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El-Mahrouk M, El-Shabrawi A, Langner C, Hau HM, Sucher R. Transduodenal resection of a large papillary tumor by means of intraoperative cholangioscopy. Int J Surg Case Rep 2024; 124:110364. [PMID: 39357480 PMCID: PMC11471639 DOI: 10.1016/j.ijscr.2024.110364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2024] [Revised: 09/23/2024] [Accepted: 09/26/2024] [Indexed: 10/04/2024] Open
Abstract
INTRODUCTION Papillary adenomas are very rare benign tumors of the gastrointestinal tract. If manageable, purely endoscopic resection is favored. As an alternative, surgical resection via ampullectomy or pancreaticoduodenectomy can be performed. Often, the depth of infiltration cannot be assessed with sufficient precision, leading to pancreaticoduodenectomy for safety reasons. CASE PRESENTATION We present the case of a 77-year-old patient in whom a transduodenal papillary resection of a large papillary adenoma was performed, after two unsuccessful endoscopic attempts. Intraoperatively, a 3 cm large papillary adenoma was identified in the duodenum. The infiltration depth into the Vater's papilla was evaluated through intraoperative cholangioscopy. Due to the shallow depth of invasion, we strived for a papillary resection under endoscopic guidance, allowing complete tumor removal. The postoperative course was uneventful, and the patient was discharged on postoperative day 14. CLINICAL DISCUSSION The decision between ampullectomy and pancreaticoduodenectomy is an intraoperative challenge. Intraoperative cholangioscopy demonstrated its potential to aid this decision-making process in this case. Larger-scale studies are needed to establish its clinical value. CONCLUSION Intraoperative cholangiography can help surgeons assess the depth of infiltration of large papillary adenomas, leading to more precise surgical decisions about the necessary extent of resection.
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Affiliation(s)
- Mohamed El-Mahrouk
- Division of General, Visceral and Transplantation Surgery, Department of Surgery, Medical University of Graz, 8036 Graz, Austria.
| | - Azab El-Shabrawi
- Division of General, Visceral and Transplantation Surgery, Department of Surgery, Medical University of Graz, 8036 Graz, Austria
| | - Cord Langner
- Diagnostic and Research Institute of Pathology, Medical University of Graz, 8010 Graz, Austria
| | - Hans Michael Hau
- Division of General, Visceral and Transplantation Surgery, Department of Surgery, Medical University of Graz, 8036 Graz, Austria
| | - Robert Sucher
- Division of General, Visceral and Transplantation Surgery, Department of Surgery, Medical University of Graz, 8036 Graz, Austria
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Li Y, Tan WH, Wu JC, Huang ZX, Shang YY, Liang B, Chen JH, Pang R, Xie XQ, Zhang JM, Ding Y, Xue L, Chen MT, Wang J, Wu QP. Microbiologic risk factors of recurrent choledocholithiasis post-endoscopic sphincterotomy. World J Gastroenterol 2022; 28:1257-1271. [PMID: 35431509 PMCID: PMC8968489 DOI: 10.3748/wjg.v28.i12.1257] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 12/10/2021] [Accepted: 02/16/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Choledocholithiasis is a severe disorder that affects a significant portion of the world’s population. Treatment using endoscopic sphincterotomy (EST) has become widespread; however, recurrence post-EST is relatively common. The bile microbiome has a profound influence on the recurrence of choledocholithiasis in patients after EST; however, the key pathogens and their functions in the biliary tract remain unclear.
AIM To investigate the biliary microbial characteristics of patients with recurrent choledocholithiasis post-EST, using next-generation sequencing.
METHODS This cohort study included 43 patients, who presented with choledocholithiasis at the Guangdong Second Provincial General Hospital between May and June 2020. The patients had undergone EST or endoscopic papillary balloon dilation and were followed up for over a year. They were divided into either the stable or recurrent groups. We collected bile samples and extracted microbial DNA for analysis through next-generation sequencing. Resulting sequences were analyzed for core microbiome and statistical differences between the diagnosis groups; they were examined using the Kyoto Encyclopedia of Genes and Genomes pathway hierarchy level using analysis of variance. Correlation between the key genera and metabolic pathways in bile, were analyzed using Pearson’s correlation test.
RESULTS The results revealed distinct clustering of biliary microbiota in recurrent choledocholithiasis. Higher relative abundances (RAs) of Fusobacterium and Neisseria (56.61% ± 14.81% vs 3.47% ± 1.10%, 8.95% ± 3.42% vs 0.69% ± 0.32%, respectively) and the absence of Lactobacillus were observed in the bile of patients with recurrent disease, compared to that in stable patients. Construction of a microbiological co-occurrence network revealed a mutual relationship among Fusobacterium, Neisseria, and Leptotrichia, and an antagonistic relationship among Lactobacillales, Fusobacteriales, and Clostridiales. Functional prediction of biliary microbiome revealed that the loss of transcription and metabolic abilities may lead to recurrent choledocholithiasis. Furthermore, the prediction model based on the RA of Lactobacillales in the bile was effective in identifying the risk of recurrent choledocholithiasis (P = 0.03).
CONCLUSION We demonstrated differences in the bile microbiome of patients with recurrent choledocholithiasis compared to that in patients with stable disease, thereby adding to the current knowledge on its microbiologic etiology.
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Affiliation(s)
- Ying Li
- Guangdong Provincial Key Laboratory of Microbial Safety and Health, Key Laboratory of Agricultural Microbiomics and Precision Application, Ministry of Agriculture and Rural Affairs, State Key Laboratory of Applied Microbiology Southern China, Institute of Microbiology, Guangdong Academy of Sciences, Guangzhou 510070, Guangdong Province, China
| | - Wen-Hui Tan
- Digestive Endoscopy Center, Guangdong Second Provincial General Hospital, Guangzhou 510000, Guangdong Province, China
| | - Jia-Chuan Wu
- Digestive Endoscopy Center, Guangdong Second Provincial General Hospital, Guangzhou 510000, Guangdong Province, China
| | - Zhi-Xin Huang
- Division of Gastrointestinal Surgery Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, Guangdong Province, China
| | - Yan-Yan Shang
- Guangdong Provincial Key Laboratory of Microbial Safety and Health, Key Laboratory of Agricultural Microbiomics and Precision Application, Ministry of Agriculture and Rural Affairs, State Key Laboratory of Applied Microbiology Southern China, Institute of Microbiology, Guangdong Academy of Sciences, Guangzhou 510070, Guangdong Province, China
| | - Biao Liang
- Digestive Endoscopy Center, Guangdong Second Provincial General Hospital, Guangzhou 510000, Guangdong Province, China
| | - Jian-Hui Chen
- Division of Gastrointestinal Surgery Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, Guangdong Province, China
| | - Rui Pang
- Guangdong Provincial Key Laboratory of Microbial Safety and Health, Key Laboratory of Agricultural Microbiomics and Precision Application, Ministry of Agriculture and Rural Affairs, State Key Laboratory of Applied Microbiology Southern China, Institute of Microbiology, Guangdong Academy of Sciences, Guangzhou 510070, Guangdong Province, China
| | - Xin-Qiang Xie
- Guangdong Provincial Key Laboratory of Microbial Safety and Health, Key Laboratory of Agricultural Microbiomics and Precision Application, Ministry of Agriculture and Rural Affairs, State Key Laboratory of Applied Microbiology Southern China, Institute of Microbiology, Guangdong Academy of Sciences, Guangzhou 510070, Guangdong Province, China
| | - Ju-Mei Zhang
- Guangdong Provincial Key Laboratory of Microbial Safety and Health, Key Laboratory of Agricultural Microbiomics and Precision Application, Ministry of Agriculture and Rural Affairs, State Key Laboratory of Applied Microbiology Southern China, Institute of Microbiology, Guangdong Academy of Sciences, Guangzhou 510070, Guangdong Province, China
| | - Yu Ding
- Guangdong Provincial Key Laboratory of Microbial Safety and Health, Key Laboratory of Agricultural Microbiomics and Precision Application, Ministry of Agriculture and Rural Affairs, State Key Laboratory of Applied Microbiology Southern China, Institute of Microbiology, Guangdong Academy of Sciences, Guangzhou 510070, Guangdong Province, China
| | - Liang Xue
- Guangdong Provincial Key Laboratory of Microbial Safety and Health, Key Laboratory of Agricultural Microbiomics and Precision Application, Ministry of Agriculture and Rural Affairs, State Key Laboratory of Applied Microbiology Southern China, Institute of Microbiology, Guangdong Academy of Sciences, Guangzhou 510070, Guangdong Province, China
| | - Mou-Tong Chen
- Guangdong Provincial Key Laboratory of Microbial Safety and Health, Key Laboratory of Agricultural Microbiomics and Precision Application, Ministry of Agriculture and Rural Affairs, State Key Laboratory of Applied Microbiology Southern China, Institute of Microbiology, Guangdong Academy of Sciences, Guangzhou 510070, Guangdong Province, China
| | - Juan Wang
- Guangdong Provincial Key Laboratory of Microbial Safety and Health, Key Laboratory of Agricultural Microbiomics and Precision Application, Ministry of Agriculture and Rural Affairs, State Key Laboratory of Applied Microbiology Southern China, Institute of Microbiology, Guangdong Academy of Sciences, Guangzhou 510070, Guangdong Province, China
| | - Qing-Ping Wu
- Guangdong Provincial Key Laboratory of Microbial Safety and Health, Key Laboratory of Agricultural Microbiomics and Precision Application, Ministry of Agriculture and Rural Affairs, State Key Laboratory of Applied Microbiology Southern China, Institute of Microbiology, Guangdong Academy of Sciences, Guangzhou 510070, Guangdong Province, China
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Vu AN, Eskander J, Chan STF, Houli N, Bui HT. Impact of single-stage laparoscopic trans-cystic exploration on hospital procedures, admissions and length-of-stay in common bile duct stone clearance. ANZ J Surg 2021; 91:2695-2700. [PMID: 34608735 DOI: 10.1111/ans.17255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 08/09/2021] [Accepted: 09/15/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Single-stage approach with bile duct exploration is considered the most efficient and cost-effective method of bile duct clearance. In Australia, apart from centres with subspecialty interests, notably in Brisbane, Queensland, a multi-stage approach with endoscopic retrograde cholangiopancreatography (ERCP) is used more frequently. We aim to evaluate the impact of single stage laparoscopic trans-cystic exploration (LTCE) versus multi-stage approach for choledocholithiasis. METHODS This was a retrospective cohort study. Medicare Benefits Schedule codings were used to identify patients who had the following procedures between December 2011 and December 2019: laparoscopic cholecystectomy (LC) and ERCP, LC and LTCE, LC and LTCE and ERCP. Primary outcomes were number of hospital procedures, admissions and additive length of stay (aLOS), the cumulative hospital stay from admission to discharge. RESULTS Of 607 patients, 204 (34%) patients received a single-stage LTCE, while 403 (66%) patients had a multi-stage approach. In the LTCE group, 82% (168) patients and 93% (190) patients had one procedure and one admission respectively for stone clearance (P = 0.001). The median aLOS was 4 days for LTCE versus 7 days for multi-stage approach (P = 0.001; 95% CI for difference - 3 to -2). In the multi-stage group, 16% (65) patients had three or more procedures and 49% (199) patients required two or more hospital admissions to achieve stone clearance. CONCLUSION LTCE for stone clearance can be successfully accomplished with reductions in hospital admissions, number of procedures and length of stay. This has further economic and health resource implications.
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Affiliation(s)
- Anh N Vu
- Department of Surgery, (Upper-Gastrointestinal/Hepato-Pancreato-Biliary Unit) Western Health, Melbourne, Australia
| | - Jacqueline Eskander
- Department of Surgery, (Upper-Gastrointestinal/Hepato-Pancreato-Biliary Unit) Western Health, Melbourne, Australia
| | - Steven T F Chan
- Department of Surgery, (Upper-Gastrointestinal/Hepato-Pancreato-Biliary Unit) Western Health, Melbourne, Australia.,Department of Surgery, Western Precinct, The University of Melbourne, Melbourne, Australia
| | - Nezor Houli
- Department of Surgery, (Upper-Gastrointestinal/Hepato-Pancreato-Biliary Unit) Western Health, Melbourne, Australia
| | - Hai T Bui
- Department of Surgery, (Upper-Gastrointestinal/Hepato-Pancreato-Biliary Unit) Western Health, Melbourne, Australia.,Department of Surgery, Western Precinct, The University of Melbourne, Melbourne, Australia
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Ali N, Nadeem M, Nauyan F, Mir I, Farooq T. Laparoscopic Management of Common Bile Duct Stones: Stratifying Risks, a District Hospital Experience. J Laparoendosc Adv Surg Tech A 2021; 32:165-170. [PMID: 33691073 DOI: 10.1089/lap.2021.0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Management of bile duct stones is variable. Selection of the appropriate treatment modality based on identifiable risk factors can increase the chances of a successful outcome. The aim of this study is to identify factors affecting outcomes of a laparoscopic bile duct exploration. Methods: Retrospective data analysis of consecutive laparoscopic bile duct explorations over a period of 13 years at a district general hospital. Results: The total number of patients in the study was 85. Elective explorations were 56 while 29 were emergency procedures. The mean operative time was 154 minutes. The conversion rate was 14% with failure to extract stones being the most common reason. Forty-two percent of conversions were in nonelective procedures and 17% in previous endoscopic retrograde cholangiopancreatography (ERCP) failures. Eleven percent patients had a transcystic clearance of bile duct and the largest stone removed transcystic was 5 mm. The largest stone removed by a laparoscopic choledochotomy was 15 mm and stones >20 mm were removed on conversion. Seven patients (8%) had a postoperative bile leak, 4 of these required a postoperative ERCP stent and radiological drainage while 3 required a reoperation. Three patients had retained stones treated by postoperative ERCP. Conclusion: Emergency procedures, increasing number and size of stones, previous failed ERCP are factors that contribute to the outcomes of a laparoscopic bile duct exploration. The chances of a successful exploration can be improved by appropriate patient and procedure selection and preparation based on identification of these factors.
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Affiliation(s)
- Nauyan Ali
- Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, United Kingdom
| | - Muhammad Nadeem
- Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, United Kingdom
| | - Farah Nauyan
- Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, United Kingdom
| | - Irfan Mir
- Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, United Kingdom
| | - Tahir Farooq
- Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, United Kingdom
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Navaratne L, Martínez Cecilia D, Martínez Isla A. The ABCdE score for PREdicting Lithotripsy Assistance during transcystic Bile duct Exploration by Laparoendoscopy (PRE-LABEL). Surg Endosc 2020; 35:5971-5979. [PMID: 33057856 DOI: 10.1007/s00464-020-08082-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 10/03/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Common bile duct (CBD) stones are reported in ~ 15% of patients who undergo laparoscopic cholecystectomy for symptomatic gallstones. Prior to lithotripsy techniques, transcystic laparoscopic common bile duct exploration (LCBDE) was limited to smaller CBD stones. The addition of lithotripsy to LCBDE increases cost, operative time and staffing requirements. Predicting which patients might require lithotripsy would be useful in operative planning. The primary aim was to investigate clinical variables for predicting lithotripsy assistance during transcystic bile duct exploration by laparoendoscopy (PRE-LABEL). Secondary aims were to develop and validate a predictive scoring tool. METHODS A retrospective review of a prospectively collected database of consecutive patients who underwent transcystic LCBDE at a single centre in the UK was performed to investigate clinical variables for PRE-LABEL and develop a scoring tool (ABCdE score: age, bilirubin, CBD diameter, ERCP). Binary logistic regression was used to investigate which independent variables (predictors) were associated with lithotripsy assistance during transcystic LCBDE. The ABCdE score was applied to both UK and Spain patient cohorts to determine its sensitivity, specificity and accuracy. RESULTS From 8 pre-operative clinical variables analysed, age ≤ 40 years, bilirubin > two-times upper limit of normal, CBD diameter ≥ 10 mm and ERCP failure of stone extraction were independent predictors of requiring lithotripsy during transcystic LCBDE and formed the ABCdE score. The hazard ratios were 2.87, 3.79, 2.78 and 10.06, respectively. An ABCdE score ≥ 2 resulted in 71% sensitivity, 81% specificity and 79% accuracy in predicting lithotripsy during LCBDE (UK cohort). Validation using a contemporary cohort from Spain yielded similar sensitivity, specificity and accuracy. CONCLUSIONS This study represents the only study to date reporting independent predictors of requiring lithotripsy assistance during transcystic LCBDE. ABCdE score ≥ 2 can highlight patients that may require lithotripsy in order to avoid failure of transcystic LCBDE and therefore avoid choledochotomy or post-operative ERCP.
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Affiliation(s)
- Lalin Navaratne
- Department of Upper GI Surgery, Northwick Park Hospital & St Marks Hospitals, London, HA1 3UJ, UK.
| | | | - Alberto Martínez Isla
- Department of Upper GI Surgery, Northwick Park Hospital & St Marks Hospitals, London, HA1 3UJ, UK
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Burdyukov M, Nechipay A. Choledocholithiasis: narrative review. DOKAZATEL'NAYA GASTROENTEROLOGIYA 2020; 9:55. [DOI: 10.17116/dokgastro2020904155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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Sardiwalla II, Koto MZ, Kumar N, Balabyeki MA. Laparoscopic Common Bile Duct Exploration Use of a Rigid Ureteroscope: A Single Institute Experience. J Laparoendosc Adv Surg Tech A 2018; 28:1169-1173. [DOI: 10.1089/lap.2018.0042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Imraan I. Sardiwalla
- Department of General Surgery, Sefako Makgatho Health Sciences University, Dr George Mukhari Academic Hospital, Pretoria, South Africa
| | - Modise Z. Koto
- Department of General Surgery, Sefako Makgatho Health Sciences University, Dr George Mukhari Academic Hospital, Pretoria, South Africa
| | - Neha Kumar
- Department of General Surgery, Sefako Makgatho Health Sciences University, Dr George Mukhari Academic Hospital, Pretoria, South Africa
| | - Moses A. Balabyeki
- Department of General Surgery, Sefako Makgatho Health Sciences University, Dr George Mukhari Academic Hospital, Pretoria, South Africa
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Abstract
Gallstone disease is a common and frequently occurring disease in human, and it is the main disease among the digestive system diseases. The incidence of gallstone disease in western countries is about 5%-22%, and common bile duct stones (CBDS) accounts for 8%-20%. CBDS easily lead to biliary obstruction, secondary cholangitis, pancreatitis, and obstructive jaundice, even endanger life. Therefore, it needs timely treatment once diagnosed. The recurrence of choledocholithiasis after bile duct stones clearance involves complicated factors and cannot be completely elaborated by a single factor. The risk factors for recurrence of choledocholithiasis include bacteria, biliary structure, endoscopic and surgical treatment, and inflammation. The modalities for management of choledocholithiasis are endoscopic retrograde cholangiopancreatography (ERCP), laparoscopic or open common bile duct exploration, dissolving solutions, extracorporeal shockwave lithotripsy (ESWL), percutaneous radiological interventions, electrohydraulic lithotripsy (EHL) and laser lithotripsy. We compare the different benefits between surgery and ERCP. And finally, we make a summary of the current strategy for reducing the recurrence of CBDS and future perspectives for CBDS management.
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Affiliation(s)
| | - Sun Qiang
- b Department of General Surgery , Jing'an District Center Hospital of Shanghai (Huashan Hospital Fudan University Jing'an Branch) , Shanghai , PR China
| | - Yin Bao-Bing
- c Department of General Surgery , Huashan Hospital, Fudan University , Shanghai , PR China
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Abstract
Choledocholithiasis occurs in up to approximately 20% of patients with cholelithiasis. A majority of stones form in the gallbladder and then pass into the common bile duct, where they generate symptoms, due to biliary obstruction. Confirmatory diagnosis of choledocholithiasis is made with advanced imaging, including magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography (ERCP). Treatment varies locally; however, ERCP with sphincterotomy is most commonly employed with a high degree of success. Difficult anatomy and difficult stone burden require advanced surgical, endoscopic, and percutaneous techniques to extract or expel biliary stones. Knowledge of these treatment strategies will optimize outcomes.
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Affiliation(s)
- Christopher Molvar
- Department of Radiology, Section of Vascular and Interventional Radiology, Loyola University Medical Center, Maywood, Illinois
| | - Bryan Glaenzer
- Department of Radiology, Section of Vascular and Interventional Radiology, Loyola University Medical Center, Maywood, Illinois
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Komanduri S, Thosani N, Abu Dayyeh BK, Aslanian HR, Enestvedt BK, Manfredi M, Maple JT, Navaneethan U, Pannala R, Parsi MA, Smith ZL, Sullivan SA, Banerjee S. Cholangiopancreatoscopy. Gastrointest Endosc 2016; 84:209-221. [PMID: 27236413 DOI: 10.1016/j.gie.2016.03.013] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 03/03/2016] [Indexed: 02/08/2023]
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Merzlikin NV, Podgornov VF, Semichev YV, Bushlanov PS, Talacheva VD. THE METHODS OF CHOLEDOCHOLITHIASIS TREATMENT. BULLETIN OF SIBERIAN MEDICINE 2015. [DOI: 10.20538/1682-0363-2015-4-99-109] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Kwon YH, Cho CM, Jung MK, Kim SG, Yoon YK. Risk factors of open converted cholecystectomy for cholelithiasis after endoscopic removal of choledocholithiasis. Dig Dis Sci 2015; 60:550-6. [PMID: 25228363 DOI: 10.1007/s10620-014-3337-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 08/13/2014] [Indexed: 01/01/2023]
Abstract
BACKGROUND Open converted cholecystectomy could occur in patients who planned for laparoscopic cholecystectomy after endoscopic removal of choledocholithiasis. AIM To evaluate the risk factors associated with open converted cholecystectomy. PATIENTS AND METHODS The data for all patients who underwent cholecystectomy after endoscopic removal of choledocholithiasis were retrospectively reviewed. Factors predictive for conversion to open cholecystectomy were analyzed. RESULTS The rate of open converted cholecystectomy was 15.7 %. In multivariate analysis, cholecystitis (OR 1.908, 95 % CI 1.390-6.388, p = 0.005), mechanical lithotripsy (OR 6.129, 95 % CI 1.867-20.123, p < 0.005), and two or more choledocholithiases (OR 2.202, 95 % CI 1.097-4.420, p = 0.026) revealed significant risk factors for conversion to open cholecystectomy. Analyzing the risk factors for open converted cholecystectomy according to duration from endoscopic stone removal to cholecystectomy (within 2 weeks, between 2 and 6 weeks, and beyond 6 weeks), acute cholangitis (OR 3.374, 95 % CI 1.267-8.988, p = 0.015), cholecystitis (OR 3.127, 95 % CI 1.100-8.894, p = 0.033), and mechanical lithotripsy (OR 17.504, 95 % CI 3.548-86.355, p < 0.005) were related to open converted cholecystectomy in ≤2 weeks group. CONCLUSIONS For patients who need cholecystectomy after endoscopic removal of choledocholithiasis, endoscopic retrograde cholangiography-related factors predictive for open converted cholecystectomy are helpful in planning the appropriate timing of surgery.
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Affiliation(s)
- Yong Hwan Kwon
- Department of Internal Medicine, Kyungpook National University Medical Center, 807 Hogukno, Buk-gu, Daegu, 702-210, South Korea
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Rábago LR, Chico I, Collado D, Olivares A, Ortega A, Quintanilla E, Delgado M, Castro JL, Llorente R, Vazquez Echarri J. Single-stage treatment with intraoperative ERCP: management of patients with possible choledocholithiasis and gallbladder in situ in a non-tertiary Spanish hospital. Surg Endosc 2012; 26:1028-1034. [PMID: 22083324 DOI: 10.1007/s00464-011-1990-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2011] [Accepted: 09/19/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND The best way to reduce endoscopic retrograde cholangiopancreatography (ERCP) complications is not to perform it if it is unnecessary. Both intraoperative and postoperative ERCP rely on use of intraoperative cholangiography as a final diagnostic test for choledocholithiasis (CLD) whenever clinical data are unable to rule out CLD. Intraoperative ERCP could become a therapeutic option when a previous preoperative ERCP fails. We present our experience with intraoperative ERCP. PATIENTS AND METHODS This is a descriptive and prospective study of a cohort of 82 patients with moderate risk of CLD. They were operated on by laparoscopic cholecystectomy with intraoperative cholangiography (IOC). We performed intraoperative ERCP using the rendezvous technique. RESULTS Thirty-six out of 82 patients had an abnormal IOC study. Mean age was 58.7 years (standard deviation, SD 16.6, 25-83 years), and 60.6% were females. Ultrasound study showed that 51.4% of patients had a dilated bile duct. Magnetic resonance cholangiography (MRC) was performed on three patients (8.3%). The success rate of intraoperative ERCP was 88.2%. Three out of the 36 patients (8.8%) had ERCP complications [2 mild papillary bleeding (5.8%), 1 acute pancreatitis (2.9%)]. The rate of conversion to open surgery was 5% with a surgical complications rate of 4% [one injured duct and two surgical bleeding which required re-operation (2.5%)]. There were no mortalities. Four patients (11.1%) needed post-surgical ERCP, with a residual CLD rate of 5.6% (two patients) in the postoperative period. Mean surgical time was 181 min (SD 60, 75-345 min). Mean hospital stay was 6.2 days (SD 4.7, 2-24 days). CONCLUSIONS Intraoperative ERCP is an option to prevent performing ERCP unnecessarily on patients with moderate risk of CLD not confirmed using appropriate radiological studies. It can resolve the biliary disease in a single step with a similar success rate to standard ERCP, but with low morbidity, especially of acute pancreatitis. The residual CLD rate is also very low.
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Affiliation(s)
- L R Rábago
- Gastroenterology Department, Hospital Severo Ochoa, Leganés, Madrid, Spain.
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Rábago LR, Ortega A, Chico I, Collado D, Olivares A, Castro JL, Quintanilla E. Intraoperative ERCP: What role does it have in the era of laparoscopic cholecystectomy? World J Gastrointest Endosc 2011; 3:248-255. [PMID: 22195234 PMCID: PMC3244943 DOI: 10.4253/wjge.v3.i12.248] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2011] [Revised: 08/24/2011] [Accepted: 12/01/2011] [Indexed: 02/05/2023] Open
Abstract
In the treatment of patients with symptomatic cholelithiasis and choledocholithiasis (CBDS) detected during intraoperative cholangiography (IOC), or when the preoperative study of a patient at intermediate risk for CBDS cannot be completed due to the lack of imaging techniques required for confirmation, or if they are available and yield contradictory radiological and clinical results, patients can be treated using intraoperative endoscopic retrograde cholangiopancreatography (ERCP) during the laparoscopic treatment or postoperative ERCP if the IOC finds CBDS. The choice of treatment depends on the level of experience and availability of each option at each hospital. Intraoperative ERCP has the advantage of being a single-stage treatment and has a significant success rate, an easy learning curve, low morbidity involving a shorter hospital stay and lower costs than the two-stage treatments (postoperative and preoperative ERCP). Intraoperative ERCP is also a good salvage treatment when preoperative ERCP fails or when total laparoscopic management also fails.
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Affiliation(s)
- Luis R Rábago
- Luis R Rábago, Alejandro Ortega, Inmaculada Chico, David Collado, Ana Olivares, Jose Luis Castro, Elvira Quintanilla, Department of Gastroenterology, Severo Ochoa Hospital, Leganes, 28911 Madrid, Spain
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Advances in hepatobiliary surgery. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2011. [DOI: 10.1016/j.tacc.2010.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Abstract
Minimally invasive therapy is currently invaluable for the treatment of biliary stones. Clinicians should be familiar with the various endoscopic modalities that have been evolving. I reviewed the treatment of biliary stones from the common practice to pioneering procedures, and here I also briefly summarize the results of many related studies. Lithotripsy involves procedures that fragment large stones, and they can be roughly classified into two groups: intracorporeal modalities and extracorporeal shock-wave lithotripsy (ESWL). Intracorporeal modalities are further divided into mechanical lithotripsy (ML), electrohydraulic lithotripsy, and laser lithotripsy. ESWL can break stones by focusing high-pressure shock-wave energy at a designated target point. Balloon dilation after minimal endoscopic sphincterotomy (EST) is effective for retrieving large biliary stones without the use of ML. Peroral cholangioscopy provides direct visualization of the bile duct and permits diagnostic procedures or therapeutic interventions. Biliary stenting below an impacted stone is sometimes worth considering as an alternative treatment in elderly patients. This article focuses on specialized issues such as lithotripsy rather than simple EST with stone removal in order to provide important information on state-of-the-art procedures.
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Affiliation(s)
- Chan Sup Shim
- Digestive Disease Center, Konkuk University Medical Center, Seoul, Korea
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Abstract
Cholangiopancreatoscopy (CP) is a well-established modality for the direct visualization of intrahepatic biliary, extrahepatic biliary, and pancreatic ductal systems. The use of CP in the treatment of difficult biliary stones has become paramount when standard endoscopic retrograde cholangiopancreatography is ineffective. This article describes the available cholangioscopic devices and technical and clinical applications of cholangiopancreatoscopy. The efficacy and limitations of CP, as well as published comparative studies, are briefly reviewed.
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La Greca G, Barbagallo F, Sofia M, Latteri S, Russello D. Simultaneous laparoendoscopic rendezvous for the treatment of cholecystocholedocholithiasis. Surg Endosc 2009; 24:769-80. [PMID: 19730946 DOI: 10.1007/s00464-009-0680-3] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2009] [Accepted: 08/09/2009] [Indexed: 12/17/2022]
Abstract
BACKGROUND Different approaches are available for the treatment of combined cholecystocholedocholithiasis including totally laparoscopic (TL) treatment, simultaneous laparoendoscopic treatment, and sequential treatments (ST) combining endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) with cholecystectomy. This review aimed to clarify the issue of the simultaneous laparoendoscopic rendezvous (RV). METHODS A careful analysis of papers was performed to determine the results, technical differences, limits, disadvantages, and advantages of RV compared with other options. RESULTS Data were collected from 27 papers concerning 795 patients. The overall effectiveness of RV was 92.3%. The morbidity rate was 5.1%, and the mortality rate was 0.37%. Almost all the authors were satisfied with the procedure. The authors' comparison to ST and TL showed that the advantages outweigh the disadvantages mostly related to logistical problems. CONCLUSIONS There is confusion concerning the definitions and techniques of RV due to differences in combining surgical and endoscopic steps of the procedure. The results are at least comparable with those of the other available approaches. The effectiveness of RV is greater with reciprocal implementation of surgical and endoscopic procedures. The morbidity and the risk of iatrogenic damage seem lower than with ERCP-ES and the risk of residual stones lower than with TL treatment. The RV procedure is safe and can sometimes be the preferable option, but collaboration between surgeon and endoscopist is mandatory.
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Affiliation(s)
- Gaetano La Greca
- Department of Surgical Science, Transplantation and Advanced Technologies, University of Catania, Cannizzaro Hospital, Via Messina, Catania, Italy.
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Kanehira E, Raestrup H, Werner HO, Ann MW, Weiss U, Moetzung T, Buess GF. Laparoscopic treatment of common bile duct stones by pulsed dye laser combined with optical feedback regulation: Phantom experiments using the bovine biliary tract. ACTA ACUST UNITED AC 2009. [DOI: 10.3109/13645709409153004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Topal B, Vromman K, Aerts R, Verslype C, Van Steenbergen W, Penninckx F. Hospital cost categories of one-stage versus two-stage management of common bile duct stones. Surg Endosc 2009; 24:413-6. [PMID: 19554369 DOI: 10.1007/s00464-009-0594-0] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2009] [Accepted: 05/31/2009] [Indexed: 12/19/2022]
Abstract
BACKGROUND In the era of cost-conscious healthcare, hospitals are focusing on costs. Analysis of hospital costs per cost category may provide indications for potential cost-saving measures in the management of common bile duct stones (CBDS) with gallbladder in situ. METHODS Between October 2005 and September 2006, 53 consecutive patients suffering from CBDS underwent either a one-stage procedure [laparoscopic common bile duct exploration (LCBDE) with stone clearance and cholecystectomy (LCCE)] or a two-stage procedure [endoscopic retrograde cholangiopancreatography with sphincterotomy and stone clearance (ERCP/ERS) followed by LCCE]. Costs were defined in different cost categories for each activity centre and were linked to the individual patient via the "bill of activities". Only patients (n = 38) with an uneventful post-procedural course and with available cost data were considered for cost analysis. Total length of hospital stay (LOS) was 2 (0-6) days after one-stage and 8 (3-18) days after two-stage procedure (p < 0.0001). RESULTS Costs per patient were significantly (p < 0.0001) less after one-stage versus two-stage management, i.e. total hospital costs (euro2,636 versus euro4,608), hospitalisation costs (euro701 versus euro2,190), consumables/pharmacy (euro645 versus euro1,476) and para-medical personnel (euro1,035 versus euro1,860; p = 0.0002). Operation room (OR) costs were comparable for one-stage and two-stage management (euro1,278 versus euro1,232; p = 0.280). Total hospital costs during ERCP were euro2,648 (euro729-4,544), during LCCE without LCBDE were euro2,101 (euro1,033-4,269), and during LCCE with LCBDE were euro2,636 (euro1,176-4,235). CONCLUSION In the management of patients with CBDS and gallbladder in situ a one-stage procedure is associated with significantly less costs as compared with a two-stage procedure. From the economical point of view these patients should preferably be treated via a one-stage procedure as long as safety and efficacy of this approach are provided.
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Affiliation(s)
- B Topal
- Department of Abdominal Surgery, University Hospital Leuven, Leuven, Belgium.
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21
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Sarkar S, Sadhu S, Jahangir T, Pandit K, Dubey S, Roy MK. Laparoscopic common bile duct exploration using a rigid nephroscope. Br J Surg 2009; 96:412-6. [PMID: 19283750 DOI: 10.1002/bjs.6579] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Abstract
Background
Patients with cholelithiasis and choledocholithiasis are increasingly managed with laparoscopic bile duct exploration and cholecystectomy. Large impacted bile duct stones continue to defy laparoscopic extraction. This study explored the feasibility of laparoscopic bile duct clearance using a rigid nephroscope, which is suited to extracting large stones.
Method
This prospective study recruited patients with large bile duct stones and a bile duct wider than 8 mm on ultrasonography. In addition to standard ports for laparoscopic cholecystectomy, a custom-made 9-mm port was introduced in the epigastrium for the rigid nephroscope, which was negotiated into the bile duct through a choledochotomy. Rigid graspers and lithotripters were introduced through the nephroscope to fragment and remove the calculi.
Results
Between December 2005 and September 2008, 18 patients had nephroscope-guided bile duct exploration (mean(s.d.) age 49(13·9) years, bile duct diameter 11·3(2·3) mm). Three patients had solitary stones and 15 had multiple calculi. Most of the stones were removed with graspers, but the lithotripter was required in five patients. The mean(s.d.) hospital stay was 6(2·3) days. Two patients required postoperative endoscopic retrograde cholangiopancreaticography for residual stones.
Conclusion
The rigid nephroscope was useful for laparoscopic bile duct exploration, particularly for large impacted stones.
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Affiliation(s)
- S Sarkar
- Department of General Surgery, Rabindranath Tagore International Institute of Cardiac Sciences, 124, Mukundapur, E. M. Bypass, Kolkata 700099, India
| | - S Sadhu
- Department of General Surgery, Rabindranath Tagore International Institute of Cardiac Sciences, 124, Mukundapur, E. M. Bypass, Kolkata 700099, India
| | - T Jahangir
- Department of General Surgery, Rabindranath Tagore International Institute of Cardiac Sciences, 124, Mukundapur, E. M. Bypass, Kolkata 700099, India
| | - K Pandit
- Department of General Surgery, Rabindranath Tagore International Institute of Cardiac Sciences, 124, Mukundapur, E. M. Bypass, Kolkata 700099, India
| | - S Dubey
- Department of General Surgery, Rabindranath Tagore International Institute of Cardiac Sciences, 124, Mukundapur, E. M. Bypass, Kolkata 700099, India
| | - M K Roy
- Department of General Surgery, Rabindranath Tagore International Institute of Cardiac Sciences, 124, Mukundapur, E. M. Bypass, Kolkata 700099, India
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Abstract
BACKGROUND T-tube drainage used to be standard practice after surgical choledocholithotomy, but there is now a tendency in some centers to close the common bile duct (CBD) primarily. This study was designed to review the complications associated with T-tube drainage after CBD exploration and to determine whether primary closure of the bile duct reduces postoperative morbidity. METHODS A retrospective audit was performed on patients undergoing CBD exploration between July 1997 and March 2007, who were identified from the theatre database of one teaching hospital. Intraoperative findings and postoperative complications were recorded from the clinical notes. RESULTS During the study period, 158 patients (97 women; median age 65 (range, 25-90) years) underwent CBD exploration. A T-tube was inserted in 91 patients (group I) and the CBD was closed primarily in 67 (group II). One or more biliary complications occurred in 26 patients (16.5%): 20 (22.0%) in group I and 6 (8.9%) in group II (p = 0.03). In group I, 15 had a biliary leak (3 needed reoperation), 2 had accidental slippage of the tube, 2 an entrapped T-tube, and 1 a retained stone. In group II, six patients had biliary leakage, two of whom were re-explored. Six patients in group I also had peritubal infection, necessitating the use of antibiotics. There were three deaths: two in group I (1 T-tube-related) and 1 in group II (p = 1, not significant). CONCLUSION There is a lower biliary complication rate associated with primary closure of the CBD than after T-tube drainage.
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23
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Shah RJ, Adler DG, Conway JD, Diehl DL, Farraye FA, Kantsevoy SV, Kwon R, Mamula P, Rodriguez S, Wong Kee Song LM, Tierney WM. Cholangiopancreatoscopy. Gastrointest Endosc 2008; 68:411-21. [PMID: 18538326 DOI: 10.1016/j.gie.2008.02.033] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2008] [Accepted: 02/11/2008] [Indexed: 02/08/2023]
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24
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Clinical models are inaccurate in predicting bile duct stones in situ for patients with gallbladder. Surg Endosc 2008; 23:38-44. [DOI: 10.1007/s00464-008-9868-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2007] [Revised: 12/21/2007] [Accepted: 01/18/2008] [Indexed: 12/20/2022]
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Laparoscopic common bile duct stone clearance with flexible choledochoscopy. Surg Endosc 2007; 21:2317-21. [PMID: 17943379 DOI: 10.1007/s00464-007-9577-1] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2006] [Revised: 04/11/2007] [Accepted: 05/07/2007] [Indexed: 12/22/2022]
Abstract
BACKGROUND Laparoscopic common bile duct exploration (LCBDE) is as safe and efficient as endoscopic retrograde cholangiopancreatography (ERCP) in achieving bile duct clearance from stones. No clear guidelines are available on LCBDE with respect to indications for trans-cystic approach versus choledochotomy, or regarding when to use either flexible choledochoscopy (FCD) or intraoperative cholangiography (IOC) guidance. METHODS From January 2001 until November 2006, 113 consecutive patients with common bile duct stones (CBDS) and gallbladder in situ were enrolled in a prospective non-randomized study to undergo laparoscopic cholecystectomy with LCBDE on an intention-to-treat basis. Twenty-three patients were aged 80 years or older with severe comorbidity. Preoperative ERCP with attempted stone clearance was performed in 24 patients. Laparoscopic common bile duct exploration was attempted for CBDS in the presence of acute cholecystitis in 24 patients. Laparoscopic common bile duct exploration was performed via the trans-cystic approach in 83 patients and via choledochotomy in 30 patients. Flexible choledochoscopy was used in 79 patients and IOC guidance in 34 patients. RESULTS No mortality occurred. Postoperative complications were encountered in nine patients. Laparoscopic stone clearance of the bile duct was successful in 91.8% of the patients. Median length of hospital stay (LOS) was two days (range, 0 to 24 days) after trans-cystic LCBDE and six days (range, 2 to 34 days) after stone clearance via choledochotomy (p < 0.0001). Choledochotomy was performed for CBDS measuring an average of 11.5 mm (range, 5 to 30 mm) in diameter while trans-cystic LCBDE was successful for stones measuring an average of 5 mm (range, 2 to 14 mm) (p < 0.0001). Mean duration of surgery was 75 minutes (range, 30 to 180 minutes) when FCD was used, and 107 minutes (range, 45 to 240 minutes) in patients undergoing LCBDE under IOC guidance (p < 0.0001). CONCLUSION Laparoscopic cholecystectomy and LCBDE with stone extraction can be performed with high efficiency, minimal morbidity and without mortality. A trans-cystic approach is feasible in most patients, whereas choledochotomy should be restricted to large bile duct stones that cannot be extracted through the cystic duct. The use of flexible choledochoscopy is preferable to IOC guidance.
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Thomas M, Howell DA, Carr-Locke D, Mel Wilcox C, Chak A, Raijman I, Watkins JL, Schmalz MJ, Geenen JE, Catalano MF. Mechanical lithotripsy of pancreatic and biliary stones: complications and available treatment options collected from expert centers. Am J Gastroenterol 2007; 102:1896-902. [PMID: 17573790 DOI: 10.1111/j.1572-0241.2007.01350.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION PD and common bile duct (CBD) stones often require mechanical lithotripsy (ML) at ERCP for successful extraction. The frequency and spectrum of complications is not well described in the literature. AIM To describe the frequency and spectrum of complications of ML. METHODS A comprehensive retrospective review of cases requiring ML of large or resistant PC and/or CBD stones using a 46-point data questionnaire on type(s) of complication, treatment attempted, and success of treatment. The study involved 7 tertiary referral centers with 712 ML cases (643 biliary and 69 pancreatic). RESULTS Overall incidence of complications were: 4-4% (31/712); 23/643 biliary, 8/69 pancreatic; 21 single, 10 multiple. Biliary complications: trapped (TR)/broken (BR) basket (N = 11), wire fracture (FX) (N = 8), broken (BR) handle (N = 7), perforation/duct injury (N = 3). Pancreatic complications: TR/BR basket (N = 7), wire FX (N = 4), BR handle (N = 5), pancreatic duct leak (N = 1). Endoscopic intervention successfully treated complications in 29/31 cases (93.5%). Biliary group treatments: sphincterotomy (ES) extension (N = 7), electrohydraulic lithotripsy (EHL) (N = 11), stent (N = 3), per-oral Soehendra lithotripsy (N = 8), surgery (N = 1), extracorporeal lithotripsy (N = 5), and dislodge stones/change basket (N = 4). Pancreatic group treatments: ES extension (N = 3), EHL (N = 2), stent (N = 5), Soehendra lithotriptor (N = 4), dislodge stones/change basket (N = 2), extracorporeal lithotripsy (ECL) (N = 1), surgery (N = 1). Perforated viscus patient died at 30 days. CONCLUSION The majority of ML in expert centers involved the bile duct. The complication rate of pancreatic ML is threefold greater than biliary lithotripsy. The most frequent complication of biliary and pancreatic ML is trapped/broken baskets. Extension of ES and EHL are the most frequently utilized treatment options.
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Affiliation(s)
- Miriam Thomas
- St. Luke's Medical Center, Pancreatic Biliary Center, Milwaukee, Wisconsin, USA
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27
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Varadarajulu S, Eloubeidi MA, Wilcox CM, Hawes RH, Cotton PB. Do all patients with abnormal intraoperative cholangiogram merit endoscopic retrograde cholangiopancreatography? Surg Endosc 2006; 20:801-805. [PMID: 16544073 DOI: 10.1007/s00464-005-0479-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2005] [Accepted: 12/27/2005] [Indexed: 12/19/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is commonly used for postoperative evaluation of an abnormal intraoperative cholangiogram (IOC). Although a normal IOC is very suggestive of a disease-free common bile duct (CBD), abnormal studies are associated with high false-positive rates. This study aimed to identify a subset of patients with abnormal IOC who would benefit from a postoperative ERCP. METHODS This prospective study investigated 51 patients with abnormal IOC at laparoscopic cholecystectomy who underwent postoperative ERCP at two tertiary referral centers over a 3-year period. Univariate and multivariate logistic regression analyses were performed to determine predictors of CBD stones at postoperative ERCP. RESULTS For all 51 patients, ERCP was successful. The ERCP showed CBD stones in 33 cases (64.7%), and normal results in 18 cases (35.2%). On univariate analysis, abnormal liver function tests (p < 0.0001) as well as IOC findings of a large CBD stone (p = 0.03), multiple stones (p = 0.01), and a dilated CBD (p = 0.07) predicted the presence of retained stones at postoperative ERCP. However, on multivariable analysis, only abnormal liver function tests correlated with the presence of CBD stones (p < 0.0001). CONCLUSIONS One-third of patients with an abnormal IOC have a normal postoperative ERCP. Elevated liver function tests can help to identify patients who merit further evaluation by ERCP. The use of less invasive methods such as endoscopic ultrasound or magnetic resonance cholangiopancreatography should be considered for patients with normal liver function tests to minimize unnecessary ERCPs.
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Affiliation(s)
- S Varadarajulu
- Division of Gastroenterology-Hepatology, University of Alabama at Birmingham, 410 Lyons Harrison Research Building, 1530 3rd Avenue South, Birmingham, AL 35294-0007, USA.
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Petelin JB. Laparoscopic common bile duct exploration. Surg Endosc 2003; 17:1705-15. [PMID: 12958681 DOI: 10.1007/s00464-002-8917-4] [Citation(s) in RCA: 163] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2002] [Accepted: 12/03/2002] [Indexed: 12/16/2022]
Abstract
BACKGROUND Herein I describe my >12-year experience with laparoscopic common bile duct exploration (LCBDE). METHODS From 21 September 1989 through 31 December 2001, 3,580 patients presented with symptomatic biliary tract disease. Laparoscopic cholecystecomy (LC) was attempted in 3,544 of them (99.1%) and completed in 3,527 (99.5%). Laparoscopic cholangiograms (IOC) were performed in 3,417 patients (96.4%); in 344 cases (9.7%), the IOC was abnormal. Forty-nine patients (1.4%) underwent preoperative endoscopic retrograde cholangiopancreatography (ERCP), and 33 patients (0.9%) underwent postoperative ERCP. LCBDE was attempted in 326 cases and completed in 321 (98.5%). It was successful in clearing the duct in 317 of the 344 patients with abnormal cholangiograms (92.2%). RESULTS The mean operating time for all patients undergoing LC with or without cholangiograms or LCBDE or other additional surgery was 56.9 min. Mean length of stay was 22.1 h. The mean operating time for LC only patients ( n = 2530)--that is, those not undergoing LCBDE or any other additional procedure--was 47.6 min; their mean postoperative length of stay was 17.2 h. Ductal exploration was performed via the cystic duct in 269 patients, (82.5%) and through a choledochotomy in 57 patients (17.5%). T-tubes were used in patients in whom there was concern for possible retained debris or stones, distal spasm, pancreatitis, or general poor tissue quality secondary to malnutrition or infection. In cases where choledochotomy was used, a T-tube was placed in 38 patients (67%), and primary closure without a T-tube was done in 19 (33%). There were no complications in the group of patients who underwent choledochotomy and primary ductal closure without T-tube placement or in the group in whom T-tubes were placed. CONCLUSIONS Common bile duct (CBD) stones still occur in 10% of patients. These stones are identified by IOC. IOC can be performed in >96.4% of cases of LC. LCBDE was successful in clearing these stones in 97.2% of patients in whom it was attempted and in 92.2% of all patients with normal IOCs. Most LCBDEs in this series were performed via the cystic duct because of the stone characteristics and ductal anatomy. Selective laparoscopic placement of T-tubes in patients requiring choledochotomy (67%) appears to be a safe and effective alternative to routine T-tube drainage of the ductal system. ERCP, which was required for 5.8% of patients with abnormal cholangiograms, and open CBDE, which was used in 2.0%, still play an important role in the management of common bile duct pathology. The role of ERCP, with or without sphincterotomy, has returned to its status in the prelaparoscopic era. LCBDE may be employed successfully in the vast majority of patients harboring CBD stones.
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Affiliation(s)
- J B Petelin
- Department of Surgery, University of Kansas School of Medicine, Kansas City, KS 66104, USA.
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Topal B, Van de Moortel M, Fieuws S, Vanbeckevoort D, Van Steenbergen W, Aerts R, Penninckx F. The value of magnetic resonance cholangiopancreatography in predicting common bile duct stones in patients with gallstone disease. Br J Surg 2003; 90:42-7. [PMID: 12520573 DOI: 10.1002/bjs.4025] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The application of available predictive scoring systems for the detection of common bile duct (CBD) stones has not reduced the number of patients who undergo unnecessary endoscopic retrograde cholangiopancreatography. The aim of this study was to create a predictive model for CBD stones and to assess the value of magnetic resonance cholangiopancreatography (MRCP) in prediction. METHODS In 1998, 366 patients with gallstone disease (118 males, 248 females; mean age 57 (range 8-84) years) underwent cholecystectomy. Statistical analysis was performed on patient data obtained at the time of first presentation. RESULTS CBD stones were demonstrated in 43 (12 per cent) of 366 patients. The predictive model for common duct stones included ultrasonography showing CBD stones or bile duct dilatation, age greater than 60 years, fever, serum alkaline phosphatase level above 670 units/l and serum amylase level above 95 units/l. In patients with a predicted probability greater than 5 per cent, CBD stones were present in 11 per cent, compared with 1 per cent in patients with a probability of 5 per cent or less. MRCP had an observed sensitivity of 95 per cent, specificity of 100 per cent, positive predictive value of 100 per cent and negative predictive value of 98 per cent. CONCLUSION In patients with a predicted probability for CBD stones of more than 5 per cent, MRCP is recommended in order to confirm the presence or absence of stones and as guidance in further management.
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Affiliation(s)
- B Topal
- Department of Abdominal Surgery, University Hospital Gasthuisberg, Catholic University Leuven, Herestraat 49, 3000 Leuven, Belgium.
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Sarli L, Iusco D, Sgobba G, Roncoroni L. Gallstone cholangitis: a 10-year experience of combined endoscopic and laparoscopic treatment. Surg Endosc 2002; 16:975-80. [PMID: 12163967 DOI: 10.1007/s00464-001-9133-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2001] [Accepted: 11/08/2001] [Indexed: 02/08/2023]
Abstract
BACKGROUND To date, no procedure has yet been identified as the gold standard for the treatment of gallstone cholangitis in the laparoscopic era. METHODS The data of 109 consecutive patients with acute cholangitis were prospectively entered into a computerized database. All patients were managed according to a standard protocol. The main treatments were endoscopic retrograde cholangiography (ERC) combined with endoscopic sphincterotomy (ES), followed by interval laparoscopic cholecystectomy (LC). Patients in whom ERC or endoscopic stone clearance failed were managed by emergency open common bile duct exploration. LC was performed with a standardized four-cannula technique. The mean duration of surgery, conversion rate, and postoperative outcome of these patients were evaluated. RESULTS ERC was successful in 103 patients (94.5%). In five of these patients (4.8%), no bile duct stones were found. The 98 patients (95.2%) with common bile duct stones were referred for ES. The bile duct stones were successfully removed after ES in 93 cases (94.9%). The overall failure rate of ERC and ES for choledocholithiasis was 10.1%. Self-limiting pancreatitis occurred in four patients (4.3%). Overall, two of the 109 patients died (1.8%). After ES, 81 patients underwent LC. LC was performed successfully in 74 patients (91.3%). Conversion to open surgery was required in seven patients (8.7%). The morbidity rate after cholecystectomy was 7.4%; the morbidity rate after open bile duct exploration was 36.4% (p<0.05). Fifteen patients were managed conservatively after initial endoscopic management of their cholangitis. The overall incidence of recurrent biliary symptoms was significantly higher among patients with gallbladder in place than for patients who underwent cholecystectomy (38.5% vs 1.5%, p<0.001). CONCLUSIONS ES followed by LC is a safe and effective approach for the management of gallstone cholangitis; cholecystectomy should be performed in patients with gallstone cholangitis unless the operative risk is extremely high. These high operative risk patients and those who refuse surgery after ES should be warned that they are at high risk for recurrent biliary symptoms.
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Affiliation(s)
- L Sarli
- Department of Surgery, Institute of General Surgery and Surgical Therapy, School of Medicine, University of Parma, 14 Via Giamsci, 43100 Parma, Italy.
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Lilly MC, Arregui ME. A balanced approach to choledocholithiasis. Surg Endosc 2001; 15:467-72. [PMID: 11353963 DOI: 10.1007/s004640080020] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2000] [Accepted: 10/03/2000] [Indexed: 02/07/2023]
Abstract
BACKGROUND We set out to review and evaluate the results of an algorithm for managing choledocholithiasis in patients undergoing laparoscopic cholecystectomy. METHODS We performed retrospective review of patients with choledocholithiasis at the time of laparoscopic cholecystectomy (LC) between March 1993 and August 1999. All patients were operated on under the direction of one surgeon (M.E.A), following a consistent algorithm that relies primarily on laparoscopic transcystic common bile duct exploration (TCCBDE) but uses laparoscopic choledochotomy (LCD) when the duct and stones are large or if the ductal anatomy is suboptimal for TCCBDE. Intraoperative endoscopic retrograde sphincterotomy (ERS) is done if sphincterotomy is required to facilitate common bile duct exploration (CBDE). Postoperative endoscopic retrograde cholangiopancreatography (ERCP) is utilized when this fails. Preoperative ERCP is used only for high-risk patients. RESULTS A total of 728 LC were performed, and there were 60 instances (8.2%) of choledocholithiasis. Primary procedures consisted of 47 TCCBDE; 37 of them required no other treatment. In five cases, the stones were flushed with no exploration. Intraoperative ERS was performed three times as the only form of duct exploration. LCD was utilized twice; one case also required intraoperative ERS, and the other had a postoperative ERCP for stent removal. One patient with small stones was observed, with no sequelae. Preoperative ERCP was done twice as the primary procedure. Of the 10 cases that were not completely cleared by TCCBDE, three had a postoperative ERCP and seven had an intraoperative ERS, one of which required a postoperative ERCP. There were three complications (6%) related to CBDE, with no long-term sequelae. There were four postoperative complications (6.7%) and no deaths. The mean number of procedures per patient was 1.12. The average postoperative hospital stay was 1.8 days (range, 0-14). CONCLUSIONS Choledocholithiasis can be managed safely by laparoscopic techniques, augmenting with ERCP as necessary. This protocol minimizes the number of procedures and decreases the hospital stay.
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Affiliation(s)
- M C Lilly
- Department of General Surgery, St. Vincent Hospital and Health Care Center, 8402 Harcourt Road., Indianapolis, IN 46260, USA
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Silva RA, Ueda RYY, Rêgo REC, Pacheco Junior AM, Fava J, Rasslan S. Tratamento cirúrgico postergado da pancreatite aguda biliar. Rev Col Bras Cir 2000. [DOI: 10.1590/s0100-69912000000300005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
A análise do tratamento cirúrgico de doentes portadores de pancreatite biliar mostra a existência de controvérsias em relação à oportunidade da intervenção, principalmente se deve ser precoce ou postergada. Do mesmo modo, a possibilidade do emprego de procedimentos endoscópicos no pré, intra ou pós-operatório e o advento da videolaparoscopia, trouxeram novos aspectos à discussão. Não existe consenso sobre a escolha da melhor conduta. Em função disso, analisamos retrospectivamente os resultados imediatos de 107 doentes portadores de forma leve de pancreatite, todos com menos de três sinais de gravidade, segundo o critério de estratificação proposto por Ranson, e que foram submetidos ao tratamento cirúrgico postergado na mesma internação, no período de janeiro de 1988 a maio de 1999, tanto por via convencional como por via laparoscópica. Desses, 80 doentes (75%) eram do sexo feminino, 90% da raça branca e a média de idade foi de 46 anos. Os doentes foram operados em média após 9,5 dias de internação e receberam alta hospitalar após 2,9 dias, o que resultou numa permanência hospitalar média de 12,6 dias. A colangiografia intra-operatória foi realizada em 102 casos (96%) e a colangiografia endoscópica pré-operatória em 24 doentes (22,4%). Os resultados mostraram incidência de coledocolitíase em 25 casos (23%), taxa de morbidade de 12% e mortalidade nula. Dos 107 casos estudados, 64 (60%) foram operados pela via de acesso convencional e 43 (40%) pela via laparoscópica. A comparação dos resultados entre as vias de acesso empregadas mostrou diferença estatística significante em relação ao intervalo de tempo pós-operatório, que foi menor nos doentes submetidos à via de acesso laparoscópica. Concluímos, assim, que o tratamento cirúrgico postergado de doentes portadores de pancreatite biliar na forma leve apresenta baixas morbidade e mortalidade e pode ser feito tanto pela via convencional como pela via laparoscópica. A presença de coledocolitíase, nesta casuística, não contribuiu para aumentar os índices de complicações pós-operatórias e nem a mortalidade.
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Basso N, Pizzuto G, Surgo D, Materia A, Silecchia G, Fantini A, Fiocca F, Trentino P. Laparoscopic cholecystectomy and intraoperative endoscopic sphincterotomy in the treatment of cholecysto-choledocholithiasis. Gastrointest Endosc 1999; 50:532-5. [PMID: 10502176 DOI: 10.1016/s0016-5107(99)70078-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND A single-stage minimally invasive procedure would be optimal for management of cholecysto-choledocholithiasis. Two alternative strategies are available: management by laparoscopy alone or a combined laparoscopic-endoscopic approach. This study evaluates the results of the latter procedure. METHODS From June 1993 to September 1997, 1400 patients with symptomatic biliary stone disease were evaluated for laparoscopic cholecystectomy. Intraoperative cholangiography was performed on the basis of a preoperative suspicion of bile duct stones; bile duct stone treatment was by intraoperative endoscopic retrograde sphincterotomy. RESULTS Intraoperative cholangiography was performed because of a preoperative suspicion of a bile duct abnormality in 141 of 1400 patients (10%) undergoing laparoscopic cholecystectomy because of biliary stone disease. Of those 141 patients, 54 (38.3%) presented with pathologic findings (bile duct stone [52] and papillary stenosis [2]); all 54 underwent intraoperative endoscopic sphincterotomy. Complete clearance of the ductal stones was achieved in 43 patients (82.7%) by intraoperative sphincterotomy, and in 9 patients by an additional postoperative endoscopic procedure. Laparoscopic cholecystectomy was carried out in all cases. There were no conversions to an open operation. Postoperative course in the uncomplicated cases was comparable to that for laparoscopic cholecystectomy alone. The postoperative complication rate was 5.6% and mortality 1.8%. Mean hospital stay was 3.3 days (range 2 to 16). At a mean 38 months follow-up, no complications related to the laparoscopic-endoscopic procedure were observed. CONCLUSION The intraoperative combined laparoscopic-endoscopic approach seems to be a feasible and effective management of cholecysto-choledocholithiasis, saving patients a subsequent invasive procedure.
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Affiliation(s)
- N Basso
- Clinica Chirurgica II, University "La Sapienza," Rome, Italy
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Sarli L, Pietra N, Franzé A, Colla G, Costi R, Gobbi S, Trivelli M. Routine intravenous cholangiography, selective ERCP, and endoscopic treatment of bile duct stones before laparoscopic cholecystectomy. Gastrointest Endosc 1999; 50:200-8. [PMID: 10425413 DOI: 10.1016/s0016-5107(99)70225-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND No procedure has yet been identified as the standard for the detection and management of choledocholithiasis in patients undergoing laparoscopic cholecystectomy. METHODS A prospective study involved 1305 patients undergoing elective laparoscopic cholecystectomy. Intravenous cholangiography was performed on all patients except those with jaundice or cholangitis, acute pancreatitis, or allergy to contrast material. Patients underwent endoscopic retrograde cholangiography (ERC) and endoscopic sphincterotomy when there was a strong suspicion of choledocholithiasis, positive or inconclusive findings on intravenous cholangiography or allergy to contrast material with signs of possible choledocholithiasis. Intraoperative cholangiography was performed when patients did not undergo ERC or intravenous cholangiography and whenever the surgeon was in doubt about biliary anatomy or biliary clearance. RESULTS Two hundred thirty-one patients (17.7%) were referred for preoperative ERC; 14 of them were referred for open surgery because of failure of ERC or sphincterotomy. Only 54 patients underwent intraoperative cholangiography. Bile duct stones, detected in 186 cases (14.2%) (68 of which were asymptomatic), were removed before surgery in 162 cases (87.1%) and during surgery in 20 (10.7%). Self-limited pancreatitis occurred in 3.6% of the patients after sphincterotomy. Laparoscopic cholecystectomy was performed in 98.7% of the cases. The conversion rate was 8% if sphincterotomy had been performed previously, and 3% after standard laparoscopic cholecystectomy (p < 0.001). The morbidity rate was 5% and the mortality rate 0.08%. During the follow-up period 4 patients had retained stones that were treated endoscopically. CONCLUSIONS Preoperative ERC followed by laparoscopy is the best approach to treatment of patients with cholecystolithiasis and suspected choledocholithiasis.
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Affiliation(s)
- L Sarli
- Institute of General Surgery, University of Parma, Italy.
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Heili MJ, Wintz NK, Fowler DL. Choledocholithiasis: Endoscopic versus Laparoscopic Management. Am Surg 1999. [DOI: 10.1177/000313489906500209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Choledocholithiasis is present in 6 to 10 per cent of patients who have cholelithiasis. In the era of laparoscopic cholecystectomy, endoscopic retrograde cholangiopancreatography with endoscopic retrograde sphincterotomy (ERCP/ERS) and laparoscopic common bile duct exploration (LSCBDE) have been used to treat choledocholithiasis. The purpose of this study is to compare ERCP/ERS with LSCBDE. A retrospective review of 913 patients undergoing laparoscopic cholecystectomy identified 61 patients who had ERCP/ERS or LSCBDE to treat choledocholithiasis at a community medical center between 1990 and 1996. Outcome parameters were hospital length of stay (LOS), hospital cost, and complications. The results were: ERCP (n = 26; LOS, 5.0 ± 3.6 days; cost, $11,823 ± $7,000; complications, 23.1%); LSCBDE (n = 35; LOS, 3.4 ±2.4 days; cost, $9,100 ± $2,884; complications, 2.9%); and P value (LOS, 0.028; cost, 0.066; complications, 0.034). LSCBDE results in a significantly shorter LOS and significantly fewer complications, and is less costly than ERCP/ERS. LSCBDE, when feasible, should be considered the gold standard for the management of choledocholithiasis.
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Affiliation(s)
- Michael J. Heili
- Departments of Surgery, Gastonia Medical Center, Gastonia, North Carolina
| | - Nancy K. Wintz
- Departments of Surgery, Olathe Medical Center, Olathe, Kansas
| | - Dennis L. Fowler
- Departments of Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania
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Ishizaki Y, Takeda Y, Miyahara T. Cystic duct dilation during laparoscopic transcystic common bile duct exploration. J Am Coll Surg 1998; 187:461-3. [PMID: 9783796 DOI: 10.1016/s1072-7515(98)00208-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Y Ishizaki
- Department of Surgery, Tokyo Rosai Hospital, Japan
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Canto MI, Chak A, Stellato T, Sivak MV. Endoscopic ultrasonography versus cholangiography for the diagnosis of choledocholithiasis. Gastrointest Endosc 1998; 47:439-48. [PMID: 9647366 DOI: 10.1016/s0016-5107(98)70242-1] [Citation(s) in RCA: 170] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Choledocholithiasis is a major source of morbidity among patients undergoing cholecystectomy for symptomatic gallstones. There is no consensus on the best approach to diagnosing bile duct stones. We compared the safety, accuracy, diagnostic yield, and cost of EUS- and ERCP-based approaches. METHODS Sixty-four consecutive pre- and post-cholecystectomy patients referred for endoscopic retrograde cholangiopancreatography (ERCP) for suspected choledocholithiasis were prospectively evaluated in a blinded fashion. All were stratified into risk groups using predefined criteria. Endoscopic ultrasonography (EUS) and ERCP were sequentially performed by two endoscopists. RESULTS The success rates of EUS and ERCP were 98% and 94%, respectively. The accuracy of EUS for diagnosing choledocholithiasis was 94%. EUS provided an additional or alternative diagnosis to bile duct stones in 21% of patients. The complication rate of EUS was significantly lower than diagnostic ERCP. An EUS-based strategy costs less than diagnostic ERCP in patients with low, moderate, or intermediate risk. CONCLUSIONS EUS is comparably accurate, but safer and less costly than ERCP for evaluating patients with suspected choledocholithiasis. It is useful in patients with an increased risk of having common bile duct stones based on clinical criteria and those with contraindications for or prior unsuccessful ERCP. EUS may enable selective performance of ERCP and improve the cost-effectiveness of diagnosing choledocholithiasis.
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Affiliation(s)
- M I Canto
- Department of Medicine (Gastroenterology), University Hospitals of Cleveland-Case Western Reserve University, Ohio, USA
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Isaji S, Murabayashi K, Hayashi M, Nakano H, Uehara S, Kusuda T, Miyahara S, Maruyama A, Kondo A, Higashiyama H, Fuke H. Management of gallbladder and common bile duct stones: Laparoscopic cholecystectomy combined with preoperative endoscopic sphincterotomy versus open surgery. JOURNAL OF HEPATO-BILIARY-PANCREATIC SURGERY 1996; 3:452-456. [DOI: 10.1007/bf02349791] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/11/2025]
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Ferzli GS, Hurwitz JB, Massaad AA, Piperno B. Laparoscopic common bile duct exploration: a review. JOURNAL OF LAPAROENDOSCOPIC SURGERY 1996; 6:413-9. [PMID: 9025026 DOI: 10.1089/lps.1996.6.413] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The use of laparoscopic methods to explore the common bile duct is now well-established, although they continue to undergo continuous evolution and improvement. In experienced hands laparoscopic management of choledocholithiasis may be undertaken with morbidity and mortality at least as good as that of open surgery. The use of diagnostic endoscopic retrograde cholangiopancreatography (ERCP) with or without sphincterotomy before or after laparoscopic intervention must be evaluated. The degree of acceptance that laparoscopic techniques for common bile duct exploration (CBDE) will achieve within the surgical community remains to be determined, but will likely increase as more practicing surgeons familiarize themselves with them.
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Affiliation(s)
- G S Ferzli
- Department of Laparoendoscopic Surgery, Staten Island University Hospital, New York 10305, USA
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41
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Materia A, Pizzuto G, Silecchia G, Fiocca F, Fantini A, Spaziani E, Basso N. Surg Laparosc Endosc Percutan Tech 1996; 6:273-277. [DOI: 10.1097/00019509-199608000-00005] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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De Palma GD, Angrisani L, Lorenzo M, Di Matteo E, Catanzano C, Persico G, Tesauro B. Laparoscopic cholecystectomy (LC), intraoperative endoscopic sphincterotomy (ES), and common bile duct stones (CBDS) extraction for management of patients with cholecystocholedocholithiasis. Surg Endosc 1996; 10:649-652. [PMID: 8662405 DOI: 10.1007/bf00188520] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND A combined method of endoscopic sphincterotomy (ES) with common bile duct stone (CBDS) extraction and laparoscopic cholecystectomy (LC) under general anesthesia for a single-session treatment of patients with colecysto-choledocholithiasis is described. METHODS From June 1994 to January 1995, 15 consecutive cases considered for elective LC with preoperative diagnosis of CBDS underwent this procedure. Following orotracheal intubation, the patient is turned on the left lateral decubitus for ES and CBDS extraction. Nasobiliary drainage is positioned for per-laparoscopic cholangiogram. Routine LC is finally performed. RESULTS These two interventions were successfully accomplished in all patients. Mean duration of the operative time for the combined procedure was 97.7 +/- 30.4 min, range 60-140 min. In four (26.6%) cases an accessory trocar with retracting instrument was used to obviate the bowel distension. CONCLUSIONS No complications of ES or LC were observed. Mean hospital stay was 3 days (range 2-5 days). Routine follow-up (mean 3 +/- 2 months, range 1-12 months) did not reveal biliary-related problems in any of the observed patients.
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Affiliation(s)
- G D De Palma
- Servizio Centralizzato di Endoscopia Digestiva, Universita' Degli Studi di Napoli 'Federico II', Facolta' di Medicina e Chirurgia, via Pansini, 5, I-80121 Napoli, Italy
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Korman J, Cosgrove J, Furman M, Nathan I, Cohen J. The role of endoscopic retrograde cholangiopancreatography and cholangiography in the laparoscopic era. Ann Surg 1996; 223:212-6. [PMID: 8597517 PMCID: PMC1235099 DOI: 10.1097/00000658-199602000-00015] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The authors reviewed the results of endoscopic retrograde cholangiopancreatography (ERCP) and intraoperative cholangiography in a series of patients who underwent laparoscopic cholecystectomy. SUMMARY BACKGROUND DATA The indications for preoperative and postoperative ERCP and intraoperative cholangiography as adjuncts to laparoscopic cholecystectomy are evolving. The debate regarding the use of selective or routine intraoperative cholangiography has intensified with the advent of laparoscopic cholecystectomy. METHODS The authors reviewed the records of 343 consecutive patients who underwent laparoscopic cholecystectomy during a 1-year period. Historical, biochemical, and radiologic findings for the patients who underwent ERCP and intraoperative cholangiography were analyzed. RESULTS Three hundred forty- three patients underwent laparoscopic cholecystectomy during the period reviewed. Preoperative ERCP was performed in 42 patients. Twenty-seven of these patients (64%) had common bile duct (CBD) stones, which were cleared with a sphincterotomy. Intraoperative cholangiography was performed for 101 patients (29%). Three cholangiograms had false- positive results (3%), leading to two CBD explorations, in which no CBD stones were found, and one normal ERCP. Six patients underwent postoperative ERCP, three for the removal of retained CBD stones (0.9%), all of which were cleared with a sphincterotomy. Fifteen patients had gallstone pancreatitis, six of whom had CBD stones (40%) that were cleared by ERCP. There were 33 complications (10%) and no CBD injuries. CONCLUSION The use of routine intraoperative cholangiography is discouraged in view of its low yield and the significant rate of false positive cholangiogram results.
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Affiliation(s)
- J Korman
- Department of Surgery, Long Island Jewish Medical Center, New Hyde Park, New York 11040, USA
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Bonatsos G, Leandros E, Polydorou A, Romanos A, Dourakis N, Birbas C, Golematis B. ERCP in association with laparoscopic cholecystectomy. A strategy to minimize the number of unnecessary ERCPs. Surg Endosc 1996; 10:37-40. [PMID: 8711603 DOI: 10.1007/s004649910009] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND With the evolution of laparoscopic cholecystectomy (LC) as the standard operation for benign gallbladder disease, the role of endoscopic retrograde cholangiopancreatography (ERCP) in the management of common bile duct (CBD) stones has to be defined. METHODS From November 1990 to April 1994 we attempted LC in 1,788 patients. Eighty-nine patients underwent ERCP preoperatively under the following indications: jaundice or a history of jaundice, cholangitis, gallstone pancreatitis, abnormal liver function tests, and a sonogram showing either CBD stones or a dilated CBD. With intent to minimize the number of unnecessary ERCPs only patients with jaundice, cholangitis, and high abnormalities on the liver function tests (LFTs) were directly referred for ERCP. All other patients with suspected choledocholithiasis were initially investigated with intravenous cholangiography (IVC) and tomography; only patients with positive findings on IVC subsequently underwent ERCP. Eighteen patients underwent ERCP postoperatively and the indications included jaundice, bile leak, and abnormal intraoperative cholangiogram. RESULTS Of the 89 patients having ERCP preoperatively 54 patients (60.7%) were found to have CBD stones which were removed endoscopically in all cases except in one patient where a large CBD stone was removed during laparoscopic exploration of the CBD. Eight patients of the 18 patients having ERCP postoperatively were found to have CBD stones and all of them had their CBD cleared endoscopically. There were no mortalities, while four patients developed a mild pancreatitis. CONCLUSIONS Although there is an increasing tendency to clear the bile duct with a laparoscopic approach, ERCP and sphincterotomy has a certain role in conjunction with LC in the management of patients with a high suspicion of CBD stones, particularly in institutions where there is easy access to expert interventional endoscopic techniques.
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Affiliation(s)
- G Bonatsos
- First Department of Propaedeutic Surgery, Athens University Hippocration Hospital, Greece
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45
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Erickson RA, Carlson B. The role of endoscopic retrograde cholangiopancreatography in patients with laparoscopic cholecystectomies. Gastroenterology 1995; 109:252-63. [PMID: 7797023 DOI: 10.1016/0016-5085(95)90292-9] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The best clinical strategy for using endoscopic retrograde cholangiopancreatography (ERCP) with laparoscopic cholecystectomy is unknown. The aim of this study is to use decision analysis to assess four different approaches to using ERCP in patients undergoing laparoscopic cholecystectomy. METHODS Decision trees were designed for four clinical strategies: (1) preoperative ERCP, with sphincterotomy for choledocholithiasis; (2) selective preoperative ERCP for patients at high risk for choledocholithiasis, choledocholithiasis found at surgery treated by postoperative ERCP; (3) no preoperative ERCP, choledocholithiasis detected intraoperatively treated by postoperative ERCP; and (4) no preoperative ERCP, choledocholithiasis detected intraoperatively treated with open common bile duct exploration. Using decision analysis with literature-derived data, the impact on outcome parameters was calculated. RESULTS Postoperative ERCP resulted in the lowest cost, procedure numbers, and hospital and back-to-work days. With high preoperative likelihood of choledocholithiasis, selective preoperative ERCP was probably a clinically equivalent strategy. Sensitivity analysis supported these conclusions when the probabilities and utilities were varied over a wide range. The open operative approach to choledocholithiasis was only favored if ERCP had < 75% diagnostic and < 50% therapeutic success rates or lengthened hospitalization by > 7 days. CONCLUSIONS This study suggests that performing ERCP after laparoscopic cholecystectomy minimizes costs and morbidity; however, when choledocholithiasis is likely, selective preoperative ERCP may be a clinically equivalent strategy.
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Affiliation(s)
- R A Erickson
- Department of Medicine, Department of Veterans Affairs Medical Center, Long Beach, California, USA
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Roush TS, Traverso LW. Management and long-term follow-up of patients with positive cholangiograms during laparoscopic cholecystectomy. Am J Surg 1995; 169:484-7. [PMID: 7747824 DOI: 10.1016/s0002-9610(99)80200-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND With a goal of minimal invasion during laparoscopic cholecystectomy, the surgeon confronts a judgement decision if the intraoperative cholangiography (IOC) is positive for common bile duct (CBD) stones. The options are postoperative endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic papillotomy (EP), transcystic laparoscopic techniques (LAP), open CBD exploration, or clinical observation. PATIENTS AND METHODS To gather this information, we reviewed the clinical course and IOC of 55 patients with positive IOC during laparoscopic cholecystectomy. Long-term follow-up (1.8 years) was obtained in 50 patients. RESULTS After review, 48 patients were felt to have CBD stones, and a LAP without choledochoscopy was the initial management in 32 (67%) patients. The remaining patients underwent EP (n = 10), CBD exploration (n = 1), or observation (n = 5). By discharge, 19 (59%) of the 32 LAP patients were successful and had avoided EP while the success rate at follow-up was 48% (14/29). There were no complications after LAP, but we observed a 9.5% (2/21) post-EP pancreatitis rate that required readmission. The success rate for CBD stone clearance with LAP was associated with single stones (87%) and surgeon experience (100% in the last year). The average hospital stay was 1.7 days for LAP and 3.3 days for EP. CONCLUSIONS LAP is safe and eliminates the need for EP in the majority of cases. Although EP is more often successful, it results in a longer hospital stay with an increased risk of complication. We recommend LAP as the initial procedure of choice for a positive IOC.
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Affiliation(s)
- T S Roush
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington 98111, USA
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47
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Miller RE, Kimmelstiel FM, Winkler WP. Management of common bile duct stones in the era of laparoscopic cholecystectomy. Am J Surg 1995; 169:273-6. [PMID: 7840393 DOI: 10.1016/s0002-9610(99)80150-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE To assess the safety and efficacy of endoscopic retrograde cholangiopancreatography (ERCP) prior to laparoscopic cholecystectomy. METHODS In patients suspected of harboring common duct stones, we performed ERCP prior to laparoscopic cholecystectomy (LC). Indications included jaundice, gallstone pancreatitis, elevated liver function tests, and visualizing a common duct stone and/or a dilated common duct on ultrasonography. Data were analyzed retrospectively. RESULTS Of 217 patients undergoing LC, 37 (17%) had ERCP with or without endoscopic sphincterotomy (ES). Of these 37, common duct stones were noted in 19 patients (51%). Only 1 of 11 (9%) patients with mild gallstone pancreatitis had choledocholithiasis. The only complication following ERCP was pancreatitis in 1 patient who underwent uneventful LC. There were no deaths in the entire series. CONCLUSIONS ERCP and ES is a safe and effective method of clearing the common duct of stones prior to LC. Patients with mild gallstone pancreatitis do not require ERCP prior to LC.
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Affiliation(s)
- R E Miller
- Surgical Service, St. Luke's-Roosevelt Hospital Center, New York, New York
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Cameron BH, O'Regan PJ, Anderson DL. A pig model for advanced laparoscopic biliary procedures. Surg Endosc 1994; 8:1423-4. [PMID: 7878510 DOI: 10.1007/bf00187349] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Advanced laparoscopic biliary procedures can be undertaken in a pig model, but the small size of the normal common bile duct makes learning difficult. We have developed a prepared pig model of common bile duct ligation on which to practice advanced laparoscopic biliary surgery. The pig's distal common bile duct was occluded using several different methods via a minilaparotomy. Laparoscopic biliary procedures were undertaken 6-21 days later. The common bile duct became dilated to between 2 and 3 cm in diameter in all cases, and this was well tolerated by the animals. All advanced laparoscopic biliary procedures were possible, including choledochoscopy, exploration of the bile duct, and cholecystojejunostomy. Short-term common bile duct ligation is well tolerated in pigs and can be used to create a model for practicing advanced laparoscopic biliary procedures.
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Affiliation(s)
- B H Cameron
- Department of Surgery, University of British Columbia, Vancouver, Canada
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Abstract
The authors report on a group of 114 patients with common bile duct (CBD) stones who were treated by laparoscopic surgery. Management through the cystic duct was considered the first option. Choledochotomy was used for those patients in which the cystic approach was not possible or was unsuccessful. Transcystic lithotripsy was considered for patients with CBD stones in disproportion with the size of the cystic duct. Laparoscopic antegrade sphincterotomy was indicated as a drainage procedure. The transcystic approach was used in 89.5% of the patients; choledochotomy was used in 6.2%; and both ways were used in 4.3%. Different procedures were used, including mechanical and electrohydraulic lithotripsy, choledochotomy with T-tube or endoprostheses drainage, laparoscopic sphincterotomy, end-to-end common bile duct anastomosis, and choledochoduodenum anastomosis. One of the patients was in the 21st week of pregnancy. The laparoscopic approach to choledocholithiasis was successfully performed in 94.8% of the patients. Mean hospital stay was 1.7 days. There was a 6.2% incidence of complications and the mortality rate was 0.9%. In 84.3% of the patients, the transcystic approach was used successfully, with a complication rate of 4.9% and a mean hospital stay of 1.6 days. Three patients were converted to open surgery early in this series. Thus far, one patients has presented residual CBD stones. The results obtained suggest that laparoscopic common bile duct exploration is a technically feasible procedure, with low complication and mortality rates, although it requires adequate selection of patients and a variety of techniques and types of equipment.
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Affiliation(s)
- A L DePaula
- Department of Surgery, Hospital Samaritano, Goiania-Go, Goias, Brazil
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Garcia-Caballero M, Martin-Palanca A, Vara-Thorbeck C. Common bile duct stones after laparoscopic cholecystectomy and its treatment. The role of ultrasound and intravenous and intraoperative cholangiography. Surg Endosc 1994; 8:1182-5. [PMID: 7809801 DOI: 10.1007/bf00591046] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
In the present work we recount our experience in handling common bile duct stones (CBDS) in our first 100 cases of laparoscopic cholecystectomy. In the first 50 cases our diagnostic procedures involved the use of ultrasound exploration and intravenous cholangiotomography 48 h before laparoscopic surgery. We found three cases of residual CBDS. One of the cases was treated by means of ERCP. The other two cases were resolved by carrying out a transparietohepatic cholangiography after the ERCP procedure failed. After this experience, we changed our strategy, introducing the intraoperative cholangiography in the cases with an unclear diagnosis. With this new approach, no residual CBDS occurred in the following 50 cases. These findings demonstrate the following: (1) In our hands, intravenous cholangiography is not more effective than ultrasound exploration in resolving dubious cases. (2) These dubious cases are more effectively diagnosed by means of selective intraoperative cholangiography. (3) When CBDS is treated by transparietohepatic cholangiography it proves to be less uncomfortable for the patient than ERCP and, as we found, even more efficient in removing the stones, although our experience is based on only two cases.
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