AIM: To evaluate the role of endoscopic retrograde cholangiopancreatography (ERCP) in patients with sickle cell disease (SCD).
METHODS: Two hundred and twenty four SCD patients with cholestatic jaundice (CJ) had ERCP. The indications for ERCP were based on clinical and biochemical evidence of CJ and ultrasound findings.
RESULTS: Two hundred and forty ERCPs were performed. The indications for ERCP were: CJ only in 79, CJ and dilated bile ducts without stones in 103, and CJ and bile duct stones in 42. For those with CJ only, ERCP was normal in 42 (53.2%), and 13 (16.5%) had dilated bile ducts without an obstructive cause. In the remaining 22, there were bile duct stones with or without dilation. For those with CJ, dilated bile ducts and no stones, ERCP was normal in 17 (16.5%), and 28 (27.2%) had dilated bile ducts without an obstructive cause. In the remaining 58, there were bile ducts stones with or without dilation. For those with CJ and bile duct stones, ERCP was normal in two (4.8%), and 14 (33.3%) had dilated bile ducts without an obstructive cause. In the remaining 26, there were bile duct stones with or without dilatation.
CONCLUSION: Considering the high frequency of biliary sludge and bile duct stones in SCD, endoscopic sphincterotomy might prove helpful in these patients.
Sickle cell disease; Hepatobiliary; Cholestsatic jaundice; Sickle cell hepatopathy; Sickle cell cholangiopathy; Endoscopic retrograde cholangiopancreatography
Common bile duct (CBD) stones are a potentially life-threatening medical condition. Patients with proven CBD stones should undergo stone extraction. The aim of this study was to evaluate whether performing endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) for symptomatic CBD stones in a single session reduces complications related to postponing treatment due to separate EUS and ERCP sessions, and to assess the safety in both options.
A total of 151 patients with EUS-proven CBD stones, with subsequent ERCP, treated in our department between January 2005 and December 2011 were included. Complications related to the procedures or sedation and complications due to the CBD stones when EUS and ERCP were not performed in a single session were assessed and compared to complications when the two procedures were performed in one session.
In total, 149 patients of the 151 (98.7 %) had a successful ERCP. Four (5 %) patients in the separate-session group (B) had a major complication compared to none in the single-session group (A) (p > 0.05). Group B received 14 % more midazolam during ERCP than group A (p < 0.05). No sedation-related complications were noted in either group. Eleven of the 80 patients in group B (13.8 %) experienced complications while waiting for ERCP compared to none in group A (p = 0.001, OR = 2.17, CI = 1.06–4.
EUS and ERCP done in a single session proved to be safe, with no increase in sedation- or procedure-related complications. Postponing treatment for symptomatic CBD stones exposes the patient to biliary complications, especially cholangitis.
EUS; ERCP; CBD; Choledocholithiasis
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.
The management of choledocholithiasis has changed radically since the introduction of laparoscopic cholecystectomy. However, perceived technical difficulties have deterred many surgeons from treating common bile duct stones laparoscopically at the time of cholecystectomy. This has lead to reliance on endoscopic retrograde cholangiopancreatography followed by endoscopic sphincterotomy to deal with common bile duct stones. We retrospectively reviewed the charts of patients who had laparoscopic common bile duct exploration at Downe Hospital between December 1999 and August 2001. Among 149 laparoscopic cholecystectomies done by our group in this period, 10 patients (6.7%) underwent laparoscopic CBD exploration, three by the transcystic technique and seven by choledochotomy. Three patients (2%) had unsuspected stones found on routine per- operative cholangiogram. The mean operative time was 2.34hrs (range 1.50-3.30hrs). The mean hospital post- operative stay was 3 days (range 1-6 days). Post-operative morbidity was zero. Stone clearance was achieved in all cases. We conclude, laparoscopic exploration of the common bile duct is relatively safe and straightforward method. The key skill required is the ability to perform laparoscopic suturing with confidence.
Common bile duct stones (CBDSs) may occur in up to 3%–14.7% of all patients for whom cholecystectomy is preformed. Patients presenting with CBDS have symptoms including: biliary colic, jaundice, cholangitis, pancreatitis or may be asymptomatic. It is important to distinguish between primary and secondary stones, because the treatment approach varies. Stones found before, during, and after cholecystectomy had also differing treatments. Different methods have been used for the treatment of CBDS but the suitable therapy depends on conditions such as patient' satisfaction, number and size of stones, and the surgeons experience in laparoscopy. Endoscopic retrograde cholangiopancreatography with or without endoscopic biliary sphincterotomy, laparoscopic CBD exploration (transcystic or transcholedochal), or laparotomy with CBD exploration (by T-tube, C-tube insertion, or primary closure) are the most commonly used methods managing CBDS. We will review the pathophysiology of CBDS, diagnosis, and different techniques of treatment with especial focus on the various surgical modalities.
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
AIM: To investigate the attenuation patterns and detectability of common bile duct (CBD) stones by multidetector computed tomography (MDCT).
METHODS: Between March 2010 and February 2012, 191 patients with suspicion of CBD stones undergoing both MDCT and endoscopic retrograde cholangiopancreatography (ERCP) were enrolled and reviewed retrospectively. The attenuation patterns of CBD stones on MDCT were classified as heavily calcified, radiopaque, less radiopaque, or undetectable. The association between the attenuation patterns of CBD stones on MDCT and stone type consisting of pure cholesterol, mixed cholesterol, brown pigment, and black pigment and the factors related to the detectability of CBD stones by MDCT were evaluated.
RESULTS: MDCT showed CBD stones in 111 of 130 patients in whom the CBD stones were demonstrated by ERCP with 85.4% sensitivity. The attenuation patterns of CBD stones on MDCT were heavily calcified 34 (26%), radiopaque 31 (24%), less radiopaque 46 (35%), and undetectable 19 (15%). The radiopacity of CBD stones differed significantly according to stone type (P < 0.001). From the receiver operating characteristic curve, stone size was useful for the determination of CBD stone by MDCT (area under curve 0.779, P < 0.001) and appropriate cut-off stone size on MDCT was 5 mm. The factors related to detectability of CBD stones on MDCT were age, stone type, and stone size on multivariate analysis (P < 0.05).
CONCLUSION: The radiopacity of CBD stones on MDCT differed according to stone type. Stone type and stone size were related to the detectability by MDCT, and appropriate cut-off stone size was 5 mm.
Common bile duct gallstones; Gallstones; Multidetector computed tomography; Endoscopic retrograde cholangiography
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.
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 introduction of laparoscopic cholecystectomy, improvements in ultrasound technology and the success of endoscopic sphincterotomy have raised new questions regarding the role of intraoperative cholangiography. Our aim was to analyse the ability of preoperative clinical and ultrasound assessments to detect common duct stones in 86 patients with symptomatic cholecystolithiasis who then underwent cholangiography after percutaneous cholecystolithotomy. Six patients gave a history suggestive of common duct stones (either jaundice, cholangitis or pancreatitis). Ultrasound showed a dilated common duct in four patients (normal < 6 mm), and one of these had a stone demonstrated in the duct. The latter patient and one other with a dilated common duct had stones on cholangiography (which were extracted at ERCP), no stones were demonstrated in the other two. Ultrasound correctly identified common duct stones in two and excluded common duct stones in four others with a history suggesting the presence of stones. For patients undergoing laparoscopic cholecystectomy we would advocate the use of preoperative ultrasound instead of intraoperative cholangiography, and that endoscopic retrograde cholangiopancreatography is performed in the small number of patients shown to have a dilated duct or common duct stone.
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
A 67-years-old male presented with periumbilical abdominal pain, fever and jaundice. His anaerobic blood culture was positive for clostridium perfringens. Computed tomogram scan of the abdomen and abdominal ultrasound showed normal gallbladder and common bile duct (CBD). Subsequently magnetic resonance cholangiopancreaticogram showed choledocholithiasis. Endoscopic retrograde cholangiopancreaticogramwith sphincterotomy and CBD stone extraction was performed. The patient progressively improved with antibiotic therapy Choledocholithiasis should be considered as a source of clostridium perfringens bacteremia especially in the setting of elevated liver enzymes with cholestatic pattern.
Choledocholithiasis; Clostridium perfringens; Bacteremia
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.
Clinicians must choose a treatment strategy for patients with symptomatic cholelithiasis without knowing whether common bile duct (CBD) stones are present. The purpose of this study was to determine the most cost-effective treatment strategy for patients with symptomatic cholelithiasis and possible CBD stones.
Our decision model included five treatment strategies: (1) laparoscopic cholecystectomy (LC) alone followed by expectant management, (2) preoperative endoscopic retrograde cholangiopancreatography (ERCP) followed by LC, (3) LC with intraoperative cholangiography (IOC) ± common bile duct exploration (CBDE), (4) LC followed by postoperative ERCP, and (5) LC with IOC ± postoperative ERCP. The rates of successful completion of diagnostic testing and therapeutic intervention, test characteristics (sensitivity and specificity), morbidity, and mortality for all procedures are from current literature. Hospitalization costs and lengths of stay are from the 2006 National CMS data. The probability of CBD stones was varied from 0% to 100% and the most cost-effective strategy was determined at each probability.
Across the CBD stone probability range of 4% to 100%, LC with IOC ± ERCP was the most cost-effective. If the probability was 0%, LC alone was the most cost-effective. Our model was sensitive to one health input: specificity of IOC, and three costs: cost of hospitalization for LC with CBDE, cost of hospitalization for LC without CBDE, and cost of LC with IOC.
The most cost-effective treatment strategy for the majority of patients with symptomatic cholelithiasis is LC with routine IOC. If stones are detected, CBDE should be forgone and the patient referred for ERCP.
Removal of bile duct stones during endoscopic retrograde cholangiopancreatography (ERCP) usually includes papillotomy. Papillotomy is associated with occasional complications and in addition, the longterm sequelae of papillotomy in young patients having laparoscopic cholecystectomy remain unclear. As an alternative to papillotomy, this study prospectively evaluated the efficacy and safety of endoscopic balloon sphincteroplasty to facilitate bile duct clearance. Of 32 patients with bile duct stones (diameter 3-30 mm) at ERCP, sphincteroplasty was considered inappropriate in four patients because of stone size (> 20 mm) necessitating papillotomy for bile duct clearance. Sphincteroplasty was performed in the remaining 28 patients to permit duct clearance by dormier basket, balloon or mechanical lithotripsy. The bile duct was cleared in 22 patients (79%) while additional measures including papillotomy or stent insertion were required in the remaining six patients (21%) because of stone size or technical difficulties. There was no associated papillary haemorrhage. Pancreatitis was seen in one patient (4%) but resolved within 24 hours. Our preliminary experience suggests that sphincteroplasty is a safe and effective sphincter preservation technique that significantly reduces the necessity for papillotomy in the management of bile duct stones.
Although endoscopic retrograde cholangiopancreatography (ERCP) is an effective modality for the diagnosis and treatment of biliary and pancreatic diseases, it is still related with several severe complications. We report on the case of a female patient who developed liver parenchyma perforation following ERCP. She underwent ERCP with sphincterotomy and extraction of a common bile duct stone. Shortly after ERCP, abdominal distension was identified. Abdominal computed tomography revealed intraabdominal air leakage and leakage of contrast dye penetrating the liver parenchyma into the space around the spleen. Since periampullary perforation related to sphincterotomy could not be denied, she was referred for immediate surgery. Obvious perforation could not be found at surgery. Cholecystectomy, insertion of a T tube into the common bile duct, placement of a duodenostomy tube and drainage of the retroperitoneum were performed. She did well postoperatively and was discharged home on postoperative day 28. In conclusion, as it is well recognized that perforation is one of the most serious complication related to ERCP, liver parenchyma perforation should be suspected as a cause.
Endoscopic retrograde cholangiopancreatography; Sphincterotomy; Complication; Guide wire; Liver injury
The aim of this study is to present an economic and convenient modification of the layout for laparoscopic cholecystectomy, utilizing a three-port technique.
The surgeon stands on the left side of the patient, while the assistant stands between the patient's legs. The scrub nurse stands on the right side of the patient facing the surgeon. The assistant also operates the camera. Only three ports are used. This technique was used in 119 consecutive patients over a 24-month period. Endoscopic retrograde chlolangiopancreotography (ERCP) was done preoperatively in patients suspected to have choledocholithiasis.
Sixteen patients had ERCP done preoperatively and in 12 of them sphincterotomy and stone removal was carried out. Laparoscopic cholecystectomy was successfully completed in 115 patients. The mean operative time was 35 minutes. Four cases were converted (3.6%), one due to bile duct injury, two others due to extensive adhesions, and a fourth due to cholecystoduodenal fistula. The total morbidity rate was 4.2%. The mean hospital stay was 1.8 days.
Laparoscopic cholecystectomy can be safely and conveniently done using only three ports in the modified position described. You need only one assistant, only one monitor and one less trocar. There is no prolongation of the operative time and the results are comparable to the classic four-trocar technique.
Laparoscopic cholecystectomy; Layout; Modified
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
The overall prevalence of gallstones in the United States is between 10% and 15%. Eighty-five percent of common bile duct (CBD) stones can be removed by endoscopic sphincterotomy with basket or balloon extraction, or both. The introduction of mechanical lithotripsy improved the results up to 90%. We present one case of retained CBD stone after 2 failed endoscopic sphincterotomies and balloon/basket extraction treated by electrohydraulic lithotripsy (EHL).
A fifty-year-old man underwent ERCP for suppurative cholangitis. Because of the failure of stone extraction, he was taken to the operating room for an open cholecystectomy and CBD exploration. The intraoperative cholangiogram showed contrast flowing into the duodenum. Seven weeks later, the patient presented with mild pancreatitis, and a T-tube cholangiogram revealed a stone impacted in the distal CBD. Percutaneous balloon extraction was again unsuccessful.
The patient underwent a single 2.5-hour session of EHL via the T-tube tract. Mild pulmonary edema occurred intraoperatively. Complete clearance of the CBD was obtained without the need for additional ERCP.
EHL is a valid and effective option for difficult retained common bile duct stones after failed ERCP.
Lithotripsy; Retained common bile duct stones; Failed endoscopic retrograde cholangiopancreatography
AIM: To evaluate the efficacy of intraductal ultrasonography (IDUS) in the diagnosis of non-opaque, common bile duct stones.
METHODS: A total of 183 patients (102 males, mean age 73 years; 81 females, mean age 70 years) with suspected common bile duct stones diagnosed through abdominal computed tomography (CT), magnetic resonance imaging (MRI), and abdominal Type-B ultrasound were included in the study. The diagnosis was confirmed through endoscopic retrograde cholangiopancreatography (ERCP) followed by IDUS.
RESULTS: A total of 183 patients with suspected common bile duct (CBD) stones were included in the study as follows: 36 patients with high-density CBD stones, 68 patients with sand-like stones, 44 patients with low-density stones, 21 patients with ampullary cancer, and 14 patients with pancreatic cancer. Conventional imaging revealed 124 cases of choledochectasia, and only 36 cases of suspected CBD stones; ERCP revealed 145 cases of CBD stones with three missed diagnoses. IDUS revealed 148 cases of CBD stones, 21 cases of ampullary tumors, and 14 cases of pancreatic cancer.
CONCLUSION: IDUS was more effective in the diagnosis of bile duct stones than ERCP, upper abdominal CT or upper abdominal MRI.
Biliary intraductal ultrasonography; Endoscopic retrograde cholangiopancreatography; Common bile duct stones; Non-opaque stones; Sand-like stones
AIM: To examine whether rendezvous endoscopic retrograde cholangiopancreatography (ERCP) is associated with less pancreatic damage, measured as leakage of proenzymes, than conventional ERCP.
METHODS: Patients (n = 122) with symptomatic gallstone disease, intact papilla and no ongoing inflammation, were prospectively enrolled in this case-control designed study. Eighty-one patients were subjected to laparoscopic cholecystectomy and if intraoperative cholangiography suggested common bile duct stones (CBDS), rendezvous ERCP was performed intraoperatively (n = 40). Patients with a negative cholangiogram constituted the control group (n = 41). Another 41 patients with CBDS, not subjected to surgery, underwent conventional ERCP. Pancreatic proenzymes, procarboxypeptidase B and trypsinogen-2 levels in plasma, were analysed at 0, 4, 8 and 24 h. The proenzymes were determined in-house with a double-antibody enzyme linked immunosorbent assay. Pancreatic amylase was measured by an enzymatic colourimetric modular analyser with the manufacturer’s reagents. All samples were blinded at analysis.
RESULTS: Post ERCP pancreatitis (PEP) occurred in 3/41 (7%) of the patients cannulated with conventional ERCP and none in the rendezvous group. Increased serum levels indicating pancreatic leakage were significantly higher in the conventional ERCP group compared with the rendezvous ERCP group regarding pancreatic amylase levels in the 4- and 8-h samples (P = 0.0015; P = 0.03), procarboxypeptidase B in the 4- and 8-h samples (P < 0.0001; P < 0.0001) and trypsinogen-2 in the 24-hour samples (P = 0.03). No differences in these markers were observed in patients treated with rendezvous cannulation technique compared with patients that underwent cholecystectomy alone (control group). Post procedural concentrations of pancreatic amylase and procarboxypeptidase B were significantly correlated with pancreatic duct cannulation and opacification.
CONCLUSION: Rendezvous ERCP reduces pancreatic enzyme leakage compared with conventional ERCP cannulation technique. Thus, laparo-endoscopic technique can be recommended with the ambition to minimise the risk for post ERCP pancreatitis.
Common bile duct stones; Procarboxypeptidase B; Trypsinogen-2; Pancreatic amylase; Intraoperative endoscopic retrograde cholangiopancreatography
AIM: To postoperative endoscopic retrograde cholangiopancreatography (ERCP) failure, we describe a modified Rendezvous technique for an ERCP in patients operated on for common bile duct stone (CBDS) having a T-tube with retained CBDSs.
METHODS: Five cases operated on for CBDSs and having retained stones with a T-tube were referred from other hospitals located in or around Istanbul city to the ERCP unit at the Haydarpasa Numune Education and Research Hospital. Under sedation anesthesia, a sterile guide-wire was inserted via the T-tube into the common bile duct (CBD) then to the papilla. A guide-wire was held by a loop snare and removed through the mouth. The guide-wire was inserted into the sphincterotome via the duodenoscope from the tip to the handle. The duodenoscope was inserted down to the duodenum with a sphincterotome and a guide-wire in the working channel. With the guidance of a guide-wire, the ERCP and sphincterotomy were successfully performed, the guide-wire was removed from the T-tube, the stones were removed and the CBD was reexamined for retained stones by contrast.
RESULTS: An ERCP can be used either preoperatively or postoperatively. Although the success rate in an isolated ERCP treatment ranges from up to 87%-97%, 5%-10% of the patients require two or more ERCP treatments. If a secondary ERCP fails, the clinicians must be ready for a laparoscopic or open exploration. A duodenal diverticulum is one of the most common failures in an ERCP, especially in patients with an intradiverticular papilla. For this small group of patients, an antegrade cannulation via a T-tube can improve the success rate up to nearly 100%.
CONCLUSION: The modified Rendezvous technique is a very easy method and increases the success of postoperative ERCP, especially in patients with large duodenal diverticula and with intradiverticular papilla.
Endoscopic retrograde cholangiopancreatography; Retained stones; Antegrade cannulation; Intradiverticular papilla; T-tube
Laparoscopic cholecystectomy is the treatment of choice for the management of cholecystolithiasis. For the management of choledocholithiasis, a number of options exist. The effectiveness of washing out common bile duct stones with laparoscopic transcystic papillary balloon dilatation (LTPBD) in patients undergoing laparoscopic cholecystectomy (LC) as a one-stage procedure was evaluated.
Retrospectively, the files of 63 patients treated with LTPBD in a one-stage procedure undergoing laparoscopic cholecystectomy between December 1996 and December 2006 were studied.
Fifty-three patients were treated successfully in a one-stage procedure, seven patients were treated in two steps with an endoscopic retrograde cholangiopancreatography (ERCP) postoperatively, and in three cases a conversion to open surgery was required. The median operation time was 128 min, and the median hospital stay was 4 days. No patients developed postoperative pancreatitis. In one case contrast leakage from the common bile duct was detected. It was the only complication directly related to the LTPBD. There were no postoperative deaths.
We consider the wash out of common bile duct stones after LTPBD in a one-stage procedure to be an easy to do and safe operation with great results. Cooperation with an intervention radiologist and application of an angioplastic dilatation dotter balloon catheter are the keys to success in this procedure. In our hospital, it is the treatment of choice for choledocholithiasis associated with cholelithiasis.
Common bile duct stones; One-stage procedure; Laparoscopic cholecystectomy; Choledocholithiasis; Cholelithiasis; Papillary balloon dilatation
Gallbladder disease is common and, if managed incorrectly, can lead to high rates of morbidity, mortality, and extraneous costs. The most common complications of gallstones include biliary colic, acute cholecystitis, common bile duct stones, and gallstone pancreatitis. Ultrasound is the initial imaging modality of choice. Additional diagnostic and therapeutic studies including computed tomography (CT), magnetic resonance imaging (MRI), magnetic resonance cholangiopancreatography (MRCP), endoscopic ultrasound (EUS), and endoscopic retrograde cholangiopancreatography (ERCP) are not routinely required but may play a role in specific situations. Biliary colic and acute cholecystitis are best treated with early laparoscopic cholecystectomy. Patients with common bile duct stones should be managed with cholecystectomy, either after or concurrent with endoscopic or surgical relief of obstruction and clearance of stones from the bile duct. Mild gallstone pancreatitis should be treated with cholecystectomy during the initial hospitalization to prevent recurrence. Emerging techniques for cholecystectomy include single-incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES). Early results in highly selected patients demonstrate the safety of these techniques. The management of complications of the gallbladder should be timely and evidence-based, and choice of procedures, particularly for common bile duct stones, is largely influenced by facility and surgeon factors.
Evidence-based; surgery; gallbladder; biliary
Therapeutic endoscopic retrograde cholangiopancreatography (ERCP) was initially utilized at Binh Dan Hospital, Viet Nam, in August 1993. From August 1993 through March 1997, 318 ERCP procedures were performed on 271 patients. It was not possible to obtain cholangiography in 32 cases of the 318 procedures of ERCP, for a success rate of diagnostic ERCP approaching 89%.
Materials and Methods:
Cases treated by ERCP included: 14 cases of Ascaris lumbricoides in the common bile duct (CBD).
69 cases of bile duct stones.
12 cases managed by nasobiliary catheter drainage.
3 cases treated by bile duct stent.
Sphincterotomy was attempted on 108 cases.
5 cases of acute pancreatitis.7 cases of purulent cholangitis, which resulted in 1 death.2 cases of retroperitoneal duodenal perforation.9 cases of postsphincterotomy bleeding.
We conclude that ERCP is a useful therapeutic modality for bile duct stones and parasitic worms in the bile ducts.
ERCP; Retained bile duct stone; Bile duct Ascaris