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Outcomes of endoscopic sphincterotomy vs open choledochotomy for common bile duct stones

World Journal of Gastroenterology 2019年第4期25卷 485-497页

作者： Xiao-Dong Zhou Qiao-Feng Chen Yuan-Yuan Zhang Ming-Ju Yu Chang Zhong Zhi-Jian Liu Guo-Hua Li Xiao-Jiang Zhou Jun-Bo Hong You-Xiang Chen Department of Gastroenterology The First Affiliated Hospital of Nanchang University

BACKGROUND Endoscopic sphincterotomy(EST) for the management of common bile duct stones(CBDS) is used increasingly widely because it is a minimally invasive procedure. However, some clinical practitioners argued that EST may be complicated by post-endoscopic retrograde cholangiopancreatography(ERCP)pancreatitis(PEP) and accompanied by a higher recurrence of CBDS than open choledochotomy(OCT). Whether any differences in outcomes exist between these two approaches for treating CBDS has not been thoroughly elucidated to date.AIM To compare the outcomes of EST vs OCT for the management of CBDS and to clarify the risk factors associated with stone recurrence.METHODS Patients who underwent EST or OCT for CBDS between January 2010 and December 2012 were enrolled in this retrospective study. Follow-up data were obtained through telephone or by searching the medical records. Statistical analysis was carried out for 302 patients who had a follow-up period of at least 5 years or had a recurrence. Propensity score matching(1:1) was performed to adjust for clinical differences. A logistic regression model was used to identify potential risk factors for recurrence, and a receiver operating characteristic(ROC)curve was generated for qualifying independent risk factors.RESULTS In total, 302 patients undergoing successful EST(n = 168) or OCT(n = 134) were enrolled in the study and were followed for a median of 6.3 years. After propensity score matching, 176 patients remained, and all covariates were balanced. EST was associated with significantly shorter time to relieving biliary obstruction, anesthetic duration, procedure time, and hospital stay than OCT(P <0.001). The number of complete stone clearance sessions increased significantly in the EST group(P = 0.009). The overall incidence of complications and mortality did not differ significantly between the two groups. Recurrent CBDS occurred in18.8%(33/176) of the patients overall, but no difference was found between the EST(20.5%, 18/88) and OCT(17.0%, 15/88) groups. Factors as

关键词： Common bile duct stone Choledochotomy Endoscopic sphincterotomy Outcome Recurrence Risk factor

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Endoscopic papillary large balloon dilatation with sphincterotomy is safe and effective for biliary stone removal independent of timing and size of sphincterotomy

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World Journal of Gastroenterology 2017年第48期23卷 8597-8604页

作者： Usman Iqbal Aujla Nimzing Ladep Laura Dwyer Stephen Hood Nicholas Stern Richard Sturgess Digestive Diseases Unit Aintree University Hospital

AIM To describe the efficacy and safety of endoscopic papillary large balloon dilatation(EPLBD) in the management of bile duct stones in a Western population. METHODS Data was collected from the endoscopic retrograde cholangiopancreatography(ERCP) and Radiology electronic database along with a review of case notes over a period of six years from 1 st August 2009 to 31 st July 2015 and incorporated into Microsoft excel. Statistical analyses were performed using Med Calc for Windows,version 12.5(Med Calc Software,Ostend,Belgium). Simple statistical applications were applied in order to determine whether significant differences exist in comparison groups. We initially used simple proportions to describe the study populations. Furthermore,we used chi-square test to compare proportions and categorical variables. Non-parametric Mann-Whitney U-test was applied in order to compare continuous variables. All comparisons were deemed to be statistically significant if P values were less than 0.05.RESULTS EPLBD was performed in 229 patients(46 females) with mean age of 68 ± 14.3 years. 115/229(50%) patients had failed duct clearance at previous ERCP referred from elsewhere with standard techniques. Duct clearance at the Index* ERCP(1 st ERCP at our centre) was 72.5%. Final duct clearance rate was 98%. EPLBD after fresh sphincterotomy was performed in 81(35.4%). Median balloon size was 13.5 mm(10-18). In addition to EPLBD,per-oral cholangioscopy(POC) and electrohydraulic lithotripsy(EHL) was performed in 35(15%) patients at index* ERCP. 63(27.5%) required repeat ERCP for stone clearance. 28(44.5%) required POC and EHL and 11(17.4%) had repeat EPLBD for complete duct clearance. Larger stone size(12.4 mm vs 17.4 mm,P < 0.000001),multiple stones(2,range(1-13) vs 3,range(1-12),P < 0.006) and dilated common bile duct(CBD)(12.4 mm vs 18.3 mm,P < 0.001) were significant predictors of failed duct clearance at index ERCP. 47 patients(20%) had ampullary or peri-ampullary diverticula. Procedure related adverse events included 2 cases of

关键词： Endoscopic sphincterotomy endoscopic papillary large balloon dilatation Endoscopic retrograde cholangiopancreatography Adverse events Common bile duct stones

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Endoscopic sphincterotomy associated cholangitis in patients receiving proximal biliary self-expanding metal stents

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Hepatobiliary & Pancreatic Diseases International 2012年第6期11卷 643-649页

作者： Hui Zhou, Lei Li, Feng Zhu, Sheng-Zheng Luo, Xiao-Bo Cai,Xin-Jian Wan Department of Gastroenterology, Shanghai First People’s Hospital, Shanghai Jiaotong University, Shanghai 200080, China Department of Gastroenterology Shanghai First People's Hospital Shanghai Jiaotong University Shanghai 200080 China

BACKGROUND: Endoscopic biliary stent placement during the procedure of endoscopic retrograde cholangiopancreatography (ERCP) is preferred to provide biliary drainage for unresectable malignant biliary obstruction. There is considerable controversy over the use of endoscopic sphincterotomy (ES) prior to stent placement. This study aimed to determine whether ES before intraductal self-expanding metal stent (SEMS) placement affects the clinical outcome and complications in patients with proximal malignant obstructive biliary diseases. METHODS: In a prospective randomized controlled trial, 82 patients with inoperable malignant biliary strictures were randomly assigned to biliary stenting groups with or without ES. Resolution of jaundice and the incidence of complications including acute cholangitis, pancreatitis and stent occlusion within 6 months were evaluated. RESULTS: SEMSs were successfully deployed in all patients, resulting in clinical and biochemical improvement of obstructive symptoms in both groups. The incidence of cholangitis was higher in the ES group than in the non-ES group (58.5% vs 31.7%, P=0.015). The interval between stent placement and the first acute cholangitis was much shorter in the ES group than in the non-ES group (P=0.024). The use of ES increased the incidence of cholangitis (P=0.004, risk ratio, 8.196). The rate of post-ERCP pancreatitis after stent placement was greater in the non-ES group than in the ES group (31.7% vs 9.8%, P=0.014). No significant differences were found in the rate of restenosis and the mortality rate between the two groups.CONCLUSIONS: ES prior to intraductal SEMS placement was associated with an increased incidence of acute cholangitis. ES should be carefully evaluated prior to its use in patients with proximal malignant obstructive biliary diseases.

关键词： sphincterotomy biliary obstructions endoscopic retrograde cholangiopancreatography cholangitis pancreatitis

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Biliary endoscopic sphincterotomy: Techniques and complications

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World Journal of Clinical Cases 2018年第16期6卷 1073-1086页

作者： Ayd?n Seref Kksal Ahmet Tarik Eminler Erkan Parlak Department of Gastroenterology Sakarya University School of Medicine Department of Gastroenterology Hacettepe University School of Medicine

Biliary endoscopic sphincterotomy(EST) refers to the cutting of the biliary sphincter and intraduodenal segment of the common bile duct following selective cannulation, using a high frequency current applied with a special knife, sphincterotome, inserted into the papilla. EST is either used solely for the treatment of diseases of the papilla of Vater, such as sphincter of Oddi dysfunction or to facilitate subsequent therapeutic biliary interventions, such as stone extraction, stenting, etc. It is a prerequisite for biliary interventions, thus every practitioner who performs endoscopic retrograde cholangiopancreatography needs to know different techniques and the clinical and anatomic parameters related to the efficacy and safety of the procedure. In this manuscript, we will review the indications, contraindications and techniques of biliary EST and the management of its complications.

关键词： Complication Indication Biliary endoscopic sphincterotomy Endoscopic retrograde cholangiopancreatography

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Successful outcome of sphincterotomy and 7 French pigtail stent insertion in the management of post-cholecystectomy bile leaks

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Hepatobiliary & Pancreatic Diseases International 2009年第3期8卷 309-311页

作者： Fergal Donnellan Faisal Zeb Garry Courtney Abdur R Aftab Department of Gastroenterology St.Luke's Hospital

BACKGROUND:Endoscopic retrograde cholangiopancrea-tography(ERCP)is widely used to manage post-cholecystectomy bile leaks.However,the best endoscopic intervention remains controversial.We investigated the success of a 7 French double pigtail stent following sphincterotomy in the management of such bile leaks. METHODS:Between July 1998 and June 2008,48 patients were referred for ERCP for presumed post-cholecystectomy bile leaks.Leaks were confirmed at ERCP and managed by a combination of sphincterotomy and stent insertion unless contraindicated. RESULTS:Bile duct cannulation was successful in 44(91.7%)patients.A leak of the cystic duct was demonstrated in 19(43.2%)patients,the duct of Luschka in 11(25.0%),and the common hepatic duct in 5 (11.4%).Complete transection of the common bile duct occurred in 4 patients.The remaining patients had no cholangiographic evidence of a leak.sphincterotomy was performed in 34 patients.A 7 French double pigtail plastic stent was placed in all 35 patients with cholangiographic evidence of a bile leak.No bile leaks were demonstrated at a follow-up of 8-16 weeks and all stents were removed successfully. CONCLUSION:The combination of sphincterotomy and insertion of a 7 French double pigtail stent results in excellent outcomes in the management of post-cholecystectomy bile leaks.

关键词： cholecystectomy bile leak sphincterotomy stent insertion

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Precut sphincterotomy:A reliable salvage for difficult biliary cannulation

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World Journal of Gastroenterology 2013年第1期19卷 1-7页

作者： Ulku Saritas Yucel Ustundag Ferda Harmandar Department of Internal Medicine Gastroenteorology ClinicsZonguldak Karaelmeas University Hospital67600 ZonguldakTurkey

Even experienced endoscopists have 90% success in achieving deep biliary cannulation with standard methods. Biliary cannulation may become difficult in 10%-15% of patients with biliary obstruction and pre- cut (access) sphincterotomy is frequently chosen as a rescue treatment in these cases. Generally, precut sphincterotomy ensures a rate of 90%-100% success- ful deep biliary cannulation. The precut technique has been performed as either a fistulotomy with a needle knife sphincterotome or as a transpapillary septotomy with a standard sphincterotome. Both methods have similar efficacy and complication rates when adminis- tered to the proper patient. Although precut sphincter- otomy ensures over 90% success of biliary cannula- tion, it has been characterized as an independent risk factor for pancreatitis. The complications of the precut technique are not limited to pancreatitis. Two more important ones, bleeding and perforation, are also re- ported in some publications as being observed more commonly than during standard sphincterotomy. It is also reported that precut sphincterotomy increases morbidity when performed in patients without dilata- tion of their biliary tract. Nevertheless, precut sphinc- terotomy is a good alternative as a rescue method in the setting of a failed standard cannulation method. This paper discusses the technical details, timing, ef- ficacy and potential complications of precut sphincter- otomy.

关键词： Biliary cannulation Salvage Precut sphincterotomy Needle knife Transpancreatic septotomy

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sphincterotomy by triple lumen needle knife using guide wire in patients with Billroth Ⅱ gastrectomy

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World Journal of Gastroenterology 2013年第48期19卷 9405-9409页

作者： Su Bum Park Hyung Wook Kim Dae Hwan Kang Cheol Woong Choi Ki Tae Yoon Mong Cho Byeong Jun Song Department of Internal Medicine Pusan National University School of Medicine Research Institute for Convergence of Biomedical Science and Technology Pusan National University Yangsan Hospital Yangsan-si Gyeongsangnam-do 626-770South Korea

AIM:To investigate the usefulness of a guide wire and triple lumen needle knife for removing stones in BillrothⅡ(B-Ⅱ)gastrectomy patients.METHODS:Endoscopic sphincterotomy in patients with B-Ⅱgastrectomy is challenging.We used a new guide wire technique involving sphincterotomy by triple lumen needle knife through a forward-viewing endoscopy.This technique was performed in nine patients between August 2010 and June 2012.sphincterotomy as described above was performed.Adequate sphincterotomy,successful stone removal,and complications were investigated prospectively.RESULTS:sphincterotomy by triple lumen needle knife using guide wire was successful in all nine patients.sphincterotomy started towards the 4-5 o’clock direction and continued to the upper margin of the papillary roof.Complete stone removal in one session was achieved in all patients.There were no procedure related complications,such as bleeding,pancreatitis,or perforation.CONCLUSION:In patients with B-Ⅱgastrectomy,guide wire using sphincterotomy by triple lumen needle knife through a forward-viewing endoscopy seems to be an effective and safe procedure for the removal of common bile duct stones.

关键词： Billroth Ⅱ gastrectomy Endoscopic sphincterotomy Forward-viewing endoscopy Guide wire Triple lumen needle knife

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Endoscopic sphincterotomy or papillary balloon dilatation for choledocholithiasis

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Hepatobiliary & Pancreatic Diseases International 2002年第1期1卷 101-105页

作者： Li-Qing Yao Yi-Qun Zhang Ping-Hong Zhou Wei-Dong Gao Guo-Jie He Mei-Dong Xu From the General Surgery Department, Zhongshan Hospital, Fu Dan University, Shanghai 200032, China General Surgery Department Zhongshan Hospital Fu Dan University Shanghai 200032 China

Objective: To assess the safety and effect of endoscopicsphincterotomy (EST) and endoscopic papillary bal-loon dilatation (EPBD) for choledocholithiasis.Methods: 328 patients with choledocholithiasis weresubjected to EST or EPBD; they included 174 patientswith single stone, 112 patients with two stones and 42patients with three stones (one patient with 20 stones).Patients with stones less than 10 mm in diameter un-derwent EPBD and those with stones larger than 11mm in diameter underwent EST.Results: EST and EPBD succeeded in 323 patients(98.5%), and failed in 5. Stones in 98 patients wereexcluded spontaneously after endoscopic therapy. 207patients were subjected to basket or balloon stone ex-traction. Stones in 14 patients were discharged bybasket lithotripsy. Four patients were given wavelithotripsy. Stones in 22 of the 323 patients were ex-tracted thoroughly after 2-3 times attempts. Totalcomplications were noted in 2.5% of the patients.Hemorrhage from the gastrointestinal tract was seenin one patient, cholangitis in 4 patients, and pancre-atitis in 3 patients. In 92 patients receiving digestivetract barium X-ray examination, 86 developed nobarium reflux to the baliary tract, 2 pneumobilia, 4barium reflux to the biliary tract.Conclusion: EST and EPBD are relatively safe and effec-tive in treatment of choledocholithiasis, and have fewcomplications.

关键词： choledocholithiasis endoscopy sphincterotomy papillary balloon dilatation

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Prior minimal endoscopic sphincterotomy to prevent pancreatitis related to endoscopic balloon sphincteroplasty

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World Journal of Gastrointestinal Endoscopy 2016年第18期8卷 663-668页

作者： Ryo Kanazawa Jin Kan Sai Tomoyasu Ito Hiroko Miura Shigeto Ishii Hiroaki Saito Ko Tomishima Ryo Shimizu Koki Sato Manabu Hayashi Sumio Watanabe Shuichiro Shiina Department of Gastroenterology Juntendo University School of Medicine

AIM To investigate the efficacy of prior minimal endoscopic sphincterotomy(EST) to prevent pancreatitis related to endoscopic balloon sphincteroplasty(EBS).METHODS After bile duct access was gained and cholangiogram confirmed the presence of stones < 8 mm in the common bile duct at endoscopic retrograde cholangiography, patients were subjected to minimal EST(up to one-third of the size the papilla) plus 8 mm EBS(ESTEBS group). The incidence of pancreatitis and the difference in serum amylase level after the procedure were examined and compared with those associated with 8-mm EBS alone in 32 patients of historical control(control group).RESULTS One hundred and five patients were included in the EST-EBS group, and complete stone removal was accomplished in all of them. The difference in serum amylase level after the procedure was- 25.0(217.9) IU/L in the EST-EBS group and this value was significantly lower than the 365.5(576.3) IU/L observed in the control group(P < 0.001). The incidence of post-procedure pancreatitis was 0%(0/105) in the EST-EBS group and 15.6%(5/32) in the control group(P < 0.001).CONCLUSION Prior minimal EST might be useful to prevent the elevation of serum amylase level and the occurrence of pancreatitis related to EBS.

关键词： Choledocholithiasis Adverse event Pancreatitis Endoscopic sphincterotomy Endoscopic balloon sphincteroplasty

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Comparison between endoscopic sphincterotomy vs endoscopic sphincterotomy associated with balloon dilation for removal of bile duct stones:A systematic review and meta-analysis based on randomized controlled trials

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World Journal of Gastrointestinal Endoscopy 2018年第8期10卷 130-144页

作者： Cesar Capel de Clemente Junior Wanderley Marques Bernardo Tomazo Prince Franzini Gustavo Oliveira Luz Marcos Eduardo Lera dos Santos Jonah Maxwell Cohen Diogo Turiani Hourneaux de Moura Fábio Ramalho Tavares Marinho Martin Coronel Paulo Sakai Eduardo Guimaraes Hourneaux de Moura Gastrointestinal Endoscopy Unit Department of GastroenterologyUniversity of Sao Paulo Medical SchoolSao Paulo 05403-010Brazil Beth Israel Deaconess Medical Center Harvard Medical SchoolBostonMA 02215United States

AIM To compare gallstones removal rate and incidence of bleeding, pancreatitis, use of mechanical lithotripsy, cholangitis and perforation between isolated sphincterotomy vs sphincterotomy associated with balloon dilation of papilla in choledocholithiasis through the meta-analysis of randomized clinical trials. METHODS We conducted a systematic review according to the PRISMA guidelines. Literature search was restricted to randomized controlled trials(RCTs) on Med Line, Cochrane Library, LILACS, and EMBASE database platforms in July 2017. The manual search included references of retrieved articles. We extracted data focusing on outcomes: The primary endpoint was the stones removal rate; Secondary endpoints were rates of pancreatitis, bleeding, use of mechanical lithotripsy(ML), perforation and cholangitis. RESULTS Eleven RCTs with 1824 patients were included. EST was associated with more post-endoscopic retrograde cholangiopancreatography(ERCP) bleeding [FE RD-0.02, CI(-0.03,-0.00), I2 = 33%, P = 0.05] and more need of mechanical lithotripsy in general [RE RD-0.16, CI(-0.25,-0.06), I2 = 90%, P = 0.002] and in subgroup analysis of stones greater than 15 mm [RE RD-0.20, CI(-0.38,-0.02), I2 = 82%, P = 0.003]. Incidence of pancreatitis [FE RD-0.01, CI(-0.03, 0.01), I2 = 0, P = 0.36], cholangitis [FE RD-0.00, CI(-0.01, 0.01), I2 =0, P = 0.97] and perforation [FE RD-0.01, CI(-0.01, 0.00), I2 = 0, P = 0.23] was similar between the groups as well as similar stone removal rates in general [FE RD-0.01, CI(-0.01, 0.04), I2 = 0, P = 0.23] and pooled analysis of stones greater than 15 mm [FE RD-0.02, CI(-0.02, 0.07), I2 = 11%, P = 0.31]. CONCLUSION Through meta-analysis of randomized clinical trials we found that isolated sphincterotomy was associated with more post-ERCP bleeding and more need for mechanical lithotripsy. However, there was no statistical difference in the stone removal rate between isolated sphincterotomy and sphincterotomy associated with balloon dilation in the approach to remove gallstones.

关键词： sphincterotomy Papillotomy Dilation Cholangiopancreatography Endoscopic retrograde Endoscopic retrograde cholangiopancreatography Cholangiography

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