Surgical Treatment for Choledocholithiasis Following Repeated Failed Endoscopic Retrograde Cholangiopancreatography

Comparative analysis of laparoscopic choledocholithiasis and ERCP treatment after cholecystectomy

OBJECTIVE

To compare the overall efficacy of laparoscopic common bile duct exploration(LCBDE) with endoscopic retrograde cholangiopancreatography (ERCP ) after cholecystectomy.

METHODS

From January 2017 to July 2021, Seventy patients with Choledocholithiasis after cholecystectomy who were admitted to our hospital were selected and divided into ERCP and LCBDE groups. comparison of baseline characteristics, clinical efficacy and postoperative complications between the ERCP and LCBDE.

RESULTS

①The overall efficacy rate of LCBDE was 97.1%, while the overall efficacy rate in the ERCP group was 76.6%. The LCBDE group demonstrated a significantly higher overall effective rate compared to the ERCP group, with a statistically significant difference (p < 0.05). ②The preoperative and postoperative complications of the LCBDE group were visibly lower than the other group (P < 0.05). The postoperative time to oral intake, postoperative ventilation time, length of hospital stay, and hospital costs were higher in the ERCP group compared to the LCBDE group, with a statistically significant difference (P < 0.05).

CONCLUSION

In the treatment of common bile duct stones after cholecystectomy, LCBDE is a superior choice compared to ERCP in terms of stone diameter, quantity, clearance rate, and hospital costs.

Gas Embolism After a Patient's Ninth ERCP Procedure

Gas embolism is a rare and potentially fatal complication of endoscopic retrograde cholangiopancreatography (ERCP). We present a 66-year-old man who developed gas embolism after undergoing therapeutic ERCP for cholangitis. Some risk factors of gas embolism in this patient included stones in the common bile duct with cholangitis and a history of multiple ERCP procedures. Early diagnosis and rapid treatment of this potentially fatal complication resulted in our patient's full recovery.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Comparing One-Stage vs Two-Stage Approaches for the Management of Choledocholithiasis

BACKGROUND

The management of symptomatic choledocholithiasis remains a controversial issue. At present, the three most common management options for choledocholithiasis include a preoperative endoscopic retrograde cholangiopancreatography with sphincterotomy and stone extraction followed by laparoscopic cholecystectomy, then by either an intraoperative endoscopic retrograde cholangiopancreatography with sphincterotomy or a laparoscopic common bile duct exploration. The purpose of this study was to assess the consequences of the decision to pursue each of these three methods.

METHODS

We conducted a review of the existing data comparing these three management options. The literature from 2009 to 2021 pertaining to these three methods was reviewed for data on duct clearance, morbidity, mortality, recurrence rate, length of stay, and operative time. Next, we constructed decision trees for each method using a utility score analysis, and these utility scores were used to create a sensitivity analysis based on stone clearance rate.

RESULTS

Laparoscopic cholecystectomy with intraoperative endoscopic retrograde cholangiopancreatography had a utility score of 0.9910, a stone clearance rate of 95.5%, a morbidity of 6.3%, and a mortality of 0.2%. Preoperative endoscopic retrograde cholangiopancreatography with laparoscopic cholecystectomy had a utility score of 0.9629, a stone clearance rate of 85.5%, a morbidity of 13.3%, and a mortality of 0.8%. Laparoscopic cholecystectomy with common bile duct exploration had a utility score of 0.9882, a stone clearance rate of 88.3%, a morbidity of 12.9%, and a mortality of 0.3%.

CONCLUSION

We have shown that a laparoscopic cholecystectomy with an intraoperative endoscopic retrograde cholangiopancreatography is associated with the best overall outcomes.