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Kobayashi S, Nakahara K, Umezawa S, Ida K, Tsuchihashi A, Koizumi S, Sato J, Tateishi K, Otsubo T. Elective Cholecystectomy After Endoscopic Gallbladder Stenting for Acute Cholecystitis: A Propensity Score Matching Analysis. Surg Laparosc Endosc Percutan Tech 2024; 34:171-177. [PMID: 38260964 DOI: 10.1097/sle.0000000000001252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 11/04/2023] [Indexed: 01/24/2024]
Abstract
OBJECTIVE To investigate the influence of endoscopic gallbladder stenting (EGBS) on subsequent cholecystectomy. We retrospectively compared the surgical outcomes of EGBS, followed by elective cholecystectomy with those of immediate cholecystectomy (IC). PATIENTS AND METHODS A total of 503 patients were included in this study. Patients who underwent EGBS as initial treatment for acute cholecystitis, followed by elective cholecystectomy, were included in the EGBS group and patients who underwent IC during hospitalization were included in the IC group. Propensity score matching analysis was used to compare the surgical outcomes. In addition, the factors that increased the amount of bleeding were examined by multivariate analysis after matching. RESULTS Fifty-seven matched pairs were obtained after propensity matching the EGBS group and the IC group. The rate of laparoscopic cholecystectomy in the EGBS versus IC groups was 91.2% versus 49.1% ( P < 0.001). The amount of bleeding was 5 mL in the EGBS versus 188 mL in the IC group ( P < 0.001). In the EGBS and IC groups, multivariate analysis of factors associated with more blood loss revealed IC (odds ratio: 4.76, 95% CI: 1.25-20.76, P = 0.022) as an independent risk factor. CONCLUSION EGBS as the initial treatment for acute cholecystitis and subsequent elective cholecystectomy after the inflammation has disappeared can be performed in minimally invasive procedures and safely.
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Affiliation(s)
- Shinjiro Kobayashi
- Department of Gastroenterological and General Surgery, School of Medicine, St. Marianna University, Kanagawa
| | - Kazunari Nakahara
- Department of Gastroenterology, School of Medicine, St. Marianna University, Kawasaki, Japan
| | - Saori Umezawa
- Department of Gastroenterological and General Surgery, School of Medicine, St. Marianna University, Kanagawa
| | - Keisuke Ida
- Department of Gastroenterological and General Surgery, School of Medicine, St. Marianna University, Kanagawa
| | - Atsuhito Tsuchihashi
- Department of Gastroenterological and General Surgery, School of Medicine, St. Marianna University, Kanagawa
| | - Satoshi Koizumi
- Department of Gastroenterological and General Surgery, School of Medicine, St. Marianna University, Kanagawa
| | - Junya Sato
- Department of Gastroenterology, School of Medicine, St. Marianna University, Kawasaki, Japan
| | - Keisuke Tateishi
- Department of Gastroenterology, School of Medicine, St. Marianna University, Kawasaki, Japan
| | - Takehito Otsubo
- Department of Gastroenterological and General Surgery, School of Medicine, St. Marianna University, Kanagawa
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Cominardi A, Aragona G, Cattaneo G, Arzù G, Capelli P, Banchini F. Current trends of minimally invasive therapy for cholecystocholedocholithiasis. Front Med (Lausanne) 2023; 10:1277410. [PMID: 38155666 PMCID: PMC10753828 DOI: 10.3389/fmed.2023.1277410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 11/09/2023] [Indexed: 12/30/2023] Open
Abstract
Introduction The minimally invasive approach of endoscopic ultrasound (EUS)-guided procedures for cholecystocholedocholithiasis, such as EUS-guided gallbladder drainage (EUS-GBD), EUS-guided rendezvous (EUS-RV), and EUS-guided biliary drainage (EUS-BD), is affirmed as an effective treatment for patients with acute cholecystitis (AC) who are unfit for surgery and for patients with common bile duct stones (CBDSs) who have experienced a previous ERCP failure. Furthermore, in cases of difficult CBDS extraction during endoscopic retrograde cholangiopancreatography (ERCP), cholangioscopy-guided electrohydraulic lithotripsy (CS-EHL) has showed optimal results. The main objective of our study was to evaluate the effectiveness of EUS-GBD and percutaneous gallbladder drainage (PT-GBD) in patients with AC who are unfit for surgery. We also aimed to evaluate the efficacy of EUS-GBD, EUS-BD, and EUS-RV following ERCP failure and the effectiveness of CS-EHL for difficult CBDS extraction in our hospital. The secondary aim was to examine the safety of these procedures. Materials and methods We conducted a retrospective evaluation of all the EUS-GBD, PT-GBD, EUS-BD, EUS-RV, and CS-EHL procedures, which were prospectively collected in the gastroenterology and digestive endoscopy unit and the general surgery unit from January 2020 to June 2023. The efficacy was expressed in terms of technical and clinical success rates, while safety was assessed based on the rate of adverse events (AEs). Results We enrolled 83 patients with AC and high surgical risk. Among them, 57 patients (68.7%, 24/57 male, median age 85 ± 11 years) underwent EUS-GBD, and 26 (31.3%, 19/26 male, median age 83 ± 7 years) underwent PT-GBD. The technical and clinical success rates were 96.5 and 100% for EUS-GBD, and 96.1 and 92% for PT-GBD. The AEs for EUS-GBD were 1.7%, and for PT-GBD, it was 12%. ERCP for CBDS extraction failed in 77 patients. Among them, 73 patients (94.8%) underwent EUS-RV with technical and clinical success rates of 72.6% (53/73) and 100%, respectively. No AEs were reported. Four out of 77 patients were directly treated with EUS-BD for pyloric inflammatory stenosis. In 12 patients (16.4%), following unsuccessful EUS-RV with a CBD diameter ≥ 12 mm, an EUS-BD was performed. Both technical and clinical success rates for EUS-BD were 100%, and no AEs were reported. EUS-GBD was the treatment of choice for the remaining 8 (10.9%) patients after failure of both ERCP and EUS-RV. The procedure had high technical and clinical success rates (both at 100%), and no AEs were reported. The 12 difficult CBDS extraction treated with CS-EHL also showed high technical and clinical success rates (both at 100%), with no reported AEs. Conclusion The minimally invasive approach for cholecystocholedocholithiasis, especially EUS-guided procedures, had high efficacy and safety in treating AC in high-risk surgical patients and CBDS extraction after a previously unsuccessful ERCP.
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Affiliation(s)
- Anna Cominardi
- Gastroenterology and Digestive Endoscopy Unit, Hospital of Piacenza, Piacenza, Italy
| | - Giovanni Aragona
- Gastroenterology and Digestive Endoscopy Unit, Hospital of Piacenza, Piacenza, Italy
| | | | - Gian Arzù
- Emergency Surgery Unit, Hospital of Piacenza, Piacenza, Italy
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Yoon SB, Jeon TY, Moon SH, Shin DW, Park JW, Kim SE, Kim MJ. Effectiveness and complication rates of percutaneous transhepatic fluoroscopy-guided management of common bile duct stones: a single-arm meta-analysis. Eur Radiol 2023; 33:7398-7407. [PMID: 37326663 DOI: 10.1007/s00330-023-09846-z] [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] [Received: 12/09/2022] [Revised: 05/15/2023] [Accepted: 05/23/2023] [Indexed: 06/17/2023]
Abstract
OBJECTIVES To perform a systematic review and meta-analysis to determine the success and complication rate of percutaneous transhepatic fluoroscopy-guided management (PTFM) for the removal of common bile duct stones (CBDS). METHODS A comprehensive literature search of multiple databases was conducted to identify original articles published between January 2010 and June 2022, reporting the success rate of PTFM for the removal of CBDS. A random-effect model was used to summarize the pooled rates of success and complications with 95% confidence intervals (CIs). RESULTS Eighteen studies involving 2554 patients met the inclusion criteria and were included in the meta-analysis. Failed or infeasible endoscopic management was the most common indication of PTFM. The meta-analytic summary estimates of PTFM for the removal of CBDS were as follows: rate of overall stone clearance 97.1% (95% CI, 95.7-98.5%); stone clearance at first attempt 80.5% (95% CI, 72.3-88.6%); overall complications 13.8% (95% CI, 9.7-18.0%); major complications 2.8% (95% CI, 1.4-4.2%); and minor complications 9.3% (95% CI, 5.7-12.8%). Egger's tests showed the presence of publication bias with respect to the overall complications (p = 0.049). Transcholecystic management of CBDS had an 88.5% pooled rate for overall stone clearance (95% CI, 81.2-95.7%), with a 23.0% rate for complications (95% CI, 5.7-40.4%). CONCLUSION The systematic review and meta-analysis answer the questions of the overall stone clearance, clearance at first attempt, and complication rate of PTFM by summarizing the available literature. Percutaneous management could be considered in cases with failed or infeasible endoscopic management of CBDS. CLINICAL RELEVANCE STATEMENT This meta-analysis highlights the excellent stone clearance rate achieved through percutaneous transhepatic fluoroscopy-guided removal of common bile duct stones, potentially influencing clinical decision-making when endoscopic treatment is not feasible. KEY POINTS • Percutaneous transhepatic fluoroscopy-guided management of common bile duct stones had a pooled rate of 97.1% for overall stone clearance and 80.5% for clearance at the first attempt. • Percutaneous transhepatic management of common bile duct stones had an overall complication rate of 13.8%, including a major complication rate of 2.8%. • Percutaneous transcholecystic management of common bile duct stones had an overall stone clearance rate of 88.5% and a complication rate of 23.0%.
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Affiliation(s)
- Seung Bae Yoon
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Tae Yeon Jeon
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sung-Hoon Moon
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, 22, Gwanpyeong-Ro 170 Beon-Gil, Dongan-Gu, Anyang, Gyeonggi-Do, 14068, South Korea.
| | - Dong Woo Shin
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, 22, Gwanpyeong-Ro 170 Beon-Gil, Dongan-Gu, Anyang, Gyeonggi-Do, 14068, South Korea
| | - Ji Won Park
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, 22, Gwanpyeong-Ro 170 Beon-Gil, Dongan-Gu, Anyang, Gyeonggi-Do, 14068, South Korea
| | - Sung Eun Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, 22, Gwanpyeong-Ro 170 Beon-Gil, Dongan-Gu, Anyang, Gyeonggi-Do, 14068, South Korea
| | - Min-Jeong Kim
- Department of Radiology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, South Korea
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Zhu J, Wang G, Xie B, Jiang Z, Xiao W, Li Y. Minimally invasive management of concomitant gallstones and common bile duct stones: an updated network meta-analysis of randomized controlled trials. Surg Endosc 2023; 37:1683-1693. [PMID: 36278995 DOI: 10.1007/s00464-022-09723-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 10/11/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND To update a 2018 meta-analysis on the comparative efficacy and safety of four surgical techniques in patients with concomitant gallstones and common bile duct (CBD) stones. METHODS Randomized controlled trials (RCTs) comparing laparoscopic cholecystectomy (LC) plus laparoscopic common bile duct exploration (LCBDE), LC plus preoperative endoscopic retrograde cholangiopancreatography (PreERCP), LC plus intraoperative ERCP (IntraERCP), and LC plus postoperative ERCP (PostERCP) were included. Primary and secondary outcomes were compared using odds ratio, weighted mean difference, and 95% confidence intervals. RESULTS Twenty-five RCTs involved 3145 patients were included. Of these, 1188 (37.8%) underwent LC + PreERCP, 1183 (37.6%) LC + LCBDE, 689 (21.9%) LC + IntraERCP, and 85 (2.7%) LC + PostERCP. This analysis demonstrated that LC plus IntraERCP was the most likely approach to achieve technical success and reduce morbidity. No significant differences were observed between the four treatments concerning major morbidity, mortality, and operative time. LC plus LCBDE was effective for increasing biliary leak and conversion as well as decreasing postoperative hemorrhage and total costs. Additionally, LC plus PreERCP was associated with higher postoperative pancreatitis, while LC plus IntraERCP was associated with a shorter length of hospital stay. There was significant heterogeneity in operative time, hospital stay, and total costs (τ2 > 1). CONCLUSIONS This analysis provides evidence that LC plus IntraERCP appears to be the optimal strategy for patients with concomitant gallstones and CBD stones owing to its advantage in technical success and morbidity. LC plus LCBDE is associated with higher biliary leak and lower postoperative hemorrhage, whereas LC plus PreERCP is associated with higher postoperative pancreatitis.
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Affiliation(s)
- Jisheng Zhu
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, No. 17 Yongwai Zhengjie, Nanchang, 330006, Jiangxi, China
| | - Guiyan Wang
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, No. 17 Yongwai Zhengjie, Nanchang, 330006, Jiangxi, China
| | - Bin Xie
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, No. 17 Yongwai Zhengjie, Nanchang, 330006, Jiangxi, China
| | - Zhengying Jiang
- Department of Burn, The First Affiliated Hospital of Nanchang University, No. 17 Yongwai Zhengjie, Nanchang, 330006, Jiangxi, China
| | - Weidong Xiao
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, No. 17 Yongwai Zhengjie, Nanchang, 330006, Jiangxi, China
| | - Yong Li
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, No. 17 Yongwai Zhengjie, Nanchang, 330006, Jiangxi, China.
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Llàcer-Millán E, Pavel MC, Memba R, Coronado D, González S, Achalandabaso M, Estalella L, Julià-Verdaguer E, Padilla-Zegarra E, Collins C, Jorba R. Comparison between Comprehensive Complication Index (CCI®) and Clavien-Dindo Classification for laparoscopic single-stage treatment of choledocholithiasis with concomitant cholelithiasis. Langenbecks Arch Surg 2023; 408:100. [PMID: 36813935 DOI: 10.1007/s00423-023-02840-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 02/13/2023] [Indexed: 02/24/2023]
Abstract
PURPOSE The Clavien-Dindo Classification (CDC) and the Comprehensive Complication Index (CCI®) are both widely used methods for reporting postoperative complications. Several studies have compared the CCI® with the CDC in evaluating postoperative complications of major abdominal surgery. However, there are no published reports comparing both indexes in single-stage laparoscopic common bile duct exploration with cholecystectomy (LCBDE) for the treatment of common bile duct stones. This study aimed to compare the accuracy of the CCI® and the CDC in evaluating the complications of LCBDE. METHODS In total, 249 patients were included. Spearman's rank test was used to calculate the correlation coefficient between CCI® and CDC with length of postoperative stay (LOS), reoperation, readmission, and mortality rates. Student t-test and Fisher's exact test were used to study, if higher ASA, age, larger surgical time, history of previous abdominal surgery, preoperative ERCP, and intraoperative cholangitis finding were associated with higher CDC grade or higher CCI® score. RESULTS Mean CCI® was 5.17 ± 12.8. CCI® ranges overlap among three CDC grades: II (20.90-36.20), IIIa (26.20-34.60), and IIIb (33.70-52.10). Age > 60 years, ASA ≥ III, and intraoperative cholangitis finding were associated with higher CCI® (p = 0.010, p = 0.044, and p = 0.031) but not with CDC ≥ IIIa (p = 0.158, p = 0.209, and p = 0.062). In patients with complications, LOS presented a significantly higher correlation with CCI® than with CDC (p = 0.044). CONCLUSION In LCBDE, the CCI® assesses better the magnitude of postoperative complications in patients older than 60 years, with a high ASA as well as in those who present intraoperative cholangitis. In addition, the CCI® correlates better with LOS in patients with complications.
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Affiliation(s)
- Erik Llàcer-Millán
- General Surgery Department, Hepato-Pancreato-Biliary Unit, University Hospital of Tarragona Joan XXIII, Tarragona, Spain.
- School of Medicine, Rovira i Virgili University, Reus, Spain.
- Institut d'Investigació Sanitària Pere Virgili, Tarragona, Spain.
| | - Mihai-Calin Pavel
- General Surgery Department, Hepato-Pancreato-Biliary Unit, University Hospital of Tarragona Joan XXIII, Tarragona, Spain
- School of Medicine, Rovira i Virgili University, Reus, Spain
- Institut d'Investigació Sanitària Pere Virgili, Tarragona, Spain
| | - Robert Memba
- General Surgery Department, Hepato-Pancreato-Biliary Unit, University Hospital of Tarragona Joan XXIII, Tarragona, Spain
- School of Medicine, Rovira i Virgili University, Reus, Spain
- Institut d'Investigació Sanitària Pere Virgili, Tarragona, Spain
| | - Daniel Coronado
- General Surgery Department, Hepato-Pancreato-Biliary Unit, Sant Joan Despí-Moises Broggi Hospital, Sant Joan Despí, Spain
| | - Sergio González
- General Surgery Department, Hepato-Pancreato-Biliary Unit, Sant Joan Despí-Moises Broggi Hospital, Sant Joan Despí, Spain
| | - Mar Achalandabaso
- General Surgery Department, Hepato-Pancreato-Biliary Unit, University Hospital of Tarragona Joan XXIII, Tarragona, Spain
| | - Laia Estalella
- General Surgery Department, Hepato-Pancreato-Biliary Unit, University Hospital of Tarragona Joan XXIII, Tarragona, Spain
- School of Medicine, Rovira i Virgili University, Reus, Spain
- Institut d'Investigació Sanitària Pere Virgili, Tarragona, Spain
| | - Elisabet Julià-Verdaguer
- General Surgery Department, Hepato-Pancreato-Biliary Unit, University Hospital of Tarragona Joan XXIII, Tarragona, Spain
- Institut d'Investigació Sanitària Pere Virgili, Tarragona, Spain
| | - Erlinda Padilla-Zegarra
- General Surgery Department, Hepato-Pancreato-Biliary Unit, University Hospital of Tarragona Joan XXIII, Tarragona, Spain
| | - Chris Collins
- Upper Gastrointestinal Surgery Department, Galway University Hospital, Galway, Ireland
| | - Rosa Jorba
- General Surgery Department, Hepato-Pancreato-Biliary Unit, University Hospital of Tarragona Joan XXIII, Tarragona, Spain
- School of Medicine, Rovira i Virgili University, Reus, Spain
- Institut d'Investigació Sanitària Pere Virgili, Tarragona, Spain
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Ukhanov AP, Zakharov DV, Zhilin SA, Bolshakov SV, Muminov KD, Aselderov YA. [Modern minimally invasive technologies for the treatment of cholelithiasis]. Khirurgiia (Mosk) 2023:33-40. [PMID: 36800867 DOI: 10.17116/hirurgia202303133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
Surgical community has not yet reached any consensus on the adequate treatment of gallstone disease with combined stones of the gallbladder and bile ducts. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic papillosphincterotomy (EPST) followed by laparoscopic cholecystectomy (LCE) have been considered the optimal treatment method for the past thirty years. Thanks to improvement of technologies and experience in laparoscopic surgery, many centers in the world offer simultaneous treatment of cholecystocholedocholithiasis, i.e. LCE and laparoscopic choledocholithotomy. Transcystical and transcholedochal extraction of calculi from the common bile duct is the most common. Intraoperative cholangiography and choledochoscopy are used to assess extraction of calculi while T-shaped drainage, biliary stent and primary suture of common bile duct are used to complete choledocholithotomy. Laparoscopic choledocholithotomy is associated with certain difficulties, requires some experience in choledochoscopy and intracorporeal suturing of common bile duct. There are many unresolved issues regarding the choice of laparoscopic choledocholithotomy technique depending on the number and dimensions of stones, diameter of cystic duct and common bile duct. The authors analyze literature data on the role of modern minimally invasive interventions in the treatment of gallstone disease.
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Affiliation(s)
- A P Ukhanov
- Central Clinical Hospital, Veliky Novgorod, Russia.,Jaroslav the Wise Novgorod State University, Veliky Novgorod, Russia
| | - D V Zakharov
- Central Clinical Hospital, Veliky Novgorod, Russia.,Jaroslav the Wise Novgorod State University, Veliky Novgorod, Russia
| | - S A Zhilin
- Central Clinical Hospital, Veliky Novgorod, Russia.,Jaroslav the Wise Novgorod State University, Veliky Novgorod, Russia
| | | | - K D Muminov
- Central Clinical Hospital, Veliky Novgorod, Russia
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Wang P, Song GD, Xie WC, Song ZS. Comparison of one-step laparoscopy and two-step endolaparoscopy in the treatment of secondary choledocholithiasis: A multicenter retrospective clinical study. Technol Health Care 2023:THC220610. [PMID: 36847032 DOI: 10.3233/thc-220610] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
BACKGROUND There are two minimally invasive ways of treating cholecystolithiasis combined with choledocholithiasis, but there remains some controversy regarding which technique is better, since they both have advantages and disadvantages. The one-step method involves laparoscopic cholecystectomy, laparoscopic common bile duct exploration, and primary close (LC + LCBDE + PC), while the two-step procedure consists of endoscopic retrograde cholangiopancreatography, endoscopic sphincterotomy, and laparoscopic cholecystectomy (ERCP + EST + LC). OBJECTIVE This multicenter retrospective study aimed to analyze and compare the effects of the two techniques. METHODS The data of patients who underwent either one-step LCBDE + LC + PC or two-step ERCP + EST + LC treatment for gallstones in the gallbladder and bile duct at the Shanghai Tenth People's Hospital, Shanghai Tongren Hospital, and Taizhou Fourth People's Hospital between January 1, 2015 and December 31, 2019 were collected, and the preoperative indicators of the two groups were compared. RESULTS The surgical success rate of the one-step laparoscopic group was 96.23% (664/690), the transit abdominal opening rate was 2.03% (14/690), and there were 21 cases of postoperative bile leakage. The success rate of the two-step endolaparoscopic surgery was 78.95% (225/285), the transit opening rate was 2.46% (7/285), and there were 43 postoperative cases of pancreatitis and five of cholangitis. Postoperative cholangitis, pancreatitis, postoperative stone recurrence, postoperative hospitalization, and treatment costs were significantly lower (P< 0.05) in the one-step laparoscopic group than in the two-step endolaparoscopic group. However, the amount of intraoperative bleeding, the postoperative extraction time of the abdominal drainage tube, and the incidence of bile leakage were higher (P< 0.05) in the one-step laparoscopic group than in the two-step endolaparoscopic group. CONCLUSION The two methods of treating choledocholithiasis combined with choledocholithiasis that were analyzed in this study were safe and effective, and each method had its own advantages.
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Affiliation(s)
- Ping Wang
- Department of General Surgery, Taizhou Fourth People's Hospital, Taizhou, Jiangsu, China
| | - Guo-Dong Song
- Department of General Surgery, Wuxi People's Hospital, Wuxi, Jiangsu, China
| | - Wang-Cheng Xie
- Department of Hepatobiliary Surgery, Shanghai Tenth People's Hospital, Shanghai, China
| | - Zhen-Shun Song
- Department of Hepatobiliary Surgery, Shanghai Tenth People's Hospital, Shanghai, China
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De Silva HM, Howard T, Bird D, Hodgson R. Outcomes following common bile duct exploration versus endoscopic stone extraction before, during and after laparoscopic cholecystectomy for patients with common bile duct stones. HPB (Oxford) 2022; 24:2125-2133. [PMID: 36130852 DOI: 10.1016/j.hpb.2022.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 07/24/2022] [Accepted: 08/25/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Laparoscopic common bile duct exploration (LCBDE) and endoscopic retrograde cholangiopancreatography (ERCP) are two methods of retrieving common bile duct (CBD) stones. The best method for CBD stone removal is debatable. The aim of this study was to compare outcomes following LCBDE and/or ERCP, including laparoscopic cholecystectomy. METHODS Data were collected retrospectively for patients undergoing LCBDE and/or ERCP at a single centre from 2008 to 2018. Patients were grouped by intention-to-treat (single-stage LCBDE, pre-operative-, intra-operative-, or post-operative ERCP) and eventual plan (surgical or endoscopic). Outcomes included complication rates (minor Clavien-Dindo 1/2, major Clavien-Dindo 3/4, non-biliary complications) and mortality. RESULTS Of 671 patients, 578 patients received LCBDE and 93 patients received ERCP as primary care. Endoscopic clearance had significantly higher complications and mortality compared to surgical clearance. On an intention-to-treat basis LCBDE had the lowest minor-, major- and non-biliary complications, and mortality (5.2%, 6.1%, 2.9% and 0.5%, respectively), whilst pre-operative ERCP the worst (39.6%, 27.1%, 29.2% and 8.3%, respectively) (p=<0.001). LCBDE and postERCP had similar major complications and mortality. CONCLUSION Surgical clearance of CBD stones was potentially safer than endoscopic clearance. Pre-operative ERCP had the worst outcomes. LCBDE and postERCP are likely to have similar short-term patient outcomes.
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Affiliation(s)
| | - Tess Howard
- Division of Surgery, The Northern Hospital, Epping, Australia
| | - David Bird
- Division of Surgery, The Northern Hospital, Epping, Australia
| | - Russell Hodgson
- Division of Surgery, The Northern Hospital, Epping, Australia; Department of Surgery, University of Melbourne, Epping, Australia.
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Lopez-Lopez V, Gil-Vazquez PJ, Ferreras D, Nassar AHM, Bansal VK, Topal B, Zhu JG, Chuang SH, Jorba R, Bekheit M, Martinez-Cecilia D, Parra-Membrives P, Sgourakis G, Mattila A, Bove A, Quaresima S, Barreras González JE, Sharma A, Ruiz JJ, Sánchez-Bueno F, Robles-Campos R, Martinez-Isla A. Multi-institutional expert update on the use of laparoscopic bile duct exploration in the management of choledocholithiasis: Lesson learned from 3950 procedures. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2022; 29:1283-1291. [PMID: 35122406 DOI: 10.1002/jhbp.1123] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Recently there has been a growing interest in the laparoscopic management of common bile duct stones with gallbladder in situ (LBDE), which is favoring the expansion of this technique. Our study identified the standardization factors of LBDE and its implementation in the single-stage management of choledocholithiasis. METHODS A retrospective multi-institutional study among 17 centers with proven experience in LBDE was performed. A cross-sectional survey consisting of a semi-structured pretested questionnaire was distributed covering the main aspects on the use of LBDE in the management of choledocholithiasis. RESULTS A total of 3950 LBDEs were analyzed. The most frequent indication was jaundice (58.8%). LBDEs were performed after failed ERCP in 15.2%. The most common approach used was the transcystic (63.11%). The overall series failure rate of LBDE was 4% and the median rate for each center was 6% (IQR, 4.5-12.5). Median operative time ranged between 60-120 min (70.6%). Overall morbidity rate was 14.6%, with a postoperative bile leak and complications ≥3a rate of 4.5% and 2.5%, respectively. The operative time decreased with experience (P = .03) and length of hospital stay was longer in the presence of a biliary leak (P = .04). Current training of LBDE was defined as poor or very poor by 82.4%. CONCLUSION Based on this multicenter survey, LBDE is a safe and effective approach when performed by experienced teams. The generalization of LBDE will be based on developing training programs.
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Affiliation(s)
- Víctor Lopez-Lopez
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de la Arrixaca, IMIB-ARRIXACA, Murcia, Spain
| | - Pedro José Gil-Vazquez
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de la Arrixaca, IMIB-ARRIXACA, Murcia, Spain
| | - David Ferreras
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de la Arrixaca, IMIB-ARRIXACA, Murcia, Spain
| | - Ahmad H M Nassar
- University Hospital Monklands, Airdrie, UK
- University of Glasgow, Glasgow, UK
| | - Virinder K Bansal
- Departments of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Baki Topal
- Department of Visceral Surgery, University Hospitals KU Leuven, Leuven, Belgium
| | - Jie-Gao Zhu
- Department of General Surgery, Beijing Key Laboratory of Cancer Invasion and Metastasis Research and National Clinical Research Centre of Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Shu-Hung Chuang
- Division of General and Digestive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Rosa Jorba
- Department of General and Digestive Surgery, Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain
| | - Mohamed Bekheit
- Department of Surgery, Aberdeen Royal Infirmary, Foresterhill Health Campus, Aberdeen, UK
| | | | - Pablo Parra-Membrives
- Hepatobiliary and Pancreatic Surgery Unit, Valme University Hospital, Sevilla, Spain
| | - Georgios Sgourakis
- Departament of General Surgery, Royal Blackburn Hospital NHS Trust, Burnley, UK
| | - Anne Mattila
- Department of Surgery, Central Finland Hospital Nova, Jyväskylä, Finland
| | - Aldo Bove
- Department of Medicine, Dentistry and Biotechnology, University "G. d'Annunzio" of Chieti-Pescara, Pescara, Italy
| | - Silvia Quaresima
- Department of General Surgery and Surgical Specialties "Paride Stefanini", Sapienza University of Rome, Rome, Italy
| | | | - Anil Sharma
- Institute of Laparoscopic, Endoscopic and Bariatric Surgery, Max Super Speciality Hospital, Dehradun, India
| | - Juan Jose Ruiz
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de la Arrixaca, IMIB-ARRIXACA, Murcia, Spain
| | - Francisco Sánchez-Bueno
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de la Arrixaca, IMIB-ARRIXACA, Murcia, Spain
| | - Ricardo Robles-Campos
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de la Arrixaca, IMIB-ARRIXACA, Murcia, Spain
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10
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Pizzicannella M, Barberio M, Lapergola A, Gregori M, Maurichi FA, Gallina S, Benedicenti P, Viola MG. One-stage approach to cholecystocholedocholithiasis treatment: a feasible surgical strategy for emergency settings and frail patients. Surg Endosc 2022; 36:8560-8567. [PMID: 35997815 DOI: 10.1007/s00464-022-09537-8] [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] [Received: 05/05/2022] [Accepted: 08/05/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Cholecystocholedocholithiasis (CCL) occurs in up to 18% of patients undergoing laparoscopic cholecystectomy (LC). The two-stage treatment using endoscopic retrograde cholangiopancreatography (ERCP) followed by LC is the treatment of choice for CCL. However, only 10 to 60% of patients have common bile duct (CBD) stones at the time of ERCP, thus exposing patients to unnecessary ERCPs, causing 3 to 15% of post-interventional pancreatitis. One-stage laparoscopic-endoscopic rendezvous (LERV) is an alternative for the treatment of CCL. Given the selective top-to-bottom CBD cannulation, LERV reduces the risk of pancreatitis and failed CBD cannulation. Additionally, LERV is performed exclusively in patients presenting CBD stones at intraoperative cholangiography, avoiding unnecessary ERCPs. Despite its advantages, considering the logistical burden of coordinating different specialties, LERV is performed in few centers. Here, we present the largest retrospective series of LERVs performed at our department, analyzing elective and emergency procedures. METHODS All consecutive patients undergoing LERV for CCL between January 2014 and December 2021 were included. LERV success rate, operative time, biliary outflow restoration rate, postoperative complications (POC), length of hospital stay (LOS), and recurrences were analyzed. RESULTS 181 patients were included (61 elective LERVs, 120 emergency LERVs). We reported a 100% LERV success rate, a 97.79% biliary outflow restoration rate, a 0% conversion rate, a mean intraoperative time of 120.17 ± 31.35 min, and LOS of 4.00 ± 2.82 days. POC included 7 Clavien-Dindo type 1, 11 type 2, and 3 type 3 cases. Seven patients presented with CBD stone recurrence: 2 within 30 days after discharge, 3 within 6 months after discharge, and 2 patients at 1 year. No statistically significant difference was found between elective and emergency patients. CONCLUSION LERV is safe, representing a valid option even in emergency settings, thus enabling the management of CCL within a single procedure, consequently sparing additional anesthesia and decreasing post-ERCP complications.
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Affiliation(s)
- Margherita Pizzicannella
- Endoscopy Unit, Ospedale Card. G. Panico, Tricase, Italy.
- IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France.
| | - Manuel Barberio
- General Surgery Department, Ospedale Card. G. Panico, Tricase, Italy
- IRCAD, Research Institute Against Digestive Cancer, Strasbourg, France
| | - Alfonso Lapergola
- Department of Visceral and Digestive Surgery, Nouvel Hôpital Civil, Strasbourg University Hospital, Strasbourg, France
| | - Matteo Gregori
- General Surgery Department, Policlinico Casilino, Rome, Italy
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11
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Isaza-Gómez E, Velásquez-Martínez MA, Camilo Andrés Díaz-Quintero CA, Molina-Céspedes IC, Salazar-Ochoa S, Posada-Moreno P, Chanci-Drago R, Guzmán-Arango N. Controversias en cirugía: colelitiasis y coledocolitiasis ¿Exploración de vías biliares laparoscópica más colecistectomía laparoscópica (cirugía en un paso) o CPRE y colecistectomía laparoscópica (cirugía en dos pasos)? REVISTA COLOMBIANA DE CIRUGÍA 2022. [DOI: 10.30944/20117582.1373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introducción. La colelitiasis tiene una prevalencia del 15 % y el 21 % tendrá coledocolitiasis al momento de la colecistectomía, con 50 % de probabilidad de presentar complicaciones asociadas. Desde el advenimiento de la colecistectomía laparoscópica, el abordaje de la coledocolitiasis ha sido endoscópico, usualmente en un tiempo diferente al vesicular, sin embargo, los avances en laparoscopia han permitido explorar la vía biliar común por la misma vía, pudiendo realizar ambos procedimientos en el mismo tiempo de forma segura.
Métodos. Se realizó una búsqueda de la literatura existente con relación al enfoque para el manejo de la colecistocoledocolitasis en un paso comparado con dos pasos.
Resultados. Existe evidencia que demuestra mayor efectividad del abordaje en dos pasos, con CPRE y posterior colecistectomía laparoscópica, sobre el abordaje en un paso, especialmente en la tasa de fuga biliar y de cálculos retenidos. El enfoque en un paso con exploración de vías biliares y colecistectomía laparoscópica en el mismo tiempo es seguro, con alta tasa de éxito, baja incidencia de complicaciones, menor estancia hospitalaria y costos.
Conclusión. El abordaje laparoscópico en un solo paso es un procedimiento seguro y eficaz para el manejo de la colecisto-coledocolitiasis, con el beneficio de estancia hospitalaria menor, sin embargo, se requieren habilidades técnicas avanzadas en cirugía laparoscópica. En nuestro medio ya existe una infraestructura para el manejo híbrido con CPRE y colecistectomía laparoscópica, pudiéndose realizar ambos en el mismo tiempo, para reducir estancia y costos.
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12
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Vaccari S, Minghetti M, Lauro A, Bellini MI, Ussia A, Khouzam S, Marino IR, Cervellera M, D'Andrea V, Tonini V. Destiny for Rendezvous: Is Cholecysto/Choledocholithiasis Better Treated with Dual- or Single-Step Procedures? Dig Dis Sci 2022; 67:1116-1127. [PMID: 35318553 DOI: 10.1007/s10620-022-07450-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/09/2022] [Indexed: 02/05/2023]
Abstract
Biliary lithiasis is common worldwide, affecting almost 20% of the general population, though few experience symptoms. The frequency of choledocholithiasis in patients with symptomatic cholelithiasis is estimated to be 10-33%, depending on patients' age. Unlike gallbladder lithiasis, the medical and surgical treatment of common bile duct stones is uncertain, having changed over the last few years. The prior gold standard treatment for cholelithiasis and choledocholithiasis was open cholecystectomy with bile duct clearance, choledochotomy, and/or surgical sphincterotomy. In the last 10-15 years, new treatment approaches to the complex pathology of choledocholithiasis have emerged with the advent of endoscopic retrograde cholangiopancreatography (ERCP), laparoscopic surgery, and advanced diagnostic procedures. Although ERCP followed by laparoscopic cholecystectomy is the preferred mode of management, a single-step strategy (laparo-endoscopic rendezvous) has gained acceptance due to lesser morbidity and a lower risk of iatrogenic damage. Given the above, a tailored approach relying on careful evaluation of the disease is necessary in order to minimize complication risks and overall costs. Yet, the debate remains open, with no consensus on the superiority of laparo-endoscopic rendezvous to more conventional approaches.
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Affiliation(s)
- S Vaccari
- Department of Surgical Sciences, Sapienza University, Rome, Italy
| | - M Minghetti
- Emergency Surgery Department, St. Orsola University Hospital, Bologna, Italy
| | - A Lauro
- Department of Surgical Sciences, Sapienza University, Rome, Italy.
| | - M I Bellini
- Department of Surgical Sciences, Sapienza University, Rome, Italy
| | - A Ussia
- Emergency Surgery Department, St. Orsola University Hospital, Bologna, Italy
| | - S Khouzam
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - I R Marino
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - M Cervellera
- Department of General Surgery, Ospedale Santissima Annunziata, Taranto, Italy
| | - V D'Andrea
- Department of Surgical Sciences, Sapienza University, Rome, Italy
| | - V Tonini
- Emergency Surgery Department, St. Orsola University Hospital, Bologna, Italy
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13
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Bradley A, Sami S, Hemadasa N, Macleod A, Brown LR, Apollos J. Decision analysis of minimally invasive management options for cholecysto-choledocholithiasis. Surg Endosc 2020; 34:5211-5222. [PMID: 32710213 DOI: 10.1007/s00464-020-07816-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 07/10/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND The management of cholecysto-choledocholithiasis is controversial with the risks and benefits of one versus two-stage approaches debated. This study aims to perform decision analysis of minimally invasive laparo-endoscopic approaches. METHODS An advanced decision tree was constructed to compare pre, intra and post-operative ERCP and laparoscopic common bile duct exploration in terms of primary ductal clearance and significant complications for patients intended to undergo laparoscopic cholecystectomy. Transition probabilities were calculated from randomised controlled trials following a comprehensive literature search. Model uncertainties were extensively tested through deterministic and probabilistic Monte Carlo sensitivity analysis. Utility outcomes were 1 and 0.5 for successful primary clearance without and with complications, respectively, and 0 for failure of primary clearance of the duct. RESULTS Twenty-one studies (n = 2697) were included in the analysis. At base case analysis, a laparo-endoscopic rendezvous approach had the highest utility output (0.90; no complication probability: 0.87/complication probability 0.06). Laparoscopic common bile duct exploration was ranked second with a utility output 0.87 (no complication probability: 0.82/complication probability 0.10). Pre-operative ERCP utility score was 0.84 (no complication probability: 0.78/ complication probability 0.11) and post-operative ERCP utility score was 0.78 (no complication probability: 0.71/complication probability 0.13). Monte Carlo analysis showed that laparo-endoscopic rendezvous and laparoscopic common bile duct exploration had an equal mean utility output of 0.57 (standard deviation 0.36; variance 0.13; 95% confidence interval 0.00-0.99 versus standard deviation 0.34; variance 0.12; 95% confidence interval 0.01-0.98). Laparo-endoscopic rendezvous had a superior treatment selection frequency of 39.93% followed by laparoscopic bile duct exploration (36.11%), pre-operative ERCP (20.67%) and post-operative ERCP (2.99%). CONCLUSION One-stage approach to the management of cholecysto-choledocholithiasis is superior to two-stage, in terms of primary clearance of the duct and risk of operative morbidity. Laparo-endoscopic rendezvous approach could offer marginal additional benefit but more high-quality randomised controlled trials are needed.
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Affiliation(s)
- Alison Bradley
- Department of General Surgery, Dumfries and Galloway Royal Infirmary, Cargenbridge, Dumfries, DG2 8RX, Scotland, UK.
| | - Sharukh Sami
- Department of General Surgery, Dumfries and Galloway Royal Infirmary, Cargenbridge, Dumfries, DG2 8RX, Scotland, UK
| | - Niroshini Hemadasa
- Department of General Surgery, Dumfries and Galloway Royal Infirmary, Cargenbridge, Dumfries, DG2 8RX, Scotland, UK
| | - Anne Macleod
- Department of General Surgery, Dumfries and Galloway Royal Infirmary, Cargenbridge, Dumfries, DG2 8RX, Scotland, UK
| | - Leo R Brown
- Department of General Surgery, Dumfries and Galloway Royal Infirmary, Cargenbridge, Dumfries, DG2 8RX, Scotland, UK
| | - Jeyakumar Apollos
- Department of General Surgery, Dumfries and Galloway Royal Infirmary, Cargenbridge, Dumfries, DG2 8RX, Scotland, UK
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14
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Navaratne L, Martinez Isla A. Transductal versus transcystic laparoscopic common bile duct exploration: an institutional review of over four hundred cases. Surg Endosc 2020; 35:437-448. [PMID: 32246237 DOI: 10.1007/s00464-020-07522-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 03/26/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Many studies have failed to demonstrate significant differences between single- and two-staged approaches for the management of choledocholithiasis with concomitant gallstones in terms of post-operative morbidity. However, none of these studies paid specific attention to the differences between the methods of accessing the bile duct during laparoscopy. The aim of this study was to report outcomes of transcystic versus transductal laparoscopic common bile duct exploration (LCBDE) from our experience of over four hundred cases. METHODS Retrospective review of 416 consecutive patients who underwent LCBDE at a single-centre between 1998 and 2018 was performed. Data collected included pre-operative demographic information, medical co-morbidity, pre-operative investigations, intra-operative findings (including negative choledochoscopy rates, use of holmium laser lithotripsy and operative time) and post-operative outcomes. RESULTS Transductal LCBDE via choledochotomy was achieved in 242 patients (58.2%), whereas 174 patients (41.8%) underwent transcystic LCBDE. Stone clearance rates, conversion to open surgery and mortality were similar between the two groups. Overall morbidity as well as minor and major post-operative complications were significantly higher in the transductal group. The main surgery-related complications were bile leak (5.8% vs 1.1%, p = 0.0181) and pancreatitis (7.4% vs 0.6%, p = 0.0005). Median length of post-operative stay was also significantly greater in the transductal group. CONCLUSION This study represents the largest single study to date comparing outcomes from transcystic and transductal LCBDE. Where possibly, the transcystic route should be used for LCBDE and this approach can be augmented with various techniques to increase successful stone clearance and reduce the need for choledochotomy.
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Affiliation(s)
- Lalin Navaratne
- Department of Upper GI Surgery, Northwick Park Hospital & St Mark's Hospital, Watford Road, London, HA1 3UJ, UK.
| | - Alberto Martinez Isla
- Department of Upper GI Surgery, Northwick Park Hospital & St Mark's Hospital, Watford Road, London, HA1 3UJ, UK
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15
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Memba R, González S, Coronado D, González V, Mata F, Rodríguez JA, Mühlenberg C, Sala J, Ribas R, Pueyo E, Mata A, O'Connor DB, Conlon KC, Jorba R. Single-stage approach for the management of choledocolithiasis with concomitant cholelithiasis. Implementation of a protocol in a secondary hospital. Surgeon 2019; 17:351-359. [PMID: 30704859 DOI: 10.1016/j.surge.2018.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 11/14/2018] [Accepted: 12/18/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Current evidence shows that single-stage treatment of concomitant choledocholithiasis and cholelithiasis is as effective and safe as two-stage treatment. However, several studies suggest that single-stage approach requires shorter hospitalization time and is more cost-effective than the two-stage approach, even though it requires considerable training. This study aimed to evaluate the implementation of a protocol for managing concomitant choledocholithiasis and cholelithiasis using single-stage treatment. METHODS A prospective cohort study of patients diagnosed with cholelithiasis and choledocholithiasis who were treated with the single-stage treatment - transcystic instrumentation, choledocotomy or intraoperative endoscopic retrograde cholangiopancreatography (ERCP) - between September 2010 and June 2017 was assessed. The primary outcomes were complications, hospital stay, operative time and recurrence rate. RESULTS 164 patients were enrolled. 141 (86%) were operated laparoscopically. Preoperatively diagnosed stones were not found by intraoperative imaging or disappeared after "flushing" in 38 patients (23.2%). Surgical approach was transcystic in 45 patients (27.41%), choledochotomy in 74 (45.1%), intraoperative ERCP in 4 (2.4%), and bilioenteric derivation in 3 (1.8%). Mean hospitalization stay was 4.4 days. Mean operative time was 166 min 27 patients (16.5%) had complications and 1 patient was exitus (0.6%). Recurrence rate was 1.2%. CONCLUSIONS Single-stage approach is a safe and effective management option for concomitant cholelithiasis and choledocolithiasis. Furthermore, a significant number of common bile duct stones pass spontaneously to duodenum or can benefit from a transcystic approach, with presumable low morbidity and cost-efficiency.
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Affiliation(s)
- Robert Memba
- Hepatobiliary and Pancreatic Surgery Unit, General Surgery Department, Sant Joan Despí-Moisès Broggi Hospital, Consorci Sanitari Integral, Barcelona, Spain; Professorial Surgical Unit, Trinity College Dublin, Tallaght Hospital, Dublin, Ireland; Hepatobiliary and Pancreatic Surgery Unit, General Surgery Department, Joan XXIII University Hospital, Tarragona, Spain.
| | - Sergio González
- Hepatobiliary and Pancreatic Surgery Unit, General Surgery Department, Sant Joan Despí-Moisès Broggi Hospital, Consorci Sanitari Integral, Barcelona, Spain
| | - Daniel Coronado
- Hepatobiliary and Pancreatic Surgery Unit, General Surgery Department, Sant Joan Despí-Moisès Broggi Hospital, Consorci Sanitari Integral, Barcelona, Spain
| | - Verónica González
- Hepatobiliary and Pancreatic Surgery Unit, General Surgery Department, Sant Joan Despí-Moisès Broggi Hospital, Consorci Sanitari Integral, Barcelona, Spain
| | - Fernando Mata
- Hepatobiliary and Pancreatic Surgery Unit, General Surgery Department, Sant Joan Despí-Moisès Broggi Hospital, Consorci Sanitari Integral, Barcelona, Spain
| | - José Antonio Rodríguez
- Hepatobiliary and Pancreatic Surgery Unit, General Surgery Department, Sant Joan Despí-Moisès Broggi Hospital, Consorci Sanitari Integral, Barcelona, Spain
| | - Carlos Mühlenberg
- Hepatobiliary and Pancreatic Surgery Unit, General Surgery Department, Sant Joan Despí-Moisès Broggi Hospital, Consorci Sanitari Integral, Barcelona, Spain
| | - Joan Sala
- Hepatobiliary and Pancreatic Surgery Unit, General Surgery Department, Sant Joan Despí-Moisès Broggi Hospital, Consorci Sanitari Integral, Barcelona, Spain
| | - Ruth Ribas
- Hepatobiliary and Pancreatic Surgery Unit, General Surgery Department, Sant Joan Despí-Moisès Broggi Hospital, Consorci Sanitari Integral, Barcelona, Spain
| | - Eva Pueyo
- Hepatobiliary and Pancreatic Surgery Unit, General Surgery Department, Sant Joan Despí-Moisès Broggi Hospital, Consorci Sanitari Integral, Barcelona, Spain
| | - Alfredo Mata
- Gastroenterologist Endoscopy Unit, Gastroenterology Department, Sant Joan Despí-Moisès Broggi Hospital, Consorci Sanitari Integral, Barcelona, Spain
| | - Donal B O'Connor
- Professorial Surgical Unit, Trinity College Dublin, Tallaght Hospital, Dublin, Ireland
| | - Kevin C Conlon
- Professorial Surgical Unit, Trinity College Dublin, Tallaght Hospital, Dublin, Ireland
| | - Rosa Jorba
- Hepatobiliary and Pancreatic Surgery Unit, General Surgery Department, Joan XXIII University Hospital, Tarragona, Spain
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16
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vanSonnenberg E, Panchanathan R. Percutaneous Transcholecystic Management of Choledocholithiasis: A Next Horizon for Interventional Radiologists? Radiology 2019; 290:244-245. [DOI: 10.1148/radiol.2018181942] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Eric vanSonnenberg
- From the Department of Radiology, University of Arizona College of Medicine Phoenix, 550 Van Buren Ave, Building HSEB, Office C536, Phoenix, AZ 85004 (E.v., R.P.); and Department of Radiology, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095 (E.v.)
| | - Roshan Panchanathan
- From the Department of Radiology, University of Arizona College of Medicine Phoenix, 550 Van Buren Ave, Building HSEB, Office C536, Phoenix, AZ 85004 (E.v., R.P.); and Department of Radiology, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095 (E.v.)
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17
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Jung GS, Kim YJ, Yun JH, Park JG, Yun BC, Han BH, Lee SU, Kim YH. Percutaneous Transcholecystic Removal of Common Bile Duct Stones: Case Series in 114 Patients. Radiology 2018; 290:238-243. [PMID: 30226454 DOI: 10.1148/radiol.2018173043] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Purpose To evaluate the safety and effectiveness of percutaneous transcholecystic removal of common bile duct (CBD) stones in 114 patients. Materials and Methods This retrospective study was approved by the institutional review board. From September 2011 through February 2017, 114 consecutive patients (68 men, 46 women; mean age, 73 years) underwent percutaneous transcholecystic removal of CBD stones. All patients had acute cholangitis or cholecystitis. Stones were extracted through a 12-F sheath by using a Wittich nitinol stone basket uder fluoroscopic guidance. Technical success rates, complications, and long-term follow-up were evaluated. Results Technical success was achieved in 96 of 114 (84.2%) patients. In 18 patients, stone removal was unsuccessful due to failure of cystic duct cannulation (n = 11), proximal migration of the CBD stone (n = 3), multiple CBD stones (n = 3), and low insertion of the cystic duct (n = 1). No major procedure-related complications were seen. During the mean follow-up of 644 days (range, 11-2206 days), CBD stones recurred in 12 patients after a mean of 884 days (range, 439-1799 days) after the procedure. Conclusion Percutaneous transcholecystic removal of common bile duct stones seems to be a safe and effective method. © RSNA, 2018 Online supplemental material is available for this article . See also the editorial by vanSonnenberg and Panchanathan in this issue.
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Affiliation(s)
- Gyoo-Sik Jung
- From the Departments of Radiology (G.S.J., J.H.Y., J.G.P.) and Internal Medicine (B.C.Y., B.H.H., S.U.L.), Kosin University College of Medicine, 34 Amnam-dong, Seo-gu, Busan 602-702, South Korea; and Department of Radiology, Andong General Hospital, Gyeongsangbuk-do, South Korea (Y.J.K., Y.H.K.)
| | - Yong Joo Kim
- From the Departments of Radiology (G.S.J., J.H.Y., J.G.P.) and Internal Medicine (B.C.Y., B.H.H., S.U.L.), Kosin University College of Medicine, 34 Amnam-dong, Seo-gu, Busan 602-702, South Korea; and Department of Radiology, Andong General Hospital, Gyeongsangbuk-do, South Korea (Y.J.K., Y.H.K.)
| | - Jong Hyuk Yun
- From the Departments of Radiology (G.S.J., J.H.Y., J.G.P.) and Internal Medicine (B.C.Y., B.H.H., S.U.L.), Kosin University College of Medicine, 34 Amnam-dong, Seo-gu, Busan 602-702, South Korea; and Department of Radiology, Andong General Hospital, Gyeongsangbuk-do, South Korea (Y.J.K., Y.H.K.)
| | - Jung Gu Park
- From the Departments of Radiology (G.S.J., J.H.Y., J.G.P.) and Internal Medicine (B.C.Y., B.H.H., S.U.L.), Kosin University College of Medicine, 34 Amnam-dong, Seo-gu, Busan 602-702, South Korea; and Department of Radiology, Andong General Hospital, Gyeongsangbuk-do, South Korea (Y.J.K., Y.H.K.)
| | - Byung Chul Yun
- From the Departments of Radiology (G.S.J., J.H.Y., J.G.P.) and Internal Medicine (B.C.Y., B.H.H., S.U.L.), Kosin University College of Medicine, 34 Amnam-dong, Seo-gu, Busan 602-702, South Korea; and Department of Radiology, Andong General Hospital, Gyeongsangbuk-do, South Korea (Y.J.K., Y.H.K.)
| | - Byung Hoon Han
- From the Departments of Radiology (G.S.J., J.H.Y., J.G.P.) and Internal Medicine (B.C.Y., B.H.H., S.U.L.), Kosin University College of Medicine, 34 Amnam-dong, Seo-gu, Busan 602-702, South Korea; and Department of Radiology, Andong General Hospital, Gyeongsangbuk-do, South Korea (Y.J.K., Y.H.K.)
| | - Sang Uk Lee
- From the Departments of Radiology (G.S.J., J.H.Y., J.G.P.) and Internal Medicine (B.C.Y., B.H.H., S.U.L.), Kosin University College of Medicine, 34 Amnam-dong, Seo-gu, Busan 602-702, South Korea; and Department of Radiology, Andong General Hospital, Gyeongsangbuk-do, South Korea (Y.J.K., Y.H.K.)
| | - Young Hwan Kim
- From the Departments of Radiology (G.S.J., J.H.Y., J.G.P.) and Internal Medicine (B.C.Y., B.H.H., S.U.L.), Kosin University College of Medicine, 34 Amnam-dong, Seo-gu, Busan 602-702, South Korea; and Department of Radiology, Andong General Hospital, Gyeongsangbuk-do, South Korea (Y.J.K., Y.H.K.)
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18
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Zhang M, Zhang J, Sun X, Xu J, Zhu J, Yuan W, Yan Q. Clinical analysis of treatment strategies to cholecystocholedocholithiasis patients with previous subtotal or total gastrectomy: a retrospective cohort study. BMC Surg 2018; 18:54. [PMID: 30092786 PMCID: PMC6085697 DOI: 10.1186/s12893-018-0388-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 07/30/2018] [Indexed: 02/07/2023] Open
Abstract
Background Previous gastrectomy can lead to an increased incidence of cholecystocholedocholithiasis (CCL) and increased morbidity rate. However, the appropriate treatment strategy for patients with CCL and a history of gastrectomy remains unclear. Methods We performed a retrospective cohort study of patients with CCL and a history of gastrectomy who underwent either one-stage laparoscopic common bile duct (CBD) exploration with stone clearance and laparoscopic cholecystectomy (LCBDE+LC) or two-stage endoscopic retrograde cholangiopancreatography followed by LC (ERCP+LC) from May 2010 to March 2018. Results The success rate of ERCP for CBD stone clearance was 81.2% in patients with a history of Billroth I gastrectomy and 23.7% in patients with a history of Billroth II or Roux-en-Y esophagojejunostomy [χ2 = 97.67, P < 0.001, risk ratio (RR) = 3.43]. The success rate of second-step LC after successful ERCP for removal of CBD stones and the success rate of LCBDE+LC after ERCP treatment failure were 96.8 and 87.7%, respectively, in patients with preoperative intra-abdominal adhesion evaluation scores of ≤3 points. These success rates were 28.6 and 27.6%, respectively, in patients with scores of > 3 points (χ2 = 59.70, P < 0.001, RR = 3.38 and χ2 = 53.41, P < 0.001, RR = 3.27, respectively). Conclusions Based on the results of this study, ERCP+LC seems to be an attractive strategy for treatment of CCL in patients with a history of Billroth I gastrectomy, and LCBDE+LC appears to be suitable for patients with a history of Billroth II or Roux-en-Y esophagojejunostomy. Preoperative evaluation of intra-abdominal adhesions helps to reduce the conversion rate of laparoscopic surgery.
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Affiliation(s)
- Mingjie Zhang
- Department of Hepatobiliary surgery, Huzhou Hospital, Zhejiang University School of Medicine (Huzhou Central Hospital), No. 198, Hongqi Road, Huzhou, 313000, Zhejiang Province, China
| | - Jianxin Zhang
- Department of General surgery, The NO.3 People's hospital of Changxing County, No. 19, Tianneng Road, Changxing, 313104, Zhejiang Province, China
| | - Xu Sun
- Department of Hepatobiliary surgery, Huzhou Hospital, Zhejiang University School of Medicine (Huzhou Central Hospital), No. 198, Hongqi Road, Huzhou, 313000, Zhejiang Province, China
| | - Jie Xu
- Department of General surgery, The NO.3 People's hospital of Changxing County, No. 19, Tianneng Road, Changxing, 313104, Zhejiang Province, China
| | - Jing Zhu
- Department of General surgery, The NO.3 People's hospital of Changxing County, No. 19, Tianneng Road, Changxing, 313104, Zhejiang Province, China
| | - Wenbin Yuan
- Department of Hepatobiliary surgery, Huzhou Hospital, Zhejiang University School of Medicine (Huzhou Central Hospital), No. 198, Hongqi Road, Huzhou, 313000, Zhejiang Province, China
| | - Qiang Yan
- Department of Hepatobiliary surgery, Huzhou Hospital, Zhejiang University School of Medicine (Huzhou Central Hospital), No. 198, Hongqi Road, Huzhou, 313000, Zhejiang Province, China.
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Ricci C, Pagano N, Taffurelli G, Pacilio CA, Migliori M, Bazzoli F, Casadei R, Minni F. Comparison of Efficacy and Safety of 4 Combinations of Laparoscopic and Intraoperative Techniques for Management of Gallstone Disease With Biliary Duct Calculi: A Systematic Review and Network Meta-analysis. JAMA Surg 2018; 153:e181167. [PMID: 29847616 DOI: 10.1001/jamasurg.2018.1167] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Importance Several techniques are used for surgical treatment of gallstone disease with biliary duct calculi, but the safety and efficacy of these approaches have not been compared. Objectives To compare the efficacy and safety of 4 surgical approaches to gallstone disease with biliary duct calculi. Data Sources MEDLINE, Scopus, and ISI-Web of Science databases, articles published between 1950 and 2017 and searched from August 12, 2017, to September 14, 2017. Search terms used were LCBDE, LC, preoperative, ERCP, postoperative, period, cholangiopancreatography, endoscopic, retrograde, rendezvous, intraoperative, one-stage, two-stage, single-stage, gallstone, gallstones, calculi, stone, therapy, treatment, therapeutics, surgery, surgical, procedures, clinical trials as topic, random, and allocation in several logical combinations. Study Selection Randomized clinical trials comparing at least 2 of the following strategies: preoperative endoscopic retrograde cholangiopancreatography (PreERCP) plus laparoscopic cholecystectomy (LC); LC with laparoscopic common bile duct exploration (LCDBE); LC plus intraoperative endoscopic retrograde cholangiopancreatography (IntraERCP); and LC plus postoperative ERCP (PostERCP). Data Extraction and Synthesis A frequentist random-effects network meta-analysis was performed. The surface under the cumulative ranking curve (SUCRA) was used to show the probability that each approach would be the best for each outcome. Main Outcomes and Measures Primary outcomes were the safety to efficacy ratio using overall mortality and morbidity rates as the main indicators of safety and the success rate as an indicator of efficacy. Secondary outcomes were acute pancreatitis, biliary leak, overall bleeding, operative time, length of hospital stay, total cost, and readmission rate. Results The 20 trials comprised 2489 patients (and 2489 procedures). Laparoscopic cholecystectomy plus IntraERCP had the highest probability of being the most successful (SUCRA, 87.2%) and safest (SUCRA, 69.7%) with respect to morbidity. All approaches had similar results regarding overall mortality. Laparoscopic cholecystectomy plus LCBDE was the most successful for avoiding overall bleeding (SUCRA, 83.3%) and for the shortest operative time (SUCRA, 90.2%) and least total cost (SUCRA, 98.9%). Laparoscopic cholecystectomy plus IntraERCP was the best approach for length of hospital stay (SUCRA, 92.7%). Inconsistency was found in operative time (indirect estimate, 19.05; 95% CI, 2.44-35.66; P = .02) and total cost (indirect estimate, 17.06; 95% CI, 3.56-107.21; P = .04). Heterogeneity was observed for success rate (τ, 0.8), operative time (τ, >1), length of stay (τ, >1), and total cost (τ, >1). Conclusions and Relevance The combined LC and IntraERCP approach had the greatest odds to be the safest and appears to be the most successful. Laparoscopic cholecystectomy plus LBCDE appears to reduce the risk of acute pancreatitis but may be associated with a higher risk of biliary leak.
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Affiliation(s)
- Claudio Ricci
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Nico Pagano
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Giovanni Taffurelli
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Carlo Alberto Pacilio
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Marina Migliori
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Franco Bazzoli
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Riccardo Casadei
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Francesco Minni
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy
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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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21
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Single-stage laparoscopic common bile duct exploration and cholecystectomy versus two-stage endoscopic stone extraction followed by laparoscopic cholecystectomy for patients with gallbladder stones with common bile duct stones: systematic review and meta-analysis of randomized trials with trial sequential analysis. Surg Endosc 2018; 32:3763-3776. [PMID: 29603004 DOI: 10.1007/s00464-018-6170-8] [Citation(s) in RCA: 85] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Accepted: 03/21/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND The ideal management of common bile duct (CBD) stones associated with gall stones is a matter of debate. We planned a meta-analysis of randomized trials comparing single-stage laparoscopic CBD exploration and cholecystectomy (LCBDE) with two-stage preoperative endoscopic stone extraction followed by cholecystectomy (ERCP + LC). METHODS We searched the Pubmed/Medline, Web of science, Science citation index, Google scholar and Cochrane Central Register of Controlled trials electronic databases till June 2017 for all English language randomized trials comparing the two approaches. Statistical analysis was performed using Review Manager (RevMan) [Computer program], Version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014 and results were expressed as odds ratio for dichotomous variables and mean difference for continuous. p value ≤ 0.05 was considered significant. Trial sequential analysis (TSA) was performed using TSA version 0.9.5.5 (Copenhagen: The Copenhagen Trial Unit, Centre for Clinical Intervention Research, 2016). PROSPERO trial registration number is CRD42017074673. RESULTS A total of 11 trials were included in the analysis, with a total of 1513 patients (751-LCBDE; 762-ERCP + LC). LCBDE was found to have significantly lower rates of technical failure [OR 0.59, 95% CI (0.38, 0.93), p = 0.02] and shorter hospital stay [MD - 1.63, 95% CI (- 3.23, - 0.03), p = 0.05]. There was no significant difference in mortality [OR 0.37, 95% CI (0.09, 1.51), p = 0.17], morbidity [OR 0.97, 95% CI (0.70, 1.33), p = 0.84], cost [MD - 379.13, 95% CI (- 784.80, 111.2), p = 0.13] or recurrent/retained stones [OR 1.01, 95% CI (0.38, 2.73), p = 0.98]. TSA showed that although the Z-curve crossed the boundaries of conventional significance, the estimated information size is yet to be achieved. CONCLUSIONS Single-stage LCBDE is superior to ERCP + LC in terms of technical success and shorter hospital stay in good-risk patients with gallstones and CBD stones, where expertise, operative time and instruments are available.
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22
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Wakabayashi G, Iwashita Y, Hibi T, Takada T, Strasberg SM, Asbun HJ, Endo I, Umezawa A, Asai K, Suzuki K, Mori Y, Okamoto K, Pitt HA, Han HS, Hwang TL, Yoon YS, Yoon DS, Choi IS, Huang WSW, Giménez ME, Garden OJ, Gouma DJ, Belli G, Dervenis C, Jagannath P, Chan ACW, Lau WY, Liu KH, Su CH, Misawa T, Nakamura M, Horiguchi A, Tagaya N, Fujioka S, Higuchi R, Shikata S, Noguchi Y, Ukai T, Yokoe M, Cherqui D, Honda G, Sugioka A, de Santibañes E, Supe AN, Tokumura H, Kimura T, Yoshida M, Mayumi T, Kitano S, Inomata M, Hirata K, Sumiyama Y, Inui K, Yamamoto M. Tokyo Guidelines 2018: surgical management of acute cholecystitis: safe steps in laparoscopic cholecystectomy for acute cholecystitis (with videos). JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2018; 25:73-86. [PMID: 29095575 DOI: 10.1002/jhbp.517] [Citation(s) in RCA: 251] [Impact Index Per Article: 41.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In some cases, laparoscopic cholecystectomy (LC) may be difficult to perform in patients with acute cholecystitis (AC) with severe inflammation and fibrosis. The Tokyo Guidelines 2018 (TG18) expand the indications for LC under difficult conditions for each level of severity of AC. As a result of expanding the indications for LC to treat AC, it is absolutely necessary to avoid any increase in bile duct injury (BDI), particularly vasculo-biliary injury (VBI), which is known to occur at a certain rate in LC. Since the Tokyo Guidelines 2013 (TG13), an attempt has been made to assess intraoperative findings as objective indicators of surgical difficulty; based on expert consensus on these difficulty indicators, bail-out procedures (including conversion to open cholecystectomy) have been indicated for cases in which LC for AC is difficult to perform. A bail-out procedure should be chosen if, when the Calot's triangle is appropriately retracted and used as a landmark, a critical view of safety (CVS) cannot be achieved because of the presence of nondissectable scarring or severe fibrosis. We propose standardized safe steps for LC to treat AC. To achieve a CVS, it is vital to dissect at a location above (on the ventral side of) the imaginary line connecting the base of the left medial section (Segment 4) and the roof of Rouvière's sulcus and to fulfill the three criteria of CVS before dividing any structures. Achieving a CVS prevents the misidentification of the cystic duct and the common bile duct, which are most commonly confused. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.
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Affiliation(s)
- Go Wakabayashi
- Department of Surgery, Ageo Central General Hospital, Saitama, Japan
| | - Yukio Iwashita
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Taizo Hibi
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Tadahiro Takada
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Steven M Strasberg
- Section of Hepato-Pancreato-Biliary Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Horacio J Asbun
- Department of Surgery, Mayo Clinic College of Medicine, Jacksonville, FL, USA
| | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Kanagawa, Japan
| | - Akiko Umezawa
- Minimally Invasive Surgery Center, Yotsuya Medical Cube, Tokyo, Japan
| | - Koji Asai
- Department of Surgery, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Kenji Suzuki
- Department of Surgery, Fujinomiya City General Hospital, Shizuoka, Japan
| | - Yasuhisa Mori
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kohji Okamoto
- Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital, Fukuoka, Japan
| | - Henry A Pitt
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Ho-Seong Han
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Tsann-Long Hwang
- Division of General Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Dong-Sup Yoon
- Department of Surgery, Yonsei University Gangnam Severance Hospital, Seoul, Korea
| | - In-Seok Choi
- Department of Surgery, Konyang University Hospital, Daejeon, Korea
| | | | - Mariano Eduardo Giménez
- Chair of General Surgery and Minimal Invasive Surgery "Taquini" University of Buenos Aires, DAICIM Foundation, Buenos Aires, Argentina
| | - O James Garden
- Clinical Surgery, University of Edinburgh, Edinburgh, UK
| | - Dirk J Gouma
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Giulio Belli
- Department of General and HPB Surgery, Loreto Nuovo Hospital, Naples, Italy
| | | | - Palepu Jagannath
- Department of Surgical Oncology, Lilavati Hospital and Research Centre, Mumbai, India
| | - Angus C W Chan
- Department of Surgery, Surgery Centre, Hong Kong Sanatorium and Hospital, Hong Kong
| | - Wan Yee Lau
- Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Keng-Hao Liu
- Division of General Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Cheng-Hsi Su
- Department of Surgery, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Takeyuki Misawa
- Department of Surgery, The Jikei University Kashiwa Hospital, Chiba, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Akihiko Horiguchi
- Department of Gastroenterological Surgery, Fujita Health University School of Medicine, Aichi, Japan
| | - Nobumi Tagaya
- Department of Surgery, Dokkyo Medical University Koshigaya Hospital, Saitma, Japan
| | - Shuichi Fujioka
- Department of Surgery, The Jikei University Kashiwa Hospital, Chiba, Japan
| | - Ryota Higuchi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | | | - Yoshinori Noguchi
- Department of General Internal Medicine, Japanese Red Cross Nagoya Daini Hospital, Aichi, Japan
| | - Tomohiko Ukai
- Department of Family Medicine, Mie Prefectural Ichishi Hospital, Mie, Japan
| | - Masamichi Yokoe
- Department of General Internal Medicine, Japanese Red Cross Nagoya Daini Hospital, Aichi, Japan
| | - Daniel Cherqui
- Hepatobiliary Center, Paul Brousse Hospital, Villejuif, France
| | - Goro Honda
- Department of Surgery, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
| | - Atsushi Sugioka
- Department of Surgery, Fujita Health University School of Medicine, Aichi, Japan
| | - Eduardo de Santibañes
- Department of Surgery, Hospital Italiano, University of Buenos Aires, Buenos Aires, Argentina
| | - Avinash Nivritti Supe
- Department of Surgical Gastroenterology, Seth G S Medical College and K E M Hospital, Mumbai, India
| | | | - Taizo Kimura
- Department of Surgery, Fujinomiya City General Hospital, Shizuoka, Japan
| | - Masahiro Yoshida
- Department of Hemodialysis and Surgery, Ichikawa Hospital, International University of Health and Welfare, Chiba, Japan.,Department of EBM and Guidelines, Japan Council for Quality Health Care, Tokyo, Japan
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine University of Occupational and Environmental Health, Fukuoka, Japan
| | | | - Masafumi Inomata
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Koichi Hirata
- Department of Surgery, JR Sapporo Hospital, Hokkaido, Japan
| | | | - Kazuo Inui
- Department of Gastroenterology, Second Teaching Hospital, Fujita Health University, Aichi, Japan
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Bailin N, Nan C, Peizhi L, Kun H, Xiwen Z, Guosheng R, Jianping G, Wenfeng Z. Changes of Foxo3a in PBMCs and its associations with stress hyperglycemia in acute obstructive suppurative cholangitis patients. Oncotarget 2017; 8:76783-76796. [PMID: 29100348 PMCID: PMC5652742 DOI: 10.18632/oncotarget.20011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 06/29/2017] [Indexed: 12/13/2022] Open
Abstract
Objective The levels of Foxo3a in the peripheral blood mononuclears cells (PBMCs) before and after treatment were detected in acute obstructive suppurative cholangitis (AOSC) patients to evaluate the associations between Foxo3a and stress hyperglycemia (SHG). Methods PBMCs were obtained from AOSC patients (n=28) on admission (AP), from patients at 1 week after cure (RP) and from healthy volunteers (HV) (n=14) to evaluate the relationship between the protein levels of Foxo3a and the serum levels of glucose. Signaling pathways, which link inflammation and glycometabolism, simultaneously affecting the expression of Foxo3a, were detected. In addition, cytokines were detected in PBMCs and AOSC mouse models, which were pre-treated with Foxo3a agonist. Results The levels of glucose and p-Foxo3a in the AP were significantly higher than those in the RP and HV, where as the levels of Foxo3a in the AP were lower than those in the RP and HV. Foxo3a levels in the AP normalized against RP were strongly negatively correlated with the glucose levels in the AP normalized against RP. The levels of sphingosine-1-phosphate receptor 2 (S1PR2) in the AP were higher than those in the RP and HV. In addition, inhibition of Foxo3a phosphorylation, coupled with the down-regulation of S1PR2, attenuated the LPS-induced inflammatory response in the PBMCs and AOSC mouse models. Conclusions Foxo3a is correlated with the dysregulation of glucose homeostasis in the pathogenesis of AOSC-induced sepsis by inhibiting the activation of PI3K/Akt-S1PR2 and NF-κB pathways, hinting at a switched role and therapeutic potentialities in the early stage of sepsis.
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Affiliation(s)
- Niu Bailin
- Department of Emergency and Department of Intensive Care Unit, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400010, P.R. China
| | - Chen Nan
- Chongqing Key Laboratory of Hepatobiliary Surgery and Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, P.R. China.,Department of Anesthesia, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, P.R. China
| | - Li Peizhi
- Chongqing Key Laboratory of Hepatobiliary Surgery and Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, P.R. China
| | - He Kun
- Chongqing Key Laboratory of Hepatobiliary Surgery and Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, P.R. China
| | - Zhu Xiwen
- Chongqing Key Laboratory of Hepatobiliary Surgery and Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, P.R. China
| | - Ren Guosheng
- Department of Endocrine and Breast Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400010, P.R. China
| | - Gong Jianping
- Chongqing Key Laboratory of Hepatobiliary Surgery and Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, P.R. China
| | - Zhang Wenfeng
- Chongqing Key Laboratory of Hepatobiliary Surgery and Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, P.R. China
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La Greca G, Pesce A, Vitale M, Mannino M, Di Marco F, Di Blasi M, Lombardo R, Puleo S, Russello D, Latteri S. Efficacy of the Laparoendoscopic "Rendezvous" to Treat Cholecystocholedocholithiasis in 210 Consecutive Patients: A Single Center Experience. Surg Laparosc Endosc Percutan Tech 2017; 27:e48-e52. [PMID: 28614175 DOI: 10.1097/sle.0000000000000434] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The simultaneous laparoendoscopic "rendezvous" (LERV) represents an alternative to sequential or totally laparoscopic approaches for patients affected by cholecystocholedocholithiasis. The aim of this study was to analyze the results in a large series of 210 consecutive patients. MATERIALS AND METHODS From 2002 to 2016 all patients affected by cholecystocholedocholithiasis were treated with a standardized "tailored" LERV. The relevant technical features of the procedure were recorded. An analysis of feasibility, effectiveness in stone clearance, and safety was performed. RESULTS Among 214 patients with common bile duct stones, 210 were treated with LERV and 4 with open rendezvous approach. Intraoperative cholangiography confirmed common bile duct stones in 179 patients (85.2%) or sludge in 18 (8.5%) and in 98.9% stone clearance was obtained endoscopically. Endoscopic papilla cannulation was feasible in 161 patients (76.7%), whereas in 49 (23.3%) a transcystic guidewire was needed. The overall LERV feasibility was 96.6%. The conversion rate to open surgery was 3.3%. Minor morbidity was observed in 1.9% of cases, mortality in 0.47%, and the mean hospital stay was 4.3 days. CONCLUSIONS These results confirm the high effectiveness of LERV. This approach to treat cholecystocholedocholithiasis should be preferred and therefore implemented where a strong collaboration between surgeons and endoscopists is possible.
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Affiliation(s)
- Gaetano La Greca
- *Department of Medical, Surgical Sciences and Advanced Technologies "G.F. Ingrassia," University of Catania †Endoscopic Unit, Cannizzaro Hospital, Catania, Italy
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25
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Intraoperative ERCP for management of cholecystocholedocholithiasis. Surg Endosc 2016; 31:809-816. [PMID: 27334962 DOI: 10.1007/s00464-016-5036-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 06/11/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND The introduction of minimally invasive techniques in management of biliary problems added new procedures for treating patients with cholecystocholedocholithiasis (CCL). This study presents the results of intraoperative ERCP (IOERCP) during LC as a single-session minimally invasive procedure for management of patients who have preoperatively diagnosed CBD stones. METHODS The database of patients presented to our center by CCL between October 2007 and December 2015 who were treated by LC and IOERCP was collected and analyzed. CBD stones were diagnosed using clinical data, laboratory tests and abdominal sonogram. MRCP was requested for doubtful cases. In the first cases ERCP was done using rendezvous technique, but in late cases standard ERCP immediately after completion of LC under the same anesthesia was used. Preoperative, intraoperative and postoperative data were recorded, analyzed and reported. Data reported include success/failure rate, complications, conversion to open surgery, operative details and incidence of residual CBD stones. RESULTS The study was conducted on 346 patients who had CCL. The mean age was 34.7 years, and 298 of them were females. The most common presentation was abdominal pain (98.5 %) and jaundice (64.9 %). Fifteen patients were excluded, and IOERCP was not done due to negative IOC results in 10 patients and conversion to open surgery in 5 patients. IOERCP was tried in the remaining 331 patients. The mean operative time was 55 min, and the mean hospital stay was 2.4 days. Major complications had been reported in 13/323 patients (4.0 %). Failure of CBD clearance was reported in 8 patients (2.4 %) with a success rate of 97.6 %. Thirty-day follow-up was possible in 142 patients, and there was a residual CBD stone in one patient and wound infection in another one. CONCLUSIONS IOERCP during LC is a safe and effective option for management of CCL.
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Gupta N. Role of laparoscopic common bile duct exploration in the management of choledocholithiasis. World J Gastrointest Surg 2016; 8:376-381. [PMID: 27231516 PMCID: PMC4872066 DOI: 10.4240/wjgs.v8.i5.376] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2015] [Revised: 12/30/2015] [Accepted: 02/24/2016] [Indexed: 02/06/2023] Open
Abstract
Surgical fraternity has not yet arrived at any consensus for adequate treatment of choledocholithiasis. Sequential treatment in the form of pre-operative endoscopic retrograde cholangio-pancreatography followed by laparoscopic cholecystectomy (LC) is considered as optimal treatment till date. With refinements in technique and expertise in field of minimal access surgery, many centres in the world have started offering one stage management of choledocholithiasis by LC with laparoscopic common bile duct exploration (LCBDE). Various modalities have been tried for entering into concurrent common bile duct (CBD) [transcystic (TC) vs transcholedochal (TD)], for confirming stone clearance (intraoperative cholangiogram vs choledochoscopy), and for closure of choledochotomy (T-tube vs biliary stent vs primary closure) during LCBDE. Both TC and TD approaches are safe and effective. TD stone extraction is involved with an increased risk of bile leaks and requires more expertise in intra-corporeal suturing and choledochoscopy. Choice depends on number of stones, size of stone, diameter of cystic duct and CBD. This review article was undertaken to evaluate the role of LCBDE for the management of choledocholithiasis.
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Ge N, Sun S, Sun S, Wang S, Liu X, Wang G. Endoscopic ultrasound-assisted transmural cholecystoduodenostomy or cholecystogastrostomy as a bridge for per-oral cholecystoscopy therapy using double-flanged fully covered metal stent. BMC Gastroenterol 2016; 16:9. [PMID: 26782105 PMCID: PMC4717638 DOI: 10.1186/s12876-016-0420-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2015] [Accepted: 01/08/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Laparoscopic cholecystectomy (LC) has become the 'gold standard' for the treatment of symptomatic gallstones. Innovative methods are being introduced, and these procedures include transgastric or transcolonic endoscopic cholecystectomy. However, before clinical implementation, instruments still need modification, and a more convenient treatment is still needed. Moreover, some gallbladders still have good functionality and cholecystectomy may be associated with various complications. The aim of this study was to evaluate the trans-gastrointestinal tract cholecystoscopy technique in the treatment of gallbladder disease without cholecystectomy. METHOD Endoscopic ultrasound (EUS)-guided cholecystoduodenostomy or cholecystogastrostomy with the placement of a double-flanged fully covered metal stent was performed and endoscopic sphincterotomy (EST) was also performed during this procedure for those patients with accompanying common bile duct stones. One or two weeks later the stent was removed and an endoscope was advanced into the gallbladder via the fistula, and cholecystolithotomy or polyp resection was performed. Four weeks later gallbladder was assessed by abdominal ultrasound. RESULTS EUS guided cholecystoduodenostomy (n = 3) or cholecystogastrostomy (n = 4) with double flanged mental stent deployment was successfully performed in all of 7 patients. After the procedure, fistulas had formed in each of the patients and the stents were removed. Endoscopic cholecystolithotomy(7) and polyps resection(2) were successfully performed through the fistulas. Common bile duct stones were also successfully removed in 5 patients. The ultrasound examination of the gallbladder 4 weeks later showed no stones remaining and also showed satisfactory functioning of the gallbladder. CONCLUSION The EUS-guided placement of a novel metal stent is a safe and simple approach for performing an endoscopic cholecystoduodenostomy or cholecystogastrostomy, which can subsequently allow procedures to be performed for treating biliary disease, including cholecystolithotomy.
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Affiliation(s)
- Nan Ge
- Endoscopy Center, Shengjing Hospital of China Medical University, No. 36, Sanhao Street, Shenyang, Liaoning Province, 110004, China
| | - Siyu Sun
- Endoscopy Center, Shengjing Hospital of China Medical University, No. 36, Sanhao Street, Shenyang, Liaoning Province, 110004, China.
| | - Shiwei Sun
- Anesthesia Department, Shengjing Hospital of China Medical University, No. 36, Sanhao Street, Shenyang, Liaoning Province, 110004, China
| | - Sheng Wang
- Endoscopy Center, Shengjing Hospital of China Medical University, No. 36, Sanhao Street, Shenyang, Liaoning Province, 110004, China
| | - Xiang Liu
- Endoscopy Center, Shengjing Hospital of China Medical University, No. 36, Sanhao Street, Shenyang, Liaoning Province, 110004, China
| | - Guoxin Wang
- Endoscopy Center, Shengjing Hospital of China Medical University, No. 36, Sanhao Street, Shenyang, Liaoning Province, 110004, China
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Aawsaj Y, Light D, Horgan L. Laparoscopic common bile duct exploration: 15-year experience in a district general hospital. Surg Endosc 2015; 30:2563-6. [PMID: 26307600 DOI: 10.1007/s00464-015-4523-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 08/17/2015] [Indexed: 12/15/2022]
Abstract
INTRODUCTION The treatment of common bile duct (CBD) stones remains controversial with debate between endoscopic cholangiopancreatography (ERCP) and CBD exploration. A recent meta-analysis has shown no significant difference between these approaches; however, there is a trend in the literature to favour a single-stage procedure in the form of laparoscopic CBD exploration. We report our experience over a 15-year period. METHODS All cases of CBD exploration were identified from 2000 to 2015 and analysed retrospectively from a large NHS Foundation Trust in Northumbria. There were no exclusions. The mean clinical follow-up was 6 months (range 3-36 months). RESULTS A total of 296 patients were included who underwent laparoscopic CBD exploration: 203 were female and 93 were male. The mean age was 60 years (range 16-84 years). A total of 231 procedures were performed electively and 65 as an emergency. Ten procedures were successfully performed as day cases. Eleven procedures were converted to an open procedure due to adhesions or a difficult dissection (4 %). Sixty-three procedures were performed with a transcystic approach with a mean post-op stay of 2 days (range 0-7). A total of 233 procedures were performed with a choledocotomy with a mean post-op stay of 6 days (range 3-14 days). Stone clearance was successful in 255 patients (86 %). Three patients died over the study period. Two were for medical complications and one for abdominal sepsis. Three patients returned to theatre for early post-operative bleeding (1 %). Sixteen patients had persistent bile leaks following a choledocotomy (6.8 %). No patients had a bile leak following transcystic exploration. Fourteen patients were followed up following failed stone removal. Nine had a successful ERCP, three had no stone seen on MRCP, and one patient required re-operation following a failed ERCP. CONCLUSIONS Laparoscopic bile duct exploration can be performed successfully in both the emergency and elective settings. Day-case surgery is feasible in selected patients. A transcystic approach should be favoured where possible.
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Affiliation(s)
- Yousif Aawsaj
- Northumbria NHS Trust, Rake Lane, North Shields, NE29 8NH, UK
| | - Duncan Light
- Northumbria NHS Trust, Rake Lane, North Shields, NE29 8NH, UK.
| | - Liam Horgan
- Northumbria NHS Trust, Rake Lane, North Shields, NE29 8NH, UK
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