Bile Duct Stones In Patients Research Articles

Urgent endoscopic retrograde cholangiopancreatography treatment useful for acute cholangitis caused by bile duct stones in patients aged 90 years and older.

Recently, the incidence of acute obstructive cholangitis caused by bile duct stones in patients aged 90 years and older (super-old) has been increasing, for which urgent endoscopic retrograde cholangiopancreatography (ERCP) treatment may be required. The aim of this study was to evaluate the efficacy and safety of urgent ERCP in super-old patients with acute cholangitis caused by bile duct stones. A total 147 consecutive patients aged between 75 and 99 years who underwent urgent ERCP for acute cholangitis caused by bile duct stones were analyzed in a retrospective manner. They were divided into the old (age 75 to 89 years, control) and super-old (age 90 to 99 years) groups. Urgent ERCP efficacy and safety, including general status, ERCP-related findings and outcomes, cardiopulmonary monitoring during ERCP, and mortality, were compared between the groups. The physical status of the super-old group was worse than that of the old group. The success rates for biliary drainage and complete clearance of bile duct stones at the first attempt in the super-old group were lower as compared to the old group, while those after two attempts increased in the super-old group and were nearly the same as in the old group. No fatal cardiopulmonary complications during ERCP were observed in either group. Mortality rate within two months was higher in the super-old group, though recovered to the same level as in the old group after two months. Efficacy and safety of urgent ERCP treatment in super-old patients were comparable to those seen in old patients, though the overall trend indicated greater difficulty. Urgent ERCP treatment can be useful for acute cholangitis caused by bile duct stones in super-old patients.

Factors affecting complete stone removal and bile duct stone recurrence in patients with surgically altered anatomy treated by double-balloon endoscopy-assisted endoscopic retrograde cholangiography.

This study assessed factors influencing the complete removal and recurrence of bile duct stones in patients with surgically altered anatomy (SAA) undergoing double-balloon endoscopy-assisted endoscopic retrograde cholangiography (DBERC). A retrospective analysis of 289 patients with SAA treated for biliary stones with DBERC at Jichi Medical University Hospital (January 2007 to December 2022) was conducted. Evaluation of factors impacting complete stone removal was performed in 257 patients with successful bile duct cannulation. Logistic and Cox proportional hazards regression models were used to compute the odds ratios (ORs) and hazard ratios (HRs) at 95% confidence intervals (CIs). Of 257 patients, 139 (54.0%) and 209 (81.3%) achieved initial and complete removal, respectively. Recurrence occurred in 55 (21.4%) patients. Factors associated with initial complete stone removal included cholangitis (P < 0.01, OR 0.48, 95% CI 0.27-0.83), number of stones (P < 0.01, OR 0.31, 95% CI 0.18-0.54), and largest stone diameter (P < 0.01, OR 0.37, 95% CI 0.20-0.67). The size of the largest stone was associated with complete removal (P = 0.01, OR 0.24, 95% CI 0.13-0.76). Recurrence was associated with cholangitis (P = 0.046, HR 0.54, 95% CI 0.29-0.99), congenital biliary dilatation (P = 0.01, HR 2.65, 95% CI 1.21-5.80), and number of stones (P = 0.02, HR 1.96, 95% CI 1.12-3.41). Successful complete bile stone removal in patients with SAA depends on the stone diameter and number. Stone recurrence is influenced by the number of stones and history of congenital biliary dilatation.

Extracorporeal shock wave lithotripsy combined with endoscopic retrograde cholangiopancreatography under guidance of percutaneous transhepatic cholangiography drainage to treat difficult bile duct stones in patients with surgically altered anatomy: Report of two cases

Extracorporeal shock wave lithotripsy combined with endoscopic retrograde cholangiopancreatography under guidance of percutaneous transhepatic cholangiography drainage to treat difficult bile duct stones in patients with surgically altered anatomy: Report of two cases

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

IntroductionThe 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.MethodsPatients 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.ResultsFifty-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.ConclusionsThis 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.

Tauroursodeoxycholic acid suppresses biliary epithelial cell apoptosis and endoplasmic reticulum stress by miR-107/NCK1 axis in a FXR-dependent manner

Tauroursodeoxycholic acid (TUDCA) can activate farnesoid X receptor (FXR) to involve in the formation of gallstones. Here, this study aimed to probe the potential mechanism of TUDCA-FXR network in the formation of bile duct stone. The levels of TUDCA, FXR and NCK1 were decreased, while the level of miR-107 was increased in the serum of bile duct stone patients. FXR expression was positively correlated with TUDCA or NCK1 expression in patients, moreover, TUDCA pretreatment in biliary epithelial cells increased the levels of FXR and NCK1, and rescued the decrease of NCK1 caused by FXR knockdown in cells. Then functional analysis showed FXR knockdown caused apoptosis and endoplasmic reticulum stress (ERS) as well as suppressed proliferation in biliary epithelial cells in vitro, which were attenuated by TUDCA pretreatment or NCK1 overexpression Mechanistically, NCK1 was a target of miR-107, which was up-regulated by FXR silencing, and FXR knockdown-induced decrease of NCK1 was rescued by miR-107 inhibition. Additionally, miR-107 expression was negatively correlated with TUDCA expression in bile duct stone patients, and TUDCA pretreatment in biliary epithelial cells decreased miR-107 expression by FXR. Functionally, the pretreatment of TUDCA or FXR agonist suppressed miR-107-evoked apoptosis and ERS in biliary epithelial cells. In conclusion, TUDCA up-regulates FXR expression to activate NCK1 through absorbing miR-107, thus suppressing the apoptosis and ERS in biliary epithelial cells, these results provided a theoretical basis for elucidating the mechanism of bile duct stone formation.

ERCP for common bile duct stones in the elderly: refining the procedure to improve outcomes.

Removal of common bile duct stones in patients with a previous cholecystectomy was one of the first indications for ERCP with biliary sphincterotomy. Thanks to a minimally invasive procedure, patients were prevented from having a new operation. Subsequently, as the technique proved to be successful, ERCP was extended to all patients with choledocholithiasis, regardless of whether or not they had gallbladder. Also contributing was the fact that, at least in the beginnings, surgical interventions on the bile duct with laparoscopic cholecystectomy were more difficult. Nowadays, many surgeons prefer to perform cholecystectomy with a bile duct clean of stones. In this issue of the Spanish Journal of Gastroenterology, Gardenyes et al. present a study on ERCP for common bile duct stones in elderly patients. The novelty of this study is not only to analyze the ERCP procedure, which we already knew has similar success and complication rates to younger patients, but also to focus on the long-term outcome, considering the frailty that frequently accompanies aging. The study concludes that older patients may benefit from enhanced care protocols to reduce medical adverse events and improve outcomes. For us gastroenterologists and endoscopists, another conclusion that can be drawn from this study is that we should not be satisfied that ERCP in older patients has the same success and complication rates as in younger patients, but rather we should strive to ensure that the results are even better.

Practical application of the modification in endoscopic retrograde cholangiopancreatography treated common bile duct stones in patients with Billroth II gastroenterostomy in Vietnam.

Endoscopic retrograde cholangiopancreatography (ERCP) in patients who have undergone Billroth II gastroenterostomy (B-II GE) has been challenging, requiring flexibility in technical approaches during execution. The study aims to assess the effectiveness of enhanced techniques in performing ERCP on this patient group in Vietnam. A total of 42 Vietnamese patients with B-II GE performed an ERCP using a duodenoscope or a modification of ERCP equipment (a cap-fitted regular forward-viewing endoscope) if the former failed. The effectiveness and safety of the ERCP technique were assessed, particularly in patients who underwent the forward-viewing endoscope method. A total of 39 out of 42 patients had the Vater's papilla identified, among whom 12 patients (30.8%) achieved successful cannulation into the bile duct using a side-viewing endoscope, significantly lower than the success rate using a forward-viewing endoscope (25/27, counted 92.6%, with p < 0.001). After successful cannulation, the rate of stone clearance, the procedural time, and the hospitalization duration of the patients were equivalent between the two methods and were not dependent on the number or size of the stones. On the other hand, post-ERCP complications in patients utilizing forward-viewing endoscopy included acute pancreatitis (22.2%), post-sphincterotomy bleeding (3.7%), septicemia (4.8%), and perforation (0%). These complications were mild and amenable to conservative endoscopic and medical management, and no mortality was observed. The rates of complications and adverse events after ERCP are comparable between the two treatment methods, even though the end-viewing endoscope is used after the failure of the side-viewing endoscope. Alter ERCP utilizing a cap-fitted forward-viewing endoscope can be a primary choice for treating common bile duct stones in patients with a Billroth II gastric resection history because of high efficacy and acceptable complications. It requires a high level of procedural expertise that requires multiple training sessions.

The outcomes of ERCP performed for bile duct stones in patients who had subsequent laparoscopic cholecystectomy: results from a large retrospective single-centre study

The outcomes of ERCP performed for bile duct stones in patients who had subsequent laparoscopic cholecystectomy: results from a large retrospective single-centre study

Different approaches to manage common bile duct stone in patients who had Roux-en-Y gastric bypass

Different approaches to manage common bile duct stone in patients who had Roux-en-Y gastric bypass

The significance of isolated hyperbilirubinemia in detecting asymptomatic common bile duct stones in patients undergoing laparoscopic cholecystectomy

AimThe aim of this study was to evaluate the role of isolated hyperbilirubinemia in the detection of choledocholithiasis. MethodsA retrospective cohort study focused on adult patients diagnosed with gallstone disease, and undergoing intra-operative cholangiogram for suspected choledocholithiasis. Those presenting with isolated hyperbilirubinemia were investigated for their risk of choledocholithiasis, and were compared with those with normal liver function tests. ResultsOut of the total 1274 patients undergoing intra-operative cholangiogram in the study period, only 18 exhibited isolated hyperbilirubinemia. Among these, four patients were found to have common bile duct (CBD) stones. This indicates that in approximately 22 % of patients, isolated hyperbilirubinemia may be associated with CBD stones. However, it is essential to note that the number of patients in the study with isolated hyperbilirubinemia was relatively small. ConclusionAlthough the incidence of isolated hyperbilirubinemia was limited in our study, the presence of CBD stones in some of these patients suggests a potential association. Isolated hyperbilirubinaemia should not be overlooked as a risk factor for CBD stones. Nonetheless, additional investigations with a larger sample size are needed to establish a more definitive understanding of the relationship between isolated hyperbilirubinemia and choledocholithiasis.

Prospective validation of the Israeli Score for the prediction of common bile duct stones in patients with acute calculous cholecystitis.

Existing guidelines for predicting common bile duct stones (CBDS) are not specific for acute calculous cholecystitis (ACC). This paper is a posthoc analysis of the S.P.Ri.M.A.C.C study aiming to prospectively validate on a large independent cohort of patients the Israeli Score (IS) in predicting CBDS in patients with ACC. The S.P.Ri.M.A.C.C. study is an observational multicenter prospective study endorsed by the World Society of Emergency Surgery (WSES). Between September 1st, 2021, and September 1st, 2022, 1201 participants were included. The Chi-Square test was used to compare categorical data. A Cochran-Armitage test was run to determine whether a linear trend existed between the IS and the presence of CBDS. To assess the accuracy of the prediction model, the receiver operating characteristic (ROC) curve was generated, and the area under the ROC curve (AUC) was calculated. Logistic regression was run to obtain Odds Ratio (OR). A two-tailed p < 0.05 was considered statistically significant. The rate of CBDS was 1.8% in patients with an IS of 0, 4.2% in patients with an IS of 1, 24.5% in patients with 2 and 56.3% in patients with 3 (p < 0.001). The Cochran-Armitage test of trend showed a statistically significant linear trend, p < 0.001. Patients with an IS of 3 had 64.4 times (95% CI 24.8-166.9) higher odds of having associated CBDS than patients with an IS of 0. The AUC of the ROC curve of IS for the prediction of CBDS was 0.809 (95% CI 0.752-0.865, p < 0.001). By applying the highest cut-off point (3), the specificity reached 99%, while using the lowest cut-off value (0), the sensitivity reached 100%. The IS is a reliable tool to predict CBDS associated with ACC. The algorithm derived from the IS could optimize the management of patients with ACC.

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

AimsPrimary 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 methodsBiliary 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 findingsFive 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. SignificanceOur 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.

WTP3.12 Value of magnetic resonance cholangiopancreatography (MRCP) in acute gallstone pancreatitis

Abstract Aims Magnetic resonance cholangiopancreatography (MRCP) is commonly performed in acute pancreatitis to rule out bile duct stones (BDS). The aim of this study was to determine if MRCP is required to rule out BDS in patients admitted with gallstone pancreatitis (GS). Method A retrospective cohort study of all consecutive MRCPs in a single surgical unit from October 2021 to September 2022 was conducted. Patient demographics, laboratory results and MRCP result data was analysed. Patients with MRCP proven BDS were compared to those without. Results Sixty-one patients were identified, 39 (63.9%) were female. Median age was 62 years (IQR 45-75) and median Scottish Index of Multiple Deprivation was 4 (IQR 3-7). 55 (90.2%) MRCPs were inpatient and 30 (49.2%) were urgent requests. Median wait time for inpatient MRCP was 1 day (IQR 0.7-1.8) and 17.1 days (IQR 14.6-28.3) for outpatient requests. 14 (23%) patients had BDS proven on MRCP. Of these, 6 (42.8%) had evidence of dilated bile ducts on preceding imaging and 8 (57.1%) had hyperbilirubinaemia and raised alkaline phosphatase levels. Median wait time for MRCP for patients with BDS was 0.8 days (IQR 0.35-1.5) compared to 1.2 days (IQR 0.85-2.85) in MRCPs with no evidence of BDS. Conclusion We conclude that MRCP is not required for low-risk patients with acute gallstone pancreatitis. However, MRCP will be beneficial in patients with jaundice and preceding radiological evidence of ductal dilatation. Intraoperative cholangiography is recommended in patients who proceed to laparoscopic cholecystectomy where MRCP has not been performed.

Efficacy of 3D-printed assisted percutaneous transhepatic one-step biliary fistulation combined with rigid choledochoscopy for intrahepatic bile duct stones

This study evaluated the efficacy and safety of three-dimensional printing model-assisted percutaneous transhepatic one-step biliary fistulation (PTOBF) combined with rigid choledochoscopy for intrahepatic bile duct stones in patients with type I bile duct classification. The clinical data of 63 patients with a type I intrahepatic bile duct were reviewed from January 2019 to January 2023; 30 patients who underwent 3D printed model-assisted PTOBF combined with rigid choledochoscopy composed the experimental group and 33 patients who underwent simple PTOBF combined with rigid choledochoscopy composed the control group. Six indicators, including one-stage operation time and clearance rate, final removal rate, bleeding volume, channel size and complications, were observed and analyzed in the two groups. The one-stage and final removal rate in the experimental group was higher than that in the control group (P = 0.034, P = 0.014 versus control group). The time of one-stage operation, bleeding volume, and incidence of complications in the experimental group were significantly lower than those in the control group (P < 0.001, P = 0.039, P = 0.026 versus control group). Compared with simple PTOBF combined with rigid choledochoscopy, 3D printed model-assisted PTOBF combined with rigid choledochoscopy is a safer and more effective method for treating intrahepatic bile duct stones.

Multicenter retrospective cohort study: Using trends in liver function tests to predict spontaneous passage of common bile duct stones in choledocholithiasis

Aim: Endoscopic retrograde cholangiopancreatography (ERCP) is the modality of choice in patients who are diagnosed with choledocholithiasis, but it carries potentially life-threatening risks and is not readily available in rural hospitals. Due to the lack of access to this service, trend of liver function tests is often used to predict the spontaneous passage of common bile duct (CBD) stone to prevent performing a negative ERCP. The aim of this study is to investigate whether the trend of liver function tests can be used to predict passage of common bile duct stone in patients who have radiological evidence of choledocholithiasis. Methods: The liver function tests (LFTs) of patients diagnosed with choledocholithiasis at two separate hospitals in New Zealand and Australia were collected at two points retrospectively. The change in LFT values between diagnosis and immediately prior to ERCP was analyzed. Results: Total of 409 patients were selected with 108 (26%) and 301 (74%) patients from Australia and New Zealand, respectively. Demographic and LFT values were statistically different between the two centers, but the female sex was significantly predominant in both. Cumulative data showed that 37% of patients diagnosed with choledocholithiasis had no stone during the ERCP procedure. Increased age was statistically significant in patients with a persistent stone on ERCP. Importantly, there was no statistical difference between LFT values of patients with persistent gallstones shown on ERCP compared to those who have passed their gallstones spontaneously. Aspartate aminotransferase (AST) was significantly associated with a persistent gallstone (p = 0.041), but its clinical value is questionable. Conclusion: Decreasing trend in LFTs and their individual components are poor predictors of persistent gallstones in patients diagnosed with choledocholithiasis. Two-thirds of these patients have persistent stones and ERCP remains an important diagnostic and therapeutic modality for patients at significant risk of disease complications.

Multicenter retrospective cohort study: Using trends in liver function tests to predict spontaneous passage of common bile duct stones in choledocholithiasis

Aim: Endoscopic retrograde cholangiopancreatography (ERCP) is the modality of choice in patients who are diagnosed with choledocholithiasis, but it carries potentially life-threatening risks and is not readily available in rural hospitals. Due to the lack of access to this service, trend of liver function tests is often used to predict the spontaneous passage of common bile duct (CBD) stone to prevent performing a negative ERCP. The aim of this study is to investigate whether the trend of liver function tests can be used to predict passage of common bile duct stone in patients who have radiological evidence of choledocholithiasis. Methods: The liver function tests (LFTs) of patients diagnosed with choledocholithiasis at two separate hospitals in New Zealand and Australia were collected at two points retrospectively. The change in LFT values between diagnosis and immediately prior to ERCP was analyzed. Results: Total of 409 patients were selected with 108 (26%) and 301 (74%) patients from Australia and New Zealand, respectively. Demographic and LFT values were statistically different between the two centers, but the female sex was significantly predominant in both. Cumulative data showed that 37% of patients diagnosed with choledocholithiasis had no stone during the ERCP procedure. Increased age was statistically significant in patients with a persistent stone on ERCP. Importantly, there was no statistical difference between LFT values of patients with persistent gallstones shown on ERCP compared to those who have passed their gallstones spontaneously. Aspartate aminotransferase (AST) was significantly associated with a persistent gallstone (p = 0.041), but its clinical value is questionable. Conclusion: Decreasing trend in LFTs and their individual components are poor predictors of persistent gallstones in patients diagnosed with choledocholithiasis. Two-thirds of these patients have persistent stones and ERCP remains an important diagnostic and therapeutic modality for patients at significant risk of disease complications.

Comparing endoscopic ultrasound-guided antegrade treatment and balloon endoscopy-assisted endoscopic retrograde cholangiopancreatography in the management of bile duct stones in patients with surgically altered anatomy: A retrospective cohort study.

Endoscopic ultrasound-guided antegrade treatment (EUS-AG) and balloon endoscopy-assisted endoscopic retrograde cholangiopancreatography (BE-ERCP) have emerged as useful procedures for managing bile duct stones (BDS) in patients with surgically altered anatomy. However, the comparison between these two procedures has not been well studied. The aim of our study was to compare the clinical outcomes of EUS-AG and BE-ERCP for managing BDS in patients with surgically altered anatomy. The database was retrospectively evaluated at two tertiary care centers to identify patients with surgically altered anatomy who underwent either EUS-AG or BE-ERCP for BDS. Clinical outcomes were compared between the procedures. The success rate of each procedure was evaluated in three steps: endoscopic approach, biliary access, and stone extraction. Among the 119 identified patients, 23 had EUS-AG, and 96 had BE-ERCP. The overall technical success rates of EUS-AG and BE-ERCP were 65.2% (15/23) and 69.8% (67/96), respectively (P= .80). The comparison of each step between the procedures EUS-AG versus BE-ERCP was as follows: endoscopic approach, 100% (23/23) versus 88.5% (85/96) (P= .11); biliary access, 73.9% (17/23) versus 80.0% (68/85) (P= .57); stone extraction, 88.2% (15/17) versus 98.5% (67/68) (P= .10). The overall adverse event rate was 17.4% (4/23) versus 7.3% (7/96) (P= .22). Both EUS-AG and BE-ERCP are effective and relatively safe procedures in the management of BDS in patients with surgically altered anatomy. The challenging steps of each procedure might be different, which could help decide which one to use to manage BDS in patients with surgically altered anatomy.

Development of a Predictive Model for Common Bile Duct Stones in Patients With Clinical Suspicion of Choledocholithiasis: A Cohort Study.

Current choledocholithiasis guidelines heavily focus on patients with low or no risk, they may be inappropriate for populations with high rates of choledocholithiasis. We aimed to develop a predictive scoring model for choledocholithiasis in patients with relevant clinical manifestations. A multivariable predictive model development study based on a retrospective cohort of patients with clinical suspicion of choledocholithiasis was used in this study. The setting was a 700-bed public tertiary hospital. Participants were patients who had completed three reference tests (endoscopic retrograde cholangiography, magnetic resonance cholangiopancreatography, and intraoperative cholangiography) from January 2019 to June 2021. The model was developed using logistic regression analysis. Predictor selection was conducted using a backward stepwise approach. Three risk groups were considered. Model performance was evaluated by area under the receiver operating characteristic curve, calibration, classification measures, and decision curve analyses. Six hundred twenty-one patients were included; the choledocholithiasis prevalence was 59.9%. The predictors were age > 55 years, pancreatitis, cholangitis, cirrhosis, alkaline phosphatase level of 125 - 250 or > 250 U/L, total bilirubin level > 4 mg/dL, common bile duct size > 6 mm, and common bile duct stone detection. Pancreatitis and cirrhosis each had a negative score. The sum of scores was -4.5 to 28.5. Patients were categorized into three risk groups: low-intermediate (score ≤ 5), intermediate (score 5.5 - 14.5), and high (score ≥ 15). Positive likelihood ratios were 0.16 and 3.47 in the low-intermediate and high-risk groups, respectively. The model had an area under the receiver operating characteristic curve of 0.80 (95% confidence interval: 0.76, 0.83) and was well-calibrated; it exhibited better statistical suitability to the high-prevalence population, compared to current guidelines. Our scoring model had good predictive ability for choledocholithiasis in patients with relevant clinical manifestations. Consideration of other factors is necessary for clinical application, particularly regarding the availability of expert physicians and specialized equipment.

The safety and feasibility of laparoscopic approach for the management of intrahepatic and extrahepatic bile duct stones in patients with prior biliary tract surgical interventions

The purpose of this study was to compare the efficacy and safety of laparoscopic and open reoperation for intrahepatic and extrahepatic bile duct stones patients with previous biliary tract surgical procedures. The clinical data were retrospectively analyzed of intrahepatic and extrahepatic bile duct stones patients with previous biliary tract surgical procedures who underwent reoperation in the Second General Surgery Department of China Medical University from January 2012 to February 2018. 44 eligible cases were selected. In accordance with the surgical procedures, they were divided into a laparoscopy group (n = 23) and an open surgery group (n = 21). No statistically significant differences were found in the preoperative general clinical data between the two group. Two patients in the laparoscopy group were converted to open surgery. Comparisons between the two groups showed that the intraoperative blood loss [90.87 ± 62.95 (ml) vs. 152.38 ± 118.82 (ml)], the proportion of postoperative analgesia [10/23 (43.5%) vs. 16/21 (76.2%)], and the length of stay [7.19 ± 5.32 (d) vs. 11.00 ± 4.66 (d)] in the laparoscopy group were significantly lower than those in the open surgery group (P < 0.05). Laparoscopic biliary reoperation for intrahepatic and extrahepatic bile duct stones was feasible. Compared with open surgery, laparoscopic surgery has the advantages of less bleeding, a shorter postoperative length of stay, and a lower rate of additional postoperative analgesia.

Endoscopic retrograde cholangiopancreatography for bile duct stones in patients with a performance status score of 3 or 4.

BACKGROUNDAs the aging population grows worldwide, the rates of endoscopic retrograde cholangiopancreatography (ERCP) for common bile duct stones (CBDS) in older patients with a poor performance status (PS) have been increasing. However, the data on the safety and efficacy of ERCP for CBDS in patients with a PS score of 3 or 4 are lacking, with only a few studies having investigated this issue among patients with poor PS.AIMTo examine the safety and efficacy of ERCP for CBDS in patients with a PS score of 3 or 4.METHODSThis study utilized a retrospective multi-centered design of three institutions in Japan for 8 years to identify a total of 1343 patients with CBDS having native papillae who underwent therapeutic ERCP. As a result, 1113 patients with a PS 0-2 and 230 patients with a PS 3-4 were included. One-to-one propensity-score matching was performed to compare the safety and efficacy of ERCP for CBDS between patients with a PS 0-2 and those with a PS 3-4.RESULTSThe overall ERCP-related complication rates in all patients and propensity score-matched patients with a PS 0-2 and 3-4 were 9.0% (100/1113) and 7.0% (16/230; P = 0.37), and 4.6% (9/196) and 6.6% (13/196; P = 0.51), respectively. In the propensity score-matched patients, complications were significantly more severe in the group with a PS 3-4 than in the group with a PS 0-2 group (P = 0.042). Risk factors for complications were indications of ERCP and absence of antibiotics in the multivariate analysis. Therapeutic success rates, including complete CBDS removal and permanent biliary stent placement, in propensity score-matched patients with a PS 0-2 and 3-4 were 97.4% (191/196) and 97.4% (191/196), respectively (P = 1.0).CONCLUSIONERCP for CBDS can be effectively performed in patients with a PS 3 or 4. Nevertheless, the indication for ERCP in such patients should be carefully considered with prophylactic antibiotics.