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

Table 1 Recommended management and evidence level in current guidelines for asymptomatic common bile duct stones

Guideline	Recommendation
ESGE[1]	ESGE recommends stone extraction in all patients with CBDS, regardless of being symptomatic or not, who are fit enough to tolerate the intervention. (Strong recommendation, low quality evidence)
BSG[3]	Stone extraction is recommended in patients diagnosed with CBDS if possible. Evidence of benefit of stone extraction is greatest for symptomatic patients (Low quality evidence; strong recommendation)
JGES[4]	Asymptomatic choledocholithiasis should be treated because of a risk of developing biliary complications. [Evidence level: A; Strength of recommendation (agreement rate): 2 (100%)]
ASGE[5]	CBDS should be treated if detected regardless of the presence or absence of significant mitigating clinical circumstances (Moderate quality)

CBDS: Common bile duct stones; ESGE: European Society of Gastrointestinal Endoscopy; BSG: The British Society of Gastroenterology; ASGE: American Society for Gastrointestinal Endoscopy; JSGE: The Japanese Society of Gastroenterology.

Table 2 Summary of studies comparing the risks of endoscopic retrograde cholangiopancreatography-related complications for asymptomatic and symptomatic patients with common bile duct stones

Ref.	Study design	Patients, n		Overall, complications (%)		PEP (%)
		Asymptomatic group	Symptomatic group	Asymptomatic group	Symptomatic group	Asymptomatic group	Symptomatic group
Kim et al[9], 2016	Single-center retrospective	32	536	15.6	10.4	12.5a	3.9
Saito et al[10], 2017	Multicenter retrospective	67	536	26.9a	3.9	16.4a	2.2
Saito et al[11], 2019	Multicenter retrospective	164	949	19.5a	6.2	14.6a	3.0
Xu et al[12], 2019	Single-center prospective	53	274	26.4a	11.7	20.8a	6.9
Xiao et al[13], 2021	Single-center retrospective	79	795	13.3	9.7	7.6	6.9

^aStatistically significant difference. ERCP: Endoscopic retrograde cholangiopancreatography; PEP: Postendoscopic retrograde cholangiopancreatography pancreatitis.

Table 3 Summary of studies reporting natural history of asymptomatic common bile duct stones

Ref.	Study design	Patients, n	Median follow-up period	Cumulative incidence of biliary complications, n (%)
Ammori et al[14], 2000	Prospective	14	1.4 yr	4 (29)
Collins et al[15], 2004	Prospective	46	6 wk	0
Caddy et al[16], 2005	Retrospective	59	4.8 yr	0
Moller et al[17], 2014	Retrospective	594	30 d	150 (25)
Hakuta et al[18], 2020	Retrospective	114	3.2 yr	20 (18)