Endoprostheses are commonly used in the treatment of biliary and pancreatic disorders. Fully-covered metal stents are intended for the palliation of malignant strictures in the biliary tree. We report a case of a patient affected by cancer of the pancreas who was treated with a proximal metallic biliary stent. The stent migrated to the oesophagus and was endoscopically removed. Proximal migration, although rare, should be kept in mind as a potential complication of the procedure.

There are more octogenarians presenting with gallstone disease each year. Many are not suitable for surgical intervention. An alternative treatment option for common bile duct stones in the elderly is endoscopic retrograde cholangiopancreatography (ERCP) with or without stent insertion.

We conducted a retrospective study using a prospectively collected database, analysing the outcomes of consecutive patients >80 years old who underwent an ERCP in a single centre for the treatment of common bile duct stones.

In total, 156 patients, with a median age of 91 years, underwent an ERCP for choledocholithiasis over a 3-year period. ERCP was successful in 90% of patients but a proportion required repeat intervention. Forty-six (29%) patients had a concurrently inserted stent due to incomplete stone extraction. Six (4%) patients required a post-ERCP cholecystectomy due to ongoing symptoms. The overall ERCP complication rate was 7% (4% Clavien-Dindo 1 and 3% Clavien-Dindo 2), with no cases of post-ERCP pancreatitis or death. Patients were followed up over 5 years following index ERCP. There was a 60% 3-year survival and 30% 5-year survival rate following index ERCP. Importantly, of those who did not survive, only four patients (2.6%) had a death attributable to a biliary cause and none were fit for definitive surgery.

ERCP can be considered as a possible definitive management option for treating common bile duct stones in the elderly, particularly in the comorbid population. Concurrent stenting is an effective temporizing strategy and mitigator of biliary-related readmission, but routine stent changes should be considered. Key messages What is already known on this topic Current guidelines advocate for laparoscopic cholecystectomy and common bile duct exploration in patients with choledocholithiasis. What this study adds Endoscopic retrograde cholangiopancreatography with or without stent insertion is a safe, alternative single-treatment modality for choledocholithiasis in the elderly comorbid population. How this study might affect research, practice, or policy Studies and guidelines evaluating treatment options for choledocholithiasis may be altered to accommodate patient-specific factors, including age and comorbid status, and the concurrent use of stenting as a either a temporizing or longer-term measure for complex stone disease.

Some studies have investigated the efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) for octogenarians, but more and larger comparative studies are still needed.

From January 2008 to June 2011, patients who underwent ERCP for common bile duct stone removal were included and divided into three groups, based upon their age. Basic information, medical records, and ERCP operation notes were retrospectively reviewed.

868 patients were included, with 474 patients in Group 1 (<65 years old), 281 patients in Group 2 (≥65 years old and <80 years old), and 113 patients in Group 3 (≥80 years old). No difference was observed regarding the rate of complete stone removal and hospital stay among the three groups. Pancreatitis occurred more frequently in Group 1 than Group 3, and the incidence of pancreatitis in Group 2 had no statistical difference when compared with Group 1 or Group 3. The occurrence of biliary infection, hemorrhage, perforation, and other complications was not statistically different among the three groups. The mortality directly related to the ERCP procedure was zero (0).

ERCP is an effective and safe therapeutic method for stone removal in octogenarians, and age per se should not be a contraindication to endoscopic intervention.

Common bile duct exploration (CBDE) is an accepted treatment for choledocholithiasis. This procedure is not well studied in the elderly population. Here we evaluate the results of CBDE in elderly patients (>70 years) and compare the open (group A) with the laparoscopic group (group B). A retrospective review was performed of elderly patients with proven common bile duct (CBD) stones who underwent CBDE from January 2005 to December 2009. There were 55 patients in group A and 33 patients in group B. Mean age was 77.6 years (70-91 years). Both groups had similar demographics, liver function tests, and stone size-12 mm (range, 5-28 mm). Patients who had empyema (n = 9), acute cholecystitis (n = 15), and those who had had emergency surgery (n = 28) were more likely to be in group A (P < 0.05). The mean length of stay for group A was 11.7 ± 7.3 days; for group B, 5.2 ± 6.3 days; the complication rate was higher in group A (group A, 38.2%; group B, 8.5%; P = 0.072). The overall complication and mortality rate was 29.5% and 3.4%, respectively. CBDE can be performed safely in the elderly with accepted morbidity and mortality. The laparoscopic approach is feasible and safe in elective setting even in the elderly.

Biliary lithiasis is an endemic condition in both Western and Eastern countries, in some studies affecting 20% of the general population. In up to 20% of cases, gallbladder stones are associated with common bile duct stones (CBDS), which are asymptomatic in up to one half of cases. Despite the wide variety of examinations and techniques available nowadays, two main open issues remain without a clear answer: how to cost-effectively diagnose CBDS and, when they are finally found, how to deal with them. CBDS diagnosis and management has radically changed over the last 30 years, following the dramatic diffusion of imaging, including endoscopic ultrasound (EUS) and magnetic resonance cholangiography (MRC), endoscopy and laparoscopy. Since accuracy, invasiveness, potential therapeutic use and cost-effectiveness of imaging techniques used to identify CBDS increase together in a parallel way, the concept of "risk of carrying CBDS" has become pivotal to identifying the most appropriate management of a specific patient in order to avoid the risk of "under-studying" by poor diagnostic work up or "over-studying" by excessively invasive examinations. The risk of carrying CBDS is deduced by symptoms, liver/pancreas serology and ultrasound. "Low risk" patients do not require further examination before laparoscopic cholecystectomy. Two main "philosophical approaches" face each other for patients with an "intermediate to high risk" of carrying CBDS: on one hand, the "laparoscopy-first" approach, which mainly relies on intraoperative cholangiography for diagnosis and laparoscopic common bile duct exploration for treatment, and, on the other hand, the "endoscopy-first" attitude, variously referring to MRC, EUS and/or endoscopic retrograde cholangiography for diagnosis and endoscopic sphincterotomy for management. Concerning CBDS diagnosis, intraoperative cholangiography, EUS and MRC are reported to have similar results. Regarding management, the recent literature seems to show better short and long term outcome of surgery in terms of retained stones and need for further procedures. Nevertheless, open surgery is invasive, whereas the laparoscopic common bile duct clearance is time consuming, technically demanding and involves dedicated instruments. Thus, although no consensus has been achieved and CBDS management seems more conditioned by the availability of instrumentation, personnel and skills than cost-effectiveness, endoscopic treatment is largely preferred worldwide.

The objective of this study is to retrospectively evaluate factors significantly contributing to a failed stone extraction (SE) in patients with difficult to extract bile duct stones (BDS). Patients and Methods. During a 10-year period 1390 patients with BDS underwent successfully endoscopic sphincterotomy. Endoscopic SE was graded as easy; relatively easy; difficult; and failed. Difficult SE was encountered in 221 patients while failed SE was encountered in 205. A retrospective analysis of the criteria governing the difficulty of endoscopic SE following the index endoscopic intervention was performed to evaluate their significance in determining failure of complete SE among patients with difficult to extract bile duct stones. Results. Age ≥ 85 years, periampullary diverticula, multiple CBD stones (>4), and diameter of CBD stones (≥15 mm) were all significant contributing factors to a failed SE in univariate statistical tests. In the definitive multivariate analysis age, multiple stones and diameter of stones were found to be the significant, independent contributors. Conclusion. Failed conventional endoscopic stone clearance in patients with difficult to extract BDS is more likely to occur in overage patients, in patients with multiple CBD stones >4, and in patients with CBD stone(s) diameter ≥15 mm.

The rate of choledocholithiasis in patients with symptomatic cholelithiasis is estimated to be approximately 10%-33%, depending on the patient's age. Development of Endoscopic Retrograde Cholangiopancreatography and Laparoscopic Surgery and improvement of diagnostic procedures have influenced new approaches to the management of common bile duct stones in association with gallstones. At present available minimally-invasive treatments of cholecysto-choledocal lithiasis include: single-stage laparoscopic treatment, perioperative endoscopic treatment and endoscopic treatment alone. Published data evidence that, associated endoscopic-laparoscopic approach necessitates increased number of procedures per patient while single-stage laparoscopic treatment is associated with a shorter hospital stay. However, current data does not suggest clear superiority of any one approach with regard to success, mortality, morbidity and cost-effectiveness. Considering the variety of therapeutic options available for management, a critical appraisal and decision-making is required. Endoscopic retrograde cholangiopancreatography/EST should be adopted on a selective basis, i.e., in patients with acute obstructive suppurative cholangitis, severe biliary pancreatitis, ampullary stone impaction or severe comorbidity. In a setting where all facilities are available, decision in the selection of the therapeutic option depends on the patients, the number and size of choledocholithiasis stones, the anatomy of the cystic duct and common bile duct, the surgical history of patients and local expertise.

The advantages of endoscopic retrograde cholangiopancreatography (ERCP) over open surgery have made it the predominant method of treating patients with choledocholithiasis. After sphincterotomy, however, 10%-15% of common bile duct (CBD) stones cannot be removed with a basket or balloon. Methods for managing "irretrievable stones" include surgery; mechanical, intraductal shock wave, and extracorporeal shock wave lithotripsy; chemical dissolution; and biliary stenting. Endoscopic biliary stent insertion, which is frequently used in specific situations, has both advantages and disadvantages. To maximize the advantages and minimize the complications of biliary endoprosthesis, it is important to recognize its proper indications and to apply the technique in proper situations.

We reviewed all publications cited in Pubmed and published through July 2011 on biliary endoprosthesis in patients with irretrievable CBD stones. We analyzed the indications, advantages, disadvantages, and long-term follow-up results of this technique.

Despite the occurrence of related complications, such as cholangitis, endoscopic placement of an endoprosthesis may reduce stone size, allowing later clearance of unextractable stones. Permanent biliary stenting may be a definitive treatment in selected elderly patients who are poor candidates for surgery.

Endoscopic biliary stenting remains a simple and safe method for patients with stones difficult to manage by conventional endoscopic methods and those patients unfit for surgery or at high surgical risks.

This is a case series of erosion of the common bile duct by an in situ stent found incidentally during laparoscopic cholecystectomy (LC). To the best of our knowledge, this is one of the first reported incidences of this nature.

Four individual case reports.

Thirty nine patients with an in situ CBD stent underwent LC for symptomatic gallstones in our institution over a 4-year time period (2005 to 2009). Four patients were found to have the stent eroding through the wall of the CBD. In these four patients, endoscopic retrograde cholangiopancreatography (ERCP) had previously been performed - extracting stone(s) - followed by sphincterotomy and insertion of a 7 Fr pigtail stent (measuring 4 cm). The operation was converted to open in two patients, and the procedure was abandoned in one of these cases. In the other two patients, the anatomy of Calots triangle was delineated well, and the operator was able to complete LC. The duration between initial pigtail stent insertion and LC ranged from 32 to 400 days. None of our patients required a definitive surgical repair of the CBD or T-tube placement. The stent was removed during surgery in one case, removed endoscopically at a later date in two patients, and passed spontaneously in one patient. All four patients made a good postoperative recovery.

CBD erosion is a complication of plastic biliary stent insertion. CBD stent erosion will make surgery more hazardous especially if it remains in situ for a significant period of time. CBD erosion can generally be managed conservatively without the need for surgical repair. Awareness of this complication should prompt earlier surgery or earlier removal of plastic pigtail stents.

The management of obstructive jaundice resulting from both benign and malignant causes relies heavily on minimally invasive techniques and particularly with the insertion of biliary endoprostheses. Migration of these biliary stents is a well-documented problem and can result in a variety of complications including perforation, intra-abdominal sepsis, fistulae formation, obstruction and appendicitis.

A literature search was performed using PubMed examining case reports, published abstracts and reviews to date (2009). In addition, we report a left groin abscess as a previously unreported complication following migration of a biliary endoprosthesis.

Stent migration can lead to serious complications and produce significant morbidity and mortality. Symptomatic patients especially those with other co-morbid abdominal pathologies such as colonic diverticulae, parastomal hernia or abdominal hernias may be at an increased risk of perforation especially when straight plastic stents are used.

Endoscopic sphincterotomy (ES) and stone extraction is the treatment of choice for bile duct stones. Therefore, if ES and conventional stone extraction fail, further treatment is mandatory. Insertion of a biliary endoprosthesis is an effective option.

We treated 30 high-risk patients (17 women and 13 men, mean age 82 years) affected by difficult common bile duct stones. The patients were randomly assigned preoperatively using closed envelopes (blind randomization) into two groups to receive insertion of polyethylene or hydrophilic hydromer-coated polyurethane stent, respectively. Follow-up was achieved by contacting referring physicians and patient's relatives.

Biliary drainage was established in all patients. Early minor complications occurred in 28%. In all these patients, the stent was a definitive measure. Median follow-up was 38 months. Late complications occurred in 34%. Cholangitis was the most frequent. During follow up, 11 patients died, two as result of a biliary-related cause. No statistically significant difference was observed on different stents patency.

Endoprosthesis insertion as a permanent therapy is an effective alternative to surgery or dissolution therapy. Therefore, biliary stenting should preferably be restricted to high-risk patients unfit for operative treatment and with a short life expectancy.

Endoscopic papillary balloon dilation (EPBD) is a possible alternative to endoscopic sphincterotomy for the treatment of bile duct stones. However, little information is available in the elderly.

Our purpose was to evaluate the safety and efficacy of EPBD for bile duct stones in patients of 85 years of age and older.

Retrospective study from a single center.

Tertiary care facility with experience in bile duct stone removal with EPBD.

A total of 406 patients (74 patients >/=85 years old, group A; 332 patients <85 years old, group B) with bile duct stones underwent EPBD.

Efficacy and safety of EPBD between the 2 groups. Baseline patient characteristics were also evaluated.

The mean American Society of Anesthesiologists score in group A was significantly higher compared with that in group B (2.4 [0.5] vs 1.9 [0.7], P < .0001). Patients received anticoagulants more frequently and had larger and more numerous stones in group A than in group B with significant differences. Overall, bile duct clearance rates were similar in the 2 groups (91% vs 95%), but the mean number of sessions required for complete stone removal was significantly higher in group A (1.6 vs 1.4, P = .0081). The incidence of overall early complications after EPBD was lower in group A than in group B (2.7% vs 8.4%) but was not statistically different. None of the patients in group A had post-EPBD pancreatitis, whereas pancreatitis occurred in 5.7% in group B (P = .036). Bleeding was not observed after EPBD in 406 patients, including 7 patients in group A who received anticoagulation therapy at the time of EPBD. There was no significant difference in the cumulative stone nonrecurrence rate between group A and group B (log-rank test, P = .6225).

EPBD is a safe and effective technique for the treatment of bile duct stones even in high-risk elderly patients without an increased risk of pancreatitis and bleeding. Because the evaluation of outcomes might be biased by our study design (an open study), further studies are needed.

When common bile duct (CBD) stones cannot be removed after conventional endoscopic techniques or mechanical lithotripsy, biliary stenting serves for further planned endoscopic attempt of stone removal or operation. The aim of our study was to investigate the effect of ursodeoxycholic acid (UDCA) or placebo plus endoprostheses on stones' fragmentation or size.

Forty-one patients with difficult to extract CBD stones were prospectively studied. They were randomised to receive either a 10 Fr straight plastic stent and oral 750 mg UDCA (group A, 21 patients) or placebo (group B, 20 patients) daily for 6 months.

A total clearance of CBD was achieved in 16 patients (76.9%) of group A and 15 patients (75%) of group B. The stones remained unchanged in size in five patients (23.8%) of group A and five patients (25%) of group B. In seven patients (33%) of group A and five patients (25%) of group B a repeated ERCP demonstrated fragmentation of CBD stones that were easily extracted. A reduction in stones' size was observed in 8 patients (38%) of group A (1.61 +/- 0.32 cm before treatment vs. 1.21 +/- 0.24 cm after treatment, p = 0.002) and 10 patients (50%) of group B (1.61 +/- 0.35 cm before vs. 1.24+/-0.22 cm after treatment, p = 0.001). There was no statistically significant difference on stone size reduction (p = 0.602) and fragmentation (p=0.558) between the two groups.

The results of this study suggest that UDCA does not seem to contribute to the reduction in stones' size or stones' fragmentation during the endoprosthetic procedure.

Endoscopic biliary stenting is often used for large or difficult common bile duct (CBD) stones, but the effect of indwelling endoprosthesis on size or fragmentation of stones after long-term treatment with biliary stenting has not been formally established. We compared the stone size or fragmentation of common bile duct stones after a long period of biliary stenting.

Endoscopic biliary endoprosthesis was performed for 49 high-risk patients with CBD stones too large or difficult to be extracted by conventional endoscopic means. Bile duct drainage was established in all the patients without complications. Of the patients, 24 died with endoprosthesis in situ all from causes unrelated to biliar disease; 22 underwent a second and three patients a third attempt at stone extraction. The largest stone diameter was >12 mm in all patients.

In 11 of 25 patients (44%) the endoprosthesis allowed resolution of the problem of unextractable common bile duct stones. Four patients showed no existence of stent, and ERCP complete stone clearance from the CBD on programmized appointment after endoprosthesis insertion. Reduced size or fragmentation of stones was obtained in seven patients, and the stones could be removed endoscopically. The remaining 14 patients demonstrated no significant change in the size or fragmentation of their stones, and endoprostheses were replaced.

These results suggest that endoscopic endoprosthesis for large or difficult CBD stones is an effective method to clear the duct in selected cases, as well as an important definitive treatment in high-risk patients.

Internal drainage with transhepatically or endoscopically placed endoprostheses has been used for many years as a temporary or definitive treatment for biliary tract obstruction. As a late complication, stent migration may occur.

We reviewed our records to identify patients who were operated on for a migrated endoprosthesis that was causing complications. In all, five such patients were identified.

One patient had a large bowel perforation. Bowel penetration led to an interenteric fistula in one patient and to a biliocolic fistula formation in another. Small bowel distension was found in two patients. Surgical treatment consisted of local excision in three patients, segmental resection in one patient, and a bypass operation in the patient with biliocolic fistula. Postoperatively, four patients recovered without problems, but one patient died during a complicated postoperative course.

If a stent becomes stuck in the gastrointestinal tract and is not accessible for endoscopic removal, early operative revision is mandatory to prevent further complications.

Biliary diseases represent particular diagnostic and therapeutic problems in elderly patients.

Patients 90 years of age or older who underwent ERCP from January 1993 to September 2001 were studied retrospectively.

A total of 126 patients underwent 147 ERCP procedures (range 1-5 per patient). Twelve additional ERCPs were performed in 9 of the patients during follow-up because of recurrent symptoms. A total of 159 procedures were, therefore, available for analysis. The most frequent indications were suspicion of bile duct stones (46.8%) and obstructive jaundice (35.7%). Midazolam (95.6%) was used for conscious sedation and hyoscine (74.8%) for duodenal ileus. Patient tolerance of the procedure was good in 92.4% of sessions. Diagnoses included bile duct stones (54%), bile duct dilatation without any apparent obstruction (11.9%), and malignant stenosis (9.5%). Therapeutic procedures were indicated in 95.6% of diagnosed patients and completed in 96.3% of cases. Complications occurred in association with 2.5% of the ERCP procedures; the procedure-related mortality rate was 0.7%.

ERCP in elderly patients is practicable. The complication rate is low, and therapeutic efficacy is good.