Multiple Common Bile Duct Stones Research Articles

Large balloon dilation for the treatment of recurrent bile duct stones in patients with previous endoscopic sphincterotomy: preliminary results

Objective. Endoscopic sphincterotomy (ES) is an established method to treat common bile duct (CBD) stones. Inevitable sequence after ES is a substantial risk of recurrent choledocholithiasis and occasional difficulty in removal of large or multiple CBD stones after ES even when mechanical lithotripsy (ML) is employed. In turn, a new endoscopic technique, large balloon dilation (LBD) after ES, has been introduced. The objective was to analyze the efficacy and safety of LBD in patients with recurrent bile duct stones who have previously undergone ES. Patients and methods. From December 2007 to November 2009, 24 patients with recurrent choledocholithiasis and a history of ES were treated with LBD without additional ES. The size of the balloon for LBD was 15–20 mm and the duration of balloon dilation was 30 s. Results. Successful stone removal and complications such as perforation, pancreatitis, and bleeding were evaluated as procedure-related outcomes. Postoperative CBD stone recurrence was evaluated as the short term outcome. Complete duct clearance rate without using ML was 96% (23/24 patients) and all stone removal was achieved in one session. Failure to remove stones occurred in one (4.2%) patient. There were no procedure-related complications although one case of aspiration pneumonia occurred after the endoscopy. Recurrent choledocholithiasis after LBD was observed in 12.5% (3/24) of the cases overall. Conclusions. LBD is an effective and safe method in patients with recurrent choledocholithiasis not only to treat large stones but also to prevent further recurrence.

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

Endoscopic 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. The aim of this study was to study the effect of biliary stenting as therapy for CBD stones. Retrospective study. Municipal hospital outpatients. Patients with large (> or = 20 mm) and/or multiple (> or = 3) stones had placement of a 7F double-pigtail plastic stent without stone extraction at the initial ERCP. Approximately 2 months later, stone removal was attempted. The number and size of CBD stones before and after stent placement, stone clearance, complications, and 180-day mortality were evaluated. Forty patients were studied. Stent placement averaged 65 days (range, 50-82 days). The median number (interquartile range) of stones per patient fell after stent placement (4.0 [3.0] before vs. 2.0 [1.0] after; P < .0001). Characteristically, larger stones became smaller and small stones disappeared (ie, the median stone index decreased from 4.6 [3.0] to 2.0 [1.5]; P < .0001). Stone clearance at the second ERCP was achieved in 37 out of 40 patients (93%). Complications included cholangitis (13%) and pancreatitis (5%) after the second ERCP. No 180-day mortality occurred. A retrospective, single-center study. Stent placement for 2 months was associated with large and/or multiple CBD stones becoming smaller and/or disappearing without any complications. Stenting followed by a wait period may assist in difficult CBD stone removal.

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

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

A Case of Early Bile Duct Cancer Arising from Villous Adenoma in Choledochal Cyst

Choledochal cyst is an uncommon premalignant anomaly. The morphology and pathogenesis of the premalignant lesion of cholangiocarcinoma arising from the choledochal cyst has not been well described. Herein, we report a rare case of bile duct adenoma arising from choledochal cyst with anomalous union of pancreaticobiliary duct (AUPBD). 50-year-old woman was admitted to our hospital with the complaint of epigastric pain. She had received common bile duct (CBD) exploration and choledocholithotomy and cholecystectomy 3 months earlier under the diagnosis of multiple CBD stones. Intraoperalive cholangiogram was not remarkable except CBD dilatation at that time. Endoscopic retrograde cholangiopancreatography revealed choledochal cyst with AUPBD and round filling defect which disappeared easily on the balloon cholaniogram. On magnetic resonance cholangiopancreatography, the filling defect was confirmed as 2 cm polypoid mass attached to the distal bile duct wall. At laparotomy, a soft whitish mass was palpable on the lower CBD. On histological examination, adenoma with focal carcinoma change arising from choledochal cyst was diagnosed.

Simultaneous Endoscopic Papillary Large Balloon Dilatation and EST for Easy Removal of Large and Multiple CBD Stones

Background/Aims: Extraction of large bile duct stones after endoscopic sphincterotomy (EST) is only successful in 80 ∼ 90% of cases and it often requires prolonged time and repeated trial. We investigated the usefulness of simultaneous endoscopic papillary large balloon dilatation and EST method for removal of large and multiple common bile duct (CBD) stones. Methods: Twenty patients with large or multiple CBD stones (size of stones were more than 15 mm) were enrolled. Endoscopic papillary balloon dilatation was carried out with one-step inflation of a 15 mm or 18 mm diameter balloon after mid incision of papilla with a pull type sphincterotome. The success and complication rate for duct clearance were evaluated prospectively. Results: Maximal stone diameter was 21.71 ± 5.45 mm (range 16.1- 34.8 mm). Seven patients had more than 4 stones, 3 patients had 2 stones, and the other patients had a single large stone. Complete duct clearance was achieved in 100% of patients. All the large CBD stones were captured with stone basket and easily pulled out via widely opened papilla. After the procedure, serum amylase and/or lipase levels were elevated in 6 patients (27.3%). However, no episode of true pancreatitis happened. Minor bleeding occurred in only one patient (4.5%) and was easily controlled by Argon-plasma coagulation. No procedure-related perforation or mortality was observed. Conclusions: Simultaneous endoscopic papillary large balloon dilatation and EST method is a safe and effective method in the treatment of large and multiple CBD stones. This method may be a good alternative treatment to mechanical lithotripsy for the treatment of large and multiple CBD stones. EST may be in a role of good guiding of papillary dilatation with large balloon and less injured to the pancreatic duct.

Common bile duct stone characteristics: correlation with treatment choice during laparoscopic cholecystectomy

Determining the most appropriate management approach for patients with unsuspected choledocholithiasis may be difficult because of the subjective nature of this decision in the absence of clinical data. Treatment of incidental choledocholithiasis during laparoscopic cholecystectomy was reviewed during a 25-month period. Operative cholangiograms were analyzed retrospectively to determine if associations exist between common bile duct stone characteristics and the intraoperative treatment selected by the operating surgeon. Cholangiographic data included quantification of common bile duct stones, stone dimension, position, and presence of radiopaque contrast flow into the duodenum. Two hundred thirty-six laparoscopic cholecystectomy patients underwent operative cholangiography; 25 (11%) demonstrated choledocholithiasis. Seven patients were converted to open common bile duct exploration (group I), 16 patients were referred for postoperative endoscopic retrograde cholangiopancreatography (group II), and two patients were observed (group III). Evaluation of the operative cholangiograms revealed multiple common bile duct stones (1) in 86% (6 of 7) in group I, 25% (4 of 16) in group II, and none in group III. All patients in group I had at least one stone larger than 5 ml in greatest diameter, whereas only 33% (6 of 18) in groups II and III combined had stones larger than 5 ml. Group I had significantly ( P = 0.027) more representation of delayed or no contrast flow during operative cholangiography compared to groups II and III. The intraoperative decision to proceed with laparoscopic cholecystectomy and rely on postoperative endoscopic retrograde cholangiopancreatography for stone retrieval rather than open common bile duct exploration was associated with (1) a single common bile duct stone, less than or equal to 5 ml in size on operative cholangiogram and (2) normal contrast flow into the duodenum. Open common bile duct exploration was more frequently associated with the demonstration of multiple or large (5 ml) stones. A periampullary stone did not discriminate among treatment choices.

Biliary stenting for management of common bile duct stones.

Large and multiple common bile duct stones may defy extraction despite an adequate endoscopic papillotomy. We treated 65 patients with symptomatic bile duct stones with endoscopic stents after failed attempts at stone extraction. Of the 65 patients, bile duct stones were extracted in eight at a second attempt, 29 underwent elective surgery and 28 patients were followed with the stent in situ for 21-52 months (median 42 months). During follow up, two patients had recurrent pain and two required surgery. The remaining 24 patients remained asymptomatic. Biliary stenting is a safe and effective mode of treatment for common bile duct stones in patients who have failed stone extraction after endoscopic papillotomy.

Diagnostic and Therapeutic ERCP in Children with Sickle Cell Disease

Over a period of less than 3 years, diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) was performed on 24 children with sickle cell disease (SCD) aged 8–18 years. The adult side-viewing duodenoscope was used. Intravenous sedation with diazepam and meperedine was used except in those children 10 years of age and younger, in whom general anesthesia was used. The indications for ERCP were obstructive jaundice in 18 patients, pancreatitis in 2, cholangitis in 2, recurrent biliary colic in 1, and postlaparoscopic cholecystectomy (LC) bile leak in 1. Cannulation of the ampulla of Vater was accomplished in all 24 patients (100%). ERCP provided valuable additional information in SCD patients with hepatobiliary and pancreatic diseases. Endoscopic sphincterotomy was successfully performed in 21 patients, 10 of whom had undergone extraction of common bile duct (CBD) stones endoscopically before LC. Nine other patients with CBD dilation and no stones underwent endoscopic sphincterotomy. In two of them, the papilla was enlarged, with an inflamed orifice suggestive of recent stone passage. Two other patients underwent endoscopic sphincterotomy and nasobiliary drainage: for papillary stenosis in one and for temporary relief of obstructive jaundice due to multiple giant CBD stones in the other. One patient underwent endoscopic mechanical lithotripsy of large CBD stones and stone extraction followed by LC. We conclude that ERCP is safe and useful in the diagnosis and treatment of children with SCD and pancreatobiliary disorders. This is especially true in the era of LC.

Laparoscopic Antegrade Sphincterotomy.

The authors describe the technique and results of laparoscopic antegrade sphincterotomy. The procedure was performed in 42 selected cases of choledocholithiasis. The indications for attempting laparoscopic antegrade sphincterotomy included impacted stones in the papilla, multiple common bile duct stones, one or more common hepatic or intrahepatic stones, dilated common bile duct requiring a drainage procedure, suspicion of papillary stenosis, whenever numerous fragments are found after lithotripsy, and as an adjunct procedure when the surgeon cannot completely remove all the stones in the bile ducts. No major complications or mortality was observed. One patient had a self-limited drop in the hematocrit and four patients presented with transitory mild hyperamylasemia that returned to normal levels in 72 hours. Laparoscopic antegrade sphincterotomy added an average of 17 minutes to the laparoscopic operation. The mean postoperative stay was 1.4 days. The results of this study conclude that laparoscopic antegrade sphincterotomy is an option of great therapeutic value for selected cases when drainage of the biliary tract concomitant to the treatment of choledocholithiasis is necessary.

Laparoscopic Antegrade Sphincterotomy

The authors describe the technique and results of laparoscopic antegrade sphincterotomy. The procedure was performed in 42 selected cases of choledocholithiasis. The indications for attempting laparoscopic antegrade sphincterotomy included impacted stones in the papilla, multiple common bile duct stones, one or more common hepatic or intrahepatic stones, dilated common bile duct requiring a drainage procedure, suspicion of papillary stenosis, whenever numerous fragments are found after lithotripsy, and as an adjunct procedure when the surgeon cannot completely remove all the stones in the bile ducts. No major complications or mortality was observed. One patient had a self-limited drop in the hematocrit and four patients presented with transitory mild hyperamylasemia that returned to normal levels in 72 hours. Laparoscopic antegrade sphincterotomy added an average of 17 minutes to the laparoscopic operation. The mean postoperative stay was 1.4 days. The results of this study conclude that laparoscopic antegrade sphincterotomy is an option of great therapeutic value for selected cases when drainage of the biliary tract concomitant to the treatment of choledocholithiasis is necessary.

Laparoscopic antegrade sphincterotomy. A new technique for the management of complex choledocholithiasis.

Laparoscopic antegrade sphincterotomy represents a new technique that expands the ability of the surgeon to manage complex choledocholithiasis at the time of laparoscopic cholecystectomy. The authors describe their experience with six patients with cholelithiasis and complex common bile duct stone disease who underwent successful laparoscopic cholecystectomy and antegrade sphincterotomies. Patients with complex choledocholithiasis have represented a technical challenge to the minimally invasive surgeon. Recently, a laparoscopic technique of antegrade biliary sphincterotomy has been reported by DePaulo in Brazil. This technique has been successful at clearing the common bile duct at the time of laparoscopic cholecystectomy. Laparoscopic antegrade sphincterotomy was performed in six patients with multiple common bile duct stones. A standard endoscopic sphincterotome was introduced antegrade via the cystic duct or common bile duct and guided through the ampulla. A side-viewing duodenoscope was used to confirm proper positioning of the sphincterotome. Then a blended current was applied until the sphincterotomy was complete. There was no mortality or morbidity associated with laparoscopic antegrade sphincterotomy. The mean additional operative time to complete laparoscopic antegrade sphincterotomy was 19 minutes. Three of the six patients were noted to have transient, asymptomatic elevation in serum amylase levels immediately after surgery (average 252 international units/L; normal < 115), which normalized within 72 hours. The mean postoperative hospital stay was 2.9 days. At a mean follow-up of 5 months (range 1 to 10 months), five patients remain asymptomatic. One individual with acquired immune deficiency syndrome had persistent symptoms, and a diagnosis of cytomegalovirus pancreatitis was eventually made. Laparoscopic antegrade sphincterotomy appears to be a safe and effective technique for the management of complex biliary tract disease.

Endoscopic retrograde cholangiopancreatography in conjunction with laparoscopic cholecystectomy.

Laparoscopic cholecystectomy (LC) has become the primary surgical treatment for symptomatic cholelithiasis. In conjunction with the dramatic rise in LC there has been an increase in the number of endoscopic retrograde cholangiopancreatographies (ERCPs) performed. For this study, the records of patients referred to the surgical endoscopy department between January 1991 and February 1992 were reviewed. Seventy-seven ERCPs were performed in conjunction with LC. The indications for ERCP included jaundice or a history of jaundice, gallstone pancreatitis, a suspicious filling defect on either ultrasound or intraoperative cholangiogram, abnormal liver function tests, cholangitis, or postoperative bile leak. Sixty-two procedures were performed prior to LC and 15 procedures after LC. Forty-two patients were female (54.5%) and the patients ages ranged from 14 to 92 years (mean 54.1 years). Of the 62 patients having ERCP preoperatively 35 patients (56.5%) had no evidence of common bile duct (CBD) stones and underwent LC as planned. Twenty-three patients were found to have CBD stones, of which six were referred for an open cholecystectomy and CBD exploration, because of large multiple CBD stones or the presence of a large duodenal diverticulum. Seventeen patients had their CBD cleared endoscopically, and four patients were not successfully cannulated. Fifteen patients had ERCP after LC. There were two patients with CBD injuries who were referred for surgical correction. Two patients had leakage from the cystic duct stump, and four patients had CBD stones, all of whom were successfully treated with endoscopic sphincterotomy. There were four patients who had a normal postoperative ERCP and two patients who could not have their CBD cannulated.(ABSTRACT TRUNCATED AT 250 WORDS)

The use of endoscopy to treat bronchobiliary fistula caused by choledocholithiasis

Bronchobiliary fistula is a rare disorder consisting of the formation of a passageway between the biliary ducts and the bronchial tree. We describe an 87-yr old woman who had a bronchobiliary fistula secondary to obstruction caused by multiple common bile duct stones. The diagnosis was confirmed by the presence of bile in the sputum and transhepatic cholangiography. Successful stone extraction with balloon and basket techniques and endoscopic sphincterotomy decompressed the biliary tract and was followed by healing of the bronchobiliary fistula without surgical intervention, which has heretofore been considered the only successful means of treatment.