Concurrent Percutaneous Transhepatic Papillary Balloon Dilatation Combined Laparoscopic Cholecystectomy For The Treatment Of Gallstones With Common Bile Duct Stones

Part 1. The study of percutaneous transhepatic papillary balloon dilatation for the removal of common bile duct stonesBackgroundCommon bile duct stones were a common surgical disease. With continuous improvement of people living standard at this stage, the incident of common bile duct stones is increasing. Although some of the smaller stones can exclude themselves, but most of patients require surgical intervention. Common bile duct stones (CBD) can caused biliary obstrustion, which can lead to the growth of bacteria and acute cholangitis, some patients may continue to cause acute obstructive suppurative cholangitis(AOSC) and severe pancreatitis and other complications if not timely and effectively treated the disease. The traditional surgical treatment of CBD was choledocholithotomy and T-tube drainage, but the surgical trauma, slowly recovery, and long-term postoperative T-tube which was inconvenient for patients. Since Endoscopic sphincterotomy (EST) treat the common bile duct stones successfully, the treatment of CBD became into the endoscopic treatment era. With the endoscopic equipments and endoscopic techniques constantly improving, EST combined basket or balloon has become an important method for the treatment of common bile duct stones. However, endoscopic treatment may cause duodenal bleeding, perforation and nipple sphincter damage which caused reflux cholangitis and other complications, especially for patients of diverticulitis type nipple and gastrectomy Billroth Ⅱ anastomosis, it was difficult to implement endoscopic treatment. Percutaneous transhepatic papillary balloon dilatation (PPBD) can protect the nipple sphincter function and deformities affect other advantages, which to provide a minimally invasive treatment option for the treatment of common bile duct stones.Objective1. Analysis the clinical safety and feasibility of percutaneous transhepatic papillary balloon dilatation of the treatment of common bile duct stones.2. Compare percutaneous transhepatic papillary balloon dilatation with endoscopic sphincterotomy, evaluate the incidence of short-term complications and the reasons.3. Evaluate the long term clinical effects of percutaneous transhepatic papillary balloon dilatation of the treatment of common bile duct stones.MethodFrom October 2010 to February 2012,60 patients with common bile duct stones were divided into two groups, all cases which undergo CT or MRI scan and confirmed choledocholithiasis patients, PPBD group were 30 patients and EST group were 30 patients,27 males and 33 females, aged 42-84 years, mean 63 years,49 cases were primary bile duct stones,11 cases were biliary recurrence stone, single stone in 47 cases, multiple stones in 13 cases.1、record the basic situation of the two groups of patients as the age, sex, stone size, total bilirubin surgery, preoperative liver function.2、record the total operative time, blood loss and surgical success rate of operate.3、record the numbers of white blood cell count, C-reactive protein, serum amylase after 2 hours,24 hours and 3 days after operate. And observed the bleeding, perforation, pancreatitis, cholangitis and other short-term complications, followed up 2 years to observe the recurrence of stones and reflux cholangitis and other long-term complications.Result1.2 groups of patients of the age, sex, stone size, total bilirubin, liver function showed no significant difference (P> 0.05).2. There were 28 cases (93.3%) and 29 cases (96.7%) successfully removed the stones in PPBD group and EST group, each of which 26 cases (86.7%) and 28 cases (93.3%) at one procedure, there was no statistical difference significance (P> 0.05).3. The numbers of WBC and CRP after operation 2h,24h,72h were no statistical difference significance (P＞0.05).The numbers of AMY after operation 2h,72h in both groups, were no statistical difference significance (P> 0.05). The numbers of AMY after operation 24h of the PPBD group was significantly lower than the EST group, the difference was statistically significant (P＜0.05)4. Early postoperative complications:there were 2 cases of hyperamylasemia and no acute pancreatitis、bleeding and perforation cases in PPBD group. There were 4 cases of hyperamylasemia and 1 case of acute pancreatitis and 1 case of bleeding and no perforation cases in EST Group. The overall incidence of early postoperative complications was higher in EST group than PPBD group, the difference was no statistically significant (P＞0.05).5. Long-term postoperative complications:follow-up of 2 years, there were 2 cases of recurrence bile duct stone and 3 cases of reflux cholangitis in EST group, there was 1 case of recurrence bile duct stone and no reflux cholangitis cases in PPBD groupConclusion1. The treatment of percutaneous transhepatic papillary balloon dilatation for common bile duct stones is safe, effective and feasible method.2. The treatment of percutaneous transhepatic papillary balloon dilatation for common bile duct stones can decrease the postoperative bleeding and perforation risk, especially reduce the incidence of high hyperlipidemia and acute pancreatitis, and protect the duodenal sphincter function, reduce the incidence of reflux cholangitis and recurrence stone.Part 2. Clinical study of concurrent percutaneous transhepatic papillary balloon dilatation combined with laparoscopic cholecystectomy for the treatment of gallstones with common bile duct stonesBackgroundGallstones with common bile duct stones were surgical common disease. With the change of people’s living environment, the incident of gallstones with common bile duct stones is increasing. The traditional treatment of gallstones with common bile duct stones is open surgery:cholecystectomy, choledocholithotomy+T tube drainage, which were prodigious trauma, slowly recovery, long hospital stay, some high-risk patients was difficult to tolerate surgery and other defects, with the constant renewal of endoscopic and laparoscopic equipment to improve, and continue to develop innovative laparoscopic techniques, traditional open surgical laparoscopic techniques and has gradually been replaced by endoscopic and laparoscopic techniques. Endoscopic therapy procedure:EST/EPBD+LC has become one of the main methods for treating gallbladder and common bile duct stones. The laparoscopic common bile duct exploration and stone removal were two ways:laparoscopic transcystic common bile duct exploration (LTCBDE), lalaparoscopic common bile duct exploration (LCBDE). LCBDE/LTCBDE+LC has become a reliable method of concurrent treatment of gallstones with common bile duct stones. But now, whether laparoscopic or endoscopic which are some limitations, the transpapillary endoscopic approach is unsuitable in some patients with common bile duct stones because of an altered gastrointestinal anatomy after Billroth Ⅱ gastrectomy, duodenal papillary deformity, duodenal diverticulum, which caused to fail cannulation to the common bile duct and not to be implemented endoscopic therapy. Laparoscopic transcystic removal of common bile stones was limited by stone size. Laparoscopic common bile duct exploration (LCBDE) usually may need to insert T-tube leads to patient discomfortable and even biliary stricture.We confirmed that the procedure of percutaneous transhepatic papillary balloon dilatation for the treatment of common bile duct stonesis safe, effective and feasible method. This procedure can reduce postoperative bleeding and perforation morbidity rate and the incidence of postoperative hyperlipidemia and acute pancreatitis, moreover, this procedure can protect duodenal sphincter function, reduce the occurrence of reflux cholangitis and stone recurrence.Based on these studies, we have the study of concurrent percutaneous transhepatic papillary balloon dilatation combined with laparoscopic cholecystectomy for the treatment of gallstones with common bile duct stones.Objective1. Evaluate the clinical effects of concurrent percutaneous transhepatic papillary balloon dilatation (PPBD) combined with laparoscopic cholecystectomy (LC) for the treatment of gallbladder stones with common bile duct stones.2. Analysis the clinical safety and feasibility of concurrent percutaneous transhepatic papillary balloon dilatation (PPBD) combined with laparoscopic cholecystectomy (LC) for the treatment of gallbladder stones with common bile duct stones.MethodA retrospective study was carry out from February 2012 to January 2013, 65 patients (31 males and 34 females) who were diagnosed by CT or MRI scan to be having gallbladder stones combined with common bile duct stones, divided into two groups according to how we were treated:EPBD+LC,40 cases; PPBD+LC,25 cases (18 cases of post gastrectomy Billroth II restriction,7 cases of failed cannulate to the bile duct). Patient age ranged from 42 to75 years (median age:61years). The maximum transverse diameter of common bile duct stone was 15 mm. We performed operatiaon after patients recovered from acute cholangitis, jaundice, liver dysfunction and acute pancreatitis (WBC≤10×109/L, Total Bilirubin≤34μmol/L, ALT ≤60U/L, CRP≤10mg/L). Written informed consent was obtained from each patient. Exclusion criteria:(1) concurrent hepatolithiasist, (2) acute pancreatitis, (3) the pancreatic or biliary malignancy tumor, (4) severe coagulation dysfunction.1. Record the basic situation of the two groups of patients as the age, sex, stone size, total bilirubin surgery, preoperative liver function.2. Record the total operative time, surgical success and rate of operate.3. Record the numbers of white blood cell count, serum amylase after 12 hours,72 hours after operation. Record time of gastrointestinal function recovery and hospitalization time. And observed the bleeding, perforation, pancreatitis, cholangitis and other short-term complications, followed up 2 years to observe the long-term complications of recurrence of stones.Results1. No cases of both groups were converted to open surgery and no deaths or other major complications. The stones were successfully pushed out into the duodenum in all patients of both groups. There was no significant difference (P＞ 0.05).2. One case occurred post-operative pancreatitis (2.5%) and five cases occurred hyperamylasemia (12.5%) of the 40 patients in EPBD+LC group. In contrast, there was no case of post-operative pancreatitis and two cases occurred hyperamylasemia (8%) among the 25 patients in PPBD+LC group. There was no statistical difference significance (P> 0.05).3. The serum amylase level of post operation 12h was statistically significant (307±39.94 IU/L in EPBD+LC group and 193±30.78 IU/L in PPBD +LC group, respectively. P＜0.05).There were significant statistically difference between two groups(P＜0.05).4. Both groups were no bleeding and perforation cases.5. There were no significant difference between the two groups in serum amylase level of post operation 72h (57.22±1.60 IU/L in EPBD+LC group and 52.88±1.70 IU/L in PPBD+LC group, respectively. P＞0.05), operation time (125.53±1.25min in EPBD+LC group and 129.52±1.72 min in PPBD+ LC group, respectively. P＞0.05), postoperative gastrointestinal function recovery time (1.66±0.43 days in EPBD+LC group and 1.77+0.60 days in PPBD+LC group, respectively. P＞0.05),hospital stay time (9.90±0.21 days in EPBD+LC group and 10.45±0.29 days in PPBD+LC group, respectively. P＞0.05), There was no statistical difference significance (P＞0.05).6. Follow-up 2 years, one case of recurrence for common bile duct stones was discovered in EPBD+LC group and was treated successfully with EPBD repeatedly.Conclusion1. PPBD combined with LC simultaneously is alternative effective and safe procedure for the treatment of gallbladder stones with common bile duct stones, especially for those endoscopic procedure was failure.2. Concurrent PPBD combined with LC for the treatment of gallbladder stones with common bile duct stones are safe, effective and feasible method that can reduce the incidence of post-operative hyperamylasemia and acute pancreatitis.