Clinical Case Summary

A 78-year-old man underwent cholecystectomy due to vesicular lithiasis in February 2023 at a private institution.
Six months later, he developed jaundice, prompting MRCP (revealing only mild bile duct dilation) followed by Endoscopic Retrograde Cholangiopancreatography (ERCP) at the same institution, which revealed a mucinous substance exiting the bile duct and raised suspicion of an irregularity in the proximal bile duct. A plastic biliary prosthesis was inserted, leading to clinical improvement.
The patient was referred to our institution for further evaluation. He was asymptomatic, but laboratory tests revealed hyperbilirubinemia (3.38 mg/dL) with elevated direct bilirubin (2.48 mg/dL), increased serum aminotransferases (AST 80 U/L, ALT 74 U/L), and cholestasis (AP 311 U/L, GGT 288 U/L). ERCP with cholangioscopy was performed: the plastic stent was removed; cholangiography showed a 12mm oval-shaped abnormality in the proximal common bile duct; cholangioscopy revealed a significant amount of mucus and a neoplasm with digitiform papillary projections consistent with a mucinous lesion observed in the aforementioned location. Biopsies confirmed high-grade intraductal papillary neoplasia of the bile ducts. The patient currently awaits evaluation for surgical resection of the extrahepatic bile ducts and biliary-enteric anastomosis.
Intraductal papillary neoplasms of the bile duct, though rare, are being increasingly diagnosed. They exhibit papillary growth within the bile duct with or without mucus production and have an 80% malignant potential. Despite this risk, they appear to have a better prognosis than classical cholangiocarcinoma. Aggressive surgical treatment is recommended due to the good prognosis.
This case highlights the importance of cholangioscopy in diagnosing this uncommon entity - the discharge of mucus through the bile duct should encourage the realization of cholangioscopy, even without obvious changes on cholangiography.

References

Chi H, Yan X, Tong W, Tian Q. SpyGlass guided PDT for advanced Intraductal papillary mucinous neoplasm of the bile tract: A case report and literature review. Photodiagnosis Photodyn Ther. 2024 Apr 18:104098. doi: 10.1016/j.pdpdt.2024.104098. Epub ahead of print. PMID: 38642727.
Le DK, Agarwal A. Intraductal papillary neoplasm of the bile duct. Proc (Bayl Univ Med Cent). 2019 Jan 7;32(1):124-125. doi: 10.1080/08998280.2018.1520623. PMID: 30956606; PMCID: PMC6442884.

Clinical Case Summary

A 77-year-old patient with diabetes insipidus underwent an abdominal computed tomography scan due to upper quadrant abdominal pain. The exam showed concentric thickening of the main and intrahepatic bile ducts. A subsequent magnetic resonance cholangiopancreatography, with diffuse thickening of the main and intrahepatic bile ducts, with diffusion restriction and reduced biliary duct caliber, without lithiasis. Due to the suspiecion of a malignant biliary stricture, the patient was proposed for endoscopic retrograde cholangiopancreatography (ERCP) with cholangioscopy. The cholangiogram showed diffuse rarefaction of the intra and extrahepatic bile ducts, with focal dilatation of the intrahepatic bile ducts. After biliary sphincterotomy, cholangioscopy revealed a narrowed main bile duct extending to the hepatic hilum, with neovascularization, and papillary projections. Multiple biopsies were taken and a plastic stent was placed. Cholangioscopy-guided biopsy revealed granulation tissue and stroma with numerous histiocytes and eosinophils. Immunohistochemistry identified histocytes expressing CD68, S100, and CD1a, consistent with biliary involvement by Langerhans Cell Histiocytosis. The procedure was complicated by acute pancreatitis, requiring Intensive Care Unit admission. The patient’s hydroelectrolytic disorders were caused by pituitary involvement (lymphocytic hypophysitis associated with granulomatous disease). The patient started corticosteroid therapy with clinical and analytical improvement.
Langerhans Cell Histiocytosis is characterized by histiocytes proliferation, with progressive fibrosis due to tissue infiltration. In this case, diabetes insipidus was the first disease manifestation, due to lymphocytic hypophysitis. LCH is a rare cause of secondary sclerosing cholangitis, and early diagnosis through cholangioscopy was essential to initiate appropriate systemic therapy, preventing disease progression with multiorgan involvement.

Introduction

Cholangioscopy-assisted electrohydraulic lithotripsy (CA-EHL) is a novel and effective method for the treatment of difficult bile duct stones that are refractory to conventional endoscopic therapy (CET).

Aims & Methods

Our objective was to compare the clinical and financial outcomes of CA-EHL and CET in the management of difficult bile duct stones.
Patients with difficult bile duct stones diagnosed via endoscopic retrograde cholangiopancreatography (ERCP) were retrospectively allocated into two groups: Group I: CET (January 1, 2022 – December 31, 2022), and Group II: CA-EHL (January 1, 2023 – January 31, 2025). Patient characteristics, success rate of stone removal, complication rates, mortality, unplanned readmissions within 30 days, intensive care unit (ICU) admissions, length of hospital stay, and cumulative treatment costs were analyzed.

Results

Group I included 37 patients, as did Group II. There were no significant differences between the groups in terms of median age (73 vs. 74 years), gender distribution (male:female = 16:21 vs. 13:24), or Charlson comorbidity index (median: 4 vs. 3; P>0.05). The success rate of stone clearance was significantly higher in Group II (32.4% vs. 91.9%; P<0.001). Surgical intervention was significantly more common in Group I (32.4% vs. 5.4%; P=0.006). Patients in Group II spent significantly less time in the surgical ward (average: 2.9 vs. 0.4; P=0.0466). There were no significant differences between the groups in the number of complications (9 vs. 11 cases, P=0.452), time spent in the internal medicine ward (median: 6 vs. 8 days; P=0.704), mortality, 30-day unplanned readmission, or ICU admission rates (P>0.05). The cumulative treatment cost was significantly higher in Group II (3,917 vs. 10,241 €/patient; P<0.001).

Conclusion

CA-EHL represents a safe and effective approach for managing difficult bile duct stones refractory to standard endoscopic techniques. Although the treatment is associated with higher costs due to the expensive instrument, it significantly enhances bile duct clearance and decreases the necessity for surgical intervention. These results support the broader adoption of cholangioscopy-guided lithotripsy in clinical practice, particularly for complex stone cases.

Clinical Case Summary

Introduction: Subtotal cholecystectomy (STC) is performed when inflammation or adhesions obscure anatomy, reducing the risk of bile duct injury. However, bile leakage is more common in STC (up to 27.8%) than in total cholecystectomy¹². We present a case of persistent bile leak following fenestrating STC (F-STC), refractory to ERCP with stenting, successfully managed by cystic duct embolization using Gelfoam.
Case description: A 25-year-old male underwent laparoscopic F-STC for acute cholecystitis with dense adhesions at Calot’s triangle. Due to ongoing bile leakage, a Jackson-Pratt drain was placed. By postoperative day 5, bilious output peaked at 1,788 mL/day (Figure 1). ERCP revealed contrast extravasation at the cystic duct and gallbladder remnant; a biliary stent was inserted (Figure 2). Despite this, output remained high (>1,600 mL/day). A second ERCP with cholangioscopy identified a long cystic duct remnant with a wide orifice into the CBD (Figure 3). Gelfoam slurry was injected into the cystic duct via the cannulation catheter, followed by stent replacement (Figure 4). Drain output dropped to 300 mL/day the following day. The patient was discharged on postoperative day 10 after drain removal. The biliary stent was removed one month later, with no recurrence of leakage.
Conclusion: Persistent bile leak after F-STC may result from a long, patent cystic duct remnant. Cystic duct embolization with Gelfoam offers a safe, minimally invasive rescue therapy when conventional ERCP fails³.

References

1. Nassar AHM, Ng HJ. Risk identification and technical modifications reduce the incidence of post-cholecystectomy bile leakage: analysis of 5,675 laparoscopic cholecystectomies. Langenbecks Arch Surg. 2021;407(1):213–223. doi:10.1007/s00423-021-02264-z
2. Ibrahim R, Abdalkoddus M, Mahendran B, et al. Subtotal cholecystectomy: is it a safe option for difficult gallbladders? Ann R Coll Surg Engl. 2023;105(5):455–460. doi:10.1308/rcsann.2021.0291
3. Pesce A, Palmucci S, La Greca G, Puleo S. Iatrogenic bile duct injury: impact and management challenges. Clin Exp Gastroenterol. 2019;12:121–128. doi:10.2147/CEG.S169492

Disclosure

No conflict of Interest Need to be Disclosed

Introduction

Endoscopic retrograde cholangiopancreatography （ERCP） with sequential cholecystectomy is the preferred treatment for patients with choledocholithiasis and cholecystolithiasis.

Aims & Methods

Aims: To investigate the incidence of residual common bile duct (CBD) stones in choledocholithiasis combined with cholelithiasis patients who undergoing ERCP and subsequent cholecystectomy, and analysis the related factors of postoperative residual stones.
Methods A retrospective analysis was performed for the clinical data of a total of 301 patients who underwent endoscopic removal of CBD stones via ERCP followed by cholecystectomy in Hangzhou First People's Hospital from January , 2017 to July, 2022. Endoscopic nasobiliary drainage tube was placed after clearance of CBD stones by ERCP in all people until cholecystectomy. Postoperative residual common bile duct stone were detected by nasobiliary cholangiography after cholecystectomy or found in follow-up within 6 months after cholecystectomy, which were confirmed and removed by ERCP. All patients were divided into residual group and non-residual group. Possible factors associated with postoperative residual CBD stones were collected and statistically analyzed, including clinical characteristics, test indices, bile duct anatomical factors, CBD stones and gallbladder stone characteristics, endoscopic factor.

Results

1. According to the inclusion and exclusion criteria, a total of 301 patients underwent cholecystectomy after endoscopic extraction in this study. 54 patients discovered suspicious residual CBD stones by nasobiliary cholangiography, of which 50 patients were confirmed to have residual stones by ERCP. 5 patients were found and removed residual CBD stones within 6 months follow-up by ERCP. The incidence of postoperative residual CBD stones was 18.3%(55/301), and nasobiliary cholangiography had a positive predictive value of 92.6%(50/54).
2. The results of univariate analysis showed that there were significant differences between the two groups in gallbladder triangle adhesion, cystic duct diameter≥5mm, CBD diameter≥15mm, multiple CBD stones, CBD stones diameter≥10mm, and applying of endoscopic mechanical lithotripsy (EML) (P<0.05). The multivariate logistic regression analysis showed that cystic duct diameter≥5mm (OR=2.297, 95% CI:1.193–4.421, P=0.013), and multiple CBD stones (OR = 2.613, 95% CI:1.017–6.717, P=0.046) were the independent risk factors for postoperative residual CBD stones.

Conclusion

There was a high incidence of residual CBD stones in patients with CBD stones combined with gall blader stones who underwent endoscopic stones extraction and subsequent cholecystectomy. Cystic duct diameter≥5mm and multiple CBD stones were independent risk factors for postoperative residual CBD stones. Patients with high-risk factors should be followed-up carefully for early detection of postoperative residual CBD stones.