Bile Duct Stones Research Articles

Long-term prognosis and risk factors associated with post-ERCP pneumobilia in patients with common bile duct stones

Post-ERCP pneumobilia is not uncommon; however, studies focusing on the long-term prognosis of patients with post-ERCP pneumobilia are limited. This study aimed to explore long-term prognosis and risk factors associated with post-ERCP pneumobilia in patients with common bile duct stones (CBDSs). We conducted a retrospective analysis of 1380 patients who underwent ERCP for CBDSs at our hospital from January 2010 to December 2017. Patients were selected based on inclusion and exclusion criteria and divided into pneumobilia and nonpneumobilia groups, followed by propensity score matching. The matched groups were then compared in terms of incidence rates of both single and multiple recurrences of CBDSs, acute cholangitis, and acute cholecystitis. Multivariate logistic regression analysis was used to explore risk factors associated with pneumobilia. After propensity matching, there was no significant difference in the rate of single recurrence of CBDSs (22.5% vs 30%; P= .446) between the pneumobilia and nonpneumobilia groups. However, the incidences of multiple recurrences of CBDSs (32.5% vs 12.5%; P= .032) and acute cholangitis without stone recurrence (32.5% vs 2.5%; P= <.001) were significantly higher in the pneumobilia group. Based on multivariate logistic regression analysis, in addition to a dilated CBD (diameter of >1 cm) (odds ratio [OR], 2.48; 95% confidence interval [CI], 1.03-3.76; P= .043), endoscopic sphincterotomy with moderate incision (OR, 5.38; 95% CI, 1.14-25.47; P= .034) and with large incision (OR, 8.7; 95% CI, 1.83-41.46; P = .007) were identified as independent risk factors for pneumobilia after initial ERCP. Patients with post-ERCP pneumobilia have increased risk of multiple recurrences of CBDSs and acute cholangitis without stone recurrence. Independent risk factors for pneumobilia include peripapillary diverticulum, a dilated CBD (>1 cm), and endoscopic sphincterotomy with moderate and large incisions. A normal-sized CBD appears to serve as a secondary barrier against enterobiliary reflux, necessitating further research for confirmation.

OGBN O09V Multi-modal Approach with Fluorescence Imaging, Intraoperative Ultrasound and Laser Lithotripsy in the Laparoscopic Management of Complex Large Bile Duct Stones

Abstract Background Choledocholithiasis is a common condition with various presentations. There are several approaches through which this can be managed. This presentation aims to explain novel techniques and various modalities in managing complex bile duct stones successfully with minimal invasive approach. Methods This video presentation depicts the procedure performed for large CBD stones with the use of indocyanine green (ICG) and intraoperative ultrasound (IOUS). The patient is a 61 year old gentleman presented with abdominal discomfort and deranged liver functions. Cross sectional imaging showed 2 large CBD calculi and attempt at endoscopic retrograde cholangio-pancreatigoraphy (ERCP) failed due to large impacted stones. Decision was made to proceed to single stage laparoscopic cholecystectomy and common bile duct exploration with use of ICG, IOUS and laser lithotripsy to achieve successful clearance of CBD. Results At laparoscopy, the CBD and common hepatic artery were identified with ICG and IOUS. A vertical choledochotomy was performed and choledochoscopy undertaken. Attempts to retrieve the stone with extraction basket were not successful. Laser lithotripsy was used to break the stones into smaller fragments which were subsequently retrieved using atraumatic graspers and extraction wire. Post operative period was uneventful and the patient was discharged home on day 2. Face to face follow-up at 6 weeks confirmed good recovery. Conclusions Laparoscopic management of complex CBD stones is challenging. Despite advances in endoscopy intervention, the role of surgery is irrefutable. Advanced laparoscopic skills and experience in bile duct exploration with advanced minimally invasive instruments and equipment are critical to achieve optimal patient outcomes, and mitigated the chances of conversion to open surgery which its associated morbidity. This presentation demonstrates a safe technique while working in the hostile area of the inflamed hepatocystic triangle and an alternative method in the retrieval of large common bile duct stones following failed ERCP.

Risk factors for cefmetazole-non-susceptible bacteremia in acute cholangitis

IntroductionCefmetazole (CMZ), an antibiotic with limited international distribution, is recommended by the Tokyo Guidelines 2018 (TG18) for non-severe cases of acute cholangitis (AC). However, the risk factors for CMZ-non-susceptible (CMZ-NS) bacteremia in AC remain unclear. Here, we aimed to investigate the risk factors for CMZ-NS bacteremia and evaluate mortality in patients with AC. MethodsThis single-center, retrospective, observational study included all patients diagnosed with definite bacteremic AC, based on TG18, from April 2019 to March 2023. Risk factors for CMZ-NS bacteremia were analyzed by univariate, and age- and sex-adjusted, logistic regression analyses. Mortality was compared by cause of obstruction, CMZ-susceptible/CMZ-NS bacteremia, and initial treatment. ResultsIn total, 165 patients were enrolled. CMZ-NS bacteremia was diagnosed in 46 (27.9 %) patients. Histories of diabetes mellitus, hepato-biliary-pancreatic cancer, malignant biliary obstruction, and endoscopic sphincterotomy were identified as significant factors associated with the risk of CMZ-NS bacteremia.Thirteen patients died within 30 days of hospital admission. The mortality of patients with AC and malignant biliary obstruction was statistically higher than that of patients with bile duct stones. No patients with AC and bile duct stones died in the group with CMZ-NS bacteremia and inappropriate initial antibiotics. ConclusionsIn AC, a history of diabetes mellitus, hepato-biliary-pancreatic cancer, malignant biliary obstruction, and endoscopic sphincterotomy are associated with an increased risk of CMZ-NS bacteremia. Therefore, the choice of empiric therapy for AC should be based on the etiology and patient background, rather than on the severity.

HPB P34 A case-controlled study of single-stage versus two-stage approach to managing common bile duct stones

Abstract Background The most common approaches to the treatment of symptomatic common bile duct (CBD) stones are endoscopic retrograde cholangiopancreatography (ERCP) followed by cholecystectomy (two-stage approach) and intra-operative imaging +/- bile duct exploration (BDE) during laparoscopic cholecystectomy (single-stage approach). Intra-operative cholangiogram (IOC) and intra-operative ultrasound (IOUS) are the two common forms of intra-operative imaging. Although IOC is used more frequently, IOUS is safer, non-invasive and can be repeated. The aim of this study was to evaluate outcomes of patients undergoing a single-stage approach with IOUS compared to patients undergoing a two-stage approach. Methods This was a retrospective case-controlled study. Outcomes of patients who had a single-stage approach (group 1) between February 2015 and June 2022 were compared with a cohort of patients (matched for age, sex, and co-morbidities) who had a two-stage approach (group 2). Outcomes included the total number of admissions from diagnosis until cholecystectomy, time from initial presentation to surgery, length of stay (LOS), post-operative and post-ERCP complications (including bile leak, pancreatitis and retained stones), readmission rate and mortality within a year. Results Seventy-four patients were included (65% female, mean age 56 years, median Charlson Comorbidity Index of 2). The median number of admissions was lower in group 1 (1 vs 3 days, p&amp;lt;0.01). The median waiting time till surgery was 4 days in group 1 (vs 128 days, p&amp;lt;0.01). The median LOS for group 1 was 5 days (vs 7 days, p=0.08). Overall complications were lower in group 1 (5% vs 11%, p=0.79). Complications included bile leak (5% vs 0%), pancreatitis (0% vs 8%) and retained stones (0% vs 3%). Readmission rate was 3% vs 16% (p=0.66). Overall mortality was zero. Conclusions Patients who were managed for CBD stones via the single-stage approach had significantly fewer hospital admissions and shorter waiting time to cholecystectomy. There was no significant difference in LOS, rate of complications or readmissions between the two groups. We therefore advocate the use of the single-stage approach using IOUS routinely over ERCP in the management of symptomatic CBD stones.

OGBN V02 Robotic common bile duct clearance

Abstract Background A 44-yar old male patient presented with painful obstructive jaundice and bilirubin of 127 μmol/L. A Contrast Enhanced Computed Tomography (CECT) revealed dilated biliary tree as a result of obstructing stone in the proximal common bile duct (CBD). The patient underwent an Endoscopic Retrograde CholangioPancreatography (ERCP) and sphincterotomy which demonstrated pus in the bile duct, but also a stone impacted in the common hepatic duct which could not be extracted endoscopically. Therefore, a 7Fr pigtail stent was inserted. Subsequently, he was discharged home and re-admitted for an elective robotic cholecystectomy and bile duct clearance 6 weeks later. Methods Robotic CBD clearance was performed using DaVinciXi system, a 12mm Airseal and four 8mm robotic ports. The patient was supine with split legs(15 degrees), in reverse Trendelenburg position and left tilt. The CBD was dissected out, the anterior duct wall was delineated and longitudinal choledochotomy was carried out. A large stone was extracted through the choledochotomy site followed by removal of stent. Subsequently, a cholangioscopy was performed using a single-use flexible ureteroscope and no further stone disease was identified proximally or distally. Following this, a bile duct closure was performed using 4-0 Polydioxanone interrupted sutures and SutureCut Needle Driver. Results There were no intra- or post-operative complications. The patient made an excellent recovery from robotic common bile duct clearance and was discharged home less than 24 hours post procedure. Conclusions This video presentation highlights the technical aspects of robotic common bile duct clearance and demonstrates that the robotic system allows for accurate dissection and precise suturing which could reduce the risk of bile duct stricture.

EGS P14 Improving Management of Obstructive Jaundice: A Single-Centre Experience

Abstract Background Timely management is essential in preventing recurrence of gallstone disease and The National Institute for Clinical Excellence (NICE) recommends that laparoscopic cholecystectomy (LC) should be performed within seven days of admission. However, there remains wide variation between NHS Trusts in managing gallstone disease. As part of an ongoing surgical quality improvement project, a restructured Upper Gastrointestinal Surgery (UGI) firm was created (with three dedicated UGI consultant surgeons, one specialist registrar, one foundation doctor), in close collaboration with interventional gastroenterologists and radiologists. The impact of this new service on gallstone disease management has been closely monitored. Methods A prospective database was maintained including patients presenting emergently with obstructive jaundice and/or common bile duct stones at our district general hospital (DGH) in the 6-month timeframe before (September 2021 to February 2022) and after (September 2022 to February 2023) implementation of the new UGI service. Outcomes included time from presentation to magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP) and LC. Results 26 and 38 patients with obstructive jaundice were admitted in the 6-month periods before and after UGI firm implementation, respectively. There were significant reductions in time from admission to receiving ERCP (6.6 days versus 40.2 days, p&amp;lt;.001), and outpatient LC (61.8 days versus 194 days, p=.02). There was also marked improvement in obtaining MRCP (2.5 days versus 5.2 days). After UGI firm implementation, 35% of eligible patients were offered an inpatient LC which were all performed within seven days (mean 6.3 days), versus none previously. Conclusions A dedicated UGI service significantly improved the treatment process for patients presenting with obstructive jaundice at our DGH. As part of ongoing quality improvement work, solutions such as introducing a ‘golden patient’ to the NCEPOD list, a ‘hot slot’ on the elective gallbladder list or a dedicated weekly ‘hot’ gallbladder list are currently being investigated. Equipment for laparoscopic transcystic common bile duct exploration is also being considered to alleviate the need for ERCP prior to surgery.

OGBN P12 Use of Computed Tomographic Scan in Diagnosis and Management of Acute Pancreatitis; A Clinical Audit

Abstract Background Acute pancreatitis is a frequently encountered emergency surgical condition, with computed tomography (CT) scans being commonly used for diagnosis and management. This audit was done in an NHS Hospital in Northwest, England with the aim to assess the utilization of CT scans in the diagnosis and management of acute pancreatitis in accordance with local policy. Methods Data were collected from all patients admitted with acute pancreatitis between October 2022 and March 2023. The focus of the investigation was on patients who underwent CT scans, with the objective of identifying the indications for their usage. Results The audit included a total of 53 patients (mean age 52.75 years, almost equal gender distribution). 64.2% had clinical pancreatitis (typical symptoms and diagnostic amylase levels), while 35.8% did not. 42 patients (79.2%) underwent CT scans. Of these scans, 42.9% were performed in patients without diagnostic amylase levels, 14.3% to rule out complications after 3 days, 9.5% due to a history of pancreatic complications, 1 was based on strong suspicion of another pathology, and another for diagnosing a common bile duct stone in a patient with an MRI incompatible pacemaker. Furthermore, 12 (28.5%) of the scans done were considered unnecessary. Conclusions The findings indicate that approximately 8 out of 10 patients with acute pancreatitis underwent at least one CT scan during their hospitalization. However, a significant proportion (28.5%) of these scans were deemed unnecessary.

Hepatitis E Virus Infection Caused Elevation of Alanine Aminotransferase Levels in a Patient with Chronic Hepatitis B and Choledocholithiasis

Hepatitis E virus (HEV) genotypes 3 and 4 are zoonotic strains that are primarily transmitted through the consumption of undercooked pork or game meat. They also cause asymptomatic infections, acute hepatitis, acute-on-chronic liver failure, chronic hepatitis, and extrahepatic manifestations. Here, we report a man in his 80s who had chronic hepatitis B, took entecavir for it, and presented with higher levels of alanine aminotransferase (ALT) and jaundice. An abdominal computed tomography scan revealed choledocholithiasis with cholecystolithiasis. Although endoscopic papillary balloon dilatation was performed for the removal of a common bile duct stone, the abnormal liver function tests, including jaundice, were prolonged. After other viral hepatitis and other causes of the liver injury were ruled out, as his serum was positive for immunoglobulin A anti-HEV and HEV genotype 3b RNA, we diagnosed him as having acute hepatitis E. In this case, with chronic hepatitis B and a common bile duct stone, the prolonged abnormal results for the liver function tests seemed to be caused by HEV infection. In conclusion, in cases with high ALT levels after removing choledocholithiasis, other factors, including HEV infection, should be considered to determine the cause of abnormal liver function test results. The further examination of hepatitis D virus infection and high ALT levels may be needed in HBV-infected individuals.

Twee patiënten met acute toxische hepatitis na recente inname van thee

Two patients with toxic hepatitis after tea ingestion Drug-induced liver injury (DILI) is common and can manifest in various degrees: from asymptomatic increased transaminases to hepatocellular jaundice with an elevated total and direct bilirubin to acute liver failure. When accompanied by jaundice, there is a mortality rate of 10%. In acute liver failure, referral to a tertiary centre is necessary. This article emphasizes the consideration of herbal and dietary supplements (HDS). The use of HDS in Europe and the US is rising. Some studies state that 1 out of 3 to 1 out of 2 Americans take dietary supplements, which raises concerns about HDS-related toxic hepatitis. HDS involve any supplement that could cause liver damage, including herbs, vitamins, minerals, amino acids and proteins. The prevalence of hepatotoxicity is underestimated. DILI is a diagnosis of exclusion. Diseases that should be excluded, are viral hepatitis, non-alcoholic steatohepatitis (NASH), alcoholic steatohepatitis (ASH), hereditary hemochromatosis, autoimmune hepatitis, Wilson’s disease and alpha-1 antitrypsin deficiency. If there is an increased total and direct bilirubin with or without cholestasis, bile duct stones and hepatobiliary malignancies should be excluded. A liver biopsy may be necessary if the diagnosis is unclear or when several diagnoses are plausible. Liver damage usually occurs within 1 to 6 months after starting the product and is usually reversible. It is important to bear in mind HDS when considering DILI as the incidence of HDS is clearly increasing.

Feasibility and safety of intraoperative bile duct clearance by antegrade transcystic balloon sphincteroplasty: A prospective observational pilot study.

Concomitant cholecystolithiasis and choledocholithiasis are common. Standard treatments are endoscopic retrograde cholangiography (ERC) followed by cholecystectomy or laparoendoscopic rendezvous. Endoscopic retrograde cholangiography has drawbacks, such as post-ERC pancreatitis or bleeding, and potentially more than one intervention is required to address common bile duct (CBD) stones. Safety and feasibility of an intraoperative antegrade transcystic single-stage approach during cholecystectomy with balloon sphincteroplasty and pushing of stones to the duodenum has not been evaluated prospectively. The aim of this pilot study was to evaluate this procedure regarding safety, feasibility, and stone clearance rate. Prospective single-center intervention study (SUPER Reporting-Guideline). Main inclusion criterion was confirmed choledocholithiasis (stones ≤6 mm) at intraoperative cholangiography. Success of the procedure was defined as CBD stone clearance at intraoperative control cholangiography, absence of symptoms and no elevated cholestasis parameters at 6 weeks follow-up. Simon's two-stage design was used to determine sample size. From January 2021 to April 2022, a total of 57 patients fulfilled the final inclusion criteria and were included. Mild pancreatitis or cholangitis were present upon admission in 15 (26%) and 15 (26%) patients, respectively. Median number of CBD-stones was 1 (1-6). Median stone diameter was 4 mm (0.1-6 mm). Common bile duct stone clearance was achieved in 54 patients (94%). The main reason for failed CBD clearance was the inability to push the guidewire along the biliary stone into the duodenum. Median intervention time was 28 minutes (14-129 minutes). While there was no postoperative pancreatitis, two patients (3.5%) had asymptomatic hyperlipasemia 4 hours postoperatively. Intraoperative CBD stone clearance by antegrade balloon sphincteroplasty appears to be safe and highly feasible. Its overall superiority to the current standards warrants evaluation by a randomized controlled trial. Therapeutic/Care Management, Level V.

A comparative study of clinicopathological and imaging features of HBV-negative and HBV-positive intrahepatic cholangiocarcinoma patients with different pathologic differentiation degrees

Hepatitis B is a risk factor for the development of intrahepatic cholangiocarcinoma. The prognosis of HBV-related ICC remains to be further investigated. To investigate the clinical, pathological and imaging features of intrahepatic cholangiocarcinoma of hepatitis B virus-positive and -negative patients. Data from January 31, 2012 to December 31, 2019 of 138 patients were retrospectively analyzed. The patients were divided into hepatitis B virus-positive group (group A[n = 66]) and virus-negative group (group B[n = 72]), and the patients were divided into groups according to pathological differentiation degree and tumor size. The differences in clinical, imaging characteristics and the progression-free survival between groups were analyzed. There were significant differences in gender, age, HBc antibody, CA125 and AFP, tumor distribution site, maximum diameter, plain scan density, inferior hepatic angle, peritumoral bile duct dilatation, vascular encasement invasion, intrahepatic bile duct dilatation and lymphadenopathy between the two groups (P < 0.05); There were statistical differences in signs of vascular encasement invasion between the two groups with well-to-moderately differentiated tumors (P < 0.05); there were statistical differences in tumor density uniformity, signs of vascular encasement invasion and lymphadenopathy between the two groups with poorly differentiated tumors (P < 0.05). Large groups A and B showed differences in tumor density uniformity, vascular encasement invasion, arterial phase, overall reinforcement pattern, peritumoral bile duct stones and biliary dilatation (P < 0.05). There was no statistical difference in postoperative PFS between the two groups (P > 0.05). The clinical and imaging features of ICC of hepatitis B virus-positive and -negative patients are different, and there is little difference in postoperative disease-free survival time.

Esophageal Foreign Body Removal by Bile Duct Stone Removal Baskets (Litho crush): Think out of the Box; A Case Report

Abstract: A foreign body or food bolus impaction in the gastrointestinal tract is a common occurrence in emergency endoscopy. In 80-90% of patients, the foreign body will pass spontaneously through the gastrointestinal tract without complications, and in 10-20% of the patients, an endoscopic or surgical intervention is deemed necessary. We report an unusual case of a foreign body, a large mango seed, that was stuck at the level of the mid-esophagus and was refractory to removal by standard endoscopic techniques.

Characteristics and metabolic potential of biliary microbiota in patients with giant common bile duct stones.

Endoscopic retrograde cholangiopancreatography (ERCP) is an effective minimally invasive operation for the management of choledocholithiasis, while successful extraction is hampered by large diameter of stones. Emerging studies have revealed the close correlation between biliary microbiota and common bile duct stones (CBDS). In this study, we aimed to investigate the community characteristics and metabolic functions of biliary microbiota in patients with giant CBDS. Eligible patients were prospectively enrolled in this study in First Affiliated Hospital of Soochow University from February 2022 to October 2022. Bile samples were collected through ERCP. The microbiota was analyzed using 16S rRNA sequencing. Metabolic functions were predicted by PICRUSTs 2.0 calculation based on MetaCyc database. Bile acids were tested and identified using ultra performance liquid chromatography-tandem mass spectrometry. A total of 26 patients were successfully included into final analysis, 8 in giant stone (GS) group and 18 in control group. Distinct biliary microbial composition was identified in patients with giant CBDS, with a significantly higher abundance of Firmicutes at phylum level. The unique composition at genus level mainly consisted of Enterococcus, Citrobacter, Lactobacillus, Pyramidobacter, Bifidobacterium and Shewanella. Pyramidobacter was exclusively found in GS group, along with the absence of Robinsoniella and Coprococcus. The contents of free bile acids were significantly higher in GS group, including cholic acid (98.39μmol/mL vs. 26.15μmol/mL, p=0.035), chenodesoxycholic acid (54.69μmol/mL vs. 5.86μmol/mL, p=0.022) and ursodeoxycholic acid (2.70μmol/mL vs. 0.17μmol/mL, p=0.047). Decreasing tendency of conjugated bile acids were also observed. Metabolic pathways concerning cholelithiasis were abundant in GS group, including geranylgeranyl diphosphate biosynthesis, gluconeogenesis, glycolysis and L-methionine biosynthesis. This study demonstrated the community structure and metabolic potential of biliary microbiota in patients with giant CBDS. The unique biliary microbial composition holds valuable predictive potential for clinical conditions. These findings provide new insights into the etiology of giant CBDS from the perspective of biliary microbiota.

Favorable impact of a novel endoscopic auxiliary system (NEAS) on fluoroscopy-guided lithotripsy for difficult bile duct stones: A pilot study.

Laser lithotripsy under fluoroscopic guidance is difficult to perform and risky due to its invisibility. In this study we aimed to investigate the efficacy and safety of a novel endoscopic auxiliary system (NEAS)-assisted lithotripsy under fluoroscopy for treating difficult common bile duct (CBD) stones. Patients with difficult CBD stones who were treated with NEAS-assisted laser lithotripsy (NEAS group) or conventional mechanical lithotripsy (ML) under fluoroscopy (ML group) were retrospectively evaluated. The primary outcome was the complete stone clearance rate and the secondary outcomes included operation time, complications, and medical cost. Seventeen patients were treated with NEAS-assisted laser lithotripsy and 144 patients underwent ML. Using the propensity score matching analysis, 17 pairs of cases treated with NEAS-assisted lithotripsy and ML were included. Patients in the NEAS group showed a higher stone clearance rate than the ML group (94.1% vs 58.8%, P = 0.039), as well as shorter operation time (41.9 min vs 49.4 min, P < 0.001) and lower medical cost (USD 4607 vs USD 5014, P < 0.001). There was no significant difference in the complication rate between the two groups (5.9% vs 17.6%, P = 0.601). NEAS-assisted fluoroscopy-guided laser lithotripsy is feasible and safe, which may be a promising technique in fluoroscopy-guided laser lithotripsy for difficult CBD stones.

Effective Removal Methods for Common Bile Duct Stones

Choledocholithiasis carries a risk of developing biliary obstruction, acute cholangitis, and pancreatitis. Therefore, removal is recommended even in asymptomatic patients. Endoscopic retrograde cholangiopancreatography (ERCP) is regarded as the standard of treatment for choledocholithiasis nowadays. However, ERCP can accompany severe complications such as bleeding, ERCP-associated pancreatitis, cholangitis, and perforations. It is important for endoscopists to know how to remove choledocholithiasis effectively while minimizing adverse events. In this review, we will go over the technical aspects and various accessories to effectively remove choledocholithiasis.

The Use of Intraoperative Cholangiography During Cholecystectomy: A Systematic Review.

Cholecystectomy is a widespread surgical procedure for gallbladder diseases. Evolving techniques and technologies, such as intraoperative cholangiography (IOC), enhance safety and outcomes by providing real-time biliary system visualization during surgery. This systematic review explored available data on using IOC during cholecystectomy, highlighting its effectiveness, safety, and cost-effectiveness. To perform this systematic review, a thorough literature search was conducted using relevant keywords in electronic databases, such as PubMed, Medical Literature Analysis and Retrieval System Online (MEDLINE), Cochrane Library, Web of Science, and Google Scholar. We included studies published during the last 10 years exploring the use of IOC during cholecystectomy. The findings showed success rates of up to 90% with a median time of 21.9 minutes without complications. Most (90%) patients with acute gallstone pancreatitis underwent cholecystectomy with IOC, with unclear IOC results in 10.7% and failure in 14.7%. IOC failure factors included age, body mass index (BMI), male sex, concurrent acute cholecystitis, common bile duct (CBD) stone evidence on imaging, CBD diameter of >6 mm, total bilirubin of >4 mg/dL, abnormal liver tests, and gallstone pancreatitis. The detection of choledocholithiasis by IOC prompted trans-cystic duct exploration and endoscopic retrograde cholangiopancreatography (ERCP). Biliary abnormalities and stone identification were observed using IOC, and routine use increased bile duct stone detection while decreasing bile duct injury and readmission rates. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of IOC for common bile duct stone detection were reported at 77%, 98%, 97.2%, 63%, and 99%, respectively. Routine IOC was projected to provide substantial quality-adjusted life years (QALY) and cost-effectiveness gains compared to selective IOC. Regarding safety, IOC was generally associated with reduced complication and open surgery conversion risks, with similar rates of CBD injury and bile leaks. These findings indicate that IOC enhances cholecystectomy outcomes through precision and decreasing complications.

Recurrence of common bile duct stones after choledocholithotomy in elderly patients: risk factor analysis and clinical prediction model development.

The reasons for the recurrence of common bile duct stones (CBDS) in elderly patients after choledocholithotomy are still unclear. This study aims to establish a prediction model for CBDS recurrence by identifying risk factors. We conducted a retrospective analysis of 1804 elderly patients aged 65 years and above who were diagnosed to have CBDS and were admitted to Nanjing First Hospital between January 1, 2010, and January 1, 2021. According to inclusion and exclusion criteria, 706 patients were selected for the final analysis. The patients were assigned to two groups according to the presence or absence of CBDS recurrence, and their clinical data were then statistically analyzed. Subsequently, a prediction model and nomogram were developed, evaluating effectiveness using the concordance index (C-index). Of the 706 elderly patients, 62 patients experienced CBDS recurrence after surgery, resulting in a recurrence rate of 8.8%. The multivariate Cox analysis showed that prior history of cholecystectomy (hazard ratio [HR] = 1.931, 95% confidence interval [CI]: 1.051-3.547, p = 0.034), white blood cell (WBC) count ≥11.0 × 109/L (HR = 2.923, 95% CI: 1.723-4.957, p < 0.001), preoperative total bilirubin (TBIL) level ≥ 36.5 mmol/L (HR = 2.172, 95% CI: 1.296-3.639, p = 0.003), number of stones ≥2 (HR = 2.093, 95% CI: 1.592-5.294, p = 0.001), maximum stone diameter ≥ 0.85 cm (HR = 1.940, 95% CI: 1.090-3.452, p = 0.024), and T-tube drainage (HR = 2.718, 95% CI: 1.230-6.010, p = 0.013) were independent risk factors of CBDS recurrence in elderly patients after choledocholithotomy. A postoperative CBDS recurrence prediction model was constructed with a C-index value of 0.758 (95% CI: 0.698-0.818) and internal validation value of 0.758 (95% CI: 0.641-0.875). A history of cholecystectomy, WBC count ≥11.0 × 109/L, preoperative TBIL level ≥ 36.5 mmol/L, number of stones ≥2, maximum stone diameter ≥ 0.85 cm, and T-tube drainage are the independent risk factors of CBDS recurrence after choledocholithotomy in elderly patients. Our developed prediction model for CBDS recurrence has good predictive ability and can help predict the prognosis of patients with CBDS.

Addition of Mechanical Lithotripsy to Endoscopic Papillary Large Balloon Dilation in Patients with Difficult Common Bile Duct Stones: A Retrospective Single-Center Study.

Introduction: This study aimed to compare the treatment outcomes of endoscopic papillary large-balloon dilation (EPLBD) with and without mechanical lithotripsy (ML) in removing difficult common bile duct stones. Methods: Patients with difficult common bile duct stones treated with EPLBD, with or without ML, at the Eastern Chiba Medical Center between April 2014 and March 2020, were retrospectively evaluated. The rates of cumulative recurrence and complications were compared between the two groups. Results: Overall, 122 patients (n = 44, EPLBD + ML and n = 78, EPLBD) treated by 12 gastroenterologists were included. Patients in the EPLBD + ML group were older (85 years versus 81.5 years) and had larger maximum stone diameter (15 mm versus 12.5 mm) than those in the EPLBD group. Compared with the EPLBD group, the EPLBD + ML group required more endoscopic retrograde cholangiopancreatography (ERCP) procedures (≥2) (86% versus 67%) and longer total ERCP time after reaching the papilla (78.5 minutes versus 25 minutes). Complication rates were not significantly different (9.1% versus 12.8%); however, the cumulative recurrence rates were higher in the EPLBD + ML group than in the EPLBD group (69.4% versus 23.5% at 4 years). Conclusion: Although there were no differences in complication rates, the long-term recurrence rate was higher in the EPLBD + ML group than in the EPLBD group. This study emphasizes the added burden imposed by performing ML during ERCP and suggests that by appropriate case selection, it is possible to treat cases of difficult biliary stones using EPLBD without ML.

Analysis of Liver Function Test in Common Bile Duct Stone: A Descriptive Cross sectional study

Introduction: Liver function test (LFT) is a useful tool to differentiate between the obstructive and hepatocellular cause for biliary obstruction. Therefore this study was done to see the accuracy of LFT in predicting common bile duct (CBD) stones. Methods: A descriptive cross sectional study was carried out on patient undergoing endoscopic retrograde cholangiopancreatography for CBD stones at Bharatpur Hospital and Dev Hospital from 2021 June 15 to 2022 October 15. Ethical clearance was taken from Institutional Review Committee Bharatpur Hospital reference number 079/80-013. The convenient sampling method was applied. Data were collected and analyzed in statistical package for the social sciences version 22. Results: Out of 95 patients higher aged female predominance was seen. The overall incidence of abnormal LFT in CBD stones was 85.3%. All the parameters of LFT were raised in majority of the cases of CBD stones and among these, SGOT was mostly increased (75.6%). In patients with ERCP findings of sludge in bile duct have increased total, direct and indirect bilirubin than in patient with CBD stone and this finding was found to be statistically significant. However, other liver parameters were comparable.Similarly, total, direct and indirect bilirubin, serum glutamic oxaloacetic transaminase (SGOT), serum glutamic pyruvic transaminase (SGPT) and alkaline phosphatase (ALP) were equally raised with both group of CBD stones with and without cholecystitis. Conclusion: Liver function test was equally raised in both case of CBD stone with and without cholecystitis. Although ALP and total bilirubin represented the most reliable predictors in obstructive jaundice, SGOT might also be added tool to exclude choledocholithiasis.

Application of laparoscopic backtracking full-thickness continuous everting suture for non-AOSC choledocholithiasis

BackgroundBased on the current trend of increasing incidence of choledocholithiasis, it is of great significance to explore the closure method of the common bile duct during laparoscopic choledocholithotomy.MethodsBacktracking full-thickness continuous everting suture was selected for primary closure of the common bile duct suture, while traditional T-tube drainage was selected for the control group. Propensity score matching (PSM) was used to reduce baseline differences between the two groups.ResultThe intraoperative blood loss, operation time, postoperative recovery speed, postoperative bleeding, postoperative pancreatitis, recurrence rate of bile duct stones, and hospitalization time in the primary closure group were all less than those in the T-tube drainage group.ConclusionUnder certain conditions, backtracking full-thickness continuous everting suture could benefit patients with choledocholithiasis compared with traditional T-tube drainage.