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Analysis on Microbial Profiles & Components of Bile in Patients with Recurrent CBD Stones after Endoscopic CBD Stone Removal: A Preliminary Study. J Clin Med 2021; 10:jcm10153303. [PMID: 34362087 PMCID: PMC8347313 DOI: 10.3390/jcm10153303] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 07/24/2021] [Accepted: 07/24/2021] [Indexed: 12/12/2022] Open
Abstract
Background/Aim: Common bile duct (CBD) stone recurrence after endoscopic treatment is a major concern as a late complication. Biliary bacterial factors and biochemical factors determine the path of gallstone formation. The aim of this preliminary study was to investigate the microbial profile and components of bile in patients with and without recurrent CBD stones after endoscopic CBD stone removal. Methods: Among patients who had undergone an initial endoscopic procedure for the removal of CBD stones and were followed up for >2 years, 11 patients who experienced at least two CBD stone recurrences, six months after endoscopic retrograde cholangiopancreatography (ERCP), were categorized into the recurrence group. Nine patients without CBD recurrence events were matched. Results: Polymicrobial infections are generally seen in all patients who have biliary sphincteroplasty. Microbial richness, measured by the numbers of operational taxonomic units (OTUs), was reduced in the recurrence group. The microbial evenness was also significantly lower than in the non-recurrence group. The overall microbial communities in the recurrence group deviated from the non-recurrence group. Infection with bacteria exhibiting β-glucuronidase activity was more frequent in the recurrence group, but there was no statistical significance. In an analysis of the bile components, the bile acid concentration was higher in the non-recurrence group than in the recurrence group. However, the other metabolites were not significantly different. Conclusions: Microbiota dysbiosis and altered bacterial community assembly in bile duct and decreased bile acid in bile juice were associated with recurrence of bile duct stone.
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Choe JW, Kim SY, Lee DW, Hyun JJ, Ahn KR, Yoon I, Jung SW, Jung YK, Koo JS, Yim HJ, Lee SW. Incidence and risk factors for postoperative common bile duct stones in patients undergoing endoscopic extraction and subsequent cholecystectomy. Gastrointest Endosc 2021; 93:608-615. [PMID: 32598960 DOI: 10.1016/j.gie.2020.06.060] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 06/15/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS In patients who undergo cholecystectomy after endoscopic common bile duct (CBD) stone extraction, CBD stones found postoperatively could be problematic. This study aimed to investigate the incidence and risk factors of postoperative CBD stones after cholecystectomy. METHODS A total of 278 patients (mean age, 59.2 years; 71 men [51.1%]) who underwent endoscopic removal of CBD stones followed by cholecystectomy from January 2013 to December 2017 were included. An endoscopic nasobiliary drainage (ENBD) tube was placed immediately after endoscopic clearance of the CBD stones in all patients until cholecystectomy. An ENBD tubogram was obtained in all patients to determine the presence of postoperative CBD stones. RESULTS Postoperative CBD stones were detected in 20.1% (56/278). An ENBD tubogram was obtained after an average of 2.42 days postoperatively. Based on univariate analysis, the statistically significant risk factors for postoperative CBD stone were CBD stones >2, CBD stone size >10 mm, cholesterol stone, maximum diameter of CBD >15 mm, treatment with endoscopic sphincterotomy alone, and use of endoscopic mechanical lithotripsy (EML). In multivariate analysis, cholesterol stone, CBD stones >2, CBD stone size >10 mm, and EML were related to postoperative CBD stones after cholecystectomy. CONCLUSIONS Based on the relatively high rate of postoperative CBD stones after cholecystectomy, careful follow-up should be considered in patients with high-risk factors to detect CBD stones early.
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Affiliation(s)
- Jung Wan Choe
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Seung Young Kim
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Dong-Won Lee
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Jong Jin Hyun
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Ke Ryun Ahn
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Ik Yoon
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Sung Woo Jung
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Young Kul Jung
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Ja Seol Koo
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Hyung Joon Yim
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Sang Woo Lee
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
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Park CY, Choi SH, Kwon CI, Cho JH, Jang SI, Lee TH, Han JH, Jeong S, Ko KH. What is the better surgical treatment option for recurrent common bile duct stones? Ann Surg Treat Res 2020; 99:329-336. [PMID: 33304860 PMCID: PMC7704274 DOI: 10.4174/astr.2020.99.6.329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/05/2020] [Accepted: 08/25/2020] [Indexed: 12/02/2022] Open
Abstract
Purpose Repeating endoscopic retrograde cholangiopancreatography (ERCP) in patients with recurrent common bile duct (CBD) stones is problematic in many ways. Choledochoduodenostomy (CDS) and choledochojejunostomy (CJS) are 2 surgical treatment options for recurrent CBD stones, and each has different advantages and disadvantages. The aim of this study was to compare the 2 surgical options in terms of the recurrence rate of CBD stones after surgical treatment. Methods This retrospective multicenter study included all patients who underwent surgical treatment due to recurrent CBD stones that were not effectively controlled by medical treatment and repeated ERCP between January 2006 and March 2015. We collected data from chart reviews and medical records. A recurrent CBD stone was defined as a stone found 6 months after the complete removal of a CBD stone by ERCP. Patients who underwent surgery for other reasons were excluded. Results A total of 27 patients were enrolled in this study. Six patients underwent CDS, and 21 patients underwent CJS for the rescue treatment of recurrent CBD stones. The median follow-up duration was 290 (180–1,975) days in the CDS group and 1,474 (180–6,560) days in the CJS group (P = 0.065). The postoperative complications were similar and tolerable in both groups (intestinal obstruction; 2 of 27, 7.4%; 1 in each group). CBD stones recurred in 4 patients after CDS (4 of 6, 66.7%), and 3 patients after CJS (3 of 21, 14.3%) (P = 0.010). Conclusion CJS may be a better surgical option than CDS for preventing further stone recurrence in patients with recurrent CBD stones.
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Affiliation(s)
- Chi Young Park
- Digestive Disease Center, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Sung Hoon Choi
- Department of General Surgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Chang-Il Kwon
- Digestive Disease Center, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Jae Hee Cho
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Gachon Gil Hospital, Gachon University College of Medicine, Incheon, Korea
| | - Sung Ill Jang
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Hoon Lee
- Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Joung-Ho Han
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Seok Jeong
- Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Kwang Hyun Ko
- Digestive Disease Center, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
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Zhang J, Ling X. Risk factors and management of primary choledocholithiasis: a systematic review. ANZ J Surg 2020; 91:530-536. [PMID: 32815266 DOI: 10.1111/ans.16211] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 07/15/2020] [Accepted: 07/18/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Primary choledocholithiasis (PC) is a common disease in biliary surgery. The treatment is always challenging due to its high recurrence. A systemic review is undertaken to determine the risk factors for recurrence and provide with the individualized management strategy. METHODS Electronic databases PubMed (Medline), Embase and Cochrane Central Register of Controlled Studies were searched for relevant articles on risk factors for PC recurrence. Its therapeutic intervention was also collected and analysed. RESULTS A total of 36 articles were eligible for inclusion. The recurrent risk factors include abnormalities of biliary anatomy (peripapillary diverticulum), dynamics (choledochal dilation, sharp angulation and stone number), metabolism (advanced age and hypothyroidism) and bacterial infection (Enterobacter and Helicobacter pylori). These factors eventually induce cholestasis and stone formation. At present, there is no guideline and expertise consensus for PC management. The treatment mainly consists of stone retrieval approaches and internal drainage surgeries. The former are minimally invasive methods: endoscopic sphincterotomy (EST), papillary balloon dilation (EPBD) and laparoscopic common bile duct exploration (LCBDE). The latter include choledochoduodenostomy (CDS) and choledochojejunostomy (CJS) with Roux-en-Y reconstruction. By far, the internal drainage surgeries have significantly lower recurrence than stone retrieval approaches. CONCLUSION Abnormal biliary anatomy, dynamics, metabolism and bacterial infection are the risk factors for PC. Both EST/EPBD and LCBDE can be performed as initial treatment. For recurrent PC, CDS is more suitable to the elderly, while Roux-en-Y CJS reserves for young patients or those in good conditions.
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Affiliation(s)
- Jie Zhang
- Department of General Surgery, Peking University Third Hospital, Beijing, China
| | - Xiaofeng Ling
- Department of General Surgery, Peking University Third Hospital, Beijing, China
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Tsai TJ, Chan HH, Lai KH, Shih CA, Kao SS, Sun WC, Wang EM, Tsai WL, Lin KH, Yu HC, Chen WC, Wang HM, Tsay FW, Lin HS, Cheng JS, Hsu PI. Gallbladder function predicts subsequent biliary complications in patients with common bile duct stones after endoscopic treatment? BMC Gastroenterol 2018; 18:32. [PMID: 29486713 PMCID: PMC6389262 DOI: 10.1186/s12876-018-0762-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 02/22/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND In patients with common bile duct stones (CBDS) and intact gallbladder, further management for the gallbladder after the CBDS clearance is still controversial. The relationship between gallbladder motility and the biliary complications were seldom discussed. Our study is to predict the subsequent biliary complications by gallbladder function test using fatty meal sonography (FMS) in patients with CBDS who had been treated by endoscopic retrograde cholangiopancreatography (ERCP). METHODS Patients with an intact gallbladder and CBDS after endoscopic clearance of bile duct were enrolled. Patients received a fatty meal sonography after liver function returned to normal. The fasting volume, residual volume, and gallbladder ejection fraction (GBEF) in FMS were measured. Relationships of patients' characteristics, gallbladder function and recurrent biliary complication were analyzed. RESULTS From 2011 to 2014, 118 patients were enrolled; 86 patients had calculus gallbladders, and 32 patients had acalculous gallbladders. After a mean follow- up of 33 months, 23 patients had recurrent biliary complications. Among 86 patients with calculus gallbladder, 15 patients had spontaneous clearance of gallbladder stones; 14 patients received cholecystectomy due to acute cholecystitis or recurrent colic pain with smooth postoperative courses. In the follow up period, six patients died of non-biliary causes. The GBEF is significant reduced in most patients with a calculus gallbladder in spite of stone color. Calculus gallbladder, alcohol drinking and more than one sessions of initial endoscopic treatment were found to be the risk factors of recurrent biliary complication. CONCLUSIONS Gallbladder motility function was poorer in patients with a calculus gallbladder, but it cannot predict the recurrent biliary complication. Since spontaneous clearance of gallbladder stone may occur, wait and see policy of gallbladder management after endoscopic treatment of CBDS is appropriate, but regular follow- up in those patients with risk factors for recurrence is necessary.
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Affiliation(s)
- Tzung-Jiun Tsai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China
| | - Hoi-Hung Chan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China. .,School of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China. .,Department of Biological Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan, Republic of China. .,Department of Business Management, National Sun Yat-sen University, Kaohsiung, Taiwan, Republic of China. .,College of Pharmacy and Health Care, Tajen University, Pingtung city, Taiwan, Republic of China.
| | - Kwok-Hung Lai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China.,School of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China
| | - Chih-An Shih
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China
| | - Sung-Shuo Kao
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China.,School of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China
| | - Wei-Chih Sun
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China
| | - E-Ming Wang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China
| | - Wei-Lun Tsai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China.,School of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China
| | - Kung-Hung Lin
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China
| | - Hsien-Chung Yu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China
| | - Wen-Chi Chen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China.,School of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China
| | - Huay-Min Wang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China
| | - Feng-Woei Tsay
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China
| | - Huey-Shyan Lin
- Department of Health-Business Administration, Fooyin University, Kaohsiung, Taiwan, Republic of China
| | - Jin-Shiung Cheng
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China
| | - Ping-I Hsu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China.,School of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China
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Predictors for bile duct stone recurrence after endoscopic extraction for naïve major duodenal papilla: A cohort study. PLoS One 2017; 12:e0180536. [PMID: 28692706 PMCID: PMC5503270 DOI: 10.1371/journal.pone.0180536] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Accepted: 06/02/2017] [Indexed: 12/27/2022] Open
Abstract
Background Predictors for bile duct stone recurrence after endoscopic stone extraction have not yet been clearly defined and a study investigating naïve major duodenal papilla is warranted because studies focusing only on naïve major duodenal papilla are rare. The aim of this study was to observe the long-term outcomes of endoscopic bile duct stone extraction for naïve major duodenal papilla and to assess the predictors for recurrence. Methods This was a retrospective cohort study that consisted of 384 patients with naïve papilla who underwent initial endoscopic bile duct stone extraction. Patients were followed up in outpatient department subsequent to complete stone clearance. Recurrence was defined as symptomatic repeated stone formation observed at least three months after the procedure. Stone recurrence, predictors of recurrence, and the recurrence rate, depending on each endoscopic treatment for major duodenal papilla, were examined. Results In this study, 34 patients (8.9%) developed stone recurrence. The median time to recurrence was 439 days. Periampullary diverticulum and multiple stones were strong predictors of bile duct stone recurrence (RR, 5.065; 95% CI, 2.435–10.539 and RR: 2.4401; 95% CI: 1.0946–5.4396, respectively). The above two factors were independent predictors of stone recurrence as per logistic regression analysis adjusted for confounders (Periampullary diverticulum: OR, 7.768; 95% CI, 3.27–18.471; multiple stones: OR, 4.144; 95% CI, 1.33–12.915). No recurrence was observed after endoscopic papillary large balloon dilatation (0/20), whereas recurrence was observed in 7 patients after endoscopic papillary balloon dilatation (7/45) and in 27 patients after endoscopic sphincterotomy (27/319). However, these differences were not statistically significant (p = 0.105). Conclusions We determined that the presence of periampullary diverticulum and multiple stones are strong predictors for recurrence after endoscopic stone extraction. Moreover, endoscopic papillary large balloon dilatation tended to be correlated with non-recurrence of bile duct stone.
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Uchida N, Hamaya S, Tatsuta M, Nakatsu T. Extracorporeal abdominal massage may help prevent recurrent bile duct stones after endoscopic sphincterotomy. Endosc Int Open 2016; 4:E870-3. [PMID: 27540575 PMCID: PMC4988836 DOI: 10.1055/s-0042-109774] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 05/30/2016] [Indexed: 12/23/2022] Open
Abstract
Endoscopic sphincterotomy (EST) is effective, but recurrent bile duct stones are a common late complication. Because there are still no effective therapies for preventing this complication, some patients have experienced bile duct stone recurrence many times. We describe herein a method of abdominal massage to treat patients with prior cholecystectomy who have experienced recurrence of bile duct stones.
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Affiliation(s)
- Naohito Uchida
- Department of Gastroenterology, Saint Martin’s Hospital, Sakaide city, Kagawa ken, Japan,Corresponding author Naohito Uchida, MD, PhD Saint Martin’s Hospital1-4-13 Tani machi, Sakaide cityKagawa kenJapan 762-0033+81 877 46 5195+81 877 46 0595
| | - Sae Hamaya
- Department of Gastroenterology, Saint Martin’s Hospital, Sakaide city, Kagawa ken, Japan
| | - Miwa Tatsuta
- Department of Gastroenterology, Saint Martin’s Hospital, Sakaide city, Kagawa ken, Japan
| | - Toshiaki Nakatsu
- Department of Gastroenterology, Saint Martin’s Hospital, Sakaide city, Kagawa ken, Japan
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Different Types of Periampullary Duodenal Diverticula Are Associated with Occurrence and Recurrence of Bile Duct Stones: A Case-Control Study from a Chinese Center. Gastroenterol Res Pract 2016; 2016:9381759. [PMID: 27143965 PMCID: PMC4837272 DOI: 10.1155/2016/9381759] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Accepted: 03/08/2016] [Indexed: 12/12/2022] Open
Abstract
Aims. We here investigated the association of different types of periampullary diverticula (PAD) with pancreaticobiliary disease and with technical success of endoscopic retrograde cholangiopancreatography (ERCP). Methods. A total of 850 consecutive patients who underwent their first ERCP were entered into a database. Of these patients, 161 patients (18.9%) had PAD and the age- and sex-matched control group comprised 483 patients. Results. PAD was correlated with common bile duct (CBD) stones (59.6% versus 35.0% in controls; P = 0.008) and negatively correlated with periampullary malignancy (6.8% versus 21.5% in controls; P = 0.004). The acute pancreatitis was more frequent (62.5%) in patients with PAD type 1 followed by PAD type 2 (28.9%, P = 0.017) and type 3 (28.0%, P = 0.006). No significant differences were observed in successful cannulation rate and post-ERCP complications among the 3 types of PAD. Type 1 PAD patients had less recurrence of CBD stones than did the patients who had type 2 or type 3 PAD (53.8% versus 85.7%; P = 0.043). Conclusions. PAD, especially type 1 PAD, is associated with an increased acute pancreatitis as well as occurrence and recurrence of CBD stones. PAD during an ERCP should not be considered as an obstacle to a successful cannulation.
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Yamamoto R, Tazuma S, Kanno K, Igarashi Y, Inui K, Ohara H, Tsuyuguchi T, Ryozawa S. Ursodeoxycholic acid after bile duct stone removal and risk factors for recurrence: a randomized trial. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2016; 23:132-6. [PMID: 26705893 DOI: 10.1002/jhbp.316] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 12/17/2015] [Indexed: 12/26/2022]
Abstract
BACKGROUND Currently, no established pharmacologic treatment exists for the prevention of recurrent common bile duct (CBD) stones. METHODS Here, we present a multi-center randomized trial that compared the CBD recurrence rate after bile duct stone removal between patients given ursodeoxycholic acid (UDCA) and the untreated group. A total of 36 patients were randomly assigned to either the UDCA (n = 15) or the untreated group (n = 21). The primary end-point was the recurrence rate of CBD stones. RESULTS The recurrence rate of CBD stones was 6.6% in the UDCA group and 18.6% in the untreated group (P = 0.171). A multivariate analysis found that not receiving UDCA was an independent risk factor for stone recurrence. The recurrence rates of CBD stones did not differ by sex, past history of cholecystectomy, or the presence of gallstones. CONCLUSIONS Our findings indicate that UDCA may be a novel treatment strategy to prevent the recurrence of CBD stones. However, further evaluation of UDCA in a larger number of subjects will be required to confirm the applicability of these results.
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Affiliation(s)
- Ryuichi Yamamoto
- Department of General Internal Medicine, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Susumu Tazuma
- Department of General Internal Medicine, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.
| | - Keishi Kanno
- Department of General Internal Medicine, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Yoshinori Igarashi
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Kazuo Inui
- Department of Internal Medicine, Banbuntane Houtokukai Hospital, Fujita Health University School of Medicine, Nagoya, Japan
| | - Hirotaka Ohara
- Department of Community-Based Medical Educations, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Toshio Tsuyuguchi
- Department of Medicine and Clinical Oncology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Shomei Ryozawa
- Saitama Medical University International Medical Center, Saitama, Japan
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Oh CH, Dong SH. Recent Advances in the Management of Recurrent Bile Duct Stones. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2015; 66:251-4. [DOI: 10.4166/kjg.2015.66.5.251] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Chi Hyuk Oh
- Department of Internal Medicine, Kyung Hee University College of Medicine, Seoul, Korea
| | - Seok Ho Dong
- Department of Internal Medicine, Kyung Hee University College of Medicine, Seoul, Korea
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Chang ZH, Dang T, Meng XM, Pan XP, Hu SQ, Tian JG. Risk factors and countermeasures for recurrence of common bile duct stones after endoscopic treatment. Shijie Huaren Xiaohua Zazhi 2014; 22:1157-1161. [DOI: 10.11569/wcjd.v22.i8.1157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the risk factors and preventive measures for recurrence of common bile duct stones after endoscopic treatment.
METHODS: Patients who underwent endoscopic treatment for common bile duct stones between January 2008 and May 2012 at our hospital were screened, and 745 patients with complete follow-up data were identified, of whom 64 (8.59%) had recurrent choledocholithiasis. Univariate and multivariate Logistic regression analyses were used to analyze the risk factors for recurrence of common bile duct stones, and preventive measures based on these risk factors were explored.
RESULTS: Periampullary diverticulum (B = 0.582, OR = 1.790), pre-cholecystectomy (B = 1.012, OR = 2.751), gallstones untreated (B = 0.744, OR = 2.103), common bile duct diameter (B = 1.062, OR = 2.892), diameter of common bile duct stones (B = 0.536, OR = 1.708), biliary gas retention (B = 1.034, OR = 2.812), and mechanical lithotripsy (B = 0.828, OR = 2.289) were risk factors for common bile duct stone recurrence after endoscopic treatment (B > 0, OR >1); normal gallbladder (B = -0.889, P = 0.410) was a protective factor (B < 0, OR < 1).
CONCLUSION: Recurrence of common bile duct stones after endoscopic treatment is associated with the patient's own factors and endoscopic manipulations. The relapse of common bile duct stones can be effectively reduced and/or prevented by improving endoscopic manipulations.
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Paik WH, Ryu JK, Park JM, Song BJ, Kim J, Park JK, Kim YT. Which is the better treatment for the removal of large biliary stones? Endoscopic papillary large balloon dilation versus endoscopic sphincterotomy. Gut Liver 2014; 8:438-44. [PMID: 25071911 PMCID: PMC4113053 DOI: 10.5009/gnl.2014.8.4.438] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2013] [Revised: 08/14/2013] [Accepted: 08/21/2013] [Indexed: 12/22/2022] Open
Abstract
Background/Aims We evaluated the efficacy and cost-effectiveness of endoscopic papillary large balloon dilation (EPLBD) for large common bile duct (CBD) stone removal compared with endoscopic sphincterotomy (EST). Methods A total of 1,580 patients who underwent endoscopic CBD stone extraction between January 2001 and July 2010 were reviewed. The following inclusion criteria were applied: choledocholithiasis treated by EPLBD with minor EST or EST with mechanical lithotripsy; and follow-up >9 months after treatment. Results Forty-nine patients with EPLBD and 41 with EST were compared. There was no significant difference in the complication rates and stone recurrence rates between the two groups. However, significantly more endoscopic retrograde cholangiopancreatography (ERCP) sessions were required in the EST group to achieve the complete removal of stones (1.7 times vs 1.3 times; p=0.03). The mean cost required for complete stone removal per patient was significantly higher in the EST group compared to the EPLBD group (USD $1,644 vs $1,225, respectively; p=0.04). Dilated CBD was the only significant factor associated with recurrent biliary stones (relative risk, 1.09; 95% confidence interval, 1.02 to 1.17; p=0.02). Conclusions EPLBD is the better treatment (compared to EST) for removing large CBD stones because EPLBD requires fewer ERCP sessions and is less expensive.
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Affiliation(s)
- Woo Hyun Paik
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Ji Kon Ryu
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Jin Myung Park
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Byeong Jun Song
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Jaihwan Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Joo Kyung Park
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Yong-Tae Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
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Risk factors for recurrence of symptomatic common bile duct stones after cholecystectomy. Gastroenterol Res Pract 2012; 2012:417821. [PMID: 22991508 PMCID: PMC3443611 DOI: 10.1155/2012/417821] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Accepted: 08/05/2012] [Indexed: 12/16/2022] Open
Abstract
Purpose. The recurrence of CBD stone is still observed in a considerable number of patients. The study was to evaluate the risk factors for recurrence of symptomatic CBD stone in patients who underwent cholecystectomy after the removal of CBD stone. Methods. The medical records of patients who underwent removal of CBD stone with subsequent cholecystectomy were reviewed. The risk factors for the recurrence of symptomatic CBD stone were compared between the recurrence and the nonrecurrence group. Results. The mean follow-up period was 40.6 months. The recurrence of symptomatic CBD stones was defined as the detection of bile duct stones no sooner than 6 months after complete clearance of CBD stones, based on symptoms or signs of biliary complication. 144 patients (68 males, 47.2%) were finally enrolled and their mean age was 59.8 (range: 26~86) years. The recurrence of CBD stone occurred in 15 patients (10.4%). The mean period until first recurrence was 25.9 months. The presence of type 1 or 2 periampullary diverticulum and multiple CBD stones were the independent risk factors. Conclusion. For the patients with type 1 or 2 periampullary diverticulum or multiple CBD stones, careful followup is needed for the risk in recurrence of symptomatic CBD stone.
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Shao D, Zhuang Y, Xu F, Chen JP. Endoscopic sphincterotomy plus balloon dilation for large bile duct stones: An analysis of 80 cases. Shijie Huaren Xiaohua Zazhi 2012; 20:1057-1060. [DOI: 10.11569/wcjd.v20.i12.1057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the therapeutic efficacy and safety of endoscopic sphincterotomy (EST) plus balloon dilation for large bile duct stones.
METHODS: Eighty patients with bile duct stones larger than 1.2 cm, who received endoscopic retrograde eholangiopancreatography (ERCP) from January 2010 to October 2011 at our hospital, were randomly and equally divided into two groups to receive EST and EST plus balloon dilation (ESBD), respectively. Balloon dilation was conducted after small EST in the ESBD group, while conventional EST was used in the EST group.
RESULTS: All stones were removed successfully from 36 patients (90%) of the EST group and 38 (95%) patients of the ESBD group. Mechanical lithotripsy was used to fragment stones in 15 (37.5%) EST procedures and 4 (10%) ESBD procedures. The operation time was longer in the EST group than in the ESBD group (41.78 ± 10.41 vs 36.28 ± 8.64, P < 0.05). Bleeding occurred in two patients of the EST group but not in patients of the ESBD group. Fever, abdominal pain, and acute pancreatitis developed in 1, 1 and 2 patients in the EST group, while abdominal pain and acute pancreatitis in 2 and 1 patients in the ESBD group, respectively. There is no significant difference in the incidence of early complications between the two groups (10% vs 7.5%, P > 0.05). No patient died.
CONCLUSION: ESBD is superior to EST in terms of operating time and the use of mechanical lithotripsy in managing large bile duct stones.
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The role of endoscopy in the management of choledocholithiasis. Gastrointest Endosc 2011; 74:731-44. [PMID: 21951472 DOI: 10.1016/j.gie.2011.04.012] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Accepted: 04/06/2011] [Indexed: 12/15/2022]
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Seo DB, Bang BW, Jeong S, Lee DH, Park SG, Jeon YS, Lee JI, Lee JW. Does the bile duct angulation affect recurrence of choledocholithiasis? World J Gastroenterol 2011; 17:4118-23. [PMID: 22039327 PMCID: PMC3203364 DOI: 10.3748/wjg.v17.i36.4118] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2010] [Revised: 03/24/2011] [Accepted: 03/31/2011] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate whether bile duct angulation and T-tube choledochostomy influence the recurrence of choledocholithiasis.
METHODS: We conducted a retrospective study inclu-ding 259 patients who underwent endoscopic sphincterotomy and cholecystectomy for choledocholithiasis between 2000 and 2007. The imaginary line was drawn along the center of the bile duct and each internal angle was measured at the two angulation sites of the bile duct respectively. The values of both angles were added together. We then tested our hypothesis by examining whether T-tube choledochostomy was performed and stone recurrence occurred by reviewing each subject’s medical records.
RESULTS: The overall recurrence rate was 9.3% (24 of 259 patients). The mean value of sums of angles in the recurrence group was 268.3°± 29.6°, while that in the non-recurrence group was 314.8°± 19.9° (P < 0.05). Recurrence rate of the T-tube group was 15.9% (17 of 107), while that of the non T-tube group was 4.6% (7 of 152) (P < 0.05). Mean value of sums of angles after T-tube drainage was 262.5°± 24.6° and that before T-tube drainage was 298.0°± 23.9° in 22 patients (P < 0.05).
CONCLUSION: The bile duct angulation and T-tube choledochostomy may be risk factors of recurrence of bile duct stones.
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Chan HH, Lai KH, Lin CK, Tsai WL, Wang EM, Hsu PI, Chen WC, Yu HC, Wang HM, Tsay FW, Tsai CC, Chen IS, Chen YC, Liang HL, Pan HB. Endoscopic papillary large balloon dilation alone without sphincterotomy for the treatment of large common bile duct stones. BMC Gastroenterol 2011; 11:69. [PMID: 21668994 PMCID: PMC3142528 DOI: 10.1186/1471-230x-11-69] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2011] [Accepted: 06/13/2011] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Lethal pancreatitis has been reported after treatment for common bile duct stones using small endoscopic papillary balloon dilation. METHODS We retrospectively evaluated the safety and efficacy of using large balloon dilation alone without the use of sphincterotomy for the treatment of large common bile duct stones in Kaohsiung Veterans General Hospital. Success rate of stone clearance, procedure-related adverse events and incidents, frequency of mechanical lithotripsy use, and recurrent stones were recorded. RESULTS A total of 247 patients were reviewed in the current study. The mean age of the patients was 71.2 years. Most of them had comorbidities. Mean stone size was 16.4 mm. Among the patients, 132 (53.4%) had an intact gallbladder and 121 (49%) had a juxtapapillary diverticulum. The mean size of dilating balloon used was 13.2 mm. The mean duration of the dilating procedure was 4.7 min. There were 39 (15.8%) patients required the help of mechanical lithotripsy while retrieving the stones. The final success rate of complete retrieval of stones was 92.7%. The rate of pancreatic duct enhancement was 26.7% (66/247). There were 3 (1.2%) adverse events and 6 (2.4%) intra-procedure bleeding incidents. All patients recovered completely after conservative and endoscopic treatment respectively, and no procedure-related mortality was noted. 172 patients had a follow-up duration of more than 6 months and among these, 25 patients had recurrent common bile duct stones. It was significantly correlated to the common bile duct size (p = 0.036) CONCLUSIONS Endoscopic papillary large balloon dilation alone is simple, safe, and effective in dealing with large common bile duct stones in relatively aged and debilitated patients.
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Affiliation(s)
- Hoi-Hung Chan
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, 386 Ta-Chung 1st Road, Kaohsiung 81362, Taiwan
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Tsai TJ, Lai KH, Hsu PI, Tsai CC, Fu TY. Gallbladder cancer manifesting as recurrent common bile duct stone and duodenal ulcer bleeding. J Chin Med Assoc 2009; 72:434-7. [PMID: 19687000 DOI: 10.1016/s1726-4901(09)70401-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Gallbladder cancer (GBC) is an uncommon disease and is usually asymptomatic. Poor prognosis and high mortality rate have been noted in patients with delayed diagnosis. We report a case of locally advanced GBC with duodenum and colon invasion manifesting as bleeding duodenal ulcer and recurrent common bile duct (CBD) stones. The patient was successfully treated with extended surgery. In patients who have multiple recurrence of CBD stones without common risk factors, concomitant biliary tract malignancy should be included in the differential diagnosis.
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Affiliation(s)
- Tzung-Jiun Tsai
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, and National Yang-Ming University School of Medicine, Taipei, Taiwan, R.O.C
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Kageoka M, Watanabe F, Maruyama Y, Nagata K, Ohata A, Noda Y, Miwa I, Ikeya K. Long-term prognosis of patients after endoscopic sphincterotomy for choledocholithiasis. Dig Endosc 2009; 21:170-5. [PMID: 19691764 DOI: 10.1111/j.1443-1661.2009.00880.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION The aims of the present study were to clarify the long-term prognosis of endoscopic sphincterotomy (EST) for choledocholithiasis and to evaluate the need for cholecystectomy after EST. METHODS Between 1993 and 2007, 262 patients who underwent successful EST for choledocholithiasis were followed up for more than 6 months). Eighteen patients had previously undergone cholecystectomy (Group A), 129 had a calculous gallbladder (GB) and underwent cholecystectomy after EST (Group B), 46 had a calculous GB in situ (Group C), and 69 had an acalculous GB in situ (Group D). Late complications, including recurrence of choledocholithiasis, acute cholecystitis and biliary carcinoma, were evaluated. RESULTS Of the 262 patients, late complications occurred in 34 patients (13.0%) and recurrence of choledocholithiasis occurred in 29 patients (11.1%). The rate of late complications was higher in Group C (23.9%) than in Group B (7.8%) (P < 0.001). The rate of recurrent choledocholithiasis was higher in Group C (17.4%) than in Group B (7.8%) (P < 0.05). Univariate analysis indicated that pneumobilia after EST was associated with the recurrence of choledocholithiasis (P < 0.001). Acute cholecystitis occurred in eight (7.0%) of 115 patients with intact GB. A gallbladder carcinoma was found after EST. Late complications were not serious and endoscopically or surgically manageable. CONCLUSIONS EST for choledocholithiasis is safe and effective. Cholecystectomy after EST is recommended in patients with calculous GB, but is not necessary in patients with acalculous GB. Pneumobilia was associated with the recurrence of choledocholithiasis.
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Affiliation(s)
- Masanobu Kageoka
- Division of Gastroenterology, Fujieda Municipal General Hospital, Fujieda, Shizuoka, Japan.
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Chan HH, Lai KH, Lin CK, Tsai WL, Peng NJ, Hsu PI, Lo GH, Wei MC, Wang EM, Chang HW. Impact of food on hepatic clearance of patients after endoscopic sphincterotomy. J Chin Med Assoc 2009; 72:10-4. [PMID: 19181591 DOI: 10.1016/s1726-4901(09)70013-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND The recurrence rate of common bile duct stones (CBDS) is around 3-21% after treatment by endoscopic sphincterotomy (ES). Fatty meal has been shown to improve hepatic clearance in both patients with intact gallbladder and post-cholecystectomy after ES. This study tested the effects of different kinds of food on hepatic clearance by using quantitative cholescintigraphy (QC) in patients after ES. METHODS Forty-seven patients after ES with abnormal QC were enrolled in our study. Complete ablation of sphincter function was confirmed by sphincter of Oddi manometry. Fasting QC was done in every patient shortly after normalization of liver function, and then followed with low-fat and fatty-meal QC. Each of the 47 subjects was observed for the effect on hepatic clearance at 3 different levels of treatments (diets and fasting). Additionally, possible factors responsible for recurrent CBDS were investigated by means of logistic regression. RESULTS Both fatty and low-fat meals could significantly improve hepatic clearance compared with fasting in most patients after ES. But the response to food types was individualized. All patients tolerated the meals well. There was no significant relationship between the recurrence of CBDS and sex, age, intact gallbladder and presence of juxtapapillary diverticulum, CBD size, and improvement in hepatic clearance (> or = 5%) by food. CONCLUSION Both fatty and low-fat meals improved hepatic clearance in most of the patients with CBDS after ES, but the response to meals was individualized. Therefore, there is no need to restrict the amount of fat intake for patients who have undergone ES.
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Affiliation(s)
- Hoi-Hung Chan
- Division of Gastroenterology, Kaohsiung Veterans General Hospital, Kaohsiung; National Yang-Ming University School of Medicine, Taipei; and Department of Biological Sciences, National Sun Yat-Sen University, Kaohsiung, Taiwan, R.O.C
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Li LB, Cai XJ, Mou YP, Wei Q. Reoperation of biliary tract by laparoscopy: Experiences with 39 cases. World J Gastroenterol 2008; 14:3081-4. [PMID: 18494063 PMCID: PMC2712179 DOI: 10.3748/wjg.14.3081] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the safety and feasibility of biliary tract reoperation by laparoscopy for the patients with retained or recurrent stones who failed in endoscopic sphincterotomy.
METHODS: A retrospective analysis of data obtained from attempted laparoscopic reoperation for 39 patients in a single institution was performed, examining open conversion rates, operative times, complications, and hospital stay.
RESULTS: Out of the 39 cases, 38 (97%) completed laparoscopy, 1 required conversion to open operation because of difficulty in exposing the common bile duct. The mean operative time was 135 min. The mean post-operative hospital stay was 4 d. Procedures included laparoscopic residual gallbladder resection in 3 cases, laparoscopic common bile duct exploration and primary duct closure at choledochotomy in 13 cases, and laparoscopic common bile duct exploration and choledochotomy with T tube drainage in 22 cases. Duodenal perforation occurred in 1 case during dissection and was repaired laparoscopically. Retained stones were found in 2 cases. Postoperative asymptomatic hyperamylasemia occurred in 3 cases. There were no complications due to port placement, postoperative bleeding, bile or bowel leakage and mortality. No recurrence or formation of duct stricture was observed during a mean follow-up period of 18 mo.
CONCLUSION: Laparoscopic biliary tract reoperation is safe and feasible if it is performed by experienced laparoscopic surgeons, and is an alternative choice for patients with choledocholithiasis who fail in endoscopic sphincterectomy.
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Keizman D, Shalom MI, Konikoff FM. An angulated common bile duct predisposes to recurrent symptomatic bile duct stones after endoscopic stone extraction. Surg Endosc 2006; 20:1594-9. [PMID: 16858527 DOI: 10.1007/s00464-005-0656-x] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2005] [Accepted: 02/15/2006] [Indexed: 12/11/2022]
Abstract
BACKGROUND Endoscopic sphincterotomy and stone extraction are standard procedures for the removal of bile duct stones. Stone recurrence can, however, occur in up to 25% of cases. Risk factors have been poorly defined, but are believed to be related to bile stasis. This study investigated whether an angulated common bile duct (CBD) that may predispose to bile stasis influences symptomatic stone recurrence after successful endoscopic therapy. METHODS This study included 232 consecutive patients (mean age, 64.1 years; 86 men) who had undergone therapeutic endoscopic retrograde cholangiopancreatography for bile duct stones. Data from the follow-up period (36 +/- 17 months) were obtained from medical records and patient questioning. Common bile duct angulation and diameter were measured from the cholangiogram after stone removal. RESULTS Symptomatic bile duct stones recurred in 16% of the patients (36/232). Three independent risk factors were identified by multivariate analysis: an angulated CBD (angle, < or = 145 degrees; relative risk [RR], 5.2; 95% confidence interval [CI], 2.2-12.5; p = 0.0002), a dilated CBD (diameter, > or = 13 mm; RR, 2.6; 95% CI, 1.2-5.7; p = 0.017), and a previous open cholecystectomy (RR, 2.7; 95% CI, 1.3-5.9; p = 0.0117). Gender, age, urgency of procedure, or a periampullary diverticulum did not influence the recurrence rate. CONCLUSIONS Angulation of the CBD (< or = 145 degrees) on endoscopic cholangiography, a dilated CBD, and a previous open cholecystectomy are independent risk factors for symptomatic recurrence of bile duct stones. The findings support the role of bile stasis in stone recurrence. Further studies using these data prospectively to identify high-risk patients are warranted.
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Affiliation(s)
- D Keizman
- Department of Gastroenterology, Tel Aviv Sourasky Medical Center, 6 Weizmann Street, Tel Aviv, 64239, Israel
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Cheon YK, Lehman GA. Identification of risk factors for stone recurrence after endoscopic treatment of bile duct stones. Eur J Gastroenterol Hepatol 2006; 18:461-4. [PMID: 16607138 DOI: 10.1097/00042737-200605000-00001] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Recurrence of bile duct stones after endoscopic stone removal has been reported ranging from 4 to 24%. The risk of late complications such as stone recurrence is an important issue, especially for relatively young, otherwise healthy, patients with many years of future exposure time. The risk factors true recurrence of bile duct stones after endoscopic sphincterotomy (EST) and stone clearance are suboptimally defined. If patients at significant risk for stone recurrence could be identified, closer follow-up, earlier intervention, and possible preventive measures could theoretically decrease stone recurrence and late complications. The majority of patients with common bile duct stone who have EST and stone clearance will have no further biliary events during the remainder of their life. Whether identifying risk factors for recurrence can improve outcomes by prophylactic treatments or earlier interventions needs further prospective study.
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Affiliation(s)
- Young Koog Cheon
- Division of Gastroenterology/Hepatology, Indiana University Medical Center, 550 N. University Boulevard, Indianapolis, IN 46202, USA
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Lee JK, Ryu JK, Park JK, Yoon WJ, Lee SH, Lee KH, Kim YT, Yoon YB. Risk factors of acute cholecystitis after endoscopic common bile duct stone removal. World J Gastroenterol 2006; 12:956-60. [PMID: 16521227 PMCID: PMC4066164 DOI: 10.3748/wjg.v12.i6.956] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the risk factors of acute cholecystitis after endoscopic common bile duct (CBD) stone removal.
METHODS: A total 100 of patients who underwent endoscopic CBD stone removal with gallbladder (GB) in situ without subsequent cholecystectomy from January 2000 to July 2004 were evaluated retrospectively. The following factors were considered while evaluating risk factors for the development of acute cholecystitis: age, gender, serum bilirubin level, GB wall thickening, cystic duct patency, presence of a GB stone, CBD diameter, residual stone, lithotripsy, juxtapapillary diverticulum, presence of liver cirrhosis or diabetes mellitus, a presenting illness of cholangitis or pancreatitis, and procedure-related complications.
RESULTS: During a mean 18-mo follow-up, 28 (28%) patients developed biliary symptoms; 17 (17%) acute cholecystitis and 13 (13%) CBD stone recurrence. Of patients with acute cholecystitis, 15 (88.2%) received laparoscopic cholecystectomy and 2 (11.8%) open cholecystectomy. All recurrent CBD stones were successfully removed endoscopically. The mean time elapse to acute cholecystitis was 10.2 mo (1-37 mo) and that to recurrent CBD stone was 18.4 mo. Of the 17 patients who received cholecystectomy, 2 (11.8%) developed recurrent CBD stones after cholecystectomy. By multivariate analysis, a serum total bilirubin level of
<1.3 mg/dL and a CBD diameter of <11 mm at the time of stone removal were found to predict the development of acute cholecystitis.
CONCLUSION: After CBD stone removal, there is no need for routine prophylactic cholecystectomy. However, patients without a dilated bile duct (<11 mm) and jaundice (<1.3 mg/dL) at the time of CBD stone removal have a higher risk of acute cholecystitis and are possible candidates for prophylactic cholecystectomy.
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Affiliation(s)
- Jun Kyu Lee
- Department of Internal Medicine, Seoul National University College of Medicine, 28 Yongon-dong, Chongno-gu, 110-744 Seoul, Korea
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Boerma D, Schwartz MP. Gallstone disease. Management of common bile-duct stones and associated gallbladder stones: Surgical aspects. Best Pract Res Clin Gastroenterol 2006; 20:1103-16. [PMID: 17127191 DOI: 10.1016/j.bpg.2006.04.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
For many years, open exploration of the common bile duct has been the treatment of choice for patients with common bile-duct stones. During recent decades endoscopic sphincterotomy has gained wide acceptance as an effective and less invasive alternative. After sphincterotomy, subsequent (laparoscopic) cholecystectomy is warranted in patients with gallbladder stones. This chapter will discuss whether sphincterotomy should be performed prior to, during or after cholecystectomy, and will also address the question of whether single-stage treatment by laparoscopic cholecystectomy and laparoscopic bile-duct exploration is in fact preferable. The rate of recurrent choledocholithiasis after endoscopic biliary sphincterotomy can reach more than 20%. This review focuses on the risk factors--delayed bile-duct clearance and bactobilia--that may lead to recurrent primary bile-duct stone formation. Underlying altered bile composition (relative phospholipid deficiency) should be recognised in a subgroup of patients. Identification of these risk factors may significantly affect treatment policy.
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Affiliation(s)
- Djamila Boerma
- Department of Surgery, St Antonius Hospital, Postbus 2500, 3430 EM Nieuwegein, The Netherlands.
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Tsai WL, Lai KH, Lin CK, Chan HH, Lo CC, Hsu PI, Chen WC, Cheng JS, Lo GH. Composition of common bile duct stones in Chinese patients during and after endoscopic sphincterotomy. World J Gastroenterol 2005; 11:4246-9. [PMID: 16015699 PMCID: PMC4615452 DOI: 10.3748/wjg.v11.i27.4246] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: Endoscopic sphincterotomy (ES) is a well-established therapeutic modality for the removal of common bile duct (CBD) stones. After ES there are still around 10% of patients that experience recurrent CBD stones. The aim of this study is to investigate the composition of CBD stones before and after ES and its clinical significance in Chinese patients.
METHODS: From January 1996 to December 2003, 735 patients with CBD stones received ES at Kaohsiung Veterans General Hospital and stone specimens from 266 patients were sent for analysis. Seventy-five patients had recurrent CBD stones and stone specimens from 44 patients were sent for analysis. The composition of the stones was analyzed by infrared (IR) spectrometry and they were classified as cholesterol or bilirubinate stones according to the predominant composition. Clinical data were analyzed.
RESULTS: In the initial 266 stone samples, 217 (82%) were bilirubinate stones, 42 (16%) were cholesterol stones, 3 were calcium carbonate stones, 4 were mixed cholesterol and bilirubinate stones. Patients with bilirubinate stones were significantly older than patients with cholesterol stones (66 ± 13 years vs 56 ± 17 years, P = 0.001). In the 44 recurrent stone samples, 38 (86%) were bilirubinate stones, 3 (7%) were cholesterol stones, and 3 were mixed cholesterol and bilirubinate stones. In 27 patients, both initial and recurrent stone specimens can be obtained, 23 patients had bilirubinate stones initially and 2 became cholesterol stones in the recurrent attack. In the four patients with initial cholesterol stones, three patients had bilirubinate stones and one patient had a cholesterol stone in the recurrent attack.
CONCLUSION: Bilirubinate stone is the predominant composition of initial or recurrent CBD stone in Chinese patients. The composition of CBD stones may be different from initial stones after ES.
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Affiliation(s)
- Wei-Lun Tsai
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, National Yang Ming University, Taiwan, China
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Tzeng JJ, Lai KH, Peng NJ, Lo GH, Lin CK, Chan HH, Hsu PI, Cheng JS, Wang EM. Influence of juxtapapillary diverticulum on hepatic clearance in patients after endoscopic sphincterotomy. J Gastroenterol Hepatol 2005; 20:772-6. [PMID: 15853993 DOI: 10.1111/j.1440-1746.2005.03782.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND AIM The role of juxtapapillary diverticulum ( JPD) in biliary stone formation is controversial. This study was designed to understand the relationship between the size of JPD, hepatic clearance and recurrent bile duct stones in patients after endoscopic sphincterotomy. METHODS Five hundred and twenty patients with choledocholithiasis who had received endoscopic sphincterotomy were enrolled. They were divided into three groups: group A (n = 268) without diverticula; group B (n = 156) with small diverticula; and group C (n = 96) with large diverticula. All patients were regularly followed with interviews, liver function test and sonogram to detect the recurrent bile duct stones. Quantitative cholescintigraphy was performed in 176 cholecystectomized patients to evaluate the hepatic clearance. Sphincter of Oddi manometry was performed to exclude incomplete sphincterotomy if quantitative cholescintigraphy was abnormal. RESULTS After 9-111 months of follow-up, 76 patients had recurrent bile duct stones. There was a significant higher bile duct stone recurrence in group C than in group A (P < 0.01), but no statistical difference was noted between group B and group A (P = 0.2). Patients with JPD were older than those without (P < 0.05). Of 176 cholecystectomized patients, two were excluded because sphincter of Oddi basal pressure was more than 10 mmHg. In the remaining 174 patients, the E45' was significantly lower in group C than in group A (41.2% +/- 18.6%vs 49.1% +/- 14.1%; P < 0.05), and there was no significant difference between group B and group A. CONCLUSIONS JPD is a predisposing factor of delayed biliary emptying and it increases the chance and incidence of recurrent bile duct stones.
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Affiliation(s)
- Jeng-Jie Tzeng
- Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
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Lin CK, Lai KH, Chan HH, Tsai WL, Wang EM, Wei MC, Fu MT, Lo CC, Hsu PI, Lo GH. Endoscopic balloon dilatation is a safe method in the management of common bile duct stones. Dig Liver Dis 2004; 36:68-72. [PMID: 14971818 DOI: 10.1016/j.dld.2003.09.014] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUNDS AND AIMS Endoscopic sphincterotomy is a widely accepted treatment for patients with common bile duct stones. Despite improvement in this technique, endoscopic sphincterotomy is still associated with some biliary complications. Endoscopic balloon dilatation is a less traumatic and sphincter preserving method for removal of common bile duct stones. However, the results of controlled studies in comparison with these two methods are contradictory. The aim of this study is to compare the safety and efficacy of endoscopic balloon dilatation and endoscopic sphincterotomy in Chinese patients. PATIENTS AND METHODS A total of 104 patients with common bile duct stones on endoscopic retrograde cholangiopancreatography were enrolled. They were randomly assigned to endoscopic balloon dilatation or endoscopic sphincterotomy. Endoscopic balloon dilatation was performed by using a balloon dilator to dilate the sphincter for 5 min. The common bile duct stones were then removed by a Dormia basket after endoscopic balloon dilatation or endoscopic sphincterotomy. Mechanical lithotripsy was performed if the stones were difficult to remove by Dormia basket. After discharge, patients were regularly followed up for biliary complications. RESULTS The successful bile duct stone clearance rate was 94.1% in endoscopic balloon dilatation group and 100% in endoscopic sphincterotomy group. Post-procedural significant haemorrhage was higher in endoscopic sphincterotomy group than in endoscopic balloon dilatation group (14/53 versus 1/48, P < 0.001). The bleeding patient from endoscopic balloon dilatation group was a case of uremia and bleeding occurred 48 h after endoscopic balloon dilatation. All the patients with post-procedural haemorrhage were controlled endoscopically. The post-procedural serum amylase level showed no significant difference in both groups and none of them developed clinical pancreatitis. After a mean 16 months follow-up, three patients (6.3%) in endoscopic balloon dilatation group and four patients (7.5%) in endoscopic sphincterotomy group developed recurrent common bile duct stones. The recurrent common bile duct stones were multiple and muddy in consistency. They were successfully removed endoscopically. CONCLUSION Both endoscopic balloon dilatation and endoscopic sphincterotomy are safe and effective techniques for the treatment of common bile duct stones. Endoscopic balloon dilatation can be safely applied in patients with coagulopathy and does not increase the incidence of pancreatitis or bleeding.
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Affiliation(s)
- C K Lin
- Department of Internal Medicine, Kaohsiung Veterans General Hospital, School of Medicine, National Yang Ming University, 386 Ta-Chung 1st Road, Kaohsiung 813, Taiwan
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Ando T, Tsuyuguchi T, Okugawa T, Saito M, Ishihara T, Yamaguchi T, Saisho H. Risk factors for recurrent bile duct stones after endoscopic papillotomy. Gut 2003; 52:116-21. [PMID: 12477771 PMCID: PMC1773534 DOI: 10.1136/gut.52.1.116] [Citation(s) in RCA: 120] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The long term outcome of endoscopic papillotomy (EPT) is not well known. The aims of this study were to clarify the clinical course of post-EPT patients and to detect predictors for bile duct stone recurrence. METHODS A total of 1042 consecutive patients who underwent EPT for bile duct stones from December 1975 to September 1998 were prospectively followed up. Patients were divided into four groups according to gall bladder (GB) status: "acalculous GB" group, "calculous GB" group, "cholecystectomy" group, and "prior cholecystectomy" group. Reliable follow up information was obtained for 983 (94.3%) of the 1042 patients. The following factors were considered in the evaluation of predisposing risk factors for recurrence of bile duct stones: age, sex, gall bladder status, periampullary diverticulum, number of bile duct stones, diameter of bile duct stones, diameter of bile duct, lithotripsy, precutting, pneumobilia, and early complications. RESULTS Recurrence occurred in 111 patients. The "acalculous GB" group was less prone to recurrence than the "prior cholecystectomy" group and the "calculous GB" group. The relative risks (RR) for the latter two compared with the former group were 2.26 (95% confidence interval (CI) 1.24-4.14; p=0.0078) and 2.16 (95% CI 1.21-3.87; p=0.0093), respectively. Other prognostic factors were lithotripsy (RR 2.37; 95% CI 1.47-3.81; p=0.0004) and pneumobilia (RR 1.57; 95% CI 1.01-2.43; p=0.044). CONCLUSIONS Gall bladder status, lithotripsy, and pneumobilia were significantly related to bile duct stone recurrence after EPT.
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Affiliation(s)
- T Ando
- First Department of Medicine, Chiba University School of Medicine, Chiba, Japan.
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Lai KH, Lo GH, Lin CK, Hsu PI, Chan HH, Cheng JS, Wang EM. Do patients with recurrent choledocholithiasis after endoscopic sphincterotomy benefit from regular follow-up? Gastrointest Endosc 2002; 55:523-6. [PMID: 11923765 DOI: 10.1067/mge.2002.122611] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
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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Affiliation(s)
- Kwok-Hung Lai
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, National Yang Ming University, Taiwan, Republic of China
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Lai KH, Peng NJ, Lo GH, Lin CK, Chan HH, Hsu PI, Cheng JS, Wang YY. Does a fatty meal improve hepatic clearance in patients after endoscopic sphincterotomy? J Gastroenterol Hepatol 2002; 17:337-41. [PMID: 11982706 DOI: 10.1046/j.1440-1746.2002.02702.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND Delayed biliary emptying is a cause of recurrent bile duct stones in patients after endoscopic sphincterotomy (ES) for choledocholithiasis. This study aimed to evaluate the effect of fatty meal on hepatic clearance in patients after ES. METHODS Sixty patients who had received ES and complete clearance of bile duct stones were enrolled. Delayed hepatic clearance (45 min clearance of radioisotope [E45'] < 57%) from quantitative cholescintigraphy (QC) and absence of sphincteric function confirmed by sphincter of Oddi manometry were found in each patient after normalization of liver function. Patients then received another QC 30 min after a fatty meal (two fried eggs and 250 mL full milk, fat 28 g) within 2 months. RESULTS Improvement of hepatic clearance in QC after fatty meal was found in 20 of 24 (83%) cholecystectomized patients and 27 of 36 (75%) patients with intact gallbladder. The E45' after fatty meal was significantly higher than that without fatty meal (56 +/- 12%vs 40 +/- 9% in cholecystectomized patients, P < 0.001; 52 +/- 16%vs 35 +/- 11% in patients with intact gallbladder, P < 0.001). All patients tolerated the fatty meal well during fatty meal QC. CONCLUSIONS Fatty meal can improve hepatic clearance in both patients with intact gallbladder and after cholecystectomy, so routine restriction of fat after ES may be inappropriate. However, further studies are needed to evaluate the role of diet in the prevention of recurrent biliary complications.
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Affiliation(s)
- Kwok-Hung Lai
- Department of Internal Medicine, Kaohsiung Veterans General Hospital, School of Medicine, National Yang Ming University, Taiwan, ROC.
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Kim DI, Kim MH, Lee SK, Seo DW, Choi WB, Lee SS, Park HJ, Joo YH, Yoo KS, Kim HJ, Min YI, Chol WB. Risk factors for recurrence of primary bile duct stones after endoscopic biliary sphincterotomy. Gastrointest Endosc 2001; 54:42-8. [PMID: 11427840 DOI: 10.1067/mge.2001.115335] [Citation(s) in RCA: 95] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Endoscopic biliary sphincterotomy (EST) is a well-established procedure for bile duct stone extraction. Bile duct stones can be classified as primary or secondary. However, few data are available on the recurrence of primary and secondary bile duct stones after EST. Therefore risk factors for the recurrence of primary bile duct stones after EST were prospectively studied. METHODS Between 1991 and 1997, 61 patients underwent EST for primary bile duct stones. All met the following criteria: (1) previous cholecystectomy without bile duct exploration, (2) detection of bile duct stones at least 2 years after initial cholecystectomy. Mean follow-up was 2.2 years. Fourteen patients were lost to follow-up. The recurrence of primary bile duct stones was defined as the detection of bile duct stones no sooner than 6 months after complete clearance of primary bile duct stones. RESULTS The overall recurrence rate of primary bile duct stones was 21% (10 of 47). Two significant risk factors for recurrence were identified by multivariate analysis: (1) patients with a bile duct diameter of 13 mm or greater after stone removal had recurrences more frequently than those with a duct diameter of 13 mm or less, and (2) patients whose papilla was located on the inner rim or deep within a diverticulum, so that the papillary orifice was not visible endoscopically, had more frequent recurrences than patients with a papilla outside the diverticulum, or no peripapillary diverticulum. CONCLUSION The independent risk factors for recurrence of primary bile duct stones were sustained dilation of the bile duct even after complete removal of stones and location of the papilla on the inner rim or deep within a diverticulum.
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Affiliation(s)
- D I Kim
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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