Comparison of Outcomes between a Basket Catheter and a Balloon Catheter for Endoscopic Common Bile Duct Stone Removal.

INTRODUCTION: Evidence for the outcomes of endoscopic retrograde cholangiopancreatography (ERCP) between a basket catheter and a balloon catheter for endoscopic common bile duct stone (CBDS) removal is lacking. This study aimed to compare ERCP outcomes using a basket catheter and a balloon catheter for endoscopic CBDS removal. METHODS: This multicenter retrospective study included 904 consecutive patients with native papilla who underwent endoscopic stone removal for CBDS ≤10 mm using a basket catheter and/or a balloon catheter at three institutions in Japan. ERCP outcomes between the basket and balloon groups were compared using inverse probability of treatment weighting (IPTW) method. RESULTS: ERCP-related adverse events occurred in 6.5% (29/449) and 7.7% (35/455) of patients in the basket and balloon groups, respectively (IPTW-adjusted p = 0.52). The incidences of post-ERCP pancreatitis, cholangitis, and perforation were similar in the basket and balloon groups (3.8% vs. 2.9%, 1.3% vs. 0.9%, and 0.7% vs. 0.7%, respectively). However, bleeding incidences were significantly higher in the balloon group than in the basket group (3.3% vs. 0.7%, IPTW-adjusted p = 0.012). Successful complete stone removal at one ERCP session using a single catheter was achieved in 17.8% (80/449) in the basket group and in 81.3% (370/455) in the balloon group (IPTW-adjusted p < 0.001). DISCUSSION: A balloon catheter is more likely to complete stone extraction for CBDS ≤10 mm with a single catheter at one endoscopic stone removal session. However, the risk for post-ERCP bleeding is higher in the balloon group than in the basket group.

Antegrade balloon dilatation of the duodenal papilla during laparoscopic cholecystectomy versus endoscopic retrograde cholangiography in patients with acute choledocholithiasis: a case control matched study.

INTRODUCTION: In acute obstructive common bile duct (CBD) stones endoscopic retrograde cholangiography for CBD stone removal before cholecystectomy (ChE) ('ERC-first') is the gold standard of treatment. Intraoperative antegrade balloon dilatation of the duodenal papilla during ChE with flushing of CBD stones to the duodenum ('ABD-during-ChE') may be an alternative 'one-stop-shop' treatment option. However, a comparison of outcomes of the 'ABD-during-ChE' technique and the'ERC-first' approach has never been performed. METHODS: Retrospective case control matched study of patients suffering from obstructive CBD stones (< 8 mm) without severe pancreatitis or cholangitis that underwent the traditional 'ERC-first' approach versus the 'ABD-during-ChE' technique. Primary endpoint was the overall Comprehensive Complication Index (CCI®) from diagnosis to complete CBD stone removal and performed ChE. RESULTS: A total of 70 patients were included (35 patients each in the 'ERC first'- and 'ABD-during-ChE'-group). There were no statistical significant differences in terms of demographics and disease specific characteristics between the two study groups. However, there was a not significant difference towards an increased overall CCI® in the 'ERC-first' group versus the 'ABD-during-ChE' group (14.4 ± 15.4 versus 9.8 ± 11.1, p = 0.225). Of note, six major complications (Clavien-Dindo classification ≥ IIIa) occurred in the 'ERC-first' group versus two in the 'ABD-during-ChE' group (17% versus 6%, p = 0.136). In addition, significantly more interventions and a longer overall time from diagnosis to complete clearance of bile ducts and performed ChE was found, when comparing the 'ERC-first' group and the 'ABD-during-ChE' group (3.7 ± 0.8 versus 1.1 ± 0.4, p < 0.001; 160.5 ± 228.6 days versus 12.0 ± 18.0 days, p < 0.001). CONCLUSION: In patients suffering from acute obstructive CBD stones smaller than 8 mm, compared to the 'ERC-first' approach, the 'ABD-during-ChE' technique resulted in significantly less interventions and reduced overall treatment time from diagnosis to complete clearance of bile ducts and performed ChE. This comes together with a strong trend of less intervention related complications in the 'ABD-during-ChE' group.

Periendoscopic Care Continuum in Acute Cholangitis Caused By Common Bile Duct Stone.

Acute cholangitis (AC) is a biliary tract infection with in-hospital mortality rates reaching up to 14.7%. The underlying condition is biliary obstruction caused by benign and malignant etiologies, as well as bacteriobilia, with commom bile duct (CBD) stone being one of the most common causes. Currently, the diagnosis is validated using Tokyo Guidelines 2018 criteria. Acute cholangitis due to CBD stone should be managed in a comprehensive manner, i.e., periendoscopic care continuum, consisting of pre-endoscopic care, endoscopic management, and post-endoscopic care. Pre-endoscopic care is primarily comprised of supportive therapy, antibiotic administration, optimal timing of endoscopic retrograde cholangiopancreatography (ERCP), pre-ERCP preparation, and informed consent. Endoscopic management is biliary decompression with stone extraction facilitated via ERCP procedure. Selective biliary cannulation should be performed meticulously. Bile aspiration and minimal bile duct contrast injection should be done to minimize the worsening of biliary infection. Endoscopic biliary sphincterotomy, endoscopic papillary balloon dilatation, and/or endoscopic papillary large balloon dilatation are all safe procedures that can be used in AC. Special precautions must be undertaken in critical and severe acute cholangitis patients who may not tolerate bleeding, in whom endoscopic biliary sphincterotomy may be postponed to decrease the risk of bleeding, and biliary decompression may be only attempted without CBD stone extraction. Nasobiliary tubes and plastic biliary stents are equally effective and safe for patients who have only undergone biliary decompression. In post-endoscopic care, management of adverse events and observation of therapy response are mandatory.

Prospective validation of the Israeli Score for the prediction of common bile duct stones in patients with acute calculous cholecystitis.

BACKGROUND: Existing guidelines for predicting common bile duct stones (CBDS) are not specific for acute calculous cholecystitis (ACC). This paper is a posthoc analysis of the S.P.Ri.M.A.C.C study aiming to prospectively validate on a large independent cohort of patients the Israeli Score (IS) in predicting CBDS in patients with ACC. METHODS: The S.P.Ri.M.A.C.C. study is an observational multicenter prospective study endorsed by the World Society of Emergency Surgery (WSES). Between September 1st, 2021, and September 1st, 2022, 1201 participants were included. The Chi-Square test was used to compare categorical data. A Cochran-Armitage test was run to determine whether a linear trend existed between the IS and the presence of CBDS. To assess the accuracy of the prediction model, the receiver operating characteristic (ROC) curve was generated, and the area under the ROC curve (AUC) was calculated. Logistic regression was run to obtain Odds Ratio (OR). A two-tailed p < 0.05 was considered statistically significant. RESULTS: The rate of CBDS was 1.8% in patients with an IS of 0, 4.2% in patients with an IS of 1, 24.5% in patients with 2 and 56.3% in patients with 3 (p < 0.001). The Cochran-Armitage test of trend showed a statistically significant linear trend, p < 0.001. Patients with an IS of 3 had 64.4 times (95% CI 24.8-166.9) higher odds of having associated CBDS than patients with an IS of 0. The AUC of the ROC curve of IS for the prediction of CBDS was 0.809 (95% CI 0.752-0.865, p < 0.001). By applying the highest cut-off point (3), the specificity reached 99%, while using the lowest cut-off value (0), the sensitivity reached 100%. CONCLUSION: The IS is a reliable tool to predict CBDS associated with ACC. The algorithm derived from the IS could optimize the management of patients with ACC.

Efficacy and safety of three endoscopic techniques for small common bile duct stones (≤ 10 mm): a multicenter, retrospective, cohort study with propensity score matching.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is a major option for common bile duct (CBD) stones. Endoscopic sphincterotomy (EST), endoscopic papillary balloon dilatation (EPBD), and endoscopic sphincterotomy plus balloon dilatation (ESBD) are procedures for opening the bile duct orifice to extract CBD stones during ERCP. The optimal method for extracting small CBD stones (≤ 10 mm) has not yet been proposed. We aimed to compare the efficacy and safety of these three techniques in extracting small CBD stones. METHODS: ERCP for small stones was performed between January 2009 and November 2020 at three tertiary care centers. The incidence of post-ERCP pancreatitis (PEP) was compared among EST, EPBD, and ESBD groups. First and overall success rates of stone extraction, utilization rate of mechanical lithotripsy, and other ERCP complications such as bleeding, perforation, infection, and hyperamylasemia were compared. RESULTS: A total of 2181 patients were enrolled between January 2009 and November 2020. The proportion of young patients (≤ 45 years) in EPBD group was more than those in EST and ESBD group. Stone size in ESBD group was much larger than EST and EPBD group. After propensity score matching, the success rates of first and overall stone extraction in the three groups were high, and the rates of mechanical lithotripsy were low, with no significant difference. The PEP incidences showed no differences among the three groups. The incidence of bleeding complication in EST group was higher than that in EPBD group. No significant differences were observed in other complications between EPBD group and ESBD group. ESBD group had higher incidence of overall, infection, and hyperamylasemia complications than EST group. CONCLUSION: EPBD is equivalent to ESBD in stone removal efficiency and complication rate, but brings a lower bleeding risk than EST. Therefore, we recommend EPBD as the first choice for small CBD stones.

Near-infrared cholangiography can increase the chance of success in laparoscopic approaches to common bile duct stones, even with previous abdominal surgery.

BACKGROUND: The treatment of common bile duct (CBD) stones with minimally invasive surgery (MIS) is more technical demanding than laparoscopic cholecystectomy (LC), especially in patients with history of previous abdominal surgery, cholangitis or cholecystitis. Near-infrared (NIR) cholangiography via systemic or biliary tree administration of indocyanine green (ICG), which enhances the visualization of the biliary tree anatomy, may increase the reassurance of CBD localization. The aim of this study was to identify the benefit of near-infrared cholangiography for laparoscopic common bile duct exploration (LCBDE). METHODS: Three groups of CBD stone patients were included in this retrospective study depending on the surgical methods: 1) open choledocholithotomy (OCC), 2) laparoscopic choledocholithotomy (LCC), and 3) near-infrared cholangiography-assisted laparoscopic choledocholithotomy (NIR-CC). For the NIR-CC group, either 3 ml (concentration: 2.5 mg/mL) of ICG were intravenously administered or 10 ml (concentration: 0.125 mg/mL) of ICG were injected directly into the biliary tree. The enhancement rate of the cystic duct (CD), CBD, the upper and lower margin of the CBD were compared using white light image. RESULTS: A total of 187 patients with a mean age of 68.3 years were included (OCC, n = 56; LCC, n = 110; NIR-CC, n = 21). The rate of previous abdominal surgery was significantly lower in the LCC group. The conversion rate was similar between the LCC and the NIR CC groups (p = 0.746). The postoperative hospital stay was significantly longer in the OCC group. No differences in morbidity and mortality were found between the three groups. In the NIR-CC group, the localization of CBD was as high as 85% compared to 24% with white light imaging. CONCLUSIONS: Near-infrared cholangiography helps increase the chance of success in minimally invasive approaches to CBD stones even in patients with previous abdominal surgeries, without increasing the rate of conversion.

Can inflammatory indexes predict the spontaneous passage of common bile duct stones?

OBJECTIVES: We aimed to determine whether inflammatory indexes (II), including the neutrophil-lymphocyte ratio (NLR), the C-reactive protein (CRP) to albumin ratio (CAR), the CRP-lymphocyte ratio (CLR), and the systemic immune-inflammation index (SIII) can be diagnostic for common bile duct stones (CBDSs) excretion before endoscopic retrograde cholangiopancreatography (ERCP). BACKGROUNDS: Because of the spontaneous clearance, it is mandatory to ascertain the presence of CBDSs before ERCP. METHODS: Retrospectively, we evaluated two groups. Group A included 96 records in which CBDSs existed in magnetic resonance cholangiopancreatography (MRCP) and ERCP. Group B included 36 records in which CBDSs existed in MRCP but not ERCP. IIs were calculated on presentation and before ERCP. RESULTS: Stone detection in ERCP had a 3.992-fold (95% 1.769-9.007) higher probability with a stone larger than 3.25 mm in MRCP. Before ERCP, CAR, and CLR values were higher in group A than in group B (3.88 [1.25-14.14] and 1.24 [0.50-9.66], p = 0.027 versus 8.79 [2.19-35] and 2.67 [1.02-20.05], p = 0.029, respectively). Higher CRP, CAR, and CLR values were considered significant for detecting a stone in ERCP (AUC: 0.627 [0.519-0.739], 0.625 [0.513-0.737], and 0.624 [0.514-0.734], respectively). CONCLUSION: Low CRP, CAR, and CLR values might associate with the spontaneous migration of CBDS.

Efficacy and Safety of Electrohydraulic Lithotripsy Using Peroral Cholangioscopy under Endoscopic Retrograde Cholangiopancreatography Guidance in Older Adults: A Single-Center Retrospective Study.

Background and objectives: The safety of electrohydraulic lithotripsy (EHL) in older adults remains unclear. We aimed to investigate the efficacy and safety of EHL using peroral cholangioscopy (POCS) under endoscopic retrograde cholangiopancreatography (ERCP) guidance in older adults aged ≥80 years. Materials and Methods: This retrospective clinical study was conducted at a single center. Fifty patients with common bile duct stones who underwent EHL using POCS under ERCP guidance at our institution, between April 2017 and September 2022, were enrolled in this study. The eligible patients were divided into an elderly group (n = 21, age ≥80 years) and a non-elderly group (n = 29, age ≤79 years), and were analyzed. Results: A total of 33 and 40 EHL procedures were performed in the elderly and non-elderly groups, respectively. After excluding cases in which stone removal was performed at other institutions, complete removal of common bile duct stones was confirmed in 93.8% and 100% of the elderly and non-elderly groups, respectively (p = 0.20). The mean number of ERCPs required for complete removal of bile duct stones was 2.9 and 4.3 in the elderly and non-elderly groups, respectively (p = 0.17). In the EHL session, the overall occurrence of adverse events was eight and seven in the elderly (24.2%) and non-elderly (17.5%) groups, respectively; however, the difference was insignificant (p = 0.48). Conclusions: EHL using POCS under ERCP guidance is effective in patients aged ≥80 years and there was no significant increase in adverse event rates compared to those aged ≤79 years.

Increased post-endoscopic retrograde cholangiopancreatography pancreatitis for choledocholithiasis without acute cholangitis.

BACKGROUND AND AIM: Choledocholithiasis is the most common indication for endoscopic retrograde cholangiopancreatography (ERCP). Identifying risk factors for post-ERCP pancreatitis (PEP) is important for reducing the risk of developing PEP after common bile duct (CBD) stone removal. However, studies examining the risk factors for PEP for CBD stones are scarce. The aim of this study was to examine whether the presence or absence of acute cholangitis is a clinical risk factor for PEP in patients with CBD stones. METHODS: In this multicenter retrospective study, 1539 patients with naïve papillae were divided into patients without and with acute cholangitis. We compared the incidence of PEP between the two groups using one-to-one propensity score matching to adjust for the potential confounding factors of PEP. RESULTS: In the entire cohort, the rates of PEP in patients without and with acute cholangitis were 9.6% (52/542) and 1.8% (18/997), respectively (P < 0.001, odds ratio = 5.8). In the propensity-matched cohort, the rates of PEP in patients without and with acute cholangitis were 8.3% (27/326) and 2.5% (8/326), respectively (P = 0.002, odds ratio = 3.6). The rate of PEP was significantly higher in patients without acute cholangitis than in those with acute cholangitis after adjusting for the confounding factors of PEP. CONCLUSIONS: The absence of acute cholangitis may be an important clinical risk factor for PEP due to CBD stone removal. In patients without acute cholangitis, endoscopists should explain the specific risk of PEP carefully and actively implement prophylaxis against PEP.

Accurate Evaluation of Residual Common Bile Duct Stones by Endoscopic Ultrasound: A Two-Step Check Method for Residual Stone Clearance.

BACKGROUND/AIMS: Residual common bile duct (CBD) stones occasionally become symptomatic after stone removal with endoscopic retrograde cholangiopancreatography (ERCP) upon removal of the endoscopic biliary stent (EBS). An accurate evaluation of residual stones before stent removal is necessary. This study evaluated a new two-step check method using endoscopic ultrasound (EUS) for the detection of residual stones after ERCP stone removal. METHODS: Fifty-six patients who underwent CBD stone removal and EBS placement were prospectively enrolled. Residual stones were evaluated by the check method. EBS was removed at the time of the check method or at a later time of residual stone removal. The primary outcome was to evaluate the efficacy of this check method. RESULTS: Residual CBD stone/sludge was detected in 20 of 56 patients (35.7%; stones: 28.6%, sludge: 7.1%) by the check method and removed by the ERCP procedure at a later time. After stent and final stone removal, patients were followed for an average of 211 days; cholangitis recurred in only 1.8% of patients. There were no adverse events associated with the check method. Temporary EBS prevented the recurrence of cholangitis by residual stone and caused no adverse events in the pancreatobiliary tract until the two-step check method (median, 113 days; range, 17-232 days). CONCLUSION: The new check method may be ideal and feasible for EBS removal because recurrences are very rare when a clear CBD has been verified, and an additional ERCP procedure is also possibly avoided.

Assessment of postoperative common bile duct stones after endoscopic extraction and subsequent cholecystectomy.

BACKGROUND: Common bile duct stones (CBDSs) occasionally cause serious diseases, and endoscopic extraction is the standard procedure for CBDS. To prevent biliary complications, cholecystectomy is recommended for patients who present with gallbladder (GB) stones after endoscopic CBDS extraction. However, CBDS can occasionally recur. To date, the occurrence of CBDS after endoscopic CBDS extraction and subsequent cholecystectomy is not fully understood. Hence, the current study aimed to evaluate the incidence of postoperative CBDSs. METHODS: This retrospective observational study included consecutive patients who underwent postoperative endoscopic retrograde cholangiography after endoscopic CBDS extraction and subsequent cholecystectomy between April 2012 and June 2021 at our institution. After endoscopic CBDS extraction, a biliary plastic stent was inserted to prevent obstructive cholangitis. Endoscopic retrograde cholangiography was performed to evaluate postoperative CBDSs after cholecystectomy until hospital discharge. The outcomes were the incidence of postoperative CBDSs and CBDSs/sludge. Moreover, the predictive factors for postoperative CBDSs were evaluated via univariate and multivariate analyses. RESULTS: Of eligible 204 patients, 52 patients (25.5%) presented with postoperative CBDSs. The incidence rate of CBDS/sludge was 36.8% (n = 75). Based on the univariate analysis, the significant predictive factors for postoperative CBDSs were ≥ 6 CBDSs, presence of cystic duct stones, and ≥ 10 GB stones (P < 0.05). Moreover, male sex and < 60-mm minor axis in GB might be predictive factors (P < 0.10). Based on the multivariate analysis, ≥ 6 CBDSs (odds ratio = 6.65, P < 0.01), presence of cystic duct stones (odds ratio = 4.39, P < 0.01), and ≥ 10 GB stones (odds ratio = 2.55, P = 0.01) were independent predictive factors for postoperative CBDSs. CONCLUSIONS: The incidence of postoperative CBDS was relatively high. Hence, patients with predictive factors for postoperative CBDS must undergo imaging tests or additional endoscopic procedure after cholecystectomy.

Routine intraoperative cholangiography during laparoscopic cholecystectomy: application of the 2016 WSES guidelines for predicting choledocholithiasis.

BACKGROUND: Routine use of intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) for detecting common bile duct stones remains controversial. The 2016 World Society of Emergency Surgery (WSES) guidelines on acute calculous cholecystitis proposed a risk stratification for choledocholithiasis. Our present study aimed to (1) examine the findings of common bile duct (CBD) stones in patients underwent LC with routine use of IOC, and (2) validate the 2016 WSES risk classes for predicting choledocholithiasis. METHODS: All patients had LC with IOC routinely performed from November 2012 to December 2017 were reviewed retrospectively. Patients were classified into high-, intermediate-, and low-risk groups based on the 2016 WSES risk classes with modification. RESULTS: A total of 990 patients with LC and routine IOC were enrolled. CBD stones were detected in 197 (19.9%) patients. The rate of CBD stone detected in low-, intermediate-, high-risk groups were 0%, 14.2%, and 89.6%, respectively. Predictors as following: evidence of CBD stones on abdominal ultrasound or computed tomography, CBD diameter > 6 mm, total bilirubin > 4 mg/dL, bilirubin level = 1.8-4 mg/dL, abnormal liver biochemical test result other than bilirubin, presence of clinical gallstone pancreatitis had statistical significance between patients with and without CBD stones. Major bile duct injury was found in 4 patients (0.4%). All 4 patients had uneventful recovery after repair surgery. CONCLUSIONS: Based on our study results, the 2016 WSES risk classes for choledocholithiasis could be an effective approach for predicting the risk of choledocholithiasis. Considering its advantages for detecting CBD stones and biliary injuries, the routine use of IOC is still suggested.

Accuracy of SAGES, ASGE, and ESGE criteria in predicting choledocholithiasis.

BACKGROUND: Patients with suspected choledocholithiasis (CDL) are stratified as high-risk (HR), intermediate-risk (IR), and low-risk (LR) according to the guidelines of Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), American Society for Gastrointestinal Endoscopy (ASGE), and European Society of Gastrointestinal Endoscopy (ESGE). Although these approaches are invaluable, paucity of validation studies are currently available. This study aimed to evaluate the diagnostic accuracy of the above risk stratification criteria in predicting CDL. METHODS: We conducted a retrospective cohort study of 280 patients with suspected CDL. All patients were stratified according to above professional societies as HR, IR, and LR, and diagnostic performance was evaluated. RESULTS: In the HR group, area under the receiver operating characteristic curve (AUC) were 0.77 [95% confidence interval (CI), 0.70-0.84], 0.75 (95% CI, 0.68-0.81), and 0.74 (95% CI, 0.68-0.81) for SAGES, ASGE, and ESGE criteria, respectively. The diagnostic accuracy were 78.93% (81.13% sensitivity, 72.06% specificity), 75% (75.47% sensitivity, 73.53% specificity), and 70% (66.04% sensitivity, 82.35% specificity) for SAGES, ASGE, and ESGE criteria, respectively. Regarding the IR group, the diagnostic accuracy were 22.50% (16.98% sensitivity, 39.71% specificity), 25% (24.53% sensitivity, 26.47% specificity), and 30.00% (33.49% sensitivity, 19.12% specificity) for SAGES, ASGE, and ESGE criteria, respectively. The common bile duct stone (CBDS) visualized on imaging has the highest risk for CDL [odds ratio (OR), 13.59 (95% CI, 5.26-35.12)], followed by CBDS plus dilated common bile duct [OR, 13.33 (95% CI, 5.16-34.47)], CBDS plus cholangitis [OR, 13.33 (95% CI, 3.17-56.15)], and CBDS plus total bilirubin level > 1.7 mg/dL [OR, 9.89 (95% CI, 3.47-28.20)]. CONCLUSIONS: The current SAGES, ASGE, and ESGE criteria have acceptable diagnostic accuracy for CDL. The patients with visualized CBDS on imaging have the highest risk for CDL.

Factors predictive of the successful treatment of choledocholithiasis.

BACKGROUND: Choledocholithiasis is a common complication of cholelithiasis, occurring in up to 18% of patients. Multiple treatments are often performed during the course of the management of choledocholithiasis, sometimes without success. Our study was performed identify the factors predictive of the success of treatment with retrograde endoscopic cholangiopancreatography (ERCP). METHODS: This was a retrospective, case-control study that used data from a biliary disease database at Hospital de Clínicas de Porto Alegre (HCPA). Demographic, clinical, radiological and procedure-related variables were compared between patients with successful biliary clearance after one ERCP procedure (Group 1) and those with unsuccessful biliary clearance after one ERCP procedure (Group 2). RESULTS: Three hundred twenty patients were included in Group 1, while 254 were included in Group 2. Multivariate analysis showed that older age, previous biliary exploration, elevated serum total bilirubin, choledocholithiasis above the level of the confluence of the hepatic ducts, stones retained in the cystic duct or Mirizzi syndrome, dilatation of the bile duct diagnosed during ERCP, and the need for suprapapillary opening were independently associated with the failure of the first ERCP to achieve bile duct clearance. The performance of imaging at the same institution prior to the procedure and the retention of stones in the duodenal papilla were associated with the success of endoscopic treatment. CONCLUSIONS: The variables identified in this study, when considered in conjunction with the results of previously published studies, can be used to guide the choice of therapeutic methods for patients with choledocholithiasis in the future, given the significant difference in outcomes between the two groups. In the future, a prospective study should be performed to determine whether the same factors are predictive of the success of other methods of treatment (surgical or percutaneous).

Comparable safety of ERCP in symptomatic and asymptomatic patients with common bile duct stones: a propensity-matched analysis.

BACKGROUND: The safety of endoscopic retrograde cholangiopancreatography (ERCP) for asymptomatic common bile duct (CBD) stones patients has not been thoroughly elucidated. This study attempted to compare the incidence and severity of ERCP complications in asymptomatic and symptomatic patients with CBD stones and to provide evidence for the treatment of asymptomatic CBD stones. METHODS: The clinical data of patients were retrospectively analyzed. These patients were divided into the asymptomatic CBD stones group and the symptomatic CBD stones group. Propensity score matching (PSM) was used to match the two groups. The incidence and severity of postoperative complications of ERCP in the two groups were analyzed. RESULTS: A total of 79 patients who had asymptomatic CBD stones and 795 patients who had symptomatic CBD stones were included in this study. After PSM, 79 patients from the asymptomatic CBD group and 316 patients from the symptomatic CBD stones group were identified. Before and after PSM, no significant differences in the incidence and severity of post-ERCP pancreatitis (PEP) were noted between the two groups (p > .05). In addition, no differences in the incidence and severity of other complications, including acute cholangitis, bleeding and perforation, between the two groups were observed before and after PSM (p > .05). CONCLUSIONS: Patients with asymptomatic CBD stones do not exhibit an increased risk of ERCP-related complications compared with those with symptomatic CBD stones. ERCP was observed to be equally safe and efficacious for patients with asymptomatic versus symptomatic CBD stones.

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

BACKGROUND: 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. METHODS: 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. RESULTS: 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 (≥ 10 mm; 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 (≥ 15 mm; OR, 3.878; 95% CI, 1.406-10.697; p = 0.008) was the independent risk factors for CBD stone recurrence after cholecystectomy. CONCLUSIONS: CBD diameter (≥ 15 mm) at the time of the initial ERCP is associated with CBD stone recurrence after cholecystectomy.

Complications of common bile duct stones: A risk factors analysis.

BACKGROUND: The latest guidelines recommended that common bile duct stones (CBDSs) should be removed, preferably endoscopically, regardless of the presence of symptoms or complications. However, the removal of CBDSs may not be feasible in very old patients or those with co-morbidities. In these cases, it is important to understand the risk factors for the development of CBDSs-related complications to decide whether or not to treat high-risk patients. Herein, we aimed to identify the risk factors for the development of complications after the diagnosis of CBDSs. METHODS: The medical records of patients with CBDSs between October 2005 and September 2019 were retrospectively analyzed. All patients with radiologically-diagnosed CBDSs, including those who received treatment and those who did not, were analyzed. RESULTS: A total of 634 patients were included and 95 (15.0%) patients had CBDS-related complications during the mean follow-up period of 32.6 months. Forty-four (6.9%) high-risk patients remained asymptomatic and did not receive treatment during the follow-up period. In multivariate analyses, size of CBDSs ≥ 5 mm and no treatment within 30 days were independent risk factors for the development of complications. The spontaneous passage of CBDSs was proved radiologically in 9 out of 81 (11.1%) patients within 30 days. CONCLUSIONS: It is recommended treating CBDSs within 30 days from the diagnosis, even in high-risk patients, especially if the size is larger than 5 mm.

Post-endoscopic retrograde cholangiopancreatography pancreatitis in patients with asymptomatic common bile duct stones.

BACKGROUND AND AIM: For asymptomatic common bile duct (CBD) stones, removal by endoscopic retrograde cholangiopancreatography (ERCP) is recommended in available guidelines. However, few studies have reported the risk of post-ERCP pancreatitis (PEP), which is the most common and serious ERCP-related complication for asymptomatic CBD stones. We performed a propensity score matching analysis to examine the risk of PEP in therapeutic ERCP for asymptomatic CBD stones. METHODS: Information from medical databases of three institutions in Japan was collected over 6 years to identify 1113 patients with native papilla who underwent therapeutic ERCP for choledocholithiasis (excluding biliary pancreatitis). We compared the risk of PEP between asymptomatic and symptomatic groups by performing one-to-one propensity score matching. RESULTS: PEP was present in 52 (4.7%) of the 1113 patients overall. Of the 949 symptomatic patients, 28 (3.0%) had PEP, and of the 164 asymptomatic patients, 24 (14.6%) had PEP. The incidence of PEP was significantly higher in the asymptomatic group than in the symptomatic group (3.0% vs 14.6%; P < 0.001, odds ratio = 5.6). Of the 158 propensity score-matched symptomatic patients, five (3.2%) had PEP. In contrast, of the 158 propensity score-matched asymptomatic patients, 24 (15.2%) had PEP. Propensity score matching analysis revealed that the risk of PEP increased significantly in the asymptomatic group compared with the symptomatic group (3.2% vs 15.2%; P < 0.001, odds ratio = 5.5). CONCLUSIONS: ERCP for asymptomatic CBD stones had a high risk of PEP. Endoscopists should explain in detail the risk of PEP to patients, especially those with asymptomatic CBD stones.

[Clinical evaluation of gallbladder and common bile duct stones treated though cholecystostomy tube].

Objective: To investigate the efficacy, feasibility and safety of treatment of gallbladder and common bile duct stones treated through cholecystostomy tube. Methods: The clinical data of 17 patients with gallbladder and common bile duct stones treated through cholecystostomy tube from January 2012 to December 2016 was analyzed retrospectively. Results: Seventeen patients were successfully treated with percutaneous transhepatic gallbladder (PTGD), and 88.2% (15/17) patients had clinical symptom relief. There was no complication happened after PTGD and fistula expansion. All the stones were removed and there was 11.7% (2/17) of gallbladder bleeding, 5.9% (1/17) of pancreatitis, and 5.9% (1/17) of hyperamylasemia after stones extraction. The patients had gone through an average treatment period of 87.8±16.0 days, hospitalization of 5.5±0.6 times and 43.3±4.5 days, cost of 60.0±8.0 thousand, 6.9±0.9 operations, 1.4±0.6 stone extraction operations with the average time of 58.4±21.2 min. The duodenal papillary balloon dilatation rate was 82.4% (14/17). Conclusion: The treatment through cholecystostomy tube is an effective, safe and feasible technique for gallbladder and common bile duct stones. However, there are many shortcomings such as long treatment cycle, large number of hospitalization and operations, difficult operation and high cost.

Effects of cholecystectomy on recurrent biliary complications after endoscopic treatment of common bile duct stone: a population-based cohort study.

BACKGROUND: The aim of this study was to evaluate the benefits of cholecystectomy on mitigating recurrent biliary complications following endoscopic treatment of common bile duct stone. METHODS: We used the data from the Taiwan National Health Insurance Research Database to conduct a population-based cohort study. Among 925 patients who received endoscopic treatment for choledocholithiasis at the first admission from 2005 to 2012, 422 received subsequent cholecystectomy and 503 had gallbladder (GB) left in situ. After propensity score matching with 1:1 ratio, the cumulative incidence of recurrent biliary complication and overall survival was analyzed with Cox's proportional hazards model. The primary endpoint of this study is recurrent biliary complications, which require intervention. RESULTS: After matching, 378 pairs of patients were identified with a median follow-up time of 53 (1-108) months. The recurrent rate of biliary complications was 8.20% in the cholecystectomy group and 24.87% in the GB in situ group (p < 0.001). In the multivariate Cox regression analysis, the only independent risk factor for recurrent biliary complications was GB left in situ (hazard ratio [HR] 3.55, 95% CI 2.36-5.33). CONCLUSIONS: Cholecystectomy after endoscopic treatment of common bile duct stone reduced the prevalence of recurrent biliary complications.