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Endoscopic sphincterotomy for obstructive cholangitis due to stone
398 SELECTED SUMMARIES
patients underwent early surgical intervention and 43 were treated by early endoscopic sphincterotomy and stone extraction. Patients treated by endoscopic sphincterotomy were significantly (p < 0.002) older and had more medical risk factors (p < 0.05). Eleven patients did not undergo surgical or endoscopic drainage either because they recovered promptly with antibiotic treatment (7 patients) or because they died before biliary drainage (4 patients). Six patients in the surgery group died (21.4%) and 16 (57.1%) developed complications that required reoperation in four instances (14.3%). By contrast, in the group treated by endoscopic sphincterotomy, 2 died (4.7%) and 12 (27.9%) had complications, 2 of which (4.7%) required surgical treatment. Four patients treated endoscopically had recurrent cholangitis, caused, in each case, by failure to clear the bile duct of stones, and 1 of these patients died. Thirty-six of the endoscopically treated patients had their gallbladders in place. Thirteen underwent elective cholecystectomy with no deaths. In 23 patients, the gallbladder was not removed. Two of these patients died in the hospital and 6 died later of unrelated causes. Two of the remaining 15 patients required surgery for empyema of the gallbladder and recurrent cholangitis during a follow-up period of 1-7 yr. The major conclusion of the authors is that, in patients with acute cholangitis secondary to common bile duct stones, urgent biliary decompression should be undertaken by endoscopic drainage. Surgical intervention should be reserved for those in whom endoscopic drainage fails or who do not improve with endoscopic drainage. Comment. This clinical review attempts to address three issues: The first issue is the identification of patients with life-threatening acute cholangitis. The second issue is the best method for establishing biliary drainage in those with calculous ductal obstruction. The last issue is the fate of patients who have undergone endoscopic sphincterotomy with the gallbladder still in place. The spectrum of acute bacterial cholangitis varies widely from mild, self-limiting symptoms to a fulminant, rapidly lethal course. In most patients, the acute illness responds well to supportive measures and antibiotics that permit elective treatment of the underlying biliary obstruction. Early identification of patients requiring emergency biliary drainage would be valuable but the present report adds little to earlier studies that have identified malignant biliary obstruction, high fevers, arterial hypotension, high bilirubin levels, anemia, and high white cell counts as factors associated with a poor prognosis (Ann Surg 1980;191:264-70, Arch Surg 1982;117:437-41). The main issue addressed by this report is the best method for biliary drainage in patients with acute cholangitis associated with choledocholithiasis. Until recently, biliary drainage could only be achieved by operative intervention. Advances in interventional radiology and in endoscopic techniques, however, have added percutaneous transhepatic drainage and endoscopic transpapillary drainage (Semin Liver Dis 1982;2:75-86). Endoscopic drainage procedures include nasobiliary catheters, endoprostheses, and endoscopic papillotomy. Percutaneous transhepatic biliary drainage has been reported in small series of patients with cholangitis and may be the preferred nonsurgical approach to proximal biliary obstruction (AJR 1982;138:25-9, Surg Gynecol Obstet 1985;160:523-7). In the present report, strong evidence is presented supporting early endoscopic sphincterotomy and stone extraction as a safer initial approach to biliary decompression
GASTROENTEROLOGYVol. 93, No. 2
than early surgery for patients with cholangitis secondary to choledocholithiasis. As with any retrospective study, it is possible to question the criteria used for patient inclusion and for selection of treatment. The fact that only 7 patients (8.5%) in the present study responded to noninvasive treatment is troubling. A higher proportion of patients with cholangitis secondary to stones will usually respond without biliary drainage (Ann Surg 1980;191:264-70). The authors have attempted to address the issue of comparability of the treatment groups by using a relatively crude scale of medical risk factors. However, the age, frequency of hypotension, degree of leukocytosis, bilirubin level, and urea levels all tended to be higher in patients managed by endoscopic drainage. It is also true that the results of this review are influenced by the relative quality of the endoscopy and surgery. The present report is from a center with substantial experience with endoscopic sphincterotomy and an enviable 98% success rate in accomplishing this procedure (Br J Surg 1985; 72:215-g). The mortality reported in some other recent reports of the surgical treatment of cholangitis secondary to calculous disease is lower than the 21.4% observed in this study but higher than the 4.7% which followed endoscopic drainage [Ann Surg 1980;191:264-70). Last, among 15 patients treated by endoscopic biliary drainage with their gallbladders remaining in place, 2 patients (13.3%) required surgical intervention. The follow-up data, however, is not clearly presented and the risks of this condition remain unclear. Overall, the data presented indicate that urgent endoscopic sphincterotomy and stone extraction can be a valuable method for establishing biliary drainage in patients with acute cholangitis secondary to choledocholithiasis who do not respond rapidly to noninvasive treatment. In experienced hands, it appears to be safer than emergency surgery. As skill with endoscopic sphincterotomy increases, this approach should be more widely employed, with surgical or percutaneous catheter drainage reserved for patients who do not respond rapidly. J. H. C. RANSON, M.D.
Reply. Thank you for giving me the opportunity to reply to the comments of Dr. Ranson. Minor errors in this summary need correction. The study period was 7 yr not 9 yr and the p value for the increased age of patients treated endoscopically was < 0.02 rather than < 0.002. The summary is also slightly misleading as it suggests that the deaths in the surgically and endoscopically treated groups (21.4% and 4.7%) were in addition to the complication rates of 57.1% and 27.9%. The deaths were actually included in the complication figures. There are potential problems with a retrospective study, but the stringent criteria used to define cholangitis appear to have selected a group of patients at the most severe end of the spectrum for this disease, as witnessed by the small percentage (8.5%) responding to noninvasive treatment alone. Patients with milder cholangitis usually did not fulfill all the clinical criteria for inclusion (temperature > 38°C with a history of rigors, clinically apparent jaundice, and upper abdominal pain or tenderness) or did not have frank pus in the common bile duct. Patients treated with initial endoscopic sphincterotomy had equally severe cholangitis on laboratory and clinical criteria and were significantly older with significantly more medical risk factors than the surgically treated patients. Low serum albumin and high serum urea on admission, together with the presence of preexisting medical risk factors, were associated with poor prognosis in this study. Similar results have been reported in biliary surgery (Br J Surg 1983;70:535-8). These criteria may be more useful than the risk factors listed by Dr. Ranson, which did not correlate with severe outcome in this study.
August 1987
Percutaneous transhepatic drainage may be indicated for proximal biliary obstruction, but for patients with obstructive cholangitis due to stone, endoscopic sphincterotomy is to be preferred. High complication rates have been reported for simple diagnostic percutaneous transhepatic cholangiography in the presence of acute cholangitis (Ann Surg 1982;195:137-45), and small drainage tubes used to minimize the major risks of hemorrhage and biliary leak may prove inadequate in the presence of viscous purulent bile. Even if percutaneous procedures are safe, they require additional procedures to clear the ducts when stones are demonstrated, though percutaneous catheter extraction (Radiology 1979;133:242-3) and dissolution methods (Surgery 1981; 90:584-7) have been suggested.
SELECTED SUMMARIES
399
Certainly the results of this study were influenced by the high quality of endoscopy available in Leicester, but they compare favorably with even the best results obtained from surgery in this high risk group of patients. Endoscopic sphincterotomy will become the procedure of choice in these patients. The leaving “in situ” of the gallbladder in frail elderly patients after the endoscopic treatment of common bile duct calculi is a well-established practice in many European centers. Long-term results are good with relatively few patients requiring subsequent cholecystectomy or dying as a result of gallbladder pathology (Br J Surg 1984;71:69-71, 1987;74:209-11, Gut 1984;25:598-602). T.LEESE,F.R.C.S.
patients underwent early surgical intervention and 43 were treated by early endoscopic sphincterotomy and stone extraction. Patients treated by endoscopic sphincterotomy were significantly (p < 0.002) older and had more medical risk factors (p < 0.05). Eleven patients did not undergo surgical or endoscopic drainage either because they recovered promptly with antibiotic treatment (7 patients) or because they died before biliary drainage (4 patients). Six patients in the surgery group died (21.4%) and 16 (57.1%) developed complications that required reoperation in four instances (14.3%). By contrast, in the group treated by endoscopic sphincterotomy, 2 died (4.7%) and 12 (27.9%) had complications, 2 of which (4.7%) required surgical treatment. Four patients treated endoscopically had recurrent cholangitis, caused, in each case, by failure to clear the bile duct of stones, and 1 of these patients died. Thirty-six of the endoscopically treated patients had their gallbladders in place. Thirteen underwent elective cholecystectomy with no deaths. In 23 patients, the gallbladder was not removed. Two of these patients died in the hospital and 6 died later of unrelated causes. Two of the remaining 15 patients required surgery for empyema of the gallbladder and recurrent cholangitis during a follow-up period of 1-7 yr. The major conclusion of the authors is that, in patients with acute cholangitis secondary to common bile duct stones, urgent biliary decompression should be undertaken by endoscopic drainage. Surgical intervention should be reserved for those in whom endoscopic drainage fails or who do not improve with endoscopic drainage. Comment. This clinical review attempts to address three issues: The first issue is the identification of patients with life-threatening acute cholangitis. The second issue is the best method for establishing biliary drainage in those with calculous ductal obstruction. The last issue is the fate of patients who have undergone endoscopic sphincterotomy with the gallbladder still in place. The spectrum of acute bacterial cholangitis varies widely from mild, self-limiting symptoms to a fulminant, rapidly lethal course. In most patients, the acute illness responds well to supportive measures and antibiotics that permit elective treatment of the underlying biliary obstruction. Early identification of patients requiring emergency biliary drainage would be valuable but the present report adds little to earlier studies that have identified malignant biliary obstruction, high fevers, arterial hypotension, high bilirubin levels, anemia, and high white cell counts as factors associated with a poor prognosis (Ann Surg 1980;191:264-70, Arch Surg 1982;117:437-41). The main issue addressed by this report is the best method for biliary drainage in patients with acute cholangitis associated with choledocholithiasis. Until recently, biliary drainage could only be achieved by operative intervention. Advances in interventional radiology and in endoscopic techniques, however, have added percutaneous transhepatic drainage and endoscopic transpapillary drainage (Semin Liver Dis 1982;2:75-86). Endoscopic drainage procedures include nasobiliary catheters, endoprostheses, and endoscopic papillotomy. Percutaneous transhepatic biliary drainage has been reported in small series of patients with cholangitis and may be the preferred nonsurgical approach to proximal biliary obstruction (AJR 1982;138:25-9, Surg Gynecol Obstet 1985;160:523-7). In the present report, strong evidence is presented supporting early endoscopic sphincterotomy and stone extraction as a safer initial approach to biliary decompression
GASTROENTEROLOGYVol. 93, No. 2
than early surgery for patients with cholangitis secondary to choledocholithiasis. As with any retrospective study, it is possible to question the criteria used for patient inclusion and for selection of treatment. The fact that only 7 patients (8.5%) in the present study responded to noninvasive treatment is troubling. A higher proportion of patients with cholangitis secondary to stones will usually respond without biliary drainage (Ann Surg 1980;191:264-70). The authors have attempted to address the issue of comparability of the treatment groups by using a relatively crude scale of medical risk factors. However, the age, frequency of hypotension, degree of leukocytosis, bilirubin level, and urea levels all tended to be higher in patients managed by endoscopic drainage. It is also true that the results of this review are influenced by the relative quality of the endoscopy and surgery. The present report is from a center with substantial experience with endoscopic sphincterotomy and an enviable 98% success rate in accomplishing this procedure (Br J Surg 1985; 72:215-g). The mortality reported in some other recent reports of the surgical treatment of cholangitis secondary to calculous disease is lower than the 21.4% observed in this study but higher than the 4.7% which followed endoscopic drainage [Ann Surg 1980;191:264-70). Last, among 15 patients treated by endoscopic biliary drainage with their gallbladders remaining in place, 2 patients (13.3%) required surgical intervention. The follow-up data, however, is not clearly presented and the risks of this condition remain unclear. Overall, the data presented indicate that urgent endoscopic sphincterotomy and stone extraction can be a valuable method for establishing biliary drainage in patients with acute cholangitis secondary to choledocholithiasis who do not respond rapidly to noninvasive treatment. In experienced hands, it appears to be safer than emergency surgery. As skill with endoscopic sphincterotomy increases, this approach should be more widely employed, with surgical or percutaneous catheter drainage reserved for patients who do not respond rapidly. J. H. C. RANSON, M.D.
Reply. Thank you for giving me the opportunity to reply to the comments of Dr. Ranson. Minor errors in this summary need correction. The study period was 7 yr not 9 yr and the p value for the increased age of patients treated endoscopically was < 0.02 rather than < 0.002. The summary is also slightly misleading as it suggests that the deaths in the surgically and endoscopically treated groups (21.4% and 4.7%) were in addition to the complication rates of 57.1% and 27.9%. The deaths were actually included in the complication figures. There are potential problems with a retrospective study, but the stringent criteria used to define cholangitis appear to have selected a group of patients at the most severe end of the spectrum for this disease, as witnessed by the small percentage (8.5%) responding to noninvasive treatment alone. Patients with milder cholangitis usually did not fulfill all the clinical criteria for inclusion (temperature > 38°C with a history of rigors, clinically apparent jaundice, and upper abdominal pain or tenderness) or did not have frank pus in the common bile duct. Patients treated with initial endoscopic sphincterotomy had equally severe cholangitis on laboratory and clinical criteria and were significantly older with significantly more medical risk factors than the surgically treated patients. Low serum albumin and high serum urea on admission, together with the presence of preexisting medical risk factors, were associated with poor prognosis in this study. Similar results have been reported in biliary surgery (Br J Surg 1983;70:535-8). These criteria may be more useful than the risk factors listed by Dr. Ranson, which did not correlate with severe outcome in this study.
August 1987
Percutaneous transhepatic drainage may be indicated for proximal biliary obstruction, but for patients with obstructive cholangitis due to stone, endoscopic sphincterotomy is to be preferred. High complication rates have been reported for simple diagnostic percutaneous transhepatic cholangiography in the presence of acute cholangitis (Ann Surg 1982;195:137-45), and small drainage tubes used to minimize the major risks of hemorrhage and biliary leak may prove inadequate in the presence of viscous purulent bile. Even if percutaneous procedures are safe, they require additional procedures to clear the ducts when stones are demonstrated, though percutaneous catheter extraction (Radiology 1979;133:242-3) and dissolution methods (Surgery 1981; 90:584-7) have been suggested.
SELECTED SUMMARIES
399
Certainly the results of this study were influenced by the high quality of endoscopy available in Leicester, but they compare favorably with even the best results obtained from surgery in this high risk group of patients. Endoscopic sphincterotomy will become the procedure of choice in these patients. The leaving “in situ” of the gallbladder in frail elderly patients after the endoscopic treatment of common bile duct calculi is a well-established practice in many European centers. Long-term results are good with relatively few patients requiring subsequent cholecystectomy or dying as a result of gallbladder pathology (Br J Surg 1984;71:69-71, 1987;74:209-11, Gut 1984;25:598-602). T.LEESE,F.R.C.S.