Common Bile Duct Clearance Research Articles

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

ImportanceRadiation exposure 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 exploration (MICBDE) and endoscopic retrograde cholangiopancreatography (ERCP) are the preferred treatment modalities for common bile duct (CBD) stone clearance. However, radiation exposure and fluoroscopy times have not been compared between these two treatment modalities. ObjectiveTo compare fluoroscopy time (FT) and radiation exposure (RE) between MICBDE and ERCP in patients with choledocholithiasis. DesignThis 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 to a retrospective analysis of all ERCPs performed between January 2020 and February 2021. Patient demographics, procedural details, fluoroscopic details, and post operative outcomes were compared between the MICBDE and ERCP. SettingSingle institution academic referral center located in the American Southwest. Participants109 patients with choledocholithiasis were divided into 2 groups. 53 patients (48.62%) underwent ERCP, and 56 patients (51.38%) underwent MICBDE. Inclusion criteria were; all patients presenting with choledocholithiasis and subsequently underwent ERCP or MICBDE. Patients who underwent ERCP for non-choledocholithiasis related reasons were excluded. Main outcomes and measuresPrimary outcomes include FT measured in minutes and RE measured in milligray (mGy). Secondary outcomes were successful clearance of the common bile duct, complications, procedural time, and reinterventions. ResultsA significant difference (P<.001) between fluoroscopy times was identified between ERCP (3.1mins) and MICBDE (1.54mins). Median RE doses between the ERCP group (38 mGy) and the MICBDE group (38.41 mGy) were not statistically different (p=0.88). Technical success of CBD clearance was similar in both groups (91% in MICBDE group vs 93% in ERCP group; p=0.711). Conclusion and RelevanceAdvantages of MICBDE over ERCP include; treatment of choledocholithiasis at the time of cholecystectomy, which reduces the risk of additional anesthesia episodes and the introduces the potential for shorter hospital length of stay. This study shows that MICDBE has lower FT compared to ERCP and comparable RE. Given the advantages of MICBDE, it should be strongly considered at the time of laparoscopic cholecystectomy.

Two institutes' experience in laparoendoscopic "rendezvous" technique for patients undergoing laparoscopic cholecystectomy for stones in the gallbladder and bile duct: a prospective randomized comparative clinical trial.

There is stilldisagreement on the best treatment optionfor cholecystocholedocholithiasis.Although there are some benefits to the single-step procedure, the "laparoendoscopic rendezvous" (LERV) technique that include a lower risk of post-ERCP pancreatitis and a shorter hospital stay,the standard technique isstill the two-step approach forclearing the common bile duct (CBD) using ERCP and then performing a laparoscopic cholecystectomy. The purpose of this study was to assess theeffectiveness and safety of the LERV technique vs.the standard two-step approach. Four hundred thirty-six patients with symptomatized concomitant stones at both the gall bladder (GB) and the (CBD), at two gastroenterology centers in Zagazig city, Egypt, from January 2010 till April 2022, were analyzed. Patients were randomly divided into two equally groups. The overall length of hospital stay was the primary outcome, and the success of CBD clearance and morbidity, particularly post-ERCP pancreatitis, were the secondary endpoints. The LERV group experienced a significantly shorter hospital stay (median 2(2-8) days compared to 4.5 (4-11) days for the two-stage approach (p < 0.001)). The two groups did not differ in terms of CBD clearing success. Also, there was no significant difference in the number of patients with post-ERCP pancreatitis between the LERV group [14 patients (6.4%)] and the two-stage approach [26 patients (11.9%)] with p value = 0.703. For patients with cholecystocholedocholithiasis, the optimal treatment must be determined by the knowledge and resources that are accessible locally. Our data further supported the idea that treating patients with cholecystocholedocholithiasis in one stage is a safe and successful strategy.

ThP3.14 - Four-Year Experience of Laparoscopic Transcystic common bile duct exploration at a District Hospital

Abstract Aim This study aims to assess the outcomes of Laparoscopic Common Bile Duct Exploration (LCBDE) as a single-stage procedure for symptomatic choledocholithiasis. Methods In this retrospective analysis we included 87 patients with high suspicion of common bile duct (CBD) stones, imaging proven choledocholithiasis or failed Endoscopic Retrograde cholangiopancreatography (ERCP). These patients underwent either LCBDE or CBD exploration under fluoroscopy between 2019 and 2023. Results Among the 87 patients selected for a single stage procedure, 59 underwent Laparoscopic transcystic CBDE. Successful CBDE was achieved in 40 cases (68%), with four patients after failed ERCP. In one case on table ERCP with rendez-vous technique was used to complete CBD clearance. Two of them needed complementary post operative ERCP to remove impacted stones. Most cases with unsuccessful CBDE, 19 in total (32%), was due to difficult cannulation of a narrow cystic duct. Three were managed with on table ERCP and five had post-operative ERCP. Six patients (7%) experienced unplanned readmissions, three with retained stones post-successful stone clearance and two after clear on table cholangiogram, who were managed with ERCP. Bile leak occurred in two cases and it was self-limited within 14 days. The mean hospital length of stay (LOS) was 5,3 days with a median LOS of 4 days. Conclusion Transcystic LCBDE, when surgical expertise and experience are available, is an effective and safe procedure for treating choledocholithiasis, providing comprehensive CBD clearance while avoiding the risks associated with ERCP.

Is Endoscopic Retrograde Cholangiopancreatography with Balloon Sweeps a Must in Postcholecystectomy Stent Removal for Choledocholithiasis?

Abstract Objectives This study aims to evaluate whether stent removal through endoscopic retrograde cholangiopancreatography (ERCP) with balloon sweeps is necessary or whether stent removal by forward-viewing gastroscope without cholangiogram is sufficient. Materials and Methods A prospective, single-center study was conducted from April 2022 to March 2023 for 1 year. Adult patients with choledocholithiasis who underwent common bile duct (CBD) clearance and CBD stenting followed by cholecystectomy were included. Then, they underwent CBD stent removal either by gastroscope directly or by side-viewing endoscopy with balloon sweeps and occlusion cholangiogram. Recurrence of stones and complications after stent removal were studied in both groups. Results Forty-seven patients were enrolled in the final study. A total of 64% of patients (n = 30) underwent CBD stent removal followed by balloon sweeps and cholangiogram, and the remaining 34% (n = 17) patients underwent direct stent removal. Time taken for the procedure was more in the balloon sweeps group compared with the direct stent removal group and was statistically significant. No statistically significant adverse events were seen in both groups. Conclusion Patients who underwent CBD stenting for choledocholithiasis after cholecystectomy can safely undergo stent removal using a gastroscope rather than be subjected again to ERCP. This will significantly reduce the duration, unplanned adverse events, and cost of ERCP.

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.

Complications of Forgotten or Neglected Biliary Plastic Stents and Their Outcome

Introduction: Before cholecystectomy, endoscopic retrograde cholangiopancreatography (ERCP) with common bile duct (CBD) stent placement is the standard therapy for choledocholithiasis. Prolonged stents in situ may present with various complications, some of which may be life-threatening. Methodology: A study in a tertiary center in South India from January 2018 to July 2023. A total of 624 patients underwent ERCP for biliary stent procedures, out of which 29 had biliary plastic stents in situ for more than 6 months. We retrospectively analyzed these 29 cases for complications and their treatment outcomes. Results: The mean ± standard deviation age was 57.5 ± 16.6 years, male-to-female ratio was 2.2:1, 55.17% had a cholecystectomy (n = 16), the most common indications for CBD stent placement were choledocholithiasis 75.8% (n = 22); the median duration of stent in situ was 7 months interquartile range (6–9). The reasons for delayed CBD stent removal were: 27.6% due to the COVID-19 pandemic (n = 8), 13.8% surgically unfit (n = 4), 6.9% financial constraints (n = 2), 3.4% of patients were unaware of the stent in situ (n = 1), and 48.3% were unknown (n = 14). The complications associated were that 69% had calculi/sludge (n = 20), 24.14% had cholangitis (n = 7), 7% were asymptomatic (n = 2), and 3% had intestinal perforation (n = 1). Conclusion: Early complication identification and treatment lead to successful clinical outcomes. Irrespective of cholecystectomy, a check cholangiogram, and CBD clearance should be done in all cases of biliary stent removal.

Pragmatic algorithm for management of common bile duct calculi in resource-limited settings in India.

Endoscopic retrograde cholangiopancreatography (ERCP) facilitates the removal of common bile duct (CBD) calculi by endoscopy. When ERCP fails, exploration of CBD is required for the clearance of CBD calculi. The optimum way for the exploration of CBD is by choledochoscopy. Dedicated flexible or rigid choledochoscopes are expensive and available only in few places in India. Since 1991, we subjected patients with suspected CBD calculi to ERCP, followed by laparoscopic cholecystectomy (LC). Patients in whom ERCP failed to clear CBD were subjected to open exploration of CBD using any easily available, suitable, straight rigid scope for choledochoscopy. Since March 1991, out of 8866 patients with cholelithiasis, 862 underwent ERCP. Ninety-six patients in whom ERCP failed to clear CBD underwent open exploration of CBD. In each case of exploration of CBD, choledochoscopy was performed using a straight rigid scope, either a cystoscope, paediatric cystoscope, hysteroscope or 5-mm laparoscopy telescope with a 5-mm cannula. The CBD clearance was complete in 95 patients, and one patient had an impacted calculus at the ampulla. CBD explorations were followed by choledochoduodenostomy, T-tube placement or suturing of choledochotomy. No residual calculi were observed after such exploration. From our results, we advocate the following algorithm for CBD calculi in resource-limited settings. Subject patients with CBD calculi to ERCP followed by LC. In case of failed ERCP, open exploration of CBD with choledochoscopy using any suitable rigid scope. Dedicated flexible or rigid choledochoscope is not essential. This approach is cost-effective and successful.

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.

Curative surgical treatment of common bile duct stones: Retrospective cohort study.

In the event of symptomatic common bile duct (CBD) stones with dilated CBD, one possible curative treatment option is stone extraction through choledocotomy associated with cholecystectomy. Endoscopic treatment is only reserved for residual stones at 6weeks. The aim of this study was to evaluate the results from laparoscopic curative surgical treatment of CBD stones with dilated CBD. This is a retrospective single-centered cohort study. All consecutive patients admitted for laparoscopic cholecystectomy with evidence of CBD stones with dilated CBD from January 2010 to December 2020 at our center were included. Success was defined by CBD clearance at 6weeks. Need for additional procedures, such as endoscopic sphincterotomy, immediate, and end-of-procedure morbi-mortality as well as factors associated with procedure failure, were also studied. A total of 246 patients who received curative treatment were included in the study. The success rate for the curative treatment was 93.1% (229 patients). Immediate postoperative morbidity was 24.4% with a 5.3% reintervention rate. Immediate and 6-week postoperative mortality rates were zero and 0.4%, respectively. The mean length of stay was 11.3days. Factors associated with procedure failure appeared to be the occurrence of an early postoperative complication and the need for readmission during the period between surgery and drain removal. This study indicates that laparoscopic curative surgical treatment for symptomatic CBD stones may be performed with acceptable results without routine need for additional procedures.

PREDICTORS OF FAILURE OF ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY IN CLEARING BILE DUCT STONES DURING INDEX PROCEDURE - A PROSPECTIVE STUDY.

Common bile duct (CBD) stones are known to complicate 10-15% of gallstone diseases. Endoscopic retrograde cholangiopancreatography (ERCP) is the therapeutic modality of choice for bile duct clearance in CBD stones but may fail to achieve stone clearance. This prospective study was done to identify the predictors of failure of CBD clearance with ERCP. This prospective study was done to identify the predictors of failure of CBD clearance with ERCP. All consecutive patients with bile duct stones undergoing ERCP at a tertiary care center were prospectively included from October 2020 to October 2021. The study's primary outcome was to identify and analyze factors that could predict the failure of complete CBD clearance. A total of 120 patients (50.8% males, median age: 53.5 years) were included in the final analysis. Successful clearance of CBD stones during the index procedure was achieved in 70% of patients. At a cut-off stone diameter of >10.5 mm and CBD diameter of >12.5 mm, the AUC was 0.890 and 0.884, respectively, to predict failed clearance of CBD. On multivariate analysis, stone diameter ≥15 mm [odds ratio (OR) 16.97, 95% confidence interval (CI): 1.629-176.785], location of stones in hepatic ducts (OR 7.74, 95%CI: 2.041-29.332), presence of stricture distal to stone (OR 6.99, 95%CI: 1.402-34.726) and impacted stone (OR 21.61, 95%CI: 1.84-253.058) were independent predictors of failed bile duct clearance. Stone size and location are independent predictors of failed bile duct clearance. The endoscopist should consider these factors while subjecting a patient to biliary ductal clearance to plan additional intervention. • Failure to clear bile duct stones in the index ERCP can be seen in 15-20% of cases, and identifying the factors associated with failure is important. • A prospective analysis was conducted to identify and analyze the factors that could predict the failure of complete CBD clearance. • The present study reported a successful clearance of CBD stones during the index procedure in only 70% of patients. • A stone diameter ≥15 mm, location of stones in hepatic ducts, presence of stricture distal to stone, and impacted stone were independent predictors of failed bile duct clearance.

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.

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.

Management of borderline common bile duct stones: Retrospective comparative study

Background Borderline Size common bile duct stones (BLS-CBDS) are associated with hepato-pancreato-biliary morbidity and complications. Its optimum management is still controversial till now. Aim Is to compare conservative treatment versus endoscopic retrograde cholangiopancreatography (ERCP) for the treatment of BLS-CBDS. Material and methods This retrospective study included patients with BLS-CBDS less than or equal to 10 mm who were treated conservatively or by ERCP endoscopic stone extraction followed by laparoscopic cholecystectomy (LC). The primary outcome was successful common bile duct (CBD) clearance, and the secondary outcomes were complications, impact on laparoscopic cholecystectomy, and hospital stay. Results Out of 270 patients, 150 were treated by ERCP and 120 by the Conservative approach. There was complete clearance of CBDS in 75 (50%) patients out of 150 patients in the ERCP group and useless procedure in the remaining 75 (50%) patients. In the conservative group, there was complete clearance of CBDS in 99 (82.5%) cases, and useless in the remaining 21 (17.5%) patients. Post-ERCP pancreatitis occurred in 33 (22%) patients. Conclusion BLS-CBDS increases the technical difficulty of ERCP and the risk of post-ERCP pancreatitis. Conservative management of CBDS is effective in clearing CBDS, it should be considered to avoid unnecessary ERCP and its complications.

Delay for cholecystectomy after common bile duct clearance with ERCP is just running after recurrent biliary event

BackgroundGallstone disease will affect 15% of the adult population with concomitant common bile duct stone (CBDS) occurring in up to 30%. Endoscopic retrograde cholangiopancreatography (ERCP) is the mainstay of management for removal of CBDS, as cholecystectomy for the prevention of recurrent biliary event (RBE). RBE occurs in up to 47% if cholecystectomy is not done. The goal of this study was to evaluate the timing of occurrence of RBE after common bile duct clearance with ERCP and associated outcomes.MethodsThe records of all patients who underwent ERCP for gallstone disease followed by cholecystectomy, in a single center from 2010 to 2022, were reviewed. All RBE were identified. Actuarial incidence of RBE was built. Patients with and without RBE were compared.ResultsThe study population is composed of 529 patients. Mean age was 58.0 (18–95). There were 221 RBE in 151 patients (28.5%), 39/151 (25.8%) having more than one episode. The most frequent RBE was acute cholecystitis (n = 104) followed by recurrent CBDS (n = 95). Median time for first RBE was 34 days. Actuarial incidence of RBE started from 2.5% at 7 days to reach 53.3% at 1 year. Incidence-rate of RBE was 2.9 per 100 person-months. Patients with RBE had significant longer hospitalisation time (11.7 vs 6.4 days; P < 0.0001), longer operative time (66 vs 48 min; P < 0.0001), longer postoperative stay (2.9 vs 0.9 days; P < 0.0001), higher open surgery rate (7.9% vs 1.3%; P < 0.0001), and more complicated pathology (23.8% vs 5.8%; P < 0.0001) and cholecystitis (64.2% vs 25.9%; P < 0.0001) as final diagnoses.ConclusionsRBE occurred in 28.5% of the subjects at a median time of 34 days, with an incidence of 2.5% as early as 1 week. Cholecystectomy should be done preferably within 7 days after common bile duct clearance in order to prevent RBE and adverse outcomes.

Indian Survey on Management of Choledocholithiasis—Opportunities for Improvement and Future Studies

Abstract Background In clinical practice, decision about management of choledocholithiasis is driven by availability of resources and expertise, patients and healthcare professional preferences. This survey is aimed to describe the approach of physicians and surgeons for the management of choledocholithiasis. Method A 36-question online survey was conducted using Google Forms on various aspects of management of choledocholithiasis. Results The responses from 323 participants were included, of which 202 (62.54%) were physicians and 121 (37.46%) were surgeons. The proportion of responders who do not follow American or European Society of Gastrointestinal Endoscopy guidelines is associated with increasing age and experience of responders (p = 0.0001), while place of work (private vs. teaching) and broad specialty (physician vs surgeon) are not associated (p &gt;0.05). For patients with high likelihood of choledocholithiasis, 123 (38.1%) participants prefer to do endoscopic ultrasound/magnetic resonance cholangiopancreatography (EUS/MRCP) rather than directly performing endoscopic retrograde cholangiopancreatography/intraoperative cholangiography (ERCP/IOC). For intermediate likelihood, MRCP is more commonly preferred compared with EUS, due to local availability (44%), expertise (39.6%), healthcare professionals preference (30.7%), and patients preference (17.3%). For difficult common bile duct (CBD) stones, short biliary sphincterotomy with large balloon sphincteroplasty (59.4%), followed by laparoscopic CBD exploration are commonly used approaches. Prophylactic CBD stent placement after ERCP and CBD clearance is common practice. Preoperative ERCP followed by cholecystectomy is more preferred approach than cholecystectomy and CBD exploration. Conclusion There is considerable variability in the management of choledocholithiasis. The practices such as use of EUS/MRCP for high likelihood group, use of prophylactic CBD stent placement after ERCP and CBD clearance, and use of single stage approach especially in patient with intermediate likelihood group should be addressed in future studies.

Evaluating Safety, Effectiveness, and Resource Efficiency in Management Strategies for Intermediate Risk Choledocholithiasis: Defining the Optimal Approach

INTRODUCTION: Optimal management of emergency department patients with intermediate-risk choledocholithiasis (IR-CDL) remains undefined. At a safety-net hospital where timely patient throughput is essential, we hypothesized that forgoing additional preoperative diagnostics and proceeding directly to laparoscopic cholecystectomy (LC) ± intraoperative cholangiogram (IOC) is a safe, effective, and resource-efficient strategy. METHODS: Adults with IR-CDL who underwent cholecystectomy during index hospitalization from 2016 to 2020 were included. IR-CDL was defined as total bilirubin 1.8 to 4.0 mg/dL, common bile duct (CBD) >6 mm, or gallstone pancreatitis on admission. Safety was assessed using the rate of CBD injury, reoperation, readmission, and retained CBD stones within 30 days of discharge. Effectiveness was assessed using the rate of successful endoscopic CBD clearance. Efficiency was measured using hospital length of stay (LOS) and direct and total cost. Patients taken direct-to-operating room (OR) for LC ± IOC were compared with those who received preoperative magnetic resonance cholangiopancreatography (MRCP) and/or endoscopic retrograde cholangiopancreatography (ERCP) (“additional-workup”). RESULTS: Of 655 patients, 611 (93%) were direct-to-OR and 44 (7%) were additional workup. Demographics were similar between groups. There was no difference in CBD injury, reoperation, readmission, or retained stones after discharge (all p > 0.05; Table). Of direct-to-OR patients who underwent LC+IOC, 34% had choledocholithiasis. Rates of successful endoscopic CBD clearance were similar between preoperative and postoperative ERCP (97% vs 100%, p = 0.96). Direct-to-OR patients had a shorter median hospital LOS by 38.5 hours and lower median direct and total cost by $5,121/patient and $8,535/patient, respectively.TableCONCLUSION: Proceeding directly to the OR for LC ± IOC expedites treatment of IR-CDL at lower cost without compromising safety or efficacy. These findings help clarify optimal management of IR-CDL.

Continuation of common bile duct clearance with gallbladder stenting after duodenal perforation with subsequent treatment for tension pneumoperitoneum and pneumothorax.

An 88-year-old woman underwent endoscopic retrograde cholangiopancreatography (ERCP) because of septic cholangitis with acute calculous cholecystitis. Unfortunately, incidental duodenal perforation (Stapfer classification type 1) [1] occurred during duodenoscope intubation by our trainee endoscopist. Gastroscopy with a transparent cap revealed a linear 4-cm defect with active oozing at the duodenal apex ([Video 1]). Perforation closure was attempted with preceding guidewire insertion into the downstream duodenal lumen ([Fig. 1]) to prevent accidental luminal closure [2]. The first traumatic type over-the-scope clip (OTSC, 12/6t; Ovesco) was deployed by suction on the lacerating tissue at the caudal side of the defect ([Fig. 2]). However, the defect did not close completely; therefore, a second OTS clip was deployed using twin graspers to appose the edges of the defect. Contrast enterography revealed no intraperitoneal leakage ([Fig. 3]). Immediately after closure, ERCP with stones removal and transpapillary gallbladder stenting with a double-pigtail plastic stent to prevent recurrent cholecystitis was successfully performed. At almost 40 minutes before completion of the procedure, the patient developed marked abdominal distension, hypotension, and desaturation. Tension pneumoperitoneum with right pneumothorax was confirmed by fluoroscopy ([Fig. 4]). Emergency needle decompression was performed using an 18 G needle to release the tension pneumoperitoneum, and the patient was then intubated. Her abdomen gradually softened with an improvement in oxygen saturation. At 4 hours later, plain radiography showed no free air ([Fig. 5]). The patient was extubated and resumed oral intake the following day.

S1730 ERCP in a Patient With Situs Inversus Totalis

Introduction: Situs inversus (SI) is a congenital anomaly resulting in transposition of thoracic and abdominal organs. SI is often found incidentally. We present a case of choledocholithiasis in a patient with situs inversus totalis (SIT). We highlight some technical considerations in performing ERCP for these patients which may increase procedural success. In addition, we included images showing the unique orientation of bile duct to the pancreatic duct. Case Description/Methods: An 89-year-old man presented to the emergency department with progressive epigastric abdominal pain for one month associated with nausea and non-bloody, non-bilious vomiting. In the emergency department, the patient was found to have elevated lipase 1903 U/L, total bilirubin 1.7 mg/dL, and a CT abdomen showed changes of acute pancreatitis with a 7 mm obstructing stone at the ampulla (Figure A). The CT also incidentally detected situs inversus totalis. After treatment of acute pancreatitis, patient underwent ERCP for removal of the common bile duct (CBD) stone. The patient was positioned in right semiprone position with the endoscopist positioned on the right side of the table. The side-viewing duodenoscope was advanced into the stomach, the gastric folds were followed with slight clockwise rotation of the scope until reaching the antrum. Long scope position was used to visualize and access the papilla. The major papilla was visualized in the upper right quadrant of the screen (Figure B). Deep biliary cannulation was challenging so a pancreatic duct stent was placed first to aid in biliary cannulation. Subsequently, biliary cannulation was achieved with biliary sphincterotomy and balloon sweep performed (Figure C shows the orientation of CBD to the right of the pancreatic duct). Clearance of the common bile duct was achieved (Figure D). The patient tolerated the procedure well and underwent laparoscopic cholecystectomy during the same hospitalization. Discussion: SI is found in approximately 1 in 10,000 which can obscure the diagnosis of abdominal pathology. Often imaging is necessary to fully determine organ position and existing anatomy. In our case SIT was noted on CT along with the culprit CBD stone that caused acute pancreatitis. Performing ERCP in this setting can be very challenging. In such patients, careful planning for ERCP to minimize adverse events and maximize success is essential.Figure 1.: CT scan demonstrating situs inversus with pancreatitis and visible stone (A), major papilla (B), CBD to the right of the pancreatic duct (C), confirmed clearance of common bile duct (D).

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.

Nasobiliary guided laparoscopic cholecystectomy following endoscopic retrograde cholangiopancreatography, randomized controlled trial

BackgroundEndoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC) is the most common management of gallstones combined with common bile duct (CBD) stones. This study aims to evaluate the impact of routine insertion of nasobiliary catheter during ERCP in cases of difficult LC. Patients & methodsFrom total 110 patients who underwent ERCP followed by LC in the period from April 2019 to April 2020, nasobiliary (NB) catheter was inserted during ERCP in 55 patients after CBD clearance (NB group). In the other 55 patients, only CBD clearance was done (Control group). In the NB group, dynamic trans-nasobiliary intraoperative cholangiography (TN-IOC) was done during dissection of Calot's triangle. At the end of the procedure, trans-nasobiliay methylene blue (MB) test was done to detect any missed biliary injury. The primary outcome to be analyzed was the incidence and severity of bile duct injury (BDI), secondary outcomes were the operative time, conversion to open surgery, and hospital stay. ResultsOf the 110 patients, 57 patients (51.8%) were males and 53 (48.2%) were females. Median age was 55 years. One case of biliary leak was reported in the NB group (1.8%), while 2 cases (3.6%) were reported in the Control group. The average operative time in the NB group was 115 min versus 128 min in the Control group (P value < 0.001). No cases were converted to open cholecystectomy in the NB group (0%) with 5 cases (9.1%) converted to open in the Control group. The average postoperative hospital stay was 2 ± 0.1 days in the NB group versus 3.6 ± 5.3 days in the Control group (P value = 0.037). ConclusionRoutine insertion of nasobiliary tube during ERCP, in patients with combined gallbladder and CBD stones, is a simple, safe and dynamic method for IOC. This maneuver does not statistically decrease the incidence of BDI but can diagnose, minimize and treat BDI with shorter operative time and hospital stay.