Clinical efficacy of laparoscopic cholecystectomy combined with endoscopic papillary balloon dilation in treatment of gallbladder stones with common bile duct stones: A retrospective study

BACKGROUND The incidence of cholelithiasis has been on the rise in recent years,but the choice of procedure is controversial.AIM To investigate the efficacy of laparoscopic cholecystectomy(LC)combined with endoscopic papillary balloon dilation(EPBD)in patients with gallbladder stones(GS)with common bile duct stones(CBDS).METHODS The clinical data of 102 patients with GS combined with CBDS were selected for retrospective analysis and divided into either an LC+EPBD group(n=50)or an LC+endoscopic sphincterotomy(EST)group(n=52)according to surgical methods.Surgery-related indexes,postoperative recovery,postoperative complications,and expression levels of inflammatory response indexes were compared between the two groups.RESULTS Total surgical time,stone free rate,rate of conversion to laparotomy,and successful stone extraction rate did not differ significantly between the LC+EPBD group and LC+EST group.Intraoperative hemorrhage,time to ambulation,and length of hospitalization in the LC+EPBD group were lower than those of the LC+EST group(P<0.05).The rate of total complications of the two groups was 9.80%and 17.65%,respectively,and the difference was not statistically significant.No serious complications occurred in either group.At 48 h postoperatively,the expression levels of interleukin-6,tumor necrosis factor-α,high-sensitivity Creactive protein,and procalcitonin were lower in the LC+EPBD group than in the LC+EST group(P<0.05).At 3 d postoperatively,the expression levels of aspartate transaminase,alanine transaminase,and total bilirubin were lower in the LC+EPBD group than in the LC+EST group(P<0.05).CONCLUSION LC combined with EPBD and LC combined with EST are both effective procedures for the treatment of GS with CBDS,in which LC combined with EPBD is beneficial to shorten the patient’s hospitalization time,reduce the magnitude of elevated inflammatory response indexes,and promote postoperative recovery.

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.

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.

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.

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.

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.

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.

Ursodeoxycholic acid combined with percutaneous transhepatic balloon dilation for management of gallstones after elimination of common bile duct stones

AIM To evaluate the effectiveness and safety of combined ursodeoxycholic acid and percutaneous transhepatic balloon dilation for management of gallstones after expulsion of common bile duct(CBD) stones.METHODS From April 2014 to May 2016, 15 consecutive patients(6 men and 9 women) aged 45-86(mean, 69.07 ± 9.91) years suffering from CBD stones associated with gallstones were evaluated. Good gallbladder contraction function was confirmed by type B ultrasonography. Dilation of the CBD and cystic duct was detected. Percutaneous transhepatic balloon dilation of the papilla was performed, ursodeoxycholic acid was administered, and all patients had a high-fat diet. All subjects underwent repeated cholangiography, and percutaneous transhepatic removal was carried out in patients with secondary CBD stones originating from the gallbladder. RESULTS All patients underwent percutaneous transhepatic balloon dilation with a primary success rate of 100%. The combined therapy was successful in 86.7% of patients with concomitant CBD stones and gallstones. No remaining stones were detected in the gallbladder. Transient adverse events include abdominal pain(n = 1), abdominal distension(n = 1), and fever(n = 1). Complications were treated successfully via nonsurgical management without long-term complications. No procedure-related mortality occurred. CONCLUSION For patients with concomitant CBD stones and gallstones, after percutaneous transhepatic removal of primary CBD stones, oral ursodeoxycholic acid and a high-fat diet followed by percutaneous transhepatic removal of secondary CBD stones appear to be a feasible and effective option for management of gallstones.

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.

Ampulla dilation with different sized balloons to remove common bile duct stones

AIM:To assess the outcomes of ampulla dilation with different sized balloons to remove common bile duct (CBD) stones.METHODS:Patients (n=208) were divided into five groups based on the largest CBD stone size of < 5,6-8,8-12,12-14,and > 14 mm.Patients underwent limited endoscopic sphincterotomy (EST) alone or limited EST followed by endoscopic papillary balloon dilation with 8,10,12 and 14 mm balloons,such that the size of each balloon did not exceed the size of the CBD.Short-and long-term outcomes,such as post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis,perforation,bleeding,and pneumobilia were compared among the five groups.RESULTS:The overall rate of successful stone removal in all groups was 100%,and all patients were cured.Eight (3.85%) patients had post-ERCP pancreatitis,none had perforations,and 6 (2.9%) had bleeding re-quiring transfusion.There were no significant differences in early complication rates among the five groups.We observed significant correlations between increased balloon size and the short-and long-term rates of postERCP pneumobilia.Post-ERCP pancreatitis and bleeding correlated significantly with age,with post-ERCP pancreatitis occurring more frequently in patients aged < 60 years,and bleeding occurring more frequently in patients aged > 70 years.We observed a significant correlation between patient age and the diameter of the largest CBD stone,with stones > 12 mm occurring more frequently in patients > 60 years old.CONCLUSION:Choosing a balloon size based on the largest stone diameter is safe and effective for removing CBD stones.Balloon size should not exceed 15 mm.

Risk factors for the development of post-endoscopic retrograde cholangiopancreatography pancreatitis in patients with asymptomatic common bile duct stones

BACKGROUND Previous studies have revealed that patients with asymptomatic common bile duct(CBD)stones are at a high risk of developing post-endoscopic retrograde cholangiopancreatography(ERCP)pancreatitis(PEP).However,no studies to date have addressed the risk factors for PEP in patients with asymptomatic CBD stones.AIM To examine the risk factors for PEP in patients with asymptomatic CBD stones.METHODS Using medical records of three institutions in Japan for 6 years,we identified a total of 1135 patients with choledocholithiasis including 967 symptomatic patients and 168 asymptomatic patients with native papilla who underwent therapeutic ERCP.We performed univariate and multivariate analyses to examine the risk factors for PEP in the 168 patients with asymptomatic CBD stones.RESULTS The overall incidence rate of PEP in all the patients with during study period was 4.7%(53/1135).Of the 168 patients with asymptomatic CBD stones,24(14.3%)developed PEP.In univariate analysis,precut sphincterotomy(P=0.009)and biliary balloon sphincter dilation(P=0.043)were significant risk factors for PEP.In multivariate analysis,precut sphincterotomy(P=0.002,95%CI:2.2-27.8,odds ratio=7.7),biliary balloon sphincter dilation(P=0.015,95%CI:1.4-17.3,odds ratio=4.9),and trainee endoscopists(P=0.048,95%CI:1.01-8.1,odds ratio=2.9)were significant risk factors for PEP.CONCLUSION ERCP for asymptomatic CBD stones should be performed by experienced endoscopists.When performing precut sphincterotomy or biliary balloon sphincter dilation in patients with asymptomatic CBD stones,the placement of a prophylactic pancreatic stent is strongly recommended to prevent PEP.

Poorly expandable common bile duct with stones on endoscopic retrograde cholangiography

AIM： To describe characteristics of a poorly expandable （PE） common bile duct （CBD） with stones on en- doscopic retrograde cholangiography.METHODS： APE bile duct was characterized by a rigid and relatively narrowed distal CBD with retro- grade dilatation of the non-PE segment. Between 2003 and 2006, endoscopic retrograde cholangiography （ERC） images and chart reviews of 1213 patients with newly diagnosed CBD stones were obtained from the computer database of Therapeutic Endoscopic Centerin Chang Gung Memoria acteristic PE bile duct on Hospital. Patients with char ERC were identified from the database. Data of the patients as well as the safety and technical success of therapeutic ERC were collected and analyzed retrospectively.RESULTS： A total of 30 patients with CBD stones and characteristic PE segments were enrolled in this study. The median patient age was 45 years （range, 20 to 92 years）; 66.7% of the patients were men. The di ameters of the widest non-PE CBD segment, the PE segment, and the largest stone were 14.3 ± 4.9 mm, 5.8±1.6 mm, and 11.2±4.7 mm, respectively. The length of the PE segment was 39.7±15.4 mm （range, 12.3 mm to 70.9 mm）. To remove the CBD stone（s） completely, mechanical lithotripsy was required in 25 （83.3%） patients even though the stone size was not as large as were the difficult stones that have been described in the literature. The stone size and stone/ PE segment diameter ratio were associated with the need for lithotripsy. Post-ERC complications occurred in 4 cases： pancreatitis in 1, cholangitis in 2, and an im- pacted Dormia basket with cholangitis in 1. Two （6.7%） of the 28 patients developed recurrent CBD stones at follow-up （50±14 mo） and were successfully managed with therapeutic ERC.CONCLUSION： Patients with a PE duct frequently require mechanical lithotripsy for stones extraction, To retrieve stones successfully and avoid complications, these patients should be identified during ERC,

Common bile duct morphology is associated with recurrence of common bile duct stones in Billroth II anatomy patients

BACKGROUND Endoscopic retrograde cholangiopancreatography(ERCP)is the primary choice for removing common bile duct(CBD)stones in Billroth II anatomy patients.The recurrence of CBD stones is still a challenging problem.AIM To evaluate CBD morphology and other predictors affecting CBD stone recurrence.METHODS A retrospective case-control analysis was performed on 138 CBD stones patients with a history of Billroth II gastrectomy,who underwent therapeutic ERCP for stone extraction at our center from January 2011 to October 2020.CBD morphology and other predictors affecting CBD stone recurrence were examined by univariate analysis and multivariate logistic regression analysis.RESULTS CBD morphology(P<0.01)and CBD diameter≥1.5 cm(odds ratio[OR]=6.15,95%confidence interval[CI]:1.87-20.24,P<0.01)were the two independent risk factors.In multivariate analysis,the recurrence rate of patients with S type was 16.79 times that of patients with straight type(OR=16.79,95%CI:4.26-66.09,P<0.01),the recurrence rate of patients with polyline type was 4.97 times that of patients with straight type(OR=4.97,95%CI:1.42-17.38,P=0.01),and the recurrence rate of S type patients was 3.38 times that of patients with polyline type(OR=3.38,95%CI:1.07-10.72,P=0.04).CONCLUSION CBD morphology,especially S type and polyline type,is associated with increased recurrence of CBD stones in Billroth II anatomy patients.

Role of endoscopic ultrasound in evaluation of patients with missed common bile duct stones

BACKGROUND Choledocholithiasis develops in up to 20%of patients with gall bladder stones.The challenge in diagnosis usually occurs with small stones that may be missed by magnetic resonance cholangiopancreatography(MRCP).Endoscopic ultrasound(EUS)is accurate in detecting common bile duct(CBD)stones missed by MRCP,especially the small ones or those impacted at the distal CBD or the papillary region.AIM To evaluate the accuracy of EUS in detecting CBD stones missed by MRCP.METHODS Patients with an intermediate likelihood of choledocholithiasis according to ESGE guidelines and those with acute pancreatitis of undetermined cause were included.The presence of choledocholithiasis was evaluated by MRCP and EUS,and then results were confirmed by endoscopic retrograde cholangiopancreatography(ERCP).The sensitivity and specificity of EUS and MRCP were compared regarding the presence of stones,the size,and the number of detected stones.RESULTS Ninety out of 100 involved patients had choledocholithiasis,while ten patients were excluded as they had pancreatic or gall bladder masses during EUS examination.In choledocholithiasis patients,the mean age was 52.37±14.64 years,and 52.2%were males.Most patients had biliary obstruction(74.4%),while only 23(25.6%)patients had unexplained pancreatitis.The overall prevalence of choledocholithiasis was 83.3%by EUS,41.1%by MRCP,and 74.4%by ERCP.Also,the number and size of CBD stones could be detected accurately in 78.2%and 75.6%by EUS and 41.1%and 70.3%by MRCP,respectively.The sensitivity of EUS was higher than that of MRCP(98.51%vs 55.22%),and their predictive value was statistically different(P<0.001).Combination of both tools raised the sensitivity to 97.22%and specificity to 100%.CONCLUSION EUS could be a useful tool in assessing patients with suspected choledocholithiasis especially if combined with MRCP.However,its usefulness depends on its availability and the experience of the local centers.

Observation effect of clinical ursodeoxycholic acid combined with holmium laser by laparoscopic choledochoscopy in the treatment of intrahepatic and intrahepatic bile duct stones

Objective: To investigate the effect of clinical ursodeoxycholic acid combined with holmium laser by laparoscopic choledochoscopy in the treatment of intrahepatic and intrahepatic bile duct stones. Methods: Patients with intrahepatic and intrahepatic bile duct stones treated by surgery in our hospital from October 2017 to December 2018 were randomly divided into control group and observation group.Patients in the control group were treated with laparoscopic choledochoscopy combined with holmium laser lithotripsy, and patients of the observation group were treated with ursodeoxycholic acid on the basis of the control group. The clinical efficacy, total bile acid (TBA), phospholipid (PLIP), cholesterol (CHO) levels and the incidence of complications of liver function and bile related indicators were compared between the two groups after 3 and 6 months treatment. Results: After 3 months treatment, there were 22 cases of cured patients, 11 cases of markedly effective and 5 cases of effective patients in the observation group of, which he clinical curative effect was significantly better than that of control group (P<0.05). After 3 months and 6 months treatment, AST, ALT, TBil, CHO levels in two groups were decreased compared with that before treatment, and TBA, PLIP levels were increased. The liver function of patientsin the observation group was obviously better than that in the control group with the statistical significance difference (P<0.05). However, the symptoms such as the right upper quadrant pain, jaundice, chills, fever in the observation group was significantly improvedthan that of the control group. The incidence of complications including nausea and vomiting, fatiguewas 4.76%, significantly lower than that 19.05% in the control group (P<0.05). After 1 year follow-up, it was found that recurrence reoperation rate of observation group was significantly lower than that the control group. The difference was statistically significant (P<0.05). Conclusion: Theclinical curative effect of the ursodeoxycholic acid combined with holmium laser by laparoscopic choledochoscopy was distinct, whichcould effectively improve the undesirable complications, reduce the postoperative recurrence and reoperation rate. The main reason may be the combination therapy could improve the patients' associates, PLIP level, lower levels of AST, ALT, TB il and CHO, which helped to improve liver function, reduce the cholestasis, prevent the recurrence of liver and gallbladder stones, and promote good prognosis.

Feasibility of endoscopic papillary large balloon dilation to remove difficult stones in patients with nondilated distal bile ducts

BACKGROUND Current guidelines recommend not performing papillary large balloon dilation in patients with nondilated distal bile ducts.AIM To assess the feasibility of balloon dilation to remove difficult stones in patients with nondilated distal bile ducts.METHODS Data from 1289 endoscopic retrograde cholangiopancreatography(ERCP)procedures were obtained from two prospective studies.While 258 cases had difficult stones(>1 cm,multiple>8,impacted,or having a thin distal duct),191 underwent biliary dilation up to 15 mm after endoscopic sphincterotomy.Cholangiographies of these cases were retrospectively reviewed in order to classify the distal bile duct and both the stone size and number.Primary outcomes were clearance rate at first ERCP and complications.RESULTS Of the 191 patients(122 women and 69 men;mean age:60 years)who underwent biliary dilation for difficult stones,113(59%)had a nondilated or tapered distal duct.Patients with a dilated distal duct were older than those with nondilated distal ducts(mean 68 and 52 years of age,respectively;P<0.05),had more stones(median 4 and 2 stones per patient,respectively;P<0.05),and had less need for additional mechanical lithotripsy(6.4%vs 25%,respectively;P<0.05).Clearance rate at first ERCP was comparable between patients with a dilated(73/78;94%)and nondilated distal ducts(103/113;91%).Procedures were faster in patients with a dilated distal duct(mean 17 vs 24 min,respectively;P<0.005).Complications were similar in both groups(6.4%vs 7.1%,respectively).CONCLUSION Large balloon dilation for difficult stones is feasible in patients with a nondilated or even tapered distal duct.

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.

Endoscopic papillary large balloon dilation alone or combined with small or complete sphincterotomy for the removal of large common bile duct stones

Background:Endoscopic papillary large balloon dilation(EPLBD)has been proposed as an alternative to manage large bile duct stones.However,EPLBD alone or combined with sphincterotomy remains controversial.Methods:Between Jan.2014 and Dec.2017,195 consecutive patients with proven large common bile duct stones(size≥10 mm)were retrospectively analyzed.We compared the baseline characteristics,procedure time,success rate of stone removal and morbidity outcomes in different groups.Results:There were no significant difference between baseline characteristics of the groups compared.A total of 89.2%,95.4%,and 93.8% of the patients in the EPLBD,EPLBD+small sphincterotomy(SES),and EPLBD+complete sphincterotomy(CES)groups had stones cleared(P=0.473),respectively.There was no difference in terms of procedure time(33.5±10.2,34.8±9.0,34.9±8.2,in the EPLBD,EPLBD+SES,and EPLBD+CES groups,respectively).However,when assigned to tvvo groups according to bile duct stones diameter(bile duct stones<13 mm,bile duct stones≥13 mm).in the bile duct stones<13 mm group,the procedure time was significantly less in the EPLBD group than the EPLBD+SES group and the EPLBD+CES group(P=0.028).In the bile duct stones≥13 mm group,the mechanical lithotripsy rate of EPLBD was significantly higher compared to EPLBD+SES or EPLBD+CES(P=0.032).The complication rates were similar among all groups.Conclusions:The diameter of bile duct stones should be taken into consideration when choosing EPLBD alone or combined with small sphincterotomy for the removal of common bile duct stones.