CHOLECYSTECTOMY WITH INTRAOPERATIVE ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY: DOES THE ORDER MATTER?

BACKGROUND

The recommended treatment for cholecystocholedocholithiasis is cholecystectomy (CCT) associated with endoscopic retrograde cholangiopancreatography (ERCP). CCT with intraoperative ERCP is associated with higher success rates and lower hospital stays and hospital costs. However, some case series do not describe the exact methodology used: whether ERCP or CCT was performed first.

AIMS

Verify if there is a difference, in terms of outcomes and complications, when intraoperative ERCP is performed immediately before or after CCT.

METHODS

This is a retrospective case-control study analyzing all patients who underwent CCT with intraoperative ERCP between January 2021 and June 2022, in a tertiary hospital in southern Brazil, for the treatment of cholecystocholedocholithiasis.

RESULTS

Out of 37 patients analyzed, 16 (43.2%) underwent ERCP first, immediately followed by CCT. The overall success rate for the cannulation of the bile duct was 91.9%, and bile duct clearance was achieved in 75.7% of cases. The post-ERCP pancreatitis rate was 10.8%. When comparing the "ERCP First" and "CCT First" groups, there was no difference in technical difficulty for performing CCT. The "CCT First" group had a higher rate of success in bile duct cannulation (p=0.020, p<0.05). Younger ages, presence of stones in the distal common bile duct and shorter duration of the procedure were factors statistically associated with the success of the bile duct clearance. Lymphopenia and cholecystitis as an initial presentation, in turn, were associated with failure to clear the bile duct.

CONCLUSIONS

There was no significant difference in terms of complications and success in clearing the bile ducts among patients undergoing CCT and ERCP in the same surgical/anesthetic procedure, regardless of which procedure was performed first. Lymphopenia and cholecystitis have been associated with failure to clear the bile duct.

Evidence-based clinical practice guidelines for cholelithiasis 2021

The Japanese Society of Gastroenterology first published evidence-based clinical practice guidelines for cholelithiasis in 2010, followed by a revision in 2016. Currently, the revised third edition was published to reflect recent evidence on the diagnosis, treatment, and prognosis of cholelithiasis conforming to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Following this revision, the present English version of the guidelines was updated and published herein. The clinical questions (CQ) in the previous version were reviewed and rearranged into three newly divided categories: background questions (BQ) dealing with basic background knowledge, CQ, and future research questions (FRQ), which refer to issues that require further accumulation of evidence. Finally, 52 questions (29 BQs, 19 CQs, and 4 FRQs) were adopted to cover the epidemiology, pathogenesis, diagnosis, treatment, complications, and prognosis. Based on a literature search using MEDLINE, Cochrane Library, and Igaku Chuo Zasshi databases for the period between 1983 and August 2019, along with a manual search of new information reported over the past 5 years, the level of evidence was evaluated for each CQ. The strengths of recommendations were determined using the Delphi method by the committee members considering the body of evidence, including benefits and harms, patient preference, and cost-benefit balance. A comprehensive flowchart was prepared for the diagnosis and treatment of gallbladder stones, common bile duct stones, and intrahepatic stones, respectively. The current revised guidelines are expected to be of great assistance to gastroenterologists and general physicians in making decisions on contemporary clinical management for cholelithiasis patients.

[Modern approaches to the treatment of patients with a complicated form of gallstone disease in the Botkin hospital]

OBJECTIVE

To determine the optimal timing of laparoscopic cholecystectomy in patients with gallstone disease complicated by cholelithiasis after endoscopic retrograde papillosphincterotomy with lithoextraction.

MATERIAL AND METHODS

We analyzed treatment outcomes in 229 patients with gallstone disease complicated by cholelithiasis between 2016 and 2020. Simultaneous surgery was performed in 31 patients, early cholecystectomy (after 1-3 days) - in 78 cases, delayed cholecystectomy (after 4-7 days) - in 35 cases and delayed cholecystectomy in 14-30 days after endoscopic retrograde papillosphincterotomy with lithoextraction in 85 cases.

RESULTS

Simultaneous laparoscopic cholecystectomy and surgery in early period after endoscopic retrograde papillosphincterotomy with lithoextraction are followed by less surgery time, few postoperative complications and less hospital-stay.

CONCLUSION

Simultaneous laparoscopic cholecystectomy and early surgery after endoscopic retrograde papillosphincterotomy with lithoextraction are preferred for patients with complicated gallstone disease. However, this requires adherence to strict criteria for patient selection.

The Bad Gallbladder

Laparoscopic cholecystectomy is a common operation; approximately 20 million Americans have gallstones, the most common indication. Surgeons who operate on the biliary tree must be familiar with the presentations and treatment options for acute and chronic biliary pathology. We focus on the difficult "bad" gallbladder. We explore the available evidence as to what to do when a gallbladder is too inflamed, too technically challenging, or a patient is too sick to undergo standard laparoscopic cholecystectomy. We discuss whether or not open cholecystectomy is a relevant tool and what can be done to manage common bile duct stones found unexpectedly intraoperatively.

Laparoendoscopic rendezvous versus ERCP followed by laparoscopic cholecystectomy for the management of cholecysto-choledocholithiasis: a retrospectively cohort study

BACKGROUND

There are a variety of strategies for the treatment of patients with cholecysto-choledocholithiasis (CCL). Although the surgical approach of choice is preoperative ERCP and laparoscopic cholecystectomy (ERCP + LC), controversy remains regarding which procedure is optimal for CCL.

METHODS

To evaluate the safety and effectiveness of laparoendoscopic rendezvous (LERV) versus ERCP + LC for CCL, a total of 528 patients with CCL were retrospectively studied from January 2013 to December 2018. The patients were scheduled to undergo either the LERV or ERCP + LC procedure. The LERV group included 123 cases, whereas the ERCP + LC group contained 137 cases. The incidence of postoperative complications, success of stone clearance, length of hospital stay, and hospitalization charges were statistically analyzed.

RESULTS

The incidence of pancreatitis was lower in the LERV group than in the ERCP + LC group (3/123 vs. 12/137, P = 0.0291). The median level of post-ERCP amylase was much lower in the LERV group (202.5 U/dL vs. 328.1 U/dL, P < 0.01). However, there was no significant difference in the stone clearance rate or other early complications between the two groups. Further study showed that the length of hospital stay and cost in the LERV group were less than those in the ERCP + LC group (12 days vs. 18 days, P < 0.01; 53591.4¥ vs. 60089.2¥, P < 0.01). In addition, more patients in the two-stage procedure group experienced later biliary complications compared with those in the one-stage approach group (34/137 vs. 4/123, P < 0.05). However, the median operation time was 107.7 min in the two-stage group and 139.8 min in the one-stage group (P < 0.05).

CONCLUSIONS

The LERV technique is a safe and effective approach for CCL with lower pancreatitis; it was associated with few later biliary complications, shortened hospital stays, and fewer charges but significantly longer operative time.

Single-stage management with combined tri-endoscopic approach for concomitant cholecystolithiasis and choledocholithiasis

OBJECTIVE

The aim of this study was to investigate the value of a single stage with combined tri-endoscopic (duodenoscopy, laparoscopy and choledochoscopy) approach for patients with concomitant cholecystolithiasis and choledocholithiasis.

METHODS

Fifty-three patients with combined gallbladder stones and common bile duct stones from February 2014 to April 2015 were randomized assigned to two groups: 29 patients underwent single-stage surgery with combined duodenoscope, laparoscope and choledochoscope (combined tri-endoscopic group), and 29 patients underwent endoscopic sphincterotomy to remove common bile duct stones followed by laparoscopic cholecystectomy several days later (control group). The success rate of complete stone removal, procedure-related complication, hospital stay and the cost of hospitalization were compared between the two groups.

RESULTS

Altogether, 53 patients (29 patients in combined tri-endoscopic group and 24 patients in control group) successfully underwent the surgery and ERCP procedure. Three patients in the control group developed post-ERCP pancreatitis. One case of bile leaking and one case of residual stone were noted in the combined tri-endoscopic group. There were no significant differences between the two groups with regard to both complete stone removal [96.6 % (28/29) vs. 100 % (24/24)] and procedure-related complication rate [3.4 % (1/29) vs. 12.5 % (3/24)] (p > 0.05). No open surgery was required in either group. There were significant differences between the two groups with regard to hospital stay (6.72 ± 1.3 days vs. 10.91 ± 1.6 days, p < 0.01) and cost of hospitalization (15,724 ± 1613 CNY vs. 19,829 ± 2433 CNY, p < 0.05).

CONCLUSION

The single-stage combined tri-endoscopic approach for concomitant cholecystolithiasis and choledocholithiasis was just as safe and successful as the control group. In addition, it resulted in a shorter hospital stay and less cost.