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Gurusamy KS, Giljaca V, Takwoingi Y, Higgie D, Poropat G, Štimac D, Davidson BR. Endoscopic retrograde cholangiopancreatography versus intraoperative cholangiography for diagnosis of common bile duct stones. Cochrane Database Syst Rev 2015; 2015:CD010339. [PMID: 25719222 PMCID: PMC6464791 DOI: 10.1002/14651858.cd010339.pub2] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) and intraoperative cholangiography (IOC) are tests used in the diagnosis of common bile duct stones in people suspected of having common bile duct stones. There has been no systematic review of the diagnostic accuracy of ERCP and IOC. OBJECTIVES To determine and compare the accuracy of ERCP and IOC for the diagnosis of common bile duct stones. SEARCH METHODS We searched MEDLINE, EMBASE, Science Citation Index Expanded, BIOSIS, and Clinicaltrials.gov to September 2012. To identify additional studies, we searched the references of included studies and systematic reviews identified from various databases (Database of Abstracts of Reviews of Effects (DARE)), Health Technology Assessment (HTA), Medion, and ARIF (Aggressive Research Intelligence Facility)). We did not restrict studies based on language or publication status, or whether data were collected prospectively or retrospectively. SELECTION CRITERIA We included studies that provided the number of true positives, false positives, false negatives, and true negatives for ERCP or IOC. We only accepted studies that confirmed the presence of common bile duct stones by extraction of the stones (irrespective of whether this was done by surgical or endoscopic methods) for a positive test, and absence of common bile duct stones by surgical or endoscopic negative exploration of the common bile duct, or symptom-free follow-up for at least six months for a negative test as the reference standard in people suspected of having common bile duct stones. We included participants with or without prior diagnosis of cholelithiasis; with or without symptoms and complications of common bile duct stones; with or without prior treatment for common bile duct stones; and before or after cholecystectomy. At least two authors screened abstracts and selected studies for inclusion independently. DATA COLLECTION AND ANALYSIS Two authors independently collected data from each study. We used the bivariate model to summarise the sensitivity and specificity of the tests. MAIN RESULTS We identified five studies including 318 participants (180 participants with and 138 participants without common bile duct stones) that reported the diagnostic accuracy of ERCP and five studies including 654 participants (125 participants with and 529 participants without common bile duct stones) that reported the diagnostic accuracy of IOC. Most studies included people with symptoms (participants with jaundice or pancreatitis) suspected of having common bile duct stones based on blood tests, ultrasound, or both, prior to the performance of ERCP or IOC. Most studies included participants who had not previously undergone removal of the gallbladder (cholecystectomy). None of the included studies was of high methodological quality as evaluated by the QUADAS-2 tool (quality assessment tool for diagnostic accuracy studies). The sensitivities of ERCP ranged between 0.67 and 0.94 and the specificities ranged between 0.92 and 1.00. For ERCP, the summary sensitivity was 0.83 (95% confidence interval (CI) 0.72 to 0.90) and specificity was 0.99 (95% CI 0.94 to 1.00). The sensitivities of IOC ranged between 0.75 and 1.00 and the specificities ranged between 0.96 and 1.00. For IOC, the summary sensitivity was 0.99 (95% CI 0.83 to 1.00) and specificity was 0.99 (95% CI 0.95 to 1.00). For ERCP, at the median pre-test probability of common bile duct stones of 0.35 estimated from the included studies (i.e., 35% of people suspected of having common bile duct stones were confirmed to have gallstones by the reference standard), the post-test probabilities associated with positive test results was 0.97 (95% CI 0.88 to 0.99) and negative test results was 0.09 (95% CI 0.05 to 0.14). For IOC, at the median pre-test probability of common bile duct stones of 0.35, the post-test probabilities associated with positive test results was 0.98 (95% CI 0.85 to 1.00) and negative test results was 0.01 (95% CI 0.00 to 0.10). There was weak evidence of a difference in sensitivity (P value = 0.05) with IOC showing higher sensitivity than ERCP. There was no evidence of a difference in specificity (P value = 0.7) with both tests having similar specificity. AUTHORS' CONCLUSIONS Although the sensitivity of IOC appeared to be better than that of ERCP, this finding may be unreliable because none of the studies compared both tests in the same study populations and most of the studies were methodologically flawed. It appears that both tests were fairly accurate in guiding further invasive treatment as most people diagnosed with common bile duct stones by these tests had common bile duct stones. Some people may have common bile duct stones in spite of having a negative ERCP or IOC result. Such people may have to be re-tested if the clinical suspicion of common bile duct stones is very high because of their symptoms or persistently abnormal liver function tests. However, the results should be interpreted with caution given the limited quantity and quality of the evidence.
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Affiliation(s)
- Kurinchi Selvan Gurusamy
- Department of Surgery, Royal Free Campus, UCL Medical School, Royal Free Hospital, Rowland Hill Street, London, UK, NW3 2PF.
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Sajid MS, Leaver C, Haider Z, Worthington T, Karanjia N, Singh KK. Routine on-table cholangiography during cholecystectomy: a systematic review. Ann R Coll Surg Engl 2012; 94:375-80. [PMID: 22943325 PMCID: PMC3954316 DOI: 10.1308/003588412x13373405385331] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2011] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION The aim of this review was to systemically analyse trials evaluating the efficacy of routine on-table cholangiography (R-OTC) versus no on-table cholangiography (N-OTC) in patients undergoing cholecystectomy. METHODS Randomised trials evaluating R-OTC versus N-OTC in patients undergoing cholecystectomy were selected and analysed. RESULTS Four trials (1 randomised controlled trial on open cholecystectomy and 3 on laparoscopic cholecystectomy) encompassing 860 patients undergoing cholecystectomy with and without R-OTC were retrieved. There were 427 patients in the R-OTC group and 433 patients in the N-OTC group. There was no significant heterogeneity among trials. Therefore, in the fixed effects model, N-OTC did not increase the risk (p=0.53) of common bile duct (CBD) injury, and it was associated with shorter operative time (p<0.00001) and fewer peri-operative complications (p<0.04). R-OTC was superior in terms of peri-operative CBD stone detection (p<0.006) and it reduced readmission (p<0.03) for retained CBD stones. CONCLUSIONS N-OTC is associated with shorter operative time and fewer peri-operative complications, and it is comparable to R-OTC in terms of CBD injury risk during cholecystectomy. R-OTC is helpful for peri-operative CBD stone detection and there is therefore reduced readmission for retained CBD stones. The N-OTC approach may be adopted routinely for patients undergoing laparoscopic cholecystectomy providing there are no clinical, biochemical or radiological features suggestive of CBD stones. However, a major multicentre randomised controlled trial is required to validate this conclusion.
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Affiliation(s)
- M S Sajid
- Western Sussex Hospitals NHS Trust, UK.
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Norton SA, Alderson D. Prospective comparison of endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography in the detection of bile duct stones. Br J Surg 2005. [DOI: 10.1111/j.1365-2168.1997.00597.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Sgourakis G, Dedemadi G, Stamatelopoulos A, Leandros E, Voros D, Karaliotas K. Predictors of common bile duct lithiasis in laparoscopic era. World J Gastroenterol 2005; 11:3267-72. [PMID: 15929180 PMCID: PMC4316061 DOI: 10.3748/wjg.v11.i21.3267] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
AIM: To analyze retrospectively the records of 294 conse-cutive patients operated upon for gallbladder stones, to determine the predictive factors of synchronous common bile duct (CBD) stones and validate prospectively the generated model.
METHODS: The prognostic estimation of a biochemical test and ultrasonography alone to differentiate between the absence and presence of choledocholithiasis was assessed using receiver operating characteristics curve analysis. Multivariate analysis was employed using discriminant analysis for establishment of a best model. Prospective validation of the model was made.
RESULTS: Discriminant forward stepwise analysis disclosed that high values (≥ 2×normal) of SGOT, ALP, conjugated bilirubin and CBD diameter on ultrasound ≥ 10 mm were all prognostic factors of CBD lithiasis in univariate and multivariate analysis, P<0.01. History was not included in the model. Prospective validation of the model was performed by multivariate analysis using Visual General Stepwise Regression. Positive predictive value, when considering all these predictors, was 93.3%, while the negative predictive value was 88.8%. Sensitivity of the model was 96.5% and specificity 80%.
CONCLUSION: The above model can be objectively applied to predict the presence of CBD stones.
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Affiliation(s)
- George Sgourakis
- 2nd Surgical Department of Korgialenio-Mpenakio Red Cross Hospital, 11 Mantzarou str., Neo Psychiko, 15451 Athens, Greece.
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Grande M, Torquati A, Tucci G, Rulli F, Adorisio O, Farinon AM. Preoperative risk factors for common bile duct stones: defining the patient at high risk in the laparoscopic cholecystectomy era. J Laparoendosc Adv Surg Tech A 2005; 14:281-6. [PMID: 15630944 DOI: 10.1089/lap.2004.14.281] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Common bile duct stones (CBDS) are present in 3-20% of patients with cholelithiasis. Intraoperative cholangiography has high sensitivity in detecting CBDS but its routine use is associated with increased costs and operating room time. The aim of our study was to define an accurate and simple model for the prediction of CBDS using preoperative variables. METHODS The study consisted of a retrospective analysis followed by a prospective study. Multivariate analysis of the retrospective data was used to create a predictive model for the presence of concurrent CBDS in patients undergoing cholecystectomy. The predictive model was then validated in a prospective series of 160 patients undergoing laparoscopic cholecystectomy. RESULTS Among the 19 potentially predictive variables for CBDS, only four were found to be statistically significant and independent: X1-alkaline phosphatase levels (UI/L); X2-number of gallbladder stones; X3-total serum bilirubin (mg/dL); and X4-CBD diameter (mm). Using these four variables, the multivariate analysis created the equation: score = 0.002 x X1 + 0.485 x X2 + 0.232 x X3 + 0.220 x X4 - 4.167 to define the risk of CBDS in each patient. The predictive model, tested prospectively in 160 patients undergoing laparoscopic cholecystectomy (LC), showed an elevated index of correlation (r = 0.75) among the predicted and the observed frequencies (chi2 = 126.6; P < 0.0001). The predictive model sensitivity and specificity were 92.9% and 99.3%, respectively. CONCLUSIONS In patients undergoing cholecystectomy, accurate prediction of the risk for concurrent CBDS can be achieved using four preoperative variables. The use of this predictive model can contribute to reducing the number of unnecessary common bile duct explorations.
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Affiliation(s)
- Michele Grande
- Department of Surgery, University of Rome Tor Vergata, Italy.
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Metcalfe MS, Ong T, Bruening MH, Iswariah H, Wemyss-Holden SA, Maddern GJ. Is laparoscopic intraoperative cholangiogram a matter of routine? Am J Surg 2004; 187:475-81. [PMID: 15041494 DOI: 10.1016/j.amjsurg.2003.12.047] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2003] [Revised: 08/11/2003] [Indexed: 02/08/2023]
Abstract
BACKGROUND Intraoperative cholangiography during laparoscopic cholecystectomy reveals the anatomy of the biliary tree and any stones contained within it. The use of intraoperative cholangiography may be routine for all laparoscopic cholecystectomy. An alternative approach is a selective policy, performing intraoperative cholangiography only for those cases in which choledocholithiasis is suspected on clinical grounds, or those for which the anatomy appears unclear at operation. The literature pertaining to both approaches is reviewed, to delineate their respective merits. METHODS Relevant articles in English were identified from the Medline database, and reviewed. RESULTS The literature reviewed consisted of retrospective analyses. Overall the incidence of unsuspected retained stones was 4%, but only 15% of these would go on to cause clinical problems. The incidence of complete transection of the common bile duct was rare for both routine and selective intraoperative cholangiography policies, and did not differ between them. Rates of minor bile duct injury did not differ between groups, but was more likely to be recognized in the routine group than the selective (P = 0.01). CONCLUSIONS Routine intraoperative cholangiography yields very little useful clinical information over and above that which is obtained with selective policies. Large numbers of unnecessary intraoperative cholangiography are performed under routine intraoperative cholangiography policy, and therefore a selective policy is advocated.
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Affiliation(s)
- Matthew S Metcalfe
- Department of Surgery, University of Adelaide, The Queen Elizabeth Hospital, Woodville Rd., Woodville, SA 5011, Australia
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Abstract
With advances in medical technology, including intensive care, new medications, alterations in the composition of parenteral nutrition, and the institution of minimally invasive surgery, our understanding of the spectrum of diseases of the gallbladder resulting in stone formation or inflammation, and the management of these disorders has changed over the past few decades. The discussion herein focuses on our thinking about the current diagnosis and treatment for these disorders.
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Affiliation(s)
- T E Lobe
- Section of Pediatric Surgery, University of Tennessee, Memphis, LeBonheur Children's Medical Center, Memphis, TN 38105, USA
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Laparoscopic Ultrasonography and Operative Cholangiography Prevent Residual Common Bile Duct Stones in Laparoscopic Cholecystectomy. Surg Laparosc Endosc Percutan Tech 1999. [DOI: 10.1097/00129689-199904000-00009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
BACKGROUND The operation of laparoscopic cholecystectomy began the modern era of laparoscopic surgery. Refinements in technique continue to appear. The techniques currently favoured by British surgeons have been reviewed. METHODS A questionnaire-based survey was carried out among surgeons with a special interest in minimal access surgery. The data collected were entered into a database and analysed. Current literature relating to surgical technique was reviewed. RESULTS Many aspects were evaluated and the results have shown that there is no uniform approach. It is interesting that only 30.8 per cent of surgeons use the open (Hasson) technique for peritoneal access. In addition, the use of intraoperative cholangiography continues to vary, with 65.8 per cent using the technique in selected cases. Fascial repair is not undertaken by 12.2 per cent of surgeons. CONCLUSION Some trends are clearly discernible. There is a greater willingness than previously to perform intraoperative cholangiography, but the consensus seems to be against performing it in all cases. Similarly, British surgeons seem to be largely unimpressed by the dangers of the Veress needle; the Hasson technique has not been widely adopted. The need to prevent port-site herniation seems to be generally accepted, with most surgeons performing fascial repair.
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Affiliation(s)
- V V Chitre
- James Paget Hospital NHS Trust, Gorleston, Great Yarmouth, UK
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Khaira HS, Ridings PC, Gompertz RH. Routine laparoscopic cholangiography: a means of avoiding unnecessary endoscopic retrograde cholangiopancreatography. J Laparoendosc Adv Surg Tech A 1999; 9:17-22. [PMID: 10194688 DOI: 10.1089/lap.1999.9.17] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Controversy exists between routine and selective on-table cholangiography during laparoscopic cholecystectomy. Endoscopic retrograde cholangiopancreatography (ERCP) has been suggested as first-line investigation in patients with suspected duct stones. We report a series of 154 on-table cholangiograms (OTC) and consider the requirements for ERCP according to historical and biochemical markers. A retrospective review of 154 consecutive patients undergoing laparoscopic cholecystectomy with OTC was performed. Historical and biochemical markers of duct stones were examined with respect to the necessity of ERCP. OTC was performed, with a 100% success rate, and took approximately 10 min. Eight (5.2%) of the patients had duct stones. Only one did not have preoperative indicators of duct stones. Sixty-six patients had preoperative markers suggesting the need for ERCP. According to the OTC findings, 59 (89.4%) of these patients would have undergone unnecessary ERCP. Routine laparoscopic OTC is advocated because it maintains expertise in the technique and avoids unnecessary ERCP with its attendant costs and complications.
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Affiliation(s)
- H S Khaira
- Queen's Hospital, Burton-on-Trent, Staffordshire, England
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Fontes PRO, Nectoux M, Eilers RJ, Chem EM, Reidner CE. Colangiografia transoperatória em colecistectomia laparoscópica. Rev Col Bras Cir 1998. [DOI: 10.1590/s0100-69911998000600005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Com o objetivo de analisar os resultados e a experiência acumulada com a realização de colangiografia transoperatória nos pacientes submetidos à colecistectomia laparoscópica, revisamos os prontuários de 309 pacientes com colelitíase sintomática tratados por videocirurgia no nosso serviço entre maio de 1993 e junho de 1997. Realizamos a colangiografia transoperatória rotineiramente, o que foi possível em 244 (78,9%) pacientes. O principal motivo para a não realização do exame nos demais pacientes foi a presença do ducto cístico de pequeno calibre em 21 (6,8%) casos. Entre os pacientes nos quais foi realizado o exame, o resultado foi normal em 229 (93,8%). Em 11 (4,5%) identificou-se coledocolitíase, sendo insuspeita em sete (2,8%); em três (1,2%), o ducto cístico desembocava no ducto hepático direito, e, em um (0,4%), diagnosticou-se um grande cisto coledociano com calculose intra e extra-hepática. A colangiografia transoperat6ria durante colecistectomia laparoscópica mostrou-se um procedimento seguro nos pacientes em que conseguimos realizá-la, já que não tivemos complicações relacionadas ao exame. Ao definir a anatomia, previne ou demonstra alterações biliares e permite a detecção de coledocolitíase insuspeita. Assim, pelos dados analisados, recomendamos o seu emprego rotineiro.
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Dwerryhouse SJ, Brown E, Vipond MN. Prospective evaluation of magnetic resonance cholangiography to detect common bile duct stones before laparoscopic cholecystectomy. Br J Surg 1998; 85:1364-6. [PMID: 9782014 DOI: 10.1046/j.1365-2168.1998.00957.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
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.
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Affiliation(s)
- S J Dwerryhouse
- Department of Surgery, Gloucestershire Royal Hospital, Gloucester, UK
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14
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Abstract
The surgeon should be aware of the extensive applications of endoscopic surgery in the pediatric patient. The ability to provide surgical care in association with either outpatient or short-stay hospitalizations appear to be cost-effective and appropriate state-of-the-art medical care. Because the array of surgical instruments continues to evolve, new and innovative endoscopic procedures will continue to become increasingly available.
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Affiliation(s)
- T E Lobe
- Section of Pediatric Surgery, University of Tennessee, Memphis, USA
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Sabharwal AJ, Minford EJ, Marson LP, Muir IM, Hill D, Auld CD. Laparoscopic cholangiography: a prospective study. Br J Surg 1998; 85:624-6. [PMID: 9635807 DOI: 10.1046/j.1365-2168.1998.00640.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The place of cholangiography has been controversial in the conventional and now in the laparoscopic setting. The aim of this study was to evaluate laparoscopic cholangiography and compare use of a portable C-arm image intensifier with conventional radiography. METHODS One hundred and ninety-seven consecutive patients undergoing laparoscopic cholecystectomy were randomized before operation to cholangiography by either C-arm image intensifier or conventional radiography. Data were collected on a pro forma completed immediately after the operation. RESULTS Cholangiography was successful in 93.0 per cent of patients. Cholangiography with an image intensifier was significantly faster. In 19 patients the ductal system was obscured by a cannula; in 17 of these cases a metal cannula was used. In 31.6 per cent of patients the clip on the cystic duct was within 1 cm or less of the common bile duct (CBD). CONCLUSION Laparoscopic cholangiography is a safe procedure. Use of an image intensifier should be the preferred method of obtaining images. Metal cannulas are more likely to obscure the ductal system. The proximity of the clip on the cystic duct to the CBD highlights the potential for injury caused by electrocautery or erroneous clip application.
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Affiliation(s)
- A J Sabharwal
- Department of Surgery, Dumfries and Galloway Royal Infirmary, Dumfries, UK
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16
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Abstract
The realm of laparoscopic surgery has extended to include the neonate as well as the pediatric patient. The advent of new and smaller instrumentation has facilitated this goal. Previous procedures exclusively relegated to laparotomy can now be accomplished as outpatient procedures. Removal of the acute appendix, correction of torsion of an adnexa, as well as the appropriate diagnosis and initial treatment of acute pelvic inflammatory disease are now well established laparoscopic procedures. This article provides insight into the laparoscopic evaluation and management of a number of challenging clinical problems for the endoscopic surgeon, thus providing a minimally invasive approach for patients ranging from neonates to adults.
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Affiliation(s)
- J S Sanfilippo
- Department of Obstetrics and Gynecology, University of Louisville School of Medicine, KY, USA
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Norton SA, Alderson D. Prospective comparison of endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography in the detection of bile duct stones. Br J Surg 1997. [PMID: 9361590 DOI: 10.1002/bjs.1800841009] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Conventional ultrasonography is used widely in the investigation of gallstone disease but is limited in the detection of bile duct stones due to poor visualization of the distal bile duct. Endoscopic retrograde cholangiopancreatography (ERCP) is currently the investigation of choice for suspected choledocholithiasis, but is not without morbidity. Endoscopic ultrasonography clearly visualizes the entire extrahepatic biliary tree and avoids the need for ERCP in many patients. METHODS Some 50 patients with suspected duct stones underwent endoscopic ultrasonography followed by ERCP. All cholangiograms were performed or interpreted by a second doctor blinded to the results of endoscopic ultrasonography. RESULTS Both tests were successful in 46 patients; both tests failed in two patients and ERCP alone failed in a further two. Duct stones were confirmed in 24 patients. Sensitivity (95 per cent confidence interval (c.i.)) of ERCP and endoscopic ultrasonography in identifying these stones was 79 (58-93) per cent and 88 (68-97) per cent respectively; specificity (95 per cent c.i.) was 92 (75-99) per cent and 96 (80-100) per cent. CONCLUSION Endoscopic ultrasonography accurately identifies bile duct stones. It is recommended in all patients with a risk of duct stones but especially in those with a history of ERCP-induced pancreatitis, when other pathology is suspected, when ERCP has failed, when bile duct abnormalities are suspected during pregnancy and in patients with acute pancreatitis.
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Affiliation(s)
- S A Norton
- Department of Surgery, Bristol Royal Infirmary, UK
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18
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Al-Salem AH, Nourallah H. Sequential endoscopic/laparoscopic management of cholelithiasis and choledocholithiasis in children who have sickle cell disease. J Pediatr Surg 1997; 32:1432-5. [PMID: 9349762 DOI: 10.1016/s0022-3468(97)90555-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND/PURPOSE Cholelithiasis and choledocholithiasis are common complications of sickle cell disease (SCD). With the recent advances in laparoscopic cholecystectomy (LC), which has been used successfully for the management of cholelithiasis in children who have SCD, exclusion of choledocholithiasis before LC is of great importance. METHODS Eighteen children who had SCD, cholelithiasis, and choledocholithiasis were treated at our hospital. Seven were treated with open cholecystectomy (OC) and common bile duct (CBD) exploration, and two were treated with transduodenal sphincteroplasty. The remaining 11 patients underwent endoscopic retrograde cholangiopancreatography (ERCP), sphincterotomy, and stone extraction followed by laparoscopic cholecystectomy (LC). RESULTS A dilated CBD noted on ultrasound, elevated alkaline phosphatase, elevated total bilirubin of more than 5 mg/dL, history of pancreatitis, either singly or in combination, should raise suspicion of choledocholithiasis, and these patients together with those who have choledocholithiasis detected on ultrasound should undergo ERCP to confirm and extract the stones before LC. CONCLUSION This sequential approach of endoscopic sphincterotomy and stone extraction followed by LC is a safe and effective approach for the management of cholelithiasis and choledocholithiasis in children who have SCD.
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Affiliation(s)
- A H Al-Salem
- Department of Surgery, Qatif Central Hospital, Saudi Arabia
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19
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Tagge EP, Tarnasky PR, Chandler J, Tagge DU, Smith C, Hebra A, Hawes RH, Cotton PB, Othersen HB. Multidisciplinary approach to the treatment of pediatric pancreaticobiliary disorders. J Pediatr Surg 1997; 32:158-64; discussion 164-5. [PMID: 9044114 DOI: 10.1016/s0022-3468(97)90171-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
A multidisciplinary approach using traditional open surgery, endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic surgery has revolutionized the care of the adult with pancreaticobiliary disease. This study focuses on a similar collaborative effort to diagnose and treat children with pancreaticobiliary disorders. Charts of all patients treated on the pediatric surgery service between June 1990 and May 1995, who also underwent ERCP, were abstracted for disease process, presenting symptoms, laboratory evaluation, surgical or endoscopic procedures, and eventual outcome. Twenty-six children were identified, ranging from 6 months to 19 years of age. Pancreaticobiliary disorders included pancreas divisum (n = 1), choledochal cyst (n = 4), pancreaticobiliary trauma (n = 4), cholelithiasis and choledocholithiasis (n = 17). The pancreaticobiliary tree was successfully visualized by ERCP in 25 of 26 (96%) patients. Fifteen of these patients also underwent attempted therapeutic endoscopic procedures, with 13 (87%) performed successfully. Three patients with choledochal cyst had stents placed preoperatively for cholangitis, all of whom have undergone successful choledochal cyst excision. Two trauma patients underwent attempted stenting of a bile leak and bile duct stricture, respectively, both of which were unsuccessful, necessitating surgical correction. Seventeen patients with cholelithiasis underwent ERCP to rule out choledocholithiasis. Ten patients were found to have common duct stones, and all stones were endoscopically extracted, including those in a 6-month-old child. Overall survival rate was 96% (25 of 26), with the one death occurring in a trauma patient unrelated to his pancreaticobiliary disorder. A multidisciplinary approach using traditional open surgery, ERCP and laparoscopic surgery can successfully treat even young children with pancreaticobiliary disorders. In experienced hands, diagnostic ERCP and therapeutic endoscopic intervention can be performed successfully in most pediatric patients, greatly simplifying the surgical management of these potentially complex problems.
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Affiliation(s)
- E P Tagge
- Department of Surgery, Medical University of South Carolina, Charleston 29425, USA
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Welbourn CR, Haworth JM, Leaper DJ, Thompson MH. Prospective evaluation of ultrasonography and liver function tests for preoperative assessment of the bile duct. Br J Surg 1995; 82:1371-3. [PMID: 7489169 DOI: 10.1002/bjs.1800821026] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Current means of predicting the presence of bile duct stones are sensitive but produce a large number of false-positive results, potentially leading to added morbidity from unnecessary invasive investigation. This study prospectively assessed 545 patients with gallbladder stones, including 55 patients with bile duct stones, to refine criteria for further investigation of the bile duct. The sensitivity, specificity, and positive and negative predictive values were calculated for bile duct dilatation (diameter abnormal if larger than 5 mm below age 50 years, normal value increasing by 1 mm per decade) and elevation of three liver function tests, singly or in combination. Depending on the number of abnormalities used the sensitivity ranged from 46 to 96 per cent and the positive predictive value from 35 to 77 per cent. All groupings gave at least 96 per cent negative predictive value for the absence of stones but none combined both high sensitivity and positive predictive value. The specificity was improved if the tests were done on the working day before operation. Refining criteria for predicting bile duct stones allows the selective use of cholangiography and may reduce the number of negative cholangiograms.
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Affiliation(s)
- C R Welbourn
- Department of Surgery, Southmead Hospital, Bristol, UK
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