Treatment of Common Bile Duct Stones in Era of Minimaly Invasive Surgery in General Hospital Setings (original) (raw)
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Useful Predictors of Bile Duct Stones in Patients Undergoing Laparoscopic Cholecystectomy
Annals of Surgery, 1994
The authors determined the most useful predictors of common bile duct (CBD) stones as diagnosed by endoscopic retrograde cholangiopancreatography (ERCP) in patients who underwent laparoscopic cholecystectomy (LC). Methods Prospective and retrospective collection of historical, biochemical and ultrasonographic data was used. Receiver operating characteristics curve analysis was used to determine optimal biochemical cutoff values. Multivariate analysis using logistic regression with generation of the best model identifying independent predictors of CBD stones also was employed. Prospective validation of the model was performed on an independent group of patients. Results Endoscopic retrograde cholangiopancreatographies were performed before LC in 106 patients, and after LC in 33. Only four of ten clinical variables evaluated independently predicted the presence of CBD stones. The optimal model predicted a 94% probability of CBD stones in a patient older than 55 years of age who presented with an elevated bilirubin (over 30 ,umol/L) and positive ultrasound findings (a dilated CBD, and a CBD stone seen on ultrasound). This model was validated prospectively in a subsequent series of 49 patients in which the probability of CBD stone was only 8% when all four predictors were absent. Conclusions The identified independent clinical predictors of a CBD stone helps select a population of symptomatic gallstone bearers who benefit most from cholangiographic assessment. Laparoscopic cholecystectomy (LC) has become the now treated this way.2 However, 3% to 33% ofall patients new therapeutic gold standard' in uncomplicated symp-with symptomatic gallstones may bear associated comtomatic cholelithiasis, and at least 80% of all patients are mon bile duct (CBD) stones.3-7 The optimal approach to
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
Surgical Endoscopy, 1996
Background: On the basis of a flowchart including prior or current jaundice or pancreatitis, abnormal liver function, ultrasound or IV cholangiography, bile duct (BD) stones were suspected in 71/593 patients referred for gallstones. Methods: When endoscopic retrograde cholangiography detected BD stones, endoscopic sphincterotomy (ES) and endoscopic BD clearance were attempted, followed by laparoscopic cholecystectomy (LC). BD stones were found in 44/71 patients. The sensitivity values of preoperative conditions were: 92% for IV cholangiography, 88% for abnormal liver function, 50% for ultrasound, and 37% for jaundice at admission. Results: Endoscopic clearance succeeded in 37 patients and LC was completed in 33 patients. Conversion to open surgery (9%) was comparable with the rate in patients without BD stones. The median hospital stay for the sequential endoscopic and laparoscopic treatments was 13 days (range 4-54) or 22 days if open surgery was used. Conclusions: In conclusion, BD stones can be endoscopically cleared preoperatively in most patients without interfeting with LC.
BMC Surgery, 2017
Background: Recent data have suggested that upfront cholecystectomy should be performed even in the presence of moderately abnormal liver function tests (LFTs). As a consequence, more common bile duct (CBD) stones are discovered on intra-operative cholangiogram. We assessed the presentation and management of such patients to refine their management plan. Methods: Adult patients (>16 years) with an acute gallstone-related disease who had undergone same-stay cholecystectomy from January 2013 to January 2015 were retrospectively assessed. We excluded patients with pre-operative endoscopic CBD exploration. Results: Among the 612 patients with same-stay cholecystectomy, 399 patients were included in the study, and 213 were excluded because of a pre-operative CBD exploration. Fifty patients (12.5%) presented an image of CBD stone on the intra-operative cholangiogram. Such patients were younger (47 vs. 55 years, P = .01) and less likely to present with fever (1 vs. 11.7%, P = .04) or signs of cholecystitis on ultrasound (66 vs. 83.7%, P = .003). Admission LFTs were higher in patients with an image of a stone. Among the 50 patients with an image on cholangiogram, a stone was confirmed in 26 (52%). Most patients (n = 32) underwent post-operative assessment with endoscopic ultrasound (EUS). LFTs did not predict the presence of a confirmed stone. However, the absence of contrast passage into the duodenum was negatively associated with a confirmed stone (P = .08), and a filling defect was positively associated with one (P = .11). Most confirmed stones were successfully extracted by endoscopic retrograde cholangiopancreatogram (ERCP) (25/26, 96%), except in one patient who needed a per-cutaneous approach because of duodenal diverticuli. Conclusions: Same-stay cholecystectomy can (and should) be performed even in the presence of moderately abnormal liver function tests. The cholangiogram suspicion of a CBD stone is confirmed in only half of the patients (more often in the presence of a filling defect, and less often with the absence of contrast passage). All stones can be safely treated after surgery (most by ERCP).
Laparoscopic Treatment of Gallbladder and Common Bile Duct Stones: A Prospective Study
World Journal of Surgery, 1996
The aim of this study was to investigate prospectively the feasibility, success rate, safety, and short-term results of single-stage laparoscopic treatment of gallstones and ductal stones in 100 consecutive, unselected patients. Common bile duct (CBD) stones were diagnosed at routine intraoperative cholangiography and choledochoscopy in 100 of 950 patients with gallstones undergoing laparoscopic cholecystectomy (LC). Unsuspected CBD stones were present in 39 patients (4.1% of 950; 39% of 100); 26 patients were referred for surgery after failed endoscopic sphinctertomy (ES) performed elsewhere. Transcystic duct CBD exploration (TC-CBDE) was the procedure of choice. When it was not feasible, choledochotomy and direct CBD exploration (D-CBDE) was performed.
Management of Common Bile Duct Stones in the Laparoscopic Era
Indian Journal of Surgery, 2012
There is no consensus regarding the ideal management of concurrent gallbladder and common bile duct (CBD) stones. Currently the treatment protocol involves most commonly a sequential approach consisting of endoscopic sphincterotomy followed by laparoscopic cholecystectomy or a single stage laparoscopic procedure, including cholecystectomy and exploration of the CBD. For this article literature search was performed using online search engines, Google, Pubmed, the online Springer link library and the Cochrane Database Systematic Review. Review articles, prospective and retrospective studies which detailed or compared the various treatment strategies for CBD stones were selected and analyzed. This review article aims to provide an insight into the optimal management of CBD stones in different clinical scenarios. Endoscopic sphincterotomy has inherent morbidity and complications like CBD stone recurrence whereas laparoscopic CBD exploration demands considerable expertise which is available only at specialized centres. The clinical presentation of the patient, number of stones, size of CBD, available resources and technical expertise at hand are an important consideration for the ideal management in different scenarios.
World Journal of Surgery
The aim of this study was to investigate prospectively the feasibility, success rate, safety, and short-term results of single-stage laparoscopic treatment of gallstones and ductal stones in 100 consecutive, unselected patients. Common bile duct (CBD) stones were diagnosed at routine intraoperative cholangiography and choledochoscopy in 100 of 950 patients with gallstones undergoing laparoscopic cholecystectomy (LC). Unsuspected CBD stones were present in 39 patients (4.1% of 950; 39% of 100); 26 patients were referred for surgery after failed endoscopic sphinctertomy (ES) performed elsewhere. Transcystic duct CBD exploration (TC-CBDE) was the procedure of choice. When it was not feasible, choledochotomy and direct CBD exploration (D-CBDE) was performed.
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.
Evaluation of different methods of laparoscopic treatment of common bile duct stones
International Surgery Journal
Background: Common bile duct (CBD) stones are the second most common complication of gall bladder stones. The best management of patients with CBD stones remains controversial. The aim of this study was to evaluate the methods of laparoscopic CBD exploration (LCBDE).Methods: This prospective study was conducted on 30 patients with CBD stones through 2 years. CBD stricture was excluded. Authors used transcystic and transcholedochotomy approaches for LCBDE either with or without choledoschope. Primary repair of the choledochotomy incision was done. Results: The mean age was 48.90±11.84 years. Biliary colic was the presentation in 63.3% of patients. The transcystic approach for CBD exploration was used in 16 cases without conversion, 11 cases were completed without choledochoscope, while 5 cases with choledochoscopic guided extraction. Choledochotomy approach had been used in 13 cases, 6 cases were completed with choledochoscope and 7 cases without it, two cases of them failed. One cas...