1. Short-Term and Long-term Complications of Endoscopic Sphincterotomy for CBD Stones Ahmad Nassar Monklands Hospital Scotland

2. 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

3. 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

4. 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

5. StudyNo. Early Comp. Late Comp. Mortality Seifert198290417.5% 5.7% recurr 3.1 restenosis 1.12% Escourou198444343%7% 12% chole 6% rec Pancr 1.5% Liquory198540957%13%4% Leese198539410.4% Surgery 3.8% 3.3% Dresemann19881853.8% Surgery 0.5% 16.9% Surgery 5.6% 2.8% Kullman1989128ALL 164 ES 16.5% Surgery 3.1% 3.1%

6. 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

7. 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

8. 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’

9. Neoptolemos 438 patients 5 years GroupNumberMorbidityMortality ES + surgery 59 23.7% * p<0.001 5.1% Surgery alone 2488.5%4% ES alone GB in situ 114 19.3% * p<0.003 7.9% ES alone NO GB 1717.6%17.6%

10. 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 !?

12. ERCP in England 1990-1999 90/91 90/91 98/99 98/99 Increase % Diagnostic; Surgery 502710400 Medicine Medicine616911252 Total Total1119621652 190 % 190 % Therapeutic; Surgery 20378162 Medicine Medicine19808197 Total Total401716359 400 % 400 % All ERCP’s 1521338011 250 % 250 %

14. We are not alone

15. 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’

16. 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

17. AND Endoscopists! Cotton P B Is your sphincterotomy really safe - and necessary? Gastrointest endosc; 1996 44:752-5 ‘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’

18. 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%

19. 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

20. StudyNo. Late Complications Conclusions Boytchev2000169; 139 5 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 Saito2001371 7.7 yr FU Chole 5.9%, Recurr 9.7%. Long-term outcome of ES is relatively favourable. Cholecystectomy is not always necessary Schreurs2002447 164 ES only 16%. Sugiyama2002 145, 60 yrs or younger 12%. Can also be treated with ERCP. ES is reasonable even in young patients Costamagna 2002 529 334 5 yr FU 11%, 2.8% multiple. ES is safe at long-term follow-up !!

21. No need for cholecystectomy? Boerma et al, Lancet 2002 7;360: 739-40 Boerma et al, Lancet 2002 7;360: 739-40 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’

22. 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

23. INCIDENCE OF REPEAT ERCP (During the same admission)

25. 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