Surgical versus endoscopic treatment of bile duct stones

Evidence-based clinical practice guidelines for cholelithiasis 2021

The Japanese Society of Gastroenterology first published evidence-based clinical practice guidelines for cholelithiasis in 2010, followed by a revision in 2016. Currently, the revised third edition was published to reflect recent evidence on the diagnosis, treatment, and prognosis of cholelithiasis conforming to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Following this revision, the present English version of the guidelines was updated and published herein. The clinical questions (CQ) in the previous version were reviewed and rearranged into three newly divided categories: background questions (BQ) dealing with basic background knowledge, CQ, and future research questions (FRQ), which refer to issues that require further accumulation of evidence. Finally, 52 questions (29 BQs, 19 CQs, and 4 FRQs) were adopted to cover the epidemiology, pathogenesis, diagnosis, treatment, complications, and prognosis. Based on a literature search using MEDLINE, Cochrane Library, and Igaku Chuo Zasshi databases for the period between 1983 and August 2019, along with a manual search of new information reported over the past 5 years, the level of evidence was evaluated for each CQ. The strengths of recommendations were determined using the Delphi method by the committee members considering the body of evidence, including benefits and harms, patient preference, and cost-benefit balance. A comprehensive flowchart was prepared for the diagnosis and treatment of gallbladder stones, common bile duct stones, and intrahepatic stones, respectively. The current revised guidelines are expected to be of great assistance to gastroenterologists and general physicians in making decisions on contemporary clinical management for cholelithiasis patients.

The short- and long-term outcome after the surgical management of common bile duct stones in a tertiary referral hospital

BACKGROUND

The removal of common bile duct stones by endoscopic retrograde cholangiopancreatography (ERCP) shows excellent results with low complication rates and is therefore considered a gold standard. However, in case of stones non-removable by ERCP, surgical extraction is needed. The surgical approach is still controversial and clinical guidelines are missing. This study aims to analyze the outcomes of patients treated with choledochotomy or hepaticojejunostomy for common bile duct stones.

METHODS

All patients who underwent choledochotomy or hepaticojejunostomy for common bile duct stones at a tertiary referral hospital over 11 years were included. The analyzed data contains basic demographics, diagnostics, surgical parameters, length of hospitalization, and morbidity and mortality.

RESULTS

Over the study period, 4375 patients underwent cholecystectomy, and 655 received an ERCP with stone extraction, with 48 of these patients receiving subsequent surgical treatment. ERCP was attempted in 23/30 (77%) of the choledochotomy patients pre/intraoperatively and 11/18 (56%) in hepaticojejunostomy patients. The 30-day major complication rate (Clavien-Dindo > II) was 1/30 (3%) in the choledochotomy group and 2/18 (11%) in the hepaticojejunostomy group. Complications after 30 days occurred in 3/30 (10%) patients and 2/18 (11%), respectively, and no mortality occurred.

CONCLUSION

ERCP should still be considered the gold standard, although due to low short- and long-term morbidity rates, choledochotomy and hepaticojejunostomy represent effective surgical solutions for common bile duct stones.

Near-infrared cholangiography can increase the chance of success in laparoscopic approaches to common bile duct stones, even with previous abdominal surgery

BACKGROUND

The treatment of common bile duct (CBD) stones with minimally invasive surgery (MIS) is more technical demanding than laparoscopic cholecystectomy (LC), especially in patients with history of previous abdominal surgery, cholangitis or cholecystitis. Near-infrared (NIR) cholangiography via systemic or biliary tree administration of indocyanine green (ICG), which enhances the visualization of the biliary tree anatomy, may increase the reassurance of CBD localization. The aim of this study was to identify the benefit of near-infrared cholangiography for laparoscopic common bile duct exploration (LCBDE).

METHODS

Three groups of CBD stone patients were included in this retrospective study depending on the surgical methods: 1) open choledocholithotomy (OCC), 2) laparoscopic choledocholithotomy (LCC), and 3) near-infrared cholangiography-assisted laparoscopic choledocholithotomy (NIR-CC). For the NIR-CC group, either 3 ml (concentration: 2.5 mg/mL) of ICG were intravenously administered or 10 ml (concentration: 0.125 mg/mL) of ICG were injected directly into the biliary tree. The enhancement rate of the cystic duct (CD), CBD, the upper and lower margin of the CBD were compared using white light image.

RESULTS

A total of 187 patients with a mean age of 68.3 years were included (OCC, n = 56; LCC, n = 110; NIR-CC, n = 21). The rate of previous abdominal surgery was significantly lower in the LCC group. The conversion rate was similar between the LCC and the NIR CC groups (p = 0.746). The postoperative hospital stay was significantly longer in the OCC group. No differences in morbidity and mortality were found between the three groups. In the NIR-CC group, the localization of CBD was as high as 85% compared to 24% with white light imaging.

CONCLUSIONS

Near-infrared cholangiography helps increase the chance of success in minimally invasive approaches to CBD stones even in patients with previous abdominal surgeries, without increasing the rate of conversion.

Observation versus intervention for incidental common bile duct stones at intraoperative cholangiogram: a systematic review

BACKGROUND

The natural history of incidental common bile duct stones (CBDS) is poorly understood. Current evidence is conflicting, with several studies suggesting the majority may pass spontaneously. Despite this, guidelines recommend routine removal even if asymptomatic. This study aimed to systematically review the outcomes of expectant management for CBDS detected on operative cholangiography during cholecystectomy.

METHODS

MEDLINE, Embase and CINAHL databases were systematically searched. Participants were adult patients with CBDS identified by intraoperative cholangiography. Intervention was regarded as any perioperative effort to remove common bile duct stones, including endoscopic retrograde cholangiopancreatography (ERCP), laparoscopic and open bile duct exploration. This was compared to observation. Outcomes of interest included rates of spontaneous stone passage, success of duct clearance and complications. Risk of bias was assessed using the ROBINS-I tool.

RESULTS

Eight studies were included. All studies were non-randomized, heterogeneous and at serious risk of bias. In patients observed after a positive IOC, 20.9% went on to have symptomatic retained stones. In patients directed to ERCP for positive IOC, persistent CBDS were found in 50.6%. Spontaneous passage was not associated with stone size. Meta-analysis is dominated by the results from one large database, which recommends intervention for incidental stones, despite low rates of persistent stones seen at postoperative ERCP.

CONCLUSIONS

Further evidence is required before a definitive recommendation on observation can be made. There is some evidence that asymptomatic stones may be safely observed. In clinical scenarios where the risks of biliary intervention are considered high, a conservative strategy could be more widely considered.

The Association of Polish Surgeons (APS) clinical guidelines for the use of laparoscopy in the management of abdominal emergencies. Part I

Introduction

Over the past three decades, almost every type of abdominal surgery has been performed and refined using the laparoscopic technique. Surgeons are applying it for more procedures, which not so long ago were performed only in the classical way. The position of laparoscopic surgery is therefore well established, and in many operations it is currently the recommended and dominant method.

Aim

The aim of the preparation of these guidelines was to concisely summarize the current knowledge on laparoscopy in acute abdominal diseases for the purposes of the continuous training of surgeons and to create a reference for opinions.

Material and methods

The development of these recommendations is based on a review of the available literature from the PubMed, Medline, EMBASE and Cochrane Library databases from 1985 to 2022, with particular emphasis on systematic reviews and clinical recommendations of recognized scientific societies. Recommendations were formulated in a directive form and evaluated by a group of experts using the Delphi method.

Results and conclusions

There are 63 recommendations divided into 12 sections: diagnostic laparoscopy, perforated ulcer, acute pancreatitis, incarcerated hernia, acute cholecystitis, acute appendicitis, acute mesenteric ischemia, abdominal trauma, bowel obstruction, diverticulitis, laparoscopy in pregnancy, and postoperative complications requiring emergency surgery. Each recommendation was supported by scientific evidence and supplemented with expert comments. The guidelines were created on the initiative of the Videosurgery Chapter of the Association of Polish Surgeons and are recommended by the national consultant in the field of general surgery. The first part of the guidelines covers 5 sections and the following challenges for surgical practice: diagnostic laparoscopy, perforated ulcer, acute pancreatitis, incarcerated hernia and acute cholecystitis. Contraindications for laparoscopy and the ERAS program are discussed.

Role of choledochotomy after mechanical lithotripsy-related adverse event in endoscopic retrograde cholangiopancreatography

In case of rupture of the mechanical lithotripter's traction wires during an ERCP, we suggest performing a choledochotomy to remove the stone, and remove the closed Dormia basket through the mouth.

Learning Curve of Laparoscopic Common Bile Duct Exploration: A Systematic Review

Background: Single-stage laparoscopic common bile duct exploration (LCBDE) with cholecystectomy has superior outcomes over two-stage endoscopic retrograde cholangiopancreatogram with interval cholecystectomy. With decreasing trend of LCBDE, this study aims to summarize the literature on learning curve (LC) in LCBDE. Materials and Methods: PubMed, Embase, Scopus, and the Cochrane Library were systematically searched for articles from inception to June 3, 2022 (PROSPERO Ref No: CRD42022328451). Basic clinical demographics were collected. Poisson means (95% confidence interval [95% CI]) was used to determine the number of cases required to surmount the LC (N_LC). Results: Eight articles (n = 2071 patients) reported LC outcomes in LCBDE with mean study period of 5.9 ± 2.8 years. Majority of studies (62.5%) used arbitrary methods of LC analysis. Most common outcomes reported were complications (any or major) (75%), open conversion (75%), length of stay (62.5%), and operating time (50%). Mean CBD diameter was 11.3 ± 4.8 mm (n = 1122 patients). Incidence of acute cholecystitis, acute cholangitis, and acute pancreatitis were 13.9% (n = 232/1668), 7.8% (n = 128/1629), and 13.7% (n = 229/1668), respectively. Pooled analysis of all the included studies showed N_LC of 78.8 cases (95% CI: 71.9-86.3). Studies that used cumulative sum control chart analysis, nonarbitrary methods, and arbitrary-based LC had N_LC of 152.0 (95% CI: 135.4-170.1), 108.0 (95% CI: 96.6-120.4), and 49.7 (95% CI: 42.0-58.3) cases, respectively. N_LC was 37.0 cases (95% CI: 29.1-46.5) for single surgeon LC, and 99.8 cases (95% CI: 90.2-110.0) for institutional LC. Conclusion: Studies reporting N_LC in LCBDE are heterogeneous. Further studies should use nonarbitrary methods of analysis for patient-reported outcome measures and procedure-specific morbidity.

Comparison between Comprehensive Complication Index (CCI®) and Clavien-Dindo Classification for laparoscopic single-stage treatment of choledocholithiasis with concomitant cholelithiasis

PURPOSE

The Clavien-Dindo Classification (CDC) and the Comprehensive Complication Index (CCI®) are both widely used methods for reporting postoperative complications. Several studies have compared the CCI® with the CDC in evaluating postoperative complications of major abdominal surgery. However, there are no published reports comparing both indexes in single-stage laparoscopic common bile duct exploration with cholecystectomy (LCBDE) for the treatment of common bile duct stones. This study aimed to compare the accuracy of the CCI® and the CDC in evaluating the complications of LCBDE.

METHODS

In total, 249 patients were included. Spearman's rank test was used to calculate the correlation coefficient between CCI® and CDC with length of postoperative stay (LOS), reoperation, readmission, and mortality rates. Student t-test and Fisher's exact test were used to study, if higher ASA, age, larger surgical time, history of previous abdominal surgery, preoperative ERCP, and intraoperative cholangitis finding were associated with higher CDC grade or higher CCI® score.

RESULTS

Mean CCI® was 5.17 ± 12.8. CCI® ranges overlap among three CDC grades: II (20.90-36.20), IIIa (26.20-34.60), and IIIb (33.70-52.10). Age > 60 years, ASA ≥ III, and intraoperative cholangitis finding were associated with higher CCI® (p = 0.010, p = 0.044, and p = 0.031) but not with CDC ≥ IIIa (p = 0.158, p = 0.209, and p = 0.062). In patients with complications, LOS presented a significantly higher correlation with CCI® than with CDC (p = 0.044).

CONCLUSION

In LCBDE, the CCI® assesses better the magnitude of postoperative complications in patients older than 60 years, with a high ASA as well as in those who present intraoperative cholangitis. In addition, the CCI® correlates better with LOS in patients with complications.

Comparison of one-step laparoscopy and two-step endolaparoscopy in the treatment of secondary choledocholithiasis: A multicenter retrospective clinical study

BACKGROUND

There are two minimally invasive ways of treating cholecystolithiasis combined with choledocholithiasis, but there remains some controversy regarding which technique is better, since they both have advantages and disadvantages. The one-step method involves laparoscopic cholecystectomy, laparoscopic common bile duct exploration, and primary close (LC + LCBDE + PC), while the two-step procedure consists of endoscopic retrograde cholangiopancreatography, endoscopic sphincterotomy, and laparoscopic cholecystectomy (ERCP + EST + LC).

OBJECTIVE

This multicenter retrospective study aimed to analyze and compare the effects of the two techniques.

METHODS

The data of patients who underwent either one-step LCBDE + LC + PC or two-step ERCP + EST + LC treatment for gallstones in the gallbladder and bile duct at the Shanghai Tenth People's Hospital, Shanghai Tongren Hospital, and Taizhou Fourth People's Hospital between January 1, 2015 and December 31, 2019 were collected, and the preoperative indicators of the two groups were compared.

RESULTS

The surgical success rate of the one-step laparoscopic group was 96.23% (664/690), the transit abdominal opening rate was 2.03% (14/690), and there were 21 cases of postoperative bile leakage. The success rate of the two-step endolaparoscopic surgery was 78.95% (225/285), the transit opening rate was 2.46% (7/285), and there were 43 postoperative cases of pancreatitis and five of cholangitis. Postoperative cholangitis, pancreatitis, postoperative stone recurrence, postoperative hospitalization, and treatment costs were significantly lower (P< 0.05) in the one-step laparoscopic group than in the two-step endolaparoscopic group. However, the amount of intraoperative bleeding, the postoperative extraction time of the abdominal drainage tube, and the incidence of bile leakage were higher (P< 0.05) in the one-step laparoscopic group than in the two-step endolaparoscopic group.

CONCLUSION

The two methods of treating choledocholithiasis combined with choledocholithiasis that were analyzed in this study were safe and effective, and each method had its own advantages.

Index admission vs elective laparoscopic common bile duct exploration: a district general hospital experience over 6 years

BACKGROUND

Laparoscopic common bile duct exploration (LCBDE) is relatively a new approach for clearing choledocholithiasis. The aim of this study is to assess the safety of this approach to clearing common bile duct (CBD) stones on an index admission including emergency setting.

METHODS

Retrospective data collection and analysis were carried out for 207 consecutive cases of LCBDE performed in Royal Cornwall Hospital over 6 years (2015-2020). Patients were divided into two groups (Index admission vs elective) then both groups compared.

RESULTS

A total of 207 cases of LCBDE were performed in our unit during the time period. One hundred twenty-two operations were performed on the index admission and 85 on a subsequent elective list. Mean operative time was 146 ± 64 min in the index admission group and 145 ± 65 min in the elective group (p = 0.913). Length of stay post-operatively was 3.3 ± 6.3 days in the index admission cases and 3.5 ± 4.6 days after elective cases. Successful clearance was achieved at the end of the operation in 116 patients in the index admission group, clearance failed in one case and negative exploration in 5 patients. In the elective group 83 patients had a successful clearance at the end of the operation, and 2 patients has had a negative exploration. Twelve patients (index admission group) and 8 patients of the elective cases required post-operative Endoscopic Retrograde Cholangiopancreatography (ERCP) to manage retained stones, recurrent stones and bile leak (p = 0.921). Three patients required re-operation for post-operative complications in each group.

CONCLUSION

Common bile duct exploration in index admission is safe with high success rate if performed by well-trained surgeons with advanced laparoscopic skills.

Laparoscopic choledochoscopy for choledocholithiasis is possible in the anatomical anomaly of left gallbladder

Laparoscopic cholecystectomy (LC) is more challenging in the anatomical variation of left-sided gallbladder with the anomaly also highly related to biliary anomalies. Therefore, there has been a reluctance to operate close to the common bile duct (CBD) in left gallbladder patients, and thus choledocholithiasis is usually treated with endoscopic retrograde cholangiopancreatography (ERCP). There is emerging evidence that single stage LC and CBD exploration for choledocholithiasis may be superior to two stage LC and ERCP in terms of short-term and long-term morbidity, cost and length of stay. With the re-emergence of laparoscopic choledochoscopy, the purpose of this case report is to demonstrate the feasibility of this approach for choledocholithiasis.

Laparoscopic Common Bile Duct Exploration Using a Disposable Bronchoscope

Laparoscopic common bile duct exploration (LCBDE) remains underutilized in the management of common bile duct (CBD) stones. The exact cause of this under-utilization remains unclear; however, identified barriers to LCBDE implementation include lack of training and unavailability of dedicated instruments. LCBDE is an attractive alternative for stone retrieval in patients with Roux-en-Y gastric bypass given the anatomical difficulty in endoscopic retrograde cholangiopaneatography (ERCP). Direct visualization through choledochoscopy is the method of choice for LCBDE. However, dedicated choledoscopes are expensive and not widely available, which may lead surgeons to seek for alternatives at their particular environment. With the COVID-19 pandemic, disposable bronchoscopes have become widely accessible at our institution, raising the possibility of using one for direct vision of the biliary tract. We present the case of a 61-year-old male with past medical history of Roux-en-Y gastric bypass, who presented to the emergency department with a CBD stone. Successful LCBDE was achieved with the aid of a disposable bronchoscope for direct visualization of the biliary tract.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12262-022-03642-7.

Dual Balloon Catheter: A Novel Laparoscopic Common Bile Duct Exploration Device

Introduction: Choledocholithiasis is a disease process that can be managed by laparoscopic common bile duct exploration at the time of cholecystectomy. However, it can be negatively perceived by surgeons as lengthening procedure time and adding technical complexity. Materials and Methods: We have created a dual balloon biliary intervention catheter designed to make common duct exploration efficient, simple, and safe. The device consists of two balloons, one compliant and one noncompliant, to perform initial cholangiography, dilate the sphincter, and occlude the proximal duct for distal power flushing of stones. The catheter design facilitates a stepwise, over the wire progression of interventions with a singular device. Results: The catheter has been successfully deployed in a porcine feasibility model and the dual balloon concepts reduced to practice using currently available devices. Conclusion: Laparoscopic common bile duct exploration is a safe and effective way to treat choledocolithiasis. The Dual Balloon Catheter is a novel device that allows for duct occlusion for cholangiogram and power flushing in conjunction with duct and sphincter dilation.

Primary closure combined with C-tube drainage through cystic duct after laparoscopic common bile duct exploration is safe and feasible for patients

OBJECTIVE

Biliary duct management is of great significance after laparoscopic cholecystectomy (LC) combined with laparoscopic common bile duct exploration (LCBDE) in the treatment of cholecystolithiasis accompanied with common bile duct (CBD) stones. This study is to evaluate the safety and effectiveness of primary closure with C-tube drainage through cystic duct after LC + LCBDE.

METHODS

Through a retrospective study, 290 patients who underwent LC + LCBDE in our hospital from January 2019 to April 2022 were enrolled and divided into 2 groups. 143 patients underwent primary closure with C-tube drainage through cystic duct (C-tube group) and the other 147 patients underwent traditional T-tube drainage (T-tube group). Personal information, perioperative examinations, surgical results, and follow-up results were collected and analyzed.

RESULTS

There were no significant differences in the average age, gender, the mean of CBD diameters and the rate of comorbidities (acute cholecystitis, obstructive jaundice, acute pancreatitis and acute cholangitis) between the two groups (P > 0.05). Hospital stay, postoperative hospital stay were significantly shorter in the C-tube group than T-tube group (P < 0.05). In addition, the average time of placing and removal the drainage tubes was significantly less than those of the T-tube group (P < 0.05). This study also showed significant differences in the incidence of postoperative abdominal infection and soft tissue infection in the two groups (P < 0.05). There were no significant differences in the incidence of postoperative complications including cholangitis, bile duct stenosis, mortality in two groups. There were also no significant differences between the two groups of the recurrence of CBD stones, reoperation and readmition in 30 days during the median follow-up of 6 months.

CONCLUSIONS

Compared with T tube drainage, patients with C-tube drainage after LC + LCBDE with primary closure of cystic duct recovered faster and had fewer complications. C-tube drainage is a safe and feasible treatment option for patients with cholecystolithiasis and choledocholithiasis.

Outcomes following balloon sphincteroplasty as an adjunct to laparoscopic common bile duct exploration

BACKGROUND

Laparoscopic common bile duct exploration (LCBDE) at the time of cholecystectomy is an efficient pathway for management of choledocholithiasis. Performing this safely under one anesthetic offers advantages over a two-step process with cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP). Despite the proven efficacy of LCBDE, endoscopy continues to be predominantly utilized. Simplifying the intervention may drive LCBDE adoption. To this end, we refined a stepwise intraoperative pathway that utilizes over the wire balloon catheters to dilate the Sphincter of Oddi to facilitate stone passage into the duodenum. To determine the efficacy during the initial adoption phase on a general surgery service, we reviewed our experience with LCBDE balloon sphincteroplasty as part of this pathway.

METHODS

We retrospectively reviewed the records of patients who underwent LCBDE with balloon sphincteroplasty at a single tertiary care center over a three-year period. Preoperative demographics, imaging/laboratory results, intra and postoperative outcomes were reviewed.

RESULTS

Choledocholithiasis was managed with transcystic balloon sphincteroplasty during LCBDE in 28 cases over a three-year period. The cohort included 16 women and 12 men with a mean age of 47 years (range = 19-89). Operative indications included cholecystitis (n = 11, 39%), choledocholithiasis (n = 13, 47%), cholelithiasis (n = 2, 7%), and gallstone pancreatitis (n = 2, 7%). The stones were successfully cleared by the balloon sphincteroplasty technique in 75% of the cases. The average fluoroscopy time during LCBDE was 338 s (± 214). The average operating room time was 173 min (± 35). Mean length of stay was 58 h (± 46). There were no intra- or postoperative complications.

CONCLUSION

Wire ready cholangiography followed by balloon sphincteroplasty with saline/contrast flush is a simple and safe way to clear the common bile duct. This technique is a gateway for further expansion and adoption of LCBDE.

Evaluation of therapeutic efficacy, safety and economy of ERCP and LTCBDE in the treatment of common bile duct stones

Objectives: This study further compared the endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic transcystic common bile duct exploration (LTCBDE) approaches in the treatment of common bile duct stones (CBDS) from the perspective of efficacy, safety and economy.

Methods: The therapeutic efficacy and safety of ERCP and LTCBDE approaches were retrospectively compared. Cost-effectiveness analysis of clinical economics was performed to analyze and evaluate the two approaches.

Results: There was no significant difference in the success rate of surgery and bile stone residue between ERCP and LTCBDE group. The incidence of postoperative complications in ERCP group was significantly higher than that in the LTCBDE group; while the incidence of pancreatitis in the ERCP group was significantly higher than that in the LTCBDE group. There was no significant difference in biliary infection, bile leakage and sepsis between ERCP and LTCBDE groups. In terms of cost, the costs of surgery and nursing were significantly lower, the costs of treatment and sanitary materials were significantly higher in the ERCP group than that in the LTCBDE group. There was no significant difference in the costs of medical examination, laboratory test, medicine cost and total cost between ERCP group and LTCBDE group. The total length of hospital stay, length of hospital stay before surgery and duration of surgery in the ERCP group were significantly lower than that in the LTCBDE group; there was no significant difference in length of hospital stay after surgery between the ERCP and LTCBDE group. The cost-effectiveness ratio of ERCP group was 34171.25, and the cost-effectiveness of LTCBDE group was 34524.25. The incremental cost-effectiveness ratio (ICER) of the two groups was 51415.

Conclusion: ERCP and LTCBDE approaches had similar therapeutic efficacy in the treatment of CBDS. The safety of LTCBDE approach is superior to that of ERCP approach for the treatment of CBDS. ERCP approach is more economical in the treatment of CBDS than LTCBDE approach.

Multimodal treatments of “gallstone cholangiopancreatitis”

Gallstone cholangiopancreatitis is a potentially life-threatening pathology which requires quick intervention involving endoscopists, interventional radiologists, anesthesiologists and surgeons in relation to clinical conditions. Treatment possibilities are varied, especially with current progress in advanced endoscopy, interventional radiology, and minimally invasive surgery. The following treatments are available: endoscopic sphincterotomy (ES) with stone extraction followed by laparoscopic cholecystectomy; simultaneous endoscopic stone extraction with laparoscopic cholecystectomy (rendezvous technique); combined laparoscopic cholecystectomy and common bile duct (CBD) exploration; open CBD exploration; ES post-cholecystectomy; percutaneous placement of biliary drains for unstable patients, followed by percutaneous cholangioscopy; and lithotripsy with different approaches, including a laser and balloon dilation of the sphincter of Oddi. Each technique has its strengths and weaknesses, and there is great discussion in the literature on choosing the ideal approach based on the patient’s clinical conditions.

[Evidence-based medicine of gallstone disease regarding development of national clinical guidelines]

OBJECTIVE

To study the Cochrane evidence base of systematic reviews and meta-analyses regarding development of national guidelines for surgical treatment of gallstone disease and its complications.

MATERIAL AND METHODS

We analyzed the original database involving 35 systematic reviews and meta-analyses of Cochrane Library devoted to gallstone disease and its complications. Methodology of electronic and manual searching of trials was used for identification and screening of information for the period until October 2021.

RESULTS

There were 430 randomized controlled trials from different countries estimated in 35 systematic reviews of Cochrane Library. At the same time, Russian-language researches are not included in the world's evidence database of biliary tract surgery. Expert groups couldn't perform meta-analysis and limited to systematic-review in 6 (17%) publications because of insufficient statistical power or primary researches. Need for further research of this issue was determined after assessment of 26 (74%) meta-analyses.

CONCLUSION

We have to convey foreign experience as subbase of national clinical guidelines taking into account deficiency of scientific trials with high level of evidence in our country. Need for further evidence trials, considering the peculiarities of surgical care in the Russian Federation, is determined by unsolved issues of treatment of gallstone disease and its complications.

Factors related to the spontaneous passage of common bile duct stones through the papilla: a single-center retrospective cohort study

OBJECTIVE

Common bile duct (CBD) stones can spontaneously pass through the papilla. This study explored factors associated with stone passage by comparing differences in the clinical features of stones retained in the CBD and excreted stones.

METHODS

Data were retrospectively collected for all patients who were hospitalized in our center between March 2016 and May 2021 with clinical, laboratory, or imaging evidence of CBD stones. All patients underwent endoscopic retrograde cholangiopancreatography (ERCP) and were classified into two groups: group A (stones extracted by ERCP, n = 86) and group B (stones discharged before ERCP, n = 15). Demographic data, biochemical and radiological findings were compared between the groups.

RESULTS

Stone size (0.82 vs. 0.33 cm), and levels of total bilirubin (58.2 vs. 28.8 μmol/L), gamma-glutamyl transpeptidase (416.7 vs. 193.9 U/L), alkaline phosphatase (191.9 vs. 123.1 U/L), carbohydrate antigen 19-9 (603.7 vs. 37.2 U/mL), and α-L-fucosidase (37.4 vs. 22.6 U/L) were significantly higher in group A than in group B. Logistic regression analyses showed that stone size was the only factor significantly associated with spontaneous passage of CBD stones.

CONCLUSIONS

CBD stones less than 0.33 cm in size may be self-expelled through the papilla.

Beyond acute cholecystitis-gallstone-related complications and what the emergency radiologist should know

The purpose of this study is to emphasize the imaging features of complications of gallstones beyond the cystic duct on ultrasound (US), enhanced and nonenhanced computed tomography (CECT and NECT), magnetic resonance imaging (MRI), magnetic resonance cholangiopancreatography (MRCP), and endoscopic retrograde cholangiopancreatography (ERCP). This article includes a brief overview of gallstone imaging and emerging trends in the detection of gallstones. This review article will highlight complications of gallstones, including choledocholithiasis, gallstone pancreatitis, acute cholangitis, Mirizzi syndrome, cholecystobiliary and cholecystoenteric fistulas, and gallstone ileus. Imaging findings and limitations of US, CT, MRI, and ERCP will be discussed. The review article will also briefly discuss the management of each disease. The presence of gallstones beyond the level of the cystic duct can lead to a spectrum of diseases, and emergency radiologists play a critical role in disease management by providing a timely diagnosis. Documenting the location of a gallstone within the common bile duct (CBD) in symptomatic cholelithiasis and the presence of acute interstitial edematous pancreatitis and/or ascending cholangitis plays a pivotal role in disease management. Establishing the presence of ectopic gallstones and biliary-enteric fistulae has a significant role in directing patient management.

Surgical methods of treatment for cholecystolithiasis combined with choledocholithiasis: six years' experience of a single institution

INTRODUCTION

The optimal treatment of choledocholithiasis combined with cholecystolithiasis remains controversial. Common surgical methods vary among endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC), laparoscopic transcystic common bile duct exploration (LTCBDE), laparoscopic transductal common bile duct exploration (LCBDE) with or without T-tube drainage. The purpose of this study is to evaluate the safety and effectiveness of surgical methods and to determine the appropriate procedure for patients with cholecystolithiasis combined with choledocholithiasis.

METHODS

From January 2013 to January 2019, a total of 1555 consecutive patients diagnosed with cholecystolithiasis combined with choledocholithiasis who underwent surgical treatment in Tongji Hospital were retrospectively analyzed. Total 521 patients with intrahepatic bile duct stones underwent LC + LCBDE + T-Tube were excluded from the analysis. At last, 1034 patients who met the inclusion criteria were divided into three groups according to their surgical methods: preoperative ERCP + subsequent LC (ERCP + LC group, n = 275), LC + LCBDE + intraoperative endoscopic nasobiliary drainage (ENBD) + primary duct closure (Tri-scope group, n = 479) and LC + laparoscopic transcystic CBD exploration (LTCBDE group, n = 280). Clinical records, operative findings and postoperative follow-up were collected and analyzed.

RESULTS

There was no mortality in three groups. Common bile duct (CBD) stone clearance rate was 97.5% in ERCP + LC group, 98.7% in Tri-scope group, and 99.3% in LTCBDE group. There were no difference in terms of demographic characteristics, biochemistry findings and presentations, but the Tri-scope group had the biggest diameter and amount of stones and diameter of CBD, the LTCBDE group had the least CBD stones and the biggest diameter of cystic gall duct (CGD). ERCP + LC group have the longest hospital stay (14.16 ± 3.88 days vs 6.92 ± 1.71 days vs 10.74 ± 5.30 days, P < 0.05), also has the longest operative time than others (126.08 ± 42.79 min vs 92.31 ± 10.26 min, 99.09 ± 8.46 min, P < 0.05). Compared to ERCP + LC group, LTCBDE group and Tri-scope group had lower postoperation-leukocyte, shorter surgery duration and hospital stay (P < 0.05). Compared to the Tri-scope group, the LTCBDE group had the shorter hospital stay, extubation time and operation time and less intraoperative bleeding. There were less postoperative complications in LTCBDE group (1.1%) compared to the ERCP + LC group (3.6%) and Tri-scope group (2.2%). Follow-up time was 6 to 72 months. Four patients in ERCP + LC group and 5 in Tri-scope group reported recurrent stones.

CONCLUSION

All the three surgical methods are safe and effective. Tri-scope approach and LTCBDE approach have superiority to preoperative ERCP + LC. LC + LTCBDE shows priority over Tri-scope approach, but should be performed in selected patients. LC + LCBDE + T-Tube can be an alternative management if the other three procedures were failed. The surgeons should choose the most appropriate surgical procedure according to the preoperative examination results and intraoperative situation.

Contemporary management of concomitant gallstones and common bile duct stones: a survey of Spanish surgeons

BACKGROUND

Concomitant gallstones and common bile duct stones (CBDS) is a relatively frequent presentation. The optimal treatment remains controversial and the debate persists between two strategies. The one-stage approach: laparoscopic cholecystectomy with laparoscopic common bile duct exploration (LCBDE) has been shown to be equally safe and more cost-effective than the more traditional two-stage approach: endoscopic retrograde cholangiography followed by laparoscopic cholecystectomy (ERCP + LC). However, many surgeons worldwide still prefer the two-stage procedure. This survey evaluated contemporary management of CBDS in Spain and assessed the impact of surgeon and hospital factors on provision of LCBDE.

METHODS

A 25-item, web-based anonymous survey was sent to general surgeons members of the Spanish Surgeons Association. Descriptive statistics were applied to summarize results.

RESULTS

Responses from 305 surgeons across 173 Spanish hospitals were analyzed. ERCP is the initial approach for preoperatively suspected CBDS for 86% of surgeons. LCBDE is the preferred method for only 11% of surgeons and only 11% treat more than 10 cases per year. For CBDS discovered intraoperatively, 59% of respondents attempt extraction while 32% defer to a postoperative ERCP. The main reasons cited for not performing LCBDE were lack of equipment, training and timely availability of an ERCP proceduralist. Despite these barriers, most surgeons (84%) responded that LCBDE should be implemented in their departments.

CONCLUSIONS

ERCP was the preferred approach for CBDS for the majority of respondents. There remains limited use of LCBDE despite many surgeons indicating it should be implemented. Focused planning and resourcing of both training and operational demands are required to facilitate adoption of LCBDE as option for patients.

Choledocholithiasis-a new clinical pathway

The incidence of cholecystectomy in children has increased considerably since the early 1990s. Management of gallbladder disease in children must include an awareness of choledocholithiasis treatment strategies. Both endoscopic retrograde cholangiopancreatography (ERCP) and common bile duct exploration (open or laparoscopic) are accepted management techniques for choledocholithiasis. Laparoscopic cholecystectomy with preoperative or postoperative ERCP is at least a two-procedure process while cholecystectomy with laparoscopic common bile duct exploration (LCBDE) can provide definitive treatment in a single procedure under one anesthetic. Despite this, the trend over the last decade continues towards less LCBDE utilization in favor of ERCP. This trend has resulted in decreased familiarity with LCBDE by adult and pediatric surgeons and their trainees. Access to the necessary tools and education on the technical aspects can allow for successful single-stage treatment of choledocholithiasis by surgeons during laparoscopic cholecystectomy. This may include a pre-defined stepwise algorithm and understanding of all the equipment and resources necessary to perform a LCBDE. Ultimately, increased understanding of the equipment and procedural steps necessary for LCBDE will result in widened adoption of the technique and thus confer advantages to the patient such as decreased length of stay and fewer required anesthetics.

Management of cholelithiasis with choledocholithiasis: Endoscopic and surgical approaches

Gallstone disease and complications from gallstones are a common clinical problem. The clinical presentation ranges between being asymptomatic and recurrent attacks of biliary pain requiring elective or emergency treatment. Bile duct stones are a frequent condition associated with cholelithiasis. Amidst the total cholecystectomies performed every year for cholelithiasis, the presence of bile duct stones is 5%-15%; another small percentage of these will develop common bile duct stones after intervention. To avoid serious complications that can occur in choledocholithiasis, these stones should be removed. Unfortunately, there is no consensus on the ideal management strategy to perform such. For a long time, a direct open surgical approach to the bile duct was the only unique approach. With the advent of advanced endoscopic, radiologic, and minimally invasive surgical techniques, however, therapeutic choices have increased in number, and the management of this pathological situation has become multidisciplinary. To date, there is agreement on preoperative management and the need to treat cholelithiasis with choledocholithiasis, but a debate still exists on how to cure the two diseases at the same time. In the era of laparoscopy and mini-invasiveness, we can say that therapeutic approaches can be performed in two sessions or in one session. Comparison of these two approaches showed equivalent success rates, postoperative morbidity, stone clearance, mortality, conversion to other procedures, total surgery time, and failure rate, but the one-session treatment is characterized by a shorter hospital stay, and more cost benefits. The aim of this review article is to provide the reader with a general summary of gallbladder stone disease in association with the presence of common bile duct stones by discussing their epidemiology, clinical and diagnostic aspects, and possible treatments and their advantages and limitations.

Innovation of endoscopic management in difficult common bile duct stone in the era of laparoscopic surgery

Common bile duct (CBD) stone is a common biliary problem, which often requires endoscopic approach as the initial treatment option. Roughly, 7%-12% of the subjects who experience cholecystectomy were subsequently referred to biliary endoscopist for further management. In general, there are three classifications of difficult CBD stone, which are based on the characteristics of the stone (larger than 15 mm, barrel or square-shaped stones, and hard consistency), accessibility to papilla related to anatomical variations, and other clinical conditions or comorbidities of the patients. Currently, endoscopic papillary large balloon dilation (EPLBD) of a previous sphincterotomy and EPLBD combined with limited sphincterotomy performed on the same session is still recommended by the European Society of Gastrointestinal Endoscopy as the main approach in difficult CBD stones with history of failed sphincterotomy and balloon and/or basket attempts. If failed extraction is still encountered, mechanical lithotripsy or cholangioscopy-assisted lithotripsy or extracorporeal shockwave lithotripsy can be considered. Surgical approach can be considered when stone extraction is still failed or the facilities to perform lithotripsy are not available. To our knowledge, conflicting evidence are still found from previous studies related to the comparison between endoscopic and surgical approaches. The availability of experienced operator and resources needs to be considered in creating individualized treatment strategies for managing difficult biliary stones.

Outcomes of laparoscopic bile duct exploration for choledocholithiasis with small common bile duct

BACKGROUND

Laparoscopic cholecystectomy (LC) combined with laparoscopic common bile duct (CBD) exploration (LCBDE) is one of the main treatments for choledocholithiasis with CBD diameter of larger than 10 mm. However, for patients with small CBD (CBD diameter ≤ 8 mm), endoscopic sphincterotomy remains the preferred treatment at present, but it also has some drawbacks associated with a series of complications, such as pancreatitis, hemorrhage, cholangitis, and duodenal perforation. To date, few studies have been reported that support the feasibility and safety of LCBDE for choledocholithiasis with small CBD.

AIM

To investigate the feasibility and safety of LCBDE for choledocholithiasis with small CBD.

METHODS

A total of 257 patients without acute cholangitis who underwent LC + LCBDE for cholecystolithiasis from January 2013 to December 2018 in one institution were reviewed. The clinical data were retrospectively collected and analyzed. According to whether the diameter of CBD was larger than 8 mm, 257 patients were divided into large CBD group (n = 146) and small CBD group (n = 111). Propensity score matching (1:1) was performed to adjust for clinical differences. The demographics, intraoperative data, short-term outcomes, and long-term follow-up outcomes for the patients were recorded and compared.

RESULTS

In total, 257 patients who underwent successful LC + LCBDE were enrolled in the study, 146 had large CBD and 111 had small CBD. The median follow-up period was 39 (14-86) mo. For small CBD patients, the median CBD diameter was 0.6 cm (0.2-2.0 cm), the mean operating time was 107.2 ± 28.3 min, and the postoperative bile leak rate, rate of residual CBD stones (CBDS), CBDS recurrence rate, and CBD stenosis rate were 5.41% (6/111), 3.60% (4/111), 1.80% (2/111), and 0% (0/111), respectively; the mean postoperative hospital stay was 7.4 ± 3.6 d. For large CBD patients, the median common bile duct diameter was 1.0 cm (0.3-3.0 cm), the mean operating time was 115.7 ± 32.0 min, and the postoperative bile leak rate, rate of residual CBDS, CBDS recurrence rate, and CBD stenosis rate were 5.41% (9/146), 1.37% (2/146), 6.85% (10/146), and 0% (0/146), respectively; the mean postoperative hospital stay was 7.7 ± 2.7 d. After propensity score matching, 184 patients remained, and all preoperative covariates except diameter of CBD stones were balanced. Postoperative bile leak occurred in 11 patients overall (5.98%), and no difference was found between the small CBD group (4.35%, 4/92) and the large CBD group (7.61%, 7/92). The incidence of CBDS recurrence did not differ significantly between the small CBD group (2.17%, 2/92) and the large CBD group (6.52%, 6/92).

CONCLUSION

LC + LCBDE is safe and feasible for choledocholithiasis patients with small CBD and did not increase the postoperative bile leak rate compared with chole-docholithiasis patients with large CBD.

Safety, quality and efficiency of intra-operative imaging for treatment decisions in patients with suspected choledocholithiasis without pre-operative magnetic resonance cholangiopancreatography

INTRODUCTION

Cholecystectomy is the accepted treatment for patients with symptomatic gallstones. In this study, we evaluate a simplified strategy for managing suspected synchronous choledocholithiasis by focussing on intra-operative imaging as the primary decision-making tool to target common bile duct (CBD) stone treatment.

METHODS

All elective and emergency patients undergoing laparoscopic cholecystectomy (LC) for gallstones with any markers of synchronous choledocholithiasis were included. Patients unfit for surgery or who had pre-operative proof of choledocholithiasis were excluded. Intra-operative imaging was used for evaluation of the CBD. CBD stone treatment was with bile duct exploration (LCBDE) or endoscopic retrograde cholangiopancreatography (LC + ERCP). Outcomes were safety, effectiveness and efficiency.

RESULTS

506 patients were included. 371 (73%) had laparoscopic ultrasound (LUS), 80 (16%) had on-table cholangiography (OTC) and 55 (11%) had both. 164 (32.4%) were found to have CBD stones. There was no increase in length of surgery for LC + LUS compared with average time for LC only in our unit (p = 0.17). 332 patients (65.6%) had clear ducts. Imaging was indeterminate in 10 (2%) patients. Overall morbidity was 10.5%. There was no mortality. 142 (86.6%) patients with stones on intra-operative imaging proceeded to LCBDE. 22 (13.4%) patients had ERCP. Sensitivity and specificity of intra-operative imaging were 93.3 and 99.1%, respectively. Success rate of LCBDE was 95.8%. Effectiveness was 97.8%.

CONCLUSIONS

Eliminating pre-operative bile duct imaging in favour of intra-operative imaging is safe and effective. When combined with intra-operative stone treatment, this method becomes a true 'single-stage' approach to managing suspected choledocholithiasis.

Applications, Limitations, and Expansion of Cholangioscopy in Clinical Practice

Peroral cholangioscopy (POC) provides minimally invasive, direct endoscopic visualization of the biliary ductal system for both diagnostic and therapeutic purposes. POC has benefited from a number of technologic advances since its first introduction several decades ago. These advances have led to improved utility and expanded functionality, making POC an integral part of managing various bile duct diseases and disorders. Over time, the clinical role of POC has expanded. Novel applications and capabilities are being increasingly appreciated and developed. This article provides an overview of the current state of POC, with a particular focus on digital single-operator cholangioscopy and its strengths, limitations, advances, and emerging applications.

Comparison of Endoscopy First and Laparoscopic Cholecystectomy First Strategies for Patients With Gallstone Disease and Intermediate Risk of Choledocholithiasis: Protocol for a Clinical Randomized Controlled Trial

Background

The optimal approach for patients with gallbladder stones and intermediate risk of choledocholithiasis remains undetermined. The use of endoscopic retrograde cholangiopancreatography for diagnosis should be minimized as it carries considerable risk of postprocedural complications, and nowadays, less invasive and safer techniques are available.

Objective

This study compares the two management strategies of endoscopic ultrasound before laparoscopic cholecystectomy and intraoperative cholangiography for patients with symptomatic cholecystolithiasis and intermediate risk of choledocholithiasis.

Methods

This is a randomized, active-controlled, single-center clinical trial enrolling adult patients undergoing laparoscopic cholecystectomy for symptomatic gallbladder stones with intermediate risk of choledocholithiasis. The risk of choledocholithiasis is calculated using an original prognostic score (the Vilnius University Hospital Index). This index in a retrospective evaluation showed better prognostic performance than the score proposed by the American Society for Gastrointestinal Endoscopy in 2010. A total of 106 participants will be included and randomized into two groups. Evaluation of bile ducts using endoscopic ultrasound and endoscopic retrograde cholangiography on demand will be performed before laparoscopic cholecystectomy for one arm (“endoscopy first”). Intraoperative cholangiography during laparoscopic cholecystectomy and postoperative endoscopic retrograde cholangiopancreatography on demand will be performed in another arm (“cholecystectomy first”). Postoperative follow-up is 6 months. The primary endpoint is the length of hospital stay. The secondary endpoints are accuracy of the different management strategies, adverse events of the interventions, duct clearance and technical success of the interventions (intraoperative cholangiography, endoscopic ultrasound, and endoscopic retrograde cholangiography), and cost of treatment.

Results

The trial protocol was approved by the Vilnius Regional Biomedical Research Ethics Committee in December 2017. Enrollment of patients was started in January 2018. As of June 2020, 66 patients have been enrolled.

Conclusions

This trial is planned to determine the superior strategy for patients with intermediate risk of common bile duct stones and to define a simple and safe algorithm for managing choledocholithiasis.

Trial Registration

ClinicalTrials.gov NCT03658863; https://clinicaltrials.gov/ct2/show/NCT03658863.

International Registered Report Identifier (IRRID)

DERR1-10.2196/18837

Routine intraoperative cholangiography during laparoscopic cholecystectomy: application of the 2016 WSES guidelines for predicting choledocholithiasis

Background

Routine use of intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) for detecting common bile duct stones remains controversial. The 2016 World Society of Emergency Surgery (WSES) guidelines on acute calculous cholecystitis proposed a risk stratification for choledocholithiasis. Our present study aimed to (1) examine the findings of common bile duct (CBD) stones in patients underwent LC with routine use of IOC, and (2) validate the 2016 WSES risk classes for predicting choledocholithiasis.

Methods

All patients had LC with IOC routinely performed from November 2012 to December 2017 were reviewed retrospectively. Patients were classified into high-, intermediate-, and low-risk groups based on the 2016 WSES risk classes with modification.

Results

A total of 990 patients with LC and routine IOC were enrolled. CBD stones were detected in 197 (19.9%) patients. The rate of CBD stone detected in low-, intermediate-, high-risk groups were 0%, 14.2%, and 89.6%, respectively. Predictors as following: evidence of CBD stones on abdominal ultrasound or computed tomography, CBD diameter > 6 mm, total bilirubin > 4 mg/dL, bilirubin level = 1.8–4 mg/dL, abnormal liver biochemical test result other than bilirubin, presence of clinical gallstone pancreatitis had statistical significance between patients with and without CBD stones. Major bile duct injury was found in 4 patients (0.4%). All 4 patients had uneventful recovery after repair surgery.

Conclusions

Based on our study results, the 2016 WSES risk classes for choledocholithiasis could be an effective approach for predicting the risk of choledocholithiasis. Considering its advantages for detecting CBD stones and biliary injuries, the routine use of IOC is still suggested.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-021-08305-4.

Cystic duct dilation through endoscopic retrograde cholangiopancreatography for treatment of gallstones and choledocholithiasis: Six case reports and review of literature

BACKGROUND

Choledocholithiasis removal via endoscopic retrograde cholangiopancreatography (ERCP) then followed by laparoscopic cholecystectomy (LC) has gradually become the principal method in the treatment of gallstones and choledocholithiasis. We use ERCP through the cystic duct to treat gallstones combined with choledocholithiasis, with the aim to preserve the normal function of the gallbladder while simultaneously decreasing risk of biliary tract injury.

CASE SUMMARY

A total of six cases of patients diagnosed with gallstones and choledocholithiasis were treated with ERCP. The efficacy was evaluated via operation success rate, calculus removal rate, postoperative hospital stay and average hospitalization costs; the safety was evaluated through perioperative complication probability, gallbladder function detection and gallstones recrudesce. The calculus removal rate reached 100%, and patients had mild adverse events, including 1 case of postoperative acute cholecystitis and another of increased blood urinary amylase; both were relieved after corresponding treatment, the remaining cases had no complications. The average hospital stay and hospitalization costs were 6.16 ± 1.47 d and 5194 ± 696 dollars. The 3-11 mo follow-up revealed that gallbladder contracted well, without recurrence of gallstones.

CONCLUSION

This is the first batch of case reports for the treatment of gallstones and choledocholithiasis through ERCP approached by natural cavity. The results and effects of six reported cases proved that the new strategy is safe and feasible and is worthy of further exploration and application.

Can T-tube drainage be replaced by primary suture technique in laparoscopic common bile duct exploration? A meta-analysis of randomized controlled trials

BACKGROUND

Although laparoscopic common bile duct exploration (LCBDE) is considered the best treatment and has the advantages of being minimally invasive for common bile duct (CBD) stones, the choice of T-tube drainage (TTD) or primary duct closure (PDC) after LCBDE is still controversial. Therefore, the aim of the study was to compare the superiority of PDC versus TTD after LCBDE for choledocholithiasis.

METHODS

All potential studies which compare the surgical effects between PDC with TTD were electronically searched for in PubMed, Web of Science, and the Cochrane library databases up to November 2019. Data synthesis and statistical analysis were carried out using RevMan 5.3 software.

RESULTS

In total, six randomized controlled trials with 604 patients (307 in the PDC group and 297 in the TTD group) were included in the current meta-analysis. As compared with the TTD group, the pooled data showed that PDC group had shorter operating time (WMD = -24.30; 95% CI = -27.02 to -21.59; p < 0.00001; I² = 0%; p < 0.88), less medical expenditure (WMD = -2255.73; 95% CI = -3330.59 to -1180.86; p < 0.0001; I² = 96%; p < 0.00001), shorter postoperative hospital stay (OR = -2.88; 95% CI = -3.22 to -2.54; p < 0.00001; I² = 60%; p < 0.03), and lower postoperative complications (OR = 0.49; 95% CI = 0.31 to 0.78; p = 0.77; I² = 0%; p = 0.003). There were no significant differences between the two groups concerning bile leakage (OR = 0.74; 95% CI = 0.36 to 1.53; p = 0.42; I² = 0%; p = 0.90) and retained stones (OR = 0.96; 95% CI = 0.36 to 2.52; p < 0.93; I² = 0%; p < 0.66).

CONCLUSIONS

LCBDE with PDC should be performed as a priority alternative compared with TTD for choledocholithiasis.

Single-stage management of choledocholithiasis: intraoperative ERCP versus laparoscopic common bile duct exploration

BACKGROUND

Laparoscopic cholecystectomy (LC) is the criterion standard for treating patients with symptomatic gallstone disease; however, the optimal technique for extracting common bile duct stones remains unclear. Recent studies have noted improved outcomes with single-stage techniques, such as intraoperative endoscopic retrograde cholangiopancreatography (iERCP) and laparoscopic common bile duct exploration (LCBDE); however only few studies have directly compared those two single-stage techniques.

OBJECTIVES

Using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database, we retrospectively analyzed the postoperative outcomes of all patients who underwent single-stage LC for choledocholithiasis from 2005 to 2017. Using Current Procedural Terminology (CPT) codes, as well as International Classification of Diseases, Ninth Revision (ICD-9) and 10th Revision (ICD-10) codes, we stratified patients into two cohorts: those who underwent iERCP and LCBDE. Applying univariate techniques, we evaluated baseline characteristics and postoperative outcomes for both cohorts. Our primary outcomes of interest were 30-day morbidity and 30-day mortality; our secondary outcomes included rates of reoperation, readmission, operative time, and hospital length of stay.

RESULTS

Of the 1814 single-stage LC patients during our 13-year study period, 1185 (65.3%) underwent LCBDE; 629 (34.6%) underwent iERCP. Our univariate analysis showed that the two cohorts were homogeneous in terms of baseline characteristics, including demographics, preoperative comorbidities, laboratory values, and American Society of Anesthesiologists (ASA) scores. 30-day postoperative morbidity (including infectious and noninfectious complications) and overall mortality between groups were low and comparable. The mean operative time was slightly longer with LCBDE (125.1 ± 62.0 min) than iERCP (113.5 ± 65.2 min; P < 0.001), however the mean hospital length of stay, readmission rate, and reoperation rate were similar.

CONCLUSION

We found that both iERCP and LCBDE resulted in low, comparable rates of morbidity and mortality. Centers with readily available endoscopic expertise might favor iERCP for its ease of access and shorter operative time. However, LCBDE remains an appropriate technique for patients with choledocholithiasis, especially when immediate endoscopic intervention is unavailable.

Cholecystectomy outcomes after endoscopic sphincterotomy in patients with choledocholithiasis: a meta-analysis

Background

Endoscopic sphincterotomy (ES) is the standard treatment for common bile duct stones. The reported findings regarding complications, such as biliary pancreatitis and cholangitis, differ between cholecystectomy after ES. The purpose of this study is to compare cholecystectomy outcomes after endoscopic treatment of common bile duct stones whether or not the incidence of recurrent pancreatitis and cholangitis is reduced, especially in high-risk patients.

Methods

We analyzed 8 studies, including 7 randomized controlled trials retrieved from the PubMed (1990–2019), Embase (1990–2019), and Cochrane (1990–2019) databases for trials comparing the two strategies for treatment of gallstones after ES. A related study on gallbladder removal after ES was acquired, followed by analysis of each group using RevMan. Risk ratios (RRs) were calculated for categorical variables and differences in means were calculated for continuous variables.

Results

We retrieved a total of 8 studies, including seven randomized controlled trials and one retrospective study. A total of 12,717 patients were included in the study (4922 in the early cholecystectomy group and 7795 in the gallbladder in situ group). During the follow-up period, 41 patients had pancreatitis after ES in the cholecystectomy group and 177 patients in the wait-and-see group. The incidence of pancreatitis in the cholecystectomy group was significantly reduced (RR, 0.38; 95% CI, 0.27–0.53; P < 0.00001; I² = 0%). The incidence of cholangitis and jaundice in the cholecystectomy group was also less than the preserved gallbladder group (RR, 0.31; 95% CI, 0.26–0.38; P < 0.00001; I² = 0%). There was no significant difference in mortality between the two groups (RR, 0.73; 95% CI, 0.52–1.02; P = 0.07; I² = 14%). There was a significant difference in cholecystitis and biliary colic (RR, 0.28; 95% CI, 0.24–0.32; P < 0.00001; I² = 17%).

Conclusion

Early cholecystectomy after removal of common bile duct stones can effectively reduce biliary complications. This is still true for high-risk patients and has no significant effect on the mortality of patients. Laparoscopic cholecystectomy is recommended after ES.

Laparoscopic Common Bile Duct Exploration With Primary Closure After Failed Endoscopic Retrograde Cholangiopancreatography Without Intraoperative Cholangiography: A Case Series from a Referral Center in Bogota, Colombia

Background: Despite the effectiveness of laparoscopic common bile duct (CBD) surgery, no case series details the use and advantages of laparoscopic CBD exploration (LCBDE) without use of intraoperative cholangiography (IOC) in endoscopic retrograde cholangiopancreatography (ERCP) failure. Therefore, we present a case series regarding our success with LCBDE in managing CBD stones (CBDSs) using laparoscopic technique without IOC. Materials and Methods: We performed a descriptive retrospective observational study. Patients with CBDSs, alone or along with gallbladder stones, were treated through LCBDE with primary CBD closure after failed ERCP. Results: All patients underwent LCBDE with choledocotomy and primary duct closure. Patients with gallbladder stones underwent laparoscopic cholecystectomy (78%). All procedures were successful, and no conversions occurred. Surgery duration averaged 106 minutes. Intraoperative bleeding averaged 15 cc, and no mortalities occurred. No patients required additional surgery or intensive care unit admission. Hospitalization duration averaged 5 days. Conclusions: Therefore, a laparoscopic approach with primary CBD closure after failed ERCP for complex CBDSs is safe and effective.

Comparison on the Efficacy of Three Duct Closure Methods after Laparoscopic Common Bile Duct Exploration for Choledocholithiasis

Background

Laparoscopic common bile duct exploration (LCBDE) is currently the best approach for complex cases of choledocholithiasis or the cases of endoscopic retrograde cholangiopancreatography (ERCP) failure. Nevertheless, there is no clear consensus on the optimal duct closure method after LCBDE. The purpose of this study was to evaluate the efficacy of 3 duct closure methods after LCBDE for choledocholithiasis.

Material/Methods

In this analysis, 189 patients with choledocholithiasis underwent LCBDE between June 2014 and December 2018. According to different duct closure methods, these patients were divided into T-tube drainage (TTD) group (n=66), common suture group (n=64) and barbed suture group (n=59). The operation time, suturing time, amount of intraoperative bleeding, tube-carried time, length of stay (LOS), hospitalization costs, pre- and post-operative common bile duct (CBD) diameters were all compared among the 3 groups. Six months after discharge, the incidence of complications and recurrent stones was observed.

Results

The operation time, suturing time, and amount of intraoperative bleeding in barbed suture group were both significantly less than those in the common suture group and the TTD group (P<0.01). When compared with the TTD group, the suturing time, tube-carried time, and LOS were decreased markedly in the common suture group and the barbed suture group (P<0.01). The post-operative CBD diameters in the 3 groups were all significantly larger than the pre-operative CBD diameters (P<0.01). There was no statistical significance among the 3 groups regarding the incidence of complications and recurrent stones (P>0.05).

Conclusions

Barbed suture shortened the suturing time, operation time, tube-carried time, and LOS, and lessened the amount of intraoperative bleeding in patients with choledocholithiasis after LCBDE. It was more effective than the common suture and TTD.

Protocol for the CREST Choles (Chinese REgistry Study on Treatment of Cholecysto-Choledocholithiasis) study: an ambispective, multicenter, observational, open-cohort study

INTRODUCTION

The best approach for choledocholithiasis remains a matter of debate. Choledocholithiasis is usually treated with endoscopic sphincterotomy (EST), laparoscopic common bile duct exploration (LCBDE) or laparoscopic transcystic common bile duct exploration (LTCBDE). Data pertaining to the clinical outcomes of these approaches in the management of patients with cholecysto-choledocholithiasis in China are limited. An analysis of the economic burden associated with these treatments is lacking. The Chinese REgistry Study on the Treatment of Cholecysto-Choledocholithiasis (CREST Choles) was designed to address these issues in a real-world setting.

METHODS AND ANALYSIS

CREST Choles was an ambispective, multicenter, observational, open-cohort study. A total of 2700 patients undergoing one of the three treatments (EST+laparoscopic cholecystectomy (LC), LCBDE+LC and LTCBDE+LC) during the period from 1 January 2013 to 1 December 2018 at participating centres were enrolled in the study. Patients with gallstones and confirmed common bile duct stones were included. Data pertaining to demographics, disease history, procedural details, imaging features and follow-up were collected. Follow-up was conducted at least 6 months after enrolment in the study and annual follow-up will be conducted until December 2020. The primary outcome is the rate of adverse outcomes within 3 years postoperatively. Economic analysis (eg, incremental cost-effectiveness ratio) would be performed to compare expense across treatments.

ETHICS AND DISSEMINATION

Ethical approval was obtained at all participating centres. The registry presented is the first attempt to comprehensively evaluate the cost of treatment for cholecysto-choledocholithiasis in China. Findings are expected to be available in 2020 and will facilitate clinical decision making in such cases.

TRIAL REGISTRATION NUMBER

NCT02554097.

Laparoscopic Transcystic Common Bile Duct Exploration in the Emergency Is as Effective and Safe as in Elective Setting

BACKGROUND

Emergent laparoscopic transcystic common bile duct exploration (LTCBDE) has been reported to be on the increase in some institutions, reflecting the growing confidence with the technique. However, no study has focused on the outcomes of LTCBDE in the non-elective setting. The aim of this study is to investigate whether LTCBDE can be performed effectively and safely in the emergency.

METHODS

This is a retrospective study of 500 consecutive patients with choledocholithiasis subjected for LTCBDE at the Hospital Italiano de Buenos Aires from January 2009 to January 2018. Procedures were classified according to the setting as emergent or elective. Demographic data and perioperative parameters were compared between groups.

RESULTS

Throughout the period comprised, 500 patients were admitted for choledocholithiasis and gallstones. A single-step treatment combining LTCBDE and laparoscopic cholecystectomy was attempted: 211 (42.2%) were performed electively and the 289 (57.8%) as an emergency. There was no significant difference in the success rate of LTCBDE (93.9% versus 93.8%, p = 0.975) for the two groups. The operative time was slightly longer in the emergency group (122 ± 63 versus 106 ± 53 min, p = 0.002). Postoperative recovery was slower in the emergency group, as reflected by a higher rate of prolonged postoperative stay (21.1% vs 5.7%, p < .001). The rates of postoperative complications were similar between groups (2.8% vs 5.9%, p = 0.109).

CONCLUSION

Emergent LTCBDE can be performed with equivalent efficacy and morbidity when compared to an elective procedure. Patients undergoing emergent procedures have longer procedures and hospital stays.

Laparoscopic Transcystic Versus Transductal Common Bile Duct Exploration: A Systematic Review and Meta-analysis

OBJECTIVE

To evaluate comparative outcomes of laparoscopic transcystic (TC) and transductal (TD) common bile duct (CBD) exploration.

METHODS

We systematically searched MEDLINE, EMBASE, CINAHL, CENTRAL, the World Health Organization International Clinical Trials Registry, ClinicalTrials.gov, ISRCTN Register, and bibliographic reference lists. CBD clearance rate, perioperative complications, and biliary complications were defined as the primary outcome parameters. Procedure time, length of hospital stay, conversion to open procedure were the secondary outcomes. Combined overall effect sizes were calculated using random-effects models.

RESULTS

We identified 30 studies reporting a total of 4073 patients comparing outcomes of laparoscopic TC (n = 2176) and TD (N = 1897) CBD exploration. The TC approach was associated with significantly lower overall complications (RD: -0.07, P = 0.001), biliary complications (RD: -0.05, P = 0.0003), and blood loss (MD: -16.20, P = 0.02) compared to TD approach. Moreover, the TC approach significantly reduced the length of hospital stay (MD: -2.62, P < 0.00001) and procedure time (MD: -12.73, P = 0.005). However, there was no significant difference in rate of CBD clearance (RD: 0.00, P = 0.77) and conversion to open procedure (RD: 0.00, P = 0.86) between two groups.

CONCLUSIONS

Laparoscopic TC CBD exploration is safe and reduces overall morbidity and biliary complications compared to the TD approach. Moreover, it is associated with significantly shorter length of hospital stay and procedure time. High-quality randomised trials may provide stronger evidence with respect to impact of the cystic duct/CBD diameter, number or size of CBD stones, or cystic duct anatomy on the comparative outcomes of TC and TD approaches.

[Laparoscopic rendezvous surgery for cholecystocholedocholithiasis]

OBJECTIVE

To present a modified technique of laparoscopic surgery (Rendezvous technique) for cholecystocholedocholithiasis.

MATERIAL AND METHODS

There were 41 patients with cholecystocholedocholithiasis who underwent hybrid single-stage laparoscopic surgery (Rendezvous technique) as an alternative to conventional two-stage approach.

RESULTS

Two (4.8%) patients had elevated serum amylase level without signs of pancreatitis in postoperative period. Other 2 patients required redo transpapillary intervention due to residual stones. Laparoscopic interventions were successful in 95.2% of cases.

The Safety and Efficacy of Single-Operator Cholangioscopy in the Treatment of Difficult Common Bile Duct Stones after Failed Conventional ERCP

Background

Common bile duct (CBD) stones are extracted with a basket or balloon during ERCP with sphincterotomy. However, some stones are difficult to extract by conventional means. Cholangioscopy with lithotripsy is a modality to treat these difficult stones. We describe the clinical efficacy of single-operator per oral cholangioscopy (SOPOC) for difficult stones and discuss cost savings by avoiding surgical intervention.

Methods

Retrospective chart review was performed for all patients referred for difficult CBD stones. Clinical success was defined as clearing the duct of all stones. The cost of cholangioscopy (in $CDN) was calculated by adding all costs associated with the procedure(s), surgery, hospital stay or treatment of adverse events. This cost was compared with the projected cost of surgical bile duct exploration.

Results

A total of 51 patients (35 female) with a mean age of 66 years underwent 58 SOPOC procedures. Median procedure time was 67 minutes (95% CI, 61.5–73.5). The CBD was successfully cleared in 47 of 51 patients (93%). Minor adverse events were seen in seven patients (14%). The actual average per procedure cost was $4555±$2647. This compares with a projected cost of $7766 and $6175 for open and laparoscopic bile duct exploration, with a cost-per-case saving of $3210 and $1619, respectively.

Conclusion

SOPOC with lithotripsy is highly effective and safe for the treatment of difficult common bile duct stones. In addition, significant cost savings may be realized by avoiding surgical bile duct exploration.

2017 WSES and SICG guidelines on acute calcolous cholecystitis in elderly population

Background

Gallstone disease is very common afflicting 20 million people in the USA. In Europe, the overall incidence of gallstone disease is 18.8% in women and 9.5% in men. The frequency of gallstones related disease increases by age. The elderly population is increasing worldwide.

Aim

The present guidelines aims to report the results of the World Society of Emergency Surgery (WSES) and Italian Surgical Society for Elderly (SICG) consensus conference on acute calcolous cholecystitis (ACC) focused on elderly population.

Material and methods

The 2016 WSES guidelines on ACC were used as baseline; six questions have been used to investigate the particularities in elderly population; the answers have been developed in terms of differences compared to the general population and to statements of the 2016 WSES Guidelines. The Consensus Conference discusses, voted, and modified the statements. International experts contributed in the elaboration of final statements and evaluation of the level of scientific evidences.

Results

The quality of the studies available decreases when we approach ACC in elderly. Same admission laparoscopic cholecystectomy should be suggested for elderly people with ACC; frailty scores as well as clinical and surgical risk scores could be adopted but no general consensus exist. The role of cholecystostomy is uncertain.

Discussion and conclusions

The evaluation of pro and cons for surgery or for alternative treatments in elderly suffering of ACC is more complex than in young people; also, the oldest old age is not a contraindication for surgery; however, a larger use of frailty and surgical risk scores could contribute to reach the best clinical judgment by the surgeon. The present guidelines offer the opportunity to share with the scientific community a baseline for future researches and discussion.

Outcomes of endoscopic sphincterotomy vs open choledochotomy for common bile duct stones

BACKGROUND

Endoscopic sphincterotomy (EST) for the management of common bile duct stones (CBDS) is used increasingly widely because it is a minimally invasive procedure. However, some clinical practitioners argued that EST may be complicated by post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) and accompanied by a higher recurrence of CBDS than open choledochotomy (OCT). Whether any differences in outcomes exist between these two approaches for treating CBDS has not been thoroughly elucidated to date.

AIM

To compare the outcomes of EST vs OCT for the management of CBDS and to clarify the risk factors associated with stone recurrence.

METHODS

Patients who underwent EST or OCT for CBDS between January 2010 and December 2012 were enrolled in this retrospective study. Follow-up data were obtained through telephone or by searching the medical records. Statistical analysis was carried out for 302 patients who had a follow-up period of at least 5 years or had a recurrence. Propensity score matching (1:1) was performed to adjust for clinical differences. A logistic regression model was used to identify potential risk factors for recurrence, and a receiver operating characteristic (ROC) curve was generated for qualifying independent risk factors.

RESULTS

In total, 302 patients undergoing successful EST (n = 168) or OCT (n = 134) were enrolled in the study and were followed for a median of 6.3 years. After propensity score matching, 176 patients remained, and all covariates were balanced. EST was associated with significantly shorter time to relieving biliary obstruction, anesthetic duration, procedure time, and hospital stay than OCT (P < 0.001). The number of complete stone clearance sessions increased significantly in the EST group (P = 0.009). The overall incidence of complications and mortality did not differ significantly between the two groups. Recurrent CBDS occurred in 18.8% (33/176) of the patients overall, but no difference was found between the EST (20.5%, 18/88) and OCT (17.0%, 15/88) groups. Factors associated with CBDS recurrence included common bile duct (CBD) diameter > 15 mm (OR = 2.72; 95%CI: 1.26-5.87; P = 0.011), multiple CBDS (OR = 5.09; 95%CI: 2.58-10.07; P < 0.001), and distal CBD angle ≤ 145° (OR = 2.92; 95%CI: 1.54-5.55; P = 0.001). The prediction model incorporating these factors demonstrated an area under the receiver operating characteristic curve of 0.81 (95%CI: 0.76-0.87).

CONCLUSION

EST is superior to OCT with regard to time to biliary obstruction relief, anesthetic duration, procedure time, and hospital stay and is not associated with an increased recurrence rate or mortality compared with OCT in the management of CBDS.

Combination of serum gamma-glutamyltransferase and alkaline phosphatase in predicting the diagnosis of asymptomatic choledocholithiasis secondary to cholecystolithiasis

BACKGROUND

Gamma-glutamyltransferase (GGT) is one of the most important laboratory tests for the evaluation of liver damage. Through a long-term clinical observation of patients with secondary asymptomatic choledocholithiasis, we found that most patients had abnormal GGT serum levels.

AIM

To investigate the combination of serum GGT and alkaline phosphatase (ALP) in predicting the diagnosis of asymptomatic choledocholithiasis secondary to cholecystolithiasis.

METHODS

In this retrospective cohort study, the clinical data of 829 patients with cholecystolithiasis admitted to the Third Affiliated Hospital of Zunyi Medical College from August 2014 to August 2017 were collected. Among these patients, 151 patients had secondary asymptomatic choledocholithiasis and served as the observation group, and the remaining 678 cholecystolithiasis patients served as the control group. Serum liver function indexes were detected in both groups, and the receiver operating characteristic (commonly known as ROC) curves were constructed for markers showing statistical significances. The cutoff value, sensitivity, and specificity of each marker were calculated according to the ROC curves.

RESULTS

The overall incidence of asymptomatic choledocholithiasis secondary to cholecystolithiasis was 18.2%. The results of liver function indexes including serum aspartate aminotransferase, alanine aminotransferase, direct bilirubin and total bilirubin levels showed no significant differences between the two groups (P > 0.05). However, the serum GGT and ALP levels were significantly higher in the observation group than in the control group (P < 0.05). The ROC curve analysis showed that the area under the curve was 0.881 (95%CI: 0.830-0.932), 0.647 (95%CI: 0.583-0.711) and 0.923 (95%CI: 0.892-0.953) for GGT, ALP, and GGT + ALP, respectively. The corresponding cut-off values of GGT and ALP were 95.5 U/L and 151.5 U/L, sensitivity were 90.8% and 65.1%, and specificity were 83.6% and 59.8%, respectively. The sensitivity and specificity of GGT + ALP were 93.5% and 85.1%, respectively.

CONCLUSION

An abnormally elevated serum GGT level has an important value in the diagnosis of asymptomatic choledocholithiasis secondary to cholecystolithiasis. The combination of serum GGT and ALP has better diagnostic performance. As a convenient, rapid and inexpensive test, it should be applied in secondary asymptomatic choledocholithiasis routine screening.

Laparoscopic common bile duct exploration plus cholecystectomy versus endoscopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy for cholecystocholedocholithiasis: a meta-analysis

BACKGROUND

The purpose of the study was to compare the safety and effectiveness of laparoscopic common bile duct exploration plus laparoscopic cholecystectomy (LCBDE+LC) with preoperative endoscopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy (pre-ERCP+LC) for cholecystocholedocholithiasis.

METHODS

An electronic search was performed using the following databases: PubMed, Embase, Web of Science, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov until 1 July 2018. Randomized controlled trials (RCTs) comparing LCBDE+LC versus pre-ERCP+LC were included. The common bile duct (CBD) stone clearance rate, postoperative bile leakage, postoperative pancreatitis, morbidity, mortality, and overall hospital stay were analyzed.

RESULTS

Twelve RCTs involving 1545 patients were included in this meta-analysis. Of the 12 RCTs, seven confirmed and five did not confirm CBD stones preoperatively. The meta-analysis showed a significantly higher CBD stone clearance rate for pre-ERCP+LC than LCBDE+LC. A similar result was found in the subgroup analysis of patients with confirmed CBD stones. A significantly lower postoperative bile leakage rate was found for pre-ERCP+LC than LCBDE+LC in all 12 RCTs and in the subgroup of patients with confirmed CBD stones. However, a significantly higher rate of pancreatitis was found in pre-ERCP+LC and in the subgroup of patients with confirmed CBD stones. LCBDE+LC was superior to pre-ERCP+LC in terms of the overall hospital stay. No significant differences were found in morbidity or mortality.

CONCLUSIONS

Pre-ERCP+LC is associated with a higher CBD stone clearance rate, lower postoperative bile leakage rate, and higher rate of pancreatitis. LCBDE+LC might help to shorten the hospital stay. Further studies on this topic are recommended.

Success of intraoperative imaging and management of suspected choledocholithiasis without pre-operative bile duct imaging - A case series

Background

Laparoscopic common bile duct exploration (LCBDE) is gaining popularity over endoscopic retrograde cholangiopancreatography (ERCP) for the management of common bile duct stones. However, its application has been almost exclusively following preoperative stone confirmation via magnetic retrograde cholangiopancreatography (MRCP), endoscopic ultrasound (EUS) or ERCP. We present our series of LCBDE following detection of common bile duct stones with intraoperative imaging (IOI) alone, in consecutive elective and emergency patients with suspected choledocholithiasis.

Materials and methods

All patients with suspected but unconfirmed choledocholithiasis undergoing LC with intention to proceed to LCBDE between January 2015 and June 2017 were included. LCBDE was performed following the discovery of choledocholithiasis on IOI.

Results

371 patients with suspected choledocholithiasis underwent LC with IOI. CBD stones or obstructing sludge was identified in 107 patients (29%), with sensitivity of 96.2% and specificity of 98.5%. 100 patients, median age 59, went on to have LCBDE as indicated by intraoperative imaging. 76% were performed as emergency cases and conversion to open rate was 2%. There were no mortalities. Bile leak and retained stones occurred in 4% and 3% respectively. 7/100 patients required re-intervention, with re-look laparoscopy (n = 4) and ERCP (n = 3). Median length of stay was 1.5 and 3 days for elective and emergency cases respectively, and 30 readmission rate was 8%.

Discussion and conclusion

Traditionally patients presenting with suspicion of choledocholithiasis undergo preoperative MRCP/EUS and/or ERCP prior to eventual LC. We propose an alternative, more streamlined, pathway of treatment without requiring preoperative cholangiography, applicable to both elective and emergency patients.

•

Laparoscopic common bile duct exploration is a safe and effective treatment for bile duct stones.

•

Intraoperative cholangiography is sensitive and specific in identification of bile duct stones.

•

Bile duct exploration can be safely performed on the basis on intraoperative imaging alone.

•

Intraoperative imaging provides sufficient information for real time decision making.

Ursodeoxycholic acid combined with percutaneous transhepatic balloon dilation for management of gallstones after elimination of common bile duct stones

AIM

To evaluate the effectiveness and safety of combined ursodeoxycholic acid and percutaneous transhepatic balloon dilation for management of gallstones after expulsion of common bile duct (CBD) stones.

METHODS

From April 2014 to May 2016, 15 consecutive patients (6 men and 9 women) aged 45-86 (mean, 69.07 ± 9.91) years suffering from CBD stones associated with gallstones were evaluated. Good gallbladder contraction function was confirmed by type B ultrasonography. Dilation of the CBD and cystic duct was detected. Percutaneous transhepatic balloon dilation of the papilla was performed, ursodeoxycholic acid was administered, and all patients had a high-fat diet. All subjects underwent repeated cholangiography, and percutaneous transhepatic removal was carried out in patients with secondary CBD stones originating from the gallbladder.

RESULTS

All patients underwent percutaneous transhepatic balloon dilation with a primary success rate of 100%. The combined therapy was successful in 86.7% of patients with concomitant CBD stones and gallstones. No remaining stones were detected in the gallbladder. Transient adverse events include abdominal pain (n = 1), abdominal distension (n = 1), and fever (n = 1). Complications were treated successfully via nonsurgical management without long-term complications. No procedure-related mortality occurred.

CONCLUSION

For patients with concomitant CBD stones and gallstones, after percutaneous transhepatic removal of primary CBD stones, oral ursodeoxycholic acid and a high-fat diet followed by percutaneous transhepatic removal of secondary CBD stones appear to be a feasible and effective option for management of gallstones.

Clinical analysis of treatment strategies to cholecystocholedocholithiasis patients with previous subtotal or total gastrectomy: a retrospective cohort study

Background

Previous gastrectomy can lead to an increased incidence of cholecystocholedocholithiasis (CCL) and increased morbidity rate. However, the appropriate treatment strategy for patients with CCL and a history of gastrectomy remains unclear.

Methods

We performed a retrospective cohort study of patients with CCL and a history of gastrectomy who underwent either one-stage laparoscopic common bile duct (CBD) exploration with stone clearance and laparoscopic cholecystectomy (LCBDE+LC) or two-stage endoscopic retrograde cholangiopancreatography followed by LC (ERCP+LC) from May 2010 to March 2018.

Results

The success rate of ERCP for CBD stone clearance was 81.2% in patients with a history of Billroth I gastrectomy and 23.7% in patients with a history of Billroth II or Roux-en-Y esophagojejunostomy [χ² = 97.67, P < 0.001, risk ratio (RR) = 3.43]. The success rate of second-step LC after successful ERCP for removal of CBD stones and the success rate of LCBDE+LC after ERCP treatment failure were 96.8 and 87.7%, respectively, in patients with preoperative intra-abdominal adhesion evaluation scores of ≤3 points. These success rates were 28.6 and 27.6%, respectively, in patients with scores of > 3 points (χ² = 59.70, P < 0.001, RR = 3.38 and χ² = 53.41, P < 0.001, RR = 3.27, respectively).

Conclusions

Based on the results of this study, ERCP+LC seems to be an attractive strategy for treatment of CCL in patients with a history of Billroth I gastrectomy, and LCBDE+LC appears to be suitable for patients with a history of Billroth II or Roux-en-Y esophagojejunostomy. Preoperative evaluation of intra-abdominal adhesions helps to reduce the conversion rate of laparoscopic surgery.