Duct Clearance Research Articles

Laparoscopic common bile duct exploration for common bile duct stones after gastric surgery.

Gallstone disease is common after gastric surgery and especially after weight loss from bariatric surgery. In patients with normal gastroduodenal anatomy, treatment of common bile duct stones (CBS) generally consists of, endoscopic retrograde cholangiopancreaticography (ERCP) and endoscopic sphincterotomy (ES), followed by cholecystectomy in a second stage. However, after gastric surgery the papilla may not be easily accessible endoscopically. The aim of our study was to evaluate the therapeutic success of single-stage laparoscopic cholecystectomy and common bile duct exploration (LCBDE) after previous gastric surgery. In this observational cohort study, all LCBDE in patients with previous gastric surgery between January 2014 and July 2022 were retrospectively reviewed. Gastric surgery consisted of Roux-en-Y gastric bypass, BII subtotal gastrectomy, total gastrectomy and subtotal gastrectomy with Roux-en-Y reconstruction. Outcomes of interest consisted of successful duct clearance, postoperative adverse events and CBS recurrence. Forty-four patients (M/F: 22/22) underwent LCBDE after previous gastric surgery, in which simultaneous cholecystectomy was performed in 38 cases. Median (range) age 68 (25-90) years. Presence of CBS was confirmed in 38 patients (85%), a choledochal polyp in one patient (2%) and recurrence of gastric cancer in another (2%). Duct clearance was successful in 37 out of 38 patients (97%). Median (range) length of stay after LCBDE was 1 (0-12) day(s). Eight patients developed a postoperative adverse event, of which three Clavien-Dindo > 3a complications. Three patients were readmitted. At a median (range) follow-up of 60 (24-120) months, no CBS recurrences were observed. LCBDE is a safe technique, with a high rate of successful duct clearance after previous gastric surgery, even after previous cholecystectomy. In experienced centers, LCBDE provides a valid alternative for complex interventional endoscopy, omitting the need for the creation of a gastro-gastric fistula.

Endoscopic Management of Benign Pancreaticobiliary Disorders.

Endoscopic management of benign pancreaticobiliary disorders encompasses a range of procedures designed to address complications in gallstone disease, choledocholithiasis, and pancreatic disorders. Acute cholecystitis is typically treated with cholecystectomy or percutaneous drainage (PT-GBD), but for high-risk or future surgical candidates, alternative decompression methods, such as endoscopic transpapillary gallbladder drainage (ETP-GBD), and endoscopic ultrasound (EUS)-guided gallbladder drainage (EUS-GBD), are effective. PT-GBD is associated with significant discomfort as well as variable adverse event rates. EUS-GBD leverages lumen-apposing metal stents (LAMS) for direct access to the gallbladder, providing the ability to treat an inflamed GB internally. Choledocholithiasis is primarily managed with ERCP, utilizing techniques to include balloon extraction, mechanical lithotripsy, or advanced methods such as electrohydraulic or laser lithotripsy in cases of complex stones. Altered anatomy from bariatric procedures like Roux-en-Y gastric bypass may necessitate specialized approaches, including balloon-assisted ERCP or EUS-directed transgastric ERCP (EDGE). Post-operative complications, including bile leaks and strictures, are managed endoscopically using sphincterotomy and stenting. Post-liver transplant anastomotic and non-anastomotic strictures often require repeated stent placements or advanced techniques like magnetic compression anastomosis in refractory cases. In chronic pancreatitis (CP), endoscopic approaches aim to relieve pain and address structural complications like pancreatic duct (PD) strictures and calculi. ERCP with sphincterotomy and stenting, along with extracorporeal shock wave lithotripsy (ESWL), achieves effective ductal clearance for PD stones. When traditional approaches are insufficient, direct visualization with peroral pancreatoscopy-assisted lithotripsy is utilized. EUS-guided interventions, such as cystgastrostomy, pancreaticogastrostomy, and celiac plexus blockade, offer alternative therapeutic options for pain management and drainage of peripancreatic fluid collections. EUS plays a diagnostic and therapeutic role in CP, with procedures tailored for high-risk patients or those with complex anatomy. As techniques evolve, endoscopic management provides minimally invasive alternatives for patients with complex benign pancreaticobiliary conditions, offering high clinical success and fewer complications.

Predictive factors of spontaneous common bile duct clearance and unnecessary ERCP in patients with choledocholithiasis.

Endoscopic retrograde cholangiopancreatography (ERCP) is the first-line procedure for choledocholithiasis treatment. However, it is associated with a 10 % rate of adverse events. Spontaneous migration of common bile duct (CBD) stones occurs in 6-33 % of choledocholithiasis cases, making ERCP avoidable. This study aimed to identify predictors of spontaneous CBD stones' migration. Retrospective study including patients diagnosed with choledocholithiasis and submitted to ERCP. Patients were divided into 2 groups considering spontaneous stone migration (i.e.: the absence of CBD stones on ERCP). Data on patients' characteristics, imaging findings, biochemical analysis, and ERCP procedure were analyzed to identify predictors of spontaneous migration of CBD stones. 334 patients with a mean age of 71.7 years were included in the study: 76.6 % without and 23.4 % with spontaneous migration of CBD stones. Although some patients' features (gender and clinical presentation), imaging findings (diameters of the largest stone and CBD), biochemical analysis (bilirubin levels at diagnosis and pre-ERCP), and ERCP procedure characteristics (time from diagnosis to ERCP) were different between groups, only three variables were defined as predictors: the absence of acute cholangitis, the largest stone diameter ≤5 mm, and the bilirubin levels pre-ERCP ≤ 2mg/dL. When using those variables together there was a chance of 81-86 % to correctly distinguishing patients with and without spontaneous CBD stone migration. The size of the largest stone at diagnosis was validated as a predictor of CBD stones' spontaneous migration. Furthermore, two new predictors were identified: bilirubin levels pre-ERCP ≤ 2 mg/dL, and no acute cholangitis at the clinical presentation of choledocholithiasis. EUS and ERCP in the same session should be considered in patients with factors predictive of stone migration, especially when combined, to minimize unnecessary ERCP and possible complications.

Impact of single layer reconstruction following surgery for chronic calcific pancreatitis: a retrospective analytical study

Background: Surgery is an effective treatment for chronic calcific pancreatitis (CCP), addressing intractable pain and complications. While many studies predict outcomes of various surgical procedures, few focus on the impact of reconstruction type. This retrospective study analyzed the outcomes of single-layer pancreaticojejunostomy (PJ) following surgery for CCP. Aim was to evaluate outcomes of single-layer PJ in CCP patients, focusing on complications, pain relief, exocrine insufficiency, and endocrine dysfunction, compared with historical controls. Methods: The study included 250 CCP patients treated at a tertiary care center in Chennai, India, from January 2011 to December 2024. Surgical ductal clearance and single-layer Roux-en-Y PJ using non-absorbable/delayed absorbable sutures were performed. Data on intraoperative parameters, postoperative complications, and follow-up assessments at 1, 2, and 3 months were analyzed. Primary outcomes included reductions in pancreatic fistula, bleeding, and infections. Secondary outcomes included operative time and duct size. Results: The median age was 38 years, with a male predominance (74%). Frey’s procedure was the most common (59.2%), and the mean operative time was 170 minutes. Complications included pancreatic fistulas (6.4%) and infections (9.6%), with a low mortality rate (0.4%). Postoperatively, 91% of patients achieved pain relief, and 64.4% of diabetics had improved glycemic control. Single-layer PJ showed shorter operative times than two-layer PJ with similar pain relief and blood loss. Complications decreased significantly (from 45% to 8%), alongside reduced postoperative pain scores. Conclusions: Single-layer PJ is a safe, effective reconstruction method for CCP, reducing surgical complexity and related complications.

Single-stage laparoendoscopic management of cholecystocholedocholithiasis: A retrospective study comparing starting with ERCP versus with laparoscopic cholecystectomy.

Endoscopic retrograde cholangiopancreatography (ERCP) combined with laparoscopic cholecystectomy (LC) remains the most common therapeutic strategy used for cholecystocholedocholithiasis (CCL). Recently, single-stage ERCP + LC has gained popularity for treating CCL due to patient satisfaction and financial considerations. In this study, we aimed to compare the feasibility and efficacy of the two variants of single-stage ERCP + LC (starting with ERCP followed by LC versus starting with LC followed by ERCP) for treatment of CCL. A total of 115 patients who underwent single-stage ERCP + LC for CCL from January 2021 to December 2023 were enrolled in a retrospective comparative cohort study. These patients were divided into two groups: Group A (ERCP-first approach) and Group B (LC-first approach). Patients in Group A had a common bile duct clearance rate of 88.2%, which was comparable to the 95.7% observed in Group B (p = 0.163). The mean duration of the ERCP procedure was comparable between the two groups (43.3 ± 11.8 vs 39.5 ± 13.5 minutes; p = 0.112). However, the mean duration of the LC procedure was significantly longer in Group A than in Group B (41.2 ± 8.98 vs 37.2 ± 12.2 minutes; p = 0.045). The mean total operative time for the combined ERCP + LC was significantly longer in Group A compared to Group B (81.9 ± 16.7 vs 75.1 ± 19.3 minutes; p = 0.046). Post-ERCP pancreatitis occurred in 4 patients in Group A and in 2 patients in Group B (p = 0.701). Both LC-1st approach and ERCP-1st approach are feasible and highly effective for treating CCL through single-stage ERCP + LC. However, the LC-1st approach has the advantage of a shorter operative time.

Treatment for recurrent choledocholithiasis: endoscopic? or laparoscopic? A prospective cohort study.

Endoscopic and laparoscopic techniques are crucial for management of bile duct stone. The aim of this study was to share our initial experiences with endoscopic and laparoscopic treatments for recurrent choledocholithiasis, with a particular focus on long-term complications. From January 2014 to June 2017, a total of 153 patients with recurrent common bile duct stones were prospectively recruited in this study. Patients were scheduled for either an endoscopic procedure (ERCP/EST group, n = 84), or a laparoscopic procedure (LCBDE group, n = 69). Data were collected on comorbid conditions, presenting symptoms, bile duct clearance, and the incidence of both short-term and long-term complications. Patients in ERCP/EST group had a stone clearance rate comparable to that of the LCBDE group (94.2% vs 91.7%, p = 0.549). Minor (Clavien-Dindo grade 1 and 2) and major short-term complications (Clavien-Dindo grade 3 and above) were similar between patients in two groups (ERCP/EST group 17.9% versus LCBDE group 26.1%, and ERCP/EST group 7.1% versus LCBDE group 5.8%, p = 0.227 and p = 0.740, respectively). Patients in the ERCP/EST group had a shorter stone free interval than patients in the LCBDE group (28.5 ± 14.7months versus 43.3 ± 17.8months, p = 0.029). During a mean follow-up period of 67.0months, more patients in the ERCP/EST group experienced stone recurrence compared to those in the LCBDE group (26.1% vs 11.6%, p = 0.020). In the ERCP/EST group, 45.5% (10/22) of the recurrent cases experienced more than two recurrences, with three patients requiring choledochojejunostomy due to repeated recurrence. Among patients with a non-dilated common bile duct (d ≤ 8mm), both groups had comparable short-term and long-term complication rates (p = 0.151 and p = 0.404, respectively). Laparoscopic treatment is a safe and effective option for patients with recurrent choledocholithiasis, extending the stone free interval, reducing the likelihood of stone recurrence, and highlighting benefits of minimally invasive surgery.

Utility of cholangioscopy in patients with surgically altered anatomy after percutaneous transhepatic biliary drainage

Background Surgical therapy that alters the biliary anatomy makes endoscopic access to the biliary system difficult. These surgeries promote cholestasis, calculi development and lead to biliary stricture. Stricture resolution and removal of intrahepatic bile duct stones remain challenging. Methods This is a retrospective analysis of prospective data of patients with altered surgical anatomy with intrahepatic bile duct stones/strictures. Percutaneous transhepatic biliary drainage (PTBD) was attempted, followed by transhepatic SpyGlass cholangioscopy for stricture or removal of intrahepatic bile duct stones. The number of sessions, stricture dilatation and complications were noted. A cholangiogram revealing a clear duct was a technical success, and stricture resolution was considered a clinical success. Complete ductal clearance was clinical success in those with stones. Patients with follow-up of a minimum of six months were included. Results Twenty-four patients [16(66.7%) male, median age 41.5(IQR 38.2-49) years] successfully underwent PTBD. The commonest indication was biliary stricture in 13(54.2%), followed by intrahepatic stones in 6(25%) and stones with strictures in 5(20.8%) patients. Most patients had undergone Roux-en-Y hepaticojejunostomy in 22(91.7%), and the level of bile duct obstruction was hilum in 20(83.3%). The median (IQR) total bilirubin levels reduced from 6.6(5.1-8.3) to 1.8(1.2-2.8) mg/dL after PTBD; p<0.001. The technical success was 90.9% after a median (IQR) number of 2(1.7-2) SpyGlass sessions; clinical success was 88.9% after a median of 3(3-4) SpyGlass sessions. Abdominal pain (8.3%) and cholangitis (12.5%) were the complications after cholangioscopy. The median (IQR) follow-up duration was 7(6-8) months. Conclusions SpyGlass cholangioscopy, although challenging, is a safe option for intrahepatic stones and strictures with excellent short-term outcomes and minimal complications.

Long-Term Outcomes of Early Surgery vs Endoscopy First in Chronic Pancreatitis

Patients with painful chronic pancreatitis and a dilated pancreatic duct can be treated by early surgery or an endoscopy-first approach. To compare long-term clinical outcomes of early surgery vs an endoscopy-first approach using follow-up data from the ESCAPE randomized clinical trial. Between April 2011 and September 2018, 88 patients with painful chronic pancreatitis were randomly assigned to early surgery or an endoscopy-first approach in 30 hospitals in the Netherlands collaborating in the Dutch Pancreatitis Study Group as part of the ESCAPE randomized clinical trial. For the present cohort study, long-term clinical data were collected after the initial 18-month follow-up. Follow-up was completed in June 2022, and data analysis was performed in June 2023. Patients with chronic pancreatitis were randomly assigned to early surgery or an endoscopy-first approach. The primary end point was pain, assessed by the Izbicki pain score; secondary end points included patient-reported complete pain relief and satisfaction. Predefined subgroups included patients who progressed from endoscopy to surgery and those with ductal clearance obtained by endoscopy. Analysis was performed according to the intention-to-treat principle. In this cohort study, 86 of 88 overall patients could be evaluated, with a mean (SD) follow-up period of 98 (16) months. Of 88 initial patients, 21 patients (24%) were female, and mean (SD) patient age was 61 (10) years. At the end of long-term follow-up, the mean (SD) Izbicki pain score was significant lower (33 [31] vs 51 [31]) in the early surgery group, as was the rate of patient-reported complete pain relief (14 of 31 patients [45%] vs 6 of 30 patients [20%]), compared to the endoscopy-first group. After the initial 18-month follow-up, 11 of 43 patients in the early surgery group (26%) underwent reinterventions vs 19 of 43 patients in the endoscopy-first group (44%). At the end of follow-up, more patients in the early surgery group were "very satisfied" with their treatment (22 of 31 patients [71%] vs 10 of 30 patients [33%]). Patients who progressed from endoscopy to surgery (22 of 43 patients [51%]) had significantly worse mean (SD) Izbicki pain scores (33 [31] vs 52 [24]) compared to the early surgery group and had a lower rate of complete pain relief (55% for early surgery vs 12% for endoscopy first). In the endoscopy-first group, patients with endoscopic ductal clearance had similar mean (SD) Izbicki pain scores as the remaining patients (49 [34] vs 53 [28]). In this cohort study evaluating long-term outcomes of the ESCAPE randomized clinical trial, after approximately 8 years of follow-up, early surgery was superior to an endoscopy-first approach in patients with painful chronic pancreatitis and a dilated main pancreatic duct in pain scores and patient satisfaction. Notably, patients who progressed from endoscopy to surgery had worse outcomes compared to patients undergoing early surgery, and obtaining endoscopic ductal clearance did not improve outcomes.

HPB SO70 - Evaluating the Outcome of Laparoscopic Common Bile Duct Exploration Against Key Performance Indicator (KPI) of the British Benign Upper GI Surgical Society (BBUGSS)

Abstract Background Treatment of common bile duct (CBD) stone(s) can be challenging with a risk of significant complications. Laparoscopic common bile duct exploration (LCBDE) displays superior outcomes when compared to endoscopic retrograde cholangiopancreatography (ERCP). Acknowledging the impact of patient variables and surgical proficiency, the British Benign Upper GI Surgical Society (BBUGSS) developed Key Performance Indicators (KPIs) to optimize LCBDE outcomes. The present study comprises an audit of LCBDE outcomes with respect to the BBUGSS KPIs and aims to determine the feasibility and quality of LCBDE that can be achieved in a district general hospital (DGH) with a recently developed LCBDE service. Method This retrospective observational study examined all adult patients who underwent LCBDE between August 2022 and June 2024 by two specialized biliary surgeons at a single surgical unit within a DGH. This DGH also serves as a referral center for biliary cases from affiliated hospitals. The preference in our surgical unit is single stage management (laparoscopic cholecystectomy and simultaneous LCBDE) of CBD stones in surgically fit patients. The analysis included preoperative assessments, intraoperative observations, and postoperative outcomes, with respect to the published BBUGSS KPIs for LCBDE. Results 60 patients were eligible for inclusion; median age was 56 years (IQR 40-67) and 40 (66.7%) were female. 33 (55%) were emergency cases. 52 (86.7%) were transcystic exploration; of these 8 (15.4%) utilised basket-in-catheter and 44 (84.6%) utilised choledochoscopes. Median post-operative stay for transcystic exploration was 1 day (IQR 0-2) and for cholechodotomy 8 days (IQR 5-9). Key Performance IndicatorBBUGSS StandardOur outcomeConversion rates<10%0%Bile duct clearance rates>85%91.7%Bile Leak Rates<5%0%Returns to theatre<5%0%Readmission rates (within 30 days)<15%6.7%Overall Morbidity<15%3.3%Overall Mortality<1%0% Conclusion This study indicates that the BBUGSS KPIs for LCBDE are satisfactorily achieved in our centre. Adequate ductal clearance with minimal morbidity was achieved. Our outcomes are likely attributed to the recent commencement of a specialist biliary service and utilisation of predominantly transcystic approach, with the aid of electrohydraulic lithotripsy where needed, as opposed to choledochotomy. Furthermore, the present study suggests a high quality LCBDE service is feasible in a DGH setting if there is sufficient clinical and managerial motivation. We suggest that single stage management of bile duct stones model should be considered in other similar centres.

The role and designation of emergency choledochoscopy in the laparoscopic treatment of patients with complicated choledocholithiasis

Background. The management of patients with cholelithiasis (gallstone disease) and choledocholithiasis who require removal of the gallbladder remains debatable and require urgent actions of the surgeon, especially in cases with concomitant mechanical jaundice. Laparoscopic choledochoscopy is an effective method of examining the bile ducts that allows for the complete removal of calculi, but in the meanwhile, there is not enough information about its effectiveness and sensitivity as part of surgical technology. Purpose: to improve the outcomes of treatment in patients with choledocholithiasis using laparoscopic choledocholithoextraction and choledochoscopy, as well as to assess the diagnostic value of laparoscopic choledochoscopy in bile duct examination and its significance as a component of surgical technology in laparoscopic choledocholithoextraction in patients with gallstone disease. Materials and methods. Between 2018 and 2024, we conducted an analysis of treatment outcomes in 139 patients with gallstone disease and choledocholithiasis, 51 males (36.7 %) and 88 females (63.3 %). The mean age of patients aged 17 to 86 years was 59.5 ± 1.7 years: males — 56.9 ± 1.7 years, females — 62.1 ± 1.7 years. All participants underwent laparoscopic choledocholithoextraction with choledochoscopy. In 29 (20.8 %) patients, choledocholithoextraction and choledochoscopy were performed through the cystic duct, the remaining 110 (79.1 %) people underwent choledocholithotomy with lithoextraction via choledochoscopy. Surgical intervention (laparoscopic choledocholithoextraction and choledochoscopy) was performed using a choledochofiberscope Olympus CHF-V with a diameter of 5 mm and a Karl Storz with a diameter of 3 mm; lithoextraction was done via choledochotomy access with the use of Dormia-type baskets (FG-55D, FG-55D Olympus). Results. All patients underwent bile duct examination via choledochoscopy with mechanical choledocholithoextraction. The first group included 110 (79.1 %) participants who had laparoscopic choledocholithotomy, lithoextraction and choledochoscopy. The second group comprised 29 (20.8 %) patients who underwent choledocholithoextraction and choledochoscopy through the cystic duct. In the first group, on average 3.4 ± 0.4 stones (from 1 to 24) were removed, in the second group — 2.6 ± 0.5 (from 0 to 6). During laparoscopic choledochoscopy with lithoextraction in the first group, bile duct clearance rate amounted to 108 (98.1 %), in the second group — 27 (93.0 %). Bile leakage through the drainage was recorded in 4 (4.5 %) patients from the first group. Endoscopic papillosphincterotomy with lithoextraction was performed in 2 (1.8 %) patients from the first group and 2 (6.8 %) from the second group, due to wedged stones that could not be removed. There were no fatal cases observed. Conclusions. Urgent laparoscopic choledocholithoextraction with choledochoscopy should be applied as one of the technologies for the treatment of gallstone disease and choledocholithiasis, which makes it possible to perform choledocholithoextraction, choledochoscopy with cholecystectomy in one step, while preserving the autonomy of the hepatopancreatobiliary zone and avoiding complications typical for transpapillary interventions.

Clinical Profile and Endoscopic Management in Patients with Choledocholithiasis.

Common bile duct stones is a common medical problem that are usually seen in association with gallstone disease. Endoscopic management of Common bile duct stones involves doing Endoscopic retrograde cholangiography for bile duct clearance which is the primary therapeutic modality of choice. This prospective study was done to identify the clinical characteristics and outcome of patients presenting with Common bile duct stones undergoing Endoscopic retrograde cholangiography. A prospective observational study was conducted on all patients undergoing Endoscopic retrograde cholangiography in department of Gastroenterology, Tribhuvan University Teaching Hospital, for management of diagnosed or suspected choledocholithiasis from April 2023 to March 2024. Patient demographics, clinical characteristics, Endoscopic retrograde cholangiography findings and post procedure outcome data were collected and analysed. A total of 110 patients (61.8% male and 38.2% female) were included in the final analysis. Successful clearance of Common bile duct was obtained in 76.4% patients with overall adverse events of 18% related to the procedure. Among patients undergoing the procedure, 16.4% couldn’t be managed with Endoscopic retrograde cholangiography and were referred for surgical management. Endoscopic management in form of Endoscopic retrograde cholangiography is a safe and effective method to manage patients with Common bile duct stones.

Conquering the common bile duct: outcomes in minimally invasive transcystic common bile duct exploration versus ERCP.

Given the increasing interest for surgeons to reclaim the common bile duct in managing choledocholithiasis, there is a growing movement to perform common bile duct exploration (CBDE). Advantages of concomitant CBDE with cholecystectomy include fewer anesthetic events and decreased length of stay. As there is a paucity of literature evaluating the use of the robotic platform for CBDE, our study aims to compare intraoperative and post-operative outcomes between robotic-assisted one-stage and two-stage management of choledocholithiasis. A retrospective chart review was performed from May 1, 2022 to December 31, 2023, identifying patients with choledocholithiasis who underwent robot-assisted laparoscopic cholecystectomy and transcystic CBDE with choledochoscopy (one-stage management). Preoperative, intraoperative, and post-operative variables were compared to a control group of subjects with choledocholithiasis who underwent laparoscopic cholecystectomy with pre- or post-operative ERCP (two-stage management). Statistical analysis was performed using Chi-squared, Fisher's exact, Student's T, or Mann-Whitney test. Fifty-three subjects who underwent one-stage management and 101 subjects who underwent two-stage management met inclusion criteria. Groups had similar demographics and medical history. Time to CBD clearance (45.2h vs 47.0h, p = .036), total length of stay (3.9days vs 5.1days, p = .007), fluoroscopy time (70.3s vs 151.4s, p < .001), and estimated radiation dose (23.0mSv vs 40.3mSv, p = .002) were significantly lower in the one-stage group compared to two-stage. Clearance rates, complication rates, and 30-day readmission rates were similar for both groups. Total length of stay and radiation exposure remained significantly lower on subanalysis comparing one-stage management to two-stage management with ERCP either before or after cholecystectomy. Robotic-assisted laparoscopic cholecystectomy with transcystic common bile duct exploration via choledochoscopy is a safe and feasible option in the management of choledocholithiasis. It offers a shorter time to duct clearance, shorter length of stay, and less radiation exposure when compared to two-stage management.

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.

SP4.1 - Incidence of recurrent bile duct stones following 6140 laparoscopic cholecystectomies and bile duct explorations: management and evaluation of risk factors

Abstract Aim To evaluate the rate of bile duct stone recurrence and possible risk factors in patients undergoing laparoscopic cholecystectomy (LC) and bile duct exploration (LCBDE) on a unit adopting routine cholangiography and LCBDE. Methods A prospective database of LC and LCBDE with confirmed ductal clearance spanning 30 years was reviewed. Those returning with clinical and laboratory suspicion of recurrence were included whether or not MRCP confirmation was obtained or intervention required. Apart from annual follow up electronic records were examined in 2020 and 2023 to capture unreported episodes. Results 1447 patients underwent LCBDE. 56 (3.8%) had suspected recurrence after a mean of 36.6 months (5-144). Mean age was 67.6 years and 57.1% were females. 12 (21.4%) settled on conservative management, including Glucagon administration, and MRCP was negative. 44 patients (78.6%) had 59 confirmed recurrence episodes; 53 needing 63 ERCPs and 6 settling conservatively. 12/44 (21.4%) had repeat recurrences. Only one biliary-enteric anastomosis was required. Only 11 of 4693 LC (0.23%) had recurrent stones (5 repeatedly) after a median interval of 30 months (5-120). 19 recurrence episodes occurred during which 13 settled spontaneously and 6 needed 9 ERCPs. In spite of average rates of ERCP morbidity no biliary related deaths resulted from stone recurrence. Compared to the rest of LCBDEs those with recurrence were more male, older, with more dilated CBD on USS &amp; required more choledochotomies for larger stones. Conclusions CBDS recurrence occurs in 3.8% after LCBDE with 3% confirmed and requiring intervention, significantly lower than after sphincterotomy. Glucagon may help small stones pass. 21.4% have repeat recurrences justifying stone dissolution agents. Identifying recurrence risk factors require further studies.

ThP5.15 - "Unusual Impaction: A Rare Case of Gallstone Ileus''

Abstract Introduction Gallstone-related mechanical gastrointestinal tract obstruction is infrequent, manifesting in only 0.3%-0.5% of cholelithiasis cases. Typically, stones exceeding 2 cm find themselves lodged in the terminal ileum. However, in Bouveret's syndrome which is observed in 1 to 3% of instances the impaction occurs in the duodenum causing gastric outlet obstruction. The epidemiology and prevalence of gallstone impaction in the proximal jejunum remain inadequately documented, making this a rare case. Case Report An 83-year-old patient with known cholelithiasis and choledocholithiasis presented with acute abdominal pain and vomiting a week after undergoing ERCP, sphincterotomy and partial duct clearance. The presence of repeated bilious vomiting prompted investigation with abdominal CT scan. This revealed an approximately 4.5 cm gallstone impacted in the proximal jejunum, prompting emergency laparotomy which confirmed that the stone was impacted 10-15 cm from the dudeno-jejunal junction. Jejunotomy, stone extraction with primary closure was performed. Post-operative recovery was uneventful. Conclusion This case demonstrates gallstone impaction in the proximal jejunum causing bowel obstruction and necessitating emergency intervention. Timely diagnosis and prompt surgical intervention led to a successful outcome. The case highlights the need for awareness and consideration of the entire spectrum of possible gallstone-related complications in the acutely presenting patient with gall stones.

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.

Multi-Institutional Analysis of Choledocholithiasis in Pediatric vs Adult Patients

BackgroundIn adults, upfront intraoperative cholangiogram with laparoscopic common bile duct exploration (LCBDE) is well accepted for management of choledocholithiasis. Despite recent evidence supporting LCBDE utility in children, there has been hesitation to adopt this surgery first (SF) approach over ERCP first (EF) due to perceived technical challenges. We compared rates of successful stone clearance during LCBDE between adult and pediatric patients to evaluate if pediatric surgeons could anticipate similar rates of successful clearance. MethodsA multicenter, retrospective review of pediatric (<18 years) and adult patients with choledocholithiasis managed from 2018 to 2024 was performed. Demographic and clinical data were obtained. Rate of successful duct clearance with LCBDE was compared. Surgical and endoscopic complications (infections, bleeding, pancreatitis, bile leak) were also compared. Results724 patients, 333 (45.9%) pediatric and 391 (54.0%) adults, were included. The median age of pediatric vs adult patients was 15.2 years [13.1, 16.6] vs 55.5 years [34.1, 70.5], respectively. Of these, 201 (60.4%) pediatric vs 169 (43.2%) adult patients underwent SF, p < 0.001. LCBDE was attempted in 84 (41.7%) pediatric vs 140 (82.8%) adults, p = 0.002. LCBDE success was higher in pediatric vs adult patients (82.1% vs 71.4%, p = 0.004). Complications rates were similar however, pediatric patients who underwent EF had higher endoscopic complications (9.1% vs 3.6%, p = 0.03). ConclusionLCBDE is highly successful in children vs adults with no increased surgical complications. This data, coupled with the limited ERCP access for children, supports that LCBDE is an equally effective tool for managing choledocholithiasis in children as is accepted in adults. Level of EvidenceLevel III.

Antegrade balloon dilatation of the duodenal papilla during laparoscopic cholecystectomy versus endoscopic retrograde cholangiography in patients with acute choledocholithiasis: a case control matched study

IntroductionIn acute obstructive common bile duct (CBD) stones endoscopic retrograde cholangiography for CBD stone removal before cholecystectomy (ChE) (‘ERC-first’) is the gold standard of treatment. Intraoperative antegrade balloon dilatation of the duodenal papilla during ChE with flushing of CBD stones to the duodenum (‘ABD-during-ChE’) may be an alternative ‘one-stop-shop’ treatment option. However, a comparison of outcomes of the ‘ABD-during-ChE’ technique and the’ERC-first’ approach has never been performed.MethodsRetrospective case control matched study of patients suffering from obstructive CBD stones (< 8 mm) without severe pancreatitis or cholangitis that underwent the traditional ‘ERC-first’ approach versus the ‘ABD-during-ChE’ technique. Primary endpoint was the overall Comprehensive Complication Index (CCI®) from diagnosis to complete CBD stone removal and performed ChE.ResultsA total of 70 patients were included (35 patients each in the ‘ERC first’- and ‘ABD-during-ChE’-group). There were no statistical significant differences in terms of demographics and disease specific characteristics between the two study groups. However, there was a not significant difference towards an increased overall CCI® in the ‘ERC-first’ group versus the ‘ABD-during-ChE’ group (14.4 ± 15.4 versus 9.8 ± 11.1, p = 0.225). Of note, six major complications (Clavien-Dindo classification ≥ IIIa) occurred in the ‘ERC-first’ group versus two in the ‘ABD-during-ChE’ group (17% versus 6%, p = 0.136). In addition, significantly more interventions and a longer overall time from diagnosis to complete clearance of bile ducts and performed ChE was found, when comparing the ‘ERC-first’ group and the ‘ABD-during-ChE’ group (3.7 ± 0.8 versus 1.1 ± 0.4, p < 0.001; 160.5 ± 228.6 days versus 12.0 ± 18.0 days, p < 0.001).ConclusionIn patients suffering from acute obstructive CBD stones smaller than 8 mm, compared to the ‘ERC-first’ approach, the ‘ABD-during-ChE’ technique resulted in significantly less interventions and reduced overall treatment time from diagnosis to complete clearance of bile ducts and performed ChE. This comes together with a strong trend of less intervention related complications in the ‘ABD-during-ChE’ group.

Severity of Gallstone-, Sludge-, or Microlithiasis-Induced Pancreatitis-All of the Same?

Severity of microlithiasis- and sludge-induced pancreatitis in comparison to gallstone-induced pancreatitis has never been studied for a lack of definition. In this retrospective cohort study, 263 patients with acute biliary pancreatitis treated at a tertiary care center from 2005 to 2021 were stratified according to the recent consensus definition for microlithiasis and sludge. The gallstone-pancreatitis cohort was compared to microlithiasis, sludge, and suspected stone passage pancreatitis cohorts in terms of pancreatitis outcome, liver function, and endosonography/endoscopic retrograde cholangiopancreatography results using one-way analysis of variance and χ 2 test. Multinomial logistic regression analysis was performed to correct for bias. Microlithiasis- and sludge-induced pancreatitis, classified according to the revised Atlanta classification, did not present with a milder course than gallstone-induced pancreatitis ( P = 0.62). Microlithiasis and sludge showed an increase in bilirubin on the day of admission to hospital, which was not significantly different from gallstone-induced pancreatitis ( P = 0.36). The likelihood of detecting biliary disease on endosonography resulting in bile duct clearance was highest on the day of admission and day 1, respectively. Microlithiasis and sludge induce gallstone-equivalent impaired liver function tests and induce pancreatitis with similar severity compared with gallstone-induced acute biliary pancreatitis.

Surgeon-Performed Percutaneous Endoscopic Biliary Lithectomy: Description of a Novel Technique and Initial Results.

Introduction: Percutaneous endoscopic biliary lithectomy (PEBL) can be performed through preexisting drain tracts, offering ductal clearance and definitive management for patients with complicated gallstone disease unable to undergo conventional therapy. The technique has not been widely adopted by general surgeons. Herein, we describe our technique with surgeon-performed PEBL and present initial results. Materials and Methods: A single institutional retrospective review of the electronic medical record was performed for patients who underwent percutaneous choledochoscopy between February 2019 and November 2020. All operations were performed by 1 of 2 board-certified general surgeons with fellowship training in surgical endoscopy. Preoperative, operative, and postoperative variables were analyzed using descriptive statistics. Results: Thirteen patients underwent PEBL. Seventeen total procedures were performed; 4 patients underwent repeat intervention. The diagnoses leading to PEBL were: cholelithiasis (8), choledocholithiasis (4), and recurrent pancreatitis (1). Complete ductal clearance was achieved in 9 patients (69.2%) during the initial procedure. The remaining 4 patients (30.8%) underwent repeat PEBL, at which point complete ductal clearance was then achieved. The percutaneous drain was removed at the time of final procedure in 5 patients (38.5%) or within 5 weeks in the remaining 8 (61.5%). No intraoperative complications occurred, and no pancreatic or biliary postoperative complications or recurrences were noted with a mean follow-up of 279 ± 240 days. Conclusion: Surgeon-performed PEBL is a safe and effective method of achieving biliary ductal clearance. The technique is readily achieved following basic endoscopic and fluoroscopic principles and should be understood by all physicians managing gallstone disease.