Choledocholithiasis In Patients Research Articles

Implementation of a Surgery-first Approach to Pediatric Choledocholithiasis

BackgroundIn choledocholithiasis, the obstructed common bile duct (CBD) requires clearance either via endoscopic retrograde cholangiopancreatography (ERCP) or intraoperative cholangiogram (IOC) and common bile duct exploration (CBDE) during cholecystectomy. We hypothesized that patients with primary cholecystectomy (PC) and IOC/CBDE will have improved clinical outcomes when compared to primary ERCP (PE) patients. MethodsWe performed a retrospective cohort study of pediatric choledocholithiasis patients who underwent treatment at our institution between 2019 and 2023. We compared clinical and cost outcomes between PC and PE cohorts and assessed protocol compliance. ResultsWe analyzed 36 PC patients and 40 PE patients. Among PC patients, 52.7% underwent postoperative ERCP of which 47.4% were negative for CBD stone. Duct-clearing procedure varied between PC and PE groups, respectively, in terms of ERCP (36.1% vs. 65%), IOC/CBDE (36.1% vs. 2.5%), and spontaneous clearance (27.8 vs. 32.5%) (p < 0.001). One-third of PC patients had CBD clearance via IOC and flush and 16.7% had successful IOC/CBDE. PC patients had longer median combined surgical/procedural anesthesia duration (186 vs. 170.5 min, p = 0.318). There were no significant differences between PC and PE patients in terms of cost of surgery/procedures or overall admission. ConclusionMost PC patients achieved duct clearance via IOC and spontaneous means. PC has the potential to enable earlier cholecystectomy and avoid postoperative ERCP altogether. In the setting of failed CBDE, combining a PC strategy with non-interventional monitoring may eliminate unnecessary postoperative ERCPs. Future studies should assess outcomes associated with an amended surgery-first protocol in a larger cohort. Level of EvidenceII.

ASGE Predictors for the Diagnosis of Choledocholithiasis: Validation in a Public Hospital of Merida, Yucatan, México

Background:: Choledocholithiasis is defined as the presence of calculus in the biliary tract, and is one of the main complications of cholelithiasis. Its prevalence among the Mexican pop-ulation is 14%. Objective:: To determine the validity of predictors of choledocholithiasis in patients attending the Hospital Agustin O’Horan from January 2019 to December 2020. Methods:: This was an observational, analytical, and retrospective study. It included patients with a diagnosis of choledocholithiasis, and it evaluated the sensitivity, specificity, as well as positive and negative predictive values for risk criteria of the American Society for Gastrointestinal Endoscopy (ASGE) Results:: Ninety-six medical histories were analyzed. Ninety were from women and six from males (94% and 6% respectively), and the average age was 40 years. The registry shows an increase of serum ALP, AST, and ALT in 98% of the reports, and elevated levels of bilirubin in 19% by 1.3-4 mg/dl, and 76% by &gt;4mg/dl of them. Moreover, the records showed pancreatitis and cholangitis (8% each one). The ultrasound reports indicates that 96% of the patients had a choledochal cyst higher than 5 mm, while 54% had a choledochal litho. Sensitivity and specificity of ASGE criteria for the diagnosis of choledocholithiasis was 96.6% and 45.5% respectively, and a Positive Predictive Value of 16% and a Negative Predictive Value of 99%. Conclusion:: It is considered that the diagnostic accuracy test of the ASGE criteria for the diagnosis of choledocholithiasis is high.

Laparoscopic-Assisted ERCP in Gastric Bypass Patients-No Stones Left Unturned: A Single Center Retrospective Cohort Study.

The long-term need for biliary duct intervention following Roux-en-Y gastric bypass surgery (RYGB) is uncertain. We investigated the rate of laparoscopic assisted retrograde cholangiopancreatography (LAERCP) following RYGB. Also, the pre-LAERCP diagnostic workup together with the true rate of choledocholithiasis in patients with or without prior cholecystectomy was investigated. Retrospective cohort study of RYGB and LAERCP performed at the Hospital South West Jutland, University Hospital of Southern Denmark, from 1 January 2013 to 31 May 2022. One percent of patients (n = 13) with a history of RYGB (n = 1363) underwent LAERCP at our facility during a median follow-up of 60.6months. The stone extraction rate was 66.7% in patients with in situ gallbladder and 12.5% in patients with prior cholecystectomy. Cannulation of the common bile duct was achieved in 96.7% of cases. Postoperative complications were observed in 22.6% of the cases. Approximately 1% of RYGB patients needed LAERCP during a median follow-up of 5years. In patients with a history of cholecystectomy, the LAERCP rate of stone extraction was very low (12.5%).

Magnetic resonance cholangiopancreatography in acute cholecystitis: Is it necessary for patients with normal common bile duct diameter?

AbstractAimInvestigating concurrent choledocholithiasis in patients with acute cholecystitis (AC) and normal common bile duct (CBD) diameter on ultrasound by performing magnetic resonance cholangiopancreatography (MRCP) can be challenging. This study aims to determine the conditions that necessitate MRCP before surgery and its potential impact on the course of treatment for these patients.Patients and methodsWe included 100 patients with AC and normal CBD diameter who were admitted to Shahid Modarres Hospital from September 2019 to September 2022. Patients with elevated levels of any liver serum markers above the upper limit of normal underwent MRCP.ResultsThe MRCP results were positive in 45.16% of cases and altered the type of treatment in 35.48% of them. The findings indicated that direct [area under the curve (AUC) = 0.782; 95% confidence interval (CI) 0.597–0.909] and total bilirubin (AUC = 0.697; 95% CI 0.507–0.849) were significantly effective in predicting the positive findings for concurrent CBD stone or Mirizzi's syndrome on MRCP. The optimal cutoff values for direct and total bilirubin were found to be above 1.02 and 2.19 mg/dL. Concerning the alteration of treatment approaches, direct bilirubin demonstrated predictive value (P = .014) at levels above 1.02 mg/dL.ConclusionsIn cases of AC with a normal CBD diameter on ultrasound and mild elevations in liver function parameters, including total and direct bilirubin, it is not routinely necessary to perform MRCP. However, if these laboratory values exceed a certain threshold, MRCP is recommended as it may reveal alternative diagnoses that could alter the clinical management.

Comparative Risks of Post-ERCP Adverse Events in Patients with Asymptomatic and Symptomatic Choledocholithiasis: A Systematic Review and Meta-Analysis.

Endoscopic retrograde cholangiopancreatography (ERCP) is the standard of care for the management of choledocholithiasis but carries risk of complications which may result in significant morbidity and mortality. While currently available guidelines endorse the use of ERCP for the management of symptomatic common bile duct stones, the need for ERCP in incidentally found asymptomatic choledocholithiasis is more controversial, and practice varies on a geographic and institutional level. This systematic review and meta-analysis is conducted to compare post-ERCP adverse events between asymptomatic and symptomatic choledocholithiasis patients. We searched PubMed/Embase/Web of Science databases to include all studies comparing post-ERCP outcomes between asymptomatic and symptomatic choledocholithiasis patients. The primary outcome was post-ERCP pancreatitis (PEP), while secondary outcomes included post-ERCP cholangitis, bleeding, and perforation. We calculated pooled risk ratios (RR) and 95% confidence intervals (CIs) using the Mantel-Haenszel method within a random-effect model. Our analysis included six observational studies, totaling 2,178 choledocholithiasis patients (392 asymptomatic and 1786 symptomatic); 53% were female. Asymptomatic patients exhibited a higher risk of PEP compared with symptomatic patients (11.7% versus 4.8%; RR 2.59, 95% CI 1.56-4.31, p ≤ 0.001). No significant difference was observed in post-ERCP cholangitis, bleeding, or perforation rates between the two groups. Asymptomatic patients with choledocholithiasis appear to have a higher risk of PEP than symptomatic patients, while the risk of other post-ERCP adverse events is similar between the two groups. Interventional endoscopists should thoroughly discuss potential adverse events (particularly PEP) with asymptomatic patients before performing ERCP and utilize PEP-prevention measures more liberally in this subgroup of patients.

Endoscopic ultrasound-guided antegrade treatment versus balloon enteroscopy endoscopic retrograde cholangiopancreatography for choledocholithiasis in patients with Roux-en-Y gastric bypass: a systematic review and meta-analysis.

The safety and technical success of endoscopic ultrasound-guided antegrade treatment (EUS-AG) compared to balloon enteroscopy-assisted endoscopic cholangiopancreatography (BE-ERCP) for choledocholithiasis in Roux-en-Y gastrectomy has not been well documented. We performed a systematic review and meta-analysis to assess the safety and efficacy of the 2 procedures. A systematic search of multiple databases was undertaken through January 25, 2024, to identify relevant studies comparing the 2 procedures. Standard meta-analysis methods were employed using a random-effects model. For each outcome, risk-ratio (RR), 95% confidence interval (CI), and P-values were generated. P<0.05 was considered significant. Heterogeneity was assessed using the I 2 statistic. Three studies with 795 patients (95 in the EUS-AG group and 700 in the BE-ERCP group) were included. The technical success rate was similar between EUS-AG and BE-ERCP (RR 1.08, 95%CI 0.84-1.38; P=0.57; I 2=56%). The overall rate of adverse effects was higher in the BE-ERCP group than in the EUS-AG group (RR 1.95, 95%CI 1.21-3.15; P=0.006; I 2=0 %). Rates of clinical success, pancreatitis, perforation, and bile peritonitis were similar between the 2 procedure techniques. Our analysis showed no distinct advantage in using one technique over the other for patients with Roux-en-Y anatomy in achieving technical and clinical success. However, the incidence of adverse effects was greater in the BE-ERCP group than in the EUS-AG group.

CHOLEDOCHOLITHIASIS IN A PATIENT CARRYING AN INTRAGASTRIC BALLOON. REMOVAL OR DIRECT ERCP?

CHOLEDOCHOLITHIASIS IN A PATIENT CARRYING AN INTRAGASTRIC BALLOON. REMOVAL OR DIRECT ERCP?

Simplified single-session EUS-guided transhepatic antegrade stone removal for management of choledocholithiasis in patients with surgically altered anatomy.

Endoscopic ultrasound (EUS)-guided transhepatic antegrade stone removal (TASR) has been reserved for choledocholithiasis after failed endoscopic retrograde cholangiopancreatography (ERCP) in recent years. The aim of this study was to evaluate the techniques, feasibility, and safety of simplified single-session EUS-TASR for choledocholithiasis in patients with surgically altered anatomy (SAA). A retrospective database of patients with SAA and choledocholithiasis from the Second Hospital of Hebei Medical University (Shijiazhuang, China) between August 2020 and February 2023 was performed. They all underwent single-session EUS-TASR after ERCP failure. Basic characteristics of the patients and details of the procedures were collected. The success rates and adverse events were evaluated and discussed. During the study period, 13 patients underwent simplified single-session EUS-TASR as a rescue procedure (8 males, median age, 64.0 [IQR, 48.5-69.5] years). SAA consisted of four Whipple procedures, one Billroth II gastrectomy, four gastrectomy with Roux-en-Y anastomoses, and four hepaticojejunostomy with Roux-en-Y anastomoses. The technical success rate was 100% and successful bile duct stone removal was achieved in 12 of the patients (92.3%). Adverse events occurred in two patients (15.4%), while one turned to laparoscopic surgery and the other was managed conservatively. Simplified single-session EUS-TASR as a rescue procedure after ERCP failure appeared to be effective and safe in the management of choledocholithiasis in patients with SAA. But further evaluation of this technique is still needed, preferably through prospective multicenter trials.

Performance of European and American Societies of Gastrointestinal Endoscopy Guidelines for Prediction of Choledocholithiasis in Patients with Acute Biliary Pancreatitis.

Background and Objectives: Up to one-third of patients with acute biliary pancreatitis also present with choledocholithiasis. Guidelines from the European Society of Gastrointestinal Endoscopy (ESGE) and the American Society for Gastrointestinal Endoscopy (ASGE) for investigating suspected choledocholithiasis suggest endoscopic retrograde cholangiopancreatography in patients with high-likelihood (ESGE)/high-probability (ASGE) predictors and endoscopic ultrasound in those with intermediate-likelihood (ESGE)/intermediate-probability (ASGE) predictors. Although both guidelines are similar, they are not identical. Furthermore, these algorithms were mainly developed from cohorts of patients without pancreatitis and are therefore poorly validated in a subset of patients with acute pancreatitis. We aimed to assess the performance of the ESGE and ASGE algorithms for the prediction of choledocholithiasis in patients with acute biliary pancreatitis. Materials and Methods: This was a retrospective analysis of 86 consecutive patients admitted to a tertiary referral centre in the year 2020 due to acute biliary pancreatitis. Results: Choledocholithiasis was confirmed in 29/86 (33.7%) of patients (13 with endoscopic retrograde cholangiopancreatography and 16 with endoscopic ultrasound). All 10/10 (100%) ESGE high-likelihood and 14/19 (73.7%) ASGE high-probability patients had choledocholithiasis. Only 19/71 (26.8%) patients with ESGE intermediate likelihood and 15/67 (22.4%) with ASGE intermediate probability had choledocholithiasis. Only 8/13 (61.5%) patients with the ASGE high-probability predictor of dilated common bile duct plus bilirubin > 68.4 µmol/mL had choledocholithiasis. Since this predictor is not considered high likelihood by ESGE, this resulted in a superior specificity of the European compared to the American guideline (100% vs. 91.2%). Following the American instead of the European guidelines would have resulted in five unnecessary endoscopic retrograde cholangiopancreatographies and five unnecessary endoscopic ultrasound examinations. Conclusions: This retrospective analysis suggests that the European guidelines may perform better than the American guidelines at predicting choledocholithiasis in the setting of acute pancreatitis. This was because dilated common bile duct plus bilirubin > 68.4 µmol/mL was not a reliable predictor for persistent bile duct stones.

EGS P12 To Perform Magnetic Resonance Cholangiopancreatography or Not in Gallstone Pancreatitis? – A Single Centre Retrospective Cohort Study

Abstract Background The management of gallstone pancreatitis (GSP) is well-described in guidelines from the Association of Upper Gastrointestinal Surgeons (AUGIS) and British Society of Gastroenterologists (BSG). Guidelines recommend laparoscopic cholecystectomy (LC) for mild GSP within 2 weeks of the admission, with endoscopic retrograde cholangiopancreatography (ERCP) as second-line for unfit patients. Magnetic resonance cholangiopancreatography (MRCP) plays a pivotal role in excluding choledocholithiasis. Our aim was to determine if MRCP is required to rule out choledocholithiasis in patients with GSP. Methods A retrospective cohort study of all consecutive adult patients who had MRCP for GSP in a single centre from September 2020 to September 2022 was conducted. Patient demographics, pre-MRCP peak liver function test (LFT) values and MRCP findings were analysed. Patients were risk-stratified based on modified AUGIS guidelines using the presence of hyperbilirubinaemia and the presence of biliary duct dilation on other imaging modalities. Patients with MRCP-proven choledocholithiasis were compared to those without. P-values were calculated using Fisher’s exact test. This study was registered with Clinical Quality Project (LanQIP 14738). Results 138 patients were identified; median age was 61 years (IQR 45-73) and 95 (68.8%) were female. 20 (14.5%) patients were post-cholecystectomy. 115 (83.3%) had inpatient scans and 66 (47.8%) were urgent. Median waiting time for inpatient MRCPs was 1.1 days (IQR 0.8-1.9) and 22.9 days (IQR 13.4-28.0) for outpatient scans. 25 (78.1%) patients had raised alkaline phosphatase levels and 23 (71.9%) had hyperbilirubinaenia. 61.1% of abdominal ultrasounds and 38.5% of CT scans reported dilated bile ducts. MRCP yielded 32 patients (23.2%) with choledocholithiasis, 3 of whom were post-cholecystectomy. Choledocholithiasis on MRCP was strongly correlated to higher risk stratification. Conclusions MRCP is useful imaging modality determining the presence of choledocholithiasis in high and moderate risk patients with GSP. We recommend that intraoperative cholangiography should still be performed during laparoscopic cholecystectomy where expertise is available.

Liver function tests for detection of choledocholithiasis in patients with acute calculous cholecystitis

Liver function tests for detection of choledocholithiasis in patients with acute calculous cholecystitis

S1233 Common Bile Duct Size, Gender, and Hispanic Origin Are Not Predictive of Incidental Choledocholithiasis in Patients Undergoing Endoscopic Ultrasound

S1233 Common Bile Duct Size, Gender, and Hispanic Origin Are Not Predictive of Incidental Choledocholithiasis in Patients Undergoing Endoscopic Ultrasound

S1256 Rising Trends of Inpatient Mortality and Resource Utilization in Choledocholithiasis Patients With History of Gastric Bypass: A United States Nationwide Inpatient Study

S1256 Rising Trends of Inpatient Mortality and Resource Utilization in Choledocholithiasis Patients With History of Gastric Bypass: A United States Nationwide Inpatient Study

S144 Comparative Risks of Post-ERCP Pancreatitis in Asymptomatic and Symptomatic Choledocholithiasis Patients: A Systematic Review and Meta-Analysis

S144 Comparative Risks of Post-ERCP Pancreatitis in Asymptomatic and Symptomatic Choledocholithiasis Patients: A Systematic Review and Meta-Analysis

Comparison Study between ERCP and PTBD for Recurrent Choledocholithiasis in Patients Following Gastrectomy.

The recurrence rate of choledocholithiasis in the general population has been reported to exceed 10%. The incidence of cholelithiasis was reported to be higher in patients following gastrectomy than that in the general population. However, there is no study for recurrent choledocholithiasis incidence in patients following gastrectomy. This study aimed to evaluate the recurrence rate of choledocholithiasis and identify risk factors for recurrent choledocholithiasis in patients following gastrectomy. A retrospective analysis was performed on patients with gastrectomy history who underwent choledocholithiasis removal in Kyungpook National University Hospital between January 2011 and December 2019. Choledocholithiases were treated by endoscopic retrograde cholangiopancreatography (ERCP) (n = 41) or percutaneous transhepatic biliary drainage (PTBD) (n = 90). The gastrectomy type was classified as subtotal gastrectomy with Billroth I (18.3%), Billroth II (45.0%), and total gastrectomy with Roux-en-Y (36.6%). During a median follow-up period of 31.5 (range, 6-105) months, choledocholithiasis recurrence was noted in 19 of 131 patients (14.5%). In subgroup analysis, the ERCP group (24.4%) had higher choledocholithiasis recurrence than the PTBD group (10.0%). Stone removal modality (ERCP), no use of balloon sphincteroplasty, and the presence of periampullary diverticulum were significant risk factors for recurrent choledocholithiasis. In multivariate analysis, ERCP (hazard ratio (HR), 3.597; 95% confidence interval (CI): 1.264-10.204) CBD stricture (HR, 3.823; 95% CI: 1.118-13.080) and no use of balloon sphincteroplasty (HR, 4.830; 95% CI: 1.669-13.889) were risk factors for recurrent choledocholithiasis following stone removal. The incidence of CBD stones in patients who underwent gastrectomy is similar to that of the general population. ERCP, CBD stricture, and no use of balloon sphincteroplasty are potential risk factors for recurrent CBD stones following gastrectomy. When we consider PTBD disadvantages, the ERCP procedure with active use of balloon sphincteroplasty is recommended to decrease recurrent CBD stones.

Role of Biliary Stent in Recurrence of Biliary Stones and Complications After Stone Clearance in Patients Awaiting Cholecystectomy: A Randomized Trial.

The role of prophylactic biliary stenting after clearance of choledocholithiasis in patients awaiting cholecystectomy for concomitant cholelithiasis is controversial. We planned a randomized controlled trial to study the effect of prophylactic biliary stenting after achieving biliary clearance in reducing recurrence of choledocholithiasis and biliary complications in patients awaiting cholecystectomy. Patients with concomitant cholelithiasis and choledocholithiasis were included, and those who had evidence of clearance of choledocholithaisis (documented on occlusion cholangiogram during endoscopic retrograde cholangiography [ERC]) were randomized to prophylactic biliary stenting or no stenting. Choledocholithaisis recurrence rate (primary outcome), biliary complications and need for repeat/emergency ERC (secondary outcomes) were compared till 3 months after clearance. Between September 2021 and July 2022, 70 patients were randomized into group A, stenting (n = 35), and group B, no stenting (n = 35). Sixty-six patients were included in the final analysis. Baseline characteristics were comparable between the 2 groups. Ten (15.2%) patients had recurrence of choledocholithiasis, and it was comparable between the 2 groups (7/34 [20.6%] and 3/34 [9.4%], P = 0.306). Five patients (2 cholecystitis and 3 post-ERC pancreatitis) from the stent group while none from the no stent group developed complications, and this difference was statistically significant ( P = 0.024). None of the patients in both the groups needed emergency ERC during the follow-up. This randomized trial shows a higher complication rate with prophylactic stenting, while there is no benefit in preventing choledocholithiasis recurrence in patients waiting for cholecystectomy after biliary clearance (CTRI registration number: CTRI/2021/09/036538).

Utility of the "BATS" Score in Predicting Choledocholithiasis in Patients With Gall Bladder Stones.

Background and aim The role of expensive, risky, and unnecessaryendoscopic interventions can be avoided by the use of non-invasive tests to predict common bile duct (CBD) stones. Therefore, our aim was to identify non-invasive predictors of choledocholithiasis (CL) in patients and further to predict a model and assess its diagnostic accuracy in predicting CL. Methods This cross-sectional study was carried out from June 1, 2020, to December 31, 2021. Patients having gall bladder stones on percutaneous transabdominal sonography and fulfilling intermediate probability criteria of CL were enrolled. These patients then underwent radial endoscopic ultrasound (EUS) followed by endoscopic retrograde cholangiopancreatography (ERCP) for detecting CBD stones. Univariate logistic regression analysis, followed by multivariate logistic regression analysis, was performed to ascertain the independent predictors of CBD stone in patients with intermediate probability. A model was proposed, and the diagnostic accuracy was calculated at an optimal cutoff. The model was then internally validated in the patients with intermediate probability and was also compared with the pre-existing score. Results Out of 131 patients included in the study, CBD stone was noted in 85 (66%) and 88 (67.2%) patients on EUS and ERCP, respectively. On multivariate analysis, high serum bilirubin (>2 mg/dL) and alkaline phosphatase (200 IU) and dilated CBD (>6 mm) on transabdominal sonography at baseline were significant predictors of CBD stone in these patients. Using these variables, a scoring system (BATS score) was developed, which had an area under the receiver operating curve (AUROC) of 0.98 in predicting the presence of CBD stone with a sensitivity of 93.18%, a specificity of 76.74%, and a diagnostic accuracy of 87.79%. In the validation cohort, a BATS score of ≥5 had a diagnostic accuracy of 95.91% in predicting CL. Conclusion TheBATS scoreshowed excellent sensitivity and good diagnostic accuracy in predicting the CBD stonewith excellent results on internal validation. However, external validation of our results is required to recommend this model on a larger scale.

TAVAC: choledochoscopy disposable scopes, and the single-stage vs. two-stage approach to choledocholithiasis.

Previous studies have been published evaluating the benefits and drawbacks of clearing the common bile duct of stones using a single-stage approach (LCBDE + LC) versus a two-stage approach (ERCP followed by LC). These studies have demonstrated that a single-stage approach offers similar outcomes and morbidities as a two-stage approach, with the added benefit of a lower cost and shorter length of stays. However,it is significant we understand why LCBDE is not commonly performed currently and also the lapse in surgical trainee exposure and competence in LCBDE. This paper aims to address the lapse in surgical trainee exposure to LCBDE,evaluate the scopes currently available to perform LCBDE, and review current data evaluating the risks and benefits of single-stage versus two-stage approaches to. We utilized PubMed to analyze all publications related to the various disposable scopes utilized to perform choledochoscopy. We also discuss the need for disposable scopes and how this new market niche is transforming the choledochoscopy space. We analyzed the data related to single-stage and two-stage approach to choledocholithiasis. We noted an overall shorter length of stay and also decreased costs in favor of a single-stage approach. A single-stage LCBDE is the most cost-effective treatment option for choledocholithiasis in patients with choledocholithiasis undergoing a cholecystectomy. In addition, single-stage approach is associated with shorter length of stay.Knowledge of the available choledochoscopes and tools available to surgeons to perform choledochoscopy is significant.The evidence does support the use of disposable choledochoscope from a cost and cross-contamination perspective.Additionally, efforts should be made to incorporate LCBDE into the teaching paradigm of surgical training programs.

Choledocholithiasis Can Present with Marked Transaminases Elevation: Systematic Review and Meta-Analysis.

Extreme transaminase elevation > 1000 international units per liter (IU/L) is typically caused by hepatocellular injury due to ischemia, drugs, or viral infection. Acute choledocholithiasis can also present with marked transaminase elevation mimicking severe hepatocellular injury, contrary to the presumed cholestatic pattern. We searched PubMed/Medline, EMBASE, Cochrane Library, and Google Scholar for studies reporting the proportion of marked elevation of alanine aminotransferase (ALT) or aspartate aminotransferase (AST) > 1000IU/L in patients with common bile duct (CBD) stones. A proportion meta-analysis with a corresponding 95% confidence interval (CI) was used to pool the proportion of patients with extreme transaminase elevation. I2 was used to examine heterogeneity. We used CMA software utilizing a random effect model for statistical analysis. Three studies (n = 1328 patients) were included in our analysis. The reported frequency of ALT or AST > 1000IU/L in choledocholithiasis patients ranged between 6 and 9.6%, with pooled frequency of 7.8% (95% CI 5.5-10.8%, I2 61%). The frequency of patients with ALT or AST > 500IU/L was higher, ranging between 28 and 47%, with pooled frequency of 33.1% (95% CI 25.3-42%, I2 88%). This is the first meta-analysis to study prevalence of severe hepatocellular injury in patients with CBD stones. Results revealed that approximately one-third of patients with choledocholithiasis present with ALT or AST > 500IU/L. Furthermore, levels > 1000IU/L are not uncommon. An elaborate work-up for alternative etiologies of severe transaminase elevation is likely unwarranted in cases with clear evidence of choledocholithiasis.

Diagnostic performance of laparoscopic transcystic common bile duct exploration for the detection of choledocholithiasis in patients with negative MRCP.

There is little research to evaluate laparoscopic transcystic common bile duct (CBD) exploration (LTCBDE) as a diagnostic test to identify choledocholithiasis undergoing laparoscopic cholecystectomy (LC). This study aimed to assess the technical success and safety of LTCBDE in patients with suspected choledocholithiasis but negative magnetic resonance cholangiopancreatography (MRCP) undergoing LC. We did an ambispective cohort study in patients with gallstones and suspected CBD stones but negative MRCP undergoing LC. The primary outcomes were the rate of complications in the hospital. Between January 2010 and December 2018, 620 patients (median age, 58years; 58.4% female) were eligible for the study. The success rate of LTCBDE was 91.8% and CBD stones were observed in 53.3% with a stone clearance rate of 99.3%. The overall postoperative complication rate was 0.65% and no death was recorded in the total cohort. Notably, the morbidity in LTCBDE is 0.53%. Retained CBD stones were diagnosed in 2 patients and managed by ERCP successfully. In the LTCBDE cohort, the median duration of operation was 78 (60-100) min and the median postoperative hospital stay was 1 (1-2) days. Overall, at a mean follow-up of 4.1 (2.3-6.1) years, recurrent CBD stones occurred in 1.1% and all-cause mortality in 0.6%. LTCBDE should be considered the favored choice in the diagnostic algorithm for patients with suspected choledocholithiasis but negative MRCP undergoing LC.