The role of endoscopy in the management of choledocholithiasis. 2022 Apr;15(2):286-300. doi: 10.1007/s12328-021-01575-4. Background: Acute gallstone pancreatitis (AGP) is the most common cause of acute pancreatitis (AP) in the United States. 0000099342 00000 n 2020 ASGE. Ultrasound findings consistent with choledocholithiasis include visualization of a common bile duct stone and a dilated common bile duct greater than 8-mm [3]. 0000007171 00000 n Br J Surg 84:14071409, DiSario J, Ram C, Croffie J, Liu J, Mishkin D, Shah R, Somogyi L, Tierney W, Song LM, Petersen BT (2007) Biliary and pancreatic lithotripsy devices. GUIDELINE The role of endoscopy in the evaluation of suspected choledocholithiasis This is one of a series of statements discussing the use of GI endoscopy in common clinical situations. Both IOC and LUS also allow for evaluation of biliary anatomy which can aid in determining the optimal approach for biliary clearance. Please do not post this document on your web site. 24.77% were diagnosed with choledocholithiasis. The American Society for Gastrointestinal Endoscopy (ASGE) revised its guidelines for risk stratification of patients with suspected choledocholithiasis. It is very important that you consult your doctor about your specific condition. Laparoscopic IOC has an approximate sensitivity of 75100% and a specificity of 76100% [14,15]. Although studies show EDGE to be safe and effective, there are concerns regarding persistent gastrogastric fistula and weight gain following stent removal in which it is recommended that either an upper endoscopy or upper GI series be obtained in all patients post-stent removal to determine the presence of persistent fistula. 243 0 obj <> endobj guidelines in patients with acute gallstone pancreatitis with choledocholithiasis. Tintara S, Shah I, Yakah W, Ahmed A, Sorrento CS, Kandasamy C, Freedman SD, Kothari DJ, Sheth SG. While the results of this study are promising, the most important consideration when deciding on the treatment of choledocholithiasis for an individual patient are expertise in the procedure, characteristics of the biliary tree, and local availability of resources. Risk factors for recurrent stones include multiple common bile duct stones, biliary dilatation>13mm, prior open cholecystectomy, prior gallstone lithotripsy, hepatolithiasis or factors leading to biliary stasis such as periampullary diverticula, papillary stenosis, biliary stricture or tumor and angulation of the common bile duct. The American Society for Gastrointestinal Endoscopy (ASGE) 2010 guidelines for suspected choledocholithiasis were recently updated by proposing more specific criteria for selection of high-risk patients to undergo direct ERCP while advocating the use of additional imaging studies for intermediate- and low-risk individuals. Biliary tract disease; Choledocholithiasis; Endoscopic retrograde cholangiopancreatography; Endoscopic ultrasound; Magnetic resonance cholangiopancreatography. Privacy Policy | Terms of Use Among more than 10,000 ERCPs performed in a 14-hospital system over 7 years, 744 cases were randomly selected from those performed for suspected choledocholithiasis, while excluding those with a prior cholecystectomy or sphincterotomy. Keywords: 39(4):335-343. obstruct the distal duct.15 The natural history of CBD The primary treatment, ERCP, is minimally . xref Online ahead of print. This study demonstrates the 2019 ASGE guideline has greater specificity for finding stones but has a larger intermediate-risk group for whom EUS, MRCP, or intraoperative cholangiography would be advisable before ERCP. recommended. The common bile duct can then be accessed with a small-bore catheter for saline flushes, which may be successful in dislodging stones into the duodenum. 2022 Oct;36(10):7233-7239. doi: 10.1007/s00464-022-09089-x. 0000019304 00000 n 0000034920 00000 n Girn F, Rodrguez LM, Conde D, Rey Chaves CE, Vanegas M, Venegas D, Gutirrez F, Nassar R, Hernndez JD, Jimnez D, Nez-Rocha RE, Nio L, Rojas S. Ann Med Surg (Lond). Endoscopic retrograde cholangio-pancreatography (ERCP) is generally the first-line procedure for definitive management of CDL. The 2019 revision of the ASGE guidelines decreases the utilization of ERCP as a diagnostic modality and offers an improved risk stratification tool. -, Savides TJ. ASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasis. Low Detection Rates of Bile Duct Stones During Endoscopic Treatment for Highly Suspected Bile Duct Stones with No Imaging Evidence of Stones. The subtleties in the management of common bile duct stones relate to the decision making on the probability of choledocholithiasis based on clinical presentation and investigations, the timing of presentation in relation to laparoscopic cholecystectomy in addition to the availability of technology and expertise of the surgeons, endoscopists and interventional radiologists. Careers. 0000021047 00000 n 1.CBD stone on transabdominal US? cholelithiasis4-7 to 18% to 33% of patients with HPB (Oxford) 2006;8:409425. Ekmektzoglou K, Apostolopoulos P, Dimopoulos K, et al. 12mg IV glucagon can also be administered to relax the Sphincter of Oddi to facilitate passage. ERCP has a success rate of approximately 8090% for ductal clearance with proper expertise. Core clinical questions were derived using an iterative process by the ASGE SOP Committee. 2006;20:981996. Image permissions obtained from Cook Medical and Boston Scientific. These range from recommendations on testing and screenings to the role of endoscopy in managing certain diagnoses to sedation and anesthesia to adverse events and quality indicators. 0000020141 00000 n However, the main disadvantage of MRCP is that common bile duct stones identified require intervention by another method to be removed. Due to the difficulty in navigation and subsequent cannulation, balloon-assisted ERCP is not always technically feasible for biliary duct clearance in these patients. Reimagining surgical care for a healthier world. If the patient is found to have a retained stone post-operatively, ERCP is the treatment of choice for biliary clearance. 0000000016 00000 n ASGE evidence-based guidelines provide clinicians with recommendations for the evaluation, diagnosis, and management of patients undergoing endoscopic procedures of the digestive tract. 83(4):577-584. It is very important that you consult your doctor about your specific condition. 0000099916 00000 n Careers. Mar 5, 2020, 18:30 PM. If the diagnosis of choledocholithiasis is confirmed pre-operatively, there are options of clearance of the CBD which include endoscopic retrograde cholangiopancreatography (ERCP) prior to cholecystectomy or common bile duct exploration combined with cholecystectomy which is described in the next section. 0000015193 00000 n Quality documents define the indicators of high-quality endoscopy and how to measure it. %PDF-1.4 % The Stan-dards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this text. webmaster@sages.org 0000100613 00000 n If intraoperative laparoscopic attempts for stone clearance are unsuccessful due to technical reasons, ampullary edema or distal stricturing, an antegrade ampullary stent can be inserted laparoscopically under fluoroscopic guidance either through a transcystic or transcholedochal approach and allows for post-operative ERCP to be performed (Fig. Rent Institute for Training and Technology, The role of endoscopy in the management of choledocholithiasis, https://doi.org/10.1016/j.gie.2018.10.001, VOLUME 89, ISSUE 6, P1075-1105.E15, JUNE 01, 2019, /docs/default-source/importfiles/assets/0/71542/71544/6876dc5f-cb7b-40ff-98ef-7a954a051cc2.pdf?Status=Master&sfvrsn=2. 0000100916 00000 n 8600 Rockville Pike 0000008437 00000 n Rev Gastroenterol Peru. ASGE,, MeSH 0000004317 00000 n J Am Coll Surg 185:274282, Barteau JA, Castro D, Arregui ME, Tetik C (1995) A comparison of intraoperative ultrasound versus cholangiography in the evaluation of the common bile duct during laparoscopic cholecystectomy. 4). The working group first determined questions relevant to the clinical practice of surgeons treating patients with choledocholithiasis. Either a temporary external drain, an internal/external biliary drain or an internal stent can be used to achieve biliary drainage (Fig. Officers and Representatives of the Society, RAFT Annual Meeting Abstract Contest and Awards, 2024 Scientific Session Call For Abstracts, 2024 Emerging Technology Call For Abstracts, Healthy Sooner Patient Information for Minimally Invasive Surgery, Choosing Wisely An Initiative of the ABIM Foundation, All in the Recovery: Colorectal Cancer Alliance, SAGES Clinical / Practice / Training Guidelines, Statements, and Standards of Practice, Surgical Endoscopy and Other Journal Information, NEW-Area of Concentrated Training Seal (ACT)-Advanced Flexible Endoscopy, SAGES Fellowship Certification for Advanced GI MIS and Comprehensive Flexible Endoscopy, Multi-Society Foregut Fellowship Certification, SAGES Go Global: Global Affairs and Humanitarian Efforts. 0000094913 00000 n Gallstone pancreatitis was not associated with the risk for choledocholithiasis. Each recommendation is based on consideration of the best medical literature, the balance between risks and benefits, cost-effectiveness, patients values, and equity. All Rights Reserved. Dig Dis 26:324329, Kedia P, Tyberg A, Kumta NA, Gaidhane M, Karia K, Sharaiha RZ, Kahaleh M (2015) EUS-directed transgastric ERCP for Roux-en-Y gastric bypass anatomy: a minimally invasive approach. Bookshelf 0000003105 00000 n We suggest that the reader also reviews the SAGES clinical spotlight review on laparoscopic common bile duct exploration for further details [16]. -, Tse F, Barkun JS, Romagnuolo J, Friedman G, Bornstein JD, Barkun AN. Following this, immediate antimicrobial therapy targeted to the biliary tract and biliary drainage are the key goals of the treatment of acute cholangitis [38]. Incidence rates of post-ERCP complications: a systematic survey of prospective studies. ASGE classified 58 (8.6 %) additional patients as intermediate, none . In balloon-assisted ERCP, the enteroscope has a working length of 200cm and the 12-mm diameter Overtube has a length of 140cm. -. For the laparoscopic transcystic approach, a transverse opening is made in the cystic duct prior to its transection. 2022 Nov-Dec;38(8):2095-2100. doi: 10.12669/pjms.38.8.6666. When choledocholithiasis is confirmed intraoperatively, a decision should be made between common bile duct exploration at the time of cholecystectomy and post-operative ERCP, which is dependent on local availability of surgical and endoscopic expertise. This American Society for Gastrointestinal Endoscopy (ASGE) Standard of Practice (SOP) Guideline provides evidence-based recommendations for the endoscopic evaluation and treatment of choledocholithiasis. Buxbaum JL, Abbas Fehmi SM, Sultan S. ASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasis . Unauthorized use of these marks is strictly prohibited. 0000102312 00000 n 0000004427 00000 n The management of choledocholithiasis depends on the timing of common bile duct stone discovery in relation to the cholecystectomy. Maple JT, Ben-Menachem T, et al. Bookshelf Los Angeles, CA 90064 USA 0000007328 00000 n 0000102225 00000 n J Hepatobiliary Pancreat Sci 24:537549, Sokal A, Sauvanet A, Fantin B, de Lastours V (2019) Acute cholangitis: diagnosis and management.J Visc Surg 156:515525, Enestvedt BK, Kothari S, Pannala R, Yang J, Fujii-Lau LL, Hwang JH, Konda V, Manfredi M, Maple JT, Murad FM, Woods KL, Banerjee S (2016) Devices and techniques for ERCP in the surgically altered GI tract. Elsevier, Philadelphia, pp 391395, Hazey JW, Conwell DL, Guy GE (eds) (2016) Multidisciplinary management of common bile duct stones. Epub 2021 Mar 22. 2023 Feb 28;12(3):482. doi: 10.3390/antibiotics12030482. Alternatively, a flexible guidewire can be placed intraoperatively across the ampulla to allow for concomitant ERCP via a single-stage laparoscopic-endoscopic rendez-vous procedure as described earlier. The SAGES clinical spotlight review on laparoscopic common bile duct exploration can be referenced for further discussion [16]. A new approach to biliary calculi after failure of routine endoscopic measures. We also found that while the 2010 ASGE guidelines in predicting high risk for choledocholithiasis had a specificity of 75.8%, using the 2019 ASGE guidelines led to an improved specificity of 89.4%. ASGE guideline on screening and surveillance of Barrett's esophagus. Although the interpretation of EUS and MRCP are both subject to bias, meta-analyses have found an observed superiority in the sensitivity of EUS as compared to MRCP due to better accuracy of EUS in detection of small stones and as such, EUS-directed ERCP has been advocated as a cost-effective method since both EUS and ERCP could be performed in the same session. The three main surgical options for re-establishing biliary drainage include choledochoduodenostomy, hepaticojejunostomy or transduodenal sphincteroplasty, which should be further pursued with involvement of a hepatopancreatobiliary surgeon [25]. migrate,13,14 and migrating stones pose a moderate Rent Institute for Training and Technology. Each guideline is scheduled for periodic review to allow incorporation of pertinent new developments in medical research knowledge, and practice. An updated literature search from PubMed based on the prior published search strategy was performed from October 1, 2019 until March 16, 2021. Comparative evidence was sought where available. 2017 Sep;86(3):525-532. doi: 10.1016/j.gie.2017.01.039. In summary, patients predicted to be at high risk for choledocholithiasis based on ASGE guidelines met the threshold of at least a 50% likelihood of having persistent choledocholithiasis. If these endoscopic approaches prove unsuccessful, a common bile duct exploration or PTBD with its associated percutaneous interventions can then be performed for common bile duct clearance, which have been described earlier in this document. Bret T. Petersen, MD, MASGE In prepar- This document was reviewed and approved by the Board of Governors of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) in Feb 2020. Choledocholithiasis (CDL) is a common clinical entity and can lead to serious complications, such as pancreatitis or ascending cholangitis. Endoscopy. Final decision on an intervention should always be based on local expertise and patient preferences. 0000048268 00000 n Gastrointest Endosc 65:750756, Costi R, Gnocchi A, Di Mario F, Sarli L (2014) Diagnosis and management of choledocholithiasis in the golden age of imaging, endoscopy and laparoscopy. 0000007642 00000 n Yu CY, Roth N, Jani N, Cho J, Van Dam J, Selby R, Buxbaum J. Surg Endosc. 2002 Jan 14-16;19(1):1-26. In 2000 and 2012, the American Society of Gastrointestinal Endoscopy (ASGE) issued guidelines regarding the performance of upper GI endoscopy. Once the diagnosis of acute cholangitis has been definitively made in this subset of patients presenting with sepsis, initial treatment includes IV fluid resuscitation with careful monitoring of hemodynamic status. Choledocholithiasis is a commonly encountered diagnosis for general surgeons. 0000013917 00000 n Methods An observational retrospective study including hospitalized patients admitted with acute cholecystitis between January 2016 and December 2020 at Edit Wolfson Medical Center. If the patient is found to have documented choledocholithiasis pre-operatively and a pre-operative ERCP is pursued without successful cannulation of the biliary tree, a pre-cut sphincterotomy can be considered, in which a needle-knife with electrocautery is used to score the region of the papilla for access. World J Gastroenterol 20:1338213401, Sauerbruch T, Stern M (1989) Fragmentation of bile duct stones by extracorporeal shock waves. eCollection 2022 Jun. 0000004091 00000 n Guidelines are developed under the auspices of the Society of American Gastrointestinal and Endoscopic Surgeons and its various committees, and approved by the Board of Governors. ASGE strives to provide clinically relevant and practical recommendations, which can help standardize patient care and improve outcomes. By directly cannulating the ampulla to access the biliary tree, a sphincterotomy is often performed with sweeping and extracting stones from the common bile duct. The diagnostic performance of the ASGE and ESGE guidelines is summarized in Table 3. Epub 2017 Feb 4. 0000101569 00000 n 2021 Mar;54(2):147-148. doi: 10.5946/ce.2021.080. If this is not successful, stones can be extracted with a wire basket or Fogarty balloons under fluoroscopic guidance. Fewer patients were classified as high risk by the 2019 guideline versus the 2010 guideline (36.8% vs 60.4%;P<.001), and more high-risk patients were found to have definitive stones, according to the 2019 guideline versus the 2010 guideline (82.5% vs 76.2%;P<.001). Cochrane Database Syst Rev 2:CD011548, Barkun AN, Barkun JS, Fried GM, Ghitulescu G, Steinmetz O, Pham C, Meakins JL, Goresky CA (1994) Useful predictors of bile duct stones in patients undergoing laparoscopic cholecystectomy: McGill Gallstone Treatment Group. sharing sensitive information, make sure youre on a federal 2). A retrospective analysis for two years. (2020)Primary Needle-Knife Fistulotomy Versus Conventional Cannulation Method in a High-Risk Cohort of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis. 0000007883 00000 n 0000006461 00000 n 11300 W. Olympic Blvd Suite 600 The primary treatment, ERCP, is minimally invasive but associated with adverse events in 6% to 15%. When financial guidance is indicated, the most recent coding data and list prices at the time of publication are provided. 2023 Feb;37(2):1194-1202. doi: 10.1007/s00464-022-09615-x. 0000004652 00000 n ASGE guideline on the role of endoscopy in the management of benign and malignant gastroduodenal obstruction. However, in the event of failure of endoscopic techniques or in patients with rapid deterioration and sepsis-induced organ damage, percutaneous transhepatic biliary drainage should be considered as described earlier in this review. Panel members provide ongoing conflict of interest (COI) disclosures, including intellectual conflicts of interest, throughout the development and publication of all guidelines in accordance with the ASGE Policy for Managing Declared Conflicts of Interests. risk of pancreatitis (25%-36%)13,14 or cholangitis if they Patients without evidence of jaundice and a normal bile duct on ultrasound have a low probability of choledocholithiasis (<5%) [9]. The excluded stomach is located endosonographically from the gastric pouch or afferent limb and accessed to deploy a lumen-apposing metal stent into the excluded gastric remnant to allow antegrade passage of a duodenoscope through the fistula where conventional ERCP can be performed to access and cannulate the ampulla and biliary tree. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). 0000004540 00000 n 2022 Apr 28;28(16):1692-1704. doi: 10.3748/wjg.v28.i16.1692. World J Gastroenterol 21:820828, Chung SC, Leung JW, Leong HT, Li AK (1991) Mechanical lithotripsy of large common bile duct stones using a basket. 0000045574 00000 n Copyright 2019. The https:// ensures that you are connecting to the Given the wide range of specifics in any health care problem, the surgeon must always choose the course best suited to the individual patient and the variables in existence at the moment of decision. Surg Endosc 28:875885, Schwab B, Teitelbaum EN, Barsuk JH, Soper NJ, Hungness ES (2018) Single-stage laparoscopic management of choledocholithiasis: an analysis after implementation of a mastery learning resident curriculum. Wang L, Mirzaie S, Dunnsiri T, Chen F, Wilhalme H, MacQueen IT, Cryer H, Eastoak-Siletz A, Guan M, Cuff C, Tabibian JH. Phone: (630) 573-0600 | Fax: (630) 963-8332 | Email: info@asge.org The algorithm presented in Fig. If the initial ductotomy made for cholangiogram is too small, the ductotomy can either be extended closer to the cystic duct-CBD junction or pneumatic cystic duct dilatation can be performed under fluoroscopy over a guidewire. Articles pertaining to management strategies for choledocholithiasis and best clinical scenarios for the application of each strategy are summarized below under each question. 0000013515 00000 n 0000005334 00000 n However, the timely availability of alternative imaging and patient morbidity may drive diagnostic and therapeutic pathways in individual patients and environments. 2023 May;68(5):2061-2068. doi: 10.1007/s10620-022-07773-5. As such, the EDGE procedure can be an alternative method of accessing the biliary tree in which an anastomosis is created typically with a lumen-apposing metal stent between the gastric pouch or jejunum to the excluded stomach under endoscopic ultrasound visualization which allows a duodenoscope to be passed to perform a conventional ERCP [35] (Fig. Acta Gastroenterol Belg. Radiology 145:9198, Magnuson TM, Bender JS, Duncan MD, Ahrendt SA, Harmon JW, Regan F (1999) Utility of magnetic resonance cholangiography in the evaluation of biliary obstruction. 0000010469 00000 n Stone visualized on imaging had the greatest specificity for choledocholithiasis. cholangiography (IOC) at elective cholecystectomy Here you will find ASGE guidelines for standards of practice. 2016 Jul;48(7):657-83. doi: 10.1055/s-0042-108641. Unable to load your collection due to an error, Unable to load your delegates due to an error. Gastrointest Endosc 2020 Nov 4. Ann Surg 220:3239, Abboud PAC, Malet PF, Berlin JA, Staroscik R, Cabana MD, Clarke JR, Shea JA, Schwartz JS, Williams SV (1996) Predictors of common bile duct stones prior to cholecystectomy: a meta-analysis. Numerous factors have been implicated as prognostic predictors to help stratify patients into low, intermediate and high probability of choledocholithiasis. A systematic English literature search was conducted in PubMed to determine the appropriate management strategies for choledocholithiasis.The following clinical spotlight review is meant to critically review the available evidence and provide recommendations for the work-up, investigations as well as the endoscopic, surgical and percutaneous techniques in the management of choledocholithiasis. 0000007249 00000 n Under the revised guidelines, 86 (32%) patients met the criteria for high risk, of whom 83% had choledocholithiasis. A transductal approach can be attempted laparoscopically if the surgeon has the needed expertise and if the common bile duct is at least 7mm in diameter to reduce the risk of post-operative stricture. Nevertheless, laparoscopic common bile duct exploration has not been adopted widely as it is technically challenging and strongly dependent on surgeon experience and equipment availability [19]. Treatment of recurrent common bile duct stones typically includes repeat endoscopic intervention (i.e., ERCP) but may also be treated surgically in patients who are at high risk of recurrence. This site needs JavaScript to work properly. and transmitted securely. Nonoperative imaging techniques in suspected biliary tract obstruction. The clinical presentation of choledocholithiasis can range from completely asymptomatic to biliary colic and symptoms of obstructive jaundice, such as pruritus, dark urine and acholic stools. Would you like email updates of new search results? Accuracy of SAGES, ASGE, and ESGE criteria in predicting choledocholithiasis. Although data regarding the natural history of choledocholithiasis Other strong predictors for choledocholithiasis include clinical evidence of acute cholangitis, a bilirubin greater than 1.7mg/dL and a dilated CBD; the presence of two or more of these factors has a pre-test probability of 50%-94% for choledocholithiasis (considered high) [7,8]. Although these approaches are invaluable . Privacy Policy | Terms of Use 2008;67:669672. Gastrointest Endosc 44:450459, Yang MH, Chen TH, Wang SE, Tsai YF, Su CH, Wu CW, Lui WY, Shyr YM (2008) Biochemical predictors for absence of common bile duct stones in patients undergoing laparoscopic cholecystectomy. undergoing laparoscopic cholecystectomy for symptomatic 0000102501 00000 n By alternating inflating and deflating the balloons and straightening the scope with the Overtube, the endoscope is progressed stepwise through the small intestine under fluoroscopic guidance and maneuvered into the biliopancreatic limb to access the ampulla [34]. 0000100990 00000 n 3,4,8,9 Not surprisingly, many practice patterns now exist to manage CBD stones, which has led to national debate regarding the optimal algorithm.
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