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Endoscopic Operation in Treating Bile Duct Stone --- EST
With the promotion of ERCP, a variety of new electronic endoscopic interventional techniques keep emerging. It further facilitates the diagnosis and treatment of pancreatic-bile duct stone disease to walk into the era of “endoscopic surgery”.
The methods of endoscopic stone retrieval by duodenal papillary have their own characteristics and advantages. In this paper, the advantages and disadvantages of EST is reviewed to explore its rational application in the treatment of bile duct stone.
Duodenal papillary sphincterotomy
Endoscopic sphincterotomy (EST) is a minimally invasive surgery by which the digital duodenoscope is inserted through the mouth to the duodenal papilla, and the sphincter is opened by a special incision on the papilla to remove gallstones or worms and drain the biliary.
In 1974, Japanese Prof. Kawai and German Prof. Classen performed EST for the first time to treat choledocholithiasis and achieved success, creating a new minimally invasive treatment method for cholelithiasis and promoting the clinical application of endoscopic minimally invasive surgery. In 1977, Professor An Rong from Shenyang Military General Hospital applied ERCP technology for the first time in China and successfully performed EST. Since then, Chinese endoscopic experts have carried out this technology widely and successively.
After year by year inheritance and development, with accumulation of experience, EST technology for the treatment of bile duct stones has gradually become mature. The indications have been continuously expanded. Contraindications have been reduced. The stone clearance rate gradually increased, and the complication rate has been gradually decreased.
Advantage of EST
Before the successful application of therapeutic ERCP through EST, patients with choledocholithiasis have to undergo open surgery with common bile duct incision, exploration and lithotomy plus T tube drainage, which have the advantages of large surgical trauma, high rate of stone residue, slow postoperative recovery, long hospitalization time and high medical cost. After open surgery, T tube drainage may have shedding, blockage, extraction difficulty. The complications may include bile leakage, bile peritonitis, choledochoduodenal fistula, acute pancreatitis and others. Additionally, long-term indwelling T canal may cause the foreign body reaction of bile duct, which may lead to the re-occurrence of bile duct stone.
After a retrospective analysis of the data of 86 patients with choledocholithiasis treated with EST and 100 patients treated with surgery during the same period, it was concluded that the cure rates of the two groups were 96.5% and 96.0% respectively. The data has no statistical significance, and the abdominal pain relief time was （2.05 ± 0.12）days and（5.05 ± 0.43）days respectively, with statistical significance. In another similar study, the operative time of the endoscopic EST group and the open surgery group was （39.6 ±1 9.23）min and（187.75 ± 69.54）min respectively, and the short-term complication rate was 5.69% and 11.11% respectively. Another example of retrospective analysis 118 cases of homogeneity simple common bile duct calculi were treated by EST or open surgery clinical data, results EST group, the average length of hospital stay (6.4 + 3.3) d significantly shorter than laparotomy group (14.7 + 5.1) (P = 0.000), d EST group of average hospitalization cost (14 to 183.5 + 4, 382.4) yuan, significantly less than laparotomy group (20 + 7 895.1 to 959.7) (P = 0.000). There was no significant difference in the surgical treatment cost between the EST group (9 447.1 3 105.0) and the open group (8 654.9 3 239.3) (P = 0.226).
The above research shows that patients receiving EST for choledocholithiasis can achieve the effect of traditional surgical treatment completely. Compared with traditional surgery, it has the characteristics of less pain, faster recovery, shorter hospitalization time and less hospitalization cost, which is more in line with the principle of economic benefits.
EST cuts open duodenal papilla through the current of the coagulator, and the direction and size of the incision can be determined according to the principles of incision, the surgeon's experience and the size of stones, so as to improve the efficiency of lithotomy and shorten the time of lithotomy. Especially for complicated stones (with a diameter of more than 10 mm or qty less than 3), EST can reduce the frequency of endoscopic treatment and increase the patency of postoperative biliary drainage, thus it reduces the incidence of postoperative pancreatitis.
In addition, EST can also be applied to cooperate treatment in patients with gallbladder stone with common bile duct stones. In a prospective randomized trial of 91 patients, one group received ERCP and EST synchronization applied in laparoscopic surgery, another group received first ERCP and EST, then laparoscopic gallbladder cutting afterwards. It is found that the successful rate of the former and the latter were 95.6% and 80. % (P = 0.06). The average hospital stay was 4.3 days and 8 days (P < 0.0001). The average cost was Euro 2829 and Euro 3834 respectively (P < 0.05), indicating that laparoscopic synchronization with ERCP and EST is more advantageous in the treatment of patients with gallbladder and common bile duct stones.
Limitations of EST
The implementation of EST will inevitably destroy the normal physiological structure of the sphincter of Oddi, resulting in permanent, irreversible damage or complete loss of sphincter function. The early postoperative complications of EST (no more than 3 months after surgery) mainly include hemorrhage, duodenal perforation, acute pancreatitis, cholangitis, sepsis, etc., while the late complications (more than 3 months after surgery) mainly include retrograde cholangitis, pancreatitis, recurrence of common bile duct stones, postoperative biliary terminal stenosis, biliary malignant transformation, etc.
Retrospective analysis was performed on 60 patients with choledocholithiasis, 38 of whom were treated with EST. The incidence of short-term complications was 5.56%, and the incidence of long-term complications was 19.4%. The authors followed up 883 patients with common bile duct stones after EST for 3 ~ 13 years, and the recurrence rate was 10.9%. The authors followed up 103 patients with choledocholithiasis after EST for 8 to 32 months, and the long-term complication rate was 12.6%, including the recurrence rate of calculus 7.8%, the incidence of cholangitis 6.8%, the incidence of calculous cholecystitis 1.9%, and the incidence of chronic pancreatitis 0.97%.
For too large stones (> 20 mm in diameter), simple EST is difficult to perform and requires surgical intervention. Situations as benign stricture nipples, nipple by huge diverticulum, diverticulum, oppression by lesions outside the cavity, tissue adhesion, patients of gastric resectionⅡtype, shall bring limitations on endoscopic operation and papilla incision. The papilla inside diverticulum and besides diverticulum make it difficult to adjust the direction of the intubation to the axial position of the bile duct. Large incision is not done in these cases to avoid intestinal wall perforation. For patients with choledochoduodenal wall stenosis, the incision of the intraural segment without direct vision is also undesirable.
Modern Digestion & Intervention 2013, Vol.18, No.5