Treatment Of Bile Duct Stones Research Articles

Surgical Intervention versus Endoscopy in the Treatment of Bile Duct Stones

Bile duct stones (BDSs) may happen in up to 4%–15% of all patients for whom cholecystectomy is performed. Patients giving CBDS have manifestations including: biliary colic, jaundice, cholangitis, pancreatitis or might be asymptomatic. It is critical to recognize essential and auxiliary stones, in light of the fact that the treatment approach shifts. Stones found some time recently, amid, and after cholecystectomy had likewise contrasting medicines. Distinctive strategies have been utilized for the treatment of CBDS yet the appropriate treatment relies on upon conditions, for example, quiet' fulfilment, number and size of stones, and the specialists involvement in laparoscopy. Endoscopic retrograde cholangiopancreatography with or without endoscopic biliary sphincterotomy, laparoscopic CBD investigation (transcystic or transcholedochal), or laparotomy with CBD investigation (by T-tube, C-tube inclusion, or essential conclusion) are the most regularly utilized strategies overseeing CBDS (Common bile duct stones). We will survey the pathophysiology of bile duct stones, finding, and distinctive procedures of treatment with particular concentrate on the different surgical modalities

Application of combination of various endoscopic techniques in treatment of bile duct stones

Application of combination of various endoscopic techniques in treatment of bile duct stones

Fatal outcome due to CO2 emboli during direct cholangioscopy

In this manuscript, we present two patients with fatal CO2 emboli who underwent direct peroral video cholangioscopy (POC). Emboli due to insufflation of air during such a procedure have been...

血清CA19-9异常增高的胆总管结石7例诊治体会

血清CA19-9是一种常见的肿瘤标志物，其升高多见于各种消化系统恶性肿瘤患者，尤其是胆管癌、胰腺癌，对于鉴别胆道良、恶性疾病具有重要参考价值。胆道良性疾病患者，血清CA19-9异常升高者少见。本文结合7例血清CA19-9异常升高的胆总管结石患者的诊治体会，深入探讨胆总管结石患者血清CA19-9异常升高的病因、诊断和治疗，以期有效提高血清CA19-9异常升高的胆道良性疾病患者的诊治效果、避免胆道恶性肿瘤的误诊和误治。 Serum CA19-9 is one of the most common tumor markers whose elevation is common in patients with various malignant tumors of digestive system, especially bile duct carcinoma, pancreatic cancer, which has important reference value in the differential diagnosis of benign and malignant biliary diseases. Patients with benign biliary tract disease, abnormal elevated serum CA19-9 are rare. Based on our experience of abnormal increase of serum CA19-9 in 7 patients with choledocholithiasis, this paper will further investigate the etiology, diagnosis and treatment of bile duct stones in patients with abnormal serum CA19-9 increased, so as to effectively improve the diagnosis and treatment effect of the biliary tract benign disease patients with abnormal elevated serum CA19-9, and to avoid misdiagnosis and mistreatment of biliary tract malignant tumor.

A comparative evaluation of treatment methods for bile duct stones after hepaticojejunostomy between percutaneous transhepatic cholangioscopy and peroral, short double-balloon enteroscopy

Background:Bile duct stones after hepaticojejunostomy are considered a troublesome adverse event. Although percutaneous transhepatic procedures using a cholangioscopy is performed to treat these bile duct stones, a peroral endoscopic procedure using a short, double-balloon enteroscope (sDBE) is an alternative. This study aimed to compare the immediate and long-term outcomes of both treatments for bile duct stones in patients who underwent prior hepaticojejunostomy.Methods:Between October 2001 and May 2013, 40 consecutive patients were treated for bile duct stones after hepaticojejunostomy at a tertiary care hospital. Initial success with biliary access, biliary intervention-related technical success, clinical success, adverse events, hospitalization duration, and stone-free survival were retrospectively evaluated.Results:The initial success rates for biliary access were 100% (8/8) with percutaneous transhepatic cholangioscopy (PTCS) and 91% (29/32) with sDBE. In three patients in whom biliary access during initial sDBE failed, successful access with subsequent PTCS was achieved, and biliary intervention-related technical success and clinical success were eventually achieved in all 40 patients. The rate of adverse events was significantly lower with sDBE than with PTCS (10% versus 45%; p = 0.025). The median hospitalization duration for complete stone clearance was significantly shorter with sDBE than with PTCS (10 versus 35 days; p < 0.001). During the median 7.2 year or 3.1 year follow up, the probabilities of being stone-free at 1, 2, and 3 years were 100%, 73%, and 64% for PTCS and 85%, 65%, and 59% for sDBE, respectively (p = 0.919).Conclusions:sDBE was useful, with few adverse events and short hospitalization; therefore, experienced endoscopists can consider it as first-line treatment for bile duct stones in patients with prior hepaticojejunostomy.

New Generation Spyglass Guided Electrohydraulic Lithotripsy as a Rescue Therapy for Impacted Gallstones Within a Dormia Basket

The treatment of bile duct stones has evolved from surgery to endoscopic management, with a success rate of 90%.1 Impaction of the lithotripsy basket during endoscopic removal of a CBD stone is seen in up to 5.9% of cases.2 Stone size and stone size to bile duct diameter ratio (greater than 1) are predictors of unsuccessful mechanical lithotripsy.3 A plethora of endoscopic techniques and devices appeared in order to facilitate rapid, safe and effective bile duct stones extraction. Large common bile duct stones are challenging though and are treated conventionally with mechanical or electro-hydraulic lithotripsy. The most fearful complication of mechanical lithotripsy is stone impaction within the basket. We present the case of a 72 year old female, who underwent laparoscopic cholecystectomy and an intra-operative cholangiogram with demonstration of retained common bile duct stones. Subsequently performed ERCP to remove these stones was complicated by the presence of multiple large stones, the largest of which was at least 20 mm in diameter. Stone retrieval was unsuccessful despite extended generous sphincterotomy, balloon extraction and balloon sphincteroplasty. Mechanical lithotripsy with a basket was attempted. This was complicated by impaction of the large stones in the basket, which then could not be closed or opened or retrieved. SpyGlass probe was advanced to the middle third of the main bile duct, alongside the basket within the bile duct. Three large stones were seen impacted within the basket. Electrohydraulic lithotripsy (EHL) was used to fragment the impacted stones within the basket. The large stones were fragmented into smaller pieces and the basket was retrieved. A plastic stent was then reinserted. Patient did well post operatively. Conclusion: Optimum visualization and ease of operability makes new generation Spyglass based EHL, an ideal rescue therapy for impacted stones within a dormia basket. This can certainly help avoid more invasive interventions such as surgical exploration.Figure 1Figure 2Figure 3

Mo2078 Endoscopic Ultrasound-Guided Antegrade Treatment of Bile Duct Stone in Patients With Surgically Altered Anatomy: A Multicenter Retrospective Cohort Study

Mo2078 Endoscopic Ultrasound-Guided Antegrade Treatment of Bile Duct Stone in Patients With Surgically Altered Anatomy: A Multicenter Retrospective Cohort Study

Endoscopic ultrasound-guided antegrade treatment of bile duct stone in patients with surgically altered anatomy: a multicenter retrospective cohort study.

Endoscopic retrograde cholangiopancreatography (ERCP) for management of bile duct stone (BDS) in patients with surgically altered anatomy is challenging even when applying enteroscopy. Endoscopic ultrasound-guided antegrade treatments (EUS-AG) for BDS have been developed but have not been well studied yet. The aim of the present study was to evaluate the feasibility and safety of EUS-AG for BDS in patients with surgically altered anatomy as a multicenter retrospective cohort study. A retrospective database analysis was performed to identify patients with surgically altered anatomy who underwent EUS-AG for the management of BDS at four academic care centers. Basic characteristics of the patients and details of the procedures were determined and the success rates and adverse event rates were evaluated. EUS-AG for BDS was attempted in 29 patients. Successful BDS removal was achieved in 72% (21/29) of patients. Reasons for failed EUS-AG were unsuccessful bile duct puncture in six, unsuccessful guidewire manipulation in one, and unsuccessful stone removal using a retrieval balloon in one. Adverse events occurred in five (17%) but were successfully managed conservatively. EUS-AG for BDS is a feasible and safe alternative in patients with surgically altered anatomy, although further evaluation and development of dedicated devices are needed.

The efficacy of peroral cholangioscopy for difficult bile duct stones and indeterminate strictures: a systematic review and meta-analysis.

Background and study aims: Current evidence supporting the efficacy of peroral cholangioscopy (POC) in the evaluation and management of difficult bile duct stones and indeterminate strictures is limited. The aims of this systematic review and meta-analysis were to assess the following: the efficacy of POC for the therapy of difficult bile duct stones, the diagnostic accuracy of POC for the evaluation of indeterminate biliary strictures, and the overall adverse event rates for POC. Patients and methods: Patients referred for the removal of difficult bile duct stones or the evaluation of indeterminate strictures via POC were included. Search terms pertaining to cholangioscopy were used, and articles were selected based on preset inclusion and exclusion criteria. Quality assessment of the studies was completed with a modified Newcastle-Ottawa Scale. After critical literature review, relevant outcomes of interest were analyzed. Meta-regression was performed to examine potential sources of between-study variation. Publication bias was assessed via funnel plots and Egger’s test. Results: A total of 49 studies were included. The overall estimated stone clearance rate was 88 % (95 % confidence interval [95 %CI] 85 % – 91 %). The accuracy of POC was 89 % (95 %CI 84 % – 93 %) for making a visual diagnosis and and 79 % (95 %CI 74 % – 84 %) for making a histological diagnosis. The estimated overall adverse event rate was 7 % (95 %CI 6 % – 9 %). Conclusions: POC is a safe and effective adjunctive tool with endoscopic retrograde cholangiopancreatography (ERCP) for the evaluation of bile duct strictures and the treatment of bile duct stones when conventional methods have failed. Prospective, controlled clinical trials are needed to further elucidate the precise role of POC during ERCP.

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.

Long- and short-term outcomes of ERCP for bile duct stones in patients over 80 years old compared to younger patients: a propensity score analysis.

Backgrounds and study aims: Endoscopic sphincterotomy (ES) is widely accepted as first-line therapy for bile duct stones (BDS). The major long-term pancreaticobiliary complication is BDS recurrence. Whether cholecystectomy should be performed after ES, especially in elderly patients, remains controversial. The aim of this study is to investigate the short-term and long-term outcomes after therapeutic endoscopic retrograde cholangiopancreatography (ERCP) for BDS and to analyze risk factors for pancreaticobiliary complications. We also compared long-term outcomes in patients older and younger than age 80. Patients and methods: A total of 1210 patients who underwent therapeutic ERCP for BDS were retrospectively reviewed to identify risk factors for pancreaticobiliary complications. We divided these patients into two groups: Group Y (< 80 years; 960 patients) and Group O (≥ 80 years; 250 patients). There were 192 matched pairs in the propensity score analysis. Results: The incidence of pancreaticobiliary complications was 13.1 % (126/960) in Group Y and 20.4 % (51/250) in Group O (P < 0.00001). Multivariate analysis showed that a gallbladder left in situ with stones was a significant independent risk factor (hazard ratio, 2.81; 95 % confidence interval, 1.62 – 4,89; P = 0.0002). There were no significant differences in the incidence of pancreaticobiliary complications between the propensity score-matched groups. Conclusions: A gallbladder in situ with stones was the only significant risk factor for pancreaticobiliary complications after treatment for BDS. Age per se should not be the major factor when deciding on treatment that minimizes the occurrence of pancreaticobiliary disease.

Su1641 Efficacy and Safety of EPLBD for Bile Duct Stones in Patients With Surgically Altered Anatomy: a Large Case Series At Single High Volume Center

In patients with surgically altered anatomy (e.g. Billroth II gastrectomy [B-II], gastrectomy plus Roux-en-Y reconstruction [R-Y]), extraction of bile duct stones can be challenging. Recently, endoscopic papillary balloon dilation (EPLBD) has been shown to be useful for the removal of difficult bile duct stones in patients with normal anatomy.Purpose: To investigate the safety and efficacy of EPLBD for the treatment of bile duct stones in patients with altered anatomy.

A Comparison Study of Ballooning Time between Immediate and Conventional Deflation Method of Endoscopic Papillary Large Balloon Dilation for the Extraction of Difficult Bile Duct Stone

Background/Aims: The ballooning time in endoscopic papillary large balloon dilation (EPLBD) remains controversial. The aim of this study was to evaluate the significance of the ballooning time comparing an immediate balloon deflation method with a conventional ballooning time of > 45 seconds. Methods: Between January 2010 and December 2010, 126 patients with bile duct stones treated with EPLBD and endoscopic sphincterotomy were divided according to the ballooning time: the immediate deflation group (n=56) and the conventional inflation group (ballooning time 45s to < 60s) (n=70). Results: The overall success rate and the success rate of the first attempt of ERCP (endoscopic retrograde cholangio-pancreatography) were 96.4% (54/56) and 80.4% (45/56) in the immediate group and 97.1% (68/70) and 77.1% (54/70) in the conventional inflation group. There were no statistically significant differences in the overall success and the first attempt of ERCP success rate (p=0.99, p=0.66). The frequency of mechanical lithotripsy was 0% in the immediate deflation group and 7.1% in the conventional inflation group (p=0.065). Complications occurred in 3.6% (2/56) patients in the immediate deflation group and 8.6% (4/70) patients in the conventional inflation group (p=0.298). Conclusions: The ballooning time in EPLBD does not affect the outcomes of the treatment for bile duct stones. And the feasibility of the immediate deflation method in EPLBD is acceptable.

Endoscopic retrograde cholangiopancreatography using a cap-assisted highly flexible colonoscope in patients with Roux-en-Y anastomosis.

In this retrospective study of 10 patients with Roux-en-Y anastomosis, endoscopic retrograde cholangiopancreatography (ERCP) using a cap-assisted thin highly flexible colonoscope was done for treatment of bile duct stones. In five patients, the papilla of Vater was successfully reached using the colonoscope alone. However, in the other five patients, combination with an overtube was needed to reach the papilla. In all cases, complete removal of bile duct stones was accomplished. Procedure-related adverse events occurred in two cases. In conclusion, use of a cap-assisted thin highly flexible colonoscope for ERCP was successful in patients with a Roux-en-Y anastomosis.

Ampullary intervention for bile duct stones in patients with surgically altered anatomy

Transpapillary endoscopic treatment is a standard technique for the treatment of bile duct stones. This technique includes biliary cannulation, ampullary interventions such as endoscopic sphincterotomy (EST) and endoscopic papillary balloon dilation (EPBD), and stone removal. In patients with Roux-en-Y anastomosis, the transpapillary approach using an ordinary scope has been challenging. A recently developed single-/double-balloon enteroscope enables therapeutic endoscopic retrograde cholangiopancreatography to be carried out in such cases. EST using a balloon enteroscope is often difficult to carry out as a result of restriction of scope maneuverability or inadequate direction of the accessory. Although EPBD is easy to carry out for any anatomy, large or multiple stones are difficult to remove by EPBD only because of insufficient opening of Vater's papilla. Endoscopic papillary large-balloon dilation following EST is reported to be useful for the treatment of large and/or multiple stones. This technique is also useful for the treatment of bile duct stones in patients with Roux-en-Y anastomosis.

Comparison of laparoscopic common bile duct exploration and endoscopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy for choledocholithiasis: a prospective randomized study

BackgroundEndoscopic retrograde cholangiopancreatography and laparoscopic common bile duct exploration are safe and efficient methods that have recently been used for the treatment of bile duct stones. The aim of this study was to compare the efficacy, safety, and surgical outcomes of the laparoscopic common bile duct exploration plus laparoscopic cholecystectomy (LCBDE+LC) and endoscopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy (ERCP+LC). MethodsOne hundred twenty patients were prospectively randomized into 2 groups: LCBDE with LC in a single intervention and LC after ERCP. ResultsThe success rate of the LCBDE+LC group (96.5%) was found to be higher than for the ERCP+LC group (94.4%). Complication rates of the LCBDE+LC and ERCP+LC group were 7% and 11.1%, respectively. Complications requiring ERCP in the postoperative period after LCBDE+LC have been noted in 3.5% of cases. ConclusionsLaparoscopic CBD exploration provides an alternative therapeutic approach that has less morbidity, is cost-effective, and allows earlier recovery with a reduced period of short-term disability.

Recent advances in endoscopic management of difficult bile duct stones

Endoscopic treatment is now recognized worldwide as the first-line treatment for bile duct stones. Endoscopic sphincterotomy combined with basket and/or balloon catheter is generally carried out for stone extraction. However, some stones are refractory to treatment under certain circumstances, necessitating additional/other therapeutic modalities. Large bile duct stones are typically treated by mechanical lithotripsy. However, if this fails, laser or electrohydraulic lithotripsy (EHL) is carried out under the guidance of conventional mother-baby cholangioscopy. More recently, direct cholangioscopy using an ultrathin gastroscope and the newly developed single-use cholangioscope system - the SpyGlass direct visualization system - are also used. In addition, extracorporeal shock wave lithotripsy has also been used for stone fragmentation. Such fragmentation techniques are effective in cases with impacted stones, including Mirizzi syndrome. Most recently, endoscopic papillary large balloon dilationhas been introduced as an easy and effective technique for treating large and multiple stones. In cases of altered anatomy, it is often difficult to reach the papilla; in such cases, a percutaneous transhepatic approach, such as EHL or laser lithotripsy under percutaneous transhepatic cholangioscopy, can be a treatment option. Moreover, enteroscopy has recently been used to reach the papilla. Furthermore, an endoscopic ultrasound-guided procedure has been attempted most recently. In elderly patients and those with very poor general condition, biliary stenting only is sometimes carried out with or without giving subsequent dissolution agents.

Genetics and treatment of bile duct stones

The global burden of gallstones is increasing. Although the gallbladder is the most common site for gallstone formation, 10-25% of patients display concurrent gallbladder and bile duct stones. Secondary stones are differentiated from primary stones that develop de novo in the biliary tree. Overall, the natural history of bile duct stones is less well defined and their diagnosis and treatment are more complex as compared to gallbladder stones. Elevated liver function tests are not always reflective of bile duct stones, and noninvasive diagnosis by endoscopic ultrasound or MRI should be pursued in ambiguous cases. For treatment, recent studies report endoscopic dilation to result in similar clearance but lower complication and recurrence rates as with sphincterotomy. Pharmacological adjuvants such as ursodeoxycholic acid with sphincterotomy and stenting have been suggested for elderly patients. Indication and timing of cholecystectcomy after endoscopic treatment of bile duct stones is critical, and early cholecystectomy within 3-7 days prevents recurrent biliary events. In this review we address the pathophysiology of bile duct stones and present the latest developments in the diagnosis and treatment of this challenging condition, with a consideration of stone recurrence.

The role of endoscopic retrograde cholangiopancreatography at an academic medical center in the era of less-invasive diagnostic tools

Evaluation of: Coté GA, Singh S, Bucksot LG et al. Association between volume of endoscopic retrograde cholangiopancreatography at an academic medical center and use of pancreatobiliarytherapy. Clin. Gastroenterol. Hepatol. 10(8), 920–924 (2012).Many patients have pancreatobiliary diseases involving complications and comorbidities. This study shows the trends in the use of endoscopic retrograde cholangiopancreatography (ERCP) at an academic medical center from 1994 to 2009. During that time, the use of ERCPs for the treatment of bile duct stones reached a plateau and those for the treatment of pancreas divisum showed a decline. However, endoscopic therapy for benign biliary stricture and management for obstructive chronic pancreatitis increased during this period. There was a trend toward greater use of therapeutic ERCP for bile duct stenting involving metal stents and for pancreatic therapeutics. In that same period, there was an increase in the proportion of patients who had undergone unsuccessful ERCP at various other centers. Consequently, at academic medical centers, ERCP has become an increasingly complex intervention. Increasing numbers of patients with comorbidities, complications and history of failed ERCPs are being referred to academic centers to receive endotherapy.

Treatment of Common Bile Duct Stones in Sweden 1989–2006: An Observational Nationwide Study of a Paradigm Shift

The preferred strategies for treatment of common bile duct stones have changed from choledochotomy with cholecystectomy to sphincterotomy with or without cholecystectomy. The aim of the present study was to compare the effectiveness of these treatment strategies on a nationwide level in Sweden. All patients with hospital care for benign biliary diagnoses 1988-2006 were identified in Swedish registers. Patients with common bile duct stones and a first admission with choledochotomy and or endoscopic sphincterotomy from 1989 through 2006 comprised the study group. These patients were analyzed with respect to readmission for biliary diagnoses and acute pancreatitis. Incidence of open and laparoscopic choledochotomy decreased from 19.4 to 5.2, whereas endoscopic sphincterotomy increased from 5.1 to 26.1 per 100,000 inhabitants per year, respectively. Among patients treated for common bile duct stones (n = 26,815), 60.0 % underwent cholecystectomy during the first hospital admission in 1989-1994, compared to 30.1 % in 2001-2006. The treatment strategy that included endoscopic sphincterotomy was associated with more readmissions for biliary diagnoses and increased risk for acute pancreatitis than the treatment strategy with choledochotomy. However, patients treated with endoscopic sphincterotomy and concurrent cholecystectomy at the index admission had the lowest risk of readmission. Cholecystectomy has been increasingly separated from treatment of bile duct stones, and endoscopic sphincterotomy has superseded choledochotomy as a first alternative for bile duct clearance in Sweden. In patients fit for surgery, clearance of the common bile duct can be combined with cholecystectomy, as it probably reduces the need for biliary related readmissions.