Direct Peroral Cholangioscopy in the Management of Difficult Biliary Stones: a New Tool to Confirm Common Bile Duct Clearance. Results of a Preliminary Study

Background & Aims: Endoscopic sphincterotomy (ES) with stone extraction is the standard treatment for choledocholithiasis. After stone retrieval, balloon-occluded cholangiography is generally performed to confirm bile duct clearance but can miss residual stones particularly in patients with residual small-sized stones, a large bile duct or pneumobilia. In addition, difficult common bile duct (CBD) stones requiring advanced endoscopic techniques for retrieval are a potential risk factor for choledocholithiasis recurrence.Methods: We performed a retrospective evaluation of a prospectively maintained procedures database. From July 2016 to December 2017, all patients with difficult CBD stones who underwent endoscopic retrograde cholangiopancreatography (ERCP) with papillary balloon dilation-assisted stone retrieval and subsequent direct per-oral cholangioscopy (DPOC) using standard gastroscopes to confirm CBD clearance were analyzed.Results: Thirty-six patients who underwent ERCP and DPOC were included. Technical success, defined as deep intubation of CBD with hepatic hilum visualization, was achieved in 31 of 36 patients (86%). During DPOC, residual CBD stones were visualized and removed in 7 of 31 patients (22.5%). After a mean of 241 ± 56 days of follow-up post-DPOC, no serious adverse events were reported, and there was no evidence orsuspicion of recurrent choledocholithiasis.Conclusions: Direct per-oral cholangioscopy immediately following difficult CBD stone removal was safe, feasible and accurate. In this setting, DPOC at the time of ERCP appears to be a very useful tool to achieve complete clearance of choledocholithiasis.

Download Full-text

EFFICACY OF ERCP WITH SPHINCTEROTOMY OR PAPILLARY BALLOON DILATION IN THE CBD STONES THERAPY

Journal of Medicine and Pharmacy ◽

10.34071/jmp.2014.2.3 ◽

2014 ◽

pp. 19-23

Author(s):

Van Huy Tran ◽

Trung Nam Phan ◽

Khanh Vinh ◽

Minh Tan Le ◽

Yamamoto Kenta ◽

...

Keyword(s):

Bile Duct ◽

Common Bile Duct ◽

Balloon Dilation ◽

Stone Disease ◽

Routine Procedure ◽

Endoscopic Retrograde ◽

Cbd Stones ◽

Biliary Sphincterotomy ◽

Cbd Stone ◽

Ballon Dilation

Background: Common bile duct (CBD) stone is the disease which leads to more severe complications than other cholelithiasis. The last 30 years have seen major developments in the management of CBD stone disease. Endoscopic retrograde cholangiopancreatography (ERCP) has become a widely available and routine procedure. The effect of this therapy is affected by patient’s condition, number, size and site of CBD stone… Aim: To evaluate the results and complications of ERCP in common bile duct (CBD) stones. Patients/Methods: Between 9/2010 and 12/2013, 42 CBD stone patients were included. According to the protocol, we treated, followed up and assessed the success rate, complication rate of ERCP combine with oddi sphincterotomy or papillary ballon dilation. Results: The successful rate of biliary stone removal was 95.2%. The rate of complication was 9.5%. Pancreatitis is common complications (7.1%). Conclusion: ERCP combine with oddi sphincterotomy or papillary ballon dilation is an effective and relatively safe therapy for CBD stones. Keywords: common bile duct stone, ERCP, Biliary sphincterotomy.

Download Full-text

Intelligent difficulty scoring and assistance system for endoscopic extraction of common bile duct stones based on deep learning: multicenter study

Endoscopy ◽

10.1055/a-1244-5698 ◽

2020 ◽

Author(s):

Li Huang ◽

Xiaoyan Lu ◽

Xu Huang ◽

Xiaoping Zou ◽

Lianlian Wu ◽

...

Keyword(s):

Deep Learning ◽

Bile Duct ◽

Common Bile Duct ◽

Balloon Dilation ◽

Technical Difficulty ◽

Assistance System ◽

Stone Clearance ◽

Cbd Stones ◽

Endoscopic Extraction ◽

Cbd Stone

Abstract Background The study aimed to construct an intelligent difficulty scoring and assistance system (DSAS) for endoscopic retrograde cholangiopancreatography (ERCP) treatment of common bile duct (CBD) stones. Methods 1954 cholangiograms were collected from three hospitals for training and testing the DSAS. The D-LinkNet34 and U-Net were adopted to segment the CBD, stones, and duodenoscope. Based on the segmentation results, the stone size, distal CBD diameter, distal CBD arm, and distal CBD angulation were estimated. The performance of segmentation and estimation was assessed by mean intersection over union (mIoU) and average relative error. A technical difficulty scoring scale, which was used for assessing the technical difficulty of CBD stone removal, was developed and validated. We also analyzed the relationship between scores evaluated by the DSAS and clinical indicators including stone clearance rate and need for endoscopic papillary large-balloon dilation (EPLBD) and lithotripsy. Results The mIoU values of the stone, CBD, and duodenoscope segmentation were 68.35 %, 86.42 %, and 95.85 %, respectively. The estimation performance of the DSAS was superior to nonexpert endoscopists. In addition, the technical difficulty scoring performance of the DSAS was more consistent with expert endoscopists than two nonexpert endoscopists. A DSAS assessment score ≥ 2 was correlated with lower stone clearance rates and more frequent EPLBD. Conclusions An intelligent DSAS based on deep learning was developed. The DSAS could assist endoscopists by automatically scoring the technical difficulty of CBD stone extraction, and guiding the choice of therapeutic approach and appropriate accessories during ERCP.

Download Full-text

Adding ursodeoxycholic acid to the endoscopic treatment and common bile duct stenting for large and multiple biliary stones: Will it improve the outcomes?

BMC Gastroenterology ◽

10.1186/s12876-020-01523-5 ◽

2020 ◽

Vol 20 (1) ◽

Author(s):

Ahmad Hormati ◽

Mohammad Reza Ghadir ◽

Seyed Saeed Sarkeshikian ◽

Faezeh Alemi ◽

Majid Moghaddam ◽

...

Keyword(s):

Bile Duct ◽

Common Bile Duct ◽

Ursodeoxycholic Acid ◽

The Elderly ◽

Success Rates ◽

Biliary Stones ◽

Cbd Stones ◽

Group A ◽

Bile Duct Stenting ◽

Group B

Abstract Background The role of common bile duct (CBD) stenting in the establishment of bile stream in the elderly patients and the ones who are not good candidates for surgery due to not responding to treatments was well documented in previous studies. The current study aimed at investigating the effect of adding Ursodeoxycholic acid (UDCA) to CBD stenting alone in order to reduce the size of large and multiple CBD stones. Methods Clinical outcomes including success rates in CBD stones clearance, incidence of pancreatitis, perforation, bleeding, as well as, decrease in size of stones and liver enzymes after a two-month period were assessed in the UDCA + CBD stenting group. Results A total of 64 patients referring to Shahid Beheshti Hospital in Qom, Iran with multiple or large CBD stones (above three or larger than 15 mm) received standard endoscopic therapies and UDCA + CBD stenting (group B) and controls only received standard endoscopic therapies with only CBD stenting (group A). The mean reduction in the size of stones in group B was significantly higher than that of group A (3.22 ± 1.31 vs 4.09 ± 1.87 mm) (p = 0.034). There was no difference in the incidence rate of complications including pancreatitis, cholangitis, bleeding, and perforation between the two groups (P > 0.05). Conclusion Adding UDCA to CBD stenting, due to decrease in the stone size and subsequently facilitation of the stones outlet, can be considered as the first-line treatment for patients with large and multiple CBD stones. Also, in the cases with large or multi stones may be effective in reducing size and subsequently stone retrieval. Trial registry The study protocol was approved by the Ethics Committee of Qom University of Medical Sciences (ethical code: IR.MUQ.REC.1397.075); the study was also registered in the Iranian Registry of Clinical Trials (No. IRCT20161205031252N8). This study adheres to CONSORT guidelines.

Download Full-text

Pre-operative MRCP: is it necessary before routine laparoscopic cholecystectomy to exclude CBD stone-prospective study in tertiary care hospital

International Surgery Journal ◽

10.18203/2349-2902.isj20174636 ◽

2017 ◽

Vol 4 (11) ◽

pp. 3633 ◽

Cited By ~ 1

Author(s):

Ganni Bhaskara Rao ◽

Samir Ranjan Nayak ◽

Sepuri Bala Ravi Teja ◽

Reshma Palacharla

Keyword(s):

Patient Safety ◽

Laparoscopic Cholecystectomy ◽

Bile Duct ◽

Common Bile Duct ◽

Liver Function ◽

Liver Function Test ◽

Ultrasound Examination ◽

Cbd Stones ◽

Function Test ◽

Cbd Stone

Background: Cholelithiasis is a common disease and at present the laparoscopic cholecystectomy is the gold standard treatment. The diagnosis of associated common bile duct stone for patients with gallstones is important for prompt surgical decision, treatment efficacy and patient safety. However, whether upper abdominal ultrasound and Liver function test (LFT) is adequate before doing lap cholecystectomy remains controversial. There are different opinions regarding the routine magnetic resonance cholangiopancreatography (MRCP) to detect the possible presence of common bile duct (CBD) stones before laparoscopic cholecystectomy.Methods: This study was carried on a total of 106 patients who were admitted and treated for gall stone diseases in the Department of General Surgery, GSL General Hospital over a period of 24 months. After admission all cases were subjected for liver function test, USG abdomen and MRCP. The collected observational data was analyzed.Results: Among the 106 patients, a total of 17cases showed concurrent gallstones and choledocholithiasis, 11 cases choledocholithiasis were revealed by ultrasound examination, while 6 cases of choledocholithiasis were not detected by ultrasound examination but were confirmed by MRCP.Conclusions: CBD stone may be missed even in the presence of deranged liver enzymes or dilated CBD in USG abdomen. Hence for patient safety routine preoperative MRCP examination is recommended before doing laparoscopic cholecystectomy to rule out the likelihood of concomitant CBD stones. The cost-effectiveness of such expensive investigation is to be studied further taking into consideration preventive costs and patient morbidity and mortality.

Download Full-text

Safety and efficacy of extracorporeal shock wave lithotripsy for difficult-to-retrieve common bile duct stones: A ten-year experience

Journal of Translational Internal Medicine ◽

10.2478/jtim-2020-0025 ◽

2020 ◽

Vol 8 (3) ◽

pp. 159-164

Author(s):

Muhammad Manzoor ul Haque ◽

Nasir Hassan Luck ◽

Abbas Ali Tasneem ◽

Syed Mudassir Laeeq ◽

Rajesh Mandhwani ◽

...

Keyword(s):

Shock Wave ◽

Bile Duct ◽

Common Bile Duct ◽

Extracorporeal Shock Wave Lithotripsy ◽

Shock Wave Lithotripsy ◽

Common Bile Duct Stones ◽

Biliary Stones ◽

Cbd Stones ◽

Electrohydraulic Lithotripsy ◽

Extracorporeal Shock Wave

AbstractBackground and ObjectiveExtracorporeal shock wave lithotripsy (ESWL) for common bile duct (CBD) stones has been used in the past, but experience is limited. We report our experience of ESWL in the management of difficult CBD stones.MethodsPatients with difficult-to-retrieve CBD stones were enrolled and underwent ESWL. Fluoroscopy is used to target the stones after injection of contrast via nasobiliary drain. CBD clearance was the main outcome of the study.ResultsEighty-three patients were included (mean age 50.5 ± 14.5 years); these patients were mainly females (43; 51.8%). Large stones >15 mm were noted in 64 (77.1%), CBD stricture in 22 (26.5%) and incarcerated stone in 8 (9.6%) patients. Patients needed 2.1 ± 1.2 sessions of lithotripsy and 4266 ± 1881 shock waves per session. In 75 (90.3%) patients, the fragments were extracted endoscopically after ESWL, while spontaneous passage was observed in 8 (9.6%). Total CBD clearance was achieved in 67 (80.6%) patients, partial clearance in 5 (6%) and no response in 11 (13.2%). Failure of the treatment was observed in large stone with size ≥2 cm (P = 0.021), incarcerated stone (P = 0.020) and pre–endoscopic retrograde cholangiopancreatography cholangitis (P = 0.047).ConclusionESWL is a noninvasive, safe and effective therapeutic alternative to electrohydraulic lithotripsy and surgical exploration for difficult biliary stones.

Download Full-text

P-BN39 The perils of MRCP requesting and early associations of data quality and likelihood of a diagnostic result

British Journal of Surgery ◽

10.1093/bjs/znab430.037 ◽

2021 ◽

Vol 108 (Supplement_9) ◽

Author(s):

Callum Jones ◽

Helena Barton ◽

Samir Pathak ◽

Jonathan Rees

Keyword(s):

Bile Duct ◽

Common Bile Duct ◽

Expectant Management ◽

Clinical Information ◽

Common Bile Duct Stones ◽

Magnetic Resonance Cholangiopancreatography ◽

Biliary Tree ◽

Cbd Stones ◽

Optimal Information ◽

Cbd Stone

Abstract Background MRCP (Magnetic resonance cholangiopancreatography) is used most to assess the biliary tree for stones or strictures. Recently, MRCP availability has increased, and it is extensively used to detect of common bile duct (CBD)stones although very frequently no stones are seen. Indeed, the currently recruiting sunflower RCT aims to determine the clinical and cost effectiveness of expectant management versus MRCP in patients undergoing laparoscopic cholecystectomy at low or moderate risk of common bile duct stones. However, it is critical when requesting an investigation that adequate information is provided. This work aimed, to describe the adequacy of information provided and correlate this with the MRCP result. We hypothesised that the less information that was provided the more common a normal result would be. Methods For a three month period (January 2021 to April 2021) all MRCP requests to detect the presence of a CBD stone were reviewed and data obtained from the Radiology CRIS (CDN Radiology Information System, CDN, Sydney, Aus.). The requesting information was compared to three pre-defined criteria (CBD diameter, presence of gallstones and LFT details) that were agreed as the optimal information that a reporting radiologist would require. The number of key pieces of information for each request and whether the request identified a CBD stone were identified. The proportion of MRCPs detecting a CBD stone was calculated according to the number of key pieces of information provided. Results 56 patients were identified, of which 16 (29%) patients had CBD stones. In 24/56 (43%) patients the presence of gallstones on a previous ultrasound was provided, 14/56 (25%) of patients had information about LFTs including bilirubin and a trend in LFTs was not stated for any patient (0/56; 0%). The rate of stone detection was calculated by the number of pieces of information provided. The rate was 71% (5/7) when all 3 pieces of data were provided, 31% (2/13) when two piece of information were provided, 30% (8/27) when a single piece of information was provided, and only 11% (1/11) when none of the specified data were provided. Conclusions It is uncommon for adequate clinical information to be provided in MRCP requests and in 16% of request no key information was provided. The LFT results were frequently omitted and the trend in LFTs never stated. The more key data provided in the request saw a higher proportion of MRCPs where a CBD stone was identified. We recommend that maximal clinical information is mandated for MRCP request perhaps using mandatory fields on electronic requesting systems and that these systems are also used to facilitate recruitment to clinical trials such the Sunflower RCT.

Download Full-text

Increased Prevalence of Subclinical Hypothyroidism in Common Bile Duct Stone Patients

The Journal of Clinical Endocrinology & Metabolism ◽

10.1210/jc.2007-1316 ◽

2007 ◽

Vol 92 (11) ◽

pp. 4260-4264 ◽

Cited By ~ 13

Author(s):

Johanna Laukkarinen ◽

Gediminas Kiudelis ◽

Marko Lempinen ◽

Sari Räty ◽

Hanna Pelli ◽

...

Keyword(s):

Bile Duct ◽

Common Bile Duct ◽

Subclinical Hypothyroidism ◽

Sphincter Of Oddi ◽

Liver Function Tests ◽

Control Group ◽

Cbd Stones ◽

History Of ◽

Cbd Stone ◽

Previous Medical History

Abstract Context: Earlier, we have shown an increased prevalence of previously diagnosed hypothyroidism in common bile duct (CBD) stone patients and a delayed emptying of the biliary tract in hypothyroidism, explained partly by the missing prorelaxing effect of T4 on the sphincter of Oddi contractility. Objective: In this study, the prevalence of previously undiagnosed subclinical hypothyroidism in CBD stone patients was compared with nongallstone controls. Patients: All patients were clinically euthyreotic and without a history of thyroid function abnormalities. CBD stones were diagnosed at endoscopic retrograde cholangiopancreatography (group 1; n = 303) or ruled out by previous medical history, liver function tests, and ultrasonography (control group II; n = 142). Main Outcome Measures: Serum free FT4 and TSH (S-TSH) were analyzed; S-TSH above the normal range (>6.0 mU/liter) was considered as subclinical and S-TSH 5.0–6.0 mU/liter as borderline-subclinical hypothyroidism. Results: A total of 5.3 and 5.0% (total 10.2%; 31 of 303) of the CBD stone patients were diagnosed to have subclinical and borderline-subclinical hypothyroidism, compared with 1.4% (P = 0.05) and 1.4% (total 2.8%, four of 142; P = 0.026) in the control group, respectively. In women older than 60 yr, the prevalence of subclinical hypothyroidism was 11.4% in CBD stone and 1.8% in control patients (P = 0.032) and subclinical plus borderline-subclinical hypothyroidism 23.8% in CBD stone and 1.8% in control patients (P = 0.012). Conclusion: Subclinical hypothyroidism is more common in the CBD stone patients, compared with nongallstone controls, supporting our hypothesis that hypothyroidism might play a role in the forming of CBD stones. At minimum, women older than 60 yr with CBD stones should be screened for borderline or overt subclinical hypothyroidism.

Download Full-text

Needle-knife fistulotomy vs. standard biliary sphincterotomy for choledocholithiasis: common bile duct stone recurrence and complication rate

Endoscopy International Open ◽

10.1055/a-1024-3789 ◽

2019 ◽

Vol 07 (12) ◽

pp. E1733-E1741 ◽

Cited By ~ 1

Author(s):

Livia Archibugi ◽

Alberto Mariani ◽

Gabriele Capurso ◽

Mariaemilia Traini ◽

Maria Chiara Petrone ◽

...

Keyword(s):

Bile Duct ◽

Common Bile Duct ◽

Proportional Hazards ◽

Proportional Hazards Model ◽

Cbd Stones ◽

Stone Recurrence ◽

Hazards Model ◽

Kaplan Meier ◽

Biliary Sphincterotomy ◽

Cbd Stone

Abstract Background and study aims With common bile duct (CBD) stones, access to the CBD can be achieved through the papilla orifice followed by standard biliary sphincterotomy (SBS), or through precut fistulotomy (PF) in case of difficult cannulation. The two methods alter papilla anatomy differently, potentially leading to a different rate of stone recurrence. No data have been published on stone recurrence after PF in patients with CBD stones. The aim of this study was to evaluate CBD stone recurrence, reintervention rate after PF versus SBS, and complications. Patients and methods This was a retrospective single-center cohort study including patients undergoing for the first time endoscopic retrograde cholangiopancreatography (ERCP) for CBD stones with PF in case of failed repeated cannulation attempts, matched for sex/age to patients with SBS randomly extracted from our database. T-test and Fisher’s tests were used for continuous and categorical variable comparison. Recurrence probability was calculated with Kaplan–Meier curve. Factors associated with ERCP repetition were evaluated with logistic regression through a Cox’s proportional hazards model. Results Eighty-five patients with PF were included, with 85 matched controls (mean age 68.7 years, 45.9 % males). Overall, patients with PF had the same reintervention rate as those with SBS (14.1 % vs. 12.9 %) with a hazard ratio (HR) of 1.11 (95 % CI 0.49 – 2.50; P = 0.81), but mean time to reintervention was significantly lower (74.9 ± 74.6 vs. 765.6 ± 961.3 days; P < 0.0001), with 100 % of stones recurring within the first year in the PF group vs. 54.5 % in the SBS group (P = 0.01). The only factor associated with ERCP repetition risk was incomplete CBD clearing. Complications, including pancreatitis, did not differ significantly. Conclusions The reintervention rate was significantly higher in the short term after PF. Therefore, closer follow-up in the first 6 to 12 months after ERCP might be appropriate for patients underoing PF.

Download Full-text

Laparoscopic Common Bile Duct Exploration as a Rescue Procedure for Failed Endoscopic Retrograde Cholangio-Pancreatography: A Case Report

JOURNAL FOR CLINICAL AND DIAGNOSTIC RESEARCH ◽

10.7860/jcdr/2021/49296.15179 ◽

2021 ◽

Author(s):

Umar Riaz ◽

Abhijit S Joshi

Keyword(s):

Case Report ◽

Bile Duct ◽

Common Bile Duct ◽

Treatment Options ◽

Common Bile Duct Exploration ◽

Endoscopic Retrograde ◽

Therapeutic Modalities ◽

Cbd Stones ◽

Billroth Ii Gastrectomy ◽

Cbd Stone

Across the world, choledocholithiasis is presently treated by a two staged approach of Endoscopic Retrograde Cholangio- Pancreatography (ERCP) followed by Laparoscopic Cholecystectomy (LC); in a vast majority of the situations. Modern day literature abounds with comparative outcomes studies between ERCP and Laparoscopic Common Bile Duct Exploration (LCBDE), as therapeutic modalities for Common Bile Duct (CBD) stones. There are strong arguments both in favour and against both these treatment options, in literature. As per literature, the advantage of LCBDE is that it is a single stage procedure, but requires advanced laparoscopic expertise and a choledochoscope in the setup. The advantage of ERCP is that it is a highly standardised procedure. In expert hands and well equipped setups, it rarely ever fails to deliver. However, ERCP is also a highly operator dependant procedure. Also, in the best of hands, sometimes, local factors such as abnormal anatomy, stone morphology can lead to failures or suboptimal results. As per literature, ERCP to extract CBD stones can fail for various reasons such as failed cannulation, previous Billroth II gastrectomy, large CBD stones, large number of CBD stones etc. The failure in retrieving CBD stones by ERCP is an absolute indication for performing CBDE. Here, authors present a case report of a 73-year-old male with failed ERCP (inspite of two attempts) due to a large, solitary but tightly impacted terminal CBD stone. It hopes to convey the message that in similar situations, LCBDE, tactically using some endoscopy accessories, is a sound backup therapeautic option, inspite of non availability of a choledochoscope in the setup. The novelty of this case was that instead of the standard use of choledochoscope to directly visually confirm the completeness of stone clearance during the LCBDE, intraoperative fluoroscopy has been used effectively for the same; by obtaining good quality proximal and distal occlusion cholangiograms at the end of the procedure.

Download Full-text

LAPAROSCOPIC MANAGEMENT OF COMMON BILE DUCT STONES

10.36106/ijsr/7223545 ◽

2020 ◽

pp. 1-4

Author(s):

Binit Prasad ◽

Mukesh Kumar ◽

Debarshi Jana

Keyword(s):

Bile Duct ◽

Common Bile Duct ◽

Open Surgery ◽

Common Bile Duct Stones ◽

Single Stage ◽

Bile Duct Stones ◽

Cbd Stones ◽

Cbd Stone ◽

Laparoscopic Cbd Exploration ◽

Cbd Exploration

Introduction: Common Bile Duct stones (CBD) are found in approximately 16% of the patients undergoing Laparoscopic cholecystectomy (LC). Till recently, the gold standard for treating CBD stones was endoscopic removal, if that failed, then open surgery. However, in the laparoscopic era, the best treatment for CBD stones is a matter of debate and it continues to evolve. The objective of the present study is to determine that laparoscopic CBD exploration (LCBDE) is a safe, feasible and single-stage option for the management of CBD stones. Materials and Methods :Out of the 2900 laparoscopic cholecystectomies we did selective intraoperative cholangiogram in 262 patients who were suspected to have CBD stones based on deranged liver function tests, dilated CBD with or without CBD stone on sonography or having the history of recent jaundice/pancreatitis. If CBD stone was found, either a transcystic or transcholedochal exploration was done depending on the size, site, number of stones and CBD diameter. Choledochotomy was closed over a t-tube in the majority of the patients. Primary closure of CBD was done in few patients and in one patient we placed an antegrade stent and in another we placed endoscopic stent into the CBD laparoscpically which was removed after four weeks. Results :Till date we have performed LCBDE in 64 patients. Transcystic exploration was done in 14 patients and transcholedochal exploration was done in 46 cases out of which 2 patients had minor biliary leak which settled on conservative treatment in 2-3 days. Four patients required conversion to open surgery as there were multiple stones. We did not have any major complication and on 6 months follow-up in 76% patients, none was found to have residual stone. Conclusion :The treatment of CBD stones depends on the resources available, technical limitations and the surgeon’s expertise. Laparoscopic CBD exploration is a safe, feasible and single-stage option for the management of CBD stones.

Download Full-text