Percutaneous treatment of common bile duct lithiasis

STUDY AIM: Biliary lithiasis in the main bile duct (particularly retained stones) may be treated percutaneously obviating reoperation or endoscopic sphincterotomy. The aim of this study was to determine risks and pitfalls of this approach. PATIENTS AND METHODS: Forty-two cases of biliary stones treated percutaneously between 1980 and 1998 were reported. Among them, 28 patients had already a biliary drainage and in 14, a drain was placed into the bile duct by transhepatic way or by punction of the intestinal loop of a bilio-jejunal anastomosis. The means to clear the bile ducts included percutaneous endoscopy and contact lithotripsy. Thirty patients had residual lithiasis (after a surgical intervention), 11 a new lithiasis above a bile duct stenosis and in 1 a bile duct lithiasis with a gallbladder lithiasis. RESULTS: Morbidity included four complications (9.5%--one severe) and no mortality. After 2.3 +/- 1 courses, desobstruction was complete in 33 cases (78.5%) and partial in one case (2.5%) allowing to optimize the patient for endoscopic sphincterotomy. Desobstruction failed in eight cases (19%), six patients were successfully treated by surgery and 2 by endoscopic sphincterotomy. CONCLUSIONS: Percutaneous desobstruction of the bile ducts may be proposed as a priority in patients with a biliary drain in place and when endoscopic sphincterotomy is impossible or contraindicated. These manoeuvres have a definitive place in hepato-biliary surgery.     

Endoscopic management of common bile duct stones leaving the gallbladder in situ. A cohort study with long-term follow-up

BACKGROUND: Obstructive jaundice caused by stones is a common disorder, mostly managed by endoscopic sphincterotomy followed by cholecystectomy. The aim of this study was to evaluate whether or not clearance of the common bile duct alone is sufficient as treatment for patients with choledocholithiasis. METHODS: A cohort with 447 patients with symptomatic cholecystocholedocholithiasis, undergoing endoscopic retrograde cholangiography (ERC) and if necessary sphincterotomy (ES). In 164 patients common bile duct stones were proven and treated endoscopically, without performing a subsequent cholecystectomy. All 164 patients were free of symptoms after the endoscopic intervention. This group of patients was compared with 78 patients who underwent cholecystectomy after endoscopic treatment of common bile duct stones. Patients were followed for 1-13 years after ERC and sphincterotomy results and complications were registered. RESULTS: The ages of the 164 patients in the in situ group were significantly higher than in the cholecystectomy group and the ASA classification (American Society of Anesthesiologists) was significantly higher in the in situ patients. Mean follow-up was 70.9 months. Of the in situ patients 27 (16%) returned with biliary symptoms; 12 with common bile duct stones, three with cholangitis, and one with stenosis of Vater's papilla. Eight patients returned with cholecystitis and 3 with symptomatic cholecystolithiasis. Thirteen patients underwent cholecystectomy and 11 were managed (also) endoscopically. Minor complications were 2 wound infections and 1 bleeding after cholecystectomy. Two patients (1%) died of abdominal sepsis due to cholecystitis. Of the patients who underwent cholecystectomy, 6 (7.6%) returned during follow-up. Three patients had common bile duct stones, 2 had cholangitis and 1 patient presented with papillostenosis. Three patients needed surgical common bile duct exploration and the other 3 were treated endoscopically. After reintervention, cardiopulmonary complications were observed in 1 patient. There was no related death. CONCLUSION: When common bile duct stones are treated successfully by endoscopic sphincterotomy and patients are free of symptoms, there is no need for routine prophylactic cholecystectomy.     

Preoperative Endoscopic Sphincterotomy and Laparoscopic Cholecystectomy for the Management of Cholecystocholedocholithiasis: 10-Year Experience

Abstract No procedure has yet been identified as the “gold standard” for the detection and treatment of common bile duct stones (CBDS) in patients undergoing laparoscopic cholecystectomy (LC). This prospective study involves 2137 patients undergoing elective laparoscopic cholecystectomy. The algorithm for diagnostic management in place until July 1997 involved routine intravenous cholangiography and selective endoscopic retrograde cholangiography (ERC). Subsequently, assessment of the bile duct was not routinely performed, but a scoring system was applied to single out those patients at risk of CBDS who should undergo intravenous cholangiography and/or ERC (see Fig. 2). Whenever bile duct stones were found, endoscopic sphincterotomy (ES) was performed, and LC was performed with a standardized four-cannula technique after endoscopic bile duct stone clearance. Common bile duct stones were suspected in 340 patients who were referred for preoperative ERC; 250 patients were referred for ES; 21 patients were referred for open surgery because of failure of ERC or sphincterotomy. Common bile duct stones, detected in 283 cases (13.2%), were removed before surgery in 250 cases (88.3%) and during surgery in 28 cases (9.9%). Self-limited pancreatitis occurred in 4.2% of the patients after sphincterotomy. Laparoscopic cholecystectomy was performed in 98.4% of the cases. The conversion rate was 8.3% if sphincterotomy had been performed previously and 3.4% after standard laparoscopic cholecystectomy (p < 0.001). The morbidity rate was 4.5%; mortality, 0.09%. During follow-up five patients (0.2%) had retained stones endoscopically treated. Future trials of novel strategies for detecting and treating CBDS should compare the results of novel strategies with those of the strategy employed in this study, which includes selective ERC, preoperative ES, and LC.     

External biliary fistulas selectively managed by endoscopic retrograde cholangiography with sphincterotomy and/or stent placement

External bile duct fistulas are inherent postoperative complications that usually appear after biliary tract surgery, traumatic bile duct injuries and liver surgery for hepatic hydatid disease or liver transplant. The management is highly individualized, while the success and long-term results of endoscopic and surgical techniques are conflicting. The study included 32 cases with external bile duct fistulas managed by endoscopic retrograde cholangiography (ERC) with sphincterotomy and/or stent placement, including "rendez-vous" procedures in 2 cases. The causes of the external fistula were represented by cholecystectomy with/without retained common bile duct stones or strictures (22 cases), cholecystectomy and drainage of a subphrenic abscess caused by severe acute pancreatitis (1 case) and surgical interventions for hepatic hydatid disease (9 cases). Due to the prospective protocol of the study we were able to apply an individualized endoscopic treatment: sphincterotomy with proper relief of the bile duct obstruction (stone extraction) or sphincterotomy with large-size (10 Fr) stent placement for large-sized bile duct defects. The results consisted in closure of the fistula in 3.5 +/- 1.7 days for the subgroup of patients with sphincterotomy alone. Among the patients with stent insertion, fistulas healed slower in 14 +/- 3.5 days. There were no complications after endoscopic treatment; however the stent could not be passed in one patient that required subsequent surgery. In conclusion, endoscopic intervention is the treatment of choice for small external biliary fistulas complicating biliary tract surgery or liver surgery for hepatic hydatid disease. When the fistula is large, the placement of a 10 Fr endoprosthesis becomes necessary, while failure of endoscopic treatment leads to surgery with hepatico-jejunal anastomosis.     

Current management of common bile duct stones in northern Italy

In order to obtain a complete picture of the current management of cholecystocholedocal lithiasis in northern Italy we've conducted the present survey. In the years 1992–1993, among 7,861 cholecystectomies, 665 patients with gallbladder and common bile duct stones were treated in 49 surgical departments. Some 271 (43%) were treated by traditional methods: open surgery or endoscopic sphincterotomy followed by laparotomic cholecystectomy; 313 patients (49%) were treated by endoscopic sphincterotomy followed by laparoscopic cholecystectomy and only 38 (6%) were treated by one-stage laparoscopy, either by a transcystic approach (27) or by laparoscopic choledochotomy (11). Morbidity and mortality were not significantly different in the different groups. We conclude that open surgery and sequential minimal invasive treatment are the standard approaches to cholecystocholedochal lithiasis in this first stage of the laparoscopic era. The laparoscopic management of common bile duct stones is at present confined to surgical departments specially devoted to laparoscopic surgery.     

Comparison of endoscopic sphincterotomy and laparoscopic exploration of the common bile duct

BACKGROUND: Laparoscopic exploration of the common bile duct is becoming more popular, although endoscopic sphincterotomy remains the usual treatment for bile duct stones. However, loss of the biliary sphincter causes permanent duodenobiliary reflux, and recurrent stone disease and biliary neoplasia may be a consequence. METHODS: A systematic literature review was conducted to compare laparoscopic exploration with endoscopic sphincterotomy. A text word search of the Medline, Pubmed and Cochrane databases, and a manual search of the citations from these references, was used. RESULTS: Endoscopic sphincterotomy is associated with a median (range) mortality rate of 1 (0-6) per cent, compared with 1 (0-5) per cent for laparoscopic bile duct exploration. The median (range) rate of pancreatitis following endoscopic sphincterotomy is 3 (1-19) per cent; this is a rare complication after laparoscopic duct exploration. The combined morbidity rate for laparoscopic cholecystectomy and endoscopic sphincterotomy is 13 (3-16) per cent, which is greater than 8 (2-17) per cent for laparoscopic bile duct exploration. Randomized trials are few and contain relatively small numbers of patients. They show little overall difference in rates of duct clearance, but a higher mortality rate and number of hospital admissions are noted for endoscopic sphincterotomy compared with laparoscopic bile duct exploration. Endoscopic sphincterotomy is associated with recurrent stone formation (up to 16 per cent) with associated cholangitis. It is also associated with bacterobilia and chronic mucosal inflammation. The late development of bile duct cancer has been reported in up to 2 per cent of patients. CONCLUSION: Laparoscopic exploration of the common bile duct may be a better way of removing stones than endoscopic sphincterotomy plus laparoscopic cholecystectomy. :     

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.     

肝移植术后胆道并发症的内镜治疗

目的:探讨内镜下逆行胰胆管造影术(ERCP)在治疗肝移植术后胆道并发症方面的临床疗效.方法:回顾性分析2002年8月-2012年12月采用ERCP治疗8例肝移植术后胆道并发症患者的临床资料,其中胆道狭窄5例(吻合口狭窄4例,肝内型胆道狭窄1例),胆瘘1例,胆石和胆泥形成2例.8例患者共行ERCP治疗21次,对胆道狭窄患者行括约肌切开、胆管扩张、鼻胆管引流和内支架置放术等治疗;对胆瘘患者行鼻胆管引流及塑料内支架置放术等治疗;对结石患者行括约肌切开、鼻胆管冲洗引流术及取石网篮取石等治疗.结果:ERCP手术成功率为100％ (21/21);4例吻合口狭窄、1例胆瘘和2例结石患者均治愈,1例肝内型胆道狭窄治疗未成功,建议再次肝移植;术后胆道感染的发生率为14.3％(3/21),胰腺炎发生率为19.0％ (4/21),经对症治疗后均痊愈.结论:ERCP是治疗肝移植术后胆道并发症微创、安全和有效的方法.     

腹腔镜胆囊切除术时胆囊管嵌顿结石的处理

目的　总结腹腔胆囊切除术 (LC)时处理胆囊管结石嵌顿的经验。　方法　 1997年 7月～ 2 0 0 1年 6月 ,5 8例胆囊管结石嵌顿。先行胆囊管切开取石而后术中胆道造影 ,如发现胆总管结石则联合内镜切石或中转开腹。　结果　 5 8例均取石成功。 5 1例行单纯LC。术中胆道造影示胆总管结石 7例 ,5例行LC术中联合内镜下括约肌切开取石 ,2例中转开腹行胆总管切开取石联合T管引流。无严重并发症发生。　结论　几乎所有胆囊管结石嵌顿都可用胆囊管切开取石的方法完成LC ,并结合术中胆道造影 ,如发现胆总管结石可联合内镜括约肌切开取石。     

Endoscopic retrograde cholangiopancreatography in conjunction with laparoscopic cholecystectomy

Summary Laparoscopic cholecystectomy (LC) has become the primary surgical treatment for symptomatic cholelithiasis. In conjunction with the dramatic rise in LC there has been an increase in the number of endoscopic retrograde cholangiopancreatographies (ERCPs) performed. For this study, the records of patients referred to the surgical endoscopy department between January 1991 and February 1992 were reviewed. Seventy-seven ERCPs were performed in conjunction with LC. The indications for ERCP included jaundice or a history of jaundice, gallstone pancreatitis, a suspicious filling defect on either ultrasound or intraoperative cholangiogram, abnormal liver function tests, cholangitis, or postoperative bile leak. Sixty-two procedures were performed prior to LC and 15 procedures after LC. Forty-two patients were female (54.5%) and the patients ages ranged from 14 to 92 years (mean 54.1 years). Of the 62 patients having ERCP preoperatively 35 patients (56.5%) had no evidence of common bile duct (CBD) stones and underwent LC as planned. Twenty-three patients were found to have CBD stones, of which six were referred for an open cholecystectomy and CBD exploration, because of large multiple CBD stones or the presence of a large duodenal diverticulum. Seventeen patients had their CBD cleared endoscopically, and four patients were not successfully cannulated.Fifteen patients had ERCP after LC. There were two patients with CBD injuries who were referred for surgical correction. Two patients had leakage from the cystic duct stump, and four patients had CBD stones, all of whom were successfully treated with endoscopic sphincterotomy. There were four patients who had a normal postoperative ERCP and two patients who could not have their CBD cannulated.There were no mortalities, but there were four cases of complications. Two patients had bleeding after stone extractions, and they required blood transfusions. One patient developed cholangitis from stenosis of the papilla after an endoscopic sphincterotomy, and one patient developed pancreatitis which resolved with conservative treatment. There is an increasing role for ERCP and sphincterotomy in patients undergoing LC. ERCP carries an inherent morbidity and therefore routine ERCP is not justified. However, with the proper suspicion of CBD stones a preoperative ERCP is indicated prior to a planned laparoscopic cholecystectomy.     

The endoscopic management of persistent bile leakage after laparoscopic cholecystectomy

Background: Bile leakage after laparoscopic biliary surgery is a surgical challenge in which endoscopy can play an important role. Methods: A total of 26 patients underwent endoscopic retrograde cholangiopancreatography (ERCP) in our department. Patients with evidence of major ductal injury were treated surgically. In all other cases, endoscopic sphincterotomy was performed, any retained bile duct stones were removed, and a biliary endoprosthesis or a nasobiliary catheter was inserted on a selective basis. Results: ERCP was successful in 24 patients. Seven patients were treated surgically after cholangiography revealed major ductal injury. Two more patients were eventually operated on due to bile peritonitis. Of the other 15 patients, 11 had leakage from the cystic duct and four had leakage from the gallbladder bed. Bile duct stones were removed from eight patients, an endoprosthesis were inserted in five patients, and a nasobiliary catheter was inserted in two patients. Bile leakage was treated successfully in all 15 patients with no further complications. Conclusion: ERCP is a means of safe diagnosing the cause of a bile leakage and offers a definitive treatment in most cases.     

返流性胆管炎与胆肠吻合术

目的 探讨返流性胆管炎的病因、治疗与胆肠吻合术的关系。方法 回顾性研究74例返流性胆管炎的病因、病理、治疗方法和效果。结果 胆道返流的主要原因为胆总管十二指肠吻合(19例)或Oddi括约肌切开(2例)术后和Oddi括约肌松弛，失去抗返流功能(53例)。反复胆道返流可导致肝胆系统急慢性炎症、结石再发。行胆管空肠Roux—en—Y型吻合术38例和胃部分切除胃空肠吻合术20例，观察6年半的优良率为83％。结论 反复胆道返流与胆管炎和结石再发密切相关，通过外科手术消除或减轻胆道返流因素，可获得良好的效果。     

单纯胆总管下段狭窄临床治疗选择:附43例报告

目的 探讨单纯胆总管下段狭窄的手术方法选择.方法 回顾性分析山东潍坊市人民医院2003年10月至2009年6月收治的43例单纯胆总管下段狭窄病人资料.43例中,12例行内窥镜下括约肌切开术(EST),9例手术行Oddis括约肌切开成形术,5例行胰十二指肠切除术,8例行胆总管-空肠R-Y吻合,5例行胆总管-十二指肠吻合,4例胆道探查扩张后"T"管引流.结果 未行根治的37例病人有6例于术后5～19个月出现占位性病变,5例再次行胰十二指肠切除术.结论 单纯胆总管下段狭窄临床应慎重处理.     

Surgery of the biliary tract in geriatric patients (author's transl)]

During 5 years 1311 operations for benign diseases of the biliary tract were performed. 281 patients were more than 70 years old, on the average 76,1 years. According to experience and the results the following is emphasized: 1. Complications of gallstones are relatively more frequent in old patients. 2. Cholecystectomy for chronic gall bladder disease should be performed even in old age. Our postoperative mortality rate was 2,5%, increasing to 15,1% when operation was done in a stage of complications. 3. Acute inflammatory cholecystitis should be treated by urgent operation, especially in old age. 4. Cholecystectomy is the method of choice for acute cholecystitis. Cholecystostomy is used only in few exceptional cases. 5. Cholangiometry and cholangiography are always executed, if the cystic duct can be cannulated, even in cases of acute inflammation. 6. If there are stones in the common duct or a stenosis of Oddi's sphineter is found, an acute inflammatory or perforated cholecystitis is no impediment for a one stage repair. 7. Cholangioscopy is the unsurpassable method for exploring the common duct, when it was opened or sphincterotomy was done. 8. Principally indications for transduodenal sphincterotomy are the same for all age groups. The postoperative mortality rate is not higher than after other operations involving the common duct. 9. In old age choledochoduodenostomy is sometimes a good alternative to sphicterotomy. 10. In cases of recurrent operation due to overlooked stones in the common duct or sclerosis of Oddi's sphincter the mortality rate is not higher than after primary interventions for such affections.     

Large bile duct stones treated by endoscopic biliary drainage

One hundred five patients with obstructive jaundice and cholangitis (49 patients), referred for diagnostic endoscopy, were found to have inextractable bile duct stones. Median age was 76 years and three quarters were more than 72 years of age. Insertion of an endoprosthesis with or without a sphincterotomy relieved jaundice in 94% and settled cholangitis in 90%. Antibiotic cover during the procedure seems essential inasmuch as pyrexia and septicemia occurred in 6 of 57 cases where it was not given. One case was lethal. Another patient died of acute pancreatitis. The patients were old. One quarter died before the follow-up, 1 to 5 years after the initial intervention. The results indicate that the combination of endoscopic sphincterotomy, insertion of an endoprosthesis, and, if feasible, stone extraction on a later occasion when the acute phase of the illness had subsided brought the disease sufficiently under control among three quarters of the patients with large common duct stones or stenoses in the biliary tract. One quarter of the patients were treated surgically. This was accomplished without mortality, but morbidity was not negligible. A policy with a surgical approach restricted to selected cases with persistent symptoms in spite of sufficient endoscopic drainage is recommended.     

内镜逆行胰胆管造影在肝移植后胆系并发症诊断和治疗中的作用

目的：评价内镜逆行胰胆管造影(ERCP)在肝移植术后胆系并发症诊治中的临床价值。方法：11例肝移植术后并发胆系并发症，其中吻合口狭窄4例，吻合口及供肝肝总管均狭窄2例，胆漏2例，多发性硬化性胆管炎样狭窄2例，移植肝胆总管与受者胆总管分离1例，分别行ERCP检查及治疗。结果：4例吻合口狭窄者，放置胆管塑料支架，2例吻合口和供肝肝总管均狭窄者放置Wallstenl，金属支架，上述6例近期黄疸均消退；2例胆漏者中，1例放置胆道塑料内支架，另1例行乳头括约肌切开术，均于2周内胆漏愈合；2例移植肝多发性硬化性胆管炎样狭窄者，1例行乳头括约肌切开后取出少量坏死胆管上皮样组织，另1例未行内镜治疗；1例移植肝胆总管与受者胆总管分离者再次手术行胆管吻合术。结论：内镜逆行胰胆管造影可用于肝移植术后的常见胆系并发症的诊断与治疗，可获得较好的近期疗效。     

Biliary complications following liver transplantation: single-center experience

Biliary complications (BC) following orthotopic liver transplantation (OLT) remain one of the major causes of postoperative complications and treatment failures. The list of common BC consists of biliary stricture, fistula, ischemic type biliary lesions (ITBL), cholangitis, and bile leakage following T-drain removal. Between July 2000 and December 2004, 101 consecutive cadaveric OLTs were performed in our institution. All but three were first full-size grafts. Seventeen patients were transplanted from the urgent list, the remaining 84 (83.16%) from the elective list. All but three patients had a choledochocholedochostomy over a straight drain. Bile cultures were taken routinely. The bile drain was removed following cholangiography 6 weeks after OLT. All patients received antibiotic prophylaxis. Ursodeoxycholic acid was used in selected cases. During the first 6 weeks positive bile cultures in absence of clinical and biochemical symptoms of cholangitis were found in 61 (60.4%) cases. Symptomatic cholangitis requiring antibiotic treatment was observed in 19 (18.8%) patients during the first 6 weeks. Two patients required endoscopic sphincterotomy and temporary stenting due to anastomotic stricture (1) or papilla of Vater fibrosis (1). Bile leakage following drain removal was observed in 8 (7.9%) patients. Five of them were treated conservatively, the remaining 3 (2.9%) required surgery (lavage) and stenting. In one case extrahepatic bile duct necrosis was diagnosed requiring reconstruction of the biliary anastomosis. No case of ITBL, bile leak at the anastomostic site, or stricture requiring surgical repair was noted. Despite the high incidence of positive bile cultures most likely related to use of a drain, the overall number of BC was low.     

Management of hemorrhage and perforation following endoscopic sphincterotomy]

Bleeding and perforation are rare but dangerous complications of diagnostic and therapeutic ERCP and endoscopic sphincterotomy (EST). To evaluate the clinical outcome of patients treated for complicated EST in our surgical department, data were collected prospectively between 1/1995 and 3/2000. A total of 9 patients were admitted to our department, 7 women and 2 men, average age 60 (range 41-72) years. 5 patients were treated for severe hemorrhage, all of them underwent laparotomy following duodenotomy and oversewing of the sphincterotomy site. In average 10 hours (range 4-20) after endoscopy. One of these patients died due to multiple organ failure. In 4 additional patients a retroperitoneal perforation was discovered, 2 of these patients underwent laparotomy and drainage of the retroperitoneal cavity. The other two patients were sufficiently treated by percutaneous drainage. One of the patients, who underwent surgical drainage for retroperitoneal perforation died.In conclusion for severe hemorrhage duodenotomy and oversewing of the bleeding site is recommended in combination with common bile duct T-drain or other draining procedures. The treatment for perforation should depend on the clinical finding. A laparotomy seems not always to be necessary.     

A simplified surgical approach in choledochal lithiasis reducing the complexity and severity of this surgery. Study of a series of 153 cases

The surgical treatment of stones of the common bile duct by transcystic extraction of stones without biliary and peritoneal drainage greatly simplifies biliary surgery. Postoperative course and average hospital stay are similar to those encountered after conventional cholecystectomy. This surgical option was successfully achieved in almost 60% of the 153 patients with stones of the common bile duct of our series, operated between 1981 and 1987. Other patients were treated more conventionally because of failure or impossibility of complete transcystic extraction of stones. A choledochoduodenostomy was performed in 28 patients. In a limited number of patients (n = 12) endoscopic sphincterotomy was associated pre or postoperatively with the surgical treatment. Although 25% of the patients were older than 75 years, there was no operative mortality, which demonstrates that biliary surgery can be performed safely without any vital risk. Successful transcystic extraction of stones simplifies the course of stones of the common bile duct and should be attempt more often.     

Risks of leaving the gallbladder in situ after endoscopic sphincterotomy for bile duct stones

There is controversy concerning the subsequent clinical course of patients whose gallbladder is left in situ following successful endoscopic removal of stones from their common bile ducts. A total of 191 patients (median age 76 years) were reviewed between 12 and 100 months (mean 38 months) after endoscopic sphincterotomy. Ten patients (5.2 per cent) had symptoms requiring cholecystectomy which was uneventful, nine in the first year. Cholangitis at presentation or failure to fill the gallbladder by endoscopic retrograde cholangiography were not helpful in identifying these patients. Forty-nine (25.6 per cent) patients died during the review period from non-biliary pathology (usually cardiovascular). Elective cholecystectomy is not required in elderly patients with symptomatic bile duct stones if the common bile duct can be cleared of stones after endoscopic sphincterotomy.