Analysis of Efficacy and Safety of Laparoscopy Plus Choledochoscopy Combined With Holmium Laser Lithotripsy for Choledocholithiasis and Hepatolithiasis

Background

With the advancement of laparoscopic technology, the combination of laparoscopy, choledochoscopy, and holmium laser lithotripsy has emerged as an effective treatment modality for both choledocholithiasis and hepatolithiasis. This study aimed to assess the efficacy and safety of this approach.

Methods

Retrospective analysis was conducted on the medical records of 76 patients diagnosed with choledocholithiasis and hepatolithiasis between April 2021 and March 2023. Patients were divided into two groups based on the treatment plan: the control group, which underwent traditional laparotomy and choledochoscopy lithotripsy (n = 38), and the experimental group, which underwent laparoscopy combined with choledochoscopy and holmium laser lithotripsy (n = 38). Comparative analysis was performed on various operation-related parameters, stone-free rate, complication rates, and changes in biochemical, liver function, inflammatory, stress response indicators, and pain scores between the two groups.

Results

The experimental group demonstrated significantly shorter stone removal time, reduced intraoperative bleeding, and shorter hospital stay compared to the control group (P < 0.05). Moreover, the experimental group exhibited lower incidence of postoperative complications and lower pain scores at 2 weeks to 3 months post-operation (P < 0.05). Biochemical indicators including total bile acid (TBA), total bilirubin (TBIL), alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), and glutamyl transpeptidase (GGT) were significantly lower in the observation group compared to the control group (P < 0.05). Additionally, stress and inflammation indicators were also lower in the experimental group (P < 0.05).

Conclusions

The combination of laparoscopy, choledochoscopy, and holmium laser lithotripsy presents favorable therapeutic outcomes in the management of choledocholithiasis and hepatolithiasis, indicating its potential for widespread clinical application.

Improving early cholecystectomy rate in acute cholecystitis with an evidence-based local multidisciplinary protocol and a surgical audit: single-center experience through an Acute Care Surgery Division

PURPOSE

To analyze if, after implementation of an evidence-based local multidisciplinary protocol for acute cholecystitis (AC), an intermediate surgical audit could improve early cholecystectomy (EC) rate and other therapeutic indicators.

METHODS

Longitudinal cohort study at a tertiary center. The local protocol, promoted, created, and periodically revised by the Acute Care Surgery Unit (ACSu) was updated and approved on March 2019. A specific registry was prospectively fulfilled with demographics, comorbidity, type of presentation, diagnostic items, therapeutic decision, and clinical course, considering both non-operative management (NOM) or cholecystectomy, early and delayed (EC and DC). Phase 1: April 2019-April 2021. A critical analysis and a surgical audit with the participation of all the involved Departments were then performed, especially focusing on improving global EC rate, considered primary outcome. Phase 2: May 2021-May 2023. Software SPSS 23.0 was used to compare data between phases.

RESULTS

Initial EC rate was significantly higher on Phase 2 (39.3%vs52.5%, p < 0.004), as a significantly inferior rate of patients were initially bailed out from EC to NOM because of comorbidity (14.4%vs8%, p < 0.02) and grade II with severe inflammatory signs (7%vs3%, p < 0.04). A higher percentage of patients was recovered for EC after an initial decision of NOM on Phase 2, but without reaching statistical significance (21.8%vs29.2%, n.s.). Global EC rate significantly increased between phases (52.5%vs66.3%, p < 0.002) without increasing morbidity and mortality. A significant minor percentage of elective cholecystectomies after AC episodes had to be performed on Phase 2 (14%vs6.7%, p < 0.009). Complex EC and those indicated after readmission or NOM failure were usually performed by the ACSu staff.

CONCLUSION

To adequately follow up the implementation of a local protocol for AC healthcare, registering and periodically analyzing data allow to perform intermediate surgical audits, useful to improve therapeutic indicators, especially EC rate. AC constitutes an ideal model to work with an ACSu.

Feasibility and safety of intraoperative bile duct clearance by antegrade transcystic balloon sphincteroplasty: A prospective observational pilot study

BACKGROUND

Concomitant cholecystolithiasis and choledocholithiasis are common. Standard treatments are endoscopic retrograde cholangiography (ERC) followed by cholecystectomy or laparoendoscopic rendezvous. Endoscopic retrograde cholangiography has drawbacks, such as post-ERC pancreatitis or bleeding, and potentially more than one intervention is required to address common bile duct (CBD) stones. Safety and feasibility of an intraoperative antegrade transcystic single-stage approach during cholecystectomy with balloon sphincteroplasty and pushing of stones to the duodenum has not been evaluated prospectively. The aim of this pilot study was to evaluate this procedure regarding safety, feasibility, and stone clearance rate.

METHODS

Prospective single-center intervention study (SUPER Reporting-Guideline). Main inclusion criterion was confirmed choledocholithiasis (stones ≤6 mm) at intraoperative cholangiography. Success of the procedure was defined as CBD stone clearance at intraoperative control cholangiography, absence of symptoms and no elevated cholestasis parameters at 6 weeks follow-up. Simon's two-stage design was used to determine sample size.

RESULTS

From January 2021 to April 2022, a total of 57 patients fulfilled the final inclusion criteria and were included. Mild pancreatitis or cholangitis were present upon admission in 15 (26%) and 15 (26%) patients, respectively. Median number of CBD-stones was 1 (1-6). Median stone diameter was 4 mm (0.1-6 mm). Common bile duct stone clearance was achieved in 54 patients (94%). The main reason for failed CBD clearance was the inability to push the guidewire along the biliary stone into the duodenum. Median intervention time was 28 minutes (14-129 minutes). While there was no postoperative pancreatitis, two patients (3.5%) had asymptomatic hyperlipasemia 4 hours postoperatively.

CONCLUSION

Intraoperative CBD stone clearance by antegrade balloon sphincteroplasty appears to be safe and highly feasible. Its overall superiority to the current standards warrants evaluation by a randomized controlled trial.

LEVEL OF EVIDENCE

Therapeutic/Care Management, Level V.

Associations of fatty acids with the risk of biliary tract calculus and inflammation: a Mendelian randomization study

BACKGROUND

The presence of gallstones in both the gallbladder and bile ducts is referred to as cholelithiasis. The prevalence of cholecystolithiasis and bile duct stones differs. Observational and Mendelian randomization (MR) studies have elucidated the significant contributing role of numerous fatty acids (FAs) in the development of cholelithiasis. Despite numerous studies about cholelithiasis, evidence on the relationship between serum FA levels and cholecystolithiasis, as well as bile duct stones with or without inflammation, remains insufficient.

METHODS

A two-sample MR study was designed to clarify the impact of serum FA levels on various bile duct inflammatory diseases. The summary statistics of single nucleotide polymorphisms (SNPs) associated with fatty acids were obtained from the UK Biobank (UKB) and included data from 114,999 participants. The researchers obtained GWAS summary statistics for cholecystolithiasis and bile duct stones in 463,010 and 361,194 European participants, including cases with and without inflammation. No sample overlap between the exposure and outcome was verified through the "mr-lap" package. The SNPs were screened to identify instrumental variables (IVs). Cochran's Q test was applied for heterogeneity assessment. Inverse variance weighting (IVW) (fixed effects or random effects), MR-Egger regression and weighted median methods were used for MR. Multivariable MR was applied to determine the direct effect of each exposure on the outcome. A false discovery rate (FDR) was applied to adjust for multiple testing correction based on the Benjamini-Hochberg method. Finally, the FinnGen Consortium was used to validate some results.

RESULTS

The overall concentration of polyunsaturated fatty acids (PUFAs) in the serum was negatively associated with the risk of calculus of the gallbladder with acute cholecystitis (IVW, OR = 0.996, P = 0.038, CI 0.992-0.999; weighted median, OR = 0.995, P = 0.025, CI 0.991-0.999). The percentage of PUFAs to total monounsaturated fatty acids(MUFAs) (IVW, OR = 0.998, P = 0.045, CI 0.997-0.999) and the percentage of PUFAs to total FAs (IVW, OR = 0.997, P = 0.025, CI 0.995-0.999) had a protective role against cholecystitis. The percentage of PUFAs to total FAs had a protective role against calculus of the gallbladder without cholecystitis (IVW, OR = 0.995, P = 0.026, CI 0.990-0.999; MR Egger, OR = 0.99, P = 0.03, CI 0.982-0.998; weighted median, OR = 0.991, P = 5.41e-06, CI 0.988-0.995). Conversely, the percentage of MUFAs to total FAs increased the risk for cholecystitis (IVW, OR = 1.001, P = 0.034, CI 1.0001-1.002). However, there were no causal effects of the above exposures on the outcomes through multivariable MR and multiple testing correction. Finally, the causal effects of the above exposures on cholecystitis were validated in the FinnGen Consortium, which suggested that the percentage of PUFAs to total FAs (IVW, OR = 0.744, P = 0.021, CI 0.579-0.957) had a protective role against cholecystitis.

CONCLUSION

These Mendelian randomization findings suggested that more attention should be focused on people who have low serum PUFA levels, which may have a potential role in the occurrence of calculus of the gallbladder or cholecystitis rather than calculus of the bile duct without cholangitis or cholecystitis.

Current trends of minimally invasive therapy for cholecystocholedocholithiasis

Introduction

The minimally invasive approach of endoscopic ultrasound (EUS)-guided procedures for cholecystocholedocholithiasis, such as EUS-guided gallbladder drainage (EUS-GBD), EUS-guided rendezvous (EUS-RV), and EUS-guided biliary drainage (EUS-BD), is affirmed as an effective treatment for patients with acute cholecystitis (AC) who are unfit for surgery and for patients with common bile duct stones (CBDSs) who have experienced a previous ERCP failure. Furthermore, in cases of difficult CBDS extraction during endoscopic retrograde cholangiopancreatography (ERCP), cholangioscopy-guided electrohydraulic lithotripsy (CS-EHL) has showed optimal results. The main objective of our study was to evaluate the effectiveness of EUS-GBD and percutaneous gallbladder drainage (PT-GBD) in patients with AC who are unfit for surgery. We also aimed to evaluate the efficacy of EUS-GBD, EUS-BD, and EUS-RV following ERCP failure and the effectiveness of CS-EHL for difficult CBDS extraction in our hospital. The secondary aim was to examine the safety of these procedures.

Materials and methods

We conducted a retrospective evaluation of all the EUS-GBD, PT-GBD, EUS-BD, EUS-RV, and CS-EHL procedures, which were prospectively collected in the gastroenterology and digestive endoscopy unit and the general surgery unit from January 2020 to June 2023. The efficacy was expressed in terms of technical and clinical success rates, while safety was assessed based on the rate of adverse events (AEs).

Results

We enrolled 83 patients with AC and high surgical risk. Among them, 57 patients (68.7%, 24/57 male, median age 85 ± 11 years) underwent EUS-GBD, and 26 (31.3%, 19/26 male, median age 83 ± 7 years) underwent PT-GBD. The technical and clinical success rates were 96.5 and 100% for EUS-GBD, and 96.1 and 92% for PT-GBD. The AEs for EUS-GBD were 1.7%, and for PT-GBD, it was 12%. ERCP for CBDS extraction failed in 77 patients. Among them, 73 patients (94.8%) underwent EUS-RV with technical and clinical success rates of 72.6% (53/73) and 100%, respectively. No AEs were reported. Four out of 77 patients were directly treated with EUS-BD for pyloric inflammatory stenosis. In 12 patients (16.4%), following unsuccessful EUS-RV with a CBD diameter ≥ 12 mm, an EUS-BD was performed. Both technical and clinical success rates for EUS-BD were 100%, and no AEs were reported. EUS-GBD was the treatment of choice for the remaining 8 (10.9%) patients after failure of both ERCP and EUS-RV. The procedure had high technical and clinical success rates (both at 100%), and no AEs were reported. The 12 difficult CBDS extraction treated with CS-EHL also showed high technical and clinical success rates (both at 100%), with no reported AEs.

Conclusion

The minimally invasive approach for cholecystocholedocholithiasis, especially EUS-guided procedures, had high efficacy and safety in treating AC in high-risk surgical patients and CBDS extraction after a previously unsuccessful ERCP.

Preoperative MRCP Can Rule Out Choledocholithiasis in Acute Cholecystitis with a High Negative Predictive Value: Prospective Cohort Study with Intraoperative Cholangiography

BACKGROUND

Magnetic resonance cholangiopancreatography (MRCP) provides a noninvasive and fast modality for imaging the biliary tree when choledocholithiasis is suspected. Guidelines suggest that MRCP is recommended when strong or moderate signs of common bile duct (CBD) stones are present. Well-performed prospective studies are scarce regarding the sensitivity and specificity of preoperative MRCP in patients with acute cholecystitis in comparison with intraoperative cholangiography, ERCP, or choledochoscopy.

METHODS

We performed a prospective, observational population-based feasibility study in Central Finland Hospital Nova between January 2019 and December 2019. We examined the diagnostic performance of preoperative MRCP on consecutive patients with acute cholecystitis scheduled for index admission cholecystectomy. The accuracy of MRCP was verified with IOC, choledochoscopy, or ERCP. The interobserver reliability of the image quality of MRCP and the sensitivity and specificity of choledocholithiasis were observed independently by three experienced radiologists.

RESULTS

A total of 180 consecutive patients diagnosed with acute cholecystitis followed by index admission cholecystectomy were identified. MRCP was performed in 113/180 (62.8%) patients, and complementary perioperative imaging of the bile ducts was performed in 72/113 (63.7%) patients. The incidence of choledocholithiasis was high (29.2%). In acute cholecystitis, the sensitivity (76.2-85.7%) and specificity (84.3-92.2%) of MRCP were equally compared to the literature with unselected patient groups. The best visibility was observed in the common hepatic duct, the inferior CBD, and the central hepatic duct. The interobserver reliability was excellent for determining the size and quantity of CBD stones.

CONCLUSION

In acute cholecystitis, MRCP yields high negative predictive value regarding detection of choledocholithiasis. If CBD stones were discovered, the interobserver reliability was excellent when measuring the size and number of CBD stones. The best-visualized area was the distal part of the biliary tract, which provides good preoperative workup if choledocholithiasis is present.

Implications of routine cholangiography during laparoscopic cholecystectomy on postoperative testing: Review of more than 2,300 cases in a community-based practice

BACKGROUND

We hypothesized that routine cholangiography during laparoscopic cholecystectomy may increase use of postoperative imaging and invasive testing.

METHODS

A retrospective review was performed of laparoscopic cholecystectomy cases at 6 community hospitals from 2017 through 2020. For surgeons performing routine vs selective cholangiography, we compared primary outcomes of operative time, 30-day complications, and postoperative imaging or procedures.

RESULTS

In total, 2359 laparoscopic cholecystectomy procedures were performed. Eighteen surgeons performed routine cholangiography (1125 cases), and 13 performed selective (1234 cases). Mean operative time was longer in the routine group (125.3 vs 98.7 min, P < .001). Between groups, 30-day complications were similar. Two common bile duct injuries were identified in the routine group. Postoperatively, the routine group underwent 2.5 times more imaging and invasive testing (P < .001).

CONCLUSIONS

In community hospitals, laparoscopic cholecystectomy can be performed safely by surgeons using cholangiography routinely or selectively. Routine cholangiography resulted in more postoperative imaging and invasive testing.

Obstructive lithiasis of the lower bile duct discovered four decades after cholecystectomy and its management by ideal choledochotomy: a case report

BACKGROUND

Residual lithiasis is the presence of stones in the common bile duct, ignored after one or more biliary interventions. We report an atypical case of chronic symptomatic lithiasis of the lower bile duct occurring 41 years after biliary surgery, managed successfully by ideal choledochotomy.

CASE PRESENTATION

A 68-year-old Black African female with several past laparotomies including a cholecystectomy forty-one years ago presented with hepatic colic-type pain that had been intermittent for several years but worsened recently. Her clinical, biological, and imaging test assessments were suggestive of a residual obstructive lithiasis of the lower common bile duct. Through an open right subcostal laparotomy approach, a dilated bile duct of approximately 3 cm was found and managed by transverse choledochotomy in which the stone was extracted in retrograde manner. After confirmation of disobstruction, a primitive bile duct suture without biliary drainage was performed and a tubular drain was positioned under the liver. The postoperative course was uneventful at follow-up of 30 days.

CONCLUSION

Residual choledocholithiasis can be avoided. We performed an ideal choledochotomy, of which the follow-up was simple.

Five-Year Experience with Transcystic Laparoscopic Common Bile Duct Exploration

Background: Common bile duct (CBD) stones associated with cholecystitis can be treated by single-stage CBD exploration at the time of cholecystectomy or a two-stage approach with endoscopic stone extraction before or after cholecystectomy. The ideal management remains a matter of debate. The aim of this study is to analyze our outcomes with transcystic laparoscopic common bile duct exploration (LCBDE). Material and Methods: A retrospective review of patients who underwent transcystic LCBDE between 2015 and 2019 was performed. Results: A total of 106 patients underwent transcystic LCBDE over 5 years. We performed 1192 laparoscopic cholecystectomies with cholangiograms from March 2015 to December 2019. Fifteen patients had a preoperative endoscopic retrograde cholangiopancreatography (ERCP) for CBD stones seen on magnetic resonance cholangiopancreatography that during laparoscopic cholecystectomy with intraoperative cholangiogram (IOC), there were stones and/or sludge found in the CBD, which required clearance through a transcystic approach. Of the 91 patients who did not have a preoperative ERCP, clearance of the CBD was successful through a transcystic approach in 78 patients (86%). In the 13 patients that intraoperative clearance was not achieved (n = 13, 14%), a postoperative ERCP was performed. A total of 28 patients underwent either pre- or postoperative ERCP (n = 28, 26%). Choledochotomy was not performed in any of the patients. The mean operative time was 127 minutes (127 ± 48). The mean hospital length of stay (LOS) was 4 days (3.9 ± 2.8) with a median LOS of 3 days. Complications observed include wound infection (n = 2, 2%), pancreatitis after ERCP (n = 1, 1%), pneumonia (n = 1, 1%), and right hepatic duct injury (n = 1, 1%). Conclusion: Transcystic LCBDE is an effective and safe option for treatment of CBD stones. While a transcystic approach does not guarantee clearance of the CBD, it avoids the morbidity associated with a choledochotomy and can often prevent patients from having to undergo an additional procedure.

Gastrointestinal Emergencies and the Role of Endoscopy

Many gastrointestinal (GI) disorders present to the emergency room with acute clinical presentations, some even life threatening. Common emergencies encountered that require urgent endoscopic interventions include GI hemorrhage (variceal and nonvariceal), foreign body ingestion, obstructive jaundice, postprocedure-related complications such as postpolypectomy bleed or perforation, etc. A major advantage of emergency endoscopy is that it is cost effective and, on many occasions, can be life-saving. The present review will highlight a practical approach on various endoscopic modalities and their use in the GI emergencies.

A UK survey on variation in the practice of management of choledocholithiasis and laparoscopic common bile duct exploration (ALiCE Survey)

BACKGROUND

The practice of managing suspected/confirmed common bile duct stones (CBDS) can vary significantly in the UK. We aimed to assess this variability in practice and challenges to form a basis for future consensus.

METHODS

An electronic survey containing 40 questions on various aspects of management of CBDS was sent to surgeons who perform cholecystectomies via five surgical associations.

RESULTS

 A total of 132 surgeons responded to the survey. The speciality of surgeons includes upper gastro-intestinal (68%), general (18%), colorectal (12%), and others (2%). For patients with suspected CBD stones, 80% would choose magnetic resonance cholangio-pancreatography, and 14.4% would proceed to intra-operative imaging. Most surgeons preferred intra-operative cholangiogram over intra-operative ultrasound (83% vs 17%). For the treatment, 62.1% preferred a two-stage approach [endoscopic retrograde cholangio-pancreatography (ERCP) followed by laparoscopic cholecystectomy (LC)] and 33.4% chose a single-stage approach [LC + laparoscopic common bile duct exploration (LCBDE)]. Eighty (60.6%) responders performed LCBDE, and 19 (23.8%) of them performed > 10 LCBDEs in a year. Two third of surgeons (62.5%) preferred a trans-choledochal approach to CBDS. Half of the surgeons that perform LCBDE use a T-tube selectively and 1.6% routinely. The "availability of very good ERCP service" and "lack of formal training" were the two main reasons for surgeons not performing LCBDE. Both surgeons' speciality and whether they perform other complex laparoscopic surgery were significantly associated with choosing a two-stage approach over a one-stage approach (χ² test, speciality p = 0.033, complex surgery p = 0.011).

CONCLUSION

 Our survey confirms the significant variability in the diagnosis and management of CBDS. The two-stage approach is still the most common way of managing CBDS in the UK. The main reasons for the low uptake of the single-stage approach are the availability of good ERCP service, lack of equipment and lack of formal training in the technique of LCBDE.

[Temporal sequence of bile duct clearance with simultaneous cholecystolithiasis or choledocholithiasis-Preoperative, intraoperative or postoperative?]

Approximately 10% of patients with symptomatic cholecystolithiasis also have choledocholithiasis. The probability of this can be estimated on the basis of sonographic and laboratory chemistry parameters. If the probability is high, endoscopic retrograde cholangiography (ERC) or cholangiopancreatography (ERCP) should be performed and if the probability is low, cholecystectomy can be performed without further diagnostics. If the findings are equivocal, further work-up should be performed to detect or exclude choledocholithiasis by endoscopic ultrasound (EUS) or magnetic resonance cholangiopancreatography (MRCP). If choledocholithiasis is detected, it can be treated by ERC preoperatively, intraoperatively or postoperatively or alternatively by laparoscopic cholangiography. Regarding the temporal sequence, there is no clear advantage of a specific time point; however, considering the high availability of ERCP in German-speaking countries, preoperative clearance of choledocholithiasis seems reasonable. With respect to the time interval between clearance of choledocholithiasis and cholecystectomy, a number of multicenter studies and a meta-analysis have shown that a short time interval or a procedure during the same period of hospitalization is advantageous.

Long-term effects of endoscopic papillary large balloon dilation in patients with challenging bile duct calculi: A retrospective observational study

Endoscopic papillary large balloon dilation (EPLBD) can be used to treat challenging common bile duct stones. No previous studies have reported intractable cases treated either by EPLBD or mechanical lithotripter use. We aimed to evaluate and compare the long-term effects of EPLBD with mechanical lithotripter use.This retrospective cohort study reviewed data from 153 patients admitted to the Eastern Chiba Medical Center from April 2014 to March 2020, presenting with common bile duct calculi that could not be removed using a basket or balloon catheter. Patients were divided into groups depending on whether the treatment was performed using a mechanical lithotripter or EPLBD. The primary outcome was the recurrence rate of common bile duct calculi, and the secondary outcome was the rate of postoperative adverse events. The Wilcoxon test was used to compare the 2 groups. Statistical significance was set at P < .05.The median age of patients included in the lithotripter and EPLBD groups were 73 years and 83 years, respectively (P = .006), while the sex ratio (male:female) in the groups was 18:13 and 55:67, respectively. The EPLBD group showed a statistically larger median bile duct diameter (13 mm [range: 8-24 mm] vs 11 mm [range: 5-16 mm]; P < .001), larger maximal calculus diameter (median, 13.5 mm [range: 8-25 mm] vs 11 mm [range: 7-16 mm]; P < .001), and shorter median cumulative treatment time after reaching the duodenal papilla (35.5 minutes [range: 10-176 minutes] vs 47 minutes [range: 22-321 minutes]; P = .026) in comparison to the lithotripter group. There was no significant difference in the rate of adverse events between the EPLBD and the mechanical lithotripter groups. The recurrence rate was significantly lower (P = .014) in the EPLBD group.EPLBD increases therapeutic efficacy and reduces treatment duration for patients in whom calculus removal is difficult, without increasing the frequency of adverse events. No serious adverse events were observed. Additionally, EPLBD appears to reduce the risk of long-term recurrence. Future studies are needed to evaluate long-term outcomes in younger patients.

One-stage versus two-stage management for acute cholecystitis associated with common bile duct stones: a retrospective cohort study

BACKGROUND

Both one-stage [laparoscopic cholecystectomy (LC) plus laparoscopic common bile duct exploration (LCBDE)] and two-stage [endoscopic retrograde cholangiopancreatography (ERCP) followed by sequential LC] approaches are effective treatment for concomitant common bile duct (CBD) stones and gallstone. Although many studies compared one-stage with two-stage surgical approach for cholecysto-choledocholithiasis, there are very few studies compared the two management strategies for acute cholecystitis (AC) associated with CBD stones.

METHODS

Between January 2014 and December 2019, patients with concomitant AC and CBD stones proposed to early surgery were retrospectively studied. The patients were scheduled to undergo either the one-stage [LCBDE and LC (LCBDE+LC) were undertaken at the same operation] or two-stage [preoperative ERCP for CBD stone clearance was followed by LC 1-3 days later (pre-ERCP+LC)] procedure. The success rate of complete stone clearance, procedure-related complication, hospital stay, hospitalization charges and later biliary complications were compared between the two groups.

RESULTS

Sixty patients were included in the study, 28 in the one-stage group and 32 in the two-stage group. There was no significant difference in the success rate of complete stone clearance (96.4% vs. 93.8%, P = 1.000), complication rate (10.7% vs. 9.4%, P = 1.000), incidence of pancreatitis (0 vs. 6.3%, P = 0.494) or length of hospital stay (12 ± 5 vs. 11 ± 4 days, P = 0.393) between the two groups.

CONCLUSION

For patients with concomitant AC and choledocholithiasis proposed to early surgery, both the one-stage (LCBDE+LC) and two-stage (pre-ERCP+LC) approaches were acceptable and broadly comparable in achieving clearance of CBD stones.

Choledocholithiasis in acute calculous cholecystitis: guidelines and beyond

Background

Acute calculous cholecystitis (ACC) is the most frequent complication of gallstones requiring cholecystectomy. These patients may have coexisting choledocholithiasis. We aimed to evaluate the role of current guidelines for choledocholithiasis in patients with ACC.

Methods

In this retrospective study, we included all patients diagnosed with ACC between December 2018 and May 2019. These patients were substratified according to the guidelines of the American and European Societies of Gastrointestinal Endoscopy (ASGE and ESGE) as having high, intermediate, or low likelihood of choledocholithiasis, and the diagnostic performance was measured. Binomial logistic regression analysis was applied to ascertain independent risk factors for choledocholithiasis.

Results

A total of 173 patients with ACC, mean age (±standard deviation) 49.89±15.74 years and 60.1% male, were included. Sixty-three (36.4%) had confirmed choledocholithiasis. ASGE high likelihood criteria had sensitivity and specificity of 61.9% (95% confidence interval [CI] 48.8-73.9) and 83.4% (95%CI 75.4-90.0) for predicting choledocholithiasis. ESGE high likelihood criteria had sensitivity and specificity of 49.2% (95%CI 36.4-62.1) and 87.3% (95%CI 79.6-92.9). On logistic regression analysis, an alkaline phosphatase level above the upper limit of normal (P=0.003; odds ratio [OR] 4.26, 95%CI 1.66-10.96) and a dilated common bile duct on ultrasound (P=0.001; OR 9.97, 95%CI 4.65-21.36) were independent positive predictors for choledocholithiasis, while acute biliary pancreatitis was an independent negative predictor (P=0.030; OR 0.36, 95%CI 0.14-0.91).

Conclusions

The performance of the ASGE and ESGE guidelines’ risk stratification criteria is inadequate in patients with ACC. We suggest the utilization of a separate predictive model for suspected choledocholithiasis in these patients.