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Toogood K, Pike T, Coe P, Everett S, Huggett M, Paranandi B, Bassi V, Toogood G, Smith A. The role of cholecystectomy following endoscopic sphincterotomy and bile duct stone removal. Ann R Coll Surg Engl 2023; 105:607-613. [PMID: 35950513 PMCID: PMC10471440 DOI: 10.1308/rcsann.2022.0027] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2022] [Indexed: 09/02/2023] Open
Abstract
INTRODUCTION Choledocholithiasis is common, with patients usually treated with endoscopic retrograde cholangiopancreatography (ERCP) and subsequent cholecystectomy to remove the presumed source of common bile duct (CBD) stones. However, previous investigations into the management of patients following ERCP have focused on recurrent CBD stones, negating the risks of cholecystectomy. This article appraises the role of cholecystectomy following successful endoscopic clearance of bile duct stones. METHODS Patients undergoing ERCP and CBD clearance for choledocholithiasis at St James's University Hospital January 2015-December 2018 were included. Patients were divided into those who received cholecystectomy and those managed non-operatively. Readmissions, operative morbidity, mortality and treatment costs were investigated. RESULTS Eight hundred and forty-four patients received ERCP and CBD clearance with 3.9 years follow-up. Two hundred and nine patients underwent cholecystectomy with 15% requiring complex surgery. Three hundred and seventy-three patients were non-operatively managed. Unplanned readmissions occurred in 15% following ERCP, mostly within two years. There was no difference in readmissions between the two groups. Accounting for the entire patient pathway, non-operative management was less expensive. CONCLUSIONS The majority of patients do not require readmission following ERCP for CBD stones, and cholecystectomy did not reduce the risk of readmission. Few patients have recurrent CBD stones, but complex biliary surgery is frequently required. Routine cholecystectomy following ERCP needs to be re-evaluated and a more stratified approach to future risk developed.
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Affiliation(s)
| | | | - P Coe
- St James’s University Hospital, UK
| | | | | | | | - V Bassi
- St James’s University Hospital, UK
| | | | - A Smith
- St James’s University Hospital, UK
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Nassar AHM, Sallam M, Khan KS, Kilpatrick R, Zino S, Katbeh TZ. A proposed difficulty grading system for laparoscopic bile duct exploration: benefits to clinical practice, training and research. Surg Endosc 2023; 37:7012-7023. [PMID: 37349591 PMCID: PMC10462500 DOI: 10.1007/s00464-023-10169-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 05/28/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND A gap remains between the mounting evidence for single session management of bile duct stones and the adoption of this approach. Laparoscopic bile duct exploration (LBDE) is limited by the scarcity of training opportunities and adequate equipment and by the perception that the technique requires a high skill-set. The aim of this study was to create a new classification of difficulty based on operative characteristics and to stratify postoperative outcomes of easy vs. difficult LBDE irrespective of the surgeon's experience. METHODS A cohort of 1335 LBDEs was classified according to the location, number and size of ductal stones, the retrieval technique, utilisation of choledochoscopy and specific biliary pathologies encountered. A combination of features indicated easy (Grades I and II A & B) or difficult (Grades III A and B, IV and V) transcystic or transcholedochal explorations. RESULTS 78.3% of patients with acute cholecystitis or pancreatitis, 37% with jaundice and 46% with cholangitis had easy explorations. Difficult explorations were more likely to present as emergencies, with obstructive jaundice, previous sphincterotomy and dilated bile ducts on ultrasound scans. 77.7% of easy explorations were transcystic and 62.3% of difficult explorations transductal. Choledochoscopy was utilised in 23.4% of easy vs. 98% of difficult explorations. The use of biliary drains, open conversions, median operative time, biliary-related complications, hospital stay, readmissions, and retained stones increased with the difficulty grade. Grades I and II patients had 2 or more hospital episodes in 26.5% vs. 41.2% for grades III to V. There were 2 deaths in difficulty Grade V and one in Grade IIB. CONCLUSION Difficulty grading of LBDE is useful in predicting outcomes and facilitating comparison between studies. It ensures fair structuring and assessment of training and progress of the learning curve. LBDEs were easy in 72% with 77% completed transcystically. This may encourage more units to adopt this approach.
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Affiliation(s)
- Ahmad H M Nassar
- Laparoscopic Biliary Unit, University Hospital Monklands, Airdrie, Scotland, UK.
- University of Glasgow, Glasgow, Scotland, UK.
- Golden Jubilee National Hospital, Glasgow, Scotland, UK.
| | - Mahmoud Sallam
- Laparoscopic Biliary Unit, University Hospital Monklands, Airdrie, Scotland, UK
| | - Khurram S Khan
- Laparoscopic Biliary Unit, University Hospital Monklands, Airdrie, Scotland, UK
- University of Glasgow, Glasgow, Scotland, UK
- University Hospital Hairmyres, Lanarkshire, UK
| | - Rhona Kilpatrick
- Laparoscopic Biliary Unit, University Hospital Monklands, Airdrie, Scotland, UK
| | - Samer Zino
- Laparoscopic Biliary Unit, University Hospital Monklands, Airdrie, Scotland, UK
- Department of Surgery, Ninewells Hospital and Medical School, Dundee, Scotland, UK
| | - Tarek Z Katbeh
- Laparoscopic Biliary Unit, University Hospital Monklands, Airdrie, Scotland, UK
- Department of Surgery, The Queen Elizabeth University Hospital, Glasgow, Scotland, UK
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Li S, Guizzetti L, Ma C, Shaheen AA, Dixon E, Ball C, Wani S, Forbes N. Epidemiology and outcomes of choledocholithiasis and cholangitis in the United States: trends and urban-rural variations. BMC Gastroenterol 2023; 23:254. [PMID: 37501115 PMCID: PMC10373232 DOI: 10.1186/s12876-023-02868-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 06/30/2023] [Indexed: 07/29/2023] Open
Abstract
BACKGROUND Gallstone disease poses a significant health burden in the United States. Choledocholithiasis and cholangitis are common complications of gallstone disease for which data on current epidemiological trends are lacking. We aimed to evaluate temporal changes in hospitalization, management, and outcomes for patients with choledocholithiasis and cholangitis. METHODS The National Inpatient Sample was used to identify discharges for choledocholithiasis and cholangitis between 2005 and 2014. Temporal trends were evaluated via annual percent changes (APCs). Joinpoint regression was used to assess inflection points. Multivariable regression models were used to evaluate associations of interest. RESULTS From 189,362 unweighted discharges for choledocholithiasis and/or cholangitis, there was an increase in discharges for choledocholithiasis (APC 2.3%, 95% confidence intervals, CI, 1.9-2.7%) and cholangitis (APC 1.5%, 95% CI 0.7-2.2%). Procedural interventions were more likely at urban hospitals for choledocholithiasis (adjusted odds ratio, aOR, 2.94, 95% CI 2.72 to 3.17) and cholangitis (aOR 2.97, 95% CI 2.50 to 3.54). In-hospital mortality significantly decreased annually for choledocholithiasis (aOR 0.90, 95% CI 0.88 to 0.93) and cholangitis (aOR 0.93, 95% CI 0.89 to 0.97). In-hospital mortality between rural and urban centers was comparable for choledocholithiasis (aOR 1.16, 95% CI 0.89 to 1.52) and cholangitis (aOR 1.12, 95% CI 0.72 to 1.72). CONCLUSIONS Hospitalizations for choledocholithiasis and cholangitis have increased between 2005 and 2014, reflecting a growing burden of gallstone disease. Hospital mortality between urban and rural centers is similar, however urban centers have a higher rate of procedural interventions suggesting limitations to accessing procedural interventions at rural centers.
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Affiliation(s)
- Suqing Li
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, TRW 6D62, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.
| | | | - Christopher Ma
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, TRW 6D62, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
- Alimentiv, Inc, London, ON, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Abdel Aziz Shaheen
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, TRW 6D62, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Elijah Dixon
- Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Chad Ball
- Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Nauzer Forbes
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, TRW 6D62, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
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Nyren MQ, Filiberto AC, Underwood PW, Abbott KL, Balch JA, Efron PA, George BC, Shickel B, Upchurch GR, Sarosi GA, Loftus TJ. A simulation curriculum for laparoscopic common bile duct exploration, balloon sphincterotomy, and endobiliary stenting: Associations with resident performance and autonomy in the operating room. Surgery 2023; 173:950-956. [PMID: 36517292 DOI: 10.1016/j.surg.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 10/30/2022] [Accepted: 11/11/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Laparoscopic common bile duct exploration is safe and effective for managing choledocholithiasis, but laparoscopic common bile duct exploration is rarely performed, which threatens surgical trainee proficiency. This study tests the hypothesis that prior operative or simulation experience with laparoscopic common bile duct exploration is associated with greater resident operative performance and autonomy without adversely affecting patient outcomes. METHODS This longitudinal cohort study included 33 consecutive patients undergoing laparoscopic common bile duct exploration in cases involving postgraduate years 3, 4, and 5 general surgery residents at a single institution during the implementation of a laparoscopic common bile duct exploration simulation curriculum. For each of the 33 cases, resident performance and autonomy were rated by residents and attendings, the resident's prior operative and simulation experience were recorded, and patient outcomes were ascertained from electronic health records for comparison among 3 cohorts: prior operative experience, prior simulation experience, and no prior experience. RESULTS Operative approach was similar among cohorts. Overall morbidity was 6.1% and similar across cohorts. The operative performance scores were higher in prior experience cohorts according to both residents (3.0 [2.8-3.0] vs 2.0 [2.0-3.0]; P = .01) and attendings (3.0 [3.0-4.0]; P < .001). The autonomy scores were higher in prior experience cohorts according to both residents (2.0 [2.0-3.0] vs 2.0 [2.0-2.0]; P = .005) and attendings (2.5 [2.0-3.0] vs 2.0 [1.0-2.0]; P = .001). Prior simulation and prior operative experience had similar associations with performance and autonomy. CONCLUSION Simulation experience with laparoscopic common bile duct exploration was associated with greater resident operative performance and autonomy, with effects that mimic prior operative experience. This illustrates the potential for simulation-based training to improve resident operative performance and autonomy for laparoscopic common bile duct exploration.
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Affiliation(s)
- Molly Q Nyren
- College of Medicine, University of Florida, Gainesville, FL
| | | | | | - Kenneth L Abbott
- Department of Surgery, University of Florida Health, Gainesville, FL
| | - Jeremy A Balch
- Department of Surgery, University of Florida Health, Gainesville, FL
| | - Philip A Efron
- Department of Surgery, University of Florida Health, Gainesville, FL
| | - Brian C George
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | | | | | - George A Sarosi
- Department of Surgery, University of Florida Health, Gainesville, FL
| | - Tyler J Loftus
- Department of Surgery, University of Florida Health, Gainesville, FL.
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Nyren MQ, Filiberto AC, Underwood PW, Abbott KL, Balch JA, Mas FD, Cobianchi L, Efron PA, George BC, Shickel B, Upchurch GR, Sarosi GA, Loftus TJ. Surgical resident experience with common bile duct exploration and assessment of performance and autonomy with formative feedback. World J Emerg Surg 2023; 18:13. [PMID: 36747289 PMCID: PMC9901129 DOI: 10.1186/s13017-023-00480-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 01/23/2023] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Common bile duct exploration (CBDE) is safe and effective for managing choledocholithiasis, but most US general surgeons have limited experience with CBDE and are uncomfortable performing this procedure in practice. Surgical trainee exposure to CBDE is limited, and their learning curve for achieving autonomous, practice-ready performance has not been previously described. This study tests the hypothesis that receipt of one or more prior CBDE operative performance assessments, combined with formative feedback, is associated with greater resident operative performance and autonomy. METHODS Resident and attending assessments of resident operative performance and autonomy were obtained for 189 laparoscopic or open CBDEs performed at 28 institutions. Performance and autonomy were graded along validated ordinal scales. Cases in which the resident had one or more prior CBDE case evaluations (n = 48) were compared with cases in which the resident had no prior evaluations (n = 141). RESULTS Compared with cases in which the resident had no prior CBDE case evaluations, cases with a prior evaluation had greater proportions of practice-ready or exceptional performance ratings according to both residents (27% vs. 11%, p = .009) and attendings (58% vs. 19%, p < .001) and had greater proportions of passive help or supervision only autonomy ratings according to both residents (17% vs. 4%, p = .009) and attendings (69% vs. 32%, p < .01). CONCLUSIONS Residents with at least one prior CBDE evaluation and formative feedback demonstrated better operative performance and received greater autonomy than residents without prior evaluations, underscoring the propensity of feedback to help residents achieve autonomous, practice-ready performance for rare operations.
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Affiliation(s)
- Molly Q. Nyren
- grid.15276.370000 0004 1936 8091University of Florida College of Medicine, Gainesville, FL USA
| | - Amanda C. Filiberto
- grid.430508.a0000 0004 4911 114XDepartment of Surgery, University of Florida Health, PO Box 100286, Gainesville, FL 32610 USA
| | - Patrick W. Underwood
- grid.430508.a0000 0004 4911 114XDepartment of Surgery, University of Florida Health, PO Box 100286, Gainesville, FL 32610 USA
| | - Kenneth L. Abbott
- grid.430508.a0000 0004 4911 114XDepartment of Surgery, University of Florida Health, PO Box 100286, Gainesville, FL 32610 USA
| | - Jeremy A. Balch
- grid.430508.a0000 0004 4911 114XDepartment of Surgery, University of Florida Health, PO Box 100286, Gainesville, FL 32610 USA
| | - Francesca Dal Mas
- grid.7240.10000 0004 1763 0578Department of Management, Ca’ Foscari University of Venice, Venice, Italy
| | - Lorenzo Cobianchi
- grid.8982.b0000 0004 1762 5736Department of Clinical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy ,grid.419425.f0000 0004 1760 3027IRCCS Policlinico San Matteo Foundation, General Surgery, Pavia, Italy
| | - Philip A. Efron
- grid.430508.a0000 0004 4911 114XDepartment of Surgery, University of Florida Health, PO Box 100286, Gainesville, FL 32610 USA
| | - Brian C. George
- grid.214458.e0000000086837370Department of Surgery, University of Michigan, Ann Arbor, MI USA
| | - Benjamin Shickel
- grid.15276.370000 0004 1936 8091Department of Biomedical Engineering, University of Florida, Gainesville, FL USA
| | - Gilbert R. Upchurch
- grid.430508.a0000 0004 4911 114XDepartment of Surgery, University of Florida Health, PO Box 100286, Gainesville, FL 32610 USA
| | - George A. Sarosi
- grid.430508.a0000 0004 4911 114XDepartment of Surgery, University of Florida Health, PO Box 100286, Gainesville, FL 32610 USA
| | - Tyler J. Loftus
- grid.430508.a0000 0004 4911 114XDepartment of Surgery, University of Florida Health, PO Box 100286, Gainesville, FL 32610 USA
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Stettler GR, Ganapathy AS, Bosley ME, Spencer AL, Neff LP, Nunn AM, Miller PR. Win or lose, nighttime transcystic laparoscopic common bile duct exploration is a win. Trauma Surg Acute Care Open 2023; 8:e001045. [PMID: 36726402 PMCID: PMC9884901 DOI: 10.1136/tsaco-2022-001045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 01/07/2023] [Indexed: 01/26/2023] Open
Abstract
Objectives Although controversial, recent data suggest nighttime versus daytime laparoscopic cholecystectomy (LC) have comparable outcomes. Laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis decreases length of stay (LOS) as compared with LC with endoscopic retrograde cholangiopancreatography (ERCP) but increases case complexity/time. The influence of time of day on LCBDE outcomes has not been evaluated. Our aim was to examine outcomes and LOS for nighttime (PM) compared with daytime LC+LCBDE (DAY). Methods Consecutive patients who underwent LCBDE were reviewed. Demographics, operative duration, success of LCBDE, time to postoperative ERCP (if required), LOS, and complications were compared. PM procedures were defined as beginning 19:00-07:00 hours. Results Between 2018 and 2022, sixty patients underwent LCBDE (PM 42%). Groups had equivalent age/sex and preoperative liver function tests (LFTs). LCBDE success was 69% PM versus 71% DAY (p=0.78). Operative duration did not differ (2.8 IQR: 2.2-3.3 hours vs. 2.8 IQR: 2.3-3.2 hours, p=0.9). LOS was compared, and PM LOS was shorter (p=0.03). Time to ERCP after a failed LCBDE at night was compared with daytime (13.8 IQR: 10.6-29.5 hours vs. 19.9 IQR: 18.7-54.4 hours, p=0.07). LOS for failed PM LCBDE requiring ERCP was similar to successful DAY LCBDE (p=0.29). One complication (transient hyperbilirubinemia) was reported in the DAY group, none in PM. Conclusion PM LCBDE cases are equivalent in safety and success rate to DAY cases but have reduced LOS. Widespread adoption of acute care surgery-driven management of choledocholithiasis via LCBDE during cholecystectomy may decrease LOS, especially in PM cases. Level of evidence Level IV.
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Affiliation(s)
- Gregory R Stettler
- Department of Surgery, Division of Trauma and Acute Care Surgery, Atrium Health Wake Forest Baptist Hospital, Winston-Salem, North Carolina, USA
| | - Aravindh S Ganapathy
- Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Maggie E Bosley
- Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Audrey L Spencer
- Department of Surgery, Division of Trauma and Acute Care Surgery, Atrium Health Wake Forest Baptist Hospital, Winston-Salem, North Carolina, USA
| | - Lucas P Neff
- Department of Surgery, Division of Pediatric Surgery, Atrium Health Wake Forest Baptist Hospital, Winston-Salem, North Carolina, USA
| | - Andrew M Nunn
- Department of Surgery, Division of Trauma and Acute Care Surgery, Atrium Health Wake Forest Baptist Hospital, Winston-Salem, North Carolina, USA
| | - Preston R Miller
- Department of Surgery, Division of Trauma and Acute Care Surgery, Atrium Health Wake Forest Baptist Hospital, Winston-Salem, North Carolina, USA
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Jagtap N, Waghmare S, Sundaram S, Khairatkar R, Modak S, Lakhtakia S, Tandan M, Rao GV, Reddy DN. Indian Survey on Management of Choledocholithiasis—Opportunities for Improvement and Future Studies. JOURNAL OF DIGESTIVE ENDOSCOPY 2022. [DOI: 10.1055/s-0042-1758533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Abstract
Background In clinical practice, decision about management of choledocholithiasis is driven by availability of resources and expertise, patients and healthcare professional preferences. This survey is aimed to describe the approach of physicians and surgeons for the management of choledocholithiasis.
Method A 36-question online survey was conducted using Google Forms on various aspects of management of choledocholithiasis.
Results The responses from 323 participants were included, of which 202 (62.54%) were physicians and 121 (37.46%) were surgeons. The proportion of responders who do not follow American or European Society of Gastrointestinal Endoscopy guidelines is associated with increasing age and experience of responders (p = 0.0001), while place of work (private vs. teaching) and broad specialty (physician vs surgeon) are not associated (p >0.05). For patients with high likelihood of choledocholithiasis, 123 (38.1%) participants prefer to do endoscopic ultrasound/magnetic resonance cholangiopancreatography (EUS/MRCP) rather than directly performing endoscopic retrograde cholangiopancreatography/intraoperative cholangiography (ERCP/IOC). For intermediate likelihood, MRCP is more commonly preferred compared with EUS, due to local availability (44%), expertise (39.6%), healthcare professionals preference (30.7%), and patients preference (17.3%). For difficult common bile duct (CBD) stones, short biliary sphincterotomy with large balloon sphincteroplasty (59.4%), followed by laparoscopic CBD exploration are commonly used approaches. Prophylactic CBD stent placement after ERCP and CBD clearance is common practice. Preoperative ERCP followed by cholecystectomy is more preferred approach than cholecystectomy and CBD exploration.
Conclusion There is considerable variability in the management of choledocholithiasis. The practices such as use of EUS/MRCP for high likelihood group, use of prophylactic CBD stent placement after ERCP and CBD clearance, and use of single stage approach especially in patient with intermediate likelihood group should be addressed in future studies.
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Affiliation(s)
- Nitin Jagtap
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Sudatta Waghmare
- Department of General Surgery, Topiwala National Medical College, Mumbai, Maharashtra, India
| | - Sridhar Sundaram
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Rohan Khairatkar
- Department of General Surgery, Dr Vaishampayan Memorial Medical College, Solapur, Maharashtra, India
| | - Shreeyash Modak
- Department of Surgical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Sundeep Lakhtakia
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Manu Tandan
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - G. Venkat Rao
- Department of Surgical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - D. Nageshwar Reddy
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
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Tanase A, Russell TB, Platt T, Griffiths EA, Aroori S. The single-stage management of bile duct stones is underutilised: A prospective multicentre cohort study with a literature review. Ann Hepatobiliary Pancreat Surg 2022; 26:333-338. [PMID: 35995582 PMCID: PMC9721244 DOI: 10.14701/ahbps.22-001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 03/11/2022] [Accepted: 03/16/2022] [Indexed: 12/15/2022] Open
Abstract
Backgrounds/Aims Bile duct stones (BDS) can be managed either prior to laparoscopic cholecystectomy (LC) using endoscopic retrograde cholangiopancreatography (ERCP) or with laparoscopic bile duct exploration (LBDE) at the time of LC. The latter is underutilised. The aim of this study was to use the dataset of the previously performed CholeS study to investigate LBDE hospital volumes, LBDE-to-LC rates, and LBDE outcomes. Methods Data from 166 United Kingdom/Republic of Ireland hospitals were used to study the utilisation of LBDE in LC patients. Results Of 8,820 LCs performed, 932 patients (10.6%) underwent preoperative ERCP and 256 patients (2.9%) underwent LBDE. Of the 256 patients who underwent LBDE, 73 patients (28.5%) had undergone prior ERCP and 112 patients (43.8%) had undergone prior magnetic resonance cholangiopancreatography. Fifteen (9.0%) of the 166 included hospitals performed less than five LBDEs in the two-month study period. LBDEs were mainly performed by upper gastrointestinal surgeons (84.4%) and colorectal surgeons (10.0%). Eighty-seven percent of the LBDEs were performed by consultants and 13.0% were performed by trainees. The laparoscopic-to-open conversion rate was 12.5%. The median operation time was 111 minutes (range: 75-155 minutes). Median hospital stay was 6 days (range: 4-11 days) for emergency LBDEs and 1 day (range: 1-4 days) for elective LBDEs. Overall morbidity was 21.5%. Bile leak rate was 5.3%. Thirty-day readmission and mortality rates were 12.1% and 0.4%, respectively. Conclusions The single-stage approach to managing BDS was underutilised. An additional prospective study with a longer study period is needed to verify this finding.
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Affiliation(s)
- Andrei Tanase
- Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Plymouth, United Kingdom
| | - Thomas Brendon Russell
- Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Plymouth, United Kingdom
| | - Timothy Platt
- Department of Upper GI Surgery, Torbay Hospital, Torquay, United Kingdom
| | | | - Somaiah Aroori
- Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Plymouth, United Kingdom,Corresponding author: Somaiah Aroori, MS, MD, PgcMEd, EBSQ Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Derriford Road, Plymouth PL6 8DH, United Kingdom Tel: +44-7837388342, Fax: +44-8451555235, E-mail: ORCID: https://orcid.org/0000-0002-5613-6463
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Inpatient Choledocholithiasis Management: a Cost-Effectiveness Analysis of Management Algorithms. J Gastrointest Surg 2022; 26:837-848. [PMID: 35083722 DOI: 10.1007/s11605-022-05249-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 01/08/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Choledocholithiasis is commonly encountered. It is frequently managed with laparoscopic common bile duct exploration or endoscopic retrograde cholangiopancreatography (either preoperative, intraoperative, or postoperative relative to laparoscopic cholecystectomy). The purpose of this study is to determine the most cost-effective method to manage inpatient choledocholithiasis. METHODS A decision tree model was created to evaluate the cost-effectiveness of laparoscopic common bile duct exploration and preoperative, intraoperative, and postoperative endoscopic retrograde cholangiopancreatography. The primary outcome was incremental cost-effectiveness ratio with a ceiling willingness to pay threshold assumed of $100,000 per quality-adjusted life year. Model parameters were determined through review of published literature and institutional data. Costs were from the perspective of the healthcare system with a time horizon of 1 year. Sensitivity analyses were performed on model parameters. RESULTS In the base case analysis, laparoscopic common bile duct exploration was cost-effective, resulting in 0.9909 quality-adjusted life years at an expected cost of $18,357. Intraoperative endoscopic retrograde cholangiopancreatography yielded more quality-adjusted life years (0.9912) at a higher cost ($19,717) with an incremental cost-effectiveness ratio of $4,789,025, exceeding the willingness to pay threshold. Both preoperative and postoperative endoscopic retrograde cholangiopancreatographies were eliminated for being both more costly and less effective. Laparoscopic common bile duct exploration remained cost-effective if the probability of successful biliary clearance was above 0.79, holding all other variables constant. If its base cost remained below $18,400 and intraoperative endoscopic retrograde cholangiopancreatography base cost rose above $18,200, then laparoscopic common bile duct exploration remained cost-effective. CONCLUSION Laparoscopic common bile duct exploration is the most cost-effective method to manage choledocholithiasis. Efforts to ensure availability of local expertise and resources for this procedure are warranted.
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Tanase A, Dhanda A, Cramp M, Streeter A, Aroori S. A UK survey on variation in the practice of management of choledocholithiasis and laparoscopic common bile duct exploration (ALiCE Survey). Surg Endosc 2022; 36:5882-5896. [PMID: 35146558 DOI: 10.1007/s00464-021-08983-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 12/31/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The practice of managing suspected/confirmed common bile duct stones (CBDS) can vary significantly in the UK. We aimed to assess this variability in practice and challenges to form a basis for future consensus. METHODS An electronic survey containing 40 questions on various aspects of management of CBDS was sent to surgeons who perform cholecystectomies via five surgical associations. RESULTS A total of 132 surgeons responded to the survey. The speciality of surgeons includes upper gastro-intestinal (68%), general (18%), colorectal (12%), and others (2%). For patients with suspected CBD stones, 80% would choose magnetic resonance cholangio-pancreatography, and 14.4% would proceed to intra-operative imaging. Most surgeons preferred intra-operative cholangiogram over intra-operative ultrasound (83% vs 17%). For the treatment, 62.1% preferred a two-stage approach [endoscopic retrograde cholangio-pancreatography (ERCP) followed by laparoscopic cholecystectomy (LC)] and 33.4% chose a single-stage approach [LC + laparoscopic common bile duct exploration (LCBDE)]. Eighty (60.6%) responders performed LCBDE, and 19 (23.8%) of them performed > 10 LCBDEs in a year. Two third of surgeons (62.5%) preferred a trans-choledochal approach to CBDS. Half of the surgeons that perform LCBDE use a T-tube selectively and 1.6% routinely. The "availability of very good ERCP service" and "lack of formal training" were the two main reasons for surgeons not performing LCBDE. Both surgeons' speciality and whether they perform other complex laparoscopic surgery were significantly associated with choosing a two-stage approach over a one-stage approach (χ2 test, speciality p = 0.033, complex surgery p = 0.011). CONCLUSION Our survey confirms the significant variability in the diagnosis and management of CBDS. The two-stage approach is still the most common way of managing CBDS in the UK. The main reasons for the low uptake of the single-stage approach are the availability of good ERCP service, lack of equipment and lack of formal training in the technique of LCBDE.
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Affiliation(s)
- Andrei Tanase
- Peninsula HPB Unit, Derriford Hospital, University Hospitals Plymouth NHS Trust, Plymouth, UK
- Peninsula Medical School (Faculty of Health), University of Plymouth, Plymouth, UK
| | - Ashwin Dhanda
- South West Liver Unit, Derriford Hospital, University Hospitals Plymouth NHS Trust, Plymouth, UK
- Peninsula Medical School (Faculty of Health), University of Plymouth, Plymouth, UK
| | - Matthew Cramp
- South West Liver Unit, Derriford Hospital, University Hospitals Plymouth NHS Trust, Plymouth, UK
- Peninsula Medical School (Faculty of Health), University of Plymouth, Plymouth, UK
| | - Adam Streeter
- Peninsula Medical School (Faculty of Health), University of Plymouth, Plymouth, UK
| | - Somaiah Aroori
- Peninsula HPB Unit, Derriford Hospital, University Hospitals Plymouth NHS Trust, Plymouth, UK.
- Peninsula Medical School (Faculty of Health), University of Plymouth, Plymouth, UK.
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11
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Jorba R, Pavel MC, Llàcer-Millán E, Estalella L, Achalandabaso M, Julià-Verdaguer E, Nve E, Padilla-Zegarra ED, Badia JM, O'Connor DB, Memba R. Contemporary management of concomitant gallstones and common bile duct stones: a survey of Spanish surgeons. Surg Endosc 2021; 35:5024-5033. [PMID: 32968916 DOI: 10.1007/s00464-020-07984-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 09/14/2020] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Rosa Jorba
- Department of Abdominal and General Surgery, Hospital Universitari de Tarragona, Joan XXIII, Dr Mallafre Guasch, 4, 43005, Tarragona, Spain.
| | - Mihai C Pavel
- Department of Abdominal and General Surgery, Hospital Universitari de Tarragona, Joan XXIII, Dr Mallafre Guasch, 4, 43005, Tarragona, Spain
| | - Erik Llàcer-Millán
- Department of Abdominal and General Surgery, Hospital Universitari de Tarragona, Joan XXIII, Dr Mallafre Guasch, 4, 43005, Tarragona, Spain
| | - Laia Estalella
- Department of Abdominal and General Surgery, Hospital Universitari de Tarragona, Joan XXIII, Dr Mallafre Guasch, 4, 43005, Tarragona, Spain
| | - Mar Achalandabaso
- Department of Abdominal and General Surgery, Hospital Universitari de Tarragona, Joan XXIII, Dr Mallafre Guasch, 4, 43005, Tarragona, Spain
| | - Elisabet Julià-Verdaguer
- Department of Abdominal and General Surgery, Hospital Universitari de Tarragona, Joan XXIII, Dr Mallafre Guasch, 4, 43005, Tarragona, Spain
| | - Esther Nve
- Department of General Surgery, Hospital de Granollers, Granollers, Spain
| | - Erlinda D Padilla-Zegarra
- Department of Abdominal and General Surgery, Hospital Universitari de Tarragona, Joan XXIII, Dr Mallafre Guasch, 4, 43005, Tarragona, Spain
| | - Josep M Badia
- Department of General Surgery, Hospital de Granollers, Granollers, Spain
| | - Donal B O'Connor
- Department of Surgery, School of Medicine, Trinity College Dublin, Dublin 2, Ireland
| | - Robert Memba
- Department of Abdominal and General Surgery, Hospital Universitari de Tarragona, Joan XXIII, Dr Mallafre Guasch, 4, 43005, Tarragona, Spain
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12
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Pan L, Deng X, Li B, Wu Q. Endoscopic Biliary Decompression by Dual Stents in Elderly Patients with Acute Cholangitis of Severe Type due to Choledocholithiasis. J Laparoendosc Adv Surg Tech A 2021; 32:282-287. [PMID: 33945325 DOI: 10.1089/lap.2021.0085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022] Open
Abstract
Background/Aims: Both endoscopic nasobiliary drainage (ENBD) and a plastic stent placement have some limitations in biliary decompression of elderly patients with acute cholangitis of severe type (ACST) due to choledocholithiasis. Dual stent placement may improve bile drainage without obvious discomfort. Here, we evaluated its advantages in the biliary decompression of elderly patients with ACST. Materials and Methods: A total of 257 elderly patients (≥65 years) with ACST had undergone urgent endoscopic decompression by nasobiliary catheter (ENBD group), single plastic stent (single-stent group), or dual plastic stents (dual-stent group). The data of the three groups was compared retrospectively. Results: The demographic data of the patients in the three groups were comparable. After endoscopic decompression, the serum total bilirubin and γ-glutamyl transferase levels in the dual-stent group were decreased faster than that in the single-stent group (P < .05). The abdominal pain in the dual-stent group was dramatically slighter than that in the ENBD group (P < .05). Compared with two other groups, the acute physiology and chronic health evaluation II scores were decreased dramatically quicker (P < .05) and the length of intensive care unit stay was significantly shorter (P < .05) in the dual-stent group. In the second endoscopic retrograde cholangiopancreatography, the rate of complete stone clearance in the dual-stent group was significantly higher than that in the ENBD group (P < .05). Conclusions: Dual-stent placement might be a better choice for elderly patients with ACST due to choledocholithiasis in comparison with ENBD or a single-stent placement.
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Affiliation(s)
- Long Pan
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xin Deng
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Bin Li
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qiao Wu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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13
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Aleknaite A, Simutis G, Stanaitis J, Jucaitis T, Drungilas M, Valantinas J, Strupas K. 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. JMIR Res Protoc 2021; 10:e18837. [PMID: 33538700 PMCID: PMC7892280 DOI: 10.2196/18837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 08/04/2020] [Accepted: 11/10/2020] [Indexed: 12/22/2022] Open
Abstract
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
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Affiliation(s)
- Ausra Aleknaite
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine of Vilnius University, Vilnius, Lithuania.,Center of Hepatology, Gastroenterology and Dietetics, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Gintaras Simutis
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine of Vilnius University, Vilnius, Lithuania.,Center of Abdominal Surgery, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Juozas Stanaitis
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine of Vilnius University, Vilnius, Lithuania.,Center of Hepatology, Gastroenterology and Dietetics, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Tomas Jucaitis
- Center of Hepatology, Gastroenterology and Dietetics, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Mantas Drungilas
- Center of Abdominal Surgery, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Jonas Valantinas
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine of Vilnius University, Vilnius, Lithuania.,Center of Hepatology, Gastroenterology and Dietetics, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Kestutis Strupas
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine of Vilnius University, Vilnius, Lithuania.,Center of Abdominal Surgery, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
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14
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Single-stage management of choledocholithiasis: intraoperative ERCP versus laparoscopic common bile duct exploration. Surg Endosc 2020; 34:4616-4625. [PMID: 31617103 DOI: 10.1007/s00464-019-07215-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 10/09/2019] [Indexed: 01/25/2023]
Abstract
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.
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15
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Yildirim M, Dasiran F, Ozsoy U, Daldal E, Kocabay A, Okan I. The Efficiency of Laparoscopic Common Bile Duct Exploration in Endoscopic Retrograde-Cholangiopancreatography-Limited Setting in a Peripheral University Hospital. J Laparoendosc Adv Surg Tech A 2020; 31:665-671. [PMID: 32907473 DOI: 10.1089/lap.2020.0525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: The aim of this study is to evaluate complications and costs in patients treated with laparoscopic and open method for common bile duct (CBD) stones. Secondary aim is to compare the effectiveness, safety, and outcomes of these methods. In addition, it is aimed to review the feasibility of laparoscopic method in rural areas. Methods: Seventy-one patients were analyzed retrospectively. Patients were divided into two groups as open and laparoscopic surgical method. These groups were analyzed comparatively in terms of complications and costs. Subgroups were formed from patients who underwent T-tube drainage, primary closure, and biliary anastomosis as choledochotomy management. As a secondary outcome, these three subgroups were investigated in terms of complications and cost. Results: The cost was lower in open method compared to laparoscopic method (484$, 707$, P = .002). There was no significant difference in postoperative complications between groups (P = .257). While the mean hospital stay was longer in the open group, the operation time was shorter (P = .002, P = .03). The mean length of hospital stay in the T-tube group was significantly higher than the primary closure (P = .001). The cost in the T-tube group was significantly higher than the primary closure and biliary anastomosis groups. Conclusion: Laparoscopic CBD exploration by experienced surgeons in endoscopic retrograde-cholangiopancreatography-limited settings is an effective and safe method in the treatment of choledocholithiasis. This procedure should not be limited to reference centers and should be performed safely in rural areas by well-trained surgeons.
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Affiliation(s)
- Murat Yildirim
- Department of General Surgery, Faculty of Medicine, Gaziosmanpasa University, Tokat, Turkey
| | - Fatih Dasiran
- Department of General Surgery, Faculty of Medicine, Gaziosmanpasa University, Tokat, Turkey
| | - Ugur Ozsoy
- Department of General Surgery, Faculty of Medicine, Gaziosmanpasa University, Tokat, Turkey
| | - Emin Daldal
- Department of General Surgery, Faculty of Medicine, Gaziosmanpasa University, Tokat, Turkey
| | - Asim Kocabay
- Department of General Surgery, Faculty of Medicine, Gaziosmanpasa University, Tokat, Turkey
| | - Ismail Okan
- Department of General Surgery, Faculty of Medicine, Gaziosmanpasa University, Tokat, Turkey
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16
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Serum Carbohydrate Antigen 199 as a Biomarker for Evaluating Patients with Choledocholithiasis. Gastroenterol Res Pract 2020; 2020:2739612. [PMID: 32308673 PMCID: PMC7132361 DOI: 10.1155/2020/2739612] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 02/25/2020] [Accepted: 02/27/2020] [Indexed: 02/08/2023] Open
Abstract
Aims Choledocholithiasis is a common and yet potentially debilitating disease of the biliary tract. While certain patients with this disease remain largely asymptomatic or experience mild discomfort, in several cases, patient can suffer biliary inflammation and other serious symptoms. Previous studies have detected elevated serum levels of carbohydrate antigen 199 in patients with choledocholithiasis. We wanted to know whether serum CA199 level in patients with choledocholithiasis is related to the level of inflammation in patients. Methods In the present study, we separated a cohort of 135 choledocholithiasis patients into two groups based on their white blood cell counts, which were either 3.5 − 9.5 × 109/L or ≥9.5 × 109/L. We also divided patients into two groups according to CPR < 10 mg/L and CRP ≥ 10 mg/L. At the same time, the correlation between CA199 and CRP level was analyzed. Results We then used a Rank-sum test to compare serum carbohydrate 199 levels between these groups, revealing significantly higher levels of this antigen in patients with a white cell count ≥9.5 × 109/L (Z = −3.584, P < 0.01). The two groups were grouped by CRP, and the CA199 level was compared. The difference between the two groups was statistically significant (P < 0.01). The correlation analysis between CA199 and CRP showed an obvious correlation (r = 0.574). Conclusion This suggests that in patients with choledocholithiasis, higher circulating carbohydrate antigen 199 levels may correspond to a higher degree of inflammation.
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17
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Bo X, Wang J, Nan L, Xin Y, Gao Z, Wang C, Li M, Shen S, Liu H, Ni X, Suo T, Lu P, Zhang D, Wang Y, Liu H. 3D laparoscopic common bile duct exploration versus 2D in choledocholithiasis patients: a propensity score analysis. Surg Endosc 2020; 35:819-825. [PMID: 32198551 DOI: 10.1007/s00464-020-07453-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 02/11/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND This study was designed to investigate whether 3D laparoscopic common bile duct (LCBDE) could improve surgical outcomes in choledocholithiasis patients compared with 2D LCBDE. METHOD Propensity score-matched analysis was performed to balance the bias in baseline characteristic between two groups. RESULTS 213 patients underwent 3D LCBDE and 212 patients receiving 2D LCBDE were enrolled in this study. The operation time and blood loss in 3D group were significantly less than that in 2D group. After propensity score matching, a total of 114 paired cases were selected from the two groups. The operation time and blood loss in 3D group remain significantly lower than in 2D group. In the end, the subgroup analysis based on abdominal adhesion level was performed and it was observed that for patients with adhesion level 1 and level 2, 3D surgery could obviously decrease the operation time and intraoperative blood loss. CONCLUSIONS 3D LCBDE would significantly reduce operation time, blood loss, and conversion rate to laparotomy in choledocholithiasis patients versus 2D LCBDE. For patients with abdominal adhesions level 1 and level 2, 3D LCBDE could provide better surgical outcomes than 2D LCBDE.
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Affiliation(s)
- Xiaobo Bo
- Department of General Surgery, Zhongshan Hospital, Fudan University, 180 Fenglin Rd, Shanghai, 200032, China.,Biliary Tract Diseases Institute, Fudan University, 180 Fenglin Rd., Shanghai, 200032, China
| | - Jie Wang
- Department of General Surgery, Zhongshan Hospital, Fudan University, 180 Fenglin Rd, Shanghai, 200032, China.,Biliary Tract Diseases Institute, Fudan University, 180 Fenglin Rd., Shanghai, 200032, China
| | - Lingxi Nan
- Department of General Surgery, Zhongshan Hospital, Fudan University, 180 Fenglin Rd, Shanghai, 200032, China.,Biliary Tract Diseases Institute, Fudan University, 180 Fenglin Rd., Shanghai, 200032, China
| | - Yanlei Xin
- Department of General Surgery, Zhongshan Hospital, Fudan University, 180 Fenglin Rd, Shanghai, 200032, China.,Biliary Tract Diseases Institute, Fudan University, 180 Fenglin Rd., Shanghai, 200032, China
| | - Zhihui Gao
- Department of General Surgery, Zhongshan Hospital, Fudan University, 180 Fenglin Rd, Shanghai, 200032, China.,Biliary Tract Diseases Institute, Fudan University, 180 Fenglin Rd., Shanghai, 200032, China
| | - Changcheng Wang
- Department of General Surgery, Zhongshan Hospital, Fudan University, 180 Fenglin Rd, Shanghai, 200032, China
| | - Min Li
- Department of General Surgery, Zhongshan Hospital, Fudan University, 180 Fenglin Rd, Shanghai, 200032, China.,Biliary Tract Diseases Institute, Fudan University, 180 Fenglin Rd., Shanghai, 200032, China
| | - Sheng Shen
- Department of General Surgery, Zhongshan Hospital, Fudan University, 180 Fenglin Rd, Shanghai, 200032, China.,Biliary Tract Diseases Institute, Fudan University, 180 Fenglin Rd., Shanghai, 200032, China
| | - Han Liu
- Department of General Surgery, Zhongshan Hospital, Fudan University, 180 Fenglin Rd, Shanghai, 200032, China.,Biliary Tract Diseases Institute, Fudan University, 180 Fenglin Rd., Shanghai, 200032, China
| | - Xiaoling Ni
- Department of General Surgery, Zhongshan Hospital, Fudan University, 180 Fenglin Rd, Shanghai, 200032, China.,Biliary Tract Diseases Institute, Fudan University, 180 Fenglin Rd., Shanghai, 200032, China
| | - Tao Suo
- Department of General Surgery, Zhongshan Hospital, Fudan University, 180 Fenglin Rd, Shanghai, 200032, China.,Biliary Tract Diseases Institute, Fudan University, 180 Fenglin Rd., Shanghai, 200032, China
| | - Pinxiang Lu
- Department of General Surgery, Zhongshan Hospital, Fudan University, 180 Fenglin Rd, Shanghai, 200032, China
| | - Dexiang Zhang
- General Surgery Department, Zhongshan-Xuhui Hospital Affiliated to Fudan University, 966 Middle Huaihai Rd., Shanghai, 200031, China
| | - Yueqi Wang
- Department of General Surgery, Zhongshan Hospital, Fudan University, 180 Fenglin Rd, Shanghai, 200032, China. .,Biliary Tract Diseases Institute, Fudan University, 180 Fenglin Rd., Shanghai, 200032, China.
| | - Houbao Liu
- Department of General Surgery, Zhongshan Hospital, Fudan University, 180 Fenglin Rd, Shanghai, 200032, China. .,General Surgery Department, Zhongshan-Xuhui Hospital Affiliated to Fudan University, 966 Middle Huaihai Rd., Shanghai, 200031, China. .,Biliary Tract Diseases Institute, Fudan University, 180 Fenglin Rd., Shanghai, 200032, China.
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18
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Warner RL, Coleman KC, Musgrove KA, Bardes JM, Borgstrom DC, Grabo DJ. A review of general surgery resident experience in common bile duct exploration in the ERCP era. Am J Surg 2020; 220:899-904. [PMID: 32087987 DOI: 10.1016/j.amjsurg.2020.02.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 02/11/2020] [Accepted: 02/14/2020] [Indexed: 01/26/2023]
Abstract
BACKGROUND Use of minimally invasive techniques for management of common bile duct (CBD) stones has led to declining number of CBD explorations (CBDE) performed at teaching and non-teaching institutions. We evaluate the impact of this decline on surgery training in bile duct procedures. STUDY DESIGN National operative data for general surgery residents (GSR) were examined from 2000 to 2018. Biliary operations including, cholecystectomy open and laparoscopic, and CBDE open and laparoscopic were evaluated for mean number of cases per graduating GSR. RESULTS Despite increases in number of GSR, case numbers for laparoscopic cholecystectomy increased 39% from 84 to 117, p < .00001, per GSR. Mean number of cases for open CBDE, however, decreased 74% from 2.7 to 0.7, p < .00001, per GSR and laparoscopic CBDE declined 22% from 0.9 to 0.7 per resident. CONCLUSION GSR operative case volume in CBDE has declined significantly creating a training deficiency for this complex skill. Novel simulation, including fresh cadavers, may offer the best option with high-fidelity, dynamic training to mitigate the loss of low volume, high acuity procedures.
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Affiliation(s)
- Rachel L Warner
- Department of Surgery, West Virginia University, Morgantown, WV, USA
| | - K Conley Coleman
- Department of Surgery, West Virginia University, Morgantown, WV, USA
| | - Kelsey A Musgrove
- Department of Surgery, West Virginia University, Morgantown, WV, USA
| | - James M Bardes
- Department of Surgery, West Virginia University, Morgantown, WV, USA
| | - David C Borgstrom
- Department of Surgery, West Virginia University, Morgantown, WV, USA
| | - Daniel J Grabo
- Department of Surgery, West Virginia University, Morgantown, WV, USA.
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19
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Zhu JG, Wu S, Feng Q, Li F, Han W, Xiu D, Tan H, Fu J, Li X, Shang D, Liu H, Li B, Yang L, Kong Y, Zhan S, Guo W, Zhang ZT. Protocol for the CREST Choles (Chinese REgistry Study on Treatment of Cholecysto-Choledocholithiasis) study: an ambispective, multicenter, observational, open-cohort study. BMJ Open 2019; 9:e030293. [PMID: 31767583 PMCID: PMC6887007 DOI: 10.1136/bmjopen-2019-030293] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
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.
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Affiliation(s)
- Jie-Gao Zhu
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Cancer Invasion and Metastasis Research, Beijing, China
- National Clinical Research Center for Digestive Diseases, Beijing, China
- Beijing Institute of Clinical Medicine, Beijing, China
| | - Shanshan Wu
- National Clinical Research Center for Digestive Diseases, Beijing, China
- Clinical Epidemiology and Evidence-Based Medicine Unit, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Qiushi Feng
- Endoscopy Center, Peking University First Hospital, Beijing, China
| | - Fei Li
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wei Han
- Department of General Surgery, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Dianrong Xiu
- Department of General Surgery, Peking University Third Hospital, Beijing, China
| | - Haidong Tan
- Department of General Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Jianzhu Fu
- Department of General Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Xun Li
- Department of General Surgery, The First Hospital of LanZhou University, Lanzhou, China
| | - Dong Shang
- Department of General Surgery, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Houbao Liu
- Department of General Surgery, Zhongshan Hospital Affiliated to Fudan University, Shanghai, China
| | - Binglu Li
- Department of General Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Li Yang
- Department of Health Policy and Management, School of Public Health, Peking University, Beijing, China
| | - Yuanyuan Kong
- National Clinical Research Center for Digestive Diseases, Beijing, China
- Clinical Epidemiology and Evidence-Based Medicine Unit, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Siyan Zhan
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
| | - Wei Guo
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Cancer Invasion and Metastasis Research, Beijing, China
- National Clinical Research Center for Digestive Diseases, Beijing, China
- Beijing Institute of Clinical Medicine, Beijing, China
| | - Zhong-Tao Zhang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Cancer Invasion and Metastasis Research, Beijing, China
- National Clinical Research Center for Digestive Diseases, Beijing, China
- Beijing Institute of Clinical Medicine, Beijing, China
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Di Mauro D, Ricciardi E, Siragusa L, Manzelli A. Outcome of Laparoscopic Common Bile Duct Exploration After Failed Endoscopic Retrograde Cholangiopancreatography: A Comparative Study. J Laparoendosc Adv Surg Tech A 2019; 29:1391-1396. [DOI: 10.1089/lap.2019.0383] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Davide Di Mauro
- Department of Upper GI Surgery, Royal Devon and Exeter NHS Foundation Trust, Exeter, United Kingdom
| | - Edoardo Ricciardi
- Department of Upper GI Surgery, Royal Devon and Exeter NHS Foundation Trust, Exeter, United Kingdom
| | - Leandro Siragusa
- Department of Surgery, University of Rome Tor Vergata, Rome, Italy
| | - Antonio Manzelli
- Department of Upper GI Surgery, Royal Devon and Exeter NHS Foundation Trust, Exeter, United Kingdom
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Gad EH, Zakaria H, Kamel Y, Alsebaey A, Zakareya T, Abbasy M, Mohamed A, Nada A, Abdelsamee MA, Housseni M. Surgical (Open and laparoscopic) management of large difficult CBD stones after different sessions of endoscopic failure: A retrospective cohort study. Ann Med Surg (Lond) 2019. [DOI: https:/doi.org/10.1016/j.amsu.2019.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
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Peponis T, Panda N, Eskesen TG, Forcione DG, Yeh DD, Saillant N, Kaafarani HM, King DR, de Moya MA, Velmahos GC, Fagenholz PJ. Preoperative endoscopic retrograde cholangio-pancreatography (ERCP) is a risk factor for surgical site infections after laparoscopic cholecystectomy. Am J Surg 2019; 218:140-144. [DOI: 10.1016/j.amjsurg.2018.09.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 09/14/2018] [Accepted: 09/24/2018] [Indexed: 12/27/2022]
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Gad EH, Zakaria H, Kamel Y, Alsebaey A, Zakareya T, Abbasy M, Mohamed A, Nada A, Abdelsamee MA, Housseni M. Surgical (Open and laparoscopic) management of large difficult CBD stones after different sessions of endoscopic failure: A retrospective cohort study. Ann Med Surg (Lond) 2019. [DOI: https://doi.org/10.1016/j.amsu.2019.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
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Gad EH, Zakaria H, Kamel Y, Alsebaey A, Zakareya T, Abbasy M, Mohamed A, Nada A, Abdelsamee MA, Housseni M. Surgical (Open and laparoscopic) management of large difficult CBD stones after different sessions of endoscopic failure: A retrospective cohort study. Ann Med Surg (Lond) 2019; 43:52-63. [PMID: 31198552 PMCID: PMC6556483 DOI: 10.1016/j.amsu.2019.05.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 05/18/2019] [Accepted: 05/23/2019] [Indexed: 02/06/2023] Open
Abstract
Objectives For complicated common bile duct stones (CBDS) that cannot be extracted by endoscopic retrograde cholangiopancreatography (ERCP), management can be safely by open or laparoscopic CBD exploration (CBDE). The study aimed to assess these surgical procedures after endoscopic failure. Methods We analyzed 85 patients underwent surgical management of difficult CBDS after ERCP failure, in the period from 2013 to 2018. Results Sixty-seven (78.8%) and 18(21.2%) of our patients underwent single and multiple ERCP sessions respectively. An impacted large stone was the most frequent cause of ERCP failure (60%). Laparoscopic CBDE(LCBDE), open CBDE(OCBDE) and the converted cases were 24.7% (n = 21), 70.6% (n = 60), and 4.7% (n = 4) respectively. Stone clearance rate post LCBDE and OCBDE reached 95.2% and 95% respectively, Eleven (12.9%) of our patients had postoperative complications without mortality. By comparing LCBDE and OCBDE; there was a significant association between the former and longer operative time. On comparing, T-tube and 1ry CBD closure in both OCBDE and LCBDE, there was significantly longer operative time, and post-operative hospital stays in the former. Furthermore, in OCBDE group, choledocoscopy had an independent direction to 1ry CBD repair and significant association with higher stone clearance rate, shorter operative time, and post-operative hospital stay. Conclusion Large difficult CBDS can be managed either by open surgery or laparoscopically with acceptable comparable outcomes with no need for multiple ERCP sessions due to their related morbidities; furthermore, Open choledocoscopy has a good impact on stone clearance rate with direction towards doing primary repair that is better than T-tube regarding operative time and post-operative hospital stay. Large difficult CBD stones can be managed either by open surgery or laparoscopically with acceptable comparable outcomes. No need for multiple ERCP sessions due to their related morbidities. Open choledocoscopy has a good impact on stone clearance rate with direction towards doing primary repair. Primary repair is better than T-tube regarding operative time and post-operative hospital stay.
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Affiliation(s)
- Emad Hamdy Gad
- Hepatobiliary Surgery, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Hazem Zakaria
- Hepatobiliary Surgery, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Yasmin Kamel
- Anaesthesia, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Ayman Alsebaey
- Hepatology and Endoscopy, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Talat Zakareya
- Hepatology and Endoscopy, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Mohamed Abbasy
- Hepatology and Endoscopy, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Anwar Mohamed
- Hepatology and Endoscopy, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Ali Nada
- Hepatology and Endoscopy, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | | | - Mohamed Housseni
- Intervention Radiology, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
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Gad EH, Zakaria H, Kamel Y, Alsebaey A, Zakareya T, Abbasy M, Mohamed A, Nada A, Abdelsamee MA, Housseni M. Surgical (Open and laparoscopic) management of large difficult CBD stones after different sessions of endoscopic failure: A retrospective cohort study. ANNALS OF MEDICINE AND SURGERY (2012) 2019. [PMID: 31198552 DOI: 10.1016/j.amsu.2019.05.007.] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/01/2022]
Abstract
Objectives For complicated common bile duct stones (CBDS) that cannot be extracted by endoscopic retrograde cholangiopancreatography (ERCP), management can be safely by open or laparoscopic CBD exploration (CBDE). The study aimed to assess these surgical procedures after endoscopic failure. Methods We analyzed 85 patients underwent surgical management of difficult CBDS after ERCP failure, in the period from 2013 to 2018. Results Sixty-seven (78.8%) and 18(21.2%) of our patients underwent single and multiple ERCP sessions respectively. An impacted large stone was the most frequent cause of ERCP failure (60%). Laparoscopic CBDE(LCBDE), open CBDE(OCBDE) and the converted cases were 24.7% (n = 21), 70.6% (n = 60), and 4.7% (n = 4) respectively. Stone clearance rate post LCBDE and OCBDE reached 95.2% and 95% respectively, Eleven (12.9%) of our patients had postoperative complications without mortality. By comparing LCBDE and OCBDE; there was a significant association between the former and longer operative time. On comparing, T-tube and 1ry CBD closure in both OCBDE and LCBDE, there was significantly longer operative time, and post-operative hospital stays in the former. Furthermore, in OCBDE group, choledocoscopy had an independent direction to 1ry CBD repair and significant association with higher stone clearance rate, shorter operative time, and post-operative hospital stay. Conclusion Large difficult CBDS can be managed either by open surgery or laparoscopically with acceptable comparable outcomes with no need for multiple ERCP sessions due to their related morbidities; furthermore, Open choledocoscopy has a good impact on stone clearance rate with direction towards doing primary repair that is better than T-tube regarding operative time and post-operative hospital stay.
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Affiliation(s)
- Emad Hamdy Gad
- Hepatobiliary Surgery, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Hazem Zakaria
- Hepatobiliary Surgery, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Yasmin Kamel
- Anaesthesia, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Ayman Alsebaey
- Hepatology and Endoscopy, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Talat Zakareya
- Hepatology and Endoscopy, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Mohamed Abbasy
- Hepatology and Endoscopy, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Anwar Mohamed
- Hepatology and Endoscopy, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Ali Nada
- Hepatology and Endoscopy, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | | | - Mohamed Housseni
- Intervention Radiology, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
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Stiles R, Reyes J, Helmer SD, Vincent KB. What Procedures are Rural General Surgeons Performing and are They Prepared to Perform Specialty Procedures in Practice? Am Surg 2019. [DOI: 10.1177/000313481908500621] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Rural surgeons are performing operations typically performed by “specialists.” This study describes specialty procedures performed by general surgeons operating in a rural state and how prepared the surgeons felt starting their rural practice after residency A survey was sent to all exclusively rural surgeons actively practicing in the state, inquiring about their perception of preparedness for rural practice and specialty procedures performed. The survey had a 65.2 per cent response rate. Responders felt well prepared for rural practice after residency (mean response 4.6 ± 0.8 on a Likert scale from 1 to 5; 5 = “well prepared”). Noteworthy, specialty procedures performed by rural surgeons included hysterectomies (51.2%), thyroidectomies (81.4%), para-thyroidectomies (60.5%), carotid endarterectomies (11.6%), video-assisted thoracoscopic surgery (37.2%), and lobectomies (23.3%). Prominent write-ins included nephrectomies (n = 1), ileal conduits (n = 1), open and endovascular abdominal aortic aneurysm repair (n = 1), Whipples (n = 3), and liver resections (n = 2). Rural general surgeons perform many major operations usually performed by specialists. These surgeons felt well prepared for these operations out of residency.
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Affiliation(s)
- Roxanne Stiles
- Department of Surgery, The University of Kansas School of Medicine–Wichita, Wichita, Kansas; and
| | - Jared Reyes
- Department of Surgery, The University of Kansas School of Medicine–Wichita, Wichita, Kansas; and
| | - Stephen D. Helmer
- Department of Surgery, The University of Kansas School of Medicine–Wichita, Wichita, Kansas; and
- Department of Medical Education, Ascension Via Christi Hospital Saint Francis, Wichita, Kansas
| | - Kyle B. Vincent
- Department of Surgery, The University of Kansas School of Medicine–Wichita, Wichita, Kansas; and
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Frazee R, Regner J, Truitt MS, Agrawal V, Swope M, Burlew CC, Dissanaike S, Vangipurum D, Bruns B, O'Meara L, Stivers J, Kwok A, Grover BT, Kothari SN, Cibari C, Dunn J, McIntyre RC, Wright F, Scherer EP, Crane C, Schroeppel TJ, Callaghan E, Gordy S, Todd R. The southwestern surgical congress multi-center trial on suspected common duct stones. Am J Surg 2019; 217:1006-1009. [PMID: 30654919 DOI: 10.1016/j.amjsurg.2018.12.062] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 10/15/2018] [Accepted: 12/29/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Choledocholithiasis is present in up to 15% of cholecystectomy patients. Treatment can be surgical, endoscopic, or via interventional radiology. We hypothesized significant heterogeneity between hospitals exists in the approach to suspected common duct stones. METHODS A retrospective review of patients that had a preoperative MRCP, endoscopic ultrasound, endoscopic retrograde cholangiopancreatogram (ERCP), or intra-operative cholangiogram was performed. Comparisons were by Wilcoxon-Mann-Whitney tests with significance of p < 0.05 for paired variables and p < 0.017 for multiple comparisons. RESULTS Twelve participating institutions identified 1263 patients (409 men and 854 women) with a median age of 49 years (IQR: 31-94). Liver function tests (LFT's) were elevated in 939 patients (75%), median bilirubin level 1.75 mg/dl (IQ: 0.8-3.7 mg/dl) and median common duct size 7 mm (IQR 5-10 mm). The most common initial procedure was cholecystectomy with IOC at seven institutions, endoscopy at four and MRCP at one. CONCLUSION Significant variation exists within the surgical community regarding suspected common duct stones. These results underscore the need for a protocol for common duct stones to minimize multiple, redundant interventions.
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Affiliation(s)
| | | | | | | | | | | | - Sharmila Dissanaike
- Department of Surgery, Texas Tech University Health, Sciences Center Lubbock TX, USA
| | - Divya Vangipurum
- Department of Surgery, Texas Tech University Health, Sciences Center Lubbock TX, USA
| | | | | | - John Stivers
- Department of Surgery, University of California San Francisco-Fresno, USA
| | - Amy Kwok
- Department of Surgery, University of California San Francisco-Fresno, USA
| | | | | | | | | | | | - Frank Wright
- University of Colorado Hospital, Aurora, Colorado, USA
| | | | | | - Thomas J Schroeppel
- University of Colorado Health - Memorial Hospital, Colorado Springs, CO, USA
| | - Emma Callaghan
- University of Colorado Health - Memorial Hospital, Colorado Springs, CO, USA
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Mei Y, Chen L, Peng CJ, Wang J, Zeng PF, Wang GX, Li WP, Luo YQ, Du C, Liu K, Xiong K, Leng K, Feng CL, Jia JH. Diagnostic value of elevated serum carbohydrate antigen 199 level in acute cholangitis secondary to choledocholithiasis. World J Clin Cases 2018; 6:441-446. [PMID: 30294608 PMCID: PMC6163149 DOI: 10.12998/wjcc.v6.i11.441] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Revised: 08/15/2018] [Accepted: 08/20/2018] [Indexed: 02/05/2023] Open
Abstract
AIM To investigate the diagnostic value of abnormal serum carbohydrate antigen 199 (CA199) level in acute cholangitis secondary to choledocholithiasis.
METHODS In this retrospective cohort study, the clinical data of 727 patients with choledocholithiasis admitted to the Third Affiliated Hospital of Zunyi Medical College from June 2011 to June 2017 were collected. Among these patients, 258 patients had secondary acute cholangitis and served as observation group, and the remaining 569 choledocholithiasis patients served as the control group. Serum liver function indexes and tumor markers were detected in both groups, and the receiver operating characteristic (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 results of liver function tests showed no significant differences between the two groups (P > 0.05). Tumor markers including serum CA125, CA153, carcinoembryonic antigen, and alpha fetoprotein levels were also not significantly different (P > 0.05); however, the serum CA199 level was 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 0.885 (95%CI: 0.841-0.929) for CA199, and the cutoff value of 52.5 kU/L had the highest diagnostic accuracy, with a sensitivity of 86.8% and a specificity of 81.6%.
CONCLUSION Abnormally elevated serum CA199 level has an important value in the diagnosis of acute cholangitis secondary to choledocholithiasis. It may be a specific inflammatory marker for acute cholangitis.
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Affiliation(s)
- Yong Mei
- Department of Hepatopancreatobiliary Surgery, the Third Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
| | - Li Chen
- Diagnostics Laboratory, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
| | - Ci-Jun Peng
- Department of Hepatopancreatobiliary Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
| | - Jun Wang
- Department of Hepatopancreatobiliary Surgery, the Third Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
| | - Peng-Fei Zeng
- Department of Hepatopancreatobiliary Surgery, the Third Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
| | - Guo-Xing Wang
- Department of Hepatopancreatobiliary Surgery, the Third Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
| | - Wen-Ping Li
- Department of Hepatopancreatobiliary Surgery, the Third Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
| | - Yan-Qing Luo
- Department of Hepatopancreatobiliary Surgery, the Third Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
| | - Chao Du
- Department of Hepatopancreatobiliary Surgery, the Third Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
| | - Kai Liu
- Department of Hepatopancreatobiliary Surgery, the Third Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
| | - Kun Xiong
- Department of Hepatopancreatobiliary Surgery, the Third Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
| | - Kai Leng
- Department of Hepatopancreatobiliary Surgery, the Third Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
| | - Chun-Lin Feng
- Department of Hepatopancreatobiliary Surgery, the Third Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
| | - Ji-Hu Jia
- Department of Hepatopancreatobiliary Surgery, the Third Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
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Predictive Factors for Long Operative Duration in Patients Undergoing Laparoscopic Cholecystectomy After Endoscopic Retrograde Cholangiography for Combined Choledochocystolithiasis. Surg Laparosc Endosc Percutan Tech 2018; 27:491-496. [PMID: 29112097 PMCID: PMC5732633 DOI: 10.1097/sle.0000000000000461] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE Choledochocystolithiasis and its associated complications such as cholangitis and pancreatitis are managed by endoscopic retrograde cholangiography (ERC), with endoscopic stone extraction followed by laparoscopic cholecystectomy (LC). However, affected patients present with complex conditions linked to operative difficulties in performing LC. The aim of this study was to elucidate the predictive factors for a prolonged LC procedure following ERC for treating patients with choledochocystolithiasis. MATERIALS AND METHODS The medical records of 109 patients who underwent LC after ERC for choledochocystolithiasis from September 2012 to August 2014 were evaluated retrospectively. The cases were divided into long and short operative duration groups using a cutoff operative time of 90 minutes. We used univariate and multivariate analyses to investigate predictive factors associated with long operative duration according to clinical variables, ERC-related factors, and peak serum levels of laboratory test values between the initial presentation and LC (intervening period). RESULTS Seventeen patients needed >90 min to complete LC. The presence of acute cholecystitis, placement of percutaneous transhepatic gallbladder drainage, higher peak serum white blood cell count and levels of C-reactive protein (CRP), and lower peak serum levels of lipase during the intervening period were associated with prolonged operative duration. Multivariate analysis showed that the independent predictive factors for long operative duration were the presence of acute cholecystitis (hazard ratio, 5.418; P=0.016) and higher peak levels of CRP (hazard ratio, 1.077; P=0.022). CONCLUSION When patients with choledochocystolithiasis are scheduled for LC after ERC, the presence of acute cholecystitis and high CRP levels during the intervening period could predict a protracted operation.
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Rehman SFU, Ballance L, Rate A. Selective Antegrade Biliary Stenting Aids Emergency Laparoscopic Cholecystectomy. J Laparoendosc Adv Surg Tech A 2018; 28:1495-1502. [PMID: 29993317 DOI: 10.1089/lap.2018.0300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Background: Symptomatic gall stone disease requires early emergency treatment to prevent complications. This early treatment is often delayed due to difficulty in the diagnosis and management of concomitant choledocholithiasis. Intervention with preoperative endoscopic retrograde cholangiopancreatography (ERCP) is associated with complications and known to be unnecessary in most cases. We follow a strategy of providing early cholecystectomy with selective utility of antegrade stent in cases of choledocholithiasis. Our main aim is to present our technique and results. Method: We conducted a 3-year (January 2014 to January 2017) review of a prospectively maintained database of our practice of performing routine intraoperative cholangiogram (IOC) during laparoscopic cholecystectomy (LC) and when choledocholithiasis is encountered on IOC; a transcystic antegrade biliary stent is inserted to decompress the common bile ducts (CBD) and facilitate postoperative ERCP at later date. Results: Of the 411 cholecystectomies performed, 77.3% were females with mean age of 48 years. Seventy-four patients were found to have CBD stones (CBDS) on IOC. Antegrade stents were successfully deployed in 69 cases. Even though Antegrade stents were done more frequently in emergency admissions (P = .001); this did not increase the length of hospital stay (LOHS) (P = .752) or the rate of complications (P = .171). However, doing a preoperative ERCP significantly increased LOHS (P = .001), and 67% of these needed two or more ERCP for complete clearance of CBD and had more complications. Nine (15.2%) out of 59 patients with pancreatitis had CBDS on IOC and were successfully managed with antegrade stent. Conclusion: This strategy can be followed by general surgeons, enabling them to perform LC in the presence of choledocholithiasis during acute admissions including pancreatitis. It does not require any specialist skills in CBD exploration and also eliminates unnecessary preoperative ERCP and avoids its potential complications.
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Affiliation(s)
- Sheik Fazal Ur Rehman
- Department of General Surgery, Royal Oldham Hospital, Oldham, Manchester, United Kingdom
| | - Laura Ballance
- Department of General Surgery, Royal Oldham Hospital, Oldham, Manchester, United Kingdom
| | - Anthony Rate
- Department of General Surgery, Royal Oldham Hospital, Oldham, Manchester, United Kingdom
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Laparoscopic Common Bile Duct Exploration for Choledocholithiasis: Analysis of Practice Patterns of Intermountain HealthCare. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.02.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Parra-Membrives P, Martínez-Baena D, Lorente-Herce JM, Martín-Balbuena R. Efficacy of fibrin-sealants in reducing biliary leakage following laparoscopic common bile duct exploration. Cir Esp 2018; 96:429-435. [PMID: 29793695 DOI: 10.1016/j.ciresp.2018.03.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 03/28/2018] [Accepted: 03/29/2018] [Indexed: 12/27/2022]
Abstract
INTRODUCTION In spite of the acquired experience with laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis management, there is still a risk of biliary leakage of 5% to 15% following choledochotomy closure. We evaluate the usefulness of fibrin-collagen sealants to reduce the incidence of biliary fistula after laparoscopic choledochorrhaphy. METHODS We report a retrospective analysis of 96 patients undergoing LCBDE from March 2009 to March 2017, whose closure of the bile duct was completed by antegrade stenting and choledochorraphy or by performing a primary suture. The study population was divided into two groups according to whether they received a collagen-fibrin sealant covering the choledochorrhaphy or not, analyzing the incidence of postoperative biliary fistula in each group. RESULTS Thirty-nine patients (41%) received a fibrin-collagen sponge while the bile duct closure was not covered in the remaining 57 patients (59%). The incidence of biliary fistula was 7.7% (3 patients) in the first group and 14% (8 patients) in the second group (P=.338). In patients who underwent primary choledochorraphy, the fibrin-collagen sealant reduced the incidence of biliary leakage significantly (4.5% vs. 33%, P=.020), which was a protective factor with an odds ratio of 10.5. CONCLUSION Fibrin-collagen sealants may decrease the incidence of biliary fistula in patients who have undergone primary bile duct closure following LCBDE.
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Affiliation(s)
- Pablo Parra-Membrives
- Departamento de Cirugía, Facultad de Medicina, Universidad de Sevilla, Sevilla, España; Unidad de Cirugía Hepatobiliar y Pancreática, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Valme, Sevilla, España.
| | - Darío Martínez-Baena
- Unidad de Cirugía Hepatobiliar y Pancreática, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Valme, Sevilla, España
| | - José Manuel Lorente-Herce
- Unidad de Cirugía Hepatobiliar y Pancreática, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Valme, Sevilla, España
| | - Ramón Martín-Balbuena
- Unidad de Cirugía Hepatobiliar y Pancreática, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Valme, Sevilla, España
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Single-stage laparoscopic common bile duct exploration and cholecystectomy versus two-stage endoscopic stone extraction followed by laparoscopic cholecystectomy for patients with gallbladder stones with common bile duct stones: systematic review and meta-analysis of randomized trials with trial sequential analysis. Surg Endosc 2018; 32:3763-3776. [PMID: 29603004 DOI: 10.1007/s00464-018-6170-8] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Accepted: 03/21/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND The ideal management of common bile duct (CBD) stones associated with gall stones is a matter of debate. We planned a meta-analysis of randomized trials comparing single-stage laparoscopic CBD exploration and cholecystectomy (LCBDE) with two-stage preoperative endoscopic stone extraction followed by cholecystectomy (ERCP + LC). METHODS We searched the Pubmed/Medline, Web of science, Science citation index, Google scholar and Cochrane Central Register of Controlled trials electronic databases till June 2017 for all English language randomized trials comparing the two approaches. Statistical analysis was performed using Review Manager (RevMan) [Computer program], Version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014 and results were expressed as odds ratio for dichotomous variables and mean difference for continuous. p value ≤ 0.05 was considered significant. Trial sequential analysis (TSA) was performed using TSA version 0.9.5.5 (Copenhagen: The Copenhagen Trial Unit, Centre for Clinical Intervention Research, 2016). PROSPERO trial registration number is CRD42017074673. RESULTS A total of 11 trials were included in the analysis, with a total of 1513 patients (751-LCBDE; 762-ERCP + LC). LCBDE was found to have significantly lower rates of technical failure [OR 0.59, 95% CI (0.38, 0.93), p = 0.02] and shorter hospital stay [MD - 1.63, 95% CI (- 3.23, - 0.03), p = 0.05]. There was no significant difference in mortality [OR 0.37, 95% CI (0.09, 1.51), p = 0.17], morbidity [OR 0.97, 95% CI (0.70, 1.33), p = 0.84], cost [MD - 379.13, 95% CI (- 784.80, 111.2), p = 0.13] or recurrent/retained stones [OR 1.01, 95% CI (0.38, 2.73), p = 0.98]. TSA showed that although the Z-curve crossed the boundaries of conventional significance, the estimated information size is yet to be achieved. CONCLUSIONS Single-stage LCBDE is superior to ERCP + LC in terms of technical success and shorter hospital stay in good-risk patients with gallstones and CBD stones, where expertise, operative time and instruments are available.
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Tarantino G, Magistri P, Ballarin R, Assirati G, Di Cataldo A, Di Benedetto F. Surgery in biliary lithiasis: from the traditional "open" approach to laparoscopy and the "rendezvous" technique. Hepatobiliary Pancreat Dis Int 2017; 16:595-601. [PMID: 29291778 DOI: 10.1016/s1499-3872(17)60031-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Accepted: 12/16/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND According to the current literature, biliary lithiasis is a worldwide-diffused condition that affects almost 20% of the general population. The rate of common bile duct stones (CBDS) in patients with symptomatic cholelithiasis is estimated to be 10% to 33%, depending on patient's age. Compared to stones in the gallbladder, the natural history of secondary CBDS is still not completely understood. It is not clear whether an asymptomatic choledocholithiasis requires treatment or not. For many years, open cholecystectomy with choledochotomy and/or surgical sphincterotomy and cleaning of the bile duct were the gold standard to treat both pathologies. Development of both endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic surgery, together with improvements in diagnostic procedures, influenced new approaches to the management of CBDS in association with gallstones. DATA SOURCES We decided to systematically review the literature in order to identify all the current therapeutic options for CBDS. A systematic literature search was performed independently by two authors using PubMed, EMBASE, Scopus and the Cochrane Library Central. RESULTS The therapeutic approach nowadays varies greatly according to the availability of experience and expertise in each center, and includes open or laparoscopic common bile duct exploration, various combinations of laparoscopic cholecystectomy and ERCP and combined laparoendoscopic rendezvous. CONCLUSIONS Although ERCP followed by laparoscopic cholecystectomy is currently preferred in the majority of hospitals worldwide, the optimal treatment for concomitant gallstones and CBDS is still under debate, and greatly varies among different centers.
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Affiliation(s)
- Giuseppe Tarantino
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, 41124 Modena, Italy.
| | - Paolo Magistri
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, 41124 Modena, Italy; Department of General Surgery, Sapienza-University of Rome, 00189 Rome, Italy
| | - Roberto Ballarin
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Giacomo Assirati
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Antonio Di Cataldo
- Department of Surgical Sciences, Organ Transplantation and Advanced Technologies, University of Catania, 95124 Catania, Italy
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, 41124 Modena, Italy
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Wang X, Dai C, Jiang Z, Zhao L, Wang M, Ma L, Tan X, Liu L, Wang X, Fan Z. Endoscopic retrograde cholangiopancreatography versus laparoscopic exploration for common bile duct stones in post-cholecystectomy patients: a retrospective study. Oncotarget 2017; 8:82114-82122. [PMID: 29137249 PMCID: PMC5669875 DOI: 10.18632/oncotarget.18839] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 03/22/2017] [Indexed: 12/21/2022] Open
Abstract
Background and Objective Common bile duct (CBD) stones are common in patients even after cholecystectomy. Besides endoscopic retrograde cholangiography (ERCP), laparoscopic common bile duct exploration (LCBDE) is also applied. This study aims to compare clinical indications, therapeutic benefits and complications for these two managements. Methods From October 2012 to February 2015, 1072 consecutive patients were diagnosed as choledocholithiasis in our single hospital. Post-cholecystectomy patients who underwent ERCP or LCBDE were included. Clinical data were analyzed, such as success rate, complications, procedure duration, postoperative hospital stay, total cost and recurrence of ductal stones. Prior ERCP, previous biliary anatomic alteration surgeries and lost to follow up were the excluding criteria. Results 141 patients were included according to the criteria, and 87 cases underwent ERCP and 54 cases underwent LCBDE. Age and sex distribution of patients were comparable between the two groups. The success rate for CBD stones clearance was 97.7% in the ERCP group, compared with 87.0% in the LCBDE group (p=0.03). The mean procedure duration was also significantly shorter in ERCP group (52.0±15.8 vs. 102.9±40.1 min; p<0.001). Postoperative hospital stay was similar (5.5±2.6 vs. 5.9±2.3 days; p=0.40). And no significant difference for postoperative complications (3.4% vs. 11.1%; p=0.15), total cost ($3787.1±1061.5 vs. $3983.54±1257.1, p=0.32), and the rate of bile duct stones recurrence (6.9% vs. 7.4%, p=1.00). Conclusions For clearing CBD stones in patients after cholecystectomy, ERCP was more efficient and might be the first choice, while LCBDE might be beneficial for patients with large stones.
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Affiliation(s)
- Xiaohong Wang
- Department of Digestive Endoscopy and Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210000, China.,Department of Gastroenterology, The Second Affiliated Hospital of Xuzhou Medical College, Xuzhou, Jiangsu 221006, China
| | - Chenguang Dai
- Digestive Endoscopy Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Zhonghua Jiang
- Department of Digestive Endoscopy and Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210000, China.,Department of Gastroenterology, The First People's Hospital of Yancheng, Yancheng, Jiangsu 224006, China
| | - Lili Zhao
- Digestive Endoscopy Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Min Wang
- Digestive Endoscopy Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Limei Ma
- Digestive Endoscopy Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Xueming Tan
- Digestive Endoscopy Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Li Liu
- Digestive Endoscopy Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Xiang Wang
- Digestive Endoscopy Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Zhining Fan
- Digestive Endoscopy Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu 210029, China
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Parra-Membrives P, Martínez-Baena D, Lorente-Herce J, Jiménez-Riera G. Comparative Study of Three Bile Duct Closure Methods Following Laparoscopic Common Bile Duct Exploration for Choledocholithiasis. J Laparoendosc Adv Surg Tech A 2017; 28:145-151. [PMID: 28976804 DOI: 10.1089/lap.2017.0433] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND There are three choledochotomy closure methods available following laparoscopic common bile duct exploration: T-tube insertion, antegrade stenting, and primary choledochorrhaphy. We reviewed the experience of 12 years at our center searching for the optimal closure technique. METHODS We analyzed retrospectively 146 patients that underwent one of the three closure methods from February 2004 to March 2016. Hospital stay, need for readmission, incidence of early and long-term complications, and biliary leakage development and their clinical impact were determined for each technique. RESULTS Hospital stay was more prolonged, and need for readmission was higher in the T-tube group. Nine patients of the T-tube group (17.3%), 5 patients (8.6%) of the antegrade stenting group, and 1 patient of the primary suture group (2.8%) developed Dindo-Clavien ≥3 complications (P = .076). The incidence of biliary leakage was 3.8%, 8.6%, and 16.7% for the T-tube group, antegrade stenting group, and primary suture group, respectively. There was no grade C biliary fistula in the primary suture group, and all grade B leaks in these patients were only due to prolonged duration. The T-tube removal caused adverse events in 21.1% of the patients, and complications directly related with stents occurred in 9.6%. CONCLUSION Antegrade stents or T-tube insertion do not provide any added value for choledochotomy closure but are charged with specific morbidity. On the contrary, despite biliary leaks being more frequent after primary suture, they are of little clinical consequence and may be managed on an outpatient basis.
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Affiliation(s)
- Pablo Parra-Membrives
- 1 Department of Surgery, University of Seville , Sevilla, Spain .,2 Hepatobiliary and Pancreatic Surgery Unit, General and Digestive Surgery Department, Valme University Hospital , Sevilla, Spain
| | - Darío Martínez-Baena
- 2 Hepatobiliary and Pancreatic Surgery Unit, General and Digestive Surgery Department, Valme University Hospital , Sevilla, Spain
| | - José Lorente-Herce
- 2 Hepatobiliary and Pancreatic Surgery Unit, General and Digestive Surgery Department, Valme University Hospital , Sevilla, Spain
| | - Granada Jiménez-Riera
- 2 Hepatobiliary and Pancreatic Surgery Unit, General and Digestive Surgery Department, Valme University Hospital , Sevilla, Spain
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Al-Temimi MH, Kim EG, Chandrasekaran B, Franz V, Trujillo CN, Mousa A, Tessier DJ, Johna SD, Santos DA. Laparoscopic common bile duct exploration versus endoscopic retrograde cholangiopancreatography for choledocholithiasis found at time of laparoscopic cholecystectomy: Analysis of a large integrated health care system database. Am J Surg 2017; 214:1075-1079. [PMID: 28939251 DOI: 10.1016/j.amjsurg.2017.08.030] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 07/31/2017] [Accepted: 08/16/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND We compared endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic common bile duct exploration (LCBDE) for managing choledocholithiasis found at time of cholecystectomy. METHODS One hundred and five LCBDE (2005-2015) were compared to 195 LC/ERCP (2014-2015) from the Southern California Kaiser Permanente database. RESULTS LC/ERCP was more effective at clearing the CBD (98% vs. 88.6%, p = 0.01); but required more procedures per patient (mean ± standard deviation, 1.1 ± 0.4 vs. 2.0 ± 0.12, p < 0.001). Morbidity, hospital length of stay and readmission were not different (P > 0.05). Four patients failed ERCP, while 12 patients failed LCBDE and had subsequent ERCP (10) or CBD exploration (2). All patients with RYGB had successful LCBDE. CONCLUSION LC/ERCP is better than LCBDE in clearing CBD stones, but has similar morbidity and is an effective alternative for patients with RYGB.
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Affiliation(s)
- Mohammed H Al-Temimi
- Arrowhead Regional Medical Center, Colton, CA, USA; Kaiser Permanente Fontana Medical Center, Fontana, CA, USA.
| | - Edwin G Kim
- Arrowhead Regional Medical Center, Colton, CA, USA; Kaiser Permanente Fontana Medical Center, Fontana, CA, USA
| | - Bindupriya Chandrasekaran
- Arrowhead Regional Medical Center, Colton, CA, USA; Kaiser Permanente Fontana Medical Center, Fontana, CA, USA
| | - Vanessa Franz
- Arrowhead Regional Medical Center, Colton, CA, USA; Kaiser Permanente Fontana Medical Center, Fontana, CA, USA
| | - Charles N Trujillo
- Arrowhead Regional Medical Center, Colton, CA, USA; Kaiser Permanente Fontana Medical Center, Fontana, CA, USA
| | - Asrai Mousa
- Arrowhead Regional Medical Center, Colton, CA, USA; Kaiser Permanente Fontana Medical Center, Fontana, CA, USA
| | | | - Samir D Johna
- Arrowhead Regional Medical Center, Colton, CA, USA; Kaiser Permanente Fontana Medical Center, Fontana, CA, USA
| | - David A Santos
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Aleknaite A, Simutis G, Stanaitis J, Valantinas J, Strupas K. Risk assessment of choledocholithiasis prior to laparoscopic cholecystectomy and its management options. United European Gastroenterol J 2017; 6:428-438. [PMID: 29774157 DOI: 10.1177/2050640617731262] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 08/12/2017] [Indexed: 12/15/2022] Open
Abstract
Background Accurate risk evaluation of choledocholithiasis prior to laparoscopic cholecystectomy is essential to determine optimal management strategy. Objective Our study aimed to evaluate the accuracy of separate predictors and Vilnius University Hospital Index (VUHI = A/30 + 0.4 × B; A = total bilirubin concentration (µmol/l), B = common bile duct (CBD) diameter (mm) measured by ultrasound) diagnosing choledocholithiasis and to assess different management strategies (cholecystectomy with intraoperative cholangiography and endoscopic retrograde cholangiopancreatography (ERCP)). Methods The retrospective study included 350 patients admitted to a tertiary care centre for laparoscopic cholecystectomy for cholecystolithiasis who were investigated for concomitant choledocholithiasis. Results Choledocholithiasis was diagnosed in 182 (76.2%) cases in the high-risk group (VUHI value ≥4.7) and 44 (39.6%) in the low, odds ratio is 4.86 (95% CI: 3.00-7.88). Its sensitivity was 80.5%, specificity 54.0%, accuracy 71.1%. Dilated CBD had the highest sensitivity (92.5%) of predictors.ERCP showed better diagnostic performance than intraoperative cholangiography. Complications of ERCP were more frequent for patients without stones. There was no significant difference of outcomes between the two management strategies. Conclusion The prognostic index has good diagnostic accuracy but dividing patients into two risk groups is insufficient. The suggested model allows determining an intermediate-risk group, which requires additional investigation. Both management approaches are appropriate.
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Affiliation(s)
- Ausra Aleknaite
- Department of Endoscopic Diagnostics and Minimally Invasive Surgery, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania.,Clinic of Gastroenterology, Nephrourology and Surgery, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Gintaras Simutis
- Clinic of Gastroenterology, Nephrourology and Surgery, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.,Centre of Abdominal Surgery, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Juozas Stanaitis
- Department of Endoscopic Diagnostics and Minimally Invasive Surgery, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania.,Clinic of Gastroenterology, Nephrourology and Surgery, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Jonas Valantinas
- Centre of Abdominal Surgery, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania.,Centre of Hepatology, Gastroenterology and Dietetics, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Kestutis Strupas
- Clinic of Gastroenterology, Nephrourology and Surgery, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.,Centre of Abdominal Surgery, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
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Saito H, Kakuma T, Kadono Y, Urata A, Kamikawa K, Imamura H, Tada S. Increased risk and severity of ERCP-related complications associated with asymptomatic common bile duct stones. Endosc Int Open 2017; 5:E809-E817. [PMID: 28879226 PMCID: PMC5585073 DOI: 10.1055/s-0043-107615] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 02/06/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Endoscopic removal of asymptomatic common bile duct stones (CBDS) is generally recommended. Although many reports have described the risk of complications in endoscopic retrograde cholangiopancreatography (ERCP), no studies have addressed this problem in the context of asymptomatic CBDS. This study examines the risk of complications arising in ERCP for asymptomatic CBDS. PATIENTS AND METHODS This retrospective study included 425 patients with naive papilla who underwent therapeutic ERCP for choledocholithiasis at 2 institutions in Japan for 2 years. The risk of complications was examined in patients who were divided into the asymptomatic and symptomatic CBDS groups. We used propensity score analysis to adjust for confounding effects. RESULTS Complications were observed in 32 (7.5 %) of the 425 patients. Of the 358 patients with symptomatic CBDS, 14 patients (3.9 %) had complications. In contrast, of the 67 patients with asymptomatic CBDS, 18 patients (26.9 %) had complications. Propensity score analysis revealed that asymptomatic CBDS was a significant risk factor, with a significantly higher incidence of complications compared with symptomatic CBDS (odds ratio, 5.3). Moderate to severe complications were observed in 15 of 18 patients (83.3 %) in the asymptomatic CBDS group, with significantly more moderate to severe complications than those in the symptomatic CBDS (odds ratio, 6.7). CONCLUSIONS Asymptomatic CBDS carried a high risk of ERCP-related complications, and these were often more severe. In asymptomatic CBDS, endoscopic treatment should be carefully performed after considering the patient's background, and detailed explanation of its possible complications should be given to patients in advance.
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Affiliation(s)
- Hirokazu Saito
- Department of Gastroenterology, Kumamoto City-Hospital, Kumamoto, Japan,Department of Gastroenterology, Kumamoto Chuo Hospital, Kumamoto, Japan,Corresponding author Hirokazu Saito Department of GastroenterologyKumamoto Chuo Hospital1-5-1, TainoshimaMinami-ku, Kumamoto-CityKumamoto, 862-0965Japan+81-96-370-4017
| | - Tatsuyuki Kakuma
- Department of Biostatics Center, Medical School, Kurume University, Fukuoka, Japan
| | - Yoshihiro Kadono
- Department of Gastroenterology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Atsushi Urata
- Department of Gastroenterology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Kentaro Kamikawa
- Department of Gastroenterology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Haruo Imamura
- Department of Gastroenterology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Shuji Tada
- Department of Gastroenterology, Kumamoto City-Hospital, Kumamoto, Japan
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Early analysis of laparoscopic common bile duct exploration simulation. Am J Surg 2017; 213:888-894. [DOI: 10.1016/j.amjsurg.2017.03.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 02/15/2017] [Accepted: 03/15/2017] [Indexed: 02/07/2023]
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Laparoscopic surgery for choledocholithiasis concomitant with calculus of the left intrahepatic duct or abdominal adhesions. Surg Endosc 2017; 31:4780-4789. [DOI: 10.1007/s00464-017-5555-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Accepted: 04/01/2017] [Indexed: 02/07/2023]
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Manning A, Frazee R, Abernathy S, Isbell C, Isbell T, Regner J, Munoz-Maldonado Y, Smith R. Protocol-Driven Management of Suspected Common Duct Stones. J Am Coll Surg 2017; 224:645-649. [PMID: 28093301 DOI: 10.1016/j.jamcollsurg.2016.12.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 12/13/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Common duct stones can be diagnosed by magnetic resonance cholangiopancreatography (MRCP), endoscopic ultrasound (EUS)/ERCP, and intraoperative cholangiogram (IOC). In 2015, our group adopted a standard approach of preoperative EUS/ERCP followed by laparoscopic cholecystectomy for patients with an admission bilirubin >4.0 mg/dL. For bilirubin <4.0 mg/dL, laparoscopic cholecystectomy with IOC was the initial procedure. Postoperative EUS/ERCP with endoscopic sphincterotomy was pursued for positive IOC. Exclusions included clinical suspicion of malignancy and surgically altered anatomy making endoscopic management impractical. STUDY DESIGN A retrospective comparison of protocol and pre-protocol (baseline) patients was performed, looking at patient demographics, presence of pancreatitis, common duct stone risk factors, comorbidities, length of hospitalization, and postoperative morbidity. Statistical analysis was performed with t-test, chi-square, and Wilcoxon rank-sum test with significance at p < 0.05. RESULTS There were 56 patients in each group, with a mean ± SD age of 50.5 ± 20.88 years and 49.3 ± 20.92 years, respectively (p = NS). There were no significant differences between baseline and protocol patients with respect to individual and cumulative preoperative comorbidities, pancreatitis, elevation of liver function tests, bilirubin, common duct size, and postoperative morbidity. There were fewer endoscopies (22 vs 35; p = 0.014), and shorter length of stay in protocol patients (2.8 days vs 3.8 days; p = 0.025). CONCLUSIONS Protocol-driven management of patients with suspected common duct stones reduced the number of endoscopies and length of hospitalization, with no change in postoperative morbidity. This approach has the potential to decrease endoscopy-related morbidity and overall cost without affecting quality of care.
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Affiliation(s)
- Anthony Manning
- Department of Surgery, Baylor Scott & White Healthcare, Temple, TX
| | - Richard Frazee
- Department of Surgery, Baylor Scott & White Healthcare, Temple, TX.
| | | | - Claire Isbell
- Department of Surgery, Baylor Scott & White Healthcare, Temple, TX
| | - Travis Isbell
- Department of Surgery, Baylor Scott & White Healthcare, Temple, TX
| | - Justin Regner
- Department of Surgery, Baylor Scott & White Healthcare, Temple, TX
| | | | - Randall Smith
- Department of Surgery, Baylor Scott & White Healthcare, Temple, TX
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Quaresima S, Balla A, Guerrieri M, Campagnacci R, Lezoche E, Paganini AM. A 23 year experience with laparoscopic common bile duct exploration. HPB (Oxford) 2017; 19:29-35. [PMID: 27890483 DOI: 10.1016/j.hpb.2016.10.011] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 10/14/2016] [Accepted: 10/28/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Laparoscopic common bile duct exploration (LCBDE) during laparoscopic cholecystectomy (LC) is as effective as two-stage endo-laparoscopic treatment, but with shorter hospital stay, lower cost and recurrent stone rate. Aim of this paper was to report the authors' experience with LCBDE during LC. METHODS A retrospective analysis of patients who underwent LCBDE for ductal stones was performed. Recurrent stones were defined as CBD stones detected beyond 6 months from the procedure. Postoperative biliary stricture was defined as a symptomatic reduction of CBD diameter. RESULTS Out of 3444 patients who underwent LC, 384 (11%) had CBD stones treated by trans-cystic duct exploration [214 (6%) patients, TCD-CBDE] or choledochotomy [170 (5%) patients, C-CBDE]. For TCD-CBDE and C-CBDE, mean operative time was 127 ± 69 and 191 ± 74 min, respectively. Major morbidity rate was 3% (n = 6) in TCD-CBDE and 6% (n = 11) in C-CBDE. The incidence of residual stones was 5% (n = 20) and complete ductal clearance rate was 95% (n = 364). After long-term follow-up (mean 189 ± 105 months) the recurrent stone rate was 2%. DISCUSSION In expert centers, LCBDE during LC is safe and effective with low short and long term morbidity rates.
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Affiliation(s)
- Silvia Quaresima
- Department of General Surgery and Surgical Specialties "Paride Stefanini", Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
| | - Andrea Balla
- Department of General Surgery and Surgical Specialties "Paride Stefanini", Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Mario Guerrieri
- Department of General Surgery, Università Politecnica delle Marche, Piazza Roma 22, 60121 Ancona, Italy
| | - Roberto Campagnacci
- Department of General Surgery, Università Politecnica delle Marche, Piazza Roma 22, 60121 Ancona, Italy
| | - Emanuele Lezoche
- Department of General Surgery and Surgical Specialties "Paride Stefanini", Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Alessandro M Paganini
- Department of General Surgery and Surgical Specialties "Paride Stefanini", Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
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Zheng C, Huang Y, Xie E, Xie D, Peng Y, Wang X. Laparoscopic common bile duct exploration: a safe and definitive treatment for elderly patients. Surg Endosc 2016; 31:2541-2547. [PMID: 28008469 DOI: 10.1007/s00464-016-5257-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 09/15/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Common bile duct (CBD) stone is one of the most common diseases among elderly people. In recent decades, there are numerous studies regarding the safety and efficacy of laparoscopic common bile duct exploration (LCBDE). Elderly patients are often regarded as high-risk patients because they are more likely to present with age-specific deterioration of organ function and coexisting chronic diseases, which may reduce their tolerance of laparoscopic surgery. Although laparoscopic surgery for choledocholithiasis is now widely accepted as the treatment for CBD stone, its appropriateness for the treatment of elderly patients or those with coexisting high-risk patients has not been well established. Therefore, the objective of this paper is to analyze the safety and efficacy of LCBDE in elderly patients. METHODS Between January 2012 and November 2015, 376 patients underwent LCBDE in our center. Based on their ages, they were divided into two groups, and a retrospective study was performed. By making comparisons between younger group who were younger than 70 years (n = 253) and elderly group who were 70 years old or older (n = 123), the demographics, clinical characteristics, laboratory data, operative parameters and outcomes were analyzed. RESULTS Before operation, elderly patients had more coexisting chronic diseases and risk factors, such as arterial hypertension, heart diseases, pulmonary diseases and previous abdominal surgery (P < 0.05). In both groups, LCBDE was equally successful with a high clearance rate (100 % in elderly patients vs. 98.8 % in younger group, P = 0.554). Besides, the operating time, intraoperative blood loss, postoperative hospital stay, total costs and overall complication showed no significant difference between two groups (P > 0.05). There was no major bile duct injury or death in either group. CONCLUSION Although elderly patients are frequently confronted with coexisting disorders, LCBDE can be considered as a safe and effective technique in choledocholithiasis treatment for elderly patients.
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Affiliation(s)
- Chufa Zheng
- Department of General Surgery, the Affiliated Shantou Hospital of Sun Yat-sen University, Guangdong, 515000, China
| | - Yaokui Huang
- Department of General Surgery, the Affiliated Shantou Hospital of Sun Yat-sen University, Guangdong, 515000, China
| | - E Xie
- Department of General Surgery, the Affiliated Shantou Hospital of Sun Yat-sen University, Guangdong, 515000, China
| | - Dejin Xie
- Department of General Surgery, the Affiliated Shantou Hospital of Sun Yat-sen University, Guangdong, 515000, China
| | - Yunheng Peng
- Department of General Surgery, the Affiliated Shantou Hospital of Sun Yat-sen University, Guangdong, 515000, China
| | - Xiaozhong Wang
- Department of General Surgery, the Affiliated Shantou Hospital of Sun Yat-sen University, Guangdong, 515000, China.
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Xu XP, Xu JB, Hu JQ. Value of liver function test for prediction of asymptomatic common bile duct stones in patients with cholecystolithiasis. Shijie Huaren Xiaohua Zazhi 2016; 24:4293-4298. [DOI: 10.11569/wcjd.v24.i31.4293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
AIM To investigate the diagnostic value of abnormal liver function parameters for concomitant asymptomatic choledocholithiasis in cholecystolithiasis patients.
METHODS The clinical data of 398 patients with cholecystolithiasis treated at our hospital from January 2012 to January 2016 were retrospectively analyzed. According to the presence of concomitant asymptomatic choledocholithiasis or not, the patients were divided into two groups: choledocholithiasis group and cholecystolithiasis group. The risk factors for the disease were evaluated. The receiver operating characteristic (ROC) curves for the significant parameters were generated to assess their sensitivities and specificities for diagnosis of concomitant asymptomatic choledocholithiasis in cholecystolithiasis patients.
RESULTS There were no significant differences in serum levels of alanine transaminase (ALT), aspartate transaminase (AST), total bilirubin (TBIL), or indirect bilirubin (DBIL) between the choledocholithiasis and cholecystolithiasis groups. Serum levels of γ-glutamyltransferase (GGT) and alkaline phosphatase (ALP) in the choledocholithiasis group were significantly higher than those in the cholecystolithiasis group (P < 0.05). The ROC curve analysis showed that the areas under the ROC curve of GGT and ALP were 0.914 and 0.569, and the corresponding cut-off values were 89.5 U/L and 136 U/L (sensitivity: 89.9% and 45.8%; specificity: 79.18% and 71.90%), respectively.
CONCLUSION Abnormally elevated GGT and ALP have value for prediction of concomitant asymptomatic choledocholithiasis in cholecystolithiasis patients.
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Intraoperative ERCP for management of cholecystocholedocholithiasis. Surg Endosc 2016; 31:809-816. [PMID: 27334962 DOI: 10.1007/s00464-016-5036-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 06/11/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND The introduction of minimally invasive techniques in management of biliary problems added new procedures for treating patients with cholecystocholedocholithiasis (CCL). This study presents the results of intraoperative ERCP (IOERCP) during LC as a single-session minimally invasive procedure for management of patients who have preoperatively diagnosed CBD stones. METHODS The database of patients presented to our center by CCL between October 2007 and December 2015 who were treated by LC and IOERCP was collected and analyzed. CBD stones were diagnosed using clinical data, laboratory tests and abdominal sonogram. MRCP was requested for doubtful cases. In the first cases ERCP was done using rendezvous technique, but in late cases standard ERCP immediately after completion of LC under the same anesthesia was used. Preoperative, intraoperative and postoperative data were recorded, analyzed and reported. Data reported include success/failure rate, complications, conversion to open surgery, operative details and incidence of residual CBD stones. RESULTS The study was conducted on 346 patients who had CCL. The mean age was 34.7 years, and 298 of them were females. The most common presentation was abdominal pain (98.5 %) and jaundice (64.9 %). Fifteen patients were excluded, and IOERCP was not done due to negative IOC results in 10 patients and conversion to open surgery in 5 patients. IOERCP was tried in the remaining 331 patients. The mean operative time was 55 min, and the mean hospital stay was 2.4 days. Major complications had been reported in 13/323 patients (4.0 %). Failure of CBD clearance was reported in 8 patients (2.4 %) with a success rate of 97.6 %. Thirty-day follow-up was possible in 142 patients, and there was a residual CBD stone in one patient and wound infection in another one. CONCLUSIONS IOERCP during LC is a safe and effective option for management of CCL.
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Gupta N. Role of laparoscopic common bile duct exploration in the management of choledocholithiasis. World J Gastrointest Surg 2016; 8:376-381. [PMID: 27231516 PMCID: PMC4872066 DOI: 10.4240/wjgs.v8.i5.376] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2015] [Revised: 12/30/2015] [Accepted: 02/24/2016] [Indexed: 02/06/2023] Open
Abstract
Surgical fraternity has not yet arrived at any consensus for adequate treatment of choledocholithiasis. Sequential treatment in the form of pre-operative endoscopic retrograde cholangio-pancreatography followed by laparoscopic cholecystectomy (LC) is considered as optimal treatment till date. With refinements in technique and expertise in field of minimal access surgery, many centres in the world have started offering one stage management of choledocholithiasis by LC with laparoscopic common bile duct exploration (LCBDE). Various modalities have been tried for entering into concurrent common bile duct (CBD) [transcystic (TC) vs transcholedochal (TD)], for confirming stone clearance (intraoperative cholangiogram vs choledochoscopy), and for closure of choledochotomy (T-tube vs biliary stent vs primary closure) during LCBDE. Both TC and TD approaches are safe and effective. TD stone extraction is involved with an increased risk of bile leaks and requires more expertise in intra-corporeal suturing and choledochoscopy. Choice depends on number of stones, size of stone, diameter of cystic duct and CBD. This review article was undertaken to evaluate the role of LCBDE for the management of choledocholithiasis.
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