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Weng F, Zhang R, Zhu L, Wu X. Laparoscopic Ultrasound-Guided Transcystic Approach for the Treatment of Common Bile Duct Stones. J Laparoendosc Adv Surg Tech A 2024; 34:568-575. [PMID: 38727570 DOI: 10.1089/lap.2024.0048] [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] [Indexed: 07/26/2024] Open
Abstract
Background: The treatment of choledocholithiasis with nondilated common bile duct (CBD) is a challenge for surgeons who often choose endoscopic retrograde cholangiopancreatography with laparoscopic cholecystectomy (LC) staging surgery instead of simultaneous laparoscopic CBD exploration with LC because of the small CBD diameter. This study aims to introduce and assess the clinical applicability of a technique we developed to identify and extract CBD stones using laparoscopic ultrasound (LUS). Methods: We retrospectively reviewed surgical procedures and clinical data of 13 patients who underwent LC and CBD exploration using LUS between May 2022 and August 2023. The cystic duct was used for CBD stone removal. Results: Ten patients were successfully treated; 2 patients with residual stones were treated with ursodeoxycholic acid, whereas 1 patient required a microincision near the CBD and choledochoscopy because of stone incarceration in the duodenal papilla. The CBD diameter was 6 mm (5-9 mm). There were less than three CBD stones, with diameters of 2-6 mm; the median operative time was 105 minutes (range, 52-155 minutes). One patient developed postoperative cholangitis. The median postoperative hospital stay was 6 days (3-8 days). The stone clearance rate was 76.9%, and the CBD stone detection rate was 100%. No intraoperative complications, postoperative bile leakage, and mortality occurred. Conclusions: CBD exploration and transcystic stone extraction under LUS guidance are safe and effective approaches for patients with choledocholithiasis; strict control over surgical indications is necessary. This study could provide new strategies for effectively treating choledocholithiasis.
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Affiliation(s)
- Fangze Weng
- Department of Hepatobiliary Surgery, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Republic of China
| | - Rixin Zhang
- Department of Hepatobiliary Surgery, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Republic of China
| | - Ling Zhu
- Department of Hepatobiliary Surgery, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Republic of China
| | - Xinhua Wu
- Department of Hepatobiliary Surgery, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Republic of China
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Marchegiani F, Conticchio M, Zadoroznyj A, Inchingolo R, Memeo R, De'angelis N. Detection and management of bile duct injury during cholecystectomy. Minerva Surg 2023; 78:545-557. [PMID: 36883937 DOI: 10.23736/s2724-5691.23.09866-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
INTRODUCTION Cholecystectomy represents one of the most performed surgical procedures. Bile duct injuries (BDIs) are a dangerous complication of this intervention. With the advent of the laparoscopy, the rate of BDIs showed a growing trend that was partially justified by the learning curve of this technique. EVIDENCE ACQUISITION A literature search was conducted on Embase, Medline, and Cochrane databases to identify studies published up to October 2022 that analyzed the intraoperative detection and management of BDIs diagnosed during cholecystectomy. EVIDENCE SYNTHESIS According to the literature, approximately 25% of BDIs is diagnosed during the laparoscopic cholecystectomy. In the clinical suspicion of BDI, an intraoperative cholangiography is performed to confirm it. Complimentary technology, such as near-infrared cholangiography, can be also adopted. Intraoperative ultrasound represents a useful tool to furtherly define the biliary and the vascular anatomy. The proper classification of the type of BDI allows to identify the correct treatment. When a good expertise in hepato-pancreato-biliary surgery is available, a direct repair is performed with good outcomes both in case of simple and complex lesions. When the local resources are limited or there is a lack of dedicated surgical experience, patient referral to a reference center shows better outcomes. In particular, complex vasculo-biliary injuries require a highly specialized treatment. The key elements to transfer the patients are a good documentation of the injury, a proper drainage of the abdomen, and an antibiotic therapy. CONCLUSIONS BDI management requires a proper diagnostic process and prompt treatment to reduce the morbidity and mortality of this feared complication occurring during cholecystectomy.
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Affiliation(s)
- Francesco Marchegiani
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, France
| | - Maria Conticchio
- Unit of Hepato-Pancreato-Biliary Surgery, F. Miulli General Regional Hospital, Acquaviva delle Fonti, Bari, Italy
| | - Alizée Zadoroznyj
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, France
| | - Riccardo Inchingolo
- Unit of Interventional Radiology, F. Miulli General Regional Hospital, Acquaviva delle Fonti, Bari, Italy
| | - Riccardo Memeo
- Unit of Hepato-Pancreato-Biliary Surgery, F. Miulli General Regional Hospital, Acquaviva delle Fonti, Bari, Italy
| | - Nicola De'angelis
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, France -
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Luo Y, Yang T, Yu Q, Zhang Y. Laparoscopic Ultrasonography Versus Magnetic Resonance Cholangiopancreatography in Laparoscopic Surgery for Symptomatic Cholelithiasis and Suspected Common Bile Duct Stones. J Gastrointest Surg 2019; 23:1143-1147. [PMID: 30187333 DOI: 10.1007/s11605-018-3949-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 08/23/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND There continues to be controversy regarding the optimal screening modality in patients with symptomatic cholelithiasis and suspected common bile duct (CBD) stones. The aim of this study was to assess the diagnostic accuracy of laparoscopic ultrasonography (LUS) compared to magnetic resonance cholangiopancreatography (MRCP). METHODS Both LUS and MRCP were performed to evaluate the CBD stones and biliary anatomy in 200 patients undergoing laparoscopic surgery. Pre-, intra-, and postoperative data were collected prospectively and reviewed retrospectively. RESULTS Coexisting CBD stones were identified in 64 of 200 (32%) patients by surgical exploration or postoperative ERCP. For the detection of CBD stones, LUS yielded a positive predictive value of 100%, a negative predictive value of 99.3%, a sensitivity of 98.4%, and a specificity of 100%. Preoperative MRCP had a positive predictive value of 87.9%, a negative predictive value of 95.5%, a sensitivity of 90.6%, and a specificity of 94.1%. The non-random concordance between MRCP and LUS was considered to be excellent with a kappa coefficient of 0.92 (p < 0.01). CONCLUSIONS LUS can reduce the need for MRCP examination and can become the primary imaging method for the evaluation of CBD stones in laparoscopic surgery.
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Affiliation(s)
- Ying Luo
- Department of Hepatobiliary Surgery, Chinese PLA General Hospital, Beijing, 100853, China.
| | - Tao Yang
- Department of Hepatobiliary Surgery, Chinese PLA General Hospital, Beijing, 100853, China
| | - Qiang Yu
- Department of Hepatobiliary Surgery, Chinese PLA General Hospital, Beijing, 100853, China
| | - Yu Zhang
- Department of Hepatobiliary Surgery, Chinese PLA General Hospital, Beijing, 100853, China
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Smereczyński A, Starzyńska T, Kołaczyk K, Kładny J. Role of sonography in assessing complications after laparoscopic cholecystectomy. J Ultrason 2014; 14:152-62. [PMID: 26674247 PMCID: PMC4579702 DOI: 10.15557/jou.2014.0015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2013] [Revised: 05/28/2013] [Accepted: 06/20/2013] [Indexed: 01/04/2023] Open
Abstract
Laparoscopic cholecystectomy, which was introduced to the arsenal of surgical procedures in the middle of the 1980s, is a common alternative for conventional cholecystectomy. Its primary advantage is less invasive character which entails shorter hospitalization and faster recovery. Nevertheless, the complications of both procedures are comparable and encompass multiple organs and tissues. The paper presents ultrasound presentation of the surgical bed after laparoscopic cholecystectomy and of complications associated with this procedure. In the first week following the surgery, the presence of up to 60 ml of fluid in the removed gallbladder bed should be considered normal in certain patients. The fluid will gradually absorb. In single cases, slight amounts of fluid are detected in the peritoneal cavity, which also should not be alarming. Carbon dioxide absorbs from the peritoneal cavity within two days. Ultrasound assessment of the surgical bed after cholecystectomy is inhibited by hemostatic material left during the surgery. Its presentation may mimic an abscess. In such cases, the decisive examination is magnetic resonance imaging but not computed tomography. On the other hand, rapidly accumulating fluid around the liver is an alarming symptom, particularly when there is inadequate blood supply or when peritoneum irritation symptoms develop. Depending on the suspected cause of the patient's deteriorating condition, it is essential to perform urgent computed tomography angiography, celiac angiography or endoscopic retrograde cholangiopancreatography or magnetic resonance cholangiopancreatography. The character of the fluid collection may be determined by its ultrasound-guided puncture. This procedure allows for aspiration of fluid and placement of a drain. Moreover, transabdominal ultrasound examination after laparoscopic cholecystectomy may contribute to the identification of: dropped stones in the right hypochondriac region, residual fragment of the gallbladder with possible concretions, undiagnosed choledocholithiasis, existing cholestasis, pseudoaneurysm of the hepatic artery, portal vein thrombosis and hematoma as well as hernias of the abdominal walls. Moreover, ultrasound examination helps to identify optimal sites in the abdominal integuments, which enables collision-free access to the peritoneal cavity.
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Affiliation(s)
| | - Teresa Starzyńska
- Klinika Gastrologii, Pomorski Uniwersytet Medyczny, Szczecin, Polska
| | - Katarzyna Kołaczyk
- Zakład Diagnostyki Obrazowej i Radiologii Interwencyjnej, Pomorski Uniwersytet Medyczny, Szczecin, Polska
| | - Józef Kładny
- Klinika Chirurgii Ogólnej i Onkologicznej, Pomorski Uniwersytet Medyczny, Szczecin, Polska
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Gwinn EC, Daly S, Deziel DJ. The use of laparoscopic ultrasound in difficult cholecystectomy cases significantly decreases morbidity. Surgery 2013; 154:909-15; discussion 915-7. [PMID: 24074430 DOI: 10.1016/j.surg.2013.04.041] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Accepted: 04/19/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND Laparoscopic ultrasound (LUS) is a method of intraoperative bile duct imaging that can be used prior to any potentially hazardous dissection. The purpose of this study was to determine whether LUS could permit safe laparoscopic completion of difficult cholecystectomy (LC) cases and to assess whether its use had any impact on clinical outcome. METHODS We identified prospectively 44 patients with severe cholecystitis in whom LUS was considered critical for intraoperative identification of the bile ducts. LC patients were compared, on an intention to treat basis, with 41 contemporaneous patients with severe cholecystitis who had planned open cholecystectomy (OC). RESULTS LUS identified the extrahepatic bile ducts in all cases. Of the cases, 40 (91%) were completed laparoscopically. OC patients had a higher rate of acute cholecystitis and preoperative percutaneous cholecystostomy tubes and a higher mean ASA classification. Intraoperatively, LC patients had significantly less estimated blood loss and fewer drains were placed. Postoperatively, LC patients had significantly fewer total complications, Clavien-Dindo grade 3 complications, biliary complications, biliary reinterventions, intra-abdominal abscesses, and bleeding complications. LC patients had significantly fewer ICU admissions and shorter LOS. CONCLUSION By allowing identification of the extrahepatic bile ducts during difficult cholecystectomy, LUS results in a high rate of successful laparoscopic completions. Laparoscopic cholecystectomy is associated with better clinical outcomes than OC for patients with severe cholecystitis.
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Affiliation(s)
- Elizabeth C Gwinn
- Department of General Surgery, Rush University Medical Center, Chicago, IL
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Assessment of Common Bile Duct Using Laparoscopic Ultrasound During Laparoscopic Cholecystectomy. Surg Laparosc Endosc Percutan Tech 2009; 19:317-20. [DOI: 10.1097/sle.0b013e3181aa6a3e] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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The routine use of laparoscopic ultrasound decreases bile duct injury: a multicenter study. Surg Endosc 2008; 23:384-8. [PMID: 18528611 DOI: 10.1007/s00464-008-9985-x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2008] [Revised: 03/26/2008] [Accepted: 05/03/2008] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Laparoscopic ultrasound (LUS) has been used for over 15 years to screen the bile duct (BD) for stones and to delineate anatomy during laparoscopic cholecystectomy (LC). LUS as a modality to prevent BD injury has not been investigated in a large series. This study evaluated the routine use of LUS to determine its effect on preventing BD injury. METHODS A multicenter retrospective study was performed by reviewing clinical outcome of LC in which LUS was used routinely. RESULTS In five centers, 1,381 patients underwent LC with LUS. LUS was successful to delineate and evaluate the BD in 1,352 patients (98.0%), although it was unsuccessful or incomplete in 29 patients (2.0%). LUS was considered remarkably valuable to safely complete LC, avoiding conversion to open, in 81 patients (5.9%). The use of intraoperative cholangiography (IOC) varied depending on centers; IOC was performed in 504 patients (36.5%). For screening of BD stones (which was positive in 151 patients, 10.9%), LUS had a false-positive result in two patients (0.1%) and a false-negative result in five patients (0.4%). There were retained BD stones in three patients (0.2%). There were minor bile leaks from the liver bed in three patients (0.2%). However, there were no other BD injuries including BD transection (0%). Retrospectively, IOC was deemed necessary in 25 patients (1.8%) to complete LC in spite of routine LUS. CONCLUSION LUS can be performed successfully to delineate BD anatomy in the majority of patients. The routine use of LUS during LC has obviated major BD injury, compared to the reported rate (1 out of 200-400 LCs). LUS improves the safety of LC by clarifying anatomy and decreasing BD injury.
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Perry KA, Myers JA, Deziel DJ. Laparoscopic ultrasound as the primary method for bile duct imaging during cholecystectomy. Surg Endosc 2007; 22:208-13. [PMID: 17721807 DOI: 10.1007/s00464-007-9558-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2007] [Accepted: 07/09/2007] [Indexed: 12/16/2022]
Abstract
BACKGROUND Intraoperative fluorocholangiography (IOC) has been the standard method for bile duct imaging during cholecystectomy. Laparoscopic ultrasound (LUS) has been evaluated as a possible alternative, but has been used less frequently. The authors examined the evolving use of these two methods to assess the relative utility of LUS as the primary method for routine bile duct imaging during laparoscopic cholecystectomy (LC). METHODS This study analyzed a prospective database containing 423 consecutive cholecystectomies performed by one attending surgeon in an academic medical center between 1995 and 2005. RESULTS Intraoperative bile duct imaging was performed in 371 (94%) of 396 LCs performed for cholelithiasis. As recorded, IOC was performed in 239 cases, LUS in 236 cases, and both in 104 cases. Choledocholithiasis was present in 50 patients (13%). Common bile duct stones (CBDS) were identified by LUS in 3% of the patients without preoperative indicators of CBDS, and in 10% of the patients with one or more indicators. As shown by the findings, LUS had a positive predictive value of 100%, a negative predictive value of 99.6%, a sensitivity of 92.3%, and a specificity of 100% for detecting CBDS. Also, LUS identified clinically significant bile duct anatomy in 6% of the patients. In 1995, LUS was used for 20% of cases, whereas by 2005, it was used for 97% of cases. Conversely, the use of IOC decreased from 93% to 23%. CONCLUSIONS With moderate experience, LUS can become the primary routine imaging method for evaluating the bile duct during LC. It is as reliable as IOC for detecting choledocholithiasis. In addition, LUS can locate the common bile duct during difficult dissections. On the basis of this experience, LUS is used currently in nearly all LCs and is the sole method for bile duct imaging in 75% of these cases. IOC is used as an adjunct to LUS when LUS imaging is inadequate, when stronger clinical indicators of choledocholithiasis are present, or when biliary anatomy remains uncertain.
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Affiliation(s)
- K A Perry
- Department of General Surgery, Rush University Medical Center, Chicago, IL, USA
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Machi J. Laparoscopic ultrasonography: an additional method for potentially preventing biliary tract injury. Surg Endosc 2007; 22:802-3. [PMID: 17593446 DOI: 10.1007/s00464-007-9432-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Machi J, Oishi AJ, Tajiri T, Murayama KM, Furumoto NL, Oishi RH. Routine laparoscopic ultrasound can significantly reduce the need for selective intraoperative cholangiography during cholecystectomy. Surg Endosc 2007; 21:270-4. [PMID: 17122981 DOI: 10.1007/s00464-005-0817-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2005] [Accepted: 06/07/2006] [Indexed: 12/14/2022]
Abstract
BACKGROUND The use of intraoperative cholangiography (IOC), routinely rather than selectively, during laparoscopic cholecystectomy (LC) is controversial. Recent findings have shown laparoscopic ultrasound (LUS) to be safe, quick, and effective not only for screening of the bile duct for stones, but also for evaluating the biliary anatomy. This study aimed to evaluate, on the basis of the LC outcome and the cost of LUS and IOC, whether and how much the routine use of LUS would be able to reduce the need for IOC. METHODS During LC, LUS was used routinely to screen the bile duct for stones and to evaluate the biliary anatomy, whereas IOC was used selectively only when LUS was unsatisfactory or unsuccessful. RESULTS For 193 (96.5%) of 200 patients, LUS was completed successfully, whereas IOC was needed for 7 patients (3.5%). Bile duct stones were identified in 20 patients (10%). For the detection of bile duct stones, LUS yielded 19 true-positive, 175 true-negative, 0 false-positive, and 1 false-negative results. It had a sensitivity of 95%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 99.4%. The postoperative complications included bile leaks from the liver bed in two patients and a retained bile duct stone in one patient. If IOC had been used selectively in a traditional manner on the basis of preoperative risk factors, IOC would have been needed for 77 patients (38.5%). The total cost of LUS plus IOC for the current 200 patients was 26,256 dollars. The total estimated cost of selective IOC, if it had been performed for the 77 patients, would have been 31,416 dollars. CONCLUSIONS Routine LUS accurately diagnosed bile duct stones and significantly reduced the need for selective IOC from a potential 38.5% to an actual 3.5% without adversely affecting the outcome of the LC or increasing the overall cost. The routine use of LUS during LC is accurate and cost effective.
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Affiliation(s)
- J Machi
- Department of Surgery, University of Hawaii and Kuakini Medical Center, 347 North Kuakini Street, Honolulu, Hawaii 96817, USA.
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