| Background Many patients with common bile duct stones may have no symptoms.Small stones maybe discharged into duodenum.Large stones may stick in common bile duct,and cause biliary colic,obstructive jaundice,infection or pancreatitis.Hence,symptomatic common bile duct stones were recommended to be treated.At present,treatment modalities include choledocholithotomy + T tube drainage,endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy.Choledocholithotomy + T tube drainage should be performed under general anesthesia with tracheal intubation,and requires good cardio-pulmonary function.Incidences of complications during and after the procedure are usually high.As minimal invasive treatments,ERCP and EST are not appropriate for stones locating in upper part of common bile duct.What's more,for patients with abnormal anatomy of gastrointestinal tract,such as those underwent Billroth ? surgery or with duodenal diverticulum,physicians may have difficulties to perform ERCP or EST.In addition,some patients refuse to undergo surgery or endoscopic procedures.For these patients,percutaneous transhepatic balloon dilation(PTBD)was reported,with Oddi sphincter dilated by balloon and stones pushed into duodenum by balloon.Compared with ERCP,this modality pushes stones by anterograde approach,which is not affected by abnormality of gastrointestinal anatomy.Compared with surgery,general anesthesia with tracheal intubation is not necessary for this kind of procedure.No similar study was reported in China.Objectives Elderly patients,patients with poor cardiopulmonary function or abnormality of gastrointestinal anatomy are not appropriate candidates for surgery or ERCP/EST.We will evaluate safety and effectiveness of PTBD for common bile duct stones,and focus on complications including biliary injury,biliary hemorrhage,intestine injury,refluxing cholangitis,pancreatitis,residual stones and stone recurrence.Materials and Method One hundred and one patients admitted in the Second Hospital of Shandong University from Jul 2008 to Apr 2015 were retrospectively analyzed.Inclusive criteria:(1)common bile duct stones;(2)failed endoscopic procedures;(3)unable to undergo endoscopic procedures or surgery;(4)unwilling to undergo endoscopic procedures or surgery;(5)common bile duct stones after Billroth II surgery;(6)patients with g astrointestinal stenosis,esophageal&gastric varices and duodenal diverticulum;(7)common bile duct stones demonstrated by cholangiography in patients with obstructive jaundice;(8)WBC count?4.0×199/L,PLT count?50×109/L,HGB?100g/L.All enrolled patients underwent PTBD.Indexes include hospital stay,success rate,failure reason and procedure-related complications.Laboratory indicators were recorded before the procedure,one week and one month after the procedure,including WBC count,AST,TBIL,DBIL and ALB.Short-term complications,such as biliary infection,hemorrhage,pancreatitis,biliary/intestine perforation,cholangitis were evaluated before discharging.Abdominal ultrasound,CT,MRCP and laboratory examinations were repeated after the procedure,to estimate incidences of stone recurrence and refluxing cholangitis for 2 years.All statistical analyses were performed using IBM SPSS Statistics 24.0.Categorical variables were presented as number and percentage.Continuous data were presented as means±standard deviations.We used paired t-tests for the same indexes before and after the procedure in the same patient.A P-value of less than 0.05 was considered statistically significant.Results All PTBD procedures were successfully performed in 101 patients.The diameter of biggest stone was larger than 10mm in 63 patients,smaller than 10mm in 38 patients,with the largest diameter of 22mm.Eleven and 25 patients underwent laparoscopic cholecystectomy(LC)and Billroth ? surgery before respectively.Seventeen patients underwent failed endoscopic procedure.Thirty-six cases suffered from severe cardiopulmonary dysfuction.Cholangiography after the procedure indicated residual stones in 6 cases,and underwent more than twice PTBD.WBC count.AST,ALT,TBIL and DBIL after PTBD were lower than before,and ALB was higher than before,with significant difference.Mean procedure time was(45.24±17.65)minutes.Incidences of perioperative biliary infection,biliary hemorrhage and pancreatitis were 3.96%(4/101),1.98%(2/101),0.99%(1/101).No biliary perforation or gastrointestinal perforation occurred.Recurrence rate of CBD stones and incidence of refluxing cholangitis were 10.89%(11/101)and 3.96%(4/101).Conclusion PTBD is feasible for common bile duct stones,with high rate of success and low incidence of complications,especially for patients who underwent failed endoscopic procedure or surgery or with abnormality of gastrointestinal anatomy.It could be considered as an alternative for CBD stones.Background Cholelithiasis is a common disease with an incidence of 20%,and simultaneous common bile duct(CBD)stones and gallbladder stones affect 10%-20%of those patients.Blocked stones in bile duct may cause obstructive jaundice,cholangitis,pancreatitis,which may induce symptoms of abdominal pain and fever.Therefore,symptomatic cholelithiasis is recommended to be treated.Nowadays,many modalities such as laparoscopic common bile duct exploration(LCBDE)?endoscopic retrograde cholangiopancreatography(ERCP)or endoscopic sphincterotomy(EST)gained more and more recognition.Gallbladder stones could be treated with open cholecystectomy(OC)or laparoscopic cholecystectomy(LC)after ERCP/EST/EPBD.However,some elderly patients with poor cardiopulmonary function may could not tolerate general anesthesia with tracheal intubation or surgery.ERCP/EST/EPBD could not be performed in some patients with abnormal anatomy.Our previous study revealed percutaneous transhepatic balloon dilation(PTBD)is a safe and feasible alternative for such subgroup of patients.Since a percutaneous transhepatic tract is established during PTBD and a drainage catheter is kept after the procedure,certain medicine,such as ursodeoxycholic acid(UDCA)may be used to promote elimination of gallbladder stones into CBD,and secondary CBD stones could be treated with PTBD.Objectives Some elderly patients with poor cardiopulmonary function may could not tolerate general anesthesia with tracheal intubation or surgery.ERCP/EST/EPBD could not be performed in some patients with abnormal anatomy.This research focuses on evaluate the effectiveness and safety of combined ursodeoxycholic acid and percutaneous transhepatic balloon dilation for management of gallstones after expulsion of CBD stones.Materials and Method From April 2014 to December 2016,19 consecutive patients(8 men and 11 women)aged 45-86(mean,69.07±9.91)years with CBD stones and gallbladder stones were retrospectively analyzed.Good gallbladder contraction function was confirmed by ultrasonography.Dilation of the CBD and cystic duct was detected.Inclusion criteria were:(1)concomitant CBD and gallbladder stones with symptoms of acute cholangitis or cholecystitis;(2)diameter of gallbladder stone<15mm;(3)gallbladder with good contraction function and dilation of cystic duct;(4)inability to tolerate or refusal to undergo general anesthesia with tracheal intubation,ERCP/EST/EPBD,or surgery because of cardiac or lung insufficiency;(5)patients with previous Billroth ? surgery or other abnormal anatomy;(6)leukocyte count>4.0×109/L.platelet count>60×109/L,and hemoglobin concentration?100g/L;(7)predicted life span of>6 months;and(8)Karnofsky score>70.Percutaneous transhepatic balloon dilation of the papilla was performed,and a drainage catheter was kept after the procedure.Then,UDCA was administered,and all patients had a high-fat diet.All subjects underwent repeated cholangiography,and percutaneous transhepatic removal was carried out in patients with secondary CBD stones originating from the gallbladder.Outcomes recorded included postoperative hospital stay,success rate.causes of failure,and procedure-related complications.The AST,TBIL,DBIL,ALB,serum amylase concentrations,WBC count and were recorded before the procedure and at 1 week and 2 weeks after the procedure.Short-terms adverse events,such as biliary duct infection,hemorrhage,pancreatitis,gastrointestinal&biliary duct perforation were accessed before discharging.Ultrasonography,computed tomography,or magnetic resonance cholangiopancreatography were performed after the procedure,Refluxing cholangitis,and recurrence of gallbladder or CBD stones,considered as long-term complications,were monitored for 2 years.All statistical analyses were performed using IBM SPSS Statistics 24.0.Categorical variables were presented as number and percentage.Continuous data were presented as means±standard deviations.We used paired t-tests for the same indexes before and after the procedure in the same patient.A P-value of less than 0.05 was considered statistically significant.Results All patients underwent percutaneous transhepatic balloon dilation with a primary success rate of 100%.The combined therapy was successful in 17(89.47%)of patients with concomitant CBD stones and gallstones.Transient adverse events include abdominal pain(n=1),abdominal distension(n=1),and fever(n=1).Complications were treated successfully via nonsurgical management without long-term complications.No procedure-related mortality occurred.Conclusion Some elderly patients with poor cardiopulmonary function may could not tolerate general anesthesia with tracheal intubation or surgery.ERCP/EST/EPBD could not be performed in some patients with abnormal anatomy.For such subgroup of patients,oral ursodeoxycholic acid and a high-fat diet followed by percutaneous transhepatic removal of secondary CBD stones appear to be a feasible and effective option for management of gallstones.Background Gallstones constitute a significant health issue,affecting 10%to 15%of the adult population in developed societies and approximately 13%of the Chinese population.Gallstones cause pain and discomfort in the right upper abdomen and are associated with other symptoms such as nausea,vomiting,and postprandial fullness,which can seriously affect a patient's quality of life.The goal of treatment is to resolve ongoing infections,thereby preventing recurrent cholecystitis,subsequent cholangitis,hepatic fibrosis,and progression to cholangiocarcinoma.Approximately 15%of patients with gallbladder stones have concomitant common bile duct(CBD)stones.Open exploration of the CBD was historically the therapeutic option for patients with CBD stones.During recent decades,laparoscopic exploration of the CBD and endoscopic retrograde cholangiopancreatography(ERCP)with endoscopic sphincterotomy(EST)has gained wide acceptance as an effective and minimal invasive alternative.After ERCP/EST/EPBD,gallbladder stones must be removed through open cholecystectomy,laparoscopic cholecystectomy,or percutaneous cholecystolithotomy.However,some older patients have pulmonary or cardiac comorbidities and cannot tolerate the risk of general anesthesia with tracheal intubation,ERCP/EST/EPBD,or surgery.Our previous study revealed that percutaneous transhepatic balloon dilation(PTBD)could be a safe and effective alternative for common bile duct stones,especially for a subgroup of patients with poor cardiopulmonary function who could not undergo or refuse to undergo endoscopic procedure or surgery.Based on established percutaneous transhepatic passage,could we treat gallbladder stone with PTBD?Objectives For elderly patients with poor cardiopulmonary function or abnormal anatomy of gastrointestinal tract who could not undergo or refuse to undergo endoscopic procedure or surgery,safety and effectiveness of sequential PTBD and percutaneous transhepatic extraction and balloon dilation(PTEBD)for clearance of concomitant gallbladder stones and common bile duct stones were estimated,as well as complications including bile duct injury,bile duct hemorrhage,intestine injury,refluxing cholangitis,pancreatitis,residual stones and stone recurrence.Materials and Method The data of 17 consecutive patients who underwent PTEBD for clearance of gallbladder stones were retrospectively analyzed.Inclusion criteria were:(1)concomitant gallbladder and CBD stones with symptoms of acute cholangitis,pancreatitis,or cholecystitis;(2)inability to tolerate or refusal to undergo general anesthesia with tracheal intubation,ERCP/EST/EPBD,or surgery because of cardiac or lung insufficiency;(3)gallbladder with poor contraction function and/or undilated cystic duct;(4)failed litholysis with ursodeoxycholic acid;(5)ERCP/EST/EPBD not possible due to prior Billroth ? surgery;(6)leukocyte count?4.0×109/L,platelet count?60×109/L,and hemoglobin concentration?100g/L;(7)predicted life span of?6 months;and(8)Karnofsky score>70.After removal of the CBD stones by percutaneous transhepatic balloon dilation(PTBD),the gallbladder stones were extracted to the CBD and pushed into the duodenum with a balloon after dilation of the sphincter of Oddi.Large stones were fragmented using a metallic basket.Outcomes recorded included postoperative hospital stay,success rate,causes of failure,and procedure-related complications.The AST,TBIL,DBIL,ALB,serum amylase concentrations,WBC count and were recorded before the procedure and at 1 week and 1 month after the procedure.Short-terms adverse events,such as biliary duct infection,hemorrhage,pancreatitis,gastrointestinal&biliary duct perforation were accessed before discharging.Ultrasonography,computed tomography,or magnetic resonance cholangiopancreatography were performed after the procedure.Refluxing cholangitis,and recurrence of gallbladder or CBD stones,considered as long-term complications,were monitored for 2 years.All statistical analyses were performed using IBM SPSS Statistics 24.0.Categorical variables were presented as number and percentage.Continuous data were presented as means±standard deviations.We used paired t-tests for the same indexes before and after the procedure in the same patient.A P-value of less than 0.05 was considered statistically significant.Results A total of 32 gallbladder stones were successfully removed by PTEBD in 16(94.1%)of the 17 patients.PTEBD was repeated in one patient.The mean hospitalization duration was(15.9±2.2)days.The diameter of 10 stones(28.6%)was smaller than 10mm,with 21(60.0%)ranging from 10-20mm and 4 stones(11.4%)larger than 20mm.Sixteen stones(45.7%)were cholesterol type,4(11.4%)of bilirubin type and 15(42.9%)of mixed type.The level of AST,TBIL,DBIL concentrations and WBC count declined markedly after PTBD and PTEBD.The differences in these indexes before PTBD,1 week after PTBD,and 1 week after PTEBD were all significant(P<0.01).In contrast,ALB concentration significantly increased after PTBD and PTEBD.One(5.9%)of the 17 patients developed a high fever(39.5?)and shivering.Escherichia coli was found in the bile,and a biliary duct infection was confirmed.Another patient developed bile duct hemorrhage and recovered after treatment with 1000 IU of reptilase and drainage clamping.No severe adverse events occurred during the perioperative period,including pancreatitis or perforation of the gastrointestinal or biliary duct.Neither recurrence of gallbladder or CBD stones nor refluxing cholangitis had occurred 2 years after the procedure.Conclusion Sequential PTBD and PTEBD is a safe,feasible,and effective treatment option for simultaneous gallbladder and CBD stones in a subgroup of elderly patients with poor cardiopulmonary function or abnormal anatomy of gastrointestinal tract. |
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