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The Accuracy of Transabdominal Ultrasound in Detection of the Common Bile Duct Stone as Compared to Endoscopic Retrograde Cholangiopancreatography (with Literature Review)

The Accuracy of Transabdominal Ultrasound in Detection of the Common Bile Duct Stone as Compared to Endoscopic Retrograde Cholangiopancreatography (with Literature Review)

Introduction: Common bile duct stone (CBDS) is a common clinical problem that can cause serious complications, such as acute cholangitis and pancreatitis. It is im- portant to have an accurate, safe, and reliable method for the definitive diagnosis of CBDS before proceeding to therapeutic endoscopic retrograde cholangiopancreato- graphy (ERCP). Objective: To compare the accuracy of trans-abdominal ultrasound (TAUS) as a diagnostic tool at our institution—Kurdistan Centre for Gastroenterol- ogy & Hepatology (KCGH)—with invasive tool like ERCP in the diagnosis of bile duct stones, using specificity, sensitivity, and positive and negative predictive values. Pa- tient and Method: After obtaining ethical committee approval & informed consent from every patient. This was a prospective study conducted on 71 patients (24 male patients and 47 females patients) where suspected to have CBDS depending on his- tory, clinical suspicion and blood tests. Their ages range between (2 - 88 years). Both TAUS and ERCP were performed. Final diagnosis was confirmed depending on ERCP as it served as a diagnostic standard in diagnosing CBDS. Result: In 71 patients sus- pected to have CBDS by TAUS, only 46 patients had stone (65%), and 55 patients had stone by ERCP (77%). In our result, sensitivity, specificity, positive predictive value and negative predictive value for TAUS were 80%, 87.5%, 65.5% and 56%, respec- tively. Conclusion: TAUS can play an important role as an initial screening proce- dure for CBDS detection because of the various advantages like easy availability, cost effectiveness, no requirement of contrast material and lack of ionizing radiation but should done with other imaging modality to avoid serious complication of ERCP. How to cite this paper: Alkarboly, T.A.M.,
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Common Bile Duct Stone Exploration: T-Tube or Biliary

Common Bile Duct Stone Exploration: T-Tube or Biliary

T-tube drain has been used routinely for biliary drainage after open or laparoscopic choledochotomy. T-tube placement helps decompress the biliary system, minimize the risk of bile leaks and provide access for follow-up imaging of biliary tree and extraction of retained stones [20,21]. Despite these advantages, specific morbidity related to T-tube usage is reported to occur in up to 6,3% in series of open choledochotomy [22,23,24]. Accidental T-tube displacement leading to CBD obstruction [9,25], bile leakage around T-tube [21], duodenal erosion [26], persistent biliary fistula [25,5], wound cellulitis around T-tube [5], excoriation of the skin, and cholangitis caused by bacteria entering through the T-tube [24] may retard recovery and prolong hospital stay. Indwelling T- tubes are uncomfortable, require continuous management and restrict patient’s activity because of the risk of dislodgement [27]. Patients with an open T-tube are at risk of dehydration and saline depletion [28]. CBD stenosis has been reported as a long-term postoperative complication following T-tube removal [29,25].
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Limited precut sphincterotomy combined with endoscopic papillary balloon dilation for common bile duct stone removal in patients with difficult biliary cannulation

Limited precut sphincterotomy combined with endoscopic papillary balloon dilation for common bile duct stone removal in patients with difficult biliary cannulation

prasugrel, ticagrelor and coumadin 5 days before ERCP according to British Society of Gastroenterology and European Society of Gastrointestinal endoscopy [14, 15]. For patients with high cardiovascular risks, the proce- dures were postponed if possible until anticoagulant could be discontinued safely (usually >12 months after insertion of drug-eluting coronary stents or >1 month after insertion of bare metal coronary stents). However, when an emergent or semi-emergent indication like an impacted stone or jaundice in need of immediate action was encountered, cardiologists were routinely consulted and replaced by other emergent non-endoscopic bilary driange procedures. Prophylactic NSAIDs were given to all patients to reduce risk of post-ERCP pancreatitis routinely in our department.
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Safety of primary common Bile Duct Closure

Safety of primary common Bile Duct Closure

Obstruction of the common bile duct as a result of the presence of stones has historically been corrected by opening the common bile duct and removing the stones [1]. In 1890, Ludwing Courvoisier was the irst to perform a choledochotomy and remove a common bile duct stone [2]. As early as 1917, Halstead described primary closure of the common bile duct that was drained using a tube through the cystic duct stump [3]. There are surgeons who practice primary closure of the common bile duct after exploration and decry the use of post operation T-tube cholangiography [4].
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Results: A total of 116 patients, 62 (53.4%) females, were operated for extra-hepatic biliary tree obstruction. Their age ranged from 21 to 80 years with a mean (±SD) of 40.3(11.2) years. Abdominal pain seen in 107 (92.2%) of the patients and jaundice in 98 (84.5%) were the two most common presenting complaints. Abdominal ultrasound was the main imaging modality used to identify the etiology in 88.8% of the patients. Benign conditions accounted for 79 (68.1% of the underlying etiology, common bile duct stone being the most common, 70 (60.3%). Pancreatic head tumor was the commonest malignant cause, 19 (51.3%), followed by cholangiocarcinoma, 15 (40.5%). Cholidochoduodenostomy was performed for 50 (43.1%) of the patients and cholecystojejunostomy with Braun’s anastomosis for 22 (19%).
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A Clinical study on Common Bile Duct Stones with special reference to management

A Clinical study on Common Bile Duct Stones with special reference to management

Common bile duct stones are present in approximately 5% of patients undergoing elective cholecystectomy and 10% of patients with acute cholecystitis. No single blood investigation or combination of blood investigations can predict whether or not a common bile duct stone is present. Intraoperative cholangiography / choledochoscopy are used for definite diagnosis but CBD stone can be diagnosed preoperatively with ultrasound, ERCP, or magnetic resonance cholangiopancreatography. If choledocholithiasis is diagnosed preoperatively, several different modalities can be utilized. The factor that determine the optimal approach include patient’s age and condition, the presence of jaundice or cholangitis and size of the duct and stone. It is also important to consider the local expertise of the surgeon and gastroenterologist in managing common duct stones. Hence, algorithm for managing these patients will vary from one locale to another. There are specific conditions that mandate CBD open exploration and therefore the practicing surgeon must be well versed in those techniques.
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Risk factors for bile leakage after primary closure following laparoscopic common bile duct exploration: a retrospective cohort study

Risk factors for bile leakage after primary closure following laparoscopic common bile duct exploration: a retrospective cohort study

The role of ERCP in diagnosis of CBD stones has been replaced by MRCP, however, it is widely used to remove CBD stones in one-stage or staged procedures. EST is associated with serious short-term complica- tions, including bleeding, post-ERCP pancreatitis (PEP), and perforation of the digestive tract. In addition, EST may increase the incidence of long-term complications such as biliary infection due to the dysfunction of the Oddi’s sphincter after the procedure [14–16]. In order to preserve (at least partly) the function of the sphinc- ter of Oddi and avoid post-EST bleeding, EPBD is more and more used in treatment of CBD stones. Actually, choledocholithiasis is the only indication for EPBD reported in large controlled series. Unfortunately, the recent RCTs failed to demonstrate the advantages of EPBD over EST in terms of post-operative complica- tions including PEP, bleeding and perforation [17, 18]. The rate of complete stone removal and utilization of endoscopic mechanical lithotripsy in EST group was comparable with EPBD group [19]. Meta-analyses also showed similar efficacy and overall safety (less bleeding but more PEP in EPBD) between the two treatments [20]. In patients with cholecystocholedocholithiasis, ERCP with stone extraction might be performed select- ively before, during or after cholecystectomy. However,
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Cholecystectomy or gallbladder in situ after endoscopic removal of bile duct stone

Cholecystectomy or gallbladder in situ after endoscopic removal of bile duct stone

Common bile duct stones are a frequent complication of and are often associated with cholangitis and cholestatichepatitis. The traditional management of patients with these stones is endoscopic sphincterotomy, and subsequent laparoscopic cholecystectomy is often lbladder stones in situ in order to prevent biliary complications such as acute cholecystitis, biliary colic, recurrent biliary stones, cholangitis, Han Lai, 2017). The subsequent treatment of patients who have residual stones in the gall has been the source of some controversy. Studies report that only about 10 percent of these patients develop biliary symptoms, leading to the wait-
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Management of suspected common bile duct stones on cholangiogram during same-stay cholecystectomy for acute gallstone-related disease

Management of suspected common bile duct stones on cholangiogram during same-stay cholecystectomy for acute gallstone-related disease

Another option would have been to perform ERCP dur- ing surgery (with or without rendezvous) [23]. Here again, we have not selected this strategy primarily because half of the patients do not show a confirmed stone on post- operative tests (and would have undergone unnecessary ERCP). Secondarily, emergency intra-operative ERCP is difficult to organize because of endoscopist availability and the positioning of the patient being non-standard for ERCP. The present study is limited by its retrospective nature and its potential for type 2 errors. However, it provides a real-life assessment of the proposed manage- ment strategy of patients at risk of CBD stones.
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The efficacy of limited endoscopic sphincterotomy plus endoscopic papillary large balloon dilation for removal of large bile duct stones

The efficacy of limited endoscopic sphincterotomy plus endoscopic papillary large balloon dilation for removal of large bile duct stones

It is very troublesome when biliary tract disease such as bile duct stones are complicated with cholangitis, obstructive jaundice, and pancreatitis. Endoscopic retrograde cholangiopancreatography (ERCP) is the best option in order to remove bile duct stones. This skill for the removal of stones involves the initial common bile duct (CBD) cannulation, subsequent papilla opening broadening. It can be done by either endoscopic sphinc- terotomy (EST) or endoscopic papillary balloon dilation (EPBD). However, EST and EPBD can cause complica- tions such as bleeding, perforation, cholangitis, and pan- creatitis [1, 2]. In general, approximately 5–15% of bile duct stones failed to be detached with single technique of EST or EPBD, even in combination with the standard size balloon and basket extraction procedures [1, 3–7]. There were several reports emphasizing that the charac- teristics and locations of stones were associated with failure of bile duct stones extraction. These included the bigger size of stones of 15 mm or more, numerous stones, rigid stones, drum-shaped stones, stones above the bile duct stricture, the distal CBD narrowing, firmed and totally impacted bile duct stones, intrahepatic duct stones [1, 2, 4, 6–11]. It was well understood that EPBD had been applied to stones smaller than 10 mm only. Unlike EST, EPBD could not expand the duct orifice as wide as EST did [12]. The EST size needed to be adapted to the CBD and papilla size and which allowed approxi- mately 80–90% of bile duct stones to be successfully extracted by EST, followed by retrieval balloons and bas- kets. Nevertheless, when EST was used alone, it might fail in larger stones extraction [2]. Whenever applicable, before the ERCP procedure, large bile duct stones re- moval might need the concomitant use of mechanical lithotripsy (ML) or intraductal electrohydraulic litho- tripsy (EHL) or laser lithotripsy, or extracorporeal shock wave lithotripsy [13]. Most endoscopists used EST or EPBD combined with ML to remove large bile duct stones. However, we must keep in mind the possibility of procedure-related severe complications like the so- called “basket and stone impaction” which usually needs surgical interventions [2]. The main concern for ML was that the procedure needs more procedure time and is as- sociated with increased risk of pancreatitis and cholan- gitis [2, 11]. To date, most studies have focused only on evaluating and comparing the efficacy and complications of EST alone and EST plus endoscopic papillary large balloon dilation (EPLBD) [3, 5, 6, 9, 14–19] or EPLBD alone and EPLBD plus EST or small or limited EST for the removal of large bile duct stones [1, 2, 10, 11, 20].
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Case Review of Impacted Bile Duct Stone at Duodenal Papilla: Detection and Endoscopic Treatment

Case Review of Impacted Bile Duct Stone at Duodenal Papilla: Detection and Endoscopic Treatment

Suspicion of an IPS is dependent usually on the clinical manifestations and findings on the radiological studies. However, as shown in this study, radiological studies do not always locate a stone in the bile duct and the papilla (n = 17, 37.0%), and the diameter of the bile duct might be within normal range (n = 11, 23.9%) even with a stone impacted in the distal bile duct. Furthermore, the typical manifestations of acute cholangitis (n = 10, 21.7%) and acute pancreatitis (n = 17, 37.0%) due to an impacted stone at the papilla were less common than expected. The absence of some of these manifestations might partially be explained by the patients who present early to the hospital because of severe abdominal pain, therefore, there was not enough time for the bile duct to become dilated and for full-blown signs and symptoms of cholangitis to develop.
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Jaundice caused by protrusion of a hepatic cyst into common bile duct that was resolved by choledochoscopic needle-knife electrotomy: a case report

Jaundice caused by protrusion of a hepatic cyst into common bile duct that was resolved by choledochoscopic needle-knife electrotomy: a case report

Endoscopic retrograde cholangiography (ERC) was performed to define the cause of obstruction. This pro- cedure showed that the right hepatic duct was ectatic, but the left hepatic duct and common bile duct were not observed. There were no stone, but a large lump was ob- served in the common bile duct, which suggested suspi- cious bile duct tumor. Endoscopic sphincterotomy, endoscopic retrograde biliary drainage(ERBD), and endoscopic nasobiliary draingage(ENBD) were success- fully performed to drain bile for severe hepatic injury and jaundice, rather than laparotomy, because of coagu- lation disorders (Fig. 2). After these procedures, the ic- teric sclera and skin gradually faded, liver function was obviously improved, and coagulation disorders were close to normal levels (Table 1).
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Comparison of the usefulness of endoscopic papillary large-balloon dilation with endoscopic sphincterotomy for large and multiple common bile duct stones

Comparison of the usefulness of endoscopic papillary large-balloon dilation with endoscopic sphincterotomy for large and multiple common bile duct stones

Several studies have compared the usefulness of EST and EST + EPLBD [13–18]. Some showed no significant difference in treatment results, whereas others reported that EST + EPLBD reduced the operative time, increased the rate of successful stone removal, and reduced the rate of ML use. In 2012, Feng et al. [19] performed a meta-analysis comparing EST and EPLBD. According to their findings, the successful stone removal rate in pa- tients with common bile duct stones treated with EPLBD was 97.35 %, 87.87 % were successful in the first session, indicating favorable results. However, the differ- ences between EPLBD and EST were not statistically significant. In addition, in patients with large stones, EML use did not differ significantly between the two groups, and the occurrence rate of bleeding, an early accidental event, was significantly lower in the EPLBD group. No consensus has been reached based on previ- ous studies.
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Preliminary experience with laparoscopic common bile duct exploration

Preliminary experience with laparoscopic common bile duct exploration

The trans-cystic approach is technically easier, feasible, and less invasive with better patients’ satisfaction. Surgeons usually try it first but it has its limitations and indications e.g. dilated cystic duct, small stones (preferably single stone) and there should be no stent in the CBD [3, 11 – 13]. We performed this approach in 103/129 (79.8%) patientswith success rate of 98/103 (95%) which is almost comparable to others. Whenever this approach is difficult or impossible, we converted to trans-choledochal one. The choledochotomy approach is technically demanding and needs advanced laparoscopic experience [6, 14, 15]. 29/129 (20.2%) patients have been undergone LCBDE through transcholedochal route with 28/29 (96.6%) suc- cess rate. We performed this choledochotomy approach after failed trials of trans-cystic route either due to failed cannulation or failed stone extraction through cystic duct. Choledochotomy technique was our first choice without trying the trans-cystic technique in three patients with failed ERCP due to impacted big stone in the CBD.
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Evidence-based Medicine in Biliary Surgery: A Model of Applicability

Evidence-based Medicine in Biliary Surgery: A Model of Applicability

grade III). In our study, wound infection was noted in 11% of cases. We administered these infections by probabilistic anti biotherapy and dressings twice daily. b. Residual common bile duct stones: Biliary sphincterot- omy and endoscopic stone extraction (ESE) is rec- ommended as the primary form of treatment for patients with CBDS post-cholecystectomy (Evidence grade III) 11 . In our series, ERCP was performed on

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A prospective analytical study about common bile duct stones in Government Rajaji Hospital

A prospective analytical study about common bile duct stones in Government Rajaji Hospital

Ductal calculi presenting 2 years or more after an operation are generally regarded to be primary or recurrent. One study has identified suture material in 30% of cases. This finding stresses the importance of avoiding non-absorbable material during operation on the biliary tract. Internalization of metal clips used to secure the medial end of the cystic duct during laparoscopic cholecystectomy is now a well-recognized complication of this procedure. The exact pathology remains unclear. The internalized clip becomes covered with calcium bilirubinate to form a brown pigment stone.
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Toothpick inside the Common Bile Duct: A Case Report and Literature Review

Toothpick inside the Common Bile Duct: A Case Report and Literature Review

There are some reports of FBs inside the biliary tract. Most cases lead to biliary obstruction and the FB is usually related to past surgical or endoscopic procedures. Endoclips, suture material, and stents in cholecystectomized patients are the most common objects [24–28]. Diagnoses are usually established after presentation of obstructive jaundice due to bile duct stone formation around the FB that works as a nidus [24–26].

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Treatment of gallbladder stone with common bile duct stones in the laparoscopic era

Treatment of gallbladder stone with common bile duct stones in the laparoscopic era

The first step of this procedure was to expose the porta hepatis by lifting the round ligament with a transparietal suture and by pulling the cystic duct up and laterally. The anterior aspect of the common bile duct was cleared up over a length of 10 to 20 mm. The LC procedure was per- formed vertically on the supraduodenal part of the anter- ior aspect of the common bile duct. All stones visible through the choledochotomy were removed with an atraumatic forceps. Stones located in the lower part of the common bile duct were pushed out through choledochot- omy by pressure on the common bile duct wall with blunt forceps or flushed out through the choledochotomy with saline irrigation. The remaining stones were extracted with a Dormia basket under choledochoscopic guidance. Impacted stones were fragmented first by electrohydraulic lithotripsy and then either retrieved with a Dormia basket or pushed out through the papilla. We never dilate the papilla because of the high risk of acute pancreatitis.
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Forgotten biliary Stent: A case report

Forgotten biliary Stent: A case report

Endoscopic sphincterotomy and stone extraction is the widely accepted treatment modality for common bile duct stones and this procedure can clear the bile ducts in 85% to 90% of patients. Endoscopic insertion of biliary endoprosthesis has been proposed as an alternative for frail, elderly patients or in those with high surgical risk. Biliary stent plastic is kept for temporary relief of biliary obstruction.It is to be kept for 3 weeks to 3 months maximum, in this patient biliary stent was kept for 5 years which is the longest period a stent remained in biliary tree. We recommend for all ERCP units provide a stent registry system that the stents placed for various therapeutic procedures are not forgotten both by the patient as well as the physician. There sould be a deadline for biliary stents in registry system for each patient.
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Ectopic opening of the common bile duct and duodenal stenosis: an overlooked association

Ectopic opening of the common bile duct and duodenal stenosis: an overlooked association

well-recognized in the western countries. Another reason may be that some endoscopists might think these patients have spontaneous biliary fistula. In a group of patients with DD/AS, failure of the procedure because the second part could not be reached or papilla could not be found may also explain why this abnormal- ity is not identified widely. Biliary stone and duodenal ulcer are common complications related with this entity leading to frequent operations especially when EO-CBD- DB could not be identified. In this sudy, EO-CBD-DB was demonstrated in a vast majority of the patients with DD/AS. We herein emphasize their association and important features of endoscopic therapy with its long-term efficacy.
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