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Sugimoto M, Murata M, Shionoya K, Tsuchiya T, Itoi T. Delayed bleeding after endoscopic sphincterotomy in patients receiving anticoagulants. Dig Endosc 2025. [PMID: 40040592 DOI: 10.1111/den.15016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2024] [Accepted: 02/12/2025] [Indexed: 03/06/2025]
Abstract
Delayed bleeding after endoscopic sphincterotomy (EST) constitutes a significant adverse event, occurring in ~0.5-5% of patients. The number of patients receiving anticoagulants to prevent cardiovascular and cerebrovascular disease has increased with the aging society worldwide; however, anticoagulants (direct oral anticoagulants [DOACs] and warfarin) are one of the most major risk factors for postprocedure bleeding. This review investigated post-EST bleeding in anticoagulant users, focusing on risk factors, clinical guidelines, pharmacological characteristics, and the future of post-EST bleeding. Several clinical guidelines for antithrombotic drug users have been established to prevent postprocedure bleeding; nevertheless, the risk of bleeding is believed to be several times higher than for nondrug users, regardless of clinical guideline compliance. The major problem in this field is that patients who experience delayed bleeding are often receiving multiple antithrombotic drugs, and no parameters that can accurately monitor the anticoagulant effect of DOACs have been identified. Therefore, identifying patients with a generally high-risk of postprocedure bleeding is crucial. Recently, the plasma level and antifactor Xa activity of factor Xa inhibitors have been investigated in relation to the risk of major bleeding in users. Similar to the prothrombin time-international normalized ratio for warfarin, plasma levels, and antifactor Xa activity may be useful parameters for monitoring the anticoagulant effect and identifying DOAC users at higher risk of postprocedure bleeding, including post-EST bleeding. Future studies should stratify the risk of post-EST delayed bleeding based on a scoring system to prevent this complication.
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Affiliation(s)
- Mitsushige Sugimoto
- Division of Genome-Wide Infectious Microbiology, Research Center for GLOBAL and LOCAL Infectious Disease, Oita University, Oita, Japan
| | - Masaki Murata
- Department of Gastroenterology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Kento Shionoya
- Department of Gastroenterology and Hepatology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Takayoshi Tsuchiya
- Department of Gastroenterology and Hepatology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University Hospital, Tokyo, Japan
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Shiihara M, Sudo Y, Matsushita N, Kubota T, Hibi Y, Osugi H, Inoue T. Is Cholecystectomy Necessary after Choledocholithiasis Treatment for the Elderly or Patients with Many Comorbidities? Dig Dis 2024:1-7. [PMID: 39102793 DOI: 10.1159/000540661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 07/15/2024] [Indexed: 08/07/2024]
Abstract
INTRODUCTION We evaluated the prognosis after endoscopic treatment for choledocholithiasis, particularly in patients with borderline tolerance to surgery. Stone removal and cholecystectomy are generally recommended for patients with choledocholithiasis combined with gallstones to prevent recurrent biliary events. However, the prognosis after choledocholithiasis treatment in patients with borderline tolerance to surgery, such as the elderly or those with many comorbidities, remains controversial. METHODS We retrospectively analyzed data from patients with choledocholithiasis treated at our facility between January 2012 and December 2021. Patients who underwent endoscopic sphincterotomy were dichotomized into the cholecystectomy (CHOLE) and conservation (CONS) groups depending on whether cholecystectomy was performed, and their prognoses were subsequently compared. Furthermore, we performed a logistic regression analysis of the factors contributing to recurrent biliary events in patients with high age-adjusted Charlson Comorbidity Index (aCCI) scores. RESULTS Of 169 participants, 110 had gallstones and were divided into the CHOLE (n = 56) and CONS (n = 54) groups. The CONS group was significantly ordered, had more comorbidities, and higher aCCI scores, whereas the CHOLE group had fewer recurrent biliary events, although not significant (p = 0.122). No difference was observed in the recurrent incidence of grade ≥2 biliary infections and mortality related to biliary events between the groups. In patients with aCCI scores ≥5, conservation without cholecystectomy was not an independent risk factor for recurrent biliary events. CONCLUSION Cholecystectomy after choledocholithiasis treatment prevents recurrent biliary events, but conservation without cholecystectomy is a feasible option for patients with high aCCI scores.
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Affiliation(s)
| | - Yasuhiro Sudo
- Department of Surgery, Kamifukuoka General Hospital, Saitama, Japan
| | | | - Takeshi Kubota
- Department of Surgery, Kamifukuoka General Hospital, Saitama, Japan
| | - Yasuhiro Hibi
- Department of Surgery, Kamifukuoka General Hospital, Saitama, Japan
| | - Harushi Osugi
- Department of Surgery, Kamifukuoka General Hospital, Saitama, Japan
| | - Tatsuo Inoue
- Department of Surgery, Kamifukuoka General Hospital, Saitama, Japan
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Hess GF, Sedlaczek P, Zeindler J, Muenst S, Schmitt AM, Däster S, Bolli M, Kollmar O, Soysal SD. The short- and long-term outcome after the surgical management of common bile duct stones in a tertiary referral hospital. Langenbecks Arch Surg 2023; 408:288. [PMID: 37515739 PMCID: PMC10386922 DOI: 10.1007/s00423-023-03011-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 07/02/2023] [Indexed: 07/31/2023]
Abstract
BACKGROUND The removal of common bile duct stones by endoscopic retrograde cholangiopancreatography (ERCP) shows excellent results with low complication rates and is therefore considered a gold standard. However, in case of stones non-removable by ERCP, surgical extraction is needed. The surgical approach is still controversial and clinical guidelines are missing. This study aims to analyze the outcomes of patients treated with choledochotomy or hepaticojejunostomy for common bile duct stones. METHODS All patients who underwent choledochotomy or hepaticojejunostomy for common bile duct stones at a tertiary referral hospital over 11 years were included. The analyzed data contains basic demographics, diagnostics, surgical parameters, length of hospitalization, and morbidity and mortality. RESULTS Over the study period, 4375 patients underwent cholecystectomy, and 655 received an ERCP with stone extraction, with 48 of these patients receiving subsequent surgical treatment. ERCP was attempted in 23/30 (77%) of the choledochotomy patients pre/intraoperatively and 11/18 (56%) in hepaticojejunostomy patients. The 30-day major complication rate (Clavien-Dindo > II) was 1/30 (3%) in the choledochotomy group and 2/18 (11%) in the hepaticojejunostomy group. Complications after 30 days occurred in 3/30 (10%) patients and 2/18 (11%), respectively, and no mortality occurred. CONCLUSION ERCP should still be considered the gold standard, although due to low short- and long-term morbidity rates, choledochotomy and hepaticojejunostomy represent effective surgical solutions for common bile duct stones.
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Affiliation(s)
- Gabriel F Hess
- Clarunis, University Centre for Gastrointestinal and Liver Diseases, 4002, Basel, Switzerland
| | - Philipp Sedlaczek
- Faculty of Medicine, University of Basel, Klingelbergstrasse 61, 4056, Basel, Switzerland
| | - Jasmin Zeindler
- Clarunis, University Centre for Gastrointestinal and Liver Diseases, 4002, Basel, Switzerland
| | - Simone Muenst
- Institute of Medical Genetics and Pathology University Hospital Basel, Schönbeinstrasse 40, 4056, Basel, Switzerland
| | - Andreas M Schmitt
- Department of Internal Medicine, Medical Oncology, University Hospital Basel, Petersgraben 4, 4051, Basel, Switzerland
| | - Silvio Däster
- Clarunis, University Centre for Gastrointestinal and Liver Diseases, 4002, Basel, Switzerland
| | - Martin Bolli
- Clarunis, University Centre for Gastrointestinal and Liver Diseases, 4002, Basel, Switzerland
| | - Otto Kollmar
- Clarunis, University Centre for Gastrointestinal and Liver Diseases, 4002, Basel, Switzerland
| | - Savas D Soysal
- Clarunis, University Centre for Gastrointestinal and Liver Diseases, 4002, Basel, Switzerland.
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Mansour S, Kluger Y, Khuri S. Primary Recurrent Common Bile Duct Stones: Timing of Surgical Intervention. J Clin Med Res 2022; 14:441-447. [PMID: 36578366 PMCID: PMC9765319 DOI: 10.14740/jocmr4826] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 10/24/2022] [Indexed: 11/30/2022] Open
Abstract
Cholelithiasis (gallstones) is a very common medical problem worldwide, with 5-30% of patients demonstrating a combined condition of cholelithiasis and choledocholithiasis (common bile duct stones (CBDS)). CBDS are usually classified as primary or secondary stones. Primary CBDS are defined as stones detected 2 years or more following cholecystectomy, while secondary stones, the most common type, usually migrate from the gallbladder to the bile ducts. Recurrent CBDS are defined as stones detected 6 months or more following endoscopic retrograde cholangiopancreatography (ERCP) with complete duct clearance. Although ERCP with endoscopic sphincterotomy has emerged as the main therapeutic option for CBDS, with up to 95% bile duct clearance rate, up to 25% of said patients develop recurrent bile duct stones. Thus far, several issues related to recurrent CBDS are still unclear and questions regarding this specific pathology have no precise answers: how many trials of ERCP and endoscopic sphincterotomy should be attempted before referring the patient for surgical management? Is there an association between risk factors and early surgical intervention? Thus, currently, there is no worldwide scientific-based consensus regarding the best management of this specific group of patients. The main issue for this article is to review the relevant English literature and find out the main high risk factors for recurrent CBDS, and form a diagnostic and treatment plan, hence, identifying the subgroup of patients that will benefit from early surgical management, preventing further ERCP-associated complications.
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Affiliation(s)
- Subhi Mansour
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Yoram Kluger
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
- HPB and Surgical Oncology Unit, Rambam Health Care Campus, Haifa, Israel
| | - Safi Khuri
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
- HPB and Surgical Oncology Unit, Rambam Health Care Campus, Haifa, Israel
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Chen JH, Chung CH, Li CH, Chien WC, Chang CF. Epidemiological Survey of Different Treatments for Choledocholithiasis in Taiwan: A Nationwide, Population-Based Cohort Analysis. J Clin Med 2022; 11:jcm11040970. [PMID: 35207241 PMCID: PMC8876383 DOI: 10.3390/jcm11040970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 01/28/2022] [Accepted: 02/10/2022] [Indexed: 12/04/2022] Open
Abstract
(1) Background: Open, laparoscopic, and endoscopic choledocholithotomy (OC, LC, and EC, respectively) are accepted choledocholithiasis treatment modalities. However, an assessment of the nationwide trends in their outcomes is lacking. This nationwide population-based analysis evaluated treatment outcomes of choledocholithiasis in Taiwan; (2) Methods: A total of 13,139,306 individuals were randomly enrolled from the Longitudinal Health Insurance Database (LHID) between 2000 to 2013 for cohort analysis. All patients with newly diagnosed choledocholithiasis aged 18 years or older who were treated during the study period were enrolled and allocated to the OC, LC, EC, or combined endoscopy and open choledocholithotomy (CEOC) groups. Age, readmission, retained stone, comorbidities, hospital stay, medical cost, complications, mortality were analyzed; (3) Results: A total of 58,064 individuals met the inclusion criteria, including 46.54%, 1.10%, 47.52%, and 4.85% who underwent OC, LC, EC, and CEOC, respectively. The endpoint characteristics showed that the LC group had higher readmission, longer hospital stay, and higher medical cost. Cox regression analysis showed that the adjusted hazard ratio (HR) of complications for EC was 1.259 times higher than that for OC. The adjusted HRs of readmission within 90 days for LC, EC, and CEOC were higher than that of OC. The adjusted HR of retreatment with surgery was higher in LC. The adjusted HR of retreatment with endoscopy was higher in CEOC. The adjusted HR of mortality in EC was 1.603 times that of OC; (4) Conclusions: Different choledocholithiasis treatments lead to different outcomes. However, further studies on other large or national data sets are required to support these findings.
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Affiliation(s)
- Jia-Hui Chen
- Division of General Surgery, Department of Surgery, Taipei Tzu Chi Hospital, The Buddhist Medical Foundation, New Taipei City 231, Taiwan;
- School of Medicine, Buddhist Tzu Chi University, Hualien 970, Taiwan
| | - Chi-Hsiang Chung
- School of Public Health, National Defense Medical Center, Taipei City 114, Taiwan;
- Taiwanese Injury Prevention and Safety Promotion Association, Taipei City 114, Taiwan
| | - Chung-Hsien Li
- Division of Gastroenterology, Department of Medicine, Taipei Tzu Chi Hospital, The Buddhist Medical Foundation, New Taipei City 231, Taiwan;
| | - Wu-Chien Chien
- School of Public Health, National Defense Medical Center, Taipei City 114, Taiwan;
- Taiwanese Injury Prevention and Safety Promotion Association, Taipei City 114, Taiwan
- Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei City 114, Taiwan
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei City 114, Taiwan
- Correspondence: (W.-C.C.); (C.-F.C.); Tel.: +886-2-87923100 (ext. 18130) (W.-C.C.); Fax: +886-2-87923147 (W.-C.C.)
| | - Chao-Feng Chang
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei City 114, Taiwan
- Correspondence: (W.-C.C.); (C.-F.C.); Tel.: +886-2-87923100 (ext. 18130) (W.-C.C.); Fax: +886-2-87923147 (W.-C.C.)
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Jorba R, Pavel MC, Llàcer-Millán E, Estalella L, Achalandabaso M, Julià-Verdaguer E, Nve E, Padilla-Zegarra ED, Badia JM, O'Connor DB, Memba R. Contemporary management of concomitant gallstones and common bile duct stones: a survey of Spanish surgeons. Surg Endosc 2021; 35:5024-5033. [PMID: 32968916 DOI: 10.1007/s00464-020-07984-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 09/14/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Concomitant gallstones and common bile duct stones (CBDS) is a relatively frequent presentation. The optimal treatment remains controversial and the debate persists between two strategies. The one-stage approach: laparoscopic cholecystectomy with laparoscopic common bile duct exploration (LCBDE) has been shown to be equally safe and more cost-effective than the more traditional two-stage approach: endoscopic retrograde cholangiography followed by laparoscopic cholecystectomy (ERCP + LC). However, many surgeons worldwide still prefer the two-stage procedure. This survey evaluated contemporary management of CBDS in Spain and assessed the impact of surgeon and hospital factors on provision of LCBDE. METHODS A 25-item, web-based anonymous survey was sent to general surgeons members of the Spanish Surgeons Association. Descriptive statistics were applied to summarize results. RESULTS Responses from 305 surgeons across 173 Spanish hospitals were analyzed. ERCP is the initial approach for preoperatively suspected CBDS for 86% of surgeons. LCBDE is the preferred method for only 11% of surgeons and only 11% treat more than 10 cases per year. For CBDS discovered intraoperatively, 59% of respondents attempt extraction while 32% defer to a postoperative ERCP. The main reasons cited for not performing LCBDE were lack of equipment, training and timely availability of an ERCP proceduralist. Despite these barriers, most surgeons (84%) responded that LCBDE should be implemented in their departments. CONCLUSIONS ERCP was the preferred approach for CBDS for the majority of respondents. There remains limited use of LCBDE despite many surgeons indicating it should be implemented. Focused planning and resourcing of both training and operational demands are required to facilitate adoption of LCBDE as option for patients.
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Affiliation(s)
- Rosa Jorba
- Department of Abdominal and General Surgery, Hospital Universitari de Tarragona, Joan XXIII, Dr Mallafre Guasch, 4, 43005, Tarragona, Spain.
| | - Mihai C Pavel
- Department of Abdominal and General Surgery, Hospital Universitari de Tarragona, Joan XXIII, Dr Mallafre Guasch, 4, 43005, Tarragona, Spain
| | - Erik Llàcer-Millán
- Department of Abdominal and General Surgery, Hospital Universitari de Tarragona, Joan XXIII, Dr Mallafre Guasch, 4, 43005, Tarragona, Spain
| | - Laia Estalella
- Department of Abdominal and General Surgery, Hospital Universitari de Tarragona, Joan XXIII, Dr Mallafre Guasch, 4, 43005, Tarragona, Spain
| | - Mar Achalandabaso
- Department of Abdominal and General Surgery, Hospital Universitari de Tarragona, Joan XXIII, Dr Mallafre Guasch, 4, 43005, Tarragona, Spain
| | - Elisabet Julià-Verdaguer
- Department of Abdominal and General Surgery, Hospital Universitari de Tarragona, Joan XXIII, Dr Mallafre Guasch, 4, 43005, Tarragona, Spain
| | - Esther Nve
- Department of General Surgery, Hospital de Granollers, Granollers, Spain
| | - Erlinda D Padilla-Zegarra
- Department of Abdominal and General Surgery, Hospital Universitari de Tarragona, Joan XXIII, Dr Mallafre Guasch, 4, 43005, Tarragona, Spain
| | - Josep M Badia
- Department of General Surgery, Hospital de Granollers, Granollers, Spain
| | - Donal B O'Connor
- Department of Surgery, School of Medicine, Trinity College Dublin, Dublin 2, Ireland
| | - Robert Memba
- Department of Abdominal and General Surgery, Hospital Universitari de Tarragona, Joan XXIII, Dr Mallafre Guasch, 4, 43005, Tarragona, Spain
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Review of the Endoscopic, Surgical and Radiological Techniques of Treating Choledocholithiasis in Bariatric Roux-en-Y Gastric Bypass Patients and Proposed Management Algorithm. Obes Surg 2021; 31:4993-5004. [PMID: 34350533 DOI: 10.1007/s11695-021-05627-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 07/17/2021] [Accepted: 07/22/2021] [Indexed: 01/22/2023]
Abstract
Choledocholithiasis in post-surgical bariatric Roux-en-Y gastric bypass patients presents a significant challenge secondary to altered anatomy. We aim to review the existing management options including either endoscopic, surgical, percutaneous or hybrid means. Current literature suggests reasonably successful cannulation rates for single- or double-balloon ERCP ranging from 50 to 70% and 63-83%, respectively. The hybrid technique of laparoscopic transgastric ERCP has gained popularity with success rates ranging from 90 to 100%. Conventional laparoscopic techniques like transcystic duct and transcholedochal bile duct exploration are still useful options (i.e. high success rates of 81-100% and 83-96%, respectively). The role of percutaneous transhepatic choledochography remains limited although it can help with rapid bile duct decompression. If feasible, treatment pathways should progress from least to more invasive options as required.
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Cianci P, Restini E. Management of cholelithiasis with choledocholithiasis: Endoscopic and surgical approaches. World J Gastroenterol 2021; 27:4536-4554. [PMID: 34366622 PMCID: PMC8326257 DOI: 10.3748/wjg.v27.i28.4536] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 04/02/2021] [Accepted: 06/25/2021] [Indexed: 02/06/2023] Open
Abstract
Gallstone disease and complications from gallstones are a common clinical problem. The clinical presentation ranges between being asymptomatic and recurrent attacks of biliary pain requiring elective or emergency treatment. Bile duct stones are a frequent condition associated with cholelithiasis. Amidst the total cholecystectomies performed every year for cholelithiasis, the presence of bile duct stones is 5%-15%; another small percentage of these will develop common bile duct stones after intervention. To avoid serious complications that can occur in choledocholithiasis, these stones should be removed. Unfortunately, there is no consensus on the ideal management strategy to perform such. For a long time, a direct open surgical approach to the bile duct was the only unique approach. With the advent of advanced endoscopic, radiologic, and minimally invasive surgical techniques, however, therapeutic choices have increased in number, and the management of this pathological situation has become multidisciplinary. To date, there is agreement on preoperative management and the need to treat cholelithiasis with choledocholithiasis, but a debate still exists on how to cure the two diseases at the same time. In the era of laparoscopy and mini-invasiveness, we can say that therapeutic approaches can be performed in two sessions or in one session. Comparison of these two approaches showed equivalent success rates, postoperative morbidity, stone clearance, mortality, conversion to other procedures, total surgery time, and failure rate, but the one-session treatment is characterized by a shorter hospital stay, and more cost benefits. The aim of this review article is to provide the reader with a general summary of gallbladder stone disease in association with the presence of common bile duct stones by discussing their epidemiology, clinical and diagnostic aspects, and possible treatments and their advantages and limitations.
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Affiliation(s)
- Pasquale Cianci
- Department of Surgery and Traumatology, Hospital Lorenzo Bonomo, Andria 76123, Italy
| | - Enrico Restini
- Department of Surgery and Traumatology, Hospital Lorenzo Bonomo, Andria 76123, Italy
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Shim DJ, Kim SH, Kim IJ, Chun HJ, Kim D, Park C. Percutaneous stone removal using a compliant balloon after papillary balloon dilatation. MINIM INVASIV THER 2021; 31:603-608. [PMID: 33612051 DOI: 10.1080/13645706.2021.1879156] [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: 10/22/2022]
Abstract
PURPOSE To evaluate the safety and efficacy of percutaneous stone removal using a compliant balloon after papillary balloon dilatation. MATERIAL AND METHODS Between March 2014 and May 2020, 123 patients with choledocholithiasis, in whom endoscopy was unsuccessful, were enrolled in this study. The ampulla of Vater was dilated using a noncompliant balloon, and stone removal was attempted via a pushing maneuver using an endoscopic stone extraction balloon. Clinical and technical success rates, complications, and risk factors for failure and complications were evaluated. RESULTS Biliary stones were completely removed in 118 of 123 patients. Major complications occurred in five patients. One patient experienced duodenal bleeding, which was successfully treated by endoscopy. Hemobilia occurred in three patients, which required transfusion, and one patient experienced four days of abdominal pain. Minor complications, including self-limiting pain, effusion, minimal hemobilia, elevated amylase and fever, occurred in 21 patients. Stone size was the only significant risk factor associated with the rate of complications (Odds ratio: 1.14, 95% confidence interval = 1.04, 1.26). Bilirubin and white blood cell levels significantly decreased after the procedure. CONCLUSION Percutaneous stone removal using a compliant balloon after papillary balloon dilatation is a safe and effective method in patients in whom endoscopic or surgical treatment is not feasible. Abbreviations: ERCP: endoscopic retrograde cholangiopancreatography; PTBD: percutaneous transhepatic biliary drainage.
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Affiliation(s)
- Dong Jae Shim
- Department of Radiology, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Su Ho Kim
- Department of Radiology, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Il Jung Kim
- Department of Radiology, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ho Jong Chun
- Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Doyoung Kim
- Department of Radiology, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chanyeong Park
- Department of Radiology, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Routine intraoperative cholangiography during laparoscopic cholecystectomy: application of the 2016 WSES guidelines for predicting choledocholithiasis. Surg Endosc 2021; 36:461-467. [PMID: 33523267 PMCID: PMC8741698 DOI: 10.1007/s00464-021-08305-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 01/09/2021] [Indexed: 02/07/2023]
Abstract
Background Routine use of intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) for detecting common bile duct stones remains controversial. The 2016 World Society of Emergency Surgery (WSES) guidelines on acute calculous cholecystitis proposed a risk stratification for choledocholithiasis. Our present study aimed to (1) examine the findings of common bile duct (CBD) stones in patients underwent LC with routine use of IOC, and (2) validate the 2016 WSES risk classes for predicting choledocholithiasis. Methods All patients had LC with IOC routinely performed from November 2012 to December 2017 were reviewed retrospectively. Patients were classified into high-, intermediate-, and low-risk groups based on the 2016 WSES risk classes with modification. Results A total of 990 patients with LC and routine IOC were enrolled. CBD stones were detected in 197 (19.9%) patients. The rate of CBD stone detected in low-, intermediate-, high-risk groups were 0%, 14.2%, and 89.6%, respectively. Predictors as following: evidence of CBD stones on abdominal ultrasound or computed tomography, CBD diameter > 6 mm, total bilirubin > 4 mg/dL, bilirubin level = 1.8–4 mg/dL, abnormal liver biochemical test result other than bilirubin, presence of clinical gallstone pancreatitis had statistical significance between patients with and without CBD stones. Major bile duct injury was found in 4 patients (0.4%). All 4 patients had uneventful recovery after repair surgery. Conclusions Based on our study results, the 2016 WSES risk classes for choledocholithiasis could be an effective approach for predicting the risk of choledocholithiasis. Considering its advantages for detecting CBD stones and biliary injuries, the routine use of IOC is still suggested. Supplementary Information The online version contains supplementary material available at 10.1007/s00464-021-08305-4.
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Fuente I, Beskow A, Wright F, Uad P, de Santibañes M, Palavecino M, Sanchez-Claria R, Pekolj J, Mazza O. Laparoscopic transcystic common bile duct exploration as treatment for choledocholithiasis after Roux-en-Y gastric bypass. Surg Endosc 2021; 35:6913-6920. [PMID: 33398581 DOI: 10.1007/s00464-020-08201-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 11/19/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Treatment of choledocholithiasis after Roux-en-Y gastric bypass (RYGB) is a therapeutic challenge given the altered anatomy. To overcome this technical difficulty, different modified endoscopic approaches have been described but significant morbidity accompanies these procedures. The aim of the present study is to report our experience with laparoscopic transcystic common bile duct exploration (LTCBDE) as treatment of choledocholithiasis after RYGB. METHODS This is a retrospective cohort study of 854 consecutive patients with RYGB at a single institution between January 2007 and December 2019. Our study population focused on patients who developed biliary events after RYGB. Demographic data and perioperative parameters were compared between patients who underwent laparoscopic cholecystectomy (LC) after RYGB with (defined as Group A) and without (defined as Group B) LTCBDE. RESULTS Fifty-seven (8.93%) patients developed a biliary event after RYGB that led to LC. Of those, 11 (19.2%) presented choledocholithiasis during intraoperative cholangiogram and were simultaneously treated with LTCBDE (Group A). Choledocholithiasis was unsuspected in the preoperative setting in 7 (63.6%) of the 11 patients. The procedure was successful in 90.9% (n = 10). Comparing Group A and B, no statistically significant differences were found regarding age, gender, length of hospital stay, and morbidity (p > 0.05). Mean operative time of Group A was 113.1 min, adding, on average, 35 min to LC (113.1 min vs 77.9 min, p = 0.004). CONCLUSIONS LTCBDE offers an effective approach for common bile duct stones in patients who underwent RYGB. This procedure did not add significant length of hospital stay nor morbidity to laparoscopic cholecystectomy.
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Affiliation(s)
- Ignacio Fuente
- Bariatric Section, General Surgery Department, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1199ABD, Buenos Aires, Argentina.
| | - Axel Beskow
- Bariatric Section, General Surgery Department, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Fernando Wright
- Bariatric Section, General Surgery Department, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Pedro Uad
- Bariatric Section, General Surgery Department, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Martín de Santibañes
- HPB Section, General Surgery Department, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Martin Palavecino
- HPB Section, General Surgery Department, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Rodrigo Sanchez-Claria
- HPB Section, General Surgery Department, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Juan Pekolj
- HPB Section, General Surgery Department, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Oscar Mazza
- HPB Section, General Surgery Department, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1199ABD, Buenos Aires, Argentina
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Antegrade Therapy for Management of Choledocholithiasis through Endoscopic Ultrasound-Guided Hepaticogastrostomy in a Patient with Surgically Altered Gastrointestinal Anatomy. Case Rep Gastrointest Med 2020; 2020:8866899. [PMID: 33274087 PMCID: PMC7676982 DOI: 10.1155/2020/8866899] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 09/25/2020] [Accepted: 11/02/2020] [Indexed: 12/19/2022] Open
Abstract
Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HG) is a technique used to access the biliary tree in patients with surgically altered anatomy. Additionally, development of EUS-HG fistula permits intraductal therapy, thereby preventing patients from requiring surgery or percutaneous transhepatic biliary drainage (PTBD), thus decreasing morbidity. This clinical vignette describes an 83-year-old man with a history of gangrenous cholecystitis requiring cholecystectomy, partial gastrectomy, and Roux-en-Y gastrojejunostomy who presented to an outside hospital with abdominal pain and fever and found to have cholangitis and choledocholithiasis. He underwent two endoscopic retrograde cholangiopancreatography (ERCP) procedures at an outside hospital which were unsuccessful due to an inaccessible major papilla in the setting of the patient's surgically altered anatomy. On arrival to Wake Forest, the patient underwent EUS-HG with successful biliary drainage and resolution of cholangitis. He returned for ERCP three months later with balloon sphincteroplasty, cholangioscopy, and electrohydraulic lithotripsy (EHL) performed through the existing metal stent (hepaticogastrostomy), resulting in stone fragmentation and antegrade removal with balloon sweeps. Repeat cholangioscopy post-EHL and balloon sweeps showed complete duct clearance with no residual stones. The hepaticogastrostomy stent was subsequently removed, and the patient recovered without any complications.
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Bradley A, Sami S, Hemadasa N, Macleod A, Brown LR, Apollos J. Decision analysis of minimally invasive management options for cholecysto-choledocholithiasis. Surg Endosc 2020; 34:5211-5222. [PMID: 32710213 DOI: 10.1007/s00464-020-07816-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 07/10/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND The management of cholecysto-choledocholithiasis is controversial with the risks and benefits of one versus two-stage approaches debated. This study aims to perform decision analysis of minimally invasive laparo-endoscopic approaches. METHODS An advanced decision tree was constructed to compare pre, intra and post-operative ERCP and laparoscopic common bile duct exploration in terms of primary ductal clearance and significant complications for patients intended to undergo laparoscopic cholecystectomy. Transition probabilities were calculated from randomised controlled trials following a comprehensive literature search. Model uncertainties were extensively tested through deterministic and probabilistic Monte Carlo sensitivity analysis. Utility outcomes were 1 and 0.5 for successful primary clearance without and with complications, respectively, and 0 for failure of primary clearance of the duct. RESULTS Twenty-one studies (n = 2697) were included in the analysis. At base case analysis, a laparo-endoscopic rendezvous approach had the highest utility output (0.90; no complication probability: 0.87/complication probability 0.06). Laparoscopic common bile duct exploration was ranked second with a utility output 0.87 (no complication probability: 0.82/complication probability 0.10). Pre-operative ERCP utility score was 0.84 (no complication probability: 0.78/ complication probability 0.11) and post-operative ERCP utility score was 0.78 (no complication probability: 0.71/complication probability 0.13). Monte Carlo analysis showed that laparo-endoscopic rendezvous and laparoscopic common bile duct exploration had an equal mean utility output of 0.57 (standard deviation 0.36; variance 0.13; 95% confidence interval 0.00-0.99 versus standard deviation 0.34; variance 0.12; 95% confidence interval 0.01-0.98). Laparo-endoscopic rendezvous had a superior treatment selection frequency of 39.93% followed by laparoscopic bile duct exploration (36.11%), pre-operative ERCP (20.67%) and post-operative ERCP (2.99%). CONCLUSION One-stage approach to the management of cholecysto-choledocholithiasis is superior to two-stage, in terms of primary clearance of the duct and risk of operative morbidity. Laparo-endoscopic rendezvous approach could offer marginal additional benefit but more high-quality randomised controlled trials are needed.
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Affiliation(s)
- Alison Bradley
- Department of General Surgery, Dumfries and Galloway Royal Infirmary, Cargenbridge, Dumfries, DG2 8RX, Scotland, UK.
| | - Sharukh Sami
- Department of General Surgery, Dumfries and Galloway Royal Infirmary, Cargenbridge, Dumfries, DG2 8RX, Scotland, UK
| | - Niroshini Hemadasa
- Department of General Surgery, Dumfries and Galloway Royal Infirmary, Cargenbridge, Dumfries, DG2 8RX, Scotland, UK
| | - Anne Macleod
- Department of General Surgery, Dumfries and Galloway Royal Infirmary, Cargenbridge, Dumfries, DG2 8RX, Scotland, UK
| | - Leo R Brown
- Department of General Surgery, Dumfries and Galloway Royal Infirmary, Cargenbridge, Dumfries, DG2 8RX, Scotland, UK
| | - Jeyakumar Apollos
- Department of General Surgery, Dumfries and Galloway Royal Infirmary, Cargenbridge, Dumfries, DG2 8RX, Scotland, UK
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Liu S, Fang C, Tan J, Chen W. A Comparison of the Relative Safety and Efficacy of Laparoscopic Choledochotomy with Primary Closure and Endoscopic Treatment for Bile Duct Stones in Patients with Cholelithiasis. J Laparoendosc Adv Surg Tech A 2020; 30:742-748. [PMID: 32101065 DOI: 10.1089/lap.2019.0775] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Background: To date, several clinical trials have demonstated that both one-stage laparoscopic cholecystectomy (LC) combined with common bile duct exploration (LC+BDE) with primary closure and one-stage LC combined with endoscopic stone extraction (LC+ESE) are the two primary clinical approaches to treat cholelithiasis. However, no studies to date have directly compared the LC+BDE with primary closure and one-stage LC+ESE procedures. We, therefore, conducted a retrospective analysis of patients with cholelithiasis who had been treated through LC+ESE or LC+BDE to compare these two approaches for the treatment of cholecystitis and common bile duct stones (CCBDS). Methods: Consecutive CCBDS patients with cholelithiasis in our hospital who were diagnosed through Media Resource Control Protocol (MRCP) and ultrasound between June 2010 and February 2017 were randomly assigned to undergo either LC+ESE or LC+BDE, as both procedures are routinely used to treat cholelithiasis in our hospital. All patients were made aware of the risks and benefits of the surgery preoperatively, and this study was approved by the ethics committee of our institute. Outcomes in these two groups, including rates of success and reasons for operative failure, were then compared, as were data pertaining to patient demographics, clinical findings, postoperative stay duration, and medical expenses. In addition, biliary reflux as measured through computed tomography or gastrointestinal imaging was monitored for a minimum of 2 years. Results: In total, 207 CCBDS patients were identified during the study period and were randomized into the LC+ESE (n = 103) or LC+BDE (n = 104) treatment groups. We found that patients treated through LC+BDE achieved a significantly higher success rate than that achieved in patients treated through LC+ESE (93.3% versus 82.5%; P < .05). Specifically, the LC+BDE with primary closure procedure failed in patients with impacted stones located at the end of the common bile duct (CBD) and in those with stenosis of the sphincter of Oddi. The only variable that differed significantly between these two treatment groups was stone location. Variables other than stone location, CBD size, and stone size did not differ significantly between the two groups. However, the LC+BDE treatment was associated with significant reductions in patient operating time, morbidity, hospital day duration, and biliary reflux of duodenal contents relative to the LC+ESE treatment. Conclusions: We found that LC+BDE with primary closure was a safer and more effective means of treated CCBDS patients than was the LC+ESE procedure and that it was not associated with risks of sphincterotomy of duodenal papilla (EST)- or T-tube-related complications. However, our data also clearly indicate that LC+BDE cannot replace LC+ESE in all patients, and that as such both approaches should be considered as being complementary to one another, with their relative advantages in a given patient being defined based upon local resource availability and expertise. In addition, when the LC+ESE procedure fails then the LC+BDE treatment can be safely employed as a salvage approach.
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Affiliation(s)
- Shuang Liu
- Graduate Department of Shanxi Medical University, Taiyuan, China
| | - Changzhong Fang
- Department of General Surgery, The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - JingWang Tan
- Department of General Surgery, Chinese PLA General Hospital, Beijing, China
| | - Wenliang Chen
- Department of General Surgery, The Second Affiliated Hospital of Shanxi Medical University, Taiyuan, China
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15
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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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16
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Zhou H, Wang S, Fan F, Peng J. Primary closure with knotless barbed suture versus traditional T-tube drainage after laparoscopic common bile duct exploration: a single-center medium-term experience. J Int Med Res 2019; 48:300060519878087. [PMID: 31612768 PMCID: PMC7262853 DOI: 10.1177/0300060519878087] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Objective Primary closure of the common bile duct (CBD) after laparoscopic CBD exploration (LCBDE) is a technical challenge. The present study was performed to evaluate the safety and effectiveness of this surgical method. Methods This retrospective study of surgical efficacy and safety involved 79 patients who underwent primary CBD closure with a knotless unidirectional barbed suture or traditional T-tube drainage after LCBDE for CBD stones. Results The average suturing time, operation time, and postoperative hospital stay were significantly shorter in the primary closure group than T-tube group. There were no significant differences in the mean diameter of the CBD, number of stones, or incidence of postoperative complications between the two groups. No patients developed recurrence of CBD stones during the median follow-up of 21.5 months. Conclusions After LCBDE and intraoperative choledochoscopy, primary closure with knotless unidirectional barbed sutures is a safe and effective therapeutic option for patients with cholelithiasis and concurrent CBD stones. This is especially true when the CBD is dilated more than 8 mm.
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Affiliation(s)
- Huijiang Zhou
- Department of General Surgery, the Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu, Zhejiang, China.,Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Shuai Wang
- Department of General Surgery, the Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu, Zhejiang, China
| | - Fuxiang Fan
- Department of General Surgery, the Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu, Zhejiang, China
| | - Jingfeng Peng
- Department of General Surgery, the Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu, Zhejiang, China
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Czerwonko ME, Pekolj J, Uad P, Mazza O, Sanchez-Claria R, Arbues G, de Santibañes E, de Santibañes M, Palavecino M. Laparoscopic Transcystic Common Bile Duct Exploration in the Emergency Is as Effective and Safe as in Elective Setting. J Gastrointest Surg 2019; 23:1848-1855. [PMID: 30421117 DOI: 10.1007/s11605-018-4029-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 10/22/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Emergent laparoscopic transcystic common bile duct exploration (LTCBDE) has been reported to be on the increase in some institutions, reflecting the growing confidence with the technique. However, no study has focused on the outcomes of LTCBDE in the non-elective setting. The aim of this study is to investigate whether LTCBDE can be performed effectively and safely in the emergency. METHODS This is a retrospective study of 500 consecutive patients with choledocholithiasis subjected for LTCBDE at the Hospital Italiano de Buenos Aires from January 2009 to January 2018. Procedures were classified according to the setting as emergent or elective. Demographic data and perioperative parameters were compared between groups. RESULTS Throughout the period comprised, 500 patients were admitted for choledocholithiasis and gallstones. A single-step treatment combining LTCBDE and laparoscopic cholecystectomy was attempted: 211 (42.2%) were performed electively and the 289 (57.8%) as an emergency. There was no significant difference in the success rate of LTCBDE (93.9% versus 93.8%, p = 0.975) for the two groups. The operative time was slightly longer in the emergency group (122 ± 63 versus 106 ± 53 min, p = 0.002). Postoperative recovery was slower in the emergency group, as reflected by a higher rate of prolonged postoperative stay (21.1% vs 5.7%, p < .001). The rates of postoperative complications were similar between groups (2.8% vs 5.9%, p = 0.109). CONCLUSION Emergent LTCBDE can be performed with equivalent efficacy and morbidity when compared to an elective procedure. Patients undergoing emergent procedures have longer procedures and hospital stays.
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Affiliation(s)
- Matias E Czerwonko
- Department of General Surgery, Division of HPB Surgery, Hospital Italiano de Buenos Aires, Juan D. Peron 4190, C1181ACH, Buenos Aires, Argentina
| | - Juan Pekolj
- Department of General Surgery, Division of HPB Surgery, Hospital Italiano de Buenos Aires, Juan D. Peron 4190, C1181ACH, Buenos Aires, Argentina
| | - Pedro Uad
- Department of General Surgery, Division of HPB Surgery, Hospital Italiano de Buenos Aires, Juan D. Peron 4190, C1181ACH, Buenos Aires, Argentina
| | - Oscar Mazza
- Department of General Surgery, Division of HPB Surgery, Hospital Italiano de Buenos Aires, Juan D. Peron 4190, C1181ACH, Buenos Aires, Argentina
| | - Rodrigo Sanchez-Claria
- Department of General Surgery, Division of HPB Surgery, Hospital Italiano de Buenos Aires, Juan D. Peron 4190, C1181ACH, Buenos Aires, Argentina
| | - Guillermo Arbues
- Department of General Surgery, Division of HPB Surgery, Hospital Italiano de Buenos Aires, Juan D. Peron 4190, C1181ACH, Buenos Aires, Argentina
| | - Eduardo de Santibañes
- Department of General Surgery, Division of HPB Surgery, Hospital Italiano de Buenos Aires, Juan D. Peron 4190, C1181ACH, Buenos Aires, Argentina
| | - Martín de Santibañes
- Department of General Surgery, Division of HPB Surgery, Hospital Italiano de Buenos Aires, Juan D. Peron 4190, C1181ACH, Buenos Aires, Argentina
| | - Martín Palavecino
- Department of General Surgery, Division of HPB Surgery, Hospital Italiano de Buenos Aires, Juan D. Peron 4190, C1181ACH, Buenos Aires, Argentina.
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Parra-Membrives P, Martínez-Baena D, Lorente-Herce JM, Jiménez-Riera G, Sánchez-Gálvez MÁ. Choledocholithiasis recurrence following laparoscopic common bile duct exploration. Cir Esp 2019; 97:336-342. [PMID: 31027833 DOI: 10.1016/j.ciresp.2019.02.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 02/16/2019] [Accepted: 02/19/2019] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Choledocholithiasis may be treated following an endoscopic approach or by laparoscopic common bile duct exploration (LCBDE). Stone recurrence following endoscopic management has been extensively investigated. We analyze the risk factors associated with stone recurrence following LCBDE. METHODS Patients who underwent LCBDE from February 2004 to July 2016 were examined in an univariate and multivariate analysis to assess the association of stone recurrence with the following variables: gender; age; hepatopathy; dyslipidemia, obesity or diabetes mellitus; previous abdominal surgery; presence of cholecystitis, cholangitis or pancreatitis; preoperative liver function tests, number of retrieved stones; method of common bile duct clearance and closure; presence of impacted or intrahepatic stones; conversion to open surgery and postoperative morbidity. RESULTS A total of 156 patients were included. Recurrence rate for choledocholithiasis was 14.1% with a mean time to recurrence of 38.18 month. Age was the only independent risk factor for stone recurrence at univariate and multivariate analysis. No patient aged under 55 years developed new common bile duct stones, and 86.4% of the recurrences occurred in patients aged above 65. CONCLUSIONS Age is the only independent risk factor associated to choledocholithiasis recurrence following LCBDE. Different mechanism in common bile duct stone development may be present for younger and older patients.
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Affiliation(s)
- Pablo Parra-Membrives
- Departamento de Cirugía, Universidad de Sevilla, España; Unidad de Cirugía Hepatobiliar y Pancreática, Servicio de Cirugía General y Digestiva, Hospital Universitario de Valme, Sevilla, España.
| | - Darío Martínez-Baena
- Unidad de Cirugía Hepatobiliar y Pancreática, Servicio de Cirugía General y Digestiva, Hospital Universitario de Valme, Sevilla, España
| | - José Manuel Lorente-Herce
- Unidad de Cirugía Hepatobiliar y Pancreática, Servicio de Cirugía General y Digestiva, Hospital Universitario de Valme, Sevilla, España
| | - Granada Jiménez-Riera
- Departamento de Cirugía, Universidad de Sevilla, España; Unidad de Cirugía Hepatobiliar y Pancreática, Servicio de Cirugía General y Digestiva, Hospital Universitario de Valme, Sevilla, España
| | - María Ángeles Sánchez-Gálvez
- Unidad de Cirugía Hepatobiliar y Pancreática, Servicio de Cirugía General y Digestiva, Hospital Universitario de Valme, Sevilla, España
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Laparoscopic common bile duct exploration plus cholecystectomy versus endoscopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy for cholecystocholedocholithiasis: a meta-analysis. Surg Endosc 2018; 33:3275-3286. [PMID: 30511313 DOI: 10.1007/s00464-018-06613-w] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Accepted: 11/26/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND The purpose of the study was to compare the safety and effectiveness of laparoscopic common bile duct exploration plus laparoscopic cholecystectomy (LCBDE+LC) with preoperative endoscopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy (pre-ERCP+LC) for cholecystocholedocholithiasis. METHODS An electronic search was performed using the following databases: PubMed, Embase, Web of Science, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov until 1 July 2018. Randomized controlled trials (RCTs) comparing LCBDE+LC versus pre-ERCP+LC were included. The common bile duct (CBD) stone clearance rate, postoperative bile leakage, postoperative pancreatitis, morbidity, mortality, and overall hospital stay were analyzed. RESULTS Twelve RCTs involving 1545 patients were included in this meta-analysis. Of the 12 RCTs, seven confirmed and five did not confirm CBD stones preoperatively. The meta-analysis showed a significantly higher CBD stone clearance rate for pre-ERCP+LC than LCBDE+LC. A similar result was found in the subgroup analysis of patients with confirmed CBD stones. A significantly lower postoperative bile leakage rate was found for pre-ERCP+LC than LCBDE+LC in all 12 RCTs and in the subgroup of patients with confirmed CBD stones. However, a significantly higher rate of pancreatitis was found in pre-ERCP+LC and in the subgroup of patients with confirmed CBD stones. LCBDE+LC was superior to pre-ERCP+LC in terms of the overall hospital stay. No significant differences were found in morbidity or mortality. CONCLUSIONS Pre-ERCP+LC is associated with a higher CBD stone clearance rate, lower postoperative bile leakage rate, and higher rate of pancreatitis. LCBDE+LC might help to shorten the hospital stay. Further studies on this topic are recommended.
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Czerwonko ME, Pekolj J, Uad P, Mazza O, Sanchez-Claria R, Arbues G, de Santibañes E, de Santibañes M, Palavecino M. Acute Pancreatitis After Laparoscopic Transcystic Common Bile Duct Exploration: An Analysis of Predisposing Factors in 447 Patients. World J Surg 2018; 42:3134-3142. [PMID: 29616319 DOI: 10.1007/s00268-018-4611-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION In laparoscopic transcystic common bile duct exploration (LTCBDE), the risk of acute pancreatitis (AP) is well recognized. The present study assesses the incidence, risk factors, and clinical impact of AP in patients with choledocholithiasis treated with LTCBDE. METHODS A retrospective database was completed including patients who underwent LTCBDE between 2007 and 2017. Univariate and multivariate analyses were performed by logistic regression. RESULTS After exclusion criteria, 447 patients were identified. There were 70 patients (15.7%) who showed post-procedure hyperamylasemia, including 20 patients (4.5%) who developed post-LTCBDE AP. Of these, 19 were edematous and one was a necrotizing pancreatitis. Patients with post-LTCBDE AP were statistically more likely to have leukocytosis (p < 0.004) and jaundice (p = 0.019) before surgery and longer operative times (OT, p < 0.001); they were less likely to have incidental intraoperative diagnosis (p = 0.031) or to have biliary colic as the reason for surgery (p = 0.031). In the final multivariate model, leukocytosis (p = 0.013) and OT (p < 0.001) remained significant predictors for AP. Mean postoperative hospital stay (HS) was significantly longer in AP group (p < 0.001). CONCLUSION The risk of AP is moderate and should be considered in patients with preoperative leukocytosis and jaundice and exposed to longer OT. AP has a strong impact on postoperative HS.
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Affiliation(s)
- Matias E Czerwonko
- Department of General Surgery, Division of HPB Surgery, Hospital Italiano de Buenos Aires, Juan D. Peron 4190, C1181ACH, Buenos Aires, Argentina
| | - Juan Pekolj
- Department of General Surgery, Division of HPB Surgery, Hospital Italiano de Buenos Aires, Juan D. Peron 4190, C1181ACH, Buenos Aires, Argentina
| | - Pedro Uad
- Department of General Surgery, Division of HPB Surgery, Hospital Italiano de Buenos Aires, Juan D. Peron 4190, C1181ACH, Buenos Aires, Argentina
| | - Oscar Mazza
- Department of General Surgery, Division of HPB Surgery, Hospital Italiano de Buenos Aires, Juan D. Peron 4190, C1181ACH, Buenos Aires, Argentina
| | - Rodrigo Sanchez-Claria
- Department of General Surgery, Division of HPB Surgery, Hospital Italiano de Buenos Aires, Juan D. Peron 4190, C1181ACH, Buenos Aires, Argentina
| | - Guillermo Arbues
- Department of General Surgery, Division of HPB Surgery, Hospital Italiano de Buenos Aires, Juan D. Peron 4190, C1181ACH, Buenos Aires, Argentina
| | - Eduardo de Santibañes
- Department of General Surgery, Division of HPB Surgery, Hospital Italiano de Buenos Aires, Juan D. Peron 4190, C1181ACH, Buenos Aires, Argentina
| | - Martín de Santibañes
- Department of General Surgery, Division of HPB Surgery, Hospital Italiano de Buenos Aires, Juan D. Peron 4190, C1181ACH, Buenos Aires, Argentina
| | - Martín Palavecino
- Department of General Surgery, Division of HPB Surgery, Hospital Italiano de Buenos Aires, Juan D. Peron 4190, C1181ACH, Buenos Aires, Argentina.
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Comparing a single-staged laparoscopic cholecystectomy with common bile duct exploration versus a two-staged endoscopic sphincterotomy followed by laparoscopic cholecystectomy. Surgery 2018; 164:1030-1034. [PMID: 30054013 DOI: 10.1016/j.surg.2018.05.052] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 05/09/2018] [Accepted: 05/13/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND With the advent of minimally invasive surgery, the limits of surgery have been stretched by questioning the more usual, established 2-stage approach for choledocholithiasis with an initial endoscopic retrograde cholangiography and endoscopic biliary sphincterotomy followed by laparoscopic cholecystectomy in favor of the single-stage laparoscopic common bile duct exploration with laparoscopic cholecystectomy. The aim of this study was to compare the related benefits, difficulties, and outcomes of these 2 methods at a single institution. METHODS A retrospective analysis of 128 patients satisfying the inclusion criteria was divided into 2 groups (n = 68 for the group with laparoscopic common bile duct exploration with laparoscopic cholecystectomy and n = 60 for the group with endoscopic retrograde cholangiography/laparoscopic cholecystectomy) between 2014 and 2017. Patient data including age, sex, duration of the operation, intraoperative and postoperative complications, and duration of hospital stay were reviewed. RESULTS The group with laparoscopic common bile duct exploration with laparoscopic cholecystectomy had 24 men and 44 women (mean age 52 years), and the group with endoscopic retrograde cholangiography/laparoscopic cholecystectomy had 16 men and 44 women (mean age 47 years). Statistically significant results were found in the clearance range (100% in the group with laparoscopic common bile duct exploration with laparoscopic cholecystectomy versus 75% in the group with endoscopic retrograde cholangiography/laparoscopic cholecystectomy), a shorter total duration of hospitalization for the group with laparoscopic common bile duct exploration with laparoscopic cholecystectomy (4.1 days vs 8.4 days) (P < .05), but a great incidence of biliary leakage in the group with laparoscopic common bile duct exploration with laparoscopic cholecystectomy. Duration of surgery was not different between the 2 groups. CONCLUSION Laparoscopic common bile duct exploration with laparoscopic cholecystectomy is a single-stage procedure that has many advantages over endoscopic retrograde cholangiography/laparoscopic cholecystectomy if appropriate experience and when expertise is available.
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22
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Laparoscopic Common Bile Duct Exploration for Choledocholithiasis: Analysis of Practice Patterns of Intermountain HealthCare. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.02.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Parra-Membrives P, Martínez-Baena D, Lorente-Herce JM, Martín-Balbuena R. Efficacy of fibrin-sealants in reducing biliary leakage following laparoscopic common bile duct exploration. Cir Esp 2018; 96:429-435. [PMID: 29793695 DOI: 10.1016/j.ciresp.2018.03.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 03/28/2018] [Accepted: 03/29/2018] [Indexed: 12/27/2022]
Abstract
INTRODUCTION In spite of the acquired experience with laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis management, there is still a risk of biliary leakage of 5% to 15% following choledochotomy closure. We evaluate the usefulness of fibrin-collagen sealants to reduce the incidence of biliary fistula after laparoscopic choledochorrhaphy. METHODS We report a retrospective analysis of 96 patients undergoing LCBDE from March 2009 to March 2017, whose closure of the bile duct was completed by antegrade stenting and choledochorraphy or by performing a primary suture. The study population was divided into two groups according to whether they received a collagen-fibrin sealant covering the choledochorrhaphy or not, analyzing the incidence of postoperative biliary fistula in each group. RESULTS Thirty-nine patients (41%) received a fibrin-collagen sponge while the bile duct closure was not covered in the remaining 57 patients (59%). The incidence of biliary fistula was 7.7% (3 patients) in the first group and 14% (8 patients) in the second group (P=.338). In patients who underwent primary choledochorraphy, the fibrin-collagen sealant reduced the incidence of biliary leakage significantly (4.5% vs. 33%, P=.020), which was a protective factor with an odds ratio of 10.5. CONCLUSION Fibrin-collagen sealants may decrease the incidence of biliary fistula in patients who have undergone primary bile duct closure following LCBDE.
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Affiliation(s)
- Pablo Parra-Membrives
- Departamento de Cirugía, Facultad de Medicina, Universidad de Sevilla, Sevilla, España; Unidad de Cirugía Hepatobiliar y Pancreática, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Valme, Sevilla, España.
| | - Darío Martínez-Baena
- Unidad de Cirugía Hepatobiliar y Pancreática, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Valme, Sevilla, España
| | - José Manuel Lorente-Herce
- Unidad de Cirugía Hepatobiliar y Pancreática, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Valme, Sevilla, España
| | - Ramón Martín-Balbuena
- Unidad de Cirugía Hepatobiliar y Pancreática, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Valme, Sevilla, España
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Ryozawa S, Itoi T, Katanuma A, Okabe Y, Kato H, Horaguchi J, Fujita N, Yasuda K, Tsuyuguchi T, Fujimoto K. Japan Gastroenterological Endoscopy Society guidelines for endoscopic sphincterotomy. Dig Endosc 2018; 30:149-173. [PMID: 29247546 DOI: 10.1111/den.13001] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 12/10/2017] [Indexed: 02/06/2023]
Abstract
The Japan Gastroenterological Endoscopy Society (JGES) has recently compiled guidelines for endoscopic sphincterotomy (EST) using evidence-based methods. Content regarding actual clinical practice, including detailed endoscopic procedures, instruments, device types and usage, has already been published by the JGES postgraduate education committee in May 2015 and, thus, in these guidelines we avoided duplicating such content as much as possible. The guidelines do not address pancreatic sphincterotomy, endoscopic papillary balloon dilation (EPBD), and endoscopic papillary large balloon dilation (EPLBD). The guidelines for EPLBD are planned to be developed separately. The evidence level in this field is often low and, in many instances, strong recommendation has to be determined on the basis of expert consensus. At this point in time, the guidelines are divided into six items including indications, techniques, specific cases, adverse events, outcomes, and postoperative follow up.
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Affiliation(s)
- Shomei Ryozawa
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Takao Itoi
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Akio Katanuma
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Hironari Kato
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Jun Horaguchi
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Naotaka Fujita
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Kenjiro Yasuda
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
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Tarantino G, Magistri P, Ballarin R, Assirati G, Di Cataldo A, Di Benedetto F. Surgery in biliary lithiasis: from the traditional "open" approach to laparoscopy and the "rendezvous" technique. Hepatobiliary Pancreat Dis Int 2017; 16:595-601. [PMID: 29291778 DOI: 10.1016/s1499-3872(17)60031-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Accepted: 12/16/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND According to the current literature, biliary lithiasis is a worldwide-diffused condition that affects almost 20% of the general population. The rate of common bile duct stones (CBDS) in patients with symptomatic cholelithiasis is estimated to be 10% to 33%, depending on patient's age. Compared to stones in the gallbladder, the natural history of secondary CBDS is still not completely understood. It is not clear whether an asymptomatic choledocholithiasis requires treatment or not. For many years, open cholecystectomy with choledochotomy and/or surgical sphincterotomy and cleaning of the bile duct were the gold standard to treat both pathologies. Development of both endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic surgery, together with improvements in diagnostic procedures, influenced new approaches to the management of CBDS in association with gallstones. DATA SOURCES We decided to systematically review the literature in order to identify all the current therapeutic options for CBDS. A systematic literature search was performed independently by two authors using PubMed, EMBASE, Scopus and the Cochrane Library Central. RESULTS The therapeutic approach nowadays varies greatly according to the availability of experience and expertise in each center, and includes open or laparoscopic common bile duct exploration, various combinations of laparoscopic cholecystectomy and ERCP and combined laparoendoscopic rendezvous. CONCLUSIONS Although ERCP followed by laparoscopic cholecystectomy is currently preferred in the majority of hospitals worldwide, the optimal treatment for concomitant gallstones and CBDS is still under debate, and greatly varies among different centers.
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Affiliation(s)
- Giuseppe Tarantino
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, 41124 Modena, Italy.
| | - Paolo Magistri
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, 41124 Modena, Italy; Department of General Surgery, Sapienza-University of Rome, 00189 Rome, Italy
| | - Roberto Ballarin
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Giacomo Assirati
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Antonio Di Cataldo
- Department of Surgical Sciences, Organ Transplantation and Advanced Technologies, University of Catania, 95124 Catania, Italy
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, 41124 Modena, Italy
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Parra-Membrives P, Martínez-Baena D, Lorente-Herce J, Jiménez-Riera G. Comparative Study of Three Bile Duct Closure Methods Following Laparoscopic Common Bile Duct Exploration for Choledocholithiasis. J Laparoendosc Adv Surg Tech A 2017; 28:145-151. [PMID: 28976804 DOI: 10.1089/lap.2017.0433] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND There are three choledochotomy closure methods available following laparoscopic common bile duct exploration: T-tube insertion, antegrade stenting, and primary choledochorrhaphy. We reviewed the experience of 12 years at our center searching for the optimal closure technique. METHODS We analyzed retrospectively 146 patients that underwent one of the three closure methods from February 2004 to March 2016. Hospital stay, need for readmission, incidence of early and long-term complications, and biliary leakage development and their clinical impact were determined for each technique. RESULTS Hospital stay was more prolonged, and need for readmission was higher in the T-tube group. Nine patients of the T-tube group (17.3%), 5 patients (8.6%) of the antegrade stenting group, and 1 patient of the primary suture group (2.8%) developed Dindo-Clavien ≥3 complications (P = .076). The incidence of biliary leakage was 3.8%, 8.6%, and 16.7% for the T-tube group, antegrade stenting group, and primary suture group, respectively. There was no grade C biliary fistula in the primary suture group, and all grade B leaks in these patients were only due to prolonged duration. The T-tube removal caused adverse events in 21.1% of the patients, and complications directly related with stents occurred in 9.6%. CONCLUSION Antegrade stents or T-tube insertion do not provide any added value for choledochotomy closure but are charged with specific morbidity. On the contrary, despite biliary leaks being more frequent after primary suture, they are of little clinical consequence and may be managed on an outpatient basis.
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Affiliation(s)
- Pablo Parra-Membrives
- 1 Department of Surgery, University of Seville , Sevilla, Spain .,2 Hepatobiliary and Pancreatic Surgery Unit, General and Digestive Surgery Department, Valme University Hospital , Sevilla, Spain
| | - Darío Martínez-Baena
- 2 Hepatobiliary and Pancreatic Surgery Unit, General and Digestive Surgery Department, Valme University Hospital , Sevilla, Spain
| | - José Lorente-Herce
- 2 Hepatobiliary and Pancreatic Surgery Unit, General and Digestive Surgery Department, Valme University Hospital , Sevilla, Spain
| | - Granada Jiménez-Riera
- 2 Hepatobiliary and Pancreatic Surgery Unit, General and Digestive Surgery Department, Valme University Hospital , Sevilla, Spain
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How can recovery be enhanced after single-stage laparoscopic management of CBD stones? Endoscopic treatment versus laparoscopic surgery. Dig Liver Dis 2017; 49:773-779. [PMID: 28389089 DOI: 10.1016/j.dld.2017.02.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 02/16/2017] [Accepted: 02/20/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Single-stage management of CBD stones comprises simultaneous common bile duct (CBD) clearance and cholecystectomy. The CBD can be cleared by using endoscopic treatment (ET) or laparoscopic surgery (LS) alone. AIMS To determine the most rapid recovery after the single-stage laparoscopic management of CBD stones. METHODS Patients with CBD stones treated at either of two centers (one performing ET only and one performing LS only for single-stage treatment) were included. The primary endpoint was "the textbook outcome". RESULTS The feasibility rate was 74% for ET and 100% for LS (p≤0.001). The proportion of cases with the textbook outcome was higher in the ET group than in the LS-only group (73% vs. 10%; p<0.001). The CBD clearance rate was similar in the ET and LS-only groups (100% vs. 96.6%, respectively; p=0.17). The overall morbidity rate was lower in the ET group than in the LS-only group (23% vs. 29%, p=0.05). CONCLUSION AND RELEVANCE Both ET and LS are feasible, safe and effective for clearance of the CBD. ET was better than LS in terms of a less frequent requirement for drainage and a shorter length of hospital stay. LS was associated with a shorter operating time.
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Evidence-based clinical practice guidelines for cholelithiasis 2016. J Gastroenterol 2017; 52:276-300. [PMID: 27942871 DOI: 10.1007/s00535-016-1289-7] [Citation(s) in RCA: 149] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Accepted: 11/14/2016] [Indexed: 02/08/2023]
Abstract
Cholelithiasis is one of the commonest diseases in gastroenterology. Remarkable improvements in therapeutic modalities for cholelithiasis and its complications are evident. The Japanese Society of Gastroenterology has revised the evidence-based clinical practice guidelines for cholelithiasis. Forty-three clinical questions, for four categories-epidemiology and pathogenesis, diagnosis, treatments, and prognosis and complications-were selected, and a literature search was performed for the clinical questions with use of the MEDLINE, Cochrane, and Igaku Chuo Zasshi databases for the period between 1983 and June 2012. The guidelines were developed with use of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. This article preferentially describes the clinical management of cholelithiasis and its complications. Following description of the diagnosis performed stepwise through imaging modalities, treatments of cholecystolithiasis, choledocholithiasis, and hepatolithiasis are introduced along with a flowchart. Since there have been remarkable improvements in endoscopic treatments and surgical techniques, the guidelines ensure flexibility in choices according to the actual clinical environment. The revised clinical practice guidelines are appropriate for use by clinicians in their daily practice.
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Ronnekleiv-Kelly SM, Cho CS. Bile duct exploration and biliary-enteric anastomosis. BLUMGART'S SURGERY OF THE LIVER, BILIARY TRACT AND PANCREAS, 2-VOLUME SET 2017:537-548.e1. [DOI: 10.1016/b978-0-323-34062-5.00031-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Garbarini A, Reggio D, Arolfo S, Bruno M, Passera R, Catalano G, Barletti C, Salizzoni M, Morino M, Petruzzelli L, Arezzo A. Cost analysis of laparoendoscopic rendezvous versus preoperative ERCP and laparoscopic cholecystectomy in the management of cholecystocholedocholithiasis. Surg Endosc 2016; 31:3291-3296. [DOI: 10.1007/s00464-016-5361-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Accepted: 11/13/2016] [Indexed: 01/15/2023]
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Barreras González JE, Torres Peña R, Ruiz Torres J, Martínez Alfonso MÁ, Brizuela Quintanilla R, Morera Pérez M. Endoscopic versus laparoscopic treatment for choledocholithiasis: a prospective randomized controlled trial. Endosc Int Open 2016; 4:E1188-E1193. [PMID: 27857966 PMCID: PMC5111834 DOI: 10.1055/s-0042-116144] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and study aims: Overall, 5 % to 15 % of patients undergoing cholecystectomy for cholelithiasis have concomitant bile duct stones, and the incidence of choledocholithiasis increases with age. There is no clear consensus on the best therapeutic approach (endoscopic versus surgical). Patients and methods: A prospective randomized controlled clinical trial was performed to compare three treatment options for patients with choledocholithiasis at the National Center for Minimally Invasive Surgery in Havana, Cuba from November 2007 to November 2011. The patients were randomized in three groups. Group I: patients who underwent intraoperative cholangiography (IOC) to confirm the choledocholithiasis followed by laparoscopic cholecystectomy (LC) associated with intraoperative endoscopic retrograde cholangiopancreatography (ERCP), group II: patients who underwent preoperative ERCP followed by LC during the same hospital admission and group III: patients who underwent IOC to confirm the choledocholithiasis followed by LC associated with laparoscopic common bile duct exploration (LCBDE). Results: A total of 300 patients with suspected choledocholithiasis were included in the trial and were randomized. As a result, a total of 134 patients were diagnosed with the presence of choledocholithiasis and treated during the study period. There were no significant differences in success rates of ductal stone clearance, but retained stone, postoperative complications and length of hospital stay were better in group I. Conclusions: Intraoperative ERCP/ES shows a higher rate of common bile duct stones clearance, a shorter hospital stay, and lower morbidity, but further research with a larger study population is necessary to determine the additional benefits of this procedure. The results to date suggests that in appropriate patients, single-stage treatments are the best options.
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Affiliation(s)
- Javier Ernesto Barreras González
- Department of Laparoscopic and Endoscopic Surgery, National Center for
Minimally Invasive Surgery, Havana Medical University, Havana, Cuba.,Corresponding author Javier Ernesto Barreras González, MD, PhD Department of Laparoscopic and Endoscopic SurgeryNational Center for Minimally Invasive SurgeryPárraga Street b/ San Mariano and Vista AlegreLa Víbora10 de OctubreHavanaCuba+537-649-0150
| | - Rafael Torres Peña
- Department of Laparoscopic and Endoscopic Surgery, National Center for
Minimally Invasive Surgery, Havana Medical University, Havana, Cuba.
| | - Julián Ruiz Torres
- Department of Laparoscopic and Endoscopic Surgery, National Center for
Minimally Invasive Surgery, Havana Medical University, Havana, Cuba.
| | - Miguel Ángel Martínez Alfonso
- Department of Laparoscopic and Endoscopic Surgery, National Center for
Minimally Invasive Surgery, Havana Medical University, Havana, Cuba.
| | - Raúl Brizuela Quintanilla
- Department of Laparoscopic and Endoscopic Surgery, National Center for
Minimally Invasive Surgery, Havana Medical University, Havana, Cuba.
| | - Maricela Morera Pérez
- Department of Laparoscopic and Endoscopic Surgery, National Center for
Minimally Invasive Surgery, Havana Medical University, Havana, Cuba.
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Di Mitri R, Mocciaro F, Pallio S, Pecoraro GM, Tortora A, Zulli C, Attardo S, Maurano A. Efficacy and safety of endoscopic papillary balloon dilation for the removal of bile duct stones: Data from a "real-life" multicenter study on Dilation-Assisted Stone Extraction. World J Gastrointest Endosc 2016; 8:646-652. [PMID: 27803771 PMCID: PMC5067471 DOI: 10.4253/wjge.v8.i18.646] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 08/24/2016] [Accepted: 09/07/2016] [Indexed: 02/05/2023] Open
Abstract
AIM To report data on Dilation-Assisted Stone Extraction (DASE) use in clinical practice and its efficacy and safety trough three Italian referral centers for biliopancreatic diseases treatment. METHODS From January 2011 to December 2015 we collected data on 120 patients treated with DASE. Technical success was obtained when the endoscopist was able to place the balloon trough the papilla inflating the balloon until the final diameter for an adequate time (at least 30 s). Clinical success was obtained after complete stone removal (no remaining stones were visible at the cholangiogram). RESULTS Forty-nine male (40.8%) and 71 female (59%) were enrolled. The mean age was 67.8 years ± 15.7. The mean common bile duct (CBD) dilation was 19.2 mm ± 3.9 and the mean size of stones 15.8 ± 2.9. DASE was applied as first approach in 38% (62% after initial failure of stones extraction). Technical and clinical success was of 91% and 87% respectively. In those in which DASE failed alternative treatment were adopted. After DASE 18% of patients experienced a complication (bleeding 9%, pancreatitis 8%, perforation 0.8%). At univariable analysis, elective endoscopic retrograde cholangiopancreatography (P = 0.031), DASE as first approach (P = 0.032), and cannulation of major papilla followed by guidewire insertion (P = 0.004) were related to low risk of complications. Pre-cut was related to an increased risk of complications (P = 0.01). CONCLUSION DASE allowed a higher first-session success rate and can be consider a valid alternative to endoscopic sphincterotomy not only for bigger CBD stones.
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Zhu JG, Guo W, Han W, Zhang ZT. Laparoscopic Transcystic Common Bile Duct Exploration in the Elderly is as Effective and Safe as in Younger Patients. J Laparoendosc Adv Surg Tech A 2016; 27:48-52. [PMID: 27672728 DOI: 10.1089/lap.2016.0116] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Choledocholithiasis represents a greater proportion of gallstone in the elderly. Elderly patients have more comorbidity, which could increase the operative risk and postoperative complications. However, no study has focused on the effect and safety of laparoscopic transcystic common bile duct exploration (LTCBDE) in elderly patients. The aim of this study was to investigate whether LTCBDE can be performed effectively and safely in elderly patients. METHODS This is a retrospective study of patients who underwent LTCBDE for choledocholithiasis performed from January 2010 to December 2012. Patients of age 70 or older were included in the elderly group. The rest integrated the younger group. Demographic data and perioperative parameters were compared between groups. RESULTS From January 2010 to December 2012, 171 patients admitted for choledocholithiasis and gallstone attempted a single-step treatment combining LTCBDE and laparoscopic cholecystectomy. There were 104 women (60.8%) and 67 men (39.2%) with a median age of 57 (range 24-87) years. Elderly patients had significantly more preoperative risk factors. However, there was no significant difference in the success rate of LTCBDE (96.9% versus 92.7%, P = .142) for the two groups. The operative time was a little longer in elderly group than in younger group: median 80 (60-110) minutes versus 70 (50-95) minutes, respectively (P < .001). Postoperative recovery was slower in elderly group than in younger group, as reflected by a longer median postoperative hospital stay (2 days versus 1 day, P < .001) and a higher rate of abdominal drain placed (17.1% versus 8.5%, P = .202). The rates of postoperative complications at discharge were similar between groups (3.0% versus 4.9%, P = .952). CONCLUSION LTCBDE in the elderly patients is as effective and safe as in younger patients.
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Affiliation(s)
- Jie-Gao Zhu
- 1 Department of General Surgery, Beijing Friendship Hospital, Capital Medical University , Beijing, P.R. China .,2 Beijing Key Laboratory of Cancer Invasion and Metastasis Research , Beijing, P.R. China .,3 National Clinical Research Center for Digestive Diseases , Beijing, P.R. China
| | - Wei Guo
- 1 Department of General Surgery, Beijing Friendship Hospital, Capital Medical University , Beijing, P.R. China .,2 Beijing Key Laboratory of Cancer Invasion and Metastasis Research , Beijing, P.R. China .,3 National Clinical Research Center for Digestive Diseases , Beijing, P.R. China
| | - Wei Han
- 4 Department of General Surgery, Beijing Luhe Hospital, Capital Medical University , Beijing, P.R. China
| | - Zhong-Tao Zhang
- 1 Department of General Surgery, Beijing Friendship Hospital, Capital Medical University , Beijing, P.R. China .,2 Beijing Key Laboratory of Cancer Invasion and Metastasis Research , Beijing, P.R. China .,3 National Clinical Research Center for Digestive Diseases , Beijing, P.R. China
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Ahn KS, Kim YH, Kang KJ, Kim TS, Cho KB, Kim ES. Impact of Preoperative ERCP on Laparoscopic Cholecystectomy: A Case-Controlled Study with Propensity Score Matching. World J Surg 2016; 39:2235-42. [PMID: 25894408 DOI: 10.1007/s00268-015-3076-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although inflammation induced by endoscopic retrograde cholangiopancreatography (ERCP) may affect laparoscopic cholecystectomy (LC), making the procedure more difficult, clinical impact of ERCP on LC is unclear. The aim of this study was to evaluate the effects of ERCP on LC and to determine appropriate time of LC after ERCP. METHODS Six hundred twenty-one patients who underwent LC for gallstone disease were enrolled. These patients were divided into two groups; patients with preoperative ERCP prior to LC (ERCP group) and patients who underwent LC without ERCP (non-ERCP group). Among these patients, patients who had shown acute cholecystitis or cholangitis were excluded. To control for different demographic factors in the two groups, propensity score case matching was used at a 1:1 ratio. Finally, 142 patients were matched with 71 patients of the ERCP group and 71 patients of the non-ERCP group. Intraoperative inflammation degree, technical difficulty, and postoperative outcome were analyzed. RESULTS In the ERCP group, the degree of inflammation was severe and operations were more difficult than those of the non-ERCP group. The operation time was longer, and rates of open conversion were higher in the ERCP group. On multivariate analysis, preoperative ERCP was significant factor for difficult operations. The difficulty of operation was not different according to the operation timing after ERCP. CONCLUSION Preoperative ERCP is a significant factor in difficult LC. Therefore, experienced surgeons should perform LC after preoperative ERCP. Since operation difficulty was similar according to the timing of cholecystectomy after ERCP, there is no reason to delay LC after ERCP.
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Affiliation(s)
- Keun Soo Ahn
- Department of Surgery, Dongsan Medical Center, Keimyung University School of Medicine, 56 Dalseong-ro, Jung-gu, Daegu, 700-712, Republic of Korea,
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Ibrarullah M, Mishra T, Dash AP, Mohapatra D, Modi MS. 'Single-Sitting' Laparoscopic Cholecystectomy and Endoscopic Removal of Common Bile Duct Stone for Cholelithiasis and Choledocholithiasis: a Feasibility Study. Indian J Surg 2016; 77:708-11. [PMID: 26730094 DOI: 10.1007/s12262-013-0937-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 06/13/2013] [Indexed: 01/12/2023] Open
Abstract
'Single-sitting' laparoscopic cholecystectomy followed by endoscopic common bile duct clearance is emerging as a viable option for management of cholelithiasis and concomitant choledocholithiasis. The only disadvantage of the procedure is logistical since it requires co-ordination between two teams-the surgeons and the endoscopists. This limitation can be overcome in centres where both the procedures are performed by one team. With a considerable experience in endoscopy, we conducted a prospective study in a select group of patients to assess the feasibility of this single-sitting approach. The study included 38 patients with a radiological diagnosis of choledocholithiasis or jaundice at presentation. After laparoscopic cholecystectomy, the patients were turned prone and subjected to endoscopic retrograde cholangiogram, sphincterotomy and extraction of the common bile duct stone. The procedure was successful in 33 (87 %) of patients. The mean procedure time and hospital stay were 2 h, 20 min and 2 days, respectively. None of the patients had any major complications. We conclude that in a select group of patients, single-sitting laparoscopic cholecystectomy followed by endoscopic clearance of the common bile duct stone is safe and effective.
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Affiliation(s)
- Md Ibrarullah
- Department of Surgical Gastroenterology, Apollo Hospitals, Bhubaneswar, 751005 Odisha India
| | - Tapas Mishra
- Department of Surgery, Hitech Medical College, Bhubaneswar, 751023 Odisha India
| | - Ambika P Dash
- Department of Surgery, Hitech Medical College, Bhubaneswar, 751023 Odisha India
| | - Devanand Mohapatra
- Department of Medicine, Hitech Medical College, Bhubaneswar, 751023 Odisha India
| | - M S Modi
- Department of Surgical Gastroenterology, Apollo Hospitals, Bhubaneswar, 751005 Odisha India
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Winder JS, Pauli EM. Common Bile Duct Stones: Health Care Problem and Incidence. MULTIDISCIPLINARY MANAGEMENT OF COMMON BILE DUCT STONES 2016:5-15. [DOI: 10.1007/978-3-319-22765-8_2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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Effects Comparison between Endoscopic Papillary Large Balloon Dilatation and Endoscopic Sphincterotomy for Common Bile Duct Stone Removal. Gastroenterol Res Pract 2015; 2015:839346. [PMID: 26351452 PMCID: PMC4553337 DOI: 10.1155/2015/839346] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 06/03/2015] [Indexed: 12/23/2022] Open
Abstract
Endoscopic sphincterotomy (EST) is a treatment of choice for stone extraction and is now most frequently used. The study was to compare the efficacy of endoscopic papillary large balloon dilatation (EPLBD) and endoscopic sphincterotomy (EST) for common bile duct stone removal. Trials comparing the effects between EPLBD and EST treatment were searched according to the study protocol. Overall stone removal rate, complete removal rate in 1st session, treatment duration, mechanical lithotripsy using rate, and overall complication rate were compared using risk ratio (RR) and mean difference (MD) and their 95% confidence interval (CI) via RevMan 5.2 software. For overall stone removal rate, two therapies showed similar effect, but EPLBD showed better overall stone removal rate for stone >10 mm in diameter. For complete stone removal rate in 1st session, no difference was found, even for those with stone >10 mm in diameter; EPLBD showed longer treatment duration, higher mechanical lithotripsy using rate obvious overall complications rate, and more serious bleeding, whereas there were no significant differences for perforation, hyperamylasemia, pancreatitis, and cholecystitis/cholangitis. EPLBD showed better efficacy in certain conditions compared to EST, however with shortcomings, such as more duration, higher mechanical lithotripsy using rate, more serious overall complications rate, and bleeding.
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Abstract
BACKGROUND The choice of surgical technique to extract stones from the common bile duct (CBD) depends on local experience, anatomical characteristics and also on the size, location and number of stones. Most authors consider choledochotomy an alternative to failed transcystic exploration, although some use it exclusively. Although the CBD is traditionally closed with T-tube drainage after choledochotomy, its use is associated with 11.3-27.5 % morbidity. This study examined the efficacy of laparoscopic CBD exploration (LCBDE) with primary closure for the treatment of CBD stones using intraoperative cholangiography (IOC). METHODS Retrospective study of 160 patients who underwent LCBDE with primary closure after choledochotomy between January 2001 and December 2012. RESULTS The diagnosis of choledocholithiasis was definitively made in all cases by IOC. The overall complication rate was 15 % and the biliary complication rate was 7.5 %. Bile leakage was reported in 11 patients (6.8 %). In over half the cases (63.6 %), no further action was required and the leak closed spontaneously. Six patients were reoperated (3.75 %), two for bile peritonitis and four for haemoperitoneum. The success rate for stone clearance was 96.2 %. The mortality rate and CBD stricture rate were 0 %. CONCLUSION Primary closure after choledochotomy to clear stones from the CBD is a safe technique that confers excellent results and allows one-stage treatment.
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Abstract
BACKGROUND When common bile duct (CBD) stones are detected during laparoscopic cholecystectomy, the insertion of baskets via the cystic duct (CD) can be difficult and may occasionally cause complications. We introduced a new technique 'basket in catheter' (BIC) for transcystic CBD exploration. METHODS Although cannulating the CD using a cholangiography catheter is successful in most cases, it may occasionally be difficult. Cystic duct anatomy may prevent the usually stiffer sharper tip of the basket, from entering the CBD, resulting in failure, perforation or a false passage. In the majority of our cases, the cholangiography catheter (CC) is not withdrawn from the duct should the intraoperative cholangiography show CBD stones. The tip of a basket is inserted into the CC and advanced to a predetermined distance, allowing the tip of the basket to exit the end of the CC into the CBD. The basket is then opened, advanced to feel the lower end and manipulated to trap the stone. The common hepatic duct is compressed gently to prevent stones from slipping upwards. The catheter and basket are pulled back together to extract the stone. RESULTS We have used this technique in 274 cases since 2010. The rate of transcystic versus choledochotomy stone extraction has increased, saving unnecessary choledochotomies. The percentage of transcystic exploration increased from 55 % for the period 2005-2009 to 70 % for the period 2010-2014. There were no conversions to open surgery and no retained stones. The morbidity rate was 4.0 % with no mortality. CONCLUSIONS We demonstrate a technique to facilitate the insertion of extraction baskets into the common bile duct using the cholangiography catheter as a guide. The 'basket-in-catheter' (BIC) technique for transcystic CBD exploration is easier and safer than inserting the basket alone.
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Lin C, Collins JN, Britt RC, Britt LD. Initial Cholecystectomy with Cholangiography Decreases Length of Stay Compared to Preoperative MRCP or ERCP in the Management of Choledocholithiasis. Am Surg 2015. [DOI: 10.1177/000313481508100724] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
There are several treatments available for choledocholithiasis, but the optimal treatment is highly debated. Some advocate preoperative endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC) with cholangiography (IOC). Others advocate initial LC + IOC followed by common bile duct exploration or ERCP. The purpose of this study was to determine whether initial LC + IOC had a shorter length of stay (LOS) compared with preoperative magnetic resonance cholangiopancreatography (MRCP) or ERCP. Patients who underwent cholecystectomy between 2012 and 2013 at two institutions were reviewed. Patients were selected if they had suspected choledocholithiasis, indicated by dilated CBD and/or elevated bilirubin, or confirmed choledocholithiasis. They were excluded if they had pancreatitis or cholangitis. There were 126 patients with suspected choledocholithiasis in this study. Of these, 97 patients underwent initial LC ± IOC with an average LOS of 3.9 days. IOC was negative in 47.4 per cent patients, and they had a shorter LOS compared with positive IOC patients (2.93 vs 4.82, P < 0.001). Laparoscopic common bile duct exploration was successful in 64.7 per cent and had a shorter LOS compared with postoperative ERCP patients ( P = 0.01). Preoperative MRCP was performed in 21 patients with an average LOS of 6.48 days. Preoperative ERCP was performed in eight patients with an average LOS of seven days. Initial LC+IOC is associated with a shorter LOS compared to preoperative MRCP or ERCP. It is recommended as the optimal treatment choice for suspected choledocholithiasis.
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Affiliation(s)
- Christine Lin
- Department of Surgery, Eastern Virginia Medical School, Norfolk, Virginia
| | - Jay N. Collins
- Department of Surgery, Eastern Virginia Medical School, Norfolk, Virginia
| | - Rebecca C. Britt
- Department of Surgery, Eastern Virginia Medical School, Norfolk, Virginia
| | - Lunzy D. Britt
- Department of Surgery, Eastern Virginia Medical School, Norfolk, Virginia
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Zhang JF, Du ZQ, Lu Q, Liu XM, Lv Y, Zhang XF. Risk Factors Associated With Residual Stones in Common Bile Duct Via T Tube Cholangiography After Common Bile Duct Exploration. Medicine (Baltimore) 2015; 94:e1043. [PMID: 26131813 PMCID: PMC4504534 DOI: 10.1097/md.0000000000001043] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Revised: 05/27/2015] [Accepted: 05/28/2015] [Indexed: 12/31/2022] Open
Abstract
Open surgery with common bile duct (CBD) exploration and T tube drainage are still traditionally performed in a large amount of selected patients with cholelithiasis and choledocholithiasis. Confirmation of CBD clearance via T tube cholangiography after surgery is a routine procedure before T tube removal. The present study aims at investigating potential risk factors associated with residual stones in CBD via T tube cholangiography.Patients undergoing open CBD exploration and T tube drainage for choledocholithiasis in the hospital were enrolled retrospectively from January 2011 to December 2013. The clinical data were reviewed and analyzed based on computer database. Patients undergoing laparoscopic CBD exploration were excluded. Patients with CBD exploration and primary choledochotomy or choledochojejunostomy were also excluded from the study. T tube cholangiography was regularly performed 4 to 8 weeks postoperatively.Two hundred seventy-five patients undergoing open CBD exploration and T tube drainage were enrolled in the study. Thirty-five patients (12.7%) were found to have gallbladder stones but without bile duct stones intraoperatively (Group A). One hundred sixty-five (Group B) and 77 patients (Group C) were diagnosed with choledocholithiasis and hepato-choledocholithiasis in operation, respectively. Disease of hepato-choledocholithiasis, size of the previous stones, and CBD exploration without intraoperative choledochoscopy were identified as risk factors associated with residue stones via T tube cholangiography (P < 0.001, P = 0.034, and P = 0.047, respectively). Patients with residual stones had a higher incidence of cholangitis during cholangiography than those without residual stones (8.9% vs 7.8%, P = 0.05). A scoring system based on the 3 risk factors has been set up. The incidence of residual stones were 5.6% in patients with score 0 to 1, 27.4% in patients with score 2 to 3 and 80.0% in patients with score 4 (P < 0.001). Abdominal distension after T tube clamp might be a strong predictor of cholangiography-associated choloangitis (P < 0.001). Intraopearative choledochoscopy should be strongly recommended as a routine procedure during CBD exploration to confirm the clearance of CBD, which could significantly lower the risk of residual stones postoperatively.
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Affiliation(s)
- Jian-Fei Zhang
- From the Department of Hepatobiliary Surgery, and Institute of Advanced Surgical Technology and Engineering, the First Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
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Zhan X, Wang Y, Zhu J, Lin X. Laparoscopic Choledocholithotomy With a Novel Articulating Forceps. Surg Innov 2015; 23:124-9. [PMID: 26092564 DOI: 10.1177/1553350615591399] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE The aim of this study was to assess the safety and effectiveness of laparoscopic common bile duct (CBD) exploration with a novel articulating forceps. METHODS A retrospective analysis was carried out of 90 patients who underwent laparoscopic transcholedochal CBD exploration for choledocholithiasis between May 2006 and June 2014. Forty-five patients underwent laparoscopic choledocholithotomy using the routine instruments (group A). Forty-five patients underwent laparoscopic choledocholithotomy using the routine instruments plus the novel articulating forceps (group B). The 2 group populations were similar with regard to demographic data and clinical presentations. RESULTS Laparoscopic transcholedochal CBD exploration was successful in all 90 patients. The mean diameter of the CBD was 14.42 mm in group A and 14.73 mm in group B (P > .05). The average number of stones extracted per patient was 4.22 in group A and 4.67 in group B (P > .05). The patients in group A had a significantly longer operative time than the patients in group B (109.38 vs 80.49 minutes; P < .01). The intraoperative blood loss was minimal in both groups, and no major complications were observed in either group. The mean hospitalization stay was 6.60 days in group A and 5.58 days in group B (P < .01). CONCLUSION Laparoscopic transcholedochal CBD exploration with the novel articulating forceps is a safe and effective approach to the management of choledocholithiasis that offers a short operating time and short postoperative hospital stay.
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Affiliation(s)
- Xiaoli Zhan
- Second Affiliated Hospital, Zhejiang University College of Medicine, Hangzhou, China
| | - Yuedong Wang
- Second Affiliated Hospital, Zhejiang University College of Medicine, Hangzhou, China
| | - Jinhui Zhu
- Second Affiliated Hospital, Zhejiang University College of Medicine, Hangzhou, China
| | - Xianming Lin
- Second Affiliated Hospital, Zhejiang University College of Medicine, Hangzhou, China
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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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El Nakeeb A, Sultan AM, Hamdy E, El Hanafy E, Atef E, Salah T, El Geidie AA, Kandil T, El Shobari M, El Ebidy G. Intraoperative endoscopic retrograde cholangio-pancreatography: A useful tool in the hands of the hepatobiliary surgeon. World J Gastroenterol 2015; 21:609-615. [PMID: 25605984 PMCID: PMC4296022 DOI: 10.3748/wjg.v21.i2.609] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Revised: 06/22/2014] [Accepted: 08/28/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the efficacy of intraoperative endoscopic retrograde cholangio-pancreatography (ERCP) combined with laparoscopic cholecystectomy (LC) for patients with gall bladder stones (GS) and common bile duct stones (CBDS).
METHODS: Patients treated for GS with CBDS were included. LC and intraoperative transcystic cholangiogram (TCC) were performed in most of the cases. Intraoperative ERCP was done for cases with proven CBDS.
RESULTS: Eighty patients who had GS with CBDS were included. LC was successful in all cases. Intraoperative TCC revealed passed CBD stones in 4 cases so intraoperative ERCP was performed only in 76 patients. Intraoperative ERCP showed dilated CBD with stones in 64 cases (84.2%) where removal of stones were successful; passed stones in 6 cases (7.9%); short lower end stricture with small stones present in two cases (2.6%) which were treated by removal of stones with stent insertion; long stricture lower 1/3 CBD in one case (1.3%) which was treated by open hepaticojejunostomy; and one case (1.3%) was proved to be ampullary carcinoma and whipple’s operation was scheduled.
CONCLUSION: The hepatobiliary surgeon should be trained on ERCP as the third hand to expand his field of therapeutic options.
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Costi R, Gnocchi A, Di Mario F, Sarli L. Diagnosis and management of choledocholithiasis in the golden age of imaging, endoscopy and laparoscopy. World J Gastroenterol 2014; 20:13382-13401. [PMID: 25309071 PMCID: PMC4188892 DOI: 10.3748/wjg.v20.i37.13382] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 03/23/2014] [Accepted: 05/29/2014] [Indexed: 02/06/2023] Open
Abstract
Biliary lithiasis is an endemic condition in both Western and Eastern countries, in some studies affecting 20% of the general population. In up to 20% of cases, gallbladder stones are associated with common bile duct stones (CBDS), which are asymptomatic in up to one half of cases. Despite the wide variety of examinations and techniques available nowadays, two main open issues remain without a clear answer: how to cost-effectively diagnose CBDS and, when they are finally found, how to deal with them. CBDS diagnosis and management has radically changed over the last 30 years, following the dramatic diffusion of imaging, including endoscopic ultrasound (EUS) and magnetic resonance cholangiography (MRC), endoscopy and laparoscopy. Since accuracy, invasiveness, potential therapeutic use and cost-effectiveness of imaging techniques used to identify CBDS increase together in a parallel way, the concept of "risk of carrying CBDS" has become pivotal to identifying the most appropriate management of a specific patient in order to avoid the risk of "under-studying" by poor diagnostic work up or "over-studying" by excessively invasive examinations. The risk of carrying CBDS is deduced by symptoms, liver/pancreas serology and ultrasound. "Low risk" patients do not require further examination before laparoscopic cholecystectomy. Two main "philosophical approaches" face each other for patients with an "intermediate to high risk" of carrying CBDS: on one hand, the "laparoscopy-first" approach, which mainly relies on intraoperative cholangiography for diagnosis and laparoscopic common bile duct exploration for treatment, and, on the other hand, the "endoscopy-first" attitude, variously referring to MRC, EUS and/or endoscopic retrograde cholangiography for diagnosis and endoscopic sphincterotomy for management. Concerning CBDS diagnosis, intraoperative cholangiography, EUS and MRC are reported to have similar results. Regarding management, the recent literature seems to show better short and long term outcome of surgery in terms of retained stones and need for further procedures. Nevertheless, open surgery is invasive, whereas the laparoscopic common bile duct clearance is time consuming, technically demanding and involves dedicated instruments. Thus, although no consensus has been achieved and CBDS management seems more conditioned by the availability of instrumentation, personnel and skills than cost-effectiveness, endoscopic treatment is largely preferred worldwide.
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Vindal A, Chander J, Lal P, Mahendra B. Comparison between intraoperative cholangiography and choledochoscopy for ductal clearance in laparoscopic CBD exploration: a prospective randomized study. Surg Endosc 2014; 29:1030-8. [PMID: 25154888 DOI: 10.1007/s00464-014-3766-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 07/19/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Laparoscopic CBD exploration (LCBDE) is an accepted treatment modality for single stage management of CBD stones in fit patients. A transcholedochal approach is preferred in patients with a dilated CBD and large impacted stones in whom ductal clearance remains problematic. There are very few studies comparing intraoperative cholangiography (IOC) with choledochoscopy to determine ductal clearance in patients undergoing transcholedochal LCBDE. This series represents the first of those comparing the two from Asia. METHODS Between April 2009 and October 2012, 150 consecutive patients with CBD stones were enrolled in a prospective randomized study to undergo transcholedochal LCBDE on an intent-to-treat basis. Patients with CBD diameter of less than 9 mm on preoperative imaging were excluded from the study. Out of the 132 eligible patients, 65 patients underwent IOC (Group A), and 67 patients underwent intraoperative choledochoscopy (Group B) to determine CBD clearance. RESULTS There were no differences between the two groups in the demographic profile and the preoperative biochemical findings. There was no conversion to open procedures, and complete stone clearance was achieved in all the 132 cases. The mean CBD diameter and the mean number of CBD stones removed were comparable between the two groups. Mean operating time was 170 min in Group A and 140 min in Group B (p < 0.001). There was no difference in complications between the two groups. Nine patients in Group A (13.8%) showed non-passage of contrast into the duodenum on IOC which resolved after administration of i.v. glucagon, suggesting a transient spasm of sphincter of Oddi. Two patients (3%) showed a false-positive result on IOC which had to be resolved with choledochoscopy. CONCLUSIONS The present study showed that intraoperative choledochoscopy is better than IOC for determining ductal clearance after transcholedochal LCBDE and is less cumbersome and less time-consuming.
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Affiliation(s)
- Anubhav Vindal
- Division of Minimal Access Surgery, Department of Surgery, Maulana Azad Medical College, University of Delhi, New Delhi, 110002, India,
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Naumowicz E, Białecki J, Kołomecki K. Results of treatment of patients with gallstone disease and ductal calculi by single-stage laparoscopic cholecystectomy and bile duct exploration. Wideochir Inne Tech Maloinwazyjne 2014; 9:179-89. [PMID: 25097684 PMCID: PMC4105674 DOI: 10.5114/wiitm.2014.41629] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Revised: 08/14/2013] [Accepted: 10/20/2013] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Choledocholithiasis is the most common cause of obstructive jaundice. Common bile duct stones are observed in 10-14% of patients diagnosed with gall bladder stones. In the case of gall bladder and common bile duct stones the procedure involves not only performing cholecystectomy but also removing the stones from bile ducts. AIM To compare the results of the treatment of patients with gallstone disease and ductal calculi by one-stage laparoscopic cholecystectomy and common bile duct exploration with two other methods: one-stage open cholecystectomy and common bile duct exploration, and a two-stage procedure involving endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy. MATERIAL AND METHODS Between 2004 and 2011 three groups of 100 patients were treated for obstructive jaundice caused by choledocholithiasis. The first group of 42 patients underwent ERCP followed by laparoscopic cholecystectomy. The second group of 23 patients underwent open cholecystectomy and common bile duct exploration, whereas the third group of 35 patients underwent laparoscopic cholecystectomy with common bile duct exploration. The data were analysed prospectively. The methods were compared according to complete execution, bile duct clearance and complication rate. Complications were analysed according to Clavien's Classification of Surgical Complications. The results were compared using the ANOVA statistical test and Student's t-test in Statistica. Value of p was calculated statistically. A p-value less than 0.05 (p < 0.05) signified that groups differed statistically, whereas a p-value more than 0.05 (p > 0.05) suggested no statistically significant differences between the groups. RESULTS The procedure could not be performed in 11.9% of patients in the first group and in 14.3% of patients in the third group. Residual stones were found in 13.5% of the patients in the first group, in 4.3% of the patients in the second group and in 6.7% of the patients in the third group. According to Clavien's classification of complications grade II and III, we can assign the range in the first group at 21.6% for grade II and 0% for grade III, in the second group at 21.4% and 3.6% and in the third group at 6.7% and 3.3% respectively. CONCLUSIONS The use of all three methods of treatment gives similar results. One-stage laparoscopic cholecystectomy with common bile duct exploration is after all the least invasive, safer and more effective procedure.
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Affiliation(s)
- Eryk Naumowicz
- Department of General Surgery, HCP Medical Centre, Poznan, Poland
| | - Jacek Białecki
- Department of General Surgery, HCP Medical Centre, Poznan, Poland
| | - Krzysztof Kołomecki
- Department of Endocrine, General and Vascular Surgery, Medical University of Lodz, Lodz, Poland
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Zhu JG, Han W, Zhang ZT, Guo W, Liu W, Li J. Short-term outcomes of laparoscopic transcystic common bile duct exploration with discharge less than 24 hours. J Laparoendosc Adv Surg Tech A 2014; 24:302-5. [PMID: 24745979 DOI: 10.1089/lap.2013.0537] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Reducing the length of stay and discharge time for patients could benefit multiple hospital units by saving money, reducing waiting time, and providing the opportunity for more patients to be treated. However, no experience of laparoscopic transcystic common bile duct exploration (LTCBDE) with discharge less than 24 hours has been reported until now. The objective of this study was to assess the feasibility and safety of LTCBDE with discharge less than 24 hours. PATIENTS AND METHODS A retrospective review showed that 34 of 111 patients scheduled in our institution were discharged less than 24 hours after LTCBDE between June 1 and December 31, 2011. A multimodal approach including appropriate preoperative assessment, education and counseling, early postoperative oral intake, and early mobilization was carried out. Outcomes were analyzed for patient demographics, postoperative stay, operation time, intraoperative bleeding, and reasons for failed LTCBDE. RESULTS Of 111 patients admitted for LTCBDE, 34 patients were discharged within 24 hours postoperatively. This study population comprised 11 males and 23 females with a mean age of 54.6±14.7 years (range, 28-79 years). The mean postoperative stay was 20.21±0.39 hours. There were no postoperative complications or deaths during the hospital stay or at the follow-up 12 months postoperatively in these 34 patients. CONCLUSIONS LTCBDE with discharge less than 24 hours is feasible and safe in selected patients with common bile duct stones of no more than three in number and no more than 6 mm in size. The benefit of the multimodal approach and LTCBDE may be synergistic, allowing a quick recovery of gastrointestinal function.
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Affiliation(s)
- Jie-gao Zhu
- 1 Department of General Surgery, Beijing Friendship Hospital of Capital Medical University , Beijing, People's Republic of China
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Turner GA, Ing AJ, Connor SJ. Endoscopic large balloon sphincteroplasty is a useful, safe adjunct for difficult to treat choledocholithiasis. ANZ J Surg 2014; 86:395-8. [PMID: 24730714 DOI: 10.1111/ans.12599] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2014] [Indexed: 01/22/2023]
Abstract
BACKGROUND The aim of this study was to assess the safety and efficacy of large balloon sphincteroplasty when used in conjunction with endoscopic biliary sphincterotomy during endoscopic retrograde cholangiopancreatography (ERCP) for therapy of choledocholithiasis. METHODS A retrospective audit of all ERCP's performed for choledocholithiasis between January 2012 and October 2013 at one institution was performed. Procedures that utilized large balloon sphincteroplasty were compared with those underwent standard endoscopic stone extraction. Outcomes including stone clearance rate for the individual procedure type, post-ERCP complications and need for surgical exploration of the bile duct were documented. RESULTS A total of 346 procedures on 306 patients that met the inclusion criteria were identified. Fifty-four (15.6%) procedures included large balloon sphincteroplasty and were compared with 292 (84.4%) procedures that used standard balloon extraction techniques. Despite those patients in the large balloon sphincteroplasty group having a higher rate of previous ERCP (33.3% versus 19.5%, P = 0.031) and a larger proportion of patients with stones greater than 10 mm (40.3% versus 11.3%, P < 0.001), the overall initial clearance rate was similar at 83%. Ultimately, only 14 out of 306 (4.6%) of all patients required surgical intervention. There was no significant difference in the rate of post-ERCP pancreatitis between the two groups (5.6% versus 3.8%, P = 0.466). CONCLUSION Large balloon sphincteroplasty of the sphincter of Oddi is a safe and effective adjunct to endoscopic biliary sphincterotomy in difficult to treat choledocholithiasis. The current study demonstrated large balloon sphincteroplasty did not result in more complications despite a tendency to being used for larger stones.
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Affiliation(s)
- Greg A Turner
- Department of General Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Andrew J Ing
- Department of General Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Saxon J Connor
- Department of General Surgery, Christchurch Hospital, Christchurch, New Zealand
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Demir U, Yazıcı P, Bostancı Ö, Kaya C, Köksal H, Işıl G, Bozdağ E, Mihmanlı M. Timing of cholecystectomy in biliary pancreatitis treatment. Turk J Surg 2014; 30:10-3. [PMID: 25931883 PMCID: PMC4379779 DOI: 10.5152/ucd.2014.2401] [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: 10/04/2013] [Accepted: 12/03/2013] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Gallstone pancreatitis constitutes 40% of all cases with pancreatitis while it constitutes up to 90% of cases with acute pancreatitis. The treatment modality in this patient population is still controversial. In this study, we aimed to compare the results of early and late cholecystectomy for patients with biliary pancreatitis. MATERIAL AND METHODS Patients treated with a diagnosis of acute biliary pancreatitis in our clinics between January 2000 and December 2011 were retrospectively reviewed. Patients were divided into two groups: Group A, patients who underwent cholecystectomy during the first pancreatitis attack, Group B, patients who underwent an interval cholecystectomy at least 8 weeks after the first pancreatitis episode. The demographic characteristics, clinical symptoms, number of episodes, length of hospital stay, morbidity and mortality data were recorded. All data were evaluated with Statistical Package for the Social Sciences (SPSS) 13.0 for windows and p <0.05 was considered as statistically significant. RESULTS During the last 12 years, a total of 91 patients with surgical treatment for acute biliary pancreatitis were included into the study. There were 62 female and 29 male patients, with a mean age of 57.9±14.6 years (range: 21-89). A concomitant acute cholecystitis was present in 46.2% of the patients. Group A and B included 48 and 43 patients, respectively. The length of hospital stay was significantly higher in group B (9.4 vs. 6.8 days) (p<0,05). More than half of the patients in Group B were readmitted to the hospital for various reasons. No significant difference was observed between the two groups, one patient died due to heart failure in the postoperative period in group B. CONCLUSION In-hospital cholecystectomy after remission of acute pancreatitis is feasible. It will not only result in lower recurrence and complication rates but also shorten length of hospital stay. We recommend performing cholecystectomy during the course of the first episode in patients with acute pancreatitis.
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Affiliation(s)
- Uygar Demir
- Clinic of General Surgery, Şişli Hamidiye Etfal Training Hospital, İstanbul, Turkey
| | - Pınar Yazıcı
- Clinic of General Surgery, Şişli Hamidiye Etfal Training Hospital, İstanbul, Turkey
| | - Özgür Bostancı
- Clinic of General Surgery, Şişli Hamidiye Etfal Training Hospital, İstanbul, Turkey
| | - Cemal Kaya
- Clinic of General Surgery, Şişli Hamidiye Etfal Training Hospital, İstanbul, Turkey
| | - Hakan Köksal
- Clinic of General Surgery, Şişli Hamidiye Etfal Training Hospital, İstanbul, Turkey
| | - Gürhan Işıl
- Clinic of General Surgery, Şişli Hamidiye Etfal Training Hospital, İstanbul, Turkey
| | - Emre Bozdağ
- Clinic of General Surgery, Şişli Hamidiye Etfal Training Hospital, İstanbul, Turkey
| | - Mehmet Mihmanlı
- Clinic of General Surgery, Şişli Hamidiye Etfal Training Hospital, İstanbul, Turkey
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