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De Silva HM, Howard T, Yong T, Hodgson R. Comparing Stone Recurrence Following Surgical Common Bile Duct Exploration or Endoscopic Stone Extraction for Patients with Common Bile Duct Stones. J Laparoendosc Adv Surg Tech A 2023; 33:389-396. [PMID: 36735566 DOI: 10.1089/lap.2022.0526] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Background: Laparoscopic common bile duct exploration (LCBDE) and endoscopic retrograde cholangiopancreatography (ERCP) are two methods of retrieving common bile duct (CBD) stones. Aspects of CBD stone management, such as sphincterotomy, have been implicated as risks for CBD stone recurrence although evidence is weak. The aim of this study was to compare stone recurrence following LCBDE and/or ERCP. Methods: Data were collected retrospectively for patients undergoing LCBDE and/or ERCP for CBD stones at a single center from 2008 to 2018. Primary outcome was stone recurrence (>6 months after duct clearance). Risk factors for recurrence were assessed using univariate and multivariate analyses. Results: A total of 445 patients underwent LCBDE-only, 79 patients underwent ERCP-only and 80 patients underwent LCBDE-ERCP. LCBDE-only patients were younger and preoperatively less morbid than ERCP-only patients. Although there was no significant difference for recurrence, there was a trend toward higher recurrence with ERCP-only compared with LCBDE-only and LCBDE-ERCP (5.1% versus 2.0% and 2.5%, P = .280). On univariate comparison, patients with a recurrence were significantly older, had a higher admission white cell count, higher number of ERCPs, increased transampullary stent use, and higher maximum CBD diameter. Total number of ERCP was the only independent predictor of stone recurrence (odds ratio 6.85 [2.55-18.42], P < .001) following multivariate regression. Conclusion: Management plan was not associated with stone recurrence. The total number of ERCP was the only independent predictor of recurrence. Within the limitations of case selection and bias toward LCBDE, this study suggests that limiting repeated ERCP may reduce CBD stone recurrence.
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Affiliation(s)
| | - Tess Howard
- Division of Surgery, Northern Health, Epping, Australia
| | - Tuck Yong
- Division of Surgery, Northern Health, Epping, Australia
| | - Russell Hodgson
- Division of Surgery, Northern Health, Epping, Australia.,Department of Surgery, University of Melbourne, Epping, Australia
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Mansour S, Kluger Y, Khuri S. Primary Recurrent Common Bile Duct Stones: Timing of Surgical Intervention. J Clin Med Res 2022; 14:441-447. [PMID: 36578366 PMCID: PMC9765319 DOI: 10.14740/jocmr4826] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 10/24/2022] [Indexed: 11/30/2022] Open
Abstract
Cholelithiasis (gallstones) is a very common medical problem worldwide, with 5-30% of patients demonstrating a combined condition of cholelithiasis and choledocholithiasis (common bile duct stones (CBDS)). CBDS are usually classified as primary or secondary stones. Primary CBDS are defined as stones detected 2 years or more following cholecystectomy, while secondary stones, the most common type, usually migrate from the gallbladder to the bile ducts. Recurrent CBDS are defined as stones detected 6 months or more following endoscopic retrograde cholangiopancreatography (ERCP) with complete duct clearance. Although ERCP with endoscopic sphincterotomy has emerged as the main therapeutic option for CBDS, with up to 95% bile duct clearance rate, up to 25% of said patients develop recurrent bile duct stones. Thus far, several issues related to recurrent CBDS are still unclear and questions regarding this specific pathology have no precise answers: how many trials of ERCP and endoscopic sphincterotomy should be attempted before referring the patient for surgical management? Is there an association between risk factors and early surgical intervention? Thus, currently, there is no worldwide scientific-based consensus regarding the best management of this specific group of patients. The main issue for this article is to review the relevant English literature and find out the main high risk factors for recurrent CBDS, and form a diagnostic and treatment plan, hence, identifying the subgroup of patients that will benefit from early surgical management, preventing further ERCP-associated complications.
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Affiliation(s)
- Subhi Mansour
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Yoram Kluger
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
- HPB and Surgical Oncology Unit, Rambam Health Care Campus, Haifa, Israel
| | - Safi Khuri
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
- HPB and Surgical Oncology Unit, Rambam Health Care Campus, Haifa, Israel
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3
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Cholecystectomy after endoscopic sphincterotomy in elderly: A dilemma. JOURNAL OF SURGERY AND MEDICINE 2022. [DOI: 10.28982/josam.1115509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background/Aim: Although cholecystectomy is recommended by many guidelines after endoscopic retrograde cholangiopancreatography (ERCP) for gallstones, the necessity of cholecystectomy in geriatric patients is a matter of debate. Here we compare the outcomes of new biliary events in cholecystectomized and non-cholecystectomized patients of geriatric age after ERCP for suspected choledocholithiasis.
Methods: Non-cholecystectomized patients who underwent ERCP for choledocholithiasis from 2015 to 2017 were included in this retrospective cohort study. Patients with other biliary pathologies, incomplete clearance of common bile duct stones, and those who could not be reached at follow-up were excluded from the study. Biliary events (cholecystitis, cholangitis, pancreatitis, re-ERCP) were evaluated by considering age groups in patients with and without cholecystectomy in their follow-up after sphincterotomy.
Results: A total of 284 patients were followed for an average of 69.77 (0.2) months. The cumulative incidence of biliary events in cholecystectomized patients was lower (16% vs. 21.5%; P < 0.001), and cholecystectomized patients had a longer time to the occurrence of events (mean 74.49 [0.27] months vs. 73.50 [0.33] months; P = 0.03). There was no significant difference in the frequency of biliary events between elderly patients with and without cholecystectomy (P = 0.81), and the cumulative incidence of biliary events in the in situ group was significantly lower than that in the geriatric group (17.5% vs 32.6%; P = 0.03)
Conclusion: Although cholecystectomy significantly reduces subsequent biliary complications in young patients, it does not provide a statistically significant benefit in geriatric patients. We believe that there may be no need for routine prophylactic cholecystectomy after endoscopic sphincterotomy in geriatric patients.
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Lee SJ, Choi IS, Moon JI, Choi YW. Optimal treatment for concomitant gallbladder stones with common bile duct stones and predictors for recurrence of common bile duct stones. Surg Endosc 2021; 36:4748-4756. [PMID: 34734299 DOI: 10.1007/s00464-021-08815-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 10/17/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND The optimal treatment for concomitant gallbladder (GB) stones with common bile duct (CBD) stones and predictors for recurrence of CBD stones are not established. METHODS This single-center, retrospective study reviewed 466 patients diagnosed with a first event of concomitant GB stones with CBD stones from January 2010 to December 2018. RESULTS 92 patients underwent single-stage laparoscopic CBD exploration (LCBDE) and laparoscopic cholecystectomy (LC) (group1), 108 underwent LCBDE + LC after endoscopic stone extraction (ESE) failure (group2), and 266 underwent ESE + LC (group3). Clearance (95.7 vs. 99.1 vs. 97.0%, p = 0.324) and recurrence rates (5.4 vs. 13.0 vs. 7.9%, p = 0.138) did not differ between groups. Group1 had fewer procedures (p < 0.001), lower post-treatment complication rates (7.6 vs. 18.5 vs. 13.9%, p = 0.082), and shorter hospital stay after the first procedure (5.7 vs 13.0 vs 9.8 days, p < 0.001). 40 patients (8.6%) had recurrence of CBD stones at mean follow-up of 17.1 months, of which 29 (72.5%) occurred within 24 months. In multivariate analysis, a CBD diameter > 8 mm, combined type-1 periampullary diverticulum, and age > 70 years were significant predictors of recurrence. CONCLUSION Single-stage LCBDE + LC is a safe and effective treatment for concomitant GB stones with CBD stones compared to ESE + LC. LCBDE should be considered in patients with a high risk of ESE failure. Careful follow-up is recommended for patients at high risk of recurrence of CBD stones, especially within 24 months after surgical or endoscopic treatment.
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Affiliation(s)
- Seung Jae Lee
- Department of Surgery, Myunggok Medical Research Center, Konyang University Hospital, Konyang University College of Medicine, 158, Gwanjeodong-ro, Seo-gu, Daejeon, 35365, South Korea
| | - In Seok Choi
- Department of Surgery, Myunggok Medical Research Center, Konyang University Hospital, Konyang University College of Medicine, 158, Gwanjeodong-ro, Seo-gu, Daejeon, 35365, South Korea.
| | - Ju Ik Moon
- Department of Surgery, Myunggok Medical Research Center, Konyang University Hospital, Konyang University College of Medicine, 158, Gwanjeodong-ro, Seo-gu, Daejeon, 35365, South Korea
| | - Yong Woo Choi
- Department of Internal Medicine, Myunggok Medical Research Center, Konyang University Hospital, Konyang University College of Medicine, Daejeon, Korea
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Retrospective comparative analysis of choledochoscopic bile duct exploration versus ERCP for bile duct stones. Sci Rep 2020; 10:14736. [PMID: 32895429 PMCID: PMC7476925 DOI: 10.1038/s41598-020-71731-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 08/20/2020] [Indexed: 12/29/2022] Open
Abstract
Debate still exists for the management of choledocholithiasis. The purpose of this study is to quantify the rate of recurrent choledocholithiasis post choledochoscopic bile duct exploration (CBDE) in comparison to ERCP and sphincterotomy, and to demonstrate the feasibility of this approach in a busy metropolitan hospital. Data of patients undergoing CBDE from 2009–2014 at the Northern Hospital, Victoria, Australia, was collected retrospectively. Primary outcomes were bile duct clearance rate and rate of recurrent stones post-clearance. Secondary outcomes measured were post-operative complications, laparoscopic to open conversion rate and operative time. Data of patients undergoing ERCP at the same institution was collected and compared. In total, there were 4,091 cholecystectomy cases performed from 2009–2014, of which 260 (6.3%) of patients had an intraoperative cholangiography (IOC) indicating a common bile duct (CBD) stone. Two hundred and forty-eight patients (95.3%) had a CBDE. The remaining 12 patients (4.6%) had radiological clearance, which were excluded from the study. The overall clearance rate for patients undergoing CBDE was 84% (209/248). The risk of recurrent stones up to 8 years post clearance was 2% (4/209). In the same institution, and between 1998–2012, a total of 1,148 patients underwent ERCP, of which 571 had endoscopic sphincterotomy (ES). Forty-three patients required a repeat ERCP for recurrent CBD stones with a complication rate of 7.5%. Time to recurrence ranged from 6 months to 10 years with a mean of 4.5 years. The rate of recurrence was lower in the CBDE group compared to the patients who had an ERCP (8.9% vs. 2%). CBDE is a feasible and effective method for clearance of CBD stones at the time of laparoscopic cholecystectomy. This approach, although not widely used, reduces the need for ERCP, which has inherent complications. In the longer term, this series showed a significant reduction in the rate of CBD stone recurrence.
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A nationwide population-based study of common bile duct stone recurrence after endoscopic stone removal in Korea. J Gastroenterol 2018; 53:670-678. [PMID: 29192348 DOI: 10.1007/s00535-017-1419-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 11/24/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND There is no consensus whether patients who underwent endoscopic common bile duct (CBD) stone removal should be followed up periodically and whether patients with gallbladder (GB) stones should undergo cholecystectomy. Thus, this study aimed to investigate the recurrence rate of CBD stones and the difference in recurrence rate according to cholecystectomy. METHODS We conducted a population-based study using the National Health Insurance database. Patients diagnosed with CBD stones and with procedure registry of endoscopic stone removal were included. The primary outcome was the recurrence rate of CBD stones. The secondary outcome was the difference in recurrence rate of CBD stones according to cholecystectomy. RESULTS A total of 46,181 patients were identified. The mean follow-up was 4.2 years. The first CBD stone recurrence occurred in 5228 (11.3%) patients. The cumulative first recurrence rate was low. However, the second and third recurrence rates were 23.4 and 33.4%, respectively. The cumulative second and third recurrence rates were high and gradually increased with time. The recurrence rate in the non-cholecystectomy group was higher than that in the cholecystectomy group (p < 0.0001). The relative risk for CBD stone recurrence in the non-cholecystectomy group was higher in younger patients, with 3.198 in patients < 50 years, 2.371 in 50-59 years, 1.618 in 60-69 years, and 1.262 in ≥ 70 years (p < 0.0001). CONCLUSIONS Regular follow-up is not routinely recommended for patients with first-time endoscopic stone removal, but is recommended for patients with recurrent stones. Cholecystectomy is recommended for patients with GB stones who are younger than 70 years.
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Tsai TJ, Chan HH, Lai KH, Shih CA, Kao SS, Sun WC, Wang EM, Tsai WL, Lin KH, Yu HC, Chen WC, Wang HM, Tsay FW, Lin HS, Cheng JS, Hsu PI. Gallbladder function predicts subsequent biliary complications in patients with common bile duct stones after endoscopic treatment? BMC Gastroenterol 2018; 18:32. [PMID: 29486713 PMCID: PMC6389262 DOI: 10.1186/s12876-018-0762-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 02/22/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND In patients with common bile duct stones (CBDS) and intact gallbladder, further management for the gallbladder after the CBDS clearance is still controversial. The relationship between gallbladder motility and the biliary complications were seldom discussed. Our study is to predict the subsequent biliary complications by gallbladder function test using fatty meal sonography (FMS) in patients with CBDS who had been treated by endoscopic retrograde cholangiopancreatography (ERCP). METHODS Patients with an intact gallbladder and CBDS after endoscopic clearance of bile duct were enrolled. Patients received a fatty meal sonography after liver function returned to normal. The fasting volume, residual volume, and gallbladder ejection fraction (GBEF) in FMS were measured. Relationships of patients' characteristics, gallbladder function and recurrent biliary complication were analyzed. RESULTS From 2011 to 2014, 118 patients were enrolled; 86 patients had calculus gallbladders, and 32 patients had acalculous gallbladders. After a mean follow- up of 33 months, 23 patients had recurrent biliary complications. Among 86 patients with calculus gallbladder, 15 patients had spontaneous clearance of gallbladder stones; 14 patients received cholecystectomy due to acute cholecystitis or recurrent colic pain with smooth postoperative courses. In the follow up period, six patients died of non-biliary causes. The GBEF is significant reduced in most patients with a calculus gallbladder in spite of stone color. Calculus gallbladder, alcohol drinking and more than one sessions of initial endoscopic treatment were found to be the risk factors of recurrent biliary complication. CONCLUSIONS Gallbladder motility function was poorer in patients with a calculus gallbladder, but it cannot predict the recurrent biliary complication. Since spontaneous clearance of gallbladder stone may occur, wait and see policy of gallbladder management after endoscopic treatment of CBDS is appropriate, but regular follow- up in those patients with risk factors for recurrence is necessary.
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Affiliation(s)
- Tzung-Jiun Tsai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China
| | - Hoi-Hung Chan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China
- Department of Biological Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan, Republic of China
- Department of Business Management, National Sun Yat-sen University, Kaohsiung, Taiwan, Republic of China
- College of Pharmacy and Health Care, Tajen University, Pingtung city, Taiwan, Republic of China
| | - Kwok-Hung Lai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China
| | - Chih-An Shih
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China
| | - Sung-Shuo Kao
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China
| | - Wei-Chih Sun
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China
| | - E-Ming Wang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China
| | - Wei-Lun Tsai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China
| | - Kung-Hung Lin
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China
| | - Hsien-Chung Yu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China
| | - Wen-Chi Chen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China
| | - Huay-Min Wang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China
| | - Feng-Woei Tsay
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China
| | - Huey-Shyan Lin
- Department of Health-Business Administration, Fooyin University, Kaohsiung, Taiwan, Republic of China
| | - Jin-Shiung Cheng
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China
| | - Ping-I Hsu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China
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Choi YS, Do JH, Suh SW, Lee SE, Kang H, Park HJ. Risk factors for the late development of common bile duct stones after laparoscopic cholecystectomy. Surg Endosc 2017; 31:4857-4862. [PMID: 28664425 DOI: 10.1007/s00464-017-5698-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 06/22/2017] [Indexed: 12/27/2022]
Abstract
BACKGROUND The development of common bile duct (CBD) stones after laparoscopic cholecystectomy (LC) could be a stressful event for surgeons and patients. The purpose of this study was to investigate the risk factors for and the time of occurrence of CBD stones, which are detected at a certain period after LC in patients who have no history of having CBD stone before operation. METHODS A total of 1938 patients who underwent LC for benign gallbladder lesion were retrospectively analyzed. The patients were categorized into two groups according to the development of CBD stones at least 6 months after LC (case group, control group). The risk factors for and the time of development of CBD stones after LC were evaluated. RESULTS In a univariate analysis, the significant factors for the development of CBD stones were old age, acute cholecystitis, the presence of periampullary diverticulum, and the presence of gall bladder stones sized <0.55 cm. By multivariate analysis, acute cholecystitis (OR: 3.082, 95% CI: 1.306-7.272, p = 0.010), the presence of periampullary diverticulum (OR: 7.950, 95% CI: 3.425-18.457, p < 0.001), and the presence of gall bladder stones sized < 0.55 cm (OR: 5.647, 95% CI: 1.310-24.346, p = 0.020) were independent factors that could predict the development of CBD stones at least 6 months after LC. The time intervals of the development of CBD stones had evenly distributed during 50 months after LC. CONCLUSION This study suggested that the surgeon should inform the possibility of the development of CBD stones who have the identified risk factors.
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Affiliation(s)
- Yoo Shin Choi
- Department of Surgery, College of Medicine, Chung-Ang University, Seoul, South Korea
| | - Jae Hyuk Do
- Department of Internal Medicine, College of Medicine, Chu ng-Ang University, 224-1 Heuksuk-dong, Dongjak-gu, 156-755, Seoul, South Korea.
| | - Suk Won Suh
- Department of Surgery, College of Medicine, Chung-Ang University, Seoul, South Korea
| | - Seung Eun Lee
- Department of Surgery, College of Medicine, Chung-Ang University, Seoul, South Korea
| | - Hyun Kang
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chung-Ang University, Seoul, South Korea
| | - Hyun Jeong Park
- Department of Radiology, College of Medicine, Chung-Ang University, Seoul, South Korea
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Zhou B, Hu J, Zhong Y. Surgical treatments for patients with recurrent bile duct stones and Oddis sphincter laxity. Intractable Rare Dis Res 2017; 6:172-176. [PMID: 28944138 PMCID: PMC5608926 DOI: 10.5582/irdr.2017.01053] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Recurrent bile duct stones is the most common complication after gallstone surgery and the incidence is about 4-24%. Sphincter of Oddi laxity will lead to duodenal content flow into the bile or pancreatic duct. Patients with recurrent bile duct stones and Oddis sphincter laxity were intractable. Here we sought to present the possible and helpful surgical treatments for such patients. Prospective randomized clinical trial are needed for evaluating the outcome of surgical treatments.
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Affiliation(s)
- Boxuan Zhou
- Department of Hepatobiliary Surgery, Third Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Jinxiong Hu
- Department of Hepatobiliary Surgery, Third Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Yuesi Zhong
- Department of Hepatobiliary Surgery, Third Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
- Address correspondence to: Dr. Yuesi Zhong, Department of Hepatobiliary Surgery, Third Affiliated Hospital, Sun Yat-Sen University, Guangzhou 510630, China. E-mail:
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10
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Bakkum MJ, Loffeld RJLF. Ascending Cholangitis due to Heavy Lifting. Case Rep Gastroenterol 2017; 11:500-503. [PMID: 29033769 PMCID: PMC5624237 DOI: 10.1159/000479550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 07/14/2017] [Indexed: 12/03/2022] Open
Abstract
Gallstone disease is the most common risk factor for cholangitis. In an anatomically normal bile duct system, cholangitis does not occur without the presence of stones. Endoscopic retrograde cholangiography with papillotomy and stone extraction is a well-established curative therapy for gallstones in the common bile duct. More important, papillotomy prevents recurrent episodes. The present case report describes a 73-year-old male with recurring cholangitis in a clear bile duct system after previous papillotomy. An etiology of duodenal reflux into the common bile duct due to heavy lifting is proposed.
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Affiliation(s)
- M J Bakkum
- Department of Internal Medicine, Zaans Medisch Centrum, Zaandam, the Netherlands
| | - R J L F Loffeld
- Department of Internal Medicine, Zaans Medisch Centrum, Zaandam, the Netherlands
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11
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Abstract
Gallstone disease is a common and frequently occurring disease in human, and it is the main disease among the digestive system diseases. The incidence of gallstone disease in western countries is about 5%-22%, and common bile duct stones (CBDS) accounts for 8%-20%. CBDS easily lead to biliary obstruction, secondary cholangitis, pancreatitis, and obstructive jaundice, even endanger life. Therefore, it needs timely treatment once diagnosed. The recurrence of choledocholithiasis after bile duct stones clearance involves complicated factors and cannot be completely elaborated by a single factor. The risk factors for recurrence of choledocholithiasis include bacteria, biliary structure, endoscopic and surgical treatment, and inflammation. The modalities for management of choledocholithiasis are endoscopic retrograde cholangiopancreatography (ERCP), laparoscopic or open common bile duct exploration, dissolving solutions, extracorporeal shockwave lithotripsy (ESWL), percutaneous radiological interventions, electrohydraulic lithotripsy (EHL) and laser lithotripsy. We compare the different benefits between surgery and ERCP. And finally, we make a summary of the current strategy for reducing the recurrence of CBDS and future perspectives for CBDS management.
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Affiliation(s)
| | - Sun Qiang
- b Department of General Surgery , Jing'an District Center Hospital of Shanghai (Huashan Hospital Fudan University Jing'an Branch) , Shanghai , PR China
| | - Yin Bao-Bing
- c Department of General Surgery , Huashan Hospital, Fudan University , Shanghai , PR China
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12
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Harris HW, Davis BR, Vitale GC. Cholecystectomy After Endoscopic Sphincterotomy for Common Bile Duct Stones: Is Surgery Necessary? Surg Innov 2016; 12:187-94. [PMID: 16224638 DOI: 10.1177/155335060501200302] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
It has been more than 30 years since the introduction of endoscopic sphincterotomy for the management of choledocholithiasis. Once introduced, this endoscopic intervention subsequently enabled clinicians to witness the natural history of leaving the gallbladder in situ once the common duct calculi were removed. Because many people were free of symptoms once the common bile duct was cleared of stones, patients and physicians alike soon questioned whether it was necessary to remove the gallbladder at all. Despite more than two decades of clinical research and numerous published reports, the answer to this question remains elusive. Similarly, the management algorithm for choledocholithiasis in patients with an intact gallbladder remains controversial. We review the available key data regarding this question. Importantly, there are only three prospective, randomized trials that have examined the need for cholecystectomy after endoscopic sphincterotomy, with case studies constituting most of the published reports. Consequently, the literature on this topic remains inconclusive, weakened by its retrospective approach, considerable variability between the patients studied, inconsistent inclusion and exclusion criteria, and frequently poor patient follow-up. Nonetheless, the preponderance of data favor removing the gallbladder after endoscopically clearing the common bile duct of gallstones because an estimated 25% of patients will experience recurrent symptoms within a 2-year follow up period. Recognizing the existence of various mitigating clinical factors, we advocate adopting a selective wait-and-see approach for high-risk patients, especially those with a life expectancy of less than 2 years or severely debilitating comorbidities.
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Affiliation(s)
- Hobart W Harris
- Division of General Surgery, University of California, San Francisco, San Francisco, CA, USA
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The Impact of Gallbladder Status on Biliary Complications After the Endoscopic Removal of Choledocholithiasis. Dig Dis Sci 2016; 61:1165-71. [PMID: 26611859 DOI: 10.1007/s10620-015-3915-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 10/02/2015] [Indexed: 12/27/2022]
Abstract
BACKGROUND Endoscopic sphincterotomy (EST) with stone extraction is the standard management for choledocholithiasis. However, the necessity for subsequent management of gallstone to prevent the biliary complications remained controversial and few data were evaluated for the impact of status of gallbladder on recurrent biliary complications. We retrospectively investigated the relationship between the status of gallbladder and the occurrence of biliary complications after endoscopic removal of choledocholithiasis. METHODS Between January 1998 and December 2008, we enrolled 453 patients with intact gallbladder who underwent EST for choledocholithiasis and allocated into two groups: calculous gallbladder (n = 256) and acalculous gallbladder (n = 197). By reviewing patients' medical records, we compared the occurrence of biliary complications according to the presence or absence of gallstone in GB in situ. RESULTS In total, biliary complications occurred in 83 patients (18.3 %) during the follow-up period. Calculous GB group had higher rate of overall complications (22.7 vs. 12.7 %; p = 0.007) and GB-associated complications (11.3 vs. 2.5 %; p = 0.001) than acalculous GB group. On the multivariate analysis, only the presence of gallstone was shown to be significant risk factor for overall biliary complication (OR 2.029; 95 % CI 1.209-3.405; p = 0.007) and GB-associated complications (OR 5.077; 95 % CI 1.917-13.446; p = 0.001). Mean event-free period was shorter in calculous GB group than acalculous GB group for overall complications (1774 vs. 2159 days; p = 0.012) and GB-associated complication (2153 vs. 2591 days; p = 0.001). CONCLUSIONS Prophylactic cholecystectomy may not be necessary to prevent biliary complication in patients with acalculous gallbladder after endoscopic removal of pigment stones from bile duct.
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Risk factors for recurrence of symptomatic common bile duct stones after cholecystectomy. Gastroenterol Res Pract 2012; 2012:417821. [PMID: 22991508 PMCID: PMC3443611 DOI: 10.1155/2012/417821] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Accepted: 08/05/2012] [Indexed: 12/16/2022] Open
Abstract
Purpose. The recurrence of CBD stone is still observed in a considerable number of patients. The study was to evaluate the risk factors for recurrence of symptomatic CBD stone in patients who underwent cholecystectomy after the removal of CBD stone. Methods. The medical records of patients who underwent removal of CBD stone with subsequent cholecystectomy were reviewed. The risk factors for the recurrence of symptomatic CBD stone were compared between the recurrence and the nonrecurrence group. Results. The mean follow-up period was 40.6 months. The recurrence of symptomatic CBD stones was defined as the detection of bile duct stones no sooner than 6 months after complete clearance of CBD stones, based on symptoms or signs of biliary complication. 144 patients (68 males, 47.2%) were finally enrolled and their mean age was 59.8 (range: 26~86) years. The recurrence of CBD stone occurred in 15 patients (10.4%). The mean period until first recurrence was 25.9 months. The presence of type 1 or 2 periampullary diverticulum and multiple CBD stones were the independent risk factors. Conclusion. For the patients with type 1 or 2 periampullary diverticulum or multiple CBD stones, careful followup is needed for the risk in recurrence of symptomatic CBD stone.
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Yasui T, Takahata S, Kono H, Nagayoshi Y, Mori Y, Tsutsumi K, Sadakari Y, Ohtsuka T, Nakamura M, Tanaka M. Is cholecystectomy necessary after endoscopic treatment of bile duct stones in patients older than 80 years of age? J Gastroenterol 2012; 47:65-70. [PMID: 21938444 DOI: 10.1007/s00535-011-0461-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2010] [Accepted: 08/01/2011] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Although patients with cholecystocholedocholithiasis are generally referred to cholecystectomy after endoscopic sphincterotomy (ES) and common bile duct clearance, we often have a conflict whether cholecystectomy is necessary in very elderly patients with comorbid diseases. The aim of this study is to assess whether cholecystectomy in very elderly patients is justified after ES. PATIENTS AND METHODS Patients with cholecystocholedocholithiasis who underwent ES and stone extraction and were followed-up for more than 10 years were retrospectively reviewed. We divided these patients into two groups: the elderly group (equal to or more than 80 years old) and young group (less than 80 years old) and compared late biliary complications and mortality. RESULTS The 10-year cumulative incidence of overall biliary complications was significantly lower in cholecystectomized patients than in patients with gallbladder in situ in the young group (7.5 vs. 21.7%, p = 0.0037), but not different in the elderly group (8.3 vs. 7.4%, p = 0.92). When each complication was evaluated separately, the rate of recurrent common bile duct stones (CBDS) was not different, but that of acute cholecystitis was significantly lower in the elderly group than in the young group (4.1 vs. 22.6%, p = 0.011). CONCLUSIONS In very elderly patients the incidence of acute cholecystitis is low even when the gallbladder is preserved after endoscopic treatment of CBDS, with a similar risk of CBDS recurrence. Thus, it may not be necessary to recommend cholecystectomy after ES for CBDS in very elderly patients.
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Affiliation(s)
- Takaharu Yasui
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Fukuoka 812-8582, Japan
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Risk factors for cholecystectomy in patients with gallbladder stones after endoscopic clearance of common bile duct stones. Surg Endosc 2009; 23:1713-9. [PMID: 19118432 DOI: 10.1007/s00464-008-0269-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2008] [Revised: 10/16/2008] [Accepted: 11/15/2008] [Indexed: 12/16/2022]
Abstract
BACKGROUND Cholecystectomy usually is recommended for patients with gallbladder (GB) stones who previously underwent endoscopic removal of common bile duct (CBD) stones. However, in practice, many patients still have GB stones after improvement of their biliary symptoms. This study aimed to evaluate risk factors for cholecystectomy in patients with GB stones after complete endoscopic clearance of CBD stones. METHODS From August 2003 to April 2006, the medical data of 61 patients with concomitant GB stones who underwent complete endoscopic clearance of CBD stones were reviewed retrospectively. The risk factors for subsequent cholecystectomy were evaluated during a 24-month of follow-up period. RESULTS Among the 61 patients, 12 (19.7%) subsequently required cholecystectomy for recurrence of biliary symptoms, and 11 of these 12 patients (91.7%) needed cholecystectomy within 12 months. Gallbladder stones 10 mm or larger (p = 0.037) and the acute pancreatitis (p = 0.049) were the independent risk factors for subsequent cholecystectomy. The actuarial probability of remaining free of subsequent cholecystectomy during the follow-up period was higher for the patients with GB stones smaller than 10 mm than for the patients with GB stones 10 mm or larger (86.7% vs. 62.5%; p = 0.037). In addition, the patients with acute pancreatitis had a higher tendency for subsequent cholecystectomy than the patients without acute pancreatitis (50% vs. 16.4%; p = 0.078). CONCLUSIONS Only a small number of patients subsequently needed to undergo cholecystectomy for recurrence of biliary symptoms, and most events developed within 12 months. For the patients with GB stones 10 mm or larger or acute pancreatitis, prophylactic cholecystectomy is strongly recommended after complete clearance of CBD stones.
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Petrone MC, Arcidiacono PG, Testoni PA. Endoscopic ultrasonography for evaluating patients with recurrent pancreatitis. World J Gastroenterol 2008; 14:1016-1022. [PMID: 18286681 PMCID: PMC2689402 DOI: 10.3748/wjg.14.1016] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2007] [Revised: 10/15/2007] [Indexed: 02/06/2023] Open
Abstract
Acute recurrent pancreatitis (ARP) is still a complex diagnostic and therapeutic challenge in clinical practice. In up to 30% of cases of ARP, it is not possible to establish the etiology of the disease. In the other 70%, many factors play an etiological role in ARP: microlithiasis, sphincter of Oddi dysfunction (SOD), pancreas divisum, hereditary pancreatitis, cystic fibrosis, a choledochocele, annular pancreas, an anomalous pancreatobiliary junction, pancreatic tumors or chronic pancreatitis are diagnosed. EUS should be useful in ARP as it is sensitive for diagnosing bile duct stones, gallbladder sludge, pancreatic lesions, ductal abnormalities and chronic pancreatitis. Endoscopic ultrasound (EUS) appears to be diagnostic in the majority of patients with previously unexplained pancreatitis, and offers an alternative to endoscopic retrograde cholangiopancreatography (ERCP) as the initial diagnostic test in patients with ARP.
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Affiliation(s)
- Peter A Banks
- Division of Gastroenterology, Center for Pancreatic Disease, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Tseng D, Hunter J. Surgery of the Biliary Tract. ZAKIM AND BOYER'S HEPATOLOGY 2006:1201-1217. [DOI: 10.1016/b978-1-4160-3258-8.50070-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Abstract
The widespread availability of endoscopic ultrasound has facilitated the evaluation of the pancreas and extrahepatic biliary system. Endosonography has been shown to be highly sensitive in the detection of choledocholithiasis (especially in patients with small stones and nondilated bile ducts) and gallbladder microlithiasis; however, the use of this technique in relation to endoscopic retrograde cholangiography and laparoscopic surgery in gallstone disease remains confusing. This article highlights the clinical performance and results of endoscopic ultrasound in this context and proposes strategies in relation to its use in association with endoscopic retrograde cholangiopancreatography and surgery in common clinical practice. Endosonography allows the correct identification of patients with acute biliary pancreatitis and proves an important adjunct in eliminating other causes of undetermined pancreatitis.
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Affiliation(s)
- Laurent Palazzo
- Medical Surgical Federation of Hepato-Gastroenterology, Beaujon Hospital, University of Paris VII, 100 Boulevard du Général Leclerc, Clichy 92110, France
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Abstract
We prospectively studied long-term (5 years) effects of endoscopic papillary balloon dilation (EPBD) on gallbladder motility. Thirteen patients with intact gallbladders (six with and seven without gallbladder stones) who had undergone EPBD for choledocholithiasis were enrolled in this study. Gallbladder volumes, while fasting and after dried egg yolk ingestion, were determined by ultrasonography, before and at 7 days, 1 month, and 1, 2, and 5 years after EPBD. Before EPBD, the gallbladder had a larger fasting volume and lower yolk-stimulated maximum contraction than in normal controls. Seven days after EPBD, fasting volume was decreased and maximum contraction was increased, regardless of whether the patient had gallbladder stones, showing significant differences from the pre-EPBD values. At 1 month to 5 years after EPBD, these changes were far less evident and gallbladder function did not differ significantly from baseline. EPBD does not adversely affect gallbladder motility in the long-term (5 years).
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Affiliation(s)
- Masanori Sugiyama
- First Department of Surgery, Kyorin University School of Medicine, Tokyo, Japan.
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Saraswat VA, Sharma BC, Agarwal DK, Kumar R, Negi TS, Tandon RK. Biliary microlithiasis in patients with idiopathic acute pancreatitis and unexplained biliary pain: response to therapy. J Gastroenterol Hepatol 2004; 19:1206-11. [PMID: 15377301 DOI: 10.1111/j.1440-1746.2004.03462.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Microlithiasis has been suspected to cause acute pancreatitis and biliary pain. We studied the frequency of microlithiasis and response to treatment in recurrent idiopathic acute pancreatitis (RIAP) and unexplained biliary pain. METHODS Gallbladder bile was examined microscopically for cholesterol monohydrate crystals (CMC) and calcium bilirubinate granules (CBG) in patients with RAIP (n = 24; mean age 36 years, range 18-56 years; 14 men), unexplained biliary pain (n = 12; mean age 32 years, range 22-55 years; six men), gallstones (n = 22; mean age 40 years, range 30-58 years; 12 men) and patients without clinical or imaging evidence of gallstone disease (n = 12; mean age 32 years, range 14-54 years; six men). The presence of a single CMC or >25 CBG/slide was considered abnormal. RESULTS Bile microscopy was abnormal in 75% patients with RAIP (18/24; CMC in 10, CBG in six, CMC and CBG in two), 83.3% patients with unexplained biliary pain (10/12; CMC in seven, CBG in one, CMC and CBG in two) and 95.4% patients with gallstones (21/22; CMC in 12, CBG in one, CMC and CBG in eight). None of the controls without gallstone disease had CMC while three patients had low counts of CBG. Twenty-eight patients with RAIP and biliary pain having microlithiasis agreed to be treated with cholecystectomy (n = 2), endoscopic sphincterotomy (n = 21) or ursodeoxycholic acid (UDCA; n = 5). The 23 patients treated with cholecystectomy or sphincterotomy remained asymptomatic during follow up (mean 23 months, range 6-48 months). Four of five patients treated with UDCA remained asymptomatic for a follow-up period of 9, 10, 11 and 18 months, respectively. One patient who had refused cholecystectomy or sphincterotomy continued to experience pain at the same frequency as before during a follow-up period of 12 months. One patient, who was asymptomatic on UDCA for 9 months, agreed to undergo sphincterotomy and remained asymptomatic over a follow-up period of 14 months. CONCLUSIONS Microlithiasis is a common cause for idiopathic acute pancreatitis and unexplained biliary pain. Lasting relief is obtained in most patients after treatment with UDCA, cholecystectomy or sphincterotomy.
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Affiliation(s)
- Vivek A Saraswat
- Department of Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Schreurs WH, Vles WJ, Stuifbergen WHNM, Oostvogel HJM. Endoscopic management of common bile duct stones leaving the gallbladder in situ. A cohort study with long-term follow-up. Dig Surg 2003; 21:60-4; discussion 65. [PMID: 14707395 DOI: 10.1159/000075944] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2002] [Accepted: 07/25/2003] [Indexed: 12/10/2022]
Abstract
BACKGROUND Obstructive jaundice caused by stones is a common disorder, mostly managed by endoscopic sphincterotomy followed by cholecystectomy. The aim of this study was to evaluate whether or not clearance of the common bile duct alone is sufficient as treatment for patients with choledocholithiasis. METHODS A cohort with 447 patients with symptomatic cholecystocholedocholithiasis, undergoing endoscopic retrograde cholangiography (ERC) and if necessary sphincterotomy (ES). In 164 patients common bile duct stones were proven and treated endoscopically, without performing a subsequent cholecystectomy. All 164 patients were free of symptoms after the endoscopic intervention. This group of patients was compared with 78 patients who underwent cholecystectomy after endoscopic treatment of common bile duct stones. Patients were followed for 1-13 years after ERC and sphincterotomy results and complications were registered. RESULTS The ages of the 164 patients in the in situ group were significantly higher than in the cholecystectomy group and the ASA classification (American Society of Anesthesiologists) was significantly higher in the in situ patients. Mean follow-up was 70.9 months. Of the in situ patients 27 (16%) returned with biliary symptoms; 12 with common bile duct stones, three with cholangitis, and one with stenosis of Vater's papilla. Eight patients returned with cholecystitis and 3 with symptomatic cholecystolithiasis. Thirteen patients underwent cholecystectomy and 11 were managed (also) endoscopically. Minor complications were 2 wound infections and 1 bleeding after cholecystectomy. Two patients (1%) died of abdominal sepsis due to cholecystitis. Of the patients who underwent cholecystectomy, 6 (7.6%) returned during follow-up. Three patients had common bile duct stones, 2 had cholangitis and 1 patient presented with papillostenosis. Three patients needed surgical common bile duct exploration and the other 3 were treated endoscopically. After reintervention, cardiopulmonary complications were observed in 1 patient. There was no related death. CONCLUSION When common bile duct stones are treated successfully by endoscopic sphincterotomy and patients are free of symptoms, there is no need for routine prophylactic cholecystectomy.
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Affiliation(s)
- W H Schreurs
- St. Elisabeth Hospital, Tilburg, The Netherlands.
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Abstract
Acute pancreatitis is caused by acute or chronic alcohol intake or choledocholithiasis in approximately 80% of cases. In the absence of alcohol abuse or gallstones, a variety of established and putative factors must be considered, any of which can cause a single or recurrent attacks of acute pancreatitis. When the underlying cause eludes detection following an initial thorough search and leads to a second attack, the term idiopathic acute recurrent pancreatitis (IARP) is applied. This article discusses IARP and its work-up.
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Affiliation(s)
- Asif Khalid
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, PA 15213, USA
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Tian MG, Shi WJ, Wen XY, Yu HW, Huo JS, Zhou DF. Outcome of gallbladder preservation in surgical management of primary bile duct stones. World J Gastroenterol 2003; 9:1871-3. [PMID: 12918142 PMCID: PMC4611565 DOI: 10.3748/wjg.v9.i8.1871] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the methods and outcome of gallbladder preservation in surgical treatment of primary bile duct stones.
METHODS: Thirty-five patients with primary bile duct stones and intact gallbladders received stone extraction by two operative approaches, 23 done through the intrahepatic duct stump (RBD-IDS, the RBD-IDS group) after partial hepatectomy and 12 through the hepatic parenchyma by retrograde puncture (RBD-RP, the RBD-RP group). The gallbladders were preserved and the common bile duct (CBD) incisions were primarily closed. The patients were examined postoperatively by direct cholangiography and followed up by ultrasonography once every six months.
RESULTS: In the RBD-IDS group, residual bile duct stones were found in three patients, which were cleared by a combination of fibrocholedochoscopic extraction and lithotripsy through the drainage tracts. The tubes were removed on postoperative day 22 (range: 16-42 days). In the RBD-RP group, one patient developed hemobilia and was cured by conservative therapy. The tubes were removed on postoperative day 8 (range: 7-11 days). Postoperative cholangiography showed that all the gallbladders were well opacified, contractile and smooth. During 54 (range: 6-120 months) months of follow-up, six patients had mildly thickened cholecystic walls without related symptoms and further changes, two underwent laparotomies because of adhesive intestinal obstruction and gastric cancer respectively, three died of cardiopulmonary diseases. No stones were found in all the preserved gallbladders.
CONCLUSION: The intact gallbladders preserved after surgical extraction of primary bile duct stones will not develop gallstones. Retrograde biliary drainage is an optimal approach for gallbladder preservation.
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Affiliation(s)
- Ming-Guo Tian
- Department of Hepatobiliary Surgery, Affiliated Hospital of Jining Medical College, Jining City 272129, Shandong Province, China.
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Boerma D, Rauws EAJ, Keulemans YCA, Janssen IMC, Bolwerk CJM, Timmer R, Boerma EJ, Obertop H, Huibregtse K, Gouma DJ. Wait-and-see policy or laparoscopic cholecystectomy after endoscopic sphincterotomy for bile-duct stones: a randomised trial. Lancet 2002; 360:761-5. [PMID: 12241833 DOI: 10.1016/s0140-6736(02)09896-3] [Citation(s) in RCA: 207] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Patients who undergo endoscopic sphincterotomy for common bile-duct stones, who have residual gallbladder stones, are referred for laparoscopic cholecystectomy. However, only 10% of patients who do not have this operation are reported to develop recurrent biliary symptoms. We aimed to assess whether a wait-and-see policy is justified. METHODS We did a prospective, randomised, multicentre trial in 120 patients (age 18-80 years) who underwent endoscopic sphincterotomy and stone extraction, with proven gallbladder stones. Patients were randomly allocated to wait and see (n=64) or laparoscopic cholecystectomy (56). Primary outcome was recurrence of at least one biliary event during 2-year follow-up, and secondary outcomes were complications of cholecystectomy and quality of life. Analysis was by intention to treat. FINDINGS 12 patients were lost to follow-up immediately. Of 59 patients allocated to wait and see, 27 (47%) had recurrent biliary symptoms compared with one (2%) of 49 patients after laparoscopic cholecystectomy (relative risk 22.42, 95% CI 3.16-159.14, p<0.0001). 22 (81%) of 27 patients underwent cholecystectomy, mainly for biliary pain (n=13) or acute cholecystitis (7). Conversion rate to open surgery was 55% in patients allocated to wait and see who underwent cholecystectomy compared with 23% in those who were allocated laparoscopic cholecystectomy (p=0.0104). Morbidity was 32% versus 14% (p=0.1048), and median hospital stay was 9 versus 7 days. Quality of life returned to normal within 3 months after either treatment policy. INTERPRETATION A wait-and-see policy after endoscopic sphincterotomy in combined cholecystodocholithiasis cannot be recommended as standard treatment, since 47% of expectantly managed patients developed at least one recurrent biliary event and 37% needed cholecystectomy. No major biliary complications arose, but conversion rate was high.
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Affiliation(s)
- Djemila Boerma
- Department of Surgery, Academic Medical Center, Amsterdam, Netherlands
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Hui CK, Lai KC, Wong WM, Yuen MF, Lam SK, Lai CL. A randomised controlled trial of endoscopic sphincterotomy in acute cholangitis without common bile duct stones. Gut 2002; 51:245-7. [PMID: 12117888 PMCID: PMC1773318 DOI: 10.1136/gut.51.2.245] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Biliary decompression with endoscopic sphincterotomy (EPT) is beneficial in patients with biliary obstruction due to common bile duct (CBD) stones. However, it is not known whether EPT with decompression of the bile duct is beneficial in patients with acute cholangitis and gall bladder stones but without evidence of CBD stones. AIM A randomised controlled study to assess the effect of EPT on the outcome of patients suffering from acute cholangitis with gall bladder stones but with no CBD stones on initial endoscopic retrograde cholangiopancreatography. PATIENTS A total of 111 patients were recruited into the study. METHODS AND RESULTS Fifty patients were randomised to receive EPT while 61 patients received no endoscopic intervention. There was a significant difference in the duration of fever in the EPT and non-EPT groups (mean (SD): 3.2 (2.2) days v 4.3 (2.1) days; p<0.001). Duration of hospital stay was also shorter in the EPT group than in the non-EPT group (mean (SD): 8.1 (3.0) v 9.1 (3.2) days; p=0.04). Patients were followed up for a mean (SD) of 42.4 (11.1) months. Twenty three patients (20.3%) developed recurrent acute cholangitis (RAC): 14 patients (12.6%) in the EPT group and nine patients (8.1%) in the non-EPT group (p=0.09). CONCLUSION EPT in patients with acute cholangitis without CBD stones decreased the duration of acute cholangitis and reduced hospital stay but it did not decrease the incidence of RAC.
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Affiliation(s)
- C-K Hui
- Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong, China
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Hui CK, Lai KC, Yuen MF, Ng MMT, Lam SK, Lai CL. Role of cholecystectomy in preventing recurrent cholangitis. Gastrointest Endosc 2002; 56:55-60. [PMID: 12085035 DOI: 10.1067/mge.2002.125545] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Whether cholecystectomy should be performed after an episode of acute cholangitis is still unresolved. The purpose of this study was to analyze the role of elective cholecystectomy in preventing recurrent acute cholangitis in Asian patients. METHODS Two hundred ten consecutive Asian patients with acute cholangitis caused by choledocholithiasis with coexisting cholelithiasis were studied prospectively. RESULTS Forty-one patients (19.5%, Group 1) agreed to elective cholecystectomy whereas 169 patients (80.5%, Group 2) did not. Mean (+/- SEM) follow-up for Groups 1 and 2 were, respectively, 110.2 +/- 6.6 and 96.8 +/- 2.9 months. Endoscopic papillotomy was performed in 120 patients, 22 (53.7%) in Group 1 and 98 (58%) in Group 2. Recurrent acute cholangitis developed in 31 patients (14.8%), 9 in Group 1 and 22 in Group 2. There was no significant difference in the Kaplan-Meier estimates of the cumulative probability of occurrence of recurrent acute cholangitis between the 2 groups (p = 0.90). Recurrent acute cholangitis developed in 10 patients (8.3%) who underwent endoscopic papillotomy and in 21 (23.3%) patients who did not. There was a significant difference in the Kaplan-Meier estimates of the cumulative probability of occurrence of recurrent acute cholangitis between the patients with endoscopic papillotomy versus those without endoscopic papillotomy (p = 0.001). CONCLUSION Cholecystectomy did not prevent recurrent acute cholangitis in Asian patients. In these patients, early endoscopic papillotomy lowered the frequency of recurrent acute cholangitis.
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Affiliation(s)
- Chee-Kin Hui
- Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong, China
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30
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Levy MJ. The hunt for microlithiasis in idiopathic acute recurrent pancreatitis: should we abandon the search or intensify our efforts? Gastrointest Endosc 2002; 55:286-93. [PMID: 11818945 DOI: 10.1067/mge.2002.121224] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Toouli J, Brooke-Smith M, Bassi C, Carr-Locke D, Telford J, Freeny P, Imrie C, Tandon R. Guidelines for the management of acute pancreatitis. J Gastroenterol Hepatol 2002; 17 Suppl:S15-39. [PMID: 12000591 DOI: 10.1046/j.1440-1746.17.s1.2.x] [Citation(s) in RCA: 264] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- J Toouli
- Flinders University, Adelaide, Australia.
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Kwon SK, Lee BS, Kim NJ, Lee HY, Chae HB, Youn SJ, Park SM. Is cholecystectomy necessary after ERCP for bile duct stones in patients with gallbladder in situ? Korean J Intern Med 2001; 16:254-9. [PMID: 11855156 PMCID: PMC4578061 DOI: 10.3904/kjim.2001.16.4.254] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The requirement for subsequent cholecystectomy in patients with gallbladder in situ after endoscopic removal of stones from the common bile duct (CBD) is controversial. The aims of this study were to assess the requirement for subsequent cholecystectomy for gallbladder-related symptoms, and to identify the patients who develop symptoms after the endoscopic removal of CBD stones. METHODS Of 241 patients with gallbladder in situ following endoscopic removal of stones from the CBD, 146 patients (78 men and 68 women; mean age 69 +/- 13 years, range 20-93) with a follow-up time of more than three months without elective cholecystectomy were enrolled in the study. Fifty-nine patients had gallbladder stones (single stones in 27 and multiple stones in 32) and 87 patients had gallbladder in situ without stones. The time from entry to the occurrences of death or cholecystectomy was evaluated retrospectively. Cox regression analysis was used to evaluate the risk factors associated with these events. RESULTS The mean duration of follow-up was 24.1 +/- 18.0 months (range 3-70 months). During follow-up, seven patients (4.8%) underwent cholecystectomy, on average 18.4 months after CBD stone removal, as the result of acute cholecystitis in four cases, biliary pain in two cases and acute pancreatitis in one case. Laparoscopic cholecystectomy was performed in four patients and open cholecystectomy in three patients. Post-operative morbidity occurred in two patients, with improvement after conservative management. Nine patients (6.2%) died as the result of unrelated biliary disease. Age, sex, presence of gallbladder stones, multiplicity of gallbladder stones and underlying disease did not correlate with subsequent cholecystectomy by Cox regression analysis. CONCLUSION Elective cholecystectomy is not warranted in patients with bile duct stones when the common duct can be cleared of stones by endoscopic sphincterotomy. We could not find any clinical predictors of further symptoms or complications arising from the retained gallbladder.
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Affiliation(s)
- S K Kwon
- Department of Internal Medicine, Chungbuk National University College of Medicine, San 48, Gaeshin-dong, Hungduk-ku, Cheongju, Korea, 361-763
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Sugiyama M, Atomi Y. Medium-term effects of endoscopic papillary balloon dilation on gallbladder motility. Gastrointest Endosc 2001; 54:459-63. [PMID: 11577307 DOI: 10.1067/mge.2001.117516] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Endoscopic papillary balloon dilation (EPBD) for removal of bile duct stones tends to preserve papillary function. However, EPBD may exert beneficial or deleterious effects on gallbladder motility. This was a prospective, medium-term investigation (2 years) of the effects of EPBD on gallbladder motility. METHODS Twelve patients with intact gallbladders (6 with and 6 without gallbladder stones) who underwent EPBD for choledocholithiasis were enrolled in this study. Gallbladder motility was examined before EPBD and at 7 days, 1 month, 1 year, and 2 years after EPBD. Gallbladder volumes, measured after fasting and after ingestion of dried egg yolk, were determined by US. RESULTS All patients were asymptomatic during the 2-year follow-up period. Before EPBD, particularly in patients with cholelithiasis, the gallbladder had a larger fasting volume and lower yolk-stimulated maximum contraction compared with normal control subjects. Seven days after EPBD, fasting volume was decreased and maximum contraction was increased, both significantly compared with pre-EPBD values and regardless of the presence or absence of gallbladder stones. At 1 month, 1 year, and 2 years after EPBD, these changes were far less evident and gallbladder function did not differ significantly from baseline. CONCLUSION EPBD does not adversely affect gallbladder motility in the medium-term (2 years). In terms of gallbladder motility, EPBD does not appear to increase the future risk of acute cholecystitis or gallbladder stone formation.
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Affiliation(s)
- M Sugiyama
- First Department of Surgery, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611 Japan
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Yi SY. Recurrence of biliary symptoms after endoscopic sphincterotomy for choledocholithiasis in patients with gall bladder stones. J Gastroenterol Hepatol 2000; 15:661-4. [PMID: 10921421 DOI: 10.1046/j.1440-1746.2000.02192.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND There are a few reports regarding the long-term results of endoscopic sphincterotomy (EST). However, little data is available on the recurrence of biliary symptoms after EST for choledocholithiasis, in patients with gall bladder stones. METHODS All patients had gall bladder and common bile duct stones (n = 60; age 32-84 years, median age 55 years), and had received an EST. One group of these patients had a laparoscopic or open cholecystectomy (n = 39; group A), while the other group did not (n = 21; group B). The follow-up- period ranged from 5 to 54 months (average 22 months). RESULTS Complications included the recurrence of common bile duct stones, recurrent acute cholecystitis, postoperative bile leakage and papillary stenosis. Nine patients (15%) had a recurrence of biliary symptoms. Two significant prognostic factors for the recurrence of biliary symptoms were identified by multivariate analysis; namely an intact gall bladder and a dilated common bile duct. The recurrence rate of biliary symptoms in group B was 20.4%, while in group A it was 10.3% (P< 0.01). Patients with a larger than average common bile duct diameter (mean diameter 14 mm) were more prone to the recurrence of symptoms than those with a smaller common bile duct diameter (mean diameter 10 mm, P< 0.016). The hospital stay period was 8.9 +/- 3.1 days in group A and 2.8 +/- 1.9 days in group B (P< 0.01). CONCLUSIONS Biliary symptom recurrence occurred in a considerable proportion of patients after EST for the treatment of choledocholithiasis, in patients with gall bladder stones. The prognostic factors associated with the recurrence of biliary symptoms were an intact gall bladder and a dilated common bile duct diameter. Regardless of their short stay in hospital, non-cholecystectomy patients had a higher rate of recurrent biliary symptoms than cholecystectomy patients.
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Affiliation(s)
- S Y Yi
- Department of Internal Medicine, Ewha Womans University College of Medicine, Medical Research Center, Seoul, Korea.
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Saito M, Tsuyuguchi T, Yamaguchi T, Ishihara T, Saisho H. Long-term outcome of endoscopic papillotomy for choledocholithiasis with cholecystolithiasis. Gastrointest Endosc 2000; 51:540-5. [PMID: 10805838 DOI: 10.1016/s0016-5107(00)70286-0] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Although endoscopic papillotomy is now considered established treatment for choledocholithiasis, therapeutic results of endoscopic papillotomy alone without subsequent cholecystectomy in patients with cholecystolithiasis have not been well evaluated. The aim of this study was to assess the long-term outcome of endoscopic papillotomy for these patients. METHODS Patients admitted with choledocholithiasis and cholecystolithiasis from 1976 to 1993 were studied retrospectively. Of 385 patients in whom the bile duct was cleared by endoscopic papillotomy and endoscopic stone extraction, 371 patients (195 men and 176 women; mean age 65.4 years) were followed. Predisposing risk factors for late complications were analyzed. RESULTS The mean duration of follow-up was 7.7 years. Cholecystitis and recurrence of choledocholithiasis as late complications occurred in 22 cases (5.9%) and 36 cases (9.7%), respectively. Cholecystitis, including 1 severe case, resolved with conservative treatment. Recurrent choledocholithiasis was successfully treated endoscopically except in 1 case. No significant risk factors were identified for cholecystitis. The presence of pneumobilia (p = 0.0016) and the need for lithotripsy (p = 0.0342) were found to be significant risk factors for the recurrence of choledocholithiasis. CONCLUSIONS Long-term outcome of endoscopic papillotomy in patients with choledocholithiasis and cholecystolithiasis was found to be relatively favorable. Cholecystectomy after endoscopic papillotomy is not always necessary in the management of cholecystolithiasis.
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Affiliation(s)
- M Saito
- First Department of Medicine, Chiba University School of Medicine, Chiba, Japan
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Abstract
BACKGROUND Endoscopic papillary balloon dilation for treatment of bile duct stones is likely to preserve papillary function. However, endoscopic papillary balloon dilation may affect gallbladder motility. We investigated the effects of endoscopic papillary balloon dilation on gallbladder motility. METHODS Ten patients with an intact gallbladder (six with and four without gallbladder stones) who underwent endoscopic papillary balloon dilation for choledocholithiasis were studied. Gallbladder motility was examined before and 7 days and 1 month after endoscopic papillary balloon dilation. Gallbladder volume, while fasting and after dried egg yolk ingestion, was determined by ultrasonography. RESULTS Before endoscopic papillary balloon dilation, particularly in patients with gallbladder stones, the gallbladder showed significantly larger fasting volume and lower yolk-stimulated maximum contraction compared with control subjects. Seven days after endoscopic papillary balloon dilation, fasting volume was decreased and maximum contraction was increased, regardless of the presence of gallbladder stones, with significant differences from the values before endoscopic papillary balloon dilation. One month after endoscopic papillary balloon dilation, these changes were reduced and gallbladder function did not differ significantly from baseline. CONCLUSIONS After endoscopic papillary balloon dilation, gallbladder motility improves transiently at 7 days but returns to baseline at 1 month. In terms of gallbladder motility, endoscopic papillary balloon dilation does not seem to increase the subsequent risk of acute cholecystitis.
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Affiliation(s)
- M Sugiyama
- First Department of Surgery, Kyorin University School of Medicine, Tokyo, Japan
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Lai KH, Lin LF, Lo GH, Cheng JS, Huang RL, Lin CK, Huang JS, Hsu PI, Peng NJ, Ger LP. Does cholecystectomy after endoscopic sphincterotomy prevent the recurrence of biliary complications? Gastrointest Endosc 1999; 49:483-487. [PMID: 10202063 DOI: 10.1016/s0016-5107(99)70047-7] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The intact gallbladder after endoscopic sphincterotomy is thought to be a potential risk factor for recurrent biliary complications. The aim of this non-randomized prospective study was to investigate whether cholecystectomy soon after endoscopic sphincterotomy could prevent the recurrence of biliary complications. METHODS From January 1991 to October 1995, 140 patients with intact gallbladder underwent endoscopic sphincterotomy for clearance of stones in the bile duct. Of the 140 patients, 46 underwent elective cholecystectomy soon after sphincterotomy (group A) and 94 did not (group B). All 140 patients had quantitative cholescintigraphy after normalization of liver function and were followed on a regular basis with liver biochemistry, sonography, and/or computed tomography. Endoscopic retrograde cholangiography was also performed if a recurrent biliary problem was suspected. RESULTS After a median 43 months (range 23 to 80) of follow-up, 5 patients in group A developed bile duct stones whereas 12 patients in group B had recurrent stones; 4 patients in group A versus 6 patients in group B had recurrent biliary symptoms. One patient in group A and 5 patients in group B with recurrent biliary stones were without symptoms. In group B, the age, gender, diameter of the bile duct, preexisting cholelithiasis, abnormal filling of the gallbladder on quantitative cholescintigraphy, and presence of juxtapapillary diverticulum were not found to be the significant factors affecting the recurrence of biliary symptoms or stones. Endoscopic removal of recurrent biliary stones was successful in all patients. Three patients in group B underwent cholecystectomy after abatement of symptoms. CONCLUSION Elective cholecystectomy after endoscopic sphincterotomy does not reduce the incidence of recurrent biliary complications.
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Affiliation(s)
- K H Lai
- Department of Internal Medicine, Veterans General Hospital Kaohsiung, National Yang Ming University, Taiwan, Republic of China
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Tanaka M, Takahata S, Konomi H, Matsunaga H, Yokohata K, Takeda T, Utsunomiya N, Ikeda S. Long-term consequence of endoscopic sphincterotomy for bile duct stones. Gastrointest Endosc 1998; 48:465-9. [PMID: 9831833 DOI: 10.1016/s0016-5107(98)70086-0] [Citation(s) in RCA: 136] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND There are many reports of early- and intermediate-term results of endoscopic sphincterotomy. However, few data are available on long-term clinical outcome of endoscopic sphincterotomy for removal of common bile duct stones. METHODS Of 419 patients who underwent endoscopic sphincterotomy, follow-up data were obtained in 410 patients (98%). The period ranged from 1 month to 20 years (average 122 months). RESULTS Late complications included recurrence of stones (12.3%), acute cholangitis, acute cholecystitis (22% of 32 patients with gallstones, 0% of 88 patients without gallstones), new gallstone formation (6 patients), liver abscess (5 patients), and biliary carcinoma (8 patients). All of the recurrent stones were bilirubinate irrespective of the type of stone at sphincterotomy. Cholangitis and liver abscess occurred in 31% and 11%, respectively, of patients with residual intrahepatic stones but not in patients with complete intrahepatic stone clearance. CONCLUSIONS Late complications occur in a considerable proportion of patients after endoscopic sphincterotomy for the treatment of common bile duct stones, including stone recurrence, acute cholecystitis (which occurs only in patients with gallstones), liver abscess in patients with residual intrahepatic stones, and biliary carcinoma. The fact that the recurrent stones are invariably of the bilirubinate type, irrespective of the type of stones at initial treatment, suggests that bacterial infestation due to ablation of the sphincter mechanism may have a causative role.
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Affiliation(s)
- M Tanaka
- Department of Surgery I, Kyushu University Faculty of Medicine and Fukuoka University School of Medicine, Japan
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Keulemans YC, Rauws EA, Huibregtse K, Gouma DJ. Current management of the gallbladder after endoscopic sphincterotomy for common bile duct stones. Gastrointest Endosc 1997; 46:514-9. [PMID: 9434218 DOI: 10.1016/s0016-5107(97)70006-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Traditionally, a cholecystectomy is performed after successful endoscopic sphincterotomy and removal of common bile duct (CBD) stones, except in patients of advanced age or with substantial comorbidity. In practice, however, the gallbladder is left in situ more frequently now in patients without contraindications for surgery. The criteria by which patients are selected for an elective cholecystectomy are unclear. The aim of the present study was to establish the proportion of patients for whom a "wait-and-see" strategy was advised and to determine which, if any, patient characteristics had influenced this decision. METHODS This study included 71 patients, all younger than 80 years of age, with both CBD stones and a gallbladder containing stones in whom endoscopic clearance of bile duct stones was achieved. RESULTS Three patients underwent a cholecystectomy within 1 week because of acute cholecystitis. Among the remaining 68 patients, cholecystectomy was recommended for 42 patients and a wait-and-see strategy was advised for 26 patients. Patient characteristics were identical in both groups except for the American Society of Anesthesiologists Physical Status (ASA) score. The ASA score was higher in the wait-and-see group, but 69% of the patients in this group had an ASA score of I or II. Six patients in the wait-and-see group had symptoms; five patients underwent cholecystectomy. The outcome of surgery was no worse in this group than in the cholecystectomy group. CONCLUSIONS Selection of patients for either elective cholecystectomy or wait-and-see was not based on established criteria but mainly dependent on preference of the specialist. The outcome of surgery, indicated in 23% of the patients in the wait-and-see group was comparable with elective cholecystectomy. A controlled trial comparing both treatment options in patients younger than 80 years of age should be performed.
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Affiliation(s)
- Y C Keulemans
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
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Dhiman RK, Phanish MK, Chawla YK, Dilawari JB. Gallbladder motility and lithogenicity of bile in patients with choledocholithiasis after endoscopic sphincterotomy. J Hepatol 1997; 26:1300-5. [PMID: 9210617 DOI: 10.1016/s0168-8278(97)80465-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND/AIMS Ablation of the sphincter of Oddi has been shown to inhibit gallstone formation in the prairie dog model, probably by alleviating gallbladder bile stasis. The effect of endoscopic sphincterotomy (ES) on gallbladder emptying and lithogenicity of bile has not been studied adequately in humans. We, therefore, studied the changes in gallbladder emptying and lithogenicity of bile following ES in patients with choledocholithiasis and gallbladder in situ. METHODS Thirteen patients with choledocholithiasis with intact gallbladder underwent ES and common bile duct clearance. Eight patients had concomitant gallstones. Gallbladder emptying was studied by real time ultrasonography after stimulation by ceruletid infusion. Fasting gallbladder bile was collected during endoscopic retrograde cholangiography by placing a 7F or 8F catheter in the common bile duct and after ceruletid stimulation of gallbladder for bile microscopy and cholesterol nucleation time determination. Gallbladder emptying, nucleation time and bile microscopy were performed before ES and again between 4 and 8 weeks after ES after cholangiographic confirmation of clearance of common bile duct stones. RESULTS Fasting and residual gallbladder volumes decreased and ejection fraction increased significantly following ES, suggesting decreased stasis and improved emptying of gallbladder. Nucleation time was prolonged and cholesterol crystal index in bile decreased after ES, suggesting decreased lithogenicity. The decrease in gallbladder volumes and increase in ejection fraction after ES were observed in both groups of patients, with or without concomitant gallstones. CONCLUSIONS ES decreases the stasis of gallbladder bile, improves gallbladder emptying and decreases the lithogenicity of bile in patients with gallstone disease as reflected by prolongation in nucleation time. ES may find a role as an adjunct to oral bile acid therapy and extracorporeal shock wave lithotripsy in addition to a prophylactic role of preventing gallstone formation in high risk groups.
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Affiliation(s)
- R K Dhiman
- Department of Hepatology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
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Abstract
BACKGROUND Some of patients with an intact gall bladder develop acute cholecystitis or have gall bladder stone formation after endoscopic sphincterotomy. Endoscopic sphincterotomy may affect gall bladder motility. AIMS To prospectively evaluate longterm effect of endoscopic sphincterotomy on gall bladder motility. PATIENTS Thirty two patients with an intact gall bladder (15 with and 17 without gall bladder stones) who underwent endoscopic sphincterotomy for choledocholithiasis. METHODS Gall bladder function was examined before and at from seven days to five years after sphincterotomy. Gall bladder volume, at fasting and after caerulein administration, was determined by ultrasonography. RESULTS After endoscopic sphincterotomy, the enlarged orifice remained patent during a five year follow up period. One patient with gall bladder stones subsequently developed acute cholecystitis, the remaining being asymptomatic. In the patients before sphincterotomy, particularly in those with gall bladder stones, the gall bladder showed larger fasting volume and lower caerulein stimulated maximum contraction than normal controls. Throughout five years after sphincterotomy, fasting volume of the gall bladder decreased and its maximum contraction increased, regardless of gall bladder stones; significantly different from the values before sphincterotomy (p < 0.05). CONCLUSIONS Endoscopic sphincterotomy decreases fasting volume of the gall bladder and increases its contraction ability for a long period. These changes may rather decrease the risk of future acute cholecystitis or gall stone formation.
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Affiliation(s)
- M Sugiyama
- First Department of Surgery, Kyorin University School of Medicine, Tokyo, Japan
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Tekant Y, Bilge O, Acarli K, Alper A, Emre A, Arioğul O. Endoscopic sphincterotomy in the treatment of postoperative biliary fistulas of hepatic hydatid disease. Surg Endosc 1996; 10:909-11. [PMID: 8703149 DOI: 10.1007/bf00188481] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Ten patients with postoperative external biliary fistula treated by endoscopic sphincterotomy are reported. METHODS Nine of these patients were operated for hepatic hydatid disease and one for a liver abscess. Mean daily output of bile through the fistulae which were present for 5-39 days was approximately 500 cc. RESULTS Treatment was successful in nine patients with closure of the fistulae in 2-15 days (mean, 7 days). No response was obtained in one patient who was reoperated, and an intrahepatic biliary duct was found to be completely eroded by the cyst wall. CONCLUSIONS Endoscopic sphincterotomy should be the first-line treatment for postoperative external biliary fistulae related to hepatic hydatid disease.
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Affiliation(s)
- Y Tekant
- Hepatopancreatobiliary Surgery Unit, Istanbul Medical Faculty, University of Istanbul, Turkey
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Lai KH, Peng NJ, Cheng JS, Lo GH, Wang EM, Wang NM, Huang RL, Chang CF, Lin CK, Chen SM. Gallbladder function and recurrent stones of the biliary tract in patients after endoscopic sphincterotomy. Scand J Gastroenterol 1996; 31:612-5. [PMID: 8789902 DOI: 10.3109/00365529609009136] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Change in gallbladder function may occur in patients with an intact gallbladder after endoscopic sphincterotomy (EST). This study was designed to evaluate the factors influencing gallbladder filling after EST and the correlation between gallbladder function and stone recurrence. METHODS Sixty Chinese patients with symptomatic choledocholithiasis and an intact gallbladder received EST to clear the bile ducts. They were further investigated with sphincter of Oddi manometry (SOM), quantitative cholescintigraphy (QC), and long-term clinical follow-up. RESULTS Fifty-six of the 60 patients in the study group were confirmed to have a loss of sphincteric function by SOM. QC showed normal gallbladder filling in 35 of these patients and delayed or non-filling in 21 patients. A significantly higher incidence of normal gallbladder filling occurred in patients with juxtapapillary diverticulum than in those without (P < 0.02), but preexisting cholecystolithiasis had no effect on it. During the follow-up period (median, 32 months: range, 9-54 months) 10 of 56 patients developed recurrent choledocholithiasis. There was no correlation between the status of gallbladder filling, preexisting cholecystolithiasis, and recurrent stones, but 9 of the 10 patients with recurrent stones had a juxtapapillary diverticulum. Repeated endoscopic treatment was satisfactory in eight patients, and only two patients received cholecystectomy. CONCLUSIONS EST does not alter gallbladder function in most patients. Juxtapapillary diverticulum may facilitate gallbladder filling after EST, but it is also a possible factor for recurrent choledocholithiasis.
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Affiliation(s)
- K H Lai
- Division of Gastroenterology, Veterans General Hospital-Kaohsiung, Taiwan
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Hammarstrom LE, Holmin T, Stridbeck H. Endoscopic treatment of bile duct calculi in patients with gallbladder in situ: long-term outcome and factors. Scand J Gastroenterol 1996; 31:294-301. [PMID: 8833361 DOI: 10.3109/00365529609004881] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Whether endoscopic sphincterotomy (EST) in elderly and/or high-risk patients with common bile duct calculi (CBD) and the gallbladder in situ should be followed by routine cholecystectomy is still a subject of controversy. METHODS To identify factors predictive of subsequent biliary tract symptoms after EST and bile duct clearance, we reviewed 265 patients with intact gallbladder and CBD calculi who were considered for EST in our department from 1981 to 1992. In 15 of 265 patients endoscopic treatment was not carried out, and the records of 4 patients were missing. RESULTS Complete removal of all bile duct calculi failed in 27 patients (11%). Cholecystectomy was performed in 35 patients (16%) with cleared bile ducts 1-765 days (median, 60 days) after EST, in spite of absence of recurrent symptoms from the biliary tract. The remaining 184 patients have been retrospectively followed up for 14-150 months (median, 69 months). Cholecystectomy was required in 35 because of acute cholecystitis (n = 23) or biliary colic (n = 12). Of the cholecystectomies 86% were performed within 24 months after EST and only one after 4 years of follow-up. Increased frequency of cholecystectomy was found in patients with complete opacification of the gallbladder at endoscopic cholangiography (p = 0.005). This was especially evident in patients younger than 80 years (p = 0.002). Cholecystectomy was also required more often in patients with gallbladder calculi (p = 0.02). The risk of cholangitis in patients without recurrent stones was higher in those with juxtapapillary diverticula (p = 0.02). Fifty-nine patients without and 17 with mild to moderate symptoms from the biliary tract died after a median time of 39 and 46 months, respectively. Seventy-three patients are alive, and 59 are symptom-free. Ten patients have had and four still have complaints of mild to moderate biliary tract symptoms. They have been followed for up to 16-146 months (median, 40 months). CONCLUSIONS These findings confirm that endoscopic treatment alone in this group of patients is a feasible treatment principle. Recognition of the registered risk factors might be helpful when selecting patients for subsequent cholecystectomy.
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Affiliation(s)
- L E Hammarstrom
- Dept. of Surgery and Diagnostic Radiology, University of Lund, Sweden
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Hammarström LE, Holmin T, Stridbeck H, Ihse I. Long-term follow-up of a prospective randomized study of endoscopic versus surgical treatment of bile duct calculi in patients with gallbladder in situ. Br J Surg 1995; 82:1516-21. [PMID: 8535807 DOI: 10.1002/bjs.1800821121] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Eighty-three patients with bile duct calculi were entered in a prospective randomized study of endoscopic sphincterotomy (ES) and stone removal (group 1) versus surgery alone (group 2), and were followed for more than 5 years. In group 1 endoscopic stone clearance was successful in 35 of 39 patients. Thirteen patients subsequently had cholecystectomy with (n = 7) or without (n = 6) biliary symptoms and one had a cholecystostomy for acute cholecystitis. Two patients have had mild biliary colic or pancreatitis. Two patients died from gallbladder carcinoma after 9 days and 18 months. In group 2 bile duct stones were cleared surgically in 37 of 41 patients. Late complications occurred in two patients (incisional hernia and recurrent stone). One patient with gallbladder carcinoma was cured and another died after 16 months. Early major and minor complications occurred in three and four respectively of 39 patients in group 1, and in three and six respectively of 41 patients in group 2. There were no deaths. During follow-up the total morbidity rate reached 28 percent (11 of 39) and 5 percent (two of 41) (P = 0.005) and the non-biliary related mortality rate was 31 percent (12 of 39) and 10 percent (four of 41) (P = 0.02) in groups 1 and 2 respectively. Nine patients in group 1 and two in group 2 died from heart disease (P = 0.02). Total hospital stay was 2-42 (median 13) days and 6-36 (median 16) days in groups 1 and 2 respectively (P not significant). Endoscopic and surgical treatment of bile duct calculi in middle-aged and elderly patients with gallbladder in situ are equally effective in the long term. However, the significantly increased mortality rate from heart disease in patients treated endoscopically compared with those treated surgically might speak in favour of operation.
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Abstract
Demands for less invasive, more cost-effective therapy have revolutionized the management of gallstones over the past 10 years. There are no reliable methods of permanently reversing the pathophysiologic defects that cause gallstones. Open cholecystectomy (OC), the gold standard for managing symptomatic cholelithiasis, has been largely replaced by laparoscopic cholecystectomy (LC), which has the advantages of a minimal hospital stay and quicker return to work. Other adjunctive therapies, limited in applicability to selected patients, include oral bile acid therapy (BAT), dissolutional agents, and extracorporeal shock wave lithotripsy. Choledocholithiasis (CDL), formerly managed exclusively with surgical common duct exploration, is increasingly treated with therapeutic biliary endoscopy. Methods of laparoscopic common bile duct exploration are being developed. Optimal algorithms for applying these techniques to patients undergoing LC are evolving. In a sense, the solution to all, or certainly most, gallstones now can be seen through a scope.
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Affiliation(s)
- C F Gholson
- Department of Medicine, Louisiana State University School of Medicine, Shreveport 71130
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Abstract
The surgical risk of common duct exploration for the treatment of biliary calculi is considerably higher than that of cholecystectomy. Therefore, introduction of endoscopic sphincterotomy in 1974 was a major advance. It has become the therapy of choice in cholecystectomized patients or in those with an increased operative risk. Endoscopic sphincterotomy has a mortality rate of around 1% and a morbidity rate of 7%. These figures compare favourably with open surgery, especially in old patients. The procedure fails in about 10% of all patients referred for endoscopic removal of their calculi. However, several techniques have been described or are currently under evaluation to overcome these failures: intracorporeal or extracorporeal lithotripsy, long-term stenting of the bile duct, or direct application of solvents. Long-term follow-up studies show that between 2% and 20% of successfully managed patients may develop recurrent stones, mainly caused by bile stasis and infection. Patients with a functioning gall-bladder and no concomitant gall-bladder stones probably do not require cholecystectomy after successful endoscopic treatment of their choledochal stones. While endoscopic stone removal has replaced surgery in the elderly frail patients it has no major advantages in the young and fit patients, especially when the gall-bladder is still in situ.
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Affiliation(s)
- T Sauerbruch
- Medical Department II, University of Munich, Federal Republic of Germany
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48
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Affiliation(s)
- M R Jacyna
- Department of Medicine, St Mary's Hospital Medical School, Imperial College, University of London, United Kingdom
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49
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Abstract
Laparoscopic cholecystectomy is a newly developed technique for removing the gallbladder. Its future is very promising and this operation will probably become the preferred method of cholecystectomy for most patients. However, the limitations of laparoscopic cholecystectomy should be realized and great care must be taken to avoid technical complications. If laparoscopic cholecystectomy is associated with a much higher incidence of injuries to the bile duct than is traditional open cholecystectomy, its promise of decreasing pain, disability, and costs to patients undergoing cholecystectomy will be unfulfilled. The practicing general surgeon should learn laparoscopic techniques, since much of the future of abdominal surgery will ultimately reside in applying "less invasive" methods to perform standard operations. When embarking on a new procedure such as laparoscopic cholecystectomy, it is imperative that the surgeon remember the basis of his or her craft, primum non nocere.
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Affiliation(s)
- N J Soper
- Washington University School of Medicine, St. Louis, Missouri
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Hill J, Martin DF, Tweedle DE. Risks of leaving the gallbladder in situ after endoscopic sphincterotomy for bile duct stones. Br J Surg 1991; 78:554-7. [PMID: 2059804 DOI: 10.1002/bjs.1800780512] [Citation(s) in RCA: 57] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
There is controversy concerning the subsequent clinical course of patients whose gallbladder is left in situ following successful endoscopic removal of stones from their common bile ducts. A total of 191 patients (median age 76 years) were reviewed between 12 and 100 months (mean 38 months) after endoscopic sphincterotomy. Ten patients (5.2 per cent) had symptoms requiring cholecystectomy which was uneventful, nine in the first year. Cholangitis at presentation or failure to fill the gallbladder by endoscopic retrograde cholangiography were not helpful in identifying these patients. Forty-nine (25.6 per cent) patients died during the review period from non-biliary pathology (usually cardiovascular). Elective cholecystectomy is not required in elderly patients with symptomatic bile duct stones if the common bile duct can be cleared of stones after endoscopic sphincterotomy.
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Affiliation(s)
- J Hill
- Department of Surgery, University Hospital of South Manchester, UK
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