitis and Hyperamylasemia after Choledocholithiasis ERCP Based on Image Denoising Algorithm

Objective

To explore the value of MRI evaluation of indomethacin suppositories in the prevention of pancreatitis and hyperamylasemia in patients with common bile duct calculi after endoscopic retrograde cholangiopancreatography (ERCP) based on image denoising algorithm.

Methods

A retrospective analysis in August 2020 to December 2021. Because of the common bile duct calculi hospitalized parallel ERCP operation, 89 cases of patients, according to the different postoperative treatments, were divided into group A (n = 44) and group B (n = 45), in which A set of separate application inhibits the pancreatic enzyme secretion after surgery drug treatment, and B group on the basis of group A linked with indole beauty Xinshuan treatment. The incidence of postoperative pancreatitis and hyperamylasemia was compared between the two groups. The levels of serum amylase were compared between the two groups. Patients in group B were diagnosed with pancreatitis by conventional MRI and MRI with denoising algorithm, respectively, and the imaging characteristics and diagnosis rate differences of the two methods were observed. ROC curve was drawn to evaluate the diagnostic efficacy of MRI denoising algorithm for postoperative pancreatitis and serum amylase level detection for hyperamylasemia.

Results

The incidence of postoperative pancreatitis and hyperamylasemia in group B was significantly lower than that in group A (P < 0.05). There were 6 cases of postoperative pancreatitis in group B, 2 cases (33.33%) were diagnosed by conventional MRI, and 5 cases (83.33%) were diagnosed by MRI based on denoising algorithm. Although there was no significant difference in diagnosis rate between the two methods, the number of cases of pancreatitis diagnosed by MRI based on denoising algorithm was slightly higher than that by conventional MRI. Compared with conventional MRI images, MRI images with denoising algorithm showed that the number of cases with pancreatic swelling, the number of cases with pancreatic duct/bile duct dilation, and the number of cases with abdominal effusion were all high (all P < 0.05). ROC results showed that the area under the curve of MRI with denoising algorithm for the diagnosis of postoperative pancreatitis was 0.855, and the sensitivity was 89.40%. The specificity was 83.20%, and the area under the curve of serum amylase for postoperative hyperamylasemia was 0.893, the sensitivity was 89.80%, and the specificity was 85.20%, all of which had high diagnostic efficacy.

Conclusion

MRI results of denoising algorithm suggest that indomethacin suppositories can effectively reduce the incidence of postoperative pancreatitis and hyperamylasemia after ERCP, which is worthy of clinical application.

Clinical safety and outcomes of glucagon use during endoscopic retrograde cholangiopancreatography (ERCP)

Background and study aims  Injectable glucagon enables easier biliary cannulation by inhibiting gastrointestinal motility and decreasing the frequency and amplitude of phasic activity of the sphincter of Oddi during endoscopic retrograde cholangiopancreatography (ERCP). Data about the safety profile of glucagon use and patient clinical outcomes are scarce. Patients and methods  We used a federated cloud-based network research database, TriNetX, comprising 92 US healthcare organizations to find adult patients undergoing ERCP with glucagon use (Group A) vs. without using glucagon (Group B) from August 1, 2010, to August 1, 2021. The primary outcomes were rates of gastrointestinal bleeding, gastrointestinal perforation, post-ERCP pancreatitis, inpatient hospitalizations, and 30-day overall mortality measured after 1:1 propensity matching of the groups based on the baseline demographics and comorbidities. Results  There were 9,008 patients in Group A compared to 256,597 in Group B. After matching, Group A patients had lower rates of gastrointestinal bleeding (risk ratio [RR], 0.68; CI, 0.52-0.86), post-ERCP pancreatitis (RR, 0.64; CI, 0.58-71), inpatient hospitalization (RR 0.34; CI:0.32 to 0.36) and overall mortality (RR, 0.81; CI, 0.66-0.99). The rates of gastrointestinal perforation (RR, 0.64; CI: 0.34 to 1.19), hyperkalemia (RR, 0.83; CI, 0.64-1.09) and hyperglycemia (RR, 0.65; CI, 0.41-1.03) did not differ between the two groups. Discussion  Glucagon use during ERCP was associated with low rates of gastrointestinal bleeding, post-ERCP pancreatitis, inpatient hospitalization, and overall mortality. Moreover, the rates of hyperkalemia and hyperglycemia did not differ between the two groups even after matching for diabetes, indomethacin use, obesity, and chronic kidney disease.