Laparoendoscopic approach to treatment of common bile duct stones

Rendezvous cannulation technique reduces post-ERCP pancreatitis: a prospective nationwide study of 12,718 ERCP procedures

OBJECTIVES

The aim of this study was to investigate if intraoperative rendezvous cannulation reduces the risk of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) because there is no universal consensus on the optimal treatment of common bile duct stones.

METHODS

We performed a nationwide case-control study, nested within the cohort of ERCP procedures reported to the Swedish Registry for Gallstone Surgery and ERCP (GallRiks), between 2007 and 2009. Data were collected prospectively from a web-based registry of ERCP procedures that includes variables such as patient characteristics, indication, cannulation technique, diagnostic findings, therapeutic measures, and complications. The primary outcome was PEP.

RESULTS

The registry included 12,718 ERCP procedures performed on patients without a history of previous ERCP. The risk of PEP when using the rendezvous technique compared with those who were cannulated by conventional means was reduced from 3.6 to 2.2% (odds ratio (OR) 0.5, 95% confidence interval 0.2-0.9, P=0.02). Although a significant reduction there are overall relatively few cases with PEP and the calculated numbers needed to treat to avoid one case of PEP is as high as 71. Other factors associated with increased risk of PEP were young age, prolonged procedure time, and elective ERCP.

CONCLUSIONS

Rendezvous bile duct cannulation during ERCP reduces the risk of PEP from 3.6 to 2.2% compared with conventional biliary cannulation.

A 10-year study of rendezvous intraoperative endoscopic retrograde cholangiography during cholecystectomy and the risk of post-ERCP pancreatitis

BACKGROUND

Rendezvous intraoperative endoscopic retrograde cholangiography (RV-IOERC), also called guidewire-facilitated IOERC, is one of the single-stage options available for managing common bile duct stones (CBDS) during laparoscopic cholecystectomy. The objective of this study is to investigate procedure-related complications in IOERC patients and stone clearance.

METHODS

All patients who underwent IOERC between January 2000 and December 2009 were identified from the local registry of Karolinska University Hospital in Huddinge. Medical charts and ERC reports were studied, and descriptive statistics were obtained. Outcomes were procedure-related complications, especially post-ERCP pancreatitis (PEP), stone clearance, and mortality.

RESULTS

307 patients were identified. In 264 of the patients, the rendezvous cannulation technique was successful (86 %); in the remaining 43 patients, conventional cannulation technique was necessary. In total, PEP occurred in seven patients (2.28 %). One of the PEP patients was in the rendezvous cannulated group (0.37 %), whereas six patients developed PEP in the nonrendezvous group (13.95 %, p < 0.001). The primary stone clearance rate was 88.27 % (271/307). There was no mortality within 90 days in the series.

CONCLUSIONS

IOERC with RV cannulation technique for management of CBDS during laparoscopic cholecystectomy has a low PEP rate and a high stone clearance rate, making it a safe and feasible method for removing CBDS. However, the technique requires logistics to perform IOERC in the operating theater. The present data suggest that IOERC with RV cannulation is superior to conventional cannulation with respect to risk of PEP.

Simultaneous laparoendoscopic rendezvous for the treatment of cholecystocholedocholithiasis

BACKGROUND

Different approaches are available for the treatment of combined cholecystocholedocholithiasis including totally laparoscopic (TL) treatment, simultaneous laparoendoscopic treatment, and sequential treatments (ST) combining endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) with cholecystectomy. This review aimed to clarify the issue of the simultaneous laparoendoscopic rendezvous (RV).

METHODS

A careful analysis of papers was performed to determine the results, technical differences, limits, disadvantages, and advantages of RV compared with other options.

RESULTS

Data were collected from 27 papers concerning 795 patients. The overall effectiveness of RV was 92.3%. The morbidity rate was 5.1%, and the mortality rate was 0.37%. Almost all the authors were satisfied with the procedure. The authors' comparison to ST and TL showed that the advantages outweigh the disadvantages mostly related to logistical problems.

CONCLUSIONS

There is confusion concerning the definitions and techniques of RV due to differences in combining surgical and endoscopic steps of the procedure. The results are at least comparable with those of the other available approaches. The effectiveness of RV is greater with reciprocal implementation of surgical and endoscopic procedures. The morbidity and the risk of iatrogenic damage seem lower than with ERCP-ES and the risk of residual stones lower than with TL treatment. The RV procedure is safe and can sometimes be the preferable option, but collaboration between surgeon and endoscopist is mandatory.

Choledochoduodenostomy: reappraisal in the laparoscopic era

BACKGROUND

With the advent of interventional endoscopic procedures and with growing experience of laparoscopic surgery, the indications for open biliary procedures have become limited. This prospective study reviews the indications of open choledochoduodenostomy for benign biliary diseases and presents the short-term and long-term outcomes of this procedure in the present minimally invasive surgical era.

METHODS

Side-to-side choledochoduodenostomy was carried out for various benign obstructive pathologies of the biliary tract. The various parameters recorded were the demographic data, indications for surgery, early and late complications and the long-term outcome of the procedure.

RESULTS

Results of choledochoduodenostomy on 54 consecutive patients over a 9-year period are presented. The mean age was 49.7 years with a male to female ratio of 1:2.6. Thirty (55.5%) patients presented with obstructive jaundice and 42.6% had cholangitis. Overall hospital morbidity was 13% with zero mortality. After a mean follow up of 7.8 years, 96.3% patients had 'good' or 'fair' and 3.7% experienced 'poor' results. No recurrent disease or biliary malignancy was observed.

CONCLUSION

Open biliary drainage procedures may still be indicated in select patients where the facility or expertise for minimally invasive biliary procedures is not available. Choledochoduodenostomy remains an effective biliary drainage procedure with acceptable morbidity and mortality, especially in the high-risk and elderly population. The procedure should be regarded as an essential in the general surgical knowledge and training.