Endoscopic treatment of bile duct stones: is stone extraction necessary after endoscopic sphincterotomy?

BACKGROUND

The current treatment for stones in the biliary tree is endoscopic sphincterotomy (ES) followed by stone extraction with the help of balloon catheters or metal baskets. Stone extraction techniques are often associated with complications. Moreover, the balloon catheters break easily which aids to the cost of the procedure. The present study was designed to examine the effectiveness of endoscopic sphincterotomy (ES) alone in allowing spontaneous expulsion of bile duct stones and to determine the circumstances which warrant stone extraction.

METHODS

Endoscopic retrograde cholangio-pancreatography (ERCP) was attempted in 68 patients with stones in the common bile duct. The stone size was determined by ultrasound, cholangiography in post cholecystectomy patients with a T-tube or by ERCP. Patients with stone size of 15 mm or less in diameter were treated with ES alone without stone extraction. Patients were discharged from the hospital within 24 hrs and returned for reassessment every week or earlier, if symptomatic, until complete clearance of stones was demonstrated.

RESULTS

Endoscopic sphincterotomy was successfully performed in 63 (93%) patients, the procedure was abandoned in the remaining 5 patients for technical reasons. Spontaneous clearance of stones was observed in 55 (87%) patients, usually without any accompanying pain (47.85%). Persistent stones were seen in 8 (13%) patients; extension of the ES resulted in spontaneous stone expulsion in 6 of these patients. Thus, 61 (97%) of the 63 patients with stones of 10 mm or less in size cleared the stones spontaneously and all 8 patients who failed the initial ES, had stones > 10 mm in size.

COMMENT

The present study shows that all small stones (< 10 mm) and most of those < 15 mm are expelled spontaneously after an adequate ES. These finding if substantiated by larger studies will reduce considerably the cost of the procedure as well as the morbidity associated with mechanical stone extraction.