1
|
Utilization of Laparoscopic Choledochoscopy During Bile Duct Exploration and Evaluation of the Wiper Blade Maneuver for Transcystic Intrahepatic Access. Ann Surg 2023; 277:e376-e383. [PMID: 33856382 PMCID: PMC9831050 DOI: 10.1097/sla.0000000000004912] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE This study aims to examine the indications, techniques, and outcomes of choledochoscopy during laparoscopic bile duct exploration and evaluate the results of the wiper blade maneuver (WBM) for transcystic intrahepatic choledochoscopy. SUMMARY OF BACKGROUND DATA Choledochoscopy has traditionally been integral to bile duct explorations. However, laparoscopic era studies have reported wide variations in choledochoscopy availability and use, particularly with the increasing role of transcystic exploration. METHODS The indications, techniques, and operative and postoperative data on choledochoscopy collected prospectively during transcystic and choledo- chotomy explorations were analyzed. The success rates of the WBM were evaluated for the 3 mm and 5 mm choledochoscopes. RESULTS Of 935 choledochoscopies, 4 were performed during laparoscopic cholecystectomies and 931 during 1320 bile duct explorations (70.5%); 486 transcystic choledochoscopies (52%) and 445 through choledochotomies (48%). Transcystic choledochoscopy was utilized more often than blind exploration (55.7%% vs 44.3%) in patients with emergency admissions, jaundice, dilated bile ducts on preoperative imaging, wide cystic ducts, and large, numerous or impacted bile duct stones. Intrahepatic choledochoscopy was successful in 70% using the 3 mm scope and 81% with the 5 mm scope. Choledochoscopy was necessary in all 124 explorations for impacted stones. Twenty retained stones (2.1%) were encountered but no choledochoscopy related complications. CONCLUSIONS Choledochoscopy should always be performed during a chol- edochotomy, particularly with multiple and intrahepatic stones, reducing the incidence of retained stones. Transcystic choledochoscopy was utilized in over 50% of explorations, increasing their rate of success. When attempted, the transcystic WBM achieves intrahepatic access in 70%-80%. It should be part of the training curriculum.
Collapse
|
2
|
Welsh S, Nassar AHM, Sallam M. The incidence, operative difficulty and outcomes of staged versus index admission laparoscopic cholecystectomy and bile duct exploration for all comers: a review of 5750 patients. Surg Endosc 2022; 36:8221-8230. [PMID: 35507063 PMCID: PMC9613731 DOI: 10.1007/s00464-022-09272-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 04/09/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND The timing of laparoscopic cholecystectomy (LC) for emergency biliary admissions remains inconsistent with national and international guidelines. The perception that LC is difficult in acute cholecystitis and the popularity of the two-session approach to pancreatitis and suspected choledocholithiasis result in delayed management. METHODS Analysis of prospectively maintained data in a unit adopting a policy of "intention to treat" during the index admission. The aim was to study the incidence of previous biliary admissions and compare the operative difficulty, complications and postoperative outcomes with patients who underwent index admission LC. RESULTS Of the 5750 LC performed, 20.8% had previous biliary episodes resulting in one admission in 93% and two or more in 7%. Most presented with biliary colic (39.6%) and acute cholecystitis (27.6%). A previous biliary history was associated with increased operative difficulty (p < 0.001), longer operating times (86.9 vs. 68.1 min, p < 0.001), more postoperative complications (7.8% vs. 5.4%, p = 0.002) and longer hospital stay (8.1 vs. 5.5 days, p < 0.001) and presentation to resolution intervals. However, conversion and mortality rates showed no significant differences. CONCLUSION Index admission LC is superior to interval cholecystectomy and should be offered to all patients fit for general anaesthesia regardless of the presenting complaints. Subspecialisation should be encouraged as a major factor in optimising resource utilisation and postoperative outcomes of biliary emergencies.
Collapse
Affiliation(s)
- Silje Welsh
- Laparoscopic Biliary Service, University Hospital Monklands, Monkscourt Avenue, Airdrie, Lanarkshire, ML6 0JS, Scotland, UK
| | - Ahmad H M Nassar
- Laparoscopic Biliary Service, University Hospital Monklands, Monkscourt Avenue, Airdrie, Lanarkshire, ML6 0JS, Scotland, UK.
| | - Mahmoud Sallam
- Laparoscopic Biliary Service, University Hospital Monklands, Monkscourt Avenue, Airdrie, Lanarkshire, ML6 0JS, Scotland, UK
| |
Collapse
|
3
|
Ng HJ, Nassar AHM. Reinterventions following laparoscopic cholecystectomy and bile duct exploration. A review of prospective data from 5740 patients. Surg Endosc 2021; 36:2809-2817. [PMID: 34076762 PMCID: PMC9001563 DOI: 10.1007/s00464-021-08568-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 05/18/2021] [Indexed: 01/24/2023]
Abstract
Background Complications following laparoscopic cholecystectomy (LC) and common bile duct exploration (CBDE) for the management of gallstones or choledocholithiasis impact negatively on patients’ quality of life and may lead to reinterventions. This study aims to evaluate the causes and types of reintervention following index admission LC with or without CBDE. Methods A prospectively maintained database of LC and CBDE performed by a single surgeon was analysed. Preoperative factors, difficulty grading and perioperative complications requiring reintervention and readmissions were examined. Results Reinterventions were required in 112 of 5740 patients (2.0%), 89 (1.6%) being subsequent to complications. The reintervention cohort had a median age of 64 years, were more likely to be females (p < 0.0023) and to be emergency admissions (67.9%, p < 0.00001) with obstructive jaundice (35.7%, p < 0.00001). 46.4% of the reintervention cohort had a LC operative difficulty grade IV or V and 65.2% underwent a CBDE. Open conversion was predictive of the potential for reintervention (p < 0.00001). The most common single cause of reintervention was retained stones (0.5%) requiring ERCP followed by bile leakage (0.3%) requiring percutaneous drainage, ERCP and relaparoscopy. Relaparoscopy was necessary in 17 patients and open surgery in 13, 6 of whom not resulting from complications. There were 5 deaths. Conclusion This large series had a low incidence of reinterventions resulting from complications in spite of a high workload of index admission surgery for biliary emergencies and bile duct stones. Surgical or endoscopic reinterventions following LC alone occurred in only 0.8%. The most common form of reintervention was ERCP for retained CBD stones. This important outcome parameter of laparoscopic biliary surgery can be optimised through early diagnosis and timely reintervention for complications.
Collapse
Affiliation(s)
- Hwei Jene Ng
- Laparoscopic Biliary Surgery Service, University Hospital Monklands, Airdrie, Scotland, UK
| | | |
Collapse
|
4
|
Nassar AHM, Zanati HE, Ng HJ, Khan KS, Wood C. Open conversion in laparoscopic cholecystectomy and bile duct exploration: subspecialisation safely reduces the conversion rates. Surg Endosc 2021; 36:550-558. [PMID: 33528666 PMCID: PMC8741693 DOI: 10.1007/s00464-021-08316-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 01/09/2021] [Indexed: 02/02/2023]
Abstract
Background Open conversion rates during laparoscopic cholecystectomy vary depending on many factors. Surgeon experience and operative difficulty influence the decision to convert on the grounds of patient safety but occasionally due to technical factors. We aim to evaluate the difficulties leading to conversion, the strategies used to minimise this event and how subspecialisation influenced conversion rates over time. Methods Prospectively collected data from 5738 laparoscopic cholecystectomies performed by a single surgeon over 28 years was analysed. Routine intraoperative cholangiography and common bile duct exploration when indicated are utilised. Patients undergoing conversion, fundus first dissection or subtotal cholecystectomy were identified and the causes and outcomes compared to those in the literature. Results 28 patients underwent conversion to open cholecystectomy (0.49%). Morbidity was relatively high (33%). 16 of the 28 patients (57%) had undergone bile duct exploration. The most common causes of conversion in our series were dense adhesions (9/28, 32%) and impacted bile duct stones (7/28, 25%). 173 patients underwent fundus first cholecystectomy (FFC) (3%) and 6 subtotal cholecystectomy (0.1%). Morbidity was 17.3% for the FFC and no complications were encountered in the subtotal cholecystectomy patients. These salvage techniques have reduced our conversion rate from a potential 3.5% to 0.49%. Conclusion Although open conversion should not be seen as a failure, it carries a high morbidity and should only be performed when other strategies have failed. Subspecialisation and a high emergency case volume together with FFC and subtotal cholecystectomy as salvage strategies can reduce conversion and its morbidity in difficult cholecystectomies.
Collapse
Affiliation(s)
- Ahmad H M Nassar
- Department of Surgery, University Hospital Monklands, Airdrie, Lanarkshire, UK. .,Laparoscopic Biliary Service, University Hospital Monklands, Monkscourt Avenue, Airdrie, Lanarkshire, Scotland, ML6 0JS, UK.
| | - Hisham El Zanati
- Department of Surgery, University Hospital Hairmyres, East Kilbride, Lanarkshire, UK.,Laparoscopic Biliary Service, University Hospital Monklands, Monkscourt Avenue, Airdrie, Lanarkshire, Scotland, ML6 0JS, UK
| | - Hwei J Ng
- Department of Surgery, NHS Greater Glasgow and Clyde, Glasgow, UK.,Laparoscopic Biliary Service, University Hospital Monklands, Monkscourt Avenue, Airdrie, Lanarkshire, Scotland, ML6 0JS, UK
| | - Khurram S Khan
- Department of Surgery, NHS Greater Glasgow and Clyde, Glasgow, UK.,Laparoscopic Biliary Service, University Hospital Monklands, Monkscourt Avenue, Airdrie, Lanarkshire, Scotland, ML6 0JS, UK
| | - Colin Wood
- Department of Surgery, NHS Greater Glasgow and Clyde, Glasgow, UK.,Laparoscopic Biliary Service, University Hospital Monklands, Monkscourt Avenue, Airdrie, Lanarkshire, Scotland, ML6 0JS, UK
| |
Collapse
|
5
|
Khan KS, Sajid MA, McMahon RK, Mahmud S, Nassar AHM. Hartmann's Pouch Stones and Laparoscopic Cholecystectomy: The Challenges and the Solutions. JSLS 2021; 24:JSLS.2020.00043. [PMID: 32831544 PMCID: PMC7434399 DOI: 10.4293/jsls.2020.00043] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background & Objective: Hartmann's pouch stones (HPS) encountered during laparoscopic cholecystectomy (LC) may hinder safe dissection of the cystic pedicle or be complicated by mucocele, empyema, or Mirizzi syndrome; distorting the anatomy and increasing the risk of bile duct injury. We studied the incidence, presentations, operative challenges, and outcomes of HPS. Methods: A cohort study of a prospectively maintained database of LCs and bile duct explorations performed by a single surgeon. Patients were divided into two groups: those with HPS and those without. Patients' demographics, clinical presentation, intra-operative findings, and postoperative outcomes were compared. Results: Of the 5136 patients, 612 (11.9%) had HPS. The HPS group were more likely to present with acute cholecystitis (27.9% vs 5.9%, P = .000) and more patients underwent emergency LC (50.7% vs 41.5%, P = .000). The HPS group had more difficult cholecystectomies, with 46.1% vs 11.8% in the non-HPS group being operative difficulty grade 4 and 5. Mucocele, empyema, and Mirizzi syndrome were more common in the HPS group (24.0% vs 3.7% P = .000, 30.9% vs 3.7% P = .000, 1.8% vs 0.9% P = .000, respectively). There was no significant difference in the open conversion rate or complications. Conclusion: HPS increase the difficulty of LC. Surgeons should be aware of their presence and should employ appropriate dissection strategies. Sharp or diathermy dissection should be avoided. Dislodging the stone into the gall bladder, stone removal, swab dissection, and cholangiography are useful measures to avoid ductal injury and reduce the conversion rate.
Collapse
Affiliation(s)
| | | | | | - Sajid Mahmud
- Department of General Surgery, University Hospital Hairmyres
| | | |
Collapse
|
6
|
Nassar AHM, Ng HJ, Ahmed Z, Wysocki AP, Wood C, Abdellatif A. Optimising the outcomes of index admission laparoscopic cholecystectomy and bile duct exploration for biliary emergencies: a service model. Surg Endosc 2020; 35:4192-4199. [PMID: 32860135 PMCID: PMC8263394 DOI: 10.1007/s00464-020-07900-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 08/17/2020] [Indexed: 01/12/2023]
Abstract
Aims The rate of acute laparoscopic cholecystectomy remains low due to operational constraints. The purpose of this study is to evaluate a service model of index admission cholecystectomy with referral protocols, refined logistics and targeted job planning. Methods A prospectively maintained dataset was evaluated to determine the processes of care and outcomes of patients undergoing emergency biliary surgery. The lead author has maintained a 28 years prospective database capturing standard demographic data, intraoperative details including the difficulty of cholecystectomy as well as postoperative outcome parameters and follow up data. Results Over five thousand (5555) consecutive laparoscopic cholecystectomies were performed. Only patients undergoing emergency procedures (2399,43.2% of entire group) were analysed for this study. The median age was 52 years with 70% being female. The majority were admitted with biliary pain (34%), obstructive jaundice (26%) and acute cholecystitis (16%). 63% were referred by other surgeons. 80% underwent surgery within 5 days (40% within 24 h). Cholecystectomies were performed on scheduled lists (44%) or dedicated emergency lists (29%). Two thirds had suspected bile duct stones and 38.1% underwent bile duct exploration. The median operating time was 75 min, median hospital stay 7 days, conversion rate 0.8%, morbidity 8.9% and mortality rate 0.2%. Conclusion Index admission cholecystectomy for biliary emergencies can have low rates of morbidity and mortality. Timely referral and flexible theatre lists facilitate the service, optimising clinical results, number of biliary episodes, hospital stay and presentation to resolution intervals. Cost benefits and reduced interval readmissions need to be weighed against the length of hospital stay per episode.
Collapse
Affiliation(s)
- Ahmad H M Nassar
- Laparoscopic Biliary Service, University Hospital Monklands, Airdrie, Scotland, UK.
| | - Hwei J Ng
- NHS Greater Glasgow and Clyde, Glasgow, UK
| | | | | | - Colin Wood
- NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Ayman Abdellatif
- Laparoscopic Biliary Service, University Hospital Monklands, Airdrie, Scotland, UK
| |
Collapse
|
7
|
Jabbar SAA, Ahmed Z, Mirza A, Nassar AHM. Laparoscopic Training Opportunities in an Emergency Biliary Service. JSLS 2019; 23:JSLS.2019.00031. [PMID: 31488943 PMCID: PMC6708413 DOI: 10.4293/jsls.2019.00031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background and Objectives: Optimizing single-session management of biliary emergencies whilst maximizing laparoscopic training opportunities is challenging. We analyzed training opportunities available in an emergency biliary department and its impact on service provision and patient outcomes. Methods: A single surgeon's practice of 2049 emergency laparoscopic cholecystectomies and common bile duct explorations was prospectively analyzed. Training involved a modular stepwise approach incorporating access, gallbladder bed dissection, pedicle dissection, intra- corporeal tying, and cholangiogram ± common bile duct exploration. Training cases were identified, trainee involvement ascertained, and parameters predictive of a training case were established. Results: Thirty percent of laparoscopic cholecystectomies were performed in part or completely by trainees, with a training component in 30% of bile duct explorations. Trainee involvement increased mean operating time by approximately 10 minutes. There was no difference in minor (5% vs 5%, P = .8) or major complications (1% vs 0.9%, P = .7) on trainee versus consultant cases. Postoperative hospital stay was greater in consultant cases (2.87 vs 4.44 days, P = .0025). Multivariate analysis identified predictors of trainee cases including lower age (OR, 1.3; 95% CI, 1.1-1.7), female sex (OR, 1.6; 95% CI, 1.3-2), normal-weight subjects (OR, 1.54; 95% CI, 1.3-1.9), lower difficulty grade (1-2) (OR, 1.8; 95% CI, 1.4-2.2), and American Society of Anesthesiologists score ≤ 2 (OR, 1.8; 95% CI, 1.4-2.4). Conclusions: Surgical training is possible in a singlesession biliary emergency service without significantly impacting theatre utilization times or early patient outcomes. Further dedicated studies will allow individual learning curves to be determined.
Collapse
Affiliation(s)
- Salman A A Jabbar
- Department of General Surgery, University Hospital Monklands, Airdrie, Lanarkshire, United Kingdom
| | - Zubir Ahmed
- Department of General Surgery, University Hospital Monklands, Airdrie, Lanarkshire, United Kingdom
| | - Ahmad Mirza
- Department of General Surgery, University Hospital Monklands, Airdrie, Lanarkshire, United Kingdom
| | - Ahmad H M Nassar
- Department of General Surgery, University Hospital Monklands, Airdrie, Lanarkshire, United Kingdom
| |
Collapse
|
8
|
Abstract
BACKGROUND When common bile duct (CBD) stones are detected during laparoscopic cholecystectomy, the insertion of baskets via the cystic duct (CD) can be difficult and may occasionally cause complications. We introduced a new technique 'basket in catheter' (BIC) for transcystic CBD exploration. METHODS Although cannulating the CD using a cholangiography catheter is successful in most cases, it may occasionally be difficult. Cystic duct anatomy may prevent the usually stiffer sharper tip of the basket, from entering the CBD, resulting in failure, perforation or a false passage. In the majority of our cases, the cholangiography catheter (CC) is not withdrawn from the duct should the intraoperative cholangiography show CBD stones. The tip of a basket is inserted into the CC and advanced to a predetermined distance, allowing the tip of the basket to exit the end of the CC into the CBD. The basket is then opened, advanced to feel the lower end and manipulated to trap the stone. The common hepatic duct is compressed gently to prevent stones from slipping upwards. The catheter and basket are pulled back together to extract the stone. RESULTS We have used this technique in 274 cases since 2010. The rate of transcystic versus choledochotomy stone extraction has increased, saving unnecessary choledochotomies. The percentage of transcystic exploration increased from 55 % for the period 2005-2009 to 70 % for the period 2010-2014. There were no conversions to open surgery and no retained stones. The morbidity rate was 4.0 % with no mortality. CONCLUSIONS We demonstrate a technique to facilitate the insertion of extraction baskets into the common bile duct using the cholangiography catheter as a guide. The 'basket-in-catheter' (BIC) technique for transcystic CBD exploration is easier and safer than inserting the basket alone.
Collapse
|
9
|
Nassar AHM, Mirza A, Qandeel H, Ahmed Z, Zino S. Fluorocholangiography: reincarnation in the laparoscopic era—evaluation of intra-operative cholangiography in 3635 laparoscopic cholecystectomies. Surg Endosc 2015; 30:1804-11. [DOI: 10.1007/s00464-015-4449-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 07/13/2015] [Indexed: 12/16/2022]
|
10
|
Alvarez FA, de Santibañes M, Palavecino M, Sánchez Clariá R, Mazza O, Arbues G, de Santibañes E, Pekolj J. Impact of routine intraoperative cholangiography during laparoscopic cholecystectomy on bile duct injury. Br J Surg 2014; 101:677-84. [PMID: 24664658 DOI: 10.1002/bjs.9486] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND The role of intraoperative cholangiography (IOC) in the diagnosis, prevention and management of bile duct injury (BDI) remains controversial. The aim of the present study was to determine the value of routine IOC in the diagnosis and management of BDI sustained during laparoscopic cholecystectomy (LC) at a high-volume centre. METHODS A retrospective analysis of a single-institution database was performed. Patients who underwent LC with routine IOC between October 1991 and May 2012 were included. RESULTS Among 11,423 consecutive LCs IOC was performed successfully in 95.7 per cent of patients. No patient had IOC-related complications. Twenty patients (0.17 per cent) sustained a BDI during LC, and the diagnosis was made during surgery in 18 patients. Most BDIs were type D according to the Strasberg classification. The sensitivity of IOC for the detection of BDI was 79 per cent; specificity was 100 per cent. All injuries diagnosed during surgery were repaired during the same surgical procedure. Two patients developed early biliary strictures that were treated by percutaneous dilatation and a Roux-en-Y hepaticojejunostomy with satisfactory long-term results. CONCLUSION The routine use of IOC during LC in a high-volume teaching centre was associated with a low incidence of BDI, and facilitated detection and repair during the same surgical procedure with a good outcome.
Collapse
Affiliation(s)
- F A Alvarez
- Hepato-Pancreato-Biliary Surgery Section and Liver Transplant Unit, General Surgery Service, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1181ACH, Buenos Aires, Argentina
| | | | | | | | | | | | | | | |
Collapse
|
11
|
Epelboym I, Winner M, Allendorf JD. MRCP is not a cost-effective strategy in the management of silent common bile duct stones. J Gastrointest Surg 2013; 17:863-71. [PMID: 23515912 DOI: 10.1007/s11605-013-2179-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Accepted: 03/01/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND Few formal cost-effectiveness analyses simultaneously evaluate radiographic, endoscopic, and surgical approaches to the management of choledocholithiasis. STUDY DESIGN Using the decision analytic software TreeAge, we modeled the initial clinical management of a patient presenting with symptomatic cholelithiasis without overt signs of choledocholithiasis. In this base case, we assumed a 10 % probability of concurrent asymptomatic choledocholithiasis. Our model evaluated four diagnostic/therapeutic strategies: universal magnetic resonance cholangiopancreatography (MRCP), universal endoscopic retrograde cholangiopancreatography (ERCP), laparoscopic cholecystectomy (LC), or laparoscopic cholecystectomy with universal intraoperative cholangiogram (LCIOC). All probabilities were estimated from a review of published literature. Procedure and intervention costs were equated with Medicare reimbursements. Costs of hospitalizations were derived from median hospitalization reimbursement for New York State using diagnosis-related groups (DRG). Sensitivity analyses were performed on all cost and probability variables. RESULTS The most cost-effective strategy in the diagnosis and management of symptomatic cholelithiasis with a 10 % risk of asymptomatic choledocholithiasis was LCIOC. This was followed by LC alone, MRCP, and ERCP. LC was preferred only when the probability that a retained CBD stone would eventually become symptomatic fell below 15 % or if the probability of technical success of an intraoperative cholangiogram (IOC) was less than 35 %. Universal MRCP and ERCP were both more costly and less effective than surgical strategies, even at a high probability of asymptomatic choledocholithiasis. Within the tested range for both procedural and hospitalization-related costs for any of the surgical or endoscopic interventions, LCIOC and LC were always more cost-effective than universal MRCP or ERCP, irrespective of the presence or absence of complications. Varying the cost, sensitivity, and specificity of MRCP had no effect on this outcome. CONCLUSIONS LC with routine IOC is the preferred strategy in a cost-effectiveness analysis of the management of symptomatic cholelithiasis with asymptomatic choledocholithiasis. MRCP was both more costly and less effective under all tested scenarios.
Collapse
Affiliation(s)
- Irene Epelboym
- Department of Surgery, College of Physicians and Surgeons, Columbia University, New York, NY, USA.
| | | | | |
Collapse
|
12
|
Hope WW, Bools L, Hooks WB, Adams A, Kotwall CA, Clancy TV. Teaching cholangiography in a surgical residency program. JOURNAL OF SURGICAL EDUCATION 2013; 70:243-247. [PMID: 23427971 DOI: 10.1016/j.jsurg.2012.09.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Revised: 09/09/2012] [Accepted: 09/24/2012] [Indexed: 06/01/2023]
Abstract
OBJECTIVE To evaluate the time associated with routine cholangiography in a residency teaching program. DESIGN We retrospectively reviewed all patients undergoing laparoscopic cholecystectomy with intraoperative cholangiography by a single surgeon from April 2010 to September 2011. Cholangiogram time, demographic, and operative information was recorded, and factors associated with increased cholangiogram times were compared using Fisher's exact test, Kruskal-Wallis test, and linear regression; a p value <0.05 was considered significant. SETTING Academic-affiliated community-based surgical residency program. PARTICIPANTS 10 surgical residents, PGY 1-5. RESULTS Laparoscopic cholecystectomy with intraoperative cholangiography was performed in 54 patients. The average patient age was 43 years; 69% were Caucasian and 74% were female. Cholangiography was successful in 96% of patients. The average time for cholangiograms performed by residents was 11 minutes (range, 6-22 minutes) and average operating room time was 68 minutes (range, 32-103 minutes). The average percentage of case time for cholangiography was 17% (range, 9%-63%). Minor technical complications related to cholangiograms occurred in 33% of cases, with the most common being difficulty with clipping the catheter (20%). There was no significant difference in completion rate or cholangiogram time based on resident level of experience (p > 0.05). CONCLUSIONS Intraoperative cholangiogram can be safely performed by residents at every level during laparoscopic cholecystectomy without adding significant time to the operation.
Collapse
Affiliation(s)
- William W Hope
- Department of Surgery, South East Area Health Education Center, Department of Surgery, New Hanover Regional Medical Center, Wilmington, North Carolina, USA.
| | | | | | | | | | | |
Collapse
|
13
|
Major biliary complications in 2,714 cases of laparoscopic cholecystectomy without intraoperative cholangiography: a multicenter retrospective study. Surg Endosc 2011; 25:3747-51. [PMID: 21656070 DOI: 10.1007/s00464-011-1780-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2010] [Accepted: 05/16/2011] [Indexed: 12/15/2022]
Abstract
BACKGROUND The ongoing debate between routine and selective users of intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) has not yet come to an end. Routine users argue that IOC decreases the rate of biliary complications such as bile duct injury, biliary leak and missed common bile duct (CBD) stones, a claim that selective users do not fully support. On the other hand, a third policy that was adopted by many other centers is performing LC without IOC. In this retrospective study, we are exploring the results of a relatively large multicenter series of LC without IOC regarding major biliary complications. METHODS We performed a retrospective analysis of LC cases operated by experienced laparoscopic surgeons, without resorting to IOC, in four surgical units of university hospitals in Egypt during a 6-year period (January 2004 through December 2009). Excluded from the study were cases with positive predictors of CBD stones, namely, sonographically detected CBD dilatation and/or CBD stones, elevated bilirubin and/or alkaline phosphatase, persistent biliary pancreatitis, cholangitis, and those who had preoperative magnetic resonance cholangiography. RESULTS Of the 2,955 cases of LC reviewed, 241 were excluded, leaving 2,714 cases enrolled in the study. Fifty-five cases (2%) were converted to open surgery. Five cases (0.18%) had major bile duct injuries requiring surgical repair. Postoperative bile leakage was encountered in seven cases (0.26%). Missed CBD stones were reported in six cases (0.22%). There was no perioperative mortality in the present study. CONCLUSION LC can be performed safely without the use of IOC, with acceptable low rates of biliary complications provided that proper detection of patients with silent CBD stones is done and facilities for pre- and postoperative endoscopic retrograde cholangiopancreatography are available.
Collapse
|