Could saline irrigation clear all residual common bile duct stones after lithotripsy?A self-controlled prospective cohort study

BACKGROUND A previous study showed that irrigation with 100 mL saline reduced residual common bile duct(CBD)stones,which potentially cause recurrent stones after endoscopic retrograde cholangiopancreatography.AIM To determine whether saline irrigation can improve CBD clearance after lithotripsy.METHODS This prospective self-controlled study enrolled patients receiving mechanical lithotripsy for large(>1.2 cm)CBD stones.After occlusion cholangiography confirmed CBD stone clearance,peroral cholangioscopy(POC)was performed to determine clearance scores based on the number of residual stones.The amounts of residual stones spotted via POC were graded on a 5-point scale(score 1,worst;score 5,best).Scores were documented after only stone removal(control)and after irrigation with 50 mL and 100 mL saline,respectively.The stone composition was analyzed using infrared spectroscopy.RESULTS Between October 2018 and January 2020,47 patients had CBD clearance scores of 2.4±1.1 without saline irrigation,3.5±0.7 with 50 mL irrigation,and 4.6±0.6 with 100 mL irrigation(P<0.001).Multivariate analysis showed that CBD diameter>15 mm[odds ratio(OR)=0.08,95%confidence interval(CI):0.01-0.49;P=0.007]and periampullary diverticula(PAD)(OR=6.51,95%CI:1.08-39.21;P=0.041)were independent risk factors for residual stones.Bilirubin pigment stones constituted the main residual stones found in patients with PAD(P=0.004).CONCLUSION Irrigation with 100 mL of saline may not clear all residual CBD stones after lithotripsy,especially in patients with PAD and/or a dilated(>15 mm)CBD.Pigment residual stones are soft and commonly found in patients with PAD.Additional saline irrigation may be required to remove retained stones.

Emergent Endoscopic Retrograde Cholangiopancreatography with Placement of Biliary Double Stents to Salvage Endoscopic Retrograde Cholangiopancreatography-lnduced Stapfer＇s Type Ⅱ Perforation

To the Editor：Endoscopic retrograde cholangiopancreatography （ERCP） plays a vital role in the management ofpancreaticobiliary diseases in recent years and it concomitantly carries a risk of complications including post-ERCP pancreatitis,cholangitis,bleeding,and perforation.The incidence of primary post-ERCP complications ranges from 5.4% to 23.0%,and ERCP-induced perforation can occur in 0.3-1.0% of cases,but the associated mortality is high ranging from 8% to 23%.[1] Because of the confluence of the bile duct and pancreatic duct meet at the papilla in proximity to the site of perforation in the duodenum,there is a potential risk of leakage of bile and pancreatic juice into the retroperitoneal space or peritoneum.Patients with Stapfer＇s Type Ⅱ perforation （perivaterian perforation） generally suffered from systemic inflammatory response syndrome,which could progress rapidly to acute lung injury and acute renal insufficiency and even multiple organ failure.All of these contribute to the significantly high mortality.A timely recognition and appropriate treatment are crucial to the management of ERCP-induced perforation to reduce the overall mortality.Conventionally,surgery remains the primary treatment for iatrogenic perforations.With the improvement in endoscopic technique and development of new accessories,nonsurgical management with endoscopic treatment of perforation is increasingly being reported.[2] We report a retrospective analysis of ERCP-induced Stapfer＇s Type Ⅱ perforations over a 5-year period managed with nonsurgical approach combined with salvage ERCP.

Anaerobic bacteria and intrahepatic stones: detections of Clostridium sp. and Bacteroides fragilis

To detect anaerobic bacteria Clostridium sp . and Bacteroides fragilis in intrahepatic stones by molecular genetic method Methods DNA was extracted from 59 stone samples and subjected to polymerase chain reaction (PCR) amplification targeting the 16S rRNA gene of Clostridium sp . and the glutamine synthetase gene of Bacteroides fragilis Single-strand conformational polymorphism (SSCP) analysis was performed to identify the Clostridium sp Results 16S rRNA gene sequences for Clostridium sp. were identified in 49 stones (83%, 49/59) The two most common groups were detected in 19 (41%) and 17 (37%) of the 46 samples using SSPC analysis, and 25/59 (42%) stones were tested positive for Bacteroides fragilis Conclusions Anaerobes such as Clostridium sp and Bacteroides fragilis present in intrahepatic stones and may play a role in stone formation PCR is a useful technique to detect fastidious pathogens, which are difficult to culture SSCP of PCR products is a rapid method in differentiating bacterial species

胆道纤维化的发生发展与治疗

胆道纤维化(BF)是病理性胆道损伤修复的结果,主要表现为胆管壁的增厚硬化和管腔的进行性狭窄,最终可能导致胆道梗阻、胆汁性肝硬化、肝衰竭、肝胆恶性肿瘤等严重不良结局。目前的研究将BF描述为某些胆管病的病理特征,对其病因、病理生理、分子机制和治疗缺乏系统总结。BF是胆道系统普遍存在但容易被忽略的疾病状态,可能通过病理性胆道损伤后的异常修复机制促进肝胆疾病的发生和进展,笔者结合国内外最新研究进展,综述BF的概念、临床表现、病因、发病机制和治疗策略,为临床医师提供参考。