CBD Stone Removal Research Articles

The Effectiveness of Combination Therapy of Gabaxate Mesylate and Somatostatin for the Prevention of Post ERCP Pancreatitis

Background and Aims: There are so many reports of how to prevent the post ERCP pancreatitis. So many drugs and endoscopic procedures were tried to prevent the post ERCP pancreatitis. Gabexate mesylate or somatostatin was one of the drugs which was used for this purpose. However wheather gabexate mesylate or somatostatin could prevent the post ERCP pancreatitis is still being debated. The aim of this study was to evaluate the effect of combination therapy of gabexate mesylate and somatostatin for the prevention of post ERCP pancreatitis. Methods: In a randomized, double blind, controlled trial, 44 patients undergoing ERCP in our hospital between May 2005 and October 2005 were randomly assigned to intravenous administration of gabexate mesylate (500 mg; n = 16), gabexate mesylate (500 mg) and somatostatin (750 mg; n = 12), and placebo (saline; n = 16). We excluded the patients with previous endoscopic sphincterotomy (EST), chronic pancreatitis, acute pancreatitis and hyperamylasemia. The drug infusion started 30 minutes before ERCP and continued for 6 hours afterward. Patients were evaluated clinically, and serum amylase levels were determined at pre-ERCP and, at 24 hr and 48hr post-ERCP. Results: No significant difference in incidences of abdominal pain or acute pancreatitis and hyperamylasemia including acute pancreatitis were observed among the placebo, gabexate mesylate alone and gabexate mesylate and somatostatin groups. Although there was no statistical significance, 2 cases of post-ERCP pancreatitis occurred only in the placebo group. These patients all had mild pancreatitis and they improved only with medical treatment. In univariate analysis of patients characteristics and ERCP maneuvers, repeated pancreatic duct injection was only significantly associated with post-ERCP hyperamylasemia (p = 0.035), also in multiple logistic regression (p = 0.043). Other variables such as age, sex, periampullary diverticulum, biliary sphincterotomy, CBD stone removal after EST, stent insertion after EST, the size of CBD were not an independent risk factor for post-ERCP pancreatitis. Conclusion: Only repeated pancreatic duct injection significantly associated with post-ERCP hyperamylasemia. This ongoing study appeared to show that prophylactic administration of gabexate mesylate and somatostatin could not reduce post-ERCP pancreatitis. Further more large scale studies would be needed to assess the effect of the combination therapy of gabaxate mesylate and somatostatin for the prevention of post-ERCP pancreatitis.

Endoscopic Papillary Balloon Dilation for Secondary Bile Duct Stones in Young Patients

BACKGROUND/AIM: The long-term complications of endoscopic sphincterotomy (ES) are still unknown. Younger patients having longer life expectancy are risky for developing late complications after ES. Secondary CBD stones are relatively small stones in normal duct and sphincter. These healthy sphincters should be preserved, if possible. Endoscopic papillary balloon dilation (EPBD) is a safe and effective sphincter preservation technique for endoscopic stone removal. We conducted a retrospective study to investigate outcomes and safety after EPBD for removal of secondary CBD stones in patients younger than 40 years of age. METHODS: Inclusion criteria was CBD stones combined with GB stone, Age < 41 and maximum diameter of bile duct stone <13 mm. Between 1997 and 2002, 32 patients with 2ndary CBD stones were removed after EPBD (EPBD group, mean age: 35.6 years). Between 1993 and 1997, 2ndary CBD stones with 28 patients were treated using ES (ES group, mean age: 37.2 years). Mean maximum diameter of stone was 7.2 mm (range: 4-12). Maximum diameter of CBD was 9.3 mm (range: 5-14). The success rates and complications were compared between the two groups. RESULTS: 1) EPBD and ES were successfully performed in all patients. Complete endoscopic clearance of the bile duct was achieved in all patients. 2) After a single endoscopic session, all stones were removed from 30 (93.7%) patients who underwent EPBD and in 27 (96.4%) patients with ES. For the complete removal of stones, an average of 1.1 endoscopic sessions was required for both groups. 3) Mechanical lithotripsy was needed to fragment stones in 2 (6.3%) EPBD procedures, but not necessary after ES. 4) Although amylase level was elevated in 14 (43.7%) EPBD patients, mild pancreatitis developed in only two (6.2%) patients. Two cases (6.2%) of bleeding and one case of mild pancreatitis occurred in ES group. CONCLUSION: Endoscopic papillary balloon dilation is a safe and effective sphincter preservation method for the removal of secondary bile duct stones in young patients who will undergo laparoscopic cholecystectomy.

Laparoscopic common bile duct exploration.

To explore the feasibility of laparoscopic techniques for the removal of common bile duct (CBD) stones. Retrospective analysis. University hospital, Sweden. 39 patients who underwent laparoscopic common bile duct exploration, either by a transcystic technique or by choledochotomy, between September 1992 and April 1995. Cholecystectomy, intraoperative cholangiography, and removal of CBD-stones by a transcystic technique (n=22), laparoscopic choledocholithotomy (n=11), or after conversion to open choledocholithotomy (n=6). Stone clearance rates, operative time, complications, and postoperative hospital stay. Stone removal was achieved in 32/39 patients (82%) by a laparoscopic approach. Reasons for failure were early in our experience, and the result of technical difficulties or stones that were too large for the transcystic approach, or with impacted stones at choledochotomy. Postoperative morbidity was low (n=4, 10%) with no mortality. Common bile duct stones can be removed in a large proportion of patients undergoing laparoscopic cholecystectomy, either by a laparoscopic transcystic technique or through a laparoscopic choledochotomy. The laparoscopic techniques need further evaluation, preferably in prospective multicentre trials comparing other treatment strategies including endoscopic sphincterotomy.

Extra-corporeal shock wave lithotripsy (ESWL) plus a novel method of removal of a burrowed CBD stone in a patient with Mirizzi syndrome

Extra-corporeal shock wave lithotripsy (ESWL) plus a novel method of removal of a burrowed CBD stone in a patient with Mirizzi syndrome

Extra-corporeal shock wave lithotripsy (ESWL) plus a novel method of removal of a burrowed CBD stone in a patient with Mirizzi syndrome

Extra-corporeal shock wave lithotripsy (ESWL) plus a novel method of removal of a burrowed CBD stone in a patient with Mirizzi syndrome

Common bile duct stones: magnetic resonance cholangiopancreatography vs. endoscopic retrograde cholangiopancreatography for detection

MRCP is a very precise imaging technology for diagnosing CBD stones. However, its cost-effectiveness and optimal role remain undefined. Decision analyses and randomized trials are underway to assess which subgroups of patients, if any, may benefit from pre- or postoperative noninvasive imaging methods such as MRCP. 7 Any conclusions must take into consideration the ongoing evolution and the availability of all competing diagnostic and therapeutic technologies, such as MRCP, endoscopic ultrasound, intraoperative ultrasound, or cholangiography followed by laparoscopic CBD stone removal and selective preoperative or postoperative ERCE 8-10

3364 Asge guidelines on therapeutic ercp training: are they appropriate?

Introduction: ASGE recommends one year of intensive therapeutic ERCP training for receiving previleges in an academic center. Aims: To examine the outcome of one year of advanced ERCP training on the technical success & complication rate of therapeutic ERCP by one endoscopist during the first year after graduation from advanced endoscopy fellowship training program. Methods & Results: ERCP Training: During 7/98-6/99, the trainee (GSR) participated in 697 ERCPs & shared the ERCP caseload with 4 GI fellows at the BIDMC. The trainee did 50% of the ERCP cases and also assisted in the training of the 3rd year GI fellows. The trainee was encouraged to do multiple stages of each procedure. If cannulation was unsuccessful, the mentor cannulated & gave the endoscope back to the trainee to complete the remaining procedure. Endoscopic sphincterotomy was taught early on & during the latter half of training, the trainee learned precut techniques. During the last quarter, the trainee completed 19 of 21 consecutive therapeutic ERCP cases successfully, without assistance from the mentor. First year after ERCP training: After joining KUMC as a therapeutic endoscopist(GSR) in 7/98, the outcome of consecutive ERCP cases done in first year by GSR was analyzed (n= 100). Classification of the ERCP cases according to the difficulty of the ERCP procedures ( Gastrointest endosc 1999;49:AB148 ): Group 1-Simple diagnostic ERCP: 22/24 (92%); Group 2-Simple therapeutic ERCP: 15/16 (94%) (biliary sphincterotomy, cbd stone ( 3) / large (>1cm) CBD stone removal, CBD stricture dilation, CBD stenting); Group 5-Ultracomplex therapeutic ERCP:13/17 (76%)(needle knife sphincteotomy, CBD stone lithotripsy+ stone removal, intrahepatic stone removal or stricture dilation, & all pancreatic therapy). Complications: pancreatitis: 8; bleeding: 0; perforation: 0; neck infection: 1; cardiac arrest: 1 (revived). Mortality: one patient died 48 hours after the procedure due to a CVA & aspiration. Conclusions: Dedicated therapeutic ERCP training for one year provides the necessary endoscopic skills to perform ERCP successfully with low complication rate. The outcome is comparable to the results published in the literature (Gastrointest endosc 1999;49:AB148). The ASGE guidelines on therapeutic ERCP training appear to be appropriate.

4637 Clinical characteristics and predictive factors of recurrent common bile duct stones after clearance of stones with endoscopic sphincterotomy.

BACKGROUND: Endoscopic sphincterotomy (EST) for stone removal is the treatment of choice for CBD stones. Unfortunately, loss of the sphincter mechanism might lead to late complications after EST. Bile duct stones recurred in 2-13.8% of patients after bile duct clearance with endoscopic or surgical stone removal. The factors affecting the recurrent stones are still controversial. AIMS: To evaluate the clinical findings and to find out the factors which may affect the recurrent CBD stones in patients after complete clearance of bile duct with EST. MATERIALS AND METHODS: Endoscopic removal of CBD stones with EST was performed on 424 patients with CBD stones, without IHD stones. Clinical and sonographic follow up searching for recurrent stones were performed every 6 to 12 months for a 1 to 7.5 years (median: 4.6) follow-up period. 45 patients were identified to have recurrent CBD stones (group A). Control (group B) had 204 patients who underwent endoscopic removal of CBD stones with EST, without recurrence of stones. RESULTS: 1) Bile duct stones recurred in 45 patients (10.6 %) after EST for stone removal with 11 of the 45 patients (24.4%) having two or more recurrences. 2) The median time from EST to the recurrence was 31.7 months (ranges: 6-106). Most (73.4%) of the recurrent bile duct stones occurred within 3 years after EST. 3) Periampullary duodenal diverticula (PADD) (A:64.4%, B:46.6%), biliary stricture (A:48.8%, B:17.6%), and fragmentation of initial stones (A:42.2%, B:18.6%) showed a significant relationship with the recurrence. 4) Initially large stones, biliary stricture, and PADD were related significantly to the multiple recurrences. 5) Septic complications were higher in patients with recurrence of stones. 6) Three cases of cholangiocarcinoma, and 7 cases of IHD stones developed during the follow-up in patients with recurrent stones. 7) 93.3% of recurrent stones in the bile duct were successfully removed by endoscopy. CONCLUSIONS: PADD, biliary stricture, and fragmentation of initial bile duct stones were contributing factors in the development of recurrent bile duct stones in patients with CBD stones after complete bile duct clearance with EST. Careful follow-up and prompt stone removal should be considered for patients with these factors for preventing serious complications.

Digestive Surgery through the Laparoscopic Approach

After a brief historical survey of the origins of laparoscopic surgery and of its application to the treatment of digestive disease, the author proposes to draw up an inventory of all the laparoscopic digestive procedures performed up to 1996. These procedures will be classified according to a method based on an evaluation on their level of use (LU) first by pioneers, then by specialized surgeons, and finally by general surgeons, over the period of time corresponding to their lifespan. A graph is obtained, called the LU graph, which depicts the relation between time (on the X-axis) and the LU (on the Y-axis). The various digestive procedures performed laparoscopically are then reviewed, organ by organ, giving a privileged place to surgery of the biliary tract, and more particularly to laparoscopic cholecystectomy, which triggered off the laparoscopic revolution. CBD stone removal is also discussed extensively, and for each of these procedures, as for the following, the author lists the indications, the advantages, disadvantages and dangers of use, the degree of validation or nonvalidation through different types of surveys, the current level of use and position on the graph. He also mentions whether new instruments and new techniques have been devised to achieve these procedures laparoscopically. This state of the art in laparoscopic digestive surgery is followed by a description of its future developments along two main lines: gradual transformation of open procedures into laparoscopic procedures, accessible to all through adequate training and ‘tutoring’, and integration of advanced technology, the privilege of a small number of institutions endowed both with money and human resources. A comprehensive bibliography is provided.