Multiple Common Bile Duct Stones Research Articles

The Jolting Method: An Efficient Method for Extracting Multiple Common Bile Duct Stones Completely in a Single Procedure

The Jolting Method: An Efficient Method for Extracting Multiple Common Bile Duct Stones Completely in a Single Procedure

Using deep learning models in magnetic resonance cholangiopancreatography images to diagnose common bile duct stones

Backgrounds and aims Magnetic resonance cholangiopancreatography (MRCP) plays a significant role in diagnosing common bile duct stones (CBDS). Currently, there are no studies to detect CBDS by using the deep learning (DL) model in MRCP. This study aimed to use the DL model You Only Look Once version 5 (YOLOv5) to diagnose CBDS in MRCP images and verify its validity compared to the accuracy of radiologists. Methods By collecting the thick-slab MRCP images of patients diagnosed with CBDS, 4 submodels of YOLOv5 were used to train and validate the performance. Precision, recall rate, and mean average precision (mAP) were used to evaluate model performance. Analyze possible reasons that may affect detection accuracy by validating MRCP images in 63 CBDS patients and comparing them with radiologist detection accuracy. Calculate the correctness of YOLOv5 for detecting one CBDS and multiple CBDS separately. Results The precision of YOLOv5l (0.970) was higher than that of YOLOv5x (0.909), YOLOv5m (0.874), and YOLOv5s (0.939). The mAP did not differ significantly between the 4 submodels, with the following results: YOLOv5l (0.942), YOLOv5x (0.947), YOLO5s (0.927), and YOLOv5m (0.946). However, in terms of training time, YOLOv5s was the fastest (4.8 h), detecting CBDS in only 7.2 milliseconds per image. In 63 patients the YOLOv5l model detected CBDS with an accuracy of 90.5% compared to 92.1% for radiologists, analyzing the difference between the positive group successfully identified and the unidentified negative group not. The incorporated variables include common bile duct diameter > 1 cm (p = .560), combined gallbladder stones (p = .706), maximum stone diameter (p = .057), combined cholangitis (p = .846), and combined pancreatitis (p = .656), and the number of CBDS (p = .415). When only one CBDS was present, the accuracy rate reached 94%. When multiple CBDSs were present, the recognition rate dropped to 70%. Conclusion YOLOv5l is the model with the best results and is almost as accurate as the radiologist’s detection of CBDS and is also capable of detecting the number of CBDS. Although the accuracy of the test gradually decreases as the number of stones increases, it can still be useful for the clinician’s initial diagnosis.

Combined endoscopic large balloon dilation with limited sphincterotomy versus sole sphincterotomy for removal of large or multiple common bile duct stones

BackgroundEndoscopic papillary large balloon dilation (EPLBD) after sphincterotomy (EST) was introduced for the removal of large (≥ 10 mm) or multiple bile duct stones. This method combines the advantages of EST and EPLBD by increasing the efficacy of stone extraction while minimizing complications of EST and EPLBD when used alone. This prospective study aimed to compare between EPLBD with prior limited EST and sole sphnicterotomy for extraction of multiple and/or large common bile duct stones.ResultsStatistical analysis revealed insignificant difference between the studied groups as regards the presence of periamullary diverticulum (23% vs. 19%, P > 0.05) and the use of mechanical lithotripsy (4% vs. 9%, P > 0.05). The rates of overall and initial stone clearance were not significantly different between both groups [94% vs. 90%), P > 0.05; and 84% vs. 78%, P > 0.05, respectively]. The procedure-related pancreatitis and bleeding in EST/EPLBD group were lower compared to EST group (3% vs. 5%, P > 0.05; and 2% vs. 6%, P > 0.05, respectively). None of the studied groups’ patients died or developed procedure-related perforation or cholangitis.ConclusionEndoscopic large balloon dilation with prior limited sphincterotomy is an effective and safe endoscopic technique for removing multiple and/or large CBDSs.

S2811 Case of a Severe Cholecystocutaneous Fistula

Introduction: Cholecystocutaneous fistulae (aberrant communications of the gallbladder with the skin) have been recognized since the 17th century as possible complications of neglected gallbladder disease. However, in the era of modern medicine they remain uncommon. Case Description/Methods: An 83 year-old female with a history of anxiety, depression, and a self-inflicted abdominal gunshot wound presented to our institution 2 years ago with acute calculous cholecystitis and choledocholithiasis. She declined surgery and endoscopic management and was treated with percutaneous cholecystostomy drainage and antibiotics. Subsequent clinical course included multiple tube changes with complaints of recurrent drain dislodgement, leakage, and weight loss. Her cholecystostomy was changed to a percutaneous transhepatic biliary drain. She ultimately presented to the gastroenterology clinic for internalization of her biliary drain. On examination, a large palpable mass was seen in the right upper quadrant with serosanguinous and bloody drainage, consistent with chronic gallbladder extrusion from the abdominal wall. ERCP with removal of percutaneous drain, sphincterotomy, stone extraction, and stent placement was performed. CT abdomen showed a gallbladder mass extending into hepatic segment V as well as through the right abdominal musculature to the skin surface. Enlarged retroperitoneal adenopathy was concerning for metastatic involvement. The patient was deemed a poor surgical candidate, and she opted for hospice care. (Figure) Discussion: Cholecystocutaneous fistula is a recognized sequela of unresolved gallbladder inflammation, usually due to persistent biliary outflow obstruction. Other causes may include trauma, iatrogenic causes, gallbladder perforation, or carcinomas. Fistulae may also develop along the track of percutaneous drains following cholecystostomy for management of acute cholecystitis. Surgical management of cholecystocutaneous fistulae with either laparoscopic or open cholecystectomies and fistulae resections have been described with good success. Cholecystocutaneous fistulae in the setting of gallbladder malignancy have poor outcomes due to the spread to adjacent structures. Improved imaging diagnosis of gallstone and gallbladder disease, antibiotic therapies, early surgical intervention for gallbladder disease, and endoscopic alleviation of biliary outflow obstructions have made such a presentation of cholecystocutaneous fistula a rarely seen phenomenon.Figure 1.: A patient found to have cholecystocutaneous fistula with (A) gallbladder extruding from the abdominal wall, (B) occlusion cholangiogram post- removal of multiple common bile duct stones showing dilated CBD and cholelithiasis in an irregular, contracted gallbladder, and (C) CT scan showing a mass (star) with extrusion of gallbladder through the liver and skin (arrow).

Multi center experience of interrupted versus continuous parachuting suturing technique of hepatico-jejunostomy posterior layer anastomosis

Background: In Biliary enteric anastomosis procedures, hepatico-jejunostomies are a crucial step. Depending on the situation, the hepatico-jejunostomy operation procedure varies depending on the surgical school, and can be continuous or interrupted. Patients and Methods: A prospective comparative randomized study included 100 Patients complaining of malignant pancreatic tumour (65%), iatrogenic bile duct injury (20%), multiple common bile duct stones (10%) and liver transplantation of cirrhotic patients (5%) underwent hepatico-jejunostomy anastomosis to review a multi-center experience of hepatico-jejunostomy anastomosis in Theodor Bilharz Research Institute and Faculty of Medicine of Cairo University with regard to the types of anastomosis performed, early and late complications, and long-term patency and outcomes. Results: According to the type of suturing technique, hepatico-jejunostomy anastomosis patients are sub grouped into posterior interrupted sutures group A and posterior parachuting sutures group B. A significant direct correlation of leakage in group A with obstructive jaundice (r = 0.327 and p value = 0.02), CBD diameter (r = 0.408 and p value = 0.001), and Duct wall thickness (r = 0.408 and p value = 0.001) While there were inverse correlations with pre-operative stent (r = -0.375 and p value = 0.01).

Choledocholithiasis characteristics with periampullary diverticulum and endoscopic retrograde cholangiopancreatography procedures: Comparison between two centers from Lanzhou and Kyoto.

BACKGROUNDMost of study regarding periampullary diverticulum (PAD) impact on endoscopic retrograde cholangiopancreatography (ERCP) therapy for choledocholithiasis based on data from one endoscopy center and lacked to compare the clinical characteristic of choledocholithiasis with PAD from different geographical patients.AIMTo compare the choledocholithiasis clinical characteristics between two regional endoscopy centers and analyze impacts of clinical characteristics on ERCP methods for choledocholithiasis patients with PAD.METHODSPatients seen in two endoscopy centers (The First Hospital of Lanzhou University, Lanzhou, Gansu Province, China, and Kyoto Second Red Cross Hospital, Kyoto, Japan) underwent ERCP treatment for the first time between January 2012 and December 2017. The characteristics of choledocholithiasis with PAD were compared between the two centers, and their ERCP procedures and therapeutic outcomes were analyzed.RESULTSA total of 829 out of 3608 patients in the Lanzhou center and 241 out of 1198 in the Kyoto center had choledocholithiasis with PAD. Lots of clinical characteristics were significantly different between the two centers. The common bile duct (CBD) diameter was wider, choledocholithiasis size was lager and multiple CBD stones were more in the Lanzhou center patients than those in the Kyoto center patients (14.8 ± 5.2 mm vs 11.6 ± 4.2 mm, 12.2 ± 6.5 mm vs 8.2 ± 5.3 mm, 45.3% vs 20.3%, P < 0.001 for all). In addition, concomitant diseases, such as acute cholangitis, gallbladder stones, obstructive jaundice, cholecystectomy, and acute pancreatitis, were significantly different between the two centers (P = 0.03 to < 0.001). In the Lanzhou center, CBD diameter and choledocholithiasis size were lower, and multiple CBD stones and acute cholangitis were less in non-PAD patients than those in PAD patients (13.4 ± 5.1 mm vs 14.8 ± 5.2 mm, 10.3 ± 5.4 mm vs 12.2 ± 6.5, 39% vs 45.3%, 13.9% vs 18.5%, P = 0.002 to < 0.001). But all these characteristics were not significantly different in the Kyoto center. The proportions of endoscopic sphincterotomy (EST), endoscopic balloon dilatation (EPBD), and EST+EPBD were 50.5%, 1.7%, and 42.5% in the Lanzhou center and 90.0%, 0.0%, and 0.4% in the Kyoto center, respectively. However, the overall post-ERCP complication rate was not significantly different between the two centers (8.9% in the Lanzhou and 5.8% in the Kyoto. P = 0.12). In the Lanzhou center, the difficulty rate in removing CBD stones in PAD was higher than in non-PAD group (35.3% vs 26.0%, P < 0.001). But the rate was no significant difference between the two groups in Kyoto center. The residual rates of choledocholithiasis were not significantly different between the two groups in both centers. Post-ERCP complications occurred in 8.9% of the PAD patients and 8.1% of the non-PAD patients in the Lanzhou Center, and it occurred in 5.8% in PAD patients and 10.0% in non-PAD patients in the Kyoto center, all P > 0.05.CONCLUSIONMany clinical characteristics of choledocholithiasis patients with PAD were significantly different between the Lanzhou and Kyoto centers. The patients had larger and multiple stones, wider CBD diameter, and more possibility of acute cholangitis and obstructive jaundice in the Lanzhou center than those in the Kyoto center. The ERCP procedures to manage native duodenal papilla were different depending on the different clinical characteristics while the overall post-ERCP complications were not significantly different between the two centers. The stone residual rate and post-ERCP complications were not significantly different between choledocholithiasis patients with PAD and without PAD in each center.

Retained plastic biliary stent presenting with obstructive jaundice: a case report

Forgotten stents may lead to serious complications. We present a case report of a forgotten common bile duct (CBD) fully covered plastic stent presenting with Obstructive Jaundice. A 66 years-old female patient presented with features of obstructive jaundice. Further enquiry revealed a history of ERCP guided biliary stent placement 12 years ago, after which she was lost to follow up. An endoscopic attempt to retrieve the old stent and relieve biliary obstruction was unsuccessful, and a fresh stent was placed across the CBD following a sphincterotomy. CT showed evidence of a stent in situ, alongside calcified fragments of the previous stent and multiple CBD stones. Patient was taken up for surgery and Roux-en-y hepaticojejunostomy was performed following CBD exploration and retrieval of the stent-stone complex.

Recurrent Cholangitis due to Hem-o-lok Clip Migration after Laparoscopic Common Bile Duct Exploration Treated with Endoscopic Retrograde Cholangiopancreatography

Clip migration into the common bile duct (CBD) is a rare complication of laparoscopic biliary surgery. We report a case of Hem-o-lok clip migration-induced CBD stone in a 66-year-old man who underwent laparoscopic cholecystectomy (LC) and laparoscopic common bile duct exploration (LCBDE) 4 years ago. The patient visited the emergency room for upper abdominal pain. CT scan revealed increased CBD diameter and multiple CBD stones. We performed endoscopic retrograde cholangiopancreatography for CBD stone extraction. Cholangiography revealed multiple suspected filling defects in the CBD; stones and unknown foreign body were removed using Basket. The foreign body found in the duodenum was a Hem-o-lok clip. When epigastric pain develops in a patient who has undergone LC and LCBDE, it is possible that biliary stone occurs due to clip migration.

Severe gastrointestinal bleeding secondary to cholecystitis: a case report and our handling experience

The patient was male, 57 years old, who was treated for "upper abdominal pain and discomfort for 4 hours". The pain was severe, with back radiation, without cold fever, nausea, vomiting, chest tightness, shortness of breath, skin or yellow eyes, also without hematemesis or black stool. Physical examination: without yellow skin and sclera, with right upper abdomen tenderness and positive Murphy sign. There were no other obvious positive signs. Abdominal CT：cholecystitis with possible occupancy, and multiple common bile duct stones. Laboratory tests: White blood cells was 10.88×109/ L, neutrophilic granulocyte was 84%, Glutamic transaminase was 666 IU/L. Past medical history: hypertension and diabetes. Preliminary diagnosis: Acute cholecystitis, Common bile duct stones, Abnormal liver function, High blood pressure, Diabetes, Admitted to hospital. Handling measures: fasting, pain relief, anti-infection, liver protection, fluid replacement treatment, and monitor blood sugar, blood pressure, and further improve the inspection.

Laparoscopic Choledochoduodenostomy in Bile Duct Stone Diseases

Common bile duct (CBD) stones are present in 5–15% of patients with gallstones. Some of these patients are candidates for a definitive biliary drainage procedure for prevention of stone recurrence. The aim of our study was to ascertain the outcome of laparoscopic choledochoduodenostomy in choledocholithiasis. After obtaining ethical clearance from the institutional ethical committee, the present prospective and observational study was conducted on 32 patients over a period from September 2017 to September 2020 in the tertiary care hospital. In our study, the total number of patients was 32, of whom 26 (81%) were females. The mean and range of age were 54.44 SD 10.827 and 24–70 years, respectively. The most common presenting feature was jaundice (53.125%). The mean CBD diameter was 24.59 SD 2.564 mm with multiple stones in CBD in 90.625% of our patients. The mean duration of surgery and intraoperative blood loss was 147.94 SD 9.732 and 76.25 SD 12.636 ml, respectively. The mean hospital stay was 6.34 SD 0.827 days with 90.6% of the patients returning to work in the 3rd week. In our study, there was no conversion to open and a single patient developed postoperative ileus which was managed conservatively. There was complete resolution of symptoms on follow-up. Laparoscopic choledochoduodenostomy is safe for benign bile duct diseases. It is physiological, with minimal intraoperative blood loss, less operative time, and fewer postoperative complications and is safe with faster recovery.

Efficacy of daily abdominal self-massage for the prevention of recurrent common bile duct stones after endoscopic biliary sphincterotomy.

Recurrent common bile duct stones (CBDS) can occur after endoscopic biliary sphincterotomy (EST). Bile flow through the papilla of Vater could be improved by means of abdominal massage. We report the results of self-abdominal massage in four patients who had previously undergone cholecystectomy and experienced multiple CBDS recurrences after EST.

Adding ursodeoxycholic acid to the endoscopic treatment and common bile duct stentingfor large and multiple biliary stones: Will it improve the outcomes?

BackgroundThe role of common bile duct (CBD) stenting in the establishment of bile stream in the elderly patients and the ones who are not good candidates for surgery due to not responding to treatments was well documented in previous studies. The current study aimed at investigating the effect of adding Ursodeoxycholic acid (UDCA) to CBD stenting alone in order to reduce the size of large and multiple CBD stones.MethodsClinical outcomes including success rates in CBD stones clearance, incidence of pancreatitis, perforation, bleeding, as well as, decrease in size of stones and liver enzymes after a two-month period were assessed in the UDCA + CBD stenting group.ResultsA total of 64 patients referring to Shahid Beheshti Hospital in Qom, Iran with multiple or large CBD stones (above three or larger than 15 mm) received standard endoscopic therapies and UDCA + CBD stenting (group B) and controls only received standard endoscopic therapies with only CBD stenting (group A). The mean reduction in the size of stones in group B was significantly higher than that of group A (3.22 ± 1.31 vs 4.09 ± 1.87 mm) (p = 0.034). There was no difference in the incidence rate of complications including pancreatitis, cholangitis, bleeding, and perforation between the two groups (P > 0.05).ConclusionAdding UDCA to CBD stenting, due to decrease in the stone size and subsequently facilitation of the stones outlet, can be considered as the first-line treatment for patients with large and multiple CBD stones. Also, in the cases with large or multi stones may be effective in reducing size and subsequently stone retrieval.Trial registry The study protocol was approved by the Ethics Committee of Qom University of Medical Sciences (ethical code: IR.MUQ.REC.1397.075); the study was also registered in the Iranian Registry of Clinical Trials (No. IRCT20161205031252N8). This study adheres to CONSORT guidelines.

An uncommon presentation of hepatic hydatid cyst leading to biliary cirrhosis and portal hypertension.

Hydatid disease is an ongoing issue in endemic areas. Hydatid cysts can be seen in any organ but, liver is one of the most common involved organs. Cystobiliary communication as an overwhelming complication of hepatic hydatid cysts can contribute to the obstructive jaundice, cholangitis, sepsis and even biliary cirrhosis if left untreated. The patient we are trying to present is a 61-year-old farmer who presented with obstructive jaundice, multiple common bile duct stones and biliary cirrhosis attributed to a long-lasting untreated hepatic hydatid cyst. Portal hypertension is introduced to be an uncommon presentation of hydatid cyst. Extrinsic compression of the porta hepatis and obstruction of inferior vena cava are amongst major causes of hydatidosis leading up to portal hypertension as reported in the literature. Portal hypertension in the presented case is proposed to emerge from long-lasting cystobiliary communication ending in biliary cirrhosis.

Choledochoduodenostomy versus T-tube drainage in patients have stones in common bile duct with risk factors of post-operative missed stones

Background: Residual or missed stones of common bile duct (CBD) and ascending cholangitis after CBD exploration are major biliary surgery problems. Repeated biliary tract interventions for correction of complications are catastrophic on both patients and surgeons.Methods: This is a prospective study of 83 patients which compares two methods for surgical management of CBD stones between June 2016 to May 2018. Group I included 43 patients who were managed by CBD exploration followed by insertion of T tube, the risk factors of the incidence of missed retained stone in CBD were multiple stones in CBD and hugely dilated CBD (&gt;15 mm).The second method was choledochoduodenal anastomosis for patients having the same previous risk factors (Group II) which included 40 patients. Postoperative follow up was for 12 to 18 months.Results: In group I, 6 patients developed residual stones in CBD, reoperation was required for 3 of them and endoscopic retrograde cholangiopancreatography with sphincterotomy for another 3 patients, while in the other group (group II) 2 patients suffered from ascending cholangitis and are managed conservatively. No missed or residual CBD stones were developed and no patients need reoperation.Conclusions: With choledochoduodenostomy in patients with multiple CBD stones or markedly dilated CBD the incidence of missed or retained stones in CBD was reduced.

Clinical research of laparoscopic common bile duct exploration with primary suture and T tube drainage in the management of choledocholithiasis

Objective To investigate the short-term clinical efficacy of laparoscopic common bile duct exploration(LCBDE) with primary suture or T tube drainage in the management of choledocholithiasis. Methods The retrospective cohort study was conducted from January 2014 to December 2018 with the clinical data of patients with choledocholithiasis being analyzed. A total of 863 patients were enrolled in this study. There were 431 males and 432 females. The median age was 60 (range 11 to 94). These patients had received LCBDE with primary suture (n=287) and T tube drainage (n=576) in the Department of General Surgery, the First Affiliated Hospital of Nanjing Medical University. Observation indicators: (1)Preoperative blood biochemistry, including blood serum levels of total bilirubin, direct bilirubin, ALT, AST, GGT. (2) Intraoperative conditions, including operation time, blood loss, diameter of common bile duct, number of common bile duct stone.(3)Short-term postoperative conditions, including postoperative hospital stay, postoperative complications. Measurement data with non-normal distribution were described as M (P25, P75), and comparison between groups was done using Mann-Whitney U test. Comparison of count data between groups were analyzed using the chi-square test. Univariate analysis and subsequent multivariable logistic regression were used to investigated the factors affecting the selection of surgical methods. Results (1) Blood serum levels of total bilirubin and direct bilirubin in the T tube drainage group were 17.0(12.2, 36.0) μmol/L, 7.6(4.9, 19.0) μmol/L, which were significantly higher than those of the primary suture group[15.7(11.8, 29.7) μmol/L, 6.7(4.4, 16.5) μmol/L)](Z=-2.023, -2.468, P 0.05). (2)The operation time of the primary suture group was 85(70, 100) min, which was significantly shorter than that of the T tube drainage group[97(75, 120) min](Z=-5.532, P 0.05). 61.32%(176/287) and 67.36%(388/576) of patients in the primary suture group and T tube drainage group were found with multiple stones in the common bile duct, with no difference between the two groups (χ2=3.083, P>0.05). (3)The primary suture group showed shorter postoperative hospital stay compared with the T tube drainage group[4(3, 5) d vs 6(5, 6) d, Z=-12.057, P<0.05]. The primary suture group showed more patients with bile leakage (2.09%) compared with that of the T tube drainage group (0.35%). Multivariable logistic regression showed that the number of common bile duct stone, diameter of common bile duct, time period of surgery, surgery group were significant factors affecting the selection of surgical methods(OR=1.687, 2.423, 0.587, 4.632, 95%CI: 1.152-2.470, 1.519-3.865, 0.511-0.675, 3.698-5.802, P<0.05). Conclusions Although different surgeons showed different opinions with the method of primary suture, laparoscopic common duct exploration with primary suture is safe and reliable in the management of choledocholithiasis with shorter operation time and faster postoperative recovery. T tube drainage is not absolutely necessary in the management of choledocholithiasis. Patients with multiple common bile duct stone or large diameter of common bile duct are likely to receive T tube drainage. Key words: Laparoscopy; Choledocholithiasis; Primary suture; T tube drainage; Surgical method

Consequences of Stenting and Endoscopic Papillary Balloon Dilatation in Treatment of Large and Multiple Common Bile Duct Stones.

BACKGROUND Although stenting for the treatment of large and multiple common bile duct stones has been acceptable to everyone, its efficacy and outcome have not been studied in comparison with other endoscopic procedures. The purpose of this study was to compare the consequences of stenting and endoscopic papilla balloon dilatation for the treatment of large and multiple common bile duct stones. METHODS In a double-blind clinical trial, of 431 patients with bile duct stones referred to the treatment center, 64 patients with multiple common bile duct stones ( ≥ 3) and more than 15 cm were selected for the study, then by random allocation rule the participants were allocated in two groups. They were entered into two different endoscopic papillary balloon dilatation (EPBD) and common bile ducts stenting treatments so that both procedures were performed by a person. Both groups were assessed from the point of views therapeutic outcomes such as duct cleaning, pancreatitis, isolated pain, and duct rupture. Data were collected by a self-made questionnaire that was used before and after the procedure to obtain the needed information. Then data were analyzed using SPSS software version 22 and descriptive and analytical tests were used as appropriated. RESULTS Although the duct cleaning and the complete removal of the stones in the stenting treatment procedure was 93.8%, and in EPBD was 78.3%, no significant difference was observed between the two groups (p = 0.14). Pancreatitis significantly increased after the first and second endoscopic retrograde cholangiopancreatography (ERCP) in the stent group compared with EPBD (p = 0.02). Also, the most frequent cases of isolated pain were in the endoscopic group EPBD (p = 0.0). However, the occurrence of perforation after first ERCP and EPBD was zero, but in the second stage of ERCP, 3.3% of the patients had perforations (p = 0.99). The results indicated that the shape of the stone (circular and angled) was not effective in the result of treatment in the two groups. CONCLUSION The results of this study indicated that in case of experience and skill in conducting the ERCP, common bile duct stenting is still the first line of treatment for large and multiple stones of the common bile ducts.

1294 Large Common Bile Duct Stones Creating a Rare Distal Choledochoduodenal Fistula Requiring Unusual Extraction Method

INTRODUCTION: Choledochoduodenal fistulas (CDF) are abnormal connections of the common bile duct to the duodenum separated into proximal and distal. Of the various enterobiliary fistula, the most common is cholecystoduodenal. The rare occurring distal CDF etiologies include cholecystolithiasis, malignancy, peptic ulcers and iatrogenic. In the case presented, common bile duct (CBD) stones were large enough to create a fistula from the common bile duct superior to the sphincter of Oddi requiring unique extraction. CASE DESCRIPTION/METHODS: A 75-year-old Caucasian female with past medical history significant for biliary colic status post cholecystectomy was found to have multiple large CBD stones on abdominal ultrasound outpatient. Physical exam and laboratory analysis was unremarkable. When the ERCP was performed, the papilla was identified and noted be abnormal. The papilla was downward facing. Shockingly, superior to the papilla was a CDF created by an impacted black CBD stone. Subsequently to this unexpected finding, selective deep cannulation of CDF, adjacent to the CBD stone, was done using a sphincterotome with a 0.035 wire. No attempts were made of cannulating the papilla. The cholangiogram showed multiple CBD stones throughout the distal CBD. A 13 mm sphincterotomy superiorly at the CDF, followed by balloon sweeps removing several large yellow cholesterol appearing stones. DISCUSSION: Distal CDF is diagnosed via endoscopy and categorized based on location using the Ikeda classification. Type 1 (distal) fistulas occur along longitudinal fold adjacent to the papilla, often due to an impacted stone. Type 2 (proximal) occurs on the posterior wall of the duodenal bulb. The classification system further separates CDF into type A, opening greater than 2 cm from the papilla, type B, opening within 2 cm from the papilla, and type C, opening on the papillary fold. In this rare case of distal CDF, the diagnosis was likely type 1A (distal and greater than 2 cm from the papilla). Treatment is often based upon the etiology of CDF formation. Given the rare occurrence, it is important for gastroenterologist to be aware of the classifications as it may assist in treatment and safe stone removal.

Laparsopcic removal of an intraductal ERCP stone retrieval basket following guide wire fracture

Background: Gallstones within the common bile duct are a common cause of biliary obstruction. Therapeutic endoscopic retrograde cholangiopancreatography (ERCP) and stone retrieval using either balloon catheters or wire basket devices is the gold standard treatment. Methods: We present the case of an 85 year old lady who presented with obstructive jaundice and deranged LFTs. Ultrasound confirmed choledocholithiasis and common bile duct (CBD) dilation. She proceeded to ERCP and sphincterotomy where multiple CBD stones were noted, the largest measuring 12 mm. Prior to removal using a wire basket device an attempt was made to crush the largest stone. In doing so the guidewire fractured with the basket and stone still within the common bile duct. A rescue mechanical lithotriptor was used in an attempt to clear the duct unsuccessfully. Further attempts to remove the stone and basket through the sphincterotomy were also unsuccessful and the patient proceeded to laparoscopy. Results: A four port laparoscopic approach was used with x1 12 mm umbilical port and x3 5 mm epigastric and right subcostal ports. A longitudinal choledochotomy revealed several stones and the wire basket. The wires were cut using scissors and the basket was retrieved along with the large impacted stone. Proximal and distal ducts were cleared using a fogarty balloon catheter. The CBD was closed using interrupted intracorporeal vicryl sutures and a T-Tube was inserted. A cholecystectomy was then performed and the specimen along with the wire basket and stones were removed using an endobag through the umbilical port. The T-Tube was brought out though one of the right subcostal ports. The patient returned to the ward and had an uncomplicated post op recovery. The T-Tube was removed several weeks later following a satisfactory tube cholangiogram. Discussion ERCP is the gold standard of treatment for the removal of common bile duct stones, with a success rate of over 95%.(1) Wire basket retention as a result of stone impaction within the basket and less commonly as a result of guide wire fracture occurs in 0.6% of cases. (2). Management of these complications can involve the use of balloon catheters, further mechanical lithotripsy techniques and in the setting of an impacted stone, extracorporeal shockwave lithotripsy (ESWL). However if these endoscopic methods fail then surgical intervention is indicated. Conclusion: Intraductal ERCP wire basket retention following wire fracture can be safely and effectively managed laparoscopically when traditional endoscopic methods have failed. This is associated with a significantly reduced level of morbidity when compared to traditional laparotomy and in specialist centres it should be considered as a first line treatment in such cases. (we have excellent video for this case that was not available at the time of this submission but will be accessible in the coming days)

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

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

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

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