Removal of intrahepatic bile duct stone could reduce the risk of cholangiocarcinoma: A single-center retrospective study in South Korea

BACKGROUND Intrahepatic duct(IHD)stones are among the most important risk factors for cholangiocarcinoma(CCC).Approximately 10%of patients with IHD stones develop CCC;however,there are limited studies regarding the effect of IHD stone removal on CCC development.AIM To investigate the association between IHD stone removal and CCC development.METHODS We retrospectively analyzed 397 patients with IHD stones at a tertiary referral center between January 2011 and December 2020.RESULTS CCC occurred in 36 of the 397 enrolled patients.In univariate analysis,chronic hepatitis B infection(11.1%vs 3.0%,P=0.03),carbohydrate antigen 19-9(CA19-9,176.00 vs 11.96 II/mL,P=0.010),stone located in left or both lobes(86.1%vs 70.1%,P=0.042),focal atrophy(52.8%vs 26.9%,P=0.001),duct stricture(47.2%vs 24.9%,P=0.004),and removal status of IHD stone(33.3%vs 63.2%,P<0.001)were significantly different between IHD stone patients with and without CCC.In the multivariate analysis,CA19-9>upper normal limit,carcinoembryonic antigen>upper normal limit,stones located in the left or both lobes,focal atrophy,and complete removal of IHD stones without recurrence were independent factors influencing CCC development.However,the type of removal method was not associated with CCC risk.CONCLUSION Complete removal of IHD stones without recurrence could reduce CCC risk.

Removal of intrahepatic bile duct stone could reduce the risk of cholangiocarcinoma

Hepatolithiasis(HL)poses a significant risk for cholangiocarcinoma(CCA)development,with reported incidences ranging from 5%-13%.Risk factors include older age,smoking,hepatitis B infection,and prolonged HL duration.Chronic inflammation and mechanical stress on the biliary epithelium contribute to CCA pathogenesis.Hepatectomy reduces CCA risk by removing stones and atrophic liver segments.However,residual stones and incomplete removal increase CCA risk.Kim et al identified carbohydrate antigen 19-9,carcinoembryonic antigen,and stone laterality as CCA risk factors,reaffirming the importance of complete stone removal.Nonetheless,challenges remain in preventing CCA recurrence post-surgery.Longer-term studies are needed to elucidate CCA risk factors further.

Risk factors for recurrence of common bile duct stones after surgical treatment and effect of ursodeoxycholic acid intervention

BACKGROUND Endoscopic retrograde cholangiopancreatography(ERCP)is an accurate diagnostic method for choledocholithiasis and treatment option for stone removal.Additionally,ursodeoxycholic acid(UDCA)can dissolve cholesterol stones and prevent their development and reappearance by lowering the cholesterol concen-tration in bile.Despite these treatment options,there are still patients who experience stone recurrence.The clinical data of 100 patients with choledochal stones who were hospitalized at the Yixing People’s Hospital and underwent ERCP for successful stone extraction between June 2020 and December 2022 were retrospectively collected.According to the post-ERCP treatment plan,100 patients were classified into UDCA(n=47)and control(n=53)groups.We aimed to assess the clinical efficacy and rate of relapse in the two patient populations.We then collected information(basic demographic data,clinical characteristics,and serum biochemical indicators)and determined the factors contributing to relapse using logistic regression analysis.Our secondary goal was to determine the effects of UDCA on liver function after ERCP.Compared to the control group,the UDCA group demonstrated a higher clinical effectiveness rate of 92.45%vs 78.72%(P<0.05).No significant differences were observed in liver function indices,including total bilirubin,direct bilirubin,gamma-glutamyl transpeptidase,alanine aminotransferase,alkaline phosphatase,and aspartate aminotransferase,between the two groups before treatment.After treatment,all liver function indices were significantly reduced.Comparing the control vs UDCA groups,the UDCA group exhibited significantly lower levels of all indices(55.39±6.53 vs 77.31±8.52,32.10±4.62 vs 45.39±5.69,142.32±14.21 vs 189.63±16.87,112.52±14.25 vs 149.36±15.36,122.61±16.00 vs 171.33±22.09,96.98±10.44 vs 121.35±11.57,respectively,all P<0.05).The stone recurrence rate was lower in the UDCA group(13.21%)in contrast with the control group(44.68%).Periampullary diverticula(OR:6.00,95%CI:1.69-21.30),maximum stone diameter(OR:1.69,95%CI:1.01-2.85),stone quantity>3(OR:4.23,95%CI:1.17-15.26),and positive bile culture(OR:7.61,95%CI:2.07-27.91)were independent factors that influenced the relapse of common bile duct stones after ERCP(P<0.05).Furthermore,postoperative UDCA was identified as a preventive factor(OR:0.07;95%CI:0.08-0.09).CONCLUSION The intervention effect of UDCA after ERCP for common bile duct stones is adequate,providing new research directions and references for the prevention and treatment of stone recurrence.

Comparison of the clinical effects of dual-modality endoscopy and traditional laparotomy for the treatment of intra-and extrahepatic bile duct stones

BACKGROUND Bile duct stones(BDSs)may cause patients to develop liver cirrhosis or even liver cancer.Currently,the success rate of surgical treatment for intrahepatic and extrahepatic BDSs is not satisfactory,and there is a risk of postoperative complic-ations.AIM To compare the clinical effects of dual-modality endoscopy(duodenoscopy and laparoscopy)with those of traditional laparotomy in the treatment of intra-and extrahepatic BDSs.METHODS Ninety-five patients with intra-and extrahepatic BDSs who sought medical services at Wuhan No.1 Hospital between August 2019 and May 2023 were selected;45 patients in the control group were treated by traditional laparotomy,and 50 patients in the research group were treated by dual-modality endoscopy.The following factors were collected for analysis:curative effects,safety(incision infection,biliary fistula,lung infection,hemobilia),surgical factors[surgery time,intraoperative blood loss(IBL)volume,gastrointestinal function recovery time,and length of hospital stay],serum inflammatory markers[tumor necrosis factor(TNF)-α,interleukin(IL)-6,and IL-8],and oxidative stress[glutathione peroxidase(GSH-Px),superoxide dismutase(SOD),malondialdehyde(MDA),and advanced protein oxidation products(AOPPs)].RESULTS The analysis revealed markedly better efficacy(an obviously higher total effective rate)in the research group than in the control group.In addition,an evidently lower postoperative complication rate,shorter surgical duration,gastrointestinal function recovery time and hospital stay,and lower IBL volume were observed in the research group.Furthermore,the posttreatment serum inflammatory marker(TNF-α,IL-6,and IL-8)levels were significantly lower in the research group than in the control group.Compared with those in the control group,the posttreatment GSH-Px,SOD,MDA and AOPPs in the research group were equivalent to the pretreatment levels;for example,the GSH-Px and SOD levels were significantly higher,while the MDA and AOPP levels were lower.CONCLUSION Dual-modality endoscopy therapy(duodenoscopy and laparoscopy)is more effective than traditional laparotomy in the treatment of intra-and extrahepatic BDSs and has a lower risk of postoperative complications;significantly shortened surgical time;shorter gastrointestinal function recovery time;shorter hospital stay;and lower intraop-erative bleeding volume,while having a significant inhibitory effect on excessive serum inflammation and causing little postoperative oxidative stress.

Surgical strategies for challenging common bile duct stones in the endoscopic era: A comprehensive review of current evidence

While endoscopic retrograde cholangiopancreatography(ERCP)remains the primary treatment modality for common bile duct stones(CBDS)or choledocho-lithiasis due to advancements in instruments,surgical intervention,known as common bile duct exploration(CBDE),is still necessary in cases of difficult CBDS,failed endoscopic treatment,or altered anatomy.Recent evidence also supports CBDE in patients requesting single-step cholecystectomy and bile duct stone removal with comparable outcomes.This review elucidates relevant clinical anatomy,selection indications,and outcomes to enhance surgical understanding.The selection between trans-cystic(TC)vs trans-choledochal(TD)approaches is described,along with stone removal techniques and ductal closure.Detailed surgical techniques and strategies for both the TC and TD approaches,including instrument selection,is also provided.Additionally,this review comprehensively addresses operation-specific complications such as bile leakage,stricture,and entrapment,and focuses on preventive measures and treatment strategies.This review aims to optimize the management of CBDS through laparoscopic CBDE,with the goal of improving patient outcomes and minimizing risks.

Asymptomatic bile duct stones:The devil is in the details

Common bile duct(CBD)stones are a common biliary tract disease.For asymp-tomatic CBD stones,stone removal by endoscopic retrograde cholangiopancreato-graphy(ERCP)is recommended in available guidelines.Because asymptomatic CBD stones is a benign disease with no noticeable symptoms,the risk vs benefit strategy should be thoroughly considered before performing ERCP in these patients.Clinical care review,technical aspects of the procedure,and patient preferences should also be considered.

Nursing Effect of Rapid Rehabilitation Surgery Concept in Laparoscopic Surgery for Extrahepatic Bile Duct Stones

Objective: To explore the application value of rapid rehabilitation concept in patients with extrahepatic bile duct stones under laparoscopy during perioperative period. Methods: 90 patients with extrahepatic bile duct stones treated in our hospital from January 2022 to February 2023 were selected as the research object and randomly divided into the study group and the control group. The control group was given routine care, and the observation group was given rapid surgical rehabilitation care. The postoperative anal exhaust time, first meal time, early activity time, pain time, abdominal drainage tube removal time, hospitalization time and complication rate were compared between the two groups. The independent sample T test was used for the measurement data, and the x2 test was used for the counting data, and the difference was statistically significant (P Results: The postoperative anal exhaust time, first meal time, early activity time, pain time, abdominal drainage tube removal time and hospitalization time in the study group were shorter than those in the control group (all P Conclusion: The concept of rapid rehabilitation can significantly improve the perioperative nursing effect of patients with extrahepatic bile duct stones and accelerate their rehabilitation, which is worth improving and popularizing.

Comprehensive review on small common bile duct stones

Common bile duct stones are among the most common conditions encountered by endoscopists.Therefore,it is well researched;however,some items,such as indications for endoscopic papillary balloon dilatation(EPBD),safety of EPBD and endoscopic sphincterotomy in patients receiving dual antiplatelet therapy or direct oral anticoagulant,selection strategy for retrieval balloons and baskets,lack adequate evidence.Therefore,the guidelines have been updated with new research,while others remain unchanged due to weak evidence.In this review,we comprehensively summarize the standard methods in guidelines and new findings from recent studies on papillary dilation,stone retrieval devices,difficult-to-treat cases,troubleshooting during the procedure,and complicated cases of cholangitis,cholecystolithiasis,or distal biliary stricture.

Cholangioscopy-assisted extraction through novel papillary support for small-calibre and sediment-like common bile duct stones

BACKGROUND To date,endoscopic retrograde cholangiopancreatography has become a wellestablished treatment for common bile duct(CBD)stones.However,it is not suitable for some special patients,such as pregnant women,children or those who cannot stop taking anti-coagulation/anti-platelet agents because of radiation injury and the risk of postoperative bleeding resulting from endoscopic sphincterotomy.To overcome these two problems,this study introduced cholangioscopy-assisted extraction through a novel papillary support for small-calibre and sediment-like CBD stones.AIM To assess the feasibility and safety of cholangioscopy-assisted extraction through a novel papillary support(CEPTS)for small-calibre and sediment-like common bile duct(CBD)stones.METHODS This Retrospective study was approved by the Ethics Committee of the Chinese PLA General Hospital.We designed a covered single dumbbell-style papillary support between 2021 and 2022.Between July 2022 and September 2022,7 consecutive patients with small-calibre(cross diameter≤1.0 cm)or sediment-like CBD stones underwent CETPS procedures in our center.The clinical characteristics and treatment outcomes of these 7 patients were extracted from a prospectively collected database.And the related data were analyzed.Informed consent was obtained from all participating patients.RESULTS A total of 2 patients had yellow sediment-like CBD stones,and aspiration extraction was performed after the insertion of papillary support.Of the 5 patients with clumpy CBD stones(0.4-1.0 cm),2 underwent basket extraction under direct vision for a single stone(0.5-1.0 cm,black and black grey),1 underwent balloon plus aspiration extraction under direct vision for 5 stones(0.4-0.6 cm,brown),and 2 underwent aspiration extraction only for a single stone(0.5-0.6 cm,yellow,none).Technical success,namely,no residual stones in the CBD or left and right hepatic ducts,was achieved in all 7 cases(100%).The median operating time was 45.0 minutes(range 13.0–87.0 minutes).Postoperative pancreatitis(PEP)occurred in one case(14.3%).Hyperamylasaemia without abdominal pain was noted in 2 of 7 patients.No residual stones or cholangitis were found during the follow-up.CONCLUSION CETPS appeared to be feasible to treat patients with small-calibre or sediment-like CBD stones.Patients,especially pregnant women and those who cannot stop anticoagulation/anti-platelet agents,could benefit from this technique.

Long-term outcomes of endoscopic papillary large-balloon dilation(12-15 mm)with or without limited sphincterotomy for removal of bile duct stones

Background:Limited endoscopic sphincterotomy with large balloon dilation(ES-LBD)and endoscopic papillary large-balloon dilation(EPLBD)have been proven safe and effective for removal of bile duct stones.However,the long-term outcomes are not clear.The aim of this study was to assess the long-term outcomes of EPLBD(12-15 mm)with or without limited sphincterotomy for removal of common bile duct(CBD)stones.Methods:Patients with EPLBD or ES-LBD referred for the removal of bile-duct stones between June 2008 and August 2020 were retrospectively reviewed.Complete stone clearance,endoscopic retrograde cholangiopancreatography(ERCP)-related adverse events,and late biliary complications during long-term follow-up were analyzed.Results:Basic patient characteristics were not significantly different between the groups that underwent EPLBD(n=168)and ES-LBD(n=57).EPLBD compared with ES-LBD resulted in similar outcomes in terms of overall successful stone removal(99.4%vs.100%,P=1.00)and ERCP-related adverse events(7.7%vs.5.3%,P=0.77).The mean duration of the follow-up were 113.6 months and 106.7 months for patients with EPLBD and ES-LBD,respectively(P=0.13).There was no significant difference between EPLBD and ES-LBD in the incidence of stone recurrence[20(11.9%)vs.9(15.8%);P=0.49].Multivariate analysis showed that a diameter of CBD≥15 mm(OR=3.001;95%CI:1.357-6.640;P=0.007)was an independent risk factor for stone recurrence.Conclusions:The application of a large balloon(12-15 mm)via EPLBD is an effective and safe alternative to ES-LBD for extraction of large CBD stones.Endoscopic sphincterotomy prior to EPLBD may be unnec-essary.A diameter of CBD≥15 mm is a risk factor of stone recurrence.

Restoration of common bile duct diameter within 2 weeks after endoscopic stone retraction is a preventive factor for stone recurrence

Background： Little information is available about the relationship between restoration of common bileduct （CBD） diameter after endoscopic stone retraction and recurrence of CBD stones in elderly patients.The present study was to determine whether restoration of CBD diameter is a preventive factor for CBDstone recurrence in elderly patients who underwent endoscopic retrograde cholangiopancreatography（ERCP）.

Outcome of a session of extracorporeal shock wave lithotripsy before endoscopic retrograde cholangiopancreatography for problematic and large common bile duct stones

AIM To compare the efficacy of a session of extracorporeal shock wave lithotripsy(ESWL) before endoscopic retrograde cholangiopancreatography(ERCP) vs ERCP only for problematic and large common bile duct(CBD) stones.METHODS Adult patients with CBD stones for whom initial ERCP was unsuccessful because of the large size of CBD stones were identified. The patients were randomized into two groups,an "ESWL + ERCP group" and an "ERCP-only" group. For ESWL + ERCP cases,ESWL was performed prior to ERCP. Clearance of the CBD,complications related to the ESWL/ERCP procedure,frequency of mechanical lithotripsy use and duration of the ERCP procedure were evaluated in both groups.RESULTS There was no significant difference in baseline characteristics between the two groups. A session of ESWL before ERCP compared with ERCP only resulted in similar outcomes in terms of successful stone removal within the first treatment session(74.2% vs 71.0%,P = 0.135),but a higher clearance rate within the second treatment session(84.4% vs 51.6%,P = 0.018) and total stone clearance(96.0% vs 86.0%,P = 0.029). Moreover,ESWL prior to ERCP not only reduced ERCP procedure time(43 ± 21 min vs 59 ± 28 min,P = 0.034) and the rate of mechanical lithotripsy use(20% vs 30%,P = 0.025),but also raised the clearance rate of extremely large stones(80.0% vs 40.0%,P = 0.016). Post-ERCP complications were similar for the two groups.CONCLUSION Based on the higher rate of successful stone removal and minimal complications,ESWL prior to ERCP appears to be a safe and effective treatment for the endoscopic removal of problematic and large CBD stones.

Spontaneous passage of common bile duct stones in jaundiced patients

BACKGROUND:Common bile duct(CBD)stones are known to pass spontaneously in a significant number of patients. This study investigated the rate of spontaneous CBD stones passage in a series of patients presenting with jaundice due to gallstones.The patients were managed surgically,allowing CBD intervention to be avoided in the event of spontaneous passage of CBD stones. METHOD:Retrospective analysis of patients presenting with jaundice due to CBD stones,and managed surgically with laparoscopic cholecystectomy and intra-operative cholangiogram with or without CBD exploration. RESULTS:The jaundice settled pre-operatively in 76/108 patients, and in 60/108 the CBD stones had passed spontaneously by the time of surgery.These 60 patients avoided any intervention to their CBD. CONCLUSIONS:CBD stones pass spontaneously in more than half of jaundiced patients.Surgical management(laparoscopic cholecystectomy and intra-operative cholangiogram,with willingness to perform CBD exploration if positive)allows the avoidance of CBD intervention in these patients.

Mechanical lithotripsy and/or stenting in management of difficult common bile duct stones

BACKGROUND:Mechanical lithotripsy and/or stent insertion is the alternative therapeutic approach in difficult endoscopic retrograde cholangiopancreatography (ERCP)case.This study was designed to investigate the appropriate treatment for extraction of bile duct stones in difficult cases of ERCP. METHODS:Between 2000 and 2008,744 ERCP procedures were performed in 592 patients with choledocholithiasis in our endoscopy unit.The demographic features,and clinical and laboratory findings were collected from a prospectively held database.Bile duct calculi were extracted by basket and/or balloon catheter following ERCP and sphincterotomy.Patients with retained stones were regarded as difficult cases.These patients were treated with mechanical lithotripsy and those with incomplete clearance of stones underwent stent placement. RESULTS:Two hundred and forty-five patients(41%) were male and 347(59%)were female with a mean age of 58 years(range 19-95 years).Stones were impacted in 27 patients(5%).Stone extraction was performed by basket and/or balloon catheter in 610 ERCP procedures,and lithotripsy was performed in 70 ERCP procedures.Forty- four patients underwent stent insertion,and 20 underwent stent replacement.Morbidity occurred in 39 patients (5%),with no mortality associated with the procedure.Hemorrhage occurred in 9 patients and basket impaction in 4.Mild pancreatitis and cholangitis developed in 12 and 11 patients,respectively. CONCLUSION:Difficult cases of bile duct stones can be treated successfully with lithotripsy,and a stent should be applied when the common bile duct cannot be cleared completely.

Intraoperative endoscopic sphincterotomy for common bile duct stones during laparoscopic cholecystectomy

INTRODUCTION The advent of laparoscopic cholecystectomy(LC)inthe late 1980s gained widespread acceptance withina short period of time and has become the preferredtreatment for symptomatic gallstones,but themanagement of coexisting gallbladder and commonbile duct(CBD)stones has remained controversialbecause the various strategies proposed have theirlimitations.In fact,choledocholithiasis

Outcome of simple use of mechanical lithotripsy of difficult common bile duct stones

AIM: The usual bile duct stone may be removed by means of Dormia basket or balloon catheter, and results are quite good. However, the degree of difficulty is increased when stones are larger. Studies on the subject reported many cases where mechanical lithotripsy is combined with a second technique, e.g. electrohydraulic lithotripsy (EHL),where stones are crushed using baby-mother scope electric shock. The extracorporeal shock-wave lithotripsy (ESWL)or laser lithotripsy also yields an excellent success rate of greater than 90%. However, the equipment for these techniques are very expensive; hence we opted for the simple mechanical lithotripsy and evaluated its performance.METHODS: During the period from August 1996 to Decemberz 2002, Mackay Memorial Hospital treated 304 patients suffering from difficult bile duct stones (stone ＞1.5 cm or stones that could not be removed by the ordinary Dormia basket or balloon catheter). These patients underwent endoscopic papillotomy (EPT) procedure, and stones were removed by means of the Olympus BML-4Q lithotripsy. A follow-up was conducted on the post-treatment conditions and complications of the patients.RESULTS: Out of the 304 patients, bile duct stones were successfully removed from 272 patients, a success rate of about 90%. The procedure failed in 32 patients, for whom surgery was needed. Out of the 272 successfully treated patients, 8 developed cholangitis, 21 developed pancreatitis,and 10 patients had delayed bleeding, and no patient died.Among these 272 successful removal cases, successful bile duct stone removal was achieved after the first lithotripsy in 211 patients, whereas 61 patients underwent multiple sessions of lithotripsy. As for the 61 patients that underwent multiple sessions of mechanical lithotripsy, 6 (9.8%) had post-procedure cholangitis, 12 (19.6%) had pancreatitis,and 9 patients (14.7%) had delayed bleeding. Compared with the 211 patients undergoing a single session of mechanical lithotripsy, 3 (1.4%) had cholangitis, 1 (0.4%)had delayed bleeding, and 7 patients (3.3%) had pancreatitis.Statistical deviation was present in post-procedure cholangitis,delayed bleeding, and pancreatitis of both groups.CONCLUSION: Mechanical bile stone lithotripsy on difficult bile duct stones could produce around 90% successful rate.Moreover, complications are minimal. This finding further confirms the significance of mechanical lithotripsy in the treatment of patients with difficult bile duct stones.

ESWL for difficult bile duct stones:A 15-year single centre experience

AIM:To evaluate the efficacy of extracorporeal shock wave lithotripsy(ESWL)for the management of refractory bile duct cholelithiasis in a third level referral centre.METHODS:The clinical records of all patients treated with a second generation electromagnetic lithotripter (Lithostar Plus,SIEMENS)from October 1990 to April 2005 were evaluated.All patients were monitored during the procedure and antibiotics were administered in case of cholangitis.Theχ 2 test and logistic regression analysis were performed as appropriate.RESULTS:Two hundred and fourteen patients(102 males,112 females;mean age 74.8±0.84 years-single stone 97,multiple stones 117)underwent ESWL.The mean number of sessions and shock waves were 3.5 ±0.13 and 3477.06±66.17,respectively.The maximum stone size was 5 cm.Complete stone clearance was achieved in 192(89.7%)patients.Of the remain-ing patients 15 required surgery,2 a palliative stent and in 5 patients stone fragmentation led to effective bile drainage with clinical resolution despite incomplete clearance.Age,sex and stone characteristics were not related to treatment outcome.Major complications occurred in two patients(haemobilia and rectal bleeding) and minor complications in 25(3 vomiting,22 arrhythmias).No procedure-related deaths occurred.CONCLUSION:ESWL is a safe and effective technique for clearance of refractory bile duct stones.

Possible relationship between cholecystectomy and subsequent occurrence of primary common bile duct stones:a retrospective review of data

BACKGROUND: Most reports on the prognosis of cholecystectomy have been short-term studied, and few long-term reports have suggested variable incidences of common bile duct stones after cholecystectomy. We retrospectively reviewed the data to find the possible association between cholecystectomy and the subsequent occurrence of primary common bile duct stones. METHODS: The data were reviewed retrospectively of 478 patients with primary common bile duct stones diagnosed and treated by endoscopic sphincterotomy at our hospitals between January 1994 and December 2003. RESULTS: Sixty-one (14.1%) of the 432 patients had a history of cholecystectomy, with an incidence rate markedly higher than that in the general population. The mean interval between cholecystectomy and the occurrence of primary common bile duct stones was 8.23 years, with the longest being 28 years and the shortest 2 years. Compared with the patients who had not undergone a prior cholecystectomy, those who had had a prior cholecystectomy more often accompanied with acute cholangiolitis (chi(2)=8.259, P<0.01), and multiple stones or sand-like stones were frequently found (chi(2)= 9.030, P<0.01). CONCLUSIONS: These results suggest a possible relationship between cholecystectomy and the subsequent occurrence of primary common bile duct stones. Perhaps patients with primary common bile duct stones who have had a prior cholecystectomy have a higher probability of infection of the biliary system. The infection may be one of the causes of occurrence of primary common bile duct stones after cholecystectomy.

Is ERCP really necessary in case of suspected spontaneous passage of bile duct stones?

AIM:To investigate the usefulness of magnetic resonance cholangiopancreatography (MRCP) and the need for endoscopic retrograde cholangiopancreatography (ERCP) in cases of suspected spontaneous passage of stones into the common bile duct.METHODS:Thirty-six patients with gallbladder stones were clinically suspected of spontaneous passage of stones into the common bile duct because they presented with clinical symptoms such as abdominal pain and fever,and showed signs of inflammatory reaction and marked rise of hepatobiliary enzymes.These symptoms resolved and they showed normalized values of blood biochemical parameters after conservative treatment without evidence of stones in the common bile duct on MRCP.All these patients were subjected to ERCP within 3 d of MRCP to check for the presence of stones.RESULTS:No stones were detected by ERCP in any patient,confi rming the results of MRCP.CONCLUSION:When clinical symptoms improve,blood biochemical parameters have normalized,and MRCP shows there are no stones in the common bile duct,it can be considered the stone has spontaneously passed and thus ERCP is not necessary.

Endoscopic management of difficult common bile duct stones:Where are we now?A comprehensive review

Endoscopic management for difficult common bile duct(CBD)stones still presents a challenge for several reasons,including anatomic anomalies,patients’individual conditions and stone features.In recent years,variable methods have emerged that have attributed to higher stone removal success rates,reduced cost and lower adverse events.In this review,we outline a stepwise approach in CBD stone management.As first line therapy,endoscopic sphincterotomy and large balloon dilation are recommended,due to a 30%-50%reduction of the use of mechanical lithotripsy.On the other hand,cholangioscopy-assisted lithotripsy has been increasingly reported as an effective and safe alternative technique to mechanical lithotripsy but remains to be reserved in special settings due to limited large-scale evidence.As discussed,findings suggest that management needs to be tailored to the patient’s characteristics and anatomical conditions.Furthermore,we evaluate the management of CBD stones in various surgical altered anatomy(Billroth II,Roux-en-Y and Roux-en-Y gastric bypass).Moreover,we could conclude that cholangioscopy-assisted lithotripsy needs to be evaluated for primary use,rather than following a failed management option.In addition,we discuss the importance of dissecting other techniques,such as the primary use of interventional endoscopic ultrasound for the management of CBD stones when other techniques have failed.In conclusion,we recognize that endoscopic sphincterotomy and large balloon dilation,mechanical lithotripsy and intraductal lithotripsy substantiate an indication to the management of difficult CBD stones,but emerging techniques are in rapid evolution with encouraging results.