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MEDIC 254 Hoøa Haûo Q. 10 TP. Hoà Chí Minh ÑT: 8357284 8355 136 fax: 8488352543 email: medic@hcm. vnn. vn
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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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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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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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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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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.