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Saito H, Kadono Y, Shono T, Kamikawa K, Urata A, Nasu J, Imamura H, Matsushita I, Tada S. Remaining issues of recommended management in current guidelines for asymptomatic common bile duct stones. World J Gastroenterol 2021; 27:2131-2140. [PMID: 34025069 PMCID: PMC8117734 DOI: 10.3748/wjg.v27.i18.2131] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 04/01/2021] [Accepted: 04/21/2021] [Indexed: 02/06/2023] Open
Abstract
Current guidelines for treating asymptomatic common bile duct stones (CBDS) recommend stone removal, with endoscopic retrograde cholangiopancreatography (ERCP) being the first treatment choice. When deciding on ERCP treatment for asymptomatic CBDS, the risk of ERCP-related complications and outcome of natural history of asymptomatic CBDS should be compared. The incidence rate of ERCP-related complications, particularly of post-ERCP pancreatitis for asymptomatic CBDS, was reportedly higher than that of symptomatic CBDS, increasing the risk of ERCP-related complications for asymptomatic CBDS compared with that previously reported for biliopancreatic diseases. Although studies have reported short- to middle-term outcomes of natural history of asymptomatic CBDS, its long-term natural history is not well known. Till date, there are no prospective studies that determined whether ERCP has a better outcome than no treatment in patients with asymptomatic CBDS or not. No randomized controlled trial has evaluated the risk of early and late ERCP-related complications vs the risk of biliary complications in the wait-and-see approach, suggesting that a change is needed in our perspective on endoscopic treatment for asymptomatic CBDS. Further studies examining long-term complication risks of ERCP and wait-and-see groups for asymptomatic CBDS are warranted to discuss whether routine endoscopic treatment for asymptomatic CBDS is justified or not.
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Affiliation(s)
- Hirokazu Saito
- Department of Gastroenterology, Kumamoto City Hospital, Kumamoto City 862-8505, Japan
| | - Yoshihiro Kadono
- Department of Gastroenterology, Tsuruta Hospital, Kumamoto City 862-0925, Japan
| | - Takashi Shono
- Department of Gastroenterology, Kumamoto Chuo Hospital, Kumamoto City 862-0965, Japan
| | - Kentaro Kamikawa
- Department of Gastroenterology, Saiseikai Kumamoto Hospital, Kumamoto City 861-4193, Japan
| | - Atsushi Urata
- Department of Gastroenterology, Saiseikai Kumamoto Hospital, Kumamoto City 861-4193, Japan
| | - Jiro Nasu
- Department of Gastroenterological Surgery, Kumamoto Chuo Hospital, Kumamoto City 862-0965, Japan
| | - Haruo Imamura
- Department of Gastroenterology, Saiseikai Kumamoto Hospital, Kumamoto City 861-4193, Japan
| | - Ikuo Matsushita
- Department of Gastroenterology, Kumamoto Chuo Hospital, Kumamoto City 862-0965, Japan
| | - Shuji Tada
- Department of Gastroenterology, Kumamoto City Hospital, Kumamoto City 862-8505, Japan
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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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Di Mauro D, Ricciardi E, Siragusa L, Manzelli A. Outcome of Laparoscopic Common Bile Duct Exploration After Failed Endoscopic Retrograde Cholangiopancreatography: A Comparative Study. J Laparoendosc Adv Surg Tech A 2019; 29:1391-1396. [DOI: 10.1089/lap.2019.0383] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Davide Di Mauro
- Department of Upper GI Surgery, Royal Devon and Exeter NHS Foundation Trust, Exeter, United Kingdom
| | - Edoardo Ricciardi
- Department of Upper GI Surgery, Royal Devon and Exeter NHS Foundation Trust, Exeter, United Kingdom
| | - Leandro Siragusa
- Department of Surgery, University of Rome Tor Vergata, Rome, Italy
| | - Antonio Manzelli
- Department of Upper GI Surgery, Royal Devon and Exeter NHS Foundation Trust, Exeter, United Kingdom
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Platt T, Smith K, Nixon M, Sinha S, Srinivas G, Andrews S. Success of intraoperative imaging and management of suspected choledocholithiasis without pre-operative bile duct imaging - A case series. Ann Med Surg (Lond) 2018; 36:173-177. [PMID: 30505436 PMCID: PMC6249395 DOI: 10.1016/j.amsu.2018.10.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 10/27/2018] [Accepted: 10/29/2018] [Indexed: 01/14/2023] Open
Abstract
Background Laparoscopic common bile duct exploration (LCBDE) is gaining popularity over endoscopic retrograde cholangiopancreatography (ERCP) for the management of common bile duct stones. However, its application has been almost exclusively following preoperative stone confirmation via magnetic retrograde cholangiopancreatography (MRCP), endoscopic ultrasound (EUS) or ERCP. We present our series of LCBDE following detection of common bile duct stones with intraoperative imaging (IOI) alone, in consecutive elective and emergency patients with suspected choledocholithiasis. Materials and methods All patients with suspected but unconfirmed choledocholithiasis undergoing LC with intention to proceed to LCBDE between January 2015 and June 2017 were included. LCBDE was performed following the discovery of choledocholithiasis on IOI. Results 371 patients with suspected choledocholithiasis underwent LC with IOI. CBD stones or obstructing sludge was identified in 107 patients (29%), with sensitivity of 96.2% and specificity of 98.5%. 100 patients, median age 59, went on to have LCBDE as indicated by intraoperative imaging. 76% were performed as emergency cases and conversion to open rate was 2%. There were no mortalities. Bile leak and retained stones occurred in 4% and 3% respectively. 7/100 patients required re-intervention, with re-look laparoscopy (n = 4) and ERCP (n = 3). Median length of stay was 1.5 and 3 days for elective and emergency cases respectively, and 30 readmission rate was 8%. Discussion and conclusion Traditionally patients presenting with suspicion of choledocholithiasis undergo preoperative MRCP/EUS and/or ERCP prior to eventual LC. We propose an alternative, more streamlined, pathway of treatment without requiring preoperative cholangiography, applicable to both elective and emergency patients.
Laparoscopic common bile duct exploration is a safe and effective treatment for bile duct stones. Intraoperative cholangiography is sensitive and specific in identification of bile duct stones. Bile duct exploration can be safely performed on the basis on intraoperative imaging alone. Intraoperative imaging provides sufficient information for real time decision making.
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Affiliation(s)
- Timothy Platt
- General Surgery, South Devon NHS Foundation Trust, United Kingdom
| | - Kristy Smith
- Core Surgical Trainee, Norfolk and Norwich University Hospitals NHS Foundation Trust, United Kingdom
| | - Martha Nixon
- StR General Surgery, Plymouth Hospitals NHS Trust, United Kingdom
| | - Surajit Sinha
- Locum Consultant Upper GI Surgery, South Devon NHS Foundation Trust, United Kingdom
| | - Gandrapu Srinivas
- Consultant Upper GI Surgeon, South Devon NHS Foundation Trust, United Kingdom
| | - Stuart Andrews
- Consultant Upper GI Surgeon, South Devon NHS Foundation Trust, United Kingdom
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Chen X, Yan XR, Zhang LP. Ursodeoxycholic acid after common bile duct stones removal for prevention of recurrence: A systematic review and meta-analysis of randomized controlled trials. Medicine (Baltimore) 2018; 97:e13086. [PMID: 30407311 PMCID: PMC6250542 DOI: 10.1097/md.0000000000013086] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 10/11/2018] [Indexed: 01/12/2023] Open
Abstract
INTRODUCTION The recurrence rate of common bile duct stones (CBDS) after removal has been reported to exceed 10% and no established pharmacologic treatment exists for the prevention of recurrent CBDS. Many studies indicated ursodeoxycholic acid (UDCA) has the potential to prevent the recurrence of CBDS. The aim of this systematic review is to evaluate the effects of UDCA for prevention of recurrence after common bile duct stones removal. METHODS AND ANALYSIS We will systematically screen all randomized controlled trials (RCTs) published through electronically and hand searching. The following search engines including Ovid Medline, EMBASE, Cochrane CENTRAL, Proquest, Scopus, Web of Science, Pubmed, the Chinese Biomedical Literature Database, the China National Knowledge Infrastructure, VIP Information, Wanfang Data. Supplementary sources will be searched including gray literature, conference proceedings, and potential identified publications in OpenGrey.eu and Google Scholar databases. Two reviewers will independently conduct the trial inclusion, data extraction and assess the quality of studies. The recurrence rate of CBDS will be assessed as the primary outcomes. The adverse event that required discontinuation of UDCA intervention and the drop-outs (lost to follow-up) before the end of the study will be measured as secondary outcomes. Methodological quality will be evaluated according to the Cochrane risk of bias. All analyses will be applied by RevMan (version 5.3). RESULTS This systemic review and meta-analysis will evaluate the effects of UDCA for prevention of recurrence after CBDS removal in RCTs. CONCLUSION Our study will provide evidence to judge whether UDCA is an effective intervention to prevent the recurrence after CBDS removal.
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Affiliation(s)
- Xun Chen
- Beijing University of Chinese Medicine
- Department of Gastroenterology, Dongfang Hospital of Beijing University of Chinese Medicine
| | - Xiao-Ru Yan
- Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Li-Ping Zhang
- Beijing University of Chinese Medicine
- Department of Gastroenterology, Dongfang Hospital of Beijing University of Chinese Medicine
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Platt TE, Smith K, Sinha S, Nixon M, Srinivas G, Johnson N, Andrews S. Laparoscopic common bile duct exploration; a preferential pathway for elderly patients. Ann Med Surg (Lond) 2018; 30:13-17. [PMID: 29946453 PMCID: PMC6016319 DOI: 10.1016/j.amsu.2018.03.044] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 03/09/2018] [Accepted: 03/31/2018] [Indexed: 12/22/2022] Open
Abstract
Background Laparoscopic common bile duct exploration (LCBDE) has emerged as a recommended alternative to endoscopic retrograde cholangiopancreatography (ERCP) for the management of choledocholithiasis. However, its use in the elderly has been limited, and evidence of its safety and efficacy in these patients is yet to be established. This study describes our experience of LCBDE in elderly patients, analysing the safety and efficacy of this technique in comparison to younger patients. Methods All patients undergoing laparoscopic cholecystectomy (LC) with LCBDE for choledocholithiasis in our unit between January 2015 and January 2017 were included. Data pertaining to patient demographics, comorbidities, investigations, operative technique and outcomes were analysed. Patients were divided into 2 groups based on age (Group A:<65 years vs Group B: >/ = 65 years) for comparative analysis. Results 124 patients (Group A: 65, Group B: 59) were included. Group B were more co-morbid and had a higher ASA grade than Group A. However, there was no significant difference between groups in rates of conversion to open or complications, including bile leak (3.1% vs 5.1%, p = 0.67), retained stone (4.6% vs 1.7%, p = 0.62), or complications according to Clavien-Dindo classification (p = 0.78). Re-intervention rates were also similar between groups (7.7% vs 3.4%, p = 0.44 and 3.1% vs 3.4%, p = 1.0 respectively), as was length of stay. Conclusion Despite higher frequency of comorbidities and ASA grade, LCBDE in elderly patients is safe and effective, and has similar outcomes to younger patients. Therefore elderly patients with choledocholithiasis should be offered LCBDE as an alternative to ERCP.
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Affiliation(s)
- T E Platt
- South Devon Upper GI Unit, Torbay Hospital, Torquay, Devon, UK
| | - K Smith
- South Devon Upper GI Unit, Torbay Hospital, Torquay, Devon, UK
| | - S Sinha
- South Devon Upper GI Unit, Torbay Hospital, Torquay, Devon, UK
| | - M Nixon
- Derriford Hospital, Plymouth, Devon, UK
| | - G Srinivas
- South Devon Upper GI Unit, Torbay Hospital, Torquay, Devon, UK
| | - N Johnson
- South Devon Upper GI Unit, Torbay Hospital, Torquay, Devon, UK
| | - S Andrews
- South Devon Upper GI Unit, Torbay Hospital, Torquay, Devon, UK
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Case series of ante-grade biliary stenting: An option during bile duct exploration. INTERNATIONAL JOURNAL OF SURGERY OPEN 2018. [DOI: 10.1016/j.ijso.2017.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Saito H, Kakuma T, Kadono Y, Urata A, Kamikawa K, Imamura H, Tada S. Increased risk and severity of ERCP-related complications associated with asymptomatic common bile duct stones. Endosc Int Open 2017; 5:E809-E817. [PMID: 28879226 PMCID: PMC5585073 DOI: 10.1055/s-0043-107615] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 02/06/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Endoscopic removal of asymptomatic common bile duct stones (CBDS) is generally recommended. Although many reports have described the risk of complications in endoscopic retrograde cholangiopancreatography (ERCP), no studies have addressed this problem in the context of asymptomatic CBDS. This study examines the risk of complications arising in ERCP for asymptomatic CBDS. PATIENTS AND METHODS This retrospective study included 425 patients with naive papilla who underwent therapeutic ERCP for choledocholithiasis at 2 institutions in Japan for 2 years. The risk of complications was examined in patients who were divided into the asymptomatic and symptomatic CBDS groups. We used propensity score analysis to adjust for confounding effects. RESULTS Complications were observed in 32 (7.5 %) of the 425 patients. Of the 358 patients with symptomatic CBDS, 14 patients (3.9 %) had complications. In contrast, of the 67 patients with asymptomatic CBDS, 18 patients (26.9 %) had complications. Propensity score analysis revealed that asymptomatic CBDS was a significant risk factor, with a significantly higher incidence of complications compared with symptomatic CBDS (odds ratio, 5.3). Moderate to severe complications were observed in 15 of 18 patients (83.3 %) in the asymptomatic CBDS group, with significantly more moderate to severe complications than those in the symptomatic CBDS (odds ratio, 6.7). CONCLUSIONS Asymptomatic CBDS carried a high risk of ERCP-related complications, and these were often more severe. In asymptomatic CBDS, endoscopic treatment should be carefully performed after considering the patient's background, and detailed explanation of its possible complications should be given to patients in advance.
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Affiliation(s)
- Hirokazu Saito
- Department of Gastroenterology, Kumamoto City-Hospital, Kumamoto, Japan,Department of Gastroenterology, Kumamoto Chuo Hospital, Kumamoto, Japan,Corresponding author Hirokazu Saito Department of GastroenterologyKumamoto Chuo Hospital1-5-1, TainoshimaMinami-ku, Kumamoto-CityKumamoto, 862-0965Japan+81-96-370-4017
| | - Tatsuyuki Kakuma
- Department of Biostatics Center, Medical School, Kurume University, Fukuoka, Japan
| | - Yoshihiro Kadono
- Department of Gastroenterology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Atsushi Urata
- Department of Gastroenterology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Kentaro Kamikawa
- Department of Gastroenterology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Haruo Imamura
- Department of Gastroenterology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Shuji Tada
- Department of Gastroenterology, Kumamoto City-Hospital, Kumamoto, Japan
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Williams E, Beckingham I, El Sayed G, Gurusamy K, Sturgess R, Webster G, Young T. Updated guideline on the management of common bile duct stones (CBDS). Gut 2017; 66:765-782. [PMID: 28122906 DOI: 10.1136/gutjnl-2016-312317] [Citation(s) in RCA: 246] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 12/08/2016] [Accepted: 12/15/2016] [Indexed: 02/06/2023]
Abstract
Common bile duct stones (CBDS) are estimated to be present in 10-20% of individuals with symptomatic gallstones. They can result in a number of health problems, including pain, jaundice, infection and acute pancreatitis. A variety of imaging modalities can be employed to identify the condition, while management of confirmed cases of CBDS may involve endoscopic retrograde cholangiopancreatography, surgery and radiological methods of stone extraction. Clinicians are therefore confronted with a number of potentially valid options to diagnose and treat individuals with suspected CBDS. The British Society of Gastroenterology first published a guideline on the management of CBDS in 2008. Since then a number of developments in management have occurred along with further systematic reviews of the available evidence. The following recommendations reflect these changes and provide updated guidance to healthcare professionals who are involved in the care of adult patients with suspected or proven CBDS. It is not a protocol and the recommendations contained within should not replace individual clinical judgement.
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Affiliation(s)
- Earl Williams
- Bournemouth Digestive Diseases Centre, Royal Bournemouth and Christchurch NHS Hospital Trust, Bournemouth, UK
| | - Ian Beckingham
- HPB Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Ghassan El Sayed
- Bournemouth Digestive Diseases Centre, Royal Bournemouth and Christchurch NHS Hospital Trust, Bournemouth, UK
| | - Kurinchi Gurusamy
- Department of Surgery, University College London Medical School, London, UK
| | - Richard Sturgess
- Aintree Digestive Diseases Unit, Aintree University Hospital Liverpool, Liverpool, UK
| | - George Webster
- Department of Hepatopancreatobiliary Medicine, University College Hospital, London, UK
| | - Tudor Young
- Department of Radiology, The Princess of Wales Hospital, Bridgend, UK
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Abstract
BACKGROUND Acute pancreatitis in pregnancy is a rare and dangerous disease. This study aimed to examine the etiology, treatment, and outcomes of pancreatitis in pregnancy. METHOD A total of 25 pregnant patients diagnosed with pancreatitis during the period of 1994 and 2014 was analyzed retrospectively. RESULTS The pregnant patients were diagnosed with pancreatitis during a period of 21 years. Most (60%) of the patients were diagnosed with pancreatitis in the third trimester. The mean age of the patients at presentation was 25.7 years, with a mean gestational age of 24.4 weeks. Abdominal pain occurred in most patients and vomiting in one patient was associated hyperemesis gravidarum. The common cause of the disease was gallstone-related (56%), followed by alcohol-related (16%), post-ERCP (4%), hereditary (4%) and undetermined conditions (20%). The level of triglycerides was minimally high in three patients. ERCP and wire-guided sphincterotomy were performed in 6 (43%) of 14 patients with gallstone-related pancreatitis and elevated liver enzymes with no complications. Most (84%) of the patients underwent a full-term, vaginal delivery. There was no difference in either maternal or fetal outcomes after ERCP. CONCLUSIONS Acute pancreatitis is rare in pregnancy, occurring most commonly in the third trimester, and gallstones are the most common cause. When laparoscopic cholecystectomy is not feasible and a common bile duct stone is highly suspected on imaging, endoscopic sphincterotomy or stenting may help to prevent recurrence and postpone cholecystectomy until after delivery.
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Jamal KN, Smith H, Ratnasingham K, Siddiqui MR, McLachlan G, Belgaumkar AP. Meta-analysis of the diagnostic accuracy of laparoscopic ultrasonography and intraoperative cholangiography in detection of common bile duct stones. Ann R Coll Surg Engl 2016; 98:244-9. [PMID: 26985813 PMCID: PMC5226022 DOI: 10.1308/rcsann.2016.0068] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Introduction During laparoscopic cholecystectomy, intraoperative cholangiography (IOC) is currently regarded as the gold standard in the detection of choledocholithiasis. Laparoscopic ultrasonography (LUS) is an attractive alternative with several potential advantages. Methods A systematic review was undertaken of the published literature comparing LUS with IOC in the assessment of common bile duct (CBD) stones. Results Twenty-one comparative studies were analysed. There were 4,566 patients in the IOC group and 5,044 in the LUS group. The combined sensitivity and specificity of IOC in the detection of CBD stones were 0.87 (95% confidence interval [CI]: 0.83-0.89) and 0.98 (95% CI: 0.98-0.98) respectively with a pooled area under the curve (AUC) of 0.985 and a diagnostic odds ratio (OR) of 260.65 (95% CI: 160.44-423.45). This compares with a sensitivity and specificity for LUS of 0.90 (95% CI: 0.87-0.92) and 0.99 (95% CI: 0.99-0.99) respectively with a pooled AUC of 0.982 and a diagnostic OR of 765.15 (95% CI: 450.78-1,298.76). LUS appeared to be more successful in terms of coming to a clinical decision regarding CBD stones than IOC (random effects, risk ratio: 0.95, 95% CI: 0.93-0.98, df=20, z=-3.7, p<0.005). Furthermore, LUS took less time (random effects, standardised mean difference: 0.95, 95% CI: 0.93-0.98, df=20, z=-3.7, p<0.005). Conclusions LUS is comparable with IOC in the detection of CBD stones. The main advantages of LUS are that it does not involve ionising radiation, is quicker to perform, has a lower failure rate and can be repeated during the procedure as required.
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Affiliation(s)
- K N Jamal
- Epsom and St Helier University Hospitals NHS Trust , UK
| | - H Smith
- Epsom and St Helier University Hospitals NHS Trust , UK
| | | | | | - G McLachlan
- Royal Surrey County Hospital NHS Foundation Trust , UK
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Dasari BVM, Tan CJ, Gurusamy KS, Martin DJ, Kirk G, McKie L, Diamond T, Taylor MA, Cochrane Hepato‐Biliary Group. Surgical versus endoscopic treatment of bile duct stones. Cochrane Database Syst Rev 2013; 2013:CD003327. [PMID: 24338858 PMCID: PMC6464772 DOI: 10.1002/14651858.cd003327.pub4] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Between 10% to 18% of people undergoing cholecystectomy for gallstones have common bile duct stones. Treatment of the bile duct stones can be conducted as open cholecystectomy plus open common bile duct exploration or laparoscopic cholecystectomy plus laparoscopic common bile duct exploration (LC + LCBDE) versus pre- or post-cholecystectomy endoscopic retrograde cholangiopancreatography (ERCP) in two stages, usually combined with either sphincterotomy (commonest) or sphincteroplasty (papillary dilatation) for common bile duct clearance. The benefits and harms of the different approaches are not known. OBJECTIVES We aimed to systematically review the benefits and harms of different approaches to the management of common bile duct stones. SEARCH METHODS We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL, Issue 7 of 12, 2013) in The Cochrane Library, MEDLINE (1946 to August 2013), EMBASE (1974 to August 2013), and Science Citation Index Expanded (1900 to August 2013). SELECTION CRITERIA We included all randomised clinical trials which compared the results from open surgery versus endoscopic clearance and laparoscopic surgery versus endoscopic clearance for common bile duct stones. DATA COLLECTION AND ANALYSIS Two review authors independently identified the trials for inclusion and independently extracted data. We calculated the odds ratio (OR) or mean difference (MD) with 95% confidence interval (CI) using both fixed-effect and random-effects models meta-analyses, performed with Review Manager 5. MAIN RESULTS Sixteen randomised clinical trials with a total of 1758 randomised participants fulfilled the inclusion criteria of this review. Eight trials with 737 participants compared open surgical clearance with ERCP; five trials with 621 participants compared laparoscopic clearance with pre-operative ERCP; and two trials with 166 participants compared laparoscopic clearance with postoperative ERCP. One trial with 234 participants compared LCBDE with intra-operative ERCP. There were no trials of open or LCBDE versus ERCP in people without an intact gallbladder. All trials had a high risk of bias.There was no significant difference in the mortality between open surgery versus ERCP clearance (eight trials; 733 participants; 5/371 (1%) versus 10/358 (3%) OR 0.51;95% CI 0.18 to 1.44). Neither was there a significant difference in the morbidity between open surgery versus ERCP clearance (eight trials; 733 participants; 76/371 (20%) versus 67/358 (19%) OR 1.12; 95% CI 0.77 to 1.62). Participants in the open surgery group had significantly fewer retained stones compared with the ERCP group (seven trials; 609 participants; 20/313 (6%) versus 47/296 (16%) OR 0.36; 95% CI 0.21 to 0.62), P = 0.0002.There was no significant difference in the mortality between LC + LCBDE versus pre-operative ERCP +LC (five trials; 580 participants; 2/285 (0.7%) versus 3/295 (1%) OR 0.72; 95% CI 0.12 to 4.33). Neither was there was a significant difference in the morbidity between the two groups (five trials; 580 participants; 44/285 (15%) versus 37/295 (13%) OR 1.28; 95% CI 0.80 to 2.05). There was no significant difference between the two groups in the number of participants with retained stones (five trials; 580 participants; 24/285 (8%) versus 31/295 (11%) OR 0.79; 95% CI 0.45 to 1.39).There was only one trial assessing LC + LCBDE versus LC+intra-operative ERCP including 234 participants. There was no reported mortality in either of the groups. There was no significant difference in the morbidity, retained stones, procedure failure rates between the two intervention groups.Two trials assessed LC + LCBDE versus LC+post-operative ERCP. There was no reported mortality in either of the groups. There was no significant difference in the morbidity between laparoscopic surgery and postoperative ERCP groups (two trials; 166 participants; 13/81 (16%) versus 12/85 (14%) OR 1.16; 95% CI 0.50 to 2.72). There was a significant difference in the retained stones between laparoscopic surgery and postoperative ERCP groups (two trials; 166 participants; 7/81 (9%) versus 21/85 (25%) OR 0.28; 95% CI 0.11 to 0.72; P = 0.008.In total, seven trials including 746 participants compared single staged LC + LCBDE versus two-staged pre-operative ERCP + LC or LC + post-operative ERCP. There was no significant difference in the mortality between single and two-stage management (seven trials; 746 participants; 2/366 versus 3/380 OR 0.72; 95% CI 0.12 to 4.33). There was no a significant difference in the morbidity (seven trials; 746 participants; 57/366 (16%) versus 49/380 (13%) OR 1.25; 95% CI 0.83 to 1.89). There were significantly fewer retained stones in the single-stage group (31/366 participants; 8%) compared with the two-stage group (52/380 participants; 14%), but the difference was not statistically significantOR 0.59; 95% CI 0.37 to 0.94).There was no significant difference in the conversion rates of LCBDE to open surgery when compared with pre-operative, intra-operative, and postoperative ERCP groups. Meta-analysis of the outcomes duration of hospital stay, quality of life, and cost of the procedures could not be performed due to lack of data. AUTHORS' CONCLUSIONS Open bile duct surgery seems superior to ERCP in achieving common bile duct stone clearance based on the evidence available from the early endoscopy era. There is no significant difference in the mortality and morbidity between laparoscopic bile duct clearance and the endoscopic options. There is no significant reduction in the number of retained stones and failure rates in the laparoscopy groups compared with the pre-operative and intra-operative ERCP groups. There is no significant difference in the mortality, morbidity, retained stones, and failure rates between the single-stage laparoscopic bile duct clearance and two-stage endoscopic management. More randomised clinical trials without risks of systematic and random errors are necessary to confirm these findings.
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Affiliation(s)
- Bobby VM Dasari
- Mater Hospital/Belfast Health and Social Care TrustGeneral and Hepatobiliary Surgery15 BoulevardWellington SquareBelfastNorthern IrelandUKBT7 3LW
| | - Chuan Jin Tan
- Mater Hospital/Belfast Health and Social Care TrustGeneral and Hepatobiliary Surgery15 BoulevardWellington SquareBelfastNorthern IrelandUKBT7 3LW
| | - Kurinchi Selvan Gurusamy
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free Hospital,Rowland Hill StreetLondonUKNW3 2PF
| | - David J Martin
- Royal Prince Alfred, Concord & Strathfield Private Hospitals3 Everton Rd StrathfieldSydneyNSWAustralia2135
| | - Gareth Kirk
- Mater Hospital/Belfast Health and Social Care TrustGeneral and Hepatobiliary Surgery15 BoulevardWellington SquareBelfastNorthern IrelandUKBT7 3LW
| | - Lloyd McKie
- Mater Hospital/Belfast Health and Social Care TrustGeneral and Hepatobiliary Surgery15 BoulevardWellington SquareBelfastNorthern IrelandUKBT7 3LW
| | - Tom Diamond
- Mater Hospital/Belfast Health and Social Care TrustGeneral and Hepatobiliary Surgery15 BoulevardWellington SquareBelfastNorthern IrelandUKBT7 3LW
| | - Mark A Taylor
- Mater Hospital/Belfast Health and Social Care TrustGeneral and Hepatobiliary Surgery15 BoulevardWellington SquareBelfastNorthern IrelandUKBT7 3LW
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Dasari BVM, Tan CJ, Gurusamy KS, Martin DJ, Kirk G, McKie L, Diamond T, Taylor MA. Surgical versus endoscopic treatment of bile duct stones. Cochrane Database Syst Rev 2013:CD003327. [PMID: 23999986 DOI: 10.1002/14651858.cd003327.pub3] [Citation(s) in RCA: 90] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Between 10% to 18% of people undergoing cholecystectomy for gallstones have common bile duct stones. Treatment of the bile duct stones can be conducted as open cholecystectomy plus open common bile duct exploration or laparoscopic cholecystectomy plus laparoscopic common bile duct exploration (LC + LCBDE) versus pre- or post-cholecystectomy endoscopic retrograde cholangiopancreatography (ERCP) in two stages, usually combined with either sphincterotomy (commonest) or sphincteroplasty (papillary dilatation) for common bile duct clearance. The benefits and harms of the different approaches are not known. OBJECTIVES We aimed to systematically review the benefits and harms of different approaches to the management of common bile duct stones. SEARCH METHODS We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL, Issue 7 of 12, 2013) in The Cochrane Library, MEDLINE (1946 to August 2013), EMBASE (1974 to August 2013), and Science Citation Index Expanded (1900 to August 2013). SELECTION CRITERIA We included all randomised clinical trials which compared the results from open surgery versus endoscopic clearance and laparoscopic surgery versus endoscopic clearance for common bile duct stones. DATA COLLECTION AND ANALYSIS Two review authors independently identified the trials for inclusion and independently extracted data. We calculated the odds ratio (OR) or mean difference (MD) with 95% confidence interval (CI) using both fixed-effect and random-effects models meta-analyses, performed with Review Manager 5. MAIN RESULTS Sixteen randomised clinical trials with a total of 1758 randomised participants fulfilled the inclusion criteria of this review. Eight trials with 737 participants compared open surgical clearance with ERCP; five trials with 621 participants compared laparoscopic clearance with pre-operative ERCP; and two trials with 166 participants compared laparoscopic clearance with postoperative ERCP. One trial with 234 participants compared LCBDE with intra-operative ERCP. There were no trials of open or LCBDE versus ERCP in people without an intact gallbladder. All trials had a high risk of bias.There was no significant difference in the mortality between open surgery versus ERCP clearance (eight trials; 733 participants; 5/371 (1%) versus 10/358 (3%) OR 0.51;95% CI 0.18 to 1.44). Neither was there a significant difference in the morbidity between open surgery versus ERCP clearance (eight trials; 733 participants; 76/371 (20%) versus 67/358 (19%) OR 1.12; 95% CI 0.77 to 1.62). Participants in the open surgery group had significantly fewer retained stones compared with the ERCP group (seven trials; 609 participants; 20/313 (6%) versus 47/296 (16%) OR 0.36; 95% CI 0.21 to 0.62), P = 0.0002.There was no significant difference in the mortality between LC + LCBDE versus pre-operative ERCP +LC (five trials; 580 participants; 2/285 (0.7%) versus 3/295 (1%) OR 0.72; 95% CI 0.12 to 4.33). Neither was there was a significant difference in the morbidity between the two groups (five trials; 580 participants; 44/285 (15%) versus 37/295 (13%) OR 1.28; 95% CI 0.80 to 2.05). There was no significant difference between the two groups in the number of participants with retained stones (five trials; 580 participants; 24/285 (8%) versus 31/295 (11%) OR 0.79; 95% CI 0.45 to 1.39).There was only one trial assessing LC + LCBDE versus LC+intra-operative ERCP including 234 participants. There was no reported mortality in either of the groups. There was no significant difference in the morbidity, retained stones, procedure failure rates between the two intervention groups.Two trials assessed LC + LCBDE versus LC+post-operative ERCP. There was no reported mortality in either of the groups. There was no significant difference in the morbidity between laparoscopic surgery and postoperative ERCP groups (two trials; 166 participants; 13/81 (16%) versus 12/85 (14%) OR 1.16; 95% CI 0.50 to 2.72). There was a significant difference in the retained stones between laparoscopic surgery and postoperative ERCP groups (two trials; 166 participants; 7/81 (9%) versus 21/85 (25%) OR 0.28; 95% CI 0.11 to 0.72; P = 0.008.In total, seven trials including 746 participants compared single staged LC + LCBDE versus two-staged pre-operative ERCP + LC or LC + post-operative ERCP. There was no significant difference in the mortality between single and two-stage management (seven trials; 746 participants; 2/366 versus 3/380 OR 0.72; 95% CI 0.12 to 4.33). There was no a significant difference in the morbidity (seven trials; 746 participants; 57/366 (16%) versus 49/380 (13%) OR 1.25; 95% CI 0.83 to 1.89). There were significantly fewer retained stones in the single-stage group (31/366 participants; 8%) compared with the two-stage group (52/380 participants; 14%), but the difference was not statistically significantOR 0.59; 95% CI 0.37 to 0.94).There was no significant difference in the conversion rates of LCBDE to open surgery when compared with pre-operative, intra-operative, and postoperative ERCP groups. Meta-analysis of the outcomes duration of hospital stay, quality of life, and cost of the procedures could not be performed due to lack of data. AUTHORS' CONCLUSIONS Open bile duct surgery seems superior to ERCP in achieving common bile duct stone clearance based on the evidence available from the early endoscopy era. There is no significant difference in the mortality and morbidity between laparoscopic bile duct clearance and the endoscopic options. There is no significant reduction in the number of retained stones and failure rates in the laparoscopy groups compared with the pre-operative and intra-operative ERCP groups. There is no significant difference in the mortality, morbidity, retained stones, and failure rates between the single-stage laparoscopic bile duct clearance and two-stage endoscopic management. More randomised clinical trials without risks of systematic and random errors are necessary to confirm these findings.
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Affiliation(s)
- Bobby V M Dasari
- General and Hepatobiliary Surgery, Mater Hospital/Belfast Health and Social Care Trust, 15 Boulevard, Wellington Square, Belfast, Northern Ireland, UK, BT7 3LW
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Lekharaju VPK, Iqbal J, Noorullah O, Polavarapu N, Menon S, Hood S, Stern N, Sturgess R. Emergency endoscopic retrograde cholangiopancreatography in critically ill patients is a safe and effective procedure. Frontline Gastroenterol 2013; 4:138-142. [PMID: 28839715 PMCID: PMC5369832 DOI: 10.1136/flgastro-2012-100239] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2012] [Revised: 10/18/2012] [Accepted: 10/23/2012] [Indexed: 02/04/2023] Open
Abstract
Emergency ERCP may be required in patients with severe cholangitis who rapidly deteriorate with multi-organ dysfunction and who cannot wait until the next available elective list. A significant proportion of patients require ventilatory and inotropic support. We describe our experience on the outcome of emergency ERCP in this cohort of critically ill patients. Medical records of cases undergoing ERCP between November 2008 and November 2011 were retrospectively reviewed. Patients who were in intensive care unit or required general anaesthesia due to haemodynamic compromise at the time of ERCP were included. Total of 2237 ERCPs were performed during this period, of which 36 (2%) emergency ERCP's were performed in 33 patients. The median age was 79 years. All procedures were performed under general anaesthesia in emergency operating room. In 27/36 procedures (75%), the patients required inotropes. Indications included cholangitis (78%), pancreatitis (14%) and post-operative bile leak (8%). Biliary cannulation was achieved in 100% of cases. Endoscopic findings included CBD stones (64%), CBD stones and an additional pathology (8%), bile leak (8%), CBD stricture (5%), Mirizzi's (3%) and blocked plastic stent (3%). In 23/36 (64%) procedures a stent was inserted. In 11/36 (30%) procedures a balloon trawl was sufficient to clear the bile duct. Thirty-day mortality was 25%. Although the 30-day mortality remains high due to multi-organ failure, ERCP is successful and effective in the majority of patients and results in a good outcome for this cohort of critically ill patients, in whom the prognosis is inevitably poor without emergency biliary drainage.
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Affiliation(s)
| | - Javaid Iqbal
- Digestive Diseases Unit, Aintree University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Omar Noorullah
- Digestive Diseases Unit, Aintree University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Naveen Polavarapu
- Digestive Diseases Unit, Aintree University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Shyam Menon
- Department of Gastroenterology, Newcross Hospital, The Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - Stephen Hood
- Digestive Diseases Unit, Aintree University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Nick Stern
- Digestive Diseases Unit, Aintree University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Richard Sturgess
- Digestive Diseases Unit, Aintree University Hospitals NHS Foundation Trust, Liverpool, UK
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Paik KY, Kim EK. Laparoscopic Common Bile Duct Exploration After Unsuccessful Endoscopic Stone Removal. J Laparoendosc Adv Surg Tech A 2013; 23:137-40. [DOI: 10.1089/lap.2012.0331] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Affiliation(s)
- Kwang Yeol Paik
- Department of Surgery, Yeouido St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Eung Kook Kim
- Department of Surgery, Yeouido St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
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16
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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
Acute pancreatitis (AP) is a rare event in pregnancy, occurring in approximately 3 in 10 000 pregnancies. The spectrum of AP in pregnancy ranges from mild pancreatitis to serious pancreatitis associated with necrosis, abscesses, pseudocysts and multiple organ dysfunction syndromes. Pregnancy related hematological and biochemical alterations influence the interpretation of diagnostic tests and assessment of severity of AP. As in any other disease associated with pregnancy, AP is associated with greater concerns as it deals with two lives rather than just one as in the non-pregnant population. The recent advances in clinical gastroenterology have improved the early diagnosis and effective management of biliary pancreatitis. Diagnostic studies such as endoscopic ultrasound, magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography and therapeutic modalities that include endoscopic sphincterotomy, biliary stenting, common bile duct stone extraction and laparoscopic cholecystectomy are major milestones in gastroenterology. When properly managed AP in pregnancy does not carry a dismal prognosis as in the past.
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Abstract
Bacterial infection that occurs in the setting of biliary obstruction can lead to acute cholangitis, a condition characterized by fever, abdominal pain and jaundice. Choledocholithiasis is the most common cause of acute cholangitis and is often associated with bacterial infection and colonization in addition to biliary obstruction. Iatrogenic introduction of bacteria into the biliary system most commonly occurs during endoscopic retrograde cholangiopancreatography in patients with biliary obstruction. The majority of patients with acute cholangitis respond to antibiotic therapy, but endoscopic biliary drainage is ultimately required to treat the underlying obstruction. Acute cholangitis is often diagnosed using the clinical Charcot triad criteria; however, recommendations from an international consensus meeting in Tokyo produced the most comprehensive recommendations for the diagnosis and management of acute cholangitis. These guidelines enable a more accurate diagnosis of acute cholangitis than do earlier methods, and they facilitate the classification of disease as mild, moderate or severe. Although these guidelines represent a notable advance toward defining a universally accepted consensus for the definition of acute cholangitis, they have several limitations. This Review discusses current recommendations for the diagnosis of acute cholangitis and addresses the advantages and disadvantages of different modalities for the treatment of this disease.
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Affiliation(s)
- John G Lee
- University of California Irvine Medical Center, 101 The City Drive, Building 53, Room 113, Orange, CA 92868, USA.
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Verbesey JE, Birkett DH. Common Bile Duct Exploration for Choledocholithiasis. Surg Clin North Am 2008; 88:1315-28, ix. [DOI: 10.1016/j.suc.2008.08.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Abstract
BACKGROUND 10% to 18% of patients undergoing cholecystectomy for gallstones have common bile duct (CBD) stones. Treatment options for these stones include pre- or post-operative endoscopic retrograde cholangiopancreatography (ERCP) or open or laparoscopic surgery. OBJECTIVES To systematically review the management of CBD stones by four approaches: (1) ERCP versus open surgical bile duct clearance. (2) Pre-operative ERCP versus laparoscopic bile duct clearance. (3) Post-operative ERCP versus laparoscopic bile duct clearance. (4) ERCP versus laparoscopic bile duct clearance in patients with previous cholecystectomy. SEARCH STRATEGY We systematically searched key relevant electronic databases, bibliographies of relevant papers, and abstracts of relevant subspecialty meetings until November 2005. SELECTION CRITERIA The quality of included trials was assessed by adequacy of allocation sequence generation, allocation concealment, blinding, and follow-up. DATA COLLECTION AND ANALYSIS Published and unpublished data relevant to 12 predefined outcome measures were used to conduct fixed- and random-effects models meta-analyses, with exploration of heterogeneity and use of sensitivity and subgroup analysis where required. MAIN RESULTS Thirteen trials randomised 1351 patients. Eight trials (n = 760) compared ERCP with open surgical clearance, three (n = 425) compared pre-operative ERCP with laparoscopic clearance, and two (n = 166) compared post-operative ERCP with laparoscopic clearance. There were no trials of ERCP versus laparoscopic clearance in patients without an intact gallbladder. Methodology was considered adequate in at least two of three assessable fields in ten trials. A significantly increased number of total procedures (including for complications) per patient was seen in the ERCP arms in all three comparisons with weighted mean differences of 0.62 (95% CI 0.15 to 1.09), 0.96 (95% CI 0.96 to 0.96), and 1.09 (95% CI 0.93 to 1.24), respectively. ERCP was less successful than open surgery in CBD stone clearance (Peto OR 2.89, 95% CI 1.81 to 4.61) with a tendency towards higher mortality (risk difference 1%, 95% CI -1% to 4%). Laparoscopic CBD stone clearance was as efficient as pre- (Peto OR 1.00, CI 0.53 to 1.80) and post-operative ERCP (OR 2.27, 95% CI 0.37 to 13.9) and with no significant difference in morbidity and mortality. Laparoscopic trials universally reported shorter hospital stays in surgical arms. Insufficient data were reported for cost analysis. AUTHORS' CONCLUSIONS In the era of open cholecystectomy, open bile duct surgery was superior to ERCP in achieving CBD stone clearance. In the laparoscopic era, data are close to excluding a significant difference between laparoscopic and ERCP clearance of CBD stones. The use of ERCP necessitates increased number of procedures per patient.
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Affiliation(s)
- D J Martin
- Copenhagen Trial Unit, Dept 71 02, Cochrane Hepato-Biliary Group, Blegdamsvej 9, Copenhagen Ø, DK-2100, DENMARK.
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21
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Lakatos L, Mester G, Reti G, Nagy A, Lakatos PL. Selection criteria for preoperative endoscopic retrograde cholangiopancreatography before laparoscopic cholecystectomy and endoscopic treatment of bile duct stones: results of a retrospective, single center study between 1996-2002. World J Gastroenterol 2004; 10:3495-3499. [PMID: 15526372 PMCID: PMC4576234 DOI: 10.3748/wjg.v10.i23.3495] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2004] [Revised: 04/22/2004] [Accepted: 05/25/2004] [Indexed: 12/15/2022] Open
Abstract
AIM The optimal treatment for bile duct stones (in terms of cost, complications and accuracy) is unclear. The aim of our study was to determine the predictive factors for preoperative endoscopic retrograde cholangiopancreatography (ERCP). METHODS Patients undergoing preoperative ERCP (< or =90 d before laparoscopic cholecystectomy) were evaluated in this retrospective study from the 1st of January 1996 to the 31st of December 2002. The indications for ERCP were elevated serum bilirubin, elevated liver function tests (LFT), dilated bile duct (> or =8 mm) and/or stone at US examination, coexisting acute pancreatitis and/or acute pancreatitis or jaundice in patient's history. Suspected prognostic factors and the combination of factors were compared to the result of ERCP. RESULTS Two hundred and six preoperative ERCPs were performed during the observed period. The rate of successful cannulation for ERC was (97.1%). Bile duct stones were detected in 81 patients (39.3%), and successfully removed in 79 (97.5%). The number of prognostic factors correlated with the presence of bile duct stones. The positive predictive value for one prognostic factor was 1.2%, for two 43%, for three 72.5%, for four or more 91.4%. CONCLUSION Based on our data preoperative ERCP is highly recommended in patients with three or more positive factors (high risk patients). In contrast, ERCP is not indicated in patients with zero or one factor (low risk patients). Preoperative ERCP should be offered to patients with two positive factors (moderate risk patients), however the practice should also be based on the local conditions (e.g. skill of the endoscopist, other diagnostic tools).
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Affiliation(s)
- Laszlo Lakatos
- 1st Department of Medicine, Csolnoky F, Province Hospital, Veszprem, H-8200, Hungary.
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Tranter SE, Thompson MH. Comparison of endoscopic sphincterotomy and laparoscopic exploration of the common bile duct. Br J Surg 2002; 89:1495-504. [PMID: 12445057 DOI: 10.1046/j.1365-2168.2002.02291.x] [Citation(s) in RCA: 138] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Laparoscopic exploration of the common bile duct is becoming more popular, although endoscopic sphincterotomy remains the usual treatment for bile duct stones. However, loss of the biliary sphincter causes permanent duodenobiliary reflux, and recurrent stone disease and biliary neoplasia may be a consequence. METHODS A systematic literature review was conducted to compare laparoscopic exploration with endoscopic sphincterotomy. A text word search of the Medline, Pubmed and Cochrane databases, and a manual search of the citations from these references, was used. RESULTS Endoscopic sphincterotomy is associated with a median (range) mortality rate of 1 (0-6) per cent, compared with 1 (0-5) per cent for laparoscopic bile duct exploration. The median (range) rate of pancreatitis following endoscopic sphincterotomy is 3 (1-19) per cent; this is a rare complication after laparoscopic duct exploration. The combined morbidity rate for laparoscopic cholecystectomy and endoscopic sphincterotomy is 13 (3-16) per cent, which is greater than 8 (2-17) per cent for laparoscopic bile duct exploration. Randomized trials are few and contain relatively small numbers of patients. They show little overall difference in rates of duct clearance, but a higher mortality rate and number of hospital admissions are noted for endoscopic sphincterotomy compared with laparoscopic bile duct exploration. Endoscopic sphincterotomy is associated with recurrent stone formation (up to 16 per cent) with associated cholangitis. It is also associated with bacterobilia and chronic mucosal inflammation. The late development of bile duct cancer has been reported in up to 2 per cent of patients. CONCLUSION Laparoscopic exploration of the common bile duct may be a better way of removing stones than endoscopic sphincterotomy plus laparoscopic cholecystectomy. :
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Affiliation(s)
- S E Tranter
- Department of Surgery, Southmead Hospital, Bristol BS10 5NB, UK
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23
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Eyre-Brook IA, Lalla R. Gastrointestinal surgical workload in the DGH and the upper gastrointestinal surgeon. Ann R Coll Surg Engl 1999; 81:37-9. [PMID: 10325683 PMCID: PMC2503242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
Abstract
Workload implications of upper gastrointestinal (UGI) subspecialisation within the district general hospital (DGH) have been assessed by prospective data collection over a 12-month period in a DGH with six general surgeons serving a population of 320,000. The single UGI surgeon (UGIS) performed all ten oesophageal resections, ten of 11 gastric resections for malignancy and all eight pancreatic operations. He also performed 91 of the 182 cholecystectomies, 164 of the 250 endoscopic retrograde cholangiopancreatograms (ERCP) and all endoscopic procedures for the palliation of unresected oesophageal tumours. The UGIS was responsible for the management of all patients with severe pancreatitis, yet he also performed 51 colorectal resections over the 12-month period. Successful management of severely ill patients with upper GI disease requires consultant supervision on a day-to-day basis. If such UGI disease is to be managed in the DGH, two surgeons with UGI experience will be required if high quality care and reasonable working conditions are to be achieved. Such UGIS will continue to perform some colorectal surgery.
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Abstract
BACKGROUND The role of preoperative ERCP and endoscopic sphincterotomy (ES) in the diagnosis and treatment of suspected common bile duct stones (CBDS) in the laparoscopic age is controversial. The preoperative diagnosis of CBDS by ERCP and the removal of CBDS by ES are advantageous because of technical difficulties in performing laparoscopic exploration of the common bile duct. Approximately 50% of preoperative ERCP examinations are normal, however. The noninvasive diagnosis of CBDS has assumed new importance, but it has proved to be an elusive goal. Neural networks are a form of artificial computer intelligence that have been used successfully to interpret ECGs and to diagnose myocardial infarcts. The purpose of this study was to determine whether a neural network could be trained to predict CBDS accurately in patients at high risk of having duct stones. STUDY DESIGN We trained a back-propagation neural network to predict the presence of CBDS. Retrospective data from patients who had a cholecystectomy and either a preoperative ERCP or intraoperative cholangiogram were used to build the network, and it was tested using unseen data. RESULTS One hundred forty patients were used to train the network, and 16 patients were used to test it. The trained network was able to predict CBDS in 100% of the patients in both the training and test sets. CONCLUSIONS Screening of high-risk patients for CBDS by neural network analysis is highly accurate. This promising new, noninvasive, and inexpensive technique can potentially decrease the need for preoperative ERCP by 50%, but additional prospective evaluation is indicated.
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Affiliation(s)
- R Golub
- Department of Surgery, The New York Flushing Hospital, 11355, USA
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25
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KOZAREK R. ERCP Interaction with Laparoscopic Cholecystectomy. J Laparoendosc Adv Surg Tech A 1998; 8:171-173. [DOI: 10.1089/lap.1998.8.171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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26
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PHILLIPS EDWARDH. Laparoscopic Transcystic Duct Common Bile Duct Exploration. J Laparoendosc Adv Surg Tech A 1998. [DOI: 10.1089/lap.1998.8.173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
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Schirmer B. SSAT/SAGES minimally invasive surgeryAdvanced laparoscopic hepatobiliary surgery. Surg Endosc 1998; 12:361. [PMID: 9543532 DOI: 10.1007/s004649900673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- B Schirmer
- Department of Surgery, University of Virginia Health Science Center, Box 181, Charlottesville, VA 22908, USA
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Taylor OM, Sedman PC, Jones BM, Royston CM, Arulampalam T, Wellwood J. Laparoscopic cholecystectomy without operative cholangiogram: 2038 cases over a 5-year period in two district general hospitals. Ann R Coll Surg Engl 1997; 79:376-80. [PMID: 9326132 PMCID: PMC2503054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
The place of cholangiography in laparoscopic cholecystectomy is debatable. This retrospective study reviews the outcome of 2061 patients operated upon for symptomatic gallstones in two district general hospitals. Intraoperative cholangiography was not used because all patients were submitted to a policy of selective preoperative investigation of the extrahepatic ducts. The conversion rate to open cholecystectomy was 3.1% and 88% of patients were discharged home within 48 h of surgery. No major duct injuries occurred and only 12 patients have presented with a proven retained stone after operation (0.7%). This policy of preoperative investigation and treatment for extrahepatic bile duct stones without intraoperative cholangiography has been employed in over 2000 patients and is at least as safe as published results using routine intraoperative cholangiography.
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Newman KD, Powell DM, Holcomb GW. The management of choledocholithiasis in children in the era of laparoscopic cholecystectomy. J Pediatr Surg 1997; 32:1116-9. [PMID: 9247246 DOI: 10.1016/s0022-3468(97)90411-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Although laparoscopic cholecystectomy has become the procedure of choice for gallbladder removal in children, the treatment of children who have choledocholithiasis remains unclear. For adults who have suspected choledocholithiasis, preoperative endoscopic retrograde cholangiopancreatography (ERCP) is a well-described and effective approach, however, its use for common bile duct stones in children has not been defined. The authors reviewed the records of 131 consecutive children undergoing laparoscopic cholecystectomy on two surgical services to define the efficacy of ERCP followed by laparoscopic cholecystectomy in managing choledocholithiasis in children. Fourteen children were suspected of having common duct stones noted on preoperative ultrasound scan and laboratory data. At ERCP, six children had no stones visualized; eight had stones and underwent stone extraction and sphincter dilation or sphincterotomy. All 14 underwent laparoscopic cholecystectomy a mean of 3.8 days after ERCP. None of the 14 had evidence of retained stones. Only one of 117 children undergoing primary laparoscopic cholecystectomy had unsuspected common bile duct stones and was treated with laparoscopic common bile duct exploration and stone removal. A management plan incorporating ERCP followed by early laparoscopic cholecystectomy is a safe and effective strategy for children who have choledocholithiasis.
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Affiliation(s)
- K D Newman
- Department of Surgery, George Washington University School of Medicine and Children's Hospital, Washington, DC 20010, USA
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Lezoche E, Paganini AM, Carlei F, Feliciotti F, Lomanto D, Guerrieri M. Laparoscopic treatment of gallbladder and common bile duct stones: a prospective study. World J Surg 1996; 20:535-41; discussion 542. [PMID: 8661627 DOI: 10.1007/s002689900083] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The aim of this study was to investigate prospectively the feasibility, success rate, safety, and short-term results of single-stage laparoscopic treatment of gallstones and ductal stones in 100 consecutive, unselected patients. Common bile duct (CBD) stones were diagnoses at routine intraoperative cholangiography and choledochoscopy in 100 of 950 patients with gallstones undergoing laparoscopic cholecystectomy (LC). Unsuspected CBD stones were present in 39 patients (4.1% of 950; 39% of 100); 26 patients were referred for surgery after failed endoscopic sphinctertomy (ES) performed elsewhere. Transcystic duct CBD exploration (TC-CBDE) was the procedure of choice. When it was not feasible, choledochotomy and direct CBD exploration (D-CBDE) was performed. Use of biliary drainage was liberal. A completion cholangiogram was obtained for all patients. Laparoscopic treatment of CBD stones was successful in 96 patients: after TC-CBDE in 63 and after D-CBDE in 33. Four operations were converted to open surgery (4%). Retained stones, observed in five patients, were treated by ES in two cases and by percutaneous endoscopic/fluoroscopic lithotripsy in three. Minor morbidity included biloma (n = 2), port site infection (n = 2), and subumbilical hematoma (n = 1). Major morbidity was bile leakage from the cystic duct stump in two cases due to clips or transcystic duct drainage displacement, respectively. One elderly, high risk patient died after being referred for several failed attempts of endoscopic clearance; she died from cardiogenic shock 3 days after successful laparoscopic treatment. Laparoscopic CBD exploration is feasible and safe in most patients, with short-term results that compare favorably with the results of sequential ES/LC reported in the literature.
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Affiliation(s)
- E Lezoche
- Department of general surgery, University of Ancona, Umberto I Hospital, Italy
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