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PubMed2005

Usefulness of endoscopic ultrasound in patients at high risk of choledocholithiasis.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) has been considered the nonsurgical gold standard for the diagnosis and treatment of choledocholithiasis (CDL). Complications include a 0.1% to 1.3% mortality rate and a 5% to 19% morbidity rate, including a reported 1.8% to 6.7% incidence of postprocedure pancreatitis. Twenty-seven percent to 67% of ERCPs done for suspected choledocholithiasis ultimately have negative results. Endoscopic ultrasound (EUS) has been proposed as an alternate means of diagnosing choledocholithiasis that may eliminate the need for ERCP and its associated morbidities in certain patients. METHODS: Retrospective chart review identified 30 patients who underwent EUS with or without ERCP for suspected choledocholithiasis. Reports of all procedures performed were obtained and data were collected on all biliary abnormalities identified on both EUS and ERCP. RESULTS: Pancreaticobiliary abnormalities were identified in 27 of 30 patients (90%) at EUS. Most common diagnoses included CDL (n = 9, 30%), biliary sludge (n = 11, 37%), pancreatitis (n = 8, 27%), and cholelithiasis (n = 7, 23%). Subsequent ERCP was performed in 14 patients (47%). Indications included a diagnosis of CDL by EUS (n = 9) and abnormal liver function tests (n = 5). CDL was identified in 5 of 14 patients (36%), and microlithiasis/biliary sludge was identified in an additional 5 patients (36%). In 4 patients, CDL was identified by EUS but not by ERCP. ERCP did not identify any new cases of CDL after EUS: of 21 patients without evidence of CDL on EUS, none were subsequently shown to have CDL or to develop any complications related to common duct stones. CONCLUSIONS: EUS is an effective method of diagnosing CDL. It demonstrates both a high sensitivity and specificity for identifying common bile duct stones. Its use as a screening modality in patients suspected of having CDL may allow more selective use of ERCP.

Journal Article↗
PubMed1999

Timing of endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy in the treatment of choledocholithiasis.

Although experience with laparoscopic approaches to common duct stones is increasing, endoscopic retrograde cholangiopancreatography (ERCP) performed either before or after laparoscopic cholecystectomy (LC) remains the most common approach. Debate remains as to the best timing for ERCP in patients with suspected choledocholithiasis. Because clinical, laboratory, and radiological data are poor predictors of choledocholithiasis, many ERCPs done before LC give negative results. ERCP performed after LC with a positive intraoperative cholangiogram (i.o.p.) would eliminate many unnecessary preoperative endoscopic studies. This is a retrospective analysis of the treatment of choledocholithiasis with the combination of LC and ERCP. All patients included could have had ERCP preoperatively or postoperatively; therefore, those with cholangitis requiring emergent preoperative ERCP were excluded. Two groups of patients were compared: those who underwent ERCP followed by LC and those who underwent LC and IOC followed by ERCP. No significant differences were found with respect to age, gender, health status, clinical presentation, laboratory values (most liver functions, white blood cell count, hemoglobin, and serum amylase), surgery time, blood loss, ERCP time, time between treatment modalities, and days to regular diet. However, the preoperative ERCP group was found to have a longer hospital stay (6.7 days vs. 3.5 days, p = 0.003) and higher hospital cost ($9,406.39 vs. $12,816.23, p = 0.05). The preoperative ERCP group had two patients requiring two ERCPs to clear the common duct, one patient requiring conversion to open procedure because of failed LC, and four minor complications. The postoperative ERCP group had no failed LC, IOC, or postoperative ERCPs and one minor complication. The rate of false positive IOC was 6.7% and of negative preoperative ERCP, 43%. We conclude that in the absence of cholangitis requiring emergent endoscopic decompression, suspected choledocholithiasis can be successfully managed first with LC, ERCP being reserved for patients with a positive IOC. This eliminates many negative preoperative ERCPs.

Adult↗
PubMed1999

Single-stage laparoscopic and endoscopic treatment for choledocholithiasis: a novel approach.

The transcystic approach is ideal for the management of choledocholithiasis detected during the course of laparoscopic cholecystectomy. When this approach is not possible or fails, current alternatives include laparoscopic choledochotomy, conversion to open common bile duct exploration, or postoperative endoscopic sphincterotomy (ES). Intraoperative ES is not routinely advised, as it is thought to be difficult to carry out in the operating room with the patient in the supine position. We challenged this concept and have performed ES intraoperatively when the transcystic approach had failed. Five consecutive patients in whom transcystic extraction of choledocholiths had failed underwent intraoperative ES. The laparoscopic procedure was terminated, the trocars were removed, the wounds were closed, and the patients were placed in the left lateral decubitus position. In this position, the endoscope was inserted, ES was performed under fluoroscopic guidance, and choledocholithiasis was treated. There were no difficulties or complications, and the postoperative course was similar to that of a simple laparoscopic cholecystectomy in all five patients. Intraoperative ES is a viable and effective treatment for choledocholithiasis when the transcystic approach fails. This novel approach to choledocholithiasis is well tolerated and may save the extra time and effort associated with all other current alternatives.

Adult↗
PubMed1988

Are duodenal diverticula associated with choledocholithiasis?

The results of 250 consecutive ERCP examinations were analysed in order to assess whether or not juxtapapillary duodenal diverticula are associated with choledocholithiasis. Cholangiography showed common bile duct stones in 71 patients of whom 25 (35%) had periampullary diverticula. Clear bile ducts were shown in 99, of whom only 12 had diverticula (12%) (p less than 0.05). After allowing for the differences in age between the two groups, patients with choledocholithiasis were 2.6 times (95% CI: 1.14-5.93) more likely to have a periampullary diverticulum than patients without choledocholithiasis. In the remaining 80 patients, cholangiography was either not successful or not indicated. Further clinical follow up and/or investigation have failed to reveal duct stones in any and only 10 (13%) of these 80 patients had diverticula. Overall, 47 patients had diverticula: 25 (53%) had duct stones, four may have had stones and 18 had none. Three or more years after cholecystectomy 59% of patients with duct stones had diverticula, while only 13% with clear ducts had them. These results show a significant association between periampullary duodenal diverticula and choledocholithiasis.

Adolescent↗
PubMed1983

Prospective diagnosis of choledocholithiasis.

Choledocholithiasis was detected by ultrasound in 11 of 87 patients (13%) overall, including 11 of 56 patients (20%) who had dilated ducts. Choledocholithiasis occurred with a normal caliber common bile duct in 31 of 87 patients (36%), and choledocholithiasis occurred without stones in the gallbladder in seven of 66 patients (11%). Biliary ultrasound plays a limited role in the exclusion of choledocholithiasis.

Cholelithiasis↗
PubMed1986

US diagnosis of choledocholithiasis: a reappraisal.

Sonographic detectability of choledocholithiasis using real-time sector scanners appears to be improved in comparison with series previously reported. To establish this premise, 78 consecutive patients with choledocholithiasis were evaluated prospectively by ultrasound (US) prior to surgery or endoscopic retrograde cholangiopancreatography. Preoperative US analysis yielded a 55% sensitivity for detection of choledocholithiasis (43 patients), representing more than a threefold increase over previous series. Dilated extrahepatic ducts were seen in 52 patients (67%), 40 of whom (77%) were seen to have an intraluminal stone. Extrahepatic ducts were normal in size in 26 patients (33%), only three of whom were seen to have a stone. This marked improvement in detection rate probably is related to improvements in imaging technology as well as to increased diagnostic efforts based on cognizance of the difficulty in making the diagnosis of choledocholithiasis sonographically.

Gallstones↗
PubMed1996

Prospective randomized trial comparing endoscopic sphincterotomy followed by surgery with surgery alone in good risk patients with choledocholithiasis.

BACKGROUND: Role of endoscopic sphincterotomy (ES) in high risk patients with choledocholithiasis is established but its role in good risk patients is unclear. DESIGN: A prospective randomized trial of endoscopic sphincterotomy followed by surgery (ES + S) versus surgery alone (SA) in good risk patients with choledocholithiasis. SETTING: A tertiary level referral hospital in north India; July 1991 to October 1993. PATIENTS AND METHODS: Thirty three out of 60 patients with choledocholithiasis were found suitable for randomization--16 were randomised to ES + S group and 17 to SA group. RESULTS: Common bile duct clearance was achieved in 11/13 (85%) patients in ES + S group and in 13/15 (87%) in SA group. Major complications occurred in 4/13 (31%) patients in ES + S group and 3/16 (19%) patients in SA group. These differences were not statistically significant, but patients in ES + S group were exposed to morbidity twice, procedure related morbidity of ES being 23%. No significant differences were observed in hospital stay and cost of treatment. CONCLUSIONS: Results of this trial do not support use of precholecystectomy ES in good risk patients with choledocholithiasis, since it did not offer any advantage over surgery alone.

Adult↗
PubMed2000

[Laparoscopic cholecystectomy in choledocholithiasis and stricture of the terminal part of the common bile duct].

The authors offer the treatment and diagnostic algorithm in choledocholithiasis, stricture of a terminal portion of the common hepatic duct and papilla stenosis revealed in laparoscopic cholecystectomy (LCE). With the purpose of intraoperative assessment of bile ducts states during LCE, the diagnostic system including laparoscopic and ultrasonic examinations, cholangiography and choledochoscopy was developed and applied. In intraoperative revealing of choledocholithiasis without bile outflow disorders and wide cystic duct the authors prefer to remove the concrements during choledochoscopy through cystic duct without intervention on Vater's papilla (VP). In combination of choledocholithiasis with bile outflow disorders and also in isolated papilla stenosis and stricture of a terminal portion of the common hepatic duct, one-stage laparoscopic cholecystectomy, intraoperative antegrade papillosphincterotomy and retrograde calculus extraction is optimal. In cases when complete endoscopic calculus extraction is impossible, the drainage of the common hepatic duct by Cholsted's with subsequent delayed endoscopic papillosphincterotomy (EPST) is acceptable. During intraoperative examination in 49 patients (57.6%) the concrements in choledochus, not diagnosed earlier, were revealed, in 21--stricture of terminal choledochus portion and in 19 patients--papilla stenosis. In 12 cases the concrements were removed during choledochoscopy through the cystic duct stump, 4 patients with big concrements required laparoscopic choledocholithotomy. In 16 cases LCE with various variants of choledochus drainage was performed as the first stage, as the second stage--EPST and lithoextraction. Antegrade papillosphincterotomy was performed in 15 patients during LCE. In 12 cases intraoperatively revealed choledocholithiasis combined with papilla stenosis (7) and choledochus stricture (5) was the indications to intraoperative papillosphincterotomy. Papilla stenosis was the indication to antegrade papillosphincterotomy in 3 patients.

Adult↗
PubMedDate not supplied

[Endoscopic management of choledocholithiasis during pregnancy].

BACKGROUND: Gallstones and extrahepatic biliary obstruction is a difficult management problem during pregnancy. Choledocholithiasis may cause cholangitis or pancreatitis, potentially life-threatening conditions. As surgery may result in significant fetal mortality when performed on these patients. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) are preferred and could be performed safely in pregnant women provided suitable precautions are taken to minimize exposure to radiation. OBJECTIVE: To show our experience in ERCP and ES for symptomatic choledocholithiasis during pregnancy. MATERIAL AND PATIENTS: We described our experience in seven young women (mean age, 27.4 years) who presented with symptoms caused by choledocholithiasis, one in first trimester of pregnancy, four in second trimester, and two in third month. All had obstructive jaundice corroborated by abnormal liver function test and dilation of biliary tree on abdominal ultrasound. RESULTS: All had ERCP, ES, and stone extraction without complication and went on to deliver healthy babies at term. A lead apron was positioned over the abdomen of the mother to shield the fetus during roentgenographic fluoroscopy. Mean fluoroscopy time was 26 (range, 5-60 sec). CONCLUSIONS: Endoscopic management should be considered in women presenting with choledocholithiasis during pregnancy.

Adult↗
PubMed1992

[Extracorporeal shock wave lithotripsy for choledocholithiasis].

By the advent of extracorporeal shock wave lithotripsy (ESWL), the plan to manage choledocholithiasis has changed greatly. As a non-operative treatment, endoscopic sphincterotomy (EST) is intensively performed, but ESWL is much safer than EST in invasiveness and complications. Without EST, 5 Fr endoscopic naso-biliary drainage (ENBD) and percutaneous transhepatic biliary drainage (PTBD) aiming at preservation of the function of the papilla Vater were inserted to make drainage first for the patients with choledocholithiasis with obstructive jaundice who visited our hospital. After the cholangitis subsided, ESWL was performed under the direct cholangiography through ENBD and PTBD and excellent results were obtained which are herein reported. ENBD has been performed on 98 cases of choledocholithiasis over the past 4 years. ESWL has been performed on 42 cases (ENBD 36 cases and PTBD 6 cases). Choledocholithiasis completely disappeared in 31 cases (73.8%). For unsuccessful cases, EST, percutaneous transhepatic cholangioscopy (PTCS), or laparotomy was performed.

Aged↗
PubMed1991

[Is surgical treatment indicated in choledocholithiasis?].

Surgical exploration of the biliary pathways on account of relapsing or forgotten concrements in the biliary pathways in patients above 70 years with associated diseases has a high morbidity and mortality. The authors present an account of a group of patients from their departments; these patients with choledocholithiasis were treated by the at present ever more frequently used method--endoscopic sphincteropapillotomy. In the discussion the authors deal with possibilities to use EPS in the treatment of choledocholithiasis with a cholecyst in situ, acute pancreatitis with biliary genesis but also acute cholangoitis with the background of choledocholithiasis. They consider EPS the therapeutic method of choice in choledocholithiasis and report very good immediate as well as long-term results.

Aged↗
PubMed1989

[Diagnosis of choledocholithiasis and residual lithiasis. Ultrasonic postcholecystectomy].

246 patients with proven common bile duct stones at surgery were studied in order to establish the accuracy of ultrasound scanning in detecting choledocholithiasis and to compare the sensitivity of real-time examinations with those performed by a static scanner. The detection of choledocholithiasis by real-time ultrasound was 45.6% compared to 26.3% for the examinations performed with a static scanner. A dilated common bile duct was detected in 83.6% using real-time scanning compared to 70.3% using a static scanner. When the common bile duct was not dilated ultrasound was unable to detect the stones. Real-time ultrasound detected 66.6% of the patients with residual choledocholithiasis compared to 23.5% of patients examined by a static scanner. Our results show that real-time ultrasound scanning is a very useful screening method in detecting choledocholithiasis and residual lithiasis.

Cholecystectomy↗
PubMed1989

[Secondary and residual choledocholithiasis. Our experience].

A retrospective study was made of 780 patients who underwent surgery of the biliary tract for lithiasis between 1973 and 1984; of them, 110 (14.1%) presented secondary choledocholithiasis and 14, residual choledocholithiasis. The decade of highest incidence of choledocholithiasis was 60 to 70 years; the proportion of women-men was 2:1. The predominant symptom was biliary colic, which occurred in 99% of patients; jaundice appeared in 65% of cases. In 5.6% of patients choledocholithiasis was complicated with suppurative cholangitis. The operation most frequently practiced was choledochotomy with extraction of calculi and closure on a Kehr tube, performed in 50% of patients, followed by transduodenal sphincteropapillotomy in 31% of patients. In 32 patients complications occurred during the immediate postoperative period, representing a morbidity of 22.5% and a mortality of 3.2%. The most frequent complications were of infectious nature.

Adolescent↗
PubMed1985

Endoscopic sphincterotomy in the treatment of choledocholithiasis and ampullar stenosis. Experience with 202 patients.

Endoscopic sphincterotomy (EST) was performed on 202 patients (265 EST) in the 5-year period 1978-1983 because of choledocholithiasis or benign stenosis of the ampulla of Vater. The indications for EST in choledocholithiasis included residual or recurrent stone(s) in 80 cholecystectomized patients, and 96 had choledocholithiasis with the gallbladder in situ. Ductal calculi passed spontaneously after EST in 87 cases (50%) and were actively extracted in 73 (41%). Ductal clearance failed in 16 patients. The overall success rate thus was 91%. Ampullar stenosis was successfully treated in 26 patients. Sphincter stenosis after EST was diagnosed in one patient. Immediate complications of EST arose in 31 patients (11.7%), one of whom died. Emergency laparotomy was required in three cases (1.1%). EST with or without stone extraction is a relatively safe procedure for managing choledocholithiasis in high-risk patients before cholecystectomy is considered, and also for stones retained or reformed after cholecystectomy. Endoscopic treatment may offer appreciable clinical and financial benefits by reducing morbidity and mortality rates and shortening hospitalization and convalescence time.

Adult↗
PubMed1982

[Ampullar choledocholithiasis].

Under observation were 111 patients with ampullar choledocholithiasis. Variants of the clinical course of choledocholithiasis are characterized. The most rational method for the surgical treatment of ampullar choledocholithiasis is the transduodenal transpapillary extraction of concrements from the major papillar followed by papillocholedochoplasty. In a number of cases papillocholedochoplasty was accompanied with additional creation of biliodigestive anastomosis and plasty of the opening of the pancreatic duct. Remote results of the operations on the major papilla of the duodenum are dependent on the amount of preoperative complications of ampullar choledocholithiasis and first of all pancreatitis.

Ampulla of Vater↗
PubMed1994

The role of endoscopic retrograde cholangiopancreatography with laparoscopic cholecystectomy in the management of choledocholithiasis.

Perioperative endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy (ES) offer the ability to remove common bile duct stones (CBDS) and still use the laparoscopic technique for cholecystectomy. The accuracy of predicting choledocholithiasis has been variable in several studies. The indications and complications of perioperative ERCP and ES with laparoscopic cholecystectomy (LC) are presented here. Between 6/1/90 and 11/11/93, 484 LC were performed at Santa Barbara Cottage Hospital. A total of 38 patients underwent perioperative ERCP; 33 patients underwent preoperative ERCP with 3/33 (9%) failing to cannulate the ampulla; 15 patients had choledocholithiasis; and 14/15 (93%) were cleared by ES. Fifteen patients had a normal CBD on ERCP. There were no deaths in this group of patients, seven of 38 (18%) had complications, including bleeding and post ERCP hyperamylasemia. Patients who had a normal CBD and underwent preoperative ERCP (9/15, 60%) had a history of gallstone pancreatitis or hyperamylasemia that was resolved or resolving before ERCP. Patients without stones on ERCP or cholangiogram (11/15, 73%) had a normal bilirubin (avg. 1.0 mg/dL; Range 0.4-2.3). Patients with choledocholithiasis (8/15, 53%) had a history of jaundice or elevated bilirubin before ERCP (avg. 2.59 mg/dL; range 0.2-9.3). ERCP with ES and laparoscopic cholecystectomy is a safe and effective method for the management of symptomatic cholelithiasis with choledocholithiasis. A history of gallstone pancreatitis or hyperamylasemia that is resolving or resolved in the absence of an elevated bilirubin does not require preoperative ERCP before LC with cholangiogram.

Adolescent↗
PubMed1996

[Treatment of choledocholithiasis in the era of laparoscopic cholecystectomy].

Laparoscopic cholecystectomy (L-CHE) is currently considered to be the optimal standard in the therapy of cholecystolithiasis. However, it is choledocholithiasis which is problematic, especially the timing of the solution in relation to L-CHE. In general, the opinion predominates that in preoperatively verified choledocholithiasis the ERCP with EPS and extraction of choleliths should be performed 24-28 hours prior to the elective L-CHE. Surgical removal of choleliths from the main biliary ducts indicated only in a small group of patients. The authors of the study reflect upon the current trends of the choledocholithiasis therapy in the era of laparoscopic cholecystectomy. They present their own set of patients and recommend the procedure of the choledocholithiasis therapy concommitted with cholecystolithiasis with the subjective of the full use of endoscopic methods in the therapy of this disease. (Ref. 14.).

Adult↗
PubMedDate not supplied

Endoscopic treatment of symptomatic choledocholithiasis.

BACKGROUND/AIMS: Today, different endoscopic techniques are available to treat choledocholithiasis. These techniques include mechanical lithotripsy (ML), electrohydraulic lithotripsy (EHL), laserlithotripsy (LL), and extracorporal shock-wave lithotripsy (ESWL). These techniques have to compete with laparoscopic stone removal which is performed with increasing frequency at some centers. METHODOLOGY: We report the results of treatment of choledocholithiasis and compare the results with a meta-analysis of studies in whom endoscopic and laparoscopic techniques were applied. From 1994-1995, 217 patients with symptomatic choledocholithiasis were treated using endoscopic retrograde cholangiography (ERC). RESULTS: Overall, complete stone removal was successful in 98% of all patients and only 5 patients had to undergo surgery. Complete endoscopic removal of stones was achieved in 70% during the first ERC session. In 47 patients consecutive ERC sessions with application of EML, EHL, or ESWL were necessary to completely remove the stones. Complication rate was 5% and included pancreatitis and bleeding from papillotomy. There was no procedure-related mortality. CONCLUSION: The study suggests that today ERC remains the treatment of choice in most patients with symptomatic choledocholithiasis.

Adult↗