Useful predictors of bile duct stones in patients undergoing laparoscopic cholecystectomy. McGill Gallstone Treatment Group

Gallstone pancreatitis: a prospective study on the incidence of cholangitis and clinical predictors of retained common bile duct stones

OBJECTIVE

The aim of this study was to define the incidence of cholangitis in gallstone pancreatitis, in the absence of cholangitis, to identify the clinical predictors of persistent common bile duct (CBD) stones at endoscopic retrograde cholangiography (ERCP) or at intraoperative cholangiography (IOC).

METHODS

A total of 122 consecutive patients with acute gallstone pancreatitis were prospectively evaluated for the presence of CBD stones as determined by elective ERCP or IOC. Urgent ERCP was restricted to patients with concomitant cholangitis. APACHE II scores and serial laboratory data were obtained.

RESULTS

Four (3%) patients had cholangitis and all underwent urgent ERCP successfully. Eighteen (15%) patients without cholangiogram were excluded. The remaining 100 patients underwent elective ERCP or IOC on a mean of hospital day 6.8. Twenty-one (21%) patients had persistent CBD stones. Univariate analysis detected significant differences in serum total bilirubin, ALT, and alkaline phosphatase levels between patients with and without persistent CBD stones. On multivariate analysis, serum total bilirubin on hospital day 2 was the best predictor of CBD stones. A serum total bilirubin level > 1.35 mg/dl had a sensitivity of 90.5% and specificity of 63%. Age, gender, mean APACHE II score, amylase, and presence of CBD dilation on ultrasound were not predictive of CBD stones.

CONCLUSION

In patients with gallstone pancreatitis, 1) cholangitis is uncommon, and 2) the best clinical predictor of persistent CBD stones is serum total bilirubin on hospital day 2.

Costs and effectiveness of extracorporeal gallbladder stone shock wave lithotripsy versus laparoscopic cholecystectomy. A randomized clinical trial. McGill Gallstone Treatment Group

Thirty-five patients were randomized to extracorporeal shock-wave lithotripsy (ESWL) and 25 to laparoscopic cholecystectomy (LC). Stone disappearance occurred in only 12 of 32 ESWL patients [38% (95% CI: 21-56%)] during a 15-month follow-up. Greater incremental gains in quality of life after 6 months were observed among LC patients (p < .01). Total duration of disability was 6.8 +/- 8.5 days for ESWL, and 22.7 +/- 16.6 days for LC (p < .01). Nine (28%) patients crossed over electively to the LC group, but only 44% of these underwent LC within the next 3 years. ESWL cost Can $58.9/ day of disability saved. ESWL is limited by its selective applicability and modest stone disappearance rate. Its cost-effectiveness is largely dependent on patient acceptance of recurrent episodes of biliary colic due to the persistence of stone fragments.

Role of endoscopic retrograde cholangiopancreatography before and after laparoscopic cholecystectomy

BACKGROUND

While the role of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (EST) in the diagnosis and management of choledocholithiasis is well established, this study evaluates the usefulness of ERCP and EST in patients with symptomatic cholecystolithiasis and suspected choledocholithiasis before undergoing laparoscopic cholecystectomy (LC), and the role of ERCP-EST in the management of complications resulting from LC.

MATERIALS AND METHODS

This paper reviews retrospectively our experience from 1992 to 1995. A total of 1221 LCs and 717 ERCPs were performed, out of which 257 ERCPs were performed on 225 patients who underwent LC (230 ERCPs before and 27 after). The age range was 10-85 years (mean 43.5). The study group comprised 148 females (66%) and 77 males (34%).

RESULTS

The overall success rate for ERCP was 92% (96% for diagnostic and 88% for therapeutic). Choledocholithiasis was found at preoperative ERCP in 45% of cases. Prediction of choledocholithiasis was accurate in 46%, based on abnormal liver chemistry, and 70% when based on a combination of abnormal liver tests and dilated main bile duct (>7 mm) by ultrasound. In 40 cases of acute biliary pancreatitis, choledocholithiasis was found at ERCP in eight cases (20%). In the post-LC group, all eight cases with residual stones and seven of eight cases with bile leaks were successfully treated endoscopically. There were four cases with major duct injuries that required surgical management. The complications related to ERCP-EST included two cases of bleeding post-EST (one was controlled with injection therapy and the second one was managed surgically), and three cases of mild pancreatitis.

CONCLUSION

ERCP and EST are effective and safe in the diagnosis and management of choledocholithiasis, and facilitate LC for symptomatic cholelithiasis. The procedures are also valuable in the diagnosis and management of most complications resulting from LC.

Magnetic resonance imaging in evaluation of the common bile duct

BACKGROUND

The ideal method for evaluation of the common bile duct (CBD) before or during cholecystectomy remains controversial. Magnetic resonance cholangiography (MRC) is a new, promising technique. A prospective evaluation is reported.

METHOD

Sixty-one patients (45 women) were studied by MRC. There were 29 patients with symptomatic gallstone disease and without clinical, biochemical or ultrasonographic evidence of CBD stones (group 1); 28 of them also underwent intraoperative cholangiography (IOC). In addition, there were 21 patients with symptomatic gallstone disease, with mild biochemical and ultrasonographic signs of CBD involvement (group 2), of whom 19 underwent IOC, and 11 patients with symptomatic CBD stones (group 3), nine of whom had preoperative endoscopic retrograde cholangiopancreatography (ERCP) following MRC.

RESULTS

MRC showed that no patient in group 1 and three patients in group 2 had CBD stones. Three patients (one in group 1, two in group 2) did not undergo IOC because of technical or clinical problems. In group 3, ERCP confirmed the results of MRC in nine patients. Two patients underwent open surgery because of ultrasonographic, MRC and radiographic signs of pancreatic malignancy.

CONCLUSION

MRC could replace IOC and ERCP for identification of asymptomatic CBD stones. In symptomatic patients MRC combined with other non-invasive imaging techniques can direct the surgeon to appropriate management.

Clinical utility of endoscopic retrograde cholangiopancreatography

BACKGROUND

ERCP is a frequently performed procedure, but its necessity for diagnosis and ability to change management plans are unclear in many cases.

METHODS

We prospectively evaluated diagnosis, certainty of diagnosis, and management recommendations, both before and after ERCP, as well as therapeutic maneuvers performed during ERCP, in unselected patients undergoing this procedure.

RESULTS

ERCP procedures (1341) were studied at a university hospital, an ERCP referral center, and two community hospitals. Among patients undergoing first-time ERCP, the preceding clinical diagnosis was correct for 64% of those predicted to have bile duct stones, 86% to 89% of those given other biliary diagnoses, and 88% predicted to be normal. In 35% of cases, diagnostic confidence improved substantially after ERCP. Endoscopic therapy was successfully completed in 51%. After ERCP, plans for other invasive procedures changed in 82%: percutaneous biliary studies and open surgical procedures were recommended less often and laparoscopic cholecystectomy more often. Endoscopic therapy and overall clinical utility were most common in patients with cholangitis, jaundice, or bile leaks.

CONCLUSIONS

ERCP is particularly helpful for diagnosis of bile duct stones but is less likely to change other diagnoses. The endoscopic therapy commonly carried out during ERCP often changes the treatment plan, leading to fewer surgical and percutaneous interventions in general, but more laparoscopic cholecystectomies.

An analysis of perioperative cholangiography in one thousand laparoscopic cholecystectomies

BACKGROUND

We undertook this retrospective study to ascertain the proper role of perioperative cholangiography in the management of 1002 patients undergoing laparoscopic cholecystectomy for symptomatic cholelithiasis.

METHODS

Nine hundred forty-one patients were categorized as being at high or low risk for choledocholithiasis according to the presence or absence of jaundice, pancreatitis, elevated bilirubin, alkaline phosphatase, serum glutamic-oxaloacetic transaminase, or radiographic evidence of common bile duct stones (CBDSs).

RESULTS

Intraoperative cholangiography (IOCG) and preoperative endoscopic retrograde cholangiopancreatography (ERCP) were equivalent in the detection of CBDSs, and laparoscopic common bile duct exploration (CBDE) was successful in 12 of the 21 patients (57%) in whom it was attempted. The ducts of the other 52 patients with CBDSs were successfully cleared by preoperative or postoperative ERCP.

CONCLUSIONS

Laparoscopic IOCG is successful in detecting CBDS in high-risk patients and half of these ducts can be cleared laparoscopically. The incidence of CBDS in low-risk patients is 1.7%, a risk that does not warrant routine cholangiography. These data suggest ERCP should be reserved for those at-risk individuals in whom IOCG or laparoscopic duct clearance has been unsuccessful.

Abnormal common bile duct sonography. The best predictor of choledocholithiasis before laparoscopic cholecystectomy

We conducted a prospective study to determine the most reliable indicator of common bile duct stones before laparoscopic cholecystectomy. One hundred thirty-seven patients were referred for endoscopic retrograde cholangiography before laparoscopic cholecystectomy for suspected choledocholithiasis due to one or more of the following abnormalities: (a) altered liver function tests, (b) increased serum amylase levels, or (c) a dilated common bile duct (> 7 mm) with or without evidence of stones on sonography. Sensitivity, specificity, positive and negative predictive values, and the likelihood of the presence or absence of morbidity were calculated for 25 different variables. Common bile duct stones were detected in 63 (46%) patients. Abnormal result of sonography of the common bile duct was the best predictor of choledocholithiasis (p < 0.0001). Abnormalities of the combined liver function tests were statistically significant predictors only when combined with abnormal sonographic results. Improving liver function tests before endoscopy had a significant negative predictive value (p = 0.01). Stepwise logistic regression analysis showed that abnormal ultrasound and the presence of common bile duct stones on ultrasound were significant (p = 0.009 and p = 0.049, respectively). Abnormal result of sonography of the common bile duct is the best predictor of choledocholithiasis before laparoscopic cholecystectomy.

Management of choledocholithiasis in the time of laparoscopic cholecystectomy

BACKGROUND

The best way to detect and manage common duct stones in conjunction with laparoscopic cholecystectomy is not agreed upon at the present time.

PATIENTS AND METHODS

Our experience with choledocholithiasis in a consecutive series of 1,123 cholecystectomies (94% by laparoscopy) has been reviewed. Suspected duct stones were investigated preoperatively or postoperatively by endoscopic retrograde cholangiography (ERC), and if necessary, duct clearance was attempted by endoscopic sphincterotomy (ES). No attempt was made to identify choledocholithiasis intraoperatively.

RESULTS

Endoscopic retrograde cholangiography was performed in 11% of patients, and 32% of these required ES. The complication rate of ERC and ES was 8%, without mortality. Two patients required a second operation for missed choledocholithiasis, for a reoperation rate of 0.2%.

CONCLUSION

We believe that primary or secondary open surgery is only occasionally necessary for the management of choledocholithiasis. Preoperative ERC and ES for suspected duct stones, with the same strategy employed as a salvage for stones presenting after cholecystectomy, was safe and efficient.

What predicts gastroenterologists' and surgeons' diagnosis and management of common bile duct stones?

BACKGROUND

Because the literature suggests numerous indicators of common bile duct stones, we undertook a systematic assessment of physicians' judgments of the clinical utility of eight indicators: patient age, history of jaundice, history of pancreatitis, levels of serum alanine aminotransferase, alkaline phosphatase, amylase, and total bilirubin, and common bile duct diameter on ultrasonography.

METHODS

Random samples of 1500 gastroenterologists and 1500 surgeons were sent a survey asking them to indicate the importance of each potential indicator of common bile duct stones, the likelihood of common bile duct stones for each of nine clinical vignettes, and whether they would order a preoperative ERCP. An abbreviated survey was sent to nonrespondents.

RESULTS

Although there was substantial variation in the importances assigned to each indicator, the most important indicators were serum total bilirubin and diameter of common bile duct on ultrasound. The best predictors of the decision to order an ERCP were perceived likelihood of stones and specialty. The average threshold for ordering an ERCP was 37%. Respondents did not differ from nonrespondents in the perceived importance of the eight indicators.

CONCLUSIONS

The substantial variation among gastroenterologists and surgeons regarding the optimal approach to common bile duct stones has clinical implications. Patients will receive varying recommendations for care, depending on whom they see.

Evaluation of the pattern of liver tests and yield of cholangiography in symptomatic choledocholithiasis: a prospective study

BACKGROUND

The role of ERCP in the management of choledocholithiasis in an era of minimally invasive therapy continues to be defined.

METHODS

We evaluated prospectively the pattern of liver test abnormalities and yield of cholangiography after presentation with illnesses suggesting choledocholithiasis. Ninety-four consecutive patients, all with liver test abnormalities (total bilirubin, alkaline phosphatase, AST, and ALT) at presentation, had serial determinations to within 24 hours of cholangiography and were divided into four groups based on their patterns of rise or fall of liver test results as well as presenting clinical syndrome. Group I: normalized liver tests; Group II: falling liver tests, and alkaline phosphatase falling greater than 50% of the difference between presentation value and upper limit of normal; Group III: alkaline phosphatase falling less than 50%; and Group IV: any liver test with increasing levels. Clinical syndromes included cholangitis, pancreatitis, combined cholangitis and pancreatitis, and biliary pain with abnormal liver tests.

RESULTS

Yields of choledocholithiasis were 13% (Group I), 50% (Group II), 67% (Group III), and 94% (Group IV). Yield by syndromes were 36% (biliary pancreatitis), 72% (biliary pain and abnormal liver tests), 87% (cholangitis), and 100% (cholangitis and pancreatitis).

CONCLUSION

The degree of decline in liver test levels is inversely related to the yield of cholangiography in symptomatic choledocholithiasis; the yield of ERCP in these patients (with normalized liver tests) is low and they do not require ERCP. Pre-ERCP estimates of the likelihood of choledocholithiasis can be made on the basis of the pattern of liver tests, and biliary pancreatitis patients with normalized liver tests do not require ERCP.

Morbidity and mortality of laparoscopic cholecystectomy in an institutional setup

Laparoscopic cholecystectomy (LC) though a very safe operative procedure does have its own morbidity and mortality. The present study was undertaken to analyze the morbidity and mortality of this procedure in an institutional setting. Between October 1992 and October 1995 a total of 433 patients received LC. Conversion to open cholecystectomy was required in 62 patients (14.3%). The decision to convert was made because the surgeon was forced to convert (3.7%) or the conversion was the operator's choice (10.6%). There was no difference in the conversion rate of consultants versus residents (14.4% vs. 14.2%). Major intraoperative and postoperative morbidity was encountered in 8.3% of patients. One patient required reexploration. The incidence of common bile duct (CBD) injury was 2.5%. There was no operative or 30 days mortality. However, two patients died in the follow-up period due to procedure-related complications. Low threshold for conversion, early recognition of morbidity, and prompt and judicious management of such complications under guided supervision is necessary in order to avoid major postoperative problems. The experience in a teaching hospital training program is different from that of an individual surgical setup.

Predictors of common bile duct stones prior to cholecystectomy: a meta-analysis

BACKGROUND

The decision of whether or not to investigate for common bile duct stones before cholecystectomy utilizes clinical, laboratory, and radiologic information (indicators). There is tremendous individual variation among clinicians in the criteria used for making this decision. Our aim was to perform a meta-analysis of published data to estimate the performance characteristics of the most commonly used preoperative indicators of common bile duct stones.

METHODS

Using predetermined exclusion criteria, we selected articles from a MEDLINE search and bibliographic review. Weighted averages were used to determine summary sensitivity, specificity, and positive and negative likelihood ratios for each indicator for stones.

RESULTS

From 2221 citations identified, 22 studies met inclusion criteria. The 10 indicators examined were reported in a common fashion in three or more articles, and could be assessed preoperatively. Seven exhibited a specificity greater than 90%. Indicators with positive likelihood ratios of 10 or above were cholangitis, preoperative jaundice, and ultrasound evidence of common bile duct stones. Positive likelihood ratios for dilated common bile duct on ultrasound, hyperbilirubinemia, and jaundice ranged from almost 4 to almost 7. Elevated levels of alkaline phosphatase, pancreatitis, cholecystitis, and hyperamylasemia exhibited positive likelihood ratios of less than 3.

CONCLUSIONS

This meta-analysis has identified indicators for duct stones and ranked them according to likelihood ratios. These findings can be applied as guidelines for whether to investigate for duct stones before cholecystectomy.

Sequential intraluminal endoscopic and laparoscopic treatment for bile duct stones associated with gallstones

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 interfering with LC.

Routine preoperative infusion cholangiography at elective cholecystectomy: a prospective study in 694 patients

The role of preoperative infusion cholangiography (PIC) before elective cholecystectomy has yet to be defined. Between 1985 and 1991 PIC was performed routinely in 694 patients with median (range) age of 52 (17-85) years with biliary calculus disease 1 or 4 days before elective cholecystectomy. Satisfactory opacification of the biliary system was achieved in 90.1 per cent and mild to moderate adverse reactions to the infusion of contrast medium occurred in 0.9 per cent of patients. Peroperative cholangiography (POC) in 43 of 499 patients with a normal PIC was normal. The presence of common bile duct stones was confirmed in 34 of 36 patients with prominent stones at bile duct exploration and in 8 of 26 with suspected stones at PIC. Bile duct dilatation (median diameter 10 mm) without concomitant stones was seen at PIC and confirmed at POC in 20 patients. Bile duct anomalies were found or suspected in 35 patients at PIC and were confirmed in six by POC (n = 5), or during the cholecystectomy making the anomaly incidence 0.9 per cent. Information provided by the PIC was not of crucial importance for safe execution of cholecystectomy in any patient, while a single (minor) bile duct lesion (1 of 694; 0.1 per cent) could be ascribed to severe pericholecystitis. The results of this study suggest that routine PIC is not warranted. However, PIC is an alternative to selective preoperative endoscopic retrograde cholangiography or selective POC. PIC needs to be supported by POC in approximately 20 per cent of patients (in case of absent or poor opacification of the bile ducts or suspicion of stones or anomalies at PIC).

The role of endoscopic retrograde cholangiopancreatography and cholangiography in the laparoscopic era

OBJECTIVE

The authors reviewed the results of endoscopic retrograde cholangiopancreatography (ERCP) and intraoperative cholangiography in a series of patients who underwent laparoscopic cholecystectomy.

SUMMARY BACKGROUND DATA

The indications for preoperative and postoperative ERCP and intraoperative cholangiography as adjuncts to laparoscopic cholecystectomy are evolving. The debate regarding the use of selective or routine intraoperative cholangiography has intensified with the advent of laparoscopic cholecystectomy.

METHODS

The authors reviewed the records of 343 consecutive patients who underwent laparoscopic cholecystectomy during a 1-year period. Historical, biochemical, and radiologic findings for the patients who underwent ERCP and intraoperative cholangiography were analyzed.

RESULTS

Three hundred forty- three patients underwent laparoscopic cholecystectomy during the period reviewed. Preoperative ERCP was performed in 42 patients. Twenty-seven of these patients (64%) had common bile duct (CBD) stones, which were cleared with a sphincterotomy. Intraoperative cholangiography was performed for 101 patients (29%). Three cholangiograms had false- positive results (3%), leading to two CBD explorations, in which no CBD stones were found, and one normal ERCP. Six patients underwent postoperative ERCP, three for the removal of retained CBD stones (0.9%), all of which were cleared with a sphincterotomy. Fifteen patients had gallstone pancreatitis, six of whom had CBD stones (40%) that were cleared by ERCP. There were 33 complications (10%) and no CBD injuries.

CONCLUSION

The use of routine intraoperative cholangiography is discouraged in view of its low yield and the significant rate of false positive cholangiogram results.

Managing gallbladder disease in a cost-effective manner

The advent of laparoscopic cholecystectomy has resulted in an increase in total health care costs for gallstone disease despite a reduced unit cost for the procedure. The total number of cholecystectomies performed annually has increased, reflecting an alteration in referral patterns and threshold for surgery in these patients. Cost-effective management of gallstones is possible by adopting strategies to limit length of stay, with discharge possible on the day of surgery for many patients. Selective cholangiography, laparoscopic common bile duct exploration, and judicious postoperative use of ERCP also have a role in cost-effective gallstone treatment. Institutions must analyze all costs and patterns of use to make informed decisions about reusable and disposable instrumentation.

Results of a change to routine fluorocholangiography during laparoscopic cholecystectomy

BACKGROUND

Early in our experience with laparoscopic cholecystectomy (LC), intraoperative cholangiography (IOC) was performed selectively with static imaging techniques. We subsequently changed to routine digital fluorocholangiography (FIOC) and evaluated the results of this strategy.

METHODS

In a consecutive series of 356 LCs, 11 patients (3%) were converted to open cholecystectomy. In the remaining 345 patients FIOC was attempted in 336 patients (97%) and was successfully completed in 328 patients (95%). Results of IOC and outcomes were compared prospectively in patients without indications for IOC (group I, n = 185) with those with criteria for selective IOC (group 2, n = 160) and retrospectively with patients without indications for IOC undergoing static IOC (group 3, n = 56).

RESULTS

Time to perform FIOC was less than for static IOC (14 +/- 1 versus 24 +/- 1 minutes, p < 0.001). Aberrant ductal anatomy was appreciated by using FIOC in 11% but affected operative management in only 3% of patients. Choledocholithiasis was detected in 23 patients (7%) undergoing FIOC; only two of these patients with stones were in Group 1. Duct stones discovered by IOC were cleared laparoscopically in 89% of those attempted (73% of all patients). Neither morbidity nor duct injury caused by FIOC was noted.

CONCLUSIONS

FIOC is much more rapid to perform than static IOC. Digital fluoroscopy is accurate and safe and permits rapid evaluation and management of bile duct stones. Selective use of FIOC efficiently assesses the common duct in the era of LC.

Prospective evaluation of ultrasonography and liver function tests for preoperative assessment of the bile duct

Current means of predicting the presence of bile duct stones are sensitive but produce a large number of false-positive results, potentially leading to added morbidity from unnecessary invasive investigation. This study prospectively assessed 545 patients with gallbladder stones, including 55 patients with bile duct stones, to refine criteria for further investigation of the bile duct. The sensitivity, specificity, and positive and negative predictive values were calculated for bile duct dilatation (diameter abnormal if larger than 5 mm below age 50 years, normal value increasing by 1 mm per decade) and elevation of three liver function tests, singly or in combination. Depending on the number of abnormalities used the sensitivity ranged from 46 to 96 per cent and the positive predictive value from 35 to 77 per cent. All groupings gave at least 96 per cent negative predictive value for the absence of stones but none combined both high sensitivity and positive predictive value. The specificity was improved if the tests were done on the working day before operation. Refining criteria for predicting bile duct stones allows the selective use of cholangiography and may reduce the number of negative cholangiograms.