Sphincterotomy For Bile Duct Stones Research Articles

Successful endoscopic closure with an over-the-scope clip for sigmoid colon perforation due to bile duct stent migration

An 86-year-old woman presented with a history of endoscopic papillary sphincterotomy for bile duct stones and diverticulitis. The patient was admitted as an emergency case of acute cholangitis due to choledocholithiasis, underwent endoscopic bile duct stenting, and was discharged with a plan for endoscopic lithotripsy. One month later, the patient was readmitted owing to abdominal pain. Abdominal computed tomography at admission showed that the bile duct stent had migrated to the sigmoid colon and the presence of a small amount of extraintestinal gas, suggesting a colonic perforation. Lower gastrointestinal endoscopy showed adhesions and intestinal stenosis in the sigmoid colon, probably after diverticulitis, and the bile duct stent that had perforated the same site. The stent was removed and endoscopic closure of the perforation was performed using an over-the-scope clip. Abdominal computed tomography 8 days after the closure showed no extraintestinal gas. The patient resumed eating and was discharged on the 14th day of admission. There was no recurrence of abdominal pain. Endoscopic closure of sigmoid colon perforation due to bile duct stent migration using an over-the-scope clip has not been reported thus far, and it may be a new treatment option in the future.

Could cholecystectomy be abandoned after removal of bile duct stones by endoscopic retrograde cholangio-pancreaticography?

Background/objectiveThe current treatment for choledocholithiasis is endoscopic common bile duct clearance followed by cholecystectomy. However, few studies have investigated whether cholecystectomy is necessary after the endoscopic removal of bile duct stones. This study aimed to determine the rate of patients without symptoms during the follow-up period after endoscopic retrograde cholangiopancreaticography (ERCP). Materials and methodsWe retrospectively analyzed data from patients with choledocholithiasis who underwent ERCP from a single centre.The patients were invited to the hospital for evaluation of symptoms during the follow-up period after ERCP. The primary outcome of this study was to determine the rate of patients with symptoms during the follow-up period after ERCP. ResultsA total of 286 patients with a median age of 57 (18–95) years old were included in the study. Of these, 195patients (68%) remained asymptomatic during the follow-up period of 18 months (1–70) after endoscopic sphincterotomy without cholecystectomy. A total of 75(50%) out of 151 patients who underwent cholecystectomy reported having symptoms after ERCP. In contrast, 119 (88%) out of 135 patients did not undergo cholecystectomy after the ERCP, remained asymptomatic during a median follow-up period of 43 months (11–70). The estimated 5-year asymptomatic rates of the patients after ERCP were 51% for the whole cohort (n = 286) according to Kaplan–Meier analysis. ConclusionMajority of patients with choledocholithiasis who did not undergo cholecystectomy after ERCP were asymptomatic during the follow-up period. Thus, cholecystectomy may be unnecessary after endoscopic sphincterotomy for bile duct stones within a midterm period.

Risk Factors for Success, Complications, and Death after Endoscopic Sphincterotomy for Bile Duct Stones: A 17-Year Experience with 2,137 Cases

Background: Risk factors for post-endoscopic retrograde cholangiopancreatography (ERCP) complications are well-studied. However, risk factors for complications and success after endoscopic sphincterotomy (EST) for duct stones are poorly determined. This study aimed to verify risk factors for mortality, complications, and success after EST. Methods: A multivariate analysis was carried out in a dataset of ERCPs performed during 17 years. Results: A total of5,226 ERCPs were performed, of which 2,137 were in patients with bile duct stones (1,458 women and 679 men; mean age = 57 years) who underwent EST with attempted stone removal. There were 171 (8%) complications, with pancreatitis in 87 (4.1%), bleeding in 48 (2.2%), other complications in 36 (1.8%), and mortality of 0.6%. Successful stone(s) removal was obtained in 2,028 cases (94.9%). On multivariate analysis, mortality was associated with age >60 years (1 vs. 0.2%), cholangitis (4.3 vs. 0.3%), and EST-related complications (5.8 vs. 0.2%). Complications were associated with unsuccessful stone removal (13.4 vs. 7.5%) and difficult cannulation (13.9 vs. 5.4%). An unsuccessful EST was independently related to difficult cannulation (86.2 vs. 98.7%), precutting (79.4 vs. 96.4%), and complications (86.5 vs. 95.6%). Conclusions: Risk factors for complications after EST for stones are delayed bile duct cannulation and failed stone retrieval. Mortality is higher in older patients, those who presented with an EST-related complication, or those who presented initially with cholangitis. Difficult cannulation, EST-related complications, and precutting were associated with an unsuccessful procedure. In this series, outpatient EST with attempted stone retrieval was found to be as safe as performing the procedure in hospitalized patients.

Arterial bleeding after endoscopic papillary large balloon dilation without endoscopic sphincterotomy for bile duct stones successfully treated by endoscopic hemostatsis

Arterial bleeding after endoscopic papillary large balloon dilation without endoscopic sphincterotomy for bile duct stones successfully treated by endoscopic hemostatsis

Comparison of endoscopic papillary balloon dilatation and endoscopic sphincterotomy for bile duct stones.

Endoscopic treatment for bile duct stones is low-invasive and currently considered as the first choice of the treatment. For the treatment of bile duct stones, papillary treatment is necessary, and the treatments used at the time are broadly classified into two types; endoscopic papillary balloon dilatation where bile duct closing part is dilated with a balloon and endoscopic sphincterotomy (EST) where bile duct closing part is incised. Both procedures have advantages and disadvantages. Golden standard is EST, however, there are patients with difficulty for EST, thus we must select the procedure based on understanding of the characteristics of the procedure, and patient backgrounds.

Cholecystectomy after endoscopic papillary balloon dilation for bile duct stones reduced late biliary complications: a propensity score-based cohort analysis.

Cholecystectomy after endoscopic sphincterotomy for bile duct stones with concomitant gallstones is known to reduce late biliary complications. Endoscopic papillary balloon dilation for bile duct stones develops fewer late biliary complications than endoscopic sphincterotomy, but no randomized controlled trials have been conducted about the role of cholecystectomy after endoscopic papillary balloon dilation. Therefore, we conducted this propensity score-matched analysis to compare cholecystectomy and wait-and-see approach after endoscopic papillary balloon dilation. Propensity score matching extracted 147 pairs of patients with cholecystectomy after endoscopic papillary balloon dilation and with gallbladder left in situ with stones (wait-and-see) from 725 patients who underwent endoscopic papillary balloon dilation for bile duct stones. Late biliary complications such as recurrent bile duct stones and cholecystitis were evaluated. Cumulative incidence of late biliary complications was calculated treating death without biliary complications as a competing risk, and its prognostic factor was evaluated. The rates of late biliary complications were 5.4 and 25.2% in the cholecystectomy after endoscopic papillary balloon dilation and wait-and-see groups: Recurrent bile duct stones rates were 4.1 and 19.0%, and cholecystitis rates were 0.7 and 6.1%. The cumulative incidences of biliary complications in the cholecystectomy after endoscopic papillary balloon dilation and wait-and-see approach were 3.1 versus 13.0% at 1year and 5.7 versus 28.0% at 5year after endoscopic papillary balloon dilation (p=0.008). Subdistribution hazard ratio of late biliary complications in the wait-and-see group was 5.1 (p=0.020). Cholecystectomy after endoscopic papillary balloon dilation for choledocholithiasis was associated with fewer late biliary complications. Prophylactic cholecystectomy should be offered to all surgically fit patients after endoscopic papillary balloon dilation for bile duct stones with concomitant gallstones.

Endoscopic sphincterotomy with large balloon dilation versus endoscopic sphincterotomy for bile duct stones: a systematic review and meta-analysis.

The safety and efficacy of endoscopic sphincterotomy with large balloon dilation (EPLBD) are unclear. This study compares the safety and efficacy between EPLBD and endoscopic sphincterotomy (EST). Patients and Methods. Literatures were searched for randomized controlled trials in PUBMED, EMBASE, and Cochrane Library. Outcome measurements included adverse events; stone removal rate; requirement of mechanical lithotripsy. Results. Four RCTs with a total of 596 patients were included. Three RCTs compared EPLBD versus EST alone for stone removal; one RCT compared EPLBD versus EST plus mechanical lithotripsy for stone removal. Pooled data from three RCTs showed that there was no significant difference in the adverse event of ERCP. A significantly higher cholangitis rate was seen in patients who received EST plus mechanical lithotripsy, compared to those treated with EPLBD (13.3% versus 0.0, P = 0.026). No statistical difference was found between EPLBD and EST for stone removal rate. Significant differences in requirement of mechanical lithotripsy were seen with removal of large stones (>15 mm), with EPLBD reducing the use of mechanical lithotripsy (RR: 0.73; 95% CI: 0.54–0.99). Conclusions. EPLBD and EST have similar efficacy and safety for bile duct stones clearance. With larger stones, EPLBD can reduce requirement of mechanical lithotripsy.

Should prophylactic cholecystectomy be performed in patients with concomitant gallstones after endoscopic sphincterotomy for bile duct stones?

Endoscopic sphincterotomy (EST) is the standard treatment for biliary duct stones. However, performing additional cholecystectomy after EST is controversial. In this study, we aimed to evaluate the effects of cholecystectomy after EST. Between December 2008 and July 2011, we performed a prospective, randomized, single-center trial in 90 patients with proven gallstones who underwent EST and stone extraction. After the procedure, patients were randomly allocated to undergo cholecystectomy (n = 45) or to the group of GB left in situ (n = 45). The primary outcome was biliary complications at follow-up. Cholecystectomy was performed in 26 patients (60.5 %) in cholecystectomy group and in 13 patients (28.9 %) in intended conservative group. The median follow-up was 41 months. An intention-to-treat analysis showed that 8 patients (18.6 %) in the cholecystectomy group and 9 (20.0 %) in those who had their GB left in situ had recurrent biliary events (Kaplan-Meier curve, Breslow test, p = 0.555). In an 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 the follow-up period (Log-rank, p = 0.037). However, additional biliary events of cholangitis were similar in the two groups, except for a case of cholecystitis (Log-rank, p = 0.998). Cholecystectomy after EST for biliary duct stones fails to reduce additional recurrent cholangitis but reduces additional cholecystitis.

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.

Endoscopic papillary balloon dilation versus endoscopic sphincterotomy for bile duct stones: Is it time to put a knife down?

Endoscopic papillary balloon dilation versus endoscopic sphincterotomy for bile duct stones: <scp>I</scp>s it time to put a knife down?

Endoscopic papillary balloon intermittent dilatation and endoscopic sphincterotomy for bile duct stones

To compare the effectiveness and safety of endoscopic papillary balloon intermittent dilatation (EPBID) and endoscopic sphincterotomy (EST) in the treatment of common bile duct stones. From March 2011 to May 2012, endoscopic retrograde cholangiopancreatography was performed in 560 patients, 262 with common bile duct stones. A total of 206 patients with common bile duct stones were enrolled in the study and randomized to receive either EPBID with a 10-12 mm dilated balloon or EST (103 patients in each group). For both groups a conventional reticular basket or balloon was used to remove the stones. After the procedure, routine endoscopic nasobiliary drainage was performed. First-time stone removal was successfully performed in 94 patients in the EPBID group (91.3%) and 75 patients in the EST group (72.8%). There was no statistically significant difference in terms of operation time between the two groups. The overall incidence of early complications in the EPBID and EST groups was 2.9% and 13.6%, respectively, with no deaths reported during the course of the study and follow-up. Multiple regression analysis showed that the success rate of stone removal was associated with stone removal method [odds ratio (OR): 5.35; 95%CI: 2.24-12.77; P = 0.00], the transverse diameter of the stone (OR: 2.63; 95%CI: 1.19-5.80; P = 0.02) and the presence or absence of diverticulum (OR: 2.35; 95%CI: 1.03-5.37; P = 0.04). Postoperative pancreatitis was associated with the EST method of stone removal (OR: 5.00; 95%CI: 1.23-20.28; P = 0.02) and whether or not pancreatography was performed (OR: 0.10; 95%CI: 0.03-0.35; P = 0.00). The EPBID group had a higher success rate of stone removal with a lower incidence of pancreatitis compared with the EST group.

Long‐term outcomes of endoscopic papillary balloon dilation and endoscopic sphincterotomy for bile duct stones

We recently reported that endoscopic papillary balloon dilation (EPBD) might suppress biliary bacterial contamination better than endoscopic sphincterotomy (EST) in patients with small bile duct stones (diameter ≤8 mm). In the present study, we evaluated immediate and long-term outcomes of endoscopic papillary balloon dilation with regard to stone size. We allocated 474 patients alternately to the two procedures. The patients were classified according to stone diameter (≤8 mm or >8 mm) and outcomes (i.e. complete stone removal, early complications, and late complications) were compared. The predictive risk factors for late complications were also investigated. In patients with small stones, complete stone removal rate and early complication rate were similar between the two procedures; the incidence of pancreatitis was higher after EPBD, although the difference was not significant. Late complication rate and stone recurrence rate were significantly lower after EPBD than after EST (5.3% vs 17.3%, P = 0.009; 4.4% vs 12.7%; P = 0.048, respectively). In patients with large stones who underwent EPBD complete stone removal rate and late complication rate were lower, but the incidence of pancreatitis was higher. However, these differences were not statistically significant. Multivariate analysis showed that the increased risk of bactobilia following EPBD for large stones or EST, and the gallbladder with stones in situ were independent risk factors for late complications. EPBD produced significantly better long-term outcomes than EST in patients with small bile duct stones.

S1786 Endoscopic Papillary Large Balloon Dilatation After Endoscopic Sphincterotomy for Bile Duct Stones in Difficult Sphincterotomy

S1786 Endoscopic Papillary Large Balloon Dilatation After Endoscopic Sphincterotomy for Bile Duct Stones in Difficult Sphincterotomy

Efficacy and safety of low‐pressured and short‐time dilation in endoscopic papillary balloon dilation for bile duct stone removal

Endoscopic papillary balloon dilation (EPBD) has been advocated as an alternative therapy to endoscopic sphincterotomy for bile duct stones. However, studies have shown that EPBD may increase the risk for pancreatitis. Pancreatitis after EPBD is believed to be related to papillary damage after balloon dilation. We changed the dilation method to a theoretically less hazardous one. This modified dilation method was compared with the initial method. A total of 324 patients with bile duct stones underwent EPBD by the modified method between June 1999 and June 2003. Three hundred and twenty-four patients undergoing EPBD by the initial method served as a historical control group. The success rate of stone removal and the incidence of procedure-related pancreatitis were compared between the two groups. In the modified method, the balloon was inflated until disappearance of the balloon waist, and the pressure was then maintained for 15 s. In the initial method, the balloon was inflated at 8 atmospheres for 2 min. Bile duct stones were successfully removed in 313 of 324 patients (96.6%) in the modified group and in 314 of 324 patients (96.9%) in the initial group (not significant). The incidence of post-procedure pancreatitis showed a lower tendency in the modified group (4.0%, 13/324) than in the initial group (7.4%, 24/324) (P-value = 0.0626). The severity of pancreatitis was significantly reduced in the modified group. The modified method of EPBD is feasible for extraction of bile duct stones, and may potentially decrease the incidence of severe post-EPBD pancreatitis.

Early Endoscopic Intervention Versus Early Conservative Management in Patients With Acute Gallstone Pancreatitis and Biliopancreatic Obstruction

To test the hypothesis that early endoscopic intervention, performed on patients with acute gallstone pancreatitis and biliopancreatic obstruction, reduces systemic and local inflammation. The role of early endoscopic intervention, in the treatment of acute gallstone pancreatitis, remains controversial. Previous randomized trials have not focused on the subgroup of patients with clinical evidence of biliopancreatic obstruction. This single-center randomized clinical trial was performed between May 2000 and September 2005. Of 238 patients, admitted within 48 hours after the onset of acute gallstone pancreatitis, 103 with a distal bile duct measuring > or =8 mm combined with a total serum bilirubin > or =1.20 mg/dL, were randomized to receive either endoscopic retrograde cholangiopancreatography followed by endoscopic papillotomy for bile duct stones (EEI, n = 51) or early conservative management (ECM, n = 52). Patients with clinical evidence of coexisting acute cholangitis were excluded. Outcome measures included changes in organ failure score and computed tomography (CT) severity index during the first week after admission, incidence of local complications, and overall morbidity and mortality. The incidence of bile duct stones at EEI was 72% and 40% of patients in the ECM group had persisting bile duct stones at elective biliary surgery. No significant differences were found between the EEI and ECM groups regarding changes in mean organ failure score (P = 0.87), mean CT severity index (P = 0.88), incidence of local complications (6% vs. 6%, P = 0.99), overall morbidity (21% vs. 18%, P = 0.80), and mortality (6% vs. 2%, P = 1). The present study failed to provide evidence that early endoscopic intervention reduces systemic and local inflammation in patients with acute gallstone pancreatitis and biliopancreatic obstruction. If acute cholangitis can be safely excluded, early endoscopic intervention is not mandatory and should not be considered a standard indication.

Endoscopic sphincterotomy for bile duct stones in patients with intact gallbladders.

Endoscopic sphincterotomy was performed in 121 patients (age ranged 34-92 years; median 80 years) with intact gallbladders and bile duct stones. Clearance of the duct by basket or balloon extraction was attempted in 97 patients (80 per cent) and achieved in 93 of these patients (96 per cent). In 24 patients the duct was left to empty spontaneously and this occurred in 22 patients. Immediate complications due to endoscopic sphincterotomy occurred in five patients (two haemorrhage, two perforation, one haemorrhage and perforation). Of the 101 patients reviewed 12-72 months (median 24 months) after endoscopic sphincterotomy, 76 (75 per cent) have remained asymptomatic throughout the follow-up period. Eighteen patients (18 per cent) required cholecystectomy for recurrent gallbladder symptoms 1-24 months after endoscopic sphincterotomy. One of the asymptomatic patients underwent cholecystectomy on the advice of his consultant. A further seven had recurrent biliary colic or cholangitis necessitating enlargement of the sphincterotomy and further stone retrieval in three of these patients. Endoscopic sphincterotomy is an effective treatment for bile duct stones in high risk patients, but subsequent cholecystectomy is required in a significant number of patients owing to continuing gallbladder symptoms.

Risks of leaving the gallbladder in situ after endoscopic sphincterotomy for bile duct stones

There is controversy concerning the subsequent clinical course of patients whose gallbladder is left in situ following successful endoscopic removal of stones from their common bile ducts. A total of 191 patients (median age 76 years) were reviewed between 12 and 100 months (mean 38 months) after endoscopic sphincterotomy. Ten patients (5.2 per cent) had symptoms requiring cholecystectomy which was uneventful, nine in the first year. Cholangitis at presentation or failure to fill the gallbladder by endoscopic retrograde cholangiography were not helpful in identifying these patients. Forty-nine (25.6 per cent) patients died during the review period from non-biliary pathology (usually cardiovascular). Elective cholecystectomy is not required in elderly patients with symptomatic bile duct stones if the common bile duct can be cleared of stones after endoscopic sphincterotomy.

Endoscopic sphincterotomy for bile duct stones in patients with intact gallbladders

Endoscopic sphincterotomy for bile duct stones in patients with intact gallbladders

Endoscopic Sphincterotomy for Bile Duct Stones in Very Elderly Patients

Endoscopic Sphincterotomy for Bile Duct Stones in Very Elderly Patients

Balloon Dilation or Sphincterotomy for Bile Duct Stones

The efficacy and safety of endoscopic papillary balloon dilation (EPBD) for removing bile duct stones are controversial. In this multicenter study,