Biowd &IPhan~acother(1992) 46,143- I48 0 Elsevier, Paris
on-surgica
of bile duct stones
Summary - Endoscopic s~~in~e~tomy with stone extraction is the non-surgical m&hod of choice for treatment of chokdochoiithiasis in patients unfit for surgery or with previous cholecystectomy. Its success rate is G-90%. Many adjunctive methods have been developed to increase the clearance rate after imtiai faiiure and are reviewed in this paper. Collaboration among the surgeon, endoscopist and radiologist offers the patient a high opportunity for successful clearance of common bile duct (CBD) stones with the least morbidity and mortality. The application of endoscopic sphincterotomy combined with laparoscopic choleeystectomy to younger patients is now debated. sphineterotomy
f non-stoical
treatment I bile stones
R&urn6 - La ~~~~~c~~r#~o~~e endos&o~iq~e avec ex~a&t~o~~ des capfuls est devenue la pre~~i~re m~thode de tra~terne~~ non chirurg~cal de la lithiase de la voie biliaire ~ri~ci~a~e. EIle est propos&e aux ~at~enrs ayant zm r~sqae op&atoire &evh ott dtiji? ~bol~wste~tornis~s. Son taMx de succ& est de 85 d 90%. Les nombreases mkthodes d’a~~int d&veloppt?espour aagme~ter ie taux d’extruction comp&te des calcuis aprk Pchec des m~thod~s e~dosco~iq~es habitue~les soat d&rites dans cef article. La coo~~ratioa entnz ~h~~~rg~e~,eados~o~~ste et radio~o~~e permet ~obte~ir tui taax de sac& 8evP au p&x d’utte morbidit et d’rme mortalire’ fuibles. L’extension des indications de la s~h~nct~rotomie endoscopique en association avec la choltfcystectomie caziioscopique r3 des patients plus jeunes est acttclellemcnt disc&e. sphinctbotomie
I traitemeet non chirurgical I calcul biliaire
The traditional approach for patients with common bile duct (CBD) stones is surgical exploraassociated with tion and ~holedochotomy cholecystectomy. Intraoperative chuledQ~has~ol)y has been &awn to decrease the incidence of overlooked stones fro& 8-10% to 4%. A T-tube should be left in the common duct for 7-14 days ts check for residual stones and to facilitate biliary decompression. The surgical complications result from the consequences of surgery itself and mure incidental events. morbidity and mortality rates vary from one report to another. On average, 68% of the patients have major complications and l-2% die. Morbidity and mortality are increased if patients are older than 65 years, jaundiced, have acute ch~langitis, or have significant systemic disease i&9, 17,21]. In 1974, endoscopic sphincterotomy with stone extraction was introduced as
altem~ti~e rna~a~~rnent in patients unfit for surgery [ 17, 19, 201. Endoscopi~ sp~i~crerotomy is now a routine procedure throughout the world. It has become the method of choice for treatment of choledocholithi~sis in the elderly and following chcY..~r*ystectomy. Its application combined with laparoscopic chalecystectomy in younger patients is now being debated. Various techniques have been used to improve the results. We examine here the non-surgical techniques available for the successful remova!! of CBD stones and we will discuss their instigations in the management of patients.
This technique uses a side-vjewing duode~useo~e and a pa~illotom~ which is a catheter with an electrosurgical wire. The papillotome is inserted into the endoscope channel and then deeply into
144
the bile duct using endoscopic and fluoroscopic guidance. The papilla and the sphincter muscles surrounding the ampulla of Vater are cut by electrodiathermy. The size of the endoscopic sphincterotomy should be tailored to the size of the stone (lo-15 mm on average). In most cases, CBD stones can be easily pulled into the duodenum using a balloon catheter or Dormia basket. Endoscopic sphincterotomy with clearance of the biliary tree is successful in U-90% of patients when performed by experienced endoscopists [8, 17, 19, 201. Failure to achieve sphincterotomy or duct clearance may occur for a variety of reasons, some of them being anatomic factors. Cannulation of the papilla can be difficult. In these circumstances, a small incision referred to as a precut can be made with a special papillotome. A prior gastrectomy with Billroth II anastomosis or periampullary diverticula. frequently observed in the elder!y, can be a cause of failed cannulation and sphincterotomy. A transhepatically placed guide wire through the papillary orifice can aid successful cannulation (combined procedure) [17, 19, 201. More often, failure to perform sphincterotomy or clear the duct is due to a large stone, impacted stone, or stone proximal to ampullary structure. At the present time, a number of nonsurgical techni iues exist for such difficult stones and will be &cussed later. The early complications of endoscopic sphincterotomy are bleeding, retroperitoneal perforation, infection and pancreatitis 14, 8, 171. The predisposition to haemorrhage and perforation is proportional to the length of the sphincterotomy. Sepsis usually occurs when clearance of CBD stones fails. Cholangitis can be prevented by prophylactic antibiotics and insertion of a nasobiliary tube. Conservative management of tl!-_ complications is usually indicated and surgical intervention is rarely required. Major complications occur in 6-10% of the patients with a mortality rate of 1%. Mortality appears low in such series of high-risk elderly patients. Long-term follow up studies following endoscopic sphincterotomy remain few in numb
on-surgica
of bile duct stones
Summary - Endoscopic s~~in~e~tomy with stone extraction is the non-surgical m&hod of choice for treatment of chokdochoiithiasis in patients unfit for surgery or with previous cholecystectomy. Its success rate is G-90%. Many adjunctive methods have been developed to increase the clearance rate after imtiai faiiure and are reviewed in this paper. Collaboration among the surgeon, endoscopist and radiologist offers the patient a high opportunity for successful clearance of common bile duct (CBD) stones with the least morbidity and mortality. The application of endoscopic sphincterotomy combined with laparoscopic choleeystectomy to younger patients is now debated. sphineterotomy
f non-stoical
treatment I bile stones
R&urn6 - La ~~~~~c~~r#~o~~e endos&o~iq~e avec ex~a&t~o~~ des capfuls est devenue la pre~~i~re m~thode de tra~terne~~ non chirurg~cal de la lithiase de la voie biliaire ~ri~ci~a~e. EIle est propos&e aux ~at~enrs ayant zm r~sqae op&atoire &evh ott dtiji? ~bol~wste~tornis~s. Son taMx de succ& est de 85 d 90%. Les nombreases mkthodes d’a~~int d&veloppt?espour aagme~ter ie taux d’extruction comp&te des calcuis aprk Pchec des m~thod~s e~dosco~iq~es habitue~les soat d&rites dans cef article. La coo~~ratioa entnz ~h~~~rg~e~,eados~o~~ste et radio~o~~e permet ~obte~ir tui taax de sac& 8evP au p&x d’utte morbidit et d’rme mortalire’ fuibles. L’extension des indications de la s~h~nct~rotomie endoscopique en association avec la choltfcystectomie caziioscopique r3 des patients plus jeunes est acttclellemcnt disc&e. sphinctbotomie
I traitemeet non chirurgical I calcul biliaire
The traditional approach for patients with common bile duct (CBD) stones is surgical exploraassociated with tion and ~holedochotomy cholecystectomy. Intraoperative chuledQ~has~ol)y has been &awn to decrease the incidence of overlooked stones fro& 8-10% to 4%. A T-tube should be left in the common duct for 7-14 days ts check for residual stones and to facilitate biliary decompression. The surgical complications result from the consequences of surgery itself and mure incidental events. morbidity and mortality rates vary from one report to another. On average, 68% of the patients have major complications and l-2% die. Morbidity and mortality are increased if patients are older than 65 years, jaundiced, have acute ch~langitis, or have significant systemic disease i&9, 17,21]. In 1974, endoscopic sphincterotomy with stone extraction was introduced as
altem~ti~e rna~a~~rnent in patients unfit for surgery [ 17, 19, 201. Endoscopi~ sp~i~crerotomy is now a routine procedure throughout the world. It has become the method of choice for treatment of choledocholithi~sis in the elderly and following chcY..~r*ystectomy. Its application combined with laparoscopic chalecystectomy in younger patients is now being debated. Various techniques have been used to improve the results. We examine here the non-surgical techniques available for the successful remova!! of CBD stones and we will discuss their instigations in the management of patients.
This technique uses a side-vjewing duode~useo~e and a pa~illotom~ which is a catheter with an electrosurgical wire. The papillotome is inserted into the endoscope channel and then deeply into
144
the bile duct using endoscopic and fluoroscopic guidance. The papilla and the sphincter muscles surrounding the ampulla of Vater are cut by electrodiathermy. The size of the endoscopic sphincterotomy should be tailored to the size of the stone (lo-15 mm on average). In most cases, CBD stones can be easily pulled into the duodenum using a balloon catheter or Dormia basket. Endoscopic sphincterotomy with clearance of the biliary tree is successful in U-90% of patients when performed by experienced endoscopists [8, 17, 19, 201. Failure to achieve sphincterotomy or duct clearance may occur for a variety of reasons, some of them being anatomic factors. Cannulation of the papilla can be difficult. In these circumstances, a small incision referred to as a precut can be made with a special papillotome. A prior gastrectomy with Billroth II anastomosis or periampullary diverticula. frequently observed in the elder!y, can be a cause of failed cannulation and sphincterotomy. A transhepatically placed guide wire through the papillary orifice can aid successful cannulation (combined procedure) [17, 19, 201. More often, failure to perform sphincterotomy or clear the duct is due to a large stone, impacted stone, or stone proximal to ampullary structure. At the present time, a number of nonsurgical techni iues exist for such difficult stones and will be &cussed later. The early complications of endoscopic sphincterotomy are bleeding, retroperitoneal perforation, infection and pancreatitis 14, 8, 171. The predisposition to haemorrhage and perforation is proportional to the length of the sphincterotomy. Sepsis usually occurs when clearance of CBD stones fails. Cholangitis can be prevented by prophylactic antibiotics and insertion of a nasobiliary tube. Conservative management of tl!-_ complications is usually indicated and surgical intervention is rarely required. Major complications occur in 6-10% of the patients with a mortality rate of 1%. Mortality appears low in such series of high-risk elderly patients. Long-term follow up studies following endoscopic sphincterotomy remain few in numb
