Role of open choledochotomy in the treatment of choledocholithiasis

Early Cholecystectomy after Endoscopic Retrograde Cholangiopancreatography Is Feasible and Safe

Laparoscopic cholecystectomy (LC) following endoscopic retrograde cholangiopancreatography (ERCP) is the preferred treatment for cholelithiasis with common bile duct stones. However, the optimal timing of LC after ERCP remains controversial. This study aimed to identify the ideal time interval between ERCP and LC. Data from patients who underwent LC after ERCP between November 2016 and August 2022 were retrieved from the electronic medical information system. The patients were categorized into early cholecystectomy (within 72 h of ERCP) and delayed cholecystectomy (after 72 h). The impact of the time interval between ERCP and LC on perioperative outcomes was analyzed. A total of 197 patients were included in the study, with 45 undergoing early cholecystectomy and 152 undergoing delayed cholecystectomy. No significant differences in the preoperative characteristics or operative morbidity were observed between the groups (p = 0.286). However, a significant correlation was found between the time interval from ERCP to LC and the total length of stay (r = -350, p < 0.001). The findings suggest that early cholecystectomy after ERCP is feasible and safe, and performing LC within the first 72 h does not adversely affect postoperative outcomes.

Outcomes of laparoscopic bile duct exploration for choledocholithiasis with small common bile duct

BACKGROUND

Laparoscopic cholecystectomy (LC) combined with laparoscopic common bile duct (CBD) exploration (LCBDE) is one of the main treatments for choledocholithiasis with CBD diameter of larger than 10 mm. However, for patients with small CBD (CBD diameter ≤ 8 mm), endoscopic sphincterotomy remains the preferred treatment at present, but it also has some drawbacks associated with a series of complications, such as pancreatitis, hemorrhage, cholangitis, and duodenal perforation. To date, few studies have been reported that support the feasibility and safety of LCBDE for choledocholithiasis with small CBD.

AIM

To investigate the feasibility and safety of LCBDE for choledocholithiasis with small CBD.

METHODS

A total of 257 patients without acute cholangitis who underwent LC + LCBDE for cholecystolithiasis from January 2013 to December 2018 in one institution were reviewed. The clinical data were retrospectively collected and analyzed. According to whether the diameter of CBD was larger than 8 mm, 257 patients were divided into large CBD group (n = 146) and small CBD group (n = 111). Propensity score matching (1:1) was performed to adjust for clinical differences. The demographics, intraoperative data, short-term outcomes, and long-term follow-up outcomes for the patients were recorded and compared.

RESULTS

In total, 257 patients who underwent successful LC + LCBDE were enrolled in the study, 146 had large CBD and 111 had small CBD. The median follow-up period was 39 (14-86) mo. For small CBD patients, the median CBD diameter was 0.6 cm (0.2-2.0 cm), the mean operating time was 107.2 ± 28.3 min, and the postoperative bile leak rate, rate of residual CBD stones (CBDS), CBDS recurrence rate, and CBD stenosis rate were 5.41% (6/111), 3.60% (4/111), 1.80% (2/111), and 0% (0/111), respectively; the mean postoperative hospital stay was 7.4 ± 3.6 d. For large CBD patients, the median common bile duct diameter was 1.0 cm (0.3-3.0 cm), the mean operating time was 115.7 ± 32.0 min, and the postoperative bile leak rate, rate of residual CBDS, CBDS recurrence rate, and CBD stenosis rate were 5.41% (9/146), 1.37% (2/146), 6.85% (10/146), and 0% (0/146), respectively; the mean postoperative hospital stay was 7.7 ± 2.7 d. After propensity score matching, 184 patients remained, and all preoperative covariates except diameter of CBD stones were balanced. Postoperative bile leak occurred in 11 patients overall (5.98%), and no difference was found between the small CBD group (4.35%, 4/92) and the large CBD group (7.61%, 7/92). The incidence of CBDS recurrence did not differ significantly between the small CBD group (2.17%, 2/92) and the large CBD group (6.52%, 6/92).

CONCLUSION

LC + LCBDE is safe and feasible for choledocholithiasis patients with small CBD and did not increase the postoperative bile leak rate compared with chole-docholithiasis patients with large CBD.

Outcomes of endoscopic sphincterotomy vs open choledochotomy for common bile duct stones

BACKGROUND

Endoscopic sphincterotomy (EST) for the management of common bile duct stones (CBDS) is used increasingly widely because it is a minimally invasive procedure. However, some clinical practitioners argued that EST may be complicated by post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) and accompanied by a higher recurrence of CBDS than open choledochotomy (OCT). Whether any differences in outcomes exist between these two approaches for treating CBDS has not been thoroughly elucidated to date.

AIM

To compare the outcomes of EST vs OCT for the management of CBDS and to clarify the risk factors associated with stone recurrence.

METHODS

Patients who underwent EST or OCT for CBDS between January 2010 and December 2012 were enrolled in this retrospective study. Follow-up data were obtained through telephone or by searching the medical records. Statistical analysis was carried out for 302 patients who had a follow-up period of at least 5 years or had a recurrence. Propensity score matching (1:1) was performed to adjust for clinical differences. A logistic regression model was used to identify potential risk factors for recurrence, and a receiver operating characteristic (ROC) curve was generated for qualifying independent risk factors.

RESULTS

In total, 302 patients undergoing successful EST (n = 168) or OCT (n = 134) were enrolled in the study and were followed for a median of 6.3 years. After propensity score matching, 176 patients remained, and all covariates were balanced. EST was associated with significantly shorter time to relieving biliary obstruction, anesthetic duration, procedure time, and hospital stay than OCT (P < 0.001). The number of complete stone clearance sessions increased significantly in the EST group (P = 0.009). The overall incidence of complications and mortality did not differ significantly between the two groups. Recurrent CBDS occurred in 18.8% (33/176) of the patients overall, but no difference was found between the EST (20.5%, 18/88) and OCT (17.0%, 15/88) groups. Factors associated with CBDS recurrence included common bile duct (CBD) diameter > 15 mm (OR = 2.72; 95%CI: 1.26-5.87; P = 0.011), multiple CBDS (OR = 5.09; 95%CI: 2.58-10.07; P < 0.001), and distal CBD angle ≤ 145° (OR = 2.92; 95%CI: 1.54-5.55; P = 0.001). The prediction model incorporating these factors demonstrated an area under the receiver operating characteristic curve of 0.81 (95%CI: 0.76-0.87).

CONCLUSION

EST is superior to OCT with regard to time to biliary obstruction relief, anesthetic duration, procedure time, and hospital stay and is not associated with an increased recurrence rate or mortality compared with OCT in the management of CBDS.

Intraoperative cholangiography during cholecystectomy in sequential treatment of cholecystocholedocholithiasis: To be, or not to be, that is the question A cohort study

BACKGROUND

Choledocholithiasis occurs in 10-15% of patients with cholecystolithiasis. Despite the existence of many therapeutic options for the treatment of cholecystocholedocholithiasis, a sequential treatment in which pre-operative ERCP is combined with intraoperative cholangiography (IOC) and laparoscopic cholecystectomy (LC), is the most commonly accepted strategy. However, use of IOC in the "splitting treatment" of cholecystocholedocholithiasis is controversial. The aim of the present study is to investigate the utility of IOC in detecting residual stones in patients undergoing LC in the sequential treatment of common biliary duct or gallbladder stones.

METHODS

Patients were recruited retrospectively among those who underwent IOC during LC, performed as second stage in the sequential treatment for cholecystocholedocholithiasis between 2010 and 2016. Demographic and clinical data were obtained from CPT codes at Ospedale Monaldi A.O.R.N dei Colli Naples, Italy. Data obtained from all pre-operative ERCP analyses were recorded, including cholangiogram findings and performance of sphincterotomy. Statistical analysis was carried out using the IBM SPSS Statistic 19.0 software package.

RESULTS

Between January 2010 and December 2016 575 patients (343 males, 242 females) underwent IOC during LC for symptomatic cholecystitis due to cholelithiasis. Among patients accrued for the study, 143 underwent preoperative ERCP for suspicion of common biliary duct stones. At the time of pre-operative ERCP, 123 were found to have common biliary duct stones while 20 (15%) presented negative ERCP. Complete removal of stones was accomplished in 119 patients. Among these patients, 13 had residual common biliary duct stones diagnosed by IOC (11%). Two patients underwent laparoscopic bile duct revision and, last, two patients were referred for ERCP at a later point. It is of note that all patients who presented residual stones by IOC had undergone pre-operative sphincterotomy.

CONCLUSION

This study demonstrates that IOC is particularly effective in detecting residual stones in patients undergoing LC in sequential treatment of common biliary duct and/or gallbladder stones, and may be used on a routine basis in the sequential treatment of cholecystocholedocholithiasis.

Hepatobiliary Hands of Hopkins

OBJECTIVE

This historical perspective documents the role that John L. Cameron played in advancing hepatobiliary research, education, and surgery at Johns Hopkins in the 1970s, 1980s, and 1990s.

SUMMARY OF BACKGROUND DATA

Dating back to William S. Halsted in the 19th century, leaders of the Department of Surgery at Johns Hopkins have been interested in hepatobiliary disease and surgery. John L. Cameron had broad hepato-pancreato-biliary (HPB) interests when he completed his surgical training. Over the next 3 decades, he focused on the pancreas. As a result, many faculty and trainee hepatobiliary careers were launched.

METHODS

This perspective is based on 18 years of service as a surgical resident and faculty member at Johns Hopkins. An extensive literature search on the hepatobiliary publications of Halsted, Trimble, Blalock, Longmire, Zuidema, and Cameron was undertaken for this manuscript. Numerous hepatobiliary publications from Johns Hopkins from the 1970s, 1980s, 1990s, and early 2000s were also reviewed.

RESULTS

John L. Cameron's early biliary interests included stones, infections, malignancies, and strictures. He was innovative with respect to portal hypertension and Budd-Chiari surgery and supportive when liver transplantation emerged in the 1980s. Volume-outcome studies in the 1990s included hepatic and complex biliary surgery. He supported and encouraged studies of biliary lithotripsy, laparoscopic cholecystectomy, clinical pathways, hepatobiliary cysts, and gallstone pathogenesis.

CONCLUSION

Lessons learned by many who worked with John L. Cameron included the importance of mentorship, innovation, friendship, and collaboration. He taught leadership and change management by example. He fostered a multidisciplinary approach and encouraged randomized controlled trials.

Pancreatogenic choledocholithiasis in common bile duct stump after Roux-en-Y hepaticojejunostomy: A case report

RATIONALE

Choledocholithiasis in common bile duct (CBD) stump after Roux-en-Y hepaticojejunostomy (RYHJ) is incredibly rare and its pathophysiology is poorly understood.

PATIENT CONCERNS

A 79-year-old woman was admitted to our hospital with upper abdominal pain radiating through to the back in November 2016.

DIAGNOSES

Abdominal computed tomography (CT) scan and magnetic resonance cholangiopancreatography (MRCP) revealed filling defects in CBD stump, chronic pancreatitis, and dilatation of CBD stump and main pancreatic duct (MPD).

INTERVENTIONS

During the endoscopic retrograde cholangiopancreatography (ERCP), cannulation proceeded easily from MPD to CBD through a variant pancreatic duct, and then white crushed stones extracted from the CBD stump. Elemental analysis and infrared spectrophotometry demonstrated that the main constituent of the calculi was calcium carbonate.

OUTCOMES

After a therapeutic ERCP, the patient's symptoms disappeared, and a 9-month follow-up indicated no remaining stones or lithiasis relapse.

LESSONS

This type of choledocholithiasis in CBD stump after RYHJ has never been reported before. We nominated it as "pancreatogenic choledocholithiasis," and pancreatobiliary reflux caused by a variant pancreatic duct may be the main cause.

Advances of recurrent risk factors and management of choledocholithiasis

Gallstone disease is a common and frequently occurring disease in human, and it is the main disease among the digestive system diseases. The incidence of gallstone disease in western countries is about 5%-22%, and common bile duct stones (CBDS) accounts for 8%-20%. CBDS easily lead to biliary obstruction, secondary cholangitis, pancreatitis, and obstructive jaundice, even endanger life. Therefore, it needs timely treatment once diagnosed. The recurrence of choledocholithiasis after bile duct stones clearance involves complicated factors and cannot be completely elaborated by a single factor. The risk factors for recurrence of choledocholithiasis include bacteria, biliary structure, endoscopic and surgical treatment, and inflammation. The modalities for management of choledocholithiasis are endoscopic retrograde cholangiopancreatography (ERCP), laparoscopic or open common bile duct exploration, dissolving solutions, extracorporeal shockwave lithotripsy (ESWL), percutaneous radiological interventions, electrohydraulic lithotripsy (EHL) and laser lithotripsy. We compare the different benefits between surgery and ERCP. And finally, we make a summary of the current strategy for reducing the recurrence of CBDS and future perspectives for CBDS management.

Basket-in-catheter access for transcystic laparoscopic bile duct exploration: technique and results

BACKGROUND

When common bile duct (CBD) stones are detected during laparoscopic cholecystectomy, the insertion of baskets via the cystic duct (CD) can be difficult and may occasionally cause complications. We introduced a new technique 'basket in catheter' (BIC) for transcystic CBD exploration.

METHODS

Although cannulating the CD using a cholangiography catheter is successful in most cases, it may occasionally be difficult. Cystic duct anatomy may prevent the usually stiffer sharper tip of the basket, from entering the CBD, resulting in failure, perforation or a false passage. In the majority of our cases, the cholangiography catheter (CC) is not withdrawn from the duct should the intraoperative cholangiography show CBD stones. The tip of a basket is inserted into the CC and advanced to a predetermined distance, allowing the tip of the basket to exit the end of the CC into the CBD. The basket is then opened, advanced to feel the lower end and manipulated to trap the stone. The common hepatic duct is compressed gently to prevent stones from slipping upwards. The catheter and basket are pulled back together to extract the stone.

RESULTS

We have used this technique in 274 cases since 2010. The rate of transcystic versus choledochotomy stone extraction has increased, saving unnecessary choledochotomies. The percentage of transcystic exploration increased from 55 % for the period 2005-2009 to 70 % for the period 2010-2014. There were no conversions to open surgery and no retained stones. The morbidity rate was 4.0 % with no mortality.

CONCLUSIONS

We demonstrate a technique to facilitate the insertion of extraction baskets into the common bile duct using the cholangiography catheter as a guide. The 'basket-in-catheter' (BIC) technique for transcystic CBD exploration is easier and safer than inserting the basket alone.

Comparative quality of life study between endoscopic sphincterotomy and surgical choledochotomy

AIM: To determine quality of life improvement in choledocholithiasis patients who underwent endoscopic sphincterotomy (EST) versus open choledochotomy (OCT).

METHODS: Eligible choledocholithiasis patients (n = 216) hospitalized in the Changhai Hospital between May 2010 and January 2011 were enrolled into a prospective study using cluster sampling. Patients underwent EST (n = 135) or OCT (n = 81) depending on the patient’s wishes. Patients were followed-up with a field survey and by correspondence. Patients were also given the self-administered Gastrointestinal Quality of Life Index (GIQLI) to measure patient quality of life before surgery, and at two and six weeks after the procedures.

RESULTS: With respect to baseline patient characteristics, the EST and OCT groups were comparable. After the procedure, gallstones were completely eliminated in all patients. Among 216 eligible patients, 191 patients (88.4%) completed all three surveys, including 118 patients who underwent EST (118/135; 87.4%) and 73 patients who underwent OCT (73/81; 90.1%). EST was associated with a significantly shorter hospital stay than OCT (8.8 ± 6.5 vs 13.9 ± 6.7 d; P < 0.001). The GIQLI score was similar between the EST and OCT groups before cholelithotomy (103.0 ± 15.4 vs 99.7 ± 10.2), but increased significantly in the EST group at two weeks (113.4 ± 12.0 vs 107.2 ± 11.2; P < 0.001) and six weeks (120.7 ± 10.6 vs 116.9 ± 7.5; P < 0.05) after the procedures.

CONCLUSION: EST, compared with OCT, is associated with better postoperative quality of life in patients treated for choledocholithiasis.

Complications of the extrahepatic biliary surgery in companion animals

Surgery of the biliary tract is demanding and is associated with several potentially life-threatening complications. Veterinarians face challenges in obtaining accurate diagnosis of biliary disease, surgical decision-making, surgical hemostasis and bile peritonitis. Intensive perioperative monitoring is required to achieve early recognition of common postoperative complications. Proper treatment and ideally, avoidance of surgical complications can be achieved by gaining a clear understanding physiology, anatomy, and the indications for hepatobiliary surgery.

Laparoscopic transcystic bile duct exploration: the treatment of first choice for common bile duct stones

BACKGROUND

This study was designed to explore the role of transcystic bile duct exploration (TCE) as a first line of treatment for patients with suspected or incidental common bile duct (CBD) stones.

METHODS

A prospective, case-control study of clinically comparable groups of patients who underwent laparoscopic cholecystectomy (LC) alone (n = 1,854) and combined LC/TCE for CBD stones (n = 253) under the care of one surgeon was performed. Other than ultrasonography, no routine preoperative imaging was used; however, we performed routine intraoperative cholangiography on all patients.

RESULTS

There was no difference in age (49 +/- 15 vs. 57 +/- 19, p = 0.7), sex (79% vs. 82% females, p = 0.6), and ASA grade (1.9 +/- 1 vs. 1.8 +/- 1, p = 0.7). A larger proportion of the TCE group presented as an emergency (TCE 45% vs. LC alone 27%, p = 0.03) and more often presented with acute biliary pain compared with LC alone (27% vs. 13%, p = 0.02). Although a majority of the patients in the TCE group had clinical or biochemical risk factors for CBD stones (86%), only 27% had suspected stones on preoperative ultrasound. The incidence of jaundice (6% vs. 20%, p = 0.01) was lower in the LC alone group compared with TCE patients. Previous abdominal surgery was noted in 34% patients who underwent LC alone and 30% in LC/TCE (p = 0.06). Significantly there was no difference in open conversion between the two groups (LC alone 0.5% vs. LC/TCE 0.6%, p = 0.07). Comparison of selected outcome parameters for LC versus TCE showed a postoperative hospital stay of 2 (1-14) vs. 2 (1-17) days (p = 0.07), presentation to resolution 1 (1-11) vs. 1 (1-11) weeks (p = 0.07), and morbidity 1.07% vs. 1.2% (p = 0.07).

CONCLUSIONS

The study advocates single-session laparoscopic cholecystectomy with transcystic CBD exploration as a feasible first choice treatment and the logical next step in the management of patients with CBD stones.

Current status of laparoscopic therapy of cholecystolithiasis and common bile duct stones

BACKGROUND

Laparoscopic cholecystectomy (LC) is the standard operation for gallstone disease. The aim of this review was to scrutinize the advantages and benefits of this minimal invasive technique compared to the conventional operation according to the available literature. Regarding the evidence-based medicine criteria, the current status of laparoscopy in the treatment of cholecystolithiasis, cholecystitis and common bile duct stones has been worked out.

METHODS

A Medline, PubMed, Cochrane search.

RESULTS

Ten randomized controlled trials (RCTs) are available comparing laparoscopic versus open cholecystectomy. The superiority of LC in less postoperative pain, shorter recovery and hospital stay is stated. Operation time was longer in the first years of LC. 3 RCTs deal with acute cholecystitis: one paper could not find any significant advantage of LC over conventional cholecystectomy, the other two found benefits in recovery, hospital stay and postoperative pain. The range of conversion is between 5 and 7% in elective cases and increases up to 27% for acute cholecystitis. With a rate of more than 90% in Europe, the standard procedure for common bile duct stones is 'therapeutic splitting' with endoscopy and retrograde cholangiopancreatography preoperatively followed by LC. Laparoscopic bile duct clearance is effective and safe in experienced hands, however, the only proven benefit is a slightly shorter hospital stay.

CONCLUSION

The laparoscopic approach is preferred in elective cholecystectomy and acute cholecystitis. The minimal invasive technique has proven to be effective, gentle and safe. The main benefits are evident within the first postoperative days.

Laparoscopic management of common bile duct stones

BACKGROUND

While laparoscopic cholecystectomy is widely accepted for therapy of cholecystolithiasis, controversy still exists concerning the management of common bile duct stones. Besides preoperative endoscopic papillotomy followed by laparoscopic cholecystectomy and open common bile duct surgery, management of common bile duct stones can be conducted by laparoscopy, if respective experience is available.

METHOD

During laparoscopic cholecystectomy a cholangiography via the cystic duct is routinely performed. If bile duct stones are detected they are retrieved via the cystic duct or via incision of the common bile duct by insertion of a Fogarty catheter or Dormia basket. Exclusion criteria against simultaneous laparoscopic management include suspicion of malignancy, severe pancreatitis, or cholangitis.

RESULTS

From November 1991 to March 2002, 200 patients primarily underwent laparoscopic therapy of bile duct stones. Retrieval was performed via cystic duct and common bile duct incision in 115 and 85 cases, respectively. Complete removal was achieved in 91%; complication rate and mortality was 7% and 0.5%, respectively. During the same period primary endoscopic papillotomy was necessary in 40 patients because of the above contraindications.

CONCLUSIONS

When correct indications and surgical expertise are observed, simultaneous laparoscopic management of common bile duct stones represents a safe and minimally invasive alternative to a two-procedure approach.

Endosonography with linear array instead of endoscopic retrograde cholangiography as the diagnostic tool in patients with moderate suspicion of common bile duct stones

AIM: To evaluate the diagnostic efficiency of endoscopic ultrasound (EUS) as the main imaging modality in patients with moderate suspicion of common bile duct stones (CBDS).

METHODS: 55 patients with moderate clinical suspicion of CBDS were prospectively included to the study and evaluated with EUS. This study was done in single blind method in the clinical and biochemical data of patients. EUS was done with echo-endoscope Pentax FG 32-UA (f = 5-7.5 MHz) and Hitachi EUB 405 ultrasound machine. Patients diagnosed with CBDS by EUS were excluded from this study and treated with ERC. All the other patients were included to the follow up study obtained by mail every 6 months for clinical evaluation (need of ERC or surgery).

RESULTS: CBDS was found in 4 patients by EUS. Diagnosis was confirmed in all cases on ERC. The remaining 51 patients without CBDS on EUS were followed up for 6-26 months (meanly 13 months) There were: 40 women, 42 cholecystectomized patients, aged: 55 (mean). Biochemical values (mean values) were as follows: bilirubin: 14.9 μmol·L^-1, alkaline phosphatase: 95 IU·L^-1, γ-GTP: 131 IU·L^-1, ALT: 50 IU·L^-1, AST: 49 IU·L^-1. Only 1 patient was lost for follow up. In the remaining 50 patients with follow up, there was only 1 (2%) patient with persistent biliary symptoms in whom CBDS was finally diagnosed by ERC with ES. All other patients remained symptoms free on follow up and did not require ERC or biliary surgery.

CONCLUSION: Vast majority of patients with moderate suspicion of CBDS and no stones on EUS with linear array can avoid invasive evaluation of biliary tree with ERC.

Tratamento cirúrgico da litíase biliar em idosos experiência em hospital de ensino

O receio de graves complicações pós-operatórias tem inibido muitas das indicações cirúrgicas da litíase biliar no paciente idoso sintomático. A finalidade principal deste trabalho foi averiguar a extensão real desse problema no Serviço de Gastroenterologia Cirúrgica do HSPE-FMO. Foram estudados 185 idosos portadores de litíase biliar com idade média de 73,0 ± 6,2 anos, no período de seis anos (1990-1995). Os pacientes foram divididos em dois grupos de acordo com a idade: I - com 118 (63,8%) pacientes de 60 a 74 anos e o II - com 67 (36,2%) pacientes entre 75 e 90 anos. O número de doentes do sexo masculino foi proporcionalmente maior no grupo II (p<0,02). Os sintomas foram similares nos dois grupos de enfermos. A maioria dos doentes foi submetida à operação eletiva-163 (88,1 %) sendo 22 (11,9%) operados de urgência por colecistite aguda. Maior número de cirurgias de urgência incidiu no grupo 11 (19,4% contra 7,6%). A colecistectomia foi realizada em todos os doentes. Cirurgia complementar indicada pela presença de coledocolitíase (15,1 %) e estenose papilar (2,7%) foi necessária em 38 (20,5%) deles, sendo maior no grupo II. A coledocolitotomia foi realizada em 28 (15,1%) doentes, a anastomose biliodigestiva em sete (3,8%) e a papilotomia em cinco (2,7%) doentes, não diferindo entre os dois grupos. Complicações pós-operatórias ocorreram em 37 (20%) doentes e foram as mesmas nos dois grupos. Não houve óbitos. Nossos resultados demonstram que a colecistectomia eletiva pode ser realizada com baixa morbidade e sem mortalidade em idosos, quando se impede a demora da indicação operatória em pacientes sintomáticos.

Yield of prospective, noninvasive evaluation of the common bile duct combined with selective ERCP/sphincterotomy in 1390 consecutive laparoscopic cholecystectomy patients

The role of noninvasive evaluation of the common bile duct combined with selective preoperative endoscopic retrograde cholangiography and sphincterotomy was prospectively evaluated in 1390 consecutive patients subjected to laparoscopic cholecystectomy. Preoperative common bile duct testing included liver chemistries, transcutaneous ultrasonography, and intravenous cholangiography. When indicated by various sets of abnormal studies, prelaparoscopic endoscopic retrograde cholangiography was attempted in 129 patients (9.3%) and successfully accomplished in 122 (94.6%). Seventy-six patients (62.3%) had duct stones or a papillary stenosis, and 73 of them (96%) were treated successfully by endoscopic duct clearance and subsequent laparoscopic cholecystectomy. No deaths occurred, and the morbidity rate was 6.2% (8/129), including 2 cases of pancreatitis and 1 case of a retained duct stone after sphincterotomy. Predicting the presence of common duct pathology was 60% accurate when based on abnormal laboratory test results alone, 69% when based on abnormal laboratory test results and concomitant radiologic abnormalities, and 42% when based on radiologic criteria alone (p < .05). We conclude that patients with altered serum liver chemistries with or without concomitant positive radiologic criteria should undergo endoscopic cholangiography before laparoscopic cholecystectomy. However, in patients with radiologic duct dilatation as the sole indicator for duct stones, the frequency of normal findings in endoscopic examinations is high. This latter group is probably better managed with intraoperative cholangiography and postlaparoscopic sphincterotomy if needed.

The E.A.E.S. Consensus Development Conferences on laparoscopic cholecystectomy, appendectomy, and hernia repair. Consensus statements--September 1994. The Educational Committee of the European Association for Endoscopic Surgery

Under the mandate of the Educational Committee of the European Association of Endoscopic Surgery (E.A.E.S.), three consensus development conferences (CDCs) were performed in order to assess the current status of the endoscopic surgical approaches for the treatment of cholelithiasis, appendicitis, and inguinal hernia. Consensus panels for the different disease states (10-13 members each) selected by the education committee on the basis of members' clinical expertise, academic activity, community influence, and geographical location weighed the evidence on the basis of published results according to the criteria for technology assessment: feasibility, efficacy, effectiveness, economy. Draft statements were prepared, discussed by the panels, and presented at plenary sessions of the 2nd European Congress of the E.A.E.S. in Madrid September 15-17, 1994. Following discussions final consensus statements were formulated to provide specific answers for each topic to a minimum of the following questions: 1. What stage of technological development is the endoscopic surgical procedure at (in September 1994)? 2. Is endoscopic surgery safe and feasible? 3. Is it beneficial to the patients? 4. Who should undergo endoscopic surgery? 5. What are the training recommendations? Laparoscopic cholecystectomy is the procedure of choice for symptomatic cholelithiasis. Laparoscopic appendectomy is presently at the efficacy stage of development, because most of the data on feasibility and safety originate from centers with special interest in endoscopic surgery: it is not yet the gold standard for acute appendicitis. Endoscopic hernia repair is presently a feasible alternative for conventional hernia repair if performed by experienced endoscopic surgeons. It appears to be efficacious in the short-term. The full text of the consensus panel's statements is given in this publication.

Traditional surgical management of common bile duct stones: a prospective study during a 20-year experience

PURPOSE

To analyze the operative findings and evaluate the hospital morbidity and mortality. This experience is documented in order to provide a basis for comparison with therapeutic alternatives.

PATIENTS AND METHODS

Prospective data were collected on 579 patients who underwent elective (n = 443) or emergent (n = 136) operations between 1970 and 1990. Their mean age was 60.1 years. Prior biliary symptoms were present in 96% and suggestive of choledocholithiasis in 69%. Acute pancreatitis was associated in 3%.

RESULTS

Cholecystectomy was performed with intraoperative cholangiography in 85% of cases. Stones were extracted via the cystic duct in 18%, through a choledochotomy in 79%, and through an additional sphincterotomy in 3%. Cholangioscopy has been routinely used since 1977. The incidence of extraction of the stones via the cystic duct increased and the incidence of biliary-enteric bypass decreased significantly during the second decade. Complications occurred in 24.5% of the patients. General complications were significantly fewer in the second decade than in the first (6% versus 15%). The main biliary complications were related to biliary tubes (5%) and retained stones (5%). Ten patients (2%) required early reoperation. The overall mortality rate was 0.3%. Mortality was 1.4% after emergency operations and zero after elective operations and in patients under 60 years of age. The mean stay was 16.6 +/- 7.2 days, decreasing with time.

CONCLUSION

Traditional open surgery is an effective and safe option for the management of cholelithiasis with choledocholithiasis. The choice between open surgery, laparoscopic surgery, and endoscopic sphincterotomy should be made for each patient according to the local availability and efficacy of these methods.

Appraisal of surgical and endoscopic management of choledocholithiasis

One hundred and ten patients with common bile duct (CBD) stones were treated in the Department of Surgical Gastroenterology at SGPGIMS, Lucknow, India between January 1989 and December 1992. The primary modality of treatment was surgery in 62 patients (group I) and endoscopic sphincterotomy (ES) in 48 (group II). The two groups were well matched with respect to clinical features and presence of medical risk factors. Surgical clearance of CBD stones was achieved in 58 patients (93.5%; group Ia). Four patients (7%) had retained stones following surgery (group Ib). In group II, the CBD was cleared by endoscopic means in 20 out of 48 patients (42%) and was categorized into group IIa. In the remaining patients ES was followed by CBD exploration (group IIb). Significantly higher morbidity was seen in patients needing CBD surgery following attempted endoscopic clearance, because of ES-related complications, such as bleeding, cholangitis, septicaemia and numerous others. Use of ES to treat CBD stones on a routine basis was therefore not found to be any better than one-time surgical exploration.