Laparoscopic transcystic bile duct stenting in the management of common bile duct stones

Preoperative admission is non-essential in most patients receiving elective laparoscopic cholecystectomy: A cohort study

We evaluated conventional overnight-stay laparoscopic cholecystectomy, focusing on the preoperative admission day, to assess the feasibility of implementing daycare laparoscopic cholecystectomy, which is currently underutilized in developing and some Asian countries. We retrospectively reviewed elective laparoscopic cholecystectomy data from March 2020 to February 2022 at a 700-bed tertiary hospital in Thailand. Variables included age, sex, body mass index, comorbidities, American Society of Anesthesiologists status, presence of preoperative anesthesiology visit, laparoscopic cholecystectomy indications, additional intraoperative cholangiography, and surgery cancellations. The primary focus was on preoperative treatment and monitoring needs; secondary outcomes included morbidity, mortality within 30 days, and prolonged hospital stay (>48 hours). Statistical analysis was conducted using the Fisher exact test, t-test, and logistic regression. The study included 405 patients. Of these, 65 (16.1%) received preoperative treatment, with 21 unnecessary (over) treatments and six under-treatments. Based on the results, approximately 12.1% (n = 49) of patients may have theoretically required preoperative admission and treatment. Multivariable analysis showed that the increasing of comorbidities was significantly associated with preoperative management (odds ratio [95% Confidence interval]: 7.0 [2.1, 23.1], 23.9 [6.6, 86.6], 105.5 [17.5, 636.6]) for one, two, and three comorbidities, respectively), but factors such as age, obesity, and American Society of Anesthesiologists status were not. The cohort had 4.2% morbidity (2.2% medical complications), with no mortality. Surgery cancellations occurred in 0.5%. In conclusion, on the basis of our data, a small proportion (12.1%) of patients undergoing elective laparoscopic cholecystectomy may require preoperative admissions to receive the necessary treatment, and most (87.9%) preoperative admissions may not provide treatment benefit. The traditional admission approach was safe but required re-evaluation for optimal resource management.

Selective Antegrade Biliary Stenting Aids Emergency Laparoscopic Cholecystectomy

Background: Symptomatic gall stone disease requires early emergency treatment to prevent complications. This early treatment is often delayed due to difficulty in the diagnosis and management of concomitant choledocholithiasis. Intervention with preoperative endoscopic retrograde cholangiopancreatography (ERCP) is associated with complications and known to be unnecessary in most cases. We follow a strategy of providing early cholecystectomy with selective utility of antegrade stent in cases of choledocholithiasis. Our main aim is to present our technique and results. Method: We conducted a 3-year (January 2014 to January 2017) review of a prospectively maintained database of our practice of performing routine intraoperative cholangiogram (IOC) during laparoscopic cholecystectomy (LC) and when choledocholithiasis is encountered on IOC; a transcystic antegrade biliary stent is inserted to decompress the common bile ducts (CBD) and facilitate postoperative ERCP at later date. Results: Of the 411 cholecystectomies performed, 77.3% were females with mean age of 48 years. Seventy-four patients were found to have CBD stones (CBDS) on IOC. Antegrade stents were successfully deployed in 69 cases. Even though Antegrade stents were done more frequently in emergency admissions (P = .001); this did not increase the length of hospital stay (LOHS) (P = .752) or the rate of complications (P = .171). However, doing a preoperative ERCP significantly increased LOHS (P = .001), and 67% of these needed two or more ERCP for complete clearance of CBD and had more complications. Nine (15.2%) out of 59 patients with pancreatitis had CBDS on IOC and were successfully managed with antegrade stent. Conclusion: This strategy can be followed by general surgeons, enabling them to perform LC in the presence of choledocholithiasis during acute admissions including pancreatitis. It does not require any specialist skills in CBD exploration and also eliminates unnecessary preoperative ERCP and avoids its potential complications.

Single-stage laparoscopic cholecystectomy and intraoperative endoscopic retrograde cholangiopancreatography: is this strategy feasible in Australia?

Currently in Australasia, concomitant cholecystolithiasis and choledocholithiasis are usually managed with two procedures: laparoscopic cholecystectomy (LC) and pre or postoperative endoscopic retrograde cholangiopancreatography (ERCP). This approach exposes the patient to the risk of complications from the common bile duct stone(s) while awaiting ERCP, the risks of the ERCP itself (particularly pancreatitis) and the need for a second anaesthetic. This article explores the evidence for a newer hybrid approach, single stage LC and intraoperative ERCP (SSLCE) and compares this approach with the commonly used alternatives. SSLCE offers reduced rates of pancreatitis, reduced length of hospital stay and reduced cost compared with the two-stage approach and requires only one anaesthetic. There is a reduced risk of bile leak compared with procedures that involve a choledochotomy, and ductal clearance rates are superior to trans-cystic exploration and equivalent to the standard two-stage approach. Barriers to widespread implementation relate largely to operating theatre logistics and availability of appropriate endoscopic expertise, although when bile duct stones are anticipated these issues are manageable. There is compelling justification in the literature to gather prospective evidence surrounding SSLCE in the Australian Healthcare system.

Surgery for common bile duct stones--a lost surgical skill; still worthwhile in the minimally invasive century?

PURPOSE

Techniques of laparoscopic bile duct exploration have been reported for over 20 years. Despite the simplicity and success of these procedures, they have failed to become commonplace in most surgical departments, as endoscopic retrograde cholangiopancreatography (ERCP) has become the preferred method for dealing with bile duct stones. There is a risk of surgeons not obtaining or losing these skills, which may still be required as a definitive treatment when ERCP fails or is not available.

METHODS AND RESULTS

This paper describes these laparoscopic operations, which can be performed to enable a 'one-stop shop' treatment of common bile duct stones (CBDS) at the time of cholecystectomy. In particular, transcystic basket clearance of the bile duct is possible in two-thirds of cases with very little increase in morbidity compared to routine cholecystectomy. The selection of patients who are most likely to be successfully treated with this technique is defined. Some of the authors have published large study series and prospective randomised trials, further refining the choices available to the surgeon who, when performing operative cholangiography, is already halfway to bile duct exploration.

CONCLUSIONS

Surgery may reclaim this lost ground by offering an excellent and safe therapeutic option for many of the symptomatic CBDS.

Systematic review and meta-analysis of minimally invasive techniques for the management of cholecysto-choledocholithiasis

BACKGROUND

The optimal management of patients with symptomatic gallstones and possible or proven common bile duct (CBD) stones and gallstones is still evolving. Today a number of options exist: preoperative endoscopic retrograde cholangiopancreatography (pre-op ERCP), laparoscopic cholecystectomy (LC) combined with intraoperative endoscopic sphincterotomy (IOES), laparoscopic common bile duct exploration (LCBDE) and postoperative ERCP (post-op ERCP). This meta-analysis was done to compare these management options and determine if any single option was clearly superior.

METHODS

A systematic search was conducted using several electronic databases. The search revealed 15 randomized controlled trials (RCTs). Six comparing pre-op ERCP with LCBDE, five comparing pre-op ERCP with IOES, two comparing IOES with LCBDE and two comparing post-op ERCP with LCBDE, comprising a total of 1992 patients.

RESULTS

The pre-op ERCP group had a significantly higher incidence of ERCP related complications (odds ratio: 2.40, 95% confidence interval: 1.21-4.75).

CONCLUSIONS

The evidence provided by this meta-analysis suggests that both of these approaches would appear comparable. To fully address which would be the better approach would require an RCT as discussed above.

Surgical versus endoscopic treatment of bile duct stones

BACKGROUND

Between 10% to 18% of people undergoing cholecystectomy for gallstones have common bile duct stones. Treatment of the bile duct stones can be conducted as open cholecystectomy plus open common bile duct exploration or laparoscopic cholecystectomy plus laparoscopic common bile duct exploration (LC + LCBDE) versus pre- or post-cholecystectomy endoscopic retrograde cholangiopancreatography (ERCP) in two stages, usually combined with either sphincterotomy (commonest) or sphincteroplasty (papillary dilatation) for common bile duct clearance. The benefits and harms of the different approaches are not known.

OBJECTIVES

We aimed to systematically review the benefits and harms of different approaches to the management of common bile duct stones.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL, Issue 7 of 12, 2013) in The Cochrane Library, MEDLINE (1946 to August 2013), EMBASE (1974 to August 2013), and Science Citation Index Expanded (1900 to August 2013).

SELECTION CRITERIA

We included all randomised clinical trials which compared the results from open surgery versus endoscopic clearance and laparoscopic surgery versus endoscopic clearance for common bile duct stones.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified the trials for inclusion and independently extracted data. We calculated the odds ratio (OR) or mean difference (MD) with 95% confidence interval (CI) using both fixed-effect and random-effects models meta-analyses, performed with Review Manager 5.

MAIN RESULTS

Sixteen randomised clinical trials with a total of 1758 randomised participants fulfilled the inclusion criteria of this review. Eight trials with 737 participants compared open surgical clearance with ERCP; five trials with 621 participants compared laparoscopic clearance with pre-operative ERCP; and two trials with 166 participants compared laparoscopic clearance with postoperative ERCP. One trial with 234 participants compared LCBDE with intra-operative ERCP. There were no trials of open or LCBDE versus ERCP in people without an intact gallbladder. All trials had a high risk of bias.There was no significant difference in the mortality between open surgery versus ERCP clearance (eight trials; 733 participants; 5/371 (1%) versus 10/358 (3%) OR 0.51;95% CI 0.18 to 1.44). Neither was there a significant difference in the morbidity between open surgery versus ERCP clearance (eight trials; 733 participants; 76/371 (20%) versus 67/358 (19%) OR 1.12; 95% CI 0.77 to 1.62). Participants in the open surgery group had significantly fewer retained stones compared with the ERCP group (seven trials; 609 participants; 20/313 (6%) versus 47/296 (16%) OR 0.36; 95% CI 0.21 to 0.62), P = 0.0002.There was no significant difference in the mortality between LC + LCBDE versus pre-operative ERCP +LC (five trials; 580 participants; 2/285 (0.7%) versus 3/295 (1%) OR 0.72; 95% CI 0.12 to 4.33). Neither was there was a significant difference in the morbidity between the two groups (five trials; 580 participants; 44/285 (15%) versus 37/295 (13%) OR 1.28; 95% CI 0.80 to 2.05). There was no significant difference between the two groups in the number of participants with retained stones (five trials; 580 participants; 24/285 (8%) versus 31/295 (11%) OR 0.79; 95% CI 0.45 to 1.39).There was only one trial assessing LC + LCBDE versus LC+intra-operative ERCP including 234 participants. There was no reported mortality in either of the groups. There was no significant difference in the morbidity, retained stones, procedure failure rates between the two intervention groups.Two trials assessed LC + LCBDE versus LC+post-operative ERCP. There was no reported mortality in either of the groups. There was no significant difference in the morbidity between laparoscopic surgery and postoperative ERCP groups (two trials; 166 participants; 13/81 (16%) versus 12/85 (14%) OR 1.16; 95% CI 0.50 to 2.72). There was a significant difference in the retained stones between laparoscopic surgery and postoperative ERCP groups (two trials; 166 participants; 7/81 (9%) versus 21/85 (25%) OR 0.28; 95% CI 0.11 to 0.72; P = 0.008.In total, seven trials including 746 participants compared single staged LC + LCBDE versus two-staged pre-operative ERCP + LC or LC + post-operative ERCP. There was no significant difference in the mortality between single and two-stage management (seven trials; 746 participants; 2/366 versus 3/380 OR 0.72; 95% CI 0.12 to 4.33). There was no a significant difference in the morbidity (seven trials; 746 participants; 57/366 (16%) versus 49/380 (13%) OR 1.25; 95% CI 0.83 to 1.89). There were significantly fewer retained stones in the single-stage group (31/366 participants; 8%) compared with the two-stage group (52/380 participants; 14%), but the difference was not statistically significantOR 0.59; 95% CI 0.37 to 0.94).There was no significant difference in the conversion rates of LCBDE to open surgery when compared with pre-operative, intra-operative, and postoperative ERCP groups. Meta-analysis of the outcomes duration of hospital stay, quality of life, and cost of the procedures could not be performed due to lack of data.

AUTHORS' CONCLUSIONS

Open bile duct surgery seems superior to ERCP in achieving common bile duct stone clearance based on the evidence available from the early endoscopy era. There is no significant difference in the mortality and morbidity between laparoscopic bile duct clearance and the endoscopic options. There is no significant reduction in the number of retained stones and failure rates in the laparoscopy groups compared with the pre-operative and intra-operative ERCP groups. There is no significant difference in the mortality, morbidity, retained stones, and failure rates between the single-stage laparoscopic bile duct clearance and two-stage endoscopic management. More randomised clinical trials without risks of systematic and random errors are necessary to confirm these findings.

Surgical versus endoscopic treatment of bile duct stones

BACKGROUND

Between 10% to 18% of people undergoing cholecystectomy for gallstones have common bile duct stones. Treatment of the bile duct stones can be conducted as open cholecystectomy plus open common bile duct exploration or laparoscopic cholecystectomy plus laparoscopic common bile duct exploration (LC + LCBDE) versus pre- or post-cholecystectomy endoscopic retrograde cholangiopancreatography (ERCP) in two stages, usually combined with either sphincterotomy (commonest) or sphincteroplasty (papillary dilatation) for common bile duct clearance. The benefits and harms of the different approaches are not known.

OBJECTIVES

We aimed to systematically review the benefits and harms of different approaches to the management of common bile duct stones.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL, Issue 7 of 12, 2013) in The Cochrane Library, MEDLINE (1946 to August 2013), EMBASE (1974 to August 2013), and Science Citation Index Expanded (1900 to August 2013).

SELECTION CRITERIA

We included all randomised clinical trials which compared the results from open surgery versus endoscopic clearance and laparoscopic surgery versus endoscopic clearance for common bile duct stones.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified the trials for inclusion and independently extracted data. We calculated the odds ratio (OR) or mean difference (MD) with 95% confidence interval (CI) using both fixed-effect and random-effects models meta-analyses, performed with Review Manager 5.

MAIN RESULTS

Sixteen randomised clinical trials with a total of 1758 randomised participants fulfilled the inclusion criteria of this review. Eight trials with 737 participants compared open surgical clearance with ERCP; five trials with 621 participants compared laparoscopic clearance with pre-operative ERCP; and two trials with 166 participants compared laparoscopic clearance with postoperative ERCP. One trial with 234 participants compared LCBDE with intra-operative ERCP. There were no trials of open or LCBDE versus ERCP in people without an intact gallbladder. All trials had a high risk of bias.There was no significant difference in the mortality between open surgery versus ERCP clearance (eight trials; 733 participants; 5/371 (1%) versus 10/358 (3%) OR 0.51;95% CI 0.18 to 1.44). Neither was there a significant difference in the morbidity between open surgery versus ERCP clearance (eight trials; 733 participants; 76/371 (20%) versus 67/358 (19%) OR 1.12; 95% CI 0.77 to 1.62). Participants in the open surgery group had significantly fewer retained stones compared with the ERCP group (seven trials; 609 participants; 20/313 (6%) versus 47/296 (16%) OR 0.36; 95% CI 0.21 to 0.62), P = 0.0002.There was no significant difference in the mortality between LC + LCBDE versus pre-operative ERCP +LC (five trials; 580 participants; 2/285 (0.7%) versus 3/295 (1%) OR 0.72; 95% CI 0.12 to 4.33). Neither was there was a significant difference in the morbidity between the two groups (five trials; 580 participants; 44/285 (15%) versus 37/295 (13%) OR 1.28; 95% CI 0.80 to 2.05). There was no significant difference between the two groups in the number of participants with retained stones (five trials; 580 participants; 24/285 (8%) versus 31/295 (11%) OR 0.79; 95% CI 0.45 to 1.39).There was only one trial assessing LC + LCBDE versus LC+intra-operative ERCP including 234 participants. There was no reported mortality in either of the groups. There was no significant difference in the morbidity, retained stones, procedure failure rates between the two intervention groups.Two trials assessed LC + LCBDE versus LC+post-operative ERCP. There was no reported mortality in either of the groups. There was no significant difference in the morbidity between laparoscopic surgery and postoperative ERCP groups (two trials; 166 participants; 13/81 (16%) versus 12/85 (14%) OR 1.16; 95% CI 0.50 to 2.72). There was a significant difference in the retained stones between laparoscopic surgery and postoperative ERCP groups (two trials; 166 participants; 7/81 (9%) versus 21/85 (25%) OR 0.28; 95% CI 0.11 to 0.72; P = 0.008.In total, seven trials including 746 participants compared single staged LC + LCBDE versus two-staged pre-operative ERCP + LC or LC + post-operative ERCP. There was no significant difference in the mortality between single and two-stage management (seven trials; 746 participants; 2/366 versus 3/380 OR 0.72; 95% CI 0.12 to 4.33). There was no a significant difference in the morbidity (seven trials; 746 participants; 57/366 (16%) versus 49/380 (13%) OR 1.25; 95% CI 0.83 to 1.89). There were significantly fewer retained stones in the single-stage group (31/366 participants; 8%) compared with the two-stage group (52/380 participants; 14%), but the difference was not statistically significantOR 0.59; 95% CI 0.37 to 0.94).There was no significant difference in the conversion rates of LCBDE to open surgery when compared with pre-operative, intra-operative, and postoperative ERCP groups. Meta-analysis of the outcomes duration of hospital stay, quality of life, and cost of the procedures could not be performed due to lack of data.

AUTHORS' CONCLUSIONS

Open bile duct surgery seems superior to ERCP in achieving common bile duct stone clearance based on the evidence available from the early endoscopy era. There is no significant difference in the mortality and morbidity between laparoscopic bile duct clearance and the endoscopic options. There is no significant reduction in the number of retained stones and failure rates in the laparoscopy groups compared with the pre-operative and intra-operative ERCP groups. There is no significant difference in the mortality, morbidity, retained stones, and failure rates between the single-stage laparoscopic bile duct clearance and two-stage endoscopic management. More randomised clinical trials without risks of systematic and random errors are necessary to confirm these findings.

Management of common bile duct stones in the laparoscopic era

There is no consensus regarding the ideal management of concurrent gallbladder and common bile duct (CBD) stones. Currently the treatment protocol involves most commonly a sequential approach consisting of endoscopic sphincterotomy followed by laparoscopic cholecystectomy or a single stage laparoscopic procedure, including cholecystectomy and exploration of the CBD. For this article literature search was performed using online search engines, Google, Pubmed, the online Springer link library and the Cochrane Database Systematic Review. Review articles, prospective and retrospective studies which detailed or compared the various treatment strategies for CBD stones were selected and analyzed. This review article aims to provide an insight into the optimal management of CBD stones in different clinical scenarios. Endoscopic sphincterotomy has inherent morbidity and complications like CBD stone recurrence whereas laparoscopic CBD exploration demands considerable expertise which is available only at specialized centres. The clinical presentation of the patient, number of stones, size of CBD, available resources and technical expertise at hand are an important consideration for the ideal management in different scenarios.

Choledocholithiasis: overdiagnosed endoscopically and undertreated laparoscopically

BACKGROUND

Two recent meta-analyses suggest that operative common bile duct (CBD) exploration (laparoscopic or open) may be superior to endoscopic retrograde cholangiopancreatography (ERCP) for the management of choledocholithiasis when the gall bladder is in situ. Much of the published work regarding laparoscopic exploration comes from enthusiasts of the technique and may not be transferable to other institutions. In our institution, both hepatobiliary and general surgeons carry out cholecystectomy, with differing levels of expertise in laparoscopic bile duct exploration. ERCP and laparoscopic antegrade transampullary endobiliary stents are available. We reviewed the management of choledocholithiasis in this setting.

METHODS

A retrospective review of all patients undergoing cholecystectomy during 2004 and 2005 at John Hunter and Belmont Hospitals (Newcastle, Australia) was conducted.

RESULTS

The overall incidence of choledocholithiasis was 10.3% (70 of 681). Fifty patients underwent preoperative ERCP, with choledocholithiasis confirmed in only 24 patients (therapeutic rate 30%). Thirty-one patients underwent CBD exploration with 100% clearance through an open approach (12 patients) and 58% clearance through a laparoscopic approach (11 of 19 patients). Hepatobiliary surgeons carried out 22 of 31 CBD explorations (clearance rate 82%) and placed 13 transampullary antegrade endobiliary stents. In comparison, general surgeons carried out nine CBD explorations (clearance rate 56%) and placed only four antegrade stents.

CONCLUSION

This series suggests that preoperative ERCP is significantly overutilized, laparoscopic CBD exploration is less successful than open CBD exploration and that antegrade transampullary intraoperative endobiliary stenting is underutilized by non-hepatobiliary surgeons.

Treatment of common bile duct stones discovered during cholecystectomy

BACKGROUND

Several techniques of laparoscopic bile duct exploration and intraoperative endoscopic sphincterotomy (ES) have been developed to treat patients with common bile duct (CBD) stones in one session and avoid the complications of ES. With all these options available, very few randomized controlled trials (RCTs) have been undertaken. This review analyzes those studies.

METHODS

We searched PubMed. Four RCTs and a Cochran Database Systematic Review were found.

RESULTS

Two RCTs compared preoperative ES and laparoscopic CBD exploration (E) for known CBD stones. Laparoscopic CBDE had shorter length of hospitalization. Two RCTs compared immediate and delayed treatment and found that length of stay was less with laparoscopic CBDE, but clearance rates and morbidity/mortality were similar.

CONCLUSIONS

Studies suggest that CBD stones discovered at the time of cholecystectomy are best treated during the same operation. The transcystic approach is safest if applicable. Individual surgeons must be aware of their own capabilities and those of the available endoscopists and perform the safest technique.

Laparoscopic deployment of biliary self-expandable metal stent (SEMS) for one-step palliation in 23 patients with advanced pancreatico-biliary tumors--a pilot trial

BACKGROUND

Exploratory laparoscopy is commonly undertaken in patients with highly suspicious biliary and pancreatic lesions to facilitate diagnosis and staging cancer is present. If an unresectable tumor is identified, a second endoscopic procedure may be required do deploy a self-expandable metal stent (SEMS) for palliation. As endoscopic retrograde cholangio pancreatography (ERCP) may be unsuccessful in up to 20% of patients, we evaluated the feasibility and safety of deployment of self-expandable metal stents at the same time as the initial laparoscopy.

PATIENTS AND METHODS

A total of 23 eligible patients (8 male and 15 female) with malignant obstruction of the common bile duct underwent deployment of SEMS at laparoscopy. Primary outcome measure was the successful laparoscopic deployment of stent and secondary outcome measure was complications rates.

RESULTS

Indications for stent deployment were unresectable pancreatic cancer in 18, cholangiocarcinoma in two, neuroendocrine tumor in one and ampullary adenocarcinoma in two patients. The median age was 73 years (range 49-93). Twenty-two of 23 stents were deployed successfully: 17 stents were deployed transcystically and five via a choledochotomy. Median times for laparoscopic exploration and SEMS deployment were 165 min (range 105-230) and 20 min (range 10-50), respectively. Pre- and post-procedures median total bilirubin were 9.4 mg/dl (range 5.4-17.5) and 4.0 (range 2.6-7.1). The median size of the pancreatic mass was 3 cm (range 2-5 cm) and that of the common bile duct (CBD) from 9.2 mm (range 7.2-17.4). The mean duration of laparoscopy was 170 min (range 120-230 min) and that for stent deployment 23 min (range 10-50 min). Complications included bleeding, obstruction, and wound infection. Bleeding occurred on day 7 in two patients and on day 30 in one patient; bleeding occurred at the gastrojejunal anastomosis site and was successfully treated with endoscopic hemostasis. A total of three stent obstructions were identified: one each at 60, 90, and 120 days follow-up. All complications were successfully managed endoscopically. There were a total of seven deaths, six as a result of progressive cancer and one of surgical wound infection and ensuing complications.

CONCLUSION

This study demonstrates that laparoscopic deployment of self-expandable metal bile duct stents is feasible and safe. This option appears to be a reasonable option in patients with inoperable malignant obstruction of the distal common bile duct.

Laparoscopic bile duct exploration: results of 160 consecutive cases with 2-year follow up

BACKGROUND

Despite numerous reports showing the advantages of laparoscopic common bile duct exploration (LCBDE), many general surgeons, particularly those working outside of nonspecialist units, continue to rely heavily on endoscopic retrograde cholangiography with sphincterotomy (ERCP) to manage bile duct stones (BDS). This article investigates the performance of LCBDE when adopted as the preferred first-line management of both suspected and incidental BDS by general surgeons in a regional setting.

METHODS

A retrospective review was conducted of all patients in whom LCBDE was attempted by a regional general surgical unit. The unit policy was to preferentially treat all incidental and suspected BDS (except in ascending cholangitis or severe pancreatitis) by LCBDE, with ERCP used only if unsuccessful. In addition to chart review, formal prospective follow up by telephone interview was carried out.

RESULTS

A total of 160 consecutive patients with BDS (mean age 66.9 years, 65% suspected and 35% incidental) underwent attempted LCBDE between January 2000 and July 2005. Successful clearance was achieved in 84.3% according to chart review. However, four additional cases of retained choledocholithiasis shown by late telephone interview (median interval 2.5 years) yielded a more accurate clearance rate of 81.8%. Major morbidity occurred in 13.8%, including biliary leak in 7.5% and one late biliary stricture (0.6%). Median length of hospital stay was 4.8 days. In-hospital mortality was 0.6%.

CONCLUSION

Laparoscopic common bile duct exploration remains an effective, efficient and safe first-line treatment of BDS even when carried out in regional nonspecialist units. In spite of the wide availability of ERCP, general surgeons should be encouraged to continue performing LCBDE in order to optimise patient care and maintain important surgical skills.

Operative cholangiography in two-port needlescopic cholecystectomy

We report the use of operative cholangiography in two-port needlescopic (minilaparoscopic) cholecystectomy. A prospective series of 11 patients underwent two-port needlescopic cholecystectomy with operative cholangiography. In ten cases, operative cholangiography was successfully performed. There were no conversions. No additional ports were required. No related complications were noted. Two cases positive for common bile duct stones were identified. The median operative time was 92.5 minutes. Operative cholangiography in two-port needlescopic cholecystectomy is safe and feasible.

Surgical versus endoscopic treatment of bile duct stones

BACKGROUND

10% to 18% of patients undergoing cholecystectomy for gallstones have common bile duct (CBD) stones. Treatment options for these stones include pre- or post-operative endoscopic retrograde cholangiopancreatography (ERCP) or open or laparoscopic surgery.

OBJECTIVES

To systematically review the management of CBD stones by four approaches: (1) ERCP versus open surgical bile duct clearance. (2) Pre-operative ERCP versus laparoscopic bile duct clearance. (3) Post-operative ERCP versus laparoscopic bile duct clearance. (4) ERCP versus laparoscopic bile duct clearance in patients with previous cholecystectomy.

SEARCH STRATEGY

We systematically searched key relevant electronic databases, bibliographies of relevant papers, and abstracts of relevant subspecialty meetings until November 2005.

SELECTION CRITERIA

The quality of included trials was assessed by adequacy of allocation sequence generation, allocation concealment, blinding, and follow-up.

DATA COLLECTION AND ANALYSIS

Published and unpublished data relevant to 12 predefined outcome measures were used to conduct fixed- and random-effects models meta-analyses, with exploration of heterogeneity and use of sensitivity and subgroup analysis where required.

MAIN RESULTS

Thirteen trials randomised 1351 patients. Eight trials (n = 760) compared ERCP with open surgical clearance, three (n = 425) compared pre-operative ERCP with laparoscopic clearance, and two (n = 166) compared post-operative ERCP with laparoscopic clearance. There were no trials of ERCP versus laparoscopic clearance in patients without an intact gallbladder. Methodology was considered adequate in at least two of three assessable fields in ten trials. A significantly increased number of total procedures (including for complications) per patient was seen in the ERCP arms in all three comparisons with weighted mean differences of 0.62 (95% CI 0.15 to 1.09), 0.96 (95% CI 0.96 to 0.96), and 1.09 (95% CI 0.93 to 1.24), respectively. ERCP was less successful than open surgery in CBD stone clearance (Peto OR 2.89, 95% CI 1.81 to 4.61) with a tendency towards higher mortality (risk difference 1%, 95% CI -1% to 4%). Laparoscopic CBD stone clearance was as efficient as pre- (Peto OR 1.00, CI 0.53 to 1.80) and post-operative ERCP (OR 2.27, 95% CI 0.37 to 13.9) and with no significant difference in morbidity and mortality. Laparoscopic trials universally reported shorter hospital stays in surgical arms. Insufficient data were reported for cost analysis.

AUTHORS' CONCLUSIONS

In the era of open cholecystectomy, open bile duct surgery was superior to ERCP in achieving CBD stone clearance. In the laparoscopic era, data are close to excluding a significant difference between laparoscopic and ERCP clearance of CBD stones. The use of ERCP necessitates increased number of procedures per patient.