Bile duct stones in the laparoscopic era. Is preoperative sphincterotomy necessary?

Novel technique for laparoscopic common bile duct exploration using flexible videobronchoscope to study on clinical outcomes of single-stage (laparoscopic cholecystectomy and laparoscopic common bile duct exploration) versus dual-stage (endoscopic retrograde cholangiopancreatography followed by laparoscopic cholecystectomy) for cholelithiasis with choledocholithiasis - Prospective study in a tertiary care centre (BRACE study - BRonchoscope Assisted Common bile duct Exploration Study)

INTRODUCTION

This study aimed to study on clinical outcomes of single-stage (laparoscopic cholecystectomy [LC] and laparoscopic common bile duct [CBD] exploration using flexible videobronchoscope) versus dual-stage (endoscopic retrograde cholangiopancreatography followed by laparoscopic cholecystectomy) for cholelithiasis with choledocholithiasis-prospective study in a tertiary care centre (BRACE STUDY-Bronchoscope-Assisted CBD Exploration [CBDE] Study).

PATIENTS AND METHODS

Between April 2022 and April 2023, patients who underwent LC with laparoscopic CBDE and endoscopic retrograde cholangiopancreatography (ERCP) followed by LC participated in this single-centre prospective research. The Institute Ethics Committee granted its approval after receiving an ethical review. The primary endpoint of the proposed research was the removal of the gall bladder and CBD stones. The secondary outcomes studied were complications using the Clavien-Dindo score, cost-effectiveness, patient satisfaction score and post-procedure duration of hospital stay.

RESULTS

A total of 168 patients were included in the study. The success rate of LC with laparoscopic CBD exploration using a flexible videobronchoscope (Group 1) was significantly higher as compared to ERCP f/b LC (Group 2) (96.4% vs. 84.5%, P value = 0.02). Out of the 84 patients in Group 1, direct choledochotomies were performed on 83 of them. Group 1 had a considerably shorter hospital stay (4.6 ± 2.4 vs. 5.3 ± 6.2 days; P = 0.03). Both the cost ( P = 0.002) and the number of procedures per patient ( P < 0.001) were considerably higher in Group 2. Major complications (Clavien-Dindo grade 3 and above) were significantly higher in Group 2 ( P = 0.04). Patient satisfaction in Group 1 scored more favourably than those in Group 2 (2.26 ± 0.3 vs. 1.92 ± 0.7; P = 0.006).

CONCLUSION

For concurrent gall bladder and CBD stones, single-stage management by LCBDE using a flexible videobronchoscope has a significantly better primary outcome and lower major complications than dual-stage management. The single-stage strategy also has advantages in terms of a shorter hospital stay, the need for fewer procedures, cost efficiency and patient satisfaction.

Single-stage procedure for the treatment of cholecysto-choledocolithiasis: a surgical procedures review

While laparoscopic cholecystectomy is generally accepted as the treatment of choice for simple gallbladder stones, in cases in which common bile duct stones are also present, clinical and diagnostic elements, along with intraoperative findings, define the optimal means of treatment. All available options must be accessible to the surgical team which must necessarily be multidisciplinary and include a surgeon, an endoscopist, and a radiologist in order to identify the best option for a truly personalized surgery. This review describes the different techniques and approaches used based on distinctive recommendations and factors, according to the specific cases treated and the results achieved.

Laparoscopic management of common bile duct stones: transpapillary stenting or external biliary drainage?

BACKGROUND

To date, the management of common bile duct stones (CBDs) is still controversial. If laparoscopic exploration is performed and biliary decompression is needed after stone removal, the placement of a laparoscopic transpapillary stent shows promising results in avoiding T-tube-related complications.

METHODS

Between January 2007 and May 2012, a series of 48 patients who underwent biliary decompression after laparoscopic common bile duct exploration (LCBDE) to treat choledocholithiasis was retrospectively analyzed. The results in patients with transpapillary stent placement (TS=35) were compared with those who had an external biliary drainage (EBD=13).

RESULTS

LCBDE and TS placement was achieved either by a choledochotomy or through the cystic duct. There was no mortality in our series. Patients with an external biliary drainage (EBD) had more surgery-related complications (P<.0001) and a longer hospital stay (P=.03). Postoperative ERCP to remove the TS was successful in all cases.

CONCLUSION

Laparoscopic TS is a safe method in the treatment of selected patients with CBD stones that can be achieved without having to perform a choledochotomy. Because of the lower morbidity and the shorter hospital stay compared with EBD, it should be considered as a first approach whenever biliary decompression is needed after LCBDE.

The Role of Choledochoscopy

Background. Identifying and surgically removing bile duct calculi is challenging and critical in order to provide good patient outcomes. The history of this surgical pursuit since the introduction of anesthesia is both enlightening and fascinating. Methods. A systematic review of the literature was conducted to identify the techniques and technology used to remove bile duct calculi. Results. All bile duct surgical exploration advances have involved creation of tools to look within the bile duct and extract stones. The Hopkin’s rod lens system was a major breakthrough in light and image transmission. However, flexible endoscope technology added the ability to maneuver better within the bile duct as well as apply the technology via laparoscopy enabling laparoscopic bile duct exploration. Conclusion. Digital, image enhanced, distal tipped chip flexible endoscopes have significantly improved the surgeons’ ability to see within the bile duct, improving the efficiency and ease of stone visualization and removal from both the most proximal and distal ends of the bile duct.

Surgical versus endoscopic treatment of bile duct stones

BACKGROUND

Between 10% to 18% of people undergoing cholecystectomy for gallstones have common bile duct stones. Treatment of the bile duct stones can be conducted as open cholecystectomy plus open common bile duct exploration or laparoscopic cholecystectomy plus laparoscopic common bile duct exploration (LC + LCBDE) versus pre- or post-cholecystectomy endoscopic retrograde cholangiopancreatography (ERCP) in two stages, usually combined with either sphincterotomy (commonest) or sphincteroplasty (papillary dilatation) for common bile duct clearance. The benefits and harms of the different approaches are not known.

OBJECTIVES

We aimed to systematically review the benefits and harms of different approaches to the management of common bile duct stones.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL, Issue 7 of 12, 2013) in The Cochrane Library, MEDLINE (1946 to August 2013), EMBASE (1974 to August 2013), and Science Citation Index Expanded (1900 to August 2013).

SELECTION CRITERIA

We included all randomised clinical trials which compared the results from open surgery versus endoscopic clearance and laparoscopic surgery versus endoscopic clearance for common bile duct stones.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified the trials for inclusion and independently extracted data. We calculated the odds ratio (OR) or mean difference (MD) with 95% confidence interval (CI) using both fixed-effect and random-effects models meta-analyses, performed with Review Manager 5.

MAIN RESULTS

Sixteen randomised clinical trials with a total of 1758 randomised participants fulfilled the inclusion criteria of this review. Eight trials with 737 participants compared open surgical clearance with ERCP; five trials with 621 participants compared laparoscopic clearance with pre-operative ERCP; and two trials with 166 participants compared laparoscopic clearance with postoperative ERCP. One trial with 234 participants compared LCBDE with intra-operative ERCP. There were no trials of open or LCBDE versus ERCP in people without an intact gallbladder. All trials had a high risk of bias.There was no significant difference in the mortality between open surgery versus ERCP clearance (eight trials; 733 participants; 5/371 (1%) versus 10/358 (3%) OR 0.51;95% CI 0.18 to 1.44). Neither was there a significant difference in the morbidity between open surgery versus ERCP clearance (eight trials; 733 participants; 76/371 (20%) versus 67/358 (19%) OR 1.12; 95% CI 0.77 to 1.62). Participants in the open surgery group had significantly fewer retained stones compared with the ERCP group (seven trials; 609 participants; 20/313 (6%) versus 47/296 (16%) OR 0.36; 95% CI 0.21 to 0.62), P = 0.0002.There was no significant difference in the mortality between LC + LCBDE versus pre-operative ERCP +LC (five trials; 580 participants; 2/285 (0.7%) versus 3/295 (1%) OR 0.72; 95% CI 0.12 to 4.33). Neither was there was a significant difference in the morbidity between the two groups (five trials; 580 participants; 44/285 (15%) versus 37/295 (13%) OR 1.28; 95% CI 0.80 to 2.05). There was no significant difference between the two groups in the number of participants with retained stones (five trials; 580 participants; 24/285 (8%) versus 31/295 (11%) OR 0.79; 95% CI 0.45 to 1.39).There was only one trial assessing LC + LCBDE versus LC+intra-operative ERCP including 234 participants. There was no reported mortality in either of the groups. There was no significant difference in the morbidity, retained stones, procedure failure rates between the two intervention groups.Two trials assessed LC + LCBDE versus LC+post-operative ERCP. There was no reported mortality in either of the groups. There was no significant difference in the morbidity between laparoscopic surgery and postoperative ERCP groups (two trials; 166 participants; 13/81 (16%) versus 12/85 (14%) OR 1.16; 95% CI 0.50 to 2.72). There was a significant difference in the retained stones between laparoscopic surgery and postoperative ERCP groups (two trials; 166 participants; 7/81 (9%) versus 21/85 (25%) OR 0.28; 95% CI 0.11 to 0.72; P = 0.008.In total, seven trials including 746 participants compared single staged LC + LCBDE versus two-staged pre-operative ERCP + LC or LC + post-operative ERCP. There was no significant difference in the mortality between single and two-stage management (seven trials; 746 participants; 2/366 versus 3/380 OR 0.72; 95% CI 0.12 to 4.33). There was no a significant difference in the morbidity (seven trials; 746 participants; 57/366 (16%) versus 49/380 (13%) OR 1.25; 95% CI 0.83 to 1.89). There were significantly fewer retained stones in the single-stage group (31/366 participants; 8%) compared with the two-stage group (52/380 participants; 14%), but the difference was not statistically significantOR 0.59; 95% CI 0.37 to 0.94).There was no significant difference in the conversion rates of LCBDE to open surgery when compared with pre-operative, intra-operative, and postoperative ERCP groups. Meta-analysis of the outcomes duration of hospital stay, quality of life, and cost of the procedures could not be performed due to lack of data.

AUTHORS' CONCLUSIONS

Open bile duct surgery seems superior to ERCP in achieving common bile duct stone clearance based on the evidence available from the early endoscopy era. There is no significant difference in the mortality and morbidity between laparoscopic bile duct clearance and the endoscopic options. There is no significant reduction in the number of retained stones and failure rates in the laparoscopy groups compared with the pre-operative and intra-operative ERCP groups. There is no significant difference in the mortality, morbidity, retained stones, and failure rates between the single-stage laparoscopic bile duct clearance and two-stage endoscopic management. More randomised clinical trials without risks of systematic and random errors are necessary to confirm these findings.

One-step Laparoscopic and Endoscopic Treatment of Gallbladder and Common Bile Duct Stones: Our Experience of the Last 9 Years in a Retrospective Study

The optimal timing and best method for removal of common bile duct stones (CBDS) associated with gallbladder stones (GBS) is still controversial. The aim of this study is to investigate the outcomes of a single-step procedure combining laparoscopic cholecystectomy (LC), intra-operative cholangiography (IOC), and endoscopic retrograde cholangiopancreatography (ERCP). Between January 2003 and January 2012, 1972 patients underwent cholecystectomy at our hospital. Of those, 162 patients (8.2%; male/female 72/90) presented with GBS and suspected CBDS. We treated 54 cases (Group 1) with ERCP and LC within 48 to 72 hours. In 108 patients (Group 2) we performed LC with IOC and, if positive, was associated with IO-ERCP and sphincterotomy. In Group 1, a preoperative ERCP and LC were completed in 50 patients (30%). In four cases (2%), an ERCP and endobiliary stents were performed without cholecystectomy and then patients were discharged because of the severity of clinical conditions and advanced American Society of Anesthesiologists score (III to IV). Two months later a preoperative ERCP and removal of biliary stents were performed followed by LC 48 to 72 hours later. In Group 2, the IOC was performed in all cases and CBDS were extracted in 94 patients (87%). In two cases, the laparoscopic choledochotomy was necessary to remove large stones. In another two cases, an open choledochotomy was performed to remove safely the stones with T-tube drainage. In three cases, conversion was necessary to safely complete the procedure. The mean operative time was 95 minutes (range, 45 to 150 minutes) in Group 1 and 130 minutes (range, 50 to 300 minutes) in Group 2. The mean hospital stay was 6.5 days (range, 4 to 21 days) in Group 1 and 4.7 days (range, 3 to 14 days) in Group 2. Five cases (two in Group 2 and three in Group 1) presented with CBDS at 12 to 18 months after surgery. They were treated successfully with a second ERCP. There was no perioperative mortality. Our experience suggests that when clinically and technically feasible, a single-stage approach combining LC, IOC, and ERCP to the patients diagnosed with chole-choledocholithiasis is indicated. The IO-ERCP with CBDS extraction is a safe and effective method with low risk of postoperative pancreatitis. One-step treatment is more comfortable for the patient and also reduces the mean hospital stay.

Single-stage laparoscopic common bile duct exploration and cholecystectomy versus two-stage endoscopic stone extraction followed by laparoscopic cholecystectomy for patients with concomitant gallbladder stones and common bile duct stones: a randomized controlled trial

BACKGROUND

The ideal method for managing concomitant gallbladder stones and common bile duct (CBD) stones is debatable. The currently preferred method is two-stage endoscopic stone extraction followed by laparoscopic cholecystectomy (LC). This prospective randomized trial compared the success and cost effectiveness of single- and two-stage management of patients with concomitant gallbladder and CBD stones.

METHODS

Consecutive patients with concomitant gallbladder and CBD stones were randomized to either single-stage laparoscopic CBD exploration and cholecystectomy (group 1) or endoscopic retrograde cholangiopancreatography (ERCP) for endoscopic extraction of CBD stones followed by LC (group 2). Success was defined as complete clearance of CBD and cholecystectomy by the intended method. Cost effectiveness was measured using the incremental cost-effectiveness ratio. Intention-to-treat analysis was performed to compare outcomes.

RESULTS

From February 2009 to October 2012, 168 patients were randomized: 84 to the single-stage procedure (group 1) and 84 to the two-stage procedure (group 2). Both groups were matched with regard to demographic and clinical parameters. The success rates of laparoscopic CBD exploration and ERCP for clearance of CBD were similar (91.7 vs. 88.1 %). The overall success rate also was comparable: 88.1 % in group 1 and 79.8 % in group 2 (p = 0.20). Direct choledochotomy was performed in 83 of the 84 patients. The mean operative time was significantly longer in group 1 (135.7 ± 36.6 vs. 72.4 ± 27.6 min; p ≤ 0.001), but the overall hospital stay was significantly shorter (4.6 ± 2.4 vs. 5.3 ± 6.2 days; p = 0.03). Group 2 had a significantly greater number of procedures per patient (p < 0.001) and a higher cost (p = 0.002). The two groups did not differ significantly in terms of postoperative wound infection rates or major complications.

CONCLUSIONS

Single- and two-stage management for uncomplicated concomitant gallbladder and CBD stones had similar success and complication rates, but the single-stage strategy was better in terms of shorter hospital stay, need for fewer procedures, and cost effectiveness.

Surgical versus endoscopic treatment of bile duct stones

BACKGROUND

Between 10% to 18% of people undergoing cholecystectomy for gallstones have common bile duct stones. Treatment of the bile duct stones can be conducted as open cholecystectomy plus open common bile duct exploration or laparoscopic cholecystectomy plus laparoscopic common bile duct exploration (LC + LCBDE) versus pre- or post-cholecystectomy endoscopic retrograde cholangiopancreatography (ERCP) in two stages, usually combined with either sphincterotomy (commonest) or sphincteroplasty (papillary dilatation) for common bile duct clearance. The benefits and harms of the different approaches are not known.

OBJECTIVES

We aimed to systematically review the benefits and harms of different approaches to the management of common bile duct stones.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL, Issue 7 of 12, 2013) in The Cochrane Library, MEDLINE (1946 to August 2013), EMBASE (1974 to August 2013), and Science Citation Index Expanded (1900 to August 2013).

SELECTION CRITERIA

We included all randomised clinical trials which compared the results from open surgery versus endoscopic clearance and laparoscopic surgery versus endoscopic clearance for common bile duct stones.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified the trials for inclusion and independently extracted data. We calculated the odds ratio (OR) or mean difference (MD) with 95% confidence interval (CI) using both fixed-effect and random-effects models meta-analyses, performed with Review Manager 5.

MAIN RESULTS

Sixteen randomised clinical trials with a total of 1758 randomised participants fulfilled the inclusion criteria of this review. Eight trials with 737 participants compared open surgical clearance with ERCP; five trials with 621 participants compared laparoscopic clearance with pre-operative ERCP; and two trials with 166 participants compared laparoscopic clearance with postoperative ERCP. One trial with 234 participants compared LCBDE with intra-operative ERCP. There were no trials of open or LCBDE versus ERCP in people without an intact gallbladder. All trials had a high risk of bias.There was no significant difference in the mortality between open surgery versus ERCP clearance (eight trials; 733 participants; 5/371 (1%) versus 10/358 (3%) OR 0.51;95% CI 0.18 to 1.44). Neither was there a significant difference in the morbidity between open surgery versus ERCP clearance (eight trials; 733 participants; 76/371 (20%) versus 67/358 (19%) OR 1.12; 95% CI 0.77 to 1.62). Participants in the open surgery group had significantly fewer retained stones compared with the ERCP group (seven trials; 609 participants; 20/313 (6%) versus 47/296 (16%) OR 0.36; 95% CI 0.21 to 0.62), P = 0.0002.There was no significant difference in the mortality between LC + LCBDE versus pre-operative ERCP +LC (five trials; 580 participants; 2/285 (0.7%) versus 3/295 (1%) OR 0.72; 95% CI 0.12 to 4.33). Neither was there was a significant difference in the morbidity between the two groups (five trials; 580 participants; 44/285 (15%) versus 37/295 (13%) OR 1.28; 95% CI 0.80 to 2.05). There was no significant difference between the two groups in the number of participants with retained stones (five trials; 580 participants; 24/285 (8%) versus 31/295 (11%) OR 0.79; 95% CI 0.45 to 1.39).There was only one trial assessing LC + LCBDE versus LC+intra-operative ERCP including 234 participants. There was no reported mortality in either of the groups. There was no significant difference in the morbidity, retained stones, procedure failure rates between the two intervention groups.Two trials assessed LC + LCBDE versus LC+post-operative ERCP. There was no reported mortality in either of the groups. There was no significant difference in the morbidity between laparoscopic surgery and postoperative ERCP groups (two trials; 166 participants; 13/81 (16%) versus 12/85 (14%) OR 1.16; 95% CI 0.50 to 2.72). There was a significant difference in the retained stones between laparoscopic surgery and postoperative ERCP groups (two trials; 166 participants; 7/81 (9%) versus 21/85 (25%) OR 0.28; 95% CI 0.11 to 0.72; P = 0.008.In total, seven trials including 746 participants compared single staged LC + LCBDE versus two-staged pre-operative ERCP + LC or LC + post-operative ERCP. There was no significant difference in the mortality between single and two-stage management (seven trials; 746 participants; 2/366 versus 3/380 OR 0.72; 95% CI 0.12 to 4.33). There was no a significant difference in the morbidity (seven trials; 746 participants; 57/366 (16%) versus 49/380 (13%) OR 1.25; 95% CI 0.83 to 1.89). There were significantly fewer retained stones in the single-stage group (31/366 participants; 8%) compared with the two-stage group (52/380 participants; 14%), but the difference was not statistically significantOR 0.59; 95% CI 0.37 to 0.94).There was no significant difference in the conversion rates of LCBDE to open surgery when compared with pre-operative, intra-operative, and postoperative ERCP groups. Meta-analysis of the outcomes duration of hospital stay, quality of life, and cost of the procedures could not be performed due to lack of data.

AUTHORS' CONCLUSIONS

Open bile duct surgery seems superior to ERCP in achieving common bile duct stone clearance based on the evidence available from the early endoscopy era. There is no significant difference in the mortality and morbidity between laparoscopic bile duct clearance and the endoscopic options. There is no significant reduction in the number of retained stones and failure rates in the laparoscopy groups compared with the pre-operative and intra-operative ERCP groups. There is no significant difference in the mortality, morbidity, retained stones, and failure rates between the single-stage laparoscopic bile duct clearance and two-stage endoscopic management. More randomised clinical trials without risks of systematic and random errors are necessary to confirm these findings.

Common bile duct stones: analysis of the videolaparoscopic surgical treatment

CONTEXT

About 9% of the Brazilian population has gallstones and the incidence increases significantly with aging. The choledocholithiasis is found around 15% of these patients, and a third to half of these cases presented as asymptomatic. Once the lithiasis in the common bile duct is characterized through intraoperative cholangiography, the laparoscopic surgical exploration can be done through the transcystic way or directly through choledochotomy.

OBJECTIVE

To evaluate the results and outcomes of the laparoscopic treatment of common bile duct lithiasis.

METHODS

Seventy consecutive patients were evaluated. They prospectively underwent the treatment of the lithiasis in the common bile duct and the exploration ways were compared according to the following parameters: criteria on their indication, success in the clearance, surgical complications. It was verified that about ½ of the choledocholithiasis carriers did not show any expression of predictive factors (clinical antecedents of jaundice and/or acute pancreatitis, compatible sonographic data and the pertaining lab tests). The laparoscopic exploration through the transcystic way is favored when there are no criteria for the practice of primary choledochotomy, which are: lithiasis in the proximal bile duct, large (over 8 mm) or numerous calculi (multiple calculosis).

RESULTS

The transcystic way was employed in about 50% of the casuistic and the choledochotomy in about 30%. A high success rate (around 80%) was achieved in the clearance of the common bile duct stones through laparoscopic exploration. The transcystic way, performed without fluoroscopy or choledochoscopy, attained a low rate of success (around 45%), being 10% of those by transpapilar pushing of calculi less than 3 mm. The exploration through choledochotomy, either primary or secondary, if the latter was performed after the transcystic route failure, showed high success rate (around 95%). When the indication to choledochotomy was primary, the necessity for choledochoscopy through choledochotomy to help in the removal of the calculi was 55%. However, when choledochotomy was performed secondarily, in situations where the common bile duct diameter was larger than 6 mm, the use of choledochoscopy with the same purpose involved about 20% of the cases. There was no mortality in this series.

CONCLUSION

The laparoscopic exploration of the common bile duct was related to a low rate of morbidity. Therefore, the use of laparoscopy for the treatment of the lithiasis in the common bile duct depends on the criteria for the choice of the best access, making it a safe procedure with very good results.

Multivariable analysis of cholecystectomy after gastrectomy: laparoscopy is a feasible initial approach even in the presence of common bile duct stones or acute cholecystitis

BACKGROUND

When performing cholecystectomy after gastrectomy, we often encounter problems, such as adhesions, nutritional insufficiency, and bowel reconstruction. The purpose of this study was to identify the factors related to surgical outcome of these associated procedures, with emphasis on the use of a laparoscopic approach.

METHODS

We retrospectively analyzed data from 58 patients who had a history of cholecystectomy after gastrectomy. Differences between subgroups with respect to operation time, length of postoperative hospital stay, and complications were analyzed. To identify the factors related with outcomes of cholecystectomy after gastrectomy, we performed multivariable analysis with the following variables: common bile duct (CBD) exploration, laparoscopic surgery, gender, acute cholecystitis, history of stomach cancer, age, body mass index, period of surgery, and interval between cholecystectomy and gastrectomy.

RESULTS

We found one case (2.9%) of open conversion. The CBD exploration was the most significant independent factor (adjusted odds ratio (OR), 45.15; 95% confidence interval (CI), 4.53-450.55) related to longer operation time. Acute cholecystitis also was a significant independent factor (adjusted OR, 14.66; 95% CI, 1.46-147.4). The laparoscopic approach was not related to operation time but was related to a shorter hospital stay (adjusted OR, 0.057; 95% CI, 0.004-0.74). Acute cholecystitis was independently related to the occurrence of complications (adjusted OR, 27.68; 95% CI, 1.15-666.24); however, CBD exploration and laparoscopic surgery were not. A lower BMI also was an independent predictor of the occurrence of complications (adjusted OR, 0.41; 95% CI, 0.2-0.87).

CONCLUSIONS

The laparoscopic approach is feasible for cholecystectomy after gastrectomy, even in cases with CBD stones or acute cholecystitis. This approach does not appear to increase operation time or complication rate and was shown to decrease the length of postoperative hospital stay.

Antegrade common bile duct (CBD) stenting after laparoscopic CBD exploration

Laparoscopic common bile duct exploration (LCBDE) has been found to be a safe, efficient and cost-effective treatment for choledocholithiasis. Following LCBDE, the clearance may be ascertained by a cholangiogram or choledochoscopy. The common bile duct (CBD) may be closed primarily with or without a stent in situ or may be drained by means of a T-tube or a biliary enteric anastomosis.

Laparoscopic management of CBD stones: an Indian experience

BACKGROUND

Common bile duct stones (CBDS) that are seen in the Asian population are very different from those seen in the west. It is not infrequent to see multiple, large, and impacted stones and a hugely dilated CBD. Many of these patients have been managed by open CBD exploration (OCBDE), even after the advent of laparoscopic cholecystectomy (LC), because these large stones pose significant challenges for extraction by endoscopic retrograde cholangiopancreatography. This series presents the largest experience of managing CBDS using a laparoscopic approach from Indian subcontinent.

METHODS

Between 2003 and 2009, 150 patients with documented CBDS were treated laparoscopically at a tertiary care hospital in New Delhi. Of these, 4 patients were managed through transcystic route and 140 through the transcholedochal route.

RESULTS

There were 34 men and 116 women patients with age ranging from 15 to 72 years. The mean size of the CBD on ultrasound was 11.7 ± 3.7 mm and on MRCP 13.8 ± 4.7 mm. The number of stones extracted varied from 1 to 70 and the size of the extracted stones from 5 to 30 mm. The average duration of surgery was 139.9 ± 26.3 min and the mean intraoperative blood loss was 103.4 ± 85.9 ml. There were 6 conversions to open procedures, 1 postoperative death (0.7%), and 23 patients (15%) had nonfatal postoperative complications. Three patients had retained stones (2%) and one developed recurrent stone (0.7%).

CONCLUSIONS

Even in patients with multiple, large, and impacted CBDS, there is scope for a minimally invasive procedure with its attendant benefits in the form of laparoscopic CBD exploration (LCBDE).

Prediction of which patients with an abnormal intraoperative cholangiogram will have a confirmed stone at ERCP

BACKGROUND

Abnormal intraoperative cholangiogram (IOC) findings are commonly evaluated using postoperative endoscopic retrograde cholangiopancreatography (ERCP). However, abnormal IOC studies are associated with high false-positive rates. This study aimed to identify a subset of patients with abnormal IOC who would benefit from a postoperative ERCP.

METHODS

This retrospective study investigated 68 patients with abnormal IOC at laparoscopic cholecystectomy (LC) who underwent postoperative ERCP at two tertiary referral centers over a 4-year period. Univariate and multivariate logistic regression analyses were performed to determine predictors of common bile duct (CBD) stones at postoperative ERCP. These predictors included: indication for LC, abnormal liver function tests, white blood cell count (WBC), amylase and lipase, abdominal ultrasound findings, and IOC findings [(1) non-passage of contrast into the duodenum, (2) single stone, (3) multiple stones, (4) dilated CBD, (5) non-visualization of the distal CBD, and (6) palpable CBD stones].

RESULTS

For all 68 patients, ERCP was successful. ERCP showed CBD stones in 36 cases (52.9%), and normal results in 32 cases (47%). On univariate and multivariate analysis, none of the variables included in this study significantly predicted stones at postoperative ERCP.

CONCLUSIONS

Approximately one-half of patients with an abnormal IOC have a normal postoperative ERCP. None of the parameters evaluated in this retrospective study helped identify patients who merit further evaluation by ERCP. The argument could be made that in patients with an abnormal IOC, less invasive methods such as endoscopic ultrasound or magnetic resonance cholangiopancreatography could be used postoperatively if symptoms arise to assess for possible retained stone.

A randomized, clinical trial to compare endoscopic sphincterotomy and subsequent laparoscopic cholecystectomy with primary laparoscopic bile duct exploration during cholecystectomy in higher risk patients with choledocholithiasis

INTRODUCTION

Outcomes after endoscopic sphincterotomy (ES) and subsequent laparoscopic cholecystectomy (LC) versus laparoscopic bile duct exploration (LBDE) during LC are comparable in fit patients with choledocholithiasis. This randomized, clinical trial aimed to determine the optimum treatment in patients with higher medical risk.

MATERIALS AND METHODS

Ninety-one higher risk patients with evidence of bile duct stones were randomized to ES/LC (group A) or LBDE during LC (group B). The primary outcome measure was duct clearance. Secondary outcome measures were complications, number of procedures per patient, conversion, and postoperative hospital stay (POS).

RESULTS

Forty-seven patients were randomized to ES/LC and 44 to LBDE. The median age was 74.56 years. On an intention-to-treat basis, duct clearance was achieved in 29 of 47 of group A and 44 of 44 of Group B patients (P < 0.001). Clavien Grade II-V complications occurred in 8 of 47 and 8 of 44 patients (P = 0.884), the median number of procedures was 2 (2-3) and 1 (1-1) (P < 0.001), 2 of 47 and 4 of 44 patients required conversion (P = 0.676), and the median POS was 3 (2-7) and 5 (2-7) days (P = 0.825), respectively.

CONCLUSIONS

There was no difference between approaches to duct clearance in terms of postoperative stay, complications, or conversion in higher risk patients, but the laparoscopic approach was more effective and efficient and avoided unnecessary procedures.

Single-step treatment of gall bladder and bile duct stones: a combined endoscopic-laparoscopic technique

INTRODUCTION

The advent of endoscopic techniques changed surgery in many regards. In the management of cholelithiasis; laparoscopic cholecystectomy (LC) is today the treatment of choice. This has created a dilemma in the management of choledocholithiasis. Today a number of options exist, including endoscopic sphincterotomy (ES) before LC in patients with suspected common bile duct (CBD) stones, laparoscopic common bile duct exploration (LCBDE) by the transcystic approach or laparoscopic choledocotomy, open CBD exploration and postoperative ERCP. A major concern regarding both pre- and postoperative extraction of CBD stones (CBDS) by the ERCP is the risk of development of pancreatitis, also more than 10% of the preoperative ERCP is normal. More recently the alternative technique of combined LC with intraoperative ERCP and ES is emerging in an attempt to manage cholecysto-choledocholithiasis in a single-step procedure.

OBJECTIVES

The aim of this work was to assess the treatment of common bile duct stones (CBDS) in a one-stage operation by laparoscopic cholecystectomy (LC) and intraoperative endoscopic retrograde cholangiopancreatography (LC+IO-ERCP) and endoscopic sphincterotomy (ES).

PATIENTS AND METHODS

This study was carried out on 45 patients with gall bladder stones and with suspected or confirmed CBDS at the Gastrointestinal Surgery Unit in the Main Alexandria University Hospital. They were treated by a single-step procedure combining LC and IO-ERCP. Laparoscopic intraoperative cholangiography (IOC) was carried out to confirm the presence of CBDS. A soft-tipped guide-wire was passed through the cystic duct and papilla into the duodenum. A papillotome was inserted endoscopically over the guide-wire. Endoscopic sphincterotomy was performed and the stones were extracted with a retrieval balloon or with a Dormia basket. The surgical operating time, surgical success rate, postoperative complications, retained CBDS, and postoperative length of hospital stay were assessed.

RESULTS

There were 30 females and 15 males. Their mean age was 45.07+11.3 years (ranging from 27 to 65 years). Twenty-seven patients had confirmed CBDS by preoperative ultrasound (US) and/or MRCP. Eighteen patients were suspected for CBDS on clinical, laboratory and/or US basis. Conversion to open cholecystectomy occurred in one case due to severe adhesions at the Calot's triangle. IOC revealed the presence of CBDS in 36 patients. IO-ERCP with ES was performed successfully in 33 patients and stones were extracted endoscopically. Passage of the guide-wire through the papilla failed in three patients. Cholecystectomy was completed laparoscopically in 44 patients. The mean operative time was 119+14.4 min (ranging from 100 to 150 min). Minor postoperative complications occurred in 15 patients. No postoperative complications related to the procedure, i.e., pancreatitis, bleeding, perforation, were encountered. Patients regained their bowel motion on the next day and were discharged after a mean hospital stay of 2.55+0.89 days. None of the patients presented on the postoperative follow-up with symptoms, signs, laboratory or radiological evidence of retained CBDS. The mean duration of the postoperative follow-up was 9+4.07 months (ranging from 3 to 14 months).

CONCLUSION

The current study suggests that LC+IO-ERCP for the management of cholecysto-choledocholithiasis is a safe and aneffective technique with a low rate of post-ERCP pancreatitis. It offers another alternative for surgeons especially those who do not practice LCBDE to treat patients in a single setting. However, additional studies with larger patient populations are needed keeping in mind that the limiting characteristic is the proximity and availability of the endoscopic settings.

Management of preoperatively suspected choledocholithiasis: a decision analysis

BACKGROUND

The management of symptomatic or incidentally discovered common bile duct (CBD) stones is still controversial. Of patients undergoing elective cholecystectomy for symptomatic cholelithiasis, 5-15% will also harbor CBD stones, and those with symptoms suggestive of choledocholithiasis will have an even higher incidence. Options for treatment include preoperative endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy (ERCP/ES) followed by laparoscopic cholecystectomy, laparoscopic cholecystectomy with intraoperative cholangiogram (LC/IOC), followed by either laparoscopic common bile duct exploration (LCBDE) or placement of a common bile duct double-lumen catheter with postoperative management. The purpose of this analysis was to determine the optimal management of such patients.

METHODS

A decision analysis was performed to analyze the management of patients with suspected common bile duct stones. The basic choice was between preoperative ERCP/ES followed by LC, LC/IOC followed by LCBDE, or common duct double-lumen catheter (Fitzgibbons tube) placement with either expectant management or postoperative ERCP/ES. Data on morbidity and mortality was obtained from the literature. Sensitivity analysis was done varying the incidence of positive CBD stones on IOC with associated morbidity and mortality.

RESULTS

One-stage management of symptomatic CBD stones with LC/LCBDE is associated with less morbidity and mortality (7% and 0.19%) than two-stage management utilizing preoperative ERCP/ES (13.5% and 0.5%). Sensitivity analysis shows that there is an increase in morbidity and mortality for LC/LCBDE as the incidence of positive IOC increases but are still less than two-stage management even with a 100% positive IOC (9.4%, 0.5%). If a double-lumen catheter is to be used for positive IOC, the morbidity would be higher than two-stage management only if the positive IOC incidence is more than 65% but still with no mortality.

CONCLUSION

LCBDE has lower morbidity and mortality rates compared to preoperative ERCP/ES in the management of patients with suspected CBD stones even if the chance of CBD stones reaches 100%. Using a common duct double-lumen catheter may be considered if LCBDE is not feasible and the chance of CBD stone is less than 65%.

An Economic Analysis of Hospital Charges for Choledocholithiasis by Different Treatment Strategies

The ideal management of presumed choledocholithiasis is controversial. We hypothesized that patients admitted with presumed choledocholithiasis would be better served financially to undergo laparoscopic cholecystectomy (LC) with possible intraoperative intervention versus preoperative endoscopic retrograde cholangiopancreatography followed by LC. A chart review was performed from September 1, 2000 to August 31, 2003. One hundred seventy-one consecutive patients identified with presumed choledocholithiasis were reviewed. Six patients were excluded because of missing charge data. Professional and technical fees from the total hospital charges were used for comparison. Three groups of patients were compared for charge analysis. Group 1 underwent LC with laparoscopic common bile duct exploration. Group 2 underwent LC with preoperative or postoperative endoscopic retrograde cholangiopancreatography. Group 3 was a control group of LC only. Student's t test was used for statistical analysis with a P value of <0.05 defined as statistically significant. P values reflect comparisons with Group 1. Group 1 charges were $13,026, Group 2 charges were $15,303, and Group 3 charges were $9,122. For suspected choledocholithiasis, LC with intraoperative intervention is the most economically advantageous approach.

Surgical versus endoscopic treatment of bile duct stones

BACKGROUND

10% to 18% of patients undergoing cholecystectomy for gallstones have common bile duct (CBD) stones. Treatment options for these stones include pre- or post-operative endoscopic retrograde cholangiopancreatography (ERCP) or open or laparoscopic surgery.

OBJECTIVES

To systematically review the management of CBD stones by four approaches: (1) ERCP versus open surgical bile duct clearance. (2) Pre-operative ERCP versus laparoscopic bile duct clearance. (3) Post-operative ERCP versus laparoscopic bile duct clearance. (4) ERCP versus laparoscopic bile duct clearance in patients with previous cholecystectomy.

SEARCH STRATEGY

We systematically searched key relevant electronic databases, bibliographies of relevant papers, and abstracts of relevant subspecialty meetings until November 2005.

SELECTION CRITERIA

The quality of included trials was assessed by adequacy of allocation sequence generation, allocation concealment, blinding, and follow-up.

DATA COLLECTION AND ANALYSIS

Published and unpublished data relevant to 12 predefined outcome measures were used to conduct fixed- and random-effects models meta-analyses, with exploration of heterogeneity and use of sensitivity and subgroup analysis where required.

MAIN RESULTS

Thirteen trials randomised 1351 patients. Eight trials (n = 760) compared ERCP with open surgical clearance, three (n = 425) compared pre-operative ERCP with laparoscopic clearance, and two (n = 166) compared post-operative ERCP with laparoscopic clearance. There were no trials of ERCP versus laparoscopic clearance in patients without an intact gallbladder. Methodology was considered adequate in at least two of three assessable fields in ten trials. A significantly increased number of total procedures (including for complications) per patient was seen in the ERCP arms in all three comparisons with weighted mean differences of 0.62 (95% CI 0.15 to 1.09), 0.96 (95% CI 0.96 to 0.96), and 1.09 (95% CI 0.93 to 1.24), respectively. ERCP was less successful than open surgery in CBD stone clearance (Peto OR 2.89, 95% CI 1.81 to 4.61) with a tendency towards higher mortality (risk difference 1%, 95% CI -1% to 4%). Laparoscopic CBD stone clearance was as efficient as pre- (Peto OR 1.00, CI 0.53 to 1.80) and post-operative ERCP (OR 2.27, 95% CI 0.37 to 13.9) and with no significant difference in morbidity and mortality. Laparoscopic trials universally reported shorter hospital stays in surgical arms. Insufficient data were reported for cost analysis.

AUTHORS' CONCLUSIONS

In the era of open cholecystectomy, open bile duct surgery was superior to ERCP in achieving CBD stone clearance. In the laparoscopic era, data are close to excluding a significant difference between laparoscopic and ERCP clearance of CBD stones. The use of ERCP necessitates increased number of procedures per patient.

Low incidence of retained common bile duct stones using a selective policy of biliary imaging

AIM

Biliary imaging has decreased since the advent of laparoscopic cholecystectomy. This study aimed to examine the incidence of retained common bile duct (CBD) stones, using a selective policy of biliary imaging.

METHODS

A prospective computerised database was used to study patients who underwent laparoscopic cholecystectomy by one surgeon over 36 months. Two hundred and thirty-five patients (191 female, 44 male) were operated on. Ages ranged from 15 to 82 years (mean 47 years). Follow-up periods ranged from six to 39 months (mean 23.3 months). Selection for pre-operative endoscopic retrograde cholangiopacreatogram (ERCP), intraoperative cholangiography (IOC) or neither depended on liver function tests (LFTs) and CBD diameter on ultrasound prior to surgery. If LFTs were persistently raised and/or the CBD was dilated on ultrasound, patients underwent pre-operative ERCP. If LFTs were raised, and returned to normal promptly, IOC was performed.

RESULTS

Of 235 patients, 26 had pre-operative ERCP, 62 had IOC and 157 had neither. Ten patients had both ERCP and IOC. To date, one patient (0.43%) has radiologically-proven unsuspected retained CBD stones; these were successfully treated with ERCP.

CONCLUSION

Selective biliary imaging in patients undergoing laparoscopic cholecystectomy is safe. This process identifies the majority of patients with ductal calculi and minimises the need for unnecessary ERCP and peroperative cholangiography.

Conversion rate of laparoscopic cholecystectomy after endoscopic retrograde cholangiography in the treatment of choledocholithiasis: does the time interval matter?

BACKGROUND

Preceding endoscopic retrograde cholangiography (ERC) in patients with choledochocystolithiasis impedes laparoscopic cholecystectomy (LC) and increases risk of conversion. We studied the influence of time interval between ERC and LC on the course of LC.

METHODS

All patients treated for choledochocystolithiasis with ERC and LC during 1996-2001 were studied retrospectively, comparing the course of LC in three time interval groups; LC < 2, 2-6, and > 6 weeks after ERC.

PRIMARY OUTCOMES

adhesions, bile duct injury, operating time, and conversion-rate.

RESULTS

Eighty-three patients were studied (group 1, n = 23; group 2, n = 15; group 3, n = 45). Adhesions, operation time, and bile duct damage did not significantly differ between the groups. The conversion rate in group 2 is significantly higher compared to group 1 (p = 0.027, OR 11 (1.13-106.8)) CONCLUSIONS: A higher conversion rate of LC is found 2-6 weeks after ERC compared to LC within 2 weeks. However, further research is needed to gain more reliable data on whether this is caused by timing.

Combined endoscopic treatment for cholelithiasis associated with choledocholithiasis

BACKGROUND

The advent of endoscopic techniques changed surgery in many ways. For the management of cholelithiasis, laparoscopic cholecystectomy (LC) is the treatment of choice. This has created a dilemma in the management of choledocholithiasis. Today a number of option exist, including endoscopic sphinterotomy (ES) before LC in patients with suspected common bile duct (CBD) stones, laparoscopic bile duct exploration, open CBD exploration, and postoperative endoscopic retrograde cholangiopancreatography (ERCP). Also, the alternative technique of peroperative ES is emerging.

METHODS

We report our experience of routine intraoperative cholangiography followed either by peroperative ERCP in one step or by transcystic drain and postoperative ERCP. In our technique, to facilitate Vater papilla cannulation we inserted a 450-cm transcystic guidewire that was caught by a duodenoscope. Papillotome was then inserted over the guidewire to ensure cannulation of the CBD.

RESULTS

Twenty-eight patients were treated successfully in one step and 24 in two steps. The mean operative time was 181 +/- 41 min for patients treated in one step and 131 +/- 30 min for patients treated in two steps. The mean hospital stay was 4.8 +/- 3.3 days for patients treated in one step and 9.6 +/- 4.0 days for patients treated in two steps. Five patients (18%) with positive intraoperative cholangiography for stones for whom peroperative ERCP was not available showed a normal postoperative transcystic cholangiogram and therefore ERCP was canceled. Fourteen of 25 patients treated in one step and none of 17 treated in two steps had raised serum amylase, which resolved spontaneously with no symptoms. No patient developed postoperative pancreatitis. Three (10%) ERCP complications were observed, consisting of mild bleeding of the papilla. All cases were managed by endoscopic adrenaline injection. There was no mortality.

CONCLUSION

We believe peroperative ERCP with the technique described should be considered as the treatment of choice for choledocholithiasis associated with cholelithiasis. When single-stage treatment is not possible, a two-step rendezvous technique should be preferred.

Feasibility of laparoscopic common bile duct exploration in a rural centre

BACKGROUND

Laparoscopic common bile duct exploration has emerged as a preferred option for the management of choledocholithiasis. The present study sought to review the feasibility of this technique in a rural centre.

METHODS

A comprehensive retrospective review was undertaken of all patients who underwent surgical treatment of biliary calculi in Lismore, NSW (Australia), between January 1996 and December 2002.

RESULTS

During the study period, 1567 consecutive patients underwent laparoscopic cholecystectomy, of whom 82 (5.2%) had choledocholithiasis identified at intraoperative cholangiography. A total of 86 laparoscopic common bile duct explorations were undertaken in these patients, 37 (43%) via a transcystic approach, and 49 (57%) via a laparoscopic choledochotomy. All common bile duct calculi were successfully removed in 78 cases, representing an overall duct clearance rate of 90.7%. Complications were noted in seven patients, a morbidity rate of 8.5%. Median operative time for the procedure over the study period was 173 min. Median hospital stay was 6 days for all patients.

CONCLUSIONS

Laparoscopic common bile duct exploration can be successfully undertaken in a rural setting by general surgeons who have appropriate laparoscopic experience, and should be the procedure of choice for the management of choledocholithiasis in these patients. It should not be restricted to specialized surgical departments in major referral centres.

Intraoperative endoscopic retrograde cholangiopancreatography (ERCP) to remove common bile duct stones during routine laparoscopic cholecystectomy does not prolong hospitalization: a 2-year experience

BACKGROUND

There is still some controversy regarding the optimal timing and best method for the removal of common bile duct stones (CBDS). Intraoperative endoscopic retrograde cholangiopancreaticography (IO-ERCP) is an alternative method that should be considered for this procedure. The aim of our study was to investigate the clinical outcome of a single-step procedure (IO-ERCP) to remove CBDS, thereby combining two existing high-volume clinical modalities-i.e., laparoscopic cholecystectomy (LC) and ERCP.

METHODS

Between January 2000 and December 2001, 674 patients, 192 male and 482 female, underwent cholecystectomy at our hospital. There were 612 LC (90.8%), 37 converted procedures (5.5%), and 25 open operations (3.7%). In 592 of the patients, (87.8%) intraoperative cholangiography (IOC) was performed. In 34 (5.7%) of those who had and IOC, an IO-ERCP was performed. While the surgeon waited for the endoscopist, care was taken to introduce a thin guidewire through the lOC catheter and pass it through the sphincter of Oddi, out into the duodenum. This complementary procedure greatly facilitated the subsequent cannulation of the bile ducts.

RESULTS

The cannulation frequency of the CBD was 100%. Common bile duct stones were successfully extracted in 93.5%. Endoscopic sphincterotomy (EST), followed by the insertion of a plastic endoprosthesis, was performed in two patients with remaining stones. The CBD of these two patients was cleared by postoperative ERCP. None of the patients developed postoperative pancreatitis. The operating time was prolonged as compared with the time for LC (192 vs 110 mins; p < 0.05). The length of hospitalization for IO-ERCP patients did not differ from that for patients undergoing cholecystectomy alone (2.6 vs 2.1. days; NS).

CONCLUSIONS

The study suggests that elective IO-ERCP is a safe and efficient method for removing CBDS that has a low risk of inducing postoperative pancreatitis and does not prolong postoperative hospitalization. This technique enables perioperative extraction of CBDS without open or laparoscopic surgical exploration of the CBD and can be used safely in a routine clinical setting.

Comparison of endoscopic sphincterotomy and laparoscopic exploration of the common bile duct

BACKGROUND

Laparoscopic exploration of the common bile duct is becoming more popular, although endoscopic sphincterotomy remains the usual treatment for bile duct stones. However, loss of the biliary sphincter causes permanent duodenobiliary reflux, and recurrent stone disease and biliary neoplasia may be a consequence.

METHODS

A systematic literature review was conducted to compare laparoscopic exploration with endoscopic sphincterotomy. A text word search of the Medline, Pubmed and Cochrane databases, and a manual search of the citations from these references, was used.

RESULTS

Endoscopic sphincterotomy is associated with a median (range) mortality rate of 1 (0-6) per cent, compared with 1 (0-5) per cent for laparoscopic bile duct exploration. The median (range) rate of pancreatitis following endoscopic sphincterotomy is 3 (1-19) per cent; this is a rare complication after laparoscopic duct exploration. The combined morbidity rate for laparoscopic cholecystectomy and endoscopic sphincterotomy is 13 (3-16) per cent, which is greater than 8 (2-17) per cent for laparoscopic bile duct exploration. Randomized trials are few and contain relatively small numbers of patients. They show little overall difference in rates of duct clearance, but a higher mortality rate and number of hospital admissions are noted for endoscopic sphincterotomy compared with laparoscopic bile duct exploration. Endoscopic sphincterotomy is associated with recurrent stone formation (up to 16 per cent) with associated cholangitis. It is also associated with bacterobilia and chronic mucosal inflammation. The late development of bile duct cancer has been reported in up to 2 per cent of patients.

CONCLUSION

Laparoscopic exploration of the common bile duct may be a better way of removing stones than endoscopic sphincterotomy plus laparoscopic cholecystectomy. :

Postoperative jaundice and total parenteral nutrition-associated hepatic dysfunction

Postoperative jaundice and TPN-induced hepatic abnormalities represent clinical situations that stem from multiple and frequently overlapping insults to the liver. The pattern of LFT abnormalities and appropriate imaging studies provide clues to the diagnosis. Greater insight into the molecular basis of cholestasis has shed light on the possible common pathways for the hepatic derangements that are seen in diverse situations. TPN-related hepatic dysfunction most likely involves a combination of nutritional deficiencies, hormonal imbalances, excessive calories, and possibly bacterial overgrowth in the small bowel. Growing clinical evidence points to a high incidence of severe liver disease in chronic TPN-dependent patients. Careful monitoring of patients is warranted in these circumstances and combined transplantation of the liver and small bowel may be the only possibility for long-term survival for such patients with progressive liver disease.

Laparoscopic surgery of the liver and biliary tract

Laparoscopic treatment of liver and biliary tract disease is growing in popularity but requires extensive experience. Among the lesions now managed with minimally invasive methods are simple cysts, polycystic liver disease, hydatid cysts, biliary stones, and benign solid tumors. Patient selection, surgical techniques, and outcomes are described.

Prevalence and laparoscopic ultrasound patterns of choledocholithiasis and biliary sludge during cholecystectomy

A prospective study of laparoscopic ultrasound (LUS) for evaluation of the common bile duct during laparoscopic cholecystectomy was started in October 1993. LUS during cholecystectomy was performed routinely to preoperatively identify unsuspected stones. Three-hundred thirty patients with symptomatic cholelithiasis were included in the study. The preoperative work-up included endoscopic retrograde cholangiopancreatography in 49 patients. Common bile duct (CBD) stones were found in 22 cases; in 19 cases the stones were removed successfully by endoscopic sphincterotomy. LUS successfully visualized the CBD in all but 10 patients (3%). CBD stones were found in 17 patients and confirmed by preoperative cholangiography and/or CBD exploration. There were two false-negative and one false-positive result for LUS. In 47 patients (14.2%) LUS detected CBD sludge as low-amplitude echoes without acoustic shadowing. The presence of CBD sludge was correlated with some biochemical and clinical variables. A significant correlation was identified between the absence or presence of CBD sludge and endoscopic retrograde cholangiopancreatography, acute pancreatitis, gallbladder sludge, age, and the levels of serum bilirubin and alkaline phosphatase. A significant difference was recorded between CBD diameter and the presence or absence of stones or sludge (p = 0.00001). In our experience, LUS allowed good diagnosis of CBD stones during laparoscopic cholecystectomy. The clinical significance of CBD sludge remains to be elucidated.

Prevalence and laparoscopic ultrasound patterns of choledocholithiasis and biliary sludge during cholecystectomy

A prospective study of laparoscopic ultrasound (LUS) for evaluation of the common bile duct during laparoscopic cholecystectomy was started in October 1993. LUS during cholecystectomy was performed routinely to preoperatively identify unsuspected stones. Three-hundred thirty patients with symptomatic cholelithiasis were included in the study. The preoperative work-up included endoscopic retrograde cholangiopancreatography in 49 patients. Common bile duct (CBD) stones were found in 22 cases; in 19 cases the stones were removed successfully by endoscopic sphincterotomy. LUS successfully visualized the CBD in all but 10 patients (3%). CBD stones were found in 17 patients and confirmed by preoperative cholangiography and/or CBD exploration. There were two false-negative and one false-positive result for LUS. In 47 patients (14.2%) LUS detected CBD sludge as low-amplitude echoes without acoustic shadowing. The presence of CBD sludge was correlated with some biochemical and clinical variables. A significant correlation was identified between the absence or presence of CBD sludge and endoscopic retrograde cholangiopancreatography, acute pancreatitis, gallbladder sludge, age, and the levels of serum bilirubin and alkaline phosphatase. A significant difference was recorded between CBD diameter and the presence or absence of stones or sludge (p = 0.00001). In our experience, LUS allowed good diagnosis of CBD stones during laparoscopic cholecystectomy. The clinical significance of CBD sludge remains to be elucidated.

Endoscopic management of bile duct stones

The advantages of endoscopic retrograde cholangiopancreatography (ERCP) over open surgery make it the predominant method of treating choledocholithiasis. Today, technologic advances such as magnetic resonance cholangiopancreatography and laparoscopic surgery are challenging ERCP's primacy in the management of common bile duct (CBD) stones. This article reviews the current status of endoscopic treatment of biliary stones and examines this in relation to laparoscopic management. The techniques and safety of endoscopic sphincterotomy and balloon sphincteroplasty are reviewed. Balloon sphincteroplasty should be limited to study protocols because of safety questions and inherent limitations. After sphincterotomy, 85% to 90% of CBD stones can be removed with a Dormia basket or balloon catheter. These techniques are described as having both advantages and disadvantages. Methods for managing "difficult stones" include mechanical lithotripsy, intraductal shock wave lithotripsy, extracorporeal shock wave lithotripsy, chemical dissolution, and biliary stenting. These approaches are presented along with data supporting their use in specific situations. Laparoscopic cholecystectomy has emerged as the preferred alternative to open cholecystectomy. Parallel advances in the endoscopic and laparoscopic management of CBD stones have made the issue regarding the optimal treatment strategy complex. Three approaches to the management of choledocholithiasis in the laparoscopic era are presented as follows: strict therapeutic splitting, flexible therapeutic splitting, and strict laparoscopic management. The optimal approach needs to be defined in prospective comparative trials. For now, preoperative endoscopic stone extraction should still be recommended as the approach of choice in patients suspected to have CBD stones based on clinical, biochemical, and imaging parameters. Primary laparoscopic evaluation and management is reasonable in patients who have a low-to-moderate probability of having CBD stones.

A critical analysis of intraoperative time utilization in laparoscopic cholecystectomy

BACKGROUND

Most of the expense of laparoscopic cholecystectomy (LC) is incurred while the patient is in the operation room; however, heretofore there has been no critical analysis of the time required to perform the various steps of the operation. An understanding of how operative time is used is the first step toward improving the efficiency of the procedure and decreasing costs while maintaining an acceptable standard of care.

METHODS

Of 194 patients undergoing LC at a university hospital between 1994 and 1997, operational videotapes of 48 randomly chosen patients were reviewed. Three groups of patients were identified: those undergoing LC for chronic cholecystitis (n = 27), those undergoing LC for acute cholecystitis (n = 11), and those with common bile duct stones (CBDS), (n = 10) undergoing LC with transcystic common bile duct exploration. The procedure was divided into the following seven steps; trocar entry, laparoscopic ultrasound, dissection of the triangle of Calot, cholangiogram, dissection of the gallbladder, extraction of the gallbladder, and irrigation-aspiration with removal of ports. Time spent for camera cleaning, bleeding control, and insertion of the cholangiocatheter into the cystic duct was also calculated. The groups were compared in terms of time spent for each step using the Kruskal-Wallis and Mann-Whitney U tests.

RESULTS

The mean +/- SD operating time was 66.5 +/- 20.5 min. The acute group had the longest operating time, followed by the CBDS and chronic groups. Dissection of the gallbladder, insertion of the cholangiocatheter, and irrigation-aspiration were longer steps in the acute group than in the other groups (p < 0.05). Dissection of the triangle of Calot took longer in acute cholecystitis than in chronic cholecystitis (p < 0.05). CBDS cases took longer (p < 0.05) than chronic cases because stone extraction added an average of 17.5 min to the time required for the cholangiogram in chronic cholecystitis. Laparoscopic ultrasound took longer in the CBDS group than in the other groups (p < 0.05). The mean +/- SD time spent for the cholangiogram and laparoscopic ultrasound in chronic cholecystitis was 7.5 +/- 4.3 and 4.8 +/- 1.9 min, respectively.

CONCLUSIONS

This time analysis study demonstrates that acute cholecystitis requires a longer operating time because most of the individual steps in the procedure take longer. In patients with choledocholithiasis, stone extraction was responsible for longer operating times. This study should serve as a basis for future studies focusing on time utilization in laparoscopic surgery.

Endoscopic management of biliary disease

Endoscopic management of biliary disease remains at the forefront of minimally invasive means of providing therapy, as well as contributing important diagnostic information in complex clinical scenarios. The authors review recent advances and reported trials of therapy and revisit important controversial issues. The management and diagnosis of choledocholithiasis are discussed, as well as endoscopic techniques for attaining biliary access at endoscopic retrograde cholangiopancreatography. In addition, management of biliary anastomotic strictures in liver transplant patients, role of cholangioscopy, and recent advances in stent technology are reviewed.

Management of Choledocholithiasis in the Era of Laparoscopic Surgery

Laparoscopic biliary surgery is changing the management of choledocholithiasis. Between November 1989 and December 1998, 2834 cholecystectomies were performed at two institutions. Choledocholithiasis was suspected in 420 patients on the basis of elevated preoperative laboratory and ultrasound criteria [bilirubin, alkaline phosphatase, serum glutamic-oxaloacetic transaminase, serum glutamate pyruvate transaminase, and common bile duct (CBD) size]. One hundred seventeen patients had preoperative endoscopic retrograde cholangiopancreatography (ERCP) because of persistent elevation in their enzymes beyond 24 to 48 hours or as an emergency. Laparoscopic intraoperative cholangiogram was attempted in 329 patients whose enzymes fell rapidly within the first 24 to 48 hours or had a failed ERCP. Eighty-one of the 329 were found to have stones. Seventy-three had laparoscopic attempt to clear the CBD, with success in 62 patients (85%). This included 41 transcystic duct and 21 direct CBD exploration. Eight patients had postoperative ERCP for retained stones. Six (0.25%) were in patients with normal preoperative enzymes. We conclude that choledocholithiasis can be suspected with preoperative laboratory and ultrasound criteria. By waiting 24 to 48 hours (except in an emergency), a good number of CBD stones will pass. With increases in laparoscopic experience, laparoscopic removal of CBD stones may replace preoperative ERCP. The small number of cases of retained or missed stones that occur with the use of selective cholangiography can be easily handled with postoperative ERCP.

Laparoscopic common bile duct exploration: the past, the present, and the future

BACKGROUND

The advent of laparoscopic cholecystectomy (LC) has created a dilemma for treating patients with known or suspected choledocholithiasis. With rapid technologic growth and experience in laparoscopic skills, many surgeons are now routinely performing laparoscopic common bile duct exploration (LCBDE) and questioning the wisdom of preoperative endoscopic retrograde cholangiography (ERC) with or without endoscopic sphincterotomy. The purpose of this article is to review the current literature on the subject of LCBDE and critically evaluate the clinical results of this emerging technology.

METHODS

Medline and Science Citation Index databases were used to search English language articles published on LCBDE since 1989.

RESULTS

Transcystic common bile duct exploration has a better clearance rate, and carries less morbidity and mortality compared with laparoscopic choledochotomy. Compared with two-stage ERCP and LC, one-stage LC and LCBDE seems to be associated with a shorter hospital stay, a quicker recovery, less expense, and less morbidity and mortality.

CONCLUSIONS

LCBDE is a feasible, safe and effective procedure that carries a low morbidity and mortality and will decrease the need for unnecessary ERC in the future for suspected or proved choledocholithiasis.

Laparoscopic antegrade biliary stenting for postoperative endoscopic clearance of biliary stones

Unsuspected ductal stones discovered during laparoscopic cholecystectomy may necessitate conversion to an open procedure, laparoscopic extraction, or postoperative endoscopic papillotomy. In order not to lose the advantages of a minimally invasive treatment and to decrease the likelihood of postoperative endoscopic failure, laparoscopic antegrade biliary stenting was attempted in 10 unselected patients (8 women, 2 men; mean age 52 +/- 11.4 years) with intraoperatively detected common bile duct stones. The mean diameter of these stones was 7 mm (range 5-11 mm). One stenting failed because of stone impaction, but the procedure was successful with effective biliary drainage in nine patients. The mean operative time was 70 (range 50-165) minutes. Subsequent ERCP was performed a mean of 8 (range 6-20) days after surgery. Deep cannulation, stent-guided papillotomy, and duct clearance was achieved in all stented patients, without any complication. Laparoscopic antegrade biliary stenting provides a guide for subsequent endoscopic stone removal, minimizing the risks of either stent migration or endoscopic failure. This combined technique is safe and cost effective and may be considered when ductal stones are discovered unexpectedly during laparoscopic cholecystectomy.

Laparoscopic Transcystic Management of Choledocholithiasis

Our objective was to review our community hospital experience with laparoscopic management of choledocholithiasis from 1991 to 1997. We performed a retrospective review of all case records of patients with choledocholithiasis managed surgically at St. Francis Hospital during the study period. Data regarding the history, presentation, investigations, operative details, and follow-up were recorded. Procedures were performed by multiple attending surgeons supervising surgical residents. All common bile duct explorations (CBDEs) were performed by a transcystic approach and followed routine cholangiography. In most cases, cystic duct dilatation over a guide wire was followed by transcystic CBDE with choledochoscopy. Stone extraction was accomplished through a combination of flushing, basket manipulation, fragmentation, retrieval, or advancement of stones through the ampulla. Data were analyzed using SPSS computer software, and P < 0.05 was considered statistically significant. During the period of study there were 1053 laparoscopic cholecystectomies with and without cholangiography and 100 total CBDE performed. Of these, 54/100 had an attempt at laparoscopic CBDE. There were 39 females and 15 males, with a median age of 52 years (range 14–88). Presentation included acute cholecystitis or biliary colic (63%), gallstone pancreatitis (20%), and jaundice or cholangitis (17%). Successful laparoscopic stone removal was achieved in 36 of 54 (67%) cases. Eighteen of the remainder (33%) were converted to an open procedure. Size, number, position of stones, technical difficulties in accessing the common bile duct, and patient factors contributed to open conversion. The rate of successful laparoscopic CBDE improved for each individual surgeon from an average of 22 per cent in the first half of the study period (1991–1994) to 87 per cent in the second half (1995–1997). There was no operative mortality. Significant morbidity in the laparoscopic group included one retained stone and two cases of postoperative pancreatitis. There were three false negative preoperative endoscopic retrograde cholangiopancreatography examinations. Multivariate analysis showed that experience of the individual surgeon was the only significant factor predicting successful laparoscopic CBDE. Low initial success rate in the early phase of the study period improved dramatically to reach an overall success rate of 87 per cent in the second half. Laparoscopic management of common bile duct stones is possible in a community setting with a high success rate and minimal morbidity. It precludes excessive use of endoscopic retrograde cholangiopancreatography with its own set of complications but is associated with a significant learning curve. It is currently our preferred therapeutic approach for choledocholithiasis discovered pre- or intraoperatively.

The prediction of common bile duct stones using a neural network

BACKGROUND

The role of preoperative ERCP and endoscopic sphincterotomy (ES) in the diagnosis and treatment of suspected common bile duct stones (CBDS) in the laparoscopic age is controversial. The preoperative diagnosis of CBDS by ERCP and the removal of CBDS by ES are advantageous because of technical difficulties in performing laparoscopic exploration of the common bile duct. Approximately 50% of preoperative ERCP examinations are normal, however. The noninvasive diagnosis of CBDS has assumed new importance, but it has proved to be an elusive goal. Neural networks are a form of artificial computer intelligence that have been used successfully to interpret ECGs and to diagnose myocardial infarcts. The purpose of this study was to determine whether a neural network could be trained to predict CBDS accurately in patients at high risk of having duct stones.

STUDY DESIGN

We trained a back-propagation neural network to predict the presence of CBDS. Retrospective data from patients who had a cholecystectomy and either a preoperative ERCP or intraoperative cholangiogram were used to build the network, and it was tested using unseen data.

RESULTS

One hundred forty patients were used to train the network, and 16 patients were used to test it. The trained network was able to predict CBDS in 100% of the patients in both the training and test sets.

CONCLUSIONS

Screening of high-risk patients for CBDS by neural network analysis is highly accurate. This promising new, noninvasive, and inexpensive technique can potentially decrease the need for preoperative ERCP by 50%, but additional prospective evaluation is indicated.

Magnetic resonance cholangiopancreatography accurately predicts the presence or absence of choledocholithiasis

Accurate common bile duct (CBD) imaging in patients with biliary calculi is an important determinant of specific therapy. Noninvasive methods to evaluate calculi in the CBD have limited accuracy and rely mainly on ultrasonography and computed tomography. Magnetic resonance cholangiopancreatography (MRCP) is a new noninvasive modality available to evaluate the biliary system. This study was undertaken to assess the accuracy of MRCP in predicting the presence or absence of CBD stones in patients at increased risk for choledocholithiasis. The medical records of 48 patients with a final diagnosis of biliary calculous disease undergoing MRCP between November 1995 and April 1997 were retrospectively reviewed. Three groups were identified: choledocholithiasis (n = 19), gallstone pancreatitis (n 5 11), and uncomplicated cholelithiasis (n = 18). In all patients the presence or absence of CBD calculi, as determined by MRCP, was correlated with the final diagnosis obtained from endoscopic retrograde cholangiopancreatography (ERCP) (n = 19), intraoperative cholangiography (n = 6), CBD exploration (n = 13), or clinical follow-up (n = 10). Sensitivity, specificity, and accuracy of MRCP were determined. The major clinical indications for MRCP in the 48 patients ware abnormal liver function tests followed by hyperamylasemia. Twenty patients were diagnosed with CBD stones and 28 were not. MRCP correctly predicted the presence of CBD stones in 19 of 20 patients and failed to detect CBD stones in one patient with gallstone pancreatitis. MRCP incorrectly predicted the presence of CBD stones in 3 of 28 patients ultimately found to have gallstones and no CBD stones. MRCP correctly predicted the absence of CBD stones in the other 25 patients including 10 patients with gallstone pancreatitis. Overall, MRCP had a sensitivity of 95%, a specificity of 89%, and an accuracy of 92%. MRCP is an accurate, noninvasive test for evaluating the CBD duct for the presence or absence of calculi in patients suspected of having CBD stones. Our data support the use of MRCP in the preoperative evaluation of these patients as findings may influence therapeutic decisions.

Preoperative screening for common bile duct stones with infusion cholangiography: review of 1000 patients

OBJECTIVE

The authors aimed to study the safety and accuracy of infusion cholangiography in patients undergoing laparoscopic cholecystectomy.

SUMMARY BACKGROUND DATA

Intravenous cholangiography is a theoretically attractive method of screening the common bile duct for stones. However, there still remain serious reservations regarding its safety and accuracy, despite some reports in the literature to the contrary.

METHODS

A personal series of 1000 patients undergoing routine preoperative infusion cholangiography was reviewed.

RESULTS

The cholangiograms detected bile duct stones with a sensitivity of 93.3% and a specificity of 99.3%. There were no serious contrast reactions, and the minor contrast reaction rate was 0.7%.

CONCLUSIONS

The authors conclude that infusion cholangiography is indeed safe and accurate and should play a substantial role in preoperative screening for incidental common bile duct stones.

Management of choledocholithiasis in the time of laparoscopic cholecystectomy

BACKGROUND

The best way to detect and manage common duct stones in conjunction with laparoscopic cholecystectomy is not agreed upon at the present time.

PATIENTS AND METHODS

Our experience with choledocholithiasis in a consecutive series of 1,123 cholecystectomies (94% by laparoscopy) has been reviewed. Suspected duct stones were investigated preoperatively or postoperatively by endoscopic retrograde cholangiography (ERC), and if necessary, duct clearance was attempted by endoscopic sphincterotomy (ES). No attempt was made to identify choledocholithiasis intraoperatively.

RESULTS

Endoscopic retrograde cholangiography was performed in 11% of patients, and 32% of these required ES. The complication rate of ERC and ES was 8%, without mortality. Two patients required a second operation for missed choledocholithiasis, for a reoperation rate of 0.2%.

CONCLUSION

We believe that primary or secondary open surgery is only occasionally necessary for the management of choledocholithiasis. Preoperative ERC and ES for suspected duct stones, with the same strategy employed as a salvage for stones presenting after cholecystectomy, was safe and efficient.