Introduction

The precise definition of a large stone is ambiguous, with sizes often ranging from 10 to 15 mm. Authors refer to a stone as "large" if its size exceeds the diameter of the CBD by more than 2mm (ratio of stone size to CBD diameter > 1). ​

Aims & Methods

Our study aimed to determine the threshold at which the diameter of the stone leads to endoscopic treatment failure.This research is a retrospective analysis that encompassed all patients who had endoscopic retrograde cholangiopancreatography (ERCP) for the treatment of common bile duct stones from January 2019 to December 2022. The examination of the ROC curve helped identify the threshold at which the diameter of the stone can predict the failure of the ERCP.

Results

We enrolled a total of 181 patients, with a mean age of 64 years (ranging from 22 to 103 years), and a male-to-female sex ratio of 0.41. The primary reasons for doing ERCP were the presence of remaining or recurring gallstones (69%, n = 129) or the need for sequential therapy (18%, n = 33). The efficacy of the first therapy was 61.5%. The mean stone size was 12.5mm, with a range of 3-40mm. Upon examining the ROC curve, it was determined that a diameter of 12 mm provided the highest accurate prediction of endoscopic treatment failure, with a sensitivity of 74% and a specificity of 73%. Univariate analysis revealed that the presence of a stone bigger than 12 mm was a significant predictor of failure of routine endoscopic therapy (p = 0.001). The average ratio of stone size to diameter of the CBD was 0.74 [0.27-1.67]. In our series, we found no significant association between this factor and ERCP failure (p = 0.276).

Conclusion

Within our dataset, we observed that stones larger than 12 mm were indicative of a higher likelihood of ERCP failure. There was no significant correlation between the ratio of stone size to the diameter of the common bile duct (CBD) and the failure of endoscopic therapy.

Introduction

It is recognised that large common bile duct (CBD) stones present a significant challenge in endoscopic practice. A key performance indicator of >80% clearance at the initial ERCP has been recommended to standardise quality of care. Standard techniques such as sphincterotomy +/- balloon sphincteroplasty are usually sufficient; however, in difficult cases, plastic stents are frequently placed to maintain biliary drainage, with elective repeat ERCP planned. When clearance remains unsuccessful, options such as mechanical lithotripsy or cholangioscopy may be employed, though these are often limited to tertiary care centres. Fully covered self-expanding metal stents (FCSEMS) have been proposed as a novel strategy to remodel the distal CBD and facilitate stone retrieval at subsequent procedures. While this approach is not currently included in formal UK guidelines, its use is expanding in complex cases. We report our early experience comparing plastic stents alone with a combination of fully covered metal stents and coaxial plastic stents in a secondary care setting.

Aims & Methods

This was a retrospective observational study conducted at a large secondary care NHS trust. We included patients undergoing ERCP between 2019 and 2024 in whom complete stone clearance could not be achieved at the initial procedure and a stent was placed. Only patients with confirmed choledocholithiasis and naïve papillae at first ERCP were included. All patients had large CBD stones, defined as stones greater than 10 mm in diameter. Patients were categorised according to whether a plastic stent alone or a fully covered metal stent with coaxial plastic stent was used at the index procedure. A 7Fr pigtail plastic stent was used in all cases; for the FCSEMS group, a fully covered metal stent was inserted with a plastic stent placed through it. Data were collected from endoscopy records and electronic patient notes. Outcomes assessed included complete stone clearance at second ERCP, need for mechanical lithotripsy, number of ERCP procedures, and referral to tertiary care for cholangioscopy. Fisher’s exact test and unpaired t-tests were used for statistical analysis.

Results

A total of 63 patients were included, with 46 in the plastic stent group and 17 in the FCSEMS group. Complete stone clearance for large stones (>10 mm) at second ERCP was achieved in 63.0% of patients in the plastic group compared with 76.5% in the FCSEMS group (p=0.380). Mechanical lithotripsy was required in 8.7% of plastic stent cases and 5.9% of FCSEMS cases (p=1.000). Referral to tertiary care for cholangioscopy occurred in 30.4% of the plastic group and 11.8% of the FCSEMS group (p=0.195). The mean number of ERCPs per patient was similar between groups, with an average of 2.50 procedures in the plastic group and 2.41 in the FCSEMS group (p=0.601).

Conclusion

The use of fully covered metal stents with coaxial plastic stents was associated with promising trends, including higher rates of complete stone clearance for large CBD stones and fewer referrals to tertiary centres. Although these findings did not reach statistical significance, they suggest a clinically relevant benefit that merits further investigation. The higher observed clearance rate and reduced need for cholangioscopy may support FCSEMS as a valuable adjunct in managing difficult bile duct stones. These results should be interpreted cautiously given the small size of our dataset, but they provide an encouraging basis for future prospective studies aimed at optimising CBD stone management and potentially reducing the need for tertiary care referral.

Disclosure

Nothing to disclose

Introduction

Periampullary diverticulum (PAD) is ordinarily asymptomatic, which is inspected occasionally during gastroscopy and endoscopic retrograde cholangiopancreatography (ERCP). Previous studies demonstrated inconsistent effect of PAD on ERCP procedures and choledocholithiasis recurrence. Thus, this study was aimed to investigate the impact of different types of PAD on the technical success, post-ERCP complications and the safety of different stone extraction methods, as well as the association of PAD with the recurrence of common bile duct stones (CBDS).

Aims & Methods

The ERCP database (March 2019 to March 2021) in West China Hospital of Sichuan University was retrospectively reviewed. Inclusion criteria were: 1) presence of original duodenal papilla; 2) patients with CBDS. However, patients with the following characteristics were excluded: 1) ERCP for other reasons; 2) absence of original papilla; 3) duodenal ampullary mass; 4) anatomical abnormalities caused by surgery; 5) under 18 years old; 6) incomplete clinical data. In this study, PAD is classified into three types based on the location of the duodenal papilla within the diverticulum (type I), the edge of the diverticulum (type II), and the outside of the diverticulum (type III). The successful cannulation, procedures of ERCP and post-ERCP complications were compared between the PAD group and the non-PAD group, as well as among the different types of PAD groups. The patients with successful stone removal were followed up every 6 months until December 2023 to determine whether PAD was associated with the recurrence of CBDS.

Results

A total of 830 CBDS cases with original duodenal papilla were eventually enrolled, including 239 cases with PAD and 591 cases without PAD. The successful cannulation rate in the PAD group was lower than that in the non-PAD group (96.7% vs. 99.2%, P = 0.013). According to the different types of PAD, the successful cannulation rate of type I PAD was lower compared with non-PAD group (76.9% vs. 99.2%, P<0.001). Additionally, PAD was associated with a wider bile duct diameter (1.55 ± 0.58 vs. 1.37 ± 0.50 mm, P<0.001), larger stone size (1.21 ± 0.68 vs. 0.97 ± 0.54 mm, P<0.001) and a higher rate of endoscopic sphincterotomy (EST) combined with endoscopic papillary balloon dilation (EPBD) (29.0% vs. 15.7%, P<0.001) and mechanical lithotripsy (41.6% vs. 26.5%, P<0.001) during the ERCP procedure. But PAD did not affect the incidence of post-ERCP complications. Of note, PAD group had a higher recurrence rate (18.8% vs. 7.3%, P<0.001) and shorter recurrence-free time (39.9 ± 13.3 vs. 42.8 ± 9.8 months, P = 0.005) compared with non-PAD group during follow-up period. Based on multivariate analysis, the presence of PAD (OR = 3.265, 95%CI: 1.854-5.751) was an independent risk factor for the recurrence of CBDS, after adjusting for age, gender and other factors.

Conclusion

PAD, especially type I PAD, decreased successful cannulation rate and increased the complexity of stone extraction of ERCP in CBDS. However, PAD did not affect the incidence of post-ERCP complications in CBDS, nor did it affect the choice of stone removal methods. PAD was an independent risk factor for the recurrence of CBDS.

Introduction

Common bile duct (CBD) stones can spontaneously migrate through the duodenal papilla. In this case, ERCP may be unnecessary and a significant rate of complications may be avoided..

Aims & Methods

Aims: The aim of our study is to evaluate the factors associated with spontaneous migration of CBD stones.
Methods:This is a retrospective descriptive and analytical study including 547 patients who underwent ERCP for CBD stones between January 2019 and September 2023.
All patients underwent MRCP for the diagnosis of CBD stones.
MRCP was considered positive if stones were present in CBD.
A positive ERCP was defined as the presence of stones in the VBP on cholangiography.
Patients were classified into 2 groups:
- Group A (n=309): positive MRCP and positive ERCP.
- Group B (n=265): positive MRCP but negative ERCP.
Statistical analysis was performed using JAMOVI software.

Results

The mean age in group A was 59.1 +/- 13.8 years and in group B 56.9 +/- 13.2 years, with no statistically significant difference (p=0.056).
The sex ratio (M/F) in group A was 0.7 and in group B 0.54, with a significant female predominance in both groups (p=0.03).
There was no statistically significant difference between the 2 groups in CBD diameter or presence of a periampullary diverticulum.
Comparing group A versus group B, patients with small stone diameter (P=0.001), a single stone (p=0,001) and distal stones (P=0.04) tended to pass their stones spontaneously.

Conclusion

In our study, the factors associated with spontaneous migration of CBD stones were a small stone diameter, a single stone and distal stones.

Introduction

Common bile duct (CBD) stones are one of the most frequent indications for endoscopic retrograde cholangiopancreatography (ERCP). Endoscopic complete sphincterotomy (EST) followed by balloon or basket extraction is widely considered the gold standard technique for the treatment of CBD stones; being successful in more than 90% of cases with approximately 5% overall rate of adverse events [1]. Endoscopic papillary large balloon dilatation (EPLBD) is an effective technique in treating large common bile duct (CBD) stones. However, the efficacy and safety of EPLBD in the setting of periampullary diverticula (PAD) are prospectively lacking.

Aims & Methods

This study aimed to compare the effectiveness and short-term safety of EPLBD after limited sphincterotomy with those of EST for extracting large CBD stones in the setting of PAD prospectively. Forty-eight patients with large CBD stone(s) > 1 cm were recruited. All patients had a PAD. Before the procedure patients were evaluated by history taking, clinical examination full investigations including proper imaging studies. During the procedure, patients were randomized to either group I; patients treated with EPLBD after limited sphincterotomy, and group II; patients treated with EST. CBD clearance was defined as a single procedure (EPLBD vs EST), single session (no repeat ERCP), and non-assisted (no lithotripsy used) stone extraction. After the procedure patients were hospitalized with clinical, laboratory, and imaging assessment.

Results

Table 1: Univariate regression of the parameters affecting stone extraction

PAD: periampullary diverticulum			* significant as P value≤ 0.05
	Odds ratio	95% CI	P value​
The used technique	5.92	1.32 to 25.3	0.009∗
Stone (s) number	0.62	0.17 to 2.25	0.468
Stone (s) diameter (mm)	2.59	0.63 to 10.56	0.187
Type of PAD​	1.32	0.65 to 2.67	0.437

The overall stone extraction rate in the current study was only 77.3% (n=34). The efficacy of stone extraction was significantly higher in the EPLBD (n= 21,87.5%) group compared to EST (n= 13, 54.17%) group (p = 0.011). The procedure-related adverse events were lower in the EPLBD group compared to the EST group. Pancreatitis was significantly higher in the EST (n=14, 58.33%) group than in the EPLBD (n=3, 12.5%) group (p= 0.001). There were no perforations or case fatalities in either group. The predictors of stone extraction were analyzed using univariate regression (Table 1), and it is noticeable that the used technique was the independent predictor of success in stone extraction (Odds Ratio: 5.92, 95% Confidence Interval: 1.38 to 25.30, p-value = 0.009).

Conclusion

The current practice guidelines of the ESGE and ASGE suggest that for large CBD stones, an EST followed by a large balloon dilatation is preferable to EST alone because combining dilatation with EST improves duct clearance and reduces the need for lithotripsy without adding risk. Our results among PAD patients seem to echo this: the EPLBD approach in comparison to EST yielded higher stone clearance on first attempt even without using lithotripsy by the study design. Hence, based on the current study these existing recommendations can be extrapolated to the PAD population based on our study which is one of the first randomized trials in the specific PAD subgroup.

References

1. Zippi M, Traversa G, Pica R, De Felici I, Cassieri C, Marzano C, et al. Efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) performed in patients with Periampullary duodenal diverticula (PAD). Clin Ter. 2014;165(4):e291-4.

Introduction

Recurrence of common bile duct (CBD) stones after initial treatment is estimated to occur in 5%-20% of cases¹, requiring additional interventions and is associated with adverse patient outcomes. Previous small scale studies evaluated the role of UDCA in the prevention of CBD stone^2,3. We aimed to investigate whether UDCA is effective in preventing de-novo CBD stone formation.

Aims & Methods

This was a cohort analysis. We analyzed the electronic records of patients diagnosed with cholangitis or choledocholithiasis who underwent endoscopic retrograde cholangiopancreatography (ERCP) with evidence of complete common bile duct (CBD) stone removal. Due to the lack of consistent evidence, recommendations for using ursodeoxycholic acid (UDCA) to prevent stone recurrence varied among endoscopists. All patients were contacted and interviewed after providing informed consent. The follow-up period was defined as the time from the index ERCP to either evidence of CBD stone recurrence or the date of the patient interview. The primary outcome was a documented case of CBD stone recurrence. We compared baseline variables and outcomes between patients who were recommended to receive UDCA following ERCP and those who did not receive a UDCA recommendation. We performed univariate survival analysis using the log rank score to compare survival distributions between groups.

Results

Ninety-eight patients were included in the analysis and contacted. Of these, 50 patients received a recommendation for UDCA treatment, and 30 patients took UDCA. Additionally, 48 patients did not receive any recommendation for UDCA, contributing to a total of 68 patients who did not take UDCA. Comparison of baseline characteristics, index ERCP findings and outcomes between groups is presented in Table 1. There were no significant differences in patient ages and rate of major comorbidities. Most patients undergone cholecystectomy more than 24 months prior to the index ERCP. Previous sphincterectomy was more common in the UDCA treatment group (70% vs 17.6%; p<0.01). No marked differences were noted in regard to other index ERCP findings between the two groups including papillary anatomy, number, size, type of stones and technique of stone removal (Table 1). No significant difference in stone recurrence was between patients who took and did not take UDCA (recurrence in 8/30 patients [26.7%] and 22/68 [32.4%] respectively, P=0.75). There was no significant difference in survival without recurrence between the two groups (p=0.84).

Conclusion

Our findings do not suggest efficacy of UDCA in prevention of de-novo CBD stone recurrence after cholecystectomy and complete CBD clearance.

References

1. Lammert F, Acalovschi M, Ercolani G, et al. EASL Clinical Practice Guidelines on the prevention, diagnosis and treatment of gallstones. J Hepatol. 2016;65(1):146-181. doi:10.1016/J.JHEP.2016.03.005
2. Yamamoto R, Tazuma S, Kanno K, et al. Ursodeoxycholic acid after bile duct stone removal and risk factors for recurrence: a randomized trial. J Hepatobiliary Pancreat Sci. 2016;23(2):132-136. doi:10.1002/jhbp.316
3. Swobodnik W, Janowitz P, Kratzer W, et al. [Preventing the recurrence of common bile duct calculi following endoscopic papillotomy with ursodeoxycholic acid]. Z Gastroenterol. 1990;28(11):621-625.

Disclosure

The authors report no conflict of interests

Introduction

Endoscopic removal of common bile duct stones (CBDS) via endoscopic retrograde cholangiopancreatography (ERCP) is the first-line treatment. In developed countries, the number of ERCP procedures for CBDS in elderly patients is increasing with the aging population. Elderly patients often present with poor performance status (PS), are frequently on antithrombotic therapy, and have multiple comorbidities. These factors raise concerns about an increased risk of ERCP-related complications; however, the safety and efficacy of ERCP in this population have not been fully evaluated.

Aims & Methods

The aim of this study was to assess the outcomes of ERCP for CBDS in elderly patients. Among 548 patients with symptomatic CBDS treated at our institution between April 2017 and February 2024, we excluded 81 cases involving altered anatomy, use of endosonography-assisted rendezvous technique, spontaneous stone passage, and biliary pancreatitis. The remaining 467 patients undergoing ERCP at our institution were retrospectively analyzed. The patients were divided into an elderly group (E group: ≥75 years, n=241) and a younger group (Y group: <75 years, n=226), and short- and long-term outcomes were compared between the two groups.

Results

Patient Characteristics: The median age was 81 years (range: 75–99) in the E group and 68 years (range: 21–74) in the Y group. Male sex was less frequent in the E group (55% vs. 68%, p=0.006). The E group had significantly higher rates of antithrombotic use (39% vs. 24%, p=0.001), American Society of Anesthesiologists physical status ≥ III (57% vs. 35%, p=0.001), and concomitant cholangitis (52% vs. 41%, p=0.012). Median stone size was slightly larger in the E group (8 mm vs. 6 mm, p=0.14), and the median bile duct diameter was significantly wider (10 mm vs. 9 mm, p=0.001). Comorbidities were more prevalent in the E group: cardiovascular disease (34% vs. 22%, p=0.004), hypertension (52% vs. 39%, p=0.004), malignancy (33% vs. 18%, p=0.001), and dementia (11% vs. 2%, p=0.001). Although endoscopic sphincterotomy (EST) was the most common papillary intervention in both groups, endoscopic papillary large balloon dilation (EPLBD) was more frequently performed in the E group (31% vs. 10%).Lithotripsy rates were similar between groups (22% vs. 16%, p=0.2).
Outcomes: Complete stone removal was achieved in 96% of the E group and 98% of the Y group (p=0.2). The median number of treatment sessions was 1 in both groups (range: 1–3, p=0.13). Overall complication rates were comparable (8% vs. 7%, p=0.63). In the E group, complications included pancreatitis (n=15), bleeding (n=5), perforation (n=1), and aspiration pneumonia (n=1); in the Y group, pancreatitis (n=10) and bleeding (n=5) were observed. No procedure-related mortality occurred in either group. There was no significant difference in the cumulative recurrence rate of stones after complete removal (p=0.29). Multivariate analysis using variables such as age, sex, presence of cholangitis, bile duct diameter, lithotripsy, and gallbladder stones revealed no definite predictors of recurrence.

Conclusion

Although recent studies have reported the potential utility of long-term biliary stenting in elderly patients, stent occlusion leading to cholangitis remains a concern. Repeated hospitalizations in elderly patients can decrease activities of daily living. Therefore, we prioritize complete stone removal in patients with a favorable long-term prognosis. This study demonstrates that even in patients aged 75 years and older, active treatment of CBDS via ERCP might be effective and safe.