Introduction

T-tube drainage, primary closure, and biliary stenting are the common bile duct closure methods. There is great debate on the optimal duct closure technique after common bile duct exploration. This study aimed to assess the safety and efficacy of the three commonest common bile duct closure methods after common bile duct exploration for common bile duct stone for future generalization.

Aims & Methods

In this analysis, 211 patients with common bile duct stone underwent common bile duct exploration from January 2016 to December 2020. The patients were divided according to common bile duct closure techniques into three groups, including the T-tube drainage group (63 patients), primary duct closure group (61 patients), and antegrade biliary stenting group (87 patients).

Results

The incidence of overall biliary complications and bile leak were statistically significantly lower in the biliary stenting group than in the other two groups. Also, Hospital stays, drain carried time, return to normal activity, re-intervention, and re-admission rates were statistically significantly lower in the biliary stenting group than in the other two groups. There were no statistically significant differences regarding operative and choledochotomy time, retained and recurrent stone, stricture, biliary peritonitis, cholangitis, and the cost among the three groups.

Conclusion

We state that the biliary stenting procedure should be the preferred first option for common bile duct closure after common bile duct exploration when compared with T-tube drainage and primary duct closure.

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.

Introduction

Bile duct injury (BDI) is one of the serious complications of cholecystectomy procedures, which has a disastrous impact on long-term survival, health-related quality of life (QoL), health-care costs as well as high rates of litigation. The standard treatment of major BDI is hepaticojejunostomy (HJ). Surgical outcomes depend on many factors, including the severity of the injury, the surgeons' experiences, the patient's condition, and the reconstruction time. We aimed to assess the impact of reconstruction time and abdominal sepsis control on the reconstruction success rate.

Aims & Methods

This is a multicenter, multi-arm, parallel-group, randomized trial that included all consecutive patients treated with HJ for major post-cholecystectomy BDI from February 2014 to January 2022. Patients were randomized according to the time of reconstruction by HJ and abdominal sepsis control into group A (early reconstruction without sepsis control), group B (early reconstruction with sepsis control), and group C (delayed reconstruction). The primary outcome was successful reconstruction rate, while blood loss, HJ diameter, operative time, drainage amount, drain and stent duration, postoperative liver function tests, morbidity and mortality, number of admissions and interventions, hospital stay, total cost, and patient QoL were considered secondary outcomes.

Results

Three hundred twenty one patients from 3 centers were randomized into three groups. 44 patients were excluded from the analysis, leaving 277 patients for intention to treat analysis. With univariate analysis, older age, male gender, laparoscopic cholecystectomy, conversion to open cholecystectomy, failure of intraoperative BDI recognition, Strasberg E4 classification, uncontrolled abdominal sepsis, secondary repair, end-to-side anastomosis, diameter of HJ (< 8 mm), non-stented anastomosis, and major complications were risk factors for successful reconstruction. With multivariate analysis, conversion to open cholecystectomy, uncontrolled sepsis, secondary repair, the small diameter of HJ, and non-stented anastomosis were the independent risk factors for the successful reconstruction. Also, group B patients showed decreased admission and intervention rates, decreased hospital stay, decreased total cost, and early improved patient QoL.

Conclusion

Early reconstruction after abdominal sepsis control can be done safely at any time with comparable results for delayed reconstruction in addition to decreased total cost and improved patient QoL.

Introduction

ERCP is effective for common bile duct stone treatment but carries post-op risks like pancreatitis and cholangitis. Biliary drainage post-surgery is vital, with methods like ENBD and ERBD being common. ENBD allows monitoring but has drawbacks like infection and inconvenience. ERBD mitigates these but can cause complications. A new solution, Detachable biliary plastic stents without flanges, uses soft materials for self-expulsion, reducing the need for further procedures and patient burden.

Aims & Methods

This study aimed to investigate the efficacy and safety of using detachable biliary plastic stents without flanges for the prevention of cholangitis following endoscopic retrograde cholangiopancreatography (ERCP) in patients with common bile duct stones.
The study cohort comprised patients diagnosed with common bile duct stones and treated at the First People's Hospital affiliated with West Lake University School of Medicine between January 2019 and January 2024. Participants were randomly assigned to either the group receiving detachable biliary plastic stents without flanges or the nasobiliary drainage group. In the former group, the stents were deployed for biliary drainage following the clearance of stones during ERCP. The latter group received nasobiliary drains for similar purposes. Comprehensive clinical data were gathered, encompassing preoperative and postoperative details, including laboratory investigations, endoscopic procedures, complications, hospital stay, and comfort levels assessed using the Visual Analogue Scale (VAS). Additionally, the incidence of cholangitis, the rate of spontaneous drain removal, and stent detachment were compared between the two groups.

Results

1. The study included 820 patients who underwent ERCP for common bile duct stones. After accounting for 10 patients lost to follow-up, a total of 810 patients were analyzed, with equal distribution across both study groups. The incidence of postoperative cholangitis was 2.0% in the stent group and 3.0% in the nasobiliary drainage group, showing no significant difference (P=0.365). Pancreatitis occurred in 2.7% of patients in the stent group and 4.2% in the drainage group, also not statistically significant (P=0.248). No instances of perforation or bleeding were reported in either group.
2. The median postoperative hospital stay was significantly shorter in the stent group at 2.0 days (range: 1.0 to 4.0d) compared to 3.0 days (range: 2.0 to 5.0d) in the nasobiliary drainage group (P＜0.001).
3. The VAS scores for postoperative comfort were significantly lower in the stent group with a mean of 2.86±1.08 versus 5.13±2.19 in the nasobiliary drainage group (P＜0.001).
4. All 405 patients in the stent group returned for follow-up one month postoperatively. Stent detachment was confirmed in 373 patients (92.1%). Among the 32 patients with retained stents, two developed cholangitis, and two reported recurrent abdominal pain, resulting in a complication rate of 1.0%. In the nasobiliary drainage group, 10 patients (2.5%) spontaneously removed their drains, with an average age of 72.2±8.3 years.

Conclusion

The deployment of detachable biliary plastic stents without flanges following ERCP for common bile duct stones is as effective as traditional nasobiliary drainage in preventing postoperative cholangitis. This approach offers enhanced patient comfort, reduced hospital stay, and a high rate of spontaneous stent detachment, demonstrating its safety and efficacy in clinical practice.

Disclosure

The authors declare that there are no conflicts of interest.

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.