Recurrent common bile duct stones as a late complication of endoscopic sphincterotomy.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (ES) has become well established as a modality for the management of common bile duct stones (CBDS), especially in the setting of associated cholangitis. Our study aims to determine the rate of long term morbidity of recurrent CBDS post ES. METHODS: A retrospective analysis of patients who underwent ERCP and ES (ERCP+ES) was undertaken on a prospectively maintained database from 1998 to 2012 at the Northern Hospital, Melbourne. Primary CBDS were defined as those detected at least 6 months after complete clearance of the CBD. Prior cholecystectomy was a requirement for inclusion and patients with primary CBD stones in the setting of an intact sphincter were excluded. RESULTS: A total of 1148 patients underwent ERCP, of which 573 had an ES. Fifty-one patients underwent an ES prior to developing primary CBDS (8.9%). The time to recurrence ranged from 6 months to 15 years (mean 3.3 years). The number of procedures per patient ranged from 2 to 11, with 51% requiring 3 or more ERCPs. Factors associated with primary CBDS recurrence included a dilated CBD > 12 mm, stricture of the major papilla post ES to 2 - 5 mm and presence of the ampulla within or on the edge of a duodenal diverticulum. CONCLUSION: The results demonstrate that ERCP + ES has an inherent long-term complication of recurrent primary CBDS formation. While this can be managed with repeat ERCP, the advent of laparoscopic bile duct exploration should lead us to re-examine the role of ERCP + ES in younger patients.

Primary adenocarcinoma arising at an ileostomy site: an unusual cause of bowel obstruction.

Adenocarcinoma of the ileostomy stoma is a rare complication of ileostomy. An instance of adenocarcinoma of the ileostomy stoma, which presented as a small bowel obstruction, is reported in a 58 year old woman who had nearly a 30-year history of abdominal problems that had been treated conservatively.

Surgical significance of the bile duct of Luschka.

In 20 post-mortem dissections, the subvesical bile duct of Luschka was noted in six specimens. Microscopic examination of ten other post-mortem gallbladders revealed small bile ducts on the gallbladder surface in five. Four cases of injury to the duct of Luschka during cholecystectomy are described and illustrated with cholangiographic and histological evidence. Post-cholecystectomy bile leaks from the drain tube, which closed spontaneously without sequelae, were noted in 9 per cent of 204 randomly selected cases and were regarded, at least in some, as being caused by a divided duct of Luschka. The practical significance of this duct during cholecystectomy is to keep close to the gallbladder wall during removal of the gallbladder, and to ligate a divided bile duct of Luschka if recognized at surgery.