Risk factors predictive of late complications after endoscopic sphincterotomy for bile duct stones: long-term (more than 10 years) follow-up study

OBJECTIVE: Widespread use of laparoscopic cholecystectomy has extended the indications for endoscopic sphincterotomy (ES) to young patients with choledocholithiasis; however, long-term results of ES and risk factors for late complications are largely unknown. METHODS: Between 1977 and 1990, 145 patients aged 60 yr or younger underwent ES for choledocholithiasis. Long-term outcomes of ES were investigated in the year 2000, and prognostic factors for late complications were multivariately analyzed. RESULTS: Long-term information was available in 135 cases (93.1%), with a median overall follow-up duration of 14.5 yr (range, 6.5-22.3 yr). There were neither biliary malignancies nor deaths attributable to biliary disease. Sixteen patients (11.9%) developed late complications, including choledochal complications (stone recurrence and/or cholangitis; 14 patients) and acute cholecystitis (two of 32 patients with the gallbladder in situ). Multivariate analysis identified two independent risk factors for choledochal complications: bile duct diameter > or = 15 mm and brown pigment stones at the initial ES. Choledochal complications were endoscopically manageable. All recurrent stones were brown pigment stones. CONCLUSIONS: Approximately 12% of patients develop late complications after ES, but retreatment with ERCP is effective. ES is a reasonable alternative even in young patients with choledocholithiasis. Careful follow-up is necessary, however, particularly for patients with a dilated bile duct or brown pigment stones.     

Small gallstones are associated with increased risk of acute pancreatitis: potential benefits of prophylactic cholecystectomy?

OBJECTIVES: Pancreatitis is a severe complication of gallstone disease with considerable mortality. Small gallstones may increase the risk of pancreatitis. Our aims were to evaluate potential association of small stones with pancreatitis and potential beneficial effects of prophylactic cholecystectomy. METHODS: Stone characteristics were determined in patients with biliary pancreatitis (115), obstructive jaundice due to gallstones (103), acute cholecystitis (79), or uncomplicated gallstone disease (231). Sizes and numbers of gallbladder and bile duct stones were determined by ultrasonography and endoscopic retrograde cholangiopancreatography, respectively. Effects of prophylactic cholecystectomy were assessed by decision analyses with a Markov model and Monte Carlo simulations. RESULTS: Patients with pancreatitis or obstructive jaundice had more and smaller gallbladder stones than those with acute cholecystitis or uncomplicated disease (diameters of smallest stones: 3 +/- 1, 4 +/- 1, 8 +/- 1, and 9 +/- 1 mm, respectively, p < 0.01). Bile duct stones were smaller in case of pancreatitis than in obstructive jaundice (diameters of smallest stones: 4 +/- 1 vs 8 +/- 1, p < 0.01). Multivariate analysis identified old age and small stones as independent risk factors for pancreatitis. Decision analysis in a representative group of patients with small (相似文献   

Risk factors for acute biliary pancreatitis

BACKGROUND: Few studies have analyzed both stone-related and pancreatobiliary anatomical factors that predispose to acute biliary pancreatitis. Both of these factor types were studied by multivariate analysis. METHODS: A total of 143 patients with (n=43) or without (n=100) recent acute biliary pancreatitis who underwent cholecystectomy for gallbladder stones after ERCP were prospectively studied. The interval between the onset of pancreatitis and ERCP ranged from 12 to 35 days (mean, 20 days). Univariate and multivariate analyses for 15 potential risk factors for acute biliary pancreatitis, including operative and ERCP findings, were performed. RESULTS: Univariate analysis identified 5 significant predictive factors for pancreatitis: a diameter of the smallest gallbladder stone of 5 mm or less, a cystic duct diameter of 5 mm or more, 20 or more gallbladder stones, a diameter of the largest gallbladder stone of 5 mm or less, and irregular gallstone surface. Of these 5 factors, the first 3 remained significant in the multivariate analysis. CONCLUSIONS: Both stone-related factors (small and multiple stones) and an anatomical factor (enlarged cystic duct) may contribute to the development of biliary pancreatitis. These features should be carefully considered during management of patients with gallstones.     

Cholecystectomy improves long-term success after endoscopic treatment of CBD stones

BACKGROUND/AIMS: The aim was to study prospectively primary endoscopic treatment of CBD stones and further the long-term need for renewed gallstone disease interventions, defined as short- and long-term outcome. METHODOLOGY: Seven years prospective follow-up of 101 consecutive patients with CBD stones who underwent endoscopic treatment with the intent of primarily achieving duct clearance. RESULTS: Many patients underwent several endoscopy sessions before stone clearance was completed in 83%. Eleven patients were treated surgically, 2 patients received a permanent stent, and the remaining 3 became stone free with other means. Complications occurred in 47 patients. During follow-up, 31 patients were readmitted for gallstone disease and 15 of these had recurrent CBD stones. Ten percent (8/78) of patients with the gallbladder in situ had acute cholecystitis during follow-up and late cholecystectomy was carried out in 22%. Risk factors for new gallstone disease were an in situ gallbladder containing stones and previous episodes of CBD stones. CONCLUSIONS: A goal of complete CBD stone clearance with ERC and ES proved to be relatively resource consuming. Subsequent cholecystectomy after duct clearance for CBD should be advised when the gallbladder lodges gallstones, especially in younger patients. Recurrent CBD stones were not influenced by cholecystectomy.     

Choledocholithiasis and gallstone pancreatitis

Gallstones are commonly found within the main bile duct (MBD) of patients undergoing cholecystectomy. Retained MBD stones are a common cause of obstructive symptoms and complications. Endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy (ES) is the recommended modality for both the detection of such stones and their extraction. Recent trials of ERCP in conjunction with laparoscopic cholecystectomy suggest that it should be reserved for use post-operatively. Gallstones within the MBD are the most common single cause of acute pancreatitis. Initial treatment is supportive, although new agents designed to suppress the systemic inflammatory response are under development and have proved beneficial in clinical trials. Severe cases should be treated with systemic antibiotics and early removal of the obstructing stones by ERCP and ES. Prophylactic cholecystectomy is recommended to prevent further attacks of gallstone pancreatitis.     

Endoscopic sphincterotomy in the management of bile duct stones in children

OBJECTIVE: Endoscopic sphincterotomy (ES) is a widely accepted method of extracting bile duct stones (BDS) in young as well as in elderly patients. The present study was undertaken to assess the safety and efficacy of ES for the treatment of BDS in children, seven of whom were critically sick because of suppurative cholangitis or pancreatitis. METHOD: Over a period of 33 months, ES was performed in 16 consecutive children aged 7-16 yr with BDS. Nine patients had gallbladder in situ, and seven had previously undergone cholecystectomy. The coexisting abnormalities were gallstones and hepatic duct stones in one patient each and dead fragmented roundworms in 11 patients. Seven (five with an intact gallbladder and two cholecystectomized) patients presented with severe complications of BDS such as severe cholangitis in six and acute severe pancreatitis in one. RESULTS: ES was technically successful in all patients, and complete stone extraction was achieved in 15 (93.8%) patients. Complications were minor bleeding in one (6.3%) patient without mortality. One patient with coexisting gallstones underwent cholecystectomy at a later date. During a mean follow-up period of 4-32 months, one patient developed recurrent biliary symptoms because of biliary ascariasis. CONCLUSIONS: We conclude ES is a safe and an effective method of treating BDS in children with previous cholecystectomy, and in those presenting with severe complications of BDS, such as pyogenic cholangitis or acute pancreatitis regardless of the presence of gallbladder.     

Do patients with recurrent choledocholithiasis after endoscopic sphincterotomy benefit from regular follow-up?

BACKGROUND: As many as 24% of patients who undergo endoscopic sphincterotomy for the removal of bile duct stones have recurrent biliary complications develop for which there is no effective method of prevention. The aim of this study was to determine whether patients who undergo routine clinical follow-up after endoscopic sphincterotomy for bile duct stones have a different outcome than those who do not. METHODS: All patients who had endoscopic sphincterotomy for bile duct stones were scheduled for follow-up visits, liver function tests, and transabdominal US every 3 to 6 months. ERCP was performed whenever symptoms recurred, or abnormal liver function or US was noted. The patients themselves decided whether to adhere to the follow-up schedule; this was not a randomized trial. RESULTS: Seven hundred sixty-seven patients underwent endoscopic sphincterotomy for bile duct stones from October 1990 to July 1999. Seventy-seven (10%) were found to have recurrent bile duct stones. Three patients who had undergone Billroth II gastrectomy were excluded. Among the remaining 74 patients (52 men, 22 women; mean age 65 years), 42 (57%) had a juxtapapillary diverticulum and 21 (28%) an intact gallbladder. The mean time to recurrence of bile duct stones was 19.7 months (range 5-72 months). Sixty-four patients (87%) had recurrent bile duct stones within 3 years. Fifty-one (69%) were followed regularly (Group A) and 23 (31%) were not (Group B). At the time of stone recurrence, 20 patients in Group A (39%) and 1 in Group B (4%) were asymptomatic (p = 0.002). Liver function tests were normal in 17 patients (13 Group A, 4 Group B). Endoscopic treatment for recurrent bile duct stones was successful in 46 patients (90%) in Group A and 16 (70%) in Group B (p = 0.04); surgical treatment was successful in all 5 patients in Group A and 4 of the 7 patients in Group B. Two patients in Group B were treated by nasobiliary drainage and biliary endoprosthesis insertion caused by extremely large stones and poor condition; both died (acute pancreatitis and sepsis). CONCLUSION: Regular follow-up after endoscopic sphincterotomy detects recurrent bile duct stones early and thus avoids complications of bile duct stones.     

ENDOSCOPIC SPHINCTEROTOMY ALONE IN THE MANAGEMENT OF LOW‐GRADE BILIARY LEAKS DUE TO CHOLECYSTECTOMY

Aim: Endoscopic retrograde cholangiopancreatography (ERCP) is important in the diagnosis and management of postoperative bile leaks. Endoscopic sphincterotomy (ES) alone, ES with stent or nasobiliary drain (NBD) placement and stent or NBD without ES are the methods of choice. In the present study, we aimed to show the efficacy of ES alone in the management of low‐grade (LGL) cystic duct stump (CDS) leaks due to cholecystectomy. Methods: Between September 2005 and January 2008, ES was carried out on 31 patients with LGL from the CDS due to cholecystectomy who were referred to the endoscopy unit of Izmir Ataturk Training and Research Hospital. Biliary leakage was detected by biliary discharge from a tube drain inserted during the operation. In cases of retaining common bile duct stones, balloon extraction was carried out. If bile discharge continued, a stent was introduced for cessation of the leak as a second procedure. Results: The success rate of ES alone was 87.1% (27 of 31 patients). In four patients (12.9%), ES alone was inadequate, therefore a stent was placed. The biliary leak ceased gradually and stopped in all patients at a mean of 11 (7–21) days. Balloon extraction of retained stones was carried out in six patients (19.6%). In two (6.5%) patients, mild hemorrhage and in two patients self‐limited pancreatitis was seen (6.5%) as complications. Conclusion: Endoscopic retrograde cholangiopancreatography is essential in the management of postoperative biliary leaks. Endoscopic sphincterotomy alone can be the initial procedure in the treatment of LGL from the CDS due to cholecystectomy.     

Piezoelectric lithotripsy in the treatment of symptomatic gallstone patients. A 12-month follow-up

Between January and May 1989, 65 patients with symptomatic gallbladder stones were treated with extracorporeal piezoelectric lithotripsy (EPL) and supplementary dissolution therapy with oral bile acids. In 98% of the patients, fragmentation of stones was achieved. On average, each patient received 3.18 treatments. In addition to attacks of colic and asymptomatic changes in laboratory parameters, one hematoma of the gallbladder and one of the liver were observed, together with pancreatitis and cholecystitis in two patients each. During the follow-up period, three patients developed symptomatic bile duct stones. An endoscopic retrograde cholangiopancreatography (ERCP) with papillotomy was performed on four occasions, while one female patient had to undergo urgent cholecystectomy for inflammation of the gallbladder and empyema. Six months after the initial treatment, 36 (55%) patients were free of stones, while the stone-free rate after 12 months was 64.5% (41 of 65). Ninety percent of the patients with a solitary stone less than or equal to 2 cm in diameter became stonefree within a year. Extracorporeal piezoelectric lithotripsy is clearly a feasible procedure for the treatment of certain gallstone patients.     

Should elective endoscopic sphincterotomy replace cholecystectomy for the treatment of high-risk patients with gallstone pancreatitis?

Since the introduction of endoscopic sphincterotomy approximately 15 years ago, the indications for this procedure have expanded. Currently endoscopic sphincterotomy is the procedure of choice for management of retained common bile duct stones following cholecystectomy. It is also being used more frequently for choledocholithiasis with an intact gallbladder in high-risk patients and in some patients with acute gallstone pancreatitis. In patients recovering from an episode of gallstone pancreatitis, standard practice has been subsequent cholecystectomy with possible exploration of the common bile duct. To avoid surgery in high-risk patients, we propose that an elective endoscopic sphincterotomy may be a reasonable therapeutic option regardless of whether common bile duct stones are present at the time of ERCP. A prospective trial is needed to examine this issue since to date there is no literature on endoscopic sphincterotomy in the absence of choledocholithiasis for gallstone pancreatitis in patients with intact gallbladders.     

The frequency of bile duct crystals in patients with presumed biliary pancreatitis.

BACKGROUND: Previous studies of biliary microlithiasis in acute pancreatitis of uncertain etiology were conducted a few weeks to months after the acute episode. Bile obtained during urgent ERCP (less than 24 hours after admission) was studied for the presence of microlithiasis during the acute phase of acute pancreatitis of suspected biliary origin. METHODS: Fifteen consecutive patients with acute pancreatitis of suspected biliary origin were recruited from a population of 309 patients with acute pancreatitis (5%) treated during the last 4 years. Patients with gallstones on US and/or ERCP and those in whom the etiology of acute pancreatitis was certain were excluded. RESULTS: Microlithiasis (mostly calcium bilirubinate granules) was found in 12 (80%) cases. Despite endoscopic sphincterotomy 3 patients died within 2 weeks because of multisystemic organ failure. Among the 12 remaining patients, 2 (16%) developed gallbladder stones and 1 underwent cholecystectomy for cholecystitis (8%) during follow-up. The average length of follow-up was 30 months. No episodes of acute pancreatitis were noted during follow-up. CONCLUSIONS: In the acute phase of acute pancreatitis of suspected biliary origin, biliary microlithiasis was found in most cases. Endoscopic sphincterotomy appears to protect patients from further episodes of acute pancreatitis.     

Gallstone-induced acute pancreatitis

In the care of acute pancreatitis, a prompt search for the etiologic condition of the disease should be conducted. A differentiation of gallstone-induced acute pancreatitis should be given top priority in its etiologic diagnosis because it is related to the decision of treatment policy. Examinations necessary for diagnosing gallstone-induced acute pancreatitis include blood tests and ultrasonography. Early ERCP/ES should be performed in patients with gallstone-induced acute pancreatitis if a complication of cholangitis and a prolonged passage disorder of the biliary tract are suspected. The treatment for bile duct stones with the use of ERCP/ES alone is not recommended in cases of gallstone-induced pancreatitis with gallbladder stones. Cholecystectomy for gallstone-induced acute pancreatitis should be performed using a laparoscopic procedure as the first option as soon as the disease has subsided.     

Relapses of biliary acute pancreatitis in patients with previous attack of biliary pancreatitis and gallbladder in situ

AIM: To evaluate relapse of acute pancreatitis in patients with biliary pancreatitis in whom coexisting diseases or patient refusal have excluded cholecystectomy. PATIENTS AND METHODS: Forty-seven patients presenting a first episode of biliary acute pancreatitis underwent urgent endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (ES). RESULTS: ERCP with ES was successful in all but one patient (97.8%) who was then cholecystectomised. Complications related to the endoscopic procedure were reported in five patients (10.6%). During the follow-up period (median time 12 months; range 1-84 months), 10 patients (21%) suffered from biliary complications. Three patients (6.4%), all with lithiasis of the gallbladder, had relapses of acute pancreatitis, two of them within 2 months of the previous episode, and one about a year later after ingestion of a rich meal and alcoholic beverages. The first two were cholecystectomised. Two patients died during the follow-up period from unrelated diseases. CONCLUSIONS: In subjects who are at high risk for anaesthesia, endoscopic procedures may be utilised.     

Endoscopic Retrograde Cholangiopancreatography in Laparoscopic Cholecystectomy

Abstract: With the widespread use of laparoscopic cholecystectomy (LC), the role of pre- and postoperative endoscopic retrograde cholangiopancreatography (ERCP) and / or endoscopic sphincterotomy (ES) has become very important. Indications for ERCP with possible ES before LC include clinical suspicion of a common bile duct (CBD) stone alone, evidence of jaundice, recent cholangitis or pancreatitis that is probably due to a duct stone or dilated CBD. Local endoscopic and surgical expertise are important factors in deciding the approach to the pre-LC patients. The success rate of ductal clearance of stones by ES approaches 90 to 95% in expert hands. ERCP is very effective in the management of post-LC patients with symptoms, as well as in diagnosing and treating complications such as retained stones, ductal leaks and strictures.     

Role of ERCP and Therapeutic Biliary Endoscopy in Association with Laparoscopic Cholecystectomy

Laparoscopic removal is rapidly becoming the preferred method of cholecystectomy; however, choledocholithiasis cannot usually be managed with a laparoscopic approach. Combined endoscopic sphincterotomy and laparoscopic cholecystectomy is a potential solution to this problem. To determine the feasibility of this combined procedure we studied 41 patients who had both endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy. Indications for ERCP included jaundice, gallstone pancreatitis, dilated ducts on sonography, elevated liver enzymes, or stones seen on operative cholangiography. Twenty-eight patients had ERCP preoperatively. Nine patients had common duct stones; these were successfully removed from eight patients after sphincterotomy. Two patients had unexpected strictures requiring a change in surgical approach. Thirteen patients had ERCP postoperatively. Eight of those patients had common duct stones, and all were successfully removed following endoscopic sphincterotomy. Three patients had postoperative strictures, one of which was treated by endoscopic stent placement. No complications as a result of ERCP or sphincterotomy were encountered. ERCP and endoscopic sphincterotomy can be safely performed both preoperatively and as early as 1 day postoperatively. If indicators of choledocholithiasis are present, preoperative ERCP is preferred, because stone removal occasionally is unsuccessful, and cholangiographic findings may change the operative approach. Postoperative ERCP can define and, in some instances, treat biliary tract injuries resulting from laparoscopic cholecystectomy.     

Cholecystectomy or gallbladder in situ after endoscopic sphincterotomy and bile duct stone removal in Chinese patients

BACKGROUND & AIMS: In patients with stones in their bile ducts and gallbladders, cholecystectomy is generally recommended after endoscopic sphincterotomy and clearance of bile duct stones. However, only approximately 10% of patients with gallbladders left in situ will return with further biliary complications. Expectant management is alternately advocated. In this study, we compared the treatment strategies of laparoscopic cholecystectomy and gallbladders left in situ. METHODS: We randomized patients (>60 years of age) after endoscopic sphincterotomy and clearance of their bile duct stones to receive early laparoscopic cholecystectomy or expectant management. The primary outcome was further biliary complications. Other outcome measures included adverse events after cholecystectomy and late deaths from all causes. RESULTS: One hundred seventy-eight patients entered into the trial (89 in each group); 82 of 89 patients who were randomized to receive laparoscopic cholecystectomy underwent the procedure. Conversion to open surgery was needed in 16 of 82 patients (20%). Postoperative complications occurred in 8 patients (9%). Analysis was by intention to treat. With a median follow-up of approximately 5 years, 6 patients (7%) in the cholecystectomy group returned with further biliary events (cholangitis, n = 5; biliary pain, n = 1). Among those with gallbladders in situ, 21 (24%) returned with further biliary events (cholangitis, n = 13; acute cholecystitis, n = 5; biliary pain, n = 2; and jaundice, n = 1; log rank, P = .001). Late deaths were similar between groups (cholecystectomy, n = 19; gallbladder in situ, n = 11; P = .12). CONCLUSIONS: In the Chinese, cholecystectomy after endoscopic treatment of bile duct stones reduces recurrent biliary events and should be recommended.     

Late biliary complications after endoscopic sphincterotomy for common bile duct stones in patients older than 65 years of age with gallbladder in situ

The aim of this retrospective study was to evaluate the nature and the frequency of biliary complications after endoscopic retrograde cholangiography for common bile duct stones in elderly patients with gallbladder in situ. METHODS: Between 1991 and 1993, 169 consecutive patients with gallbladder in situ, older than 65 years (79 +/- 8) had an endoscopic retrograde cholangiography with sphincterotomy for choledocholithiasis. Information on the early (<1 month) and late biliary complications, treatment and mortality were obtained by mail or phone calls from patients and general practitioners. Long-term data were obtained for 139 patients (82%). Mean follow-up was 56.5 months (80 months for patients still alive at the end of the study). RESULTS: Early complications occurred in 13 patients (10.8%). Seven patients had acute cholecystitis, present before the procedure in all cases; all were treated by surgery. Other early complications included cholangitis (n =7), mild acute pancreatitis (n =3), bleeding (n =1), perforation (n =1), biliary colic (n =1), pneumopathy (n =1) and bradycardia (n =1), all treated medically. Forty patients underwent early cholecystectomy, and 5 died during the first month without biliary disease. Late complications were thus assessed in 94 patients and occurred in 13 (14%), i.e around 2% per year. Complications were acute cholangitis (n=4), biliary pain (n =4), cholecystitis (n =2), abdominal pain (n =2) and jaundice due to sphincterotomy stenosis (n =1). Five patients had cholecystectomy, 1 a radiological drainage and 7 were treated medically. No death due to a biliary complication was observed. The presence of gallstones, the absence of gallbladder opacification at cholangiography were not prognostic factors for the recurrence of biliary symptoms. 65 patients (50%) died without biliary disease during the follow-up (actuarial death rate 10.5% per year). CONCLUSION: Late biliary complications after endoscopic retrograde cholangiography for choledocholithiasis in patients with gallbladder in situ are rare (2% per year). Prophylactic cholecystectomy after sphincterotomy does not seem warranted in elderly patients, because of rare recurrent biliary symptoms, low mortality rate, and limited life expectancy.     

Acute cholecystitis and cholelithiasis developed after esophagectomy.

BACKGROUND: Although the prevalence of gallstone disease after gastrectomy is reported to be high, its prevalence after esophagectomy is scarcely reported. MATERIALS AND METHODS: Gallbladder disease following an esophagectomy was prospectively evaluated in 237 patients with esophageal cancer by abdominal ultrasonography twice a year up to five years postoperatively. The median follow-up period was 18.6 months. RESULTS: One patient (0.4%) developed acute acalculous cholecystitis postoperatively, and 13 patients (5.5%) developed gallstone disease during the follow-up period. Nine (69%) of these 13 patients developed gallstone disease within two years, and another two patients developed the disease three years after esophagectomy. Another patient developed gallbladder debris at 35 months postoperatively, and one developed gallbladder polyps at 33 months. Seven of the 13 patients with gallstone disease underwent cholecystectomy between 13 and 125 months after esophagectomy: two developed acute cholecystitis; two had associated common bile duct stones; the remaining three patients had upper abdominal pain. Nine of the 13 patients who developed gallstone disease showed a history of alcoholism, whereas only 81 of 224 patients without gallstone disease had a similar history (P<0.05). CONCLUSION: A certain number of patients with esophageal carcinoma and a history of alcoholism develop cholelithiasis within three years after esophagectomy, and subsequently undergo cholecystectomy during the follow-up period.     

Wait-and-see policy versus cholecystectomy after endoscopic sphincterotomy for bile-duct stones in high-risk patients with co-existing gallbladder stones: A prospective randomised trial

Background and study aimsEndoscopic sphincterotomy (ES) is one of the most important advances in the treatment of common bile duct (CBD) stones. However, the use of ES to remove CBD stones in high-risk patients without cholecystectomy is still debatable. The aim of this study was to compare the efficacy of a wait-and-see policy versus cholecystectomy after ES for CBD stones in high-risk patients with co-existing cholelithiasis.Patients and methodsA total of 162 patients after undergoing ES with the clearance of CBD stones were randomised after informed consent to cholecystectomy or conservative management of their gallbladder stones.ResultsThe results indicated that cholecystectomy after ES for CBD stones significantly reduced the biliary complications in high-risk patients.ConclusionEvery patient who has both CBD stones and gallstones with significant co-morbid illnesses, after clearance of CBD stones by ES, should undergo early cholecystectomy.     

Risk factors of acute cholecystitis after endoscopic common bile duct stone removal

AIM:To evaluate the risk factors of acute cholecystitisafter endoscopic common bile duct(CBD)stone removal.METHODS:A total 100 of patients who underwent en-doscopic CBD stone removal with gallbladder(GB)in situwithout subsequent cholecystectomy from January 2000to July 2004 were evaluated retrospectively.The follow-ing factors were considered while evaluating risk factorsfor the development of acute cholecystitis:age,gender,serum bilirubin level,GB wall thickening,cystic duct pa-tency,presence of a GB stone,CBD diameter,residualstone,lithotripsy,juxtapapillary diverticulum,presence ofliver cirrhosis or diabetes mellitus,a presenting illness ofcholangitis or pancreatitis,and procedure-related compli-cations.RESULTS:During a mean 18-mo follow-up,28(28%)patients developed biliary symptoms;17(17%)acutecholecystitis and 13(13%)CBD stone recurrence.Of patients with acute cholecystitis,15(88.2%)re-ceived laparoscopic cholecystectomy and 2(11.8%)open cholecystectomy.All recurrent CBD stones weresuccessfully removed endoscopically.The mean timeelapse to acute cholecystitis was 10.2 mo(1-37 mo)and that to recurrent CBD stone was 18.4 mo.Of the17 patients who received cholecystectomy,2(11.8%)developed recurrent CBD stones after cholecystectomy.By multivariate analysis,a serum total bilirubin level of<1.3 mg/dL and a CBD diameter of <11 mm at the timeof stone removal were found to predict the developmentof acute cholecystitis.CONCLUSION:After CBD stone removal,there is noneed for routine prophylactic cholecystectomy.However,patients without a dilated bile duct(<11 mm)and jaun-dice(<1.3 mg/dL)at the time of CBD stone removal