Large Common Bile Duct Stones Research Articles

Management of impacted common bile duct stones during a laparoscopic procedure: A Retrospective Cohort Study of 377 Consecutive Patients

IntroductionTo explore the techniques for managing impacted common bile duct (CBD) stones during laparoscopic common bile duct exploration (LCBDE). MethodsWe retrospectively analyzed 377 consecutive patients undergoing LCBDE from January 2008 to June 2015. Group 1 was defined as patients with impacted CBD stones. Group 2 included patients without impacted CBD stones. The outcomes of LCBDE were compared between the two groups. ResultsThere were 65 patients in Group 1 and 312 patients in Group 2. The incidence of jaundice, abnormal liver function tests, cholangitis and pancreatitis was higher in Group 1. Forty-one patients with small impacted CBD stones were managed using the tipless Nitinol basket. Seventeen patients with large impacted CBD stones and 7 patients with small impacted CBD stones underwent laser lithotripsy via choledochoscopy. None of the patients in Group 1 was converted to open procedures for impacted CBD stones. Operation duration was 13.6 min longer in Group 1 (133.2 min). Postoperative hospital stay was significantly longer in Group 1 (9.7 ± 2.5 d) than in Group 2 (6.3 ± 1.8 d). There was no difference in the overall postoperative complication rate, retained stone rate, and recurrence rate between the two groups. ConclusionRational utilization of laser lithotripsy and an appropriate basket in LCBDE may avoid conversion to open procedures in patients with impacted CBD stones.

Endoscopic Papillary Large Balloon Dilatation Without Sphincterotomy for the Treatment of Large Common Bile Duct Stone: Long-Term Outcomes at a Single Center.

Endoscopic papillary large balloon dilatation (EPLBD) without endoscopic sphincterotomy (EST) is an accepted, simplified endoscopic technique for large common bile duct (CBD) stone removal. However, little is known about the long-term outcomes of this technique. The purpose of this study was to evaluate the long-term outcomes of EPLBD without EST for the treatment of large CBD stones. This retrospective study of EPLBD without EST for a large CBD stone was conducted between June 2005 and October 2010. A total of 128 patients with a large CBD stone were included. The primary outcome measurement was complete CBD stone removal after EPLBD. Clinical data obtained from medical records were analyzed. The overall complete stone removal rate was 94.5%. Mechanical lithotripsy was needed in 18 (14.1%) patients. Post-procedural pancreatitis and asymptomatic hyperamylasemia occurred in 1 (0.8%) and 11 (8.6%) patients, respectively. One (0.8%) patient experienced minor bleeding. The rate of stone recurrence was 13.1%, and median time to stone recurrence was 600days (range 144-2284days). Over a half (64.3%) of stone recurrences occurred during the 2years following stone removal. Recurrence tended to be more frequent in patients with a large CBD diameter and in patients requiring multiple endoscopic sessions for complete CBD stone retrieval. EPLBD without EST may be safe and effective in patients with a large bile duct stone.

Laparoscopic Transcystic Common Bile Duct Exploration: T-Shaped Incision of Cystic Duct with FREDDY Laser Lithotripsy.

Optimal laparoscopic techniques for management of gallstones concomitant with common bile duct (CBD) stones remain under debate. The aim of this study was to evaluate a novel approach to managing gallstones concomitant with large or impacted CBD stones through a modified laparoscopic transcystic CBD exploration (LTCBDE) with frequency-doubled double-pulse neodymium:YAG (FREDDY) laser lithotripsy. This retrospective review includes 32 consecutive patients with gallstones concomitant with large or impacted CBD stones who were offered LTCBDE with FREDDY laser lithotripsy between June 2012 and December 2014. Demographic, perioperative, and follow-up data were collected and analyzed retrospectively. CBD stone clearance was achieved for all patients. There were 13 males and 19 females, among whom there were three patients with a history of abdominal surgery. The diameter of the CBD ranged from 10 to 20 (mean 15.1) mm, and the number of CBD stones ranged from 1 to 5. CBD stones ranged in diameter from 9 to 18 (mean 11.7) mm and 9 patients had stones that were impacted in the CBD. The mean operative time was 123 ± 18 minutes with a range of 72 to 155 minutes. The mean length of postoperative hospital stay was 5.3 (range 4-7) days. All patients recovered normally without morbidity or mortality. The modified LTCBDE with a T-shaped incision of the cystic duct and FREDDY laser lithotripsy is a safe and effective means of managing gallstones concomitant with large or impacted CBD stones.

Laparoscopic Common Bile Duct Exploration: 9 Years Experience from a Single Center.

The aim of the study was to evaluate the safety and feasibility of laparoscopic common bile duct exploration (LCBDE) through cholangiotomy with T-tube placement in one séance for common bile duct stones (CBDS). Between January 2005 and December 2010, a total of 99 patients with CBDS stones undergoing LCBDE with T-tube insertion at Enköping Hospital, Sweden, were registered prospectively. All patients were followed up by review of the patient records according to a standardized protocol. No severe intraoperative complications were registered. Four procedures required conversion to open cholecystectomy due to impacted stones or technical difficulty. The mean operative time was 194 min [(SD) 57 min]. The mean postoperative hospital stay was 4.8 days, SD 2.4 days. At secondary cholangiography, 2 (2%) retained stones were found. Two (2%) patients had minor bile leakage, which resolved spontaneously. None of the patients experienced biliary peritonitis, biliary fistula, pancreatitis, or cholangitis. No death within 30 days after surgery was seen. No patient was readmitted with clinical signs of stricture. If performed by a surgeon familiar with the technique, LCBDE is a safe and feasible alternative for managing CBDS. The advantages are most pronounced in the case of multiple and large CBDS. The risk for retained stones and stricture is low.

Successful Removal of a Large Common Bile Duct Stone by Using Direct Peroral Cholangioscopy and Laser Lithotripsy in a Patient with Severe Kyphosis

A 75-year-old woman with hypertension presented with acute suppurative cholangitis. Chest radiography revealed severe kyphosis. Abdominal computed tomography revealed a large stone impacted in the common bile duct (CBD). The patient underwent emergent endoscopic retrograde cholangiopancreatography, and cholangiography revealed a large stone (7×3 cm) in the CBD that could not be captured using a large basket. We could not use the percutaneous approach for stone fragmentation by using a cholangioscope because of severe degenerative kyphosis. Finally, we performed holmium laser lithotripsy under peroral cholangioscopy by using an ultraslim endoscope, and the large stone in the CBD was successfully fragmented and removed without complications.

Lithotripsy of Biliary Calculi in a Complex Biliary Tract Using Endourologic Equipment

Lithotripsy of Biliary Calculi in a Complex Biliary Tract Using Endourologic Equipment

Laparoscopic common bile duct exploration for choledocholithiasis: Theodor Bilharz Research Institute preliminary experience

Background Laparoscopic common bile duct stones exploration (LCBDE) is a potential option for the management of stones within the biliary tree at the same time as laparoscopic cholecystectomy. Materials and methods All data on LCBDE were prospectively collected from April 2014 to June 2015; 36 consecutive patients diagnosed with cholelithiasis and common bile duct stones were enrolled in this study. There were 10 men and 26 women, median age 57 years (range 43-71 years). Our inclusion criteria were as follows: patients with obstructive jaundice because of stones, patients who had not undergone upper abdominal surgery, surgically fit patients with concomitant gallstones and common bile duct (CBD) stones (de-novo cases), patients in whom endoscopic retrograde cholangiopancreatectomy retrieval had failed previously mainly because of instrumentation failure; large or multiple CBD stones requiring extraction and drainage with remaining stent; LCBDE that could be approached either through the cystic duct or directly through a choledochotomy incision. Results All patients survived the operation. Successful LCBDE and stone clearance were achieved in 34 of 36 patients, whereas treatment failure occurred in the other two patients. The reasons for failure were due to instruments issues e.g. balloon rupture and broken basket. No incidences of bile leakage, hemobilia, abdominal bleeding, or pancreatitis occurred in the patients in our series. Transient colic pain occurred in two patients and was treated conservatively. A transient increase in the liver function tests (aspartate aminotransferase and alanine aminotransferase) was observed in three patients and returned to normal on postoperative day 3 without any treatment. The external drainage tube was removed 48 h postoperatively. Conclusion LCBDE can be performed after proper training and with the availability of adequate equipment and laparoscopic facilities. LCBDE is a safe and cost-effective treatment option for gall bladder and CBD stones in the short term.

Impacted and Fractured Biliary Basket: A Second Basket Rescue Technique.

A 59-year-old woman was treated with ERCP, ES, and biliary plastic stent, for large and multiple common bile duct stones. During a second ERCP basket extraction was impacted with a round entrapped stone. The basket handle was cut off; a metal sheath of extraendoscopic lithotriptor was advanced over the basket. The mechanical lithotripsy was complicated with basket traction wires fracturing, without breakage of the stone. A rescue standard basket was pushed until it caught the basket/stone complex. Using this method disengagement of the whole fractured basket/stone complex was achieved without need of surgery. It is the third case reported in the English literature.

Is endoscopic papillary large balloon dilation safe for treating large CBD stones?

In recent years, endoscopic papillary large balloon dilation (EPLBD) with endoscopic sphincterotomy (EST) has been shown to be an effective technique for the removal of large or difficult common bile duct (CBD) stones, as an alternative to EST. Reviewing the literature published since 2003, it is understood that EPLBD has fewer associated overall complications than EST. Bleeding occurred less frequently with EPLBD than with EST. There was no significant difference in postendoscopic retrograde cholangiopancreatography pancreatitis or perforation. Recent accumulated results of EPLBD with or even without EST suggest that it is a safe and effective procedure for the removal of large or difficult bile duct stones without any additional risk of severe adverse events, when performed under appropriate guidelines. Since use of a larger balloon can tear the sphincter as well as the bile duct, possibly resulting in bleeding and perforation, a balloon size that is equal to or smaller in diameter than the diameter of the native distal bile duct is recommended. The maximum transverse diameter of the stone and the balloon-stone diameter ratio have a tendency to affect the success or failure of complete removal of stones by large balloon dilation to prevent adverse effects such as perforation and bleeding. One should take into account the size of the native bile duct, the size and burden of stones, the presence of stricture of distal bile duct, and the presence of the papilla in or adjacent to a diverticulum. Even though the results of EPLBD indicate that it is a relatively safe procedure in patients with common duct stones with a dilated CBD, the recommended guidelines should be followed strictly for the prevention of major adverse events such as bleeding and perforation.

Effectiveness and safety of biliary stenting in the management of difficult common bile duct stones in elderly patients.

To investigate the efficacy and safety of endoscopic biliary stenting for difficult common bile duct (CBD) stones in elderly patients. Elderly patients (≥65 years) with large (≥20 mm) or multiple (≥3) CBD stones were studied. The patients underwent placement of single (n=34, group A) or double (n=30, group B) plastic stents at the time of initial endoscopic retrograde cholangiopancreatography (ERCP). Approximately 3 months later, stone removal was attempted at the second ERCP. The reduction of stone size and number before and after biliary stenting, complete stone removal, 3-month stent patency rate, and complications were compared. The mean size (longitudinal/transverse diameter) of the CBD stones was significantly reduced after biliary stenting in both groups (p<0.001). Complete stone removal at the second ERCP was 94.1% in group A and 100% in group B (p=0.494). Kaplan-Meier analysis indicated that group B had a higher 3-month stent patency rate than group A (p=0.008). Endoscopic biliary stenting is safe and feasible for the management of difficult CBD stones in elderly patients, while double biliary stenting is superior to single stenting in maintaining higher stent patency rates.

The short and long term outcomes of ampulla dilation with balloons of different sizes for removing common bile duct stones

Objective To assess the short and long term outcomes of endoscopic papillary balloon dilation (EPBD) with different sized balloon for removal of common bile duct (CBD) stones. Methods A total of 485 consecutive patients were enrolled, who were divided into five groups based on the largest CBD stone size, i. e. group 1 ≤6 mm, group 2 >6-8 mm, group 3 >8-10 mm, group 4 >10-12 mm, and group 5 >12 mm. Patients in each group underwent limited endoscopic sphincterotomy (EST) alone, or limited EST followed by EPBD with 8 mm, 10 mm, 12 mm, or 14 mm balloons, respectively. CBD stones were removed with retrieval balloon, Dormia basket, and/or mechanical lithotripsy if necessary. The short and long term outcomes were compared among these five groups. Results The overall success rates of stone removal in all groups were 100%, and no perforation or death occurred. Twenty-three (4.74%) patients had post-ERC pancreatitis, and 8 (1.65%) had post-operative bleeding. The incidences of post-ERC acute pancreatitis of each group were 3.1%(3/98), 4.9%(4/81), 3.5%(7/203), 8.9%(6/67), 8.3%(3/36), respectively (P=0.285). The incidences of bleeding in each group were 3.1%(3/98), 0(0/81), 0.5%(1/203), 3.0%(2/67)and 5.5%(2/36), respectively(P=0.080). There was no significant differences in early complication rates among the five groups. The incidences of pneumobilia of each group were 2.0%(2/98), 4.9%(4/81), 8.4%(17/203), 14.9%(10/67) and 52.8%(19/36), respectively (P<0.001). The incidence of pneumobilia increased with the size of the balloon. Conclusion Choice of a balloon size based on the largest CBD stone diameter is safe and effective for removing CBD stones, but with the increase of balloon size, Oddi function may be damaged more severely. Key words: Endoscopic papillary balloon dilation; Endoscopic sphincterotomy; Common bile duct stones

1059 Endoscopic Papillary Large Balloon Dilation With Versus Without Sphincterotomy for the Treatment of Large Common Bile-Duct Stone: a Multicenter, Prospective, Randomized, Controlled Trial

Endoscopic papillary large balloon dilation (EPLBD) without endoscopic sphincterotomy (EST) may be comparable with outcomes from EPLBD with EST for the treatment of large common bile-duct (CBD) stone. However, there is no prospective comparative data for both procedures yet. We aimed to compare prospectively safety and efficacy of EPLBD with preceding EST to those of EPLBD without EST for the treatment of large CBD stone.

Clinical observation of small endoscopic sphincterectomy combined with endoscopic papillary balloon dilation in the treatment of large common bile duct stones

Objective To observe the clinical effect of small endoscopic sphincterectomy (SES) combined with endoscopic papillary balloon dilation (EPBD) in the treatment of large common bile duct stones. Methods The patients were randomly divided into 3 groups: normal endoscopic sphincterotomy(EST), EPBD, SES combined with EPBD. The incidence of pancreatitis at 1 week after operation and the recurrence rate of inner duct stone within 15 months after operation were statistically analyzed. Results At 1 week after treatment, the incidence of pancreatitis was lower in group EST and group SES combind with EPBD than in group EPBD 〔3.3%(1/30), 3.3%(1/30) vs.20.0% (6/30), both P<0.05〕. After 15 months of treatment, the recurrence rate of inner duct stone were lower in group B and group C than in group A 3.3%(1/30), 3.3%(1/30) vs. 23.3%(7/30), both P<0.05). Conclusions In the treatment of large common bile duct stones, SES combined with EPBD can reduce the incidence of postoperative acute pancreatitis and the long-term recurrence rate of common bile duct stones. Key words: Duodenum; Balloon dilation; Choledocholithiasis; Sphincterectomy, transhepatic

The therapeutic effect of endoscopic papillary large–balloon dilation for juxtapapillary duodenal diverticulim combined with large common bile duct stones

Objective To investigate the effectiveness and safety of endoscopic papillary large–balloon dilation(EPLBD) for juxtapapillary duodenal diverticulum(JPD)combined with large common bile duct stones. Methods A total of 87 patients with juxtapapillary duodenal diverticulum and large common bile duct stones were randomly divided to 2 groups. Forty–five cases received endoscopic papillary large–balloon dilation(EPLBD group) as the treatment group, and 42 cases were treated by conventional endoscopic sphincterotomy(EST group) as the control group. The success rate of stone clearance in a single session, operation time, the rate of mechanical lithotripsy and complications were observed. Results Stone clearance in a single session of 2 groups were 91.1%(EPLBD group)and 92.9%(EST group) respectively with no significant difference(P>0.05). The stone removal time were(25.48±7.92)min in EPLBD group and(35.56±9.23)min in EST group(P 0.05). No death happened in any group. Conclusion EPLBD is a safe and effective method for clearance of large common bile duct stones combined with juxtapapillary duodenal diverticulum which can reduce the occurrence of mechanically breaking stone and operation time. Key words: Choledocholithiasis; Juxtapapillary duodenal diverticulim; Sphincterotomy; Ballon dilatation

Percutaneous papillary large balloon dilation during percutaneous cholangioscopic lithotripsy for the treatment of large bile-duct stones: a feasibility study.

When access to a major duodenal papilla or endoscopic retrograde cholangiopancreatography has failed, percutaneous transhepatic cholangioscopic lithotripsy (PTCS-L) may be useful for removing common bile duct (CBD) stones. However, the feasibility and usefulness of percutaneous transhepatic papillary large-balloon dilation (PPLBD) during PTCS-L for the removal of large CBD stones has not been established. We aimed to determine the safety and efficacy of PPLBD for the treatment of large CBD stones. Eleven patients with large CBD stones in whom the access to the major papilla or bile duct had failed were enrolled prospectively. Papillary dilation was performed using a large (12-20 mm) dilation balloon catheter via the percutaneous transhepatic route. Post-procedure adverse events and efficacy of the stone retrieval were measured. The initial success rate of PPLBD was 100%. No patient required a basket to remove a stone after PPLBD. Electrohydraulic lithotripsy was required in 2 (18.2%) patients. The median time to complete stone removal after PPLBD was 17.8 min and no adverse events occurred after PPLBD. Asymptomatic hyperamylasemia was not encountered in any patients. This study indicates that PPLBD is safe and effective for removal of large CBD stones.

Reappraisal of endoscopic papillary balloon dilation for the management of common bile duct stones.

Although endoscopic sphincterotomy (EST) is still considered as a gold standard treatment for common bile duct (CBD) stones in western guideline, endoscopic papillary balloon dilation (EPBD) is commonly used by the endoscopists in Asia as the first-line treatment for CBD stones. Besides the advantages of a technical easy procedure, endoscopic papillary large balloon dilation (EPLBD) can facilitate the removal of large CBD stones. The indication of EPBD is now extended from removal of the small stones by using traditional balloon, to removal of large stones and avoidance of lithotripsy by using large balloon alone or after EST. According to the reports of antegrade papillary balloon dilatation, balloon dilation itself is not the cause of pancreatitis. On the contrary, adequate dilation of papillary orifice can reduce the trauma to the papilla and pancreas by the basket or lithotripter during the procedure of stone extraction. EPLBD alone is as effective as EPLBD with limited EST. Longer ballooning time may be beneficial in EPLBD alone to achieve adequate loosening of papillary orifice. The longer ballooning time does not increase the risk of pancreatitis but may reduce the bleeding episodes in patients with coagulopathy. Slowly inflation of the balloon, but not exceed the diameter of bile duct and tolerance of the patients are important to prevent the complication of perforation. EPBLD alone or with EST are not the sphincter preserved procedures, regular follow up is necessary for early detection and management of CBD stones recurrence.

Different techniques for management of common bile duct stones: a single centre experience.

Local experience on the combined technique of endoscopic sphincterotomy followed by endo: scopic balloon dilation is scarce. This study clarified whether this crombined technique will offer any advantages, with respect to therapeutic outcome and complications rate, as compared with endoscopic sphincterotomy (ES) and endoscopic balloon dilatation (EBD) alone for the extraction of large and/or multiple common bile duct stones. For a total of 76 patients, extraction of large and/or multiple common bile duct (CBD) stones during endoscopic retrograde cholangiopancreatography was performed. According to the used technique, they were categorized into 3 groups; Endoscopic sphincterotomy, endoscopic balloon dilatation or combined technique. The success rate of complete stone removal and the incidence of procedure-related complications were compared among the three groups. Success rate after one session was recorded to be comparable among the three groups. Relative Risk Ratio assessment of success rate after single session among the three groups showed no statistically significant difference. Regarding bleeding, only 3 (10%) cases were recorded in the ES group with no cases in the, other 2 groups. No significant difference was noted among the three groups regarding other complication. The combined technique of ES followed by EBD is an effective and safe technique enables extraction of multiple and/or relatively large stones. It could be a reasonable alternative option when standard techniques are inadequate to remove bile duct stones.

Tips in biliary stone removal using endoscopic papillary large balloon dilation.

The use of limited endoscopic sphincterotomy with large balloon dilation (ESLBD) has recently been shown to be useful for removal of large common bile duct stones in a dilated bile duct. The technique can reduce the need of mechanical lithotripsy, risk of adverse events and costs of the procedure. The aim of the review is to provide an overview in the current status of ESLBD with particular focus on the technical aspects of the technique for bile duct stone removal.

Role of ERCP SpyGlass® Electrohydraulic Lithotripsy in Patients With Chronic Pancreatitis and Pancreatic Duct Calculi Causing Duct Obstruction: A Case Series

Introduction: ERCP with SpyGlass® cholangioscopy and electrohydraulic lithotripsy (EHL) is an established treatment for large common bile duct stones. However, the role of SpyGlass® EHL in treating patients with pancreatic duct calculi has yet to be well studied. The current management of pancreatic duct stones consists of extracorporeal shock wave lithotripsy (ESWL) or surgical intervention. The purpose of this case series is to study the safety and efficacy of SpyGlass® EHL in patients with pancreatic duct calculi. Methods: In patients with chronic pancreatitis and pancreatic duct stones, we performed ERCP with SpyGlass® pancreatoscopy and EHL in an attempt to break the calculi into smaller fragments in order to relieve the pancreatic duct obstruction. Consecutive patients with pancreatic duct stones were included in the study. Pancreatic duct stents were placed following lithotripsy in all patients. The stents were later removed at a 4-6 week interval after the procedure. Results: ERCP with SpyGlass® EHL was performed in 7 patients with chronic pancreatitis and stones. Two patients were relieved of their obstruction after only 1 procedure. Four patients required 2 procedures, and 1 patient required 3 procedures. ERCP with SpyGlass® EHL was successful in relieving the main pancreatic duct obstruction in 5 patients. The remaining 2 patients were referred to a multidisciplinary pancreas team for ESWL therapy. However, both these patients ended up requiring surgery. One patient received Puestow’s procedure while the other received Berger’s operation. Two patients had pain following the ERCP and EHL treatment and required overnight hospitalization. One patient had mild pancreatitis. No other complications were reported. Conclusion: ERCP with EHL appears to be a safe and effective therapeutic procedure in the majority of patients with chronic pancreatitis and pancreatic duct calculi. Larger studies are needed to validate the results of our pilot study.

Comparison of Two Capture Methods for Endoscopic Removal of Large Common Bile Duct Stones

Large common bile duct (CBD) stones remain a major challenge for endoscopists. The capture of large CBD stones is a limiting factor for successful removal. The aim of the study is to evaluate the efficacy and safety of stretching the basket out at the bottom of the stones to capture large CBD stones. Sixty-five patients with large stones (>20 mm in diameter) were selected and randomly divided into Group A (33 cases) and Group B (34 cases). After appropriate sphincterotomy with balloon dilation, two different methods were used to capture stones. For Method A, the basket was inserted above a large stone and opened to capture it. For Method B, the basket was stretched out at the bottom of the large stone and opened slowly to capture it. The success rate of capturing stones was 33.3% in Group A and 94.1% in Group B (P<.05). There was no statistically significant difference in complication rate between the two groups (P>.05). The success rate for capturing large CBD stones can be increased by stretching the basket out at the bottom of the stones to capture the stone.