The endoscopic appearance of the major duodenal papilla influences biliary cannulation and complications. This study aimed to investigate the role of major duodenal papillae in the endoscopic treatment of common bile duct (CBD) stones.

This retrospective study was conducted at Bishan Hospital of Chongqing Medical University between January 2018 and August 2022. Patients with native papillae who underwent endoscopic treatment for CBD stones were recruited and divided into four groups according to Haraldsson's classification of papillae (types I-IV). Univariate and multivariate logistic regression analyses were used to identify risk factors for difficult cannulation and post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP).

A total of 596 patients with CBD stones were enrolled. The proportion of patients with type I papilla was the highest (n = 231, 38.8%), followed by type III papilla (n = 175, 29.4%), type IV papilla (n = 101, 16.9%) and type II papilla (n = 89, 14.9%). Difficult cannulation occurred in 188 of 596 patients (31.5%), with most cases occurring in those with type III papilla (71/175, 40.6%, P = 0.020). Multivariate logistic analysis revealed that age [odds ratio (OR) = 1.034, 95% confidence interval (CI): 1.021-1.047, P < 0.001], type III papilla (OR = 2.255, 95% CI: 1.439-3.535, P < 0.001), gallbladder in situ (OR = 2.486, 95% CI: 1.346-4.590, P = 0.004), and CBD diameter < 10 mm (OR = 1.600, 95% CI: 1.049-2.441, P = 0.029) were risk factors for difficult cannulation. The total incidence of PEP was 10.9%. Compared with the other types of papillae, the rate of PEP was the highest in those with type I papilla (15.2%, P = 0.030). Multivariate analysis demonstrated that PEP was associated with difficult cannulation (OR = 1.811, 95% CI: 1.044-3.143, P = 0.035) and white blood cells (WBCs) < 10 × 109/L (OR = 2.199, 95% CI: 1.051-4.600, P = 0.036).

The endoscopic appearance of the major papilla is an important factor that influences both biliary cannulation and outcomes. Type III papilla is more frequently difficult to cannulate in the endoscopic treatment of CBD stones.

To assess the outcomes of liver resection for primary intrahepatic lithiasis in a Western population, emphasizing the evolution of surgical techniques, including minimally invasive surgery, and their impact on patient outcomes.

We performed a retrospective analysis of 164 patients who underwent liver resection for primary intrahepatic lithiasis at the Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy. Data included demographics, surgical techniques, complications, and long-term outcomes. Minimally invasive surgery was introduced and progressively adopted, and its outcomes were compared with open surgery using propensity score matching. This represents the largest Western dataset on liver resection for primary intrahepatic lithiasis published to date.

Liver resections were predominantly unilateral (96%) and commonly targeted the left liver (65%). Minimally invasive surgery use increased to 60% in the most recent period, showing reduced morbidity and shorter hospital stays compared with open surgery. Postoperative complications included bile fistula (16%) and septic events (30%). Independent risk factors for bile fistula were previous cholangitis (odds ratio, 4.7; P = .006) and major hepatectomy (odds ratio, 7.8; P = .002). Septic complications were associated with previous cholangitis (odds ratio, 2.3; P = .026), bilateral lithiasis (odds ratio, 4.0; P = .010), and major hepatectomy (odds ratio, 3.5; P = .003), with minimally invasive surgery providing a protective effect (odds ratio, 0.34; P = .028). Long-term follow-up revealed a 20% recurrence rate, linked to incomplete intraoperative stone clearance (hazard ratio, 2.645; P = .019) and biliary fistula (hazard ratio, 2.799; P = .016). Cholangiocarcinoma occurred in 6.6%, underscoring the need for surveillance.

Liver resection is an effective, curative treatment for primary intrahepatic lithiasis in Western populations. Minimally invasive surgery advancements significantly improve short-term outcomes, bridging the East-West gap in primary intrahepatic lithiasis management and highlighting the importance of individualized surgical approaches.

Different techniques have been proposed to reduce the incidence of the intraoperative bile duct injury during laparoscopic cholecystectomy (LC). Among these, Near-Infrared Fluorescence Cholangiography (NIFC) with Indocyanine Green (ICG) represents a relatively recent addition. At present, there is considerable variation in the protocols for the administration of ICG.

The aim of this randomized multicenter clinical trial (RCT) is to ascertain whether there are differences between the dosage and administration intervals of ICG, with a view to optimizing a good-quality NIFC during LC. Furthermore, an analysis was conducted to determine the potential impact of different factors on the outcomes of this technique. The trial was approved by the local institutional Ethics Committee.

From June 2022 to June 2023, 200 patients were randomized in four arms (G1: 2.5 mg ICG > 3 h prior to surgery, G2: 2.5 mg ICG 15-30 min prior to surgery, G3: 0.05 mg/kg ICG > 3 h prior to surgery and G4: 0.05 mg/kg ICG 15-30 min prior to surgery). We found differences in the DISTURBED score between the groups (p < 0.001), suggesting that ICG administration 15-30 min before surgery was worse than administration > 3 h after LC (p = 0.02). Additionally, it was observed that body mass index (BMI), gender, ASA Classification System, previous liver and biliary disease and the type of surgery had influence on NIFC. Finally, the NIFC had an impact in intraoperative and postoperative complications, operative time and hospital length of stay.

The administration of ICG > 3 h improve liver background fluorescence in the NIFC during LC. There are different factors may affect NIFC results (BMI, ASA grade, previous liver disease, presence of gallbladder inflammation and type of surgery). Finally, high-quality NIFC was associated with fewer surgical complications, shorter surgical time and shorter length of hospital stay.

Statins may reduce the risk of recurrent gallstone disease by decreasing bile cholesterol saturation and pathogenicity. However, limited studies have investigated this issue. This study aimed to assess whether statin doses and serum cholesterol levels were associated with a decreased risk of recurrent biliary stone diseases after the first event index, with a follow-up time of 15 years.

Based on the Chang Gung Research Database (CGRD) between January 1, 2001, and December 31, 2020, we enrolled 68,384 patients with the International Classification of Diseases, Ninth and Tenth Revision codes of choledocholithiasis. After exclusions, 32,696 patients were divided into non-statin (<28 cDDD, cumulative defined daily doses) (n = 27,929) and statin (≥28 cDDD) (n = 4767) user groups for analysis. Serum cholesterol trajectories were estimated using group-based trajectory modeling (n = 8410).

The statin users had higher Charlson Comorbidity Index (CCI) scores than the non-statin users. Time-dependent Cox regression analysis showed that statin use >365 cDDD was associated with a significantly lower risk of recurrent biliary stones (adjusted hazard ratio [aHR] = 0.28, 95% CI, 0.24-0.34; p < 00.0001), acute pancreatitis (aHR = 0.24, 95% CI, 0.17-0.32, p < 00.0001), and cholangitis (aHR = 0.28, 95% CI, 0.25-0.32, p < 00.0001). Cholecystectomy was also a protective factor for recurrent biliary stones (aHR = 0.41, 95% CI, 0.37-0.46; p < 00.0001). The higher trajectory serum cholesterol group (Group 3) had a lower risk trend for recurrent biliary stones (aHR = 0.79, p = 0.0700) and a lower risk of cholangitis (aHR = 0.79, p = 0.0071).

This study supports the potential benefits of statin use and the role of cholecystectomy in reducing the risk of recurrent biliary stone diseases.

Endoscopic gallbladder-preserving cholecystolithotomy (EGPC) has become an alternative option for treating cholecystolithiasis. However, developing a new method of EGPC in which the gallbladder wall is not damaged remains a challenge. This study introduced a new EGPC method called endoscopic retrograde cholangiopancreatography (ERCP) combined with extracorporeal shock wave lithotripsy (ESWL), which preserves the integrity of the gallbladder wall in the treatment of cholecystolithiasis complicated with choledocholithiasis.

In total, six patients (aged 23-72 years, 3 males and 3 females, Han ethnicity) who had large gallbladder stones (diameter ≥ 1 cm) complicated with common bile duct (CBD) stones and who underwent ERCP combined with ESWL at the First Affiliated Hospital of Nanchang University from July 2022 to December 2022 were enrolled. The patients' clinical characteristics, endoscopic treatment and follow-up data were analyzed. A paired t test was performed to compare the differences in the main serological indicators before and after EGPC.

Of the six patients, five completed EGPC, and one failed due to intolerable abdominal pain during ESWL and was subsequently transferred to surgery. With respect to post-EGPC adverse events, one patient developed mild post-ERCP pancreatitis, and no other adverse events occurred. Both the technical success rate and clinical success rate of ERCP combined with ESWL were 83.3% and the incidence of adverse events was 16.7%. The six patients were followed up for an average of 24 months, during which only one patient experienced a recurrence of gallbladder stones at the 3-month follow-up, but no gallbladder stones were found at the 6-month follow-up after oral administration of ursodeoxycholic acid.

ERCP combined with ESWL is a potentially safe and effective treatment for large gallbladder stones.

This study was registered at the Chinese Clinical Trial Registry site. [Registration number: ChiCTR2200060927 ( http://www.chictr.org.cn/ ); registration date: June 14, 2022].

The advantages of indocyanine green (ICG) fluorescence cholangiography have been emphasized, but its disadvantages remain unclear. This study investigated the advantages and disadvantages of this modality, particularly the optimal timing of administration of ICG fluorescence.

This was a retrospective analysis of prospectively collected patient data.

Data were gathered from a single institution.

69 patients scheduled for cholecystectomy were included.

We administered intravenous ICG injections at three different times: preoperatively (5 mg/body weight (BW), 15 min before incision), morning of the surgery (12.5 mg/BW 4 hours before surgery), and on the day before the surgery (25 mg/BW, 20 hours before surgery). The PINPOINT or SPY-PHI (Stryker) systems were used for fluorescence imaging.

The course of the common bile and cystic ducts was identified using fluorescence imaging. The visualization quality was graded on a three-point scale: good, poor, and unobservable.

There were 17 patients for preoperative administration, 14 on the morning of the surgery, and 38 on the day before the surgery. The cystic duct could not be visualized in five patients because of insufficient dose, impacted gallstones, cystic duct stones, after endoscopic retrograde biliary drainage (ERBD), and severe cholecystitis. The observations were poor in 14 patients. The reasons for the poor visualization were cholecystitis after ERBD and a low signal-to-noise ratio due to intense light emission from the liver, which is a characteristic of preoperative administration.

The cystic and common bile ducts were well visualized using ICG fluorescence cholangiography, except in patients with impacted gallstones, cystic duct stones, ERBD, and severe cholecystitis. The most effective timing for ICG administration was the day before the surgery. ICG fluorescence cholangiography is not a substitute for intraoperative cholangiography or preoperative biliary imaging; however, it would be desirable in all patients who undergo cholecystectomy.

jRCTs041180006.

This study aimed to investigate the safety, feasibility, and possible advantages of the cystic plate approach during laparoscopic cholecystectomy in a retrospective cohort of surgical patients.

We summarized the key points of the technical approach, retrospectively analyzed the clinical outcomes of 156 patients in the cystic plate approach group from July 2018 to July 2023, and compared the findings with those of 173 cases in the routine approach group from the same period.

We observed no differences in the average stone size, operation time, postoperative hospital stay, conversion rate, complications, or Visual Analog Scale pain scores on the second day of surgery between the two groups (p = 0.076, 0.067, 0.278, 1.000, 0.633, and 0.131, respectively). However, intraoperative blood loss, number of clips used, volume of postoperative drainage fluid, and Visual Analog Scale pain scores on the day of surgery in the cystic plate approach group were significantly lower than those in the routine approach group (p = 0.000, 0.031, 0.027, and 0.021, respectively).

The cystic plate approach is a safe, feasible, and effective approach that has the advantages of minimal invasiveness with less bleeding and seepage, reduced use of biological clips, and less pain, potentially minimizing the risk of iatrogenic biliary injury.

This study was registered at the International Clinical Trial Registry (ChiCTR2100052860). Registration date: November 6, 2021.

Methods for accurately predicting the prognosis of patients with recurrent hepatolithiasis (RH) after biliary surgery are lacking. This study aimed to develop a model that dynamically predicts the risk of hepatolithiasis recurrence using a machine-learning (ML) approach based on multiple clinical high-order correlation data.

Data from patients with RH who underwent surgery at five centres between January 2015 and December 2020 were collected and divided into training and testing sets. Nine predictive models, which we named the Correlation Analysis and Recurrence Evaluation System (CARES), were developed and compared using machine learning (ML) methods to predict the patients' dynamic recurrence risk within 5 post-operative years. We adopted a k-fold cross validation with k = 10 and tested model performance on a separate testing set. The area under the receiver operating characteristic curve was used to evaluate the performance of the models, and the significance and direction of each predictive variable were interpreted and justified based on Shapley Additive Explanations.

Models based on ML methods outperformed those based on traditional regression analysis in predicting the recurrent risk of patients with RH, with Extreme Gradient Boosting (XGBoost) and Light Gradient Boosting Machine (LightGBM) showing the best performance, both yielding an AUC (Area Under the receiver operating characteristic Curve) of∼0.9 or higher at predictions. These models were proved to have even better performance on testing sets than in a 10-fold cross validation, indicating that the model was not overfitted. The SHAP method revealed that immediate stone clearance, final stone clearance, number of previous surgeries, and preoperative CA19-9 index were the most important predictors of recurrence after reoperation in RH patients. An online version of the CARES model was implemented.

The CARES model was firstly developed based on ML methods and further encapsulated into an online version for predicting the recurrence of patients with RH after hepatectomy, which can guide clinical decision-making and personalised postoperative surveillance.

This study aimed to evaluate the outcomes and complications of secondary hepatolithiasis following choledochoenterostomy to guide suitable management.

The study analyzed 127 patients from a 2017 national survey conducted by the Ministry of Health, Labor, and Welfare. The 2023 cohort study assessed residual stones, recurrences, cholangitis, cholangiocarcinoma, and prognosis.

The median follow-up duration was 48 months. Balloon endoscopy-assisted endoscopic retrograde cholangiography (BE-ERC) was the most common treatment, achieving complete stone clearance in 84.4% of patients. Anatomical hepatectomy was the most common surgery. Predictors of residual stones were stone number ≥10 (odds ratio [OR], 7.480; p = .028) and stone diameter ≥10 mm (OR, 5.280; p = .020). Predictors of stone recurrence during follow-up were biliary strictures (hazard ratio [HR], 3.580; p = .005) and cholangitis (HR, 2.700; p = .037). Predictors of cholangitis during follow-up were biliary stricture (HR, 5.016; p = .006) and dilatation (HR, 3.560; p = .029). Any treatment for hepatolithiasis reduced cholangitis occurrence (HR, 0.168; p = .042). Balloon dilation combined with stenting for ≥3 months improved biliary strictures in 57.1% of patients.

This study recommends BE-ERC as the first-choice treatment for secondary hepatolithiasis. Stone removal and relief of biliary strictures and dilatation are crucial to prevent stone recurrence and cholangitis after treatment.

Gastrointestinal tumors represent a significant component of the cancer burden in Asia. This study aims to evaluate the burden of gastrointestinal tumors in Asia from 1990 to 2021 using data from the Global Burden of Disease Study 2021 (GBD 2021).

The absolute incidence, mortality, and disability adjusted life years (DALYs) number and rate of six gastrointestinal tumors(colon and rectum cancer (CRC), stomach cancer (SC), pancreatic cancer (PC), esophageal cancer (EC), liver cancer (LC) and gallbladder and biliary tract cancer (GBTC)) in 48 Asian countries were extracted from GBD 2021. Differences were analyzed based on gender, age, year, location and socio-demographic index (SDI).

In 2021, SC accounted for the highest disease burden in Asia (DALYs=16.41million [95% UI: 13.70, 19.62]). From 1990 to 2021, the age-standardized incidence rates of EC, LC, and SC in Asia declined, while the incidence rates of CRC and PC increased significantly, with CRC showing the largest rise (AAPC=1.08 [95% CI: 1.02 to 1.12]). Gastrointestinal tumors DALY rates peaked at age 70 and above, with males generally exhibiting higher rates than females. Furthermore, East Asia bears a higher burden compared to other Asian subregions. A higher SDI correlates with increased DALY rates for PC, but no linear relationship was observed for other gastrointestinal tumors.

The burden of gastrointestinal tumors in Asia remains high and may continue to increase. Therefore, effective prevention and treatment measures are essential to address the challenge posed by gastrointestinal tumors.

Percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) provides an effective alternative procedure for the management of complex hepatolithiasis and choledocholithiasis. Enhanced recovery after surgery (ERAS) program is an evidence-based approach that was developed to reduce surgical stress and accelerate postoperative recovery. However, little is known regarding PTCSL in the context of ERAS. The aim of this study was to evaluate the efficacy and safety of PTCSL within ERAS programs.

The clinical data of patients who underwent PTCSL within ERAS programs consulted at our hospital between November 2017 and November 2022 was retrospectively reviewed. Individualized perioperative ERAS items were evaluated for all patients. The demographics, intraoperative variables, and postoperative outcomes were analyzed.

A total of 43 patients who underwent PTCSL were included in the study. There were 13 men and 30 women aged between 39 and 89 years with an average age of 60 years (60.49 ± 12.37). The stone clearance rate was 77 % after the first operation, and the final clearance rate was 95 %. The incidence of complications in this study is 18.6 % (8/43), including 6 patients with Clavien-Dindo I-II, and 2 patients with Clavien-Dindo III. Pleural effusion, abdominal effusion, infection, bile leakage, and biliary bleeding are the most common complications, however, all patients recovered after aggressive treatment.

PTCSL is a relatively safe, feasible, and efficient method for treating complex hepatolithiasis and choledocholithiasis within ERAS programs. Individualized ERAS entries and precise disease management are required to minimize the occurrence of complications and to provide effective treatment.

Backgrounds Laparoscopic cholecystectomy (LC) is the gold standard for surgical removal of gallbladder today. In challenging cholecystectomy cases, conversion to an open technique may be necessary. Therefore, the preoperative prediction of conversion to open technique holds significant importance for patient safety and surgical strategy. In the literature, conversion to open cholecystectomy has been associated with many contradictory predictive factors. The aim of this study is to identify and comprehensively evaluate the predictive laboratory parameters and ratios associated with the conversion from laparoscopic to open cholecystectomy. Methods In this historical cohort study, the data of patients who were scheduled for and underwent LC between January 1, 2018, and September 1, 2023, were retrospectively evaluated. The preoperative laboratory findings and surgical notes of the patients were reviewed retrospectively from the archives. The correlation between patient data and the cholecystectomy groups was analyzed, and comparisons were made between the groups. Results All 160 patients initially underwent a laparoscopic approach. In emergency cases, a statistically significant association was found between lymphocyte count (p = 0.017) and lymphocyte-to-monocyte ratio (LMR) (p = 0.041) with operations completed laparoscopically and between neutrophil-to-lymphocyte ratio (NLR) (p = 0.007) and Systemic Inflammatory Response Index (SIRI) (p = 0.031) with operations converted to open surgery. In elective cases, gamma-glutamyl transferase (GGT) (p = 0.024) and total bilirubin (TBIL) (p = 0.003) were found to have a statistically significant association with operations converted to open surgery. In the logistic regression analysis, hematological parameters and ratios were not found to have a statistically significant relationship in predicting the conversion to open surgery. Conclusion Although significant differences were observed in laboratory parameters and derived ratios such as the NLR and LMR, logistic regression analysis did not identify any of these measures as significant predictors of conversion from laparoscopic to open surgery. Further prospective studies with larger sample sizes are needed in this area.

Gallbladder Adenomyomatosis (GA) is a benign rare condition that is mostly asymptomatic but can present as abdominal pain. GA usually occurs in the middle-aged population with an equal sex distribution.

A case of a 49-years-old female who sought medical care several times due to abrupt abdominal pain. She underwent echography, Computed Tomography (CT) scan and Magnetic Resonance Imaging (MRI) before performing laparoscopic cholecystectomy for symptomatic GA. The pathology report confirmed acalculous cholecystitis in the presence of GA.

In fact, echography can reveal the "comet- tail" sign, the CT can show the "rosary sign"; and MRI shows the "pearl necklace" sign. These signs, in the absence of gallstones, can justify the abdominal pain hence the diagnosis of symptomatic GA.

GA is being increasingly reported; however, symptomatic cases remain the exception. We believe that awareness to this entity should be raised so that healthcare professionals can establish the diagnosis efficiently.

Intraoperative bile duct injury is a significant complication in laparoscopic cholecystectomy (LC). Near-infrared fluorescence cholangiography (NIFC) can reduce this complication. Therefore, determining the optimal indocyanine green (ICG) dosage for effective NIFC is crucial. This study aimed to determine the optimal ICG dosage for NIFC.

This was a prospective, randomized, double-blind clinical trial at a single tertiary referral center, including 195 patients randomly assigned to three groups: lower dose (0.01 mg/BMI) ICG (n = 63), medium dose (0.02 mg/BMI) ICG (n = 68), and higher dose (0.04 mg/BMI) ICG (n = 64). Surgeon satisfaction and detection rates for seven biliary structures were compared among the three dose groups.

Demographic parameters did not significantly differ among the groups. The medium dose (72.1%) and higher dose ICG groups (70.3%) exhibited superior visualization of the common hepatic duct compared to the lower dose group (41.3%) (p < 0.001). No differences existed between the medium and higher dose groups. Similar trends were observed for the common bile duct and cystic common bile duct junction.

In patients undergoing fluorescent laparoscopic cholecystectomy, the 0.02 mg/BMI dose of indocyanine green demonstrated better biliary structure detection rates than the 0.01 mg/BMI dose and was non-inferior to the 0.04 mg/BMI dose.

The burgeoning field of metabolomics has piqued the interest of researchers in the context of benign gallbladder diseases, which include conditions such as gallbladder polyps, gallstones, and cholecystitis, which are common digestive system disorders. As metabolomics continues to advance, researchers have increasingly focused their attention on its applicability in the study of benign gallbladder diseases to provide new perspectives for diagnostic, therapeutic, and prognostic evaluation. This comprehensive review primarily describes the techniques of liquid chromatography-mass spectrometry, gas chromatography-mass spectrometry, and nuclear magnetic resonance and their respective applications in the study of benign gallbladder disease. Metabolomics has made remarkable progress in various aspects of these diseases, ranging from early diagnosis, etiological research, assessment of disease progression and prognosis, and optimization of therapeutic strategies. However, challenges remain in the field of metabolomics in the study of benign gallbladder diseases. These include issues related to data processing and analysis, biomarker discovery and validation, interdisciplinary research integration, and the advancement of personalized medicine. This article attempts to summarize research findings to date, highlight future research directions, and provide a reference point for metabolomics research in benign gallbladder disease.

Patients with cholelithiasis (CL) or cholecystectomy (CE) would have more chances of getting colorectal adenoma (CRA) or cancer (CRC). We aimed to figure out the effects of gut microbiota and bile acid on colorectal neoplasm in CL and CE patients.

This was a retrospective observational study that recruited 514 volunteers, including 199 people with normal gallbladders (normal), 152 CL, and 163 CE patients. Discovery cohort was established to explore the difference in gut microbiota through 16S rRNA and metagenomics sequencing. Validation cohort aimed to verify the results through quantitative polymerase chain reaction (qPCR).

Significant enrichment of Escherichia coli was found in patients with cholelithiasis or cholecystectomy both in the discovery cohort (16S rRNA sequencing, PNormal-CL = 0.013, PNormal-CE = 0.042; metagenomics sequencing, PNormal-CE = 0.026) and validation cohort (PNormal-CL < 0.0001, PNormal-CE < 0.0001). Pks+ E. coli was found enriched in CL and CE patients through qPCR (in discovery cohort: PNormal-CE = 0.018; in validation cohort: PNormal-CL < 0.0001, PNormal-CE < 0.0001). The differences in bile acid metabolism were found both through Tax4Fun analysis of 16S rRNA sequencing (Ko00120, primary bile acid biosynthesis, PNormal-CE = 0.014; Ko00121, secondary bile acid biosynthesis, PNormal-CE = 0.010) and through metagenomics sequencing (map 00121, PNormal-CE = 0.026). The elevation of serum total bile acid of CE patients was also found in validation cohort (PNormal-CE < 0.0001). The level of serum total bile acid was associated with the relative abundance of pks+ E. coli (r = 0.1895, P = 0.0012).

E. coli, especially pks+ species, was enriched in CL and CE patients. Pks+ E. coli and bile acid metabolism were found associated with CRA and CRC in people after cholecystectomy.

Balloon endoscopy-assisted endoscopic retrograde cholangiopancreatography (BE-ERCP) is an emerging procedure for pancreatobiliary diseases in patients with surgically altered anatomy. However, data on BE-ERCP for hepatolithiasis after hepaticojejunostomy (HJS) are still limited.

Stone removal success, adverse events and recurrence were retrospectively studied in consecutive patients who underwent BE-ERCP for hepatolithiasis after HJS between January 2011 and October 2022. Subgroup analysis was performed to compare clinical outcomes between patients who had undergone HJS over 10 years before (past HJS group) and within 10 years (recent HJS group).

A total of 131 patients were included; 39% had undergone HJS for malignancy and 32% for congenital biliary dilation. Scope insertion and complete stone removal were successful in 89% and 73%, respectively. Early adverse events were observed in 9.9%. Four patients (3.1%) developed gastrointestinal perforation but could be managed conservatively. Hepatolithiasis recurrence rate was 17%, 20% and 31% in 1-year, 3-year, and 5-year after complete stone removal. The past HJS group was the only risk factor for failed stone removal (odds ratio 10.4, 95% confidence interval 2.99-36.5) in the multivariable analysis. Failed scope insertion (20%) and failed guidewire or device insertion to the bile duct (22%) were two major reasons for failed stone removal in the past HJS group.

BE-ERCP for hepatolithiasis was effective and safe in cases with HJS but the complete stone removal rate was low in the past HJS group. Recurrent hepatolithiasis was common and careful follow up study is needed even after complete stone removal.

There is a lack of validated predictive models for the occurrence of systemic inflammatory response syndrome (SIRS) after percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) for the treatment of hepatolithiasis. This is the first study to estimate the incidence of SIRS after PTCSL.

A retrospective analysis of 284 PTCSL sessions for the treatment of hepatolithiasis at our institution between January 2019 and January 2023 was performed. The development of SIRS after PTCSL was the primary study endpoint. Independent risk factors for SIRS after PTCSL were identified using univariate and multivariate logistic regression analyses. A nomogram prediction model was constructed using these independent risk factors, and the predictive value was assessed using receiver operating characteristic (ROC) curves.

The incidence of SIRS after PTCSL was 20.77%. According to multivariate analysis, the number of PTCSL sessions (odds ratio [OR]=0.399, 95% confidence interval [CI]=0.202-0.786, p=0.008), stone location (OR=2.194, 95% CI=1.107-4.347, p=0.024), intraoperative use of norepinephrine (OR=0.301, 95% CI=0.131-0.689, p=0.004), intraoperative puncture (OR=3.476, 95% CI=1.749-6.906, P<0.001), preoperative gamma-glutamyltransferase (OR=1.002, 95% CI=1.001-1.004, p=0.009), and preoperative total lymphocyte count (OR=1.820, 95% CI=1.110-2.985, p=0.018) were found to be independent risk factors for the development of SIRS after PTCSL. These six independent risk factors were used to construct a nomogram prediction model, which showed satisfactory accuracy with an area under the ROC curve of 0.776 (95% CI: 0.702-0.850).

The number of PTCSL sessions, stone location, intraoperative use of norepinephrine, intraoperative puncture, preoperative gamma-glutamyltransferase, and preoperative total lymphocyte count may predict the occurrence of SIRS after PTCSL. This prediction model may help clinicians identify high-risk patients in advance.

The term hepatolithiasis describes the presence of biliary stones within the intrahepatic bile ducts, above the hilar confluence of the hepatic ducts. The disease is more prevalent in Asia, mainly owing to socioeconomic and dietary factors, as well as the prevalence of biliary parasites. In the last century, owing to migration, its global incidence has increased. The main pathophysiological mechanisms involve cholangitis, bile infection and biliary strictures, creating a self-sustaining cycle that perpetuates the disease, frequently characterised by recurrent episodes of bacterial infection referred to as syndrome of "recurrent pyogenic cholangitis". Furthermore, long-standing hepatolithiasis is a known risk factor for development of intrahepatic cholangiocarcinoma. Various classifications have aimed at providing useful insight of clinically relevant aspects and guidance for treatment. The management of symptomatic patients and those with complications can be complex, and relies upon a multidisciplinary team of hepatologists, endoscopists, interventional radiologists and hepatobiliary surgeons, with the main goal being to offer relief from the clinical presentations and prevent the development of more serious complications. This comprehensive review provides insight on various aspects of hepatolithiasis, with a focus on epidemiology, new evidence on pathophysiology, most important clinical aspects, different classification systems and contemporary management.

Choledochoduodenostomy (CDD) is performed to treat choledocholithiasis (CDL) cases where endoscopic stone removal is difficult. Recognizing CDD characteristics is important for CDL treatment planning.

A total of 116 patients, including 33 patients ≥ 80 years old (29 with previous total gastrectomy, 19 with previous distal gastrectomy, 20 with built-up stones, 19 with periampullary diverticulum, 10 with confluence stones, 8 with repetitive recurrent stones, 4 with hard stones, 3 with endoscopic retrograde cholangiography [ERC] not available due to lack of cooperation, 2 with a history of pancreatitis post-ERC, and 2 in whom ERC could not be performed due to a disturbed anatomy) underwent CDD for CDL. Postoperative complications and long-term outcomes were evaluated.

The in-hospital mortality rate was 0%. The morbidity (grade ≥ IIIA according to the Clavien-Dindo classification) rates in the elderly (≥ 80 years old) and non-elderly (51-79 years old) patients were 3.0% (1/33) and 2.4% (2/83), respectively (p = 0.85). Long-term complications included cholangitis in eight (7%) patients, of which three cases were repetitive and seven had an operative history of total or distal gastrectomy. The incidence of postoperative cholangitis after total or distal gastrectomy was 15% (7/48), which was significantly higher than that involving other causes (1.5%, 1/68; p < 0.01). Two patients with cholangitis after total gastrectomy experienced early recurrence of lithiasis at 2 and 9 months after surgery.

CDD is safe, even in elderly patients. However, a history of total gastrectomy or distal gastrectomy may increase the incidence of postoperative cholangitis.

Choledocholithiasis presents variably, with some patients remaining asymptomatic, complicating decisions regarding the timing and necessity of endoscopic retrograde cholangiopancreatography (ERCP). This study represents the first meta-analysis assessing the impact of symptomatic status on post-ERCP complications and provides critical data to optimize treatment strategies. A systematic review and meta-analysis were conducted by searching PubMed, Embase, and Google Scholar through February 2024, focusing on comparing ERCP outcomes between symptomatic and asymptomatic patients with choledocholithiasis. Seven studies were included from an initial pool of 1,200 articles screened. The analysis revealed that asymptomatic patients exhibited a significantly higher overall complication rate (17.4% vs. 6.6%), including a threefold increase in the risk of developing complications overall (OR: 3.02; 95% CI: 2.26-4.03) and specifically post-ERCP pancreatitis (OR: 3.62; 95% CI: 2.63-4.99). Perforation and procedural durations were also notably higher among asymptomatic individuals. Subgroup analyses highlighted prolonged cannulation times and the use of precut sphincterotomy as potential influential factors. These findings challenge the current practice that does not differentiate based on symptomatic status and suggest a need for more tailored approaches in managing asymptomatic individuals to minimize risks associated with ERCP.

Endoscopic treatment of common bile duct (CBD) stones involves the use of basket or balloon catheters; however, what is the appropriate device remains controversial. In this study we aimed to prospectively evaluate the usefulness of a novel 8-wire helical basket (8WB) catheter made of Nitinol for the removal of CBD stones ≤10 mm.

We conducted a multicenter prospective trial. Patients with CBD stones ≤10 mm were enrolled. The primary endpoint was the rate of complete stone removal within 10 min using the 8WB. The number of cases was determined using a previous study of stone removal by a conventional basket catheter as a historical control.

A total of 155 patients were enrolled and 139 were ultimately included in the analysis. Patients with a single stone were the most common (84 cases, 60.4%), with a median maximum stone diameter of 5 mm. The median stone removal time using the 8WB was 6 min. The complete stone removal rate was 95.0% (132/139). Adverse events were observed in 14 patients (10.1%).

The novel 8WB catheter is useful in the treatment of CBD stones ≤10 mm, presenting a high complete stone removal rate in this study.

jRCT1032200324.

We compared ERCP using a balloon-assisted endoscope (BE-ERCP) with EUS-guided antegrade treatment (EUS-AG) for removal of common bile duct (CBD) stones in patients with Roux-en-Y (R-Y) gastrectomy.

Consecutive patients who had previous R-Y gastrectomy undergoing BE-ERCP or EUS-AG for CBD stones in 16 centers were retrospectively analyzed.

BE-ERCP and EUS-AG were performed in 588 and 59 patients, respectively. Baseline characteristics were similar, except for CBD diameter and angle. The technical success rate was 83.7% versus 83.1% (P = .956), complete stone removal rate was 78.1% versus 67.8% (P = .102), and early adverse event rate was 10.2% versus 18.6% (P = .076) in BE-ERCP and EUS-AG, respectively. The mean number of endoscopic sessions was smaller in BE-ERCP (1.5 ± .8 vs 1.9 ± 1.0 sessions, P = .01), whereas the median total treatment time was longer (90 vs 61.5 minutes, P = .001). Among patients with biliary access, the complete stone removal rate was significantly higher in BE-ERCP (93.3% vs 81.6%, P = .009). Negative predictive factors were CBD diameter ≥15 mm (odds ratio [OR], .41) and an angle of CBD <90 degrees (OR, .39) in BE-ERCP and a stone size ≥10 mm (OR, .07) and an angle of CBD <90 degrees (OR, .07) in EUS-AG. The 1-year recurrence rate was 8.3% in both groups.

Effectiveness and safety of BE-ERCP and EUS-AG were comparable in CBD stone removal for patients after R-Y gastrectomy, but complete stone removal after technical success was superior in BE-ERCP.

In the past quite a long time, intraoperative cholangiography(IOC)was necessary during laparoscopic cholecystectomy (LC). Now magnetic resonance cholangiopancreatography (MRCP) is the main method for diagnosing common bile duct stones (CBDS). Whether MRCP can replace IOC as routine examination before LC is still inconclusive. The aim of this study was to analyze the clinical data of patients undergoing LC for cholecystolithiasis, and to explore the necessity and feasibility of preoperative routine MRCP in patients with cholecystolithiasis.

According to whether MRCP was performed before operation, 184 patients undergoing LC for cholecystolithiasis in the Department of General Surgery, Beijing Shijitan Hospital, Capital Medical University from January 1, 2017 to December 31, 2018 were divided into non-MRCP group and MRCP group for this retrospective study. The results of preoperative laboratory test, abdominal ultrasound and MRCP, biliary related comorbidities, surgical complications, hospital stay and hospitalization expenses were compared between the two groups.

Among the 184 patients, there were 83 patients in non-MRCP group and 101 patients in MRCP group. In MRCP group, the detection rates of cholecystolithiasis combined with CBDS and common bile duct dilatation by MRCP were higher than those by abdominal ultrasound (P < 0.05). The incidence of postoperative complications in non-MRCP group (8.43%) was significantly higher (P < 0.05) than that in MRCP group (0%). There was no significant difference in hospital stay (P > 0.05), but there was significant difference in hospitalization expenses (P < 0.05) between the two groups. According to the stratification of gallbladder stone patients with CBDS, hospital stay and hospitalization expenses were compared, and there was no significant difference between the two groups (P > 0.05).

The preoperative MRCP can detect CBDS, cystic duct stones and anatomical variants of biliary tract that cannot be diagnosed by abdominal ultrasound, which is helpful to plan the surgical methods and reduce the surgical complications. From the perspective of health economics, routine MRCP in patients with cholecystolithiasis before LC does not increase hospitalization costs, and is necessary and feasible.

The project was performed to determine if referrals to non-surgical providers after an initial presentation of symptomatic cholelithiasis are associated with a delay in surgical management.

A single institution chart review of all adult patients who underwent a cholecystectomy from 2015 to 2019 was completed. Quantitative data was analyzed using independent t-tests.

Of 574 reviewed, 482 patients met criteria. Following initial presentation, 295 (61.2%) received a referral to surgery and 187 (38.8%) received follow up with a non-surgical provider. Those in the latter group had a significantly longer time from initial symptom presentation to surgical evaluation (65.7 days vs. 10.3 days, p ​< ​0.001) and cholecystectomy (102.0 days vs 39.1 days, p ​< ​0.001) when compared to the surgery referral group.

This study demonstrated that cholecystectomy was significantly delayed for patients who had been referred to non-surgical providers after initial presentation, prolonging symptoms and increasing use of healthcare resources.

Laparoscopic surgery is effective for treating common bile duct (CBD) stones. However, it has high requirements for surgeons and the risk of conversion to laparotomy cannot be ignored. However, when conditions during surgery are not favorable, persisting with laparoscopic procedures blindly can lead to serious complications. Our study aimed to establish a nomogram model for predicting conversion of laparoscopic to laparotomy for choledocholithiasis.

A total of 867 patients who were diagnosed with choledocholithiasis and underwent laparoscopic surgery were randomly divided into a training group (70%, n = 607) and a validation group (30%, n = 260). A nomogram was constructed based on the results of logistic regression analysis. The area under the receiver operating characteristic curve (AUC), calibration curve, and decision curve analysis (DCA) were used to assess the predictive performance of the nomogram.

Previous upper abdominal surgery, maximum diameter of stone ≥12 mm, medial wall of the duodenum stone, thickening of the gallbladder wall, thickening of CBD wall, stone size/CBD size ≥0.75, and simultaneous laparoscopic hepatectomy were included in the nomogram. The AUC values were 0.813 (95% CI: 0.766-0.861) and 0.804 (95% CI: 0.737-0.871) in the training and validation groups, respectively. The calibration curve showed excellent consistency between the nomogram predictions and actual observations. DCA showed a positive net benefit for the nomogram.

We constructed a nomogram with a good ability to predict conversion to open surgery in laparoscopic surgery for choledocholithiasis, which can help surgeons to make a reasonable operation plan before surgery and timely convert to laparotomy during operation to reduce potential harm to the patient.

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.

To systematically evaluate the methodological quality of the current up-to-date guidelines pertaining to choledocholithiasis, we conducted a comprehensive analysis of key recommendations and corresponding evidence, focusing on the heterogeneity among these guidelines.

Systematic searches across various databases were performed to identify the latest guidelines. The identified guidelines, which met the inclusion criteria, underwent evaluation using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. The key recommendations and evidence from the included guidelines were extracted and reclassified using the Oxford Centre for Evidence-Based Medicine (OCEBM) grading system, and the obtained results were analyzed.

Nine guidelines related to choledocholithiasis were included in this study, out of which 4 achieved an overall standardized score of more than 60%, indicating their suitability for recommendation. Upon closer examination of the main recommendations within these guidelines, we discovered significant discrepancies concerning the utilization of similar treatment techniques for different diseases or different treatment methods under comparable conditions, and discrepancies in the recommended treatment duration. High-quality research evidence was lacking, and some recommendations either failed to provide supporting evidence or cited inappropriate and low-level evidence.

The quality of guidelines pertaining to choledocholithiasis is uneven. Recommendations for the treatment of choledocholithiasis demonstrate considerable disparities among the guidelines, particularly regarding the utilization of endoscopic retrograde cholangiopancreatography as a treatment method and the management approaches for difficult stone cases. Improvements by guideline developers for these factors contributing to the heterogeneity would be a reasonable approach to further update the guidelines for cholangiolithiasis.

Current guidelines recommend treating choledocholithiasis, regardless of symptoms or stone size, with endoscopic retrograde cholangiopancreatography (ERCP). However, asymptomatic choledocholithiasis, discovered incidentally on imaging, may carry a higher risk of ERCP-related adverse events, and some asymptomatic and diminutive stones may not cause biliary adverse events during extended follow-up. Therefore, we aimed to clarify the best treatment strategies for asymptomatic choledocholithiasis based on stone size.

We retrospectively identified patients with incidental imaging-found asymptomatic diminutive (≤ 4 mm) or non-diminutive (> 4 mm) choledocholithiasis and divided them into two groups: those who did not undergo ERCP and were treated when complications arose (on-demand group) and those who underwent ERCP before being symptomatic (intervention group). Adverse events were defined as any biliary or pancreatic complication related to ERCP or arising during observation or after intervention. The primary outcome was the adjusted overall adverse event-free survival using the propensity score-based matching weights method comparing the two groups of stone size.

Among 148 patients identified (median follow-up period, 969 days), 68 had diminutive stones and 80 had non-diminutive stones. Of the 68 patients with diminutive stones, 51 were in the on-demand group and 17 in the intervention group. The overall adjusted adverse event-free survival was significantly higher in the on-demand group for diminutive stones (97.4% and 70.1%, respectively, at 3 years; p = 0.01).

Patients with incidental imaging-detected asymptomatic diminutive choledocholithiasis may benefit from clinical observation, pursuing ERCP when symptoms develop.

This study aimed to investigate the safety and efficacy of laparoscopic anatomical left hemihepatectomy guided by the middle hepatic vein (MHV) for the treatment of patients with hepatolithiasis who had a history of upper abdominal surgery.

Retrospective data analysis was performed on patients who underwent laparoscopic left hepatectomy for hepatolithiasis and with previous upper abdominal surgery at the Second Affiliated Hospital of Nanchang University from January 2018 to April 2022. According to the different surgical approaches, patients were divided into laparoscopic anatomical left hepatectomy guided by the MHV group (MHV-AH group) and laparoscopic traditional anatomical left hepatectomy not guided by the MHV group (non-MHV-AH group).

This study included 81 patients, with 37 and 44 patients in the MHV-AH and non-MHV-AH groups, respectively. There was no significant difference in the basic information between the two groups. Five cases were converted to laparotomy, and the remaining were successfully completed under laparoscopy. Compared to the non-MHV-AH group, the MHV-AH group had a slightly longer operation time (319.30 min vs 273.93 min, P = 0.032), lower bile leakage rate (5.4% vs 20.5%, P = 0.047), stone residual rate (2.7% vs 20.5%, P = 0.015), stone recurrence rate (5.4% vs 22.7%, P = 0.028), and cholangitis recurrence rate (2.7% vs 22.7%, P = 0.008).There were no significant differences in the results of other observation indices between the groups.

Laparoscopic anatomical left hepatectomy guided by the MHV is safe and effective in the treatment of left hepatolithiasis with a history of upper abdominal surgery. It does not increase intraoperative bleeding and reduces the risk of postoperative bile leakage, residual stones, stone recurrence, and cholangitis recurrence.

To perform a systematic review and meta-analysis to determine the success and complication rate of percutaneous transhepatic fluoroscopy-guided management (PTFM) for the removal of common bile duct stones (CBDS).

A comprehensive literature search of multiple databases was conducted to identify original articles published between January 2010 and June 2022, reporting the success rate of PTFM for the removal of CBDS. A random-effect model was used to summarize the pooled rates of success and complications with 95% confidence intervals (CIs).

Eighteen studies involving 2554 patients met the inclusion criteria and were included in the meta-analysis. Failed or infeasible endoscopic management was the most common indication of PTFM. The meta-analytic summary estimates of PTFM for the removal of CBDS were as follows: rate of overall stone clearance 97.1% (95% CI, 95.7-98.5%); stone clearance at first attempt 80.5% (95% CI, 72.3-88.6%); overall complications 13.8% (95% CI, 9.7-18.0%); major complications 2.8% (95% CI, 1.4-4.2%); and minor complications 9.3% (95% CI, 5.7-12.8%). Egger's tests showed the presence of publication bias with respect to the overall complications (p = 0.049). Transcholecystic management of CBDS had an 88.5% pooled rate for overall stone clearance (95% CI, 81.2-95.7%), with a 23.0% rate for complications (95% CI, 5.7-40.4%).

The systematic review and meta-analysis answer the questions of the overall stone clearance, clearance at first attempt, and complication rate of PTFM by summarizing the available literature. Percutaneous management could be considered in cases with failed or infeasible endoscopic management of CBDS.

This meta-analysis highlights the excellent stone clearance rate achieved through percutaneous transhepatic fluoroscopy-guided removal of common bile duct stones, potentially influencing clinical decision-making when endoscopic treatment is not feasible.

• Percutaneous transhepatic fluoroscopy-guided management of common bile duct stones had a pooled rate of 97.1% for overall stone clearance and 80.5% for clearance at the first attempt. • Percutaneous transhepatic management of common bile duct stones had an overall complication rate of 13.8%, including a major complication rate of 2.8%. • Percutaneous transcholecystic management of common bile duct stones had an overall stone clearance rate of 88.5% and a complication rate of 23.0%.

This current study aimed to explore whether gastrectomy history influenced surgical outcomes while undergoing laparoscopic cholecystectomy (LC).

The PubMed, Embase, and Cochrane Library databases were searched for eligible studies from inception to April 29, 2023. The Newcastle-Ottawa Scale (NOS) was adopted to assess the quality of included studies. The mean differences (MDs) and 95% confidence intervals (CIs) were calculated for continuous variables, and the odds ratios (ORs) and 95% CIs were calculated for dichotomous variables. RevMan 5.4 was used for data analysis.

Seven studies enrolling 8193 patients were eligible for the final pooling up analysis (380 patients in the previous gastrectomy group and 7813 patients in the non-gastrectomy group). The patients in the gastrectomy group were older (MD = 11.11, 95%CI = 7.80-14.41, P < 0.01) and had a higher portion of males (OR = 3.74, 95%CI = 2.92-4.79, P < 0.01) than patients in the non-gastrectomy group patients. Moreover, the gastrectomy group had longer LC operation time (MD = 34.17, 95%CI = 25.20-43.14, P < 0.01), a higher conversion rate (OR = 6.74, 95%CI = 2.17-20.26, P = 0.01), more intraoperative blood loss (OR = 1.96, 95%CI = 0.59-3.32, P < 0.01) and longer postoperative hospital stays (MD = 1.07, 95%CI = 0.38-1.76, P < 0.01) than the non-gastrectomy group.

Patients with a previous gastrectomy history had longer operation time, a higher conversion rate, more intraoperative blood loss, and longer postoperative hospital stays than patients without while undergoing LC. Surgeons should pay more attention to these patients and make prudent decisions to avoid worse surgical outcomes as much as possible.

Evidence for the outcomes of endoscopic retrograde cholangiopancreatography (ERCP) between a basket catheter and a balloon catheter for endoscopic common bile duct stone (CBDS) removal is lacking. This study aimed to compare ERCP outcomes using a basket catheter and a balloon catheter for endoscopic CBDS removal.

This multicenter retrospective study included 904 consecutive patients with native papilla who underwent endoscopic stone removal for CBDS ≤10 mm using a basket catheter and/or a balloon catheter at three institutions in Japan. ERCP outcomes between the basket and balloon groups were compared using inverse probability of treatment weighting (IPTW) method.

ERCP-related adverse events occurred in 6.5% (29/449) and 7.7% (35/455) of patients in the basket and balloon groups, respectively (IPTW-adjusted p = 0.52). The incidences of post-ERCP pancreatitis, cholangitis, and perforation were similar in the basket and balloon groups (3.8% vs. 2.9%, 1.3% vs. 0.9%, and 0.7% vs. 0.7%, respectively). However, bleeding incidences were significantly higher in the balloon group than in the basket group (3.3% vs. 0.7%, IPTW-adjusted p = 0.012). Successful complete stone removal at one ERCP session using a single catheter was achieved in 17.8% (80/449) in the basket group and in 81.3% (370/455) in the balloon group (IPTW-adjusted p < 0.001).

A balloon catheter is more likely to complete stone extraction for CBDS ≤10 mm with a single catheter at one endoscopic stone removal session. However, the risk for post-ERCP bleeding is higher in the balloon group than in the basket group.

Cholelithiasis has a major impact on global health and affects an average of 20% of the Western population. The main risk factors are females, age over 40 years, obesity and pregnancy. Most of the time it is asymptomatic, but when there are symptoms, they are generally nonspecific. Bile was considered sterile, but today it is known that it contains a complex bacterial flora, which causes biofilm in the gallbladder and gallstones. Among the main bacteria associated with cholelithiasis are Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae, species of Enterococcus spp. and Acinetobacter spp. Antibiotic prophylaxis is used in an attempt to reduce postoperative infections, especially at the surgical site. However, some authors found no relationship between the use of antibiotic prophylaxis and a lower risk of surgical site infection. Thus, the aim of this double-blind randomized clinical trial was to compare the existence or not of bacteriobilia in patients at low anesthetic risk who underwent videolaparoscopic cholecystectomy, and its correlation with the use of prophylactic antibiotics. This study included 40 patients between 18 and 65 years old, diagnosed with cholelithiasis, symptomatic or not, with low anesthetic risk classified by the American Society of Anesthesiology in ASA I or ASA II, without complications or previous manipulation of the bile duct, who underwent elective video cholecystectomy, divided into two groups: Experimental Group A (n = 20), which received 2 g of Cephalotin (first-generation Cephalosporin, Keflin®, ABL antibiotics, Cosmópolis, Brazil) during anesthetic induction, and Control Group B (n = 20), where no antibiotics were administered until bile collection. After the procedure, a bile sample was collected and culture and antibiogram were performed. In the sample, 22 (55%) were classified as ASA I and 18 (45%) as ASA II. It was observed that 81.8% of the patients who had a positive culture did not use antibiotics, against 18.2% of those who used prophylaxis. When comparing patients regarding anesthetic risk, ASA I patients had a positive culture in 9.1% of cases, against 90.9% in patients classified as ASA II. It was concluded that patients with higher anesthetic risk (ASA II) have a higher chance of bacteriobilia and benefit from antibiotic prophylaxis when compared to patients with lower anesthetic risk (ASA I).

To explore the surgical risk factors of laparoscopic left-sided hepatectomy for hepatolithiasis and establish and validate a nomogram to estimate the corresponding surgical risks.

Patients with hepatolithiasis who underwent laparoscopic left-sided hepatectomy were retrospectively enrolled. Demographic data, clinicopathological parameters, and surgical factors were collected. Three hundred fifty-three patients were enrolled and randomly divided into training set (n=267) and validation set (n=86) by 3:1. Conversion to laparotomy was used as a surrogate index to evaluate the surgical risk. Univariate analysis was used to screen potential surgical risk factors, and multivariate analysis using logistic regression model was used to screen independent surgical risk factors. Nomogram predicting the surgical risks was established based on the independent risk factors. Discrimination, calibration, decision curve, and clinical impact analyses were used to evaluate the performance of the nomogram on the statistical and clinical aspects both in the training and validation sets.

Five independent surgical risk factors were identified in the training set, including recurrent abdominal pain, bile duct stricture, ASA classification ≥2, extent of liver resection, and biliary tract T tube drainage. No collinearity was found among these five factors, and a nomogram was established. Performance analyses of the nomogram showed good discrimination (AUC=0.850 and 0.817) and calibration (Hosmer-Lemeshow test, p=0.530 and 0.930) capabilities both in the training and validation sets. Decision curve and clinical impact analyses also showed that the prediction performance was clinically valuable.

A nomogram was established and validated to be effective in evaluating and predicting the surgical risk of patients undergoing laparoscopic left-sided hepatectomies for hepatolithiasis.

Gallstones are one of the most common and costly diseases of the gastrointestinal tract and occur when a combination of deposits consisting of fat or minerals accumulate in the gallbladder or common bile duct (CBD). This paper provides a comprehensive review of gallstone epidemiology, diagnosis, and management, focusing on current clinical guidelines and evidence-based approaches.

A systematic literature review gathered information from various sources, including PubMed, Trip, Google Scholar, Clinical Key, and reputable medical association websites. Keywords related to gallstones, CBD stones, cholelithiasis, choledocholithiasis, and guidelines were used to extract relevant recommendations. Expert consultations and consensus meetings localized the recommendations based on the target population and available resources.