AIM: To evaluate the role of endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis in patients with sickle cell anemia (SCA) in the era of laparoscopic cholecystectomy (LC).
METHODS: Two hundred and twenty four patients (144 male, 80 female; mean age, 22.4 years; range, 5-70 years) with SCA underwent ERCP as part of their evaluation for cholestatic jaundice (CJ). The indications for ERCP were: CJ only in 97, CJ and dilated bile ducts on ultrasound in 103, and CJ and common bile duct (CBD) stones on ultrasound in 42.
RESULTS: In total, CBD stones were found in 88 (39.3%) patients and there was evidence of recent stone passage in 16. Fifteen were post-LC patients. These had endoscopic sphincterotomy and stone extraction. The remaining 73 had endoscopic sphincterotomy and stone extraction followed by LC without an intraoperative cholangiogram.
CONCLUSION: In patients with SCA and cholelithiasis, ERCP is valuable whether preoperative or postoperative, and in none was there a need to perform intraoperative cholangiography. Sequential endoscopic sphincterotomy and stone extraction followed by LC is beneficial in these patients. Endoscopic sphincterotomy may also prove to be useful in these patients as it may prevent the future development of biliary sludge and bile duct stones.
Sickle cell anemia; Cholelithiasis; Choledocholithiasis; Laparoscopic cholecystectomy; Cholangiography; Endoscopic retrogradecholangiopancreatography
AIM: To address endoscopic outcomes of post-Orthotopic liver transplantation (OLT) patients diagnosed with a “redundant bile duct” (RBD).
METHODS: Medical records of patients who underwent OLT at the Liver Transplant Center, University Texas Health Science Center at San Antonio Texas were retrospectively analyzed. Patients with suspected biliary tract complications (BTC) underwent endoscopic retrograde cholangiopancreatography (ERCP). All ERCP were performed by experienced biliary endoscopist. RBD was defined as a looped, sigmoid-shaped bile duct on cholangiogram with associated cholestatic liver biomarkers. Patients with biliary T-tube placement, biliary anastomotic strictures, bile leaks, bile-duct stones-sludge and suspected sphincter of oddi dysfunction were excluded. Therapy included single or multiple biliary stents with or without sphincterotomy. The incidence of RBD, the number of ERCP corrective sessions, and the type of endoscopic interventions were recorded. Successful response to endoscopic therapy was defined as resolution of RBD with normalization of associated cholestasis. Laboratory data and pertinent radiographic imaging noted included the pre-ERCP period and a follow up period of 6-12 mo after the last ERCP intervention.
RESULTS: One thousand two hundred and eighty-two patient records who received OLT from 1992 through 2011 were reviewed. Two hundred and twenty-four patients underwent ERCP for suspected BTC. RBD was reported in each of the initial cholangiograms. Twenty-one out of 1282 (1.6%) were identified as having RBD. There were 12 men and 9 women, average age of 59.6 years. Primary indication for ERCP was cholestatic pattern of liver associated biomarkers. Nineteen out of 21 patients underwent endoscopic therapy and 2/21 required immediate surgical intervention. In the endoscopically managed group: 65 ERCP procedures were performed with an average of 3.4 per patient and 1.1 stent per session. Fifteen out of 19 (78.9%) patients were successfully managed with biliary stenting. All stents were plastic. Selection of stent size and length were based upon endoscopist preference. Stent size ranged from 7 to 11.5 Fr (average stent size 10 Fr); Stent length ranged from 6 to 15 cm (average length 9 cm). Concurrent biliary sphincterotomy was performed in 10/19 patients. Single ERCP session was sufficient in 6/15 (40.0%) patients, whereas 4/15 (26.7%) patients needed two ERCP sessions and 5/15 (33.3%) patients required more than two (average of 5.4 ERCP procedures). Single biliary stent was sufficient in 5 patients; the remaining patients required an average of 4.9 stents. Four out of 19 (21.1%) patients failed endotherapy (lack of resolution of RBD and recurrent cholestasis in the absence of biliary stent) and required either choledocojejunostomy (2/4) or percutaneous biliary drainage (2/4). Endoscopic complications included: 2/65 (3%) post-ERCP pancreatitis and 2/10 (20%) non-complicated post-sphincterotomy bleeding. No endoscopic related mortality was found. The medical records of the 15 successful endoscopically managed patients were reviewed for a period of one year after removal of all biliary stents. Eleven patients had continued resolution of cholestatic biomarkers (73%). One patient had recurrent hepatitis C, 2 patients suffered septic shock which was not associated with ERCP and 1 patient was transferred care to an outside provider and records were not available for our review.
CONCLUSION: Although surgical biliary reconstruction techniques have improved, RBD represents a post-OLT complication. This entity is rare however, endoscopic management of RBD represents a reasonable initial approach.
Redundant bile duct; Orthotopic liver transplantation; Biliary complications; Biliary stent; Endoscopic retrograde cholangiopancreatography
AIM: To compare diagnostic sensitivity, specificity and accuracy of magnetic resonance cholangiopancreatography (MRCP) without contrast medium and endoscopic ultrasound (EUS)/endoscopic retrograde cholangiopancreatography (ERCP) for biliary calculi.
METHODS: From January 2012 to December 2013, two-hundred-sixty-three patients underwent MRCP at our institution, all MRCP procedure were performed with the same machinery. In two-hundred MRCP was done for pure hepatobiliary symptoms and these patients are the subjects of this study. Among these two-hundred patients, one-hundred-eleven (55.5%) underwent ERCP after MRCP. The retrospective study design consisted in the systematic revision of all images from MRCP and EUS/ERCP performed by two radiologist with a long experience in biliary imaging, an experienced endoscopist and a senior consultant in Hepatobiliopancreatic surgery. A false positive was defined an MRCP showing calculi with no findings at EUS/ERCP; a true positive was defined as a concordance between MRCP and EUS/ERCP findings; a false negative was defined as the absence of images suggesting calculi at MRCP with calculi localization/extraction at EUS/ERCP and a true negative was defined as a patient with no calculi at MRCP ad at least 6 mo of asymptomatic follow-up. Biliary tree dilatation was defined as a common bile duct diameter larger than 6 mm in a patient who had an in situ gallbladder. A third blinded radiologist who examined the MRCP and ERCP data reviewed misdiagnosed cases. Once obtained overall data on sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) we divided patients in two groups composed of those having concordant MRCP and EUS/ERCP (Group A, 72 patients) and those having discordant MRCP and EUS/ERCP (Group B, 20 patients). Dataset comparisons had been made by the Student’s t-test and χ2 when appropriate.
RESULTS: Two-hundred patients (91 men, 109 women, mean age 67.6 years, and range 25-98 years) underwent MRCP. All patients attended regular follow-up for at least 6 mo. Morbidity and mortality related to MRCP were null. MRCP was the only exam performed in 89 patients because it did show only calculi into the gallbladder with no signs of the presence of calculi into the bile duct and symptoms resolved within a few days or after colecistectomy. The patients remained asymptomatic for at least 6 mo, and we assumed they were true negatives. One hundred eleven (53 men, 58 women, mean age 69 years, range 25-98 years) underwent ERCP following MRCP. We did not find any difference between the two groups in terms of race, age, and sex. The overall median interval between MRCP and ERCP was 9 d. In detecting biliary stones MRCP Sensitivity was 77.4%, Specificity 100% and Accuracy 80.5% with a PPV of 100% and NPV of 85%; EUS showed 95% sensitivity, 100% specificity, 95.5% accuracy with 100% PPV and 57.1% NPV. The association of EUS with ERCP performed at 100% in all the evaluated parameters. When comparing the two groups, we did not find any statistically significant difference regarding age, sex, and race. Similarly, we did not find any differences regarding the number of extracted stones: 116 stones in Group A (median 2, range 1 to 9) and 27 in Group B (median 2, range 1 to 4). When we compared the size of the extracted stones we found that the patients in Group B had significantly smaller stones: 14.16 ± 8.11 mm in Group A and 5.15 ± 2.09 mm in Group B; 95% confidence interval = 5.89-12.13, standard error = 1.577; P < 0.05. We also found that in Group B there was a significantly higher incidence of stones smaller than 5 mm: 36 in Group A and 18 in Group B, P < 0.05.
CONCLUSION: Major finding of the present study is that choledocholithiasis is still under-diagnosed in MRCP. Smaller stones (< 5 mm diameter) are hardly visualized on MRCP.
Biliary strictures; Magnetic resonance cholangiopancreatography; Biliary stones; Endoscopic retrograde cholangiopancreatography; Endoscopic ultrasound
Endoscopic sphincterotomy has become the first line treatment for patients with common bile duct (CBD) stones. This technique may fail, however, due to difficult anatomy, previous surgery, periampullary diverticula or the presence of a large stone. The importance of stone size to the success of endoscopic sphincterotomy has not been fully assessed. A prospective study was carried out over the period January 1987 to December 1989 on 100 patients (45 male, 55 female, median age 69 years, range 19-97) with CBD stones in which a policy of early duct clearance was followed. Endoscopic retrograde cholangiopancreatography (ERCP) was performed and the stone size and number recorded from the cholangiograms and corrected for magnification. Sphincterotomy was performed using a diathermy unit with a cutting current and stones were extracted using a balloon catheter or a Dormia basket. Of the 100 patients with CBD stones receiving ERCP, successful clearance of the biliary tree was possible in seven without endoscopic sphincterotomy and five were felt to be unsuitable for endoscopic sphincterotomy. Of the remaining 88 patients endoscopic sphincterotomy was successful in 75 (85%). Of the 75 patients having endoscopic sphincterotomy stone clearance was successful in 44 (59%). There were no deaths and only four complications, which rapidly resolved on conservative treatment (two acute pancreatitis, two bleeding). The number of CBD stones present was similar in those patients with successful endoscopic sphincterotomy and duct clearance (median 1, range 1-10, n = 44) as in those in whom it failed (median 2, range 1-6, n = 31). In contrast there was a highly significant difference when stone size was analysed (successful clearance median stone size 10 mm, range 3-27 mm; unsuccessful: median 18 mm, range 10-42, p<0.001). Stones less than 10 mm in diameter (n=21) were all removed successfully whereas in patients with stones over 15 mm (n=25) only three were removed endoscopically (12%). All patients with evidence of residual stones had additional treatment. Of these 31 patients, 10 had surgery, 11 had insertion of an endoprosthesis, and 10 had dissolution treatment with methyl-tert-butyl ether through a nasobiliary catheter. This study shows the importance of stone size to the success rate of endoscopic removal of bile duct stones.
AIM: To evaluate the efficacy and safety of endoscopic sphincterotomy (EST) + endoscopic papillary large balloon dilation (EPLBD) vs isolated EST.
METHODS: We conducted a retrospective single center study over two years, from February 2010 to January 2012. Patients with large (≥ 10 mm), single or multiple bile duct stones (BDS), submitted to endoscopic retrograde cholangio-pancreatography (ERCP) were included. Patients in Group A underwent papillary large balloon dilation after limited sphincterotomy (EST+EPLBD), using a through-the-scope balloon catheter gradually inflated to 12-18 mm according to the size of the largest stone and the maximal diameter of the distal bile duct on the cholangiogram. Patients in Group B (control group) underwent isolated sphincterotomy. Stones were removed using a retrieval balloon catheter and/or a dormia basket. When necessary, mechanical lithotripsy was performed. Complete clearance of the bile duct was documented with a balloon catheter cholangiogram at the end of the procedure. In case of residual lithiasis, a double pigtail plastic stent was placed and a second ERCP was planned within 4-6 wk. Some patients were sent for extracorporeal lithotripsy prior to subsequent ERCP. Outcomes of EST+EPLBD (Group A) vs isolated EST (Group B) were compared regarding efficacy (complete stone clearance, number of therapeutic sessions, mechanical and/or extracorporeal lithotripsy, biliary stent placement) and safety (frequency, type and grade of complications). Statistical analysis was performed using χ2 or Fisher’s exact tests for the analysis of categorical parameters and Student’s t test for continuous variables. A P-value of less than 0.05 was considered statistically significant.
RESULTS: One hundred and eleven patients were included, 68 (61.3%) in Group A and 43 (38.7%) in Group B. The mean diameter of the stones was similar in the two groups (16.8 ± 4.4 and 16.0 ± 6.7 in Groups A and B, respectively). Forty-eight (70.6%) patients in Group A and 21 (48.8%) in Group B had multiple BDS (P = 0.005). Overall, balloon dilation was performed up to 12 mm in 10 (14.7%) patients, 13.5 mm in 17 (25.0%), 15 mm in 33 (48.6%), 16.5 mm in 2 (2.9%) and 18 mm in 6 (8.8%) patients, taking into account the diameter of the largest stone and that of the bile duct. Complete stone clearance was achieved in sixty-five (95.6%) patients in Group A vs 30 (69.8%) patients in Group B, and was attained within the first therapeutic session in 82.4% of patients in Group A vs 44.2% in Group B (P < 0.001). Patients submitted to EST+EPLBD underwent fewer therapeutic sessions (1.1 ± 0.3 vs 1.8 ± 1.1, P < 0.001), and fewer required mechanical (14.7% vs 37.2%, P = 0.007) or extracorporeal (0 vs 18.6%, P < 0.001) lithotripsy, as well as biliary stenting (17.6% vs 60.5%, P < 0.001). The rate of complications was not significantly different between the two groups.
CONCLUSION: EST+EPLBD is a safe and effective technique for treatment of difficult BDS, leading to high rates of complete stone clearance and reducing the need for lithotripsy and biliary stenting.
Endoscopic papillary large balloon dilation; Bile duct stones; Endoscopic sphincterotomy; Choledocholithiasis
Less than 67% of patients with intermediate risk for common bile duct (CBD) stones require therapeutic intervention. It is important to have an accurate, safe, and reliable method for the definitive diagnosis of CBD stones before initiating therapeutic endoscopic retrograde cholangiopancreatography (ERCP). Few publications detail the diagnostic efficacy of linear echoendoscopy (EUS) for CBD stones.
30 patients with biliary colic, pancreatitis, unexplained derangement of liver function tests, and/or dilated CBD without an identifiable cause were enrolled in the study. When a CBD stone was disclosed by linear EUS, ERCP with stone extraction was performed. Patients who failed ERCP were referred for surgical intervention. If no stone was found by EUS, ERCP would not be performed and patients were followed-up for possible biliary symptoms for up to three months.
The major reason for enrollment was acute pancreatitis. The mean predicted risk for CBD stones was 47% (28–61). Of the 12 patients who were positive for CBD stones by EUS, nine had successful ERCP, one failed ERCP (later treated successfully by surgical intervention) and two were false-positive cases. No procedure-related adverse events were noted. For those 18 patients without evidence of CBD stones by EUS, no false-negative case was noted during the three-month follow-up period. Linear EUS had sensitivity, specificity, positive and negative predicted values for the detection of CBD stones of 1, 0.9, 0.8 and 1, respectively.
Linear EUS is safe and efficacious for the diagnosis of occult CBD stones in patients with intermediate risk for the disease.
Linear echoendoscope; Occult common bile duct stones
The value of serum liver function tests and abdominal ultrasound as screening tests of the need for endoscopic retrograde cholangiopancreatography (ERCP) was determined in patients with unexplained abdominal pain without associated jaundice. In 1989 and 1990 1005 ERCPs were undertaken, of which 138 (14%) were for this indication. The duct or ducts of interest were delineated by ERCP in 95% of patients. The lesions found were bile duct stones in 10 patients, chronic pancreatitis in five, pancreatic carcinoma in one, peptic ulcer or duodenitis in four. A satisfactory ultrasound examination had been performed in 94% of patients. For chronic pancreatitis, its sensitivity was 60% and specificity 95%. For choledocholithiasis, the ultrasonic detection of duct dilatation or stones had a sensitivity of 90% and specificity of 86%. Of the liver function tests, the alkaline phosphatase was more sensitive (67%) than the transaminases (44%) in indicating the presence of bile duct stones and had a high specificity (95%). None of the 10 patients with duct stones had normal ultrasound and normal alkaline phosphatase. Thus it was found that demonstration of a normal common bile duct by abdominal ultrasound and normal serum alkaline phosphatase together have 100% specificity in excluding bile duct stones. Using such knowledge over the two year period of this study would have spared 36 patients the need for ERCP.
To identify factors involved in choledocholithiasis, clinical characteristics were studied
using univariate and multivariate analyses. Factors involved in recurrence were also
investigated. The subjects consisted of 51 patients with calcium bilirubinate stones (B group) and 52 patients with cholesterol stones (C group). All patients had choledocholithiasis
and underwent lithotripsy by endoscopic sphincterotomy (EST) during the
past 9 years. Twenty variables, including clinical symptoms and endoscopic retrograde
cholangiopancreatography (ERCP) findings, were analyzed using a Statistical Analysis
System (SAS) software package. Univariate analysis were done using Student's t-test and
the chi-square test. Multivariate analyses were done by stepwise logistic regression
analysis. In univariate analyses, there were significant differences between the B group
and C group in nine variables: age, common bile duct diameter, common hepatic duct
diameter, common bile duct stone diameter, cystic duct diameter, and the presence of
gallbladder stones, atypical arrangement of the hepatic duct, parapapillary diverticulum,
and large parapapillary diverticulum. In multivariate analysis, the four variables of
no gallbladder stone, large parapapillary diverticulum, cystic duct less than 8 mm, and
atypical arrangement of the hepatic duct were significant independent factors for the
development of stones in the B group, with relative risks of 37.75, 16.73, 5.56, and 5.49,
respectively. The results indicated that calcium bilirubinate stones were frequently associated
with parapapillary diverticulum and abnormal arrangement of the bile duct. The
formation of these stones was attributed to chronic biliary stasis caused by dysfunction
of the biliary tract, including the papilla. In contrast, most cholesterol stones found in the
common bile duct had apparently descended from the gallbladder. Common bile duct
stones recurred after EST in 9 patients, all of whom had calcium bilirubinate stones. On
ERCP, recurrence was found to be frequently associated with gallbladder stones, large
parapapillary diverticula, and atypical arrangement of the hepatic duct. Patients with
these characteristics on initial ERCP should therefore receive appropriate treatment
and undergo strict follow-up observations owing to the increased risk of recurrence
caused by dysfunction of the biliary tract.
Background and study aims: Data on double-balloon enteroscopy (DBE)-assisted endoscopic retrograde cholangiopancreatogrphy (ERCP) in patients with Billroth II gastrectomy and the use of endoscopic papillary large-balloon dilation (EPLBD) for the removal of common bile duct stones in Billroth II anatomy are limited. The aims of the study were to evaluate the success of DBE-assisted ERCP in patients with Billroth II gastrectomy and examine the efficacy of EPLBD ( ≥ 10 mm) for the removal of common bile duct stones.
Patients and methods: A total of 77 patients with Billroth II gastrectomy in whom standard ERCP had failed underwent DBE-assisted ERCP. DBE success was defined as visualizing the papilla and ERCP success as completing the intended intervention. The clinical results of EPLBD for the removal of common bile duct stones were analyzed.
Results: DBE was successful in 73 of 77 patients (95 %), and ERCP success was achieved in 67 of these 73 (92 %). Therefore, the rate of successful DBE-assisted ERCP was 87 % (67 of a total of 77 patients). The reasons for ERCP failure (n = 10) included tumor obstruction (n = 2), adhesion obstruction (n = 2), failed cannulation (n = 3), failed stone removal (n = 2), and bowel perforation (n = 1). Overall DBE-assisted ERCP complications occurred in 5 of 77 patients (6.5 %). A total of 48 patients (34 male, mean age 75.5 years) with common bile duct stones underwent EPLBD. Complete stone removal in the first session was accomplished in 36 patients (75 %); mechanical lithotripsy was required in 1 patient. EPLBD-related mild perforation occurred in 2 patients (4 %). No acute pancreatitis occurred.
Conclusions: DBE permits therapeutic ERCP in patients who have a difficult Billroth II gastrectomy with a high success rate and acceptable complication rates. EPLBD is effective and safe for the removal of common bile duct stones in patients with Billroth II anatomy.
AIM: To present our experience with pregnant patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) without using radiation, and to evaluate the acceptability of this alternative therapeutic pathway for ERCP during pregnancy.
METHODS: Between 2000 and 2008, six pregnant women underwent seven ERCP procedures. ERCP was performed under mild sedoanalgesia induced with pethidine HCl and midazolam. The bile duct was cannulated with a guidewire through the papilla. A catheter was slid over the guidewire and bile aspiration and/or visualization of the bile oozing around the guidewire was used to confirm correct cannulation. Following sphincterotomy, the bile duct was cleared by balloon sweeping. When indicated, stents were placed. Confirmation of successful biliary cannulation and stone extraction was made by laboratory, radiological and clinical improvement. Neither fluoroscopy nor spot radiography was used during the procedure.
RESULTS: The mean age of the patients was 28 years (range, 21-33 years). The mean gestational age for the fetus was 23 wk (range, 14-34 wk). Five patients underwent ERCP because of choledocholithiasis and/or choledocholithiasis-induced acute cholangitis. In one case, a stone was extracted after precut papillotomy with a needle-knife, since the stone was impacted. One patient had ERCP because of persistent biliary fistula after hepatic hydatid disease surgery. Following sphincterotomy, scoleces were removed from the common bile duct. Two weeks later, because of the absence of fistula closure, repeat ERCP was performed and a stent was placed. The fistula was closed after stent placement. Neither post-ERCP complications nor premature birth or abortion was seen.
CONCLUSION: Non-radiation ERCP in experienced hands can be performed during pregnancy. Stent placement should be considered in cases for which complete common bile duct clearance is dubious because of a lack of visualization of the biliary tree.
Cholangitis; Choledocholithiasis; Endoscopic retrograde cholangiopancreatography; Jaundice; Pregnancy
The false-positive rates of a positive intraoperative cholangiogram (IOC) are as high as 60%. Endoscopic retrograde cholangiopancreatography (ERCP) for stone removal is required after a positive IOC. It is unclear which clinical factors identify patients most likely to have a stone after a positive IOC. This study was conducted to identify factors predictive of common bile duct (CBD) stone(s) on ERCP after a positive IOC. A retrospective review of our endoscopic database identified all ERCP and/or endoscopic ultrasound (EUS) procedures performed for a positive IOC between August 2003 and August 2009. Collected data included patient demographics; indication for cholecystectomy; IOC findings; blood tests before and after cholecystectomy, including liver function tests, complete blood count, and amylase and lipase measurements; and ERCP and/or EUS results. Patients who had a negative EUS for CBD stones and no subsequent ERCP were contacted by phone to see if they eventually required an ERCP. Univariate and multi-variable analyses were performed. A total of 114 patients were included in the study. IOC findings included a single stone, multiple stones, nonpassage of contrast into the duodenum, dilated CBD, and poor visualization of the bile duct. Eighty-four percent of patients had ERCP only, 9% had EUS only, and 7% had EUS followed by ERCP. Sixty-five patients (57%) had CBD stones on ERCP or EUS. Older age, multiple stones, dilated CBD on IOC, and elevated postcholecystectomy bilirubin levels were the clinical variables with statistically significant differences on univariate analysis. On multivariable analysis, older age and elevated postcholecystectomy total bilirubin levels correlated with the presence of CBD stones on ERCP. Fifty-seven percent of patients referred for endoscopic evaluation after a positive IOC had CBD stones on ERCP. Patients with CBD stones after a positive IOC were more likely to be older with elevated post-cholecystectomy total serum bilirubin levels.
Common bile duct stone; intraoperative cholangiogram; endoscopic retrograde cholangiopancreatogra-phy; endoscopic ultrasound
Background: Endoscopic sphincterotomy (ES) carries a substantial risk of recurrent choledocholithiasis but retreatment with endoscopic retrograde cholangiopancreatography (ERCP) is safe and feasible. However, long term results of repeat ERCP and risk factors for late complications are largely unknown.
Aims: To investigate the long term outcome of repeat ERCP for recurrent bile duct stones after ES and to identify risk factors predicting late choledochal complications.
Methods: Eighty four patients underwent repeat ERCP, combined with ES in 69, for post-ES recurrent choledocholithiasis. Long term outcomes of repeat ERCP were retrospectively investigated and factors predicting late complications were assessed by multivariate analysis.
Results: Complete stone clearance was achieved in all patients. Forty nine patients had no visible evidence of prior sphincterotomy. Two patients experienced early complications. During a follow up period of 2.2–26.0 years (median 10.9 years), 31 patients (37%) developed late complications, including stone recurrence (n = 26), acute acalculous cholangitis(n = 4), and acute cholecystitis (n = 1). There were neither biliary malignancies nor deaths attributable to biliary disease. Multivariate analysis identified three independent risk factors for choledochal complications: interval between initial ES and repeat ERCP ⩽5 years, bile duct diameter ⩾15 mm, and periampullary diverticulum. Choledochal complications were successfully treated with repeat ERCP in 29 patients.
Conclusions: Choledochal complications after repeat ERCP are relatively frequent but are endoscopically manageable. Careful follow up is necessary, particularly for patients with a dilated bile duct, periampullary diverticulum, or early recurrence. Repeat ERCP is a reasonable treatment even for recurrent choledocholithiasis after ES.
endoscopic sphincterotomy; endoscopic retrograde cholangiopancreatography; recurrent choledocholithiasis; bile duct stones
We describe a 66-year-old Caucasian man with type 1 Mirizzi syndrome diagnosed on endoscopic ultrasound. He presented with acute onset of jaundice, malaise, dark urine over 3–4 days, and was found to have obstructive jaundice on lab testing. CT scan of the abdomen showed intrahepatic biliary ductal dilation, a 1.5 cm common bile duct (CBD) above the pancreas, and possible stones in the CBD, but no masses. Endoscopic retrograde cholangiopancreatography (ERCP) by a community gastroenterologist failed to cannulate the CBD. At the University Center, type 1 Mirizzi syndrome was noted on endoscopic ultrasound with narrowing of the CBD with extrinsic compression from cystic duct stone. During repeat ERCP, the CBD could be cannulated over the pancreatic duct wire. A mid CBD narrowing, distal CBD stones, proximal CBD and extrahepatic duct dilation were noted, and biliary sphincterotomy was performed. A small stone in the distal CBD was removed with an extraction balloon. The cystic duct stone was moved with the biliary balloon into the CBD, mechanical basket lithotripsy was performed and stone fragments were delivered out with an extraction balloon. The patient was seen 7 weeks later in the clinic. Skin and scleral icterus had cleared up and he is scheduled for an elective cholecystectomy. Mirizzi syndrome refers to biliary obstruction resulting from impacted stone in the cystic duct or neck of the gallbladder and commonly presents with obstructive jaundice. Type 1 does not have cholecystocholedochal fistulas, but they present in types 2, 3 and 4. Surgery is the mainstay of therapy. Endoscopic treatment is effective and can also be used as a temporizing measure or definitive treatment in poor surgical risk candidates.
Mirizzi syndrome; Gallstone; Endoscopic ultrasound; Obstructive jaundice
Common bile duct (CBD) stones can cause serious morbidity or mortality, and evidence for them should be sought in all patients with symptomatic gallstones undergoing cholecystectomy. Routine intra-operative cholangiography (IOC) involves a large commitment of time and resources, so a policy of selective cholangiography was adopted. This study prospectively evaluated the policy of selective cholangiography for patients suspected of having choledocholithiasis, and aimed to identify the factors most likely to predict the presence of CBD stones positively.
PATIENTS AND METHODS
Data from 501 consecutive patients undergoing laparoscopic cholecystectomy (LC) for symptomatic gallstones, of whom 166 underwent IOC for suspected CBD stones, were prospectively collected. Suspicion of choledocholithiasis was based upon: (i) deranged liver function tests (past or present); (ii) history of jaundice (past or present) or acute pancreatitis; (iii) a dilated CBD or demonstration of CBD stones on imaging; or (iv) a combination of these factors. Patient demographics, intra-operative findings, complications and clinical outcomes were recorded.
Sixty-four cholangiograms were positive (39%). All indications for cholangiogram yielded positive results. Current jaundice yielded the highest positive predictive value (PPV; 86%). A dilated CBD on pre-operative imaging gave a PPV of 45% for CBD calculi; a history of pancreatitis produced a 26% PPV for CBD calculi. Patients with the presence of several factors suggestive of CBD stones yielded higher numbers of positive cholangiograms. Of the 64 patients having a laparoscopic common bile duct exploration (LCBDE), four (6%) required endoscopic retrograde cholangiopancreatography (ERCP) for retained stones (94% successful surgical clearance of the common bile duct) and one (2%) for a bile leak. Of the 335 patients undergoing LC alone, three (0.9%) re-presented with a retained stone, requiring intervention. There were 12 (7%) requiring conversion to open operation.
A selective policy for intra-operative cholangiography yields acceptably high positive results. Pre-operatively, asymptomatic bile duct stones rarely present following LC; thus, routine imaging of the biliary tree for occult calculi can safely be avoided. Therefore, a rationing approach to the use of intra-operative imaging based on the pre-operative indicators presented in this paper, successfully identifies those patients with bile duct stones requiring exploration. Laparoscopic bile duct exploration, performed by an experienced laparoscopic surgeon, is a safe and effective method of clearing the bile duct of calculi, with minimal complications, avoiding the necessity for an additional intervention and prolonged hospital stay.
Bile duct stones; Intra-operative imaging; Pre-operative indicators; Cholangiography
The aim of the present study was to assess the success and outcome of bile duct stent placement without the use of endoscopic biliary sphincterotomy (EBS).
Patients and Methods
Over a period of 10 years and 9 months, all patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) were prospectively identified. Bile duct stent placement was routinely done without EBS unless additional therapy (stone removal, multiple stenting) was anticipated.
Of 5020 patients who underwent ERCP, bile duct stents were placed in 1668 patients. After excluding those requiring additional endoscopic therapy, 1112 patients (89.5%) had ERCP and stent placement without a sphincterotomy and 130 patients (10.5%) had ERCP and stent placement with a sphincterotomy. Deployed endoprostheses were self-expandable metallic stents in 15.7% and plastic in 77.5%. Caliber of plastic stents was 10 Fr in 78.9% and <10 Fr in 21.1%. All stents were successfully placed in these 1112 patients without the need for EBS. Comparing patients undergoing bile duct stenting with and without sphincterotomy, no difference was seen in rates of pancreatitis (1.54% vs 2.07%, P > 0.9999).
Single bile duct stents, both plastic and metal, can be deployed without EBS.
bile duct stent; endoscopic biliary sphincterotomy (EBS); endoscopic retrograde cholangiopancreatography (ERCP); jaundice; pancreatitis
The aim of this study was to evaluate our experience with laparoscopic surgery in children with sickle cell disease.
A retrospective chart review was performed to analyze the indication for surgery, perioperative management, surgical technique, complications, duration of hospitalization, and outcome. One pediatric surgeon performed all procedures.
Thirteen children underwent laparoscopic surgery for the following indications: symptomatic cholelithiasis/cholecystitis in 9; recurrent splenic sequestration in 3; and hypersplenism/symptomatic cholelithiasis in 1. The 7 boys and 6 girls had a median age of 7.8 years. Patients undergoing splenectomy only were younger than those undergoing cholecystectomy (median age, 3.6 years versus 11.5 years, respectively). Four children underwent endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy because of common bile duct dilatation and stones. Twelve patients received packed red blood cell transfusions prior to surgery. The median operative time was 150 minutes, and the median hospitalization was 3 days. Four patients suffered postoperative complications (2 with acute chest syndrome, 1 with recurrent abdominal pain, and 1 with priapism). The patient with abdominal pain was found to have a retained stone in the common bile duct, which was retrieved via endoscopic retrograde cholangiopancreatography and sphincterotomy. All complications resolved with medical management.
Laparoscopic surgery is safe in children with sickle cell disease. Meticulous attention to perioperative management, transfusion guidelines, and pulmonary care may decrease the incidence of acute chest syndrome.
Sickle cell anemia; Laparoscopic surgery; Child; Adolescence
Since the advent of laparoscopic cholecystectomy, there has been controversy about the investigation of the bile ducts and the management of common bile duct stones. Routine peroperative cholangiography (POC) in all cases has been recommended. We have adopted a policy of not performing routine POC, and the results of 700 cases are reported.
Since 1990, all patients have undergone pre-operative ultrasound scan. We have performed selective preoperative endoscopic retrograde cholangiopancreatography (ERCP) because of a clinical history of jaundice and/or pancreatitis, abnormal liver function tests and ultra-sound evidence of dilated bile ducts (N=78, 11.1%). The remaining 622 patients did not have a routine POC, but selective peroperative cholangiogram (POC) was per-formed only in 42 patients (6%) because of unsuccessful ERCP or mild alteration in the criteria for the presence of bile duct stones. The remaining 580 patients did not undergo POC. Careful dissection of Calot's triangle was performed in all cases to reduce the risk of bile duct injuries.
The overall operative complications, postoperative morbidity and mortality was 1.71%, 2.14% and 0.43%, respectively. Bile duct injuries occurred in two patients (0.26%) and both were recognized during the operation and repaired. There was a single incidence of retained stone in this series of 700 cases (0.14%), which required postoperative ERCP.
This policy of selective preoperative ERCP, and not routine peroperative cholangiogram, is cost effective and not associated with significant incidence of retained stones or bile duct injuries after laparoscopic cholecystectomy.
Cholecystectomy; Laparoscopic; Cholangiography; Endoscopic retrograde cholangiography; Common bile duct calculi
The paucity of controlled data for the treatment of most biliary sphincter of Oddi disorder (SOD) types and the incomplete response to therapy seen in clinical practice and several trials has generated controversy as to the best course of management of these patients. In this observational study we aimed to assess the outcome of patients with biliary SOD managed without sphincter of Oddi manometry.
Fifty-nine patients with biliary SOD (14% type I, 51% type II, 35% type III) were prospectively enrolled. All patients with a dilated common bile duct were offered endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy whereas all others were offered medical treatment alone. Patients were followed up for a median of 15 months and were assessed clinically for response to treatment.
At follow-up 15.3% of patients reported complete symptom resolution, 59.3% improvement, 22% unchanged symptoms, and 3.4% deterioration. Fifty-one percent experienced symptom resolution/improvement on medical treatment only, 12% after sphincterotomy, and 10% after both medical treatment/sphincterotomy. Twenty percent experienced at least one recurrence of symptoms after initial response to medical and/or endoscopic treatment. Fifty ERCP procedures were performed in 24 patients with an 18% complication rate (16% post-ERCP pancreatitis). The majority of complications occurred in the first ERCP these patients had. Most complications were mild and treated conservatively. Age, gender, comorbidity, SOD type, dilated common bile duct, presence of intact gallbladder, or opiate use were not related to the effect of treatment at the end of follow-up (p > 0.05 for all).
Patients with biliary SOD may be managed with a combination of endoscopic sphincterotomy (performed in those with dilated common bile duct) and medical therapy without manometry. The results of this approach with regards to symptomatic relief and ERCP complication rate are comparable to those previously published in the literature in cohorts of patients assessed by manometry.
The use of endoscopic instruments other than the standard duodenoscope to access anatomical landmarks of the small bowel for certain procedures such as endoscopic retrograde cholangiopancreatography have met with limited success. The double-balloon enteroscope (DBE), however, has revolutionized the ability to access the small bowel, with indications for its use expanding. The DBE has been shown to be safe, effective and less invasive in patients with surgically altered upper gastrointestinal tracts compared with percutaneous transhepatic cholangiography or surgery. This article describes a retrospective review of 20 patients with previous small bowel reconstruction who underwent endoscopic retrograde cholangiopancreatography using a ‘short’ DBE at a major health sciences centre in Toronto, Ontario.
Endoscopic retrograde cholangiopancreatography (ERCP) remains a challenge for endoscopists in patients with surgically altered anatomy of the upper gastrointestinal tract. Double-balloon enteroscopes (DBEs) have revolutionized the ability to access the small bowel. The indication for its therapeutic use is expanding to include ERCP for patients who have undergone small bowel reconstruction. Most of the published experiences in DBE-assisted ERCP have used conventional double-balloon enteroscopes that are 200 cm in length, which do not permit use of the standard ERCP accessories. The authors report their experience with DBE-assisted ERCP using a ‘short’ DBE in patients with surgically altered anatomy.
A retrospective review of patients with previous small bowel reconstruction who underwent ERCP with a ‘short’ DBE at the Centre for Therapeutic Endoscopy and Endoscopic Oncology (Toronto, Ontario) between February 2007 and November 2008 was performed.
A total of 20 patients (10 men) with a mean age of 57.9 years (range 26 to 85 years) underwent 29 sessions of ERCP with a DBE. Six patients underwent Billroth II gastroenterostomy, seven patients Roux-en-Y hepaticojejunostomy, five patients Roux-en-Y gastrojejunostomy, one patient Roux-en-Y esophagojejunostomy and one patient a Whipple’s operation with choledochojejunostomy. Some patients (n=12 [60%]) underwent previous attempts at ERCP in which the papilla of Vater or bilioenteric anastomosis could not be reached with either a duodenoscope or pediatric colonoscope. All procedures were performed with a commercially available DBE (working length 152 cm, distal end diameter 9.4 mm, channel diameter 2.8 mm). The procedures were performed under conscious sedation with intravenous midazolam, fentanyl and diazepam, except in one patient in whom general anesthesia was administered. Either the papilla of Vater or bilioenteric anastomosis was reached in 25 of 29 cases (86.2%) in a mean duration of 20.8 min (range 5 min to 82 min). Bile duct cannulation was successful in 24 of 25 cases in which the papilla or bilioenteric anastomosis was reached. Therapeutic interventions were successful in 15 patients (24 procedures) including sphincterotomy (n=7), stone extraction (n=9), biliary dilation (n=8), stent placement (n=9) and stent removal (n=8). The mean total duration of the procedures was 70.7 min (range 30 min to 117 min). There were no procedure-related complications.
DBEs enable successful diagnostic and therapeutic ERCP in patients with a surgically altered anatomy of the upper gastrointestinal tract. It is a safe, feasible and less invasive therapeutic option in this group of patients. Standard ‘long’ DBEs have limitations of long working length and the need for modified ERCP accessories. ‘Short’ DBEs are equally as effective in reaching the target limb as standard ‘long’ DBEs, and overcomes some limitations of long DBEs to result in high success rates for endoscopic therapy.
Double-balloon enteroscope; ERCP; Surgically altered upper gastrointestinal tract
Anomalous biliary opening especially the presence of the ampulla of Vater in the duodenal bulb is a very rare phenomenon. We report clinical implications, laboratory and ERCP findings and also therapeutic approaches in 53 cases.
The data were collected from the records of 12.158 ERCP. The diagnosis was established as an anomalous opening of the common bile duct (CBD) into the duodenal bulb when there is an orifice observed in the bulb with the absence of a papillary structure at its normal localization and when the CBD is visualized by cholangiography through this orifice without evidence of any other opening.
A total of 53 cases were recruited. There was an obvious male preponderance (M/F: 49/4). Demographic data and ERCP findings were available for all, but clinical characteristics and laboratory findings could be obtained from 39 patients with full records. Thirty – seven of 39 cases had abdominal pain (95%) and 23 of them (59%) had cholangitis as well. Elevated AP and GGT were found in 97.4% (52/53). History of cholecystectomy was present in 64% of the cases, recurrent cholangitis in 26% and duodenal ulcer in 45%. Normal papilla was not observed in any of the patients and a cleft-like opening was evident instead. The CBD was hook shaped at the distal part that opens to the duodenal bulb. Pancreatic duct (PD) was opening separately into the bulb in all the cases when it was possible to visualize. Dilated CBD in ERCP was evident in 94% and the CBD stone was demonstrated in 51%. PD was dilated in four of 12 (33%) cases. None of them has a history of pancreatitis. Endoscopically, Papillary Balloon Dilatation instead of Sphincterotomy carried out in 19 of 27 patients (70%) with choledocholithiazis. Remaining eight patients had undergone surgery (30%). Clinical symptoms were resolved with medical treatment in 16(32%) patients with dilated CBD but no stone. Perforation and bleeding were occurred only in two patients, which stones extracted with sphincterotomy (each complication in 1 patient).
The opening of the CBD into the duodenal bulb is a rare event that may be associated with biliary and gastric/duodenal diseases. To date, surgical treatment has been preferred. In our experience, sphincterotomy has a high risk since it may lead to bleeding and perforation by virtue of the fact that a true papillary structure is absent. However, we performed balloon dilatation of the orifice successfully without any serious complication and suggest this as a safe therapeutic modality.
Options for managing the common bile duct during laparoscopic cholecystectomy include routine peroperative cholangiography and selected preoperative endoscopic retrograde cholangiopancreatography (ERCP). The use of these methods was reviewed in 350 patients with symptomatic gall stones referred for laparoscopic cholecystectomy. Unit A (n = 114) performed routine cystic duct cholangiography but undertook preoperative ERCP in patients at very high risk of duct stones only; unit B (n = 236) performed selected preoperative ERCP on the basis of known risk factors for duct stones. The detection rate for common bile duct stones was similar for units A and B (16% v 20%). In unit A, five of seven patients who had preoperative ERCP had duct stones. Operative cholangiography was technically successful in 90% of patients and duct stones were confidently identified in 13, one of whom went on to immediate open duct exploration. Postoperative ERCP identified duct stones in only four patients, indicating spontaneous passage in eight. In unit B, preoperative ERCP was undertaken in 76 of 236 (32%) patients and duct stones were identified in 47 (20%). Duct clearance was successful in 42 (18%) but failed in five (2%), necessitating elective open duct exploration. Both protocols for imaging the common bile duct worked well and yielded satisfactory short term results.
AIM: To assess the outcomes of ampulla dilation with different sized balloons to remove common bile duct (CBD) stones.
METHODS: Patients (n = 208) were divided into five groups based on the largest CBD stone size of < 5, 6-8, 8-12, 12-14, and > 14 mm. Patients underwent limited endoscopic sphincterotomy (EST) alone or limited EST followed by endoscopic papillary balloon dilation with 8, 10, 12 and 14 mm balloons, such that the size of each balloon did not exceed the size of the CBD. Short- and long-term outcomes, such as post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis, perforation, bleeding, and pneumobilia were compared among the five groups.
RESULTS: The overall rate of successful stone removal in all groups was 100%, and all patients were cured. Eight (3.85%) patients had post-ERCP pancreatitis, none had perforations, and 6 (2.9%) had bleeding requiring transfusion. There were no significant differences in early complication rates among the five groups. We observed significant correlations between increased balloon size and the short- and long-term rates of post-ERCP pneumobilia. Post-ERCP pancreatitis and bleeding correlated significantly with age, with post-ERCP pancreatitis occurring more frequently in patients aged < 60 years, and bleeding occurring more frequently in patients aged > 70 years. We observed a significant correlation between patient age and the diameter of the largest CBD stone, with stones > 12 mm occurring more frequently in patients > 60 years old.
CONCLUSION: Choosing a balloon size based on the largest stone diameter is safe and effective for removing CBD stones. Balloon size should not exceed 15 mm.
Endoscopic papillary balloon dilation; Endoscopic sphincterotomy; Common bile duct stone; Endoscopic retrograde cholangiopancreatography; Pancreatitis
Choledocholithiasis is the most common cause of obstructive jaundice. Common bile duct stones are observed in 10–14% of patients diagnosed with gall bladder stones. In the case of gall bladder and common bile duct stones the procedure involves not only performing cholecystectomy but also removing the stones from bile ducts.
To compare the results of the treatment of patients with gallstone disease and ductal calculi by one-stage laparoscopic cholecystectomy and common bile duct exploration with two other methods: one-stage open cholecystectomy and common bile duct exploration, and a two-stage procedure involving endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy.
Material and methods
Between 2004 and 2011 three groups of 100 patients were treated for obstructive jaundice caused by choledocholithiasis. The first group of 42 patients underwent ERCP followed by laparoscopic cholecystectomy. The second group of 23 patients underwent open cholecystectomy and common bile duct exploration, whereas the third group of 35 patients underwent laparoscopic cholecystectomy with common bile duct exploration. The data were analysed prospectively. The methods were compared according to complete execution, bile duct clearance and complication rate. Complications were analysed according to Clavien’s Classification of Surgical Complications. The results were compared using the ANOVA statistical test and Student’s t-test in Statistica. Value of p was calculated statistically. A p-value less than 0.05 (p < 0.05) signified that groups differed statistically, whereas a p-value more than 0.05 (p > 0.05) suggested no statistically significant differences between the groups.
The procedure could not be performed in 11.9% of patients in the first group and in 14.3% of patients in the third group. Residual stones were found in 13.5% of the patients in the first group, in 4.3% of the patients in the second group and in 6.7% of the patients in the third group. According to Clavien’s classification of complications grade II and III, we can assign the range in the first group at 21.6% for grade II and 0% for grade III, in the second group at 21.4% and 3.6% and in the third group at 6.7% and 3.3% respectively.
The use of all three methods of treatment gives similar results. One-stage laparoscopic cholecystectomy with common bile duct exploration is after all the least invasive, safer and more effective procedure.
common bile duct stones; laparoscopic exploration of the common bile duct; choledochotomy
AIM: To evaluate our experience in endoscopic retrograde cholangio-pancreatography (ERCP) in terms of fulfilling the ASGE guidelines in indications, positive findings, and complications in the post-magnetic resonance cholangiopancreatography (MRCP) era.
METHODS: Between November 2001 and February 2003, consecutive ERCP cases were prospectively evaluated with regard to the indications, findings, cannulation techniques, devices used during the procedure, sedation given, duration of procedure, and complications. These data were entered in a database for subsequent processing and analysis.
RESULTS: Of 336 cases, 21.4% were diagnostic and 78.6% therapeutic ERCP. The indications for ERCP fulfilled the ASGE guidelines in 323 cases (96.1%). Suspected bile duct stone was the most frequent indication (26.8%), and this was followed by cholangitis (24.4%), dilated common bile duct (14.9%), and cholestatic jaundice (13.4%). Cannulation success rate was 94%. Biliary sphincterotomy was performed in 175 (52.1%) patients. Repeated ERCP was performed on 31.5% of the patients. Overall, the complication rate was 9.8% with 0.3% being procedure-related mortality. The complications were pancreatitis (5.4%), bleeding (0.8%), cholangitis (2.4%) and others (1.5%). No significant difference was observed between the complication rate and the type of ERCP performed.
CONCLUSION: Our study showed that post-ERCP complication rate was comparable with the other large prospective studies and there was no difference in the complication between the diagnostic and therapeutic ERCP.
Endoscopic retrograde cholangiopancrea-togram; Complication; Pancreatitis
AIM: To evaluate the necessity of endoscopic nasobiliary drainage (ENBD) catheter placement after clearance of common bile duct (CBD) stones.
METHODS: Patients enrolled in this study were randomly divided into two groups, according to whether or not they received ENBD after the removal of CBD stones. Group 1 (ENBD group) was then subdivided into three groups: G1a patients received an endoscopic papillary balloon dilatation (EPBD), G1b patients received an endoscopic sphincterotomy (EST), and G1c patients received neither. Group 2 (non-ENBD group) patients were also subdivided into three groups (G2a, G2b, and G2c), similar to Group 1. The maximum CBD diameter, the time for C-reactive protein (CRP) to normalize, levels of serum amylase, total serum bilirubin (TB) and alanine aminotransferase (ALT), and postoperative hospitalization duration (PHD) were measured.
RESULTS: A total of 218 patients (139 males, 79 females), with an average age of 60.1 ± 10.8 years, were enrolled in this study. One hundred and thirteen patients who received ENBD were included in Group 1, and 105 patients who did not receive ENBD were included in Group 2. The baseline clinical characteristics were similar in both groups. There were no significant differences in post-endoscopic retrograde cholangiopancreatography (ERCP)-related complications when Groups 1 and 2 were compared. Seventy-seven patients underwent EPBD, and 41 received an ENBD tube (G1a) and 36 did not (G2a). Seventy-three patients underwent EST, and 34 patients received an ENBD tube (G1b) and 39 did not (G2b). The remaining 68 patients underwent neither EPBD nor EST; of these patients, 38 received an ENBD tube (G1c) and 30 did not (G2c). For each of the three pairs of subgroups (G1a vs G2a, G1b vs G2b, G1c vs G2c), there were no significant differences detected in the PHD or the time to normalization of CRP, TB and ALT. In the EPBD group, the incidence of post-ERCP pancreatitis, hyperamylasemia and overall patient complications was significantly higher for G2a (post-ERCP pancreatitis: 6/36 vs 0/41, P = 0.0217; hyperamylasemia: 11/36 vs 4/41, P = 0.0215; overall patient complications: 18/36 vs 7/41, P = 0.0029).
CONCLUSION: After successful CBD stone clearance, ENBD is only beneficial when an EPBD procedure has been performed.
Endoscopic papillary balloon dilatation; Endoscopic nasobiliary drainage; Post-endoscopic retrograde cholangiopancreatography pancreatitis; Hyperamylasemia