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Wang S, Yuan W, Yu A, Gu W, Wang T, Zhang C, Zhang C. Efficacy of different indocyanine green doses in fluorescent laparoscopic cholecystectomy: A prospective, randomized, double-blind trial. J Surg Oncol 2024; 129:1534-1541. [PMID: 38736301 DOI: 10.1002/jso.27684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Revised: 04/25/2024] [Accepted: 05/06/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND AND OBJECTIVES Intraoperative bile duct injury is a significant complication in laparoscopic cholecystectomy (LC). Near-infrared fluorescence cholangiography (NIFC) can reduce this complication. Therefore, determining the optimal indocyanine green (ICG) dosage for effective NIFC is crucial. This study aimed to determine the optimal ICG dosage for NIFC. METHODS This was a prospective, randomized, double-blind clinical trial at a single tertiary referral center, including 195 patients randomly assigned to three groups: lower dose (0.01 mg/BMI) ICG (n = 63), medium dose (0.02 mg/BMI) ICG (n = 68), and higher dose (0.04 mg/BMI) ICG (n = 64). Surgeon satisfaction and detection rates for seven biliary structures were compared among the three dose groups. RESULTS Demographic parameters did not significantly differ among the groups. The medium dose (72.1%) and higher dose ICG groups (70.3%) exhibited superior visualization of the common hepatic duct compared to the lower dose group (41.3%) (p < 0.001). No differences existed between the medium and higher dose groups. Similar trends were observed for the common bile duct and cystic common bile duct junction. CONCLUSIONS In patients undergoing fluorescent laparoscopic cholecystectomy, the 0.02 mg/BMI dose of indocyanine green demonstrated better biliary structure detection rates than the 0.01 mg/BMI dose and was non-inferior to the 0.04 mg/BMI dose.
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Affiliation(s)
- Siyu Wang
- Department of General Surgery, the First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Wenkang Yuan
- Department of General Surgery, the First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Anhai Yu
- Department of General Surgery, the First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Wang Gu
- Department of General Surgery, the First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Tianqi Wang
- Department of General Surgery, the First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Chong Zhang
- Department of General Surgery, the First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Chao Zhang
- Department of General Surgery, the First Affiliated Hospital of Anhui Medical University, Hefei, China
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İnan B, Akbay A, Güven İE, Ersoy O. Assessment of The Factors Related to The Spontaneous Passage of Common Bile Duct Stones. J Clin Med 2024; 13:2672. [PMID: 38731201 PMCID: PMC11084940 DOI: 10.3390/jcm13092672] [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: 03/20/2024] [Revised: 04/15/2024] [Accepted: 04/30/2024] [Indexed: 05/13/2024] Open
Abstract
Background: Common bile duct (CBD) stones may pass spontaneously without any intervention. Assessment of the predictors of spontaneous passage can contribute to avoiding unnecessary endoscopic retrograde cholangiopancreatography (ERCP) implementation. This study aimed to investigate the factors related to spontaneous passage of CBD stones. Methods: From January 2021 to August 2023, patients with naïve papilla who had undergone biliary ERCP and with CBD stones detected by MRCP before the procedure were analyzed retrospectively. Subjects were divided into two groups on the basis of the presence of stones during the ERCP procedure: the spontaneous passage group and the non-passage group. Groups were compared in terms of demographic, laboratory, and radiological data. Results: A total of 236 patients, including 26 in the spontaneous passage group and 210 in the non-passage group, were involved. Multivariate logistic regression analyses revealed that only stone size was significantly associated with spontaneous passage. From ROC curve analysis, stone size with a cut-off value of 4.3 mm predicted spontaneous passage with 58% sensitivity and 85% specificity. Conclusions: Stones with a size of less than 4.3 mm are more likely to pass spontaneously without endoscopic intervention. Paying attention to the stone diameter before ERCP procedures can contribute to avoiding unnecessary ERCP implementation.
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Affiliation(s)
- Bayram İnan
- Department of Gastroenterology, Ankara City Hospital, Bilkent, Ankara 06800, Turkey; (B.İ.); (A.A.); (O.E.)
| | - Ahmet Akbay
- Department of Gastroenterology, Ankara City Hospital, Bilkent, Ankara 06800, Turkey; (B.İ.); (A.A.); (O.E.)
| | - İbrahim Ethem Güven
- Department of Gastroenterology, Ankara City Hospital, Bilkent, Ankara 06800, Turkey; (B.İ.); (A.A.); (O.E.)
- Departmant of Gastroenterology, Ankara Yildirim Beyazit University Yenimahalle Training and Research Hospital, Ankara 06370, Turkey
| | - Osman Ersoy
- Department of Gastroenterology, Ankara City Hospital, Bilkent, Ankara 06800, Turkey; (B.İ.); (A.A.); (O.E.)
- Departmant of Gastroenterology, School of Medicine, Ankara Yildirim Beyazit University, Ankara 06800, Turkey
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Beany A, Ghataura AS, Yong STE, Loo KF, Singh R, George B, Chinnaratha MA. Endoscopic retrograde cholangiopancreatography is not necessary in all patients with an abnormal intraoperative cholangiogram. JGH Open 2023; 7:797-799. [PMID: 38034047 PMCID: PMC10684990 DOI: 10.1002/jgh3.12984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 10/13/2023] [Indexed: 12/02/2023]
Affiliation(s)
- Andrawus Beany
- Department of GastroenterologyLyell McEwin HospitalElizabeth ValeSouth AustraliaAustralia
| | - Anandpreet S Ghataura
- Department of GastroenterologyLyell McEwin HospitalElizabeth ValeSouth AustraliaAustralia
| | - Shaanan T E Yong
- Faculty of Health and Medical SciencesUniversity of AdelaideAdelaideSouth AustraliaAustralia
| | - Kee F Loo
- Department of GastroenterologyLyell McEwin HospitalElizabeth ValeSouth AustraliaAustralia
| | - Rajvinder Singh
- Department of GastroenterologyLyell McEwin HospitalElizabeth ValeSouth AustraliaAustralia
- Faculty of Health and Medical SciencesUniversity of AdelaideAdelaideSouth AustraliaAustralia
| | - Biju George
- Department of GastroenterologyLyell McEwin HospitalElizabeth ValeSouth AustraliaAustralia
- Faculty of Health and Medical SciencesUniversity of AdelaideAdelaideSouth AustraliaAustralia
| | - Mohamed A Chinnaratha
- Department of GastroenterologyLyell McEwin HospitalElizabeth ValeSouth AustraliaAustralia
- Faculty of Health and Medical SciencesUniversity of AdelaideAdelaideSouth AustraliaAustralia
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Ding S, Dong S, Zhu H, Wu W, Hu Y, Li Q, Zheng S. Factors related to the spontaneous passage of common bile duct stones through the papilla: a single-center retrospective cohort study. J Int Med Res 2021; 49:3000605211058381. [PMID: 34787001 PMCID: PMC8607487 DOI: 10.1177/03000605211058381] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 10/14/2021] [Indexed: 12/07/2022] Open
Abstract
OBJECTIVE Common bile duct (CBD) stones can spontaneously pass through the papilla. This study explored factors associated with stone passage by comparing differences in the clinical features of stones retained in the CBD and excreted stones. METHODS Data were retrospectively collected for all patients who were hospitalized in our center between March 2016 and May 2021 with clinical, laboratory, or imaging evidence of CBD stones. All patients underwent endoscopic retrograde cholangiopancreatography (ERCP) and were classified into two groups: group A (stones extracted by ERCP, n = 86) and group B (stones discharged before ERCP, n = 15). Demographic data, biochemical and radiological findings were compared between the groups. RESULTS Stone size (0.82 vs. 0.33 cm), and levels of total bilirubin (58.2 vs. 28.8 μmol/L), gamma-glutamyl transpeptidase (416.7 vs. 193.9 U/L), alkaline phosphatase (191.9 vs. 123.1 U/L), carbohydrate antigen 19-9 (603.7 vs. 37.2 U/mL), and α-L-fucosidase (37.4 vs. 22.6 U/L) were significantly higher in group A than in group B. Logistic regression analyses showed that stone size was the only factor significantly associated with spontaneous passage of CBD stones. CONCLUSIONS CBD stones less than 0.33 cm in size may be self-expelled through the papilla.
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Affiliation(s)
- Songming Ding
- Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren
University, Zhejiang Shuren
University, Shulan International Medical College, Hangzhou, Zhejiang,
P.R. China
| | - Shanjie Dong
- Zhejiang University School of Medicine, Hangzhou, Zhejiang, P.R.
China
| | - Hengkai Zhu
- Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren
University, Zhejiang Shuren
University, Shulan International Medical College, Hangzhou, Zhejiang,
P.R. China
| | - Weilin Wu
- Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren
University, Zhejiang Shuren
University, Shulan International Medical College, Hangzhou, Zhejiang,
P.R. China
| | - Yiting Hu
- Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren
University, Zhejiang Shuren
University, Shulan International Medical College, Hangzhou, Zhejiang,
P.R. China
| | - Qiyong Li
- Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren
University, Zhejiang Shuren
University, Shulan International Medical College, Hangzhou, Zhejiang,
P.R. China
| | - Shusen Zheng
- Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren
University, Zhejiang Shuren
University, Shulan International Medical College, Hangzhou, Zhejiang,
P.R. China
- Zhejiang University School of Medicine, Hangzhou, Zhejiang, P.R.
China
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Kaif M, Agrawal D, Sreenarasimhaiah J. Can clinical factors predict the need for intervention after a positive intraoperative cholangiogram? J Dig Dis 2017; 18:410-415. [PMID: 28547873 DOI: 10.1111/1751-2980.12488] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Revised: 05/20/2017] [Accepted: 05/23/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To determine whether clinical factors such as the elevation or decline of biochemical liver tests and bile duct dilation can help to identify patients who will truly benefit from therapeutic endoscopic retrograde cholangiopancreatography (ERCP) following a positive intraoperative cholangiography (IOC) study. METHODS All cholecystectomies during a 3-year period were examined retrospectively for positive intraoperative cholangiograms. Sonographic findings of bile duct dilation and transaminase levels at admission, including trends during the course of hospitalization and prior to ERCP, were evaluated. RESULTS Of 369 patients with intraoperative cholangiogram studies, 80 (21.7%) were positive. Prior to surgery, a sonogram showed biliary dilation in 50 (62.5%) and ERCP demonstrated actual stones in 27 (61.4%) out of 44 patients. In 24 patients with persistent elevation in transaminases and no biliary dilation, ERCP revealed stones in 12 (50.0%). Sonographic finding of biliary dilation had a positive predictive value (PPV) of 61.4% and a negative predictive value (NPV) of 60.0%. Persistent elevation in transaminases had a PPV of 59.3%. A 50% decline in transaminases had a NPV of 41.2%. Overall, only 39 (48.8%) of all patients with a positive intraoperative cholangiogram study required therapeutic ERCP. CONCLUSIONS Elevated transaminases and sonographic biliary dilation have poor predictive values for choledocholithiasis. Thus, patients with a positive intraoperative cholangiogram may benefit from additional studies, such as endoscopic ultrasound or magnetic resonance cholangiopancreatography prior to ERCP.
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Affiliation(s)
- Mohammed Kaif
- Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Deepak Agrawal
- Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jayaprakash Sreenarasimhaiah
- Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Luthra AK, Aggarwal V, Mishra G, Conway J, Evans JA. A Prospective Blinded Study Evaluating the Role of Endoscopic Ultrasound before Endoscopic Retrograde Cholangiopancreatography in the Setting of “Positive” Intraoperative Cholangiogram during Cholecystectomy. Am Surg 2016. [DOI: 10.1177/000313481608200420] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
During laparoscopic cholecystectomy, intraoperative cholangiography (IOC) is used to identify common bile duct (CBD) stones. In patients whose IOC is suspicious for stones, endoscopic retrograde cholangiopancreatography (ERCP) is the modality of choice for stone removal. However, IOC has a false positive rate of 30 to 60 per cent, and ERCP adverse events may occur in 11 per cent of patients. Endoscopic ultrasound (EUS) may serve as a noninvasive means of diagnosing suspected CBD stones. This study sought to assess the role of EUS in predicting the likelihood of choledocholithiasis at ERCP in patients found to have a positive IOC. This was a prospective blinded study of EUS before ERCP in patients with a positive IOC. Recruited subjects who underwent cholecystectomy and had an IOC with suspicion for obstruction were referred for ERCP within one month of their procedure. In patients with a positive IOC, EUS had a positive predictive value of 95 per cent in detecting choledocholithiasis. IOC with single or multiple filling defects more often correlated to the presence of CBD stones. At ERCP, choledocholithiasis was present in 65 per cent of patients who had an IOC suspicious for CBD stones. EUS should be used as a noninvasive method to correctly identify retained CBD stones in low-to-moderate risk patients with a positive IOC.
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Affiliation(s)
- Anjuli K. Luthra
- Department of Gastroenterology, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Vipul Aggarwal
- Department of Gastroenterology, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Girish Mishra
- Department of Gastroenterology, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Jason Conway
- Department of Gastroenterology, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - John A. Evans
- Department of Gastroenterology, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
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Bill JG, Kushnir VM, Mullady DK, Murad FM, Azar RR, Easler JJ, Early DS, Edmundowicz SA. Evaluation of patients with abnormalities on intraoperative cholangiogram: time to abandon endoscopic retrograde cholangiopancreatography as the initial follow-up study. Frontline Gastroenterol 2016; 7:105-109. [PMID: 28839843 PMCID: PMC5369474 DOI: 10.1136/flgastro-2015-100597] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Revised: 05/28/2015] [Accepted: 05/30/2015] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is currently the method of choice for the postoperative evaluation of suspected bile duct stones seen on intraoperative cholangiogram (IOC); however, the sensitivity of IOC for identifying biliary pathology is unclear, with studies reporting false positive rates between 30% and 60%. OBJECTIVE Evaluate the sensitivity of IOC for biliary pathology, using ERCP with sphincterotomy and balloon sweep as gold standard. DESIGN Retrospective cohort study. SETTING Tertiary medical centre. PATIENTS 130 consecutive patients (age 51.3±1.7 years, 69.2% women) who underwent ERCP for the evaluation of abnormalities identified on IOC between 2005 and 2013. INTERVENTIONS Endoscopic retrograde cholangiopancreatography. MAIN OUTCOME MEASUREMENTS Sensitivity of IOC, identify predictors of positive postoperative ERCP and ERCP-related complications. RESULTS ERCP was successful in all 130 subjects. ERCP-related adverse events occurred in six (4.3%) patients, including self-limited post-sphincterotomy bleeding in three (2.3%) and mild post-ERCP pancreatitis in three (2.3%). Overall, 41 (31.5%) patients had normal cholangiogram at time of ERCP. Finding of a filling defect on IOC was the only predictor for the presence of common bile duct stones on postoperative ERCP (OR 3.3, 95% CI 1.0 to 10.8, p=0.05). LIMITATIONS Retrospective study design. CONCLUSIONS Nearly one-third of patients with abnormal IOC had a normal postoperative ERCP. Significant pathology could have been missed in 1/130 patients. Based on these findings, we believe the use of less-invasive diagnostic modalities may be used in place of ERCP in patients with suspected choledocholithiasis on IOC.
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Affiliation(s)
- Jason G Bill
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Vladimir M Kushnir
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Daniel K Mullady
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Faris M Murad
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Riad R Azar
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Jeffery J Easler
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Dayna S Early
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Steven A Edmundowicz
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
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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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Major biliary complications in 2,714 cases of laparoscopic cholecystectomy without intraoperative cholangiography: a multicenter retrospective study. Surg Endosc 2011; 25:3747-51. [PMID: 21656070 DOI: 10.1007/s00464-011-1780-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2010] [Accepted: 05/16/2011] [Indexed: 12/15/2022]
Abstract
BACKGROUND The ongoing debate between routine and selective users of intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) has not yet come to an end. Routine users argue that IOC decreases the rate of biliary complications such as bile duct injury, biliary leak and missed common bile duct (CBD) stones, a claim that selective users do not fully support. On the other hand, a third policy that was adopted by many other centers is performing LC without IOC. In this retrospective study, we are exploring the results of a relatively large multicenter series of LC without IOC regarding major biliary complications. METHODS We performed a retrospective analysis of LC cases operated by experienced laparoscopic surgeons, without resorting to IOC, in four surgical units of university hospitals in Egypt during a 6-year period (January 2004 through December 2009). Excluded from the study were cases with positive predictors of CBD stones, namely, sonographically detected CBD dilatation and/or CBD stones, elevated bilirubin and/or alkaline phosphatase, persistent biliary pancreatitis, cholangitis, and those who had preoperative magnetic resonance cholangiography. RESULTS Of the 2,955 cases of LC reviewed, 241 were excluded, leaving 2,714 cases enrolled in the study. Fifty-five cases (2%) were converted to open surgery. Five cases (0.18%) had major bile duct injuries requiring surgical repair. Postoperative bile leakage was encountered in seven cases (0.26%). Missed CBD stones were reported in six cases (0.22%). There was no perioperative mortality in the present study. CONCLUSION LC can be performed safely without the use of IOC, with acceptable low rates of biliary complications provided that proper detection of patients with silent CBD stones is done and facilities for pre- and postoperative endoscopic retrograde cholangiopancreatography are available.
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