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Background: Sometimes, no definite filling defect could be found by cholangiogram (ERC) during the endoscopic retrograde cholangio-pancreatiographic (ERCP) exam; even prior images had evidence of common bile duct stones (CBDS). We aimed in estimating the positive rate of extraction of CBDS who had treated by endoscopic sphincterotomy/endoscopic papillary balloon dilation (EST/EPBD) with negative ERC finding., Methods: One hundred forty-one patients with clinically suspicious of CBDS but negative ERC, who had received EST/EPBD treatments was enrolled. Potential factors for predicting CBDS, as well as the treatment-related complications were analyzed., Results: Nearly half of the patients with negative ERC, had a positive stone extraction. Only patients with high probability of CBDS were significantly associated with positive stone extraction. Moreover, patients with intermediate probability of CBDS had higher rates of overall complications, including post-ERCP pancreatitis. In addition, no significant difference of post-ERCP pancreatitis was found between EST and EPBD groups in any one group of patients with the same probability of CBDS., Conclusions: Regarding patients with negative ERC, therapeutic ERCP is beneficial and safe for patients present with high probability of CBDS. Moreover, under the same probability of CBDS, there was no significance difference in post-ERCP pancreatitis between EST and EPBD.

Background: Endoscopic sphincterotomy (ES) is an established treatment for patients with choledocholithiasis or common bile duct stones (CBDS), but further management of patients after ES with recurrent CBDS remains controversial. Endoscopic papillary large balloon dilation (EPLBD) has been used safely and effectively for stone removal in patients after ES with recurrent CBDS. The aim of this study was to evaluate the clinical efficacy of EPLBD in patients after complete ES with recurrent CBDS., Methods: Records of 891 patients with CBDS after complete ES from January 1991 to December 2008 were reviewed. Of 133 patients with recurrent CBDS, 122 had complete endoscopic bile duct clearance. Twenty-three patients (Group 1) underwent EPLBD and 99 (Group 2) underwent stone extraction without dilatation. Basic demographics and endoscopic findings at the first recurrence were recorded and analyzed. The primary end point was the second CBDS recurrence., Results: No statistical differences were observed between the two groups, except for larger CBDS size in Group 1. The bile duct clearance rate was 96% in Group 1 and 91% in Group 2. No complications such as pancreatitis, perforation, and bleeding were noted in Group 1, and one patient in Group 2 suffered from bleeding after stone extraction. The rate of second recurrent CBDS after endoscopic clearance for the first recurrent CBDS was 17% in Group 1 and 60% in Group 2 (p < 0.001). There were two independent factors for the second recurrence, including cirrhosis (odds ratio 4.734, p = 0.023) and stone extraction directly without major papilla expansion (odds ratio 6.050, p = 0.003)., Conclusion: EPLBD is a safe and effective endoscopic treatment for recurrent CBDS in patients after ES. It can also facilitate complete clearance of CBDS and prevent further CBDS recurrence., (Copyright © 2014. Published by Elsevier Taiwan.)

Background: The recurrence rate of common bile duct stones (CBDS) is around 3-21% after treatment by endoscopic sphincterotomy (ES). Fatty meal has been shown to improve hepatic clearance in both patients with intact gallbladder and post-cholecystectomy after ES. This study tested the effects of different kinds of food on hepatic clearance by using quantitative cholescintigraphy (QC) in patients after ES., Methods: Forty-seven patients after ES with abnormal QC were enrolled in our study. Complete ablation of sphincter function was confirmed by sphincter of Oddi manometry. Fasting QC was done in every patient shortly after normalization of liver function, and then followed with low-fat and fatty-meal QC. Each of the 47 subjects was observed for the effect on hepatic clearance at 3 different levels of treatments (diets and fasting). Additionally, possible factors responsible for recurrent CBDS were investigated by means of logistic regression., Results: Both fatty and low-fat meals could significantly improve hepatic clearance compared with fasting in most patients after ES. But the response to food types was individualized. All patients tolerated the meals well. There was no significant relationship between the recurrence of CBDS and sex, age, intact gallbladder and presence of juxtapapillary diverticulum, CBD size, and improvement in hepatic clearance (> or = 5%) by food., Conclusion: Both fatty and low-fat meals improved hepatic clearance in most of the patients with CBDS after ES, but the response to meals was individualized. Therefore, there is no need to restrict the amount of fat intake for patients who have undergone ES.

Background and Aim: The role of juxtapapillary diverticulum ( JPD) in biliary stone formation is controversial. This study was designed to understand the relationship between the size of JPD, hepatic clearance and recurrent bile duct stones in patients after endoscopic sphincterotomy., Methods: Five hundred and twenty patients with choledocholithiasis who had received endoscopic sphincterotomy were enrolled. They were divided into three groups: group A (n = 268) without diverticula; group B (n = 156) with small diverticula; and group C (n = 96) with large diverticula. All patients were regularly followed with interviews, liver function test and sonogram to detect the recurrent bile duct stones. Quantitative cholescintigraphy was performed in 176 cholecystectomized patients to evaluate the hepatic clearance. Sphincter of Oddi manometry was performed to exclude incomplete sphincterotomy if quantitative cholescintigraphy was abnormal., Results: After 9-111 months of follow-up, 76 patients had recurrent bile duct stones. There was a significant higher bile duct stone recurrence in group C than in group A (P < 0.01), but no statistical difference was noted between group B and group A (P = 0.2). Patients with JPD were older than those without (P < 0.05). Of 176 cholecystectomized patients, two were excluded because sphincter of Oddi basal pressure was more than 10 mmHg. In the remaining 174 patients, the E45' was significantly lower in group C than in group A (41.2% +/- 18.6%vs 49.1% +/- 14.1%; P < 0.05), and there was no significant difference between group B and group A., Conclusions: JPD is a predisposing factor of delayed biliary emptying and it increases the chance and incidence of recurrent bile duct stones.

Background: As many as 24% of patients who undergo endoscopic sphincterotomy for the removal of bile duct stones have recurrent biliary complications develop for which there is no effective method of prevention. The aim of this study was to determine whether patients who undergo routine clinical follow-up after endoscopic sphincterotomy for bile duct stones have a different outcome than those who do not., Methods: All patients who had endoscopic sphincterotomy for bile duct stones were scheduled for follow-up visits, liver function tests, and transabdominal US every 3 to 6 months. ERCP was performed whenever symptoms recurred, or abnormal liver function or US was noted. The patients themselves decided whether to adhere to the follow-up schedule; this was not a randomized trial., Results: Seven hundred sixty-seven patients underwent endoscopic sphincterotomy for bile duct stones from October 1990 to July 1999. Seventy-seven (10%) were found to have recurrent bile duct stones. Three patients who had undergone Billroth II gastrectomy were excluded. Among the remaining 74 patients (52 men, 22 women; mean age 65 years), 42 (57%) had a juxtapapillary diverticulum and 21 (28%) an intact gallbladder. The mean time to recurrence of bile duct stones was 19.7 months (range 5-72 months). Sixty-four patients (87%) had recurrent bile duct stones within 3 years. Fifty-one (69%) were followed regularly (Group A) and 23 (31%) were not (Group B). At the time of stone recurrence, 20 patients in Group A (39%) and 1 in Group B (4%) were asymptomatic (p = 0.002). Liver function tests were normal in 17 patients (13 Group A, 4 Group B). Endoscopic treatment for recurrent bile duct stones was successful in 46 patients (90%) in Group A and 16 (70%) in Group B (p = 0.04); surgical treatment was successful in all 5 patients in Group A and 4 of the 7 patients in Group B. Two patients in Group B were treated by nasobiliary drainage and biliary endoprosthesis insertion caused by extremely large stones and poor condition; both died (acute pancreatitis and sepsis)., Conclusion: Regular follow-up after endoscopic sphincterotomy detects recurrent bile duct stones early and thus avoids complications of bile duct stones.