Selective Antegrade Biliary Stenting Aids Emergency Laparoscopic Cholecystectomy

The Conservative Management of Choledocholithiasis With Ursodeoxycholic Acid

Choledocholithiasis has been defined as the presence of stones within the common bile duct (CBD) with up to one-half of the cases remaining asymptomatic. We report a case of an 84-year-old frail male admitted for the treatment of pneumonia, pleural effusion, and bacteraemia with co-incidental deranged liver function tests (LFTs). Ensuing magnetic resonance cholangiopancreatography (MRCP) noted three CBD stones; however, the patient remained asymptomatic. After discussing the benefits and risks of treatment options with the gastroenterology team, the patient refused endoscopic retrograde cholangiopancreatography (ERCP) and opted for close monitoring in the community whilst taking ursodeoxycholic acid (UDCA). In the months following, his LFTs normalised, and repeat MRCP no longer showed stones. This case demonstrates that UDCA with close monitoring may be considered a non-invasive alternative treatment of CBD stones, particularly in elderly or frail patients with multiple comorbidities.

Laparoscopic Cholecystectomy with Intraoperative Cholangiogram and Antegrade Biliary Stenting in Acute Gallstone Pancreatitis: A Pilot Study

Aims: To demonstrate feasibility and efficacy of simultaneous intraoperative cholangiogram (IOC) and antegrade biliary stenting (ABS) with laparoscopic cholecystectomy (LC) compared with preoperative biliary investigation and delayed LC in acute gallstone pancreatitis (AGP). Methods: A retrospective case-control study was performed comparing patients who had a simultaneous IOC ± ABS with LC at index admission with those who had delayed LC in the treatment of AGP. 74 patients were included in this study from January 2016 to October 2018. All patients who underwent LC for AGP were included in a prospective database with 1 year follow-up. Results: 30 (40.5%) patients underwent simultaneous IOC ± ABS with LC, 11 of these required ABS insertion. 2 (6.7%) patients also underwent magnetic resonance cholangiopancreatography (MRCP). No patients underwent endoscopic retrograde cholangiopancreatography (ERCP). No patients were readmitted with AGP or symptomatic gallbladder. Mean length of total hospital admission was 10.1 days. 44 (59.5%) patients underwent delayed LC. Of this cohort, 7 (15.9%) patients underwent ERCP and 19 (43.2%) underwent MRCP. In total, there were 19 (43.2%) readmissions in this group with pancreatitis or symptomatic gallbladder. Mean length of total hospital admission was 13 days. Conclusions: In our pilot study we demonstrated that performing simultaneous IOC ± ABS with LC is a feasible option in the secondary care setting. Using this surgical technique, we have demonstrated a reduction in readmissions with AGP and symptomatic gallbladder while also reducing the number of CBD investigations required. Using simultaneous IOC ± ABS with LC reduced the mean total length of stay in hospital.