Gallstone disease. Management of common bile-duct stones and associated gallbladder stones: Surgical aspects

Research of the clinical features, risk factors, and surgical diagnosis of intramural stones in patients with gallbladder stones

Crystals or stones within the gallbladder wall in patients with gallbladder stones (GBS) have been occasionally reported, but their clinical features and aetiology remain unclear. This retrospective study analysed 323 consecutive patients with GBS who underwent rigid choledochoscopic gallbladder-preserving cholecystolithotomy to determine the detection rate, clinical features, and potential risk factors of gallbladder intramural stones (IS). IS were found in 24.1% (78/323) of patients, characterised by distinct cholangioscopic findings, including stone shadows, yellow floating bands, or a combination of both within the gallbladder wall. Compared to patients without IS, those with IS had a higher prevalence of Clonorchis sinensis (C. sinensis) eggs (60.3% vs. 40.8%, P < 0.05) and elevated serum cholesterol, LDL cholesterol, and Apo-B levels (P < 0.05). However, stone composition and C. sinensis egg detection rates did not differ between intraluminal stones and IS within the same patient (P > 0.05). Logistic regression analysis revealed that IS were associated with C. sinensis infection and elevated Apo-B levels. In conclusion, IS share homology with intraluminal stones in the same patient with GBS and exhibit unique appearances in rigid choledochoscopy. For patients with GBS and IS, elevated serum Apo-B levels and C. sinensis infection were independent risk factors.

Comparison of the clinical effects of dual-modality endoscopy and traditional laparotomy for the treatment of intra- and extrahepatic bile duct stones

BACKGROUND

Bile duct stones (BDSs) may cause patients to develop liver cirrhosis or even liver cancer. Currently, the success rate of surgical treatment for intrahepatic and extrahepatic BDSs is not satisfactory, and there is a risk of postoperative complications.

AIM

To compare the clinical effects of dual-modality endoscopy (duodenoscopy and laparoscopy) with those of traditional laparotomy in the treatment of intra- and extrahepatic BDSs.

METHODS

Ninety-five patients with intra- and extrahepatic BDSs who sought medical services at Wuhan No.1 Hospital between August 2019 and May 2023 were selected; 45 patients in the control group were treated by traditional laparotomy, and 50 patients in the research group were treated by dual-modality endoscopy. The following factors were collected for analysis: curative effects, safety (incision infection, biliary fistula, lung infection, hemobilia), surgical factors [surgery time, intraoperative blood loss (IBL) volume, gastrointestinal function recovery time, and length of hospital stay], serum inflammatory markers [tumor necrosis factor (TNF)-α, interleukin (IL)-6, and IL-8], and oxidative stress [glutathione peroxidase (GSH-Px), superoxide dismutase (SOD), malondialdehyde (MDA), and advanced protein oxidation products (AOPPs)].

RESULTS

The analysis revealed markedly better efficacy (an obviously higher total effective rate) in the research group than in the control group. In addition, an evidently lower postoperative complication rate, shorter surgical duration, gastrointestinal function recovery time and hospital stay, and lower IBL volume were observed in the research group. Furthermore, the posttreatment serum inflammatory marker (TNF-α, IL-6, and IL-8) levels were significantly lower in the research group than in the control group. Compared with those in the control group, the posttreatment GSH-Px, SOD, MDA and AOPPs in the research group were equivalent to the pretreatment levels; for example, the GSH-Px and SOD levels were significantly higher, while the MDA and AOPP levels were lower.

CONCLUSION

Dual-modality endoscopy therapy (duodenoscopy and laparoscopy) is more effective than traditional laparotomy in the treatment of intra- and extrahepatic BDSs and has a lower risk of postoperative complications; significantly shortened surgical time; shorter gastrointestinal function recovery time; shorter hospital stay; and lower intraoperative bleeding volume, while having a significant inhibitory effect on excessive serum inflammation and causing little postoperative oxidative stress.

Laparoscopic Transcystic Common Bile Duct Exploration: 8-Year Experience at a Single Institution

BACKGROUND

Laparoscopic transcystic common bile duct exploration (LTCBDE) is used to treat cholecystolithiasis and choledocholithiasis. This study aimed to investigate the safety, effectiveness and generalisability of LTCBDE in patients with cholecystolithiasis and choledocholithiasis based on our LTCBDE experience within 8 years.

METHODS

Four hundred patients with cholecystolithiasis and choledocholithiasis (including 62 of cholecystolithiasis and choledocholithiasis with common bile duct no-dilatation) treated with LTCBDE at a single centre from January 2014 to February 2022 were retrospectively evaluated. They were divided into the first 200 and last 200 LTCBDE cases. The disease characteristics, cystic duct incision methods, surgical outcomes and follow-up data were analysed retrospectively. Each patient was followed up for > 3 months.

RESULTS

Four hundred patients underwent LTCBDE, including 188 males and 212 females aged from 15 to 91 years (average age: 56 years). LTCBDE was successful in 377 (94.3%) patients, while treatment was converted to laparoscopic choledocholithotomy with T-tube drainage in 23 (5.8%), owing to intraoperative choledochoscope insertion failure. The CBD diameter (10.89 ± 1.76 vs 9.97 ± 2.39, P < 0.05), cystic duct diameter (4.62 ± 1.03 vs 5.03 ± 1.29, P < 0.05), and operation time (164.60 ± 24.30 vs 135.34 ± 30.00, P < 0.05). Residual stones were found in six (1.5%) patients and removed during the second operation; post-operative bile leakage was found in one (0.3%) patient, who was discharged safely after the second operation.

CONCLUSIONS

Phase I LTCBDE is safe and effective in treating cholecystolithiasis and choledocholithiasis. With continuous technological advances, LTCBDE has been effectively promoted and applied.

Cardiovascular complications after common bile duct stone extractions

BACKGROUND

Common bile duct stone (CBDS) is a common condition the rate of which increases with age. Decision to treat in particular elderly and frail patients with CBDS is often complex and requires careful assessment of the risk for treatment-related cardiovascular complications. The aim of this study was to compare the rate of postoperative cardiovascular events in CBDS patients treated with the following: ERCP only; cholecystectomy only; cholecystectomy followed by delayed ERCP; cholecystectomy together with ERCP; or ERCP followed by delayed cholecystectomy.

METHODS

The study was based on data from procedures for gallstone disease registered in the Swedish National Quality Register for Cholecystectomy and Endoscopic Retrograde Cholangiopancreatography (GallRiks) 2006-2014. ERCP and cholecystectomy procedures performed for confirmed or suspected CBDS were included. Postoperative events were registered by cross-matching GallRiks with the National Patient Register (NPR). A postoperative cardiovascular event was defined as an ICD-code in the discharge notes indicating myocardial infarct, pulmonary embolism or cerebrovascular disease within 30 days after surgery. In cases where a patient had undergone ERCP and cholecystectomy on separate occasions, the 30-day interval was timed from the first intervention.

RESULTS

A total of 23,591 underwent ERCP or cholecystectomy for CBDS during the study period. A postoperative cardiovascular event was registered in 164 patients and death within 30 days in 225 patients. In univariable analysis, adverse cardiovascular event and death within 30 days were more frequent in patients who underwent primary ERCP (p < 0.05). In multivariable analysis, adjusting for history of cardiovascular disease or events, neither risk for cardiovascular complication nor death within 30 days remained statistically significant in the ERCP group.

CONCLUSIONS

Primary ERCP as well as cholecystectomy may be performed for CBDS with acceptable safety. More studies are required to provide reliable guidelines for the management of CBDS.

Risk factors for complications after cholecystectomy for common bile duct stones: An EAST multicenter study

BACKGROUND

We sought to prospectively identify risk factors for biliary complications and 30-day readmission after cholecystectomy for choledocholithiasis and gallstone pancreatitis across multiple US hospitals.

METHODS

We performed a prospective, observational study of patients who underwent same admission cholecystectomy for choledocholithiasis and gallstone pancreatitis between 2016 and 2019 at 12 US centers. Patients with prior history of endoscopic retrograde cholangiopancreatography or diagnosis of cholangitis were excluded. We used logistic regression to determine associations between preoperative demographics, labs, and imaging on primary outcomes: postoperative biliary complications and 30-day readmission.

RESULTS

There were 989 patients in the cohort. There were 16 (1.6%) patients with postoperative biliary complications, including intra-abdominal abscesses, endoscopic retrograde cholangiopancreatography-induced pancreatitis, and biliary leaks. Increasing operative time (odds ratio 1.01, 95% confidence interval 1.00-1.01, P = .02), worsening leukocytosis (odds ratio 1.16, 95% confidence interval 1.07-1.25, P = .0002), and jaundice (odds ratio 3.25, 95% confidence interval 1.01-10.42, P = .04) were associated with postoperative biliary complications. There were 36 (3.6%) patients readmitted within 30 days owing to a surgical complication. A prior postoperative biliary complication (odds ratio 7.8, 95% confidence interval 1.63-37.27, P = .01), male sex (odds ratio 2.42, 95% confidence interval 1.2-4.87, P = .01), and index operative duration (odds ratio 1.01, 95% confidence interval 1.00-1.01, P = .03) were associated with 30-day readmission.

CONCLUSION

Among patients undergoing cholecystectomy for common bile duct stones, jaundice, worsening leukocytosis, and longer operations are associated with postoperative biliary complications. A prior biliary complication is also predictive of a 30-day readmission. Surgeons should recognize these factors and avoid prematurely discharging at-risk patients given their propensity to develop complications and require readmission.

Surgical (Open and laparoscopic) management of large difficult CBD stones after different sessions of endoscopic failure: A retrospective cohort study

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.

Surgical (Open and laparoscopic) management of large difficult CBD stones after different sessions of endoscopic failure: A retrospective cohort study

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.

Total bilirubin trend as a predictor of common bile duct stones in acute cholecystitis and symptomatic cholelithiasis

BACKGROUND

We hypothesized that trends in total bilirubin in the context of cholecystitis and symptomatic cholelithiasis could be used to guide testing for the presence of common bile duct stones (CBDS).

METHODS

A review of adult patients with acute cholecystitis or biliary colic with elevated total bilirubin and at least two levels drawn prior to procedural intervention was performed. Trends of total bilirubin and other serum makers were examined to predict the presence of CBDS.

RESULTS

The total bilirubin level at presentation, average over 24 h and average over 48 h (3.74 mg/dl vs. 2.29 mg/dl, p = 0.005; 3.72 mg/dl vs. 2.40 mg/dl, p = 0.009; 2.41 mg/dl vs. 1.47 mg/dl, p < 0.001) respectively, were all higher in those with CBDS. However, prediction was not improved by following levels over time.

CONCLUSION

Patients presenting with elevated serum bilirubin, should undergo immediate imaging or procedural intervention rather than obtaining follow-up bilirubin levels.

Intraoperative cholangiography during cholecystectomy in sequential treatment of cholecystocholedocholithiasis: To be, or not to be, that is the question A cohort study

BACKGROUND

Choledocholithiasis occurs in 10-15% of patients with cholecystolithiasis. Despite the existence of many therapeutic options for the treatment of cholecystocholedocholithiasis, a sequential treatment in which pre-operative ERCP is combined with intraoperative cholangiography (IOC) and laparoscopic cholecystectomy (LC), is the most commonly accepted strategy. However, use of IOC in the "splitting treatment" of cholecystocholedocholithiasis is controversial. The aim of the present study is to investigate the utility of IOC in detecting residual stones in patients undergoing LC in the sequential treatment of common biliary duct or gallbladder stones.

METHODS

Patients were recruited retrospectively among those who underwent IOC during LC, performed as second stage in the sequential treatment for cholecystocholedocholithiasis between 2010 and 2016. Demographic and clinical data were obtained from CPT codes at Ospedale Monaldi A.O.R.N dei Colli Naples, Italy. Data obtained from all pre-operative ERCP analyses were recorded, including cholangiogram findings and performance of sphincterotomy. Statistical analysis was carried out using the IBM SPSS Statistic 19.0 software package.

RESULTS

Between January 2010 and December 2016 575 patients (343 males, 242 females) underwent IOC during LC for symptomatic cholecystitis due to cholelithiasis. Among patients accrued for the study, 143 underwent preoperative ERCP for suspicion of common biliary duct stones. At the time of pre-operative ERCP, 123 were found to have common biliary duct stones while 20 (15%) presented negative ERCP. Complete removal of stones was accomplished in 119 patients. Among these patients, 13 had residual common biliary duct stones diagnosed by IOC (11%). Two patients underwent laparoscopic bile duct revision and, last, two patients were referred for ERCP at a later point. It is of note that all patients who presented residual stones by IOC had undergone pre-operative sphincterotomy.

CONCLUSION

This study demonstrates that IOC is particularly effective in detecting residual stones in patients undergoing LC in sequential treatment of common biliary duct and/or gallbladder stones, and may be used on a routine basis in the sequential treatment of cholecystocholedocholithiasis.

Percutaneous transhepatic papilla balloon dilatation combined with a percutaneous transcystic approach for removing concurrent gallbladder stone and common bile duct stone in a patient with billroth II gastrectomy and acute cholecystitis: A case report

BACKGROUND

A 61-year-old man presented with upper abdominal pain and jaundice. Abdominal computed tomography imaging revealed stones in the gallbladder and the common bile duct, with a thickening of the gallbladder wall and an obvious increase in the volume of the gallbladder. Initial treatment using endoscopic retrograde cholangiopancreatography failed due to the presence of surgically altered gastrointestinal anatomy. Stones in the gallbladder and common bile duct were subsequently removed concurrently via percutaneous transhepatic papilla balloon dilatation combined with a percutaneous transcystic approach. Liver function recovered rapidly, with total bilirubin and direct bilirubin levels decreasing to normal, with a concomitant improvement in hemoglobin and thrombocyte levels and resolution of the upper abdominal pain and jaundice.

CONCLUSION

Percutaneous transhepatic papilla balloon dilatation, combined with a percutaneous transcystic approach, provided an effective alternative treatment for removing concurrent stones in the common bile duct and gallbladder in a patient with a previous Billroth II gastrectomy and presenting with an acute cholecystitis.

Three modalities on management of choledocholithiasis: A prospective cohort study

BACKGROUND

Choledocholithiasis can be managed by endoscopic retrograde cholangiopancreaticography/endoscopic sphincterotomy (ERCP/EST) or laparoscopic common bile duct (CBD) exploration by transcystic (TC) or transductal (TD) stone extraction.

OBJECTIVE

The aim of this study was to evaluate the safety and effectiveness of common bile duct stones extraction by ERCP/EST, TC approach and TD approach for choledocholithiasis, with specific emphasis on ERCP/EST, TC approach versus TD approach.

METHODS

Between January 2011 and June 2014, a total of 161 patients were scheduled for two-stage (preoperative ERCP/EST followed by cholecystectomy, ERCP group, n = 52)or single-stage (laparoscopic exploration of the CBD combined with cholecystectomy, n = 109) treatment for choledocholithiasis with concomitant cholecystitis. Laparoscopic common bile duct exploration was performed by TC approach (TC group, n = 63)or TD approach (TD group, n = 46). T-tube insertion was performed in selected patients. Patients were regularly followed up at bimonthly intervals or more frequently in presence of any symptom. Primary outcomes measures included length of hospital stay, successful bile duct clearance, postoperative/procedural morbidity and mortality.

RESULTS

Successful bile duct clearance was 100.0% in TD group, 93.7% in TC group and 92.3% in ERCP group. 4 cases in the TC group and 4 cases in the ERCP group required an extra choledocholithotomy due to impacted stones. 9 patients underwent T-tube drainage in TD group comparing to 1 case in ERCP group and no cases in TC group. Comparing to TC group, there was more postoperative morbidity in TD and ERCP group. Bile leaks were more frequent in TD group (8.7%) than TC (3.2%) and ERCP group (3.8%), which prolonged hospitalization in TD group than TC and ERCP group. 2 patients in ERCP group suffered duodenal perforation and one of them died because of the complication. However, total procedural morbidity was 0% in TC and TD group.

CONCLUSION

TD stone extraction has a higher stone clearance but with a higher risk of bile leaks. Procedural morbidity is more often happened in ERCP/EST, which may result in serious consequences. TC stone extraction, which seems an effective approach with lower complication rates, is accessible techniques simplifying the operation procedure by avoiding choledocholithotomy and subsequent T-tube insertion.

Transcystic or transductal stone extraction during single-stage treatment of choledochocystolithiasis: a systematic review

BACKGROUND

Choledochocystolithiasis can be managed by endoscopic retrograde cholangiopancreaticography (ERCP) or laparoscopically by transcystic (TC) or transductal (TD) stone extraction.

OBJECTIVE

The aim of this study was to systematically review safety and effectiveness of combined endoscopic/laparoscopic management versus total laparoscopic management for choledochocystolithiasis with specific emphasis on TC versus TD stone extraction.

METHODS

MEDLINE/PubMed, EMBASE, the Cochrane Library, and clinicaltrials.gov were searched systematically to identify trials on combined endoscopic/laparoscopic and total laparoscopic management for choledochocystolithiasis. Laparoscopic common bile duct (CBD) exploration was divided into TD and TC approach. Primary outcomes were successful stone clearance from CBD, postoperative/procedural morbidity, and mortality.

RESULTS

Eight randomized trials with 965 patients were included. Successful bile duct clearance varied between 52.6 and 97 % in the ERCP groups, 80.4 and 100 % in the TC groups, and 58.3 and 100 % in the TD groups. There were more bile leaks after TD stone extraction (11 %) than after ERCP (1 %) and TC stone extraction (1.7 %). Total morbidity varied between 9.1 and 38.3 % in the ERCP groups, 7 and 10.5 % in the TC groups, and 18.4 and 26.7 % in the TD groups. Methodological and statistical heterogeneity among the trials precluded a meaningful meta-analysis.

CONCLUSION

Stone clearance rates are comparable between the three modalities, but TD stone extraction is associated with a higher risk of bile leaks and should only be performed by highly experienced surgeons. TC stone extraction seems a more accessible technique with lower complication rates. If unsuccessful, per- or postoperative endoscopic stone extraction is a viable option.

Laparoscopic choledochojejunostomy in various hepatobiliary and pancreatic surgeries: a single surgeon's experience

BACKGROUND

The aims of this study were to measure the learning curve for laparoscopic choledochojejunostomy (LCJ), to describe the technical tips and to report the follow-up data.

MATERIALS AND METHODS

The results of LCJ performed on 84 patients were analyzed. Patients were divided into eight groups, by surgical order. The plateau of the learning curve was defined as the period during which the operative time showed a dramatic decrease. The exact operative time was recorded using video analysis.

RESULTS

Compared with the first three groups, the fourth group showed a significantly shorter LCJ time. The subsequent groups showed a plateau, indicating that there were no more significant changes in the LCJ time. After the plateau of the learning curve was reached, the average LCJ time was 27.4±4.7 minutes. Six cases of postoperative bile leakage occurred, with all occurring before the plateau of the learning curve was reached. Five of the 6 cases of bile leakage had a nondilated common bile duct.

CONCLUSIONS

Even for a surgeon experienced in laparoscopic surgery, there is a steep learning curve for the performance of LCJ. With careful video review, education of the surgical team, and various technical tips, the learning curve can be shortened. After the learning curve, experienced surgeons can perform LCJ with acceptable results.

Laparoscopy in cholecysto-choledocholithiasis

Gallstone disease is one of the most common problems in the gastroenterology and is associated with significant morbidity. It may present as stones in the gallbladder (cholecystolithiasis) or in the common bile duct (choledocholithiasis). At the end of the 1980s laparoscopy was introduced and first laparoscopic cholecystectomy was performed in 1985. The laparoscopic technique for removing the gallbladder is the current treatment of choice, although indications for open surgery exist. To perform laparoscopic cholecystectomy as safe as possible multiple safety measures were developed. The gold standard for diagnosing and removing common bile duct stones is Endoscopic Retrograde Cholangiopancreatography (ERCP). The surgical treatment option for choledocholithiasis is laparoscopic cholecystectomy with common bile duct exploration. If experience is not available, than ERCP followed by elective cholecystectomy is by far the best therapeutic modality. The present review will discuss the use, benefits and drawbacks of laparoscopy in patients with cholecystolithiasis and choledocholithiasis.

Comparative evaluation of two laparoscopic procedures for treating common bile duct stones

Cholesystolithiasis is often associated with common bile duct stones (CBDS). In order to assess the choice of surgery in terms of effectiveness and complications in the treatment of CBDS, we have compared three surgical procedures, viz., laparoscopic choledocholithotomy T-tube drainage (LCH-TD), laparoscopic cholecystectomy with endoscopic sphincterotomy (LC-EST), and the traditional open choledocholithotomy with T-tube drainage (OCHTD). This study is a retrospective comparative analysis of LCH-TD (77 patients), LC-EST (43 patients), and OCHTD (60 patients) for CBDS. The success of the surgical procedures was assessed in terms of recovery duration, hospitalization, and post-operative complications. Both the micro-invasive procedures, LCH-TD and LC-EST, with a success rate of 92.5%, are found to be superior to the traditional OCHTD. Between the two micro-invasive procedures, patients in LCH-TD group had shorter operation time and hospital stay, and fewer post-operative complications. Although the size of the stones is comparable between these two groups, the CBD diameter was significantly larger in patients who underwent LCH-TD. In comparison to OCHTD, both LCH-TD and LC-EST are micro-invasive, safe, and suitable for routine use in patients with CBDS. Moreover, when the CBD diameter is wider than 1 cm, LCH-TD is strongly advocated.

Timing of elective laparoscopic cholecystectomy after endoscopic retrograde cholangiopancreaticography with sphincterotomy: a prospective observational study of 308 patients

PURPOSE

Endoscopic retrograde cholangiopancreaticography (ERCP) with sphincterotomy is associated with higher rates of conversion to open surgery during subsequent laparoscopic cholecystectomy (LC). The mechanisms of this association are unclear. The aim of this study was to investigate whether the time interval between the two procedures can affect the course of LC in terms of conversion rate or complications.

METHODS

In this prospective observational study, 308 consecutive patients underwent ERCP with sphincterotomy followed at various intervals by elective LC. According to these intervals, the patients' data were assigned to one of three groups: short-interval (2 days or less), medium-interval (3-42 days), or long-interval (43 days or more). Groups were also defined in terms of whether gallstones were extracted during ERCP and in terms of the number of ERCPs performed (single or multiple) prior to LC. The main outcome measures for all groups were the frequency of complications during or after LC and the frequency of conversions to open surgery.

RESULTS

Of the 308 patients, 43 required conversion to open cholecystectomy (14%). The short-interval (95 patients), medium-interval (100 patients), and long-interval (113 patients) groups did not differ significantly in terms of intraoperative complications, postoperative complications, or conversion to open surgery (p = 0.985, 0.340, and 0.472, respectively). The conversion rate also did not differ significantly according to the presence or absence of gallstones on ERCP (14.7% versus 12.8%, respectively, p = 0.392). However, compared with patients who underwent single ERCP (n = 290), those who underwent multiple ERCPs (n = 18) experienced significantly more conversion to open surgery (p = 0.026).

CONCLUSIONS

The length of time between endoscopic sphincterotomy and LC did not affect the latter procedure in terms of complications or conversion to open surgery. However, the lack of an association between conversion rate and gallstone presence on ERCP and the higher conversion rate among patients who underwent multiple ERCPs, suggest that ERCP with sphincterotomy itself may be a factor in the higher conversion rates that have been observed after this procedure.

Early laparoscopic cholecystectomy improves outcomes after endoscopic sphincterotomy for choledochocystolithiasis

BACKGROUND & AIMS

Patients with choledochocystolithiasis generally undergo endoscopic sphincterotomy (ES) followed by laparoscopic cholecystectomy (LC). However, many patients receive this surgery 6-8 weeks after ES. There is a high conversion rate of elective LC after ES, and patients can develop recurrent biliary events during the waiting period. We investigated whether the timing of surgery influences outcome.

METHODS

We performed a randomized trial of patients with choledochocystolithiasis who underwent successful ES. Patients were randomly assigned to groups that received early LC (within 72 hours after ES, n = 49) or delayed LC (after 6-8 weeks, n = 47), based on an expected difference in conversion rate of 25% vs 5%, respectively. Conversion rate, biliary events during follow-up, duration and difficulty of surgeries, postoperative morbidity, and hospital stay were scored. Intention-to-treat analyses were performed.

RESULTS

Groups were comparable in age, sex, and comorbidity. There was no difference between groups in conversion rate (4.3% in early vs 8.7% in delayed group) nor were there differences in operating times and/or difficulties or hospital stays. During the waiting period for LC, 17 patients in the delayed group (36.2%) developed recurrent biliary events compared with 1 patient in the early group (P < .001).

CONCLUSIONS

In a randomized trial to evaluate timing of LC after ES, recurrent biliary events occurred in 36.2% of patients whose LC was delayed for 6-8 weeks. Early LC (within 72 hours) appears to be safe and might prevent the majority of biliary events in this period following sphincterotomy.

Open common bile duct exploration without T-tube insertion- two decade experience from a limited resource setting in the Caribbean

PURPOSE

Despite advancements in gallbladder surgery with the introduction of endoscopic and laparoscopic techniques, many surgeons, especially in the developing world, still perform open cholecystectomy with common bile duct (CBD) exploration for choledocholithiasis. The purpose of the study is to report the outcomes of a case series of open CBD exploration without the use of T-tubes.

MATERIALS AND METHODS

A retrospective chart review of all consecutive open CBD exploration done by the first author over a period of 23 years was conducted. Demographic data, preoperative investigations, the surgical techniques and perioperative outcomes were recorded.

RESULTS

Of 690 open cholecystectomies performed during the study period, 108 had common bile duct exploration. In 94 cases this was done via a supraduodenal choledochotomy, in 10 cases via a transduodenal sphincteroplasty and in 4 cases via the cystic duct. In 90 cases, a simple choledochotomy and primary closure was done while in 4 cases choledocho-duodenostomy was required. Eighty-seven percent of surgeries were done on elective basis and 13% on an emergency basis and no T-tubes were used in any patients. The mean hospital length of stay was 3.2 days and the perioperative morbidity was negligible.

CONCLUSIONS

In a limited resource setting, there is still a role for open CBD exploration and primary closure without the necessity of T-tubes and stents as evidenced by a good perioperative patient outcome.

Various techniques for the surgical treatment of common bile duct stones: a meta review

Common bile duct stones (CBDSs) may occur in up to 3%–14.7% of all patients for whom cholecystectomy is preformed. Patients presenting with CBDS have symptoms including: biliary colic, jaundice, cholangitis, pancreatitis or may be asymptomatic. It is important to distinguish between primary and secondary stones, because the treatment approach varies. Stones found before, during, and after cholecystectomy had also differing treatments. Different methods have been used for the treatment of CBDS but the suitable therapy depends on conditions such as patient' satisfaction, number and size of stones, and the surgeons experience in laparoscopy. Endoscopic retrograde cholangiopancreatography with or without endoscopic biliary sphincterotomy, laparoscopic CBD exploration (transcystic or transcholedochal), or laparotomy with CBD exploration (by T-tube, C-tube insertion, or primary closure) are the most commonly used methods managing CBDS. We will review the pathophysiology of CBDS, diagnosis, and different techniques of treatment with especial focus on the various surgical modalities.