Retained Common Bile Duct Stones Research Articles

Diagnostic performance of laparoscopic transcystic common bile duct exploration for the detection of choledocholithiasis in patients with negative MRCP.

There is little research to evaluate laparoscopic transcystic common bile duct (CBD) exploration (LTCBDE) as a diagnostic test to identify choledocholithiasis undergoing laparoscopic cholecystectomy (LC). This study aimed to assess the technical success and safety of LTCBDE in patients with suspected choledocholithiasis but negative magnetic resonance cholangiopancreatography (MRCP) undergoing LC. We did an ambispective cohort study in patients with gallstones and suspected CBD stones but negative MRCP undergoing LC. The primary outcomes were the rate of complications in the hospital. Between January 2010 and December 2018, 620 patients (median age, 58years; 58.4% female) were eligible for the study. The success rate of LTCBDE was 91.8% and CBD stones were observed in 53.3% with a stone clearance rate of 99.3%. The overall postoperative complication rate was 0.65% and no death was recorded in the total cohort. Notably, the morbidity in LTCBDE is 0.53%. Retained CBD stones were diagnosed in 2 patients and managed by ERCP successfully. In the LTCBDE cohort, the median duration of operation was 78 (60-100) min and the median postoperative hospital stay was 1 (1-2) days. Overall, at a mean follow-up of 4.1 (2.3-6.1) years, recurrent CBD stones occurred in 1.1% and all-cause mortality in 0.6%. LTCBDE should be considered the favored choice in the diagnostic algorithm for patients with suspected choledocholithiasis but negative MRCP undergoing LC.

Evaluating Safety, Effectiveness, and Resource Efficiency in Management Strategies for Intermediate Risk Choledocholithiasis: Defining the Optimal Approach

INTRODUCTION: Optimal management of emergency department patients with intermediate-risk choledocholithiasis (IR-CDL) remains undefined. At a safety-net hospital where timely patient throughput is essential, we hypothesized that forgoing additional preoperative diagnostics and proceeding directly to laparoscopic cholecystectomy (LC) ± intraoperative cholangiogram (IOC) is a safe, effective, and resource-efficient strategy. METHODS: Adults with IR-CDL who underwent cholecystectomy during index hospitalization from 2016 to 2020 were included. IR-CDL was defined as total bilirubin 1.8 to 4.0 mg/dL, common bile duct (CBD) >6 mm, or gallstone pancreatitis on admission. Safety was assessed using the rate of CBD injury, reoperation, readmission, and retained CBD stones within 30 days of discharge. Effectiveness was assessed using the rate of successful endoscopic CBD clearance. Efficiency was measured using hospital length of stay (LOS) and direct and total cost. Patients taken direct-to-operating room (OR) for LC ± IOC were compared with those who received preoperative magnetic resonance cholangiopancreatography (MRCP) and/or endoscopic retrograde cholangiopancreatography (ERCP) (“additional-workup”). RESULTS: Of 655 patients, 611 (93%) were direct-to-OR and 44 (7%) were additional workup. Demographics were similar between groups. There was no difference in CBD injury, reoperation, readmission, or retained stones after discharge (all p > 0.05; Table). Of direct-to-OR patients who underwent LC+IOC, 34% had choledocholithiasis. Rates of successful endoscopic CBD clearance were similar between preoperative and postoperative ERCP (97% vs 100%, p = 0.96). Direct-to-OR patients had a shorter median hospital LOS by 38.5 hours and lower median direct and total cost by $5,121/patient and $8,535/patient, respectively.TableCONCLUSION: Proceeding directly to the OR for LC ± IOC expedites treatment of IR-CDL at lower cost without compromising safety or efficacy. These findings help clarify optimal management of IR-CDL.

Intervention versus surveillance in patients with common bile duct stones detected by intraoperative cholangiography: a population-based registry study.

Each year 13 000 patients undergo cholecystectomy in Sweden, and routine intraoperative cholangiography (IOC) is recommended to minimize bile duct injuries. The risk of requiring endoscopic retrograde cholangiopancreatography (ERCP) following cholecystectomy for common bile duct (CBD) stones where IOC is omitted and in patients with CBD stones left in situ is not well known. Data were retrieved from the population-based Swedish Registry of Gallstone Surgery and ERCP between 1 January 2009 and 10 December 2019. Primary outcome was risk for postoperative ERCP for retained CBD stones. A total of 134 419 patients that underwent cholecystectomy were included and 2691 (2.0 per cent) subsequently underwent ERCP for retained CBD stones. When adjusting for emergency or planned cholecystectomy, preoperative symptoms suggestive of CBD stones, sex and age, there was an increased risk for ERCP when IOC was not performed (hazard ratio (HR) 1.4, 95 per cent c.i. 1.3 to 1.6). The adjusted risk for ERCP was also increased if CBD stones identified by IOC were managed with surveillance (HR 5.5, 95 per cent c.i. 4.8 to 6.4). Even for asymptomatic small stones (less than 4 mm), the adjusted risk for ERCP was increased in the surveillance group compared with the intervention group (HR 3.5, 95 per cent c.i. 2.4 to 5.1). IOC plus an intervention to remove CBD stones identified during cholecystectomy was associated with reduced risk for retained stones and unplanned ERCP, even for the smallest asymptomatic CBD stones.

A Preliminary Study on the Efficacy of Single-Operator Cholangioscopy with a New Basket for Residual Stone Retrieval After Mechanical Lithotripsy.

The detection of residual or fragmented common bile duct (CBD) stones after lithotripsy can be improved by the high-resolution imaging quality of digital, single-operator cholangioscopy (SOC). However, therapeutic interventions for the removal of residual CBD stones are limited by the lack of appropriate tools. We retrospectively evaluated the role of SOC and the newly developed Dormia basket for the evaluation and removal of stones remaining after lithotripsy. Thirty-four patients who had undergone lithotripsy for retained CBD stones with no evidence of filling defects in occluded balloon cholangiography from March 2017 to October 2018 were included in the study. After balloon cholangiography, the bile duct was evaluated by SOC for complete evacuation of the stones. The detected residual CBD stones were directly retrieved by inserting the newly developed Dormia basket into the working channel of the SOC. The incidence of residual stones detected by SOC and the success rate of residual stone retrieval by SOC were investigated. Digital SOC was successfully performed in all patients. Of these, 11 patients (32.4%) had residual CBD stones. The residual stones were successfully removed in 10 patients (90.9%) by SOC using the Dormia basket, except in one case of residual stones left in the hepatic duct. There were no adverse events associated with the SOC procedures or direct stone removal. Digital SOC combined with the newly developed Dormia basket was useful for the detection and extraction of residual CBD stones under direct visualization after lithotripsy.

Single Setting ERCP and Laparoscopic Cholecystectomy is a Safe Procedure in Patients with Cholecysto-Choledocholithiasis: A Prospective Study in a Peripheral-Level Hospital

The ideal management of cholecysto-choledocholithiasis is an open cholecystectomy (OC) with the common bile duct (CBD) exploration worldwide. The single setting 2-stage approach- endoscopic retrograde cholangiopancreatography (ERCP), endoscopic sphincterotomy (EST), and CBD clearance followed by laparoscopic cholecystectomy (LC) offers an advantage, mainly by reducing the hospital stay, the cost, and the morbidity. The Objective of the study is to compare the ERCP+LC single setting approach with an OC+CBD exploration for the treatment of cholecysto-choledocholithiasis. This is an interim analysis of 160 patients with 83 (51.9%) patients in ERCP+LC and 77 (48.1%) in an open procedure (OC+CBD exploration) group respectively. We did a prospective study in patients admitted for the management of the cholecysto-choledocholithiasis in the Department of Surgery at the Lumbini Medical College and Teaching Hospital from November 2012–October 2015. They underwent 2-stage ERCP+LC in a single setting and we compared them with 2-stage OC+CBD exploration in a single setting approach. The patients with the open procedure were our control group. All the included cases in the study were elective. The procedure was feasible in our hospital. Similarly, the hospital stay was significantly shorter in the ERCP+LC group; 3.92±0.719 days vs 10.30±1.557 days, p <0.05. There was a significant difference in the total morbidity of ERCP+LC group 7 (8.4%) vs 14 (18.2%), p <0.05. Here, wound infection in the ERCP+LC group was 2 (2.4%) vs 4 (5.2%) and there was one case of abdominal collection 1 (1.2%) which was managed symptomatically. The incidence of retained CBD stone in the ERCP+LC was 3 (1.2%) which was managed successfully with ERCP. In all the cases, post- ERCP amylase value was found to be within the normal limit. The result of our study suggests, single setting ERCP+LC at the peripheral-level hospital is feasible in terms of cost, length of hospital stay, morbidity and stone clearance.

Dilation of the cystic duct confluence in laparoscopic common bile duct exploration and stone extraction in patients with secondary choledocholithiasis

BackgroundMany options exist for the management of cholelithiasis and secondary choledocholithiasis. Among them, laparoscopic common bile duct exploration (LCBDE) with choledocotomy followed by laparoscopic cholecystectomy has gained popularity. However, efforts should be made to ensure minimally invasive or noninvasive management of the common bile duct (CBD). The purpose of this study was to explore the clinical experience of non-invasive surgical modality, i.e., laparoscopic transcystic dilation of the cystic duct confluence in CBD exploration (LTD-CBDE), including feasibility, safety, adverse events, and incidence.MethodsIn this retrospective analysis, 68 patients were offered the LTD-CBDE technique from December 2015 to April 2018 based on patient’s own intention. During the surgery, the cystic duct confluence was dilated with separation forceps and/or a columnar dilation balloon. Subsequently, CBD exploration and stone extraction were performed with a choledochoscope. The entrance of the CBD was covered with a cystic duct stump wall and was subjected to primary closure at the end of surgery.ResultsForty-nine females and 19 males with cholelithiasis and secondary choledocholithiasis were included. The mean age was 53 years old (18 to 72 year). Of these patients, 62 (91.2%) were successfully treated with the LTD-CBDE technique, and bile leakage was observed in 3 patients (4.4%). The mean operation time was 106 min, and the mean hospital stay was 5.9 days. Among the other 6 patients, 3 were converted to open cholecystectomy due to severe fibrosis, unclear anatomical structure at Calot’s triangle (n = 2) or Mirizze syndrome (n = 1); LCBDE was performed in 3 patients due to cystic duct atresia (n = 2) and low level of flow from the gallbladder duct into the CBD (n = 1). These patients had a smooth postoperative course. In total, 43/68 of the patients presented no radiological evidence of retained CBD stones at the postoperative follow-up (40 patients treated with LTD-CBDE) 1 year later.ConclusionsThe current work suggests that LTD-CBDE for the management of cholelithiasis and secondary choledocholithiasis is a feasible, safe and effective technique with a low complication rate. LTD-CBDE offers another alternative for surgeons to treat patients in similar scenarios. However, additional randomized, controlled studies are needed to demonstrate its efficacy, safety, and impact on CBD stenosis.

52 Decline in Total Serum Bilirubin Level Is Sensitive but Not Specific Marker for Spontaneous Common Bile Duct Stones Passage

INTRODUCTION: Increased serum total bilirubin (T. bili: mg/dl) on presentation is one of the commonly used markers for the presence of common bile duct (CBD) stones. We sought to examine the relationship between the decrease in T. bili level and the probability of spontaneous stone passage in patients (pts) with suspected or confirmed choledocholithiasis. METHODS: Pts who were 18 or older and admitted to our institution between October 2015 and December 2017 with ICD 10 code(s) used in pts with confirmed or suspected choledocholithiasis were identified through the University of Kentucky Medical Services Database. Only pts with documented elevated T. bili with at least 3 measurements 12 hours apart were included for further review. Only pts with high-probability of choledocholithiasis based on very strong and/or strong clinical predictors of choledocholithiasis per ASGE guidelines were included in the final analysis. All selected pts underwent one or more of the following confirmatory studies: MRCP, ERCP, EUS or IOC. Categorical variables were compared using chi square tests and continuous variables using two-sample t-tests. Regression analysis was performed to identify independent variables associated with retained stone despite consistent decline in T. bili level. RESULTS: 825 pts were identified according to the screening criteria. 723 pts were excluded due to having pathologies and 102 pts were included in this study (48 males & 54 females). Mean age of 57.4 years ± 22. 33 pts had fluctuation or no decline in T. bili level and 30 of them (92%) were confirmed to have retained stones. Among the 75 pts with consistent decline in T. bili level after 48 hours from initial presentation, 26 (34.7%) were found to have retained stone while 49 (65.3%) were confirmed to have no retained stones (passed spontaneously). On regression analysis, predictors of the presence of retained CBD stone(s) despite consistent decline in T. bili level included: pts older than 55 (OR 1.9; 95% CI: 1.1, 3.4) and pts presented with severe cholangitis defined as WBC > 16,000 and hypotension (OR 1.6; 95% CI 1.2–2.7). CONCLUSION: Although consistent decline in T. bili level is a sensitive predictor for spontaneous CBD stone passage, it is not specific and can be seen in at least one third of patients with documented retained stones. Possible explanations for decreased specificity include vigorous medical support (hydration & antibiotics) that may contribute to decline in T. bili level even in the setting of retained stones.

Comparative study between laparoscopic common bile duct exploration and endoscopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy for choledocholithiasis

Background: Endoscopic retrograde cholangiopancreatography (ERCP) with consequent laparoscopic cholecystectomy (LC) has been the favored approach for the treatment of choledocholithiasis for a long time; however recently, laparoscopic common bile duct exploration (LCBDE) has been offered to patients with suspected choledocholithiasis. Objective and aim of this work was to compare the efficacy, safety, and the surgical outcomes of LCBDE with ERCP followed by LC and determine the most appropriate approach for patients with choledocholithiasis.Methods: A prospective clinical study was carried out from March 2017 to September 2018. It included 50 patients with cholecysto-choledocholithiasis who were divided into two groups: group A (25 patients) included patients who underwent transcystic LCBDE and stone extraction with LC in one stage, and group B (25 patients) included patients who underwent ERCP followed by LC in two stages. The common bile duct (CBD) stone clearance rate, postoperative bile leakage, postoperative morbidity, mortality, overall hospital stay, and patient satisfaction were analyzed.Results: LCBDE and ERCP+LC were similar in terms of clearance rate, operative time, postoperative complications, retained CBD stones, and postoperative length of stay, but there was a significant difference in number of procedures and patient satisfaction.Conclusions: Although both approaches have equivalent success rates, LCBDE is better in terms of fewer procedures, and better satisfaction compared with ERCP + LC. Our study suggests that one-stage management is the treatment of choice for patients with cholecysto-choledocholithiasis.

Comparative Study between Laparoscopic Common Bile Duct Exploration and Endoscopic Retrograde Cholangiopancreatography Plus Laparoscopic Cholecystectomy for Choledocholithiasis

AbstractBackground: Overall, 5% to 15% of patients undergoing cholecystectomy for cholelithiasis have concomitant bile duct stones, and the incidence of choledocholithiasis increases with age. Endoscopic Retrograde Cholangiopancreatography (ERCP) with consequent Laparoscopic Cholecystectomy (LC) has been the favored approach for the treatment of choledo-cholithiasis for quite a long time; however in the course of recent years, Laparoscopic Common Bile Duct Exploration (LCBDE) has been offered to patients with suspected choledo-cholithiasis.Aim of Study: The aim of this work is to compare the efficacy, safety, and the surgical outcomes of LCBDE with ERCP followed by laparoscopic cholecystectomy and deter-mine the most appropriate approach for patients with choledo-cholithiasis.Patients and Methods: A prospective randomized clinical study was carried out from March 2017 to September 2018. It included 50 patients with cholecysto-choledocholithiasis who were divided into two groups: Group A (25 patients) included patients who underwent laparoscopic transcystic common bile duct exploration and stone extraction with LC in one stage, and Group B (25 patients) included patients who underwent endoscopic retrograde cholangiopancreatography for CBD stone extraction followed by LC in two stages. The Common Bile Duct (CBD) stone clearance rate, post-operative bile leakage, post-operative morbidity, mortality, overall hospital stay, and patient satisfaction were analyzed.Results: LCBDE and ERCP+LC were similar in terms of clearance rate, operative time postoperative complications, retained CBD stones, and postoperative length of stay, but there was a significant difference in number of procedures and patient satisfaction.Conclusion: Although both approaches have equivalent success rates, LCBDE is better in terms of fewer procedures, and better satisfaction compared with ERCP + LC. Our study suggests that one-stage management is the treatment of choice for patients with cholecystocholedocholithiasis.

Clinical patterns of postcholecystectomy syndrome.

Backgrounds/AimsPostcholecystectomy syndrome represents a heterogeneous group of symptoms and findings in patients who have previously undergone cholecystectomy. It is rare and under-reported in Saudi Arabia. It can be attributed to many complications such as bile duct injury, biliary leak, retained common bile duct stones, recurrent bile duct stones, and bile duct strictures. In this study, we aimed to analyze the causes and evaluate the approach to postcholecystectomy syndrome in our local Saudi Arabian community because of the vast number of cases encountered in our hospital for gallbladder clinical conditions and its related complications.MethodsA prospective cohort database analysis of 272 patients who were diagnosed and treated for postcholecystectomy syndrome between January 2000 and December 2013 were reviewed.ResultsThe incidence rate of postcholecystectomy syndrome was 19.8%. The male to female ratio was 1:1.45. The mean age was 37.41±7.12 years. The most common causes were as follows: No obvious cause in 50 (18.4%) patients, Helicobacter pylori infection in 43 (15.8%), pancreatitis in 42 (15.4%), peptic ulcer disease in 41 (15.1%), recurrent common bile duct (CBD) stone in 26 (9.6%), retained CBD stone in 22 (8.1%), bile leakage in 19 (7%), stenosis of the sphincter of Oddi in 12 (4.4%), cystic duct stump syndrome in 11 (4%), and CBD Stricture in 5 (1.8%). The mortality rate was 0%.ConclusionsAny clinical presentation of postcholecystectomy should not be underestimated and be thoroughly investigated. Multidisciplinary collaboration is crucial for the best outcome and a safe approach for all the patients.

Analysis of post-operative complication in single-port laparoscopic cholecystectomy: A retrospective analysis in 817 cases from a surgeon.

Background:Single-port laparoscopic cholecystectomy (SPLC) is a new advanced technique in laparoscopic surgery which has many benefits according to previous reports. The purpose of this study was to present personal experiences with SPLC in >800 cases performed by a surgeon to evaluate the safety and feasibility of this procedure.Materials and Methods:A retrospective review of 817 cases of SPLC was conducted. All patients had received elective SPLC by a surgeon in our centre during March 2009–August 2015. Our review suggests patients’ character, peri-operative data and post-operative outcome.Results:Three hundred and ninety-eight men (48.7%) and 419 women (51.3%) with an average age of 48.3 years had received SPLC. Their mean body mass index (BMI) was 23.75 kg/m2. The mean operating time took 46.9 min (19–130). Seventy-nine cases (9.7%) needed additional port during operation. BMI, age and previous abdominal surgical history did not affect conversion to multiport surgery. Bile spillage during operation occurred in 73 cases (8.9%). There were 4 cases of open conversion because of bleeding (2 cases, 0.2%) and common bile duct (CBD) injury (2 cases, 0.2%). Mean duration of hospital stay was 2.36 days. We have experienced 38 cases (4.7%) of post-operative complication: 8 cases (1.0%) of major one and 30 cases (3.7%) of minor one. Major complication occurred in 3 cases (0.4%) of retained CBD stone, 3 cases (0.4%) of cystic duct leakage needed endoscopic retrograde cholangiopancreatography and 2 cases (0.2%) of CBD injury needed reoperation. Most minor complications were wound infections that have healed after conservative treatment. There were no post-operative mortalities.Conclusion:SPLC is a safe and practicable technique. With surgical experience, criteria and area of SPLC can be broadened. SPLC is occupying a greater domain of a laparoscopic cholecystectomy.

Laparoscopic Exploration Can Salvage Recurrent Common Bile Duct Stone after Cholecystectomy

Conventionally, patients suffered from recurrent common bile duct (CBD) stone after cholecystectomy are suggested to be treated with endoscopic retrograde cholangiopancreaticography. This study was designed to explore the feasibility of laparoscopic common bile duct exploration (LCBDE) as a salvage procedure for recurrent CBD calculi after cholecystectomy. A retrospective review was conducted of data from 65 patients who underwent LCBDE for recurrent CBD calculi after cholecystectomy from January 2011 to July 2015. LCBDE was successfully carried out in 61 cases, with a successful rate of 93.8 per cent. Three cases required open conversion because of serious abdominal adhesion, and one case for intraoperative bleeding. Postoperative bile leakage occurred in two cases, and bile peritonitis developed in one case; all these three patients with complications were fully cured by conservative treatment. A postoperative retained CBD stone was found in one patient, which was extracted with endoscopic sphincterotomy. Furthermore, it was found that the mean operative time and length of postoperative hospital stay were much shorter in primary closure group (n = 49) than in T-tube drainage group (n = 12), and the hospital expense was also lower in primary closure group. We suggest that LCBDE could be a novel approach as a salvage procedure for the recurrent CBD stone after cholecystectomy, and we prefer to intraoperative primary closure of CBD if possible.

Preliminary experience with laparoscopic common bile duct exploration

BackgroundHerein we present our experience with laparoscopic common bile duct exploration (LCBDE) in managing common bile duct stones.MethodsData of 129 consecutive patients who underwent laparoscopic cholecystectomy (LC) and LCBDE done at our institutes from April 2011 through June 2016 were prospectively recorded and retrospectively reviewed.ResultsSince 2011, 3012 laparoscopic cholecystectomy were performed at our institutes, intraoperative cholangiogram (IOC) was done in 295 (9.8%) patients which detected choledocholithiasis in 129 (4.3%) of them. LCBDE was successful to clear the common bile duct (CBD) in 123/129 (95.4%). Six patients underwent postoperative endoscopic retrograde cholangiopancreatography (ERCP) because of incomplete CBD clearance (4 cases), symptomatic stenosed papilla (2 cases). LCBDE was performed in 103 patients via trans-cystic approach and choledochotomy one in 26 patients. In the choledochotomy group, seven patients had primary closure of the CBD, CBD was closed over T-tube in nine patients whereas the remaining 10 patients the CBD was closed over antegrade inserted stent. The median time of hospital stay was 4 (range; 1–15) days. No patients showed retained CBD stones with mean follow up was 9 ± 3.4 months.ConclusionLCBDE is a safe and cost effective option for CBD stones in short-term outcome and can be performed provided proper laparoscopic expertise and facilities are available.

Elective laparoscopic cholecystectomy without intraoperative cholangiography: role of preoperative magnetic resonance cholangiopancreatography - a retrospective cohort study.

BackgroundLaparoscopic cholecystectomy (LC) is the standard treatment for gallbladder diseases. Intraoperative cholangiography (IOC) can reduce biliary complications of LC; however, with the emergence of magnetic resonance cholangiopancreatography (MRCP), IOC nowadays is faced with unprecedented challenge. The purpose of this study is to evaluate whether preoperative MRCP can safely replace IOC during elective LC in terms of retained common bile duct (CBD) stones and bile duct injury (BDI).MethodsA retrospective study on candidates for elective LC who underwent IOC or preoperative MRCP between January 2009 and December 2014 was conducted.ResultsIn the IOC group, 1972 patients underwent LC and 213 required IOC. In the MRCP group, 2268 patients underwent LC and 257 required MRCP. In the IOC group, the rate of retained CBD stones was 0.45 % without IOC and 1.41 % with IOC. In five of 157 patients who underwent IOC, endoscopic retrograde cholangiopancreatography or laparoscopic CBD exploration showed no evidence of CBD stones. In the MRCP group, the rate of retained CBD stones was 0.45 % without MRCP. No patients with normal MRCP findings returned with symptomatic CBD stones during 1-year follow-up. The rate of BDIs was 0.20 % in the IOC group and 0.13 % in the MRCP group.ConclusionsSelective use of preoperative MRCP is an effective and safe strategy when conducting elective LC to treat gallstones. LC resorting to preoperative MRCP can be performed safely without IOC, with an acceptable rate of retained CBD stones and BDIs.

Covered self-expanding metal stents for the management of common bile duct stones.

Little medical literature exists for the use of fully covered self-expanding metal stents (CSEMSs) in the management of retained common bile duct (CBD) stones. Our aim was to assess the safety and efficacy of CSEMSs for the indication of retained "difficult" CBD stones. This retrospective cases series included 44 patients (30 women; median age, 69 years [range, 24-88]) who underwent CSEMS insertion for the indication of retained "difficult" CBD stones in 2 tertiary referral centers. Patients underwent temporary placement of CSEMSs after incomplete stone clearance at ERCP. Follow-up ERCP was arranged for stent removal and subsequent attempt at duct clearance. Procedure-related adverse events were also recorded. Successful biliary drainage was achieved in all cases after CSEMS placement. Forty-two stents were removed with successful duct clearance achieved in 36 cases (82%) after a median in-stent duration of 8 weeks. There were 10 cases (22.7%) of stent migration, all noted incidentally during follow-up. One patient died of nonbiliarycauses before attempted removal. This is the largest published retrospective case series for use of CSEMSs for management of retainedCBD stone disease to date. We have shown high success rates for this indication. A well-designed, multicenter,randomized controlled trial might address the uncertainty of cost-to-benefit ratio and appropriate duration for CSEMSs to be left in situ. Specific stent modification for this indication, including wider distal flare and retrieval purse string loop, may also be useful.

A Prospective Blinded Study Evaluating the Role of Endoscopic Ultrasound before Endoscopic Retrograde Cholangiopancreatography in the Setting of “Positive” Intraoperative Cholangiogram during Cholecystectomy

During laparoscopic cholecystectomy, intraoperative cholangiography (IOC) is used to identify common bile duct (CBD) stones. In patients whose IOC is suspicious for stones, endoscopic retrograde cholangiopancreatography (ERCP) is the modality of choice for stone removal. However, IOC has a false positive rate of 30 to 60 per cent, and ERCP adverse events may occur in 11 per cent of patients. Endoscopic ultrasound (EUS) may serve as a noninvasive means of diagnosing suspected CBD stones. This study sought to assess the role of EUS in predicting the likelihood of choledocholithiasis at ERCP in patients found to have a positive IOC. This was a prospective blinded study of EUS before ERCP in patients with a positive IOC. Recruited subjects who underwent cholecystectomy and had an IOC with suspicion for obstruction were referred for ERCP within one month of their procedure. In patients with a positive IOC, EUS had a positive predictive value of 95 per cent in detecting choledocholithiasis. IOC with single or multiple filling defects more often correlated to the presence of CBD stones. At ERCP, choledocholithiasis was present in 65 per cent of patients who had an IOC suspicious for CBD stones. EUS should be used as a noninvasive method to correctly identify retained CBD stones in low-to-moderate risk patients with a positive IOC.

CHOLEDOCHOLITHIASIS

Objectives: To determine the frequency of choleducholethiasis in patientswith symptomatic gall stone disease and evaluation of primary closure of common bile ductwithout T-Tube placement after open exploration as a treatment modality in its management.Study Design: Prospective (descriptive) study. Setting: Surgical Unit of Postgraduate MedicalInstitute, Lady Reading Hospital, Peshawar. Period: One year from 15-03-2013 to 15-03-2014. Subjects and methods: Total 0f 206 patients of symptomatic gallstones disease wereincluded in the study to find out frequency of choledcholithias and patients with common bileduct (CBD) stones were subjected to open choledochotomy and primary choledochorrhaphy,and follow up of patients was done to find out any post operative complication. Results: Atotal of 206 patients underwent open cholecystectomy during the study period. The age ofthe patients ranged from 17 to 70 years with mean of 44.24±1.23 years. Most of the patientswith symptomatic gall stones disease were female in the age range of 41-50 years. Frequencyof choledocholethiasis was 24 out of 206 constituting 11.65%. Among the patients with CBDstones 4 were male constituting 16.6% and 20 were female that is 83.33% with male to femaleratio of 1:4 respectively. Mean hospital stay of the patients in which open CBD explorationand primary repair was performed was 7.25±1.45 days. Complications developed in only 4patients constituting 16.66%. Complications were wound infection in 2 (8.33%) patients, intraabdominalpus collection in 1 (4.16%) patient and bile leak in 1 (4.16%). One patient lost fromfollow up. In none of the patients retained CBD stones and stricture observed. Conclusions:There should be low

Prevalence and characteristics of clinically significant retained common bile duct stones after laparoscopic cholecystectomy for symptomatic cholelithiasis.

PurposeTo investigate the prevalence and clinical features of retained symptomatic common bile duct (CBD) stone detected after laparoscopic cholecystectomy (LC) in patients without preoperative evidence of CBD or intrahepatic duct stones.MethodsOf 2,111 patients who underwent cholecystectomy between September 2007 and December 2014 at Seoul Metropolitan Government-Seoul National University Boramae Medical Center, 1,467 underwent laparoscopic cholecystectomy for symptomatic gallbladder stones and their medical records were analyzed. We reviewed the clinical data of patients who underwent postoperative endoscopic retrograde cholangiopancreatography (ERCP) for clinically significant CBD stones (i.e., symptomatic stones requiring therapeutic intervention).ResultsOverall, 27 of 1,467 patients (1.84%) underwent postoperative ERCP after LC because of clinical evidence of retained CBD stones. The median time from LC to ERCP was 152 days (range, 60–1,015 days). Nine patients had ERCP-related complications. The median hospital stay for ERCP was 6 days.ConclusionThe prevalence of clinically significant retained CBD stone after LC for symptomatic cholelithiasis was 1.84% and the time from LC to clinical presentation ranged from 2 months to 2 years 9 months. Therefore, biliary surgeons should inform patients that retained CBD stone may be detected several years after LC for simple gallbladder stones.

Accuracy of ASGE criteria for the prediction of choledocholithiasis.

Few studies have validated the performance of guidelines for the prediction of choledocholithiasis (CL). Our objective was to prospectively assess the accuracy of the American Society for Gastrointestinal Endoscopy (ASGE) guidelines for the identification of CL. A two-year prospective evaluation of patients with suspected CL was performed. We evaluated the ASGE guidelines and its component variables in predicting CL. A total of 256 patients with suspected CL were analyzed. Of the 208 patients with high-probability criteria for CL, 124 (59.6%) were found to have a stone/sludge at endoscopic retrograde cholangiopancreatography (ERCP). Among 48 patients with intermediate-probability criteria, 21 (43.8%) had a stone/sludge. The performance of ASGE high- and intermediate-probability criteria in our population had an accuracy of 59.0% (85.5% sensitivity, 24.3% specificity) and 41.0% (14.4% sensitivity, 75.6% specificity), respectively. The mean ERCP delay time was 6.1 days in the CL group and 6.4 days in the group without CL, p = 0.638. The presence of a common bile duct (CBD) > 6 mm (OR 2.21; 95% CI, 1.20-4.10), ascending cholangitis (OR 2.37; 95% CI, 1.01-5.55) and a CBD stone visualized on transabdominal US (OR 3.33; 95% CI, 1.48-7.52) were stronger predictors of CL. The occurrence of biliary pancreatitis was a strong protective factor for the presence of a retained CBD stone (OR 0.30; 95% CI, 0.17-0.55). Irrespective of a patient's ASGE probability for CL, the application of current guidelines in our population led to unnecessary performance of ERCPs in nearly half of cases.

Timing and nature of presentation of unsuspected retained common bile duct stones after laparoscopic cholecystectomy: a retrospective study.

Common bile duct (CBD) stones may be over looked at the time of laparoscopic cholecystectomy (LC), particularly when intra-operative cholangiography (IOC) is not performed. Currently, there is no data available about the time course and pattern of presentation for stones retained in the CBD at the time of LC. The aim of this study was to establish the time course and pattern of presentation of unsuspected retained CBD stones post LC. Patients presenting with symptomatic CBD stones from 1994 until 2010, having previously undergone LC were studied in this retrospective, case note review. CBD stones were confirmed at ERCP. Data collected included LC date, mode of presentation, imaging results including CBD diameter, stone appearance, length of stay and post ERCP complications. Patients having an ERCP for stones found on IOC at LC were excluded. Sixty-one patients met the inclusion criteria. The most common mode of presentation was abdominal pain (n = 38, 62%) with (17) or without (21) deranged liver function tests. Nineteen (31%) patients presented with clinical complications of the CBD stones: cholangitis (10), acute biliary pancreatitis (6) or obstructive jaundice (3). The CBD was usually mild-to-moderately dilated (8-15 mm) on ultrasound. The median time span from LC to presentation with CBD stones was 4 years (range: 6 days-18 years). Five (8.2%) patients had a complication from their ERCP; mild pancreatitis (3), bleed (1) and cholangitis (1). Nineteen (31.1%) patients required more than one ERCP to complete stone/stent removal. The median time for patients to present with symptomatic CBD stones after LC is 4 years. Patients with retrained stones may remain asymptomatic for many years. A third of the patients presented with potentially serious complications of the retained CBD stone. Future studies for CBD stones after LC need to follow patients for at least 10 years.