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     

胆总管结石十二指肠镜治疗后复发因素研究

目的 探讨胆总管结石经ERCP治疗后复发的相关因素.方法 选择资料完整经ERCP治疗的胆总管结石患者,共802例,其中297例伴胆囊结石,222例胆囊已切除,283例胆囊无结石,统计复发频度并对复发因素进行单变量和多变量logistic回归分析.结果 802例患者平均随访84.8个月,92例（11.5%）结石复发.胆囊结石,胆总管直径≥1.5 cm,机械碎石及胆管角度≤120°在单因素及多因素分析中均显示为复发因素;胆固醇结石,乳头狭窄或Oddi括约肌功能障碍在多因素分析中为复发因素;胆囊切除,毕Ⅱ式胃大部切除,结石≥1.5 cm及多发结石在单因素分析中为复发因素.结论 ERCP治疗胆总管结石的病例中胆囊结石,胆总管直径≥1.5 cm,机械碎石及胆管角度≤120°可能为主要的复发因素;胆囊切除,毕Ⅱ式胃大部切除,乳头狭窄或Oddi括约肌功能障碍,结石≥1.5 cm,胆固醇结石及多发结石也是复发相关因素.     

Management of gallstone pancreatitis: cholecystectomy or ERCP and endoscopic sphincterotomy

BACKGROUND: Currently, cholecystectomy is recommended for patients with gallstone-induced pancreatitis. ERCP with endoscopic sphincterotomy (ES) within 24 to 48 hours is also suggested for the treatment of acute gallstone pancreatitis. The aim of this study was to determine outcome after cholecystectomy versus ES alone in patients with gallstone pancreatitis. METHODS: One hundred seventeen patients with gallstone pancreatitis were included in this prospective observational study. Inclusion criteria were typical abdominal pain; serum amylase level 3 times or greater than normal; and gallbladder stones and a dilated bile duct, with or without stones, by US, CT, or ERCP. RESULTS: Eighty-three patients (Group A) underwent cholecystectomy after initial evaluation including ERCP in 43 (53%) and ERCP with ES in 38 (47%). The remaining 34 (Group B) underwent successful ERCP with ES alone. Mean follow-up was 33 months for Group A and 34 months for Group B. Recurrent gallstone pancreatitis was noted in 2 patients (2.4%) in Group A (bile duct stone in 2, sludge and papillary stenosis in 1), and in 1 patient (2.9%) in Group B. Ten patients in Group B had follow-up US of the gallbladder that showed disappearance of stones in 3. During follow-up, there was no significant difference in the rates of biliary complications (Group A, 3.6% vs. Group B, 11.6%; p = 0.19) or serious complications (pancreatitis, cholecystitis, cholangitis) (Group A, 3.6% vs. Group B, 5.8%). Also, there was no significant difference in procedure-related complications. CONCLUSIONS: Recurrence of pancreatitis after ERCP with ES alone for gallstone pancreatitis is rare. In patients who have undergone ES alone, cholecystectomy should be considered only if there are overt manifestations of gallbladder disease (e.g., biliary pain, cholecystitis, cystic duct obstruction) and not for prevention of recurrent gallstone pancreatitis. Because treatment by ES alone may be associated with a higher risk of biliary complications during follow-up compared with cholecystectomy, these patients may require close surveillance.     

Trypsin level in gallbladder bile and ductitis and width of the cystic duct

BACKGROUND/AIMS: The change from laparotomy to laparoscopy for cholecystectomy has raised the question of how to manage concomitant bile duct stones. The present-day interest--and controversy--has focused on a transcystic approach reported to be feasible in 66-96% of cases, but without explaining the necessary prerequisite: the widening of the cystic duct. The cystic duct, wide mainly in patients with bile duct stones, has been reported to be highly variable: from strictured to very wide. The present study aims at comparing the trypsin level in the gallbladder bile and the cystic duct morphology and width in patients with and without bile duct stones. METHODOLOGY: A prospective series of 63 gallstone patients, 30 with and 33 without bile duct stones (controls), underwent cholecystectomy and bile duct clearance. The study includes the trypsin level in the gallbladder bile, the width and morphology of the cystic duct, and the size of the gallstones. RESULTS: The patients with bile duct stones had, in contrast to the controls, higher trypsin levels in the gallbladder bile (P < 0.001) and wider cystic ducts (P < 0.001) with more pronounced signs of chronic ductitis. CONCLUSIONS: The obtained results strongly suggest that the increased trypsin level, a sign of reflux of pancreatic juice, caused changes in the cystic duct that facilitate gallstone migration, which also ought to render a transcystic stone extraction feasible.     

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.     

Current management of the gallbladder after endoscopic sphincterotomy for common bile duct stones

Background: Traditionally, a cholecystectomy is performed after successful endoscopic sphincterotomy and removal of common bile duct (CBD) stones, except in patients of advanced age or with substantial comorbidity. In practice, however, the gallbladder is left in situ more frequently now in patients without contraindications for surgery. The criteria by which patients are selected for an elective cholecystectomy are unclear. The aim of the present study was to establish the proportion of patients for whom a “wait-and-see” strategy was advised and to determine which, if any, patient characteristics had influenced this decision. Methods: This study included 71 patients, all younger than 80 years of age, with both CBD stones and a gallbladder containing stones in whom endoscopic clearance of bile duct stones was achieved. Results: Three patients underwent a cholecystectomy within 1 week because of acute cholecystitis. Among the remaining 68 patients, cholecystectomy was recommended for 42 patients and a wait-and-see strategy was advised for 26 patients. Patient characteristics were identical in both groups except for the American Society of Anesthesiologists Physical Status (ASA) score. The ASA score was higher in the wait-and-see group, but 69% of the patients in this group had an ASA score of I or II. Six patients in the wait-and-see group had symptoms; five patients underwent cholecystectomy. The outcome of surgery was no worse in this group than in the cholecystectomy group. Conclusions: Selection of patients for either elective cholecystectomy or wait-and-see was not based on established criteria but mainly dependent on preference of the specialist. The outcome of surgery, indicated in 23% of the patients in the wait-and-see group was comparable with elective cholecystectomy. A controlled trial comparing both treatment options in patients younger than 80 years of age should be performed. (Gastrointest Endosc 1997;46:514-9.)     

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.     

RISK FACTORS FOR RECURRENT BILE DUCT STONES AFTER ENDOSCOPIC PAPILLARY BALLOON DILATION: LONG‐TERM FOLLOW‐UP STUDY

Background: Little is known about the long‐term results of endoscopic papillary balloon dilation (EPBD) for bile duct stones. Methods: Between 1995 and 2000, 204 patients with bile duct stones successfully underwent EPBD and stone removal. Complete stone clearance was confirmed using balloon cholangiography and intraductal ultrasonography (IDUS). Long‐term outcomes of EPBD were investigated retrospectively in the year 2007, and risk factors for stone recurrence were multivariately analyzed. Results: Long‐term information was available in 182 cases (89.2%), with a mean overall follow‐up duration of 9.3 years. Late biliary complications occurred in 22 patients (12.1%), stone recurrence in 13 (7.1%), cholangitis in 10 (5.5%), cholecystitis in four, and gallstone pancreatitis in one. In 11 of 13 patients (84.6%), stone recurrence developed within 3 years after EPBD. All recurrent stones were bilirubinate. Multivariate analysis identified three risk factors for stone recurrence: dilated bile duct (>15 mm), previous cholecystectomy, and no confirmation of clean duct using IDUS. Conclusion: Approximately 7% of patients develop stone recurrence after EPBD; however, retreatment with endoscopic retrograde cholangiopancreatography is effective. Careful follow up is necessary in patients with dilated bile duct or previous cholecystectomy. IDUS is useful for reducing stone recurrence after EPBD.     

Management of unsuspected common bile duct stones found during laparoscopic cholecystectomy by means of transcystic catheter placement and papillary dilation

BACKGROUND: The optimal treatment strategy for treatment of bile duct stones first diagnosed during laparoscopic cholecystectomy has not been established. We prospectively treated unsuspected bile duct stones by means of intraoperative placement of a transcystic catheter followed by postoperative pharmacologic papillary dilation or endoscopic papillary balloon dilation. METHODS: In 17 patients with bile duct stones first found at laparoscopic cholecystectomy, a catheter was introduced via the cystic duct into the bile duct. If postoperative cholangiography via a transcystic catheter showed stones 5 mm or less in diameter, glyceryl trinitrate was infused via the catheter into the bile duct. Patients in whom medical dilation was unsuccessful or who had larger stones underwent endoscopic papillary balloon dilation. RESULTS: Stone diameter measured 3 to 11 mm (mean 6.4 mm). Postoperative cholangiography revealed spontaneous passage in four patients. After pharmacologic papillary dilation, two of five patients with stones 5 mm or less in diameter had stone clearance. The remaining 11 patients underwent successful endoscopic papillary balloon dilation with stone clearance. In two patients, a guidewire introduced via a transcystic catheter through the papilla facilitated selective biliary cannulation. One early minor complication occurred. All patients remained without symptoms for a mean follow-up of 13 months. CONCLUSION: For unsuspected bile duct stones (usually small ones), this strategy is a simple and effective alternative to laparoscopic bile duct exploration and postoperative sphincterotomy and may minimize early and late complications. Transcystic catheterization ensures access to the bile duct, thereby avoiding endoscopic treatment failures.     

Endoscopic papillary balloon dilation for bile duct stone removal in patients 60 years old or younger

Background

The aim of this study was to evaluate short- and long-term outcomes in relatively young patients (≤60 years old) who underwent endoscopic papillary balloon dilation (EPBD) for bile duct stone removal.

Methods

Immediate and long-term outcomes were evaluated in 311 patients who were 60 years old or younger at the time of EPBD. The stone recurrence rate was compared among four groups stratified according to gallbladder (GB) status before and after EPBD (cholecystectomy after EPBD, GB left in situ with stones, GB left in situ without stones, and cholecystectomy before EPBD).

Results

Bile duct stones were completely removed via EPBD alone in 304 patients (97.7%). Post-EPBD pancreatitis occurred in 24 patients (7.7%), and was mild in 18 patients, moderate in 5 patients, and severe in 1 patient. The rate of pancreatitis was significantly higher in these patients than in patients aged more than 60 years who underwent EPBD during the same study period (4.7%). Long-term outcomes were evaluated in 217 patients who were followed for at least 1 year after complete stone removal via EPBD. During a mean follow-up period of 5.6 years (range, 1.0–13.4 years), stone recurrence was observed in 13 patients (6.0%). The cumulative stone recurrence rates at 5 and 10 years after EPBD were 5.9 and 7.1%, respectively. Patients in the cholecystectomy after EPBD group had the lowest risk of stone recurrence among the four groups (2.0%).

Conclusion

EPBD removes bile duct stones in the majority of younger patients without increasing the risk of severe pancreatitis. Post-EPBD pancreatitis is more likely to occur in younger patients as compared to older patients. The long-term outcomes of EPBD appear favorable, especially in patients who have undergone cholecystectomy after EPBD.     

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.     

Failure of sequential biliary stenting for unsuccessful common bile duct stone removal

AIM: To determine the factors associated with the failure of stone removal by a biliary stenting strategy.METHODS: We retrospectively reviewed 645 patients with common bile duct (CBD) stones who underwent endoscopic retrograde cholangiography for stone removal in Siriraj GI Endoscopy center, Siriraj Hospital from June 2009 to June 2012. A total of 42 patients with unsuccessful initial removal of large CBD stones that underwent sequential biliary stenting were enrolled in the present study. The demographic data, laboratory results, stone characteristics, procedure details, and clinical outcomes were recorded and analyzed. In addition, the patients were classified into two groups based on outcome, successful or failed sequential biliary stenting, and the above factors were compared.RESULTS: Among the initial 42 patients with unsuccessful initial removal of large CBD stones, there were 37 successful biliary stenting cases and five failed cases. Complete CBD clearance was achieved in 88.0% of cases. The average number of sessions needed before complete stone removal was achieved was 2.43 at an average of 25 wk after the first procedure. Complications during the follow-up period occurred in 19.1% of cases, comprising ascending cholangitis (14.3%) and pancreatitis (4.8%). The factors associated with failure of complete CBD stone clearance in the biliary stenting group were unchanged CBD stone size after the first biliary stenting attempt (10.2 wk) and a greater number of endoscopic retrograde cholangio-pancreatography sessions performed (4.2 sessions).CONCLUSION: The sequential biliary stenting is an effective management strategy for the failure of initial large CBD stone removal.     

Small gallstones are associated with increased risk of acute pancreatitis: potential benefits of prophylactic cholecystectomy?

OBJECTIVES: Pancreatitis is a severe complication of gallstone disease with considerable mortality. Small gallstones may increase the risk of pancreatitis. Our aims were to evaluate potential association of small stones with pancreatitis and potential beneficial effects of prophylactic cholecystectomy. METHODS: Stone characteristics were determined in patients with biliary pancreatitis (115), obstructive jaundice due to gallstones (103), acute cholecystitis (79), or uncomplicated gallstone disease (231). Sizes and numbers of gallbladder and bile duct stones were determined by ultrasonography and endoscopic retrograde cholangiopancreatography, respectively. Effects of prophylactic cholecystectomy were assessed by decision analyses with a Markov model and Monte Carlo simulations. RESULTS: Patients with pancreatitis or obstructive jaundice had more and smaller gallbladder stones than those with acute cholecystitis or uncomplicated disease (diameters of smallest stones: 3 +/- 1, 4 +/- 1, 8 +/- 1, and 9 +/- 1 mm, respectively, p < 0.01). Bile duct stones were smaller in case of pancreatitis than in obstructive jaundice (diameters of smallest stones: 4 +/- 1 vs 8 +/- 1, p < 0.01). Multivariate analysis identified old age and small stones as independent risk factors for pancreatitis. Decision analysis in a representative group of patients with small (相似文献   

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.     

Factors influencing the technical difficulty of endoscopic clearance of bile duct stones

BACKGROUND: There has been no report concerning the factors that contribute to the technical difficulty of endoscopic clearance of common bile duct (CBD) stones. OBJECTIVE: Our purpose was to determine the factors that contribute to the technical difficulty of endoscopic clearance of CBD stones. DESIGN: Prospective study. SETTING: A tertiary referral endoscopy center. PATIENTS: A total of 102 patients who underwent ERCP, endoscopic biliary sphincterotomy, and CBD stone extraction at our institution from August 2004 to September 2006. MAIN OUTCOME MEASUREMENTS: The technical difficulty of CBD stone clearance was graded as follows: easy, moderately difficult, very difficult, and failed. Distal CBD angulation seen on cholangiogram was defined as the first angulation from the ampullary orifice with the patients in the prone position and the distal arm of CBD angulation as the length (in millimeters) between angular point and ampullary orifice. RESULTS: Older age (>65 years), previous gastrojejunostomy, larger CBD stone (>/=15 mm), impacted CBD stone, use of mechanical lithotripsy, shorter length of the distal CBD arm (相似文献   

Endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy during the same session:Feasibility and safety

AIM:To explore the feasibility and safety of endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy(LC)performed during the same session.METHODS:Between July 2010 and May 2013,156patients with gallstones and common bile duct(CBD)stones were enrolled in this retrospective study.According to the sequence of endoscopic procedures and LC,patients were classified into two groups:in group1,patients underwent endoscopic stone extraction and LC during the same session,and in group 2,patients underwent LC at least 3 d after endoscopic stone extraction.Outcomes of the endoscopic procedures and LC were compared between the two groups,respectively.RESULTS:There were 91 patients in group 1 and65 patients in group 2.The characteristics of the two groups were similar.The mean duration of the endoscopic procedures was 34.9 min in group 1 and 35.3min in group 2.There were no significant differences in the success rate of the endoscopic procedures(97.8%for group 1 vs 98.5%for group 2),the total rate of endoscopic complications(4.40%for group 1 vs 4.62%for group 2)and CBD stone clearance rate(96.7%for group 1 vs 96.9%for group 2).Duration of LC was53.6 min in group 1 and 52.8 min in group 2.There were no significant differences in the overall LC-related morbidity and postoperative hospital stay.CONCLUSION:Endoscopic stone extraction and LC performed during the same session was feasible and safe in patients with gallstones and concomitant CBD stones.     

Laparoscopic cholecystectomy and intraoperative endoscopic sphincterotomy in the treatment of cholecysto-choledocholithiasis.

BACKGROUND: A single-stage minimally invasive procedure would be optimal for management of cholecysto-choledocholithiasis. Two alternative strategies are available: management by laparoscopy alone or a combined laparoscopic-endoscopic approach. This study evaluates the results of the latter procedure. METHODS: From June 1993 to September 1997, 1400 patients with symptomatic biliary stone disease were evaluated for laparoscopic cholecystectomy. Intraoperative cholangiography was performed on the basis of a preoperative suspicion of bile duct stones; bile duct stone treatment was by intraoperative endoscopic retrograde sphincterotomy. RESULTS: Intraoperative cholangiography was performed because of a preoperative suspicion of a bile duct abnormality in 141 of 1400 patients (10%) undergoing laparoscopic cholecystectomy because of biliary stone disease. Of those 141 patients, 54 (38.3%) presented with pathologic findings (bile duct stone [52] and papillary stenosis [2]); all 54 underwent intraoperative endoscopic sphincterotomy. Complete clearance of the ductal stones was achieved in 43 patients (82.7%) by intraoperative sphincterotomy, and in 9 patients by an additional postoperative endoscopic procedure. Laparoscopic cholecystectomy was carried out in all cases. There were no conversions to an open operation. Postoperative course in the uncomplicated cases was comparable to that for laparoscopic cholecystectomy alone. The postoperative complication rate was 5.6% and mortality 1.8%. Mean hospital stay was 3.3 days (range 2 to 16). At a mean 38 months follow-up, no complications related to the laparoscopic-endoscopic procedure were observed. CONCLUSION: The intraoperative combined laparoscopic-endoscopic approach seems to be a feasible and effective management of cholecysto-choledocholithiasis, saving patients a subsequent invasive procedure.     

不同内镜术式治疗胆总管结石青年患者的长期随访研究

目的探讨不同的常用内镜治疗方法对胆总管结石青年患者治疗后结石复发的影响以及结石近期复发、远期复发的危险因素。方法选择经一次性治疗性内镜逆行胰胆管术（ERCP）成功取石后随访资料完整的胆总管结石青年（21～45岁）患者,按手术方式分为内镜下乳头球囊扩张术（EPBD）组、乳头括约肌切开术（EST）组、EST（切开〈0．5cm）＋EPBD组,进行随访,统计近期（≤3年）及远期（〉3年）结石复发率,并对复发危险因素进行Logistic回归分析。结果资料完整的327例患者平均随访76．5个月,54例（16．5％）结石复发,其中近期复发35例（10．7％）,远期复发19例（5．8％）。近期胆总管结石复发率EPBD组（11．3％）和EST组（13．2％）均高于EST＋EPBD组（8．1％）,但无统计学差异（P均〉0．05）。远期胆总管结石复发率EPBD组（11．3％）和EST组（6．6％）均显著高于EST＋EPBD组（0．8％）,差异具统计学意义（P均〈0．05）。Logistic回归分析结果表明,胆囊结石、结石最大径、结石个数、机械碎石与近期结石复发显著相关（P〈0．05）,而远期胆总管结石复发则与结石最大径及单纯球囊扩张显著相关（P〈0．05）。结论对于胆总管结石青年患者,单纯EPBD取石固然可保留乳头括约肌功能,但增加了结石的远期复发风险,而乳头括约肌小切开联合EPBD取石可显著降低胆总管结石复发率。     

Fortuitous discovery of common bile duct stones: results of a conservative strategy

OBJECTIVE: The incidence of fortuitously discovered stones in the common bile duct is about 5%. The purpose of this study was to determine the rate of spontaneous clearance of asymptomatic stones in the common bile duct discovered fortuitously during cholecystectomy. PATIENTS AND METHODS: Intraoperative cholangiography was performed in all patients undergoing cholecystectomy for symptomatic gallbladder stones. If a filling defect of the common bile duct was discovered, a transcystic drain was inserted. Surgical or endoscopic extraction was not proposed initially. A control cholangiogram was performed on the second postoperative day then during the sixth postoperative week. If a stone persisted at the sixth week, endoscopic extraction was undertaken. RESULTS: Cholecystectomy was performed in 124 patients with symptomatic gallstones and no signs predictive of stones in the common bile duct. A stone was found fortuitously in the common bile duct in 12 patients. The control cholangiogram was normal in two of these patients on day two (16.7%) and in six others (50%) at the six-week control. All 12 patients remained free of symptoms suggesting the presence of a stone in the common duct. Presence of the drain had no impact on quality-of-life. Endoscopic extraction was finally performed for four patients (33.3%) to remove a stone from the common bile duct. CONCLUSION: Early surgical or endoscopic extraction of stones in the common bile duct should not be undertaken systematically in asymptomatic patients. Spontaneous asymptomatic clearance of the common bile duct is observed in about half of patients.