Short-Term and Long-term Complications of Endoscopic Sphincterotomy for CBD Stones

Ahmad Nassar Monklands Hospital Scotland

ES for CBD Stones

Classen and Kawai- mid 70s

Safrany L, Lancet, Nov 1978: ES is increasingly 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 Seifert 1982 Escourou 1984 Liquory 1985 Leese 1985 Dresemann 1988 Kullman 1989

No. Early Comp. 9041 7.5%

443 7% 43% 409 13% 57% 394 10.4% 3.3% Surgery 3.8% 185 3.8% 16.9% 2.8% Surgery 0.5% Surgery 5.6% 128 164 ES 16.5% 3.1% ALL Surgery 3.1%

Late Comp. Mortality 5.7% recurr 1.12% 3.1 restenosis 12% chole 1.5% 6% rec Pancr 4%

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 the pathology

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 common bile 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
Surgery alone ES alone GB in situ ES alone NO GB

59
248 114 17

23.7% * p<0.001 8.5%

19.3% * p<0.003 17.6%

5.1%
4% 7.9% 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 !?

5000 4500 4000 3500 3000 2500 2000 1500 1000 500 0 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 Diagnostic; Surgery 5027 98/99 10400 Increase %

Medicine
Total

6169
11196

11252
21652 8162 8197 16359 400 % 190 %

Therapeutic; Surgery 2037 Medicine 1980 Total 4017

All ERCPs

15213

38011

250 %

Number of deaths and mortality rate for patients undergoing ERCP procedures and diagnosed with benign gallstone dise p Time period: January 1992 to December 2001
Ye a r 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001p Num be r of de a ths 48 66 79 63 107 105 119 76 88 60 3.4 3.5 3.7 2.6 4.2 4.1 4.3 2.7 3.2 2.3

Morta li ra te (%

Sourc e: ISD link ed data s et 30 January 2003 p prov is ional

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 & ES9-11% stone recurrence within 6 years 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 B
Is your sphincterotomy really safe - and necessary? Gastrointest endosc; 1996 44:752-5 It could be that too many people have found themselves inadequately 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 endoscopic sphincterotomy in light of long-term complications in the data

But, what about the patient ?

19

year olds having sphincterotomies 34 year old, mother of three, dying after an ERCP for mild derangement of LFTs
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 Boytchev 2000 Saito 2001

No.

Late Complications Conclusions

169; 14%. Late complications after ES for CBD 139 5 yr FU stones with GB in situ are rare(2%/year)
Cholecystectomy does not seem to be warranted

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 Sugiyama 2002

447 16%. 164 ES only 145, 60 yrs 12%. Can also be treated with ERCP. ES or younger is reasonable even in young patients

Costamagna 529 11%, 2.8% multiple. ES is safe at 2002 334 5 yr FU 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 (During the same admission)

6000 5000 4000 3000 2000 1000 0 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

5

ERCP MORTALITY (%)

0 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001p

Conclusions
ES still has complications and mortality Even if the rates are the same, 2-3 times as many 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