Post written by Enqiang Linghu, MD, from the Department of Gastroenterology, The First Medical Center of Chinese PLA General Hospital, Beijing, China.

This investigation comprehensively assesses the long-term outcomes of patients experiencing post-ERCP pneumobilia and identifies the risk factors associated with post-ERCP pneumobilia.

Post-ERCP pneumobilia is not uncommon, and its occurrence often indicates disruption of the enterobiliary reflux barrier. However, previous studies have not comprehensively investigated the long-term prognosis of patients with pneumobilia, with most research merely mentioning pneumobilia as a risk factor for recurrent common bile duct stones.

Furthermore, studies referring to pneumobilia have not provided a reliable definition, potentially leading to biased outcomes. A thorough understanding of the long-term prognosis of pneumobilia can help us indirectly grasp whether the disruption of the enterobiliary reflux barrier carries long-term adverse consequences. The disruption of this barrier is not an indicator that is easily and directly measurable. Investigating the long-term prognosis of patients with post-ERCP pneumobilia underscores its significant clinical importance, and exploring the risk factors for pneumobilia informs how to best avoid it.

Our investigation presents novel findings that patients with post-ERCP pneumobilia demonstrate a significantly increased propensity for multiple recurrences of common bile duct stones (32.5% vs 12.5%; P = .032) and an elevated risk of acute cholangitis (32.5% vs 2.5%; P = <.001).

In addition, our analysis identifies independent risk factors for pneumobilia, including periampullary diverticula, common bile duct dilation (diameter of >1 cm), and endoscopic sphincterotomy with moderate and large incisions. Our study enhances understanding of post-ERCP pneumobilia, underscoring the necessity and potential strategies for preventing pneumobilia during ERCP procedures. This insight will aid in adhering to the principle of super minimally invasive surgery during stone extraction via ERCP, which is to treat the disease while preserving the integrity of organs and structures.

Considering the not insignificant incidence of post-ERCP pneumobilia and its associated adverse events, future research should focus on how to protect the sphincter of Oddi and prevent enterobiliary reflux.

In our ongoing work, we are dedicated to preserving the function of the sphincter of Oddi. By using a novel papillary support designed to uphold the duodenal papilla as an outlet for stone removal, our approach avoids sphincterotomy and the sphincter tears associated with balloon dilation. Preliminary measurements of manometry of the sphincter of Oddi indicate that, compared with preoperative values, there is no significant change in sphincter of Oddi pressure 1 week postoperatively, suggesting normal sphincter function. The application of this technique is expected to bring long-term benefits to patients.

Patient selection flow diagram. The PSM analysis was based on the following variables: sex, CBDS diameter, CBD diameter, gallbladder status (cholecystectomy before second ERCP, cholecystectomy after second ERCP, gallbladder in situ with stones, gallbladder in situ without stones), size of EST (small, moderate, large), stone extraction tool (balloon, basket, balloon plus basket), periampullary diverticulum, and number of stones (1, ≥2). CBD, Common bile duct; CBDS, common bile duct stone; EST, endoscopic sphincterotomy; MRI, magnetic resonance imaging; PSM, propensity score matching.

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