Selective ERCP and preoperative stone removal in bile duct surgery

Changes in the Management of Common Bile Duct Stones: 1980 to Date

OBJECTIVE

To compare the results of treating patients with common bile duct (CBD) stones by endoscopic sphincterotomy (ES), surgical exploration, or a combination of ES and surgical CBD exploration (the rendezvous technique).

METHODS

A narrative review of the literature.

SUMMARY OF DATA

Before 1990, 17 cohort studies indicated that ES cleared CBD stones in 92.0% of patients, with a mortality rate of 1.5%. Surgery removed CBD stones in 90.2% of patients, with a 2.1% mortality rate. A single randomized controlled trial in 1987 showed that ES removed CBD stones in 91% of 55 patients, with a 3.6% mortality rate and a 27% complication rate, whereas surgical CBD exploration removed CBD stones in 92%, with a 1.8% mortality rate and a 22% complication rate. Since 1991, 26 randomized controlled trials have shown that laparoscopic-ES rendezvous is as effective as ES alone and laparoscopic surgery alone but is associated with fewer complications, a reduced need for additional procedures, and a shorter hospital stay.

CONCLUSIONS

A laparoscopic-ES rendezvous appears to be the optimal approach to the treatment of CBD stones in younger and fit patients. The choice between ES alone and laparoscopic-ES rendezvous in older or high-risk patients remains uncertain.

Epidemiological Survey of Different Treatments for Choledocholithiasis in Taiwan: A Nationwide, Population-Based Cohort Analysis

(1) Background: Open, laparoscopic, and endoscopic choledocholithotomy (OC, LC, and EC, respectively) are accepted choledocholithiasis treatment modalities. However, an assessment of the nationwide trends in their outcomes is lacking. This nationwide population-based analysis evaluated treatment outcomes of choledocholithiasis in Taiwan; (2) Methods: A total of 13,139,306 individuals were randomly enrolled from the Longitudinal Health Insurance Database (LHID) between 2000 to 2013 for cohort analysis. All patients with newly diagnosed choledocholithiasis aged 18 years or older who were treated during the study period were enrolled and allocated to the OC, LC, EC, or combined endoscopy and open choledocholithotomy (CEOC) groups. Age, readmission, retained stone, comorbidities, hospital stay, medical cost, complications, mortality were analyzed; (3) Results: A total of 58,064 individuals met the inclusion criteria, including 46.54%, 1.10%, 47.52%, and 4.85% who underwent OC, LC, EC, and CEOC, respectively. The endpoint characteristics showed that the LC group had higher readmission, longer hospital stay, and higher medical cost. Cox regression analysis showed that the adjusted hazard ratio (HR) of complications for EC was 1.259 times higher than that for OC. The adjusted HRs of readmission within 90 days for LC, EC, and CEOC were higher than that of OC. The adjusted HR of retreatment with surgery was higher in LC. The adjusted HR of retreatment with endoscopy was higher in CEOC. The adjusted HR of mortality in EC was 1.603 times that of OC; (4) Conclusions: Different choledocholithiasis treatments lead to different outcomes. However, further studies on other large or national data sets are required to support these findings.

Long term outcome of EUS-based strategy for suspected choledocholithiasis but negative CT finding

OBJECTIVES

The American Society for Gastrointestinal Endoscopy (ASGE) guidelines offered the risk-stratified approach in suspected choledocholithiasis. Previous studies have raised concern about the insufficient accuracy of the guideline, especially in high probability group. The purposes of this study were to authenticate the stratification and clinical predictors of the guidelines for suspected choledocholithiasis with no visible choledocholithiasis on computed tomography (CT) and to make clear the clinical strategy of endoscopic ultrasonography (EUS).

MATERIALS AND METHODS

We carried out the retrospective single-center study of 156 patients with suspected choledocholithiasis but negative findings on CT who underwent EUS for about 8 years at Samsung Medical Center. We assessed the clinical predictors of the ASGE guidelines in predicting the presence of choledocholithiasis and the outcome of the EUS.

RESULTS

Fifty-three of the 156 patients had positive findings on EUS that included choledocholithiasis (n = 43, 27.6%) or obstructive papillitis (n = 10, 6.4%). Among the 53 patients, 51 (96.2%) had choledocholithiasis or obstructive papillitis on ERCP. The 101 patients of 103 patients with negative finding on EUS did not show biliary events during follow-up period. EUS accuracy was 98.7% (sensitivity 100%; specificity 98.1%). Among the 49 patients with high probability, 21 (42.9%) had choledocholithiasis on ERCP. In 107 patients who were classified as intermediate probability, 30 (27.3%) had choledocholithiasis. There were no complications related to EUS.

CONCLUSIONS

Not only intermediate probability group but also high probability group without definite acute cholangitis may require EUS. Application of EUS for suspected choledocholithiasis is highly accurate, safe and reduces unnecessary invasive ERCP in 57.1% of patients with high probability group.

Surgery in biliary lithiasis: from the traditional "open" approach to laparoscopy and the "rendezvous" technique

BACKGROUND

According to the current literature, biliary lithiasis is a worldwide-diffused condition that affects almost 20% of the general population. The rate of common bile duct stones (CBDS) in patients with symptomatic cholelithiasis is estimated to be 10% to 33%, depending on patient's age. Compared to stones in the gallbladder, the natural history of secondary CBDS is still not completely understood. It is not clear whether an asymptomatic choledocholithiasis requires treatment or not. For many years, open cholecystectomy with choledochotomy and/or surgical sphincterotomy and cleaning of the bile duct were the gold standard to treat both pathologies. Development of both endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic surgery, together with improvements in diagnostic procedures, influenced new approaches to the management of CBDS in association with gallstones.

DATA SOURCES

We decided to systematically review the literature in order to identify all the current therapeutic options for CBDS. A systematic literature search was performed independently by two authors using PubMed, EMBASE, Scopus and the Cochrane Library Central.

RESULTS

The therapeutic approach nowadays varies greatly according to the availability of experience and expertise in each center, and includes open or laparoscopic common bile duct exploration, various combinations of laparoscopic cholecystectomy and ERCP and combined laparoendoscopic rendezvous.

CONCLUSIONS

Although ERCP followed by laparoscopic cholecystectomy is currently preferred in the majority of hospitals worldwide, the optimal treatment for concomitant gallstones and CBDS is still under debate, and greatly varies among different centers.

Results of Medium Seventeen Years' Follow-Up after Laparoscopic Choledochotomy for Ductal Stones

Introduction. In a previously published article the authors reported the long-term follow-up results in 138 consecutive patients with gallstones and common bile duct (CBD) stones who underwent laparoscopic transverse choledochotomy (TC) with T-tube biliary drainage and laparoscopic cholecystectomy (LC). Aim of this study is to evaluate the results at up to 23 years of follow-up in the same series. Methods. One hundred twenty-one patients are the object of the present study. Patients were evaluated by clinical visit, blood assay, and abdominal ultrasound. Symptomatic patients underwent cholangio-MRI, followed by endoscopic retrograde cholangiopancreatography (ERCP) as required. Results. Out of 121 patients, 61 elderly patients died from unrelated causes. Fourteen patients were lost to follow-up. In the 46 remaining patients, ductal stone recurrence occurred in one case (2,1%) successfully managed by ERCP with endoscopic sphincterotomy. At a mean follow-up of 17.1 years no other patients showed signs of bile stasis and no patient showed any imaging evidence of CBD stricture at the site of choledochotomy. Conclusions. Laparoscopic transverse choledochotomy with routine T-tube biliary drainage during LC has proven to be safe and effective at up to 23 years of follow-up, with no evidence of CBD stricture when the procedure is performed with a correct technique.

Surgical versus endoscopic treatment of bile duct stones

BACKGROUND

Between 10% to 18% of people undergoing cholecystectomy for gallstones have common bile duct stones. Treatment of the bile duct stones can be conducted as open cholecystectomy plus open common bile duct exploration or laparoscopic cholecystectomy plus laparoscopic common bile duct exploration (LC + LCBDE) versus pre- or post-cholecystectomy endoscopic retrograde cholangiopancreatography (ERCP) in two stages, usually combined with either sphincterotomy (commonest) or sphincteroplasty (papillary dilatation) for common bile duct clearance. The benefits and harms of the different approaches are not known.

OBJECTIVES

We aimed to systematically review the benefits and harms of different approaches to the management of common bile duct stones.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL, Issue 7 of 12, 2013) in The Cochrane Library, MEDLINE (1946 to August 2013), EMBASE (1974 to August 2013), and Science Citation Index Expanded (1900 to August 2013).

SELECTION CRITERIA

We included all randomised clinical trials which compared the results from open surgery versus endoscopic clearance and laparoscopic surgery versus endoscopic clearance for common bile duct stones.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified the trials for inclusion and independently extracted data. We calculated the odds ratio (OR) or mean difference (MD) with 95% confidence interval (CI) using both fixed-effect and random-effects models meta-analyses, performed with Review Manager 5.

MAIN RESULTS

Sixteen randomised clinical trials with a total of 1758 randomised participants fulfilled the inclusion criteria of this review. Eight trials with 737 participants compared open surgical clearance with ERCP; five trials with 621 participants compared laparoscopic clearance with pre-operative ERCP; and two trials with 166 participants compared laparoscopic clearance with postoperative ERCP. One trial with 234 participants compared LCBDE with intra-operative ERCP. There were no trials of open or LCBDE versus ERCP in people without an intact gallbladder. All trials had a high risk of bias.There was no significant difference in the mortality between open surgery versus ERCP clearance (eight trials; 733 participants; 5/371 (1%) versus 10/358 (3%) OR 0.51;95% CI 0.18 to 1.44). Neither was there a significant difference in the morbidity between open surgery versus ERCP clearance (eight trials; 733 participants; 76/371 (20%) versus 67/358 (19%) OR 1.12; 95% CI 0.77 to 1.62). Participants in the open surgery group had significantly fewer retained stones compared with the ERCP group (seven trials; 609 participants; 20/313 (6%) versus 47/296 (16%) OR 0.36; 95% CI 0.21 to 0.62), P = 0.0002.There was no significant difference in the mortality between LC + LCBDE versus pre-operative ERCP +LC (five trials; 580 participants; 2/285 (0.7%) versus 3/295 (1%) OR 0.72; 95% CI 0.12 to 4.33). Neither was there was a significant difference in the morbidity between the two groups (five trials; 580 participants; 44/285 (15%) versus 37/295 (13%) OR 1.28; 95% CI 0.80 to 2.05). There was no significant difference between the two groups in the number of participants with retained stones (five trials; 580 participants; 24/285 (8%) versus 31/295 (11%) OR 0.79; 95% CI 0.45 to 1.39).There was only one trial assessing LC + LCBDE versus LC+intra-operative ERCP including 234 participants. There was no reported mortality in either of the groups. There was no significant difference in the morbidity, retained stones, procedure failure rates between the two intervention groups.Two trials assessed LC + LCBDE versus LC+post-operative ERCP. There was no reported mortality in either of the groups. There was no significant difference in the morbidity between laparoscopic surgery and postoperative ERCP groups (two trials; 166 participants; 13/81 (16%) versus 12/85 (14%) OR 1.16; 95% CI 0.50 to 2.72). There was a significant difference in the retained stones between laparoscopic surgery and postoperative ERCP groups (two trials; 166 participants; 7/81 (9%) versus 21/85 (25%) OR 0.28; 95% CI 0.11 to 0.72; P = 0.008.In total, seven trials including 746 participants compared single staged LC + LCBDE versus two-staged pre-operative ERCP + LC or LC + post-operative ERCP. There was no significant difference in the mortality between single and two-stage management (seven trials; 746 participants; 2/366 versus 3/380 OR 0.72; 95% CI 0.12 to 4.33). There was no a significant difference in the morbidity (seven trials; 746 participants; 57/366 (16%) versus 49/380 (13%) OR 1.25; 95% CI 0.83 to 1.89). There were significantly fewer retained stones in the single-stage group (31/366 participants; 8%) compared with the two-stage group (52/380 participants; 14%), but the difference was not statistically significantOR 0.59; 95% CI 0.37 to 0.94).There was no significant difference in the conversion rates of LCBDE to open surgery when compared with pre-operative, intra-operative, and postoperative ERCP groups. Meta-analysis of the outcomes duration of hospital stay, quality of life, and cost of the procedures could not be performed due to lack of data.

AUTHORS' CONCLUSIONS

Open bile duct surgery seems superior to ERCP in achieving common bile duct stone clearance based on the evidence available from the early endoscopy era. There is no significant difference in the mortality and morbidity between laparoscopic bile duct clearance and the endoscopic options. There is no significant reduction in the number of retained stones and failure rates in the laparoscopy groups compared with the pre-operative and intra-operative ERCP groups. There is no significant difference in the mortality, morbidity, retained stones, and failure rates between the single-stage laparoscopic bile duct clearance and two-stage endoscopic management. More randomised clinical trials without risks of systematic and random errors are necessary to confirm these findings.

Surgical versus endoscopic treatment of bile duct stones

BACKGROUND

Between 10% to 18% of people undergoing cholecystectomy for gallstones have common bile duct stones. Treatment of the bile duct stones can be conducted as open cholecystectomy plus open common bile duct exploration or laparoscopic cholecystectomy plus laparoscopic common bile duct exploration (LC + LCBDE) versus pre- or post-cholecystectomy endoscopic retrograde cholangiopancreatography (ERCP) in two stages, usually combined with either sphincterotomy (commonest) or sphincteroplasty (papillary dilatation) for common bile duct clearance. The benefits and harms of the different approaches are not known.

OBJECTIVES

We aimed to systematically review the benefits and harms of different approaches to the management of common bile duct stones.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL, Issue 7 of 12, 2013) in The Cochrane Library, MEDLINE (1946 to August 2013), EMBASE (1974 to August 2013), and Science Citation Index Expanded (1900 to August 2013).

SELECTION CRITERIA

We included all randomised clinical trials which compared the results from open surgery versus endoscopic clearance and laparoscopic surgery versus endoscopic clearance for common bile duct stones.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified the trials for inclusion and independently extracted data. We calculated the odds ratio (OR) or mean difference (MD) with 95% confidence interval (CI) using both fixed-effect and random-effects models meta-analyses, performed with Review Manager 5.

MAIN RESULTS

Sixteen randomised clinical trials with a total of 1758 randomised participants fulfilled the inclusion criteria of this review. Eight trials with 737 participants compared open surgical clearance with ERCP; five trials with 621 participants compared laparoscopic clearance with pre-operative ERCP; and two trials with 166 participants compared laparoscopic clearance with postoperative ERCP. One trial with 234 participants compared LCBDE with intra-operative ERCP. There were no trials of open or LCBDE versus ERCP in people without an intact gallbladder. All trials had a high risk of bias.There was no significant difference in the mortality between open surgery versus ERCP clearance (eight trials; 733 participants; 5/371 (1%) versus 10/358 (3%) OR 0.51;95% CI 0.18 to 1.44). Neither was there a significant difference in the morbidity between open surgery versus ERCP clearance (eight trials; 733 participants; 76/371 (20%) versus 67/358 (19%) OR 1.12; 95% CI 0.77 to 1.62). Participants in the open surgery group had significantly fewer retained stones compared with the ERCP group (seven trials; 609 participants; 20/313 (6%) versus 47/296 (16%) OR 0.36; 95% CI 0.21 to 0.62), P = 0.0002.There was no significant difference in the mortality between LC + LCBDE versus pre-operative ERCP +LC (five trials; 580 participants; 2/285 (0.7%) versus 3/295 (1%) OR 0.72; 95% CI 0.12 to 4.33). Neither was there was a significant difference in the morbidity between the two groups (five trials; 580 participants; 44/285 (15%) versus 37/295 (13%) OR 1.28; 95% CI 0.80 to 2.05). There was no significant difference between the two groups in the number of participants with retained stones (five trials; 580 participants; 24/285 (8%) versus 31/295 (11%) OR 0.79; 95% CI 0.45 to 1.39).There was only one trial assessing LC + LCBDE versus LC+intra-operative ERCP including 234 participants. There was no reported mortality in either of the groups. There was no significant difference in the morbidity, retained stones, procedure failure rates between the two intervention groups.Two trials assessed LC + LCBDE versus LC+post-operative ERCP. There was no reported mortality in either of the groups. There was no significant difference in the morbidity between laparoscopic surgery and postoperative ERCP groups (two trials; 166 participants; 13/81 (16%) versus 12/85 (14%) OR 1.16; 95% CI 0.50 to 2.72). There was a significant difference in the retained stones between laparoscopic surgery and postoperative ERCP groups (two trials; 166 participants; 7/81 (9%) versus 21/85 (25%) OR 0.28; 95% CI 0.11 to 0.72; P = 0.008.In total, seven trials including 746 participants compared single staged LC + LCBDE versus two-staged pre-operative ERCP + LC or LC + post-operative ERCP. There was no significant difference in the mortality between single and two-stage management (seven trials; 746 participants; 2/366 versus 3/380 OR 0.72; 95% CI 0.12 to 4.33). There was no a significant difference in the morbidity (seven trials; 746 participants; 57/366 (16%) versus 49/380 (13%) OR 1.25; 95% CI 0.83 to 1.89). There were significantly fewer retained stones in the single-stage group (31/366 participants; 8%) compared with the two-stage group (52/380 participants; 14%), but the difference was not statistically significantOR 0.59; 95% CI 0.37 to 0.94).There was no significant difference in the conversion rates of LCBDE to open surgery when compared with pre-operative, intra-operative, and postoperative ERCP groups. Meta-analysis of the outcomes duration of hospital stay, quality of life, and cost of the procedures could not be performed due to lack of data.

AUTHORS' CONCLUSIONS

Open bile duct surgery seems superior to ERCP in achieving common bile duct stone clearance based on the evidence available from the early endoscopy era. There is no significant difference in the mortality and morbidity between laparoscopic bile duct clearance and the endoscopic options. There is no significant reduction in the number of retained stones and failure rates in the laparoscopy groups compared with the pre-operative and intra-operative ERCP groups. There is no significant difference in the mortality, morbidity, retained stones, and failure rates between the single-stage laparoscopic bile duct clearance and two-stage endoscopic management. More randomised clinical trials without risks of systematic and random errors are necessary to confirm these findings.

[Laparoscopic versus endoscopic primary management of choledocholithiasis. A retrospective case-control study]

BACKGROUND

The aim was to present the long-term results of one-stage laparoscopic procedure for the management of common bile duct (CBD) lithiasis in comparison with the primary endoscopic approach via ERCP.

PATIENTS AND METHODS

A retrospective case-control study was performed to determine the outcome of patients treated for CBD lithiasis (04/1997 - 11/2011). Data of patients with choledocholithiasis undergoing the two treatment modalities - laparoscopic common bile duct exploration plus laparoscopic cholecystectomy (LCBDE + LC, group A, n = 101) versus endoscopic retrograde cholangiopancreatography/sphincterotomy and laparoscopic cholecystectomy (ERCP/S + LC, group B, n = 116) were matched according to their clinical characteristics. Patients of group A underwent either laparoscopic choledochotomy or transcystic exploration. The policy was to convert to open choledochotomy only after the sequential application of the two treatment modalities (laparoscopic/endoscopic procedure) had failed.

RESULTS

No significant difference in morbidity was found between the groups (group A 8% versus group B 11.2%). Conversion to another procedure was mandatory in 12 out of 101 and 17 out of 116 patients of groups A and B, respectively. The mean follow-up period was 7.8 years (range 1-12 years). Effective laparoscopic treatment of CBD stones (cholecystectomy and CBD clearance) was possible in 89 of the 101 patients in group A (88.1%) compared with 99 of the 116 patients in group B (85.4%) after the endoscopic approach.

CONCLUSIONS

This study showes that both - primary endoscopy and one-stage laparoscopic management of CBD lithiasis - are highly effective and safe with comparable results.

Intraoperative ERCP: What role does it have in the era of laparoscopic cholecystectomy?

In the treatment of patients with symptomatic cholelithiasis and choledocholithiasis (CBDS) detected during intraoperative cholangiography (IOC), or when the preoperative study of a patient at intermediate risk for CBDS cannot be completed due to the lack of imaging techniques required for confirmation, or if they are available and yield contradictory radiological and clinical results, patients can be treated using intraoperative endoscopic retrograde cholangiopancreatography (ERCP) during the laparoscopic treatment or postoperative ERCP if the IOC finds CBDS. The choice of treatment depends on the level of experience and availability of each option at each hospital. Intraoperative ERCP has the advantage of being a single-stage treatment and has a significant success rate, an easy learning curve, low morbidity involving a shorter hospital stay and lower costs than the two-stage treatments (postoperative and preoperative ERCP). Intraoperative ERCP is also a good salvage treatment when preoperative ERCP fails or when total laparoscopic management also fails.

Single-stage treatment with intraoperative ERCP: management of patients with possible choledocholithiasis and gallbladder in situ in a non-tertiary Spanish hospital

BACKGROUND

The best way to reduce endoscopic retrograde cholangiopancreatography (ERCP) complications is not to perform it if it is unnecessary. Both intraoperative and postoperative ERCP rely on use of intraoperative cholangiography as a final diagnostic test for choledocholithiasis (CLD) whenever clinical data are unable to rule out CLD. Intraoperative ERCP could become a therapeutic option when a previous preoperative ERCP fails. We present our experience with intraoperative ERCP.

PATIENTS AND METHODS

This is a descriptive and prospective study of a cohort of 82 patients with moderate risk of CLD. They were operated on by laparoscopic cholecystectomy with intraoperative cholangiography (IOC). We performed intraoperative ERCP using the rendezvous technique.

RESULTS

Thirty-six out of 82 patients had an abnormal IOC study. Mean age was 58.7 years (standard deviation, SD 16.6, 25-83 years), and 60.6% were females. Ultrasound study showed that 51.4% of patients had a dilated bile duct. Magnetic resonance cholangiography (MRC) was performed on three patients (8.3%). The success rate of intraoperative ERCP was 88.2%. Three out of the 36 patients (8.8%) had ERCP complications [2 mild papillary bleeding (5.8%), 1 acute pancreatitis (2.9%)]. The rate of conversion to open surgery was 5% with a surgical complications rate of 4% [one injured duct and two surgical bleeding which required re-operation (2.5%)]. There were no mortalities. Four patients (11.1%) needed post-surgical ERCP, with a residual CLD rate of 5.6% (two patients) in the postoperative period. Mean surgical time was 181 min (SD 60, 75-345 min). Mean hospital stay was 6.2 days (SD 4.7, 2-24 days).

CONCLUSIONS

Intraoperative ERCP is an option to prevent performing ERCP unnecessarily on patients with moderate risk of CLD not confirmed using appropriate radiological studies. It can resolve the biliary disease in a single step with a similar success rate to standard ERCP, but with low morbidity, especially of acute pancreatitis. The residual CLD rate is also very low.

Case review of impacted bile duct stone at duodenal papilla: detection and endoscopic treatment

PURPOSE

A bile duct stone impacted at the duodenal papilla is an urgent condition that can rapidly lead to either suppurative cholangitis or acute pancreatitis due to almost complete obstruction of the bilio-pancreatic outflow. This study evaluated the clinical characteristics and results of endoscopic treatment for a bile duct stone impacted at the duodenal papilla.

MATERIALS AND METHODS

Forty-six patients who had been diagnosed with an impacted papillary stone were retrospectively reviewed.

RESULTS

The typical features of acute cholangitis (Charcot's triad) and pancreatitis were only observed only in 10 patients (21.7%) and 17 patients (37.0%), respectively. After the endoscopic retrograde cholangiopancreatography, 30 patients (65.2%) were found to have a solitary stone impacting the duodenal papilla and 16 patients had one or more stones in the bile duct. On the radiological studies, the former patients were associated more commonly with no visible stone or no bile duct dilatation (p < 0.05). All impacted papillary stones were successfully removed by endoscopic sphincterotomy: 23 by a needle knife and 23 by a pull type papillotome. The procedure- related complications (n = 7, 4 bleeding, 3 pancreatitis) were not serious and did not differ, based on endoscopic findings and the procedure used.

CONCLUSION

A bile duct stone impacted at the duodenal papilla requires both clinical and radiographic evidence to support the diagnosis. Endoscopic sphincterotomy, either with a needle knife or a pull type papillotome, was safe and effective for removing the impacted papillary stone.

Cholecystocholedocholithiasis: a case-control study comparing the short- and long-term outcomes for a "laparoscopy-first" attitude with the outcome for sequential treatment (systematic endoscopic sphincterotomy followed by laparoscopic cholecystectomy)

BACKGROUND

No unanimous consensus has been achieved regarding the ideal management of cholecystocholedocholithiasis. The treatment of gallbladder and common bile duct (CBD) stones may be achieved currently according to a two-step-protocol (endoscopic sphincterotomy associated with laparoscopic cholecystectomy) or by a one-step laparoscopic procedure, including exploration of the CBD and cholecystectomy. Endoscopic sphincterotomy is reported to have considerable morbidity/mortality and CBD stone recurrence rates, whereas laparoscopic CBD clearance is a demanding procedure, which to date has not spread beyond specialized environments.

METHODS

To evaluate our "laparoscopy first" (LF) approach for patients affected by gallbladder/CBD stones (laparoscopic exploration and intraoperative decision whether to proceed with laparoscopic CBD exploration or to postpone CBD stone treatment to a postoperative endoscopic retrograde cholangiopancreatography [ERCP]), we performed a retrospective, two-center case-control comparison of the postoperative outcome for 49 consecutive patients treated for gallbladder/CBD stones from January 2000 through December 2004. The results obtained with this LF approach were compared with those achieved with the traditional, "endoscopy-first" (EF) approach (ERCP plus endoscopic sphincterotomy, followed by laparoscopic cholecystectomy). The mean follow-up period was 6.4 years (range, 4-8 years).

RESULTS

No difference emerged concerning early and late complications, mortality, or laparotomies needed to accomplish cholecystectomy and CBD clearance. The postoperative hospital stay was shorter for the LF group. In the LF group, only 22 patients underwent choledochotomy (45%), and 15 patients underwent perioperative ERCP (30%). Conversions decreased with practice. After choledochotomy, an increasing number of patients underwent primary closure of the CBD (with no biliary drain), without complications.

CONCLUSIONS

An LF approach to gallbladder/CBD stones is safe and feasible. It may allow the majority of surgeons to avoid excessively difficult/dangerous surgical procedures as well as unnecessary ERCPs in most cases. A tendency toward a lower incidence of conversions and a rarer use of biliary drains may lead to an improved immediate outcome for patients undergoing an LF approach.

Surgical versus endoscopic treatment of bile duct stones

BACKGROUND

10% to 18% of patients undergoing cholecystectomy for gallstones have common bile duct (CBD) stones. Treatment options for these stones include pre- or post-operative endoscopic retrograde cholangiopancreatography (ERCP) or open or laparoscopic surgery.

OBJECTIVES

To systematically review the management of CBD stones by four approaches: (1) ERCP versus open surgical bile duct clearance. (2) Pre-operative ERCP versus laparoscopic bile duct clearance. (3) Post-operative ERCP versus laparoscopic bile duct clearance. (4) ERCP versus laparoscopic bile duct clearance in patients with previous cholecystectomy.

SEARCH STRATEGY

We systematically searched key relevant electronic databases, bibliographies of relevant papers, and abstracts of relevant subspecialty meetings until November 2005.

SELECTION CRITERIA

The quality of included trials was assessed by adequacy of allocation sequence generation, allocation concealment, blinding, and follow-up.

DATA COLLECTION AND ANALYSIS

Published and unpublished data relevant to 12 predefined outcome measures were used to conduct fixed- and random-effects models meta-analyses, with exploration of heterogeneity and use of sensitivity and subgroup analysis where required.

MAIN RESULTS

Thirteen trials randomised 1351 patients. Eight trials (n = 760) compared ERCP with open surgical clearance, three (n = 425) compared pre-operative ERCP with laparoscopic clearance, and two (n = 166) compared post-operative ERCP with laparoscopic clearance. There were no trials of ERCP versus laparoscopic clearance in patients without an intact gallbladder. Methodology was considered adequate in at least two of three assessable fields in ten trials. A significantly increased number of total procedures (including for complications) per patient was seen in the ERCP arms in all three comparisons with weighted mean differences of 0.62 (95% CI 0.15 to 1.09), 0.96 (95% CI 0.96 to 0.96), and 1.09 (95% CI 0.93 to 1.24), respectively. ERCP was less successful than open surgery in CBD stone clearance (Peto OR 2.89, 95% CI 1.81 to 4.61) with a tendency towards higher mortality (risk difference 1%, 95% CI -1% to 4%). Laparoscopic CBD stone clearance was as efficient as pre- (Peto OR 1.00, CI 0.53 to 1.80) and post-operative ERCP (OR 2.27, 95% CI 0.37 to 13.9) and with no significant difference in morbidity and mortality. Laparoscopic trials universally reported shorter hospital stays in surgical arms. Insufficient data were reported for cost analysis.

AUTHORS' CONCLUSIONS

In the era of open cholecystectomy, open bile duct surgery was superior to ERCP in achieving CBD stone clearance. In the laparoscopic era, data are close to excluding a significant difference between laparoscopic and ERCP clearance of CBD stones. The use of ERCP necessitates increased number of procedures per patient.

Selective intraoperative cholangiography and single-stage management of common bile duct stone in laparoscopic cholecystectomy

BACKGROUND

There are still debates and controversies in the detection and the management of common bile duct (CBD) stones in the era of laparoscopic cholecystectomy (LC). This prospective study was performed to evaluate a single-stage management of CBD stone during LC.

METHODS

Between May 1998 and January 2000, 249 consecutive patients with gallstone and cholecystitis were enrolled in this study. The mean age was 52.5 +/- 12.4 years. Male to female ratio was 106:143. All patients underwent abdominal sonography and the determination of the serum biochemical profile preoperatively. Patients presented with sepsis or with total bilirubin > or = 6 ng/dL were excluded from the study.

RESULTS

244 (98%) patients underwent LC and 5 (2%) patients were converted to open cholecystectomy. Intraoperative cholangiogram (IOC) was only performed in patients who fulfilled our predetermined criteria. Among 90 patients who had IOC, only 23 patients had CBD stones that were removed either by transcystic duct stone extraction (61%) or CBD exploration (39%). The additional procedures to remove CBD stone did not prolong the hospitalization. There were four wound infections and one cystic stump leakage. One patient developed CBD stone during the follow-up period up to 37 months.

CONCLUSIONS

Our study indicates that routine use of IOC during LC is not necessary. In addition, single-stage approach for the management of CBD stone during LC is feasible and should be considered by laparoscopic surgeons.

Laparoscopic management of common bile duct stones

BACKGROUND

While laparoscopic cholecystectomy is widely accepted for therapy of cholecystolithiasis, controversy still exists concerning the management of common bile duct stones. Besides preoperative endoscopic papillotomy followed by laparoscopic cholecystectomy and open common bile duct surgery, management of common bile duct stones can be conducted by laparoscopy, if respective experience is available.

METHOD

During laparoscopic cholecystectomy a cholangiography via the cystic duct is routinely performed. If bile duct stones are detected they are retrieved via the cystic duct or via incision of the common bile duct by insertion of a Fogarty catheter or Dormia basket. Exclusion criteria against simultaneous laparoscopic management include suspicion of malignancy, severe pancreatitis, or cholangitis.

RESULTS

From November 1991 to March 2002, 200 patients primarily underwent laparoscopic therapy of bile duct stones. Retrieval was performed via cystic duct and common bile duct incision in 115 and 85 cases, respectively. Complete removal was achieved in 91%; complication rate and mortality was 7% and 0.5%, respectively. During the same period primary endoscopic papillotomy was necessary in 40 patients because of the above contraindications.

CONCLUSIONS

When correct indications and surgical expertise are observed, simultaneous laparoscopic management of common bile duct stones represents a safe and minimally invasive alternative to a two-procedure approach.

Laparoscopic transcystic bile duct stenting in the management of common bile duct stones

BACKGROUND

The management of patients with common bile duct stones associated with stones in the gall bladder remains controversial.

METHODS

Over the three-year period from 1996 to 1999, patients with cholelithiasis and known choledocholithiasis, or choledocholithiasis found at laparoscopic cholecystectomy, were initially treated by placing a stent across the sphincter of Oddi. The stent was pushed along a guide wire through the cystic duct and then down the common bile duct, before the cystic duct was closed. Subsequently, the stent was used to facilitate performance of a needle knife endoscopic sphincterotomy. The stent was then removed, a cholangiography was performed and the common bile duct was cleared. Patients with persistent jaundice usually had a preoperative endoscopic retrograde cholangio-pancreatography.

RESULTS

Transcystic stenting was the 'intention-to-treat' basis of therapy for 56 of the patients. The placement of the stent only failed once when the stent became trapped in the cystic duct. Complications of the operation included: pain and jaundice (n = 2), cholangitis (n = 1), and pulmonary embolus (n = 1). The median postoperative hospitalization was 2 days (range: 1-15). Five further patients had common bile duct stones removed via a choledochotomy; a stent was placed through the choledochotomy before its closure. The selective common bile duct cannulation rate at the first endoscopic retrograde cholangio-pancreatography, was 98%. A second endoscopic retrograde cholangio-pancreatography was required in 15% of patients. The only complication of all the endoscopic procedures was a single case of mild cholangitis; there were no cases of pancreatitis.

CONCLUSION

A treatment option open to all surgeons for non-jaundiced patients with known choledocholithiasis or choledocholithiasis found at operative cholangiogram, is the transcystic stenting of the sphincter of Oddi at the time of laparoscopic cholecystectomy. At a subsequent sitting, the common bile duct can be safely cleared endoscopically using a sphincterotomy facilitated by the stent.

Laparoscopic surgery of the liver and biliary tract

Laparoscopic treatment of liver and biliary tract disease is growing in popularity but requires extensive experience. Among the lesions now managed with minimally invasive methods are simple cysts, polycystic liver disease, hydatid cysts, biliary stones, and benign solid tumors. Patient selection, surgical techniques, and outcomes are described.

Common bile duct stone characteristics: correlation with treatment choice during laparoscopic cholecystectomy

Determining the most appropriate management approach for patients with unsuspected choledocholithiasis may be difficult because of the subjective nature of this decision in the absence of clinical data. Treatment of incidental choledocholithiasis during laparoscopic cholecystectomy was reviewed during a 25-month period. Operative cholangiograms were analyzed retrospectively to determine if associations exist between common bile duct stone characteristics and the intraoperative treatment selected by the operating surgeon. Cholangiographic data included quantification of common bile duct stones, stone dimension, position, and presence of radiopaque contrast flow into the duodenum. Two hundred thirty-six laparoscopic cholecystectomy patients underwent operative cholangiography; 25 (11%) demonstrated choledocholithiasis. Seven patients were converted to open common bile duct exploration (group I), 16 patients were referred for postoperative endoscopic retrograde cholangiopancreatography (group II), and two patients were observed (group III). Evaluation of the operative cholangiograms revealed multiple common bile duct stones (>1) in 86% (6 of 7) in group I, 25% (4 of 16) in group II, and none in group III. All patients in group I had at least one stone larger than 5 ml in greatest diameter, whereas only 33% (6 of 18) in groups II and III combined had stones larger than 5 ml. Group I had significantly (P = 0.027) more representation of delayed or no contrast flow during operative cholangiography compared to groups II and III. The intraoperative decision to proceed with laparoscopic cholecystectomy and rely on postoperative endoscopic retrograde cholangiopancreatography for stone retrieval rather than open common bile duct exploration was associated with (1) a single common bile duct stone, less than or equal to 5 ml in size on operative cholangiogram and (2) normal contrast flow into the duodenum. Open common bile duct exploration was more frequently associated with the demonstration of multiple or large (>5 ml) stones. A periampullary stone did not discriminate among treatment choices.

Endoscopic management of biliary tract disease

Endoscopic management of biliary tract disease continues to be influenced by new advances in technology and shaped by further examination of old controversies. This review covers and highlights recent world literature concerning biliary endoscopy and its effect on the management of biliary disorders. In particular, we examine the role and consequence of the endoscopic management of choledocholithiasis and the continuing controversy over endoscopic treatment of pancreatic disease. The increasing impact of endoscopic ultrasound in the biliary tree is explored, as well as the latest developments in biliary stent technology.

Management of Bile Duct Stones in 1572 Patients Undergoing Laparoscopic Cholecystectomy

Evidence of bile duct stones (BDSs) was identified on routine cholangiogram in 136 (8.7%) of 1572 patients undergoing laparoscopic cholecystectomy from March 1989 through March 1997. Forty-two (30.9%) were unsuspected. All patients with evidence of BDSs underwent laparoscopic bile duct exploration (LBDE). Initially, a standard choledochotomy with T-tube drainage as in the open approach was used. Later, transcystic duct exploration was added to the algorithm. The algorithm evolved into an ongoing treatment protocol study that was initiated in March 1992. Through March 1997, 100 patients underwent LBDE based on the protocol. The study is divided into two groups. Group A comprises the total 136 patients undergoing LBDE, including those in the protocol study. A subgroup, Group B, comprises only the 100 patients in the protocol study. In Group A, LBDE was successful in 114 patients (83.8%). Stones were missed in seven patients and left behind for spontaneous passage or later retrieval in six patients. Eleven patients (8.1%) were converted to open. There were 13 major complications (9.6%), including the seven missed stones and two deaths. In Group B, LBDE was successful in 94 per cent. Stones were missed in one patient and intentionally left behind in four patients. One patient was converted to open. There were seven major complications (7%), including one of the missed stones and one death. Using the protocol algorithm and the techniques described, BDSs can be effectively managed laparoscopically at the time of cholecystectomy in approximately 94 per cent of cases.

Endoscopic and surgical integration in the approach to biliary tract disease

Several techniques are available today to access the bile ducts, all equally safe and effective. Since 1990, we have studied three groups of patients treated with different methods: the sequential endoscopic sphincterotomy + laparoscopic cholecystectomy, the single-stage laparoscopic approach, and the single laparoscopic-endoscopic approach. The results obtained in 127 patients to date suggest that one single-stage treatment is more convenient for the patient, while the combination of endoscopic sphincterotomy with laparoscopic cholecystectomy is preferable in terms of efficacy and safety.

Laparoscopic cholecystectomy (LC), intraoperative endoscopic sphincterotomy (ES), and common bile duct stones (CBDS) extraction for management of patients with cholecystocholedocholithiasis

BACKGROUND

A combined method of endoscopic sphincterotomy (ES) with common bile duct stone (CBDS) extraction and laparoscopic cholecystectomy (LC) under general anesthesia for a single-session treatment of patients with colecysto-choledocholithiasis is described.

METHODS

From June 1994 to January 1995, 15 consecutive cases considered for elective LC with preoperative diagnosis of CBDS underwent this procedure. Following orotracheal intubation, the patient is turned on the left lateral decubitus for ES and CBDS extraction. Nasobiliary drainage is positioned for per-laparoscopic cholangiogram. Routine LC is finally performed.

RESULTS

These two interventions were successfully accomplished in all patients. Mean duration of the operative time for the combined procedure was 97.7 +/- 30.4 min, range 60-140 min. In four (26.6%) cases an accessory trocar with retracting instrument was used to obviate the bowel distension.

CONCLUSIONS

No complications of ES or LC were observed. Mean hospital stay was 3 days (range 2-5 days). Routine follow-up (mean 3 +/- 2 months, range 1-12 months) did not reveal biliary-related problems in any of the observed patients.

Laparoscopic treatment of known choledocholithiasis

BACKGROUND

Occasionally patients present to the surgeon with known common duct stones. These will frequently have been detected by imaging modalities: ultrasound, computed tomography (CT) scans, transhepatic cholangiogram (THC) or IV cholangiography. Occasionally there are stones that had failed attempts at endoscopic retrieval (ERCP).

METHODS

A retrospective analysis of a prospectively gathered database of 77 laparoscopic common bile duct explorations was done to assess the incidence, treatments and outcomes of patients who had known common duct stones (CDS) before surgery.

RESULTS

Eighteen patients (23%) were identified as having a preoperative diagnosis of CDS. All underwent a laparoscopic common bile duct exploration. This exploration was successful in all cases. Outcomes were good with a 4% complication rate and one case of retained common duct stones (4%).

CONCLUSIONS

Before laparoscopic cholecystectomy, known choledocholithiasis was considered a surgical disease except in cases of acute cholangitis or the very morbidly ill. The ability to perform cholecystectomy laparoscopically made many practitioners avoid open common duct exploration and, instead, rely on ERCP as primary treatment for known or suspected common duct stones. As techniques of laparoscopic common duct exploration improve, the ability to deal with common duct pathology surgically has increased, offering new options for treatment of this patient population. We present our experience with 18 patients who presented with known choledocholithiasis and were treated laparoscopically with good results.

Laparoscopic common bile duct exploration: evolution of a new technique

Laparoscopic exploration of the common bile duct (CBD) with a choledochoscope or a stone basket during laparoscopic cholecystectomy was attempted in 60 patients and was successful in 56. The cystic duct was used for entry to the CBD in 46 patients and in 14 a choledochotomy was performed. Of 51 patients with confirmed common duct stones, 38 had complete laparoscopic clearance (75 per cent). In 13 patients the duct was not cleared or was only partially cleared, of whom four went on to have clearance by postoperative percutaneous choledochoscopy down a cystic duct or T-tube track. Two patients with cystic duct tubes passed their remaining stones spontaneously. One patient had open exploration and six required endoscopic retrograde cholangiopancreatography. Of nine patients without stones, choledochoscopy was impossible in three patients whose cholangiogram was later considered to be normal. In five patients stones were excluded by choledochoscopy and in one patient laparoscopic choledochoscopy was undertaken to better define abnormal biliary anatomy; this helped to avoid major bile duct injury. Choledochoscopy was easier with the smaller 3.6-mm ureteroscope but stone removal was more difficult when the basket was too small for the stones, the cystic duct too small relative to stone size or the number of stones was too great. Successful stone clearance was proportional to the level of effort expended, and was limited by operating time and equipment.

Open common bile duct exploration--end of an epoch?

With the advent of laparoscopic cholecystectomy and the impending replacement of open common bile duct exploration, we have reviewed our ten year experience of conventional common bile duct exploration. Open cholecystectomy was performed in 1681 patients and the common bile duct was explored in 325 (19%). Following initial duct exploration, rigid choledo identified residual choledocholithiasis in 58 and periampullary neoplasia in 2 patients. Unexpected retained stones were identified in 3 patients (0.9%). In a further 4 patients, stones which could not be dislodged from the hepatic ducts were confirmed on 10 day T-tube cholangiogram--transduodenal sphincteroplasty had been performed at the time of original surgery in all four. The mortality was 1.9% overall and 1% during the last 5 years. Endoscopic exploration must compare favourably with these data for safe transition to less invasive techniques.

Long-term follow-up of a prospective randomized study of endoscopic versus surgical treatment of bile duct calculi in patients with gallbladder in situ

Eighty-three patients with bile duct calculi were entered in a prospective randomized study of endoscopic sphincterotomy (ES) and stone removal (group 1) versus surgery alone (group 2), and were followed for more than 5 years. In group 1 endoscopic stone clearance was successful in 35 of 39 patients. Thirteen patients subsequently had cholecystectomy with (n = 7) or without (n = 6) biliary symptoms and one had a cholecystostomy for acute cholecystitis. Two patients have had mild biliary colic or pancreatitis. Two patients died from gallbladder carcinoma after 9 days and 18 months. In group 2 bile duct stones were cleared surgically in 37 of 41 patients. Late complications occurred in two patients (incisional hernia and recurrent stone). One patient with gallbladder carcinoma was cured and another died after 16 months. Early major and minor complications occurred in three and four respectively of 39 patients in group 1, and in three and six respectively of 41 patients in group 2. There were no deaths. During follow-up the total morbidity rate reached 28 percent (11 of 39) and 5 percent (two of 41) (P = 0.005) and the non-biliary related mortality rate was 31 percent (12 of 39) and 10 percent (four of 41) (P = 0.02) in groups 1 and 2 respectively. Nine patients in group 1 and two in group 2 died from heart disease (P = 0.02). Total hospital stay was 2-42 (median 13) days and 6-36 (median 16) days in groups 1 and 2 respectively (P not significant). Endoscopic and surgical treatment of bile duct calculi in middle-aged and elderly patients with gallbladder in situ are equally effective in the long term. However, the significantly increased mortality rate from heart disease in patients treated endoscopically compared with those treated surgically might speak in favour of operation.

Value of endoscopic ultrasonography in the diagnosis of common bile duct stones: comparison with surgical exploration and ERCP

An accurate and safe preoperative method of imaging the common bile duct is essential for the proper diagnosis of calculous biliary tract disease, especially in the current era of laparoscopic cholecystectomy. The value of endoscopic ultrasonography in detecting common duct stones has been reported, albeit in small series. The aim of this retrospective study was to assess the accuracy of EUS in a large series of patients. We compared EUS to direct cholangiography in the evaluation of 422 patients for common duct stones. Ductal stones were imaged by EUS in 168 patients (43.4%). No complications were encountered. EUS failed in 2.3% of cases, ERCP failed in 8.3%, and surgical exploration failed in 0.5%. Comparison of EUS with surgical exploration in 185 patients showed a sensitivity of 94.9%, a specificity of 97.8%, and an accuracy of 95.9%. EUS was compared to ERCP in 219 patients. All common duct stones found by ERCP were evident by EUS. Concordance was obtained in 91.3% of cases. Review of videotapes disclosed 3 false-positives and 16 unequivocal true-positives. We conclude that EUS is a safe and highly accurate means of detecting common duct stones and should be proposed before laparoscopic cholecystectomy in patients at risk of choledocholithiasis.

Selective preoperative endoscopic retrograde cholangiopancreatography in laparoscopic biliary surgery

The management of common bile duct (CBD) stones in patients subjected to laparoscopic cholecystectomy is still a subject of debate. A prospective study was performed of all 699 patients with symptomatic gallstones at risk of CBD stones between mid-1987 and 1994. Based on clinical, biochemical and ultrasonographic criteria, 119 patients underwent preoperative endoscopic retrograde cholangiopancreatography (ERCP) with or without endoscopic sphincterotomy. Results showed a high positive predictive value (over 85 per cent) for the presence of CBD stones in patients with acute cholangitis, persistent obstructive jaundice or in the acute phase of gallstone pancreatitis. In the other groups (increased liver enzyme levels, a wide CBD and after resolution of jaundice or pancreatitis) the positive predictive value was less than 25 per cent. The complication rate of ERCP with sphincterotomy was 14 per cent with a mortality rate of 2 per cent. These results argue for more selective use of preoperative ERCP only for patients with acute cholangitis, persistent jaundice or acute gallstone pancreatitis. Other patients at risk of harbouring CBD stones should undergo intraoperative laparoscopic cholangiography and, if stones are found, laparoscopic exploration of the bile duct or postoperative ERCP.

The role of endoscopic retrograde cholangiopancreatography in patients with laparoscopic cholecystectomies

BACKGROUND & AIMS

The best clinical strategy for using endoscopic retrograde cholangiopancreatography (ERCP) with laparoscopic cholecystectomy is unknown. The aim of this study is to use decision analysis to assess four different approaches to using ERCP in patients undergoing laparoscopic cholecystectomy.

METHODS

Decision trees were designed for four clinical strategies: (1) preoperative ERCP, with sphincterotomy for choledocholithiasis; (2) selective preoperative ERCP for patients at high risk for choledocholithiasis, choledocholithiasis found at surgery treated by postoperative ERCP; (3) no preoperative ERCP, choledocholithiasis detected intraoperatively treated by postoperative ERCP; and (4) no preoperative ERCP, choledocholithiasis detected intraoperatively treated with open common bile duct exploration. Using decision analysis with literature-derived data, the impact on outcome parameters was calculated.

RESULTS

Postoperative ERCP resulted in the lowest cost, procedure numbers, and hospital and back-to-work days. With high preoperative likelihood of choledocholithiasis, selective preoperative ERCP was probably a clinically equivalent strategy. Sensitivity analysis supported these conclusions when the probabilities and utilities were varied over a wide range. The open operative approach to choledocholithiasis was only favored if ERCP had < 75% diagnostic and < 50% therapeutic success rates or lengthened hospitalization by > 7 days.

CONCLUSIONS

This study suggests that performing ERCP after laparoscopic cholecystectomy minimizes costs and morbidity; however, when choledocholithiasis is likely, selective preoperative ERCP may be a clinically equivalent strategy.

Laparoscopic trans-cystic-duct common-bile-duct exploration

One thousand seventy-one consecutive laparoscopic cholecystectomies were performed. Routine cholangiography was employed with a 99% success rate. One hundred thirty patients were found to have common duct stones (CBDS). In 48 (37%) patients they were unsuspected. One hundred eleven patients underwent attempted trans-cystic-duct extraction techniques (TCD-CBDE). One hundred three (93%) were successful. The following techniques were employed: 101--biliary endoscopy, 23--ampullary balloon dilation, 2--fluoroscopic basket retrieval. The average operative time was 136 min. The average postsurgical stay was 3.7 days. There were 19 (17%) complications--6 (5%) major. There were 4 retained stones (2 intentional) and 1 death. Patients over 65 years of age had more complications and patients with unsuspected CBDS under 65 years of age had the fewest. TCD-CBDE is a safe, effective way to extract common duct calculi. Endoscopy and basket stone retrieval was the primary technique employed.

Selective use of ERCP in patients undergoing laparoscopic cholecystectomy

With the advent of laparoscopic cholecystectomy (LCH) various strategies have been proposed for the management of common bile duct (CBD) stones. In a consecutive series of 1140 patients subjected to LCH, preoperative endoscopic retrograde cholangiopancreatography (ERCP) was attempted in 128 patients (11.2%) and successfully accomplished in 121 (94.5%). Based on the prediction of CBD stones by laboratory tests, ultrasonography, and intravenous cholangiography, prelaparoscopic ERCP was performed in 106 patients (9.3%). CBD stones were identified in 56 patients and benign papillary stenosis in 5 patients (57.5%). Of these 61 patients, 58 (95%) were treated by endoscopic sphincterotomy (ES) and stone extraction followed by LCH after a mean interval of 1.6 days. Three patients with failure of endoscopic ductal stone extraction required open CBD exploration. In 39 of the 106 patients (36.8%) ERCP was negative for ductal stones but revealed unexpected ampullary and pancreatic cancer in two cases. Six patients (of the 106) with preoperative ERCP cannulation failure (5.7%) were managed either by LCH and intraoperative cholangiography or by open CBD exploration. In 22 of the 1140 total patients (1.9%) ERCP was performed at various intervals after LCH. Retained CBD stones were found in eight patients, and ES and ductal clearance was achieved in all eight. There was no mortality among the entire surgical group who underwent perioperative ERCP/ES. Including two cases of ES-related pancreatitis, the overall morbidity was 5.5% (7 of 128). Perioperative ERCP/ES in conjunction with LCH is an attractive approach for patients with cholecystocholedocholithiasis, at least until laparoscopic ductal clearance becomes a standard procedure.

Common bile duct stones after laparoscopic cholecystectomy and its treatment. The role of ultrasound and intravenous and intraoperative cholangiography

In the present work we recount our experience in handling common bile duct stones (CBDS) in our first 100 cases of laparoscopic cholecystectomy. In the first 50 cases our diagnostic procedures involved the use of ultrasound exploration and intravenous cholangiotomography 48 h before laparoscopic surgery. We found three cases of residual CBDS. One of the cases was treated by means of ERCP. The other two cases were resolved by carrying out a transparietohepatic cholangiography after the ERCP procedure failed. After this experience, we changed our strategy, introducing the intraoperative cholangiography in the cases with an unclear diagnosis. With this new approach, no residual CBDS occurred in the following 50 cases. These findings demonstrate the following: (1) In our hands, intravenous cholangiography is not more effective than ultrasound exploration in resolving dubious cases. (2) These dubious cases are more effectively diagnosed by means of selective intraoperative cholangiography. (3) When CBDS is treated by transparietohepatic cholangiography it proves to be less uncomfortable for the patient than ERCP and, as we found, even more efficient in removing the stones, although our experience is based on only two cases.

Appraisal of surgical and endoscopic management of choledocholithiasis

One hundred and ten patients with common bile duct (CBD) stones were treated in the Department of Surgical Gastroenterology at SGPGIMS, Lucknow, India between January 1989 and December 1992. The primary modality of treatment was surgery in 62 patients (group I) and endoscopic sphincterotomy (ES) in 48 (group II). The two groups were well matched with respect to clinical features and presence of medical risk factors. Surgical clearance of CBD stones was achieved in 58 patients (93.5%; group Ia). Four patients (7%) had retained stones following surgery (group Ib). In group II, the CBD was cleared by endoscopic means in 20 out of 48 patients (42%) and was categorized into group IIa. In the remaining patients ES was followed by CBD exploration (group IIb). Significantly higher morbidity was seen in patients needing CBD surgery following attempted endoscopic clearance, because of ES-related complications, such as bleeding, cholangitis, septicaemia and numerous others. Use of ES to treat CBD stones on a routine basis was therefore not found to be any better than one-time surgical exploration.

Endoscopic retrograde cholangiopancreatography following laparoscopic cholecystectomy

Laparoscopic cholecystectomy is the preferred method of treatment for symptomatic choledocholithiasis. Since its introduction there has been an increase in postoperative diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study was to assess the indications and results of ERCP following laparoscopic cholecystectomy. Sixty-one patients had an ERCP following laparoscopic cholecystectomy. Two broad groups were identified: Group 1 (35 patients) had filling defects (consistent with stones) noted on operative cholangiography, which were not successfully flushed or extracted at the time of laparoscopic cholecystectomy; Group 2 consisted of patients who developed problems following laparoscopic cholecystectomy. Nine patients had post-laparoscopic cholecystectomy pain with abnormal liver function tests (LFT), four of whom had common bile duct (CBD) injuries and three had CBD stones. Eleven patients had post-laparoscopic cholecystectomy pain with a normal diameter common bile duct on ultrasound and normal LFT; only one had a CBD stone. Five patients with a persisting bile leak following laparoscopic cholecystectomy had an ERCP and endoscopic sphincterotomy. In three the leak ceased, while two required subsequent open surgery to drain bile collections and ligate the cystic duct. One patient presented with an episode of transient jaundice but had a normal ERCP. There were six post-ERCP complications; three patients had mild pancreatitis, two had a minor haemorrhage and one an asymptomatic duodenal perforation. Endoscopic retrograde cholangiopancreatography post-laparoscopic cholecystectomy was most valuable for the management of retained stones and the diagnosis and management of post-laparoscopic cholecystectomy pain in association with abnormal LFT. The diagnostic yield was low (9%) when the LFT were normal.

Management of bile duct stones in the era of laparoscopic cholecystectomy

The introduction of laparoscopic cholecystectomy has resulted in increased options for the management of bile duct stones and has stimulated a fundamental reappraisal of the situation before the laparoscopic era. This article reviews the natural history of bile duct stones and details the different ways in which they may now be treated. New areas of controversy are highlighted and the need for further studies is emphasized.

Endoscopic bile duct stone removal prior to laparoscopic cholecystectomy

Of 1049 patients referred for laparoscopic cholecystectomy (LC) for symptomatic gallstone disease, 67 (6%) had clinical, biochemical, or echographic findings suggesting common bile duct stones. Patients in this group were studied preoperatively with endoscopic retrograde cholangiopancreatography (ERCP). In 26 patients (39%), the diagnosis was confirmed. In 12 other cases (18%), the macroscopic finding of a stripped or bleeding papilla without common bile duct stones suggested stone migration. ERCP in the remaining 29 patients (43%) was normal. Thirty-four endoscopic sphincterotomies (ES) were performed, 26 for common bile duct stones and 8 for cystic lithiasis or gallbladder microlithiasis. In the entire group of patients with choledocholithiasis, stone removal was possible. All 67 patients underwent laparoscopic cholecystectomy on an average of 2.8 days following the endoscopic procedure. Twenty-one patients (31%) had acute cholecystitis, and 5 had chronic scleroatrophic cholecystitis. Five (7.5%) of the 67 patients were converted to an open procedure. In 10 cases (16%), the cystic diameter was larger than an 8-mm M-L clip, which made necessary the use of endoligature or extra clips. No complications or deaths resulted from ERCP or ES. Two of the 62 patients (3.2%) who underwent LC had to be reoperated on, 1 because of a right subphrenic collection, and the other because of bilious ascites. No common bile duct lesions or deaths resulted in the analyzed group. The average hospitalization time, with the exception of those patients converted or reoperated on, was 8 days.

Laparoscopic cholecystectomy combined with endoscopic sphincterotomy and stone extraction or laparoscopic choledochoscopy and electrohydraulic lithotripsy for management of cholelithiasis with choledocholithiasis

Six hundred twenty-two laparoscopic cholecystectomies were performed at St. Vincent Hospital over a 14-month period. We reviewed the records of 366 of these patients who were referred to the authors. Thirty-six patients had suspected choledocholithiasis. The primary author (M.E.A.) performed 38 endoscopic retrograde cholangiopancreatography (ERCPs) on these patients for diagnosis and management. Seventeen of the 36 patients had common bile duct stones; 19 patients had negative studies. Of the 17 patients with choledocholithiasis, 15 had successful cannulation of the common bile duct, and, of these, 10 underwent laparoscopic cholecystectomy plus endoscopic sphincterotomy and extraction of the common duct stone(s). In one high-risk elderly patient, we extracted the stone from the common duct and left the gallbladder in situ. Two patients failed endoscopic cannulation and underwent open cholecystectomy with common bile duct exploration. Four additional patients, cannulated successfully, had unsuccessful endoscopic stone removal because the stones were too large or were impacted. Two of these patients underwent open cholecystectomy and common duct exploration. The two other patients underwent laparoscopic cholecystectomy and choledochoscopy through the cystic duct with the flexible choledochoscope. An electrohydraulic lithotripsy probe was then inserted through the choledochoscope to fragment the stones, and stone fragments were allowed to pass through the previously created sphincterotomy. We believe our data, supported by data in the literature, show that these alternative methods for treating choledocholithiasis are safe and effective and should be considered primary modalities for treating this condition now that laparoscopic cholecystectomy is the treatment of choice for cholelithiasis.

Combined laparoscopic and endoscopic treatment of gallstones and bile duct stones: a prospective study

In patients with symptomatic gallstones the management of choledocholithiasis has been controversial since the introduction of laparoscopic cholecystectomy. A prospective study was made of 300 consecutive patients with symptomatic gallstones managed by laparoscopic cholecystectomy and preoperative endoscopic retrograde cholangiography (ERC) over 2 years. Fourteen patients were excluded either because urgent surgery was required or because they were unfit for laparoscopic cholecystectomy. ERC was performed on 96 patients (34 per cent) who were at risk of choledocholithiasis. The presence of bile duct calculi was confirmed in 59 patients (21 per cent of the total, 61 per cent of those undergoing ERC); stones were removed endoscopically in 53 cases (90 per cent of attempts). The remaining six patients underwent open cholecystectomy and bile duct exploration. Laparoscopic cholecystectomy was attempted in 280 patients (98 per cent); it was necessary to convert to open operation in only three (1 per cent). There were no deaths, no retained stones and no bile duct injuries, and only three patients (1 per cent) developed a significant postoperative complication. Symptomatic gallstones can be managed by preoperative ERC and laparoscopic cholecystectomy with minimal morbidity and mortality.

The utility of laparoscopic common bile duct exploration in the treatment of choledocholithiasis

Laparoscopic common bile duct exploration (CBDE) was performed in 24 patients over a 23-month period. Fourteen of these patients were suspected preoperatively of harboring common bile duct (CBD) calculi. Of these, endoscopic sphincterotomy was unsuccessful in eight. Laparoscopic CBDE was performed either transcystically or via a choledochotomy. In all cases, completion cholangiography demonstrated that the CBD was free of stones. All patients were sent home with drains placed in their extrahepatic biliary system. Mean hospital stay was 2.7 days. There was no mortality. The overall morbidity rate was 29.1%. It included one trocar site infection (4.1%), four cases of mild postoperative amylasemia (16.6%), and two cases of retained stones (8.3%) seen in two patients on follow-up tube cholangiography that were successfully extracted percutaneously. The authors feel that laparoscopic CBDE is a safe and effective method of CBD stone removal that offers an alternative to preoperative ERCP and sphincterotomy.

Laparoscopic transcystic choledochoscopy

Preoperative prediction of common bile duct stones (CBDS) is imprecise. Cholangiography during laparoscopic cholecystectomy (LC) is the best method for detection of CBDS. Treatment of most stones detected at LC can be safely accomplished using transcystic choledochoscopy and stone extraction. This technique is applicable in nearly 90% of patients with CBD calculi. It may be preferable to endoscopic sphincterotomy (ES) in younger patients and is probably equivalent to ES in patients over 65 years of age.

Recent advances in the management of gallstones

Demands for less invasive, more cost-effective therapy have revolutionized the management of gallstones over the past 10 years. There are no reliable methods of permanently reversing the pathophysiologic defects that cause gallstones. Open cholecystectomy (OC), the gold standard for managing symptomatic cholelithiasis, has been largely replaced by laparoscopic cholecystectomy (LC), which has the advantages of a minimal hospital stay and quicker return to work. Other adjunctive therapies, limited in applicability to selected patients, include oral bile acid therapy (BAT), dissolutional agents, and extracorporeal shock wave lithotripsy. Choledocholithiasis (CDL), formerly managed exclusively with surgical common duct exploration, is increasingly treated with therapeutic biliary endoscopy. Methods of laparoscopic common bile duct exploration are being developed. Optimal algorithms for applying these techniques to patients undergoing LC are evolving. In a sense, the solution to all, or certainly most, gallstones now can be seen through a scope.