Impact of the COVID-19 pandemic on the treatment of acute cholangitis caused by choledocholithiasis: A single-center retrospective study in Japan.

Objectives: This study aimed to determine the impact of the coronavirus disease 2019 (COVID-19) pandemic on the treatment of acute cholangitis caused by choledocholithiasis. Methods: The Japanese government declared a state of emergency in April 2020 due to the COVID-19 pandemic. We retrospectively reviewed the medical records of 309 patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) for acute cholangitis caused by choledocholithiasis between April 2017 and December 2022. Results: Patients were categorized into a pregroup (n = 134) and a postgroup (n = 175), depending on whether they were diagnosed before or after the state of emergency declaration. The total number of ERCP cases and the number of ERCP cases with endoscopic stone removals increased after the state of emergency declaration. Compared with the pregroup, the numbers of patients with performance status of 0-1 and surgically altered anatomy increased, whereas the numbers of patients taking oral antiplatelets or anticoagulants and those with cerebrovascular disease decreased in the postgroup. The number of single-stage endoscopic stone removals increased and hospital stays were significantly shorter in the postgroup. No differences in adverse event rates were detected between the two groups. Conclusions: Although our hospital provides tertiary care, the number of patients with cholangitis in good general condition and no underlying disease increased after the state of emergency declaration. The COVID-19 pandemic resulted in an increase in the number of single-stage endoscopic treatments and shortened hospital stays for patients with acute cholangitis caused by choledocholithiasis. No safety issues with ERCP were detected, even during the pandemic.

Single stage laparoscopic cholecystectomy with intraoperative endoscopic retrograde cholangiopancreatography for cholecysto-choledocholithiasis. Lesson learnt from the COVID-19 pandemic.

Introduction: Choledocholithiasis, a common complication of gallstone disease, poses significant risks including cholangitis and pancreatitis. Various treatment approaches exist, including single-stage and two-stage techniques, with recent literature suggesting advantages of the single-stage approach in terms of outcomes and cost-effectiveness. This study evaluates the feasibility, efficacy, and safety of single-stage laparoscopic cholecystectomy combined with intraoperative endoscopic retrograde cholangiopancreatography (LC + iERCP) compared to the previously adopted two-stage approach. Methods: A retrospective analysis was conducted on patients undergoing single-stage LC + iERCP for cholecysto-choledocholithiasis during the COVID-19 pandemic (2020-2022). Data on demographics, preoperative assessments, intraoperative parameters, and postoperative outcomes were collected and compared with an historical control group undergoing the two-stage approach (LC + preopERCP). Hospitalization costs were also compared between the two groups. Results: A total of 190 patients were included, with 105 undergoing single-stage LC + iERCP. The single-stage approach demonstrated successful completion without cystic duct cannulation, with no conversions to open surgery. Operative time was comparable to the two-stage approach, while hospital stay, and costs were significantly lower in the single-stage group. Complication rates were similar between the groups. Conclusions: Single-stage LC + iERCP appears to be a feasible, effective, and safe approach for treating cholecysto-choledocholithiasis, offering potential benefits in terms of reduced hospital stay, OR occupation time, and costs compared to the two-stage approach. Integration of this approach into clinical practice warrants consideration, unless there are logistical challenges that cannot be overcome or lack of endoscopic expertise also for treating challenging urgent cases.

Multifaceted complications and surgical management of bronchobiliary fistula with associated pneumonia and intrahepatic stones: A case report.

Background: Bronchobiliary fistulas (BBFs), primarily stemming from choledocholithiasis, present considerable diagnostic and treatment challenges. Their prolonged nature can lead to life-threatening situations without timely management, often complicated by lung abscesses. Case presentation: A 64-year-old man, presenting with fever, chills, and a cough initially misdiagnosed as a common cold, developed severe respiratory distress and delirium upon admission. Urgent intensive care unit (ICU) admission was prompted by a computed tomography (CT) scan revealing a right lung abscess. Enhanced CT scans and elevated bilirubin levels confirmed the biliary origin of the BBFs. Comprehensive treatment included laparoscopic partial hepatectomy, choledochojejunostomy, stone extraction, choledochoscopy, T-tube drainage, and BBFs closure. The patient was discharged with a T-tube. Follow-up CT after two months showed no recurrence. Conclusions: Managing BBFs, especially with concurrent lung abscesses in choledocholithiasis patients, remains challenging but feasible. Early diagnosis and intervention are crucial to improving survival rates and quality of life, highlighting the need for vigilance. This case underscores the importance of early detection and comprehensive treatment for successful outcomes in such complex conditions.

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 choledocholithiasis 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.

Laparoscopic cholecystectomy and laparoscopic common bile duct exploration for cholecystolithiasis and choledocholithiasis in a patient with situs inversus totalis: A case report.

Situs inversus complicates diagnosis and treatment due to the mirrored organ placement in relation to normal anatomy. This report describes a 78-year-old female patient with situs inversus totalis who underwent laparoscopic cholecystectomy and laparoscopic common bile duct exploration for cholecystolithiasis and choledocholithiasis. Utilizing the "French mirror technique" for port placement, the surgeon adeptly mirrored standard maneuvers with a 2-mm needle forceps in the left hand and a 5-mm forceps in the right in a reversed anatomical setting. This technique maintained familiar hand movements, despite the patient's unique anatomy. The surgeon applied transcystic ductal bile duct exploration, using choledochoscopy for duct exploration and a basket catheter for stone removal. Laparoscopic cholecystectomy and common bile duct exploration through the transcystic ductal route are viable and effective for patients with situs inversus.

Enhanced recovery after surgery in percutaneous transhepatic cholangioscopic lithotripsy for patients with hepatolithiasis and choledocholithiasis.

Background: Percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) provides an effective alternative procedure for the management of complex hepatolithiasis and choledocholithiasis. Enhanced recovery after surgery (ERAS) program is an evidence-based approach that was developed to reduce surgical stress and accelerate postoperative recovery. However, little is known regarding PTCSL in the context of ERAS. The aim of this study was to evaluate the efficacy and safety of PTCSL within ERAS programs. Patient and methods: The clinical data of patients who underwent PTCSL within ERAS programs consulted at our hospital between November 2017 and November 2022 was retrospectively reviewed. Individualized perioperative ERAS items were evaluated for all patients. The demographics, intraoperative variables, and postoperative outcomes were analyzed. Results: A total of 43 patients who underwent PTCSL were included in the study. There were 13 men and 30 women aged between 39 and 89 years with an average age of 60 years (60.49 ± 12.37). The stone clearance rate was 77 % after the first operation, and the final clearance rate was 95 %. The incidence of complications in this study is 18.6 % (8/43), including 6 patients with Clavien-Dindo I-II, and 2 patients with Clavien-Dindo III. Pleural effusion, abdominal effusion, infection, bile leakage, and biliary bleeding are the most common complications, however, all patients recovered after aggressive treatment. Conclusion: PTCSL is a relatively safe, feasible, and efficient method for treating complex hepatolithiasis and choledocholithiasis within ERAS programs. Individualized ERAS entries and precise disease management are required to minimize the occurrence of complications and to provide effective treatment.

Clinicopathological features and management of obstructive jaundice at Queen Elizabeth Central Hospital, Malawi. A retrospective cohort analysis.

Introduction: The diagnosis of obstructive jaundice (OJ) is a challenge and is often made late especialy in low-resource settings. There is a paucity of data on the aetiology and prognosis of patients with obstructive jaundice in Malawi and Sub-Saharan Africa. The objective of this study was to determine the aetiology, clinical presentations, and short-term treatment outcomes of patients managed for OJ in Malawi. Methodology: A review of case notes of all patients admitted with a clinical diagnosis of OJ from 2012 to 2022 was done. We reviewed the clinical presentation, laboratory findings, management, intra and post-operative complications, and patient outcomes. Data was entered into an Excel spreadsheet and analysed using SPSS version 25. Results: Of 26,796 patient admissions, 5339 (19.9%) were for non-trauma abdominal symptoms, of which 164 (0.6% of surgical admissions and 3% of abdominal symptoms) were for obstructive jaundice. Ages varied from 16 to 89 years. Females were 45 (58.4 %) of the population. The commonest presenting complaint was jaundice followed by abdominal pain and distention. The mean duration of symptoms at presentation was 8.5 weeks. The most frequent imaging modality was abdominal ultrasound 50(65 %). Twenty-six patients (33.8 %) were discharged with a diagnosis of obstructive jaundice of undetermined pathogenesis. The commonest diagnosis was pancreatic cancer 20(26.0 %) followed by Choledocholithiasis11(14.3 %). Patients younger than 50 years had the same likelihood of presenting with cancer as those older than 50 years. Conclusion: It is important to have a high index of suspicion in all adult patients presenting with obstructive jaundice as patients younger than 50 years have a similar risk of malignancy as older patients.

Is there a role for routine intraoperative cholangiogram in diagnosing CBD stones in patients with normal liver function tests? A prospective study.

Objectives: Cholecystectomy with or without intraoperative cholangiogram (IOC) is an accepted treatment for cholelithiasis. Up to 11.6 % of cholecystectomies have incidental common bile duct (CBD) stones on IOC and 25.3 % of undiagnosed CBD stones will develop life-threatening complications. These will require additional intervention after primary cholecystectomy, further straining the healthcare system. We seek to examine the role of IOC in patients with normal LFTs by evaluating its predictive values, intending to treat undiagnosed CBD stones and therefore ameliorate these issues. Methods: All patients who underwent cholecystectomies with normal LFTs from October 2019 to December 2020 were prospectively enrolled. IOC was done, ERCPs were performed for filling defects and documented as "true positive" if ERCP was congruent with the IOC. "False positives" were recorded if ERCP was negative. "True negative" was assigned to normal IOC and LFT after 2 weeks of follow-up. Those with abnormal LFTs were subjected to ERCP and documented as "false negative". Sensitivity, specificity, and predictive values were calculated. Results: A total of 180 patients were analysed. IOC showed a specificity of 85.5 % and a NPV of 88.1 % with an AUC of 73.7 %. The positive predictive value and sensitivity were 56.5 and 61.9 % respectively. Conclusions: Routine IOC is a specific diagnostic tool with good negative predictive value. It is useful to exclude the presence of CBD stones when LFT is normal. It does not significantly prolong the length of hospitalization or duration of the cholecystectomy hence reducing the incidence of undetected retained stones and preventing its complications effectively.

Over 2000 gallstones of varying sizes and types during a cholecystectomy.

This rare case highlights the number of over 2000 mixed gallstones, which shows the importance of thorough evaluation in patients with RUQ pain to identify underlying conditions and associated complications.

Laparoscopic-Assisted ERCP in Gastric Bypass Patients-No Stones Left Unturned: A Single Center Retrospective Cohort Study.

PURPOSE: The long-term need for biliary duct intervention following Roux-en-Y gastric bypass surgery (RYGB) is uncertain. We investigated the rate of laparoscopic assisted retrograde cholangiopancreatography (LAERCP) following RYGB. Also, the pre-LAERCP diagnostic workup together with the true rate of choledocholithiasis in patients with or without prior cholecystectomy was investigated. MATERIALS AND METHODS: Retrospective cohort study of RYGB and LAERCP performed at the Hospital South West Jutland, University Hospital of Southern Denmark, from 1 January 2013 to 31 May 2022. RESULTS: One percent of patients (n = 13) with a history of RYGB (n = 1363) underwent LAERCP at our facility during a median follow-up of 60.6 months. The stone extraction rate was 66.7% in patients with in situ gallbladder and 12.5% in patients with prior cholecystectomy. Cannulation of the common bile duct was achieved in 96.7% of cases. Postoperative complications were observed in 22.6% of the cases. CONCLUSION: Approximately 1% of RYGB patients needed LAERCP during a median follow-up of 5 years. In patients with a history of cholecystectomy, the LAERCP rate of stone extraction was very low (12.5%).

Simplified single-session EUS-guided transhepatic antegrade stone removal for management of choledocholithiasis in patients with surgically altered anatomy.

Background: Endoscopic ultrasound (EUS)-guided transhepatic antegrade stone removal (TASR) has been reserved for choledocholithiasis after failed endoscopic retrograde cholangiopancreatography (ERCP) in recent years. The aim of this study was to evaluate the techniques, feasibility, and safety of simplified single-session EUS-TASR for choledocholithiasis in patients with surgically altered anatomy (SAA). Methods: A retrospective database of patients with SAA and choledocholithiasis from the Second Hospital of Hebei Medical University (Shijiazhuang, China) between August 2020 and February 2023 was performed. They all underwent single-session EUS-TASR after ERCP failure. Basic characteristics of the patients and details of the procedures were collected. The success rates and adverse events were evaluated and discussed. Results: During the study period, 13 patients underwent simplified single-session EUS-TASR as a rescue procedure (8 males, median age, 64.0 [IQR, 48.5-69.5] years). SAA consisted of four Whipple procedures, one Billroth II gastrectomy, four gastrectomy with Roux-en-Y anastomoses, and four hepaticojejunostomy with Roux-en-Y anastomoses. The technical success rate was 100% and successful bile duct stone removal was achieved in 12 of the patients (92.3%). Adverse events occurred in two patients (15.4%), while one turned to laparoscopic surgery and the other was managed conservatively. Conclusions: Simplified single-session EUS-TASR as a rescue procedure after ERCP failure appeared to be effective and safe in the management of choledocholithiasis in patients with SAA. But further evaluation of this technique is still needed, preferably through prospective multicenter trials.

Non-Invasive Prediction of Choledocholithiasis Using 1D Convolutional Neural Networks and Clinical Data.

This paper introduces a novel one-dimensional convolutional neural network that utilizes clinical data to accurately detect choledocholithiasis, where gallstones obstruct the common bile duct. Swift and precise detection of this condition is critical to preventing severe complications, such as biliary colic, jaundice, and pancreatitis. This cutting-edge model was rigorously compared with other machine learning methods commonly used in similar problems, such as logistic regression, linear discriminant analysis, and a state-of-the-art random forest, using a dataset derived from endoscopic retrograde cholangiopancreatography scans performed at Olive View-University of California, Los Angeles Medical Center. The one-dimensional convolutional neural network model demonstrated exceptional performance, achieving 90.77% accuracy and 92.86% specificity, with an area under the curve of 0.9270. While the paper acknowledges potential areas for improvement, it emphasizes the effectiveness of the one-dimensional convolutional neural network architecture. The results suggest that this one-dimensional convolutional neural network approach could serve as a plausible alternative to endoscopic retrograde cholangiopancreatography, considering its disadvantages, such as the need for specialized equipment and skilled personnel and the risk of postoperative complications. The potential of the one-dimensional convolutional neural network model to significantly advance the clinical diagnosis of this gallstone-related condition is notable, offering a less invasive, potentially safer, and more accessible alternative.

Minimally Invasive Common Bile Duct Stone Management in Gastric Bypass Patients: Laparoscopic Common Bile Duct Exploration with Disposable Bronchoscope.

BACKGROUND: Bariatric surgery patients may develop common bile duct stones, and the alterations in their anatomy present challenges in treating this condition. Methods such as laparoscopic bile duct exploration is impractical in many healthcare facilities, due to the absence of a choledochoscope. This study assesses the feasibility of laparoscopic exploration of the common bile duct using a disposable bronchoscope in these individuals. METHOD: The study involved 32 participants who had undergone gastric bypass surgery. These participants presented with both bile duct stones and bile ducts exceeding 8 mm in diameter, diagnosed through either MRCP or cholangiography conducted during the surgery. Stone extraction was carried out through either choledotomy or transcystic routes using a disposable bronchoscope and endoscopic baskets. RESULTS: The patients' ages ranged from 27 to 66 years, with a mean bile duct diameter of 11.6 mm (SD 3.1 mm). A 100% stone clearance rate was achieved for all patients. None of the patients required conversion to open surgery. No T-tubes were placed. One patient developed biloma and intra-abdominal abscesses, which were successfully treated with a percutaneous drain over the course of a week. No mortalities were recorded during the course of this study. CONCLUSION: Our study results demonstrate that laparoscopic bile duct exploration is both feasible and safe in patients who have undergone gastric bypass surgery. The utilization of a disposable bronchoscope emerges as a practical and cost-effective alternative to a choledochoscope in this procedure.

Development and validation of a predictive model for choledocholithiasis.

BACKGROUND: Gallstone-related conditions affect a significant portion of the population, with varying prevalence among different ethnic groups. Complications such as pancreatitis and cholangitis are associated with the presence of common bile duct (CBD) stones. Existing guidelines for diagnosing choledocholithiasis lack precision, leading to excessive use of invasive procedures like endoscopic retrograde cholangiopancreatography (ERCP). METHODS: A prospective study was conducted at Hospital Central "Dr. Ignacio Morones Prieto," involving 374 patients in the development cohort and 154 patients in the validation cohort. Patients meeting inclusion criteria underwent biochemical testing and ultrasonography. A predictive scoring system was developed using logistic regression and validated in an independent cohort. Clinical and laboratory variables were collected, and model performance was assessed using receiver-operator characteristic (ROC) curves. RESULTS: The predictive model incorporated variables such as age, pancreatitis, cholangitis, bilirubin levels, and CBD stone presence on ultrasound. The model demonstrated an area under the ROC curve (AUC) of 93.81% in the validation dataset. By adjusting the threshold defining high-risk probability to 40%, the model improved specificity and sensitivity compared to existing guidelines. Notably, the model reclassified patients, leading to a more accurate risk assessment. CONCLUSIONS: The developed algorithm accurately predicts choledocholithiasis non-invasively in patients with symptomatic gallstones. This tool has the potential to reduce reliance on costly or invasive procedures like magnetic resonance cholangiopancreatography and ERCP, offering a more efficient and cost-effective approach to patient management. The user-friendly calculator developed in this study could streamline diagnostic procedures, particularly in resource-limited healthcare settings, ultimately improving patient care.

Antegrade balloon dilatation of the duodenal papilla during laparoscopic cholecystectomy versus endoscopic retrograde cholangiography in patients with acute choledocholithiasis: a case control matched study.

INTRODUCTION: In acute obstructive common bile duct (CBD) stones endoscopic retrograde cholangiography for CBD stone removal before cholecystectomy (ChE) ('ERC-first') is the gold standard of treatment. Intraoperative antegrade balloon dilatation of the duodenal papilla during ChE with flushing of CBD stones to the duodenum ('ABD-during-ChE') may be an alternative 'one-stop-shop' treatment option. However, a comparison of outcomes of the 'ABD-during-ChE' technique and the'ERC-first' approach has never been performed. METHODS: Retrospective case control matched study of patients suffering from obstructive CBD stones (< 8 mm) without severe pancreatitis or cholangitis that underwent the traditional 'ERC-first' approach versus the 'ABD-during-ChE' technique. Primary endpoint was the overall Comprehensive Complication Index (CCI®) from diagnosis to complete CBD stone removal and performed ChE. RESULTS: A total of 70 patients were included (35 patients each in the 'ERC first'- and 'ABD-during-ChE'-group). There were no statistical significant differences in terms of demographics and disease specific characteristics between the two study groups. However, there was a not significant difference towards an increased overall CCI® in the 'ERC-first' group versus the 'ABD-during-ChE' group (14.4 ± 15.4 versus 9.8 ± 11.1, p = 0.225). Of note, six major complications (Clavien-Dindo classification ≥ IIIa) occurred in the 'ERC-first' group versus two in the 'ABD-during-ChE' group (17% versus 6%, p = 0.136). In addition, significantly more interventions and a longer overall time from diagnosis to complete clearance of bile ducts and performed ChE was found, when comparing the 'ERC-first' group and the 'ABD-during-ChE' group (3.7 ± 0.8 versus 1.1 ± 0.4, p < 0.001; 160.5 ± 228.6 days versus 12.0 ± 18.0 days, p < 0.001). CONCLUSION: In patients suffering from acute obstructive CBD stones smaller than 8 mm, compared to the 'ERC-first' approach, the 'ABD-during-ChE' technique resulted in significantly less interventions and reduced overall treatment time from diagnosis to complete clearance of bile ducts and performed ChE. This comes together with a strong trend of less intervention related complications in the 'ABD-during-ChE' group.

Gallbladder remnant: A potential source for biliary stones postcholecystectomy; a case report in a child with sickle cell disease.

Stone formation in a gallbladder remnant is a rare postcholecystectomy complication. This report describes the case of gallstones in a gallbladder remnant of an adolescent with sickle cell disease (SCD) years after laparoscopic cholecystectomy. A 15-year-old female with SCD presented to our gastroenterology clinic with concerns of recurrent choledocholithiasis despite cholecystectomy 2 years before presentation. About 4 months before presentation to our clinic, she was evaluated at the referring physician's emergency department for recurrent severe abdominal pain of 1 month duration. After admission to the hospital, common bile duct stones were seen on magnetic resonance cholangiopancreatography (MCRP) imaging and subsequently removed via endoscopic retrograde cholangiopancreatography (ERCP). On review of her MRCP and ERCP at our hospital, a remnant of gallbladder containing multiple stones was identified. She subsequently underwent a laparoscopic resection of the gallbladder remnant. Clinicians should consider biliary duct imaging in children with biliary colic following cholecystectomy, especially those with history of chronic hemolysis.

Laparoscopic Ultrasound-Guided Transcystic Approach for the Treatment of Common Bile Duct Stones.

Background: The treatment of choledocholithiasis with nondilated common bile duct (CBD) is a challenge for surgeons who often choose endoscopic retrograde cholangiopancreatography with laparoscopic cholecystectomy (LC) staging surgery instead of simultaneous laparoscopic CBD exploration with LC because of the small CBD diameter. This study aims to introduce and assess the clinical applicability of a technique we developed to identify and extract CBD stones using laparoscopic ultrasound (LUS). Methods: We retrospectively reviewed surgical procedures and clinical data of 13 patients who underwent LC and CBD exploration using LUS between May 2022 and August 2023. The cystic duct was used for CBD stone removal. Results: Ten patients were successfully treated; 2 patients with residual stones were treated with ursodeoxycholic acid, whereas 1 patient required a microincision near the CBD and choledochoscopy because of stone incarceration in the duodenal papilla. The CBD diameter was 6 mm (5-9 mm). There were less than three CBD stones, with diameters of 2-6 mm; the median operative time was 105 minutes (range, 52-155 minutes). One patient developed postoperative cholangitis. The median postoperative hospital stay was 6 days (3-8 days). The stone clearance rate was 76.9%, and the CBD stone detection rate was 100%. No intraoperative complications, postoperative bile leakage, and mortality occurred. Conclusions: CBD exploration and transcystic stone extraction under LUS guidance are safe and effective approaches for patients with choledocholithiasis; strict control over surgical indications is necessary. This study could provide new strategies for effectively treating choledocholithiasis.

Predictors of Choledocholithiasis in Cholecystectomy Patients and Their Cutoff Values and Prediction Model in Korea in Comparison with the 2019 ASGE Guidelines.

Background/Aims: : In 2019, the American Society for Gastrointestinal Endoscopy (ASGE) established clinical predictors for choledocholithiasis. Our study was designed to evaluate these predictors within the Korean clinical context, establish cutoff values, and develop a predictive model. Methods: : This retrospective study analyzed patients who underwent laparoscopic cholecystectomy. The relationships between choledocholithiasis and predictors including age, blood tests, and imaging findings were assessed through univariate and multivariate logistic regression analyses. We established Korean cutoff values for these predictors and developed a scoring system for choledocholithiasis using a multivariate logistic regression. The performance of this scoring system was then compared with that of the 2019 ASGE guidelines through a receiver operating characteristic curve. Results: : We established Korean cutoff values for age (>70 years), alanine aminotransferase (>26.5 U/L), aspartate aminotransferase (>28.5 U/L), gamma-glutamyl transferase (GGT; >82.5 U/L), alkaline phosphatase (ALP; >77.5 U/L), and total bilirubin (>0.95 mg/dL). In the multivariate analysis, only age >70 years, GGT >77.5 U/L, ALP >77.5 U/L, and common bile duct dilatation remained significant. We then developed a new Korean risk stratification model from the multivariate analysis, with an area under the curve of 0.777 (95% confidence interval, 0.75 to 0.81). Our model was stratified into the low-risk, intermediate-risk, and high-risk groups with the scores being <1.0, 1.0-5.5, and >5.5, respectively. Conclusions: : Predictors of choledocholithiasis in cholecystectomy patients and their cutoff values in Korean should be adjusted and further studies are needed to develop appropriate guidelines.

Hepatic Duct Adenoma Identified Using Direct Cholangioscopy.

Bile duct adenomas (BDAs) are rare benign tumors that can arise in the intra-hepatic or extra-hepatic biliary tree. We present a case of a 46-year-old female who presented with symptoms suggestive of choledocholithiasis. Direct cholangioscopy identified a 15 mm polypoid lesion in the common hepatic duct (CHD). Biopsy revealed a BDA. We present this case to highlight the role of direct cholangioscopy in the diagnosis and management of BDAs.