Invited Lecture 25 ES Complications

8/3/2019 Invited Lecture 25 ES Complications

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Short-Term and Long-term

Complications of EndoscopicSphincterotomy for CBD Stones

Ahmad Nassar

Monklands HospitalScotland



ES for CBD Stones

Classen and Kawai- mid 70’s

Safrany L, Lancet, Nov 1978: ‘ES isincreasingly replacing surgery in the

treatment of choledocholithiasis’

Manegold BC, Langenbecks Arch Chir, Nov 1978: ‘ Late complications after EST

are unknown and not to be expected



Early Complications of ES

Sedation

Basket impaction

Pancreatitis

Bleeding

Cholangitis

Perforation

Failure

Early papillary stenosis



Late Complications of ES

Recurrent stones

Acute cholecystitis

Recurrent pancreatitis Re-stenosis of papilla

Cholangiocarcinoma

Rare complications: new GB stones,gallstone ileus, Ascaris in CBD



Study No. Early Comp. Late Comp. Mortality

Seifert

1982

9041 7.5% 5.7% recurr

3.1 restenosis

1.12%

Escourou

1984

443

43%

7% 12% chole

6% rec Pancr

1.5%

Liquory

1985

409

57%

13% 4%

Leese

1985

394 10.4%

Surgery 3.8%

3.3%

Dresemann

1988

185

3.8%

Surgery 0.5%

16.9%

Surgery 5.6%

2.8%

Kullman

1989

128

ALL

164 ES 16.5%

Surgery 3.1%

3.1%



Pre-Laparoscopic Era

Great majority cholecystectomised

Almost all those with GB in situ unfit for

surgery Few specialised, skilled, high-volume

centres

Morbidity and mortality go with thepathology



Risk Factors in ES

Clinical:

Acute cholangitis

Sphincter of Oddi Dysfunction

Coagulopathy

Technical:

Difficult cannulation

Pre-cut Small ducts

Wide ducts



Lessons: pre-laparoscopic era

Neoptolemos J P, et al

Br Med J. 1987;294:470-4 Prospective

randomised study of preoperative endoscopic

sphincterotomy versus surgery alone for commonbile duct stones

No advantage for ES+cholecystectomy over BDE

‘Routine preoperative ES is of questionable value’



Neoptolemos 438 patients 5 years

Group Number Morbidity Mortality

ES +

surgery

59 23.7% *

p<0.001

5.1%

Surgery

alone

248 8.5% 4%

ES alone

GB in situ

114 19.3% *

p<0.003

7.9%

ES alone

NO GB

17 17.6% 17.6%



The ‘new’ concepts of the

laparoscopic era

Clear the CBD before cholecystectomy !

Laparoscopic IOC is time-consuming !

Laparoscopic CBDE is difficult !

‘Plan operating lists’ !

Limited facilities for urgent biliary surgery ! Gallstone surgery is minimally invasive !?



0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

1989/90 1990/91 1991/92 1992/93 1993/94 1994/95 1995/96 1996/97 1997/98 1998/99

ERCPs (OPCS4 J38:J45) recorded in any position

Laparoscopic cholecystectomy (OPCSJ08.8, J18+Y50.8)

Cholecystectomy & exploration of common bile duct (J18.2) recorded in any position

Calculus of bile duct with/without cholangitis or cholocystitis recorded in any position* with any or no procedure recorded



ERCP in England 1990-1999

90/91 98/99 Increase %

Diagnostic; Surgery 5027 10400

Medicine 6169 11252

Total 11196 21652 190 %

Therapeutic; Surgery 2037 8162

Medicine 1980 8197

Total 4017 16359 400 %

All ERCP’s 15213 38011 250 %



Number of deaths and mortality rate for patients undergoing ERCP procedures and diagnosed with benign gallstone dis

Time period: January 1992 to December 2001 p

Year

Number

of deaths

Mortali

rate (

1992 48 3.4

1993 66 3.5

1994 79 3.7

1995 63 2.6

1996 107 4.2

1997 105 4.1

1998 119 4.3

1999 76 2.7

2000 88 3.2

2001p 60 2.3

Source: ISD linked data set

30 January 2003

p provisional



We are not alone



Berci G,

J Laparoendosc Surg,1993:4:427

‘.. Surgeons performing LC should

nowadays consider advancing their

technique in learning how to do

laparoscopic choledocho-lithotomy

‘.. I think it is the wrong philosophy to

divide biliary stone disease to be treated

in two sessions or even by two disciplines’



Cetta F, CBD stones in the era of LC:

changing treatments and new pathological

entities. J Laparoendosc Surg 1994; 4:41-4

Need to preserve the Sphincter of Oddi

SS & ES — 9-11% stone recurrence within 6years increasing with time. Recurrent brown

stones due to stasis & infection

High rate of long term complications of ES

Resist ES without proper indication even at

expense of risk of increased complications

in the first phases of LCBDE



AND Endoscopists!Cotton P BIs your sphincterotomy really safe - and necessary?Gastrointest endosc; 1996 44:752-5

‘It could be that too many people have found themselvesinadequately trained and are stretching the indications to

maintain their experience and income’

Baillie J

Biliary sphincterotomy: less benign than once thought?curr gastroentrol rep;1999 2:102-6

‘ Endoscopists must re-evaluate their use of endoscopicsphincterotomy in light of long-term complications in thedata’



But, what about the patient ?

19 year olds having sphincterotomies

34 year old, mother of three, dying after an

ERCP for mild derangement of LFT’s

Anecdote or reality?

General ERCP mortality is NOT 0.5-1%



ES in the Laparoscopic Era

Is it any different?

What are the indications?

Perhaps there are no complications!! May be we do not hear of them!

Most do not WANT to know



Study No. Late Complications Conclusions

Boytchev

2000

169;

139 5 yr FU

14%. Late complications after ES for CBD

stones with GB in situ are rare(2%/year)Cholecystectomy does not seem to be warranted

Saito

2001

371

7.7 yr FU

Chole 5.9%, Recurr 9.7%. Long-term

outcome of ES is relatively favourable.

Cholecystectomy is not always necessary

Schreurs

2002

447

164 ES only

16%.

Sugiyama

2002

145, 60 yrs

or younger

12%. Can also be treated with ERCP. ES

is reasonable even in young patients

Costamagna

2002

529

334 5 yr FU

11%, 2.8% multiple. ES is safe at

long-term follow-up !!



No need for cholecystectomy?

Boerma et al, Lancet 2002 7;360: 739-40

Wait and see policy or laparoscopic

cholecystectomy after ES for bile duct

stones: a randomised trial.

‘ cannot be recommended as standard

treatment’



The cost of two-session management

Longer waiting

Interval complications

Multiple emergency admissions Longer presentation to resolution periods

ERCP

The economic cost can not be estimated

INCIDENCE OF REPEAT ERCP



INCIDENCE OF REPEAT ERCP

(During the same admission)

0

1000

2000

3000

4000

5000

6000

1989/90 1990/91 1991/92 1992/93 1993/94 1994/95 1995/96 1996/97 1997/98 1998/99

ERCPs (OPCS4 J38:J45) recorded in any position

ERCP as main operation with ERCP recorded also as secondary procedure



DEATHS IN ERCP FOR BENIGN GALLSTONE DISEASE

0

1

2

3

4

5

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001p

E R

C P M O R T A L

I T Y ( % )



Conclusions

ES still has complications and mortality

Even if the rates are the same, 2-3 times asmany patients are exposed to the risk

Main indication in laparoscopic era!?

We should not forget the patient

Evidence for one-session management is

stronger Guidelines, Training and Specialisation

Invited Lecture 25 ES Complications

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