Recurrence of choledocholithiasis following endoscopic bile duct clearance: Long term results and factors associated with recurrent bile duct stones

Feasibility of cholecystectomy in patients with silent common bile duct stones cohort prospective single arm multicentre study

BACKGROUND

The management of patients with concomitant gallbladder stones with silent CBDS still involves a wide range of debates, and there is little evidence regarding the recommendation of CBD clearance either before cholecystectomy or in the same session. In this study, we aimed to discuss the feasibility of performing LC with a wait-and-see strategy for patients with silent CBS.

METHOD

Patients with silent CBDS identified during preoperative examinations for gallbladder stones were studied for the feasibility of performing LC with a wait-and-see strategy for silent CBS.

RESULTS

Sixty patients who presented with gallbladder stones with silent CBDS underwent LC between February 2023 and July 2023. Seventeen patients (28.3%) underwent laparoscopic acute cholecystectomy, and 43 (71.7%) patients underwent laparoscopic elective cholecystectomy; all of these procedures were completed laparoscopically. Two patients (3.3%) developed symptomatic CBDS, both of whom were treated medically without intervention. Sixteen patients (26.7%) experienced spontaneous CBDS during the follow-up period.

CONCLUSION

Patients who present with symptomatic gall bladder stones either acutely or electively with asymptomatic CBDS can undergo laparoscopic cholecystectomy without suffering from CBDS with acceptable short-term outcomes.

TRIAL REGISTRATION

This study was registered at Suez med - IRB office under trial registration no. 6 and registered at clinicaltrials.gov (NCT06349876) in 31/3/2024.

Treatment for recurrent choledocholithiasis: endoscopic? or laparoscopic? A prospective cohort study

BACKGROUND

Endoscopic and laparoscopic techniques are crucial for management of bile duct stone.

OBJECTIVE

The aim of this study was to share our initial experiences with endoscopic and laparoscopic treatments for recurrent choledocholithiasis, with a particular focus on long-term complications.

METHODS

From January 2014 to June 2017, a total of 153 patients with recurrent common bile duct stones were prospectively recruited in this study. Patients were scheduled for either an endoscopic procedure (ERCP/EST group, n = 84), or a laparoscopic procedure (LCBDE group, n = 69). Data were collected on comorbid conditions, presenting symptoms, bile duct clearance, and the incidence of both short-term and long-term complications.

RESULTS

Patients in ERCP/EST group had a stone clearance rate comparable to that of the LCBDE group (94.2% vs 91.7%, p = 0.549). Minor (Clavien-Dindo grade 1 and 2) and major short-term complications (Clavien-Dindo grade 3 and above) were similar between patients in two groups (ERCP/EST group 17.9% versus LCBDE group 26.1%, and ERCP/EST group 7.1% versus LCBDE group 5.8%, p = 0.227 and p = 0.740, respectively). Patients in the ERCP/EST group had a shorter stone free interval than patients in the LCBDE group (28.5 ± 14.7 months versus 43.3 ± 17.8 months, p = 0.029). During a mean follow-up period of 67.0 months, more patients in the ERCP/EST group experienced stone recurrence compared to those in the LCBDE group (26.1% vs 11.6%, p = 0.020). In the ERCP/EST group, 45.5% (10/22) of the recurrent cases experienced more than two recurrences, with three patients requiring choledochojejunostomy due to repeated recurrence. Among patients with a non-dilated common bile duct (d ≤ 8 mm), both groups had comparable short-term and long-term complication rates (p = 0.151 and p = 0.404, respectively).

CONCLUSIONS

Laparoscopic treatment is a safe and effective option for patients with recurrent choledocholithiasis, extending the stone free interval, reducing the likelihood of stone recurrence, and highlighting benefits of minimally invasive surgery.

Microbial characteristics of bile in gallstone patients: a comprehensive analysis of 9,939 cases

Introduction

The exact triggers of gallstone formation remain incompletely understood, but research indicates that microbial infection is a significant factor and can interfere with treatment. There is no consensus on the bile microbial culture profiles in previous studies, and determining the microbial profile could aid in targeted prevention and treatment. The primary aim of this study is to investigate the differences in microbial communities cultured from bile specimens of patients with gallstones.

Methods

We collected the clinical characteristics and bile microbial status of 9,939 gallstone patients. Statistical analysis was employed to assess the relationship between microbes and clinical features, and a random forest model was utilized to predict recurrence.

Results

Results showed a higher proportion of females among patients, with the age group of 60-74 years being the most prevalent. The most common type of gallstone was solitary gallbladder stones. A total of 76 microbes were cultured from 5,153 patients, with Escherichia coli, Klebsiella pneumoniae, and Enterococcus faecalis being the most frequently identified. Significant differences in microbial diversity and positive detection rates were observed across different age groups, types of gallstones, and recurrence status. Positive frequencies of E. coli, Enterococcus faecium, and K. pneumoniae varied significantly by age group and gallstone type. The microbial diversity in the recurrence group was significantly lower compared to the non-recurrence group. The recurrence rate was significantly higher in the group with single microbial species compared to those with no microbes or multiple microbes. For the recurrence group, there were significant differences in the frequencies of seven microbes (Aeromonas hydrophila, Enterococcus casseliflavus, Enterococcus faecium, E. coli, K. pneumoniae, Proteus mirabilis, Pseudomonas aeruginosa) before and after recurrence, with these microbes appearing in a higher number of patients after recurrence. Regression analysis identified patient age, stone size, diabetes, venous thrombosis, liver cirrhosis, malignancy, coronary heart disease, and the number of microbial species as important predictors of recurrence. A random forest model constructed using these variables demonstrated good performance and high predictive ability (ROC-AUC = 0.862).

Discussion

These findings highlight the significant role of microbial communities in gallstone formation and recurrence. Furthermore, the identified predictors of recurrence, including clinical factors and microbial diversity, may help develop personalized prevention and recurrence strategies for gallstone patients.

Characterization of biliary and duodenal microbiota in patients with primary and recurrent choledocholithiasis

Purpose

To explore the biliary and duodenal microbiota features associated with the formation and recurrence of choledocholithiasis (CDL).

Methods

We prospectively recruited patients with primary (P-CDL, n = 29) and recurrent CDL (R-CDL, n = 27) for endoscopic retrograde cholangiopancreatography (ERCP). Duodenal mucosa (DM), bile and bile duct stones (BDS) samples were collected in P- and R-CDL patients. DM samples were also collected in 8 healthy controls (HC). The microbiota profile analysis was performed with 16S rRNA gene sequencing.

Results

Short-course antibiotic application before ERCP showed no significant effects in alpha and beta diversities of the biliary and duodenal microbiota in CDL. Alpha diversity showed no difference between DM and bile samples in CDL. The duodenal microbial richness and diversity was lower in both P- and R-CDL than HC. The biliary microbiota composition showed a high similarity between P- and R-CDL. Fusobacterium and Enterococcus were higher abundant in DM, bile, and BDS samples of R-CDL than P-CDL, as well as Escherichia and Klebsiella in bile samples of R-CDL. The enriched duodenal and biliary bacteria in CDL were closely associated with cholecystectomy, inflammation and liver dysfunction. The bile-associated microbiota of R-CDL expressed enhanced capacity of D-glucuronide and D-glucuronate degradation, implicating an elevated level of β-glucuronidase probably produced by enriched Escherichia and Klebsiella in bile.

Conclusions

The duodenal microbiota was in an imbalance in CDL. The duodenal microbiota was probably the main source of the biliary microbiota and was closely related to CDL formation and recurrence. Enterococcus, Fusobacterium, Escherichia and Klebsiella might contribute to CDL recurrence.

Clinical trials

The study was registered at the Chinese Clinical Trial Registry (https://www.chictr.org.cn/index.html, ChiCTR2000033940).

Supplementary Information

The online version contains supplementary material available at 10.1007/s13755-023-00267-2.

A Grading System for Assessing the Status of the Sphincter of Oddi During Intraoperative Choledochoscopy: A Surgeon's Perspective

BACKGROUND

The aim of this study was to establish a simple and practical grading system for evaluating the status of the sphincter of Oddi (SO) during intraoperative choledochoscopy. This system helps identify relevant variables that influence the status of the SO and provides recommendations for preventing stone recurrence.

METHODS

Ninety-three patients were selected retrospectively from a total of 316 patients diagnosed with choledocholithiasis between July 2020 and June 2023. All patients underwent common bile duct (CBD) exploration surgery and intraoperative choledochoscopy. The status of the SO was assessed during choledochoscopy. According to the severity of the condition, the patients were categorized into 4 groups. Data from each group, grades 1, 2, 3, 4, was analyzed statistically.

RESULTS

The number of patients in grade 1 was significantly lower than that of the other 3 groups. Except for grade 1, patients in grade 4 exhibited significant differences compared with the other 2 groups in terms of the diameter of the CBD, size of stones, presence of pneumobilia, and history of endoscopic retrograde cholangiopancreatography (ERCP) ( P <0.05). There were no significant differences between the groups in terms of sex, age, liver function, number of stones, history of gastrectomy, cholecystectomy, or CBD exploration.

CONCLUSIONS

The grading system helps us classify different sphincter functions and better understand the formation of choledocholithiasis by subdividing the status of the SO. Endoscopic sphincterotomy (EST) treatment can easily result in the loss of SO function, which increases the risk of stone recurrence.

The ABCG8 polymorphism increases the risk of gallbladder cancer in the general population and gallstones in obese patients from Poland

BACKGROUND

Gallstone disease (GD) is common but remains asymptomatic in most cases. However, gallstones can lead to complications like choledocholithiasis or gallbladder cancer. In this study, we analyse the common genetic risk factor for GD, the p.D19H variant in the sterol transporter ABCG8, in Polish patients with gallstones and gallbladder cancer.

METHODS

Three adult cohorts were prospectively recruited: 65 patients with gallbladder cancer, 170 obese individuals scheduled for bariatric surgery and 72 patients who underwent endoscopic retrograde cholangiopancreatography due to recurrent choledocholithiasis. The control cohort consisted of 172 gallstone-free adults. The ABCG8 p.D19H (rs11887534) polymorphism was genotyped using TaqMan assays.

RESULTS

The minor allele frequency (MAF) of the ABCG8 p.D19H polymorphism was significantly (p = .02) higher among cases with either gallstones or gallbladder cancer (MAF = 8.4%) as compared to controls (MAF = 4.0%). The highest frequency of the risk allele was detected in patients with gallbladder cancer (18.5%) and obese patients with GD (17.5%), followed by individuals with choledocholithiasis (13.9%). Notably, the p.19H variant was associated with an increased risk of developing gallbladder cancer (OR 2.76, 95% CI 1.16-6.54, p = .01) and an increased risk of GD in obese individuals scheduled for bariatric surgery (OR = 2.70, 95% CI 1.05-6.49, p = .03), but did not significantly affect the risk of choledocholithiasis.

CONCLUSIONS

The ABCG8 p.D19H common risk variant increases the risk of developing gallbladder cancer in Central Europeans and enhances the risk of gallstones in the obese. Carriers of the p.D19H variant might benefit from personalized preventive strategies, particularly regarding gallbladder cancer.

Recurrence of common bile duct stones after endoscopic clearance and its predictors: A systematic review

Background

The primary therapeutic strategy for the management of bile duct stones (BDS) is endoscopic retrograde cholangiopancreatography. However, there may be a recurrence of BDS on follow-up. Multiple risk factors have been studied for the prediction of BDS recurrence. We aimed to analyze the incidence of symptomatic BDS recurrence, systematically review the risk factors, and analyze the most important risk factors among those.

Methods

A comprehensive search of three databases was conducted from inception to November 2022 for studies reporting the recurrence of BDS recurrence after endoscopic retrograde cholangiopancreatography with clearance, along with an analysis of risk factors.

Results

A total of 37 studies with 12,952 patients were included in the final analysis. The pooled event rate for the recurrence of BDS stones was 12.6% (95% confidence interval: 11.2-13.9). The most important risk factor was a bile duct diameter ≥15 mm, which had a significant association with recurrence in twelve studies. Other risk factors with significant association with recurrence in three or more studies were the reduced angulation of the bile duct, the presence of periampullary diverticulum, type I periampullary diverticulum, in-situ gallbladder with stones, cholecystectomy, multiple stones in the bile duct, use of mechanical lithotripsy, and bile duct stent placement.

Conclusion

Around one out of seven patients have BDS recurrence after the initial endoscopic retrograde cholangiopancreatography. Bile duct size and anatomy are the most important predictors of recurrence. The assessment of risk factors associated with recurrence may help keep a close follow-up in high-risk patients.

Recurrence of common bile duct stones after endoscopic clearance and its predictors: A systematic review

Background

The primary therapeutic strategy for the management of bile duct stones (BDS) is endoscopic retrograde cholangiopancreatography. However, there may be a recurrence of BDS on follow‐up. Multiple risk factors have been studied for the prediction of BDS recurrence. We aimed to analyze the incidence of symptomatic BDS recurrence, systematically review the risk factors, and analyze the most important risk factors among those.

Methods

A comprehensive search of three databases was conducted from inception to November 2022 for studies reporting the recurrence of BDS recurrence after endoscopic retrograde cholangiopancreatography with clearance, along with an analysis of risk factors.

Results

A total of 37 studies with 12,952 patients were included in the final analysis. The pooled event rate for the recurrence of BDS stones was 12.6% (95% confidence interval: 11.2–13.9). The most important risk factor was a bile duct diameter ≥15 mm, which had a significant association with recurrence in twelve studies. Other risk factors with significant association with recurrence in three or more studies were the reduced angulation of the bile duct, the presence of periampullary diverticulum, type I periampullary diverticulum, in‐situ gallbladder with stones, cholecystectomy, multiple stones in the bile duct, use of mechanical lithotripsy, and bile duct stent placement.

Conclusion

Around one out of seven patients have BDS recurrence after the initial endoscopic retrograde cholangiopancreatography. Bile duct size and anatomy are the most important predictors of recurrence. The assessment of risk factors associated with recurrence may help keep a close follow‐up in high‐risk patients.

Endoscopic papillary large-balloon dilation with sphincterotomy for difficult common bile duct stones ≤12 mm: a prospective study

Background

Stone recurrence is a significant complication following endoscopic bile duct clearance. Endoscopic papillary large-balloon dilation (EPLBD) with biliary sphincterotomy (EBS) has shown satisfactory results in preventing recurrence of "large" common bile duct stones (CBDS). However, data on outcomes after EPLBD+EBS for CBDS ≤12 mm remain scarce. The present study prospectively evaluated the mid- and long-term efficacy of EPLBD+EBS for CBDS recurrence among this group of patients.

Methods

Consecutive patients with CBDS ranging from 8-12 mm, treated with EPLBD+EBS from June 2018 through June 2020, were prospectively followed-up for at least 36 months. CBDS recurrence was defined as recurrent stones confirmed by endoscopic retrograde cholangiopancreatography (ERCP) during the follow-up period.

Results

Overall, 72 patients (mean age: 67 years, 52.8% male) were included, of whom 22 (30.5%) had multiple (≥3) CBDS, 23 (31.9%) had a history of cholecystectomy, 13 (18.1%) had a periampullary diverticulum and 22 (30.5%) had a previous EBS. The mean CBD diameter was 11.6±1 mm, while a tapered duct was noted in 7 (9.7%). Post-procedural bleeding and cholangitis occurred in 1 and 2 cases respectively. No cases of perforation and post-ERCP pancreatitis were observed. During a mean follow up of 46.4±6.2 months (range 37-60), no mid-term recurrence was observed, whereas CBDS recurred in 2/72 (2.7%) in the long term.

Conclusions

EPLBD+EBS in patients with CBDS ≤12 mm was associated with a very low rate of mid- and long-term CBDS recurrence. Our results need to be further investigated with randomized controlled trials.

Preventive Saline Irrigation of the Bile Duct to Reduce the Rate of Residual Common Bile Duct Stones Without Intraductal Ultrasonography: A Systematic Review and Meta-Analysis

Endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (EST) has been proven efficacious in the removal of CBD stones. Even after endoscopic stone removal, recurring cholangitis due to a residual common bile duct (CBD) stone is prevalent in clinical practice with a residual recurrence rate of 4-24% after successful stone retrieval. This comprehensive study and meta-analysis aimed to determine if preventive saline irrigation of the bile duct (PSIB) reduces the amount of residual CBD stones. Through a comprehensive search of PubMed, EMBASE, Cochrane Library, and Web of Science until November 20, 2022, we identified 164 articles comparing the efficacy of PSIB and non-PSIB post-endoscopic CBD stone removal. After stringent selection, three studies were included for meta-analysis using ReviewManager (ReVman version 5.4.1; Cochrane, London, UK). Using a random effect (RE) model, we derived a pooled odds ratio (OR) with confidence interval (CI) (95%CI). A total of three studies have been included in the analysis. Out of which, two are randomized controlled trials (RCTs) and one is a non-randomized study. Out of 323 patients, 157 underwent PSIB after an endoscopic stone removal of CBD stones to reduce the residual of CBD stones, whereas 166 did not undergo saline irrigation (non-PSIB). In our analysis, PSIB significantly reduced the risk of residual stones (OR: 0.22, 95%CI: 0.11-0.45). However, there was no notable link between PSIB and post-irrigation cholangitis (OR: 1.08, 95%CI: 0.21-2.21). Although not statistically significant, PSIB showed a trend toward lowered risks of post-procedural pancreatitis (OR: 0.65), bleeding (OR: 0.68), and other complications (OR: 0.64). PSIB effectively reduces residual CBD stones after endoscopy, offering a cost-effective alternative to invasive procedures such as intraductal ultrasound (IDUS). However, larger RCTs are needed to validate its definitive role.

Is the use of a routine intraoperative cholangiogram necessary in laparoscopic cholecystectomy?

INTRODUCTION

Although laparoscopic cholecystectomy (LC) has been standard of care for symptomatic gallstone disease for almost 30 years, the use of routine intraoperative cholangiogram (IOC) remains controversial. There are marked variations in the use IOC during LC internationally. Debate has continued about its benefit, in part because of inconsistent benefit, time, and resources required to complete IOC. This literature review is presented as a debate to outline the arguments in favour of and against routine IOC in laparoscopic cholecystectomy.

METHODS

A standard literature review of PubMed, Medline, OVID, EMBASE, CINHIL and Web of Science was performed, specifically for literature pertaining to the use of IOC or alternative intra-operative methods for imaging the biliary tree in LC. Two authors assembled the evidence in favour, and two authors assembled the evidence against.

RESULTS

From this controversies piece we found that there is little discernible change in the number of BDIs requiring repair procedures. Although IOC is associated with a small absolute reduction in bile duct injury, there are other confounding factors, including a change in laparoscopic learning curves. Alternative technologies such as intra-operative ultrasound, indocyanine green imaging, and increased access to ERCP may contribute to a reduction in the need for routine IOC.

CONCLUSIONS

In spite of 30 years of accumulating evidence, routine IOC remains controversial. As technology advances, it is likely that alternative methods of imaging and accessing the bile duct will supplant routine IOC.

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.

Stone removal by percutaneous papillary balloon dilatation for cystic duct and bile duct stones after cholecystectomy and distal gastrectomy with Roux-en-Y gastrojejunostomy

A 71-year-old woman was referred to our department for abdominal pain. She was diagnosed with acute obstructive cholangitis due to cystic duct and bile duct stones after cholecystectomy and Roux-en-Y gastrojejunostomy. Two years ago, the patient underwent endoscopic and laparoscopic treatment for cystic duct and bile duct stones, however, the stones remained. This time, she was treated with stone removal using percutaneous papillary balloon dilatation (PPBD). Large stones in the common hepatic and bile ducts were crushed by electrohydraulic lithotripsy and then pushed out into the duodenum through the dilated papilla of Vater using a balloon catheter covered with the sheath and cholangioscopy. Stone in the cystic duct was pulled to the common bile duct and pushed to the duodenum. Stone removal using PPBD is an excellent alternative for patients with cystic duct and bile duct stones unable to be treated with endoscopic or laparoscopic stone removal.

Preferable timing of intraductal ultrasonography during endoscopic retrograde cholangiopancreatography lithotomy: A prospective cohort study

Aim

Intraductal ultrasonography (IDUS) is a highly sensitive and non-invasive detective method that can be used to detect complete calculus clearance during endoscopic retrograde cholangiopancreatography (ERCP). In this study, we examined the preferable timing of IDUS during ERCP lithotomy.

Methods

From 2017 to 2020, patients with choledocholithiasis were randomized into IDUS-BL (IDUS performed before lithotomy) group, IDUS-ALC (cholangiography and IDUS performed after lithotomy) group, and IDUS-AL group (IDUS performed after lithotomy) group. The influence of IDUS on the accuracy of prejudgment, the incidence of residual stones, the need for repeated lithotomy (RL), and fluoroscopy time were analyzed.

Results

A total of 184 patients were enrolled. No residual stones were found during follow-up in any of the three groups. There was no difference in prejudgment accuracy rate on size and number of stones between different groups (all P &gt; 0.05). RL were performed in 5, 9, and 9 cases of IDUS-BL, IDUS-ALC, and IDUS-AL group, respectively (P &gt; 0.05). IDUS-AL group had a shorter fluoroscopy time than the other two groups (1.5 ± 0.6 vs. 2.8 ± 1.2, 2.5 ± 1.0 min, P &lt; 0.05). Incidence of RL was related to the location of calculus [middle or lower part of common bile duct (CBD)], lithotripsy, dilated CBD (2.12 ± 0.46 vs. 1.78 ± 0.40 cm, P &lt; 0.01), and inaccuracy prejudgment.

Conclusion

IDUS performed after lithotomy is preferable for shorten fluoroscopy time during ERCP. IDUS is a reliable solution for the stone omission, which may be more valuable for patients with high-risk factors of RL.

Endoskopik olarak tedavi edilemeyen koledok taşlarında koledokoduodenostomi. Hem geleneksel hem de güncel yöntem

Amaç: Koledok taşlarının altın standart güncel tedavi yöntemi endoskopik retrograd kolanjiopankreatografi (ERCP) ile taş çıkarılmasıdır. Bunun başarısız olduğu durumlarda alternatif cerrahi tedavi yöntemleri ön plana çıkmaktadır. Geleneksel bir yöntem olan koledokoduodenostomi (CDD) de bunlardan biridir. Biz de ERCP'nin başarısız olduğu hastalardaki konvansiyonel CDD sonuçlarımızı sunmayı amaçladık. Yöntemler: Mart 2015 ve Şubat 2022 tarihleri arasında ERCP ile tedavi edilemeyen koledok taşı olan ve konvansiyonel koledok eksplorasyonu, taş çıkarılması ve CDD uygulanan 23 hastanın klinikodemografik verileri, perioperatif bulguları ve postoperatif sonuçları retrospektif olarak analiz edildi. Bulgular: Hastaların median yaşı 71 (41-85) olup, 13’ü (%56) kadındı. Hastaların 5’inde (21%) geçirilmiş kolesistektomi, 7’sinde (30%) gastrektomi + gastroenterostomi ameliyatı öyküsü vardı. En sık başvuru semptomu karın ağrısıydı (39 %). Başarısız ERCP sayısı median 1 (1-6) olup, başarısızlık nedenleri 7 hastada gastroenterostomi olması, 9 hastada impakte taş olması, 6 hastada taş boyutu ve sayısının fazla olması, 1 hastada da papilla açılım anomalisiydi. Hastaların median koledok çapı 15 (10-40) mm'di. Operasyon süresi median 120 (60-240) dk olup, perioperatif komplikasyon gelişmedi. Yatış süresi median 7 (4-14) gündü. Postoperatif erken dönemde 2 (8%) hastada yara yeri enfeksiyonu, 1 (4%) hastada da eviserasyon görüldü. Mortalite izlenmedi. Hastaların ortalama takip süresi median 27 (2-77) aydı ve geç dönemde 2 (8%) hastada insizyonel herni ile karşılaşıldı. Sump sendromuna ait bulgular hiçbir hastamızda gözlenmedi. Sonuç: ERCP ile çıkarılamayan koledok taşlarının tedavisinde CDD seçilmiş hastalarda efektif ve güvenli bir cerrahi tedavi yöntemidir.

Application of ERCP Procedures in Choledocholithiasis with Duodenal Stenosis Patients

Objective

The treatment of choledocholithiasis with duodenal stenosis is a clinical difficult problem. This study aimed to investigate the efficacy and safety of ERCP via gastroscopy in the treatment of choledocholithiasis and duodenal stenosis.

Methods

From January 2015 to December 2020, 21 patients with choledocholithiasis with duodenal stenosis who underwent ERCP treatment under gastroscopy in our hospital were enrolled. The patients' case characteristics, ERCP status, and complication rate were analyzed.

Results

Among the 21 patients, 17 cases were successful in ERCP, and a total of 29 times ERCPs were performed, with an average of 1.71 times per patient. Among the failures of ERCP, selective deep intubation of common bile duct was unsuccessful in 4 cases. Six patients underwent multiple lithotomies, after the operation, of which 4 patients underwent secondary ERCP lithotomy and 2 patients underwent triple ERCP lithotomy. All patients successfully completed the balloon dilation without serious complications. Two patients developed mild acute pancreatitis after ERCP, and all recovered after medication.

Conclusion

In patients with choledocholithiasis and duodenal stenosis, ERCP treatment by gastroscopy has a higher success rate and does not increase the incidence of complications, but there is a problem of cholecystolithiasis recurrence.

Endoscopic Papillary Large Balloon Dilation Reduces Further Recurrence in Patients With Recurrent Common Bile Duct Stones: A Randomized Controlled Trial

INTRODUCTION

Up to 60% of patients with common bile duct stone (CBDS) recurrence suffer from further recurrence after endoscopic retrograde cholangiopancreatography (ERCP). There are no effective methods to prevent recurrence in most patients. In this study, we aimed to assess the short-term and long-term efficacies of endoscopic papillary large balloon dilation (EPLBD) for the management of recurrent CBDS in a randomized controlled trial.

METHODS

Consecutive patients with recurrent CBDS were eligible and randomly assigned in a 1:1 ratio to the EPLBD group or the control group. The primary outcome was the CBDS recurrence rate within 2 years after ERCP. The analysis followed the intention-to-treat principle.

RESULTS

From 2014 to 2021, 180 patients with recurrent CBDS were included, with 90 in each group. All patients underwent complete CBDS clearance by 1 or several sessions of ERCP. The rate of complete clearance in 1 session was significantly higher with EPLBD treatment (95.6% vs 85.6%, P = 0.017). During the follow-up, the CBDS recurrence rate within 2 years was significantly lower in the EPLBD group than in the control group (21.1% [19/90] vs 36.7% [33/90], relative risk 0.58, 95% confidence interval 0.36-0.93, P = 0.021). At a median follow-up of approximately 56 months, CBDS recurrence was found in 34.4% of the patients (31/90) in the EPLBD group and 51.1% (46/90) in the control group (hazard ratio 0.57, 95% confidence interval 0.36-0.89, P = 0.012). Multiple recurrences (≥2) were also decreased in the EPLBD group (4.4% vs 18.9%, P = 0.020).

DISCUSSION

During the long-term follow-up, nearly half of the patients with recurrent CBDS experienced stone recurrence after traditional ERCP. Our study was the first to show that EPLBD effectively reduced the recurrence of CBDS.

New common bile duct morphological subtypes: Risk predictors of common bile duct stone recurrence

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is the primary treatment for removing common bile duct (CBD) stones. The risk factors for CBD stone recurrence after ERCP have been discussed for many years. However, the influence of CBD morphology has never been noticed.

AIM

To evaluate CBD morphology and other predictors affecting CBD stone recurrence in average patients.

METHODS

A retrospective analysis of 502 CBD stone patients who underwent successful therapeutic ERCP for stone extraction at our centre from February 2020 to January 2021 was conducted. CBD morphology and other predictors affecting CBD stone recurrence were examined by univariate analysis and multivariate logistic regression analysis.

RESULTS

CBD morphology (P < 0.01), CBD diameter ≥ 1.5 cm [odds ratio (OR) = 2.20, 95%CI: 1.08-4.46, P = 0.03], and endoscopic biliary sphincterotomy with balloon dilation (ESBD) (OR = 0.35, 95%CI: 0.17-0.75, P < 0.01) are three independent risk factors for CBD stone recurrence. Furthermore, the recurrence rate of patients with the S type was 6.61-fold that of patients with the straight type (OR = 6.61, 95%CI: 2.61-16.77, P < 0.01). The recurrence rate of patients with the polyline type was 2.45-fold that of patients with the straight type (OR = 2.45, 95%CI: 1.14-5.26, P = 0.02). The recurrence rate of S type patients was 2.70-fold that of patients with the polyline type (OR = 2.70, 95%CI: 1.08-6.73, P = 0.03). Compared with no-ESBD, ESBD could decrease the risk of recurrence.

CONCLUSION

CBD diameter ≥ 1.5 cm and CBD morphology, especially S type and polyline type, were associated with increased recurrence of CBD stones. In addition, ESBD was related to decreased recurrence. Patients with these risk factors should undergo periodic surveillance and standard prophylactic therapy.

Predictors of recurrent bile duct stone after clearance by endoscopic retrograde cholangiopancreatography: A case-control study

BACKGROUND

Recurrent common bile duct (CBD) stone is a long-term sequalae among patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) with CBD stone extraction. Data regarding risk factors for recurrent CBD stone are scarce. We aimed to identify predictors of recurrent CBD stone.

METHODS

We performed a retrospective case-controlled study from January 2010 to December 2019. Inclusion criteria included patients who had recurrent CBD stone at least 6 months after the index ERCP, in which complete stone extraction was performed and normal cholangiogram was obtained. Overall, 457 patients were included. Forty-two patients (9.2%) had recurrent CBD stone, and 415 patients (90.8%) did not have recurrent CBD stone.

RESULTS

In univariate analysis, male sex [odds ratio (OR) = 0.49, P = 0.033] was a protective factor, while endoscopic stone extraction by basket vs. balloon (OR = 2.55, P = 0.005), older age (OR = 1.03, P = 0.003), number of CBD stones (OR = 1.99, P = 0.037), size of CBD stone (OR = 4.06, P = 0.003) and mechanical lithotripsy (OR = 9.22, P = 0.004) were risk factors for recurrent CBD stone. In multivariate logistic regression analysis, mechanical lithotripsy [OR = 9.73, 95% confidence interval (CI): 1.69-55.89, P = 0.010], basket clearance vs. combined basket and balloon (OR = 18.25, 95% CI: 1.05-318.35, P = 0.046) and older age (OR = 1.02, 95% CI: 1.00-1.05, P = 0.023) were risk factors, and male sex (OR = 0.39, 95% CI: 0.19-0.81, P = 0.012) was a protective factor.

CONCLUSIONS

We identified modifiable and non-modifiable risk factors for recurrent CBD stone. Taking into consideration those factors might aid in minimizing the CBD stone recurrence risk.

Analysis of symptomatic recurrences of common bile ducts stones after endoscopic removal: Factors related to early or multiple recurrences

Early or multiple recurrences of symptomatic common bile duct (CBD) stones are troublesome late complications after endoscopic stone removal. We aimed to determine the factors related to early or multiple recurrences of CBD stones.We retrospectively analyzed patients who underwent endoscopic CBD stone extraction in a single institute between January 2006 and December 2015. Patients were divided into 2 groups according to the number and interval of CBD stone recurrences: single versus multiple (≥2) and early (<1.5 years) versus late (≥1.5 years) recurrence.After exclusion, 78 patients were enrolled and followed up for a median of 1974 (IQR: 938-3239) days. Twenty-seven (34.6%) patients experienced multiple recurrences (≥2 times), and 26 (33.3%) patients experienced early first recurrence (<1.5 years). In the multivariate analysis, CBD angulation was independently related to multiple CBD stone recurrence (OR: 4.689, P = .016), and endoscopic papillary large balloon dilation was independently related to late first CBD stone recurrence (OR: 3.783, P = .025). The mean CBD angles were more angulated with increasing instances of recurrence (0, 1, 2, 3, and ≥4 times) with corresponding values of 150.3°, 148.2°, 143.6°, 142.2°, and 126.7°, respectively (P = .011). The period between the initial treatment and first recurrence was significantly longer than the period between the first and second recurrence (P = .048).In conclusion, greater CBD angulation is associated with the increased number of CBD stone recurrence, and EPLBD delays the recurrence of CBD stones after endoscopic CBD stone removal.

Differences in Outcome and Comparison of Stress and Immune Status in Patients with Recurrent Common Bile Duct Stones after Biliary Tract Surgery Choosing Three Procedures (ERCP, OCBDE, and LCBDE) for Treatment

OBJECTIVE

To compare the effect of choosing ERCP, OCBDE, and LCBDE for the treatment of patients with recurrent common bile duct stones after biliary tract surgery.

METHOD

115 patients with recurrent common bile duct stones after biliary surgery in our hospital were retrospectively analyzed and divided into three groups according to the procedure, 36 patients in the ERCP group, 38 patients in the OCBDE group, and 41 patients in the LCBDE group, and compared the efficacy, stress status, and immune status of the three groups.

RESULT

The stone removal rates were 91.67%, 97.37%, and 97.56% in the ERCP, OCBDE, and LCBDE groups, respectively (P > 0.05). There were statistical differences between the ERCP, OCBDE, and LCBDE groups in terms of operative time, postoperative recovery time of exhaustion, recovery time of defecation, recovery time of feeding, and hospitalization time (P < 0.05). The postoperative complication rates were 8.33%, 10.53%, and 7.32% in the ERCP, OCBDE, and LCBDE groups, respectively (P > 0.05). The recurrence rates within 1 year after surgery were 2.78%, 7.89%, and 2.44% in the ERCP, OCBDE, and LCBDE groups, respectively (P > 0.05).

CONCLUSION

ERCP has short operative time, short hospital stay, and rapid postoperative recovery. LCBDE has mild trauma, and OCBDE has a wide range of application. Each of the three procedures has its own advantages and shortcomings, and the most appropriate procedure should be selected on the basis of comprehensive evaluation.

Laparoscopic treatment of a recurrent biliary stone forming around a Hem-o-lok clip in a patient with previous gastrectomies: Case report

RATIONALE

A history of gastrectomy is associated with an increased incidence of gallstones requiring surgery. Endoscopic retrograde cholangiopancreatography is challenging for patients who undergo total or Billroth II gastrectomy. Laparoscopic common bile duct exploration (LCBDE) has been attempted in such cases. Herein, we report a case of choledocholithiasis in which a stone formed around a migrated Hem-o-lok clip.

PATIENT CONCERNS

A 67-year-old man was admitted to the hospital for acute right upper abdominal pain. He had a history of 2 open gastric cancer surgeries in the previous seven years and had undergone LCBDE 12 months prior to this admission. Postoperative examination revealed recurrence of bile duct stones.

INTERVENTIONS

The patient underwent repeat LCBDE plus primary closure with an evaluation of abdominal adhesion. A stone had formed around a Hem-o-lok clip in the common bile duct was removed.

OUTCOMES

The patient had an uneventful recovery with no stone recurrence or movement of the remaining Hem-o-lok clips after a 1-year follow-up.

LESSONS

LCBDE with primary closure should be carefully considered in patients with certain gallstone diseases after complicated upper abdominal surgery.Postoperative clip migration is a rare complication; hence care must be taken in placing the clip appropriately to ensure that it is not too close to the common bile duct.

Reinterventions following laparoscopic cholecystectomy and bile duct exploration. A review of prospective data from 5740 patients

Background

Complications following laparoscopic cholecystectomy (LC) and common bile duct exploration (CBDE) for the management of gallstones or choledocholithiasis impact negatively on patients’ quality of life and may lead to reinterventions. This study aims to evaluate the causes and types of reintervention following index admission LC with or without CBDE.

Methods

A prospectively maintained database of LC and CBDE performed by a single surgeon was analysed. Preoperative factors, difficulty grading and perioperative complications requiring reintervention and readmissions were examined.

Results

Reinterventions were required in 112 of 5740 patients (2.0%), 89 (1.6%) being subsequent to complications. The reintervention cohort had a median age of 64 years, were more likely to be females (p < 0.0023) and to be emergency admissions (67.9%, p < 0.00001) with obstructive jaundice (35.7%, p < 0.00001). 46.4% of the reintervention cohort had a LC operative difficulty grade IV or V and 65.2% underwent a CBDE. Open conversion was predictive of the potential for reintervention (p < 0.00001). The most common single cause of reintervention was retained stones (0.5%) requiring ERCP followed by bile leakage (0.3%) requiring percutaneous drainage, ERCP and relaparoscopy. Relaparoscopy was necessary in 17 patients and open surgery in 13, 6 of whom not resulting from complications. There were 5 deaths.

Conclusion

This large series had a low incidence of reinterventions resulting from complications in spite of a high workload of index admission surgery for biliary emergencies and bile duct stones. Surgical or endoscopic reinterventions following LC alone occurred in only 0.8%. The most common form of reintervention was ERCP for retained CBD stones. This important outcome parameter of laparoscopic biliary surgery can be optimised through early diagnosis and timely reintervention for complications.

Incidence and risk factors for postoperative common bile duct stones in patients undergoing endoscopic extraction and subsequent cholecystectomy

BACKGROUND AND AIMS

In patients who undergo cholecystectomy after endoscopic common bile duct (CBD) stone extraction, CBD stones found postoperatively could be problematic. This study aimed to investigate the incidence and risk factors of postoperative CBD stones after cholecystectomy.

METHODS

A total of 278 patients (mean age, 59.2 years; 71 men [51.1%]) who underwent endoscopic removal of CBD stones followed by cholecystectomy from January 2013 to December 2017 were included. An endoscopic nasobiliary drainage (ENBD) tube was placed immediately after endoscopic clearance of the CBD stones in all patients until cholecystectomy. An ENBD tubogram was obtained in all patients to determine the presence of postoperative CBD stones.

RESULTS

Postoperative CBD stones were detected in 20.1% (56/278). An ENBD tubogram was obtained after an average of 2.42 days postoperatively. Based on univariate analysis, the statistically significant risk factors for postoperative CBD stone were CBD stones >2, CBD stone size >10 mm, cholesterol stone, maximum diameter of CBD >15 mm, treatment with endoscopic sphincterotomy alone, and use of endoscopic mechanical lithotripsy (EML). In multivariate analysis, cholesterol stone, CBD stones >2, CBD stone size >10 mm, and EML were related to postoperative CBD stones after cholecystectomy.

CONCLUSIONS

Based on the relatively high rate of postoperative CBD stones after cholecystectomy, careful follow-up should be considered in patients with high-risk factors to detect CBD stones early.

Could saline irrigation clear all residual common bile duct stones after lithotripsy? A self-controlled prospective cohort study

BACKGROUND

A previous study showed that irrigation with 100 mL saline reduced residual common bile duct (CBD) stones, which potentially cause recurrent stones after endoscopic retrograde cholangiopancreatography.

AIM

To determine whether saline irrigation can improve CBD clearance after lithotripsy.

METHODS

This prospective self-controlled study enrolled patients receiving mechanical lithotripsy for large (> 1.2 cm) CBD stones. After occlusion cholangiography confirmed CBD stone clearance, peroral cholangioscopy (POC) was performed to determine clearance scores based on the number of residual stones. The amounts of residual stones spotted via POC were graded on a 5-point scale (score 1, worst; score 5, best). Scores were documented after only stone removal (control) and after irrigation with 50 mL and 100 mL saline, respectively. The stone composition was analyzed using infrared spectroscopy.

RESULTS

Between October 2018 and January 2020, 47 patients had CBD clearance scores of 2.4 ± 1.1 without saline irrigation, 3.5 ± 0.7 with 50 mL irrigation, and 4.6 ± 0.6 with 100 mL irrigation (P < 0.001). Multivariate analysis showed that CBD diameter > 15 mm [odds ratio (OR) = 0.08, 95% confidence interval (CI): 0.01-0.49; P = 0.007] and periampullary diverticula (PAD) (OR = 6.51, 95%CI: 1.08-39.21; P = 0.041) were independent risk factors for residual stones. Bilirubin pigment stones constituted the main residual stones found in patients with PAD (P = 0.004).

CONCLUSION

Irrigation with 100 mL of saline may not clear all residual CBD stones after lithotripsy, especially in patients with PAD and/or a dilated (> 15 mm) CBD. Pigment residual stones are soft and commonly found in patients with PAD. Additional saline irrigation may be required to remove retained stones.

Biliary Microbial Structure of Gallstone Patients With a History of Endoscopic Sphincterotomy Surgery

The biliary microbiota is related to the pathogenesis of human bile duct stones. However, the extent to which a history of invasive endoscopic sphincterotomy (EST) affects the biliary bacterial community remains largely unknown. We collected bile samples from the common bile duct of 100 choledocholithiasis patients. We performed 16S rRNA sequencing to investigate and compare the biliary microbial community. The patients without antibiotic treatment (AT) were grouped into three clusters based on their biliary microbial compositions. The patients with a history of EST were significantly enriched in one cluster mainly consisting of gastrointestinal bacteria compared with the other two clusters consisting of oral and environmental bacteria. The β-diversities of patients with and without EST were also significantly different, whereas the α-diversities were comparable. The only significantly enriched bacterial genus associated with a history of EST was Pyramidobacter, while eight other genera were significantly decreased. For patients with AT, seven of these genera maintained their association with EST, including Pyramidobacter. However, after AT, the difference in β-diversities was diminished. EST induced a marked shift in the biliary microbial composition. A cluster of biliary bacteria was associated with a history of EST, and Pyramidobacter was specific to EST.

Unsuspected choledocholithiasis found by routine intra-operative cholangiography during laparoscopic cholecystectomy

BACKGROUND

The true incidence of unsuspected choledocholithiasis found during laparoscopic cholecystectomy (LC) is unknown. Untreated 'silent' stones may be associated with significant long-term risks. The aim of this study was to establish the incidence of unsuspected common bile duct stones (CBDS) and to determine the management and associated risk factors for unsuspected CBDS.

METHODS

Retrospective review of a large consecutive series of patients from Australia who underwent LC in a tertiary referral setting. Percentages of unsuspected CBDS, management and complications were reported. Pre-operative and intra-operative factors associated with unsuspected CBDS were determined using multivariable logistic regression analysis.

RESULTS

From a total of 1998 patients who underwent LC, 747 (37.4%) patients with no pre-operative suspicious factors were the subject of this study. CBDS were detected in 24 (3.2%) patients and all were managed either laparoscopically or endoscopically. Risk factors independently associated with unsuspected CBDS included patients >55 years of age (odds ratio 2.93, P = 0.038) and a large cystic duct size (odds ratio = 3.13, P < 0.001) on multivariable analysis.

CONCLUSION

The incidence of patients with unsuspected CBDS on intra-operative cholangiography is low. Complete clearance of these stones can be achieved using a combination of laparoscopic and endoscopic methods.

Percutaneous transhepatic endoscopic lithotripsy of biliary stones with holmium laser for the treatment of recurrent cholangitis

PURPOSE

To evaluate the efficacy and safety of percutaneous transhepatic endoscopic holmium laser biliary lithotripsy (PTBL) to treat recurrent cholangitis due to intra/extrahepatic stones, in patients not candidate for traditional endoscopic treatment.

MATERIALS AND METHODS

We retrospectively evaluated 28 patients (M:F = 19:9, mean age = 65 years, SD = 14) undergoing 43 PTBL for stone-related recurrent cholangitis from January 1, 2012 to January 31, 2019 in a single academic center. Data collected included demographics, location and number of stones, clinical success after one (primary) or more than one (secondary) PTBL, procedure time, duration of hospital stay, number of retreatments and post-procedural complications. Clinical success was defined as the resolution of cholangitis at 30-day follow-up.

RESULTS

PTBL were successful for 23/28 (82%) patients, 16 (57%) with one and 7 (88%) with repeat procedures. The remaining 5 (18%) patients were finally treated with surgery (3, 11%) or further antibiotics (2, 7%). PTBL were performed to treat intrahepatic stones (22 treatments, 51%), extrahepatic (14, 33%), and both intra/extrahepatic (7, 16%). One to three stones were found in 12/43 (28%) PTBL, more than three in 31/43 (72%). Single PTBL was performed in 20/28 (71%) patients, two in 3/28 (11%), three in 3/28 (11%), and four in 2/28 (7%). Median procedure duration was 115 (29-210, 95% CI 101-129) minutes; median hospital stay was 5.5 (2-42) days. The only major complication was the breakage of a guidewire tip, surgically retrieved; minor complications included one aspiration pneumonia and three instances of intrahepatic hemorrhage, treated conservatively.

CONCLUSIONS

PTBL was clinically successful in the 82% of patients not candidate for endoscopic treatment, with a low complication rate.

Risk factors of stone recurrence after endoscopic retrograde cholangiopancreatography for common bile duct stones

To explore the risk factors related to the recurrence of common bile duct stones (CBDS) after endoscopic retrograde cholangiopancreatography (ERCP), so as to provide reference for reducing the recurrence of CBDS after ERCP.The clinical data of 385 patients with CBDS treated by ERCP from March 2012 to May 2016 were collected. According to the diagnostic criteria of recurrence of CBDS, the patients were divided into recurrence group and control group. The general information of the patients, personal history, past history, and surgical-related information were collected. Univariate analysis and multivariate logistic regression analysis were performed on the collected data to identify risk factors for recurrence of CBDS after ERCP.A total of 262 patients were included in the study, of which 51 had recurrence of CBDS, with a recurrence rate of 19.46%. Multivariate Logistic analysis () showed greasy diet (P = .436), history of cholecystectomy (P = .639) and gallstone size (P = .809) were not independent risk factor for recurrence of stones after ERCP in CBDS. But age ≥65 (P = .013), history of common bile duct incision (P = .001), periampullary diverticulum (P = .001), common bile duct diameter ≥1.5 cm (P = .024), ERCP ≥2 (P = .003), the number of stones ≥2 (P = .015), the common bile duct angle ≤120° (P = .002) and the placement of bile duct stent (P = .004) are important independent risk factor for recurrence of stones after ERCP in CBDS.This study confirmed that ag ≥65, history of choledochotomy, periampullary diverticulum, diameter of common bile duct (≥15 mm), multiple ERCP, the number of stones ≥2, stent placement and angle of common bile duct < 120° were independent risk factors for recurrence of CBDS after ERCP.

Efficacy of endoscopic ultrasound after removal of common bile duct stone

Objective: Endoscopic retrograde cholangiopancreatography (ERCP) is a standard procedure for choledocholithiasis. Nonetheless, the recurrence rate remains quite high. This study aimed to investigate the prevalence and related factors of remnant biliary stone or sludge using endoscopic ultrasound (EUS) after the removal of common bile duct (CBD) stone and to evaluate the long-term clinical outcomes. Methods: A prospective study enrolling a consecutive series of patients who underwent ERCP for CBD stone removal was performed between June 2014 and November 2015. Following confirmation of complete CBD stone removal by the operator, EUS was performed to determine whether biliary stone or sludge remained. Patients underwent cholecystectomy if a gallstone was identified and were subsequently followed up at a regular interval of 3-6 months. We investigated whether symptomatic recurrence would occur. Results: A total of 130 patients were enrolled. The presence of remnant biliary stone or sludge after ERCP was confirmed in 36.9% (48/130) of patients. Acute angulation of the distal CBD was the sole factor associated with remnant biliary stone or sludge (p < .01). During the follow-up period, the overall recurrence rate was 17.7% (23/130). Recurrent symptomatic choledocholithiasis was predicted by remnant biliary sludge and large CBD diameter in multivariate analysis. Conclusions: Acute angulation of the distal CBD was associated with remnant biliary stone or sludge after ERCP. Remnant biliary sludge on EUS and large CBD diameter were strong predictors of symptomatic recurrence. EUS evaluation following CBD stone removal could be an effective strategy in the treatment of choledocholithiasis.

Outcomes of endoscopic sphincterotomy vs open choledochotomy for common bile duct stones

BACKGROUND

Endoscopic sphincterotomy (EST) for the management of common bile duct stones (CBDS) is used increasingly widely because it is a minimally invasive procedure. However, some clinical practitioners argued that EST may be complicated by post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) and accompanied by a higher recurrence of CBDS than open choledochotomy (OCT). Whether any differences in outcomes exist between these two approaches for treating CBDS has not been thoroughly elucidated to date.

AIM

To compare the outcomes of EST vs OCT for the management of CBDS and to clarify the risk factors associated with stone recurrence.

METHODS

Patients who underwent EST or OCT for CBDS between January 2010 and December 2012 were enrolled in this retrospective study. Follow-up data were obtained through telephone or by searching the medical records. Statistical analysis was carried out for 302 patients who had a follow-up period of at least 5 years or had a recurrence. Propensity score matching (1:1) was performed to adjust for clinical differences. A logistic regression model was used to identify potential risk factors for recurrence, and a receiver operating characteristic (ROC) curve was generated for qualifying independent risk factors.

RESULTS

In total, 302 patients undergoing successful EST (n = 168) or OCT (n = 134) were enrolled in the study and were followed for a median of 6.3 years. After propensity score matching, 176 patients remained, and all covariates were balanced. EST was associated with significantly shorter time to relieving biliary obstruction, anesthetic duration, procedure time, and hospital stay than OCT (P < 0.001). The number of complete stone clearance sessions increased significantly in the EST group (P = 0.009). The overall incidence of complications and mortality did not differ significantly between the two groups. Recurrent CBDS occurred in 18.8% (33/176) of the patients overall, but no difference was found between the EST (20.5%, 18/88) and OCT (17.0%, 15/88) groups. Factors associated with CBDS recurrence included common bile duct (CBD) diameter > 15 mm (OR = 2.72; 95%CI: 1.26-5.87; P = 0.011), multiple CBDS (OR = 5.09; 95%CI: 2.58-10.07; P < 0.001), and distal CBD angle ≤ 145° (OR = 2.92; 95%CI: 1.54-5.55; P = 0.001). The prediction model incorporating these factors demonstrated an area under the receiver operating characteristic curve of 0.81 (95%CI: 0.76-0.87).

CONCLUSION

EST is superior to OCT with regard to time to biliary obstruction relief, anesthetic duration, procedure time, and hospital stay and is not associated with an increased recurrence rate or mortality compared with OCT in the management of CBDS.

Hem-o-lok clip found in the common bile duct 3 years after laparoscopic cholecystectomy and surgical exploration

Endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction is a common and preferred choice for gallstone disease. Laparoscopic common bile duct exploration (LCBDE) and laparoscopic cholecystectomy (LC) are being increasingly used for managing choledocholithiasis and cholecystolithiasis. We report a case of a Hem-o-lok clip that was dropped into the common bile duct (CBD) after LC and surgical common bile duct exploration (CBDE). An 84-year-old man presented with right upper quadrant pain and jaundice for 2 months, and chills and hyperpyrexia for 1 day. The patient had received ERCP and surgical CBDE at a local hospital 3 years previously. The patient first received ERCP and endoscopic nasobiliary drainage (ENBD). When laboratory tests were normal, the patient then received LCBDE. During exploration, stones and a Hem-o-lok clip in the CBD were removed. The patient made good progress after LCBDE + T-tube placement and was discharged from hospital. The findings from this case suggest the following: 1) an appropriate therapy method should be considered for certain gallstone diseases, especially for choledocholithiasis and cholecystolithiasis; and 2) a Hem-o-lok clip should be carefully used during laparoscopic or robot-assisted surgery and the Hem-o-lok clip should not be in close proximity to the incision on the CBD.

Risk factors for recurrence of common bile duct stones after endoscopic biliary sphincterotomy

Objective

Late complications after endoscopic biliary sphincterotomy (EST) include stone recurrence, but no definite risk factors for recurrence have been established. This study was performed to identify the predictors of recurrence and evaluate the clinical outcomes of EST for common bile duct stones.

Methods

In total, 345 eligible patients who successfully underwent EST were evaluated and followed up. Statistical analysis was performed on patients with recurrence or who had undergone at least 6 months of reliable follow-up to detect the risk factors for recurrence.

Results

A total of 57 patients (16.52%) developed recurrence of common bile duct stones. The median length of time until recurrence was 10.25 months (range, 6–54.4 months). Univariate analyses showed that the following factors were associated with recurrence: cholecystectomy prior to EST, prior biliary tract surgery, periampullary diverticulum, diameter of the common bile duct (>15 vs. ≤15 mm), quantity of stones, complete stone removal at the first session, and lithotripsy. Multivariate analysis identified two independent risk factors for recurrence: previous biliary tract surgery and lithotripsy.

Conclusions

EST for common bile duct stones is safe as indicated by patients’ long-term outcomes. Patients with a history of biliary surgery or lithotripsy are more prone to recurrence.

Evaluation of risk factors for recurrent primary common bile duct stone in patients with cholecystectomy

OBJECTIVES

Recurrence of primary common bile duct (CBD) stone commonly occurs after complete removal of CBD stones in patients with cholecystectomy. This study aimed to investigate potential risk factors for the recurrence of primary CBD stones after endoscopic treatment.

MATERIALS AND METHODS

Between January 2005 and December 2015, the endoscopic retrograde cholangiopancreatography (ERCP) database of our medical center was retrospectively reviewed; information regarding eligible patients who had recurrent CBD stones with a history of previous cholecystectomy was collected. The characteristics of the patients, CBD stone, CBD and ERCP-related factors were analyzed.

RESULTS

The recurrence rate of CBD stone was 18.5% (115/622) after endoscopic treatment in patients with cholecystectomy. In univariate analysis, the number of CBD stones (≥2), CBD stone diameter (≥10 mm), stone composition, stone consistency, CBD diameter (≥15 mm), bile duct dilatation pattern, sharp bile duct angulation (<145°), balloon dilatation, large balloon (>12 mm) dilatation, endoscopic mechanical lithotripsy, endoscopic sphincterotomy, and endoscopic papillary balloon dilatation alone method were significant between the non-recurrence and recurrence groups. However, in multivariate analysis (based on the binary logistic regression method), the number of CBD stones (≥2) (adjusted odds ratio [AOR] 3.232; 95% confidence interval [CI] 1.344-7.773; p = .009), cholesterol stone (AOR 2.824; 95% CI 1.175-6.786; p =.02) and sharp bile duct angulation (<145°) (AOR 2.462; 95% CI 1.062-5.711; p = .036) were independent risk factors of CBD stone recurrence after cholecystectomy.

CONCLUSIONS

CBD stone number (≥2), cholesterol stone and sharp bile duct angulation (<145°) are associated with recurrent common bile duct stones after cholecystectomy.

Application of remifentanil for conscious sedation and analgesia in short-term ERCP and EST surgery

This study aims to observe and evaluate the use of remifentanil in conscious sedation and analgesia for the safety and comfort of patients undergoing short-term endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (EST).Sixty-eight patients who underwent ERCP and EST were randomly divided into two groups: research group and control group. Patients in the research group were intravenously injected with remifentanil (80-2/3* age) for 1 to 2 minutes, combined with the intravenous injection of propofol (20-30 mg) during the course of treatment. ERCP surgery was performed when Ramsay sedation scale (RSS) score reached 2-3. During the surgery, patients were closely monitored for cough symptoms, aspiration, and respiratory and circulatory system performance, and timely treatment was performed. Sedative drugs were not given in patients in the control group.In research group, the circulatory and respiratory depression of patients was mild, only one patient needed to be treated, and there was no arrhythmia requiring treatment. Five patients had respiratory depression (blood oxygen saturation decreased to <90%), which was immediately corrected. There were no interruptions during surgery due to body movement, cough, or aspiration.The use of remifentanil for conscious sedation and analgesia can be broadly applied in short-term ERCP, which greatly improves patient comfort during the surgery. This approach may bear promise for a widespread use in future clinical practice.