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Percutaneous biliary interventions that can be inserted by interventional radiology. A Example of a percutaneous transhepatic biliary drain which can either be an external biliary drain in the intrahepatic ducts or an internal/external biliary drain that traverses the ampulla into the duodenum. B Example of an internal biliary stents that can be placed percutaneously under fluoroscopic guidance. Credits to BSIR and Boston Scientific for permission to use the images of the internal/external biliary drain and biliary stents
Source publication
Choledocholithiasis is a common presentation of symptomatic cholelithiasis that can result in biliary obstruction, cholangitis, and pancreatitis. A systematic English literature search was conducted in PubMed to determine the appropriate management strategies for choledocholithiasis. The following clinical spotlight review is meant to critically re...
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Despite technological advances, obstructive jaundice has significant morbidity and mortality rates. When studying obstructive jaundice, endoscopic retrograde cholangiopancreatography (ERCP), the "gold standard" for biliary obstruction identification, might be replaced with magnetic resonance cholangiopancreatography (MRCP), which is a...
Background:
Endoscopic retrograde cholangiopancreatography (ERCP) is an emerging option in the management of common bile duct stones and has a high success rate for biliary stone extraction. However, due to the lack of knowledge and understanding of this technique, some patients often experience varying degrees of anxiety and depression. There is...
A 61-year-old man presented with intermittent right-upper-quadrant pain, nausea, and vomiting. A CT scan of the abdomen revealed choledocholithiasis and large cholelithiasis. His medical and surgical history included severe obesity, Roux-en-Y gastric bypass, bowel perforation complicated by extensive resection and short gut syndrome, rheumatoid art...
Background
Choledocholithiasis is a common surgical presentation with an incidence of 8% to 16% in symptomatic cholelithiasis. Treatment often requires a multi-stage approach via endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC), which can prolong the length of stay (LoS) and expose patients to unnecessary...
Background
An estimated 8–15% of patients undergoing cholecystectomy have concomitant common bile duct stones. In this 14-year study, we utilize data of patients at a high-volume tertiary care academic center and compare the clinical outcomes of patients undergoing intraoperative cholangiography (IOC) and endoscopic retrograde pancreatography (ERCP...
Citations
... Meski tidak dapat menyingkirkan atau menegakkan adanya batu CBD secara langsung, kecuali CBD dan batu di dalamnya tervisualisasi, pemeriksaan ultrasonografi (USG) dapat membantu diagnosis apabila ditemukan pelebaran saluran empedu di dalam dan di luar hati (intrahepatic/extrahepatic bile duct, IHBD/EHB). 1,4,5 Penatalaksanaan yang standar digunakan saat ini untuk mengatasi batu CBD adalah endoscopic retrograde cholangiopancreatography (ERCP), atau dapat juga dilakukan kolesistektomi laparoskopi dengan tindakan eksplorasi saluran empedu. Di Amerika Serikat, ERCP biasanya diikuti oleh kolesistektomi laparoskopi pada batu saluran empedu yang disertai batu empedu. ...
... Dilatasi saluran empedu dapat berupa ukuran CBD >6 mm, dengan penambahan 1 mm tiap 10 tahun diatas usia 60 tahun, dilatasi CBD >10 mm pada pasien pascakolesistektomi, atau adanya pelebaran saluran empedu intrahepatic. 5,8,11 Skoring Batu CBD pada Pasien dengan Gejala Bilier ...
... Pada pasien dengan risiko sedang direkomendasikan MRCP atau EUS preoperatif, atau kolangiografi intraoperatif (IOC)/laparoskopik ultrasonografi intraoperatif, Sedangkan pada pasien dengan risiko tinggi disarankan prosedur untuk penanganan batu CBD. 4,5 Stratifikasi risiko diperlukan untuk menentukan kelompok pasien yang membutuhkan terapi yang lebih agresif. 12 Faktor-faktor yang berhubungan dengan peningkatan risiko mortalitas pada pasien ikterus obstruktif sehingga memerlukan tindakan dekompresi duktus biliaris terlebih dahulu, antara lain bilirubin total >10 mg/dL, usia <60 tahun, albumin <3 g/dL, hematokrit <30%, leukosit >10.000/mm 3 , ALP >100 IU, dan kreatinin serum >1,3 mg/dL. ...
Pendahuluan: Koledokolitiasis, adanya batu pada common bile duct (CBD), merupakan tantangan dalam bidang bedah digestif karena ragam kasus yang sangat bervariasi dengan tingkat kesulitan yang berbeda-beda. Hingga saat ini, pilihan modalitas diagnosis dan terapi semakin berkembang, baik dari prosedur noninvasif hingga invasif. Oleh sebab itu, Perhimpunan Spesialis Bedah Digestif Indonesia (IKABDI) memberikan rekomendasi terhadap pengelolaan kasus batu CBD di Indonesia.Metode: Konsensus disusun menggunakan survei Delphi yang melibatkan para pakar bedah digestif dari berbagai kota di Indonesia. Berbagai isu terkait diagnosis dan tatalaksana batu CBD disusun dan dijawab sesuai dengan penelitian terkini, namun juga mempertimbangkan pendapat dari para pakar.Hasil: Konsensus ini terdiri dari dua bagian, yaitu 15 rekomendasi terkait pemilihan modalitas diagnosis dan 10 rekomendasi terkait pilihan tatalaksana. Rekomendasi terkait diagnosis mencakup penggunaan ultrasonografi, CT-scan abdomen, dan magnetic resonance cholangiopancreatography (MRCP). Selain prosedur terapeutik standar, konsensus ini juga memberikan rekomendasi mengenai prosedur terkini, seperti endoscopic retrograde cholangiopancreatography (ERCP), laparoscopic common bile duct exploration (LCBDE), hingga open common bile duct exploration (OCBDE).Kesimpulan: Rekomendasi ini diharapkan dapat membantu para ahli bedah digestif dalam memberikan tatalaksana terbaik pada kasus batu CBD.
... For those who present to the hospital with clear subjective and objective evidence of common bile duct stones, symptomatic management is initiated, and subsequent endoscopic retrograde cholangiopancreatography (ERCP) for stone clearance is the standard of care [3]. Guidelines from multiple societies including the American Society for Gastrointestinal Endoscopy (ASGE), the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), the European Society of Gastrointestinal Endoscopy (ESGE), the British Association for the Study of the Liver (EASL), the British Society of Gastroenterology (BSG) and the National Institute for Health and Care Excellence in United Kingdom (NICE) [3,[5][6][7][8][9] all advocate for stone clearance by ERCP in patients with symptomatic choledocholithiasis as data show a clear benefit [10]. There is a subset of patients however, who are incidentally found to have choledocholithiasis while undergoing cross-sectional imaging despite having no related symptoms. ...
Background and Aims
Endoscopic retrograde cholangiopancreatography (ERCP) is the standard of care for the management of choledocholithiasis but carries risk of complications which may result in significant morbidity and mortality. While currently available guidelines endorse the use of ERCP for the management of symptomatic common bile duct stones, the need for ERCP in incidentally found asymptomatic choledocholithiasis is more controversial, and practice varies on a geographic and institutional level. This systematic review and meta-analysis is conducted to compare post-ERCP adverse events between asymptomatic and symptomatic choledocholithiasis patients.
Methods
We searched PubMed/Embase/Web of Science databases to include all studies comparing post-ERCP outcomes between asymptomatic and symptomatic choledocholithiasis patients. The primary outcome was post-ERCP pancreatitis (PEP), while secondary outcomes included post-ERCP cholangitis, bleeding, and perforation. We calculated pooled risk ratios (RR) and 95% confidence intervals (CIs) using the Mantel–Haenszel method within a random-effect model.
Results
Our analysis included six observational studies, totaling 2,178 choledocholithiasis patients (392 asymptomatic and 1786 symptomatic); 53% were female. Asymptomatic patients exhibited a higher risk of PEP compared with symptomatic patients (11.7% versus 4.8%; RR 2.59, 95% CI 1.56–4.31, p ≤ 0.001). No significant difference was observed in post-ERCP cholangitis, bleeding, or perforation rates between the two groups.
Conclusions
Asymptomatic patients with choledocholithiasis appear to have a higher risk of PEP than symptomatic patients, while the risk of other post-ERCP adverse events is similar between the two groups. Interventional endoscopists should thoroughly discuss potential adverse events (particularly PEP) with asymptomatic patients before performing ERCP and utilize PEP-prevention measures more liberally in this subgroup of patients.
... The management of choledocholithiasis, particularly when it presents after LC, poses a significant challenge to surgeons worldwide [4,5]. This case report underscores the complexities involved in diagnosing and treating hidden bile duct stones post-cholecystectomy, a scenario that is not uncommon but often underreported in clinical literature. ...
This case report details the diagnostic and management challenges encountered with hidden bile duct stones post-cholecystectomy in a 58-year-old female patient. Despite a successful laparoscopic cholecystectomy, the patient developed sudden upper abdominal pain and jaundice, leading to the discovery of an impacted bile duct stone. The case underscores the limitations of conventional preoperative diagnostics and highlights the importance of advanced imaging techniques and a multidisciplinary approach for optimal outcomes. The successful extraction of the stone via endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy demonstrates the efficacy of this therapeutic strategy. This report emphasizes the need for heightened vigilance and comprehensive evaluation in the postoperative management of gallstone disease, contributing valuable insights into the complexities of choledocholithiasis post-cholecystectomy.
... An alternative method is extracorporeal shock wave lithotripsy (ESWL), which can be performed when mechanical lithotripsy is unsuccessful [3,49]. During this procedure, high-pressure electrohydraulic or electromagnetic energy is delivered extracorporeally, aiming to fragment the stones. ...
... An alternative method is extracorporeal shock wave lithotripsy (ESWL), which can be performed when mechanical lithotripsy is unsuccessful [3,49]. During this procedure, highpressure electrohydraulic or electromagnetic energy is delivered extracorporeally, aiming to fragment the stones. ...
... On the contrary, Billroth I surgery leaves intact the track towards the ampulla of Vater, permitting standard ERCP procedures. However, due to the rise of bariatric surgeries, the Roux-en-Y gastric bypass is the most common anatomical modification, in which either balloon enteroscopy-assisted ERCP or endoscopic ultrasound-directed transgastric ERCP (EDGE procedure) is performed [49,82,83]. The EDGE procedure was first introduced in 2014 [84], and includes the placement of a lumen-apposing metal stent (LAMS) under endoscopic ultrasound which connects the jejunum or gastric pouch to the excluded stomach, in order for the duodenoscope to be promoted. ...
Choledocholithiasis is one of the most common indications for endoscopic retrograde cholangiopancreatography (ERCP) in daily practice. Although the majority of stones are small and can be easily removed in a single endoscopy session, approximately 10–15% of patients have complex biliary stones, requiring additional procedures for an optimum clinical outcome. A plethora of endoscopic methods is available for the removal of difficult biliary stones, including papillary large balloon dilation, mechanical lithotripsy, and electrohydraulic and laser lithotripsy. In-depth knowledge of these techniques and the emerging literature on them is required to yield the most optimal therapeutic effects. This narrative review aims to describe the definition of difficult bile duct stones based on certain characteristics and streamline their endoscopic retrieval using various modalities to achieve higher clearance rates.
... На сегодняшний день наиболее широко распространенным лучевым методом для оценки состояния желчных протоков как по доступности, так и по скорости выполнения является ультразвуковой. Чувствительность УЗИ к холедохолитиазу, по разным оценкам, составляет от 11,8 до 83,7%, а специфичность -91% [7][8][9]. Антеградная (или чрескожная, чреспеченочная) холецистохолангиография, являясь малоинвазивной альтернативой интраоперационной холангиографии со схожим принципом выполнения (прямое введение контрастного вещества в желчные протоки под рентгеновским контролем), также является достоверным методом оценки состояния желчных протоков. Однако этот метод, в отличие от УЗИ, требует предварительной установки холецистостомы и сопряжен с ионизирующим излучением. ...
Objective . Our goal was to establish common bile duct (CBD) diameter reference levels for abdominal ultrasound and percutaneous transhepatic cholecysto-cholangiography (PTCC) measurements with relevance to age and gender across the cohort of patients with underlying gallbladder disease excluding any intra- or extrahepatic bile ducts lesions.
Materials and methods . 251 symptomatic patients with gallbladder disease and no signs of choledocholithiasis or biliary obstruction presenting to Liver and Pancreas Surgery Department, Sklifosovsky Research Institute for Emergency Medicine from January 2019 to June 2023 were reviewed. All the selected subjects underwent transabdominal ultrasound examination of hepato-biliary zone and PTCC. Common bile duct diameter, if not obscured, was measured at its widest visible portion by means of electronic calipers. The relationship between CBD size, age and gender was examined by nonparametric tests across stratified groups.
Results . Mean sonographic CBD diameter was as high as 4.99 ± 1.17 mm with no evidence of correlation with age or gender. Mean cholecysto-cholangiography CBD diameter made up 6.49 ± 1.52 mm and reflected a considerable increase with age only: patients under 60 had CBD diameter significantly narrower, then those over 60. Basing upon the 95-percentile, we derived upper reference limit of 6.0 mm for US measurements without age and sex association, and for PTCC measurements regarding distinct age groups (8.0 mm in subjects < 60 years and 9.0 mm in subjects ≥ 60 years). Diameter of common bile duct was substantially higher on cholangiograms versus sonograms.
Conclusion . Present study displayed notable common bile duct diameter discrepancies not only between ultrasound and cholangiography measurements, but also throughout age-dependent groups on cholangiograms. We imply those variations to be taken in consideration in case of contrasting various radiological evaluations of common bile duct, and in case of ruling out the diagnosis of choledocholithiasis or bile flow abnormality.
... Gallstones form as a consequence of cholesterol supersaturation in bile and decreased contractility of the biliary epithelium due to multiple factors including diet, hormones, and genetics. [1][2][3][4] The clinical presentation of choledocholithiasis ranges from completely asymptomatic to biliary colic and obstructive jaundice. 2 Where LFTs are within normal range and imaging is negative, the risk of developing choledocholithiasis is <10%. ...
... [1][2][3][4] The clinical presentation of choledocholithiasis ranges from completely asymptomatic to biliary colic and obstructive jaundice. 2 Where LFTs are within normal range and imaging is negative, the risk of developing choledocholithiasis is <10%. Where imaging shows mild dilatation of the common bile duct, without the presence of gallstones but with elevated LFTs, the risk rises to between 10 and 50%. ...
... Additional diagnostic methods include endoscopic ultrasound, which has a sensitivity and specificity of 95 and 97%, respectively. 2,3 Since 1974, ERCP has been the treatment of choice for choledocholithiasis. However, it is associated with a 6-15% rate of adverse events, such as pancreatitis, hemorrhage, and duodenal perforation. ...
... Additionally, early preoperative diagnosis of choledocholithiasis facilitates adequate planning of common bile duct (CBD) stone removal, preferably performed as a single-stage procedure. 4 Magnetic resonance cholangiopancreatography (MRCP) provides a noninvasive and fast modality with 80-95% sensitivity and 93-100% specificity for imaging the biliary tree. [5][6][7][8][9] Guidelines suggest that MRCP is recommended when strong or moderate signs of CBD stones are present. ...
Background:
Magnetic resonance cholangiopancreatography (MRCP) provides a noninvasive and fast modality for imaging the biliary tree when choledocholithiasis is suspected. Guidelines suggest that MRCP is recommended when strong or moderate signs of common bile duct (CBD) stones are present. Well-performed prospective studies are scarce regarding the sensitivity and specificity of preoperative MRCP in patients with acute cholecystitis in comparison with intraoperative cholangiography, ERCP, or choledochoscopy.
Methods:
We performed a prospective, observational population-based feasibility study in Central Finland Hospital Nova between January 2019 and December 2019. We examined the diagnostic performance of preoperative MRCP on consecutive patients with acute cholecystitis scheduled for index admission cholecystectomy. The accuracy of MRCP was verified with IOC, choledochoscopy, or ERCP. The interobserver reliability of the image quality of MRCP and the sensitivity and specificity of choledocholithiasis were observed independently by three experienced radiologists.
Results:
A total of 180 consecutive patients diagnosed with acute cholecystitis followed by index admission cholecystectomy were identified. MRCP was performed in 113/180 (62.8%) patients, and complementary perioperative imaging of the bile ducts was performed in 72/113 (63.7%) patients. The incidence of choledocholithiasis was high (29.2%). In acute cholecystitis, the sensitivity (76.2-85.7%) and specificity (84.3-92.2%) of MRCP were equally compared to the literature with unselected patient groups. The best visibility was observed in the common hepatic duct, the inferior CBD, and the central hepatic duct. The interobserver reliability was excellent for determining the size and quantity of CBD stones.
Conclusion:
In acute cholecystitis, MRCP yields high negative predictive value regarding detection of choledocholithiasis. If CBD stones were discovered, the interobserver reliability was excellent when measuring the size and number of CBD stones. The best-visualized area was the distal part of the biliary tract, which provides good preoperative workup if choledocholithiasis is present.
... Indicated for calculi larger than 1.5 cm, these techniques are associated with quite important complications (5-15%): perforations, instrument blockages, hemobilia, acute pancreatitides, angiocolitis. Multiple sessions are often required, with the procedure being repeated, thus adding extra risks (15)(16)(17). From our point of view, based on the experience presented here, 3 categories of therapeutic indications in CL could be outlined. Thus, the first category can be called the "endoscopic choledochus". ...
Introduction: Cholelithiasis still remains one of the most frequent pathologies encountered in surgical practice. The authors review the stages which marked the evolution of the treatment of choledochal lithiasis (CL) during the last 50 years, based on their own experience. From the exclusively surgical choledochus, we have reached a multidisciplinary therapy in which both endoscopy and interventional radiology have found their place. Material and Method: The authors studied 2 groups of patients: Group 1 included patients from the period 1959-1997 (38 years - 982 cases of choledocholithiasis) who underwent classical surgery. Group 2 included patients treated between 1997-2017 (20 years â?" 347 cases) in whom both endoscopic surgery and classic surgery were used to obtain choledochal clearance. The types of choledochal lithiasis (CL) according to which the method of obstruction clearance was decided upon and chosen are presented here. Results: All the patients in group 1 underwent classical surgery, representing 9.8% of operations for biliary lithiasis. In group 2, classical surgery was recorded in 23.4% of patients, and endoscopic surgery in 76.6% of them. We mention that there was no laparoscopic approach for the treatment of CL due to the absence of experience. In group 2 we recorded 26.3% endoscopic failure, while in the classical approach group there was 12.3% failure of obstruction clearance, the solution being biliodigestive anastomoses. Conclusions: The authors propose three categories of therapeutic indications in CL. A first category is represented by the "endoscopic choledochus", which includes migrated lithiasis. A second category is the "surgical choledocus". It is the situation of complex and complicated lithiases. Finally, there would be a third category - the "lithogenic choledocus". This last group includes the most aggressive lithiases with repeated relapses, panlithiases, etc. For categories 2 and 3, endoscopic - laparoscopic clearance attempts have no chance of success or are even contraindicated.
... In comparison, the negative predictive value (NPV) was 87.7% [17]. Table 4 concisely summarizes the current diagnostic guidelines for choledocholithiasis from various societies [16,18,19]. Notably, none of these guidelines include gallstone hepatitis or transaminase elevation in the high-likelihood criteria, nor do they specify the degree of transaminase elevation within the intermediate-likelihood criteria. ...
Background
Extreme transaminase elevation > 1000 international units per liter (IU/L) is typically caused by hepatocellular injury due to ischemia, drugs, or viral infection. Acute choledocholithiasis can also present with marked transaminase elevation mimicking severe hepatocellular injury, contrary to the presumed cholestatic pattern.
Methods
We searched PubMed/Medline, EMBASE, Cochrane Library, and Google Scholar for studies reporting the proportion of marked elevation of alanine aminotransferase (ALT) or aspartate aminotransferase (AST) > 1000 IU/L in patients with common bile duct (CBD) stones. A proportion meta-analysis with a corresponding 95% confidence interval (CI) was used to pool the proportion of patients with extreme transaminase elevation. I² was used to examine heterogeneity. We used CMA software utilizing a random effect model for statistical analysis.
Results
Three studies (n = 1328 patients) were included in our analysis. The reported frequency of ALT or AST > 1000 IU/L in choledocholithiasis patients ranged between 6 and 9.6%, with pooled frequency of 7.8% (95% CI 5.5–10.8%, I² 61%). The frequency of patients with ALT or AST > 500 IU/L was higher, ranging between 28 and 47%, with pooled frequency of 33.1% (95% CI 25.3–42%, I² 88%).
Conclusion
This is the first meta-analysis to study prevalence of severe hepatocellular injury in patients with CBD stones. Results revealed that approximately one-third of patients with choledocholithiasis present with ALT or AST > 500 IU/L. Furthermore, levels > 1000 IU/L are not uncommon. An elaborate work-up for alternative etiologies of severe transaminase elevation is likely unwarranted in cases with clear evidence of choledocholithiasis.
... Gallbladder stone disease has an overall prevalence of approximately 15%. Choledocholithiasis is present in about 10-20% of patients with symptomatic cholelithiasis [1][2][3][4][5]. Secondary choledocholithiasis remains the leading cause of common bile duct stones (CBDS), originating from migration of gallbladder stones into hepatocholedochal duct, while primary choledocholithiasis is a rare cause, mainly affecting the eastern population [4,6]. ...
... Recurrent primary choledocholithiasis is a chronic pathology conceptually characterized by recurrence of common bile duct stones after, at least, 6 months of cholecystectomy. Some risk factors are bile duct greater than 13-15 mm in diameter and with angle smaller than 145°, presence of periampullary diverticulum, biliary stricture or papilla stenosis, and identification of two or more stones in bile duct [3,[11][12][13]. ...
... There are specific predictors of choledocholithiasis, which include clinical findings (obstructive jaundice, acute pancreatitis, or cholangitis), abnormal hepatogram, and presence of a choledochal stone or bile duct dilatation >8 mm [3,4]. Based on this, patients are stratified in low, intermediate, or high risk of choledocholithiasis which will guide all diagnostic effort and, therefore, treatment approach [1,2,6,14]. ...
Common bile duct stones (CBDS) incidence is about 10–15%. Clinical signs and symptoms are nonspecific but when associated with biochemical tests and abdominal ultrasound, patients can be categorized into low, intermediate, and high risk of choledocholithiasis. These clinical, biochemical, and radiological predictors will direct the diagnostic approach through cholangio magnetic resonance, endoscopic ultrasound, laparoscopic ultrasound, or intraoperative cholangiography. Treatment options must consider technological availability, technical skills, stone size, and bile duct diameter. In general, it involves endoscopic retrograde cholangiopancreatography or surgery for CBDS clearance. For difficult stones, endoscopic sphincterotomy followed by large balloon dilation, mechanical lithotripsy, cholangioscopy-guided lithotripsy, and extracorporeal shock wave lithotripsy are described, mainly as a bridge procedure.
