Routine intravenous cholangiography, selective ERCP, and endoscopic treatment of bile duct stones before laparoscopic cholecystectomy.

BACKGROUND: No procedure has yet been identified as the standard for the detection and management of choledocholithiasis in patients undergoing laparoscopic cholecystectomy. METHODS: A prospective study involved 1305 patients undergoing elective laparoscopic cholecystectomy. Intravenous cholangiography was performed on all patients except those with jaundice or cholangitis, acute pancreatitis, or allergy to contrast material. Patients underwent endoscopic retrograde cholangiography (ERC) and endoscopic sphincterotomy when there was a strong suspicion of choledocholithiasis, positive or inconclusive findings on intravenous cholangiography or allergy to contrast material with signs of possible choledocholithiasis. Intraoperative cholangiography was performed when patients did not undergo ERC or intravenous cholangiography and whenever the surgeon was in doubt about biliary anatomy or biliary clearance. RESULTS: Two hundred thirty-one patients (17.7%) were referred for preoperative ERC; 14 of them were referred for open surgery because of failure of ERC or sphincterotomy. Only 54 patients underwent intraoperative cholangiography. Bile duct stones, detected in 186 cases (14.2%) (68 of which were asymptomatic), were removed before surgery in 162 cases (87.1%) and during surgery in 20 (10.7%). Self-limited pancreatitis occurred in 3.6% of the patients after sphincterotomy. Laparoscopic cholecystectomy was performed in 98.7% of the cases. The conversion rate was 8% if sphincterotomy had been performed previously, and 3% after standard laparoscopic cholecystectomy (p < 0.001). The morbidity rate was 5% and the mortality rate 0.08%. During the follow-up period 4 patients had retained stones that were treated endoscopically. CONCLUSIONS: Preoperative ERC followed by laparoscopy is the best approach to treatment of patients with cholecystolithiasis and suspected choledocholithiasis.     

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.     

Echo-endoscopy versus endoscopic retrograde cholangiography for the diagnosis of choledocholithiasis: the influence of the size of the stone and diameter of the common bile duct

BACKGROUND: Endoscopic retrograde cholangiography is highly accurate in diagnosing choledocholithiasis, but it is the most invasive of the available methods. Endoscopic ultrasonography is a very accurate test for the diagnosis of choledocholithiasis with a risk of complications similar to that of upper gastrointestinal endoscopy. AIM: To compare the accuracy of endoscopic ultrasonography and endoscopic retrograde cholangiography in the diagnosis of common bile duct stones before laparoscopic cholecystectomy and to analyze endoscopic ultrasound results according to stone size and common bile duct diameter. PATIENTS AND METHODS: Two hundred and fifteen patients with symptomatic gallstones were admitted for laparoscopic cholecystectomy. Sixty-eight of them (31.7%) had a dilated common bile duct and/or hepatic biochemical parameter abnormalities. They were submitted to endoscopic ultrasonography and endoscopic retrograde cholangiography. Sphincterotomy and sweeping of the common bile duct were performed if endoscopic ultrasonography or endoscopic retrograde cholangiography were considered positive for choledocholithiasis. After sphincterotomy and common bile duct clearance the largest stone was retrieved for measurement. Endoscopic or surgical explorations of the common bile duct were considered the gold-standard methods for the diagnosis of choledocholithiasis. RESULTS: All 68 patients were submitted to laparoscopic cholecystectomy with intraoperative cholangiography with confirmation of the presence of gallstones. Endoscopic ultrasonography was a more sensitivity test than endoscopic retrograde cholangiography (97% vs. 67%) for the detection of choledocholithiasis. When stones >4.0 mm were analyzed, endoscopic ultrasonography and endoscopic retrograde cholangiography presented similar results (96% vs. 90%). Neither the size of the stone nor the common bile duct diameter had influence on endoscopic ultrasonographic performance. CONCLUSIONS: For a group of patients with an intermediate or moderate risk with respect to the likelihood of having common bile duct stones, endoscopic ultrasonography is a better test for the diagnosis of choledocholithiasis when compared to endoscopic retrograde cholangiography mainly for small-sized calculi.     

Pre-operative endoscopic ultrasonography can optimise the management of patients undergoing laparoscopic cholecystectomy with abnormal liver function tests as the sole risk factor for choledocholithiasis: a prospective study

BACKGROUND: Pre-operative endosonography has been proposed as a cost-effective procedure in the management of patients who undergo laparoscopic cholecystectomy having an intermediate risk of common bile duct stones. We prospectively evaluated the impact of pre-operative endosonography on the management of patients facing laparoscopic cholecystectomy with abnormal liver function tests as the sole risk factor for choledocolithiasis. METHODS: Among 587 consecutive patients scheduled for laparoscopic cholecystectomy, 47 (8%) patients having one or more abnormal liver function tests but a normal appearance of common bile duct at abdominal ultrasound, underwent pre-operative endosonography. In patients with endosonography-detected common bile duct stones, a pre-operative endoscopic retrograde cholangiography was performed, or an intra-operative endoscopic retrograde cholangiography was scheduled. In all endosonography-negative patients, an intra-operative trans-cystic cholangiography was performed. RESULTS: Endosonography detected common bile duct stones in nine patients (19%) but only in five of them stones were radiologically confirmed (PPV 0.55). Endosonography-detected stones were confirmed in four of four (100%) patients in whom cholangiography was performed within 1 week, but only in one of five (20%) patients in whom radiology was further delayed (P < 0.05). In three of four cases (75%), stones detected at endosonography but not confirmed at X-rays, were smaller than 2.0 mm. Among 38 patients with negative endosonography, common bile duct stones were found in two patients (NPV 0.95), whereas unplanned endoscopic stone extraction was needed only in one patient (NPV 0.97). CONCLUSIONS: Pre-operative endosonography can spare unnecessary pre-operative endoscopic retrograde cholangiography as well as inappropriate scheduling of intra-operative endoscopic retrograde cholangiography in patients undergoing laparoscopic cholecystectomy with abnormal liver function tests. To maximise the impact of endosonography on the management of these patients, the procedure should be performed immediately before laparoscopic cholecystectomy.     

Selective preoperative endoscopic retrograde cholangiography with sphincterotomy avoids bile duct exploration during laparoscopic cholecystectomy.

A policy of preoperative endoscopic retrograde cholangiography (ERC) for suspected bile duct stones was used in 1507 patients considered for laparoscopic cholecystectomy in three district general hospitals. Altogether 306 patients underwent ERC, and bile duct cannulation was achieved in 276 (90%). Bile ducts were cleared by endoscopic sphincterotomy in 128 of 161 patients (79%) with proven duct stones. Laparoscopic cholecystectomy was completed in 1396 patients. Ten laparotomies were necessary for complications of laparoscopic cholecystectomy. The complication rate for endoscopic sphincterotomy/laparoscopic cholecystectomy was 2.7%, with no mortality. Overall, a combined endoscopic/laparoscopic approach succeeded in 1386 patients (92%). Fourteen patients (1%) had retained stones during a median of 14 months (range 1-42) follow up, all of which were removed by ERC/endoscopic sphincterotomy. If a policy of selective ERC before laparoscopic cholecystectomy is used for all patients with symptomatic gall stones, most will avoid an open operation and laparoscopic exploration of the bile duct is not necessary.     

Acute biliary pancreatitis: staging and management

BACKGROUND/AIMS: Acute biliary pancreatitis is a clinical entity with a high morbidity rate (15-50%) and mortality rate (20-35%). Early diagnosis has a primary importance for an appropriate treatment (75% of cases of idiopathic acute pancreatitis are of biliary origin). METHODOLOGY: Diagnosis of acute biliary pancreatitis in 78 patients was based on careful clinical and instrumental assessment: ultrasonography (76.9% of cases) and laboratory tests in 23.1% of cases. In our study we used the Ranson and APACHE II scores and 24 of the cases (30.7%) were classified as severe, while 54 (69.2%) were mild. All patients with severe acute biliary pancreatitis underwent emergency endoscopic retrograde cholangiopancreatography + endoscopic sphincterotomy (within 24-48 hours) followed by laparoscopic cholecystectomy (10 days). Patients with mild acute biliary pancreatitis underwent laparoscopic cholecystectomy associated with intraoperative cholangiography, within 10 days. RESULTS: In 19 patients with severe acute biliary pancreatitis operative endoscopy was curative. Subsequent laparoscopic cholecystectomy provoked subcutaneous emphysema only in one case but did not show any other serious morbidity. In the remaining 5 cases laparotomy was required because of necrosis, with a mortality rate of 60%. In all cases of mild acute biliary pancreatitis, laparoscopic cholecystectomy was successfully performed with a morbidity rate of 7.3%. Common bile duct stones were revealed with intraoperative cholangiography in 31.4% of the mild cases and in 75% of the severe cases. CONCLUSIONS: In conclusion acute biliary pancreatitis treatment is always surgical; in almost all severe cases it is performed with minimally invasive procedures (endoscopic retrograde cholangiopancreatography + endoscopic sphincterotomy with laparoscopic cholecystectomy < or = 10 days) if surgery is carried out within 24-48 hrs, as well in the mild cases (laparoscopic cholecystectomy + intraoperative cholangiography) when surgery is performed within 10 days.     

Can common bile duct lithiasis be removed laparoscopically without external biliary drainage?

AIM OF THE STUDY: To evaluate the indications, feasibility and results of laparoscopic treatment of common bile duct stones without biliary drainage.PATIENTS AND METHODS: Between 1992 and 1999, laparoscopic procedures were performed in 70 consecutive patients, mean age 60 +/- 15 years (range: 18-82). Stone removal was attempted via the cystic duct (n=25) or choledocotomy (n=45). The emptiness of the common bile duct was checked by intraoperative cholangiography or endoscopy. After choledocotomy, closure was performed by interrupted or non-interrupted suture with slowly resorbable thread. Transcystic drainage was used whenever necessary.RESULTS: Nine conversions to laparotomy were necessary (12.8%). Among the 61 patients who had an exclusively laparoscopic procedure, 21 were treated via the transcystic route and 40 through choledocotomy. Biliary endoscopy was possible in only 10 of the 21 patients (47.6%) treated via the transcystic route and in all with choledocotomy. No biliary drainage was used in 16 of the 21 patients treated via the transcystic route and in 39 of the 40 treated through choledocotomy. The 30-day mortality was 1/61 (1.6%). Morbidity was 9.8% and 2 patients underwent a second laparoscopic procedure (one fistula on a choledocotomy suture, one hemoperitoneum of unknown origin). An endoscopic sphincterotomy for residual stone was necessary in 4 patients (4/61, 6.5%), 2 after choledocotomy for an unrecognized stone without biliary drainage.CONCLUSIONS: These results confirm the feasibility of laparoscopic treatment of common bile duct stones and suggest it can be performed without biliary drainage in most cases.     

Role of ERCP and Therapeutic Biliary Endoscopy in Association with Laparoscopic Cholecystectomy

Laparoscopic removal is rapidly becoming the preferred method of cholecystectomy; however, choledocholithiasis cannot usually be managed with a laparoscopic approach. Combined endoscopic sphincterotomy and laparoscopic cholecystectomy is a potential solution to this problem. To determine the feasibility of this combined procedure we studied 41 patients who had both endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy. Indications for ERCP included jaundice, gallstone pancreatitis, dilated ducts on sonography, elevated liver enzymes, or stones seen on operative cholangiography. Twenty-eight patients had ERCP preoperatively. Nine patients had common duct stones; these were successfully removed from eight patients after sphincterotomy. Two patients had unexpected strictures requiring a change in surgical approach. Thirteen patients had ERCP postoperatively. Eight of those patients had common duct stones, and all were successfully removed following endoscopic sphincterotomy. Three patients had postoperative strictures, one of which was treated by endoscopic stent placement. No complications as a result of ERCP or sphincterotomy were encountered. ERCP and endoscopic sphincterotomy can be safely performed both preoperatively and as early as 1 day postoperatively. If indicators of choledocholithiasis are present, preoperative ERCP is preferred, because stone removal occasionally is unsuccessful, and cholangiographic findings may change the operative approach. Postoperative ERCP can define and, in some instances, treat biliary tract injuries resulting from laparoscopic cholecystectomy.     

Endoscopic retrograde cholangiography and laparoscopic cholecystectomy: stones,stents and sphincterotomy

Endoscopic retrograde cholangiopancreatography (ERCP) is clearly a useful adjunct in the management of patients undergoing laparoscopic cholecystectomy who have common bile duct stones. Whether endoscopic sphincterotomy plus laparoscopic cholecystectomy is superior to traditional open cholecystectomy and bile duct exploration is a question which remains to be answered by prospective, randomized trials. The immense popularity of laparoscopic cholecystectomy may prohibit such a study in the USA. In expert hands, endoscopic stone extraction is usually successful, so ERCP can be deferred until after cholecystectomy unless there is serious suspicion of a duct stone preoperatively. Actual clinical practice will depend, however, on the skill of the surgeon, the skill of the endoscopist, and the commitment to removing the gallbladder laparoscopically. It would seem prudent for surgeons to continue to direct their energy toward conquering the common bile duct via the laparoscope, and leave ERCP and stone extraction in the realm of the endoscopist who has been extensively trained in this difficult technique. Proficiency at ERCP, sphincterotomy and stone extraction requires considerable training, and the procedure should not be attempted by individuals who have performed fewer than 100 ERCPs and 25 individually supervised sphincterotomies, according to the ASGE Standards of Training 1992. As experience with video endoscopic surgery increases and technology improves, it will become possible to remove most duct stones at the time of cholecystectomy, thus obviating the need for endoscopic sphincterotomy.In addition, ERCP should be regarded as the treatment of choice for postoperative cystic duct stump leaks. Studies have shown that any type of biliary decompression, i.e. sphincterotomy, stents or nasobiliary catheters, will be successful. The authors recommend that, in the absence of duct stones, stenting or nasobiliary catheters be used as they are less invasive. Bile duct leaks may also be managed endoscopically, but success depends on the individual characteristics of the duct injury. The decision to manage late onset strictures endoscopically should be individualized, and consideration of local endoscopic expertise, operative risk, interval between surgery and stricture, and the patient's wishes should be made.     

Cystic Duct Stones Detected During Intraoperative Cholangiography in Laparoscopic Cholecystectomy

During intraoperative cholangiography, cystic duct stones were diagnosed in 79 of 898 consecutive patients (8.8%) who underwent laparoscopic cholecystectomy over a 45-month period. The stones were successfully removed laparoscopically. In addition, it should be mentioned that the stones were identified and retrieved before the cholangiography was started in all but 8 of the 79 cases. Of these 79, only 27 cases (34.2%) had been diagnosed as having cystic duct stones preoperatively by intravenous cholangiography and/or endoscopic retrograde cholangiography. From the results obtained, it can be concluded that intraoperative cholangiography is mandatory to detect unsuspected retained stones not only in the common duct but also in the cystic duct during laparoscopic cholecystectomy, and also provides vital information as to biliary anatomic variations, the proximity of the cystic duct to the common duct, and the confirmation of inadvertent bile duct injury.     

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.     

腹腔镜下胆道造影术

为探讨腹腔镜下胆道造影的方法和价值，对６００例胆囊结石并慢性或急性胆囊炎（其中４例伴阻塞性黄疸，６例为胆源性胰腺炎）病人行无选择性腹腔镜胆囊切除和常规术中经胆囊管插管胆道造影术。５６８例（９４．７％）完成了术中胆道造影。术中造影发现胆总管病变４２例，其中３２例为术前未曾检查出的胆管异常。全组共发生胆管损伤３例（０．５％）。表明腹腔镜下经胆囊管插管胆道造影成功率高，术中胆道造影具提高手术质量和防止或减少胆管损伤的作用。     

Endoscopic management of postoperative bile leaks

BACKGROUND: Significant bile leak as an uncommon complication after biliary tract surgery may constitute a serious and difficult management problem. Surgical management of biliary fistulae is associated with high morbidity and mortality. Biliary endoscopic procedures have become the treatment of choice for management of biliary Gstulae. METHODS: Ninety patients presented with bile leaks after cholecystectomy ( open cholecystectomy in 45 patients, cholecystectomy with common bile duct exploration in 20 and laparoscopic cholecystectomy in 25). The presence of bile leaks was confirmed by ERCP and the appearance of bile in percutaneous drainage of abdominal collections. Of the 90 patients with postoperative bile leaks, 18 patients had complete transaction of the common bile duct by ERCP and were subjected to bilioenteric anastomosis. In the remaining patients after cholangiography and localization of the site of bile leaks. therapeutic procedures like sphinctero-tomy, biliary stenting and nasobiliary drainage ( NBD ) were performed. If residual stones were seen in the common bile duct, sphincterotomy was followed by stone extraction using dormia basket. Nasobiliary drain or stents of 7F size were placed according to the standard techniques. The NBD was removed when bile leak stopped and closure of the fistula confirmed cholangiographically. The stents were removed after an interval of 6-8 weeks. RESULTS: Bile leaks in 72 patients occurred in the cystic duct (38 patients), the common bile duct (30 ), and the right hepatic duct (4). Of the 72 patients with post-operative bile leak, 24 had associated retained common bile duct stones and 1 had ascaris in common bile duct. All the 72 patients were subjected to therapeutic procedures including sphincterotomy with stone extraction followed by biliary stenting (24 patients), removal of ascaris and biliary stenting (1), sphincterotomy with biliary stenting (18), sphincterotomy with NBD (12), biliary stenting alone (12), and NBD alone (5). Bile leaks stopped in all patients at a median interval of 3 days (range 3-16 days) after endoscopic in- terventions. No difference was observed in efficacy and in time for the treatment of bile leak by sphincterotomy with endoprosthesis or endoprosthesis alone in patients with bile leak after surgery. CONCLUSIONS: Post-cholecystectomy bile leaks occur most commonly in the cystic duct and associated common bile duct stones are found in one-third of cases. Endoscopic therapy is safe and effective in the management of bile leaks and fistulae after surgery. Sphincterotomy with endoprosthesis or endoprosthesis alone is equally effective in the management of postoperative bile leak.     

Gallstone disease. Management of common bile-duct stones and associated gallbladder stones: Surgical aspects

For many years, open exploration of the common bile duct has been the treatment of choice for patients with common bile-duct stones. During recent decades endoscopic sphincterotomy has gained wide acceptance as an effective and less invasive alternative. After sphincterotomy, subsequent (laparoscopic) cholecystectomy is warranted in patients with gallbladder stones. This chapter will discuss whether sphincterotomy should be performed prior to, during or after cholecystectomy, and will also address the question of whether single-stage treatment by laparoscopic cholecystectomy and laparoscopic bile-duct exploration is in fact preferable. The rate of recurrent choledocholithiasis after endoscopic biliary sphincterotomy can reach more than 20%. This review focuses on the risk factors--delayed bile-duct clearance and bactobilia--that may lead to recurrent primary bile-duct stone formation. Underlying altered bile composition (relative phospholipid deficiency) should be recognised in a subgroup of patients. Identification of these risk factors may significantly affect treatment policy.     

Introduction of a "Safety Zone" for the Safety of Laparoscopic Cholecystectomy

Anatomic variations of the biliary tract were found in 18 cases of 600 patients (3.0%) undergoing laparoscopic cholecystectomy. All bile duct anomalies were confirmed preoperatively by endoscopic retrograde cholangiography. In every case, the cystic duct and cystic artery were exposed in a "safety zone" near the gallbladder neck in Calot's triangle. Laparoscopic cholecystectomy was successfully performed on all 18 cases. Intraoperative cholangiography clearly demonstrated the anatomic variations in all cases, unequivocally identified the cystic duct, and confirmed the absence of bile duct injury. Preoperative endoscopic retrograde cholangiography and intraoperative cholangiography, which have been performed routinely in all patients, improve the safety of laparoscopic cholecystectomy. Moreover, the observance of the essential rule of "keep operating in the safety zone" protects against inadvertent complications, especially against bile duct injury during laparoscopic cholecystectomy. Laparoscopic cholecystectomy was thus successfully performed on all 600 cases in the present series, except for three cases, which were converted to open surgery (conversion rates, 0.5%), because of pin-hole bleeding on the portal vein in our first case of 600, and severe adhesion in two (46th and 302nd) cases.     

Selective use of perioperative ERCP in patients undergoing laparoscopic cholecystectomy

BACKGROUND/AIMS: Management of common bile duct stones in the era of laparoscopic surgery is still controversial. The purpose of this study is to investigate the safety, feasibility, success rate and short-term results of the selective use of endoscopic retrograde cholangiopancreatography in patients undergoing laparoscopic cholecystectomy. METHODOLOGY: A prospective study comprising 300 consecutive patients with either symptomatic or complicated gallbladder stones was performed between January 1994 and November 1996. Depending on clinical, laboratory and ultrasonographic criteria, 73 patients (24.3%) underwent endoscopic retrograde cholangiopancreatography with or without endoscopic sphincterotomy. The procedure was successful in 71 patients (97%) either preoperatively in 62 patients (21%) or postoperatively in 9 patients (3%). RESULTS: Endoscopic retrograde cholangiopancreatography was positive in 37 cases (52%), endoscopic sphincterotomy and stone extraction was performed in 35 cases and endoscopic sphincterotomy alone was performed in 2 cases for benign papillary stenosis. The overall predictive value for the presence of common bile duct stone was 52%, the predictive value for patients with jaundice, dilated common bile duct together with elevated liver enzymes was 73.3%. Complications of perioperative endoscopic retrograde cholangiopancreatography were encountered in 4 patients (5.5%) with no mortality. CONCLUSIONS: We conclude that the combination of perioperative endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy is a useful approach for the management of choledochocholelithiasis.     

Microscopic examination of bile directly collected during endoscopic cannulation of the papilla

The usefulness of microscopic examination of pure bile directly collected from the biliary tract during endoscopic retrograde cholangiography and without hormonal simulation was prospectively evaluated in 72 patients. According to clinical, biochemical, ultrasonographic, and radiographic data, the patients were separated into two groups: group 1, patients with proven stones (N = 50), and group 2, patients with suspected microlithiasis presenting symptoms suggestive of cholelithiasis but without evidence of macroscopic stones at echography or cholangiography (N = 22). Cholesterol crystals and/or bilirubinate granules were observed (eg, positive examination) in the bile of 41 of the 50 patients of group 1 (82%). Among patients of group 2, seven (32%) had a positive bile examination: cholecystectomy (N = 2) or endoscopic sphincterotomy (N = 5) disclosed minute stones in all cases. In the 15 patients of group 2 with a negative bile examination, cholecystectomy (N = 3), sphincterotomy (N = 2), and clinical (and/or echographic) 20-month follow-up (N = 9) revealed biliary lithiasis in only one patient, in whom recurrent cholangitis led to disclosure of one bile duct stone. According to these results, microscopic examination of bile samples collected during endoscopic retrograde cholangiography exhibited a sensitivity and a specificity for cholelithiasis recognition of 82.7% and 100%, respectively, with a positive predictive value of 88%. We conclude that the accuracy of this method makes it useful to investigate and manage patients with suspected microlithiasis.     

ENDOSCOPIC SPHINCTEROTOMY OF THE PAPILLA OF VATER: AN ANALYSIS OF 300 CASES

Endoscopic sphincterotomy was performed on 300 patients with biliary and/or pancreatic disease during the period 1978–1983. The most frequent indications were choledocholithiasis after cholecystectomy (59%), choledocholithiasis without cholecystectomy (17%) and presumed motility disorders of the sphincter of Oddi (15%). In choledocholithiasis, stones passed spontaneously or were extracted from the bile duct in 147 of 164 patients (90%) in whom the outcome was determined by cholangiography immediately after stone extraction or by a second retrograde cholangiogram. In presumed motility disorders, only 51% of patients have shown sustained improvement in symptoms. Complications were uncommon (5%) but included bleeding from the margins of the incision, pancreatitis, cholangitis and an entrapped Dormia basket; no patient died. Duodenal diverticula were more frequent (p<0.005) in patients with bile duct stones after cholecystectomy (28%) than in patients in whom retrograde cholangiography did not reveal stones (9%) but the presence of diverticula did not influence the outcome of the procedure. Endoscopic sphincterotomy is a safe and effective procedure of particular relevance to elderly patients with choledocholithiasis after cholecystectomy and to high-risk patients with choledocholithiasis without cholecystectomy.     

EUS diagnosis and simultaneous endoscopic retrograde cholangiography treatment of common bile duct stones by using an oblique-viewing echoendoscope

BACKGROUND: MRCP and EUS have replaced ERCP in the diagnosis of biliary diseases, but the latter is needed for treatment. This study evaluates a new approach in the management of common bile duct stones, by using an oblique-viewing echoendoscope. METHODS: Nineteen patients with acute abdominal pain associated with increased liver tests entered the study. Evaluation of the biliary tree was performed by using an oblique-viewing echoendoscope (JF-UM20; Olympus Europe GmbH, Hamburg, Germany). When biliary stones or sludge were found, bile duct cannulation and sphincterotomy were performed in the same session. RESULTS: Bile duct stones were diagnosed by EUS in 4 patients and biliary sludge in 12; the subsequent cholangiography and sphincterotomy with stone extraction confirmed the diagnosis in all patients. Bile duct cannulation failed in 1 patient. EUS showed features of chronic pancreatitis in 3 cases. The mean time for the whole procedure (EUS plus endoscopic retrograde cholangiography with biliary treatment) was 27 minutes. No procedure-related complications were observed. CONCLUSION: This new approach appears to be feasible and safe, providing an accurate diagnosis and, at the same time, an appropriate treatment of common bile duct stones when needed. With technical improvements, this extended EUS technique could be used as the first-line procedure in patients with biliopancreatic diseases.     

Sphincterotomy in patients with gallstones, elevated LFTs and a normal CBD on ERCP

BACKGROUND/AIMS: To determine whether an endoscopic sphincterotomy affects outcome in patients with symptomatic gallstones, elevated liver function tests and a normal common bile duct on endoscopic retrograde cholangiopancreatogram. METHODOLOGY: A total of 163 patients with symptomatic gallstones and elevated liver function tests, and found to have a normal common bile duct on endoscopic retrograde cholangiopancreatogram were included in the study. Endoscopic sphincterotomy was performed in 78 (47.8%) patients, while 85 (52.1%) patients did not have an endoscopic sphincterotomy. The two groups were compared for detection of small unseen common bile duct stones/debris, endoscopic retrograde cholangiopancreatogram related complications, and biliary complications after cholecystectomy. RESULTS: Small common bile duct stones/debris were recovered in 11/43 (25.5%) patients who had instrumentation of the common bile duct performed after endoscopic sphincterotomy. Common bile duct instrumentation was not performed in any of the patients without endoscopic sphincterotomy. No patient had any biliary complication after cholecystectomy, both in the immediate postoperative period and on a follow-up of 37.5 +/- 13.6 months (range 17-66). Endoscopic retrograde cholangiopancreatogram related complications occurred in 8 patients who had an endoscopic sphincterotomy and in 2 without endoscopic sphincterotomy (p < 0.05). CONCLUSIONS: Performing an endoscopic sphincterotomy in these patients increases the detection of small unseen common bile duct stones/debris without changing the clinical outcome after cholecystectomy. It also increases the endoscopic retrograde cholangiopancreatogram related complication rate, and therefore may not be necessary.