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Obata T, Tsutsumi K, Kato H, Ueki T, Miyamoto K, Yamazaki T, Matsumi A, Fujii Y, Matsumoto K, Horiguchi S, Yasugi K, Ogawa T, Takenaka R, Okada H. Balloon Enteroscopy-Assisted Endoscopic Retrograde Cholangiopancreatography for the Treatment of Common Bile Duct Stones in Patients with Roux-en-Y Gastrectomy: Outcomes and Factors Affecting Complete Stone Extraction. J Clin Med 2021; 10:jcm10153314. [PMID: 34362098 PMCID: PMC8348346 DOI: 10.3390/jcm10153314] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 07/24/2021] [Accepted: 07/25/2021] [Indexed: 12/21/2022] Open
Abstract
Background: Endoscopic retrograde cholangiopancreatography (ERCP) for extraction of common bile duct (CBD) stones in patients with Roux-en-Y gastrectomy (RYG) remains technically challenging. Methods: Seventy-nine RYG patients (median 79 years old) underwent short-type double-balloon enteroscopy-assisted ERCP (sDBE-ERCP) for CBD stones at three referral hospitals from 2011–2020. We retrospectively investigated the treatment outcomes and potential factors affecting complete stone extraction. Results: The initial success rates of reaching the papilla of Vater, biliary cannulation, and biliary intervention, including complete stone extraction or biliary stent placement, were 92%, 81%, and 78%, respectively. Of 57 patients with attempted stone extraction, complete stone extraction was successful in 74% for the first session and ultimately in 88%. The adverse events rate was 5%. The multivariate analysis indicated that the largest CBD diameter ≥ 14 mm (odds ratio (OR), 0.04; 95% confidence interval (CI), 0.01–0.58; p = 0.018) and retroflex position (OR, 6.43; 95% CI, 1.12–36.81; p = 0.037) were independent predictive factors affecting complete stone extraction achievement. Conclusions: Therapeutic sDBE-ERCP for CBD stones in a relatively elderly RYG cohort, was effective and safe. A larger CBD diameter negatively affected complete stone extraction, but using the retroflex position may be useful for achieving complete stone clearance.
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Affiliation(s)
- Taisuke Obata
- Department of Gastroenterology, Okayama University Hospital, Okayama 7008558, Japan; (T.O.); (H.K.); (T.Y.); (A.M.); (Y.F.); (K.M.); (S.H.); (H.O.)
| | - Koichiro Tsutsumi
- Department of Gastroenterology, Okayama University Hospital, Okayama 7008558, Japan; (T.O.); (H.K.); (T.Y.); (A.M.); (Y.F.); (K.M.); (S.H.); (H.O.)
- Correspondence: ; Tel.: +81-86-235-7219
| | - Hironari Kato
- Department of Gastroenterology, Okayama University Hospital, Okayama 7008558, Japan; (T.O.); (H.K.); (T.Y.); (A.M.); (Y.F.); (K.M.); (S.H.); (H.O.)
| | - Toru Ueki
- Department of Internal Medicine, Fukuyama City Hospital, Fukuyama 7218511, Japan; (T.U.); (K.Y.); (T.O.)
| | - Kazuya Miyamoto
- Department of Internal Medicine, Tsuyama Chuo Hospital, Okayama 7080841, Japan; (K.M.); (R.T.)
| | - Tatsuhiro Yamazaki
- Department of Gastroenterology, Okayama University Hospital, Okayama 7008558, Japan; (T.O.); (H.K.); (T.Y.); (A.M.); (Y.F.); (K.M.); (S.H.); (H.O.)
| | - Akihiro Matsumi
- Department of Gastroenterology, Okayama University Hospital, Okayama 7008558, Japan; (T.O.); (H.K.); (T.Y.); (A.M.); (Y.F.); (K.M.); (S.H.); (H.O.)
| | - Yuki Fujii
- Department of Gastroenterology, Okayama University Hospital, Okayama 7008558, Japan; (T.O.); (H.K.); (T.Y.); (A.M.); (Y.F.); (K.M.); (S.H.); (H.O.)
| | - Kazuyuki Matsumoto
- Department of Gastroenterology, Okayama University Hospital, Okayama 7008558, Japan; (T.O.); (H.K.); (T.Y.); (A.M.); (Y.F.); (K.M.); (S.H.); (H.O.)
| | - Shigeru Horiguchi
- Department of Gastroenterology, Okayama University Hospital, Okayama 7008558, Japan; (T.O.); (H.K.); (T.Y.); (A.M.); (Y.F.); (K.M.); (S.H.); (H.O.)
| | - Kengo Yasugi
- Department of Internal Medicine, Fukuyama City Hospital, Fukuyama 7218511, Japan; (T.U.); (K.Y.); (T.O.)
| | - Tsuneyoshi Ogawa
- Department of Internal Medicine, Fukuyama City Hospital, Fukuyama 7218511, Japan; (T.U.); (K.Y.); (T.O.)
| | - Ryuta Takenaka
- Department of Internal Medicine, Tsuyama Chuo Hospital, Okayama 7080841, Japan; (K.M.); (R.T.)
| | - Hiroyuki Okada
- Department of Gastroenterology, Okayama University Hospital, Okayama 7008558, Japan; (T.O.); (H.K.); (T.Y.); (A.M.); (Y.F.); (K.M.); (S.H.); (H.O.)
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Efficacy and safety of cholangioscopy guided laser lithotripsy for difficult bile duct stones - A prospective study from a tertiary care centre in Eastern India. Arab J Gastroenterol 2021; 22:111-114. [PMID: 34120850 DOI: 10.1016/j.ajg.2021.05.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 02/22/2021] [Accepted: 05/18/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND STUDY AIMS Endoscopic sphincterotomy combined with endoscopic papillary balloon dilatation, mechanical lithotripsy or both, are effective modalities for the ex- traction of difficult common bile duct (CBD) stones. However, approximately 5-15% of cases are still difficult to treat. In the present study, we have evaluated the safety and efficacy of single- operator cholangioscopy guided laser lithotripsy (LL) for difficult to treat CBD stones. PATIENTS AND METHODS Consecutive patients undergoing LL for the extraction of difficult CBD stones were enrolled in the study. The primary outcomes were related to the efficacy of the procedure in terms of ductal clearance and safety in terms of complications. RESULTS During the 36 months, 764 patients presented for biliary stone extraction. Most of the patients, 683 (89.4%), had a successful stone extraction with standard techniques. Thirteen patients (1.7%) were not suitable for endoscopic therapy or did not consent for endoscopic therapy, and were referred directly for surgical treatment. Sixty-seven patients (8.8%) were included in the study. Cholangioscope was able to reach the stone in all the cases but one. Complete ductal clearance was achieved in 61 (91%) patients. Complications were encountered in 8 (11.9%) patients. All patients were asymptomatic at one-month of follow-up. CONCLUSION LL is a highly effective and safe procedure with minimal and transient complications.
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Zhu J, Zhang Y, Du P, Hu W, Xiao W, Li Y. Systematic Review and Meta-analysis of Laparoscopic Common Bile Duct Exploration in Patients With Previous Failed Endoscopic Retrograde Cholangiopancreatography. Surg Laparosc Endosc Percutan Tech 2021; 31:654-662. [PMID: 33973942 DOI: 10.1097/sle.0000000000000949] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 03/30/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND The aim was to compare the outcomes of laparoscopic common bile duct exploration (LCBDE) after failed endoscopic retrograde cholangiopancreatography (group A) versus primary LCBDE (group B) for the management of gallbladder and common bile duct stones. MATERIALS AND METHODS A comprehensive and systematic literature search was performed in several databases, including PubMed, Ovid, and Cochrane Library. Meta-analysis of operative outcomes, postoperative outcomes, and gallstone clearance rates was conducted using random-effect models. RESULTS Six studies including 642 patients (239 in group A and 403 in group B) were included. The operative time was longer in group A (P=0.02). The overall complication, bile leakage, conversion, postoperative hospital stay, and reoperation were comparable in group A and group B. Similarly, no significant difference was present concerning the incidence of stone clearance, residual stone, and recurrent stone (P>0.05). CONCLUSION LCBDE is an alternative acceptable procedure when removal of common bile duct stones by endoscopic therapy fails.
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Affiliation(s)
- Jisheng Zhu
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
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Kim MU, Lee Y, Lee JH, Cho SB, Lee MS, So YH, Choi YH. Predictive factors affecting percutaneous drainage duration in the percutaneous treatment of common bile duct stones. PLoS One 2021; 16:e0248003. [PMID: 33651811 PMCID: PMC7924786 DOI: 10.1371/journal.pone.0248003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 02/17/2021] [Indexed: 12/24/2022] Open
Abstract
The duration of percutaneous transhepatic biliary drainage (PTBD) is a critical factor that determines the duration of treatment. This study aimed to evaluate factors affecting the PTBD duration in patients who underwent percutaneous treatment of common bile duct (CBD) stones. This study analyzed data of 169 patients who underwent percutaneous treatment of CBD stones from June 2009 to June 2019. Demographic data, characteristics of stone, procedure-related factors, and laboratory findings before the insertion of PTBD tubes were retrospectively evaluated. To assess the effect of confounding factors on the PTBD duration, multivariate linear regression analysis was applied, incorporating significant predictive factors identified in the univariate regression analysis. In the univariate regression analysis, the predictive factor that showed high correlation with the PTBD duration was the initial total bilirubin level (coefficient = 0.68, P < .001) followed by the short diameter of the largest stone (coefficient = 0.19, P = .056), and previous endoscopic sphincterotomy (coefficient = -2.50, P = .086). The multivariate linear regression analysis showed that the initial total bilirubin level (coefficient = 0.50, P < .001) and short diameter of the largest stone (coefficient = 0.16, P = .025) were significantly related to the PTBD duration. The total bilirubin level before PTBD tube insertion and the short diameter of the largest CBD stone were predictive factors for the PTBD duration in patients who underwent percutaneous CBD stone removal. Careful assessment of these factors might help in predicting the treatment period, thereby improving the quality of patient care.
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Affiliation(s)
- Min Uk Kim
- Department of Radiology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Yoontaek Lee
- Department of Surgery, Ewha Womans University Seoul Hospital, Seoul, Korea
- * E-mail:
| | - Jae Hwan Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Korea
| | - Soo Buem Cho
- Department of Radiology, Ewha Womans University Seoul Hospital, Seoul, Korea
| | - Myoung Seok Lee
- Department of Radiology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Young Ho So
- Department of Radiology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Young Ho Choi
- Department of Radiology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
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Sandha J, van Zanten SV, Sandha G. The Safety and Efficacy of Single-Operator Cholangioscopy in the Treatment of Difficult Common Bile Duct Stones after Failed Conventional ERCP. J Can Assoc Gastroenterol 2019; 1:181-190. [PMID: 31294359 PMCID: PMC6530813 DOI: 10.1093/jcag/gwy021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background Common bile duct (CBD) stones are extracted with a basket or balloon during ERCP with sphincterotomy. However, some stones are difficult to extract by conventional means. Cholangioscopy with lithotripsy is a modality to treat these difficult stones. We describe the clinical efficacy of single-operator per oral cholangioscopy (SOPOC) for difficult stones and discuss cost savings by avoiding surgical intervention. Methods Retrospective chart review was performed for all patients referred for difficult CBD stones. Clinical success was defined as clearing the duct of all stones. The cost of cholangioscopy (in $CDN) was calculated by adding all costs associated with the procedure(s), surgery, hospital stay or treatment of adverse events. This cost was compared with the projected cost of surgical bile duct exploration. Results A total of 51 patients (35 female) with a mean age of 66 years underwent 58 SOPOC procedures. Median procedure time was 67 minutes (95% CI, 61.5–73.5). The CBD was successfully cleared in 47 of 51 patients (93%). Minor adverse events were seen in seven patients (14%). The actual average per procedure cost was $4555±$2647. This compares with a projected cost of $7766 and $6175 for open and laparoscopic bile duct exploration, with a cost-per-case saving of $3210 and $1619, respectively. Conclusion SOPOC with lithotripsy is highly effective and safe for the treatment of difficult common bile duct stones. In addition, significant cost savings may be realized by avoiding surgical bile duct exploration.
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Affiliation(s)
- Jaskiran Sandha
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | | | - Gurpal Sandha
- Division of Gastroenterology, University of Alberta Hospital, Edmonton, Alberta, Canada
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Okuno N, Hara K, Mizuno N, Hijioka S, Tajika M, Tanaka T, Ishihara M, Hirayama Y, Onishi S, Niwa Y, Yamao K. Endoscopic Ultrasound-guided Rendezvous Technique after Failed Endoscopic Retrograde Cholangiopancreatography: Which Approach Route Is the Best? Intern Med 2017; 56:3135-3143. [PMID: 28943555 PMCID: PMC5742383 DOI: 10.2169/internalmedicine.8677-16] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Objective The endoscopic ultrasound-guided rendezvous technique (EUS-RV) is a salvage method for failed selective biliary cannulation. Three puncture routes have been reported, with many comparisons between the intra-hepatic and extra-hepatic biliary ducts. We used the trans-esophagus (TE) and trans-jejunum (TJ) routes. In the present study, the utility of EUS-RV for biliary access was evaluated, focusing on the approach routes. Methods and Patients In 39 patients, 42 puncture routes were evaluated in detail. EUS-RV was performed between January 2010 and December 2014. The patients were prospectively enrolled, and their clinical data were retrospectively collected. Results The patients' median age was 71 (range 29-84) years. The indications for endoscopic retrograde cholangiopancreatography (ERCP) were malignant biliary obstruction in 24 patients and benign biliary disease in 15. The technical success rate was 78.6% (33/42) and was similar among approach routes (p=0.377). The overall complication rate was 16.7% (7/42) and was similar among approach routes (p=0.489). However, mediastinal emphysema occurred in 2 TE route EUS-RV patients. No EUS-RV-related deaths occurred. Conclusion EUS-RV proved reliable after failed ERCP. The selection of the appropriate route based on the patient's condition is crucial.
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Affiliation(s)
- Nozomi Okuno
- Department of Gastroenterology, Aichi Cancer Center Hospital, Japan
| | - Kazuo Hara
- Department of Gastroenterology, Aichi Cancer Center Hospital, Japan
| | - Nobumasa Mizuno
- Department of Gastroenterology, Aichi Cancer Center Hospital, Japan
| | - Susumu Hijioka
- Department of Gastroenterology, Aichi Cancer Center Hospital, Japan
| | - Masahiro Tajika
- Department of Endoscopy, Aichi Cancer Center Hospital, Japan
| | - Tsutomu Tanaka
- Department of Endoscopy, Aichi Cancer Center Hospital, Japan
| | - Makoto Ishihara
- Department of Endoscopy, Aichi Cancer Center Hospital, Japan
| | - Yutaka Hirayama
- Department of Endoscopy, Aichi Cancer Center Hospital, Japan
| | - Sachiyo Onishi
- Department of Endoscopy, Aichi Cancer Center Hospital, Japan
| | - Yasumasa Niwa
- Department of Gastroenterology, Aichi Cancer Center Hospital, Japan
- Department of Endoscopy, Aichi Cancer Center Hospital, Japan
| | - Kenji Yamao
- Department of Gastroenterology, Aichi Cancer Center Hospital, Japan
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Schünemann M, Haes J, Oette M. [A 61-year-old man with jaundice following stomach cancer]. Internist (Berl) 2015; 56:833-7. [PMID: 26036656 DOI: 10.1007/s00108-015-3742-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
A 61-year-old man with occlusion of the common bile duct due to metachronous metastases after surgery for adenocarcinoma of the stomach underwent a bile drainage intervention using endoscopic ultrasound (EUS). A self-expanding metal stent was inserted into the common bile duct of the liver via the esophagus. Successful drainage of the bile fluid into the duodenum was achieved for 14 months until the death of the patient. EUS interventions are becoming increasingly common. Although many questions such as the methodological details still remain, EUS interventions have the potential to become standard procedures especially in the situation of malignant stenoses of the bile or pancreatic duct.
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Affiliation(s)
- M Schünemann
- Klinik für Allgemeine Innere Medizin, Gastroenterologie und Infektiologie, Krankenhaus der Augustinerinnen, Jakobstr. 27-31, 50678, Köln, Deutschland
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Kint JF, van den Bergh JE, van Gelder RE, Rauws EA, Gouma DJ, van Delden OM, Laméris JS. Percutaneous treatment of common bile duct stones: results and complications in 110 consecutive patients. Dig Surg 2015; 32:9-15. [PMID: 25613598 DOI: 10.1159/000370129] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 11/24/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND/AIMS Choledocholithiasis is a common complication of cholecystolithiasis, occurring in 15-20% of patients who have gallbladder stones. Endoscopic retrograde cholangio-pancreatography is the standard treatment. When this is not possible or not feasible, percutaneous transhepatic stone removal is an alternative treatment. In this retrospective study, we analyze 110 patients who were treated with percutaneous transhepatic removal of Common Bile Duct (CBD) stones. PATIENTS AND METHODS Between March 1998 and September 2013 110 patients (61 men, 49 women; aged 14-96, mean age 69.7 years) with confirmed bile duct stones were included. PTC was done using ultrasound and fluoroscopy. Balloon dilatation of the papilla was done with 8-12 mm balloons. If stone size exceeded 10 mm, mechanical lithotripsy was performed. Stones were then removed by percutaneous extraction or evacuation into the duodenum. RESULTS In 104 patients (104/110; 94.5%) total stone clearance of the CBD was achieved. A total of 12 complications occurred (10.9%), graded with the Clavien-Dindo scale as IVa, IVb, and V, respectively; hypoxia requiring resuscitation, sepsis and death due to ongoing cholangiosepsis (n = 1, 4, 1). Minor complications I, II, and IIIa included: small liver abscess, pleural empyema, transient hemobilia and mild fever (n = 1, 1, 2, 2). CONCLUSION Percutaneous removal of CBD stones is an effective alternative treatment, when endoscopic treatment is contra-indicated, fails or is not feasible. It is effective, has a low complication rate and using deep sedation potentially requires only a very limited number of treatment sessions.
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Affiliation(s)
- Johan F Kint
- Department of Radiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Yasuda I, Itoi T. Recent advances in endoscopic management of difficult bile duct stones. Dig Endosc 2013; 25:376-85. [PMID: 23650878 DOI: 10.1111/den.12118] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Accepted: 03/21/2013] [Indexed: 12/12/2022]
Abstract
Endoscopic treatment is now recognized worldwide as the first-line treatment for bile duct stones. Endoscopic sphincterotomy combined with basket and/or balloon catheter is generally carried out for stone extraction. However, some stones are refractory to treatment under certain circumstances, necessitating additional/other therapeutic modalities. Large bile duct stones are typically treated by mechanical lithotripsy. However, if this fails, laser or electrohydraulic lithotripsy (EHL) is carried out under the guidance of conventional mother-baby cholangioscopy. More recently, direct cholangioscopy using an ultrathin gastroscope and the newly developed single-use cholangioscope system - the SpyGlass direct visualization system - are also used. In addition, extracorporeal shock wave lithotripsy has also been used for stone fragmentation. Such fragmentation techniques are effective in cases with impacted stones, including Mirizzi syndrome. Most recently, endoscopic papillary large balloon dilationhas been introduced as an easy and effective technique for treating large and multiple stones. In cases of altered anatomy, it is often difficult to reach the papilla; in such cases, a percutaneous transhepatic approach, such as EHL or laser lithotripsy under percutaneous transhepatic cholangioscopy, can be a treatment option. Moreover, enteroscopy has recently been used to reach the papilla. Furthermore, an endoscopic ultrasound-guided procedure has been attempted most recently. In elderly patients and those with very poor general condition, biliary stenting only is sometimes carried out with or without giving subsequent dissolution agents.
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Affiliation(s)
- Ichiro Yasuda
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan.
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The role of endoscopy in the management of choledocholithiasis. Gastrointest Endosc 2011; 74:731-44. [PMID: 21951472 DOI: 10.1016/j.gie.2011.04.012] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Accepted: 04/06/2011] [Indexed: 12/15/2022]
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Two decades of percutaneous transjejunal biliary intervention for benign biliary disease: a review of the intervention nature and complications. Insights Imaging 2011; 2:557-65. [PMID: 23100019 PMCID: PMC3289021 DOI: 10.1007/s13244-011-0119-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2011] [Revised: 06/29/2011] [Accepted: 07/11/2011] [Indexed: 12/29/2022] Open
Abstract
Objective To assess outcomes of percutaneous transjejunal biliary intervention (PTJBI) in terms of success and effectiveness in patients with a Roux-en-Y hepaticojejunostomy for benign biliary strictures and stones. Methods Clinical and radiographic records of 63 patients with a Roux-en-Y choledochojejunostomy or hepaticojejunostomy for benign disease who underwent at least one PTJBI between 1986 and 2007 were reviewed. Effectiveness was determined by successful access rate, rates of stricture dilatation and/or stone extraction, morbidity, complications and hospitalisation. Results PTJBI was attempted 494 times. Successful access to the Roux-en-Y was accomplished in 93% of interventions. After access to the Roux-en-Y was granted, all strictures were effectively dilated. Ninety-seven percent of extraction attempts of intrahepatic calculi were successful. The median number of interventions per patient was five. The median interval between interventions was 51.5 weeks (range 2.7–1,279.6 weeks). The early complication rate was 3%. Morbidity, measured in terms of cholangitis episodes was 14%, in 25 out of 63 patients. Mean hospitalisation was 4.1 nights per year. Conclusion PTJBI is safe and effective in treating benign biliary strictures and/or calculi. High success rates and short hospitalisation periods, together with few complications make it a well-accepted and integral part of managing complex biliary problems.
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Hartmann D, Riemann J. Tonnenkonkremente – Besonderheiten beim Hochbetagten. DER GASTROENTEROLOGE 2007. [DOI: 10.1007/s11377-007-0129-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Lyon SM, Terhaar O, Given MF, O'Dwyer HM, McGrath FP, Lee MJ. Percutaneous embolization of transhepatic tracks for biliary intervention. Cardiovasc Intervent Radiol 2007; 29:1011-4. [PMID: 16823517 DOI: 10.1007/s00270-005-0183-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Significant pain can occur after removing transhepatic catheters from biliary access tracks, after percutaneous biliary drainage (PBD) or stenting. We undertook a randomized prospective study to ascertain whether track embolization decreases the amount of pain or analgesic requirement after PBD. Fifty consecutive patients (M:F, 22:28; age range: 29-85 years; mean age: 66.3 years) undergoing PBD were randomized to receive track embolization or no track embolization after removal of biliary drainage catheters. A combination of Lipoidol and n-butyl cyanoacrylate were used to embolize transhepatic tracks using an 8F dilator. The patients who did not have track embolization performed had biliary drainage catheters removed over a guide wire. A visual analog scoring (VAS) system was used to grade pain associated with catheter removal, 24 h afterward. A required analgesic score (RAS) was devised to tabulate the analgesia required. No analgesia had a score of 0, oral or rectal nonopiate analgesics had a score of 1, oral opiates had a score of 2, and parenteral opiates had a score of 3. The average VAS and RAS for both groups were calculated and compared. Seven patients were excluded for various reasons, leaving 43 patients in the study group. Twenty-one patients comprised the embolization group and 22 patients comprised the nonembolization group. The mean biliary catheter dwell time was not significantly different (p > 0.05) between the embolization group and nonembolization (mean: 5.4 days vs 6.9 days, respectively). In the nonembolization group, the mean VAS was 3.4. Eight patients required parenteral opiates, three patients required oral opiates, and five patients required oral or rectal analgesics, yielding a mean RAS of 1.6. In the embolization group, the mean VAS was 0.9. No patient required parenteral opiates, six patients required oral opiates, and two patients had oral analgesia. The average RAS was 0.6. Both the VAS and the RAS were significantly lower in the embolization group compared with the nonembolization group (p < 0.0023 and p < 0.002, respectively). No complications were seen related to track embolization. Percutaneous track embolization after removal of biliary drainage catheters decreases patient's perception of pain and decreases the amount of required analgesia. In particular, the amount of opiate analgesia required is considerably less.
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Affiliation(s)
- Stuart M Lyon
- Department of Academic Radiology, Beaumont Hospital, Dublin 9, Ireland
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Amplatz S, Piazzi L, Felder M, Comberlato M, Benvenuti S, Zancanella L, Di Fede F, de'Guelmi A, Bertozzo A, Farris P, Grasso T, Mega A, Chilovi F. Extracorporeal shock wave lithotripsy for clearance of refractory bile duct stones. Dig Liver Dis 2007; 39:267-72. [PMID: 17275426 DOI: 10.1016/j.dld.2006.11.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2006] [Revised: 11/11/2006] [Accepted: 11/14/2006] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND STUDY AIMS Following endoscopic sphincterotomy, 90% of bile duct stones can be removed with a Dormia basket or balloon catheter. The removal can fail in patients with large stones, intrahepatic stones, bile duct strictures or a difficult anatomy. The aim of this retrospective study is to investigate the efficacy and safety of extracorporeal shock wave lithotripsy in fragmenting and allowing the extraction of bile duct stones that could not be cleared by routine endoscopic means including mechanical lithotripsy. PATIENTS AND METHODS From 1989 to January 2005, we treated with extracorporeal shock wave lithotripsy 376 patients (133 males and 243 females, median age 71.4 years) with bile duct stones that were not removable following endoscopic sphincterotomy, using the extracorporeal shock wave lithotripsy Lithostar Plus machine built by Siemens Co. of Erlangen, Germany. Stone targeting was performed fluoroscopically following injection of contrast via nasobiliary drain or T-tube in 362 patients and by ultrasonography in eight patients. Residual fragments were cleared at endoscopic retrograde cholangiopancreatograhy. Two hundred and ten of the 370 patients treated (56.7%) showed only 1 stone, 57 (15.4%) showed 2, 45 (12.1%) showed 3, 58 (15.6%) showed more than 3 stones. The median diameter of the stones was 21mm (range 7-80mm). RESULTS Complete stone clearance was achieved in 334 of the 376 patients who underwent the extracorporeal shock wave lithotripsy procedure (90.2%). Six patients (1.5%) dropped out of treatment during their first sessions, mainly because of intolerance. Each patient averaged 3.7 treatments (1-12), at an average rate of 3470 shocks per session (1500-5400), at an average energy level of 3.4mJ (1-7). Complications were recorded in 34 patients (9.1%); 22 patients experienced symptomatic cardiac arrhythmia, 4 haemobilia, 2 cholangitis, 3 haematuria, 3 dyspnoea; no deaths were associated with the procedure. CONCLUSIONS Extracorporeal shock wave lithotripsy is a safe and effective therapy in those patients in whom endoscopic techniques have failed with a clearing rate of 90.2% of refractory bile duct stones with a low rate of complications.
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Affiliation(s)
- S Amplatz
- Gastrointestinal Unit, Ospedale Centrale, Bolzano, Italy.
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Abstract
Bile duct stones are routinely removed at time of endoscopic retrograde cholangiopancreatography (ERCP) after biliary sphincterotomy with standard balloon or basket extraction techniques. However, in approximately 10% to 15% of patients, bile duct stones may be difficult to remove due to challenging access to the bile duct (periampullary diverticulum, Billroth II anatomy, Roux-en-Y gastrojejunostomy), large (> 15 mm in diameter) bile duct stones, intrahepatic stones, or impacted stones in the bile duct or cystic duct. The initial approach to the removal of the difficult bile duct stone is to ensure adequate biliary sphincter orifice diameter with extension of biliary sphincterotomy or balloon dilation of the orifice. Mechanical lithotripsy is a readily available adjunct to standard stone extraction techniques and should be available in all ERCP units. If stone extraction fails with these maneuvers, two or more bile duct stents should be inserted, and ursodiol added to aid in duct decompression, stone fragmentation, and stone dissolution. Follow-up ERCP attempts to remove the difficult bile duct stones may be performed locally if expertise is available or alternatively referred to a tertiary center for advanced extracorporeal or intracorporeal fragmentation (mother-baby laser or electrohydraulic lithotripsy) techniques. Nearly all patients with bile duct stones can be treated endoscopically if advanced techniques are utilized. For the rare patient who fails despite these efforts, surgical bile duct exploration, percutaneous approach to the bile duct, or long-term bile duct stenting should be discussed with the patient and family to identify the most appropriate therapeutic option. A thoughtful approach to each patient with difficult bile duct stones and a healthy awareness of the operator/endoscopy unit limitations is necessary to ensure the best patient outcomes. Consultation with a dedicated tertiary ERCP specialty center may be necessary.
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Affiliation(s)
- Lee McHenry
- Indiana University Medical Center, Indianapolis, IN 46202, USA.
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Tse F, Barkun JS, Romagnuolo J, Friedman G, Bornstein JD, Barkun AN. Nonoperative imaging techniques in suspected biliary tract obstruction. HPB (Oxford) 2006; 8:409-25. [PMID: 18333096 PMCID: PMC2020758 DOI: 10.1080/13651820600746867] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Evaluation of suspected biliary tract obstruction is a common clinical problem. Clinical data such as history, physical examination, and laboratory tests can accurately identify up to 90% of patients whose jaundice is caused by extrahepatic obstruction. However, complete assessment of extrahepatic obstruction often requires the use of various imaging modalities to confirm the presence, level, and cause of obstruction, and to aid in treatment plan. In the present summary, the literature on competing technologies including endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangiopancreatography (PTC), endoscopic ultrasound (EUS), intraductal ultrasonography (IDUS), magnetic resonance cholangiopancreatography (MRCP), helical CT (hCT) and helical CT cholangiography (hCTC) with regards to diagnostic performance characteristics, technical success, safety, and cost-effectiveness is reviewed. Patients with obstructive jaundice secondary to choledocholithiasis or pancreaticobiliary malignancies are the primary focus of this review. Algorithms for the management of suspected obstructive jaundice are put forward based on current evidence. Published data suggest an increasing role for EUS and other noninvasive imaging techniques such as MRCP, and hCT following an initial transabdominal ultrasound in the assessment of patients with suspected biliary obstruction to select candidates for surgery or therapeutic ERCP. The management of patients with a suspected pancreaticobiliary condition ultimately is dependent on local expertise, availability, cost, and the multidisciplinary collaboration between radiologists, surgeons, and gastroenterologists.
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Affiliation(s)
- Frances Tse
- Division of Gastroenterology, McMaster University Medical Centre, McMaster UniversityHamilton OntarioCanada
| | - Jeffrey S. Barkun
- Division of Gastroenterology, Montreal General Hospital and Royal Victoria Hospital Sites, McGill University Health CentreMontreal QuebecCanada
| | - Joseph Romagnuolo
- Division of Gastroenterology and Hepatology, Medical University of South CarolinaCharleston SCUSA
| | - Gad Friedman
- Division of Gastroenterology, Sir Mortimer B. Davis-Jewish General Hospital, McGill UniversityMontreal QuebecCanada
| | | | - Alan N Barkun
- Division of Gastroenterology, Montreal General Hospital and Royal Victoria Hospital Sites, McGill University Health CentreMontreal QuebecCanada
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18
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Wada S, Yano T, Tamada K, Tomiyama T, Tano S, Ido K, Sugano K. Endoscopic microwave lithotripsy of a biliary stone lodged at a choledochoduodenal anastomosis. Gastrointest Endosc 2003; 58:464-6. [PMID: 14528233 DOI: 10.1067/s0016-5107(03)00033-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Shinichi Wada
- Department of Gastroenterology, Jichi Medical School, Kawachi-gun, Tochigi, Japan
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19
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Affiliation(s)
- Gary C Vitale
- Director of Interventional Endoscopy of the Center for Advanced Surgical Technologies, Norton Hospital Surgical Director, Digestive Disease Center, University of Louisville, Louisville, Kentucky, USA
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Lee SK, Seo DW, Myung SJ, Park ET, Lim BC, Kim HJ, Yoo KS, Park HJ, Joo YH, Kim MH, Min YI. Percutaneous transhepatic cholangioscopic treatment for hepatolithiasis: an evaluation of long-term results and risk factors for recurrence. Gastrointest Endosc 2001; 53:318-23. [PMID: 11231390 DOI: 10.1016/s0016-5107(01)70405-1] [Citation(s) in RCA: 105] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Percutaneous transhepatic cholangioscopy (PTCS) has a major role in the treatment of hepatolithiasis. The aims of this study were to evaluate immediate and long-term results of PTCS treatment and to elucidate the risk factors for recurrence of stones or cholangitis. METHODS A retrospective study was conducted of patients with hepatolithiasis who underwent PTCS treatment. A total of 92 patients underwent PTCS treatment and 68 were followed for 24 to 60 months (median 42 months). RESULTS Complete clearance of stones was achieved in 74 (80%) patients. The rate of complete clearance was significantly lower in patients with severe intrahepatic strictures compared with that for those with no strictures (14 of 24, 58% vs. 16 of 16, 100%, p < 0.01) and those with mild to moderate strictures (14 of 24, 58% vs. 44 of 52, 85%, p < 0.05). Patients with severe intrahepatic strictures had a higher recurrence rate than those with no or mild strictures (100% vs. 28%, p < 0.01). In addition the recurrence rate in patients with advanced biliary cirrhosis (Child's class B or C) was higher than in those with no or mild (Child's class A) cirrhosis (89% vs. 29%, p < 0.01). In patients with type I and II hepatolithiasis (Tsunoda classification), stones recurred in 2 (12%) patients at 28 and 32 months after successful stone removal, without further recurrence afterwards. The recurrence rate in patients with type III and IV hepatolithiasis increased gradually up to 50% at 60 months of follow-up. CONCLUSIONS Severe intrahepatic stricture was the only factor that affected the immediate success rate of PTCS in the treatment of hepatolithiasis. Several risk factors including severe biliary stricture, advanced biliary cirrhosis and Tsunoda type III and IV affected the long-term results.
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Affiliation(s)
- S K Lee
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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