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Endoscopic Stone Extraction followed by Laparoscopic Cholecystectomy in Tandem for Concomitant Cholelithiasis and Choledocholithiasis: A Prospective Study. J Clin Exp Hepatol 2022; 12:129-134. [PMID: 35068793 PMCID: PMC8766527 DOI: 10.1016/j.jceh.2021.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 03/12/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Single-session endoscopic stone extraction (ESE) and laparoscopic cholecystectomy (LC) has the best outcome in managing concomitant cholelithiasis (gallstone disease [GSD]) and choledocholithiasis (common bile duct stone [CBDS]). Traditional rendezvous technique with an intraoperative cholangiogram is associated with various technical (bowel distention, frozen Calot's triangle, limitation of intraoperative cholangiogram and so on) and logistical difficulties (lack of trained personnel and equipment for ESE in the operating room). We modified our approach of ESE-LC (tandem ESE-LC) to study the safety of the approach and overcome these disadvantages of the traditional rendezvous approach. METHODS A prospective study of patients with GSD and suspected CBDS from January 2017 to December 2019 was conducted. Tandem ESE-LC involves ESE and LC under the same general anaesthesia in a single day, while ESE is performed in the endoscopic suite using carbon dioxide insufflation, a balloon/basket was used for achieving bile duct clearance and the same was confirmed with an occlusion cholangiogram. Patients were then shifted to the operating room for LC. The primary outcome included bile duct clearance and safety of the procedure. RESULTS Of 56 patients assessed for eligibility, 42 were included in the study (median age: 53 years, 25 [60%] women). Biliary colic was the most common presenting symptom (n = 24, 57%), followed by acute cholecystitis (n = 11, 26%). The median number of stones and stone size was 1 (1-6) and 4 mm (3-10), respectively. All patients had successful bile duct clearance. Stenting was performed in 5 (12%) patients. Intraoperatively, Calot's dissection was difficult and frozen in 10 and 11 patients respectively. The cystic duct was short and wide in 13 (31%) patients. Subtotal cholecystectomy was performed in 6 (14%) patients. The median duration of postprocedural hospital stay was 1 (0-13) day. Three patients had tandem ESE-LC on a day-care basis. One patient had post-endoscopic retrograde cholangiopancretography pancreatitis, and another required percutaneous drainage for gall bladder fossa collection. No patient had retained CBDS at a median follow-up of 18 (3-28) months. CONCLUSION Tandem ESE-LC is safe and effective method in managing concomitant GSD and CBDS.
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Key Words
- ASGE, American Society for Gastrointestinal Endoscopy
- CBD stones
- CBDS, common bile duct stone
- ERC, endoscopic retrograde cholangiography
- ERCP, endoscopic retrograde cholangiopancretography
- ESE, endoscopic stone extraction
- GB, gall bladder
- GSD, gallstone disease
- LC, laparoscopic cholecystectomy
- OR, operating room
- POD, postoperative day
- SIRS, systemic inflammatory response syndrome
- TAP, transversus abdominis plane
- bile duct clearance
- rendezvous
- retained stones
- single sitting
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Chandran A, Rashtak S, Patil P, Gottlieb A, Bernstam E, Guha S, Ramireddy S, Badillo R, DaVee RT, Kao LS, Thosani N. Comparing diagnostic accuracy of current practice guidelines in predicting choledocholithiasis: outcomes from a large healthcare system comprising both academic and community settings. Gastrointest Endosc 2021; 93:1351-1359. [PMID: 33160977 DOI: 10.1016/j.gie.2020.10.033] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 10/20/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The American Society for Gastrointestinal Endoscopy (ASGE) 2010 guidelines for suspected choledocholithiasis were recently updated by proposing more specific criteria for selection of high-risk patients to undergo direct ERCP while advocating the use of additional imaging studies for intermediate- and low-risk individuals. We aim to compare the performance and diagnostic accuracy of 2019 versus 2010 ASGE criteria for suspected choledocholithiasis. METHODS We performed a retrospective chart review of a prospectively maintained database (2013-2019) of over 10,000 ERCPs performed by 70 gastroenterologists in our 14-hospital system. We randomly selected 744 ERCPs in which the primary indication was suspected choledocholithiasis. Patients with a history of cholecystectomy or prior sphincterotomy were excluded. The same patient cohort was assigned as low, intermediate, or high risk according to the 2010 and 2019 guideline criteria. Overall accuracy of both guidelines was compared against the presence of stones and/or sludge on ERCP. RESULTS Of 744 patients who underwent ERCP, 544 patients (73.1%) had definite stones during ERCP and 696 patients (93.5%) had stones and/or sludge during ERCP. When classified according to the 2019 guidelines, fewer patients were high risk (274/744, 36.8%) compared with 2010 guidelines (449/744, 60.4%; P < .001). Within the high-risk group per both guidelines, definitive stone was found during ERCP more frequently in the 2019 guideline cohort (226/274, 82.5%) compared with the 2010 guideline cohort (342/449, 76.2%; P < .001). In our patient cohort, overall specificity of the 2010 guideline was 46.5%, which improved to 76.0% as per 2019 guideline criteria (P < .001). However, no significant change was noted for either positive predictive value or negative predictive value between 2019 and 2010 guidelines. CONCLUSIONS The 2019 ASGE guidelines are more specific for detection of choledocholithiasis during ERCP when compared with the 2010 guidelines. However, a large number of patients are categorized as intermediate risk per 2019 guidelines and will require an additional confirmatory imaging study.
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Affiliation(s)
- Aswathi Chandran
- Center for Interventional Gastroenterology at UTHealth (iGUT), McGovern Medical School, UTHealth, Houston, Texas, USA
| | - Shahrooz Rashtak
- Center for Interventional Gastroenterology at UTHealth (iGUT), McGovern Medical School, UTHealth, Houston, Texas, USA
| | - Prithvi Patil
- Center for Interventional Gastroenterology at UTHealth (iGUT), McGovern Medical School, UTHealth, Houston, Texas, USA
| | - Assaf Gottlieb
- School of Biomedical Informatics, UTHealth, Houston, Texas, USA
| | - Elmer Bernstam
- School of Biomedical Informatics, UTHealth, Houston, Texas, USA
| | - Sushovan Guha
- Center for Interventional Gastroenterology at UTHealth (iGUT), McGovern Medical School, UTHealth, Houston, Texas, USA
| | - Srinivas Ramireddy
- Center for Interventional Gastroenterology at UTHealth (iGUT), McGovern Medical School, UTHealth, Houston, Texas, USA
| | - Ricardo Badillo
- Center for Interventional Gastroenterology at UTHealth (iGUT), McGovern Medical School, UTHealth, Houston, Texas, USA
| | - Roy Tomas DaVee
- Center for Interventional Gastroenterology at UTHealth (iGUT), McGovern Medical School, UTHealth, Houston, Texas, USA
| | | | - Nirav Thosani
- Center for Interventional Gastroenterology at UTHealth (iGUT), McGovern Medical School, UTHealth, Houston, Texas, USA
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Mansy W, Mohamed M, Mahmmoud W, Lofty M, Gharib O. Management of concomitant gall bladder and common bile duct stones, single stages laparoscopic versus endo-laparoscopic: A center experience. THE EGYPTIAN JOURNAL OF SURGERY 2015. [DOI: 10.4103/1110-1121.163149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Vindal A, Chander J, Lal P, Mahendra B. Comparison between intraoperative cholangiography and choledochoscopy for ductal clearance in laparoscopic CBD exploration: a prospective randomized study. Surg Endosc 2014; 29:1030-8. [PMID: 25154888 DOI: 10.1007/s00464-014-3766-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 07/19/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Laparoscopic CBD exploration (LCBDE) is an accepted treatment modality for single stage management of CBD stones in fit patients. A transcholedochal approach is preferred in patients with a dilated CBD and large impacted stones in whom ductal clearance remains problematic. There are very few studies comparing intraoperative cholangiography (IOC) with choledochoscopy to determine ductal clearance in patients undergoing transcholedochal LCBDE. This series represents the first of those comparing the two from Asia. METHODS Between April 2009 and October 2012, 150 consecutive patients with CBD stones were enrolled in a prospective randomized study to undergo transcholedochal LCBDE on an intent-to-treat basis. Patients with CBD diameter of less than 9 mm on preoperative imaging were excluded from the study. Out of the 132 eligible patients, 65 patients underwent IOC (Group A), and 67 patients underwent intraoperative choledochoscopy (Group B) to determine CBD clearance. RESULTS There were no differences between the two groups in the demographic profile and the preoperative biochemical findings. There was no conversion to open procedures, and complete stone clearance was achieved in all the 132 cases. The mean CBD diameter and the mean number of CBD stones removed were comparable between the two groups. Mean operating time was 170 min in Group A and 140 min in Group B (p < 0.001). There was no difference in complications between the two groups. Nine patients in Group A (13.8%) showed non-passage of contrast into the duodenum on IOC which resolved after administration of i.v. glucagon, suggesting a transient spasm of sphincter of Oddi. Two patients (3%) showed a false-positive result on IOC which had to be resolved with choledochoscopy. CONCLUSIONS The present study showed that intraoperative choledochoscopy is better than IOC for determining ductal clearance after transcholedochal LCBDE and is less cumbersome and less time-consuming.
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Affiliation(s)
- Anubhav Vindal
- Division of Minimal Access Surgery, Department of Surgery, Maulana Azad Medical College, University of Delhi, New Delhi, 110002, India,
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Abstract
Gallstone disease is the most common cause of acute pancreatitis in the Western world. In most cases, gallstone pancreatitis is a mild and self-limiting disease, and patients may proceed without complications to cholecystectomy to prevent future recurrence. Severe disease occurs in about 20% of cases and is associated with significant mortality; meticulous management is critical. A thorough understanding of the disease process, diagnosis, severity stratification, and principles of management is essential to the appropriate care of patients presenting with this disease. This article reviews these topics with a focus on surgical management, including appropriate timing and choice of interventions.
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Affiliation(s)
- Daniel Cucher
- Department of Surgery, College of Medicine, University of Arizona, PO Box 245005, Tucson, AZ 85724, USA
| | - Narong Kulvatunyou
- Division of Acute Care Surgery, Department of Surgery, Arizona Health Sciences Center, University of Arizona, 1501 North Campbell Avenue, PO Box 245063, Tucson, AZ 85724-5063, USA
| | - Donald J Green
- Division of Acute Care Surgery, Department of Surgery, Arizona Health Sciences Center, University of Arizona, 1501 North Campbell Avenue, PO Box 245063, Tucson, AZ 85724-5063, USA
| | - Tun Jie
- Division of Hepatobiliary Surgery, Department of Surgery, Arizona Health Sciences Center, University of Arizona, 1501 North Campbell Avenue, PO Box 245066, Tucson, AZ 85724, USA
| | - Evan S Ong
- Division of Hepatobiliary Surgery, Department of Surgery, Arizona Health Sciences Center, University of Arizona, 1501 North Campbell Avenue, PO Box 245066, Tucson, AZ 85724, USA.
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Comparison of laparoscopic common bile duct exploration and endoscopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy for choledocholithiasis: a prospective randomized study. Am J Surg 2013; 206:457-63. [PMID: 23871320 DOI: 10.1016/j.amjsurg.2013.02.004] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Revised: 01/26/2013] [Accepted: 02/07/2013] [Indexed: 01/15/2023]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography and laparoscopic common bile duct exploration are safe and efficient methods that have recently been used for the treatment of bile duct stones. The aim of this study was to compare the efficacy, safety, and surgical outcomes of the laparoscopic common bile duct exploration plus laparoscopic cholecystectomy (LCBDE+LC) and endoscopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy (ERCP+LC). METHODS One hundred twenty patients were prospectively randomized into 2 groups: LCBDE with LC in a single intervention and LC after ERCP. RESULTS The success rate of the LCBDE+LC group (96.5%) was found to be higher than for the ERCP+LC group (94.4%). Complication rates of the LCBDE+LC and ERCP+LC group were 7% and 11.1%, respectively. Complications requiring ERCP in the postoperative period after LCBDE+LC have been noted in 3.5% of cases. CONCLUSIONS Laparoscopic CBD exploration provides an alternative therapeutic approach that has less morbidity, is cost-effective, and allows earlier recovery with a reduced period of short-term disability.
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Abstract
Technologic advancements have allowed imaging modalities to become more useful in the diagnosis of hepatobiliary and pancreatic disorders. Computed tomography scanners now use multidetector row technology with contrast-delayed imaging for quicker and more accurate imaging. Magnetic resonance imaging with cholangiopancreatography can more clearly delineate liver lesions and the biliary and pancreatic ducts, and can diagnose pathologic conditions early in their course. Newer technologies, such as single-operator cholangioscopy and endoscopic ultrasonography, have sometimes shown superiority to traditional modalities. This article addresses the literature regarding available imaging techniques in the diagnosis and treatment of common surgical hepatobiliary and pancreatic diseases.
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Various techniques for the surgical treatment of common bile duct stones: a meta review. Gastroenterol Res Pract 2009; 2009:840208. [PMID: 19672460 PMCID: PMC2722154 DOI: 10.1155/2009/840208] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2009] [Accepted: 05/25/2009] [Indexed: 02/08/2023] Open
Abstract
Common bile duct stones (CBDSs) may occur in up to 3%–14.7% of all patients for whom cholecystectomy is preformed. Patients presenting with CBDS have symptoms including: biliary colic, jaundice, cholangitis, pancreatitis or may be asymptomatic. It is important to distinguish between primary and secondary stones, because the treatment approach varies. Stones found before, during, and after cholecystectomy had also differing treatments. Different methods have been used for the treatment of CBDS but the suitable therapy depends on conditions such as patient' satisfaction, number and size of stones, and the surgeons experience in laparoscopy. Endoscopic retrograde cholangiopancreatography with or without endoscopic biliary sphincterotomy, laparoscopic CBD exploration (transcystic or transcholedochal), or laparotomy with CBD exploration (by T-tube, C-tube insertion, or primary closure) are the most commonly used methods managing CBDS. We will review the pathophysiology of CBDS, diagnosis, and different techniques of treatment with especial focus on the various surgical modalities.
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Abstract
The best predictors for the presence of common bile duct stones (CBDS) are cholangitis, jaundice, and direct visualization of stones with ultrasound. In the setting of high suspicion of choledocholithiasis, endoscopic retrograde cholangiography (ERC) is indicated because when CBDS are identified, it allows immediate therapy in the same sitting. If there is a moderate probability of choledocholithiasis, endosonography or magnetic resonance cholangiopancreatography are the first-line options. In patients with gallbladder stones and CBDS, preoperative ERC with or without endoscopic sphincterotomy (ES) is widely recommended as a standard approach. The interval between that and laparoscopic cholecystectomy (LC) should be at least 24 h (<6 weeks) to exclude possible complications due to the ERC/ES. In the setting of open cholecystectomy, open bile duct surgery is significantly superior to ERC with sphincterotomy in achieving common bile duct clearance and is the method of choice. Only in centres with advanced laparoscopic expertise is the laparoscopic removal of CBDS an equivalent treatment option.
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Affiliation(s)
- Peter A Banks
- Division of Gastroenterology, Center for Pancreatic Disease, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Miletic D, Uravic M, Mazur-Brbac M, Stimac D, Petranovic D, Sestan B. Role of Magnetic Resonance Cholangiography in the Diagnosis of Bile Duct Lithiasis. World J Surg 2006; 30:1705-12. [PMID: 16850153 DOI: 10.1007/s00268-005-0459-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
AIM The aim of our study was to assess diagnostic value of magnetic resonance cholangiography (MRC) in patients with suspected common bile duct (CBD) stones focusing on the capability of this noninvasive method to replace invasive diagnostic procedures in these patients and to limit the use of endoscopic retrograde cholangiography (ERC) to the patients who need simultaneous therapeutic intervention. MATERIALS AND METHODS Single-shot fast-spin-echo rapid-acquisition thick-section MRC images were obtained in 310 patients recruited into this prospective study. There were 136 male and 174 female patients aged 21-95 years [mean +/- standard deviation (SD) 64.9 +/- 13.6 years]. Patients were subsequently classified into different risk groups (high, moderate, low) according to biochemical abnormalities or morphological features on abdominal ultrasonography and computed tomography. Direct cholangiography was the reference method of CBD evaluation. RESULTS CBD stones were diagnosed in 115 (37%) patients; 86 of 175 patients in the high-risk group, 24 of 83 patients in the moderate-risk group, and 5 of 50 patients in the low-risk group. In dependent risk groups, the mean CBD caliber was 9.7 +/- 4.5, 7.1 +/- 2.0, and 4.8 +/- 1.2 mm, respectively. The difference was significant between all three groups (P < 0.05). The median size of CBD stones was 7 mm (range 3-21 mm). MRC achieved accuracy and positive and negative predictive values of 97%, 94%, and 98%, respectively. CONCLUSIONS MRC has a potential to substitute diagnostic ERC in all patients with suspected choledocholithiasis due to its high accuracy, reducing invasive direct cholangiography to patients who require therapeutic intervention.
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Abstract
Cholelithiasis, one of the most common medical conditions leading to surgical intervention, affects approximately 10 % of the adult population in the United States. Choledocholithiasis develops in about 10%-20% of patients with gallbladder stones and the literature suggests that at least 3%-10% of patients undergoing cholecystectomy will have common bile duct (CBD) stones.
CBD stones may be discovered preoperatively, intraoperatively or postoperatively Multiple modalities are available for assessing patients for choledocholithiasis including laboratory tests, ultrasound, computed tomography scans (CT), and magnetic resonance cholangiopancreatography (MRCP). Intraoperative cholangiography during cholecystectomy can be used routinely or selectively to diagnose CBD stones.
The most common intervention for CBD stones is ERCP. Other commonly used interventions include intraoperative bile duct exploration, either laparoscopic or open. Percutaneous, transhepatic stone removal other novel techniques of biliary clearance have been devised. The availability of equipment and skilled practitioners who are facile with these techniques varies among institutions. The timing of the intervention is often dictated by the clinical situation.
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Affiliation(s)
- Marilee-L Freitas
- Department of Surgery, Yale University School of Medicine, 40 Temple Street, Suite 3A, New Haven, CT 06510, USA
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