Duct Stones In Patients Research Articles

Prospective study of EUS guided ERCP or IOC approach in the detection of common bile duct stones in patients undergoing cholecystectomy

Introduction: Choledocholithiasis (common bile duct stones) develops in up to 20 percent of patients with gallbladder stones. It is generally accepted that stones in the common bile duct (CBD) should be removed, even if patients are asymptomatic, because they may be associated with severe complications such as pancreatitis and cholangitis. Materials and Methods: This is a Prospective and analytical study conducted at Department of Surgical Gastroentrology in a Tertiary care Teaching Hospital with suspected common bile duct stones consenting to study protocol were recruited and outcome on management was recorded for each arm of the study over a period of 1 year. In positive EUS group, therapeutic ERCP was performed at the same EUS session or later if CBD stone was found. In the EUS group negative for CBD stones, IOC was performed during laparoscopic cholecystectomy. Result: Mean patient age was 62 years (range, 44 to 74 years), 12 were women and 7 men. Eight of 19 patients (42%) had undergone a previous cholecystectomy; none had undergone previous ERCP. Seven patients (37%) had mild acute biliary pancreatitis (Glasgow score <3) at admission. Six patients, who were referred by other hospitals for EUS, previously had undergone MRCP without evidence of biliary stones. Conclusion: MRCP and EUS have only diagnostic roles, and ERCP is needed for therapeutic purposes. It has been suggested that, when CBDS are found at EUS, they should be treated in the same session. Ideally EUS should be performed in a facility that allows ERCP and to be performed immediately thereafter with no interruption.

Balloon Enteroscopy-Assisted Endoscopic Retrograde Cholangiopancreatography for the Treatment of Common Bile Duct Stones in Patients with Roux-en-Y Gastrectomy: Outcomes and Factors Affecting Complete Stone Extraction

Background: Endoscopic retrograde cholangiopancreatography (ERCP) for extraction of common bile duct (CBD) stones in patients with Roux-en-Y gastrectomy (RYG) remains technically challenging. Methods: Seventy-nine RYG patients (median 79 years old) underwent short-type double-balloon enteroscopy-assisted ERCP (sDBE-ERCP) for CBD stones at three referral hospitals from 2011–2020. We retrospectively investigated the treatment outcomes and potential factors affecting complete stone extraction. Results: The initial success rates of reaching the papilla of Vater, biliary cannulation, and biliary intervention, including complete stone extraction or biliary stent placement, were 92%, 81%, and 78%, respectively. Of 57 patients with attempted stone extraction, complete stone extraction was successful in 74% for the first session and ultimately in 88%. The adverse events rate was 5%. The multivariate analysis indicated that the largest CBD diameter ≥ 14 mm (odds ratio (OR), 0.04; 95% confidence interval (CI), 0.01–0.58; p = 0.018) and retroflex position (OR, 6.43; 95% CI, 1.12–36.81; p = 0.037) were independent predictive factors affecting complete stone extraction achievement. Conclusions: Therapeutic sDBE-ERCP for CBD stones in a relatively elderly RYG cohort, was effective and safe. A larger CBD diameter negatively affected complete stone extraction, but using the retroflex position may be useful for achieving complete stone clearance.

Endoscopic ultrasound-guided antegrade procedures for managing bile duct stones in patients with surgically altered anatomy: Comparison with double-balloon enteroscopy-assisted endoscopic retrograde cholangiography (with video).

Management of bile duct stones (BDSs) in patients with surgically altered anatomies (SAAs) remains challenging. An endoscopic ultrasound-guided antegrade (EUS-AG) procedure and double-balloon enteroscopy-assisted endoscopic retrograde cholangiography (DB-ERC) have been used to remove BDSs from patients with SAAs. However, few comparative data have been reported. Therefore, we compared the efficacy and safety of the techniques. This was a single-center retrospective study. Patients with SAA who underwent the EUS-AG procedure or DB-ERC to remove intra- or extra-BDSs between November 2010 and March 2020 were included. The primary outcome was the technical success rate, defined as stent insertion or stone removal during the initial session. The secondary outcomes were the procedure time, incidence of adverse events (AEs), and complete stone removal rate. Of the 54 patients enrolled, 23 underwent the EUS-AG procedure and 31 DB-ERC. The technical success rates of EUS-AG and DB-ERC were 87.0% and 64.5%, respectively (P=0.11). The procedure time was significantly shorter in the EUS-AG group than in the DB-ERC group (51.9±15.4 vs 72.6±32.2min; P=0.01), and the early AE rates were 26.1% and 12.9%, respectively (P=0.71). The complete stone removal rates in patients who underwent previous stone removal were 94.1% in the EUS-AG group and 85.7% in the DB-ERC group (P=0.61). The EUS-AG afforded technical success and complete stone removal rates comparable with those of DB-ERC, but the former procedure was shorter. The AE rate was acceptable.

Laparoscopic transcystic common bile duct exploration as treatment for choledocholithiasis after Roux-en-Y gastric bypass.

Treatment of choledocholithiasis after Roux-en-Y gastric bypass (RYGB) is a therapeutic challenge given the altered anatomy. To overcome this technical difficulty, different modified endoscopic approaches have been described but significant morbidity accompanies these procedures. The aim of the present study is to report our experience with laparoscopic transcystic common bile duct exploration (LTCBDE) as treatment of choledocholithiasis after RYGB. This is a retrospective cohort study of 854 consecutive patients with RYGB at a single institution between January 2007 and December 2019. Our study population focused on patients who developed biliary events after RYGB. Demographic data and perioperative parameters were compared between patients who underwent laparoscopic cholecystectomy (LC) after RYGB with (defined as Group A) and without (defined as Group B) LTCBDE. Fifty-seven (8.93%) patients developed a biliary event after RYGB that led to LC. Of those, 11 (19.2%) presented choledocholithiasis during intraoperative cholangiogram and were simultaneously treated with LTCBDE (Group A). Choledocholithiasis was unsuspected in the preoperative setting in 7 (63.6%) of the 11 patients. The procedure was successful in 90.9% (n = 10). Comparing Group A and B, no statistically significant differences were found regarding age, gender, length of hospital stay, and morbidity (p > 0.05). Mean operative time of Group A was 113.1min, adding, on average, 35min to LC (113.1min vs 77.9min, p = 0.004). LTCBDE offers an effective approach for common bile duct stones in patients who underwent RYGB. This procedure did not add significant length of hospital stay nor morbidity to laparoscopic cholecystectomy.

Long-Term Outcomes of Endoscopic Treatment for Bile Duct Stones in Patients Aged ≥ 85 Years

Long-Term Outcomes of Endoscopic Treatment for Bile Duct Stones in Patients Aged ≥ 85 Years

Comparable safety of ERCP in symptomatic and asymptomatic patients with common bile duct stones: a propensity-matched analysis

Background The safety of endoscopic retrograde cholangiopancreatography (ERCP) for asymptomatic common bile duct (CBD) stones patients has not been thoroughly elucidated. This study attempted to compare the incidence and severity of ERCP complications in asymptomatic and symptomatic patients with CBD stones and to provide evidence for the treatment of asymptomatic CBD stones. Methods The clinical data of patients were retrospectively analyzed. These patients were divided into the asymptomatic CBD stones group and the symptomatic CBD stones group. Propensity score matching (PSM) was used to match the two groups. The incidence and severity of postoperative complications of ERCP in the two groups were analyzed. Results A total of 79 patients who had asymptomatic CBD stones and 795 patients who had symptomatic CBD stones were included in this study. After PSM, 79 patients from the asymptomatic CBD group and 316 patients from the symptomatic CBD stones group were identified. Before and after PSM, no significant differences in the incidence and severity of post-ERCP pancreatitis (PEP) were noted between the two groups (p > .05). In addition, no differences in the incidence and severity of other complications, including acute cholangitis, bleeding and perforation, between the two groups were observed before and after PSM (p > .05). Conclusions Patients with asymptomatic CBD stones do not exhibit an increased risk of ERCP-related complications compared with those with symptomatic CBD stones. ERCP was observed to be equally safe and efficacious for patients with asymptomatic versus symptomatic CBD stones.

The influence of stone size on spontaneous passage of common bile duct stones in patients with acute cholangitis: A retrospective cohort study

BackgroundThe common bile duct (CBD) stones passage in patients with cholangitis was unclear.This study aimed to evaluate the effect on CBD stone sizes and predicting factors on spontaneous passage in patients with cholangitis. MethodThe medical records of cholangitis at Her Royal Highness Princess Maha Chakri Sirindhorn Medical Center, Srinakharinwirot University from January 2014 to December 2019 were retrospectively reviewed. Patients with acute cholangitis from CBD stones underwent ERCP in the same admission were enrolled. ResultOf the 96 patients, The rate of spontaneous passage of CBD stones was 19.8%. By univariate analysis, factors significantly associated with a predictor of spontaneous CBD stone passage in patient with cholangitis were single CBD stone (p = 0.001), CBD stone diameter < 5 mm (p < 0.001), and clinical symptom improved before ERCP procedure (p = 0.004). Multivariate logistic regression analyses also revealed that these three factors were significantly associated with spontaneous passage. From ROC curve analysis, stone size of less than 4.85 mm was more likely to pass spontaneously with acceptable sensitivity (81.8%) and specificity (78.9%). ConclusionsCBD stone diameter < 5 mm, single CBD stone and improved clinical symptom before ERCP procedure are key predictors of spontaneous CBD stone passage in cholangitis.

Post endoscopic retrograde cholangiopancreatography cholecystitis: The incidence and risk factors analysis.

For decades, endoscopic retrograde cholangiopancreatography (ERCP) has been widely performed as a diagnostic and therapeutic procedure for biliary and pancreatic diseases. Complications of ERCP include pancreatitis, hemorrhage, perforation, cholangitis, and cholecystitis. There are few studies that focus on the incidence of post-ERCP cholecystitis and its potential risk factors. A retrospective single-center study was performed in 1345 ERCP procedures after excluding patients with current cholecystitis or post-cholecystectomy between January 2009 and December 2011. Potential risk factors for post-ERCP acute cholecystitis, including age, gender, biochemistry, imaging data, procedures such as endoscopic sphincterotomy (EPT), or endoscopic retrograde biliary drainage (ERBD), were obtained and analyzed by multivariate logistic regression analysis. Cholecystitis developed after 13 (0.96%) of the 1345 ERCP procedures. Univariate and multivariate logistic regression analyses showed that cystic duct stones (odds ratio [OR] = 198.26; 95% CI, 5.12-7835.44) and ERBD (OR = 37.58; 95% CI, 3.25-445.56) were important potential risk factors for post-ERCP cholecystitis. The percentage of ERBD procedures and cystic duct stones in patients with post-ERCP cholecystitis was 76.9% and 39.8%, respectively. The 13 patients with post-ERCP cholecystitis all received antibiotics, and four of them also received percutaneous gallbladder drainage. All patients recovered without significant clinical event or mortality. The incidence of post-ERCP cholecystitis was 0.96% in the 1345 ERCP procedures performed. Cyst duct stones and ERBD were found to be risk factors for post-ERCP cholecystitis.

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.

Right posteroinferior bile duct angulation correlates with bile duct stone occurrence in patients with hepatolithiasis.

This study aimed to examine the correlation between right posteroinferior bile duct (RPBD) angulation and the occurrence of bile duct stones in patients with hepatolithiasis. Patients presenting with hepatolithiasis in our hospital from January 2011 to July 2016 were divided into two groups according to whether their RPBD was affected by stones. A statistical analysis for the relevant factors associated with bile duct stone formation in the RPBD was performed. The binary logistic regression results showed that stenosis of the right hepatic duct [odds ratio (OR): 7.313; 95% confidence interval (CI) 4.131-12.945)] and the angle of the RPBD (OR 0.896; 95%CI 0.877-0.916) were risk factors associated with the formation of RPBD stones. Further, the receiver operating characteristic curve indicated that, when the angle of the RPBD was less than 44.58°, stones were able to form more easily in the RPBD. The occurrence of bile duct stones is well correlated with sharp bile duct angulation.

Surgical Techniques for the Laparoscopic Treatment of Bile Duct Stones in Patients With a History of Upper Abdominal Operations: Retrospective Cohort Study.

Few authors have studied applying the laparoscopic approach in patients with previous upper abdominal operations, but no comparison has been made between laparoscopic and open approaches in patients with previous upper abdominal operations. This article aims to introduce surgical techniques and details in treatment to surgeons specialized in minimally invasive surgery. From January 2010 to January 2018, 460 eligible patients were divided into 3 groups and analyzed retrospectively. Group A: patients with a history of upper abdominal operations who underwent laparoscopy (n=124); group B: patients without a history of upper abdominal operations who underwent laparoscopy (n=140); and group C: patients with a history of upper abdominal operations who underwent an open operation (n=196). Group A was the experimental group; groups B and C served as the control groups. No significant difference was found between groups A and B. Significant differences were found between groups A and C in estimated blood loss (258.3±67.2 vs. 424.7±103.7 mL, P<0.001), postoperative hospitalization (5.7±2.3 vs. 10.2±3.1 d, P<0.001), and postoperative complications (16.1% vs. 42.9%, P=0.013). The final rate of stones clearance was 100% in 3 groups. The total rate of stone recurrence was 7.8%. Laparoscopy with certain surgical techniques was feasible, effective, and advantageous for patients with previous upper abdominal operations by experienced surgeons. It is necessary for surgeons to have advanced skills and surgical techniques to achieve a successful laparoscopy.

Sensitivity and specificity of clinical, biochemical, and radiological predictors of common bile duct stones in patients who underwent endoscopic retrograde cholangiopancreatography: a binary logistic regression analysis

Sensitivity and specificity of clinical, biochemical, and radiological predictors of common bile duct stones in patients who underwent endoscopic retrograde cholangiopancreatography: a binary logistic regression analysis

Incidence and predictors of common bile duct stones in patients with acute cholecystitis: a systematic literature review and meta-analysis.

Acute cholecystitis (AC) is a surgical condition that is usually managed by emergency surgery. The presence of common bile duct stones (CBDS) in this setting mandates definitive treatment to avoid complications such as cholangitis. The incidence of CBDS in the setting of AC is poorly defined. A systematic English literature search was conducted in PubMed, MEDLINE and Embase to determine the incidence of CBDS in patients presenting with AC. Outlier studies identified by funnel plot analysis were excluded and the incidence of CBDS was identified. The mean CBD diameter and liver function test values of patients with AC and CBDS were calculated. Data were extracted from 19 studies representing a total 4057 patients with AC. Routine biliary imaging was not performed in all studies. The pooled incidence of CBDS was 13.7% (95% confidence interval 11.8-15.9). The incidence of unsuspected retained CBDS was 1.1%. Histologically confirmed cases of AC had a similar rate of CBDS compared to those diagnosed clinically. The mean CBD diameter of patients with AC and CBDS was 7.2 mm compared to 5.8 mm without. Liver function test values in the presence of CBDS were more likely to be deranged, with gamma-glutamyltransferase the most sensitive and specific marker for CBDS in the setting of AC. CBDS is present in a significant proportion of patients presenting with AC. Routine biliary imaging is advised in all patients presenting with AC where possible.

A Preliminary Study of Biliary Microbiota in Patients with Bile Duct Stones or Distal Cholangiocarcinoma.

Background and Objective The distal cholangiocarcinoma (dCCA) is associated with many factors: genes, environment, infection, etc. The current changes in biliary flora are thought to be involved in the formation of many gastrointestinal tract (GIT) diseases, like colon adenocarcinoma. Therefore we want to investigate whether the dCCA has a certain correlation with biliary microecology, and to detect specific strains. Methods A total of 68 adults were enrolled, of whom 8 with dCCA, 16 with recurrent choledocholithiasis, and 44 with the onset of common bile duct stones. Endoscopic Retrograde Cholangiopancretography (ERCP) was utilized to collect bile samples for DNA extraction and 16S rRNA gene sequencing, followed by analysis of bile microbiota composition. Results First, Proteobacteria, Firmicutes, Bacteroidetes, and Actinobacteria are the most dominant phyla in the bile of patients with dCCA and the onset of common bile duct stoes. Secondly, compared with the onset of common bile duct stones patients, we got a significant increase in the phylum Gemmatimonadetes, Nitrospirae, Chloroflexi, Latescibacteria, and Planctomycetes in dCCA patients. Finally, at the genus level, we obtained sequencing results of 252 bacterial genera from patients with dCCA, recurrent choledocholithiasis, and the new onset of common bile duct stones, revealing heterogeneity among individuals. Conclusion To the best of our knowledge, this is the first study of the dysbiosis of bile flora in patients with dCCA. This micro-ecological disorder may be a decisive factor in the formation of dCCA. At the same time, for the first time, this study provides a test chart of biliary microbial populations that may be associated with recurrent choledocholithiasis. The compositional changes of the core microbial group of the biliary tract have potentially important biological and medical significance for the microbiological biliary disorders of dCCA.

2019 Canadian Surgery Forum Abstracts.

# 01. The future of general surgery training: a Canadian resident nationwide Delphi consensus statement {#article-title-2} Various pedagogical models have been introduced in an attempt to improve and restructure surgical training, but significant obstacles remain. Before implementing national

Surgical management of the impacted dormia basket during ERCP

The incidence of associated common bile duct stones in patients undergoing cholecystectomy is 10%. The present day management of common bile duct stone is pre- or post-operative endoscopic retrograde cholangio-pancreatography and clearance of common bile duct. Complications of ERCP and CBD stone extraction have been reported to occur in 5 to 10% cases which may range from mild to life threatenin Here we report a case of cholelithiasis with choledocholithiasis with obstructive jaundice and patient while undergoing ERCP and stone retrieval had complication of impacted dormia basket which was managed by surgery.

RETRACTED:Correlation analysis of biochemical indicators in common bile duct stone patients with negative magnetic resonance cholangiopancreatography

RETRACTED:Correlation analysis of biochemical indicators in common bile duct stone patients with negative magnetic resonance cholangiopancreatography

The necessity and development of a new modified scoring system for simultaneous detection of common bile duct stones in patients with planned laparoscopic cholecystectomy

IntroductionCholedocholithiasis is one of the undesirable consequences of gallbladder stones. Identifying such patients before cholecystectomy will prevent biliary leakage which develops secondarily to stones in the common bile duct (CBD). Scoring systems can be useful for prevention of complications.Material and methodsA total of 201 patients with symptomatic cholecystolithiasis were prospectively evaluated with regards to stone presence in the CBD. These evaluations identified those patients suspected of having CBD stones. Parameters were established as clinically obstructive jaundice or acute cholangitis attack, biochemically abnormal liver functions tests (LFT), radiological identification of CBD stone or choledochal dilatation (&gt; 8 mm) as revealed by ultrasonography (USG). Residual stone controls were conducted through abdominal USG and LFT in the 3rd and 6th postoperative months. The patients’ physical examinations were routinely conducted at each follow-up. Patients with common bile duct stones and those without were statistically compared as per the following data: age, sex, cholangitis, γ-glutamyl transpeptidase (GGT), alkaline phosphatase (ALP), Aspartate aminotransferase (AST), alanine aminotransferase (ALT), cholesterol, triglyceride, total bilirubin, direct bilirubin, CBD stone presence and choledochal size as revealed by USG.ResultsThe parameters of our scoring system were: choledocholithiasis and choledochal dilatation in USG, total and direct bilirubin elevation, cholangitis episode in the last month, elevated AST, ALT, ALP, GGT, age ≥ 55 and TG level. Twenty-seven patients had choledocholithiasis. With this scoring system, the minimum score required for preoperative ERCP was 9. The rate of simultaneous CBD stones was 13.4%.ConclusionsSelective cholangiography that uses this scoring system brings about more cost utility than that of its routine performance.

Endoscopic management of bile duct stones in patients with surgically altered anatomy.

Bile duct stones in patients with surgically altered anatomy still pose a challenge to endoscopists. For successful endoscopic management of bile duct stones, there are multiple hurdles: Intubation to the afferent limb, biliary cannulation, ampullary intervention and stone extraction. The major advancement in this area is the development of dedicated device-assisted endoscopes for endoscopic retrograde cholangiopancreatography (ERCP). In patients with Billroth II reconstruction, a high technical success rate is reported using a duodenoscope but can be complicated by a potentially high perforation rate. In patients with Roux-en-Y reconstruction, device-assisted ERCP shows high technical success and low adverse event rates. Meanwhile, endoscopic papillary large balloon dilation enables safe and effective stone extraction with less use of endoscopic mechanical lithotripsy in patients with a dilated distal bile duct, but intraductal lithotripsy is sometimes necessary for management of very large bile duct stones. In cases with difficult stones, alternative approaches such as laparoscopy-assisted ERCP and endoscopic ultrasound (EUS)-guided intervention are increasingly reported with preliminary but promising results. However, comparative studies are still lacking in this area and prospective randomized controlled trials are warranted in terms of safety, efficacy and cost-effectiveness.

Self-expandable metal stents for the extraction of common bile duct stones in patients receiving dual antiplatelet agents: a pilot study.

Endoscopic sphincterotomy or endoscopic papillary balloon dilatation during endoscopic retrograde cholangiopancreatography (ERCP) are associated with a high risk of bleeding in patients receiving dual antiplatelet agents (APAs). However, the discontinuation of antiplatelet agents increases the risk of thromboembolic events in these patients. To date, the placement of self-expandable metal stents (SEMSs) in patients receiving dual APAs has not been well investigated. The aim of this study was to evaluate the feasibility and safety of SEMS placement for the removal of common bile duct (CBD) stones in patients in whom APAs were not discontinued. Ten consecutive patients who were suspected of having CBD stones and who were receiving dual APAs were prospectively enrolled and underwent temporary SEMS placement, followed by stone extraction and SEMS removal. The patients continued taking dual APAs at the time of undergoing the procedure. SEMS placement was successful in all ten patients. Complete duct clearance with the SEMSs was achieved in a single session in all patients with CBD stones (9/9, 100%). One patient had cholangitis, but ERCP did not reveal biliary stones. There were no cases of bleeding during or after the procedure, even though all patients continued to take dual APAs. There were no new thromboembolic events. SEMSs can be used for the extraction of CBD stones in patients on dual APAs, and does not lead to hemorrhagic or thromboembolic events.