Management of bile duct stones in the era of laparoscopic cholecystectomy

Microbiologic risk factors of recurrent choledocholithiasis post-endoscopic sphincterotomy

BACKGROUND

Choledocholithiasis is a severe disorder that affects a significant portion of the world’s population. Treatment using endoscopic sphincterotomy (EST) has become widespread; however, recurrence post-EST is relatively common. The bile microbiome has a profound influence on the recurrence of choledocholithiasis in patients after EST; however, the key pathogens and their functions in the biliary tract remain unclear.

AIM

To investigate the biliary microbial characteristics of patients with recurrent choledocholithiasis post-EST, using next-generation sequencing.

METHODS

This cohort study included 43 patients, who presented with choledocholithiasis at the Guangdong Second Provincial General Hospital between May and June 2020. The patients had undergone EST or endoscopic papillary balloon dilation and were followed up for over a year. They were divided into either the stable or recurrent groups. We collected bile samples and extracted microbial DNA for analysis through next-generation sequencing. Resulting sequences were analyzed for core microbiome and statistical differences between the diagnosis groups; they were examined using the Kyoto Encyclopedia of Genes and Genomes pathway hierarchy level using analysis of variance. Correlation between the key genera and metabolic pathways in bile, were analyzed using Pearson’s correlation test.

RESULTS

The results revealed distinct clustering of biliary microbiota in recurrent choledocholithiasis. Higher relative abundances (RAs) of Fusobacterium and Neisseria (56.61% ± 14.81% vs 3.47% ± 1.10%, 8.95% ± 3.42% vs 0.69% ± 0.32%, respectively) and the absence of Lactobacillus were observed in the bile of patients with recurrent disease, compared to that in stable patients. Construction of a microbiological co-occurrence network revealed a mutual relationship among Fusobacterium, Neisseria, and Leptotrichia, and an antagonistic relationship among Lactobacillales, Fusobacteriales, and Clostridiales. Functional prediction of biliary microbiome revealed that the loss of transcription and metabolic abilities may lead to recurrent choledocholithiasis. Furthermore, the prediction model based on the RA of Lactobacillales in the bile was effective in identifying the risk of recurrent choledocholithiasis (P = 0.03).

CONCLUSION

We demonstrated differences in the bile microbiome of patients with recurrent choledocholithiasis compared to that in patients with stable disease, thereby adding to the current knowledge on its microbiologic etiology.

Factors predictive of the successful treatment of choledocholithiasis

BACKGROUND

Choledocholithiasis is a common complication of cholelithiasis, occurring in up to 18% of patients. Multiple treatments are often performed during the course of the management of choledocholithiasis, sometimes without success. Our study was performed identify the factors predictive of the success of treatment with retrograde endoscopic cholangiopancreatography (ERCP).

METHODS

This was a retrospective, case-control study that used data from a biliary disease database at Hospital de Clínicas de Porto Alegre (HCPA). Demographic, clinical, radiological and procedure-related variables were compared between patients with successful biliary clearance after one ERCP procedure (Group 1) and those with unsuccessful biliary clearance after one ERCP procedure (Group 2).

RESULTS

Three hundred twenty patients were included in Group 1, while 254 were included in Group 2. Multivariate analysis showed that older age, previous biliary exploration, elevated serum total bilirubin, choledocholithiasis above the level of the confluence of the hepatic ducts, stones retained in the cystic duct or Mirizzi syndrome, dilatation of the bile duct diagnosed during ERCP, and the need for suprapapillary opening were independently associated with the failure of the first ERCP to achieve bile duct clearance. The performance of imaging at the same institution prior to the procedure and the retention of stones in the duodenal papilla were associated with the success of endoscopic treatment.

CONCLUSIONS

The variables identified in this study, when considered in conjunction with the results of previously published studies, can be used to guide the choice of therapeutic methods for patients with choledocholithiasis in the future, given the significant difference in outcomes between the two groups. In the future, a prospective study should be performed to determine whether the same factors are predictive of the success of other methods of treatment (surgical or percutaneous).

The Overall Poor Specificity of MRCP in the Preoperative Evaluation of the Jaundiced Patient Will Increase the Incidence of Nontherapeutic ERCP

Laparoscopic cholecystectomy remains one of the most common surgical operations. Common bile duct stones (CBDS) are estimated to be present in 10%-20% of individuals with symptomatic gallstones. Preoperative magnetic resonance cholangiopancreatography (MRCP) and intraoperative cholangiography (IOC) remain the most common methods of evaluation, with subsequent endoscopic retrograde cholangiopancreatography (ERCP) for stone extraction if positive for CBDS. We examined our experience with preoperative MRCP versus IOC for the management of the jaundiced patient with cholelithiasis. This is a retrospective single-institution study that examined all laparoscopic cholecystectomies performed over a 15-month period between 2017 and 2018. Outpatient elective cases were excluded from the analysis. Charts were reviewed for demographics, operative details, and whether an MRCP, IOC, or ERCP was performed. Data were evaluated using a 2-sample t-test. A total of 460 patients underwent laparoscopic cholecystectomy over a 15-month period. Of those, 147 underwent either an MRCP or an IOC for clinical suspicion for CBDS. ERCP after MRCP was nontherapeutic in 11/32 (34%) compared with 2/12 (17%) of patients following IOC. The sensitivity and specificity of MRCP were 91% and 80%, respectively, with a positive predictive value of 66% and a negative predictive value of 96%. The sensitivity and specificity of IOC were 83% and 97%, respectively, with a positive predictive value of 83% and a negative predictive value of 97%. MRCP and IOC have unique advantages and disadvantages. MRCP has greater sensitivity, but poor specificity, resulting in unnecessary ERCPs with associated morbidity and increased costs to the patient.

Technical Aspects of Bile Duct Evaluation and Exploration: An Update

Consensus guidelines recommend patients with symptomatic cholelithiasis and suspected choledocholithiasis have common bile duct exploration (CBDE) at the time of cholecystectomy to prevent downstream problems. Despite superiority of single-stage cholecystectomy with CBDE, 2-stage precholecystectomy/postcholecystectomy with endoscopic clearance of the duct is commonly practiced. This is related to inadequate training in minimally invasive techniques, lack of technical support for efficient and safe CBDE, and surgeons' inexperience with complex biliary pathologic condition. This article provides a framework for evaluating and treating patients with CBD pathologic condition with an emphasis on technical aspects of CBDE and preoperative planning and preparation.

Preliminary experience with laparoscopic common bile duct exploration

Background

Herein we present our experience with laparoscopic common bile duct exploration (LCBDE) in managing common bile duct stones.

Methods

Data of 129 consecutive patients who underwent laparoscopic cholecystectomy (LC) and LCBDE done at our institutes from April 2011 through June 2016 were prospectively recorded and retrospectively reviewed.

Results

Since 2011, 3012 laparoscopic cholecystectomy were performed at our institutes, intraoperative cholangiogram (IOC) was done in 295 (9.8%) patients which detected choledocholithiasis in 129 (4.3%) of them. LCBDE was successful to clear the common bile duct (CBD) in 123/129 (95.4%). Six patients underwent postoperative endoscopic retrograde cholangiopancreatography (ERCP) because of incomplete CBD clearance (4 cases), symptomatic stenosed papilla (2 cases). LCBDE was performed in 103 patients via trans-cystic approach and choledochotomy one in 26 patients. In the choledochotomy group, seven patients had primary closure of the CBD, CBD was closed over T-tube in nine patients whereas the remaining 10 patients the CBD was closed over antegrade inserted stent. The median time of hospital stay was 4 (range; 1–15) days. No patients showed retained CBD stones with mean follow up was 9 ± 3.4 months.

Conclusion

LCBDE is a safe and cost effective option for CBD stones in short-term outcome and can be performed provided proper laparoscopic expertise and facilities are available.

Advances of recurrent risk factors and management of choledocholithiasis

Gallstone disease is a common and frequently occurring disease in human, and it is the main disease among the digestive system diseases. The incidence of gallstone disease in western countries is about 5%-22%, and common bile duct stones (CBDS) accounts for 8%-20%. CBDS easily lead to biliary obstruction, secondary cholangitis, pancreatitis, and obstructive jaundice, even endanger life. Therefore, it needs timely treatment once diagnosed. The recurrence of choledocholithiasis after bile duct stones clearance involves complicated factors and cannot be completely elaborated by a single factor. The risk factors for recurrence of choledocholithiasis include bacteria, biliary structure, endoscopic and surgical treatment, and inflammation. The modalities for management of choledocholithiasis are endoscopic retrograde cholangiopancreatography (ERCP), laparoscopic or open common bile duct exploration, dissolving solutions, extracorporeal shockwave lithotripsy (ESWL), percutaneous radiological interventions, electrohydraulic lithotripsy (EHL) and laser lithotripsy. We compare the different benefits between surgery and ERCP. And finally, we make a summary of the current strategy for reducing the recurrence of CBDS and future perspectives for CBDS management.

Choledocholithiasis: Evaluation, Treatment, and Outcomes

Choledocholithiasis occurs in up to approximately 20% of patients with cholelithiasis. A majority of stones form in the gallbladder and then pass into the common bile duct, where they generate symptoms, due to biliary obstruction. Confirmatory diagnosis of choledocholithiasis is made with advanced imaging, including magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography (ERCP). Treatment varies locally; however, ERCP with sphincterotomy is most commonly employed with a high degree of success. Difficult anatomy and difficult stone burden require advanced surgical, endoscopic, and percutaneous techniques to extract or expel biliary stones. Knowledge of these treatment strategies will optimize outcomes.

Periampullary diverticulum may be an important factor for the occurrence and recurrence of bile duct stones

BACKGROUND

The aim of this study was to examine the relation between periampullary diverticula (PAD) and biliary tract stones.

METHODS

A total of 732 cases of patients with PAD identified from among 6,221 patients who underwent endoscopic retrograde cholangiopancreatography were compared to 750 controls (without PAD) in terms of biliary stone formation, incidence of sphincter of Oddi dysfunction (SOD), and choledocholithiasis. The biliary tract diseases were diagnosed based on medical history, clinical symptoms and signs, and imaging findings using ultrasonography, computed tomography, or magnetic resonance cholangiopancreatography.

RESULTS

The PAD group contained a significantly larger number of patients with biliary stones including stones in the primary common bile duct, SOD with bile duct stones (p < 0.05), and choledocholithiasis after cholecystectomy (p < 0.01).

CONCLUSIONS

There is a close correlation between PAD and the formation of biliary tract stones. A particularly close correlation was found between PAD and choledocholithiasis after cholecystectomy. PAD may be an important risk factor for the occurrence or recurrence of biliary tract stones.

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.

Antegrade papillary balloon dilation for extrahepatic bile duct stone clearance: lessons learned from treating 300 patients

PURPOSE

To report the authors' experience with percutaneous papillary balloon dilation for extrahepatic bile duct stone clearance to the duodenum in 300 patients.

MATERIALS AND METHODS

During a 16-year period, 300 patients with extrahepatic bile duct stones who underwent papillary balloon dilation were retrospectively evaluated. Two hundred eighty-six patients with retained extrahepatic bile duct stones were treated through a postoperative drain placed during cholecystectomy; 245 patients were treated through a T-tube route and 41 through a transcystic approach. In the remaining 14 patients, the procedure was performed through a newly created percutaneous transhepatic route. Success rates, technical features, reasons for failure, and complications were evaluated.

RESULTS

Biliary duct stone removal after papillary dilation was successful in 288 patients (96%). In 244 patients, the procedure was successfully completed on the first attempt. Forty-three patients needed two sessions, and in one patient it took three sessions. Stone diameters ranged from 4 mm to 18 mm (mean, 8 mm). Two hundred fourteen patients had four or fewer stones (mean, 2.3), and 86 patients had more than four (mean, 8.8; range, 5-25). Two patients required surgical intervention after loss of transcystic drainage, with subsequent development of peritonitis. During the follow-up period (mean, 26.6 months), no clinical or laboratory abnormalities were observed.

CONCLUSIONS

Percutaneous antegrade papillary balloon dilation and stone clearance is a safe and effective tool in removing common bile duct stones. Some technical issues should be considered to achieve complete stone removal while minimizing the incidence of complications.

Reduction of radiation doses to patients and staff during endoscopic retrograde cholangiopancreatography

BACKGROUND/AIM

Endoscopic retrograde cholangiopancreatography (ERCP) is associated with a considerable radiation exposure for patients and staff. While optimization of the radiation dose is recommended, few studies have been published. The purpose of this study has been to measure patient and staff radiation dose, to estimate the effective dose and radiation risk using digital fluoroscopic images. Entrance skin dose (ESD), organ and effective doses were estimated for patients and staff.

MATERIALS AND METHODS

Fifty-seven patients were studied using digital X-ray machine and thermoluminescent dosimeters (TLD) to measure ESD at different body sites. Organ and surface dose to specific radiosensitive organs was carried out. The mean, median, minimum, third quartile and the maximum values are presented due to the asymmetry in data distribution.

RESULTS

The mean ESD, exit and thyroid surface dose were estimated to be 75.6 mGy, 3.22 mGy and 0.80 mGy, respectively. The mean effective dose for both gastroenterologist and assistant is 0.01 mSv. The mean patient effective dose was 4.16 mSv, and the cancer risk per procedure was estimated to be 2 × 10(-5).

CONCLUSION

ERCP with fluoroscopic technique demonstrate improved dose reduction, compared to the conventional radiographic based technique, reducing the surface dose by a factor of 2, without compromising the diagnostic findings. The radiation absorbed doses to the different organs and effective doses are relatively low.

Laparoscopic common bile duct exploration in patients with gallstones and choledocholithiasis

Failed ERCP appears to decrease the success rate of a laparoscopic approach for common bile duct exploration.

Objectives:

To compare the effectiveness of laparoscopic common bile duct exploration in patients with failed endoscopic retrograde cholangiopancreatography (ERCP).

Methods:

This is a descriptive, comparative study. Patients with an indication of common bile duct exploration between February 2005 and October 2008 were included. We studied 2 groups: Group A: patients with failed ERCP who underwent LCBDE plus LC. Group B: patients with common bile duct stones managed with the 1-step approach (LCBDE + LC) with no prior ERCP.

Results:

Twenty-five patients were included. Group A: 9 patients, group B: 16 patients. Success rate, operative time, and hospital stay were as follows: group A 66% vs group B 87.5%; group A 187 minutes vs 106 minutes; group A 4.5 days vs 2.3 days; respectively.

Conclusion:

Patients with failed ERCP should be considered as high-complex cases in which the laparoscopic procedure success rate decreases, and the conversion rate increases considerably.

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.

Technical aspects in the laparoscopic management of complicated common bile duct stones

The management of common bile duct (CBD) stones traditionally required open laparotomy and bile duct exploration. With the advent of endoscopic and laparoscopic technology in the latter half of last century, endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC) has become the mainstream treatment for CBD stones and gallstones in most medical centers around the world. However, in certain situations, ERCP cannot be feasible because of difficult cannulation and extraction. ERCP can also be associated with potential serious complications, in particular for complicated stones requiring repeated sessions and additional maneuvers. Since our first laparoscopic exploration of the CBD (LECBD) in 1995, we now adopt the routine practice of the laparoscopic approach in dealing with endoscopically irretrievable CBD stones. The aim of this article is to describe the technical details of this approach and to review the results from our series.

Is magnetic resonance cholangiopancreatography the new gold standard in biliary imaging?

The timing and technique of perioperative biliary imaging in relation to laparoscopic surgery remains controversial. This study assessed the predictive value of magnetic resonance cholangiopancreatography (MRCP) in the diagnosis of biliary pathology. Clinical, laboratory and investigational data were evaluated from 374 patients undergoing MRCP at two hospital sites over a 5-year period. MRCP findings were compared with endoscopic retrograde cholangiopancreatography (ERCP) or operative findings and appropriate clinical endpoints. Complete data were available for 351 of the 374 patients (94%), of whom 232 (66%) were female. Median age was 64 years. The predominant presentation was abdominal pain (n = 190). Features of pancreatitis were present in 59, cholangitis in 26 and jaundice in 109 patients. Ultrasound was the initial investigation in 312 (89%) (176-gallstone positive). Common duct dilatation was evident in 114 patients and ductal calculi in 31. ERCP was successful in 212/283 (75%) patients. Significant ERCP induced pancreatitis occurred in 12 (5.6%). Comparison between MRCP and ERCP was not possible in 85 due to failure of either technique. Nine patients underwent other investigations including intraoperative cholangiogram (IOC), percutaneous transhepatic cholangiogram (PTC) and were included. Of the 221 patients with full comparative data available the MRCP showed a sensitivity of 97.98% and specificity of 84.4%. MRCP is highly sensitive and specific for choledocholithiasis and avoids the need for invasive imaging in most patients with suspected choledocholithiasis.

Preoperative evaluation of common bile duct stones in patients with gallstone disease

OBJECTIVE

Our objective was to suggest criteria for selection of a preoperative diagnostic technique for patients with gallstone disease.

CONCLUSION

Use of MR cholangiography preferentially before laparoscopic cholecystectomy, on patients who have a moderate or high risk of common bile duct stones, can significantly reduce purely diagnostic endoscopic retrograde cholangiography.

Contemporary minimally invasive approaches to the management of acute cholecystitis: a review and appraisal

Acute cholecystitis is one of the most common emergency admissions in surgical practice. This review appraises the available evidence from the English-language literature regarding the minimally invasive approaches to the management of this condition. The following aspects of care are reviewed and appraised: (1) the diagnostic criteria for acute cholecystitis, (2) the optimal timing for cholecystectomy (early, delayed, or interval surgery), (3) the optimal approach to cholecystectomy (laparoscopic versus open), (4) the role of intraoperative cholangiography, and (5) the management of patients unfit for surgery.

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.

Predição da coledocolitíase pela associação de indicadores clínicos e laboratoriais em dois momentos do pré-operatório da colecistectomia

OBJETIVO: O propósito deste estudo foi determinar a probabilidade de ocorrência de coledocolitíase através do estudo da associação de indicadores clínicos e laboratoriais desta doença em dois momentos do pré-operatório de colecistectomia. MÉTODO: Entre março de 2001 e março de 2002, 48 pacientes consecutivos com colelitíase foram submetidos a colecistectomia e colangiografia intra-operatória (CIO). Os pacientes foram divididos em dois grupos, sendo o grupo A constituído por 13 pacientes com coledocolitíase e o grupo B por 35 pacientes sem esta doença. Os pacientes foram investigados quanto aos indicadores clínicos e laboratoriais da coledocolitíase, analisados em dois períodos, tomando como ponto de corte as 48 horas que precederam a cirurgia. Posteriormente, estes indicadores pré-operatórios foram associados na equação da regressão logística em diferentes combinações. RESULTADOS: Utilizando a equação da regressão logística, constatou-se que a associação de dois indicadores clínicos em ambos os períodos (icterícia e sinal de Murphy) e dois laboratoriais ( nível de corte da gama glutamil transpeptidase e bilirrubina direta 48 horas antes da cirurgia) foi a mais adequada para a predição da coledocolitíase. Os valores obtidos por esta equação mostraram concordância com os grupos A e B, de 95,6%, e discordância de 4,4% (p= 0,0000007 e k = 0,89). Esta equação mostrou sensibilidade de 92,3%, especificidade de 97,0%, valor preditivo positivo de 92,3% e valor preditivo negativo de 97%. Estes valores foram próximos aos obtidos pela CIO, que mostrou concordância com os grupos estudados de 95,8%, e discordância de 4,2% (k = 0,90). CONCLUSÃO: Considerando os resultados obtidos, recomenda-se a associação de indicadores da coledocolitíase na equação da regressão logística para estabelecer a probabilidade de ocorrer coledocolitíase associada à colelitíase. A utilização desta equação pode orientar melhor a conduta diagnóstica e terapêutica nesta doença.

Biliary stones: including acute biliary pancreatitis

The widespread availability of endoscopic ultrasound has facilitated the evaluation of the pancreas and extrahepatic biliary system. Endosonography has been shown to be highly sensitive in the detection of choledocholithiasis (especially in patients with small stones and nondilated bile ducts) and gallbladder microlithiasis; however, the use of this technique in relation to endoscopic retrograde cholangiography and laparoscopic surgery in gallstone disease remains confusing. This article highlights the clinical performance and results of endoscopic ultrasound in this context and proposes strategies in relation to its use in association with endoscopic retrograde cholangiopancreatography and surgery in common clinical practice. Endosonography allows the correct identification of patients with acute biliary pancreatitis and proves an important adjunct in eliminating other causes of undetermined pancreatitis.

Balloon Sphincteroplasty and Transpapillary Elimination of Bile Duct Stones:10 Years' Experience

OBJECTIVE

The usual way for interventional radiology to treat stones in the bile duct involves their extraction with Dormia baskets. The technique of dilating the sphincter with a balloon and the transpapillary elimination of the stones has only sporadically been reported in the literature. In this article, we describe our experience with this technique.

MATERIALS AND METHODS

Between 1992 and 2001, we used this technique on 100 patients between the ages of 17 and 93 years (mean age, 68 years). The minimum diameter of the stones varied between 4 and 22 mm (mean size, 11 mm), and in 46 patients, only a single stone was seen. The stones were located in the common bile duct, and in 11 patients, intrahepatic stones were also observed. The approach was performed through a percutaneous biliary drainage tract in 48 patients, following the surgical tract of the Kehr tube in 36 patients, through a surgical transcystic drainage catheter in 10 patients, and through a percutaneous cholecystostomy in six patients.

RESULTS

The procedure was successful in 95% of the patients. The morbidity rate was 5%, and the procedure did not produce mortality in any of the cases. Eighty-nine patients required one session, 10 patients required two sessions, and the remaining patient required five sessions. The mean period of hospitalization after the procedure was 5.5 days (range, 1-40 days).

CONCLUSION

Balloon sphincteroplasty and transpapillary elimination of bile duct stones is an effective and safe technique.

A prospective study of common bile duct calculi in patients undergoing laparoscopic cholecystectomy: natural history of choledocholithiasis revisited

OBJECTIVE

To define the incidence of problematic common bile duct calculi in patients undergoing laparoscopic cholecystectomy.

SUMMARY BACKGROUND DATA

In patients selected for laparoscopic cholecystectomy, the true incidence of potentially problematic common bile duct calculi and their natural history has not been determined. We evaluated the incidence and early natural history of common bile duct calculi in all patients undergoing laparoscopic cholecystectomy with intraoperative and delayed postoperative cholangiography.

METHODS

Operative cholangiography was attempted in all patients. In those patients in whom a filling defect was noted in the bile duct, the fine bore cholangiogram catheter was left securely clipped in the cystic duct for repeated cholangiography at 48 hours and at approximately 6 weeks postoperatively.

RESULTS

Operative cholangiography was attempted in 997 consecutive patients and was accomplished in 962 patients (96%). Forty-six patients (4.6%) had at least one filling defect. Twelve of these had a normal cholangiogram at 48 hours (26% possible false-positive operative cholangiogram) and a further 12 at 6 weeks (26% spontaneous passage of calculi). Spontaneous passage was not determined by either the number or size of calculi or by the diameter of the bile duct. Only 22 patients (2.2% of total population) had persistent common bile duct calculi at 6 weeks after laparoscopic cholecystectomy and retrieved by endoscopic retrograde cholangiopancreatography.

CONCLUSIONS

Choledocholithiasis occurs in 3.4% of patients undergoing laparoscopic cholecystectomy but more than one third of these pass the calculi spontaneously within 6 weeks of operation and may be spared endoscopic retrograde cholangiopancreatography. Treatment decisions based on assessment by operative cholangiography alone would result in unnecessary interventions in 50% of patients who had either false positive studies or subsequently passed the calculi. These data support a short-term expectant approach in the management of clinically silent choledocholithiasis in patients selected for LC.

Scoring system to predict asymptomatic choledocholithiasis before laparoscopic cholecystectomy. A matched case-control study

BACKGROUND

The purpose of this prospective study was to evaluate if a recently proposed score system based on six preoperative parameters [history of colic pain and/or jaundice, dyspepsia, cholecystitis, ultrasound (US), evidence of common bile duct stones (CBDS), number and size of gallbladder stones at US, level of serum glutamic oxalacetic transaminase and/or alkaline phosphatase is effective in the selection of patients undergoing laparoscopic cholecystectomy (LC) with asymptomatic CBDS and could allow a significant reduction of the total number of preoperative examinations.

METHODS

In the case group, 408 patients were categorized into low-, medium-, and high-risk classes and underwent, respectively, no further preoperative assessment of the bile duct, intravenous cholangiography (IVC), and endoscopic retrograde cholangiography (ERC). Intraoperative cholangiography (IOC) was performed whenever the surgeon was in doubt as to biliary anatomy or bile duct clearance. These patients were compared with 408 retrospectively matched patients (control group) undergoing routine preoperative IVC and/or ERC.

RESULTS

In the case group, significantly lower numbers of IVC (120 vs 392) and IOC (3 vs 16) were performed ( p < 0.005), whereas no difference in the total number of ERCs was noted. One patient in the control group had retained CBDS detected during follow-up evaluation, whereas none occurred in the case group.

CONCLUSION

The proposed scoring system allows selective use of IVC, ERC, and/or IOC in patients undergoing elective LC.

Outcomes of emergency common bile duct exploration: impact of preoperative endoscopic decompression

BACKGROUND

Emergency common bile duct exploration (CBDE) is still required in patients acutely ill with complicated biliary tract stone disease when endoscopic decompression fails to reverse their condition. This study looks at the clinical profile of patients requiring emergency CBDE and examines the various factors influencing the postoperative outcome.

METHODS

Clinical records of patients with emergency CBDE in Singapore General Hospital from January 1991 to December 1998 were reviewed. Factors influencing postoperative outcomes, for example, pre-existing medical problems, hepatic parameters, the impact of endoscopic procedures (if any) and indications for surgery, were correlated with postoperative morbidity and 30-day mortality.

RESULTS

The records of 100 patients were available for review. Major indications for emergency CBDE were cholangitis (51%) and intraoperative findings of common bile duct obstruction during emergency laparotomy (23%). Six patients had emergency CBDE because of iatrogenic complication of attempted therapeutic endoscopic retrograde cholangiopancreaticography (ERCP) for biliary stones. Overall mortality was 14.0% and 8.0% had retained stones. Mortality was significantly influenced by age, prior biliary disease, preoperative endoscopic biliary decompression in acute cholangitis (33.3%vs 9.4%, P = 0.035) and endoscopic complications.

CONCLUSIONS

Among patients requiring emergency CBDE, uncomplicated preoperative endoscopic biliary decompression benefits patients with acute cholangitis.

Risk factors predictive of late complications after endoscopic sphincterotomy for bile duct stones: long-term (more than 10 years) follow-up study

OBJECTIVE

Widespread use of laparoscopic cholecystectomy has extended the indications for endoscopic sphincterotomy (ES) to young patients with choledocholithiasis; however, long-term results of ES and risk factors for late complications are largely unknown.

METHODS

Between 1977 and 1990, 145 patients aged 60 yr or younger underwent ES for choledocholithiasis. Long-term outcomes of ES were investigated in the year 2000, and prognostic factors for late complications were multivariately analyzed.

RESULTS

Long-term information was available in 135 cases (93.1%), with a median overall follow-up duration of 14.5 yr (range, 6.5-22.3 yr). There were neither biliary malignancies nor deaths attributable to biliary disease. Sixteen patients (11.9%) developed late complications, including choledochal complications (stone recurrence and/or cholangitis; 14 patients) and acute cholecystitis (two of 32 patients with the gallbladder in situ). Multivariate analysis identified two independent risk factors for choledochal complications: bile duct diameter > or = 15 mm and brown pigment stones at the initial ES. Choledochal complications were endoscopically manageable. All recurrent stones were brown pigment stones.

CONCLUSIONS

Approximately 12% of patients develop late complications after ES, but retreatment with ERCP is effective. ES is a reasonable alternative even in young patients with choledocholithiasis. Careful follow-up is necessary, however, particularly for patients with a dilated bile duct or brown pigment stones.

Laparoscopic cholecystectomy without routine operative cholangiography does not result in significant problems related to retained stones

BACKGROUND

This study investigated whether failure to identify common bile duct stones at laparoscopic cholecystectomy results in significant postoperative complications related to retained stones.

METHODS

We performed a retrospective analysis of the case notes of 377 consecutive patients undergoing laparoscopic cholecystectomy without routine operative cholangiography under a single surgeon in a district general hospital between 1995 and 1999. Highly selective preoperative endoscopic retrograde cholangiopancreatography (ERCP) was employed to identify and manage suspected bile duct stones in pancreatitis, jaundice, persistently elevated liver function tests, or a dilated common bile duct.

RESULTS

Eighteen (4.8%) of 377 patients presented postoperatively with symptoms/signs suggesting biliary pathology. Two (0.5%) were confirmed to have retained duct stones/debris (ultrasound/ERCP); both recovered with conservative treatment. Only 1 patient of 274 (0.4%) without preoperative ERCP subsequently presented with a symptomatic retained stone, the other having been stented preoperatively.

CONCLUSIONS

Highly selective preoperative ERCP without routine operative cholangiography is not associated with a significant increase in morbidity/mortality related to retained stones following laparoscopic cholecystectomy.

Selective use of preoperative endoscopic retrograde cholangiopancreatography in the era of laparoscopic cholecystectomy

BACKGROUND

The use of endoscopic retrograde cholangiopancreatography (ERCP) in the management of suspected common bile duct (CBD) stones prior to laparoscopic cholecystectomy is common. The associated morbidity can be significant. The present study determines significant predictors of CBD stones and improves the selection of patients for preoperative ERCP.

METHODS

All preoperative ERCP for suspected CBD stones in the year 1998 were studied retrospectively. Univariate and multivariate analyses of a number of clinical, biochemical and radiological variables were carried out to determine the best predictors of CBD stones.

RESULTS

A total of 112 patients had successful preoperative ERCP. Sixty-one per cent of these were negative for stones and the morbidity was 9%. Univariate analysis revealed the following variables as predictors: cholangitis (P = 0.006), abnormal serum bilirubin > or = 3 days (P = 0.002), serum alkaline phosphatase > or = 130 U/L (P = 0.002), deranged liver function tests (P = < 0.001) and CBD diameter > or = 8 mm (P = 0.009) with positive predictive values of 80%, 68%, 49%, 38% and 52%, respectively. Multivariate analysis revealed the model with the best ability to discriminate for CBD stones (P = 0.0005) was cholangitis, abnormal serum bilirubin for > or = 3 days and CBD diameter > or = 8 mm. The best predictors from this study had a sensitivity of 80% and a specificity of 27%.

CONCLUSIONS

The predictors of CBD stones are imprecise. Until laparoscopic exploration of CBD becomes widely available, ERCP prior to cholecystectomy will remain popular. The use of stricter selection criteria can reduce the number of negative preoperative ERCP.

Prospective analysis of a scoring system to predict choledocholithiasis

BACKGROUND

The management of choledocholithiasis in the laparoscopic era remains debatable. A common policy is to perform preoperative endoscopic retrograde cholangiopancreatography (ERCP) on patients suspected of having common bile duct (CBD) stones, using standard risk criteria. The aim of this study was to evaluate prospectively a scoring system designed to improve the accuracy of CBD stone prediction before laparoscopic cholecystectomy.

METHODS

Known clinical, biochemical and radiological risk factors for CBD stones were analysed retrospectively in 233 patients. The presence (n = 77) or absence (n = 156) of CBD stones was determined by preoperative ERCP and/or laparoscopic cholangiography. Using multivariate analysis, the significant risk factors for CBD stones were identified and a new preoperative scoring system was developed. A score of 3 or more was taken as the cut-off point to suggest CBD stones and the need for preoperative ERCP. This scoring system was then tested prospectively in 211 consecutive patients with symptomatic gallstones requiring surgery. Patients whose bile ducts could not be demonstrated by ERCP or operative cholangiography were excluded.

RESULTS

Fifty-five patients scored 3 or more (predicted ERCP rate of 29 per cent), of whom 23 (42 per cent) had proven CBD stones. Intraoperative cholangiography was successful in 87 per cent. Five patients (4 per cent) who scored less than 3 had small stones (less than 5 mm) demonstrated at operative cholangiography. The overall sensitivity and specificity of this scoring were 82 and 80 per cent respectively.

CONCLUSION

Formal risk assessment of the presence of CBD stones using this scoring system is simple and may be used for preoperative selection of patients for biliary tract imaging by magnetic resonance cholangiography or ERCP.

Role of biliary scintiscan in predicting the need for cholangiography

BACKGROUND

Currently used predictors for bile duct calculi in patients undergoing cholecystectomy have low specificity resulting in unnecessary cholangiograms being performed. The role of biliary scintiscan in predicting the presence of bile duct calculi was assessed.

METHODS

Seventy-five patients with symptomatic gallstone disease were studied prospectively regard- ing the value of a history of jaundice or acute pancreatitis, raised serum bilirubin and serum alkaline phosphatase levels, and visualization of stones or presence of dilated bile ducts on ultrasonography (standard criteria) in detecting bile duct calculi. Results of biliary scintiscan were evaluated against a combination of standard criteria. The 'gold standard' for evaluation was endoscopic or peroperative cholangiography.

RESULTS

Biliary scintiscan had a higher sensitivity and specificity (93 and 94 per cent) than a combination of the above standard and modified predictors for biliary calculi (89 and 71 per cent). A combination of ultrasonography and selective use of scintiscan, in the absence of bile duct dilatation only, had higher values (96 and 98 per cent).

CONCLUSION

A combination of ultrasonography and biliary scintiscan can accurately predict bile duct calculi and could be used as a guide for selective cholangiography.

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.

Selective endoscopic retrograde cholangiography prior to laparoscopic cholecystectomy for gallstones

BACKGROUND

To assess the outcome of endoscopic retrograde cholangiography (ERC) before laparoscopic cholecystectomy (LC) for symptomatic gallbladder and suspected duct stones.

METHODS

During 3 years, one or more of four criteria led to ERC: jaundice, choledocus >8 mm, cholestasis, and severe biliary pancreatitis. Endoscopic extraction (ESE) of ductal stones was attempted before LC.

RESULTS

In all, 990 patients were prospectively included. There were no exclusions. There were no deaths. A multivariate logistic regression analysis identified jaundice (P = 0.001), pancreatitis (P = 0.001), and cholestasis (P = 0.001) as statistically significant predictors of ductal stones. Choledocus >8 mm was not a significant predictor (P = 0.12). A total of 155 (16%) patients underwent ERC for suspected stones: 21 of 155 (13%) patients had no stones; and 6 of 134 (4%) patients had stone impaction cleared at open surgery. ERC clearance rate was 95% (128 of 134). LC was performed in 149 of 155 patients after a median interval of 3 days (range 1 to 7). Morbidity rates were 3% (4 of 134), 2% (3 of 149), and nil (0 of 6) after ESE, LC, or open surgery, respectively. Median hospital stay was 11 days. A total of 835 patients underwent LC with a 1.5% complication rate. Laparoscopic fluoro-cholangiography showed < or =3 mm-sized stones in 10 of 835 (1.2%) patients. No stones were reported at a median follow-up of 4 months including 990 patients.

CONCLUSIONS

Ninety-five percent of patients with ductal stones can be successfully and safely managed by ERC prior to LC.

Periampullary diverticula and pancreaticobiliary disease

BACKGROUND

Periampullary diverticula (PAD) are extraluminal outpouchings of the duodenum arising within a radius of 2-3 cm from the ampulla of Vater. They are frequently encountered in elderly patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) and contribute to failure of ERCP. This review details the relationship of PAD to pancreaticobiliary disease and the influence of PAD on the management of patients.

METHODS

The United States National Library of Medicine Medline database was searched for articles on and related to PAD published in English within the past 15 years. Major earlier works were also reviewed.

RESULTS

The prevalence of PAD increases with age and could be as high as 27 per cent. PAD are associated with an incompetent sphincter of Oddi and colonization of bile duct with beta-glucuronidase-producing organisms. PAD are implicated in the pathogenesis of pigment common bile duct stones, but there is no conclusive evidence to associate them with cholecystolithiasis or pancreatitis. PAD are a major cause of failure of ERCP, but success rates of more than 90 per cent have been achieved in specialist centres.

CONCLUSION

With an ageing population, there will be an increase in elderly patients with PAD and symptomatic pancreaticobiliary disease. Continuing improvements in radiological and endoscopic techniques should enable this vulnerable group to be treated effectively and safely.

Does endoscopic sphincterotomy cause prolonged pancreatobiliary reflux?

OBJECTIVE

Endoscopic sphincterotomy (ES) reduces sphincter function, which may allow reflux of pancreatic juice and intestinal contents into the common bile duct. The reflux, if present, may cause development of biliary tract carcinomas, as may anomalous pancreaticobiliary junction. We prospectively investigated pancreatobiliary and duodenobiliary reflux after ES.

METHODS

In 15 patients with choledocholithiasis, ductal bile was sampled for amylase concentration and bacterial culture during endoscopic retrograde cholangiopancreatography, before and at 7 days to 5 yr after ES. To provide comparative data, ductal bile was sampled in 11 patients with gallbladder cholesterol polyps or anomalous pancreaticobiliary junction who did not undergo ES.

RESULTS

Amylase concentration of ductal bile in patients with choledocholithiasis before ES was not different from that in patients with gallbladder polyps. Its concentration was increased 7 days after ES compared with that before ES, reaching the level of that in patients with anomalous pancreaticobiliary junction. Thereafter, amylase concentration gradually decreased, returning to that before ES by 1 yr. After ES, bactobilia occurred in 60-80% of patients, although none developed acute cholangitis.

CONCLUSIONS

Although ES causes transient pancreatobiliary reflux, the reflux is abolished by 1 yr after ES. ES is unlikely to increase the risk for development of biliary tract carcinoma as long as cholangitis or bile duct stones do not recur.

Prospective evaluation of magnetic resonance cholangiography to detect common bile duct stones before laparoscopic cholecystectomy

BACKGROUND

With the advent of laparoscopic cholecystectomy, endoscopic retrograde cholangiography (ERC) is frequently employed before operation to detect common bile duct stones. However, this is an invasive technique with recognized complications. This study evaluated the accuracy of magnetic resonance cholangiography (MRC) to detect choledocholithiasis in selected patients before laparoscopic cholecystectomy.

METHODS

Patients scheduled for elective laparoscopic cholecystectomy, with risk factors for common bile duct stones, underwent MRC followed by ERC or peroperative cholangiography.

RESULTS

Over a 2-year period 40 patients were studied. MRC had a sensitivity of 88 per cent, specificity of 93 per cent, positive predictive value of 78 per cent and negative predictive value of 97 per cent for the detection of common bile duct stones.

CONCLUSION

MRC is a simple non-invasive method for preoperative screening for common bile duct stones in at-risk patients. In this study it would have reduced the need for ERC by three-quarters.

Towards T-tube free laparoscopic bile duct exploration: a methodologic evolution during 300 consecutive procedures

OBJECTIVE

To establish a simple, reproducible, and safe technique of laparoscopic common bile duct exploration (CBDE) with high clearance rates and low morbidity and mortality rates.

SUMMARY BACKGROUND DATA

For most general surgeons, laparoscopic CBDE appears an unduly complex and demanding procedure. Since the introduction of laparoscopic cholecystectomy, many surgeons use endoscopic cholangiography (ERC) and endoscopic sphincterotomy as their only option in treating bile duct stones. ERC is more specific if used after surgery, but it carries an appreciable morbidity rate and has the disadvantage of requiring a second procedure to deal with bile duct stones. To this end, various methods of laparoscopic CBDE have been developed.

METHODS

Between August 1991 and February 1997, 300 consecutive unselected patients underwent laparoscopic CBDE.

RESULTS

Of 300 laparoscopic CBDE procedures, 173 (58%) were managed using a transcystic approach and 127 (42%) with choledochotomy. Successful laparoscopic stone clearance was achieved in 271 (90%). Of the 29 (10%) patients not cleared laparoscopically, 10 had an elective postsurgical ERC, 12 were converted to an open procedure early in the series, and 7 had unexpected retained stones. There was one death (mortality rate 0.3%) and major morbidity occurred in 22 patients (7%). The last 100 procedures were performed from July 1995 to February 1997, and stone clearance was unsuccessful in only two patients.

CONCLUSIONS

Laparoscopic transcystic basket extraction of common duct stones under fluoroscopic guidance is a relatively quick, successful, and safe technique. Choledochotomy, when required, is associated with a higher morbidity rate, particularly with T-tube insertion, and the authors advocate primary bile duct closure with or without insertion of a biliary stent as a more satisfactory technique for both surgeon and patient. Most patients with gallbladder and common duct calculi should expect a curative one-stage laparoscopic procedure without the need for external biliary drainage or ERC.

Follow-up of more than 10 years after endoscopic sphincterotomy for choledocholithiasis in young patients

BACKGROUND

With the advent of laparoscopic cholecystectomy, the indications for endoscopic sphincterotomy (ES) have been extended to young patients with choledocholithiasis. However, the long-term results of ES are largely unknown.

METHODS

Between 1977 and 1986, 115 patients aged 60 years or less underwent ES for choledocholithiasis. Stone classification, and early and long-term outcomes of ES were analysed retrospectively.

RESULTS

Early complications occurred in nine patients (7.8 per cent), but there were no deaths. ES and stone clearance were successful in 110 patients. Long-term information was available in 103 of the 110 patients, with a mean overall follow-up duration of 14-2 (range 10.4-19.3) years. Ten patients (9.7 per cent) developed late complications, including stone recurrence and/or cholangitis (nine patients) and acute cholecystitis (one of 23 patients with the gallbladder in situ). The choledochal complication rate was somewhat higher in patients with calcium bilirubinate stones at ES (seven of 65 patients) than in those with cholesterol stones (two of 38 patients). Choledochal complications were manageable endoscopically.

CONCLUSION

Approximately 10 per cent of patients develop late complications. However, endoscopic retreatment is safe and effective. ES is a reasonable method for treating choledocholithiasis, even in young patients.

Routine cholecystocholangiography: a viable alternative during laparoscopic cholecystectomy

BACKGROUND

The advantages of cholangiography during laparoscopic cholecystectomy (LC), including identification of biliary anatomy and biliary calculi, are well known. The usefulness of cholecystocholangiography (CCC), by direct injection through the gall-bladder, compared to the more popular cystic duct cholangiography (CDC), however, is not so well known.

METHODS

Two hundred consecutive patients who underwent LC were included in a prospective study of routine CCC. Between 5 and 60 mL of contrast is injected through the gall-bladder fundus, using image intensifier control.

RESULTS

Cholecystocholangiography was attempted in 194 cases and was successful in 157 (80.9%). Twenty-one of the 37 cases with a failed CCC proceeded to have a successful CDC, giving an overall cholangiography success rate of 91.8%. The presence of acute inflammation decreased the success rate. Eleven (6%) true positive cases of common bile duct (CBD) calculi were demonstrated (nine on CCC and two on CDC after failed CCC). There was one case of false positive CBD calculus and no false negatives.

CONCLUSIONS

We have found that the routine use of CCC during LC is safe, successful, quick to perform, and does not prevent conversion to attempted CDC in the cases where it fails. Cholecystocholangiography may have advantages over CDC and be an alternative as the preferred imaging technique.

Role of endoscopic retrograde cholangiopancreatography before and after laparoscopic cholecystectomy

BACKGROUND

While the role of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (EST) in the diagnosis and management of choledocholithiasis is well established, this study evaluates the usefulness of ERCP and EST in patients with symptomatic cholecystolithiasis and suspected choledocholithiasis before undergoing laparoscopic cholecystectomy (LC), and the role of ERCP-EST in the management of complications resulting from LC.

MATERIALS AND METHODS

This paper reviews retrospectively our experience from 1992 to 1995. A total of 1221 LCs and 717 ERCPs were performed, out of which 257 ERCPs were performed on 225 patients who underwent LC (230 ERCPs before and 27 after). The age range was 10-85 years (mean 43.5). The study group comprised 148 females (66%) and 77 males (34%).

RESULTS

The overall success rate for ERCP was 92% (96% for diagnostic and 88% for therapeutic). Choledocholithiasis was found at preoperative ERCP in 45% of cases. Prediction of choledocholithiasis was accurate in 46%, based on abnormal liver chemistry, and 70% when based on a combination of abnormal liver tests and dilated main bile duct (>7 mm) by ultrasound. In 40 cases of acute biliary pancreatitis, choledocholithiasis was found at ERCP in eight cases (20%). In the post-LC group, all eight cases with residual stones and seven of eight cases with bile leaks were successfully treated endoscopically. There were four cases with major duct injuries that required surgical management. The complications related to ERCP-EST included two cases of bleeding post-EST (one was controlled with injection therapy and the second one was managed surgically), and three cases of mild pancreatitis.

CONCLUSION

ERCP and EST are effective and safe in the diagnosis and management of choledocholithiasis, and facilitate LC for symptomatic cholelithiasis. The procedures are also valuable in the diagnosis and management of most complications resulting from LC.

Endoscopic sphincterotomy for stones by experts is safe, even in younger patients with normal ducts

OBJECTIVE

To provide current information on the risks of endoscopic sphincterotomy for stone.

SUMMARY BACKGROUND DATA

In recent years (since the popularity of laparoscopic cholecystectomy), endoscopic sphincterotomy has been used increasingly for the management of bile duct stones in relatively young and healthy patients. The validity of this trend has been questioned using data on short-term complications derived from earlier decades that involved more elderly and high-risk patients.

METHODS

Seven academic centers collected data prospectively using a common database. Complications within 30 days of the procedures were documented by standard criteria.

RESULTS

Of 1921 patients, 112 (5.8%) developed complications; two thirds of these events were graded as mild (<3 days in hospital). There was no evidence of increased risk in younger patients or in those with smaller bile ducts. There was only one severe complication and there were no fatalities in 238 patients age <60, with bile duct diameters of <9 mm.

CONCLUSION

Sphincterotomy for stones can be performed very safely by experienced endoscopists.

Randomised trial of laparoscopic exploration of common bile duct versus postoperative endoscopic retrograde cholangiography for common bile duct stones

BACKGROUND

The management of stones in the common bile duct in the laparoscopic era is controversial. The three major options are preoperative endoscopic retrograde cholangiography (ERCP), laparoscopic exploration of the common bile duct (LECBD), or postoperative ERCP.

METHODS

Between August, 1995, and August, 1997, 471 laparoscopic cholecystectomies were done in our department. In 427 (91%), satisfactory peroperative cholangiography was obtained. In 80 (17%) of these cases there were stones in the common bile duct, 40 patients were randomised to LECBD and 40 to postoperative ERCP. If LECBD failed, patients had either open exploration of the common bile duct or postoperative ERCP. If one postoperative ERCP failed, the procedure was repeated until the common bile duct was cleared of stones or an endoprosthesis was placed to prevent stone impaction. The primary endpoints were duct-clearance rates, morbidity, operating time, and hospital stay. Analyses were by intention to treat.

FINDINGS

Age and sex distribution of patients was similar in the randomised groups. Duct clearance after the first intervention was 75% in both groups. By the end of treatment, duct clearance was 100% in the laparoscopic group compared with 93% in the ERCP group. Duration of treatment was a median of 90 min (range 25-310) in the laparoscopic group (including ERCPs for failed LECBD) compared with 105 min (range 60-255) in the postoperative ERCP group (p = 0.1, 95% CI for difference -5 to 40). Hospital stay was a median of 1 day (range 1-26) in the laparoscopic group compared with 3.5 days (range 1-11) in the ERCP group (p = 0.0001, 95% CI 1-2).

INTERPRETATION

LECBD is as effective as ERCP in clearing the common bile duct of stones. There is a non-significant trend to shorter time in the operating theatre and a significantly shorter hospital stay in patients treated by LECBD.