Endoscopic Common Bile Duct Research Articles

Emerging Trends in Endoscopic Retrograde Cholangiopancreatography and Common Bile Duct Exploration

Emerging Trends in Endoscopic Retrograde Cholangiopancreatography and Common Bile Duct Exploration

Emerging Trends in Endoscopic Retrograde Cholangiopancreatography and Common Bile Duct Exploration—Reply

Emerging Trends in Endoscopic Retrograde Cholangiopancreatography and Common Bile Duct Exploration—Reply

The role of endoscopy in the management of choledocholithiasis

The role of endoscopy in the management of choledocholithiasis

Biliary Obstruction During Cholecystectomy: Endoscopic Retrograde Cholangiopancreatography, Evade, or Explore?

Biliary obstruction discovered during cholecystectomy remains a challenging problem. To determine the best management, this retrospective study compared intervention during the same admission (SA) versus delayed/no intervention (DN). Furthermore, this study demonstrates the power of a deidentified research database derived from electronic medical records. Patients undergoing cholecystectomy and intraoperative cholangiogram (IOC) were identified in the Vanderbilt Synthetic Derivative database. Patients with biliary obstruction discovered during IOC were included and a cohort study was performed. Interventions for biliary obstruction included endoscopic retrograde cholangiopancreatography or common bile duct exploration. A composite measure of any biliary complication served as the primary outcome. A total of 1899 patients who underwent cholecystectomy were evaluated; 151 met inclusion criteria. Mean age was 44 years with 69 per cent women. Sixty-three per cent of patients had intervention during the SA for cholecystectomy compared with 37 per cent for DN. Nineteen per cent of patients in the SA group had biliary complications versus 16 per cent for DN (P = 0.656). Patients in the SA group had a significantly increased length of stay (4.7 vs 2.1 days, P < 0.05). These data suggest an aggressive approach to biliary obstruction seen on IOC does not reduce postoperative biliary complications and may incur unnecessary resource use.

Ways to improve quality of endoscopic sphincterotomy in difficult technic cases

During examining endoscopic sphincterotomy difficulties to be discovered that the small papilla of Vater cause technological problems of identification common bile duct orice. The best way to overcame that difficulties is performing of of hepar bile ductes punction with endoscopic common bile duct orice identification.

Long-Term Follow-up Study of Gallbladder in Situ After Endoscopic Common Duct Stone Removal in Korean Patients

Background Although there has been much debate over the fate of the gallbladder (GB) after endoscopic common bile duct (CBD) stone removal, subsequent cholecystectomy is generally recommended in patients with GB stones to prevent further biliary complications. The aims of this study were to assess the natural course of the patients with GB in situ after endoscopic CBD stone removal and to evaluate the necessity of prophylactic cholecystectomy.

Early Laparoscopic Cholecystectomy After Endoscopic Common Bile Duct Stone Extraction

The optimal timing of laparoscopic cholecystectomy (LC) after endoscopic common bile duct stone extraction remains controversial. The aim of this China-based retrospective study was to investigate the outcomes of patients who underwent early LC after endoscopic procedures. The retrospective study enrolled patients who underwent LC after endoscopic common bile duct stone extraction between January 2007 and February 2010. On the basis of intervals between LC and endoscopic procedures, patients were classified into 2 groups: early LC group, including patients receiving LC within 3 days; and delayed LC group, including patients receiving LC after 3 days. Operation time, surgical complications, postoperative hospital stay, and the cost of hospitalization were compared between 2 groups. There were 92 patients in the early LC group and 115 patients in the delayed LC group. The characteristics and endoscopic procedures of the 2 groups were similar. There were no differences between the 2 groups in operative duration, incidence of surgical complications, restoration of bowel motion, postoperative hospital stay, and LC-related cost. However, total hospital cost of early LC was less than that of delayed LC. Early LC after endoscopic common bile duct stone extraction in developing countries is feasible and safe. Moreover, it can reduce the total hospital cost effectively. Thus, early LC after endoscopic procedures should be recommended in developing countries.

The Efficacy of Early Scheduled Follow-Up Endoscopic Retrograde Cholangiopancreatography after Common Bile Duct Stone Removal

To investigate the efficacy of early scheduled follow-up endoscopic retrograde cholangiopancreatography (ERCP) after common bile duct (CBD) stone removal. Patients who underwent endoscopic CBD stone removal and who had at least one risk factor for stone recurrence were enrolled. Six months after complete clearance of the CBD, patients underwent follow-up ERCP at an ambulatory care center, irrespective of symptoms. The incidence of symptoms and cholangitis at follow-up ERCP was significantly lower in Group A (ERCP at 6 months after stone removal) than that in Group B (ERCP at >6 months) (14.3% vs 71.4%, p=0.00; 9.5% vs 33.3%, p=0.02, respectively). However, the recurrence rates of CBD stones were not different between Groups A and B (33.3% vs 47.6%). When comparing the subgroups, Group AR (stone recurrence in Group A) displayed significantly fewer symptoms and lesser cholangitis and spent fewer days in the hospital than did Group BR (stone recurrence in Group B) (21.4% vs 70%, p=0.02; 14.3% vs 60%, p=0.02; 2.43±1.87 vs 6.10±3.35, p=0.00, respectively). Our data suggest that, irrespective of symptoms, early scheduled follow-up ERCP for patients who are at a high risk of recurrence is effective and safe.

Variations in the preoperative resources use and the practice pattern in Japanese cholecystectomy patients

There are several preoperative treatment options, such as the staged bile duct intervention (BDI), for the successful completion of a cholecystectomy, regardless of the use of an open cholecystectomy (OC) or a laparoscopic cholecystectomy (LC). However, few studies have investigated how the characteristics of the patient or the hospital affect the preoperative resource use. This study determined the factors, including the hospital characteristics, associated with the preoperative resource utilization or with the treatment process. Cholecystectomy patients (n = 12 627) who were treated for benign gallbladder diseases were examined. The study variables were: the patient demographics; the comorbid conditions; the presence of inflammation; the BDI, including endoscopic retrograde cholangiopancreatography, percutaneous gallbladder or common bile duct drainage, endoscopic sphincterotomy, clearance of choledocholithiasis; the preoperative length of stay (LOS) or the total charges; and the hospital region, ownership, and function. A multivariate analysis was used to measure the variables associated with the use of preoperative resources. A total of 11,690 (85.1%) patients underwent LC. The inflammation was diagnosed in 72.5% of OC and 41.5% of LC patients. Bile duct intervention was performed in more of the OC patients. The preoperative BDI had a significantly greater impact on the LOS. The hospital demographics predicted the preoperative resource use and the implementation of the BDI. The preoperative BDI involved the use of more preoperative resources. A wide variation of the use of BDI was observed in the hospital demographics. Further study is needed to establish a preoperative treatment strategy for cholecystectomy patients.

Acute biliary pancreatitis: Diagnosis and treatment

Gallstones are the commonest cause of acute pancreatitis (AP), a potentially life-threatening condition, worldwide. The pathogenesis of acute pancreatitis has not been fully understood. Laboratory and radiological investigations are critical for diagnosis as well prognosis prediction. Scoring systems based on radiological findings and serologic inflammatory markers have been proposed as better predictors of disease severity. Early endoscopic retrograde cholangiopancreatography (ERCP) is beneficial in a group of patients with gallstone pancreatitis. Laparoscopic cholecystectomy with preoperative endoscopic common bile duct clearance is recommended as a treatment of choice for acute biliary pancreatitis. The timing of cholecystectomy, following ERCP, for biliary pancreatitis can vary markedly depending on the severity of pancreatitis

Laparoscopic common bile duct exploration after failed endoscopic stone extraction

Our objective was to present the technical aspects and results of laparoscopic common bile duct (CBD) exploration following failed endoscopic stone extraction. From April 1997 to December 2006, 32 patients were referred to us after unsuccessful attempts at endoscopic CBD stone extraction. Transcholedochal laparoscopic CBD exploration was used in all patients. Previous operations, several pathologic entities, and stone impaction were studied as potential predictors of failure of the laparoscopic approach. Previous operations, cholangitis, anatomic abnormalities, and stone impaction were the principal reasons for failure of endoscopic retrograde cholangiopancreatography (ERCP). Stone extraction under direct laparoscopic choledochotomy was achieved in 20 of 31 patients (64.51%). Biliary stents were inserted in 7 patients (21.8%) and T tubes were placed in 21 patients (65.6%). Five laparoscopic choledochoduodenostomies were performed. There were 11 conversions to open surgery. Morbidity was 12.5%. Laparoscopic choledochotomy is an efficacious procedure in dealing with unsuccessful endoscopic CBD clearance.

Prospective Randomized Trial for the Effectiveness of a Routine ENBD Insertion After Endoscopic CBD Stone Clearance in Patients with Acute Cholangitis: A Preliminary Report

Backgrounds: Endoscopic sphincterotomy (EST) with a common bile duct (CBD) stone extraction is the treatment of choice for patients with acute cholangitis and most endoscopists preferentially insert either a endoscopic nasobiliary drain (ENBD) or a biliary stent for decompressional purpose. Although some prospective studies compared the efficacy of a temporarily inserted ENBD and a biliary stent until the definite clearance of CBD or results of full EST with stone extraction versus minor EST with a biliary stent, there has been no study concerning the effectiveness of the placement of a ENBD after clearance of CBD.

Risk factors of acute cholecystitis after endoscopic common bile duct stone removal

To evaluate the risk factors of acute cholecystitis after endoscopic common bile duct (CBD) stone removal. A total 100 of patients who underwent endoscopic CBD stone removal with gallbladder (GB) in situ without subsequent cholecystectomy from January 2000 to July 2004 were evaluated retrospectively. The following factors were considered while evaluating risk factors for the development of acute cholecystitis: age, gender, serum bilirubin level, GB wall thickening, cystic duct patency, presence of a GB stone, CBD diameter, residual stone, lithotripsy, juxtapapillary diverticulum, presence of liver cirrhosis or diabetes mellitus, a presenting illness of cholangitis or pancreatitis, and procedure-related complications. During a mean 18-mo follow-up, 28 (28%) patients developed biliary symptoms; 17 (17%) acute cholecystitis and 13 (13%) CBD stone recurrence. Of patients with acute cholecystitis, 15 (88.2%) received laparoscopic cholecystectomy and 2 (11.8%) open cholecystectomy. All recurrent CBD stones were successfully removed endoscopically. The mean time elapse to acute cholecystitis was 10.2 mo (1-37 mo) and that to recurrent CBD stone was 18.4 mo. Of the 17 patients who received cholecystectomy, 2 (11.8%) developed recurrent CBD stones after cholecystectomy. By multivariate analysis, a serum total bilirubin level of <1.3 mg/dL and a CBD diameter of <11 mm at the time of stone removal were found to predict the development of acute cholecystitis. After CBD stone removal, there is no need for routine prophylactic cholecystectomy. However, patients without a dilated bile duct (<11 mm) and jaundice (<1.3 mg/dL) at the time of CBD stone removal have a higher risk of acute cholecystitis and are possible candidates for prophylactic cholecystectomy.

Acute gallstone pancreatitis: timing of laparoscopic cholecystectomy in mild and severe disease.

In acute gallstone pancreatitis, the ideal point in time for laparoscopic cholecystectomy with special reference to the severity of the disease has been prospectively analyzed. A total of 77 patients with biliary acute pancreatitis were admitted between November 1993 and July 1998 (37 men and 40 women; mean age, 63 years; median Apache II score, 13.3) and staged by contrast-enhanced computed tomography findings as having edematous or necrotizing disease. In 48 patients, laparoscopic cholecystectomy was found to be possible: 35 patients (73%) with mild and 13 patients (27%) with severe acute pancreatitis. The overall success rate was 79% (38 of 48 patients), with 85% (30 of 35 patients) and 62% (8 of 13 patients) having mild and severe disease, respectively. Median duration of time between onset of symptoms and surgery was 10 days (range, 4-19 days) in edematous and 14 days (range, 7-29 days) in necrotizing pancreatitis (p = 0.0353). Operating time (median, 80 min) and hospital stay (median, 5 days) were almost the same in both groups. Total morbidity was 8%, with no mortality. Laparoscopic cholecystectomy with preoperative endoscopic common bile duct clearance is recommended as a treatment of choice for biliary acute pancreatitis. In mild disease, this is performed safely within 7 days, whereas in severe disease, especially in extended pancreatic necrosis, at least 3 weeks should elapse because of an increased infection risk.

Single-centre audit of endoscopic common bile duct stone retrieval

Abstract Background Endoscopic extraction of stones in the bile duct is not without risk, with complications occurring in up to 10 per cent of patients. The aim of this study was to determine the success and complications of stone retrieval by endoscopic retrograde cholangiopancreatography (ERCP) in this institution. Methods This was a retrospective analysis of a prospective database for all ERCPs (single operator, single institution) between 1990 and 1995. Some 271 consecutive patients with a strong suspicion of bile duct stones, from history or investigations, were studied. All patients underwent ERCP and attempted retrieval of bile duct stones if detected. Treatment success was strictly defined as a stone-free postprocedure radiograph. All patients were followed to identify complications occurring within 30 days of the procedure. Results The median age of the 271 patients was 73 (range 17–96) years; 62 per cent were women. Some 139 patients had 162 significant other medical conditions (61 per cent cardiopulmonary) that required specialist treatment. The presenting symptoms included painful jaundice (34 per cent), acute pancreatitis (25 per cent), cholangitis (17 per cent), painless jaundice (14 per cent) and abdominal pain alone (9 per cent). Stones were seen at ERCP in 192 patients (71 per cent); the median number of stones was 1 (range 0–20). Successful endoscopic stone retrieval was achieved in 136 patients (71 per cent) at the first attempt, with an overall success rate of 90 per cent. The median number of ERCPs per patient was 1 (range 1–4). There were five false-negative ERCPs (2 per cent) and 19 retrieval failures (10 per cent), which included requirement for percutaneous cholangiography or endoscopic stenting for successful treatment. Complications occurred in eight␣patients (3 per cent), and included cholangitis (1␣per cent), pancreatitis (less than 1 per cent) and haemorrhage (less than 1 per cent). There were two procedure-related deaths (1 per cent), from myocardial infarction and cholangitis. Conclusion Endoscopic stone retrieval can be achieved successfully with low morbidity and mortality rates, even in patients with significant co-morbidity. These data provide further support for dedicated units offering a regional ERCP service.

Costs of endoscopic vs. laparoscopic common bile duct stone extraction

Costs of endoscopic vs. laparoscopic common bile duct stone extraction

Surgical Therapy for Gallstone Disease

Surgery, in particular laparoscopic cholecystectomy, will probably remain the preferred treatment for symptomatic gallbladder stones. It is unlikely that other methods of treatment, such as oral dissolution therapy or lithotripsy, can match the results and patient acceptance of this procedure. With the advent of laparoscopic cholecystectomy, however, more patients with choledocholithiasis will undergo endoscopic sphincterotomy and endoscopic common bile duct clearance. This may change, however, if the common bile duct can be explored safely through the laparoscope. Finally, severe gallstone pancreatitis will continue to be treated by early endoscopic sphincterotomy followed by cholecystectomy. Nevertheless, endoscopic sphincterotomy alone will be used more often as a definitive treatment to prevent recurrent attacks, especially in elderly patients who are poor candidates for cholecystectomy.

Acute suppurative obstructive cholangitis due to stones: treatment by urgent endoscopic sphincterotomy

Endoscopic sphincterotomy is an accepted treatment for retained common bile duct stones, but there is little specific information available regarding its application in acute suppurative obstructive cholangitis with sepsis due to choledocholithiasis. Thirteen patients with this condition were referred to the authors for consideration of urgent endoscopic common bile duct decompression. All had been judged to be poor surgical candidates. Pus was released from the common bile duct by sphincterotomy within 24 hours of admission in all 13. Stones were removed endoscopically in 10 patients (77%) without complications. After endoscopic stone removal, symptoms, signs, and abnormal laboratory values returned to normal rapidly; follow-up endoscopic retrograde cholangiography did not show retained stones. Three patients whose large stones precluded endoscopic removal underwent operative choledocholithotomy. Urgent endoscopic sphincterotomy offers an important alternative in the treatment of acute suppurative obstructive cholangitis secondary to choledocholithiasis.