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Chon HK, Kozarek RA. History of the Interventional Pancreaticobiliary Endoscopy. Gastrointest Endosc Clin N Am 2024; 34:383-403. [PMID: 38796288 DOI: 10.1016/j.giec.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2024]
Abstract
With the introduction of endoscopic retrograde cholangiopancreatography and linear endoscopic ultrasound, interventional pancreaticobiliary (PB) endoscopy has had an enormous impact in the management of pancreatic and biliary diseases. Continuous efforts to improve various devices and techniques have revolutionized these treatment modalities as viable alternatives to surgery. In recent years, trends toward combining endoscopic techniques with other modalities, such as laparoscopic and radiological interventions, for complex PB diseases have emerged using a multidisciplinary approach. Ongoing research and clinical experience will lead to refinements in interventional PB endoscopic techniques and subsequently improve outcomes and reduce complication rates.
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Affiliation(s)
- Hyung Ku Chon
- Division of Biliopancreas, Department of Internal Medicine, Wonkwang University Medical School, and Hospital, Iksan, Republic of Korea; Institution of Wonkwang Medical Science, Iksan, Republic of Korea
| | - Richard A Kozarek
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason Franciscan Health, 1100 Ninth Avenue, Seattle, WA 98101, USA; Center for Interventional Immunology, Benaroya Research Institute, Virginia Mason Franciscan Health, 1201 Ninth Avenue, Seattle, WA 98101, USA.
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Tanisaka Y, Mizuide M, Fujita A, Jinushi R, Ogawa T, Katsuda H, Saito Y, Miyaguchi K, Terada R, Tashima T, Mashimo Y, Ryozawa S. Factors affecting complete stone extraction in the initial procedure in short type single-balloon enteroscopy-assisted endoscopic retrograde cholangiography for patients with Roux-en-Y gastrectomy. Scand J Gastroenterol 2022; 57:1390-1396. [PMID: 35723063 DOI: 10.1080/00365521.2022.2088245] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES This study aimed to evaluate the efficacy and safety of stone extraction in patients who underwent Roux-en-Y gastrectomy using short-type single-balloon enteroscopy (SBE) and to clarify the factors affecting complete stone extraction in the initial procedure. METHODS The data of patients with Roux-en-Y gastrectomy who underwent endoscopic stone extraction using short SBE between September 2011 and January 2022 was analyzed. RESULTS Overall, 85 patients were scheduled to undergo stone extraction. 77 patients were intended stone extraction after successful biliary cannulation. The complete stone extraction success in the initial procedure, overall complete stone extraction success including repeated procedures, and adverse event rates were 68.2% (95% confidence interval [CI], 57.2%-77.9%), 87.1% (95% CI, 78.0%-93.4%), and 8.2% (95% CI, 3.4%-16.2%), respectively. Multiple logistic regression analysis indicated that bile duct diameter affected the success of complete stone extraction after successful biliary cannulation in the initial procedure (odds ratio 0.53, 95% CI, 0.30-0.94, p = .03). CONCLUSIONS Stone extraction in patients with Roux-en-Y gastrectomy using short SBE was effective. Patients with a large diameter bile duct required several sessions for complete stone extraction, suggesting that more dedicated devices are warranted for patients with surgically altered anatomy.
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Affiliation(s)
- Yuki Tanisaka
- Department of Gastroenterology, Saitama Medical University International Medical Center
| | - Masafumi Mizuide
- Department of Gastroenterology, Saitama Medical University International Medical Center
| | - Akashi Fujita
- Department of Gastroenterology, Saitama Medical University International Medical Center
| | - Ryuhei Jinushi
- Department of Gastroenterology, Saitama Medical University International Medical Center
| | - Tomoya Ogawa
- Department of Gastroenterology, Saitama Medical University International Medical Center
| | - Hiromune Katsuda
- Department of Gastroenterology, Saitama Medical University International Medical Center
| | - Yoichi Saito
- Department of Gastroenterology, Saitama Medical University International Medical Center
| | - Kazuya Miyaguchi
- Department of Gastroenterology, Saitama Medical University International Medical Center
| | - Rie Terada
- Department of Gastroenterology, Saitama Medical University International Medical Center
| | - Tomoaki Tashima
- Department of Gastroenterology, Saitama Medical University International Medical Center
| | - Yumi Mashimo
- Department of Gastroenterology, Saitama Medical University International Medical Center
| | - Shomei Ryozawa
- Department of Gastroenterology, Saitama Medical University International Medical Center
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Paspatis GA, Papastergiou V, Mpitouli A, Velegraki M, Nikolaou P, Fragkaki M, Voudoukis E, Theodoropoulou A, Chlouverakis G, Vardas E, Paraskeva KD. Distal Biliary Stent Migration in Patients with Irretrievable Bile Duct Stones: Long-Term Comparison Between Straight and Double-Pigtail Stents. Dig Dis Sci 2022; 67:4557-4564. [PMID: 35305168 DOI: 10.1007/s10620-022-07461-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 11/08/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Prolonged biliary stenting may be considered in high-risk patients with irretrievable bile duct stones (IBDS). Distal stent migration (DSM) is a known complication, although data beyond the recommended interval of temporary stenting (3-6 months) are lacking. We compared the long-term incidence of DSM between straight and double-pigtail stents in patients with IBDS. METHODS Consecutive patients with IBDS undergoing plastic biliary stenting (1/2009-12/2019) were retrospectively reviewed. DSM was confirmed on follow-up examination when the stent was no longer present at the papillary orifice nor fluoroscopically visible in the bile duct. Kaplan-Meier and Cox regression analyses were used to determine estimates and predictors of DSM. RESULTS Overall, 618 biliary stenting procedures (410 patients) were included: 289 with a straight stent (group A) and 329 with a double-pigtail (group B). By Kaplan-Meier analysis, the DSM rates were 8.4 and 14.6% at 6 months, 21.4 and 27.7% at 12 months, 27 and 43.5% at 18 months, and 37.2 and 60.4% at 24 months, for groups A and B, respectively (p = 0.004). Double-pigtail stents were at higher risk for DSM (HR = 7.38, p = 0.04), whereas an inverse correlation was noted with age (HR = 0.97, p = 0.0001). Considering only temporary stenting procedures (≤ 6 months; n = 297), the probability of DSM was not significantly different between the two groups (p = 0.07). CONCLUSIONS In a setting of prolonged stenting for IBDS, the probability of DSM appears to be higher when a double-pigtail stent is used and in younger patients. A relative anti-migratory advantage of double-pigtail over straight stents appears negligible in this study.
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Affiliation(s)
- Gregorios A Paspatis
- Department of Gastroenterology, Benizelion" General Hospital, L. Knossou, 71409, Heraklion, Crete, Greece.
| | - Vasilios Papastergiou
- Department of Gastroenterology, "Konstantopoulio-Patision" General Hospital, Athens, Greece
| | - Afroditi Mpitouli
- Department of Gastroenterology, Benizelion" General Hospital, L. Knossou, 71409, Heraklion, Crete, Greece
| | - Magdalini Velegraki
- Department of Gastroenterology, Benizelion" General Hospital, L. Knossou, 71409, Heraklion, Crete, Greece
| | - Pinelopi Nikolaou
- Department of Gastroenterology, Benizelion" General Hospital, L. Knossou, 71409, Heraklion, Crete, Greece
| | - Maria Fragkaki
- Department of Gastroenterology, Benizelion" General Hospital, L. Knossou, 71409, Heraklion, Crete, Greece
| | - Evangelos Voudoukis
- Department of Gastroenterology, Benizelion" General Hospital, L. Knossou, 71409, Heraklion, Crete, Greece
| | - Angeliki Theodoropoulou
- Department of Gastroenterology, Benizelion" General Hospital, L. Knossou, 71409, Heraklion, Crete, Greece
| | | | - Emmanouil Vardas
- Department of Gastroenterology, Benizelion" General Hospital, L. Knossou, 71409, Heraklion, Crete, Greece
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Phillpotts S, Webster G, Arvanitakis M. Endoscopic Management of Complex Biliary Stones. Gastrointest Endosc Clin N Am 2022; 32:477-492. [PMID: 35691692 DOI: 10.1016/j.giec.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Complex biliary stones may be challenging to remove with standard endoscopic techniques. Factors contributing to complexity include large stone size (≥15 mm), multiple stones, high stone:distal duct ratio, stones above strictures and those in difficult anatomic position. In these cases, additional techniques may be needed, such as endoscopic papillary large balloon dilatation, mechanical lithotripsy, cholangioscopic visually directed lithotripsy, and extracorporeal shockwave lithotripsy. The choice of technique depends on local expertise and resources. Cases should be planned to identify the appropriate technique to avoid multiple procedures. This article describes the factors linked to difficulty and the steps to overcome them.
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Affiliation(s)
- Simon Phillpotts
- Department of Gastroenterology, University College London Hospitals, 250 Euston Road, London, England
| | - George Webster
- Department of Gastroenterology, University College London Hospitals, 250 Euston Road, London, England.
| | - Marianna Arvanitakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik 808, Brussels 1070, Belgium
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Dollhopf M, Schmetkamp H. Endoscopic management of difficult common bile duct stones. Minerva Gastroenterol (Torino) 2021; 68:144-153. [PMID: 34142521 DOI: 10.23736/s2724-5985.21.02876-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Common bile duct stones are a very frequent problem in the western world and endoscopic stone clearance is the method of choice for treatment. Despite its common use, endoscopic clearance of common bile duct stones is not always trivial especially in cases involving large or multiple stones. EVIDENCE ACQUISITION A literature review regarding different endoscopic techniques was performed for this article and a recommended therapeutic algorithm developed based on the guidelines of the European Society of Gastrointestinal Endoscopy (ESGE) and the German Gastroenterological Society (DGVS). EVIDENCE SYNTHESIS This review gives an overview of currently applied endoscopic techniques, their success and complication rates as well as alternative methods used for cases involving anatomic anomalies. The purpose of this review is to recommend a therapeutic algorithm for the treatment of difficult common bile duct stones. CONLCLUSIONS For the treatment of difficult common bile duct stones, combined sphincterotomy and endoscopic large balloon dilation should be first choice. Mechanical lithotripsy and cholangioscopy-guided lithotripsy are close alternatives with nearly equal clearance rates and should be used if accessible. The insertion of a temporary plastic stent is a good choice to gain time to explore further treatment options. Enteroscopy-based ERCP, PTCS or EUS-guided hepaticogastrostomy and stone treatment, while good alternatives for select cases involving anatomic anomalies, should be performed at specialised units.
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Affiliation(s)
- Markus Dollhopf
- Endoscopy Section, Gastroenterology, München Klinik Neuperlach, Munich, Germany
| | - Henning Schmetkamp
- Endoscopy Section, Gastroenterology, München Klinik Neuperlach, Munich, Germany -
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Fujita A, Nakahara K, Michikawa Y, Morita R, Suetani K, Sato J, Igarashi Y, Araki R, Ikeda H, Matsunaga K, Watanabe T, Itoh F. Pancreatic duct guidewire placement for biliary cannulation as a risk factor for stone residue after endoscopic transpapillary stone removal. BMC Gastroenterol 2020; 20:285. [PMID: 32831030 PMCID: PMC7446213 DOI: 10.1186/s12876-020-01428-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 08/17/2020] [Indexed: 02/08/2023] Open
Abstract
Background Recent improvements in stone extraction implements and apparatus have lessened the complexity of the endoscopic bile duct stone treatment. However, despite confirmation of complete removal, cases of residual stones have been reported, which can result in recurrent biliary symptoms, cholangitis, and pancreatitis and considerably increase cost given the need for repeat imaging and/or procedures. To date, risk factors for residual bile duct stones following endoscopic retrograde cholangiopancreatography (ERCP) extraction have not been thoroughly evaluated. This study retrospectively investigated the incidence and risk factors of residual bile duct stones following extraction via ERCP. Methods We retrospectively reviewed all ERCP cases that underwent endoscopic bile duct stone extraction between April 2014 and March 2019. A total of 505 patients were enrolled and evaluated for the incidence and risk factors of residual bile duct stones after ERCP. Results The rate of residual stones was 4.8% (24/505). Residual stones were detected by computed tomography (12/24) or magnetic resonance cholangiopancreatography (12/24). In univariate analyses, a large number of stones (P = 0.01), long procedure time (P = 0.005), and performance of the pancreatic duct guidewire placement method (P-GW) for selective bile duct cannulation (P = 0.01) were the factors involved in residual stones. In multiple logistic regression analysis, performing P-GW was retained as the only independent factor of residual stones (adjusted odds ratio, 3.44; 95% CI, 1.19–9.88; P = 0.02). Conclusions When removing bile duct stones with a pancreatic guidewire in place, paying attention to residual stones is necessary.
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Affiliation(s)
- Akashi Fujita
- Department of Gastroenterology and Hepatology, St. Marianna University, School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Kazunari Nakahara
- Department of Gastroenterology and Hepatology, St. Marianna University, School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan.
| | - Yosuke Michikawa
- Department of Gastroenterology and Hepatology, St. Marianna University, School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Ryo Morita
- Department of Gastroenterology and Hepatology, St. Marianna University, School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Keigo Suetani
- Department of Gastroenterology and Hepatology, St. Marianna University, School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Junya Sato
- Department of Gastroenterology and Hepatology, St. Marianna University, School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Yosuke Igarashi
- Department of Gastroenterology and Hepatology, St. Marianna University, School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Ryuichiro Araki
- Community Health Science Center, Saitama Medical University, Saitama, Japan
| | - Hiroki Ikeda
- Department of Gastroenterology and Hepatology, St. Marianna University, School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Kotaro Matsunaga
- Department of Gastroenterology and Hepatology, St. Marianna University, School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Tsunamasa Watanabe
- Department of Gastroenterology and Hepatology, St. Marianna University, School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Fumio Itoh
- Department of Gastroenterology and Hepatology, St. Marianna University, School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
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Franzini T, Moura RN, Bonifácio P, Luz GO, de Souza TF, dos Santos MEL, Rodela GL, Ide E, Herman P, Montagnini AL, D’Albuquerque LAC, Sakai P, de Moura EGH. Complex biliary stones management: cholangioscopy versus papillary large balloon dilation - a randomized controlled trial. Endosc Int Open 2018; 6:E131-E138. [PMID: 29399609 PMCID: PMC5794432 DOI: 10.1055/s-0043-122493] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 10/25/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Endoscopic removal of biliary stones has high success rates, ranging between 85 % to 95 %. Nevertheless, some stones may be challenging and different endoscopic methods have evolved. Papillary large balloon dilation after sphincterotomy is a widely used technique with success rates ranging from 68 to 90 % for stones larger than 15 mm. Cholangioscopy allows performing lithotripsy under direct biliary visualization, either by laser or electrohydraulic waves, which have similar success rate (80 % - 90 %). However, there is no study comparing these 2 techniques. PATIENTS AND METHODS From April 2014 to June 2016, 100 patients were enrolled and randomized in 2 groups, using a non-inferiority hypothesis: cholangioscopy + electrohydraulic lithotripsy (group 1) and endoscopic papillary large balloon dilation (group 2). The main outcome was complete stone removal. Adverse events were documented. Mechanical lithotripsy was not performed. Failure cases had a second session with crossover of the methods. RESULTS The mean age was 56 years. 74 (75.5 %) patients were female. The initial overall complete stone removal rate was 74.5 % (77.1 % in group 1 and 72 % in group 2, P > 0.05). After second session the overall success rate achieved 90.1 %. Procedure time was significantly lower in group 2, - 25.2 min (CI95 % - 12.48 to - 37.91). There were no significant differences regarding technical success rate, radiologic exposure and adverse events. CONCLUSION Single-operator cholangioscopy-guided lithotripsy and papillary large balloon dilation are effective and safe approaches for removing complex biliary stones.
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Affiliation(s)
- Tomazo Franzini
- University of Sao Paulo Medical School – Department of Gastroenterology, Sao Paulo, Brazil,Corresponding author Tomazo Franzini, MD, PhD Av. Dr. Enéas de Carvalho Aguiar255 – Prédio dos Ambulatórios Pinheiros05403-000 Sao PauloSP – Brazil
| | - Renata Nobre Moura
- University of Sao Paulo Medical School – Department of Gastroenterology, Sao Paulo, Brazil
| | - Priscilla Bonifácio
- University of Sao Paulo Medical School – Department of Gastroenterology, Sao Paulo, Brazil
| | - Gustavo Oliveira Luz
- University of Sao Paulo Medical School – Department of Gastroenterology, Sao Paulo, Brazil
| | | | | | - Gustavo Luis Rodela
- University of Sao Paulo Medical School – Department of Gastroenterology, Sao Paulo, Brazil
| | - Edson Ide
- University of Sao Paulo Medical School – Department of Gastroenterology, Sao Paulo, Brazil
| | - Paulo Herman
- University of Sao Paulo Medical School – Department of Gastroenterology, Sao Paulo, Brazil
| | - André Luis Montagnini
- University of Sao Paulo Medical School – Department of Gastroenterology, Sao Paulo, Brazil
| | | | - Paulo Sakai
- University of Sao Paulo Medical School – Department of Gastroenterology, Sao Paulo, Brazil
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Hartery K, Lee CS, Doherty GA, Murray FE, Cullen G, Patchett SE, Mulcahy HE. Covered self-expanding metal stents for the management of common bile duct stones. Gastrointest Endosc 2017; 85:181-186. [PMID: 27262891 DOI: 10.1016/j.gie.2016.05.038] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 05/25/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Little medical literature exists for the use of fully covered self-expanding metal stents (CSEMSs) in the management of retained common bile duct (CBD) stones. Our aim was to assess the safety and efficacy of CSEMSs for the indication of retained "difficult" CBD stones. METHODS This retrospective cases series included 44 patients (30 women; median age, 69 years [range, 24-88]) who underwent CSEMS insertion for the indication of retained "difficult" CBD stones in 2 tertiary referral centers. Patients underwent temporary placement of CSEMSs after incomplete stone clearance at ERCP. Follow-up ERCP was arranged for stent removal and subsequent attempt at duct clearance. Procedure-related adverse events were also recorded. RESULTS Successful biliary drainage was achieved in all cases after CSEMS placement. Forty-two stents were removed with successful duct clearance achieved in 36 cases (82%) after a median in-stent duration of 8 weeks. There were 10 cases (22.7%) of stent migration, all noted incidentally during follow-up. One patient died of nonbiliary causes before attempted removal. CONCLUSION This is the largest published retrospective case series for use of CSEMSs for management of retained CBD stone disease to date. We have shown high success rates for this indication. A well-designed, multicenter, randomized controlled trial might address the uncertainty of cost-to-benefit ratio and appropriate duration for CSEMSs to be left in situ. Specific stent modification for this indication, including wider distal flare and retrieval purse string loop, may also be useful.
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Affiliation(s)
- Karen Hartery
- Department of Gastroenterology, St. Vincent's University Hospital and School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
| | - Chung Sen Lee
- Department of Gastroenterology, St. Vincent's University Hospital and School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
| | - Glen A Doherty
- Department of Gastroenterology, St. Vincent's University Hospital and School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
| | - Frank E Murray
- Department of Gastroenterology, Beaumont Hospital and Royal College of Surgeons, Dublin, Ireland
| | - Garret Cullen
- Department of Gastroenterology, St. Vincent's University Hospital and School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
| | - Stephen E Patchett
- Department of Gastroenterology, Beaumont Hospital and Royal College of Surgeons, Dublin, Ireland
| | - Hugh E Mulcahy
- Department of Gastroenterology, St. Vincent's University Hospital and School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
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Tao T, Zhang QJ, Zhang M, Zhu X, Sun SX, Li YQ. Using cholecystokinin to facilitate endoscopic clearance of large common bile duct stones. World J Gastroenterol 2014; 20:10121-10127. [PMID: 25110439 PMCID: PMC4123341 DOI: 10.3748/wjg.v20.i29.10121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 02/07/2014] [Accepted: 04/29/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the effect of cholecystokinin (CCK) during extracorporeal shockwave lithotripsy (ESWL) in the clearance of common bile duct (CBD) stones in endoscopic retrograde cholangiopancreatography (ERCP).
METHODS: Between January 2007 and September 2012, patients with large CBD stones who were treated with ESWL and ERCP were identified retrospectively. Patients were randomized in equal numbers to cholecystokinin (CCK) and no CCK groups. For each CCK case, a dose (3 ng/kg per min for 10 min) of sulfated octapeptide of CCK-8 was administered intravenously near the beginning of ESWL. ERCP was performed 4 h after a session of ESWL. The clearance rate of the CBD was assessed between the two groups.
RESULTS: A total of 148 consecutive cases (CCK group: 74, no CCK group: 74) were tallied. Overall there were 234 ESWLs and 228 ERCPs in the 148 cases. The use of CCK showed a significantly higher rate of successful stone removal in the first ESWL/ERCP procedure (71.6% vs 55.4%, P = 0.035), but resulted in similar outcomes in the second (42.8% vs 39.4%) and third (41.7% vs 40.0%) sessions, as well as total stone clearance (90.5% vs 83.8%). The use of mechanical lithotripsy was reduced in the CCK group (6.8% vs 17.6%, P = 0.023), and extremely large stone (≥ 30 mm) removal was higher in the CCK group (72.7% vs 41.7%, P = 0.038).
CONCLUSION: CCK during ESWL can aid with the clearance of CBD stones in the first ESWL/ERCP session. Mechanical lithotripsy usage was reduced and the extremely large stone (≥ 30 mm) clearance rate can be raised.
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Aljebreen AM, Alharbi OR, Azzam N, Almadi MA. Efficacy of spyglass-guided electrohydraulic lithotripsy in difficult bile duct stones. Saudi J Gastroenterol 2014; 20:366-70. [PMID: 25434318 PMCID: PMC4271012 DOI: 10.4103/1319-3767.145329] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND/AIMS We aimed to evaluate the efficacy and safety of Spyglass-guided electrohydraulic lithotripsy (EHL) for difficult common bile duct stones (CBD) not amenable to conventional endoscopic therapy. DESIGN A retrospective study evaluating the efficacy of Spyglass-guided EHL in treating difficult CBD stones, in a single tertiary care center. PATIENTS AND METHODS All patients who underwent Spyglass-guided EHL from 2012 to 2013 were compared with a historical cohort who had ECSWL. RESULTS A total number of 13 patients underwent Spyglass-guided EHL, 8 (61.5%) of them were males. The mean age was 46.5 ± 5.6 years. Bile duct clearance was achieved in 13 (100%) of them. Seventy-six percent required only one Endoscopic Retrograde Cholangiopancreatography (ERCP) to clear the CBD, 7.7% required two ERCPs, and 15.4% required three ERCPs. Adverse effects (cholangitis) occurred in one patient (10%), whereas only 30 patients (64.4%) of the ESWL group had complete CBD stone clearance. Thirty-seven percent required one ERCP to clear the CBD, 35.6% required two ERCPs, and 20% required three ERCPs. Adverse effects happened in seven (15.5%) patients, where five (11%) had cholangitis and two (4.4%) had pancreatitis. CONCLUSION Although a retrospective design with a small sample size, we concluded that Spyglass-guided EHL is an effective procedure in treating difficult CBD stones.
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Affiliation(s)
- Abdulrahman M. Aljebreen
- Gastroenterology Division, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia,Address for correspondence: Dr. Abdulrahman M. Aljebreen, Department of Internal Medicine, PO Box 2925, King Khalid University Hospital, Riyadh, 11461, Saudi Arabia. E-mail:
| | - Othman R. Alharbi
- Gastroenterology Division, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Nahla Azzam
- Gastroenterology Division, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Majid A. Almadi
- Gastroenterology Division, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia,Gastroenterology Division, The McGill University Health Center, Montreal General Hospital, McGill University, Montreal, Canada
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Yang J, Peng JY, Pang EJ, Chen W. Efficacy of endoscopic nasobiliary drainage for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis and cholangitis after repeated clearance of common bile duct stones: experience from a Chinese center. Dig Endosc 2013; 25:453-8. [PMID: 23363031 DOI: 10.1111/den.12013] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Accepted: 10/30/2012] [Indexed: 12/24/2022]
Abstract
BACKGROUND The aim of the present study was to investigate whether it is reasonable to insert an endoscopic nasobiliary drainage (ENBD) tube in patients with endoscopic sphincterotomy (EST) and repeated clearance of common bile duct (CBD) stones. PATIENTS AND METHODS Patients with choledocholithiasis who underwent EST and CBD stone clearance at our center from January 2010 to May 2012 were reviewed. The following parameters were evaluated: (i) serum amylase 2 and 24 h after ERCP; (ii) incidence of endoscopic retrograde cholangiopancreatography (ERCP)-related pancreatitis and cholangitis; (iii) time elapsed to normalization of total serum bilirubin levels for those with jaundice before ERCP; and (iv) length of hospital stay. RESULTS Compared with the no-ENBD group, the ENBD group presented a significantly lower postoperative serum amylase of 2 and 24 h (81.3 ± 31.8 U/L vs 90.8 ± 31.2 U/L, 107.0 ± 51.1 U/Lvs 132.3 ± 100.8 U/L, respectively). The incidence of post-ERCP pancreatitis and cholangitis was also lower in the ENBD group, although the differences were not significant (1% vs 4.4%, 0 vs 4.5%, respectively). Time elapsed to normalization of total serum bilirubin levels and length of hospital stay was shorter in the ENBD group (4.3 days ± 0.6 days vs 4.5 days ± 0.7 days, P > 0.05; 4.8 days ± 2.1 days vs 6.3 days ± 2.8 days, respectively, P < 0.01). CONCLUSIONS ENBD significantly reduces the incidence of hyperamylasemia and decreases the length of hospital stay in patients with EST and repeated stone extraction. ENBD should be considered for patients with large or multiple CBD stones.
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Affiliation(s)
- Jun Yang
- Department of Surgery, Shanghai Jiao Tong University School of Medicine Affiliated Sixth People's Hospital, Shanghai, China
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Cerefice M, Sauer B, Javaid M, Smith LA, Gosain S, Argo CK, Kahaleh M. Complex biliary stones: treatment with removable self-expandable metal stents: a new approach (with videos). Gastrointest Endosc 2011; 74:520-6. [PMID: 21872710 DOI: 10.1016/j.gie.2011.05.026] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Accepted: 05/17/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND Complex biliary stones often require temporary stent placement before a repeat attempt at extraction. To date, covered self-expandable metal stents (CSEMSs) have not been formally investigated for this indication. OBJECTIVE To evaluate the efficacy and safety of CSEMSs in patients with retained complex biliary stones. DESIGN Retrospective case series. SETTING Large quaternary-care center. PATIENTS Thirty-six patients (24 women) with complex biliary stones with incomplete stone clearance after endoscopic retrograde cholangiography (ERC) with biliary sphincterotomy. INTERVENTIONS Patients with incomplete stone clearance after ERC with biliary sphincterotomy underwent temporary placement of CSEMSs, with subsequent removal before repeat stone extraction. MAIN OUTCOME MEASUREMENTS Success achieving immediate biliary drainage and eventual complete duct clearance. Procedure-related complications were also assessed. RESULTS CSEMS placement was successful in establishing immediate biliary drainage in all 36 patients. Complete duct clearance at repeat ERC was achieved in 29 of 35 patients after a mean duration of 6.4 weeks. Four of the remaining 6 patients underwent sequential CSEMS placement, with eventual duct clearance after multiple ERCPs. There were no complications related to biliary obstruction. One patient died of a nonbiliary cause. Of the total 42 CSEMSs placed, there were 4 cases (9.5%) of clinically insignificant stent migration. LIMITATIONS Single-center experience, retrospective design. CONCLUSIONS CSEMSs permit management of complex biliary stones, but require multiple sessions. The cost-effectiveness of this technique needs further investigation.
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Affiliation(s)
- Mark Cerefice
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York 10021, USA
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Is the addition of choleretic agents in multiple double-pigtail biliary stents effective for difficult common bile duct stones in elderly patients? A prospective, multicenter study. Gastrointest Endosc 2011; 74:96-102. [PMID: 21531412 DOI: 10.1016/j.gie.2011.03.005] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2010] [Accepted: 03/06/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND Temporary biliary stenting is both technically easy and feasible, and choleretic agents such as ursodeoxycholic acid (UDCA) and a terpene preparation may promote a reduction in stone size. However, there are few comparative data on the effectiveness of choleretic agents available. OBJECTIVE To investigate the efficacy of multiple double-pigtail stents with or without UDCA and terpene on difficult common bile duct (CBD) stones. DESIGN A prospective, multicenter study. SETTING Four tertiary-care referral centers. PATIENTS This study involved 51 patients. INTERVENTION In total, 51 elderly patients with comorbidities who had difficult CBD stones refractory to conventional methods were randomized to receive either multiple 7F double-pigtail stents (group A) or stents in combination with UDCA and terpene (group B) for a period of 6 months. MAIN OUTCOME MEASUREMENTS Stone size reduction, successful duct clearance, and complications. RESULTS Complete endoscopic duct clearance was achieved in 14 patients (73.7%) in group A and 19 patients (86.4%) in group B (P = .826). The mean size of CBD stones (transverse/longitudinal diameter, mean ± SD) was 19.12 ± 4.48 mm/20.47 ± 3.86 mm in group A and 21.30 ± 7.08 mm/22.58 ± 7.61 mm in group B. Stone size decreased significantly to 12.04 ± 3.26 mm/13.31 ± 5.12 mm and 13.67 ± 5.40 mm/14.04 ± 6.12 mm, respectively (P < .01). However, there was no statistical difference in stone size reduction between the two groups (P = .685, P = .289). No serious complications related to the stent or endoscopic procedures were observed, except for cholangitis (n = 1, group A) and distal stent migration (n = 2, group B). LIMITATIONS Small number of patients in East Asia. CONCLUSION Temporary multiple double-pigtail biliary stenting was a safe and feasible method of treating difficult and large CBD stones in elderly patients and contributed to a reduction in stone size and successful duct clearance. However, the addition of choleretic agents did not result in a statistical difference in stone size or rate of successful duct clearance.
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Lee TH, Park SH, Lee SH, Lee CK, Lee SH, Chung IK, Kim HS, Kim SJ. Modified rendezvous intrahepatic bile duct cannulation technique to pass a PTBD catheter in ERCP. World J Gastroenterol 2010; 16:5388-90. [PMID: 21072905 PMCID: PMC2980691 DOI: 10.3748/wjg.v16.i42.5388] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [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
The rendezvous procedure combines an endoscopic technique with percutaneous transhepatic biliary drainage (PTBD). When a selective common bile duct cannulation fails, PTBD allows successful drainage and retrograde access for subsequent rendezvous techniques. Traditionally, rendezvous procedures such as the PTBD-assisted over-the-wire cannulation method, or the parallel cannulation technique, may be available when a bile duct cannot be selectively cannulated. When selective intrahepatic bile duct (IHD) cannulation fails, this modified rendezvous technique may be a feasible alternative. We report the case of a modified rendezvous technique, in which the guidewire was retrogradely passed into the IHD through the C2 catheter after end-to-end contact between the tips of the sphincterotome and the C2 catheter at the ampulla’s orifice, in a 39-year-old man who had been diagnosed with gallbladder carcinoma with a metastatic right IHD obstruction. Clinically this procedure may be a feasible and timesaving technique.
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Percutaneous transhepatic choledochoscopic lithotomy as a rescue therapy for removal of bile duct stones in Billroth II gastrectomy patients who are difficult to perform ERCP. Eur J Gastroenterol Hepatol 2009; 21:1358-62. [PMID: 19282768 DOI: 10.1097/meg.0b013e328326caa1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is more difficult and dangerous in patients with Billroth II (B II) gastrectomy than those with normal anatomy. OBJECTIVES To evaluate the clinical efficacy of percutaneous transhepatic choledochoscopic lithotomy (PTCSL) for removing common bile duct stones in B II gastrectomy patients who are difficult to perform ERCP. METHODS This study was designed as prospectively uncontrolled in a large tertiary referral center. In 20 patients, mostly men, with bile duct stones and an earlier B II gastrectomy, PTCSL was tried because of failed ERCP and high risk. The PTCSL was performed using electrohydraulic lithotripsy or papillary balloon dilation. Successful stone removal and complications were measured. RESULTS Stone removal was achieved in all 20 patients. The mean number of procedures and session time were 4.5 and 45 min, respectively. Minor PTCSL-related complications, such as fever, hemobilia, hyperamylasemia, and wound pain, occurred in five patients (25%). There were no major procedure-related complications, including perforation or mortality. CONCLUSION The PTCSL procedure is an effective and safe rescue therapy for common bile duct stones in B II gastrectomy patients with failed ERCP and high risk.
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Bratcher J, Kasmin F. Choledochoscopy-assisted intraductal shock wave lithotripsy. Gastrointest Endosc Clin N Am 2009; 19:587-95. [PMID: 19917464 DOI: 10.1016/j.giec.2009.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
In more than 90% of choledocholithiasis cases, endoscopic retrograde cholangiopancreatography with sphincterotomy and stone extraction are successful therapeutic options for clearance of the bile duct with the use of a stone retrieval balloon or basket. However, these techniques fail in a small percentage of patients with biliary stones, and advanced techniques for fragmentation must be used. Intraductal shock wave lithotripsy offers the endoscopist a therapeutic option that may be effective despite the difficulties of a large, impacted stone that cannot be captured by a basket, or a stricture that prohibits delivery of a stone beyond it. This article reviews the use of electrohydraulic lithotripsy and laser lithotripsy in the clinical setting.
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Affiliation(s)
- Jason Bratcher
- Division of Gastroenterology, Beth Israel Medical Center, 10 Nathan Perlman Place, First Avenue at 16th Street, New York, NY 10003, USA
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17
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Elhassan OM, Booq YI, Fazili FM. Laparoscopic cholecystectomy without cholangiography: Is it a safe procedure? MINIM INVASIV THER 2009. [DOI: 10.3109/13645709509152781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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18
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Nonsurgical management of an impacted mechanical lithotriptor with fractured traction wires: endoscopic intracorporeal electrohydraulic shock wave lithotripsy followed by extra-endoscopic mechanical lithotripsy. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2008; 22:699-702. [PMID: 18701948 DOI: 10.1155/2008/798527] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
In a patient with a mid-common bile duct stone, the traction wires of a mechanical lithotriptor snapped, resulting in lithotriptor basket impaction. Simultaneous occurrence of these two potential complications of endoscopic stone extraction is very rarely reported. Extracorporeal shock wave lithotripsy failed to fragment the stone entrapped within the impacted basket. Endoscopic intracorporeal electrohydraulic shock wave lithotripsy successfully fragmented the stone under direct visualization through a cholangioscope. The entrapped stone within the basket could subsequently be pulled into the supra-ampullary bile duct for the final fragmentation with an extra-endoscopic mechanical lithotriptor cable. The present report is the first to describe a safe and effective use of endoscopic intracorporeal electrohydraulic shock wave lithotripsy followed by extra-endoscopic mechanical lithotripsy in the management of an impacted lithotriptor basket.
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Abstract
The use of non-absorbable suture materials for cystic duct ligation after cholecystectomy can expose patients to the risk of recurrent stone formation in the common bile duct (CBD). However, in Korea suture materials have rarely been found to act as a nidus for common bile duct calculus formation. Recently, we experienced a case in which suture material, that had migrated from a previous cholecystectomy site into the CBD, probably served as a nidus for common bile duct stone formation. The stone was confirmed by endoscopic retrograde cholangiopancreatography (ERCP) and removed successfully using a basket. The authors report a case of surgical suture migration and discuss its subsequent role as a stone forming nucleus within the CBD in a patient who underwent open cholecystectomy; and include a review of the literature.
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Affiliation(s)
- Kook-Hyun Kim
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
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Abstract
Gallstone disease is one of the most prevalent gastrointestinal diseases with a substantial burden to health care systems that is supposed to increase in ageing populations at risk. Aetiology and pathogenesis of cholesterol gallstones still are not well defined, and strategies for prevention and efficient nonsurgical therapies are missing. This review summarizes current concepts on the pathogenesis of cholesterol gallstones with focus on the uptake and secretion of biliary lipids and special emphasis on recent studies into the genetic background.
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Affiliation(s)
- H-U Marschall
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Huddinge, Stockholm, Sweden.
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21
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Abstract
With a prevalence of 10-15% in adults in Europe and the USA, gallstones are the most common digestive disease needing admission to hospital in the West. The interplay between interprandial and postprandial physiological responses to endogenous and dietary lipids underscores the importance of coordinated hepatobiliary and gastrointestinal functions to prevent crystallisation and precipitation of excess biliary cholesterol. Indeed, identifying the metabolic and transcriptional pathways that drive the regulation of biliary lipid secretion has been a major achievement in the field. We highlight scientific advances in protein and gene regulation of cholesterol absorption, synthesis, and catabolism, and biliary lipid secretion with respect to the pathogenesis of cholesterol gallstone disease. We discuss the physical-chemical mechanisms of gallstone formation in bile and the active role of the gallbladder and the intestine. We also discuss gaps in our knowledge of the pathogenesis of gallstone formation and the potential for gene targeting in therapy.
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Affiliation(s)
- Piero Portincasa
- Department of Internal and Public Medicine, University Medical School, Bari, Italy.
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22
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Portincasa P, Moschetta A, Petruzzelli M, Palasciano G, Di Ciaula A, Pezzolla A. Gallstone disease: Symptoms and diagnosis of gallbladder stones. Best Pract Res Clin Gastroenterol 2006; 20:1017-29. [PMID: 17127185 DOI: 10.1016/j.bpg.2006.05.005] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The clinical aspects and the diagnostic features of gallstone disease are described. The natural history of silent gallstones is overviewed, and the risk of developing symptoms and complications is also discussed. The importance of colicky pain as a specific gallstone symptom is highlighted, and the role of both laboratory tests and diagnostic investigations for differential diagnosis is discussed. Finally, we describe the diagnostic features of gallbladder stone disease, including indications, sensitivity, specificity, and limitations of different test investigations under special circumstances.
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Affiliation(s)
- P Portincasa
- Clinica Medica A. Murri, Department of Internal and Public Medicine, University of Bari Medical School, Piazza Giulio Cesare 11-Policlinico-70124 Bari, Italy.
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Cheng CL, Sherman S, Watkins JL, Barnett J, Freeman M, Geenen J, Ryan M, Parker H, Frakes JT, Fogel EL, Silverman WB, Dua KS, Aliperti G, Yakshe P, Uzer M, Jones W, Goff J, Lazzell-Pannell L, Rashdan A, Temkit M, Lehman GA. Risk factors for post-ERCP pancreatitis: a prospective multicenter study. Am J Gastroenterol 2006; 101:139-47. [PMID: 16405547 DOI: 10.1111/j.1572-0241.2006.00380.x] [Citation(s) in RCA: 408] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Pancreatitis is the most common and serious complication of diagnostic and therapeutic ERCP. The aim of this study is to examine the potential patient- and procedure-related risk factors for post-ERCP pancreatitis in a prospective multicenter study. METHODS A 160-variable database was prospectively collected by a defined protocol on patients undergoing diagnostic or therapeutic ERCP at 15 centers in the Midwest Pancreaticobiliary Group and participating in a randomized controlled study evaluating whether prophylactic corticosteroids will reduce the incidence of post-ERCP pancreatitis. Data were collected prior to the procedure, at the time of procedure, and 24-72 h after discharge. Post-ERCP pancreatitis was diagnosed and its severity graded according to consensus criteria. RESULTS Of the 1,115 patients enrolled, diagnostic ERCP with or without sphincter of Oddi manometry (SOM) was performed in 536 (48.1%) and therapeutic ERCP in 579 (51.9%). Suspected sphincter of Oddi dysfunction (SOD) was the indication for the ERCP in 378 patients (33.9%). Pancreatitis developed in 168 patients (15.1%) and was graded mild in 112 (10%), moderate in 45 (4%), and severe in 11(1%). There was no difference in the incidence of pancreatitis or the frequency of investigated potential pancreatitis risk factors between the corticosteroid and placebo groups. By univariate analysis, the incidence of post-ERCP pancreatitis was significantly higher in 19 of 30 investigated variables. In the multivariate risk model, significant risk factors with adjusted odds ratios (OR) were: minor papilla sphincterotomy (OR: 3.8), suspected SOD (OR: 2.6), history of post-ERCP pancreatitis (OR: 2.0), age <60 yr (OR: 1.6), > or =2 contrast injections into the pancreatic duct (OR: 1.5), and trainee involvement (OR: 1.5). Female gender, history of recurrent idiopathic pancreatitis, pancreas divisum, SOM, difficult cannulation, and major papilla sphincterotomy (either biliary or pancreatic) were not multivariate risk factors for post-ERCP pancreatitis. CONCLUSION This study emphasizes the role of patient factors (age, SOD, prior history of post-ERCP pancreatitis) and technical factors (number of PD injections, minor papilla sphincterotomy, and operator experience) as the determining high-risk predictors for post-ERCP pancreatitis.
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Affiliation(s)
- Chi-Liang Cheng
- Indiana University Medical Center, Indianapolis, Indiana 46202, USA
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Arya N, Nelles SE, Haber GB, Kim YI, Kortan PK. Electrohydraulic lithotripsy in 111 patients: a safe and effective therapy for difficult bile duct stones. Am J Gastroenterol 2004; 99:2330-4. [PMID: 15571578 DOI: 10.1111/j.1572-0241.2004.40251.x] [Citation(s) in RCA: 138] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Choledocholithiasis and intrahepatic bile duct stones pose a significant health hazard, especially in the elderly. The large stone not removable with conventional endoscopic techniques, can be effectively and safely managed with electrohydraulic lithotripsy (EHL). METHODS This study is a retrospective review of consecutive patients at the Wellesley Central Hospital and St. Michael's Hospital, who underwent peroral endoscopic fragmentation of bile duct stones with EHL under direct cholangioscopic control using a "mother-baby" endoscopic system between October 1990 and March 2002. RESULTS To date, 111 patients have been analyzed. Of the 111 patients reviewed, 94 patients have had complete records and were included in this study. Mean follow-up was 26.2 months (range 0-80). Prior to EHL, 93 of 94 patients (99%) had endoscopic retrograde cholangiopancreatography (ERCP) and failed standard stone extraction techniques (mean 1.9 ERCPs/patient, range 0-5). Indications for EHL were large stones (81 patients) or a narrow caliber bile duct below a stone of average size (13 patients). Successful fragmentation (61 complete, 28 partial) was achieved in 89 of 93 patients (96%) (1 patient was excluded from analysis due to a broken endoscope). Fragmentation failures were due to targeting problems (2 patients) and hard stones (2 patients). Seventy-six percent of patients required 1 EHL session, 14% required 2 sessions, and 10% required 3 or more. All patients with successful stone fragmentation required post-EHL balloon or basket extraction of fragments. Complications included: cholangitis and/or jaundice (13 patients); mild hemobilia (1 patient); mild post-ERCP pancreatitis (1 patient); biliary leak (1 patient); and bradycardia (1 patient). There were no deaths related to EHL. Final stone clearance was achieved in 85 of 94 patients (90%). CONCLUSIONS EHL via peroral endoscopic choledochoscopy is a highly successful and safe technique for use in the management of difficult choledocholithiasis and intrahepatic stones. This study has shown a stone fragmentation rate of 96% (89 of 93 patients), and a final stone clearance rate of 90% (85 of 94 patients).
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Affiliation(s)
- Naveen Arya
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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Moon JH, Cha SW, Ryu CB, Kim YS, Hong SJ, Cheon YK, Cho YD, Kim YS, Lee JS, Lee MS, Shim CS, Kim BS. Endoscopic treatment of retained bile-duct stones by using a balloon catheter for electrohydraulic lithotripsy without cholangioscopy. Gastrointest Endosc 2004; 60:562-6. [PMID: 15472679 DOI: 10.1016/s0016-5107(04)02012-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Electrohydraulic lithotripsy is a highly effective method for fragmenting biliary stones, but direct visual control is required. The efficacy and the safety of electrohydraulic lithotripsy without cholangioscopy by using a balloon catheter were evaluated in patients with bile-duct stones that could not be extracted by using standard techniques. METHODS Nineteen patients with extrahepatic bile-duct stones that could not be extracted by using conventional endoscopic methods, e.g., mechanical lithotripsy, were selected to undergo electrohydraulic lithotripsy without peroral cholangioscopy. An electrohydraulic lithotripsy probe with a 3.0 F radio-opaque tip was inserted through a balloon catheter. Electrohydraulic lithotripsy was performed under fluoroscopy until the fragmented stone could be captured in a large basket for mechanical lithotripsy. Endoscopic removal of the fragments was attempted during the electrohydraulic lithotripsy session. RESULTS Stones were successfully fragmented in 17 of 19 patients. In 16 patients (84.2%), the bile duct was cleared of all stones. A mean of 1.8 endoscopic sessions was required for complete removal. Additional mechanical lithotripsy was performed in 9 (56.2%) of the 16 patients. Minor complications were noted in 4 patients (2 hemobilia, 1 pancreatitis, 1 cholangitis). There was no 30-day mortality. CONCLUSIONS For a selected group of patients with bile-duct stones not extractable by using standard techniques, fluoroscopically controlled electrohydraulic lithotripsy with a balloon catheter seems to be an effective method of fragmentation.
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Affiliation(s)
- Jong Ho Moon
- Digestie Disease Center, Institute for Digestive Research, Soon Chun Hyang University College of Medicine, Seoul, Korea
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Metcalfe MS, Ong T, Bruening MH, Iswariah H, Wemyss-Holden SA, Maddern GJ. Is laparoscopic intraoperative cholangiogram a matter of routine? Am J Surg 2004; 187:475-81. [PMID: 15041494 DOI: 10.1016/j.amjsurg.2003.12.047] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2003] [Revised: 08/11/2003] [Indexed: 02/08/2023]
Abstract
BACKGROUND Intraoperative cholangiography during laparoscopic cholecystectomy reveals the anatomy of the biliary tree and any stones contained within it. The use of intraoperative cholangiography may be routine for all laparoscopic cholecystectomy. An alternative approach is a selective policy, performing intraoperative cholangiography only for those cases in which choledocholithiasis is suspected on clinical grounds, or those for which the anatomy appears unclear at operation. The literature pertaining to both approaches is reviewed, to delineate their respective merits. METHODS Relevant articles in English were identified from the Medline database, and reviewed. RESULTS The literature reviewed consisted of retrospective analyses. Overall the incidence of unsuspected retained stones was 4%, but only 15% of these would go on to cause clinical problems. The incidence of complete transection of the common bile duct was rare for both routine and selective intraoperative cholangiography policies, and did not differ between them. Rates of minor bile duct injury did not differ between groups, but was more likely to be recognized in the routine group than the selective (P = 0.01). CONCLUSIONS Routine intraoperative cholangiography yields very little useful clinical information over and above that which is obtained with selective policies. Large numbers of unnecessary intraoperative cholangiography are performed under routine intraoperative cholangiography policy, and therefore a selective policy is advocated.
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Affiliation(s)
- Matthew S Metcalfe
- Department of Surgery, University of Adelaide, The Queen Elizabeth Hospital, Woodville Rd., Woodville, SA 5011, Australia
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Ebner S, Rechner J, Beller S, Erhart K, Riegler FM, Szinicz G. Laparoscopic management of common bile duct stones. Surg Endosc 2004; 18:762-5. [PMID: 14752631 DOI: 10.1007/s00464-003-9029-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2003] [Accepted: 10/02/2003] [Indexed: 02/07/2023]
Abstract
BACKGROUND While laparoscopic cholecystectomy is widely accepted for therapy of cholecystolithiasis, controversy still exists concerning the management of common bile duct stones. Besides preoperative endoscopic papillotomy followed by laparoscopic cholecystectomy and open common bile duct surgery, management of common bile duct stones can be conducted by laparoscopy, if respective experience is available. METHOD During laparoscopic cholecystectomy a cholangiography via the cystic duct is routinely performed. If bile duct stones are detected they are retrieved via the cystic duct or via incision of the common bile duct by insertion of a Fogarty catheter or Dormia basket. Exclusion criteria against simultaneous laparoscopic management include suspicion of malignancy, severe pancreatitis, or cholangitis. RESULTS From November 1991 to March 2002, 200 patients primarily underwent laparoscopic therapy of bile duct stones. Retrieval was performed via cystic duct and common bile duct incision in 115 and 85 cases, respectively. Complete removal was achieved in 91%; complication rate and mortality was 7% and 0.5%, respectively. During the same period primary endoscopic papillotomy was necessary in 40 patients because of the above contraindications. CONCLUSIONS When correct indications and surgical expertise are observed, simultaneous laparoscopic management of common bile duct stones represents a safe and minimally invasive alternative to a two-procedure approach.
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Affiliation(s)
- S Ebner
- Department of General Surgery, General Hospital Bregenz, C.-Pedenz-Str. 2, 6900 Bregenz, Austria.
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Lin LF, Siauw CP, Ho KS, Tung JN. Guidewire technique for endoscopic transpapillary procurement of bile duct biopsy specimens without endoscopic sphincterotomy. Gastrointest Endosc 2003; 58:272-4. [PMID: 12872103 DOI: 10.1067/mge.2003.329] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Endoscopic sphincterotomy may be required when endoscopic transpapillary bile duct biopsy specimens are needed for tissue diagnosis. However, endoscopic sphincterotomy has potential complications. A guidewire technique for obtaining transpapillary biopsy specimens without endoscopic sphincterotomy was evaluated. METHODS A total of 13 patients (11 men, 2 women; mean age 67.5 years) with biliary stricture or obstruction underwent endoscopic retrograde cholangiography. A guidewire was then inserted across the stricture or obstruction and into an intrahepatic duct. Alongside the guidewire, the biopsy forceps (1.5 mm diameter) was introduced into the papillary orifice with the duodenoscope extremely close to the papilla. OBSERVATIONS Tissue was obtained in 92.3% of the cases for histopathologic evaluation without difficulty or complication. The single failure occurred in a patient who had undergone a partial gastrectomy with Billroth I anastomosis. CONCLUSIONS The guidewire technique for endoscopic transpapillary procurement of biopsy specimens of the bile duct obviates the need for endoscopic sphincterotomy.
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Affiliation(s)
- Lien-Fu Lin
- Division of Gastroenterology, Department of Internal Medicine, Tung's Taichung Metroharbor Hospital, Taichung, Taiwan, Republic Of China
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Stefanidis G, Karamanolis G, Viazis N, Sgouros S, Papadopoulou E, Ntatsakis K, Mantides A, Nastos H. A comparative study of postendoscopic sphincterotomy complications with various types of electrosurgical current in patients with choledocholithiasis. Gastrointest Endosc 2003; 57:192-7. [PMID: 12556783 DOI: 10.1067/mge.2003.61] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Whether the type of electrosurgical current used for endoscopic sphincterotomy influences the frequency of postsphincterotomy complications is unknown. METHODS One hundred eighty-six patients with choledocholithiasis were prospectively randomized to undergo endoscopic sphincterotomy with pure cutting current (n = 62, Group A), blended current (n = 62, Group B), or pure cutting initially followed by blended current (n = 62, Group C). Serum concentrations of amylase and lipase were evaluated in all patients 12 and 24 hours after sphincterotomy. Clinical pancreatitis was classified as mild, moderate, or severe. Postsphincterotomy bleeding was defined as a decrease in hematocrit of greater than 5%. RESULTS Serum concentrations of amylase and lipase were greater in Groups B and C at 12 and 24 hours after the procedure, as compared with Group A. Clinical mild pancreatitis occurred in 2 patients in Group A (3.2%), 8 in Group B (12.9%), and in 8 in Group C (12.9%). The differences were statistically significant for Group A compared with either Group B or Group C (p = 0.048). Postsphincterotomy bleeding occurred in 3 patients (1.6%), one in each group. CONCLUSION The use of pure cutting electrosurgical current during endoscopic sphincterotomy in patients with choledocholithiasis is associated with a lesser degree of pancreatic enzyme elevation and lower frequency of pancreatitis, whereas bleeding is not increased compared with blended current. Changing from pure cutting to blended current after the first 3 to 5 mm of the incision is associated with an increased rate of complications compared to the use of pure cutting current for the entire sphincterotomy.
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Mora J, Aguilera V, Sala T, Martínez F, Bastida G, Palau A, Argüello L, Pons V, Pertejo V, Berenguer J, Alapont JM. [Endoscopic treatment combined with extracorporeal shock wave lithotripsy of difficult bile duct stones]. GASTROENTEROLOGIA Y HEPATOLOGIA 2002; 25:585-8. [PMID: 12459119 DOI: 10.1016/s0210-5705(02)70320-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES The aim of this study was to determine the safety and effectiveness of extracorporeal shock wave lithotripsy (ESWL) in difficult bile duct stones resistant to endoscopic extraction. PATIENTS AND METHOD From January 1997 to February 2002, combined treatment with endoscopy and ESWL was used in 19 patients who had undergone unsuccessful endoscopic bile duct stone extraction after sphincterotomy. The procedure was carried out using analgesic and sedative drugs or deep sedation, prophylactic antibiotic therapy, and monitoring of vital signs. Bile duct stone localization was performed by contrast injection through nasobiliary drainage and fluoroscopy. After each ESWL session, lavage was performed through drainage and stone fragments were extracted endoscopically. RESULTS The 19 patients presented high surgical risk due to advanced aged and/or concomitant diseases. All presented jaundice and pain and nine (47.3%) presented associated cholangitis. Thirty ESWL sessions were performed (1.57 sessions per patient), with a mean of 2,120 shock waves per session. In 16 of the 19 patients (84.2%), combined treatment with ESWL and subsequent instrumental endoscopic extraction achieved complete clearance of the biliary tract. The treatment failed in 3 patients who were referred for surgical treatment. No early or late complications were observed, except in one patient who presented a self-limiting febrile syndrome. CONCLUSIONS Therapeutic endoscopy combined with ESWL is safe and effective in patients with difficult bile duct stones. It represents a therapeutic alternative in patients at high surgical risk.
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Affiliation(s)
- J Mora
- Unidad de Endoscopias. Servicios de Medicina Digestiva. Hospital La Fe. Valencia. España.
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Kaw M, Al-Antably Y, Kaw P. Management of gallstone pancreatitis: cholecystectomy or ERCP and endoscopic sphincterotomy. Gastrointest Endosc 2002; 56:61-5. [PMID: 12085036 DOI: 10.1067/mge.2002.125544] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Currently, cholecystectomy is recommended for patients with gallstone-induced pancreatitis. ERCP with endoscopic sphincterotomy (ES) within 24 to 48 hours is also suggested for the treatment of acute gallstone pancreatitis. The aim of this study was to determine outcome after cholecystectomy versus ES alone in patients with gallstone pancreatitis. METHODS One hundred seventeen patients with gallstone pancreatitis were included in this prospective observational study. Inclusion criteria were typical abdominal pain; serum amylase level 3 times or greater than normal; and gallbladder stones and a dilated bile duct, with or without stones, by US, CT, or ERCP. RESULTS Eighty-three patients (Group A) underwent cholecystectomy after initial evaluation including ERCP in 43 (53%) and ERCP with ES in 38 (47%). The remaining 34 (Group B) underwent successful ERCP with ES alone. Mean follow-up was 33 months for Group A and 34 months for Group B. Recurrent gallstone pancreatitis was noted in 2 patients (2.4%) in Group A (bile duct stone in 2, sludge and papillary stenosis in 1), and in 1 patient (2.9%) in Group B. Ten patients in Group B had follow-up US of the gallbladder that showed disappearance of stones in 3. During follow-up, there was no significant difference in the rates of biliary complications (Group A, 3.6% vs. Group B, 11.6%; p = 0.19) or serious complications (pancreatitis, cholecystitis, cholangitis) (Group A, 3.6% vs. Group B, 5.8%). Also, there was no significant difference in procedure-related complications. CONCLUSIONS Recurrence of pancreatitis after ERCP with ES alone for gallstone pancreatitis is rare. In patients who have undergone ES alone, cholecystectomy should be considered only if there are overt manifestations of gallbladder disease (e.g., biliary pain, cholecystitis, cystic duct obstruction) and not for prevention of recurrent gallstone pancreatitis. Because treatment by ES alone may be associated with a higher risk of biliary complications during follow-up compared with cholecystectomy, these patients may require close surveillance.
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Affiliation(s)
- Madhukar Kaw
- Division of Gastroenterology, Medical College of Ohio, Toledo, Ohio, USA
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Abstract
BACKGROUND Acute pancreatitis can develop after either ERCP or endoscopic sphincterotomy (ES). The pathogenesis of this complication remains poorly understood. METHODS The frequency and severity of acute pancreatitis were retrospectively evaluated after 17,602 ERCP procedures and 3003 ES procedures. Pancreatitis was diagnosed and evaluated according to the scoring system of Ranson and criteria developed in Japan. RESULTS Pancreatitis developed after 15 (0.09%) of 17,602 ERCP procedures and 13 (0.43%) of 3003 ES procedures (p = 0.0001, chi-square). The severity of pancreatitis (Ranson score) was less than 3 in 10 cases of ERCP-induced pancreatitis and from 3 to 5 in 5 cases. One (7%) of the 15 patients with ERCP-related pancreatitis died. All 13 patients with ES-induced pancreatitis had a Ranson score of less than 3; none died (p = 0.04, Fisher exact test). The ERCP pancreatitis score (Japanese criteria) beyond 48 hours after the onset of pancreatitis increased in 5 (33%) of the 15 patients with ERCP-induced pancreatitis; the score did not increase in any of the 13 patients with ES-induced pancreatitis (p = 0.04, Fisher exact test). CONCLUSIONS Although the frequency of ES-induced pancreatitis is significantly higher than that of post-ERCP pancreatitis, the frequency of severe pancreatitis within 48 hours and worsening of pancreatitis after 48 hours is significantly lower with ES-induced pancreatitis. Our hypothesis is that the lowering of pancreatic intraductal pressure after ES mitigates the severity of postprocedure pancreatitis.
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Affiliation(s)
- Jost Langhorst
- Department of Medicine, Evangelisches Krankenhaus Düsseldorf, Academic Teaching Hospital of the University of Düsseldorf, Düsseldorf, Germany
| | - Horst Neuhaus
- Department of Medicine, Evangelisches Krankenhaus Düsseldorf, Academic Teaching Hospital of the University of Düsseldorf, Düsseldorf, Germany
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Ghazanfari K, Gollapudi PR, Konicek FJ, Olivera A, Madayag M, Warner J. Surgical clip as a nidus for common bile duct stone formation and successful endoscopic therapy. Gastrointest Endosc 2001; 38:611-3. [PMID: 1397924 DOI: 10.1016/s0016-5107(92)70532-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- K Ghazanfari
- Department of Medicine (Gastroenterology) and Radiology, Illinois Masonic Medical Center, Chicago 60657
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36
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Sackmann M, Holl J, Sauter GH, Pauletzki J, von Ritter C, Paumgartner G. Extracorporeal shock wave lithotripsy for clearance of bile duct stones resistant to endoscopic extraction. Gastrointest Endosc 2001; 53:27-32. [PMID: 11154485 DOI: 10.1067/mge.2001.111042] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Endoscopic extraction of bile duct stones after sphincterotomy has a success rate of up to 95%. Failures occur in patients with extremely large stones, intrahepatic stones, and bile duct strictures. This study examined the efficacy and the safety of extracorporeal shock-wave lithotripsy in a large cohort of patients in whom routine endoscopic measures including mechanical lithotripsy had failed to extract bile duct stones. METHODS Out of 1587 consecutive patients, endoscopic stone extraction including mechanical lithotripsy was unsuccessful in 313 (20%). These 313 patients (64% women, median age, 73 years) underwent high-energy extracorporeal shock-wave lithotripsy. Stone targeting was performed fluoroscopically (99%) or by ultrasonography (1%). RESULTS Complete clearance of bile duct calculi was achieved in 281 (90%) patients. In 80% of the patients, the fragments were extracted endoscopically after shock-wave therapy; spontaneous passage was observed in 10%. For patients with complete clearance compared with those without there were no differences with regard to size or number of the stones, intrahepatic or extrahepatic stone location, presence or absence of bile duct strictures, or type of lithotripter. Cholangitis (n = 4) and acute cholecystitis (n = 1) were the rare adverse effects. CONCLUSIONS In patients with bile duct calculi that are difficult to extract endoscopically, high-energy extracorporeal shock-wave lithotripsy is a safe and effective therapy regardless of stone size, stone location, or the presence of bile duct stricture.
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Affiliation(s)
- M Sackmann
- Department of Medicine II, Klinikum Grosshadern, Ludwig-Maximilian's University, Munich, Germany
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Sbeih F, Aljohani M, Altraif I, Khan H. Role of endoscopic retrograde cholangiopancreatography before and after laparoscopic cholecystectomy. Ann Saudi Med 1998; 18:117-9. [PMID: 17341940 DOI: 10.5144/0256-4947.1998.117] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND While the role of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (EST) in the diagnosis and management of choledocholithiasis is well established, this study evaluates the usefulness of ERCP and EST in patients with symptomatic cholecystolithiasis and suspected choledocholithiasis before undergoing laparoscopic cholecystectomy (LC), and the role of ERCP-EST in the management of complications resulting from LC. MATERIALS AND METHODS This paper reviews retrospectively our experience from 1992 to 1995. A total of 1221 LCs and 717 ERCPs were performed, out of which 257 ERCPs were performed on 225 patients who underwent LC (230 ERCPs before and 27 after). The age range was 10-85 years (mean 43.5). The study group comprised 148 females (66%) and 77 males (34%). RESULTS The overall success rate for ERCP was 92% (96% for diagnostic and 88% for therapeutic). Choledocholithiasis was found at preoperative ERCP in 45% of cases. Prediction of choledocholithiasis was accurate in 46%, based on abnormal liver chemistry, and 70% when based on a combination of abnormal liver tests and dilated main bile duct (>7 mm) by ultrasound. In 40 cases of acute biliary pancreatitis, choledocholithiasis was found at ERCP in eight cases (20%). In the post-LC group, all eight cases with residual stones and seven of eight cases with bile leaks were successfully treated endoscopically. There were four cases with major duct injuries that required surgical management. The complications related to ERCP-EST included two cases of bleeding post-EST (one was controlled with injection therapy and the second one was managed surgically), and three cases of mild pancreatitis. CONCLUSION ERCP and EST are effective and safe in the diagnosis and management of choledocholithiasis, and facilitate LC for symptomatic cholelithiasis. The procedures are also valuable in the diagnosis and management of most complications resulting from LC.
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Affiliation(s)
- F Sbeih
- Department of Medicine, Section of Gastroenterology, King Fahad National Guard Hospital, Riyadh, Saudi Arabia
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38
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White DM, Correa RJ, Gibbons RP, Ball TJ, Kozarek RJ, Thirlby RC. Extracorporeal shock-wave lithotripsy for bile duct calculi. Am J Surg 1998; 175:10-3. [PMID: 9445230 DOI: 10.1016/s0002-9610(97)00234-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Bile duct calculi (BDC) can be cleared or treated with modern endoscopic techniques in most patients. However, large stones, bile duct strictures, or unusual anatomy may make endoscopic clearance difficult. The purpose of the present study was to determine the efficacy of extracorporeal shock-wave lithotripsy (ESWL) in treating patients with complicated BDC. METHODS Between 1989 and January 1995, 16 patients with BDC were treated at our institution with ESWL using a Dornier HM-3 lithotropter. The average age of patients was 62 years (range 32 to 88). Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and attempted stone extraction (100%), nasobiliary drainage (83%), and biliary stents (6%) were used prior to ESWL. Eleven patients (61 %) had solitary stones, ranging in diameter from 0.5 to 2.6 cm, whereas 7 patients had multiple stones, ranging in diameter from 0.5 to 5.0 cm. The indications for ESWL were stone impaction (56%), stone size (38%), and bile duct stricture (6%). RESULTS The 16 patients received 27 ESWL treatments (mean = 2101 shock at 21 kV); with 4 patients (22%) requiring multiple treatments. Stone fragmentation was achieved in 94% of patients. All patients had ERCP performed post-ESWL, and only 2 (13%) patients required immediate operations. At discharge, 94% of patients were stone-free. Minor complications (eg, pain, hematuria) were common. With an average follow-up of 3 years, only 1 patient (6%) has required retreatment for BDC. Hepatic transplantation was required in an additional patient. CONCLUSIONS In this cohort of patients with both major medical comorbidities and/or technical contraindications to standard methods of endoscopic and surgical clearance of BDC, we found that ESWL facilitated stone clearance in 94% of patients with minimal morbidity and no mortality. In our opinion, ESWL should be used more frequently in the treatment of these complex patients.
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Affiliation(s)
- D M White
- Virginia Mason Medical Center, Seattle, Washington 98111, USA
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Abstract
BACKGROUND Successful extraction of common bile duct stones after endoscopic sphincterotomy may be achieved in 86-96 per cent of cases. However, some stones are too large to be removed in this manner. This study looks at the role of extracorporeal shock-wave lithotripsy to break up common bile duct stones as an adjunct to sphincterotomy in patients with stones greater than 10 mm in size. METHODS Twenty-seven patients with large (10-35 mm) common bile duct stones were treated with piezoelectric generated extracorporeal shock-wave lithotripsy (ESWL) following failed stone extraction after endoscopic sphincterotomy (ES). The stones were visualized ultrasonographically and a piezolith 2300 Wolf lithotripter used to administer the shockwaves. RESULTS Visualized stone fragmentation was reported in 20 of 48 sessions. Clearance of targeted stones was achieved in 18 of the 27 patients, but actual duct clearance was demonstrated in only 17 of the 27. There were few adverse effects and mortality was nil. CONCLUSION This study concludes that ESWL following failed ES is a useful additional treatment option for very large bile duct stones, but should only be used after surgical risk and past history of biliary disease have been carefully reviewed and found to contraindicate conventional surgical management. An algorithm of treatment options for common bile duct stones is presented.
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40
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Gilchrist AM, Ross B, Thomas WEG. Extracorporeal shockwave lithotripsy for common bile duct stones. Br J Surg 1997. [DOI: 10.1002/bjs.1800840109] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Silver RI, Daniels MA, Rollins NK, Andrews WS, Preminger GM. Percutaneous transhepatic endoscopic electrohydraulic lithotripsy of biliary tract calculi after orthotopic liver transplantation. JOURNAL OF LAPAROENDOSCOPIC SURGERY 1996; 6:357-64. [PMID: 8897251 DOI: 10.1089/lps.1996.6.357] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The development of biliary tract calculi after orthotopic liver transplantation presents a unique clinical problem. Previously described techniques for removing biliary stones by shock wave lithotripsy, litholytic therapy with oral bile acids, and endoscopic mechanical extraction may be ineffective or contraindicated in liver transplant patients. For this reason, percutaneous transhepatic electrohydraulic lithotripsy (EHL) was performed using an 11 French flexible ureteroscope in two pediatric patients who developed biliary tract calculi following orthotopic liver transplant. There were no complications and postoperative follow-up over 4 years has been uneventful. To our knowledge, these represent the first reported cases of percutaneous transhepatic endoscopic EHL to fragment biliary tract stones in a transplanted liver, which for us has been a safe and effective therapeutic option.
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Affiliation(s)
- R I Silver
- Department of Urology, Children's Medical Center of Dallas, USA
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Tomioka T, Ikematsu Y, Inoue K, Tajima Y, Sasaki M, Kanematsu T, Tsunoda T. A new, secure drainage method from the cystic duct after choledocholithotomy using the cystic tube and the cystic clip: an experimental study. Surg Today 1996; 26:496-500. [PMID: 8840430 DOI: 10.1007/bf00311555] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The effectiveness of the cystic tube (C-tube) and the cystic clip (C-clip) for primary closure of the common bile duct after choledocholithotomy was examined in 10 dogs, followed by an observation period of either 3 months (n = 6) or 1 year (n = 4). No early complications were observed in any of the animals either during or after surgery. The laboratory data were within the normal range during the observation period. No bile leakage or slippage of the C-clip was evident on fistulography from the C-tube in animals examined 5 days after surgery. The tube could be pulled out easily from the cystic duct without any bile leakage or slippage of the clip. A second operation to confirm late complications showed no adhesions around the common bile duct, no bile duct stenosis similar to the Mirizzi syndrome, and no cystic changes of the bile duct or biloma. Our newly designed C-clip for primary closure of the common bile duct after a choledocholithotomy therefore appears to be beneficial and applicable to clinical patients undergoing traditional as well as laparoscopic surgery.
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Affiliation(s)
- T Tomioka
- Second Department of Surgery, Nagasaki University School of Medicine, Japan
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44
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Erickson RA, Carlson B. The role of endoscopic retrograde cholangiopancreatography in patients with laparoscopic cholecystectomies. Gastroenterology 1995; 109:252-63. [PMID: 7797023 DOI: 10.1016/0016-5085(95)90292-9] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The best clinical strategy for using endoscopic retrograde cholangiopancreatography (ERCP) with laparoscopic cholecystectomy is unknown. The aim of this study is to use decision analysis to assess four different approaches to using ERCP in patients undergoing laparoscopic cholecystectomy. METHODS Decision trees were designed for four clinical strategies: (1) preoperative ERCP, with sphincterotomy for choledocholithiasis; (2) selective preoperative ERCP for patients at high risk for choledocholithiasis, choledocholithiasis found at surgery treated by postoperative ERCP; (3) no preoperative ERCP, choledocholithiasis detected intraoperatively treated by postoperative ERCP; and (4) no preoperative ERCP, choledocholithiasis detected intraoperatively treated with open common bile duct exploration. Using decision analysis with literature-derived data, the impact on outcome parameters was calculated. RESULTS Postoperative ERCP resulted in the lowest cost, procedure numbers, and hospital and back-to-work days. With high preoperative likelihood of choledocholithiasis, selective preoperative ERCP was probably a clinically equivalent strategy. Sensitivity analysis supported these conclusions when the probabilities and utilities were varied over a wide range. The open operative approach to choledocholithiasis was only favored if ERCP had < 75% diagnostic and < 50% therapeutic success rates or lengthened hospitalization by > 7 days. CONCLUSIONS This study suggests that performing ERCP after laparoscopic cholecystectomy minimizes costs and morbidity; however, when choledocholithiasis is likely, selective preoperative ERCP may be a clinically equivalent strategy.
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Affiliation(s)
- R A Erickson
- Department of Medicine, Department of Veterans Affairs Medical Center, Long Beach, California, USA
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Al Amri SM, Al Rashed RS, Al Mofleh IA. Treatment options for large common bile duct stones. Ann Saudi Med 1995; 15:212-4. [PMID: 17590569 DOI: 10.5144/0256-4947.1995.212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
This is a retrospective analysis of the medical records of patients diagnosed to have large common bile duct stones (> 15 mm). The study was designed to evaluate different modalities of large bile duct stone treatment. The setting is King Khalid University Hospital, Gastroenterology Unit. The medical records of patients (n=64) diagnosed to have large common bile duct stones by endoscopic retrograde cholangiography over a period of nine years were included. Files were reviewed and information obtained which included patients' age, sex, nationality, presenting symptoms, number and size of bile duct stones, presence of ascending cholangitis, mode of treatment received, complications and outcome. There were a total of 64 patients; 28 males and 36 females, with a mean age of 61 + 16.6 years. Successful stone extraction was achieved in 44 (69%) patients while surgical treatment was required in 20 patients. Surgically managed patients had significantly larger stones (P<0.003) and were more frequently jaundiced (P<0.014). There was 7.8% of the total number of patients who developed complications that were managed conservatively with full recovery. It was concluded that large stones are difficult to extract endoscopically and more frequently require additional treatment.
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Affiliation(s)
- S M Al Amri
- Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Abstract
Demands for less invasive, more cost-effective therapy have revolutionized the management of gallstones over the past 10 years. There are no reliable methods of permanently reversing the pathophysiologic defects that cause gallstones. Open cholecystectomy (OC), the gold standard for managing symptomatic cholelithiasis, has been largely replaced by laparoscopic cholecystectomy (LC), which has the advantages of a minimal hospital stay and quicker return to work. Other adjunctive therapies, limited in applicability to selected patients, include oral bile acid therapy (BAT), dissolutional agents, and extracorporeal shock wave lithotripsy. Choledocholithiasis (CDL), formerly managed exclusively with surgical common duct exploration, is increasingly treated with therapeutic biliary endoscopy. Methods of laparoscopic common bile duct exploration are being developed. Optimal algorithms for applying these techniques to patients undergoing LC are evolving. In a sense, the solution to all, or certainly most, gallstones now can be seen through a scope.
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Affiliation(s)
- C F Gholson
- Department of Medicine, Louisiana State University School of Medicine, Shreveport 71130
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Uzer M, Hawes RH. Endoscopic retrograde cholangiography and laparoscopic cholecystectomy: stones, stents and sphincterotomy. BAILLIERE'S CLINICAL GASTROENTEROLOGY 1993; 7:921-40. [PMID: 8118081 DOI: 10.1016/0950-3528(93)90023-l] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is clearly a useful adjunct in the management of patients undergoing laparoscopic cholecystectomy who have common bile duct stones. Whether endoscopic sphincterotomy plus laparoscopic cholecystectomy is superior to traditional open cholecystectomy and bile duct exploration is a question which remains to be answered by prospective, randomized trials. The immense popularity of laparoscopic cholecystectomy may prohibit such a study in the USA. In expert hands, endoscopic stone extraction is usually successful, so ERCP can be deferred until after cholecystectomy unless there is serious suspicion of a duct stone preoperatively. Actual clinical practice will depend, however, on the skill of the surgeon, the skill of the endoscopist, and the commitment to removing the gallbladder laparoscopically. It would seem prudent for surgeons to continue to direct their energy toward conquering the common bile duct via the laparoscope, and leave ERCP and stone extraction in the realm of the endoscopist who has been extensively trained in this difficult technique. Proficiency at ERCP, sphincterotomy and stone extraction requires considerable training, and the procedure should not be attempted by individuals who have performed fewer than 100 ERCPs and 25 individually supervised sphincterotomies, according to the ASGE Standards of Training, 1992. As experience with video endoscopic surgery increases and technology improves, it will become possible to remove most duct stones at the time of cholecystectomy, thus obviating the need for endoscopic sphincterotomy. In addition, ERCP should be regarded as the treatment of choice for postoperative cystic duct stump leaks. Studies have shown that any type of biliary decompression, i.e. sphincterotomy, stents or nasobiliary catheters, will be successful. The authors recommend that, in the absence of duct stones, stenting or nasobiliary catheters be used as they are less invasive. Bile duct leaks may also be managed endoscopically, but success depends on the individual characteristics of the duct injury. The decision to manage late onset strictures endoscopically should be individualized, and consideration of local endoscopic expertise, operative risk, interval between surgery and stricture, and the patient's wishes should be made.
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Affiliation(s)
- M Uzer
- Division of Gastroenterology, Indiana, University School of Medicine, Indianapolis 46202
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Barkun JS, Fried GM, Barkun AN, Sigman HH, Hinchey EJ, Garzon J, Wexler MJ, Meakins JL. Cholecystectomy without operative cholangiography. Implications for common bile duct injury and retained common bile duct stones. Ann Surg 1993; 218:371-7; discussion 377-9. [PMID: 8373278 PMCID: PMC1242982 DOI: 10.1097/00000658-199309000-00016] [Citation(s) in RCA: 90] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE This study evaluated the selective use of endoscopic retrograde cholangiopancreatography (ERCP) in the context of laparoscopic cholecystectomy (LC) while minimizing the use of operative cholangiography. SUMMARY BACKGROUND DATA There has been a long-standing debate between routine and selective operative cholangiography that has resurfaced with LC. METHODS Prospective data were collected on the first 1300 patients undergoing LC at McGill University. Preoperative indications for ERCP were recorded, radiologic findings were standardized, and technical points for a safe LC were emphasized. RESULTS A total of 106 patients underwent 127 preoperative ERCPs. Fifty patients were found to have choledocholithiasis (3.8%), and clearance of the common bile duct (CBD) with endoscopic sphincterotomy was achieved in 45 patients. The other five patients underwent open cholecystectomy with common duct exploration. Intraoperative cholangiography (IOC) was attempted in only 54 patients (4.2%), 6 of whom demonstrated choledocholithiasis. Forty-nine postoperative ERCPs were performed in 33 patients and stones were detected in 17 (1.3%), with a median follow-up time of 22 months. Endoscopic duct clearance was successful in all of these. The incidence of CBD injury was 0.38%, and a policy of routine operative cholangiography might only have led to earlier recognition of duct injury in one case. The rate of complication for all ERCPs was 9% and the associated median duration of the hospital stay was 4 days. The median duration of the hospital stay after open CBD exploration was 13 days. CONCLUSIONS LC can be performed safely without routine IOC. The selective use of preoperative and postoperative ERCP will clear the CBD of stones in 92.5% of patients.
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Affiliation(s)
- J S Barkun
- Division of General Surgery, McGill University, Montreal, Quebec, Canada
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Clements WD, Diamond T, McCrory DC, Rowlands BJ. Biliary drainage in obstructive jaundice: experimental and clinical aspects. Br J Surg 1993; 80:834-42. [PMID: 7690298 DOI: 10.1002/bjs.1800800707] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Jaundiced patients undergoing invasive diagnostic and therapeutic procedures are at increased risk of complications and death. Despite the large number of clinical and experimental investigations carried out to identify relevant risk factors, no single parameter has been found to be consistently useful in predicting morbidity or mortality. Biliary decompression was initially employed by surgeons and subsequently by interventional radiologists. More recently, endoscopic retrograde cholangiopancreatography has provided an alternative route for decompression of the biliary tree and preliminary data using this method are encouraging. Although there are enthusiastic proponents of various therapeutic techniques, controlled trials have not been convincing in highlighting the benefits of biliary drainage or in determining the best approach. This article reviews the literature pertaining to this complex surgical problem; an attempt has been made to balance the advantages and disadvantages of biliary decompression as palliation and/or preliminary treatment for extrahepatic biliary obstruction.
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Affiliation(s)
- W D Clements
- Department of Surgery, Queen's University of Belfast, UK
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Abstract
Few laparoscopic surgeons currently explore the bile duct at cholecystectomy, which has focused attention on the role of preoperative endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis and treatment of duct stones. Indications for ERCP depend on the likelihood of duct pathology; clinical, biochemical, and radiologic predictive factors are well established. Expert endoscopists use ERCP sparingly, only in patients known or very likely to have duct stones, believing that the duct can be cleared after laparoscopic cholecystectomy (LC) when necessary in almost every case. Paradoxically, when the level of local ERCP expertise is modest, ERCP may be attempted before LC more often, thus leaving the option of open exploration if ERCP fails. ERCP is highly efficient in the management of patients with symptoms after LC in order to exclude, diagnose, and treat complications such as retained stones, cystic duct leaks, and strictures. Concern about performing sphincterotomy in young patients (especially those with normal-sized ducts) because of unknown long-term effects is leading some endoscopists to remove small stones through the intact papilla. Selected patients with gallbladder and duct stones may be best treated by endoscopic duct clearance alone, without cholecystectomy (unless or until symptoms develop). Overall, ERCP techniques are currently used in about 10% of patients before or after LC. Each surgical/endoscopic team should develop an algorithm to maximize the effectiveness of the combined approach and to minimize problems.
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Affiliation(s)
- P B Cotton
- Division of Gastroenterology, Duke University Medical Center, Durham, North Carolina 27710
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