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

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

Clinical and biochemical comparative study of different types of common bile duct stones.

BACKGROUND: The chemical composition of common bile duct (CBD) stones may have significance with regard to the origin, clinical presentation and treatment. OBJECTIVE: To study the chemical composition of CBD stones and compare different types of CBD stones. METHODS: Consecutive patients with CBD stones seen over a 1-year period were studied prospectively. Their stones were analyzed for cholesterol, bilirubin and calcium contents. RESULTS: Of 74 patients with CBD stones, 42 had associated gall bladder (GB) stones (Group 1), 14 had post-cholecystectomy CBD stones (Group 2) and 18 had CBD stones with a stoneless GB in situ (Group 3). Of the 40 patients whose CBD stones were analyzed, 34 (85%; 18/19 in Group 1, 5/6 in Group 2 and 11/15 in Group 3) had cholesterol stones; the remaining 6 patients had pigment stones. CONCLUSION: Most CBD stones in northern Indian patients are cholesterol stones. Even in patients with isolated CBD stones (with stoneless GB in situ), three-quarters are cholesterol stones.     

Management of acute cholangitis

Endoscopic sphincterotomy (ES) is the treatment of choice for patients with (severe) acute cholangitis. For fit patients without co-morbidity with mild cholangitis and CBD stones with a gallbladder in situ, the one-stage laparoscopic approach could be considered as an alternative in centers with sufficient experience. The results of both procedures are comparable. Open surgery is relatively safe. It has a high success rate, good/excellent long-term results, but is not very attractive for the patient and should not be used routinely nowadays. Therefore, the indication should be limited for management of severe complications after ES as perforations of the duodenum, large CBD stones and patients with Mirizzi's syndrome or intrahepatic stones with stenosis of the bile duct. ES as primary treatment for CBD stones should be followed by laparoscopic cholecystectomy in 'fit' patients. In patients with malignant disease, particularly after repeated stent failure and subsequent cholangitis, bypass surgery should be considered in patients with a life expectancy of >3 months.     

Selection criteria for pre-operative endoscopic retrograde cholangiography and endoscopic-laparoscopic treatment of biliary stones.

OBJECTIVE: Pre-operative endoscopic retrograde cholangiography (ERCP) prior to laparoscopic cholecystectomy (LC) is the most common treatment of gallbladder and common bile duct (CBD) stones. In this study we evaluate our selection criteria for pre-operative ERCP and the results of endoscopic-laparoscopic treatment in patients with CBD stones. DESIGN: Consecutive adult patients admitted to the department of surgery because of symptomatic cholelithiasis were included in a prospective open trial. PARTICIPANTS: Between January 1996 and December 1996, 841 patients underwent LC at our hospital. ERCP pre-LC was performed in 95 of the 841 patients, on the basis of our selection criteria. INTERVENTIONS: The indication to perform ERCP was suggested by a dilatated CBD (> 10 mm) or ductal stones, abnormal serum liver tests, persisting for more than 3 days, jaundice, cholangitis or pancreatitis. Twelve months after surgery, all patients were contacted by telephone to exclude symptoms related to residual stones. RESULTS: Cannulation of the CBD was successful in 94 of 95 patients submitted to pre-LC ERCP. CBD stones were found in 87 patients (95.6%) in 22 of whom (25.2%) they were in the form of small stones or sludge. In only three of 94 patients (3.2%) no alterations of the CBD or papilla were found. Complications occurred in eight of 98 patients (in five after endoscopic sphincterotomy (ES), and in three after LC). CONCLUSIONS: Pre-operative ES in selected patients with coexisting gallbladder and CBD stones has been a good approach and the criteria that we used for selection of patients to be submitted to pre-operative ERCP/ES seem to be effective.     

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

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

Does endoscopic sphincterotomy cause prolonged pancreatobiliary reflux?

OBJECTIVE: Endoscopic sphincterotomy (ES) reduces sphincter function, which may allow reflux of pancreatic juice and intestinal contents into the common bile duct. The reflux, if present, may cause development of biliary tract carcinomas, as may anomalous pancreaticobiliary junction. We prospectively investigated pancreatobiliary and duodenobiliary reflux after ES. METHODS: In 15 patients with choledocholithiasis, ductal bile was sampled for amylase concentration and bacterial culture during endoscopic retrograde cholangiopancreatography, before and at 7 days to 5 yr after ES. To provide comparative data, ductal bile was sampled in 11 patients with gallbladder cholesterol polyps or anomalous pancreaticobiliary junction who did not undergo ES. RESULTS: Amylase concentration of ductal bile in patients with choledocholithiasis before ES was not different from that in patients with gallbladder polyps. Its concentration was increased 7 days after ES compared with that before ES, reaching the level of that in patients with anomalous pancreaticobiliary junction. Thereafter, amylase concentration gradually decreased, returning to that before ES by 1 yr. After ES, bactobilia occurred in 60-80% of patients, although none developed acute cholangitis. CONCLUSIONS: Although ES causes transient pancreatobiliary reflux, the reflux is abolished by 1 yr after ES. ES is unlikely to increase the risk for development of biliary tract carcinoma as long as cholangitis or bile duct stones do not recur.     

Endoscopic sphincterotomy for common bile duct calculi in patients without stones in the gallbladder

Endoscopic sphincterotomy (ES) was performed in 25 patients for common bile duct (CBD) calculi in the absence of stones in the gallbladder. Eighteen of these patients were considered unfit for surgery because of age or concomitant disease. All ES procedures were technically successful with complete evacuation of the CBD in all cases. Early complications occurred in only one patient, a 91-year-old female who died from nonbiliary tract disease. Long-term follow up over a period of 42 months was available in 19 of the 24 patients. Late complications occurred in two patients (10%), both of whom developed cholecystitis; they underwent surgery without subsequent morbidity or mortality. This 10% incidence of long-term complications is similar to that of other series that did not differentiate between patients with isolated CBD calculi and those with stones also present in the gallbladder. The observed complication rate does not justify routine prophylactic cholecystectomy after ES for isolated CBD stones.     

Utility of Endoscopic Retrograde Cholangiopancreatography in the Evaluation of Idiopathic Abdominal Pain

We investigated the role of endoscopic retrograde cholangiopancreatography in 86 consecutive patients with idiopathic chronic or recurrent abdominal pain. There were 18 males and 68 females with a mean age of 48 yr. Forty patients (47%) had previous cholecystectomy. Patients were divided into two groups: group I (normal serum alkaline phosphatase and total bilirubin) (n = 52), and group II (elevated serum alkaline phosphatase and/or total bilirubin) (n = 34). Panereatograms were normal in all patients, including five with pancreas divisum. Cholangiograms were abnormal in 10 of the 34 patients in group II (30%), and in only three of the 52 patients in group I (6%) ( p = 0.003). Bile duct stones were present in 18% of the patients in group II, and in none of the patients in group I ( p = 0.003). Of the 40 post-cholecystectomy patients, four patients had bile duct stones and five had common bile duct dilation without stones. However, no stones were found in any post-cholecystectomy patients with normal liver tests. Of the 46 patients with gallbladder in situ , two patients with abnormal liver tests had common bile duct stones and two patients had common bile duct dilation without stones. These results indicate that, among patients with idiopathic abdominal pain, cholangiography should be performed primarily in those with abnormal liver tests; however, further investigation with pancreatography is unnecessary.     

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

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

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

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

Does endoscopic sphincterotomy reduce the recurrence rate of cholangitis in patients with cholangitis and suspected of a common bile duct stone not detected by ERCP?

BACKGROUND: It has not been established whether endoscopic sphincterotomy (ES) prevents subsequent cholangitis in patients with cholangitis and with a common bile duct (CBD) stone not documented by ERCP. OBJECTIVE: The aim of this study was to investigate the role of ES on the recurrence of cholangitis in patients with a high probability of having a CBD stone, not demonstrated by ERCP. DESIGN AND PATIENTS: A total of 117 patients who were diagnosed as having cholangitis and a high probability of a CBD stone, not detected by ERCP, were retrospectively reviewed. Cumulative recurrence rates of cholangitis were compared for treatments with and without ES. SETTING: Multicenter, retrospective study. INTERVENTIONS: ES. MAIN OUTCOME MEASUREMENTS: Cumulative recurrence of cholangitis after ERCP. RESULTS: Eighty-three patients underwent ES (ES group) and 34 patients did not (non-ES group). No statistically significant differences between the 2 groups were evident in terms of demographic factors or laboratory findings. The mean (standard deviation) follow-up was 22.1 +/- 17.2 months (range 3-66 months) in the ES group and 23.3 +/- 14.9 months (range 6-84 months) in the non-ES group (P = .72). The cumulative rates of cholangitis were 6.3% (4.8% vs 9.9%) at 1 year, 15.6% (9.2% vs 29.3%) at 3 years, and 19.5% (9.2% vs 52.9%) at 5 years for ES vs non-ES groups, respectively (P = .04). By multivariate analysis, ES reduced cholangitis recurrence, with a hazard ratio of 0.305 (95% CI 0.095-0.975, P = .045). LIMITATIONS: Retrospective study. CONCLUSIONS: ES reduced further episodes of cholangitis in patients with an episode of cholangitis and a high probability of choledocholithiasis, despite the lack of a CBD stone seen on ERCP.     

Common bile duct stones: management strategies in the laparoscopic era

We reviewed our experience with the treatment of common bile duct (CBD) stones in 70 patients by sequential endoscopic-laparoscopic management and single-stage laparoscopic treatment during the past 7 years. The advantages, disadvantages, and feasibility of the two procedures are discussed to elucidate therapeutic strategies for patients harboring gallbladder stones and associated choledocholithiasis. In 44 patients, sequential endoscopic-laparoscopic management was indicatedd, and was successful in 37 of them but, in seven patients endoscopic stone extraction could not be accomplished. Single-stage laparoscopic treatment was attempted in 26 patients. In practice, laparoscopic transcystic common duct exploration or choledochotomy may not always be feasible if the cystic duct or CBD are not dilated; there is a high risk of intraoperative CBD injury in such circumstances. Laparoscopic management was considered to be especially useful for the treatment of numerous, large or difficult stones, because stone removal could be succesfully performed without any injury to the papilla of Vater. This last issue is of particular importance in patients with dilated CBD, because insufficient opening of the ampulla of Vater made by endoscopic sphincterotomy (EST) may lead to stasis and reflux-related complications such as cholangitis and recurrent stones. We conclude that the most rational management of CBD stones should be decided according to the size of the CBD, which depends on the size, number, and location of stones. Patients with dilated CBD are indicated to under-go laparoscopic single-stage treatment and combined endoscopic-laparoscopic treatment may be best for patients with non-dilated CBD.     

Endoscopic sphincterotomy in the management of bile duct stones in children

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

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

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

Bacteriology and antimicrobial susceptibility in biliary tract disease: an audit of 10-year's experience

Cholelithiasis, choledocholithiasis and hepatolithiasis are common biliary tract diseases. These diseases may cause severe infection and/or sepsis. In addition to surgical treatments, prompt administration of appropriate antibiotic is important to control the biliary tract infection. The purpose of this study is to illustrate the bacteriology in biliary tract disease and provide information for antibiotic choices. From Jan 1991 to Aug 2000, 1394 patients including gallbladder (GB) stones, common bile duct (CBD) stones, intrahepatic duct (IHD) stones, GB polyps and biliary malignancy were subjects for this retrospective study. The overall positive rate of bile culture is 36% in this study while it was 25%, 66%, 67% and 9% for GB stones, CBD stones, IHD stones and biliary malignancy, respectively. A significantly higher (p = 0.001) positive culture rate was found for GB stones with acute cholecystits (47%) compared with that without inflammation (17%). Similarly, the culture rate for hepatolithiasis with acute cholangitis was higher than that without cholangitis (75% vs 51%, p = 0.011). Long-term external biliary drainage in biliary malignancy increased the risk of bacterial culture rate. For gallstone diseases, the most common organisms cultured were Gram negative bacteria (74%), in which Escherichia coli (36%) and Klebsiella (15%) were most commonly found, followed by Gram positive (15%) bacteria such as Enterococcus (6%), Staphylcoccus (3%), Streptococcus (2%). Bacteroides (5%) and Clostridium (3%) were occasionally found anaerobes (9%). Polymicrobial infection was encountered in 19%, 31% and 29% for patients with GB stones, CBD stones and IHD stones, respectively; frequency of mixed aerobic and anaerobic infection was 7%, 12% and 9%. In the current study, ampicillin in combination with sulbactam and aminoglycoside is still a suggestive empirical therapy. Antibiotic treatment should be adjusted based on later bacteriological cultures and clinical condition.     

Bile duct clearance,endoscopic or laparoscopic?

Endoscopic sphincterotomy (ES) has become the gold standard nonoperative modality for the removal of common bile duct (CBD) stones. Morbidity is 2%–10%, and mortality less than 2%. Immediate complications include bleeding, cholangitis, pancreatitis, and duodenal perforation, but many of these can be prevented by using various tools, including an alternating coagulating and cutting diathermy unit, routine biliary stenting, frequent use of guide‐wires to avoid precutting, and mechanical lithotripsy. Long‐term results have shown that the stone recurrence rate reaches 15%, probably due to a strong recurrent tendency inherent to bilirubinate stones. Choice of the appropriate lithotomy modality is of paramount importance to reduce invasiveness. ES is the choice for recurrent or residual stones and for choledocholithiasis alone. Acalculous gallbladders left in place carry no risk of acute cholecystitis. In patients with cholecystocholedocholithiasis, CBD stones should be removed via the cystic duct or by choledochotomy during laparoscopic cholecystectomy, not to preserve the sphincter of Oddi but to reduce the interventional burden. Safety and safeguards of papillary balloon dilation must still be investigated in a limited number of institutions. Marked progress in lithotomy/lithotripsy procedures has almost obviated the need for laparotomy. Patients with CBD stones benefit from the less invasive and more efficient modalities of transpapillary, percutaneous, and laparoscopic lithotomy.     

IMPACT OF ENDOSCOPIC TRANSPAPILLARY NASO‐GALLBLADDER DRAINAGE AFTER ENDOSCOPIC SPHINCTEROTOMY IN PATIENTS WITH ACUTE CHOLECYSTITIS AND CHOLEDOCHOLITHIASIS

Aim: To evaluate prospectively the efficacy of endoscopic transpapillary naso‐gallbladder drainage (ETGBD) after endoscopic sphincterotomy (ES) in patients with acute cholecystitis with choledocholithiasis. Patients: Twenty‐six patients with acute cholecystitis and choledocholithiasis, but without pericholecystic liver abscess, were evaluated. After ES and extraction of stones, ETGBD was performed immediately. Results: In 24 of the 26 patients with ES, complete bile duct clearance was achieved. In the other two cases treated with ES, stones could be completely removed in an additional session after ETGBD. ETGBD was successfully performed in 23 patients (88%). In three patients with unsuccessful ETGBD, a percutaneous cholecystostomy (PC) was performed. Of the 23 patients that underwent ETGBD, a positive clinical response at 72 h was seen in 22 (96%) patients. In one patient who did not show a clinical response at 72 h, catheter drainage was continued and a positive clinical response was seen 5 days after the procedure. In three patients treated with PC, a clinical response at 72 h was seen in all cases (100%). No major procedure‐related complications occurred. Conclusions: ETGBD after ES proved useful in the management of acute cholecystitis and choledocholithiasis.     

Preoperative endoscopic sphincterotomy in the treatment of patients with cholecystocholedocholithiasis

Preoperative endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) prior to laparoscopic cholecystectomy (LC) are the most common methods for the diagnosis and treatment of patients with cholecystocholedocholithiasis. We evaluated the selection criteria for preoperative ERCP examination and the results of endoscopic‐laparoscopic treatment of patients with choledocholithiasis. Between January 1993 and December 1998, 1630 patients with symptomatic cholelithiasis were admitted for surgical intervention. Preoperative ERCP was performed in 247 patients according to the selection criteria. The criteria to perform ERCP were dilated common bile duct (CBD; more than 8mm), abnormal serum liver test results, and a recent history of pancreatitis. Endoscopic sphincterotomy (ES) was performed if CBD stones were found during the procedure. LC was then carried out within 3 days after ES. Of the 247 patients selected for preoperative ERCP, CBD stones were confirmed in 146 patients (59.1%). ES was successful in 141 patients, and stone clearance was achieved in 133 patients, resulting in a 94.3% success rate. Eight patients (5.5%) had complications after endoscopic intervention, all of which resolved uneventfully. Open operative procedures were carried out in a total of 31 patients. Overall, 115 patients were successfully treated by this endoscopic laparoscopic sequence. The length of hospital stay in these groups was significantly lower than that for patients in whom an open method was employed. Preoperative ES combined with LC is a safe and effective therapy for cholecystocholedocholithiasis, and the criteria that we used for the selection of patients seem to be appropriate.     

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.     

Acute transient hepatocellular injury in cholelithiasis and cholecystitis without evidence of choledocholithiasis

AIM： To investigate acute transient hepatocellular injury in patients with cholelithiasis and cholecystitis but no evidence of choledocholithiasis.
METHODS： The medical records of patients with cholelithiasis who underwent cholecystectomy between July 2003 and June 2007 were retrospectively reviewed. Imaging studies to detect common bile duct （CBD） stones were performed in 186 patients, who constituted the study population. Biochemical liver tests before and after surgery, and with the presence or absence of CBD stones were analyzed.
RESULTS： In 96 patients with cholelithiasis and cholecystitis without evidence of CBD stones, 49 （51.0%） had an alanine aminotransferase level elevated to 2-3 times the upper limit of normal, and 40 （41.2%） had an elevated aspartate aminotransferase level. Similar manifestations of hepatocellular injury were, as would be expected, even more obvious in the 90 patients with CBD stones. These markers of hepatocellular injury resolved almost completely within 2 wk to 1 mo after cholecystectomy. Compared to 59 patients with histologically less severe cholecystitis
in the group undergoing urgent surgery （total 74 patients）, the 15 patients with a gangrenous gallbladder had a higher mean level of total bilirubin （2.14 ± 1.27 mg/dL vs 2.66 ± 2.97 mg/dL, P 〈 0.001） and white cell count （9480 ± 4681/μL vs 12840 ± 5273/μL, P = 0.018）.CONCLUSION： Acute hepatocellular injury in cholelithiasis and cholecystitis without choledocholithiasis is mild and transient. Hyperbilirubinemia and leukocytosis may predict severe inflammatory changes in the gallbladder.