Non-surgical removal of common bile duct stones

Impaction of a lithotripsy basket during endoscopic lithotomy of a common bile duct stone

The treatments for common bile duct (CBD) stones are being continually developed. Impaction of the lithotripsy basket during endoscopic removal of CBD stones was seen in 5.9% patients. We report the case of a 66-year-old woman who underwent surgery for the removal of an impacted biliary basket. She was admitted to our hospital with a complaint of right upper abdominal pain. Magnetic resonance cholangiopancreatography revealed a CBD stone (20 mm × 15 mm). We diagnosed her with choledocholithiasis and performed endoscopic retrograde cholangiopancreatography to remove the stone. However, unfortunately, the retrievable basket around the stone became impacted. An endotriptor along with forceps could not be used owing to the entrapment of the basket, and thus we performed urgent surgery. The basket containing the stone was removed through a longitudinal choledochotomy. The wires leading to the basket were cut, and the basket containing the stone was removed via the incision. A T-tube was inserted, and the choledochotomy was closed. The postoperative course was uneventful. In conclusion, if the diameter of a CBD stone is more than 20 mm, then the risk of basket impaction increases, and surgery may be necessary as the initial treatment of the CBD stone.

Technical problem: impacted retained distal common duct stone

We report a three-stage technique for use when impacted, retained distal common bile duct stones are encountered. It minimises instrumentation of the ampullary region during any one interventional session, provides drainage of biliary and pancreatic ducts between sessions and, in our opinion, maximises the chances of safely extracting such a stone.

Endoscopic retrograde cholangiopancreatography, endoscopic sphincterotomy, and biliary drainage

Endoscopic retrograde cholangiopancreatography, endoscopic sphincterotomy, and endoscopic biliary drainage have dramatically changed the diagnosis and management of disorders of the pancreas and hepatobiliary tract. Endoscopic retrograde cholangiopancreatography will provide a high-resolution study that will define accurately the nature and location of the disease process involving the pancreas or bile ducts. Although sonography, CT, and, recently, MRI may provide clues to the diagnosis, it often remains for endoscopic retrograde cholangiopancreatography to establish the diagnosis with certainty. Endoscopic sphincterotomy has been invaluable in the management of common bile-duct stones. In patients who have had their gallbladders removed, sphincterotomy has avoided reoperation in the same field and the risk of general anesthesia. Sphincterotomy also is assuming an increasingly important role in the management of common-duct stones in patients with their gallbladders in situ who are poor operative candidates. In these patients, sphincterotomy likewise avoids the risk of general anesthesia and the surgical stress of opening a major body cavity. The technique has also proved to be helpful in the palliative treatment of ampullary and distal common bile-duct carcinomas in those patients who are poor operative candidates. Finally, sphincterotomy has found a role in the treatment of choledochal cysts and may provide relief of pain in those patients with the elusive diagnoses of postcholecystectomy syndromes, biliary dyskinesias, and sphincter of Oddi dysfunction. Endoscopic biliary drainage is becoming an increasingly popular option for the palliation of malignant biliary obstruction. In those patients who are poor operative candidates, the risk of general anesthesia and major surgery is avoided. In those patients with obviously incurable tumors, endoscopic drainage allows for a brief hospitalization without surgery in the face of a short life expectancy.

Large gallstones may pass spontaneously

We report two cases in which gallstones greater than 1 cm in diameter passed spontaneously from the common bile duct into the duodenum. The possibility of spontaneous passage should be borne in mind in the management of patients with common duct stones.

Percutaneous antegrade electropapillotomy. Study in dogs

Antegrade electropapillotomy using the percutaneous transcystic approach was successfully performed in 11 of 16 dogs. When the intervention was effective, the pressure gradient between common bile duct and duodenum decreased from 6 to 1.3 mm Hg on average and returned to gradients slightly below the initial values after 4 weeks, owing to reactivation of the sphincter mechanism. Ineffective cutting, however, resulted in a temporary pressure rise. In one dog a papillary stenosis developed and was relieved by antegrade electrocutting. Irrespective of the success of the papillotomy, rises in levels of serum glutamine oxaloacetic and pyruvic transaminase, alkaline phosphatase, serum amylase and leukocytes were seen. Although the method is technically feasible, its clinical significance is not so much for antegrade papillotomy but rather for transhepatic incision of stenoses after hepaticojejunostomy.

Cholangiography in rabbits before and after papillotomy

The gallbladder and the function of the sphincter of Oddi were studied after papillotomy (EPT) in New Zealand white rabbits. Intravenous cholangiography (IVC) was performed before and after papillotomy. After papillotomy, IVC showed gallbladder opacification in one of seven test animals, whereas gallbladder filling occurred in all six control animals. The bile ducts were not visualized in any of the test animals, whereas five of six controls showed contrast filling of the bile ducts. Reflux cholangiography was performed after EPT and showed free reflux of contrast from the duodenum to the bile ducts. These findings indicate that papillotomy results in the insufficiency of the sphincter mechanism of the ampulla of Vater, and hence intravenous cholangiography may not be valid for showing the gallbladder and the bile ducts after papillotomy.

Management of stones in the biliary tree

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Gallbladder and duodenal bacterial flora after papillotomy in rabbits

Gallbladder and duodenal bacteria were studied in New Zealand white rabbits 1 and 4 weeks after papillotomy. The gallbladder bile was sterile in all animals before papillotomy. One and 4 weeks after papillotomy growth of both aerobic and anaerobic bacteria was found in the gallbladder bile in five of eight test animals and in none of the control rabbits. The number of bacteria in the duodenum increased in rabbits that developed growth of bacteria in the gallbladder bile after papillotomy. In the test rabbits that did not develop bacteria in the gallbladder bile and in the control group no changes in duodenal bacteria were observed.

Endoscopic papillotomy in the treatment of biliary tract disease: 258 procedures and results

Endoscopic papillotomy has been successfully performed in 258 of 267 patients (96.6%) presenting with common duct stones, papillary stenosis, or ampullary adenocarcinoma. A low morbidity was experienced (5%) while mortality was 0.77% (2 deaths). Surgical intervention was necessary in 2 patients. The mean age of the group is 66.4 years (range 26-95 years), while the mean hospital stay remains low at 3 days (range 1-12) days. The procedure has proven to be safe and effective, creating a permanent biliary enteric fistula comparable to standard surgical procedures, but does not require a laparotomy/duodenotomy. Eliminating the latter reduces morbidity, immobility, and convalescence. Papillotomy is not a procedure to be performed by inexperienced endoscopists as it is the only endoscopic procedure with predictable morbidity and mortality. In order to maintain the progress achieved to date, papillotomy should be performed by those with extensive endoscopic experience in the diagnostic area before embarking onto the therapeutic procedure.

Dissolution of retained duct stones by perfusion with monooctanoin via a Teflon catheter introduced endoscopically

Retained bile duct stones in patients who have undergone prior cholecystectomy are removed by operation or endoscopic sphincterotomy. We achieved dissolution of cholesterol duct stones by perfusion with monooctanoin, a commercially available mixture of medium chain glycerides. Sixteen patients were treated in whom endoscopic sphincterotomy was impossible or unsuccessful. In 12 patients, 16 stones were dissolved within 6 to 25 days (mean, 15.6 days). In all successfully treated patients elevated serum liver enzymes became normal during therapy.

Retained and recurrent bile duct stones. Surgical or nonsurgical removal?

An experience with 69 patients who underwent 72 common bile duct reoperations for retained or recurrent choledocholithiasis is presented. The mean age of the patients was 57 years, and 35 patients had associated conditions. In this series six patients (8.3%) had minor complications and no patient developed major complications or died. Two (2.9%) patients developed recurrent choledocholithiasis. In recent years, nonoperative removal of retained stones through a T-tube by mechanical extraction or chemical dissolution, and removal of retained or recurrent stones by endoscopic sphincterotomy has gained widespread popularity. Retained or recurrent choledocholithiasis should be managed on an individual basis. Reoperation has a good success rate, low morbidity and mortality rates. It should be considered as the treatment of choice in low risk patients, in whom a retained stone cannot be mechanically extracted through a T-tube, and in patients with recurrent choledocholithiasis diagnosed after removal of the T-tube.

Endoscopic papillotomy in the geriatric patient with complicated biliary-tract disease

Biliary-tract disease is not only more common in the geriatric population but carries an increased surgical risk. Described is a series of 10 middle-aged and elderly patients who had stones in the common bile duct associated with significant underlying medical illness or peri-ampullary pathologic changes. They were successfully treated by endoscopic papillotomy. The 80 percent success rate in such critically ill patients suggests that endoscopic papillotomy might be used as the initial treatment modality in aging patients with amenable biliary-tract disease.

Recurrent choledocholithiasis following cholecystectomy, sphincterotomy and choledochoduodenostomy: successful treatment with chenodeoxycholic acid

An elderly woman presented with recurrent choledocholithiasis. She had had three prior surgical procedures on the biliary tract, including a cholecystectomy with common duct exploration, a second common duct exploration with choledocholithotomy and sphincteroplasty, and subsequently a third common duct exploration with choledochoenterostomy. She refused further surgical therapy and chenodeoxycholic acid therapy was instituted. Within six months, there was partial dissolution of the gallstones. One year later, the stones were not longer demonstrable, and the patient was symptom-free. The potential role of chenodeoxycholic acid therapy, endoscopic papillotomy and postoperative extraction of common duct stones via the T-tube tract, using a Dormia basket, as alternates to surgical therapy of recurrent or retained gallstones are discussed.

Diathermy ERCP: an alternative method for endoscopic retrograde cholangiopancreatography (ERCP) in jaundiced patients

Standard ERCP was unsuccessful in 5 jaundiced patients. This problem was surmounted in 4 of these patients by endoscopically inducing a small choledochoduodenal fistula through which a catheter could be inserted and diagnostic cholangiograms were obtained. In the fifth patient, the attempt to create a fistula was insufficient, and the contrast material infiltrated the duodenal wall with transient ensuing fever. In subsequent observations, the induced fistulas promptly healed. The method is offered as an alternative procedure when standard ERCP fails.

What is involved in endoscopic sphincterotomy for gallstones?

This study reports our first year's experience of endoscopic sphincterotomy for common bile duct stones. Forty patients were considered for the procedure and it was attempted in 37. An effective endoscopic sphincterotomy was eventually achieved in 32 (86 cases per cent), 7 after a "pre-cut". Twenty-three patients passed stones spontaneously (72 per cent), 6 could not be reassessed and 3 still had stones present (9 per cent). Bed occupancy was 9.5 +/- 5.9 days. Complications occurred in 30 per cent, the most common being pancreatitis in 6 cases with 1 death. It is concluded that endoscopic sphincterotomy offers a valuable alternative to surgery in the management of common bile duct stones.

The non-operative management of gallstones

During the last decade the non-surgical management of gallbladder stones has become possible. Oral chenodeoxycholic acid (CDCA) and more recently, ursodeoxycholic acid (UDCA), have proved to be safe and effective. For the treatment of bile duct stones, various methods including flushing, chemical dissolution and mechanical procedures are now available. A combination of these techniques can be used in a logical sequence and should enable the successful treatment of most patients with bile ducts stones.

Non-operative treatment of retained bile duct calculi in patients with an indwelling T tube

The results of combined instrumental and chemical treatment of retained bile duct calculi in 18 patients with an indwelling T tube are reported. The instrumental extraction of stones was carried out through the T tube channel using a modified Dormia apparatus. The chemical method involved continuous infusion through the T tube of heparin in saline alternating with sodium cholate. The treatment was successful in 16 of 18 patients with from 1 to 14 residual stones. The instrumental extraction of stones is recommended as the treatment of choice 5--6 weeks after choledochotomy in patients with residual stones and an indwelling T tube. Subsequent chemical treatment is recommended if remnants of stones are left in the bile duct after instrumental treatment.