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Multiquadrant precut papillotomy for extraction of large impacted common bile duct stone
Gastrointest Radiol 1978;3:349-51. 14. Farkas IE, Patk6 A, Szebeni A, Tulassay Z. Diverticulum ofthe bile duct: diagnosis by endoscopic retrograde cholangiopancreatography and ultrasonography. Am J Gastroenterol 1980;73:310-4. 15. Kagawa Y, Kashihara S, Kuramoto S, Maetani S. Carcinoma arising in a congenitally dilated biliary tract: report of a case and review of the literature. Gastroenterology 1978;74:1286-94. 16. Todani T, Tabuchi K, Watanabe Y, Kobayashi T. Carcinoma
ansmg in the wall of congenital bile duct cysts. Cancer 1979;44:1134-41. 17. Fischer HG. Primiires karzinom in der wand einer angeborenen zystischen gallengangserweitenmg (sog. hepatikuszyste). Zentralbl Chir 1958;83:1234-41. 18. MacFarlane JR, Glenn F. Carcinoma in choledochal cyst. JAMA 1967;202:1003-6. 19. Filler RM, Stringel G. Treatment of choledochal cyst by excision. J Pediatr Surg 1980;15:437-42.
Technical Notes Multiquadrant precut papillotomy for extraction of large impacted common bile duct stone John B. Marshall, MD William N. Stassen, MD
The successful endoscopic removal of common duct calculi appears, in part, to be dependent on stone size. Several reports have indicated that the presence of a common duct stone greater than 25 mm in diameter is a relative contraindication to removal via endoscopic sphincterotomy.1-3 However, these reports fail to note that the shape, relative location in the common duct, and degree of impaction, if present, may equally influence successful, uncomplicated stone extraction. We recently encountered a patient with a giant, impacted common duct stone, which we removed using a multiquadrant precut sphincterotomy technique. In this report we describe this technique and discuss those factors which influence the endoscopic removal of large calculi. CASE REPORT
A 92-year-old woman was admitted to Cleveland Metropolitan General Hospital with a history of progressive obtundation, jaundice first noted on the day of admission, and spiking fevers of several days' duration. No further history was available as the patient was aphasic secondary to a remote left-sided cerebral vascular accident. Physical examination revealed a debilitated, dehydrated, icteric white female, responsive only to painful stimuli. Her temperature was 38.8°C (rectal); pulse, 120 beats per min; blood pressure, 130/50 mm Hg; and respirations, 32 per min. The abdominal examination failed to show guarding, rebound tenderness, or hepatosplenomegaly. The gallbladder was not palpable and bowel sounds were hypoactive. The urine was positive for both bile and glucose. The From the Division of Gastroenterology, Cleveland Metropolitan General Hospital, Case Western Reserve University, Cleveland, Ohio. Reprint requests: John B. Marshall, MD, Division of Gastroenterology, Clevelarid Metropolitan Gen7!ral Hospital, 3395 Scranton Road, Cleveland, Ohio 44109.
336
hematocrit was 34%; the white cell count was 21,900/mm3 with 56% neutrophils, 39% bands, 3% lymphocytes, and 2% monocytes. The platelet count was 196,OOO/mm3 , prothrombin time was 11.9/11.9 sec (patient/control), and partial thromboplastin time was 26.7/26.2 sec (patient/control). The blood glucose was 269 mg/dl; total bilirubin, 7.0 mg/dl; SGOT, 32 mD/ml, and SGPT, 35 mD/ml (normal for both, <40); alkaline phosphatase, 960 mD/ml (normal, <125); amylase, 1320 IU/liter (normal, <125); lipase, 5.9 D/ml (normal, <2.0). Abdominal ultrasound revealed a massively dilated gallbladder containing multiple calculi. The common bile duct measured greater than 2 cm in diameter, and there was associated dilation of the intrahepatic biliary tree. With a tentative diagnosis of choledocholithiasis and ascending cholangitis, the patient was first treated with intravenous fluids and broad spectrum antibiotics. She subsequently underwent endoscopic evaluation of the biliary tree. With only topical anesthesia of the posterior pharynx, the side-viewing duodenoscope was introduced into the duodenum and the ampulla of Vater was identified. A very large yellow-black calculus was noted to be tightly impacted in the ampulla with the rounded leading end of the stone slightly protruding into the duodenum. The rim of the ampulla was stretched to a diameter of approximately 1.5 cm, and that portion of the stone lying in the intraduodenal segment of the common duct caused a bulge in the medial wall of the duodenum proximal to the ampulla. In order to free the impacted stone, a tapered-tip papillotome was wedged under the lip of the ampulla so that the papillotome wire was in the 12 o'clock position. A series of short applications of cutting current were used to extend this incision over the edge of the calculus. The duodenoscope and papillotome were then repositioned to permit similar incisions in the 3 and 9 o'clock positions (Fig. 1). The papillotome was then withdrawn and the tip of the duodenoscope was used to free the impacted stone by pushing on that portion of the calculus bulging into the duodenum. Following extraction of this giant calculus, a large volume of pus and bile flowed into the duodenum. The common bile duct was then flushed with normal saline, and a cholangiogram was obtained to ensure the absence of additional calculi. This cholangiogram demonstrated a massively dilated biliary tree and a giant calculus in the second portion of the duodenum (Fig. 2). Following the procedure, the patient developed transient GASTROINTESTINAL ENDOSCOPY
Figure 1. Schematic representation of a calculus impacted in the papilla of Vater. Note the three-quadrant, precut sphincterotomy with sphincterotome in position to extend the 12 o'clock incision.
hypotension requiring further intravenous fluid and blood pressure support. Thereafter, her recovery was uneventful. Eight hours following the procedure she passed a calculus which measured 2.6 cm in diameter and 3.5 cm in length. The patient subsequently returned to the nursing home in her usual state of health. DISCUSSION
The majority of common duct calculi are small (less than 10 mm in diameter)4 and probably pass through the muscular sphincter of the ampulla of Vater without inducing symtoms. 5 In contrast, moderate (10 to 19 mm in diameter) and large (20 to 25 mm in diameter) calculi account for 35% and 13% of retained stones, respectively,6 and can be associated with a variety of symptoms including pancreatitis? andjaundice with or without ascending cholangitis. 8 Less than 5% of retained calculi remain in the common duct long enough for sufficient cholesterol and/or pigment deposition on their surface to cause them to grow to greater than 25 mm in diameter (giant calculi). These large calculi may form above the common bile duct sphincter, remain free floating, and because of ball-valve motion, assume a spherical shape. Their endoscopic removal may be contraindicated because the length of the incision required to provide a 20- to 25-mm hiatus through the duodenal wall and ampullary musculature exceeds the limits of a safe sphincterotomy and is associated with an increased frequency of perforation. This problem may ultimately be resolved by the use of the recently developed meVOLUME 31, NO.5, 1985
2. Postsphincterotomy cholangiogram showing the dilated biliary tree outlined with contrast (open arrows) and a giant calculus in the duodenum (solid arrows).
Figure
chanicallithotripter, which has been adapted for endoscopic insertion into the common duct following sphincterotomy to break up large retained calculi. 9 In a small number of patients, large calculi may either form in the ampullary region below the common bile duct sphincter or, alternatively, may be gradually forced through this sphincter causing it to progressively dilate. These stones may then become impacted at the papilla of Vater, and extraction may require the interruption of the restricting muscle fibers of the papillary sphincter itself. In our patient, a single precut incision at 12 o'clock did not relieve the tension sufficiently to allow stone passage. However, by using several additional short (3 to 5 mm) precut incisions at 9 and 3 o'clock on the dilated lip of the papilla, we were able to free the leading edge of the impacted giant calculus. Although ERCP is useful in defining the size, shape, and mobility of free floating stones, impaction of the calculus at the papilla precludes radiologic evaluation of either the pancreatic duct or biliary tree by ERCP. Thus, both the anatomic orientation of these ducts in the region of the sphincter and the size and shape of the nonvisible portion of the calculus remain unknown. Although precut papillotomy at the 12 o'clock position is an accepted, relatively safe procedure,1O precut incisions in other positions may be associated with an increased risk of perforation or pancreatitis, par337
ticularly if the length of the cut is not controlled. Multiquadrant precut papillotomy should only be performed by an experienced endoscopist, highly experienced in endoscopic papillotomy. Because our patient had a prominent intraduodenal common duct segment and the calculus could be seen bulging into the duodenum, we were able to effect stone passage by pushing it into the duodenum with the tip of the endoscope, rather than by using forceps to work it free. Alternatively, the leading edge of an impacted calculus can occasionally be freed enough by the precut sphincterotomy to permit a balloon catheter to be slipped above the impacted calculus, thereby permitting balloon extraction. If possible, an impacted calculus which has been delivered into the duodenum should be retained in a basket snare and withdrawn with the endoscope to eliminate the possibility of mechanical obstruction resulting from gallstone ileus. If basket extraction is technically not feasible, the patient should be monitored until the calculus has passed via the stool. Although the need for multiquadrant precut sphincterotomy occurs infrequently, if performed with skill and care, it can enhance one's success in removing
ERCP and endoscopic sphincterotomy in patients with situs inversus R. P. Venu, MD J. E. Geenen, MD W. J. Hogan, MD G. K. Johnson, MD A. J. Taylor, MD E. T. Stewart, MD A. Jackson, RT
Endoscopic retrograde cholangiopancreatography (ERCP) is associated with a successful cannulation rate of 80% to 95%.1,2 Technical difficulty may be experienced, however, if patients have structural alterations of the distal stomach, duodenum, or papilla. These anatomic alterations usually result from operative procedures involving the stomach or duodenum. Situs inversus, a congenital malposition of the internal viscera, is a relatively rare situation in which successful cannulation and ERCP may be technically difficult. We have successfully performed diagnostic ERCP and endoscopic sphincterotomy in three patients with From the Department of Radiology and Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; and St. Luke's Hospital, Racine, Wisconsin. Reprint requests: J. E. Geenen, MD, Department of Medicine, 1333 College Ave., Racine, Wisconsin 53403. 338
those large, impacted calculi that are particularly difficult to extract via the endoscope and often require surgical removal. REFERENCES 1. Viceconte G, Viceconte GW, Pietropaolo V, Montori A. Endo-
2. 3. 4. 5. 6. 7. 8. 9. 10.
sopic sphincterotomy: indications and results. Br J Surg 1981;68:376-80. Cotton PB. Non-operative removal of bile duct stones by duodenoscopic sphincterotomy. Br J Surg 1980;67:1-5. Safrany L. Duodenoscopic sphincterotomy and gallstone removal. Gastroenterology 1977;72:338-43. Liquory C, Loriga P. Endoscopic sphincterotomy analysis of 15 cases. Am J Surg 1978;136:609-13. Kreel L. Radiology of the biliary system. Clin Gastroenterol 1973;2:185-9. Summerfield JA, Hunt RH, Lister AH, Kirk AP. Endoscopic sphincterotomy for bile duct stones. Br J RadioI1980;53:10416. Safrany L, Cotton PB. A preliminary report: urgent duodenoscopic sphincterotomy for acute gallstone pancreatitis. Surgery 1981;89:424-8. Cotton PB, Vallon AG. British experience with duodenoscopic sphincterotomy for removal of bile duct stones. Br J Surg 1981;68:373-5. Demling L. Endoscopic papillotomy (EPT)-indications and technique. Endoscopy 1983;15:162-4. Siegel JH. Precut papillotomy: a method to improve success of ERCP and papillotomy. Endoscopy 1980;12:13Q.-3.
situs inversus. Two of these patients had common bile duct stones, and one patient had papillary stenosis. The endoscopic technique we found useful for successful ERCP in patients with situs inversus is discussed briefly. PATIENTS AND METHOD Patients
Case 1. An 87-year-old white woman presented with a history of intermittent left upper quadrant abdominal pain and jaundice. The patient was known to have situs inversus totalis characterized by dextroposition of the heart and abdominal viscera. She had a cholecystectomy for symptomatic cholelithiasis performed 10 years earlier. Physical examination disclosed jaundice, mild epigastric, and left upper quadrant abdominal tenderness. Laboratory studies showed elevation of bilirubin 2.5 mg/dl (normal, 0.22 to 1.2); alkaline phosphatase, 300 U/liter (normal, 85 to 115); and SGOT, 55 IV/liter (normal, 0 to 40). Ultrasound examination of the biliary tract was unremarkable. ERCP revealed a normal papilla and a 5-mm stone in an otherwise normal appearing common bile duct (Fig. 1). Endoscopic sphincterotomy was performed and the stone was extracted. Case 2. A 79-year-old white woman was referred for suspected biliary tract obstruction. She had intermittent epiGASTROINTESTINAL ENDOSCOPY
ansmg in the wall of congenital bile duct cysts. Cancer 1979;44:1134-41. 17. Fischer HG. Primiires karzinom in der wand einer angeborenen zystischen gallengangserweitenmg (sog. hepatikuszyste). Zentralbl Chir 1958;83:1234-41. 18. MacFarlane JR, Glenn F. Carcinoma in choledochal cyst. JAMA 1967;202:1003-6. 19. Filler RM, Stringel G. Treatment of choledochal cyst by excision. J Pediatr Surg 1980;15:437-42.
Technical Notes Multiquadrant precut papillotomy for extraction of large impacted common bile duct stone John B. Marshall, MD William N. Stassen, MD
The successful endoscopic removal of common duct calculi appears, in part, to be dependent on stone size. Several reports have indicated that the presence of a common duct stone greater than 25 mm in diameter is a relative contraindication to removal via endoscopic sphincterotomy.1-3 However, these reports fail to note that the shape, relative location in the common duct, and degree of impaction, if present, may equally influence successful, uncomplicated stone extraction. We recently encountered a patient with a giant, impacted common duct stone, which we removed using a multiquadrant precut sphincterotomy technique. In this report we describe this technique and discuss those factors which influence the endoscopic removal of large calculi. CASE REPORT
A 92-year-old woman was admitted to Cleveland Metropolitan General Hospital with a history of progressive obtundation, jaundice first noted on the day of admission, and spiking fevers of several days' duration. No further history was available as the patient was aphasic secondary to a remote left-sided cerebral vascular accident. Physical examination revealed a debilitated, dehydrated, icteric white female, responsive only to painful stimuli. Her temperature was 38.8°C (rectal); pulse, 120 beats per min; blood pressure, 130/50 mm Hg; and respirations, 32 per min. The abdominal examination failed to show guarding, rebound tenderness, or hepatosplenomegaly. The gallbladder was not palpable and bowel sounds were hypoactive. The urine was positive for both bile and glucose. The From the Division of Gastroenterology, Cleveland Metropolitan General Hospital, Case Western Reserve University, Cleveland, Ohio. Reprint requests: John B. Marshall, MD, Division of Gastroenterology, Clevelarid Metropolitan Gen7!ral Hospital, 3395 Scranton Road, Cleveland, Ohio 44109.
336
hematocrit was 34%; the white cell count was 21,900/mm3 with 56% neutrophils, 39% bands, 3% lymphocytes, and 2% monocytes. The platelet count was 196,OOO/mm3 , prothrombin time was 11.9/11.9 sec (patient/control), and partial thromboplastin time was 26.7/26.2 sec (patient/control). The blood glucose was 269 mg/dl; total bilirubin, 7.0 mg/dl; SGOT, 32 mD/ml, and SGPT, 35 mD/ml (normal for both, <40); alkaline phosphatase, 960 mD/ml (normal, <125); amylase, 1320 IU/liter (normal, <125); lipase, 5.9 D/ml (normal, <2.0). Abdominal ultrasound revealed a massively dilated gallbladder containing multiple calculi. The common bile duct measured greater than 2 cm in diameter, and there was associated dilation of the intrahepatic biliary tree. With a tentative diagnosis of choledocholithiasis and ascending cholangitis, the patient was first treated with intravenous fluids and broad spectrum antibiotics. She subsequently underwent endoscopic evaluation of the biliary tree. With only topical anesthesia of the posterior pharynx, the side-viewing duodenoscope was introduced into the duodenum and the ampulla of Vater was identified. A very large yellow-black calculus was noted to be tightly impacted in the ampulla with the rounded leading end of the stone slightly protruding into the duodenum. The rim of the ampulla was stretched to a diameter of approximately 1.5 cm, and that portion of the stone lying in the intraduodenal segment of the common duct caused a bulge in the medial wall of the duodenum proximal to the ampulla. In order to free the impacted stone, a tapered-tip papillotome was wedged under the lip of the ampulla so that the papillotome wire was in the 12 o'clock position. A series of short applications of cutting current were used to extend this incision over the edge of the calculus. The duodenoscope and papillotome were then repositioned to permit similar incisions in the 3 and 9 o'clock positions (Fig. 1). The papillotome was then withdrawn and the tip of the duodenoscope was used to free the impacted stone by pushing on that portion of the calculus bulging into the duodenum. Following extraction of this giant calculus, a large volume of pus and bile flowed into the duodenum. The common bile duct was then flushed with normal saline, and a cholangiogram was obtained to ensure the absence of additional calculi. This cholangiogram demonstrated a massively dilated biliary tree and a giant calculus in the second portion of the duodenum (Fig. 2). Following the procedure, the patient developed transient GASTROINTESTINAL ENDOSCOPY
Figure 1. Schematic representation of a calculus impacted in the papilla of Vater. Note the three-quadrant, precut sphincterotomy with sphincterotome in position to extend the 12 o'clock incision.
hypotension requiring further intravenous fluid and blood pressure support. Thereafter, her recovery was uneventful. Eight hours following the procedure she passed a calculus which measured 2.6 cm in diameter and 3.5 cm in length. The patient subsequently returned to the nursing home in her usual state of health. DISCUSSION
The majority of common duct calculi are small (less than 10 mm in diameter)4 and probably pass through the muscular sphincter of the ampulla of Vater without inducing symtoms. 5 In contrast, moderate (10 to 19 mm in diameter) and large (20 to 25 mm in diameter) calculi account for 35% and 13% of retained stones, respectively,6 and can be associated with a variety of symptoms including pancreatitis? andjaundice with or without ascending cholangitis. 8 Less than 5% of retained calculi remain in the common duct long enough for sufficient cholesterol and/or pigment deposition on their surface to cause them to grow to greater than 25 mm in diameter (giant calculi). These large calculi may form above the common bile duct sphincter, remain free floating, and because of ball-valve motion, assume a spherical shape. Their endoscopic removal may be contraindicated because the length of the incision required to provide a 20- to 25-mm hiatus through the duodenal wall and ampullary musculature exceeds the limits of a safe sphincterotomy and is associated with an increased frequency of perforation. This problem may ultimately be resolved by the use of the recently developed meVOLUME 31, NO.5, 1985
2. Postsphincterotomy cholangiogram showing the dilated biliary tree outlined with contrast (open arrows) and a giant calculus in the duodenum (solid arrows).
Figure
chanicallithotripter, which has been adapted for endoscopic insertion into the common duct following sphincterotomy to break up large retained calculi. 9 In a small number of patients, large calculi may either form in the ampullary region below the common bile duct sphincter or, alternatively, may be gradually forced through this sphincter causing it to progressively dilate. These stones may then become impacted at the papilla of Vater, and extraction may require the interruption of the restricting muscle fibers of the papillary sphincter itself. In our patient, a single precut incision at 12 o'clock did not relieve the tension sufficiently to allow stone passage. However, by using several additional short (3 to 5 mm) precut incisions at 9 and 3 o'clock on the dilated lip of the papilla, we were able to free the leading edge of the impacted giant calculus. Although ERCP is useful in defining the size, shape, and mobility of free floating stones, impaction of the calculus at the papilla precludes radiologic evaluation of either the pancreatic duct or biliary tree by ERCP. Thus, both the anatomic orientation of these ducts in the region of the sphincter and the size and shape of the nonvisible portion of the calculus remain unknown. Although precut papillotomy at the 12 o'clock position is an accepted, relatively safe procedure,1O precut incisions in other positions may be associated with an increased risk of perforation or pancreatitis, par337
ticularly if the length of the cut is not controlled. Multiquadrant precut papillotomy should only be performed by an experienced endoscopist, highly experienced in endoscopic papillotomy. Because our patient had a prominent intraduodenal common duct segment and the calculus could be seen bulging into the duodenum, we were able to effect stone passage by pushing it into the duodenum with the tip of the endoscope, rather than by using forceps to work it free. Alternatively, the leading edge of an impacted calculus can occasionally be freed enough by the precut sphincterotomy to permit a balloon catheter to be slipped above the impacted calculus, thereby permitting balloon extraction. If possible, an impacted calculus which has been delivered into the duodenum should be retained in a basket snare and withdrawn with the endoscope to eliminate the possibility of mechanical obstruction resulting from gallstone ileus. If basket extraction is technically not feasible, the patient should be monitored until the calculus has passed via the stool. Although the need for multiquadrant precut sphincterotomy occurs infrequently, if performed with skill and care, it can enhance one's success in removing
ERCP and endoscopic sphincterotomy in patients with situs inversus R. P. Venu, MD J. E. Geenen, MD W. J. Hogan, MD G. K. Johnson, MD A. J. Taylor, MD E. T. Stewart, MD A. Jackson, RT
Endoscopic retrograde cholangiopancreatography (ERCP) is associated with a successful cannulation rate of 80% to 95%.1,2 Technical difficulty may be experienced, however, if patients have structural alterations of the distal stomach, duodenum, or papilla. These anatomic alterations usually result from operative procedures involving the stomach or duodenum. Situs inversus, a congenital malposition of the internal viscera, is a relatively rare situation in which successful cannulation and ERCP may be technically difficult. We have successfully performed diagnostic ERCP and endoscopic sphincterotomy in three patients with From the Department of Radiology and Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; and St. Luke's Hospital, Racine, Wisconsin. Reprint requests: J. E. Geenen, MD, Department of Medicine, 1333 College Ave., Racine, Wisconsin 53403. 338
those large, impacted calculi that are particularly difficult to extract via the endoscope and often require surgical removal. REFERENCES 1. Viceconte G, Viceconte GW, Pietropaolo V, Montori A. Endo-
2. 3. 4. 5. 6. 7. 8. 9. 10.
sopic sphincterotomy: indications and results. Br J Surg 1981;68:376-80. Cotton PB. Non-operative removal of bile duct stones by duodenoscopic sphincterotomy. Br J Surg 1980;67:1-5. Safrany L. Duodenoscopic sphincterotomy and gallstone removal. Gastroenterology 1977;72:338-43. Liquory C, Loriga P. Endoscopic sphincterotomy analysis of 15 cases. Am J Surg 1978;136:609-13. Kreel L. Radiology of the biliary system. Clin Gastroenterol 1973;2:185-9. Summerfield JA, Hunt RH, Lister AH, Kirk AP. Endoscopic sphincterotomy for bile duct stones. Br J RadioI1980;53:10416. Safrany L, Cotton PB. A preliminary report: urgent duodenoscopic sphincterotomy for acute gallstone pancreatitis. Surgery 1981;89:424-8. Cotton PB, Vallon AG. British experience with duodenoscopic sphincterotomy for removal of bile duct stones. Br J Surg 1981;68:373-5. Demling L. Endoscopic papillotomy (EPT)-indications and technique. Endoscopy 1983;15:162-4. Siegel JH. Precut papillotomy: a method to improve success of ERCP and papillotomy. Endoscopy 1980;12:13Q.-3.
situs inversus. Two of these patients had common bile duct stones, and one patient had papillary stenosis. The endoscopic technique we found useful for successful ERCP in patients with situs inversus is discussed briefly. PATIENTS AND METHOD Patients
Case 1. An 87-year-old white woman presented with a history of intermittent left upper quadrant abdominal pain and jaundice. The patient was known to have situs inversus totalis characterized by dextroposition of the heart and abdominal viscera. She had a cholecystectomy for symptomatic cholelithiasis performed 10 years earlier. Physical examination disclosed jaundice, mild epigastric, and left upper quadrant abdominal tenderness. Laboratory studies showed elevation of bilirubin 2.5 mg/dl (normal, 0.22 to 1.2); alkaline phosphatase, 300 U/liter (normal, 85 to 115); and SGOT, 55 IV/liter (normal, 0 to 40). Ultrasound examination of the biliary tract was unremarkable. ERCP revealed a normal papilla and a 5-mm stone in an otherwise normal appearing common bile duct (Fig. 1). Endoscopic sphincterotomy was performed and the stone was extracted. Case 2. A 79-year-old white woman was referred for suspected biliary tract obstruction. She had intermittent epiGASTROINTESTINAL ENDOSCOPY