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

Benign bile duct obstruction is commonly caused by choledocholithiasis, while hepato-biliary-pancreatic tumors contributed to the most of malignant obstruction. With the development of next generation sequencing technology, the existence of microbiota was confirmed in biliary system, both in healthy and illness population. The characteristics of biliary microbiota in malignant bile duct obstruction remains poorly understood.

Aims & Methods

This study aims to investigate the composition and metabolic functions of biliary microbiota in patients with malignant bile duct obstruction. 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 December 2022 to October 2023, including distal cholangiocarcinoma, hilar cholangiocarcinoma, pancreatic ductal adenocarcinoma, periampullary carcinoma and gallbladder carcinoma. The patients with choledocholithiasis served as controls. Bile samples were collected via endoscopic retrograde cholangiopancreatography. The inclusion criteria were as follows: (1) patients who suffered from bile duct obstruction; (2) all the diagnosis confirmed by imaging examinations or histopathological tests; (3) no antibiotics usage within the preceding three months. The exclusion criteria were as follows: (1) patients who were attacked by acute obstructive suppurative cholangitis or acute hepatic failure at the same time; (2) without gallbladder; (3) surgical history concerning upper gastrointestinal tract or common bile duct; (4) history of gastrointestinal or hepato-biliary-pancreatic neoplastic diseases. 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 56 patients were successfully enrolled in this study, 25 in the tumor group and 31 in the stone group. No significant difference concerning demographics was found between the two groups. A distinct biliary microbial community was identified in patients with malignant bile duct obstruction. Firmicutes accounted for 40.67% at the phylum level in the tumor group, followed by Proteobacteria (36.44%), Bacteroidetes (11.33%), Actinobacteria (6.81%) and Fusobacteria (3.71%). The unique composition at genus level mainly consisted of Prevotella, Uruburuella, Atopostipes, Clostridium IV, Halomonas, Tannerella, Porphyromonas, Achromobacter, Rouxiella, Campylobacter, Corynebacterium, Turicibacter, Muribaculum, Selenomonas and Alloprevotella. Notably, Clostridium IV, Halomonas, Rouxiella and Turicibacter were exclusively present in the tumor group. Bile acids levels were significantly lower in the tumor group (p<0.05), except for ursodeoxycholic acid and taurocholic acid. There are 22 metabolic pathways were enriched in the tumor group.

Conclusion

This study elucidates the community and metabolic potential of biliary microbiota in malignant bile duct obstruction. The findings offer valuable insights for disease assessment and provide a foundation for further research into the role of biliary microbiota in malignancy.

References

1. Xue C, Chu Q, Zheng Q, Yuan X, Su Y, Bao Z, et al. Current understanding of the intratumoral microbiome in various tumors. Cell Rep Med 2023; 4 (1):100884.
2. Helmink BA, Khan MAW, Hermann A, Gopalakrishnan V, Wargo JA. The microbiome, cancer, and cancer therapy. Nature medicine 2019; 25 (3):377-388.
3. Li Z, Chu J, Su F, Ding X, Zhang Y, Dou L, et al. Characteristics of bile microbiota in cholelithiasis, perihilar cholangiocarcinoma, distal cholangiocarcinoma, and pancreatic cancer. Am J Transl Res 2022; 14 (5):2962-2971.

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.

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

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

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

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