Outcome of mechanical lithotripsy of bile duct stones in an unselected series of 704 patients

BACKGROUND/AIMS: This paper evaluates the potential benefit of non mechanical bile duct stone lithotripsy techniques. The efficacy, limitations and risks of mechanical lithotripsy as first choice procedure were studied. MATERIAL AND METHODS: Endoscopic sphincterotomy was performed by Erlangen-type papillotomes, stone extraction by Olympus baskets and mechanical lithotripsy by the Wurbs-system. In an unselected series of 704 patients, everyone with common bile and hepatic duct stones (independent of size, number, location and stone consistency) was included in the study. RESULTS: Complete stone clearance by endoscopic sphincterotomy and basket extraction was possible in 87.6%. Additional mechanical lithotripsy led to a success rate of 98.4% and in combination with ESWL of 98.5%. In 11 patients without possibility of endoscopic stone removal (1.6%), 4 had no access transpapillary (B-II-situs or duodenal diverticulum), 5 anatomical problems (S-shaped common bile duct, intrahepatic stones or impacted stones in cystic duct orifice), and 2 refused further endoscopic interventions. Complication rate was 1.4% (thereof 1.1% successful treatment by endoscopic or surgical means), lethality rate 0.3%. CONCLUSIONS: A very high rate of stone clearance by standard endoscopic procedures is possible. In those patients where mechanical lithotripsy is not successful, other non-surgical lithotriptic procedures either cannot be applied because of anatomical reasons or if performed, the improvement in success rate is marginal.     

Sequential treatment of lithiasis of the common bile duct

The purpose of this study is to evaluate the sequential endoscopic-laparoscopic approach for clearance of common bile duct (CBD) and removal of gallbladder in patients with simultaneous cholecystolithiasis and choledocholithiasis. A data base of 990 patients undergoing Laparoscopic Cholecystectomy (LC) was compiled during an 5 years period. 88 patients were suspected of having CBD stones based upon clinical, biological and ultrasound evidence. The CBD cannulation rate was 93% (82/88). CBD stones were found in 43 patients (49%). The stones were removed preoperatively by Endoscopic Sphincterotomy (ES) in 37 patients of these 43 cases (86%). LC was performed in all patients after endoscopic retrograde cholangiopancreatography (ERCP). This treatment had showed no mortality and a morbidity of 14%. Efficacy of this sequential method of treatment of LVBP was 86%. With inclusion of laparoscopic extractions, the efficacy rate was 91%. The rate of residual stones was 1% (1/88). Experience with ERCP and ES before LC has been growing. ERCP-SE in the treatment of choice to clear the CBD before LC in high risk elderly patients (26) as well as in complicated stones. However, in this era of laparoscopic surgery, CBD stone can be removed laparoscopically in specialized centres with the advantage of a non-invasive single procedure for the patient. Laparoscopic CBD desobstruction and ES are not opposite but complementary. Preoperative ERCP and ES should be reserved for patients with serious illness. All other patients should be managed laparoscopically; in this case the future of sequential treatment resides in a one step-approach: preoperative ERCP if cholangiography is positive.     

Current results of endoscopic sphincterotomy for lithiasis of the common bile duct

Between January 1989 and June 1990, endoscopic sphincterotomy was performed in 308 consecutive patients with common bile duct stones (mean age: 74 years). Complete clearance of common bile duct was achieved at the first attempt in 65% of cases. This rate was significantly related to the size and the number of biliary stones. The success rate reached 97 percent after repeated endoscopic sessions (127 patients), mechanical lithotripsy (20 patients), extracorporeal or intracorporeal lithotripsy (18 and 11 patients, respectively). During the month following the endoscopic sphincterotomy, 39 patients (13%) developed one or more complications and 11 patients (3.7%) died. The complication rate was related to the time elapsed between biliary opacification and endoscopic sphincterotomy (P = 0.04) and between endoscopic sphincterotomy and total common bile duct clearance (P = 0.0007). No patient younger than 75 years died, but death occurred in 4.5% of the patients older than 75 years. Thirty patients (10%) developed endoscopic sphincterotomy-related complications. Cholangitis and bleeding were the most frequent complications (4 and 2%, respectively). Cholangitis occurred more frequently among the patients older than 75 (P < 0.05) or when transhepatic guided endoscopic sphincterotomy or intracorporeal lithotripsy was used (P < 0.005). Cholangitis led to death in 2 patients, 86 and 87 years old (0.7%). Endoscopic sphincterotomy related complications developed within 48 hours in all but 4 patients (2 patients with pancreatitis and 2 patients with cholecystitis).     

Bile duct cysts in adults

INTRODUCTION: Bile duct cysts are rare, congenital dilations of the intrahepatic and/or extrahepatic biliary tract. Most of them present during childhood. The classical triad right upper quadrant pain, jaundice and abdominal mass is present only in a few instances. We report here the bile duct cysts which were diagnosed at our institution from 1989 to 1996. METHODS: 3245 consecutive endoscopic retrograde cholangiopancreatograms (ERCP) were evaluated retrospectively. Diagnosis was made when localized cystic dilations of the intrahepatic and/or extrahepatic biliary tract were present. Diffuse dilations of the intrahepatic and extrahepatic biliary tract were excluded. RESULTS: Bile duct cysts were found in 20 patients (17 females, 3 males) among 3245 ERCPs. Their mean age was 56 +/- 20 (median 64, range 10 to 83) years. The cyst types (according to the Alonso-Lej classification with the Todani modification) were type I in 11 (55%), type II, III and IV in two instances each (10%), and type V (or Caroli's disease) in 3 patients (15%). Leading symptoms were cholestasis in 14 patients, 10 of whom had abdominal pain, jaundice in 4 patients, and single cases of pancreatitis, cholangitis, and abdominal mass. In 2 patients the diagnosis was made incidentally. 10 patients had bile duct stones. We performed endoscopic sphincterotomy in 15 patients with concretions or persistent symptoms, 3 patients had cyst resection. One of these, with a type I cyst, already had a disseminated cholangiocarcinoma. 10 of 17 patients without cyst resection are currently symptom-free after complete removal of all gallstones. One male patient with cholecystolithiasis, who is not operable due to advanced liver disease, has recurrent cholangitis, 4 patients have died from causes unrelated to the bile duct cysts, and 2 patients are lost to follow up. CONCLUSION: Bile duct cysts in adults are rare. There is a preponderance in the female gender, and the most common type is the extrahepatic (choledochal) cyst. The leading symptoms are cholestasis and right upper quadrant pain. There is an increased risk of cholangiocarcinoma. In young patients the cysts should be entirely removed to prevent malignancy. Older persons are usually symptomless after complete removal of gallstones.     

A patient with choledocholithiasis--no therapy without risk

A 73-year-old man was admitted to the hospital because of recurrent fever and intermittent cholestasis. A cholecystectomy with hepatico-duodenostomy was performed ten years ago because of acute cholecystitis and impacted bile duct stones. Recurrent episodes of cholangitis occurred postoperatively and ERCP showed shrinkage of the hepatico-duodenal anastomosis with sump syndrome and recurrent bile duct stones. Endoscopic sphincterotomy for the improvement of bile flow was considered too dangerous at this time-point because of unfavourable intraduodenal position of the papilla Vateri. The patient refused reoperation. During the present hospitalization, endoscopic sphincterotomy and gallstone removal were performed. Within hours after intervention, necrotizing pancreatitis developed which could be managed without operation. No further episodes of cholangitis reoccurred after discharge from hospital. This case report demonstrates the risks of bile duct surgery and endoscopic sphincterotomy.     

Single application extracorporeal shock wave lithotripsy is the first choice for patients with pancreatic duct stones

OBJECTIVES: We performed extracorporeal shock wave lithotripsy (ESWL) as the treatment of first choice on 32 chronic pancreatitis patients with main pancreatic duct (MPD) stones prospectively to establish more convenient and safer treatment. METHODS: All patients were treated in a prone position, and shock waves were discharged from the ventral side. ESWL was performed once or twice a week, and no other treatments before ESWL had been applied. RESULTS: Disintegration of all MPD stones to 3 mm or less in diameter could be achieved in all treated patients. Complete clearance of the stones was obtained in 24 patients (75%) without the necessity of endoscopic extraction of fragments. Reduction of MPD diameters after ESWL was statistically significant (p < 0.01). Epigastric and/or back pain complaints before ESWL were completely alleviated in 79% (periods of follow-up: 16-63 months, mean 44), and the pancreatic exocrine function also improved in 61%. No severe complications occurred in any of the patients. CONCLUSIONS: ESWL, which is comparatively easy to perform, is a safe and efficient approach that changes endoscopy's status as an indispensable pretreatment. Therefore, ESWL can be recommended as the first choice treatment for patients with chronic pancreatitis accompanied by MPD stones that should be tried before consideration of either surgical or endoscopic procedures.     

Percutaneous and transpapillary laser lithotripsy of intrahepatic gallstones

PROBLEM AND OBJECTIVE: In the last few years several intra- and extracorporeal endoscopic methods have been developed for treating intrahepatic gallstones, but as yet no ideal instrumentation has been found. This study was undertaken to test the efficacy and possible complications of intracorporeal laser lithotripsy for intrahepatic gallstones. PATIENTS AND METHODS: 16 consecutive patients were included (13 women and 3 men, median age 64 [28-82] years) with intrahepatic biliary tract stones which could not be removed by conventional endoscopy. A rhodamine-6G-laser with an integrated stone recognition system was used. The glass fibres of the laser instrument were introduced perorally or percutaneously and placed at the stone. RESULTS: The percutaneous procedure under cholangioscopic control succeeded in four of the patients, while 12 were treated by a transpapillary approach (two under fluoroscopic, ten under cholangioscopic control). In eight of the latter group all stones were completely fragmented, i.e. 12 of the total were successfully treated. Of the remaining four patients two were cleared of stone by additional measures (extracorporeal shockwave lithotripsy and electrohydraulic lithotripsy, respectively), two were treated pallatively by endoprosthesis. One patient developed an acute cholangitis which was successfully treated with antibiotics and biliary drainage. There were no deaths. CONCLUSIONS: Particularly when performed transcutaneously, laser lithotripsy provides effective treatment of intrahepatic gall stones. Cholangioscopic monitoring, to place the glass fibre at the stone, is usually required in the transpapillary approach.     

Ca(2+)-permeable, outwardly-rectifying K+ channels in mesophyll cells of Arabidopsis thaliana

Advances in cannulation techniques and instruments have helped in difficult bile duct cannulation and thus stone extraction. For small common bile duct (CBD) stones, endoscopic papillary balloon dilatation has been proposed as an alternative to endoscopic papillotomy (EPT). The technique must undergo further evaluation before recommending its routine use. For most patients with bile duct stones, EPT remains the method of choice. Out of 8204 patients treated in three surgical endoscopy centers (Chile, Germany, and India), 86% to 91% of all CBD stones could be extracted subsequently after EPT using a Dormia basket; 4% to 7% required mechanical lithotripsy (ML) before removal and 3% to 10% of the patients needed other sophisticated techniques, such as electrohydraulic lithotripsy (EHL), laser-induced shock-wave lithotripsy (LISL), or extracorporeal shock-wave lithotripsy (ESWL). The local expertise and availability of equipment determines the choice of method used. In general, EHL or LISL is used for impacted CBD stones including stones in Mirizzi syndrome refractory to ML. ESWL is best suited for intrahepatic stones. Permanent stenting can be offered to poor risk patients instead of extensive procedures to clear the bile duct. Using currently available nonsurgical techniques, fewer than 1% of all patients with bile duct stones still require surgical intervention.     

Endoscopic treatment of symptomatic choledocholithiasis

BACKGROUND/AIMS: Today, different endoscopic techniques are available to treat choledocholithiasis. These techniques include mechanical lithotripsy (ML), electrohydraulic lithotripsy (EHL), laserlithotripsy (LL), and extracorporal shock-wave lithotripsy (ESWL). These techniques have to compete with laparoscopic stone removal which is performed with increasing frequency at some centers. METHODOLOGY: We report the results of treatment of choledocholithiasis and compare the results with a meta-analysis of studies in whom endoscopic and laparoscopic techniques were applied. From 1994-1995, 217 patients with symptomatic choledocholithiasis were treated using endoscopic retrograde cholangiography (ERC). RESULTS: Overall, complete stone removal was successful in 98% of all patients and only 5 patients had to undergo surgery. Complete endoscopic removal of stones was achieved in 70% during the first ERC session. In 47 patients consecutive ERC sessions with application of EML, EHL, or ESWL were necessary to completely remove the stones. Complication rate was 5% and included pancreatitis and bleeding from papillotomy. There was no procedure-related mortality. CONCLUSION: The study suggests that today ERC remains the treatment of choice in most patients with symptomatic choledocholithiasis.     

Endoscopic management of acute calculous cholangitis

Acute cholangitis is associated with significant morbidity and mortality. Endoscopic drainage procedures have been shown to be a safe and effective mode of treatment in acute cholangitis. As there is paucity of large series on endoscopic management of acute cholangitis, a study was performed to evaluate safety and efficiency of endoscopic biliary decompression in acute cholangitis. The study included 89 consecutive patients (mean age 55+/-15 years; range 35-70 years; 50 males) with acute cholangitis requiring biliary drainage. Main presenting features were upper abdominal pain (84%), fever with chills (90%) and jaundice (74%). Altered sensorium, hypotension, features of peritonitis and acute renal failure were present in 15, 11, 18 and 5%, respectively. Endoscopic procedures performed were endoscopic sphincterotomy (ES) with stone extraction (n=40); ES with endoscopic nasobiliary drainage (ENBD; n=30); ENBD without ES (n=8); and ES with stent placement (n=11). Of the 89 patients, 85 (95%) responded within 48-72 h. Endoscopic common duct clearance could be achieved in 58 of 78 (74%) patients, whereas in 11 patients undergoing stent placement, stone extraction was not attempted. Complications included post-sphincterotomy bleed (n=2), retroduodenal perforation (n=1) and acute pancreatitis (n=1) with an overall complication rate of 4.4%. All the complications were seen in patients undergoing ES with stone extraction. Mortality was 3.3%. In conclusion, endoscopic biliary drainage is a safe and effective mode of treatment for acute cholangitis. Endoscopic nasobiliary drainage or stent placement is safer than ES in acute cholangitis as an initial step.     

Endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy for symptomatic choledocholithiasis after recent myocardial infarction

In the general population, endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy is preferable to surgery as therapy for gallstone pancreatitis and acute cholangitis. It is particularly attractive to perform therapeutic. ERCP for symptomatic choledocholithiasis after recent myocardial infarction because of the increased risk of the alternative therapy of cholecystectomy and choledochal exploration. However, after myocardial infarction, patients might theoretically be particularly susceptible to the cardiopulmonary risks of ERCP. The safety of therapeutic ERCP after myocardial infarction is unknown, with only one previously reported case. In a review of 11,367 patients with acute myocardial infarction at four hospitals, four patients (0.04%) underwent therapeutic ERCP after recent myocardial infarction, for indications of recent biliary pancreatitis in three of the patients and recent cholangitis in all four. Cholangitis occurred before, simultaneous with, or after myocardial infarction in the four cases. Initially, the cholangitis was managed medically in three patients. The fourth patient underwent cholecystostomy with local anesthesia. ERCP was performed at 15, 25, 30, or 56 days after myocardial infarction. Endoscopic cholangiography revealed multiple choledocholithiasis in all cases. The calculi were successfully extracted by endoscopic papillotomy and by sweeping the choledochus with a balloon-tipped catheter or basket in all cases. During ERCP, the vital signs remained stable; no cardiac arrhythmias or cardiovascular complications occurred. However, one patient developed mild pancreatitis after ERCP, which rapidly resolved with medical therapy. The four patients rapidly improved after ERCP, with normalization of serum levels of routine biochemical parameters of liver function. These four cases and the one prior case report demonstrate that therapeutic ERCP is not absolutely contraindicated after myocardial infarction and suggest that therapeutic ERCP is preferable to surgery for symptomatic choledocholithiasis after myocardial infarction because of the increased mortality of surgery after myocardial infarction.     

Management of choledocholithiasis in patients undergoing laparoscopic cholecystectomy

The development of laparoscopic cholecystectomy has rekindled the issue of management of choledocholithiasis. A number of options exist including pre or postoperative endoscopic sphincterotomy (ERCP-ES), laparoscopic common duct exploration or open common duct exploration. We present here our experience with the management of choledocholithiasis in patients treated with laparoscopic cholecystectomy. From January 1991 to January 1995, 900 patients underwent laparoscopic cholecystectomy. 71 ERCP were carried out in 71 patients with suspicion or evidence of choledocholithiasis. Common duct stones were detected in 44 patients. Preoperative ERCP was done in 56 patients, with suspicion of choledocholithiasis, based on clinical, laboratory or ultrasonographic findings. 29 of these patients (51.7%) had common duct stones, that were successfully removed by endoscopic sphincterotomy. One patient suffered mild pancreatitis and a second one had transient hyperamylasemia. Postoperative ERCP was performed in 15 patients. Indications for ERCP were the evidence of common duct stones in intraoperative cholangiography in 7 cases, and clinical or laboratory suspicion of choledocholithiasis, 3 months to 3 years after laparoscopic cholecystectomy. Stones were detected in 100% of the patients. In 11 patients (73.3%), the stones were extracted by endoscopic sphincterotomy and 4 patients underwent open common duct exploration. Two patients had transient hyperamylasemia. ERCP is a safe and effective method for detection and treatment of common duct stones. ERCP prior to laparoscopic cholecystectomy in patients suspected of having choledocholithiasis, is safe and offers with good results. Rutinary intraoperative cholangiography is recommended, for the detection of unsuspected choledocholithiasis and as an effective treatment (postoperative-ERCP, open or laparoscopic common duct exploration) can be chosen depending on surgeon's skills and patient's characteristics.     

Sequential intraluminal endoscopic and laparoscopic treatment for bile duct stones associated with gallstones

BACKGROUND: On the basis of a flowchart including prior or current jaundice or pancreatitis, abnormal liver function, ultrasound or IV cholangiography, bile duct (BD) stones were suspected in 71/593 patients referred for gallstones. METHODS: When endoscopic retrograde cholangiography detected BD stones, endoscopic sphincterotomy (ES) and endoscopic BD clearance were attempted, followed by laparoscopic cholecystectomy (LC). BD stones were found in 44/71 patients. The sensitivity values of preoperative conditions were: 92% for IV cholangiography, 88% for abnormal liver function, 50% for ultrasound, and 37% for jaundice at admission. RESULTS: Endoscopic clearance succeeded in 37 patients and LC was completed in 33 patients. Conversion to open surgery (9%) was comparable with the rate in patients without BD stones. The median hospital stay for the sequential endoscopic and laparoscopic treatments was 13 days (range 4-54) or 22 days if open surgery was used. CONCLUSIONS: In conclusion, BD stones can be endoscopically cleared preoperatively in most patients without interfering with LC.     

Combined laparoscopic and endoscopic management of cholelithiasis and choledocholithiasis

With the advent of laparoscopic cholecystectomy, optimal management of common duct stones remains controversial. Seven hundred six patients underwent laparoscopic cholecystectomy in our institution from January 1990 through January 1992. From this group of patients, 50 were identified as having clinical or radiographic evidence of common duct stones. Thirty-one patients demonstrated preoperative risk factors for common duct stones and underwent preoperative endoscopic retrograde cholangiopancreatography (ERCP). The risk factors included jaundice (19%), pancreatitis (23%), elevated liver function tests (52%), and ultrasound evidence of choledocholithiasis (6%). Preoperative ERCP was performed in 94% of patients. There were two failures due to periampullary diverticula. Common duct stones were identified in 18 patients (62%) and successfully removed by endoscopic sphincterotomy in all of these patients. Nineteen patients were found to have unsuspected common duct stones on intraoperative cholangiography. Eighteen patients (95%) underwent successful ERCP and endoscopic sphincterotomy with stone extraction. Overall, major morbidity was 2% and included one patient who experienced endoscopic sphincteroplasty. The three endoscopic failures were managed by open common duct exploration, laparoscopic duct exploration, and combined laparoscopic and open common duct exploration. We conclude that combined laparoscopic and endoscopic therapy is a viable option for the management of cholelithiasis with choledocholithiasis.     

Laparoscopic cholecystectomy and lithiasis of the common bile duct: prospective study on the importance of preoperative endoscopic ultrasonography and endoscopic retrograde cholangiography

OBJECTIVES: Laparoscopic cholecystectomy is the standard treatment of symptomatic gallstones. At present, no consensus has been reached on the diagnostic and therapeutic methods of concomitant common bile duct stones. Systematic preoperative endoscopic ultrasonography followed, if necessary, by endoscopic retrograde cholangiography and sphincterotomy during the same anesthetic procedure could be a diagnostic and therapeutic alternative for common bile duct stones making possible a laparoscopic cholecystectomy without intraoperative investigation of the common bile duct. METHODS: One hundred and twenty-five patients underwent a prospective endoscopic ultrasonographic evaluation prior to laparoscopic cholecystectomy for symptomatic gallstones. Fourty-four patients (35%) had at least one predictive factor for common bile duct stones. Endoscopic ultrasonography and cholecystectomy were performed on the same day. Endoscopic ultrasonography was followed by endoscopic retrograde cholangiography and sphincterotomy by the same endoscopist in case of common bile duct stones on endoscopic ultrasonography. Patients were routinely followed up between 3 and 6 months and one year after cholecystectomy. RESULTS: Endoscopic ultrasonography suggested common bile duct stones in 21 patients (17%). Endoscopic ultrasonography identified a stone in 17 of 44 patients (38.6%) with predictor of common bile duct stones and only in 4 of 81 patients (4.9%) without predictor of common bile duct stone. Among these 21 patients, one patient was not investigated with endoscopic retrograde cholangiography because of the high risk of sphincterotomy, 19 patients had a stone removed after sphincterotomy, one patient had no visible stone neither on endoscopic retrograde cholangiography, nor on exploration of the common bile duct after sphincterotomy. Endoscopic ultrasonography was normal in 104 patients (83%). However, two patients in this group were investigated with endoscopic retrograde cholangiography because endoscopic ultrasonography was incomplete in one case and because endoscopic ultrasonography was normal in the second case but a stone in the left hepatic duct was detected by ultrasonography. A stone was removed after endoscopic sphincterotomy in these two patients. In the group of 102 patients without stone, 91 out of 92, continued to be asymptomatic during a median follow-up of 8.5 months. One patient with symptoms one month after cholecystectomy underwent endoscopic sphincterotomy but no stone was found. CONCLUSIONS: Systematic preoperative endoscopic ultrasonography followed, if necessary with endoscopic retrograde cholangiography and sphincterotomy is a diagnostic and therapeutic alternative for common bile duct stones making possible a laparoscopic cholecystectomy without intraoperative investigation of the common bile duct for all patients. This alternative is only justifiable in patients with predictor of common bile duct stones.     

Efficacy of endoscopic diagnosis and treatment for postoperative biliary leak

BACKGROUND/AIMS: The purpose of this study was to evaluate the efficacy of endoscopic approaches for the diagnosis and treatment of postoperative biliary leak. METHODOLOGY: Endoscopic retrograde cholangiopancreatography (ERCP) was performed in eight patients with postoperative biliary leak. Of 8 cases, 6 had biliary leak alone (4 cases with a cystic duct leak and 2 cases with a bile duct leak) and 2 cases with a bile duct leak were associated with a bile duct stricture. Endoscopic sphincterotomy (ES) and endoscopic biliary stenting (EBS) were employed in 5 patients and nasobiliary tube drainage (NBD) without ES was performed in 3 patients. RESULTS: In all the patients, ERCP was successfully performed and could demonstrate exact nature and site of postoperative bile duct injuries. In 2 patients with a concomitant bile duct stricture, repetitive endoprosthesis placements were required. The remaining six patients with biliary leak alone were successfully treated by temporary stenting, i.e., ES and EBS (n = 3), and NBD (n = 3). CONCLUSIONS: The patients with postoperative biliary leaks can be successfully diagnosed by ERCP and treated by temporary endoscopic methods. Among various endoscopic treatments, NBD alone appears to be preferable in treating patients with small bile leaks. However, cases with a concomitant bile duct stricture were intractable and required longer period of stenting.     

Laparoscopic cholecystectomy for gallbladder stones

The authors describe the technique for the treatment of gallbladder stones using a laparoscopic approach and discuss the diagnostic and operative flow chart stressing complications and ways to avoid them. A total of 2517 non-selected patients underwent surgery since october 1990 up to september 1995. 252 were affected by acute cholecystitis (10%); 172 underwent emergency laparoscopic cholecystectomy. ERCP was performed in 278 patients (11.04%): 177 underwent endoscopic sphincterotomy and laparoscopic cholecystectomy, 21 underwent laparoscopic cholecystectomy before sphincterotomy, 8 laparoscopic cholecystectomy and ESWL. Laparoscopic cholecystectomy was converted into laparotomy in 37 patients (1.4%); surgery was abandoned in 3 patients following to onset of intense bradycardia. Major complications were observed in 0.63%; bile duct injury occurred in four patients (0.15%). One patient died following a massive intraoperative myocardial infarction. Average operative time was 21 minutes. Only 22.8% of patients required mild analgesia on the first day after surgery. The average hospital postoperative stay was 2.6 days. Return to work took place in 98% of non complicated patients within one week of being discharged from hospital.     

Endoscopic papillary balloon dilatation for common bile duct stones: efficacy of combination with extracorporeal shockwave lithotripsy for large stones

BACKGROUND: Endoscopic papillary balloon dilatation (EPBD) is generally considered a safe and effective technique for removal of common bile duct (CBD) stones. However, some reports have prompted concern about the risk of pancreatitis following the procedure, and it seems to be more difficult and to require adjunctive procedures more frequently in patients with large stones. AIMS: To analyse the factors influencing pancreatitis after the procedure, and to examine which is the more suitable adjunct for treating large stones, mechanical lithotripsy (ML) or extracorporeal shockwave lithotripsy (ESWL). PATIENTS AND METHODS: EPBD was performed in 92 patients, including 40 with large stones (> or = 12 mm). These 40 patients were randomly assigned to two groups receiving ML or ESWL to fragment stones (20 patients each). RESULTS: Complete ductal clearance was obtained in all 92 patients. Significant elevation of the serum amylase level compared with the prior value (> 300 IU/l) was observed in 26 (28%), and eight (8.7%) developed clinical pancreatitis. To assess the influence of various factors on the amylase level, multivariate analysis was used. The number of stones and the time required for treatment had a significant influence on the incidence of increased amylase level (P < 0.05), and ML also significantly increased it (P < 0.05). On the other hand, the amylase level remained low in the ESWL group. ML caused elevation of amylase level in 11 patients (55%), while three (15%) had elevation after ESWL. CONCLUSIONS: In patients with multiple stones, elevation of the amylase level is more frequent. This seems to be because repeated cannulation and much time is required for treatment. In patients with large stones, the rate was also high if ML was used, but was low when ESWL was used. ESWL may reduce the incidence of pancreatitis.     

Retained common bile duct stones after endoscopic sphincterotomy: temporary and longterm treatment with biliary stenting

Basket extraction after endoscopic sphincterotomy failed to clear the bile ducts immediately in 85 (30%) of 283 consecutive patients with common bile duct stones. Temporary biliary drainage was established by the insertion of a single 7 Fr double pigtail stent before further planned endoscopic attempts at stone removal. In 84 patients (21 male: 63 female, mean age 77 years) this measure relieved biliary obstruction, mean serum bilirubin falling from 101 to 18 umol/l by the time of the second endoscopic retrograde cholangiopancreatography. Six patients died from non-biliary causes with temporary stents in situ. Common bile duct stone extraction was achieved endoscopically in 50 of the remaining 79 patients after a mean of 4.3 months (range 1-12), 34 (68%) requiring only one further procedure. Three patients were referred for biliary surgery. Single stents were also effective for longterm biliary drainage in the remaining 26 elderly patients with unextractable stones. The main biliary complication of stenting was 13 episodes of cholangitis but all except one responded to medical treatment and early stent exchange. If common bile duct stones remain after endoscopic sphincterotomy, a single 7 Fr double pigtail stent is effective and safe for temporary biliary drainage before further endoscopic attempts at duct clearance and for longterm biliary drainage especially in the old and frail.     

Treatment results of unresected or partially resected desmoid tumors

BACKGROUND: The role of preoperative ERCP and endoscopic sphincterotomy (ES) in the diagnosis and treatment of suspected common bile duct stones (CBDS) in the laparoscopic age is controversial. The preoperative diagnosis of CBDS by ERCP and the removal of CBDS by ES are advantageous because of technical difficulties in performing laparoscopic exploration of the common bile duct. Approximately 50% of preoperative ERCP examinations are normal, however. The noninvasive diagnosis of CBDS has assumed new importance, but it has proved to be an elusive goal. Neural networks are a form of artificial computer intelligence that have been used successfully to interpret ECGs and to diagnose myocardial infarcts. The purpose of this study was to determine whether a neural network could be trained to predict CBDS accurately in patients at high risk of having duct stones. STUDY DESIGN: We trained a back-propagation neural network to predict the presence of CBDS. Retrospective data from patients who had a cholecystectomy and either a preoperative ERCP or intraoperative cholangiogram were used to build the network, and it was tested using unseen data. RESULTS: One hundred forty patients were used to train the network, and 16 patients were used to test it. The trained network was able to predict CBDS in 100% of the patients in both the training and test sets. CONCLUSIONS: Screening of high-risk patients for CBDS by neural network analysis is highly accurate. This promising new, noninvasive, and inexpensive technique can potentially decrease the need for preoperative ERCP by 50%, but additional prospective evaluation is indicated.