[show abstract][hide abstract] ABSTRACT: The last 30 years have seen major developments in the management of gallstone-related disease, which in the United States alone costs over 6 billion dollars per annum to treat. Endoscopic retrograde cholangiopancreatography (ERCP) has become a widely available and routine procedure, whilst open cholecystectomy has largely been replaced by a laparoscopic approach, which may or may not include laparoscopic exploration of the common bile duct (LCBDE). In addition, new imaging techniques such as magnetic resonance cholangiography (MR) and endoscopic ultrasound (EUS) offer the opportunity to accurately visualise the biliary system without instrumentation of the ducts. As a consequence clinicians are now faced with a number of potentially valid options for managing patients with suspected CBDS. It is with this in mind that the following guidelines have been written.
[show abstract][hide abstract] ABSTRACT: Over a 34-month period (1989-1991), 791 patients were diagnosed at endoscopic retrograde cholangiography to have bile duct stones. All patients underwent sphincterotomy and attempted extraction by Dormia basket. This was successful in 683 patients (86%). The remaining 108 patients with "difficult stones" (mean age 72 years) underwent mechanical, electrohydraulic or extracorporeal shock wave lithotripsy according to the following algorithm: (1) Mechanical lithotripsy for stones which could not be extracted after entrapment in the Dormia basket (n = 33); (2) peroral cholangioscopic electrohydraulic lithotripsy for stones which could not be engaged in the Dormia basket (n = 65); or (3) extracorporeal shock wave lithotripsy for intrahepatic stones (n = 10). Stone fragmentation and clearance was successful in all patients treated by mechanical lithotripsy, was unsuccessful in one patient submitted to electrohydraulic lithotripsy due to inability to insert the cholangioscope into the bile duct and failed in 3 patients treated by extracorporeal shock wave lithotripsy. Overall, 95% of difficult bile duct stones refractory to conventional endoscopic basket extraction were removed using the above lithotripsy techniques. There were no serious procedure-related complications.
[show abstract][hide abstract] ABSTRACT: There has been no report concerning the factors that contribute to the technical difficulty of endoscopic clearance of common bile duct (CBD) stones.
Our purpose was to determine the factors that contribute to the technical difficulty of endoscopic clearance of CBD stones.
A tertiary referral endoscopy center.
A total of 102 patients who underwent ERCP, endoscopic biliary sphincterotomy, and CBD stone extraction at our institution from August 2004 to September 2006.
The technical difficulty of CBD stone clearance was graded as follows: easy, moderately difficult, very difficult, and failed. Distal CBD angulation seen on cholangiogram was defined as the first angulation from the ampullary orifice with the patients in the prone position and the distal arm of CBD angulation as the length (in millimeters) between angular point and ampullary orifice.
Older age (>65 years), previous gastrojejunostomy, larger CBD stone (>/=15 mm), impacted CBD stone, use of mechanical lithotripsy, shorter length of the distal CBD arm (</=36 mm), and more acute distal CBD angulation (</=135 degrees) were all significant contributing factors to the technical difficulty of CBD stone clearance in exploratory univariate statistical tests. In the definitive multivariate analysis, more acute distal CBD angulation and a shorter length of the distal CBD arm were found to be significant, independent contributors to technical difficulty.
Complete clearance of CBD stones was technically more difficult for the patients with more acute distal CBD angulation and a shorter length of the distal CBD arm.
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