Common bile duct(CBD)stone is a common biliary problem,which often requires endoscopic approach as the initial treatment option.Roughly,7%-12%of the subjects who experience cholecystectomy were subsequently referred t...Common bile duct(CBD)stone is a common biliary problem,which often requires endoscopic approach as the initial treatment option.Roughly,7%-12%of the subjects who experience cholecystectomy were subsequently referred to biliary endoscopist for further management.In general,there are three classifications of difficult CBD stone,which are based on the characteristics of the stone(larger than 15 mm,barrel or square-shaped stones,and hard consistency),accessibility to papilla related to anatomical variations,and other clinical conditions or comorbidities of the patients.Currently,endoscopic papillary large balloon dilation(EPLBD)of a previous sphincterotomy and EPLBD combined with limited sphincterotomy performed on the same session is still recommended by the European Society of Gastrointestinal Endoscopy as the main approach in difficult CBD stones with history of failed sphincterotomy and balloon and/or basket attempts.If failed extraction is still encountered,mechanical lithotripsy or cholangioscopy-assisted lithotripsy or extracorporeal shockwave lithotripsy can be considered.Surgical approach can be considered when stone extraction is still failed or the facilities to perform lithotripsy are not available.To our knowledge,conflicting evidence are still found from previous studies related to the comparison between endoscopic and surgical approaches.The availability of experienced operator and resources needs to be considered in creating individualized treatment strategies for managing difficult biliary stones.展开更多
While endoscopic retrograde cholangiopancreatography(ERCP)remains the primary treatment modality for common bile duct stones(CBDS)or choledocho-lithiasis due to advancements in instruments,surgical intervention,known ...While endoscopic retrograde cholangiopancreatography(ERCP)remains the primary treatment modality for common bile duct stones(CBDS)or choledocho-lithiasis due to advancements in instruments,surgical intervention,known as common bile duct exploration(CBDE),is still necessary in cases of difficult CBDS,failed endoscopic treatment,or altered anatomy.Recent evidence also supports CBDE in patients requesting single-step cholecystectomy and bile duct stone removal with comparable outcomes.This review elucidates relevant clinical anatomy,selection indications,and outcomes to enhance surgical understanding.The selection between trans-cystic(TC)vs trans-choledochal(TD)approaches is described,along with stone removal techniques and ductal closure.Detailed surgical techniques and strategies for both the TC and TD approaches,including instrument selection,is also provided.Additionally,this review comprehensively addresses operation-specific complications such as bile leakage,stricture,and entrapment,and focuses on preventive measures and treatment strategies.This review aims to optimize the management of CBDS through laparoscopic CBDE,with the goal of improving patient outcomes and minimizing risks.展开更多
AIM: To evaluate the safety and efficacy of endoscopic papillary large balloon dilatation(EPLBD) without endoscopic sphincterotomy in a prospective study.METHODS: From July 2011 to August 2013, we performed EPLBD on 4...AIM: To evaluate the safety and efficacy of endoscopic papillary large balloon dilatation(EPLBD) without endoscopic sphincterotomy in a prospective study.METHODS: From July 2011 to August 2013, we performed EPLBD on 41 patients with nae papillae prospectively. For sphincteroplasty of EPLBD,endoscopic sphincterotomy(EST) was not performed,and balloon diameter selection was based on the distal common bile duct diameter. The balloon was inflated to the desired pressure. If the balloon waist did not disappear, and the desired pressure was satisfied, we judged the dilatation as complete. We used a retrieval balloon catheter or mechanical lithotripter(ML) to remove stones and assessed the rates of complete stone removal, number of sessions, use of ML and adverse events. Furthermore, we compared the presence or absence of balloon waist disappearance with clinical characteristics and endoscopic outcome.RESULTS: The mean diameters of the distal and maximum common bile duct were 13.5 ± 2.4 mm and16.4 ± 3.1 mm, respectively. The mean maximum transverse-diameter of the stones was 13.4 ± 3.4mm, and the mean number of stones was 3.0 ± 2.4.Complete stone removal was achieved in 97.5%(40/41)of cases, and ML was used in 12.2%(5/41) of cases.The mean number of sessions required was 1.2 ± 0.62.Pancreatitis developed in two patients and perforation in one. The rate of balloon waist disappearance was73.1%(30/41). No significant differences were noted in procedure time, rate of complete stone removal(100% vs 100%), number of sessions(1.1 vs 1.3, P= 0.22), application of ML(13% vs 9%, P = 0.71),or occurrence of pancreatitis(3.3% vs 9.1%, P =0.45) between cases with and without balloon waist disappearance.CONCLUSION: EST before sphincteroplasty may be unnecessary in EPLBD. Further investigations are needed to verify the relationship between the presence or absence of balloon waist disappearance.展开更多
文摘Common bile duct(CBD)stone is a common biliary problem,which often requires endoscopic approach as the initial treatment option.Roughly,7%-12%of the subjects who experience cholecystectomy were subsequently referred to biliary endoscopist for further management.In general,there are three classifications of difficult CBD stone,which are based on the characteristics of the stone(larger than 15 mm,barrel or square-shaped stones,and hard consistency),accessibility to papilla related to anatomical variations,and other clinical conditions or comorbidities of the patients.Currently,endoscopic papillary large balloon dilation(EPLBD)of a previous sphincterotomy and EPLBD combined with limited sphincterotomy performed on the same session is still recommended by the European Society of Gastrointestinal Endoscopy as the main approach in difficult CBD stones with history of failed sphincterotomy and balloon and/or basket attempts.If failed extraction is still encountered,mechanical lithotripsy or cholangioscopy-assisted lithotripsy or extracorporeal shockwave lithotripsy can be considered.Surgical approach can be considered when stone extraction is still failed or the facilities to perform lithotripsy are not available.To our knowledge,conflicting evidence are still found from previous studies related to the comparison between endoscopic and surgical approaches.The availability of experienced operator and resources needs to be considered in creating individualized treatment strategies for managing difficult biliary stones.
文摘While endoscopic retrograde cholangiopancreatography(ERCP)remains the primary treatment modality for common bile duct stones(CBDS)or choledocho-lithiasis due to advancements in instruments,surgical intervention,known as common bile duct exploration(CBDE),is still necessary in cases of difficult CBDS,failed endoscopic treatment,or altered anatomy.Recent evidence also supports CBDE in patients requesting single-step cholecystectomy and bile duct stone removal with comparable outcomes.This review elucidates relevant clinical anatomy,selection indications,and outcomes to enhance surgical understanding.The selection between trans-cystic(TC)vs trans-choledochal(TD)approaches is described,along with stone removal techniques and ductal closure.Detailed surgical techniques and strategies for both the TC and TD approaches,including instrument selection,is also provided.Additionally,this review comprehensively addresses operation-specific complications such as bile leakage,stricture,and entrapment,and focuses on preventive measures and treatment strategies.This review aims to optimize the management of CBDS through laparoscopic CBDE,with the goal of improving patient outcomes and minimizing risks.
文摘AIM: To evaluate the safety and efficacy of endoscopic papillary large balloon dilatation(EPLBD) without endoscopic sphincterotomy in a prospective study.METHODS: From July 2011 to August 2013, we performed EPLBD on 41 patients with nae papillae prospectively. For sphincteroplasty of EPLBD,endoscopic sphincterotomy(EST) was not performed,and balloon diameter selection was based on the distal common bile duct diameter. The balloon was inflated to the desired pressure. If the balloon waist did not disappear, and the desired pressure was satisfied, we judged the dilatation as complete. We used a retrieval balloon catheter or mechanical lithotripter(ML) to remove stones and assessed the rates of complete stone removal, number of sessions, use of ML and adverse events. Furthermore, we compared the presence or absence of balloon waist disappearance with clinical characteristics and endoscopic outcome.RESULTS: The mean diameters of the distal and maximum common bile duct were 13.5 ± 2.4 mm and16.4 ± 3.1 mm, respectively. The mean maximum transverse-diameter of the stones was 13.4 ± 3.4mm, and the mean number of stones was 3.0 ± 2.4.Complete stone removal was achieved in 97.5%(40/41)of cases, and ML was used in 12.2%(5/41) of cases.The mean number of sessions required was 1.2 ± 0.62.Pancreatitis developed in two patients and perforation in one. The rate of balloon waist disappearance was73.1%(30/41). No significant differences were noted in procedure time, rate of complete stone removal(100% vs 100%), number of sessions(1.1 vs 1.3, P= 0.22), application of ML(13% vs 9%, P = 0.71),or occurrence of pancreatitis(3.3% vs 9.1%, P =0.45) between cases with and without balloon waist disappearance.CONCLUSION: EST before sphincteroplasty may be unnecessary in EPLBD. Further investigations are needed to verify the relationship between the presence or absence of balloon waist disappearance.
