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Mauro A, Mazza S, Scalvini D, Lusetti F, Bardone M, Quaretti P, Cobianchi L, Anderloni A. The Role of Cholangioscopy in Biliary Diseases. Diagnostics (Basel) 2023; 13:2933. [PMID: 37761300 PMCID: PMC10528268 DOI: 10.3390/diagnostics13182933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/01/2023] [Accepted: 08/10/2023] [Indexed: 09/29/2023] Open
Abstract
Endoscopy plays a central role in diagnostic and therapeutic approaches to biliary disease in both benign and malignant conditions. A cholangioscope is an endoscopic instrument that allows for the direct exploration of the biliary tree. Over the years, technology has improved endoscopic image quality and allowed for the development of an operative procedure that can be performed during cholangioscopy. Different types of instruments are available in this context, and they can be used in different anatomical access points according to the most appropriate clinical indication. The direct visualization of biliary mucosa is essential in the presence of biliary strictures of unknown significance, allowing for the appropriate allocation of patients to surgery or conservative treatments. Cholangioscopy has demonstrated excellent performance in discriminating malignant conditions (such as colangiocarcinoma) from benign inflammatory strictures, and more recent advances (e.g., artificial intelligence and confocal laser endomicroscopy) could further increase its diagnostic accuracy. Cholangioscopy also plays a primary role in the treatment of benign conditions such as difficult bile stones (DBSs). In this case, it may not be possible to achieve complete biliary drainage using standard ERCP. Therapeutic cholangioscopy-guided lithotripsy allows for stone fragmentation and complete biliary drainage. Indeed, other complex clinical situations, such as patients with intra-hepatic lithiasis and patients with an altered anatomy, could benefit from the therapeutic role of cholangioscopy. The aim of the present review is to explore the most recent diagnostic and therapeutic advances in the roles of cholangioscopy in the management of biliary diseases.
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Affiliation(s)
- Aurelio Mauro
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy (A.A.)
| | - Stefano Mazza
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy (A.A.)
| | - Davide Scalvini
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy (A.A.)
- Department of Internal Medicine, University of Pavia, 27100 Pavia, Italy
| | - Francesca Lusetti
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy (A.A.)
- Department of Internal Medicine, University of Pavia, 27100 Pavia, Italy
| | - Marco Bardone
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy (A.A.)
| | - Pietro Quaretti
- Unit of Interventional Radiology, Department of Radiology, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Lorenzo Cobianchi
- Department of General Surgery, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Andrea Anderloni
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy (A.A.)
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Liu B, Fu L, Lu T, Zhang G, Dong X, Zhao Q, Yu M, Ma H, Yang K, Cai H. Comparison of Efficacy and Safety of Laparoscopic Holmium laser Lithotripsy and Laparoscopic Bile Duct Exploration for Bile Duct Stones: A Systematic Review and Meta-Analysis. World J Surg 2023; 47:1809-1820. [PMID: 37041308 DOI: 10.1007/s00268-023-06995-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2023] [Indexed: 04/13/2023]
Abstract
BACKGROUND Laparoscopic holmium laser lithotripsy (LHLL) has been used to treat bile duct stones with unclear outcomes. A meta-analysis was conducted to investigate the LHLL and laparoscopic bile duct exploration (LBDE) efficacy and safety in treating bile duct stones. METHODS The correlational studies were searched databases, such as PubMed, Embase, Cochrane Library, Web of Science, CNKI, Wanfang, and VIP, to identify eligible studies from inception to July 2022. The dichotomous and continuous outcomes were evaluated using odds ratio (OR), risk difference (RD) and weighted mean difference (WMD) with 95% confidence intervals (CIs). Stata 15.0 and Review Manager 5.3 software helped in data analyses. RESULTS A total of 23 studies with 1,890 patients, primarily from China, were included. The results indicated that operation time (WMD = - 26.94; 95% CI:(- 34.30, - 19.58); P < 0.00001), estimated blood loss (WMD = - 17.97; 95% CI: (- 22.94, - 13.00); P = 0.002), rate of residual stone (OR = 0.15, 95%CI: (0.10, 0.23); P < 0.00001), length of hospital stay (WMD = - 2.88; 95% CI:(- 3.80, - 1.96); P < 0.00001) and time to bowel function recovery (WMD = - 0.59; 95% CI: (- 0.76, - 0.41); P < 0.00001) had statistically significant differences between the two groups. In postoperative complications, biliary leakage (RD = -0.03; 95% CI: (- 0.05, -0.00); P = 0.02), infection (RD = - 0.06; 95% CI: (- 0.09,- 0.03); P < 0.00001) and Hepatic injury (RD = - 0.06; 95% CI: (- 0.11, - 0.01); P = 0.02) revealed statistically significant differences. However, no significant differences were observed in biliary damage (RD = - 0.03; 95% CI: (- 0.06, 0.00); P = 0.06) and hemobilia (RD = - 0.03; 95% CI: (- 0.06, 0.00); P = 0.08). CONCLUSION The current meta-analysis indicated that LHLL could be more effective and safer than LBDC. However, these results should be confirmed with a larger sample size and rigorously designed randomized controlled trials.
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Affiliation(s)
- Bin Liu
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730000, Gansu Province, China
- Key Laboratory of Molecular Diagnostics and Precision Medicine for Surgical Oncology in Gansu Province, Gansu Provincial Hospital, Lanzhou, 730000, Gansu Province, China
| | - Liangyin Fu
- The First Clinical Medical College, Gansu University of Chinese Medicine, Lanzhou, 730000, Gansu Province, China
| | - Tingting Lu
- Institution of Clinical Research and Evidence Based Medicine, Gansu Provincial Hospital, Lanzhou, 730000, Gansu Province, China
| | - Guangming Zhang
- The First Clinical Medical College, Gansu University of Chinese Medicine, Lanzhou, 730000, Gansu Province, China
| | - Xiaohua Dong
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730000, Gansu Province, China
- Key Laboratory of Molecular Diagnostics and Precision Medicine for Surgical Oncology in Gansu Province, Gansu Provincial Hospital, Lanzhou, 730000, Gansu Province, China
| | - Qiqi Zhao
- Key Laboratory of Molecular Diagnostics and Precision Medicine for Surgical Oncology in Gansu Province, Gansu Provincial Hospital, Lanzhou, 730000, Gansu Province, China
| | - Miao Yu
- Key Laboratory of Molecular Diagnostics and Precision Medicine for Surgical Oncology in Gansu Province, Gansu Provincial Hospital, Lanzhou, 730000, Gansu Province, China
| | - Haizhong Ma
- Key Laboratory of Molecular Diagnostics and Precision Medicine for Surgical Oncology in Gansu Province, Gansu Provincial Hospital, Lanzhou, 730000, Gansu Province, China
| | - Kehu Yang
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, 730000, Gansu Province, China
| | - Hui Cai
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730000, Gansu Province, China.
- Key Laboratory of Molecular Diagnostics and Precision Medicine for Surgical Oncology in Gansu Province, Gansu Provincial Hospital, Lanzhou, 730000, Gansu Province, China.
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Zhu J, Han W, Zhang Z, Guo W. Microincision of the Cyst Duct Is Safe and Effective for the Failed Laparoscopic Transcystic Common Bile Duct Exploration. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03304-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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4
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Suwatthanarak T, Akaraviputh T, Phalanusitthepha C, Chinswangwatanakul V, Methasate A, Swangsri J, Trakarnsanga A, Parakonthun T, Taweerutchana V, Srisuworanan N. Outcomes of Laparoscopic Common Bile Duct Exploration by Chopstick Technique in Choledocholithiasis. JSLS 2021; 25:JSLS.2021.00008. [PMID: 34248338 PMCID: PMC8245271 DOI: 10.4293/jsls.2021.00008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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 Laparoscopic cholecystectomy with common bile duct exploration (LC with LCBDE) remains the preferred technique for difficult common bile duct stone (CBDS) removal. The chopstick method uses commonly available instruments and may be cost-saving compared to other techniques. We studied the outcome of LCBDE using the chopstick technique to determine if it could be considered a first-choice method. Methods Data from all patients that underwent LCBDE from January 1, 2012 to April 30, 2019 were retrospectively analyzed. A standard 4-port incision and CBDS permitted extraction with two laparoscopic instruments by chopstick technique via vertical choledochotomy. Demographic data, stone clearance rate, surgical outcomes, complications, and other associated factors were evaluated. Results Thirty-two patients underwent LCBDE. The mean number of preoperative endoscopic retrograde cholangiopancreatography (ERCP) sessions was 2.4. In 65.5% of cases, the CBDS was completely removed by the chopstick technique, while 96.9% of stones were removed after using additional tools. The need for additional instruments was associated with increased age, increased numbers of stones, longer period from the latest ERCP session, and previous upper abdominal surgery. The conversion rate to open surgery was 28.1% and was significantly associated with a history of upper abdominal surgery. Conclusion The chopstick technique is a good alternative and could be considered as a first-line technique in LCBDE to remove the CBDS in cases with 1 to 2 large suprapancreatic CBDS due to instrument availability, cost-effectiveness, and comparable surgical outcomes.
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Affiliation(s)
- Tharathorn Suwatthanarak
- Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Thawatchai Akaraviputh
- Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | | | - Asada Methasate
- Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Jirawat Swangsri
- Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Atthaphorn Trakarnsanga
- Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Thammawat Parakonthun
- Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Voraboot Taweerutchana
- Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Nicha Srisuworanan
- Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand (All authors)
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Ma Z, Zhou J, Yao L, Dai Y, Xie W, Song G, Meng H, Xu B, Zhang T, Zhou B, Yang T, Song Z. Safety and efficacy of laparoscopic common bile duct exploration for the patients with difficult biliary stones: 8 years of experiences at a single institution and literature review. Surg Endosc 2021; 36:718-727. [PMID: 33619595 DOI: 10.1007/s00464-021-08340-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 01/27/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Laparoscopic common bile duct exploration (LCBDE) has gained wide popularity for the treatment of choledocholithiasis. However, it remains unclear whether LCBDE is a better alternative option for the patients with difficult biliary stones. Thus, the aim of the present study was to explore the safety and efficacy of LCBDE for these patients by retrospectively analyzing our data and combing with literature review. METHODS Between September 2011 and February 2019, 1064 consecutive patients who underwent LCBDE at Shanghai Tenth People's Hospital were reviewed. The clinical data of patients with difficult biliary stones were selected and retrospectively analyzed. RESULTS Of these patients, 334 cases were confirmed with difficult biliary stones, and the overall complete stone clearance rate was 98.8% (330/334). 34 cases (10.2%) were performed with laser lithotripsy. A total of 296 patients (88.6%) underwent primary closure of common bile duct, and T-tube drainage was indwelled in 38 patients (11.4%). No bile duct injury, bleeding, perforation and surgery-related deaths were observed. The overall morbidity rate was 6.6%. 16 cases (4.8%) occurred in bile leakage with primary closure procedure, and all of them were managed successfully with conservative therapy. The median follow-up period was 9 months with stone recurrence occurring in 9 patients (2.7%). There was no evidence of bile duct stricture in all cases. CONCLUSIONS The current study suggests that LCBED is a considerable safe and effective option for the patients with difficult biliary stones. A randomized clinical trial is needed to further evaluate the benefit of LCBDE in this subgroup.
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Affiliation(s)
- Zhilong Ma
- Department of General Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China.,Department of General Surgery, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200336, China
| | - Jia Zhou
- Department of General Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China.,Department of General Surgery, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200336, China
| | - Le Yao
- Department of General Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China.,Department of General Surgery, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200336, China
| | - Yuxiang Dai
- Department of General Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Wangcheng Xie
- Department of General Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Guodong Song
- Department of General Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Hongbo Meng
- Department of General Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Bin Xu
- Department of General Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Ti Zhang
- Department of General Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Bo Zhou
- Department of General Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Tingsong Yang
- Department of General Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China.
| | - Zhenshun Song
- Department of General Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China.
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Al-Ardah M, Barnett RE, Morris S, Abdelrahman T, Nutt M, Boyce T, Rasheed A. Lessons learnt from the first 200 unselected consecutive cases of laparoscopic exploration of common bile duct stones at a district general hospital. Surg Endosc 2020; 35:6268-6277. [PMID: 33140155 DOI: 10.1007/s00464-020-08127-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 10/21/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND The management of choledocholithiasis evolves with diagnostic imaging and therapeutic technology, facilitating a laparoscopic approach. We review our first 200 cases of laparoscopic exploration of the common bile duct, highlighting challenges and lessons learnt. METHODS We retrospectively studied the first 200 cases of laparoscopic cholecystectomy with common bile duct exploration between 2006 and 2019. The database contains demographics, clinicopathological characteristics, diagnostic modalities, operative techniques, duration and outcomes. RESULTS We compared two approaches: transcystic vs. transcholedochal in our 200 cases. Choledocholithiasis was suspected preoperatively in 163 patients. 21 cases found no stones. Of the remainder, 111/179 cases were completed via the transcystic route and the remaining were completed transcholedochally (68/179); 25% of the transcholedochal cases were converted from a transcystic approach. CBD diameter for transcystic route was 8.2 vs. 11.0 mm for transcholedochal. Total clearance rate was 84%. Retained or recurrent stones were noted in 7 patients. Length of stay was 5.8 days, 3.5 days in the transcystic route vs. 9.4 days after transcholedochal clearance. Eight patients required re-operation for bleeding or bile leak. No mortalities were recorded in this cohort, but 2 cases (1%) developed a subsequent CBD stricture. CONCLUSION Concomitant laparoscopic common bile duct clearance with cholecystectomy is feasible, safe and effective in a district general hospital, despite constraints of time and resources. The transcystic route has a lower complication rate and shorter hospital stay, and hence our preference of this route for all cases. Advancements in stone management technology will allow wider adoption of this technique, benefitting more patients.
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Affiliation(s)
- Mahmoud Al-Ardah
- Gwent Centre for Digestive Diseases, Royal Gwent Hospital, Newport, NP20 2UB, UK.
| | - Rebecca E Barnett
- Department of General Surgery, University Hospital of Wales, Heath Park, Cardiff, CF14 4XW, UK
| | - Simon Morris
- Gwent Centre for Digestive Diseases, Royal Gwent Hospital, Newport, NP20 2UB, UK
| | - Tarig Abdelrahman
- Department of General Surgery, University Hospital of Wales, Heath Park, Cardiff, CF14 4XW, UK
| | - Michael Nutt
- Gwent Centre for Digestive Diseases, Royal Gwent Hospital, Newport, NP20 2UB, UK
| | - Tamsin Boyce
- Gwent Centre for Digestive Diseases, Royal Gwent Hospital, Newport, NP20 2UB, UK
| | - Ashraf Rasheed
- Gwent Centre for Digestive Diseases, Royal Gwent Hospital, Newport, NP20 2UB, UK
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Abstract
BACKGROUND Mirizzi syndrome is an uncommon complication of longstanding gallstone disease. Pre-operative diagnosis is challenging, and to date, there is no consensus on the standard management for this condition. Until recently open cholecystectomy was the standard of care for type II Mirizzi syndrome (McSherry classification). The objective of this study was to assess the incidence and management of type II Mirizzi syndrome in patients with proven or suspected choledocholithiasis undergoing laparoscopic common bile duct (CBD) exploration and present our experience in the laparoscopic management of this rare condition over the last 21 years. METHODS Prospective data collection of eleven cases of type II Mirizzi syndrome amongst a series of 425 laparoscopic bile duct explorations was performed between 1998 and 2019. Demographic, clinical, diagnostic, intra-operative, and post-operative data were recorded. RESULTS The incidence of type II Mirizzi syndrome was 2.6% in 425 laparoscopic CBD explorations. All operations were completed laparoscopically with closure of the defect over a decompressed CBD (T-tube n = 3, antegrade stent n = 5, transcystic drain n = 2), and in one case a non-drained duct was closed with Endoloop. Stone clearance rate was 100% (11 cases). In two patients the transinfundibular approach was used in conjunction with holmium laser lithotripsy to enable choledochoscopy and successful stone clearance. Three patients were complicated in the post-operative period with bile leak (n = 2) and lower respiratory tract infection (n = 1). An incidental gallbladder carcinoma was found in one patient. CONCLUSION Laparoscopic management of type II Mirizzi syndrome is feasible and safe when performed by experienced laparoscopic foregut surgeons. Laparoscopy and choledochoscopy can be combined with novel approaches and techniques to increase the likelihood of treatment success.
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Jones T, Al Musawi J, Navaratne L, Martinez-Isla A. Holmium laser lithotripsy improves the rate of successful transcystic laparoscopic common bile duct exploration. Langenbecks Arch Surg 2019; 404:985-992. [PMID: 31822986 PMCID: PMC6935391 DOI: 10.1007/s00423-019-01845-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 11/18/2019] [Indexed: 01/11/2023]
Abstract
Purpose Transcystic laparoscopic common bile duct exploration (LCBDE) seems safer than transductal LCBDE and is associated with fewer biliary complications. It has traditionally been limited to smaller bile duct stones however. This study aimed to assess the ability of laser-assisted bile duct exploration by laparoendoscopy (LABEL) to increase the rate of successful transcystic LCBDE in patients with bile duct stones at the time of laparoscopic cholecystectomy. Methods Patients undergoing LCBDE between 2014 and 2018 were retrospectively analysed. Baseline demographic and medical characteristics were recorded, as well as intra-operative findings and post-procedure outcomes. Standard LCBDE via the transcystic route was initially attempted in all patients, and LABEL was only utilised if there was failure to achieve transcystic duct clearance. The transductal route was utilised for failed transcystic extraction. Results One hundred and seventy-nine consecutive patients underwent LCBDE; 119 (66.5%) underwent unaided transcystic extraction, 29 (16.2%) required LABEL to achieve transcystic extraction and 31 (17.3%) failed transcystic extraction (despite the use of LABEL in 7 of these cases) and hence required conversion to transductal LCBDE. As such, LABEL could be considered to increase the rate of successful transcystic extraction from 66.5% (119/179) to 82.7% (148/179). Patients requiring LABEL were however more likely to experience major complications (CD III–IV 5.6% vs 0.7%, p = 0.042) although none were specifically attributable to the laser intra-operatively. Conclusions LABEL is an effective adjunct to LCBDE that improves the rate of successful transcystic extraction.
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Affiliation(s)
- Timothy Jones
- Department of Upper GI Surgery, Northwick Park and St Mark's Hospitals, London North West University Healthcare NHS Trust, Watford Road, Harrow, HA1 3UJ, UK.
- Department of Surgery and Cancer, Imperial College London, South Kensington Campus, London, SW7 2AZ, UK.
| | - Jasim Al Musawi
- Department of Upper GI Surgery, Northwick Park and St Mark's Hospitals, London North West University Healthcare NHS Trust, Watford Road, Harrow, HA1 3UJ, UK
| | - Lalin Navaratne
- Department of Upper GI Surgery, Northwick Park and St Mark's Hospitals, London North West University Healthcare NHS Trust, Watford Road, Harrow, HA1 3UJ, UK
| | - Alberto Martinez-Isla
- Department of Upper GI Surgery, Northwick Park and St Mark's Hospitals, London North West University Healthcare NHS Trust, Watford Road, Harrow, HA1 3UJ, UK
- Department of Surgery and Cancer, Imperial College London, South Kensington Campus, London, SW7 2AZ, UK
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Yang T, Ma Z, Xu B, Sun W, Meng H, Liu D, Zhou B, Song Z. Clinical role of frequency-doubled double-pulse neodymium YAG laser lithotripsy for removal of difficult biliary stones in laparoscopic common bile duct exploration. ANZ J Surg 2019; 89:E358-E362. [PMID: 31441206 DOI: 10.1111/ans.15364] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 06/19/2019] [Accepted: 06/21/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND The optimal methods for patients with difficult biliary stones remain under debate. The aim of this study was to evaluate the role of frequency-doubled double-pulse neodymium YAG (FREDDY) laser lithotripsy for removing difficult biliary stones during laparoscopic common bile duct exploration (LCBDE). METHODS Between March 2013 and January 2015, 42 consecutive patients with difficult biliary stones who underwent LCBDE with FREDDY laser lithotripsy were included in this study. The clinical data of all patients were retrospectively collected and analysed. RESULTS Bile ducts were completely cleared in all patients. The complications related to laser lithotripsy were not noted. A total of 38 patients (90.5%) underwent primary closure of common bile duct, and T-tube drainage was applied to four patients (9.5%). No bile duct injury, bleeding and perforation were observed. There were no post-operative surgery-related deaths. Bile leakage occurred in four patients (9.5%) with primary closure procedure, and all of them were managed successfully with conservative therapy. The median follow-up period was 42.8 months, with no evidence of bile duct stricture and stone recurrence in all patients. CONCLUSIONS The LCBDE combined with FREDDY laser lithotripsy appear to be effective and safe for the treatment of difficult biliary stones.
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Affiliation(s)
- Tingsong Yang
- Department of Hepatobiliary and Pancreatic Surgery, Cholelithiasis Treatment Center, Shanghai Tenth People's Hospital, Tongji University of Medicine, Shanghai, China
| | - Zhilong Ma
- Department of Hepatobiliary and Pancreatic Surgery, Cholelithiasis Treatment Center, Shanghai Tenth People's Hospital, Tongji University of Medicine, Shanghai, China
| | - Bin Xu
- Department of Hepatobiliary and Pancreatic Surgery, Cholelithiasis Treatment Center, Shanghai Tenth People's Hospital, Tongji University of Medicine, Shanghai, China
| | - Wei Sun
- Department of Hepatobiliary and Pancreatic Surgery, Cholelithiasis Treatment Center, Shanghai Tenth People's Hospital, Tongji University of Medicine, Shanghai, China
| | - Hongbo Meng
- Department of Hepatobiliary and Pancreatic Surgery, Cholelithiasis Treatment Center, Shanghai Tenth People's Hospital, Tongji University of Medicine, Shanghai, China
| | - Dalu Liu
- Department of Hepatobiliary and Pancreatic Surgery, Cholelithiasis Treatment Center, Shanghai Tenth People's Hospital, Tongji University of Medicine, Shanghai, China.,Department of General Surgery, Shanghai Clinical Medical College of Anhui Medical University, Shanghai, China
| | - Bo Zhou
- Department of Hepatobiliary and Pancreatic Surgery, Cholelithiasis Treatment Center, Shanghai Tenth People's Hospital, Tongji University of Medicine, Shanghai, China
| | - Zhenshun Song
- Department of Hepatobiliary and Pancreatic Surgery, Cholelithiasis Treatment Center, Shanghai Tenth People's Hospital, Tongji University of Medicine, Shanghai, China
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Helton WS, Ayloo S. Technical Aspects of Bile Duct Evaluation and Exploration: An Update. Surg Clin North Am 2019; 99:259-282. [PMID: 30846034 DOI: 10.1016/j.suc.2018.12.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Consensus guidelines recommend patients with symptomatic cholelithiasis and suspected choledocholithiasis have common bile duct exploration (CBDE) at the time of cholecystectomy to prevent downstream problems. Despite superiority of single-stage cholecystectomy with CBDE, 2-stage precholecystectomy/postcholecystectomy with endoscopic clearance of the duct is commonly practiced. This is related to inadequate training in minimally invasive techniques, lack of technical support for efficient and safe CBDE, and surgeons' inexperience with complex biliary pathologic condition. This article provides a framework for evaluating and treating patients with CBD pathologic condition with an emphasis on technical aspects of CBDE and preoperative planning and preparation.
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Affiliation(s)
| | - Subhashini Ayloo
- Rutgers, New Jersey Medical School, 185 South Orange Avenue, MSB G586, Newark, NJ 07103, USA.
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Jin P, Jing W, Zhan W, Han C, Si M, Yang J, Li Y, Gu Y, Ma Y, Guo T. Efficacy and safety of laparoscopic holmium laser lithotripsy in the treatment of complicated biliary calculus: A PRISMA-compliant systematic reviews and meta-analysis. Medicine (Baltimore) 2019; 98:e14286. [PMID: 30681633 PMCID: PMC6358380 DOI: 10.1097/md.0000000000014286] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Revised: 11/19/2018] [Accepted: 01/06/2019] [Indexed: 01/26/2023] Open
Abstract
BACKGROUD The aim of this study was to assess the efficacy and safety of laparoscopic holmium laser lithotripsy (LHLL) in the treatment of complicated biliary calculus. METHODS We systematically searched the electronic database (PubMed, EMBASE, Cochrane library, Web of science, and Chinese Biomedical Literature Database) up to May 2018 to identify case-controlled studies that compared LHLL with laparoscopic bile duct exploration (LBDE) for complicated biliary calculus. RESULTS Five case-controlled studies were included, with 541 patients (273 in the LHLL group and 268 in the LBDE group). Compared with LBDE, LHLL was associated with shorter operative time (weighted mean difference [WMD] = -40.04, P < .001) and lower estimated blood loss (EBL) (WMD = -56.42, P < .001), lesser duration of hospitalization (WMD = -3.93, P < .001) and lower rate of residual stone (OR = 0.13, P < .001). There was no statistically significant differences in bile leakage (OR = 0.48, P = .23) and hemobilia (OR = 0.49, 0.41). CONCLUSION Current evidence suggests that the efficacy of LHLL is superior to that of LBDE but they are similarly safe for the treatment of complicated biliary calculus. Limited by the quantity and quality of the studies included, these conclusions need to be verified by more high-quality studies.
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Affiliation(s)
- Penghui Jin
- Clinical Medical College, Gansu University of Chinese Medicine, Lanzhou, Gansu
| | - Wutang Jing
- Gansu Provincial Hospital, Lanzhou, Gansu, China
| | - Weipeng Zhan
- Gansu Provincial Hospital, Lanzhou, Gansu, China
| | - Caiwen Han
- Gansu Provincial Hospital, Lanzhou, Gansu, China
| | - Moubo Si
- Gansu Provincial Hospital, Lanzhou, Gansu, China
| | - Jia Yang
- Gansu Provincial Hospital, Lanzhou, Gansu, China
| | - Yiping Li
- Gansu Provincial Hospital, Lanzhou, Gansu, China
| | - Yuanhui Gu
- Gansu Provincial Hospital, Lanzhou, Gansu, China
| | - Yuntao Ma
- Gansu Provincial Hospital, Lanzhou, Gansu, China
| | - Tiankang Guo
- Gansu Provincial Hospital, Lanzhou, Gansu, China
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Watson RR, Parsi MA, Aslanian HR, Goodman AJ, Lichtenstein DR, Melson J, Navaneethan U, Pannala R, Sethi A, Sullivan SA, Thosani NC, Trikudanathan G, Trindade AJ, Maple JT. Biliary and pancreatic lithotripsy devices. VIDEOGIE : AN OFFICIAL VIDEO JOURNAL OF THE AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY 2018; 3:329-338. [PMID: 30402576 PMCID: PMC6205352 DOI: 10.1016/j.vgie.2018.07.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIMS Lithotripsy is a procedure for fragmentation or destruction of stones to facilitate their removal or passage from the biliary or pancreatic ducts. Although most stones may be removed endoscopically using conventional techniques such as endoscopic sphincterotomy in combination with balloon or basket extraction, lithotripsy may be required for clearance of large, impacted, or irregularly shaped stones. Several modalities have been described, including intracorporeal techniques such as mechanical lithotripsy (ML), electrohydraulic lithotripsy (EHL), and laser lithotripsy, as well as extracorporeal shock-wave lithotripsy (ESWL). METHODS In this document, we review devices and methods for biliary and pancreatic lithotripsy and the evidence regarding efficacy, safety, and financial considerations. RESULTS Although many difficult stones can be safely removed using ML, endoscopic papillary balloon dilation (EPBD) has emerged as an alternative that may lessen the need for ML and also reduce the rate of adverse events. EHL and laser lithotripsy are effective at ductal clearance when conventional techniques are unsuccessful, although they usually require direct visualization of the stone by the use of cholangiopancreatoscopy and are often limited to referral centers. ESWL is effective but often requires coordination with urologists and the placement of stents or drains with subsequent procedures for extracting stone fragments and, thus, may be associated with increased costs. CONCLUSIONS Several lithotripsy techniques have been described that vary with respect to ease of use, generalizability, and cost. Overall, lithotripsy is a safe and effective treatment for difficult biliary and pancreatic duct stones.
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Key Words
- ASGE, American Society for Gastrointestinal Endoscopy
- C-APCS, Comprehensive Ambulatory Payment Classification
- CMS, Centers for Medicare and Medicaid Services
- CPT, Current Procedural Terminology (https://www.asge.org/docs/default-source/education/Technology_Reviews/doc-enteral-nutrition-access-devices.pdf?sfvrsn=4)
- EHL, electrohydraulic lithotripsy
- EPBD, endoscopic papillary balloon dilation
- ERCP, endoscopic retrograde cholangiopancreatography
- ES, endoscopic sphincterotomy
- ESWL, extracorporeal shock wave lithotripsy
- FDA, U.S. Food and Drug Administration
- FREDDY, frequency-doubled, double-pulse neodymium
- HCPCS, Healthcare Common Procedure Coding System
- MAUDE, Manufacturer and User Facility Device Experience
- ML, mechanical lithotripsy
- RCT, randomized controlled trial
- YAG, yttrium aluminum garnet
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Combination of Electronic Choledochoscopy and Holmium Laser Lithotripsy for Complicated Biliary Calculus Treatment: A New Exploration. Surg Laparosc Endosc Percutan Tech 2018; 28:e68-e73. [PMID: 29668665 DOI: 10.1097/sle.0000000000000531] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The safety and efficacy of the combination of electronic choledochoscopy and holmium laser lithotripsy for complicated bile duct stones were assessed. In total, 20 patients participated in this study, which was conducted between 2012 and 2017. None of the patients were candidates for endoscopic retrograde cholangiopancreatography with stone extraction. Outcome measures included complete stone clearance and complications postprocedure. Mean stone size was 17±5.2 mm (8 to 30 mm) and mean number of stones was 1.7±1.3 (1 to 5). The mean number of laser sessions was 1.3±0.7 (1 to 4). A mean of 1.0 to 1.5 J/20 to 25 Hz was applied during laser lithotripsy sessions with a mean operative time of 67.8±24.8 minutes. The clearance rate of stone was 18/20 (90%). No mortality existed in this study; however, 1 patient developed acute pancreatitis. The combination of holmium laser lithotripsy and electronic choledochoscopy for complicated biliary calculi is safe, reliable, and minimally invasive and has low residual stone rate.
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A novel laparoscopic transcystic approach using an ultrathin choledochoscope and holmium laser lithotripsy in the management of cholecystocholedocholithiasis: An appraisal of their safety and efficacy. Am J Surg 2017. [PMID: 28624229 DOI: 10.1016/j.amjsurg.2017.05.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Although laparoscopic transcystic common bile duct exploration (LTCBDE) is the preferred approach for CBD stone clearance, the success rate can vary between 55% and 85%. This study evaluated if ultrathin choledochoscope and holmium laser lithotripsy could improve the success rate of LTCBDE. METHODS Records of 126 patients (average age, 46.1 ± 13.8 years) with cholecystocholedocholithiasis treated with laparoscopic cholecystectomy (LC) and LTCBDE were retrospectively reviewed. RESULTS LC+LTCBDE was performed successfully in 118 of 126 patients, with a surgical success rate of 93.7%. An ultrathin choledochoscope was used in 75 (63.5%) patients, and holmium lithotripsy was performed in 38 (32.2%) patients. The stone clearance rate was 99.2% (117/118). No significant complications occurred. One hundred (84.7%) patients had excellent and 13 (11%) had good outcomes for an overall success rate (excellent plus good) of 95.7%. CONCLUSION Ultrathin choledochoscope and holmium laser lithotripsy can improve the surgical outcomes of LC+LTCBDE with minimal complications.
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Williams E, Beckingham I, El Sayed G, Gurusamy K, Sturgess R, Webster G, Young T. Updated guideline on the management of common bile duct stones (CBDS). Gut 2017; 66:765-782. [PMID: 28122906 DOI: 10.1136/gutjnl-2016-312317] [Citation(s) in RCA: 226] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 12/08/2016] [Accepted: 12/15/2016] [Indexed: 02/06/2023]
Abstract
Common bile duct stones (CBDS) are estimated to be present in 10-20% of individuals with symptomatic gallstones. They can result in a number of health problems, including pain, jaundice, infection and acute pancreatitis. A variety of imaging modalities can be employed to identify the condition, while management of confirmed cases of CBDS may involve endoscopic retrograde cholangiopancreatography, surgery and radiological methods of stone extraction. Clinicians are therefore confronted with a number of potentially valid options to diagnose and treat individuals with suspected CBDS. The British Society of Gastroenterology first published a guideline on the management of CBDS in 2008. Since then a number of developments in management have occurred along with further systematic reviews of the available evidence. The following recommendations reflect these changes and provide updated guidance to healthcare professionals who are involved in the care of adult patients with suspected or proven CBDS. It is not a protocol and the recommendations contained within should not replace individual clinical judgement.
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Affiliation(s)
- Earl Williams
- Bournemouth Digestive Diseases Centre, Royal Bournemouth and Christchurch NHS Hospital Trust, Bournemouth, UK
| | - Ian Beckingham
- HPB Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Ghassan El Sayed
- Bournemouth Digestive Diseases Centre, Royal Bournemouth and Christchurch NHS Hospital Trust, Bournemouth, UK
| | - Kurinchi Gurusamy
- Department of Surgery, University College London Medical School, London, UK
| | - Richard Sturgess
- Aintree Digestive Diseases Unit, Aintree University Hospital Liverpool, Liverpool, UK
| | - George Webster
- Department of Hepatopancreatobiliary Medicine, University College Hospital, London, UK
| | - Tudor Young
- Department of Radiology, The Princess of Wales Hospital, Bridgend, UK
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Abstract
BACKGROUND AND OBJECTIVES Laparoscopic transcystic common bile duct exploration (LTCBDE) is a complex procedure requiring expertise in laparoscopic and choledochoscopic skills. The purpose of this study was to investigate the safety and feasibility of treating biliary calculi through laparoscopic transcystic exploration of the CBD via an ultrathin choledochoscope combined with dual-frequency laser lithotripsy. METHODS From August 2011 through September 2014, 89 patients at our hospital were treated for cholecystolithiasis with biliary calculi. Patients underwent laparoscopic cholecystectomy and exploration of the CBD via the cystic duct and the choledochoscope instrument channel. A dual-band, dual-pulse laser lithotripsy system was used to destroy the calculi. Two intermittent laser emissions (intensity, 0.12 J; pulse width 1.2 μs; and pulse frequency, 10 Hz) were applied during each contact with the calculi. The stones were washed out by water injection or removed by a stone-retrieval basket. RESULTS Biliary calculi were removed in 1 treatment in all 89 patients. No biliary tract injury or bile leakage was observed. Follow-up examination with type-B ultrasonography or magnetic resonance cholangiopancreatography 3 months after surgery revealed no instances of retained-calculi-related biliary tract stenosis. CONCLUSION The combined use of laparoscopic transcystic CBD exploration by ultrathin choledochoscopy and dual-frequency laser lithotripsy offers an accurate, convenient, safe, effective method of treating biliary calculi.
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Affiliation(s)
- Jun Liu
- Department of General Surgery, Beijing Friendship Hospital, Capital Medicine University Beijing, China
| | - Lan Jin
- Department of General Surgery, Beijing Friendship Hospital, Capital Medicine University Beijing, China
| | - Zhongtao Zhang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medicine University Beijing, China
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LABEL procedure: Laser-Assisted Bile duct Exploration by Laparoendoscopy for choledocholithiasis: improving surgical outcomes and reducing technical failure. Surg Endosc 2016; 31:2103-2108. [PMID: 27572062 DOI: 10.1007/s00464-016-5206-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Accepted: 08/18/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Laparoscopic bile duct exploration (LBDE) is recommended in current treatment guidelines for the management of choledocholithiasis with gallbladder in situ. Failure of this technique is common as a consequence of large or impacted common bile duct (CBD) stones. In this series, we present our experience in using holmium laser lithotripsy as an adjunct to LBDE for the treatment of choledocholithiasis. METHODS Between 2014 and 2016, eighteen laparoscopic bile duct explorations utilising holmium laser lithotripsy were performed after failure of standard retrieval techniques. RESULTS Choledocholithiasis was successfully treated in 18 patients using laparoscopic holmium laser lithotripsy (transcystically in 14 patients). There was one failure where a CBD stricture prevented the scope reaching the stone. Two medical complications were recorded (Clavien-Dindo I and II). There were no mortalities or re-interventions. CONCLUSIONS LABEL technique is a successful and safe method to enhance LBDE in cases of impacted or large stones. In our experience, this approach increases the feasibility of the transcystic stone retrieval and may reduce overall operative time.
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Laparoscopic common bile duct exploration: choledochotomy versus transcystic approach? Surg Laparosc Endosc Percutan Tech 2016; 25:218-22. [PMID: 25799258 DOI: 10.1097/sle.0000000000000133] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE To compare the difference of primary suture following 3-port laparoscopic common bile duct exploration (LCBDE) between modified transcystic and transcholedochal approach in the treatment of choledocholithiasis. MATERIALS AND METHODS Patients who underwent 3-port LCBDE by modified transcystic approach (n = 80) and those who underwent 3-port LCBDE by transcholedochal approach (n = 209) were included in this study. The operative time, duration of hospital stay, diameter of the cystic duct, diameter of the common bile duct (CBD), complications, and demographics were retrospectively analyzed in all patients. RESULTS All operations were successfully performed. No patient was converted to laparotomy. No mortality was associated with the 2 groups. There was no significant difference between the 2 groups for the operative time (91.94 ± 34.21 min vs. 96.13 ± 32.15 min), duration of hospital stay (9.82 ± 3.48 d vs. 10.74 ± 5.34 d), diameter of cystic duct (0.47 ± 0.09 cm vs. 0.47 ± 0.08 cm), and complications (2.5% vs. 2.87%) (all P > 0.05). A significant difference was observed in terms of the diameter of CBD (1.18 ± 0.29 cm vs. 1.04 ± 0.24 cm P < 0.05). CONCLUSIONS The modified transcystic LCBDE was safe and feasible for treating choledocholithiasis but it might be more suitable for the CBD with a smaller diameter.
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Cheng LM, Liu Y, Sun ZD, Liu SM, Zhang XJ. Clinical effects of laparoscopic common bile duct exploration vs laparoscopic common bile duct exploration plus T-tube drainage in treatment of secondary extrahepatic bile duct stones. Shijie Huaren Xiaohua Zazhi 2015; 23:4574-4578. [DOI: 10.11569/wcjd.v23.i28.4574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the clinical effects of laparo-scopic transcyctic common bile duct exploration (LTCBDE) and laparoscopic common bile duct exploration (LCBDE) plus T-tube drainage in the treatment of extrahepatic bile duct stones.
METHODS: Ninety patients with secondary extrahepatic bile duct stones treated from January 2012 to June 2014 at our hospital were divided into either an observation group or a control group, with 45 cases in each group. The observation group received LTCBDE, and the control group received LCBDE plus T-tube drainage. Operative time, intraoperative blood loss, hospitalization expenses, and postoperative complications were compared between the two groups.
RESULTS: The operative time was significantly longer in the observation group than in the control group, but intraoperative blood loss, postoperative hospital stay, postoperative rehydration, postoperative hospitalization expenses, and time to tube removal were significantly lower in the observation group than in the control group. The incidence rates of early and late complications were significantly lower in the observation group than in the control group (2.22% vs 13.33%, 0 vs 11.11%, χ2 = 7.349 and 5.281, respectively, P < 0.05).
CONCLUSION: As long as the surgical indications are properly selected, LTCBDE is minimally invasive and associated with less complications and faster postoperative recovery than LCBDE plus T-tube drainage in the treatment of secondary extrahepatic bile duct stones.
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Hu WD, Chen CB, Zhao WW, Gu YY. Second laparoscopic surgery vs endoscopic retrograde cholangiopancreatography for treatment of recurrent common bile duct stones: A randomized study. Shijie Huaren Xiaohua Zazhi 2015; 23:1834-1839. [DOI: 10.11569/wcjd.v23.i11.1834] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the curative effects of a second laparoscopic surgery with endoscopic retrograde cholangiopancreatography (ERCP) in the treatment of recurrence of common bile duct stones.
METHODS: A total of 1372 patients who underwent laparoscopic choledocholithotomy from 2007 to 2013 at our hospital were included in this study. Among them, 68 had recurrent common bile duct stones, of whom 35 underwent a second laparoscopic surgery and 33 received ERCP. The patients were observed for their postoperative liver function, length of hospital stay, and hospitalization expense, and the complications were also assessed.
RESULTS: There were no significant differences between the two groups in liver function at 2 wk postoperatively (P > 0.05), hospitalization expenses (t = 1.515, P = 0.135), operation duration (t = 1.923, P = 0.059) and time to recovery of gastrointestinal function (t = 1.807, P = 0.075). Compared with the ERCP group, the laparoscopic surgery group had significantly longer hospitalization time (t = 3.929, P < 0.001) and a significantly lower rate of complications (P = 0.025). No serious complication was seen in the laparoscope surgery group, but 3 cases appeared in the ERCP group.
CONCLUSION: For patients with simple recurrent common bile duct stones, a second laparoscopic surgery is more reasonable than ERCP.
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Laparoscopic Transcystic Laser Lithotripsy for Common Bile Duct Stone Clearance. Surg Laparosc Endosc Percutan Tech 2015; 25:33-36. [DOI: 10.1097/sle.0b013e31829cec5d] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Abstract
Background and Objectives: One-stage laparoscopic management for common bile duct stones in patients with gallbladder stones has gained wide acceptance. We developed a novel technique using a transcystic approach for common bile duct exploration as an alternative to the existing procedures. Methods: From April 2010 to June 2012, 9 consecutive patients diagnosed with cholelithiasis and common bile duct stones were enrolled in this study. The main inclusion criteria included no upper abdominal surgical history and the presence of a stone measuring <5 mm. After the gallbladder was dissected free from the liver connections in a retrograde fashion, the fundus of the gallbladder was extracted via the port incision in the right epigastrium. The choledochoscope was inserted into the gallbladder through the small opening in the fundus of the gallbladder extracorporeally and was advanced toward the common bile duct via the cystic duct under the guidance of both laparoscopic imaging and endoscopic imaging. After stones were retrieved under direct choledochoscopic vision, a drainage tube was placed in the subhepatic space. Results: Of 9 patients, 7 had successful transcystic common bile duct stone clearance. A narrow cystic duct and the unfavorable anatomy of the junction of the cystic duct and common bile duct resulted in losing access to the common bile duct. No bile leakage, hemobilia, or pancreatitis occurred. Wound infection occurred in 2 patients. Transient epigastric colic pain occurred in 2 patients and was relieved by use of anisodamine. A transient increase in the amylase level was observed in 3 patients. Short-term follow-up did not show any recurrence of common bile duct stones. Conclusion: Our novel transcystic approach to laparoscopic common bile duct exploration is feasible and efficient.
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Affiliation(s)
- Dawei Chen
- Department of General Surgery, ChongMing Branch, Shanghai XinHua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Zhewei Fei
- Department of General Surgery, ChongMing Branch, Shanghai XinHua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xia Huang
- Department of General Surgery, ChongMing Branch, Shanghai XinHua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xiaojun Wang
- Department of General Surgery, ChongMing Branch, Shanghai XinHua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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Costi R, Gnocchi A, Di Mario F, Sarli L. Diagnosis and management of choledocholithiasis in the golden age of imaging, endoscopy and laparoscopy. World J Gastroenterol 2014; 20:13382-13401. [PMID: 25309071 PMCID: PMC4188892 DOI: 10.3748/wjg.v20.i37.13382] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 03/23/2014] [Accepted: 05/29/2014] [Indexed: 02/06/2023] Open
Abstract
Biliary lithiasis is an endemic condition in both Western and Eastern countries, in some studies affecting 20% of the general population. In up to 20% of cases, gallbladder stones are associated with common bile duct stones (CBDS), which are asymptomatic in up to one half of cases. Despite the wide variety of examinations and techniques available nowadays, two main open issues remain without a clear answer: how to cost-effectively diagnose CBDS and, when they are finally found, how to deal with them. CBDS diagnosis and management has radically changed over the last 30 years, following the dramatic diffusion of imaging, including endoscopic ultrasound (EUS) and magnetic resonance cholangiography (MRC), endoscopy and laparoscopy. Since accuracy, invasiveness, potential therapeutic use and cost-effectiveness of imaging techniques used to identify CBDS increase together in a parallel way, the concept of “risk of carrying CBDS” has become pivotal to identifying the most appropriate management of a specific patient in order to avoid the risk of “under-studying” by poor diagnostic work up or “over-studying” by excessively invasive examinations. The risk of carrying CBDS is deduced by symptoms, liver/pancreas serology and ultrasound. “Low risk” patients do not require further examination before laparoscopic cholecystectomy. Two main “philosophical approaches” face each other for patients with an “intermediate to high risk” of carrying CBDS: on one hand, the “laparoscopy-first” approach, which mainly relies on intraoperative cholangiography for diagnosis and laparoscopic common bile duct exploration for treatment, and, on the other hand, the “endoscopy-first” attitude, variously referring to MRC, EUS and/or endoscopic retrograde cholangiography for diagnosis and endoscopic sphincterotomy for management. Concerning CBDS diagnosis, intraoperative cholangiography, EUS and MRC are reported to have similar results. Regarding management, the recent literature seems to show better short and long term outcome of surgery in terms of retained stones and need for further procedures. Nevertheless, open surgery is invasive, whereas the laparoscopic common bile duct clearance is time consuming, technically demanding and involves dedicated instruments. Thus, although no consensus has been achieved and CBDS management seems more conditioned by the availability of instrumentation, personnel and skills than cost-effectiveness, endoscopic treatment is largely preferred worldwide.
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Milella M, Alfa-Wali M, Leuratti L, McCall J, Bonanomi G. Percutaneous transhepatic cholangiography for choledocholithiasis after laparoscopic gastric bypass surgery. Int J Surg Case Rep 2014; 5:249-52. [PMID: 24705194 DOI: 10.1016/j.ijscr.2014.03.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 02/25/2014] [Accepted: 03/04/2014] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION Gallstones are a common condition in bariatric patients after a laparoscopic Roux-en-Y gastric bypass (LRYGB). The management of ductal stones is challenging due to the altered gastrointestinal anatomy. Various techniques have been reported to manage bile duct stones. PRESENTATION OF CASE We present the successful percutaneous trans hepatic management of common bile duct stones after LRYGB. One year after a LRYGB for morbid obesity, a 59-year-old female presented with acute cholecystitis. One month after laparoscopic cholecystectomy a 1cm calculus was found within the distal CBD and patient underwent a percutaneous trans hepatic cholangiography under local anesthetic. This involved a right sided anterior segmental duct puncture. With the sphincter dilated to 10mm, a balloon catheter was used to push the stone into the duodenum leaving an internal- external drain. Patient recovered completely at follow up. DISCUSSION Patients with morbid obesity have a higher incidence of gallstones. After LRYGB, the altered anatomy does not allow the conventional endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis. Various techniques have been reported as means of managing bile duct stones in LRYGB patients. These include a double balloon enteroscope-assisted ERCP, laparoscopic transgastric ERCP, laparoscopic or open biliary surgery and interventional radiology. We report a non-surgical approach using percutaneous transhepatic technique under local anesthetic that resulted effective and could be applied more extensively. CONCLUSION Due to the increase of global obesity, bariatric centers need to strategically plan resources such as interventional radiology in order to manage post LRYGB choledocholithiasis safely, efficiently and in a cost effective manner.
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Wang CC, Gao M. Management of recurrent stones in patients with hepatolithiasis after surgery. Shijie Huaren Xiaohua Zazhi 2012; 20:3340-3343. [DOI: 10.11569/wcjd.v20.i34.3340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Recurrent stones is a common postoperative complication in patients with hepatolithiasis and is hard to treat. There are many treatments available to treat recurrent stones, but satisfactory results can be achieved in few patients. Nonsurgical treatments include the dissolution of stones, extrahepatic lithotripsy, and stone removal without surgery. Surgical treatments include hepatolithectomy, hepatic resection, hepatico-jejuno anastomosis, and liver transplantation. Hepatic resection and liver transplantation are radical surgery for recurrent stones. Personalized retreatment should be adopted for recurrent stones according to the conditions of each patient.
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Lee TY, Cheon YK, Choe WH, Shim CS. Direct cholangioscopy-based holmium laser lithotripsy of difficult bile duct stones by using an ultrathin upper endoscope without a separate biliary irrigating catheter. Photomed Laser Surg 2011; 30:31-6. [PMID: 22043820 DOI: 10.1089/pho.2011.3094] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE We investigated the impact of direct peroral cholangioscopy (POC)-based holmium laser lithotripsy using an ultrathin endoscope with direct irrigation via a 2-mm-diameter working channel to remove difficult common bile duct (CBD) stones without a separate biliary catheter. BACKGROUND DATA Few clinical studies have reported the successful removal of difficult CBD stones by direct POC-based laser lithotripsy using an ultrathin upper endoscope. Previous studies used a separate biliary catheter to ensure continuous irrigation. METHODS Ten patients (6 males; mean age 63.3 years) with difficult CBD stones who were not amenable to conventional endoscopic procedures were examined. Direct POC using an ultrathin upper endoscope was performed in all patients. Holmium laser lithotripsy with direct saline irrigation via the operating channel of an ultrathin endoscope was performed until stone fragments were captured in a basket. RESULTS The overall success rate of bile duct clearance was 90% (9 of 10 patients) and the mean number of treatment sessions was 1.2 (range, 1-2). Mechanical lithotripsy was performed to complete stone removal in one patient (10%) who had a distal CBD stricture. One patient experienced mild cholangitis following laser lithotripsy. CONCLUSIONS Holmium laser lithotripsy under direct POC using an ultrathin upper endoscope may be an effective and safe technique for removal of difficult CBD stones. Direct irrigation via the 2-mm-diameter working channel of the ultrathin endoscope provides sufficient fluid medium and affords good endoscopic viewing to assure stone fragmentation without any need for a separate biliary catheter.
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Affiliation(s)
- Tae Yoon Lee
- Digestive Disease Center, Konkuk University Medical Center, Konkuk University School of Medicine, Hwayangdong, Gwangjingiu, Seoul, Korea
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