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The increase of laparoscopic cholecystectomy has resulted in an increase of bile duct injuries. The purpose of this article is to define the types of injury, their occurrence and frequency, and their management by endoscopic and surgical techniques. Three investigations were included in the present study. 1. A 3-year retrospective study among 29 hospitals with 25,007 laparoscopic cholecystectomies. 2. An 8-year prospective study at our institution of 6488 patients. 3. A prospective endoscopic study of 94 patients with injuries and strictures of the common bile duct (CBD) after laparoscopic cholecystectomy. A special classification for bile duct injuries was developed. Among 25,007 patients from 29 hospitals, a total of 74 lesions were detected with an incidence of 0.29%. At our institution, 20 cases were seen (0.29%) with type I, II, and III injuries. The 94 cases managed by endoscopic procedure were submitted to endoscopic retrograde cholangiopancreatography (ERCP) and papillotomy, with placement of several stents 5 to 10 F during 8 months. The results of this procedure have been excellent to good in 76% of the cases up to 3 years of follow-up. According to our previous and present experience, bile duct injuries after laparoscopic procedure are two times higher than after open procedure. The best treatment is the prevention of these injuries by careful surgical technique. If they occur, the best moment to repair them is during surgery. If they are noticed after the operation, endoscopic or surgical procedures can be employed.

Advances in cannulation techniques and instruments have helped in difficult bile duct cannulation and thus stone extraction. For small common bile duct (CBD) stones, endoscopic papillary balloon dilatation has been proposed as an alternative to endoscopic papillotomy (EPT). The technique must undergo further evaluation before recommending its routine use. For most patients with bile duct stones, EPT remains the method of choice. Out of 8204 patients treated in three surgical endoscopy centers (Chile, Germany, and India), 86% to 91% of all CBD stones could be extracted subsequently after EPT using a Dormia basket; 4% to 7% required mechanical lithotripsy (ML) before removal and 3% to 10% of the patients needed other sophisticated techniques, such as electrohydraulic lithotripsy (EHL), laser-induced shock-wave lithotripsy (LISL), or extracorporeal shock-wave lithotripsy (ESWL). The local expertise and availability of equipment determines the choice of method used. In general, EHL or LISL is used for impacted CBD stones including stones in Mirizzi syndrome refractory to ML. ESWL is best suited for intrahepatic stones. Permanent stenting can be offered to poor risk patients instead of extensive procedures to clear the bile duct. Using currently available nonsurgical techniques, fewer than 1% of all patients with bile duct stones still require surgical intervention.

The COVID-19 pandemic has had a profound impact on provision of endoscopy services globally as staff and real estate were repurposed. As we begin to recover from the pandemic, a cohesive international approach is needed, and guidance on how to resume endoscopy services safely to avoid unintended harm from diagnostic delays. The aim of these guidelines is to provide consensus recommendations that clinicians can use to facilitate the swift and safe resumption of endoscopy services. An evidence-based literature review was carried out on the various strategies used globally to manage endoscopy during the COVID-19 pandemic and control infection. A modified Delphi process involving international endoscopy experts was used to agree on the consensus statements. A threshold of 80% agreement was used to establish consensus for each statement. 27 of 30 statements achieved consensus after two rounds of voting by 34 experts. The statements were categorised as pre-endoscopy, during endoscopy and postendoscopy addressing relevant areas of practice, such as screening, personal protective equipment, appropriate environments for endoscopy and infection control precautions, particularly in areas of high disease prevalence. Recommendations for testing of patients and for healthcare workers, appropriate locations of donning and doffing areas and social distancing measures before endoscopy are unique and not dealt with by any other guidelines. This international consensus using a modified Delphi method to produce a series of best practice recommendations to aid the safe resumption of endoscopy services globally in the era of COVID-19.