Remaining issues of recommended management in current guidelines for asymptomatic common bile duct stones

Saito, Hirokazu; Kadono, Yoshihiro; Shono, Toshiyuki; Kamikawa, Kentaro; Urata, Atsushi; Nasu, Jiro; Imamura, Haruo; Matsushita, Ikuo; Tada, Shuji

doi:10.3748/wjg.v27.i18.2131

Cited by 9 publications

(8 citation statements)

References 48 publications

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“…Unfavourable outcomes in the observation cohort also included complications post‐ERCP complications for patients initially observed, who then became symptomatic. This was not included in the unfavourable outcomes of treatment strategies and may underestimate the rate of ERCP complications 23 …”

Section: Discussionmentioning

confidence: 99%

“…This was not included in the unfavourable outcomes of treatment strategies and may underestimate the rate of ERCP complications. 23 Four of eight included studies favoured an observation-based approach, [15][16][17][18] albeit with relatively small sample sizes (total 196 patients). Two studies do not make a clear recommendation in relation to a policy of observation.…”

Section: Discussionmentioning

confidence: 99%

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Observation versus intervention for incidental common bile duct stones at intraoperative cholangiogram: a systematic review

Crichton

Cox

Tong

et al. 2023

ANZ Journal of Surgery

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Background The natural history of incidental common bile duct stones (CBDS) is poorly understood. Current evidence is conflicting, with several studies suggesting the majority may pass spontaneously. Despite this, guidelines recommend routine removal even if asymptomatic. This study aimed to systematically review the outcomes of expectant management for CBDS detected on operative cholangiography during cholecystectomy. Methods MEDLINE, Embase and CINAHL databases were systematically searched. Participants were adult patients with CBDS identified by intraoperative cholangiography. Intervention was regarded as any perioperative effort to remove common bile duct stones, including endoscopic retrograde cholangiopancreatography (ERCP), laparoscopic and open bile duct exploration. This was compared to observation. Outcomes of interest included rates of spontaneous stone passage, success of duct clearance and complications. Risk of bias was assessed using the ROBINS‐I tool. Results Eight studies were included. All studies were non‐randomized, heterogeneous and at serious risk of bias. In patients observed after a positive IOC, 20.9% went on to have symptomatic retained stones. In patients directed to ERCP for positive IOC, persistent CBDS were found in 50.6%. Spontaneous passage was not associated with stone size. Meta‐analysis is dominated by the results from one large database, which recommends intervention for incidental stones, despite low rates of persistent stones seen at postoperative ERCP. Conclusions Further evidence is required before a definitive recommendation on observation can be made. There is some evidence that asymptomatic stones may be safely observed. In clinical scenarios where the risks of biliary intervention are considered high, a conservative strategy could be more widely considered.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Observation versus intervention for incidental common bile duct stones at intraoperative cholangiogram: a systematic review

Crichton

Cox

Tong

et al. 2023

ANZ Journal of Surgery

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“…ERCP-ES and subsequent LC, the most preferred method worldwide[ 4 , 17 , 50 ], is a safe management process even in patients with cardiovascular disease[ 51 ]. A randomized controlled study showed that routine nasobiliary tubes after endoscopic CBD stone clearance can facilitate subsequent LC by the ability of the intraoperative cholangiography and ensure the anatomical integrity of the CBD[ 52 ].…”

Section: Managementmentioning

confidence: 99%

“…For asymptomatic CBD stones, ERCP-ES is the first choice of recommended management despite the higher complication rate, especially of acute pancreatitis, than that of symptomatic cases. However, it is not yet clear by evidence-based data that this approach is justifiable[ 50 ]. The opposite point of view postulates by assessing the natural history that while early endoscopic removal of silent stones does not absolutely prevent further biliary complications, it has the risk of post-ERCP severe pancreatitis (5.2%).…”

Section: Managementmentioning

confidence: 99%

Current management of concomitant cholelithiasis and common bile duct stones

Pavlidis¹,

Pavlidis²

2023

World J Gastrointest Surg

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The management policy of concomitant cholelithiasis and choledocholithiasis is based on a one- or two-stage procedure. It basically includes either laparoscopic cholecystectomy (LC) with laparoscopic common bile duct (CBD) exploration (LCBDE) in the same operation or LC with preoperative, postoperative and even intraoperative endoscopic retrograde cholangiopancreatography-endoscopic sphincterotomy (ERCP-ES) for stone clearance. The most frequently used worldwide option is preoperative ERCP-ES and stone removal followed by LC, preferably on the next day. In cases where preoperative ERCP-ES is not feasible, the proposed alternative of intraoperative rendezvous ERCP-ES simultaneously with LC has been advocated. The intraoperative extraction of CBD stones is superior to postoperative rendezvous ERCP-ES. However, there is no consensus on the superiority of laparoendoscopic rendezvous. This is equivalent to a traditional two-stage procedure. Endoscopic papillary large balloon dilation reduces recurrence. LCBDE and intraoperative ERCP have similar good outcomes. The risk of recurrence after ERCP-ES is greater than that after LCBDE. Laparoscopic ultrasonography may delineate the anatomy and detect CBD stones. The majority of surgeons prefer the transcductal instead of the transcystic approach for CBDE with or without T-tube drainage, but the transcystic approach must be used where possible. LCBDE is a safe and effective choice when performed by an experienced surgeon. However, the requirement of specific equipment and advanced training are drawbacks. The percutaneous approach is an alternative when ERCP fails. Surgical or endoscopic reintervention for retained stones may be needed. For asymptomatic CBD stones, ERCP clearance is the first-choice method. Both one-stage and two-stage management are acceptable and can ensure improved quality of life.

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“…Therefore, given the high incidence of AEs, it should be carefully considered whether aggressive ERCP should be performed for asymptomatic CBDS. 12 In cases of CBDS with surgically altered anatomy, the treatment of choice is ERCP, as in cases with normal anatomy; however, the ERCP is assisted by balloon-enteroscopy (BE) in cases of surgically altered anatomy due to the increased distance from the afferent loop to the duodenal papilla. [13][14][15][16] In a Japanese multicenter cohort study, which included our facility, the success rate of BE-assisted ERCP cannulation for surgically altered anatomies (76.3% were benign biliary cases, including CBDS) was 87.0%, with an AE rate of 7.7% (PEP rate was 3.1%), 17 making it an effective treatment method similar to that for normal anatomies.…”

Section: Introductionmentioning

confidence: 99%

Balloon enteroscopy‐assisted endoscopic retrograde cholangiopancreatography for asymptomatic common bile duct stones on surgically altered anatomy: A high risk factor for post‐endoscopic retrograde cholangiopancreatography pancreatitis

Watanabe,

Okuwaki,

Iwai

et al. 2023

J Hepato Biliary Pancreat

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BackgroundPost‐endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is more common in patients with asymptomatic common bile duct stones (CBDSs) and normal anatomy than in those with symptomatic CBDS; however, studies on the effect of surgically altered anatomy are lacking. We aimed to investigate whether asymptomatic CBDS in balloon enteroscopy‐assisted ERCP cases for surgically altered anatomy also has a high incidence of PEP and analyze the risk factors for PEP.MethodsWe retrospectively analyzed 108 consecutive patients who underwent initial ERCP for CBDS with surgically altered anatomies and with naive papilla at Kitasato University Hospital from April 2015 to December 2022.ResultsStudy participants were as follows: 92 (85%) patients with symptomatic CBDS and 16 (15%) patients asymptomatic CBDS. The overall bile duct cannulation success rate was 89.8%, with PEP occurring in 7.4% of patients (symptomatic CBDS: 3.3%, asymptomatic CBDS: 31.3%). PEP incidence was significantly higher for asymptomatic CBDS (p = .0017). Multivariate analysis identified asymptomatic CBDS and precut sphincterotomy as significant risk factors for PEP.ConclusionsAsymptomatic CBDS may be a risk factor for PEP onset in balloon enteroscopy‐assisted ERCP with surgically altered anatomy. Therefore, the procedure should be performed after obtaining sufficient informed consent and adequate preparation.

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Remaining issues of recommended management in current guidelines for asymptomatic common bile duct stones

Cited by 9 publications

References 48 publications

Observation versus intervention for incidental common bile duct stones at intraoperative cholangiogram: a systematic review

Observation versus intervention for incidental common bile duct stones at intraoperative cholangiogram: a systematic review

Current management of concomitant cholelithiasis and common bile duct stones

Balloon enteroscopy‐assisted endoscopic retrograde cholangiopancreatography for asymptomatic common bile duct stones on surgically altered anatomy: A high risk factor for post‐endoscopic retrograde cholangiopancreatography pancreatitis

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