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BACKGROUND: As many as 24% of patients who undergo endoscopic sphincterotomy for the removal of bile duct stones have recurrent biliary complications develop for which there is no effective method of prevention. The aim of this study was to determine whether patients who undergo routine clinical follow-up after endoscopic sphincterotomy for bile duct stones have a different outcome than those who do not. METHODS: All patients who had endoscopic sphincterotomy for bile duct stones were scheduled for follow-up visits, liver function tests, and transabdominal US every 3 to 6 months. ERCP was performed whenever symptoms recurred, or abnormal liver function or US was noted. The patients themselves decided whether to adhere to the follow-up schedule; this was not a randomized trial. RESULTS: Seven hundred sixty-seven patients underwent endoscopic sphincterotomy for bile duct stones from October 1990 to July 1999. Seventy-seven (10%) were found to have recurrent bile duct stones. Three patients who had undergone Billroth II gastrectomy were excluded. Among the remaining 74 patients (52 men, 22 women; mean age 65 years), 42 (57%) had a juxtapapillary diverticulum and 21 (28%) an intact gallbladder. The mean time to recurrence of bile duct stones was 19.7 months (range 5-72 months). Sixty-four patients (87%) had recurrent bile duct stones within 3 years. Fifty-one (69%) were followed regularly (Group A) and 23 (31%) were not (Group B). At the time of stone recurrence, 20 patients in Group A (39%) and 1 in Group B (4%) were asymptomatic (p = 0.002). Liver function tests were normal in 17 patients (13 Group A, 4 Group B). Endoscopic treatment for recurrent bile duct stones was successful in 46 patients (90%) in Group A and 16 (70%) in Group B (p = 0.04); surgical treatment was successful in all 5 patients in Group A and 4 of the 7 patients in Group B. Two patients in Group B were treated by nasobiliary drainage and biliary endoprosthesis insertion caused by extremely large stones and poor condition; both died (acute pancreatitis and sepsis). CONCLUSION: Regular follow-up after endoscopic sphincterotomy detects recurrent bile duct stones early and thus avoids complications of bile duct stones.
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BACKGROUND: The aim was to investigate a possible association between D-glucaric acid (DGA), biliary bilirubin glucuronidation and brown pigment stones in the common bile duct. METHODS: A high performance liquid chromatography method with a strong cation resin (HPX-87H) was developed for measuring biliary DGA. Bile was obtained during ERCP by deep cannulation of the common bile duct in 100 patients with suspected biliary disease. RESULTS: The concentration of DGA in common bile duct bile was 60 (1.1-633) micromol l(-1) (median, range). The values were lower than previously reported. There were no differences in DGA concentrations in patients with common bile duct stones compared to patients without common bile duct stones, irrespective of stone type, cholesterol or brown pigment stones. Bilirubin conjugates in common duct bile did not vary with DGA concentrations. CONCLUSION: DGA is probably insignificant in the pathogenesis of common bile duct stones.
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We present a case of a 67-year-old woman, in which a clip in the common bile duct (CBD) was the nidus of stone formation. The ultrasonographic examination reported a CBD with an abnormally large diameter and an endoscopic retrograde sphincterotomy showed a stone in the ampulla. The stone was extracted through the Vater's Papilla and the patient was discharged after 24 hours.
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This report summarizes the experience with 144 choledochoscopic examinations performed in the course of 499 common bile duct explorations for stones. Routine choledochoscopy added 15--20 minutes to the operation and caused no complications. In 24% of the patients, additional stones were discovered with the choledochoscope after completion of routine bile duct exploration. In spite of this, the incidence of retained stones found postoperatively remained 4%, with or without choledochoscopy. The factors contributing to the failure of choledochoscopy, thus far, to prevent all retained stones are identified as inexperience of surgeons learning to perform biliary endoscopy, failure to scan the biliary tree systematically and thoroughly (including the left hepatic duct), and failure to reach the duodenum with the choledochoscope, meaning failure to see the lower segment of the common duct and ampullary orifice. With a modicum of experience and attention to detail, it should be possible to reduce considerably further the number of retained stones.
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