Cholelithiasis and Cholecystitis: Surgical Treatment

Endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis of biliary and pancreatic duct disease: A prospective study on 668 Jordanian patients

Endoscopic retrograde cholangiopancreatography (ERCP) is the method of choice in establishing the nature and the site of common bile and pancreatic duct disease and related complications. It was used in 668 Jordanian patients who presented with biliary or pancreatic disease and unexplained upper abdominal pain. Common bile duct (CBD) stones, postsurgical traumatic CBD strictures, papillary stenosis and malignant strictures were the most common findings in this study. The incidence of malignant strictures was less and the postsurgical CBD injuries, mainly CBD complete ligation, were more than what was reported by others. This procedure was also valuable in the investigation of unexplained upper abdominal pain and pancreatic disease.

Biliary tract emergencies. Acute cholecystitis, acute cholangitis, and acute pancreatitis

Acute cholecystitis, acute cholangitis, and acute pancreatitis represent the most common biliary tract emergencies. Most are due to gallstones in the gallbladder and bile ducts. Acute cholecystitis is treated by surgery in most cases. Laparoscopic cholecystectomy combined with endoscopic sphincterotomy may become more common in the future for treatment of acute cholecystitis as well as in cases of acute cholangitis and pancreatitis if the bile ducts are cleared of gallstones. Although the role of either surgery or endoscopic treatment may be more clearly defined in some biliary tract emergencies, in other situations either modality may be appropriate or they may compliment each other. Most biliary emergencies should be managed by gastroenterologists, surgeons, and radiologists working together in a harmonious fashion.

Cost-effectiveness of laparoscopic cholecystectomy versus open cholecystectomy

To assess the cost-effectiveness of laparoscopic cholecystectomy versus open cholecystectomy from the payer's perspective, we estimated the probabilities of potential outcomes of each procedure, associated quality-of-life effects, and related direct medical charges and incorporated these estimates into a computerized simulation model. The model projects that laparoscopic cholecystectomy will be more effective than open surgery in terms of total mortality and quality-adjusted survival, for both sexes and all ages. Projected 5-year cumulative charges are lower for laparoscopic cholecystectomy than for open cholecystectomy ($5,354 versus $5,525 for 45-year-old women; $6,036 versus $6,830 for 45-year-old men), and the differences increase substantially with increasing age. We concluded that laparoscopic cholecystectomy is likely to be less costly and more effective than open cholecystectomy for most patients, as long as it does not routinely require preoperative cholangiography and is not associated with increased professional fees or increased risks of retained stones or bile duct injury.

Non-surgical management of bile duct stones

Endoscopic sphincterotomy with stone extraction is the non-surgical method of choice for treatment of choledocholithiasis in patients unfit for surgery or with previous cholecystectomy. Its success rate is 85-90%. Many adjunctive methods have been developed to increase the clearance rate after initial failure and are reviewed in this paper. Collaboration among the surgeon, endoscopist and radiologist offers the patient a high opportunity for successful clearance of common bile duct (CBD) stones with the least morbidity and mortality. The application of endoscopic sphincterotomy combined with laparoscopic cholecystectomy to younger patients is now debated.

Cost-effectiveness of extracorporeal shock-wave lithotripsy versus cholecystectomy for symptomatic gallstones

To evaluate the cost-effectiveness of extracorporeal shock-wave lithotripsy vs. cholecystectomy for symptomatic gallstones, a model was constructed that projects charges and survival for both treatments. For a 45-year-old woman with one small stone, treatment with extracorporeal shock-wave lithotripsy rather than cholecystectomy is projected to result in an average gain of only 3 days of life and an average increase in direct medical charges of $1729 over 5 years of follow-up. The resulting marginal cost-effectiveness of extracorporeal shock-wave lithotripsy vs. cholecystectomy is $216,000 of extra charges per year of life gained with extracorporeal shock-wave lithotripsy. Extracorporeal shock-wave lithotripsy is projected to be much more cost-effective for elderly than for young patients (10-20-fold difference), but considerably less cost-effective for multiple stones than a single stone (2-4-fold difference), and less cost-effective for women than men (twofold difference). Adjusting for effects of morbidity on quality of life, extracorporeal shock-wave lithotripsy is projected to have slightly better quality-adjusted survival than cholecystectomy for the small subset of patients with one stone (by 8 to 43 days at 5 years) but not for young patients with multiple stones. It is concluded that decisions about appropriate use of extracorporeal shock-wave lithotripsy should consider the effects of patient characteristics on clinical and economic outcomes.

Common bile duct calculi. 1. Surgical therapy

Multiple techniques are now available for management of the patient with retained or recurrent common bile duct calculi. The goal of treatment is extraction of calculi with the lowest possible incidence of morbidity and mortality, the lowest cost and least discomfort to the patient, and the best long-term results. The choice of therapy--surgical or nonsurgical--depends on several factors, including presence or absence of the gallbladder and a T tube, type of calculi, operative risk, accompanying conditions, and expertise available at a particular institution. The decision to explore the common bile duct at the time of elective cholecystectomy is based on clinical, operative, and cholangiographic information. A rigorous technique of surgical exploration that includes duodenal mobilization, choledochoscopy, and cholangiography is necessary. In selected patients, biliary enteric anastomosis decreases the incidence of retained or recurrent calculi.