Post-endoscopic retrograde cholangiopancreatography pancreatitis in patients with asymptomatic common bile duct stones

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.

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.

Balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography for asymptomatic common bile duct stones on surgically altered anatomy: A high risk factor for post-endoscopic retrograde cholangiopancreatography pancreatitis

BACKGROUND

Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is more common in patients with asymptomatic common bile duct stones (CBDSs) and normal anatomy than in those with symptomatic CBDS; however, studies on the effect of surgically altered anatomy are lacking. We aimed to investigate whether asymptomatic CBDS in balloon enteroscopy-assisted ERCP cases for surgically altered anatomy also has a high incidence of PEP and analyze the risk factors for PEP.

METHODS

We retrospectively analyzed 108 consecutive patients who underwent initial ERCP for CBDS with surgically altered anatomies and with naive papilla at Kitasato University Hospital from April 2015 to December 2022.

RESULTS

Study participants were as follows: 92 (85%) patients with symptomatic CBDS and 16 (15%) patients asymptomatic CBDS. The overall bile duct cannulation success rate was 89.8%, with PEP occurring in 7.4% of patients (symptomatic CBDS: 3.3%, asymptomatic CBDS: 31.3%). PEP incidence was significantly higher for asymptomatic CBDS (p = .0017). Multivariate analysis identified asymptomatic CBDS and precut sphincterotomy as significant risk factors for PEP.

CONCLUSIONS

Asymptomatic CBDS may be a risk factor for PEP onset in balloon enteroscopy-assisted ERCP with surgically altered anatomy. Therefore, the procedure should be performed after obtaining sufficient informed consent and adequate preparation.

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.

Impact of center and endoscopist ERCP volume on ERCP outcomes: a systematic review and meta-analysis

BACKGROUND AND AIMS

Endoscopist experience and center volume might be associated with ERCP outcomes, as in other fields of endoscopy and in surgery. An effort to assess this relationship is important to improve practice. This systematic review and meta-analysis aimed to evaluate these comparative data and to assess the impact of endoscopist and center volume on ERCP procedure outcomes.

METHODS

We performed a literature search in PubMed, Web of Science, and Scopus through March 2022. Volume classification included high- and low-volume (HV and LV) endoscopists and centers. The primary outcome was the impact of endoscopist and center volume on ERCP success. Secondary outcomes were the overall adverse event (AE) rate and the specific AE rate. The quality of the studies was assessed using the Newcastle-Ottawa scale. Data synthesis was obtained by direct meta-analyses using a random-effects model; results are presented as odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

Of 6833 relevant publications, 31 studies met the inclusion criteria. Procedure success was higher among HV endoscopists (OR, 1.81; 95% CI, 1.59-2.06; I2 = 57%) and in HV centers (OR, 1.77; 95% CI, 1.22-2.57; I2 = 67%). The overall AE rate was lower for procedures performed by HV endoscopists (OR, .71; 95% CI, .61-.82; I2 = 38%) and in HV centers (OR, .70; 95% CI, .51-.97; I2 = 92%). Bleeding was less frequent in procedures performed by HV endoscopists (OR, .67; 95% CI, .48-.95; I2 = 37%) but did not differ based on center volume (OR, .68; 95% CI, .24-1.90; I2 = 89%). No statistical differences were detected concerning pancreatitis, cholangitis, and perforation rates.

CONCLUSIONS

HV endoscopists and centers provide higher ERCP success rates with fewer overall AEs, especially bleeding, compared with respective LV comparators.

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.

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.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Emergency Endoscopic Retrograde Cholangiopancreatography Did Not Increase the Incidence of Postprocedural Pancreatitis Compared With Elective Cases: A Prospective Multicenter Observational Study

OBJECTIVE

The aim of this study was to identify the incidence of and risk factors for post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) after emergency endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

We performed a prospective multicenter observational study of 3914 patients who underwent ERCP. We compared the incidence of PEP after emergency and elective ERCP.

RESULTS

A total of 3410 patients were enrolled in this study. Post-ERCP pancreatitis occurred in 44 of 800 patients (5.5%) and in 190 of 2418 patients (7.9%) in the emergency and elective groups, respectively. No significant difference was noted between the groups (odds ratio [OR], 0.73; 95% confidence interval [CI], 0.52-1.03; P = 0.07). Multivariate analysis showed that the following factors increased the risk for PEP after emergency ERCP: contrast medium injection into the pancreatic duct (OR, 2.56; 95% CI, 1.30-5.03; P = 0.005), >4 cannulation attempts (OR, 5.72; 95% CI, 2.61-12.50; P < 0.001), and endoscopic papillary balloon dilatation (OR, 9.24; 95% CI, 2.13-40.10; P < 0.001).

CONCLUSIONS

No significant difference was noted in the incidence of PEP in patients after emergency and elective ERCP. We may prevent PEP even after emergency ERCP by avoiding contrast injection into the pancreatic duct, multiple cannulation attempts, and endoscopic papillary balloon dilatation.

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.

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.

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.

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 single-stage endoscopic common bile duct stone removal

Background and Aims

Papillary treatment, such as endoscopic sphincterotomy or endoscopic papillary balloon dilation, and subsequent single-stage endoscopic stone removal are often performed for choledocholithiasis; however, the incidence of postendoscopic retrograde cholangiopancreatography pancreatitis (PEP) is unclear. This study aimed to compare the overall incidence of PEP between single- and two-stage stone removal groups and the incidence of PEP between these two groups based on cannulation time.

Methods

We included 897 patients with native papilla who underwent papillary treatment and stone removal for choledocholithiasis with no inflammation or mild-to-moderate acute cholangitis at three institutions between April 2012 and March 2018 in Japan. We performed a propensity-matched analysis and regression adjustment by propensity score to adjust for potential confounding factors.

Results

In the propensity-matched analysis with 234 pairs, there was no significant difference in the overall incidence of PEP between single- and two-stage stone removal procedures (15/234, 6.4% vs 6/234, 2.6%, P = 0.072, respectively). Although single-stage stone removal after a cannulation time of ≤15 min was not a significant risk factor of PEP, the procedure after a cannulation time of >15 min was a significant risk factor of PEP as estimated by regression adjustment by propensity score (P = 0.014, 95% CI = 1.4-19.4, odds ratio = 5.2).

Conclusions

Single-stage endoscopic stone removal after a long cannulation time of >15 min increased the incidence of PEP compared with the two-stage stone removal procedure. Thus, single-stage stone removal should be performed in patients with a cannulation time ≤ 15 min.