P-BN18 Cholecystectomy following ERCP: A retrospective audit from a single centre

Background 15% of the adult population are estimated to have gallstones (GS) and managing GS related disease can represent a significant challenge to surgical and endoscopic services alike. One particular challenge is the management of bile duct calculi (BDC), and treatment can vary according to the unit/institution. NICE has published guidelines (CG188) on the management of GS disease with the recommendation that bile duct clearance and cholecystectomy be offered for symptomatic and asymptomatic BDC. This retrospective audit was performed to determine compliance of a single centre with respect to offering cholecystectomy following ERCP for BDC. Methods A retrospective audit was performed for the year 2018 at a single centre utilising the trust ERCP database. The audit was analysed against NICE guideline CG188 and specifically whether patients treated with ERCP for BDC were then treated with cholecystectomy or had a documented justification as to why cholecystectomy was declined. 2018 was chosen so that at least a 2-year period of follow-up could be analysed. As well as the trust ERCP database, the trust electronic documentation record and paper notes were consulted to determine compliance with the guideline. Results 149 ERCPs were performed on 121 patients at this centre in 2018. Of these, 82 patients were included as 39 had an ERCP for malignant disease or had already had a cholecystectomy. Of those 82, 51 (62%) had an ERCP as an emergency while 31 (38%) had an elective procedure. The median age was 65, 54% being male and 46% female. 45 (55%) had a cholecystectomy following ERCP, 29 as an emergency, and 16 electively. Of those 37 who did not have a cholecystectomy, 20 (54%) had no recorded documentation to justify a decision not to proceed to cholecystectomy. Conclusions GS disease has the potential to cause significant morbidity. If an ERCP has been performed for BDC, NICE recommends that cholecystectomy should be offered to mitigate further GS related complications. Patients may of course decline an operation, or a joint decision made not to pursue operative management due to identified surgical risks. This audit demonstrated that 54% of patients at this institution who did not have a cholecystectomy following ERCP had no documented reason why cholecystectomy was declined. Robust follow-up and documentation measures have since been put in place and a follow-up audit is being performed to monitor improvement.

A case report of spontaneous passage of large (>1.5 cm) common bile duct calculi (4 in number) through faeces

Gallbladder (GB) stones are commonly associated with common bile duct stones (CBDS). While they may remain asymptomatic, some may present with symptoms like biliary colic, jaundice and cholecystitis. Most of these stones in the CBD, if small, pass through faeces. Passing larger stones through faeces is relatively rare and if it does occur, is usually associated with fatal complications like acute pancreatitis. The authors reported a case wherein symptomatic large CBD stones were spontaneously passed through faeces and the patient was relieved of the symptoms and did not suffer any further complications. Choledocholithiasis is usually managed by endoscopic retrograde cholangiopancreatography or by laparoscopic or open choledocholithotomy. Spontaneous passage of small CBD and GB calculi through faeces although common is associated often with the development of pancreatitis. Passage of large CBD calculi (size >1.5 cm) through faeces is rarely seen.

Low invasive surgical treatment of choledocholithiasis in an elderly patient. Description of own clinical case and operating technique

In modern surgery, choledocholithiasis has acquired the status of an independent problem, on the solution of which the further progress of surgery of the hepatobiliopancreatoduodenal zone depends. The article is based on a clinical case of surgical treatment with a diagnosis of a complicated form of cholelithiasis, choledocholithiasis. Purpose of the study. To demonstrate minimally invasive surgical treatment of choledocholithiasis in an elderly patient, based on the example of our own clinical case. Materials and methods. A retrospective analysis of a case of surgical treatment of a complicated form of cholelithiasis, choledocholithiasis, in an elderly patient was carried out. The patient is 84 years old. The patient underwent endoscopic retrograde cholangiopancreatography (ERCP), non-cannulation papillosphincterotomy (NPST) and stenting of the common bile duct for choledocholithiasis. The calculi were not removed due to their large size. Later she turned to JSC “NSC” Neftyanik” (Tyumen). Results. Taking into account the patient’s extrahepatic bile duct calculi, the phenomena of previous cholangitis, the patient underwent laparoscopic cholecystectomy, choledochotomy, extraction of calculi and stent, intraoperative choledochoscopy, and completed the operation with laparoscopic choledochoduodenoanastomosis under ETN on 11/19/2019. Conclusion. In this clinical case, we come to the conclusion that the only possible treatment option is the removal of calculi. If it is impossible to remove calculi by minimally invasive antegrade or retrograde methods, they can be considered as preparing the patient for further radical surgical treatment. Modern minimally invasive methods, in particular, laparoscopy, makes it possible to carry out an operation at almost any age aimed at completely eliminating the disease, thereby improving the quality of life.

Management of common bile duct calculi in a tertiary care hospital in North East India

Background: Common bile duct calculi are frequently encountered in patients with cholelithiasis. Treatment ranges from endoscopic retrograde cholangiopancreatography (ERCP) to various surgical treatment modalities done either by laparoscopic or open techniques.Methods: This was a retrospective cross-sectional study carried out in General Surgery department of NEIGRIHMS Hospital from April 2014 to March 2020. Patients attending the hospital with choledocholithiasis during the time period have been included in the study.Results: A total of 82 patients were included in the study. The prevalence of common bile duct (CBD) calculi in patients attending NEIGRIHMS Hospital with symptomatic gallstone diseases was 5.16%. Treatments ranged from primary CBD closure or T-tube drainage after CBD exploration either by laparoscopic techniques, choledocho-duodenostomy and ERCP. Bile peritonitis in 9 patients and retained stone were observed in some patients who were managed accordingly. No mortality was seen in any patient.Conclusions: The number of patients with CBD calculi and symptomatic gallstone disease attending NEIGRIHMS Hospital is less and standard of care is provided to the patients with acceptable morbidity and mortality.

Extracorporeal Shock Wave Lithotripsy for Large Common Bile Duct and Pancreatic Duct Stones: Efficacy, Safety and Analysis of Factors That Favor Stone Fragmentation

Background: Extracorporeal shockwave lithotripsy (ESWL) with subsequent endoscopic extraction of residual fragments is an established treatment option in technically challenging situations for extraction of pancreatic and common bile duct calculi. Common bile duct (CBD) stone fragmentation rates of 71 to 95% have been reported with ESWL, leading to final duct clearance rates of 70 to 90%. While complete clearance of 76% and partial clearance of 17% of pancreatic duct calculi have been documented with ESWL, our study was undertaken to investigate the efficacy and safety of ESWL in clearance of difficult bile duct and large pancreatic duct calculi. Methods: The study population consisted of 61 patients who had either large or difficult bile duct calculi or large pancreatic duct calculi documented on ultrasonography abdomen or magnetic resonance cholangiopancreatography (MRCP). All patients were subjected to ESWL sessions with endoscopic nasobiliary drainage (ENBD) placement till stones got fragmented. Results: A total of 1,284 patients underwent ERCP for either choledocholithiasis or pancreatic duct calculi during the study period (June 2015 to December 2016). Out of them 61 patients had either large or difficult CBD calculi or large pancreatic duct calculi. Forty (65.57%) had choledocholithiasis (Group-A) and 21 (34.42%) had chronic calcific pancreatitis (Group-B). CBD was cleared in 37 patients (92.5%) and 3 patients (7.5%) underwent surgical intervention. Main pancreatic duct (MPD) was cleared in all patients with clearance rate of 100%. Conclusions: ESWL is an effective and safe method for clearance of difficult CBD and pancreatic duct calculi. Combined efficacy of duct clearance is >90%. Complications are minimal and managed conservatively.