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Lammert F, Wittenburg H. Gallstones: Prevention, Diagnosis, and Treatment. Semin Liver Dis 2024; 44:394-404. [PMID: 39095030 DOI: 10.1055/a-2378-9025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
Gallstones are common and affect up to 20% of the general adult population and >20% of them will develop symptoms or complications of cholelithiasis. The high risk of gallbladder stone formation can be reduced by ursodeoxycholic acid in the case of significant weight reduction resulting from diet or bariatric surgery. Laparoscopic cholecystectomy is indicated for symptomatic gallstones, as the risk of recurrence or complications increases over the course of the disease. Biliary colic is treated with nonsteroidal anti-inflammatory drugs and spasmolytics; opioids can also be used in cases of severe acute pain. Acute cholecystitis represents a common complication of gallbladder stones and a cholecystectomy should be performed early electively, i.e., within 24 hours of admission to hospital. Symptomatic bile duct stones are primarily treated endoscopically. Immediate anti-infective therapy is mandatory in acute cholangitis. Although knowledge on the genetics and pathophysiology of gallstones has increased, current treatment algorithms remain predominantly invasive, based on interventional endoscopy and surgery. Future efforts should focus on novel strategies to prevent the development of gallstones.
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Affiliation(s)
- Frank Lammert
- Health Sciences, Hannover Medical School (MHH), Hannover, Germany
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Sharma SS, Maharshi S, Sapra B, Nijhawan S, Sharma D. Outcome of forgotten biliary stents for more than five years-A two-decade experience. Indian J Gastroenterol 2024; 43:768-774. [PMID: 38206449 DOI: 10.1007/s12664-023-01493-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 11/24/2023] [Indexed: 01/12/2024]
Abstract
BACKGROUND AND OBJECTIVES Prolonged biliary stenting may lead to complications such as cholangitis, stentolith and stent migration. There is limited data on forgotten biliary stents for more than five years in literature. The aim of this retrospective study was to analyze the complications and outcomes in patients who forgot to get their biliary stents removed or exchanged for more than five years. METHODS The study population included patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) and plastic biliary stent placements in a tertiary care center from 1990 to 2022 for benign biliary diseases. Loss to follow-up and subsequent forgotten stent for more than five years were observed in 40 patients who underwent ERCP during this study period. We retrospectively analyzed the indications of stenting, present status of stent, complications and outcomes in the study patients. RESULTS The mean age of the study patients was 51.5 ± 11.5 years with 27 females. Indications of biliary stent placement were choledocholithiasis (33, 82.5%), bile leak (3, 7.5%), benign biliary stricture (2, 5%) and choledochal cyst (2, 5%). The mean duration of forgotten stent was 5.9 ± 3.6 years. Presenting symptoms were abdominal pain (37, 92.5%), fever (26, 65%) and jaundice (32, 80%). Most commonly placed stent was 7 French double pigtail of 10 cm length. Complications in the study patients were cholangitis (35, 87.5%), internal migration (2, 5%), pancreatitis (1, 2.5%) and portal hypertension (1, 2.5%). The outcomes were stone removal (30, 90.9%), stent removal (31, 77.5%), stent reinsertion (19, 47.5%), broken stent (3, 7.5%) and surgery (2, 5%). CONCLUSIONS Prolonged duration (> 5 years) of forgotten stent is uncommon and is observed most commonly in patients with choledocholithiasis. The most common complication of long duration of forgotten stents was cholangitis followed by internal migration, pancreatitis and portal hypertension. Stone and stent removal was successful in a majority of patents, while surgery was required in less number of patients.
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Affiliation(s)
- Shyam Sunder Sharma
- Department of Gastroenterology, S M S Medical College and Hospitals, Room No. 218, Superspeciality Block, Jaipur, 302 004, India
| | - Sudhir Maharshi
- Department of Gastroenterology, S M S Medical College and Hospitals, Room No. 218, Superspeciality Block, Jaipur, 302 004, India.
| | - Bharat Sapra
- Department of Gastroenterology, S M S Medical College and Hospitals, Room No. 218, Superspeciality Block, Jaipur, 302 004, India
| | - Sandeep Nijhawan
- Department of Gastroenterology, S M S Medical College and Hospitals, Room No. 218, Superspeciality Block, Jaipur, 302 004, India
| | - Dhruv Sharma
- Department of Surgery, Mahatma Gandhi Medical College and Hospitals, Jaipur, 303 905, India
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Cui Y, Kozarek RA. Evolution of Pancreatic Endotherapy. Gastrointest Endosc Clin N Am 2023; 33:679-700. [PMID: 37709404 DOI: 10.1016/j.giec.2023.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
In the last half century, endotherapy for pancreatic diseases has changed considerably. Although endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) were introduced initially as diagnostic tools, they quickly evolved into therapeutic tools for preventing and managing complications of pancreatitis. More recently, therapeutic endoscopy has shown potential in palliation and cure of pancreatic neoplasms. This article discusses the changing landscape of pancreatic endotherapy as therapeutic ERCP and EUS were introduced and because they have evolved to treat different diseases.
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Affiliation(s)
- YongYan Cui
- Department of Gastroenterology, Virginia Mason Medical Center
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Koksal AS, Eminler AT, Parlak E. Fully Covered Metal Stents Safely Facilitate Extraction of Difficult Bile Duct Stones. Surg Laparosc Endosc Percutan Tech 2023; 33:152-161. [PMID: 36821696 DOI: 10.1097/sle.0000000000001147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 01/02/2023] [Indexed: 02/25/2023]
Abstract
BACKGROUND Ten to 15% of the common bile duct (CBD) stones require advanced endoscopic extraction techniques during endoscopic retrograde cholangiopancreatography. The study aimed to evaluate the efficacy and safety of fully covered self-expandable metal stents (FC-SEMS) for facilitating the extraction of difficult bile duct stones. METHODS Patients who received FC-SEMS for the extraction of difficult CBD stones were retrospectively reviewed. Group 1 included patients with extrahepatic stones above a distal CBD stricture, Group 2 included patients with intrahepatic stones above a hilar stricture, and Group 3 included patients with complex stone(s) and no biliary stricture. Complete stone clearance rate and complications of FC-SEMS treatment were evaluated. RESULTS The study group included 33 procedures on 32 patients (mean age: 55±17, 56.3% male). FC-SEMS was placed as a primary treatment in 15 (45.5%) procedures. Complete stone clearance was achieved in 84.6% of the procedures in Group 1, 100% in Group 2, and 87.5% in Group 3 ( P =0.23). Overall, complete stone clearance was achieved in 30 of the 33 procedures (90.9%). None of the patients developed pancreatitis, cholecystitis, or cholangitis. Stent migration occurred in 4 procedures (12.1%), and all were clinically insignificant. CONCLUSION FC-SEMS is effective and safe for facilitating treatment of difficult bile duct stones.
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Affiliation(s)
- Aydin Seref Koksal
- Faculty of Medicine, Department of Gastroenterology, Sakarya University, Sakarya
| | - Ahmet Tarik Eminler
- Faculty of Medicine, Department of Gastroenterology, Sakarya University, Sakarya
| | - Erkan Parlak
- Faculty of Medicine, Department of Gastroenterology, Hacettepe University, Ankara, Turkey
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Sbeit W, Khoury T, Kadah A, M. Livovsky D, Nubani A, Mari A, Goldin E, Mahamid M. Long-Term Safety of Endoscopic Biliary Stents for Cholangitis Complicating Choledocholithiasis: A Multi-Center Study. J Clin Med 2020; 9:2953. [PMID: 32932631 PMCID: PMC7564722 DOI: 10.3390/jcm9092953] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 08/27/2020] [Accepted: 09/10/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Treatment of cholangitis complicating choledocholithiasis includes biliary sphincterotomy and stone extraction. In certain cases of elderly comorbid patients with high risk for definitive endoscopic treatment, biliary stenting is the only measure for relieving biliary obstruction. AIM We aimed to report the safety of retained biliary stone. METHODS a multi-center, retrospective case-control study conducted at two Israeli medical centers from January 2013 to December 2018 including all patients 18 years of age or older who underwent ERCP and biliary stent insertion for the treatment of acute cholangitis due to choledocholithiasis. RESULTS Three-hundred and eight patients were identified. Eighty-three patients had retained long-term biliary stents of more than 6 months (group A) from insertion compared to 225 patients whose biliary stents were removed within a 6-month period (group B). The mean follow-up in group A was 66.1± 16.3 vs. 11.1 ± 2.7 weeks in group B. Overall complications during the follow-up were similar between groups A and B (6% vs. 4.9%, OR 1.24, Chi square 0.69). Similarly, the rate of each complication alone was not different when comparing group A to group B (3.6%, 1.2% and 1.2% vs. 2.7%, 0.44% and 1.8%) for cholangitis, stent related pancreatitis and biliary colic, respectively (Chi square 0.85). Even after 12 months, the rates of overall complications and each complication alone were not higher compared to less than 12 months (Chi square 0.72 and 0.8, respectively). CONCLUSION endoscopic biliary stenting for cholangitis complicating choledocholithiasis is safe for the long-term period without increase in stent related complications.
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Affiliation(s)
- Wisam Sbeit
- Department of Gastroenterology, Galilee Medical Center, Nahariya 2221006, Israel; (W.S.); (A.K.)
- Faculty of Medicine in the Galilee, Bar-Ilan University, Safed 13100, Israel;
| | - Tawfik Khoury
- Department of Gastroenterology, Galilee Medical Center, Nahariya 2221006, Israel; (W.S.); (A.K.)
- Faculty of Medicine in the Galilee, Bar-Ilan University, Safed 13100, Israel;
| | - Anas Kadah
- Department of Gastroenterology, Galilee Medical Center, Nahariya 2221006, Israel; (W.S.); (A.K.)
- Faculty of Medicine in the Galilee, Bar-Ilan University, Safed 13100, Israel;
| | - Dan M. Livovsky
- Gastroenterology Department, Sha’arei Zedek Medical Center, Jerusalem 9103102, Israel; (D.M.L.); (A.N.); (E.G.); (M.M.)
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112102, Israel
| | - Adi Nubani
- Gastroenterology Department, Sha’arei Zedek Medical Center, Jerusalem 9103102, Israel; (D.M.L.); (A.N.); (E.G.); (M.M.)
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112102, Israel
| | - Amir Mari
- Faculty of Medicine in the Galilee, Bar-Ilan University, Safed 13100, Israel;
- Gastroenterology and Endoscopy Units, The Nazareth Hospital, EMMS, Nazareth 16100, Israel
| | - Eran Goldin
- Gastroenterology Department, Sha’arei Zedek Medical Center, Jerusalem 9103102, Israel; (D.M.L.); (A.N.); (E.G.); (M.M.)
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112102, Israel
| | - Mahmud Mahamid
- Gastroenterology Department, Sha’arei Zedek Medical Center, Jerusalem 9103102, Israel; (D.M.L.); (A.N.); (E.G.); (M.M.)
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112102, Israel
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Akazawa Y, Ohtani M, Nosaka T, Saito Y, Takahashi K, Naito T, Ofuji K, Matsuda H, Hiramatsu K, Nemoto T, Nakamoto Y. Long-term prognosis after biliary stenting for common bile duct stones in high-risk elderly patients. J Dig Dis 2018; 19:626-634. [PMID: 30117280 DOI: 10.1111/1751-2980.12656] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 07/19/2018] [Accepted: 08/10/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To evaluate the long-term outcomes of complete common bile duct (CBD) stone removal and biliary stenting in elderly patients (≥85 years) with CBD stones. METHODS We retrospectively examined 65 patients who underwent complete CBD stone removal (the duct clearance group) and 40 patients who underwent biliary stenting (the biliary stenting group) between July 2006 and March 2016. To reduce selection bias, we also conducted a propensity score matching analysis and generated 30 pairs of patients. Cholangitis recurrence-free survival and overall survival were compared between the two groups and independent prognostic factors of survival were identified by univariate and multivariate analyses. RESULTS Cholangitis recurrence-free survival was significantly better in the duct clearance group than in the biliary stenting group (P < 0.001). Their overall survival did not significantly differ after propensity score matching (P = 0.388). In all cohorts, univariate analysis demonstrated that poor performance status and biliary stenting were factors of poor prognosis, and in multivariate analysis only performance status remained associated with poor prognosis for survival. Similarly, in the propensity score-matched cohort, only performance status independently predicted poorer survival (hazard ratio [HR] 2.726, 95% confidence interval [CI] 1.105-6.675, P = 0.029). The choice of endoscopic treatment was not a significant factor associated with prognosis (HR 1.354, 95% CI 0.678-2.701, P = 0.391). CONCLUSIONS Biliary stenting was similar to complete stone removal in terms of prognosis for long-term survival. Biliary stenting for CBD stones could be an effective therapeutic tool in high-risk elderly patients.
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Affiliation(s)
- Yu Akazawa
- Faculty of Medical Sciences, Second Department of Internal Medicine, Fukui University, Fukui, Japan
| | - Masahiro Ohtani
- Faculty of Medical Sciences, Second Department of Internal Medicine, Fukui University, Fukui, Japan
| | - Takuto Nosaka
- Faculty of Medical Sciences, Second Department of Internal Medicine, Fukui University, Fukui, Japan
| | - Yasushi Saito
- Faculty of Medical Sciences, Second Department of Internal Medicine, Fukui University, Fukui, Japan
| | - Kazuto Takahashi
- Faculty of Medical Sciences, Second Department of Internal Medicine, Fukui University, Fukui, Japan
| | - Tatsushi Naito
- Faculty of Medical Sciences, Second Department of Internal Medicine, Fukui University, Fukui, Japan
| | - Kazuya Ofuji
- Faculty of Medical Sciences, Second Department of Internal Medicine, Fukui University, Fukui, Japan
| | - Hidetaka Matsuda
- Faculty of Medical Sciences, Second Department of Internal Medicine, Fukui University, Fukui, Japan
| | - Katsushi Hiramatsu
- Faculty of Medical Sciences, Second Department of Internal Medicine, Fukui University, Fukui, Japan
| | - Tomoyuki Nemoto
- Faculty of Medical Sciences, Second Department of Internal Medicine, Fukui University, Fukui, Japan
| | - Yasunari Nakamoto
- Faculty of Medical Sciences, Second Department of Internal Medicine, Fukui University, Fukui, Japan
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Franzini T, Moura RN, Bonifácio P, Luz GO, de Souza TF, dos Santos MEL, Rodela GL, Ide E, Herman P, Montagnini AL, D’Albuquerque LAC, Sakai P, de Moura EGH. Complex biliary stones management: cholangioscopy versus papillary large balloon dilation - a randomized controlled trial. Endosc Int Open 2018; 6:E131-E138. [PMID: 29399609 PMCID: PMC5794432 DOI: 10.1055/s-0043-122493] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 10/25/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Endoscopic removal of biliary stones has high success rates, ranging between 85 % to 95 %. Nevertheless, some stones may be challenging and different endoscopic methods have evolved. Papillary large balloon dilation after sphincterotomy is a widely used technique with success rates ranging from 68 to 90 % for stones larger than 15 mm. Cholangioscopy allows performing lithotripsy under direct biliary visualization, either by laser or electrohydraulic waves, which have similar success rate (80 % - 90 %). However, there is no study comparing these 2 techniques. PATIENTS AND METHODS From April 2014 to June 2016, 100 patients were enrolled and randomized in 2 groups, using a non-inferiority hypothesis: cholangioscopy + electrohydraulic lithotripsy (group 1) and endoscopic papillary large balloon dilation (group 2). The main outcome was complete stone removal. Adverse events were documented. Mechanical lithotripsy was not performed. Failure cases had a second session with crossover of the methods. RESULTS The mean age was 56 years. 74 (75.5 %) patients were female. The initial overall complete stone removal rate was 74.5 % (77.1 % in group 1 and 72 % in group 2, P > 0.05). After second session the overall success rate achieved 90.1 %. Procedure time was significantly lower in group 2, - 25.2 min (CI95 % - 12.48 to - 37.91). There were no significant differences regarding technical success rate, radiologic exposure and adverse events. CONCLUSION Single-operator cholangioscopy-guided lithotripsy and papillary large balloon dilation are effective and safe approaches for removing complex biliary stones.
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Affiliation(s)
- Tomazo Franzini
- University of Sao Paulo Medical School – Department of Gastroenterology, Sao Paulo, Brazil,Corresponding author Tomazo Franzini, MD, PhD Av. Dr. Enéas de Carvalho Aguiar255 – Prédio dos Ambulatórios Pinheiros05403-000 Sao PauloSP – Brazil
| | - Renata Nobre Moura
- University of Sao Paulo Medical School – Department of Gastroenterology, Sao Paulo, Brazil
| | - Priscilla Bonifácio
- University of Sao Paulo Medical School – Department of Gastroenterology, Sao Paulo, Brazil
| | - Gustavo Oliveira Luz
- University of Sao Paulo Medical School – Department of Gastroenterology, Sao Paulo, Brazil
| | | | | | - Gustavo Luis Rodela
- University of Sao Paulo Medical School – Department of Gastroenterology, Sao Paulo, Brazil
| | - Edson Ide
- University of Sao Paulo Medical School – Department of Gastroenterology, Sao Paulo, Brazil
| | - Paulo Herman
- University of Sao Paulo Medical School – Department of Gastroenterology, Sao Paulo, Brazil
| | - André Luis Montagnini
- University of Sao Paulo Medical School – Department of Gastroenterology, Sao Paulo, Brazil
| | | | - Paulo Sakai
- University of Sao Paulo Medical School – Department of Gastroenterology, Sao Paulo, Brazil
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Sohn SH, Park JH, Kim KH, Kim TN. Complications and management of forgotten long-term biliary stents. World J Gastroenterol 2017; 23:622-628. [PMID: 28216968 PMCID: PMC5292335 DOI: 10.3748/wjg.v23.i4.622] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 12/16/2016] [Accepted: 12/21/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate complications and management outcomes of retained long-term plastic biliary stents.
METHODS Endoscopic plastic biliary stent placement was performed in 802 patients at Yeungnam University Hospital between January 2000 and December 2014. Follow-up loss with a subsequently forgotten stent for more than 12 mo occurred in 38 patients. We retrospectively examined the cause of biliary stent insertion, status of stents, complications associated with biliary stents and management outcomes of long-term plastic biliary stents. Continuous variables were analyzed using the t test. Observed frequencies in subsets of the study population were compared using Fisher’s exact test and χ2 tests. Statistical significance was defined as P < 0.05 (two-tailed).
RESULTS Mean age of patients was 73.7 ± 12 years and male-to-female ratio was 2.2:1. Indications of plastic biliary stent insertion were bile duct stones (63.2%, 24/38) and benign bile duct stricture (52.6%, 20/38). Mean duration of retained plastic stent was 22.6 ± 12.2 mo, and in 10 cases (26.3%), stents were retained for more than 24 mo. Common bile duct (CBD) stones or sludge were found in most cases (92.1%, 35/38). The most common complication was acute cholangitis (94.7%, 36/38). Stent removal by endoscopic approach was successfully performed in 92.1% (35/38) of the cases. In 3 cases, an additional plastic stent was inserted alongside the previous stent due to failure of the stent removal. Endoscopic removal of bile duct stones was successful in 73.7% (28/38) of the cases. When patients were divided into two groups by duration of stent placement (12 to 24 mo vs over 24 mo), there were no differences in the development of cholangitis, presence of biliary stones, and success rate of endoscopic removal of stones and biliary stents.
CONCLUSION The most common complication of retained long-term plastic biliary stents was acute cholangitis associated with CBD stones. Endoscopic management was successfully performed in most cases.
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Tao T, Zhang QJ, Zhang M, Zhu X, Sun SX, Li YQ. Using cholecystokinin to facilitate endoscopic clearance of large common bile duct stones. World J Gastroenterol 2014; 20:10121-10127. [PMID: 25110439 PMCID: PMC4123341 DOI: 10.3748/wjg.v20.i29.10121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 02/07/2014] [Accepted: 04/29/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the effect of cholecystokinin (CCK) during extracorporeal shockwave lithotripsy (ESWL) in the clearance of common bile duct (CBD) stones in endoscopic retrograde cholangiopancreatography (ERCP).
METHODS: Between January 2007 and September 2012, patients with large CBD stones who were treated with ESWL and ERCP were identified retrospectively. Patients were randomized in equal numbers to cholecystokinin (CCK) and no CCK groups. For each CCK case, a dose (3 ng/kg per min for 10 min) of sulfated octapeptide of CCK-8 was administered intravenously near the beginning of ESWL. ERCP was performed 4 h after a session of ESWL. The clearance rate of the CBD was assessed between the two groups.
RESULTS: A total of 148 consecutive cases (CCK group: 74, no CCK group: 74) were tallied. Overall there were 234 ESWLs and 228 ERCPs in the 148 cases. The use of CCK showed a significantly higher rate of successful stone removal in the first ESWL/ERCP procedure (71.6% vs 55.4%, P = 0.035), but resulted in similar outcomes in the second (42.8% vs 39.4%) and third (41.7% vs 40.0%) sessions, as well as total stone clearance (90.5% vs 83.8%). The use of mechanical lithotripsy was reduced in the CCK group (6.8% vs 17.6%, P = 0.023), and extremely large stone (≥ 30 mm) removal was higher in the CCK group (72.7% vs 41.7%, P = 0.038).
CONCLUSION: CCK during ESWL can aid with the clearance of CBD stones in the first ESWL/ERCP session. Mechanical lithotripsy usage was reduced and the extremely large stone (≥ 30 mm) clearance rate can be raised.
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Abstract
Recent advances in developmental biology have greatly expanded our understanding of progenitor cell programming and the fundamental roles that Sox9 plays in liver and pancreas organogenesis. In the last 2 years, several studies have dissected the behavior of the Sox9+ duct cells in adult organs, but conflicting results have left unanswered the long-standing question of whether physiologically functioning progenitors exist in adult liver and pancreas. On the other hand, increasing evidence suggests that duct cells function as progenitors in the tissue restoration process after injury, during which embryonic programs are sometimes reactivated. This article discusses the role of Sox9 in programming liver and pancreatic progenitors as well as controversies in the field.
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Affiliation(s)
- Yoshiya Kawaguchi
- Department of Clinical Application, Center for iPS cell Research and Application (CiRA), Kyoto University, Kyoto, Japan.
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11
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Is the addition of choleretic agents in multiple double-pigtail biliary stents effective for difficult common bile duct stones in elderly patients? A prospective, multicenter study. Gastrointest Endosc 2011; 74:96-102. [PMID: 21531412 DOI: 10.1016/j.gie.2011.03.005] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2010] [Accepted: 03/06/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND Temporary biliary stenting is both technically easy and feasible, and choleretic agents such as ursodeoxycholic acid (UDCA) and a terpene preparation may promote a reduction in stone size. However, there are few comparative data on the effectiveness of choleretic agents available. OBJECTIVE To investigate the efficacy of multiple double-pigtail stents with or without UDCA and terpene on difficult common bile duct (CBD) stones. DESIGN A prospective, multicenter study. SETTING Four tertiary-care referral centers. PATIENTS This study involved 51 patients. INTERVENTION In total, 51 elderly patients with comorbidities who had difficult CBD stones refractory to conventional methods were randomized to receive either multiple 7F double-pigtail stents (group A) or stents in combination with UDCA and terpene (group B) for a period of 6 months. MAIN OUTCOME MEASUREMENTS Stone size reduction, successful duct clearance, and complications. RESULTS Complete endoscopic duct clearance was achieved in 14 patients (73.7%) in group A and 19 patients (86.4%) in group B (P = .826). The mean size of CBD stones (transverse/longitudinal diameter, mean ± SD) was 19.12 ± 4.48 mm/20.47 ± 3.86 mm in group A and 21.30 ± 7.08 mm/22.58 ± 7.61 mm in group B. Stone size decreased significantly to 12.04 ± 3.26 mm/13.31 ± 5.12 mm and 13.67 ± 5.40 mm/14.04 ± 6.12 mm, respectively (P < .01). However, there was no statistical difference in stone size reduction between the two groups (P = .685, P = .289). No serious complications related to the stent or endoscopic procedures were observed, except for cholangitis (n = 1, group A) and distal stent migration (n = 2, group B). LIMITATIONS Small number of patients in East Asia. CONCLUSION Temporary multiple double-pigtail biliary stenting was a safe and feasible method of treating difficult and large CBD stones in elderly patients and contributed to a reduction in stone size and successful duct clearance. However, the addition of choleretic agents did not result in a statistical difference in stone size or rate of successful duct clearance.
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12
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Lee TH, Park SH, Lee SH, Lee CK, Lee SH, Chung IK, Kim HS, Kim SJ. Modified rendezvous intrahepatic bile duct cannulation technique to pass a PTBD catheter in ERCP. World J Gastroenterol 2010; 16:5388-90. [PMID: 21072905 PMCID: PMC2980691 DOI: 10.3748/wjg.v16.i42.5388] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The rendezvous procedure combines an endoscopic technique with percutaneous transhepatic biliary drainage (PTBD). When a selective common bile duct cannulation fails, PTBD allows successful drainage and retrograde access for subsequent rendezvous techniques. Traditionally, rendezvous procedures such as the PTBD-assisted over-the-wire cannulation method, or the parallel cannulation technique, may be available when a bile duct cannot be selectively cannulated. When selective intrahepatic bile duct (IHD) cannulation fails, this modified rendezvous technique may be a feasible alternative. We report the case of a modified rendezvous technique, in which the guidewire was retrogradely passed into the IHD through the C2 catheter after end-to-end contact between the tips of the sphincterotome and the C2 catheter at the ampulla’s orifice, in a 39-year-old man who had been diagnosed with gallbladder carcinoma with a metastatic right IHD obstruction. Clinically this procedure may be a feasible and timesaving technique.
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13
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Cho YD, Cheon YK, Moon JH, Jeong SW, Jang JY, Lee JS, Shim CS. Clinical role of frequency-doubled double-pulsed yttrium aluminum garnet laser technology for removing difficult bile duct stones (with videos). Gastrointest Endosc 2009; 70:684-9. [PMID: 19573867 DOI: 10.1016/j.gie.2009.03.1170] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2008] [Accepted: 03/20/2009] [Indexed: 02/08/2023]
Abstract
BACKGROUND Very few clinical trials have reported on the success rate of frequency-doubled double-pulse yttrium aluminum garnet (YAG) laser (FREDDY) technology for removal of difficult bile duct stones. OBJECTIVE Our purpose was to evaluate the role of FREDDY technology for removing difficult bile duct stones. DESIGN Nonrandomized, retrospective study. SETTING Academic medical center. PATIENTS Fifty-two patients with difficult bile duct stones were treated via the transpapillary route by using a FREDDY system. The inclusion criteria were impacted or large common bile duct stones (>15 mm, mean 23.5 mm, range 15-35 mm, mean number of stones 1.7, range 1-4). Laser lithotripsy was performed with cholangioscopy guidance in 7 patients and fluoroscopic guidance alone in 45 patients. MAIN OUTCOME MEASUREMENTS The success rate of complete stone removal and the complication rate related to the procedure. RESULTS Of the 52 patients treated via the transpapillary route, complete stone removal was achieved in 48 patients (92.3%). The complete removal of stones required a mean of 1.4 (range 1-2) endoscopic sessions. The rate of complications related to laser lithotripsy was 23.0% (acute pancreatitis, 3 cases; transient hemobilia, 8 cases; acute cholangitis, 1 case). LIMITATIONS Nonrandomized, retrospective design. CONCLUSION Laser lithotripsy by using the FREDDY system seems safe and effective and allows "blind" fragmentation of bile duct stones under fluoroscopic guidance only.
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Affiliation(s)
- Young Deok Cho
- Department of Internal Medicine, Institute for Digestive Research, Soon Chun Hyang University, College of Medicine, Seoul, Korea.
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Combination of endoprostheses and oral ursodeoxycholic acid or placebo in the treatment of difficult to extract common bile duct stones. Dig Liver Dis 2008; 40:453-9. [PMID: 18187374 DOI: 10.1016/j.dld.2007.11.012] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2007] [Revised: 11/02/2007] [Accepted: 11/14/2007] [Indexed: 12/11/2022]
Abstract
BACKGROUND When common bile duct (CBD) stones cannot be removed after conventional endoscopic techniques or mechanical lithotripsy, biliary stenting serves for further planned endoscopic attempt of stone removal or operation. The aim of our study was to investigate the effect of ursodeoxycholic acid (UDCA) or placebo plus endoprostheses on stones' fragmentation or size. METHODS Forty-one patients with difficult to extract CBD stones were prospectively studied. They were randomised to receive either a 10 Fr straight plastic stent and oral 750 mg UDCA (group A, 21 patients) or placebo (group B, 20 patients) daily for 6 months. RESULTS A total clearance of CBD was achieved in 16 patients (76.9%) of group A and 15 patients (75%) of group B. The stones remained unchanged in size in five patients (23.8%) of group A and five patients (25%) of group B. In seven patients (33%) of group A and five patients (25%) of group B a repeated ERCP demonstrated fragmentation of CBD stones that were easily extracted. A reduction in stones' size was observed in 8 patients (38%) of group A (1.61 +/- 0.32 cm before treatment vs. 1.21 +/- 0.24 cm after treatment, p = 0.002) and 10 patients (50%) of group B (1.61 +/- 0.35 cm before vs. 1.24+/-0.22 cm after treatment, p = 0.001). There was no statistically significant difference on stone size reduction (p = 0.602) and fragmentation (p=0.558) between the two groups. CONCLUSION The results of this study suggest that UDCA does not seem to contribute to the reduction in stones' size or stones' fragmentation during the endoprosthetic procedure.
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15
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Kim HJ, Park DI, Park JH, Cho YK, Sohn CI, Jeon WK, Kim BI, Kim SK. Multidetector computed tomography cholangiography with multiplanar reformation for the assessment of patients with biliary obstruction. J Gastroenterol Hepatol 2007; 22:400-5. [PMID: 17295774 DOI: 10.1111/j.1440-1746.2006.04503.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND We sought to evaluate the diagnostic use of multidetector computed tomography (MDCT) cholangiography with multiplanar reformation (MPR) for the assessment of patients with biliary obstruction. METHODS MDCT cholangiography with the MPR technique was performed in 58 patients who were thought to have biliary obstruction. No cholangiographic contrast agent was administered. MRCP in 24 patients, Endoscopic retrograde cholangiopancreatography (ERCP) in 46 patients and percutaneous transhepatic cholangiography (PTC) in 24 patients were performed. Eighteen patients underwent biopsy or surgery. The findings on MDCT cholangiography were compared with those of MRCP, ERCP, PTC, biopsy or surgery. RESULTS The findings of MDCT cholangiography were as follows: choledocholithiasis (n = 34, 56.7%), malignant stricture (n = 14, 23.3%), benign stricture (n = 1, 1.7%), and cholelithiasis (n = 11, 18.3%). A small common bile duct (CBD) stone in one patient could not be detected on MDCT cholangiography. One patient with a small stone in distal CBD detected on MDCT cholangiography had no stone on ERCP. Two patients with initial diagnoses of CBD stones by MDCT cholangiography were disclosed to have malignant bile duct stricture by reference examination. The sensitivity and specificity of MDCT cholangiography for the diagnosis of bile duct stones were 96.9% and 96.2%, respectively. The sensitivity and specificity of MDCT cholangiography for the diagnosis of bile duct stricture were 85.7% and 100%, respectively. The overall accuracy of MDCT cholangiography for the diagnoses of the causes of biliary obstruction was 89.8%. CONCLUSION MDCT cholangiography with the MPR technique is a fast and non-invasive technique with relatively high sensitivity and specificity for the diagnoses of the causes of biliary obstruction.
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Affiliation(s)
- Hong Joo Kim
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University, Seoul, Korea.
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16
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Abstract
Bile duct stones are routinely removed at time of endoscopic retrograde cholangiopancreatography (ERCP) after biliary sphincterotomy with standard balloon or basket extraction techniques. However, in approximately 10% to 15% of patients, bile duct stones may be difficult to remove due to challenging access to the bile duct (periampullary diverticulum, Billroth II anatomy, Roux-en-Y gastrojejunostomy), large (> 15 mm in diameter) bile duct stones, intrahepatic stones, or impacted stones in the bile duct or cystic duct. The initial approach to the removal of the difficult bile duct stone is to ensure adequate biliary sphincter orifice diameter with extension of biliary sphincterotomy or balloon dilation of the orifice. Mechanical lithotripsy is a readily available adjunct to standard stone extraction techniques and should be available in all ERCP units. If stone extraction fails with these maneuvers, two or more bile duct stents should be inserted, and ursodiol added to aid in duct decompression, stone fragmentation, and stone dissolution. Follow-up ERCP attempts to remove the difficult bile duct stones may be performed locally if expertise is available or alternatively referred to a tertiary center for advanced extracorporeal or intracorporeal fragmentation (mother-baby laser or electrohydraulic lithotripsy) techniques. Nearly all patients with bile duct stones can be treated endoscopically if advanced techniques are utilized. For the rare patient who fails despite these efforts, surgical bile duct exploration, percutaneous approach to the bile duct, or long-term bile duct stenting should be discussed with the patient and family to identify the most appropriate therapeutic option. A thoughtful approach to each patient with difficult bile duct stones and a healthy awareness of the operator/endoscopy unit limitations is necessary to ensure the best patient outcomes. Consultation with a dedicated tertiary ERCP specialty center may be necessary.
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Affiliation(s)
- Lee McHenry
- Indiana University Medical Center, Indianapolis, IN 46202, USA.
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Kim HC, Park SJ, Park SII, Park SH, Kim HJ, Shin HC, Bae WK, Kim IIY, Lee HK. Multislice CT cholangiography using thin-slab minimum intensity projection and multiplanar reformation in the evaluation of patients with suspected biliary obstruction. Clin Imaging 2005. [DOI: 10.1016/j.clinimag.2004.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Moon JH, Cha SW, Ryu CB, Kim YS, Hong SJ, Cheon YK, Cho YD, Kim YS, Lee JS, Lee MS, Shim CS, Kim BS. Endoscopic treatment of retained bile-duct stones by using a balloon catheter for electrohydraulic lithotripsy without cholangioscopy. Gastrointest Endosc 2004; 60:562-6. [PMID: 15472679 DOI: 10.1016/s0016-5107(04)02012-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Electrohydraulic lithotripsy is a highly effective method for fragmenting biliary stones, but direct visual control is required. The efficacy and the safety of electrohydraulic lithotripsy without cholangioscopy by using a balloon catheter were evaluated in patients with bile-duct stones that could not be extracted by using standard techniques. METHODS Nineteen patients with extrahepatic bile-duct stones that could not be extracted by using conventional endoscopic methods, e.g., mechanical lithotripsy, were selected to undergo electrohydraulic lithotripsy without peroral cholangioscopy. An electrohydraulic lithotripsy probe with a 3.0 F radio-opaque tip was inserted through a balloon catheter. Electrohydraulic lithotripsy was performed under fluoroscopy until the fragmented stone could be captured in a large basket for mechanical lithotripsy. Endoscopic removal of the fragments was attempted during the electrohydraulic lithotripsy session. RESULTS Stones were successfully fragmented in 17 of 19 patients. In 16 patients (84.2%), the bile duct was cleared of all stones. A mean of 1.8 endoscopic sessions was required for complete removal. Additional mechanical lithotripsy was performed in 9 (56.2%) of the 16 patients. Minor complications were noted in 4 patients (2 hemobilia, 1 pancreatitis, 1 cholangitis). There was no 30-day mortality. CONCLUSIONS For a selected group of patients with bile-duct stones not extractable by using standard techniques, fluoroscopically controlled electrohydraulic lithotripsy with a balloon catheter seems to be an effective method of fragmentation.
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Affiliation(s)
- Jong Ho Moon
- Digestie Disease Center, Institute for Digestive Research, Soon Chun Hyang University College of Medicine, Seoul, Korea
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19
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Katsinelos P, Galanis I, Pilpilidis I, Paroutoglou G, Tsolkas P, Papaziogas B, Dimiropoulos S, Kamperis E, Katsiba D, Kalomenopoulou M, Papagiannis A. The effect of indwelling endoprosthesis on stone size or fragmentation after long-term treatment with biliary stenting for large stones. Surg Endosc 2003; 17:1552-5. [PMID: 12915970 DOI: 10.1007/s00464-002-9240-9] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2002] [Accepted: 04/09/2003] [Indexed: 12/11/2022]
Abstract
BACKGROUND Endoscopic biliary stenting is often used for large or difficult common bile duct (CBD) stones, but the effect of indwelling endoprosthesis on size or fragmentation of stones after long-term treatment with biliary stenting has not been formally established. We compared the stone size or fragmentation of common bile duct stones after a long period of biliary stenting. METHODS Endoscopic biliary endoprosthesis was performed for 49 high-risk patients with CBD stones too large or difficult to be extracted by conventional endoscopic means. Bile duct drainage was established in all the patients without complications. Of the patients, 24 died with endoprosthesis in situ all from causes unrelated to biliar disease; 22 underwent a second and three patients a third attempt at stone extraction. The largest stone diameter was >12 mm in all patients. RESULTS In 11 of 25 patients (44%) the endoprosthesis allowed resolution of the problem of unextractable common bile duct stones. Four patients showed no existence of stent, and ERCP complete stone clearance from the CBD on programmized appointment after endoprosthesis insertion. Reduced size or fragmentation of stones was obtained in seven patients, and the stones could be removed endoscopically. The remaining 14 patients demonstrated no significant change in the size or fragmentation of their stones, and endoprostheses were replaced. CONCLUSIONS These results suggest that endoscopic endoprosthesis for large or difficult CBD stones is an effective method to clear the duct in selected cases, as well as an important definitive treatment in high-risk patients.
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Affiliation(s)
- P Katsinelos
- Department of Endoscopy and Motility Unit, Central Hospital, Ethnikis Aminis 41, TK 546 35 Thessaloniki, Greece.
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20
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Zargar SA, Javid G, Khan BA, Yattoo GN, Shah AH, Gulzar GM, Singh J, Rehman BU, ud-din Z. Endoscopic sphincterotomy in the management of bile duct stones in children. Am J Gastroenterol 2003; 98:586-589. [PMID: 12650791 DOI: 10.1111/j.1572-0241.2003.07229.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Endoscopic sphincterotomy (ES) is a widely accepted method of extracting bile duct stones (BDS) in young as well as in elderly patients. The present study was undertaken to assess the safety and efficacy of ES for the treatment of BDS in children, seven of whom were critically sick because of suppurative cholangitis or pancreatitis. METHOD Over a period of 33 months, ES was performed in 16 consecutive children aged 7-16 yr with BDS. Nine patients had gallbladder in situ, and seven had previously undergone cholecystectomy. The coexisting abnormalities were gallstones and hepatic duct stones in one patient each and dead fragmented roundworms in 11 patients. Seven (five with an intact gallbladder and two cholecystectomized) patients presented with severe complications of BDS such as severe cholangitis in six and acute severe pancreatitis in one. RESULTS ES was technically successful in all patients, and complete stone extraction was achieved in 15 (93.8%) patients. Complications were minor bleeding in one (6.3%) patient without mortality. One patient with coexisting gallstones underwent cholecystectomy at a later date. During a mean follow-up period of 4-32 months, one patient developed recurrent biliary symptoms because of biliary ascariasis. CONCLUSIONS We conclude ES is a safe and an effective method of treating BDS in children with previous cholecystectomy, and in those presenting with severe complications of BDS, such as pyogenic cholangitis or acute pancreatitis regardless of the presence of gallbladder.
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Affiliation(s)
- Showkat Ali Zargar
- Department of Gastroenterology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India
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Mora J, Aguilera V, Sala T, Martínez F, Bastida G, Palau A, Argüello L, Pons V, Pertejo V, Berenguer J, Alapont JM. [Endoscopic treatment combined with extracorporeal shock wave lithotripsy of difficult bile duct stones]. GASTROENTEROLOGIA Y HEPATOLOGIA 2002; 25:585-8. [PMID: 12459119 DOI: 10.1016/s0210-5705(02)70320-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES The aim of this study was to determine the safety and effectiveness of extracorporeal shock wave lithotripsy (ESWL) in difficult bile duct stones resistant to endoscopic extraction. PATIENTS AND METHOD From January 1997 to February 2002, combined treatment with endoscopy and ESWL was used in 19 patients who had undergone unsuccessful endoscopic bile duct stone extraction after sphincterotomy. The procedure was carried out using analgesic and sedative drugs or deep sedation, prophylactic antibiotic therapy, and monitoring of vital signs. Bile duct stone localization was performed by contrast injection through nasobiliary drainage and fluoroscopy. After each ESWL session, lavage was performed through drainage and stone fragments were extracted endoscopically. RESULTS The 19 patients presented high surgical risk due to advanced aged and/or concomitant diseases. All presented jaundice and pain and nine (47.3%) presented associated cholangitis. Thirty ESWL sessions were performed (1.57 sessions per patient), with a mean of 2,120 shock waves per session. In 16 of the 19 patients (84.2%), combined treatment with ESWL and subsequent instrumental endoscopic extraction achieved complete clearance of the biliary tract. The treatment failed in 3 patients who were referred for surgical treatment. No early or late complications were observed, except in one patient who presented a self-limiting febrile syndrome. CONCLUSIONS Therapeutic endoscopy combined with ESWL is safe and effective in patients with difficult bile duct stones. It represents a therapeutic alternative in patients at high surgical risk.
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Affiliation(s)
- J Mora
- Unidad de Endoscopias. Servicios de Medicina Digestiva. Hospital La Fe. Valencia. España.
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Affiliation(s)
- Jost Langhorst
- Department of Medicine, Evangelisches Krankenhaus Düsseldorf, Academic Teaching Hospital of the University of Düsseldorf, Düsseldorf, Germany
| | - Horst Neuhaus
- Department of Medicine, Evangelisches Krankenhaus Düsseldorf, Academic Teaching Hospital of the University of Düsseldorf, Düsseldorf, Germany
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Ghazanfari K, Gollapudi PR, Konicek FJ, Olivera A, Madayag M, Warner J. Surgical clip as a nidus for common bile duct stone formation and successful endoscopic therapy. Gastrointest Endosc 2001; 38:611-3. [PMID: 1397924 DOI: 10.1016/s0016-5107(92)70532-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- K Ghazanfari
- Department of Medicine (Gastroenterology) and Radiology, Illinois Masonic Medical Center, Chicago 60657
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24
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Sackmann M, Holl J, Sauter GH, Pauletzki J, von Ritter C, Paumgartner G. Extracorporeal shock wave lithotripsy for clearance of bile duct stones resistant to endoscopic extraction. Gastrointest Endosc 2001; 53:27-32. [PMID: 11154485 DOI: 10.1067/mge.2001.111042] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Endoscopic extraction of bile duct stones after sphincterotomy has a success rate of up to 95%. Failures occur in patients with extremely large stones, intrahepatic stones, and bile duct strictures. This study examined the efficacy and the safety of extracorporeal shock-wave lithotripsy in a large cohort of patients in whom routine endoscopic measures including mechanical lithotripsy had failed to extract bile duct stones. METHODS Out of 1587 consecutive patients, endoscopic stone extraction including mechanical lithotripsy was unsuccessful in 313 (20%). These 313 patients (64% women, median age, 73 years) underwent high-energy extracorporeal shock-wave lithotripsy. Stone targeting was performed fluoroscopically (99%) or by ultrasonography (1%). RESULTS Complete clearance of bile duct calculi was achieved in 281 (90%) patients. In 80% of the patients, the fragments were extracted endoscopically after shock-wave therapy; spontaneous passage was observed in 10%. For patients with complete clearance compared with those without there were no differences with regard to size or number of the stones, intrahepatic or extrahepatic stone location, presence or absence of bile duct strictures, or type of lithotripter. Cholangitis (n = 4) and acute cholecystitis (n = 1) were the rare adverse effects. CONCLUSIONS In patients with bile duct calculi that are difficult to extract endoscopically, high-energy extracorporeal shock-wave lithotripsy is a safe and effective therapy regardless of stone size, stone location, or the presence of bile duct stricture.
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Affiliation(s)
- M Sackmann
- Department of Medicine II, Klinikum Grosshadern, Ludwig-Maximilian's University, Munich, Germany
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25
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Abstract
Cholelithiasis is a common disease in the United States associated with significant morbidity. Surgical treatment with cholecystectomy has been increasing with a significant cost to the health care system. Surgical management is not without risk. Cholecystectomy has also been associated with a significant morbidity and mortality in elderly patients. Cholecystectomies are often performed unnecessarily in gallstone patients for nonspecific symptoms. Many patients with nonspecific pain, which may have a psychogenic component, continue to experience similar pain after cholecystectomy. There are problems in determining the symptom status of patients. Patients who believe surgery will relieve symptoms may maximize their symptoms, whereas patients who are reluctant to undergo surgery may minimize their symptoms. Although cholecystectomy is the mainstay of gallstone treatment, bile acid therapy and, if available, ESWL and topical dissolution are nonsurgical treatment alternatives in selected patients. In selected cases, in particular in the elderly and in other patients at increased risk from surgery, nonsurgical management offers lower morbidity and mortality than does operative treatment. The decision for surgical versus nonsurgical management should be based on both objective selection criteria and patient choice.
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Affiliation(s)
- D E Howard
- Department of Medicine, George Washington University Medical Center, Washington, DC, USA
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26
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Neuhaus H, Zillinger C, Born P, Ott R, Allescher H, Rösch T, Classen M. Randomized study of intracorporeal laser lithotripsy versus extracorporeal shock-wave lithotripsy for difficult bile duct stones. Gastrointest Endosc 1998; 47:327-34. [PMID: 9609422 DOI: 10.1016/s0016-5107(98)70214-7] [Citation(s) in RCA: 120] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Endoscopic treatment modalities are well established for the removal of bile duct stones. For the small percentage of stones that are difficult or impossible to extract by conventional means, more sophisticated endoscopic techniques or associated modalities such as intracorporeal laser lithotripsy (ILL) and extracorporeal shock wave lithotripsy (ESWL) have to be applied. Little is known, however, about the relative value of these different techniques. We therefore compared endoscopic ILL with ESWL in patients with difficult bile duct stones in a prospective randomized study. METHODS The study included 60 patients (35 women; mean age 70+/-15 years) with bile duct stones in whom standard extraction failed (n=33) or in whom the papilla was not accessible, thus requiring percutaneous access (n=27). They were randomized to receive ESWL under fluoroscopic targeting (maximum discharge number per session: 6000) or ILL using a pulsed dye laser with an automatic stone recognition system, which was mostly performed (28 of 30 cases) under cholangioscopic control. Endoscopic removal of fragments was attempted within the subsequent (ESWL) or the same (ILL) session. Failure was defined as failure to remove all ductal stones/fragments after a maximum of three lithotripsy sessions. RESULTS There were no statistical differences in background variables between the two groups. Bile duct clearance was achieved in 22 of 30 patients (73%) in the ESWL group and in 29 of 30 patients (97%) in the ILL group (p < 0.05). The number of treatment sessions (ESWL 3.0+/-1.3; ILL 1.2+/-0.4; p < 0.001) and the duration of treatment (ESWL 3.9+/-3.5 days; ILL 0.9+/-2.3 days; p < 0.001) were also significantly different in favor of ILL. Two minor complications occurred in each group; there was no 30-day mortality. Crossover therapy to ILL led to stone removal in seven of the eight cases in which ESWL failed, whereas ESWL fragmented the stone in the single patient in whom ILL failed. CONCLUSIONS ILL is more effective in the treatment of difficult bile duct stones than ESWL in terms of stone clearance rate and treatment duration.
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Affiliation(s)
- H Neuhaus
- Medizinische Klinik, Evangelisches Krankenhaus, Düsseldorf, Germany
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Zajicek G, Shamir R, Nordenberg J, Sidi Y, Arber N. Increased turnover of intrahepatic bile ducts induced by bromobenzene. Dig Dis Sci 1995; 40:730-3. [PMID: 7720461 DOI: 10.1007/bf02064969] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Intrahepatic bile duct epithelium consists of two kinetic compartments: a progenitor (P) and a functional (Q) compartment. Hitherto bromobenzene was known to poison only hepatocytes in the third acinus zone. The present experiment aims to demonstrate that bromobenzene affects also bile duct turnover. Thirty male adult rats received one intraperitoneal injection of bromobenzene and were sacrificed in groups of five at the following times: 1, 2, 3, 4, 7, and 14 days. They received [3H]thymidine 1 hr before sacrificing. Autoradiography was done. Bile ducts were evaluated in all portal tracts of the section. The number of epithelial cells in each duct cross section was counted and defined as bile duct class, which is roughly proportional to bile duct size. In each cross section the number of labeled cells was counted. Initially the labeling index was 0.76 +/- 0.3%. By day 3, it reached a peak of 4.1 +/- 1.1%, and then declined to its initial level. Following bromobenzene poisoning, hepatocyte and bile duct epithelia turn over in the same fashion. In both, labeling index and progenitor compartment size initially rise and return by the end of the first week to their initial level. We propose that bile duct epithelia and hepatocytes originate in one determined uncommitted stem cell that resides in the Herring duct. Bromobenzene-induced necrosis triggers proliferation of progenitors in both cell lineages, as well as in the stem cell itself.
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Affiliation(s)
- G Zajicek
- H. H. Humphrey Center for Experimental Medicine and Cancer Research, Hebrew University-Hadassah Medical School, Israel
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29
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Hixson LJ. Biliary obstruction. Postgrad Med 1993; 94:61-74. [PMID: 29206562 DOI: 10.1080/00325481.1993.11945744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Preview In a state-of-the art medical center, stones in the bile duct can be fragmented with stone-crushing baskets or electro- hydraulic or laser probes passed through an endoscope. Or they can be snared in a basket catheter inserted through a T-tube tract and guided by fluoroscopy. Expanding metallic mesh stents are being developed for use in biliary strictures and may have prolonged patency. However, as Dr Hixson emphasizes, the success of these and the other techniques described in this article depends on the skill and experience of available endoscopists and interventional radiologists.
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30
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Abstract
Common bile duct stones are frequently discovered after cholecystectomy or are the first sign of biliary tract disease. Because detection usually requires cholangiography and reoperation is technically difficult, risky, and thus undesirable, nonsurgical methods of identifying and removing the stones have evolved. Among these, endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic retrograde sphincterotomy and stone extraction is the method of choice after cholecystectomy. As newer methods of dealing with biliary disease evolve and alter the spectrum of complications, ERCP will remain an essential diagnostic and management tool.
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Affiliation(s)
- C F Gholson
- Division of gastroenterology and hepatology, St Louis University School of Medicine
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31
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Abstract
Endoscopic sphincterotomy with stone extraction is the non-surgical method of choice for treatment of choledocholithiasis in patients unfit for surgery or with previous cholecystectomy. Its success rate is 85-90%. Many adjunctive methods have been developed to increase the clearance rate after initial failure and are reviewed in this paper. Collaboration among the surgeon, endoscopist and radiologist offers the patient a high opportunity for successful clearance of common bile duct (CBD) stones with the least morbidity and mortality. The application of endoscopic sphincterotomy combined with laparoscopic cholecystectomy to younger patients is now debated.
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Affiliation(s)
- G Pelletier
- Service des Maladies du Foie et de l'Appareil Digestif, Hôpital de Bicêtre, Kremlin-Bicêtre, France
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