The Association Between Cotinine-Verified Smoking Status and Risk of Gallstones: A Cohort Study.

BACKGROUND AND AIMS: Previous epidemiological data on the association between cigarette smoking and risk of gallstone development remain controversial, and most relevant studies have relied on self-reported questionnaires. We aimed to elucidate this association using both an objective biomarker of tobacco exposure (urinary cotinine) and a self-reported questionnaire. METHODS: We analyzed 221,721 asymptomatic adults who underwent abdominal ultrasonography and urinary cotinine measurement between January 2011 and December 2016. Cotinine-verified current smokers were defined as participants with urinary cotinine levels ≥50 ng/mL. RESULTS: The mean age of the study population was 35.9 years, and the proportion of men was 55.8%. The proportions of self-reported and cotinine-verified current smokers were 21.3% and 21.2%, respectively. After adjusting for confounding factors, self-reported current smoking was associated with an increased risk of gallstone development [adjusted odds ratio (aOR) 1.14; 95% confidence interval (95%CI), 1.04-1.25]. Moreover, among the current smokers, the risk of gallstone development increased with an increase in the amount of cigarette smoking (<20 and ≥20 pack-years vs. never smoked; aOR=1.11 and 1.25; 95%CI: 1.01-1.22 and 1.07-1.45, respectively). Cotinine-verified current smoking was also associated with an increased risk of gallstone development (aOR=1.16; 95%CI: 1.07-1.25). Among the self-reported never or former smokers, the cotinine-verified current smokers (aOR=1.20; 95%CI: 1.01-1.44) showed a significantly higher risk of gallstones than cotinine-verified never smokers. CONCLUSIONS: Cotinine-verified and self-reported current smoking were independent risk factors for gallstones, suggesting a distinct role of tobacco smoking in gallstone development.

PREDICTORS OF FAILURE OF ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY IN CLEARING BILE DUCT STONES DURING INDEX PROCEDURE - A PROSPECTIVE STUDY.

BACKGROUND: Common bile duct (CBD) stones are known to complicate 10-15% of gallstone diseases. Endoscopic retrograde cholangiopancreatography (ERCP) is the therapeutic modality of choice for bile duct clearance in CBD stones but may fail to achieve stone clearance. This prospective study was done to identify the predictors of failure of CBD clearance with ERCP. OBJECTIVE: This prospective study was done to identify the predictors of failure of CBD clearance with ERCP. METHODS: All consecutive patients with bile duct stones undergoing ERCP at a tertiary care center were prospectively included from October 2020 to October 2021. The study's primary outcome was to identify and analyze factors that could predict the failure of complete CBD clearance. RESULTS: A total of 120 patients (50.8% males, median age: 53.5 years) were included in the final analysis. Successful clearance of CBD stones during the index procedure was achieved in 70% of patients. At a cut-off stone diameter of >10.5 mm and CBD diameter of >12.5 mm, the AUC was 0.890 and 0.884, respectively, to predict failed clearance of CBD. On multivariate analysis, stone diameter ≥15 mm [odds ratio (OR) 16.97, 95% confidence interval (CI): 1.629-176.785], location of stones in hepatic ducts (OR 7.74, 95%CI: 2.041-29.332), presence of stricture distal to stone (OR 6.99, 95%CI: 1.402-34.726) and impacted stone (OR 21.61, 95%CI: 1.84-253.058) were independent predictors of failed bile duct clearance. CONCLUSION: Stone size and location are independent predictors of failed bile duct clearance. The endoscopist should consider these factors while subjecting a patient to biliary ductal clearance to plan additional intervention. BACKGROUND: • Failure to clear bile duct stones in the index ERCP can be seen in 15-20% of cases, and identifying the factors associated with failure is important. BACKGROUND: • A prospective analysis was conducted to identify and analyze the factors that could predict the failure of complete CBD clearance. BACKGROUND: • The present study reported a successful clearance of CBD stones during the index procedure in only 70% of patients. BACKGROUND: • A stone diameter ≥15 mm, location of stones in hepatic ducts, presence of stricture distal to stone, and impacted stone were independent predictors of failed bile duct clearance.

Management of intraoperatively identified small bile duct stones in patients undergoing cholecystectomy.

INTRODUCTION: The management of CBDS (common bile duct stones) in patients with co-existing gallbladder stones has been debated. Guidelines recommend patients with CBDS identified on imaging should be offered duct clearance; however, this is based on low-quality evidence. This study aimed to investigate the natural history of small CBDS identified using IOUS (intraoperative ultrasound) in patients undergoing cholecystectomy. This may provide evidence to support a short-term expectant management approach in such patients. METHODS: Patients with CBDS diagnosed on IOUS during cholecystectomy were identified from a database of consecutive patients undergoing surgery. Patients with CBDS identified were divided into small stone (SS, ≤5 mm) and large stone (LS, >5 mm) groups. Intraoperative CBDS management, postoperative investigations, postoperative bile duct clearance, re-admissions, complications, length of stay (LOS) and follow-up are described. RESULTS: Fifty-nine of 427 patients had CBDS identified on IOUS. In the SS group (n=51), 46 patients underwent short-term expectant management rather than immediate/planned bile duct clearance. Following short-term expectant management, 41/46 patients (89.1%) did not require postoperative endoscopic retrograde cholangiopancreatography and at >3 year follow-up, none has since presented with residual CBDS. Median LOS was 0 days in the short-term expectant management group and 2 days in the immediate/planned bile duct clearance group, P=0.039. CONCLUSIONS: This study reports the natural history of small CBDS identified on IOUS in patients undergoing cholecystectomy. Such patients were safely treated with short-term expectant management associated with a reduced hospital LOS. This provides rationale for undertaking further research to establish this as a preferred management strategy.

Novel 8-wire basket catheter is useful for endoscopic removal of common bile duct stones up to 10 mm: A multicenter prospective study.

BACKGROUND/PURPOSE: Endoscopic treatment of common bile duct (CBD) stones involves the use of basket or balloon catheters; however, what is the appropriate device remains controversial. In this study we aimed to prospectively evaluate the usefulness of a novel 8-wire helical basket (8WB) catheter made of Nitinol for the removal of CBD stones ≤10 mm. METHODS: We conducted a multicenter prospective trial. Patients with CBD stones ≤10 mm were enrolled. The primary endpoint was the rate of complete stone removal within 10 min using the 8WB. The number of cases was determined using a previous study of stone removal by a conventional basket catheter as a historical control. RESULTS: A total of 155 patients were enrolled and 139 were ultimately included in the analysis. Patients with a single stone were the most common (84 cases, 60.4%), with a median maximum stone diameter of 5 mm. The median stone removal time using the 8WB was 6 min. The complete stone removal rate was 95.0% (132/139). Adverse events were observed in 14 patients (10.1%). CONCLUSIONS: The novel 8WB catheter is useful in the treatment of CBD stones ≤10 mm, presenting a high complete stone removal rate in this study. TRIAL REGISTRATION NUMBER: jRCT1032200324.

Traveling gallstones: review of MR imaging and surgical pathology features of gallstone disease and its complications in the gallbladder and beyond.

Gallstone-related disease comprises a spectrum of conditions resulting from biliary stone formation, leading to obstruction and inflammatory complications. These can significantly impact patient quality of life and carry high morbidity if not accurately detected. Appropriate imaging is essential for evaluating the extent of gallstone disease and assuring appropriate clinical management. Magnetic Resonance Imaging (MRI) techniques (including Magnetic Resonance Cholangiopancreatography (MRCP) are increasingly used for diagnosis of gallstone disease and its complications and provide high contrast resolution and facilitate tissue-level assessment of gallstone disease processes. In this review we seek to delve deep into the spectrum of MR imaging in diagnose of gallstone-related disease within the gallbladder and complications related to migration of the gallstones to the gall bladder neck or cystic duct, common hepatic duct or bile duct (choledocholithiasis) and beyond, including gallstone pancreatitis, gallstone ileus, Bouveret syndrome, and dropped gallstones, by offering key examples from our practice. Furthermore, we will specifically highlight the crucial role of MRI and MRCP for enhancing diagnostic accuracy and improving patient outcomes in gallstone-related disease and showcase relevant surgical pathology specimens of various gallstone related complications.

Gallstones Detection on Dual-Energy Computerized Tomography-Is It Ready for Real-World Use? A Retrospective Observational Study.

AIMS: The aims of the study are to evaluate the performance of dual-energy computed tomography (DECT) imaging in the detection of noncalcified gallstones (GSs) and to assess its performance relative to transabdominal ultrasound (US) in identifying cholelithiasis. METHOD: This study is a retrospective review of radiology records and images to find all patients who had both US and DECT scans within a 6-month period and were found to have GSs. Patients who did not have GSs on US served as the control group. The CT scans were reviewed by 4 radiologists who did not have access to the US results when assessing the presence or absence of GSs on the DECT scans. In case of any discrepancies among the radiologists, the majority opinion was considered. If there was a split opinion, a fifth reviewer was consulted. The data were analyzed to calculate sensitivity, specificity, positive and negative predictive values, as well as overall accuracy and to evaluate interreader variability. The absolute Hounsfield unit (HU) differences of the GSs and bile were compared between polychromatic (PC), virtual noncontrast (VNC), and virtual monochromatic (VMC) images. RESULTS: Considering at least 3-reader agreement, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were found to be 92%, 96%, 96%, 92%, and 94%, respectively. Individual reader sensitivity varied between 87% and 92%. There was good interobserver agreement with a Fleiss' kappa of 0.76. Quantification of the whole data set showed that no significant difference was observed in the HU values for the stones between the PC images and the VNC images. A significant increase was observed on the 50-keV VMC images compared with the PC and VNC images. In the study group, 17% stones were visualized only on the VNC or/and 50-keV VMC images, and not on the PC images. On quantitative analysis of these cases, there was a significant increase of HU in the VNC images as compared with PC images and a significant decrease of HU in the 50-keV VMC images as compared with PC images. CONCLUSIONS: Low-keV images increase stone-bile contrast. Evaluation of cholelithiasis using VNC and 50-keV VMC images demonstrated a 14% increase in sensitivity relative to conventional CT.

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

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

ERCP using balloon-assisted endoscopes versus EUS-guided treatment for common bile duct stones in Roux-en-Y gastrectomy.

BACKGROUND AND AIMS: We compared ERCP using a balloon-assisted endoscope (BE-ERCP) with EUS-guided antegrade treatment (EUS-AG) for removal of common bile duct (CBD) stones in patients with Roux-en-Y (R-Y) gastrectomy. METHODS: Consecutive patients who had previous R-Y gastrectomy undergoing BE-ERCP or EUS-AG for CBD stones in 16 centers were retrospectively analyzed. RESULTS: BE-ERCP and EUS-AG were performed in 588 and 59 patients, respectively. Baseline characteristics were similar, except for CBD diameter and angle. The technical success rate was 83.7% versus 83.1% (P = .956), complete stone removal rate was 78.1% versus 67.8% (P = .102), and early adverse event rate was 10.2% versus 18.6% (P = .076) in BE-ERCP and EUS-AG, respectively. The mean number of endoscopic sessions was smaller in BE-ERCP (1.5 ± .8 vs 1.9 ± 1.0 sessions, P = .01), whereas the median total treatment time was longer (90 vs 61.5 minutes, P = .001). Among patients with biliary access, the complete stone removal rate was significantly higher in BE-ERCP (93.3% vs 81.6%, P = .009). Negative predictive factors were CBD diameter ≥15 mm (odds ratio [OR], .41) and an angle of CBD <90 degrees (OR, .39) in BE-ERCP and a stone size ≥10 mm (OR, .07) and an angle of CBD <90 degrees (OR, .07) in EUS-AG. The 1-year recurrence rate was 8.3% in both groups. CONCLUSIONS: Effectiveness and safety of BE-ERCP and EUS-AG were comparable in CBD stone removal for patients after R-Y gastrectomy, but complete stone removal after technical success was superior in BE-ERCP.

A Pilot Study of Percutaneous Cholecystoenteric Anastomosis: A New Option for High-Risk Patients with Symptomatic Gallstones.

PURPOSE: To evaluate the safety and effectiveness of percutaneous cholecystoenteric anastomosis (PCEA) creation in patients with indwelling cholecystostomy tubes who are high-risk surgical candidates. MATERIALS AND METHODS: Fourteen (male, 10; female, 4) patients with a mean age of 79 years (range, 53-92 years) with previously inserted cholecystostomy tubes underwent PCEA with the adjacent duodenum using a lumen-apposing metal stent (LAMS) between January 2015 and October 2022. Intraprocedural adverse events and postprocedural safety and effectiveness outcomes were evaluated. Nine procedures were performed under sedation and 5 under general anesthesia. RESULTS: Technical success was achieved in 100% of the patients. In 12 patients (86%), the existing cholecystostomy tube was removed after the insertion of the LAMS. Three patients (21%) had a pre-existing cholecystoduodenal fistula, in which the stent was placed, and 11 (79%) underwent creation of a de novo anastomosis. The mean procedure time was 1.5 hours (range, 1-2 hours). The mean length of stay after the procedure was 2.4 days (range, 1-10 days). There were no intraprocedural adverse events. One patient with severe pre-existing cardiac comorbidities died during his postprocedural stay despite a technically successful procedure. One patient had delayed closure of the long-standing cholecystocutaneous tract. CONCLUSIONS: Early clinical experience with PCEA using an LAMS suggests that it is a safe and effective option for the creation of internal gallbladder drainage in patients who are not candidates for surgical cholecystectomy.

Balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography for asymptomatic common bile duct stones on surgically altered anatomy: A high risk factor for post-endoscopic retrograde cholangiopancreatography pancreatitis.

BACKGROUND: Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is more common in patients with asymptomatic common bile duct stones (CBDSs) and normal anatomy than in those with symptomatic CBDS; however, studies on the effect of surgically altered anatomy are lacking. We aimed to investigate whether asymptomatic CBDS in balloon enteroscopy-assisted ERCP cases for surgically altered anatomy also has a high incidence of PEP and analyze the risk factors for PEP. METHODS: We retrospectively analyzed 108 consecutive patients who underwent initial ERCP for CBDS with surgically altered anatomies and with naive papilla at Kitasato University Hospital from April 2015 to December 2022. RESULTS: Study participants were as follows: 92 (85%) patients with symptomatic CBDS and 16 (15%) patients asymptomatic CBDS. The overall bile duct cannulation success rate was 89.8%, with PEP occurring in 7.4% of patients (symptomatic CBDS: 3.3%, asymptomatic CBDS: 31.3%). PEP incidence was significantly higher for asymptomatic CBDS (p = .0017). Multivariate analysis identified asymptomatic CBDS and precut sphincterotomy as significant risk factors for PEP. CONCLUSIONS: Asymptomatic CBDS may be a risk factor for PEP onset in balloon enteroscopy-assisted ERCP with surgically altered anatomy. Therefore, the procedure should be performed after obtaining sufficient informed consent and adequate preparation.