The Recalcitrant Bile Duct Stone

Primary Recurrent Common Bile Duct Stones: Timing of Surgical Intervention

Cholelithiasis (gallstones) is a very common medical problem worldwide, with 5-30% of patients demonstrating a combined condition of cholelithiasis and choledocholithiasis (common bile duct stones (CBDS)). CBDS are usually classified as primary or secondary stones. Primary CBDS are defined as stones detected 2 years or more following cholecystectomy, while secondary stones, the most common type, usually migrate from the gallbladder to the bile ducts. Recurrent CBDS are defined as stones detected 6 months or more following endoscopic retrograde cholangiopancreatography (ERCP) with complete duct clearance. Although ERCP with endoscopic sphincterotomy has emerged as the main therapeutic option for CBDS, with up to 95% bile duct clearance rate, up to 25% of said patients develop recurrent bile duct stones. Thus far, several issues related to recurrent CBDS are still unclear and questions regarding this specific pathology have no precise answers: how many trials of ERCP and endoscopic sphincterotomy should be attempted before referring the patient for surgical management? Is there an association between risk factors and early surgical intervention? Thus, currently, there is no worldwide scientific-based consensus regarding the best management of this specific group of patients. The main issue for this article is to review the relevant English literature and find out the main high risk factors for recurrent CBDS, and form a diagnostic and treatment plan, hence, identifying the subgroup of patients that will benefit from early surgical management, preventing further ERCP-associated complications.

Endoscopic sphincterotomy plus endoprostheses in the treatment of large or multiple common bile duct stones

BACKGROUND AND AIM

Little information is available on the outcomes of endoscopic sphincterotomy plus biliary stent placement without stone extraction as primary therapy at initial endoscopic retrograde cholangiopancreatography (ERCP) in the treatment of large or multiple common bile duct (CBD) stones. The aim of the present study was to study the effect of biliary stents and sphincterotomy as primary therapy for patients with choledocholithiasis.

METHODS

Patients with large (≥20 mm) or multiple (≥3) CBD stones were retrospectively studied. The patients underwent endoscopic sphincterotomy and placement of plastic stents in the bile duct without stone extraction at the initial ERCP. Three or more months later, a second ERCP was carried out and stone removal was attempted. Differences in stone size and the largest CBD diameter before and after stenting were compared. Stone clearance and complications were also evaluated.

RESULTS

52 patients were enrolled. After a median of 124 days of biliary plastic stent placement the mean maximal stone diameter decreased from 16.6 mm to 10.0 mm (P < 0.01). The mean CBD diameter also decreased from 15.3 mm to 11.5 mm (P < 0.01). The total stone clearance at second ERCP was 94.2%, only 5.7% of which needed mechanical lithotripsy.

COMPLICATIONS

pancreatitis in one (1.9%) at initial ERCP, cholangitis in two (3.8%) after 52 days and 84 days of placement of stent. No complications were recorded at second ERCP.

CONCLUSIONS

Biliary plastic stents plus endoscopic sphincterotomy without stone extraction as primary therapy at initial ERCP is a safe and effective method in the management of large or multiple CBD stones.

Obstinate Choledocholithiasis

Obstinate choledocholithiasis occurs when an obstructing common duct stone is large in size and does not easily respond to simple endoscopic or laparoscopic removal techniques. Such stones increase the risk of complications from causing biliary obstruction and from requiring more invasive methods of extraction. Sonography combined with computed tomography can confirm the presence, size, and position of common duct stones under ideal conditions before deciding if and how to treat choledocholithiasis. The sonographer must often battle bowel gas and difficult body habitus to image common duct stones, but it is crucial to document them when possible for proper diagnosis and management.

Various techniques for the surgical treatment of common bile duct stones: a meta review

Common bile duct stones (CBDSs) may occur in up to 3%–14.7% of all patients for whom cholecystectomy is preformed. Patients presenting with CBDS have symptoms including: biliary colic, jaundice, cholangitis, pancreatitis or may be asymptomatic. It is important to distinguish between primary and secondary stones, because the treatment approach varies. Stones found before, during, and after cholecystectomy had also differing treatments. Different methods have been used for the treatment of CBDS but the suitable therapy depends on conditions such as patient' satisfaction, number and size of stones, and the surgeons experience in laparoscopy. Endoscopic retrograde cholangiopancreatography with or without endoscopic biliary sphincterotomy, laparoscopic CBD exploration (transcystic or transcholedochal), or laparotomy with CBD exploration (by T-tube, C-tube insertion, or primary closure) are the most commonly used methods managing CBDS. We will review the pathophysiology of CBDS, diagnosis, and different techniques of treatment with especial focus on the various surgical modalities.