Evaluation of Routine on Table Cholangiography in Paediatric Cholecystectomy (original) (raw)
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Journal of Pediatric Surgery, 2004
Background: Evidence for diagnostic accuracy and clinical efficacy of intraoperative cholangiogram (IOC) and endoscopic retrograde cholangiopancreatography (ERCP) in the management of common bile duct (CBD) stones in children is sparse and unclear. Methods: Retrospective analysis of 202 children who underwent laparoscopic cholecystectomy (LC) between 1996 and 2002 was performed. Forty-eight children had suspected CBD stones on clinical, biochemical, and radiologic grounds. Two clinical pathways, LC followed by ERCP (L3 E) versus ERCP followed by LC (E3 L) were compared. Results: From the cohort of 202 patients, 154 did not have suspected CBD stones. Of the 48 patients that did have suspected stones, 2 management pathways were followed: (1) ERCP first: 14 of 48 patients (including 1 failed examination). Three yielded positive findings on ERCP. Ten had negative findings on ERCP, 3 of which went on to have a subsequent IOC. All 3 had negative IOC examination findings. (2) LC Ϯ IOC first: 34 of 48 patients. Twenty-eight had negative findings on IOC and had no further investigations. Three patients had positive IOC examination findings and went on to have postoperative ERCP. Two of these 3 patients
Laparoscopic Common Bile Duct Exploration in Children
Pediatric Endosurgery & Innovative Techniques, 1998
Purpose: Our aim was to compare outcomes of children undergoing laparoscopic cholecystectomy with laparoscopic common bile duct exploration (LC+CBDE) to those undergoing laparoscopic cholecystectomy with adjunctive endoscopic retrograde cholangiopancreatography (LC+ERCP). Methods: We performed a two-center retrospective chart review of all children (b18 years) undergoing LC+CBDE or LC+ERCP between January 2000 and July 2011. Wilcoxon test was performed on continuous variables and logistic regression modeling on categorical data. A P value b 0.05 was considered significant. Outcomes with a P value b 0.2 were selected for multivariable analysis. Results: Forty-two patients were identified. Twenty-four (57%) underwent LC+ERCP, and eighteen (43%) underwent LC+CBDE. Demographic and clinical factors were well matched between groups. Total operative time was similar between groups (157 min vs. 152 min, P = .26). LC+CBDE patients had zero major complications and five minor complications (retained stone: 3, pancreatitis: 1, late recurrence: 1). LC +ERCP patients experienced two major complications (duodenal perforation: 1, bleeding requiring transfusion: 1), and four minor complications (pancreatitis: 2, retained stone: 2, P = .57). Median length of stay was significantly longer (15.7 days vs. 6.6 days, P = .02), and median hospital cost was significantly higher ($18,132 vs. $12,735, P b .01) in the LC+ERCP group. Multivariable analysis revealed that cost was significantly lower in patients undergoing LC+CBDE (P = .05, OR= 0.71; 95% CI: 0.51-0.97). Conclusion: LC+CBDE at the time of cholecystectomy is associated with decreased length of stay, decreased cost, and has similar or improved morbidity compared to LC+ERCP.
Routine versus selective intraoperative cholangiography during laparoscopic cholecystectomy
Surgical Endoscopy, 2006
Background: Routine use of intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) is a matter of debate. Methods: Data from 2,130 consecutive LCs and pa-tientsÕ follow-up during 9 years were collected and analyzed. During the first 4 years of the study, 800 patients underwent LC, and IOC was performed selectively (SIOC). Thereafter, 1,330 patients underwent LC, and IOC was routinely attempted (RIOC) for all. Results: In the IOC group, 159 patients met the criteria for SIOC, which was completed successfully in 141 cases (success rate, 88.6%). Bile duct calculi were found in nine patients. All other patients with no criteria or failed SIOC were followed, and in nine patients retained stones were documented. Thus, the incidence of ductal stones was 1.1% and sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) for the detection of ductal stones were 50, 100, 98.6, and 100%, respectively. In the RIOC group, IOC was routinely attempted in 1,330 patients and was successful in 1,133 (success rate, 90.9%; p = 0.015). Bile duct stones were detected in 37 patients (including 14 asymptomatic stones). In two cases, IOC failed to reveal ductal stones (false negative). There was no false-positive IOC. Therefore, with RIOC policy, the incidence of ductal stones, sensitivity, specificity, NPV, and PPV were 3.3, 97.4, 100, 99.8, and 100%, respectively (significantly higher for success rate, incidence, sensitivity, and NPV; p < 0.05). Abnormal IOC findings were also significantly higher in the RIOC group. Common bile duct injury occurred only in the SIOC group [two cases of all 2,130 LCs (0.09%)]. Conclusion: RIOC during LC is a safe, accurate, quick, and cost-effective method for the detection of bile duct anatomy and stones. A highly disciplined performance of RIOC can minimize potentially debilitating and hazardous complications of bile duct injury.
Research Square (Research Square), 2024
Introduction: Gallbladder disease incidence in the pediatric population and its complications have been consistently increasing. The standard treatment for choledocholithiasis involves performing endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC). These therapeutic methods require pediatric patients to undergo two different procedures. This study aims to demonstrate the safety of performing ERCP and LC in a single session in patients diagnosed with choledocholithiasis. Design and Methods: A prospective cohort study was conducted on patients under 18 years diagnosed with choledocholithiasis. They were divided into two groups: the "intervention group" underwent simultaneous ERCP and LC, while the "control group" underwent ERCP and LC in two separate sessions. Results: The present study includes forty-two patients, with 27 assigned to the "intervention group" and 15 to the "control group". The difference in the average anesthesia time between the two groups was signi cant (p=0.001). Two patients in the "control group" developed cholecystitis while awaiting LC. Discussion: Most patients endured both procedures without experiencing signi cant complications. The main goals were to reduce the total anesthesia duration and the morbidity associated with gallbladder stones. This prospective study, conducted at two centers, supports the safety of performing both procedures simultaneously in pediatric patients.
Gastrointestinal Endoscopy, 1999
No procedure has yet been identified as the standard for the detection and management of choledocholithiasis in patients undergoing laparoscopic cholecystectomy. A prospective study involved 1305 patients undergoing elective laparoscopic cholecystectomy. Intravenous cholangiography was performed on all patients except those with jaundice or cholangitis, acute pancreatitis, or allergy to contrast material. Patients underwent endoscopic retrograde cholangiography (ERC) and endoscopic sphincterotomy when there was a strong suspicion of choledocholithiasis, positive or inconclusive findings on intravenous cholangiography or allergy to contrast material with signs of possible choledocholithiasis. Intraoperative cholangiography was performed when patients did not undergo ERC or intravenous cholangiography and whenever the surgeon was in doubt about biliary anatomy or biliary clearance. Two hundred thirty-one patients (17.7%) were referred for preoperative ERC; 14 of them were referred for open surgery because of failure of ERC or sphincterotomy. Only 54 patients underwent intraoperative cholangiography. Bile duct stones, detected in 186 cases (14.2%) (68 of which were asymptomatic), were removed before surgery in 162 cases (87.1%) and during surgery in 20 (10.7%). Self-limited pancreatitis occurred in 3.6% of the patients after sphincterotomy. Laparoscopic cholecystectomy was performed in 98.7% of the cases. The conversion rate was 8% if sphincterotomy had been performed previously, and 3% after standard laparoscopic cholecystectomy (p < 0.001). The morbidity rate was 5% and the mortality rate 0.08%. During the follow-up period 4 patients had retained stones that were treated endoscopically. Preoperative ERC followed by laparoscopy is the best approach to treatment of patients with cholecystolithiasis and suspected choledocholithiasis.
Routine on-table cholangiography during cholecystectomy: a systematic review
Annals of The Royal College of Surgeons of England, 2012
INTRODUCTION The aim of this review was to systemically analyse trials evaluating the efficacy of routine on-table cholangiography (R-OTC) versus no on-table cholangiography (N-OTC) in patients undergoing cholecystectomy. METHODS Randomised trials evaluating R-OTC versus N-OTC in patients undergoing cholecystectomy were selected and analysed. RESULTS Four trials (1 randomised controlled trial on open cholecystectomy and 3 on laparoscopic cholecystectomy) encompassing 860 patients undergoing cholecystectomy with and without R-OTC were retrieved. There were 427 patients in the R-OTC group and 433 patients in the N-OTC group. There was no significant heterogeneity among trials. Therefore, in the fixed effects model, N-OTC did not increase the risk (p=0.53) of common bile duct (CBD) injury, and it was associated with shorter operative time (p<0.00001) and fewer peri-operative complications (p<0.04). R-OTC was superior in terms of peri-operative CBD stone detection (p<0.006) and it reduced readmission (p<0.03) for retained CBD stones. CONCLUSIONS N-OTC is associated with shorter operative time and fewer peri-operative complications, and it is comparable to R-OTC in terms of CBD injury risk during cholecystectomy. R-OTC is helpful for peri-operative CBD stone detection and there is therefore reduced readmission for retained CBD stones. The N-OTC approach may be adopted routinely for patients undergoing laparoscopic cholecystectomy providing there are no clinical, biochemical or radiological features suggestive of CBD stones. However, a major multicentre randomised controlled trial is required to validate this conclusion.
Laparoscopic approach as primary treatment of common bile duct stones in children
Journal of pediatric …, 2005
Background: Preoperative endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy (ES) are an effective strategy for choledocholithiasis, but complications such as pancreatitis and outcome in children are unknown. The laparoscopic cholecystectomy became the new gold standard in children for cholelithiasis. For the choledocholithiasis in children, the attitude is more controversial. We analyzed our series of laparoscopic approach for the management of choledocholithiasis in children to determine if it is an effective procedure. Patients and Method: Between 1996 and 2001, 126 children were treated for cholelithiasis in our institution; 13 children (10.3%) were managed for a choledocholithiasis. We reviewed age at symptom onset results of paraclinical examinations, the type of laparoscopic management, and postoperative outcome. Results: The mean age at clinical signs was 9.9 years (range, 3 months-15.5 years). One child was excluded because he had a preoperative ES. Twelve children had a laparoscopic cholecystectomy and cholangiogram at the same time. A choledocholithiasis was found in 10 cases. A flush of the common bile duct (CBD) was performed in all cases with a 3F or 5F ureteral catheter; the stone was pushed into the duodenum in 3 cases and successfully extracted in 3 with a 4F Dormia or Fogarty catheter. One child needed a conversion to open surgery. Three times, an ES was necessary in postoperative course in each case for clinical and biologic signs of CBD obstruction or pancreatitis (30%). All children are symptomfree with an average follow-up of 28 months. Conclusion: Laparoscopic CBD exploration for choledocholithiasis can be performed safely in children at the time of cholecystectomy and can clear all of the stones in the CBD in two thirds of cases. If there is residual obstruction, a postoperative ES can be performed. We suggest primary treatment of choledocholithiasis by laparoscopic approach in children.
World Journal of Laparoscopic Surgery with DVD, 2021
Introduction: Intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) is valuable in the detection of biliary abnormalities. In this study, we aimed to investigate the diagnostic accuracy of IOC during LC for the detection of anatomic variations of the biliary system, as well as the visualization ability of IOC on determining the normal anatomy of the biliary tree. Materials and methods: This cross-sectional study was conducted on patients who were presented to the surgery outpatient clinic and were scheduled for elective LC for symptomatic cholelithiasis. Patients underwent intraoperative laparoscopic ultrasound (LUS) before the dissection of Calot's triangle and IOC video fluoroscopy examination of the extrahepatic biliary tree. Results: Our study enrolled 53 patients. No intraoperative complications occurred in all enrolled patients. LUS was successful in all 53 (100%) cases, while IOC was successful in 50 (94.3%) cases. IOC had accuracy rate of 100% (50 patients) in defining biliary ducts at the porta hepatis compared to 84.91% (45 patients) for LUS with a failure rate of 15.09% (p = 0.60). Concerning stones detection, LUS accuracy indexes were as follows: sensitivity = 80%; specificity = 95.83%; positive predictive value (PPV) = 66.67%; negative predictive value (NPV) = 97.87% 99; and diagnostic odds ratio (DOR) = 92. IOC accuracy indexes were as follows: sensitivity = 80%; specificity = 93.33%; PPV = 57.14%; NPV = 90%; and DOR = 56. Conclusion: The results of the current study encourage using IOC as an effective, accurate, feasible, and safe technique to visualize the biliary tree while performing LC.