Endoscopic Common Bile Duct Stone Removal Research Articles

Risk Factors for Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis After Endoscopic Removal of Common Bile Duct Stones: An Update in Chinese Patients with Choledocholithiasis

Aim: Endoscopic Retrograde Cholangiopancreatography (ERCP) has been widely used in endoscopic surgery for many biliary and pancreatic diseases. Post-ERCP Pancreatitis (PEP) is the most common complication that occurs, even with expert surgeons. However, few reports have addressed the risk of PEP by focusing on the removal of Common Bile Duct Stones (CBDS). Methods: To detect potential risk factors for PEP after endoscopic removal of CBDS, the medical records of CBDS patients who received ERCP procedures at the First Affiliated Hospital of Nanjing Medical University between January 2021 and December 2023 were retrospectively analyzed. Patient- and procedure-related data were collected, and PEP was reevaluated. Single- and multiplevariable analyses were conducted to identify potential risk factors. Results: A total of 1,251 procedures were performed in 1,173 patients and PEP occurred in 84 cases (6.71%). Univariate and multivariate logistic regression analyses showed that female sex (P= 0.049, 95% Confidence Interval [CI]: 1.002-2.521), cerebral infarction (P=0.011, 95% CI: 1.197-3.964), acute pancreatitis history (P=0.001, 95% CI: 2.436-7.249), fatty liver disease (P=0.021, 95% CI: 1.140 -4.843), common bile duct diameter <10 mm (P=0.005, 95% CI: 1.299-4.313), and Endoscopic Papillary Balloon Dilatation (EBD) (P=0.01, 95% CI: 0.321-0.855) were independent risk factors for PEP in CBDS patients. Conclusion: Female sex, a history of Fatty Liver Disease (FLD), previous acute pancreatitis, and common bile duct stenosis are risk factors for PEP, whereas EPBD is a protective factor for PEP in patients with CBDS, which should be considered by clinicians.

Endoscopic removal of common bile duct stones in nonagenarians: a tertiary centre experience.

There are few studies assessed the efficacy and mortality of endoscopic retrograde cholangiopancreatography (ERCP) for the removal of common bile duct (CBD) stones in the elderly aged ≥90 years. We aimed to assess the safety and efficacy of endoscopic removal of CBD stones in nonagenarians. We retrospectively reviewed ERCP reports for CBD stone removal. The endoscopic and therapeutic outcomes were collected. The length of stay (LOS), the total number of adverse events, and mortality rate were compared between groups. A total of 125 nonagenarians were compared with 1,370 controls (65-89 years old individuals). The mean LOS for nonagenarians was significantly higher than in controls (13.6 days vs. 6.5 days). Completed intended treatment was similar in the nonagenarians and controls (89.8% and 89.5%, respectively). The overall complication rate did not differ between the groups. However, nonagenarians had a higher incidence of post-ERCP pneumonia (3.9%). None of the nonagenarians were readmitted to the hospital within 7 days. Four nonagenarians (3.2%) and 25 (1.8%) controls died within 30 days. Advanced age alone did not affect the decision to perform the procedure. However, prompt diagnosis and treatment of post-ERCP pneumonia in nonagenarians could improve the outcomes and reduce mortality.

OGBN P06 Expectant Management Following Endoscopic Sphincterotomy for Choledocholithiasis: Is It Safe?

Abstract Background Gallstone disease is one of the most common gastrointestinal conditions in the UK. It is estimated that 10–15% of adults in the UK have gallstones. Most gallstones are found in the gallbladder but sometimes they can pass through the cystic duct into the common bile duct (CBD) causing choledocholithiasis. CBD stones may present with symptoms of jaundice, cholangitis, pancreatitis or be asymptomatic. Endoscopic sphincterotomy (ES), first reported in 1974, is considered a safe and effective method for managing choledocholithiasis. A significant proportion of patients who undergo ES for symptomatic CBD stones are subsequently referred for cholecystectomy. However, it is unclear whether cholecystectomy itself is necessary after endoscopic CBD stone removal. Some studies recently have indicated that cholecystectomy may not always be needed following endoscopic duct clearance (expectant management), especially for patients that remain asymptomatic or decline surgery (due to frailty, significant comorbidities or patient choice). The primary aim of this study was to assess the outcomes of patients who had expectant management (EM) after endoscopic CBD stone removal. Methods We retrospectively analysed the records of patients who underwent Endoscopic Retrograde Cholangiopancreatography (ERCP) in a UK District General Hospital between 01 January 2019 and 31 December 2019. Inclusion criteria were a) presence of CBD stones, and b) patients who underwent ERCP without prior cholecystectomy. The following patients were excluded: a) previous cholecystectomy, b) patients who underwent ERCP for other biliary pathologies, including malignancy. The original data set was obtained from the clinical coding department. ERCP reports, clinic letters, discharge summaries and the hospital results reporting systems were reviewed to extract patient data including demographics, comorbidities, management decision following ERCP, need for repeat ERCP and readmission rate. Results A total of 220 patients underwent ERCP in 2019. After excluding patients who did not fit the inclusion criteria,106 patients were included in this study. The median age was 75 years (22–97). 60 patients were women and 46 were men. Median follow up period was 36 months (30–42), excluding patients who died within the follow up period. 63 (59%) patients had a course of expectant management following ERCP for choledocholithiasis while 43 (41%) had a planned cholecystectomy (CS). Of the sixty-three patients who had EM, 40 were considered unfit for surgery, 18 were asymptomatic following ERCP, 3 did not wish to have surgery and the reason is unknown in 2. The median age for EM patients was 80 years (22–91), whereas the CS group had a median age of 62 years (25–82). In the EM group, 11 patients passed away within the follow-up period, none related to biliary pathology. Of the remaining 52 patients, only 1 proceeded to have cholecystectomy during the 3 year follow-up period due to multiple episodes of cholangitis. 2 out of 52 (4%) were readmitted with biliary complications but they continued to be managed conservatively due to frailty. Conclusions Endoscopic sphincterotomy and clearance of ductal stones followed by cholecystectomy is the most common treatment for choledocholithiasis. Recent NICE guidelines recommend CS for all patients with symptomatic or asymptomatic CBD stones. However, there is minimal evidence regarding the safety of leaving the gallbladder in situ after ES and thus the issue remains debatable. The majority of studies that have evaluated the complication rates of EM have focused only on elderly patients (age>80years), whereas our study has evaluated all patients after ERCP regardless of age and comorbidities. Pancreatitis did not occur during follow-up in any patients without cholecystectomy. This is in keeping with previous evidence as ES may in itself be definitive in prophylaxis against pancreatitis as it decreases the risk of pancreatic duct obstruction. The majority of patients (95%) with choledocholithiasis who did not undergo cholecystectomy after ERCP remained asymptomatic, indicating that expectant management is safe. However, we recognise this was a single centre study with limited patient numbers and medium-term follow-up. We suggest that future randomized controlled trials be multicentre and should include an assessment of patients’ quality of life and non-hospital managed symptoms.

Common bile duct stone-related parameters and their potential prognostic values for stone extraction requiring endoscopic papillary large balloon dilation.

For difficult common bile duct (CBD) stones, endoscopic sphincterotomy accompanied by endoscopic papillary large balloon dilatation (EPLBD) may be the preferred initial procedure according to the selection criteria. The purpose of this study was to determine the association between CBD stone-related parameters and their potential prognostic values for technically difficult CBD stone extraction requiring EPLBD. We retrospectively analyzed the data of 80 patients who underwent endoscopic retrograde cholangiopancreatography (ERCP), endoscopic biliary sphincterotomy, or the aforementioned procedures combined with EPLBD, resulting in successful CBD stone extraction in the first session from January 2018 and December 2021. The association between CBD stone-related parameters and stone extraction requiring EPLBD was analyzed by multivariable risk regression analysis. In multivariable analysis, the independent predictors of CBD stone extraction that required EPLBD were CBD stones larger than distal CBD diameterby >2 mm (risk ratio [RR] 2.34, 95% CI 1.30-4.19) and the presence of shaped stones (round shape RR 1.69 [95% CI 1.05-2.73]; square shape RR 2.34 [95% CI 1.24, 4.44] vs oval shape). Endoscopic CBD stone removal is technically difficult in patients with stones larger than 2 mm in diameter in comparison to the distal CBD diameter or round or square-shaped stones.

Risk prediction of common bile duct stone recurrence based on new common bile duct morphological subtypes.

Stones in the common bile duct (CBD) are reported worldwide, and this condition is majorly managed through endoscopic retrograde cholangiopancreatography (ERCP). CBD stone recurrence is an important issue after endoscopic stone removal. Therefore, it is essential to identify its risk factors to determine the necessity of regular follow-up in patients who underwent endoscopic removal of CBD stones. The authors identified that the S and polyline morphological subtypes of CBD were associated with increased stone recurrence. New morphological subtypes of CBD presented by the authors can be important risk predictors of recurrence after endoscopic stone removal. Furthermore, the new morphological subtypes of CBD may predict the risk of residual CBD stones or technical difficulty in CBD stone removal. Further studies with a large sample size and longer follow-up durations are warranted to examine the usefulness of the newly identified morphological subtypes of CBD in predicting the outcomes of ERCP for CBD stone removal.

Analysis of symptomatic recurrences of common bile ducts stones after endoscopic removal: Factors related to early or multiple recurrences.

Early or multiple recurrences of symptomatic common bile duct (CBD) stones are troublesome late complications after endoscopic stone removal. We aimed to determine the factors related to early or multiple recurrences of CBD stones.We retrospectively analyzed patients who underwent endoscopic CBD stone extraction in a single institute between January 2006 and December 2015. Patients were divided into 2 groups according to the number and interval of CBD stone recurrences: single versus multiple (≥2) and early (<1.5 years) versus late (≥1.5 years) recurrence.After exclusion, 78 patients were enrolled and followed up for a median of 1974 (IQR: 938–3239) days. Twenty-seven (34.6%) patients experienced multiple recurrences (≥2 times), and 26 (33.3%) patients experienced early first recurrence (<1.5 years). In the multivariate analysis, CBD angulation was independently related to multiple CBD stone recurrence (OR: 4.689, P = .016), and endoscopic papillary large balloon dilation was independently related to late first CBD stone recurrence (OR: 3.783, P = .025). The mean CBD angles were more angulated with increasing instances of recurrence (0, 1, 2, 3, and ≥4 times) with corresponding values of 150.3°, 148.2°, 143.6°, 142.2°, and 126.7°, respectively (P = .011). The period between the initial treatment and first recurrence was significantly longer than the period between the first and second recurrence (P = .048).In conclusion, greater CBD angulation is associated with the increased number of CBD stone recurrence, and EPLBD delays the recurrence of CBD stones after endoscopic CBD stone removal.

Analysis on Microbial Profiles & Components of Bile in Patients with Recurrent CBD Stones after Endoscopic CBD Stone Removal: A Preliminary Study.

Background/Aim: Common bile duct (CBD) stone recurrence after endoscopic treatment is a major concern as a late complication. Biliary bacterial factors and biochemical factors determine the path of gallstone formation. The aim of this preliminary study was to investigate the microbial profile and components of bile in patients with and without recurrent CBD stones after endoscopic CBD stone removal. Methods: Among patients who had undergone an initial endoscopic procedure for the removal of CBD stones and were followed up for >2 years, 11 patients who experienced at least two CBD stone recurrences, six months after endoscopic retrograde cholangiopancreatography (ERCP), were categorized into the recurrence group. Nine patients without CBD recurrence events were matched. Results: Polymicrobial infections are generally seen in all patients who have biliary sphincteroplasty. Microbial richness, measured by the numbers of operational taxonomic units (OTUs), was reduced in the recurrence group. The microbial evenness was also significantly lower than in the non-recurrence group. The overall microbial communities in the recurrence group deviated from the non-recurrence group. Infection with bacteria exhibiting β-glucuronidase activity was more frequent in the recurrence group, but there was no statistical significance. In an analysis of the bile components, the bile acid concentration was higher in the non-recurrence group than in the recurrence group. However, the other metabolites were not significantly different. Conclusions: Microbiota dysbiosis and altered bacterial community assembly in bile duct and decreased bile acid in bile juice were associated with recurrence of bile duct stone.

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.

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.

Effects of Saline Irrigation of the Bile Duct to Reduce the Rate of Residual Common Bile Duct Stones: A Multicenter, Prospective, Randomized Study.

In clinical practice, recurrent cholangitis due to residual common bile duct (CBD) stone occurs frequently even after endoscopic stone removal. This study aimed to determine whether preventive saline irrigation of the bile duct (PSIB) after endoscopic removal of CBD stones would decrease the residual CBD stones. In this multicenter, prospective, randomized study, patients who received endoscopic retrograde cholangiopancreatography for removal of CBD stone were randomized to either receiving PSIB after stone removal (PSIB group) or not receiving PSIB (non-PSIB group). Patients were prospectively followed up and the presence of residual CBD stones was evaluated within 6 months after endoscopic stone removal. A total of 148 patients were enrolled and completed follow-up (73 in PSIB group and 75 in non-PSIB group). The two groups were similar with regard to baseline characteristics. Residual CBD stones were detected in 22 patients (14.9%). The incidences of residual CBD stones were 6.8% in PSIB group and 22.7% in non-PSIB group (P=0.010). Multivariate analysis revealed that the performance of PSIB and the presence of only a single-CBD stone were the significant factors for the decrease of the occurrence of the residual CBD stones. Although, procedure time was slightly longer in PSIB group (22.0 vs 19.2 min, P=0.037), no significant difference was observed in the procedure-related complications between the two groups. PSIB could reduce the residual CBD stones without increasing complications. Considering the efficacy and safety, routine PSIB after endoscopic CBD stone removal seems to be preferred (ClinicalTrials.gov identifier: NCT01425177).

The Management of Common Bile Duct Stones

Common bile duct (CBD) stone is a relatively frequent disorder with a prevalence of 10-20% in patients with gallstones. This is also associated with serious complications, including obstructive jaundice, acute suppurative cholangitis, and acute pancreatitis. Early diagnosis and prompt treatment is the most important for managing CBD stones. According to a recent meta-analysis, endoscopic ultrasonography and magnetic resonance cholangiopancreatography have high sensitivity, specificity, and accuracy for the diagnosis of CBD stones. Endoscopic ultrasonography, in particular, has been reported to have higher sensitivity between them. A suggested management algorithm for patients with symptomatic gallstones is based on whether they are at low, intermediate, or high probability of CBD stones. Single-stage laparoscopic CBD exploration and cholecystectomy is superior to endoscopic retrograde cholangiopancreatography (ERCP) plus laparoscopic cholecystectomy with respect to technical success and shorter hospital stay in high risk patients with gallstones and CBD stones, where expertise, operative time, and instruments are available. ERCP plus laparoscopic cholecystectomy is usually performed to treat patients with CBD stones and gallstones in many institutions. Patients at intermediate probability of CBD stones after initial evaluation benefit from additional biliary imaging. Patients with a low probability of CBD stones should undergo cholecystectomy without further evaluation. Endoscopic sphincterotomy and endoscopic papillary balloon dilation in ERCP are the primary methods for dilating the papilla of Vater for endoscopic removal of CBD stones. Endoscopic papillary large balloon dilation is now increasingly performed due to the usefulness in the management of giant or difficult CBD stones. Scheduled repeated ERCP may be considered in patients with high risk of recurrent CBD stones.

Feasibility of initial endoscopic common bile duct stone removal in patients with acute cholangitis.

AIMTo investigate the feasibility of initial endoscopic common bile duct (CBD) stone removal in patients with acute cholangitis (AC).METHODSA single-center, retrospective study was conducted between April 2013 and December 2014 and was approved by the Medical Ethics Committee at our institution. Written informed consent was obtained from each patient prior to the procedure. The cohort comprised 31 AC patients with CBD stones who underwent endoscopic biliary drainage (EBD) for naïve papilla within 48 h after AC onset. We retrospectively divided the participants into two groups: 19 patients with initial endoscopic CBD stone removal (initial group) and 12 patients with delayed endoscopic CBD stone removal (delayed group). We evaluated the feasibility of initial endoscopic CBD stone removal in patients with AC.RESULTSWe observed no significant differences between the groups regarding patient characteristics. According to the assessments based on the Tokyo Guidelines, the AC severity of patients with initial endoscopic CBD stone removal was mild to moderate. The use of antithrombotic agents before EBD was less frequent in the initial group than in the delayed group (11% vs 58%, respectively; P = 0.004). All the patients underwent successful endoscopic CBD stone removal and adverse events did not differ significantly between the groups. The number of endoscopic retrograde cholangiopancreatography procedures was significantly lower in the initial group than in the delayed group [median (interquartile range) 1 (1-1) vs 2 (2-2), respectively; P < 0.001]. The length of hospital stay was significantly shorter for the initial group than for the delayed group [10 (9-15) vs 17 (14-20), respectively; P = 0.010].CONCLUSIONInitial endoscopic CBD stone removal in patients with AC may be feasible when AC severity and the use of antithrombotic agents are carefully considered.

Su1610 A Comparative Study Between PTGBD and Etgd As a Bridge to Surgery in Patients With Acute Cholecystitis and a Suspicion of CBD Stone

To compare the technical feasibility, clinical and surgical outcomes between a single-step approach of endoscopic removal of common bile duct (CBD) stones with endoscopic transpapillary gallbladder drainage (ETGD group) and a two-step approach of endoscopic removal of CBD stones and percutaneous transhepatic gallbladder drainage (PTGBD group) as a bridge treatment before cholecystectomy, in patients with acute cholecystitis and a high suspicion of CBD stones.

Laparoscopic Common Bile Duct Exploration After Unsuccessful Endoscopic Stone Removal

When common bile duct (CBD) stone removal by endoscopy fails, stone removal is a mandatory procedure for the surgeon. However, it is unclear that the laparoscopic procedure is the alternative treatment in this setting. The purpose of this study is to investigate the result of laparoscopic CBD exploration (LCBDE) following unsuccessful CBD stone removal by endoscopy. This study is a retrospective analysis of 82 consecutive LCBDEs. Group 1 included patients who underwent secondary LCBDE after stone removal by endoscopic retrograde cholangiopancreatography (ERCP) failed. Group 2 was defined when primary LCBDE was performed without ERCP. Perioperative outcomes were compared between the two groups. There were 44 patients in Group 1 and 38 patients in Group 2. There were no significant differences in demographics. Stone clearance was nearly complete in both groups. There was no significant difference between the two groups for operative time, hospital days, open conversion rate, recurrence rate, or complications. LCBDE is an acceptable alternative treatment when endoscopic CBD stone removal is impossible or incomplete.

Long-term follow-up study of gallbladder in situ after endoscopic common duct stone removal in Korean patients

Although there has been much debate over the fate of the gallbladder (GB) after endoscopic common bile duct (CBD) stone removal, subsequent cholecystectomy is generally recommended in patients with GB stones to prevent further biliary complications. The aims of this study were to assess the natural course of the patients with GB in situ after endoscopic CBD stone removal and to evaluate the necessity of prophylactic cholecystectomy. Four hundred sixty-one patients who had undergone CBD stone removal at Yeungnam University Hospital between January 2000 and December 2004 were retrospectively analyzed, and 232 patients were ultimately enrolled in this study. The mean duration of follow-up was 73 (range = 7-126) months in the cholecystectomy group and 66 (6-127) months in the GB in situ group (p = 0.168). Ten patients (14.7 %) in the cholecystectomy group and 31 patients (18.9 %) in the GB in situ group developed recurrent CBD stones (p = 0.295). The highest percentage of recurrent CBD stones in both groups was that for brown stones (80 and 80.6 %). In the GB in situ group, cumulative recurrence rates of CBD stones were not significantly different between patients with GB stones and without GB stones (15.9 vs. 20 %, p = 0.798). However, the incidence of acute cholecystitis was significantly higher in patients with GB stones compared to patients without GB stones (13.6 vs. 2.5 %, p = 0.003). Prophylactic cholecystectomy seems to be unnecessary in patients without GB stones after endoscopic sphincterotomy. However, in patients with GB stones, elective cholecystectomy or close observation is recommended due to the higher risk of cholecystitis.

Role of Intraoperative Cholangiography in Patients Whose Biliary Tree Was Evaluated Preoperatively by Magnetic Resonance Cholangiopancreatography

Routine performance of intraoperative cholangiography (IOC) during cholecystectomy is controversial. The aim of this study was to evaluate the role of IOC during cholecystectomy in addition to preoperative magnetic resonance cholangiopancreatography (MRCP) in our institution over a 12-year period. A total of 425 consecutive patients who underwent IOC during cholecystectomy were included in this study. MRCP was performed preoperatively for bile duct evaluation in all patients. When common bile duct (CBD) stones were detected, they were removed endoscopically before the operation. We estimated the results of IOC in terms of the success rate, the detection rate of anatomic abnormality of the biliary system, and the incidence of residual CBD stones. MRCP preoperatively identified 6 (1.4 %) patients with abnormal biliary systems and 56 with CBD stones, which were endoscopically removed. The success rate of IOC was 93.8 % (399/425). Abnormalities of the biliary system were detected in 12 patients (12/399, 3.0 %) and CBD stones in 8 (8/399, 2.0 %). Of the eight patients with stones, seven had been examined by endoscopy preoperatively and found to have CBD stones. The detection rate of bile duct stones in patients with preoperative endoscopic removal of CBD stones (7/56, 12.5 %) was significantly higher than those with CBD stones first detected during IOC (1/365, 0.3 %) (p < 0.01). Moreover, no residual CBD stones were detected in patients who were operated on within fewer than 12 days from endoscopic treatment to the operation. IOC is indicated even after preoperative sphincterotomy for CBD stones. In our study, it resulted in a 12.5 % incidence of persistent stones after sphincterotomy. IOC plays an additional role in detecting CBD stones and in revealing abnormalities of the biliary tree in patients whose biliary tree was preoperatively evaluated by MRCP.