ASGE evidence-based guidelines provide clinicians with recommendations for the evaluation, diagnosis, and management of patients undergoing endoscopic procedures of the digestive tract. A Cochrane review on the topic has shown that single-stage laparoscopic common bile duct exploration with cholecystectomy and two-stage ERCP followed by laparoscopic cholecystectomy have similar efficacy rates in clearing the CBD with no significant difference in patient morbidity and mortality [17]. Reasons for failure include large or impacted stones, duodenal diverticula, altered gastric or duodenal anatomy and intrahepatic stones. Prat F, Meduri B, Ducot B, Chiche R, Salimbeni-Bartolini R, Pelletier G (1999) Prediction of common bile duct stones by noninvasive tests. Final decision on an intervention should always be based on local expertise and patient preferences. The role of endoscopy in the management of choledocholithiasis VOLUME 89, ISSUE 6, P1075-1105.E15 . sharing sensitive information, make sure youre on a federal Image permissions obtained from Cook Medical and Boston Scientific. Accuracy of ASGE high-risk criteria in evaluation of patients with suspected common bile duct stones. 0000007249 00000 n Several studies have scrutinized the accuracy of the ASGE-SAGES guidelines at predicting choledocholithiasis; however, they are often based on single-center, retrospective data. 0000005560 00000 n Image permissions obtained from Dr. Prashant Kedia, Depiction of laparoscopic transgastric access of the gastric remnant to perform ERCP following Roux-en-Y gastric bypass. 0000007406 00000 n This has been associated, however, with an increased complication rate of 530%, which include perforation and post-ERCP pancreatitis [18]. additional patients as high likelihood compared with ESGE . 0000007328 00000 n We evaluated and validated the clinical utility of these new risk stratification criteria for . In the case that endoscopic retrieval is unsuccessful, percutaneous biliary drainage or less frequently laparoscopic or open common bile duct exploration may be required. -, ASGE Standards of Practice Committee. Guidelines are applicable to all physicians who address the clinical problem(s) without regard to specialty training or interests, and are intended to indicate the preferable, but not necessarily the only acceptable approaches due to the complexity of the healthcare environment. 2022 Nov-Dec;38(8):2095-2100. doi: 10.12669/pjms.38.8.6666. (ASGE). 2022 Apr 28;28(16):1692-1704. doi: 10.3748/wjg.v28.i16.1692. 0000102101 00000 n If the patient is found to have choledocholithiasis intraoperatively and the biliary tree cannot be successfully cannulated for stone extraction, a post-operative ERCP, further surgical attempts via laparoscopic or open techniques or percutaneous biliary drainage can be pursued depending on local expertise and resource availability (Fig. 0000017914 00000 n This American Society for Gastrointestinal Endoscopy (ASGE) Standard of Practice (SOP) Guideline provides evidence-based recommendations for the endoscopic evaluation . Furthermore, laparoscopic common bile duct exploration is contraindicated in the absence of common bile duct pathology, in patients with hemodynamic instability, or when a hostile porta hepatis is encountered intraoperatively [16]. We suggest that the reader also reviews the SAGES clinical spotlight review on laparoscopic common bile duct exploration for further details [16]. Gastrointest Endosc 71:1-9, Khan MA, Khan Z, Tombazzi CR, Gadiparthi C, Lee W, Wilcox CM (2018) Role of cholecystectomy after endoscopic sphincterotomy in the management of choledocholithiasis in high-risk patients: a systematic review and meta-analysis. Keywords: Unauthorized use of these marks is strictly prohibited. Although up to a third of patients with common bile duct (CBD) stones will pass them spontaneously without intervention, the majority of patients will require endoscopic and/or surgical intervention [2]. Quality documents define the indicators of high-quality endoscopy and how to measure it. 0000102312 00000 n We measured the association between individual criteria and choledocholithiasis. Bethesda, MD 20894, Web Policies ASGE strives to provide clinically relevant and practical recommendations, which can help standardize patient care and improve outcomes. 0000007803 00000 n Each year choledocholithiasis results in biliary obstruction, cholangitis, and pancreatitis in a signicant number of patients. Panels consist of content experts, stakeholders from other specialties, patient representatives, and members of the ASGE Standards of Practice (SOP) Committee. If present, argon plasma coagulation and over-the-scope clip placement or revisional surgery with gastrogastric fistula takedown may be required for fistula closure [36]. 2006;20:981996. 0000006068 00000 n 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. 2demonstrates the recommended approach to choledocholithiasis dependent on whether it is discovered pre-operatively, intraoperatively or post-operatively. Based on initial laboratory data and imaging findings, each patient was categorized as low/intermediate probability or high probability of choledocholithiasis as per both 2010 and 2019 ASGE guideline criteria ().The 2019 guidelines consider CBD stones on abdominal US or cross-sectional imaging or clinical ascending cholangitis or total bilirubin >4 mg/dL along with a dilated CBD as high . Br J Surg 78:14481450, Cipolletta L, Coastamagna G, Bianco MA, Rotondano G, Piscopo R, Mutignani M, Marmo R (1997) Endoscopic mechanical lithotripsy of difficult common bile duct stones. 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. -. eCollection 2023 Apr. Percutaneous biliary interventions that can be inserted by interventional radiology. (2020)Retrospective comparative analysis of choledochoscopic bile duct exploration versus ERCP for bile duct stones. Choledocholithiasis is a common presentation of symptomatic cholelithiasis that can result in biliary obstruction, cholangitis, and pancreatitis. FOIA 83(4):577-584. 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. 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. PMC Gastrointest Endosc 39:528531, Koornstra JJ, Fry L, Monkemuller K (2008) ERCP with the balloon-assisted enteroscopy technique: a systematic review. J Hepatobiliary Pancreat Sci 25:3140, Mukai S, Itoi T, Baron TH, Takada T, Strasberg SM, Pitt HA, Ukai T, Shikata S, Teoh AYB, Kim MH, Kiriyama S, Mori Y, Miura F, Chen MF, Lau WY, Wada K, Supe AN, Gimnez ME, Yoshida M, Mayumi T, Hirata K, Sumiyama Y, Inui K, Yamamoto M (2017) Indications and techniques of biliary drainage for acute cholangitis in updated Tokyo Guidelines 2018. Based on the criteria from the two guidelines, patients were categorized preprocedure as low, intermediate, or high risk for findings of duct stones or sludge. 0000013917 00000 n 3300 Woodcreek Dr., Downers Grove, IL 60515 Quality documents define the indicators of high-quality endoscopy and how to measure it. P . Clin Endosc. Scand J Gastroenterol 53:13881392, Hope WW, Fanelli R, Walsh DS, Narula VK, Price R, Stefanidis D, Richardson WS (2017) SAGES clinical spotlight review: intraoperative cholangiogram. Elsevier, Philadelphia, pp 391395, Hazey JW, Conwell DL, Guy GE (eds) (2016) Multidisciplinary management of common bile duct stones. Patients with AGP may also present with choledocholithiasis. Laparoscopic IOC has an approximate sensitivity of 75100% and a specificity of 76100% [14,15]. Regardless, the surgeon must be familiar with all possible options at their disposal for managing the patient presenting with choledocholithiasis which are highlighted in this document. All Rights Reserved. 0000003388 00000 n 0000101569 00000 n Buxbaum JL, Abbas Fehmi SM, Sultan S. ASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasis . J Am Coll Surg 189:6372, Meeralam Y, Al-Shammari K, Yaghoobi M (2017) Diagnostic accuracy of EUS compared with MRCP in detecting choledocholithiasis:a meta-analysis of diagnostic test accuracy in head-to-head studies. 0000101495 00000 n Electrohydraulic lithotripsy involves shock waves that are delivered in brief pulses directly at the stone by the probe, which is optimally located approximately 12mm from the stone. However, its role in preventing the formation of common bile duct stones is still unclear. Under the original guidelines, 165 (62%) patients met the criteria for high risk, of whom 79% had confirmed choledocholithiasis. webmaster@sages.org 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]. Phone: (630) 573-0600 | Fax: (630) 963-8332 | Email: info@asge.org . stones incidentally discovered during routine intraoperative Guidelines are intended to be flexible. Evaluations are based on a literature review and a search of the MAUDE (U.S. Food and Drug Administration Center for Devices and Radiological Health) database to identify the reported adverse events of a given technology. 0000100313 00000 n The primary treatment, ERCP, is minimally invasive but associated with adverse events in 6% to 15%. If you have any questions or suggestions, please contact Customer Support at Info@asge.org. 0000004878 00000 n Forest plot of randomized trials comparing endoscopic sphincterotomy followed by large balloon dilation versus endoscopic sphincterotomy for stone clearance. This topic will review the clinical manifestations and diagnosis of choled . %PDF-1.4 % adults2 at an annual cost of $6.2 billion.3 The incidence of ASGE quality indicators are based on a rigorous review process which results in valid metrics for evaluating GI endoscopic procedures. 4). -, Savides TJ. 0000010469 00000 n Intermediate risk of choledocholithiasis: are we on the right path? 0000005832 00000 n ASGE quality indicators are based on a rigorous review process which results in valid metrics for evaluating GI endoscopic procedures. 0000006146 00000 n 0000102414 00000 n (2020)Multicenter randomized trial of endoscopic papillary large balloon dilation without sphincterotomy versus endoscopic sphincterotomy for removal of bile duct stones: MARVELOUS trial. World J Gastroenterol. https://doi.org/10.1016/j.gie.2020.10.033. 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. Furthermore, ESWL has particular contraindications, such as portal thrombosis and varices of the umbilical plexus [32]. This document was reviewed and approved by the Board of Governors of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) in Feb 2020. Predicting common bile duct stones: Comparison of SAGES, ASGE and ESGE criteria for accuracy. Please enable it to take advantage of the complete set of features! 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. Ultrasound findings consistent with choledocholithiasis include visualization of a common bile duct stone and a dilated common bile duct greater than 8-mm [3]. 0000029131 00000 n 0000100231 00000 n Phone: (630) 573-0600 | Fax: (630) 963-8332 | Email: info@asge.org Please enable it to take advantage of the complete set of features! undergoing laparoscopic cholecystectomy for symptomatic acute biliary pancreatitis.8-11 The diagnostic approach to Gastrointest Endosc. 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. Using ASGE guidelines, 230 (22.1 %), 678 (65.1 %), and 134 (12.9 %) met high, intermediate, and low likelihood criteria, respectively. Balloon-assisted ERCP or endoscopic ultrasound-directed transgastric ERCP (EDGE procedure) can be attempted but both require advanced endoscopic expertise. 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. pancreatitis and cholangitis may be life-threatening conditions, Ekmektzoglou K, Apostolopoulos P, Dimopoulos K, et al. 8600 Rockville Pike Technology evaluations provide a review of existing, new, or emerging endoscopic technologies that have an impact on the practice of GI endoscopy. The SAGES clinical spotlight review on laparoscopic common bile duct exploration can be referenced for further discussion [16]. 2016 Jul;48(7):657-83. doi: 10.1055/s-0042-108641. 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. HHS Vulnerability Disclosure, Help The algorithm presented in Fig. 0000007485 00000 n The management of choledocholithiasis depends on the timing of common bile duct stone discovery in relation to the cholecystectomy. ERCP has a success rate of approximately 8090% for ductal clearance with proper expertise. 2020 ASGE. 2020 ASGE. 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]. The revised categorization had a lower sensitivity and higher specificity of 37% and 80%, respectively. This has been increasing in frequency due to the popularity of gastric bypass surgery, and is also seen in patients following gastric resection surgery, Whipple procedure or liver transplantation. In 2019, the American Society for Gastrointestinal Endoscopy (ASGE) guideline on the endoscopic management of choledocholithiasis modified the individual predictors of choledocholithiasis proposed in the widely referenced 2010 guideline to improve predictive performance. 2023 Society of American Gastrointestinal and Endoscopic Surgeons. 0000006934 00000 n Surg Endosc. xref Wang L, Mirzaie S, Dunnsiri T, Chen F, Wilhalme H, MacQueen IT, Cryer H, Eastoak-Siletz A, Guan M, Cuff C, Tabibian JH. Risks associated with ERCP include pancreatitis (1.36.7%), infection (0.65%), hemorrhage (0.32%), perforation (0.11%) and mortality (up to 1%) [10]. A variety of recommendations have been proposed for predicting choledocholithiasis based upon presenting signs, symptoms, initial laboratory studies, and imaging. NIH Consens State Sci Statements. 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. 0000006225 00000 n An updated literature search from PubMed based on the prior published search strategy was performed from October 1, 2019 until March 16, 2021. 2023 May;68(5):2061-2068. doi: 10.1007/s10620-022-07773-5. ASGE classified 58 (8.6 %) additional patients as intermediate, none . Surg Endosc 15:413, Bansal VK, Misra MC, Rajan K, Kilambi R, Kumar S, Krishna A, Kumar A, Pandav CS, Subramaniam R, Arora MK, Garg PK (2013) Single-stage laparoscopic common bile duct exploration and cholecystectomy versus two-stage endoscopic stone extraction followed by laparoscopic cholecystectomy for patients with concomitant gallbladder stones and common bile duct stones: A randomized controlled trial. 3). Guidelines are not a substitute for physicians opinion on individual patients. 0000098091 00000 n Dynamic liver test patterns do not predict bile duct stones. 0000016291 00000 n Patients with choledocholithiasis that present challenges include those with recurrent CBD stones, large or impacted stones, altered gastric or duodenal anatomy such as Billroth II or Roux-en-Y gastric bypass and those presenting with sepsis secondary to acute cholangitis. If the diagnosis of choledocholithiasis is still in question following these tests, magnetic resonance cholangiopancreatography (MRCP) is a non-invasive option, which has a sensitivity of>90% and specificity nearing 100% [4]. Reimagining surgical care for a healthier world. 0000094913 00000 n However, there are a variety of other minimally invasive techniques that can be employed prior to surgical intervention. Serial biochemical testing by using high . When financial guidance is indicated, the most recent coding data and list prices at the time of publication are provided. HHS Vulnerability Disclosure, Help Common bile duct exploration was traditionally performed as an open procedure but can be performed laparoscopically either via a transcystic approach or transductal approach. Each year choledocholithiasis results in biliary obstruction, cholangitis, and pancreatitis in a significant number of patients. Background: Recent guidelines from the European Society of Gastrointestinal Endoscopy (ESGE) and American Society for Gastrointestinal Endoscopy (ASGE) recommend risk stratification according to liver function test (LFT) and abdominal ultrasound in patients with suspected choledocholithiasis. 2017 Sep;86(3):525-532. doi: 10.1016/j.gie.2017.01.039. choledocholithiasis ranges from 5% to 10% in those patients 0000021047 00000 n patients with known choledocholithiasis. Bookshelf Each clinical practice guideline has been systematically researched, reviewed and revised by the guidelines committee, and reviewed by an appropriate multidisciplinary team. 2010;71:19. Add to your cart and watch on-demand on your own device, at a time convenient with your schedule. Management algorithm for patients based on probability of choledocholithiasis. Gastrointest Endosc 82:560565, James TW, Baron TH (2019) Endoscopic ultrasound-directed transgastric ERCP (EDGE): a single-center us experience with follow-up data on fistula closure. An official website of the United States government. A variety of recommendations have been proposed for predicting choledocholithiasis based upon presenting signs, symptoms, initial laboratory studies, and imaging. Systematic review and meta-analysis of the 2010 ASGE non-invasive predictors of choledocholithiasis and comparison to the 2019 ASGE predictors. 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. In this method, energy is delivered directly to a large or impacted stone under direct visualization with the aid of continuous irrigation of the CBD. Lei Y, Lethebe BC, Wishart E, Bazerbachi F, Elmunzer BJ, Thosani N, Buxbaum JL, Chen YI, Bass S, Cole MJ, Turbide C, Brenner DR, Heitman SJ, Mohamed R, Forbes N. J Clin Med. Summary of Evidence. Background/aims: The American Society for Gastrointestinal Endoscopy (ASGE) revised its guidelines for risk stratification of patients with suspected choledocholithiasis. 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. 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 . 2022 Apr;15(2):286-300. doi: 10.1007/s12328-021-01575-4. Gallstone pancreatitis was not associated with the risk for choledocholithiasis. Evaluations are based on a literature review and a search of the MAUDE (U.S. Food and Drug Administration Center for Devices and Radiological Health) database to identify the reported adverse events of a given technology. Surg Endosc. 0000007171 00000 n The choledochotomy can then be closed either primarily using absorbable 40 or 50 sutures or over a T-tube, an antegrade biliary stent or with an external biliary drain depending on the surgeons discretion and the clinical situation depending on the potential risk of post-operative CBD stricture, increased pressure within the CBD leading to bile leak or retained common bile duct stones [16].
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