Surgical versus endoscopic treatment of bile duct stones

Laparoscopic common bile duct exploration; a preferential pathway for elderly patients

Background

Laparoscopic common bile duct exploration (LCBDE) has emerged as a recommended alternative to endoscopic retrograde cholangiopancreatography (ERCP) for the management of choledocholithiasis. However, its use in the elderly has been limited, and evidence of its safety and efficacy in these patients is yet to be established. This study describes our experience of LCBDE in elderly patients, analysing the safety and efficacy of this technique in comparison to younger patients.

Methods

All patients undergoing laparoscopic cholecystectomy (LC) with LCBDE for choledocholithiasis in our unit between January 2015 and January 2017 were included. Data pertaining to patient demographics, comorbidities, investigations, operative technique and outcomes were analysed. Patients were divided into 2 groups based on age (Group A:<65 years vs Group B: >/ = 65 years) for comparative analysis.

Results

124 patients (Group A: 65, Group B: 59) were included. Group B were more co-morbid and had a higher ASA grade than Group A. However, there was no significant difference between groups in rates of conversion to open or complications, including bile leak (3.1% vs 5.1%, p = 0.67), retained stone (4.6% vs 1.7%, p = 0.62), or complications according to Clavien-Dindo classification (p = 0.78). Re-intervention rates were also similar between groups (7.7% vs 3.4%, p = 0.44 and 3.1% vs 3.4%, p = 1.0 respectively), as was length of stay.

Conclusion

Despite higher frequency of comorbidities and ASA grade, LCBDE in elderly patients is safe and effective, and has similar outcomes to younger patients. Therefore elderly patients with choledocholithiasis should be offered LCBDE as an alternative to ERCP.

Laparoscopic-endoscopic rendezvous versus preoperative endoscopic sphincterotomy in people undergoing laparoscopic cholecystectomy for stones in the gallbladder and bile duct

BACKGROUND

The management of gallbladder stones (lithiasis) concomitant with bile duct stones is controversial. The more frequent approach is a two-stage procedure, with endoscopic sphincterotomy and stone removal from the bile duct followed by laparoscopic cholecystectomy. The laparoscopic-endoscopic rendezvous combines the two techniques in a single-stage operation.

OBJECTIVES

To compare the benefits and harms of endoscopic sphincterotomy and stone removal followed by laparoscopic cholecystectomy (the single-stage rendezvous technique) versus preoperative endoscopic sphincterotomy followed by laparoscopic cholecystectomy (two stages) in people with gallbladder and common bile duct stones.

SEARCH METHODS

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, MEDLINE Ovid, Embase Ovid, Science Citation Index Expanded Web of Science, and two trials registers (February 2017).

SELECTION CRITERIA

We included randomised clinical trials that enrolled people with concomitant gallbladder and common bile duct stones, regardless of clinical status or diagnostic work-up, and compared laparoscopic-endoscopic rendezvous versus preoperative endoscopic sphincterotomy procedures in people undergoing laparoscopic cholecystectomy. We excluded other endoscopic or surgical methods of intraoperative clearance of the bile duct, e.g. non-aided intraoperative endoscopic retrograde cholangiopancreatography or laparoscopic choledocholithotomy (surgical incision of the common bile duct for removal of bile duct stones).

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane.

MAIN RESULTS

We included five randomised clinical trials with 517 participants (257 underwent a laparoscopic-endoscopic rendezvous technique versus 260 underwent a sequential approach), which fulfilled our inclusion criteria and provided data for analysis. Trial participants were scheduled for laparoscopic cholecystectomy because of suspected cholecysto-choledocholithiasis. Male/female ratio was 0.7; age of men and women ranged from 21 years to 87 years. The run-in and follow-up periods of the trials ranged from 32 months to 84 months. Overall, the five trials were judged at high risk of bias. Athough all trials measured mortality, there was just one death reported in one trial, in the laparoscopic-endoscopic rendezvous group (low-quality evidence). The overall morbidity (surgical morbidity plus general morbidity) may be lower with laparoscopic rendezvous (RR 0.59, 95% CI 0.29 to 1.20; participants = 434, trials = 4; I² = 28%; low-quality evidence); the effect was a little more certain when a fixed-effect model was used (RR 0.56, 95% CI 0.32 to 0.99). There was insufficient evidence to determine the effects of the two approaches on the failure of primary clearance of the bile duct (RR 0.55, 95% CI 0.22 to 1.38; participants = 517; trials = 5; I² = 58%; very low-quality evidence). The effects of either approach on clinical post-operative pancreatitis were unclear (RR 0.29, 95% CI 0.07 to 1.12; participants = 517, trials = 5; I² = 24%; low-quality evidence). Hospital stay appeared to be lower in the laparoscopic-endoscopic rendezvous group by about three days (95% CI 3.51 to 2.50 days shorter; 515 participants in five trials; low-quality evidence). There was very low-quality evidence that suggested longer operative time with laparoscopic-endoscopic rendezvous (MD 34.07 minutes, 95% CI 11.41 to 56.74; participants = 313; trials = 3; I² = 93%). The Trial Sequential Analyses of operating time and the length of hospital stay indicated that all the trials crossed the conventional boundaries, suggesting that the sample sizes were adequate, with a low risk of random error.

AUTHORS' CONCLUSIONS

There was insufficient evidence to determine the effects of the laparoscopic-endoscopic rendezvous versus preoperative endoscopic sphincterotomy techniques in people undergoing laparoscopic cholecystectomy on mortality and morbidity. The laparoscopic-endoscopic rendezvous procedure may lead to longer operating times, but it may reduce the length of the hospital stay when compared with preoperative endoscopic sphincterotomy followed by laparoscopic cholecystectomy. However, no firm conclusions could be drawn because the quality of evidence was low or very low. If confirmed by future trials, these data might re-design the scenario of treatment of this condition, albeit requiring greater organisational effort. Future trials should also address issues such as quality of life and cost analysis.

Single-stage laparoscopic common bile duct exploration and cholecystectomy versus two-stage endoscopic stone extraction followed by laparoscopic cholecystectomy for patients with gallbladder stones with common bile duct stones: systematic review and meta-analysis of randomized trials with trial sequential analysis

BACKGROUND

The ideal management of common bile duct (CBD) stones associated with gall stones is a matter of debate. We planned a meta-analysis of randomized trials comparing single-stage laparoscopic CBD exploration and cholecystectomy (LCBDE) with two-stage preoperative endoscopic stone extraction followed by cholecystectomy (ERCP + LC).

METHODS

We searched the Pubmed/Medline, Web of science, Science citation index, Google scholar and Cochrane Central Register of Controlled trials electronic databases till June 2017 for all English language randomized trials comparing the two approaches. Statistical analysis was performed using Review Manager (RevMan) [Computer program], Version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014 and results were expressed as odds ratio for dichotomous variables and mean difference for continuous. p value ≤ 0.05 was considered significant. Trial sequential analysis (TSA) was performed using TSA version 0.9.5.5 (Copenhagen: The Copenhagen Trial Unit, Centre for Clinical Intervention Research, 2016). PROSPERO trial registration number is CRD42017074673.

RESULTS

A total of 11 trials were included in the analysis, with a total of 1513 patients (751-LCBDE; 762-ERCP + LC). LCBDE was found to have significantly lower rates of technical failure [OR 0.59, 95% CI (0.38, 0.93), p = 0.02] and shorter hospital stay [MD - 1.63, 95% CI (- 3.23, - 0.03), p = 0.05]. There was no significant difference in mortality [OR 0.37, 95% CI (0.09, 1.51), p = 0.17], morbidity [OR 0.97, 95% CI (0.70, 1.33), p = 0.84], cost [MD - 379.13, 95% CI (- 784.80, 111.2), p = 0.13] or recurrent/retained stones [OR 1.01, 95% CI (0.38, 2.73), p = 0.98]. TSA showed that although the Z-curve crossed the boundaries of conventional significance, the estimated information size is yet to be achieved.

CONCLUSIONS

Single-stage LCBDE is superior to ERCP + LC in terms of technical success and shorter hospital stay in good-risk patients with gallstones and CBD stones, where expertise, operative time and instruments are available.

Acute pancreatitis: current perspectives on diagnosis and management

The last two decades have seen the emergence of significant evidence that has altered certain aspects of the management of acute pancreatitis. While most cases of acute pancreatitis are mild, the challenge remains in managing the severe cases and the complications associated with acute pancreatitis. Gallstones are still the most common cause with epidemiological trends indicating a rising incidence. The surgical management of acute gallstone pancreatitis has evolved. In this article, we revisit and review the methods in diagnosing acute pancreatitis. We present the evidence for the supportive management of the condition, and then discuss the management of acute gallstone pancreatitis. Based on the evidence, our local institutional pathways, and clinical experience, we have produced an outline to guide clinicians in the management of acute gallstone pancreatitis.

Inpatient Choledocholithiasis Requiring ERCP and Cholecystectomy: Outcomes of a Combined Single Inpatient Procedure Versus Separate-Session Procedures

OBJECTIVES

Separate-session endoscopic retrograde cholangiography (ERCP) and laparoscopic cholecystectomy (LC) is the usual method for management of inpatient choledocholithiasis. Our goal was to compare single operative-session LC and ERCP to a multi-session approach for both the same hospitalization and within 30 days after; there is limited data comparing the three groups.

METHODS

A retrospective review on inpatients with choledocholithiasis that underwent ERCP and LC was performed. Single operative-session ERCP + LC (SOS group) and separate hospitalization ERCP + LC (DH group) were compared against the control cohort: separate-session ERCP + LC performed during the same hospitalization (SH group).

RESULTS

Among the 214 cases, 37 (17%) had LC + ERCP performed under a single operative session (SOS), 130 (60.7%) cases had LC + ERCP performed in separate operative sessions during the same hospitalization (SH), and 47 (22%) cases had LC + ERCP performed in different hospitalizations, within 30 days (DH). There was no statistically significant difference in efficacy or adverse events. The SOS group had a statistically significant mean shorter length of hospital stay as compared to the SH and DH groups (5.46 vs 7.15 vs 9.38; p = 0.05 and 0.02). There was a statistically significant reduction in the total cost of care in the SOS group versus the SH group ($59,221 vs $75, 808; p = 0.007).

CONCLUSION

The SOS approach is safe, efficacious, and cost-efficient when compared to separate operative sessions. This approach can be considered in situations where it is preferable for the patient to undergo a single session of anesthesia, without compromising technical success and safety.

Safety and efficacy of extending a previous endoscopic sphincterotomy for the treatment of retained or recurrent common bile duct stones

Background:

The aim of the study was to evaluate the safety and efficacy of extending a previous endoscopic sphincterotomy (ES) in patients with retained or recurrent common bile duct (CBD) stones.

Methods:

Between 2001 and 2013, extension of a previous ES, for known or suspected CBD stones, was performed in 118 patients (m/f, 53/65) with a median age of 74 (range: 31-91) years (group A). During the same period, ES was performed in 1064 patients with suspected or known choledocholithiasis (group B). The efficacy and complications of the extension (group A) were analyzed and a comparison was made between groups regarding complications.

Results:

Bile duct cannulation was straightforward in all patients in group A, while it was considered difficult in 49% of patients in group B. Complete clearance was achieved in 76/97 patients (78%) with CBD stones, after a mean of 1.18 attempts per patient. Mechanical lithotripsy was required in 10% of patients. After extension, immediate bleeding occurred in 24 patients (20%), which stopped spontaneously in 9 (37%) and endoscopic hemostasis was required in the remainder. Complications were more frequent in group B (5.3% vs. 0.8%, P=0.031), but there was no significant difference for any individual complication. Immediate bleeding was more common in group B (29% vs. 20%, P=0.035), but there was no difference in clinical bleeding.

Conclusion:

Extension of a previous ES seems to be a simple, effective and safe technique, allowing stone clearance in nearly 80% of patients; it is thus recommended in patients with CBD stones after ES.

Acute calculous cholecystitis: Review of current best practices

Acute calculous cholecystitis (ACC) is the most frequent complication of cholelithiasis and represents one-third of all surgical emergency hospital admissions, many aspects of the disease are still a matter of debate. Knowledge of the current evidence may allow the surgical team to develop practical bedside decision-making strategies, aiming at a less demanding procedure and lower frequency of complications. In this regard, recommendations on the diagnosis supported by specific criteria and severity scores are being implemented, to prioritize patients eligible for urgency surgery. Laparoscopic cholecystectomy is the best treatment for ACC and the procedure should ideally be performed within 72 h. Early surgery is associated with better results in comparison to delayed surgery. In addition, when to suspect associated common bile duct stones and how to treat them when found are still debated. The antimicrobial agents are indicated for high-risk patients and especially in the presence of gallbladder necrosis. The use of broad-spectrum antibiotics and in some cases with antifungal agents is related to better prognosis. Moreover, an emerging strategy of not converting to open, a difficult laparoscopic cholecystectomy and performing a subtotal cholecystectomy is recommended by adept surgical teams. Some authors support the use of percutaneous cholecystostomy as an alternative emergency treatment for acute Cholecystitis for patients with severe comorbidities.

Laparoscopic common bile duct exploration: a safe and definitive treatment for elderly patients

BACKGROUND

Common bile duct (CBD) stone is one of the most common diseases among elderly people. In recent decades, there are numerous studies regarding the safety and efficacy of laparoscopic common bile duct exploration (LCBDE). Elderly patients are often regarded as high-risk patients because they are more likely to present with age-specific deterioration of organ function and coexisting chronic diseases, which may reduce their tolerance of laparoscopic surgery. Although laparoscopic surgery for choledocholithiasis is now widely accepted as the treatment for CBD stone, its appropriateness for the treatment of elderly patients or those with coexisting high-risk patients has not been well established. Therefore, the objective of this paper is to analyze the safety and efficacy of LCBDE in elderly patients.

METHODS

Between January 2012 and November 2015, 376 patients underwent LCBDE in our center. Based on their ages, they were divided into two groups, and a retrospective study was performed. By making comparisons between younger group who were younger than 70 years (n = 253) and elderly group who were 70 years old or older (n = 123), the demographics, clinical characteristics, laboratory data, operative parameters and outcomes were analyzed.

RESULTS

Before operation, elderly patients had more coexisting chronic diseases and risk factors, such as arterial hypertension, heart diseases, pulmonary diseases and previous abdominal surgery (P < 0.05). In both groups, LCBDE was equally successful with a high clearance rate (100 % in elderly patients vs. 98.8 % in younger group, P = 0.554). Besides, the operating time, intraoperative blood loss, postoperative hospital stay, total costs and overall complication showed no significant difference between two groups (P > 0.05). There was no major bile duct injury or death in either group.

CONCLUSION

Although elderly patients are frequently confronted with coexisting disorders, LCBDE can be considered as a safe and effective technique in choledocholithiasis treatment for elderly patients.

Value of liver function test for prediction of asymptomatic common bile duct stones in patients with cholecystolithiasis

AIM

To investigate the diagnostic value of abnormal liver function parameters for concomitant asymptomatic choledocholithiasis in cholecystolithiasis patients.

METHODS

The clinical data of 398 patients with cholecystolithiasis treated at our hospital from January 2012 to January 2016 were retrospectively analyzed. According to the presence of concomitant asymptomatic choledocholithiasis or not, the patients were divided into two groups: choledocholithiasis group and cholecystolithiasis group. The risk factors for the disease were evaluated. The receiver operating characteristic (ROC) curves for the significant parameters were generated to assess their sensitivities and specificities for diagnosis of concomitant asymptomatic choledocholithiasis in cholecystolithiasis patients.

RESULTS

There were no significant differences in serum levels of alanine transaminase (ALT), aspartate transaminase (AST), total bilirubin (TBIL), or indirect bilirubin (DBIL) between the choledocholithiasis and cholecystolithiasis groups. Serum levels of γ-glutamyltransferase (GGT) and alkaline phosphatase (ALP) in the choledocholithiasis group were significantly higher than those in the cholecystolithiasis group (P < 0.05). The ROC curve analysis showed that the areas under the ROC curve of GGT and ALP were 0.914 and 0.569, and the corresponding cut-off values were 89.5 U/L and 136 U/L (sensitivity: 89.9% and 45.8%; specificity: 79.18% and 71.90%), respectively.

CONCLUSION

Abnormally elevated GGT and ALP have value for prediction of concomitant asymptomatic choledocholithiasis in cholecystolithiasis patients.

2016 WSES guidelines on acute calculous cholecystitis

Acute calculus cholecystitis is a very common disease with several area of uncertainty. The World Society of Emergency Surgery developed extensive guidelines in order to cover grey areas. The diagnostic criteria, the antimicrobial therapy, the evaluation of associated common bile duct stones, the identification of “high risk” patients, the surgical timing, the type of surgery, and the alternatives to surgery are discussed. Moreover the algorithm is proposed: as soon as diagnosis is made and after the evaluation of choledocholitiasis risk, laparoscopic cholecystectomy should be offered to all patients exception of those with high risk of morbidity or mortality. These Guidelines must be considered as an adjunctive tool for decision but they are not substitute of the clinical judgement for the individual patient.

Accuracy of ASGE criteria for the prediction of choledocholithiasis

BACKGROUND/AIMS

Few studies have validated the performance of guidelines for the prediction of choledocholithiasis (CL). Our objective was to prospectively assess the accuracy of the American Society for Gastrointestinal Endoscopy (ASGE) guidelines for the identification of CL.

METHODS

A two-year prospective evaluation of patients with suspected CL was performed. We evaluated the ASGE guidelines and its component variables in predicting CL.

RESULTS

A total of 256 patients with suspected CL were analyzed. Of the 208 patients with high-probability criteria for CL, 124 (59.6%) were found to have a stone/sludge at endoscopic retrograde cholangiopancreatography (ERCP). Among 48 patients with intermediate-probability criteria, 21 (43.8%) had a stone/sludge. The performance of ASGE high- and intermediate-probability criteria in our population had an accuracy of 59.0% (85.5% sensitivity, 24.3% specificity) and 41.0% (14.4% sensitivity, 75.6% specificity), respectively. The mean ERCP delay time was 6.1 days in the CL group and 6.4 days in the group without CL, p = 0.638. The presence of a common bile duct (CBD) > 6 mm (OR 2.21; 95% CI, 1.20-4.10), ascending cholangitis (OR 2.37; 95% CI, 1.01-5.55) and a CBD stone visualized on transabdominal US (OR 3.33; 95% CI, 1.48-7.52) were stronger predictors of CL. The occurrence of biliary pancreatitis was a strong protective factor for the presence of a retained CBD stone (OR 0.30; 95% CI, 0.17-0.55).

CONCLUSIONS

Irrespective of a patient's ASGE probability for CL, the application of current guidelines in our population led to unnecessary performance of ERCPs in nearly half of cases.

Role of laparoscopic common bile duct exploration in the management of choledocholithiasis

Surgical fraternity has not yet arrived at any consensus for adequate treatment of choledocholithiasis. Sequential treatment in the form of pre-operative endoscopic retrograde cholangio-pancreatography followed by laparoscopic cholecystectomy (LC) is considered as optimal treatment till date. With refinements in technique and expertise in field of minimal access surgery, many centres in the world have started offering one stage management of choledocholithiasis by LC with laparoscopic common bile duct exploration (LCBDE). Various modalities have been tried for entering into concurrent common bile duct (CBD) [transcystic (TC) vs transcholedochal (TD)], for confirming stone clearance (intraoperative cholangiogram vs choledochoscopy), and for closure of choledochotomy (T-tube vs biliary stent vs primary closure) during LCBDE. Both TC and TD approaches are safe and effective. TD stone extraction is involved with an increased risk of bile leaks and requires more expertise in intra-corporeal suturing and choledochoscopy. Choice depends on number of stones, size of stone, diameter of cystic duct and CBD. This review article was undertaken to evaluate the role of LCBDE for the management of choledocholithiasis.

Use of the Ambu® aScope 2TM in laparoscopic common bile duct exploration

BACKGROUND

We have recently begun to use a sterile disposable endoscope to perform laparoscopic common bile duct exploration. We evaluated our practice in a large district general hospital and reported the early feasibility of this equipment in performing bile duct exploration.

METHODS

We began to use the Ambu^® aScope 2^TM from June 2015 in our institution. Any case eligible for a laparoscopic common bile duct exploration was included. Our study period is from June 2015 to November 2015. Data were collected and analysed retrospectively.

RESULTS

Thirteen patients were included. Nine were female and five were male. The mean age was 59 years old (range 28 to 82 years). Seven were performed as an emergency and six were performed for elective cases. All patients had common bile duct stones with no history of previous cholecystectomy. The Ambu^® aScope 2^TM was used in 11 cases, and a standard choledocoscope was used in two cases due to lack of availability of the Ambu^® aScope 2^TM. There was one conversion due to an impacted bile duct stone and technical difficulty intra-operatively. Five cases were performed as a transcystic exploration with 1 case being converted to a choledocotomy due to inability to pass the cystic duct using the Ambu^® aScope 2^TM. The mean operating time was 158 min (range 85-255 min). The mean operative time using the reusable endoscope was 130 min. The mean postoperative stay was 3 days (range 0-8 days).

CONCLUSIONS

The use of the Ambu^® aScope 2^TM is safe and feasible in laparoscopic common bile duct exploration. It confers significant financial benefits and offers an economical alternative to expensive reusable endoscopes.

Diagnosis and treatment of cholelithiasis: A review based on meta-analyses

Cholelithiasis is common disease whose diagnosis and treatment are important for doctors. Nowadays, main diagnostic methods include X-ray, ultrasonography, CT and MRI. Major treatments are surgical and endoscopic approaches. With evidence based medicine developing, more and more meta-analyses, which provide much best evidence, are reported. By means of summarizing these meta-analyses, we provide the best evidence for clinicians to update their knowledge on the diagnosis and treatment of cholelithiasis.

Endoscopic ultrasound-assisted transmural cholecystoduodenostomy or cholecystogastrostomy as a bridge for per-oral cholecystoscopy therapy using double-flanged fully covered metal stent

BACKGROUND

Laparoscopic cholecystectomy (LC) has become the 'gold standard' for the treatment of symptomatic gallstones. Innovative methods are being introduced, and these procedures include transgastric or transcolonic endoscopic cholecystectomy. However, before clinical implementation, instruments still need modification, and a more convenient treatment is still needed. Moreover, some gallbladders still have good functionality and cholecystectomy may be associated with various complications. The aim of this study was to evaluate the trans-gastrointestinal tract cholecystoscopy technique in the treatment of gallbladder disease without cholecystectomy.

METHOD

Endoscopic ultrasound (EUS)-guided cholecystoduodenostomy or cholecystogastrostomy with the placement of a double-flanged fully covered metal stent was performed and endoscopic sphincterotomy (EST) was also performed during this procedure for those patients with accompanying common bile duct stones. One or two weeks later the stent was removed and an endoscope was advanced into the gallbladder via the fistula, and cholecystolithotomy or polyp resection was performed. Four weeks later gallbladder was assessed by abdominal ultrasound.

RESULTS

EUS guided cholecystoduodenostomy (n = 3) or cholecystogastrostomy (n = 4) with double flanged mental stent deployment was successfully performed in all of 7 patients. After the procedure, fistulas had formed in each of the patients and the stents were removed. Endoscopic cholecystolithotomy(7) and polyps resection(2) were successfully performed through the fistulas. Common bile duct stones were also successfully removed in 5 patients. The ultrasound examination of the gallbladder 4 weeks later showed no stones remaining and also showed satisfactory functioning of the gallbladder.

CONCLUSION

The EUS-guided placement of a novel metal stent is a safe and simple approach for performing an endoscopic cholecystoduodenostomy or cholecystogastrostomy, which can subsequently allow procedures to be performed for treating biliary disease, including cholecystolithotomy.

Results of Medium Seventeen Years' Follow-Up after Laparoscopic Choledochotomy for Ductal Stones

Introduction. In a previously published article the authors reported the long-term follow-up results in 138 consecutive patients with gallstones and common bile duct (CBD) stones who underwent laparoscopic transverse choledochotomy (TC) with T-tube biliary drainage and laparoscopic cholecystectomy (LC). Aim of this study is to evaluate the results at up to 23 years of follow-up in the same series. Methods. One hundred twenty-one patients are the object of the present study. Patients were evaluated by clinical visit, blood assay, and abdominal ultrasound. Symptomatic patients underwent cholangio-MRI, followed by endoscopic retrograde cholangiopancreatography (ERCP) as required. Results. Out of 121 patients, 61 elderly patients died from unrelated causes. Fourteen patients were lost to follow-up. In the 46 remaining patients, ductal stone recurrence occurred in one case (2,1%) successfully managed by ERCP with endoscopic sphincterotomy. At a mean follow-up of 17.1 years no other patients showed signs of bile stasis and no patient showed any imaging evidence of CBD stricture at the site of choledochotomy. Conclusions. Laparoscopic transverse choledochotomy with routine T-tube biliary drainage during LC has proven to be safe and effective at up to 23 years of follow-up, with no evidence of CBD stricture when the procedure is performed with a correct technique.

Cost Utility of Competing Strategies to Prevent Endoscopic Transmission of Carbapenem-Resistant Enterobacteriaceae

OBJECTIVES

Prior reports have linked patient transmission of carbapenem-resistant Enterobacteriaceae (CRE, or "superbug") to endoscopes used during endoscopic retrograde cholangiopancreatography (ERCP). We performed a decision analysis to measure the cost-effectiveness of four competing strategies for CRE risk management.

METHODS

We used decision analysis to calculate the cost-effectiveness of four approaches to reduce the risk of CRE transmission among patients presenting to the hospital for symptomatic common bile duct stones. The strategies included the following: (1) perform ERCP followed by US Food and Drug Administration (FDA)-recommended endoscope reprocessing procedures; (2) perform ERCP followed by "endoscope culture and hold"; (3) perform ERCP followed by ethylene oxide (EtO) sterilization of the endoscope; and (4) stop performing ERCP in lieu of laparoscopic cholecystectomy (LC) with common bile duct exploration (CBDE). Our outcome was incremental cost per quality-adjusted life year (QALY) gained.

RESULTS

In the base-case scenario, ERCP with FDA-recommended endoscope reprocessing was the most cost-effective strategy. Both the ERCP with culture and hold ($4,228,170/QALY) and ERCP with EtO sterilization ($50,572,348/QALY) strategies had unacceptable incremental costs per QALY gained. LC with CBDE was dominated, being both more costly and marginally less effective vs. the alternatives. In sensitivity analysis, ERCP with culture and hold became the most cost-effective approach when the pretest probability of CRE exceeded 24%.

CONCLUSIONS

In institutions with a low CRE prevalence, ERCP with FDA-recommended reprocessing is the most cost-effective approach for mitigating CRE transmission risk. Only in settings with an extremely high CRE prevalence did ERCP with culture and hold become cost-effective.

Training vs practice: A tale of opposition in acute cholecystitis

Acute cholecystitis is one of the most common surgical diagnoses encountered by general surgeons. Despite its high incidence there remains a range of treatment of approaches. Current practices in biliary surgery vary as to timing, intraoperative utilization of biliary imaging, and management of bile duct stones despite growing evidence in the literature defining best practice. Management of patients with acute cholecystitis with early laparoscopic cholecystectomy (LC) results in better patient outcomes when compared with delayed surgical management techniques including antibiotic therapy or percutaneous cholecystostomy. Regardless of this data, many surgeons still prefer to utilize antibiotic therapy and complete an interval LC to manage acute cholecystitis. The use of intraoperative biliary imaging by cholangiogram or laparoscopic ultrasound has been demonstrated to facilitate the safe completion of cholecystectomy, minimizing the risk for inadvertent injury to surrounding structures, and lowering conversion rates, however it is rarely utilized. Choledocholithiasis used to be a diagnosis managed exclusively by surgeons but current practice favors referral to gastroenterologists for performance of preoperative endoscopic removal. Yet, there is evidence that intraoperative laparoscopic stone extraction is safe, feasible and may have added advantages. This review aims to highlight the differences between existing management of acute cholecystitis and evidence supported in the literature regarding best practice with the goal to change surgical practice to adopt these current recommendations.

The Surgical Management of Concomitant Gallbladder and Common Bile Duct Stones

Background. The management of choledocholithiasis has evolved from open common bile duct exploration (OCBDE) to therapeutic endoscopic retrograde cholangiopancreatography (ERCP) to laparoscopic common bile duct exploration (LCBDE). Each entails a degree of difficulty. Aim. To review 5-year results of bile duct exploration in an UGI unit. Methods. Common bile duct explorations (CBDEs) performed between January 2008 and January 2013 were identified from a prospectively collected clinical audit system and results reviewed retrospectively. Results. 216 CBDEs were performed, 119 (55%) as an emergency and 52 (24%) following failed ERCP. Open CBDE (OCBDE) was performed primarily in 34/216 (16%) patients and attempted laparoscopically in 182 (84%). Fifty nine (32%) Laparoscopic CBDEs (LCBDEs) were converted to OCBDE. Of the remaining 123 LCBDEs, 51 (41%) primary choledochotomies and 72 (59%) primary transcystic CBDEs (TC-CBDEs) were performed. Forty nine (68%) TC-CBDEs were considered successful and 23 (32%) failed. Fifteen failed TC-CBDEs were converted to a successful laparoscopic choledochotomy. Ductal clearance was achieved in 187/216 (87%) patients and retained stones were identified in 20/123 (16%) LCBDEs. Complications occurred in 52/216 (24%) patients. There were 8/216 (4%) bile leaks requiring further intervention. Postoperative ERCP was carried out in 32/216 (15%) patients and 9/216 (4%) required relaparoscopy/laparotomy. No patient died. Conclusions. Successful management of choledocholithiasis requires a breadth of laparoscopic and endoscopic expertise.

Laparoscopic common bile duct exploration: 15-year experience in a district general hospital

INTRODUCTION

The treatment of common bile duct (CBD) stones remains controversial with debate between endoscopic cholangiopancreatography (ERCP) and CBD exploration. A recent meta-analysis has shown no significant difference between these approaches; however, there is a trend in the literature to favour a single-stage procedure in the form of laparoscopic CBD exploration. We report our experience over a 15-year period.

METHODS

All cases of CBD exploration were identified from 2000 to 2015 and analysed retrospectively from a large NHS Foundation Trust in Northumbria. There were no exclusions. The mean clinical follow-up was 6 months (range 3-36 months).

RESULTS

A total of 296 patients were included who underwent laparoscopic CBD exploration: 203 were female and 93 were male. The mean age was 60 years (range 16-84 years). A total of 231 procedures were performed electively and 65 as an emergency. Ten procedures were successfully performed as day cases. Eleven procedures were converted to an open procedure due to adhesions or a difficult dissection (4 %). Sixty-three procedures were performed with a transcystic approach with a mean post-op stay of 2 days (range 0-7). A total of 233 procedures were performed with a choledocotomy with a mean post-op stay of 6 days (range 3-14 days). Stone clearance was successful in 255 patients (86 %). Three patients died over the study period. Two were for medical complications and one for abdominal sepsis. Three patients returned to theatre for early post-operative bleeding (1 %). Sixteen patients had persistent bile leaks following a choledocotomy (6.8 %). No patients had a bile leak following transcystic exploration. Fourteen patients were followed up following failed stone removal. Nine had a successful ERCP, three had no stone seen on MRCP, and one patient required re-operation following a failed ERCP.

CONCLUSIONS

Laparoscopic bile duct exploration can be performed successfully in both the emergency and elective settings. Day-case surgery is feasible in selected patients. A transcystic approach should be favoured where possible.

Basket-in-catheter access for transcystic laparoscopic bile duct exploration: technique and results

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.

Risk Factors Associated With Residual Stones in Common Bile Duct Via T Tube Cholangiography After Common Bile Duct Exploration

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.

Surgery for common bile duct stones--a lost surgical skill; still worthwhile in the minimally invasive century?

PURPOSE

Techniques of laparoscopic bile duct exploration have been reported for over 20 years. Despite the simplicity and success of these procedures, they have failed to become commonplace in most surgical departments, as endoscopic retrograde cholangiopancreatography (ERCP) has become the preferred method for dealing with bile duct stones. There is a risk of surgeons not obtaining or losing these skills, which may still be required as a definitive treatment when ERCP fails or is not available.

METHODS AND RESULTS

This paper describes these laparoscopic operations, which can be performed to enable a 'one-stop shop' treatment of common bile duct stones (CBDS) at the time of cholecystectomy. In particular, transcystic basket clearance of the bile duct is possible in two-thirds of cases with very little increase in morbidity compared to routine cholecystectomy. The selection of patients who are most likely to be successfully treated with this technique is defined. Some of the authors have published large study series and prospective randomised trials, further refining the choices available to the surgeon who, when performing operative cholangiography, is already halfway to bile duct exploration.

CONCLUSIONS

Surgery may reclaim this lost ground by offering an excellent and safe therapeutic option for many of the symptomatic CBDS.

Diagnosis and management of choledocholithiasis in the golden age of imaging, endoscopy and laparoscopy

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.

Calculated Antibiosis of Acute Cholangitis and Cholecystitis

Background

The aim of this article is to present the most recent suggestions for the therapy of acute cholangitis and cholecystitis based on a review of the current literature.

Methods

We performed a systematic literature search in the Medline, PubMed, and Google Scholar databases using the keywords mentioned above. This article is strongly influenced by the publication of the Tokyo Guidelines for the management of acute cholangitis and cholecystitis (TG07, TG13) in 2007 and 2013. These were the first practical guidelines targeting diagnosis and treatment of acute cholangitis and cholecystitis. These guidelines are based on the best published evidence and a consensus conference of international experts in the field.

Results and Conclusion

Acute cholangitis and acute cholecystitis are common conditions that may result in progressively severe infection and death when not treated appropriately. Beside supportive therapy and antiobstructive measures, therapy with antimicrobial agents is an important component in the management of affected patients. Here, we discuss the use of antimicrobial agents that are suitable for the first-line management of these infections. Empirical therapy depends upon the knowledge of local microbial epidemiology and patient-specific factors affecting the selection of appropriate agents.