Removal Of Common Bile Duct Stones Research Articles

Risk Factors for Recurrence of Common Bile Duct Stones after Common Bile Duct Exploration Surgery

Purpose: Recurrent common bile duct (CBD) stone is a significant delayed complication after CBD exploration surgery. However, no definite risk factors for recurrence have been established. The aim of this study is to identify the risk factors of recurrent CBD stone following surgical CBD stone removal. Methods: In total, 253 patients who underwent CBD exploration surgery from Jan 2000 to Jan 2018 were identified and included in this study. We retrospectively collected clinical data based on the medical records of the patients and investigated risk factors with logistic regression analysis. Results: A total of 31 patients (12.3%) developed recurrent CBD stones. The median follow-up period was 9.6 months. Univariate analyses showed that the following factors were associated with recurrent CBD stones: delayed diet start after 7 days, longer hospital duration, and preoperative endoscopic sphincterotomy. However, sex, age, gallstone, operation time, transfusion, T-tube insertion, and postoperative complications were not associated with recurrent CBD stone. In multivariate analysis, longer hospital duration and preoperative endoscopic sphincterotomy were associated with recurrent CBD stone (OR = 1.047; CI 1.001 to 1.095; p = 0.048 and OR = 3.615; CI 1.081 to 12.087; p = 0.037, respectively). Conclusion: Recurrent CBD stones can often occur and require regular follow-up although it is safe to remove by surgical CBD exploration. Further investigation is needed on the risk factors of recurrent CBD stones.

Asymptomatic Common Bile Duct Stones Are Associated with Increased Risk of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis.

Introduction: Common bile duct stones (CBDS) are a common disease that can cause biliary complications, including cholangitis, obstructive jaundice, and biliary pancreatitis. Regardless of the presence or absence of symptoms, endoscopic removal of CBDS is generally recommended, but endoscopic retrograde cholangiopancreatography (ERCP) is a high-risk procedure with complications, such as post-ERCP pancreatitis (PEP). As few reports have addressed the risk of PEP by focusing on asymptomatic CBDS, the purpose of this study is to examine the incidence of PEP for asymptomatic CBDS. Methods: This retrospective study included data from 302 patients with naive papilla who underwent therapeutic ERCP for CBDS between January 2012 and December 2019 at our hospital. Univariate and multivariate logistic regression models were used to investigate independent risk factors for PEP. Results: Of the 302 patients, 32 were asymptomatic, and the remaining 270 were symptomatic. Five asymptomatic patients (15.6%) suffered from mild PEP, whereas 10 (3.7%) symptomatic patients suffered from PEP (9 were mild, and 1 was severe). Univariate analysis identified deep cannulation time more than 10 min, endoscopic papillary balloon dilation (EPBD), and asymptomatic CBDS as risk factors for PEP, whereas multivariate analysis revealed deep cannulation time more than 10 min (odds ratio (OR), 6.67; p < 0.001), EPBD (HR, 5.70; p < 0.001), and asymptomatic CBDS (HR, 5.49; p < 0.001) as independent risk factors for PEP. Conclusions: A wait-and-see approach may be an option for the management of asymptomatic CBDS. EPBD may be avoided, especially in case of asymptomatic or if difficult for bile duct cannulation.

Intelligent difficulty scoring and assistance system for endoscopic extraction of common bile duct stones based on deep learning: multicenter study.

The study aimed to construct an intelligent difficulty scoring and assistance system (DSAS) for endoscopic retrograde cholangiopancreatography (ERCP) treatment of common bile duct (CBD) stones. 1954 cholangiograms were collected from three hospitals for training and testing the DSAS. The D-LinkNet34 and U-Net were adopted to segment the CBD, stones, and duodenoscope. Based on the segmentation results, the stone size, distal CBD diameter, distal CBD arm, and distal CBD angulation were estimated. The performance of segmentation and estimation was assessed by mean intersection over union (mIoU) and average relative error. A technical difficulty scoring scale, which was used for assessing the technical difficulty of CBD stone removal, was developed and validated. We also analyzed the relationship between scores evaluated by the DSAS and clinical indicators including stone clearance rate and need for endoscopic papillary large-balloon dilation (EPLBD) and lithotripsy. The mIoU values of the stone, CBD, and duodenoscope segmentation were 68.35 %, 86.42 %, and 95.85 %, respectively. The estimation performance of the DSAS was superior to nonexpert endoscopists. In addition, the technical difficulty scoring performance of the DSAS was more consistent with expert endoscopists than two nonexpert endoscopists. A DSAS assessment score ≥ 2 was correlated with lower stone clearance rates and more frequent EPLBD. An intelligent DSAS based on deep learning was developed. The DSAS could assist endoscopists by automatically scoring the technical difficulty of CBD stone extraction, and guiding the choice of therapeutic approach and appropriate accessories during ERCP.

Cholecystostomy as an Exclusive Access to Remove Cystic, Common Hepatic, and Common Bile Duct Stones.

OBJECTIVE. The purpose of this article was to evaluate the feasibility and efficacy of percutaneous fluoroscopic-guided stone retrieval from the cystic duct and antegrade common bile duct (CBD) stone advancement into the duodenum exclusively through a cholecystostomy tube. MATERIALS AND METHODS. Twenty-one patients with acute cholecystitis and choledocholithiasis or an impacted cystic duct stone who underwent percutaneous cholecystostomy tube placement were retrospectively enrolled in this study. The patients had a contra-indication for cholecystectomy (17 patients because of comorbidities and one who declined surgery) or had failed endoscopic retrograde stone removal attempts (three patients). RESULTS. The 21 patients underwent subsequent percutaneous CBD (17 patients) and cystic duct (nine patients) stone removal on follow-up sessions through the percutaneous cholecystostomy track using moderate sedation. A total of 32 stone removal procedures were performed. Seventeen patients underwent balloon dilatation sphincterotomy, after which the CBD stones were pushed forward into the duodenum using a compliant balloon. Seven patients also had stone removal from the cystic duct by a stone retrieval basket. The primary technical success rate for removal of all CBD and cystic duct stones was 76%. The secondary technical success rate was 100%. The clinical success rate was 74%. All patients tolerated the procedures well without major complication. The clinical follow-up interval ranged from 2 to 2310 days (median, 30 days), with no incidence of postprocedural complications. CONCLUSION. Percutaneous transcholecystic common bile and cystic duct stone removal through an existing cholecystostomy access is a safe and effective procedure that is well tolerated.

Effect of stent placement on stone recurrence and post-procedural cholangitis after endoscopic removal of common bile duct stones.

Background/AimsAfter endoscopic treatment of common bile duct (CBD) stones, recurrence of choledocholithiasis due to small stone fragments and post-endoscopic retrograde cholangiopancreatography (post-ERCP) cholangitis can occur. We determined the effect of biliary stenting after removal of CBD stones on the recurrence of CBD stones and the incidence of post-ERCP cholangitis. MethodsWe performed a retrospective single-center study involving 483 patients who underwent ERCP for the removal of CBD stones. The patients were classified into two groups according to their biliary stenting status. The primary outcome was the rate of CBD stone recurrence and the secondary outcome was the incidence of post-ERCP cholangitis. ResultsAmong the 483 patients, 219 and 264 did and did not receive a biliary stent after CBD stone removal, respectively. The incidence of stone recurrence was 15.5% and 7.6% in the non-stenting and stenting groups (p = 0.006), respectively, while the incidence of post-ERCP cholangitis was 4.6% and 2.7% (p = 0.256). In a multivariate analysis, biliary stenting significantly reduced the stone recurrence rate (odds ratio, 0.30; p = 0.004). ConclusionsBiliary stenting after the removal of CBD stones reduces the stone recurrence rate and assisted recovery. For patients with large and multiple stones who undergo lithotripsy, preventive biliary stent insertion can reduce the rate of stone recurrence.

The influence of periampullary diverticula on ERCP for treatment of common bile duct stones

In order to evaluate the effectiveness of various methods we applied to decrease the influence of periampullary diverticula (PAD) on the success rate and complications of endoscopic retrograde cholangiopancreatography (ERCP) in the treatment of common bile duct (CBD) stones, we enrolled patients with CBD stones who had been treated by ERCP in our hospital between January 2015 and December 2018. According to the presence of PAD, the patients were divided into a PAD group and a non-PAD group. The rate of complete stone removal in the first session, the rate of overall stone removal, the frequency of application of mechanical lithotripsy, and procedure-related complications, including bleeding, hyperamylasemia, pancreatitis, perforation, and infection of biliary tract were recorded. A total of 183 cases, including 72 cases in the PAD group and 111 cases in the non-PAD group were enrolled. There was no statistical difference between the two groups regarding gender (P = 0.354). However, regarding age, there was a statistical difference (P = 0.002), and the incidence of PAD increased with age. There were 5 (6.9%) cases in the PAD group and 14 (12.6%) cases in the non-PAD group where mechanical lithotripsy was applied. There were 59 (81.9%) cases in the PAD group and 102 (91.9%) cases in the non-PAD group where there was complete removal of CBD stones in the first session, and there were 68 (94.4%) cases in the PAD group and 107 (96.4%) cases in the non-PAD group where there was complete removal of all stones. In the PAD group, there were 0 cases (0%) with gastrointestinal bleeding, 0 cases (0%) with gastrointestinal perforation, 13 cases (18.1%) with post-ERCP hyperamylasemia, 3 cases (4.2%) with post-ERCP pancreatitis, and 4 cases (5.6%) with biliary tract infection. In the non-PAD group, 1 case (0.9%) had gastrointestinal bleeding, 0 cases had gastrointestinal perforation, 18 cases (16.2%) had post-ERCP hyperamylasemia, 5 cases (4.5%) had post-ERCP pancreatitis, and 11 cases (9.9%) had biliary tract infection. This retrospective study showed that there was a statistical difference between the two groups regarding complete removal of CBD stones in the first session and application of mechanical lithotripsy (both P < 0.05), but no statistical difference according to the rates of overall stone removal and the complications (P > 0.05), which means that we can reduce the influence of PAD on ERCP for treatment of common bile duct stones.

Incidence and risk factors for postoperative common bile duct stones in patients undergoing endoscopic extraction and subsequent cholecystectomy

In patients who undergo cholecystectomy after endoscopic common bile duct (CBD) stone extraction, CBD stones found postoperatively could be problematic. This study aimed to investigate the incidence and risk factors of postoperative CBD stones after cholecystectomy. A total of 278 patients (mean age, 59.2 years; 71 men [51.1%]) who underwent endoscopic removal of CBD stones followed by cholecystectomy from January 2013 to December 2017 were included. An endoscopic nasobiliary drainage (ENBD) tube was placed immediately after endoscopic clearance of the CBD stones in all patients until cholecystectomy. An ENBD tubogram was obtained in all patients to determine the presence of postoperative CBD stones. Postoperative CBD stones were detected in 20.1% (56/278). An ENBD tubogram was obtained after an average of 2.42 days postoperatively. Based on univariate analysis, the statistically significant risk factors for postoperative CBD stone were CBD stones >2, CBD stone size >10mm, cholesterol stone, maximum diameter of CBD >15mm, treatment with endoscopic sphincterotomy alone, and use of endoscopic mechanical lithotripsy (EML). In multivariate analysis, cholesterol stone, CBD stones >2, CBD stone size >10mm, and EML were related to postoperative CBD stones after cholecystectomy. Based on the relatively high rate of postoperative CBD stones after cholecystectomy, careful follow-up should be considered in patients with high-risk factors to detect CBD stones early.

Single‐stage retrograde endoscopic common bile duct stone removal might be sufficient in moderate acute cholangitis with a stone size ≤12 mm: A retrospective cohort study with propensity score matching

AbstractStudies elucidating the efficacy and safety of single‐stage endoscopic treatment for acute moderate cholangitis with choledocholithiasis are limited. Therefore, we performed a retrospective analysis of single‐stage endoscopic treatment for common bile duct (CBD) stone removal in patients with moderate cholangitis to determine the rates of successful stone extraction and complications. A retrospective chart review was conducted for all consecutive patients (n = 632) undergoing endoscopic retrograde cholangiopancreatography (ERCP) for CBD stone removal between January 2010 and September 2013 at the study institution. A total of 346 patients excluded based on the following criteria: procedural failure requiring an anatomy‐modifying operation, stenosis of the pyloric ring, tumor‐related obstruction, treatment requiring only biliary drainage, failure to locate the papilla, intolerance due to inadequate sedation, CBD stone &gt; 12 mm, CBD sludge, and non‐naïve papilla in ERCP. The remaining 286 patients were randomly matched at a 1:2 ratio using propensity score together with age and sex with the Number Cruncher Statistical System statistical software. After propensity score matching, there were 90 and 134 patients in the moderate and no/mild cholangitis groups, respectively. The baseline characteristics and endoscopic findings were comparable between the two groups. The success rate of complete stone extraction was similar between the moderate and no/mild cholangitis groups (90.0% vs 91.0%, P = .793). Additionally, the complication rates were comparable between the moderate and no/mild cholangitis groups (post‐ERCP pancreatitis, 13.3% vs 10.4%, P = .542; pneumonia, 4.4% vs 1.5%, P = .183; perforation, 0% vs 1.5%, P = .243; and mortality, 2.2% vs 0.7%, P = .350). However, there was a trend for higher bleeding rate in the moderate cholangitis group compared with the no/mild cholangitis group (2.2% vs 0%, P = .084). Single‐stage retrograde endoscopic CBD stone removal in patients with moderate cholangitis and choledocholithiasis sized ≤12 mm might be adequate based on the high success rate (90.0%) for stone removal and low complication rates.

Long-term Outcomes of Endoscopic Papillary Large-balloon Dilation for Common Bile Duct Stones.

Objective Endoscopic papillary large-balloon dilation (EPLBD) for common bile duct (CBD) stone removal has been confirmed to be safe and effective in the short term. The long-term outcomes of EPLBD, which have not been sufficiently evaluated, were therefore investigated in this study. Methods For patients who had undergone endoscopic CBD stone removal with EPLBD between October 2011 and December 2015, follow-up surveys were conducted using a postal survey, telephone interview, or medical record review in August 2017. The main outcome measurement was the recurrence rate of CBD stones after complete stone removal with EPLBD in patients who received follow-up for more than one year. Risk factors for such recurrence were secondarily analyzed. Results Of the 98 patients treated using EPLBD, 93 (95%) were followed up after complete stone removal and analyzed for the long-term outcomes. During the mean follow-up period of 33.7±16.6 months, CBD stones recurred in 16 patients (17%) with a mean interval of 12.7±12.7 months. Univariate analyses showed that a large stone size, multiple stones, a large distal CBD diameter, and a history of cholecystectomy were significant risk factors for stone recurrence (p=0.022, 0.013, 0.001 and 0.035, respectively). The large distal CBD diameter was the only significant risk factor for stone recurrence in a multivariate analysis (hazard ratio, 1.227; p=0.031). Conclusion The long-term outcomes of EPLBD for CBD stones, including the rate of stone recurrence, were found to be acceptable. A large distal CBD diameter was an independent risk factor for stone recurrence.

Cholecystectomy after Endoscopic Papillotomy for Choledocholithiasis in the Elderly—Is It Necessary?

Although elective laparoscopic cholecystectomy is the accepted strategy after endoscopic retrograde cholangiopancreatography (ERCP), papillotomy, and common bile duct (CBD) clearance, the decision to perform a cholecystectomy in high-risk elderly comorbid patients remains subjective and is controversial. The aim of this study was to examine the outcome of elderly patients with cholecystectomy deferral after successful initial endoscopic removal of CBD stones. The study examined a retrospective patient database, which included all patients aged &gt;60 years who underwent an ERCP for CBD stones at the Chaim Sheba Medical Center. The study cohort was divided according to whether a subsequent cholecystectomy was performed and also by age 60 to 80 or &gt;80 years. All biliary-related complications were recorded. The primary outcome measures were biliary complications, perioperative and periprocedural mortality, CBD stone recurrence, and the need for future surgical intervention. There were 111 patients (mean age 79.4 ± 9.1 years) who underwent ERCP with follow-up. After excluding 11 patients, 100 patients were left for analysis, 46 of whom underwent a cholecystectomy and 54 were observed without operation. There were significant longer term biliary complications in five of the operated patients (10.9%) and in four of the unoperated cases (7.4%). All biliary-related complications were managed successfully by conservative means except for one fatality in the nonoperated group. Biliary-related complications after successful ERCP for CBD stones were unaffected by surgery but were more commonly observed in older cases. A watch and wait policy may be justified in elderly comorbid patients.

Computed tomography findings of ceftriaxone-associated biliary pseudocholelithiasis in adults.

This study aimed to characterize the computed tomography (CT) findings of pseudolithiasis and investigate the outcomes and natural history in adult patients receiving CTRX therapy. A total of 17 patients were diagnosed with CTRX-associated biliary pseudolithiasis on CT between April 2013 and March 2017. The medical records, characteristics, complications, treatment options, and outcomes of these patients were examined. Serial CT images and the form, density, and location of pseudolithiasis were reviewed by two radiologists. Of the 17 patients with CTRX-associated pseudolithiasis, seven were men and ten were women. The median patient age was 78years (range 31-88years). The median interval from CTRX administration to the diagnosis of pseudolithiasis was 10days (range 4-32days). The CT findings of pseudolithiasis included a sludge pattern (11 patients [64.7%]), stone pattern (two patients [11.8%]), and stone plus sludge pattern (four patients [23.5%]). Seven patients (41.2%) showed gall bladder enlargement along with a common bile duct (CBD) stone. Two patients with CBD stones underwent endoscopic CBD stone removal. The median time to pseudolithiasis resolution after CTRX cessation was 69days. The high-density sludge pattern is the most common typical CT finding of CTRX-associated pseudolithiasis in adults.

Post-endoscopic retrograde cholangiopancreatography pancreatitis in single-stage endoscopic common bile duct stone removal.

Background and AimsPapillary treatment, such as endoscopic sphincterotomy or endoscopic papillary balloon dilation, and subsequent single‐stage endoscopic stone removal are often performed for choledocholithiasis; however, the incidence of postendoscopic retrograde cholangiopancreatography pancreatitis (PEP) is unclear. This study aimed to compare the overall incidence of PEP between single‐ and two‐stage stone removal groups and the incidence of PEP between these two groups based on cannulation time.MethodsWe included 897 patients with native papilla who underwent papillary treatment and stone removal for choledocholithiasis with no inflammation or mild‐to‐moderate acute cholangitis at three institutions between April 2012 and March 2018 in Japan. We performed a propensity‐matched analysis and regression adjustment by propensity score to adjust for potential confounding factors.ResultsIn the propensity‐matched analysis with 234 pairs, there was no significant difference in the overall incidence of PEP between single‐ and two‐stage stone removal procedures (15/234, 6.4% vs 6/234, 2.6%, P = 0.072, respectively). Although single‐stage stone removal after a cannulation time of ≤15 min was not a significant risk factor of PEP, the procedure after a cannulation time of >15 min was a significant risk factor of PEP as estimated by regression adjustment by propensity score (P = 0.014, 95% CI = 1.4–19.4, odds ratio = 5.2).ConclusionsSingle‐stage endoscopic stone removal after a long cannulation time of >15 min increased the incidence of PEP compared with the two‐stage stone removal procedure. Thus, single‐stage stone removal should be performed in patients with a cannulation time ≤ 15 min.

Efficacy of endoscopic ultrasound after removal of common bile duct stone

Objective: Endoscopic retrograde cholangiopancreatography (ERCP) is a standard procedure for choledocholithiasis. Nonetheless, the recurrence rate remains quite high. This study aimed to investigate the prevalence and related factors of remnant biliary stone or sludge using endoscopic ultrasound (EUS) after the removal of common bile duct (CBD) stone and to evaluate the long-term clinical outcomes.Methods: A prospective study enrolling a consecutive series of patients who underwent ERCP for CBD stone removal was performed between June 2014 and November 2015. Following confirmation of complete CBD stone removal by the operator, EUS was performed to determine whether biliary stone or sludge remained. Patients underwent cholecystectomy if a gallstone was identified and were subsequently followed up at a regular interval of 3–6 months. We investigated whether symptomatic recurrence would occur.Results: A total of 130 patients were enrolled. The presence of remnant biliary stone or sludge after ERCP was confirmed in 36.9% (48/130) of patients. Acute angulation of the distal CBD was the sole factor associated with remnant biliary stone or sludge (p < .01). During the follow-up period, the overall recurrence rate was 17.7% (23/130). Recurrent symptomatic choledocholithiasis was predicted by remnant biliary sludge and large CBD diameter in multivariate analysis.Conclusions: Acute angulation of the distal CBD was associated with remnant biliary stone or sludge after ERCP. Remnant biliary sludge on EUS and large CBD diameter were strong predictors of symptomatic recurrence. EUS evaluation following CBD stone removal could be an effective strategy in the treatment of choledocholithiasis.

A comparison between non-sedation and general endotracheal anesthesia for retrograde endoscopic common bile duct stone removal: A tertiary center experience

BackgroundConscious sedation is not routinely administered for therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in many countries. The aim of our retrospective study was to compare the safety and rate of success and complications during common bile duct (CBD) stone extraction using ERCPs performed with no-sedation (NS) or under general endotracheal anesthesia (GET). MethodsThe medical records of all patients who underwent ERCP for biliary stone extraction between January 2010 and September 2013 were reviewed, and patients classified to the NS and GET groups. The primary outcomes were the rate of success of complete stone removal and rate of complications, including post-ERCP pancreatitis (PEP), perforation, bleeding, pneumonia, and mortality within 30 days post-ERCP. Operative time was recorded for analysis. ResultsDuring the study period, 630 patients underwent ERCP, 402 with NS and 105 with GET. Among the 402 patients in the NS group, 37 (9.2%) could not complete the procedure due to an inability to tolerate the procedure. The success rate of complete stone extraction was higher among patients in the GET group than the NS group (94.3% versus 75.6%, respectively; p < 0.001). The rate of contrast injection into the pancreatic duct was higher for the NS than GET group (24.9% versus 15.2%, respectively; p = 0.008). Although non-significant, there was a higher incidence of post-ERCP pancreatitis (PEP) in the NS than in the GET group (10.4% versus 5.7%, respectively; p = 0.105), while the incidence of pneumonia was higher for the GET group. Biliary pancreatitis, contrast injection into the pancreatic duct and an operation time ≥30 min were independent risks factors for PEP. ConclusionsERCP under GET is effective for CBD stone removal, but with slightly higher pneumonia rate after the procedure than non-sedated ERCP.

Direct peroral cholangioscopy in the management of difficult biliary stones: a new tool to confirm common bile duct clearance. Results of a preliminary study

Endoscopic sphincterotomy (ES) with stone extraction is the standard treatment for choledocholithiasis. After stone retrieval, balloon-occluded cholangiography is generally performed to confirm bile duct clearance but can miss residual stones particularly in patients with residual small-sized stones, a large bile duct or pneumobilia. In addition, difficult common bile duct (CBD) stones requiring advanced endoscopic techniques for retrieval are a potential risk factor for choledocholithiasis recurrence. We performed a retrospective evaluation of a prospectively maintained procedures database. From July 2016 to December 2017, all patients with difficult CBD stones who underwent endoscopic retrograde cholangiopancreatography (ERCP) with papillary balloon dilation-assisted stone retrieval and subsequent direct per-oral cholangioscopy (DPOC) using standard gastroscopes to confirm CBD clearance were analyzed. Thirty-six patients who underwent ERCP and DPOC were included. Technical success, defined as deep intubation of CBD with hepatic hilum visualization, was achieved in 31 of 36 patients (86%). During DPOC, residual CBD stones were visualized and removed in 7 of 31 patients (22.5%). After a mean of 241 +/- 56 days of follow-up post-DPOC, no serious adverse events were reported, and there was no evidence or suspicion of recurrent choledocholithiasis. Direct per-oral cholangioscopy immediately following difficult CBD stone removal was safe, feasible and accurate. In this setting, DPOC at the time of ERCP appears to be a very useful tool to achieve complete clearance of choledocholithiasis.

Direct Peroral Cholangioscopy in the Management of Difficult Biliary Stones: a New Tool to Confirm Common Bile Duct Clearance. Results of a Preliminary Study

Background &amp; Aims: Endoscopic sphincterotomy (ES) with stone extraction is the standard treatment for choledocholithiasis. After stone retrieval, balloon-occluded cholangiography is generally performed to confirm bile duct clearance but can miss residual stones particularly in patients with residual small-sized stones, a large bile duct or pneumobilia. In addition, difficult common bile duct (CBD) stones requiring advanced endoscopic techniques for retrieval are a potential risk factor for choledocholithiasis recurrence.Methods: We performed a retrospective evaluation of a prospectively maintained procedures database. From July 2016 to December 2017, all patients with difficult CBD stones who underwent endoscopic retrograde cholangiopancreatography (ERCP) with papillary balloon dilation-assisted stone retrieval and subsequent direct per-oral cholangioscopy (DPOC) using standard gastroscopes to confirm CBD clearance were analyzed.Results: Thirty-six patients who underwent ERCP and DPOC were included. Technical success, defined as deep intubation of CBD with hepatic hilum visualization, was achieved in 31 of 36 patients (86%). During DPOC, residual CBD stones were visualized and removed in 7 of 31 patients (22.5%). After a mean of 241 ± 56 days of follow-up post-DPOC, no serious adverse events were reported, and there was no evidence orsuspicion of recurrent choledocholithiasis.Conclusions: Direct per-oral cholangioscopy immediately following difficult CBD stone removal was safe, feasible and accurate. In this setting, DPOC at the time of ERCP appears to be a very useful tool to achieve complete clearance of choledocholithiasis.

Sphincterotomy plus balloon dilation versus sphincterotomy alone for choledocholithiasis: a meta-analysis.

Endoscopic sphincterotomy plus balloon dilation (ESBD) is considered to be a promising method for the removal of large common bile duct (CBD) stones. However, when compared with endoscopic sphincterotomy (EST) alone, the efficacy and safety of ESBD remain controversial. This meta-analysis aimed to compare the efficacy and safety of ESBD vs. EST for the removal of large CBD stones. Electronic databases were searched up to 15 July 2018 for literature that compared ESBD with EST for the removal of CBD stones. Pooled odds ratios (ORs) of the stone clearance rate and the complication rate were used to compare the efficacy and safety of ESBD vs. EST. A total of 18 studies with 2789 patients were included. The results showed that the stone removal rate was much higher in the ESBD group than in the EST group, both across all endoscopic retrograde cholangiopancreatography (ERCP) sessions (OR 2.68, 95 % confidence interval [CI] 1.79 to 4.01) and during the first ERCP session (OR 2.07, 95 %CI 1.37 to 3.12). The ESBD group had fewer complications than EST alone (OR 0.63, 95 %CI 0.47 to 0.85). Moreover, the ESBD group needed less mechanical lithotripsy (OR 0.38, 95 %CI 0.24 to 0.61) and had a shorter procedure time (mean difference - 4.05, 95 %CI - 7.02 to - 1.09) than EST alone. The efficacy and safety of ESBD were superior to those of EST for the removal of large CBD stones. Moreover, less mechanical lithotripsy and shorter procedure times were needed with ESBD to manage large stones.

A cumulative meta-analysis of endoscopic papillary balloon dilation versus endoscopic sphincterotomy for removal of common bile duct stones

Endoscopic papillary balloon dilation (EPBD) was introduced to overcome the risk of adverse events associated with endoscopic sphincterotomy in the removal of common bile duct (CBD) stones. We performed a meta-analysis of randomized controlled trials (RCTs) comparing efficacy and safety of EPBD vs. endoscopic sphincterotomy, focusing on stone size, balloon diameter, and balloon dilation time. A multiple database search was performed, including MEDLINE, EMBASE and Cochrane Library, from their inception date until October 2017. RCTs comparing the efficacy and safety of EPBD vs. endoscopic sphincterotomy in the removal of CBD stones were included. Cumulative meta-analyses over time, and subgroup analyses according to stone size, and balloon diameter and dilation time were carried out. 25 RCTs met the inclusion criteria. Despite the cumulative meta-analysis showing a trend over time in favor of endoscopic sphincterotomy in studies published up to 2004, the conventional meta-analysis revealed that EPBD was equally efficacious compared with endoscopic sphincterotomy in stone removal at first attempt (odds ratio [OR] 0.95, 95 % confidence interval [CI] 0.65 - 1.38). Endoscopic sphincterotomy was superior to EPBD in terms of overall stone clearance (OR 0.65, 95 %CI 0.43 - 0.99) in studies published since 2002, but no differences emerged in studies using large ( ≥ 10 mm) balloons (OR 1.37, 95 %CI 0.72 - 2.62). No statistically significant difference in pancreatitis occurrence emerged between EPBD and endoscopic sphincterotomy (OR 1.35, 95 %CI 0.90 - 2.03). Pancreatitis was more common with EPBD than with endoscopic sphincterotomy in studies using balloons < 10 mm (OR 1.78, 95 %CI 1.07 - 2.97), whereas no difference emerged in studies using large balloons (OR 0.84, 95 %CI 0.46 - 1.53). EPBD had lower rates of bleeding and cholecystitis. Our latest data confirm that EPBD is currently inferior to endoscopic sphincterotomy in terms of overall stone clearance. However, EPBD using large balloons (≥ 10 mm) was as effective as endoscopic sphincterotomy, both in stone clearance and the need for endoscopic mechanical lithotripsy, without carrying an increased risk of pancreatitis.

Prophylactic Biliary Stenting Before Cholecystectomy in Patients With Gallstones and Common Bile Duct Stones.

BackgroundThe usefulness of prophylactic biliary stenting for patients with common bile duct stones (CBDS) and gallstones (GS) to prevent recurrent biliary events after endoscopic sphincterotomy (EST) and CBDS extraction before elective cholecystectomy remains controversial. The aim of this study was to evaluate the risk of recurrent CBDS around the perioperative period and clarify its risk factors.MethodsThe clinical data of all patients who received prophylactic biliary stenting after EST for CBDS and later underwent cholecystectomy for GS followed by stent extraction in our institution were retrospectively reviewed. The numbers of residual CBDS at the end first and second endoscopic retrograde cholangiography (ERC) studies were compared. Univariate and multivariate analyses were performed using a logistic regression model to determine risk factors for recurrent CBDS in the perioperative period.ResultsForty-two consecutive patients received prophylactic biliary stenting and subsequent cholecystectomy for GS. Three of these patients were excluded from this study because the number of residual stones was not confirmed. The median maximum CBDS diameter at second ERC was 0 mm (range, 0 - 10 mm); six patients had multiple CBDS (≥ 5). The number of CBDS at second ERC was increased in comparison to that at the first ERC in 15 patients (38.4%), and was unchanged or decreased in 24 patients. The median minimum cystic duct diameter was 4 mm (range, 1 - 8 mm). The median interval between first ERC and operation was 26 days (range, 2 - 131 days). The median interval between operation and second ERC was 41 days (range, 26 - 96 days). Laparoscopic cholecystectomy (LC) was performed in 38 patients, one of whom was converted from LC to open cholecystectomy. Postoperative complications (transient bacteremia) occurred in one patient. The cystic duct diameter was an independent risk factor for an increased number of CBDS at second ERC in the multivariate analysis (odds ratio 0.611 (95% confidence interval (0.398 - 0.939)), P = 0.03).ConclusionRecurrent CBDS around the perioperative period of cholecystectomy is not a rare complication after EST and the removal of CBDS with concomitant GS. Prophylactic biliary stenting is considered useful for preventing CBDS-associated complications, especially for patients in whom the cystic duct diameter is larger (≥ 5 mm).

Comparison of endoscopic papillary large balloon dilation with and without a prior endoscopic sphincterotomy for the treatment of patients with large and/or multiple common bile duct stones: a systematic review and meta-analysis.

AimTo compare endoscopic papillary large balloon dilation (EPLBD) alone with EPLBD following endoscopic sphincterotomy (EST) in patients with large and/or multiple common bile duct stones.MethodsWe conducted a comprehensive search of PubMed, EMBASE, and the Cochrane Library database to identify relevant available articles until July 19, 2018. Complete common bile duct stone (CBDS) removal rate, frequency of mechanical lithotripsy (ML) usage, total procedure time and intra- and postoperative adverse events were analyzed. We used RevMan 5.3 to perform the pooled analyses.ResultsSeven RCTs matched the selection criteria. A total of 369 patients underwent EPLBD alone, and 367 patients underwent EPLBD following EST. Our meta-analysis revealed that there were no significant differences in terms of initial success rate (OR =0.69, 95% CI=0.44–1.09, P=0.11), frequency of ML usage (OR =1.18, 95% CI=0.68–2.05, P=0.55), rate of post-endoscopy pancreatitis (PEP) (OR =0.88, 95% CI=0.43–1.78, P=0.72), total procedure time (MD =1.52, 95% CI=-0.13–3.17, P=0.07), or other intra- and postoperative adverse events between the groups for patients with large and/or multiple CBDSs.ConclusionsEPLBD alone was comparable to EPLBD with prior EST in patients with large and/or multiple CBDSs. Further studies are required to confirm the mechanisms of PEP in patients who accept EPLBD during endoscopic retrograde cholangiopancreatography (ERCP).