Multiple Common Bile Duct Stones Research Articles

Bouncing Off the Balloon: A New Trick for Selective Cystic Duct Cannulation

Introduction: Management of acute cholecystitis in non-surgical or high-risk candidates includes endoscopic (transpapillary or transmural stenting) or percutaneous drainage of the gallbladder (GB). Endoscopic cannulation of the cystic duct (CD) for transpapillary GB drainage in such cases can be technically challenging and difficult, given narrowing of cystic duct orifice from edema, stones and valves in the cystic duct, and angulation of the cystic duct takeoff. Here we describe a novel technique, using no special equipment that can be utilized in cases of angulated CD takeoff. Case Description: A 47-year-old woman was admitted with acute cholecystitis and choledocholithiasis. Her vitals were stable with no signs of sepsis. Her WBC was 7.7 X 103/dl, AST 78 unit/L, ALT 267 unit/L, ALP 207 unit/L, total bilirubin was 1.2 mg/dl. Given her morbid obesity (BMI 53) and multiple comorbidities (history of recent uterine infection with perforation, multiple intra-abdominal abscesses, and a diversion colostomy) she was deemed not a surgical candidate for cholecystectomy. Subsequently, she underwent an endoscopic retrograde cholangiography (ERC) with successful mechanical lithotripsy and balloon extraction of multiple common bile duct (CBD) stones. Selective CD cannulation was then attempted; however, was unsuccessful despite multiple attempts using different guidewires and catheters given the downward angulation (Image 1) of the CD takeoff that made it technically challenging. A 15 mm extraction balloon was inflated in the distal common hepatic duct (1 cm proximal to the CD orifice) and a 0.035-inch guidewire was inserted into the CBD alongside the extraction balloon catheter. The guidewire was further advanced into the bile duct allowing the guidewire to recoil (bounce) off the balloon, and was carefully manipulated into the angulated CD takeoff (Image 2). Contrast injection showed filling defect in the neck of the gallbladder. Pus was seen draining from the major ampulla after CD cannulation. A transpapillary 7 Fr x 22 cm double-pigtail plastic stent was successfully placed across the CD with the internal pigtail in the gallbladder lumen (Image 3).1323_A.tif Figure 1: No Caption available.1323_B.tif Figure 2: No Caption available.1323_C.tif Figure 3: No Caption available.Discussion: There is a paucity of techniques describing CD cannulation. These include using intraductal ultrasound or cholangioscopy for guidance, however, such devices may not be readily available. We believe our novel and simple method can be utilized for selective CD cannulation in such difficult cases.

Percutaneous Transcholecystic Removal of Common Bile Duct Stones: Case Series in 114 Patients.

Purpose To evaluate the safety and effectiveness of percutaneous transcholecystic removal of common bile duct (CBD) stones in 114 patients. Materials and Methods This retrospective study was approved by the institutional review board. From September 2011 through February 2017, 114 consecutive patients (68 men, 46 women; mean age, 73 years) underwent percutaneous transcholecystic removal of CBD stones. All patients had acute cholangitis or cholecystitis. Stones were extracted through a 12-F sheath by using a Wittich nitinol stone basket uder fluoroscopic guidance. Technical success rates, complications, and long-term follow-up were evaluated. Results Technical success was achieved in 96 of 114 (84.2%) patients. In 18 patients, stone removal was unsuccessful due to failure of cystic duct cannulation (n = 11), proximal migration of the CBD stone (n = 3), multiple CBD stones (n = 3), and low insertion of the cystic duct (n = 1). No major procedure-related complications were seen. During the mean follow-up of 644 days (range, 11-2206 days), CBD stones recurred in 12 patients after a mean of 884 days (range, 439-1799 days) after the procedure. Conclusion Percutaneous transcholecystic removal of common bile duct stones seems to be a safe and effective method. © RSNA, 2018 Online supplemental material is available for this article . See also the editorial by vanSonnenberg and Panchanathan in this issue.

Risk factors and consequences of conversion to open surgery in laparoscopic common bile duct exploration.

Although laparoscopic common bile duct exploration (LCBDE) has shown many obvious advantages compared with open surgery in the treatment of common bile duct (CBD) stones, it remains unclear regarding risk factors of conversion from LCBDE to open surgery and whether conversion will counteract the advantages of LCBDE. The purpose of this study was to explore risk factors and consequences of conversion from LCBDE to open surgery. A retrospective study was conducted, using a database of 644 patients with LCBDE between 2011 and 2017. Risk factors for conversion to open surgery were determined based on univariable and multivariable analysis. The consequences of conversion to open surgery in LCBDE were analyzed. Conversion was required in 27 (4.2%) of 644 patients undergoing LCBDE. Independent risk factors for conversion were as follows: the max diameter of stones in CBD (odds ratio (OR) 2.234, 95%CI 1.031-4.842; p = 0.042), edema of CBD (OR 12.530, 95%CI 4.633-33.887; p < 0.001), and multiple stones in CBD (OR 3.438, 95%CI: 1.133-10.428; p = 0.029). These risk factors and their combined were good predictors for conversion in LCBDE. More blood loss, longer operative time, longer postoperative hospital stay, and higher incision infection were identified in patients with conversion than those without conversion. However, no significant differences were observed regarding mortality, readmission within 30 days, reoperation, bile leakage, and intra-abdominal fluid collection. Conversion to open surgery in LCBDE was associated with acute edematous CBD with large and multiple stones. Conversion can offset the advantages of LCBDE.

Successful access to the ampulla for endoscopic retrograde cholangiopancreatography in patients with situs inversus totalis: a case report

BackgroundAlthough various endoscopic techniques in situs inversus have been reported, endoscopic retrograde cholangiopancreatography (ERCP) in patients with situs inversus is always challenging even for an experienced endoscopist. We performed ERCP using two different techniques, and compare the merits of each technique.Case presentationA 74-year-old woman presented with epigastric pain and jaundice for 3 days. Computed tomography revealed diffuse dilatation of the biliary tree, with multiple intrahepatic duct and common bile duct (CBD) stones, in addition to situs inversus totalis. ERCP was performed twice for CBD stone to remove the CBD stones using two techniques. For the first technique used, the patient was placed in a prone position with the endoscopist on the right side of the table. First, the endoscope was rotated 180° counterclockwise in the stomach, and was then shortened by turning 180° the counterclockwise again in the duodenum. For the second technique, we assessed the second portion of the duodenum by following the lesser curvature, while slowly turning the endoscope clockwise.ConclusionWe present an unusual case of biliary stones in a patient with situs inversus who was treated using modified ERCP techniques.

¿Tiene el páncreas divisum un rol determinante en la pancreatitis aguda?

PurposePancreatic developmental anomalies are a spectrum of anatomical variations, including the pancreas divisum, where its association with acute pancreatitis continues being controversial. Materials and methodsFirstly, a non-experimental cross-sectional study was carried out on one hundred cadaveric duodenpancreatic pieces, and secondly was analyzed the case report of a patient with extrahepatic cholestasis and acute pancreatitis associated with pancreas divisum. The objective was to determinate the prevalence of the decompressive pancreatic system. ResultsThere is a statistically significant difference between the dimensions of the accessory pancreatic duct and its relation with the permeability. In terms of pancreatic volumetry, the section corresponding to the upper third cephalic, neck, body and tail of the organ registers an average dimension of 21.99cm3, while the section of the last two thirds cephalic was 8.17cm3. Simultaneously, the patient reported presented a pancreatitis with amylase 280UI/l, lipase 173UI/l, associated with cholestasis. On the second day of hospitalization, endoscopic retrograde cholangiopancreatography was performed with a greater duodenal papillotomy and extraction of multiple common bile duct stones, evidencing a complete pancreas divisum. DiscussionThe exposed case shows that pancreatitis, in presence of pancreas divisum, would have the denomination of a subclinical ventral pancreatitis. ConclusionThe pancreas divisum would be a predictor of acute pancreatitis by losing the decompressive pancreatic protective mechanism.

Sa1435 Investigation on the Treatment Success of Large Multiple Common Bile Duct Stones for the Elderly Including the Long Term Outcomes by Comparing EPLBD and EST

Sa1435 Investigation on the Treatment Success of Large Multiple Common Bile Duct Stones for the Elderly Including the Long Term Outcomes by Comparing EPLBD and EST

Role of biliary stenting in management of large or multiple common bile duct stones

Background Common bile duct (CBD) stones are seen in ∼7–12%. They vary in size ranging from rather small (∼1–2 mm) to very large (>3 cm). Endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy and basket or balloon extraction are well-established therapeutic procedures for the management of CBD stones. Aim The aim of the present study was to assess the role of biliary stenting in management of large or multiple CBD stones by comparison between stone size, number, and index between both sessions of ERCP, with average duration of 2 months. Patients and methods A total of 25 patients referred to our center with radiological evidence of large CBD stones (≥2 cm) and/or multiple stones (≥3) were included. Initial ERCP with biliary stenting was performed. After 2 months or more, second-look ERCP was performed with stone extraction, with comparison of stone number, size, and index between both sessions. Results Our study showed statistical significant reduction in stone size, index, and number, with availability of stones removal in the second session. Moreover, reduction in bilirubin level was observed. Conclusion In conclusion, temporary biliary stenting within an average of 2 months has a role in the management of large and multiple CBD stones and will facilitate stone extraction.

Laparoscopic Exploration of the Common Bile Duct and T-Tube Drainage in China

Biliary stones that are seen in the Asian population are very different from those seen in the west. It is frequent to see multiple, large, and impacted stones and a hugely dilated Common Bile Duct (CBD). Many of these patients have been managed by open cholecystectomy, even after the advent of Laparoscopic Cholecystectomy (LC) because these large stones pose significant challenges for extraction by endoscopic retrograde cholangio-pancreatography. This study represents an experience of managing intra and extra hepatic bile ducts using a laparoscopic approach. A retrospective data analysis was done during the period of November 2010-April 2015 and correspondingly 85 patients with documented intra and extra hepatic biliary stones were treated laparoscopically at Qilu Hospital under Shandong University, School of Medicine. There were 23 men and 62 women patients with age ranging from 23 to 76 years. The mean diameter of the CBD was 12mm. The number of stones extracted varied from 1 to 35 and the size of the extracted stones from 0.3X0.3X0.3 to 4X3.5X3.5 mm. The average duration of surgery was 170 min. There were 7 conversions to open procedures and 24 patients (29%) had nonfatal postoperative complications. Four patients had retained stones (4.7%). Though patients presented with multiple and impacted CBD stones, laparoscopy presents a unique approach for a minimally invasive procedure with its benefits in the form of laparoscopic intra and extra hepatic bile ducts exploration. &#x0D; JCMCTA 2015 ; 26 (2) : 53 - 61

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.

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.

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.

Analysis on the risk factors of multiple recurrent common bile duct stones after endoscopic treatment

Objective To investigate the risk factors of multiple recurrent bile duct stones in patients with common bile duct (CBD) stones and received endoscopic sphincterotomy (EST) treatment. Methods From June 1st, 2007 to June 1st, 2011, the patients received EST treatment were followed up, the follow-up time was three to seven years. A total of 2 738 patients were successfully followed up, including 24 patients with two or more than two times of recurrent bile stone after EST who were enrolled in multiple recurrence group. One hundred patients without recurrence were randomly selected by table of random number as control group. The clinical data of two groups were compared by t test or Chi-square test. The factors were analyzed with multivariate Logistic regression analysis and try to find out the risk factors of multiple recurrence. Results The comparative analysis between two groups showed that the three factors of juxtapapillary duodenal diverticula [17.0%(17/100) vs 41.7%(10/24)], history of biliary tract surgery [13.0%(13/100) vs 45.8%(11/24)] and the angle enclosed between the horizontal portion of the CBD and the horizontal plane (angleofbile duct) less than 45° [2.0%(2/100) vs 20.8%(5/24)] were statistically significant (χ2=6.914、13.37、9.595, all P<0.01). Furthermore, logistic regression analysis indicated that juxtapapillary duodenal diverticula (B=1.421, OR=4.142, P=0.01), history of biliary tract surgery (B=1.612, OR=5.011, P=0.004) and the angle of bile ductless than 45°(B=2.661, OR=14.31, P=0.005) were risk factors of multiple recurrence. Conclusion Juxtapapillary duodenal diverticula, history of biliary tract surgery, and the angle of bile duct less than 45° are independent risk factors of multiple recurrence of CBD stones. Key words: Cholangiopancreatography, endoscopic retrograde; Sphincterotomy, endoscopic; Choledocholithiasis; Multiple recurrence; Risk factors

Ectopic Opening of the Common Bile Duct into the Duodenal Bulb Accompanied with Cholangitis and Gallbladder Cancer: A Report of Two Cases.

An ectopic opening of the common bile duct (CBD) into the duodenal bulb is a very rare congenital anomaly of the biliary system, which may cause recurrent duodenal ulcer or biliary diseases such as choledocholithiasis and cholangitis. Endoscopic retrograde cholangiopancreatography (ERCP) plays a major role in the diagnosis of this anomaly. We report two such cases: one in a 61-year-old man and the other in a 57-year-old man. In the first case, this anomaly caused acute cholangitis with multiple CBD stones, which were successfully treated by ERCP. In the second case, abdominal computed tomography showed pneumobilia, which was further evaluated using ERCP. Besides, this patient was diagnosed with an ectopic opening of the CBD associated with gallbladder cancer. We report these unusual cases and review the relevant medical literature.

Risk Factors for the Presence of Residual Bile Duct Stones after Endoscopic Treatment of Stones of the Common Bile Duct

목적: 총담관담석의 내시경 제거술 이후 발생하는 잔여담석은 재발성 총담관담석으로 발현하거나 총담관담석으로자라는데 핵으로 작용할 수 있다. 그러나 관련된 위험인자에관한 연구는 드물다. 본 연구의 목적은 총담관담석의 내시경제거술 후 잔여 담석과 관련이 있는 인자들을 확인하고자하였다. 방법: 2008년 7월부터 2013년 6월까지 부산백병원에서 총담관담석으로 생애 처음 내시경 제거술을 시행 받은 환자중 잔여 담석이 발견된 환자 55명, 잔여 담석이 발견되지 않은 환자 281명을 선정하여 후향적으로 환자 대조군 연구를시행하였다. 두 군 간의 나이, 성별, 총담관담석의 성상, 혈액학적 검사 결과, 유두부 주위 게실의 유무, 기계식 쇄석술시행 유무, 유두부 풍선확장술 단독 사용 유무, 다발성 총담관담석의 동반 유무, 총담관담석의 크기, 총담관의 직경, 담낭 담석의 존재 유무, 이전에 담낭 절제술 시행 유무, 총담관담석의 내시경 제거술 시행 후 담낭 절제술 시행 여부를 비교 분석하였다. 결과: 단변량 분석에서 기계식 쇄석술을 시행 받은 경우,10 mm 이내의 유두부 풍선확장술만을 시행한 경우, 다수의총담관담석을 제거한 경우, 총담관담석의 크기가 1 cm보다큰 경우가 잔여 담석의 위험인자로 확인되었다. 다변량 분석에서 10 mm 이내의 유두부 풍선확장술만을 시행한 경우(OR, 3.174; p = 0.000), 4개 이상의 총담관담석을 제거한 경우(OR, 2.459; p = 0.013)가 잔여 담석의 발생에 관여하는 독립적인 위험인자로 확인되었다. 결론: 10 mm 크기 이내의 유두부 풍선확장술 단독 사용,4개 이상의 총담관담석이 동반된 경우가 총담관담석의 내시경 제거술 후 잔여 담석의 발생과 관련된 독립된 위험인자이고 이런 인자들이 동반된 환자의 시술 시 더욱 주의를 기울임과 동시에 2차 내시경 역행 담췌관조영술을 고려해야하겠다.

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.

Efficacy of endoscopic nasobiliary drainage for the prevention of post‐endoscopic retrograde cholangiopancreatography pancreatitis and cholangitis after repeated clearance of common bile duct stones: Experience from a Chinese center

The aim of the present study was to investigate whether it is reasonable to insert an endoscopic nasobiliary drainage (ENBD) tube in patients with endoscopic sphincterotomy (EST) and repeated clearance of common bile duct (CBD) stones. Patients with choledocholithiasis who underwent EST and CBD stone clearance at our center from January 2010 to May 2012 were reviewed. The following parameters were evaluated: (i) serum amylase 2 and 24 h after ERCP; (ii) incidence of endoscopic retrograde cholangiopancreatography (ERCP)-related pancreatitis and cholangitis; (iii) time elapsed to normalization of total serum bilirubin levels for those with jaundice before ERCP; and (iv) length of hospital stay. Compared with the no-ENBD group, the ENBD group presented a significantly lower postoperative serum amylase of 2 and 24 h (81.3 ± 31.8 U/L vs 90.8 ± 31.2 U/L, 107.0 ± 51.1 U/Lvs 132.3 ± 100.8 U/L, respectively). The incidence of post-ERCP pancreatitis and cholangitis was also lower in the ENBD group, although the differences were not significant (1% vs 4.4%, 0 vs 4.5%, respectively). Time elapsed to normalization of total serum bilirubin levels and length of hospital stay was shorter in the ENBD group (4.3 days ± 0.6 days vs 4.5 days ± 0.7 days, P > 0.05; 4.8 days ± 2.1 days vs 6.3 days ± 2.8 days, respectively, P < 0.01). ENBD significantly reduces the incidence of hyperamylasemia and decreases the length of hospital stay in patients with EST and repeated stone extraction. ENBD should be considered for patients with large or multiple CBD stones.

Large-balloon dilation of the sphincter of Oddi after sphincterotomy or infundibulotomy to extract large calculi or multiple common bile duct stones without using mechanical lithotripsy

Objective.Endoscopic sphincterotomy plus large-balloon dilatation (ESLBD) has an efficacy equal to or higher than that of endoscopic sphincterotomy alone for biliary lithiasis extractions. Our purpose was to evaluate the feasibility, efficacy and morbidity of large-balloon dilatation of the sphincter of Oddi after sphincterotomy or infundibulotomy for large or multiple common bile duct stones. Material and methods. Retrospective analysis. Results.A total of 64 ESLBD procedures were performed in 62 patients: 57 after sphincterotomy and 7 after infundibulotomy. The feasibility was 100%, and full clearance of the common bile duct was achieved in a single session without using mechanical lithotripsy in 95.3% of cases. Short-term complications were observed in 9 patients (14%). There were no perforations. The most frequent complication was delayed bleeding (7.8%). There was no significant difference of overall complications after sphincterotomy or after infundibulotomy (12.3% vs. 28.6%, p = 0.25). The incidence of acute pancreatitis was significantly higher after infundibulotomy than after sphincterotomy (28.6% vs. 0%, p = 0.01). Conclusions.ESLBD after endoscopic sphincterotomy or infundibulotomy is a simple, reproducible and effective technique, associated with a low morbidity rate and helps in avoiding mechanical lithotripsy in 95.3% of cases for the endoscopic extraction of large or multiple common bile duct stones.

Laparoscopic Pancreatic Necrosectomy in a Child with Severe Acute Pancreatitis

Acute pancreatitis (AP) in children usually follows a mild course but occasionally may be severally problematic. We report the case of a 12-year-old boy with severe AP who was managed with repeated laparoscopic pancreatic necrosectomy. Three weeks later he represented with a pancreatic pseudocyst that was treated with endoscopic gastrocystotomy. His abdominal pain persisted and a subsequent magnetic resonance cholangiopancreatogram showed multiple gallbladder and common bile duct (CBD) stones that were missed on previous imaging investigations. He underwent laparoscopic cholecystectomy with transcystic exploration of the CBD. The patient is currently well, more than 2 years following the definitive corrective surgery. To the best of our knowledge, this is the first case of laparoscopic pancreatic necrosectomy in a child.

A Unique Case of Accelerated Common Bile Duct Stones/Biliary Sludge Secondary to Tacrolimus Use in a Kidney Transplant Recipient

Purpose: Organ transplant recipients are at high risk for complications of biliary calculi. Use of certain immunosuppressant's has been associated with increased incidence of cholelithiasis with exact etiology being unknown. We show a unique example of accelerated common bile duct (CBD) stone and biliary sludge formation over a short period of time in a patient taking tacrolimus. A 48-year-old Hispanic male with end stage renal disease status post two kidney transplants on tacrolimus, presented with complaint of intermittent colicky epigastric pain for two weeks getting progressively worse, aggravated by food and associated with nausea and vomiting. Physical exam revealed icterus of sclera and skin with epigastric tenderness. Lab studies revealed protein= 7.2, albumin=3.5, bilirubin=6.7 (conjugated=1.3), ALP=381, AST=108 &\and ALT=73. Imaging studies revealed marked intra and extrahepatic biliary dilation with suspected choledocolithiasis with no evidence of gallstones. Endoscopic retrograde colangiopancreatography (ERCP) revealed multiple filling defects of more than 1 cm, which was consistent with CBD stones. Adequate size sphincterotomy was performed and plastic stent was placed. Subsequently, he underwent cholecystectomy and CBD exploration with T-tube placement. T-tube cholangiogram was performed, with no evidence of biliary stricture or calculi seen. He presented again after 11 weeks with similar symptoms. Laboratory studies revealed protein=7.8, albumin=4.1, bilirubin=5.3 (conjugated=1.3), ALP=233, AST=102 and ALT=188. Imaging revealed marked intra and extrahepatic biliary dilation with absent gallbladder. ERCP was performed revealing multiple CBD stones & biliary sludge. Review of literature shows that some adverse effects from tacrolimus result in increased incidence of biliary sludge and gallstone formation. Regular ultrasound to detect biliary disease is recommended in such patients. Cholecystectomy is also indicated in patients showing evidence of cholecystitis. However, there are no reports of CBD stone and biliary sludge formation in such a short interval of time in post-sphincterotomy patient as seen in our case. We hypothesize that relapse of stone formation in our patient was due to usage of tacrolimus. Controlled studies are needed to investigate exact incidence and to document association between accelerated CBD stone formation/biliary sludge and tacrolimus use. Exact mechanism for formation of CBD stones and biliary sludge in such a short time interval in such patients remains unknown.

ENDOSCOPIC SPHINCTEROTOMY PLUS ENDOPROSTHESES IN THE TREATMENT OF LARGE OR MULTIPLE COMMON BILE DUCT STONES

Little information is available on the outcomes of endoscopic sphincterotomy plus biliary stent placement without stone extraction as primary therapy at initial endoscopic retrograde cholangiopancreatography (ERCP) in the treatment of large or multiple common bile duct (CBD) stones. The aim of the present study was to study the effect of biliary stents and sphincterotomy as primary therapy for patients with choledocholithiasis. Patients with large (≥20 mm) or multiple (≥3) CBD stones were retrospectively studied. The patients underwent endoscopic sphincterotomy and placement of plastic stents in the bile duct without stone extraction at the initial ERCP. Three or more months later, a second ERCP was carried out and stone removal was attempted. Differences in stone size and the largest CBD diameter before and after stenting were compared. Stone clearance and complications were also evaluated. 52 patients were enrolled. After a median of 124 days of biliary plastic stent placement the mean maximal stone diameter decreased from 16.6 mm to 10.0 mm (P < 0.01). The mean CBD diameter also decreased from 15.3 mm to 11.5 mm (P < 0.01). The total stone clearance at second ERCP was 94.2%, only 5.7% of which needed mechanical lithotripsy. pancreatitis in one (1.9%) at initial ERCP, cholangitis in two (3.8%) after 52 days and 84 days of placement of stent. No complications were recorded at second ERCP. Biliary plastic stents plus endoscopic sphincterotomy without stone extraction as primary therapy at initial ERCP is a safe and effective method in the management of large or multiple CBD stones.