Endoscopic removal of large common bile duct stones in recurrent pyogenic cholangitis

Long-term follow-up after peroral cholangioscopy-directed lithotripsy in patients with difficult bile duct stones, including Mirizzi syndrome: an analysis of risk factors predicting stone recurrence

BACKGROUND

Peroral cholangioscopy-directed lithotripsy (PC-directed lithotripsy) has been successfully used for the treatment of difficult bile duct stones, including Mirizzi syndrome (MS). However, long-term outcome and risk factors for stone recurrence after PC-directed lithotripsy have not yet been elucidated. The aim of this study was to assess the outcomes of long-term follow-up after PC-directed lithotripsy and to clarify risk factors predicting stone recurrence.

METHODS

One hundred twenty-two consecutive patients with difficult bile duct stones, including MS type II (McSherry classification system), were included in the study.

RESULTS

Successful stone removal was achieved in 117 (95.9%) of the 122 patients treated with PC-directed lithotripsy. Of these 117 patients, reliable follow-up information for a median period of 5.5 years (range=0.19-16.6) was obtained for 111 patients (94.9%) in whom stone type was classified into one of the following three categories: (1) MS type II (47 patients); (2) impacted stones (45 patients); and (3) large stones (≥20 mm in short diameter, 19 patients). Bile duct stone recurrence was observed in 18 patients (16.1%), of whom 4 had MS type II, 9 had impacted stones, and 5 had large stones. Statistical analysis showed that dilated bile duct diameter greater than or equal to 20 mm was the only risk factor for stone recurrence.

CONCLUSIONS

PC-directed lithotripsy used for the treatment of difficult bile duct stones, including MS type II and impacted stones, and is found to be safe at long-term follow-up. Dilated bile duct diameter is the only risk factor for stone recurrence. Careful follow-up is indispensable, particularly for patients with dilated bile ducts.

Choledocholithiasis, ascending cholangitis, and gallstone pancreatitis

Gallstone disease is encountered commonly in clinical practice. The diagnosis of biliary stones has become less problematic with current, less-invasive imaging methods. The relatively invasive endoscopic techniques should be reserved for therapy and not used for diagnosis. Acute cholangitis and gallstone pancreatitis are two major complications that require prompt recognition and timely intervention to limit morbidity and prevent mortality or recurrence. Appropriate noninvasive diagnostic studies, adequate monitoring/supportive care, and proper patient selection for invasive therapeutic procedures are elements of good clinical practice.

How to predict the outcome of endoscopic mechanical lithotripsy in patients with difficult bile duct stones?

OBJECTIVE

Endoscopic mechanical lithotripsy is frequently used to overcome the difficulties of removing large bile duct stones endoscopically. The aim of this study was to identify predictors of endoscopic mechanical lithotripsy failure.

MATERIAL AND METHODS

One hundred and thirty-four patients who underwent mechanical lithotripsy for difficult choledocholithiasis were evaluated retrospectively. Predictive factors of outcome and procedure-related complications were analyzed. The clinical outcomes of subsequent management were also evaluated in cases of unsuccessful endoscopic mechanical lithotripsy.

RESULTS

Endoscopic mechanical lithotripsy was successful in 102 patients (76.1%). Stone impaction, size (>or=30 mm), and the stone size to bile duct diameter ratio (>1.0) were significant predictors of endoscopic mechanical lithotripsy failure, with estimated odds ratios of 17.83, 4.32 and 5.47, respectively. There was no difference in complication rates between the successful and failed mechanical lithotripsy groups. When mechanical lithotripsy failed, all patients were successfully treated using various modalities, including surgery, without mortality.

CONCLUSIONS

An impacted stone, stone size (>or=30 mm) and stone size to bile duct diameter ratio (>1.0) were predictors of failure of endoscopic mechanical lithotripsy for a difficult bile duct stone. Alternative approaches should be considered in patients with predictors of unsuccessful endoscopic mechanical lithotripsy in order to avoid wasting time and resources.

Predictors of unsuccessful mechanical lithotripsy and endoscopic clearance of large bile duct stones

BACKGROUND

Mechanical lithotripsy is used to break large bile duct stones. This study investigated the predictors of unsuccessful mechanical lithotripsy.

METHODS

Consecutive patients with bile duct stones underwent endoscopic retrograde cholangiography, sphincterotomy, and basket removal of stones. Mechanical lithotripsy was performed for stones of large size (>15 mm diameter) that precluded extraction intact. Success was defined as complete clearance of the duct. Various predictive factors, including size and number of stones, stone impaction, serum bilirubin, presence of cholangitis, and bile duct diameter were analyzed in relation to the success or failure of lithotripsy.

RESULTS

A total of 669 patients underwent endoscopic retrograde cholangiography for suspected choledocholithiasis, which was found in 401 patients. Of the latter patients, 87 had large stones that required mechanical lithotripsy. Lithotripsy was successful in 69 (79%) patients. Impaction of the stone(s) in the bile duct was the only significant factor that predicted failure of lithotripsy and consequent failure of bile duct clearance. Other factors, including stone size, were not significant.

CONCLUSIONS

Mechanical lithotripsy is successful in about 79% of patients with large bile duct stones. The only significant factor that predicts failure of mechanical lithotripsy is stone impaction in the bile duct.

Clinical application of a new disposable lithotripter: a prospective multicenter study

BACKGROUND

Mechanical lithotripsy has become a well-accepted method of bile duct stone fragmentation and removal. The Olympus lithotripter (Olympus American, Melville, NY) is the standard reusable lithotripter at the institutions that participated in this study. A disposable device with a preassembled pistol grip may perform equally well and facilitate operation.

METHODS

Twenty patients with bile duct stones were evaluated as part of a multicenter prospective study. Data were obtained regarding stone size and number, bile duct diameter, and configuration, ease of cannulation, basket function, stone capture and crushing success, and complications.

RESULTS

The maximum stone size averaged 16.5 +/- 1.2 mm (range 10 to 30 mm). Sixteen patients had multiple stones (median 5, range 2 to 12). The mean bile duct diameter was 20.5 +/- 1.5 mm (range 12 to 38 mm). Cannulation was successful in all within 5 attempts. Basket deployment failed in 1 patient because of stone size and the basket was misshapen in 14. Bile duct clearance was complete in 16 subjects (80%), incomplete in 2 patients, and failed in 2 patients. Abnormal duct configuration (sigmoid, stricture) was noted in 2 of 4 patients with failed capture and 7 of 16 patients with successful clearance. No statistically significant difference was observed between the bile duct diameter, maximum stone size, number of stones, and successful clearance.

CONCLUSION

The disposable lithotripter is easy to use and, compared with the published results for the reusable lithotripter, performs almost as well.

Detectability and appearance of bile duct calculus on MR imaging of the abdomen using axial T1- and T2-weighted sequences

This is a retrospective study with the objective of assessing the appearance and detectability of bile duct calculi on axial abdominal magnetic resonance imaging (MRI). Axial spin-echo (SE) T1-weighted and Turbo-spin-echo (TSE) T2-weighted images of the upper abdomen of 23 patients suffering from acute cholangitis with known bile duct calculi were retrospectively analysed. Bile duct calculi could be visualized on a T1-weighted SE sequence in 10 (47%) patients. T2-weighted TSE images identified bile duct calculi in 20 (87%) patients. On the T1-weighted sequence, eight out of 10 (80%) visualized common duct stones were slightly hyperintense compared to bile. On T2-weighted sequence, 27 out of 34 (79%) detectable common duct stones were uniformly hypointense compared to bile, but seven stones (21%) had mixed signal intensity.

The management of problematic biliary calculi

Recent advances in modern medical technology have significantly reduced the number of patients with 'problematic calculi'. When a patient does present with a difficult bile duct stone, various non-surgical treatment options are now available. In experienced hands, with healthy or high-risk patients, percutaneous treatment is as safe and as efficacious as endoscopy or surgery. Since it does not require general anaesthesia, and patients recover much more quickly than after surgery, the percutaneous approach is preferred when endoscopy fails to achieve ductal clearance. Surgery is indicated for patients with lesions requiring surgical removal or correction, but seldom for removal of biliary calculi alone.

Mechanical lithotripsy of large common bile duct stones using a basket

Experience with the Olympus basket mechanical lithotriptor (BML-1Q) in crushing large common bile duct stones before their endoscopic removal is reported. From January 1988 to January 1990, 68 patients with common duct stones too large to be extracted by Dormia baskets or balloon catheters after sphincterotomy were treated with the BML system. The largest stones in each patient ranged from 1.0 to 4.9 cm in diameter. Fifty-seven patients required one session of lithotripsy, ten patients two sessions and one patient three sessions; 26 patients required further endoscopic extraction of stone fragments after successful lithotripsy. The stones were successfully crushed by the BML system and the ducts cleared in 55 patients (81 per cent). In 13 patients mechanical lithotripsy failed because the stones could not be engaged in the lithotriptor basket. In one patient the stone was crushed with the Soehendra lithotriptor, six patients were successfully managed by electrohydraulic lithotripsy through a 'mother and baby' endoscope, indwelling stents were inserted in four patients and two patients underwent surgery.

Endoscopic management of bile duct stones at Riyadh Military Hospital: An eight-year experience

Over a period of eight years, 161 Saudi patients with biliary stones underwent 200 endoscopic retrograde cholangiopancreatographic studies at the Armed Forces Hospital, Riyadh, Saudi Arabia. Endoscopic sphincterotomy was performed in 93.2% of these patients and not attempted in the remainder who were referred for surgery because of biliary stones in both the common bile duct and gallbladder. All patients were symptomatic and the most common presenting symptom was biliary colic, seen in 42.2% of these patients. Either acute gallstone pancreatitis or cholangitis was seen in 14.2%, and this resolved completely following gallstone extraction. Endoscopic extraction of common bile duct stones was successful in 138 (85.7%) patients. Failure of stone extraction occurred in nine patients, three of whom received extracorporeal shockwave lithotripsy, which was successful in only one. Complications from endoscopic sphicterotomy and stone extractions occurred in 12 patients, of which bleeding was the most common.

Extracorporeal shock wave lithotripsy for bile duct stones: an Australian experience

Choledocholithiasis requires prompt therapy, particularly if complicated by ascending cholangitis. Endoscopic sphincterotomy with balloon and basket extraction clears the bile duct in 90% of patients. Failure is usually associated with large stones, that is, greater than 2 cm. Until recently such patients would have required surgical intervention. In 1986 St Vincent's Hospital installed a Dornier HM3 Lithotriptor to be used for both urinary tract and bile duct calculi. A retrospective analysis of patients referred for extracorporeal shock wave lithotripsy (ESWL) to bile duct stones was performed. There were 47 patients (28 female, 19 male) with an average age of 76 years. Twenty-two patients had a single stone with a mean diameter of 2.4 cm and 25 had multiple stones. In two patients the stone was not able to be visualized, so ESWL could not be performed. Complete stone clearance was achieved without further intervention in 13 patients, and in a further 23 after endoscopic extraction of fragments. In five patients only partial duct clearance was achieved. However, this provided palliation and enabled the patient to be discharged. Surgical intervention was required in the remaining four cases. Overall success rate was 80% with a further 11% being palliated with improved biliary drainage. There were no serious adverse effects from ESWL. All patients were discharged from hospital. Mortality at 30 days was 4.7% and at 6 months was 19.4%. One patient succumbed to ascending cholangitis 22 weeks post-ESWL (2.7%). All other deaths were unrelated to ESWL or biliary disease. We conclude that ESWL is a safe and effective treatment for bile duct stones not amenable to endoscopic extraction.

Frontiers of biliary endoscopy

The value of endoscopic retrograde cholangiography has been expanded recently by attention to technical detail and new methods for tissue diagnosis. Diagnostic information has been complemented by the new techniques of peroral choledochoscopy and endoscopic ultrasonography. The indications for endoscopic management of bile duct stones have become clearer, especially in patients with the gallbladder in situ. Techniques for distintegration and removal of large stones have improved. In patients with benign and malignant strictures recent emphasis has focused on the role of endoscopic management when compared with percutaneous and surgical approaches. Expandable metal stents are an interesting new option. The latest frontier is the gallbladder, which can now be reached with endoscopic catheters, and even directly with choledochoscopes through the papilla.

Non-admission or non-invitation? A case-control study of failed admissions

OBJECTIVE

To examine the causes of non-admission to hospital.

DESIGN

Validation of published rates of non-admission by examination of medical records, followed by a case-control study of non-attenders (cases) and attenders (controls).

SETTING

General hospital.

SUBJECTS

246 Patients (cases in the case-control study) booked for admissions in four specialties (general surgery, gynaecology, otorhinolaryngology, and trauma and orthopaedics) during April, May, and June 1987 who were not admitted for reasons that seemed to be attributable to the patients. Controls comprised 167 patients admitted to the same specialty on the same day.

RESULTS

The validation of administrative records indicated that it is unusual for patients to fail to present for admission without advising the hospital beforehand; this occurred in only 1-3% of all bookings. Information on the circumstances of non-admission and clinical and personal details were collected by means of a six page questionnaire completed by the patients. The case-control study showed that those not admitted were younger and had been on the waiting list longer. Otherwise only small differences were found in the social and clinical characteristics.

CONCLUSIONS

Despite a common tendency to blame patients for non-admission, factors due to patients are fairly unimportant.

Electrohydraulic lithotripsy with peroral choledochoscopy

OBJECTIVE

To determine the efficacy of peroral electrohydraulic lithotripsy performed with an extra large duodenoscope (outside diameter 14.8 mm) and a choledochoscope with a diameter of 4.1 mm (Olympus "mother and baby" endoscope system) in the removal of very large stones from the common bile duct.

DESIGN

Prospective study of patients with giant stones in the common bile duct that were resistant to extraction by conventional means.

SETTING

Endoscopy unit at a university hospital.

PATIENTS

Four women and one man aged 48-82 (mean 66.4 years) with a total of nine stones in their common bile ducts ranging from 2.2 to 3.6 cm in diameter.

INTERVENTIONS

Peroral electrohydraulic lithotripsy was performed after intravenous sedation and under antibiotic cover. Two endoscopists took part in each procedure, coordination being achieved by means of a video monitor. The procedures were performed with a Lithotron EL-23 lithotripter and a 3 French lithotripsy probe inserted through the choledochoscope under direct vision.

MAIN OUTCOME MEASURE

Complete clearance of the common bile duct confirmed by occlusion cholangiography.

RESULTS

All nine stones (mean minimal diameter 2.6 cm; mean maximal diameter 3.1 cm) were successfully fragmented by electrohydraulic lithotripsy, allowing subsequent extraction with the aid of endoscopy and clearance of the common bile duct. A median of three (range two to five) sessions of endoscopic retrograde cholangiopancreatography were required to achieve complete clearance of the ducts. Patients stayed a median of eight days in hospital after lithotripsy (range eight to 14). There were no complications.

CONCLUSION

Peroral electrohydraulic lithotripsy offers a safe and effective alternative for the management of patients with large stones in the common bile duct.

Endoscopic management of bile duct stones

Endoscopic sphincterotomy is the procedure of choice for choledocholithiasis in patients who have had a cholecystectomy. The bile duct is cleared of stones in about 80 to 90 percent of patients. Available data, largely retrospective, suggest that surgery and endoscopic sphincterotomy are about equal with respect to removal of stones, morbidity, and mortality. Certain technical problems are discussed, including inability to insert the papillotome, the large stone, and problems relating to anatomy such as peripapillary diverticulum and prior gastrectomy. The treatment of patients with bile duct stones who have not had a cholecystectomy, with and without cholelithiasis, is controversial. Endoscopic sphincterotomy without subsequent cholecystectomy is adequate treatment for the majority of patients who are unfit for surgery, even if there are stones in the gallbladder, provided they are asymptomatic after endoscopic removal of stones from the bile ducts. Endoscopic sphincterotomy has been performed in the treatment of gallstone-induced pancreatitis, acute obstructive cholangitis, and sump syndrome. The complication rate for endoscopic sphincterotomy ranges from 6.5 to 8.7 percent, with a mortality rate of 0 to 1.3 percent. The most common serious complications are perforation, hemorrhage, acute pancreatitis, and sepsis.