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PubMed1989

[Choledocholithiasis in non-cholecystectomized patients: endoscopic sphincterotomy and afterwards ... cholecystectomy?].

Choledocholithiasis in patients with a gallbladder "in situ" is presently one of the most frequent indications of endoscopic sphincterotomy. The crucial problem of these patients is whether or not they require eventual cholecystectomy to avoid the risks of potential complications of cholelithiasis. Of the 39 patients (mean age 80.1 +/- 8.2 years) with choledocholithiasis and gallbladder "in situ" released from this hospital from October 1979 to December 1985 after a successful endoscopic sphincterotomy (expulsion, spontaneous or not, of gallstones), 33 (84.6%) have been followed-up for an average of 41.5 +/- 20.8 months (7-92 range). During this time only one patient (3%) developed acute cholecystitis that required cholecystectomy, and two (6%) denoted mild pains in the right upper quadrant, while the other 30 (91%) remained asymptomatic. Over these years 10 patients (30.3%) died from nonbiliary causes. In conclusion, in elderly or high surgical risk patients who present choledocholithiasis and gallbladder "in situ", endoscopic sphincterotomy is effective. Later cholecystectomy to prevent the complications of cholelithiasis would not be justified as a routine measure in most of these patients.

Aged↗
PubMed1989

Fate of the gallbladder with cholelithiasis after endoscopic sphincterotomy for choledocholithiasis.

Endoscopic sphincterotomy is the treatment of choice for choledocholithiasis after cholecystectomy. Its role has been expanded to treat choledocholithiasis in patients with gallbladders still in place. The authors report their experience with endoscopic sphincterotomy, with emphasis on the safety of the procedure, in high-operative-risk patients with choledocholithiasis and gallbladder in situ. Stones were successfully removed in 72 of 75 patients (96%); 1 required an emergency operation and 2 an elective one. Complications included bleeding, pancreatitis and cholangitis; there were no associated deaths. Follow-up of 54 of the patients, who had associated cholelithiasis at the time of endoscopic sphincterotomy, showed that 14 died of causes unrelated to the biliary tract. Of the others, 14 underwent cholecystectomy for failure of endoscopic sphincterotomy (2), acute cholecystitis (4) or persistent biliary tract symptoms (8). The other 26 patients were well after a mean follow-up of 30.4 months; 1 had mild biliary tract symptoms. Ultrasonography in 16 of the 26 patients showed persistent cholelithiasis in 12. Life-table analysis revealed a 15% probability of acute cholecystitis within 5 years of endoscopic sphincterotomy.

Adult↗
PubMed1987

Endoscopic treatment of choledocholithiasis.

The authors report on their experience with endoscopic treatment of choledocholithiasis. Out of a total of 363 successful procedures of endoscopic papillosphincterotomy (EPS), choledocholithiasis was the indication for EPS in 270 patients (74.4%). Most often, EPS and extraction were performed in patients after cholecystectomy (79.6%) and those with choledocholithiasis and an in situ gallbladder, but free of stones (13.4%). In patients with concomitant cholecystolithiasis, EPS was carried out only in those cases in which surgery was contraindicated. EPS was performed in four cases of acute biliary pancreatitis. Removal of stones from the choledochus was successful in 95.5%. Of the total of 363 successful EPS's, complications were observed in 17 cases (4.7%), with a mortality of 1.1% (4 deaths). Most frequently, the causes included bleeding (1.9%) and perforation (1.1%). Of other complications, the authors noted acute pancreatitis, acute cholangitis and impaction of stone in the hepatocholedochus in two cases each. The complications required emergency surgery in six patients (35.3%).

Adult↗
PubMed1987

[The value of various imaging technics in the preoperative diagnosis of choledocholithiasis].

In a retrospective study different methods of detecting choledocholithiasis-sonography, intravenous cholangiography, computed tomography and transhepatic cholangiography-have been compared to evaluate their accuracy. A total of 130 investigations in 93 patients were analysed. Choledocholithiasis could be predicted by sonography in 42.9%, by intravenous cholangiography in 60% and by transhepatic cholangiography in 85.7%. The overall accuracy rate with a single investigation was 51.6%. The combination of different methods increased the accuracy rate of 81.6%. We use sonography as the screening examination. In unclear cases transhepatic cholangiography has proven helpful in demonstrating choledocholithiasis. Only cholangiography, together with cholangioscopy, is performed intraoperatively. Due to high cost and limited availability, computed tomography should not be used as a basic examination.

Cholangiography↗
PubMed1985

Choledochoscopy in common bile duct surgery for choledocholithiasis: A must: Eight years experience in 441 consecutive patients.

Between 1975 and 1983, 441 choledochoscopy were performed in a series of 451 consecutive patients undergoing surgical common biliary duct exploration for choledocholithiasis. In 127 patients (27.8%), no stones were found. Forty-five cases (10%) of choledocholithiasis missed by surgical and radiologic exploration methods were found by choledochoscopy. Therefore the retained stone rate decreased from 10 per cent to 2 per cent. Fourteen patients (3%) died at surgery, ten of whom (2%) were over 70. Postoperative biliary tract was drained in 98 patients (8%) using external drainage. Biliary tract patency was checked on the tenth postoperative day by the tube cholangiography. When retained stones were not found, T-tube was removed on the 20th day after surgery. When retained stones were found (11 patients, 2%) an endoscopic papillotomy was performed. Choledochoscopy is a significant addition in biliary surgery. It reduces operative mortality and morbidity, decreases retained stone rate, diminishes indications for biliary anastomosis and sphincterotomy, and is easy to perform without specific training. Its extensive and systematic use is advocated when- ever common bile duct patency has to be surgically demonstrated in choledocholithiasis.

Adult↗
PubMed1984

Histopathologic changes in the intra- and extrahepatic biliary tree in patients with postcholecystectomy choledocholithiasis.

To assess the incidence of biliary stasis in recurrent choledocholithiasis, 155 patients with postcholecystectomy choledocholithiasis, all of whom were recommended for choledochoduodenostomy, are presented in this paper. Data show that in patients of advanced age and with a long history of the disease there is a higher incidence of common bile duct dilatation, primary common bile duct stones, and increased bile contamination rate. Furthermore, these elements are associated with advanced pathologic changes in the liver and biliary tree histology. This hypothesis is supported by barium meal studies through the constructed choledochoduodenostomy where the extent and progress of those pathologic changes have been illustrated by visualization of the entire biliary tree at different postoperative intervals. In this series of patients, the progress of the liver and biliary damage was studied after the relief of the obstruction. It would appear reasonable to accept that in patients with the above-mentioned characteristics, the evidence of biliary stasis is clear. In these patients, the demand for a drainage procedure supplementary to choledochotomy seems to be warranted in order to eliminate the risk of recurrent choledocholithiasis as a result of existing biliary stasis.

Adult↗
PubMed1983

Diagnosis of choledocholithiasis.

A review of the records of 75 consecutive patients with a discharge diagnosis of choledocholithiasis has been conducted. Clinical assessment as well as laboratory assessment of patients who are suspected of having common duct calculi continues to present significant problems in diagnostic accuracy. More than 90 per cent of the patients who presented with Charcot's triad of pain, fever and jaundice had common duct calculi; however, only one-fourth of the patients in our study with choledocholithiasis had this combination of symptoms. Imaging techniques before operation are associated with a significant incidence of false-negative and false-positive findings. Palpation of the common duct and cholangiography at the time of operation remain the most reliable means of detecting choledocholithiasis.

Adult↗
PubMed1995

Preoperative assessment of choledocholithiasis in laparoscopic cholecystectomy.

In order to determine the predictive value of noninvasive investigations for choledocholithiasis, we conducted a prospective preoperative study on 82 patients with symptomatic gallstones who received laparoscopic cholecystectomy. Ultrasonography (US), liver function tests and endoscopic retrograde cholangiography (ERC) were routinely performed in all cases prior to operation. The results showed a strong correlation between noninvasive procedures (liver function tests and US) and the presence of choledocholithiasis as shown by ERC. Using ERC as a reference, the sensitivity and selectivity of ductal dilatation at US and the elevation of alkaline phosphatase (ALP), gamma-glutamyltransferase and total bilirubin in the serum were studied for the detection of common bile duct (CBD) stones. The values of the combination of these tests were also calculated. From receiver operator characteristics curves, the best cut-off point for US in conjunction with ALP was chosen. ERC should be restricted to patients with possible CBD stones, suspected after a combination of the noninvasive US and ALP tests. This study emphasized the necessity and timing of performing ERC as a preoperative modality in the detection of choledocholithiasis in patients who are to undergo laparoscopic cholecystectomy.

Cholecystectomy, Laparoscopic↗
PubMed1993

Prospective randomized study of routine intraoperative cholangiography during open cholecystectomy: long-term follow-up and multivariate analysis of predictors of choledocholithiasis.

A prospective randomized study was performed to assess the value of routine intraoperative cholangiography (IOC) during cholecystectomy for gallstone disease. Four hundred and fifty-seven consecutive patients were screened for the presence of 11 predefined clinical criteria assumed to indicate choledocholithiasis. Two hundred and eighty patients who had no positive criteria and in whom preoperative endoscopic retrograde cholangiography had not been performed were randomized at the operating table to the IOC or no-IOC group. Follow-up was performed 6 to 8 years after the operation with a questionnaire and by use of clinical, biochemical, and radiologic investigations as indicated. Multivariate analysis was used to identify independent predictors of choledocholithiasis and the combination of criteria having the best predictive ability. The frequency of common bile duct calculi at operation was significantly correlated with age and with all clinical criteria except recent or present pancreatitis. However, only serum bilirubin level, cystic duct diameter, demonstration of common bile duct calculi on preoperative imaging or intraoperative palpation, and age at operation were independent predictors of choledocholithiasis. The overall best subset of clinical indicators contained all criteria with the exception of pancreatitis and alkaline phosphatase level. Negative predictive ability of the set of criteria was 100% for patients up to 60 years of age and 97% for patients older than 60 years at the time of operation. No case of residual common bile duct calculi was present in the IOC and no-IOC groups at follow-up. Our data strongly support a policy of performing IOC during cholecystectomy only when clinical criteria suggest the presence of common bile duct abnormalities or to clarify ductal anatomy.

Biliary Tract↗
PubMed1996

Role of endoscopic sphincterotomy alone in patients with choledocholithiasis and cholelithiasis.

OBJECTIVE: To study the long-term effects of endoscopic sphincterotomy alone in elderly patients with choledocholithiasis and cholelithiasis. DESIGN: A chart review. SETTING: A university-affiliated hospital. PATIENTS: Twenty-one patients over 60 years of age, who presented with cholecystitis, jaundice or cholangitis. The follow-up ranged from 1 to 5 years (mean 3.51 years). INTERVENTION: Endoscopic sphincterotomy. MAIN OUTCOME MEASURES: The occurrence of postsphincterotomy pancreatitis, cholangitis and cholecystitis. RESULTS: In the early postsphincterotomy period, 3 of the 21 patients had pancreatitis, which was treated conservatively. One patient had cholangitis. In this patient the initial sphincterotomy did not clear the common bile duct of all stones, but a repeat procedure was successful and the cholangitis resolved. One patient had mild cholecystitis that responded to conservative therapy. In the long term, 9 of the 21 patients had cholecystitis. This was treated conservatively in six patients, but three required cholecystectomy. One patient had choledocholithiasis requiring exploration of the common bile duct. CONCLUSIONS: In elderly debilitated patients with cholelithiasis and choledocholithiasis, endoscopic sphincterotomy alone may be adequate therapy. However, patients presenting with cholangitis and cholelithiasis may eventually require cholecystectomy.

Age Factors↗
PubMedDate not supplied

[Primary choledocholithiasis after side-to-side choledochojejunostomy].

Primary choledocholithiasis represents a quite unusual sequela of biliary tract surgery. Primary stones originate in the common bile duct and are soft, smooth, with a yellowish or brown-reddish colour, reproducing the shape of the duct in which arise. The Authors report a review of the cases observed in the division of General and Vascular Surgery-Department of Surgery and Surgical Emergencies of the University of Perugia. From January 1988 to December 1993, 577 laparotomic biliary tract operations were performed, and in 8 cases a re-operation was needed. Among the latter, particularly interesting were 2 cases of primary choledocholithiasis occurred in two patients with bilio-digestive anastomosis previously performed, i.e. two side-to-side Roux-en-Y or Braun loop choledochojejunostomies, respectively. Therefore, primary lithiasis following a choledochojejunostomy occurred when the bilio-digestive anastomoses were performed with the indication of a curative re-operation on the biliary tract. On the contrary, most choledochojejunostomies are performed as a palliative procedure in patients presenting a low survival rate not allowing to develop a Sump Syndrome and a consequent choledocholithiasis, which are long-term complications.

Biliary Tract Surgical Procedures↗
PubMed1996

Value of three-dimensional gradient-echo magnetic resonance cholangiography in diagnosing choledocholithiasis.

OBJECTIVE: To evaluate the role of magnetic resonance cholangiography (MRC) in patients with suspected choledocholithiasis. PATIENTS AND METHODS: Twenty-six consecutive patients with suspected choledocholithiasis (11 men and 15 women ranging in age from 25 to 81 years) underwent three-dimensional gradient-echo MRC; each patient also underwent endoscopic retrograde cholangiography or operative cholangiography. Each set of images for each patient was reviewed independently by a radiologist who was unaware of the results of the other type of imaging. RESULTS: Diagnostic-quality MRC images were obtained for 17 of the patients. Of these, 13 had stones in the common bile duct, as confirmed by another imaging method, and MRC indicated the presence of these stones in all 13 patients. In the other four patients bile duct obstruction was due to either acute pancreatitis (in three) or cholangiocarcinoma (in one). For seven of the nine nondiagnostic-quality MRC studies, the bile duct was not obstructed, so there was no bile stasis and the MRC images could not be obtained. Motion artifacts due to inability to hold the breath were the limiting factors in the other two patients. CONCLUSION: Although MRC has some limitations, this new noninvasive technique may be used as a screening test in selected patients with suspected choledocholithiasis.

Acute Disease↗
PubMed1996

Endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy for symptomatic choledocholithiasis after recent myocardial infarction.

In the general population, endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy is preferable to surgery as therapy for gallstone pancreatitis and acute cholangitis. It is particularly attractive to perform therapeutic. ERCP for symptomatic choledocholithiasis after recent myocardial infarction because of the increased risk of the alternative therapy of cholecystectomy and choledochal exploration. However, after myocardial infarction, patients might theoretically be particularly susceptible to the cardiopulmonary risks of ERCP. The safety of therapeutic ERCP after myocardial infarction is unknown, with only one previously reported case. In a review of 11,367 patients with acute myocardial infarction at four hospitals, four patients (0.04%) underwent therapeutic ERCP after recent myocardial infarction, for indications of recent biliary pancreatitis in three of the patients and recent cholangitis in all four. Cholangitis occurred before, simultaneous with, or after myocardial infarction in the four cases. Initially, the cholangitis was managed medically in three patients. The fourth patient underwent cholecystostomy with local anesthesia. ERCP was performed at 15, 25, 30, or 56 days after myocardial infarction. Endoscopic cholangiography revealed multiple choledocholithiasis in all cases. The calculi were successfully extracted by endoscopic papillotomy and by sweeping the choledochus with a balloon-tipped catheter or basket in all cases. During ERCP, the vital signs remained stable; no cardiac arrhythmias or cardiovascular complications occurred. However, one patient developed mild pancreatitis after ERCP, which rapidly resolved with medical therapy. The four patients rapidly improved after ERCP, with normalization of serum levels of routine biochemical parameters of liver function. These four cases and the one prior case report demonstrate that therapeutic ERCP is not absolutely contraindicated after myocardial infarction and suggest that therapeutic ERCP is preferable to surgery for symptomatic choledocholithiasis after myocardial infarction because of the increased mortality of surgery after myocardial infarction.

Aged↗
PubMed2005

The value of drip infusion cholangiography using multidetector-row helical CT in patients with choledocholithiasis.

The purposes of this study were to investigate the feasibility of drip infusion cholangiography computed tomography (CTCh) for choledocholithiasis and to compare the detection of the stone on CTCh with that of MR cholangiopancreatography (MRCP). CTCh examinations were performed after infusion of intravenous biliary contrast material (iotroxic acid meglumine, 100 ml) for patients with suspected biliary diseases and were reconstructed to maximum intensity projection (MIP) and multiplanar reformation (MPR). Of 432 patients who underwent CTCh, we identified 15 who underwent surgery or cholangioscopic removal for choledocholithiasis and 32 patients who underwent cholecystectomy due to cholecystolithiasis. Their MRCP images were compared with the CTCh images. The sensitivity and specificity of CTCh for detecting choledochal stones were 87% and 96% whereas those of MRCP were 80% and 88%. The sensitivity and specificity of CTCh for detecting gallstones were 78% and 100% whereas those of MRCP were 94% and 88%. CTCh allowed high sensitivity and specificity for detecting choledochal stones but diminished the detection for cholecystolithiasis compared with MRCP.

Adult↗
PubMed2005

Combined endoscopic treatment for cholelithiasis associated with choledocholithiasis.

BACKGROUND: The advent of endoscopic techniques changed surgery in many ways. For the management of cholelithiasis, laparoscopic cholecystectomy (LC) is the treatment of choice. This has created a dilemma in the management of choledocholithiasis. Today a number of option exist, including endoscopic sphinterotomy (ES) before LC in patients with suspected common bile duct (CBD) stones, laparoscopic bile duct exploration, open CBD exploration, and postoperative endoscopic retrograde cholangiopancreatography (ERCP). Also, the alternative technique of peroperative ES is emerging. METHODS: We report our experience of routine intraoperative cholangiography followed either by peroperative ERCP in one step or by transcystic drain and postoperative ERCP. In our technique, to facilitate Vater papilla cannulation we inserted a 450-cm transcystic guidewire that was caught by a duodenoscope. Papillotome was then inserted over the guidewire to ensure cannulation of the CBD. RESULTS: Twenty-eight patients were treated successfully in one step and 24 in two steps. The mean operative time was 181 +/- 41 min for patients treated in one step and 131 +/- 30 min for patients treated in two steps. The mean hospital stay was 4.8 +/- 3.3 days for patients treated in one step and 9.6 +/- 4.0 days for patients treated in two steps. Five patients (18%) with positive intraoperative cholangiography for stones for whom peroperative ERCP was not available showed a normal postoperative transcystic cholangiogram and therefore ERCP was canceled. Fourteen of 25 patients treated in one step and none of 17 treated in two steps had raised serum amylase, which resolved spontaneously with no symptoms. No patient developed postoperative pancreatitis. Three (10%) ERCP complications were observed, consisting of mild bleeding of the papilla. All cases were managed by endoscopic adrenaline injection. There was no mortality. CONCLUSION: We believe peroperative ERCP with the technique described should be considered as the treatment of choice for choledocholithiasis associated with cholelithiasis. When single-stage treatment is not possible, a two-step rendezvous technique should be preferred.

Adult↗
PubMed2005

Expectant treatment or cholecystectomy after endoscopic retrograde cholangiopancreatography for choledocholithiasis in patients over 80 years old?

BACKGROUND: It is recommended that most patients between 18-80 years old, who have had an endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis, should be offered cholecystecytomy. However, we were uncertain whether this was the correct advice for patients over 80. METHOD: A retrospective case note analysis was performed on 81 patients over 80, who had had an ERCP for choledocholithiasis. The primary end points were further biliary symptoms, cholecystectomy, death from biliary independent causes, and those still alive without further biliary symptoms. RESULTS: The records of 81 patients (median age 87; range, 80-96 years) were analyzed. Of the patients, 11% experienced further biliary symptoms at a median time of 4.5 months [interquartile range (IQR), 2.25-8.5 months] from the ERCP; 6% received cholecystectomy; 61% were still alive with no further biliary symptoms at a median time of 17 months (IQR, 12.25-23.75 months) after ERCP; and 22% had died from biliary independent causes at a median time of 9 months after ERCP (IQR, 3-12 months). CONCLUSION: Expectant treatment can be recommended in this group of patients. Those who do present with further biliary symptoms do so soon after ERCP. Therefore, we recommend follow-up for 12 months after ERCP, prior to discharge.

Aged, 80 and over↗
PubMed2006

Endoscopic ultrasonography versus other diagnostic modalities in the diagnosis of choledocholithiasis.

Until recently, endoscopic retrograde cholangiopancreatography (ERCP) has been considered the gold standard for the diagnosis of and therapy in patients with suspected choledocholithiasis. However, the non-negligible complication rate of diagnostic and therapeutic ERCP has led investigators to identify different noninvasive diagnostic modalities. Endoscopic ultrasonography has been proved to be of great sensitivity (up to 97%) in the diagnosis of even tiny stones that can be easily masked by contrast medium during ERCP, without any procedure-related complications and with a negative predictive value reaching 100%, meaning that it can accurately and safely identify patients with choledocholithiasis, thereby avoiding inappropriate instrumental exploration of the common bile duct.

Cholangiography↗
PubMed2004

Endoscopic sphincterotomy vs. endoscopic papillary balloon dilation for choledocholithiasis in patients with liver cirrhosis and coagulopathy.

BACKGROUND: To determine whether endoscopic papillary balloon dilation decreases the risk of hemorrhage without increasing the risk of acute pancreatitis, the results of endoscopic papillary balloon dilation were compared with those of endoscopic biliary sphincterotomy in patients with cirrhosis and coagulopathy. METHODS: Twenty-one patients with liver cirrhosis with coagulopathy had endoscopic papillary balloon dilation for choledocholithiasis from January 2001 to September 2003. Twenty patients with cirrhosis and coagulopathy who underwent endoscopic biliary sphincterotomy from January 1998 to December 2000, served as a historical control group. RESULTS: The rate of endoscopic biliary sphincterotomy related hemorrhage was 30% (6/20), whereas the rate for endoscopic papillary balloon dilation related hemorrhage was 0% (p=0.009). With regard to rates of hemorrhage in relation to Child-Pugh class, most (n=5) of the bleeding complications occurred in patients with Child-Pugh class C cirrhosis; bleeding occurred in only one patient with Child-Pugh B cirrhosis. There was no significant difference between the endoscopic biliary sphincterotomy and the endoscopic papillary balloon dilation groups for procedure-related pancreatitis (10% vs. 4.7%, respectively; p>0.05). CONCLUSIONS: Endoscopic papillary balloon dilation may significantly reduce the risk of bleeding compared with endoscopic biliary sphincterotomy in patients with advanced cirrhosis and coagulopathy. In these patients, the substitution of endoscopic papillary balloon dilation for endoscopic biliary sphincterotomy is recommended for treatment of choledocholithiasis.

Adult↗