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Safe laparoscopic cholecystectomy: A systematic review of bile duct injury prevention. Int J Surg 2018; 60:164-172. [PMID: 30439536 DOI: 10.1016/j.ijsu.2018.11.006] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Revised: 10/14/2018] [Accepted: 11/04/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Since the introduction of laparoscopic cholecystectomy (LC), a substantial increase in bile duct injury (BDI) incidence was noted. Multiple methods to prevent this complication have been developed and investigated. The most suitable method however is subject to debate. In this systematic review, the different modalities to aid in the safe performance of LC and prevent BDI are delineated. MATERIALS AND METHODS A systematic search for articles describing methods for the prevention of BDI in LC was conducted using EMBASE, Medline, Web of science, Cochrane CENTRAL and Google scholar databases from inception to 11 June 2018. RESULTS 90 studies were included in this systematic review. Overall, BDI preventive techniques can be categorized as dedicated surgical approaches (Critical View of Safety (CVS), fundus first, partial laparoscopic cholecystectomy), supporting imaging techniques (intraoperative radiologic cholangiography, intraoperative ultrasonography, fluorescence imaging) and others. Dedicated surgical approaches demonstrate promising results, yet limited research is provided. Intraoperative radiologic cholangiography and ultrasonography demonstrate beneficial effects in BDI prevention, however the available evidence is low. Fluorescence imaging is in its infancy, yet this technique is demonstrated to be feasible and larger trials are in preparation. CONCLUSION Given the low sample sizes and suboptimal study designs of the studies available, it is not possible to recommend a preferred method to prevent BDI. Surgeons should primarily focus on proper dissection techniques, of which CVS is most suitable. Additionally, recognition of hazardous circumstances and knowledge of alternative techniques is critical to complete surgery with minimal risk of injury to the patient.
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Gao Y, Li M, Song ZF, Cui L, Wang BR, Lou XD, Zhou T, Zhang Y, Zheng QC. Mechanism of dynamic near-infrared fluorescence cholangiography of extrahepatic bile ducts and applications in detecting bile duct injuries using indocyanine green in animal models. ACTA ACUST UNITED AC 2017; 37:44-50. [PMID: 28224425 DOI: 10.1007/s11596-017-1692-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 10/28/2016] [Indexed: 12/17/2022]
Abstract
Fluorescence intraoperative cholangiography (IOC) is a potential alternative for identifying anatomical variation and preventing iatrogenic bile duct injuries by using the near-infrared probe indocyanine green (ICG). However, the dynamic process and mechanism of fluorescence IOC have not been elucidated in previous publications. Herein, the optical properties of the complex of ICG and bile, dynamic fluorescence cholangiography and iatrogenic bile duct injuries were investigated. The emission spectrum of ICG in bile peaked at 844 nm and ICG had higher tissue penetration. Extrahepatic bile ducts could fluoresce 2 min after intravenous injection, and the fluorescence intensity reached a peak at 8 min. In addition, biliary dynamics were observed owing to ICG excretion from the bile ducts into the duodenum. Quantitative analysis indicated that ICG-guided fluorescence IOC possessed a high signal to noise ratio compared to the surrounding peripheral tissue and the portal vein. Fluorescence IOC was based on rapid uptake of circulating ICG in plasma by hepatic cells, excretion of ICG into the bile and then its interaction with protein molecules in the bile. Moreover, fluorescence IOC was sensitive to detect bile duct ligation and acute bile duct perforation using ICG in rat models. All of the results indicated that fluorescence IOC using ICG is a valid alternative for the cholangiography of extrahepatic bile ducts and has potential for measurement of biliary dynamics.
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Affiliation(s)
- Yang Gao
- Department of Hepatobiliary Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Min Li
- Department of Hepatobiliary Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Zi-Fang Song
- Department of Hepatobiliary Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Le Cui
- Department of Breast and Thyroid Surgery, Puai Hospital, Wuhan, 430035, China
| | - Bi-Rong Wang
- Department of Breast and Thyroid Surgery, Puai Hospital, Wuhan, 430035, China
| | - Xiao-Ding Lou
- Key Laboratory for Large-Format Battery Materials and System, Ministry of Education, School of Chemistry and Chemical Engineering, Huazhong University of Science and Technology, Wuhan, 430074, China
| | - Tao Zhou
- Department of Otorhinolaryngology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Yong Zhang
- Department of Hepatobiliary Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Qi-Chang Zheng
- Department of Hepatobiliary Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
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Lee DH, Ahn YJ, Lee HW, Chung JK, Jung IM. Prevalence and characteristics of clinically significant retained common bile duct stones after laparoscopic cholecystectomy for symptomatic cholelithiasis. Ann Surg Treat Res 2016; 91:239-246. [PMID: 27847796 PMCID: PMC5107418 DOI: 10.4174/astr.2016.91.5.239] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 07/07/2016] [Accepted: 07/27/2016] [Indexed: 02/08/2023] Open
Abstract
PURPOSE To investigate the prevalence and clinical features of retained symptomatic common bile duct (CBD) stone detected after laparoscopic cholecystectomy (LC) in patients without preoperative evidence of CBD or intrahepatic duct stones. METHODS Of 2,111 patients who underwent cholecystectomy between September 2007 and December 2014 at Seoul Metropolitan Government-Seoul National University Boramae Medical Center, 1,467 underwent laparoscopic cholecystectomy for symptomatic gallbladder stones and their medical records were analyzed. We reviewed the clinical data of patients who underwent postoperative endoscopic retrograde cholangiopancreatography (ERCP) for clinically significant CBD stones (i.e., symptomatic stones requiring therapeutic intervention). RESULTS Overall, 27 of 1,467 patients (1.84%) underwent postoperative ERCP after LC because of clinical evidence of retained CBD stones. The median time from LC to ERCP was 152 days (range, 60-1,015 days). Nine patients had ERCP-related complications. The median hospital stay for ERCP was 6 days. CONCLUSION The prevalence of clinically significant retained CBD stone after LC for symptomatic cholelithiasis was 1.84% and the time from LC to clinical presentation ranged from 2 months to 2 years 9 months. Therefore, biliary surgeons should inform patients that retained CBD stone may be detected several years after LC for simple gallbladder stones.
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Affiliation(s)
- Doo-Ho Lee
- Department of Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Young Joon Ahn
- Department of Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Hae Won Lee
- Department of Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Jung Kee Chung
- Department of Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - In Mok Jung
- Department of Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
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Lepner U, Grünthal V. Intraoperative Cholangiography Can Be Safely Omitted during Laparoscopic Cholecystectomy: A Prospective Study of 413 Consecutive Patients. Scand J Surg 2016; 94:197-200. [PMID: 16259167 DOI: 10.1177/145749690509400304] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background and Aims: The aim of the study was to show that laparoscopic cholecystectomy (LC) can be performed safely without intraoperative cholangiography (IOC). Material and Methods: We conducted a prospective study of 413 consecutive patients with symptomatic gallstone disease, who underwent LC. According to the preoperative clinical, laboratory and ultrasound criteria, 38 patients (9.2 %) were selected for preoperative endoscopic retrograde cholangiography (ERC). All patients were followed postoperatively for symptoms and signs of common bile duct (CBD) stones. Results: Preoperative ERC allowed to make a diagnosis of choledocholithiasis in 22 (58 %) of the 38 selected patients. Stone clearance was achieved with endoscopic sphincterotomy (ES) in all cases. Three patients (7.9 %) had an episode of mild self-limited pancreatitis after the procedure. Eight patients (1.9 %) of 413 required conversion from LC to open cholecystectomy. There were no CBD injuries and no death cases. Of the postoperative complications, 1.5 % were recorded during hospital stay. During the follow-up period, for at least 2 years after surgery, retained CBD stones were verified in 6 patients (1.5 %); however, the supposed rate of residual stones was 2.4 %. Conclusions: This study demonstrates that performance of selective preoperative ERC with ES when necessary, followed by LC, is an appropriate and safe approach to the treatment of patients with cholecystolithiasis and unsuspected choledocholithiasis. This approach allows to omit IOC and to perform LC safely without biliary duct injuries, ensuring low rate of retained CBD stones in the late follow-up period.
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Affiliation(s)
- U Lepner
- Department of Surgery, University of Tartu, 51014 Tartu, Estonia.
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Nassar AHM, Mirza A, Qandeel H, Ahmed Z, Zino S. Fluorocholangiography: reincarnation in the laparoscopic era—evaluation of intra-operative cholangiography in 3635 laparoscopic cholecystectomies. Surg Endosc 2015; 30:1804-11. [DOI: 10.1007/s00464-015-4449-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 07/13/2015] [Indexed: 12/16/2022]
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Gurusamy KS, Giljaca V, Takwoingi Y, Higgie D, Poropat G, Štimac D, Davidson BR. Endoscopic retrograde cholangiopancreatography versus intraoperative cholangiography for diagnosis of common bile duct stones. Cochrane Database Syst Rev 2015; 2015:CD010339. [PMID: 25719222 PMCID: PMC6464791 DOI: 10.1002/14651858.cd010339.pub2] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) and intraoperative cholangiography (IOC) are tests used in the diagnosis of common bile duct stones in people suspected of having common bile duct stones. There has been no systematic review of the diagnostic accuracy of ERCP and IOC. OBJECTIVES To determine and compare the accuracy of ERCP and IOC for the diagnosis of common bile duct stones. SEARCH METHODS We searched MEDLINE, EMBASE, Science Citation Index Expanded, BIOSIS, and Clinicaltrials.gov to September 2012. To identify additional studies, we searched the references of included studies and systematic reviews identified from various databases (Database of Abstracts of Reviews of Effects (DARE)), Health Technology Assessment (HTA), Medion, and ARIF (Aggressive Research Intelligence Facility)). We did not restrict studies based on language or publication status, or whether data were collected prospectively or retrospectively. SELECTION CRITERIA We included studies that provided the number of true positives, false positives, false negatives, and true negatives for ERCP or IOC. We only accepted studies that confirmed the presence of common bile duct stones by extraction of the stones (irrespective of whether this was done by surgical or endoscopic methods) for a positive test, and absence of common bile duct stones by surgical or endoscopic negative exploration of the common bile duct, or symptom-free follow-up for at least six months for a negative test as the reference standard in people suspected of having common bile duct stones. We included participants with or without prior diagnosis of cholelithiasis; with or without symptoms and complications of common bile duct stones; with or without prior treatment for common bile duct stones; and before or after cholecystectomy. At least two authors screened abstracts and selected studies for inclusion independently. DATA COLLECTION AND ANALYSIS Two authors independently collected data from each study. We used the bivariate model to summarise the sensitivity and specificity of the tests. MAIN RESULTS We identified five studies including 318 participants (180 participants with and 138 participants without common bile duct stones) that reported the diagnostic accuracy of ERCP and five studies including 654 participants (125 participants with and 529 participants without common bile duct stones) that reported the diagnostic accuracy of IOC. Most studies included people with symptoms (participants with jaundice or pancreatitis) suspected of having common bile duct stones based on blood tests, ultrasound, or both, prior to the performance of ERCP or IOC. Most studies included participants who had not previously undergone removal of the gallbladder (cholecystectomy). None of the included studies was of high methodological quality as evaluated by the QUADAS-2 tool (quality assessment tool for diagnostic accuracy studies). The sensitivities of ERCP ranged between 0.67 and 0.94 and the specificities ranged between 0.92 and 1.00. For ERCP, the summary sensitivity was 0.83 (95% confidence interval (CI) 0.72 to 0.90) and specificity was 0.99 (95% CI 0.94 to 1.00). The sensitivities of IOC ranged between 0.75 and 1.00 and the specificities ranged between 0.96 and 1.00. For IOC, the summary sensitivity was 0.99 (95% CI 0.83 to 1.00) and specificity was 0.99 (95% CI 0.95 to 1.00). For ERCP, at the median pre-test probability of common bile duct stones of 0.35 estimated from the included studies (i.e., 35% of people suspected of having common bile duct stones were confirmed to have gallstones by the reference standard), the post-test probabilities associated with positive test results was 0.97 (95% CI 0.88 to 0.99) and negative test results was 0.09 (95% CI 0.05 to 0.14). For IOC, at the median pre-test probability of common bile duct stones of 0.35, the post-test probabilities associated with positive test results was 0.98 (95% CI 0.85 to 1.00) and negative test results was 0.01 (95% CI 0.00 to 0.10). There was weak evidence of a difference in sensitivity (P value = 0.05) with IOC showing higher sensitivity than ERCP. There was no evidence of a difference in specificity (P value = 0.7) with both tests having similar specificity. AUTHORS' CONCLUSIONS Although the sensitivity of IOC appeared to be better than that of ERCP, this finding may be unreliable because none of the studies compared both tests in the same study populations and most of the studies were methodologically flawed. It appears that both tests were fairly accurate in guiding further invasive treatment as most people diagnosed with common bile duct stones by these tests had common bile duct stones. Some people may have common bile duct stones in spite of having a negative ERCP or IOC result. Such people may have to be re-tested if the clinical suspicion of common bile duct stones is very high because of their symptoms or persistently abnormal liver function tests. However, the results should be interpreted with caution given the limited quantity and quality of the evidence.
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Affiliation(s)
- Kurinchi Selvan Gurusamy
- Department of Surgery, Royal Free Campus, UCL Medical School, Royal Free Hospital, Rowland Hill Street, London, UK, NW3 2PF.
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Timing and nature of presentation of unsuspected retained common bile duct stones after laparoscopic cholecystectomy: a retrospective study. Surg Endosc 2014; 29:2033-8. [DOI: 10.1007/s00464-014-3907-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Accepted: 09/16/2014] [Indexed: 12/15/2022]
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Surgery for common bile duct stones--a lost surgical skill; still worthwhile in the minimally invasive century? Langenbecks Arch Surg 2014; 400:119-27. [PMID: 25366358 DOI: 10.1007/s00423-014-1254-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Accepted: 10/20/2014] [Indexed: 02/06/2023]
Abstract
PURPOSE Techniques of laparoscopic bile duct exploration have been reported for over 20 years. Despite the simplicity and success of these procedures, they have failed to become commonplace in most surgical departments, as endoscopic retrograde cholangiopancreatography (ERCP) has become the preferred method for dealing with bile duct stones. There is a risk of surgeons not obtaining or losing these skills, which may still be required as a definitive treatment when ERCP fails or is not available. METHODS AND RESULTS This paper describes these laparoscopic operations, which can be performed to enable a 'one-stop shop' treatment of common bile duct stones (CBDS) at the time of cholecystectomy. In particular, transcystic basket clearance of the bile duct is possible in two-thirds of cases with very little increase in morbidity compared to routine cholecystectomy. The selection of patients who are most likely to be successfully treated with this technique is defined. Some of the authors have published large study series and prospective randomised trials, further refining the choices available to the surgeon who, when performing operative cholangiography, is already halfway to bile duct exploration. CONCLUSIONS Surgery may reclaim this lost ground by offering an excellent and safe therapeutic option for many of the symptomatic CBDS.
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Vindal A, Chander J, Lal P, Mahendra B. Comparison between intraoperative cholangiography and choledochoscopy for ductal clearance in laparoscopic CBD exploration: a prospective randomized study. Surg Endosc 2014; 29:1030-8. [PMID: 25154888 DOI: 10.1007/s00464-014-3766-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 07/19/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Laparoscopic CBD exploration (LCBDE) is an accepted treatment modality for single stage management of CBD stones in fit patients. A transcholedochal approach is preferred in patients with a dilated CBD and large impacted stones in whom ductal clearance remains problematic. There are very few studies comparing intraoperative cholangiography (IOC) with choledochoscopy to determine ductal clearance in patients undergoing transcholedochal LCBDE. This series represents the first of those comparing the two from Asia. METHODS Between April 2009 and October 2012, 150 consecutive patients with CBD stones were enrolled in a prospective randomized study to undergo transcholedochal LCBDE on an intent-to-treat basis. Patients with CBD diameter of less than 9 mm on preoperative imaging were excluded from the study. Out of the 132 eligible patients, 65 patients underwent IOC (Group A), and 67 patients underwent intraoperative choledochoscopy (Group B) to determine CBD clearance. RESULTS There were no differences between the two groups in the demographic profile and the preoperative biochemical findings. There was no conversion to open procedures, and complete stone clearance was achieved in all the 132 cases. The mean CBD diameter and the mean number of CBD stones removed were comparable between the two groups. Mean operating time was 170 min in Group A and 140 min in Group B (p < 0.001). There was no difference in complications between the two groups. Nine patients in Group A (13.8%) showed non-passage of contrast into the duodenum on IOC which resolved after administration of i.v. glucagon, suggesting a transient spasm of sphincter of Oddi. Two patients (3%) showed a false-positive result on IOC which had to be resolved with choledochoscopy. CONCLUSIONS The present study showed that intraoperative choledochoscopy is better than IOC for determining ductal clearance after transcholedochal LCBDE and is less cumbersome and less time-consuming.
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Affiliation(s)
- Anubhav Vindal
- Division of Minimal Access Surgery, Department of Surgery, Maulana Azad Medical College, University of Delhi, New Delhi, 110002, India,
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Atahan K, Gur S, Durak E, Cokmez A, Tarcan E. The Feasibility and Safety of Laparoscopic Cholecystectomy Approach without the Intraopertative Cholangiography Use: A Retrospective Study on 750 Consecutive Patients. Gastroenterology Res 2012; 5:144-148. [PMID: 27785195 PMCID: PMC5051082 DOI: 10.4021/gr462e] [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] [Accepted: 05/31/2012] [Indexed: 11/19/2022] Open
Abstract
Background We have retrospectively reviewed the results of all common bile duct (CBD)-stone preoperative asymptomatic patients operated on our unit to point out the feasibility and safety of the laparoscopic cholecystectomy approach without the IOC use. Methods From January 2004 and June 2008 we analyzed all the data from hospital records and follow up results of all the patients who underwent LC. The indications for performing preoperative endoscopic retrograde cholangiopancreatography (ERCP) or selective IOC were abnormal liver function tests, history of jaundice, cholangitis or pancreatitis, and ultrasonographic evidence of CBD stone or dilation (≥ 10 mm). These patients were excluded from study. The follow up of the all patients were done by liver function tests and abdominal ultrasonography when needed at the time of the visit. Results Between January 2006 and June 2010, 750 patients were operated in our clinic. In 34 patients, operations were converted to open cholecystectomy (OC). Of these 750 patients, 98 of them had one or more exclusion criteria and were excluded from the further analyzes. We did not perform any IOC during LC. Regular follow up of at least two years was obtained in 618 (618/657, 94.0%) patients. No operative mortality was encountered among the patients. Postoperative morbidity was detected in 15 of the patients (2.5%). In one patient, CBD injury was detected (0.017%). The mean follow up was 35 (24 - 74) months. Retained stone was detected in three patients (3/577, 0.5%) during the follow up. Conclusion This approach allows to omit routine IOC and to perform LC safely in selected patients group given the low percentage of both CBD injuries and symptomatic retained stones observed in the late follow up period in our 618 operated patients, we consider our approach a feasible and safe approach to manage patients with gallbladder stones re-confirming the results of other studies.
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Affiliation(s)
- Kemal Atahan
- Ataturk Educational and Research Hospital 1st Surgical Department, Izmir, Turkey
| | - Serhat Gur
- Ataturk Educational and Research Hospital 1st Surgical Department, Izmir, Turkey
| | - Evren Durak
- Ataturk Educational and Research Hospital 1st Surgical Department, Izmir, Turkey
| | - Atilla Cokmez
- Ataturk Educational and Research Hospital 1st Surgical Department, Izmir, Turkey
| | - Ercument Tarcan
- Ataturk Educational and Research Hospital 1st Surgical Department, Izmir, Turkey
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Ford JA, Soop M, Du J, Loveday BPT, Rodgers M. Systematic review of intraoperative cholangiography in cholecystectomy. Br J Surg 2011; 99:160-7. [PMID: 22183717 DOI: 10.1002/bjs.7809] [Citation(s) in RCA: 135] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND Intraoperative cholangiography (IOC) is used to detect choledocholithiasis and identify or prevent bile duct injury. The aim of this study was systematically to review the randomized clinical trials of IOC for these two indications. METHODS MEDLINE, Embase, the Cochrane Library, clinicaltrials.gov and the World Health Organization database of clinical trials were searched systematically (January 1980 to February 2011) to identify trials. Two authors performed the literature search and extracted data independently. Primary endpoints were bile duct injury and retained common bile duct (CBD) stones diagnosed at any stage after surgery. Preliminary meta-analysis was undertaken, but the trials were too methodologically heterogeneous and the outcome events too infrequent to allow meaningful meta-analysis. RESULTS Eight randomized trials were identified including 1715 patients. Six trials assessed the value of routine IOC in patients at low risk of choledocholithiasis. Two trials randomized all patients (including those at high risk) to routine or selective IOC. Two cases of major bile duct injury were reported, and 13 of retained CBD stones. No trial demonstrated a benefit in detecting CBD stones. IOC added a mean of 16 min to the total operating time. CONCLUSION There is no robust evidence to support or abandon the use of IOC to prevent retained CBD stones or bile duct injury. Level 1 evidence for IOC is of poor to moderate quality. None of the trials, alone or in combination, was sufficiently powered to demonstrate a benefit of IOC. Further small trials cannot be recommended.
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Affiliation(s)
- J A Ford
- Health Technology Assessment Group, University of Aberdeen, Aberdeen, UK
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Ikeda T, Yonemura Y, Ueda N, Kabashima A, Mashino K, Yamashita K, Fujii K, Tashiro H, Sakata H. Intraoperative cholangiography using an endoscopic nasobiliary tube during a laparoscopic cholecystectomy. Surg Today 2011; 41:667-73. [PMID: 21533939 DOI: 10.1007/s00595-010-4334-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2009] [Accepted: 01/04/2010] [Indexed: 01/07/2023]
Abstract
PURPOSE The goals of this report are to present the characteristics of biliary complications associated with laparoscopic cholecystectomies (LC) performed at a single center, and to evaluate the efficacy of intraoperative cholangiography (IOC) using an endoscopic nasobiliary tube (ENBT) during an LC in order to prevent biliary complications. METHODS A retrospective audit was conducted on a total of 657 patients who underwent either LC or open cholecystectomies (OC). There were 19 patients who developed bile duct injury (BDI; n = 9) or bile leakage (BL; n = 10) during an LC and were actively treated. After May of 1999, the patients with a higher risk of developing biliary complications were selected for preoperative placement of an ENBT, and IOC was performed. RESULTS Intraoperative cholangiography using ENBT was performed on 93 (27.1%) out of 343 patients who underwent either LC or OC after May of 1999. An LC was performed in 335 cases (97.7%), and a conversion from an LC to OC was necessary in only three cases. Even though BDI never occurred, BL from the cystic duct and gallbladder bed were recognized in five cases. CONCLUSIONS The selective use of IOC using ENBT may help to prevent BDI during LC, thereby expanding the indications for LC, while also reducing the rate of conversion to open procedures.
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Affiliation(s)
- Tetsuo Ikeda
- Department of Surgery, Oita Prefectural Hospital, 476 Oaza-Bunyou, Oita, 870-8511, Japan
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Kim SY, Kim KH, Kim ID, Suh BS, Shin DW, Kim SW, Park JS, Lim HI. The Variation of Hepatic Duct Confluence and Asymptomatic Common Bile Duct Stone with Routine Intraoperative Cholangiogram during Laparoscopic Cholecystectomy. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2011; 58:338-45. [DOI: 10.4166/kjg.2011.58.6.338] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Se Young Kim
- Department of Sugery, Bundang Jaesaeng Hospital, Seongnam, Korea
| | - Ki Ho Kim
- Department of Sugery, Bundang Jaesaeng Hospital, Seongnam, Korea
| | - Il Dong Kim
- Department of Sugery, Bundang Jaesaeng Hospital, Seongnam, Korea
| | - Byung Sun Suh
- Department of Sugery, Bundang Jaesaeng Hospital, Seongnam, Korea
| | - Dong Woo Shin
- Department of Sugery, Bundang Jaesaeng Hospital, Seongnam, Korea
| | - Sang Wook Kim
- Department of Sugery, Bundang Jaesaeng Hospital, Seongnam, Korea
| | - Jin Soo Park
- Department of Sugery, Bundang Jaesaeng Hospital, Seongnam, Korea
| | - Hye In Lim
- Department of Sugery, Bundang Jaesaeng Hospital, Seongnam, Korea
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Prediction of which patients with an abnormal intraoperative cholangiogram will have a confirmed stone at ERCP. Dig Dis Sci 2010; 55:1479-84. [PMID: 19629686 DOI: 10.1007/s10620-009-0894-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2009] [Accepted: 06/19/2009] [Indexed: 01/16/2023]
Abstract
BACKGROUND Abnormal intraoperative cholangiogram (IOC) findings are commonly evaluated using postoperative endoscopic retrograde cholangiopancreatography (ERCP). However, abnormal IOC studies are associated with high false-positive rates. This study aimed to identify a subset of patients with abnormal IOC who would benefit from a postoperative ERCP. METHODS This retrospective study investigated 68 patients with abnormal IOC at laparoscopic cholecystectomy (LC) who underwent postoperative ERCP at two tertiary referral centers over a 4-year period. Univariate and multivariate logistic regression analyses were performed to determine predictors of common bile duct (CBD) stones at postoperative ERCP. These predictors included: indication for LC, abnormal liver function tests, white blood cell count (WBC), amylase and lipase, abdominal ultrasound findings, and IOC findings [(1) non-passage of contrast into the duodenum, (2) single stone, (3) multiple stones, (4) dilated CBD, (5) non-visualization of the distal CBD, and (6) palpable CBD stones]. RESULTS For all 68 patients, ERCP was successful. ERCP showed CBD stones in 36 cases (52.9%), and normal results in 32 cases (47%). On univariate and multivariate analysis, none of the variables included in this study significantly predicted stones at postoperative ERCP. CONCLUSIONS Approximately one-half of patients with an abnormal IOC have a normal postoperative ERCP. None of the parameters evaluated in this retrospective study helped identify patients who merit further evaluation by ERCP. The argument could be made that in patients with an abnormal IOC, less invasive methods such as endoscopic ultrasound or magnetic resonance cholangiopancreatography could be used postoperatively if symptoms arise to assess for possible retained stone.
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For patients with predicted low risk for choledocholithiasis undergoing laparoscopic cholecystectomy, selective intraoperative cholangiography and postoperative endoscopic retrograde cholangiopancreatography is an effective strategy to limit unnecessary procedures. Surg Endosc 2008; 23:1933-7. [PMID: 19116743 DOI: 10.1007/s00464-008-0250-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2008] [Accepted: 10/17/2008] [Indexed: 12/20/2022]
Abstract
BACKGROUND There is debate about whether intraoperative cholangiography (IOC) should be performed routinely or selectively during laparoscopic cholecystectomy (LC) in patients with suspected choledocholithiasis. The timing of endoscopic retrograde cholangiopancreatography (ERCP) in these patients also is an issue. We reviewed the experience in our center, where a management algorithm limiting ERCP in relation to LC was adopted. METHODS We retrospectively reviewed every LC performed by one surgeon during 6 years and the related ERCPs. RESULTS A total of 264 LCs were performed. In 30 patients, stones were cleared or excluded by preoperative ERCP. In the remaining 234 LCs, 31 of 34 IOCs were successfully performed. Two of 31 IOCs were positive for bile duct stones; stone removal was successful in each patient at subsequent ERCP. Only 10 of 201 patients who did not have IOC required postsurgical ERCP within 10 weeks of LC, 3 of whom had common bile duct stones at ERCP. CONCLUSIONS For patients who underwent LC, we performed selective IOC with postoperative ERCP for positive studies. Review of our experience using this algorithm showed it to be a powerful tool in limiting unnecessary ERCPs. Our data suggest that routine preoperative ERCP cannot be justified. Selective IOC during LC misses relatively few cases of biliary stones; these can be managed quickly by experienced endoscopists.
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Stevens KA, Chi A, Lucas LC, Porter JM, Williams MD. Immediate laparoscopic cholecystectomy for acute cholecystitis: no need to wait. Am J Surg 2006; 192:756-61. [PMID: 17161089 DOI: 10.1016/j.amjsurg.2006.08.040] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2006] [Revised: 08/10/2006] [Accepted: 08/10/2006] [Indexed: 11/28/2022]
Abstract
BACKGROUND Early, within 72 hours, laparoscopic cholecystectomy (LC) for acute chlolecystitis (AC) is the standard of care. We reviewed our experience with immediate (within 24 hours) LC for AC to determine whether this also was safe. METHODS Group 1, those patients who had LC for AC within 24 hours was compared with group 2, those who had LC for AC after 24 hours. RESULTS Of 253 consecutive patients, 132 were in group 1 and 121 were in group 2. There were no differences in group 1 versus group 2 in demographics, clinical severity of disease, mean operating time (92 minutes versus 95 minutes, P =.2), conversion (9% versus 6%, P = .3), and complications (7% versus 9%, P = .5). Multivariate logistic regression analysis confirmed that the timing of LC for AC was not associated with longer than average operating times. CONCLUSIONS Immediate LC for AC is safe and has become our standard of practice.
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Affiliation(s)
- Kent A Stevens
- University of Arizona Health Sciences Center, Trauma/Critical Care, Rm 5411, 1501 N Campbell Avenue, Tucson, AZ 85724-5063, USA
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Miletic D, Uravic M, Mazur-Brbac M, Stimac D, Petranovic D, Sestan B. Role of Magnetic Resonance Cholangiography in the Diagnosis of Bile Duct Lithiasis. World J Surg 2006; 30:1705-12. [PMID: 16850153 DOI: 10.1007/s00268-005-0459-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
AIM The aim of our study was to assess diagnostic value of magnetic resonance cholangiography (MRC) in patients with suspected common bile duct (CBD) stones focusing on the capability of this noninvasive method to replace invasive diagnostic procedures in these patients and to limit the use of endoscopic retrograde cholangiography (ERC) to the patients who need simultaneous therapeutic intervention. MATERIALS AND METHODS Single-shot fast-spin-echo rapid-acquisition thick-section MRC images were obtained in 310 patients recruited into this prospective study. There were 136 male and 174 female patients aged 21-95 years [mean +/- standard deviation (SD) 64.9 +/- 13.6 years]. Patients were subsequently classified into different risk groups (high, moderate, low) according to biochemical abnormalities or morphological features on abdominal ultrasonography and computed tomography. Direct cholangiography was the reference method of CBD evaluation. RESULTS CBD stones were diagnosed in 115 (37%) patients; 86 of 175 patients in the high-risk group, 24 of 83 patients in the moderate-risk group, and 5 of 50 patients in the low-risk group. In dependent risk groups, the mean CBD caliber was 9.7 +/- 4.5, 7.1 +/- 2.0, and 4.8 +/- 1.2 mm, respectively. The difference was significant between all three groups (P < 0.05). The median size of CBD stones was 7 mm (range 3-21 mm). MRC achieved accuracy and positive and negative predictive values of 97%, 94%, and 98%, respectively. CONCLUSIONS MRC has a potential to substitute diagnostic ERC in all patients with suspected choledocholithiasis due to its high accuracy, reducing invasive direct cholangiography to patients who require therapeutic intervention.
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Wu SC, Chen FC, Lo CJ. Selective intraoperative cholangiography and single-stage management of common bile duct stone in laparoscopic cholecystectomy. World J Surg 2006; 29:1402-8. [PMID: 16228924 DOI: 10.1007/s00268-005-7694-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND There are still debates and controversies in the detection and the management of common bile duct (CBD) stones in the era of laparoscopic cholecystectomy (LC). This prospective study was performed to evaluate a single-stage management of CBD stone during LC. METHODS Between May 1998 and January 2000, 249 consecutive patients with gallstone and cholecystitis were enrolled in this study. The mean age was 52.5 +/- 12.4 years. Male to female ratio was 106:143. All patients underwent abdominal sonography and the determination of the serum biochemical profile preoperatively. Patients presented with sepsis or with total bilirubin > or = 6 ng/dL were excluded from the study. RESULTS 244 (98%) patients underwent LC and 5 (2%) patients were converted to open cholecystectomy. Intraoperative cholangiogram (IOC) was only performed in patients who fulfilled our predetermined criteria. Among 90 patients who had IOC, only 23 patients had CBD stones that were removed either by transcystic duct stone extraction (61%) or CBD exploration (39%). The additional procedures to remove CBD stone did not prolong the hospitalization. There were four wound infections and one cystic stump leakage. One patient developed CBD stone during the follow-up period up to 37 months. CONCLUSIONS Our study indicates that routine use of IOC during LC is not necessary. In addition, single-stage approach for the management of CBD stone during LC is feasible and should be considered by laparoscopic surgeons.
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Affiliation(s)
- Shih-Chi Wu
- Division of Trauma, Changhua Christian Hospital, Changhua, Taiwan
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Keus F, Broeders IAMJ, van Laarhoven CJHM. Gallstone disease: Surgical aspects of symptomatic cholecystolithiasis and acute cholecystitis. Best Pract Res Clin Gastroenterol 2006; 20:1031-51. [PMID: 17127186 DOI: 10.1016/j.bpg.2006.05.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Indications for cholecystectomy are limited to clearly symptomatic gallstones. Relatively high failure rates of pain relief are probably caused by incorrect selection of patients for the operation. Contraindications for (laparoscopic) cholecystectomy are related to anaesthesiological considerations. Laparoscopic cholecystectomy was accepted by consensus as the gold standard within 5 years of its introduction. Nevertheless, both the classical open and small-incision cholecystectomies are safe alternatives, and superiority of any one of the three techniques over the others has not been proven. Primary outcome measures (mortality, complications, and symptom relief) seem to be equal for the three techniques. Acute cholecystitis is a complication of gallstones. Generally it is recommended that early cholecystectomy be performed, as delayed cholecystectomy is associated with longer total hospital stay and convalescence due to recurrent cholecystitis episodes. Cholecystostomy is an alternative technique for patients unfit for general anaesthesia. Reported complication and conversion rates in cholecystectomy for acute cholecystitis vary, but are higher than for symptomatic cholecystolithiasis. New developments--such as robot-assisted surgery--are expected to have a significant impact in the near future.
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Affiliation(s)
- F Keus
- Diakonessenhuis, Bosboomstraat 1, 3582 KE Utrecht, The Netherlands.
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Griniatsos J, Karvounis E, Isla A. Early versus delayed single-stage laparoscopic eradication for both gallstones and common bile duct stones in mild acute biliary pancreatitis. Am Surg 2005; 71:682-6. [PMID: 16217952 DOI: 10.1177/000313480507100812] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Several studies addressed that preoperative endoscopic retrograde cholangiopancreatography (ERCP) for common bile duct (CBD) clearance, followed by interval laparoscopic cholecystectomy (two-stage approach), constitutes the most common practice in cases of uncomplicated mild acute biliary pancreatitis. Between June 1998 and December 2002, 44 patients (35 females and 9 males with a median age of 62 years) suffering from uncomplicated mild acute biliary pancreatitis were treated in our unit. All patients were electively submitted to surgery after subsidence of the acute symptoms, and for definitive treatment we favored the single-stage laparoscopic management, avoiding preoperative ERCP. All patients underwent laparoscopic cholecystectomy plus fluoroscopic intraoperative cholangiogram (IOC). If filling defect(s) were detected in the IOC, a finding suggestive of concomitant choledocholithiasis, laparoscopic common bile duct exploration (LCBDE) was added in the same sitting. Twenty patients were operated upon within 2 weeks since the attack of the acute symptoms and constitute the early group (n=20), whereas 24 patients underwent an operation later on and constitute the delay group (n=24). We retrospectively compare the safety, effectiveness, and outcome after the single-stage laparoscopic management between the two groups of patients. Laparoscopic cholecystectomy alone constituted the definitive treatment in 38 patients, while an additional LCBDE was performed in the remaining 6 patients (14%), and all operations were achieved laparoscopically. There was no statistically significant difference between the groups in terms of operative time, incidence of concomitant choledocholithiasis, morbidity rate, and postoperative hospital stay. During the follow-up, none of the patients experienced recurrent pancreatitis. In uncomplicated mild acute biliary pancreatitis cases, a single-stage definitive laparoscopic management, avoiding preoperative ERCP, can be safely performed during the same admission, after the improvement of symptoms and local inflammation. Postoperative ERCP should be selectively used in patients in whom the single-stage method failed to resolve the problem.
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Affiliation(s)
- John Griniatsos
- Upper GI and Laparoscopic Unit, Ealing Hospital, Southall-Middlesex, London, United Kingdom
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Griniatsos J, Karvounis E, Isla AM. Limitations of fluoroscopic intraoperative cholangiography in cases suggestive of choledocholithiasis. J Laparoendosc Adv Surg Tech A 2005; 15:312-7. [PMID: 15954836 DOI: 10.1089/lap.2005.15.312] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Fluoroscopic intraoperative cholangiography (IOC) has been proposed as a safe and accurate screening method for choledocholithiasis, with a sensitivity and specificity of nearly 100% in selected cases. In the present study we retrospectively reviewed the diagnostic accuracy of IOC in cases highly suggestive of choledocholithiasis. MATERIALS AND METHODS Between January 1999 and December 2002, 103 patients underwent IOC as an imaging method for common bile duct (CBD) stone detection. We did not routinely perform IOC in all patients who were submitted to laparoscopic cholecystectomy, reserving the method for patients with a high probability of choledocholithiasis, namely patients with a history or the presence of painful obstructive jaundice at the time of referral, patients with a history of mild acute pancreatitis of biliary origin, and patients with abnormalities in their liver biochemistry profile as measured by liver function tests (LFT). RESULTS The mean rates of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for IOC were 98%, 94%, 94.5%, and 98% for the whole series, respectively. The diagnostic accuracy was 100% in patients with a history of obstructive jaundice or liver biochemical derangement, but was less in patients with a history of biliary pancreatitis. There were 3 false positive cases and 1 case of false negative results, all of which occurred in the subgroup of patients with a history of pancreatitis. CONCLUSION Selective fluoroscopic IOC is generally feasible and safe, as well as highly accurate (100%) for CBD stone detection in patients with obstructive jaundice or abnormal LFT. The PPV of the method decreases in patients with a history of pancreatitis (75%), while a negative result is highly suggestive of the absence of CBD stones (NPV = 98%). The present study concluded in a higher incidence of false results in patients with a normal size CBD, suggesting that the diagnostic accuracy of IOC is probably related to the size of the CBD rather than the indication for its performance.
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Affiliation(s)
- John Griniatsos
- Upper GI and Laparoscopic Unit, Ealing Hospital, London, United Kingdom.
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22
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El Shallaly G, Seow C, Sharp C, Mughrabi A, Nassar AHM. Intraoperative cholangiography time in laparoscopic cholecystectomy. Surg Endosc 2005; 19:1370-2. [PMID: 16228860 DOI: 10.1007/s00464-004-2242-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2004] [Accepted: 03/05/2005] [Indexed: 12/18/2022]
Abstract
BACKGROUND The debate for and against the routine use of intraoperative cholangiography (IOC) continues. One of the main arguments against the routine use of the technique during laparoscopic cholecystectomy (LC) is the length of time it takes, which in turn increases the cost. In this study, we recorded the time spent by the radiographer providing IOC service in the context of optimizing the utilization of the radiographer and IOC time. METHODS A total of 91 consecutive LCS, including 19 laparoscopic bile duct explorations, from April 2003 to January 2004 were included in the study. We recorded the time the radiographer took from receiving a call to arriving in the theater, the time he or she spent performing the IOC, and the total time spent in theater. We also recorded the total operative time. RESULTS The mean time from call to arrival was 9 min (SD = 3, n = 91). The mean total time spent by the radiographer in the theater involved in performing the IOC during LC was 15 min (SD = 8, n = 72), and that during laparoscopic exploration was 46 min (SD = 20, n = 19). The mean operative time was 67 min (SD = 24) and 135 min (SD = 59), respectively. CONCLUSION Radiographer services as well as IOC time could be optimized to facilitate the routine use of this important technique in LC. Optimizing the logistics and time factor in IOC is an integral component of single-stage management of patients with suspected bile duct stones.
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Affiliation(s)
- G El Shallaly
- Department of Surgery, Monklands Hospital, Airdrie, Lanarkshire, ML6 OJS Scotland, United Kingdom
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Bhattacharya D, Ammori BJ. Contemporary minimally invasive approaches to the management of acute cholecystitis: a review and appraisal. Surg Laparosc Endosc Percutan Tech 2005; 15:1-8. [PMID: 15714147 DOI: 10.1097/01.sle.0000153730.24862.0a] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Acute cholecystitis is one of the most common emergency admissions in surgical practice. This review appraises the available evidence from the English-language literature regarding the minimally invasive approaches to the management of this condition. The following aspects of care are reviewed and appraised: (1) the diagnostic criteria for acute cholecystitis, (2) the optimal timing for cholecystectomy (early, delayed, or interval surgery), (3) the optimal approach to cholecystectomy (laparoscopic versus open), (4) the role of intraoperative cholangiography, and (5) the management of patients unfit for surgery.
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Metcalfe MS, Ong T, Bruening MH, Iswariah H, Wemyss-Holden SA, Maddern GJ. Is laparoscopic intraoperative cholangiogram a matter of routine? Am J Surg 2004; 187:475-81. [PMID: 15041494 DOI: 10.1016/j.amjsurg.2003.12.047] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2003] [Revised: 08/11/2003] [Indexed: 02/08/2023]
Abstract
BACKGROUND Intraoperative cholangiography during laparoscopic cholecystectomy reveals the anatomy of the biliary tree and any stones contained within it. The use of intraoperative cholangiography may be routine for all laparoscopic cholecystectomy. An alternative approach is a selective policy, performing intraoperative cholangiography only for those cases in which choledocholithiasis is suspected on clinical grounds, or those for which the anatomy appears unclear at operation. The literature pertaining to both approaches is reviewed, to delineate their respective merits. METHODS Relevant articles in English were identified from the Medline database, and reviewed. RESULTS The literature reviewed consisted of retrospective analyses. Overall the incidence of unsuspected retained stones was 4%, but only 15% of these would go on to cause clinical problems. The incidence of complete transection of the common bile duct was rare for both routine and selective intraoperative cholangiography policies, and did not differ between them. Rates of minor bile duct injury did not differ between groups, but was more likely to be recognized in the routine group than the selective (P = 0.01). CONCLUSIONS Routine intraoperative cholangiography yields very little useful clinical information over and above that which is obtained with selective policies. Large numbers of unnecessary intraoperative cholangiography are performed under routine intraoperative cholangiography policy, and therefore a selective policy is advocated.
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Affiliation(s)
- Matthew S Metcalfe
- Department of Surgery, University of Adelaide, The Queen Elizabeth Hospital, Woodville Rd., Woodville, SA 5011, Australia
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25
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Sun XD, Cai XY, Li JD, Cai XJ, Mu YP, Wu JM. Prospective study of scoring system in selective intraoperative cholangiography during laparoscopic cholecystectomy. World J Gastroenterol 2003; 9:865-7. [PMID: 12679950 PMCID: PMC4611467 DOI: 10.3748/wjg.v9.i4.865] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate of scoring system in predicting choledocholithiasis in selective intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC).
METHODS: The scoring system of predicting choledocholithiasis was developed during the retrospective study in 264 cases, and was tested in 184 to evaluate its predictive value in choledocholithiasis.
RESULTS: The scoring system was developed in a retrospective study of 264 cases, the statistical analyses showed the predictive factors included sex, transaminase levels, alkaline phosphatase level, bilirubin level, and common bile duct diameter on ultrasonography. The scoring system was used in 184 cases prospectively, of which, 3 of 162 (1.9%) cases scoring < 3 had choledocholithiasis, 17 of 22 (77.3%) cases scores≥3 had choledocholithiasis. A case of scores≥3 or more prospectively should be considered highly intraoperative cholangiography during laparoscopic cholecystectomy.
CONCLUSION: The scoring system can predict choledocholithiasis and is helpful in selection patietns for intraoperative cholangiography.
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Affiliation(s)
- Xiao-Dong Sun
- Department of General Surgery, The Affiliated Sir Run Run Shaw Hospital, Zhejiang University Medical College, Hangzhou 310016, Zhejiang Province, China.
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Isla A, Griniatsos J, Rodway A. Single-stage definitive laparoscopic management in mild acute biliary pancreatitis. J Laparoendosc Adv Surg Tech A 2003; 13:77-81. [PMID: 12737719 DOI: 10.1089/109264203764654687] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Population-based studies have shown that nearly one third of patients with acute biliary pancreatitis undergo endoscopic retrograde cholangiopancreatography (ERCP) before undergoing laparoscopic cholecystectomy (LC) (two-stage approach). The present study was designed to evaluate the safety of single-stage laparoscopic management to avoid preoperative ERCP. MATERIALS AND METHODS Between June 1998 and June 2002, 35 female patients and 10 male patients (median age, 59 years) with uncomplicated mild acute biliary pancreatitis were studied prospectively and reviewed retrospectively. LC with fluoroscopic intraoperative cholangiography (IOC) or with fluoroscopic IOC and laparoscopic CBD exploration in cases of concomitant choledocholithiasis was performed as the definitive treatment (single-stage approach). Patients underwent surgery electively when symptoms had subsided and laboratory parameters had improved. RESULTS LC alone was performed in 39 patients, and an additional laparoscopic CBD exploration was performed in the remaining six. In one patient, IOC yielded a false-positive result. CBD stones were detected in four cases, and debris in the CBD in one case, for an 11% incidence of concomitant choledocholithiasis. The conversion rate was zero, and single-stage laparoscopic treatment was successful in all cases. The overall morbidity rate was 4%. The 30-day postoperative mortality rate was zero. CONCLUSION Although preoperative ERCP and sphincterotomy still have a role in complicated cases of mild acute biliary pancreatitis, laparoscopic single-stage definitive treatment is feasible and safe in uncomplicated cases of disease when local experience is available.
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Affiliation(s)
- A Isla
- Upper GI and Laparoscopic Unit, Ealing Hospital, London, United Kingdom.
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Ludwig K, Bernhardt J, Lorenz D. Value and consequences of routine intraoperative cholangiography during cholecystectomy. Surg Laparosc Endosc Percutan Tech 2002; 12:154-9. [PMID: 12080254 DOI: 10.1097/00129689-200206000-00003] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Since the introduction of laparoscopic cholecystectomy (LC), an increase in accidental common bile duct (CBD) injuries of up to 1.2-1.6% has been reported. In the present prospective study of 1,710 patients undergoing cholecystectomy (1,241 LC procedures and 469 open cholecystectomies [OC]), we tested the predicative value of routine intraoperative cholangiography (IOC). The IOC was feasible in 92.4% of the cases in the LC group and in 83% of cases in the OC group and presented a complete depiction of the extrahepatic bile system in 98.3%. Anatomic variations of the bile duct system, which influenced the operative management, were found in 13.2% of cases (13.4% LC versus 12.8% OC). In 2.5% of the patients, preoperatively undetected CBD stones were also found. Method-specific complications did not occur in any of the patients. Additionally, in a controlled subgroup analysis of 163 patients, we evaluated preoperative intravenous cholangiography (IVC) and IOC. Intravenous cholangiography showed only 72.4% of the operation-relevant anatomic variations (vs. 100% by IOC); in 6.1% of the cases, there were reactions to the dye (vs. none in IOC), and in only 28.6% of the patients, CBD stones were detected (vs. 71.4% IOC). There were four bile duct injuries (0.29%) during LC and two (0.4%) during OC. All injuries were detected intraoperatively and fixed in the same setting without postoperative complications. In conclusion, we recommend the use of routine IOC during cholecystectomy. By this technique, anatomic variations of the bile duct system will be visualized and therefore accidental injuries will be avoided.
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Affiliation(s)
- Kaja Ludwig
- Department of Surgery, University of Greifswald, Germany.
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28
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Bresadola V, Intini S, Terrosu G, Baccarani U, Marcellino MG, Sistu M, Scanavacca F, Bresadola F. Intraoperative cholangiography in laparoscopic cholecystectomy during residency in general surgery. Surg Endosc 2001; 15:812-5. [PMID: 11443457 DOI: 10.1007/s004640090006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2000] [Accepted: 09/04/2000] [Indexed: 10/26/2022]
Abstract
BACKGROUND The role of laparoscopic intraoperative cholangiography (IC) in the diagnosis of asymptomatic choledocholithiasis is still controversial. The aim of this study was to evaluate the diagnostic-therapeutic impact and the educational implications of this method for residents specializing in general surgery. METHODS We reviewed the records of 835 patients who underwent laparoscopic cholecystectomy for cholecystolithiasis without choledocholithiasis. IC was routinely performed by both expert surgeons and residents in general surgery. RESULTS The cholecystectomy was completed laparoscopically in 804 cases, but conversion to open surgery was required in 31 cases. IC was not completed in 140 cases (17.4%), and in 44 cases it revealed a suspected choledocholithiasis. The stones were treated via laparoscopy in 36 cases, laparotomy in six cases, and endoscopic retrograde cholangiopancreatography (ERCP) in two cases. Five patients were not diagnosed wit h choledocholithiasis. In one case, a lesion of the choledochus was discovered and treated laparoscopically. A total of 610 IC were done by expert surgeons and 225 by residents. The duration of the cholecystectomy with IC was significantly different between the two groups (76.9 +/- 12 vs 92.4 +/- 11), as was the feasibility index (88.6% vs 80.6%). CONCLUSIONS Laparoscopic IC is a safe and accurate procedure for the diagnosis of unrecognized choledocholithiasis. Teaching of this procedure as part of the specialization in general surgery would be opportune because it would provide surgical residents with an additional tool for the diagnosis and treatment of this pathology of the common bile duct.
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Affiliation(s)
- V Bresadola
- Department of Surgery, University Hospital of Udine, P. le S. M. della Misericordia, 33100 Udine, Italy.
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Ishikawa M, Tagami Y, Toyota T, Nishioka M, Hanaki N, Sasaki K, Yagi Y, Kashiwagi Y, Miki H, Uemura N, Inoue S, Komatsu Y. Surg Laparosc Endosc Percutan Tech 2000; 10:351-356. [DOI: 10.1097/00019509-200012000-00002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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30
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Can Three-Dimensional Helical CT Cholangiography Before Laparoscopic Cholecystectomy Be a Substitute Study for Endoscopic Retrograde Cholangiography? Surg Laparosc Endosc Percutan Tech 2000. [DOI: 10.1097/00129689-200012000-00002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Nickkholgh A, Soltaniyekta S, Kalbasi H. Butyrylcholinesterase activity in plasma of rats and rabbits fed high-fat diets. Surg Endosc 1991; 20:868-74. [PMID: 16738972 DOI: 10.1007/s00464-005-0425-x] [Citation(s) in RCA: 61] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2005] [Accepted: 12/18/2005] [Indexed: 12/21/2022]
Abstract
1. Comparative studies with rats and rabbits were carried out to address the question as to whether the amount of dietary fat affects butyrylcholinesterase (EC 3.1.1.8.) activity in plasma. 2. Plasma butyrylcholinesterase activities were about 5-fold higher in rabbits than rats. 3. Ad libitum feeding of diets enriched with corn oil caused increased body weights in rabbits but not in rats 4. Plasma butyrylcholinesterase activities of rats were increased with increasing intakes of corn oil. In rabbits, such an effect could not be demonstrated conclusively. 5. Evidence is presented that in rats the substitution of dietary corn oil for isocaloric amounts of either carbohydrates or protein produces similar increases in plasma butyrylcholinesterase activity. 6. This suggests that among macronutrients the amount of fat primarily determines butyrylcholinesterase activity in the plasma of rats.
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Affiliation(s)
- A Nickkholgh
- Department of General and Laparoscopic Surgery, Arad General Hospital, Tehran, Iran.
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