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Biliary stenting in the management of large or multiple common bile duct stones
Letter to the Editor
REFERENCES 1. Pang SH, Ching JY, Lau JY, et al. Comparing the Blatchford and preendoscopic Rockall score in predicting the need for endoscopic therapy in patients with upper GI hemorrhage. Gastrointest Endosc 2010;71: 1134-40. 2. Qureshi W, Adler DG, Egan J, et al. ASGE guideline: the role of endoscopy in the management of variceal hemorrhage, updated July 2005. Gastrointest Endosc 2005;62:651-5. 3. Barkun AN, Bardou M, Kuipers EJ, et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med 2010;152:101-13. doi:10.1016/j.gie.2010.08.025
Biliary stenting in the management of large or multiple common bile duct stones To the Editor: I was interested to read the article by Horiuchi et al1 on stenting for difficult bile duct stones. Endoscopists new to ERCP will welcome the news that biliary stenting can reduce the size and number of large bile duct stones, facilitating their extraction, but this is not—as claimed by the authors—an original observation. They state, “For the first time, the present study proposes that stenting could be a primary method to reduce the size and number of difficult bile duct stones, making extraction possible.” They also opine that “the role of adjuvants such as ursodeoxycholic acid is unclear,” citing two recent studies (from 2008 and 2009)2,3 with contradictory findings. In 1993, Johnson et al4 published their experience of 22 patients with difficult-to-extract bile duct stones: all were treated with biliary stents. In addition, 10 patients were given oral ursodeoxycholate. Nine of 10 patients in the ursodeoxycholate-plus-stent group had complete bile duct clearance of stones after a median follow-up period of 9 ⫾ 2 months, whereas none of the control group (stent alone) had complete clearance, and only 6 of 40 stones could be removed after a follow-up period of 31 ⫾ 6 months. Stenting for “difficult” bile duct stones was commonplace before the introduction of modern mechanical lithotripters and contact lithotripsy (ie, laser and electrohydraulic). A standard PubMed review reveals thoughtful work on this subject in the late 1980s and early 1990s.5-7 Because pigtail biliary stents are more difficult to place and occlude more quickly than straight ones, it is hard to support their preferential use in this setting. Finally, the authors offer stenting as an alternative to extracorporeal shock-wave lithotripsy, which— along with electrohydraulic (contact) lithotripsy—they say is “used often.” At least in the United States, extracorporeal shock-wave lithotripsy has almost disappeared; I doubt if more than a handful of tertiary-care 644 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 3 : 2011
centers have it available for managing large biliary and pancreatic stones. John Baillie, MB, ChB, FRCP, FASGE Section on Gastroenterology Wake Forest University Health Sciences Winston-Salem, North Carolina, USA
REFERENCES 1. Horiuchi A, Yoshiko N, Masashi K, et al. Biliary stenting in the management of large or multiple common bile duct stones. Gastrointest Endosc 2010;71:1200-3. 2. Katsinelos P, Kountouras J, Paroutoglou G, et al. Combination of endoprostheses and oral ursodeoxycholic acid or placebo in the treatment of difficult to extract common bile duct stones. Dig Liver Dis 2008;40:453-9. 3. Han J, Moon JH, Koo HC, et al. Effect of biliary stenting combined with ursodeoxycholic acid and terpene treatment on retained common bile duct stones in elderly patients: a multicenter study. Am J Gastroenterol 2009;104:2418-21. 4. Johnson GK, Geenen JE, Venu RP, et al. Treatment of non-extractable common bile duct stones with combination ursodeoxycholic acid plus endoprostheses. Gastrointest Endosc 1993;39:528-31. 5. Cotton PB, Forbes A, Leung JW, et al. Endoscopic stenting for long-term treatment of large common bile duct stones: 2- to 5-year follow-up. Gastrointest Endosc 1987;33:411-2. 6. Maxton DG, Tweedle DE, Martin DF. Retained common bile duct stones after endoscopic sphincterotomy: temporary and longterm treatment with biliary stenting. Gut 1995;36:446-9. 7. Lauri A, Horton RC, Davidson BR, et al. Endoscopic extraction of bile duct stones: management related to stone size. Gut 1993;34:1718-21. doi:10.1016/j.gie.2010.06.038
Response: We thank Dr Baillie for his thoughtful comments on our article. Possibly we were not clear regarding what was new versus what was not. We agree that there were many studies in the late 1980s and early 1990s. The primary goal of stenting was to prevent stone impaction, and it was not intentionally performed to facilitate the extraction of difficult stones. Our, and we believe original, observations are based on our findings that intentional biliary stenting using a double-pigtail stent for about 2 months resulted in a reduction in the size and number of large or multiple bile duct stones. We also believe that prospective studies to examine whether there is an additional beneficial effect of adjuvants such as ursodeoxycholic acid are needed and that these should be done as prospective, randomized trials so that the results will be evidence based. We mentioned extracorporeal shock wave lithotripsy because it is used for managing large biliary and pancreatic stones at tertiary endoscopy centers in Japan. Anytime there are a number of potential methods to solve a clinical problem, the approach should be to compare them. The fact that double-pigtail stenting alone has a beneficial effect www.giejournal.org
REFERENCES 1. Pang SH, Ching JY, Lau JY, et al. Comparing the Blatchford and preendoscopic Rockall score in predicting the need for endoscopic therapy in patients with upper GI hemorrhage. Gastrointest Endosc 2010;71: 1134-40. 2. Qureshi W, Adler DG, Egan J, et al. ASGE guideline: the role of endoscopy in the management of variceal hemorrhage, updated July 2005. Gastrointest Endosc 2005;62:651-5. 3. Barkun AN, Bardou M, Kuipers EJ, et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med 2010;152:101-13. doi:10.1016/j.gie.2010.08.025
Biliary stenting in the management of large or multiple common bile duct stones To the Editor: I was interested to read the article by Horiuchi et al1 on stenting for difficult bile duct stones. Endoscopists new to ERCP will welcome the news that biliary stenting can reduce the size and number of large bile duct stones, facilitating their extraction, but this is not—as claimed by the authors—an original observation. They state, “For the first time, the present study proposes that stenting could be a primary method to reduce the size and number of difficult bile duct stones, making extraction possible.” They also opine that “the role of adjuvants such as ursodeoxycholic acid is unclear,” citing two recent studies (from 2008 and 2009)2,3 with contradictory findings. In 1993, Johnson et al4 published their experience of 22 patients with difficult-to-extract bile duct stones: all were treated with biliary stents. In addition, 10 patients were given oral ursodeoxycholate. Nine of 10 patients in the ursodeoxycholate-plus-stent group had complete bile duct clearance of stones after a median follow-up period of 9 ⫾ 2 months, whereas none of the control group (stent alone) had complete clearance, and only 6 of 40 stones could be removed after a follow-up period of 31 ⫾ 6 months. Stenting for “difficult” bile duct stones was commonplace before the introduction of modern mechanical lithotripters and contact lithotripsy (ie, laser and electrohydraulic). A standard PubMed review reveals thoughtful work on this subject in the late 1980s and early 1990s.5-7 Because pigtail biliary stents are more difficult to place and occlude more quickly than straight ones, it is hard to support their preferential use in this setting. Finally, the authors offer stenting as an alternative to extracorporeal shock-wave lithotripsy, which— along with electrohydraulic (contact) lithotripsy—they say is “used often.” At least in the United States, extracorporeal shock-wave lithotripsy has almost disappeared; I doubt if more than a handful of tertiary-care 644 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 3 : 2011
centers have it available for managing large biliary and pancreatic stones. John Baillie, MB, ChB, FRCP, FASGE Section on Gastroenterology Wake Forest University Health Sciences Winston-Salem, North Carolina, USA
REFERENCES 1. Horiuchi A, Yoshiko N, Masashi K, et al. Biliary stenting in the management of large or multiple common bile duct stones. Gastrointest Endosc 2010;71:1200-3. 2. Katsinelos P, Kountouras J, Paroutoglou G, et al. Combination of endoprostheses and oral ursodeoxycholic acid or placebo in the treatment of difficult to extract common bile duct stones. Dig Liver Dis 2008;40:453-9. 3. Han J, Moon JH, Koo HC, et al. Effect of biliary stenting combined with ursodeoxycholic acid and terpene treatment on retained common bile duct stones in elderly patients: a multicenter study. Am J Gastroenterol 2009;104:2418-21. 4. Johnson GK, Geenen JE, Venu RP, et al. Treatment of non-extractable common bile duct stones with combination ursodeoxycholic acid plus endoprostheses. Gastrointest Endosc 1993;39:528-31. 5. Cotton PB, Forbes A, Leung JW, et al. Endoscopic stenting for long-term treatment of large common bile duct stones: 2- to 5-year follow-up. Gastrointest Endosc 1987;33:411-2. 6. Maxton DG, Tweedle DE, Martin DF. Retained common bile duct stones after endoscopic sphincterotomy: temporary and longterm treatment with biliary stenting. Gut 1995;36:446-9. 7. Lauri A, Horton RC, Davidson BR, et al. Endoscopic extraction of bile duct stones: management related to stone size. Gut 1993;34:1718-21. doi:10.1016/j.gie.2010.06.038
Response: We thank Dr Baillie for his thoughtful comments on our article. Possibly we were not clear regarding what was new versus what was not. We agree that there were many studies in the late 1980s and early 1990s. The primary goal of stenting was to prevent stone impaction, and it was not intentionally performed to facilitate the extraction of difficult stones. Our, and we believe original, observations are based on our findings that intentional biliary stenting using a double-pigtail stent for about 2 months resulted in a reduction in the size and number of large or multiple bile duct stones. We also believe that prospective studies to examine whether there is an additional beneficial effect of adjuvants such as ursodeoxycholic acid are needed and that these should be done as prospective, randomized trials so that the results will be evidence based. We mentioned extracorporeal shock wave lithotripsy because it is used for managing large biliary and pancreatic stones at tertiary endoscopy centers in Japan. Anytime there are a number of potential methods to solve a clinical problem, the approach should be to compare them. The fact that double-pigtail stenting alone has a beneficial effect www.giejournal.org