Value of EST in treating bile duct stones

 Value of EST in treating bile duct stones

In recent years, the application of EST has provided a new and effective method for the treatment of bile duct stones, which is considered as the preferred method for the treatment of common bile duct stones.

To evaluate the efficacy of EST in the treatment of choledocholithiasis

From March 1990 to May 1996, we conducted a clinical comparison study on 160 cases of patients with bile duct stones by EST and surgical methods. There were 160 cases in the whole group, 156 cases were cured, and the total cure rate was 97.5%.

The cure rates of the two groups were shown below, with no significant difference (P>0. 05).

EST group – healing cases79 cases in 80 cases, healing rate 75%.

Open surgery operation group --- healing cases 77 cases in 80 cases healing rate 25%.

In this group of 80 cases EST, 79 cases (98.75%) were had stone removed completely. Among them, 27 cases (33.75%) were immediately removed with a basket after incision, and the remaining patients were left to get stones discharged by themselves. In most cases, stones were discharged in 2 ~ 3 days after the surgery, generally in the second day after the surgery the patients took the traditional Chinese medicine, daily dose for 3 ~ 5 days.  12 cases did not have stone discharged in one week. In these 12 cases, stones need to be removed with a basket or with additional incision. All of the patients received good effective results.

The result of this study showed that the EST healing rate was 98.75% for the stone formation with diameter < 1.5 cm. In addition, EST is also an effective method for patients with choledocholithiasis complicated with other biliary diseases. Such is gallbladder stone accompanied with common bile duct stone.

In a group of 2656 cases for research, the mean rate of post cholecystectomy was 9.7 %.

In this research, there are 6 cases with gall bladder stone. All of them are old –aged patients. 5 cases of them have stone discharged after operation. If acute cholecystitis did not attack, there is no need to carry out gallbladder excision operation.

Although gallbladder excision operation shall be taken afterwards, it can shorten hospital stay time. For patients with common bile duct stones and inflammatory stricture at the lower end of common bile duct (33 cases in this group), large incision was adopted, which relieved the stricture, discharged the stones, and prevented the bile duct restenosis and retrograde infection, and the total cure rate was higher than that of the surgical group (96.25%).

Discussion:

Selection of EST patient age

EST has been confirmed a good operation approach for older patients, but whether it is feasible in younger patients or those who have not had prior biliary tract surgery remains controversial. The controversial issue is that EST may cause permanent sphincter damage and intestinal reflux.

From the anatomical point of view, the bile duct enters duodenal wall in oblique line with length 1.5 ~ 3cm. The bile duct muscle and duodenal muscle form the Oddi sphincter. The proximal end is called upper sphincter. The contraction of upper sphincter prevents the bile from discharging. The Vater sphincter part is called the lower sphincter, which regulates the entry of bile and pancreatic juice into the duodenum.

In general, EST incision is limited to 1. 0 ~ 3. 0 cm, and even a large incision is not more than the oral eminence. The upper sphincter has not been completely destroyed, because the sphincter often exceeds part of the intestinal wall, so the anti-reflux function still exists. The age of EST should not be restricted.

The relationship between EST and surgical treatment of bile duct stones

EST and surgery are both effective methods for the treatment of choledocholithiasis. The results showed that the reoperation rate of EST group was significantly lower than that of surgery. Therefore, endoscopic treatment should be carried out first for common bile duct stones, especially for those who undergo repeated biliary tract surgery or those who cannot tolerate surgery due to high body weakness.

Most of the problems or symptoms can be solved or relieved after EST treatment, and surgery should be performed for a small number of large or complex bile duct stones that cannot be effectively treated by various methods such as lithotripsy and stone dissolution after EST.

Intrahepatic and extrahepatic bile duct stones are often difficult to solve through one operation. As long as there is no intrahepatic bile duct stenosis, EST should be firstly performed. If there is intrahepatic bile duct stenosis, endoscopic balloon dilatation or surgical operation is feasible. For patients with gall-stone combining acute obstructive suppurative cholangitis, firstly perform acute EST or place nasal biliary canal drainage. Waiting for patient’s general condition to improve then take other measures.

EST should be carried out for stone residue after open surgery.

In some emergent cases, only simple drainage was taken. Or if Papilla stenosis was found in the operation, Oddis sphincteroplasty could not be performed in operation, postoperative EST should be taken.  In this group of 80 cases of surgical operations, 7 cases (8.75%) received further EST treatment. Therefore, EST is also used as a supplementary treatment after surgery.

Chinese Journal of Open Surgery, 1997, vol. 17, No. 5