Hideo Yoshimoto

Choledochoscopic electrohydraulic lithotripsy and lithotomy for stones in the common bile duct, intrahepatic ducts, and gallbladder.

Choledochoscopic lithotomy with the aid of electrohydraulic lithotripsy was performed in 40 patients, including 16 patients with choledocholithiasis, 15 with hepatolithiasis, and 9 with cholecystolithiasis. As a route for the choledochoscopy, a T-tube tract, external cholecystostomy, or jejunal limb of hepaticojejunostomy was used in nine patients, while percutaneous transhepatic biliary drainage followed by dilatation of the track was established in 31 patients. The largest cholesterol stone measured 55 mm by 33 mm and the largest bilirubinate stone measured 52 mm by 37 mm. The stones were disintegrated in all but one patient in whom choledochoscopic access to a gallstone was difficult due to deformity of the gallbladder. Complete removal of the stones was achieved in 38 of 39 patients. In a patient with hepatolithiasis, small stones located deep in inaccessible branches of the intrahepatic duct remained unremovable. There were no serious complication. Minor complications occurred, including bleeding from the bile duct mucosa in four patients and postprocedure chills and fever in three. Choledochoscopic lithotomy with electrohydraulic lithotripsy is efficient and useful to remove biliary calculi in patients who are poor surgical risks.

The long-term fate of the gallbladder after endoscopic sphincterotomy: complete follow-up study of 122 patients

One hundred twenty-two patients with common bile duct stones and intact gallbladders underwent endoscopic sphincterotomy without cholecystectomy and were followed for 6 months to 9 years (mean 3 years). Nineteen patients died from unrelated causes. One hundred of 103 surviving patients (97 percent) were asymptomatic, whereas 3 had complaints. Acute cholecystitis did not occur in 91 patients without gallstones, whereas it did occur in 5 of 31 patients (16 percent) with gallstones (25 patients) or nonvisualization of the gallbladder (6 patients). Two patients in the former subgroup had formation of new gallstones. We conclude that cholecystectomy should be advocated whenever possible in patients with gallstones or nonvisualization of the gallbladder after endoscopic sphincterotomy due to the high incidence of acute cholecystitis in this subgroup and that operation is not necessary in patients without gallstones; however, one should be aware of possible formation of new stones in the gallbladder.

Manometric diagnosis of sphincter of Oddi spasm as a cause of postcholecystectomy pain and the treatment by endoscopic sphincterotomy.

Seventeen patients with postcholecystectomy pain and nine controls were studied by nonoperative biliary manometry with stimulation of sphincter of Oddi spasm by morphine. The controls remained asymptomatic despite an elevation of bile duct pressure after morphine. In 13 patients with postcholecystectomy pain, morphine induced pain paralleling a pressure rise. Three other patients had pain not paralleling a pressure change, and another showed a pressure rise without pain. None of the controls, four with the parallel pain-pressure change, and one with the discordant pain-pressure correlation were positive at the traditional morphine-Prostigmin test. Endoscopic sphincterotomy provided complete (8), moderate (3), or slight (1) relief of pain to 12 patients with the parallel pain-pressure relationship. Postsphincterotomy manometry showed disappearance of both the pressure elevation and pain induction, and the morphine-Prostigmin test turned negative. It is concluded that morphine-induced bile duct pressure elevation coinciding with pain is diagnostic of sphincter spasm as a cause of postcholecystectomy pain, the morphine-Prostigmin test, although helpful, is less specific and less sensitive in diagnosing sphincter spasm than the manometry, and endoscopic sphincterotomy relieves the pain due to this condition in most cases.

Improved visualization of intrahepatic bile ducts by endoscopic retrograde balloon catheter cholangiography.

In seven patients with a patulous sphincter of Oddi, choledocho-duodenal fistula, previous sphincterotomy, sphincteroplasty or bilioenteric anastomosis in which standard endoscopic retrograde cholangiography (ERC) with a #5 French catheter failed to visualize intrahepatic ducts sufficiently due to a backflow of contrast into the duodenum, ERC was attempted via a balloon catheter to prevent escape of contrast. The results were compared with those using a #7 French catheter. In contrast to the latter, which gave only insufficient filling of hepatic ducts, the former permitted full visualization in all cases. Consequently, intrahepatic stones were demonstrated in three patients, and bile duct changes consistent with carcinoma in another. The absence of hepatic lesions was confirmed in the remaining three patients. No adverse reactions were experienced. It is concluded that the use of a balloon catheter constitutes an effective aid in ERC for the diagnosis of hepatic lesions in selected cases where conventional ERC fails

Sphincter of Oddi motor activity in patients with stones in gall‐bladder, common bile duct or intrahepatic duct and the effect of morphine

Abstract Sphincter of Oddi phasic motor activity and common bile duct pressure were investigated in controls (seven patients) and in patients with gall‐bladder stones (five patients), common bile duct stones (15 patients), or intrahepatic stones (13 patients). There were no significant differences in amplitude and frequency of the phasic activity or the common bile duct pressure between the controls and disease groups. Basal pressure of the phasic contraction, however, was significantly lower in patients with common bile duct or intrahepatic stones than in the controls or gall‐bladder stone group. The administration of morphine, known to cause spasm of the sphincter of Oddi, increased the basal pressure and frequency of the phasic waves in all groups, while the amplitude remained unchanged. Response to morphine in patients with common bile duct or intrahepatic stones was similar to the controls. However, the basal pressure in these latter groups was lower than in the controls, even after stimulation by morphine. The high incidence of bacterial growth in bile from these patients hitherto reported may be attributable to ascending infection possibly resulting from the low basal pressure of the sphincter of Oddi.

Nonoperative removal of giant common bile duct calculi.

Endoscopic sphincterotomy has allowed us to extract relatively large stones from the common bile duct as compared with other methods utilizing a T-tube tract or the percutaneous transhepatic route. Twenty-four patients with large stones over 20 mm in diameter were selected and reviewed from a series of 469 sphincterotomy patients. Eleven stones passed into the duodenum spontaneously, the maximal size of which was 30 by 43 mm. Passage occurred within 4 days after sphincterotomy in 27 percent, 5 to 7 days after the procedure in 55 percent, and 8 to 13 days after the procedure in 18 percent and was accompanied by cholangitis in 55 percent of the patients. The small diameter of the stone and common bile duct dilatation down to the distal end seemed to be the factors favoring stone delivery. Five stones were removed using ordinary basket catheters by duodenoscopy; however, the largest one required 28 attempts. More recently, four stones were efficiently extracted after destruction by electrohydraulic or mechanical lithotripsy. Failure of removal in five patients was mainly due to a lack of space around the stone for basket manipulation or occurrence of severe cholangitis. Further refinements in technique in this regard are needed.