ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP) AND STENT PLACEMENT IN THE MANAGEMENT OF LARGE COMMON BILE-DUCT STONES

Management of large common bile duct (CBD) calculi is controversial. E ndoscopic treatment is fraught with difficulty, particularly when ston es are over one centimetre in diameter and the patient's coagulation i s deranged. Between 1988 and 1993, 56 patients have been managed by en doscopic retrograde cholangiopancreatography (ERCP) and stent placemen t as the initial treatment for large CBD calculi. Complete follow up h as been possible in 50 cases (89.3C/o). The median age was 73.5 years (range 29-92) and primary presenting symptoms were jaundice (n = 39), cholangitis (n = 6) or abdominal pain (n=5). Median bilirubin was 99 m u mol/L (range 7-926) and 60% of the patients had deranged clotting wi th a median thrombotest of 61%. Stones ranged in size from 0.9 to 4.5 cm (median 1.6 cm). Treatment was with a 7F 'pigtail' stent in 39 case s and a 10F straight stent in 11 patients. Morbidity occurred in 12% o f cases with two deaths (4%). Stents remained in place for a median of 1 month (range 0.2-59). Definitive treatment of CBD stones, once the jaundice and sepsis had settled, involved surgery in 24 patients and r epeat ERCP with sphincterotomy +/- mechanical lithotripsy in 17 cases. Nine patients remain alive and well with their stents still in place. Initial management of large CBD calculi by ERCP and stent placement c arries a low morbidity and mortality and is a useful adjunct in the ma nagement of a difficult clinical problem.