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Endoscopic sphincterotomy: A procedure of choice in the management of retained common bile duct stones and papillary stenosis
SCIENTIFIC PAPERS
Endoscopic Sphincterotomy: A Procedure of Choice in the Management of Retained Common Bile Duct Stones And Papillary Stenosis
Rudolph A. Weitemeyer, BSc, MD, FRCS(C), New Westminster, British Columbia, Canada
Endoscopic sphincterotomy is a new procedure used in the management of biliary tract disease. The initial experience of Classen and Safrany [I], Koch [21, Montori et al [3], and Safrany [4] resulted in the spread of this technique worldwide. Endoscopic sphincterotomy was initially reserved for high risk patients. Now, after 9 years of experience with over 5,000 patients, the technique is being acclaimed as the preferred choice in the management of common bile duct stones and papillary stenosis [5]. Technique Endoscopic sphincterotomy has evolved from the diagnostic technique of endoscopic retrograde cholangiopancreatography. Classen and Demling [S] and Kawai et al [ 71, along with many others, helped develop techniques for endoscopic electrosurgical sphincterotomy. The sphincterotome (Figure l), which utilizes the preferred pull method, requires selective bile duct cannulation-a difficult maneuver-but more than compensates by the better control of the length and direction of the sphincterotomy incision. The modified Dormia basket (Figure 2) is used to extract stones. The technique of endoscopic sphincterotomy and stone extraction is shown schematically in Figure 3. Roentgenographic visualization is always used to confirm that the sphincterotome is in the appropriate duct. Indications The well-established indications for endoscopic sphincterotomy are (I) choledocholithiasis in cholecystectomized patients; (2) choledocholithiasis in high risk patients with or without cholelithiasis; (3) papillary stenosis; and (4) ampullary carcinoma (for palliation only). Absolute contraindications for this procedure are (1) a long, From the Department of GeneralSurgery, The Royal Coiumbian Hospital, New Westminster, Srltish Columbia, Canada. Requests for reprints should be addressed to Rudolph A. Weitemeyer, MD, 505-625 Fifth Avenue, New Westminster, British Columbia VIM 1x4. Canada. Presented at the 66th Annual Meeting of the North Pacific Surgical Association, Vancouver, British Columbia, Canada, November 13 and 14, 1961.
536
funnel-shaped stenosis of the distal common bile duct; (2) abnormalities of the proximal parts of the biliary tree; and (3) markedly abnormal clotting factors. Relative contraindications for endoscopic sphincterotomy are huge stones and pancreatitis as a complication of choledocholithiasis [8].
Material and Methods Patients were examined and then admitted to a 24 hour ambulatory care unit for observation. Most patients had had previous cholecystectomy or common bile duct exploration. The male to female ratio was 1 to 1.07 and the patients ranged in age from 33 to 92 years (mean 70.2). If conditions are right after endoscopic sphincterotomy, then the stones are extracted at the first sitting (Figure 4). In half of our endoscopic sphincterotomies we were able to extract the stones at the first sitting. Sometimes with larger stones we had to enlarge the sphincterotomy. If the initial cannulation was not possible with the sphincterotome, then a precutting papillotomy was made according to Cremer. The precutting maneuver usually allows an easy cannulation the following week. If the distal common bile duct is funnel-shaped, good judgment must be exercised to get the maximum length of incision and still prevent a retroperitoneal perforation. Results Endoscopic sphincterotomy was performed successfully in 48 of 58 eligible patients (Table I). In 10 patients the papilla of Vater could not be cannulated. In five patients a funnel-shaped distal common bile duct prevented extraction of stones; however, in these patients infected bile was effectively drained with endoscopic sphincterotomy. In half of the remaining 38 patients with choledocholithiasis, stone extraction was possible at the first sitting. Four patients required two or more attempts at extraction, and in the remainder stones passed spontaneously. The pneumobilogram (Figure 5) 1 year after endoscopic sphincterotomy in a patient with choledocholithiasis demonstrates that long-term patency of this type of sphincterotomy can also be achieved. The American Journal of Surgery
Endoscopic
TABLE I
Sphincterotomy
Summary et Findlngs in 48 Patients Who Underwent Successtul Endoscopic Sphincterotomy
Choledocholithiasis’ With cholecystectomy With intact gallbladder Papillary stenosis With pseudocalculus Lower common bile duct polyp
43 35 8 3
Total
48
89.6
.6:3
1 2
‘h:l 100
In five patients stone extraction was contraindicated due to a funnel-shaped distal common bile duct. l
F/gufe 1. The taut sphlncterotome will cut /Ike a knife when frequency diathermy current is applied.
creatic ducts may be affected by the stenotic process. A 15 mm incision in all three patients showed no clinical signs of restenosis after an 18 month followUP*
Three patients fulfilled the criteria of papillary stenosis: (1) upper abdominal pain related to meals; (2) intermittent jaundice; and (3) chemical evidence of cholestasis. A pseudocalculus sign was seen in one patient with papillary stenosis. Both bile and pan-
Figure 2. Modified Dorm/a basket, open and closed.
Volume 143, May 1992
Two patients had a polyp in the intersphincteric portion of the common bile duct. In one patient a soft, muddy stone was hidden behind the polyp as it was pulled into the duodenal lumen. This patient had repeated bouts of cholangitis despite several common
Figure 3. A, the sphlncterotome Is /nsefted Into the $ommon bile wlrefsvfW?&ed~outsktethe &ct. 6, the&llt~ papilla of Vater. C, diathermy currant is applkcr to cut the sphincter. D, the stone Is extracted w/th a modkfed Dormla basket.
537
Weitemeyer
Fi@ee 4. Left, comwt posMonof the sphlnctemtome.Center, hmnla basketpullinga stonehvm ths commonbile duct.Ri#t, v filling of the bile duct system afler stone extractlon.
bile duct explorations. The other patient had an abnormality of the distal common bile duct at routine operative cholangiography, which was followed by common bile duct exploration, and also at postoperative cholangiography 5 days later. Three attempts at Burhenne extraction of an “impacted stone” 6 weeks later failed. Endoscopic sphincterotomy of this “stone” showed it to be a polyp that fell out of the papilla next to a juxtaampullary duodenal diverticulum. Both polyps were benign on biopsy. Complications: The morbidity rate in the study was 8.3 percent (four patients). One postsphincterotomy hemorrhage stopped within several hours of the procedure. One patient had a suspected retroperitoneal perforation and responded well to nasogastric suction and intravenous antibiotics. Two patients had a Dormia basket containing stones jammed in the distal end of the common bile duct; in both patients the basket was pulled free after 2 days of observation. No patient required emergency laparotomy, and there was no mortality. Comments
F@au5. AkinthehtrshepatlcfMhrytme Iyeara~Terendasc sphlncterotomyhstrates the long-termpatency of endosc sphlncterotomy.
530
The European success rate with endoscopic sphincterotomy is now 92 percent, compared with 81 percent in our small series. A cholecystectomized patient with choledocholithiasis is an obvious candidate for endoscopic sphincterotomy. Similarly, the
The Amwlcan Journal of Surgeq
Endoscopic
high risk patient with cholelithiasis and jaundice due to common bile duct stones will also benefit from this less taxing procedure. The drainage of purulent bile leaves patients in better condition for subsequent stone removal by elective endoscopic or surgical methods. The long-term patency of sphincterotomy as compared with sphincteroplasty has often been a cause of controversy. The review of Braasch et al [9] of long-term patency with surgical sphincterotomy at the Lahey Clinic leads us to expect similar longterm patency with endoscopic sphincterotomy. The assessment of sphincter of Oddi function in papillary stenosis should be done without narcotics. Even analogues of narcotics will leave an erroneous impression of papillary stenosis. It is hoped that an adequate length of incision will prevent the restenosis so common in this condition. In our experience and that of others [IO], a 15 mm incision has kept the ampulla of Vater patent over 18 months of followUP.
Although very rare, bile duct polyps may be a cause of cholestasis and biliary mud formation [II]. Polyps may also mimic stones. The low mortality and morbidity rates associated with endoscopic sphincterotomy make this procedure a desirable alternative in the treatment of choledocholithiasis and papillary stenosis. The short hospital stay is less of a physical and economic strain and has obvious benefits to the health care delivery system. An unsuccessful endoscopic sphincterotomy does not impair the chances for subsequent surgical treatment. Summary Endoscopic sphincterotomy was attempted in 58 patients and was successful in 48 (81 percent). The findings in these 48 patients were as follows: 43 had
Volume 143, May 1992
Sphincterotomy
choledocholithiasis, 3 had papillary stenosis, and 2 had a lower common bile duct polyp. The morbidity rate was 8.3 percent. No emergency laparotomy was required and there was no mortality. Duodenoscopic sphincterotomy is a safe method for relieving some common conditions of extrahepatic cholestasis. In expert hands the complication and mortality rates appear lower than with conventional surgical techniques. References 1. Classen M, Safrany L. Endoscopic papillotomy and removal of gallstones. Br Med J 1975;4:371-4. 2. Koch H. Endoscopic papillotomy. Endoscopy 1975;7:89-93. 3. Montori A, Viceconte G, Miscusi G, Viceconti GW, Pastorino C. Endoscopic papillotomy. Surg Italy 1975;5:181-4. 4. Safrany L. Duodenoscopic sphincterotomy and gallstone removal. Gastroenterology 1977;72:330-43. 5. Reiter J, Bayer H, Mennicken C, Manegold B. Results of endoscopic papillotomy. A collective experience from endoscopic centers in West Germany. World J Surg 1978;2: 50511. 6. Classen M, Demling L. Endoskopische Sphinkterotomie der Papilla Vateri und Stein-extraktion aus dem Ductus Choledochus. Dtsch Med Wochenschr 1974;99:46@-70. 7. Kawai K, Alasaka Y, Murakami K. Tada M, Kohle Y, Nakajima M. Endoscopic sphincterotomy of the ampulla of Vater. Gastrointest Endosc 1974;20:148-51. 8. Safrany L. Endoscopic sphincterotomy in common bile duct stone induced pancreatitis. An international symposium on the diagnostic and therapeutic aspects of ERCP, Cleveland, Ohio. Syllabus by the Cleveland Clinic FounUation and the Cleveland Clinic International Center for Specialty Studies. March 19-21. 1961. 9. Braasch JW, McCann JC Jr. Observation on single section of the sphincter of Oddi. Surg - Gynecol Obstet 1967;124: 355-8. 10. Safrany L, Kautz G, van Husen N, Weitemeyer R. Endoskopische Papillotomie. Therapiewoche 1979;29:4139-49. 11. Bondestam S, Kivilaakso EO, StandertskjoldNordenstam CM, Holmstrom T, Hastbacka J. Sonographic diagnosis of bile duct polyp. AJR 1980;135:610-1.
539
Endoscopic Sphincterotomy: A Procedure of Choice in the Management of Retained Common Bile Duct Stones And Papillary Stenosis
Rudolph A. Weitemeyer, BSc, MD, FRCS(C), New Westminster, British Columbia, Canada
Endoscopic sphincterotomy is a new procedure used in the management of biliary tract disease. The initial experience of Classen and Safrany [I], Koch [21, Montori et al [3], and Safrany [4] resulted in the spread of this technique worldwide. Endoscopic sphincterotomy was initially reserved for high risk patients. Now, after 9 years of experience with over 5,000 patients, the technique is being acclaimed as the preferred choice in the management of common bile duct stones and papillary stenosis [5]. Technique Endoscopic sphincterotomy has evolved from the diagnostic technique of endoscopic retrograde cholangiopancreatography. Classen and Demling [S] and Kawai et al [ 71, along with many others, helped develop techniques for endoscopic electrosurgical sphincterotomy. The sphincterotome (Figure l), which utilizes the preferred pull method, requires selective bile duct cannulation-a difficult maneuver-but more than compensates by the better control of the length and direction of the sphincterotomy incision. The modified Dormia basket (Figure 2) is used to extract stones. The technique of endoscopic sphincterotomy and stone extraction is shown schematically in Figure 3. Roentgenographic visualization is always used to confirm that the sphincterotome is in the appropriate duct. Indications The well-established indications for endoscopic sphincterotomy are (I) choledocholithiasis in cholecystectomized patients; (2) choledocholithiasis in high risk patients with or without cholelithiasis; (3) papillary stenosis; and (4) ampullary carcinoma (for palliation only). Absolute contraindications for this procedure are (1) a long, From the Department of GeneralSurgery, The Royal Coiumbian Hospital, New Westminster, Srltish Columbia, Canada. Requests for reprints should be addressed to Rudolph A. Weitemeyer, MD, 505-625 Fifth Avenue, New Westminster, British Columbia VIM 1x4. Canada. Presented at the 66th Annual Meeting of the North Pacific Surgical Association, Vancouver, British Columbia, Canada, November 13 and 14, 1961.
536
funnel-shaped stenosis of the distal common bile duct; (2) abnormalities of the proximal parts of the biliary tree; and (3) markedly abnormal clotting factors. Relative contraindications for endoscopic sphincterotomy are huge stones and pancreatitis as a complication of choledocholithiasis [8].
Material and Methods Patients were examined and then admitted to a 24 hour ambulatory care unit for observation. Most patients had had previous cholecystectomy or common bile duct exploration. The male to female ratio was 1 to 1.07 and the patients ranged in age from 33 to 92 years (mean 70.2). If conditions are right after endoscopic sphincterotomy, then the stones are extracted at the first sitting (Figure 4). In half of our endoscopic sphincterotomies we were able to extract the stones at the first sitting. Sometimes with larger stones we had to enlarge the sphincterotomy. If the initial cannulation was not possible with the sphincterotome, then a precutting papillotomy was made according to Cremer. The precutting maneuver usually allows an easy cannulation the following week. If the distal common bile duct is funnel-shaped, good judgment must be exercised to get the maximum length of incision and still prevent a retroperitoneal perforation. Results Endoscopic sphincterotomy was performed successfully in 48 of 58 eligible patients (Table I). In 10 patients the papilla of Vater could not be cannulated. In five patients a funnel-shaped distal common bile duct prevented extraction of stones; however, in these patients infected bile was effectively drained with endoscopic sphincterotomy. In half of the remaining 38 patients with choledocholithiasis, stone extraction was possible at the first sitting. Four patients required two or more attempts at extraction, and in the remainder stones passed spontaneously. The pneumobilogram (Figure 5) 1 year after endoscopic sphincterotomy in a patient with choledocholithiasis demonstrates that long-term patency of this type of sphincterotomy can also be achieved. The American Journal of Surgery
Endoscopic
TABLE I
Sphincterotomy
Summary et Findlngs in 48 Patients Who Underwent Successtul Endoscopic Sphincterotomy
Choledocholithiasis’ With cholecystectomy With intact gallbladder Papillary stenosis With pseudocalculus Lower common bile duct polyp
43 35 8 3
Total
48
89.6
.6:3
1 2
‘h:l 100
In five patients stone extraction was contraindicated due to a funnel-shaped distal common bile duct. l
F/gufe 1. The taut sphlncterotome will cut /Ike a knife when frequency diathermy current is applied.
creatic ducts may be affected by the stenotic process. A 15 mm incision in all three patients showed no clinical signs of restenosis after an 18 month followUP*
Three patients fulfilled the criteria of papillary stenosis: (1) upper abdominal pain related to meals; (2) intermittent jaundice; and (3) chemical evidence of cholestasis. A pseudocalculus sign was seen in one patient with papillary stenosis. Both bile and pan-
Figure 2. Modified Dorm/a basket, open and closed.
Volume 143, May 1992
Two patients had a polyp in the intersphincteric portion of the common bile duct. In one patient a soft, muddy stone was hidden behind the polyp as it was pulled into the duodenal lumen. This patient had repeated bouts of cholangitis despite several common
Figure 3. A, the sphlncterotome Is /nsefted Into the $ommon bile wlrefsvfW?&ed~outsktethe &ct. 6, the&llt~ papilla of Vater. C, diathermy currant is applkcr to cut the sphincter. D, the stone Is extracted w/th a modkfed Dormla basket.
537
Weitemeyer
Fi@ee 4. Left, comwt posMonof the sphlnctemtome.Center, hmnla basketpullinga stonehvm ths commonbile duct.Ri#t, v filling of the bile duct system afler stone extractlon.
bile duct explorations. The other patient had an abnormality of the distal common bile duct at routine operative cholangiography, which was followed by common bile duct exploration, and also at postoperative cholangiography 5 days later. Three attempts at Burhenne extraction of an “impacted stone” 6 weeks later failed. Endoscopic sphincterotomy of this “stone” showed it to be a polyp that fell out of the papilla next to a juxtaampullary duodenal diverticulum. Both polyps were benign on biopsy. Complications: The morbidity rate in the study was 8.3 percent (four patients). One postsphincterotomy hemorrhage stopped within several hours of the procedure. One patient had a suspected retroperitoneal perforation and responded well to nasogastric suction and intravenous antibiotics. Two patients had a Dormia basket containing stones jammed in the distal end of the common bile duct; in both patients the basket was pulled free after 2 days of observation. No patient required emergency laparotomy, and there was no mortality. Comments
F@au5. AkinthehtrshepatlcfMhrytme Iyeara~Terendasc sphlncterotomyhstrates the long-termpatency of endosc sphlncterotomy.
530
The European success rate with endoscopic sphincterotomy is now 92 percent, compared with 81 percent in our small series. A cholecystectomized patient with choledocholithiasis is an obvious candidate for endoscopic sphincterotomy. Similarly, the
The Amwlcan Journal of Surgeq
Endoscopic
high risk patient with cholelithiasis and jaundice due to common bile duct stones will also benefit from this less taxing procedure. The drainage of purulent bile leaves patients in better condition for subsequent stone removal by elective endoscopic or surgical methods. The long-term patency of sphincterotomy as compared with sphincteroplasty has often been a cause of controversy. The review of Braasch et al [9] of long-term patency with surgical sphincterotomy at the Lahey Clinic leads us to expect similar longterm patency with endoscopic sphincterotomy. The assessment of sphincter of Oddi function in papillary stenosis should be done without narcotics. Even analogues of narcotics will leave an erroneous impression of papillary stenosis. It is hoped that an adequate length of incision will prevent the restenosis so common in this condition. In our experience and that of others [IO], a 15 mm incision has kept the ampulla of Vater patent over 18 months of followUP.
Although very rare, bile duct polyps may be a cause of cholestasis and biliary mud formation [II]. Polyps may also mimic stones. The low mortality and morbidity rates associated with endoscopic sphincterotomy make this procedure a desirable alternative in the treatment of choledocholithiasis and papillary stenosis. The short hospital stay is less of a physical and economic strain and has obvious benefits to the health care delivery system. An unsuccessful endoscopic sphincterotomy does not impair the chances for subsequent surgical treatment. Summary Endoscopic sphincterotomy was attempted in 58 patients and was successful in 48 (81 percent). The findings in these 48 patients were as follows: 43 had
Volume 143, May 1992
Sphincterotomy
choledocholithiasis, 3 had papillary stenosis, and 2 had a lower common bile duct polyp. The morbidity rate was 8.3 percent. No emergency laparotomy was required and there was no mortality. Duodenoscopic sphincterotomy is a safe method for relieving some common conditions of extrahepatic cholestasis. In expert hands the complication and mortality rates appear lower than with conventional surgical techniques. References 1. Classen M, Safrany L. Endoscopic papillotomy and removal of gallstones. Br Med J 1975;4:371-4. 2. Koch H. Endoscopic papillotomy. Endoscopy 1975;7:89-93. 3. Montori A, Viceconte G, Miscusi G, Viceconti GW, Pastorino C. Endoscopic papillotomy. Surg Italy 1975;5:181-4. 4. Safrany L. Duodenoscopic sphincterotomy and gallstone removal. Gastroenterology 1977;72:330-43. 5. Reiter J, Bayer H, Mennicken C, Manegold B. Results of endoscopic papillotomy. A collective experience from endoscopic centers in West Germany. World J Surg 1978;2: 50511. 6. Classen M, Demling L. Endoskopische Sphinkterotomie der Papilla Vateri und Stein-extraktion aus dem Ductus Choledochus. Dtsch Med Wochenschr 1974;99:46@-70. 7. Kawai K, Alasaka Y, Murakami K. Tada M, Kohle Y, Nakajima M. Endoscopic sphincterotomy of the ampulla of Vater. Gastrointest Endosc 1974;20:148-51. 8. Safrany L. Endoscopic sphincterotomy in common bile duct stone induced pancreatitis. An international symposium on the diagnostic and therapeutic aspects of ERCP, Cleveland, Ohio. Syllabus by the Cleveland Clinic FounUation and the Cleveland Clinic International Center for Specialty Studies. March 19-21. 1961. 9. Braasch JW, McCann JC Jr. Observation on single section of the sphincter of Oddi. Surg - Gynecol Obstet 1967;124: 355-8. 10. Safrany L, Kautz G, van Husen N, Weitemeyer R. Endoskopische Papillotomie. Therapiewoche 1979;29:4139-49. 11. Bondestam S, Kivilaakso EO, StandertskjoldNordenstam CM, Holmstrom T, Hastbacka J. Sonographic diagnosis of bile duct polyp. AJR 1980;135:610-1.
539