Michael Vitale, MD. Digeclinic, Guatemala City, Guatemala
Introduction: In the minimally invasive era, endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (ES) is the treatment of choice for patients with bile duct stones. Endoscopic stone extraction is successful in over 96% of patients, with a low procedure-related morbidity (5.8%) and mortality (0.2%). The purpose of this study was to assess safety, efficacy and outcome in an outpatient unit for endoscopic stone extraction.
Methods: A retrospective review was carried out of patients undergoing ERCP with ES for bile duct stones performed at the surgical endoscopy outpatient unit between October 2011 and September 2014. Procedures were performed by a single surgical endoscopist. Pre-procedure diagnosis was reached by evaluating liver function tests, ultrasound, T-tube cholangiogram or magnetic resonance cholangiopancreatography.
Results: 381 procedures were performed on 374 patients (64% women), mean age 35 years (range 16 to 77 years). Indications for ERCP with ES and stone extraction were: choledocholithiasis (58.3%), retained bile duct stones (26.2%) and recurrent bile duct stones (15.5%). Endoscopic sphincterotomy with stone extraction was performed in 301 (80.5%) patients, pre-cut sphincterotomy with stone extraction in 56 (15%) patients and 17 (4.5%) patients were not successful for stone extraction. Endoscopic stone extraction was successful in 95.5%. Of the 17 patients, in which endoscopic approach was unsuccessful, 7 were from the choledocholithiasis group. These patients were managed with an insertion of a biliary plastic stent and scheduled for a second ERCP. Lithotripsy with successful stone extraction was performed at second procedure. Ten patients were taken to surgery, 8 of them were from the retained bile duct stone group which underwent open common bile duct exploration. The remaining two patients were from the recurrent bile duct stone group and presented with impacted stone at the ampulla of Vater. Transduodenal sphincteroplasty was performed on the 2 patients. Complications occurred in 23 patients (6.1%): mild pancreatitis (3.2%), sphincterotomy bleeding (2.6%) and moderate pancreatitis (0.3%). Procedure-related mortality was 0%.
Conclusions: Our study demonstrates that ERCP with ES and bile duct stone extraction performed in an outpatient facility is safe and effective. The success and complication rate obtained in this review is within the expected range reported in the literature.
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