Gallstone Ileus Following Endoscopic Retrograde Cholangiopancreatography and Endoscopic Sphincterotomy

Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) is the treatment of choice for common bile duct (CBD) stones. Complication rates of 5-15%, and mortality rates of 1.0% have been reported. We report a case of gallstone ileus presenting 12 days after ERCP and ES.     

Hemobilia after Percutaneous Liver Biopsy: Role of Endoscopic Retrograde Cholangiopancreatography and Sphincterotomy

Hemobilia is a rare complication of percutaneous liver biopsy. We present such a case that demonstrates the usefulness of endoscopic retrograde cholangiopancreatography in establishing the diagnosis, the importance of localization of the bleeding site by angiography, and the therapeutic usefulness of arterial embolization for the control of persistent bleeding. Also, we propose a possible indication for endoscopic sphincterotomy in the rare case where retained intrabiliary blood clot causes progressive obstructive jaundice complicated by severe pain and sepsis.     

Pneumomediastinum after Endoscopic Sphincterotomy

Pneumomediastinum is a rare complication of endoscopy that usually indicates free peritoneal or retroperito-neal perforation. We report an unusual case of self-limiting pneumomediastinum after endoscopic sphincterotomy in which there was no radiological evidence of gut wall perforation. We postulate that this was due to interstitial tracking of air from the duodenal wall, and we discuss the possible pathophysiology. This complication should be recognized as distinct from pneumomediastinum associated with perforation, particularly as it appears to be benign and therefore does not require surgical or radiological intervention.     

Gallstone Ileus and Bowel Perforation after Endoscopic Sphincterotomy

Gallstone ileus as a complication of endoscopic sphincterotomy (ES) is exceptional, and this is only the second reported case. The present case is unique in that there was no previous instrumentation to the papilla, the bowel was obstructed and perforated, and the patient survived. This case again points out the danger of performing ES for large common bile duct stones. When a large stone is not extracted after ES, close monitoring is mandatory until unequivocal stone passage through the intestine is proven. In both cases reported so far, the lack of adequate monitoring after failure of stone extraction by ES was critical to the severity of gallstone ileus.     

Evaluation of Endoscopic Naso-biliary Drainage Established without Endoscopic Sphincterotomy for Malignant Obstructive Jaundice

Abstract: Endoscopic naso-biliary drainage (ENBD) without endoscopic sphincterotoyny (ES) was carried out using 7.2 Fr naso-biliary tubes in 36 patients with malignant obstructive jaundice. The success rate of this method was SO .4% (37/16 cases). The effectiveness of ENBD without ES in terms of lowering total bilirubin values was good or excellent in 24 out of 29 cases (82.8%). Complications were observed in 1 out of 37 cases (10.8%);fortunately, none were as severe as perforation or bleeding. After ENBD established without ES serum amylase levels increased makcdly in 7 cases (17.9%), but these increases were transient and decveased vapidly. Endoscopic internal bilio-duodenal drainage established without ES was also successfully performed, using 10 or 12 Fr endoprosthetic tirbes, in 6 cases of malignant obstructive jaundice. Amylase levels after this procedure did not show any significant elevation. This fact suggests that compression of the pancreatic orifice by the naso-biliary tube dose not cause hyperamylaseynia. Endoscopic biliary drainage established without ES is an effective, safe, and simple method which can be applied to patients with malignant obstructive jaundice.     

Common Bile Duct Obstruction Caused by Hydatid Daughter Cysts—Management by Endoscopic Retrograde Sphincterotomy

Four patients with cholestatic jaundice due to ruptured hydatid liver cyst into the biliary tract underwent endoscopic retrograde sphincterotomy with clearance of the bile ducts. Prompt relief of jaundice followed the produced and no complications occurred. After the procedure all patients received medical treatment (Meben-dazole) for 3–4 months and were well at a mean follow-up of 8 months. We conclude that endoscopic retrograde sphincterotomy is a safe and effective treatment for cholestatic jaundice caused by hydatid daughter cysts obstructing the bile ducts. This method may serve as an alternative to surgery in selected, high risk, patients.     

Usefulness of Mechanical Lithotripters in Endoscopic Sphincterotomy

We have been performing bile duct lithotripsy by EST at Kumamoto Regional Medical Center since January 1982. A balloon catheter is the method of choice for performing lithotripsy. For stone removal, a conventional FG-22Q basket catheter was used from January 1982 to June 1984 (extraction rate: 88.5%), and a prototype EML BML-1Q basket catheter was used with a FG-22Q basket catheter from July 1984 to April 1990 (extraction rate: 91.5%). Since May 1990, lithotripsy has been performed in the following sequence with excellent results (extraction rate: 97.0%): EST-balloon catheter, slide-type EML BML-3Q-balloon catheter. Although the difference between the extraction rates for BML-1Q and BML-3Q basket catheters were only marginally significant, the difference between the conventional basket FG-22Q and BML-3Q was clearly significant. Lithotomy using the procedure employed since May 1990 is therefore recommended as a highly effective means of extracting gallstones and is considered to be superior to conventional methods.     

An Alternative Procedure for Endoscopic Sphincterotomy in Patients with Billroth II Gastrectomy

An EST was performed on 33 patients with choledocholithiasis and a previous Billroth II gastrectomy according to an alternative technique, using a cannula as a cutting guide. This seems to be an easy and safe technique which may be used in cases in which the deep cannulation of the common bile duct is possible.     

Endoscopic Sphincterotomy in the Management of Biliary-Cutaneous Fistula

Endoscopic sphincterotomy was performed on two patients who had biliary-cutaneous fistula after cholecystectomy. The outcome was favorable. The author recommends this procedure as a desirable alternative to laparotomy with secondary biliary surgery.     

Role of Endoscopic Retrograde Cholangiopancreatography after Orthotopic Liver Transplantation

We reviewed the records of 20 liver transplant patients who underwent 28 procedures [endoscopic retrograde cholangiopancreatography (ERCP)] to rule out biliary obstruction, treat bile leaks, dilate and/or stent strictures, or remove stones and debris. Three patients (two with abnormal T-tube cholangiograms and one with hyperbilirubinemia) underwent ERCP to rule out obstruction. Therapeutic ERCP (sphincterotomy with balloon dilatation or stone extraction) was successful in 16 of 17 patients, including seven of nine in whom there was resolution of bile leaks without the use of stents or surgery. Mild pancreatitis occurring in one patient was the only complication experienced that was related to ERCP. We conclude that ERCP is a safe and important modality in the medical management of biliary tract complications after orthotopic liver transplantation.     

Effect of Endoscopic Sphincterotomy on Gallbladder Motility

In experimental animals, sphincterotomyfacilitates passage of solids from the gallbladder andinhibits gallstone formation apparently by improvementin gallbladder emptying. In humans, however, gallbladder emptying has not been studied followingendoscopic sphincterotomy (ES) in patients withgallstones. We therefore prospectively studied restingand cerulinstimulated gallbladder volumes by real timeultrasonography in 15 patients of choledocholithiasis withgallbladder in situ (eight with and seven withoutgallbladder calculi) before and after (after bile ductclearance) ES. ES significantly lowered restinggallbladder volume (21.2 ± 10.6 vs 11.1 ±5.0; P < 0.0001) and cerulin-stimulated residualgallbladder volume (10.8 ± 5.6 vs 4.4 ±2.1; P < 0.0001). ES also significantly increased thegallbladder ejection fraction (47.3 ± 12.1% vs 58.8 ± 11.1%; P < 0.0001). Therate constant for gallbladder emptying after cerulininfusion also increased significantly after ES(–0.022/min vs –0.031/ min; P < 0.0001).Significant improvement in gallbladder motility was observed in both groups ofpatients with and without gallbladder calculi. ESsignificantly improves gallbladder motility inhumans.     

Immediate or Interval Endoscopic Papillary Large-balloon Dilation after Limited Endoscopic Sphincterotomy for Bile Duct Stone Removal

Objective Endoscopic papillary large-balloon dilation (EPLBD) with limited endoscopic sphincterotomy (EST) is widely used for removing multiple large common bile duct (CBD) stones. However, the safety and effectiveness of immediate EPLBD after limited EST and EPLBD at an interval after limited EST is unclear. Thus, this multicenter retrospective study was conducted to examine this matter. Methods Propensity score-matching was performed to adjust the baseline characteristics between the immediate and interval EPLBD groups. We compared the incidence of post-endoscopic retrograde cholangiopancreatography (ERCP) complications and the early outcomes of ERCP between the 2 matched groups, which comprised 66 patients each. Results The complete stone clearance rate in each study group was 100%. The overall incidence of post-ERCP complications in the propensity score-matched interval and immediate EPLBD groups was 3/33 (9.1%) and 1/33 (3.0%), respectively (p=0.61). The immediate EPLBD group had significantly fewer mean ERCP sessions for complete stone removal and a significantly lower rate of endoscopic mechanical lithotripsy (EML) usage than the interval EPLBD group [1.6 vs. 2.4 sessions, p<0.001; and 4/33 (12.1%) vs. 12/33 (36.4%), p=0.042, respectively]. Conclusion The incidence of post-ERCP complications in the immediate EPLBD group was not significantly different from that in the interval EPLBD group. Compared with interval EPLBD, immediate EPLBD may result in a reduced number of ERCP sessions for complete stone clearance and reduce the rate of EML usage.