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).     

Laparo-endoscopic "rendezvous": a new technique in the choledocholithiasis treatment

BACKGROUND/AIMS: Endoscopic sphincterotomy for common bile duct stone clearance during laparoscopic cholecystectomy may fail due to difficulties in cannulating the papilla major. In this study we propose a new technique that facilitates the cannulation of the papilla and the common bile duct stone clearance during a standard laparoscopic cholecystectomy. Its clearance percentage, complication rate and post-operative stay have been evaluated and compared with standardized procedures such as open surgery and endoscopic sphincterotomy before laparoscopic cholecystectomy. METHODOLOGY: In a group of 16 patients presenting with cholelithiasis and common bile duct stones or papillitis, the sphincterotome was driven across the papilla into the choledochus by a Dormia basket passed in the duodenum through the cystic duct during laparoscopic cholecystectomy. Measures of outcome were clearance rate, mortality, morbidity and hospital stay. Furthermore, data obtained from this sample of patients were compared with those from another two groups of 16 patients in which choledocholithiasis was managed either by endoscopic sphincterotomy performed before laparoscopic cholecystectomy or by open cholecystectomy and trans-duodenal sphincterotomy. RESULTS: The rate of cannulation of the papilla and of the common bile duct stone clearance was 100% when the combined endo-laparoscopic approach was used in 15 patients with endoscopic sphincterotomy (93,7%) and in 15 patients with open sphincterotomy (93,7%), cholecystectomy was successful in every case. The groups were statistically similar with regard to complications; none of the patients required blood transfusion. The mean post operative stay was 95.2 hours (range 48-240) for the first group, 350.1 hours (range 192-1680) for the second and 69.7 hours (range 24-132) for the third. CONCLUSION: The laparo-endoscopic rendezvous, though still in evolution, is an efficacious method which can be used during the laparoscopic strategy of common bile duct clearance.     

Introduction to instrument development: scaling methods

Endoscopic removal of biliary calculi is a safe and effective alternative to surgical exploration of the common bile duct. However, as stones increase in diameter, endoscopic retrieval becomes more difficult and hazardous. Mechanical lithotripsy is an endoscopic technique used to crush common bile duct stones that are too large to be removed by conventional methods. In the 3 years following the introduction of this technique at our institution, 145 patients underwent endoscopic retrograde cholangiopancreatography for symptomatic choledocholithiasis. Endoscopic mechanical lithotripsy improved the overall success rate of common bile duct clearance from 86.2% to 94.5%. No morbidity or mortality was associated with the procedure. Therefore, we recommend mechanical lithotripsy when bile duct stones cannot be removed with conventional techniques.     

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 mechanical lithotripsy of difficult common bile duct stones

BACKGROUND: Mechanical lithotripsy for the management of difficult common bile duct stones has sometimes yielded conflicting results. METHODS: A series of 162 consecutive patients who underwent mechanical lithotripsy was evaluated retrospectively and a large number of variables tested for their association with successful outcome. RESULTS: The procedure was safe (morbidity rate 1.8 per cent) and effective (84.0 per cent stone clearance rate). Univariate and multivariate analysis showed that stone size was the only outcome predictor (mean(s.d.) diameter of grasped versus non-grasped stones 21.7 (6.7) versus 28.3(10.4) mm; F = 10.72, 98 d.f., P = 0.002). The cumulative probability of bile duct clearance ranged from over 90 per cent for stones with a diameter less than 10 mm to 68 per cent for those greater than 28 mm in diameter (P < 0.02). CONCLUSION: Patients at high risk of lithotripsy failure (stone diameter of 28 mm or more) might more wisely undergo surgery or other non-surgical procedures, such as extracorporeal shock-wave lithotripsy or long-term biliary stenting.     

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.     

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.     

Control of the mutagenicity of arylamines by protein kinases and phosphatases: II. Lack of response of rat liver N-acetyl transferases to phosphorylation modulators

OBJECTIVES: Endoscopic sphincterotomy has become a generally accepted method for extracting common bile duct stones in high risk or cholecystectomized patients. However, stone extraction is impossible by the usual methods in 5 to 10% of cases. The purpose of this study was to evaluate the effect of a recently developed solvent system in patients with large bile duct stones. METHODS: Forty four patients (15 men and 29 women, median age of years) underwent contact dissolution after unsuccessful Dormia extraction. Solvents were administered via a nasobiliary catheter in 41 patients following papillotomy and through a T-tube in 3 patients. Solvent mixtures (26 mM ethylene diamine tetraacetic acid, 40 mM sodium deoxycholate and 30% dimethyl sulfoxide in an alkaline aqueous solution; and a 70/30 dimethyl sulfoxide/methyl tert-butyl ether mixture) were infused continuously and alternatively for 2 hours. RESULTS: Bile duct stones disappeared in 13-24 hours of infusion in 11 patients. In 29 patients, a clear reduction in stone volume occurred, allowing complete endoscopic extraction of the fragments. In 4 patients, the size of the stone did not change. Only mild and transient side-effects including abdominal pain (68%), nausea (72%), vomiting (52%), diarrhea and sleepiness (50%) were observed. CONCLUSION: Direct dissolution therapy could be an effective method for the non-surgical management of large bile duct stones in selected patients when intra- or extracorporeal lithotripsy is unsuccessful.     

Laser lithotripsy of difficult bile duct stones: results in 60 patients using a rhodamine 6G dye laser with optical stone tissue detection system

INTRODUCTION: Laser lithotripsy of bile duct stones has become a widely accepted endoscopic treatment modality for giant, impacted, or very hard stones. The procedure is usually carried out under direct endoscopic control in view of the potential risk of bile duct injuries in "blind" laser application. AIMS: To investigate the use of a rhodamine 6G laser lithotriptor with an integrated optical stone tissue detection system (oSTDS). METHODS: From 1 September 1991 to 7 March 1997, 60 patients with giant or impacted common bile duct stones refractory to endoscopic papillotomy stone extraction, and mechanical lithotripsy were treated via the endoscopic retrograde route using a rhodamine 6G dye laser (595 nm, 2.5 micros, 80-150 mJ pp, Lithognost Telemit/Baasel Corp., Germany) with integrated oSTDS. In case of tissue contact oSTDS cuts off the laser pulse after 190 ns (transmission of 5-8% of the total pulse energy). 47 patients (78.3%) were subjected to x ray targeting (oSTDS) alone, five (8.3%) to choledochoscope targeting alone, and eight (13.3%) to both techniques. RESULTS: At the end of treatment 52 (87%) patients were completely stone-free. The only major complications included transient haemobilia, cholangitis, and pancreatitis in five patients. All five were successfully treated by conservative methods. CONCLUSIONS: Laser lithotripsy using the described rhodamine 6G dye laser with oSTDS seems to be safe and effective and allows "blind" fragmentation of difficult common bile duct stones under radiological control only.     

Intra-corporeal shockwave lithotripsy in the treatment of complex lithiasis of the bile ducts. Comparison of endoscopic techniques and long-term results

OBJECTIVES: About 2% of common bile duct stones and most intra-hepatic stones cannot be removed by conventional endoscopy. Intra-corporeal lithotripsy is an alternative technique for these patients. Contact lithotripsy can be obtained by a pulsed dye laser or by electro-hydraulic shockwaves. We compared and assessed the results of these two methods. METHODS: Thirty-seven patients (79 +/- 9.8 years, 25 women and 12 men) underwent laser lithotripsy (n = 21), electro-hydraulic lithotripsy (n = 9) or both methods consecutively (n = 7) for common bile duct stones (n = 31), intra-hepatic stones (n = 3) or diffuse lithiasis (n = 3). The mean diameter of the largest stone was 23 +/- 12 mm. Lithotripsy was performed by a retrograde approach in 35 cases and a combined, retrograde and transhepatic approach in 2 cases. RESULTS: The mean number of lithotripsy sessions was 1.5 +/- 0.65. The overall success rate (free bile ducts with patent drainage) was 95%. In 2 patients, stones were not fully extracted: one underwent surgery, the other one was treated conservatively with antibiotics. The duration of the hospital stay was 9.3 +/- 4.5 days. Morbidity at 30 days was 27% and only one case of major morbidity (hemorrhage after sphincterotomy, 2.7%) was observed. There were no procedure-related mortality. Electro-hydraulic and laser groups did not differ significantly for success rate, morbidity and time spent at hospital. Follow-up information was obtained in 34 patients (91.8%) a median of 17 months after lithotripsy (range: 4.52 months). Ten patients died of non-biliary diseases. Two patients (5.8%) developed biliary symptoms 24 and 34 months after lithotripsy, one after unsuccessful lithotripsy. CONCLUSION: Intra-corporeal lithotripsy is a valuable tool for the most complex cases of duct stones, and with an acceptable morbidity. The results of the two techniques are similar. Late biliary complications after intra-corporeal lithotripsy appear to be rare.     

Medical management of common bile duct stones

Common bile duct stones are a common cause of morbidity and mortality in adults. An increasing number of surgical and medical therapies are available to manage them, with different success rates reported. The various medical treatment strategies were developed during the last decade, but these medical modalities should not be contemplated as a first-line alternative of treatment. A consensus from experts is that there is no primary indication to use solvents on common bile duct stones because they have a relatively high rate of adverse effects and their success is limited compared with lithotripsy. However, there is a subgroup of patients in whom invasive or surgical treatment is risky or may fail. In these patients stone dissolution by solvent may constitute a plausible therapeutic alternative or may help reduce the size of the stones sufficiently to facilitate subsequent endoscopic extraction. Solvents may also be indicated in settings where endoscopic techniques or lithotripsy are not available and the patient has a T-tube in the common bile duct. Even in this condition, however, it is probably quicker and more effective to refer the patient to a center with expertise and technologic support to practice stone removal.     

15 years of endoscopic therapy in choledocholithiasis

INTRODUCTION: The relevance of endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis and treatment of common bile duct stones has increased since the introduction of laparoscopic cholecystectomy in 1989-1990. METHODS: The number, indications, success and complication rate of ERCP were analyzed retrospectively in 1121 consecutive patients with bile duct stones treated at Berne University Hospital between 1980 and 1994. RESULTS: The number of patients undergoing endoscopic stone extraction increased slowly from 1980 to 1990, but has shown a 4-fold increase in the last 5 years parallel to the introduction of laparoscopic cholecystectomy. Failure to diagnose and remove bile duct stones decreased 5-fold from 23% (14 of 60 patients) in 1986 to 4.4% (10 of 225 patients) in 1994. Major complications occurred in 3.2% (30 of 617 patients) and consisted of acute pancreatitis (1.6%), hemorrhage of the papilla (1%), and cholangitis (0.6%). The severity but not the number of complications has decreased in the last 15 years. CONCLUSION: Gallbladder stones with common bile duct stones are usually treated by endoscopic stone extraction combined with laparoscopic cholecystectomy. Open operation with bile duct exploration is reserved for a small subgroup of patients with specific problems.     

Delayed response to phenobarbital treatment of a Crigler-Najjar type II patient with partially inactivating missense mutations in the bilirubin UDP-glucuronosyltransferase gene

BACKGROUND: Mechanical lithotripsy has become a well-accepted method of bile duct stone fragmentation and removal. The Olympus lithotripter (Olympus American, Melville, NY) is the standard reusable lithotripter at the institutions that participated in this study. A disposable device with a preassembled pistol grip may perform equally well and facilitate operation. METHODS: Twenty patients with bile duct stones were evaluated as part of a multicenter prospective study. Data were obtained regarding stone size and number, bile duct diameter, and configuration, ease of cannulation, basket function, stone capture and crushing success, and complications. RESULTS: The maximum stone size averaged 16.5 +/- 1.2 mm (range 10 to 30 mm). Sixteen patients had multiple stones (median 5, range 2 to 12). The mean bile duct diameter was 20.5 +/- 1.5 mm (range 12 to 38 mm). Cannulation was successful in all within 5 attempts. Basket deployment failed in 1 patient because of stone size and the basket was misshapen in 14. Bile duct clearance was complete in 16 subjects (80%), incomplete in 2 patients, and failed in 2 patients. Abnormal duct configuration (sigmoid, stricture) was noted in 2 of 4 patients with failed capture and 7 of 16 patients with successful clearance. No statistically significant difference was observed between the bile duct diameter, maximum stone size, number of stones, and successful clearance. CONCLUSION: The disposable lithotripter is easy to use and, compared with the published results for the reusable lithotripter, performs almost as well.     

Factors predictive of early complications of endoscopic treatment of bile duct calculi

BACKGROUND/AIMS: Factors associated with an increased early complication rate of the endoscopic sphincterotomy procedure have been identified. Precut or needle knife papillotomy has been shown to improve the success rate of endoscopic retrograde cholangiography and endoscopic sphincterotomy, but has often been reported to be hazardous. In order to identify patients with bile duct stones at risk for a complicated course in connection with endoscopic clearance of the calculi, factors predictive of early complications were sought. METHODOLOGY: 417 consecutive patients with bile duct calculi at endoscopic retrograde cholangiography were considered for endoscopic treatment in our department from 1981 to 1992. Endoscopic sphincterotomy was performed in 246 patients with intact gallbladders and in 147 with prior cholecystectomy, 55 of whom had retained calculi. RESULTS: There was a 9.4% overall and 7.1% major early complication rate of the EST procedure and a 30-day mortality of 0.5% (2 patients, non-procedure related). In 22% (6/27) of the patients with major complications, surgery was required or preferred to additional endoscopic measures. Complete stone removal failed in 35/393 patients (8.9%). The immediate and early complication rate of standard sphincterotomy was not found to be increased in patients with prior or present biliopancreatic complications, failed bile duct clearance at first attempt, or juxtapapillary diverticula. It was the same after standard sphincterotomy as after precut papillotomy followed by immediate or delayed sphincterotomy. No increased morbidity was found after failed therapy as compared to failed diagnostic precut papillotomy. There was neither a greater need for, nor an increased complication rate following, precut papillotomy in patients with, as compared to those without, juxtapapillary diverticula. Endoscopic experience did not influence the complication rate. There were no significant differences regarding outcome or risk factors associated morbidity between patients with and without intact gallbladder. CONCLUSIONS: These findings confirm that endoscopic treatment is safe and that precut papillotomy can be performed without increased morbidity. Furthermore, none of the commonly identified factors associated with increased morbidity were found to be risk factors in this study.     

Management of traction wire fracture complicating mechanical basket lithotripsy

BACKGROUND AND STUDY AIMS: The application of basket catheters has become the main method of removing calculi from the biliary and pancreatic duct. However, larger or impacted stones have to be crushed and fragmented by mechanical lithotriptors before removal is possible. Sometimes, fracture of the traction wire occurs as a severe and fraught complication. We describe a precautionary measure which helps to manage this complication. PATIENTS AND METHODS: In a series of 569 consecutive patients suffering from bile or pancreatic duct stones we found 60 (10.5%) who required mechanical lithotripsy for oversized or impacted calculi. Mechanical lithotripsy was always performed initially with a long metal sheath (80 cm) in combination with a standard traction wire. If the traction wire fractured we replaced the long metal sheath stepwise by shorter ones (70cm, 60cm and 50 cm, respectively), allowing immediate continuation of the lithotriptic procedure using the same traction wire. RESULTS: During the lithotriptic procedure three of our patients (5%) were afflicted by traction wire fracture. Two patients could be relieved directly by changing the initial metal sheath to shorter ones. Because of the exceptional hardness of a pancreatic duct stone the third patient needed stone fragmentation by extracorporeal shock wave lithrotripsy (ESWL) before complete mechanical clearance of the duct could be accomplished. CONCLUSION: We advocate the initial use of a long metal sheath (80cm) to perform mechanical lithotripsy. In case of traction wire fracture the use of a shorter metal sheath allows immediate successful continuation of the procedure, thereby frequently avoiding procedures such as ESWL or surgery.     

Endoscopic sphincterotomy for lithotripsy (EST-L) of bile duct stones

We performed EST-L for 555 patients with choledocholithiasis between 1981 and 1992. With the aid of conventional occlusion balloons and dormia-type baskets, calculi < or = 1.5 cm was extracted with relative ease. In patients with larger stone (> 1.5 cm), the mechanical lithotripter, extracorporeal shock wave lithotripsy (ESWL) and electrohydrolic lithotripsy were used for the lithotripsy. The overall success rate was 95%. Important early and late complications from these procedures occurred in 6.9% and 9.1% of all cases respectively. This result reveal that EST-L is safe and effective therapeutic procedures for choledocholithiasis. We would recommend EST-L is adopted as an initial measure to remove common bile duct stones.     

The vaccine adverse event reporting system

BACKGROUND: Endoscopic papillary dilation (EPD) by balloon in the management of bile duct stones has recently been claimed to be effective for removing bile duct stones. METHODS: Without endoscopic sphincterotomy, we attempted to remove large or multiple bile duct stones through EPD combined with drip infusion of isosorbide dinitrate in 35 patients. Isosorbide dinitrate, at a rate of 5 mg/h, was administered intravenously, and a balloon dilator with a 10-mm diameter was inflated within 3 min across the papilla. Stones were then smashed using a mechanical lithotriptor, and the fragments were extracted with a basket or the balloon. RESULTS: Extraction of stones was successful in 33 (94%) of 35 patients by the combined therapy. Two of them (6%) developed mild pancreatitis. CONCLUSION: EPD combined with medical sphincter dilation was effective for large and multiple bile duct stones.     

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.     

Combined laparoscopic and endoscopic approach in patients with cholelithiasis and choledocholithiasis

BACKGROUND: The Optimal management of common bile duct stones in patients undergoing laparoscopic cholecystectomy remains controversial. METHODS: A prospective study was conducted in 145 of the 481 patients who had a preoperative endoscopic retrograde cholangiogram before their laparoscopic cholecystectomy. RESULTS: Endoscopic retrograde cholangiogram was successful in 138 patients (95%), and common duct calculi were found in 72 (50%) of them. Endoscopic sphincterotomy with ductal clearance was achieved in 62 of 67 patients during a mean of 1.4 sessions (range, 1 to 5). Five (3.4%) patients had complications after endoscopic intervention, all of which resolved uneventfully . Fourteen patients underwent laparoscopic common duct exploration, five had failed endoscopic extraction, five had their common duct stones left intentionally for laparoscopic intervention, and, in addition, four of the seven patients who had a failed endoscopic retrograde cholangiogram had stones identified by intraoperative cholangiogram. Ten of these 14 patients underwent a successful laparoscopic common duct exploration. Laparoscopic cholecystectomy was successfully completed in 134 of the 145 patients, and none had major intraoperative or postoperative complications. The mean postoperative stay was 2.7 days for those patients who underwent a successful laparoscopic procedure. The overall mean number of admissions for completing the treatment was 2.3. CONCLUSIONS: Combined laparoscopic and endoscopic approach is a viable option for patients with gallstones and choledocholithiasis.     

Comparison of routine and selective endoscopic retrograde cholangiography before laparoscopic cholecystectomy

To evaluate the role of endoscopic retrograde cholangiography (ERC) before laparoscopic cholecystectomy, we compared the frequency of concomitant common bile duct stones, their clinical outcome, and the frequency of bile duct injury between a group of 128 patients with routine preoperative ERC (group A) and 1010 patients with selective ERC (group B). Overall, 48 patients (4.2%) had duct stones, but the predictive signs were absent in six of them (12.5%). The stones were demonstrated by ERC and removed by sphincterotomy in all 11 patients in group A. Of 37 patients in group B, 22 were diagnosed by selective ERC and underwent endoscopic removal. Of four patients whose stones were found by operative cholangiography, one had immediate open surgery, another passed a stone spontaneously, and the other two underwent postoperative sphincterotomy, which failed in one. The stones were not recognized until pain recurred in the remaining 11 patients. Sphincterotomy was successful in nine patients but failed in the other two. Thus postoperative sphincterotomy failed in 3 of 13 patients (23%), necessitating open surgery. Forty-two patients overall (3.7%) had aberrant biliary tract anatomy, which did not lead to bile duct injury in any of the patients. Morbidity of routine ERC (3.1%) was lower than that of selective ERC (7.4%) (p < 0.05). It should be noted that a certain proportion of duct stones may be missed by selective ERC, necessitating laparotomy when sphincterotomy fails. The routine use of preoperative ERC may be justified at institutions where the expertise is available, at least until laparoscopic lithotomy becomes easy.