Comparison of Outcomes and Complications of Endoscopic Common Bile Duct Stone Removal Between Asymptomatic and Symptomatic Patients

Synergistic effect of independent risk factors for post-endoscopic retrograde cholangiopancreatography pancreatitis: a multicenter retrospective study in Japan

BACKGROUND/AIMS

This study aimed to examine the synergistic effect of independent risk factors on post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP).

METHODS

This multicenter retrospective study included 1,273 patients with native papillae who underwent ERCP for bile duct stones in Japan. Independent PEP risk factors were identified using univariate and multivariate analyses. Significant risk factors for PEP in the multivariate analysis were included in the final analysis to examine the synergistic effect of independent risk factors for PEP.

RESULTS

PEP occurred in 45 of 1,273 patients (3.5%). Three factors including difficult cannulation ≥10 minutes, pancreatic injection, and normal serum bilirubin level were included in the final analysis. The incidences of PEP in patients with zero, one, two, and three factors were 0.5% (2/388), 1.9% (9/465), 6.0% (17/285), and 12.6% (17/135), respectively. With increasing risk factors for PEP, the incidence of PEP significantly increased (1 factor vs. 2 factors, p=0.006; 2 factors vs. 3 factors, p=0.033).

CONCLUSIONS

As the number of risk factors for PEP increases, the risk of PEP may not be additive; however, it may multiply. Thus, aggressive prophylaxis for PEP is strongly recommended in patients with multiple risk factors.

Asymptomatic bile duct stones: The devil is in the details

Common bile duct (CBD) stones are a common biliary tract disease. For asymptomatic CBD stones, stone removal by endoscopic retrograde cholangiopancreatography (ERCP) is recommended in available guidelines. Because asymptomatic CBD stones is a benign disease with no noticeable symptoms, the risk vs benefit strategy should be thoroughly considered before performing ERCP in these patients. Clinical care review, technical aspects of the procedure, and patient preferences should also be considered.

Comparative Risks of Post-ERCP Adverse Events in Patients with Asymptomatic and Symptomatic Choledocholithiasis: A Systematic Review and Meta-Analysis

BACKGROUND AND AIMS

Endoscopic retrograde cholangiopancreatography (ERCP) is the standard of care for the management of choledocholithiasis but carries risk of complications which may result in significant morbidity and mortality. While currently available guidelines endorse the use of ERCP for the management of symptomatic common bile duct stones, the need for ERCP in incidentally found asymptomatic choledocholithiasis is more controversial, and practice varies on a geographic and institutional level. This systematic review and meta-analysis is conducted to compare post-ERCP adverse events between asymptomatic and symptomatic choledocholithiasis patients.

METHODS

We searched PubMed/Embase/Web of Science databases to include all studies comparing post-ERCP outcomes between asymptomatic and symptomatic choledocholithiasis patients. The primary outcome was post-ERCP pancreatitis (PEP), while secondary outcomes included post-ERCP cholangitis, bleeding, and perforation. We calculated pooled risk ratios (RR) and 95% confidence intervals (CIs) using the Mantel-Haenszel method within a random-effect model.

RESULTS

Our analysis included six observational studies, totaling 2,178 choledocholithiasis patients (392 asymptomatic and 1786 symptomatic); 53% were female. Asymptomatic patients exhibited a higher risk of PEP compared with symptomatic patients (11.7% versus 4.8%; RR 2.59, 95% CI 1.56-4.31, p ≤ 0.001). No significant difference was observed in post-ERCP cholangitis, bleeding, or perforation rates between the two groups.

CONCLUSIONS

Asymptomatic patients with choledocholithiasis appear to have a higher risk of PEP than symptomatic patients, while the risk of other post-ERCP adverse events is similar between the two groups. Interventional endoscopists should thoroughly discuss potential adverse events (particularly PEP) with asymptomatic patients before performing ERCP and utilize PEP-prevention measures more liberally in this subgroup of patients.

The Influence of Symptomatic Status on Post-endoscopic Retrograde Cholangiopancreatography (ERCP) Complications in Choledocholithiasis: A Systematic Review and Meta-Analysis

Choledocholithiasis presents variably, with some patients remaining asymptomatic, complicating decisions regarding the timing and necessity of endoscopic retrograde cholangiopancreatography (ERCP). This study represents the first meta-analysis assessing the impact of symptomatic status on post-ERCP complications and provides critical data to optimize treatment strategies. A systematic review and meta-analysis were conducted by searching PubMed, Embase, and Google Scholar through February 2024, focusing on comparing ERCP outcomes between symptomatic and asymptomatic patients with choledocholithiasis. Seven studies were included from an initial pool of 1,200 articles screened. The analysis revealed that asymptomatic patients exhibited a significantly higher overall complication rate (17.4% vs. 6.6%), including a threefold increase in the risk of developing complications overall (OR: 3.02; 95% CI: 2.26-4.03) and specifically post-ERCP pancreatitis (OR: 3.62; 95% CI: 2.63-4.99). Perforation and procedural durations were also notably higher among asymptomatic individuals. Subgroup analyses highlighted prolonged cannulation times and the use of precut sphincterotomy as potential influential factors. These findings challenge the current practice that does not differentiate based on symptomatic status and suggest a need for more tailored approaches in managing asymptomatic individuals to minimize risks associated with ERCP.

Non-interventional Management of Asymptomatic Diminutive Choledocholithiasis Versus Endoscopic Extraction in Consecutive Patients

BACKGROUND

Current guidelines recommend treating choledocholithiasis, regardless of symptoms or stone size, with endoscopic retrograde cholangiopancreatography (ERCP). However, asymptomatic choledocholithiasis, discovered incidentally on imaging, may carry a higher risk of ERCP-related adverse events, and some asymptomatic and diminutive stones may not cause biliary adverse events during extended follow-up. Therefore, we aimed to clarify the best treatment strategies for asymptomatic choledocholithiasis based on stone size.

METHODS

We retrospectively identified patients with incidental imaging-found asymptomatic diminutive (≤ 4 mm) or non-diminutive (> 4 mm) choledocholithiasis and divided them into two groups: those who did not undergo ERCP and were treated when complications arose (on-demand group) and those who underwent ERCP before being symptomatic (intervention group). Adverse events were defined as any biliary or pancreatic complication related to ERCP or arising during observation or after intervention. The primary outcome was the adjusted overall adverse event-free survival using the propensity score-based matching weights method comparing the two groups of stone size.

RESULTS

Among 148 patients identified (median follow-up period, 969 days), 68 had diminutive stones and 80 had non-diminutive stones. Of the 68 patients with diminutive stones, 51 were in the on-demand group and 17 in the intervention group. The overall adjusted adverse event-free survival was significantly higher in the on-demand group for diminutive stones (97.4% and 70.1%, respectively, at 3 years; p = 0.01).

DISCUSSION

Patients with incidental imaging-detected asymptomatic diminutive choledocholithiasis may benefit from clinical observation, pursuing ERCP when symptoms develop.

Evaluation of Clinical Indications of Three Treatments for Choledocholithiasis with Acute Cholangitis

Objective

This study aimed to assess the efficacy of Endoscopic Retrograde Cholangiopancreatography (ERCP), common bile duct exploration, and percutaneous transhepatic cholangiography combined with common bile duct exploration for treating choledocholithiasis with acute cholangitis, to guide management strategies.

Methods

A retrospective evaluation was conducted on a cohort of 283 inpatients diagnosed with choledocholithiasis and acute cholangitis at the affiliated hospital. Patients were categorized into three groups: Group A (ERCP group), Group B(common bile duct exploration group), and Group C(PTCD combine common bile duct exploration group.) Parameters such as hepatic function recovery, inflammation level control, blood loss, postoperative hospital duration, and postoperative complications were compared.

Results

All groups exhibited notable reductions in postoperative biochemical parameters including alanine aminotransferase (ALT), aspartate aminotransferase (AST), gamma-glutamyl transferase (GGT), total bilirubin (TBIL), and WBC (P < 0.05). Group A had the least blood loss(P < 0.05), and shortest hospital stay(P < 0.05), but a higher incidence of pancreatitis(P < 0.05), with a total of 8 cases occurred(7.3%). Group C had a shorter hospital stay compared to Group B(P < 0.05).

Conclusion

For patients with fewer and smaller common bile duct stones and milder symptoms, it is recommended to primarily choose endoscopic retrograde cholangiopancreatography (ERCP), endoscopic sphincterotomy (EST), and endoscopic nasobiliary drainage (ENBD), it procedures offer quicker recovery and cause minimal trauma. For patients with numerous, larger common bile duct stones but stable conditions, bile duct exploration is recommended. For those with severe conditions and significant inflammation, PTCD and common bile duct exploration are advised.

Evidence-based clinical practice guidelines for cholelithiasis 2021

The Japanese Society of Gastroenterology first published evidence-based clinical practice guidelines for cholelithiasis in 2010, followed by a revision in 2016. Currently, the revised third edition was published to reflect recent evidence on the diagnosis, treatment, and prognosis of cholelithiasis conforming to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Following this revision, the present English version of the guidelines was updated and published herein. The clinical questions (CQ) in the previous version were reviewed and rearranged into three newly divided categories: background questions (BQ) dealing with basic background knowledge, CQ, and future research questions (FRQ), which refer to issues that require further accumulation of evidence. Finally, 52 questions (29 BQs, 19 CQs, and 4 FRQs) were adopted to cover the epidemiology, pathogenesis, diagnosis, treatment, complications, and prognosis. Based on a literature search using MEDLINE, Cochrane Library, and Igaku Chuo Zasshi databases for the period between 1983 and August 2019, along with a manual search of new information reported over the past 5 years, the level of evidence was evaluated for each CQ. The strengths of recommendations were determined using the Delphi method by the committee members considering the body of evidence, including benefits and harms, patient preference, and cost-benefit balance. A comprehensive flowchart was prepared for the diagnosis and treatment of gallbladder stones, common bile duct stones, and intrahepatic stones, respectively. The current revised guidelines are expected to be of great assistance to gastroenterologists and general physicians in making decisions on contemporary clinical management for cholelithiasis patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Prevention of post-ERCP pancreatitis: current strategies and novel perspectives

Endoscopic retrograde cholangiopancreatography (ERCP) is an advanced endoscopic procedure that might lead to severe adverse events. Post-ERCP pancreatitis (PEP) is the most common post-procedural complication, which is related to significant mortality and increasing healthcare costs. Up to now, the prevalent approach to prevent PEP consisted of employing pharmacological and technical expedients that have been shown to improve post-ERCP outcomes, such as the administration of rectal nonsteroidal anti-inflammatory drugs, aggressive intravenous hydration, and the placement of a pancreatic stent. However, it has been reported that PEP originates from a more complex interaction of procedural and patient-related factors. Appropriate ERCP training has a pivotal role in PEP prevention strategy, and it is not a chance that a low PEP rate is universally considered one of the most relevant indicators of proficiency in ERCP. Scant data on the acquisition of skills during the ERCP training are currently available, although some efforts have been recently done to shorten the learning curve by way of simulation-based training and demonstrate competency by meeting technical requirements as well as adopting skill evaluation scales. Besides, the identification of adequate indications for ERCP and accurate pre-procedural risk stratification of patients might help to reduce PEP occurrence regardless of the endoscopist's technical abilities, and generally preserve safety in ERCP. This review aims at delineating current preventive strategies and highlighting novel perspectives for a safer ERCP focusing on the prevention of PEP.

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

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

Increased post-endoscopic retrograde cholangiopancreatography pancreatitis for choledocholithiasis without acute cholangitis

BACKGROUND AND AIM

Choledocholithiasis is the most common indication for endoscopic retrograde cholangiopancreatography (ERCP). Identifying risk factors for post-ERCP pancreatitis (PEP) is important for reducing the risk of developing PEP after common bile duct (CBD) stone removal. However, studies examining the risk factors for PEP for CBD stones are scarce. The aim of this study was to examine whether the presence or absence of acute cholangitis is a clinical risk factor for PEP in patients with CBD stones.

METHODS

In this multicenter retrospective study, 1539 patients with naïve papillae were divided into patients without and with acute cholangitis. We compared the incidence of PEP between the two groups using one-to-one propensity score matching to adjust for the potential confounding factors of PEP.

RESULTS

In the entire cohort, the rates of PEP in patients without and with acute cholangitis were 9.6% (52/542) and 1.8% (18/997), respectively (P < 0.001, odds ratio = 5.8). In the propensity-matched cohort, the rates of PEP in patients without and with acute cholangitis were 8.3% (27/326) and 2.5% (8/326), respectively (P = 0.002, odds ratio = 3.6). The rate of PEP was significantly higher in patients without acute cholangitis than in those with acute cholangitis after adjusting for the confounding factors of PEP.

CONCLUSIONS

The absence of acute cholangitis may be an important clinical risk factor for PEP due to CBD stone removal. In patients without acute cholangitis, endoscopists should explain the specific risk of PEP carefully and actively implement prophylaxis against PEP.

Disease-Based Risk Stratification of Postendoscopic Retrograde Cholangiopancreatography Pancreatitis for Common Bile Duct Stones

BACKGROUND

Risk stratification of postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) for common bile duct (CBD) stones is needed for clinicians to adequately explain to patients regarding the risk of PEP in advance of ERCP and to proactively take preventive measures in high-risk patients.

AIMS

To stratify the risk of PEP for CBD stones based on CBD-related diseases.

METHODS

A total of 1551 patients with naïve papilla who underwent ERCP for CBD stones were divided into three groups: Group A: asymptomatic CBD stones, Group B: obstructive jaundice and elevated liver test values without cholangitis, and Group C: mild, moderate, and severe cholangitis. We stratified the risk of PEP by comparing its incidence among the three groups using the Holm's method. Furthermore, we performed one-to-one propensity score matching between Group A and the other groups to examine the risk of PEP in Group A.

RESULTS

The incidence rates in Groups A, B, and C were 13.7%, 7.3%, and 1.8%, respectively. The Holm-adjusted p values between Groups A and B, Groups A and C, and Groups B and C were 0.023, < 0.001, and < 0.001, respectively. Propensity score matching revealed that the incidence of PEP was significantly more in Group A than in the other groups (13.3% vs. 1.5%; p < 0.001).

CONCLUSIONS

The risk of PEP for CBD stones was stratified into low risk (Group C), intermediate risk (Group B), and high risk (Group A). This simple disease-based risk stratification may be useful to predict the risk of PEP in advance of ERCP.

Endoscopic retrograde cholangiopancreatography-related complications for bile duct stones in asymptomatic and symptomatic patients

Background and Aim

Current guidelines recommend the removal of common bile duct (CBD) stones by endoscopic retrograde cholangiopancreatography (ERCP) for both asymptomatic and symptomatic patients. We conducted this study because of the limited research comparing the risks of ERCP-related complications between these two groups.

Methods

This retrospective study involved 1491 patients with native major duodenal papilla diagnosed with choledocholithiasis at three institutions in Japan. The rates of ERCP-related complications, including post-ERCP pancreatitis (PEP), cholangitis, bleeding, and perforation, were compared using one-to-one propensity score matching between the asymptomatic and symptomatic patients.

Results

Complications were observed in 112 (7.5%) of the 1491 patients (asymptomatic group: 31/172 [18.0%] vs symptomatic group: 81/1319 [6.1%], P < 0.001). The rate of severe complications was higher in the asymptomatic group than that in the symptomatic group (asymptomatic group: 5/31 [16.1%] vs symptomatic group: 3/81 [3.7%], P = 0.036). In the propensity-matched asymptomatic and symptomatic patients, the incidences of PEP, cholangitis, bleeding, and perforation were 18/143 (12.6%) vs 4/143 (2.8%) (P = 0.003); 4/107 (3.7%) vs 6/107 (5.6%) (P = 0.75); 1/140 (0.7%) vs 3/140 (2.1%) (P = 0.62); and 2/140 (1.4%) vs 2/140 (1.4%) (P = 1.0).

Conclusions

ERCP for asymptomatic patients with CBD stones is associated with a higher risk of overall and severe complications than that for symptomatic patients with CBD stones; the overall rate is influenced by the high incidence of PEP in the asymptomatic group. Endoscopists should explain the risk of ERCP-related complications for asymptomatic patients before performing the procedure.

Factors Predicting Difficult Biliary Cannulation during Endoscopic Retrograde Cholangiopancreatography for Common Bile Duct Stones

Background/Aims

Difficult biliary cannulation is an important risk factor for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). Therefore, this study aimed to identify the factors that predict difficult cannulation for common bile duct stones (CBDS) to reduce the risk for PEP.

Methods

This multicenter retrospective study included 1,406 consecutive patients with native papillae who underwent ERCP for CBDS. Factors predicting difficult cannulation for CBDS were identified using univariate and multivariate analyses.

Results

Univariate analysis showed that six factors significantly predicted difficult cannulation: ERCP performed by non-expert endoscopists, low-volume center, absence of acute cholangitis, normal serum bilirubin, intradiverticular papilla, and type of major duodenal papilla. Multivariate analysis identified ERCP performed by non-expert endoscopists (odds ratio [OR], 2.5; p<0.001), low-volume center (OR, 1.6; p<0.001), intradiverticular papilla (OR, 1.3; p=0.007), normal serum bilirubin (OR, 1.3; p=0.038), and absence of acute cholangitis (OR, 1.3; p=0.049) as factors significantly predicting difficult cannulation for CBDS.

Conclusions

Initial cannulation by an experienced endoscopist, early rescue cannulation, or early takeover by an experienced endoscopist should be considered when performing ERCP for CBDS in the presence of factors predicting difficult cannulation.

Complications of common bile duct stones: A risk factors analysis

BACKGROUND

The latest guidelines recommended that common bile duct stones (CBDSs) should be removed, preferably endoscopically, regardless of the presence of symptoms or complications. However, the removal of CBDSs may not be feasible in very old patients or those with co-morbidities. In these cases, it is important to understand the risk factors for the development of CBDSs-related complications to decide whether or not to treat high-risk patients. Herein, we aimed to identify the risk factors for the development of complications after the diagnosis of CBDSs.

METHODS

The medical records of patients with CBDSs between October 2005 and September 2019 were retrospectively analyzed. All patients with radiologically-diagnosed CBDSs, including those who received treatment and those who did not, were analyzed.

RESULTS

A total of 634 patients were included and 95 (15.0%) patients had CBDS-related complications during the mean follow-up period of 32.6 months. Forty-four (6.9%) high-risk patients remained asymptomatic and did not receive treatment during the follow-up period. In multivariate analyses, size of CBDSs ≥ 5 mm and no treatment within 30 days were independent risk factors for the development of complications. The spontaneous passage of CBDSs was proved radiologically in 9 out of 81 (11.1%) patients within 30 days.

CONCLUSIONS

It is recommended treating CBDSs within 30 days from the diagnosis, even in high-risk patients, especially if the size is larger than 5 mm.

Remaining issues of recommended management in current guidelines for asymptomatic common bile duct stones

Current guidelines for treating asymptomatic common bile duct stones (CBDS) recommend stone removal, with endoscopic retrograde cholangiopancreatography (ERCP) being the first treatment choice. When deciding on ERCP treatment for asymptomatic CBDS, the risk of ERCP-related complications and outcome of natural history of asymptomatic CBDS should be compared. The incidence rate of ERCP-related complications, particularly of post-ERCP pancreatitis for asymptomatic CBDS, was reportedly higher than that of symptomatic CBDS, increasing the risk of ERCP-related complications for asymptomatic CBDS compared with that previously reported for biliopancreatic diseases. Although studies have reported short- to middle-term outcomes of natural history of asymptomatic CBDS, its long-term natural history is not well known. Till date, there are no prospective studies that determined whether ERCP has a better outcome than no treatment in patients with asymptomatic CBDS or not. No randomized controlled trial has evaluated the risk of early and late ERCP-related complications vs the risk of biliary complications in the wait-and-see approach, suggesting that a change is needed in our perspective on endoscopic treatment for asymptomatic CBDS. Further studies examining long-term complication risks of ERCP and wait-and-see groups for asymptomatic CBDS are warranted to discuss whether routine endoscopic treatment for asymptomatic CBDS is justified or not.

Asymptomatic Common Bile Duct Stones Are Associated with Increased Risk of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis

Introduction: Common bile duct stones (CBDS) are a common disease that can cause biliary complications, including cholangitis, obstructive jaundice, and biliary pancreatitis. Regardless of the presence or absence of symptoms, endoscopic removal of CBDS is generally recommended, but endoscopic retrograde cholangiopancreatography (ERCP) is a high-risk procedure with complications, such as post-ERCP pancreatitis (PEP). As few reports have addressed the risk of PEP by focusing on asymptomatic CBDS, the purpose of this study is to examine the incidence of PEP for asymptomatic CBDS.

Methods: This retrospective study included data from 302 patients with naive papilla who underwent therapeutic ERCP for CBDS between January 2012 and December 2019 at our hospital. Univariate and multivariate logistic regression models were used to investigate independent risk factors for PEP.

Results: Of the 302 patients, 32 were asymptomatic, and the remaining 270 were symptomatic. Five asymptomatic patients (15.6%) suffered from mild PEP, whereas 10 (3.7%) symptomatic patients suffered from PEP (9 were mild, and 1 was severe). Univariate analysis identified deep cannulation time more than 10 min, endoscopic papillary balloon dilation (EPBD), and asymptomatic CBDS as risk factors for PEP, whereas multivariate analysis revealed deep cannulation time more than 10 min (odds ratio (OR), 6.67; p < 0.001), EPBD (HR, 5.70; p < 0.001), and asymptomatic CBDS (HR, 5.49; p < 0.001) as independent risk factors for PEP.

Conclusions: A wait-and-see approach may be an option for the management of asymptomatic CBDS. EPBD may be avoided, especially in case of asymptomatic or if difficult for bile duct cannulation.

Best evidence topic: Should patients with asymptomatic choledocholithiasis be treated differently from those with symptomatic or complicated disease?

Choledocholithiasis is a common finding in clinical practice, with presentation varying from asymptomatic to life-threatening complications. In symptomatic patients, there is no doubt that treatment to clear the bile duct is indicated, but there is still a debate regarding the treatment of patients with silent common bile duct stones (CBDS). The question addressed by this best evidence topic is whether patients with asymptomatic CBDS should be managed in the same way as patients with symptoms or complications. The search strategy yielded 609 articles, from which 8 articles found to be relevant to this topic. We also summarised the most notable societal guidelines recommendations, regarding this topic. We tabulated the article title, author, year, country, study type, outcomes, results, and comments. We concluded that patients with asymptomatic CBD stones should be offered endoscopic treatment If they are fit, after discussion of the potential risks and benefits of both options of conservative and interventional treatment with the patients.

Comparable safety of ERCP in symptomatic and asymptomatic patients with common bile duct stones: a propensity-matched analysis

BACKGROUND

The safety of endoscopic retrograde cholangiopancreatography (ERCP) for asymptomatic common bile duct (CBD) stones patients has not been thoroughly elucidated. This study attempted to compare the incidence and severity of ERCP complications in asymptomatic and symptomatic patients with CBD stones and to provide evidence for the treatment of asymptomatic CBD stones.

METHODS

The clinical data of patients were retrospectively analyzed. These patients were divided into the asymptomatic CBD stones group and the symptomatic CBD stones group. Propensity score matching (PSM) was used to match the two groups. The incidence and severity of postoperative complications of ERCP in the two groups were analyzed.

RESULTS

A total of 79 patients who had asymptomatic CBD stones and 795 patients who had symptomatic CBD stones were included in this study. After PSM, 79 patients from the asymptomatic CBD group and 316 patients from the symptomatic CBD stones group were identified. Before and after PSM, no significant differences in the incidence and severity of post-ERCP pancreatitis (PEP) were noted between the two groups (p > .05). In addition, no differences in the incidence and severity of other complications, including acute cholangitis, bleeding and perforation, between the two groups were observed before and after PSM (p > .05).

CONCLUSIONS

Patients with asymptomatic CBD stones do not exhibit an increased risk of ERCP-related complications compared with those with symptomatic CBD stones. ERCP was observed to be equally safe and efficacious for patients with asymptomatic versus symptomatic CBD stones.

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.

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.

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 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.

Percutaneous management of residual bile duct stones through T-tube tract after cholecystectomy: A retrospective analysis of 89 patients

PURPOSE

The purpose of this study was to analyze the outcome of percutaneous management of residual common bile duct (CBD) stones in patients with surgically inserted T-tube in CBD after cholecystectomy.

MATERIAL AND METHODS

Between April 2001 and August 2015, 89 patients (52 women, 37 men) with a mean age of 55.7 years±18 (SD) (range, 22-88 years) underwent percutaneous sphincteroplasty and stone expulsion into the duodenum with a Fogarty balloon catheter through the T-tube tract for residual CBD stones. All patients had previously undergone open cholecystectomy with CBD exploration and T-tube insertion 7 to 60 days (mean, 14.4 days) before the procedure. Results of the procedure and complications were evaluated by a review of clinical notes, imaging and laboratory findings.

RESULTS

The procedure was successful in 87/89 patients (97.7%). Complete CBD clearance was achieved in a first session in 86 patients (96.6%). One patient (1.1%) needed a second session. The procedure was unsuccessful in 2 patients (2.2%) due to inappropriate position of T-tube and stone impaction into the cystic duct remnant. Two complications (2.2%) including intra-abdominal bile collection and distal CBD stricture were observed after the procedure.

CONCLUSION

Percutaneous CBD expulsion into the duodenum through the T-tube tract is a non-traumatic, effective and safe method for the treatment of residual CBD stones in patients who had cholecystectomy and T-tube insertion.