The influence of periampullary diverticula on ERCP for treatment of common bile duct stones

Predictors of technical success of percutaneous transhepatic common bile duct stone removal: is it only a matter of stone size?

OBJECTIVES

The common practice is to remove symptomatic common bile duct (CBD) stones in patients. This study aimed to investigate the factors affecting the percutaneous transhepatic removal of CBD stones.

METHODS

We retrospectively analyzed the data of 100 patients (66 men and 34 women; age: 25-105 years, mean 79.1 years) with symptomatic CBD stones who underwent percutaneous transhepatic stone removal (PTSR) from January 2010 through October 2019. After balloon dilation of the ampulla of Vater or bilioenteric anastomosis, the stones were pushed out of the CBD into the small bowel with a balloon catheter. If failed, basket lithotripsy was performed. Technical success was defined as complete clearance of the bile ducts on a cholangiogram.

RESULTS

The technical success rate was 83%, and achieved 90.2% in patients with altered gastroduodenal/pancreatobiliary anatomy. Multivariable analysis revealed that CBD diameter (odds ratio [OR]: 506.460, p = 0.015), failed ERCP (OR: 16.509, p = 0.004), Tokyo guidelines TG18/TG13 severity (grade III; OR: 60.467, p = 0.006), and left-sided transhepatic approach (OR: 21.621, p = 0.012) were risk factors for technical failure. The appropriate cutoff CBD size was 15.5 mm (area under the curve: 0.91). CBD stone size, radiopacity of stones, and CBD angle between retroduodenal and pancreatic portion did not influence technical success.

CONCLUSIONS

PTSR is effective for CBD stone removal in older adults and individuals with altered gastrointestinal tract anatomy. The aforementioned risk factors for technical failure should be considered in preoperative evaluation before PTSR to improve the success rate.

KEY POINTS

• PTSR is effective in symptomatic CBD stone management among older adults and individuals with altered anatomy. Investigating clinical /anatomic factors can guide radiologists toward a more comprehensive preoperative evaluation to maximize the success rate. • Our data indicate that dilated CBD (diameter ≥ 15.5 mm) and left-sided PTBDs reduce the technical success rate by 506-fold and 22-fold, respectively. • Clinical factors such as previous failed ERCP for stone removal and higher severity of acute cholangitis lessen the technical success rate.

Residual choledocholithiasis after choledocholithotomy T-tube drainage: what is the best intervention strategy?

BACKGROUND

The best intervention approach for residual choledocholithiasis after choledocholithotomy T-tube drainage remains controversial, especially during the period of indwelling T tube and the formation of a sinus. The purpose of the study was to estimate the effects of two therapeutic modalities, namely endoscopic retrograde cholangiopancreatography (ERCP) and choledochfiberscope via the T-tube sinus tract (CDS) on residual choledocholithiasis after choledocholithotomy T-tube drainage.

METHODS

A total of 112 patients with residual choledocholithiasis after choledochotomy were included in the study, 50 of which underwent ERCP and 62 patients experienced choledochoscopy via the T-tube sinus tract. The primary outcome measures included the success rate of remove biliary stones, T-tube drainage time, and the average length of hospital stay. The secondary objective was to consider incidence of adverse events including cholangitis, bile leakage, T-tube migration, pancreatitis, bleeding and perforation. After hospital discharge, patients were followed up for two years and the recurrence of choledocholithiasis was recorded.

RESULTS

There was no significant difference in the success rate of stone removal between the two groups. Compared to CDS group, T-tube drainage time and the average length of hospital stay was significantly shorter in the ERCP group. The incidence of complications (cholangitis and bile leakage) in the ERCP group was lower than that in the CDS group, but there was no statistically significant difference. When the T-tube sinus tract is not maturation, ERCP was the more appropriate endoscopic intervention to remove residual choledocholithiasis, particularly complicated with cholangitis at this time period.

CONCLUSIONS

ERCP is a safe and effective endoscopic intervention to remove residual choledocholithiasis after choledocholithotomy T-tube Drainage without the condition of T-tube sinus tract restriction.