Clearance Of Bile Duct Stones Research Articles

Routine single-incision laparoscopic common bile duct exploration with concomitant cholecystectomy for elderly patients: a 6-year retrospective comparative study.

While single-incision laparoscopic cholecystectomy (SILC) has gained more popularity in recent years, its application to elderly patients needs further evaluation. Few SILC studies regarded this rapidly growing vulnerable population, and single-incision laparoscopic common bile duct exploration (SILCBDE) was never mentioned. We conducted an observational study of 146 routine SILCBDE to address this issue. One hundred forty-six consecutive patients underwent SILCBDE with concomitant cholecystectomies during a period of 6 years (July 2012-June 2016 and July 2018-July 2020). Forty patients with an age of 65years or older were the study target. Characteristics and operative outcomes were compared with the remaining 106 younger patients by retrospective chart review. The primary outcomes include complications and mortality, while the secondary outcomes contain intraoperative blood loss, operative time, procedural conversions, postoperative length of hospital stay, and bile duct stone recurrence. There was no mortality. The bile duct stone clearance rate was 98.6%. The elderly group had higher American Society of Anesthesiologists (ASA) scores, higher comorbidity rate, higher acute cholangitis rate, lower completion intraoperative cholangiography (IOC) rate, longer operative time, more blood loss, longer postoperative hospital stay (p < .001), longer total hospital stay (p < .001), higher procedural conversion rate (p < .05), higher complication rate (p < .001), and the exclusive open conversion (2.5%). The difference in complications derived from Clavien-Dindo grade I. Routine SILCBDE with concomitant cholecystectomy by experienced surgeons is safe and efficacious for elderly patients as for younger patients. Randomized controlled trials are anticipated.

Comparison of radiation exposure and fluoroscopy time between minimally invasive common bile duct exploration and endoscopic retrograde cholangiopancreatography for choledocholithiasis

BackgroundRadiation exposure (RE) causes dose-dependent deleterious effects, and efforts should be made to decrease patient exposure to ionizing radiation. Patients with choledocholithiasis are commonly exposed to ionizing radiation as fluoroscopy-guided interventions including minimally invasive common bile duct (CBD) exploration (MICBDE) and endoscopic retrograde cholangiopancreatography (ERCP) are the preferred treatment modalities for CBD stone clearance. However, RE and fluoroscopy times (FTs) have not been compared between these 2 treatment modalities. Thus, this study aimed to compare FT and RE between MICBDE and ERCP in patients with choledocholithiasis. MethodsThis is a retrospective analysis of a prospectively maintained database of a single surgeon performing MICBDE at an academic referral center between May 2021 and June 2023 compared with a retrospective analysis of all ERCPs performed between January 2020 and February 2021. Patient demographics, procedural details, fluoroscopic details, and postoperative outcomes were compared between the MICBDE and ERCP. The study was conducted as a single institution academic referral center located in the American Southwest. A total of 109 patients with choledocholithiasis were divided into 2 groups. A total of 53 (48.62%) patients underwent ERCP, and 56 (51.38%) patients underwent MICBDE. Inclusion criterion was all patients presenting with choledocholithiasis and subsequently undergoing ERCP or MICBDE. Patients who underwent ERCP for non–choledocholithiasis-related reasons were excluded. Primary outcomes include FT measured in minutes and RE measured in milligray (mGy). Secondary outcomes were successful clearance of the CBD, complications, procedural time, and reinterventions. ResultsA significant difference (P < .001) between FTs was identified between ERCP (3.1 min) and MICBDE (1.54 min). Median RE doses between the ERCP group (38 mGy) and the MICBDE group (38.41 mGy) were not statistically different (P = .88). Technical success of CBD clearance was similar in both groups (91% in the MICBDE group vs 93% in ERCP group; P = .711). ConclusionAdvantages of MICBDE over ERCP include the treatment of choledocholithiasis at the time of cholecystectomy, which reduces the risk of additional anesthesia episodes and introduces the potential for shorter hospital length of stay. This study showed that MICDBE had lower FT than had ERCP, and comparable RE. Given the advantages of MICBDE, it should be strongly considered at the time of laparoscopic cholecystectomy.

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;

Intraoperative transcystic laparoscopic common bile duct stone clearance with SpyGlass™ discover during emergency and elective cholecystectomy: a single-center case series

Background and study aimThe development of a new cholangioscope, the SpyGlass™ Discover (Boston Scientific), has allowed the laparoscopic transcystic common bile duct exploration and stone clearance. The possibility of simultaneous treatment of choledocholithiasis during early laparoscopic cholecystectomy offers the opportunity to enormously reduce the time between acute cholecystitis diagnosis and the execution of cholecystectomy with better outcomes for patients. Furthermore, an altered anatomy of the gastrointestinal tract is not an obstacle to this technique. The aim of the study was to determine whether this new procedure is feasible, safe, and effective.Patients and methodsThe investigation employs a retrospective case series study including all consecutive patients with a diagnosis of common bile duct stones undergoing cholecystectomy and intraoperative laparoscopic common bile duct clearance using SpyGlass™ Discover at IRCCS Policlinico San Matteo in Pavia (Italy). Eighteen patients were included from May 2022 to May 2023.ResultsA complete clearance of the common bile duct was obtained in 88.9% of patients. The mean postoperative length of stay was 3 days. No major complications occurred. After a median follow-up of 8 months, no recurrence of biliary events or readmissions occurred.ConclusionThis procedure has proven to be feasible, safe, and effective.

CONVERSION TO OPEN CHOLECYSTECTOMY - A SAFE ALTERNATIVE, NOT A FAILURE!

Background: Understanding factors that predict conversion in laparoscopic cholecystectomy (LC) to an open procedure is important as it allows better patient selection, preparation, operating list planning, referral, counseling and lowers the threshold for a safe conversion, thereby minimizing undue prolongation of attempts at laparoscopic completion and inadvertent complications.Methods: Records of 1010 consecutive patients who were taken up for LC, at a tertiary care teaching institute in northern India, were reviewed retrospectively. Preoperative and intraoperative characteristics of patients who underwent a successful LC were compared with those who required conversion to open surgery.Results: The conversion rate was 7.5% (76 patients). The most common reason for conversion was the inability to define the ‘Critical view of safety’ in 48, (63%) of patients. Other reasons included dense peri-cholecystic 9 (12%) and intra-abdominal 8 (11%) adhesions, suspicion of bile duct injury 4 (5%) or malignancy 3 (4%). Prior upper abdominal surgery, intraoperative finding of a contracted and thick-walled gallbladder (GB), empyema GB, Mirizzi’s syndrome, cholecysto-enteric fistula, and a prior endoscopic common bile duct stone clearance were significant predictors of conversion. Xanthogranulomatous cholecystitis was found more commonly (43% vs 5%) in the conversion group.Conclusion: Conversion to an open procedure during LC should always be treated as an integral component of sound judgement to achieve the safest outcome in a particular patient. Due consideration of pre-operative and intra-operative factors predictive of a higher chance of conversion assists pre-operative patient preparation and counseling as well as surgical planning, conduct and mentoring of residents-in-training.

Prospective study on planned biliary stent placement to treat small common bile duct stones.

Small common bile duct stones are known to occasionally clear spontaneously. This study aimed to prospectively assess the role of biliary stent placement in promoting the spontaneous clearance of small common bile duct stones. We analyzed patients presenting with common bile duct stones of ≤5 mm diameter between June 2020 and May 2022. The exclusion criteria included asymptomatic patients, biliary pancreatitis, altered gastrointestinal anatomy, bile duct strictures (malignant or benign), and a history of EST. The biliary stents were inserted without stone removal. Stone clearance was assessed using endoscopic ultrasonography or endoscopic retrograde cholangiopancreatography after 3 months. Our primary endpoint was the clearance rate of common bile duct stones over 6 months, targeting a lower limit for the 95% confidence interval (CI) exceeding 25%. Of the 32 enrolled patients, 18 (56.3%; 95% CI: 37.7-73.6%) exhibited stone clearance. Early complications occurred in 11 patients (34.4%), totaling 12 incidents: acute cholecystitis in four, acute pancreatitis in three, biliary pain in three, and cholangitis in two patients. No severe complications occurred. Six (18.8%) patients experienced asymptomatic stent migration. Following stone clearance, four (12.5%) patients experienced stone recurrence, with an average duration of 256 ± 164 days. Biliary stenting appeared to effectively promote the clearance of small common bile duct stones in approximately half of the patients. However, the potential complications and risks of stone recurrence warrant close monitoring.This trial was registered in the Japan Registry of Clinical Trials (jRCT1042200020).

Obesity and Risk for Incomplete Stone Clearance in Patients with Bile Duct Stones Undergoing ERCP.

Obesity degrades fluoroscopic image quality and could impact on the endoscopic retrograde cholangiopancreatography (ERCP) outcomes. Our study aimed to compare the clinical outcomes and adverse events (AEs) between obese and non-obese patients undergoing ERCP for biliary stone-related conditions. Patients who underwent ERCP for biliary-stone related conditions were included. The analyzed outcomes included the rates of successful bile duct cannulation, incomplete bile duct stone clearance, recurrent bile duct stones, and AEs. A total of 229 patients (116 obese patients and 113 non-obese patients) were included. All patients had successful bile duct cannulation. The rates of incomplete bile duct stone clearance (11.3% vs. 9.0%, P = 0.51), recurrent bile duct stones (1.9% vs. 4.2%, P = 0.24), and AEs (1.8% vs. 0.7%, P = 0.43) were not significantly different between the two groups, respectively. Our study demonstrates no associations between obesity and the rates of incomplete stone clearance, recurrent stones, successful cannulation, or AEs in patients undergoing ERCP for biliary stone-related disease.

Orlando Protocol for single session ductal clearance of common bile duct stones at endosopic retrograde cholangiopancreatography.

Approach to management of common bile duct stones (CBDS) by endoscopic retrograde cholangiopancreatography (ERCP) is not standardized. We examined outcomes by applying predetermined protocol for CBDS management. When standard extraction techniques failed at ERCP, presence of tapered bile duct and stone-duct ratio were calculated. Large balloon sphincteroplasty (LBS) and/or mechanical/single-operator cholangioscopy-guided lithotripsy was performed based on presence of tapered bile duct and stone-duct mismatch. Primary outcome was single-session ductal clearance. Secondary outcome was adverse events. Of 409 patients treated over 16 months, 321 (78.5%) had no tapered bile duct or stone-duct mismatch, and single-session ductal clearance was achieved using standard techniques in 99.7% over median duration of 14 min (interquartile range [IQR] 9-21 min). Of 88 (21.5%) patients with difficult CBDS, tapered duct was seen in 79 (89.8%) and/or stone-duct mismatch in 36 (40.9%). Single-session ductal clearance was achieved in all 88 patients (100%) by LBS in 79 (89.8%), mechanical lithotripsy in 20 (22.7%), and single-operator cholangioscopy-guided lithotripsy in 16 (18.2%) over a median duration of 29 min (IQR 17-47 min). Overall, single-session ductal clearance was achieved in 99.8% with adverse events in 17 (4.2%) that included perforation in two, postsphincterotomy bleeding in one, and mild/moderate post-ERCP pancreatitis in 14 patients. A predetermined protocol optimized outcomes by enabling single-session ductal clearance of CBDS with high technical success and low adverse events.

Single Anesthesia ERCP and Laparoscopic Cholecystectomy for Management of Common Bile Duct Stones

Abstract Management of choledocho-cholelithiasis requires a multi-disciplinary approach. It involves clearance of common bile duct stones (CBDS) on the one hand and addressing gallstone disease (GSD) on the other hand. With technological advancements and growing expertise in the fields of endoscopy and laparoscopy, endoscopic retrograde (or radiological) cholangiopancreatography (ERCP) and laparoscopy cholecystectomy (LC) have become modalities of choice for CBDS and GSD, respectively. Conventionally, in patients with choledocho-cholelithiasis, ERCP is performed first followed by LC after an interval of 4–6 weeks. This approach requires two separate admissions involving anesthesia twice, thus increasing the risk related to multiple general anesthesia, higher cost of care, and greater loss of man hours. These issues can be mitigated by the novel approach of single anesthesia ERCP and laparoscopic cholecystectomy (SERLAC). At our center, we follow both approaches, depending on the availability of resources and patient characteristics. Aim: This study aims to evaluate the safety of SERLAC. Materials and Methods: In this retrospective, descriptive study, we analyzed data of patients undergoing SERLAC for outcome, complications, benefits, and constraints. Results: Of the 36 patients who underwent ERCP before LC for choledocho-cholelithiasis, 10 opted for SERLAC. Despite relatively prolonged anesthesia time (mean 85.3 min), owing to both ERCP and LC being performed in the same sitting, no anesthesia-related adverse event was noted. SERLAC was preferred in two cases to avoid exposure to second general anesthesia due to comorbidities such as old age with polytrauma and use of oral anticoagulant related to a prosthetic cardiac valve. Hospital stay was significantly lower (mean 4.3 days) in patients opting for SERLAC and it provided a definite cure for 8 out of 10 patients. The major constraint noted was logistical, in terms of ensuring the availability of the operating room (OR) and teams for both procedures besides setting up the ERCP and laparoscopy workstations in the same OR in quick succession. Our study shows that SERLAC is a safe approach and further studies are required to build consensus. Conclusion: This study has proven that SERLAC is safe and comparable to interval ERCP and LC. It offers a definite cure with a single admission, single anaesthesia, and significantly shorter hospital stay and thus results in much greater patient satisfaction in expert hands.

Endoscopic clearance of non-complex biliary stones using fluoroscopy-free direct solitary cholangioscopy: Initial multicenter experience.

Fluoroscopy-free endoscopic retrograde cholangiopancreatography for common bile duct stone (CBDS) clearance is usually offered only to pregnant patients. We initiated a multicenter, randomized controlled trial comparing clearance of non-complex CBDSs using fluoroscopy-free direct solitary cholangioscopy (DSC) to standard endoscopic retrograde cholangiography (ERC) to evaluate the wider applicability of the DSC-based approach. Here we report the initial results of stone clearance and safety in roll-in cases for the randomized controlled trial. Twelve expert endoscopists at tertiary care centers in four countries prospectively enrolled 47 patients with non-complex CBDSs for DSC-assisted CBDS removal in an index procedure including fluoroscopy-free cannulation. Successful CBDS clearance was first determined by DSC and subsequently validated by final occlusion cholangiogram as the ERC gold standard. Fully fluoroscopy-free cannulation was successful in 42/47 (89.4%) patients. Brief fluoroscopy with minimal contrast injection was used in 4/47 (8.5%) patients during cannulation. Cannulation failed in 1/47 (2.1%) patients. Fluoroscopy-free complete stone clearance was reached in 38/46 (82.6%) cases. Residual stones were detected in the validation ERC occlusion cholangiogram in three cases. Overall serious adverse event rate was 2.1% (95% confidence interval 0.1-11.3): postprocedural pancreatitis in one patient. In patients with non-complex CBDS, the fluoroscopy-free technique is easily transferred to endoscopic retrograde cholangiopancreatography experts with acceptable rates of cannulation and stone clearance and few serious adverse events. (ClinicalTrials.gov number, NCT03421340).

Is early laparoscopic cholecystectomy after clearance of common bile duct stones by endoscopic retrograde cholangiopancreatography superior?: A systematic review and meta-analysis of randomized controlled trials.

With medical advancement, common bile duct stones were treated by endoscopic retrograde cholangiopancreatography (ERCP), considered the standard treatment. However, ERCP might induce complications including pancreatitis and cholecystitis that could affect a subsequent laparoscopic cholecystectomy (LC), leading to conversion to open cholecystectomy perioperative complications. It is not yet known whether or not the time interval between ERCP and LC plays a role in increasing conversion rate and complications. Bides, in the traditional sense, after ERCP, for avoiding edema performing LC was several weeks later. Even no one study could definite whether early laparoscopic cholecystectomy after ERCP affected the prognosis or not clearly. Comparing some different surgical timings of LC after ERCP. Searching databases consist of all kinds of searching tools, such as Medline, Cochrane Library, Embase, PubMed, etc. All the included studies should meet the demands of this meta-analysis. In all interest outcomes below, we took full advantage of RevMan5 and WinBUGS to assess; the main measure was odds ratio (OR) with 95% confidence. Moreover, considering the inconsistency of the specific time points in different studies, we set a subgroup to analyze the timing of LC after ERCP. For this part, Bayesian network meta-analysis was done with WinBUGS. In the pool of conversion rate, the result suggested that the early LC group was equal compared with late LC (OR = 0.68, I2 = 0%, P = .23). Besides, regarding morbidity, there was no significant difference between the 2 groups (OR = 0.74, I2 = 0%, P = .26). However, early LC, especially for laparoscopic-endoscopic rendezvous that belonged to performing LC within 24 hours could reduce the post-ERCP pancreatitis (OR = 0.16, I2 = 29%, P = .0003). Considering early LC included a wide time and was not precise enough, we set a subgroup by Bayesian network, and the result suggested that performing LC during 24 to 72 hours was the lowest conversion rate (rank 1: 0%). In the present study, LC within 24 to 72 hours conferred advantages in terms of the conversion rate, with no recurrence of acute cholecystitis episodes.

Prophylactic cholecystectomy offers best outcomes following ERCP clearance of common bile duct stones: a meta-analysis

BackgroundSymptomatic calculus biliary disease is common with associated morbidity and occasional mortality, further confounded when there is concomitant common bile duct (CBD) stones. Choledocholithiasis and clearance of the duct reduces recurrent cholangitis, but the question is whether after clearance of the CBD if there is a need to perform a cholecystectomy. This meta-analysis evaluated outcomes in patients undergoing ERCP with or without sphincterotomy to determine if cholecystectomy post-ERCP clearance offers optimal outcomes over a wait-and-see approach.MethodsA Prospero registered meta-analysis of the literature using PRISMA guidelines incorporating articles related to ERCP, choledocholithiasis, cholangitis and cholecystectomy was undertaken for papers published between 1st January 1991 and 31st May 2021. Existing research that demonstrates outcomes of ERCP with no cholecystectomy versus ERCP and cholecystectomy was reviewed to determine the related key events, complications and mortality of leaving the gallbladder in situ and removing it. Odds ratios (OR) were calculated using Review Manager Version 5.4 and meta-analyses performed using OR using fixed-effect (or random-effect) models, depending on the heterogeneity of studies.Results13 studies (n = 2598), published between 2002 and 2019, were included in this meta-analysis, 6 retrospective, 2 propensity score-matched retrospective studies, 3 prospective studies and 2 randomised control trials from a total of 11 countries. There were 1433 in the no cholecystectomy cohort (55.2%) and 1165 in the prophylactic cholecystectomy (44.8%) cohort. Cholecystectomy resulted in a decreased risk of cholecystitis (OR = 0.15; CI 0.07–0.36; p < 0.0001), cholangitis (OR = 0.51; CI 0.26–1.00; p = 0.05) and mortality (OR = 0.38; CI 0.16–0.9; p = 0.03). In addition, prophylactic cholecystectomy resulted in a significant reduction in biliary events, biliary pain and pancreatitis.ConclusionsIn patients undergoing CBD clearance, consideration should be given to performing prophylactic cholecystectomy to optimise outcomes.

The role of cholecystectomy following endoscopic sphincterotomy and bile duct stone removal.

Choledocholithiasis is common, with patients usually treated with endoscopic retrograde cholangiopancreatography (ERCP) and subsequent cholecystectomy to remove the presumed source of common bile duct (CBD) stones. However, previous investigations into the management of patients following ERCP have focused on recurrent CBD stones, negating the risks of cholecystectomy. This article appraises the role of cholecystectomy following successful endoscopic clearance of bile duct stones. Patients undergoing ERCP and CBD clearance for choledocholithiasis at St James's University Hospital January 2015-December 2018 were included. Patients were divided into those who received cholecystectomy and those managed non-operatively. Readmissions, operative morbidity, mortality and treatment costs were investigated. Eight hundred and forty-four patients received ERCP and CBD clearance with 3.9 years follow-up. Two hundred and nine patients underwent cholecystectomy with 15% requiring complex surgery. Three hundred and seventy-three patients were non-operatively managed. Unplanned readmissions occurred in 15% following ERCP, mostly within two years. There was no difference in readmissions between the two groups. Accounting for the entire patient pathway, non-operative management was less expensive. The majority of patients do not require readmission following ERCP for CBD stones, and cholecystectomy did not reduce the risk of readmission. Few patients have recurrent CBD stones, but complex biliary surgery is frequently required. Routine cholecystectomy following ERCP needs to be re-evaluated and a more stratified approach to future risk developed.

TH4.10 Prophylactic cholecystectomy offers best outcomes following ERCP Clearance of Common Bile Duct stones

Abstract Aims Clearance of choledocholithiasis reduces recurrent cholangitis, but following clearance of the CBD, cholecystectomy is required. This meta-analysis evaluated outcomes in patients undergoing ERCP with or without sphincterotomy to determine if cholecystectomy post ERCP clearance offers more favourable outcomes than a wait-and-see approach. Methods A Prospero-registered meta-analysis of the literature using PRISMA guidelines incorporating articles relating to ERCP, choledocholithiasis, cholangitis and cholecystectomy was undertaken for papers published between 1st January 1991 and 31st May 2021. Existing research demonstrating outcomes of ERCP with no cholecystectomy versus ERCP and cholecystectomy was reviewed to determine key events, complications, and mortality. Odds Ratios (OR) were calculated using Review Manager Version 5.4 and meta-analyses using OR with either fixed- or random-effect models, depending on heterogeneity of studies. Results 13 studies (n=2,598), published between 2002 and 2019 were included in this meta-analysis: six retrospective studies, two retrospective propensity score matched studies, three prospective studies and two randomised control trials from a total of 11 countries. There were 1,433 in the no cholecystectomy cohort (55.2%) and 1,165 in the prophylactic cholecystectomy cohort (44.8%). Cholecystectomy resulted in a decreased risk of cholecystitis (OR= 0.15; CI, 0.07–0.36; p&amp;lt;0.0001), cholangitis (OR= 0.51; CI; 0.26–1.00; p=0.05) and mortality (OR= 0.38; CI; 0.16–0.9; p=0.03). In addition, prophylactic cholecystectomy resulted in a significant reduction in biliary events, biliary pain and pancreatitis. Conclusions In patients undergoing CBD clearance consideration should be given to performing prophylactic cholecystectomy to optimise outcomes.

Outcome of Digital Cholangioscopy and Laser Lithotripsy for Impacted Biliary Stones

Abstract Background and Aims Impacted stones in the bile duct are difficult to extract, and are predictor of failure of conventional endoscopic retrograde cholangiopancreatography techniques including mechanical lithotripsy and large balloon dilatation. Intracorporeal lithotripsy may be an effective technique for these stones. The aim of this study is to report the efficacy and safety of intracorporeal laser lithotripsy for impacted stones in the bile duct. Method This study is retrospective analysis of prospectively collected data. Patients with impacted stones in the bile duct underwent cholangioscopy with spyglass DS system and laser lithotripsy. Outcome measures were proportion of patients with complete clearance of bile duct after the first session, number of sessions required for complete clearance, and the complications. Results Forty-three patients (27 female) with mean age of 56.12 ± 15.16 years underwent digital cholangioscopy and laser lithotripsy. Mean bilirubin value was 1.8 ± 1.6 mg/dL, 20 (46.51%) patients had single stone, 35(81.39%) patients had only bile duct stones, and 8(18.61%) patients had additional stones in cystic duct or intrahepatic biliary radical. Mean size of largest stone was 16.2 ± 4.4mm. Average duration of the procedure was 69.11 ± 28.12minutes, and complete clearance was achieved in 41/43 (95.34%) patients after the first session. Mean number of sessions required for complete clearance was 1.02 ± .26. Postprocedure cholangitis occurred in one patient. Conclusion Intracorporeal laser lithotripsy is an effective and safe modality for the clearance of impacted bile duct stones.

Cholecystectomy after endoscopic sphincterotomy in elderly: A dilemma

Background/Aim: Although cholecystectomy is recommended by many guidelines after endoscopic retrograde cholangiopancreatography (ERCP) for gallstones, the necessity of cholecystectomy in geriatric patients is a matter of debate. Here we compare the outcomes of new biliary events in cholecystectomized and non-cholecystectomized patients of geriatric age after ERCP for suspected choledocholithiasis.&#x0D; Methods: Non-cholecystectomized patients who underwent ERCP for choledocholithiasis from 2015 to 2017 were included in this retrospective cohort study. Patients with other biliary pathologies, incomplete clearance of common bile duct stones, and those who could not be reached at follow-up were excluded from the study. Biliary events (cholecystitis, cholangitis, pancreatitis, re-ERCP) were evaluated by considering age groups in patients with and without cholecystectomy in their follow-up after sphincterotomy.&#x0D; Results: A total of 284 patients were followed for an average of 69.77 (0.2) months. The cumulative incidence of biliary events in cholecystectomized patients was lower (16% vs. 21.5%; P &lt; 0.001), and cholecystectomized patients had a longer time to the occurrence of events (mean 74.49 [0.27] months vs. 73.50 [0.33] months; P = 0.03). There was no significant difference in the frequency of biliary events between elderly patients with and without cholecystectomy (P = 0.81), and the cumulative incidence of biliary events in the in situ group was significantly lower than that in the geriatric group (17.5% vs 32.6%; P = 0.03)&#x0D; Conclusion: Although cholecystectomy significantly reduces subsequent biliary complications in young patients, it does not provide a statistically significant benefit in geriatric patients. We believe that there may be no need for routine prophylactic cholecystectomy after endoscopic sphincterotomy in geriatric patients.

Predictors for stone recurrence after a successful common bile duct surgical exploration for choledocholithiasis.

Recurrence after common bile duct stone (CBDS) clearance is the major long-term drawback of their management. Its prevalence is significant, and it occurs after all primary therapeutic alternatives. The aim of this study was to determine the predictive factors associated with stone recurrence after surgical common bile duct exploration (CBDE). A retrospective cohort study based on patients undergoing CBDE between 2000 and 2018 was conducted. Uni- and multivariate hierarchical regression analyses were performed to assess the independent predictive factors associated with recurrent CBDS in patients with initially successful surgery. A total of 365 patients underwent successful surgical procedures. After a median follow-up of 43.2 (IQR 84) months, 31 (8.4%) patients were diagnosed with CBD stone recurrence. The median time to recurrence was 30.3 (IQR 38) months. The only variable associated with CBDS recurrence was preoperative endoscopic sphincterotomy (HR 2.436, 95% CI: 1.031-5.751, P = 0.042)). Patients who undergo preoperative endoscopic sphincterotomy and then cholecystectomy with successful common bile duct clearance may be at increased risk for recurrent stone disease compared to those who go straight to surgery.

Complete Endoscopic Clearance of Common Bile Duct Stones

Common bile duct stones (CBDS) are the most common cause of acute cholangitis. Removal by endoscopic retrograde cholangiopancreatography became the standard of care after endoscopic sphincterotomy was introduced. On the other hand, it is still difficult to remove 10-15% of CBDS completely in the first attempt for various reasons. This review describes the methods for the complete endoscopic clearance of CBDS, including difficult cases, reflecting the latest knowledge and techniques.

Comparison of endoscopic papillary large‐balloon dilatation with endoscopic sphincterotomy in clearing large common bile duct stones: A systematic review and meta‐analysis of randomized controlled trials

AbstractThere are three methods to retrieve large common bile duct stones, the first is endoscopic sphincterotomy (EST), the second is endoscopic papillary large‐balloon dilatation (EPLBD), and the third is limited EST plus EPLBD. Although EST is the most popularly used method, it has higher risk of bleeding complication and basket stuck. EPLBD alone without EST demonstrated safe and quick in the clinical practice, but there were only few studies focused on comparing EST or EPLBD alone. Thus, this study aims to compare the efficacy and safety of EPLBD with EST. We searched for PubMed, Embase, and Cochrane Library databases to collect relevant articles until August 31st, 2019. We included randomized controlled trials, common bile duct stones &gt; 10 mm, comparison of endoscopic papillary large‐balloon dilatation with endoscopic sphincterotomy, and patients older than 18. We compare endoscopic papillary large‐balloon dilatation with endoscopic sphincterotomy on the clearance of large common bile duct stones, the adverse events, and the need for mechanical lithotripsy. This systematic review and meta‐analysis was registered on PROSPERO and the registration number is CRD42020150485. Total six studies met inclusion criteria and 762 participants were enrolled. The data revealed that endoscopic papillary large‐balloon dilatation alone was comparable to endoscopic sphincterotomy on the clearance of large common bile duct stones (RR = 1.02, 95% CI: 0.93‐1.12), the adverse events (RR = 1.01, 95% CI: 0.71‐1.43) and the need for mechanical lithotripsy. In the subgroup analysis, the requirement of mechanical lithotripsy decreased in the non‐Chinese group (RR = 0.58, 95% CI: 0.41‐0.84). The efficacy and safety to clean large common bile duct stones are comparable in either EPLBD or EST. In addition, EPLBD alone not only saves the operation time but also reduces the chance of mechanical lithotripsy in the subgroup analysis.

O-EGS05 The Prevalence of Bile Duct Stones in Patients Presenting with Acute Pancreatitis vs. Jaundice in a 5774 patient series. The Case for Single Session Surgical Management

Abstract Background There is increasing evidence that single session laparoscopic cholecystectomy with cholangiography and, when necessary and available, bile duct exploration offers optimal clinical outcomes and superior cost benefits to patients with suspected bile duct stones. There is a perception that preoperative endoscopic clearance of bile duct stones is necessary in patients presenting with pancreatitis and jaundice. However, most patients do not have severe disease and are fit for index admission surgical management. We aim to study the prevalence of bile duct stones in pancreatitis vs. jaundice and evaluate this management approach with regards to preoperative and operative parameters and postoperative outcomes. Methods Analysis of prospectively maintained database of 5774 consecutive laparoscopic cholecystectomies, cholangiography(IOC) with or without bile duct exploration was undertaken. Patients with suspected bile duct stones are referred to one firm with an intention of single surgical treatment in the index admission. Data of patients presenting with acute pancreatitis and obstructive jaundice was extracted. In the absence of suspected malignancy there was a limited role for preoperative MRCP and ERCP. The incidence of confirmed CBD stones requiring exploration, type of exploration, morbidity, re-operations and readmissions, hospital stay, number of episodes, and presentation to resolution intervals were compared in the two groups. Results Conclusions Single session surgical treatment of patients with acute pancreatitis and jaundice by specialist firms in the index admission (89% and 86% if previous admissions by other units is excluded) offers many advantages. MRCP and ERCP utilisation is minimised in favour of IOC; two thirds of pancreatitis patients and one third of jaundiced patients have no CBD stones. Simple transcystic explorations deals with most stones in both groups. The morbidity, open conversion, readmissions, retained stones and re-operations are low. Total hospital stay, number of treatment episodes and presentation to resolution are optimised and should persuade surgeons to avoid subjecting patients to multiple treatments.