Trends and current clinical aspects of complicated gallstone disease - with special reference to endoscopic treatment

• Time trends regarding incidence, management, and outcome of acute (AC) and elective cholecystectomy (EC), as well as symptomatic (cholangitis, pancreatitis, jaundice) and asymptomatic (detected accidentally during cholecystectomy) common bile duct (CBD) stones were studied during the time period 1970-1986 in a welldefined Swedish population. From period I (1970-1978) to period II (1979-1986) there was a four-fold increase in the ratio of AC (period I: mean 10/100,000/year, period II: mean 30/100,000/year) to EC (period 1: mean 190/100,000/year, period II: mean 120/100,000/year). For both AC and EC the fraction of patients older than 70 years increased significantly with time. For AC, the female to male ratio decreased significantly from 2.6 to 1.0. The duration of history and frequency of previous hospital stay for gallstone disease decreased significantly for both groups. The postoperative morbidity did not change, whereas the postoperative mortality after AC decreased significantly. Postoperative mortality was significantly higher after AC than EC in both periods. Complications occurred less frequently among patients with a short history of gallstone symptoms than among those with a long history.During the same time periods, there was a significant increase in the incidence of symptomatic CBD stones (8 - 20 cases/100,000 inhabitants/year), and a slight decrease in the incidence of asymptomatic CBD stones (12- 10 cases/lOO cholecystectomies/year). The fraction of patients older than 70 years increased from 31% to 60% for patients with symptomatic CBD stones and from 17% to 27% for patients with asymptomatic CBD stones. In period 11 endoscopic sphincterotomy (EST) accounted for 81 % of all primary procedures performed in patients with symptomatic CBD stones. Type of treatment disregarded, the frequency of clinically overt retained CBD stones increased from 7 % to 22 %. Overall, the frequency of general complications decreased significantly,mainly due to a decrease in the group with symptomatic CBD stones. The frequency of procedure related complications also decreased in the symptomatic group, whereas it increased in the asymptomatic group. Theoverall mortality rate decreased significantly. The total time of stay in hospital decreased by 48 % for patients with symptomatic CBD stones and 23 %for those with asymptomatic stones.EST for retained or recurrent CBD stones after cholecystectomy was performed in 128 patients with an overall success rate of 92 %. Late bile duct complications (recurrent stones and/or stenosis) occurred in seven patients at a median time of 20 months after EST and were best treated with repeat EST. To minimize short-term complications, efforts to extract all stones and confirmation of CBD clearance is mandatory at the initialprocedure. EST is safe and efficient as the first procedure of choice in patients with retained and recurrent CBD stones.EST was performed in 148 patients with CBD stones and the gallbladder left in situ with an overall success rate of 88 %. The median observation time in 118 patients discharged with the gallbladder in situ was 42 months. Complications necessitating acute surgery arose from the remaining gallbladder in seven patients (6 %) at a median of 14 months after EST. Another six patients (5 %) underwent elective cholecystectomy at a median of 21 months after EST. A stone bearing gallbladder left in situ after EST does not appear to be an additional risk factor for future complications compared to the natural history in patients with verified cholelithiasis. Leaving the gallbladder in situ after EST is justified in elderly and frail patients. Surgery should be restricted to patients in whom symptoms develop.The occurrence of bacteremia in association with diagnostic or therapeutic ERCP were studied in 180 patients undergoing 194 examinations, and it occurred in 15 % and 27 %, respectively. There was no correlation between the occurrence of bacteremia and the duration of the procedure. The frequency of complications in patients with bacteremia did not diffef from that in patients without bacteremia, whether the procedure was diagnostic or therapeutic. Routine antibiotic prophylaxis is not indicated in patients undergoing diagnostic or therapeutic ERCP.Extracorporeal shock wave lithotripsy (ESWL) was performed in 28 patients with problematic CBD stones and 9 patients with intrahepatic duct (IHD) stones. The overall fraction of successfully treated patients was 89 %, with no major complications or mortality. It is concluded that ESWL is a safe and efficient treatment modality for CBD and IHD stones after failed endoscopic treatment. It further extends the number of patients with bile duct stones who can be treated by non-surgical means.

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