Removal Of Bile Duct Stones Research Articles

Endoscopic Papillary Balloon Dilation Versus Small Endoscopic Sphincterotomy for Endoscopic Retrograde Cholangiopancreatography-Related Adverse Events in Patients With Non-Dilated Distal Bile Duct.

Endoscopic papillary balloon dilation (EPBD), small endoscopic sphincterotomy (EST), and small EST plus EPBD are commonly used as rescue techniques to remove bile duct stones. However, we often encountered challenging cases with non-dilated distal bile ducts, especially in those undergoing EPBD. We aimed to explore the reasons by assessing whether patients without the dilated bile duct had a higher risk of early complications and whether it was impacted by the rescue techniques. We performed a retrospective cohort study by frequency matching design in patients diagnosed with stones in non-dilated distal bile duct who received rescue techniques from July 2016 to June 2022. Besides, patients with stones and without dilatation of the distal bile duct (DDBD) were divided into 3 subgroups according to the rescue technique received. Outcomes were compared between the subgroups. The non-DDBD group was more likely to develop post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) and hyperamylasemia (HP) than the DDBD group (P < 0.05). Some cases had mild or moderate pancreatitis, but no one in either group developed severe pancreatitis. For subgroup analysis, each technique resulted in complete stone removal; the EPBD group had a higher HP rate than the other subgroups and reached statistical significance: the EPBD group versus the small EST group (P = 0.013) and the EPBD group versus the EPBD plus small EST group (P = 0.008). Although there was no statistical significance, PEP incidence in the EPBD group was 13.7% higher than in other subgroups (P > 0.05/3). Non-DDBD patients have a higher risk for endoscopic retrograde cholangiopancreatography-related pancreatic inflammation. EPBD should be used cautiously due to the significant association with increased rates of PEP and HP. Conversely, small EST and combination therapy are suitable for non-dilated bile duct stones because of their high safety profile and efficacy.

Utility of cholangioscopy in patients with surgically altered anatomy after percutaneous transhepatic biliary drainage

Background Surgical therapy that alters the biliary anatomy makes endoscopic access to the biliary system difficult. These surgeries promote cholestasis, calculi development and lead to biliary stricture. Stricture resolution and removal of intrahepatic bile duct stones remain challenging. Methods This is a retrospective analysis of prospective data of patients with altered surgical anatomy with intrahepatic bile duct stones/strictures. Percutaneous transhepatic biliary drainage (PTBD) was attempted, followed by transhepatic SpyGlass cholangioscopy for stricture or removal of intrahepatic bile duct stones. The number of sessions, stricture dilatation and complications were noted. A cholangiogram revealing a clear duct was a technical success, and stricture resolution was considered a clinical success. Complete ductal clearance was clinical success in those with stones. Patients with follow-up of a minimum of six months were included. Results Twenty-four patients [16(66.7%) male, median age 41.5(IQR 38.2-49) years] successfully underwent PTBD. The commonest indication was biliary stricture in 13(54.2%), followed by intrahepatic stones in 6(25%) and stones with strictures in 5(20.8%) patients. Most patients had undergone Roux-en-Y hepaticojejunostomy in 22(91.7%), and the level of bile duct obstruction was hilum in 20(83.3%). The median (IQR) total bilirubin levels reduced from 6.6(5.1-8.3) to 1.8(1.2-2.8) mg/dL after PTBD; p&lt;0.001. The technical success was 90.9% after a median (IQR) number of 2(1.7-2) SpyGlass sessions; clinical success was 88.9% after a median of 3(3-4) SpyGlass sessions. Abdominal pain (8.3%) and cholangitis (12.5%) were the complications after cholangioscopy. The median (IQR) follow-up duration was 7(6-8) months. Conclusions SpyGlass cholangioscopy, although challenging, is a safe option for intrahepatic stones and strictures with excellent short-term outcomes and minimal complications.

Comparative Success Rate and Adverse Effects of Endoscopic Sphincterotomy Versus Endoscopic Papillary Large Balloon Dilation in Large Common Bile Duct Stones Removal. A Propensity Scores Inverse Weighting Analysis.

Endoscopic sphincterotomy (EST) is a standard treatment for common bile duct (CBD) stones. Endoscopic sphincterotomy combined with endoscopic papillary large balloon dilation (EST-EPLBD) is an effective treatment for difficult CBD stones. This study aims to evaluate and compare the effectiveness and adverse effects of EST-EPLBD and EST in treating large CBD stones. We retrospectively analyzed the data of 85 patients with large CBD stones who underwent either EST or EST-EPLBD, resulting in successful CBD stone extraction from January 2018 to June 2022. Propensity score inverse weighting was performed to reduce the possible bias in baseline characteristics between the two treatment groups. The success rate of complete stone removal in the first session, mechanical lithotripsy use, and adverse events were analyzed by multivariable risk regression analysis. The rate of complete stone removal in one session of the EST-EPLBD group was higher than that of the EST group at 28.78% (95% confidence interval [CI] 4.43, 50.1; p = 0.003). Mechanical lithotripsy use was decreased in the EST-EPLBD group by 25.81% (95% CI 42.33,9.28; p = 0.002). However, the incidence of adverse events is comparable. EST-EPLBD may be utilized in the treatment of CBD stones that exceed a diameter of 10 mm. The EST-EPLBD increased the rate of complete stone removal in a single session and reduced the need for mechanical lithotripsy. Conversely, the incidence rate of adverse events is similar.

The effect of single pigtail bile duct stents without lateral wings bile duct drainage after removal of common bile duct stones in endoscopic retrograde cholangiopancreatography

Objective: To analyze the effect of single pigtail bile duct stents without lateral wings bile duct drainage after removal of common bile duct stones in endoscopic retrograde cholangiopancreatography (ERCP). Methods: Patients who underwent ERCP and implantation of a single pigtail bile duct stent for choledocholithiasis in Cholelithic Center of East Hospital Affiliated to Tongji University from January 2019 to September 2023 were retrospectively selected and divided into lateral wingless group (without the lateral wing) and lateral wing group(with the lateral wing) according to whether the lateral wings of the single pigtail bile plastic stents were preserved. The patients were followed up for 1 to 3 months. The stent detachment rate at 2 days, 1 week and 1 month, as well as the incidence of postoperative complications at 1 week and 1 month after ERCP were compared between the two groups. Results: A total of 402 patients were included, including 177 males and 225 females, aged 32-83 (58±12) years. There were 215 cases in the lateral wingless group and 187 cases in the lateral wing group. The stent detachment rate in the lateral wingless group was higher than that in the lateral wing group at 2 days after ERCP [12.6% (27/215) vs 5.9% (11/187), P=0.022]. The stent detachment rate in the lateral wingless was higher than that in the lateral wing group at 1 week after ERCP [87.0% (187/215) vs 25.1% (47/187), P<0.001]. The stent detachment rate in the lateral wing group was higher than that in the lateral wing group at 1 month after ERCP [97.2% (206/215) vs 67.3% (126/187), P<0.001]. The incidence of postoperative complications at 1 week after ERCP revealed no statistical significance between the two groups[(10.7% (23/215) vs 8.6% (16/187), P>0.05]. The incidence of postoperative complications at 1 month after ERCP in the lateral wingless group was lower than that in the lateral wing group [0.9% (2/215) vs 9.6% (18/187), P=0.001]. Conclusion: After the removal of choledocholithiasis with ERCP, bile is drained by a single pigtail bile duct stent with lateral removal, which has a high rate of natural shedding and a low incidence of complications.

Dental floss clip traction-assisted endoscopic ultrasound-guided hepaticogastrostomy for transluminal intrahepatic bile duct stone fragmentation and removal.

Dental floss clip traction-assisted endoscopic ultrasound-guided hepaticogastrostomy for transluminal intrahepatic bile duct stone fragmentation and removal.

Endoscopic ultrasound-assisted removal of an intrahepatic bile duct stone.

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Evaluation of the Outcomes of Primary Closure after Open Common Bile Duct Exploration for Common Bile Duct Stones

Abstract Background The incidence of CBD stone develops in about 10–15% of patients with gall bladder stones and encountered in approximately 7–15% of patients undergoing cholecystectomy. It is common to be treated by endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (EST), however in cases who has large or multiple CBD stone or difficult to be cleared by ERCP. Aim of the Work To evaluate of the outcomes of primary closure after open common bile duct exploration for removal of common bile duct stones. Methods This descriptive prospective randomized clinical controlled trial was conducted on 30 patients at Hepatobiliary Pancreatic Department (HBP) - Faculty of Medicine – Ain Shams University from January 2022 until March 2023. Primary closure was performed after removal of CBD stones with follow up for 6 months. Results Operative time ranged from 1.3 to 3 hours with mean 2.03 and ± SD 0.48 hours. Biliary leakage was estimated 13.3% of the candidates (4 cases). One of the 30 patients developed CBD stricture. Total and direct bilirubin levels were statistically significant decrease in T and direct bilirubin in follow up “1st 5 days and post-operative 10th day”. Conclusion The primary closure after open common bile duct exploration for removal of common bile duct stones is a safe, effective and time saving procedure.

Comparative study of Indocyanine Green fluorescence imaging versus conventional fiber-optic imaging in laparoscopic choledochotomy for stone extraction and immediate biliary incision suturing.

To explore the Advantages of Indocyanine Green (ICG) Fluorescence Imaging over Conventional Fiber-Optic Imaging in Laparoscopic Cholangiography and Immediate Suture for Stone Removal. The study is a randomized controlled descriptive research. Consecutive patient data were collected from October 2022 to January 2024 at the Second People's Hospital of Chengdu for those who underwent laparoscopic bile duct exploration and stone removal, totaling 72 cases. According to the order of admission, they were randomly assigned to either the study group or the control group, with 36 cases in each group. Ten minutes preoperatively, indocyanine green (ICG) was administered intravenously through a peripheral vein to the subjects in the study group, to enable real-time fluorescent tracing of the extrahepatic bile ducts during surgery. This study compares the efficiency of bile duct structure and boundary recognition, the timeliness of bile duct incision positioning, operative time, blood loss, and the incidence of bile duct injury between patients who were injected with ICG and those who were not. In addition, it assesses liver function and white blood-cell counts rechecked 24h postoperatively, the duration of postoperative hospital stay, and the occurrence of bile leakage. The study included 72 patients, with 36 in the indocyanine green (ICG) fluorescence group and 36 in the conventional fiber-optic group, comprising 26 males and 46 females. There were 18 patients with a history of previous biliary exploration surgery and 23 who had undergone previous cholecystectomy. During surgery, ICG fluorescence was successfully visualized in all 36 cases of the ICG group, allowing for a clear view of the anatomical structure and boundaries of the extrahepatic bile ducts. Compared to the control group, the ICG fluorescence group demonstrated a reduction in the time required for identification of the biliary system and positioning of the bile duct incision, as well as a decrease in operative time and postoperative hospital stay; intraoperative blood loss and the incidence of bile leakage were also relatively reduced, with statistically significant differences (P < 0.05). However, there were no statistically significant differences in postoperative serum alanine aminotransferase levels, white blood-cell counts, direct bilirubin, and indirect bilirubin between the two groups (P > 0.05). One case of bile duct injury occurred in the control group. The application of ICG fluorescence navigation in laparoscopic cholecystectomy can effectively enhance the visibility of the bile ducts, rapidly identify the location for bile duct incision, and is conducive to reducing both the duration of surgery and postoperative hospital stay. It also minimizes intraoperative blood loss, prevents bile leakage and bile duct injuries. This program has demonstrating significant clinical value.

A novel 3D-printed educational model for the training of laparoscopic bile duct Exploration:a pilot study for beginning trainees

BackgroundLaparoscopic common bile duct exploration (LCBDE) is a minimally invasive procedure for the removal of bile duct stones that is often performed by experienced hepatobiliary surgeons; beginners do not easily master this approach. AimTo investigate the effectiveness and practicality of a three-dimensional printed (3DP) anatomical model based on radiographic images in the training of LCBDE techniques and formulate standardized educational workflows. MethodsColored LCBDE training models were produced using 3DP technology. Twenty standardized training trainees were randomly divided into two groups: a 3DP model training group and a traditional laparoscopic simulation training group. Both groups received the same number of teaching hours. After a 4-weeks training course, the trainees’ subjective and objective progress in basic knowledge and manipulations were evaluated and compared. ResultsCompared with traditional laparoscopic simulation, 3DP model simulation training is of great significance in improving trainers' understanding of surgical procedures and cooperation during the operation. Trainees with 3DP models training demonstrated a significant improvement in their understanding of the key points of surgery (χ2 = 6.139, p = 0.013) and skills scores, especially in core procedural steps operation. More importantly, the trainees showed higher levels of satisfaction and self-confidence while assisting in the surgery. ConclusionWith the development of 3DP models, improvements in the learning effect for theoretical understanding and practical skills were significant. The present study is the initial educational experience with 3DP models to facilitate the operational capabilities of the trainees for LCBDE.

Artificial intelligence-empowered assessment of bile duct stone removal challenges

The aim of this investigation was to unravel the complexities inherent in endoscopic retrograde cholangiopancreatography (ERCP) procedures for bile duct stone removal by leveraging advanced artificial intelligence (AI) methodologies to support clinical decision-making and optimize patient outcomes. We introduced the Assessment of Stone Removal Challenges (ACRS) system, a novel integration of Data-efficient Image Transformers (DeiT) for image data analysis and eXtreme Gradient Boosting (XGBoost) for clinical data interpretation. Our study included a patient cohort of 2,129 individuals, focusing on training the ACRS system to achieve high diagnostic precision. Using logistic regression, we identified pivotal predictors affecting the complexity of bile duct stone removal. These findings were visually represented through forest plots and nomograms. Analytical and visualization processes were conducted using the Python and R programming languages, adhering to a p value significance threshold of less than 0.05. By utilizing DeiT enhanced by transfer learning and XGBoost for clinical data interpretation, the system achieved an accuracy of 0.83 and a perfect recall rate on a test set of 2,129 patients. Gradient-weighted class activation mapping (Grad-CAM) and SHapley Additive exPlanations (SHAP) provided in-depth diagnostic insights. Logistic regression was applied to identify crucial clinical predictors for stone removal difficulty, as visualized through forest plots and nomograms. These tools facilitated measurable assessments of procedural complexity, making significant strides in gastroenterology diagnostics and decision-making. By adopting causal inference techniques, the system effectively quantifies the influence of various clinical entities on stone removal difficulty, thereby augmenting both diagnostic precision and procedural strategies in ERCP.

Early onset Bouveret syndrome: a unique case in a young patient

BackgroundBouveret syndrome is a rare etiology of gastric outlet obstruction, presenting with clinical manifestations that resemble those of several gastric pathologies. Timely diagnosis is imperative to mitigate potentially fatal consequences associated with this condition.Case presentationThis case report involves a male patient, aged 35, who exhibited symptoms of intense abdominal discomfort, nausea, and vomiting over a 24-h period. The individual experienced identical symptoms of lesser intensity on three separate occasions throughout the preceding 4-month period, during which they resorted to analgesic medication for temporary relief. A contrast-enhanced computed tomography (CT) scan of the abdomen was performed, which identified the presence of the Rigler triad, characterized by pneumobilia, a cholecysto-antral fistula, and an ectopic gallstone lodged in the gastric antrum resulting in an obstruction. The patient’s diagnosis of Bouveret syndrome was determined based on the imaging findings. A surgical procedure known as cholecystectomy was conducted, which confirmed the existence of the sizable cholecystoduodenal fistula that was previously detected in the computed tomography (CT) scan. The surgical procedures that were conducted included a partial duodenectomy, a gastrojejunostomy, a cholecystectomy, and a common bile duct exploration with the removal of common bile duct stones. After examining the bile duct, a t-tube was inserted into the bile duct.ConclusionThis case demonstrates a distinctive occurrence of a condition in a young man, typically observed in elderly females. There is a lack of established treatment guidelines for this particular entity. The appropriate course of action depends on various factors, including the patient’s condition, CT scan results, medical history, presence of co-existing illnesses, and intraoperative circumstances. These considerations are taken into account when determining whether a single-step surgical strategy or a multi-step approach should be pursued in order to minimize complications in patients. In this case, due to favorable conditions, a single-step approach was taken that yielded promising results.

Multiple intraductal papillary neoplasms of bile duct diagnosed based on endoscopic ultrasonography and peroral cholangioscopy findings

A man in his 30s was referred to our department for evaluation of bile duct stricture and removal of an intrahepatic bile duct stone. Five years before his presentation, he underwent left hepatectomy for a giant hepatic hemangioma. There were no abnormalities in blood biochemical tests. Magnetic resonance cholangiopancreatography showed one 5 mm oval defect in region B6 and two 8 mm semicircular defects in the hilar bile duct. Endoscopic ultrasound revealed a 3.5 mm hypoechoic focal raised lesion in the hilar bile duct. Oral cholangioscopy revealed his two lesions in the hilar bile duct as white papillary elevations with mucus production. The pathological diagnosis of intraductal papillary neoplasm was determined (low-grade dysplasia, type 1, gastric type). After 1 and a half years, no expansion of the bile duct lesion was observed. Initially, it was thought to be a benign stenosis after liver resection, but based on the results of endoscopic ultrasound, we suspected a tumorous lesion, and we were able to make an accurate diagnosis, including histological type, using transoral cholangioscopy.

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.

Surgical strategies for challenging common bile duct stones in the endoscopic era: A comprehensive review of current evidence.

While endoscopic retrograde cholangiopancreatography (ERCP) remains the primary treatment modality for common bile duct stones (CBDS) or choledocholithiasis due to advancements in instruments, surgical intervention, known as common bile duct exploration (CBDE), is still necessary in cases of difficult CBDS, failed endoscopic treatment, or altered anatomy. Recent evidence also supports CBDE in patients requesting single-step cholecystectomy and bile duct stone removal with comparable outcomes. This review elucidates relevant clinical anatomy, selection indications, and outcomes to enhance surgical understanding. The selection between trans-cystic (TC) vs trans-choledochal (TD) approaches is described, along with stone removal techniques and ductal closure. Detailed surgical techniques and strategies for both the TC and TD approaches, including instrument selection, is also provided. Additionally, this review comprehensively addresses operation-specific complications such as bile leakage, stricture, and entrapment, and focuses on preventive measures and treatment strategies. This review aims to optimize the management of CBDS through laparoscopic CBDE, with the goal of improving patient outcomes and minimizing risks.

Lost in transition? Loss of follow-up and quality of life in adults after resection of choledochal malformation in childhood.

Choledochal malformation (CM) is a rare disease that can lead to malignancy and potential long-term sequelae despite surgical resection. There is no long-term follow-up data on patients after CM resection in Germany. We aimed to determine the long-term outcome of our patients with a duration of follow-up >10 years and focused on long-term sequelae and health-related quality of life (HRQOL). All patients who had undergone CM-resection in our department from 01/1978 to 06/2009 were contacted. Patients were interviewed about postoperative complications and their present medical attendance. HRQOL was determined using Pediatric Quality of Life Inventory 4.0 (PedsQL), version for adults. The PedsQL scales the HRQOL from 0 to 100, with higher scores indicating a better HRQOL. Scores were compared to those published for a healthy population. Out of 56 patients who were contacted, 23 (41 %) participated. The median age at time of surgery was 3.1 years (6days-16.1 years) and at time of the survey 24.3 years (11.1-53.8 years). Eighteen patients (78 %) had ceased their gastroenterologic follow-up at a median time of 4.3 years after surgery. Five (22 %) were still in gastroenterologic follow-up, two of these had an uneventful clinical course, and three (13 %) had ongoing complications attributed to the CM. One of these had undergone hemihepatectomy 34 years postoperatively due to bile duct stenosis, one had undergone removal of bile duct stones 14 years postoperatively, and one suffered from portal vein thrombosis with esophageal and jejunal varices. There was no mortality in our series. Median total HRQOL score was 89. There was no significant difference in the median total health, physical health, and psychosocial health scores of our patients in comparison to the healthy population. We confirmed that the majority of patients after CM resection are lost to follow-up. Those who answered our questionnaire showed a good HRQOL. Given the high rate of severe long-term complications and the life-long risk of malignancy, we recommend a transition program for all patients.

A Hidden Cause of Hypertransaminasemia: Liver Toxicity Caused by Chelidonium Majus L.: Report of Two Cases of Herb-Induced Liver Injury and Literature Review.

In instances where individuals manifest elevated transaminase levels without a clearly discernible cause, a comprehensive patient history proves invaluable in unveiling latent triggers. In this report, we present 2 cases of herb-induced liver injury (HILI) characterized by severe hypertransaminasemia attributed to the consumption of Chelidonium majus L. (also known as greater celandine [GC]), an agent considered an alternative therapeutic remedy. Exploring the occurrence and range of clinical manifestations in HILI linked to Chelidonium majus L., while also investigating the potential triggers and predisposing factors for hepatotoxic reactions post Chelidonium majus L. usage, remains challenging due to the absence of definitive laboratory tests to identify the causative agent. Two case reports were detailed, and a systematic literature review using PubMed was conducted including published literature till March 2023. Moreover, a manual search of reference lists of pertinent articles was performed to identify any additional relevant missed publications. In the first case, a 64-year-old woman presented with jaundice, revealing a 1-month history of using GC capsules to manage gallstones. Diagnostic assessment identified HILI, gallstones, and choledocolithiasis, with transaminase levels exceeding 1000 IU/L. After discontinuing GC and receiving intravenous therapy with amino acids and phospholipids, the patient's condition significantly improved. Subsequently, she underwent endoscopic common bile duct stone removal and cholecystectomy. In the second case, a 66-year-old woman presented with elevated liver function test results discovered incidentally during musculoskeletal pain evaluation. Upon further questioning, the patient disclosed regular consumption of GC tea for "health promotion." Following intravenous therapy using amino acids and phospholipids, her transaminase levels returned to normal. The literature review identified 38 cases of HILI associated with GC preparations, primarily in adult women aged 27-77 years, with a predominant reporting location in Germany. Various forms of GC were used, with treatment durations ranging from 1 week to a year. Discontinuation of GC generally led to recovery in these cases. Chelidonium majus L., a potent herb often used in alternative medicine, has significant hepatotoxic potential, requiring physicians to be vigilant in cases of unexplained liver injury.

Endoscopic treatment of bile duct stones with benign choledochojejunal anastomotic stenosis

Endoscopic interventions for bile duct stones (BDSs) with benign choledochojejunal anastomotic stenosis (bCJS) are challenging. Therefore, we investigated endoscopic interventions for BDSs with bCJS. Seventeen patients with BDSs with bCJS were retrospectively analyzed. Patient characteristics, technical success, adverse events (AEs), and recurrence were evaluated. In 17 patients, the median diameters of the bile duct and BDSs were both 8mm. The median number of BDSs was 3. The technical success rate was 94% (16/17). Ten patients underwent balloon dilation at the choledochojejunal anastomotic site (CAS), the median diameter of balloon dilation was 10.5mm, and waist disappearance was achieved in 2. Six patients had fully covered self-expandable metal stents (FCSEMSs) with a diameter of 10mm placed at the CAS. BDSs were removed after balloon dilation or FCSEMS removal, and 6 of 16 patients were treated with a combination of lithotripsy and 5 with peroral direct cholangioscopy (PDCS). Regarding AEs, perforation at the CAS by balloon dilation occurred in 1 patient. The median follow-up was 3701 days. Nine of 16 patients (56%) had recurrence. The patients treated with a combination of PDCS at BDS removal (P= .022) and waist disappearance at the CAS by balloon dilation (P= .035) had significantly fewer recurrences. Endoscopic interventions for BDSs with bCJS are useful and relatively safe; however, long-term follow-up showed frequent recurrences. Recurrence was common in patients not treated with the combination of PDCS at BDS removal and those without waist disappearance at the CAS by balloon dilation.

A novel technique of percutaneous transhepatic treatment of biliary-enteric anastomotic occlusive strictures with compliant balloon-occluded distal cholangiography and large-bore catheter: a retrospective case series.

Endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic biliary balloon dilatation (PTBD) is a challenge in resolving biliary-enteric anastomotic occlusive strictures (BEAOS) and/or coexisting stones. The biliary-enteric anastomosis (BEA) often cannot be seen because of the surgically altered gastrointestinal anatomy. Here, a technique that combined percutaneous compliant-occluded distal cholangiography and the maintenance of a large-bore catheter is described to resolve this issue. A retrospective review of 10 patients who presented with BEAOS with/without coexisting stones who were treated with percutaneous compliant balloon-occluded distal cholangiography, bile duct stone removal, and the maintenance of a large-bore catheter between February 2017 and January 2021 was performed. Treatment response, laboratory examinations, including hepatic function tests, routine blood tests, and blood electrolytes, complications, and imaging data were evaluated. Paired t-tests were used to investigate the difference of laboratory examinations before and after the procedure. All 10 cases were technically successful. A total of 9 stones in 6 patients were successfully removed by the compliant balloon. All catheters were removed after the patency of the stricture was confirmed by percutaneous transhepatic cholangiography (PTHC) 6 months later. No severe adverse events occurred during the perioperative period. There were 2 patients who experienced episodes of cholangitis during the follow-up period (mean, 17 months; range, 4-24 months), and neither BEAOS nor bile duct stones recurred within 2 years after the procedure. White blood cells (WBC), total bilirubin (TB), alanine aminotransferase (ALT), and aspartate aminotransferase (AST) were (6.0±1.4)×109/L and (6.0±1.6)×109/L (P=0.91), 31.4±15.7 and 29.6±10.3 µmol/L (P=0.74), 50.8±20.0 and 85.8±67.0 U/L (P=0.16), and 42.6±15.2 and 71.8±44.9 U/L (P=0.09) pre and postintervention, respectively. Percutaneous transhepatic compliant balloon-occluded distal cholangiography and the maintenance of a large-bore catheter probably provide an effective and safe alternative method for resolving BEAOS and/or coexisting stones.

Choledochoscopy in the laparoscopic treatment of patients with choledocholithiasis: a single-centre study

Choledochoscopy is a minimally invasive procedure used for laparoscopic bile duct exploration and the removal of bile duct stones. However, there is insufficient information available about its advantages in diagnosing choledocholithiasis and its role in laparoscopic choledocholithoextraction.&#x0D; Objective — to compare the diagnostic efficacy of imaging techniques and choledochoscopy in patients with choledocholithiasis and to evaluate the role of choledochoscopy in laparoscopic choledocholithoextraction.&#x0D; Materials and methods. The study examined the results of 128 patients with calculous cholecystitis and choledocholithiasis who had laparoscopic choledocholithoextraction in combination with choledochoscopy. We assessed the sensitivity and specificity of ultrasound, CT, and MRI in the diagnosis of choledocholithiasis, as well as the efficacy of one‑stage treatment of calculous cholecystitis and choledocholithiasis using choledochoscopy and laparoscopic choledocholithoextraction.&#x0D; Results. Imaging techniques demonstrated limited sensitivity and specificity in determining the diameter and number of common bile duct stones. A total of 89 (69.5%) patients achieved complete bile duct clearance after blind laparoscopic choledocholithoextraction: 86 (81.1%) had choledochotomy, and 3 (13.6%) underwent transcystic common bile duct exploration. The combination of choledochoscopy and laparoscopic choledocholithoextraction ensured the complete removal of bile duct stones in 97.6% of patients.&#x0D; Conclusions. The imaging techniques used for determining the number of common bile duct stones in choledocholithiasis had sensitivity and specificity rates of 41.4% and 92.7% for ultrasound, 72.7% and 83.3% for CT, and 86.7% and 60.9% for MRI, respectively. A total of 89 (69.5%) patients achieved complete bile duct clearance after blind laparoscopic choledocholithoextraction: 86 (81.1%) had choledochotomy, and 3 (13.6%)underwent transcystic common bile duct exploration. Choledochoscopy was required for laparoscopic choledocholithoextraction in 18.9% of choledochotomy patients and in 86.4% of those who underwent transcystic common bile duct exploration. Choledochoscopy demonstrated an overall bile duct stone clearance rate of 97.6%.&#x0D;

Risk Factors for Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis After Endoscopic Removal of Common Bile Duct Stones: An Update in Chinese Patients with Choledocholithiasis

Aim: Endoscopic Retrograde Cholangiopancreatography (ERCP) has been widely used in endoscopic surgery for many biliary and pancreatic diseases. Post-ERCP Pancreatitis (PEP) is the most common complication that occurs, even with expert surgeons. However, few reports have addressed the risk of PEP by focusing on the removal of Common Bile Duct Stones (CBDS). Methods: To detect potential risk factors for PEP after endoscopic removal of CBDS, the medical records of CBDS patients who received ERCP procedures at the First Affiliated Hospital of Nanjing Medical University between January 2021 and December 2023 were retrospectively analyzed. Patient- and procedure-related data were collected, and PEP was reevaluated. Single- and multiplevariable analyses were conducted to identify potential risk factors. Results: A total of 1,251 procedures were performed in 1,173 patients and PEP occurred in 84 cases (6.71%). Univariate and multivariate logistic regression analyses showed that female sex (P= 0.049, 95% Confidence Interval [CI]: 1.002-2.521), cerebral infarction (P=0.011, 95% CI: 1.197-3.964), acute pancreatitis history (P=0.001, 95% CI: 2.436-7.249), fatty liver disease (P=0.021, 95% CI: 1.140 -4.843), common bile duct diameter &lt;10 mm (P=0.005, 95% CI: 1.299-4.313), and Endoscopic Papillary Balloon Dilatation (EBD) (P=0.01, 95% CI: 0.321-0.855) were independent risk factors for PEP in CBDS patients. Conclusion: Female sex, a history of Fatty Liver Disease (FLD), previous acute pancreatitis, and common bile duct stenosis are risk factors for PEP, whereas EPBD is a protective factor for PEP in patients with CBDS, which should be considered by clinicians.