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ENDOSCOPIC TECHNIQUES OF SPHINCTEROTOMY AND REMOVING COMMON BILE
DUCT STONES
NGUYEN PHUC BAO HUNG - MD Endoscopist - MEDIC
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ENDOSCOPIC SPHINCTEROMY (ES) is a unique therapeutic modality that
has revolutionized the non operative treatment of various biliary
and pancreatic disorders.
In 1974, endoscopic sphincterotomy for common bile duct stone was
first reported by classen and demlling in Germany and by KAWAI and
al in Japan. Nowadays, endoscopic sphincterotomy is routinely
carried out for diagnosis and treatment of pancreatic and biliary
diseases.
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- Common bile duct stone.
- Sphincter of Oddi dysfunction.
- Benign stricture of either the papilla of Vater or the distal
common bile duct.
- Benign stricture of the pancreatic duct.
- Pancreatic duct stones.
2. Obtructive jaundice in malignant diseases of pancreas and bile
duct.
3. Removing parasites in the bile duct or pancreatic duct.
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- Stenosis of esophagus, cardia orifice and pylorus.
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1. Anatomic consideration:
The distal end of the common bile duct course downward and medially
through the duodenal wall beforeits intestinal exit at the papilla
of Vater, a smooth, nipple-like elevation at the posteromedial wall
of the descending duodenum (fig-1).
The intramural segment of the bile duct is invested with a bundle
of smooth muscle fibers that interdigitate with each other and with
the duodenal musculature constituting the sphincter of Oddi
(fig-2).
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MRI
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Figure 1 : The anatomy of the descending uodenum, with the
intramural segment of the distal common bile duct cephalad to the
papilla of Vater. Folds of the plicae duodeni longitudinalis run
cephalad and end at the papilla.
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MRI
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Figure 2 : Normal papilla is seen on the medial duodenal wall, with
longitudinal folds just below it. The configuration is papillary or
protruding.
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Figure 3 : These are side-viewing duodenoscopes.
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Figure 4a : A double-channel. sphincterotome allows"over-a-wire"
placement and is useful in achieving difficult cannulations because
its tip may be manipulates to seek an orifice and a wire can be
passed through it.
Figure 4b : (A) A 20-mm papillotome(B) A 30-mm papillotome.
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Figure 6 :
(A) Balloon catheter (American Edwards Co) for extraction of bile
duct stones.
(B) Fully inflated 1-cm diameter balloon of balloon extraction
catheter.
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- Mechanichal lithotriptor (fig-7).
Figure 7 : A mechanical lithotriptor can be used to surround large
or difficult stones and crush them.
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- Suction machine.
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3. Techniques of endoscopic sphincterrotomy for common bile duct
stones :
(A) Patient preparation :
- Fasting for a minimum of 8 hours before the procedure.
- Antibiotic are given 2 hours prior to the procedure and
continueed for two doses 8 and 16 hours after the procedure.
- Intravenous infusion.
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(B) Technique :
- The patient lies in a semiprone position with the right side up
and the left arm behind him.
- Checking the esophagus, stomach and duodenum by an end-viewing
upper endoscope.
- Lateral-viewing scope is inserted and advanced into the stomach,
pylorus and duodenum. After reaching the second portion of duodenum
and straightening out the scope, the papilla is brought to an en
face position. Cannulation is performed with regular cannula,
documenting the presence of the stones or any other pathologic
condition of the common bile duct.
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Once the endoscopic retrograde
cholangio-pancreatography (ERCP) is completed, the cannula is
removed and if there is a need for papillotomy, a proper
papillotome is reintroduced through the biopsy channel and advanced
into the common bile duct.
Proper placement of the papillotome in the common bile duct should
be permanently documented by fluoroscopy or a radiograph. If access
to the common bile duct is difficult, the endoscopist should leave
the cannula in place and insert a long wire through the cannula
into the common bile duct and then remove the cannula. This will
allow the use of the wire -guided papillotome and easier access for
insertion of the papillotome into the common bile duct and then
remove a long wire and withdraw the sphincterotome from the common
bile duct until a small portion of the papillome is visible in the
duodenum.
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MRI
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The gastrointestinal surgical assitant will pull the handle of the
papillotome slowly to the cutting position. when the papillotome is
in the cutting position, an incision is made in the papilla of
vater, starting from the center and continouing to the 11-12
o’clock position. The length of the cut should be between 10-15 mm.
Extending the incision beyond the transverse duodenal fold will
increase the chance of perforation. this incision should be made
slowly and deliberately in step wire fashion with small bursts of
cutting current.
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The important points are:
The endoscopist should not proceed if the direction of the incision
is incorrect.
The papilla must always remain in view while an incision is being
made.
In difficult cases, the following techniques are available remedies
this situation :
Over -the wire papillotomy.
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Endoscopic sphicterotomy:
The sphicterome is placed in the duct and cutting will be
proced
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The sphincterotomy is complete and sphincterotome will be pulled
off the bile duct.
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Fig- 8 : Cholelithiasis with multiple gallstones and a single
common bile duct stone (arrow).
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Figure 8: Technique of endoscopic retrograde sphincterotomy.
(A) A papilla is located in the descending duodenum. Note the
longitudinal fold just below the pappila.
(B) The pappila is cannulated for diagnosis.
(C) The cannula is replacedwith a papillotome. After the position
in the common bile duct is confirmed, the papillotome is bowed in
preparation for endoscopic retrograde sphincterotomy.
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Fig-8 (cont) :
(D) A cutting current is passed through the wire and partial
incision is made.
(E) The incision is extended.
(F) Endoscopic retrograde sphincterotomy is completed.
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MRI
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Figure 9 : A balloon catheter is placed and inflated (arrow) after
papillotomy and is used to extract the calculus.
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REMOVING STONE FROM THE COMMON BILE DUCT:
Once the papilotomy is completed, the endoscopist should evaluate
the situation and if no complications are present, proceed with the
removal of the stone.
By balloon (size of the stone 10 mm) :
The extraction balloon catheter is inserted through the biopsy
channel and under fluorosopic observation is advanced past the
stone in the proximal common bile duct. After that, balloon is
inflated, the endosopist slowly pulls it back toward the duodenum.
One may observe the delivery of the stone into the duodenum through
the scope or the monitor.
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Figure 10 : (A) A balloon with a 1cm diameter is passed, inflated,
and withdrawn to calibrate the papillotomy orifice.
(B) The ballon has been passed above the retained stone, inflated,
and pulled down to bring out the stone. The stone can be seen
exiting the papilla.
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By basket ( size of the stone 10 mm ) :
The basket should be primed with contrast material. After insertion
of its tip above the stone is in the basket. At this time, the
gastrointestinal surgical assistant closes the handle of the basket
until the stone is trapped inside it and then endoscopist will pull
back into the duodenum. If size of stone in large, mechanical
lithotriptor is used to break stone into multiple small
stones.
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Figure 11 : Stages of removing common bile duct stones by
basket.
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ERCP: stones in common bile duct and common hepatic duct
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Stones are pulled from common bile duct into the duodenum.
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- Bleeding : 2%-- 3%.
- Perforation : 0, 8%.
- Panceatitis : 5%- 10%.
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Endoscopic sphincterotomy has helped treatment of biliary and
pancreatic diseases easier and simpler.
Today with the advent of endoscopic sphincterotomy, the morbidity
and mortality of stone extraction is possibly less than with
surgical removal.
The hospital stay is shorter, revovery and return to work is much
quicker and the most important, the patients feel less
painful.
In MEDIC center, patient can be removed common bile duct stones and
come back their home in 24 hour after the procedure.
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References:
1. Jeffrey L, Ponsky. Endoscopic retrograde
cholangiopancreatography and the management of common bile duct
stones. Frederick L. G ; Jeffrey L. P; eds. Endoscopic surgery.
Ehiladelphia : Saunders, 1994: 185-- 191.
2. Fred E. S, Guido N, J, T. endoscopic retograde
cholangiopancreatography. Fred E,S ; Guido N, J, T, eds.
gastrointestinal endoscopy. Barcelona: Mosby-wolfe; 1997: 68--
90.
3. Ira m. Jacobson. ERCP dianostic and therapeutic applications.
Elsevier science publishing co. inc. 1989
4. Michael V. Sivak, JR. ERCP. Benjamin H. Sullivan, JR.
Gastroenterology endoscopy. 1987: 502-- 735.