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 70’s Classen and Kawai- mid 70’s Safrany L, Lancet, Nov 1978: ‘ES is increasingly replacing surgery in the treatment of choledocholithiasis’ 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 Manegold BC, Langenbecks Arch Chir, Nov 1978: ‘ Late complications after EST are unknown and not to be expected

Early Complications of ES Sedation Sedation Basket impaction Basket impaction Pancreatitis Pancreatitis Bleeding Bleeding Cholangitis Cholangitis Perforation Perforation Failure Failure Early papillary stenosis Early papillary stenosis

Late Complications of ES Recurrent stones Recurrent stones Acute cholecystitis Acute cholecystitis Recurrent pancreatitis Recurrent pancreatitis Re-stenosis of papilla Re-stenosis of papilla Cholangiocarcinoma Cholangiocarcinoma Rare complications: new GB stones, gallstone ileus, Ascaris in CBD Rare complications: new GB stones, gallstone ileus, Ascaris in CBD

StudyNo. Early Comp. Late Comp. Mortality Seifert % 5.7% recurr 3.1 restenosis 1.12% Escourou %7% 12% chole 6% rec Pancr 1.5% Liquory %13%4% Leese % Surgery 3.8% 3.3% Dresemann % Surgery 0.5% 16.9% Surgery 5.6% 2.8% Kullman ALL 164 ES 16.5% Surgery 3.1% 3.1%

Pre-Laparoscopic Era Great majority cholecystectomised Great majority cholecystectomised Almost all those with GB in situ unfit for surgery Almost all those with GB in situ unfit for surgery Few specialised, skilled, high-volume centres Few specialised, skilled, high-volume centres Morbidity and mortality go with the pathology Morbidity and mortality go with the pathology

Risk Factors in ES Clinical: Acute cholangitis Acute cholangitis Sphincter of Oddi Dysfunction Sphincter of Oddi Dysfunction Coagulopathy CoagulopathyTechnical: Difficult cannulation Difficult cannulation Pre-cut Pre-cut Small ducts Small ducts Wide 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 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 No advantage for ES+cholecystectomy over BDE ‘Routine preoperative ES is of questionable value’ ‘Routine preoperative ES is of questionable value’

Neoptolemos 438 patients 5 years GroupNumberMorbidityMortality ES + surgery % * p< % Surgery alone %4% ES alone GB in situ % * p< % ES alone NO GB %17.6%

The ‘new’ concepts of the laparoscopic era Clear the CBD before cholecystectomy ! Clear the CBD before cholecystectomy ! Laparoscopic IOC is time-consuming ! Laparoscopic IOC is time-consuming ! Laparoscopic CBDE is difficult ! Laparoscopic CBDE is difficult ! ‘Plan operating lists’ ! ‘Plan operating lists’ ! Limited facilities for urgent biliary surgery ! Limited facilities for urgent biliary surgery ! Gallstone surgery is minimally invasive !? Gallstone surgery is minimally invasive !?

ERCP in England /91 90/91 98/99 98/99 Increase % Diagnostic; Surgery Medicine Medicine Total Total % 190 % Therapeutic; Surgery Medicine Medicine Total Total % 400 % All ERCP’s % 250 %

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 ‘.. 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’ ‘.. 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 Need to preserve the Sphincter of Oddi SS & ES—9-11% stone recurrence within 6 years increasing with time. Recurrent brown stones due to stasis & infection SS & ES—9-11% stone recurrence within 6 years increasing with time. Recurrent brown stones due to stasis & infection High rate of long term complications of ES 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 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; :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 LFT’s  Anecdote or reality?  General ERCP mortality is NOT 0.5-1%

ES in the Laparoscopic Era Is it any different? Is it any different? What are the indications? What are the indications? Perhaps there are no complications!! Perhaps there are no complications!! May be we do not hear of them! May be we do not hear of them! Most do not WANT to know Most do not WANT to know

StudyNo. Late Complications Conclusions Boytchev ; yr FU 14%. Late complications after ES for CBD stones with GB in situ are rare(2%/year) Cholecystectomy does not seem to be warranted Saito yr FU Chole 5.9%, Recurr 9.7%. Long-term outcome of ES is relatively favourable. Cholecystectomy is not always necessary Schreurs ES only 16%. Sugiyama , 60 yrs or younger 12%. Can also be treated with ERCP. ES is reasonable even in young patients Costamagna yr FU 11%, 2.8% multiple. ES is safe at long-term follow-up !!

No need for cholecystectomy? Boerma et al, Lancet ;360: Boerma et al, Lancet ;360: Wait and see policy or laparoscopic cholecystectomy after ES for bile duct stones: a randomised trial. 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 Longer waiting Interval complications Interval complications Multiple emergency admissions Multiple emergency admissions Longer presentation to resolution periods Longer presentation to resolution periods ERCP ERCP The economic cost can not be estimated

INCIDENCE OF REPEAT ERCP (During the same admission)

Conclusions ES still has complications and mortality ES still has complications and mortality Even if the rates are the same, 2-3 times as many patients are exposed to the risk Even if the rates are the same, 2-3 times as many patients are exposed to the risk Main indication in laparoscopic era!? Main indication in laparoscopic era!? We should not forget the patient We should not forget the patient Evidence for one-session management is stronger Evidence for one-session management is stronger Guidelines, Training and Specialisation Guidelines, Training and Specialisation