Low incidence of retained common bile duct stones using a selective policy of biliary imaging

A meta-analysis of the use of intraoperative cholangiography; time to revisit our approach to cholecystectomy?

BACKGROUND

Despite some evidence of improved survival with intraoperative cholangiography during cholecystectomy, debate has raged about its benefit, in part because of its questionable benefit, time, and resources required to complete.

METHODS

An International Prospective Register of Systematic Reviews-registered (ID CRD42018102154) meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using PubMed, Scopus, Web of Science, and Cochrane library from 2003 to 2018 was undertaken including search strategy "intraoperative AND cholangiogra* AND cholecystectomy." Articles scoring ≥ 16 for comparative and ≥ 10 for noncomparative using the Methodological Index for Non-Randomized Studies criteria were included. A dichotomous random effects meta-analysis using the Mantel-Haenszel method performed on Review Manager Version 5.3 was carried out.

RESULTS

Of 2,059 articles reviewed, 62 met criteria for final analysis. The mean rate of intraoperative cholangiography was 38.8% (range 1.6%-96.4%).There was greater detection of bile duct stones during cholecystectomy with routine intraoperative cholangiography compared with selective intraoperative cholangiography (odds ratio = 3.28, confidence interval = 2.80-3.86, P value < .001). While bile duct injury during cholecystectomy was less with intraoperative cholangiography (0.39%) than without intraoperative cholangiography (0.43%), it was not statistically significant (odds ratio = 0.88, confidence interval = 0.65-1.19, P value = .41). Readmission following cholecystectomy with intraoperative cholangiography was 3.0% compared to 3.5% without intraoperative cholangiography (odds ratio = 0.91, confidence interval = 0.78-1.06, P value = .23).

CONCLUSION

The use of intraoperative cholangiography still has its place in cholecystectomy based on the detection of choledocholithiasis and the potential reduction of unfavorable outcomes associated with common bile duct stones. This meta-analysis, the first to review intraoperative cholangiography use, identified a marked variation in cholangiography use. Retrospective studies limit the ability to critically define association between intraoperative cholangiography use and bile duct injury.

Serology and ultrasound for diagnosis of choledocholithiasis

INTRODUCTION

Magnetic resonance cholangiopancreatography (MRCP) is not a routine investigation to exclude choledocholithiasis unless there is clinical or biochemical suspicion of common bile duct (CBD) stones. This study attempted to determine which radiological or serological parameters best predicted CBD stones.

METHODS

All patients undergoing MRCP from 2005 to 2011 were selected. Patients with pancreatitis were excluded. Liver function tests (LFTs) at admission and prior to MRCP were recorded, as was abdominal ultrasonography and MRCP results. Parameters measured routinely on LFTs included alkaline phosphatase (ALP), alanine transaminase (ALT) and bilirubin. Receiver operating characteristic curve area analysis (area under the curve [AUC]) and chi-squared analysis were undertaken.

RESULTS

Overall, 195 patients were identified, 71 of whom had CBD stones on MRCP. Raised ALP levels on admission demonstrated a correlation with CBD stones (AUC: 0.619, odds ratio [OR]: 3.16, p=0.06). At ultrasonography, a dilated CBD (OR: 3.76, p<0.001) and intrahepatic duct dilation (OR: 5.56, p<0.001) were highly significant predictors. However, only 37% of patients had a dilated CBD on ultrasonography. Ongoing elevation of LFT parameters, particularly ALP (AUC: 0.707, OR: 4.64, p<0.001) and ALT (AUC: 0.646, OR: 5.40, p<0.001), displayed a significant correlation with CBD stones.

CONCLUSIONS

Ongoing (even if minor) elevations of liver function test parameters should prompt the need to exclude CBD stones even in the presence of a normal CBD diameter on ultrasonography.

Evidence-based current surgical practice: calculous gallbladder disease

BACKGROUND

Gallbladder disease is common and, if managed incorrectly, can lead to high rates of morbidity, mortality, and extraneous costs. The most common complications of gallstones include biliary colic, acute cholecystitis, common bile duct stones, and gallstone pancreatitis. Ultrasound is the initial imaging modality of choice. Additional diagnostic and therapeutic studies including computed tomography, magnetic resonance imaging, magnetic resonance cholangiopancreatography, endoscopic ultrasound, and endoscopic retrograde cholangiopancreatography are not routinely required but may play a role in specific situations.

DISCUSSION

Biliary colic and acute cholecystitis are best treated with early laparoscopic cholecystectomy. Patients with common bile duct stones should be managed with cholecystectomy, either after or concurrent with endoscopic or surgical relief of obstruction and clearance of stones from the bile duct. Mild gallstone pancreatitis should be treated with cholecystectomy during the initial hospitalization to prevent recurrence. Emerging techniques for cholecystectomy include single-incision laparoscopic surgery and natural orifice transluminal endoscopic surgery. Early results in highly selected patients demonstrate the safety of these techniques. The management of complications of the gallbladder should be timely and evidence-based, and choice of procedures, particularly for common bile duct stones, is largely influenced by facility and surgeon factors.

The Feasibility and Safety of Laparoscopic Cholecystectomy Approach without the Intraopertative Cholangiography Use: A Retrospective Study on 750 Consecutive Patients

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.

Variation in the use of intraoperative cholangiography during cholecystectomy

BACKGROUND

The role of intraoperative cholangiography (IOC) in prevention of common bile duct (CBD) injuries and the management of CBD stones is controversial, and current variation in use of IOC has not been well described.

STUDY DESIGN

Multilevel hierarchical models using data from the Texas Hospital Inpatient Discharge Public Use data files (2001 to 2008) were used to evaluate the percentage of variance in the use of IOC that was attributable to patient, surgeon, and hospital factors.

RESULTS

A total of 176,981 cholecystectomies were performed in 212 hospitals in Texas. There was wide variation in IOC use, ranging from 2.4% to 98.4% of cases among surgeons and 3.7% to 94.8% of cases among hospitals, even after adjusting for case mix differences. The percentage of variance in IOC use attributable to the surgeon was 20.7% and an additional 25.7% was attributable to the hospital. IOC use was associated with increased age, gallstone pancreatitis or CBD stones, Hispanic race, decreased illness severity, insurance, and later year of cholecystectomy. ERCP (24.0% vs 14.9%, p < 0.0001) and CBD exploration (1.63% vs 0.42%, p < 0.0001) were more commonly performed in patients undergoing IOC.

CONCLUSIONS

Uncertainty regarding the benefit of IOC leads to wide variation in use across surgeons and hospitals. The surgeon and hospital are more important determinants of IOC use than measured patient characteristics. Our study highlights the need for further evaluation of comparative effectiveness of IOC in the prevention of CBD injuries and retained stones, taking into account patient risk factors, surgeon skill, cost, and availability of local expertise.

Laparoscopic cholecystectomy without intraoperative cholangiography

BACKGROUND

The role of intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) remains controversial. This study evaluates the outcomes of a management policy of LC without IOC.

SUBJECTS AND METHODS

Patients with symptomatic cholecystolithiasis were classified regarding their potential risk for choledocholithiasis, and those at low risk received no further investigations, whereas medium- and high-risk patients underwent preoperative magnetic resonance cholangiopancreatography (MRCP) and/or endoscopic retrograde cholangiopancreatography (ERCP) with duct clearance. Those who required duct exploration were excluded. LC proceeded without IOC. Data were collected prospectively.

RESULTS

Between 2002 and 2011, 717 consecutive patients underwent LC; 168 (23.4%) were classified as medium or high risk, and 57 of those had preoperative duct clearance at ERCP. The conversion rate from LC to open surgery was 4.7%. The morbidity rate was 3.9%, and there were no mortalities. Nineteen patients in the low-risk group were re-admitted, of whom three patients (0.4% of 717 patients) had choledocholithiasis on ERCP. Minor bile duct injury occurred in 3 patients, and a fourth developed ischemic bile duct stricture 7 months following open conversion.

CONCLUSIONS

The selective use of preoperative MRCP and ERCP to detect and treat choledocholithiasis facilitates the safe application of a policy of LC without IOC. Careful operative technique is necessary to avoid duct injury.

Laparoscopic cholecystectomy in elderly patients

Laparoscopic surgery can be safely applied in the elderly. Complications can be minimized by carefully selecting patients aged 80 years or older and operating on these patients with experienced teams with good technical capabilities.

Background and Objective:

In this study, we investigated whether laparoscopic cholecystectomy, a minimally invasive procedure, is advantageous in elderly patients.

Methods:

Data from 595 patients who underwent laparoscopic cholecystectomy between January 2003 and December 2007 were prospectively collected in a database. The patients were separated into 2 groups; patients >70 years of age (group A), and patients <70 years of age (group B). Group A was further divided into 3 subgroups, ages 70 to 74, 75 to 79, and 80 and above. Comparison between the groups was made with Mann-Whitney U and chi-square tests where appropriate.

Results:

ASA scores increased in conjunction with increased age (P<0.001). Of patients with an operative time longer than one hour, 26 patients aged 70 or older, and 152 patients aged 69 or younger had no difference with respect to PaCO₂ and pH measurements (P>0.05). In patients aged 80 or older, the rates of acute cholecystitis, conversion to open surgery, and postoperative complications were significantly higher than in other groups (P>0.05).

Conclusion:

We believe that in elderly patients, laparoscopic surgery can be applied safely without further increasing the surgical risks. The complications can be minimized by carefully selecting the patients aged 80 or older and by experienced teams with high technical capabilities operating on such patients.

Laparoscopic cholecystectomy

Laparoscopic cholecystectomy (LC) has supplanted open cholecystectomy for most gallbladder pathology. Experience has allowed the development of now well-established technical nuances, and training has raised the level of performance so that safe LC is possible. If safe cholecystectomy cannot be performed because of acute inflammation, LC tube placement should occur. A systematic approach in every case to open a window beyond the triangle of Calot, well up onto the liver bed, is essential for the safe completion of the operation.

Laparoscopic common bile duct exploration

OBJECTIVE

To describe the technique of laparoscopic common bile duct exploration (LCBDE) with high clearance rates, low morbidity, and mortality rates.

SUMMARY BACKGROUND DATA

LCBDE is well accepted by patients because treatment is obtained during the same anesthesia. If one stage therapy for gallstones and common bile duct stones provides success rates equivalent to those of the sequential approach, with lower costs, this should be considered the standard of care.

METHODS

From September 1991 to March 2007, 5201 laparoscopic cholecystectomies were performed at São José Avaí Hospital. LCBDE was carried out in 481 patients (9.25%).

RESULTS

Of 481 LCBDE, 225 (46.78%) were managed using a transcystic approach and 183 (38.05%) with choledochotomy (114 with transcystic choledochotomy and 69 with longitudinal opening of the common bile duct). Successful laparoscopic stone clearance was achieved in 468 (97.3%). An elective postsurgical endoscopic sphincterotomy were done on the 13 (2.70%) patients not cleared laparoscopically. Seven patients had unexpected retained stones.

CONCLUSIONS

LCBDE during laparoscopic cholecystectomy solves 2 problems during the same anesthesia with high success rates and may be employed successfully.