Endoscopic sphincterotomy for bile duct stones in patients with intact gallbladders

Endoscopic sphincterotomy was performed in 121 patients (age ranged 34-92 years; median 80 years) with intact gallbladders and bile duct stones. Clearance of the duct by basket or balloon extraction was attempted in 97 patients (80 per cent) and achieved in 93 of these patients (96 per cent). In 24 patients the duct was left to empty spontaneously and this occurred in 22 patients. Immediate complications due to endoscopic sphincterotomy occurred in five patients (two haemorrhage, two perforation, one haemorrhage and perforation). Of the 101 patients reviewed 12-72 months (median 24 months) after endoscopic sphincterotomy, 76 (75 per cent) have remained asymptomatic throughout the follow-up period. Eighteen patients (18 per cent) required cholecystectomy for recurrent gallbladder symptoms 1-24 months after endoscopic sphincterotomy. One of the asymptomatic patients underwent cholecystectomy on the advice of his consultant. A further seven had recurrent biliary colic or cholangitis necessitating enlargement of the sphincterotomy and further stone retrieval in three of these patients. Endoscopic sphincterotomy is an effective treatment for bile duct stones in high risk patients, but subsequent cholecystectomy is required in a significant number of patients owing to continuing gallbladder symptoms.     

Endoscopic sphincterotomy for common bile duct stones: Impact of recent technical advances

Technical improvements, such as mechanical lithotripsy, stenting or nasobiliary drainage, and wire-guided cannulation, have reduced the risk of complications in endoscopic sphincterotomy. To determine the extent of this reduction in risk, we assessed the medical records of 1352 patients with common bile duct stones in whom the procedure was conducted. Complications examined were: acute cholangitis and pancreatitis. Stone clearance was achieved in 1256 patients (92.8%), with an overall morbidity rate of 7.7% and a mortality rate of 0.15%. One hundred and forty-two patients had stones with a diameter greater than 20mm; 97 of these patients did not undergo lithotripsy. Cholangitis occurred in 10 of these 97 patients (10.3%), whereas, in the 45 patients who underwent lithotripsy, there were no cases of cholangitis (P=0.02). Stone removal was not immediately accomplished or attempted in 396 patients. In 82 of these patients in whom a stent or a nasobiliary drain was placed in the common bile duct, the incidence of cholangitis was 1.2%, significantly less (P=0.045) than the incidence of 6.4% in the other 314 patients given no stenting or nasobiliary drain. To overcome difficult cannulation, precut sphincterotomy was conducted in 134 patients and wireguided sphincterotomy, a recently introduced procedure, was conducted in 55 patients. When the precutting technique was used, the incidence of acute pancreatitis was significantly higher (8/134; 6.0%) than that in the patients in whom the standard procedure was conducted, i.e., neither the precut technique nor wire-guided ES was used (23/1218; 1.9%) (P=0.008). There were no cases of pancreatitis in the 55 patients in whom wire-guided sphincterotomy was performed, although the difference was not statistically significant because of the small number of patients (P=0.06). Based on these findings, we conclude that improved technologies have led to a significant reduction of complications in endoscopic sphincterotomy.     

Endoscopic sphincterotomy for bile duct stones: an institutional review of 272 patients

The results of the first 283 endoscopic sphincterotomies (ES) attempted in Oxford for bile duct stones are described. Endoscopic sphincterotomy was achieved in 272 patients (96%) and complete duct clearance was achieved in 88% of these patients; an overall success rate of 85%. Complications occurred in 26 patients (10%), five of whom required an emergency laparotomy. Eight patients died within 30 days of ES but only two deaths were attributed directly to the procedure. Although the sphincterotomies were performed by several endoscopists in varying stages of training, the results are similar to those from other large reports. In the last year of the study (1987), 58 patients were referred from within the Oxfordshire District which suggests an annual demand for ES for bile duct stones of 11 patients per 100,000 of population.     

Endoscopic sphincterotomy and mechanical basket lithotripsy for management of difficult common bile duct stones

Endoscopic sphincterotomy (EST) for removal of stones is a major therapeutic advance in the management of choledocholithiasis. However, this technique, using a standard Dormia basket or balloon catheters, often fails with large stones (exceeding 15mm in diameter). Mechanical basket lithotripsy (MBL) has been developed to overcome this deficiency. With recently improved devices, consisting of an entirely, i.e., one self-contained system which can be used without removing the endoscope, the overall efficacy of stone removal is more than 93%, regardless of the size of the stones. This MBL is a simple, safe, effective and inexpensive procedure in experienced hands and has emerged as the procedure of choice for endoscopic management of difficult stones.     

Endoscopic removal of common bile duct stones without subsequent cholecystectomy

Good results from endoscopic sphincterotomy (EST) for removing choledochal stones following cholecystectomy, have led to increasing use of the method when the gallbladder is in situ. The need for cholecystectomy after successful EST has been questioned. As cholecystectomy in elderly patients involves substantial risk, we routinely defer cholecystectomy in such patients while they remain asymptomatic. Experience of 40 cases is reported. Thirty-four were discharged without cholecystectomy and one underwent elective cholecystectomy at his own request. The remaining 33 patients were followed up for 6-53 (mean 21.5) months. Four died from causes unrelated to gallstone disease. Symptoms requiring cholecystectomy arose in two cases (6%). We found no problems due to refraining from routine elective cholecystectomy following EST for common bile duct stones. The rarity of later symptoms appears to justify a "wait and see" attitude to post-EST cholecystectomy.     

Endoscopic sphincterotomy for common bile duct stones during laparoscopic cholecystectomy is safe and effective

Management strategy for common bile duct (CBD) stones is controversial with several treatment options if stones in the CBD are recognized intraoperatively. The aim of this study was to report our experience with same-session combined endoscopic-laparoscopic treatment of gallbladder and CBD stones. We retrospectively evaluated 31 patients with cholecystolithiasis and CBD stones undergoing same-session combined endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and endoscopic stone extraction and laparoscopic cholecystectomy. Same-session ERCP and sphincterotomy were performed in all patients, and stone extraction was successfully performed in 29 patients (93%) with 2 failures (7%) due to impacted stones. In 8 patients (26%), the laparoscopic procedure was converted to open cholecystectomy because of dense adhesions or unclear anatomy. Two patients (7%) developed mild pancreatitis postoperatively and no other morbidity or mortality. In conclusion, same-session ERCP with stone extraction and laparoscopic cholecystectomy seems to be a safe and effective treatment strategy for CBD stones.     

Transduodenal endoscopic sphincterotomy and extraction of bile duct stones

Retained and recurrent common bile duct stones have required surgical treatment. Recent advances in endoscopy, however, have made possible endoscopic management of choledocholithiasis. This report describes the method of endoscopic sphincterotomy and the results in 562 patients with choledocholithiasis in whom the procedure was attempted during the past 4 years. Endoscopic sphincterotomy was successfully accomplished in 523 patients (93%). There were 428 patients with retained or recurrent common bile duct stones after cholecystectomy. In 95 high-risk patients with choledocholithiasis and cholelithiasis, endoscopic sphincterotomy was carried out to relieve jaundice. In 188 patients the stones passed spontaneously after sphincterotomy. In 306 patients, the stones were extracted. Residual stones remained in 29 patients. Complications consisting of bleeding, retroperitoneal perforation, pancreatitis, cholangitis, and stone impaction occurred in 36 patients (6.9%). In 10 patients (1.9%), complications made emergency surgery necessary and resulted in 5 deaths for a mortality rate of 1%. The good results, low morbidity, and low mortality of endoscopic sphincterotomy support the suggestion that this method of treatment has earned a firm place in modern biliary surgery.

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Résumé Les calculs cholédociens oubliés ou récidivants exigeaient, il y a peu temps encore, un traitement chirurgical. Mais la lithiase cholédocienne peut actuellement être traitée par endoscopie. Ce rapport décrit la technique de la sphinctérotomie endoscopique et les résultats obtenus chez 562 malades atteints de lithiase cholédocienne et traités au cours des 4 dernières années. La sphinctérotomie endoscopique a été réalisée avec succès chez 523 patients (93%), dont 428 avec calculs oubliés ou récidivants après cholécystectomie. Chez 95 malades à haut risque, atteints de lithiase vésiculaire ou cholédocienne, la sphinctérotomie endoscopique a été faite pour lever l'obstruction biliaire. Dans 188 cas, les calculs ont été éliminés spontanément après sphinctérotomie. Dans 306 cas, ils ont été extraits. Chez 29 patients, les calculs n'ont pas été éliminés du cholédoque. Des complications ont été observées chez 36 malades (6.9%); elles ont consisté en hémorragie, perforation rétropéritonéale, pancréatite, angiocholite et enclavement des calculs. Dans 10 cas (1.9%), ces complications ont exigé une thérapeutique chirurgicale d'urgence, avec 5 décès (1%). Les bons résultats, la mortalité et la morbidité faibles démontrent que la sphinctérotomie endoscopique a sa place dans la chirurgie biliaire moderne.

     

Endoscopic versus surgical treatment of downstream pancreatic duct stones in chronic pancreatitis

Pancreatic duct stone is thought not only to be the cause of abdominal pain but also to be a risk factor for pancreatic cancer. Several treatment options have been implemented in the treatment of pancreatic duct stones. Stone location is a critical factor in selecting treatment. We present the results of 27 endoscopic treatments and 35 surgical treatments performed in three hospitals at a single university between January 2000 and January 2005. The results were compared retrospectively in terms of success rate of stone removal, length of hospital stay, complications, pain relief, and changes of pancreatic functions. In our study, endoscopy resulted in a similar success rate of stone removal and short-term pain relief rate as the surgical approach and with a shorter length of hospital stay. However, the surgical group had a more favorable long-term clinical result, as well as a lower number of hospital readmissions at the 5-year follow-up point. Based on long-term results, surgical treatment is more effective than endoscopy.     

Endoscopic sphincterotomy for common bile duct calculi

A series of 74 patients having endoscopic sphincterotomy for common bile duct calculi is reported. Complete stone extraction was achieved in 53 cases (72%). Seventeen of 21 patients with retained calculi following recent biliary surgery had successful extractions (80%). Of 30 patients having had a cholecystectomy, 21 (70%) were successful, but only 15 of 23 patients with obstructive jaundice and no previous biliary surgery had the ducts cleared of calculi. Failure was due to multiple stones in the duct, or calculi too large to pass through the sphincterotomy. Endoscopic sphincterotomy is advocated in patients with obstructive jaundice due to stones, moving to early surgery should it prove unsuccessful. The results in patients with a T-tube in situ are comparable to extraction of the calculi along the T-tube tract.     

Endoscopic management of bile duct stones

Endoscopic sphincterotomy is the procedure of choice for choledocholithiasis in patients who have had a cholecystectomy. The bile duct is cleared of stones in about 80 to 90 percent of patients. Available data, largely retrospective, suggest that surgery and endoscopic sphincterotomy are about equal with respect to removal of stones, morbidity, and mortality. Certain technical problems are discussed, including inability to insert the papillotome, the large stone, and problems relating to anatomy such as peripapillary diverticulum and prior gastrectomy. The treatment of patients with bile duct stones who have not had a cholecystectomy, with and without cholelithiasis, is controversial. Endoscopic sphincterotomy without subsequent cholecystectomy is adequate treatment for the majority of patients who are unfit for surgery, even if there are stones in the gallbladder, provided they are asymptomatic after endoscopic removal of stones from the bile ducts. Endoscopic sphincterotomy has been performed in the treatment of gallstone-induced pancreatitis, acute obstructive cholangitis, and sump syndrome. The complication rate for endoscopic sphincterotomy ranges from 6.5 to 8.7 percent, with a mortality rate of 0 to 1.3 percent. The most common serious complications are perforation, hemorrhage, acute pancreatitis, and sepsis.     

Routine early endoscopic cholangiography, sphincterotomy and removal of common duct stones in acute gallstone pancreatitis.

OBJECTIVE--To study the efficacy, safety and timing of endoscopic retrograde cholangiography (ERC) and sphincterotomy in patients with acute gallstone pancreatitis. DESIGN--Open study in Tampere University Hospital, Finland. SUBJECTS--45 consecutive patients with acute gallstone pancreatitis who underwent ERC, with or without sphincterotomy. MAIN OUTCOME MEASURES--The results of early, compared with late, ERC with or without sphincterotomy. RESULTS--ERC was successful in all 45 patients. Ampullary impacted stone was found in eight. Common duct stones were found in 21 (47%) and sphincterotomy was successful in 19 of these (90%). Nine patients developed complications (20%), five of the nine in whom severe disease had been predicted (56%) and four of the 36 in whom mild disease had been predicted (11%, p < 0.01). Three patients required operations for necrotising pancreatitis, in two of whom sphincterotomy had failed. There was no difference in outcome between the 21 patients who had ERC with or without sphincterotomy within 72 hours (median 48 h) of the onset of symptoms and the 24 in whom it was delayed for a median of 144 hours. CONCLUSION--ERC and sphincterotomy may be done safely as a routine in patients with acute gallstone pancreatitis, and delay for a median of six days (range 3-14) from the onset of symptoms did not seem to affect the outcome in our patients.     

Early postoperative endoscopic sphincterotomy for retained common duct stones

The results of endoscopic sphincterotomy in 30 patients with retained common bile duct stones and a T-tube in situ following surgical exploration of the common bile duct are presented. Successful stone extraction was achieved in 27 cases (90%). There was one death, which was not procedure related. Early postoperative T-tube cholangiography is advocated and if necessary sphincterotomy can be safely performed 1 week following surgery. This approach has advantages in shortening hospital stay and minimising patient discomfort.     

经内镜乳头气囊扩张术治疗胆总管结石102例分析

目的分析经内镜气囊扩张治疗胆总管结石的疗效和近期并发症。方法回顾性分析2003年3月至2009年5月经内镜气囊扩张治疗胆总管结石102例的疗效及并发症的防治。结果本组取石成功率为98.0%。术后出现一过性高淀粉酶血症11例,其中急性胰腺炎5例(4.9%),经药物治疗后痊愈。无一例发生胆道感染、出血、穿孔等严重并发症。结论经内镜气囊扩张治疗胆总管结石疗效好,并发症发生率低,是安全、有效的微创治疗措施。     

乳头括约肌小切开加大口径柱状气囊扩张治疗胆总管结石的价值

目的探讨采用内镜下乳头括约肌小切开加大口径气囊扩张(ESBD)治疗胆总管结石的有效性及并发症。方法将90例肝外胆管结石且胆管直径13 mm的患者,随机分成3组各30例,EST(内镜下乳头括约肌切开)组、EPBD(内镜下乳头柱状气囊扩张术)组、ESBD组,再行取石治疗。观察3组病例的结石清除率、结石清除时间、多次取石数、碎石器使用率及并发症等情况。结果 EST、EPBD和ESBD组I期结石清除率分别为96.7%(29/30)、90.0%(27/30)和100%(30/30)(P=0.160),结石清除时间分别为(21.50±6.69)min、(22.97±6.62)min和(17.77±4.37)min(P=0.004),碎石器使用率分别为36.7%、30.0%和10.0%(P=0.048),多次取石数分别为23、25和16例(P=0.027)。3组近期并发症差异无统计学意义;远期并发症分别为8、4和1例(P=0.036)。结论内镜下乳头括约肌小切开加大口径气囊扩张是清除胆总管结石的有效方法,尤其适合于胆总管巨大结石或行乳头切开取石困难者。