Prediction of common bile duct stones by noninvasive tests

Recurrent acute biliary pancreatitis: the protective role of cholecystectomy and endoscopic sphincterotomy

BACKGROUND

Recurrent attacks of acute biliary pancreatitis (RABP) are prevented by (laparoscopic) cholecystectomy. Since the introduction of endoscopic retrograde cholangiopancreaticography (ERCP), several series have described a similar reduction of RABP after endoscopic sphincterotomy (ES). This report discusses the different treatment options for preventing RABP including conservative treatment, cholecystectomy, ES, and combinations of these options as well as their respective timing.

METHODS

A search in PubMed for observational studies and clinical (comparative) trials published in the English language was performed on the subject of recurrent acute biliary pancreatitis and other gallstone complications after an initial attack of acute pancreatitis.

RESULT

Cholecystectomy and ES both are superior to conservative treatment in reducing the incidence of RABP. Cholecystectomy provides additional protection for gallstone-related complications and mortality. Observational studies indicate that cholecystectomy combined with ES is the most effective treatment for reducing the incidence of RABP attacks.

CONCLUSION

From the literature data it can be concluded that ES is as effective in reducing RABP as cholecystectomy but inferior in reducing mortality and overall morbidity. The combination of ES and cholecystectomy seems superior to either of the treatment methods alone. A prospective randomized clinical trial comparing ES plus cholecystectomy with cholecystectomy alone is needed.

For patients with predicted low risk for choledocholithiasis undergoing laparoscopic cholecystectomy, selective intraoperative cholangiography and postoperative endoscopic retrograde cholangiopancreatography is an effective strategy to limit unnecessary procedures

BACKGROUND

There is debate about whether intraoperative cholangiography (IOC) should be performed routinely or selectively during laparoscopic cholecystectomy (LC) in patients with suspected choledocholithiasis. The timing of endoscopic retrograde cholangiopancreatography (ERCP) in these patients also is an issue. We reviewed the experience in our center, where a management algorithm limiting ERCP in relation to LC was adopted.

METHODS

We retrospectively reviewed every LC performed by one surgeon during 6 years and the related ERCPs.

RESULTS

A total of 264 LCs were performed. In 30 patients, stones were cleared or excluded by preoperative ERCP. In the remaining 234 LCs, 31 of 34 IOCs were successfully performed. Two of 31 IOCs were positive for bile duct stones; stone removal was successful in each patient at subsequent ERCP. Only 10 of 201 patients who did not have IOC required postsurgical ERCP within 10 weeks of LC, 3 of whom had common bile duct stones at ERCP.

CONCLUSIONS

For patients who underwent LC, we performed selective IOC with postoperative ERCP for positive studies. Review of our experience using this algorithm showed it to be a powerful tool in limiting unnecessary ERCPs. Our data suggest that routine preoperative ERCP cannot be justified. Selective IOC during LC misses relatively few cases of biliary stones; these can be managed quickly by experienced endoscopists.

Prospective validation study of an algorithm for triage to MRCP or ERCP for investigation of suspected pancreatico-biliary disease

BACKGROUND

In patients with suspected pancreatico-biliary disease, endoscopic retrograde cholangiopancreatography (ERCP) should be reserved for those requiring therapeutic intervention. However, difficulty arises in identifying patients likely to require therapy in the early phase of diagnostic work-up. An algorithm has been developed by the authors based upon prospective assessment of ERCP patients for triage of patients to magnetic resonance cholangiopancreatography (MRCP) or ERCP with suspected pancreatico-biliary disease. We aimed to validate this algorithm in an independent group of patients using a different group of endoscopists blinded to the algorithm.

METHODS

Patients were stratified into different categories by clinical, ultrasound and liver function test findings. The algorithm stratified patients by the likelihood of therapeutic intervention. The accuracy of the algorithm for a therapeutic outcome was assessed by receiver operator characteristics (ROC) curve analysis.

RESULTS

Hundred and twenty-five consecutive patients (Oct 2005 to July 2006) were prospectively assessed by MRCP or ERCP according to the algorithm, and the outcomes recorded. Fifty-seven patients were triaged to MRCP and 63 patients were triaged to ERCP. A category was not assessable in five patients. Three patients from the MRCP group required subsequent therapeutic ERCP. Diagnostic ERCP was performed in three patients in the ERCP group. ERCP-related complications occurred in four patients. The algorithm performed well in predicting the requirement for intervention as determined by the area under the ROC curve [0.84 (95%CI 0.76-0.92)].

CONCLUSIONS

Our study confirms that an algorithm-based approach can reproducibly predict those patients requiring therapeutic biliary intervention.

EUS: a meta-analysis of test performance in suspected choledocholithiasis

BACKGROUND

EUS has been proposed as a less invasive means of diagnosing choledocholithiasis and may eliminate the need for ERCP and its associated risks. The literature pertaining to EUS for the diagnosis of choledocholithiasis reports widely varying sensitivities and specificities.

OBJECTIVE

To more precisely estimate the diagnostic accuracy of EUS in suspected choledocholithiasis.

DESIGN

MEDLINE and EMBASE databases were used to identify prospective cohort studies in which the results of EUS were compared with the results of an acceptable criterion standard, including ERCP, intraoperative cholangiography, or surgical exploration. Two independent reviewers extracted standardized data and assessed trial quality. A random effects model was used to estimate the sensitivity, specificity, likelihood, and diagnostic odds ratio (DOR), and a summary receiver operating characteristic curve was constructed. All predefined potential sources of heterogeneity were explored by subgroup analysis and meta-regression.

PATIENTS

A total of 2673 patients with suspected choledocholithiasis were reported in 27 studies that satisfied the inclusion criteria.

RESULTS

EUS had a high overall pooled sensitivity of 0.94 (95% CI, 0.93-0.96), a specificity of 0.95 (95% CI, 0.94-0.96), and an area under the curve of 0.98. Three variables appeared to yield a higher DOR: a higher disease prevalence, an adequate time interval between index test and criterion standards, and the presence of verification bias.

LIMITATIONS

Misclassification of patients by imperfect criterion standards could potentially underestimate the performance of an EUS.

CONCLUSIONS

An EUS is a noninvasive test, with excellent overall sensitivity and specificity for diagnosing choledocholithiasis. An EUS should, therefore, be used to select patients for a therapeutic ERCP to minimize the risk of complications associated with unnecessary diagnostic ERCP.

Biochemical predictors for absence of common bile duct stones in patients undergoing laparoscopic cholecystectomy

BACKGROUND

To provide optimal selection of patients for preoperative endoscopic retrograde cholangiopancreatography or intraoperative cholangiography, we evaluated simple, noninvasive biochemical parameters as screening tests to predict the absence of common bile duct stones prior to laparoscopic cholecystectomy.

METHODS

A total of 1002 patients underwent laparoscopic cholecystectomy. Five biochemical parameters were measured preoperatively: gamma glutamyl transferase (GGT), alkaline phosphatase, total bilirubin, alanine aminotransferase, and aspartate aminotransferase. Conventional diagnostic tests, including ultrasound imaging, computed tomography, magnetic resonance imaging, common bile duct diameter, endoscopic retrograde cholangiopancreatography, and serum amylase were performed. Along with the five biochemical tests above, these diagnostic tests were scrutinized and compared as potential predictors for common bile duct stones.

RESULTS

Eighty-eight (8.8%) patients with gallstone disease who underwent laparoscopic cholecystectomy had concurrent common bile duct stones. Among all diagnostic tests, endoscopic retrograde cholangiopancreatography had the highest sensitivity (96.0%), specificity (99.1%), probability ratio (107.3), accuracy (98.0%), and positive predictive value (98.8%) in detecting common bile duct stones. At least one abnormal elevation among the five biochemical parameters had the highest sensitivity (87.5%). Total bilirubin had the highest specificity (87.5%), highest probability ratio (3.9), highest accuracy (84.1%), and highest positive predictive value (27.4%). All five biochemical predictors had high negative predictive values; gamma glutamyl transferase was highest (97.9%), while the lowest was total bilirubin (94.7%). Multivariate analysis showed only gamma glutamyl transferase, alkaline phosphatase, and total bilirubin to be independent predictors; gamma glutamyl transferase appeared to be the most powerful predictor (odds ratio 3.20).

CONCLUSION

Biochemical tests, especially gamma glutamyl transferase with 97.9% negative predictive value, are ideal noninvasive predictors for the absence of common bile duct stones in patients undergoing laparoscopic cholecystectomy. We suggest that unnecessary, costly, or risky procedures such as endoscopic retrograde cholangiopancreatography can be omitted prior to laparoscopic cholecystectomy in patients without abnormal elevation of these biochemical values.

Selective intraoperative cholangiography and single-stage management of common bile duct stone in laparoscopic cholecystectomy

BACKGROUND

There are still debates and controversies in the detection and the management of common bile duct (CBD) stones in the era of laparoscopic cholecystectomy (LC). This prospective study was performed to evaluate a single-stage management of CBD stone during LC.

METHODS

Between May 1998 and January 2000, 249 consecutive patients with gallstone and cholecystitis were enrolled in this study. The mean age was 52.5 +/- 12.4 years. Male to female ratio was 106:143. All patients underwent abdominal sonography and the determination of the serum biochemical profile preoperatively. Patients presented with sepsis or with total bilirubin > or = 6 ng/dL were excluded from the study.

RESULTS

244 (98%) patients underwent LC and 5 (2%) patients were converted to open cholecystectomy. Intraoperative cholangiogram (IOC) was only performed in patients who fulfilled our predetermined criteria. Among 90 patients who had IOC, only 23 patients had CBD stones that were removed either by transcystic duct stone extraction (61%) or CBD exploration (39%). The additional procedures to remove CBD stone did not prolong the hospitalization. There were four wound infections and one cystic stump leakage. One patient developed CBD stone during the follow-up period up to 37 months.

CONCLUSIONS

Our study indicates that routine use of IOC during LC is not necessary. In addition, single-stage approach for the management of CBD stone during LC is feasible and should be considered by laparoscopic surgeons.

Nonoperative imaging techniques in suspected biliary tract obstruction

Evaluation of suspected biliary tract obstruction is a common clinical problem. Clinical data such as history, physical examination, and laboratory tests can accurately identify up to 90% of patients whose jaundice is caused by extrahepatic obstruction. However, complete assessment of extrahepatic obstruction often requires the use of various imaging modalities to confirm the presence, level, and cause of obstruction, and to aid in treatment plan. In the present summary, the literature on competing technologies including endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangiopancreatography (PTC), endoscopic ultrasound (EUS), intraductal ultrasonography (IDUS), magnetic resonance cholangiopancreatography (MRCP), helical CT (hCT) and helical CT cholangiography (hCTC) with regards to diagnostic performance characteristics, technical success, safety, and cost-effectiveness is reviewed. Patients with obstructive jaundice secondary to choledocholithiasis or pancreaticobiliary malignancies are the primary focus of this review. Algorithms for the management of suspected obstructive jaundice are put forward based on current evidence. Published data suggest an increasing role for EUS and other noninvasive imaging techniques such as MRCP, and hCT following an initial transabdominal ultrasound in the assessment of patients with suspected biliary obstruction to select candidates for surgery or therapeutic ERCP. The management of patients with a suspected pancreaticobiliary condition ultimately is dependent on local expertise, availability, cost, and the multidisciplinary collaboration between radiologists, surgeons, and gastroenterologists.

Combined endoscopic treatment for cholelithiasis associated with choledocholithiasis

BACKGROUND

The advent of endoscopic techniques changed surgery in many ways. For the management of cholelithiasis, laparoscopic cholecystectomy (LC) is the treatment of choice. This has created a dilemma in the management of choledocholithiasis. Today a number of option exist, including endoscopic sphinterotomy (ES) before LC in patients with suspected common bile duct (CBD) stones, laparoscopic bile duct exploration, open CBD exploration, and postoperative endoscopic retrograde cholangiopancreatography (ERCP). Also, the alternative technique of peroperative ES is emerging.

METHODS

We report our experience of routine intraoperative cholangiography followed either by peroperative ERCP in one step or by transcystic drain and postoperative ERCP. In our technique, to facilitate Vater papilla cannulation we inserted a 450-cm transcystic guidewire that was caught by a duodenoscope. Papillotome was then inserted over the guidewire to ensure cannulation of the CBD.

RESULTS

Twenty-eight patients were treated successfully in one step and 24 in two steps. The mean operative time was 181 +/- 41 min for patients treated in one step and 131 +/- 30 min for patients treated in two steps. The mean hospital stay was 4.8 +/- 3.3 days for patients treated in one step and 9.6 +/- 4.0 days for patients treated in two steps. Five patients (18%) with positive intraoperative cholangiography for stones for whom peroperative ERCP was not available showed a normal postoperative transcystic cholangiogram and therefore ERCP was canceled. Fourteen of 25 patients treated in one step and none of 17 treated in two steps had raised serum amylase, which resolved spontaneously with no symptoms. No patient developed postoperative pancreatitis. Three (10%) ERCP complications were observed, consisting of mild bleeding of the papilla. All cases were managed by endoscopic adrenaline injection. There was no mortality.

CONCLUSION

We believe peroperative ERCP with the technique described should be considered as the treatment of choice for choledocholithiasis associated with cholelithiasis. When single-stage treatment is not possible, a two-step rendezvous technique should be preferred.

Preoperative risk factors for common bile duct stones: defining the patient at high risk in the laparoscopic cholecystectomy era

BACKGROUND

Common bile duct stones (CBDS) are present in 3-20% of patients with cholelithiasis. Intraoperative cholangiography has high sensitivity in detecting CBDS but its routine use is associated with increased costs and operating room time. The aim of our study was to define an accurate and simple model for the prediction of CBDS using preoperative variables.

METHODS

The study consisted of a retrospective analysis followed by a prospective study. Multivariate analysis of the retrospective data was used to create a predictive model for the presence of concurrent CBDS in patients undergoing cholecystectomy. The predictive model was then validated in a prospective series of 160 patients undergoing laparoscopic cholecystectomy.

RESULTS

Among the 19 potentially predictive variables for CBDS, only four were found to be statistically significant and independent: X1-alkaline phosphatase levels (UI/L); X2-number of gallbladder stones; X3-total serum bilirubin (mg/dL); and X4-CBD diameter (mm). Using these four variables, the multivariate analysis created the equation: score = 0.002 x X1 + 0.485 x X2 + 0.232 x X3 + 0.220 x X4 - 4.167 to define the risk of CBDS in each patient. The predictive model, tested prospectively in 160 patients undergoing laparoscopic cholecystectomy (LC), showed an elevated index of correlation (r = 0.75) among the predicted and the observed frequencies (chi2 = 126.6; P < 0.0001). The predictive model sensitivity and specificity were 92.9% and 99.3%, respectively.

CONCLUSIONS

In patients undergoing cholecystectomy, accurate prediction of the risk for concurrent CBDS can be achieved using four preoperative variables. The use of this predictive model can contribute to reducing the number of unnecessary common bile duct explorations.

Predição da coledocolitíase pela associação de indicadores clínicos e laboratoriais em dois momentos do pré-operatório da colecistectomia

OBJETIVO: O propósito deste estudo foi determinar a probabilidade de ocorrência de coledocolitíase através do estudo da associação de indicadores clínicos e laboratoriais desta doença em dois momentos do pré-operatório de colecistectomia. MÉTODO: Entre março de 2001 e março de 2002, 48 pacientes consecutivos com colelitíase foram submetidos a colecistectomia e colangiografia intra-operatória (CIO). Os pacientes foram divididos em dois grupos, sendo o grupo A constituído por 13 pacientes com coledocolitíase e o grupo B por 35 pacientes sem esta doença. Os pacientes foram investigados quanto aos indicadores clínicos e laboratoriais da coledocolitíase, analisados em dois períodos, tomando como ponto de corte as 48 horas que precederam a cirurgia. Posteriormente, estes indicadores pré-operatórios foram associados na equação da regressão logística em diferentes combinações. RESULTADOS: Utilizando a equação da regressão logística, constatou-se que a associação de dois indicadores clínicos em ambos os períodos (icterícia e sinal de Murphy) e dois laboratoriais ( nível de corte da gama glutamil transpeptidase e bilirrubina direta 48 horas antes da cirurgia) foi a mais adequada para a predição da coledocolitíase. Os valores obtidos por esta equação mostraram concordância com os grupos A e B, de 95,6%, e discordância de 4,4% (p= 0,0000007 e k = 0,89). Esta equação mostrou sensibilidade de 92,3%, especificidade de 97,0%, valor preditivo positivo de 92,3% e valor preditivo negativo de 97%. Estes valores foram próximos aos obtidos pela CIO, que mostrou concordância com os grupos estudados de 95,8%, e discordância de 4,2% (k = 0,90). CONCLUSÃO: Considerando os resultados obtidos, recomenda-se a associação de indicadores da coledocolitíase na equação da regressão logística para estabelecer a probabilidade de ocorrer coledocolitíase associada à colelitíase. A utilização desta equação pode orientar melhor a conduta diagnóstica e terapêutica nesta doença.

Three-dimensional virtual cholangioscopy: a reliable tool for the diagnosis of common bile duct stones

OBJECTIVE

Our goal was to evaluate the clinical reliability of a new software system employing 3-dimensional (3D) virtual anatomic reconstruction and intraluminal virtual exploration for detection of choledocholithiasis and preoperative visualization of the biliary anatomy.

SUMMARY BACKGROUND DATA

Virtual reality systems have been proposed for gastroscopy, bronchoscopy, and colonoscopy, as well as for the 3D reconstruction of liver anatomy and hepatic lesions. The impact of these systems in preoperative diagnostics has not been established due to the lack of large clinical series evaluating their reliability.

METHODS

From November 2000 to July 2002, all patients presenting to our Institute with suspected choledocholithiasis were prospectively included in the study. All patients underwent conventional magnetic resonance cholangiopancreatography (MRCP) and either intraoperative cholangiogram (IOC) or endoscopic retrograde cholangiopancreatography (ERCP). The digital data from MRCP were incorporated into an original virtual reality software system to generate a 3D reconstruction. All 3D reconstructions were evaluated by a surgeon and a computer software engineer who were blind to the results of the IOC or ERCP. Sensitivity and specificity were then calculated based on the results of either the IOC or ERCP.

RESULTS

Sixty-five patients were enrolled in the study. The average time required to reconstruct the images into navigable virtual reality was 7.5 minutes (range, 4-13.5). The 3D virtual cholangioscopy had sensitivity and specificity rates of 71% and 91%, respectively, compared with 61% and 86% of the standard MRCP.

CONCLUSION

: The 3D virtual cholangioscopy provides detailed preoperative reconstruction of biliary anatomy and reliable identification of choledocholithiasis with acceptable sensitivity and specificity in a clinical setting. Newer software developments may further enhance its accuracy, so that virtual cholangioscopy might challenge or replace more invasive diagnostic measures in the near future.

Mathematical model for predicting biliary therapeutic endoscopic retrograde pancreatography (ERCP)

INTRODUCTION

Magnetic resonance cholangiopancreatography is as sensitive as endoscopic retrograde pancreatography in the evaluation of biliary tract diseases but does not offer therapeutic options. The aim of the present study was to develop a mathematical model to predict 'therapeutic endoscopic retrograde pancreatography' using clinical variables so that patients with low probability could be more appropriately investigated by magnetic resonance cholangiopancreatography in future.

METHODS

Endoscopic retrograde pancreatography cases between January 1996 to December 1997 were retrospectively reviewed (before introduction of magnetic resonance cholangiopancreatography). Clinical, biochemical and radiological variables were analysed and a model was developed using multiple logistic regression.

RESULTS

Case notes for 573 patients were successfully reviewed. A total of 330 patients underwent therapeutic endoscopic retrograde pancreatography (sphincterotomy or stent insertion). Clinical indications of obstructive jaundice and cholangitis, ultrasonographic findings of dilated common bile duct, and raised liver function tests (two or more elevated parameters) were each found to be predictive for 'therapeutic' endoscopic retrograde pancreatography. Using these variables, the mathematical model in the present study has specificity of 77% and sensitivity of 75% at the probability level of 50% or higher. This model has been tested in a separate group of endoscopic retrograde pancreatography cases carried out in 1998 and was found to have sensitivity 77.6%, specificity 80.3%, positive predictive value 68.5% and negative predictive value 86.6%.

CONCLUSIONS

The model reported in the present study can help clinicians to identify cases for therapeutic endoscopic retrograde pancreatography and diagnostic magnetic resonance cholangiopancreatography.

The role of ultrasound in biliary and pancreatic diseases

The possibilities and the limits of transabdominal ultrasonography (US) in the diagnosis of bilio-pancreatic diseases are reviewed here in the light of the last 10 years' research. US remains the method of choice for the diagnosis of gallstones and is generally accepted as an initial imaging technique in gallstone complications, such as acute cholecystitis. Moreover the method can be useful for the detection of the biliary complications after laparoscopic cholecystectomy and after liver transplantation. US is still considered the first diagnostic procedure when stones are suspected in the common bile duct. The use of color Doppler can provide a differential diagnosis of gallbladder cancer with respect to other benign inflammatory or polypoid lesions. Color Doppler US allows to detect vascular complications of acute pancreatitis such as pseudoaneurysms. US is still considered useful for the initial screening of the pancreatic cancer. However, for staging other imaging techniques must be employed. With US useful informations are obtained in the diagnosis of cystic tumors of the pancreas and of pancreatic metastases. US is generally of little use for the diagnosis of endocrine tumors.

The value of magnetic resonance cholangiopancreatography in predicting common bile duct stones in patients with gallstone disease

BACKGROUND

The application of available predictive scoring systems for the detection of common bile duct (CBD) stones has not reduced the number of patients who undergo unnecessary endoscopic retrograde cholangiopancreatography. The aim of this study was to create a predictive model for CBD stones and to assess the value of magnetic resonance cholangiopancreatography (MRCP) in prediction.

METHODS

In 1998, 366 patients with gallstone disease (118 males, 248 females; mean age 57 (range 8-84) years) underwent cholecystectomy. Statistical analysis was performed on patient data obtained at the time of first presentation.

RESULTS

CBD stones were demonstrated in 43 (12 per cent) of 366 patients. The predictive model for common duct stones included ultrasonography showing CBD stones or bile duct dilatation, age greater than 60 years, fever, serum alkaline phosphatase level above 670 units/l and serum amylase level above 95 units/l. In patients with a predicted probability greater than 5 per cent, CBD stones were present in 11 per cent, compared with 1 per cent in patients with a probability of 5 per cent or less. MRCP had an observed sensitivity of 95 per cent, specificity of 100 per cent, positive predictive value of 100 per cent and negative predictive value of 98 per cent.

CONCLUSION

In patients with a predicted probability for CBD stones of more than 5 per cent, MRCP is recommended in order to confirm the presence or absence of stones and as guidance in further management.

Changing methods of imaging the common bile duct in the laparoscopic cholecystectomy era in Western Australia: implications for surgical practice

OBJECTIVE

To assess changes in the use of endoscopic retrograde cholangiopancreatography (ERCP), intraoperative cholangiography (IOC), and surgical exploration of the common bile duct (CBD) associated with the introduction of laparoscopic cholecystectomy (LC).

SUMMARY BACKGROUND DATA

The optimal strategy for dealing with potential stones of the CBD during LC remains controversial.

METHODS

The authors conducted a population-based study of all cases of cholecystectomy (20,084) in Western Australia in the periods before, during, and after the introduction of LC (1988-1994). Index admissions were linked to previous or subsequent admissions for ERCP. Factors associated with ERCP were analyzed by multivariate regression models.

RESULTS

Between 1988 and 1994, admissions for ERCP almost doubled, whereas the use of IOC decreased from 71% to 51%. Different trends were found for open and laparoscopic procedures. Exploration of the CBD declined because of the infrequent use of this procedure in LC. Preoperative ERCP was significantly more common in older patients and men; the reverse was found for IOC. There was an adjusted 3.5-fold increase in preoperative ERCP both during and after the introduction of LC. The adjusted odds ratios for IOC were 0.48 and 0.52 for these periods.

CONCLUSIONS

The introduction of LC was associated with increasing reliance on ERCP to image the CBD and a decrease in the use of IOC. These changes were observed in both LC and open cholecystectomy. They suggest that the use of ERCP before cholecystectomy has partly replaced IOC for visualization of the CBD for suspected stones. Although more than 40% of patients undergoing LC had IOC, surgeons appear to be reluctant to perform surgical exploration of the CBD when stones are present. Savings in terms of both complications and cost can be expected if preoperative ERCPs performed for suspicion of uncomplicated CBD stones are replaced by IOC.

Practical recommendations for the prediction and management of common bile duct stones in patients with gallstones

BACKGROUND

Approximately 10% of patients with symptomatic gallstones may have associated common bile duct stones (CBDS). However, the predictive value of noninvasive tests as well as the preoperative diagnosis and management of CBDS have not been well defined. The aim of this study was to define an accurate and simple model for the prediction and management of CBDS.

METHODS

A prospective database containing 986 cholecystectomies performed from 1994 through 1999 was evaluated. Univariate analysis using the Pearson chi-square test was performed to determine the factors significantly related to the presence of CBDS. Then logistic regression analysis was performed for multivariate analysis to discover independent predictors.

RESULTS

Of the 986 patients in this study, 48 (5%) had CBDS. Of the 48 patients with choledocholithiasis, 22 (46%) were men and 26 (54%) were women. The mean age was 55.3 years (range, 16-87 years). As a result of multivariate analysis, abdominal ultrasonographic findings suggestive of CBDS (common bile duct diameter exceeding 8 mm or visible stones), total bilirubin, and gamma glutamyl transpeptidase levels above normal were the independent predictors of CBDS in patients age 70 or younger. On the other hand, an elevated bilirubin level was found to be the single independent factor related to CBDS in the elderly.

CONCLUSIONS

For patients with gallstones, suggestive ultrasonographic findings in those younger than 71 years and elevated direct or total bilirubin level in those older than 70 years are the most valuable and practical predictors of CBDS, and thus are the proper indications for preoperative endoscopic retrograde cholangiography.

A non-icteric cholecystectomized patient with recurrent attacks of right epigastric pain and dilated common bile duct--do liver function tests predict bile duct stones?

Cholecystectomized patients with recurrent attacks of right epigastric pain and with dilated common bile duct are a clinical challenge. In a number of these patients dilatation of the common bile duct is explained as a normal postoperative state following cholecystectomy and the recurrent pain attacks are of origin other than bile disorder, but in some cases dilatation of the common bile duct and attacks are caused by bile duct stones. The aim of the present work was to study the value of common plasma liver function tests in predicting bile duct stones in the group of non-icteric cholecystectomized patients with recurrent attacks of right epigastric pain and with dilated common bile duct. The study population comprised 24 consecutive non-icteric cholecystectomized patients admitted for elective endoscopic retrograde cholangiopancreatography because of attacks of right epigastric pain and dilated common bile duct in ultrasonography. All the liver function tests seemed to assist in separating patients with bile duct stones (n=11) from those without (n=13). Alanine aminotransferase levels were significantly higher (p=0.05) in patients with bile duct stones than in those without, but also alkaline phosphatase (p=0.07), gamma-glutamyl transferase (p=0.09) and bilirubin (p=0.09) levels seemed to be higher in patients with bile duct stones than in those without, although the differences in these values did not reach statistical significance. In conclusion, common plasma liver function tests assist in separating patients with bile duct stones from those without in this small but clinically important group of non-icteric cholecystectomized patients with recurrent attacks of right epigastric pain and with dilated common bile duct. However, the actual value of these measurements is limited in clinical decision making since overlapping of values occured.

Hepatobiliary surgery

The transformation of liver and biliary tract surgery into a full speciality began with the application of functional anatomy to segmental surgery in the 1950's, reinforced by ultrasound and new imaging techniques. The spectrum of gall-stone disease encountered by the hepatobiliary surgeon has changed with the laparoscopic approach to cholecystectomy. There is increased need for conservation techniques to repair the bile duct injuries that arise more often in the laparoscopic approach to cholecystectomy. These and other surgical interventions on the bile ducts should be selected as a function of risk versus benefit in relation to the patient's requirements and the institutional expertise. Bile duct cancers, including hilar cholangiocarcinoma, and gallbladder cancers have a dismal reputation, but evidence is accumulating for better survivals from aggressive approaches performed by specialist hepatobiliary surgeons. Hepatic surgery has increased in safety and effectiveness, largely due to the segmental approach, but also to experience with techniques for vascular control and exclusion used in liver transplantation. Techniques such as portal vein embolisation, which induces hypertrophy of the future remnant liver, percutaneous local tumour destruction using cryotherapy or radiofrequency tumour coagulation and more effective chemotherapy are beginning to increase the number of patients who can undergo curative resection. In liver transplantation, segmental surgery has been applied to graft reduction and to split liver grafts, and is opening new perspectives for living donor transplantation. Today the limitation to survival in primary and metastatic liver cancer lies not in the surgical technique but in the difficulty of dealing with microscopic and extrahepatic disease. Progress in these fields will enable the hepatobiliary surgeon to further extend the possibilities for proposing curative resections.