Introduction

Treatment and follow-up strategies for silent gallbladder (GB) stones in patients prior to kidney transplantation (KT) have not been established.

Aims & Methods

We performed a retrospective cohort analysis comparing the risk of gallstone-related biliary complications and complications after cholecystectomy in KT recipients. By obtaining this information, we expected to evaluate the role of prophylactic cholecystectomy in KT recipients. A total of 2,295 KT recipients at Seoul National University Hospital from January 2005 to July 2022 were evaluated. Silent gallstones were identified from abdominal images(US, CT or MRI) 3 years before and 1 year after KT. The main outcome was the incidence of biliary complication and post-cholecystectomy complications and their severity in KT recipients. Secondary outcomes included death-censored graft failure (DCGF), graft failure (GF), and all-cause mortality. The Fisher exact test was used to assess the significance of the incidence of postoperative complications. The Kaplan-Meier (KM) curve was plotted for biliary complication-free survival in the observation group. The Cox proportional hazards model was used to identify risk factors associated with biliary complications in the observation group. A P<0.05 was considered indicative of statistical significance. All analyses were performed using the IBM SPSS Statistics 27.

Results

A total of 230 patients with gallstones were enrolled in this study. Among them, 16 underwent cholecystectomy prior to KT and 214 were followed without any intervention or surgery. Of the 214 patients observed, the median follow-up was 73.8 months and biliary complications occurred in 20 patients, with an incidence rate of biliary complications of 9.3%. 20 had acute cholecystitis, 2 had acute cholangitis, and 3 had gallstone pancreatitis. When cholecystectomy was performed, the incidence rates of postoperative complications were 6.3% in the pre-KT cholecystectomy group and 38.8% in the post-KT cholecystectomy group, respectively (p = 0.04). The severity of postoperative complications was based on the Clavien-Dindo classification, and the post-KT cholecystectomy group had a higher incidence of fatal complications greater than grade 4 compared to the pre-KT cholecystectomy group. Patients with multiple GB stones (adjusted hazard ratio [aHR] 2.46, 95% CI 1.56-8.30, p = 0.04), GB wall thickening ([aHR] 5.41, 95% CI 1.63-17.91, p = 0.006) and large GB stones greater than 1 cm ([aHR] 5.55, 95% CI 2.02-15.23, p = 0.001) were more likely to have biliary complications.

Table 4. List of postoperative complications in pre-KT and post-KT cholecystectomy group

Conclusion

Gallstone-related biliary complications and subsequent cholecystectomy after kidney transplantation results in more serious complications and worse treatment outcomes. Therefore, it may be helpful to recommend prophylactic cholecystectomy for KT candidate with significant risk factors for biliary complications, such as multiple gallstones, large gallbladder stone greater than 1cm or Gallbladder wall thickening.

References

1. Weaver L, et al. Kidney and pancreas transplant recipients undergoing cholecystectomy experience superior outcomes in transplant centers. HPB (Oxford). 2021;23(4):609-617.
2. Rinaldis A, et al. Cholecystectomy-Associated Complications in Kidney Transplant Recipients Compared With the General Population. Transplant Proc. 2021;53(7):2291-2297.
3. Sarkio S, et al. Complications of gallstone disease in kidney transplantation patients. Nephrol Dial Transplant. 2007;22(3):886-890.
4. Sianesi M, et al. The role of cholecystectomy in renal transplantation. Transplant Proc. 2005;37(5):2129-2130. doi:10.1016/j.transproceed.2005.03.028
5. Kao LS, et al. Should cholecystectomy be performed for asymptomatic cholelithiasis in transplant patients?. J Am Coll Surg. 2003;197(2):302-312.
6. Kao LS, et al. Prophylactic cholecystectomy in transplant patients: a decision analysis. J Gastrointest Surg. 2005;9(7):965-972.
7. Jackson T, et al. Management of asymptomatic cholelithiasis for patients awaiting renal transplantation. Surg Endosc. 2005;19(4):510-513.
8. Sarkio S, et al. Complications of gallstone disease in kidney transplantation patients. Nephrol Dial Transplant. 2007;22(3):886-890.
9. Greenstein SM, et al. Prevalence of asymptomatic cholelithiasis and risk of acute cholecystitis after kidney transplantation. Transplantation. 1997;63(7):1030-1032. doi:10.1097/00007890-199704150-00023
10. Melvin WS, et al. Prophylactic cholecystectomy is not indicated following renal transplantation. Am J Surg. 1998;175(4):317-319.

Disclosure

1

Introduction

Recurrent bile duct stones (RBDS) develop in up to 20% of patients after successful endoscopic clearance of initial stones. While anatomical and procedural risk factors are well recognized, the role of bile acid composition and bile microbiota in RBDS has gained attention. Bile acids, critical for cholesterol solubilization and intestinal homeostasis, may undergo deconjugation or biotransformation when exposed to intestinal flora via duodenobiliary reflux, altering their physicochemical properties and promoting lithogenicity.

Aims & Methods

We aimed to investigate whether alterations in bile acid composition and microbial colonization are associated with stone recurrence. A total of 184 patients who underwent biliary drainage at Konyang University Hospital (2019–2022) were enrolled. Patients were categorized into First Diagnosis Group (n=155) and Recurrence Group (n=29). Bile was aspirated after ERCP or PTBD, and 15 bile acids (5 unconjugated, 10 conjugated) were quantified using HPLC-MS/MS. Bile cultures were analyzed for microbial composition. Statistical comparisons were made using independent t-tests and chi-square analysis.

Results

Patients with RBDS were significantly older (77.8 vs. 69.0 years, P=0.005). Total bile acid concentration was lower in the Recurrence Group (4734 vs. 5902 ppm, P=0.083). Conjugated bile acids—including T-CA, T-DCA, G-CA, G-DCA, and G-LCA—were significantly reduced (P<0.05). Taurine-conjugated bile acids showed a marked decline (1326 vs. 1876 ppm, P=0.041). Primary bile acids were lower in the Recurrence Group (3272 vs. 4339 ppm, P=0.035), while the primary-to-secondary bile acid ratio was significantly decreased (3.29 vs. 7.35, P=0.001), indicating a shift toward hydrophobic bile.
Microbiologically, Enterococcus spp. were significantly more prevalent in the Recurrence Group (76% vs. 30%, P<0.001), particularly E. faecalis, E. casseliflavus, and E. gallinarum. Notably, E. faecalis possesses bile salt hydrolase (BSH) activity that can deconjugate bile acids, promoting accumulation of hydrophobic, poorly soluble forms. This aligns with the observed increase in unconjugated LCA and DCA.

Conclusion

Recurrent bile duct stone patients exhibit reduced levels of conjugated and primary bile acids and increased prevalence of bile-resident Enterococcus spp., known for bile salt hydrolase activity. These changes may lead to deconjugation, increased hydrophobicity, and impaired micelle formation, contributing to bile lithogenicity. These findings support the potential utility of bile acid profiling and bile microbiota analysis as predictive and preventive tools in RBDS management.

References

1. Hofmann AF, Mysels KJ. Bile acids as biological surfactants. Colloids Surf. 1987;30(1):145–173.
2. Begley M, Hill C, Gahan CG. Bile salt hydrolase activity in probiotics. Appl Environ Microbiol. 2006;72(3):1729–1738.
3. Choe JW, Lee JM, Hyun JJ, Lee HS. Analysis on microbial profiles and components of bile in patients with recurrent CBD stones after endoscopic removal: a preliminary study. J Clin Med. 2021;10(15):3303.
4. Ryu KH. Gut Microbiota and Pancreatobiliary System. Korean J Gastroenterol. 2020;75(5):231–239. (Korean)
5. Di Ciaula A, Garruti G, Baccetto RL, Molina-Molina E, Bonfrate L, Portincasa P. Bile acid physiology. Ann Hepatol. 2018;16(1):4–14.
6. Wang DQ, Cohen DE, Carey MC. Biliary lipids and cholesterol gallstone disease. J Lipid Res. 2009;50 Suppl:S406–S411.

Introduction

Insufficient disinfection of duodenoscopes, particularly the elevator site, can cause ERCP-related infections and serve as a significant source of multidrug-resistant (MDR) infection. To address this issue, a disposable elevator cap (DEC) was developed, and a recent randomized clinical trial demonstrated its effectiveness in reducing contamination following high-level disinfection. However, there is limited evidence in actual clinical practice to reduce cholangitis caused by MDR pathogens. This study aimed to compare the efficacy of the novel DEC duodenoscope with the standard duodenoscope in preventing infection transmission.

Aims & Methods

We conducted a prospective non-randomized cohort study in a single institution comparing baseline characteristics, technical performance, and incidence of acute cholangitis, including MDR pathogen, in 95 patients using a standard duodenoscope and 101 patients using a DEC duodenoscope.

Results

Age, sex, comorbidities, and indication for ERCP were similar between the two groups. However, the standard duodenoscope group had a higher proportion of naïve papilla (51% vs. 34%, p = 0.04), while the technical success rate was slightly higher in the DEC duodenoscope group (95% vs. 85%, p = 0.15). The rates of procedure-related adverse events were similar between the two groups (16% for DEC vs. 15% for standard). The incidence of post-ERCP cholangitis was also similar (10% for DEC vs. 11% for standard, p = 0.90). The proportion of post-ERCP cholangitis caused by MDR pathogens was similar in the two groups (1% for DEC vs. 2% for standard, p = 0.39).

Conclusion

​This study suggests that the technical performance of the DEC duodenoscope is similar to that of the standard duodenoscope. However, more clinical data are needed to confirm the efficacy of the DEC duodenoscope in preventing ERCP-related infection transmission.

Disclosure

Research grant from PENTAX MEDICAL

Introduction

Uncomplicated choledocholithiasis may progress to obstructive jaundice, cholangitis, or acute pancreatitis¹. The current therapeutic standard for choledocholithiasis is Endoscopic Retrograde Cholangiopancreatography (ERCP), however, this procedure is associated with a complication rate of approximately 10%. Identifying factors that contribute to spontaneous resolution of uncomplicated choledocholithiasis may allow clinicians to avoid unnecessary ERCP, thereby minimizing procedural risks and costs.

Aims & Methods

This retrospective cohort study was conducted to identify predictive factors for spontaneous passage of biliary stones in patients diagnosed with uncomplicated choledocholithiasis^​. We included patients who underwent ERCP for confirmed choledocholithiasis, excluding those with a history of prior ERCP or complications related to untreated biliary calculi, such as obstructive jaundice, acute cholangitis, or acute pancreatitis. The primary endpoint was the rate of spontaneous resolution of choledocholithiasis prior to ERCP.

Results

A total of 104 patients were included, 61.5% female with a mean age of 68 ± 14 years. Most patients (62.5%) presented with abdominal pain and/or abnormal liver enzymes, while the remaining 37.5% were diagnosed incidentally. Among the 104 patients, 21.6% showed no evidence of lithiasis on ERCP, despite the identification of stones >3 mm on imaging studies. The median time to the endoscopic procedure was similar between patients with and without stones on ERCP (12 IQR 25 vs. 15 IQR 24 weeks; p=0.821). Imaging findings, such as common bile duct ectasia (p=0.517), intrahepatic bile duct dilation (p=0.528), and the number of calculi (p=0.236), did not associate with spontaneous resolution. The average size of the largest stone was also comparable between patients with and without choledocholithiasis identified on ERCP (9 ± 4 mm vs. 8 ± 4 mm; p=0.452). The presence of peri-diverticular papillae did not impact the likelihood of spontaneous resolution (p=0.777). Remarkably, patients with an intact gallbladder exhibited a significantly higher rate of spontaneous resolution (31.5%) compared to those with prior cholecystectomy (6.1%, p=0.005). This association was confirmed as an independent predictor of spontaneous resolution (OR 7.1, 95% CI: 1.5–33.3, p=0.013).

Conclusion

Spontaneous resolution of uncomplicated choledocholithiasis is common, especially in patients with an intact gallbladder. Our data support a conservative approach in these patients, such as performing endoscopic ultrasonography immediately prior to ERCP to identify those who may not require intervention.

References

Manes, G. et al. Endoscopic management of common bile duct stones: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy 51, 472–491 (2019).

Introduction

Cholecystolithiasis is a common digestive disorder worldwide, affecting about 7% of adults aged 20-74 years. Laparoscopic cholecystectomy (LC) is considered as a safe and preferred surgical treatment for gallstone. Here, we assessed performance of ERCP-based transcystic duct gallbladder-preserving cholecystolithotom for patients having cholecystolithiasis with or without common bile duct stones.

Aims & Methods

A total of 41 patients having cholecystolithiasis with or without common bile duct stones (CBDS) and treated with ERCP-based transcystic duct gallbladder-preserving cholecystolithotom were enrolled in this study from March 2021 to April 2023 at the endoscopy center, Shenzhen University General Hospital.

Results

Of the 41 patients, 26 (63.4 %) had cholecystolithiasis without CBDS, while the rest 15 (36.6%) had concomitant cholecystolithiasis and CBDS. Among them, 33 (80.5%) patients had their gallbladder stones successfully removed by ERCP. The success rate of stone removal, operation time, and the full-covering metal stent (FCMS) implantation time were similar between patients with cholecystolithiasis only or with concomitant CBDS. The reported adverse events include post-ERCP pancreatitis (n=1), postoperative peritonitis (n=1), and postoperative acute cholecystitis (n=1), which were all resolved by subsequent intervention. Patients (n=33) who underwent this operation were followed up for 1 to 24 months, and none of them reported residue nor recurrence of gallbladder stones.

Conclusion

Cholecystolithiasis removal by ERCP-based transcystic duct gallbladder-preserving cholecystolithotom is a safe and effective treatment for cholecystolithiasis, and it preserves gallbladder function without incisions to abdominal wall or gastrointestinal tract. ERCP-based transcystic duct gallbladder-preserving cholecystolithotomis equally effective for cholecystolithiasis with or without CBDS.

Disclosure

Nil

Introduction

Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is becoming an important and effective alternative to percutaneous drainage (PTD) for patients not suitable for surgery. It is also an acceptable option for biliary drainage in oncologic patient, if retrograde drainage failed. Placing of a lumen apposing metal stent (LAMS) for EUS-GBD allows the removal of gallbladder stones too, so becoming a possible alternative to surgery in very selected cases.

Aims & Methods

The study aims to describe our endoscopic experience and management in patients unfit for surgery and in those oncologically advanced. Retrospectively analyzed cases with EUS-GBD, from December 2019 to September 2023, in a single peripheral hospital (Hopital Riviera-Chablais), using 3 types of LAMS (10x10mm, 15x10mm, 16x20mm), delivered with an electrocautery-enhanced catheter.

Results

EUS-GBD was performed in 23 patients (15:8=M:F) with median age of 83 years old (52-89). 13 patients (56.2%) had advanced cancer (6 pancreatic metastatic cancer, 5 cholangiocarcinoma, 1 breast metastatic cancer, 1 metastatic pulmonary NET) and 10 patients were affected by symptomatic lithiasic cholecystitis and they were not considered fit for surgery (whose 2 already received a PTD). EUS-GBD was attempted through the duodenum in all cases but one, previously treated with PTD and that was drained through the stomach. In one case, the stent was mis-deployed through the duodenum (without entering the gallbladder lumen), so requiring the placement of an over-the-scope-clip and a different biliary drainage for biliary obstruction in an oncological patient. A 15x10 mm LAMS was used in 14 cases, 10x10 mm LAMS was used in 6 cases (including the failed one), and 16x20 mm in 2 cases. A double pigtail 5 Fr 7cm was placed through all 22 successfully placed LAMS. 3 patients underwent electrohydraulic-lithotripsy (EHL) through the LAMS after 4-8 weeks. In 5 patients LAMS was then removed. Generally, except one complication, it was not described short term or long-term adverse events. 6/23 (26%) patients died for oncological disease progression and for other causes not procedure related.

Conclusion

EUS-GBD represents a promising therapeutic approach in patients with high risk of mortality. Considering the high rate of clinical and technical success as well as the possibility of managing endoscopically potential complications, this approach could be also proposed in peripheral centers and not only in advanced endoscopic ones.

References

1. Anthony Yuen Bun Teoh et al. EUS-guided gallbladder drainage versus laparoscopic cholecystectomy for acute cholecystitis: a propensity score analysis with 1-year follow-up data,
Gastrointestinal Endoscopy, Volume 93, Issue 3, 2021.
2. van der Merwe SW et al. Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2022 Feb;54(2):185-205.
3. McDonagh, P et al.Endoscopic Ultrasound-Guided Gallbladder Drainage for Malignant Biliary Obstruction: A Systematic Review. Cancers 2023, 15, 2988.