Duodenoscopic sphincterotomy for common bile duct stones in patients with gallbladder in situ.
Duodenoscopic sphincterotomy (DS) is a well established treatment for common bile duct (CBD) stones in post-cholecystectomy patients, but not in patients with gallbladder in situ. The main argument against the procedure in the latter set of patients has been that by performing it, one is leaving behind the diseased gallbladder which may require further treatment. We have, however, performed 60 DS in 49 patients with gallbladder in situ. The clinical picture of these patients was characterized by abdominal pain in 79.6%, jaundice in 91.8%, history of cholangitis in 46.9%, severe acute cholangitis at the time of DS in 28.6% and a major associated illness in 10.2% of them. Adequate sphincterotomy was performed in 91.8% of the patients with successful stone extractions in 93.3% and an overall CBD clearance in 85.7%. One patient (2%) with severe acute cholangitis, who had presented in a moribund state, died despite adequate DS. Three patients (6%) experienced an exacerbation of acute cholangitis after DS, two of them requiring emergency surgery. During subsequent follow-up, elective cholecystectomy was performed in 26 (54%) patients. Five additional patients are awaiting surgery. Seventeen (36%) patients continue to have their gallbladders in situ and over a mean follow-up period of 12.8 months (range, 4-32 mos) they have remained asymptomatic except for brief episodes of biliary pain in 2 patients. It is concluded that DS relieves the symptoms of CBD stones even in patients with gallbladders in situ and may suffice for patients who are frail, elderly and who have major associated illnesses.