(陳欣然)，(周鳴清)，(金穎明)，

Treatment for 63 cases of the elderly with choledocholith by duodenoscope

Chen Xinran(陳欣然)，Zhou Mingqing(周鳴清)，Jin Yingming(金穎明)Department of Hepatobiliary Surgery，Shanghai Zhabei Central Hospital

ObjectiveTo explore the effect of duodenoscope in the treatment for the elderly cases.Method Retrospective analysis of the treatment by duodenoscope for 63 elderly patients(all aged over 80 years old)with high risk choledocholith from Jan 2006 to Dec 2010.ResultsAll of the 63 cases obtained a success in the endoscopic operation.The operative time was within 15 ～60 min.Endoscopic stone extraction was performed on 21 cases，bile duct plastic stent in 35，of them 2 cases had the second operation because their stones were too big.In 2 cases of 9 who suffered from acute obstructive suppurative cholangitis(AOSC)，plastic stents were placed.In the rest 7 cases，nasobiliary drainages(NBD)were inserted，on 4 of the 7 cases，stone extraction were performed 5 －7 days later，in 3 of the 7 cases，stents were inserted for the second time，of the 3 cases，2 were found blood oozing on the surface of wound after EST(endoscopic sphicterectomy)，the bleeding was stopped by local spray of noradrenaline，no hematorrhea or perforation occurred.Postoperative choledochitis was found in 1 case，to whom anti-inflammatory therapy was applied.Pancreatitis was found in 3 cases，blood amylase increasing in 12，who were cured with fast，pancreatic secretion inhibition and anti-inflammatory drugs.One patient died of acute left heart failure(ALHF)，no death from the bile duct diseases or concerned were found.ConclusionAlthough many basal diseases of the elderly increase the risks in the endoscopic treatment，it proves to be practical for it has less complications，high security and definite curative results.

choledocholith;treatment;duodenoscope;elderly;age

Sixty-three elderly patients with choledocholith，aged over 80 years old，were treated from Jan.2006 to Dec.2010.the details are reported as follows:

1 Clinical data

From Jan.2006 to Dec.2010，63 cases with choledocholith，aged over 80，were treated with endoscope.Of them，29 were male，34 famale，aged from 80 to 94(85.3 on average)，56 aged 80 to 89，7 over 90.Of them，30 cases suffered from choledocholith post cholecystectomy，and choledocholith complicated with gallstones were found in 16 cases，single choledocholith in 7，choledocholith with inflammatory stenosis of the bile duct in 1 case，with AOSC(acute obstructive suppuractive cholangitis)in 9 cases，60 cases

had verious basal diseases，such as cardiopulmonary，and some systemic diseases else.Of them 49 had hypertension，25 had coronary heart diseases，chronic respiratory diseases 13，renal insufficiency 3，uremia 1，Alzheimer’s disease 1.

2 Method

Properative routine examinations(EKG，chest X ray，blood routine，bleeding and coagulation time test，and renal function，etc)CT，MRI were performed to understand general condition of bile duct so that the internal diseases found could be actively，properly treated before the following operations.Before operation，the patients fasted for 8 hours，half an hour ahead，were given diazepam 5 mg，pethidine 50 －100 mg，and atropine 0.5 mg，for the patients in poor condition，lidocain plasmage 10 mL，orally，oxygen inhalation，and ECG monitoring were used.The first-aid medicine should be thoughtfully prepared.Generally endoscope was inserted into the descending part of duodenum，with retrograde contrast，the stones sites，sizes and numbers in the common bile ducts could be observed.The difficulties for stone extraction could be properly assessed.If the stones could be completely taken out and which the patients could tolerate，medium or small incisions(expansion)was recommended with EST(endoscopic sphincterectomy)or EPBD(endoscopic papillary balloon dilation)according to stone size and papillary shape.In case of difficult insertion caused by incarcerated papillary stones，needle-knife should be used for papillary open-window or pre-cutting.EST(expansion)was performed when bile duct insertion，contrast were completed.When stone was less than 1.0 cm，basket extractor was used to remove them;When between 1.0 － 1.5 cm，removed them directly by baskst or by lithoclast in several times according to incision size and the hardness of stones，as over 1.5 cm，by lithoclast in several times，then routine nasobiliary drainage was inserted and kept for 3 － 5 days.For multiple or large stones which could not be removed in one time，the next operation was scheduled 3－7 days later subjected to patient＇s condition.When patients had too big or too many stones，or anatomic abnormality in common bile duct，or operating time was too long for them to tolerate，bile duct stents should be placed under endoscope.For AOPC patients，nasobiliary drainage should be inserted above stone，then followed the next operation when patients condition turned better and stable.Postoperatively，routine broad-spectrum antibiotics were given for 2 －4 days，abdominal pain and body temperature changes were monitored，blood amylase，blood routine were tested，to the patients with elevated serum amylase，pancreatic juice inhibitors were given.

3 Results

Endoscopic operation on all of 63 cases obtained a completely success，Operative time was within 15 －60 min.Of 63 cases，stone extraction was done in 21 cases，including 2 cases by one time，in 5 cases with small stone and relaxant papillary，stone extraction penformed following EST，14 cases following EPBD.All stones were removed clear in one time in 16 cases，twice in 2 cases，bile duct stenosis found in 1 case，giant stone in 7 cases，multiple stones in CBD in 8 cases，who were considered unable tolerate longtime operation，3 cases complicated with intrahepatic bile duct stone.Stents were placed in 14 in poor condition.Of them，2 cases with giant stones were cured by another operation.CBD stones with AOPC were found in 9 cases，plastic bile stents were placed in 2 of them，nasobiliary drainage was inserted in 7 cases，the second extraction with endoscope was done in 4 cases 5 －7 days later.Stents were placed in 3 cases for the second time.

Of 63 cases，wound bleeding occurred in 2 cases after EST，bleeding ceased with local spray of norepinephrine，no hematorrhea or perforation occurred.Post-operative cholangitis appeared in 1 case，who was curred with anti-inflammatory injection，pancreatitis was found in 3，and high serum amylase in 12 cases.Who were cured with fast and pancreatic secretion inhibitor，and the injections，1case died of acute left heart failure(ALHF).

4 Discussion

Choledocholithiasis is a common disease in China，Coventional treatment is choledocholithotomy with T tube drainage.If the disease recur the second operation had to be done.Since many elderly patients have multiple basal diseases，many risks would happen perioperatively.Hence the mortality is quite high.Compared with open surgery，endoscopic treatment has more advantages，such as，without anesthesia and abdominal exposure，less peri-post operative complications，easy performace，etc.So it can replace the conventional surgery and become the first choice of treatment for elderly with CBD stones［1］.Generally，the elderly have many basal diseases and immune dysfuction.There are more difficulties and risks to treat them than to treat the youngers.Along with the development and application of basket extractor，airsac，and mechanical lithotripsy device，electrohydraulic lithotripsy.ESWL and the techniques concerned，80%of clinical extrahepatic bile duct stones can be removed by ERCP［2］clearance of CBD stones by endoscopy is about 90%，in the group，21 cases，removed clean，CBD stones with AOS cholangitis cleared out by the second operating with ND，the clearance is 39%，which is obviously lower than that of the younger population，which may be attributed to that the elderly have more internal diseases，less tolerance，etc.choices of EST or EPBD depends on the patient＇s condition.EPBD is the best choice for the patients with diverticula ampullae and flat papilla，while EST is proper for the cases with big stones or big papilla over 8 mm.EPBD combined with mechanical lithotripsy has higher curative rate and less complications［3］.The operators had better to use small cut so as to reduced shortor long-term complications.2 cases with wound bleeding after EST were cured with norepinephrine spraying.Hematorrhea and perforation were not found.33 cases underwent ERBD，their bile ducts are patent.The author believes that stone clearance need not be over emphasized for plastic stent drainage can act as an effectively supplementary means.It is reported that CBD can be reduced along with stent drainage［4－5］.For some high-risk patients，it can even be used as a permanent method.For elderly patients AOSC may result in a crisis.Certainly the first aid should be the drainage instead of the extraction，ERBD can effectively drain bile and reduce the pressure on bile duct and along with it antibiotics can be injected to improve the condition of AOSC patients，then the extraction can be smoothly performed.4 AOSC cases in the group were cured by this method.Be careful of pulling-out of NBD from the patients.Direct insertion of stents can also obtain an ideal drainage，if difficult to care the NBD.2 cases had direct insertion in the group，the outcome is good.Pancreatitis and high amylase are frequent complications，the incidence of the latter is about 30% ～65%，the fomer is 1% ～31%［6］Pancreatitis following ERCP is often complicated with papilledema，which may be related with the facts that repeated intubation，contrast agent in pancreatic duct，repeated imaging，heat injuries byEST，etc.The sphincterotomy may increase the incidence of pancreatitis after ERCP.While NBD or stenting can reduce it.The contrast should avoid papilla-opening and the common channel，and use selective cholangiography(ERC)to avoid pancreatic duct imaging，medium or small incision should be used as far as possible.3 cases with acute pancreatitis，12 cases with blood amylase increasing were cured by the regimen and inhibition.

In brief，the treatment results show that although the olderly have more basal diseases and more risks in operation，endoscopic treatment proves to be a good method to cure elderly patients with CBD stones，for it can be practised with less complications，high safety and definite curative results.

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