Biliary stenting in the management of large or multiple common bile duct stones

Abstract

I was interested to read the article by Horiuchi et al1Horiuchi A. Yoshiko N. Masashi K. et al.Biliary stenting in the management of large or multiple common bile duct stones.Gastrointest Endosc. 2010; 71: 1200-1203Abstract Full Text Full Text PDF PubMed Scopus (82) Google Scholar on stenting for difficult bile duct stones. Endoscopists new to ERCP will welcome the news that biliary stenting can reduce the size and number of large bile duct stones, facilitating their extraction, but this is not—as claimed by the authors—an original observation. They state, “For the first time, the present study proposes that stenting could be a primary method to reduce the size and number of difficult bile duct stones, making extraction possible.” They also opine that “the role of adjuvants such as ursodeoxycholic acid is unclear,” citing two recent studies (from 2008 and 2009)2Katsinelos P. Kountouras J. Paroutoglou G. et al.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: 453-459Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar, 3Han J. Moon J.H. Koo H.C. et al.Effect of biliary stenting combined with ursodeoxycholic acid and terpene treatment on retained common bile duct stones in elderly patients: a multicenter study.Am J Gastroenterol. 2009; 104: 2418-2421Crossref PubMed Scopus (60) Google Scholar with contradictory findings. In 1993, Johnson et al4Johnson G.K. Geenen J.E. Venu R.P. et al.Treatment of non-extractable common bile duct stones with combination ursodeoxycholic acid plus endoprostheses.Gastrointest Endosc. 1993; 39: 528-531Abstract Full Text PDF PubMed Scopus (52) Google Scholar published their experience of 22 patients with difficult-to-extract bile duct stones: all were treated with biliary stents. In addition, 10 patients were given oral ursodeoxycholate. Nine of 10 patients in the ursodeoxycholate-plus-stent group had complete bile duct clearance of stones after a median follow-up period of 9 ± 2 months, whereas none of the control group (stent alone) had complete clearance, and only 6 of 40 stones could be removed after a follow-up period of 31 ± 6 months. Stenting for “difficult” bile duct stones was commonplace before the introduction of modern mechanical lithotripters and contact lithotripsy (ie, laser and electrohydraulic). A standard PubMed review reveals thoughtful work on this subject in the late 1980s and early 1990s.5Cotton P.B. Forbes A. Leung J.W. et al.Endoscopic stenting for long-term treatment of large common bile duct stones: 2- to 5-year follow-up.Gastrointest Endosc. 1987; 33: 411-412Abstract Full Text PDF PubMed Scopus (130) Google Scholar, 6Maxton D.G. Tweedle D.E. Martin D.F. Retained common bile duct stones after endoscopic sphincterotomy: temporary and longterm treatment with biliary stenting.Gut. 1995; 36: 446-449Crossref PubMed Scopus (88) Google Scholar, 7Lauri A. Horton R.C. Davidson B.R. et al.Endoscopic extraction of bile duct stones: management related to stone size.Gut. 1993; 34: 1718-1721Crossref PubMed Scopus (100) Google Scholar Because pigtail biliary stents are more difficult to place and occlude more quickly than straight ones, it is hard to support their preferential use in this setting. Finally, the authors offer stenting as an alternative to extracorporeal shock-wave lithotripsy, which—along with electrohydraulic (contact) lithotripsy—they say is “used often.” At least in the United States, extracorporeal shock-wave lithotripsy has almost disappeared; I doubt if more than a handful of tertiary-care centers have it available for managing large biliary and pancreatic stones. Biliary stenting in the management of large or multiple common bile duct stonesGastrointestinal EndoscopyVol. 71Issue 7PreviewEndoscopic biliary stenting with a plastic stent is often performed to prevent impaction of common bile duct (CBD) stones. The therapeutic effect of a plastic stent placement in terms of reduction in stone size and number has not been established. Full-Text PDF ResponseGastrointestinal EndoscopyVol. 73Issue 3PreviewWe thank Dr Baillie for his thoughtful comments on our article. Possibly we were not clear regarding what was new versus what was not. We agree that there were many studies in the late 1980s and early 1990s. The primary goal of stenting was to prevent stone impaction, and it was not intentionally performed to facilitate the extraction of difficult stones. Our, and we believe original, observations are based on our findings that intentional biliary stenting using a double-pigtail stent for about 2 months resulted in a reduction in the size and number of large or multiple bile duct stones. Full-Text PDF