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Castelan JDB, Zapelini AP, Cacciatori FA, Zilberstein B. CHOLECYSTECTOMY WITH INTRAOPERATIVE ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY: DOES THE ORDER MATTER? ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2024; 37:e1816. [PMID: 39166653 PMCID: PMC11338519 DOI: 10.1590/0102-6720202400023e1816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 05/18/2024] [Indexed: 08/23/2024]
Abstract
BACKGROUND The recommended treatment for cholecystocholedocholithiasis is cholecystectomy (CCT) associated with endoscopic retrograde cholangiopancreatography (ERCP). CCT with intraoperative ERCP is associated with higher success rates and lower hospital stays and hospital costs. However, some case series do not describe the exact methodology used: whether ERCP or CCT was performed first. AIMS Verify if there is a difference, in terms of outcomes and complications, when intraoperative ERCP is performed immediately before or after CCT. METHODS This is a retrospective case-control study analyzing all patients who underwent CCT with intraoperative ERCP between January 2021 and June 2022, in a tertiary hospital in southern Brazil, for the treatment of cholecystocholedocholithiasis. RESULTS Out of 37 patients analyzed, 16 (43.2%) underwent ERCP first, immediately followed by CCT. The overall success rate for the cannulation of the bile duct was 91.9%, and bile duct clearance was achieved in 75.7% of cases. The post-ERCP pancreatitis rate was 10.8%. When comparing the "ERCP First" and "CCT First" groups, there was no difference in technical difficulty for performing CCT. The "CCT First" group had a higher rate of success in bile duct cannulation (p=0.020, p<0.05). Younger ages, presence of stones in the distal common bile duct and shorter duration of the procedure were factors statistically associated with the success of the bile duct clearance. Lymphopenia and cholecystitis as an initial presentation, in turn, were associated with failure to clear the bile duct. CONCLUSIONS There was no significant difference in terms of complications and success in clearing the bile ducts among patients undergoing CCT and ERCP in the same surgical/anesthetic procedure, regardless of which procedure was performed first. Lymphopenia and cholecystitis have been associated with failure to clear the bile duct.
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Affiliation(s)
| | | | - Felipe Antônio Cacciatori
- Hospital São José, General Surgery Service – Criciúma (SC), Brazil
- Santa Casa de Misericórdia, Hepatobiliopancreatic and Liver Transplant Service – Porto Alegre (RS), Brazil
- Universidade Federal do Rio Grande do Sul, Master in Surgical Sciences – Porto Alegre (RS), Brazil
| | - Bruno Zilberstein
- Universidade de São Paulo, Faculty of Medicine, Cancer Institute – São Paulo (SP), Brazil
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Sanin G, Cambronero G, Patterson J, Bosley M, Ganapathy A, Wescott C, Neff L. ERCP findings provide further justification for a "surgery-first" mindset in choledocholithiasis. Surg Endosc 2023; 37:8714-8719. [PMID: 37524916 DOI: 10.1007/s00464-023-10329-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 07/19/2023] [Indexed: 08/02/2023]
Abstract
INTRODUCTION Choledocholithiasis is most often managed in a two-procedure pathway including endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC). In contrast, a single-stage, surgery-first approach consisting of LC, cholangiogram, and laparoscopic common bile duct exploration (LCBDE) is associated with reduced hospital stays and equivalent morbidity. Despite this, nationwide referral patterns heavily favor ERCP, obscuring those undergoing ERCP with obstructions amenable to simple intraoperative interventions. We hypothesized that most patients had endoscopic findings consistent with simple sludge or small-to-medium stones, which could have been cleared by basic LCBDE maneuvers. METHODS We retrospectively reviewed 294 patients > 18 years old who underwent preoperative ERCP for the management of suspected choledocholithiasis. Exclusion criteria included: failed ERCP, cholangitis, prior cholecystectomy, patient refusal of surgery, or medical conditions precluding surgical candidacy. Stone size was categorized as small (0-4 mm), medium (5-7 mm), and large (≥ 8 mm). RESULTS At the time of ERCP, 37 (20.1%) patients had sludge only, 96 (52.2%) had stones only, 42 (22.8%) had sludge and stones, and 9 (4.8%) had no stones. Of the 138 patients with any stones, 37 (26.8%) had small stones, 41 (29.7%) medium, 43 (31.2%) large, and 17 (12.3%) had uncharacterizable stones. Overall, 74.3% of patients had findings of sludge, stones (0-7 mm), or negative ERCP. CONCLUSION The majority of patients who underwent preoperative ERCP for suspected choledocholithiasis had findings that are amenable to simple intraoperative interventions. In fact, over a quarter of the patients had a negative ERCP, sludge, or small stones which would likely be cleared by flushing/glucagon precluding any further instrumentation. While large stones may require more advanced techniques, this represents a small percentage of patients. Surgery-first management for suspected choledocholithiasis can offer an efficient alternative for the majority of patients.
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Affiliation(s)
- Gloria Sanin
- Wake Forest Baptist Medical Center, 1 Medical Center Blvd, Winston-Salem, NC, 27157, USA.
| | - Gabriel Cambronero
- Wake Forest Baptist Medical Center, 1 Medical Center Blvd, Winston-Salem, NC, 27157, USA
| | - James Patterson
- Wake Forest Baptist Medical Center, 1 Medical Center Blvd, Winston-Salem, NC, 27157, USA
| | - Maggie Bosley
- Wake Forest Baptist Medical Center, 1 Medical Center Blvd, Winston-Salem, NC, 27157, USA
| | - Aravindh Ganapathy
- Wake Forest Baptist Medical Center, 1 Medical Center Blvd, Winston-Salem, NC, 27157, USA
| | - Carl Wescott
- Wake Forest Baptist Medical Center, 1 Medical Center Blvd, Winston-Salem, NC, 27157, USA
| | - Lucas Neff
- Wake Forest Baptist Medical Center, 1 Medical Center Blvd, Winston-Salem, NC, 27157, USA
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Almaslamani A, Aldusari R, Arishi H, Alaamri A, Almudaiheem F, Almutairi S, Alshuraymi A, El-Boghdadly S. Compliance to endoscopic retrograde cholangiopancreatography according to current guidelines and adverse outcomes of suspected choledocholithiasis in an acute care setting. Surg Endosc 2022; 36:5602-5609. [PMID: 35277770 DOI: 10.1007/s00464-022-09113-0] [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: 10/14/2020] [Accepted: 02/07/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Common bile duct (CBD) stones are common among patients who underwent cholecystectomy. However, few studies have investigated the compliance with the guidelines for the prediction of choledochlithiasis (CL). Therefore, we aim to study the compliance with the American Society for Gastrointestinal Endoscopy (ASGE) guidelines for the identification of CL in a major hospital in Saudi Arabia's capital. METHODS We conducted a retrospective chart review on adult patients admitted to emergency department at King Abdulaziz Medical City, Riyadh with gallstones between January 2016 and January 2019. Our data collection includes demographics and level of suspicion based on Transabdominal Ultrasound, liver function, amylase, and lipase tests. We then determined the likelihood of CL based on ASGE guidelines in order to assess the adherence to ASGE guidelines, the procedure's outcomes and adverse outcomes. RESULTS We identified 826 patients who met the study's criteria: 384 (46.4%) were compliant, while 442 (53.6%) were non-compliant with ASGE guidelines. There was a significant association between compliance and the presence of stones on ERCP in high likelihood patients. 48 (21.3%) of total ERCP procedures among all the likelihoods had adverse outcomes. 13 (40.6%) of non-compliant ERCP performed in intermediate likelihood have experienced adverse outcomes. There was a significant association between having adverse outcomes and being non-complaint with ASGE guidelines. CONCLUSION Despite ASGE guidelines' recommendations, a third of high likelihood cases and the majority of intermediate likelihood cases were non-compliant. Additionally, the current guidelines for the intermediate group are somewhat vague, giving ample leeway for patients to be placed in the intermediate group, which might subject them to unnecessary interventions. To conclude, there was a great lack of compliance with ASGE guidelines that is significantly associated with adverse outcomes. Hence, reassessing the current guidelines and monitoring healthcare facilities' compliance with the updated guidelines is highly recommended.
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Affiliation(s)
- Abdulrahman Almaslamani
- College of Medicine, AlMaarefa University, 7265 Alnahdah District, Shabwah street, Riyadh, 13221-3122, Saudi Arabia.
| | - Rakan Aldusari
- College of Medicine, King Saud Bin Abdulaziz University for Health Science, Riyadh, Saudi Arabia
| | - Hassan Arishi
- King Abdulaziz Medical City, National Guard, Riyadh, Saudi Arabia
| | - Ahmed Alaamri
- College of Medicine, King Khalid University, Abha, Saudi Arabia
| | | | - Sami Almutairi
- College of Medicine, Qassim University, Buraydah, Saudi Arabia
| | - Abdulhakim Alshuraymi
- College of Medicine, AlMaarefa University, 7265 Alnahdah District, Shabwah street, Riyadh, 13221-3122, Saudi Arabia
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Kim BS, Joo SH, Cho S, Han MS. Who experiences endoscopic retrograde cholangiopancreatography after laparoscopic cholecystectomy for symptomatic gallstone disease? Ann Surg Treat Res 2016; 90:309-14. [PMID: 27274506 PMCID: PMC4891521 DOI: 10.4174/astr.2016.90.6.309] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 03/07/2016] [Accepted: 03/24/2016] [Indexed: 12/21/2022] Open
Abstract
Purpose Laparoscopic cholecystectomy (LC) has become a standard treatment of symptomatic gallstone disease. But, some patients suffer from retained common bile duct stones after LC. The aim of this study is to analyze the predicting factors associated with subsequent postoperative endoscopic retrograde cholangiopancreatography (ERCP) after LC. Methods We retrospectively reviewed a database of every LC performed between July 2006 and September 2012. We classify 28 patients who underwent ERCP within 6 months after LC for symptomatic gallstone disease as the ERCP group and 56 patients who underwent LC for symptomatic gallstone disease during same period paired by sex, age, underlying disease, operation history, and body mass index as the control group. To identify risk factor performing postoperative ERCP after LC, we compared admission route, preoperative biochemical liver function test, number of gall stones, gallstone size, adhesion around GB, wall thickening of GB, and existence of acute cholecystitis between the 2 groups. Results Admission route, preoperative AST, ALT, and ALP, stone size, longer operation time, and acute cholecystitis were identified as risk factors of postoperative ERCP in univariate analyses. But, longer operation time (P = 0.004) and acute cholecystitis (P = 0.048) were identified as independent risk factors of postoperative ERCP in multivariate analyses. Conclusion The patient who underwent ERCP after LC for symptomatic gallstone disease are more likely experienced longer operation time and acute cholecystitis than the patient who did not undergo ERCP after LC.
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Affiliation(s)
- Bum-Soo Kim
- Department of Surgery, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Sun-Hyung Joo
- Department of Surgery, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Sungsin Cho
- Department of Surgery, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Min-Soo Han
- Department of Surgery, School of Medicine, Kyung Hee University, Seoul, Korea
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Gurusamy KS, Koti R, Davidson BR. T-tube drainage versus primary closure after laparoscopic common bile duct exploration. Cochrane Database Syst Rev 2013:CD005641. [PMID: 23794201 DOI: 10.1002/14651858.cd005641.pub3] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND T-tube drainage may prevent bile leak from the biliary tract following bile duct exploration and it offers post-operative access to the bile ducts for visualisation and exploration. Use of T-tube drainage after laparoscopic common bile duct (CBD) exploration is controversial. OBJECTIVES To assess the benefits and harms of T-tube drainage versus primary closure after laparoscopic common bile duct exploration. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until April 2013. SELECTION CRITERIA We included all randomised clinical trials comparing T-tube drainage versus primary closure after laparoscopic common bile duct exploration. DATA COLLECTION AND ANALYSIS Two of four authors independently identified the studies for inclusion and extracted data. We analysed the data with both the fixed-effect and the random-effects model meta-analyses using Review Manager (RevMan) Analysis. For each outcome we calculated the risk ratio (RR), rate ratio (RaR), or mean difference (MD) with 95% confidence intervals (CI) based on intention-to-treat analysis. MAIN RESULTS We included three trials randomising 295 participants: 147 to T-tube drainage versus 148 to primary closure. All trials had a high risk of bias. No one died during the follow-up period. There was no significant difference in the proportion of patients with serious morbidity (17/147 (weighted percentage 11.3%) in the T-tube drainage versus 9/148 (6.1%) in the primary closure group; RR 1.86; 95% CI 0.87 to 3.96; three trials), and no significant difference was found in the serious morbidity rates (weighted serious morbidity rate = 97 events per 1000 patients) in participants randomised to T-tube drainage versus serious morbidity rate = 61 events per 1000 patients in the primary closure group; RR 1.59; 95% CI 0.66 to 3.83; three trials). Quality of life was not reported in any of the trials. The operating time was significantly longer in the T-tube drainage group compared with the primary closure group (MD 21.22 minutes; 95% CI 12.44 minutes to 30.00 minutes; three trials). The hospital stay was significantly longer in the T-tube drainage group compared with the primary closure group (MD 3.26 days; 95% CI 2.49 days to 4.04 days; three trials). According to one trial, the participants randomised to T-tube drainage returned to work approximately eight days later than the participants randomised to the primary closure group (P < 0.005). AUTHORS' CONCLUSIONS T-tube drainage appears to result in significantly longer operating time and hospital stay as compared with primary closure without any evidence of benefit after laparoscopic common bile duct exploration. Based on currently available evidence, there is no justification for the routine use of T-tube drainage after laparoscopic common bile duct exploration in patients with common bile duct stones. More randomised trials comparing the effects of T-tube drainage versus primary closure after laparoscopic common bile duct exploration may be needed. Such trials should be conducted with low risk of bias, assessing the long-term beneficial and harmful effects including long-term complications such as bile stricture and recurrence of common bile duct stones.
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For patients with predicted low risk for choledocholithiasis undergoing laparoscopic cholecystectomy, selective intraoperative cholangiography and postoperative endoscopic retrograde cholangiopancreatography is an effective strategy to limit unnecessary procedures. Surg Endosc 2008; 23:1933-7. [PMID: 19116743 DOI: 10.1007/s00464-008-0250-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2008] [Accepted: 10/17/2008] [Indexed: 12/20/2022]
Abstract
BACKGROUND There is debate about whether intraoperative cholangiography (IOC) should be performed routinely or selectively during laparoscopic cholecystectomy (LC) in patients with suspected choledocholithiasis. The timing of endoscopic retrograde cholangiopancreatography (ERCP) in these patients also is an issue. We reviewed the experience in our center, where a management algorithm limiting ERCP in relation to LC was adopted. METHODS We retrospectively reviewed every LC performed by one surgeon during 6 years and the related ERCPs. RESULTS A total of 264 LCs were performed. In 30 patients, stones were cleared or excluded by preoperative ERCP. In the remaining 234 LCs, 31 of 34 IOCs were successfully performed. Two of 31 IOCs were positive for bile duct stones; stone removal was successful in each patient at subsequent ERCP. Only 10 of 201 patients who did not have IOC required postsurgical ERCP within 10 weeks of LC, 3 of whom had common bile duct stones at ERCP. CONCLUSIONS For patients who underwent LC, we performed selective IOC with postoperative ERCP for positive studies. Review of our experience using this algorithm showed it to be a powerful tool in limiting unnecessary ERCPs. Our data suggest that routine preoperative ERCP cannot be justified. Selective IOC during LC misses relatively few cases of biliary stones; these can be managed quickly by experienced endoscopists.
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Gurusamy KS, Samraj K. Primary closure versus T-tube drainage after laparoscopic common bile duct stone exploration. Cochrane Database Syst Rev 2007:CD005641. [PMID: 17253566 DOI: 10.1002/14651858.cd005641.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Use of T-tube drainage after laparoscopic common bile duct exploration is controversial. We were unable to identify any meta-analysis or systematic reviews of the benefits and harms of T-tube drainage after common bile duct exploration. OBJECTIVES To assess the benefits and harms of routine primary closure versus T-tube drainage following laparoscopic common bile duct stone exploration. SEARCH STRATEGY We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until January 2006. SELECTION CRITERIA We considered for inclusion all randomised clinical trials comparing primary closure (with or without a biliary stent) versus T-tube drainage after laparoscopic common bile duct exploration. DATA COLLECTION AND ANALYSIS We collected the data on the characteristics, methodological quality, mortality, morbidity, operating time, and hospital stay from the one identified trial. We analysed the data using the fixed-effect model using RevMan Analysis. For each outcome we calculated the odds ratio (OR) and weighted mean difference (WMD) with 95% confidence intervals based on intention-to-treat analysis. MAIN RESULTS We included one trial with 55 patients randomised: 27 to the primary closure and 28 to the T-tube group. This trial was of inadequate methodological quality. There was no mortality in either group. There was no statistically significant difference between the two groups for any of the outcomes except for the hospital stay (WMD -2.8 days, 95% CI -1.93 to -3.67), which was lower in the primary closure group. AUTHORS' CONCLUSIONS We have insufficient evidence to recommend T-tube drainage over primary closure after laparoscopic common bile duct stone exploration or vice versa. Further randomised trials are necessary to assess the benefits and harms of T-tube drainage compared with primary closure after laparoscopic common bile duct exploration.
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Affiliation(s)
- K S Gurusamy
- Royal Free Hospital, Surgery, 291 Greenhaven Drive, Thamesmead, London, UK, SE28 8FY.
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Varadarajulu S, Eloubeidi MA, Wilcox CM, Hawes RH, Cotton PB. Do all patients with abnormal intraoperative cholangiogram merit endoscopic retrograde cholangiopancreatography? Surg Endosc 2006; 20:801-5. [PMID: 16544073 DOI: 10.1007/s00464-005-0479-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2005] [Accepted: 12/27/2005] [Indexed: 12/19/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is commonly used for postoperative evaluation of an abnormal intraoperative cholangiogram (IOC). Although a normal IOC is very suggestive of a disease-free common bile duct (CBD), abnormal studies are associated with high false-positive rates. This study aimed to identify a subset of patients with abnormal IOC who would benefit from a postoperative ERCP. METHODS This prospective study investigated 51 patients with abnormal IOC at laparoscopic cholecystectomy who underwent postoperative ERCP at two tertiary referral centers over a 3-year period. Univariate and multivariate logistic regression analyses were performed to determine predictors of CBD stones at postoperative ERCP. RESULTS For all 51 patients, ERCP was successful. The ERCP showed CBD stones in 33 cases (64.7%), and normal results in 18 cases (35.2%). On univariate analysis, abnormal liver function tests (p < 0.0001) as well as IOC findings of a large CBD stone (p = 0.03), multiple stones (p = 0.01), and a dilated CBD (p = 0.07) predicted the presence of retained stones at postoperative ERCP. However, on multivariable analysis, only abnormal liver function tests correlated with the presence of CBD stones (p < 0.0001). CONCLUSIONS One-third of patients with an abnormal IOC have a normal postoperative ERCP. Elevated liver function tests can help to identify patients who merit further evaluation by ERCP. The use of less invasive methods such as endoscopic ultrasound or magnetic resonance cholangiopancreatography should be considered for patients with normal liver function tests to minimize unnecessary ERCPs.
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Affiliation(s)
- S Varadarajulu
- Division of Gastroenterology-Hepatology, University of Alabama at Birmingham, 410 Lyons Harrison Research Building, 1530 3rd Avenue South, Birmingham, AL 35294-0007, USA.
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Gurusamy KS, Yu Z. T-tube drain in laparoscopic common bile duct stone exploration. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2006. [DOI: 10.1002/14651858.cd005641] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Livingston EH, Miller JAG, Coan B, Rege RV. Indications for selective intraoperative cholangiography. J Gastrointest Surg 2005; 9:1371-7. [PMID: 16332496 DOI: 10.1016/j.gassur.2005.07.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2005] [Accepted: 07/21/2005] [Indexed: 01/31/2023]
Abstract
The indications for selective intraoperative cholangiography (IOC) include a clinical history of jaundice, pancreatitis, elevated bilirubin level, abnormal liver function test results, increased amylase levels, a high lipase level, or dilated common bile duct on preoperative ultrasonography. Although these clinical features are widely accepted as indications for IOC, they have not been tested for their ability to predict choledocholithiasis. Charts were reviewed for a 6-month time period in 2003 at Parkland Memorial Hospital for all patients undergoing cholecystectomy. Univariate analysis and logistic regression were used to determine which factors predicted choledocholithiasis. Of the 572 patients undergoing cholecystectomies during the study period, 189 underwent IOC and common bile duct stones were found in 57. Only preoperative hyperbilirubinemia or ultrasonograph identification of common bile duct dilation reliably predicted choledocholithiasis. There were 13 cases of choledocholithiasis that would not have been identified by preoperative hyperbilirubinemia or an enlarged common bile duct. However, common bile duct stones were clinically significant in only 2 of the 13 cases. One of these was treated with postoperative endoscopic retrograde cholangiopancreatography, and the other was treated with laparoscopic common bile duct exploration. Preoperative identification of a dilated common bile duct or elevated bilirubin levels can be the sole criteria for performing IOC on a selective basis in patients without malignancy. Reliance on a history of remote jaundice, pancreatitis, elevated liver function test values, or pancreatic enzymes results in unnecessary IOCs.
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Affiliation(s)
- Edward H Livingston
- Veterans Administration North Texas Health Care System, University of Texas Southwestern School of Medicine, Dallas, Texas 75390-9156, USA.
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Collins C, Maguire D, Ireland A, Fitzgerald E, O'Sullivan GC. A prospective study of common bile duct calculi in patients undergoing laparoscopic cholecystectomy: natural history of choledocholithiasis revisited. Ann Surg 2004; 239:28-33. [PMID: 14685097 PMCID: PMC1356189 DOI: 10.1097/01.sla.0000103069.00170.9c] [Citation(s) in RCA: 297] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To define the incidence of problematic common bile duct calculi in patients undergoing laparoscopic cholecystectomy. SUMMARY BACKGROUND DATA In patients selected for laparoscopic cholecystectomy, the true incidence of potentially problematic common bile duct calculi and their natural history has not been determined. We evaluated the incidence and early natural history of common bile duct calculi in all patients undergoing laparoscopic cholecystectomy with intraoperative and delayed postoperative cholangiography. METHODS Operative cholangiography was attempted in all patients. In those patients in whom a filling defect was noted in the bile duct, the fine bore cholangiogram catheter was left securely clipped in the cystic duct for repeated cholangiography at 48 hours and at approximately 6 weeks postoperatively. RESULTS Operative cholangiography was attempted in 997 consecutive patients and was accomplished in 962 patients (96%). Forty-six patients (4.6%) had at least one filling defect. Twelve of these had a normal cholangiogram at 48 hours (26% possible false-positive operative cholangiogram) and a further 12 at 6 weeks (26% spontaneous passage of calculi). Spontaneous passage was not determined by either the number or size of calculi or by the diameter of the bile duct. Only 22 patients (2.2% of total population) had persistent common bile duct calculi at 6 weeks after laparoscopic cholecystectomy and retrieved by endoscopic retrograde cholangiopancreatography. CONCLUSIONS Choledocholithiasis occurs in 3.4% of patients undergoing laparoscopic cholecystectomy but more than one third of these pass the calculi spontaneously within 6 weeks of operation and may be spared endoscopic retrograde cholangiopancreatography. Treatment decisions based on assessment by operative cholangiography alone would result in unnecessary interventions in 50% of patients who had either false positive studies or subsequently passed the calculi. These data support a short-term expectant approach in the management of clinically silent choledocholithiasis in patients selected for LC.
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Affiliation(s)
- Chris Collins
- Department of Surgery, Mercy University Hospital, Cork, Ireland
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Patel AP, Lokey JS, Harris JB, Sticca RP, McGill ES, Arrillaga A, Miller RS, Kopelman TR. Current Management of Common Bile Duct Stones in a Teaching Community Hospital. Am Surg 2003. [DOI: 10.1177/000313480306900702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The advent of laparoscopic cholecystectomy (LC) has complicated management of common bile duct (CBD) stones. While LC is routine, laparoscopic CBD exploration (LCBDE) is not, and an algorithm to manage suspected choledocholithiasis has not been uniformly accepted. We evaluated current management of choledocholithiasis. Patients suspected of having CBD stones over a 2-year period were evaluated, and 42 studies in the literature were reviewed. Thirty-two patients were identified. Fourteen patients (44%) had LC with intraoperative cholangiogram (IOC) with no preoperative studies. IOC revealed CBD stones in nine (64%). Seven had CBD exploration (CBDE) at cholecystectomy, and two had postoperative endoscopic retrograde cholangiopancreatography (ERCP). CBDE was successful in five cases, and ERCP was successful in one. Eighteen patients (56%) underwent preoperative ERCP. Five (28%) had no CBD stones. ERCP removed stones in nine patients, and four had open CBDE after failed ERCP. Current literature supports LC with IOC without any preoperative studies. Laparoscopic CBDE is highly successful but depends on surgeon experience. Removing CBD stones with ERCP is also very successful but is associated with increased cost, hospital stay, and complications. We conclude that LC with IOC should be performed without preoperative ERCP when choledocholithiasis is suspected. If found, stones should be removed laparoscopically if possible.
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Affiliation(s)
- Ajay P. Patel
- From the Academic Department of Surgery, Greenville Hospital System, Greenville, South Carolina
| | - Jonathan S. Lokey
- From the Academic Department of Surgery, Greenville Hospital System, Greenville, South Carolina
| | - James B. Harris
- From the Academic Department of Surgery, Greenville Hospital System, Greenville, South Carolina
| | - Robert P. Sticca
- From the Academic Department of Surgery, Greenville Hospital System, Greenville, South Carolina
| | - Eric S. McGill
- From the Academic Department of Surgery, Greenville Hospital System, Greenville, South Carolina
| | - Abenamar Arrillaga
- From the Academic Department of Surgery, Greenville Hospital System, Greenville, South Carolina
| | - Richard S. Miller
- From the Academic Department of Surgery, Greenville Hospital System, Greenville, South Carolina
| | - Tammy R. Kopelman
- From the Academic Department of Surgery, Greenville Hospital System, Greenville, South Carolina
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Wright BE, Freeman ML, Cumming JK, Quickel RR, Mandal AK. Current management of common bile duct stones: is there a role for laparoscopic cholecystectomy and intraoperative endoscopic retrograde cholangiopancreatography as a single-stage procedure? Surgery 2002; 132:729-35; discussion 735-7. [PMID: 12407359 DOI: 10.1067/msy.2002.127671] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Although laparoscopic cholecystectomy (LC) and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) have revolutionized the management of secondary common bile duct (CBD) stones, the use of these modalities as a single-stage procedure remains controversial. The aim of this study is to determine whether LC and intraoperative ERCP as a single procedure has any advantages to LC and either preoperative or postoperative therapeutic ERCP performed in 2 stages. METHODS A retrospective 5-year review involved all patients undergoing both LC and ERCP for management of CBD stones from January 1997 to December 2001. Patients were categorized into 3 groups: (1) preoperative ERCP, followed by LC (ERCP then LC); (2) LC, followed by postoperative ERCP (LC then ERCP); and (3) LC with intraoperative ERCP as a single procedure (LC/ERCP). RESULTS Sixty-seven patients were treated for secondary CBD stones. Forty-three patients underwent ERCP then LC, 10 underwent LC then ERCP, and 14 patients underwent LC/ERCP. There were no differences among the groups in terms of patient demographics or overall complication rates. CBD access and stone clearance was achieved in all 67 (100%) patients, with 1 mild ERCP-related complication in the ERCP-then-LC group. Overall complication rates, hospital length of stay, and total hospital charges were not statistically different among the 3 groups. CONCLUSION Single-stage LC/ERCP provides efficacious therapy for CBD stones and may be beneficial in select patients who may not tolerate a second anesthetic procedure.
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Affiliation(s)
- Byron E Wright
- Department of Surgery and Division of Gastroenterology, Hennepin County Medical Center, Minneapolis, Minn, USA
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14
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Barwood NT, Valinsky LJ, Hobbs MST, Fletcher DR, Knuiman MW, Ridout SC. Changing methods of imaging the common bile duct in the laparoscopic cholecystectomy era in Western Australia: implications for surgical practice. Ann Surg 2002; 235:41-50. [PMID: 11753041 PMCID: PMC1422394 DOI: 10.1097/00000658-200201000-00006] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To assess changes in the use of endoscopic retrograde cholangiopancreatography (ERCP), intraoperative cholangiography (IOC), and surgical exploration of the common bile duct (CBD) associated with the introduction of laparoscopic cholecystectomy (LC). SUMMARY BACKGROUND DATA The optimal strategy for dealing with potential stones of the CBD during LC remains controversial. METHODS The authors conducted a population-based study of all cases of cholecystectomy (20,084) in Western Australia in the periods before, during, and after the introduction of LC (1988-1994). Index admissions were linked to previous or subsequent admissions for ERCP. Factors associated with ERCP were analyzed by multivariate regression models. RESULTS Between 1988 and 1994, admissions for ERCP almost doubled, whereas the use of IOC decreased from 71% to 51%. Different trends were found for open and laparoscopic procedures. Exploration of the CBD declined because of the infrequent use of this procedure in LC. Preoperative ERCP was significantly more common in older patients and men; the reverse was found for IOC. There was an adjusted 3.5-fold increase in preoperative ERCP both during and after the introduction of LC. The adjusted odds ratios for IOC were 0.48 and 0.52 for these periods. CONCLUSIONS The introduction of LC was associated with increasing reliance on ERCP to image the CBD and a decrease in the use of IOC. These changes were observed in both LC and open cholecystectomy. They suggest that the use of ERCP before cholecystectomy has partly replaced IOC for visualization of the CBD for suspected stones. Although more than 40% of patients undergoing LC had IOC, surgeons appear to be reluctant to perform surgical exploration of the CBD when stones are present. Savings in terms of both complications and cost can be expected if preoperative ERCPs performed for suspicion of uncomplicated CBD stones are replaced by IOC.
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Affiliation(s)
- Nigel T Barwood
- Fremantle Hospital and Health Service, Perth, and the University of Western Australia, Perth, Western Australia
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15
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Kozarek RA. Endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy (the relationship is strained, but they are still together for the children's sake). J Clin Gastroenterol 2001; 33:183-4. [PMID: 11500604 DOI: 10.1097/00004836-200109000-00003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
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16
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Lilly MC, Arregui ME. A balanced approach to choledocholithiasis. Surg Endosc 2001; 15:467-72. [PMID: 11353963 DOI: 10.1007/s004640080020] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2000] [Accepted: 10/03/2000] [Indexed: 02/07/2023]
Abstract
BACKGROUND We set out to review and evaluate the results of an algorithm for managing choledocholithiasis in patients undergoing laparoscopic cholecystectomy. METHODS We performed retrospective review of patients with choledocholithiasis at the time of laparoscopic cholecystectomy (LC) between March 1993 and August 1999. All patients were operated on under the direction of one surgeon (M.E.A), following a consistent algorithm that relies primarily on laparoscopic transcystic common bile duct exploration (TCCBDE) but uses laparoscopic choledochotomy (LCD) when the duct and stones are large or if the ductal anatomy is suboptimal for TCCBDE. Intraoperative endoscopic retrograde sphincterotomy (ERS) is done if sphincterotomy is required to facilitate common bile duct exploration (CBDE). Postoperative endoscopic retrograde cholangiopancreatography (ERCP) is utilized when this fails. Preoperative ERCP is used only for high-risk patients. RESULTS A total of 728 LC were performed, and there were 60 instances (8.2%) of choledocholithiasis. Primary procedures consisted of 47 TCCBDE; 37 of them required no other treatment. In five cases, the stones were flushed with no exploration. Intraoperative ERS was performed three times as the only form of duct exploration. LCD was utilized twice; one case also required intraoperative ERS, and the other had a postoperative ERCP for stent removal. One patient with small stones was observed, with no sequelae. Preoperative ERCP was done twice as the primary procedure. Of the 10 cases that were not completely cleared by TCCBDE, three had a postoperative ERCP and seven had an intraoperative ERS, one of which required a postoperative ERCP. There were three complications (6%) related to CBDE, with no long-term sequelae. There were four postoperative complications (6.7%) and no deaths. The mean number of procedures per patient was 1.12. The average postoperative hospital stay was 1.8 days (range, 0-14). CONCLUSIONS Choledocholithiasis can be managed safely by laparoscopic techniques, augmenting with ERCP as necessary. This protocol minimizes the number of procedures and decreases the hospital stay.
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Affiliation(s)
- M C Lilly
- Department of General Surgery, St. Vincent Hospital and Health Care Center, 8402 Harcourt Road., Indianapolis, IN 46260, USA
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