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 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

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

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) is now the gold standard for treating biliopancreatic conditions. With growing operator experience and significant advancements in endoscope and instrument design, outcomes have markedly improved. However, the procedure still carries a risk of complications and is not always successful in clearing bile duct stones on the first attempt. In this context, our study aims to evaluate the complication rate of ERCP in the management of common bile duct stones and to explore what factors predict failure to clear these stones during the initial procedure.

Aims & Methods

The aim of this study is to evaluate the predictive factors associated with failure of complete biliary stone clearance during the initial endoscopic retrograde cholangiopancreatography (ERCP) procedure. This is a retrospective, descriptive, and analytical study conducted over a 20-year period, from September 2005 to September 2025. It includes all patients with bile duct stones who underwent ERCP with endoscopic sphincterotomy, followed by stone extraction using standard techniques such as an extraction balloon or Dormia basket.

Results

A total of 1,080 ERCP procedures were performed for the extraction of bile duct stones. The mean age of the patients was 58.9 ± 14.4 years, with a female predominance (59.5%). The average diameter of the common bile duct (CBD) was 13.4 ± 4.31 mm, and biliary strictures were observed in 6.3% of cases. The primary duct clearance rate was 75.1%, while supplementary techniques were required in 22.7% of cases.
On univariate analysis, several factors were significantly associated with failure of stone clearance using standard techniques: younger age (OR: 0.9; 95% CI: -0.03 to -0.01; p < 0.001), male gender (OR: 0.7; 95% CI: -0.5 to -0.02; p = 0.036), history of cholecystectomy (OR: 1.3; 95% CI: 0.02 to 0.6; p = 0.035), presence of cholangitis (OR: 0.4; 95% CI: -1.1 to -0.4; p < 0.001), CBD dilation >15 mm (OR: 0.8; 95% CI: -0.2 to 0.1; p < 0.001), biliary stricture (OR: 0.3; 95% CI: -1.7 to -0.7; p < 0.001), and presence of impacted and/or large stones (OR: 0.1; 95% CI: -2 to -1; p < 0.001).
Multivariate analysis identified four independent predictors of primary clearance failure: presence of cholangitis (OR: 1.9; 95% CI: 0.2 to 1; p = 0.001), impacted and/or large stones (OR: 2.5; 95% CI: 0.5 to 1.3; p < 0.001), CBD dilation >15 mm (OR: 0.88; 95% CI: -0.17 to -0.07; p < 0.001), and biliary stricture (OR: 2.9; 95% CI: 0.4 to 1.7; p = 0.002).
Following the application of supplementary techniques, the overall bile duct clearance rate increased to 92.4%.

Conclusion

In our study, the main predictors of failure to achieve primary common bile duct clearance were cholangitis, the presence of impacted and/or large stones, CBD dilation greater than 15 mm, and biliary strictures.

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

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