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Shabanzadeh DM, Christensen DW, Ewertsen C, Friis-Andersen H, Helgstrand F, Nannestad Jørgensen L, Kirkegaard-Klitbo A, Larsen AC, Ljungdalh JS, Nordblad Schmidt P, Therkildsen R, Vilmann P, Vogt JS, Sørensen LT. National clinical practice guidelines for the treatment of symptomatic gallstone disease: 2021 recommendations from the Danish Surgical Society. Scand J Surg 2022; 111:11-30. [PMID: 36000716 DOI: 10.1177/14574969221111027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
BACKGROUND AND OBJECTIVE Gallstones are highly prevalent, and more than 9000 cholecystectomies are performed annually in Denmark. The aim of this guideline was to improve the clinical course of patients with gallstone disease including a subgroup of high-risk patients. Outcomes included reduction of complications, readmissions, and need for additional interventions in patients with uncomplicated gallstone disease, acute cholecystitis, and common bile duct stones (CBDS). METHODS An interdisciplinary group of clinicians developed the guideline according to the GRADE methodology. Randomized controlled trials (RCTs) were primarily included. Non-RCTs were included if RCTs could not answer the clinical questions. Recommendations were strong or weak depending on effect estimates, quality of evidence, and patient preferences. RESULTS For patients with acute cholecystitis, acute laparoscopic cholecystectomy is recommended (16 RCTs, strong recommendation). Gallbladder drainage may be used as an interval procedure before a delayed laparoscopic cholecystectomy in patients with temporary contraindications to surgery and severe acute cholecystitis (1 RCT and 1 non-RCT, weak recommendation). High-risk patients are suggested to undergo acute laparoscopic cholecystectomy instead of drainage (1 RCT and 1 non-RCT, weak recommendation). For patients with CBDS, a one-step procedure with simultaneous laparoscopic cholecystectomy and CBDS removal by laparoscopy or endoscopy is recommended (22 RCTs, strong recommendation). In high-risk patients with CBDS, laparoscopic cholecystectomy is suggested to be included in the treatment (6 RCTs, weak recommendation). For diagnosis of CBDS, the use of magnetic resonance imaging or endoscopic ultrasound prior to surgical treatment is recommended (8 RCTs, strong recommendation). For patients with uncomplicated symptomatic gallstone disease, observation is suggested as an alternative to laparoscopic cholecystectomy (2 RCTs, weak recommendation). CONCLUSIONS Seven recommendations, four weak and three strong, for treating patients with symptomatic gallstone disease were developed. Studies for treatment of high-risk patients are few and more are needed. ENDORSEMENT The Danish Surgical Society.
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Affiliation(s)
| | | | - Caroline Ewertsen
- Department of Diagnostic Radiology, Rigshospitalet, Copenhagen, Denmark
| | - Hans Friis-Andersen
- Department of Surgery, Regionshospitalet Horsens, Horsens, DenmarkInstitute for Clinical Medicine, Faculty of Health, University of Aarhus, Aarhus, Denmark
| | | | - Lars Nannestad Jørgensen
- Digestive Disease Center, Surgical Section, Bispebjerg Hospital, Copenhagen, DenmarkInstitute for Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | - Anders Christian Larsen
- Department of Gastrointestinal Surgery, Aalborg University Hospital, Aalborg, DenmarkDepartment of Clinical Medicine, The Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | | | - Palle Nordblad Schmidt
- Department of Gastroenterology and Gastrointestinal Surgery, Hvidovre Hospital, Copenhagen, Denmark
| | | | - Peter Vilmann
- Institute for Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, DenmarkDepartment of Surgery, Herlev Gentofte Hospital, Herlev, Denmark
| | - Jes Sefland Vogt
- Department of Gastrointestinal Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Lars Tue Sørensen
- Digestive Disease Center, Surgical Section, Bispebjerg Hospital, Copenhagen, DenmarkInstitute for Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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A Systematic Review and Meta-analysis of Basket or Balloon Catheter for the Retrieval of Choledocholithiasis. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03435-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
AbstractCholedocholithiasis means the presence of gallstone inside the common bile duct (CBD). Removing the bile duct stones can be done surgically using endoscopic catheters. In this study, we aim to assess the safety and efficacy of basket catheters compared to balloon catheters at bile duct stone clearance. We searched four databases for clinical trial and cohort studies that compare basket catheter and balloon catheter in bile duct stone extraction. We extracted data from the included studies. These data were pooled as mean difference (MD) or risk ratio (RR) with 95% confidence interval (CI) using Review Manager software (version 5.3) and OpenMetaAnalyst software for zero-event outcomes. In a total of 728 patients, we find that the balloon catheter was better than the basket catheter regarding incomplete bile duct stone clearance (RR = 0.91, 95% CI [0.85, 0.98], P = 0.01). Regarding the number of the extracted stones by both catchers, the analysis favored the balloon catheter over the basket for clearance when less than four stones (RR = 0.91, 95% CI [0.85, 0.99], P = 0.02) but no significant difference for more than four stones (RR = 0.77, 95% CI [0.48, 1.24], P = 0.29). There was no significant difference between the two groups. The analysis revealed that the balloon catheter is better than the basket catheter for choledocholithiasis regarding the complete clearance of the stone. However, there was no significant difference regarding the safety outcome.
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Is the use of fully covered metal stents effective in the treatment of difficult lithiasis of the common bile duct? Surg Endosc 2022; 36:5684-5691. [PMID: 34993589 DOI: 10.1007/s00464-021-08919-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 11/21/2021] [Indexed: 12/07/2022]
Abstract
BACKGROUND The management of difficult lithiasis of common bile duct (CBD) often requires a multimodal approach. Fully Covered Metal Stents (FCSEMS) could fragment the stones, dilate strictures of the CBD and progressively enlarge the papillary orifice. The aim of the study was to evaluate the efficacy of FCSEMS in the treatment of difficult lithiasis of CBD. METHODS All consecutive cases of difficult lithiasis of CBD after an attempt of clearance with complete sphincterotomy were retrospectively considered from 2009 to 2019. Intrahepatic lithiasis cases were excluded. Multivariable analysis (stepwise logistic regression if p value < 0.1 at univariable analysis) was made to understand factors associated with efficacy of FCSEMS in difficult lithiasis of CBD. RESULTS 163 cases of difficult lithiasis over 1516 cases of lithiasis of CBD (incidence of 11%) were considered. Among eligible patients, 96 (mean age 78 ± 11.9 years, 43% males) placed a FCSEMS during the first ERCP. Mean diameter of stone was 17.5 ± 5.5 mm. An attempt of dilation during the same procedure was made in 18% cases. After removal of the stent, 52 (54%) patients had complete clearance of CBD at cholangiography. The rest of patients (44), subsequently underwent multimodal treatment (final success of 95%). After logistic regression, variables positively associated with clearance of CBD were sex male (OR 3.5) and stent permanence ≥ 30 days (OR 3.2). Diameter of the stone ≥ 2 cm was associated with failure (OR 0.2). 7 post-ERCP pancreatitis, 6 post-sphincterotomy bleeding and 3 cholangitis occurred. CONCLUSIONS FCSEMS are useful in the approach of difficult lithiasis of CBD with no significant adverse events associated.
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McCarty TR, Gulati R, Rustagi T. Efficacy and safety of peroral cholangioscopy with intraductal lithotripsy for difficult biliary stones: a systematic review and meta-analysis. Endoscopy 2021; 53:110-122. [PMID: 32544959 DOI: 10.1055/a-1200-8064] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND : Peroral cholangioscopy with intraductal lithotripsy facilitates optically guided stone fragmentation of difficult biliary stones refractory to conventional endoscopic therapy. The aim of this study was to evaluate the efficacy and safety of peroral cholangioscopy with intraductal lithotripsy for difficult biliary stones. METHODS : Searches of PubMed, EMBASE, Web of Science, and Cochrane databases were performed in accordance with PRISMA and MOOSE guidelines. Measured outcomes included overall fragmentation success, single-session fragmentation and duct clearance, and rate of adverse events. Sensitivity and subgroup analyses were performed based upon cholangioscopy technique and type of lithotripsy (laser versus electrohydraulic). Heterogeneity was assessed with I 2 statistics. Publication bias was ascertained by funnel plot and Egger regression testing. RESULTS : 35 studies were included with 1762 participants (43.4 % men; mean age 61.5 [standard deviation (SD) 11.0]). Prior cholecystectomy had been performed in 37 % of patients, with a mean number of 1.6 (SD 0.5) ERCPs performed prior to lithotripsy. Mean stone size was 1.8 (SD 0.3) cm. Peroral cholangioscopy with intraductal lithotripsy achieved an overall stone fragmentation success of 91.2 % (95 %CI 88.1 % - 93.6 %; I 2 = 63.2 %) with an average of 1.3 [SD 0.6] lithotripsy sessions performed. Complete single-session fragmentation success was 76.9 % (95 %CI 71.6 % - 81.4 %; I 2 = 74.3 %). The adverse events rate was 8.9 % (95 %CI 6.5 % - 12.2 %; I 2 = 60.6 %). Mean procedure time for peroral cholangioscopy was 67.1 (SD 21.4) minutes. There was no difference in overall fragmentation rate or adverse events; however, laser lithotripsy was associated with a higher single-session fragmentation rate and shorter procedure time compared with electrohydraulic lithotripsy. CONCLUSIONS : Peroral cholangioscopy with intraductal lithotripsy appears to be a relatively safe and effective modality for difficult biliary stones.
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Affiliation(s)
- Thomas R McCarty
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Rishabh Gulati
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico, USA
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico, USA
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Hormati A, Ghadir MR, Sarkeshikian SS, Alemi F, Moghaddam M, Ahmadpour S, Mohammadbeigi A, Sivandzadeh GR. Adding ursodeoxycholic acid to the endoscopic treatment and common bile duct stenting for large and multiple biliary stones: Will it improve the outcomes? BMC Gastroenterol 2020; 20:374. [PMID: 33172395 PMCID: PMC7653844 DOI: 10.1186/s12876-020-01523-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 11/02/2020] [Indexed: 02/06/2023] Open
Abstract
Background The role of common bile duct (CBD) stenting in the establishment of bile stream in the elderly patients and the ones who are not good candidates for surgery due to not responding to treatments was well documented in previous studies. The current study aimed at investigating the effect of adding Ursodeoxycholic acid (UDCA) to CBD stenting alone in order to reduce the size of large and multiple CBD stones.
Methods Clinical outcomes including success rates in CBD stones clearance, incidence of pancreatitis, perforation, bleeding, as well as, decrease in size of stones and liver enzymes after a two-month period were assessed in the UDCA + CBD stenting group. Results A total of 64 patients referring to Shahid Beheshti Hospital in Qom, Iran with multiple or large CBD stones (above three or larger than 15 mm) received standard endoscopic therapies and UDCA + CBD stenting (group B) and controls only received standard endoscopic therapies with only CBD stenting (group A). The mean reduction in the size of stones in group B was significantly higher than that of group A (3.22 ± 1.31 vs 4.09 ± 1.87 mm) (p = 0.034). There was no difference in the incidence rate of complications including pancreatitis, cholangitis, bleeding, and perforation between the two groups (P > 0.05). Conclusion Adding UDCA to CBD stenting, due to decrease in the stone size and subsequently facilitation of the stones outlet, can be considered as the first-line treatment for patients with large and multiple CBD stones. Also, in the cases with large or multi stones may be effective in reducing size and subsequently stone retrieval. Trial registry The study protocol was approved by the Ethics Committee of Qom University of Medical Sciences (ethical code: IR.MUQ.REC.1397.075); the study was also registered in the Iranian Registry of Clinical Trials (No. IRCT20161205031252N8). This study adheres to CONSORT guidelines.
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Affiliation(s)
- Ahmad Hormati
- Gastroenterology and Hepatology Diseases Research Center, Qom University of Medical Sciences, Qom, Iran.,Gastrointestinal and Liver Diseases Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Ghadir
- Gastroenterology and Hepatology Diseases Research Center, Qom University of Medical Sciences, Qom, Iran
| | - Seyed Saeed Sarkeshikian
- Gastroenterology and Hepatology Diseases Research Center, Qom University of Medical Sciences, Qom, Iran
| | - Faezeh Alemi
- Gastroenterology and Hepatology Diseases Research Center, Qom University of Medical Sciences, Qom, Iran.
| | - Majid Moghaddam
- Gastroenterology and Hepatology Diseases Research Center, Qom University of Medical Sciences, Qom, Iran
| | - Sajjad Ahmadpour
- Gastroenterology and Hepatology Diseases Research Center, Qom University of Medical Sciences, Qom, Iran
| | - Abolfazl Mohammadbeigi
- Research Center for Environmental Pollutants, Qom University of Medical Sciences, Qom, Iran
| | - Gholam Reza Sivandzadeh
- Department of Internal Medicine, Gatroenterohepatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Barakat MT, Girotra M, Thosani N, Kothari S, Banerjee S. Escalating complexity of endoscopic retrograde cholangiopancreatography over the last decade with increasing reliance on advanced cannulation techniques. World J Gastroenterol 2020; 26:6391-6401. [PMID: 33244200 PMCID: PMC7656203 DOI: 10.3748/wjg.v26.i41.6391] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 09/22/2020] [Accepted: 10/13/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND At our academic tertiary care medical center, we have noted patients referred for endoscopic retrograde cholangiopancreatography (ERCP) who increasingly require advanced cannulation techniques. This trend is noted despite increased endoscopist experience and annual ERCP volume over the same period.
AIM To evaluate this phenomenon of perceived escalation in complexity of cannulation at ERCP and assessed potential underlying factors.
METHODS Demographic/clinical variables and records of ERCP patients at the beginning (2008), middle (2013) and end (2018) of the last decade were reviewed retrospectively. Cannulation approaches were classified as “standard” or “advanced” and duodenoscope position was labeled as “standard” (short position) or “non-standard” (e.g., long, semi-long).
RESULTS Patients undergoing ERCP were older in 2018 compared to 2008 (69.7 ± 15.2 years vs 55.1 ± 14.7, P < 0.05). Increased ampullary distortion and peri-ampullary diverticula were noted in 2018 (P < 0.001). ERCPs were increasingly performed with a non-standard duodenoscope position, from 2.2% (2008) to 5.6% (2013) and 16.1% (2018) (P < 0.001). Utilization of more than one advanced cannulation technique for a given ERCP increased from 0.7% (2008) to 0.9% (2013) to 6.6% (2018) (P < 0.001). Primary mass size > 4 cm, pancreatic uncinate mass, and bilirubin > 10 mg/dL predicted use of advanced cannulation techniques (P < 0.03 for each).
CONCLUSION Complexity of cannulation at ERCP has sharply increased over the past 5 years, with an increased proportion of elderly patients and those with malignancy requiring advanced cannulation approaches. These data suggest that complexity of cannulation at ERCP may be predicted based on patient/ampulla characteristics. This may inform selection of experienced, high-volume endoscopists to perform these complex procedures.
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Affiliation(s)
- Monique T Barakat
- Divisions of Adult and Pediatric Gastroenterology and Hepatology, Stanford University Medical Center, Cupertino, CA 95014, United States
| | - Mohit Girotra
- Division of Gastroenterology and Hepatology, University of Miami Miller School of Medicine, Miami, FL 33136, United States
| | - Nirav Thosani
- Department of Internal Medicine, Division of Gastroenterology, Hepatology & Nutrition, University of Texas Health Science Center Houston, Houston, TX 77030, United States
| | - Shivangi Kothari
- Division of Gastroenterology and Hepatology, University of Rochester Medical Center, Rochester, NY 14627, United States
| | - Subhas Banerjee
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Stanford, CA 94304, United States
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Tracy BM, Paterson CW, Torres DM, Young K, Hochman BR, Zielinski MD, Burruss SK, Mulder MB, Yeh DD, Gelbard RB. Risk factors for complications after cholecystectomy for common bile duct stones: An EAST multicenter study. Surgery 2020; 168:62-66. [PMID: 32466829 DOI: 10.1016/j.surg.2020.04.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 03/13/2020] [Accepted: 04/07/2020] [Indexed: 01/26/2023]
Abstract
BACKGROUND We sought to prospectively identify risk factors for biliary complications and 30-day readmission after cholecystectomy for choledocholithiasis and gallstone pancreatitis across multiple US hospitals. METHODS We performed a prospective, observational study of patients who underwent same admission cholecystectomy for choledocholithiasis and gallstone pancreatitis between 2016 and 2019 at 12 US centers. Patients with prior history of endoscopic retrograde cholangiopancreatography or diagnosis of cholangitis were excluded. We used logistic regression to determine associations between preoperative demographics, labs, and imaging on primary outcomes: postoperative biliary complications and 30-day readmission. RESULTS There were 989 patients in the cohort. There were 16 (1.6%) patients with postoperative biliary complications, including intra-abdominal abscesses, endoscopic retrograde cholangiopancreatography-induced pancreatitis, and biliary leaks. Increasing operative time (odds ratio 1.01, 95% confidence interval 1.00-1.01, P = .02), worsening leukocytosis (odds ratio 1.16, 95% confidence interval 1.07-1.25, P = .0002), and jaundice (odds ratio 3.25, 95% confidence interval 1.01-10.42, P = .04) were associated with postoperative biliary complications. There were 36 (3.6%) patients readmitted within 30 days owing to a surgical complication. A prior postoperative biliary complication (odds ratio 7.8, 95% confidence interval 1.63-37.27, P = .01), male sex (odds ratio 2.42, 95% confidence interval 1.2-4.87, P = .01), and index operative duration (odds ratio 1.01, 95% confidence interval 1.00-1.01, P = .03) were associated with 30-day readmission. CONCLUSION Among patients undergoing cholecystectomy for common bile duct stones, jaundice, worsening leukocytosis, and longer operations are associated with postoperative biliary complications. A prior biliary complication is also predictive of a 30-day readmission. Surgeons should recognize these factors and avoid prematurely discharging at-risk patients given their propensity to develop complications and require readmission.
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Affiliation(s)
- Brett M Tracy
- Department of Surgery, Emory University School of Medicine, Atlanta, GA; Emory Department of Surgery, Grady Memorial Hospital, Atlanta, GA.
| | - Cameron W Paterson
- Department of Surgery, Emory University School of Medicine, Atlanta, GA; Emory Department of Surgery, Grady Memorial Hospital, Atlanta, GA
| | - Denise M Torres
- Department of Surgery, Geisinger Medical Center, Danville, PA
| | - Katelyn Young
- Department of Surgery, Geisinger Medical Center, Danville, PA
| | - Beth R Hochman
- Department of Surgery, Columbia University Irving Medical Center, New York, NY
| | - Martin D Zielinski
- Department of Trauma, Critical Care, and General Surgery, Mayo Clinic, Rochester, MN
| | - Sigrid K Burruss
- Department of Surgery, Loma Linda University Medical Center, Loma Linda, CA
| | | | | | - Rondi B Gelbard
- Department of Surgery, Emory University School of Medicine, Atlanta, GA; Emory Department of Surgery, Grady Memorial Hospital, Atlanta, GA
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Zhou Y, Zha WZ, Fan RG, Jiang GQ, Wu XD. Two-stage versus single-stage procedure for the management of cholecystocholedocholithiasis in elderly patients: a retrospectively cohort study. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 111:176-181. [PMID: 30507246 DOI: 10.17235/reed.2018.5822/2018] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND there is an increasing incidence rate of cholecysto-choledocholithiasis associated with the increasing proportion of senile individuals. METHODS a total of 100 elderly patients (over 80 years of age) suffering both from cholelithiasis and choledocholithiasis were retrospectively studied from January 2010 to December 2016. Patients were scheduled for either a single-stage or two-stage procedure. The LCBDE group (n = 54) included cases that underwent a single stage procedure of laparoscopic exploration of the common bile duct combined with cholecystectomy. The ERCP/EST group (n = 46) included cases that underwent a two stage procedure of preoperative endoscopic retrograde cholangiopancreaticography with endoscopic sphincterotomy followed by cholecystectomy. Comorbidity conditions, presenting symptoms, bile duct clearance, length of hospital stay and the frequency of procedural, postoperative and long-term complications were recorded. RESULTS the LCBDE group had a higher stones clearance rate than the ERCP/EST group (100.0% vs 89.1%, p < 0.05). Postoperative complications and hospitalization length were comparable in the two groups (p > 0.05). There were more procedural complications in the ERCP/EST group than in the LCBDE group (10.8% vs 0%, p < 0.05). Furthermore, a patient in the ERCP/EST group died due to duodenal perforation. More patients in the ERCP/EST group experienced long-term complications than those in the LCBDE group (23.9% vs 3.7%, p < 0.05) during a mean follow-up period of 28.4 months. CONCLUSIONS the single-stage procedure is a safe and effective technique for elderly patients with cholecysto-choledocholithiasis. LCBDE provides a good stone clearance rate with few long term complications.
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Affiliation(s)
- Yong Zhou
- General Surgery, Yancheng City NO.1 People's Hospital, china
| | | | | | - Guo-Qin Jiang
- The Second Affiliated of Hospital of Soochow University
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Laparoscopic common bile duct exploration for elderly patients with choledocholithiasis: a systematic review and meta-analysis. Surg Endosc 2020; 34:1522-1533. [PMID: 32016517 DOI: 10.1007/s00464-020-07394-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 01/28/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Laparoscopic common bile duct exploration (LCBDE) has been becoming more and more popular in patients with symptomatic choledocholithiasis. However, the safety and effectiveness of LCBDE in elderly patients with choledocholithiasis is still uncertain. This meta-analysis is aimed to appraise the safety and feasibility of LCBDE for elderly patients with choledocholithiasis. MATERIALS AND METHODS Studies comparing elderly patients and younger patients who underwent LCBDE for common bile duct stone were reviewed and collected from the PubMed, Medline, EMBASE, and Cochrane Library. Primary outcomes were stone clearance rate, overall complication rate, and mortality rate. Secondary outcomes were operative time, conversion rate, pulmonary complication, bile leakage, reoperation, residual stone rate, and recurrent stone rate. RESULTS Nine studies, including two prospective studies and seven retrospective studies, met the inclusion criteria. There were 2004 patients in this meta-analysis, including 693 elderly patients and 1311 younger patients. There was no statistically significant difference between elderly patients and younger patients regarding stone clearance rate (OR 0.73; 95% CI 0.42-1.26; p = 0.25), overall complication rate (OR 1.31; 95% CI 0.94-1.82; p = 0.12), and mortality rate (OR 2.80; 95% CI 0.82-9.53; p = 0.10). Similarly, the operative time, conversion rate, bile leakage, reoperation, residual stone rate, and recurrent stone rate showed no significant difference between two groups (p > 0.05). While elderly patients showed high risk for pulmonary complication (OR 4.41; 95% CI 1.78-10.93; p = 0.001) compared with younger patients. CONCLUSION Although there is associated with higher pulmonary complication, LCBDE is still considered as a safe and effective treatment for elderly patients with choledocholithiasis.
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Hormati A, Ghadir MR, Hasanpour Dehkordi A, Yadollahi F, Salehitali S, Afifian M. Consequences of Stenting and Endoscopic Papillary Balloon Dilatation in Treatment of Large and Multiple Common Bile Duct Stones. Middle East J Dig Dis 2019; 11:205-210. [PMID: 31824623 PMCID: PMC6895848 DOI: 10.15171/mejdd.2019.150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 09/01/2019] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Although stenting for the treatment of large and multiple common bile duct stones has been acceptable to everyone, its efficacy and outcome have not been studied in comparison with other endoscopic procedures. The purpose of this study was to compare the consequences of stenting and endoscopic papilla balloon dilatation for the treatment of large and multiple common bile duct stones. METHODS In a double-blind clinical trial, of 431 patients with bile duct stones referred to the treatment center, 64 patients with multiple common bile duct stones ( ≥ 3) and more than 15 cm were selected for the study, then by random allocation rule the participants were allocated in two groups. They were entered into two different endoscopic papillary balloon dilatation (EPBD) and common bile ducts stenting treatments so that both procedures were performed by a person. Both groups were assessed from the point of views therapeutic outcomes such as duct cleaning, pancreatitis, isolated pain, and duct rupture. Data were collected by a self-made questionnaire that was used before and after the procedure to obtain the needed information. Then data were analyzed using SPSS software version 22 and descriptive and analytical tests were used as appropriated. RESULTS Although the duct cleaning and the complete removal of the stones in the stenting treatment procedure was 93.8%, and in EPBD was 78.3%, no significant difference was observed between the two groups (p = 0.14). Pancreatitis significantly increased after the first and second endoscopic retrograde cholangiopancreatography (ERCP) in the stent group compared with EPBD (p = 0.02). Also, the most frequent cases of isolated pain were in the endoscopic group EPBD (p = 0.0). However, the occurrence of perforation after first ERCP and EPBD was zero, but in the second stage of ERCP, 3.3% of the patients had perforations (p = 0.99). The results indicated that the shape of the stone (circular and angled) was not effective in the result of treatment in the two groups. CONCLUSION The results of this study indicated that in case of experience and skill in conducting the ERCP, common bile duct stenting is still the first line of treatment for large and multiple stones of the common bile ducts.
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Affiliation(s)
- Ahmad Hormati
- Assistant Professor, Gastroenterology and Hepatology Disease Research Center, Qom University of Medical Sciences, Shahid Beheshti Hospital, Qom, Iran.,Assistant Professor, Gastrointestinal and Liver Disease Research Center, Iran University of Medical Sciences, Firoozgar Hospital, Tehran, Iran
| | - Mohammad Reza Ghadir
- Professor, Gastroenterology and Hepatology Disease Research Center, Qom University of Medical Sciences, Shahid Beheshti Hospital, Qom, Iran
| | - Ali Hasanpour Dehkordi
- Associate Professor, School of Allied Medical Sciences, Shahrekord, University of Medical Sciences, Shahrekord, Iran
| | - Farshad Yadollahi
- Medical Resident, Medical College, Shahrekord University of Medical Sciences, Shahrekord, Iran
| | - Shahriar Salehitali
- Assistant Professor , School of Nursing and Midwifery, Shahrekord University of Medical Sciences, Shahrekord, Iran
| | - Mahboobeh Afifian
- MSc of Health Information Technology of Tehran University of Medical Sciences, Tehran, Iran
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Søreide JA, Karlsen LN, Sandblom G, Enochsson L. Endoscopic retrograde cholangiopancreatography (ERCP): lessons learned from population-based national registries: a systematic review. Surg Endosc 2019; 33:1731-1748. [DOI: 10.1007/s00464-019-06734-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 03/06/2019] [Indexed: 02/07/2023]
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Huang RJ, Barakat MT, Girotra M, Lee JS, Banerjee S. Unplanned Hospital Encounters After Endoscopic Retrograde Cholangiopancreatography in 3 Large North American States. Gastroenterology 2019; 156:119-129.e3. [PMID: 30243620 PMCID: PMC6309462 DOI: 10.1053/j.gastro.2018.09.037] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 09/07/2018] [Accepted: 09/14/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND & AIMS We have few population-level data on the performance of endoscopic retrograde cholangiopancreatography (ERCP) in the United States. We investigated the numbers of unplanned hospital encounters (UHEs), patient and facility factors associated with UHEs, and variation in quality and outcomes in the performance of ERCP in 3 large American states. METHODS We collected data on 68,642 ERCPs, performed at 635 facilities in California, Florida, and New York from 2009 through 2014. The primary endpoint was number of UHEs with an ERCP-related event within 7 days of ERCP; secondary endpoints included number of UHEs within 30 days and mortality within 30 days. Each facility was assigned a risk-standardized cohort, and variations in number of UHEs were analyzed with multivariable analysis. RESULTS Among all ERCPs, 5.8% resulted in a UHE within 7 days and 10.2% within 30 days. Performance of sphincterotomy was significantly associated with a higher risk of UHE at 7 and 30 days (P < .001). Younger age, female sex, and more advanced comorbidity were associated with UHE. There was substantial heterogeneity in rates of UHE among facilities: 4.2% at facilities in the 5th percentile and 25.2% at facilities in the 95th percentile. Increasing facility volume and ability to perform endoscopic ultrasonography were associated inversely with risk. The median number of ERCPs performed each year was 68.7, but 69% of facilities performed 100 or fewer ERCPs per year. Risk for UHE after sphincterotomy decreased with increasing facility volume until an inflection point of 157 ERCPs per year was reached. CONCLUSIONS In an analysis of outcomes of 68,642 ERCPs performed in 3 states, we found a higher-than-expected number of UHEs. There is substantial unexplained variation in risk for adverse events after ERCPs among facilities, and volume is the strongest predictor of risk. Annual facility volumes above approximately 150 ERCPs per year may protect against UHE.
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Affiliation(s)
- Robert J. Huang
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, CA,Department of Health Research and Policy, Stanford University, Stanford, CA
| | - Monique T. Barakat
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, CA
| | - Mohit Girotra
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, CA
| | - Jennifer S. Lee
- Department of Health Research and Policy, Stanford University, Stanford, CA,Department of Medicine, Stanford University, Stanford, CA
| | - Subhas Banerjee
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, California.
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Noel R, Arnelo U, Swahn F. Intraoperative versus postoperative rendezvous endoscopic retrograde cholangiopancreatography to treat common bile duct stones during cholecystectomy. Dig Endosc 2019; 31:69-76. [PMID: 29947437 DOI: 10.1111/den.13222] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 06/22/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIM The rendezvous postoperative endoscopic retrograde cholangiopancreatography (ERCP) technique has been introduced as a modification of the single-session rendezvous intraoperative ERCP procedure in the management of concurrent common bile duct stones during cholecystectomy. There are no reports on the impact of this modified technique on post-ERCP morbidity. The objective of the present study was to study and compare the rendezvous techniques in terms of procedure-associated morbidities, such as post-ERCP pancreatitis and postoperative infections. METHODS The Swedish National Registry for Gallstone Disease and ERCP was searched for ERCP procedures cross-matched with cholecystectomies for the same patient carried out for gallstone indications between 2008 and 2014. A total of 1770 rendezvous ERCP procedures were retrieved and included in this study. The ERCP procedures were considered rendezvous intraoperative or rendezvous postoperative, depending on whether the ERCP procedure was carried out during or after completing the cholecystectomy. RESULTS There were 1205 and 565 ERCP procedures in the rendezvous intraoperative and the rendezvous postoperative groups, respectively. The cohorts were similar in age and gender distribution. Overall complication rates were higher in the rendezvous postoperative group compared with the rendezvous intraoperative group (19.7% vs 14%, P = 0.004), involving specifically post-ERCP pancreatitis (6.4% vs 3.2% P = 0.003) and postoperative infections (4.4% vs 2.3% P = 0.028). Despite similar stone clearance rates, there were higher rates of retained stones in the rendezvous postoperative group (5.5% vs 0.6%, P < 0.001). CONCLUSIONS Single-session rendezvous intraoperative ERCP is superior to the rendezvous postoperative ERCP technique in terms of post-ERCP pancreatitis and postoperative infections.
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Affiliation(s)
- Rozh Noel
- Division of Surgery, CLINTEC, Karolinska Institutet and Centre for Digestive Diseases at Karolinska University Hospital, Stockholm, Sweden
| | - Urban Arnelo
- Division of Surgery, CLINTEC, Karolinska Institutet and Centre for Digestive Diseases at Karolinska University Hospital, Stockholm, Sweden
| | - Fredrik Swahn
- Department of Surgery, Skåne University Hospital at Lund, Lund University, Lund, Sweden
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Rehman SFU, Ballance L, Rate A. Selective Antegrade Biliary Stenting Aids Emergency Laparoscopic Cholecystectomy. J Laparoendosc Adv Surg Tech A 2018; 28:1495-1502. [PMID: 29993317 DOI: 10.1089/lap.2018.0300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Background: Symptomatic gall stone disease requires early emergency treatment to prevent complications. This early treatment is often delayed due to difficulty in the diagnosis and management of concomitant choledocholithiasis. Intervention with preoperative endoscopic retrograde cholangiopancreatography (ERCP) is associated with complications and known to be unnecessary in most cases. We follow a strategy of providing early cholecystectomy with selective utility of antegrade stent in cases of choledocholithiasis. Our main aim is to present our technique and results. Method: We conducted a 3-year (January 2014 to January 2017) review of a prospectively maintained database of our practice of performing routine intraoperative cholangiogram (IOC) during laparoscopic cholecystectomy (LC) and when choledocholithiasis is encountered on IOC; a transcystic antegrade biliary stent is inserted to decompress the common bile ducts (CBD) and facilitate postoperative ERCP at later date. Results: Of the 411 cholecystectomies performed, 77.3% were females with mean age of 48 years. Seventy-four patients were found to have CBD stones (CBDS) on IOC. Antegrade stents were successfully deployed in 69 cases. Even though Antegrade stents were done more frequently in emergency admissions (P = .001); this did not increase the length of hospital stay (LOHS) (P = .752) or the rate of complications (P = .171). However, doing a preoperative ERCP significantly increased LOHS (P = .001), and 67% of these needed two or more ERCP for complete clearance of CBD and had more complications. Nine (15.2%) out of 59 patients with pancreatitis had CBDS on IOC and were successfully managed with antegrade stent. Conclusion: This strategy can be followed by general surgeons, enabling them to perform LC in the presence of choledocholithiasis during acute admissions including pancreatitis. It does not require any specialist skills in CBD exploration and also eliminates unnecessary preoperative ERCP and avoids its potential complications.
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Affiliation(s)
- Sheik Fazal Ur Rehman
- Department of General Surgery, Royal Oldham Hospital, Oldham, Manchester, United Kingdom
| | - Laura Ballance
- Department of General Surgery, Royal Oldham Hospital, Oldham, Manchester, United Kingdom
| | - Anthony Rate
- Department of General Surgery, Royal Oldham Hospital, Oldham, Manchester, United Kingdom
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Parra-Membrives P, Martínez-Baena D, Lorente-Herce JM, Martín-Balbuena R. Efficacy of fibrin-sealants in reducing biliary leakage following laparoscopic common bile duct exploration. Cir Esp 2018; 96:429-435. [PMID: 29793695 DOI: 10.1016/j.ciresp.2018.03.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 03/28/2018] [Accepted: 03/29/2018] [Indexed: 12/27/2022]
Abstract
INTRODUCTION In spite of the acquired experience with laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis management, there is still a risk of biliary leakage of 5% to 15% following choledochotomy closure. We evaluate the usefulness of fibrin-collagen sealants to reduce the incidence of biliary fistula after laparoscopic choledochorrhaphy. METHODS We report a retrospective analysis of 96 patients undergoing LCBDE from March 2009 to March 2017, whose closure of the bile duct was completed by antegrade stenting and choledochorraphy or by performing a primary suture. The study population was divided into two groups according to whether they received a collagen-fibrin sealant covering the choledochorrhaphy or not, analyzing the incidence of postoperative biliary fistula in each group. RESULTS Thirty-nine patients (41%) received a fibrin-collagen sponge while the bile duct closure was not covered in the remaining 57 patients (59%). The incidence of biliary fistula was 7.7% (3 patients) in the first group and 14% (8 patients) in the second group (P=.338). In patients who underwent primary choledochorraphy, the fibrin-collagen sealant reduced the incidence of biliary leakage significantly (4.5% vs. 33%, P=.020), which was a protective factor with an odds ratio of 10.5. CONCLUSION Fibrin-collagen sealants may decrease the incidence of biliary fistula in patients who have undergone primary bile duct closure following LCBDE.
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Affiliation(s)
- Pablo Parra-Membrives
- Departamento de Cirugía, Facultad de Medicina, Universidad de Sevilla, Sevilla, España; Unidad de Cirugía Hepatobiliar y Pancreática, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Valme, Sevilla, España.
| | - Darío Martínez-Baena
- Unidad de Cirugía Hepatobiliar y Pancreática, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Valme, Sevilla, España
| | - José Manuel Lorente-Herce
- Unidad de Cirugía Hepatobiliar y Pancreática, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Valme, Sevilla, España
| | - Ramón Martín-Balbuena
- Unidad de Cirugía Hepatobiliar y Pancreática, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Valme, Sevilla, España
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Yang D, Yachimski P. When Does Assessment for Bile Duct Stones Need to Be Performed Prior to Cholecystectomy for Calculus Gallbladder Disease? Clin Gastroenterol Hepatol 2018; 16:331-332. [PMID: 28669660 DOI: 10.1016/j.cgh.2017.06.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 06/26/2017] [Indexed: 02/07/2023]
Affiliation(s)
- Dennis Yang
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida College of Medicine, Gainesville, Florida
| | - Patrick Yachimski
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee.
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Muratori R, Mandolesi D, Pierantoni C, Festi D, Colecchia A, Mazzella G, Bazzoli F, Azzaroli F. Ductal stones recurrence after extracorporeal shock wave lithotripsy for difficult common bile duct stones: Predictive factors. Dig Liver Dis 2017. [PMID: 28625406 DOI: 10.1016/j.dld.2017.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND & PURPOSE Extra-corporeal shock wave lithotripsy (ESWL) can be considered in difficult common bile duct stones (DCBDS), with a success rate greater than 90% but data on stone recurrence after ESWL are limited. We performed a retrospective analysis to evaluate long-term outcomes in patients who underwent ESWL for DCBDS. METHODS From May 1992 to October 2012, patients who underwent ESWL treatment for DCBDS, not amenable to endoscopic extraction, were included. Data on long-term outcome were collected through phone interviews and medical records. RESULTS A total of 201 patients with a successful clearance of DCBDS after ESWL were included. During a median follow-up period of 4.64 years, 40 patients (20%) developed a recurrence of bile duct stones. Logistic regression analysis showed that the common bile duct diameter, gallstones presence and the maximum stone size were significantly associated with recurrence. CONCLUSIONS We observed a recurrence rate of 20% over a median follow-up of 4 years. Gallbladder stones, stone size and a dilated common bile duct diameter are risk factors for recurrent stone formation, while ursodeoxycholic acid treatment did not influence recurrence in our population.
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Affiliation(s)
- Rosangela Muratori
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Italy
| | - Daniele Mandolesi
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Italy.
| | - Chiara Pierantoni
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Italy
| | - Davide Festi
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Italy
| | - Antonio Colecchia
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Italy
| | - Giuseppe Mazzella
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Italy
| | - Franco Bazzoli
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Italy
| | - Francesco Azzaroli
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Italy
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Zheng C, Huang Y, Xie E, Xie D, Peng Y, Wang X. Laparoscopic common bile duct exploration: a safe and definitive treatment for elderly patients. Surg Endosc 2016; 31:2541-2547. [PMID: 28008469 DOI: 10.1007/s00464-016-5257-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 09/15/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Common bile duct (CBD) stone is one of the most common diseases among elderly people. In recent decades, there are numerous studies regarding the safety and efficacy of laparoscopic common bile duct exploration (LCBDE). Elderly patients are often regarded as high-risk patients because they are more likely to present with age-specific deterioration of organ function and coexisting chronic diseases, which may reduce their tolerance of laparoscopic surgery. Although laparoscopic surgery for choledocholithiasis is now widely accepted as the treatment for CBD stone, its appropriateness for the treatment of elderly patients or those with coexisting high-risk patients has not been well established. Therefore, the objective of this paper is to analyze the safety and efficacy of LCBDE in elderly patients. METHODS Between January 2012 and November 2015, 376 patients underwent LCBDE in our center. Based on their ages, they were divided into two groups, and a retrospective study was performed. By making comparisons between younger group who were younger than 70 years (n = 253) and elderly group who were 70 years old or older (n = 123), the demographics, clinical characteristics, laboratory data, operative parameters and outcomes were analyzed. RESULTS Before operation, elderly patients had more coexisting chronic diseases and risk factors, such as arterial hypertension, heart diseases, pulmonary diseases and previous abdominal surgery (P < 0.05). In both groups, LCBDE was equally successful with a high clearance rate (100 % in elderly patients vs. 98.8 % in younger group, P = 0.554). Besides, the operating time, intraoperative blood loss, postoperative hospital stay, total costs and overall complication showed no significant difference between two groups (P > 0.05). There was no major bile duct injury or death in either group. CONCLUSION Although elderly patients are frequently confronted with coexisting disorders, LCBDE can be considered as a safe and effective technique in choledocholithiasis treatment for elderly patients.
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Affiliation(s)
- Chufa Zheng
- Department of General Surgery, the Affiliated Shantou Hospital of Sun Yat-sen University, Guangdong, 515000, China
| | - Yaokui Huang
- Department of General Surgery, the Affiliated Shantou Hospital of Sun Yat-sen University, Guangdong, 515000, China
| | - E Xie
- Department of General Surgery, the Affiliated Shantou Hospital of Sun Yat-sen University, Guangdong, 515000, China
| | - Dejin Xie
- Department of General Surgery, the Affiliated Shantou Hospital of Sun Yat-sen University, Guangdong, 515000, China
| | - Yunheng Peng
- Department of General Surgery, the Affiliated Shantou Hospital of Sun Yat-sen University, Guangdong, 515000, China
| | - Xiaozhong Wang
- Department of General Surgery, the Affiliated Shantou Hospital of Sun Yat-sen University, Guangdong, 515000, China.
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19
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Gilg S, Sparrelid E, Isaksson B, Lundell L, Nowak G, Strömberg C. Mortality-related risk factors and long-term survival after 4460 liver resections in Sweden-a population-based study. Langenbecks Arch Surg 2016; 402:105-113. [PMID: 27695941 PMCID: PMC5309267 DOI: 10.1007/s00423-016-1512-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 09/08/2016] [Indexed: 12/23/2022]
Abstract
Purpose The objectives of this study were to analyze the outcome after hepatectomy and to identify contributing factors to mortality and long-term survival in a population-based setting. Method A retrospective, nationwide register study was performed. All patients who underwent hepatectomy in Sweden between 2002 and 2011 were identified in the Swedish Hospital Discharge Registry using their unique personal identification numbers. This cohort was linked to the National Cancer Registry (cancer diagnosis), the National Registry of Causes of Death, and the Migration Registry. Survival analysis by Kaplan-Meier method was performed to assess long-term outcome. A Cox regression model was used to analyze risk factors affecting long-term survival. Results Overall, 4460 hepatectomies were performed. The 30- and 90-day mortalities were 1.8 and 3.1 %, respectively. The overall 5- and 10-year survival rates for all diagnoses were 45 and 38 %, respectively. Independent risk factors for 5-year mortality were as follows: patient age, comorbidity, male gender, intrahepatic/extrahepatic cholangiocarcinoma, gallbladder cancer, extent of hepatectomy, and hepatectomies performed at non-university hospitals. Re-resection (78.1 % with diagnosis “metastasis”) was performed on 374 patients. In these patients, mortality risk decreased by >50 % (HR 0.42; 95 %, CI 0.33–0.53). Conclusion In a population-based analysis, liver resections are done with a low mortality risk and good long-term outcome. Patients who underwent resection at a University Hospital showed a significant better outcome compared to patients resected at non-University Hospitals. These results support further centralization of liver surgery. Re-resection should be performed if feasible.
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Affiliation(s)
- Stefan Gilg
- Institution for Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Solna, Sweden. .,Department of Surgery at Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.
| | - Ernesto Sparrelid
- Institution for Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Solna, Sweden.,Department of Surgery at Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Bengt Isaksson
- Institution for Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Solna, Sweden.,Department of Surgery at Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Lars Lundell
- Institution for Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Solna, Sweden.,Department of Surgery at Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Greg Nowak
- Institution for Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Solna, Sweden.,Department of Transplantation Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Cecilia Strömberg
- Institution for Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Solna, Sweden.,Department of Surgery at Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
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20
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Han JY, Lee DH, Jeong S, Choi HJ, Moon JH, Han JH, Kwon CI, Lee TH, Hyun JJ, Hwang JC, Koh DH. Clinical Features and Outcomes of Endoscopic Treatment for Stones in Stemware-Shaped Common Bile Ducts: A Multicenter Data Analysis. Gut Liver 2016; 9:800-4. [PMID: 26087795 PMCID: PMC4625711 DOI: 10.5009/gnl14433] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND/AIMS Various anatomical features of the biliary tree affect ability to remove difficult common bile duct (CBD) stones. In this study, we evaluated the clinical characteristics and outcomes of the endoscopic treatment of stones in stemware-shaped CBDs. METHODS Thirty-four patients with a stone and a stemware-shaped CBD who were treated at different tertiary referral centers from January 2008 to December 2012 were studied retrospectively. When stone removal failed, percutaneous or direct peroral cholangioscopic lithotripsy, endoscopic retrograde biliary drainage, or surgery was performed as a second-line procedure. RESULTS The overall success rate of the first-line procedure was 41.2%. Five of the 34 patients (14.7%) experienced procedure-related complications. No procedure-related mortality occurred. Mechanical lithotripsy was required to completely remove stones in 13 patients (38.2%). Conversion to a second-line procedure was required in 20 patients (58.8%). Mechanical lithotripsy was needed in 75% and 66.7% of those with a stone size of <1 cm or ≥1 cm, respectively. Stone recurrence occurred in two patients (9.1%) after 6 months and 27 months, respectively. CONCLUSIONS The endoscopic treatment of stones in a stemware-shaped CBD is challenging. The careful assessment of difficult CBD stones is required before endoscopic procedures.
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Affiliation(s)
- Jee Young Han
- Department of Internal Medicine, Inha University Hospital, Incheon, Korea.,Korea Association of Health Promotion, Jeonbuk Branch, Jeonju, Korea
| | - Don Haeng Lee
- Department of Internal Medicine, Inha University Hospital, Incheon, Korea.,National Center of Efficacy Evaluation for the Development of Health Products Targeting Digestive Disorders (NCEED), and Utah-Inha DDS & Advanced Therapeutics Research Center, Incheon,Korea
| | - Seok Jeong
- Department of Internal Medicine, Inha University Hospital, Incheon, Korea.,National Center of Efficacy Evaluation for the Development of Health Products Targeting Digestive Disorders (NCEED), and Utah-Inha DDS & Advanced Therapeutics Research Center, Incheon,Korea
| | - Hyun Jong Choi
- Digestive Disease Center and Research Institute, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Jong Ho Moon
- Digestive Disease Center and Research Institute, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Joung-Ho Han
- Division of Gastroenterology, Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Chang-Il Kwon
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Tae Hoon Lee
- Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Soonchunhyang University School of Medicine, Cheonan, Korea
| | - Jong Jin Hyun
- Division of Gastroenterology, Department of Internal Medicine, Korea University Ansan Hospital, Korea University School of Medicine, Ansan, Korea
| | - Jae Chul Hwang
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea
| | - Dong Hee Koh
- Division of Gastroenterology, Department of Internal Medicine, Dongtan Sacred Heart Hospital, Hwaseong, Korea
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El Nakeeb A, El Geidie A, El Hanafy E, Atef E, Askar W, Sultan AM, Hamdy E, El Shobary M, Hamed H, Abdelrafee A, Zeid MA. Management and Outcome of Borderline Common Bile Duct with Stones: A Prospective Randomized Study. J Laparoendosc Adv Surg Tech A 2016; 26:161-7. [PMID: 26828596 DOI: 10.1089/lap.2015.0493] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Management of common bile duct stones (CBDS) in patients with borderline CBD presents a surgical challenge. The aim of this study was to compare conservative treatment with endoscopic stone extraction for the treatment of borderline CBD with stones. PATIENTS AND METHODS This prospective randomized controlled trial includes patients with CBDS in borderline CBD (CBD <10 mm) associated with gallbladder stones who were treated with conservative treatment or endoscopic stone extraction followed by laparoscopic cholecystectomy (LC) and intraoperative cholangiogram (IOC). The primary outcome was successful CBD clearance. The secondary outcomes were the overall complications, cost, and hospital stay. RESULTS LC and IOC revealed complete clearance of CBDS in 48 (96%) cases in the endoscopic retrograde cholangiopancreatography (ERCP) group (52% of patients by ERCP, and 44% of patient passed the stone spontaneously), and in the remaining two patients, the CBDS was removed by transcystic exploration. In the conservative group, LC and IOC revealed complete clearance of CBDS in 90% of cases, and in the remaining 10% of patients, the CBDS was removed by transcystic exploration. Post-ERCP pancreatitis (PEP) is noticed significantly in the ERCP group (2 [4%] versus 8 [16%]; P = .04). The average net cost was significantly higher in the ERCP group. Recurrent biliary symptoms developed significantly in the ERCP group after 1 year (10% versus 0%; P = .02) in the form of recurrent cholangititis and recurrent CBDS. CONCLUSIONS Management of CBDS in patients with borderline CBD represents a surgical challenge. Borderline CBD increases the technical difficulty of ERCP and increases the risk of PEP. Conservative management of CBDS in borderline CBD not only avoids the risks inherent in ERCP and unnecessary preoperative ERCP, but it is also effective in clearing CBDS. The hepatobiliary surgeon should consider a conservative line of treatment in CBDS in borderline CBD in order to decrease the cost and avoid unnecessary ERCP.
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Affiliation(s)
- Ayman El Nakeeb
- Gastroenterology Surgical Center, Mansoura University , Mansoura, Egypt
| | - Ahmed El Geidie
- Gastroenterology Surgical Center, Mansoura University , Mansoura, Egypt
| | - Ehab El Hanafy
- Gastroenterology Surgical Center, Mansoura University , Mansoura, Egypt
| | - Ehab Atef
- Gastroenterology Surgical Center, Mansoura University , Mansoura, Egypt
| | - Waleed Askar
- Gastroenterology Surgical Center, Mansoura University , Mansoura, Egypt
| | - Ahmad M Sultan
- Gastroenterology Surgical Center, Mansoura University , Mansoura, Egypt
| | - Emad Hamdy
- Gastroenterology Surgical Center, Mansoura University , Mansoura, Egypt
| | | | - Hosam Hamed
- Gastroenterology Surgical Center, Mansoura University , Mansoura, Egypt
| | - Ahmed Abdelrafee
- Gastroenterology Surgical Center, Mansoura University , Mansoura, Egypt
| | - Mostafa Abu Zeid
- Gastroenterology Surgical Center, Mansoura University , Mansoura, Egypt
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22
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Laparoscopic common bile duct exploration in elderly patients: is there still a difference? Surg Laparosc Endosc Percutan Tech 2015; 24:e118-22. [PMID: 24710237 DOI: 10.1097/sle.0b013e31829012f6] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
PURPOSE Although surgery is frequently not the first treatment option in elderly patients diagnosed with common bile duct stones (CBDS) because of the fear of high morbidity and mortality rates, there are few data about the safety and efficacy of laparoscopic common bile duct exploration (LCBDE) in the elderly. METHODS From February 2004 to January 2012, 94 patients underwent LCBDE at our center. Data about sex, age, comorbidity, American Society of Anesthesiologists (ASA) score, conversion to open surgery and bile duct clearance rate, postoperative complications, need for reoperation, and mortality were analyzed comparing patients of age 70 or older (group A, n=38) with patients aged under 70 (group B, n=56). RESULTS Elderly patients had significantly more preoperative risk factors. Stone extraction was equally successful in both groups (89.5% in group A vs. 96.4% in group B, P=0.176). Six patients developed medical complications (7.9% in group A vs. 5.4% in group B, P=0.621). Surgical morbidity was equivalent for both groups (13.2% in group A vs. 10.7% in group B, P=0.718). Four patients in each group experienced some grade of bile leakage. Three patients were reoperated (1 patient in group A because of a biliary peritonitis and 2 in group B after an intra-abdominal hemorrhage). There were no mortality cases directly related to surgery. CONCLUSIONS This study reveals that LCBDE is safe in the elderly patients and results are not different from those described in the general population. Patients with choledocholithiasis should be offered to undergo an LCBDE irrespective of their age at diagnosis.
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Abstract
Background. Identifying and surgically removing bile duct calculi is challenging and critical in order to provide good patient outcomes. The history of this surgical pursuit since the introduction of anesthesia is both enlightening and fascinating. Methods. A systematic review of the literature was conducted to identify the techniques and technology used to remove bile duct calculi. Results. All bile duct surgical exploration advances have involved creation of tools to look within the bile duct and extract stones. The Hopkin’s rod lens system was a major breakthrough in light and image transmission. However, flexible endoscope technology added the ability to maneuver better within the bile duct as well as apply the technology via laparoscopy enabling laparoscopic bile duct exploration. Conclusion. Digital, image enhanced, distal tipped chip flexible endoscopes have significantly improved the surgeons’ ability to see within the bile duct, improving the efficiency and ease of stone visualization and removal from both the most proximal and distal ends of the bile duct.
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Affiliation(s)
- E. Phillips
- Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - G. Berci
- Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - K. Barber
- Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - J. Williams
- Cedars Sinai Medical Center, Los Angeles, CA, USA
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Cook JA, Collins GS. The rise of big clinical databases. Br J Surg 2015; 102:e93-e101. [PMID: 25627139 DOI: 10.1002/bjs.9723] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 10/20/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND The routine collection of large amounts of clinical data, 'big data', is becoming more common, as are research studies that make use of these data source. The aim of this paper is to provide an overview of the uses of data from large multi-institution clinical databases for research. METHODS This article considers the potential benefits, the types of data source, and the use to which the data is put. Additionally, the main challenges associated with using these data sources for research purposes are considered. RESULTS Common uses of the data include: providing population characteristics; identifying risk factors and developing prediction (diagnostic or prognostic) models; observational studies comparing different interventions; exploring variation between healthcare providers; and as a supplementary source of data for another study. The main advantages of using such big data sources are their comprehensive nature, the relatively large number of patients they comprise, and the ability to compare healthcare providers. The main challenges are demonstrating data quality and confidently applying a causal interpretation to the study findings. CONCLUSION Large clinical database research studies are becoming ubiquitous and offer a number of potential benefits. However, the limitations of such data sources must not be overlooked; each research study needs to be considered carefully in its own right, together with the justification for using the data for that specific purpose.
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Affiliation(s)
- J A Cook
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Nuffield Orthopaedic Centre, Windmill Road, Oxford OX3 7LD, UK
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Sugrue M, Sahebally SM, Ansaloni L, Zielinski MD. Grading operative findings at laparoscopic cholecystectomy- a new scoring system. World J Emerg Surg 2015; 10:14. [PMID: 25870652 PMCID: PMC4394404 DOI: 10.1186/s13017-015-0005-x] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Accepted: 02/09/2015] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Variation in outcomes from surgery is a major challenge and defining surgical findings may help set benchmarks, which currently do not exist in laparoscopic cholecystectomy. This study outlines a new surgical scoring system incorporating key operative findings. METHODS English language studies (from January 1965 to July 2014) pertaining to severity scoring and predictors of difficult laparoscopic cholecystectomy were searched for in PubMed, Embase and Cochrane databases using the search terms 'Laparoscopic cholecystectomy or Lap chole' and/or 'Scoring Index or Grading system or Prediction of difficulty or Conversion to open' in various combinations. Cross-referencing from papers retrieved in the original search identified additional articles. RESULTS Sixteen published papers report a gallbladder (GB) scoring system, but all relate to pre-operative clinical and imaging findings, rather than operative findings. The current scoring system, using operative findings incorporates the appearance of the GB, presence of GB distension, ease of access, potential biliary complications and time taken to identify cystic duct and artery. A score of <2 would imply mild difficulty, 2-4 moderate, 5-7 severe and 8-10 extreme. CONCLUSION This paper reports one of the first operative classifications of findings at laparoscopic cholecystectomy. It has the potential to allow benchmarks for international collaboration of operative and patient outcomes in patients undergoing laparoscopic cholecystectomy.
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Affiliation(s)
- Michael Sugrue
- Department of Surgery, Letterkenny Hospital and Donegal Clinical Research Academy, National University Ireland Galway, Letterkenny, Donegal Ireland
| | - Shaheel M Sahebally
- Department of Surgery, Letterkenny Hospital and Donegal Clinical Research Academy, National University Ireland Galway, Letterkenny, Donegal Ireland
| | - Luca Ansaloni
- Department of Surgery, Papa Giovanni XXIII Hospital, Bergamo, Italy
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Factors significantly contributing to a failed conventional endoscopic stone clearance in patients with "difficult" choledecholithiasis: a single-center experience. DIAGNOSTIC AND THERAPEUTIC ENDOSCOPY 2014; 2014:861689. [PMID: 25349470 PMCID: PMC4199065 DOI: 10.1155/2014/861689] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Revised: 09/09/2014] [Accepted: 09/17/2014] [Indexed: 12/31/2022]
Abstract
The objective of this study is to retrospectively evaluate factors significantly contributing to a failed stone extraction (SE) in patients with difficult to extract bile duct stones (BDS). Patients and Methods. During a 10-year period 1390 patients with BDS underwent successfully endoscopic sphincterotomy. Endoscopic SE was graded as easy; relatively easy; difficult; and failed. Difficult SE was encountered in 221 patients while failed SE was encountered in 205. A retrospective analysis of the criteria governing the difficulty of endoscopic SE following the index endoscopic intervention was performed to evaluate their significance in determining failure of complete SE among patients with difficult to extract bile duct stones. Results. Age ≥ 85 years, periampullary diverticula, multiple CBD stones (>4), and diameter of CBD stones (≥15 mm) were all significant contributing factors to a failed SE in univariate statistical tests. In the definitive multivariate analysis age, multiple stones and diameter of stones were found to be the significant, independent contributors. Conclusion. Failed conventional endoscopic stone clearance in patients with difficult to extract BDS is more likely to occur in overage patients, in patients with multiple CBD stones >4, and in patients with CBD stone(s) diameter ≥15 mm.
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Mattila A, Luhtala J, Mrena J, Kautiainen H, Kellokumpu I. An audit of short- and long-term outcomes after laparoscopic removal of common bile duct stones in Finland. Surg Endosc 2014; 28:3451-7. [DOI: 10.1007/s00464-014-3620-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Accepted: 05/14/2014] [Indexed: 01/16/2023]
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Di Mauro D, Faraci R, Mariani L, Cudazzo E, Costi R. Rendezvous technique for cholecystocholedochal lithiasis in octogenarians: is it as effective as in younger patients, or should endoscopic sphincterotomy followed by laparoscopic cholecystectomy be preferred? J Laparoendosc Adv Surg Tech A 2013; 24:13-21. [PMID: 24229423 DOI: 10.1089/lap.2013.0278] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The treatment of cholecystocholedochal lithiasis (CCL) requires cholecystectomy and common bile duct (CBD) clearance, which can be achieved surgically or with a combination of surgery and endoscopy. The latter includes a two-stage-approach-preoperative retrograde cholangiography (ERC) and sphincterotomy (ST) followed by delayed laparoscopic cholecystectomy (LC), or vice versa-or a one-stage-approach-the rendezvous technique (RVT), where ERC, ST, and LC are performed during the same procedure. No data on the use of RVT in octogenarians have been reported in the literature so far. The study aims to show whether the RVT is as effective in elderly as in younger patients. Moreover, results of RVT are compared with those of a two-stage sequential treatment (TSST) in octogenarians, to identify the best approach to such a population. SUBJECTS AND METHODS Prospectively collected data of 131 consecutive patients undergoing RVT for biliary tract stone disease were retrospectively analyzed. Two analyses were performed: (1) results of RVT (operative time, conversion rate, CBD clearance, morbidity/mortality, hospital stay, costs, and need for further endoscopy) were compared between octogenarians and younger patients, and (2) results of RVT in the elderly were compared with those of 27 octogenarians undergoing TSST for CCL. RESULTS Octogenarians undergoing RVT were in poorer general condition (P<.0001) and had a higher conversion rate (P<.0001) and a longer hospital stay (P<.007) than younger patients. No differences in the rates of CBD clearance, surgery-related morbidity, mortality, and costs were recorded. Although octogenarians undergoing RVT were in poorer general condition than those undergoing TSST, the results of the two approaches were similar. CONCLUSIONS RVT in the elderly seems to be as cost-effective as in younger patients; nevertheless, it may lead to a higher conversion rate and longer hospital stay. In octogenarians, RVT is not inferior to TSST in the treatment of CCL even for patients in poor condition.
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Affiliation(s)
- Davide Di Mauro
- 1 Department of Abdominal Medicine and Surgery, St. Thomas' Hospital , London, United Kingdom
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Abstract
T-tube placement into the common bile duct (CBD) is most commonly performed after CBD exploration for cholelithiasis or repair of an iatrogenic CBD injury. Bile peritonitis occurring after T-tube removal is generally considered an exceedingly rare complication, which on occurrence necessitates urgent intervention. No clear guidance exists on the timing of T-tube removal and its relationship to the development of bile peritonitis. This study aimed to determine the incidence of bile peritonitis after T-tube removal, its relationship to the timing of removal and how knowledge of this can help the general surgeon.
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Affiliation(s)
- M Ahmed
- Shrewsbury and Telford Hospital NHS Trust, UK, Princess Royal Hospital, Apley Castle, Telford TF1 6TF, UK.
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Peng C, Nietert PJ, Cotton PB, Lackland DT, Romagnuolo J. Predicting native papilla biliary cannulation success using a multinational Endoscopic Retrograde Cholangiopancreatography (ERCP) Quality Network. BMC Gastroenterol 2013; 13:147. [PMID: 24112846 PMCID: PMC3882886 DOI: 10.1186/1471-230x-13-147] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2013] [Accepted: 09/29/2013] [Indexed: 02/08/2023] Open
Abstract
Background Success in deep biliary cannulation via native ampullae of Vater is an accepted measure of competence in ERCP training and practice, yet prior studies focused on predicting adverse events alone, rather than success. Our aim is to determine factors associated with deep biliary cannulation success, with/ without precut sphincterotomy. Methods The ERCP Quality Network is a unique prospective database of over 10,000 procedures by over 80 endoscopists over several countries. After data cleaning, and eliminating previously stented or cut papillae, two multilevel fixed effect multivariate models were used to control for clustering within physicians, to predict biliary cannulation success, with and without allowing “precut” to assist an initially failed cannulation. Results 13018 ERCPs were performed by 85 endoscopists (March 2007 - May 2011). Conventional (without precut) and overall cannulation rates were 89.8% and 95.6%, respectively. Precut was performed in 876 (6.7%). Conventional success was more likely in outpatients (OR 1.21), but less likely in complex contexts (OR 0.59), sicker patients (ASA grade (II, III/V: OR 0.81, 0.77)), teaching cases (OR 0.53), and certain indications (strictures, active pancreatitis). Overall cannulation success (some precut-assisted) was more likely with higher volume endoscopists (> 239/year: OR 2.79), more efficient fluoroscopy practices (OR 1.72), and lower with moderate (versus deeper) sedation (OR 0.67). Conclusion Biliary cannulation success appears influenced by both patient and practitioner factors. Patient- and case-specific factors have greater impact on conventional (precut-free) cannulation success, but volume influences ultimate success; both may be used to select appropriate cases and can help guide credentialing policies.
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Affiliation(s)
- Chunyan Peng
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, 25 Courtenay Drive, ART 7100A, Charleston, SC 29425, USA.
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Trikudanathan G, Navaneethan U, Parsi MA. Endoscopic management of difficult common bile duct stones. World J Gastroenterol 2013; 19:165-73. [PMID: 23345939 PMCID: PMC3547556 DOI: 10.3748/wjg.v19.i2.165] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2011] [Revised: 05/18/2012] [Accepted: 05/26/2012] [Indexed: 02/06/2023] Open
Abstract
Endoscopy is widely accepted as the first treatment option in the management of bile duct stones. In this review we focus on the alternative endoscopic modalities for the management of difficult common bile duct stones. Most biliary stones can be removed with an extraction balloon, extraction basket or mechanical lithotripsy after endoscopic sphincterotomy. Endoscopic papillary balloon dilation with or without endoscopic sphincterotomy or mechanical lithotripsy has been shown to be effective for management of difficult to remove bile duct stones in selected patients. Ductal clearance can be safely achieved with peroral cholangioscopy guided laser or electrohydraulic lithotripsy in most cases where other endoscopic treatment modalities have failed. Biliary stenting may be an alternative treatment option for frail and elderly patients or those with serious co morbidities.
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Short SS, Frykman PK, Nguyen N, Liu Q, Berel D, Wang KS. Laparoscopic common bile duct exploration in children is associated with decreased cost and length of stay: results of a two-center analysis. J Pediatr Surg 2013; 48:215-20. [PMID: 23331818 DOI: 10.1016/j.jpedsurg.2012.10.041] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2012] [Accepted: 10/13/2012] [Indexed: 01/01/2023]
Abstract
PURPOSE Our aim was to compare outcomes of children undergoing laparoscopic cholecystectomy with laparoscopic common bile duct exploration (LC+CBDE) to those undergoing laparoscopic cholecystectomy with adjunctive endoscopic retrograde cholangiopancreatography (LC+ERCP). METHODS We performed a two-center retrospective chart review of all children (<18 years) undergoing LC+CBDE or LC+ERCP between January 2000 and July 2011. Wilcoxon test was performed on continuous variables and logistic regression modeling on categorical data. A P value < 0.05 was considered significant. Outcomes with a P value < 0.2 were selected for multivariable analysis. RESULTS Forty-two patients were identified. Twenty-four (57%) underwent LC+ERCP, and eighteen (43%) underwent LC+CBDE. Demographic and clinical factors were well matched between groups. Total operative time was similar between groups (157 min vs. 152 min, P = .26). LC+CBDE patients had zero major complications and five minor complications (retained stone: 3, pancreatitis: 1, late recurrence: 1). LC+ERCP patients experienced two major complications (duodenal perforation: 1, bleeding requiring transfusion: 1), and four minor complications (pancreatitis: 2, retained stone: 2, P = .57). Median length of stay was significantly longer (15.7 days vs. 6.6 days, P = .02), and median hospital cost was significantly higher ($18,132 vs. $12,735, P < .01) in the LC+ERCP group. Multivariable analysis revealed that cost was significantly lower in patients undergoing LC+CBDE (P = .05, OR= 0.71; 95% CI: 0.51-0.97). CONCLUSION LC+CBDE at the time of cholecystectomy is associated with decreased length of stay, decreased cost, and has similar or improved morbidity compared to LC+ERCP.
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Duncan CB, Riall TS. Evidence-based current surgical practice: calculous gallbladder disease. J Gastrointest Surg 2012; 16:2011-25. [PMID: 22986769 PMCID: PMC3496004 DOI: 10.1007/s11605-012-2024-1] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Accepted: 08/15/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Gallbladder disease is common and, if managed incorrectly, can lead to high rates of morbidity, mortality, and extraneous costs. The most common complications of gallstones include biliary colic, acute cholecystitis, common bile duct stones, and gallstone pancreatitis. Ultrasound is the initial imaging modality of choice. Additional diagnostic and therapeutic studies including computed tomography, magnetic resonance imaging, magnetic resonance cholangiopancreatography, endoscopic ultrasound, and endoscopic retrograde cholangiopancreatography are not routinely required but may play a role in specific situations. DISCUSSION Biliary colic and acute cholecystitis are best treated with early laparoscopic cholecystectomy. Patients with common bile duct stones should be managed with cholecystectomy, either after or concurrent with endoscopic or surgical relief of obstruction and clearance of stones from the bile duct. Mild gallstone pancreatitis should be treated with cholecystectomy during the initial hospitalization to prevent recurrence. Emerging techniques for cholecystectomy include single-incision laparoscopic surgery and natural orifice transluminal endoscopic surgery. Early results in highly selected patients demonstrate the safety of these techniques. The management of complications of the gallbladder should be timely and evidence-based, and choice of procedures, particularly for common bile duct stones, is largely influenced by facility and surgeon factors.
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Affiliation(s)
- Casey B Duncan
- Department of Surgery, The University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555-0541, USA
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