Endoscopic Sphincterotomy For Bile Duct Stones Research Articles

Endoscopic papillary large balloon dilation without sphincterotomy for users of antithrombotic agents: A multicenter retrospective study.

With an aging population, an increasing number of individuals on antithrombotic agents are diagnosed with large bile duct stones. Studies have shown the effectiveness of endoscopic papillary large balloon dilation (EPLBD) for removal of large bile duct stones. EPLBD without endoscopic sphincterotomy (EST) may reduce the risk of procedure-related bleeding, but the safety of this procedure for users of antithrombotic agents remains unclear. In this multicenter retrospective study, we included patients who underwent EPLBD without EST for bile duct stones between March 2008 and December 2017. We compared adverse events and other clinical outcomes between users and non-users of antithrombotic agents (antiplatelet agents and anticoagulants). We analyzed a total of 144 patients (47 users and 97 non-users of antithrombotic agents). Among the users, the agents were continued in 13% and were replaced with heparin in 62% during the periprocedural period. We did not observe clinically significant bleeding and thrombotic events irrespective of the use of antithrombotic agents. Overall rate of early adverse events did not differ between users and non-users (6.4% and 7.2%, P = 0.99). Procedural outcomes did not differ between the groups (necessity for lithotripsy, 28% vs. 29%; and complete stone removal in a single session, 72% vs. 71%, for users and non-users, respectively). Endoscopic papillary large balloon dilation without EST may be done without a substantial increase in procedure-related bleeding for users of antithrombotic agents. A larger study is required to refine the management strategy for those agents during the periprocedural period.

Tu1964 Randomised Clinical Trial: Should Cholecystectomy Be Needed After Endoscopic Sphincterotomy for Bile-Duct Stones?

Background Endoscopic sphincterotomy is regarded as a standard treatment for biliary duct stones. However, it is another issue for the need of additional cholecystectomy after endoscopic sphincterotomy. Especially, unlike Western patients, primary bile duct stones are more prevalent in Korean people. In this study, we compared the treatment strategies of cholecystectomy and gallbladders left in situ. Methods We did a prospective, randomized, single center trial in 90 patients who underwent endoscopic sphincterotomy and stone extraction, with proven gallbladder stones. Patients were randomly allocated to cholecystectomy (n=45) or expectant management (n=45). The primary outcome was further biliary complications. Other outcome measures are included adverse events after cholecystectomy and risk factors of biliary complications. Results Two patients were lost to follow-up immediately in cholecystectomy group. 26 patients (60.5%) in cholecystectomy group and 13 patients (28.9%) in expectant management group underwent cholecystectomy. Median follow-up was 40 months. In intention to treat analysis, 8 patients (18.6%) in the cholecystectomy group returned with further biliary events. Among those with expectant management, 9 (20%) had recurrent biliary events (Breslow, P = 0.349). Adverse events of cholecystectomy (6.9% vs. 4.4%, P = 0.305) and the rate of conversion to open surgery (13.8% vs. 4.4%, P = 1.000) were not different in both groups. In as treated analysis, 4 patients (10.3%) who underwent cholecystectomy and 13 patients (26.5%) who did not undergo cholecystectomy had additional biliary events during follow up period (Log Rank, P = 0.037). However, after excepting the event of cholecystitis, additional biliary events (cholangitis) were not different each other (Log Rank, P = 0.998). Conclusion In this study in Korea, cholecystectomy after endoscopic sphincterotomy for bile duct stones did not reduce additional recurrent cholangitis but additional cholecystitis.

Wait-and-see policy versus cholecystectomy after endoscopic sphincterotomy for bile-duct stones in high-risk patients with co-existing gallbladder stones: A prospective randomised trial

Background and study aimsEndoscopic sphincterotomy (ES) is one of the most important advances in the treatment of common bile duct (CBD) stones. However, the use of ES to remove CBD stones in high-risk patients without cholecystectomy is still debatable. The aim of this study was to compare the efficacy of a wait-and-see policy versus cholecystectomy after ES for CBD stones in high-risk patients with co-existing cholelithiasis. Patients and methodsA total of 162 patients after undergoing ES with the clearance of CBD stones were randomised after informed consent to cholecystectomy or conservative management of their gallbladder stones. ResultsThe results indicated that cholecystectomy after ES for CBD stones significantly reduced the biliary complications in high-risk patients. ConclusionEvery patient who has both CBD stones and gallstones with significant co-morbid illnesses, after clearance of CBD stones by ES, should undergo early cholecystectomy.

Preserved Gallbladder Prevents Recurrent Common Bile Duct Stones After Endoscopic Sphincterotomy

Background: There are many reports of long-term results of endoscopic sphincterotomy (ES) for common bile duct stones. Cholecystectomy is generally recommended after ES because of possible further biliary complications especially for patients with gallbladder stones. However, only approximately 10% of patients with gallbladders left in situ will return with further biliary complications. Its not well known about the impact of gallbladder on recurrent bile duct stones. The requirement for subsequent cholecystectomy in patients with gallbladder in situ after ES is controversial. Methods: Patients who underwent ES for bile duct stones were enrolled. Long-term follow-up data (>120 months) were obtained in 666 patients. The follow up period ranged from 120 to 334 months (average 150.4 months). The patients were divided into subgroups according to the state of gallbladder. The rates of recurrence of bile duct stones were compared between each group. Results: 237 out of 666 patients had already undergone cholecystectectomy before ES (Group I). Remaining 429 patients had a gallbladder in place (Group II). 134 of the 429 patients underwent elective cholecystectomy immediately after ES (Group IIA), whereas the other 295 patients were followed up with the gallbladder in place (Group IIB). The cumulative recurrence rate of bile duct stones were significantly higher in Group I compared to Group IIB (p<0.05). However there was no significant difference between group I and group IIA. Conclusions: Bile duct stones recur less frequently after ES in patients with gallbladder in situ. The preserved gallbladder might have a preventive role for recurrent bile duct stones after ES.

Wait-and-see policy or laparoscopic cholecystectomy after endoscopic sphincterotomy for bile-duct stones: a randomised trial

Patients who undergo endoscopic sphincterotomy for common bile-duct stones, who have residual gallbladder stones, are referred for laparoscopic cholecystectomy. However, only 10% of patients who do not have this operation are reported to develop recurrent biliary symptoms. We aimed to assess whether a wait-and-see policy is justified. We did a prospective, randomised, multicentre trial in 120 patients (age 18-80 years) who underwent endoscopic sphincterotomy and stone extraction, with proven gallbladder stones. Patients were randomly allocated to wait and see (n=64) or laparoscopic cholecystectomy (56). Primary outcome was recurrence of at least one biliary event during 2-year follow-up, and secondary outcomes were complications of cholecystectomy and quality of life. Analysis was by intention to treat. 12 patients were lost to follow-up immediately. Of 59 patients allocated to wait and see, 27 (47%) had recurrent biliary symptoms compared with one (2%) of 49 patients after laparoscopic cholecystectomy (relative risk 22.42, 95% CI 3.16-159.14, p<0.0001). 22 (81%) of 27 patients underwent cholecystectomy, mainly for biliary pain (n=13) or acute cholecystitis (7). Conversion rate to open surgery was 55% in patients allocated to wait and see who underwent cholecystectomy compared with 23% in those who were allocated laparoscopic cholecystectomy (p=0.0104). Morbidity was 32% versus 14% (p=0.1048), and median hospital stay was 9 versus 7 days. Quality of life returned to normal within 3 months after either treatment policy. A wait-and-see policy after endoscopic sphincterotomy in combined cholecystodocholithiasis cannot be recommended as standard treatment, since 47% of expectantly managed patients developed at least one recurrent biliary event and 37% needed cholecystectomy. No major biliary complications arose, but conversion rate was high.

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

Background: Little is known about the long-term effects of endoscopic biliary sphincterotomy. Methods: We retrospectively evaluated the rate of late complications after endoscopic sphincterotomy (EST) for bile duct stones. Patients had to meet the following inclusion criteria: (1) treated between 1976 and 1980, (2) complete stone removal after EST, (3) prior cholecystectomy or elective cholecystectomy within 2 months after EST, and (4) 60 years old or younger at the time of ERCP. A total of 100 patients were identified. Information was obtained from general practitioners and patients by telephone. Patients completed a postal questionnaire and a blood sample was obtained for liver function tests. Results: Information was obtained for 94 patients (in the majority of cases [87%] from multiple sources). There were 26 men and 68 women with a mean age of 51 years at the time of ERCP (range, 23 to 60 years). Early complications (<30 days) occurred in 14 patients (15%). One patient died of a retroperitoneal perforation secondary to EST. During a median period of 15 years (range, 3 to 18 years), 22 patients (24%) developed a total of 36 late complications. There were 21 patients with symptoms of recurrent bile duct stones and one patient with biliary pancreatitis. Other late complications, such as recurrent ascending cholangitis or malignant degeneration, were not observed. An ERCP was performed in 20 of the 22 patients with late complications and demonstrated bile duct stones in 13, combined with stenosis of the EST opening in 9 patients. Late complications were initially managed endoscopically and/or conservatively. One patient underwent surgery after failed endoscopic treatment and one patient died of cholangitis before she could undergo an ERCP. Twelve other patients died of unrelated causes during follow-up. Conclusions: After EST for bile duct stones, late complications occur in a significant proportion of patients. Stone recurrence remains the most important problem, but can in general be managed endoscopically. (Gastrointest Endosc 1996;44:643-9.)