Treatment of lithiasis of the common bile duct by endoscopic sphincterotomy and laparoscopic cholecystectomy

This paper describes the ongoing development of a region-wide system for monitoring the short-term outcomes of total knee replacement surgery. The system aims to collect data from a dozen hospitals, and relies on a close collaboration with locally based surgeons and medical audit staff. The intention is to provide routine comparative information based on a broad conception of outcome, that includes both clinical/technical measures and patient-derived assessments of general health status. These data may be reported in the context of relatively detailed case mix information. To date, both data capture and clinical support for the project have been good. Example reports are presented together with a discussion of current limitations and possible future developments.     

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.     

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.     

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.     

Population-based study of cancer risk and relative survival following sphincterotomy for stones in the common bile duct

An external nasal dilator (Breathe Right, CNS, Inc., Bloomington, MN) has become popular with athletes. The dilator is an adhesive band with a central elastic strip. When applied across the nasal valve, the device theoretically increases nasal valve area. We used acoustic rhinometry (Hood Laboratories, Pembroke, MA) to measure the cross-sectional area at the nasal valve with and without the device in 53 athletes. Thirty athletes were exercised on a cycle ergometer with and without the device while measuring physiologic parameters, including oxygen consumption (VO2), heart rate, and respiratory rate. The study was conducted in a randomized, double-blind, placebo-controlled manner. At rest, the external nasal dilator was found to significantly increase nasal valve area in all demographic groups measured. The device was also found to significantly decrease submaximal exercise perceived exertion, heart rate, ventilation, and VO2 when compared with placebo.     

Retained stones in the common bile duct: results of management

Seventeen patients underwent treatment for retained common bile duct stones. In 7 patients the stones were removed via a T-tube tract using steerable catheters while 5 patients underwent ERCP and sphincterotomy and 5 underwent surgical re-exploration. Considering morbidity, mortality, success rate and patients' stay in the hospital, non-operative modalities should be the treatment of choice for retained common bile duct stones.     

Long-term follow-up after endoscopic sphincterotomy for bile duct stones in patients younger than 60 years of age

PURPOSE: To study the clinical histories and courses of six patients with choroidal neovascularization secondary to endogenous Candida albicans chorioretinitis. METHODS: The medical records, fundus photographs, and fluorescein angiograms of six patients who developed C. albicans chorioretinitis secondary to candidemia and who subsequently developed choroidal neovascularization in one or both eyes were reviewed. RESULTS: The six patients ranged in age from 18 to 79 years. Four were women and two men; all but one showed evidence of bilateral chorioretinal scarring secondary to C. albicans chorioretinitis. All patients had been treated successfully with systemic antifungal therapy (amphotericin B). Two weeks to two years after the chorioretinitis, choroidal neovascularization developed in one eye (four cases) or both eyes (two cases). The neovascularization on initial examination was subfoveal in four eyes, extrafoveal in three eyes, and juxtafoveal in one eye. Laser photocoagulation was used in four of the eight involved eyes. In these cases, the active choroidal neovascularization was brought under control. In one eye, the patient had submacular surgery for excision of the choroidal neovascular membrane. Final visual acuities ranged from 20/20 to 20/200 in treated eyes and from 20/50 to 20/400 in untreated eyes. CONCLUSION: Choroidal neovascularization is a potential cause of late visual loss in patients who have had C. albicans sepsis and endogenous C. albicans chorioretinitis. Eyes that have chorioretinal scarring from C. albicans chorioretinitis should be watched for the development of choroidal neovascularization. Laser photocoagulation or perhaps surgical excision of the neovascular complex may be of benefit in selected cases.     

Retrograde cholangiopancreatography (ERCP) and endoscopic sphincteropapillotomy (ES) in the diagnosis and treatment of common bile duct (CBD) lithiasis

The common bile duct (CBD) stones often gives real difficulties of diagnosis and treatment. The ultrasound (US) does not offer in a significant percentage of cases certain diagnostic data, and the unconventional imaging techniques such as computer tomography (CT) are yet less accessible. ERCP appeared in the last period as an optional method for the diagnosis of common bile duct stones, and, moreover, permitted the development of the nonsurgical treatment possibilities. ES and the extraction of stones revealed in this frame as preferable, especially in the high surgical risk cases. This study presents the results of ERCP performed in 547 and the therapeutic value of ES in 284 cases with CBD stones (conclusions of the ERCP and ES used in the clinical practice, in our clinic, in the last three years). In 81.69% cases ES managed the dezobstruction of the CBD, with a frequency of complications of 4.33% and a related mortality rate of 0.78%.     

The role of endoscopic therapy in chronic pancreatitis-induced common bile duct strictures

During endoscopic retrograde cholangiography, common bile duct strictures are encountered in up to 30% of patients with chronic pancreatitis. The indications for treatment of these strictures are discussed. A surgical biliodigestive anastomosis has always been the traditional treatment modality. Not all patients need treatment, however, and endoscopic biliary drainage is the treatment of choice for certain subgroups of patients.     

Spontaneous rupture of an intrahepatic bile duct with biloma treated by percutaneous drainage and endoscopic sphincterotomy

A case of spontaneous rupture of an intrahepatic bile duct with biloma formation treated by percutaneous drainage and endoscopic sphincterotomy is reported. A 73-yr-old woman was admitted with fever and abdominal pain. There was no past history of abdominal surgery, instrumentation, or trauma. Ultrasound and computed tomography revealed a massive fluid collection in the abdominal cavity. Endoscopic retrograde cholangiography demonstrated extravasation of contrast medium from a distal biliary radicle in the left lobe of the liver. After successful treatment by percutaneous drainage and endoscopic sphincterotomy, the patient did well. Ultrasound and computed tomography showed resolution of the biloma. Nontraumatic bilomas are very rare: in fact, only 24 cases of spontaneous biloma have been reported. Endoscopic treatment for patients with spontaneous bilomas can be safe and effective, and should be considered.     

Choledochocele of the common bile duct

The eighth report case of choledochocele is described. This lesion is a cyst communicating with the terminal portion of the common bile duct. It is characteristically lined with duodenal mucosa and is probably a form of duplication of the duodenum. The surgical treatment is marsupialization of the cyst to the interior of the duodenum.     

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.     

Cystic dilatation of the common bile duct

The Authors report a case of cystic dilatation of the common bile duct and a review of the Literature. The lesion is a congenital malformation of infancy or childhood, being rare in adult life. The main symptoms are biliary colic with jaundice and fever. Modern techniques such as abdominal ultrasonography, CT, ERCP, PTC generally provide to achieve preoperative diagnosis. When radical surgery is possible the complete excision of the cyst is the management of choice. The case reported is classified as type 1 of Todani's classification. Surgical management consisted in a complete excision of the cyst. Bile flow was re-established by hepaticojejunostomy.     

Primary non-Hodgkin's lymphoma of the common bile duct

Primary non-Hodgkin's lymphoma of the common bile duct is rare. To date, nine cases have been recorded in the literature. We report an additional case of a 39-yr-old woman presented with obstructive jaundice. Pathological studies of the surgical specimen disclosed that the wall of the common bile duct was transmurally infiltrated by non-Hodgkin's lymphoma of diffuse large cell type of B-cell lineage intimately associated with reticular fibers. The patient received postoperative brachytherapy, followed by six cycles of chemotherapy according to the CHOP regimen. There is no evidence of lymphoma recurrence 13 months after the surgery. Our analysis of the reported cases indicates that common bile duct non-Hodgkin's lymphoma is a rapidly progressive disease, terminating in death within a year. A complete surgical resection of the lymphoma followed by chemotherapy has shown a promising result.     

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.