BACKGROUND Endoscopic retrograde cholangiopancreatography(ERCP)is an accurate diagnostic method for choledocholithiasis and treatment option for stone removal.Additionally,ursodeoxycholic acid(UDCA)can dissolve choles...BACKGROUND Endoscopic retrograde cholangiopancreatography(ERCP)is an accurate diagnostic method for choledocholithiasis and treatment option for stone removal.Additionally,ursodeoxycholic acid(UDCA)can dissolve cholesterol stones and prevent their development and reappearance by lowering the cholesterol concen-tration in bile.Despite these treatment options,there are still patients who experience stone recurrence.The clinical data of 100 patients with choledochal stones who were hospitalized at the Yixing People’s Hospital and underwent ERCP for successful stone extraction between June 2020 and December 2022 were retrospectively collected.According to the post-ERCP treatment plan,100 patients were classified into UDCA(n=47)and control(n=53)groups.We aimed to assess the clinical efficacy and rate of relapse in the two patient populations.We then collected information(basic demographic data,clinical characteristics,and serum biochemical indicators)and determined the factors contributing to relapse using logistic regression analysis.Our secondary goal was to determine the effects of UDCA on liver function after ERCP.Compared to the control group,the UDCA group demonstrated a higher clinical effectiveness rate of 92.45%vs 78.72%(P<0.05).No significant differences were observed in liver function indices,including total bilirubin,direct bilirubin,gamma-glutamyl transpeptidase,alanine aminotransferase,alkaline phosphatase,and aspartate aminotransferase,between the two groups before treatment.After treatment,all liver function indices were significantly reduced.Comparing the control vs UDCA groups,the UDCA group exhibited significantly lower levels of all indices(55.39±6.53 vs 77.31±8.52,32.10±4.62 vs 45.39±5.69,142.32±14.21 vs 189.63±16.87,112.52±14.25 vs 149.36±15.36,122.61±16.00 vs 171.33±22.09,96.98±10.44 vs 121.35±11.57,respectively,all P<0.05).The stone recurrence rate was lower in the UDCA group(13.21%)in contrast with the control group(44.68%).Periampullary diverticula(OR:6.00,95%CI:1.69-21.30),maximum stone diameter(OR:1.69,95%CI:1.01-2.85),stone quantity>3(OR:4.23,95%CI:1.17-15.26),and positive bile culture(OR:7.61,95%CI:2.07-27.91)were independent factors that influenced the relapse of common bile duct stones after ERCP(P<0.05).Furthermore,postoperative UDCA was identified as a preventive factor(OR:0.07;95%CI:0.08-0.09).CONCLUSION The intervention effect of UDCA after ERCP for common bile duct stones is adequate,providing new research directions and references for the prevention and treatment of stone recurrence.展开更多
Objective: To explore the application value of rapid rehabilitation concept in patients with extrahepatic bile duct stones under laparoscopy during perioperative period. Methods: 90 patients with extrahepatic bile duc...Objective: To explore the application value of rapid rehabilitation concept in patients with extrahepatic bile duct stones under laparoscopy during perioperative period. Methods: 90 patients with extrahepatic bile duct stones treated in our hospital from January 2022 to February 2023 were selected as the research object and randomly divided into the study group and the control group. The control group was given routine care, and the observation group was given rapid surgical rehabilitation care. The postoperative anal exhaust time, first meal time, early activity time, pain time, abdominal drainage tube removal time, hospitalization time and complication rate were compared between the two groups. The independent sample T test was used for the measurement data, and the x<sup>2</sup> test was used for the counting data, and the difference was statistically significant (P Results: The postoperative anal exhaust time, first meal time, early activity time, pain time, abdominal drainage tube removal time and hospitalization time in the study group were shorter than those in the control group (all P Conclusion: The concept of rapid rehabilitation can significantly improve the perioperative nursing effect of patients with extrahepatic bile duct stones and accelerate their rehabilitation, which is worth improving and popularizing.展开更多
The principle of PCNL is the extraction through a nephrostomy channel of kidney stones which are defined as the presence of crystalline concretions in the kidneys. Objectives: The objective of this work was to study t...The principle of PCNL is the extraction through a nephrostomy channel of kidney stones which are defined as the presence of crystalline concretions in the kidneys. Objectives: The objective of this work was to study the epidemiological, clinical and paraclinical aspects of patients with renal lithiasis treated by PCNL and on the other hand the different technical aspects of PCNL. Materials and Methods: This was a retrospective descriptive study, conducted in the urology department of HOGIP, covering the period from January 2015 to January 2019. We studied the demographic and clinical aspects of patients presenting renal lithiasis;we also studied the technical aspects and treatment outcomes. Statistical significance was set for α = 0.05. Results: Our series covered 82 PCNLs performed during the study period. The average age was 45.95 years, the age group [40 - 49 years] was more affected. Our study involved 44 men and 38 women, a sex ratio of 1.15. At the clinic, atypical lumbar pain was more frequent in 45.83% of cases. On URO-CT, the calculations were located more at the pyelic level (31.2%) and lower caliceal (27.2%). The size of stones measured between 15 and 20 mm in 30.52%. The stone density was between 500 and 1000 HU in 47.54% of cases. Intraoperatively, the patients were placed in lateral decubitus in 41.46% of cases. Only one access to the kidney was necessary in 87.8% of cases. The lithoclast was used in 65.85% of cases. The overall success rate (stone free) in our series was 96%. The majority of cases, 41.44%, drainage were done by natural means (totally tubeless). The average duration was 92 minutes. The complications encountered in our experience concerned 10 cases, a rate of 12.19%. Conclusion: Urinary lithiasis is more and more frequent in our regions. The development of Endo-urology offers several therapeutic options. Thus, PCNL occupies an important place in the management of kidney stones.展开更多
BACKGROUND Several studies have explored the long-term prognosis of patients with asymp-tomatic gallbladder stones.These reports were primarily conducted in facilities equipped with beds for addressing symptomatic cas...BACKGROUND Several studies have explored the long-term prognosis of patients with asymp-tomatic gallbladder stones.These reports were primarily conducted in facilities equipped with beds for addressing symptomatic cases.AIM To report the long-term prognosis of patients with asymptomatic gallbladder stones in clinics without bed facilities.METHODS We investigated the prognoses of 237 patients diagnosed with asymptomatic gallbladder stones in clinics without beds between March 2010 and October 2022.When symptoms developed,patients were transferred to hospitals where appropriate treatment was possible.We investigated the asymptomatic and survival periods during the follow-up.RESULTS Among the 237 patients,214(90.3%)remained asymptomatic,with a mean asymptomatic period of 3898.9279±46.871 d(50-4111 d,10.7 years on average).Biliary complications developed in 23 patients(9.7%),with a mean survival period of 4010.0285±31.2788 d(53-4112 d,10.9 years on average).No patient died of biliary complications.CONCLUSION The long-term prognosis of asymptomatic gallbladder stones in clinics without beds was favorable.When the condition became symptomatic,the patients were transferred to hospitals with beds that could address it;thus,no deaths related to biliary complications were reported.This finding suggests that follow-up care in clinics without beds is possible.展开更多
Common bile duct stones are among the most common conditions encountered by endoscopists.Therefore,it is well researched;however,some items,such as indications for endoscopic papillary balloon dilatation(EPBD),safety ...Common bile duct stones are among the most common conditions encountered by endoscopists.Therefore,it is well researched;however,some items,such as indications for endoscopic papillary balloon dilatation(EPBD),safety of EPBD and endoscopic sphincterotomy in patients receiving dual antiplatelet therapy or direct oral anticoagulant,selection strategy for retrieval balloons and baskets,lack adequate evidence.Therefore,the guidelines have been updated with new research,while others remain unchanged due to weak evidence.In this review,we comprehensively summarize the standard methods in guidelines and new findings from recent studies on papillary dilation,stone retrieval devices,difficult-to-treat cases,troubleshooting during the procedure,and complicated cases of cholangitis,cholecystolithiasis,or distal biliary stricture.展开更多
BACKGROUND To date,endoscopic retrograde cholangiopancreatography has become a wellestablished treatment for common bile duct(CBD)stones.However,it is not suitable for some special patients,such as pregnant women,chil...BACKGROUND To date,endoscopic retrograde cholangiopancreatography has become a wellestablished treatment for common bile duct(CBD)stones.However,it is not suitable for some special patients,such as pregnant women,children or those who cannot stop taking anti-coagulation/anti-platelet agents because of radiation injury and the risk of postoperative bleeding resulting from endoscopic sphincterotomy.To overcome these two problems,this study introduced cholangioscopy-assisted extraction through a novel papillary support for small-calibre and sediment-like CBD stones.AIM To assess the feasibility and safety of cholangioscopy-assisted extraction through a novel papillary support(CEPTS)for small-calibre and sediment-like common bile duct(CBD)stones.METHODS This Retrospective study was approved by the Ethics Committee of the Chinese PLA General Hospital.We designed a covered single dumbbell-style papillary support between 2021 and 2022.Between July 2022 and September 2022,7 consecutive patients with small-calibre(cross diameter≤1.0 cm)or sediment-like CBD stones underwent CETPS procedures in our center.The clinical characteristics and treatment outcomes of these 7 patients were extracted from a prospectively collected database.And the related data were analyzed.Informed consent was obtained from all participating patients.RESULTS A total of 2 patients had yellow sediment-like CBD stones,and aspiration extraction was performed after the insertion of papillary support.Of the 5 patients with clumpy CBD stones(0.4-1.0 cm),2 underwent basket extraction under direct vision for a single stone(0.5-1.0 cm,black and black grey),1 underwent balloon plus aspiration extraction under direct vision for 5 stones(0.4-0.6 cm,brown),and 2 underwent aspiration extraction only for a single stone(0.5-0.6 cm,yellow,none).Technical success,namely,no residual stones in the CBD or left and right hepatic ducts,was achieved in all 7 cases(100%).The median operating time was 45.0 minutes(range 13.0–87.0 minutes).Postoperative pancreatitis(PEP)occurred in one case(14.3%).Hyperamylasaemia without abdominal pain was noted in 2 of 7 patients.No residual stones or cholangitis were found during the follow-up.CONCLUSION CETPS appeared to be feasible to treat patients with small-calibre or sediment-like CBD stones.Patients,especially pregnant women and those who cannot stop anticoagulation/anti-platelet agents,could benefit from this technique.展开更多
Objective:To evaluate the long-term stone-free rate(SFR)of retrograde intrarenal surgery(RIRS)in the treatment of lower pole renal calculi using only basket relocation and identify independent predictors of stone-free...Objective:To evaluate the long-term stone-free rate(SFR)of retrograde intrarenal surgery(RIRS)in the treatment of lower pole renal calculi using only basket relocation and identify independent predictors of stone-free status.Methods:All consecutive patients undergoing RIRS lower pole renal calculi at a single highvolume tertiary center were analyzed retrospectively.Lower pole stones were relocated to the upper pole,where laser lithotripsy was performed.All patients were followed up in the clinic following the surgery and yearly thereafter.The stone-free status was assessed with a combination of an abdominal ultrasound and abdominal X-ray,or an abdominal non-contrast computed tomography if the stones were known to be radiolucent.Results:A total of 480 consecutive patients who underwent RIRS for treatment of lower pole renal calculi,between January 2012 and December 2018,were analyzed from a prospectively maintained database of 3000 ureteroscopies.With a median follow-up time of 18.6 months,the mean SFR was 94.8%.The procedures were unsuccessful in 26(5.4%)patients due to unreachable stones.The median stone size of the unreachable stones was 12 mm(range 10e30 mm).Multivariable logistic regression analysis revealed two predictors of SFR for lower pole stones:a small cumulative stone burden(odds ratio[OR]:0.903,95%confidence interval[CI]:0.867e0.941,p<0.0001)and preoperative ureteral stent insertion(OR:0.515,95%CI:0.318e0.835,pZ0.007).Conclusion:The long-term SFR of RIRS for the treatment of lower pole stones with basket displacement with appropriate patient selection is high.展开更多
Objective Ureteral lesions caused by impacted ureteral stones are likely to result in postoperative ureteral stricture.On this basis,the study aimed to investigate if dual-energy spectral computed tomography can predi...Objective Ureteral lesions caused by impacted ureteral stones are likely to result in postoperative ureteral stricture.On this basis,the study aimed to investigate if dual-energy spectral computed tomography can predict ureteral hardening caused by impacted stones and to explore the relationship between different types of ureteral lesions and the risk of ureteral stricture.Methods This prospective study collected data of 93 patients with impacted stones from hospital automation system during January 2018 to October 2019.They underwent an abdominal scan on a dual-energy spectral computed tomography.During surgery,the operator used ureteroscopy to identify ureteral lesions,which were classified into four categories:edema,polyps,pallor,and hardening.Seven months later,90 patients were reviewed for the degree of hydronephrosis.Results Endoscopic observations revealed 38(41%)cases of ureteral edema,20(22%)cases of polyps,13(14%)cases of pallor,and 22(24%)cases of hardening.There were significant differences in hydronephrosis,the period of impaction,the calcium concentration of the ureter,and the slope of the spectral Hounsfield unit curve between the four groups.After that,we evaluated the factors associated with ureteral hardening and found that the calcium concentration of the ureter and hydronephrosis remained independent predictors of ureteral hardening.Receiver operating characteristic curve analysis showed that 5.3 mg/cm^(3)calcium concentration of the ureter is an optimal cut-off value to predict ureteral hardening.The result of follow-up showed that 80 patients had complete remission of hydronephrosis,with a complete remission rate of 61.9%(13/21)in the hardening group and 97.1%(67/69)in the non-hardening group(p<0.001).Conclusion Calcium concentration of the ureter is an independent predictor of ureteral hardening.Patients with ureteral hardening have more severe hydronephrosis after ureteroscopic lithotripsy.When the calcium concentration of the ureter is less than 5.3 mg/cm^(3),ureteral lesions should be actively treated.展开更多
Background:Limited endoscopic sphincterotomy with large balloon dilation(ES-LBD)and endoscopic papillary large-balloon dilation(EPLBD)have been proven safe and effective for removal of bile duct stones.However,the lon...Background:Limited endoscopic sphincterotomy with large balloon dilation(ES-LBD)and endoscopic papillary large-balloon dilation(EPLBD)have been proven safe and effective for removal of bile duct stones.However,the long-term outcomes are not clear.The aim of this study was to assess the long-term outcomes of EPLBD(12-15 mm)with or without limited sphincterotomy for removal of common bile duct(CBD)stones.Methods:Patients with EPLBD or ES-LBD referred for the removal of bile-duct stones between June 2008 and August 2020 were retrospectively reviewed.Complete stone clearance,endoscopic retrograde cholangiopancreatography(ERCP)-related adverse events,and late biliary complications during long-term follow-up were analyzed.Results:Basic patient characteristics were not significantly different between the groups that underwent EPLBD(n=168)and ES-LBD(n=57).EPLBD compared with ES-LBD resulted in similar outcomes in terms of overall successful stone removal(99.4%vs.100%,P=1.00)and ERCP-related adverse events(7.7%vs.5.3%,P=0.77).The mean duration of the follow-up were 113.6 months and 106.7 months for patients with EPLBD and ES-LBD,respectively(P=0.13).There was no significant difference between EPLBD and ES-LBD in the incidence of stone recurrence[20(11.9%)vs.9(15.8%);P=0.49].Multivariate analysis showed that a diameter of CBD≥15 mm(OR=3.001;95%CI:1.357-6.640;P=0.007)was an independent risk factor for stone recurrence.Conclusions:The application of a large balloon(12-15 mm)via EPLBD is an effective and safe alternative to ES-LBD for extraction of large CBD stones.Endoscopic sphincterotomy prior to EPLBD may be unnec-essary.A diameter of CBD≥15 mm is a risk factor of stone recurrence.展开更多
AIM To evaluate the effectiveness and safety of combined ursodeoxycholic acid and percutaneous transhepatic balloon dilation for management of gallstones after expulsion of common bile duct(CBD) stones.METHODS From Ap...AIM To evaluate the effectiveness and safety of combined ursodeoxycholic acid and percutaneous transhepatic balloon dilation for management of gallstones after expulsion of common bile duct(CBD) stones.METHODS From April 2014 to May 2016, 15 consecutive patients(6 men and 9 women) aged 45-86(mean, 69.07 ± 9.91) years suffering from CBD stones associated with gallstones were evaluated. Good gallbladder contraction function was confirmed by type B ultrasonography. Dilation of the CBD and cystic duct was detected. Percutaneous transhepatic balloon dilation of the papilla was performed, ursodeoxycholic acid was administered, and all patients had a high-fat diet. All subjects underwent repeated cholangiography, and percutaneous transhepatic removal was carried out in patients with secondary CBD stones originating from the gallbladder. RESULTS All patients underwent percutaneous transhepatic balloon dilation with a primary success rate of 100%. The combined therapy was successful in 86.7% of patients with concomitant CBD stones and gallstones. No remaining stones were detected in the gallbladder. Transient adverse events include abdominal pain(n = 1), abdominal distension(n = 1), and fever(n = 1). Complications were treated successfully via nonsurgical management without long-term complications. No procedure-related mortality occurred. CONCLUSION For patients with concomitant CBD stones and gallstones, after percutaneous transhepatic removal of primary CBD stones, oral ursodeoxycholic acid and a high-fat diet followed by percutaneous transhepatic removal of secondary CBD stones appear to be a feasible and effective option for management of gallstones.展开更多
Objective:To assess the effect of the adherence to medical treatment on urinary parameters in the 24-h metabolic study of patients with kidney stones.Methods:A retrospective,longitudinal,descriptive,and observational ...Objective:To assess the effect of the adherence to medical treatment on urinary parameters in the 24-h metabolic study of patients with kidney stones.Methods:A retrospective,longitudinal,descriptive,and observational study was carried out by reviewing the hospital electronic medical record from 2014 to 2018.The adherence to drug treatment was measured 6 months after its initiation,and the numerical values of the metabolic studies were compared.Wilcoxon tests were performed to compare the difference before and after treatment.Results:Ninety patients were evaluated,with 73.3% of adherence.The 180-day overall adherence rate was 61.2% in patients treated with a single drug and 85.4% in patients treated with multiple drugs.There is a statistically significant increase in citrate levels in patients with good adherence in comparison with non-adherent patients(p=0.031 vs.p=0.528).Conclusions:Medical treatment and dietary measures in patients with kidney stones have an initial impact at 6 months on the values of the main urinary metabolic alterations that predispose to calculi formation;the most significant is seen in those patients with adherence to medical treatment for hypocitraturia.展开更多
INTRODUCTION The advent of laparoscopic cholecystectomy(LC)inthe late 1980s gained widespread acceptance withina short period of time and has become the preferredtreatment for symptomatic gallstones,but themanagement ...INTRODUCTION The advent of laparoscopic cholecystectomy(LC)inthe late 1980s gained widespread acceptance withina short period of time and has become the preferredtreatment for symptomatic gallstones,but themanagement of coexisting gallbladder and commonbile duct(CBD)stones has remained controversialbecause the various strategies proposed have theirlimitations.In fact,choledocholithiasis展开更多
Endoscopy is widely accepted as the first treatment option in the management of bile duct stones.In this review we focus on the alternative endoscopic modalities for the management of difficult common bile duct stones...Endoscopy is widely accepted as the first treatment option in the management of bile duct stones.In this review we focus on the alternative endoscopic modalities for the management of difficult common bile duct stones.Most biliary stones can be removed with an extraction balloon,extraction basket or mechanical lithotripsy after endoscopic sphincterotomy.Endoscopic papillary balloon dilation with or without endoscopic sphincterotomy or mechanical lithotripsy has been shown to be effective for management of difficult to remove bile duct stones in selected patients.Ductal clearance can be safely achieved with peroral cholangioscopy guided laser or electrohydraulic lithotripsy in most cases where other endoscopic treatment modalities have failed.Biliary stenting may be an alternative treatment option for frail and elderly patients or those with serious co morbidities.展开更多
Although endoscopic sphincterotomy(EST) is still considered as a gold standard treatment for common bile duct(CBD) stones in western guideline, endoscopic papillary balloon dilation(EPBD) is commonly used by the endos...Although endoscopic sphincterotomy(EST) is still considered as a gold standard treatment for common bile duct(CBD) stones in western guideline, endoscopic papillary balloon dilation(EPBD) is commonly used by the endoscopists in Asia as the first-line treatment for CBD stones. Besides the advantages of a technical easy procedure, endoscopic papillary large balloon dilation(EPLBD) can facilitate the removal of large CBD stones.The indication of EPBD is now extended from removal of the small stones by using traditional balloon, to removal of large stones and avoidance of lithotripsy by using large balloon alone or after EST. According to the reports of antegrade papillary balloon dilatation, balloon dilation itself is not the cause of pancreatitis. On the contrary, adequate dilation of papillary orifice can reduce the trauma to the papilla and pancreas by the basket or lithotripter during the procedure of stone extraction. EPLBD alone is as effective as EPLBD with limited EST. Longer ballooning time may be beneficial in EPLBD alone to achieve adequate loosening of papillary orifice. The longer ballooning time does not increase the risk of pancreatitis but may reduce the bleeding episodes in patients with coagulopathy. Slowly inflation of the balloon, but not exceed the diameter of bile duct and tolerance of the patients are important to prevent the complication of perforation. EPBLD alone or with EST are not the sphincter preserved procedures, regular follow up is necessary for early detection and management of CBD stones recurrence.展开更多
BACKGROUND A clinical pathway(CP)is a standardized approach for disease management.However,big data-based evidence is rarely involved in CP for related common bile duct(CBD)stones,let alone outcome comparisons before ...BACKGROUND A clinical pathway(CP)is a standardized approach for disease management.However,big data-based evidence is rarely involved in CP for related common bile duct(CBD)stones,let alone outcome comparisons before and after CP implementation.AIM To investigate the value of CP implementation in patients with CBD stones undergoing endoscopic retrograde cholangiopancreatography(ERCP).METHODS This retrospective study was conducted at Nanjing Drum Tower Hospital in patients with CBD stones undergoing ERCP from January 2007 to December 2017.The data and outcomes were compared by using univariate and multivariable regression/linear models between the patients who received conventional care(non-pathway group,n=467)and CP care(pathway group,n=2196).RESULTS At baseline,the main differences observed between the two groups were the percentage of patients with multiple stones(P<0.001)and incidence of cholangitis complication(P<0.05).The percentage of antibiotic use and complications in the CP group were significantly less than those in the nonpathway group[adjusted odds ratio(OR)=0.72,95%confidence interval(CI):0.55-0.93,P=0.012,adjusted OR=0.44,95%CI:0.33-0.59,P<0.001,respectively].Patients spent lower costs on hospitalization,operation,nursing,medication,and medical consumable materials(P<0.001 for all),and even experienced shorter length of hospital stay(LOHS)(P<0.001)after the CP implementation.No significant differences in clinical outcomes,readmission rate,or secondary surgery rate were presented between the patients in the non-pathway and CP groups.CONCLUSION Implementing a CP for patients with CBD stones is a safe mode to reduce the LOHS,hospital costs,antibiotic use,and complication rate.展开更多
Since therapeutic endoscopic retrograde cholangiopancreatography replaced surgery as the first approach in cases of choledocolithiasis,a plethora of endoscopic techniques and devices appeared in order to facilitate ra...Since therapeutic endoscopic retrograde cholangiopancreatography replaced surgery as the first approach in cases of choledocolithiasis,a plethora of endoscopic techniques and devices appeared in order to facilitate rapid,safe and effective bile duct stones extraction.Nowadays,endoscopic sphincterotomy combined with balloon catheters and/or baskets is the routine endoscopic technique for stone extraction in the great majority of patients.Large common bile duct stones are treated conventionally with mechanical lithotripsy,while the most serious complication of the procedure is "basket and stone impaction" that is predominately resolved surgically.In cases of difficult,impacted,multiple or intrahepatic stones,more sophisticated procedures have been used.Electrohydraulic lithotripsy and laser lithotripsy are performed using conventional mother-baby scope systems,ultra-thin cholangio-scopes,thin endoscopes and ultimately using the novel single use,single operator SpyGlass Direct Visualization System,in order to deliver intracorporeal shock wave energy to fragment the targeted stone,with very good outcomes.Recently,large balloon dilation after endoscopic sphincterotomy confirmed its effectiveness in the extraction of large stones in a plethora of trials.When compared with mechanical lithotripsy or with balloon dilation alone,it proved to be superior.Moreover,dilation is an ideal alternative in cases of altered anatomy where access to the papilla is problematic.Endoscopic sphincterotomy followed by large balloon dilation represents the onset of a new era in large bile duct stone extraction and the management of "impaction" because it seems that is an effective,inexpensive,less traumatic,safe and easy method that does not require sophisticated apparatus and can be performed widely by skillful endoscopists.When complete extraction of large stones is unsuccessful,the drainage of the common bile duct is mandatory either for bridging to the final therapy or as a curative therapy for very elderly patients with short life expectancy.Placing of more than one plastic endoprostheses is better while the administration of Ursodiol is ineffective.The great majority of patients with large stones can be treated endoscopically.In cases of unsuccessful stone extraction using balloons,baskets,mechanical lithotripsy,electrohydraulic or laser lithotripsy and large balloon dilation,the patient should be referred for extracorporeal shock wave lithotripsy or a percutaneous approach and finally surgery.展开更多
AIM:To detect and manage residual common bile duct(CBD)stones using ultraslim endoscopic peroral cholangioscopy(POC)after a negative balloon-occluded cholangiography.METHODS:From March 2011 to December 2011,a cohort o...AIM:To detect and manage residual common bile duct(CBD)stones using ultraslim endoscopic peroral cholangioscopy(POC)after a negative balloon-occluded cholangiography.METHODS:From March 2011 to December 2011,a cohort of 22 patients with CBD stones who underwent both endoscopic retrograde cholangiography(ERC)and direct POC were prospectively enrolled in this study.Those patients who were younger than 20 years of age,pregnant,critically ill,or unable to provide informed consent for direct POC,as well as those with concomitant gallbladder stones or CBD with diameters less than 10 mm were excluded.Direct POC using an ultraslim endoscope with an overtube balloon-assisted technique was carried out immediately after a negative balloon-occluded cholangiography was obtained.RESULTS:The ultraslim endoscope was able to be advanced to the hepatic hilum or the intrahepatic bile duct(IHD)in 8 patients(36.4%),to the extrahepatic bile duct where the hilum could be visualized in 10 patients(45.5%),and to the distal CBD where the hilum could not be visualized in 4 patients(18.2%).The procedure time of the diagnostic POC was 8.2 ± 2.9 min(range,5-18 min).Residual CBD stones were found in 5(22.7%)of the patients.There was one residual stone each in 3 of the patients,three in 1 patient,and more than five in 1 patient.The diameter of the residual stones ranged from 2-5 mm.In 2 of the patients,the residual stones were successfully extracted using either a retrieval balloon catheter(n = 1)or a basket catheter(n = 1)under direct endoscopic control.In the remaining 3 patients,the residual stones were removed using an irrigation and suction method under direct endoscopic visualization.There were no serious procedure-related complications,such as bleeding,pancreatitis,biliary tract infection,or perforation,in this study.CONCLUSION:Direct POC using an ultraslim endoscope appears to be a useful tool for both detecting and treating residual CBD stones after conventional ERC.展开更多
AIM: To compare diagnostic sensitivity, specificity and accuracy of magnetic resonance cholangiopancreatography(MRCP) without contrast medium and endoscopic ultrasound(EUS)/endoscopic retrograde cholangiopancreatograp...AIM: To compare diagnostic sensitivity, specificity and accuracy of magnetic resonance cholangiopancreatography(MRCP) without contrast medium and endoscopic ultrasound(EUS)/endoscopic retrograde cholangiopancreatography(ERCP) for biliary calculi. METHODS: From January 2012 to December 2013, two-hundred-sixty-three patients underwent MRCP at our institution, all MRCP procedure were performed with the same machinery. In two-hundred MRCP was done for pure hepatobiliary symptoms and these patients are the subjects of this study. Among these two-hundred patients, one-hundred-eleven(55.5%) underwent ERCP after MRCP. The retrospective study design consisted in the systematic revision of all images from MRCP and EUS/ERCP performed by two radiologist with a long experience in biliary imaging, an experienced endoscopist and a senior consultant in Hepatobiliopancreatic surgery. A false positive was defined an MRCP showing calculi with no findings at EUS/ERCP; a true positive was defined as a concordance between MRCP and EUS/ERCP findings; a false negative was defined as the absence of images suggesting calculi at MRCP with calculi localization/extraction at EUS/ERCP and a true negative was defined as a patient with nocalculi at MRCP ad at least 6 mo of asymptomatic followup. Biliary tree dilatation was defined as a common bile duct diameter larger than 6 mm in a patient who had an in situ gallbladder. A third blinded radiologist who examined the MRCP and ERCP data reviewed misdiagnosed cases. Once obtained overall data on sensitivity, specificity, accuracy, positive predictive value(PPV) and negative predictive value(NPV) we divided patients in two groups composed of those having concordant MRCP and EUS/ERCP(Group A, 72 patients) and those having discordant MRCP and EUS/ERCP(Group B, 20 patients). Dataset comparisons had been made by the Student's t-test and χ2 when appropriate.RESULTS: Two-hundred patients(91 men, 109 women, mean age 67.6 years, and range 25-98 years) underwent MRCP. All patients attended regular follow-up for at least 6 mo. Morbidity and mortality related to MRCP were null. MRCP was the only exam performed in 89 patients because it did show only calculi into the gallbladder with no signs of the presence of calculi into the bile duct and symptoms resolved within a few days or after colecistectomy. The patients remained asymptomatic for at least 6 mo, and we assumed they were true negatives. One hundred eleven(53 men, 58 women, mean age 69 years, range 25-98 years) underwent ERCP following MRCP. We did not find any difference between the two groups in terms of race, age, and sex. The overall median interval between MRCP and ERCP was 9 d. In detecting biliary stones MRCP Sensitivity was 77.4%, Specificity 100% and Accuracy 80.5% with a PPV of 100% and NPV of 85%; EUS showed 95% sensitivity, 100% specificity, 95.5% accuracy with 100% PPV and 57.1% NPV. The association of EUS with ERCP performed at 100% in all the evaluated parameters. When comparing the two groups, we did not find any statistically significant difference regarding age, sex, and race. Similarly, we did not find any differences regarding the number of extracted stones: 116 stones in Group A(median 2, range 1 to 9) and 27 in Group B(median 2, range 1 to 4). When we compared the size of the extracted stones we found that the patients in Group B had significantly smaller stones: 14.16 ± 8.11 mm in Group A and 5.15 ± 2.09 mm in Group B; 95% confidence interval = 5.89-12.13, standard error = 1.577; P < 0.05. We also found that in Group B there was a significantly higher incidence of stones smaller than 5 mm: 36 in Group A and 18 in Group B, P < 0.05.CONCLUSION: Major finding of the present study is that choledocholithiasis is still under-diagnosed in MRCP. Smaller stones(< 5 mm diameter) are hardly visualized on MRCP.展开更多
AIM:To evaluate the effect of cholecystokinin(CCK)during extracorporeal shockwave lithotripsy(ESWL)in the clearance of common bile duct(CBD)stones in endoscopic retrograde cholangiopancreatography(ERCP).METHODS:Betwee...AIM:To evaluate the effect of cholecystokinin(CCK)during extracorporeal shockwave lithotripsy(ESWL)in the clearance of common bile duct(CBD)stones in endoscopic retrograde cholangiopancreatography(ERCP).METHODS:Between January 2007 and September2012,patients with large CBD stones who were treated with ESWL and ERCP were identified retrospectively.Patients were randomized in equal numbers to cholecystokinin(CCK)and no CCK groups.For each CCK case,a dose(3 ng/kg per min for 10 min)of sulfated octapeptide of CCK-8 was administered intravenously near the beginning of ESWL.ERCP was performed 4 h after a session of ESWL.The clearance rate of the CBD was assessed between the two groups.RESULTS:A total of 148 consecutive cases(CCK group:74,no CCK group:74)were tallied.Overall there were 234 ESWLs and 228 ERCPs in the 148 cases.The use of CCK showed a significantly higher rate of successful stone removal in the first ESWL/ERCP procedure(71.6%vs 55.4%,P=0.035),but resulted in similar outcomes in the second(42.8%vs 39.4%)and third(41.7%vs 40.0%)sessions,as well as total stone clearance(90.5%vs 83.8%).The use of mechanical lithotripsy was reduced in the CCK group(6.8%vs17.6%,P=0.023),and extremely large stone(≥30mm)removal was higher in the CCK group(72.7%vs41.7%,P=0.038).CONCLUSION:CCK during ESWL can aid with the clearance of CBD stones in the first ESWL/ERCP session.Mechanical lithotripsy usage was reduced and the extremely large stone(≥30 mm)clearance rate can be raised.展开更多
BACKGROUND:Common bile duct(CBD)stones are known to pass spontaneously in a significant number of patients. This study investigated the rate of spontaneous CBD stones passage in a series of patients presenting with ja...BACKGROUND:Common bile duct(CBD)stones are known to pass spontaneously in a significant number of patients. This study investigated the rate of spontaneous CBD stones passage in a series of patients presenting with jaundice due to gallstones.The patients were managed surgically,allowing CBD intervention to be avoided in the event of spontaneous passage of CBD stones. METHOD:Retrospective analysis of patients presenting with jaundice due to CBD stones,and managed surgically with laparoscopic cholecystectomy and intra-operative cholangiogram with or without CBD exploration. RESULTS:The jaundice settled pre-operatively in 76/108 patients, and in 60/108 the CBD stones had passed spontaneously by the time of surgery.These 60 patients avoided any intervention to their CBD. CONCLUSIONS:CBD stones pass spontaneously in more than half of jaundiced patients.Surgical management(laparoscopic cholecystectomy and intra-operative cholangiogram,with willingness to perform CBD exploration if positive)allows the avoidance of CBD intervention in these patients.展开更多
文摘BACKGROUND Endoscopic retrograde cholangiopancreatography(ERCP)is an accurate diagnostic method for choledocholithiasis and treatment option for stone removal.Additionally,ursodeoxycholic acid(UDCA)can dissolve cholesterol stones and prevent their development and reappearance by lowering the cholesterol concen-tration in bile.Despite these treatment options,there are still patients who experience stone recurrence.The clinical data of 100 patients with choledochal stones who were hospitalized at the Yixing People’s Hospital and underwent ERCP for successful stone extraction between June 2020 and December 2022 were retrospectively collected.According to the post-ERCP treatment plan,100 patients were classified into UDCA(n=47)and control(n=53)groups.We aimed to assess the clinical efficacy and rate of relapse in the two patient populations.We then collected information(basic demographic data,clinical characteristics,and serum biochemical indicators)and determined the factors contributing to relapse using logistic regression analysis.Our secondary goal was to determine the effects of UDCA on liver function after ERCP.Compared to the control group,the UDCA group demonstrated a higher clinical effectiveness rate of 92.45%vs 78.72%(P<0.05).No significant differences were observed in liver function indices,including total bilirubin,direct bilirubin,gamma-glutamyl transpeptidase,alanine aminotransferase,alkaline phosphatase,and aspartate aminotransferase,between the two groups before treatment.After treatment,all liver function indices were significantly reduced.Comparing the control vs UDCA groups,the UDCA group exhibited significantly lower levels of all indices(55.39±6.53 vs 77.31±8.52,32.10±4.62 vs 45.39±5.69,142.32±14.21 vs 189.63±16.87,112.52±14.25 vs 149.36±15.36,122.61±16.00 vs 171.33±22.09,96.98±10.44 vs 121.35±11.57,respectively,all P<0.05).The stone recurrence rate was lower in the UDCA group(13.21%)in contrast with the control group(44.68%).Periampullary diverticula(OR:6.00,95%CI:1.69-21.30),maximum stone diameter(OR:1.69,95%CI:1.01-2.85),stone quantity>3(OR:4.23,95%CI:1.17-15.26),and positive bile culture(OR:7.61,95%CI:2.07-27.91)were independent factors that influenced the relapse of common bile duct stones after ERCP(P<0.05).Furthermore,postoperative UDCA was identified as a preventive factor(OR:0.07;95%CI:0.08-0.09).CONCLUSION The intervention effect of UDCA after ERCP for common bile duct stones is adequate,providing new research directions and references for the prevention and treatment of stone recurrence.
文摘Objective: To explore the application value of rapid rehabilitation concept in patients with extrahepatic bile duct stones under laparoscopy during perioperative period. Methods: 90 patients with extrahepatic bile duct stones treated in our hospital from January 2022 to February 2023 were selected as the research object and randomly divided into the study group and the control group. The control group was given routine care, and the observation group was given rapid surgical rehabilitation care. The postoperative anal exhaust time, first meal time, early activity time, pain time, abdominal drainage tube removal time, hospitalization time and complication rate were compared between the two groups. The independent sample T test was used for the measurement data, and the x<sup>2</sup> test was used for the counting data, and the difference was statistically significant (P Results: The postoperative anal exhaust time, first meal time, early activity time, pain time, abdominal drainage tube removal time and hospitalization time in the study group were shorter than those in the control group (all P Conclusion: The concept of rapid rehabilitation can significantly improve the perioperative nursing effect of patients with extrahepatic bile duct stones and accelerate their rehabilitation, which is worth improving and popularizing.
文摘The principle of PCNL is the extraction through a nephrostomy channel of kidney stones which are defined as the presence of crystalline concretions in the kidneys. Objectives: The objective of this work was to study the epidemiological, clinical and paraclinical aspects of patients with renal lithiasis treated by PCNL and on the other hand the different technical aspects of PCNL. Materials and Methods: This was a retrospective descriptive study, conducted in the urology department of HOGIP, covering the period from January 2015 to January 2019. We studied the demographic and clinical aspects of patients presenting renal lithiasis;we also studied the technical aspects and treatment outcomes. Statistical significance was set for α = 0.05. Results: Our series covered 82 PCNLs performed during the study period. The average age was 45.95 years, the age group [40 - 49 years] was more affected. Our study involved 44 men and 38 women, a sex ratio of 1.15. At the clinic, atypical lumbar pain was more frequent in 45.83% of cases. On URO-CT, the calculations were located more at the pyelic level (31.2%) and lower caliceal (27.2%). The size of stones measured between 15 and 20 mm in 30.52%. The stone density was between 500 and 1000 HU in 47.54% of cases. Intraoperatively, the patients were placed in lateral decubitus in 41.46% of cases. Only one access to the kidney was necessary in 87.8% of cases. The lithoclast was used in 65.85% of cases. The overall success rate (stone free) in our series was 96%. The majority of cases, 41.44%, drainage were done by natural means (totally tubeless). The average duration was 92 minutes. The complications encountered in our experience concerned 10 cases, a rate of 12.19%. Conclusion: Urinary lithiasis is more and more frequent in our regions. The development of Endo-urology offers several therapeutic options. Thus, PCNL occupies an important place in the management of kidney stones.
文摘BACKGROUND Several studies have explored the long-term prognosis of patients with asymp-tomatic gallbladder stones.These reports were primarily conducted in facilities equipped with beds for addressing symptomatic cases.AIM To report the long-term prognosis of patients with asymptomatic gallbladder stones in clinics without bed facilities.METHODS We investigated the prognoses of 237 patients diagnosed with asymptomatic gallbladder stones in clinics without beds between March 2010 and October 2022.When symptoms developed,patients were transferred to hospitals where appropriate treatment was possible.We investigated the asymptomatic and survival periods during the follow-up.RESULTS Among the 237 patients,214(90.3%)remained asymptomatic,with a mean asymptomatic period of 3898.9279±46.871 d(50-4111 d,10.7 years on average).Biliary complications developed in 23 patients(9.7%),with a mean survival period of 4010.0285±31.2788 d(53-4112 d,10.9 years on average).No patient died of biliary complications.CONCLUSION The long-term prognosis of asymptomatic gallbladder stones in clinics without beds was favorable.When the condition became symptomatic,the patients were transferred to hospitals with beds that could address it;thus,no deaths related to biliary complications were reported.This finding suggests that follow-up care in clinics without beds is possible.
文摘Common bile duct stones are among the most common conditions encountered by endoscopists.Therefore,it is well researched;however,some items,such as indications for endoscopic papillary balloon dilatation(EPBD),safety of EPBD and endoscopic sphincterotomy in patients receiving dual antiplatelet therapy or direct oral anticoagulant,selection strategy for retrieval balloons and baskets,lack adequate evidence.Therefore,the guidelines have been updated with new research,while others remain unchanged due to weak evidence.In this review,we comprehensively summarize the standard methods in guidelines and new findings from recent studies on papillary dilation,stone retrieval devices,difficult-to-treat cases,troubleshooting during the procedure,and complicated cases of cholangitis,cholecystolithiasis,or distal biliary stricture.
基金Supported by National Key Research and Development Program of China,No.2022YFC2503600.
文摘BACKGROUND To date,endoscopic retrograde cholangiopancreatography has become a wellestablished treatment for common bile duct(CBD)stones.However,it is not suitable for some special patients,such as pregnant women,children or those who cannot stop taking anti-coagulation/anti-platelet agents because of radiation injury and the risk of postoperative bleeding resulting from endoscopic sphincterotomy.To overcome these two problems,this study introduced cholangioscopy-assisted extraction through a novel papillary support for small-calibre and sediment-like CBD stones.AIM To assess the feasibility and safety of cholangioscopy-assisted extraction through a novel papillary support(CEPTS)for small-calibre and sediment-like common bile duct(CBD)stones.METHODS This Retrospective study was approved by the Ethics Committee of the Chinese PLA General Hospital.We designed a covered single dumbbell-style papillary support between 2021 and 2022.Between July 2022 and September 2022,7 consecutive patients with small-calibre(cross diameter≤1.0 cm)or sediment-like CBD stones underwent CETPS procedures in our center.The clinical characteristics and treatment outcomes of these 7 patients were extracted from a prospectively collected database.And the related data were analyzed.Informed consent was obtained from all participating patients.RESULTS A total of 2 patients had yellow sediment-like CBD stones,and aspiration extraction was performed after the insertion of papillary support.Of the 5 patients with clumpy CBD stones(0.4-1.0 cm),2 underwent basket extraction under direct vision for a single stone(0.5-1.0 cm,black and black grey),1 underwent balloon plus aspiration extraction under direct vision for 5 stones(0.4-0.6 cm,brown),and 2 underwent aspiration extraction only for a single stone(0.5-0.6 cm,yellow,none).Technical success,namely,no residual stones in the CBD or left and right hepatic ducts,was achieved in all 7 cases(100%).The median operating time was 45.0 minutes(range 13.0–87.0 minutes).Postoperative pancreatitis(PEP)occurred in one case(14.3%).Hyperamylasaemia without abdominal pain was noted in 2 of 7 patients.No residual stones or cholangitis were found during the follow-up.CONCLUSION CETPS appeared to be feasible to treat patients with small-calibre or sediment-like CBD stones.Patients,especially pregnant women and those who cannot stop anticoagulation/anti-platelet agents,could benefit from this technique.
文摘Objective:To evaluate the long-term stone-free rate(SFR)of retrograde intrarenal surgery(RIRS)in the treatment of lower pole renal calculi using only basket relocation and identify independent predictors of stone-free status.Methods:All consecutive patients undergoing RIRS lower pole renal calculi at a single highvolume tertiary center were analyzed retrospectively.Lower pole stones were relocated to the upper pole,where laser lithotripsy was performed.All patients were followed up in the clinic following the surgery and yearly thereafter.The stone-free status was assessed with a combination of an abdominal ultrasound and abdominal X-ray,or an abdominal non-contrast computed tomography if the stones were known to be radiolucent.Results:A total of 480 consecutive patients who underwent RIRS for treatment of lower pole renal calculi,between January 2012 and December 2018,were analyzed from a prospectively maintained database of 3000 ureteroscopies.With a median follow-up time of 18.6 months,the mean SFR was 94.8%.The procedures were unsuccessful in 26(5.4%)patients due to unreachable stones.The median stone size of the unreachable stones was 12 mm(range 10e30 mm).Multivariable logistic regression analysis revealed two predictors of SFR for lower pole stones:a small cumulative stone burden(odds ratio[OR]:0.903,95%confidence interval[CI]:0.867e0.941,p<0.0001)and preoperative ureteral stent insertion(OR:0.515,95%CI:0.318e0.835,pZ0.007).Conclusion:The long-term SFR of RIRS for the treatment of lower pole stones with basket displacement with appropriate patient selection is high.
文摘Objective Ureteral lesions caused by impacted ureteral stones are likely to result in postoperative ureteral stricture.On this basis,the study aimed to investigate if dual-energy spectral computed tomography can predict ureteral hardening caused by impacted stones and to explore the relationship between different types of ureteral lesions and the risk of ureteral stricture.Methods This prospective study collected data of 93 patients with impacted stones from hospital automation system during January 2018 to October 2019.They underwent an abdominal scan on a dual-energy spectral computed tomography.During surgery,the operator used ureteroscopy to identify ureteral lesions,which were classified into four categories:edema,polyps,pallor,and hardening.Seven months later,90 patients were reviewed for the degree of hydronephrosis.Results Endoscopic observations revealed 38(41%)cases of ureteral edema,20(22%)cases of polyps,13(14%)cases of pallor,and 22(24%)cases of hardening.There were significant differences in hydronephrosis,the period of impaction,the calcium concentration of the ureter,and the slope of the spectral Hounsfield unit curve between the four groups.After that,we evaluated the factors associated with ureteral hardening and found that the calcium concentration of the ureter and hydronephrosis remained independent predictors of ureteral hardening.Receiver operating characteristic curve analysis showed that 5.3 mg/cm^(3)calcium concentration of the ureter is an optimal cut-off value to predict ureteral hardening.The result of follow-up showed that 80 patients had complete remission of hydronephrosis,with a complete remission rate of 61.9%(13/21)in the hardening group and 97.1%(67/69)in the non-hardening group(p<0.001).Conclusion Calcium concentration of the ureter is an independent predictor of ureteral hardening.Patients with ureteral hardening have more severe hydronephrosis after ureteroscopic lithotripsy.When the calcium concentration of the ureter is less than 5.3 mg/cm^(3),ureteral lesions should be actively treated.
基金supported by a grant from the Shuguang Hos-pital,Shanghai University of Traditional Chinese Medicine(SGKJ-202010).
文摘Background:Limited endoscopic sphincterotomy with large balloon dilation(ES-LBD)and endoscopic papillary large-balloon dilation(EPLBD)have been proven safe and effective for removal of bile duct stones.However,the long-term outcomes are not clear.The aim of this study was to assess the long-term outcomes of EPLBD(12-15 mm)with or without limited sphincterotomy for removal of common bile duct(CBD)stones.Methods:Patients with EPLBD or ES-LBD referred for the removal of bile-duct stones between June 2008 and August 2020 were retrospectively reviewed.Complete stone clearance,endoscopic retrograde cholangiopancreatography(ERCP)-related adverse events,and late biliary complications during long-term follow-up were analyzed.Results:Basic patient characteristics were not significantly different between the groups that underwent EPLBD(n=168)and ES-LBD(n=57).EPLBD compared with ES-LBD resulted in similar outcomes in terms of overall successful stone removal(99.4%vs.100%,P=1.00)and ERCP-related adverse events(7.7%vs.5.3%,P=0.77).The mean duration of the follow-up were 113.6 months and 106.7 months for patients with EPLBD and ES-LBD,respectively(P=0.13).There was no significant difference between EPLBD and ES-LBD in the incidence of stone recurrence[20(11.9%)vs.9(15.8%);P=0.49].Multivariate analysis showed that a diameter of CBD≥15 mm(OR=3.001;95%CI:1.357-6.640;P=0.007)was an independent risk factor for stone recurrence.Conclusions:The application of a large balloon(12-15 mm)via EPLBD is an effective and safe alternative to ES-LBD for extraction of large CBD stones.Endoscopic sphincterotomy prior to EPLBD may be unnec-essary.A diameter of CBD≥15 mm is a risk factor of stone recurrence.
基金Supported by the Natural Science Foundation of Shandong Province,No.ZR2014HM050the Youth Foundation of the Second Hospital of Shandong University,No.Y2014010047+1 种基金the Nature Science Foundation of Shandong Province,No.ZR2018PH032 and No.ZR2018PH033the National Natural Science Foundation of China,No.61671276
文摘AIM To evaluate the effectiveness and safety of combined ursodeoxycholic acid and percutaneous transhepatic balloon dilation for management of gallstones after expulsion of common bile duct(CBD) stones.METHODS From April 2014 to May 2016, 15 consecutive patients(6 men and 9 women) aged 45-86(mean, 69.07 ± 9.91) years suffering from CBD stones associated with gallstones were evaluated. Good gallbladder contraction function was confirmed by type B ultrasonography. Dilation of the CBD and cystic duct was detected. Percutaneous transhepatic balloon dilation of the papilla was performed, ursodeoxycholic acid was administered, and all patients had a high-fat diet. All subjects underwent repeated cholangiography, and percutaneous transhepatic removal was carried out in patients with secondary CBD stones originating from the gallbladder. RESULTS All patients underwent percutaneous transhepatic balloon dilation with a primary success rate of 100%. The combined therapy was successful in 86.7% of patients with concomitant CBD stones and gallstones. No remaining stones were detected in the gallbladder. Transient adverse events include abdominal pain(n = 1), abdominal distension(n = 1), and fever(n = 1). Complications were treated successfully via nonsurgical management without long-term complications. No procedure-related mortality occurred. CONCLUSION For patients with concomitant CBD stones and gallstones, after percutaneous transhepatic removal of primary CBD stones, oral ursodeoxycholic acid and a high-fat diet followed by percutaneous transhepatic removal of secondary CBD stones appear to be a feasible and effective option for management of gallstones.
文摘Objective:To assess the effect of the adherence to medical treatment on urinary parameters in the 24-h metabolic study of patients with kidney stones.Methods:A retrospective,longitudinal,descriptive,and observational study was carried out by reviewing the hospital electronic medical record from 2014 to 2018.The adherence to drug treatment was measured 6 months after its initiation,and the numerical values of the metabolic studies were compared.Wilcoxon tests were performed to compare the difference before and after treatment.Results:Ninety patients were evaluated,with 73.3% of adherence.The 180-day overall adherence rate was 61.2% in patients treated with a single drug and 85.4% in patients treated with multiple drugs.There is a statistically significant increase in citrate levels in patients with good adherence in comparison with non-adherent patients(p=0.031 vs.p=0.528).Conclusions:Medical treatment and dietary measures in patients with kidney stones have an initial impact at 6 months on the values of the main urinary metabolic alterations that predispose to calculi formation;the most significant is seen in those patients with adherence to medical treatment for hypocitraturia.
文摘INTRODUCTION The advent of laparoscopic cholecystectomy(LC)inthe late 1980s gained widespread acceptance withina short period of time and has become the preferredtreatment for symptomatic gallstones,but themanagement of coexisting gallbladder and commonbile duct(CBD)stones has remained controversialbecause the various strategies proposed have theirlimitations.In fact,choledocholithiasis
文摘Endoscopy is widely accepted as the first treatment option in the management of bile duct stones.In this review we focus on the alternative endoscopic modalities for the management of difficult common bile duct stones.Most biliary stones can be removed with an extraction balloon,extraction basket or mechanical lithotripsy after endoscopic sphincterotomy.Endoscopic papillary balloon dilation with or without endoscopic sphincterotomy or mechanical lithotripsy has been shown to be effective for management of difficult to remove bile duct stones in selected patients.Ductal clearance can be safely achieved with peroral cholangioscopy guided laser or electrohydraulic lithotripsy in most cases where other endoscopic treatment modalities have failed.Biliary stenting may be an alternative treatment option for frail and elderly patients or those with serious co morbidities.
文摘Although endoscopic sphincterotomy(EST) is still considered as a gold standard treatment for common bile duct(CBD) stones in western guideline, endoscopic papillary balloon dilation(EPBD) is commonly used by the endoscopists in Asia as the first-line treatment for CBD stones. Besides the advantages of a technical easy procedure, endoscopic papillary large balloon dilation(EPLBD) can facilitate the removal of large CBD stones.The indication of EPBD is now extended from removal of the small stones by using traditional balloon, to removal of large stones and avoidance of lithotripsy by using large balloon alone or after EST. According to the reports of antegrade papillary balloon dilatation, balloon dilation itself is not the cause of pancreatitis. On the contrary, adequate dilation of papillary orifice can reduce the trauma to the papilla and pancreas by the basket or lithotripter during the procedure of stone extraction. EPLBD alone is as effective as EPLBD with limited EST. Longer ballooning time may be beneficial in EPLBD alone to achieve adequate loosening of papillary orifice. The longer ballooning time does not increase the risk of pancreatitis but may reduce the bleeding episodes in patients with coagulopathy. Slowly inflation of the balloon, but not exceed the diameter of bile duct and tolerance of the patients are important to prevent the complication of perforation. EPBLD alone or with EST are not the sphincter preserved procedures, regular follow up is necessary for early detection and management of CBD stones recurrence.
文摘BACKGROUND A clinical pathway(CP)is a standardized approach for disease management.However,big data-based evidence is rarely involved in CP for related common bile duct(CBD)stones,let alone outcome comparisons before and after CP implementation.AIM To investigate the value of CP implementation in patients with CBD stones undergoing endoscopic retrograde cholangiopancreatography(ERCP).METHODS This retrospective study was conducted at Nanjing Drum Tower Hospital in patients with CBD stones undergoing ERCP from January 2007 to December 2017.The data and outcomes were compared by using univariate and multivariable regression/linear models between the patients who received conventional care(non-pathway group,n=467)and CP care(pathway group,n=2196).RESULTS At baseline,the main differences observed between the two groups were the percentage of patients with multiple stones(P<0.001)and incidence of cholangitis complication(P<0.05).The percentage of antibiotic use and complications in the CP group were significantly less than those in the nonpathway group[adjusted odds ratio(OR)=0.72,95%confidence interval(CI):0.55-0.93,P=0.012,adjusted OR=0.44,95%CI:0.33-0.59,P<0.001,respectively].Patients spent lower costs on hospitalization,operation,nursing,medication,and medical consumable materials(P<0.001 for all),and even experienced shorter length of hospital stay(LOHS)(P<0.001)after the CP implementation.No significant differences in clinical outcomes,readmission rate,or secondary surgery rate were presented between the patients in the non-pathway and CP groups.CONCLUSION Implementing a CP for patients with CBD stones is a safe mode to reduce the LOHS,hospital costs,antibiotic use,and complication rate.
文摘Since therapeutic endoscopic retrograde cholangiopancreatography replaced surgery as the first approach in cases of choledocolithiasis,a plethora of endoscopic techniques and devices appeared in order to facilitate rapid,safe and effective bile duct stones extraction.Nowadays,endoscopic sphincterotomy combined with balloon catheters and/or baskets is the routine endoscopic technique for stone extraction in the great majority of patients.Large common bile duct stones are treated conventionally with mechanical lithotripsy,while the most serious complication of the procedure is "basket and stone impaction" that is predominately resolved surgically.In cases of difficult,impacted,multiple or intrahepatic stones,more sophisticated procedures have been used.Electrohydraulic lithotripsy and laser lithotripsy are performed using conventional mother-baby scope systems,ultra-thin cholangio-scopes,thin endoscopes and ultimately using the novel single use,single operator SpyGlass Direct Visualization System,in order to deliver intracorporeal shock wave energy to fragment the targeted stone,with very good outcomes.Recently,large balloon dilation after endoscopic sphincterotomy confirmed its effectiveness in the extraction of large stones in a plethora of trials.When compared with mechanical lithotripsy or with balloon dilation alone,it proved to be superior.Moreover,dilation is an ideal alternative in cases of altered anatomy where access to the papilla is problematic.Endoscopic sphincterotomy followed by large balloon dilation represents the onset of a new era in large bile duct stone extraction and the management of "impaction" because it seems that is an effective,inexpensive,less traumatic,safe and easy method that does not require sophisticated apparatus and can be performed widely by skillful endoscopists.When complete extraction of large stones is unsuccessful,the drainage of the common bile duct is mandatory either for bridging to the final therapy or as a curative therapy for very elderly patients with short life expectancy.Placing of more than one plastic endoprostheses is better while the administration of Ursodiol is ineffective.The great majority of patients with large stones can be treated endoscopically.In cases of unsuccessful stone extraction using balloons,baskets,mechanical lithotripsy,electrohydraulic or laser lithotripsy and large balloon dilation,the patient should be referred for extracorporeal shock wave lithotripsy or a percutaneous approach and finally surgery.
基金Supported by Chang Gung Memorial Hospital,No. CMRPG300011
文摘AIM:To detect and manage residual common bile duct(CBD)stones using ultraslim endoscopic peroral cholangioscopy(POC)after a negative balloon-occluded cholangiography.METHODS:From March 2011 to December 2011,a cohort of 22 patients with CBD stones who underwent both endoscopic retrograde cholangiography(ERC)and direct POC were prospectively enrolled in this study.Those patients who were younger than 20 years of age,pregnant,critically ill,or unable to provide informed consent for direct POC,as well as those with concomitant gallbladder stones or CBD with diameters less than 10 mm were excluded.Direct POC using an ultraslim endoscope with an overtube balloon-assisted technique was carried out immediately after a negative balloon-occluded cholangiography was obtained.RESULTS:The ultraslim endoscope was able to be advanced to the hepatic hilum or the intrahepatic bile duct(IHD)in 8 patients(36.4%),to the extrahepatic bile duct where the hilum could be visualized in 10 patients(45.5%),and to the distal CBD where the hilum could not be visualized in 4 patients(18.2%).The procedure time of the diagnostic POC was 8.2 ± 2.9 min(range,5-18 min).Residual CBD stones were found in 5(22.7%)of the patients.There was one residual stone each in 3 of the patients,three in 1 patient,and more than five in 1 patient.The diameter of the residual stones ranged from 2-5 mm.In 2 of the patients,the residual stones were successfully extracted using either a retrieval balloon catheter(n = 1)or a basket catheter(n = 1)under direct endoscopic control.In the remaining 3 patients,the residual stones were removed using an irrigation and suction method under direct endoscopic visualization.There were no serious procedure-related complications,such as bleeding,pancreatitis,biliary tract infection,or perforation,in this study.CONCLUSION:Direct POC using an ultraslim endoscope appears to be a useful tool for both detecting and treating residual CBD stones after conventional ERC.
文摘AIM: To compare diagnostic sensitivity, specificity and accuracy of magnetic resonance cholangiopancreatography(MRCP) without contrast medium and endoscopic ultrasound(EUS)/endoscopic retrograde cholangiopancreatography(ERCP) for biliary calculi. METHODS: From January 2012 to December 2013, two-hundred-sixty-three patients underwent MRCP at our institution, all MRCP procedure were performed with the same machinery. In two-hundred MRCP was done for pure hepatobiliary symptoms and these patients are the subjects of this study. Among these two-hundred patients, one-hundred-eleven(55.5%) underwent ERCP after MRCP. The retrospective study design consisted in the systematic revision of all images from MRCP and EUS/ERCP performed by two radiologist with a long experience in biliary imaging, an experienced endoscopist and a senior consultant in Hepatobiliopancreatic surgery. A false positive was defined an MRCP showing calculi with no findings at EUS/ERCP; a true positive was defined as a concordance between MRCP and EUS/ERCP findings; a false negative was defined as the absence of images suggesting calculi at MRCP with calculi localization/extraction at EUS/ERCP and a true negative was defined as a patient with nocalculi at MRCP ad at least 6 mo of asymptomatic followup. Biliary tree dilatation was defined as a common bile duct diameter larger than 6 mm in a patient who had an in situ gallbladder. A third blinded radiologist who examined the MRCP and ERCP data reviewed misdiagnosed cases. Once obtained overall data on sensitivity, specificity, accuracy, positive predictive value(PPV) and negative predictive value(NPV) we divided patients in two groups composed of those having concordant MRCP and EUS/ERCP(Group A, 72 patients) and those having discordant MRCP and EUS/ERCP(Group B, 20 patients). Dataset comparisons had been made by the Student's t-test and χ2 when appropriate.RESULTS: Two-hundred patients(91 men, 109 women, mean age 67.6 years, and range 25-98 years) underwent MRCP. All patients attended regular follow-up for at least 6 mo. Morbidity and mortality related to MRCP were null. MRCP was the only exam performed in 89 patients because it did show only calculi into the gallbladder with no signs of the presence of calculi into the bile duct and symptoms resolved within a few days or after colecistectomy. The patients remained asymptomatic for at least 6 mo, and we assumed they were true negatives. One hundred eleven(53 men, 58 women, mean age 69 years, range 25-98 years) underwent ERCP following MRCP. We did not find any difference between the two groups in terms of race, age, and sex. The overall median interval between MRCP and ERCP was 9 d. In detecting biliary stones MRCP Sensitivity was 77.4%, Specificity 100% and Accuracy 80.5% with a PPV of 100% and NPV of 85%; EUS showed 95% sensitivity, 100% specificity, 95.5% accuracy with 100% PPV and 57.1% NPV. The association of EUS with ERCP performed at 100% in all the evaluated parameters. When comparing the two groups, we did not find any statistically significant difference regarding age, sex, and race. Similarly, we did not find any differences regarding the number of extracted stones: 116 stones in Group A(median 2, range 1 to 9) and 27 in Group B(median 2, range 1 to 4). When we compared the size of the extracted stones we found that the patients in Group B had significantly smaller stones: 14.16 ± 8.11 mm in Group A and 5.15 ± 2.09 mm in Group B; 95% confidence interval = 5.89-12.13, standard error = 1.577; P < 0.05. We also found that in Group B there was a significantly higher incidence of stones smaller than 5 mm: 36 in Group A and 18 in Group B, P < 0.05.CONCLUSION: Major finding of the present study is that choledocholithiasis is still under-diagnosed in MRCP. Smaller stones(< 5 mm diameter) are hardly visualized on MRCP.
文摘AIM:To evaluate the effect of cholecystokinin(CCK)during extracorporeal shockwave lithotripsy(ESWL)in the clearance of common bile duct(CBD)stones in endoscopic retrograde cholangiopancreatography(ERCP).METHODS:Between January 2007 and September2012,patients with large CBD stones who were treated with ESWL and ERCP were identified retrospectively.Patients were randomized in equal numbers to cholecystokinin(CCK)and no CCK groups.For each CCK case,a dose(3 ng/kg per min for 10 min)of sulfated octapeptide of CCK-8 was administered intravenously near the beginning of ESWL.ERCP was performed 4 h after a session of ESWL.The clearance rate of the CBD was assessed between the two groups.RESULTS:A total of 148 consecutive cases(CCK group:74,no CCK group:74)were tallied.Overall there were 234 ESWLs and 228 ERCPs in the 148 cases.The use of CCK showed a significantly higher rate of successful stone removal in the first ESWL/ERCP procedure(71.6%vs 55.4%,P=0.035),but resulted in similar outcomes in the second(42.8%vs 39.4%)and third(41.7%vs 40.0%)sessions,as well as total stone clearance(90.5%vs 83.8%).The use of mechanical lithotripsy was reduced in the CCK group(6.8%vs17.6%,P=0.023),and extremely large stone(≥30mm)removal was higher in the CCK group(72.7%vs41.7%,P=0.038).CONCLUSION:CCK during ESWL can aid with the clearance of CBD stones in the first ESWL/ERCP session.Mechanical lithotripsy usage was reduced and the extremely large stone(≥30 mm)clearance rate can be raised.
文摘BACKGROUND:Common bile duct(CBD)stones are known to pass spontaneously in a significant number of patients. This study investigated the rate of spontaneous CBD stones passage in a series of patients presenting with jaundice due to gallstones.The patients were managed surgically,allowing CBD intervention to be avoided in the event of spontaneous passage of CBD stones. METHOD:Retrospective analysis of patients presenting with jaundice due to CBD stones,and managed surgically with laparoscopic cholecystectomy and intra-operative cholangiogram with or without CBD exploration. RESULTS:The jaundice settled pre-operatively in 76/108 patients, and in 60/108 the CBD stones had passed spontaneously by the time of surgery.These 60 patients avoided any intervention to their CBD. CONCLUSIONS:CBD stones pass spontaneously in more than half of jaundiced patients.Surgical management(laparoscopic cholecystectomy and intra-operative cholangiogram,with willingness to perform CBD exploration if positive)allows the avoidance of CBD intervention in these patients.
