Management of cholelithiasis with choledocholithiasis: Endoscopic and surgical approaches

Structural or functional abnormality of sphincter of Oddi: an important factor for the recurrence of choledocholithiasis after endoscopic treatment

A high recurrence rate is undesirable after treatment of common bile duct (CBD) stones. A major risk factor identified for recurrence is that invasive techniques, including surgical or endoscopic treatments, will impair the biliary tract system either by direct incision of the CBD or by cutting or dilating the ampulla of Vater. During endoscopic treatment, two main assisted methods for lithotomy, sphincterotomy and papillary balloon dilation, can result in different degrees of damage to the structure and function of the sphincter of Oddi (SO), contributing to slowing of biliary excretion, cholestasis, biliary bacterial infection, and promotion of bile duct stone recurrence. In this review, the relationship between endoscopic lithotomy and structural impairment or functional abnormality of the SO will be summarized, and their relationship with the recurrence of CBD stones will also be analyzed. Further improvement of these endoscopic methods or exploration of some novel methods, such as endoscopic endoclip papilloplasty, temporary insertion of a self-expandable metal stent, and combined application of peroral cholangioscopy, may aid in providing more appropriate treatment for patients with choledocholithiasis, repair or protect the function and structure of SO, reduce or prevent the recurrence of bile duct stones, and improve patient outcomes.

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

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

Clinical application of indocyanine green fluorescence imaging in laparoscopic cholecystectomy with common bile duct exploration and J-Tube drainage

BACKGROUND

Intraoperative and postoperative biliary injuries remain significant complications of laparoscopic common bile duct exploration (LCBDE). Indocyanine green (ICG) has been shown to significantly reduce injuries caused by intraoperative operational errors. We found that the J-tube can reduce postoperative strictures and injuries to the common bile duct. At this moment, we aim to analyze and compare the complications, efficacy, short-term outcomes, and feasibility of these two adjunctive tools for LCBDE.

AIM

To evaluate the efficacy of ICG fluorescence imaging In LCBDE and J-tube drainage for patients with common bile duct stones.

METHODS

We retrospectively collected the clinical case data of patients who were treated at the Hepatobiliary Surgery Department of the Third People's Hospital of Nantong, affiliated with Nantong University, from January 2016 to January 2021 due to gallbladder stones with choledocholithiasis and who underwent LCBDE combined with a primary suture and either J-tube or T-tube drainage. The patients were divided into groups: Traditional white-light laparoscopy + T-tube group (WL + T-tube), traditional WL + J-tube group, fluorescent laparoscopy + T-tube group (ICG + T-tube) and fluorescent laparoscopy + J-tube group (ICG + J-tube). The preoperative and postoperative clinical case data, laboratory examination data, and intraoperative and postoperative complications (including postoperative bile leakage, electrolyte disturbances, biliary peritonitis, and postoperative infections) and other relevant indicators were compared.

RESULTS

A total of 198 patients (112 males and 86 females) were included in the study, with 74 patients in the WL + T-tube, 47 in the WL + J-tube, 42 in the ICG + T-tube, and 35 in the ICG + J-tube. Compared with the other groups, the ICG + J had significantly shorter operation time (114 minutes, P = 0.001), less blood loss (42 mL, P = 0.02), shorter postoperative hospital stays (7 days, P = 0.038), and lower surgical costs (China yuan 30178, P = 0.001). Furthermore, patients were subdivided into two groups based on whether a T-tube or J-tube was placed during the surgery. By the third postoperative day, the aspartate transaminase, glutamic pyruvic transaminase, total bilirubin, and direct bilirubin levels were lower in the J-tube group than in the T-tube group (P < 0.001). At last, follow-up observations showed that the incidence of biliary strictures at three months postoperatively was significantly lower in the J-tube group than in the T-tube group (P = 0.002).

CONCLUSION

ICG fluorescence imaging in laparoscopic cholecystectomy with common bile duct exploration and J-tube drainage facilitates rapid identification of biliary anatomy and variations, reducing intraoperative bile duct injury, blood loss, surgery duration, and postoperative bile duct stenosis rates, supporting its clinical adoption.

Endoscopic retrograde cholangiopancreatography combined with extracorporeal shock wave lithotripsy for the removal of large gallbladder stones: a pilot study

BACKGROUND

Endoscopic gallbladder-preserving cholecystolithotomy (EGPC) has become an alternative option for treating cholecystolithiasis. However, developing a new method of EGPC in which the gallbladder wall is not damaged remains a challenge. This study introduced a new EGPC method called endoscopic retrograde cholangiopancreatography (ERCP) combined with extracorporeal shock wave lithotripsy (ESWL), which preserves the integrity of the gallbladder wall in the treatment of cholecystolithiasis complicated with choledocholithiasis.

METHODS

In total, six patients (aged 23-72 years, 3 males and 3 females, Han ethnicity) who had large gallbladder stones (diameter ≥ 1 cm) complicated with common bile duct (CBD) stones and who underwent ERCP combined with ESWL at the First Affiliated Hospital of Nanchang University from July 2022 to December 2022 were enrolled. The patients' clinical characteristics, endoscopic treatment and follow-up data were analyzed. A paired t test was performed to compare the differences in the main serological indicators before and after EGPC.

RESULTS

Of the six patients, five completed EGPC, and one failed due to intolerable abdominal pain during ESWL and was subsequently transferred to surgery. With respect to post-EGPC adverse events, one patient developed mild post-ERCP pancreatitis, and no other adverse events occurred. Both the technical success rate and clinical success rate of ERCP combined with ESWL were 83.3% and the incidence of adverse events was 16.7%. The six patients were followed up for an average of 24 months, during which only one patient experienced a recurrence of gallbladder stones at the 3-month follow-up, but no gallbladder stones were found at the 6-month follow-up after oral administration of ursodeoxycholic acid.

CONCLUSIONS

ERCP combined with ESWL is a potentially safe and effective treatment for large gallbladder stones.

TRIAL REGISTRATION

This study was registered at the Chinese Clinical Trial Registry site. [Registration number: ChiCTR2200060927 ( http://www.chictr.org.cn/ ); registration date: June 14, 2022].

Telerobotic Versus Standard Ultrasound in the Assessment of the Abdomen and Pelvis: A Real-World Prospective Study

Introduction: Telerobotic ultrasound has emerged as a promising technology in medicine, especially in settings with limited medical access or a lack of specialized personnel. However, there are very few studies evaluating its usefulness in real-world clinical practice. Objective: This study evaluates the usefulness of abdominopelvic telerobotic ultrasound in a real-world practice setting. Methods: A prospective study was performed in a cohort of adult patients who underwent abdominal ultrasound in a remote secondary hospital for suspected abdominal or pelvic pathology. Examinations were performed by an on-site technician and a remote abdominal radiologist. Satisfaction of patients and explorers, scan times, quality of visualization of anatomical structures, and ultrasound findings were measured and compared with standard ultrasound examinations performed by an on-site radiologist blinded to telerobotic ultrasound findings. Multivariate analyses were performed to predict variables related to the visualization quality of abdominopelvic organs. Results: The sample included 40 patients (60% women; mean age, 51.2 ± 16.1 years; 35% overweight and 17.5% obese). Significant differences in ultrasound duration were observed between telerobotic ultrasound and standard ultrasound (27.4 ± 8.3 and 12.7 ± 3.1 min, respectively; p < 0.001). The mean satisfaction of radiologists, technicians, and patients with telerobotic ultrasound was high (7.35 ± 1.14 for radiologists, 7.93 ± 0.83 for technicians, and 8.43 ± 1.38 for patients). Visualization of anatomical structures was acceptable for most organs on telerobotic ultrasound but significantly worse than conventional ultrasound when "excellent visualization" was the reference standard. In addition, telerobotic ultrasound did not identify potentially relevant findings in a significant (70%) proportion of patients. Conclusions: Telerobotic ultrasound offers acceptable results in the assessment of abdominopelvic organs and can help provide adequate healthcare to patients in locations with limited access to radiology specialists. However, there are significant limitations compared to standard ultrasound for their optimal evaluation.

Giant Primary Choledocholithiasis: A Rare Case Report and Comprehensive Review of Literature

Choledocholithiasis is the second most common complication of gallstone disease. Giant primary choledocholithiasis is a rare occurrence. Ultrasonography is the initial mode of imaging, and endoscopic ultrasound is considered superior to other modalities. Endoscopic retrograde cholangiopancreatography can be used for stone extraction. Other treatment modalities include laparoscopic or open common bile duct (CBD) exploration. Many institutions in underdeveloped countries still practice open CBD exploration. Factors such as larger stone diameter, edema of the CBD, and the presence of multiple lithiasis can influence the treatment approach. In this article we are presenting a case of 62 years-old-female with no any known comorbidities had presented to emergency with severe upper quadrant pain and giant choledocholithiasis was diagnosed in ultrasound and computed tomography scan with no other features of complications and patient successfully underwent open CBD exploration with intraoperative choledochoscopy and primary closure.

Modern Management of Common Bile Duct Stones: Breakthroughs, Challenges, and Future Perspectives

Common bile duct (CBD) stone management has evolved significantly with technological advances and an improved understanding of pathophysiology. This comprehensive review examines current evidence and emerging trends in CBD stone management, emphasizing modern diagnostic approaches and treatment paradigms. Recent developments in imaging techniques, including AI-assisted analysis, have enhanced diagnostic accuracy. Treatment strategies now emphasize minimally invasive approaches, with endoscopic techniques showing success rates exceeding 90% in experienced centers. Special considerations for specific populations, including elderly patients and those with altered anatomy, have led to refined management algorithms. Future directions include novel stone fragmentation technologies, biodegradable materials, and personalized medicine approaches. The integration of these advances, combined with a multidisciplinary approach, has improved patient outcomes while presenting new opportunities for enhanced care delivery. Continued technological innovation and refined techniques suggest a promising future for CBD stone management, although challenges remain in optimizing treatment selection and preventing recurrence.

Laparoscopic cholecystectomy plus common bile duct exploration for extrahepatic bile duct stones and postoperative recurrence-associated risk factors

BACKGROUND

There remain controversies regarding the surgical treatment of extrahepatic bile duct stones (EHBDSs) in clinical practice.

AIM

To explore the curative effect of laparoscopic cholecystectomy (LC) plus common bile duct exploration (CBDE) for the surgical treatment of EHBDSs and to analyze the risk factors that affect postoperative stone recurrence.

METHODS

Eighty-two patients with EHBDSs admitted between March 2017 and March 2023 were selected. Among them, patients treated with open choledocholithotomy plus LC or open cholecystectomy (OC) were set as the control group (n = 40), and those treated with LC plus CBDE served as the observation group (n = 42). The surgical outcomes of the two groups were compared, the surgical complications and Gastrointestinal Quality of Life Index (GIQLI) scores were counted, and the one-year prognostic recurrence was recorded. Independent factors for postoperative recurrence were determined using univariate and multivariate analyses.

RESULTS

The two groups were comparable in the stone residual rate (P > 0.05). The operation time (P < 0.05), intraoperative bleeding (P < 0.05), and total complication rate (P = 0.005) were lower in the observation group than in the control group. The observation group exhibited a marked increase in the GIQLI score, which was higher than the control group (P < 0.05). A lower one-year recurrence rate was determined in the observation group vs the control group (P = 0.027). Sphincter of Oddi dysfunction [odds ratio (OR) = 5.712, P = 0.007] and the treatment scheme of open choledocholithotomy plus LC or OC (OR = 6.771, P = 0.008) were the independent risk factors for one-year recurrence in patients after surgery.

CONCLUSION

LC plus CBDE for patients with EHBDSs can reduce stone residuals, intraoperative bleeding, complications, and postoperative recurrence.

Safety, efficacy, and feasibility of percutaneous transhepatic endoscopic holmium laser lithotripsy for bile duct stones

OBJECTIVE

To evaluate the safety and efficacy of percutaneous transhepatic endoscopic holmium laser lithotripsy (PTEHL) for patients with intrahepatic bile duct (IHBD) and common bile duct (CBD) stones.

MATERIAL AND METHODS

This retrospective study included 530 patients (mean age: 55.6 ± 8.5; 64.2% female) with IHBD and/or CBD stones at a single institution from January 2019 to December 2021. PTEHL was the chosen treatment for patients with large, complex stones, or those for whom Endoscopic Retrograde Cholangiopancreatography (ERCP) failed or presented difficulties. Patients showing signs of cholangitis required pre-PTEHL drainage. Stone clearance was confirmed by post-procedural cholangiography, and the technique was deemed successful when target stones were removed. Complications were recorded according to the Society of Interventional Radiology adverse event classification.

RESULTS

The mean stone size was 20.9 ± 11.9 mm, multiple stones observed in 460 patients (86.8%). A total of 225 patients (42.5%) had stones in both the IHBD and CBD; biliary-enteric anastomosis in 50 patients (9.4%). ERCP for stone removal proved unsuccessful in 18 patients (3.4%). Pre-IHBD drainage was performed in 271 patients (51.1%). The majority (488 patients, 92.1%) underwent a single PTEHL session. The technique was successful in 523 patients (98.7%), with 7 patients requiring surgery due to unsuccessful target stone removal. Complications were noted in 75 patients (14.2%), including 4.7% with severe complications and 9.4% with minor complications.

CONCLUSION

PTEHL is a safe and effective method for the treatment of both intrahepatic and extrahepatic bile duct stones. This approach is a valuable option for complex stone cases, particularly when ERCP is unsuccessful or encounters significant challenges.

CLINICAL RELEVANCE STATEMENT

Percutaneous Transhepatic Endoscopic Holmium Laser Lithotripsy is a safe and effective treatment method for intrahepatic and extrahepatic biliary stones, particularly in cases of complex stones.

KEY POINTS

Percutaneous transhepatic biliary stone removal is difficult for large or intraductal stones. Percutaneous Transhepatic Endoscopic Holmium Laser Lithotripsy (PTEHL) demonstrated a high success rate with few major complications. PTEHL can treat biliary stones, particularly stones that are difficult or have failed ERCP treatment.

Outcomes of Gallbladder Drainage Techniques in Acute Cholecystitis: Percutaneous Versus Endoscopic Methods

Acute cholecystitis, often caused by gallstones obstructing the cystic duct, is a potentially life-threatening condition that requires timely intervention. High-risk patients, particularly those with significant comorbidities, may not be suitable candidates for laparoscopic cholecystectomy, necessitating alternative drainage techniques such as percutaneous cholecystostomy (PC) and endoscopic gallbladder drainage (EGD). This systematic review aims to compare the efficacy, safety, and outcomes of PC and EGD in managing acute cholecystitis in high-risk surgical patients. A comprehensive literature search was conducted across multiple databases, including PubMed, Medline, Embase, Cochrane Library, and Scopus, from inception to October 2024. Studies were included if they assessed the outcomes of PC versus EGD in high-risk patients with acute cholecystitis. Data extraction focused on primary outcomes such as complication rates, reintervention needs, symptom resolution, hospital stay duration, and mortality. A qualitative synthesis was conducted due to heterogeneity in the study designs. Four randomized controlled trials and cohort studies were included, encompassing a total of 238 high-risk patients. Laparoscopic cholecystectomy showed significantly better outcomes compared to percutaneous drainage in reducing major complications, reintervention rates, and recurrent biliary disease. Endoscopic drainage techniques, including naso-gallbladder drainage and gallbladder stenting, demonstrated similar clinical success rates with fewer complications than percutaneous methods, particularly in patients with concurrent biliary conditions. The findings suggest that while percutaneous drainage provides rapid symptom relief, it is associated with higher reintervention rates. Endoscopic techniques offer fewer complications and are particularly beneficial for patients with suspected choledocholithiasis. However, the choice of drainage method should be based on individual patient profiles, taking into account overall health status and comorbidities. Both percutaneous and endoscopic drainage methods are effective in managing acute cholecystitis in high-risk patients, with distinct advantages depending on patient-specific factors. Further research is needed to explore long-term outcomes and hybrid approaches that may optimize care for these patients.

Diagnostic value of T-tube cholangiography and choledochoscopy in residual calculi after biliary surgery

BACKGROUND

T-tube cholangiography and choledochoscopy are commonly used techniques for detecting residual bile duct stones after biliary surgery. However, the utility of routine cholangiography before T-tube removal needs further investigation. This study aims to evaluate the diagnostic efficacy of various methods for detecting residual calculi following biliary surgery.

METHODS

We retrospectively analyzed the clinical data of 287 adult patients who underwent common bile duct exploration with T-tube drainage, followed by T-tube cholangiography and choledochoscopy, at the Department of General Surgery, Xuanwu Hospital, Capital Medical University, between 2017 and 2022. Exclusion criteria were patients with bile duct tumors, incomplete medical records or loss to follow-up, and patients with contraindications to T-tube or choledochoscopy. McNemanr test and Kappa test were used to compare the results and consistency between choledochoscopy and T-tube cholangiography. All patients underwent both cholangiography and choledochoscopy six to eight weeks after laparoscopic cholecystectomy combined with common bile duct exploration and T-tube drainage. The results of T-tube cholangiography and choledochoscopy for each patient were recorded, analyzed, and compared.

RESULTS

Among the 287 patients, T-tube cholangiography detected residual stones in 38 cases, which were confirmed by choledochoscopy in 29 cases. Conversely, of the 249 patients without evidence of residual stones on T-tube angiography, 11 patient was later found to have retained stones through choledochoscopy. There was no significant difference between the results of T-tube cholangiography and choledochoscopy (P = 0.82), indicating a high level of agreement between the two methods (Kappa value: 0.70) (95% CI, 0.65-0.76).

CONCLUSION

There is no significant difference in the diagnostic accuracy between T-tube cholangiography and choledochoscopy for detecting residual bile duct stones after surgery (P = 0.82). The two methods demonstrated a high level of consistency (Kappa value: 0.70) (95% CI, 0.65-0.76). The choice of diagnostic method for postoperative residual bile duct stones should be based on the specific condition of the patient.

Open versus laparoscopic completion cholecystectomy in patients with previous open partial cholecystectomy: a retrospective comparative study

Background

Some patients report recurrence or persistence of their manifestations after cholecystectomy, and retained gallstones may be a relevant etiology for their complaint. Completion cholecystectomy is advised for these cases to alleviate their manifestations. No previous studies have compared the outcomes of open versus laparoscopic outcomes in these patients, especially in patients who had initial open partial procedures. That is why we performed this study to report the perioperative outcomes of the two approaches in such patients.

Methodology

This is a retrospective analysis of 80 patients who had a completion cholecystectomy in the authors' center (40 open and 40 laparoscopic cases) after initial open partial cholecystectomy.

Results

The duration elapsed since the primary procedure had an average of 18 months in the open group and 21 months in the laparoscopic group. Abdominal pain and dyspepsia were the most common presentations. Some patients had stump cholecystitis or jaundice. The intraoperative assessment revealed either the residual gallbladder or a long cystic duct stump. Laparoscopy yielded shorter operative time, earlier oral intake, and shorter hospitalization periods compared to the open approach (P<0.05). The latter was associated with a 20% wound infection rate that was never encountered after laparoscopy (P =0.003).

Conclusion

Previous open partial cholecystectomy does not hinder subsequent laparoscopic completion cholecystectomy. Additionally, laparoscopy is associated with better perioperative outcomes than the open approach.

One-Stage Intraoperative ERCP combined with Laparoscopic Cholecystectomy Versus Two-Stage Preoperative ERCP Followed by Laparoscopic Cholecystectomy in the Management of Gallbladder with Common Bile Duct Stones: A Meta-analysis

INTRODUCTION

Concomitant gallbladder and common bile duct (CBD) stones, known as cholecystocholedocholithiasis, are clinically prevalent. There is currently no consensus on sequential versus simultaneous management approaches, and, if simultaneous, which approach to adopt. This meta-analysis evaluates the safety and efficacy of one-stage laparoscopic cholecystectomy (LC) with intraoperative endoscopic retrograde cholangiopancreatography (ERCP) versus two-stage ERCP followed by LC for treating concomitant gallbladder and CBD stones.

METHODS

A comprehensive literature search was conducted in five databases, PubMed, Embase, Web of Science, VIP, and Wanfang, for all randomized controlled trials (RCTs), cohort and retrospective studies published up to February 2024. Data extraction was performed independently by two reviewers. The primary outcomes were CBD stone clearance rate and postoperative complications morbidity. Secondary outcomes included conversion to other procedures and length of hospital stay. Statistical analyses were performed using R (v.4.3.2) with weighted mean differences and odds ratios (ORs) calculated for continuous and dichotomous variables, respectively, with 95% confidence intervals (CIs).

RESULTS

A total of 17 studies involving 2120 patients have been included, with 898 patients receiving single-stage and 1222 patients undergoing two-stage treatment. Of these studies, 9 were RCTs and 8 were retrospective cohort study. The one-stage group demonstrated superior outcomes in terms of CBD stone clearance (OR = 2.07, p = 0.0004), overall morbidity (OR = 0.35, p < 0.0001), post-operative pancreatitis (OR = 0.49, p = 0.006), conversion to other procedures (OR = 0.38, p = 0.0006), and length of hospital stay (MD = - 2.6456, 95% CI - 3.5776; - 1.7136, p < 0.0001). No significant differences were observed in post-operative cholangitis (OR = 0.44, p = 0.12), post-operative bleeding (OR = 0.76, p = 0.47), or bile leakage (OR = 1.28, p = 0.54).

CONCLUSION

For patients with concomitant gallbladder and CBD stones, the one-stage approach combining ERCP and LC appears safer and more effective, with advantages including higher stone clearance rates, reduced postoperative complications (particularly pancreatitis), shorter hospital stays, fewer residual stones, and decreased need for additional procedures. However, additional high-quality clinical trials are needed to establish the optimal treatment approach for various patient scenarios.

Investigating causal links between gallstones, cholecystectomy, and 33 site-specific cancers: a Mendelian randomization post-meta-analysis study

BACKGROUND AND AIM

The association between gallstones/cholecystectomy and cancer remains inconclusive in the current literature. This study aimed to explore the causal connections between gallstones/cholecystectomy and cancer risk by utilizing a bidirectional two-sample multivariable Mendelian randomization approach with Genome-Wide Association Studies data.

METHODS

Utilizing Genome-Wide Association Studies data from the UK Biobank and FinnGen, this research employed multivariable Mendelian randomization analyses to explore the impact of gallstones and cholecystectomy on the risk of 33 distinct cancer types. Instrumental variables for gallstones and cholecystectomy were carefully selected to ensure robust analyses, and sensitivity and heterogeneity tests were conducted to verify the findings' validity.

RESULTS

Multivariable Mendelian randomization analysis, incorporating data from more than 450,000 individuals for gallstones and cholecystectomy, revealed nuanced associations with cancer risk. Cholecystectomy was associated with a significantly increased risk of nonmelanoma skin cancer (OR = 1.59, 95% CI: 1.21 to 2.10, P = 0.001), while gallstones were linked to a decreased risk of the same cancer type (OR = 0.63, 95% CI: 0.47 to 0.84, P = 0.002). Interestingly, the analysis also suggested that cholecystectomy may lower the risk of small intestine tumors (OR = 0.18, 95% CI: 0.043 to 0.71, P = 0.015), with gallstones showing an inverse relationship, indicating an increased risk (OR = 6.41, 95% CI: 1.48 to 27.80, P = 0.013).

CONCLUSIONS

The multivariable Mendelian randomization analysis highlights the differential impact of gallstones and cholecystectomy on cancer risk, specifically for nonmelanoma skin cancer and small intestine tumors. These results underscore the importance of nuanced clinical management strategies and further research to understand the underlying mechanisms and potential clinical implications of gallstone disease and cholecystectomy on cancer risk.

Emodin repairs interstitial cells of Cajal damaged by cholelithiasis in the gallbladder

Background

Hypercholesterolemia induces cholelithiasis and dysfunction of gallbladder motility. Interstitial cells of Cajal (ICCs) contribute to gallbladder motility. Emodin modulates the contractility of the gallbladder muscle; however, the underlying mechanism is unknown.

Aim

This study aimed to explore the effects of emodin on gallbladder ICCs with cholelithiasis in a guinea pig model.

Methods

Animals were randomly divided into a healthy control group and three study groups. All study groups received a high-cholesterol diet (HCD) for 8 weeks. Subsequently, they were randomly assigned to either the HCD group or one of the emodin treatment groups lasting 4 or 8 weeks. Total cholesterol (TC) and triglycerides (TG) were measured to determine changes in serum lipid levels. Immunohistochemistry was performed to detect the morphology and number of ICCs. TUNEL assays were performed to detect ICC apoptosis. Transmission electron microscopy was employed to observe ICC structure. Western blotting and real-time polymerase chain reaction were used to detect changes in stem cell factor (SCF)/c-kit pathway expression.

Results

Serum TC and TG were higher in all study groups. In cases of cholelithiasis, the SCF/c-kit pathway was downregulated, the number of gallbladder ICCs decreased, apoptosis increased, and the ICC network structure was damaged. After emodin treatment, the SCF/c-kit pathway was upregulated, the number of gallbladder ICCs increased, apoptosis decreased, and the ICC network structure recovered.

Conclusion

Cholelithiasis downregulates the SCF/c-kit pathway and damages gallbladder ICCs. Emodin upregulates the SCF/c-kit pathway and increases gallbladder ICCs, contributing to recovery from gallbladder motility disorders.\.

Double-Needle Bidirectional Barbed Wire Continuous Layered Suture Technique for Laparoscopic Stage I Common Bile Duct Surgery

Background: Laparoscopic common bile duct exploration (LCBDE) proves a safe and effective treatment for choledochal stones. After LCBDE, preferred choledochal closure is favored for short- and long-term outcomes compared with t-tube drainage. However, there are no relevant studies on the technique of layered closure of the common bile duct with double-needle bidirectional barbed suture at home and abroad. Materials and Methods: A retrospective study of 37 patients who underwent laparoscopic choledochotomy from January 2021 to October 2023 in our hospital was performed. A continuous layered one-stage suture using two-needle bidirectional barb wire. The primary outcomes were stone clearance, operative time, blood loss, and complications. Secondary outcomes were complications, length of hospitalization, and time to drain removal. Results: During the study period, laparoscopic surgery was successful in all cases, and the initial stones were removed without complications. Conclusion: The treatment of choledocholithiasis with continuous layered one-stage suture with double-needle bidirectional barbed wire after LCBDE is a new convenient and effective treatment in selected patients.

Percutaneous transhepatic papillary ballooning and extraction for common bile duct stones: a single-center experience

Background

At present, some common bile duct stones (CBDSs) cannot be removed by conventional endoscopic treatment. Percutaneous transhepatic papillary ballooning and extraction (PTPBE) is a promising treatment for CBDSs. This study aimed to evaluate the feasibility and efficacy of PTPBE for removing CBDSs.

Methods

From April 2013 to April 2021, 29 patients with CBDSs underwent PTPBE at The First Affiliated Hospital of Zhengzhou University; their clinical data were retrospectively analyzed. The technical success, clinical success, procedure time, radiation dose, 1-year CBDSs recurrence rate, and incidence of early/late complications were recorded, and white blood cell (WBC) counts and alanine aminotransferase (ALT), C-reactive protein (CRP), total bilirubin (TBIL), and carbohydrate antigen-199 (CA-199) levels were compared before the interventional procedure and 1 month later.

Results

The CBDSs were successfully removed in 29 patients (the CBDSs in 20 patients were resolved once, and in 9 patients, they were resolved twice). The mean procedure time and radiation dose were 56.38±13.56 minutes and 732.07±262.23 miligray (mGy), respectively. The technical and clinical success rates were both 100%. The incidence of early complications (including pancreatitis and bile duct bleeding) and late complications (reflux cholangitis) was 10.34% and 3.45%, respectively. The WBC (both P<0.01), ALT (both P<0.01), CRP (both P<0.01), CA-199 (both P<0.01), and TBIL (both P<0.01) significantly decreased before PTPBE and 1 month later.

Conclusions

PTPBE is a safe and effective alternative solution for elderly patients who cannot undergo or refuse traditional surgical and endoscopic treatments.

Is Cholecystectomy Necessary after Choledocholithiasis Treatment for the Elderly or Patients with Many Comorbidities?

INTRODUCTION

We evaluated the prognosis after endoscopic treatment for choledocholithiasis, particularly in patients with borderline tolerance to surgery. Stone removal and cholecystectomy are generally recommended for patients with choledocholithiasis combined with gallstones to prevent recurrent biliary events. However, the prognosis after choledocholithiasis treatment in patients with borderline tolerance to surgery, such as the elderly or those with many comorbidities, remains controversial.

METHODS

We retrospectively analyzed data from patients with choledocholithiasis treated at our facility between January 2012 and December 2021. Patients who underwent endoscopic sphincterotomy were dichotomized into the cholecystectomy (CHOLE) and conservation (CONS) groups depending on whether cholecystectomy was performed, and their prognoses were subsequently compared. Furthermore, we performed a logistic regression analysis of the factors contributing to recurrent biliary events in patients with high age-adjusted Charlson Comorbidity Index (aCCI) scores.

RESULTS

Of 169 participants, 110 had gallstones and were divided into the CHOLE (n = 56) and CONS (n = 54) groups. The CONS group was significantly ordered, had more comorbidities, and higher aCCI scores, whereas the CHOLE group had fewer recurrent biliary events, although not significant (p = 0.122). No difference was observed in the recurrent incidence of grade ≥2 biliary infections and mortality related to biliary events between the groups. In patients with aCCI scores ≥5, conservation without cholecystectomy was not an independent risk factor for recurrent biliary events.

CONCLUSION

Cholecystectomy after choledocholithiasis treatment prevents recurrent biliary events, but conservation without cholecystectomy is a feasible option for patients with high aCCI scores.

Advancements in Cholelithiasis Diagnosis: A Systematic Review of Machine Learning Applications in Imaging Analysis

Gallstone disease is a common condition affecting a substantial number of individuals globally. The risk factors for gallstones include obesity, rapid weight loss, diabetes, and genetic predisposition. Gallstones can lead to serious complications such as calculous cholecystitis, cholangitis, biliary pancreatitis, and an increased risk for gallbladder (GB) cancer. Abdominal ultrasound (US) is the primary diagnostic method due to its affordability and high sensitivity, while computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) offer higher sensitivity and specificity. This review assesses the diagnostic accuracy of machine learning (ML) technologies in detecting gallstones. This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for reporting systematic reviews and meta-analyses. An electronic search was conducted in PubMed, Cochrane Library, Scopus, and Embase, covering literature up to April 2024, focusing on human studies, and including all relevant keywords. Various Boolean operators and Medical Subject Heading (MeSH) terms were used. Additionally, reference lists were manually screened. The review included all study designs and performance indicators but excluded studies not involving artificial intelligence (AI)/ML algorithms, non-imaging diagnostic modalities, microscopic images, other diseases, editorials, commentaries, reviews, and studies with incomplete data. Data extraction covered study characteristics, imaging modalities, ML architectures, training/testing/validation, performance metrics, reference standards, and reported advantages and drawbacks of the diagnostic models. The electronic search yielded 1,002 records, of which 34 underwent full-text screening, resulting in the inclusion of seven studies. An additional study identified through citation searching brought the total to eight articles. Most studies employed a retrospective cross-sectional design, except for one prospective study. Imaging modalities included ultrasonography (four studies), computed tomography (three studies), and magnetic resonance cholangiopancreatography (one study). Patient numbers ranged from 60 to 2,386, and image numbers ranged from 60 to 17,560 images included in the training, validation, and testing of the diagnostic models. All studies utilized neural networks, predominantly convolutional neural networks (CNNs). Expert radiologists served as the reference standard for image labelling, and model performances were compared against human doctors or other algorithms. Performance indicators such as sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were commonly used. In conclusion, while the reviewed machine learning models show promising performance in diagnosing gallstones, significant work remains to be done to ensure their reliability and generalizability across diverse clinical settings. The potential for these models to improve diagnostic accuracy and efficiency is evident, but the careful consideration of their limitations and rigorous validation are essential steps toward their successful integration into clinical practice.

Comparison of the therapeutic effects of three minimally invasive approaches for laparoscopic cholecystectomy combined with common bile duct exploration-- a 5-year retrospective analysis

OBJECTIVE

The aim of this retrospective study was to explore the indications for three minimally invasive approaches-T-tube external drainage, double J-tube internal drainage, and primary closure-in laparoscopic cholecystectomy combined with common bile duct exploration.

METHODS

Three hundred eighty-nine patients with common bile duct stones who were treated at the Second People's Hospital of Hefei between February 2018 and January 2023 were retrospectively included. Patients were divided into three groups based on the surgical approach used: the T-tube drainage group, the double J-tube internal drainage group, and the primary closure group. General data, including sex, age, and BMI, were compared among the three groups preoperatively. Surgical time, length of hospital stay, pain scores, and other aspects were compared among the three groups. Differences in liver function, inflammatory factors, and postoperative complications were also compared among the three groups.

RESULTS

There were no significant differences among the three groups in terms of sex, age, BMI, or other general data preoperatively (P > 0.05). There were significant differences between the primary closure group and the T-tube drainage group in terms of surgical time and pain scores (P < 0.05). The primary closure group and double J-tube drainage group differed from the T-tube drainage group in terms of length of hospital stay, hospitalization expenses, and time to passage of gas (P <0.05). Among the three groups, there were no statistically significant differences in inflammatory factors or liver function, TBIL, AST, ALP, ALT, GGT, CRP, or IL-6, before surgery or on the third day after surgery (P > 0.05). However, on the third day after surgery, liver function in all three groups was significantly lower than that before surgery (P<0.05). In all three groups, the levels of CRP and IL-6 were significantly lower than their preoperative levels. The primary closure group had significantly lower CRP and IL-6 levels than did the T-tube drainage group (P < 0.05). The primary closure group differed from the T-tube drainage group in terms of the incidences of bile leakage and electrolyte imbalance (P < 0.05). The double J-tube drainage group differed from the T-tube drainage group in terms of the tube dislodgement rate (P < 0.05).

CONCLUSION

Although primary closure of the bile ducts has clear advantages in terms of length of hospital stay and hospitalization expenses, it is associated with a higher incidence of postoperative complications, particularly bile leakage. T-tube drainage and double J-tube internal drainage also have their own advantages. The specific surgical approach should be selected based on the preoperative assessment, indications, and other factors to reduce the occurrence of postoperative complications.

Clinical efficacy of laparoscopic cholecystectomy combined with endoscopic papillary balloon dilation in treatment of gallbladder stones with common bile duct stones: A retrospective study

BACKGROUND

The incidence of cholelithiasis has been on the rise in recent years, but the choice of procedure is controversial.

AIM

To investigate the efficacy of laparoscopic cholecystectomy (LC) combined with endoscopic papillary balloon dilation (EPBD) in patients with gallbladder stones (GS) with common bile duct stones (CBDS).

METHODS

The clinical data of 102 patients with GS combined with CBDS were selected for retrospective analysis and divided into either an LC + EPBD group (n = 50) or an LC + endoscopic sphincterotomy (EST) group (n = 52) according to surgical methods. Surgery-related indexes, postoperative recovery, postoperative complications, and expression levels of inflammatory response indexes were compared between the two groups.

RESULTS

Total surgical time, stone free rate, rate of conversion to laparotomy, and successful stone extraction rate did not differ significantly between the LC + EPBD group and LC + EST group. Intraoperative hemorrhage, time to ambulation, and length of hospitalization in the LC + EPBD group were lower than those of the LC + EST group (P < 0.05). The rate of total complications of the two groups was 9.80% and 17.65%, respectively, and the difference was not statistically significant. No serious complications occurred in either group. At 48 h postoperatively, the expression levels of interleukin-6, tumor necrosis factor-α, high-sensitivity C-reactive protein, and procalcitonin were lower in the LC + EPBD group than in the LC + EST group (P < 0.05). At 3 d postoperatively, the expression levels of aspartate transaminase, alanine transaminase, and total bilirubin were lower in the LC + EPBD group than in the LC + EST group (P < 0.05).

CONCLUSION

LC combined with EPBD and LC combined with EST are both effective procedures for the treatment of GS with CBDS, in which LC combined with EPBD is beneficial to shorten the patient's hospitalization time, reduce the magnitude of elevated inflammatory response indexes, and promote postoperative recovery.

Prediction for post-ERCP pancreatitis in non-elderly patients with common bile duct stones: a cross-sectional study at a major Chinese tertiary hospital (2015-2023)

BACKGROUND

Post-ERCP pancreatitis is one of the most common adverse events in ERCP-related procedures. The purpose of this study is to construct an online model to predict the risk of post-ERCP pancreatitis in non-elderly patients with common bile duct stones through screening of relevant clinical parameters.

METHODS

A total of 919 cases were selected from 7154 cases from a major Chinese tertiary hospital. Multivariable logistic regression model was fitted using the variables selected by the LASSO regression from 28 potential predictor variables. The internal and external validation was assessed by evaluating the receiver operating characteristic curve and the area under curve. Restricted cubic spline modelling was used to explore non-linear associations. The interactive Web application developed for risk prediction was built using the R "shiny" package.

RESULTS

The incidence of post-ERCP pancreatitis was 5.22% (48/919) and significantly higher in non-elderly patients with female, high blood pressure, the history of pancreatitis, difficult intubation, endoscopic sphincterotomy, lower alkaline phosphatase and smaller diameter of common bile duct. The predictive performance in the test and external validation set was 0.915 (95% CI, 0.858-0.972) and 0.838 (95% CI, 0.689-0.986), respectively. The multivariate restricted cubic spline results showed that the incidence of pancreatitis was increased at 33-50 years old, neutrophil percentage > 58.90%, hemoglobin > 131 g/L, platelet < 203.04 or > 241.40 × 109/L, total bilirubin > 18.39 umol / L, aspartate amino transferase < 36.56 IU / L, alkaline phosphatase < 124.92 IU / L, Albumin < 42.21 g / L and common bile duct diameter between 7.25 and 10.02 mm. In addition, a web server was developed that supports query for immediate PEP risk.

CONCLUSION

The visualized networked version of the above model is able to most accurately predict the risk of PEP in non-elderly patients with choledocholithiasis and allows clinicians to assess the risk of PEP in real time and provide preventive treatment measures as early as possible.

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.

Risk factors analyses associated with postoperative infection in choledochoscopy for intrahepatic bile duct stones (IHDs): a single-center retrospective study in real-world setting

BACKGROUND

Choledochoscopy is a highly effective approach for managing intrahepatic bile duct stones (IHDs). However, postoperative infection is a common complication that significantly impacts treatment outcomes. Despite its clinical relevance, the risk factors associated with this procedure remain largely unexplored.

METHODS

This study focused on a consecutive cohort of patients who underwent choledochoscopy for IHDs at our institution between January 2016 and December 2022. The primary objective was to analyze the relationship between various clinical factors and postoperative infection, and to compare the postoperative infection of different choledochoscopic procedures.

RESULTS

The study cohort consisted of 126 patients, with 60 individuals (47.6%) experiencing postoperative infection. Notably, preoperative biliary obstruction (odds ratio [OR] 1.861; 95% confidence interval [CI] 1.314-8.699; p = 0.010) and operation time (OR 4.414; 95% CI 1.635-12.376; p = 0.004) were identified as risk factors for postoperative infection. Additionally, biliary tract infections (60.00%) were primarily responsible for postoperative infection, with Escherichia coli (47.22%) being the predominant bacterial strain identified in bile cultures. Furthermore, biliary tract obstruction (OR 4.563; 95% CI 1.554-13.401; p = 0.006) and body mass index (BMI) (OR 1.186; 95% CI 1.015-1.386; p = 0.031) were determined to be independent risk factors for postoperative biliary tract infection.

CONCLUSIONS

The occurrence of postoperative infection in patients undergoing choledochoscopy was primarily associated with the duration of the operation and the presence of preoperative biliary obstruction.

Comparison of the clinical effects of dual-modality endoscopy and traditional laparotomy for the treatment of intra- and extrahepatic bile duct stones

BACKGROUND

Bile duct stones (BDSs) may cause patients to develop liver cirrhosis or even liver cancer. Currently, the success rate of surgical treatment for intrahepatic and extrahepatic BDSs is not satisfactory, and there is a risk of postoperative complications.

AIM

To compare the clinical effects of dual-modality endoscopy (duodenoscopy and laparoscopy) with those of traditional laparotomy in the treatment of intra- and extrahepatic BDSs.

METHODS

Ninety-five patients with intra- and extrahepatic BDSs who sought medical services at Wuhan No.1 Hospital between August 2019 and May 2023 were selected; 45 patients in the control group were treated by traditional laparotomy, and 50 patients in the research group were treated by dual-modality endoscopy. The following factors were collected for analysis: curative effects, safety (incision infection, biliary fistula, lung infection, hemobilia), surgical factors [surgery time, intraoperative blood loss (IBL) volume, gastrointestinal function recovery time, and length of hospital stay], serum inflammatory markers [tumor necrosis factor (TNF)-α, interleukin (IL)-6, and IL-8], and oxidative stress [glutathione peroxidase (GSH-Px), superoxide dismutase (SOD), malondialdehyde (MDA), and advanced protein oxidation products (AOPPs)].

RESULTS

The analysis revealed markedly better efficacy (an obviously higher total effective rate) in the research group than in the control group. In addition, an evidently lower postoperative complication rate, shorter surgical duration, gastrointestinal function recovery time and hospital stay, and lower IBL volume were observed in the research group. Furthermore, the posttreatment serum inflammatory marker (TNF-α, IL-6, and IL-8) levels were significantly lower in the research group than in the control group. Compared with those in the control group, the posttreatment GSH-Px, SOD, MDA and AOPPs in the research group were equivalent to the pretreatment levels; for example, the GSH-Px and SOD levels were significantly higher, while the MDA and AOPP levels were lower.

CONCLUSION

Dual-modality endoscopy therapy (duodenoscopy and laparoscopy) is more effective than traditional laparotomy in the treatment of intra- and extrahepatic BDSs and has a lower risk of postoperative complications; significantly shortened surgical time; shorter gastrointestinal function recovery time; shorter hospital stay; and lower intraoperative bleeding volume, while having a significant inhibitory effect on excessive serum inflammation and causing little postoperative oxidative stress.

EUS-Guided Cholecystoduodenostomy for a Poor Surgical Candidate With Chronic Octreotide-Associated Gallstones From Metastatic Neuroendocrine Tumor

Chronic octreotide use has been associated with gallstone formation. Historically, cholecystectomy has been the defining treatment for those who have gallstone-related disease. For those who are poor surgical candidates, percutaneous and endoscopic approaches have been used. We describe the endoscopic management of a 74-year-old man with significant gallstone burden and associated sequelae because of chronic octreotide for metastatic neuroendocrine tumor through endoscopic ultrasound-guided cholecystoduodenostomy with gallstone extraction using lumen-apposing metal stents.

Management of intraoperatively identified small bile duct stones in patients undergoing cholecystectomy

INTRODUCTION

The management of CBDS (common bile duct stones) in patients with co-existing gallbladder stones has been debated. Guidelines recommend patients with CBDS identified on imaging should be offered duct clearance; however, this is based on low-quality evidence. This study aimed to investigate the natural history of small CBDS identified using IOUS (intraoperative ultrasound) in patients undergoing cholecystectomy. This may provide evidence to support a short-term expectant management approach in such patients.

METHODS

Patients with CBDS diagnosed on IOUS during cholecystectomy were identified from a database of consecutive patients undergoing surgery. Patients with CBDS identified were divided into small stone (SS, ≤5 mm) and large stone (LS, >5 mm) groups. Intraoperative CBDS management, postoperative investigations, postoperative bile duct clearance, re-admissions, complications, length of stay (LOS) and follow-up are described.

RESULTS

Fifty-nine of 427 patients had CBDS identified on IOUS. In the SS group (n=51), 46 patients underwent short-term expectant management rather than immediate/planned bile duct clearance. Following short-term expectant management, 41/46 patients (89.1%) did not require postoperative endoscopic retrograde cholangiopancreatography and at >3 year follow-up, none has since presented with residual CBDS. Median LOS was 0 days in the short-term expectant management group and 2 days in the immediate/planned bile duct clearance group, P=0.039.

CONCLUSIONS

This study reports the natural history of small CBDS identified on IOUS in patients undergoing cholecystectomy. Such patients were safely treated with short-term expectant management associated with a reduced hospital LOS. This provides rationale for undertaking further research to establish this as a preferred management strategy.

Risk factors for recurrence of common bile duct stones after surgical treatment and effect of ursodeoxycholic acid intervention

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is an accurate diagnostic method for choledocholithiasis and treatment option for stone removal. Additionally, ursodeoxycholic acid (UDCA) can dissolve cholesterol stones and prevent their development and reappearance by lowering the cholesterol concentration in bile. Despite these treatment options, there are still patients who experience stone recurrence.

AIM

To analyze the risk factors for choledocholithiasis recurrence after ERCP retrograde cholangiopancreatography and the effect of UDCA intervention.

METHODS

The clinical data of 100 patients with choledochal stones who were hospitalized at the Yixing People's Hospital and underwent ERCP for successful stone extraction between June 2020 and December 2022 were retrospectively collected. According to the post-ERCP treatment plan, 100 patients were classified into UDCA (n = 47) and control (n = 53) groups. We aimed to assess the clinical efficacy and rate of relapse in the two patient populations. We then collected information (basic demographic data, clinical characteristics, and serum biochemical indicators) and determined the factors contributing to relapse using logistic regression analysis. Our secondary goal was to determine the effects of UDCA on liver function after ERCP.

RESULTS

Compared to the control group, the UDCA group demonstrated a higher clinical effectiveness rate of 92.45% vs 78.72% (P < 0.05). No significant differences were observed in liver function indices, including total bilirubin, direct bilirubin, gamma-glutamyl transpeptidase, alanine aminotransferase, alkaline phosphatase, and aspartate aminotransferase, between the two groups before treatment. After treatment, all liver function indices were significantly reduced. Comparing the control vs UDCA groups, the UDCA group exhibited significantly lower levels of all indices (55.39 ± 6.53 vs 77.31 ± 8.52, 32.10 ± 4.62 vs 45.39 ± 5.69, 142.32 ± 14.21 vs 189.63 ± 16.87, 112.52 ± 14.25 vs 149.36 ± 15.36, 122.61 ± 16.00 vs 171.33 ± 22.09, 96.98 ± 10.44 vs 121.35 ± 11.57, respectively, all P < 0.05). The stone recurrence rate was lower in the UDCA group (13.21%) in contrast with the control group (44.68%). Periampullary diverticula (OR: 6.00, 95%CI: 1.69-21.30), maximum stone diameter (OR: 1.69, 95%CI: 1.01-2.85), stone quantity >3 (OR: 4.23, 95%CI: 1.17-15.26), and positive bile culture (OR: 7.61, 95%CI: 2.07-27.91) were independent factors that influenced the relapse of common bile duct stones after ERCP (P < 0.05). Furthermore, postoperative UDCA was identified as a preventive factor (OR: 0.07; 95%CI: 0.08-0.09).

CONCLUSION

The intervention effect of UDCA after ERCP for common bile duct stones is adequate, providing new research directions and references for the prevention and treatment of stone recurrence.

The Safety and Cost Analysis of Outpatient Laparoendoscopy in the Treatment of Cholecystocholedocholithiasis: A Retrospective Study

INTRODUCTION

The advantages of single-stage treatment of cholecystocholedocholithiasis are well established, but the conditions for carrying out treatment on an outpatient basis require a review of concepts and practices of medical corporations.

OBJECTIVE

To evaluate the practice of treating cholecystocholedocholithiasis by laparoendoscopy on an outpatient basis with cost analysis.

METHOD

A retrospective study was conducted on patients with cholecystocholedocholithiasis treated by combined laparoscopic cholecystectomy and endoscopic choledocholithotomy from January 2015 to January 2019. After collecting data from physical and digital medical records, the patients were divided into two groups-AR (n = 42)-ambulatory regimen and HR (n = 28)-hospitalization regimen-which were compared in terms of demographic, clinical and treatment variables and their results, as well as in terms of costs.

RESULTS

The mean age of the AR group was lower than that of the HR group and the physical status of the AR patients was better when assessed according to the American Society of Anesthesiologists (ASA) (p = 0.01). There was no difference between groups regarding the risk of choledocholithiasis (p = 0.99). For the AR group, the length of stay was shorter: 11.29 h × 65.21 h (p = 0.02), as was the incidence of postoperative complications assessed by applying the Clavien-Dindo classification: 3 (7.1%) × 11 (39.2%) (p < 0.01). The total mean costs were higher for the HR group (USD 2489.93) than the AR group (USD 1650.98) (p = 0.02).

CONCLUSION

Outpatient treatment of cholecystocholedocholithiasis by laparoendoscopy is safe and viable for most cases, has a lower cost and can support the reorientation of training and practice of hepatobiliary surgeons.

Clinical study on the necessity and feasibility of routine MRCP in patients with cholecystolithiasis before LC

BACKGROUND

In the past quite a long time, intraoperative cholangiography(IOC)was necessary during laparoscopic cholecystectomy (LC). Now magnetic resonance cholangiopancreatography (MRCP) is the main method for diagnosing common bile duct stones (CBDS). Whether MRCP can replace IOC as routine examination before LC is still inconclusive. The aim of this study was to analyze the clinical data of patients undergoing LC for cholecystolithiasis, and to explore the necessity and feasibility of preoperative routine MRCP in patients with cholecystolithiasis.

METHODS

According to whether MRCP was performed before operation, 184 patients undergoing LC for cholecystolithiasis in the Department of General Surgery, Beijing Shijitan Hospital, Capital Medical University from January 1, 2017 to December 31, 2018 were divided into non-MRCP group and MRCP group for this retrospective study. The results of preoperative laboratory test, abdominal ultrasound and MRCP, biliary related comorbidities, surgical complications, hospital stay and hospitalization expenses were compared between the two groups.

RESULTS

Among the 184 patients, there were 83 patients in non-MRCP group and 101 patients in MRCP group. In MRCP group, the detection rates of cholecystolithiasis combined with CBDS and common bile duct dilatation by MRCP were higher than those by abdominal ultrasound (P < 0.05). The incidence of postoperative complications in non-MRCP group (8.43%) was significantly higher (P < 0.05) than that in MRCP group (0%). There was no significant difference in hospital stay (P > 0.05), but there was significant difference in hospitalization expenses (P < 0.05) between the two groups. According to the stratification of gallbladder stone patients with CBDS, hospital stay and hospitalization expenses were compared, and there was no significant difference between the two groups (P > 0.05).

CONCLUSIONS

The preoperative MRCP can detect CBDS, cystic duct stones and anatomical variants of biliary tract that cannot be diagnosed by abdominal ultrasound, which is helpful to plan the surgical methods and reduce the surgical complications. From the perspective of health economics, routine MRCP in patients with cholecystolithiasis before LC does not increase hospitalization costs, and is necessary and feasible.

Risk factors for post‑retrograde cholangiopancreatography pancreatitis in patients with common bile duct stones: A meta‑analysis

Endoscopic retrograde cholangiopancreatography (ERCP) has become a common treatment method for common bile duct stones. However, ERCP is also associated with a high risk of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). Identification of risk factors is essential for reducing the incidence of PEP. The present study aimed to summarize the risk factors for PEP by performing a meta-analysis. Therefore, studies published between 2000 and 2022 were screened in PubMed, Cochrane Library, Embase, Web of Science, China National Knowledge Infrastructure, Wanfang Digital Periodicals and the Weipu Database, with no language restrictions. Newcastle-Ottawa Scale was used to assess the quality of the included studies. Stata 17.0 software was utilized for the meta-analysis of 14 possible risk factors. Overall, 15 high-quality studies were included into the present meta-analysis. The results showed that female [odds ratio (OR), 1.42; 95% CI, 1.23-1.64), age <60 years (OR, 1.53; 95% CI, 1.06-2.21), difficult intubation (OR, 4.87; 95% CI, 2.73-8.68), ≥3 cannulation attempts (OR, 9.64; 95% CI, 4.16-22.35), cannulation time ≥10 min (OR, 2.37; 95% CI, 1.67-3.35), history of pancreatitis (OR, 2.95; 95% CI, 1.06-5.51), pancreatic duct visualization (OR, 3.63; 95% CI, 2.47-5.34) and sphincter of Oddi dysfunction (OR, 5.72; 95% CI, 1.80-18.24) are potential risk factors for PEP (P<0.05). In conclusion, the present meta-analysis suggests that PEP can be affected by several risk factors, particularly the technique-related factors such as the frequency and time of cannulation. Therefore, effective precautions should be taken as early as possible to reduce the incidence of PEP.

Ultrasound-Guided Percutaneous Transhepatic Cholangioscopic Lithotripsy for the Treatment of Common Bile Duct Stones and Analysis of Risk Factors for Recurrence

BACKGROUND

As a minimally invasive treatment for common bile duct (CBD) stones, ultrasound-guided percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) is gaining attention and recognition from the medical community.

METHODS

A retrospective analysis was conducted on patients with CBD stones treated in our hospital from January 2016 to April 2022. Patients were divided into three groups: 77 treated with PTCSL, 93 with endoscopic retrograde cholangiopancreatography (ERCP), and 103 with laparoscopic common bile duct exploration (LCBDE). Their clinical data, perioperative indicators, and complications were analyzed comparatively. Then, risk factors for the post-PTCSL recurrence of CBD stones were analyzed by logistic regressions. Finally, the receiver operating characteristic curve was drawn.

RESULTS

All perioperative indicators of the PTCSL group were better than the LCBDE group (P < 0.001). The incidences of cholangitis, hemobilia, and incisional infection after surgery were lower in the PTCSL group than in the LCBDE group (P < 0.05). Pancreatitis, reflux esophagitis, and papillary stenosis occurred less frequently in the PTCSL group than in the ERCP group (P < 0.05). Logistic regression analysis indicated that gallstones and family history were independent risk factors. The AUC for recurrent CBD stones predicted by multi-indicators was 0.895 (95% CI 0.792-0.999, P < 0.001) with a sensitivity of 96.7% and specificity of 68.8%.

CONCLUSIONS

Ultrasound-guided PTCSL is a safe and effective treatment for CBD stones. Patients recovered quickly with fewer postoperative complications. It can be a first-line treatment for CBD stones. Gallstones and family history are independent risk factors for recurrent CBD stones, which provide a reference for clinicians in identifying the high-risk population needing close follow-up.

Primary choledocholithiasis occurrence and recurrence is synergetcally modulated by the bile microbiome and metabolome alternations

AIMS

Primary choledocholithiasis is a common digestive disease with high morbidity and relapse. However, the compositions and functions of the bile microbial ecosystem and the pathogenesis of microfloral regulation of host metabolism resulting in stone formation are poorly understood.

MAIN METHODS

Biliary samples collected from patients with acute cholangitis induced by benign biliary stricture (nonlithiasis group, n = 17) and primary choledocholithiasis (lithiasis group, n = 33) were subjected to multiomics analyses. Furthermore, clinicopathological features collected over a 24-month follow-up period were examined to evaluate the predictive value of candidate microbes.

KEY FINDINGS

Five alpha diversity indices of the bile microbiome were significantly decreased in the lithiasis group. Furthermore, we identified 49 differential bile flora between the two groups, and the relative abundances of 6 bacteria, Actinobacteria, Actinobacteriota, Staphylococcales, Micrococcales, Altererythrobacter and Carnobacteriaceae, were associated with primary choledocholithiasis relapse conditions. Multiomics analyses showed that specific changes in disease-related bacterial taxa were closely related to metabolite variation (low-molecular weight carboxylic acids, sterol liquid and acylcarnitine), which might reflect disease prognosis. According to microbiomic and metabolomic pathway analyses, we revealed that bacterial infections, microbiota-derived amino acid metabolites and secondary bile acid-related pathways were significantly enriched in the stone-formation group, suggesting a novel host-microbial metabolic mechanism of primary choledocholithiasis.

SIGNIFICANCE

Our study first indicates bile host-microbial dysbiosis modulates the abnormal accumulation of metabolites might further disrupt calcium homeostasis and generate insoluble saponification. Additionally, we determined the predictive value of Actinomycetes phylum reduction for recurrence in primary common bile duct stone patients.

Intrahepatic Gallbladder Rupture and Biloma Mimicking Pulmonary Embolism Following Orthopedic Surgery

In this case report, a 75-year-old male with a history of coronary artery disease, type 2 diabetes, hypertension, and benign prostate hypertrophy developed postoperative fever and chest pain following left knee arthroplasty. Upon admission to the emergency department, pulmonary embolism was considered highly probable, and the patient was treated with anticoagulation and antibiotics due to diagnostic uncertainty. However, further investigations revealed a complex condition involving an intraparenchymal gallbladder rupture resulting in a biloma secondary to choledocholithiasis. The patient's history of receiving spinal anesthesia with intrathecal morphine was identified as a potential causative factor to the sphincter of Oddi constriction, leading to increased biliary pressure and gallbladder rupture. This case highlights the importance of having a broad differential diagnosis in postoperative patients, especially when the clinical presentation is atypical. With the diagnosis being confirmed, the patient underwent successful treatment, including biliary stenting, drainage of the biloma, and ultimately cholecystectomy. This case underlines the need for vigilance and a multidisciplinary approach in managing complex postoperative complications, emphasizing that clinical presentations may sometimes deviate significantly from the expected, requiring further investigation and individualized treatment.

Endoclip papillaplasty (ECPP) versus limited EST plus EPLBD for a decrease in recurrent choledocholithiasis: a prospective cohort study

BACKGROUND AND AIMS

Limited EST plus EPLBD has been widely used for the therapy of large CBDS; however, long-term complication-relevant studies suggested that it damaged the function of the sphincter of Oddi (SO) and resulted in recurrent choledocholithiasis. Thus, we designed Endoclip papillaplasty (ECPP) and previous studies have shown that it successfully restored the function of SO. In this study, we designed a prospective cohort and aimed to verify the safety and effectiveness of ECPP.

METHODS

Eligible patients were divided into the ECPP group and the limited EST plus EPLBD group based on papillary morphology and the ratio of maximum size of stones to length of intramural segments of CBD. All participants in the ECPP group received endoscopy at 3 weeks to retrieve the biliary stent, perform SOM, and were divided into grade A and grade B based on the healing grade of SO. All patients were followed up every 6 months until recurrent choledocholithiasis, patient death, or at the 36-month follow-up end. The primary outcome was the incidence of recurrent choledocholithiasis. The secondary outcomes included mechanical lithotrip usage and adverse events.

RESULTS

The incidences of recurrent choledocholithiasis in the ECPP group and limited EST plus EPLBD group were 13.6 and 22.1%, respectively (P = 0.204). The ECPP-A group had a lower incidence of recurrent choledocholithiasis than the limited EST plus EPLBD groups (5.1 vs. 22.1%, P = 0.020*), and certified the function of SO successfully restored in the ECPP-A group.

CONCLUSION

The ECPP-A group had a decrease in recurrent choledocholithiasis, and ECPP was safe and effective for CBDS.

One-stage laparoscopic cholecystectomy with intraoperative endoscopic retrograde cholangiography bile duct stone extraction is a feasible option in Indonesia within the National Health Insurance System

INTRODUCTION AND IMPORTANCE

Bile duct stones are a widespread condition that can pose a significant risk to life due to the occurrence of complications. In recent years, there has been a growing inclination toward the use of one-stage minimally invasive procedures for the treatment of this condition. However, it is important to note that in developing countries, such as Indonesia, where the National Healthcare Insurance System is established, the implementation of these procedures is still relatively uncommon due to limitations in healthcare facilities.

CASE PRESENTATION

This study presents a case series involving 13 patients who underwent a consecutive initial attempt of one-stage Laparoscopic Cholecystectomy with subsequent Intraoperative Endoscopic Retrograde Cholangiopancreatography (LC-ERCP) for the extraction of bile duct stones. These patients were among the 124 individuals treated for bile duct stones at our hospital for one year (June 2022 to May 2023). All the participants in this study were covered by the National Health Insurance.

CLINICAL DISCUSSION

Among the 124 patients diagnosed with bile duct stones, thirteen (10.5 %) were subjected to an initial attempt of one-stage LC-ERCP procedure, which had a success rate of 76.4 %. However, three of them experienced difficulties during the cannulation of bile duct, leading to the failure of this approach. The patients included in the study had a mean age of 46.5 years, with average serum levels of total bilirubin and direct bilirubin measuring 2.1 and 1.4 mg/dL, respectively. The average duration of successful and unsuccessful procedures was 121.5 min and 183.3 min, respectively. The average length of postoperative hospital stay was 3.5 days, and no instances of mortality or complications were recorded during the study.

CONCLUSION

One-stage LC-ERCP procedure offered a promising treatment option for bile duct stones in Indonesia, particularly for patients registered under the National Healthcare Insurance System. This approach could serve as a viable alternative for facilities that lack proficiency in LC-CBDE skills. Furthermore, the ability to perform ERCP in a supine position is crucial in achieving a high success rate. The results of this study showed the need for advancements in Indonesian public healthcare facilities to meet the growing demand for improved treatment modalities.

Comparison of Efficacy and Safety of Laparoscopic Holmium laser Lithotripsy and Laparoscopic Bile Duct Exploration for Bile Duct Stones: A Systematic Review and Meta-Analysis

BACKGROUND

Laparoscopic holmium laser lithotripsy (LHLL) has been used to treat bile duct stones with unclear outcomes. A meta-analysis was conducted to investigate the LHLL and laparoscopic bile duct exploration (LBDE) efficacy and safety in treating bile duct stones.

METHODS

The correlational studies were searched databases, such as PubMed, Embase, Cochrane Library, Web of Science, CNKI, Wanfang, and VIP, to identify eligible studies from inception to July 2022. The dichotomous and continuous outcomes were evaluated using odds ratio (OR), risk difference (RD) and weighted mean difference (WMD) with 95% confidence intervals (CIs). Stata 15.0 and Review Manager 5.3 software helped in data analyses.

RESULTS

A total of 23 studies with 1,890 patients, primarily from China, were included. The results indicated that operation time (WMD = - 26.94; 95% CI:(- 34.30, - 19.58); P < 0.00001), estimated blood loss (WMD = - 17.97; 95% CI: (- 22.94, - 13.00); P = 0.002), rate of residual stone (OR = 0.15, 95%CI: (0.10, 0.23); P < 0.00001), length of hospital stay (WMD = - 2.88; 95% CI:(- 3.80, - 1.96); P < 0.00001) and time to bowel function recovery (WMD = - 0.59; 95% CI: (- 0.76, - 0.41); P < 0.00001) had statistically significant differences between the two groups. In postoperative complications, biliary leakage (RD = -0.03; 95% CI: (- 0.05, -0.00); P = 0.02), infection (RD = - 0.06; 95% CI: (- 0.09,- 0.03); P < 0.00001) and Hepatic injury (RD = - 0.06; 95% CI: (- 0.11, - 0.01); P = 0.02) revealed statistically significant differences. However, no significant differences were observed in biliary damage (RD = - 0.03; 95% CI: (- 0.06, 0.00); P = 0.06) and hemobilia (RD = - 0.03; 95% CI: (- 0.06, 0.00); P = 0.08).

CONCLUSION

The current meta-analysis indicated that LHLL could be more effective and safer than LBDC. However, these results should be confirmed with a larger sample size and rigorously designed randomized controlled trials.

Comprehensive review on small common bile duct stones

Common bile duct stones are among the most common conditions encountered by endoscopists. Therefore, it is well researched; however, some items, such as indications for endoscopic papillary balloon dilatation (EPBD), safety of EPBD and endoscopic sphincterotomy in patients receiving dual antiplatelet therapy or direct oral anticoagulant, selection strategy for retrieval balloons and baskets, lack adequate evidence. Therefore, the guidelines have been updated with new research, while others remain unchanged due to weak evidence. In this review, we comprehensively summarize the standard methods in guidelines and new findings from recent studies on papillary dilation, stone retrieval devices, difficult-to-treat cases, troubleshooting during the procedure, and complicated cases of cholangitis, cholecystolithiasis, or distal biliary stricture.

Use of lasers in gastrointestinal endoscopy: a review of the literature

Lasers emit highly directional light with consistent wavelengths, and recent studies have demonstrated their successful applications in gastrointestinal endoscopic therapy. Although argon plasma coagulators (APC) became the preferred treatment option due to improved safety profile and lower costs, advancements in laser and optic fiber manufacturing have reignited interest in laser treatment. Different laser wavelengths have distinct features and applications based on their tissue absorption coefficient. Lasers with shorter wavelengths are effectively absorbed by hemoglobin, resulting in a good coagulation effect. Near-infrared lasers have ability to ablate solid tumors, while far-infrared lasers can make precise mucosal incisions without causing peripheral thermal damage. Lasers have proven to be highly applicable to endoscopy devices such as endoscopes, endoscopic ultrasound (EUS), double-balloon enteroscopes (DBE), and endoscopic retrograde cholangiopancreatography (ERCP), making them a potent tool to enhance the effectiveness of endoscopic treatments with minimal adverse events. This review aims to help readers understand the applications and effectiveness of lasers in gastrointestinal endoscopy, with the potential to promote the development and application of laser technology in the medical field.

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

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

Current management of concomitant cholelithiasis and common bile duct stones

The management policy of concomitant cholelithiasis and choledocholithiasis is based on a one- or two-stage procedure. It basically includes either laparoscopic cholecystectomy (LC) with laparoscopic common bile duct (CBD) exploration (LCBDE) in the same operation or LC with preoperative, postoperative and even intraoperative endoscopic retrograde cholangiopancreatography-endoscopic sphincterotomy (ERCP-ES) for stone clearance. The most frequently used worldwide option is preoperative ERCP-ES and stone removal followed by LC, preferably on the next day. In cases where preoperative ERCP-ES is not feasible, the proposed alternative of intraoperative rendezvous ERCP-ES simultaneously with LC has been advocated. The intraoperative extraction of CBD stones is superior to postoperative rendezvous ERCP-ES. However, there is no consensus on the superiority of laparoendoscopic rendezvous. This is equivalent to a traditional two-stage procedure. Endoscopic papillary large balloon dilation reduces recurrence. LCBDE and intraoperative ERCP have similar good outcomes. The risk of recurrence after ERCP-ES is greater than that after LCBDE. Laparoscopic ultrasonography may delineate the anatomy and detect CBD stones. The majority of surgeons prefer the transcductal instead of the transcystic approach for CBDE with or without T-tube drainage, but the transcystic approach must be used where possible. LCBDE is a safe and effective choice when performed by an experienced surgeon. However, the requirement of specific equipment and advanced training are drawbacks. The percutaneous approach is an alternative when ERCP fails. Surgical or endoscopic reintervention for retained stones may be needed. For asymptomatic CBD stones, ERCP clearance is the first-choice method. Both one-stage and two-stage management are acceptable and can ensure improved quality of life.

Laparoscopic choledochoscopy for choledocholithiasis is possible in the anatomical anomaly of left gallbladder

Laparoscopic cholecystectomy (LC) is more challenging in the anatomical variation of left-sided gallbladder with the anomaly also highly related to biliary anomalies. Therefore, there has been a reluctance to operate close to the common bile duct (CBD) in left gallbladder patients, and thus choledocholithiasis is usually treated with endoscopic retrograde cholangiopancreatography (ERCP). There is emerging evidence that single stage LC and CBD exploration for choledocholithiasis may be superior to two stage LC and ERCP in terms of short-term and long-term morbidity, cost and length of stay. With the re-emergence of laparoscopic choledochoscopy, the purpose of this case report is to demonstrate the feasibility of this approach for choledocholithiasis.

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.

Outcomes following common bile duct exploration versus endoscopic stone extraction before, during and after laparoscopic cholecystectomy for patients with common bile duct stones

BACKGROUND

Laparoscopic common bile duct exploration (LCBDE) and endoscopic retrograde cholangiopancreatography (ERCP) are two methods of retrieving common bile duct (CBD) stones. The best method for CBD stone removal is debatable. The aim of this study was to compare outcomes following LCBDE and/or ERCP, including laparoscopic cholecystectomy.

METHODS

Data were collected retrospectively for patients undergoing LCBDE and/or ERCP at a single centre from 2008 to 2018. Patients were grouped by intention-to-treat (single-stage LCBDE, pre-operative-, intra-operative-, or post-operative ERCP) and eventual plan (surgical or endoscopic). Outcomes included complication rates (minor Clavien-Dindo 1/2, major Clavien-Dindo 3/4, non-biliary complications) and mortality.

RESULTS

Of 671 patients, 578 patients received LCBDE and 93 patients received ERCP as primary care. Endoscopic clearance had significantly higher complications and mortality compared to surgical clearance. On an intention-to-treat basis LCBDE had the lowest minor-, major- and non-biliary complications, and mortality (5.2%, 6.1%, 2.9% and 0.5%, respectively), whilst pre-operative ERCP the worst (39.6%, 27.1%, 29.2% and 8.3%, respectively) (p=<0.001). LCBDE and postERCP had similar major complications and mortality.

CONCLUSION

Surgical clearance of CBD stones was potentially safer than endoscopic clearance. Pre-operative ERCP had the worst outcomes. LCBDE and postERCP are likely to have similar short-term patient outcomes.

Nephro-protective effect of Daphnetin in hyperoxaluria-induced rat renal injury via alterations of the gut microbiota

It is well proved that hyperoxaluria induces the renal injury and finally causes the end stage kidney disease. Daphnetin (coumarin derivative) already confirmed renal protective effect in renal model, but hyperoxaluria protective effect still unexplore. The objective of this research was to scrutinize the renal protective effect of daphnetin against ethylene glycol (GC)-induced hyperoxaluria via altering the gut microbiota. GC (1% v/v) was used for the induction of hyperoxaluria in the rats and the rats were received the oral administration of daphnetin (5, 10 and 15 mg/kg). The body and renal weight were assessed. Urine, renal, inflammatory cytokines, antioxidant, inflammatory parameters, and gut microbiota were appraised. Daphnetin effectually improved the body weight and reduced the renal weight. Its also remarkably boosted the magnesium, calcium, citrate level and suppressed the level of uric acid and oxalate formation. Daphnetin significantly (p < .001) ameliorate the level of urinary kidney injury molecule 1 (KIM-1), blood urea nitrogen (BUN), urea, serum creatinine (Scr), neutrophil gelatinase-associated lipocalin (NGAL) and uric acid along with inflammatory cytokines and inflammatory mediators. Daphnetin considerably repressed the malonaldehyde (MDA) level, protein carbonyl and improved the level of glutathione reductase (GR), superoxide dismutase (SOD), glutathione (GSH) and catalase (CAT). Daphnetin treatment considerably altered the microbial composition of different bacteria at phylum, genus and family level. Daphnetin significantly suppressed the Firmicutes relative abundance and boosted the Bacteroidetes relative abundance. Our result clearly indicated that daphnetin remarkably ameliorates the GC induced hyperoxaluria in rats via altering the oxidative stress, inflammatory reaction and gut microbiota. PRACTICAL APPLICATION: Nephrotoxicity is a serious health disease worldwide. We induce the renal toxicity in the experimental rats using the ethylene glycol and scrutinized the renal protective effect of daphnetin. Daphnetin considerably suppress the renal, urine parameters. For estimation the underlying mechanism, we estimated the gut microbiota in all group rats. Daphnetin remarkably altered the level of gut microbiota and suggesting the renal protective effect.

Primary closure combined with C-tube drainage through cystic duct after laparoscopic common bile duct exploration is safe and feasible for patients

OBJECTIVE

Biliary duct management is of great significance after laparoscopic cholecystectomy (LC) combined with laparoscopic common bile duct exploration (LCBDE) in the treatment of cholecystolithiasis accompanied with common bile duct (CBD) stones. This study is to evaluate the safety and effectiveness of primary closure with C-tube drainage through cystic duct after LC + LCBDE.

METHODS

Through a retrospective study, 290 patients who underwent LC + LCBDE in our hospital from January 2019 to April 2022 were enrolled and divided into 2 groups. 143 patients underwent primary closure with C-tube drainage through cystic duct (C-tube group) and the other 147 patients underwent traditional T-tube drainage (T-tube group). Personal information, perioperative examinations, surgical results, and follow-up results were collected and analyzed.

RESULTS

There were no significant differences in the average age, gender, the mean of CBD diameters and the rate of comorbidities (acute cholecystitis, obstructive jaundice, acute pancreatitis and acute cholangitis) between the two groups (P > 0.05). Hospital stay, postoperative hospital stay were significantly shorter in the C-tube group than T-tube group (P < 0.05). In addition, the average time of placing and removal the drainage tubes was significantly less than those of the T-tube group (P < 0.05). This study also showed significant differences in the incidence of postoperative abdominal infection and soft tissue infection in the two groups (P < 0.05). There were no significant differences in the incidence of postoperative complications including cholangitis, bile duct stenosis, mortality in two groups. There were also no significant differences between the two groups of the recurrence of CBD stones, reoperation and readmition in 30 days during the median follow-up of 6 months.

CONCLUSIONS

Compared with T tube drainage, patients with C-tube drainage after LC + LCBDE with primary closure of cystic duct recovered faster and had fewer complications. C-tube drainage is a safe and feasible treatment option for patients with cholecystolithiasis and choledocholithiasis.

The Laparoscopic Cholecystectomy and Common Bile Duct Exploration: A Single-Step Treatment of Pediatric Cholelithiasis and Choledocholithiasis

BACKGROUND

In recent years, complicated biliary tract diseases are increasingly diagnosed in children. Laparoscopic exploration of the common bile duct (LCBDE) followed by laparoscopic cholecystectomy has gained popularity in children. The aim of this study was to investigate the outcomes of LCBDE in children and compare them with the treatment outcomes of previously used endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

From January 2000 to January 2022, a total of 84 children (78.5% female) underwent laparoscopic cholecystectomy with a median follow-up of 11.4 (IQR 8, 14) years. Of these, 6 children underwent laparoscopic cholecystectomy (LC) + ERCP and 14 children underwent LCBDE for choledochiothiasis. The primary end point of the study was the success of treatment in terms of the incidence of complications, recurrence rate, and rate of reoperation. Secondary endpoints were stone characteristics, presenting symptoms, duration of surgery, and length of hospital stay.

RESULTS

The majority of patients were female in both groups (83.5% vs. 85.7%), mostly overweight with a median BMI of 27.9 kg/m² and 27.4 kg/m², respectively. Obstructive jaundice, colicky pain, acute pancreatitis, and obstruction of the papilla were the most common symptoms in both groups. The majority of patients (68%) had one stone, whereas two or more stones were found in 32% of patients. The median diameter of the common bile duct was 9 mm in both groups. The procedure was successfully completed in all patients in the ERCP group. In the group of patients treated with LCBDE, endoscopic extraction of the stone with a Dormia basket was successfully performed in ten patients (71.4%), while in the remaining four patients (28.6%) the stones were fragmented with a laser because extraction with the Dormia basket was not possible. The median operative time was 79 min in the LCBDE group (IQR 68, 98), while it was slightly longer in the ERCP group, 85 min (IQR 74, 105) (p = 0.125). The length of hospital stay was significantly shorter in the LCBDE group (2 vs. 4 days, p = 0.011). No complications occurred in the LCBDE group, while two (40%) complications occurred in the ERCP group: pancreatitis and cholangitis (p = 0.078). During the follow-up period, no conversions, papillotomies, or recurrences were recorded in either group.

CONCLUSIONS

Exploration of the common bile duct and removal of stones by LCBDE is safe and feasible in pediatric patients for the treatment of choledocholithiasis. Through this procedure, choledocholithiasis and cholelithiasis can be treated in a single procedure without papillotomy or fluoroscopy. Compared with LC + ERCP, LCBDE is associated with a shorter hospital stay. The incidence of complications was rather low but not statistically significant.