Should we redefine large common bile duct stone？

The definition of large stones is not clear ranging from 10 mm to 15 mm and does not include the lower common bile duct （CBD） diameter. Three hundred and four patients who underwent endoscopic retrograde cholangiopancreatography and stone extraction were retrospectively analyzed over a 1-year period, Sixteen patients were different from others in that 10 patients with large stones had stone extraction with a wire basket or a balloon catheter and 6 patients with small stones had stone extraction with mechanical lithotripsy. The definition of large stones should include diameter of the lower CBD and any stone in lower CBD with its diameter greater than 2 mm,     

Could saline irrigation clear all residual common bile duct stones after lithotripsy? A self-controlled prospective cohort study

BACKGROUNDA previous study showed that irrigation with 100 mL saline reduced residual common bile duct (CBD) stones, which potentially cause recurrent stones after endoscopic retrograde cholangiopancreatography.AIMTo determine whether saline irrigation can improve CBD clearance after lithotripsy.METHODSThis prospective self-controlled study enrolled patients receiving mechanical lithotripsy for large (> 1.2 cm) CBD stones. After occlusion cholangiography confirmed CBD stone clearance, peroral cholangioscopy (POC) was performed to determine clearance scores based on the number of residual stones. The amounts of residual stones spotted via POC were graded on a 5-point scale (score 1, worst; score 5, best). Scores were documented after only stone removal (control) and after irrigation with 50 mL and 100 mL saline, respectively. The stone composition was analyzed using infrared spectroscopy.RESULTSBetween October 2018 and January 2020, 47 patients had CBD clearance scores of 2.4 ± 1.1 without saline irrigation, 3.5 ± 0.7 with 50 mL irrigation, and 4.6 ± 0.6 with 100 mL irrigation (P < 0.001). Multivariate analysis showed that CBD diameter > 15 mm [odds ratio (OR) = 0.08, 95% confidence interval (CI): 0.01-0.49; P = 0.007] and periampullary diverticula (PAD) (OR = 6.51, 95%CI: 1.08-39.21; P = 0.041) were independent risk factors for residual stones. Bilirubin pigment stones constituted the main residual stones found in patients with PAD (P = 0.004).CONCLUSIONIrrigation with 100 mL of saline may not clear all residual CBD stones after lithotripsy, especially in patients with PAD and/or a dilated (> 15 mm) CBD. Pigment residual stones are soft and commonly found in patients with PAD. Additional saline irrigation may be required to remove retained stones.     

Recurrence of bile duct stones after endoscopic papillary large balloon dilation combined with limited sphincterotomy: long-term follow-up study

Background/Aims

Endoscopic papillary large-balloon dilation combined with limited endoscopic sphincterotomy (EPLBD+ES) is promising for the treatment of common bile duct (CBD) stones. The aim of this study was to clarify the recurrence rate and the risk factors for CBD stones after EPLBD+ES.

Methods

In total, 100 patients who underwent EPLBD+ES from 2006 to 2007 were evaluated retrospectively. One hundred and nine patients who were treated with endoscopic sphincterotomy (ES) from 2004 to 2005 were set as the historical control group. Various risk factors for the recurrence of bile duct stones were analyzed.

Results

Of the 209 patients, the duration of follow-up was 32.5±4.5 months in the EPLBD+ES group and 31.8±6.0 months in the ES group. The recurrence rate of CBD stones was 11.0% (11/100) in the EPLBD+ES group and 13.8% (15/109) in the ES group (p=0.546). The cumulative recurrence rate of stones was not significantly different between the EPLBD+ES and ES groups (log rank, p=0.537). Univariate analysis showed that the diameter of the CBD (≥22 mm) was the only predictive variable that could differentiate recurrence from nonrecurrence in the EPLBD+ES group. Multivariate analysis revealed that the diameter of the bile duct was the only risk factor for stone recurrence (p=0.022; odds ratio, 1.175; 95% confidence interval, 1.023 to 1.348).

Conclusions

The recurrence rate of CBD stones after EPLBD+ES is comparable to that of the ES group, and a dilated CBD appears to increase the risk of bile duct stone recurrence.     

Prospective study of endoscopic ultrasound performance in suspected choledocholithiasis

Background: The close proximity of the echoendoscope to the extrahepatic bile ductal system and its safety make endoscopic ultrasonography (EUS) an excellent method for examining the common bile duct (CBD). The aim of the present study was to compare EUS diagnostic performance for CBD stones with endoscopic retrograde cholangiography (ERC). Methods: A prospective series of our first 60 patients (65% women, average age 43 years) who were referred for ERC for suspicion of choledocholithiasis based on clinical, biochemical and cross‐sectional imaging (ultrasonography [US] or computed tomography [CT]) data underwent radial EUS. EUS results were recorded as positive or negative for CBD stones before starting the ERC. All patients underwent ERC with a balloon sweep of the bile duct as the standard of reference for CBD stone. All procedures were performed during the same endoscopy session by a single endoscopist who was blinded to the clinical, biochemical and imaging data. Results: Sixty‐five percent of our patients had low to moderate risk for CBD stones. EUS diagnoses were confirmed by ERC as follows: 23 true positive, 33 true negative, three false negative and one false positive (sensitivity of 89%, specificity of 97%, positive predictive value of 96%, and negative predictive value of 92%; overall accuracy of 93%). Compared to the EUS diagnostic accuracy (90%) during the first 30 cases, EUS had a very high diagnostic accuracy (97%) for CBD stones during the last 30 cases (P = 0.31). Conclusion: EUS is highly accurate for the diagnosis of choledocholithiasis. The EUS learning curve is relatively short for CBD stones.     

内镜下机械碎石术治疗胆总管大结石

目的 探讨内镜下机械碎石术治疗胆总管大结石的价值。方法 32例经ERC证实胆总管结石直径≥1．5cm。其中结石直径1．5～1．9cm17例，2．0～2．4cm9例，≥2．5cm6例，单颗结石24例，2颗结石5例，3颗或以上结石3例。先行乳头肌切开，然后使用机械碎石器于胆管内将结石粉碎取出。结果 机械碎石成功31例，成功率96．9％，失败1例。1次碎石取净结石28例，2次3例，3次1例。发生并发症4例，发生率12．5％，其中切口渗血和出血2例，急性胰腺炎1例．急性胆管炎1例，症状均较轻微。结论 对于直径≥1．5cm的胆总管大结石，单纯使用普通取石网篮难以取出，机械碎石术可不受结石大小限制，是理想、有效的碎石取石方法。     

Predictors of unsuccessful mechanical lithotripsy and endoscopic clearance of large bile duct stones

BACKGROUND: Mechanical lithotripsy is used to break large bile duct stones. This study investigated the predictors of unsuccessful mechanical lithotripsy. METHODS: Consecutive patients with bile duct stones underwent endoscopic retrograde cholangiography, sphincterotomy, and basket removal of stones. Mechanical lithotripsy was performed for stones of large size (>15 mm diameter) that precluded extraction intact. Success was defined as complete clearance of the duct. Various predictive factors, including size and number of stones, stone impaction, serum bilirubin, presence of cholangitis, and bile duct diameter were analyzed in relation to the success or failure of lithotripsy. RESULTS: A total of 669 patients underwent endoscopic retrograde cholangiography for suspected choledocholithiasis, which was found in 401 patients. Of the latter patients, 87 had large stones that required mechanical lithotripsy. Lithotripsy was successful in 69 (79%) patients. Impaction of the stone(s) in the bile duct was the only significant factor that predicted failure of lithotripsy and consequent failure of bile duct clearance. Other factors, including stone size, were not significant. CONCLUSIONS: Mechanical lithotripsy is successful in about 79% of patients with large bile duct stones. The only significant factor that predicts failure of mechanical lithotripsy is stone impaction in the bile duct.     

Evaluation of risk factors for recurrent primary common bile duct stone in patients with cholecystectomy

Objectives: Recurrence of primary common bile duct (CBD) stone commonly occurs after complete removal of CBD stones in patients with cholecystectomy. This study aimed to investigate potential risk factors for the recurrence of primary CBD stones after endoscopic treatment.

Materials and methods: Between January 2005 and December 2015, the endoscopic retrograde cholangiopancreatography (ERCP) database of our medical center was retrospectively reviewed; information regarding eligible patients who had recurrent CBD stones with a history of previous cholecystectomy was collected. The characteristics of the patients, CBD stone, CBD and ERCP-related factors were analyzed.

Results: The recurrence rate of CBD stone was 18.5% (115/622) after endoscopic treatment in patients with cholecystectomy. In univariate analysis, the number of CBD stones (≥2), CBD stone diameter (≥10?mm), stone composition, stone consistency, CBD diameter (≥15?mm), bile duct dilatation pattern, sharp bile duct angulation (<145°), balloon dilatation, large balloon (>12?mm) dilatation, endoscopic mechanical lithotripsy, endoscopic sphincterotomy, and endoscopic papillary balloon dilatation alone method were significant between the non-recurrence and recurrence groups. However, in multivariate analysis (based on the binary logistic regression method), the number of CBD stones (≥2) (adjusted odds ratio [AOR] 3.232; 95% confidence interval [CI] 1.344–7.773; p?=?.009), cholesterol stone (AOR 2.824; 95% CI 1.175–6.786; p?=.02) and sharp bile duct angulation (<145°) (AOR 2.462; 95% CI 1.062–5.711; p?=?.036) were independent risk factors of CBD stone recurrence after cholecystectomy.

Conclusions: CBD stone number (≥2), cholesterol stone and sharp bile duct angulation (<145°) are associated with recurrent common bile duct stones after cholecystectomy.     

胆管内超声对胆管结石诊断价值的研究

目的 通过对磁共振胰胆管成像（MRCP）、内镜下逆行胆管造影（ERC）和十二指肠镜下胆管腔内超声（IDUS）对肝外胆管结石诊断作用的比较,评价IDUS对胆管结石的诊断价值.方法 对30例临床怀疑肝外胆管结石的患者,先行MRCP,然后行ERC,同时用经导丝的腔内超声探头行胆管内扫查.IDUS检查完成后,行内镜下取石,证实诊断.结果 30例中,MRCP准确诊断结石22例,将胆管絮状物诊断为结石2例,漏诊2例,其诊断结石的准确性、敏感性、特异性分别为86.7%（26/30）、91.7%（22/24）、66.7%（4/6）;ERC准确诊断结石23例,将胆管积气诊断为结石2例,漏诊1例,其诊断结石的准确性、敏感性、特异性分别为90%（27/30）、92%（23/25）、66.7%（4/6）;IDUS准确诊断结石24例,絮状物4例,气泡2例,无漏诊及误诊,其诊断结石的准确率、敏感性、特异性均为100%.结论 IDUS是一项安全可靠的技术,在确定胆管结石方面优于ERCP和MRCP.     

What Are the Risk Factors for Acute Suppurative Cholangitis Caused by Common Bile Duct Stones?

Background/Aims

Acute suppurative cholangitis (ASC), a severe form of acute cholangitis, is a life-threatening condition that must be treated with appropriate and timely management. The purpose of this study was to identify the factors that predispose patients to ASC.

Methods

We retrospectively investigated 181 patients (100 men, 81 women; age, 70.66±7.38 years, mean±SD) who were admitted to Wonkwang University Hospital between January 2005 and June 2007 for acute cholangitis with common bile duct (CBD) stones. All patients underwent endoscopic retrograde cholangiopancreatogram to remove the stones. Variables and factors that could be assessed upon admission were analyzed to identify the risk factors for the development of ASC.

Results

Of the 181 patients, 44 (24.3%) presented with ASC. On multivariate analysis, the followings were found to be independent risk factors for the development of ASC: impacted common bile duct stone (p=0.010), current smoker status (p=0.008), advanced age (>70 years; p=0.002), and gallstone (p=0.016). The most commonly isolated organisms in bile culture were Enterococcus species, Escherichia coli, and Klebsiella species.

Conclusions

Impacted bile-duct stones, current smoking, advanced age, and gallstones were identified as independent risk factors for the development of ASC in patients with CBD stones. These results suggest that emergency biliary drainage is beneficial in patients with these risk factors.     

Ampulla dilation with different sized balloons to remove common bile duct stones

AIM:To assess the outcomes of ampulla dilation with different sized balloons to remove common bile duct (CBD) stones.METHODS:Patients (n=208) were divided into five groups based on the largest CBD stone size of < 5,6-8,8-12,12-14,and > 14 mm.Patients underwent limited endoscopic sphincterotomy (EST) alone or limited EST followed by endoscopic papillary balloon dilation with 8,10,12 and 14 mm balloons,such that the size of each balloon did not exceed the size of the CBD.Short-and long-term outcomes,such as post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis,perforation,bleeding,and pneumobilia were compared among the five groups.RESULTS:The overall rate of successful stone removal in all groups was 100%,and all patients were cured.Eight (3.85%) patients had post-ERCP pancreatitis,none had perforations,and 6 (2.9%) had bleeding re-quiring transfusion.There were no significant differences in early complication rates among the five groups.We observed significant correlations between increased balloon size and the short-and long-term rates of postERCP pneumobilia.Post-ERCP pancreatitis and bleeding correlated significantly with age,with post-ERCP pancreatitis occurring more frequently in patients aged < 60 years,and bleeding occurring more frequently in patients aged > 70 years.We observed a significant correlation between patient age and the diameter of the largest CBD stone,with stones > 12 mm occurring more frequently in patients > 60 years old.CONCLUSION:Choosing a balloon size based on the largest stone diameter is safe and effective for removing CBD stones.Balloon size should not exceed 15 mm.     

Residual common bile duct stones on direct peroral cholangioscopy using ultraslim endoscope

AIM:To detect and manage residual common bile duct(CBD)stones using ultraslim endoscopic peroral cholangioscopy(POC)after a negative balloon-occluded cholangiography.METHODS:From March 2011 to December 2011,a cohort of 22 patients with CBD stones who underwent both endoscopic retrograde cholangiography(ERC)and direct POC were prospectively enrolled in this study.Those patients who were younger than 20 years of age,pregnant,critically ill,or unable to provide informed consent for direct POC,as well as those with concomitant gallbladder stones or CBD with diameters less than 10 mm were excluded.Direct POC using an ultraslim endoscope with an overtube balloon-assisted technique was carried out immediately after a negative balloon-occluded cholangiography was obtained.RESULTS:The ultraslim endoscope was able to be advanced to the hepatic hilum or the intrahepatic bile duct(IHD)in 8 patients(36.4%),to the extrahepatic bile duct where the hilum could be visualized in 10 patients(45.5%),and to the distal CBD where the hilum could not be visualized in 4 patients(18.2%).The procedure time of the diagnostic POC was 8.2 ± 2.9 min(range,5-18 min).Residual CBD stones were found in 5(22.7%)of the patients.There was one residual stone each in 3 of the patients,three in 1 patient,and more than five in 1 patient.The diameter of the residual stones ranged from 2-5 mm.In 2 of the patients,the residual stones were successfully extracted using either a retrieval balloon catheter(n = 1)or a basket catheter(n = 1)under direct endoscopic control.In the remaining 3 patients,the residual stones were removed using an irrigation and suction method under direct endoscopic visualization.There were no serious procedure-related complications,such as bleeding,pancreatitis,biliary tract infection,or perforation,in this study.CONCLUSION:Direct POC using an ultraslim endoscope appears to be a useful tool for both detecting and treating residual CBD stones after conventional ERC.     

Giant choledocholithiasis treated by mechanical lithotripsy using a gastric bezoar basket

Mechanical lithotripsy (ML) is usually considered as a standard treatment option for large bile duct stones. However, it is impossible to retrieve oversized stones because the conventional lithotripsy basket may not be able to grasp the stone. However, there is no established endoscopic extraction method for such giant stone removal. We describe a case of successful extraction of a 4-cm large stone using a gastric bezoar basket. A 78-year-old woman had suffered from upper abdominal pain for 20 d. Contrast-enhanced computed tomogram revealed a 4-cm single stone in the distal common bile duct (CBD). Endoscopic stone retraction was decided upon and endoscopic papillary balloon dilation was performed using a large balloon. An attempt to capture the stone using a standard lithotripsy basket failed due to the large stone size. Subsequently, we used a gastric bezoar basket to successfully capture the stone. The stone was fragmented into small pieces and extracted. The stone was completely removed after two sessions of endoscopic retrograde cholangiopancreatography; each of which took 30 min. No complications occurred during or after the procedure. The patient was fully recovered and discharged on day 11 of hospitalization. ML using a gastric bezoar basket is a safe and effective retrieval method in select cases, and is considered as an alternative nonoperative option for the management of difficult CBD stones.     

Methyltert-butyl ether in the endoscopic treatment of common bile duct radiolucent stones in elderly patients with nasobiliary tube

Methyltert-butyl ether is an effective dissolution agent for cholesterol stones. The aim of this work was to evaluate the effect of methyltert-butyl ether on radiolucent common bile duct stones in patients in whom endoscopic extraction has failed. From September 1985 to September 1987, 1374 patients underwent endoscopic retrograde cholangiopancreatography in our Liver Unit. An endoscopic sphincterotomy was indicated in 195 patients with common bile duct (CBD) stones because of an age over 65 years and/or surgical contraindications. Endoscopic sphincterotomy was efficient in 187 patients, allowing complete stone removal in association with conventional endoscopic methods and mechanical lithotripsy in 170 patients. Twelve of the 17 patients with failure of conventional endoscopic treatments were either older than 75 years (11 patients; mean age, 86±4.5 years) or exhibited a surgical contraindication. Stones completely obstructed CBD in six patients and had a diameter exceeding 25 mm in the six other patients. These subjects were selected for stone dissolution by methyltert-butyl either (MTBE) according to the following protocol. MTBE was directly infused into CBD through a nasobiliary catheter, twice daily for 4–13 days (mean, seven days). Bile duct opacification, repeated after MTBE treatment, revealed the complete disappearance of CBD stones in one patient, a decrease in stone size in five patients and no change in the six tther patients. MTBE treatment was well tolerated except in three patients who complained from transient abdominal pains and nausea. At the second attempt of endoscopic treatment, CBD stones were found to be softened and easily broken up, allowing a complete clearance in six patients. MTBE treatment failed to improve stone extraction in the five other patients. These results show that, in patients with large radiolucent stones in the CBD, unextractable by conventional endoscopic methods, the direct infusion of MTBE in CBD rarely led to a complete stone dissolution; however, this treatment partially solubilizes stones, enabling their complete endoscopic extraction thereafter in half the patients.A preliminary report of this work was presented at the American Gastroenterological Association, Digestive Disease Week, 1988, New Orleans.     

Common bile duct stones on multidetector computed tomography:Attenuation patterns and detectability

AIM:To investigate the attenuation patterns and detectability of common bile duct(CBD) stones by multidetector computed tomography(MDCT).METHODS:Between March 2010 and February 2012,191 patients with suspicion of CBD stones undergoing both MDCT and endoscopic retrograde cholangiopancreatography(ERCP) were enrolled and reviewed retrospectively.The attenuation patterns of CBD stones on MDCT were classified as heavily calcified,radiopaque,less radiopaque,or undetectable.The association between the attenuation patterns of CBD stones on MDCT and stone type consisting of pure cholesterol,mixed cholesterol,brown pigment,and black pigment and the factors related to the detectability of CBD stones by MDCT were evaluated.RESULTS:MDCT showed CBD stones in 111 of 130 patients in whom the CBD stones were demonstrated by ERCP with 85.4% sensitivity.The attenuation patterns of CBD stones on MDCT were heavily calcified 34(26%),radiopaque 31(24%),less radiopaque 46(35%),and undetectable 19(15%).The radiopacity of CBD stones differed significantly according to stone type(P < 0.001).From the receiver operating characteristic curve,stone size was useful for the determination of CBD stone by MDCT(area under curve 0.779,P < 0.001) and appropriate cut-off stone size on MDCT was 5 mm.The factors related to detectability of CBD stones on MDCT were age,stone type,and stone size on multivariate analysis(P < 0.05).CONCLUSION:The radiopacity of CBD stones on MDCT differed according to stone type.Stone type and stone size were related to the detectability by MDCT,and appropriate cut-off stone size was 5 mm.     

Choledocholithiasis: a prospective study of spontaneous common bile duct stone migration

BACKGROUND: The rate of spontaneous migration of bile duct stones through the duodenal papilla is not well known. Endoscopic retrograde cholangiography (ERC) has been the standard method to diagnose bile duct stones, but accumulating data show there is a good agreement between ERC and endoscopic ultrasonography (EUS). The aim of the study was to evaluate the incidence and time course of stone migration in patients with bile duct stones by analyzing discrepancies between EUS and ERC as a function of the elapsed time between these two procedures. Stone migration was considered as the absence of stones at time of ERC regardless of the number of stones seen at EUS. METHODS: The main criterion for inclusion was the presence of bile duct stone as shown by EUS. Ninety-two consecutive patients were prospectively included in this study. RESULTS: Choledocholithiasis was absent at ERC in 12 patients. In univariate analysis, presence of gallbladder was significantly associated with an increased rate of stone migration (correction for multiple testing would remove this statistical significance). The size of the stone was the only independent factor to predict migration. CONCLUSION: Migration occurred in about 21% of cases within 1 month. Our study emphasizes the need to analyze carefully the results of comparative imaging studies of bile duct stones.     

胆管腔内超声与逆行胆管造影诊断胆管结石的对比研究

目的 比较十二指肠镜下胆管腔内超声（IDUS）和内镜下逆行胆管造影（ERC）诊断肝外胆管结石的作用。方法 对30例临床怀疑有肝外胆管结石的患者，先进行ERC，再经内镜活检孔道将超声微探头直接送入胆管腔内探查，而后行乳头切开取石。结果 30例患者中，ERC准确诊断结石26例，将胆管絮状物诊断为结石1例，漏诊2例，其诊断结石的准确率，敏感性分别为86.7%(26/30),92.9%(26/28)；而IDUS准确诊断结石28例，无漏诊，误诊，其诊断结石的准确率，敏感性均为100.0%。结论 IDUS可弥补ERC的视觉误差且在确定胆管结石方面优于ERC。     

Impact of magnetic resonance cholangiography on endoscopic therapy before and after laparoscopic cholecystectomy.

OBJECTIVE: To assess the impact of magnetic resonance cholangiography (MRC) on endoscopic therapy before and after laparoscopic cholecystectomy (LC). METHODS: Ninety-six patients were referred for endoscopic retrograde cholangiography (ERC) before or after LC because of abnormal liver function tests, raised serum amylase, or abnormal ultrasound scan (USS) of the biliary system. All patients underwent MRC before ERC. RESULTS: Common bile duct (CBD) stones were detected in 48 patients on ERC, 40 on MRC, and 23 on USS. The CBD was dilated on ERC (> 8 mm) in 59 patients, on MRC (> 7 mm) in 51, and on USS (> 7 mm) in 42. Abnormal CBD (dilated +/- stone) was detected in 69 patients on ERC, 57 on MRC, and 44 on USS. Intrahepatic ducts were dilated on ERC in 26 patients, on MRC in 24, and on USS in 18. The study was abnormal on ERC in 81 patients, on MRC in 63, and on USS in 51. Endoscopic therapy was attempted in 80 patients. Presence of CBD stone (p = 0.03), dilated CBD (p = 0.01), abnormal CBD (p = 0.0007), and abnormal study (p = 0.0004) on MRC were significantly related to endoscopic therapy. In 6 cases LC was deferred because MRC revealed CBD calculi which could not be cleared endoscopically. ERC could have been avoided in 14/ 19 patients who did not benefit from it. CONCLUSION: MRC findings are significantly related to endoscopic therapy in patients referred for ERC before and after LC, and they influence therapeutic decisions in some of them.     

Wire-guided intraductal US: an adjunct to ERCP in the management of bile duct stones.

BACKGROUND: Endoscopic retrograde cholangiography (ERC) may misdiagnose bile duct stones if air bubbles are introduced during contrast injection, and it may also fail to diagnose stones in the presence of bile duct dilation. METHODS: Our aim was to determine whether intraductal US (IDUS) improves the accuracy of cholangiography and whether it is a useful adjunct in the management of bile duct stones. IDUS with a wire-guided US probe was performed after initial ERC in patients in whom bile duct stones were suspected. The diagnostic accuracy of ERC alone was compared with that of ERC plus IDUS. RESULTS: ERC with IDUS was performed in 62 patients who were suspected to have bile duct stones. Both IDUS and ERC were performed by the same endoscopist, and ERC was performed with a C-arm fluoroscope. The presence of bile duct stones and/or sludge were confirmed after sphincterotomy and extraction in 34 patients. Overall, the accuracy of ERC combined with IDUS in the diagnosis of bile duct stone and/or sludge was higher than that of ERC alone (97% vs. 87%, p < 0.05). With dilated bile ducts, the diagnostic accuracy of ERC combined with IDUS was also higher than that of ERC alone (95.5% vs. 72.7%, p < 0.05). Additional diagnostic information provided by IDUS included identification of cystic duct stones in 5 patients, characterization of bile duct strictures in 2 patients, and choledochal varices in 1 patient. Performance of wire-guided IDUS required 5% of the total procedure time. CONCLUSIONS: IDUS improves diagnostic accuracy of ERC and is a useful adjunct to ERC when bile duct stones are suspected.     

两种手术方法处理腹腔镜胆囊切除术后胆总管残余结石患者临床疗效比较

目的 分析比较经内镜逆行性胰胆管造影（ERCP）下取石与开腹胆道探查（CBDE）治疗腹腔镜胆囊切除术（LC）后胆总管残余结石患者的临床疗效。方法 2015年2月~2016年12月我院收住的经LC术后存在胆总管残余结石患者84例,其中38例采取CBDE法（A组）治疗,46例采取ERCP下取石（B组）。结果 B组术中出血量明显少于A组[（3.4±1.3）ml对（124.2±65.8）ml,P<0.05],手术时间[（34.8±4.2）min对（123.3±15.8）min,P<0.05]、术后排气时间[（1.0±0.7）h对（42.6±9.1）h,P<0.05]和住院时间[（4.9±3.5）d对（9.3±4.3）d,P<0.05]均明显短于A组;术后1 w,B组血清GGT水平为（63.7±7.5）IU/L,与A组的（70.2±7.9）IU/L 比无显著性相差（P>0.05）,血清ALP水平为（105.6±11.5）IU/L,与A组的（115.4±12.8）IU/L比无显著性相差（P>0.05）;A组并发症发生率为23.7%、结石再复发率为5.3%,而B组分别为15.2%和6.5%,两组比较无显著性差异（P>0.05）。结论 相对于CBDE术,采用ERCP下取石处理经LC术后胆总管残余结石患者可有效降低术中出血量,缩短手术时间,并因可反复进行而具有优势。     

Hepatectomy with primary closure of common bile duct for hepatolithiasis combined with choledocholithiasis

AIM: To evaluate the feasibility of hepatectomy and primary closure of common bile duct for intrahepatic and extrahepatic calculi. METHODS: From January 2008 to May 2013, anatomic hepatectomy followed by biliary tract exploration without biliary drainage(non-drainage group) was performed in 43 patients with intrahepatic and extrahepatic calculi. After hepatectomy, flexible choledochoscopy was used to extract residual stones and observe the intrahepatic bile duct and common bile duct(CBD) for determination of biliary stricture and dilatation. Function of the sphincter of Oddi was determined by manometry of the CBD. Primary closure of the CBD without T-tube drainage or bilioenteric anastomosis was performed when there was no biliary stricture or sphincter of Oddi dysfunction. Dexamethasone and anisodamine were intravenously injected 2-3 d after surgery to prevent postoperative retrograde infection due to intraoperative bile duct irrigation, and to maintain relaxation of the sphincter of Oddi, respectively. During the same period, anatomic hepatectomy followed by biliary tract exploration with biliary drainage(drainage group) was performed in 48 patients as the control group. Postoperative complications and hospital stay were compared between the two groups.RESULTS: There was no operative mortality in either group of patients. Compared to intrahepatic and extrabiliary drainage, hepatectomy with primary closure of the CBD(non-drainage) did not increase the incidenceof complications, including residual stones, bile leakage, pancreatitis and cholangitis(P > 0.05). Postoperative hospital stay and costs were nevertheless significantly less in the non-drainage group than in the drainage group. The median postoperative hospital stay was shorter in the non-drainage group than in the drainage group(11.2 ± 2.8 d vs 15.4 ± 2.1 d, P = 0.000). The average postoperative cost of treatment was lower in the non-drainage group than in the drainage group(29325.6 ± 5668.2 yuan vs 32933.3 ± 6235.1 yuan, P = 0.005). CONCLUSION: Hepatectomy followed by choledochoendoscopic stone extraction without biliary drainage is a safe and effective treatment of hepatolithiasis combined with choledocholithiasis.