Endoscopic Choledochoduodenostomy (ECDT): A Practical Approach to Management of Impacted Papillary Gallstones and Ampullary Tumors

Abstract

We report five cases of impacted papillary stones and two cases of ampullary carcinoma treated by endoscopic choledochoduodenostomy (ECDT) at Riyadh Armed Forces Hospital (RAFH).The procedure was carried out successfully in all five cases with impacted stones and in one of the two cases of ampullary carcinoma. No complications were noted. In the presence of the necessary endoscopic expertise and in cases of impossible cannulation of the papilla of Vater due to stone impaction or the presence of a papillary tumor, we recommend endoscopic choledochoduodenostomy (ECDT). This approach provides an access to the common bile duct thus allowing appropriate therapeutic procedures on the biliary system to be performed. Endoscopic removal of common bile duct (CBD) stones is an established, effective, and safe procedure, particularly in the very sick and elderly [1][2][3]. However, cannulating the papilla is not always successful and even in experienced hands, there is a failure rate of 10% to 15% [4]. This is particularly the case when gallstones are impacted in the para-papillary region or there are occluding tumors rendering cannulation of the papillary orifice impossible.Endoscopic choledochoduodenostomy (ECDT) was introduced as an alternative procedure for these sort of cases [5,6] and the results have so far been encouraging. Its indications include both impacted papillary stones and palliative treatment for bile duct and ampullary cancer [7].Between 1984 and 1989, we treated seven patients; five with impacted papillary stones and two with ampullary carcinoma using ECDT at the Gastroenterology Unit in Riyadh Armed Forces Hospital, Riyadh, Saudi Arabia. This report describes the procedure in these seven patients and discusses its indications, morbidity, and outcome. Patients and MethodsA total of seven cases (five men and two women) age group 32 to 86 years (mean 59 years) with cholestatic jaundice were managed by the ECDT at the Gastroenterology Unit, Riyadh Armed Forces Hospital.Prior to treatment, all patients were admitted to the hospital, clinically examined, and the relevant blood tests and abdominal ultrasound examinations were performed. At endoscopy, routine premedication with midazolam and buscopan were given intravenously. A side-view duodenoscope (Videoscope JFX IT or IT10) was used.At endoscopy, the papilla was swollen (Figure 1a). After several unsuccessful attempts to cannulate the papilla with a conventional sphincterotome, this was removed and replaced by a needle knife (5 mm wire papillotome). A small incision was then carefully made on the roof of the papilla 1 to 1.5 cm proximal to the assumed site of the orifice and below the transverse duodenal fold (Figures lb and 1c). The flow of bile indicated the establishment of a communication between the common bile duct and duodenal lumen (Figure 1d). The conventional sphincterotome was then reintroduced and contrast was injected to visualize the biliary tree, and the cut further extended superiorly

Clinical features of gallstone impaction at the ampulla of Vater and the effectiveness of endoscopic biliary drainage without papillotomy

“…Papillotomy is standard treatment for gallstone impaction 1 2 3 4 5 6. Dramatic improvements can be expected from the removal of stone.…”

“…Gallstone impaction at the ampulla of Vater can cause cholangitis as well as pancreatitis, and urgent stone removal is critical for improving the patient’s condition 1 2 3 4 5 6. Occasionally, the clinical course is fatal.…”

A novel method of endoscopic removal of an impacted ampullary stone using a snare (case report with video)

“…4 The risk of post papillotomy bleeding and perforation is increased with the use of needle knife papillotomy; therefore, it is recommended that this be performed by an experienced endoscopist. Needle knife precut papillotomy provides access into the biliary system and facilitate subsequent deep cannulation and completion of the papillotomy using a standard papillotome.…”

“…Suppurative cholangitis is associated with a significantly high morbidity and mortality and warrants urgent ERCP for biliary decompression and removal of the impacted stone. [1][2][3][4] However, stone impaction often leads to swelling and deformity of the papilla and the impacted stone makes deep cannulation and standard papillotomy technically difficult. Needle-knife precut papillotomy has been described for the removal of an impacted ampullary stone but this is risky especially when performed by inexperienced or trainee endoscopists.…”

Needle-Knife Sphincterotome and Endoscopic Choledochoduodenostomy: For Experts Only

“…In such conditions, a needle-knife has been used to gain access to the biliary tree for both diagnostic and therapeutic purposes [2][3][4][5][6]. AlKarawi et al [7] recently reported the successful use of needle-knife in performing endoscopic choledochoduodenostomy in five such cases of distal ampullary obstruction. We would like to share our experience in similar circumstances.…”