The Role of Endoscopic Biliary Drainage without Sphincterotomy in Gallstone Patients with Cholangitis and Suspected Common Bile Duct Stones Not Detected by Cholangiogram or Intraductal Ultrasonography

Abstract

Background/AimsTreatment for cholangitis without common bile duct (CBD) stones has not been established in patients with gallstones. We investigated the usefulness of endoscopic biliary drainage (EBD) without endoscopic sphincterotomy (EST) in patients diagnosed with gallstones and cholangitis without CBD stones by endoscopic retrograde cholangiopancreatography (ERCP) and intraductal ultrasonography (IDUS).MethodsEBD using 5F plastic stents without EST was performed prospectively in patients with gallstones and cholangitis if CBD stones were not diagnosed by ERCP and IDUS. After ERCP, all patients underwent laparoscopic cholecystectomy. The primary outcomes were clinical and technical success. The secondary outcomes were recurrence rate of biliary events and procedure-related adverse events.ResultsAmong 187 patients with gallstones and cholangitis, 27 patients without CBD stones according to ERCP and IDUS received EBD using 5F plastic stents without EST. The stents were maintained in all patients until laparoscopic cholecystectomy, and recurrence of cholangitis was not observed. After cholecystectomy, the stents were removed spontaneously in 12 patients and endoscopically in 15 patients. Recurrence of CBD stones was not detected during the follow-up period (median, 421 days).ConclusionsEBD using 5F plastic stents without EST may be safe and effective for the management of cholangitis accompanied by gallstones in patients without CBD stones according to ERCP and IDUS.

Laparoscopic common bile duct exploration in patients with previous abdominal biliary tract operations

“…Moreover, it may be difficult or impossible to clear large, multiple, intrahepatic ducts or impacted stones in the CBD by ERCP, and patients with these symptoms can benefit from open CBD exploration (OCBDE) or LCBDE, as these procedures have a high success rate in salvaging such stones [4]. In addition, it has been reported that endoscopic sphincterotomy (EST) may cause duodenobiliary, pancreatic juice and intestinal content reflux that results in recurrent bile duct stone formation, cholecystitis, inflammation in the bile duct, and cholangiocarcinoma [5]. Currently, some experts also suggest that ERCP be applied with appropriate indications in clinical practice.…”

PANC Study (Pancreatitis: A National Cohort Study): national cohort study examining the first 30 days from presentation of acute pancreatitis in the UK

“…A supporting recommendation is seen in guidance published within the UK two decades ago, and, without a clear consensus to refute this practice, this recommendation is still a common part of definitive management 2 . Conflicting recommendations suggest that sphincterotomy should not be performed in the absence of choledocholithiasis or cholangitis due to the increased risk of the procedure 27 , 28 . Other studies recommend sphincterotomy as definitive treatment in patients who are deemed unfit for cholecystectomy 29 and as an indication for gallbladder drainage 30 .…”

Comprehensive review on small common bile duct stones

“…The incidence of short-term cholecystitis after ERCP could be caused by resistance to initial antibiotics on admission[ 29 ], and the incidence of long-term cholecystitis and the recurrence of stones in CBD could be decreased by EPBD compared to EST[ 6 , 12 ]. EST causes significant damages to the Oddi sphincter, and post-EST sphincter dysfunction easily occurs[ 30 ]. Then, the reflux of intestinal contents such as digestive juices, food residue, and bacteria may increase the risk of biliary tract infection and stone recurrence[ 31 , 32 ].…”