Preserved function of the Oddi sphincter after endoscopic papillary balloon dilation

BACKGROUND/AIMS: Endoscopic papillary balloon dilation (EPBD) is a safe and effective procedure for the treatment of bile duct stones that appears to be less hazardous to the sphincter of Oddi than endoscopic sphincterotomy. However, little is known about the function of Oddi muscle after EPBD. The aim of the present study is to evaluate Oddi muscle function using quantitative cholescintigraphy. METHODOLOGY: This study was conducted using 12 patients treated for bile duct stones by EPBD, and 8 patients treated by endoscopic sphincterotomy, followed by laparoscopic cholecystectomy thereafter. For the controls, 10 asymptomatic cholecystectomized patients were used. From 1-3 years after the interventional procedures, patients received a quantitative cholescintigraphy examination using 185 MBq of technetium-99m-N-pyridoxyl-5-methyl-tryptophan. The hepatic hilum-duodenum transit time on quantitative cholescintigraphy was measured as the time interval between the initial appearance of isotope activity at the hepatic hilum and that at the duodenum. RESULTS: Mean hilum-duodenum transit time in patients after EPBD (6.3 min, 95%CI 4.5-8.0) was not different from that in control patients (6.5 min, 95%CI 4.3-8.7), whereas mean hilum-duodenum transit time in endoscopic sphincterotomy patients (3.2 min, 95%CI 2.4-4.0) was markedly shorter than both the control and EPBD groups (p = 0.0053). CONCLUSIONS: The function of the sphincter of Oddi may be preserved after endoscopic papillary balloon dilation.     

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.     

Does a fatty meal improve hepatic clearance in patients after endoscopic sphincterotomy?

BACKGROUND: Delayed biliary emptying is a cause of recurrent bile duct stones in patients after endoscopic sphincterotomy (ES) for choledocholithiasis. This study aimed to evaluate the effect of fatty meal on hepatic clearance in patients after ES. METHODS: Sixty patients who had received ES and complete clearance of bile duct stones were enrolled. Delayed hepatic clearance (45 min clearance of radioisotope [E45'] < 57%) from quantitative cholescintigraphy (QC) and absence of sphincteric function confirmed by sphincter of Oddi manometry were found in each patient after normalization of liver function. Patients then received another QC 30 min after a fatty meal (two fried eggs and 250 mL full milk, fat 28 g) within 2 months. RESULTS: Improvement of hepatic clearance in QC after fatty meal was found in 20 of 24 (83%) cholecystectomized patients and 27 of 36 (75%) patients with intact gallbladder. The E45' after fatty meal was significantly higher than that without fatty meal (56 +/- 12%vs 40 +/- 9% in cholecystectomized patients, P < 0.001; 52 +/- 16%vs 35 +/- 11% in patients with intact gallbladder, P < 0.001). All patients tolerated the fatty meal well during fatty meal QC. CONCLUSIONS: Fatty meal can improve hepatic clearance in both patients with intact gallbladder and after cholecystectomy, so routine restriction of fat after ES may be inappropriate. However, further studies are needed to evaluate the role of diet in the prevention of recurrent biliary complications.     

Endoscopic balloon dilatation is a safe method in the management of common bile duct stones

BACKGROUNDS AND AIMS: Endoscopic sphincterotomy is a widely accepted treatment for patients with common bile duct stones. Despite improvement in this technique, endoscopic sphincterotomy is still associated with some biliary complications. Endoscopic balloon dilatation is a less traumatic and sphincter preserving method for removal of common bile duct stones. However, the results of controlled studies in comparison with these two methods are contradictory. The aim of this study is to compare the safety and efficacy of endoscopic balloon dilatation and endoscopic sphincterotomy in Chinese patients. PATIENTS AND METHODS: A total of 104 patients with common bile duct stones on endoscopic retrograde cholangiopancreatography were enrolled. They were randomly assigned to endoscopic balloon dilatation or endoscopic sphincterotomy. Endoscopic balloon dilatation was performed by using a balloon dilator to dilate the sphincter for 5 min. The common bile duct stones were then removed by a Dormia basket after endoscopic balloon dilatation or endoscopic sphincterotomy. Mechanical lithotripsy was performed if the stones were difficult to remove by Dormia basket. After discharge, patients were regularly followed up for biliary complications. RESULTS: The successful bile duct stone clearance rate was 94.1% in endoscopic balloon dilatation group and 100% in endoscopic sphincterotomy group. Post-procedural significant haemorrhage was higher in endoscopic sphincterotomy group than in endoscopic balloon dilatation group (14/53 versus 1/48, P < 0.001). The bleeding patient from endoscopic balloon dilatation group was a case of uremia and bleeding occurred 48 h after endoscopic balloon dilatation. All the patients with post-procedural haemorrhage were controlled endoscopically. The post-procedural serum amylase level showed no significant difference in both groups and none of them developed clinical pancreatitis. After a mean 16 months follow-up, three patients (6.3%) in endoscopic balloon dilatation group and four patients (7.5%) in endoscopic sphincterotomy group developed recurrent common bile duct stones. The recurrent common bile duct stones were multiple and muddy in consistency. They were successfully removed endoscopically. CONCLUSION: Both endoscopic balloon dilatation and endoscopic sphincterotomy are safe and effective techniques for the treatment of common bile duct stones. Endoscopic balloon dilatation can be safely applied in patients with coagulopathy and does not increase the incidence of pancreatitis or bleeding.     

Prediction of recurrent choledocholithiasis by quantitative cholescintigraphy in patients after endoscopic sphincterotomy

Background—Endoscopic sphincterotomy(EST) is widely used for the removal of stones from the bile duct, butstones recur in about one fifth of patients.
Aims—To investigate hepatic clearance byquantitative cholescintigraphy (QC) in patients after EST and todiscern the relationship between biliary emptying and stone recurrence.
Methods—One hundred and forty nine patients whohad EST and clearance of the bile duct for choledocholithiasis wereselected. All patients were confirmed to have complete EST by sphincter of Oddi manometry and underwent QC soon after normalisation of liverfunction. Regular clinical follow up was performed for each patient.
Results—During a mean 36 month follow up, 22 (14.8%) patients developed recurrent stones in the bileduct. Irrespective of the status of the gall bladder, patients withrecurrent stones had a slower hepatic clearance of radioisotope duringQC compared with patients without stone recurrence, but only thedifferences in cholecystectomised patients had statisticalsignificance. After carrying out multivariate analysis, one parameterof QC, percentage clearance of maximal count at 45 minutes, was foundto be the only significant factor for stone recurrence. All recurrentstones in the common bile duct were successfully removed at endoscopy.
Conclusion—Slower hepatic clearance as shown by QCis an important factor responsible for stone recurrence after sphincter ablation.

Keywords:hepatic clearance; recurrent choledocholithiasis; quantitative cholescintigraphy; endoscopic sphincterotomy

     

Small sphincterotomy combined with endoscopic papillary large balloon dilation versus sphincterotomy

AIM： To compare small sphincterotomy combined with endoscopic papillary large balloon dilation （SES ＋ ELBD） and endoscopic sphincterotomy （EST） for large bile duct stones. METHODS： We compared prospectively SES ＋ ELBD （group A, n = 27） with conventional EST （group B, n = 28） for the treatment of large bile duct stones （≥ 15 mm）. When the stone could not be removed with a normal basket, mechanical lithotripsy was performed. We compared the rates of complete stone removal with one session and application of mechanical lithotripsy. RESULTS： No significant differences were observed in the mean largest stone size （A： 20.8 mm, B： 21.3 mm）, bile duct diameter （A： 21.4 turn, B： 20.5 ram）, number of stones （A： 2.2, B： 2.3）, or procedure time （A： 18 min, B： 19 rain） between the two groups. The rates of complete stone removal with one session was 85% in group A and 86% in group B （P = 0.473）. Mechanical lithotripsy was required for stone removal in nine of 27 patients （33%） in group A and nine of 28 patients （32%, P = 0.527） in group B.CONCLUSION： SES ＋ ELBD did not show significant benefits compared to conventional EST, especially for the removal of large （≥ 15 mm） bile duct stones.     

Juxtapapillary duodenal diverticula: association with biliary stone disease

In order to explore the relationship between duodenal diverticula and biliary stone disease, we reviewed 2231 endoscopic retrograde cholangio-pancreatography procedures. We found at least one juxtapapillary diverticulum per 239 patients (10.8%). The occurrence of duodenal diverticula increases with age. Patients with duodenal diverticula were older, had more gallbladder stones, more common bile duct stones, had undergone cholecystectomy more frequently, and experienced more frequently common bile duct stone recurrence after cholecystectomy. We thus confirm an association between the presence of diverticula of the second part of the duodenum, and biliary stone pathology, including gallbladder stones, common bile duct stones, and recurrent stones after cholecystectomy. We discuss the aetiopathogeny of this affection.     

Role of prophylactic endoscopic sphincterotomy in patients with acute biliary pancreatitis due to transient common bile duct obstruction

BACKGROUND AND AIM: The role of prophylactic endoscopic sphincterotomy in patients with transient common bile duct obstruction is controversial. The aim of this study was to assess the value of performing prophylactic endoscopic sphincterotomy in patients suffering from acute biliary pancreatitis and absent common bile duct stones on endoscopic retrograde cholangiopancreatography (ERCP). METHODS: Hospital notes of patients admitted to our unit with a diagnosis of acute pancreatitis from January 2000 to January 2005 were reviewed. Endoscopic sphincterotomy was performed when patients were deemed unfit for cholecystectomy, suffering from a severe attack of acute pancreatitis and/or showing evidence of transient common bile duct obstruction. The outcomes of patients with and without endoscopic sphincterotomy were compared. RESULTS: A total of 427 patients were admitted with a diagnosis of acute pancreatitis during the study period. Eighty-eight patients with absent common bile duct stones on ERCP were identified. Endoscopic sphincterotomy was performed in 71 patients and not performed in 17 patients. There was no significant difference in recurrent pancreatitis rates (1.4% vs 5.8%, P = 0.35), recurrent biliary complication rates (5.6% vs 5.9%, P = 1) or mortality rates (5.8% vs 1.5%, P = 0.35). The time to recurrent complications (38.4 days vs 41.0 days, P = 0.38) was not significantly different between the two groups. There was no ERCP-related morbidity or mortality. CONCLUSION: Prophylactic endoscopic sphincterotomy is not recommended in patients with transient common bile duct obstruction or as an option to cholecystectomy in elderly patients. Early cholecystectomy should be performed.     

Prognostic factors for recurrence of bile duct stones after endoscopic treatment by sphincter dilation

BACKGROUND: The long-term outcome for patients after endoscopic sphincter of Oddi dilation is poorly documented. This study investigates the recurrence rate for bile duct stones in patients followed for 1 year or more after endoscopic sphincter dilation and stone extraction, and assessed prognostic factors associated with recurrence of ductal calculi. METHODS: A total of 169 patients with bile duct stones were treated with endoscopic sphincter dilation between July 1998 and August 2001. Follow-up studies consisted of periodic biochemical tests and out-patient evaluations with endoscopic retrograde cholangiography or magnetic resonance cholangiography performed when follow-up exceeded 1 year. Putative risk factors for stone recurrence included gender, age, stone size and number, associated peripapillary diverticulum, gallbladder status, color of bile duct stones, and bile duct diameter. Statistical analysis consisted of both a Kaplan-Meier estimation and a multivariate Cox regression model. RESULTS: Complete stone clearance was achieved in 162 (95.8%) patients, of whom 151 were followed (13 patients died from unrelated disorders). Mean follow-up was 23 months. Stone recurrence was documented in 13 patients. Patients with dilated bile duct or peripapillary diverticulum were at high risk for recurrence. CONCLUSIONS: The interval between treatment of bile duct stones by endoscopic sphincter dilation and the recurrence of biliary calculi is relatively short. Bile duct size and peripapillary diverticula are risk factors for early recurrence.     

Immediate effects of the endoscopic sphincterotomy on the motility of the sphincter of Oddi

An endoscopic manometric technique was used to determine the CBD-duodenum junction pressure profile before and immediately after endoscopic sphincterotomy in 13 patients with common bile duct stones. Premedication (meperidine, atropine, and diazepam) was given to all patients and endoscopic retrograde cholangiopancreatography was performed before endoscopic sphincterotomy. In the patients with intact papilla the features of the sphincter of Oddi motility were similar to those previously described for patients not given premedication or submitted to cholangiography before endoscopic sphincterotomy. Endoscopic sphincterotomy which was successful for immediate stone removal in 9 of 13 patients caused an immediate reduction of sphincter of Oddi motility in all patients, but abolished it in only 2 of them. The present results show that successful common bile duct stone extraction by means of endoscopic sphincterotomy can be accomplished without total abolition of sphincter of Oddi motility.     

Endoscopic papillary balloon dilation and endoscopic sphincterotomy for bile duct stones: long-term outcomes in a prospective randomized controlled trial

BACKGROUND: Little is known about the long-term outcome of endoscopic papillary balloon dilation for removal of bile duct stones. A randomized trial that compared long-term outcomes after endoscopic papillary balloon dilation and endoscopic sphincterotomy was conducted. METHODS: Thirty-two patients with bile duct stones were randomized to endoscopic papillary balloon dilation or endoscopic sphincterotomy, with 16 patients in each group. Endoscopic papillary balloon dilation was performed by using an 8-mm-diameter balloon; endoscopic sphincterotomy was performed in the standard manner. The success rates for stone removal, as well as the frequency and types of early (<15 days), mid-term (<1 year), and long-term (1-6 years) post-procedure complications were evaluated. RESULTS: The success rates for stone removal and early complication rates were similar for both groups. The frequency of stone recurrence was approximately 4-fold higher in the endoscopic papillary balloon dilation group (25%) vs. the endoscopic sphincterotomy group (6.3%) at mid-term evaluation. However, over the long term, Kaplan-Meier estimated probability of stone recurrence tended to be higher in the endoscopic sphincterotomy group vs. the endoscopic papillary balloon dilation group; recurrent stones were found in, respectively, 26.7% vs. 6.3%. Complications occurred in 7 patients in each group. CONCLUSIONS: Long-term outcome of endoscopic papillary balloon dilation for bile duct stone removal is satisfactory, provided that consideration is given to recurrence of stones by early follow-up evaluation.     

Endoscopic sphincterotomy for retained common duct stones

Twenty-one patients with retained stones after biliary surgery were managed by endoscopic sphincterotomy and stone extraction in the postoperative period. The bile duct was cleared of stones in 20 patients (95%). In one patient stone extraction was unsuccessful. There were no complications. Compared to percutaneous trans-T-tube tract stone extraction, endoscopic sphincterotomy does not require a 6 week waiting period. Endoscopic sphincterotomy should be considered for retained bile duct stones if endoscopic expertise is available.     

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.     

An analysis of the relationship between bile duct stones and periampullary duodenal diverticula

Previous studies have suggested a relationship between bile duct stones and periampullary duodenal diverticula. The aim of the present study was to examine this association in more detail, including step-wise logistic regression to identify independent predictors for the presence of diverticula. Clinical, endoscopic and radiological data were analysed from 794 consecutive subjects with bile duct stones; 44 with primary duct stones (without gall-bladder stones) and 750 with bile duct stones associated with current or previous gall-bladder stones. Frequencies of diverticula in subjects with bile duct stones were compared with those in age-matched controls who had undergone upper gastrointestinal endoscopy using a side-viewing endoscope (n = 100) or who had undergone endoscopic retrograde cholangiopancreatography (ERCP) for pancreatic cancer (n = 100). The frequencies of diverticula in subjects with primary duct stones (70%) and bile duct stones with current or previous gall-bladder stones (25%) were significantly higher than in both control groups (7 and 8%, respectively). When subjects with bile duct stones were analysed by step-wise logistic regression, age and bile duct diameter were independent predictors of the presence of diverticula, but diverticula were unrelated to gender, mode of presentation, number of bile duct stones and outcome after endoscopic sphincterotomy. A significant association exists between duodenal diverticula and bile duct stones, perhaps because diverticula predispose to stone formation through the combined effects of bile stasis and bacterial contamination of bile.     

Complications of endoscopic sphincterotomy. A prospective series with emphasis on the increased risk associated with sphincter of Oddi dysfunction and nondilated bile ducts

Mostly retrospective series with limited use of sphincter of Oddi manometry have indicated that early complications are more common when endoscopic sphincterotomy is performed for sphincter of Oddi dysfunction than for common duct stones. The current study was undertaken to prospectively evaluate the frequency and type of complications of endoscopic sphincterotomy performed for sphincter of Oddi dysfunction compared with endoscopic sphincterotomy performed for other conditions. Four hundred twenty-three patients underwent sphincterotomy for sphincter of Oddi dysfunction (166), common duct stone(s) (163), tumor (60), and miscellaneous reasons (34). Patients were observed in the hospital for at least 24 hours after the procedure, and 30-day follow-up data were obtained. The overall complication rate was 6.9%, but complications were more frequent when sphincterotomy was performed for sphincter of Oddi dysfunction than for all other indications (10.8% vs. 4.3%; P = 0.009). Precut sphincterotomy was more frequently required in the sphincter of Oddi dysfunction group (21.1% vs. 11.7%, P = 0.009) but was no more likely to result in a complication (6.2%) than standard sphincterotomy. The risk of a complication was considerable for a small-diameter common bile duct (less than or equal to 5 mm), particularly when sphincterotomy was performed for sphincter of Oddi dysfunction (37.5%). The overall 30-day mortality rate was 1.7%, but the procedure-related mortality rate was believed to be 0.2%. It is concluded that endoscopic sphincterotomy for sphincter of Oddi dysfunction is more hazardous than for other conditions, particularly when a small common bile duct is present.     

Recurrence of biliary symptoms after endoscopic sphincterotomy for choledocholithiasis in patients with gall bladder stones

BACKGROUND: There are a few reports regarding the long-term results of endoscopic sphincterotomy (EST). However, little data is available on the recurrence of biliary symptoms after EST for choledocholithiasis, in patients with gall bladder stones. METHODS: All patients had gall bladder and common bile duct stones (n = 60; age 32-84 years, median age 55 years), and had received an EST. One group of these patients had a laparoscopic or open cholecystectomy (n = 39; group A), while the other group did not (n = 21; group B). The follow-up- period ranged from 5 to 54 months (average 22 months). RESULTS: Complications included the recurrence of common bile duct stones, recurrent acute cholecystitis, postoperative bile leakage and papillary stenosis. Nine patients (15%) had a recurrence of biliary symptoms. Two significant prognostic factors for the recurrence of biliary symptoms were identified by multivariate analysis; namely an intact gall bladder and a dilated common bile duct. The recurrence rate of biliary symptoms in group B was 20.4%, while in group A it was 10.3% (P< 0.01). Patients with a larger than average common bile duct diameter (mean diameter 14 mm) were more prone to the recurrence of symptoms than those with a smaller common bile duct diameter (mean diameter 10 mm, P< 0.016). The hospital stay period was 8.9 +/- 3.1 days in group A and 2.8 +/- 1.9 days in group B (P< 0.01). CONCLUSIONS: Biliary symptom recurrence occurred in a considerable proportion of patients after EST for the treatment of choledocholithiasis, in patients with gall bladder stones. The prognostic factors associated with the recurrence of biliary symptoms were an intact gall bladder and a dilated common bile duct diameter. Regardless of their short stay in hospital, non-cholecystectomy patients had a higher rate of recurrent biliary symptoms than cholecystectomy patients.     

Endoscopic management of bile duct stones

The surgical risk of common duct exploration for the treatment of biliary calculi is considerably higher than that of cholecystectomy. Therefore, introduction of endoscopic sphincterotomy in 1974 was a major advance. It has become the therapy of choice in cholecystectomized patients or in those with an increased operative risk. Endoscopic sphincterotomy has a mortality rate of around 1% and a morbidity rate of 7%. These figures compare favourably with open surgery, especially in old patients. The procedure fails in about 10% of all patients referred for endoscopic removal of their calculi. However, several techniques have been described or are currently under evaluation to overcome these failures: intracorporeal or extracorporeal lithotripsy, long-term stenting of the bile duct, or direct application of solvents. Long-term follow-up studies show that between 2% and 20% of successfully managed patients may develop recurrent stones, mainly caused by bile stasis and infection. Patients with a functioning gall-bladder and no concomitant gall-bladder stones probably do not require cholecystectomy after successful endoscopic treatment of their choledochal stones. While endoscopic stone removal has replaced surgery in the elderly frail patients it has no major advantages in the young and fit patients, especially when the gall-bladder is still in situ.     

内镜下局限性乳头括约肌切开联合大气囊扩张清除难治性胆总管结石:单中心169例经验总结

背景:近年内镜下乳头括约肌切开(EST)联合内镜下乳头大气囊扩张(EPLBD)越来越多地应用于胆总管大结石或难治性结石的清除。目的:评价局限性EST联合EPLBD用于清除直径≥10 mm胆总管结石的有效性和安全性。方法:收集2006年4月~2011年10月东方肝胆外科医院行内镜下取石术的患者,结石直径≥10 mm,取石方法为局限性EST联合EPLBD(气囊直径≥12 mm)。分析入选病例的临床资料、内镜操作及其结果。结果:共169例患者行171例次取石,平均年龄69.3岁(19~97岁),结石直径和气囊直径中位数分别为15 mm和13 mm。结石一次性清除163例次(95.3%),使用机械碎石(ML)66例次(38.6%),且ML使用率随结石直径增大而升高(P0.01)。伴有乳头旁憩室患者与不伴乳头旁憩室患者的结石清除率(97.3%对93.8%)、ML使用率(36.5%对40.2%)和并发症发生率(2.7%对6.2%)均无明显差异(P均0.05)。7例患者共发生8例次并发症,包括轻度或中度出血4例次、微小穿孔1例次,轻度胰腺炎2例次,胆管炎1例次。结论:局限性EST联合EPLBD用于清除胆总管大结石是有效、安全的,尤其是对难治性结石患者。     

Endoscopic extraction of bile duct stones: management related to stone size.

Endoscopic sphincterotomy has become the first line treatment for patients with common bile duct (CBD) stones. This technique may fail, however, due to difficult anatomy, previous surgery, periampullary diverticula or the presence of a large stone. The importance of stone size to the success of endoscopic sphincterotomy has not been fully assessed. A prospective study was carried out over the period January 1987 to December 1989 on 100 patients (45 male, 55 female, median age 69 years, range 19-97) with CBD stones in which a policy of early duct clearance was followed. Endoscopic retrograde cholangiopancreatography (ERCP) was performed and the stone size and number recorded from the cholangiograms and corrected for magnification. Sphincterotomy was performed using a diathermy unit with a cutting current and stones were extracted using a balloon catheter or a Dormia basket. Of the 100 patients with CBD stones receiving ERCP, successful clearance of the biliary tree was possible in seven without endoscopic sphincterotomy and five were felt to be unsuitable for endoscopic sphincterotomy. Of the remaining 88 patients endoscopic sphincterotomy was successful in 75 (85%). Of the 75 patients having endoscopic sphincterotomy stone clearance was successful in 44 (59%). There were no deaths and only four complications, which rapidly resolved on conservative treatment (two acute pancreatitis, two bleeding). The number of CBD stones present was similar in those patients with successful endoscopic sphincterotomy and duct clearance (median 1, range 1-10, n = 44) as in those in whom it failed (median 2, range 1-6, n = 31). In contrast there was a highly significant difference when stone size was analysed (successful clearance median stone size 10 mm, range 3-27 mm; unsuccessful: median 18 mm, range 10-42, p<0.001). Stones less than 10 mm in diameter (n=21) were all removed successfully whereas in patients with stones over 15 mm (n=25) only three were removed endoscopically (12%). All patients with evidence of residual stones had additional treatment. Of these 31 patients, 10 had surgery, 11 had insertion of an endoprosthesis, and 10 had dissolution treatment with methyl-tert-butyl ether through a nasobiliary catheter. This study shows the importance of stone size to the success rate of endoscopic removal of bile duct stones.     

Endoscopic balloon dilatation versus endoscopic sphincterotomy for the removal of bile duct stones: a prospective randomised trial

BACKGROUND: Endoscopic balloon dilatation (EBD) of the sphincter of Oddi has been proposed as an alternative therapy with possible advantages, as compared with endoscopic sphincterotomy (ES), for removal of bile duct stones. PATIENTS AND METHODS: In a randomised study, we compared the efficacy and complication rate of the two techniques in 202 patients with common bile duct stones. Patients were followed up for 12 months. RESULTS: A total of 103 patients were randomised to the EBD group and 99 to the ES group. Overall duct clearance was 87.1% and did not differ between the two groups (EBD 87.4%; ES 86.9%). The complication rate at 24 hours was 6.8% in the EBD group and 3.0% in the ES group (NS). Complications during follow up were 11.7% and 15.2% respectively (NS). A multivariate logistic regression analysis showed only the size of the largest stone to be predictive of success for either technique. CONCLUSION: Endoscopic balloon dilatation offers no significant advantage over the well established technique of endoscopic sphincterotomy for the removal of bile duct stones.