Management of common bile duct stones in the era of laparoscopic cholecystectomy (original) (raw)
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Common bile duct stones, an experience in Ondokuz Mayis University
Journal of Experimental and Clinical Medicine, 2013
Common bile duct stones, obstructive jaundice, cholangitis and acute pancreatitis are diseases that can lead to serious complications. In our clinic between May 1993 and October 2011 the results of 101 patients who underwent surgery for common bile duct stone were retrospectively evaluated. Among 101 patients who were included in the study, 45 had symptomatic gallstones accompanied by common bile duct stone, 27 had mechanical icterus, 15 had common bile duct stone and 8 had cholangitis (five patients with suppurative cholangitis), six had acute cholecystitis. Thirthy one patients with common bile duct stones were treated with endoscopic retrograde cholangiopancreatography (ERCP). Surgical procedures were as follows; choledochoduodenostomy in 50 cases, T-tube drainage in 17 patients and transduodenal sphincteroplasty in three patients. Synchronous cholecystectomies were performed in all patients who had not undergone biliary surgery before. Early postoperative mortality was 3.9%. In this study, we detected choledocholithiasis in 11.31% of the all symptomatic cholelithiasis cases. Since our clinic provide tertiary healthcare, this rate becomes 9.85% by excluding those who underwent cholecystectomy for common bile duct stones at other hospitals. Given that the patients who referred to our clinic are in high-risk group, the actual rate of choledocholithiasis in our society is expected to be slightly below that value.
7251 Natural history of asymptomatic bile duct stones at time of cholecystectomy
Gastrointestinal Endoscopy, 2000
Objectives: There is little data on the natural history of asymptomatic bile duct stones and hence there is uncertainty on the management of asymptomatic bile duct stones discovered incidentally at the time of laparoscopic cholecystectomy. We retrospectively reviewed a group of patients who had previously underwent laparoscopic cholecystectomy, but who did not have a pre-operative suspicion of intra-ductal stones, to determine if any biliary complications had subsequently developed.A group of patients who had no pre-operative suspicion of intra-ductal stones, but routinely underwent intraoperative cholangiogram (IOC) at time of cholecystectomy, served as the control group. Methods: A telephone questionnaire was completed by each patient's family practitioner in 59 of 79 (75%) patients who underwent laparoscopic cholecystectomy. In the remaining 20 patients additional information was obtained from hospital records and from the central services agency (CSA). These patients had no pre-operative suspicion of bile duct stones and therefore did not undergo an IOC or ERCP. The control group (73 patients) had no pre-operative suspicion of bile duct stones but had a routine IOC performed to define the biliary anatomy. Results: 59 patients were followed up for an average of 57 months (range 30 -78 months) after laparoscopic cholecystectomy. None of these patients developed pancreatitis, jaundice, deranged liver function tests (LFT's), or required ERCP or other biliary intervention. In the additional 20 patients where no information was available from the family practitioner, 11 patients had follow up appointments with no documentation of biliary complications or abnormal LFT's. 19 of 20 patients were traceable through the CSA and were all alive. Only 1 patient was untraceable and therefore unknown if biliary complications had developed. In the control group, 4 of 73 (6%) patients had intraductal stones detected and extracted. Thus the prevalence of asymptomatic bile duct stones during the time of cholecystectomy in our population was 6%. Conclusions: Asymptomatic bile duct stones discovered at the time of cholecystectomy do not appear to cause any biliary complications over a 5-year follow up. Incidental bile duct stones found in patients undergoing laparoscopic cholecystectomy may not need to be removed.
Surgical Endoscopy, 2020
Background The management of choledocholithiasis evolves with diagnostic imaging and therapeutic technology, facilitating a laparoscopic approach. We review our first 200 cases of laparoscopic exploration of the common bile duct, highlighting challenges and lessons learnt. Methods We retrospectively studied the first 200 cases of laparoscopic cholecystectomy with common bile duct exploration between 2006 and 2019. The database contains demographics, clinicopathological characteristics, diagnostic modalities, operative techniques, duration and outcomes. Results We compared two approaches: transcystic vs. transcholedochal in our 200 cases. Choledocholithiasis was suspected preoperatively in 163 patients. 21 cases found no stones. Of the remainder, 111/179 cases were completed via the transcystic route and the remaining were completed transcholedochally (68/179); 25% of the transcholedochal cases were converted from a transcystic approach. CBD diameter for transcystic route was 8.2 vs. 11.0 mm for transcholedochal. Total clearance rate was 84%. Retained or recurrent stones were noted in 7 patients. Length of stay was 5.8 days, 3.5 days in the transcystic route vs. 9.4 days after transcholedochal clearance. Eight patients required re-operation for bleeding or bile leak. No mortalities were recorded in this cohort, but 2 cases (1%) developed a subsequent CBD stricture. Conclusion Concomitant laparoscopic common bile duct clearance with cholecystectomy is feasible, safe and effective in a district general hospital, despite constraints of time and resources. The transcystic route has a lower complication rate and shorter hospital stay, and hence our preference of this route for all cases. Advancements in stone management technology will allow wider adoption of this technique, benefitting more patients. Keywords Common bile duct exploration • Common bile duct clearance • Transcystic • Choledocholithiasis Choledocholithiasis is present in approximately 10-15% of patients with gallstones [1, 2]. This proportion may reach 15-60% in elderly patients [3], making it a common problem to manage by both surgeons and endoscopists. The management of choledocholithiasis remains a challenge, despite progress in instrumentation and technology and advancement in endoscopic and laparoscopic skills with no universal consensus on the best therapeutic approach. The significant resultant morbidity and mortality from the presence of stones in the common bile duct (CBD) led to development of the European Association of Endoscopic Surgery (EAES) Guidelines advising treatment of all CBD stones even if asymptomatic [3]. Management protocols for CBD stones with gallbladder in situ vary widely, depending on availability of equipment, expertise and resources. The main approaches are preoperative endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC); LC with intra-operative ERCP, LC and post-operative ERCP; and open CBD exploration and the evolving single-stage
Fortuitous discovery of common bile duct stones: Results of a conservative strategy
Gastroentérologie Clinique et Biologique, 2008
Objective. -The incidence of fortuitously discovered stones in the common bile duct is about 5%. The purpose of this study was to determine the rate of spontaneous clearance of asymptomatic stones in the common bile duct discovered fortuitously during cholecystectomy. Patients and methods. -Intraoperative cholangiography was performed in all patients undergoing cholecystectomy for symptomatic gallbladder stones. If a filling defect of the common bile duct was discovered, a transcystic drain was inserted. Surgical or endoscopic extraction was not proposed initially. A control cholangiogram was performed on the second postoperative day then during the sixth postoperative week. If a stone persisted at the sixth week, endoscopic extraction was undertaken.
Guidelines on the management of common bile duct stones (CBDS
The last 30 years have seen major developments in the management of gallstone-related disease, which in the United States alone costs over 6 billion dollars per annum to treat. Endoscopic retrograde cholangiopancreatography (ERCP) has become a widely available and routine procedure, whilst open cholecystectomy has largely been replaced by a laparoscopic approach, which may or may not include laparoscopic exploration of the common bile duct (LCBDE). In addition, new imaging techniques such as magnetic resonance cholangiography (MR) and endoscopic ultrasound (EUS) offer the opportunity to accurately visualise the biliary system without instru-mentation of the ducts. As a consequence clinicians are now faced with a number of potentially valid options for managing patients with suspected CBDS. It is with this in mind that the following guidelines have been written.
Management of Common Bile Duct Stones: A Comprehensive Review
Biomedical Sciences, 2020
Bile duct stones (BDS) are usually secondary to gallstones but may be found primarily in biliary system, although the percentage is minimal. They are usually suspected on history and clinical examination alone but symptoms may be variable ranging from asymptomatic to complications such as biliary colic, pancreatitis, jaundice or cholangitis, the latter can be life-threatening in some patients. Abnormalities in the liver function tests especially the elevated direct bilirubin and alkaline phosphatase indirectly raise the suspicion. The majority of BDS can be diagnosed by Transabdominal Ultrasound, but in some cases further imaging such as, Computed Tomography, Endoscopic Ultrasound or Magnetic Resonance Cholangiography are employed prior to endoscopic or laparoscopic removal. Approximately 90% of BDS can be removed following Endoscopic Retrograde Cholangiography (ERC) + sphincterotomy. Most of the remaining stones can be removed using mechanical lithotripsy. Patients with uncorrected coagulopathies may be treated with ERC + pneumatic dilatation of the sphincter of Oddi. Shockwave lithotripsy (intraductal and extracorporeal) and laser lithotripsy have also been used to fragment large bile duct stones prior to endoscopic removal. Despite all the minimally invasive procedures the role of open surgery for the removal of difficult or impacted stones cannot be completely forgotten. The role of medical therapy in treatment of BDS is currently uncertain. This review focuses on the clinical presentation, investigation and current management of BDS.
Annals of The Royal College of Surgeons of England, 2010
INTRODUCTION Common bile duct (CBD) stones can cause serious morbidity or mortality, and evidence for them should be sought in all patients with symptomatic gallstones undergoing cholecystectomy. Routine intra-operative cholangiography (IOC) involves a large commitment of time and resources, so a policy of selective cholangiography was adopted. This study prospectively evaluated the policy of selective cholangiography for patients suspected of having choledocholithiasis, and aimed to identify the factors most likely to predict the presence of CBD stones positively. PATIENTS AND METHODS Data from 501 consecutive patients undergoing laparoscopic cholecystectomy (LC) for symptomatic gallstones, of whom 166 underwent IOC for suspected CBD stones, were prospectively collected. Suspicion of choledocholithiasis was based upon: (i) deranged liver function tests (past or present); (ii) history of jaundice (past or present) or acute pancreatitis; (iii) a dilated CBD or demonstration of CBD stones on imaging; or (iv) a combination of these factors. Patient demographics, intra-operative findings, complications and clinical outcomes were recorded. RESULTS Sixty-four cholangiograms were positive (39%). All indications for cholangiogram yielded positive results. Current jaundice yielded the highest positive predictive value (PPV; 86%). A dilated CBD on pre-operative imaging gave a PPV of 45% for CBD calculi; a history of pancreatitis produced a 26% PPV for CBD calculi. Patients with the presence of several factors suggestive of CBD stones yielded higher numbers of positive cholangiograms. Of the 64 patients having a laparoscopic common bile duct exploration (LCBDE), four (6%) required endoscopic retrograde cholangiopancreatography (ERCP) for retained stones (94% successful surgical clearance of the common bile duct) and one (2%) for a bile leak. Of the 335 patients undergoing LC alone, three (0.9%) represented with a retained stone, requiring intervention. There were 12 (7%) requiring conversion to open operation. CONCLUSIONS A selective policy for intra-operative cholangiography yields acceptably high positive results. Pre-operatively, asymptomatic bile duct stones rarely present following LC; thus, routine imaging of the biliary tree for occult calculi can safely be avoided. Therefore, a rationing approach to the use of intra-operative imaging based on the pre-operative indicators presented in this paper, successfully identifies those patients with bile duct stones requiring exploration. Laparoscopic bile duct exploration, performed by an experienced laparoscopic surgeon, is a safe and effective method of clearing the bile duct of calculi, with minimal complications, avoiding the necessity for an additional intervention and prolonged hospital stay.