Papillary dilation vs sphincterotomy in endoscopic removal of bile duct stones. A randomized trial with manometric function

Medium-term effects of endoscopic papillary balloon dilation on gallbladder motility

BACKGROUND

Endoscopic papillary balloon dilation (EPBD) for removal of bile duct stones tends to preserve papillary function. However, EPBD may exert beneficial or deleterious effects on gallbladder motility. This was a prospective, medium-term investigation (2 years) of the effects of EPBD on gallbladder motility.

METHODS

Twelve patients with intact gallbladders (6 with and 6 without gallbladder stones) who underwent EPBD for choledocholithiasis were enrolled in this study. Gallbladder motility was examined before EPBD and at 7 days, 1 month, 1 year, and 2 years after EPBD. Gallbladder volumes, measured after fasting and after ingestion of dried egg yolk, were determined by US.

RESULTS

All patients were asymptomatic during the 2-year follow-up period. Before EPBD, particularly in patients with cholelithiasis, the gallbladder had a larger fasting volume and lower yolk-stimulated maximum contraction compared with normal control subjects. Seven days after EPBD, fasting volume was decreased and maximum contraction was increased, both significantly compared with pre-EPBD values and regardless of the presence or absence of gallbladder stones. At 1 month, 1 year, and 2 years after EPBD, these changes were far less evident and gallbladder function did not differ significantly from baseline.

CONCLUSION

EPBD does not adversely affect gallbladder motility in the medium-term (2 years). In terms of gallbladder motility, EPBD does not appear to increase the future risk of acute cholecystitis or gallbladder stone formation.

Stent placement in the pancreatic duct prevents pancreatitis after endoscopic sphincter dilation for removal of bile duct stones

BACKGROUND

Pancreatitis is the most serious complication of endoscopic sphincter dilation. The aim of this study was to determine whether temporary stent placement in the main pancreatic duct decreases the frequency of pancreatitis and level of hyperamylasemia.

METHODS

Stents were placed in the pancreatic duct after endoscopic sphincter dilation in 40 consecutive patients with bile duct stones. Stents were removed endoscopically 3 days later. Changes in serum amylase and the frequency of pancreatitis for this group were compared with those in 92 patients who underwent sphincter dilation without pancreatic duct stent placement.

RESULTS

Stent placement was successful in 38 of 40 patients. Although the difference in the frequency of pancreatitis was not significantly different between stent and control groups, there was a trend toward a decrease in pancreatitis in the stent group. The level of postprocedure hyperamylasemia was significantly less in the stent group (p < 0.05). There were no procedure-related complications.

CONCLUSIONS

Temporary placement of a stent in the pancreatic duct after sphincter dilation for removal of bile duct stones has a beneficial effect in terms of postprocedure hyperamylasemia and appears to reduce the frequency of postprocedure pancreatitis.

The role of percutaneous transhepatic papillary balloon dilation in percutaneous choledochoscopic lithotomy

BACKGROUND

When choledochoscopic lithotomy with basket and electrohydraulic lithotripsy is used to remove intrahepatic duct stones, fragments or small stones usually remain in the bile duct that are too small to be captured with a basket.

METHODS

An attempt was made to remove stone fragments in 16 patients with intrahepatic duct stones by antegrade balloon dilation of the sphincter of Oddi with a conventional balloon catheter. After balloon dilation, remnant stones and sludge were pushed through the papilla with the choledochoscope.

RESULTS

Bile duct stones were completely removed in 12 of 16 patients (75%); stones were removed in 1 session. There was no clinical evidence of procedure-related pancreatitis or fatal complications.

CONCLUSIONS

Percutaneous transhepatic papillary balloon dilation of the sphincter of Oddi and clearance of remnant bile duct stones and stone fragments with the tip of choledochoscope is simple and effective in patients undergoing percutaneous transhepatic choledochoscopic lithotomy.

Epinephrine irrigation for the prevention of pancreatic damage after endoscopic balloon sphincteroplasty

BACKGROUND AND AIM

Endoscopic balloon sphincteroplasty (EBS) is an alternative to sphincterotomy for the treatment of bile duct stones. The purpose of this study was to determine if epinephrine irrigation of the papilla can prevent the pancreatic damage associated with EBS.

METHODS

A total of 173 patients with bile duct stones were treated by EBS. After conventional endoscopic retrograde cholangiography, EBS was performed by using a biliary dilatation catheter (balloon diameter: 8 mm). The duct was then cleared by using Dormia baskets or retrieval balloon catheters. Mechanical lithotripsy was performed before extraction when the stones were greater than 8 mm in diameter. In 81 patients, the dilated orifice was irrigated with 40-120 mL (50 +/- 37 mL) of 1:1,000,000 epinephrine (epinephrine group). In the remaining 92 patients, epinephrine irrigation was not performed (control group). Acute pancreatitis was defined by a serum amylase concentration fivefold greater than the upper limits of normal in association with abdominal pain.

RESULTS

After EBS, serum amylase concentrations were significantly increased in both groups. However, the degree of hyperamylasemia was less in the epinephrine group than in the control group (617 +/- 611 vs 1037 +/- 1491 IU/L, P < 0.05). The incidence of pancreatitis was lower in the epinephrine group than in the control group (1.2 vs 7.6%, P < 0.05).

CONCLUSIONS

Epinephrine irrigation is a simple and useful method to prevent post-EBS pancreatic damage and pancreatitis.

Endoscopic management of bile duct stones

The advantages of endoscopic retrograde cholangiopancreatography (ERCP) over open surgery make it the predominant method of treating choledocholithiasis. Today, technologic advances such as magnetic resonance cholangiopancreatography and laparoscopic surgery are challenging ERCP's primacy in the management of common bile duct (CBD) stones. This article reviews the current status of endoscopic treatment of biliary stones and examines this in relation to laparoscopic management. The techniques and safety of endoscopic sphincterotomy and balloon sphincteroplasty are reviewed. Balloon sphincteroplasty should be limited to study protocols because of safety questions and inherent limitations. After sphincterotomy, 85% to 90% of CBD stones can be removed with a Dormia basket or balloon catheter. These techniques are described as having both advantages and disadvantages. Methods for managing "difficult stones" include mechanical lithotripsy, intraductal shock wave lithotripsy, extracorporeal shock wave lithotripsy, chemical dissolution, and biliary stenting. These approaches are presented along with data supporting their use in specific situations. Laparoscopic cholecystectomy has emerged as the preferred alternative to open cholecystectomy. Parallel advances in the endoscopic and laparoscopic management of CBD stones have made the issue regarding the optimal treatment strategy complex. Three approaches to the management of choledocholithiasis in the laparoscopic era are presented as follows: strict therapeutic splitting, flexible therapeutic splitting, and strict laparoscopic management. The optimal approach needs to be defined in prospective comparative trials. For now, preoperative endoscopic stone extraction should still be recommended as the approach of choice in patients suspected to have CBD stones based on clinical, biochemical, and imaging parameters. Primary laparoscopic evaluation and management is reasonable in patients who have a low-to-moderate probability of having CBD stones.

Comparison of intraductal ultrasonography with percutaneous transhepatic cholangioscopy for the identification of residual bile duct stones during lithotripsy

BACKGROUND

An imaging modality that can be used to identity small stones after a biliary lithotripsy is required. Intraductal ultrasonography was evaluated by using percutaneous transhepatic cholangioscopy as the gold standard.

METHODS

Lithotripsy, under percutaneous transhepatic cholangioscopy guidance, was performed in 20 patients. A thin-caliber ultrasonic probe (2.0 mm in diameter and 20 MHz frequency) was inserted into the bile duct through the percutaneous tract after lithotripsy, and residual stones were identified. This was followed by percutaneous transhepatic cholangioscopy.

RESULTS

In the extrahepatic bile ducts, intraductal ultrasonography provided images of all the stones demonstrated on cholangioscopy (n = 11). The sensitivity was superior to that of cholangiography (P < 0.005). However, in the intrahepatic bile ducts, intraductal ultrasonography only visualized the stones located in the cannulated lobe. Extrahepatic stones smaller than 5.0 mm in diameter or in a common hepatic duct larger than 15.0 mm in diameter were missed by cholangiography, but were visualized by the use of intraductal ultrasonography (P < 0.05).

CONCLUSIONS

Intraductal ultrasonography is equivalent to cholangioscopy in the extrahepatic bile ducts. Cholangiography and intraductal ultrasonography should be used in combination to image intrahepatic and extrahepatic stones.

A randomized trial of endoscopic balloon dilation and endoscopic sphincterotomy for removal of bile duct stones in patients with a prior Billroth II gastrectomy

BACKGROUND

A prior Billroth II gastrectomy renders endoscopic sphincterotomy (EST) more difficult in patients with bile duct stones. Endoscopic balloon dilation (EBD) is a relatively easy procedure that potentially reduces the risk of bleeding and perforation.

METHODS

Thirty-four patients with bile duct stones and a previous Billroth II gastrectomy were randomized to EST or EBD. Complications were graded in a blinded fashion. Results were compared with those for a group of 180 patients with normal anatomy from a previously reported randomized trial of EBD versus EST.

RESULTS

All stones were removed in 1 endoscopic retrograde cholangiopancreatography in 14 of 16 patients who underwent EBD versus 14 of 18 who had EST (p = 1.00). Mechanical lithotripsy was used in 3 EBD procedures versus 4 EST procedures (p = 1.00). Early complications occurred in 3 patients who had EBD versus 7 who underwent EST (p = 0.27). Three patients had bleeding after EST; 1 patient had mild pancreatitis after EBD. The median time required for stone removal was 30 minutes in both groups. Compared with patients with a normal anatomy, patients with a previous Billroth II gastrectomy had a significantly increased risk of bleeding after EST (17% vs. 2%, relative risk = 7.25, p < 0.05).

CONCLUSIONS

A prior Billroth II gastrectomy renders EST more difficult and increases the risk of a complication. EBD in these patients is easy to perform and is not associated with an increased need for mechanical lithotripsy or a longer procedure time. The risk of bleeding is virtually absent after EBD and the risk of pancreatitis after EBD seems not significantly increased in these patients.

Sphincter of Oddi contractile function after balloon dilation: detailed manometric evaluation in conscious dogs

BACKGROUND

Endoscopic balloon dilation is under investigation as a treatment modality for bile duct stones. It may have an advantage of preserving the sphincter of Oddi function, but little is known about sphincter of Oddi cyclic motility after dilation.

METHODS

Four dogs with a duodenal cannula underwent sphincter of Oddi dilation and repeated manometry to assess sphincter of Oddi cyclic motility until 3 months after dilation. Histologic changes in the sphincter of Oddi were examined in another group of four dogs.

RESULTS

Motility index (sum of amplitude of sphincter of Oddi phasic waves counted per minute) and basal pressure decreased on day 3. Sphincter of Oddi amplitude during phase III of the duodenal migrating motor complex tended to be increased on day 3 and decreased to the minimum on day 21. Thereafter, it gradually recovered to baseline. By histology, severe acute inflammation was present in the sphincter of Oddi muscle layer on day 3. However, basal pressure remained significantly low even 3 months after dilation.

CONCLUSIONS

Sphincter of Oddi amplitude is incompletely reduced on day 3 after balloon dilation. Sphincter of Oddi basal pressure and motility index in the early phase of sphincter of Oddi cyclic motility remain low for at least 3 months after dilation. Further long-term follow-up is necessary to determine whether sphincter of Oddi function is actually preserved.

Morphometric study of the sphincter of oddi (hepatopancreatic) and configuration of the submucosal portion of the sphincteric muscle mass

The sphincter of Oddi (SO) hepatopancreatic sphincter from 114 Japanese adults, especially the sphincteric muscle mass lying in the duodenal mucosal layer (the submucosal portion of the SO: SMSO), was measured macroscopically under a binocular microscope. The SMSO was classified into two types according to shape. The horizontal type (95/114) usually displayed a rod-like shape (6.0 mm at average diameter at the root) directed toward the anus and was situated on the duodenal muscle wall with the papillary orifice at or near the tip (anal side) of the SMSO. The horizontal type SMSO followed the underlying muscle wall widely ranging from 5.0 mm to 17.9 mm length (9.8 mm at average) and was attached to the wall by the loose connective tissue along the entire length. In the horizontal type, the extramural portion (the portion penetrating and outside of duodenal muscle of the SO) of the SO was very small. The vertical type (19/114) erected on the muscle wall vertically into the lumen of the duodenum. The average length and average maximum diameter of the vertical type were 6.0 mm and 6.2 mm, respectively. The extramural portion of the SO was thicker and tighter in the vertical type, which suggested that endoscopic sphincterotomy might preserve the length of the SO longer than endoscopic papillary balloon dilation (EPBD). Of the individuals in our study, 18% (19/114) had SO diameters <5 mm, a finding that may have implications for selection of balloon size in EPBD.

Effectiveness and safety of balloon dilation of the papilla and the use of an occlusion balloon for clearance of bile duct calculi

OBJECTIVE

The purpose of this study was to describe a technique for percutaneous bile duct stone clearance by pushing the stones into the small bowel after balloon dilation of the papilla.

SUBJECTS AND METHODS

During a 2-year period, 38 patients were treated percutaneously for stones in the biliary tree. Twenty-one patients were treated through a T tube or transcystic tract. Seventeen patients were treated through a transhepatic tract. Twenty-three patients had one stone each. Eight patients had two stones, and seven patients had three or more calculi. Stone size ranged from 3 to 16 mm in diameter (mean size, 6.7 nm). Balloon diameter based on the transverse diameter of the stones ranged from 7 to 18 mm (mean, 6.7 mm). An 11.5-mm occlusion balloon was used for pushing the stones through a 7- to 9-French vascular introducer. A catheter was left in the common bile duct from 1 to 6 days for external drainage.

RESULTS

The technique was successfully used for clearance of stones in 36 (94.7%) of the 38 patients. With 29 patients, the procedure was performed with only one attempt. Two attempts were necessary for five patients, and three attempts were necessary for four patients. Two major complications were cholangitis and biliary pleural effusion. No deaths were related to the procedure.

CONCLUSION

Percutaneous bile duct stone clearance by dilation of the papilla and evacuation of the stones in an antegrade fashion with an occlusion balloon is a safe and effective technique. It can be an alternative to basketing stones in selected patients.

Percutaneous treatment of bile duct stones in patients treated unsuccessfully with endoscopic retrograde procedures

BACKGROUND

The preferred treatment for stones in the bile duct is endoscopic sphincterotomy followed by stone extraction. When this fails, percutaneous treatment is an alternative to surgery. The purpose of this study was to evaluate the success and complication rate of percutaneous treatment.

METHODS

Between April 1990 and April 1997, a total of 31 consecutive patients (20 men, 11 women, mean age 70.1 years) underwent percutaneous treatment of bile duct stones (average of 2.2 per patient, range 1 to 10). The percutaneous treatment was considered successful if all stones could be removed. Time and number of sessions needed for imaging, percutaneous treatment, and complications were scored.

RESULTS

Twenty-seven patients (87%) were free of stones after 2 to 15 sessions (mean 5.6). The median time for treatment was 16 days (3 to 299). Complications occurred in 3 of the 31 patients: one myocardial infarction during extracorporeal shockwave lithotripsy, one pancreatitis, and one bacteremia. None of these complications were life threatening. Four patients (13%) underwent surgery after failed percutaneous treatment.

CONCLUSION

Percutaneous treatment of bile duct stones is an alternative with a high success rate when endoscopic stone removal fails. Surgery can be avoided in nearly 90% of cases.

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

BACKGROUND

The optimal treatment strategy for treatment of bile duct stones first diagnosed during laparoscopic cholecystectomy has not been established. We prospectively treated unsuspected bile duct stones by means of intraoperative placement of a transcystic catheter followed by postoperative pharmacologic papillary dilation or endoscopic papillary balloon dilation.

METHODS

In 17 patients with bile duct stones first found at laparoscopic cholecystectomy, a catheter was introduced via the cystic duct into the bile duct. If postoperative cholangiography via a transcystic catheter showed stones 5 mm or less in diameter, glyceryl trinitrate was infused via the catheter into the bile duct. Patients in whom medical dilation was unsuccessful or who had larger stones underwent endoscopic papillary balloon dilation.

RESULTS

Stone diameter measured 3 to 11 mm (mean 6.4 mm). Postoperative cholangiography revealed spontaneous passage in four patients. After pharmacologic papillary dilation, two of five patients with stones 5 mm or less in diameter had stone clearance. The remaining 11 patients underwent successful endoscopic papillary balloon dilation with stone clearance. In two patients, a guidewire introduced via a transcystic catheter through the papilla facilitated selective biliary cannulation. One early minor complication occurred. All patients remained without symptoms for a mean follow-up of 13 months.

CONCLUSION

For unsuspected bile duct stones (usually small ones), this strategy is a simple and effective alternative to laparoscopic bile duct exploration and postoperative sphincterotomy and may minimize early and late complications. Transcystic catheterization ensures access to the bile duct, thereby avoiding endoscopic treatment failures.

Endoscopic sphincter dilation in patients with bile duct stones: immediate and medium-term results

BACKGROUND

Endoscopic sphincter dilation (ESD) is believed to successfully treat bile duct stones without serious procedure-related complications.

METHODS

We evaluated the efficacy, safety and limitations of this relatively new procedure in a consecutive series of patients to establish the clinical role of this modality for treating bile duct stones. One hundred and forty-three consecutive patients were treated by ESD between July 1995 and March 1998. The balloons used were a Maxforce 5-Fr or Olbert 5-Fr balloon-tipped catheter with a maximal diameter of 8 mm. Mechanical lithotriptor (ML) or extracorporeal shock wave lithotripsy (ESWL) were used when stones were large and/or numerous and a Dormia basket or retrievable balloon catheter was used to extract the stones entirely. Procedure-related symptoms and chemical data after the procedure were monitored during and after ESD at least until the following morning. To diagnose residual stones accurately, intraductal ultrasonography was routinely used.

RESULTS

Although the majority of patients complained of subtle pain during balloon inflation and demonstrated oozing during and after balloon inflation, the procedures were well tolerated. Complete stone extraction was achieved in 139 (97.2%) of the patients. Mechanical lithotriptor and ESWL were used to assist stone clearance in 79 (55.2%) and 23 (16.1%) patients, respectively. Mild pancreatitis occurred in six patients (4.2%). However, there were no other serious complications. Stone recurrence was identified in six patients and these stones were re-extracted by subsequent ESD procedures.

CONCLUSIONS

A high success rate for stone extraction and the relative safety of this procedure was confirmed. However, there was recurrence in a relatively high percentage of patients within a short period and this may be a forthcoming issue in ESD. Long-term follow-up observation and the establishment of countermeasures for stone recurrence seem to be essential.

Does endoscopic papillary balloon dilation affect gallbladder motility?

BACKGROUND

Endoscopic papillary balloon dilation for treatment of bile duct stones is likely to preserve papillary function. However, endoscopic papillary balloon dilation may affect gallbladder motility. We investigated the effects of endoscopic papillary balloon dilation on gallbladder motility.

METHODS

Ten patients with an intact gallbladder (six with and four without gallbladder stones) who underwent endoscopic papillary balloon dilation for choledocholithiasis were studied. Gallbladder motility was examined before and 7 days and 1 month after endoscopic papillary balloon dilation. Gallbladder volume, while fasting and after dried egg yolk ingestion, was determined by ultrasonography.

RESULTS

Before endoscopic papillary balloon dilation, particularly in patients with gallbladder stones, the gallbladder showed significantly larger fasting volume and lower yolk-stimulated maximum contraction compared with control subjects. Seven days after endoscopic papillary balloon dilation, fasting volume was decreased and maximum contraction was increased, regardless of the presence of gallbladder stones, with significant differences from the values before endoscopic papillary balloon dilation. One month after endoscopic papillary balloon dilation, these changes were reduced and gallbladder function did not differ significantly from baseline.

CONCLUSIONS

After endoscopic papillary balloon dilation, gallbladder motility improves transiently at 7 days but returns to baseline at 1 month. In terms of gallbladder motility, endoscopic papillary balloon dilation does not seem to increase the subsequent risk of acute cholecystitis.

Pancreatitis induced by endoscopic balloon sphincter dilation and changes in serum amylase levels after the procedure

BACKGROUND

The short-term safety of endoscopic balloon sphincter dilation remains to be defined. We prospectively investigated the rate of pancreatitis and changes in pancreatic enzyme values induced by endoscopic balloon sphincter dilation.

METHODS

One hundred nine patients with bile duct stones were treated using endoscopic balloon sphincter dilation between July 1995 and September 1997. Serum amylase values were determined before and after the procedure in 100 patients treated 106 times, and these values were compared with the incidence of pancreatitis. Patients were classified into 3 categories according to serum amylase levels before therapy (group A, within the normal range; group B, above the normal upper limit up to 500 mU/mL; group C, above 500 mU/mL). The severity of pancreatitis was categorized into 4 grades (minimal, postprocedural abdominal pain lasting no longer than the next morning; mild, elevation of amylase values to at least three times normal accompanied by postprocedural abdominal pain necessitating treatment for 3 nights; moderate, required 4 to 10 nights of treatment; severe, required intensive care).

RESULTS

Postprocedural serum amylase levels in groups A and B were significantly elevated compared with baseline levels. In contrast, these levels in group C were decreased. Overall, postprocedural amylase levels were elevated in 95 studies. Minimal or mild pancreatitis developed in 21 (15 minimal and 6 mild) patients in groups A and B only.

CONCLUSIONS

Although pancreatic serum enzymes were elevated in almost all patients after endoscopic balloon sphincter dilation, procedure-related pancreatitis developed in a small percentage. There does not seem to be any contraindication to the use of endoscopic balloon sphincter dilation in patients with high amylase levels and an indication for the procedure, although such patients sometimes have stone-related pancreatitis or may be predisposed to developing pancreatitis.

Assessment of residual bile duct stones with use of intraductal US during endoscopic balloon sphincteroplasty: comparison with balloon cholangiography

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).

Washout of small stones in the bile duct by saline infusion using a side-holed balloon catheter in patients undergoing endoscopic papillary balloon dilation

BACKGROUND

Complete bile duct clearance of stones should be achieved in patients managed with endoscopic papillary balloon dilation. However, complete retrieval of small stones or tiny fragments sometimes proves difficult using conventional devices.

METHODS

We attempted the removal of fine stone fragments by saline infusion using a specially designed retrieval balloon catheter with a blind tip and a side hole located proximal to the balloon in 14 patients.

RESULTS

Using this technique, bile duct clearance was achieved in a single attempt in 13 of 14 patients; 2 attempts were required in 1 patient. Cholecystitis occurred in 2 patients with gallstones in situ after the procedure.

CONCLUSIONS

Saline washout using a side-holed retrieval balloon catheter effectively cleans stones and stone fragments from the bile duct in patients treated with endoscopic papillary balloon dilation.

Comparing the treatment outcomes of endoscopic papillary dilation and endoscopic sphincterotomy for removal of bile duct stones

To compare the clinical usefulness of endoscopic papillary dilation (EPD) and endoscopic sphincterotomy (EST) for removal of bile duct stones, 110 patients with stones up to 15 mm in diameter and less than 10 in number were randomly treated with either EPD (55 patients) or EST (55 patients). The patients were followed up for a median period of 23 months and endoscopic manometry with the administration of morphine was carried out in 17 patients who were observed more than 12 months after the procedures to evaluate the post-procedure papillary function. Duct clearance was achieved in 51 EPD (92.7%) and 54 EST patients (98.1%, not significantly different). Forty EPD (78.4%) and 51 EST patients (94.4%) achieved duct clearance in the initial procedure (P=0.02). Early complications occurred in one EPD (2.0%) and in three EST patients (5.6%, P=0.62). Complications during the follow-up period occurred in two EPD and eight EST patients. Recurrence of bile duct stones was observed in two EPD and three EST patients (P=0.98). Acute cholecystitis was observed in one EPD and five EST patients (P=0.06) and among patients with gall-bladder stones in situ, the rate of acute cholecystitis after EPD was significantly lower than that after EST (P=0.03). Endoscopic manometry showed the existence of a choledochoduodenal pressure gradient only after EPD, while papillary contractile function was observed after both procedures. In conclusion, both EPD and EST are safe therapeutic modalities, although EPD is more clinically effective in decreasing the risk of acute cholecystitis in patients with gall-bladder stones in situ and in preserving post-procedure papillary function.

Endoscopic papillary dilation by balloon and isosorbide dinitrate drip infusion for removing bile duct stone

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.

Endoscopic dilatation of the biliary sphincter for removal of bile duct stones: an overview of current indications and limitations

Endoscopic balloon dilatation (EBD) of the biliary sphincter may be an alternative to endoscopic sphincterotomy (EST) for removal of bile duct stones. After EBD of the biliary sphincter to a diameter of 8 mm, stones are removed according to standard guidelines. In the event that stone removal fails after EBD, an additional EST is performed. The overall success rate of stone removal after EBD (90%) is comparable to that of EST. After EBD, an additional EST and mechanical lithotripsy are required in 10% and 30% of patients, respectively. In patients with bile duct stones < 10 mm and a stone number < or = 3, EBD is nearly always successful without the need for additional EST or mechanical lithotripsy. Pancreatitis post-EBD occurs at a rate of 5-7%, which is not significantly different from that after EST. Significant bleeding post-EBD has not been observed in over 400 patients undergoing EBD. EBD is a valuable alternative to EST, especially in patients with smaller bile duct stones and in patients with haemostatic disorders.

The role of endoscopic balloon sphincteroplasty in patients with gallbladder and bile duct stones

We clarified the significance of endoscopic balloon sphincteroplasty (EBS) in the therapeutic treatment of biliary tract stones in the present era of laparoscopic cholecystectomy (LC). Patients with cholecysto-choledocholithiasis (n = 33) were treated by EBS. After endoscopic retrograde cholangiography (ERC), a balloon catheter (8 mm in diameter and 3 cm in width) was inserted into the bile duct using a guidewire, and positioned at the sphincter of Oddi. After inflating the balloon catheter, bile duct stones were removed by mechanical lithotripsy, a basket catheter, or a balloon catheter. In all patients, bile duct stones were removed by EBS without endoscopic sphincterotomy. No complication occurred except for 2 cases of mild pancreatitis, which was resolved within 48 hours. Twenty-four patients underwent LC before or after EBS. The remaining 9 patients did not undergo LC due to a poor-risk status for general anesthesia. None of them, however, experienced cholecystitis or colicky attacks after EBS. The combination of EBS and LC is an excellent method for treating cholecysto-choledocholithiasis.

Biliary manometry, bacterial characteristics, bile composition, and histologic changes fifteen to seventeen years after endoscopic sphincterotomy

AIM

To evaluate the function of the biliary sphincter 15 to 17 years after endoscopic sphincterotomy and to investigate if loss of sphincter function is associated with bacterial colonization, changes in bile composition, or inflammation of the biliary system.

METHODS

Eight patients who had undergone endoscopic sphincterotomy for bile duct stones 15 to 17 years previously underwent ERCP with biliary manometry, bile sampling, and biopsy. Manometry was performed using a perfused triple-lumen manometry catheter and a station pull-through technique. Bile samples were cultured and analyzed for biliary lipids, bile salts, bacterial beta-glucuronidase, and phospholipase A2. Biopsy specimens were taken from the proximal common heptic duct for histologic examination.

RESULTS

Manometry demonstrated absent basal sphincter pressure and no choledochoduodenal pressure gradient in all patients. Phasic contractions were observed in two patients. Cholangiography showed stones in one patient. Positive cultures were obtained in three patients, including the patient with stones. All bile samples showed a high content of biliary lipids and cholesterol. Some samples contained considerable amounts of hydrophobic bile salts. Five samples contained very high levels of phospholipase A2 activity. Significant bacterial beta-glucuronidase activity was found in one patient, the patient with stones. Biopsy specimens of the proximal common hepatic duct in three patients showed chronic inflammation with fibrosis and reactive epithelial changes.

CONCLUSIONS

After endoscopic sphincterotomy for bile duct stones, the function of the biliary sphincter is permanently lost. This is associated with bacterial colonization, presence of cytotoxic components in the bile, and chronic inflammation of the biliary system.

Randomised trial of endoscopic balloon dilation versus endoscopic sphincterotomy for removal of bileduct stones

BACKGROUND

Endoscopic sphincterotomy (EST) for the removal of bileduct stones is associated with acute complications and a permanent loss of biliary-sphincter function. Endoscopic balloon dilation (EBD) causes less trauma to the biliary sphincter, but may be less effective in allowing stone removal.

METHODS

218 consecutive patients with bileduct stones on endoscopic retrograde cholangiopancreatography (ERCP) were enrolled. 202 who met all eligibility criteria were randomly assigned EST or EBD. The patients were observed in hospital for at least 24 h and followed up at 1 month and 6 months. Complications were classified by an expert panel unaware of treatment allocation and outcome. Analysis was done by intention to treat.

FINDINGS

After a single ERCP, all stones were removed from 92 (91%) of 101 patients assigned EST and 90 (89%) of 101 assigned EBD (p = 0.81); in nine of the latter, successful removal required additional EST. Mechanical lithotripsy was used to fragment stones in 31 EBD procedures and 13 EST procedures (p < 0.005). Early complications (before 15 days) occurred in 24 EST patients and 17 EBD patients (p = 0.29). One patient died of retroperitoneal perforation after EBD. Four patients had bleeding after EST. Seven patients in each group had pancreatitis. Complications during follow-up occurred in 23 EST patients and 18 EBD patients (p = 0.48). Acute cholecystitis was observed in seven EST patients and one EBD patient (p < 0.05).

INTERPRETATION

The success rate of EBD was similar to that of EST. We found there is no evidence of the previously suggested higher risk of pancreatitis with EBD and suggest that EBD is preferred in patients at risk of bleeding after EST. Preservation of biliary-sphincter function after EBD may prevent long-term complications and reduce the risk of acute cholecystitis during follow-up. This procedure is a valuable alternative to EST in patients with bileduct stones.