Detection and management of bile duct stones (original) (raw)
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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(ERCP) has become a widely available and routine procedure, whilst open cholecystectomy has largely been replaced by a laparoscopic approach, which may or may not include laparoscopic exploration of the common bile duct (LCBDE).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.
Surgical Endoscopy, 1998
Background: Common bile duct stones (CBDS) are a frequent problem (10-15%) in patients with symptomatic cholecystolithiasis. Over the last decade, new diagnostic and surgical techniques have expanded the options for their management. This report of the Consensus Development Conference is intended to summarize the current state of the art, including principal guidelines and an extensive review of the literature. Methods: An international panel of 12 experts met under the auspices of the European Association of Endoscopic Surgery (EAES) to investigate the diagnostic and therapeutic alternatives for gallstone disease. Prior to the conference, all the experts were asked to submit their arguments in the form of published results. All papers received were weighted according to their scientific quality and relevance. The preconsensus document compiled out of this correspondence was altered following a discussion of the external evidence made available by the panel members and presented at the public conference session. The personal experiences of the participants and other aspects of individualized therapy were also considered. Results: Our panel of experts agreed that the presence of common bile duct stones should be investigated in all patients with symptomatic cholecystolithiasis. Based on preoperative noninvasive diagnostics, either endoscopic retrograde cholangiopancreaticography (ERCP) or intraoperative cholangiography should be employed for detecting CBDS. Eight of the 12 panelists recommended treating any diagnosed CBDS. For patients with no other extenuating circumstances, several treatment options exist. Stones can be extracted during ERCP, or either before or (in exceptional cases) after laparoscopic or open surgery. Bile duct clearance should always be combined with cholecystectomy. Evidence for further special aspects of CBDS treatment is equivocal and drawn from nonrandomized trials only. Conclusions: The management of common bile duct stones is currently undergoing some major changes. Many diagnostic and therapeutic strategies need further study.
The Egyptian Journal of Surgery, 2017
Background and aim of the work Around 10-18% of patients undergoing cholecystectomy for gallstones have common bile duct (CBD) stones. Treatment can be provided as open cholecystectomy plus open CBD exploration, laparoscopic cholecystectomy plus laparoscopic common bile duct exploration (LC+LCBDE), or precholecystectomy or postcholecystectomy endoscopic retrograde cholangio-pancreatography (ERCP) in two stages for CBD clearance. The aim of this study is to compare the CBD clearance rate by each procedure in a well-equipped tertiary center. Patients and methods A total of 250 patients with choledocholithiasis were included from the General Surgery Department, Sohag and Assiut University Hospitals, and managed randomly by either conventional surgery, endoscopic, or laparoscopic procedures. Results The ages of our patients ranged from 20 to 60 years (mean=40 years), with a slight female predominance (1.6 : 1); most of them presented with calcular obstruction (54.3%). However, there were also other presentations such as colic, cholangitis, or accidental discovery in 14.3, 10, and 21.5%, respectively. Patients were categorized randomly into three groups: group I included 100 patients (40%) who were treated by open choledocholithotomy and T-tube insertion; the operative time was 90 (60-180) min, with the success rate of the attempted procedures reaching 100%, and CBD clearance of stones was achieved in 95% of cases (five cases of missed stones). Hospital stay was 8 (5-12) days, with no mortality, and morbidity rate reached 15% in the form of wound infection, bile leak, and missed stone. The patient could return to work after 2 weeks (12-20 days). Group II included 100 patients (40%) treated by endoscopic sphincterotomy; basket extraction was performed in 45%, balloon in 25%, the combined maneuver in 15%, and mechanical lithotripsy in 13%, with failure of the technique in two cases (2%); the duration of the procedure was about 30 (20-45) min, with a success rate of attempted procedures of 98%, and CBD clearance of stones was achieved by 100%, with no mortality; the morbidity rate was 9% in the form of cholangitis (3%) and mild pancreatitis with hyperamylasemia (6%). The period of hospital stay was 1 (1-2) days and the patient returned to work after 3 (2-5) days. Group III included 50 patients (20%) treated by laparoscopic approaches: transcystic approaches in five cases and transcholedochotomy approaches in 45 cases. Choledochoscopic exploration was performed in almost all cases (45 cases) to detect, extract the stones, and test CBD clearance, and there was conversion to open techniques in one case. The time needed for this procedure was 123 (70-292) min, with CBD clearance of stones in 96% (two cases of missed stone), with no mortality, and a morbidity rate of about 10% in the form of mild hyperamylasemia, fever, and missed stone. The period of hospital stay was 3.2 (2-4) days, with return to work after 7 (5-10) days. Conclusion Both ERCP/LC and LCBDE were highly effective in CBD clearance, and equal in terms of the overall cost and patient acceptance. However, the overall duration of hospitalization was shorter for LCBDE with elimination of the potential risks of ERCP-associated pancreatitis, further procedures, and anesthesia risks. It is feasible, cost-effective, and ultimately should be available for most patients in each specialized center.
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.
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 Hepato-Biliary-Pancreatic Surgery
Bile duct stones (BDS) can be managed either prior to laparoscopic cholecystectomy (LC) using endoscopic retrograde cholangiopancreatography (ERCP) or with laparoscopic bile duct exploration (LBDE) at the time of LC. The latter is underutilised. The aim of this study was to use the dataset of the previously performed CholeS study to investigate LBDE hospital volumes, LBDE-to-LC rates, and LBDE outcomes. Methods: Data from 166 United Kingdom/Republic of Ireland hospitals were used to study the utilisation of LBDE in LC patients. Results: Of 8,820 LCs performed, 932 patients (10.6%) underwent preoperative ERCP and 256 patients (2.9%) underwent LBDE. Of the 256 patients who underwent LBDE, 73 patients (28.5%) had undergone prior ERCP and 112 patients (43.8%) had undergone prior magnetic resonance cholangiopancreatography. Fifteen (9.0%) of the 166 included hospitals performed less than five LBDEs in the two-month study period. LBDEs were mainly performed by upper gastrointestinal surgeons (84.4%) and colorectal surgeons (10.0%). Eighty-seven percent of the LBDEs were performed by consultants and 13.0% were performed by trainees. The laparoscopic-to-open conversion rate was 12.5%. The median operation time was 111 minutes (range: 75-155 minutes). Median hospital stay was 6 days (range: 4-11 days) for emergency LBDEs and 1 day (range: 1-4 days) for elective LBDEs. Overall morbidity was 21.5%. Bile leak rate was 5.3%. Thirty-day readmission and mortality rates were 12.1% and 0.4%, respectively. Conclusions: The single-stage approach to managing BDS was underutilised. An additional prospective study with a longer study period is needed to verify this finding.
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