Surgical audit of patients undergoing common bile duct exploration for stone

Changes in the Management of Common Bile Duct Stones: 1980 to Date

OBJECTIVE

To compare the results of treating patients with common bile duct (CBD) stones by endoscopic sphincterotomy (ES), surgical exploration, or a combination of ES and surgical CBD exploration (the rendezvous technique).

METHODS

A narrative review of the literature.

SUMMARY OF DATA

Before 1990, 17 cohort studies indicated that ES cleared CBD stones in 92.0% of patients, with a mortality rate of 1.5%. Surgery removed CBD stones in 90.2% of patients, with a 2.1% mortality rate. A single randomized controlled trial in 1987 showed that ES removed CBD stones in 91% of 55 patients, with a 3.6% mortality rate and a 27% complication rate, whereas surgical CBD exploration removed CBD stones in 92%, with a 1.8% mortality rate and a 22% complication rate. Since 1991, 26 randomized controlled trials have shown that laparoscopic-ES rendezvous is as effective as ES alone and laparoscopic surgery alone but is associated with fewer complications, a reduced need for additional procedures, and a shorter hospital stay.

CONCLUSIONS

A laparoscopic-ES rendezvous appears to be the optimal approach to the treatment of CBD stones in younger and fit patients. The choice between ES alone and laparoscopic-ES rendezvous in older or high-risk patients remains uncertain.

Laparoscopic transcystic bile duct stenting in the management of common bile duct stones

BACKGROUND

The management of patients with common bile duct stones associated with stones in the gall bladder remains controversial.

METHODS

Over the three-year period from 1996 to 1999, patients with cholelithiasis and known choledocholithiasis, or choledocholithiasis found at laparoscopic cholecystectomy, were initially treated by placing a stent across the sphincter of Oddi. The stent was pushed along a guide wire through the cystic duct and then down the common bile duct, before the cystic duct was closed. Subsequently, the stent was used to facilitate performance of a needle knife endoscopic sphincterotomy. The stent was then removed, a cholangiography was performed and the common bile duct was cleared. Patients with persistent jaundice usually had a preoperative endoscopic retrograde cholangio-pancreatography.

RESULTS

Transcystic stenting was the 'intention-to-treat' basis of therapy for 56 of the patients. The placement of the stent only failed once when the stent became trapped in the cystic duct. Complications of the operation included: pain and jaundice (n = 2), cholangitis (n = 1), and pulmonary embolus (n = 1). The median postoperative hospitalization was 2 days (range: 1-15). Five further patients had common bile duct stones removed via a choledochotomy; a stent was placed through the choledochotomy before its closure. The selective common bile duct cannulation rate at the first endoscopic retrograde cholangio-pancreatography, was 98%. A second endoscopic retrograde cholangio-pancreatography was required in 15% of patients. The only complication of all the endoscopic procedures was a single case of mild cholangitis; there were no cases of pancreatitis.

CONCLUSION

A treatment option open to all surgeons for non-jaundiced patients with known choledocholithiasis or choledocholithiasis found at operative cholangiogram, is the transcystic stenting of the sphincter of Oddi at the time of laparoscopic cholecystectomy. At a subsequent sitting, the common bile duct can be safely cleared endoscopically using a sphincterotomy facilitated by the stent.

Complications of biliary T-tubes after choledochotomy

BACKGROUND

Traditional management of choledocholithiasis has been supraduodenal choledochotomy, duct exploration and insertion of a T-tube. This study reviews the complications associated with T-tube use and assesses whether laparoscopic procedures are associated with an increase in complications relating to T-tube use.

METHODS

Case records from two large public hospitals in New South Wales (Australia) were analysed retrospectively for a 10-year period using a standardized data collection form. Morbidity, mortality and potential factors influencing the complication rate after choledochotomy and T-tube insertion were recorded. All complications were reviewed by an experienced biliary surgeon.

RESULTS

T-tubes were inserted in 274 patients, with 42 patients (15.3%) experiencing a total of 60 complications relating to T-tube use. Morbidity occurring while the tube was in situ included fluid and electrolyte disturbance (five patients), sepsis (10 patients), premature dislodgement (three patients) and bile leakage (six patients). Complications resulting after planned tube removal included localized pain (13 patients), biliary peritonitis (seven patients), a prolonged biliary fistula (seven patients) and a late bile duct stricture (one patient). T-tube complications resulted in a prolonged hospital stay (19 days vs 13 days, P = 0.005), 10 additional abdominal operations and two deaths. Complications related to T-tubes were constant over the study period and were similar between laparoscopic and open cases (13.8% vs 15.5%, P = 0.81).

CONCLUSIONS

Although this retrospective review is likely to have underestimated the incidence of T-tube complications, it has demonstrated significant morbidity associated with T-tube use. The incidence of these complications has been constant and is unrelated to a laparoscopic approach.

Long-term results (7 to 10 years) of endoscopic papillotomy for choledocholithiasis. Multivariate analysis of prognostic factors for the recurrence of biliary symptoms

BACKGROUND

The long-term outcome after endoscopic papillotomy is poorly defined. The aim of this study was to determine the long-term results of this method in the treatment of common duct calculi and to determine which prognostic factors are associated with the relapse of biliary symptoms.

METHODS

Between 1985 and 1988, 223 consecutive (149 women, mean age 67.9 years) patients underwent endoscopic papillotomy for duct stones; 127 had already undergone cholecystectomy or underwent this operation during the same hospitalization. Follow-up data were obtained retrospectively from the patients and patients' relatives and general practitioners.

RESULTS

The procedure was successful in 217 of 223 cases (97%), of which 203 were followed-up; 2 patients died in the first month after treatment (0.89%). Mean follow-up for the 201 patients was 6.2 years, during which 31 relapsed (15%). Three significant prognostic factors for late complications were identified in a multivariate analysis. The recurrence rate of biliary symptoms in patients who were left with an in situ gallbladder was 20.2%, and 11% for those whose gallbladder was removed (p = 0.04). Patients with a bile duct 15 mm or greater in diameter were more prone to recurrence of symptoms than those with a bile duct 10 mm or less in diameter (41% vs. 10%, p = 0.025) and were especially at higher risk to develop recurrent stones (19.5% vs. 4.9%, p = 0.019). Stone recurrence, but not biliary symptoms as a whole, was more frequent in patients with a peripapillary diverticulum (p = 0.035).

CONCLUSIONS

The long-term results of endoscopic papillotomy are comparable with those of surgical techniques. The prognostic factors associated with relapse of biliary symptoms as a whole are gallbladder left in situ and choledochal diameter. Bile duct size and peripapillary diverticula are associated with recurrent bile duct stones.

A cost-minimization analysis of laparoscopic cholecystectomy versus open cholecystectomy

BACKGROUND

Earlier economic analyses have evaluated charges but not costs, and have not considered the cost of production losses associated with open and laparoscopic cholecystectomy. This study attempted to accomplish an economic evaluation of open versus laparoscopic cholecystectomy from the point of view of society.

METHODS

A cost-minimization analysis, using a clinical decision model, was performed. The data used were taken from different clinical studies, Swedish national registers, local patient statistics, and hospital accounting systems. The direct and indirect costs were measured.

RESULTS

Laparoscopic cholecystectomy resulted in cost savings per patient amounting to about 2,400 SEK (as of 31 August 1994, Pound = 11.90 SEK; $1 = 7.76 SEK) compared with open surgery.

CONCLUSIONS

From the point of view of society, laparoscopic cholecystectomy was a cost-saving strategy if at least 68 patients were operated on yearly. However, with regard to hospital costs, open cholecystectomy was less expensive than laparoscopic cholecystectomy.

Audit of open cholecystectomy in a district general hospital

This retrospective study audited all non-malignant biliary surgery carried out in a district general hospital between January 1985 and December 1990. Surgery was performed on 722 patients: 555 (77 per cent) were women and 167 (23 per cent) were men. The mean(s.d.) age of the patients was 49(16) years. Elective admissions accounted for 70 per cent of cases and 30 per cent were emergency admissions. Ultrasonography confirmed the diagnosis in 93 per cent of cases. An elective operation was performed in 542 patients and 180 patients underwent an urgent or emergency operation. Simple cholecystectomy was performed on 616 patients (85 per cent); 92 (13 per cent) also underwent common bile duct exploration and 14 (2 per cent) had an additional unrelated procedure. The mean(s.d.) hospital stay was 12.3(6.3) (range 4-34) days. There was one perioperative death. The general overall morbidity rate was 25 per cent and the procedure-related morbidity rate was 7 per cent. For simple cholecystectomy (n = 630) there were no deaths; the general morbidity rate was 15 per cent and the procedure-related rate was 3 per cent.

Endoscopic sphincterotomy complications and their management: an attempt at consensus

Despite its relative safety (in comparison with surgery), and undoubted role in many clinical circumstances, biliary sphincterotomy is the most dangerous procedure routinely performed by endoscopists. Complications occur in about 10% of patients; 2 to 3% have a prolonged hospital stay, with a risk of dying. This document is an attempt to provide guidelines for prevention and management of complications, based on a workshop of selected experts, and a comprehensive review of the literature. We emphasize particularly the importance of specialist training, disinfection, drainage, and collaboration with surgical colleagues.