Response letter to “Acute cholangitis: Does malignant biliary obstruction vs choledocholithiasis etiology change the outcomes?” with imaging aspects

Radiological imaging findings may contribute to the differentiation of malignant biliary obstruction from choledocholithiasis in the etiology of acute cholangitis.

Effect of the extrahepatic bile duct anatomy on choledocholithiasis and its clinical significance

BACKGROUND A comprehensive understanding of the extrahepatic bile duct anatomy is vital to guide surgical procedures and perform endoscopic retrograde cholangiography.Anatomical irregularities within the extrahepatic bile duct may increase susceptibility to bile duct stones.AIM To investigate the anatomical risk factors associated with extrahepatic bile ducts in patients diagnosed with choledocholithiasis,with a specific focus on preventing stone recurrence after surgical intervention and endoscopic lithotomy.METHODS We retrospectively analyzed the medical records of 124 patients without choledocholithiasis and 108 with confirmed choledocholithiasis who underwent magnetic resonance cholangiopancreatography examinations at our center between January 2022 and October 2022.Logistic regression analyses were conducted to identify the anatomical risk factors influencing the incidence of common bile duct stones.RESULTS Multivariate logistic regression analysis revealed that several factors independently contributed to choledocholithiasis risk.Significant independent risk factors for choledocholithiasis were diameter of the common hepatic[adjusted odds ratio(aOR)=1.43,95%confidence interval(CI):1.07-1.92,adjusted P value=0.016]and common bile(aOR=1.68,95%CI:1.27-2.23,adjusted P value<0.001)ducts,length of the common hepatic duct(aOR=0.92,95%CI:0.84-0.99,adjusted P value=0.034),and angle of the common bile duct(aOR=0.92,95%CI:0.89–0.95,adjusted P value<0.001).The anatomical features of the extrahepatic bile duct were directly associated with choledocholithiasis risk.Key risk factors include an enlarged diameter of the common hepatic and bile ducts,a shorter length of the common hepatic duct,and a reduced angle of the common bile duct.

Clinical efficacy of laparoscopic cholecystectomy plus cholangioscopy for the treatment of cholecystolithiasis combined with choledocholithiasis

BACKGROUND Currently,endoscopic retrograde cholangiopancreatography(ERCP)plus laparoscopic cholecystectomy(LC)is the main treatment for cholecystolithiasis combined with choledocholithiasis.However,the treatment is unsatisfactory,and the development of better therapies is needed.AIM To determine the clinical efficacy of LC plus cholangioscopy for cholecystolithiasis combined with choledocholithiasis.METHODS Patients(n=243)with cholecystolithiasis and choledocholithiasis admitted to The Affiliated Haixia Hospital of Huaqiao University(910th Hospital of Joint Logistic Support Force)between January 2019 and December 2023 were included in the study;111 patients(control group)underwent ERCP+LC and 132 patients(observation group)underwent LC+laparoscopic common bile duct exploration(LCBDE).Surgical success rates,residual stone rates,complications(pancreatitis,hyperamylasemia,biliary tract infection,and bile leakage),surgical indicators[intraoperative blood loss(IBL)and operation time(OT)],recovery indices(postoperative exhaust/defecation time and hospital stay),and serum inflammatory markers[C-reactive protein(CRP)],tumor necrosis factor-α(TNF-α),and interleukin-6(IL-6)were compared.RESULTS No significant differences in surgical success rates and residual stone rates were detected between the observation and control groups.However,the complication rate,IBL,OT,postoperative exhaust/defecation time,and hospital stays were significantly reduced in the observation group compared with the control group.Furthermore,CRP,TNF-α,and IL-6 Levels after treatment were reduced in the observation group compared with the levels in the control group.CONCLUSION These results indicate that LC+LCBDE is safer than ERCP+LC for the treatment of cholecystolithiasis combined with choledocholithiasis.The surgical risks and postoperative complications were lower in the observation group compared with the control group.Thus,patients may recover quickly with less inflammation after LCBDE.

Biliary complications associated with weight loss,cholelithiasis and choledocholithiasis

Biliary complications like cholelithiasis and choledocholithiasis are more common in bariatric surgery patients due to obesity and rapid weight loss.Patients with a body mass index>40 face an eightfold risk of developing cholelithiasis.Postbariatric surgery,especially after laparoscopic Roux-en-Y gastric bypass(LRYGB),30%of patients develop biliary disease due to rapid weight loss.The aim of this review is to analyze the main biliary complications that occur after bariatric surgery and its management.A review of the literature was conducted mainly from 2010 up to 2023 with regard to biliary complications associated with bariatric patients in SciELO,PubMed,and MEDLINE.Patients undergoing LRYGB have a higher incidence(14.5%)of symptomatic calculi post-surgery compared to those undergoing laparoscopic sleeve gastrectomy at 4.1%.Key biliary complications within 6 to 12 months post-surgery include:Cholelithiasis:36%;Biliary colic/dyskinesia:3.86%;Acute cholecystitis:0.98%-18.1%;Chronic cholecystitis:70.2%;Choledocholithiasis:0.2%-5.7%and Pancreatitis:0.46%-9.4%.Surgeons need to be aware of these complications and consider surgical treatments based on patient symptoms to enhance their quality of life.

Risk factors of recurrent choledocholithiasis following therapeutic endoscopic retrograde cholangiopancreatography

Background:The risk factors for the recurrent choledocholithiasis after endoscopic retrograde cholangiopancreatography(ERCP)have not been well studied.The aim of this study was to explore the risk factors of recurrent choledocholithiasis.Methods:We carried out a retrospective analysis of data collected between January 1,2010 and January 1,2020.Univariate analysis and multivariate analysis were used to explore the independent risk factors of recurrent choledocholithiasis following therapeutic ERCP.Results:In total,598 patients were eventually selected for analysis,299 patients in the recurrent choledocholithiasis group and 299 patients in the control group.The overall rate of recurrent choledocholithiasis was 6.91%.Multivariate analysis showed that diabetes[odds ratio(OR)=3.677,95%confidence interval(CI):1.875-7.209;P<0.001],fatty liver(OR=4.741,95%CI:1.205-18.653;P=0.026),liver cirrhosis(OR=3.900,95%CI:1.358-11.201;P=0.011),history of smoking(OR=3.773,95%CI:2.060-6.908;P<0.001),intrahepatic bile duct stone(OR=4.208,95%CI:2.220-7.976;P<0.001),biliary stent(OR=2.996,95%CI:1.870-4.800;P<0.001),and endoscopic papillary balloon dilation(EPBD)(OR=3.009,95%CI:1.921-4.715;P<0.001)were independent risk factors of recurrent choledocholithiasis.However,history of drinking(OR=0.183,95%CI:0.099-0.337;P<0.001),eating light food frequently(OR=0.511,95%CI:0.343-0.760;P=0.001),and antibiotic use before ERCP(OR=0.315,95%CI:0.200-0.497;P<0.001)were independent protective factors of recurrent choledocholithiasis.Conclusions:Patients with the abovementioned risk factors are more likely to have recurrent CBD stones.Patients who eat light food frequently and have a history of drinking are less likely to present with recurrent CBD calculi.

Laparoscopic common bile duct exploration to treat choledocholithiasis in situs inversus patients:A technical review

Situs inversus(SI)is a rare congenital condition characterized by a mirror-image transposition of the major visceral organs.Since the 1990s,more than one hundred SI patients have been reported to have successfully undergone laparoscopic cholecystectomy.In these cases,the major problem is to overcome is the left-right condition for right-handed surgeons.Laparoscopic common bile duct exploration(LCBDE),an alternative to treat patients with bile duct stones,has shown equivalent efficacy and is less likely to cause pancreatitis than endoscopic retrograde cholangiopancreatography.Recent updated meta-analyses revealed that a shorter postoperative hospital stay,fewer procedural interventions,cost-effectiveness,a higher stone clearance rate,and fewer perioperative complications are additional advantages of LCBDE.However,the technique is technically demanding,even for skilled laparoscopic surgeons.Conducting LCBDE in patients with difficult situations,such as SI,is more complex than usual.We herein review published SI patients with choledocholithiasis treated by LCBDE,including our own experience,and this paper focuses on the technical aspects.

A Case of Choledocholithiasis Complicated by Choledochoduodenal Fistula

Duodenal fistula refers to the pathological channel formed between the duodenum and the hollow viscera of the human body.If it is connected to a single cavity organ,it is a simple duodenal fistula.If it is connected to≥2 and the hollow viscera are connected,it is a complicated internal duodenal fistula,but simple ones are more common.Once a duodenal fistula develops,it establishes a pathological communication between duodenal contents and related organs,resulting in compromised organ function,infections,malnutrition,bleeding,and other detrimental effects.A patient with choledocholithiasis and choledochoduodenal fistula was treated in our hospital.She underwent laparoscopic left hemi-hepatectomy+laparoscopic choledochojejunostomy and was discharged 4 days after surgery.

Recurrence of choledocholithiasis following endoscopic bile duct clearance: Long term results and factors associated with recurrent bile duct stones

AIMTo evaluate the rate of recurrence of symptomatic choledocholithiasis and identify factors associated with the recurrence of bile duct stones in patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (EST) for bile duct stone disease. METHODSAll patients who underwent ERCP and EST for bile duct stone disease and had their bile duct cleared from 1/1/2005 until 31/12/2008 was enrolled. All symptomatic recurrences during the study period (until 31/12/2015) were recorded. Clinical and laboratory data potentially associated with common bile duct (CBD) stone recurrence were retrospectively retrieved from patients&rsquo; files. RESULTSA total of 495 patients were included. Sixty seven (67) out of 495 patients (13.5%) presented with recurrent symptomatic choledocholithiasis after 35.28 &plusmn; 16.9 mo while twenty two (22) of these patients (32.8%) experienced a second recurrence after 35.19 &plusmn; 23.2 mo. Factors associated with recurrence were size (diameter) of the largest CBD stone found at first presentation (10.2 &plusmn; 6.9 mm vs 7.2 &plusmn; 4.1 mm, P = 0.024), diameter of the CBD at the first examination (15.5 &plusmn; 6.3 mm vs 12.0 &plusmn; 4.6 mm, P = 0.005), use of mechanical lithotripsy (ML) (P = 0.04) and presence of difficult lithiasis (P = 0.04). Periampullary diverticula showed a trend towards significance (P = 0.066). On the contrary, number of stones, angulation of the CBD, number of ERCP sessions required to clear the CBD at first presentation, more than one ERCP session needed to clear the bile duct initially and a gallbladder in situ did not influence recurrence. CONCLUSIONBile duct stone recurrence is a possible late complication following endoscopic stone extraction and CBD clearance. It appears to be associated with anatomical parameters (CBD diameter) and stone characteristics (stone size, use of ML, difficult lithiasis) at first presentation.

Diagnosis and management of choledocholithiasis in the golden age of imaging, endoscopy and laparoscopy

Biliary lithiasis is an endemic condition in both Western and Eastern countries, in some studies affecting 20% of the general population. In up to 20% of cases, gallbladder stones are associated with common bile duct stones (CBDS), which are asymptomatic in up to one half of cases. Despite the wide variety of examinations and techniques available nowadays, two main open issues remain without a clear answer: how to cost-effectively diagnose CBDS and, when they are finally found, how to deal with them. CBDS diagnosis and management has radically changed over the last 30 years, following the dramatic diffusion of imaging, including endoscopic ultrasound (EUS) and magnetic resonance cholangiography (MRC), endoscopy and laparoscopy. Since accuracy, invasiveness, potential therapeutic use and cost-effectiveness of imaging techniques used to identify CBDS increase together in a parallel way, the concept of &#x0201c;risk of carrying CBDS&#x0201d; has become pivotal to identifying the most appropriate management of a specific patient in order to avoid the risk of &#x0201c;under-studying&#x0201d; by poor diagnostic work up or &#x0201c;over-studying&#x0201d; by excessively invasive examinations. The risk of carrying CBDS is deduced by symptoms, liver/pancreas serology and ultrasound. &#x0201c;Low risk&#x0201d; patients do not require further examination before laparoscopic cholecystectomy. Two main &#x0201c;philosophical approaches&#x0201d; face each other for patients with an &#x0201c;intermediate to high risk&#x0201d; of carrying CBDS: on one hand, the &#x0201c;laparoscopy-first&#x0201d; approach, which mainly relies on intraoperative cholangiography for diagnosis and laparoscopic common bile duct exploration for treatment, and, on the other hand, the &#x0201c;endoscopy-first&#x0201d; attitude, variously referring to MRC, EUS and/or endoscopic retrograde cholangiography for diagnosis and endoscopic sphincterotomy for management. Concerning CBDS diagnosis, intraoperative cholangiography, EUS and MRC are reported to have similar results. Regarding management, the recent literature seems to show better short and long term outcome of surgery in terms of retained stones and need for further procedures. Nevertheless, open surgery is invasive, whereas the laparoscopic common bile duct clearance is time consuming, technically demanding and involves dedicated instruments. Thus, although no consensus has been achieved and CBDS management seems more conditioned by the availability of instrumentation, personnel and skills than cost-effectiveness, endoscopic treatment is largely preferred worldwide.

Choledocholithiasis: Evolving standards for diagnosis and management

Cholelithiasis, one of the most common medical conditions leading to surgical intervention, affects approximately 10 % of the adult population in the United States. Choledocholithiasis develops in about 10%-20% of patients with gallbladder stones and the literature suggests that at least 3%-10% of patients undergoing cholecystectomy will have common bile duct （CBD） stones. CBD stones may be discovered preoperatively, intraoperatively or postoperatively Multiple modalities are available for assessing patients for choledocholithiasis including laboratory tests, ultrasound, computed tomography scans （CT）, and magnetic resonance cholangiopancreatography （MRCP）. Intraoperative cholangiography during cholecystectomy can be used routinely or selectively to diagnose CBD stones. The most common intervention for CBD stones is ERCP. Other commonly used interventions include intraoperative bile duct exploration, either laparoscopic or open. Percutaneous, transhepatic stone removal other novel techniques of biliary clearance have been devised. The availability, of equipment and skilled practitioners who are facile with these techniques varies among institutions. The timing of the intervention is olden dictated by the clinical situation.

Endoscopic sphincterotomy plus large-balloon dilation vs endoscopic sphincterotomy for choledocholithiasis:A meta-analysis

AIM:To perform a meta-analysis of large-balloon dilation(LBD)plus endoscopic sphincterotomy(EST)vs EST alone for removal of bile duct stones.METHODS:Databases including PubMed,EMBASE,the Cochrane Library,the Science Citation Index,and important meeting abstracts were searched and evaluated by two reviewers independently.The main outcome measures included:complete stone removal,stone removal in the first session,use of mechanical lithotripsy,procedure time,and procedure-related complications.A fixed-effects model weighted by the Mantel-Haenszel method was used for pooling the odds ratio(OR)when heterogeneity was not significant among the studies.When a Q test or I2statistic indicated substantial heterogeneity,a random-effects model weighted by the DerSimonian-Laird method was used.RESULTS:Six randomized controlled trials involving835 patients were analyzed.There was no significant heterogeneity for most results;we analyzed these using a fixed-effects model.Meta-analysis showed EST plus LBD caused fewer overall complications than EST alone(OR=0.53,95%CI:0.33-0.85,P=0.008);sub-category analysis indicated a significantly lower risk of perforation in the EST plus LBD group(Peto OR=0.14,95%CI:0.20-0.98,P=0.05).Use of mechanical lithotripsy in the EST plus LBD group decreased significantly(OR=0.26,95%CI:0.08-0.82,P=0.02),especially in patients with a stone size larger than 15 mm(OR=0.15,95%CI:0.03-0.68,P=0.01).There were no significant differences between the two groups regarding complete stone removal,stone removal in the first session,post-endoscopic retrograde cholangiopancreatography pancreatitis,bleeding,infection of biliary tract,and procedure time.CONCLUSION:EST plus LBD is an effective approach for the removal of large bile duct stones,causing fewer complications than EST alone.

Management of cholelithiasis with choledocholithiasis:Endoscopic and surgical approaches

Gallstone disease and complications from gallstones are a common clinical problem.The clinical presentation ranges between being asymptomatic and recurrent attacks of biliary pain requiring elective or emergency treatment.Bile duct stones are a frequent condition associated with cholelithiasis.Amidst the total cholecystectomies performed every year for cholelithiasis,the presence of bile duct stones is 5%-15%;another small percentage of these will develop common bile duct stones after intervention.To avoid serious complications that can occur in choledocholithiasis,these stones should be removed.Unfortunately,there is no consensus on the ideal management strategy to perform such.For a long time,a direct open surgical approach to the bile duct was the only unique approach.With the advent of advanced endoscopic,radiologic,and minimally invasive surgical techniques,however,therapeutic choices have increased in number,and the management of this pathological situation has become multidisciplinary.To date,there is agreement on preoperative management and the need to treat cholelithiasis with choledocholithiasis,but a debate still exists on how to cure the two diseases at the same time.In the era of laparoscopy and miniinvasiveness,we can say that therapeutic approaches can be performed in two sessions or in one session.Comparison of these two approaches showed equivalent success rates,postoperative morbidity,stone clearance,mortality,conversion to other procedures,total surgery time,and failure rate,but the onesession treatment is characterized by a shorter hospital stay,and more cost benefits.The aim of this review article is to provide the reader with a general summary of gallbladder stone disease in association with the presence of common bile duct stones by discussing their epidemiology,clinical and diagnostic aspects,and possible treatments and their advantages and limitations.

Role of laparoscopic common bile duct exploration in the management of choledocholithiasis

Surgical fraternity has not yet arrived at any consensus for adequate treatment of choledocholithiasis. Sequential treatment in the form of pre-operative endoscopic retrograde cholangio-pancreatography followed by laparoscopic cholecystectomy(LC) is considered as optimal treatment till date. With refinements in technique and expertise in field of minimal access surgery, many centres in the world have started offering one stage management of choledocholithiasis by LC with laparoscopic common bile duct exploration(LCBDE). Various modalities have been tried for entering into concurrent common bile duct(CBD) [transcystic(TC) vs transcholedochal(TD)], for confirming stone clearance(intraoperative cholangiogram vs choledochoscopy), and for closure of choledochotomy(T-tube vs biliary stent vs primary closure) during LCBDE. Both TC and TD approaches are safe and effective. TD stone extraction is involved with an increased risk of bile leaks and requires more expertise in intra-corporeal suturing and choledochoscopy. Choice depends on number of stones, size of stone, diameter of cystic duct and CBD. This review article was undertaken to evaluate the role of LCBDE for the management of choledocholithiasis.

Various approaches of laparoscopic common bile duct exploration plus primary duct closure for choledocholithiasis:A systematic review and meta-analysis

Background： Common bile duct （CBD） stones may occur in up to 3%–14.7% of all patients with cholecystectomy.Various approaches of laparoscopic CBD exploration plus primary duct closure （PDC） are the most commonly used and the best methods to treat CBD stone. This systematic review was to comparethe effectiveness and safety of the various approaches of laparoscopic CBD exploration plus PDC forcholedocholithiasis

Causes associated with recurrent choledocholithiasis following therapeutic endoscopic retrograde cholangiopancreatography: A large sample sized retrospective study

BACKGROUND Recurrence of primary choledocholithiasis commonly occurs after complete removal of stones by therapeutic endoscopic retrograde cholangiopancreatography(ERCP). The potential causes of the recurrence of choledocholithiasis after ERCP are unclear.AIM To analyze the potential causes of the recurrence of choledocholithiasis after ERCP.METHODS The ERCP database of our medical center for the period between January 2007 and January 2016 was retrospectively reviewed, and information regarding eligible patients who had choledocholithiasis recurrence was collected. A 1:1 case-control study was performed for this investigation. Data including general characteristics of the patients, past medical history, ERCP-related factors,common bile duct(CBD)-related factors, laboratory indicators, and treatment was analyzed by univariate and multivariate logistic regression analysis and KaplanMeier analysisly.RESULTS First recurrence of choledocholithiasis occurred in 477 patients; among these patients, the second and several instance(≥ 3 times) recurrence rates were 19.5%and 44.07%, respectively. The average time to first choledocholithiasis recurrence was 21.65 mo. A total of 477 patients who did not have recurrence were selected as a control group. Multivariate logistic regression analysis showed that age > 65 years(odds ratio [OR] = 1.556; P = 0.018), combined history of choledocholithotomy(OR = 2.458; P < 0.01), endoscopic papillary balloon dilation(OR = 5.679; P = 0.000), endoscopic sphincterotomy(OR = 3.463; P = 0.000), CBD stent implantation(OR = 5.780; P = 0.000), multiple ERCP procedures(≥2; OR =2.75; P = 0.000), stones in the intrahepatic bile duct(OR = 2.308; P = 0.000),periampullary diverticula(OR = 1.627; P < 0.01), choledocholithiasis diameter ≥10 mm(OR = 1.599; P < 0.01), bile duct-duodenal fistula(OR = 2.69; P < 0.05),combined biliary tract infections(OR = 1.057; P < 0.01), and no preoperative antibiotic use(OR = 0.528; P < 0.01) were independent risk factors for the recurrence of choledocholithiasis after ERCP.CONCLUSION Patient age greater than 65 years is an independent risk factor for the development of recurrent choledocholithiasis following ERCP, as is history of biliary surgeries, measures during ERCP, and prevention of postoperative complications.

Diagnostic value of magnetic resonance cholangiopancreatography in choledocholithiasis

AIM:To evaluate the diagnostic accuracy of magnetic resonance cholangiopancreatography(MRCP) in patients with choledocholithiasis.METHODS:We systematically searched MEDLINE,EMBASE,Web of Science,and Cochrane databases for studies reporting on the sensitivity,specificity and other accuracy measures of diagnostic effectiveness of MRCP for detection of common bile duct(CBD) stones.Pooled analysis was performed using random effects models,and receiver operating characteristic curves were generated to summarize overall test performance.Two reviewers independently assessed the methodological quality of studies using standards for reporting diagnostic accuracy and quality assessment for studies of diagnostic accuracy tools.RESULTS:A total of 25 studies involving 2310 patients with suspected choledocholithiasis and 738 patients with CBD stones met the inclusion criteria.The average inter-rater agreement on the methodological quality checklists was 0.96.Pooled analysis of the ability of MRCP to detect CBD stones showed the following effect estimates:sensitivity,0.90(95%CI:0.88-0.92,χ2 = 65.80; P < 0.001); specificity,0.95(95%CI:0.93-1.0,χ2 = 110.51; P < 0.001); positive likelihood ratio,13.28(95%CI:8.85-19.94,χ2 = 78.95; P < 0.001); negative likelihood ratio,0.13(95%CI:0.09-0.18,χ2 = 6.27; P < 0.001); and diagnostic odds ratio,143.82(95%CI:82.42-250.95,χ2 = 44.19; P < 0.001).The area under the receiver operating characteristic curve was 0.97.Significant publication bias was not detected(P = 0.266).CONCLUSION:MRCP has high diagnostic accuracy for the detection of choledocholithiasis.MRCP should be the method of choice for suspected cases of CBD stones.

Hepatectomy with primary closure of common bile duct for hepatolithiasis combined with choledocholithiasis

AIM: To evaluate the feasibility of hepatectomy and primary closure of common bile duct for intrahepatic and extrahepatic calculi. METHODS: From January 2008 to May 2013, anatomic hepatectomy followed by biliary tract exploration without biliary drainage(non-drainage group) was performed in 43 patients with intrahepatic and extrahepatic calculi. After hepatectomy, flexible choledochoscopy was used to extract residual stones and observe the intrahepatic bile duct and common bile duct(CBD) for determination of biliary stricture and dilatation. Function of the sphincter of Oddi was determined by manometry of the CBD. Primary closure of the CBD without T-tube drainage or bilioenteric anastomosis was performed when there was no biliary stricture or sphincter of Oddi dysfunction. Dexamethasone and anisodamine were intravenously injected 2-3 d after surgery to prevent postoperative retrograde infection due to intraoperative bile duct irrigation, and to maintain relaxation of the sphincter of Oddi, respectively. During the same period, anatomic hepatectomy followed by biliary tract exploration with biliary drainage(drainage group) was performed in 48 patients as the control group. Postoperative complications and hospital stay were compared between the two groups.RESULTS: There was no operative mortality in either group of patients. Compared to intrahepatic and extrabiliary drainage, hepatectomy with primary closure of the CBD(non-drainage) did not increase the incidenceof complications, including residual stones, bile leakage, pancreatitis and cholangitis(P > 0.05). Postoperative hospital stay and costs were nevertheless significantly less in the non-drainage group than in the drainage group. The median postoperative hospital stay was shorter in the non-drainage group than in the drainage group(11.2 ± 2.8 d vs 15.4 ± 2.1 d, P = 0.000). The average postoperative cost of treatment was lower in the non-drainage group than in the drainage group(29325.6 ± 5668.2 yuan vs 32933.3 ± 6235.1 yuan, P = 0.005). CONCLUSION: Hepatectomy followed by choledochoendoscopic stone extraction without biliary drainage is a safe and effective treatment of hepatolithiasis combined with choledocholithiasis.

Limited endoscopic sphincterotomy plus large balloon dilation for choledocholithiasis with periampullary diverticula

AIM: To investigate the effectiveness and safety of limited endoscopic sphincterotomy (EST) plus large balloon dilation (LBD) for removing choledocholithiasis in patients with periampullary diverticula (PAD). METHODS: A total of 139 patients with common bile duct (CBD) stones were treated with LBD (10-20 mm balloon diameter) after limited EST. Of this total, 73 patients had PAD and 66 patients did not have PAD (controls). The results of stone removal and complications were retrospectively evaluated. RESULTS: There were no significant differences between the PAD and the control groups in overall successful stone removal (94.5% vs 93.9%), stone removal in first session (69.9% vs 81.8%), mechanical lithotripsy (12.3% vs 13.6%), and complications (11.0% vs 7.6%). Clinical outcomes were also similar between the types of PAD, but the rate of stone removal in first session and the number of sessions were significantly lower and more frequent, respectively, in type B PAD (papilla located near the diverticulum) than controls [23/38 (60.5%) vs 54/66 (81.8%), P = 0.021; and 1 (1-2) vs 1 (1-3), P = 0.037, respectively] and the frequency of pancreatitis was significantly higher in type A PAD (papilla located inside or in the margin of the diverticulum) than in controls (16.1% vs 3.0%, P = 0.047). CONCLUSION: Limited EST plus LBD was an effective and safe procedure for removing choledocholithiasis in patients with PAD. However, some types of PAD should be managed with caution.

Does the bile duct angulation affect recurrence of choledocholithiasis?

AIM:To investigate whether bile duct angulation and T-tube choledochostomy influence the recurrence of choledocholithiasis.METHODS:We conducted a retrospective study including 259 patients who underwent endoscopic sphincterotomy and cholecystectomy for choledocholithiasis between 2000 and 2007.The imaginary line was drawn along the center of the bile duct and each internal angle was measured at the two angulation sites ofthe bile duct respectively.The values of both angles were added together.We then tested our hypothesis by examining whether T-tube choledochostomy was performed and stone recurrence occurred by reviewing each subject's medical records.RESULTS:The overall recurrence rate was 9.3% (24 of 259 patients).The mean value of sums of angles in the recurrence group was 268.3°± 29.6°,while that in the non-recurrence group was 314.8°± 19.9° (P < 0.05).Recurrence rate of the T-tube group was 15.9% (17 of 107),while that of the non T-tube group was 4.6% (7 of 152) (P < 0.05).Mean value of sums of angles after T-tube drainage was 262.5°± 24.6° and that before T-tube drainage was 298.0°± 23.9° in 22 patients (P < 0.05).CONCLUSION:The bile duct angulation and T-tube choledochostomy may be risk factors of recurrence of bile duct stones.

Endoscopic papillary balloon dilation after sphincterotomy for difficult choledocholithiasis:A case-controlled study

AIM:To evaluate the efficacy and safety of endoscopic sphincterotomy(EST) + endoscopic papillary large balloon dilation(EPLBD)vs isolated EST.METHODS:We conducted a retrospective single center study over two years,from February 2010 to January 2012.Patients with large(≥ 10 mm),single or multiple bile duct stones(BDS),submitted to endoscopic retrograde cholangio-pancreatography(ERCP) were included.Patients in Group A underwent papillary large balloon dilation after limited sphincterotomy(EST+EPLBD),using a through-the-scope balloon catheter gradually inflated to 12-18 mm according to the size of the largest stone and the maximal diameter of the distal bile duct on the cholangiogram.Patients in Group B(control group) underwent isolated sphincterotomy.Stones were removed using a retrieval balloon catheter and/or a dormia basket.When necessary,mechanical lithotripsy was performed.Complete clearance of the bile duct was documented with a balloon catheter cholangiogram at the end of the procedure.In case of residual lithiasis,a double pigtail plastic stent was placed and a second ERCP was planned within 4-6 wk.Some patients were sent for extracorporeal lithotripsy prior to subsequent ERCP.Outcomes of EST+EPLBD(Group A) vs isolated EST(Group B) were compared regarding efficacy(complete stone clearance,number of therapeutic sessions,mechanical and/or extracorporeal lithotripsy,biliary stent placement) and safety(frequency,type and grade of complications).Statistical analysis was performed using χ 2 or Fisher’s exact tests for the analysis of categorical parameters and Student’s t test for continuous variables.A P-value of less than 0.05 was considered statistically significant.RESULTS:One hundred and eleven patients were included,68(61.3%) in Group A and 43(38.7%) in Group B.The mean diameter of the stones was similar in the two groups(16.8 ± 4.4 and 16.0 ± 6.7 in Groups A and B,respectively).Forty-eight(70.6%) patients in Group A and 21(48.8%) in Group B had multiple BDS(P = 0.005).Overall,balloon dilation was performed up to 12 mm in 10(14.7%) patients,13.5 mm in 17(25.0%),15 mm in 33(48.6%),16.5 mm in 2(2.9%) and 18 mm in 6(8.8%) patients,taking into account the diameter of the largest stone and that of the bile duct.Complete stone clearance was achieved in sixty-five(95.6%) patients in Group A vs 30(69.8%) patients in Group B,and was attained within the first therapeutic session in 82.4% of patients in Group A vs 44.2% in Group B(P 【 0.001).Patients submitted to EST+EPLBD underwent fewer therapeutic sessions(1.1 ± 0.3 vs 1.8 ± 1.1,P 【 0.001),and fewer required mechanical(14.7% vs 37.2%,P = 0.007) or extracorporeal(0 vs 18.6%,P 【 0.001) lithotripsy,as well as biliary stenting(17.6% vs 60.5%,P 【 0.001).The rate of complications was not significantly different between the two groups.CONCLUSION:EST+EPLBD is a safe and effective technique for treatment of difficult BDS,leading to high rates of complete stone clearance and reducing the need for lithotripsy and biliary stenting.