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

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.

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 retrograde cholangiopancreatography (ERCP) is an effective minimally invasive approach for the treatment of choledocholithiasis, while successful extraction is hampered by large diameter of stones. Emerging studies have revealed the close correlation between biliary microbiota and common bile duct stones (CBDS).

Aims & Methods

We aimed to investigate the community characteristics and metabolic functions of biliary microbiota in patients with giant CBDS. The present study was designed as a case-control study, which was approved by the ethics committee of First Affiliated Hospital of Soochow University (approval number: 2020-082). Consecutive patients were prospectively enrolled from February 2023 to October 2023. The inclusion criteria were as follows: (1) CBDS were confirmed by at least one imaging examination; (2) no antibiotics use within three months. The patients who had a history of surgery involved in upper gastrointestinal tract or hepatobiliary system were excluded. The CBDS would be recognized as a giant stone if its diameter was larger than 15mm and the diameter ratio of stone against CBD was larger than 1.0. Bile samples were collected through ERCP. The microbiota was analyzed using 16S rRNA sequencing. Metabolic functions were predicted by PICRUSTs 2.0 calculation based on MetaCyc database. Bile acids were tested and identified using ultra performance liquid chromatography-tandem mass spectrometry.

Results

A total of 26 patients were successfully included into final analysis, 8 in giant stone (GS) group and 18 in control group. No significant difference concerning demographics was found between the two groups (Table.1). Distinct biliary microbial composition was identified in patients with giant CBDS, with a significantly higher abundance of Firmicutes at phylum level. The unique composition at genus level mainly consisted of Enterococcus, Citrobacter, Lactobacillus, Pyramidobacter, Bifidobacterium and Shewanella. Pyramidobacter was exclusively found in GS group, along with the absence of Robinsoniella and Coprococcus. The contents of free bile acids were significantly higher in GS group, including cholic acid (98.39μmol/mL vs. 26.15μmol/mL, p=0.035), chenodesoxycholic acid (54.69μmol/mL vs. 5.86μmol/mL, p=0.022) and ursodeoxycholic acid (2.70μmol/mL vs. 0.17μmol/mL, p=0.047). Decreasing tendency of conjugated bile acids were also observed. Metabolic pathways concerning cholelithiasis were abundant in GS group, including geranylgeranyl diphosphate biosynthesis, gluconeogenesis, glycolysis and L-methionine biosynthesis.

Table.1 Patient demographics and preoperative characteristics

Conclusion

This study demonstrated the community structure and metabolic potential of biliary microbiota in patients with giant CBDS. The unique biliary microbial composition holds valuable predictive potential for clinical conditions. These findings provide new insights into the etiology of giant CBDS from the perspective of biliary microbiota.

References

1. Committee ASoP, Buxbaum JL, Abbas Fehmi SM, Sultan S, Fishman DS, Qumseya BJ, et al. ASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasis. Gastrointest Endosc 2019;89:1075-1105 e15.
2. Manes G, Paspatis G, Aabakken L, Anderloni A, Arvanitakis M, Ah-Soune P, et al. Endoscopic management of common bile duct stones: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy 2019;51:472-491.
3. Nicoletti A, Ponziani FR, Nardella E, Ianiro G, Gasbarrini A, Zileri Dal Verme L. Biliary tract microbiota: a new kid on the block of liver diseases? Eur Rev Med Pharmacol Sci 2020;24:2750-2775.
4. Tan W, Chen R, Song J, He D, Wu J, Chen X, et al. Microbiota analysis with next-generation 16S rDNA gene sequencing in recurrent common bile duct stones. Ann Transl Med 2022;10:576.
5. Molinero N, Ruiz L, Milani C, Gutierrez-Diaz I, Sanchez B, Mangifesta M, et al. The human gallbladder microbiome is related to the physiological state and the biliary metabolic profile. Microbiome 2019;7:100.
6. Shen H, Zhu J, Ye F, Xu D, Fang L, Yang J, et al. Biliary Microbial Structure of Gallstone Patients With a History of Endoscopic Sphincterotomy Surgery. Front Cell Infect Microbiol 2020;10:594778.

Introduction

Aims & Methods

Results

Conclusion

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

Hilar malignant biliary stricture, caused by malignant tumors, often leads to late diagnosis due to subtle initial symptoms, resulting in poor outcomes. Effective endoscopic interventions significantly improve quality of life and survival, yet often lead to post-operative complications like cholangitis.

Aims & Methods

This study aims to assess the effectiveness and safety of utilizing sequential nasobiliary tube cutting as an alternative to stent placement post-nasobiliary drainage in patients, specifically in mitigating post-operative cholangitis. Additionally, to identify risk factors associated with the development of post-operative cholangitis.
Patients diagnosed at Hangzhou First People's Hospital from January 2015 to January 2023 were divided into nasobiliary tube cutting group and conventional stent group. The former underwent nasobiliary drainage followed by tube cutting when stable, transitioning from external to internal drainage, while the latter received standard stent placement. Statistical analyses compared postoperative cholangitis incidence, drainage success, interventions, complications, and hospital stay, further examining risk factors for postoperative cholangitis.

Results

1. This study encompassed a total of 208 patients, with 103 in the nasobiliary tube cutting group and 105 in the conventional stent group. Postoperative cholangitis occurred in 40 patients, with 12 cases (11.7%) in the nasobiliary tube cutting group and 28 cases (26.7%) in the conventional stent group, showing a statistically significant difference between the two groups (P=0.006). The number of patients whose total bilirubin levels decreased by more than 50% within 7 days postoperatively was 50 (48.5%) in the nasobiliary tube cutting group and 29 (27.6%) in the conventional stent group, a statistically significant difference favoring the nasobiliary tube cutting group (P=0.002). There was no statistically significant difference in the overall drainage success rate between the two groups (P=0.207). Besides postoperative cholangitis, there were no statistically significant differences in other postoperative complications between the two groups (P>0.05). The postoperative hospital stay was longer for patients in the nasobiliary tube cutting group than those in the conventional stent group, with median durations of 10.0 (7.0, 14.0) days versus 7.0 (5.5, 12.5) days, respectively, a difference that was statistically significant (P=0.024).
2. Based on whether postoperative cholangitis occurred, the patients were further categorized into a postoperative cholangitis group (n=40) and a non-postoperative cholangitis group (n=168). Univariate analysis revealed significant differences between the postoperative cholangitis group and the non-postoperative cholangitis group in terms of gender (male), Bismuth-Corlette classification (Type IV), number of ERCP procedures (≥2 times), and re-intervention (P<0.05). Multivariate logistic regression analysis identified Bismuth-Corlette classification (Type IV) (OR=3.207, 95%CI: 1.253-8.210, P=0.015) as an independent risk factor for developing postoperative cholangitis.

Conclusion

For patients with hilar malignant biliary stricture, sequential cutting of nasobiliary tubes as an alternative to stent placement after nasobiliary drainage can reduce the incidence of postoperative cholangitis and achieve early successful drainage, but it results in a prolonged postoperative hospital stay. Bismuth-Corlette classification (Type IV) is an independent risk factor for the development of postoperative cholangitis.

References

[1] VALLE J W, KELLEY R K, NERVI B, et al. Biliary tract cancer [J]. Lancet (London, England), 2021, 397(10272): 428-444.
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[3] ELMUNZER B J, MARANKI J L, GóMEZ V, et al. ACG Clinical Guideline: Diagnosis and Management of Biliary Strictures [J]. Am J Gastroenterol, 2023, 118(3): 405-426.
[4] PIMPINELLI M, MAKAR M, KAHALEH M. Endoscopic management of benign and malignant hilar stricture [J]. Digestive endoscopy : official journal of the Japan Gastroenterological Endoscopy Society, 2023, 35(4): 443-452.
[5] BANG J Y, HAWES R, VARADARAJULU S. Endoscopic biliary drainage for malignant distal biliary obstruction: Which is better - endoscopic retrograde cholangiopancreatography or endoscopic ultrasound? [J]. Digestive endoscopy : official journal of the Japan Gastroenterological Endoscopy Society, 2022, 34(2): 317-324.
[6] IRISAWA A, MIYOSHI H, ITOI T, et al. Recent innovations in therapeutic endoscopy for pancreatobiliary diseases [J]. Digestive endoscopy : official journal of the Japan Gastroenterological Endoscopy Society, 2020, 32(3): 309-315.

Disclosure

The authors declare that there are no conflicts of interest.