Correlation between miR-210 and serum levels of GGT, ALP and AST in patients with choledocholithiasis.

The purpose of this study was to explore the association between miR-210 and serum GGT, ALP and AST levels in patients with choledocholithiasis. The clinical data of 82 patients with biliary stones admitted to the hospital from May 2020 to May 2022 were collected and divided into observation group (n=40) and control group (n=42) according to whether asymptomatic combined. The relative expression level of miR-210 was measured by RT-PCR, serum GGT, ALP, and AST by rate method, and the correlation of miR-210 expression level with serum GGT, ALP, AST and the diagnostic value for choledochal stones was analyzed. The relative expression of serum GGT, ALP, AST and miR-210 were all higher than the control group (P <0.05); the relative expression level of miR-210 and serum GGT, ALP and AST, 0.756, 0.832, 0.326, r = P <0.05), 0.782, 0.776, 0.681, 0.568, respectively. Serum miR-210 level was upregulated in patients with choledocholithiasis, and its expression was positively correlated with serum GGT, ALP, and AST, which can be used for early auxiliary diagnosis of choledocholithiasis.

[Diagnostic performance of biliopancreatic endosonography in patients with intermediate risk of choledocholithiasis]. / Rendimiento diagnóstico de la endosonografía biliopancreática en pacientes con riesgo intermedio de coledocolitiasis.

OBJECTIVE: Determine the sensitivity and specificity of the ESBP for diagnosis in patients with intermediate risk of choledocholithiasis, referred to the specialized surgical Gastroenterology center of Unión de Cirujanos SAS - Oncologists of the West Zentria group - Manizales - Colombia between March 01, 2020 to January 31, 2022. MATERIALS AND METHODS: Retrospective cross-sectional study in patients with intermediate risk for choledocholithiasis. The diagnostic performance of ESBP was calculated and confirmed with ERCP. Negative ESBPs were followed up by telephone. RESULTS: 752 cases with ESBP were analyzed, of which 43.2% (n=325) were positive and 56.8% (n=427) were negative. ERCP was performed in positive cases who accepted the procedure (n=317); 73.5% (n:233) were positive for choledocholithiasis, 25.8% (n=82) tumors and 0.6% (n=2) biliary roundworms. Patients with positive ESBP underwent ERCP. S= 98.3% (95% CI: 95.7-99.5) was obtained; E= 88.1% (95% CI: 79.2-94.1); PPV = 95.8% (95% CI: 92.4-98.0); NPV = 94.9% (95% CI: 87.4-98.7). The AUC of ESBP was 0.9319 (95% CI 0.8961-0.967). CONCLUSION: In patients with intermediate risk for choledocholithiasis, ESBP is a useful diagnostic option in the study of pancreatic pathologies, extrahepatic biliary tree, and the identification of biliary microlithiasis; Therefore, it also allows us to complement it with a therapeutic intervention such as ERCP in a single time.

Urgent one-stage endoscopic treatment for choledocholithiasis related moderate to severe acute cholangitis: A propensity score-matched analysis.

BACKGROUND: During emergency endoscopic retrograde cholangiopancreatography (ERCP), the safety and feasibility of performing one-stage endoscopic treatment for patients with acute cholangitis (AC) due to choledocholithiasis are unclear. AIM: To investigate the safety and feasibility of one-stage endoscopic treatment for moderate to severe AC. METHODS: We enrolled all patients diagnosed with moderate to severe cholangitis due to common bile duct stones from January 2019 to July 2023. The outcomes were compared in this study between patients who underwent ERCP within 24 h and those who underwent ERCP 24 h later, employing a propensity score (PS) framework. Our primary outcomes were intensive care unit (ICU) admission rates, ICU length of stay, and duration of antibiotic use. RESULTS: In total, we included 254 patients and categorized them into two groups based on the time elapsed between admission and intervention: The urgent group (≤ 24 h, n = 102) and the elective group (> 24 h, n = 152). Ninety-three pairs of patients with similar characteristics were selected by PS matching. The urgent ERCP group had more ICU admissions (34.4% vs 21.5%, P = 0.05), shorter ICU stays (3 d vs 9 d, P < 0.001), fewer antibiotic use (6 d vs 9 d, P < 0.001), and shorter hospital stays (9 d vs 18.5 d, P < 0.001). There were no significant differences observed in adverse events, in-hospital mortality, recurrent cholangitis occurrence, 30-d readmission rate or 30-d mortality. CONCLUSION: Urgent one-stage ERCP provides the advantages of a shorter ICU stay, a shorter duration of antibiotic use, and a shorter hospital stay.

Symptomatic gallstone disease: Recurrence patterns and risk factors for relapse after first admission, the RELAPSTONE study.

BACKGROUND: Delayed cholecystectomy in patients with symptomatic gallstone disease is associated with recurrence. Limited data on the recurrence patterns and the factors that determine them are available. OBJECTIVE: We aimed to determine the pattern of relapse in each symptomatic gallstone disease (acute pancreatitis, cholecystitis, cholangitis, symptomatic choledocholithiasis, and biliary colic) and determine the associated factors. METHODS: RELAPSTONE was an international multicenter retrospective cohort study. Patients (n = 3016) from 18 tertiary centers who suffered a first episode of symptomatic gallstone disease from 2018 to 2020 and had not undergone cholecystectomy during admission were included. The main outcome was relapse-free survival. Kaplan-Meier curves were used in the bivariate analysis. Multivariable Cox regression models were used to identify prognostic factors associated with relapses. RESULTS: Mean age was 76.6 [IQR: 59.7-84.1], and 51% were male. The median follow-up was 5.3 months [IQR 2.1-12.4]. Relapse-free survival was 0.79 (95% CI: 0.77-0.80) at 3 months, 0.71 (95% CI: 0.69-0.73) at 6 months, and 0.63 (95% CI: 0.61-0.65) at 12 months. In multivariable analysis, older age (HR = 0.57; 95% CI: 0.49-0.66), sphincterotomy (HR = 0.58, 95% CI: 0.49-0.68) and higher leukocyte count (HR = 0.79; 95% CI: 0.70-0.90) were independently associated with lower risk of relapse, whereas higher levels of alanine aminotransferase (HR = 1.22; 95% CI: 1.02-1.46) and multiple cholelithiasis (HR = 1.19, 95% CI: 1.05-1.34) were associated with higher relapse rates. CONCLUSION: The relapse rate is high and different in each symptomatic gallstone disease. Our independent predictors could be useful for prioritizing patients on the waiting list for cholecystectomies.

Feasibility and safety of intraoperative bile duct clearance by antegrade transcystic balloon sphincteroplasty: A prospective observational pilot study.

BACKGROUND: Concomitant cholecystolithiasis and choledocholithiasis are common. Standard treatments are endoscopic retrograde cholangiography (ERC) followed by cholecystectomy or laparoendoscopic rendezvous. Endoscopic retrograde cholangiography has drawbacks, such as post-ERC pancreatitis or bleeding, and potentially more than one intervention is required to address common bile duct (CBD) stones. Safety and feasibility of an intraoperative antegrade transcystic single-stage approach during cholecystectomy with balloon sphincteroplasty and pushing of stones to the duodenum has not been evaluated prospectively. The aim of this pilot study was to evaluate this procedure regarding safety, feasibility, and stone clearance rate. METHODS: Prospective single-center intervention study (SUPER Reporting-Guideline). Main inclusion criterion was confirmed choledocholithiasis (stones ≤6 mm) at intraoperative cholangiography. Success of the procedure was defined as CBD stone clearance at intraoperative control cholangiography, absence of symptoms and no elevated cholestasis parameters at 6 weeks follow-up. Simon's two-stage design was used to determine sample size. RESULTS: From January 2021 to April 2022, a total of 57 patients fulfilled the final inclusion criteria and were included. Mild pancreatitis or cholangitis were present upon admission in 15 (26%) and 15 (26%) patients, respectively. Median number of CBD-stones was 1 (1-6). Median stone diameter was 4 mm (0.1-6 mm). Common bile duct stone clearance was achieved in 54 patients (94%). The main reason for failed CBD clearance was the inability to push the guidewire along the biliary stone into the duodenum. Median intervention time was 28 minutes (14-129 minutes). While there was no postoperative pancreatitis, two patients (3.5%) had asymptomatic hyperlipasemia 4 hours postoperatively. CONCLUSION: Intraoperative CBD stone clearance by antegrade balloon sphincteroplasty appears to be safe and highly feasible. Its overall superiority to the current standards warrants evaluation by a randomized controlled trial. LEVEL OF EVIDENCE: Therapeutic/Care Management, Level V.

Performance of European and American Societies of Gastrointestinal Endoscopy Guidelines for Prediction of Choledocholithiasis in Patients with Acute Biliary Pancreatitis.

Background and Objectives: Up to one-third of patients with acute biliary pancreatitis also present with choledocholithiasis. Guidelines from the European Society of Gastrointestinal Endoscopy (ESGE) and the American Society for Gastrointestinal Endoscopy (ASGE) for investigating suspected choledocholithiasis suggest endoscopic retrograde cholangiopancreatography in patients with high-likelihood (ESGE)/high-probability (ASGE) predictors and endoscopic ultrasound in those with intermediate-likelihood (ESGE)/intermediate-probability (ASGE) predictors. Although both guidelines are similar, they are not identical. Furthermore, these algorithms were mainly developed from cohorts of patients without pancreatitis and are therefore poorly validated in a subset of patients with acute pancreatitis. We aimed to assess the performance of the ESGE and ASGE algorithms for the prediction of choledocholithiasis in patients with acute biliary pancreatitis. Materials and Methods: This was a retrospective analysis of 86 consecutive patients admitted to a tertiary referral centre in the year 2020 due to acute biliary pancreatitis. Results: Choledocholithiasis was confirmed in 29/86 (33.7%) of patients (13 with endoscopic retrograde cholangiopancreatography and 16 with endoscopic ultrasound). All 10/10 (100%) ESGE high-likelihood and 14/19 (73.7%) ASGE high-probability patients had choledocholithiasis. Only 19/71 (26.8%) patients with ESGE intermediate likelihood and 15/67 (22.4%) with ASGE intermediate probability had choledocholithiasis. Only 8/13 (61.5%) patients with the ASGE high-probability predictor of dilated common bile duct plus bilirubin > 68.4 µmol/mL had choledocholithiasis. Since this predictor is not considered high likelihood by ESGE, this resulted in a superior specificity of the European compared to the American guideline (100% vs. 91.2%). Following the American instead of the European guidelines would have resulted in five unnecessary endoscopic retrograde cholangiopancreatographies and five unnecessary endoscopic ultrasound examinations. Conclusions: This retrospective analysis suggests that the European guidelines may perform better than the American guidelines at predicting choledocholithiasis in the setting of acute pancreatitis. This was because dilated common bile duct plus bilirubin > 68.4 µmol/mL was not a reliable predictor for persistent bile duct stones.

[Minimally invasive technologies of lithotripsy and antegrade hydraulic lithoextraction in complex treatment of choledocholithiasis]. / Primenenie mini-invazivnykh tekhnologii litotripsii i antegradnoi gidravlicheskoi litoekstraktsii v kompleksnom lechenii bol'nykh kholedokholitiazom.

OBJECTIVE: To evaluate the effectiveness of minimally invasive technologies of lithotripsy and hydraulic antegrade lithoextraction in complex treatment of choledocholithiasis. MATERIAL AND METHODS: In the main group, 74 patients with choledocholithiasis underwent complex treatment with minimally invasive lithotripsy and hydraulic antegrade lithoextraction. In the control group, 177 patients with choledocholithiasis complicated by obstructive jaundice underwent complex treatment without minimally invasive lithotripsy and hydraulic antegrade lithoextraction. RESULTS: Both groups were characterized by significant decrease of serum bilirubin, markers of cytolysis and cholestasis with regression of clinical manifestations of obstructive jaundice. At the same time, early and delayed postoperative complications were significantly more common in the control group. Most of these complications accounted for interventions through laparotomy such as external drainage of the common bile duct and hepaticojejunostomy. There were no similar procedures in the main group due to the use of minimally invasive technologies of lithotripsy and antegrade hydraulic lithoextraction. CONCLUSION: Minimally invasive lithotripsy and antegrade hydraulic lithoextraction are safe alternatives to traditional methods of lithoextraction and can be recommended in case of ineffective laparoscopic and retrograde endoscopic lithoextraction.

[Complex endoscopic treatment of a patient with a large adenoma of the major duodenal papilla, choledocholithiasis and stricture of the common bile duct]. / Kompleksnoe endoskopicheskoe lechenie patsientki s krupnoi adenomoi bol'shogo sosochka dvenadtsatiperstnoi kishki, kholedokholitiazom i strikturoi obshchego zhelchnogo protoka.

Incidence of adenomas of the major duodenal papilla has increased in recent years due to widespread endoscopic screening. These adenomas require resection due to high risk of malignant transformation. Currently, minimally invasive endoscopic interventions are often considered as an alternative to surgical treatment. Combination of major duodenal papilla neoplasms with choledocholithiasis and bile duct strictures are particularly difficult for endoscopic treatment. A 56-year-old patient underwent complex endoscopic treatment for a large adenoma of the major duodenal papilla spreading to duodenal walls and distal segment of the common bile duct combined with choledocholithiasis and stricture of the common bile duct. The patient underwent complex minimally invasive treatment with endoscopic lithoextraction, fragment-by-fragment removal of the neoplasm with intra-ductal ablation of residual adenomatous tissue and subsequent staged biliary stenting for the stricture of the common bile duct, as well as stenting of the main pancreatic duct for prevention of pancreatitis. An integrated approach to the treatment of a patient with a large adenoma of the major duodenal papilla, choledocholithiasis and stricture of the common bile duct provided clinical success without complications and the need for long-term rehabilitation.

Systematic Appraisal of Guidelines for the Diagnosis and Treatment of Choledocholithiasis.

BACKGROUND: To systematically evaluate the methodological quality of the current up-to-date guidelines pertaining to choledocholithiasis, we conducted a comprehensive analysis of key recommendations and corresponding evidence, focusing on the heterogeneity among these guidelines. METHOD: Systematic searches across various databases were performed to identify the latest guidelines. The identified guidelines, which met the inclusion criteria, underwent evaluation using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. The key recommendations and evidence from the included guidelines were extracted and reclassified using the Oxford Centre for Evidence-Based Medicine (OCEBM) grading system, and the obtained results were analyzed. RESULTS: Nine guidelines related to choledocholithiasis were included in this study, out of which 4 achieved an overall standardized score of more than 60%, indicating their suitability for recommendation. Upon closer examination of the main recommendations within these guidelines, we discovered significant discrepancies concerning the utilization of similar treatment techniques for different diseases or different treatment methods under comparable conditions, and discrepancies in the recommended treatment duration. High-quality research evidence was lacking, and some recommendations either failed to provide supporting evidence or cited inappropriate and low-level evidence. CONCLUSION: The quality of guidelines pertaining to choledocholithiasis is uneven. Recommendations for the treatment of choledocholithiasis demonstrate considerable disparities among the guidelines, particularly regarding the utilization of endoscopic retrograde cholangiopancreatography as a treatment method and the management approaches for difficult stone cases. Improvements by guideline developers for these factors contributing to the heterogeneity would be a reasonable approach to further update the guidelines for cholangiolithiasis.

Hyperbilirubinemia and Choledocholithiasis in an Extremely Premature Neonate.

Cholestasis affects 2% of newborns admitted to the neonatal intensive care unit and 20% of premature infants and requires a thoughtful evaluation and diagnostic workup.There may be a single responsible etiology, or its development may be multifactorial. Premature neonates are especially predisposed because of their increased risk of infections and acute illness, need for parenteral nutrition, and exposure to certain medications. Clinically, an infant may present with jaundice, evidence of hepatic injury, or worsening hepatic function. Diagnosis may be made in consultation with various pediatric subspecialists including gastroenterology, genetics, and surgery. Treatment depends on the etiology but may include medications or surgical interventions. Timely recognition and intervention improve outcomes. [Pediatr Ann. 2023;52(8):e297-e302.].

Preoperative MRCP Can Rule Out Choledocholithiasis in Acute Cholecystitis with a High Negative Predictive Value: Prospective Cohort Study with Intraoperative Cholangiography.

BACKGROUND: Magnetic resonance cholangiopancreatography (MRCP) provides a noninvasive and fast modality for imaging the biliary tree when choledocholithiasis is suspected. Guidelines suggest that MRCP is recommended when strong or moderate signs of common bile duct (CBD) stones are present. Well-performed prospective studies are scarce regarding the sensitivity and specificity of preoperative MRCP in patients with acute cholecystitis in comparison with intraoperative cholangiography, ERCP, or choledochoscopy. METHODS: We performed a prospective, observational population-based feasibility study in Central Finland Hospital Nova between January 2019 and December 2019. We examined the diagnostic performance of preoperative MRCP on consecutive patients with acute cholecystitis scheduled for index admission cholecystectomy. The accuracy of MRCP was verified with IOC, choledochoscopy, or ERCP. The interobserver reliability of the image quality of MRCP and the sensitivity and specificity of choledocholithiasis were observed independently by three experienced radiologists. RESULTS: A total of 180 consecutive patients diagnosed with acute cholecystitis followed by index admission cholecystectomy were identified. MRCP was performed in 113/180 (62.8%) patients, and complementary perioperative imaging of the bile ducts was performed in 72/113 (63.7%) patients. The incidence of choledocholithiasis was high (29.2%). In acute cholecystitis, the sensitivity (76.2-85.7%) and specificity (84.3-92.2%) of MRCP were equally compared to the literature with unselected patient groups. The best visibility was observed in the common hepatic duct, the inferior CBD, and the central hepatic duct. The interobserver reliability was excellent for determining the size and quantity of CBD stones. CONCLUSION: In acute cholecystitis, MRCP yields high negative predictive value regarding detection of choledocholithiasis. If CBD stones were discovered, the interobserver reliability was excellent when measuring the size and number of CBD stones. The best-visualized area was the distal part of the biliary tract, which provides good preoperative workup if choledocholithiasis is present.

Effect of Frailty on the Management of Suspected Choledocholithiasis.

INTRODUCTION: The American Society for Gastrointestinal Endoscopy and The Society of American Gastrointestinal and Endoscopic Surgeons (ASGE-SAGES) guidelines for managing choledocholithiasis (CDL) omit patient-specific factors like frailty. We evaluated how frail patients with CDL undergoing same-admission cholecystectomy were managed within ASGE-SAGES guidelines. METHODS: We analyzed patients undergoing same-admission cholecystectomy for CDL and/or acute biliary pancreatitis (ABP) from 2016 to 2019 at 12 US academic medical centers. Patients were grouped by Charlson comorbidity index into non-frail (NF), moderately frail (MF), and severely frail (SF). ASGE-SAGES guidelines stratified likelihood of CDL and were used to compare actual to suggested management. Rate of guideline deviation was our primary outcome. Secondary outcomes included rates of surgical site infections (SSIs), biliary leaks, and 30-day surgical readmissions. Rates are presented as NF, MF, and SF. RESULTS: Among 844 patients, 43.3% (n = 365) were NF, 25.4% (n = 214) were MF, and 31.4% (n = 265) were SF. Frail patients were older (33y vs 56.7y vs 73.5y, P < .0001) and more likely to have ABP (32.6% vs 47.7% vs 43.8%, P = .0005). As frailty increased, guideline deviation increased (41.1% vs 43.5% vs 53.6%, P < .006). Severe frailty was predictive of guideline deviation compared to MF (aOR 1.47, 95% CI 1.02-2.12, P = .04) and NF (aOR 1.46, 95% CI 1.01-2.12, P = .04). There was no difference in SSIs (P = .2), biliary leaks (P = .7), or 30-day surgical readmission (P = .7). CONCLUSION: Frail patients with common bile duct stones had more management deviating from guidelines yet no difference in complications. Future guidelines should consider including frailty to optimize detection and management of CDL in this population.

Evaluating approaches to diagnosis and management of idiopathic acute pancreatitis.

INTRODUCTION: Idiopathic acute pancreatitis (IAP) is a diagnosis of exclusion; systematic work-up is challenging but essential. Recent advances suggest IAP results from micro-choledocholithiasis, and that laparoscopic cholecystectomy (LC) or endoscopic sphincterotomy (ES) may prevent recurrence. METHODS: Patients diagnosed with IAP from 2015-21 were identified from discharge billing records. Acute pancreatitis was defined by the 2012 Atlanta classification. Complete workup was defined per Dutch and Japanese guidelines. RESULTS: A total of 1499 patients were diagnosed with IAP; 455 screened positive for pancreatitis. Most (N = 256, 56.2%) were screened for hypertriglyceridemia, 182 (40.0%) for IgG-4, and 18 (4.0%) MRCP or EUS, leaving 434 (29.0%) patients with potentially idiopathic pancreatitis. Only 61 (14.0%) received LC and 16 (3.7%) ES. Overall, 40% (N = 172) had recurrent pancreatitis versus 46% (N = 28/61) following LC and 19% (N = 3/16) following ES. Forty-three percent had stones on pathology after LC; none developed recurrence. CONCLUSION: Complete workup for IAP is necessary but was performed in <5% of cases. Patients who potentially had IAP and received LC were definitively treated 60% of the time. The high rate of stones on pathology further supports empiric LC in this population. A systematic approach to IAP is lacking. Interventions aimed at biliary-lithiasis to prevent recurrent IAP have merit.

Colangiografía videolaparoscópica intraoperatoria y colangiopancreatografía retrógrada endoscópica en pacientes con sospecha de colédocolitiasis / Intraoperative Videolaparoscopic Cholangiography and Endoscopic Retrograde Cholangiopancreatography in Patients with Suspected Choledocholithiasis

Introducción: La coledocolitiasis se ha convertido en un problema de salud para el cual existen disímiles opciones de tratamiento. Objetivo: Exponer los resultados obtenidos con la colangiografía videolaparoscópica intraoperatoria y la colangiopancreatografía retrógrada endoscópica en pacientes con sospecha de coledocolitiasis. Métodos: Se realizó un estudio descriptivo retrospectivo en pacientes con sospecha de coledocolitiasis sometidos a colangiografía videolaparoscópica y la colangiopancreatografía endoscópica en el Hospital Militar Clínico Quirúrgico Docente de Camagüey Dr. Octavio de la Concepción y de la Pedraja durante el período de enero de 2015 a diciembre de 2019. El universo lo conformaron los 117 pacientes sometidos a ambos procederes. Se controlaron las variables de sospecha de coledocolitiasis, grupos de edades, sexo, hallazgos imagenológicos, complicaciones e índice de sospecha de coledocolitiasis. Resultados: En la colangiografía videolaparoscópica intraoperatoria fue mayor la posibilidad diagnóstica y menor las complicaciones. El diagnóstico de coledocolitiasis fue mayor en los pacientes sometidos a colangiopancreatografía retrógrada endoscópica, aunque esta no permitió evaluar a pacientes con bajo riesgo. Los pacientes del sexo femenino fueron más frecuentes en ambos grupos y la sospecha de coledocolitiasis se observó en grupo de edades entre 31 y 45 años. Sin embargo, fue normal el hallazgo de las vías biliares en ambos procederes. Conclusiones: Ambos métodos son seguros y útiles en el estudio en pacientes con sospecha de coledocolitiasis, con mayor eficacia diagnóstica para la técnica videolaparoscópica y menos complicaciones. El hallazgo normal de la vía biliar fue el resultado que prevaleció en ambos procederes(AU)

Introduction: Choledocholithiasis has become a health problem for which there are dissimilar treatment options. Objective: To present the results obtained with intraoperative videolaparoscopic cholangiography and endoscopic retrograde cholangiopancreatography in patients with suspected choledocholithiasis. Methods: A retrospective and descriptive study was conducted in patients with suspected choledocholithiasis and submitted to videolaparoscopic cholangiography and endoscopic cholangiopancreatography at Hospital Militar Clínico Quirúrgico Docente Dr. Octavio de la Concepción y de la Pedraja, of Camagüey, during the period from January 2015 to December 2019. The study universe consisted of 117 patients submitted to both procedures. The variables of suspected choledocholithiasis, age groups, sex, imaging findings, complications and index of suspected choledocholithiasis were controlled. Results: Intraoperative videolaparoscopic cholangiography had a higher diagnostic possibility and lower complications. The diagnosis of choledocholithiasis was higher in patients submitted to endoscopic retrograde cholangiopancreatography, although this did not allow the assessment of low-risk patients. Female patients were more frequent in both groups, while suspected choledocholithiasis was observed in patients between 31 and 45 years of age. However, the finding of a normal biliary tract was common to both procedures. Conclusions: Both methods are safe and useful in the study in patients with suspected choledocholithiasis, with greater diagnostic efficacy, as well as fewer complications, for the videolaparoscopic technique. The finding of a normal biliary tract was the prevailing result in both procedures(AU)

Long-Term Outcomes of Laparoscopic Common Bile Duct Exploration Through Diathermy, Choledochotomy, and Primary Closure: A 6-Year Retrospective Cohort Study.

Background and Objective: Choledocholithiasis is a frequent pathology, unfortunately when its endoscopic management fails, there is no consensus of how it should be addressed. The aim of this study was to evaluate the safety, feasibility, and long-term outcomes of laparoscopic common bile duct exploration (LCBDE) using electrosurgery (coagulation) for choledochotomy followed by primary closure after endoscopic treatment failure. Materials and Methods: A retrospective cohort study of patients who underwent LCBDE from 2013 to 2018 was conducted in Bogotá, Colombia. Clinical demographics, operative outcomes, recurrence rate of common bile duct stones, and long-term bile duct complications were analyzed. A descriptive analysis was performed. Results: A total of 168 patients were analyzed. Most of the patients were males (53.37%) with a median age of 73 years with no comorbidities (65%). Stone clearance was successful in 167 patients (99.4%). Nonlethal complications were noted in 3 patients during the surgery or in the immediate postoperative (1.79%) and managed with T-tube or endoscopically. No cases of mortality surgery related were observed. There were no signs of any type of biliary injury or stricture observed in any of the patients during the 24-month follow-up period. Conclusions: LCBDE with diathermy and primary closure is a safe and effective treatment option for choledocholithiasis for failed endoscopic retrograde cholangiopancreatography in terms of long-term outcome as well as short-term outcome.

A Predictive Tool for Choledocholithiasis in Patients Undergoing Emergency Cholecystectomy.

Background: Management of acute cholecystitis with emergency laparoscopic cholecystectomy has been established; however, detection and management of concurrent choledocholithiasis are debated. The aim of this study is to develop a more accurate choledocholithiasis predictive model. Materials and Methods: A 9-year audit of emergency cholecystectomies and evaluation of preoperative factors in predictive models. Receiver Operating Curve (ROC) analysis/Youdon Index was used to identify thresholds maximizing these associations for continuous variables. Results: 1601/1828 patients were analyzed. Patients who were diagnosed with choledocholithiasis were more likely to be febrile on admission, have a higher C-reactive Protein, and higher median bilirubin (25.0 µmol/L versus 11.0 µmol/L, P < .001). When excluding bilirubin, multivariate analysis detected several significant variables, including fever, biliary tree dilatation, or a common bile duct stone seen on ultrasound. When bilirubin was included into the model, bilirubin of 20-39 µmol/L (odds ratio [OR] 2.44, 95% confidence interval [CI]: 1.74-3.44) and ≥40 µmol/L (OR 4.84, 95% CI: 3.40-6.91) were shown to have increased likelihood of choledocholithiasis detection on intraoperative cholangiogram, with the ROC model having a significant C-statistic of 0.796 (P < .001). Discussion: A perfect predictive model for concurrent choledocholithiasis in acute cholecystitis does not exist; however, the results from this study are encouraging that high and low predictive groups can be established.

Magnetic resonance imaging following the demonstration of a normal common bile duct on ultrasound in children with suspected choledocholithiasis: what is the benefit?

BACKGROUND: The role of MRI in evaluating children with an in situ gallbladder and suspected choledocholithiasis following a negative or inconclusive US is unclear. OBJECTIVE: To determine whether MRI benefits children with suspected choledocholithiasis and a normal common bile duct (CBD) without stones on US. MATERIALS AND METHODS: We conducted a retrospective 10-year review of paired US and MRI (within 10 days) in children 18 years or younger with suspected choledocholithiasis. With MRI as a reference standard, two reviewers independently evaluated the images for CBD diameter, choledocholithiasis, cholelithiasis and pancreatic edema. Serum lipase was recorded. We calculated exact binomial confidence limits for test positive predictive values (PPVs) and negative predictive values (NPVs) using R library epiR. RESULTS: Of 87 patients (46 female, 41 male; mean age 14 years, standard deviation [SD] 4.6 years; mean interval between US and MRI 1.6 days, SD 1.8 days), 55% (48/87) had true-negative US, without CBD dilation/stones confirmed on MRI; 5% (4/87) had false-positive US showing CBD dilatation without stones, not confirmed on MRI; 33% (29/87) had true-positive US, with MRI confirming CBD dilatation; and 7% (6/87) had false-negative US, where MRI revealed CBD stones without dilatation (2 patients) and CBD dilatation with or without stones (4 patients). Patients with false-negative US had persistent or worsening symptoms, pancreatitis or SCD. The overall US false-negative rate was 17% (6/35). Normal-caliber CBD on US without stones had an NPV of 89% (48/54, 95% confidence interval: 0.77-0.96). CONCLUSION: MRI adds little information in children with a sonographically normal CBD except in the setting of pancreatitis or worsening clinical symptoms. Further evaluation is warranted in children with elevated risk of stone disease.

[Endoscopically non-removable stones of the common bile duct]. / Endoskopicheski ne udalimye kamni obshchego zhelchnogo protoka: puti resheniya problemy.

OBJECTIVE: To evaluate the effectiveness of long-term biliary stenting in the treatment of endoscopically intractable common bile duct stones. MATERIAL AND METHODS: The study enrolled 247 patients with endoscopically non-removable bile duct calculi («difficult¼ choledocholithiasis) divided into two comparable groups. The main group included 129 patients who underwent biliary stenting with original stents with a nanocarbon inert coating (RF patent No. 84226), including those with inclusion of silver nanoclusters (RF patent No. 129397). The control group included 118 patients who underwent all methods of surgical treatment of choledocholithiasis, while biliary stents with original nanocarbon silver-containing inert coating were excluded. The vast majority of patients were women of advanced age (mean 66.8±4.7 and 66.3±5.6, max 89 and 90, min 32 and 37 years, respectively). RESULTS: In the control group, all patients underwent endoscopic transpapillary interventions as soon as possible. We could not extract common bile duct stones via endoscopic approach in 56.8% of cases. These patients underwent open or laparoscopic choledocholithotomy with lithoextraction. Complications occurred in 28.5% of cases. Mortality rate was 4.2%. Standard stenting of common bile duct was performed in 28.8% of cases. At the same time, stent dysfunction followed by relapse of obstructive jaundice occurred in 27.1% of patients within 3-3.5 months. Of these, 16 patients (13.5%) underwent stent removal and lithoextraction. Re-stenting was performed in 18 patients (15.3%). Moreover, shock wave lithotripsy with subsequent removal of common bile duct calculi was performed in 8 (6.8%) of these patients the next day. In the main group, original biliary plastic stents with nanocarbon silver-containing inert coating were implanted in all patients. Under permanent therapy with ursodeoxycholic acid drugs, we observed significant shrinkage of calculi to 11.8±1.8 mm and decrease in their density. This made it possible to carry out successful extraction of calculi in 81 patients (62.8%) after 6±0.3 months. Shock wave lithotripsy was performed in 36 (27.9%) cases. This procedure was successful and allowed final lithoextraction in 28 patients (21.7%). Re-stenting was performed in 15 (11.6%) cases, laparotomy - in 5 (3.9%) patients. Mortality rate was 0.78%. CONCLUSION: Our data allow us to discuss high efficiency of long-term bile duct stenting with plastic stents with nanocarbon silver-containing inert coating in complex treatment of choledocholithiasis. This approach ensures acceptable incidence of undesirable complications and mortality. This situation undoubtedly dictates the need for further larger prospective studies.