Operative and postoperative choledochofiberoscopy

Indications for the choledochoscopic removal of intrahepatic stones based on the biliary anatomy

BACKGROUND

Choledochoscopic treatment has been used primarily to remove intrahepatic stones. However, failure in removing such stones can occasionally occur, resulting in the need for additional surgery. The aim of this study was to clarify the clinical indications and limitations of choledocoscopic treatment for the removal of intrahepatic stones.

METHODS

A review of the records of 86 patients treated for intrahepatic stones between April 1974 and December 1993 formed the basis of this study. These patients were evaluated based on their bile-duct findings (no strictures, mild strictures, or severe strictures), the site of the stones (left hepatic lobe, right hepatic lobe, and the bilateral lobes), and the presence of variations in the posterior segmental bile-duct drainage.

RESULTS

Complete removal of stones was achieved in 59 patients (69%). Further, choledochoscopic removal was mainly successful in patients with no strictures or, to a lesser degree, with mild strictures; whereas stone removal was impossible in all patients (19) with severe strictures (P < 0.0001). As for the site of the stones, no statistical differences were seen among the three groups. Regarding the presence of drainage variations of the segmental bile duct, removal of the stones was more difficult in patients with variations than in those without variations (P < 0.01). With respect to long-term clinical outcomes, of the 59 successful patients, only 2 (3%) developed recurring stones.

CONCLUSION

Based on these findings, choledochoscopic treatment should be indicated for patients who have no, or only mild, bile-duct strictures and who mainifest normal segmental bile-duct drainage.

Choledochoscopy. A cost-minimization analysis

Although choledochoscopy for the prevention of retained bile duct stones has been postulated as cost effective, no economic evaluation exists to substantiate this claim. We performed a cost-minimization analysis on 287 patients who underwent choledochoscopy during operations for biliary tract calculi between 1981 and 1987 to assess the economic impact of choledochoscopy versus noncholedochoscopic alternatives in obtaining a stone-free duct. Common duct exploration was positive for calculi in 75% of patients. Choledochoscopy-detected residual stones after duct exploration in 10% of patients. Residual stones were more frequent after positive (12.5%) than negative (2.7%) duct explorations. retained stones occurred in 4.5% of patients after operation. Sensitivity, specificity, and negative predictive values of choledochoscopy were 67%, 100%, and 95%, respectively. Cost-minimization analysis showed that total cost of either selective ($75,250) or routine ($110,450) choledochoscopy significantly exceeded the total cost of obtaining a stone-free duct for patients with retained stones via either extraction through a T-tube tract ($17,545) or by endoscopic papillotomy ($45,675). Because choledochoscopy was not economically competitive with noncholedochoscopic, nonoperative alternatives, reduction of choledochoscopy fees was implemented to economically justify continued use of choledochoscopy. We conclude that choledochoscopy is clinically efficacious in obtaining a stone-free duct, but endorsement of either routine or selective choledochoscopy by cost-minimization analysis requires careful assessment of fee structure to make choledochoscopy competitive economically.

The use of a rigid choledochoscope in exploration of the common bile duct

In 62 consecutive explorations of the common bile duct during a 2-year period, a Storz rigid choledochoscope was used to visualize the lumen of the duct before its closure over a T tube. All patients had radiological abnormalities on cholangiography: 45 had stones and 17 apparent strictures. In those with stones, the instrument was introduced after apparent removal of the stones to confirm the completeness of the manoeuvre. This examination showed that 11 patients (25 per cent) still had stones present and needed further manipulation. When the duct was seen to be clear, a T tube was inserted and the validity of the choledochoscopic findings checked by postoperative T-tube cholangiography. This confirmed the visual accuracy in all but one patient, an accuracy of 98 per cent. Of the 17 patients explored for other radiological abnormalities, choledochoscopy correctly determined the aetiology or excluded abnormalities in all cases. No complications of the procedure were encountered.