Urgent one-stage endoscopic treatment for choledocholithiasis related moderate to severe acute cholangitis: A propensity score-matched analysis.

BACKGROUND: During emergency endoscopic retrograde cholangiopancreatography (ERCP), the safety and feasibility of performing one-stage endoscopic treatment for patients with acute cholangitis (AC) due to choledocholithiasis are unclear. AIM: To investigate the safety and feasibility of one-stage endoscopic treatment for moderate to severe AC. METHODS: We enrolled all patients diagnosed with moderate to severe cholangitis due to common bile duct stones from January 2019 to July 2023. The outcomes were compared in this study between patients who underwent ERCP within 24 h and those who underwent ERCP 24 h later, employing a propensity score (PS) framework. Our primary outcomes were intensive care unit (ICU) admission rates, ICU length of stay, and duration of antibiotic use. RESULTS: In total, we included 254 patients and categorized them into two groups based on the time elapsed between admission and intervention: The urgent group (≤ 24 h, n = 102) and the elective group (> 24 h, n = 152). Ninety-three pairs of patients with similar characteristics were selected by PS matching. The urgent ERCP group had more ICU admissions (34.4% vs 21.5%, P = 0.05), shorter ICU stays (3 d vs 9 d, P < 0.001), fewer antibiotic use (6 d vs 9 d, P < 0.001), and shorter hospital stays (9 d vs 18.5 d, P < 0.001). There were no significant differences observed in adverse events, in-hospital mortality, recurrent cholangitis occurrence, 30-d readmission rate or 30-d mortality. CONCLUSION: Urgent one-stage ERCP provides the advantages of a shorter ICU stay, a shorter duration of antibiotic use, and a shorter hospital stay.

The value of endoscopic duodenal papilloplasty with titanium clip in improving post-operative complications of choledocholithiasis.

OBJECTIVE: To investigate the value of endoscopic duodenal papillary sphincterotomy combined with balloon dilatation in the treatment of duodenal papilloplasty with titanium clip after choledocholithiasis in post-operative complications. MATERIALS AND METHODS: One hundred and twenty-five patients (69 males and 56 females) with a median age of 65 (32-81) years were included. The treatment plan was randomly divided into Group A (n = 59) and Group B (n = 66) according to the random number table. Patients in Group A were treated with endoscopic sphincterotomy (EST) combined with endoscopic papillary large balloon dilation (EPLBD), followed by a titanium clip for duodenal papilloplasty and then indwelling nasobiliary drainage, whereas those in Group B were treated with EST combined EPLBD to remove stones and then indwelling nasobiliary drainage. RESULTS: In patients with choledocholithiasis or with anatomical changes that make stone extraction difficult, this prospective study attempted to perform duodenal papilloplasty with titanium clips after EST and EPLBD lithotripsy to compare and observe post-operative papillary healing, biliary reflux, and complication rates. CONCLUSIONS: The use of endoscopic duodenal papilloplasty with a titanium clip can improve biliary reflux after lithotripsy and reduce the incidence of post-operative cholangitis complications.

OBJETIVO: Investigar el valor de la esfinterotomía papilar duodenal endoscópica combinada con dilatación con balón en el tratamiento de la papiloplastia duodenal con clip de titanio después de coledocolitiasis en complicaciones postoperatorias. MATERIALES Y MÉTODOS: Se incluyeron un total de 125 pacientes (69 hombres y 56 mujeres) con una mediana de edad de 65 (32-81) años. Los pacientes del Grupo A se trataron con esfinterotomía endoscópica (EST) combinada con dilatación papilar endoscópica con balón grande (EPLBD), seguida de clip de titanio para papiloplastia duodenal y luego drenaje nasobiliar permanente, mientras que los del Grupo B se trataron con EPLBD combinado con EST para eliminar cálculos y luego drenaje nasobiliar permanente. RESULTADOS: En pacientes con coledocolitiasis o con cambios anatómicos que dificultan la extracción de cálculos, este estudio prospectivo intentó realizar papiloplastia duodenal con clips de titanio después de litotricia EST y EPLBD para comparar y observar la cicatrización papilar postoperatoria, el reflujo biliar y las tasas de complicaciones. CONCLUSIÓN: El uso de papiloplastia duodenal endoscópica con clips de titanio puede mejorar el reflujo biliar después de la litotricia y reducir la incidencia de complicaciones de colangitis postoperatorias.

Endoscopic features of low-phospholipid-associated cholelithiasis syndrome: A retrospective cohort study.

BACKGROUND AND OBJECTIVE: LPAC (low phospholipid-associated cholelithiasis) syndrome is a rare genetic form of cholelithiasis. ERCP (endoscopic retrograde cholangiopancreatography) is often used to remove gallstones in the bile duct. No published data is available on the role of ERCP in LPAC syndrome. PATIENTS AND METHODS: In this retrospective cohort study, we included patients diagnosed with LPAC syndrome in a single tertiary referral center between 2009 and 2021. Our aim was to assess the frequency, indications, modalities, results, and complications of ERCP, as well as predictive factors for ERCP, in LPAC syndrome. Independent factors associated with ERCP occurrence were identified using a multivariable Cox regression analysis. RESULTS: ERCP was required in 31.2 % of the 269 patients included for analysis. Among patients who required ERCPs, 78.6 % had the procedure before diagnosis (i.e., starting UDCA). Most common indications were choledocholithiasis (53.6 %) and acute cholangitis (29.5 %). Post ERCP pancreatitis, perforation and bleeding rates were 7.2 %, 2.6 %, and 1.3 %, respectively. Age and history of cholelithiasis in first-degree relatives were associated with a higher risk of ERCP (Hazard-ratio [HR]=1.30 [95 %confidence-interval [CI] 1.04-1.62] and HR=1.88 [95 %CI 1.15-3.07] respectively). Female gender and UDCA intake ≥ 1 year were associated with a lower risk of ERCP (HR=0.49 [95 %CI 0.29-0.82] and HR=0.44 [95 %CI 0.22-0.90] respectively). Median follow-up was 10.8 years. CONCLUSION: One-third of patients with LPAC syndrome undergo sphincterotomy. However, most procedures are performed before diagnosis and UDCA is associated with a lower risk of endoscopic procedure. Earlier diagnosis and treatment with UDCA may further reduce the need for ERCP in patients with LPAC syndrome.

Hepatic subcapsular hematoma: A rare complication post-ERCP; a case report.

INTRODUCTION: Endoscopic retrograde cholangiopancreatography (ERCP) is commonly used in gastroenterology wards for both diagnostic and therapeutic purposes. It doesn't however come free of complications. As a matter of fact, complications are reported in up to 10% of patients undergoing ERCP. PATIENT CONCERNS: In this article, we report the case of a patient who underwent ERCP and sphincterotomy for choledocholithiasis. Twenty-four hours after the procedure, the patient developed sudden sharp abdominal pain and dropped her hemoglobin levels. DIAGNOSIS: An emergent gastroscopy was done and it ruled out bleeding from the sphincterotomy. Computed tomography of the abdomen showed a large hepatic subcapsular hematoma. INTERVENTIONS: Blood was urgently transfused and the patient was transferred to the intensive care unit for monitoring. OUTCOMES: The patient's condition quickly deteriorated despite extensive resuscitative measures, and eventually passed away on day 4 post ERCP. LESSONS: Hepatic subcapsular hematoma is a very rare but fatal complication after ERCP and should be ruled out in patients who underwent the procedure and develop sudden abdominal pain with hemodynamic and laboratory instability.

Index admission cholecystectomy for biliary acute pancreatitis or choledocholithiasis reduces 30-day readmission rates in children.

BACKGROUND: Adult patients with biliary acute pancreatitis (BAP) or choledocholithiasis who do not undergo cholecystectomy on index admission have worse outcomes. Given the paucity of data on the impact of cholecystectomy during index hospitalization in children, we examined readmission rates among pediatric patients with BAP or choledocholithiasis who underwent index cholecystectomy versus those who did not. METHODS: Retrospective study of children (< 18 years old) admitted with BAP, without infection or necrosis (ICD-10 K85.10), or choledocholithiasis (K80.3x-K80.7x) using the 2018 National Readmission Database (NRD). Exclusion criteria were necrotizing pancreatitis with or without infected necrosis and death during index admission. Multivariable logistic regression was performed to identify factors associated with 30-day readmission. RESULTS: In 2018, 1122 children were admitted for index BAP (n = 377, 33.6%) or choledocholithiasis (n = 745, 66.4%). Mean age at admission was 13 (SD 4.2) years; most patients were female (n = 792, 70.6%). Index cholecystectomy was performed in 663 (59.1%) of cases. Thirty-day readmission rate was 10.9% in patients who underwent cholecystectomy during that index admission and 48.8% in those who did not (p < 0.001). In multivariable analysis, patients who underwent index cholecystectomy had lower odds of 30-day readmission than those who did not (OR 0.16, 95% CI 0.11-0.24, p < 0.001). CONCLUSIONS: Index cholecystectomy was performed in only 59% of pediatric patients admitted with BAP or choledocholithiasis but was associated with 84% decreased odds of readmission within 30 days. Current guidelines should be updated to reflect these findings, and future studies should evaluate barriers to index cholecystectomy.

Efficacy and safety of double endoscopy combined with exploration in the treatment of elderly patients with cholecystolithiasis complicated with choledocholithiasis.

OBJECTIVE: To investigate the efficacy and safety of laparoscopy combined with choledochoscopy in the treatment of elderly patients with cholecystolithiasis complicated with choledocholithiasis. METHODS: A retrospective analysis of 114 patients admitted to our hospital from January 2020 to January 2023 was conducted. These patients underwent laparoscopic cholecystectomy combined with choledocholithiasis and were divided into an elderly group (≥ 60 years old) of 63 cases and a young and middle-aged group (< 60 years old) of 51 cases according to age. The efficacy and safety indicators of the two groups of patients were observed, and complications were followed up by telephone within 6 months after surgery. The follow-up deadline was June 2023. RESULTS: Among the eligible patients (53 men, 61 women, average age 57 years), all were successfully operated, and 1 case was converted to laparotomy. The elderly and young and middle-aged groups were compared concerning hospitalisation time, bowel sound recovery time, and total postoperative complications, and the differences were statistically significant (P-values were 0.009, 0.006, and 0.039). However, there was no statistically significant difference between the two groups of patients in terms of hospitalisation costs, intraoperative blood loss, operation time, drainage tube removal time, conversion to laparotomy rate, and stone clearance rate (P-values > 0 0.05). CONCLUSION: Strict adherence to surgical standards and enhanced postoperative care resulted in similar efficacy and safety results for double endoscopy combined with the exploration of treatment for elderly and young patients with cholecystolithiasis and choledocholithiasis.

Long-term outcomes of choledochoduodenostomy for choledocholithiasis: increased incidence of postoperative cholangitis after total or distal gastrectomy.

PURPOSE: Choledochoduodenostomy (CDD) is performed to treat choledocholithiasis (CDL) cases where endoscopic stone removal is difficult. Recognizing CDD characteristics is important for CDL treatment planning. METHODS: A total of 116 patients, including 33 patients ≥ 80 years old (29 with previous total gastrectomy, 19 with previous distal gastrectomy, 20 with built-up stones, 19 with periampullary diverticulum, 10 with confluence stones, 8 with repetitive recurrent stones, 4 with hard stones, 3 with endoscopic retrograde cholangiography [ERC] not available due to lack of cooperation, 2 with a history of pancreatitis post-ERC, and 2 in whom ERC could not be performed due to a disturbed anatomy) underwent CDD for CDL. Postoperative complications and long-term outcomes were evaluated. RESULTS: The in-hospital mortality rate was 0%. The morbidity (grade ≥ IIIA according to the Clavien-Dindo classification) rates in the elderly (≥ 80 years old) and non-elderly (51-79 years old) patients were 3.0% (1/33) and 2.4% (2/83), respectively (p = 0.85). Long-term complications included cholangitis in eight (7%) patients, of which three cases were repetitive and seven had an operative history of total or distal gastrectomy. The incidence of postoperative cholangitis after total or distal gastrectomy was 15% (7/48), which was significantly higher than that involving other causes (1.5%, 1/68; p < 0.01). Two patients with cholangitis after total gastrectomy experienced early recurrence of lithiasis at 2 and 9 months after surgery. CONCLUSIONS: CDD is safe, even in elderly patients. However, a history of total gastrectomy or distal gastrectomy may increase the incidence of postoperative cholangitis.

Laparoscopic common bile duct exploration: what factors determine success?

BACKGROUNDS: Laparoscopic common bile duct exploration (LCBDE) has been shown to be effective in managing choledocholithiasis whilst avoiding ERCP-related complications. However, patient and technical factors effects outcome. This study aimed to explore the matters effecting the failure of LCBDE. METHODS: All patients who underwent a laparoscopic cholecystectomy (LC) between 2007 and 2021 were identified using a prospective database. Data were collected for patients who underwent LCBDE including demographics, pre-operative investigations, intra-operative findings, technique of bile duct clearance and clearance rates, and post-operative outcomes. Predictors of failed LCBDE were identified. RESULTS: Laparoscopic cholecystectomy was performed in 3648 patients. Of these, 374 underwent LCBDE for suspected choledocholithiasis. Choledochoscopy was most frequently used (58.8%) with a success rate of 84.1%. Small cystic duct diameter (4.7 vs. 3.4 mm, P = 0.002), stone size >6 mm (P = 0.02), stone: cystic duct ratio >1 (P = 0.04), and >3 stones was associated with failed LCBDE by univariate analysis. Small cystic duct diameter (OR: 0.45, 95% CI: 0.26-0.77, P = 0.004) and stone size >6 mm (OR: 0.23, 95% CI: 0.06-0.92), P = 0.04) correlated with failure by multivariate analysis. Failed LCBDE was associated with increased length of stay (6.6 days vs. 3.1 days, P = 0.001), however the rate of serious complications or mortality was unaffected. CONCLUSION: LCBDE is safe and effective in managing choledocholithiasis. Factors such as cystic duct diameter, size and number of CBD stones, and stone: cystic duct ratio are associated with increased likelihood of inadequate clearance. The presence of these factors can help clinicians in decision making during LCBDE to improve chance of success.

The Comparison of Clinical Outcomes in Elderly (≥75 Years) and Non-Elderly (<75 Years) Patients with Acute Cholangitis Due to Choledocholithiasis.

Background and Objectives: Acute cholangitis may be fatal, particularly in elderly patients. According to the Tokyo Guidelines 2018, those aged ≥75 years are classified as moderate (Grade II) severity. However, it has not been established whether age itself is the deciding factor of poor outcomes. We studied the impact of old age (≥75 years) on the mortality and morbidity of acute cholangitis due to choledocholithiasis. Materials and Methods: We retrospectively examined 260 patients with calculous acute cholangitis who had undergone biliary drainage. Patients were divided into two groups: elderly (≥75 years) and non-elderly (<75 years). We aimed to compare organ dysfunction, in-hospital mortality, intensive care unit (ICU) hospitalization, and the severity of acute cholangitis. Results: Of 260 patients, 134 (51.5%) were in the elderly group and 126 (48.5%) were in the non-elderly group. The mean age was 72.3 ± 14.4 years, and 152 (58.5%) were men. The elderly patients showed a higher incidence of shock (12.7% vs. 4.8%, p = 0.029), respiratory dysfunction (7.5% vs. 0%, p = 0.002), and renal dysfunction (8.2% vs. 0.8%, p = 0.006) than the non-elderly patients. The overall in-hospital mortality rate was 2.7%, with no significant differences between the elderly and the non-elderly (4.5% vs. 0.8%, p = 0.121). The incidence of severe acute cholangitis was significantly higher in the elderly group (26.9% vs. 9.5%, p < 0.001). However, there was no significant difference in the rates of ICU hospitalization (9.7% vs. 4%, p = 0.088) and lengths of hospital stay (LOS) (8.3 d vs. 7.1 d, p = 0.086). Conclusions: No difference was observed in the in-hospital mortality, ICU hospitalization, or LOS between the elderly (≥75 years) and the non-elderly (<75 years) with calculous acute cholangitis. However, severe acute cholangitis was significantly more frequent in elderly patients.

Performance of European and American Societies of Gastrointestinal Endoscopy Guidelines for Prediction of Choledocholithiasis in Patients with Acute Biliary Pancreatitis.

Background and Objectives: Up to one-third of patients with acute biliary pancreatitis also present with choledocholithiasis. Guidelines from the European Society of Gastrointestinal Endoscopy (ESGE) and the American Society for Gastrointestinal Endoscopy (ASGE) for investigating suspected choledocholithiasis suggest endoscopic retrograde cholangiopancreatography in patients with high-likelihood (ESGE)/high-probability (ASGE) predictors and endoscopic ultrasound in those with intermediate-likelihood (ESGE)/intermediate-probability (ASGE) predictors. Although both guidelines are similar, they are not identical. Furthermore, these algorithms were mainly developed from cohorts of patients without pancreatitis and are therefore poorly validated in a subset of patients with acute pancreatitis. We aimed to assess the performance of the ESGE and ASGE algorithms for the prediction of choledocholithiasis in patients with acute biliary pancreatitis. Materials and Methods: This was a retrospective analysis of 86 consecutive patients admitted to a tertiary referral centre in the year 2020 due to acute biliary pancreatitis. Results: Choledocholithiasis was confirmed in 29/86 (33.7%) of patients (13 with endoscopic retrograde cholangiopancreatography and 16 with endoscopic ultrasound). All 10/10 (100%) ESGE high-likelihood and 14/19 (73.7%) ASGE high-probability patients had choledocholithiasis. Only 19/71 (26.8%) patients with ESGE intermediate likelihood and 15/67 (22.4%) with ASGE intermediate probability had choledocholithiasis. Only 8/13 (61.5%) patients with the ASGE high-probability predictor of dilated common bile duct plus bilirubin > 68.4 µmol/mL had choledocholithiasis. Since this predictor is not considered high likelihood by ESGE, this resulted in a superior specificity of the European compared to the American guideline (100% vs. 91.2%). Following the American instead of the European guidelines would have resulted in five unnecessary endoscopic retrograde cholangiopancreatographies and five unnecessary endoscopic ultrasound examinations. Conclusions: This retrospective analysis suggests that the European guidelines may perform better than the American guidelines at predicting choledocholithiasis in the setting of acute pancreatitis. This was because dilated common bile duct plus bilirubin > 68.4 µmol/mL was not a reliable predictor for persistent bile duct stones.

Rendezvous procedure, a simultaneous endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy for choledocholithiasis, in a rural surgical program in Northwest Ontario.

Introduction: Northwest Ontario has a high prevalence of cholelithiasis, at 1.6 times the provincial norm. There is a concomitant 14% rate of choledocholithiasis. Accessing surgical services in the region often requires extensive travel by air. Choledocholithiasis management is typically with a 2-staged approach, an endoscopic retrograde cholangiopancreatography (ERCP) followed several days or weeks later by laparoscopic cholecystectomy (LC). Regional surgeons were concerned about the patient burden of travel and the loss to follow-up inherent in scheduling two independent procedures at separate hospital admissions. They adopted a 1-stage management, called the rendezvous procedure, which describes the simultaneous performance of an ERCP and LC. Methods: We accessed Sioux Lookout Meno Ya Win Health Centre hospital data for all patients receiving an ERCP and LC between 1 June 2019 and 1 December 2022. We documented patient demographics, operative outcomes, length of stay and transfer to other facilities. Results: There were 29 rendezvous procedures performed, with successful cannulation of the ampulla of Vater in 27 (93%) cases and stone removal in 23 (79%), with a complication rate of 7%. The operating time averaged 136 min, and two patients required transfer to a tertiary care centre and four were stented locally and required a return trip to Sioux Lookout for repeat ERCP and successful stone removal. The average length of stay was 2.1 ± 1.3 days. Patients who could not access a rendezvous procedure averaged 46.1 ± 78.1 days between procedures. Conclusion: Managing choledocholithiasis with a 1-stage approach was safe and effective and reduced patient travel, time to definitive care and hospital admissions.

Résumé Introduction: Le nord-ouest de l'Ontario présente une prévalence élevée de cholélithiase, soit 1,6 fois la norme provinciale. Le taux de cholédocholithiase concomitant est de 14%. L'accès aux services chirurgicaux de la région nécessite souvent de longs déplacements en avion. La prise en charge de la cholédocholithiase SE fait généralement en deux étapes: Une cholangiopancréatographie rétrograde endoscopique (CPRE) suivie, plusieurs jours ou semaines plus tard, d'une cholécystectomie laparoscopique (CL). Les chirurgiens régionaux étaient préoccupés par le fardeau que représentaient pour le patient les déplacements et la perte de suivi inhérents à la programmation de deux procédures indépendantes à des admissions hospitalières distinctes. Ils ont adopté une gestion en une étape appelée procédure de rendez-vous, qui décrit la réalisation simultanée d'une CPRE et d'une CL. Méthodes: Nous avons accédé aux données hospitalières du centre de santé Meno Ya Win de Sioux Lookout pour tous les patients ayant bénéficié d'une CPRE et d'une CL entre le 1er juin 2019 et le 1er décembre 2022. Nous avons documenté les données démographiques des patients, les résultats opératoires, la durée du séjour et le transfert vers d'autres établissements. Résultats: Vingt-neuf procédures de rendez-vous ont été réalisées, avec une canulation réussie de l'ampoule de Vater dans 27 cas (93%) et l'ablation des calculs dans 23 cas (79%), avec un taux de complication de 7%. Le temps d'opération a été en moyenne de 136 min. Two patients ont dû être transférés dans un centre de soins tertiaires et 4 ont été stentés localement et ont dû être ramenés à Sioux Lookout pour une nouvelle CPRE et une extraction réussie du calcul. La durée moyenne du séjour était de 2,1 ± 1,3 jours. Les patients qui n'ont pas pu accéder à une procédure de rendez-vous ont passé en moyenne 46.1 ± 78.1 jours entre les procédures. Conclusion: La prise en charge de la cholédocholithiase en une seule étape s'est avérée sûre et efficace et a permis de réduire les déplacements des patients, les délais de prise en charge définitive et les admissions à l'hôpital. Mots-clés: Rural, chirurgie, maladie de la vésicule biliaire.

Haemorrhagic cholecystitis in a young patient, complicated by gallbladder perforation and choledocholithiasis.

Haemorrhagic cholecystitis is a rare condition associated with a high risk of morbidity and mortality. Its pathophysiology is thought to be due to gallbladder wall erosion and infarction secondary to inflammation, which subsequently leads to haemorrhage into the gallbladder lumen or the peritoneal cavity. There is no current official guidance on optimal management of this condition. We describe a case of a female patient in her 40s who presented with right upper quadrant pain, followed by haematemesis. After CT scan, a diagnosis of haemorrhagic cholecystitis was made and initially managed conservatively. In this case, haemorrhagic cholecystitis was later complicated by gallbladder perforation and choledocholithiasis. Definitive management was with emergency open cholecystectomy. We believe this to be the first reported case of haemorrhagic cholecystitis complicated by gallbladder perforation and choledocholithiasis. This report highlights the need for early definitive management of haemorrhagic cholecystitis to prevent subsequent complications.

[Complex endoscopic treatment of a patient with a large adenoma of the major duodenal papilla, choledocholithiasis and stricture of the common bile duct]. / Kompleksnoe endoskopicheskoe lechenie patsientki s krupnoi adenomoi bol'shogo sosochka dvenadtsatiperstnoi kishki, kholedokholitiazom i strikturoi obshchego zhelchnogo protoka.

Incidence of adenomas of the major duodenal papilla has increased in recent years due to widespread endoscopic screening. These adenomas require resection due to high risk of malignant transformation. Currently, minimally invasive endoscopic interventions are often considered as an alternative to surgical treatment. Combination of major duodenal papilla neoplasms with choledocholithiasis and bile duct strictures are particularly difficult for endoscopic treatment. A 56-year-old patient underwent complex endoscopic treatment for a large adenoma of the major duodenal papilla spreading to duodenal walls and distal segment of the common bile duct combined with choledocholithiasis and stricture of the common bile duct. The patient underwent complex minimally invasive treatment with endoscopic lithoextraction, fragment-by-fragment removal of the neoplasm with intra-ductal ablation of residual adenomatous tissue and subsequent staged biliary stenting for the stricture of the common bile duct, as well as stenting of the main pancreatic duct for prevention of pancreatitis. An integrated approach to the treatment of a patient with a large adenoma of the major duodenal papilla, choledocholithiasis and stricture of the common bile duct provided clinical success without complications and the need for long-term rehabilitation.

Laparoscopic common bile duct exploration with primary closure could be safely performed among elderly patients with choledocholithiasis.

BACKGROUND: For patients with choledocholithiasis, laparoscopic common bile duct exploration (LCBDE) is preferred over open surgery. Whether primary closure of the common bile duct (CBD) should be performed upon completion of choledochotomy remains unclear, and the corresponding indications for primary closure of the common bile duct have yet to be fully identified. This study was performed to evaluate the safety and feasibility of primary closure of CBD among elderly patients (≥ 70 years) after LCBDE. METHODS: Patients with choledocholithiasis who had undergone LCBDE with primary closure of the CBD between July 2014 and December 2020 were retrospectively reviewed. Included patients were assigned into two groups (Group A: ≥70 years and Group B: <70 years) according to age. Group A was compared with Group B in terms of preoperative characteristics, intraoperative results and postoperative outcomes. RESULTS: The mean operative time for Group A was 176.59 min (± 68.950), while the mean operative time for Group B was 167.64 min (± 69.635) (P = 0.324). The mean hospital stay after surgery for Group A was 8.43 days (± 4.440), while that for Group B was 8.30 days (± 5.203) (P = 0.849). Three patients in Group A experienced bile leakage, while bile leakage occurred in 10 patients in Group B (3.8% vs. 4.5%, P = 0.781). Group A was not significantly different from Group B in terms of postoperative complications and 30-day mortality except pneumonia (P = 0.016), acute cardiovascular event (P = 0.005) and ICU observation (P = 0.037). After a median follow-up time of 60 months, 2 patients in Group A and 2 patients in Group B experienced stone recurrence (2.5% vs. 0.9%, P = 0.612). One patient in Group A experienced stenosis of the CBD, while stenosis of the CBD occurred in 5 patients in Group B (1.3% vs. 2.2%, P = 0.937). CONCLUSIONS: Primary closure of CBD upon completion of LCBDE could be safely performed among patients ≥ 70 years.

Comparison of laparoscopic common bile duct exploration and endoscopic retrograde cholangiopancreatography combined with laparoscopic cholecystectomy for patients with gallbladder and common bile duct stones a meta-analysis of randomized controlled trials.

OBJECTIVE: This study aimed to compare the efficacy and safety of laparoscopic common bile duct exploration (LCBDE) and endoscopic retrograde cholangiopancreatography (ERCP) combined with laparoscopic cholecystectomy (LC) to determine which one provides a better outcome for patients with gallbladder and common bile duct stones. MATERIALS AND METHODS: An electronic literature search was undertaken using Embase, Medline, PubMed, and Cochrane Library databases up to April 2022. For quality assessment of included studies, randomized controlled trials (RCTs) were assessed by utilizing the Jadad scale. The primary outcome includes surgical success rate, retained stone rate, stone clearance rate, major morbidity, and mortality. The second outcome includes conversion to open surgery rate, postoperative pancreatitis, bile leakage, cholangitis, hemorrhage, pneumonia, and surgical-site infection. RESULTS: 14 randomized controlled trials with 2,181 patients were included. No significant difference was seen between the two groups in terms of surgical success, stone clearance, retained stones, operation time, and total morbidity. LC-LCBDE had higher rate of bile leakage [relative risk (RR): 4.52; 95% confidence interval (CI): 2.19-9.31] and lower rate of postoperative pancreatitis (RR: 0.25; 95% CI: 0.13-0.46), cholangitis (RR: 0.17; 95% CI: 0.05-0.67), and hemorrhage (RR: 0.18; 95% CI: 0.07-0.42). CONCLUSIONS: Both LC+LCBDE and LC+ERCP are safe, effective, and minimal-invasive treatments for concomitant gallbladder and CBD stones. LC-LCBDE was associated with comparable effects compared with LC+ERCP in terms of surgical success rate, stone clearance rate, retained stones rate, operation time, and total morbidity. At the same time, LC-LCBDE had a higher rate of bile leakage and a lower rate of postoperative pancreatitis, cholangitis, and hemorrhage.

Choledocholithiasis Can Present with Marked Transaminases Elevation: Systematic Review and Meta-Analysis.

BACKGROUND: Extreme transaminase elevation > 1000 international units per liter (IU/L) is typically caused by hepatocellular injury due to ischemia, drugs, or viral infection. Acute choledocholithiasis can also present with marked transaminase elevation mimicking severe hepatocellular injury, contrary to the presumed cholestatic pattern. METHODS: We searched PubMed/Medline, EMBASE, Cochrane Library, and Google Scholar for studies reporting the proportion of marked elevation of alanine aminotransferase (ALT) or aspartate aminotransferase (AST) > 1000 IU/L in patients with common bile duct (CBD) stones. A proportion meta-analysis with a corresponding 95% confidence interval (CI) was used to pool the proportion of patients with extreme transaminase elevation. I2 was used to examine heterogeneity. We used CMA software utilizing a random effect model for statistical analysis. RESULTS: Three studies (n = 1328 patients) were included in our analysis. The reported frequency of ALT or AST > 1000 IU/L in choledocholithiasis patients ranged between 6 and 9.6%, with pooled frequency of 7.8% (95% CI 5.5-10.8%, I2 61%). The frequency of patients with ALT or AST > 500 IU/L was higher, ranging between 28 and 47%, with pooled frequency of 33.1% (95% CI 25.3-42%, I2 88%). CONCLUSION: This is the first meta-analysis to study prevalence of severe hepatocellular injury in patients with CBD stones. Results revealed that approximately one-third of patients with choledocholithiasis present with ALT or AST > 500 IU/L. Furthermore, levels > 1000 IU/L are not uncommon. An elaborate work-up for alternative etiologies of severe transaminase elevation is likely unwarranted in cases with clear evidence of choledocholithiasis.

Gallstone Ileus With Persistent Cholelithiasis and Choledocholithiasis.

Gallstone ileus is an uncommon but well-described occurrence in general surgery. However, discrepancy regarding optimal surgical management with 1 or 2 stage operation is still debated. This case report presents a 73-year-old woman who presented to the emergency department (ED) with a small bowel obstruction due to a gallstone lodged in a portion of the proximal ileum. The patient was also noted to have persistent cholelithiasis and cholecystoduodenal fistula. A single-stage surgery involving enterolithotomy, cholecystectomy, fistula repair, and cholangioscopy was performed. The patient progressed well and was discharged home without recurrent symptoms. Therefore, in a hemodynamically stable patient with persistent cholelithiasis or choledocholithiasis, it is reasonable to perform a definitive single-stage operation.

Observation versus intervention for incidental common bile duct stones at intraoperative cholangiogram: a systematic review.

BACKGROUND: The natural history of incidental common bile duct stones (CBDS) is poorly understood. Current evidence is conflicting, with several studies suggesting the majority may pass spontaneously. Despite this, guidelines recommend routine removal even if asymptomatic. This study aimed to systematically review the outcomes of expectant management for CBDS detected on operative cholangiography during cholecystectomy. METHODS: MEDLINE, Embase and CINAHL databases were systematically searched. Participants were adult patients with CBDS identified by intraoperative cholangiography. Intervention was regarded as any perioperative effort to remove common bile duct stones, including endoscopic retrograde cholangiopancreatography (ERCP), laparoscopic and open bile duct exploration. This was compared to observation. Outcomes of interest included rates of spontaneous stone passage, success of duct clearance and complications. Risk of bias was assessed using the ROBINS-I tool. RESULTS: Eight studies were included. All studies were non-randomized, heterogeneous and at serious risk of bias. In patients observed after a positive IOC, 20.9% went on to have symptomatic retained stones. In patients directed to ERCP for positive IOC, persistent CBDS were found in 50.6%. Spontaneous passage was not associated with stone size. Meta-analysis is dominated by the results from one large database, which recommends intervention for incidental stones, despite low rates of persistent stones seen at postoperative ERCP. CONCLUSIONS: Further evidence is required before a definitive recommendation on observation can be made. There is some evidence that asymptomatic stones may be safely observed. In clinical scenarios where the risks of biliary intervention are considered high, a conservative strategy could be more widely considered.

Clinical Analysis of Laparoscopic Common Bile Duct Primary Suture and T-Tube Drainage in the Treatment of Common Bile Duct Stones.

Background: At present, T-tube drainage or primary suture for common bile duct stones is common management. Methods: The clinical data of 100 patients who underwent laparoscopic common bile duct exploration and T-tube drainage or primary suture for common bile duct stones from 2019 to 2021 were analyzed retrospectively, including 50 cases of primary suture and 50 cases of T-tube drainage. Results: The operation time and postoperative hospital stay of patients with primary suture were lower than those in T-tube drainage group (P < .05). There was no significant difference in the incidence of postoperative complications and hospitalization expenses between the two groups (P > .05). Conclusions: It has been suggested that the therapeutic effect of laparoscopic primary suture is better than that of T-tube drainage; although they have different indications, they should be selected according to the specific individual situation of patients.

Ingesta-associated choledocholithiasis in horses: 2 cases and literature review.

Equine ingesta-associated choledocholithiasis is a rare cause of morbidity and mortality. We describe here the clinical, gross, histologic, and microbiologic features of this condition in 2 horses and compare the features to 2 previous cases. Case 1 was a 4-y-old Thoroughbred mare with colic. Case 2 was an 18-y-old American Paint Horse mare with colic, chronic weight loss, and inappropriate mentation. Both had elevated biochemical markers of hepatocellular injury and cholestasis and were euthanized given a poor prognosis. Case 1 had a well-formed 5-cm choledocholith surrounding a piece of hay, and had chronic neutrophilic cholangiohepatitis, bridging fibrosis, and extrahepatic obstruction. Case 2 had an ill-formed choledocholith with occasional hay fragments, wood stick, and twigs, and had regionally extensive hepatocellular necrosis with mild neutrophilic cholangiohepatitis and bridging fibrosis. Enterococcus casseliflavus and Escherichia coli were isolated in both cases; Clostridium spp. were also isolated from case 2. All 4 reported cases had increased activity of cholestatic enzymes, hyperbilirubinemia, portal inflammation, and bridging fibrosis. Colic, pyrexia, leukocytosis with neutrophilia, and elevated hepatocellular enzyme activity were documented in 3 cases. Foreign material in all 4 cases was plant origin (choledochophytolithiasis), including hay (n = 2), sticks/twigs (n = 2), and grass awns (n = 1). Ingesta-associated choledocholithiasis may be considered as a cause of colic, pyrexia, and elevated cholestatic biomarkers in horses.