Endoscopic treatment of choledocholithiasis in the era of laparoscopic cholecystectomy: prospective analysis of 386 patients.

BACKGROUND/AIMS: Endoscopic papillotomy is a well-established procedure for treating choledocholithiasis. The aim of this study is to expose our experience with this method in a prospectively collected series of 386 patients and to analyze the safety and efficacy of the pre-cut procedure. METHODOLOGY: Between October 1995 and December 1999, 760 endoscopic retrograde cholangiopancreatographies were performed in 670 patients. Of these, 449 were done to treat 386 patients with choledocholithiasis. The pre-cut technique was performed after failure of multiple cannulation attempts. RESULTS: Bile duct clearance was achieved in 344 (89.1%) cases, however the success rate would increase to 95.1%, if the cases, which endoscopic stone extraction was not feasible, were excluded. Pre-cut was performed in 31 (8.03%) patients, and 11 of them presented some procedure-related complication, while the complication rate of standard sphincterotomy was 3.9% (relative risk = 8.4; 95% confidence interval = 4.2-16.7). Overall complication rate was 6.7% (26 out of 386)--pancreatitis = 13, bleeding = 9, acute cholecystitis = 2, cholangitis = 1, guide-wire-related choledochal perforation = 1. Thirty-day mortality was 1.55% (n = 6), but procedure-related mortality was 0.25% (n = 1). CONCLUSIONS: Endoscopic papillotomy is a safe and effective procedure for patients with symptomatic choledocholithiasis. The pre-cut procedure increases the complication rate of the endoscopic approach, and should be restricted to cases, in which an endoscopic intervention is mandatory.

Endoscopic removal of Ascaris lumbricoides from the biliary tract as emergency treatment for acute suppurative cholangitis.

Ascariasis is the most common intestinal helminthiasis worldwide. Heavily infected individuals are prone to develop bowel obstruction or perforation as well as biliary disease. Nevertheless, the presence of roundworms in the biliary tree outside endemic areas is very uncommon. The migration of these worms to the biliary system can cause biliary colic, pancreatitis, or even acute suppurative cholangitis with hepatic abscesses and septicemia. We report here on 2 infants with 14 and 15 months and a 9-year-old boy who suffered from massive biliary ascariasis and who presented with acute suppurative cholangitis. All cases were successfully treated by endoscopic retrograde cholangiopancreatography with worm extraction and adjuvant medical therapy. Physicians should be aware of ascariasis in patients with pancreatobiliary symptoms who have traveled to endemic areas or in immigrants from these areas.

High power setting argon plasma coagulation for the eradication of Barrett's esophagus.

OBJECTIVE: The term Barrett's esophagus refers to a premalignant condition that is characterized by the replacement of the esophageal squamous mucosa by a columnar-lined one. Preliminary studies have demonstrated reversal of Barrett's mucosa after endoscopic coagulation with different techniques associated with acid inhibition. However, most of these studies have shown that residual Barrett's glands are found underneath the new squamous epithelium in up to 40% of patients. The goal of our study is to verify whether complete restoration of Barrett's mucosa can be achieved by the combination of high power setting argon plasma coagulation and omeprazole. METHODS: A total of 33 patients (mean age: 55.2 yr, range: 21-84 yr; 21 men and 12 women) with histologically demonstrated Barrett's esophagus (mean length: 4.05 cm, range: 0.5-7 cm) were treated. Fourteen cases presented with low-grade dysplasia and one with high-grade dysplasia. All of the extent, or until a maximum of 4 cm, of the Barrett's mucosa was cauterized in each session using argon beam coagulation at a power setting of 65-70 W. All patients received 60 mg omeprazole during the treatment period. RESULTS: Complete restoration of squamous mucosa was obtained in all 33 cases after a mean of 1.96 sessions (range, 1-4). Endoscopic results were histologically confirmed. Nineteen (57.5%) patients experienced moderate to severe chest pain and odyno-dysphagia lasting for 3-10 days after the procedure. Five of these cases experienced high fever and a small volume of pleural effusion, and three patients developed esophageal strictures that needed to be dilated. Another patient developed pneumomediastinum and subcutaneous emphysema without evidences of perforation. After a mean follow-up of 10.6 months there was one endoscopic, as well as histological, recurrence of Barrett's mucosa in a patient with an ineffective laparoscopic fundoplication. CONCLUSIONS: High power setting argon plasma coagulation combined with intensive acid suppression is an effective treatment for the total endoscopic ablation of Barrett's esophagus, at least in the short term. Long-term follow-up of treated patients in whom gastroesophageal reflux is surgically or medically alleviated seems mandatory before drawing definitive conclusions about this therapy.