Laparoscopic common bile duct exploration (LCBDE) is safe and efficacious. "Classic" LCBDE technique utilizes isolated choledochoscope-guided retrograde basketing; however, it is less effective than transcholedochal exploration. We report on the evolution of our LCBDE technique away from "classic" transcystic approach towards prioritizing antegrade clearance using a novel algorithm utilizing a variety of tools, which we term laparoscopic reverse cholangiopancreatography (LRCP).

We report an algorithm-driven LRCP technique for LCBDE that tailors intervention to the patient's anatomy and stone burden (size, location, number) seen on cholangiogram (IOC). For cystic ducts ≥4 mm, we use a choledochoscope-assisted technique versus a fluoroscopy-guided technique if <4 mm. For small stones, we use wire basketing (with the "classic" technique) or the "snow-plow" maneuver. For medium (≤10 mm) or multiple stones, we utilize sphincteroplasty plus "snow-plow" if needed. For large (>10 mm), we use laser or electrohydraulic lithotripsy. Fallback methods are ERCP or transcholedochal exploration.

We retrospectively reviewed our 80 LCBDE cases at a single Veterans Affairs hospital: 50 cases in the "classic" phase and 30 subsequent cases using LRCP. Transcystic clearance was significantly higher for LRCP at 97% vs. 56% during the "classic" phase (χ2=15.14, P<0.001). There was zero utilization of choledochotomy during LRCP.

Algorithm-driven LRCP dramatically improved transcystic clearance success and reduced reliance on choledochotomy. Our algorithm serves as a decision aid, allowing surgeons to utilize a variety of available tools for LCBDE.

The combined technology of laparoscopy, choledochoscope and gastroscope was used in the treatment of gallbladder stones combined with common bile duct stones, which consists of laparoscopic cholecystectomy (LC), laparoscopic common bile duct exploration with primary closure (LCBDE-PC) and combined gastroscopic and choledochoscopic transabdominal nasobiliary drainage (GC-NBD). The clinical effects of the combined technology were evaluated based on hospital stay, hospital costs, postoperative complications, recurrence of stones, and overall patient satisfaction.

From July 2017 to December 2020, 206 patients with gallbladder stones combined with common bile duct stones were reviewed retrospectively. According to the surgical method, the patients were divided into Triple-Scope group (LC + LCBDE-PC + GC-NBD), (n = 38), ERCP + LC group [endoscopic retrograde cholangiopancreatography (ERCP) followed by LC], (n = 96) and T tube group (LC + LCBDE + T tube drainage), (n = 72). The differences in stone size, hospital stay, hospital cost, postoperative gallstone recurrence rate and postoperative complications were compared among three groups.

No postoperative bile leak occurred in Triple-Scope group, and patients were discharged successfully, and the abdominal drain was removed around 3 days after surgery, and the nasobiliary drainage was removed around 5 days after surgery with a hospital stay of 9.5 ± 2.65 days. The length of hospital stay and hospital cost in the Triple-Scope group were lower than those in the ERCP + LC group (P < 0.01), but not significantly different from those in the T tube group (P > 0.05). The diameter of common bile duct and stone size were significantly larger in the Triple-Scope group and T-tube group than in the ERCP + LC group (P = 0.001; P = 0.004), and the recurrence rate of stones in the Triple-Scope group was not significantly different compared with those in the other two groups (P = 0.43).

For patients with gallbladder stones combined with common bile duct stones, the triple-scope combination is safe and effective with fast recovery, and it is worthy of clinical promotion and application.

Gallstone disease is common after gastric surgery and especially after weight loss from bariatric surgery. In patients with normal gastroduodenal anatomy, treatment of common bile duct stones (CBS) generally consists of, endoscopic retrograde cholangiopancreaticography (ERCP) and endoscopic sphincterotomy (ES), followed by cholecystectomy in a second stage. However, after gastric surgery the papilla may not be easily accessible endoscopically. The aim of our study was to evaluate the therapeutic success of single-stage laparoscopic cholecystectomy and common bile duct exploration (LCBDE) after previous gastric surgery.

In this observational cohort study, all LCBDE in patients with previous gastric surgery between January 2014 and July 2022 were retrospectively reviewed. Gastric surgery consisted of Roux-en-Y gastric bypass, BII subtotal gastrectomy, total gastrectomy and subtotal gastrectomy with Roux-en-Y reconstruction. Outcomes of interest consisted of successful duct clearance, postoperative adverse events and CBS recurrence.

Forty-four patients (M/F: 22/22) underwent LCBDE after previous gastric surgery, in which simultaneous cholecystectomy was performed in 38 cases. Median (range) age 68 (25-90) years. Presence of CBS was confirmed in 38 patients (85%), a choledochal polyp in one patient (2%) and recurrence of gastric cancer in another (2%). Duct clearance was successful in 37 out of 38 patients (97%). Median (range) length of stay after LCBDE was 1 (0-12) day(s). Eight patients developed a postoperative adverse event, of which three Clavien-Dindo > 3a complications. Three patients were readmitted. At a median (range) follow-up of 60 (24-120) months, no CBS recurrences were observed.

LCBDE is a safe technique, with a high rate of successful duct clearance after previous gastric surgery, even after previous cholecystectomy. In experienced centers, LCBDE provides a valid alternative for complex interventional endoscopy, omitting the need for the creation of a gastro-gastric fistula.

Choledocholithiasis is the leading cause of biliary pancreatitis and biliary sepsis. Endoscopic retrograde cholangiopancreatography (ERCP) is considered a minimally invasive treatment for choledocholithiasis. However, diagnostic ERCP should be avoided. We conducted a prospective trial in high-risk choledocholithiasis patients based on the American Society for Gastrointestinal Endoscopy (ASGE) 2019 criteria to investigate the diagnostic accuracy of the current guideline.

This multicenter, prospective cohort study included 240 consecutive patients. The primary outcome was the performance of the criteria in predicting choledocholithiasis. The secondary outcome was a percentage reduction in diagnostic ERCP when endoscopic ultrasound was used in tandem with ERCP in individuals without ascending cholangitis.

The overall criteria revealed a positive common bile duct (CBD) stone in 87.1% of patients. Regarding the diagnostic performance of each criterion, ascending cholangitis had a specificity of 67.7% and a positive predictive value (PPV) of 90.2%; total bilirubin >4 mg/dL and dilated CBD had a specificity of 74.2% and a PPV of 55.6%; and CBD stone on ultrasound/cross-sectional imaging had a specificity of 58.1% and a PPV of 89.2%. Of the 138 patients without ascending cholangitis who met the other two high-risk criteria and were sent for EUS first, 21 cases (15.2%) were able to avoid a diagnostic ERCP.

The current ASGE 2019 criteria yield acceptable choledocholithiasis diagnostic accuracy. Using endoscopic ultrasound to confirm CBD stones before ERCP can help almost half of patients with the specific condition of total bilirubin >4 mg/dL and dilated CBD to avoid diagnostic ERCP.

For treatment of common bile duct stones (CBDS), guidelines recommend a one-stage approach, including laparoscopic common bile duct exploration (LCBDE) or intraoperative endoscopic retrograde cholangiopancreatography (intraERCP). Studies show favourable outcomes with transcystic LCBDE (tLCBDE), but this technique is not widely adopted. The use of tLCBDE may be limited by several factors, but to what degree is unknown. The aim of this study is to examine the feasibility and, secondarily, outcomes of tLCBDE for patients undergoing removal of CBDS and laparoscopic cholecystectomy (LC) when tLCBDE is the first-line treatment.

A retrospective cross-sectional study including patients with removal of CBDS and LC at Horsens Regional Hospital during June 2017-March 2022. We classified patients into three groups: tLCBDE, preoperative ERCP (preERCP), and other procedures. The reasons for not performing tLCBDE were registered from medical charts. In the tLCBDE and the preERCP group, we registered clearance rate, postoperative complications, and subsequent ERCP.

In total, 229 patients received a procedure due to CBDS, of which 73% were emergency procedures. The groups were as follows: 179 (78%) tLCBDE, 25 (11%) preERCP, and 25 (11%) other procedures. preERCP was chosen due to the patient being unfit for emergency surgery, tLCBDE not being technically possible, and other reasons. Other procedures were chosen, because tLCBDE was not technically possible, lack of equipment or qualified surgeon, and other reasons. In the tLCBDE group, 94% of patients with CBDS were cleared, 5.6% had a complication of Clavien-Dindo grade ≥ 3, and 3.9% patients needed a subsequent ERCP.

tLCBDE is feasible, safe, and effective treatment which can be performed in the majority of patients with CBDS and should be considered an equivalent to ERCP or choledochotomy as first-line treatment of patients with CBDS. As some patients require ERCP or choledochotomy, tLCBDE should not be the sole treatment available.

Early and effective management of choledocholithiasis is imperative to decrease patient morbidity. Despite the widespread use of ERCP, advancements in laparoscopy and choledochoscopy have renewed interest in laparoscopic CBD exploration (LCBDE). This meta-analysis compares outcomes of 2-stage ERCP followed by laparoscopic cholecystectomy (LC) versus one-stage transcystic LCBDE plus LC.

A comprehensive literature search was performed in PubMed, CENTRAL, and Embase databases according to PRISMA guidelines. Studies were selected based on specific criteria. Data on stone clearance, postoperative pancreatitis, bleeding, mortality, and length of stay were extracted.

Seven comparative non-randomized studies enrolling 669 "one-stage LCBDE patients" and 724 "two-stage ERCP patients" were included. Overall, there were no statistically significant differences regarding the rates of stone clearance, pancreatitis, bleeding, and mortality between the 2 groups.

One-stage transcystic LCBDE is noninferior to the 2-stage ERCP + LC approach, supporting its use as a first-line treatment for choledocholithiasis.

In recent years, the use of ultrafine choledochoscopy has gradually increased in the treatment of cholelithiasis. However, stone incarceration and residual spasm of the sphincter of Oddi may be inevitable when an ultrafine choledochoscope is used alone.

To investigate the safety and feasibility of ultrafine choledochoscopy combined with low-dose atropine in the treatment of Oddi intersphincter stones.

Seventeen patients with Oddi intersphincter stones were retrospectively analyzed. The perioperative clinical data and follow-up information were collected.

Among the 17 patients, 3 were male and 14 were female. The mean age was 40.6 ± 13.9 years, and the mean diameter of the common bile duct was 7.8 ± 1.3 mm. All patients successfully underwent Oddi intersphincter stone removal using a combination of ultrafine choledochoscopy and low-dose atropine. No serious complications, such as postoperative hemorrhage, pancreatitis or bile leakage occurred in the 17 patients. During the one-year follow-up, none of the patients experienced stone recurrence.

Ultrafine choledochoscopy combined with low-dose atropine is safe and feasible for the treatment of Oddi intersphincter stones.

The aim of this study was to evaluate the efficacy, safety, and surgical outcomes of 2-stage management, namely preoperative endoscopic retrograde cholangiopancreatography (ERCP) + laparoscopic cholecystectomy (ERCP+LC) or LC + postoperative ERCP (LC+ERCP), as well as 1-stage management, LC + laparoscopic common bile duct exploration (LCBDE) for treating patients with gallstones and common bile duct stones (CBDS).

This retrospective study analyzed the data of 180 patients with common bile duct stones (CBDS) who were admitted to the Department of General Surgery at Tongji Hospital, Tongji University, between January 2019 and June 2021. The study included 3 groups: ERCP+LC (group 1), LC+ERCP (group 2), and LC+LCBDE (group 3), each consisting of 60 patients. Clinical metrics of the patients were collected and compared among the groups.

Group 3 had the shortest operation duration and hospital stay compared with group 1 and group 2. In addition, group 3 had the lowest long-term postoperative complications, particularly the recurrence rate of CBDS. The total cost was also the lowest in group 3. Furthermore, patients in group 3 had the lowest postoperative amylase levels. All patients in the study achieved successful stone clearance. There were no significant differences in the conversion to other procedures rate, postoperative alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin, and mortality among the three groups ( P > 0.05).

Both 1-stage management and 2-stage management are effective treatments for CBDS. The LC+LCBDE management is a safe treatment option, offering shorter hospital stays and operation duration, lower costs, and fewer complications.

Laparoscopic transcystic bile duct exploration (LTCBDE) represents a secure and efficacious approach for managing common bile duct (CBD) stones, particularly in patients concurrently undergoing laparoscopic cholecystectomy (LC). The decision to proceed with LTCBDE hinges on real-time assessment of the intraoperative cholangiogram (IOC), which is highly operator-dependent and poorly interpreted. No established criteria exist to guide the evaluation of IOCs for LTCBDE. This study aims to ascertain the concordance among surgeons, experienced in LTCBDE, on critical aspects of IOC interpretation.

A retrospective collection of IOC images of 40 patients who underwent LC, IOC, and LTCBDE at a tertiary university hospital between 2017 and 2018 was undertaken. Two hepato-pancreato-biliary (HPB) and 2 acute care surgery (ACS) specialists independently reviewed the images. They were tasked with assessing IOC features hypothesized to influence duct exploration and stone extraction complexity, along with overall suitability for LTCBDE based exclusively on the IOC images. Agreement percentages were calculated and Kappa inter-rater reliability statistics were assessed.

The overall agreement percentages concerning IOC features ranged between 52.5% and 82.5% with agreements surpassing 75% deemed robust. Maximum agreement was achieved in the interpretation of cystic duct morphology, whether straight or characterized by spiral valves. The concurrence for amenability of LTCBDE also demonstrated substantial accord among surgeons (ACS: 92.5%, HPB: 95%, total: 87.5%). Consistently high agreement was evident within specialty groups.

Anatomical attributes displayed superior agreement levels, as opposed to variables necessitating measurements. We recommend the development of a structured approach for the interpretation of IOC to facilitate surgical education in LTCBDE.

Endoscopic retrograde cholangiopancreatography (ERCP) combined with laparoscopic cholecystectomy (LC) remains the most common therapeutic strategy used for cholecystocholedocholithiasis (CCL). Recently, single-stage ERCP + LC has gained popularity for treating CCL due to patient satisfaction and financial considerations. In this study, we aimed to compare the feasibility and efficacy of the two variants of single-stage ERCP + LC (starting with ERCP followed by LC versus starting with LC followed by ERCP) for treatment of CCL.

A total of 115 patients who underwent single-stage ERCP + LC for CCL from January 2021 to December 2023 were enrolled in a retrospective comparative cohort study. These patients were divided into two groups: Group A (ERCP-first approach) and Group B (LC-first approach).

Patients in Group A had a common bile duct clearance rate of 88.2%, which was comparable to the 95.7% observed in Group B (p = 0.163). The mean duration of the ERCP procedure was comparable between the two groups (43.3 ± 11.8 vs 39.5 ± 13.5 minutes; p = 0.112). However, the mean duration of the LC procedure was significantly longer in Group A than in Group B (41.2 ± 8.98 vs 37.2 ± 12.2 minutes; p = 0.045). The mean total operative time for the combined ERCP + LC was significantly longer in Group A compared to Group B (81.9 ± 16.7 vs 75.1 ± 19.3 minutes; p = 0.046). Post-ERCP pancreatitis occurred in 4 patients in Group A and in 2 patients in Group B (p = 0.701).

Both LC-1st approach and ERCP-1st approach are feasible and highly effective for treating CCL through single-stage ERCP + LC. However, the LC-1st approach has the advantage of a shorter operative time.

Background: Different techniques have been proposed to manage Cholecysto-choledocholithiasis (CCL) advantageously in one stage. Among these, Laparoendoscopic Rendezvous (LERV) addresses the CCL issue with a laparoscopic cholecystectomy, with insertion of a guide wire into the common bile duct through an incision of the cystic duct, followed by the clearance of the bile duct carried out by the endoscopists. The aim of this study was to evaluate the safety and the efficacy of the one-stage vs. a two-stage approach (pre-operative ERCP followed by cholecystectomy), and to compare our results with data from the current literature. Methods: All patients that underwent LERV in our facilities between January 2018 and December 2023 were evaluated. As a control group, we included patients that underwent a two-stage technique called the "sequential approach". The primary outcome was to evaluate the efficacy in obtaining complete clearance of the common bile duct (CBD). The secondary outcomes included morbidity, mortality, operative time, conversion rate, hospital stay and CDB stone recurrence. Results: 120 patients in the LERV group were included; meanwhile, 70 patients underwent pre-operative ERCP plus cholecystectomy. A 97% bile duct clearance success rate in the LERV group and 93% in the ERCP group was observed, respectively. The median intraoperative time for the one-stage technique was 122 min (p < 0.001) and the median hospital stay was 4 days (p < 0.001). In the LERV group, an overall morbidity of 15% was reported (18/120): 15 Clavien-Dindo type 1, one type 3a and two type 3b (p < 0.001). At a median follow-up of 14 months, five patients experienced stone recurrence. In the ERCP group, we had a 93% success rate; meanwhile, we had longer hospitalization (p < 0.001), 27% post-ERCP pancreatitis (p < 0.001) and a cumulative morbidity of 30%. Conclusions: LERV offers the advantages of a being single-stage procedure and shorter hospitalization, with a lower risk of clinically relevant post-ERCP pancreatitis and failed CBD cannulation.

Background: Minimally invasive treatments for cholelithiasis have gained popularity. The complexity of diagnosing and treating choledocholithiasis offers multiple surgical options, including laparoscopic common bile duct exploration plus laparoscopic cholecystectomy (LCBDE+LC) and endoscopic retrograde cholangiopancreatography and/or endoscopic sphincterotomy plus laparoscopic cholecystectomy (ERCP/EST+LC). Objective: To compare outcomes in patients with typical signs, symptoms, laboratory, and imaging features of cholelithiasis combined with common bile duct stones, we retrospectively analyzed the short-term outcomes of LCBDE+LC and ERCP/EST+LC. Methods: We analyzed 318 patients with gallbladder stones treated between January 2022 and May 2024. Of these, 152 underwent LCBDE+LC, and 166 underwent ERCP/EST+LC. We compared patients' baseline characteristics, perioperative outcomes, and short-term complications between the two groups. The primary outcome was the effectiveness of choledochal stone removal, while secondary outcomes included length of stay, hospitalization costs, and patient satisfaction. Results: Patients' baseline characteristics were similar between the LCBDE+LC and ERCP/EST+LC groups. Stone clearance rates were comparable (97.37% versus 95.18%, P = .306), with a slight advantage in the LCBDE+LC group. The length of hospitalization was significantly shorter in the LCBDE+LC group (6.49 ± 1.18 days versus 6.77 ± 1.11 days, P < .05). The LCBDE+LC group also had lower total hospitalization costs ($5188.78 ± 861.26 versus $6498.76 ± 1190.58 P < .01). Additionally, the incidence of pancreatitis was lower in the LCBDE+LC group (0.66% versus 6.02%, P < .01). There were no significant differences between the groups in other short-term complications such as abdominal infection, cholangitis, biliary bleeding, or bile leakage. Postoperative follow-up indicated higher patient satisfaction and acceptance in the LCBDE+LC group (SSQ-8, 85.84 ± 4.31 points versus 81.20 ± 4.54 points, P < .01). Conclusion: Our findings suggest that the LCBDE+LC holds promise as a safe and efficacious approach for the management of cholelithiasis combined with common bile duct stones. However, further prospective clinical trials are essential to corroborate these results and confirm their broader applicability.

Data consistently supports a surgery-first approach to common bile duct (CBD) stones in patients with a gallbladder via laparoscopic CBD exploration (LCBDE). LCBDE has equivalent efficacy and decreased cost as compared with cholecystectomy plus endoscopic retrograde cholangiopancreatography (ERCP). However, adoption has been low due to the technical limitations of laparoscopy. We describe a straightforward and highly reproducible robotic CBDE (RBCDE) technique.

A cystic ductotomy is made after obtaining a critical view of safety. Through a 5 mm port, a wire-ready cholangiogram catheter is secured in the cystic duct and intraoperative cholangiogram performed. Based on stone burden, small versus large, either an antegrade balloon snowplow (push stones forward) or sphincteroplasty is performed over a wire under fluoroscopy. If concern persists for retained stones, choledochoscopy is performed.

Our simplified antegrade-only RCBDE technique allows surgeons to consistently offer a surgery-first, single-stage approach to CBD stones in patients with a gallbladder.

Super-elderly patients with choledocholithiasis are considered to be at high risk for undergoing surgery. While laparoscopic transcystic common bile duct exploration (LTCBDE) is regarded as a challenging procedure for super-elderly patients with choledocholithiasis, there have been no reported cases of its use in super-elderly patients over the age of 96.

This case study presents the case of a 96-year-old female patient with acute calculous cholecystitis and choledocholithiasis. Despite the presence of multiple high-risk comorbidities, the patient underwent with laparoscopic cholecystectomy (LC) plus LTCBDE, with appropriate perioperative safety measures in place, and made a full recovery, being discharged from the hospital on the seventh day following the operation.

The case study demonstrates the successful treatment of a 96-year-old patient with choledocholithiasis via LTCBDE, utilising skilled laparoscopic and choledochoscopic techniques along with robust perioperative safety measures. This achievement sets a historical precedent for the successful treatment of a 96-year-old patient with choledocholithiasis via LTCBDE, both domestically and internationally.

Introduction: The traditional method of performing open common bile duct exploration (OCBDE) was replaced by a less invasive procedure known as laparoscopic common bile duct exploration (LCBDE) in elective surgery. But at present, the application of this technique is considered novel and controversial to treat acute cholangitis (AC). The aim of our systematic review was to investigate the safety and efficacy of laparoscopic surgery in patients with AC. Methods: Studies containing information on patients diagnosed with AC who underwent LCBDE were included. A search for relevant articles was carried out, in the Cochrane Library, PubMed, and Google Scholar databases. All studies included in the systematic review were assessed using the Newcastle-Ottawa Quality Assessment Scale. Results: A total of 10 studies were included. Seven were retrospective and three were prospective. Only one was a randomized controlled trial. There were three studies that compared elective LCBDE and emergency LCBDE. Two studies compared between primary closure and T-tube drainage. Two other studies focused on the comparison between LCBDE and OCBDE. One study examined the comparison of LCBDE and endoscopic retrograde cholangiopancreatography. Another study addressed the issue of conversion in LCBDE. One study compared early and delayed LCBDE. Conversion rates ranged from 0% to 16.92%. Morbidity ranged from 0% to 26.3%, and mortality ranged from 0% to 3.07%. There was no difference in terms of retained, residual, or recurrent stones, bile leak, hemorrhage, and postoperative pancreatitis, and this, comparing the different groups of patients. Bile duct and intestinal injuries as well as biliary stricture were not common. The average length of hospital stays was approximately 5.86 days, ranging from 2 to 11.12 days. Conclusion: The one-stage urgent LCBDE, while subject to debate, proves to be a secure, feasible, approach for managing nonsevere AC.

Choledocholithiasis is the second most common complication of gallstone disease. Giant primary choledocholithiasis is a rare occurrence. Ultrasonography is the initial mode of imaging, and endoscopic ultrasound is considered superior to other modalities. Endoscopic retrograde cholangiopancreatography can be used for stone extraction. Other treatment modalities include laparoscopic or open common bile duct (CBD) exploration. Many institutions in underdeveloped countries still practice open CBD exploration. Factors such as larger stone diameter, edema of the CBD, and the presence of multiple lithiasis can influence the treatment approach. In this article we are presenting a case of 62 years-old-female with no any known comorbidities had presented to emergency with severe upper quadrant pain and giant choledocholithiasis was diagnosed in ultrasound and computed tomography scan with no other features of complications and patient successfully underwent open CBD exploration with intraoperative choledochoscopy and primary closure.

While laparoscopic common bile duct exploration with primary duct closure (LCBDE + PDC) has been considered a feasible and safe treatment for cholecystocholedocholithiasis, uncertainties remain regarding its effectiveness and safety in patients with mild-to-moderate calculus-associated acute cholangitis. Therefore, this study aims to investigate the safety and efficacy of LCBDE + PDC specifically in patients with mild-to-moderate acute cholangitis (AC). Patients with cholecystocholedocholithiasis who underwent LCBDE + PDC treatment at our hospital between July 2020 and September 2022 were included. The patients were divided into two groups based on the presence of cholangitis: acute cholangitis (AC group) and non-acute cholangitis (non-AC group). A total of 136 patients underwent LCBDE + PDC treatment, with 65 in the AC group and 71 in the non-AC group. No deaths occurred after surgery in either group. The AC group had longer drainage tube retention time (5 (4-7) days vs. 4 (3-5) days, P < 0.001), postoperative hospital stay (8 (6-9) days vs. 6 (5-7) days, P < 0.001), and total hospital stay (12 (9.5-15) days vs. 10 (8-13) days, P < 0.001) compared to the non-AC group. However, there were no significant differences between the two groups in terms of operation time, estimated blood loss, and the rate of using holmium laser lithotripsy. The incidence of postoperative complications was similar between the two groups. Our study demonstrates that LCBDE + PDC is a safe and feasible treatment for patients with mild-to-moderate calculus-associated acute cholangitis who meet the criteria for primary duct closure.

While single-incision laparoscopic cholecystectomy (SILC) has gained more popularity in recent years, its application to elderly patients needs further evaluation. Few SILC studies regarded this rapidly growing vulnerable population, and single-incision laparoscopic common bile duct exploration (SILCBDE) was never mentioned. We conducted an observational study of 146 routine SILCBDE to address this issue.

One hundred forty-six consecutive patients underwent SILCBDE with concomitant cholecystectomies during a period of 6 years (July 2012-June 2016 and July 2018-July 2020). Forty patients with an age of 65 years or older were the study target. Characteristics and operative outcomes were compared with the remaining 106 younger patients by retrospective chart review. The primary outcomes include complications and mortality, while the secondary outcomes contain intraoperative blood loss, operative time, procedural conversions, postoperative length of hospital stay, and bile duct stone recurrence.

There was no mortality. The bile duct stone clearance rate was 98.6%. The elderly group had higher American Society of Anesthesiologists (ASA) scores, higher comorbidity rate, higher acute cholangitis rate, lower completion intraoperative cholangiography (IOC) rate, longer operative time, more blood loss, longer postoperative hospital stay (p < .001), longer total hospital stay (p < .001), higher procedural conversion rate (p < .05), higher complication rate (p < .001), and the exclusive open conversion (2.5%). The difference in complications derived from Clavien-Dindo grade I.

Routine SILCBDE with concomitant cholecystectomy by experienced surgeons is safe and efficacious for elderly patients as for younger patients. Randomized controlled trials are anticipated.

While single-incision laparoscopic cholecystectomy (SILC) has gained more popularity in recent years, its application to elderly patients needs further evaluation. Few SILC studies regarded this rapidly growing vulnerable population, and single-incision laparoscopic common bile duct exploration (SILCBDE) was never mentioned. We conducted an observational study of 146 routine SILCBDE to address this issue.

One hundred forty-six consecutive patients underwent SILCBDE with concomitant cholecystectomies during a period of 6 years (July 2012-June 2016 and July 2018-July 2020). Forty patients with an age of 65 years or older were the study target. Characteristics and operative outcomes were compared with the remaining 106 younger patients by retrospective chart review. The primary outcomes include complications and mortality, while the secondary outcomes contain intraoperative blood loss, operative time, procedural conversions, postoperative length of hospital stay, and bile duct stone recurrence.

There was no mortality. The bile duct stone clearance rate was 98.6%. The elderly group had higher American Society of Anesthesiologists (ASA) scores, higher comorbidity rate, higher acute cholangitis rate, lower completion intraoperative cholangiography (IOC) rate, longer operative time, more blood loss, longer postoperative hospital stay (p < .001), longer total hospital stay (p < .001), higher procedural conversion rate (p < .05), higher complication rate (p < .001), and the exclusive open conversion (2.5%). The difference in complications derived from Clavien-Dindo grade I.

Routine SILCBDE with concomitant cholecystectomy by experienced surgeons is safe and efficacious for elderly patients as for younger patients. Randomized controlled trials are anticipated.

Rates of subtotal cholecystectomy (STC) are increasing in response to challenging cases of laparoscopic cholecystectomy (LC) to avoid bile duct injury, yet are associated with significant morbidity. The present study identifies risk factors for STC and both derives and validates a risk model for STC.

LC performed for all biliary pathology across three general surgical units were included (2015-2020). Clinicopathological, intraoperative and post-operative details were reported. Backward stepwise multivariable regression was performed to derive the most parsimonious predictive model for STC. Bootstrapping was performed for internal validation and patients were categorised into risk groups.

Overall, 2768 patients underwent LC (median age, 53 years; median ASA, 2; median BMI, 29.7 kg/m2), including 99 cases (3.6%) of STC. Post-operatively following STC, there were bile leaks in 29.3%, collections in 19.2% and retained stones in 10.1% of patients. Post-operative intervention was performed in 29.3%, including ERCP (22.2%), laparoscopy (5.0%) and laparotomy (3.0%). The following variables were positive predictors of STC and were included in the final model: age >  60 years, male sex, diabetes mellitus, acute cholecystitis (AC), increased severity of AC (CRP > 90 mg/L), ≥ 3 biliary admissions, pre-operative ERCP with/without stent, pre-operative cholecystostomy and emergency LC (AUC = 0.84). Low, medium and high-risk groups had a STC rate of 0.8%, 3.9% and 24.5%, respectively.

The present study determines the morbidity of STC and identifies high-risk features associated with STC. A risk model for STC is derived and internally validated to help surgeons identify high-risk patients and both improve pre-operative decision-making and patient counselling.

Endoscopic retrograde cholangiopancreatography (ERCP) facilitates the removal of common bile duct (CBD) calculi by endoscopy. When ERCP fails, exploration of CBD is required for the clearance of CBD calculi. The optimum way for the exploration of CBD is by choledochoscopy. Dedicated flexible or rigid choledochoscopes are expensive and available only in few places in India. Since 1991, we subjected patients with suspected CBD calculi to ERCP, followed by laparoscopic cholecystectomy (LC). Patients in whom ERCP failed to clear CBD were subjected to open exploration of CBD using any easily available, suitable, straight rigid scope for choledochoscopy.

Since March 1991, out of 8866 patients with cholelithiasis, 862 underwent ERCP. Ninety-six patients in whom ERCP failed to clear CBD underwent open exploration of CBD. In each case of exploration of CBD, choledochoscopy was performed using a straight rigid scope, either a cystoscope, paediatric cystoscope, hysteroscope or 5-mm laparoscopy telescope with a 5-mm cannula.

The CBD clearance was complete in 95 patients, and one patient had an impacted calculus at the ampulla. CBD explorations were followed by choledochoduodenostomy, T-tube placement or suturing of choledochotomy. No residual calculi were observed after such exploration.

From our results, we advocate the following algorithm for CBD calculi in resource-limited settings. Subject patients with CBD calculi to ERCP followed by LC. In case of failed ERCP, open exploration of CBD with choledochoscopy using any suitable rigid scope. Dedicated flexible or rigid choledochoscope is not essential. This approach is cost-effective and successful.

Currently, endoscopic retrograde cholangiopancreatography (ERCP) plus laparoscopic cholecystectomy (LC) is the main treatment for cholecystolithiasis combined with choledocholithiasis. However, the treatment is unsatisfactory, and the development of better therapies is needed.

To determine the clinical efficacy of LC plus cholangioscopy for cholecystolithiasis combined with choledocholithiasis.

Patients (n = 243) with cholecystolithiasis and choledocholithiasis admitted to The Affiliated Haixia Hospital of Huaqiao University (910th Hospital of Joint Logistic Support Force) between January 2019 and December 2023 were included in the study; 111 patients (control group) underwent ERCP + LC and 132 patients (observation group) underwent LC + laparoscopic common bile duct exploration (LCBDE). Surgical success rates, residual stone rates, complications (pancreatitis, hyperamylasemia, biliary tract infection, and bile leakage), surgical indicators [intraoperative blood loss (IBL) and operation time (OT)], recovery indices (postoperative exhaust/defecation time and hospital stay), and serum inflammatory markers [C-reactive protein (CRP), tumor necrosis factor-α (TNF-α), and interleukin-6 (IL-6) were compared.

No significant differences in surgical success rates and residual stone rates were detected between the observation and control groups. However, the complication rate, IBL, OT, postoperative exhaust/defecation time, and hospital stays were significantly reduced in the observation group compared with the control group. Furthermore, CRP, TNF-α, and IL-6 Levels after treatment were reduced in the observation group compared with the levels in the control group.

These results indicate that LC + LCBDE is safer than ERCP + LC for the treatment of cholecystolithiasis combined with choledocholithiasis. The surgical risks and postoperative complications were lower in the observation group compared with the control group. Thus, patients may recover quickly with less inflammation after LCBDE.

Laparoscopic cholecystectomy (LC) following endoscopic retrograde cholangiopancreatography (ERCP) is the preferred treatment for cholelithiasis with common bile duct stones. However, the optimal timing of LC after ERCP remains controversial. This study aimed to identify the ideal time interval between ERCP and LC. Data from patients who underwent LC after ERCP between November 2016 and August 2022 were retrieved from the electronic medical information system. The patients were categorized into early cholecystectomy (within 72 h of ERCP) and delayed cholecystectomy (after 72 h). The impact of the time interval between ERCP and LC on perioperative outcomes was analyzed. A total of 197 patients were included in the study, with 45 undergoing early cholecystectomy and 152 undergoing delayed cholecystectomy. No significant differences in the preoperative characteristics or operative morbidity were observed between the groups (p = 0.286). However, a significant correlation was found between the time interval from ERCP to LC and the total length of stay (r = -350, p < 0.001). The findings suggest that early cholecystectomy after ERCP is feasible and safe, and performing LC within the first 72 h does not adversely affect postoperative outcomes.

This study aimed to study on clinical outcomes of single-stage (laparoscopic cholecystectomy [LC] and laparoscopic common bile duct [CBD] exploration using flexible videobronchoscope) versus dual-stage (endoscopic retrograde cholangiopancreatography followed by laparoscopic cholecystectomy) for cholelithiasis with choledocholithiasis-prospective study in a tertiary care centre (BRACE STUDY-Bronchoscope-Assisted CBD Exploration [CBDE] Study).

Between April 2022 and April 2023, patients who underwent LC with laparoscopic CBDE and endoscopic retrograde cholangiopancreatography (ERCP) followed by LC participated in this single-centre prospective research. The Institute Ethics Committee granted its approval after receiving an ethical review. The primary endpoint of the proposed research was the removal of the gall bladder and CBD stones. The secondary outcomes studied were complications using the Clavien-Dindo score, cost-effectiveness, patient satisfaction score and post-procedure duration of hospital stay.

A total of 168 patients were included in the study. The success rate of LC with laparoscopic CBD exploration using a flexible videobronchoscope (Group 1) was significantly higher as compared to ERCP f/b LC (Group 2) (96.4% vs. 84.5%, P value = 0.02). Out of the 84 patients in Group 1, direct choledochotomies were performed on 83 of them. Group 1 had a considerably shorter hospital stay (4.6 ± 2.4 vs. 5.3 ± 6.2 days; P = 0.03). Both the cost ( P = 0.002) and the number of procedures per patient ( P < 0.001) were considerably higher in Group 2. Major complications (Clavien-Dindo grade 3 and above) were significantly higher in Group 2 ( P = 0.04). Patient satisfaction in Group 1 scored more favourably than those in Group 2 (2.26 ± 0.3 vs. 1.92 ± 0.7; P = 0.006).

For concurrent gall bladder and CBD stones, single-stage management by LCBDE using a flexible videobronchoscope has a significantly better primary outcome and lower major complications than dual-stage management. The single-stage strategy also has advantages in terms of a shorter hospital stay, the need for fewer procedures, cost efficiency and patient satisfaction.

To compare the clinical efficacy of endoscopic retrograde cholangiopancreatography (ERCP) combined with laparoscopic cholecystectomy (LC) and laparoscopic common bile duct exploration and lithotomy (LCBDE) in the treatment of cholecystolithiasis combined with bile duct stones.

From September 2018 to January 2022, 195 patients with cholecystolithiasis complicated with extrahepatic bile duct stones from Department of Department of General Surgery, Shanghai Jiading Central Hospital met the inclusion criteria, including 60 cases in the LC group and 86 cases in the LCBDE group. The general condition, operation success rate, complications and residual stone rate of the two groups were retrospectively analyzed.

In the simultaneous operation group, 58 patients successfully performed ERCP, and the indwelling rate of the abdominal drainage tube (41.7 % vs. 95.3 %) was significantly better than that in the LCBDE group. There was no significant difference in the conversion rate to open surgery, operation time, and intraoperative blood loss between the two groups. In the simultaneous surgery group, 4 patients (6.7 %) developed pancreatitis after ERCP, which was cured by conservative treatment. The pain score at 6 h after operation was significantly lower than that in the LCBDE group (3.9 ± 1.6 vs 6.5 ± 2.4). There were no significant differences in biliary leakage (1.7 % vs. 4.7 %), postoperative cholangitis (5.0 % vs. 5.8 %), incision infection (3.3 % vs. 3.5 %), and bile duct stone residue rate (5.0 % vs 3.5 %) between the two groups. There was no severe pancreatitis, second operation or death. The duration of hospital stay was shortened in the concurrent operation group (5.1 ± 2.3d vs 7.9 ± 3.7d), and the operation cost was significantly higher than that in the LCBDE group (48839.9 ± 8549.5 vs 34635.9 ± 5893.7 yuan).

ERCP combined with LC and LCBDE are both safe and effective methods for the treatment of cholecystolithiasis combined with extrahepatic bile duct stones. The simultaneous operation group has certain advantages in patient comfort and rapid rehabilitation, which can be popularized in qualified units.

Common bile duct (CBD) stones commonly occur in cholecystectomy cases. The management options include laparoscopic CBD exploration (LCBDE) or endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC). Although ERCP is fully developed, it has complications, and LCBDE is a proven alternative. This study aimed to evaluate the safety and efficacy of these treatments in elderly individuals aged ≥70 years.

A retrospective study between January 2015 and July 2022 included 160 elderly patients (aged ≥70 years) diagnosed with cholelithiasis and choledocholithiasis. The patients were divided into 1-stage (LCBDE [n = 80]) or 2-stage (ERCP followed by LC [n = 80]) treatment groups. Data collected encompassed comorbidities, symptoms, bile duct clearance, postoperative complications, and long-term outcomes for systematic analysis.

This study analyzed 160 patients treated for CBD stones, comparing 1-stage and 2-stage groups. The 1-stage group had more female patients than the 2-stage group (57.5% vs 37.5%, respectively). The 1-stage group had a mean age of 80.55 ± 7.00 years, which was higher than the mean age in the 2-stage group. American Society of Anesthesiologists classification, Charlson Comorbidity Index, and laboratory findings were similar. Pancreatitis and cholangitis occurred after ERCP in the 2-stage group. Stone clearance rates (92.35% [1-stage group] vs 95.00% [2-stage group]) and biliary leakage incidence (7.5% [1-stage group] vs 3.0% [2-stage group]) were similar, as were postoperative complications and long-term recurrence rates (13.0% [1-stage group] vs 12.5% [2-stage group]).

Our research indicates that both the combination of LCBDE and LC and the sequence of ERCP followed by LC are equally efficient and secure when treating CBD stones in elderly patients. Consequently, the 1-stage procedure may be considered the preferred treatment approach for this demographic.

<b>Introduction:</b> Choledocholithiasis (CCL) is one of the most common serious health consequences of cholelithiasis. For years, evacuation of stones using endoscopic retrograde cholangiopancreatography (ERCP) has been the first-line treatment. In 10-15% of cases, gallstones cannot be removed using the above-mentioned method and auxiliary methods are necessary; these are so-called difficult gallstones. Surgical treatment is sometimes necessary. The European Society of Gastrointestinal Endoscopy (ESGE) has recommended the use of cholangioscopy, including direct peroral cholangioscopy (DPOC), as one of the main treatment methods since 2015.<b>Aim:</b> The following article aims to investigate the safety and efficacy of direct cholangioscopy with laser lithotripsy in the treatment of CCL.<b>Materials and methods:</b> The study was conducted at the Department of General and Transplant Surgery, Medical University of Lodz. From October 2022 to November 2023, 13 procedures of difficult gallstone evacuation from the bile duct were performed using the technique of direct cholangioscopy with laser lithotripsy.<b>Results:</b> Thirteen cases of difficult gallstones were retrospectively analyzed. The bile duct was intubated via the ampulla of Vater using direct cholangioscopy. The bile duct was cleared of gallstones using laser lithotripsy, followed by a Dormia basket or an extraction balloon to remove stone fragments. The procedure was performed successfully in all patients. No complications were observed.<b>Conclusions:</b> DPOC with laser lithotripsy seems to be an effective and safe method of clearing even very large gallstones from the bile duct. The relatively low price of tools and the resulting cost reduction may allow this procedure to become more popular.

Laparoscopic common bile duct exploration (LCBDE) has been shown to be effective in managing choledocholithiasis whilst avoiding ERCP-related complications. However, patient and technical factors effects outcome. This study aimed to explore the matters effecting the failure of LCBDE.

All patients who underwent a laparoscopic cholecystectomy (LC) between 2007 and 2021 were identified using a prospective database. Data were collected for patients who underwent LCBDE including demographics, pre-operative investigations, intra-operative findings, technique of bile duct clearance and clearance rates, and post-operative outcomes. Predictors of failed LCBDE were identified.

Laparoscopic cholecystectomy was performed in 3648 patients. Of these, 374 underwent LCBDE for suspected choledocholithiasis. Choledochoscopy was most frequently used (58.8%) with a success rate of 84.1%. Small cystic duct diameter (4.7 vs. 3.4 mm, P = 0.002), stone size >6 mm (P = 0.02), stone: cystic duct ratio >1 (P = 0.04), and >3 stones was associated with failed LCBDE by univariate analysis. Small cystic duct diameter (OR: 0.45, 95% CI: 0.26-0.77, P = 0.004) and stone size >6 mm (OR: 0.23, 95% CI: 0.06-0.92), P = 0.04) correlated with failure by multivariate analysis. Failed LCBDE was associated with increased length of stay (6.6 days vs. 3.1 days, P = 0.001), however the rate of serious complications or mortality was unaffected.

LCBDE is safe and effective in managing choledocholithiasis. Factors such as cystic duct diameter, size and number of CBD stones, and stone: cystic duct ratio are associated with increased likelihood of inadequate clearance. The presence of these factors can help clinicians in decision making during LCBDE to improve chance of success.

A prediction system for common bile duct (CBD) stones was originally published by the American Society for Gastrointestinal Endoscopy (ASGE) in 2010 and was last revised in 2019. We wanted to investigate its application in an Asian population, who have different etiologies of bile duct stone formation and accessibility to medical service compared to the West.

This is a single center retrospective study. Patients who received endoscopic ultrasound (EUS) for suspected CBD stones were collected from our endoscopic record system over a 10-year period. The accuracy of the revised ASGE criteria was estimated according to the results of EUS. A minimum follow-up of 6 months was required to detect false negative results.

142 patients were enrolled, 87 (61%) patients had CBD stones. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of the revised ASGE criteria for high-risk patients were 69%, 38%, 64%, 44%, and 57%. 36% of the ASGE-defined high-risk patients negative for CBD stones on EUS. The two significant predictors for CBD stone were CBD dilatation (adjusted OR 3.06, 95% C.I. 1.31-7.17, p = 0.010) and ascending cholangitis (adjusted OR 2.28, 95% C.I. 1.01-5.15, p = 0.047).

ASGE recommends that patients defined as high-risk for choledocholithiasis be considered for direct ERCP without prior need for confirmation imaging. However, our findings indicate a high rate (36%) of patients in that group negative for CBD stones on EUS. Hence, EUS is still be suggested first in selective high-risk patients so that diagnostic ERCP can be avoided in our Asian society.

To investigate the efficacy and safety of laparoscopy combined with choledochoscopy in the treatment of elderly patients with cholecystolithiasis complicated with choledocholithiasis.

A retrospective analysis of 114 patients admitted to our hospital from January 2020 to January 2023 was conducted. These patients underwent laparoscopic cholecystectomy combined with choledocholithiasis and were divided into an elderly group (≥ 60 years old) of 63 cases and a young and middle-aged group (< 60 years old) of 51 cases according to age. The efficacy and safety indicators of the two groups of patients were observed, and complications were followed up by telephone within 6 months after surgery. The follow-up deadline was June 2023.

Among the eligible patients (53 men, 61 women, average age 57 years), all were successfully operated, and 1 case was converted to laparotomy. The elderly and young and middle-aged groups were compared concerning hospitalisation time, bowel sound recovery time, and total postoperative complications, and the differences were statistically significant (P-values were 0.009, 0.006, and 0.039). However, there was no statistically significant difference between the two groups of patients in terms of hospitalisation costs, intraoperative blood loss, operation time, drainage tube removal time, conversion to laparotomy rate, and stone clearance rate (P-values > 0 0.05).

Strict adherence to surgical standards and enhanced postoperative care resulted in similar efficacy and safety results for double endoscopy combined with the exploration of treatment for elderly and young patients with cholecystolithiasis and choledocholithiasis.

Laparoscopic cholecystectomy with common bile duct exploration (LCBDE) is equivalent in safety and efficacy to endoscopic retrograde cholangiopancreatography (ERCP) plus laparoscopic cholecystectomy (LC) while decreasing number of procedures and length of stay (LOS). Despite these advantages LCBDE is infrequently utilized. We hypothesized that formal, simulation-based training in LCBDE would result in increased utilization and improve patient outcomes across participating institutions.

Data was obtained from an on-going multi-center study in which simulator-based transcystic LCBDE training curricula were instituted for attending surgeons and residents. A 2-year retrospective review of LCBDE utilization prior to LCBDE training was compared to utilization up to 2 years after initiation of training. Patient outcomes were analyzed between LCBDE strategy and ERCP strategy groups using χ2, t tests, and Wilcoxon rank tests.

A total of 50 attendings and 70 residents trained in LCBDE since November 2020. Initial LCBDE utilization rate ranged from 0.74 to 4.5%, and increased among all institutions after training, ranging from 9.3 to 41.4% of cases. There were 393 choledocholithiasis patients analyzed using LCBDE (N = 129) and ERCP (N = 264) strategies. The LCBDE group had shorter median LOS (3 days vs. 4 days, p < 0.0001). No significant differences in readmission rates between LCBDE and ERCP groups (4.7% vs. 7.2%, p = 0.33), or in post-procedure pancreatitis (0.8% v 0.8%, p > 0.98). In comparison to LCBDE, the ERCP group had higher rates of bile duct injury (0% v 3.8%, p = 0.034) and fluid collections requiring intervention (0.8% v 6.8%, p < 0.009) secondary to cholecystectomy complications. Laparoscopic antegrade balloon sphincteroplasty had the highest technical success rate (87%), followed by choledochoscopic techniques (64%).

Simulator-based training in LCBDE results in higher utilization rates, shorter LOS, and comparable safety to ERCP plus cholecystectomy. Therefore, implementation of LCBDE training is strongly recommended to optimize healthcare utilization and management of patients with choledocholithiasis.

The advantages of single-stage treatment of cholecystocholedocholithiasis are well established, but the conditions for carrying out treatment on an outpatient basis require a review of concepts and practices of medical corporations.

To evaluate the practice of treating cholecystocholedocholithiasis by laparoendoscopy on an outpatient basis with cost analysis.

A retrospective study was conducted on patients with cholecystocholedocholithiasis treated by combined laparoscopic cholecystectomy and endoscopic choledocholithotomy from January 2015 to January 2019. After collecting data from physical and digital medical records, the patients were divided into two groups-AR (n = 42)-ambulatory regimen and HR (n = 28)-hospitalization regimen-which were compared in terms of demographic, clinical and treatment variables and their results, as well as in terms of costs.

The mean age of the AR group was lower than that of the HR group and the physical status of the AR patients was better when assessed according to the American Society of Anesthesiologists (ASA) (p = 0.01). There was no difference between groups regarding the risk of choledocholithiasis (p = 0.99). For the AR group, the length of stay was shorter: 11.29 h × 65.21 h (p = 0.02), as was the incidence of postoperative complications assessed by applying the Clavien-Dindo classification: 3 (7.1%) × 11 (39.2%) (p < 0.01). The total mean costs were higher for the HR group (USD 2489.93) than the AR group (USD 1650.98) (p = 0.02).

Outpatient treatment of cholecystocholedocholithiasis by laparoendoscopy is safe and viable for most cases, has a lower cost and can support the reorientation of training and practice of hepatobiliary surgeons.

Cholecystitis is a common diagnosis which requires management by general surgeons. Morbidity from cholecystitis is often life-threatening, especially in patients with underlying liver cirrhosis or other medical comorbidities. Diagnosis and management of this disease can vary among providers and hospitals. The decision to utilize a radiological or endoscopic temporizing maneuver in severe acute cholecystitis and the timing of later definitive cholecystectomy are relevant points of discussion within general surgery societies. In the last 5 years, the use of intraoperative ductal imaging by conventional vs fluorescence cholangiography had gained significant interest due to the widespread availability of indocyanine green. Finally, the operative strategies and how to manage intra-/postoperative complications are very important to optimizing patient outcomes. In this review paper, we discuss all treatment aspects of cholecystitis and provide updates in its management.

Endoscopic retrograde cholangiopancreatography (ERCP) has become a common treatment method for common bile duct stones. However, ERCP is also associated with a high risk of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). Identification of risk factors is essential for reducing the incidence of PEP. The present study aimed to summarize the risk factors for PEP by performing a meta-analysis. Therefore, studies published between 2000 and 2022 were screened in PubMed, Cochrane Library, Embase, Web of Science, China National Knowledge Infrastructure, Wanfang Digital Periodicals and the Weipu Database, with no language restrictions. Newcastle-Ottawa Scale was used to assess the quality of the included studies. Stata 17.0 software was utilized for the meta-analysis of 14 possible risk factors. Overall, 15 high-quality studies were included into the present meta-analysis. The results showed that female [odds ratio (OR), 1.42; 95% CI, 1.23-1.64), age <60 years (OR, 1.53; 95% CI, 1.06-2.21), difficult intubation (OR, 4.87; 95% CI, 2.73-8.68), ≥3 cannulation attempts (OR, 9.64; 95% CI, 4.16-22.35), cannulation time ≥10 min (OR, 2.37; 95% CI, 1.67-3.35), history of pancreatitis (OR, 2.95; 95% CI, 1.06-5.51), pancreatic duct visualization (OR, 3.63; 95% CI, 2.47-5.34) and sphincter of Oddi dysfunction (OR, 5.72; 95% CI, 1.80-18.24) are potential risk factors for PEP (P<0.05). In conclusion, the present meta-analysis suggests that PEP can be affected by several risk factors, particularly the technique-related factors such as the frequency and time of cannulation. Therefore, effective precautions should be taken as early as possible to reduce the incidence of PEP.

This study aimed to investigate the safety and efficacy of endoscopic retrograde cholangiopancreatography (ERCP) + EyeMax (single-operator cholangioscopy system; SOC) (i.e., ERCP+SOC) for the treatment of choledocholithasis-associated acute cholecystitis. Twenty-five patients were evaluated between January 2022 and June 2023. The success rate (technical + clinical), procedure time, postoperative recovery, postoperative length of hospital stay, and complications rates were recorded. The procedure and clinical success rates were 92% (23/25) and 96% (24/25), respectively. The mean procedure time was 36.6±10 minutes (standard deviation [SD]). The average postoperative hospitalization was 2±0.8 days. No adverse events such as bleeding, perforation, or bile leakage occurred. Cholecystitis did not recur during the 2 to 18 months of follow-up. ERCP+SOC may be a feasible, safe, and effective alternative treatment for acute cholecystitis secondary to choledocholithiasis. ERCP+SOC was able to simultaneously resolve both biliary tract and gallbladder problems via natural orifice endoscopy. Its advantages included no skin wound, reduced postoperative pain, quick recovery, limited to no exposure to x-rays, and a short hospital stay.

As a minimally invasive treatment for common bile duct (CBD) stones, ultrasound-guided percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) is gaining attention and recognition from the medical community.

A retrospective analysis was conducted on patients with CBD stones treated in our hospital from January 2016 to April 2022. Patients were divided into three groups: 77 treated with PTCSL, 93 with endoscopic retrograde cholangiopancreatography (ERCP), and 103 with laparoscopic common bile duct exploration (LCBDE). Their clinical data, perioperative indicators, and complications were analyzed comparatively. Then, risk factors for the post-PTCSL recurrence of CBD stones were analyzed by logistic regressions. Finally, the receiver operating characteristic curve was drawn.

All perioperative indicators of the PTCSL group were better than the LCBDE group (P < 0.001). The incidences of cholangitis, hemobilia, and incisional infection after surgery were lower in the PTCSL group than in the LCBDE group (P < 0.05). Pancreatitis, reflux esophagitis, and papillary stenosis occurred less frequently in the PTCSL group than in the ERCP group (P < 0.05). Logistic regression analysis indicated that gallstones and family history were independent risk factors. The AUC for recurrent CBD stones predicted by multi-indicators was 0.895 (95% CI 0.792-0.999, P < 0.001) with a sensitivity of 96.7% and specificity of 68.8%.

Ultrasound-guided PTCSL is a safe and effective treatment for CBD stones. Patients recovered quickly with fewer postoperative complications. It can be a first-line treatment for CBD stones. Gallstones and family history are independent risk factors for recurrent CBD stones, which provide a reference for clinicians in identifying the high-risk population needing close follow-up.

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 risks. A single-stage procedure, such as LC with common bile duct exploration (CBDE), is a safe and effective option that may decrease LoS. This study compares patient outcomes and management in a regional center and aims to identify factors that predict the presence of confirmed choledocholithiasis. Methods A retrospective cross-sectional analysis was performed on all patients admitted to Toowoomba Hospital for management of diagnosed or suspected choledocholithiasis from January 2021 to March 2023. Patient demographics, ERCP findings, and operative data were collated. Results A total of 195 patients were identified, including 136 patients undergoing multi-stage management, 34 patients who had an ERCP alone, and 25 patients who underwent single-stage management. Single-stage procedures had an 80% success rate with an average LoS of 3.6 days. Multi-stage procedures had an average LoS of 8.1 days and an ERCP success rate of 93%. Complication rates between ERCP (11.7%) and LC with CBDE (9.7%) were comparable. Time to index ERCP and serum bilirubin level were found to be significantly lower in those with positive index ERCP findings compared to those without. Conclusion Single-stage procedures are a safe way to manage choledocholithiasis and are associated with a reduced LoS when compared to multi-stage management, with comparable efficacy and morbidity rates.

Gallstone disease will affect 15% of the adult population with concomitant common bile duct stone (CBDS) occurring in up to 30%. Endoscopic retrograde cholangiopancreatography (ERCP) is the mainstay of management for removal of CBDS, as cholecystectomy for the prevention of recurrent biliary event (RBE). RBE occurs in up to 47% if cholecystectomy is not done. The goal of this study was to evaluate the timing of occurrence of RBE after common bile duct clearance with ERCP and associated outcomes.

The records of all patients who underwent ERCP for gallstone disease followed by cholecystectomy, in a single center from 2010 to 2022, were reviewed. All RBE were identified. Actuarial incidence of RBE was built. Patients with and without RBE were compared.

The study population is composed of 529 patients. Mean age was 58.0 (18-95). There were 221 RBE in 151 patients (28.5%), 39/151 (25.8%) having more than one episode. The most frequent RBE was acute cholecystitis (n = 104) followed by recurrent CBDS (n = 95). Median time for first RBE was 34 days. Actuarial incidence of RBE started from 2.5% at 7 days to reach 53.3% at 1 year. Incidence-rate of RBE was 2.9 per 100 person-months. Patients with RBE had significant longer hospitalisation time (11.7 vs 6.4 days; P < 0.0001), longer operative time (66 vs 48 min; P < 0.0001), longer postoperative stay (2.9 vs 0.9 days; P < 0.0001), higher open surgery rate (7.9% vs 1.3%; P < 0.0001), and more complicated pathology (23.8% vs 5.8%; P < 0.0001) and cholecystitis (64.2% vs 25.9%; P < 0.0001) as final diagnoses.

RBE occurred in 28.5% of the subjects at a median time of 34 days, with an incidence of 2.5% as early as 1 week. Cholecystectomy should be done preferably within 7 days after common bile duct clearance in order to prevent RBE and adverse outcomes.

Choledocholithiasis is most often managed in a two-procedure pathway including endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC). In contrast, a single-stage, surgery-first approach consisting of LC, cholangiogram, and laparoscopic common bile duct exploration (LCBDE) is associated with reduced hospital stays and equivalent morbidity. Despite this, nationwide referral patterns heavily favor ERCP, obscuring those undergoing ERCP with obstructions amenable to simple intraoperative interventions. We hypothesized that most patients had endoscopic findings consistent with simple sludge or small-to-medium stones, which could have been cleared by basic LCBDE maneuvers.

We retrospectively reviewed 294 patients > 18 years old who underwent preoperative ERCP for the management of suspected choledocholithiasis. Exclusion criteria included: failed ERCP, cholangitis, prior cholecystectomy, patient refusal of surgery, or medical conditions precluding surgical candidacy. Stone size was categorized as small (0-4 mm), medium (5-7 mm), and large (≥ 8 mm).

At the time of ERCP, 37 (20.1%) patients had sludge only, 96 (52.2%) had stones only, 42 (22.8%) had sludge and stones, and 9 (4.8%) had no stones. Of the 138 patients with any stones, 37 (26.8%) had small stones, 41 (29.7%) medium, 43 (31.2%) large, and 17 (12.3%) had uncharacterizable stones. Overall, 74.3% of patients had findings of sludge, stones (0-7 mm), or negative ERCP.

The majority of patients who underwent preoperative ERCP for suspected choledocholithiasis had findings that are amenable to simple intraoperative interventions. In fact, over a quarter of the patients had a negative ERCP, sludge, or small stones which would likely be cleared by flushing/glucagon precluding any further instrumentation. While large stones may require more advanced techniques, this represents a small percentage of patients. Surgery-first management for suspected choledocholithiasis can offer an efficient alternative for the majority of patients.

In children, laparoscopic cholecystectomy (LC) is now considered the gold standard for gallbladder (GB) removal. In the past, hemolytic disorders associated with cholelithiasis represented the most frequent conditions requiring LC; this is being overtaken by cholelithiasis and biliary conditions in overweight or ex-premature children.

This study aims to describe current indications and timing for LC in pediatric patients.

Retrospective study. Data on previous medical therapy, ultrasound, pre- and intraoperative aspects, and histology were collected for patients treated in 2020-2023.

In total, 45 patients were enrolled: 15 who underwent urgent surgery and 30 electives. Groups differed in terms of obesity rate, symptoms, ultrasound features, and intraoperative status. The most relevant risk factors for surgical complexity were age and pubertal stage, elevated cholestasis indexes, and gallbladder wall thickness > 3 mm at ultrasound. GB wall thickening ≥3 mm, US Murphy sign, fluid collections, and gallbladder distention on ultrasound correlated with high surgical scores.

Indications for laparoscopic cholecystectomy in children seem to evolve caused by changing characteristics of the pediatric population. Patients with overweight/obesity may develop more complex GB diseases. Asymptomatic patients should be considered for surgery after observation, considering age and/or pubertal maturation when other risk factors are absent.