Endoscopic sphincterotomy plus large-balloon dilation versus endoscopic sphincterotomy for removal of bile-duct stones

Endoscopic large-diameter balloon dilation after fistulotomy for the removal of bile duct stones in a difficult cannulation

BACKGROUND

When standard methods of biliary cannulation fail, needle-knife fistulotomy may be used. However, large stones cannot be easily extracted through the necessarily smaller opening made when using the fistulotomy technique.

OBJECTIVE

We report the efficacy and safety of endoscopic large-diameter balloon dilation after fistulotomy for the removal of bile duct stones in patients in whom cannulation is difficult.

DESIGN

A case series.

SETTING

A tertiary referral center.

PATIENTS AND INTERVENTIONS

Six patients (6 of 115, 5.2%) with bile duct stones in whom cannulation by the conventional method had failed underwent fistulotomy and large-diameter (12-15 mm) balloon dilation through the fistulotomy tract.

MAIN OUTCOME MEASUREMENTS

Successful biliary cannulation, outcome of therapy, and post-ERCP complications including pancreatitis were recorded.

RESULTS

Biliary cannulation was successful in 6 of 6 patients (100%) with fistulotomy. After endoscopic large-diameter balloon dilation of the fistulotomy tract, stone extraction was successfully performed in 6 of 6 patients. None of the patients developed post-ERCP pancreatitis. One of the 6 patients had minor delayed bleeding, which stopped spontaneously.

LIMITATIONS

A small case series, retrospective design, and no control group.

CONCLUSION

Endoscopic large-diameter balloon dilation through the fistulotomy tract may be a feasible and safe alternative method for the removal of bile duct stones in patients in whom cannulation is difficult.

Endoscopic sphincterotomy combined with large balloon dilation can reduce the procedure time and fluoroscopy time for removal of large bile duct stones

OBJECTIVES

We sought to evaluate the safety, efficacy, and feasibility of endoscopic sphincterotomy plus large balloon dilation (ESLBD) and to compare procedural time and fluoroscopy time of ESLBD with those of endoscopic sphincterotomy (EST) alone for patients with large bile duct stones.

METHODS

Retrospective analysis.

RESULTS

A total of 101 patients with large bile duct stones were treated: 53 were treated by ESLBD and 48 with EST alone. ESLBD resulted in similar outcomes in overall successful stone removal (100% vs. 97%) and complications (4% vs. 6%); however, although the rate of complete stone removal in the first session using ESLBD tended to be higher than when EST alone was used, it was not statistically significant (96% vs. 85%, P=0.057). Mechanical lithotripsy was required significantly more often in the EST group compared to the ESLBD group (25% vs. 6%, P<0.01). Total procedure time in the ESLBD group was significantly shorter than that of the EST group (32 vs. 40 min, P<0.05). Total fluoroscopy time in the ESLBD group was significantly shorter in the EST group (13 vs. 22 min, P<0.05).

CONCLUSIONS

ESLBD is an effective and safe treatment in patients with large bile duct stones. In addition, ESLBD appears to decrease procedure time and fluoroscopy time and reduce the need for mechanical lithotripsy as compared to EST alone.

Post-sphincterotomy transampullary balloon dilation is a safe and effective technique

PURPOSE

To evaluate the safety and efficacy of performing ampullary balloon dilation (ABD) following endoscopic sphincterotomy (ES).

METHODS

Retrospective review of patients that underwent ABD at Thomas Jefferson University from 2000 to 2007. In all cases, dilation was performed with Hurricane RX hydrostatic balloons (Boston Scientific, Natick MA) or CRE esophageal dilating balloons (Boston Scientific, Natick MA).

RESULTS

ABD following ES was performed in 69 patients. The procedure was performed for choledocholithiasis in 58%, abnormal imaging in 26%, and abnormal liver enzymes in 23% of patients. ABD following ES was 86% successful in achieving the intended therapeutic goal of the procedure. Pancreatitis (2.9%) post endoscopic retrograde cholangiopancreatography (ERCP) occurred in two individuals, with one case of hemorrhage (1.5%) and one perforation (1.5%).

CONCLUSION

ABD following ES is a safe and effective alternative to ES alone, particularly for the extraction of large common bile duct (CBD) stones.

Therapeutic endoscopic retrograde cholangiopancreatography using an anterior oblique-viewing endoscope for bile duct stones in patients with prior Billroth II gastrectomy

BACKGROUND

Prior Billroth II gastrectomy is an important factor presenting difficulties in endoscopic retrograde cholangiopancreatography (ERCP) administration. We retrospectively evaluated the usefulness and safety of therapeutic ERCP using an anterior oblique-viewing endoscope for bile duct stones in patients with prior Billroth II gastrectomy.

METHODS

Forty-three patients with bile duct stones after Billroth II gastrectomy who underwent ERCP from January 1998 to February 2008 were enrolled in this study. We used anterior oblique-viewing endoscopes for all procedures. Endoscopic sphincterotomy was performed using a needle knife guided by a biliary stent. A total of 808 patients without gastrectomy who had undergone ERCP for bile duct stones in the same period were reviewed as controls.

RESULTS

The success rate of access to the papilla of Vater was 88.4%, and the average time required for such access was 13 min. In cases of successful access, selective cannulation of the bile duct and complete stone removal were achieved in 94.7% and 94.6% of patients, respectively. The incidence of complications was 4.7%. As for the success rate of selective cannulation, complete stone removal ratio, and the incidence of complications, there were no significant differences compared with the control group.

CONCLUSIONS

Use of an anterior oblique-viewing endoscope enables good success rates in selective cannulation and complete stone removal to be achieved in patients with prior Billroth II gastrectomy. The safety of therapeutic ERCP for removal of bile duct stones in those patients is comparable to that in patients with normal anatomy.

Endoscopic removal of bile-duct stones by using a rotatable papillotome and a large-balloon dilator in patients with a Billroth II gastrectomy (with video)

BACKGROUND

Endoscopic stone removal is difficult in patients with a Billroth II gastrectomy.

OBJECTIVE

To evaluate the usefulness of a rotatable papillotome and large-balloon dilation for removing bile-duct stones in patients with a Billroth II gastrectomy.

DESIGN

A case series.

SETTING

A large tertiary-referral center.

PATIENTS AND INTERVENTION

Nine patients with bile-duct stones and a previous Billroth II gastrectomy were included. An endoscopic sphincterotomy (EST) was performed with a rotatable papillotome that could correct the axis of the cut toward the 5-o'clock direction; a large-balloon dilation (LBD) was then performed.

MAIN OUTCOME MEASUREMENTS

The ability to perform an EST in the desired direction, successful stone removal, and complications.

RESULTS

Rotation of the papillotome toward the 5-o'clock direction and an EST were achieved in 8 patients (89%). Stones were removed by EST and LBD in all 8 patients. There were no complications.

LIMITATION

A small sample size.

CONCLUSIONS

Limited EST by using a rotatable papillotome plus large-balloon dilation seemed to be safe, easy, and effective for removing bile-duct stones in patients with a Billroth II gastrectomy.

Reoperation of biliary tract by laparoscopy: Experiences with 39 cases

AIM: To evaluate the safety and feasibility of biliary tract reoperation by laparoscopy for the patients with retained or recurrent stones who failed in endoscopic sphincterotomy.

METHODS: A retrospective analysis of data obtained from attempted laparoscopic reoperation for 39 patients in a single institution was performed, examining open conversion rates, operative times, complications, and hospital stay.

RESULTS: Out of the 39 cases, 38 (97%) completed laparoscopy, 1 required conversion to open operation because of difficulty in exposing the common bile duct. The mean operative time was 135 min. The mean post-operative hospital stay was 4 d. Procedures included laparoscopic residual gallbladder resection in 3 cases, laparoscopic common bile duct exploration and primary duct closure at choledochotomy in 13 cases, and laparoscopic common bile duct exploration and choledochotomy with T tube drainage in 22 cases. Duodenal perforation occurred in 1 case during dissection and was repaired laparoscopically. Retained stones were found in 2 cases. Postoperative asymptomatic hyperamylasemia occurred in 3 cases. There were no complications due to port placement, postoperative bleeding, bile or bowel leakage and mortality. No recurrence or formation of duct stricture was observed during a mean follow-up period of 18 mo.

CONCLUSION: Laparoscopic biliary tract reoperation is safe and feasible if it is performed by experienced laparoscopic surgeons, and is an alternative choice for patients with choledocholithiasis who fail in endoscopic sphincterectomy.

Endoscopy in the management of choledocholithiasis

Choledocholithiasis (bile duct stones) occurs in 10% to 15% of patients with cholelithiasis. Endoscopic retrograde cholangiopancreatography and biliary sphincterotomy, combined with the use of a variety of available accessories (eg, mechanical lithotriptors), are highly effective in managing most common bile duct stones. The combination of biliary sphincterotomy and papillary balloon dilation allows removal of many stones without the need for mechanical lithotripsy. Large stones may require additional expertise and the use of cholangioscopy with intraductal lithotripsy. Some patients, especially those with intrahepatic stones, require the help of an interventional radiologist or a biliary surgeon. The availability of endoscopists, radiologists, and surgeons interested in and experienced with biliary diseases will allow successful and safe therapy to be tailored to the individual patient.