Bile duct stones are divided into three types according to their anatomical locations: intrahepatic bile duct stones, gallbladder stones, and common bile duct stones, of which gallbladder stones and common bile duct stones are collectively called extrahepatic bile duct stones.
Intrahepatic bile duct stones are mostly caused by unhygienic drinking water, resulting in biliary tract roundworm or hookworm infection, which further develops into intrahepatic bile duct stones. The incidence of intrahepatic bile duct stones is very low, especially in economically developed areas like Shanghai, where patients with intrahepatic bile duct stones are rarely seen. However, with the improvement of people’s living standard, the incidence of extrahepatic biliary stones, especially gallbladder stones, has increased significantly, with an incidence rate of about 10%, i.e. 1 in 10 people suffer from this disease. Therefore, this article introduces the endoscopic (laparoscopic, choledochoscopic and duodenoscopic) treatment of extrahepatic biliary stones.
The most common type of extrahepatic biliary stones is gallbladder stones, followed by gallbladder stones in combination with common bile duct stones, and in a few cases, only common bile duct stones without gallbladder stones.
In the following, regarding these three cases of extrahepatic biliary stones, according to my treatment experience, combined with domestic and international treatment progress, we will talk about how to apply laparoscopy, choledochoscopy and duodenoscopy in an integrated way and individualize minimally invasive treatment according to each patient’s condition, so that patients can get the treatment with the least pain and the best therapeutic effect.
I. Endoscopic treatment options for gallbladder stones
1.Laparoscopic cholecystectomy (LC) for gallbladder stones
It is suitable for most patients with stage II or even III gallbladder stones with complications who have abdominal pain symptoms, and the surgery is less invasive and quicker to recover.
2.Laparoscopic combined with choledochoscopic biliary stone retrieval treatment of gallbladder stones
In other words, a minimally invasive laparoscopic method is used to make an incision at the bottom of the gallbladder, remove the stones from the gallbladder with a choledochoscope, and then stitch up the gallbladder incision.
This surgical method is simple and does not cause serious complications such as bile duct injury that may exist when the gallbladder is removed, and preserves the gallbladder, which is welcomed by patients and has been carried out more and more in recent years in China. However, this method is still very controversial in the medical community, mainly because it does not remove the gallbladder, the hotbed of gallbladder stones, and the recurrence of gallbladder stones is the focus of controversy. It is mainly suitable for young patients with good gallbladder function, low inflammation in the gallbladder wall, no mass lesions in the gallbladder wall, and a small number of gallbladder stones.
Endoscopic treatment options for gallbladder stones combined with common bile duct stones
1.Laparoscopic cholecystectomy + choledochotomy + choledochoscopy for stone extraction + T-tube drainage
It is suitable for patients with thicker common bile duct and more and larger common bile duct stones. The advantages are less traumatic and faster recovery than caesarean operation.
Disadvantages are.
1. cannot be used for those with a history of upper abdominal surgery and heavy abdominal adhesions.
2. as with cesarean surgery, it cannot be used in patients who cannot tolerate the procedure
3, long treatment time, the need to discharge with tubes, the patient’s life is not convenient.
2.Duodenoscopic choledocholith extraction + laparoscopic cholecystectomy
It is a treatment option that has been adopted more and more in recent years. Firstly, duodenoscopy (like gastroscopy) is used to reach the duodenum through the mouth, esophagus and stomach, find the opening of the common bile duct in the duodenum, insert a tube into the common bile duct, and after imaging the common bile duct stones, the stones are removed with a lithotripsy mesh basket and a lithotripsy balloon. After an interval of 1-2 days, laparoscopic cholecystectomy is performed. In recent years, simultaneous ERCP+LC in the operating room has also been introduced, which is less painful for the patient. It is suitable for patients with a thin diameter of the common bile duct and a small number of stones in the common bile duct.
The advantages are.
(1) Less invasive, suitable not only for general patients with gallbladder stones combined with common bile duct stones, but also for patients with poor general condition.
(2) Short treatment time, no need to discharge with tubes.
Disadvantages are.
(1) High cost.
(2) Difficult to remove stones by ERCP in patients with common bile duct full of stones, or with many stones in the common bile duct, large diameter, or who have had gastric surgery with type II anastomosis.
(3) Endoscopic ERCP itself has a certain incidence of complications, such as intestinal perforation, bleeding, pancreatitis, etc.
3.Laparoscopic cholecystectomy and transcystic duct choledochoscopic lithotripsy
This procedure involves removing the common bile duct stones through the cystic duct without incising the common bile duct, which eliminates the need to place a common bile duct T-tube for drainage, and thus this is the most ideal treatment option.
This option requires that the patient has a thick cystic duct, that the choledochoscope can enter the common bile duct through the cystic duct, and that the common bile duct stones are not very large and not very numerous. In most people, the bile duct is too thin for the choledochoscope to enter and is therefore not suitable for this approach. However, many patients now have secondary stones in the common bile duct, that is, the stones enter the common bile duct from the gallbladder, and the stones dilate the cystic duct in the process of entering the common bile duct.
Endoscopic treatment options for simple common bile duct stones
1.Duodenoscopic choledocholith extraction
This is the most used treatment option in recent years. After using duodenal papillotomy (EST) or dilatation (EPBD), the stones are removed with a lithotripsy balloon or mesh basket. This is also the most ideal treatment method. Not only is it less invasive and quicker to recover, it is also suitable for patients who are in poor general condition and find it difficult to tolerate the procedure. Sometimes patients have many stones and large diameters, requiring multiple ERCPs for stone extraction.
Although duodenoscopic stone extraction is not surgery, it is equivalent to surgery and has complications, sometimes even serious complications, such as intestinal perforation, severe pancreatitis and bleeding.
2.Duodenoscopic biliary drainage
If the patient has severe cholangitis and poor general condition, and it is difficult to tolerate the risk of stone extraction, internal drainage of biliary stent or external drainage of nasobiliary duct can be performed first, and then ERCP can be performed again to remove the common bile duct stone after the patient’s condition has improved and stabilized.