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Tsai TJ, Chan HH, Lai KH, Shih CA, Kao SS, Sun WC, Wang EM, Tsai WL, Lin KH, Yu HC, Chen WC, Wang HM, Tsay FW, Lin HS, Cheng JS, Hsu PI. Gallbladder function predicts subsequent biliary complications in patients with common bile duct stones after endoscopic treatment? BMC Gastroenterol 2018; 18:32. [PMID: 29486713 PMCID: PMC6389262 DOI: 10.1186/s12876-018-0762-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 02/22/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND In patients with common bile duct stones (CBDS) and intact gallbladder, further management for the gallbladder after the CBDS clearance is still controversial. The relationship between gallbladder motility and the biliary complications were seldom discussed. Our study is to predict the subsequent biliary complications by gallbladder function test using fatty meal sonography (FMS) in patients with CBDS who had been treated by endoscopic retrograde cholangiopancreatography (ERCP). METHODS Patients with an intact gallbladder and CBDS after endoscopic clearance of bile duct were enrolled. Patients received a fatty meal sonography after liver function returned to normal. The fasting volume, residual volume, and gallbladder ejection fraction (GBEF) in FMS were measured. Relationships of patients' characteristics, gallbladder function and recurrent biliary complication were analyzed. RESULTS From 2011 to 2014, 118 patients were enrolled; 86 patients had calculus gallbladders, and 32 patients had acalculous gallbladders. After a mean follow- up of 33 months, 23 patients had recurrent biliary complications. Among 86 patients with calculus gallbladder, 15 patients had spontaneous clearance of gallbladder stones; 14 patients received cholecystectomy due to acute cholecystitis or recurrent colic pain with smooth postoperative courses. In the follow up period, six patients died of non-biliary causes. The GBEF is significant reduced in most patients with a calculus gallbladder in spite of stone color. Calculus gallbladder, alcohol drinking and more than one sessions of initial endoscopic treatment were found to be the risk factors of recurrent biliary complication. CONCLUSIONS Gallbladder motility function was poorer in patients with a calculus gallbladder, but it cannot predict the recurrent biliary complication. Since spontaneous clearance of gallbladder stone may occur, wait and see policy of gallbladder management after endoscopic treatment of CBDS is appropriate, but regular follow- up in those patients with risk factors for recurrence is necessary.
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Affiliation(s)
- Tzung-Jiun Tsai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China
| | - Hoi-Hung Chan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China. .,School of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China. .,Department of Biological Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan, Republic of China. .,Department of Business Management, National Sun Yat-sen University, Kaohsiung, Taiwan, Republic of China. .,College of Pharmacy and Health Care, Tajen University, Pingtung city, Taiwan, Republic of China.
| | - Kwok-Hung Lai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China.,School of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China
| | - Chih-An Shih
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China
| | - Sung-Shuo Kao
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China.,School of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China
| | - Wei-Chih Sun
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China
| | - E-Ming Wang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China
| | - Wei-Lun Tsai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China.,School of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China
| | - Kung-Hung Lin
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China
| | - Hsien-Chung Yu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China
| | - Wen-Chi Chen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China.,School of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China
| | - Huay-Min Wang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China
| | - Feng-Woei Tsay
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China
| | - Huey-Shyan Lin
- Department of Health-Business Administration, Fooyin University, Kaohsiung, Taiwan, Republic of China
| | - Jin-Shiung Cheng
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China
| | - Ping-I Hsu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China.,School of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China
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Oliveira-Cunha M, Dennison AR, Garcea G. Late Complications After Endoscopic Sphincterotomy. Surg Laparosc Endosc Percutan Tech 2016; 26:1-5. [PMID: 26679684 DOI: 10.1097/sle.0000000000000226] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The introduction of endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy (ES) has changed the treatment of choledocholithiasis. An increasing number of young patients are requiring ES, and this raises concern regarding any potential long-term complications arising from irreversibly altering the anatomy of the sphincter of Oddi. In particular, concern has been raised regarding the risk of late cholangiocarcioma. A review was performed evaluating the relationship between ES for benign disease and the subsequent development of late complications, including biliary tract malignancy, the formation of primary duct stones, and recurring cholangitis. A systematic review of articles published between 1970 and 2013 was undertaken. Current evidence shows that ES is a safe and effective treatment for common bile duct stones. The long-term risk of subsequent cholangiocarcinoma has not been convincingly proven although in many of these studies the follow-up period was inadequate. There does appear to be an associated increased incidence of cholangiocarcinomas following sphincterotomy although this is not proven to be causative. If there is an increased risk of cholangiocarcinoma following ES, it is likely to be small in western populations. However, until longer follow-up studies are published, it may be prudent to avoid ES in the very young.
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Affiliation(s)
- Melissa Oliveira-Cunha
- Department of Hepatobiliary and Pancreatic Surgery, University Hospitals of Leicester, NHS Trust, Leicester, UK
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Yang XM, Hu B, Pan YM, Gao DJ, Wang TT, Wu J, Ye X. Endoscopic papillary large-balloon dilation following limited sphincterotomy for the removal of refractory bile duct stones: experience of 169 cases in a single Chinese center. J Dig Dis 2013; 14:125-31. [PMID: 23167553 DOI: 10.1111/1751-2980.12013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To evaluate the efficacy and safety of endoscopic papillary large-balloon dilation (EPLBD) combined with limited endoscopic sphincterotomy (EST) for the removal of large biliary duct stones (≥10 mm). METHODS Data of patients who underwent an attempted removal of large bile duct stones by limited EST followed by EPLBD (≥12 mm in diameter) from April 2006 to October 2011 in our center were reviewed. Clinical characteristics, endoscopic methods and outcomes of the patients were collected and analyzed. RESULTS A total of 169 patients with a mean age of 69.3 years (range 19-97 years) underwent 171 procedures. Median stone size and balloon diameter was 15 mm and 13 mm, respectively. Complete stone removal in a single session was achieved in 163 procedures (95.3%) with mechanical lithotripsy (ML) used in 66 (38.6%). Patients with a larger stone size required more frequent use of ML with a comparable success rate (P < 0.01). There were no significant differences between patients with and without periampullary diverticula in stone clearance (97.3% vs 93.8%), ML requirement (36.5% vs 40.2%) and complications (2.7% vs 6.2%) (all P > 0.05). Seven patients had eight procedure-related complications including moderate or mild bleeding (n = 4), minor perforation (n = 1), mild pancreatitis (n = 2) and cholangitis (n = 1). CONCLUSION EPLBD following limited EST is an effective and safe approach for the removal of large biliary duct stones, especially for those refractory cases.
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Affiliation(s)
- Xiao Ming Yang
- Department of Endoscopy, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
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Endoscopic papillary large balloon dilation for the treatment of recurrent bile duct stones in patients with prior sphincterotomy. J Gastroenterol 2010; 45:1283-8. [PMID: 20635102 DOI: 10.1007/s00535-010-0284-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2009] [Accepted: 06/17/2010] [Indexed: 02/04/2023]
Abstract
BACKGROUND Endoscopic sphincterotomy (EST) is a standard procedure for the removal of bile duct stones. However, additional EST may increase the risk of bleeding and perforation in patients with prior EST. Endoscopic papillary large balloon dilation (EPLBD) can be an alternative method for removing recurrent common bile duct stones with lower risk of bleeding and perforation. The aim of this study was to evaluate the therapeutic outcomes and complications of EPLBD in patients with recurrent common duct stones who underwent EST previously. METHODS Between January 2006 and August 2009, 70 patients with recurrent bile duct stones who had a history of EST were studied retrospectively. All patients underwent EPLBD without additional EST to enlarge the ampullary orifice. The size of the balloon for EPLBD was 12-18 mm and the duration of the balloon dilatation was 30-60 s. RESULTS Of the 70 patients, there were 24 patients (34.3%) with periampullary diverticula, 18 patients (25.7%) with hypertension, 4 patients (5.7%) with ischemic heart diseases, 2 patients (2.9%) with liver cirrhosis, and 1 patient (1.4%) with chronic kidney disease. Mean diameter of the stones was 12.5 ± 5.5 mm. Complete clearance of the duct was achieved in all patients and mechanical lithotripsy was needed in 1 patient (1.4%). Sixty-eight cases (97.1%) required only 1 session of ERCP to achieve complete ductal clearance. Mild pancreatitis occurred in 1 patient (2.3%), but there was no bleeding or perforation. CONCLUSION EPLBD is an effective and safe method for the treatment of recurrent common duct stones in patients with prior EST.
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Kim HG, Cheon YK, Cho YD, Moon JH, Park DH, Lee TH, Choi HJ, Park SH, Lee JS, Lee MS. Small sphincterotomy combined with endoscopic papillary large balloon dilation versus sphincterotomy. World J Gastroenterol 2009; 15:4298-304. [PMID: 19750573 PMCID: PMC2744186 DOI: 10.3748/wjg.15.4298] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare small sphincterotomy combined with endoscopic papillary large balloon dilation (SES + ELBD) and endoscopic sphincterotomy (EST) for large bile duct stones.
METHODS: We compared prospectively SES + ELBD (group A, n = 27) with conventional EST (group B, n = 28) for the treatment of large bile duct stones (≥ 15 mm). When the stone could not be removed with a normal basket, mechanical lithotripsy was performed. We compared the rates of complete stone removal with one session and application of mechanical lithotripsy.
RESULTS: No significant differences were observed in the mean largest stone size (A: 20.8 mm, B: 21.3 mm), bile duct diameter (A: 21.4 mm, B: 20.5 mm), number of stones (A: 2.2, B: 2.3), or procedure time (A: 18 min, B: 19 min) between the two groups. The rates of complete stone removal with one session was 85% in group A and 86% in group B (P = 0.473). Mechanical lithotripsy was required for stone removal in nine of 27 patients (33%) in group A and nine of 28 patients (32%, P = 0.527) in group B.
CONCLUSION: SES + ELBD did not show significant benefits compared to conventional EST, especially for the removal of large (≥ 15 mm) bile duct stones.
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Minami A, Hirose S, Nomoto T, Hayakawa S. Small sphincterotomy combined with papillary dilation with large balloon permits retrieval of large stones without mechanical lithotripsy. World J Gastroenterol 2007. [PMID: 17465497 DOI: 10.3748/wjg.v13.i485.2179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM To introduce a new method: small endoscopic sphincterotomy (ES) combined with endoscopic papillary large balloon dilation (SES + EPLBD) to treat patients with large biliary stones. METHODS Retrieval of large biliary stones was performed in 88 patients. Mean stone size was 14 +/- 3 mm and mean number of stones was 2.5 +/- 3.5. Firstly, ES with a small incision was performed. Next, endoscopic papillary dilation was performed with a large balloon to slowly match the size of the bile duct. Stones were then retrieved from the biliary duct with a balloon and a basket. RESULTS Stone retrieval was successful in all cases except one cystic duct stone case without the need to crush large stones. Mean procedure time was 30 +/- 5 min. Dilating the papillary orifice with a large balloon made it possible to remove large stones smoothly without crushing them. After dilation with the large balloon, there were some instances of oozing, but no perforations. One instance of post-procedural pancreatitis (1%) occurred. CONCLUSION SES + EPLBD was effective for the retrieval of large biliary stones without the use of mechanical lithotripsy.
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Affiliation(s)
- Atsushi Minami
- Kawasaki Kyodo Hospital 2-1-5 Sakuramoto Kawasaki City 210-0833, Japan.
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QIAN L, KONOMI H, KIMURA H, YOKOHATA K, OGAWA Y, CHUIIWA K, DEENITCHIN GP, TANAKA M. Recurrence of Common Bile Duct Stones Correlates with Stenosis Following Endoscopic Sphincterotomy. Dig Endosc 2007. [DOI: 10.1111/j.1443-1661.1995.tb00157.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Affiliation(s)
- Li‐Wu QIAN
- Department of Surgery I, Kyushu University Faculty of Medicine, Fukuoka, Japan
| | - Hirouyki KONOMI
- Department of Surgery I, Kyushu University Faculty of Medicine, Fukuoka, Japan
| | - Hiroshi KIMURA
- Department of Surgery I, Kyushu University Faculty of Medicine, Fukuoka, Japan
| | - Kazunori YOKOHATA
- Department of Surgery I, Kyushu University Faculty of Medicine, Fukuoka, Japan
| | - Yoshiaki OGAWA
- Department of Surgery I, Kyushu University Faculty of Medicine, Fukuoka, Japan
| | - Kazuo CHUIIWA
- Department of Surgery I, Kyushu University Faculty of Medicine, Fukuoka, Japan
| | | | - Masao TANAKA
- Department of Surgery I, Kyushu University Faculty of Medicine, Fukuoka, Japan
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Minami A, Hirose S, Nomoto T, Hayakawa S. Small sphincterotomy combined with papillary dilation with large balloon permits retrieval of large stones without mechanical lithotripsy. World J Gastroenterol 2007; 13:2179-82. [PMID: 17465497 PMCID: PMC4146840 DOI: 10.3748/wjg.v13.i15.2179] [Citation(s) in RCA: 109] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To introduce a new method: small endoscopic sphincterotomy (ES) combined with endoscopic papillary large balloon dilation (SES + EPLBD) to treat patients with large biliary stones.
METHODS: Retrieval of large biliary stones was performed in 88 patients. Mean stone size was 14 ± 3 mm and mean number of stones was 2.5 ± 3.5. Firstly, ES with a small incision was performed. Next, endoscopic papillary dilation was performed with a large balloon to slowly match the size of the bile duct. Stones were then retrieved from the biliary duct with a balloon and a basket.
RESULTS: Stone retrieval was successful in all cases except one cystic duct stone case without the need to crush large stones. Mean procedure time was 30 ± 5 min. Dilating the papillary orifice with a large balloon made it possible to remove large stones smoothly without crushing them. After dilation with the large balloon, there were some instances of oozing, but no perforations. One instance of post-procedural pancreatitis (1%) occurred.
CONCLUSION: SES + EPLBD was effective for the retrieval of large biliary stones without the use of mechanical lithotripsy.
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Affiliation(s)
- Atsushi Minami
- Kawasaki Kyodo Hospital 2-1-5 Sakuramoto Kawasaki City 210-0833, Japan.
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9
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Lee JK, Ryu JK, Park JK, Yoon WJ, Lee SH, Lee KH, Kim YT, Yoon YB. Risk factors of acute cholecystitis after endoscopic common bile duct stone removal. World J Gastroenterol 2006; 12:956-60. [PMID: 16521227 PMCID: PMC4066164 DOI: 10.3748/wjg.v12.i6.956] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the risk factors of acute cholecystitis after endoscopic common bile duct (CBD) stone removal.
METHODS: A total 100 of patients who underwent endoscopic CBD stone removal with gallbladder (GB) in situ without subsequent cholecystectomy from January 2000 to July 2004 were evaluated retrospectively. The following factors were considered while evaluating risk factors for the development of acute cholecystitis: age, gender, serum bilirubin level, GB wall thickening, cystic duct patency, presence of a GB stone, CBD diameter, residual stone, lithotripsy, juxtapapillary diverticulum, presence of liver cirrhosis or diabetes mellitus, a presenting illness of cholangitis or pancreatitis, and procedure-related complications.
RESULTS: During a mean 18-mo follow-up, 28 (28%) patients developed biliary symptoms; 17 (17%) acute cholecystitis and 13 (13%) CBD stone recurrence. Of patients with acute cholecystitis, 15 (88.2%) received laparoscopic cholecystectomy and 2 (11.8%) open cholecystectomy. All recurrent CBD stones were successfully removed endoscopically. The mean time elapse to acute cholecystitis was 10.2 mo (1-37 mo) and that to recurrent CBD stone was 18.4 mo. Of the 17 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 time of stone removal were found to predict the development of acute cholecystitis.
CONCLUSION: After CBD stone removal, there is no need for routine prophylactic cholecystectomy. However, patients without a dilated bile duct (<11 mm) and jaundice (<1.3 mg/dL) at the time of CBD stone removal have a higher risk of acute cholecystitis and are possible candidates for prophylactic cholecystectomy.
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Affiliation(s)
- Jun Kyu Lee
- Department of Internal Medicine, Seoul National University College of Medicine, 28 Yongon-dong, Chongno-gu, 110-744 Seoul, Korea
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Macadam RCA, Goodall RJR. Long-term symptoms following endoscopic sphincterotomy for common bile duct stones. Surg Endosc 2004; 18:363-6. [PMID: 14716552 DOI: 10.1007/s00464-002-9285-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2002] [Accepted: 05/07/2003] [Indexed: 01/30/2023]
Abstract
BACKGROUND Endoscopic sphincterotomy (ES) has an important role in the management of biliary stones. However, the long-term effects of free duodenobiliary reflux are not established, and it may lead to low-grade morbidity. METHODS We used a questionnaire survey to assess the prevalence of symptoms of biliary disorder in patients who had undergone endoscopic retrograde cholangio pancreatography (ERCP) and ES under the care of a single surgeon (R.J.R.G) between November 1993 and May 1998. RESULTS ES was carried out on 136 patients during this period. Current addresses were available for 94 patients, and 54 of them (57%) responded. Patients were surveyed a mean of 43 months after ES. Only 42.1% of patients denied having any symptoms. Nausea and pale stools were reported by 28% and 26% of patients, respectively, and nearly one-fifth of patients had symptoms suggestive of cholangitis. In addition, 18.5% of patients experienced one or more symptoms frequently. CONCLUSION Severe long-term symptoms are uncommon following ES; however, a significant minority of patients do suffer occasional symptoms that suggest biliary dysfunction.
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Affiliation(s)
- R C A Macadam
- Department of Surgery, Calderdale Royal Hospital, Salterhebble, Halifax, England HX3 OPW, United Kingdom.
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Sugiyama M, Atomi Y. Risk factors predictive of late complications after endoscopic sphincterotomy for bile duct stones: long-term (more than 10 years) follow-up study. Am J Gastroenterol 2002; 97:2763-7. [PMID: 12425545 DOI: 10.1111/j.1572-0241.2002.07019.x] [Citation(s) in RCA: 109] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Masanori Sugiyama
- The First Department of Surgery, Kyorin University School of Medicine, Mitaka, Tokyo, Japan
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12
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Hui CK, Lai KC, Yuen MF, Ng MMT, Lam SK, Lai CL. Role of cholecystectomy in preventing recurrent cholangitis. Gastrointest Endosc 2002; 56:55-60. [PMID: 12085035 DOI: 10.1067/mge.2002.125545] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Whether cholecystectomy should be performed after an episode of acute cholangitis is still unresolved. The purpose of this study was to analyze the role of elective cholecystectomy in preventing recurrent acute cholangitis in Asian patients. METHODS Two hundred ten consecutive Asian patients with acute cholangitis caused by choledocholithiasis with coexisting cholelithiasis were studied prospectively. RESULTS Forty-one patients (19.5%, Group 1) agreed to elective cholecystectomy whereas 169 patients (80.5%, Group 2) did not. Mean (+/- SEM) follow-up for Groups 1 and 2 were, respectively, 110.2 +/- 6.6 and 96.8 +/- 2.9 months. Endoscopic papillotomy was performed in 120 patients, 22 (53.7%) in Group 1 and 98 (58%) in Group 2. Recurrent acute cholangitis developed in 31 patients (14.8%), 9 in Group 1 and 22 in Group 2. There was no significant difference in the Kaplan-Meier estimates of the cumulative probability of occurrence of recurrent acute cholangitis between the 2 groups (p = 0.90). Recurrent acute cholangitis developed in 10 patients (8.3%) who underwent endoscopic papillotomy and in 21 (23.3%) patients who did not. There was a significant difference in the Kaplan-Meier estimates of the cumulative probability of occurrence of recurrent acute cholangitis between the patients with endoscopic papillotomy versus those without endoscopic papillotomy (p = 0.001). CONCLUSION Cholecystectomy did not prevent recurrent acute cholangitis in Asian patients. In these patients, early endoscopic papillotomy lowered the frequency of recurrent acute cholangitis.
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Affiliation(s)
- Chee-Kin Hui
- Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong, China
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13
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Yi SY. Recurrence of biliary symptoms after endoscopic sphincterotomy for choledocholithiasis in patients with gall bladder stones. J Gastroenterol Hepatol 2000; 15:661-4. [PMID: 10921421 DOI: 10.1046/j.1440-1746.2000.02192.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND There are a few reports regarding the long-term results of endoscopic sphincterotomy (EST). However, little data is available on the recurrence of biliary symptoms after EST for choledocholithiasis, in patients with gall bladder stones. METHODS All patients had gall bladder and common bile duct stones (n = 60; age 32-84 years, median age 55 years), and had received an EST. One group of these patients had a laparoscopic or open cholecystectomy (n = 39; group A), while the other group did not (n = 21; group B). The follow-up- period ranged from 5 to 54 months (average 22 months). RESULTS Complications included the recurrence of common bile duct stones, recurrent acute cholecystitis, postoperative bile leakage and papillary stenosis. Nine patients (15%) had a recurrence of biliary symptoms. Two significant prognostic factors for the recurrence of biliary symptoms were identified by multivariate analysis; namely an intact gall bladder and a dilated common bile duct. The recurrence rate of biliary symptoms in group B was 20.4%, while in group A it was 10.3% (P< 0.01). Patients with a larger than average common bile duct diameter (mean diameter 14 mm) were more prone to the recurrence of symptoms than those with a smaller common bile duct diameter (mean diameter 10 mm, P< 0.016). The hospital stay period was 8.9 +/- 3.1 days in group A and 2.8 +/- 1.9 days in group B (P< 0.01). CONCLUSIONS Biliary symptom recurrence occurred in a considerable proportion of patients after EST for the treatment of choledocholithiasis, in patients with gall bladder stones. The prognostic factors associated with the recurrence of biliary symptoms were an intact gall bladder and a dilated common bile duct diameter. Regardless of their short stay in hospital, non-cholecystectomy patients had a higher rate of recurrent biliary symptoms than cholecystectomy patients.
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Affiliation(s)
- S Y Yi
- Department of Internal Medicine, Ewha Womans University College of Medicine, Medical Research Center, Seoul, Korea.
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Saito M, Tsuyuguchi T, Yamaguchi T, Ishihara T, Saisho H. Long-term outcome of endoscopic papillotomy for choledocholithiasis with cholecystolithiasis. Gastrointest Endosc 2000; 51:540-5. [PMID: 10805838 DOI: 10.1016/s0016-5107(00)70286-0] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Although endoscopic papillotomy is now considered established treatment for choledocholithiasis, therapeutic results of endoscopic papillotomy alone without subsequent cholecystectomy in patients with cholecystolithiasis have not been well evaluated. The aim of this study was to assess the long-term outcome of endoscopic papillotomy for these patients. METHODS Patients admitted with choledocholithiasis and cholecystolithiasis from 1976 to 1993 were studied retrospectively. Of 385 patients in whom the bile duct was cleared by endoscopic papillotomy and endoscopic stone extraction, 371 patients (195 men and 176 women; mean age 65.4 years) were followed. Predisposing risk factors for late complications were analyzed. RESULTS The mean duration of follow-up was 7.7 years. Cholecystitis and recurrence of choledocholithiasis as late complications occurred in 22 cases (5.9%) and 36 cases (9.7%), respectively. Cholecystitis, including 1 severe case, resolved with conservative treatment. Recurrent choledocholithiasis was successfully treated endoscopically except in 1 case. No significant risk factors were identified for cholecystitis. The presence of pneumobilia (p = 0.0016) and the need for lithotripsy (p = 0.0342) were found to be significant risk factors for the recurrence of choledocholithiasis. CONCLUSIONS Long-term outcome of endoscopic papillotomy in patients with choledocholithiasis and cholecystolithiasis was found to be relatively favorable. Cholecystectomy after endoscopic papillotomy is not always necessary in the management of cholecystolithiasis.
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Affiliation(s)
- M Saito
- First Department of Medicine, Chiba University School of Medicine, Chiba, Japan
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15
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Ohashi A, Ueno N, Tamada K, Tomiyama T, Wada S, Miyata T, Nishizono T, Tano S, Aizawa T, Ido K, Kimura K. Assessment of residual bile duct stones with use of intraductal US during endoscopic balloon sphincteroplasty: comparison with balloon cholangiography. Gastrointest Endosc 1999; 49:328-33. [PMID: 10049416 DOI: 10.1016/s0016-5107(99)70009-x] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND We sought to determine the utility of intraductal ultrasonography (IDUS) in detecting residual bile duct stones during endoscopic balloon sphincteroplasty. METHODS Eighty-one consecutive patients with bile duct stones who underwent IDUS during endoscopic balloon sphincteroplasty were studied. IDUS was performed with a thin-caliber ultrasonic probe (diameter 2.0 mm, frequency 20 MHz) by a transpapillary route after stone extraction. When IDUS or balloon-retrograde cholangiography suggested residual stones, the bile duct was cleared again with a Dormia basket. Extraction of the stones was confirmed by direct duodenoscopic visualization. Videotapes of IDUS and cholangiograms were reviewed retrospectively without knowledge of the results of other diagnostic modalities. RESULTS In 27 of 81 patients (33%), IDUS detected small residual stones not seen on cholangiography. When stones were fragmented with mechanical lithotripsy, the accuracy of IDUS in detecting small residual stones was significantly greater than that of balloon-endoscopic retrograde cholangiography (95% vs 50%, p < 0. 001). When the bile duct was greater than 10 mm in diameter, the accuracy of IDUS in detecting small residual stones was significantly greater than that of cholangiography (92% vs. 56%, p < 0.001). CONCLUSIONS IDUS is useful for detecting small residual bile duct stones during endoscopic balloon sphincteroplasty when stones are fragmented by mechanical lithotripsy or when there is evidence of a dilated bile duct (>10 mm).
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Affiliation(s)
- A Ohashi
- Department of Gastroenterology, Jichi Medical School, Tochigi, Japan
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16
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Pereira-Lima JC, Jakobs R, Winter UH, Benz C, Martin WR, Adamek HE, Riemann JF. Long-term results (7 to 10 years) of endoscopic papillotomy for choledocholithiasis. Multivariate analysis of prognostic factors for the recurrence of biliary symptoms. Gastrointest Endosc 1998; 48:457-64. [PMID: 9831832 DOI: 10.1016/s0016-5107(98)70085-9] [Citation(s) in RCA: 133] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The long-term outcome after endoscopic papillotomy is poorly defined. The aim of this study was to determine the long-term results of this method in the treatment of common duct calculi and to determine which prognostic factors are associated with the relapse of biliary symptoms. METHODS Between 1985 and 1988, 223 consecutive (149 women, mean age 67.9 years) patients underwent endoscopic papillotomy for duct stones; 127 had already undergone cholecystectomy or underwent this operation during the same hospitalization. Follow-up data were obtained retrospectively from the patients and patients' relatives and general practitioners. RESULTS The procedure was successful in 217 of 223 cases (97%), of which 203 were followed-up; 2 patients died in the first month after treatment (0.89%). Mean follow-up for the 201 patients was 6.2 years, during which 31 relapsed (15%). Three significant prognostic factors for late complications were identified in a multivariate analysis. The recurrence rate of biliary symptoms in patients who were left with an in situ gallbladder was 20.2%, and 11% for those whose gallbladder was removed (p = 0.04). Patients with a bile duct 15 mm or greater in diameter were more prone to recurrence of symptoms than those with a bile duct 10 mm or less in diameter (41% vs. 10%, p = 0.025) and were especially at higher risk to develop recurrent stones (19.5% vs. 4.9%, p = 0.019). Stone recurrence, but not biliary symptoms as a whole, was more frequent in patients with a peripapillary diverticulum (p = 0.035). CONCLUSIONS The long-term results of endoscopic papillotomy are comparable with those of surgical techniques. The prognostic factors associated with relapse of biliary symptoms as a whole are gallbladder left in situ and choledochal diameter. Bile duct size and peripapillary diverticula are associated with recurrent bile duct stones.
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Affiliation(s)
- J C Pereira-Lima
- Department of Medicine C (Gastroenterology-Hepatology) of the Klinikum Ludwigshafen, Academic Teaching Hospital of the University of Mainz, Germany
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17
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Ueno N, Tomiyama T. Endoscopic Diagnosis of Biliary Tract Lesions Using Hydrostatic Balloon Sphincter Dilation: A Preliminary Experience. Dig Endosc 1998; 10:312-317. [PMID: 30650926 DOI: 10.1111/j.1443-1661.1998.tb00575.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/1998] [Accepted: 07/27/1998] [Indexed: 02/08/2023]
Abstract
We report some encouraging results of endoscopic balloon sphincter dilation (EBSD) and discuss its clinical relevance in the diagnosis of bile duct lesions by endoscopically accessing the biliary tree. Endoscopic approach to the bile duct was performed in seven patients with various biliary tract diseases (bile duct cancer in 2 cases, pancreatic cancer in 1, Caroli disease with bile duct stones in 1, gallbladder cancer in 1, and hepatocellular carcinoma in 2) after passing a baby scope through the papilla of Vater using EBSD. The instrument used was a Maxforce 5 French balloon-tipped biliary catheter for EBSD, an Olympus CHF-BP30 or Pentax FCP-9P baby fiberscope, and an Olympus TJF-M20 mother fiberscope for endoscopic examination. Using EBSD, it was possible to advance a baby fiberscope through the papilla of Vater in all cases. In 6 patients, endoscopic observation was successfully achieved. Apart from minimal self-limiting venous oozing seen following balloon deflation, there was no papillary hemorrhage or perforation observed. Pancreatitis developed in one patient and was resolved within 24 hours. Although our series is limited and several technical issues remain to be solved, this new procedure has potential for endoscopic diagnosis of biliary tract lesions. One of the major advantages may lie in the possibility of preserving sphincter function. We favor the use of EBSD for diagnostic evaluation of bile duct diseases.
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Affiliation(s)
- Norio Ueno
- Department of Gastroenterology, Jichi Medical School, Yakushiji, Tochigi, Japan
| | - Takeshi Tomiyama
- Department of Gastroenterology, Jichi Medical School, Yakushiji, Tochigi, Japan
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18
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Sugiyama M, Atomi Y. Follow-up of more than 10 years after endoscopic sphincterotomy for choledocholithiasis in young patients. Br J Surg 1998; 85:917-21. [PMID: 9692563 DOI: 10.1046/j.1365-2168.1998.00750.x] [Citation(s) in RCA: 73] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND With the advent of laparoscopic cholecystectomy, the indications for endoscopic sphincterotomy (ES) have been extended to young patients with choledocholithiasis. However, the long-term results of ES are largely unknown. METHODS Between 1977 and 1986, 115 patients aged 60 years or less underwent ES for choledocholithiasis. Stone classification, and early and long-term outcomes of ES were analysed retrospectively. RESULTS Early complications occurred in nine patients (7.8 per cent), but there were no deaths. ES and stone clearance were successful in 110 patients. Long-term information was available in 103 of the 110 patients, with a mean overall follow-up duration of 14-2 (range 10.4-19.3) years. Ten patients (9.7 per cent) developed late complications, including stone recurrence and/or cholangitis (nine patients) and acute cholecystitis (one of 23 patients with the gallbladder in situ). The choledochal complication rate was somewhat higher in patients with calcium bilirubinate stones at ES (seven of 65 patients) than in those with cholesterol stones (two of 38 patients). Choledochal complications were manageable endoscopically. CONCLUSION Approximately 10 per cent of patients develop late complications. However, endoscopic retreatment is safe and effective. ES is a reasonable method for treating choledocholithiasis, even in young patients.
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Affiliation(s)
- M Sugiyama
- First Department of Surgery, Kyorin University School of Medicine, Mitaka, Tokyo, Japan
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19
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Minami A, Maeta T, Kohi F, Nakatsu T, Morshed SA, Nishioka M. Endoscopic papillary dilation by balloon and isosorbide dinitrate drip infusion for removing bile duct stone. Scand J Gastroenterol 1998; 33:765-8. [PMID: 9712243 DOI: 10.1080/00365529850171738] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Endoscopic papillary dilation (EPD) by balloon in the management of bile duct stones has recently been claimed to be effective for removing bile duct stones. METHODS Without endoscopic sphincterotomy, we attempted to remove large or multiple bile duct stones through EPD combined with drip infusion of isosorbide dinitrate in 35 patients. Isosorbide dinitrate, at a rate of 5 mg/h, was administered intravenously, and a balloon dilator with a 10-mm diameter was inflated within 3 min across the papilla. Stones were then smashed using a mechanical lithotriptor, and the fragments were extracted with a basket or the balloon. RESULTS Extraction of stones was successful in 33 (94%) of 35 patients by the combined therapy. Two of them (6%) developed mild pancreatitis. CONCLUSION EPD combined with medical sphincter dilation was effective for large and multiple bile duct stones.
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Affiliation(s)
- A Minami
- Third Dept. of Internal Medicine, Kagawa Medical University, Japan
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20
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Bergman JJ, van der Mey S, Rauws EA, Tijssen JG, Gouma DJ, Tytgat GN, Huibregtse K. Long-term follow-up after endoscopic sphincterotomy for bile duct stones in patients younger than 60 years of age. Gastrointest Endosc 1996; 44:643-9. [PMID: 8979051 DOI: 10.1016/s0016-5107(96)70045-7] [Citation(s) in RCA: 154] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Little is known about the long-term effects of endoscopic biliary sphincterotomy. METHODS We retrospectively evaluated the rate of late complications after endoscopic sphincterotomy (EST) for bile duct stones. Patients had to meet the following inclusion criteria: (1) treated between 1976 and 1980, (2) complete stone removal after EST, (3) prior cholecystectomy or elective cholecystectomy within 2 months after EST, and (4) 60 years old or younger at the time of ERCP. A total of 100 patients were identified. Information was obtained from general practitioners and patients by telephone. Patients completed a postal questionnaire and a blood sample was obtained for liver function tests. RESULTS Information was obtained for 94 patients (in the majority of cases [87%] from multiple sources). There were 26 men and 68 women with a mean age of 51 years at the time of ERCP (range, 23 to 60 years). Early complications (< 30 days) occurred in 14 patients (15%). One patient died of a retroperitoneal perforation secondary to EST. During a median period of 15 years (range, 3 to 18 years), 22 patients (24%) developed a total of 36 late complications. There were 21 patients with symptoms of recurrent bile duct stones and one patient with biliary pancreatitis. Other late complications, such as recurrent ascending cholangitis or malignant degeneration, were not observed. An ERCP was performed in 20 of the 22 patients with late complications and demonstrated bile duct stones in 13, combined with stenosis of the EST opening in 9 patients. Late complications were initially managed endoscopically and/or conservatively. One patient underwent surgery after failed endoscopic treatment and one patient died of cholangitis before she could undergo an ERCP. Twelve other patients died of unrelated causes during follow-up. CONCLUSIONS After EST for bile duct stones, late complications occur in a significant proportion of patients. Stone recurrence remains the most important problem, but can in general be managed endoscopically.
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Affiliation(s)
- J J Bergman
- Department of Gastroenterology, University of Amsterdam, The Netherlands
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21
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Minami A, Nakatsu T, Uchida N, Hirabayashi S, Fukuma H, Morshed SA, Nishioka M. Papillary dilation vs sphincterotomy in endoscopic removal of bile duct stones. A randomized trial with manometric function. Dig Dis Sci 1995; 40:2550-4. [PMID: 8536511 DOI: 10.1007/bf02220440] [Citation(s) in RCA: 143] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
To circumvent the long-term effects of papillary ablation for extracting common bile duct stones (< 12 mm in diameter) in endoscopic sphincterotomy (EST), endoscopic papillary dilation (EPD) was attempted in 20 patients. To evaluate papillary function before and after the procedures, manometry of the sphincter of Oddi was carried out in 13 with EPD and 10 of 20 patients with EST. Extraction of all stones was successful (100%) in both groups at an equal rate. Repeated numbers of procedures were common in both groups. However, the mean duration of the procedure was high in EPD compared to EST (63 min vs 42 min, P < NS). Adjunctive therapies like mechanical lithotripsy (ML), nasobiliary drainage, and choledochoscopy were included in EPD, while EST required a basket catheter and ML. There was no significant difference on manometry before and after the procedures (P = NS), although papillary function was found to have decreased after the EPD. In contrast, all patients in the EST group lost papillary function after the procedure. Thirty-day morbidity and mortality rate were absent in both groups. Immediate and 2.5-year follow up complications were uncommon in both groups. As a simple method, EPD may be an effective and safe alternative to EST in the management of patients with bile duct stones who require maintenance of papillary function.
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Affiliation(s)
- A Minami
- Third Department of Internal Medicine, Kagawa Medical School, Japan
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22
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Testoni PA, Tittobello A. Long-term efficacy of endoscopic papillo-sphincterotomy for common bile duct stones and benign papillary stenosis. Surg Endosc 1991; 5:135-9. [PMID: 1763400 DOI: 10.1007/bf02653220] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Since its introduction in 1974, endoscopic sphincterotomy (EST) for common bile duct stones and benign papillary stenosis has become a well-established therapeutic procedure; however, at present, its long-term efficacy in comparison with that of biliary tract surgery remains a matter of debate. The long-term results observed during our follow-up (4 +/- 2 years) were satisfactory, revealing the disappearance of or an improvement in symptoms in 85.6% of subjects who had undergone EST. Recurrent stones were documented in 10.2% of patients; EST-related stenosis occurred in 3.8% of cases, approximately 3 times more frequently in papillary stenosis than in choledocholithiasis, likely due to the presence of a more extended incision in cases with common duct stones. A gallbladder in situ did not seem to be an additional risk factor after EST. As documented in other recent follow-up studies, the long-term efficacy of EST seems to be confirmed and comparable with that of biliary surgery.
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Affiliation(s)
- P A Testoni
- Institute of Internal Medicine, University of Milan, Italy
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23
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Winslet MC, Neoptolemos JP. The place of endoscopy in the management of gallstones. BAILLIERE'S CLINICAL GASTROENTEROLOGY 1991; 5:99-129. [PMID: 1854990 DOI: 10.1016/0950-3528(91)90008-o] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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24
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Hawes RH, Cotton PB, Vallon AG. Follow-up 6 to 11 years after duodenoscopic sphincterotomy for stones in patients with prior cholecystectomy. Gastroenterology 1990; 98:1008-12. [PMID: 2311858 DOI: 10.1016/0016-5085(90)90026-w] [Citation(s) in RCA: 147] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
One hundred sixty-three postcholecystectomy patients with retained or recurrent duct stones under-went successful duodenoscopic sphincterotomy and duct clearance between 1975 and 1980. Follow-up information was obtained on 148 patients in 1982, and on 115 of these in 1986 (at a mean of 8 yr). Fifteen patients (13%) were found to have had further biliary problems, but only 5 were known to have had sphincter stenosis and/or stones, and only 3 had not responded to endoscopic or conservative treatment. One had undergone choledochoduodenostomy for recurrent cholangitis (but continued to have problems), and 1 had died with jaundice, the precise cause of which was unknown. The third continued to have episodes of cholangitis requiring antibiotics despite the apparent lack of biliary obstruction. Bile showed significant bacterial contamination in 60% of 44 patients undergoing check endoscopy, but there was no correlation with symptoms. These long-term results are comparable with those of surgical procedures and justify the continuing use of endoscopic treatment for patients with duct stones.
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Affiliation(s)
- R H Hawes
- Department of Gastroenterology, Middlesex Hospital, London, England
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25
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Ingoldby CJ, el-Saadi J, Hall RI, Denyer ME. Late results of endoscopic sphincterotomy for bile duct stones in elderly patients with gall bladders in situ. Gut 1989; 30:1129-31. [PMID: 2767510 PMCID: PMC1434161 DOI: 10.1136/gut.30.8.1129] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Endoscopic sphincterotomy was undertaken in 186 patients with common bile duct stones and an intact gall bladder who were considered unfit for surgery. One hundred and seventy one patients had jaundice of whom 18 also had clinical cholangitis. The mean age of treated patients was 79.7 years (range 27-92) and only 13 were aged less than 60. Sphincterotomy was successful in 185 (99%) and complete clearance achieved in 172 (92.5%). Early complications occurred in nine patients (4.8%) of whom three died (1.6%). The patients have been followed on average for 32 months (range six to 72 months). Eighteen patients have subsequently required cholecystectomy (9.6%), with six major complications, but no deaths. There have been 27 natural deaths and 156 patients remain alive and symptom free. Endoscopic treatment alone is safe and effective in the majority of frail and elderly patients and can reduce the need for surgery in this high risk group.
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Affiliation(s)
- C J Ingoldby
- University Department of Surgery, St James's University Hospital, Leeds
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Abstract
Since 1970, endoscopic retrograde cholangiopancreaticography (ERCP) has received much attention as a diagnostic method in pancreaticobiliary disease. The information given by ERCP is of great value in the management of patients with symptoms after biliary tract surgery and especially in patients with suspected obstructive jaundice. In patients with symptoms highly suggestive of cholelithiasis, ERCP examination should be considered for definitive diagnosis despite a negative oral cholecystogram and ultrasound finding. Endoscopic papillotomy is a major advance in the treatment of many elderly and high-risk patients with common bile duct stones. It should replace surgery in most of these patients with retained or recurrent stones and appears justified in many patients who have not yet undergone cholecystectomy, either in the hope of avoiding biliary surgery altogether or to defuse an acute clinical situation. The rule of endoscopic treatment in the young and fit has yet to be established.
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Abstract
Abstract
This review discusses the natural history, diagnosis and treatment of stones in the bile ducts. A rational plan of management is outlined.
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28
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Thatcher BS, Sivak MV, Tedesco FJ, Vennes JA, Hutton SW, Achkar EA. Endoscopic sphincterotomy for suspected dysfunction of the sphincter of Oddi. Gastrointest Endosc 1987; 33:91-5. [PMID: 3569807 DOI: 10.1016/s0016-5107(87)71517-x] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Fifty-one patients who underwent endoscopic sphincterotomy for suspected dysfunction of the sphincter of Oddi were evaluated retrospectively. The procedure resulted in complete abolition of pain allowing discontinuation of analgesics in 31 of the 46 patients available for follow-up. Patients with a dilated bile duct and delayed drainage of contrast material as demonstrated at endoscopic retrograde cholangiopancreatography (ERCP) had a more favorable response to sphincterotomy than those with normal ductal findings (p = 0.01). There was a higher complication rate in those without ductal dilation and delayed drainage compared to those with these ERCP abnormalities (p = 0.03). Sphincter of Oddi manometry was obtained in 29 patients prior to sphincterotomy; 24 were available for follow-up. A favorable outcome for sphincterotomy did not correlate with manometric assessment, particularly in patients with an abnormal ductal system.
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Winstanley PA, Ellis WR, Hamilton I, Lintott DJ, Axon AT. Medium term complications of endoscopic biliary sphincterotomy. Gut 1985; 26:730-3. [PMID: 4018638 PMCID: PMC1432994 DOI: 10.1136/gut.26.7.730] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
One hundred and fifteen patients were reviewed between 18 months and five years after successful endoscopic biliary sphincterotomy for choledocholithiasis, postcholecystectomy in 93 (81%). Thirteen (14%) postcholecystectomy patients and 11 (50%, p less than 0.001) with intact gall bladders are dead (cause of death was ascertained in each case). Of the others, 43 were interviewed and 48 completed a postal questionnaire. Stone free common ducts had been documented in 69 (76%), presumed in 16 (17%), and not achieved in six (7%, excluded from analysis). None of the responding patients had developed serious new problems. Current symptoms of those with and without gall bladders and those with 'documented' and 'presumed' duct clearance are similar. In no case has an episode of cholangitis since sphincterotomy been confirmed and only one patient has had documented recurrent duct stones. Continued incompetence of the sphincter was shown radiologically by the presence of bile duct gas in 14 (41%) of 32 patients. These results suggest that medium term complications of endoscopic sphincterotomy are unusual.
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30
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Greenfield C, Cleland P, Dick R, Masters S, Summerfield JA, Sherlock S. Biliary sequelae of endoscopic sphincterotomy. Postgrad Med J 1985; 61:213-5. [PMID: 2858846 PMCID: PMC2418191 DOI: 10.1136/pgmj.61.713.213] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Twenty five patients were reviewed a mean of 36 months after successful endoscopic sphincterotomy for the removal of bile duct stones. All the patients had improved symptomatically but 20% had episodes of mild abdominal pain and a similar number had elevated serum gamma glutamyltranspeptidase activities (up to 3 times normal). In 12 patients (50%) biliary gas was demonstrated indicating reflux of duodenal contents. Clinical cholangitis did not occur. Aspiration liver biopsy revealed mild portal tract fibrosis and inflammation in patients with biliary reflux. Biliary reflux was significantly associated with mild upper abdominal pain (P less than 0.05). This study has shown that mild abnormalities of biliary function persist after endoscopic sphincterotomy. The long term consequence of these changes is unclear.
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