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.

Cystic duct dilation through endoscopic retrograde cholangiopancreatography for treatment of gallstones and choledocholithiasis: Six case reports and review of literature

BACKGROUND Choledocholithiasis removal via endoscopic retrograde cholangiopancreatography(ERCP)then followed by laparoscopic cholecystectomy(LC)has gradually become the principal method in the treatment of gallstones and choledocholithiasis.We use ERCP through the cystic duct to treat gallstones combined with choledocholithiasis,with the aim to preserve the normal function of the gallbladder while simultaneously decreasing risk of biliary tract injury.CASE SUMMARY A total of six cases of patients diagnosed with gallstones and choledocholithiasis were treated with ERCP.The efficacy was evaluated via operation success rate,calculus removal rate,postoperative hospital stay and average hospitalization costs;the safety was evaluated through perioperative complication probability,gallbladder function detection and gallstones recrudesce.The calculus removal rate reached 100%,and patients had mild adverse events,including 1 case of postoperative acute cholecystitis and another of increased blood urinary amylase;both were relieved after corresponding treatment,the remaining cases had no complications.The average hospital stay and hospitalization costs were 6.16±1.47 d and 5194±696 dollars.The 3-11 mo follow-up revealed that gallbladder contracted well,without recurrence of gallstones.CONCLUSION This is the first batch of case reports for the treatment of gallstones and choledocholithiasis through ERCP approached by natural cavity.The results and effects of six reported cases proved that the new strategy is safe and feasible and is worthy of further exploration and application.

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.

Endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis: From guidelines to clinical practice

AIM: To study the practical applicability of the American Society for Gastrointestinal Endoscopy guidelines in suspected cases of choledocholithiasis.METHODS: This was a retrospective single center study, covering a 4-year period, from January 2010 to December 2013. All patients who underwent endoscopic retrograde cholangiopancreatography(ERCP) for suspected choledocholithiasis were included. Based on the presence or absence of predictors of choledocholithiasis(clinical ascending cholangitis, common bile duct(CBD) stones on ultrasonography(US), total bilirubin > 4 mg/d L, dilated CBD on US, total bilirubin 1.8-4 mg/d L, abnormal liver function test, age > 55 years and gallstone pancreatitis), patients were stratified in low, intermediate or high risk for choledocholithiasis. For each predictor and risk group we used the χ2 to evaluate the statistical associations with the presence of choledocolithiasis at ERCP. Statistical analysis was performed using SPSS version 21.0. A P value of less than 0.05 was considered statistically significant. RESULTS: A total of 268 ERCPs were performed for suspected choledocholithiasis. Except for gallstone pancreatitis(P = 0.063), all other predictors of cho-ledocholitiasis(clinical ascending cholangitis, P = 0.001; CBD stones on US, P ≤ 0.001; total bilirubin > 4 mg/dL, P = 0.035; total bilirubin 1.8-4 mg/dL, P = 0.001; dilated CBD on US, P ≤ 0.001; abnormal liver function test, P = 0.012; age > 55 years, P = 0.002) showed a statistically significant association with the presence of choledocholithiasis at ERCP. Approximately four fifths of patients in the high risk group(79.8%, 154/193 patients) had confirmed choledocholithiasis on ERCP, vs 34.2%(25/73 patients) and 0(0/2 patients) in the intermediate and low risk groups, respectively. The definition of "high risk group" had a sensitivity of 86%, positive predictive value 79.8% and specificity 56.2% for the presence of choledocholithiasis at ERCP. CONCLUSION: The guidelines should be considered to optimize patients' selection for ERCP. For high risk patients specificity is still low, meaning that some patients perform ERCP unnecessarily.

Radiation exposure during image-guided endoscopic procedures: The next quality indicator for endoscopic retrograde cholangiopancreatography

Endoscopic retrograde cholangiopancreatography(ERCP) is one of the most frequently used image-guided procedures in gastrointestinal endoscopy. Post-ERCP pancreatitis is an important concern, and prophylaxis, cannulation and other related technical procedures have been well documented by endoscopists. In addition, medical radiation exposure is of great concern in the general population because of its rapidly increasing frequency and its potential carcinogenic effects. International organizations and radiological societies have established diagnostic reference levels, which guide proper radiation use and serve as global standards for all procedures that use ionizing radiation. However, data on gastrointestinal fluoroscopic procedures are still lacking because the demand for these procedures has recently increased. In this review, we present the current status of quality indicators for ERCP and the methods for measuring radiation exposure in the clinical setting as the next quality indicator for ERCP. To reduce radiation exposure, knowledge of its adverse effects and the procedures for proper measurement and protection are essential. Additionally, further studies on the factors that affect radiation exposure, exposure management and diagnostic reference levels are necessary. Then, we can discuss how to manage medical radiation use inthese complex fluoroscopic procedures. This knowledge will help us to protect not only patients but also endoscopists and medical staff in the fluoroscopy unit.

Continued evidence for safety of endoscopic retrograde cholangiopancreatography during pregnancy

AIM: To report the safety of continued use of endoscopic retrograde cholangiopancreatography(ERCP) during pregnancy at various maternal ages.METHODS: A retrospective chart review of pregnant patients who underwent ERCP at a tertiary academic center was undertaken between 2002 and 2012. Pertinent past medical history and initial presenting laboratory data were collected. Review of the procedure note for each ERCP performed provided documentation of lead shielding, type of sedation, fluoroscopy time, and post-procedure complications. Patients' clinical courses were reviewed until the time of delivery and pregnancy complications with fetal outcomes were examined. Data was stratified based upon the mother's age at the time of ERCP: 18-21, 22-29, and ≥ 30 years of age.RESULTS: Twenty pregnant patients who underwent ERCP between 2002 and 2012 were identified. The mean age at the time of ERCP was 26.4 years(18-38 years) and the average trimester was the second. The indications for ERCP were choledocholithiasis in 17 patients, gallstone pancreatitis in 2 patients, and cholangitis in 1 patient. The mean fluoroscopy time of ERCP was 3.8 min(0.3-23.6 min). Sphincterotomy was performed in 18 patients with therapeutic intent and not as a prophylactic measure to prevent recurrences. Clinical documentation of use of protective shielding was found in only 8 notes(40%). Post procedure complications were limited to two cases of post-ERCP pancreatitis(10%). Elective cholecystectomy was performed shortly after ERCP in 11 of the pregnant patients. Birth records were available for 16 patients, of which 15 had fullterm pregnancies. Cesarean sections were performed in 5(31%) patients. Term birth weight was greater than 2500 g in all cases except one in which the mother had a known hypercoagulable state. CONCLUSION: ERCP during pregnancy is both safe and efficacious regardless of maternal age or trimester.

Diagnosis of myocardial infarction with nonobstructive coronary arteries in a young man in the setting of acute myocardial infarction after endoscopic retrograde cholangiopancreatography: A case report

BACKGROUND Acute myocardial infarction(AMI) is characterized by chest pain as well as cardiac troponin I(cTnI) and electrocardiography(ECG) changes. Recently,clinical researchers have used the term "MINOCA" to indicate myocardial infarction with nonobstructive coronary arteries. To the best of our knowledge,no report has documented MINOCA in a young patient after choledocholithiasis by endoscopic retrograde cholangiopancreatography(ERCP).CASE SUMMARY An 18-year-old Chinese man presented to the cardiac intensive care unit with chest pain radiating to the left shoulder for 1 h after choledocholithiasis by ERCP and the following treatment. ECG showed a sinus rhythm with ST-segment elevation in the Ⅱ,Ⅲ, and aVF leads compared with the baseline. Laboratory data revealed cTnI levels of 67.55 ng/mL and 80 ng/mL at the peak(relative index below 0.034 ng/mL) and creatine kinase-MB levels of 56 U/L and 543 U/L at the peak(relative index below 24 U/L). AMI was suspected, and coronary angiography was performed the second day. The results revealed a smooth angiographic appearance of all arteries. The patient had been diagnosed with gallstones and cholecystitis for four years but had not accepted treatment. He had abdominal pain and bloating a week previously and underwent ERCP and subsequent treatments on the second day of admission;1.4 cm × 1.6 cm of stones were removed from his common bile duct during surgery. The results of his laboratory tests at admission revealed abnormal alanine aminotransferase,aspartate aminotransferase, glutamyl transpeptidase, total bile acid, total bilirubin, direct bilirubin, and indirect bilirubin levels. His temperature, heart rate, blood pressure, and body mass index were normal. His echocardiographic examination revealed no obvious abnormalities in the structure and movement of the ventricular wall and an estimated left ventricular ejection fraction of 57% after the heart attack. His cholesterol and triglycerides were within normal ranges, and his low-density lipoprotein cholesterol was 2.23 mmol/L(normal range 2.03-3.34 mmol). Further testing after AMI revealed nothing remarkable in his erythrocyte sedimentation rate, thyroid function, and tumour markers.CONCLUSION We ultimately made a diagnosis of MINOCA caused by coronary artery spasm,which seemed to be the most suitable diagnosis of this young patient. We are concerned that the heart attack may have been induced by the ERCP rather than occurred coincidentally afterward, so we should investigate the timing of the event further. Additional studies are needed to unravel the underlying pathophysiology.

Endoscopic retrograde cholangiopancreatography during pregnancy without radiation

AIM： To present our experience with pregnant patients who underwent endoscopic retrograde cholangiopancreatography （ERCP） without using radiation, and to evaluate the acceptability of this alternative therapeutic pathway for ERCP during pregnancy. METHODS： Between 2000 and 2008, six pregnant women underwent seven ERCP procedures. ERCP was performed under mild sedoanalgesia induced with pethidine HCI and midazolam. The bile duct was cannulated with a guidewire through the papilla. A catheter was slid over the guidewire and bile aspiration and/or visualization of the bile oozing around the guidewire was used to confirm correct cannulation. Following sphincterotomy, the bile duct was cleared by balloon sweeping. When indicated, stents were placed. Confirmation of successful biliary cannulation and stone extraction was made by laboratory, radiological and clinical improvement. Neither fluoroscopy nor spot radiography was used during the procedure. RESULTS： The mean age of the patients was 28 years （range, 21-33 years）. The mean gestational age for the fetus was 23 wk （range, 14-34 wk）. Five patients underwent ERCP because of choledocholithiasis and/or choledocholithiasis-induced acute cholangitis. In one case, a stone was extracted after precut papillotomy with a needle-knife, since the stone was impacted. One patient had ERCP because of persistent biliary fistula after hepatic hydatid disease surgery. Following sphincterotomy, scoleces were removed from the common bile duct. Two weeks later, because of the absence of fistula closure, repeat ERCP was performed and a stent was placed. The fistula was closed after stent placement. Neither post-ERCP complications nor premature birth or abortion was seen. CONCLUSION： Non-radiation ERCP in experienced hands can be performed during pregnancy. Stent placement should be considered in cases for which complete common bile duct clearance is dubious because of a lack of visualization of the biliary tree.

Endoscopic retrograde cholangiopancreatography training in the United Kingdom: A critical review

Endoscopic retrograde cholangiopancreatography training used to be in virtually all district general hospitals, resulting in a large number of trainees with an inadequate case load and achieving poor levels of skill. Training is now restricted to a small number of trai nees working in approved units. Continuous audit of outcomes and the appointment of a training lead in the unit are essential. Use of the global rating scale helps clinicians advise hospital administration on the prior it ies for a quality training program.

Endoscopic retrograde cholangiopancreatography for diagnosing and treating pediatric biliary and pancreatic diseases

BACKGROUND This study evaluated the safety and effectiveness of endoscopic retrograde cholangiopancreatography(ERCP)in pediatric patients with biliary and pancreatic diseases.A retrospective analysis was conducted on 57 ERCP procedures performed in 41 children,primarily for treating pancreatic diseases.The overall success rate was 91.2%,with no major complications observed.Post-ERCP pancreatitis(PEP)occurred in 8.8%of cases.Follow-up examinations over one year showed no recurrence of biliary or pancreatic diseases.Notably,endoscopic treatment led to a significant increase in body mass index(BMI).These findings demonstrate the valuable role of ERCP in managing such conditions.AIM To evaluate the safety and efficacy of ERCP for the management of biliary and pancreatic diseases in pediatric patients.METHODS We conducted a retrospective analysis of data from children aged 1-18 years who underwent ERCP for biliary and pancreatic diseases at Beijing Children’s Hospital between January 2021 and December 2022.The collected data included procedure time,endoscopic treatment,success rate,and postoperative complications.RESULTS Forty-one children underwent 57 ERCP procedures,including 14 with biliary duct disease and 27 with pancreatic disease.The mean age of the patients was 7.48±3.48 years.Biliary duct-related treatments were performed 18 times,and pancreatic disease treatments were performed 39 times.ERCP was primarily used to treat pediatric pancreatic diseases[68.4%(39/57)of the procedures].The overall success rate was 91.2%(52/57 patients).PEP was noted in five patients(8.8%,5/57),and no instances of bleeding,perforation,or cholangitis were observed.The patients were followed up for over one year,and no recurrence of biliary or pancreatic diseases was detected.Importantly,BMI significantly increased after endoscopic treatment compared to that before treatment(P=0.001).CONCLUSION The high success rate and lack of major complications support the valuable role of ERCP in the management of pediatric biliary and pancreatic diseases in the pediatric population.

Comparison of endoscopic retrograde cholangiopancreatography performed without radiography and with ultrasound-guidance in the management of acute pancreaticobiliary disease in pregnant patients

Background Currently, the recommendation when treating acute biliary or pancreatic disease during pregnancy is to perform endoscopic retrograde cholangiopancreatography （ERCP） without radiation exposure, either empirically （with no radiographic guidance） or with ultrasound guidance. However, few published studies compared these two ways. This study aimed to compare ultrasound-guided ERCP with the procedure without radiographic guidance in the treatment of acute pancreaticobiliary disease in pregnant patients. Methods The clinical data of 68 pregnant patients with acute pancreaticobiliary disease admitted to our hospital between January 2004 and May 2010 were reviewed retrospectively. ERCP was performed without radiographic guidance in 36 cases （group A） and with ultrasound guidance in 32 cases （group B）. Data on the following variables were compared between the two groups： surgical success rate, rate of complete stone removal, time to resolution of clinical manifestations and laboratory indicators, length of hospital stay, complications, outcome and differences in efficacy of ERCP during different stages of pregnancy. Results In group A, the rates of surgical success and complete removal of stones were 69% and 60%, respectively; the corresponding values were 91% and 89% in group B （P 〈0.05）. Postoperatively, clinical manifestations improved rapidly in all patients; there was no statistically significant difference between the groups （P 〉0.05）. Leukocyte counts and liver function had improved significantly after one week in all patients; they recovered more quickly in group B （（8.64±1.83） days vs. （14.57±3.74） days, （14.29±4.64） days vs. （20.00±5.40） days, P 〈0.01）. The hospital stay was shorter in group B （（16.28±7.25） days vs. （28.00±6.83） days, P〈0.001）. The complication rate was 14% in group A and 3% in group B （P 〈0.05）. There were no significant differences between the two groups in the procedure＇s efficacy during different stages of pregnancy. Conclusions In the treatment of acute pancreaticobiliary disease during pregnancy, ultrasound-guided ERCP is safer and more effective than performing the procedure empirically without radiographic guidance when performed by experienced practitioners. Its more widespread use is recommended.

Comparative quality of life study between endoscopic sphincterotomy and surgical choledochotomy

AIM: To determine quality of life improvement in choledocholithiasis patients who underwent endoscopic sphincterotomy (EST) versus open choledochotomy (OCT).

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.

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.

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.

Effect of pancreatic endotherapy on quality of life in chronic pancreatitis patients:A systematic review

BACKGROUND Pancreatic endotherapy provides treatment options for the management of chronic pancreatitis-related structural complications such as pancreatic duct stones,strictures,and pancreatic fluid collections.Most studies detailing endotherapy,however,have focused on technical success outcomes such as stone clearance or stricture resolution.AIM To review the effect of pancreatic endotherapy on patient-centered outcomes.METHODS Systematic review of studies examining pancreatic endotherapy.RESULTS A total of 13 studies including 3 randomized clinical trials were included.The majority of studies found an improvement in quality of life with pancreatic endotherapy.CONCLUSION While pancreatic endotherapy does appear to improve quality of life,there are clear gaps in knowledge regarding many pancreatic endotherapy modalities.Furthermore,qualitative analysis is lacking in these studies and further work is needed to elucidate the patient experience with pancreatic endotherapy.

Evaluating the accuracy of American Society for Gastrointestinal Endoscopy guidelines in patients with acute gallstone pancreatitis with choledocholithiasis

BACKGROUND Acute gallstone pancreatitis(AGP) is the most common cause of acute pancreatitis(AP) in the United States. Patients with AGP may also present with choledocholithiasis. In 2010, the American Society for Gastrointestinal Endoscopy(ASGE) suggested a management algorithm based on probability for choledocholithiasis, recommending additional imaging for patients at intermediate risk and endoscopic retrograde cholangiopancreatography(ERCP) for patients at high risk of choledocholithiasis. In 2019, the ASGE guidelines were updated using more specific criteria to categorize individuals at high risk for choledocholithiasis. Neither ASGE guideline has been studied in AGP to determine the probability of having choledocholithiasis.AIM To determine compliance with ASGE guidelines, assess outcomes, and compare 2019 vs 2010 ASGE criteria for suspected choledocholithiasis in AGP.METHODS We conducted a retrospective cohort study of 882 patients admitted with AP to a single tertiary care center from 2008-2018. AP was diagnosed using revised Atlanta criteria and AGP was defined as the presence of gallstones on imaging or with cholestatic pattern of liver injury in the absence of another cause. Patients with chronic pancreatitis and pancreatic malignancy were excluded as were those who went directly to cholecystectomy prior to assessment for choledocholithiasis. Patients were assigned low, intermediate or high risk based on ASGE guidelines. Our primary outcomes of interest were the proportion of patients in the intermediate risk group undergoing magnetic resonance cholangiopancreatography(MRCP) first and the proportion of patients in the high risk group undergoing ERCP directly without preceding imaging. Secondary outcomes of interest included outcome differences based on if guidelines were not adhered to. We then evaluated the diagnostic accuracy of 2019 in comparison to the 2010 ASGE criteria for patients with suspected choledocholithiasis. We performed the t test or Wilcoxon rank sum test, as appropriate, to analyze if there were outcome differences based on if guidelines were not adhered to. Kappa coefficients were calculated to measure the degree of agreement between pairs of variables.RESULTS In this cohort, we identified 235 patients with AGP of which 79 patients were excluded as they went directly to surgery for cholecystectomy without prior MRCP or ERCP. Of the remaining 156 patients, 79 patients were categorized as intermediate risk and 77 patients were high risk for choledocholithiasis according to the 2010 ASGE guidelines. Among 79 intermediate risk patients, 54(68%) underwent MRCP first whereas 25 patients(32%) went directly to ERCP. For the 54 patients with intermediate risk who had MRCP first, 36 patients had no choledocholithiasis while 18 patients had evidence of choledocholithiasis prompting ERCP. Of these patients, ERCP confirmed stone disease in 11 patients. Of the 25 intermediate risk patients who directly underwent ERCP, 18 patients had stone disease. One patient with a normal ERCP developed post ERCP pancreatitis. Patients undergoing MRCP in this group had a significantly longer length of stay(5.0 vs 4.0 d, P = 0.02). In the high risk group, 64 patients(83%) had ERCP without preceding imaging, of which, 53 patients had findings consistent with choledocholithiasis, of which 13 patients(17%) underwent MRCP before ERCP, all of which showed evidence of stone disease. Furthermore, all of these patients ultimately had an ERCP, of which 8 patients had evidence of stones and 5 had normal examination.RESULTS Our cohort also demonstrated that 58% of all 156 patients with AGP had confirmed choledocholithiasis(79% of the high risk group and 37% of the intermediate group when risk was assigned based on the 2010 ASGE guidelines). When the updated 2019 ASGE guidelines were applied instead of the original 2010 guidelines, there was moderate agreement between the 2010 and 2019 guidelines(kappa = 0.46, 95%CI: 0.34-0.58). Forty-two of 77 patients were still deemed to be high risk and 35 patients were downgraded to intermediate risk. Thirty-five patients who were originally assigned high risk were reclassified as intermediate risk. For these 35 patients, 26 patients had ERCP findings consistent with choledocholithiasis and 9 patients had a normal examination. Based on the 2019 criteria, 9/35 patients who were downgraded to intermediate risk had an unnecessary ERCP with normal findings(without a preceding MRCP).CONCLUSION Two-thirds in intermediate risk and 83% in high risk group followed ASGE guidelines for choledocholithiasis. One intermediate-group patient with normal ERCP had post-ERCP AP, highlighting the risk of unnecessary procedures.

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.

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.