Endoscopic Papillotomy for Common Bile Duct Stones: Factors Influencing the Complication Rate

Abstract

In a prospective study, the complications observed in 242 consecutive patients after endoscopic sphincterotomy for common bile duct stones were recorded over a period of up to three months. Patients with previous gastric surgery, papillotomy, or additional pancreato-biliary disease other than gallbladder stones were excluded. The overall complication rate was 14%, 74% of these complications being moderate or severe. The complication rate due to cholangitis was higher in (1) the group with retained stones following complete papillotomy and without biliary drainage, and (2) the group with failed precut papillotomy and drainage after cholangiography, both compared to patients with successful drainage (75% vs. 2.6%: p < 0.001 and 40% vs. 2.6%: p = 0.001 respectively). Both pancreatitis and retroperitoneal air leakage occurred in 1.7% of cases. They were more frequently observed in patients with a smaller diameter (< 10 mm) in the distal common bile duct (5.6% vs. 0%: p = 0.007 for pancreatitis, and 2.8% vs. 1.2%; n.s. for perforation) and especially following precut papillotomy (13.0% for pancreatitis and 8.7% for perforation), which had to be performed more often in these patients. Bleeding following sphincterotomy was relatively frequent when the papilla was located at the lower rim of or inside a diverticulum, compared to patients without a diverticulum (16.2% vs. 2.7%: p = 0.004 and 26.7% vs. 2.7%: p < 0.001 respectively). When the papilla was located inside diverticula, both the rate of perforation and bleeding increased following precut papillotomy, compared with standard papillotomy only (33% vs. 0%, n.s., and 33% vs. 22%, n.s.).(ABSTRACT TRUNCATED AT 250 WORDS)

The impact of periampullary diverticula on the endoscopic treatment of choledocholithiasis

“…The location of the papillary ostium may differ according to the size of the diverticulum. This might inhibit deep cannulation by a standard sphincterotome, or restrict safe sphincterotomy after cannulation [7] since a large diverticulum or the papilla being located within a large diverticulum would theoretically make cannulation more difficult due to the luminal defect, and also facilitate sphincterotomy-related complications [2,3,7]. In the study by Zoepf et al, papillary location was 54.9% within the diverticulum and 37.7% at the edge of the diverticulum, while the incidence of bleeding was 8.8% in the patient group and 4.8% in the control group (p < 0.05).…”

“…However, these results are considered to be controversial due to the small number of patients and the differences in study designs [6,7].…”

The role of ERCP in choledocholithiasis

“…A difficult cannulation or sphincterotomy can be overcome by ''precutting'' the major papilla by many biliary experts [76]. Even though this precutting maneuver is proven safe in experienced centers [75,77,78], the potential for excessive perforation, pancreatitis, and bleeding prohibits its use in the general community [76,[79][80][81].…”

Is ERCP really necessary in case of suspected spontaneous passage of bile duct stones?

“…Thus, MRCP is very useful for the diagnosis of bile duct stones and the determination of a therapeutic strategy. Since ERCP involves the risk of complications such as acute pancreatitis [18][19][20][21] , it should be performed only when absolutely necessary. In some patients clinically suspected of choledocholithiasis, ERCP shows a cleavage at the duodenal papilla, but does not detect the stones in the common bile duct.…”