The long-term follow-up of patients with positive intraoperative cholangiograms during laparoscopic cholecystectomy

Biliary Obstruction During Cholecystectomy: Endoscopic Retrograde Cholangiopancreatography, Evade, or Explore?

Biliary obstruction discovered during cholecystectomy remains a challenging problem. To determine the best management, this retrospective study compared intervention during the same admission (SA) versus delayed/no intervention (DN). Furthermore, this study demonstrates the power of a deidentified research database derived from electronic medical records. Patients undergoing cholecystectomy and intraoperative cholangiogram (IOC) were identified in the Vanderbilt Synthetic Derivative database. Patients with biliary obstruction discovered during IOC were included and a cohort study was performed. Interventions for biliary obstruction included endoscopic retrograde cholangiopancreatography or common bile duct exploration. A composite measure of any biliary complication served as the primary outcome. A total of 1899 patients who underwent cholecystectomy were evaluated; 151 met inclusion criteria. Mean age was 44 years with 69 per cent women. Sixty-three per cent of patients had intervention during the SA for cholecystectomy compared with 37 per cent for DN. Nineteen per cent of patients in the SA group had biliary complications versus 16 per cent for DN ( P = 0.656). Patients in the SA group had a significantly increased length of stay (4.7 vs 2.1 days, P < 0.05). These data suggest an aggressive approach to biliary obstruction seen on IOC does not reduce postoperative biliary complications and may incur unnecessary resource use.

Long-term outcomes after laparoscopic bile duct exploration: a 5-year follow up of 150 consecutive patients

BACKGROUND

The treatment of common bile duct stones discovered at routine intraoperative cholangiography includes postoperative endoscopic retrograde cholangiography or intraoperative laparoscopic common bile duct exploration. Given the equivalence of short-term outcome data for these two techniques, the choice of one over the other may be influenced by long-term follow-up data. We aimed to establish the long-term outcomes following laparoscopic common bile duct exploration and compare this with endoscopic retrograde cholangiography.

METHODS

One hundred and fifty consecutive patients underwent laparoscopic common bile duct exploration between March 1998 and March 2006 carried out by a single surgeon. All were prospectively studied for 1 month followed by a late-term phone questionnaire ascertaining the prevalence of adverse symptoms. Patients presented with a standardized series of questions, with reports of symptoms corroborated by review of medical records.

RESULTS

In 150 patients, operations included laparoscopic transcystic exploration (135), choledochotomy (10) and choledochoduodenostomy (2). At long-term follow up (mean 63 months), 116 (77.3%) patients were traceable, with 24 (20.7%) reporting an episode of pain and 18 (15.5%) had more than a single episode of pain. There was no long-term evidence of cholangitis, stricture or pancreatitis identified in any patient.

CONCLUSION

Laparoscopic bile duct exploration appears not to increase the incidence of long-term adverse sequelae beyond the reported prevalence of postcholecystectomy symptoms. There was no incidence of bile duct stricture, cholangitis or pancreatitis. It is a safe procedure, which obviates the need and expense of preoperative or postoperative endoscopic retrograde cholangiography in most instances.

An Economic Analysis of Hospital Charges for Choledocholithiasis by Different Treatment Strategies

The ideal management of presumed choledocholithiasis is controversial. We hypothesized that patients admitted with presumed choledocholithiasis would be better served financially to undergo laparoscopic cholecystectomy (LC) with possible intraoperative intervention versus preoperative endoscopic retrograde cholangiopancreatography followed by LC. A chart review was performed from September 1, 2000 to August 31, 2003. One hundred seventy-one consecutive patients identified with presumed choledocholithiasis were reviewed. Six patients were excluded because of missing charge data. Professional and technical fees from the total hospital charges were used for comparison. Three groups of patients were compared for charge analysis. Group 1 underwent LC with laparoscopic common bile duct exploration. Group 2 underwent LC with preoperative or postoperative endoscopic retrograde cholangiopancreatography. Group 3 was a control group of LC only. Student's t test was used for statistical analysis with a P value of <0.05 defined as statistically significant. P values reflect comparisons with Group 1. Group 1 charges were $13,026, Group 2 charges were $15,303, and Group 3 charges were $9,122. For suspected choledocholithiasis, LC with intraoperative intervention is the most economically advantageous approach.

Intraoperative cholangiography facilitates simple transcystic clearance of ductal stones in units without expertise for laparoscopic bile duct surgery

BACKGROUND

In the absence of facilities and expertise for laparoscopic bile duct exploration (LBDE), most patients with suspected ductal calculi undergo preoperative endoscopic duct clearance. Intraoperative cholangiography (IOC) is not performed at the subsequent laparoscopic cholecystectomy. This study aimed to investigate the rate of successful duct clearance after simple transcystic manipulations.

METHODS

This prospective study investigated 1,408 patients over 13 years in a unit practicing single-session management of biliary calculi. For the great majority, IOC was attempted. Abnormalities were dealt with by flushing of the duct, glucagon injection, Dormia basket trawling, choledochoscopic transcystic exploration, or choledochotomy.

RESULTS

Of 1,056 cholangiograms performed (75%), 287 were abnormal (27.2%). Surgical trainees, operating under supervision, successfully performed 24% of all cholangiograms. Of 396 patients admitted with biliary emergencies, 94.1% had abnormal cholangiograms. Of the 287 patients with abnormal IOCs, 9.4% required no intervention, 18% were clear after glucagon and flushing, and 13% were cleared using Dormia basket trawling under fluoroscopy. A total of 95 patients required formal LBDE, and 2 required postoperative endoscopic retrograde cholangiopancreatography (ERCP). No postoperative ERCP for retained stones was required after simple transcystic manipulation. Eight conversions occurred, one during a transcystic exploration. Follow-up evaluation continued for as long as 6 years in some cases. Two patients had recurrent stones after LBDE and a clear postoperative tube cholangiogram.

CONCLUSION

In this series, 10% of the abnormal cholangiograms occurred in patients without preoperative risk factors for bile duct stones. Altogether, 88 IOCs (31%) were cleared after either simple flushing or trawling with a Dormia basket. Formal LBDE was not required for 40% of abnormal cholangiograms. Simple transcystic manipulations to clear the bile ducts justify the use of routine IOC in units without laparoscopic biliary expertise.