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Elsayed MOK, Talkhan MG. Asymptomatic bile duct stones: The devil is in the details. World J Gastrointest Endosc 2024; 16:227-231. [PMID: 38813578 PMCID: PMC11130548 DOI: 10.4253/wjge.v16.i5.227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 03/08/2024] [Accepted: 04/24/2024] [Indexed: 05/14/2024] Open
Abstract
Common bile duct (CBD) stones are a common biliary tract disease. For asymptomatic CBD stones, stone removal by endoscopic retrograde cholangiopancreatography (ERCP) is recommended in available guidelines. Because asymptomatic CBD stones is a benign disease with no noticeable symptoms, the risk vs benefit strategy should be thoroughly considered before performing ERCP in these patients. Clinical care review, technical aspects of the procedure, and patient preferences should also be considered.
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Affiliation(s)
| | - Mohamed Gamal Talkhan
- Department of Gastroenterology, South Tees Hospitals NHS Foundation Trust, Middlesbrough TS4 3BW, United Kingdom
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2
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Obaitan I, Mohamed MFH, Beran A, Rosenheck M, Obomanu ET, Berzin TM, Ramai D, Wehbe H, Aziz M, Mahendraker N, Al-Haddad M, Easler JJ, Fogel EL. Comparative Risks of Post-ERCP Adverse Events in Patients with Asymptomatic and Symptomatic Choledocholithiasis: A Systematic Review and Meta-Analysis. Dig Dis Sci 2024; 69:1880-1888. [PMID: 38555329 DOI: 10.1007/s10620-024-08374-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 02/26/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND AND AIMS Endoscopic retrograde cholangiopancreatography (ERCP) is the standard of care for the management of choledocholithiasis but carries risk of complications which may result in significant morbidity and mortality. While currently available guidelines endorse the use of ERCP for the management of symptomatic common bile duct stones, the need for ERCP in incidentally found asymptomatic choledocholithiasis is more controversial, and practice varies on a geographic and institutional level. This systematic review and meta-analysis is conducted to compare post-ERCP adverse events between asymptomatic and symptomatic choledocholithiasis patients. METHODS We searched PubMed/Embase/Web of Science databases to include all studies comparing post-ERCP outcomes between asymptomatic and symptomatic choledocholithiasis patients. The primary outcome was post-ERCP pancreatitis (PEP), while secondary outcomes included post-ERCP cholangitis, bleeding, and perforation. We calculated pooled risk ratios (RR) and 95% confidence intervals (CIs) using the Mantel-Haenszel method within a random-effect model. RESULTS Our analysis included six observational studies, totaling 2,178 choledocholithiasis patients (392 asymptomatic and 1786 symptomatic); 53% were female. Asymptomatic patients exhibited a higher risk of PEP compared with symptomatic patients (11.7% versus 4.8%; RR 2.59, 95% CI 1.56-4.31, p ≤ 0.001). No significant difference was observed in post-ERCP cholangitis, bleeding, or perforation rates between the two groups. CONCLUSIONS Asymptomatic patients with choledocholithiasis appear to have a higher risk of PEP than symptomatic patients, while the risk of other post-ERCP adverse events is similar between the two groups. Interventional endoscopists should thoroughly discuss potential adverse events (particularly PEP) with asymptomatic patients before performing ERCP and utilize PEP-prevention measures more liberally in this subgroup of patients.
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Affiliation(s)
- Itegbemie Obaitan
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Mouhand F H Mohamed
- Department of Internal Medicine, Warren Alpert Medical School Brown University, Providence, RI, USA
| | - Azizullah Beran
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Michael Rosenheck
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Elvis T Obomanu
- Department of Internal Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | - Tyler M Berzin
- Center for Advanced Endoscopy, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Daryl Ramai
- Division of Gastroenterology and Hepatology, University of Utah, Salt Lake City, UT, USA
| | - Hisham Wehbe
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Muhammad Aziz
- Division of Gastroenterology, Bon Secours Mercy Health, Toledo, OH, USA
| | - Neetu Mahendraker
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mohammad Al-Haddad
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jeffrey J Easler
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Evan L Fogel
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
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Sirimanna P, Suh H, Falk GL. Laparoscopic common bile duct exploration: what factors determine success? ANZ J Surg 2024; 94:375-379. [PMID: 37888880 DOI: 10.1111/ans.18756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 09/30/2023] [Accepted: 10/17/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUNDS Laparoscopic common bile duct exploration (LCBDE) has been shown to be effective in managing choledocholithiasis whilst avoiding ERCP-related complications. However, patient and technical factors effects outcome. This study aimed to explore the matters effecting the failure of LCBDE. METHODS All patients who underwent a laparoscopic cholecystectomy (LC) between 2007 and 2021 were identified using a prospective database. Data were collected for patients who underwent LCBDE including demographics, pre-operative investigations, intra-operative findings, technique of bile duct clearance and clearance rates, and post-operative outcomes. Predictors of failed LCBDE were identified. RESULTS Laparoscopic cholecystectomy was performed in 3648 patients. Of these, 374 underwent LCBDE for suspected choledocholithiasis. Choledochoscopy was most frequently used (58.8%) with a success rate of 84.1%. Small cystic duct diameter (4.7 vs. 3.4 mm, P = 0.002), stone size >6 mm (P = 0.02), stone: cystic duct ratio >1 (P = 0.04), and >3 stones was associated with failed LCBDE by univariate analysis. Small cystic duct diameter (OR: 0.45, 95% CI: 0.26-0.77, P = 0.004) and stone size >6 mm (OR: 0.23, 95% CI: 0.06-0.92), P = 0.04) correlated with failure by multivariate analysis. Failed LCBDE was associated with increased length of stay (6.6 days vs. 3.1 days, P = 0.001), however the rate of serious complications or mortality was unaffected. CONCLUSION LCBDE is safe and effective in managing choledocholithiasis. Factors such as cystic duct diameter, size and number of CBD stones, and stone: cystic duct ratio are associated with increased likelihood of inadequate clearance. The presence of these factors can help clinicians in decision making during LCBDE to improve chance of success.
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Affiliation(s)
- Pramudith Sirimanna
- Department of Upper GI Surgery, Concord Repatriation General Hospital, Concord, New South Wales, Australia
| | - Hyerim Suh
- Department of Upper GI Surgery, Concord Repatriation General Hospital, Concord, New South Wales, Australia
| | - Gregory L Falk
- Department of Upper GI Surgery, Concord Repatriation General Hospital, Concord, New South Wales, Australia
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Lim YP, Leow VM, Koong JK, Subramaniam M. Is there a role for routine intraoperative cholangiogram in diagnosing CBD stones in patients with normal liver function tests? A prospective study. Innov Surg Sci 2024; 9:37-45. [PMID: 38826633 PMCID: PMC11138406 DOI: 10.1515/iss-2023-0059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 02/19/2024] [Indexed: 06/04/2024] Open
Abstract
Objectives Cholecystectomy with or without intraoperative cholangiogram (IOC) is an accepted treatment for cholelithiasis. Up to 11.6 % of cholecystectomies have incidental common bile duct (CBD) stones on IOC and 25.3 % of undiagnosed CBD stones will develop life-threatening complications. These will require additional intervention after primary cholecystectomy, further straining the healthcare system. We seek to examine the role of IOC in patients with normal LFTs by evaluating its predictive values, intending to treat undiagnosed CBD stones and therefore ameliorate these issues. Methods All patients who underwent cholecystectomies with normal LFTs from October 2019 to December 2020 were prospectively enrolled. IOC was done, ERCPs were performed for filling defects and documented as "true positive" if ERCP was congruent with the IOC. "False positives" were recorded if ERCP was negative. "True negative" was assigned to normal IOC and LFT after 2 weeks of follow-up. Those with abnormal LFTs were subjected to ERCP and documented as "false negative". Sensitivity, specificity, and predictive values were calculated. Results A total of 180 patients were analysed. IOC showed a specificity of 85.5 % and a NPV of 88.1 % with an AUC of 73.7 %. The positive predictive value and sensitivity were 56.5 and 61.9 % respectively. Conclusions Routine IOC is a specific diagnostic tool with good negative predictive value. It is useful to exclude the presence of CBD stones when LFT is normal. It does not significantly prolong the length of hospitalization or duration of the cholecystectomy hence reducing the incidence of undetected retained stones and preventing its complications effectively.
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Affiliation(s)
- Yi Ping Lim
- Department of Surgery, University Malaya, Kuala Lumpur, Malaysia
| | - Voon Meng Leow
- USMMC, Bertam, Kepala Batas, USM, Penang, Malaysia
- Hepatobiliary Unit, Department of General Surgery, Hospital Sultanah Bahiyah, Alor Setar, Kedah, Malaysia
| | - Jun Kit Koong
- Department of Surgery, University Malaya, Kuala Lumpur, Malaysia
| | - Manisekar Subramaniam
- Hepatobiliary Unit, Department of General Surgery, Hospital Sultanah Bahiyah, Alor Setar, Kedah, Malaysia
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Zhang H, Gao J, Sun Z, Zhang Q, Qi B, Jiang X, Li S, Shang D. Diagnostic accuracy of updated risk assessment criteria and development of novel computational prediction models for patients with suspected choledocholithiasis. Surg Endosc 2023; 37:7348-7357. [PMID: 37474825 DOI: 10.1007/s00464-023-10087-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Accepted: 04/17/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND There are risks of choledocholithiasis in symptomatic gallstones, and some surgeons have proposed the identification of choledocholithiasis before cholecystectomy. Our goal was to evaluate the diagnostic accuracy of the latest guidelines and create computational prediction models for the accurate prediction of choledocholithiasis. METHODS We retrospectively reviewed symptomatic gallstone patients hospitalized with suspected choledocholithiasis. The diagnostic performance of 2019 and 2010 guidelines of the American Society for Gastrointestinal Endoscopy (ASGE) and 2019 guideline of the European Society of Gastrointestinal Endoscopy (ESGE) in different risks. Lastly, we developed novel prediction models based on the preoperative predictors. RESULTS A total of 1199 patients were identified and 681 (56.8%) had concurrent choledocholithiasis and were included in the analysis. The specificity of the 2019 ASGE, 2010 ASGE, and 2019 ESGE high-risk criteria was 85.91%, 72.2%, and 88.42%, respectively, and their positive predictive values were 85.5%, 77.4%, and 87.3%, respectively. For Mid-risk patients who followed 2019 ASGE about 61.8% of them did not have CBD stones in our study. On the choice of surgical procedure, laparoscopic cholecystectomy + laparoscopic transcystic common bile duct exploration can be considered the optimal treatment choice for cholecysto-choledocholithiasis instead of Endoscopic Retrograde Cholangio-Pancreatography (ERCP). We build seven machine learning models and an AI diagnosis prediction model (ModelArts). The area under the receiver operating curve of the machine learning models was from 0.77 to 0.81. ModelArts AI model showed predictive accuracy of 0.97, recall of 0.97, precision of 0.971, and F1 score of 0.97, surpassing any other available methods. CONCLUSION The 2019 ASGE guideline and 2019 ESGE guideline have demonstrated higher specificity and positive predictive value for high-risk criteria compared to the 2010 ASGE guideline. The excellent diagnostic performance of the new artificial intelligence prediction model may make it a better choice than traditional guidelines for managing patients with suspected choledocholithiasis in future.
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Affiliation(s)
- Haoxiang Zhang
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
- Department of Hepatopancreatobiliary Surgery, Fujian Provincial Hospital, Fuzhou, Fujian, China
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Jiangping Gao
- Department of Surgical Oncology, Gansu Provincial Hospital, Lanzhou, China
| | - Zhen Sun
- Department of Gastrointestinal Surgery, The Second Hospital of Jilin University, Changchun, China
| | - Qingkai Zhang
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
- Institute (College) of Integrative Medicine, Dalian Medical University, Dalian, Liaoning, China
| | - Bing Qi
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
- Institute (College) of Integrative Medicine, Dalian Medical University, Dalian, Liaoning, China
| | - Xingchi Jiang
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
- Institute (College) of Integrative Medicine, Dalian Medical University, Dalian, Liaoning, China
| | - Shuang Li
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
- Institute (College) of Integrative Medicine, Dalian Medical University, Dalian, Liaoning, China
| | - Dong Shang
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China.
- Institute (College) of Integrative Medicine, Dalian Medical University, Dalian, Liaoning, China.
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Crichton J, Cox S, Tong C, Leow P, Field X, Welsh F. Observation versus intervention for incidental common bile duct stones at intraoperative cholangiogram: a systematic review. ANZ J Surg 2023; 93:1839-1846. [PMID: 37381094 DOI: 10.1111/ans.18581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 06/15/2023] [Accepted: 06/20/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND The natural history of incidental common bile duct stones (CBDS) is poorly understood. Current evidence is conflicting, with several studies suggesting the majority may pass spontaneously. Despite this, guidelines recommend routine removal even if asymptomatic. This study aimed to systematically review the outcomes of expectant management for CBDS detected on operative cholangiography during cholecystectomy. METHODS MEDLINE, Embase and CINAHL databases were systematically searched. Participants were adult patients with CBDS identified by intraoperative cholangiography. Intervention was regarded as any perioperative effort to remove common bile duct stones, including endoscopic retrograde cholangiopancreatography (ERCP), laparoscopic and open bile duct exploration. This was compared to observation. Outcomes of interest included rates of spontaneous stone passage, success of duct clearance and complications. Risk of bias was assessed using the ROBINS-I tool. RESULTS Eight studies were included. All studies were non-randomized, heterogeneous and at serious risk of bias. In patients observed after a positive IOC, 20.9% went on to have symptomatic retained stones. In patients directed to ERCP for positive IOC, persistent CBDS were found in 50.6%. Spontaneous passage was not associated with stone size. Meta-analysis is dominated by the results from one large database, which recommends intervention for incidental stones, despite low rates of persistent stones seen at postoperative ERCP. CONCLUSIONS Further evidence is required before a definitive recommendation on observation can be made. There is some evidence that asymptomatic stones may be safely observed. In clinical scenarios where the risks of biliary intervention are considered high, a conservative strategy could be more widely considered.
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Affiliation(s)
- J Crichton
- Department of General Surgery, Te Whatu Ora Waitaha Canterbury, Christchurch Hospital, Christchurch, New Zealand
- Department of General Surgery, Te Whatu Ora Waikato, Waikato Hospital, Hamilton, New Zealand
| | - S Cox
- Department of General Surgery, Te Whatu Ora Waikato, Waikato Hospital, Hamilton, New Zealand
| | - C Tong
- Department of General Surgery, Te Whatu Ora Waikato, Waikato Hospital, Hamilton, New Zealand
| | - P Leow
- Department of General Surgery, Te Whatu Ora Waikato, Waikato Hospital, Hamilton, New Zealand
| | - X Field
- Department of General Surgery, Te Whatu Ora Waikato, Waikato Hospital, Hamilton, New Zealand
| | - F Welsh
- Department of General Surgery, Te Whatu Ora Waikato, Waikato Hospital, Hamilton, New Zealand
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The Symptomatic Outcomes of Cholecystectomy for Gallstones. J Clin Med 2023; 12:jcm12051897. [PMID: 36902684 PMCID: PMC10004100 DOI: 10.3390/jcm12051897] [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: 02/07/2023] [Revised: 02/22/2023] [Accepted: 02/26/2023] [Indexed: 03/08/2023] Open
Abstract
Cholecystectomy is the definite treatment for symptomatic gallstones, and rates are rapidly rising. Symptomatic complicated gallstones are generally treated with cholecystectomy, but there is no consensus on the clinical selection of patients with symptomatic uncomplicated gallstones for cholecystectomy. The aim of this review is to describe symptomatic outcomes before versus after cholecystectomy in patients with symptomatic gallstones as reported in prospective clinical studies and to discuss patient selection for cholecystectomy. Following cholecystectomy, resolution of biliary pain is high and reported for 66-100%. Dyspepsia has an intermediate resolution of 41-91% and may co-exist with biliary pain but may also develop following cholecystectomy with an increase of 150%. Diarrhea has a high increase and debuts in 14-17%. Persisting symptoms are mainly determined by preoperative dyspepsia, functional disorders, atypical pain locations, longer duration of symptoms, and poor psychological or physical health. Patient satisfaction following cholecystectomy is high and may reflect symptom alleviation or a change in symptoms. Comparison of symptomatic outcomes in available prospective clinical studies is limited by variations in preoperative symptoms, clinical presentations, and clinical management of post-cholecystectomy symptoms. When selecting patients with biliary pain only in a randomized controlled trial, 30-40% still have persisting pain. Strategies for the selection of patients with symptomatic uncomplicated gallstones based on symptoms alone are exhausted. For the development of a selection strategy, future studies should explore the impact of objective determinants for symptomatic gallstones on pain relief following cholecystectomy.
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Phillpotts S, Webster G, Arvanitakis M. Endoscopic Management of Complex Biliary Stones. Gastrointest Endosc Clin N Am 2022; 32:477-492. [PMID: 35691692 DOI: 10.1016/j.giec.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Complex biliary stones may be challenging to remove with standard endoscopic techniques. Factors contributing to complexity include large stone size (≥15 mm), multiple stones, high stone:distal duct ratio, stones above strictures and those in difficult anatomic position. In these cases, additional techniques may be needed, such as endoscopic papillary large balloon dilatation, mechanical lithotripsy, cholangioscopic visually directed lithotripsy, and extracorporeal shockwave lithotripsy. The choice of technique depends on local expertise and resources. Cases should be planned to identify the appropriate technique to avoid multiple procedures. This article describes the factors linked to difficulty and the steps to overcome them.
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Affiliation(s)
- Simon Phillpotts
- Department of Gastroenterology, University College London Hospitals, 250 Euston Road, London, England
| | - George Webster
- Department of Gastroenterology, University College London Hospitals, 250 Euston Road, London, England.
| | - Marianna Arvanitakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik 808, Brussels 1070, Belgium
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Lee YS. “Wait-and-See” Strategy for Asymptomatic Patients with Common Bile Duct Stones. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2022. [DOI: 10.4166/kjg.2022.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Yoon Suk Lee
- Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
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10
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Tanase A, Dhanda A, Cramp M, Streeter A, Aroori S. A UK survey on variation in the practice of management of choledocholithiasis and laparoscopic common bile duct exploration (ALiCE Survey). Surg Endosc 2022; 36:5882-5896. [PMID: 35146558 DOI: 10.1007/s00464-021-08983-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 12/31/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The practice of managing suspected/confirmed common bile duct stones (CBDS) can vary significantly in the UK. We aimed to assess this variability in practice and challenges to form a basis for future consensus. METHODS An electronic survey containing 40 questions on various aspects of management of CBDS was sent to surgeons who perform cholecystectomies via five surgical associations. RESULTS A total of 132 surgeons responded to the survey. The speciality of surgeons includes upper gastro-intestinal (68%), general (18%), colorectal (12%), and others (2%). For patients with suspected CBD stones, 80% would choose magnetic resonance cholangio-pancreatography, and 14.4% would proceed to intra-operative imaging. Most surgeons preferred intra-operative cholangiogram over intra-operative ultrasound (83% vs 17%). For the treatment, 62.1% preferred a two-stage approach [endoscopic retrograde cholangio-pancreatography (ERCP) followed by laparoscopic cholecystectomy (LC)] and 33.4% chose a single-stage approach [LC + laparoscopic common bile duct exploration (LCBDE)]. Eighty (60.6%) responders performed LCBDE, and 19 (23.8%) of them performed > 10 LCBDEs in a year. Two third of surgeons (62.5%) preferred a trans-choledochal approach to CBDS. Half of the surgeons that perform LCBDE use a T-tube selectively and 1.6% routinely. The "availability of very good ERCP service" and "lack of formal training" were the two main reasons for surgeons not performing LCBDE. Both surgeons' speciality and whether they perform other complex laparoscopic surgery were significantly associated with choosing a two-stage approach over a one-stage approach (χ2 test, speciality p = 0.033, complex surgery p = 0.011). CONCLUSION Our survey confirms the significant variability in the diagnosis and management of CBDS. The two-stage approach is still the most common way of managing CBDS in the UK. The main reasons for the low uptake of the single-stage approach are the availability of good ERCP service, lack of equipment and lack of formal training in the technique of LCBDE.
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Affiliation(s)
- Andrei Tanase
- Peninsula HPB Unit, Derriford Hospital, University Hospitals Plymouth NHS Trust, Plymouth, UK
- Peninsula Medical School (Faculty of Health), University of Plymouth, Plymouth, UK
| | - Ashwin Dhanda
- South West Liver Unit, Derriford Hospital, University Hospitals Plymouth NHS Trust, Plymouth, UK
- Peninsula Medical School (Faculty of Health), University of Plymouth, Plymouth, UK
| | - Matthew Cramp
- South West Liver Unit, Derriford Hospital, University Hospitals Plymouth NHS Trust, Plymouth, UK
- Peninsula Medical School (Faculty of Health), University of Plymouth, Plymouth, UK
| | - Adam Streeter
- Peninsula Medical School (Faculty of Health), University of Plymouth, Plymouth, UK
| | - Somaiah Aroori
- Peninsula HPB Unit, Derriford Hospital, University Hospitals Plymouth NHS Trust, Plymouth, UK.
- Peninsula Medical School (Faculty of Health), University of Plymouth, Plymouth, UK.
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Abstract
Laparoscopic cholecystectomy is a common operation; approximately 20 million Americans have gallstones, the most common indication. Surgeons who operate on the biliary tree must be familiar with the presentations and treatment options for acute and chronic biliary pathology. We focus on the difficult "bad" gallbladder. We explore the available evidence as to what to do when a gallbladder is too inflamed, too technically challenging, or a patient is too sick to undergo standard laparoscopic cholecystectomy. We discuss whether or not open cholecystectomy is a relevant tool and what can be done to manage common bile duct stones found unexpectedly intraoperatively.
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Affiliation(s)
- Miloš Buhavac
- Texas Tech University Health Sciences Center, Department of Surgery, 3601 4th Street, Lubbock, TX 79430, USA.
| | - Ali Elsaadi
- Texas Tech University Health Sciences Center, Department of Surgery, 3601 4th Street, Lubbock, TX 79430, USA
| | - Sharmila Dissanaike
- Texas Tech University Health Sciences Center, Department of Surgery, 3601 4th Street, Lubbock, TX 79430, USA
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12
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Abstract
Cholecystectomy is one of the most common general surgery procedures performed worldwide. Complications include bile duct injury, strictures, bleeding, infection/abscess, retained gallstones, hernias, and postcholecystectomy syndrome. Obtaining a critical view of safety and following the other tenets of the Safe Cholecystectomy Task Force will aid in the prevention of bile duct injury and other morbidity associated with cholecystectomy.
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Affiliation(s)
- Xiaoxi Chelsea Feng
- Department of Surgery, Cedars Sinai Medical Center, 8635 W Third Street, West Medical Office Tower, Suite 795, Los Angeles, CA 90048, USA
| | - Edward Phillips
- Department of Surgery, Cedars Sinai Medical Center, 8635 W Third Street, West Medical Office Tower, Suite 795, Los Angeles, CA 90048, USA
| | - Daniel Shouhed
- Department of Surgery, Cedars Sinai Medical Center, 459 North Croft Avenue, Los Angeles, CA 90048, USA.
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13
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Strohäker J, Wiegand L, Beltzer C, Königsrainer A, Ladurner R, Bachmann R. Routine postoperative blood tests fail to reliably predict procedure-related complications after laparoscopic cholecystectomy. Langenbecks Arch Surg 2021; 406:1155-1163. [PMID: 33760977 PMCID: PMC8208910 DOI: 10.1007/s00423-021-02115-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 02/02/2021] [Indexed: 11/26/2022]
Abstract
Purpose Laparoscopic cholecystectomy is a highly standardized surgical procedure with a low risk of complications. However, once complications develop, they can be life-threatening. The aim of this study was to evaluate the value of blood tests on postoperative day one regarding their potential to predict postoperative complications Methods A cohort study of 1706 consecutive cholecystectomies performed at a tertiary hospital and teaching facility over a 5-year period between 2014 and 2019. Results Patients that had open CCE or conversion CCE were excluded. One thousand five hundred eighty-six patients were included in the final analysis that received a laparoscopic cholecystectomy (CCE). One thousand five hundred twenty-three patients had blood tests on POD 1. Forty-one complications were detected including 14 bile leaks, 2 common bile duct injuries, 13 choledocholithiasis, 9 hematomas, and 2 active bleedings. Bilirubin was elevated in 351 patients on POD 1. A drop of more than 3 mg/dl of hemoglobin was reported in 39 patients. GPT was elevated 3 × above the upper limit in 102 patients. All three tests showed a low sensitivity and specificity in detecting postoperative complications. Conclusions Early postoperative blood tests alone show a low specificity in detecting postoperative complications after laparoscopic CCE. Their main benefit appears to be the negative predictive value, when they are normal. Routine blood testing appears to be unnecessary and should be based on the intraoperative diagnosis and postoperative clinical findings.
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Affiliation(s)
- Jens Strohäker
- Department of General, Visceral and Transplantation Surgery, University Hospital of Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany.
| | - Lisa Wiegand
- Department of General, Visceral and Transplantation Surgery, University Hospital of Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| | - Christian Beltzer
- Department of General, Visceral and Transplantation Surgery, University Hospital of Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| | - Alfred Königsrainer
- Department of General, Visceral and Transplantation Surgery, University Hospital of Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| | - Ruth Ladurner
- Department of General, Visceral and Transplantation Surgery, University Hospital of Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| | - Robert Bachmann
- Department of General, Visceral and Transplantation Surgery, University Hospital of Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
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Donnellan E, Coulter J, Mathew C, Choynowski M, Flanagan L, Bucholc M, Johnston A, Sugrue M. A meta-analysis of the use of intraoperative cholangiography; time to revisit our approach to cholecystectomy? Surg Open Sci 2021; 3:8-15. [PMID: 33937738 PMCID: PMC8076912 DOI: 10.1016/j.sopen.2020.07.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/16/2020] [Accepted: 07/27/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Despite some evidence of improved survival with intraoperative cholangiography during cholecystectomy, debate has raged about its benefit, in part because of its questionable benefit, time, and resources required to complete. METHODS An International Prospective Register of Systematic Reviews-registered (ID CRD42018102154) meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using PubMed, Scopus, Web of Science, and Cochrane library from 2003 to 2018 was undertaken including search strategy "intraoperative AND cholangiogra* AND cholecystectomy." Articles scoring ≥ 16 for comparative and ≥ 10 for noncomparative using the Methodological Index for Non-Randomized Studies criteria were included. A dichotomous random effects meta-analysis using the Mantel-Haenszel method performed on Review Manager Version 5.3 was carried out. RESULTS Of 2,059 articles reviewed, 62 met criteria for final analysis. The mean rate of intraoperative cholangiography was 38.8% (range 1.6%-96.4%).There was greater detection of bile duct stones during cholecystectomy with routine intraoperative cholangiography compared with selective intraoperative cholangiography (odds ratio = 3.28, confidence interval = 2.80-3.86, P value < .001). While bile duct injury during cholecystectomy was less with intraoperative cholangiography (0.39%) than without intraoperative cholangiography (0.43%), it was not statistically significant (odds ratio = 0.88, confidence interval = 0.65-1.19, P value = .41). Readmission following cholecystectomy with intraoperative cholangiography was 3.0% compared to 3.5% without intraoperative cholangiography (odds ratio = 0.91, confidence interval = 0.78-1.06, P value = .23). CONCLUSION The use of intraoperative cholangiography still has its place in cholecystectomy based on the detection of choledocholithiasis and the potential reduction of unfavorable outcomes associated with common bile duct stones. This meta-analysis, the first to review intraoperative cholangiography use, identified a marked variation in cholangiography use. Retrospective studies limit the ability to critically define association between intraoperative cholangiography use and bile duct injury.
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Affiliation(s)
- Eoin Donnellan
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Letterkenny, County Donegal, Ireland
- School of Medicine, National University of Ireland, Galway, Ireland
| | - Jonathan Coulter
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Letterkenny, County Donegal, Ireland
- EU INTERREG Emergency Surgery Outcome Advancement Project, Centre for Personalised Medicine, Letterkenny, Ireland
| | - Cherian Mathew
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Letterkenny, County Donegal, Ireland
- School of Medicine, National University of Ireland, Galway, Ireland
| | - Michelle Choynowski
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Letterkenny, County Donegal, Ireland
| | - Louise Flanagan
- EU INTERREG Emergency Surgery Outcome Advancement Project, Centre for Personalised Medicine, Letterkenny, Ireland
| | - Magda Bucholc
- Intelligent Systems Research Centre, School of Computing, Engineering and Intelligent Systems, Ulster University, Londonderry, Northern Ireland
| | - Alison Johnston
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Letterkenny, County Donegal, Ireland
| | - Michael Sugrue
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Letterkenny, County Donegal, Ireland
- EU INTERREG Emergency Surgery Outcome Advancement Project, Centre for Personalised Medicine, Letterkenny, Ireland
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15
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Donoghue S, Jones RM, Bush A, Srinivas G, Bowling K, Andrews S. Cost effectiveness of intraoperative laparoscopic ultrasound for suspected choledocholithiasis; outcomes from a specialist benign upper gastrointestinal unit. Ann R Coll Surg Engl 2020; 102:598-600. [PMID: 32538107 DOI: 10.1308/rcsann.2020.0109] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Common bile duct stones are present in 10% of patients with symptomatic gallstones. One-third of UK patients undergoing cholecystectomy will have preoperative ductal imaging, commonly with magnetic resonance cholangiopancreatography. Intraoperative laparoscopic ultrasound is a valid alternative but is not widely used. The primary aim of this study was to assess cost effectiveness of laparoscopic ultrasound compared with magnetic resonance cholangiopancreatography. MATERIALS AND METHODS A prospective database of all patients undergoing laparoscopic cholecystectomy between 2015 and 2018 at a district general hospital was assessed. Inclusion criteria were all patients, emergency and elective, with symptomatic gallstones and suspicion of common bile duct stones (derangement of liver function tests with or without dilated common bile duct on preoperative ultrasound, or history of pancreatitis). Patients with known common bile duct stones (magnetic resonance cholangiopancreatography or failed endoscopic retrograde cholangiogram) were excluded. Ninety-day morbidity data were also collected. RESULTS A total of 420 (334 elective and 86 emergency) patients were suspected to have common bile duct stones and were included in the study. The cost of a laparoscopic ultrasound was £183 per use. The cost of using the magnetic resonance cholangiopancreatography unit was £365 per use. Ten postoperative magnetic resonance cholangiopancreatographies were performed for inconclusive intraoperative imaging. The estimated cost saving was £74,650. Some 128 patients had common bile duct stones detected intraoperatively and treated. There was a false positive rate of 4.7%, and the false negative rate at 90 days was 0.7%. laparoscopic ultrasound use saved 129 bed days for emergency patients and 240 magnetic resonance cholangiopancreatography hours of magnetic resonance imaging. CONCLUSION The use of laparoscopic ultrasound during laparoscopic cholecystectomy for the detection of common bile duct stone is safe, accurate and cost effective. Equipment and maintenance costs are quickly offset and hospital bed days can be saved with its use.
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Affiliation(s)
| | | | - A Bush
- Torbay Hospital, Torquay, Devon, UK
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16
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O'Neill RS, Wennmacker SZ, Bhimani N, Dijk AH, Reuver P, Hugh TJ. Unsuspected choledocholithiasis found by routine intra‐operative cholangiography during laparoscopic cholecystectomy. ANZ J Surg 2020; 90:2279-2284. [DOI: 10.1111/ans.16016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 05/08/2020] [Accepted: 05/09/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Robert S. O'Neill
- Upper GI Surgery Unit Royal North Shore Hospital Sydney New South Wales Australia
| | - Sarah Z. Wennmacker
- Department of Surgery Radboud University Medical Center Nijmegen The Netherlands
| | - Nazim Bhimani
- Upper GI Surgery Unit Royal North Shore Hospital Sydney New South Wales Australia
| | - Aafke H. Dijk
- Department of Surgery Academic Medical Center Amsterdam The Netherlands
| | - Philip Reuver
- Department of Surgery Radboud University Medical Center Nijmegen The Netherlands
| | - Thomas J. Hugh
- Upper GI Surgery Unit Royal North Shore Hospital Sydney New South Wales Australia
- Northern Clinical School University of Sydney Sydney New South Wales Australia
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17
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Chen H, Jorissen R, Walcott J, Nikfarjam M. Incidence and predictors of common bile duct stones in patients with acute cholecystitis: a systematic literature review and meta‐analysis. ANZ J Surg 2019; 90:1598-1603. [DOI: 10.1111/ans.15565] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 09/16/2019] [Accepted: 09/18/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Hongyi Chen
- Department of Surgery The University of Melbourne, Austin Health Melbourne Victoria Australia
| | - Robert Jorissen
- Systems Biology and Personalised Medicine Division Walter and Eliza Hall Institute of Medical Research Melbourne Victoria Australia
| | - James Walcott
- Department of Surgery The University of Melbourne, Austin Health Melbourne Victoria Australia
| | - Mehrdad Nikfarjam
- Department of Surgery The University of Melbourne, Austin Health Melbourne Victoria Australia
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18
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Chisholm PR, Patel AH, Law RJ, Schulman AR, Bedi AO, Kwon RS, Wamsteker EJ, Anderson MA, Elta GH, Govani SM, Prabhu A. Preoperative predictors of choledocholithiasis in patients presenting with acute calculous cholecystitis. Gastrointest Endosc 2019; 89:977-983.e2. [PMID: 30465770 DOI: 10.1016/j.gie.2018.11.017] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Accepted: 11/07/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Markedly increased liver chemistries in patients presenting with acute calculous cholecystitis (AC) often prompt an evaluation for concomitant choledocholithiasis (CDL). However, current guidelines directing the workup for CDL fail to address this unique population. The aims of this study are to define the range of presenting laboratory values and imaging findings in AC, develop a model to predict the presence of concurrent CDL, and develop a management algorithm that can be easily applied on presentation. METHODS We conducted a retrospective review of patients presenting with AC to a large tertiary hospital over a 3.5-year period. CDL was defined as common bile duct (CBD) stone(s), sludge, or debris seen on any of the following studies: US, CT, magnetic resonance imaging/MRCP, EUS, ERCP, or intraoperative cholangiogram. A multivariable model to predict CDL was developed on 70% of the patients and validated on the remaining 30%. RESULTS A total of 366 patients were identified and 65 (17.8%) had concurrent CDL. Univariable analysis was used to predict CDL and demonstrated statistically significant odds ratios for transaminases >3 times the upper limit of normal, alkaline phosphatase (AlkPhos) above normal, lipase >3 times the upper limit of normal, total bilirubin ≥1.8 mg/dL, and CBD diameter >6 mm. In the validation cohort, an optimal model containing alanine transaminase (ALT) >3 times the upper limit of normal, abnormal AlkPhos, and CBD diameter >6 mm was found to have an area under the receiver operating curve of 0.91. When 0 or 1 risk factors were present, 98.6% of patients did not have CDL. When all 3 risk factors were present, 77.8% were found to have CDL. CONCLUSIONS The prevalence of CDL is high among patients with AC. When a validated model is used, application of cutoffs for ALT, AlkPhos, and CBD diameter can effectively triage patients with low and high likelihood for CDL to surgery or ERCP, respectively.
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Affiliation(s)
| | - Arpan H Patel
- University of Michigan Health Care System, Ann Arbor, Michigan, USA
| | - Ryan J Law
- University of Michigan Health Care System, Ann Arbor, Michigan, USA
| | | | - Arti O Bedi
- University of Michigan Health Care System, Ann Arbor, Michigan, USA
| | - Richard S Kwon
- University of Michigan Health Care System, Ann Arbor, Michigan, USA
| | - Erik J Wamsteker
- University of Michigan Health Care System, Ann Arbor, Michigan, USA
| | | | - Grace H Elta
- University of Michigan Health Care System, Ann Arbor, Michigan, USA
| | - Shail M Govani
- University of Michigan Health Care System, Ann Arbor, Michigan, USA; South Texas VA Healthcare System, San Antonio, Texas, USA; UT Health San Antonio, San Antonio, Texas, USA
| | - Anoop Prabhu
- University of Michigan Health Care System, Ann Arbor, Michigan, USA; VA Healthcare System, Ann Arbor, Michigan, USA
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19
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Parra-Membrives P, Martínez-Baena D, Lorente-Herce JM, Jiménez-Riera G, Sánchez-Gálvez MÁ. Choledocholithiasis recurrence following laparoscopic common bile duct exploration. Cir Esp 2019; 97:336-342. [PMID: 31027833 DOI: 10.1016/j.ciresp.2019.02.012] [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] [Received: 12/23/2018] [Revised: 02/16/2019] [Accepted: 02/19/2019] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Choledocholithiasis may be treated following an endoscopic approach or by laparoscopic common bile duct exploration (LCBDE). Stone recurrence following endoscopic management has been extensively investigated. We analyze the risk factors associated with stone recurrence following LCBDE. METHODS Patients who underwent LCBDE from February 2004 to July 2016 were examined in an univariate and multivariate analysis to assess the association of stone recurrence with the following variables: gender; age; hepatopathy; dyslipidemia, obesity or diabetes mellitus; previous abdominal surgery; presence of cholecystitis, cholangitis or pancreatitis; preoperative liver function tests, number of retrieved stones; method of common bile duct clearance and closure; presence of impacted or intrahepatic stones; conversion to open surgery and postoperative morbidity. RESULTS A total of 156 patients were included. Recurrence rate for choledocholithiasis was 14.1% with a mean time to recurrence of 38.18 month. Age was the only independent risk factor for stone recurrence at univariate and multivariate analysis. No patient aged under 55 years developed new common bile duct stones, and 86.4% of the recurrences occurred in patients aged above 65. CONCLUSIONS Age is the only independent risk factor associated to choledocholithiasis recurrence following LCBDE. Different mechanism in common bile duct stone development may be present for younger and older patients.
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Affiliation(s)
- Pablo Parra-Membrives
- Departamento de Cirugía, Universidad de Sevilla, España; Unidad de Cirugía Hepatobiliar y Pancreática, Servicio de Cirugía General y Digestiva, Hospital Universitario de Valme, Sevilla, España.
| | - Darío Martínez-Baena
- Unidad de Cirugía Hepatobiliar y Pancreática, Servicio de Cirugía General y Digestiva, Hospital Universitario de Valme, Sevilla, España
| | - José Manuel Lorente-Herce
- Unidad de Cirugía Hepatobiliar y Pancreática, Servicio de Cirugía General y Digestiva, Hospital Universitario de Valme, Sevilla, España
| | - Granada Jiménez-Riera
- Departamento de Cirugía, Universidad de Sevilla, España; Unidad de Cirugía Hepatobiliar y Pancreática, Servicio de Cirugía General y Digestiva, Hospital Universitario de Valme, Sevilla, España
| | - María Ángeles Sánchez-Gálvez
- Unidad de Cirugía Hepatobiliar y Pancreática, Servicio de Cirugía General y Digestiva, Hospital Universitario de Valme, Sevilla, España
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20
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Lai JH, Chen CJ, Chu CH, Lin CC, Sun FJ. Cholecystectomy after Sphincterotomy for Preventing Recurrence in Elderly Patients with Acute Cholangitis. INT J GERONTOL 2017. [DOI: 10.1016/j.ijge.2016.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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21
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Routine Cysticotomy and Flushing of the Cystic Duct in Patients with Low Risk of Common Duct Stones: Can It Be Beneficial? Minim Invasive Surg 2017; 2017:9814389. [PMID: 28781893 PMCID: PMC5525064 DOI: 10.1155/2017/9814389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 06/01/2017] [Indexed: 11/24/2022] Open
Abstract
Background Gallstone disease affects 15–20% of the general population and up to 20% of these patients present common bile duct stones. Aim This observational study reports our experience on routine cysticotomy and flushing of the cystic duct in patients with low risk of common duct stones. Materials and Methods We analyzed 731 patients who underwent laparoscopic cholecystectomy between September 2013 and September 2015. Results Patients were preoperatively stratified on the clinical risk; those presenting with low preoperative risk of common bile duct stones were referred to undergo laparoscopic cholecystectomy and routine cysticotomy with bile duct flushing. Patients presenting thick bile sludge, solid debrides, and/or increased tension of bile outflow underwent unplanned cholangiography. No intraoperative complications or conversion to open technique occurred. Average follow-up time was 22,8 months (range 12 to 37). Rate of retained ductal stones accounted for 0,3%. Conclusions Routine cysticotomy and bile flushing in our experience is a valid, simple, and not time consuming manoeuvre that can help decompressing and flushing CBD. Moreover, it is a valid tool for extending selective IOC approach in a focused manner. Further evaluations have to be conducted to evaluate risks and effectiveness of this manoeuvre.
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22
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Acute biliary pancreatitis in cholecystectomised patients. North Clin Istanb 2017; 4:73-76. [PMID: 28752146 PMCID: PMC5530161 DOI: 10.14744/nci.2017.08108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Accepted: 02/10/2017] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE: The present study is an evaluation of cases of acute biliary pancreatitis that developed subsequent to cholecystectomy. METHODS: Total of 44 patients were assessed in this retrospective study. Demographic characteristics, severity of illness, time elapsed between cholecystectomy and development of pancreatitis, whether endoscopic sphincterotomy (ES) was performed, surgical procedure used, duration of hospitalization, and mortality data were recorded. RESULTS: Mean age of all patients was 60.14±16.4 years (range: 20–85 years), and female:male ratio was 28:16. Mean length of time elapsed between cholecystectomy and development of acute pancreatitis was 80.6 months (range: 5–230 months). Gallstones and biliary sand were found in the choledochi of 36 patients upon endoscopic retrograde cholangiopancreatography (ERCP), but not observed in the remaining 8 patients. ES was performed and material was extracted in 32 of the 36 patients, but stone extraction was unsuccessful in 4 cases; 3 patients underwent open surgery with choledochus exploration and 1 patient died. Excluding this patient, mean duration of hospitalization was 7.5±2.5 days. CONCLUSION: Stones in bile ducts may remain asymptomatic for long periods after cholecystectomy. However, some stones trigger acute pancreatitis months or years after cholecystectomy, causing risk of mortality. ERCP and ES are the standard treatments. If these are unsuccessful, the choledochus may be explored via open or laparoscopic surgery.
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23
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Risk factors for the late development of common bile duct stones after laparoscopic cholecystectomy. Surg Endosc 2017; 31:4857-4862. [DOI: 10.1007/s00464-017-5698-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 06/22/2017] [Indexed: 12/27/2022]
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24
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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: 221] [Impact Index Per Article: 31.6] [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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25
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Lee DH, Ahn YJ, Lee HW, Chung JK, Jung IM. Prevalence and characteristics of clinically significant retained common bile duct stones after laparoscopic cholecystectomy for symptomatic cholelithiasis. Ann Surg Treat Res 2016; 91:239-246. [PMID: 27847796 PMCID: PMC5107418 DOI: 10.4174/astr.2016.91.5.239] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 07/07/2016] [Accepted: 07/27/2016] [Indexed: 02/08/2023] Open
Abstract
PURPOSE To investigate the prevalence and clinical features of retained symptomatic common bile duct (CBD) stone detected after laparoscopic cholecystectomy (LC) in patients without preoperative evidence of CBD or intrahepatic duct stones. METHODS Of 2,111 patients who underwent cholecystectomy between September 2007 and December 2014 at Seoul Metropolitan Government-Seoul National University Boramae Medical Center, 1,467 underwent laparoscopic cholecystectomy for symptomatic gallbladder stones and their medical records were analyzed. We reviewed the clinical data of patients who underwent postoperative endoscopic retrograde cholangiopancreatography (ERCP) for clinically significant CBD stones (i.e., symptomatic stones requiring therapeutic intervention). RESULTS Overall, 27 of 1,467 patients (1.84%) underwent postoperative ERCP after LC because of clinical evidence of retained CBD stones. The median time from LC to ERCP was 152 days (range, 60-1,015 days). Nine patients had ERCP-related complications. The median hospital stay for ERCP was 6 days. CONCLUSION The prevalence of clinically significant retained CBD stone after LC for symptomatic cholelithiasis was 1.84% and the time from LC to clinical presentation ranged from 2 months to 2 years 9 months. Therefore, biliary surgeons should inform patients that retained CBD stone may be detected several years after LC for simple gallbladder stones.
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Affiliation(s)
- Doo-Ho Lee
- Department of Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Young Joon Ahn
- Department of Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Hae Won Lee
- Department of Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Jung Kee Chung
- Department of Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - In Mok Jung
- Department of Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
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26
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Sutton AJ, Vohra RS, Hollyman M, Marriott PJ, Buja A, Alderson D, Pasquali S, Griffiths EA. Cost-effectiveness of emergency versus delayed laparoscopic cholecystectomy for acute gallbladder pathology. Br J Surg 2016; 104:98-107. [PMID: 27762448 DOI: 10.1002/bjs.10317] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 07/29/2016] [Accepted: 08/15/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND The optimal timing of cholecystectomy for patients admitted with acute gallbladder pathology is unclear. Some studies have shown that emergency cholecystectomy during the index admission can reduce length of hospital stay with similar rates of conversion to open surgery, complications and mortality compared with a 'delayed' operation following discharge. Others have reported that cholecystectomy during the index acute admission results in higher morbidity, extended length of stay and increased costs. This study examined the cost-effectiveness of emergency versus delayed cholecystectomy for acute benign gallbladder disease. METHODS Using data from a prospective population-based cohort study examining the outcomes of cholecystectomy in the UK and Ireland, a model-based cost-utility analysis was conducted from the perspective of the UK National Health Service, with a 1-year time horizon for costs and outcomes. Probabilistic sensitivity analysis was used to investigate the impact of parameter uncertainty on the results obtained from the model. RESULTS Emergency cholecystectomy was found to be less costly (£4570 versus £4720; €5484 versus €5664) and more effective (0·8868 versus 0·8662 QALYs) than delayed cholecystectomy. Probabilistic sensitivity analysis showed that the emergency strategy is more than 60 per cent likely to be cost-effective across willingness-to-pay values for the QALY from £0 to £100 000 (€0-120 000). CONCLUSION Emergency cholecystectomy is less costly and more effective than delayed cholecystectomy. This approach is likely to be beneficial to patients in terms of improved health outcomes and to the healthcare provider owing to the reduced costs.
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Affiliation(s)
- A J Sutton
- Health Economics Unit, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.,National Institute for Health Research Diagnostic Evidence Co-operative Leeds, Leeds, UK
| | - R S Vohra
- Trent Oesophago-Gastric Unit, Nottingham University Hospitals NHS Foundation Trust, Nottingham, UK
| | - M Hollyman
- West Midlands Surgical Research Collaborative, Birmingham, UK
| | - P J Marriott
- West Midlands Surgical Research Collaborative, Birmingham, UK.,Department of Upper Gastrointestinal Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | - A Buja
- Laboratory of Public Health and Population Studies, Department of Molecular Medicine, University of Padua
| | - D Alderson
- Academic Department of Surgery, University of Birmingham, Birmingham, UK
| | - S Pasquali
- Surgical Oncology Unit, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - E A Griffiths
- Department of Upper Gastrointestinal Surgery, Queen Elizabeth Hospital, Birmingham, UK
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27
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Pham XBD, de Virgilio C, Al-Khouja L, Bermudez MC, Schwed AC, Kaji AH, Plurad DS, Lee SL, Bennion RS, Saltzman DJ, Kim DY. Routine intraoperative cholangiography is unnecessary in patients with mild gallstone pancreatitis and normalizing bilirubin levels. Am J Surg 2016; 212:1047-1053. [PMID: 27780559 DOI: 10.1016/j.amjsurg.2016.09.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Revised: 09/06/2016] [Accepted: 09/08/2016] [Indexed: 01/18/2023]
Abstract
BACKGROUND The benefit of intraoperative cholangiography (IOC) is controversial in patients with gallstone pancreatitis whose bilirubin levels are normalizing. IOC with subsequent endoscopic retrograde cholangiopancreatography may lengthen duration of surgery and length of stay, whereas failure to clear the common bile duct may result in recurrent pancreatitis. METHODS We performed a 6-year retrospective cohort analysis of consecutive adult patients with mild gallstone pancreatitis undergoing same-admission cholecystectomy at 2 university-affiliated medical centers. Institution A routinely performed IOC, whereas institution B did not. The primary outcome was readmission within 30 days for recurrent pancreatitis. RESULTS Of 520 patients evaluated, 246 (47%) were managed at institution A (routine IOC) and 274 (53%) were managed at institution B (restricted IOC). Patients at institution B had a shorter duration of surgery (1.0 vs 1.6 hours, P < .001), shorter length of stay (4 vs 5 days, P < .001), and fewer postoperative endoscopic retrograde cholangiopancreatographies performed (1.8% vs 21%, P < .001), without a difference in readmissions (1.5% vs 0%, P = .12). CONCLUSIONS Routine IOC is not necessary in the setting of mild gallstone pancreatitis with normalizing bilirubin values.
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Affiliation(s)
- Xuan-Binh D Pham
- Department of Surgery, Harbor-UCLA Medical Center, 1000 West Carson Street, Torrance, CA 90509, USA
| | - Christian de Virgilio
- Department of Surgery, Harbor-UCLA Medical Center, 1000 West Carson Street, Torrance, CA 90509, USA
| | - Lutfi Al-Khouja
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | | | - Alexander C Schwed
- Department of Surgery, Harbor-UCLA Medical Center, 1000 West Carson Street, Torrance, CA 90509, USA
| | - Amy H Kaji
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - David S Plurad
- Department of Surgery, Harbor-UCLA Medical Center, 1000 West Carson Street, Torrance, CA 90509, USA
| | - Steven L Lee
- Department of Surgery, Harbor-UCLA Medical Center, 1000 West Carson Street, Torrance, CA 90509, USA
| | - Robert S Bennion
- Department of Surgery, Olive View-UCLA Medical Center, Sylmar, CA, USA
| | - Darin J Saltzman
- Department of Surgery, Olive View-UCLA Medical Center, Sylmar, CA, USA
| | - Dennis Y Kim
- Department of Surgery, Harbor-UCLA Medical Center, 1000 West Carson Street, Torrance, CA 90509, USA.
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Kim BS, Joo SH, Cho S, Han MS. Who experiences endoscopic retrograde cholangiopancreatography after laparoscopic cholecystectomy for symptomatic gallstone disease? Ann Surg Treat Res 2016; 90:309-14. [PMID: 27274506 PMCID: PMC4891521 DOI: 10.4174/astr.2016.90.6.309] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 03/07/2016] [Accepted: 03/24/2016] [Indexed: 12/21/2022] Open
Abstract
Purpose Laparoscopic cholecystectomy (LC) has become a standard treatment of symptomatic gallstone disease. But, some patients suffer from retained common bile duct stones after LC. The aim of this study is to analyze the predicting factors associated with subsequent postoperative endoscopic retrograde cholangiopancreatography (ERCP) after LC. Methods We retrospectively reviewed a database of every LC performed between July 2006 and September 2012. We classify 28 patients who underwent ERCP within 6 months after LC for symptomatic gallstone disease as the ERCP group and 56 patients who underwent LC for symptomatic gallstone disease during same period paired by sex, age, underlying disease, operation history, and body mass index as the control group. To identify risk factor performing postoperative ERCP after LC, we compared admission route, preoperative biochemical liver function test, number of gall stones, gallstone size, adhesion around GB, wall thickening of GB, and existence of acute cholecystitis between the 2 groups. Results Admission route, preoperative AST, ALT, and ALP, stone size, longer operation time, and acute cholecystitis were identified as risk factors of postoperative ERCP in univariate analyses. But, longer operation time (P = 0.004) and acute cholecystitis (P = 0.048) were identified as independent risk factors of postoperative ERCP in multivariate analyses. Conclusion The patient who underwent ERCP after LC for symptomatic gallstone disease are more likely experienced longer operation time and acute cholecystitis than the patient who did not undergo ERCP after LC.
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Affiliation(s)
- Bum-Soo Kim
- Department of Surgery, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Sun-Hyung Joo
- Department of Surgery, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Sungsin Cho
- Department of Surgery, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Min-Soo Han
- Department of Surgery, School of Medicine, Kyung Hee University, Seoul, Korea
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29
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Verma S, Wichmann MW, Gunning T, Beukes E, Maddern G. Intraoperative cholangiogram during laparoscopic cholecystectomy: A clinical trial in rural setting. Aust J Rural Health 2016; 24:415-421. [DOI: 10.1111/ajr.12279] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2015] [Indexed: 12/13/2022] Open
Affiliation(s)
- Shreya Verma
- Department of General Surgery; Mount Gambier Hospital; Mount Gambier South Australia Australia
| | - Matthias W. Wichmann
- Department of General Surgery; Mount Gambier Hospital; Mount Gambier South Australia Australia
| | - Thomas Gunning
- Department of General Surgery; Mount Gambier Hospital; Mount Gambier South Australia Australia
| | - Eben Beukes
- Department of General Surgery; Mount Gambier Hospital; Mount Gambier South Australia Australia
| | - Guy Maddern
- Division of Surgery; Queen Elizabeth Hospital; University of Adelaide; Woodville South Australia Australia
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30
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Routine ultrasound and blood tests after laparoscopic cholecystectomy-are they worthwhile? A diagnostic accuracy study. Langenbecks Arch Surg 2016; 401:489-94. [PMID: 27023218 DOI: 10.1007/s00423-016-1411-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 03/17/2016] [Indexed: 02/06/2023]
Abstract
PURPOSE Delayed recognition of complications can have life-threatening sequelae and is a leading cause of medical litigation. Minimal evidence exists for benefits of postoperative surveillance. This study investigated whether ultrasound (US) and blood tests can detect complications after laparoscopic cholecystectomy. METHODS A series of 772 laparoscopic cholecystectomies performed between February 2008 and October 2009 was retrospectively analyzed. Routine US was performed within 6 h postoperatively, and a blood sample was taken at the second postoperative day. RESULTS Postoperative US was performed in 722 patients. Fluid accumulation was documented in 104 patients; only two of these patients had clinically significant findings requiring treatment. The best predictor of infectious complications was elevated postoperative C-reactive protein (≥123 mg/L), with an area under the curve (AUC) of 0.94 and a number needed to misdiagnose (NNM) of 8.7. To predict postoperative choledocholithiasis, a combination of total bilirubin, aspartate aminotransferase and alkaline phosphatase elevations, with cutoff values of 1.3 mg/dL, 37 IU/L, and 136 IU/L, respectively, attained the highest accuracy with a NNM of 29.5. Ultrasonographic detection of bile duct dilation further improved specificity, while lowering sensitivity. CONCLUSIONS The value of early routine postoperative US is low, unless there is clinical suspicion of complications. Routine blood tests have a high sensitivity for infectious complications and a high specificity for remnant biliary duct stones. Therefore, we recommend avoiding routine US postoperatively and performing routine postoperative blood tests. We also recommend facilitating easy access to postoperative US, as it can aid the decision to take therapeutic measures in symptomatic patients.
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