Primary Common Bile Duct Stones Research Articles

Primary choledocholithiasis occurrence and recurrence is synergetcally modulated by the bile microbiome and metabolome alternations

AimsPrimary choledocholithiasis is a common digestive disease with high morbidity and relapse. However, the compositions and functions of the bile microbial ecosystem and the pathogenesis of microfloral regulation of host metabolism resulting in stone formation are poorly understood. Main methodsBiliary samples collected from patients with acute cholangitis induced by benign biliary stricture (nonlithiasis group, n = 17) and primary choledocholithiasis (lithiasis group, n = 33) were subjected to multiomics analyses. Furthermore, clinicopathological features collected over a 24-month follow-up period were examined to evaluate the predictive value of candidate microbes. Key findingsFive alpha diversity indices of the bile microbiome were significantly decreased in the lithiasis group. Furthermore, we identified 49 differential bile flora between the two groups, and the relative abundances of 6 bacteria, Actinobacteria, Actinobacteriota, Staphylococcales, Micrococcales, Altererythrobacter and Carnobacteriaceae, were associated with primary choledocholithiasis relapse conditions. Multiomics analyses showed that specific changes in disease-related bacterial taxa were closely related to metabolite variation (low-molecular weight carboxylic acids, sterol liquid and acylcarnitine), which might reflect disease prognosis. According to microbiomic and metabolomic pathway analyses, we revealed that bacterial infections, microbiota-derived amino acid metabolites and secondary bile acid-related pathways were significantly enriched in the stone-formation group, suggesting a novel host-microbial metabolic mechanism of primary choledocholithiasis. SignificanceOur study first indicates bile host-microbial dysbiosis modulates the abnormal accumulation of metabolites might further disrupt calcium homeostasis and generate insoluble saponification. Additionally, we determined the predictive value of Actinomycetes phylum reduction for recurrence in primary common bile duct stone patients.

Primary Recurrent Common Bile Duct Stones: Timing of Surgical Intervention.

Cholelithiasis (gallstones) is a very common medical problem worldwide, with 5-30% of patients demonstrating a combined condition of cholelithiasis and choledocholithiasis (common bile duct stones (CBDS)). CBDS are usually classified as primary or secondary stones. Primary CBDS are defined as stones detected 2 years or more following cholecystectomy, while secondary stones, the most common type, usually migrate from the gallbladder to the bile ducts. Recurrent CBDS are defined as stones detected 6 months or more following endoscopic retrograde cholangiopancreatography (ERCP) with complete duct clearance. Although ERCP with endoscopic sphincterotomy has emerged as the main therapeutic option for CBDS, with up to 95% bile duct clearance rate, up to 25% of said patients develop recurrent bile duct stones. Thus far, several issues related to recurrent CBDS are still unclear and questions regarding this specific pathology have no precise answers: how many trials of ERCP and endoscopic sphincterotomy should be attempted before referring the patient for surgical management? Is there an association between risk factors and early surgical intervention? Thus, currently, there is no worldwide scientific-based consensus regarding the best management of this specific group of patients. The main issue for this article is to review the relevant English literature and find out the main high risk factors for recurrent CBDS, and form a diagnostic and treatment plan, hence, identifying the subgroup of patients that will benefit from early surgical management, preventing further ERCP-associated complications.

Microbiota analysis with next-generation 16S rDNA gene sequencing in recurrent common bile duct stones.

BackgroundEndoscopic retrograde cholangiopancreatography (ERCP) is the main remedy for gallstones, but the postoperative recurrence rate is high. Recent research has indicated that the biliary microbiome takes part in the pathogenesis of cholelithiasis. However, it is not yet known whether biliary microbiome dysbiosis is relevant to recurrent cholelithiasis.MethodsThus, we investigated the bacterial communities of the biliary microbiomes of patients with recurrent common bile duct (CBD) stones and analyzed the relationship between recurrent CBD stones and biliary microbiota. The bile specimens of 5 patients with recurrent CBD stones (FF) and 45 patients with primary CBD stones (YF) were collected during the ERCP process. The microbiota was analyzed using 16S ribosomal DNA (rDNA) high-throughput sequencing. We also identified the link between recurrent CBD stones and biliary microbiota.ResultsOur results showed that at the phylum level, proteobacteria and firmicutes were the main two genera groups, and proteobacteria was high in FF patients. Additionally, synergistetes were high, but Bacteroidetes and actinobacteria were low in FF patients. The microbiomes in the bile of the YF patients were more evenly distributed than those in the bile of the FF patients. We also discovered that FF patients had decreased microbial bile diversity. At the genus level, klebsiella dominated in the FF patients, while Escherichia-shigella dominated in the YF patients. Additionally, klebsiella was higher in the FF patients than the YF patients.ConclusionsThe observed differences in the genera between the recurrent CBD stone FF patients and the YF patients provide novel insights into the link between biliary microbiota changes and recurrent CBD stones.

Laparoscopic Common Bile Duct Exploration with Gallbladder Preservation: An Innovative Technique for Primary Common Bile Duct Stones.

Background: Primary common bile duct (CBD) stones can be treated with laparoscopic CBD exploration (LCBDE), during which cholecystectomy is routinely performed. For patients without gallstones, we have developed a new procedure, LCBDE with gallbladder preservation. The purpose of this study was to evaluate the management of LCBDE with gallbladder preservation at our institution. Methods: Retrospective analysis the clinical data of 105 patients with primary CBD stones. Demographic data, clinical characteristics, preoperative risk factors, and postoperative complications were evaluated. Results: All patients were divided into two groups depending on the presence of gallstones: the primary CBD stone coexistence gallstones group (Group A, n = 15) and the primary CBD stones absence gallstones group (Group B, n = 90). Complete stones clearance was achieved in all patients. There were no significant differences in postoperative complications rates and mortality between the two groups. The mean postoperative hospital stay was 3.2 days for Group A and 4.1 days for Group B (P = .03). Conclusion: This study found that LCBDE with gallbladder preservation can effectively and safely treat primary CBD stones without gallbladder stones.

Analysis of the relationship between bile duct and duodenal microbiota reveals that potential dysbacteriosis is the main cause of primary common bile duct stones

Bacteria play an important role in the formation of primary Common Bile Duct (CBD) stones. However, the composition and function of the microbiota of bile duct in patients with primary CBD stones remained to be explored. We utilized the 16S rRNA gene high-throughput sequencing technology to analyze the microbial diversity and community composition of biliary and duodenal microbiota in 15 patients with primary CBD stones and 4 patients without biliary tract diseases. Alpha diversity analysis showed that the microbiota richness was similar in bile and intestinal fluid; Beta diversity analysis showed that there were differences in the composition between biliary microbiota and the duodenal microbiota, but the abundance of the main groups showed similarities. The composition of the biliary microbiota from gallstone patients was more complex, as was the duodenal microbiota. Proteobacteria and Firmicutes were the dominant bacteria at phylum level, accounting for at least 75% of the total reads in each subgroup. Pseudomonas and Escherichia−Shigella were the major genus among subgroups, but Escherichia-Shigella had increased abundance in duodenal microbiota with primary choledocholithiasis, which may play an important role in stone formation. It is noteworthy that Clostridiumsensu_stricto, Lachnospiraceae _UCG-008, Butyrivibrio and Roseburia which could produce short chain fatty acids (SCFAs), were significantly decreased in biliary microbiota with primary CBD stones (p < 0.05). Our study provided new insights into the compositional of normal biliary microbiota. The micro-ecology of biliary and duodenal in patients with stones is complex and closely related, and there is a potential for dysbacteriosis. The decrease in abundance of certain major acid-producing bacteria affects the health of the biliary tract and thus leads to the formation of stones.

Assessment of the possible risk factors for primary common bile duct stone recurrence after cholecystectomy.

Common bile duct (CBD) stone recurrence is considered an unresolved concern after cholecystectomy and complete extraction of previous CBD stones. This study aimed to investigate the potential risk factors for primary CBD stone recurrence after cholecystectomy and endoscopic treatment. The endoscopic retrograde cholangiopancreatography (ERCP) database of our medical center was retrospectively reviewed between February 2008 and May 2018. A total of 45 patients with CBD stone recurrence with a history of previous cholecystectomy were recruited in the study. Moreover, 104 patients who underwent cholecystectomy at our medical center and who were followed up for more than 1 year without CBD stone recurrence were assigned to the control group. The characteristics of the patients, surgical records during cholecystectomy, and ERCP records obtained immediately before cholecystectomy were analyzed. Univariate analysis, based on the binary logistic regression method, indicated that age (p = 0.01) and the presence of the periampullary diverticulum (PAD; p = 0.006) were significantly different between the non-recurrence and recurrence groups. However, the surgical records during cholecystectomy were not significantly different between the two groups. The CBD stone number (p = 0.039), CBD stone diameter (≥ 10mm; p = 0.05), and CBD diameter (≥ 15 mm; p < 0.001), based on the ERCP findings were significantly different between the two groups. Multivariate analysis revealed that CBD diameter (≥ 15mm; OR, 3.878; 95% CI, 1.406-10.697; p = 0.008) was the independent risk factors for CBD stone recurrence after cholecystectomy. CBD diameter (≥ 15mm) at the time of the initial ERCP is associated with CBD stone recurrence after cholecystectomy.

Laparoscopic-assisted transgastric endoscopic retrograde cholangiopancreatography for management of choledocolithiasis after mini-gastric bypass surgery

Background Gallstones commonly form after bariatric surgery owing to rapid weight loss. Choledocolithiasis is one of the dangerous sequelae of gallstones. Mini-gastric bypass (MGBP) excludes the biliary tree from traditional evaluation and treatment with endoscopic retrograde cholangiopancreatography (ERCP). This prevents ERCP to be done through the normal route. Objective To assess the feasibility and outcome of laparoscopic-assisted transgastric ERCP in patients with choledocolithiasis after MGBP for extraction of common bile duct (CBD) stones. Patients and methods A retrospective study was conducted on 15 patients who had gallstones discovered in the CBD after MGBP in five bariatric centers. Overall, 750 participants (BMI >35 kg/m2) were observed after undergoing MGBP over 2 years, and 10 of them were included in the study after being diagnosed with primary CBD stones and presented with jaundice during a period of 2 years after surgery. All patients were hospitalized, and gallstones were extracted laparoscopically through a transgastric approach except for two patients. Results Of 15 patients, 11were managed laparoscopically, and gallstones were extracted successfully. Four patients were converted to open surgery, but the scope was still used in three of them to extract the stones, and the last one underwent open CBD exploration. Conclusion Laparoscopic-assisted transgastric ERCP is an effective and safe way of management of choledocholithiasis in post-MGBP patients.

Ursodeoxycholic acid combined with percutaneous transhepatic balloon dilation for management of gallstones after elimination of common bile duct stones.

AIMTo evaluate the effectiveness and safety of combined ursodeoxycholic acid and percutaneous transhepatic balloon dilation for management of gallstones after expulsion of common bile duct (CBD) stones.METHODSFrom April 2014 to May 2016, 15 consecutive patients (6 men and 9 women) aged 45-86 (mean, 69.07 ± 9.91) years suffering from CBD stones associated with gallstones were evaluated. Good gallbladder contraction function was confirmed by type B ultrasonography. Dilation of the CBD and cystic duct was detected. Percutaneous transhepatic balloon dilation of the papilla was performed, ursodeoxycholic acid was administered, and all patients had a high-fat diet. All subjects underwent repeated cholangiography, and percutaneous transhepatic removal was carried out in patients with secondary CBD stones originating from the gallbladder.RESULTSAll patients underwent percutaneous transhepatic balloon dilation with a primary success rate of 100%. The combined therapy was successful in 86.7% of patients with concomitant CBD stones and gallstones. No remaining stones were detected in the gallbladder. Transient adverse events include abdominal pain (n = 1), abdominal distension (n = 1), and fever (n = 1). Complications were treated successfully via nonsurgical management without long-term complications. No procedure-related mortality occurred.CONCLUSIONFor patients with concomitant CBD stones and gallstones, after percutaneous transhepatic removal of primary CBD stones, oral ursodeoxycholic acid and a high-fat diet followed by percutaneous transhepatic removal of secondary CBD stones appear to be a feasible and effective option for management of gallstones.

Evaluation of risk factors for recurrent primary common bile duct stone in patients with cholecystectomy

Objectives: Recurrence of primary common bile duct (CBD) stone commonly occurs after complete removal of CBD stones in patients with cholecystectomy. This study aimed to investigate potential risk factors for the recurrence of primary CBD stones after endoscopic treatment.Materials and methods: Between January 2005 and December 2015, the endoscopic retrograde cholangiopancreatography (ERCP) database of our medical center was retrospectively reviewed; information regarding eligible patients who had recurrent CBD stones with a history of previous cholecystectomy was collected. The characteristics of the patients, CBD stone, CBD and ERCP-related factors were analyzed.Results: The recurrence rate of CBD stone was 18.5% (115/622) after endoscopic treatment in patients with cholecystectomy. In univariate analysis, the number of CBD stones (≥2), CBD stone diameter (≥10 mm), stone composition, stone consistency, CBD diameter (≥15 mm), bile duct dilatation pattern, sharp bile duct angulation (<145°), balloon dilatation, large balloon (>12 mm) dilatation, endoscopic mechanical lithotripsy, endoscopic sphincterotomy, and endoscopic papillary balloon dilatation alone method were significant between the non-recurrence and recurrence groups. However, in multivariate analysis (based on the binary logistic regression method), the number of CBD stones (≥2) (adjusted odds ratio [AOR] 3.232; 95% confidence interval [CI] 1.344–7.773; p = .009), cholesterol stone (AOR 2.824; 95% CI 1.175–6.786; p =.02) and sharp bile duct angulation (<145°) (AOR 2.462; 95% CI 1.062–5.711; p = .036) were independent risk factors of CBD stone recurrence after cholecystectomy.Conclusions: CBD stone number (≥2), cholesterol stone and sharp bile duct angulation (<145°) are associated with recurrent common bile duct stones after cholecystectomy.

Laparoscopic-Assisted Transgastric ERCP: A Single-Institution Experience

Background Laparoscopic-assisted transgastric endoscopic retrograde cholangiopancreatography (LAERCP) is used for treatment in patients after Roux-en-Y gastric bypass (RYGB), where transoral access to the biliary tree is not possible. We describe our technique and experience with this procedure. Methods Electronic medical record search was performed from September 2012 to January 2016, identifying patients who underwent LAERCP per operative records. Charts were reviewed for demographic, clinical, and outcomes data. Results Sixteen patients were identified. Average time since bypass was 6.9 years, and length of stay was 3.7 days. Five patients underwent simultaneous cholecystectomy. Eleven patients, or 43%, had cholecystectomy more than 2 years previously. ERCP with sphincterotomy was completed in 15 of 16 patients (94%). Our technique involves access to the bypassed stomach via a laparoscopically placed 15 mm port. We observed one major complication of post-ERCP necrotizing pancreatitis. No minor complications nor mortalities were seen in our series. Conclusion Biliary obstruction can occur many years after RYGB and cholecystectomy. Our findings suggest that RYGB patients may be at a higher risk of primary CBD stone formation. LAERCP is a reliable option for common bile duct (CBD) clearance; our technique of LAERCP is technically simple and associated with low complication rate, making it appealing to surgeons not trained in advanced laparoscopy.

Current assessment of choledochoduodenostomy: 130 consecutive series.

Introduction Cholelithiasis usually can be managed successfully by endoscopic sphincterotomy. Choledochoduodenostomy (CDD) is one of the surgical treatment options but its acceptance remains debated because of the risk of reflux cholangitis and sump syndrome. The aim of this study was to assess the current features and outcomes of patient undergoing CDD. Patients and methods We retrospectively analysed the surgical results of consecutive 130 patients treated by CDD between 1991 and 2013 and excluded five cases with a malignant disorder. Indications for surgery included endoscopic management where stones were difficult or failed to pass and primary common bile duct stones with choledochal dilatation. Incidences of reflux cholangitis, stone recurrence, pancreatitis or sump syndrome were investigated and the data between end-to-side and side-to-side CDD were compared. Results Reflux cholangitis and stone recurrence was 1.6% (2/125) and 0% (0/125) of cases by CDD. There is no therapeutic-related pancreatitis in CDD. Sump syndrome was not also observed in side-to-side CDD. Conclusions This study is a first comparative study between end-to-side and side-to-side CDD. The surgical outcomes for CDD treatment of choledocholithiasis were acceptable. The incidence of reflux cholangitis, stone recurrence, pancreatitis and sump syndrome was very low.

Management of biliary symptoms after bariatric surgery

BackgroundBiliary disease requiring intervention can be complicated in the postbariatric surgery patient. MethodsA retrospective review was completed to identify patients who underwent laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy from September 2001 to September 2014, and those who underwent biliary intervention were identified. ResultsA total of 1527 patients underwent bariatric surgery during the study period. Of the 1,112 patients without prior cholecystectomy, 91 (8%) had biliary symptoms requiring intervention. Ninety patients underwent cholecystectomy, with 86 successfully completed laparoscopically. Six patients required laparoscopy-assisted percutaneous transgastric endoscopic retrograde cholangiopancreatography along with cholecystectomy to clear gallstones from the common bile duct. Three patients who had undergone cholecystectomy before bariatric surgery developed primary common bile duct stones. ConclusionsSurgery for biliary disease after bariatric surgery can be completed successfully with minimal complications, and percutaneous transgastric endoscopic retrograde cholangiopancreatography has a high success rate of access to and clearance of the biliary tree.

Primary choledocholithiasis after long-term self-expansible metallic stent for ampullary carcinoma: A rare case

AbstractIn patients with periampullary carcinoma presenting in the inoperable stage, self-expansible metallic stents (SEMS) are preferred for palliation of jaundice. The primary common bile duct (CBD) stones are very rare in a patient who is treated with SEMS for ampullary cancer. We report here a case of primary CBD stones after 2 years of placement of SEMS, whether, reflux of duodenal contents or foreign body reaction to the stent material is the etiology of the formation of stone is a matter of debate.

Laparoscopic Choledochoduodenostomy for Biliary Stone Disease: A Single-Center 10-Year Experience

Patients with a dilated common bile duct (CBD) and multiple, primary, or recurrent stones are candidates for choledochoduodenostomy. This article reviews our technique and results of laparoscopic choledochoduodenostomy (LCDD) in patients with CBD stones. Prospectively maintained data of patients with a dilated CBD and multiple, primary, or recurrent CBD stones who underwent LCDD after laparoscopic CBD exploration (LCBDE) at a tertiary-care teaching hospital in New Delhi, India, during a 10-year period from April 2001 to March 2011 were analyzed. During this period, of 195 patients who underwent LCBDE for CBD stones, 27 patients underwent LCDD. The mean age of patients was 45.7±13.5 years. There were 6 male and 21 female patients. Sixteen (59.2%) patients had jaundice at presentation. Average CBD diameter was 19.6±4.4 mm. On average, 11.5±15.7 stones were removed from the CBD. Mean operative time was 156.3±25.4 minutes. Mean operative blood loss was 143.3±85.5 mL. Average postoperative hospital stay was 6.4±3.8 days. CBD clearance was obtained in all cases. One patient had a bile leak that resolved with conservative treatment. There was no mortality. No patient has had recurrence of symptoms or cholangitis after a follow-up of up to 9 years. LCDD can be safely performed in patients with a large stone burden and recurrent or primary CBD stones. Although it requires advanced laparoscopic skills, the benefits of a single-stage laparoscopic procedure can be extended to these patients safely with good results.

Refining papillary balloon dilation: Less is better!

Refining papillary balloon dilation: Less is better!

Multiple Primary Choledocholithiasis in Sickle Cell Disease

Choledocholithiasis can be caused by either primary or secondary bile duct stones. Although patients with sickle cell disease (SCD) are at high risk of development of pigmented gallstones due to chronic hemolysis, primary choledocholithiasis in SCD is very uncommon. The delay in the diagnosis of biliary tract pathology can occur in patients who had a prior cholecystectomy. There is a possible relationship between prior cholecystectomy and the subsequent occurrence of primary common bile duct stones, due to the higher probability of infection of the biliary system. Here, we report an unusual and severe case of multiple primary choledocholithiasis, associated with pancreatitis, in a patient with SCD, fourteen years after cholecystectomy.

An 80-Year-Old Lady With Choledocholithiasis In A Cystic Dilated Common Bile Duct: Cause Or Consequence?

Congenital cysts of the common bile duct (CBD) are rare. Mostly they are found in children and do not typically lead to the formation of common bile duct stones. It is uncertain whether primary CBD stones and acquired choledochal cysts exist. We present an 80-year-old woman presented with epigastric discomfort. Investigation revealed dilatation of the CBD with large concrements. The gallbladder showed no abnormalities and no stones. A cholecystectomy and CBD exploration with stone extraction were performed. Choledochal cysts are usually congenital and discovered in childhood. Congenital CBD cysts are known for their risk of forming a bile duct malignancy with an increasing incidence with age. Presentation at the age of 80 years has not been reported before. We believe that in this patient the underlying aetiology was a choledochal cyst-like dilatation acquired during life leading to stasis of bile and formation of primary CBD stones.

Pigment gallstone pathogenesis: slime production by biliary bacteria is more important than beta-glucuronidase production

Pigment stones are thought to form as a result of deconjugation of bilirubin by bacterial β-glucuronidase, which results in precipitation of calcium bilirubinate. Calcium bilirubinate is then aggregated into stones by an anionic glycoprotein. Slime (glycocalyx), an anionic glycoprotein produced by bacteria causing foreign body infections, has been implicated in the formation of the precipitate that blocks biliary stents. We previously showed that bacteria are present within the pigment portions of gallstones and postulated a bacterial role in pigment stone formation through β-glucuronidase or slime production. Ninety-one biliary bacterial isolates from 61 patients and 12 control stool organisms were tested for their production of β-glucuronidase and slime. The average slime production was 42 for biliary bacteria and 2.5 for stool bacteria ( P <0.001). Overall, 73% of biliary bacteria and 8% of stool bacteria produced slime (optical density > 3). In contrast, only 38% of biliary bacteria produced β-glucuronidase. Eighty-two percent of all patients, 90% of patients with common bile duct (CBD) stones, 100% of patients with primary CBD stones, and 93% of patients with biliary tubes had one or more bacterial species in their stones that produced slime. By comparison, only 47% of all patients, 60% of patients with CBD stones, 62% of patients with primary CBD stones, and 50% of patients with biliary tubes had one or more bacteria that produced β-glucuronidase. Most biliary bacteria produced slime, and slime production correlated better than β-glucuronidase production did with stone formation and the presence of biliary tubes or stents. Patients with primary CBD stones and biliary tubes had the highest incidence of slime production. These findings suggest that bacterial slime is important in gallstone formation and the blockage of biliary tubes.

4639 The risk factors for the recurrence of primary common bile duct stones after endoscopic biliary sphincterotomy.

Background: Endoscopic biliary sphincterotomy (EST) is a well-established procedure for removing common bile duct (CBD) stones. CBD stones can be clssified into primary and secondary stones. However, few data are available on the recurrence of primary and secondary CBD stones after EST, respectively. We therefore studied risk factors prospectively for the recurrence of primary CBD stones after EST. METHODS: Between 1991 and 1997, 47 patients underwent endoscopic sphincterotomy for primary CBD stones. They were included in primary CBD stones which had the following criteria; 1) previous cholecystectomy without surgical CBD exploration 2) the detection of CBD stones at least two years after initial cholecystectomy. The results of 47 cases were analyzed prospectively and mean follow-up was 2.3 years. The recurrence of primary CBD stones was defined as the detection of stones at least 6 months after complete removal of stones. Results: The recurrence rate of primary CBD stones was 21% (10 of 47). The cumulative recurrence rate increased over time, and reached 60% at 4 years after EST. Two significant risk factors for the recurrence of primary CBD stones were identified in a multivariate analysis. first, patients with CBD stones ≥13 mm in post-stone removal state relapsed more frequently than those with CBD diameter

Primary common bile duct stones without cholelithiasis: Are juxtapapillary duodenal diverticula the cause?

Primary common bile duct stones without cholelithiasis: Are juxtapapillary duodenal diverticula the cause?