The role of endoscopic retrograde cholangiopancreatography and cholangiography in the laparoscopic era

Laparoscopic lithotripsy and lithotomy of impacted stone at the terminal end of the common bile duct using a laparotomy biliary lithotomy spoon: A case report

Introduction and importance

Endoscopic intervention is considered first-line therapy for common bile duct (CBD) stones, in recent times. However, surgically altered anatomy and consequent inaccessibility of the duodenal papilla necessitate surgery in some patients.

Case presentation

A 61-year-old woman presented with fever and right subcostal pain. She underwent total gastrectomy and Roux-en-Y reconstruction for gastric ulcer, 4 years prior to presentation. Based on the clinical findings, she was diagnosed with acute obstructive cholangitis secondary to a CBD stone. Endoscopic retrograde biliary drainage was attempted; however, the duodenal papilla was endoscopically inaccessible owing to the previous Roux-en-Y reconstruction, and we performed percutaneous transhepatic gallbladder drainage (PTGBD). She underwent laparoscopic cholecystectomy and choledocholithotomy, 6 days after the PTGBD. Choledocholithotomy was attempted using basket forceps under choledochoscopic guidance; however, this procedure was unsuccessful, and we performed laparoscopic choledocholithotomy using a laparotomy biliary lithotomy spoon.

Clinical discussion

Usually, laparoscopic cholecystectomy concomitant with CBD exploration is performed in patients with an endoscopically inaccessible duodenal papilla. However, an inadequately opened basket may not capture large impacted stones at the duodenal end of the CBD. Intraductal shock wave lithotripsy (electrohydraulic or laser lithotripsy) is considered in such cases; however, the specialized instruments required for this procedure are unavailable at all centers. Laparoscopic choledocholithotomy using a laparotomy biliary lithotomy spoon may be useful to overcome this surgically challenging situation.

Conclusion

A laparotomy biliary lithotomy spoon is a simple, user-friendly, and economical device that may be useful for laparoscopic lithotripsy and lithotomy of impacted stones.

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Endoscopy did not show the duodenal papilla owing to surgically altered anatomy.

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Stone impaction was observed at the terminal portion of the common bile duct.

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Choledochoscopic basket lithotomy could not be performed.

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Laparoscopic lithotomy was performed using a laparotomy biliary lithotomy spoon.

Artificial intelligence in gastrointestinal radiology: A review with special focus on recent development of magnetic resonance and computed tomography

Artificial intelligence (AI), particularly the deep learning technology, have been proven influential to radiology in the recent decade. Its ability in image classification, segmentation, detection and reconstruction tasks have substantially assisted diagnostic radiology, and has even been viewed as having the potential to perform better than radiologists in some tasks. Gastrointestinal radiology, an important subspecialty dealing with complex anatomy and various modalities including endoscopy, have especially attracted the attention of AI researchers and engineers worldwide. Consequently, recently many tools have been developed for lesion detection and image construction in gastrointestinal radiology, particularly in the fields for which public databases are available, such as diagnostic abdominal magnetic resonance imaging (MRI) and computed tomography (CT). This review will provide a framework for understanding recent advancements of AI in gastrointestinal radiology, with a special focus on hepatic and pancreatobiliary diagnostic radiology with MRI and CT. For fields where AI is less developed, this review will also explain the difficulty in AI model training and possible strategies to overcome the technical issues. The authors’ insights of possible future development will be addressed in the last section.

Outcomes From Routine Use of Intraoperative Cholangiogram in Laparoscopic Cholecystectomy: Factors Predicting Benefit From Selective Cholangiography

Background and objective

Laparoscopic cholecystectomy is used for the treatment of symptomatic gallstones. Intraoperative cholangiogram (IOC) is used to diagnose common bile duct (CBD) stones. There is controversy surrounding routine vs selective use of IOC based on clinical, biochemical and ultrasound criteria. The aim of this study was to evaluate the outcomes from routine IOC and its utility in laparoscopic cholecystectomy.

Materials and methods

This was a UK-based single-centre retrospective study evaluating the outcomes from IOC for all laparoscopic cholecystectomies performed between May 2014 and February 2020. All adult patients undergoing elective, semi-elective or emergency operations were included. Demographics, biochemistry as well as radiological and endoscopic investigations were analysed. IOC was performed using a standardised technique and was interpreted by a single surgeon.

Results

A total of 744 out of 804 patients underwent IOC. The median age of the cohort was 51 years (SD: ±17.5); there were 468 females (62.9%) and 276 males (37.1%). Filling defects were identified in 43/744 (5.8%) patients, with 23/43 having stone extraction via endoscopic retrograde cholangiopancreatography (ERCP). Logistic regression analysis identified alkaline phosphatase (ALP) as a predictor of filling defects in IOC (OR: 1.003; 95% CI: 1.001-1.005, p=0.015).

Conclusion

Based on our findings, the routine use of IOC during laparoscopic cholecystectomy is safe and effective. Preoperative clinical, radiological and biochemical parameters apart from ALP have a limited role in predicting the diagnostic yield of IOC.

Intraoperative Cholangiography Can Be Safely Omitted during Laparoscopic Cholecystectomy: A Prospective Study of 413 Consecutive Patients

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.

[Design of a preoperative predictive score for choledocholithiasis]

INTRODUCTION

Choledocholithiasis is the most common cause of obstructive jaundice and occurs in 5-10% of patients with cholelithiasis.

OBJECTIVES

To design a preoperative predictive score for choledocholithiasis.

MATERIAL AND METHODS

A prospective study was carried out in 556 patients admitted to our department for biliary disease. Preoperative clinical, laboratory, and ultrasound variables were compared between patients without choledocholithiasis and 65 patients with this diagnosis. A multivariate logistic analysis was performed to obtain a predictive model of choledocholithiasis, determining sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).

RESULTS

Predictors of choledocholithiasis were the presence of a prior history of biliary disease (history of biliary colic, acute cholecystitis, choledocholithiasis or acute biliary pancreatitis) (p=0.021, OR=2.225, 95% CI: 1.130-4.381), total bilirubin values >4mg/dl (p=0.046, OR=2.403, 95% CI: 1.106-5.685), alkaline phosphatase values >150mg/dl (p=0.022 income, OR=2.631, 95%: 1.386-6.231), gamma-glutamyltransferase (GGT) values >100mg/dl (p=0.035, OR=2.10, 95% CI: 1.345-5.850), and an ultrasound finding of biliary duct >8mm (p=0.034, OR=3.063 95% CI: 1086-8649). A score superior to 5 had a specificity and PPV of 100% for detecting choledocholithiasis and a score less than 3 had a sensitivity and NPV of 100% for excluding this diagnosis.

CONCLUSIONS

The preoperative score can exclude or confirm the presence of choledocholithiasis and allows patients to directly benefit from laparoscopic cholecystectomy (LC) or prior endoscopic retrograde cholangiopancreatography (ERCP).

Identifying patients most likely to have a common bile duct stone after a positive intraoperative cholangiogram

The false-positive rates of a positive intraoperative cholangiogram (IOC) are as high as 60%. Endoscopic retrograde cholangiopancreatography (ERCP) for stone removal is required after a positive IOC. It is unclear which clinical factors identify patients most likely to have a stone after a positive IOC. This study was conducted to identify factors predictive of common bile duct (CBD) stone(s) on ERCP after a positive IOC. A retrospective review of our endoscopic database identified all ERCP and/or endoscopic ultrasound (EUS) procedures performed for a positive IOC between August 2003 and August 2009. Collected data included patient demographics; indication for cholecystectomy; IOC findings; blood tests before and after cholecystectomy, including liver function tests, complete blood count, and amylase and lipase measurements; and ERCP and/or EUS results. Patients who had a negative EUS for CBD stones and no subsequent ERCP were contacted by phone to see if they eventually required an ERCP. Univariate and multi-variable analyses were performed. A total of 114 patients were included in the study. IOC findings included a single stone, multiple stones, nonpassage of contrast into the duodenum, dilated CBD, and poor visualization of the bile duct. Eighty-four percent of patients had ERCP only, 9% had EUS only, and 7% had EUS followed by ERCP. Sixty-five patients (57%) had CBD stones on ERCP or EUS. Older age, multiple stones, dilated CBD on IOC, and elevated postcholecystectomy bilirubin levels were the clinical variables with statistically significant differences on univariate analysis. On multivariable analysis, older age and elevated postcholecystectomy total bilirubin levels correlated with the presence of CBD stones on ERCP. Fifty-seven percent of patients referred for endoscopic evaluation after a positive IOC had CBD stones on ERCP. Patients with CBD stones after a positive IOC were more likely to be older with elevated post-cholecystectomy total serum bilirubin levels.

Role of ERCP in the era of laparoscopic cholecystectomy for the evaluation of choledocholithiasis in sickle cell anemia

AIM: To evaluate the role of endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis in patients with sickle cell anemia (SCA) in the era of laparoscopic cholecystectomy (LC).

METHODS: Two hundred and twenty four patients (144 male, 80 female; mean age, 22.4 years; range, 5-70 years) with SCA underwent ERCP as part of their evaluation for cholestatic jaundice (CJ). The indications for ERCP were: CJ only in 97, CJ and dilated bile ducts on ultrasound in 103, and CJ and common bile duct (CBD) stones on ultrasound in 42.

RESULTS: In total, CBD stones were found in 88 (39.3%) patients and there was evidence of recent stone passage in 16. Fifteen were post-LC patients. These had endoscopic sphincterotomy and stone extraction. The remaining 73 had endoscopic sphincterotomy and stone extraction followed by LC without an intraoperative cholangiogram.

CONCLUSION: In patients with SCA and cholelithiasis, ERCP is valuable whether preoperative or postoperative, and in none was there a need to perform intraoperative cholangiography. Sequential endoscopic sphincterotomy and stone extraction followed by LC is beneficial in these patients. Endoscopic sphincterotomy may also prove to be useful in these patients as it may prevent the future development of biliary sludge and bile duct stones.

Role of intra operative cholangiogram in current day practice

The role of Intra Operative Cholangiogram during laparoscopic cholecystectomy remains controversial. This review discusses the modalities used in the pre- and peri-operative assessment of Common Bile Duct. It also discusses the advantages and disadvantages of selective and routine IOC. In this review we explore the role of Intra Operative Cholangiogram in current day practice.

Prediction of which patients with an abnormal intraoperative cholangiogram will have a confirmed stone at ERCP

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.

Common bile duct stones - their presentation, diagnosis and management

Common Bile duct stones (CBD) continue to pose a significant problem both to the patient and the Surgeon. They increase the morbidity of a patient undergoing Cholecystectomy from less than 5% to as much as 20% and almost zero mortality to as high as 30%. Recent times have thrown up a fair share of controversy in the management of this condition both due to technological innovations and costreduction-pressures. The aim in CBD stone disease, as in any benign disease is to discover a therapeutic algorithm with minimal morbidity, no mortality and at reasonable cost. This can be achieved only by a thorough understanding of the disease and also the available diagnostic and treatment modalities.This article dicusses the diagnosis, investigation and therapy of Common Bile Duct Stones (CBD) and gives a therapeutic algorithm.

Is ductal evaluation always necessary before or during surgery for biliary pancreatitis?

BACKGROUND

Whether all patients undergoing cholecystectomy following an episode of biliary pancreatitis require direct common bile duct evaluation is controversial. We hypothesized such evaluation can be omitted safely among select patients at low risk for choledocholithiasis.

METHODS

One hundred forty-eight patients undergoing cholecystectomy for biliary pancreatitis (January 1995-December 2005) met the following inclusion criteria: (1) no preoperative endoscopic retrograde cholangiography (ERC) or endoscopic retrograde cholangiopancreatography (ERCP); (2) normal or decreasing liver function tests (LFTs) preoperatively; and (3) no ductal dilation on non-invasive preoperative imaging. Group I had intraoperative cholangiography (IOC, n = 27); group II did not (n = 121).

RESULTS

No differences between groups I and II were evident in postoperative retained-stone related events: recurrent pancreatitis (11% vs 8%, P = .7), cholangitis (0% in both groups), and asymptomatic LFT elevation (0% vs 3%, P > .99).

CONCLUSIONS

Direct ductal evaluation can be omitted safely in select patients undergoing cholecystectomy for biliary pancreatitis who are at low risk for choledocholithiasis.

Biochemical predictors for absence of common bile duct stones in patients undergoing laparoscopic cholecystectomy

BACKGROUND

To provide optimal selection of patients for preoperative endoscopic retrograde cholangiopancreatography or intraoperative cholangiography, we evaluated simple, noninvasive biochemical parameters as screening tests to predict the absence of common bile duct stones prior to laparoscopic cholecystectomy.

METHODS

A total of 1002 patients underwent laparoscopic cholecystectomy. Five biochemical parameters were measured preoperatively: gamma glutamyl transferase (GGT), alkaline phosphatase, total bilirubin, alanine aminotransferase, and aspartate aminotransferase. Conventional diagnostic tests, including ultrasound imaging, computed tomography, magnetic resonance imaging, common bile duct diameter, endoscopic retrograde cholangiopancreatography, and serum amylase were performed. Along with the five biochemical tests above, these diagnostic tests were scrutinized and compared as potential predictors for common bile duct stones.

RESULTS

Eighty-eight (8.8%) patients with gallstone disease who underwent laparoscopic cholecystectomy had concurrent common bile duct stones. Among all diagnostic tests, endoscopic retrograde cholangiopancreatography had the highest sensitivity (96.0%), specificity (99.1%), probability ratio (107.3), accuracy (98.0%), and positive predictive value (98.8%) in detecting common bile duct stones. At least one abnormal elevation among the five biochemical parameters had the highest sensitivity (87.5%). Total bilirubin had the highest specificity (87.5%), highest probability ratio (3.9), highest accuracy (84.1%), and highest positive predictive value (27.4%). All five biochemical predictors had high negative predictive values; gamma glutamyl transferase was highest (97.9%), while the lowest was total bilirubin (94.7%). Multivariate analysis showed only gamma glutamyl transferase, alkaline phosphatase, and total bilirubin to be independent predictors; gamma glutamyl transferase appeared to be the most powerful predictor (odds ratio 3.20).

CONCLUSION

Biochemical tests, especially gamma glutamyl transferase with 97.9% negative predictive value, are ideal noninvasive predictors for the absence of common bile duct stones in patients undergoing laparoscopic cholecystectomy. We suggest that unnecessary, costly, or risky procedures such as endoscopic retrograde cholangiopancreatography can be omitted prior to laparoscopic cholecystectomy in patients without abnormal elevation of these biochemical values.

The role of intraoperative cholangiogram in the management of patients recovering from acute biliary pancreatitis

BACKGROUND

Use of the standard management for gallstone-associated acute pancreatitis calls for cholecystectomy with cholangiography performed during the same hospitalization after acute symptoms has decreased. No previous studies, however, have objectively addressed the usefulness of intraoperative cholangiography (IOC) for the management of this condition. This study aimed to determine the incidence of common bile duct (CBD) stones after an acute episode of gallstone pancreatitis.

METHODS

The medical records of all patients who underwent a cholecystectomy and IOC after an episode of gallstone pancreatitis during the same admission between 1999 and 2004 at the University of Alberta and Royal Alexandra hospitals were examined to determine the incidence of CBD stones after resolution of gallstone pancreatitis.

RESULTS

After a chart review for a series of 86 patients, 63 met the inclusion criteria. All except for one patient had undergone successful IOC (98%). Among the patients who had no evidence of CBD obstruction on preoperative imaging or lab work, three were found to have a filling defect on IOC and stones on their postoperative endoscopic retrograde cholangiopancreatography (ERCP) (3/63, 5%). This is not significantly different from the 4.6% incidence of CBD stones among patients with cholelithiasis who had normal preoperative imaging and blood work.

CONCLUSION

In the setting of normal preoperative imaging and lab work, the incidence of CBD stones among patients recovering from acute mild to moderate gallstone pancreatitis is not significantly higher than among patients with no history of pancreatitis. Therefore, an IOC for post-gallstone pancreatitis does not alter management.

[National project for the clinical management of healthcare processes. The surgical treatment of cholelithiasis. Development of a clinical pathway]

INTRODUCTION

Because surgical treatment of gallstones is highly prevalent, this topic is particularly suitable for a national study aimed at determining the most important indicators and developing a clinical pathway.

OBJECTIVES

To analyze the results obtained during the hospital phase of the process. To define the key indicators of the process. To design a clinical pathway for laparoscopic cholecystectomy.

PATIENTS AND METHODS

A multicenter, prospective, cross-sectional, descriptive study was performed of patients who consecutively underwent surgery for gallstones in 2002. The sample size calculated with data provided by the National Institute of Statistics was 304 patients, which was increased by 45% to compensate for possible losses. Inclusion criteria consisted of elective cholecystectomy for gallstones, without preoperative findings suggestive of common duct stones. A database was designed (Microsoft Access 2000) with 76 variables analyzed in each patient.

RESULTS

Completed questionnaires were obtained from 37 hospitals with 426 patients. The mean age was 55.69 years, with a predominance of women (68.3%). The most frequent symptom was biliary colic (23%). A total of 20.3% of the patient had prior episodes of cholecystitis and 18% had a history of mild pancreatitis. Diagnosis was given by ultrasonography in 93.2% of the patients. Informed consent was provided by 93.2%. The intervention was performed on an inpatient basis in 96.1% and in the ambulatory setting in the remainder. Antibiotic and antithrombotic prophylaxis was administered in 78.9% and 75.1% of the patients respectively. The laparoscopic approach was used in 84.6%, with a conversion rate of 4.9%. Intraoperative cholangiography was performed in 17.8% of the patients and common duct stones were found in 7 patients. The most frequent complication was surgical wound infection (1.1%). Possible accidental lesion of the biliary tract occurred in 0.7% of the patients and was described as biliary fistula. There were four reinterventions: biliary fistula (1), hemoperitoneum (2) and cause unknown (1). The mean surgical time was 73.17 minutes, with a median of 60 minutes. Postoperative length of stay was 4.75 days in open surgery and 2.67 days in laparoscopic surgery. Ninety-nine percent of the patients were satisfied or highly satisfied with the healthcare received.

CONCLUSIONS

Analysis of the process and review of the literature identified a series of areas requiring improvement, which were gathered in the clinical pathway developed. These areas consisted of increasing the number of patients with correctly indicated antibiotic and antithrombotic prophylaxis, increasing the percentage of patients providing informed consent and undergoing adequate preoperative tests, limiting intraoperative cholangiography to selected patients, and reducing the number of patients with an overall stay of 3 days.

Do all patients with abnormal intraoperative cholangiogram merit endoscopic retrograde cholangiopancreatography?

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is commonly used for postoperative evaluation of an abnormal intraoperative cholangiogram (IOC). Although a normal IOC is very suggestive of a disease-free common bile duct (CBD), abnormal 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 prospective study investigated 51 patients with abnormal IOC at laparoscopic cholecystectomy who underwent postoperative ERCP at two tertiary referral centers over a 3-year period. Univariate and multivariate logistic regression analyses were performed to determine predictors of CBD stones at postoperative ERCP.

RESULTS

For all 51 patients, ERCP was successful. The ERCP showed CBD stones in 33 cases (64.7%), and normal results in 18 cases (35.2%). On univariate analysis, abnormal liver function tests (p < 0.0001) as well as IOC findings of a large CBD stone (p = 0.03), multiple stones (p = 0.01), and a dilated CBD (p = 0.07) predicted the presence of retained stones at postoperative ERCP. However, on multivariable analysis, only abnormal liver function tests correlated with the presence of CBD stones (p < 0.0001).

CONCLUSIONS

One-third of patients with an abnormal IOC have a normal postoperative ERCP. Elevated liver function tests can help to identify patients who merit further evaluation by ERCP. The use of less invasive methods such as endoscopic ultrasound or magnetic resonance cholangiopancreatography should be considered for patients with normal liver function tests to minimize unnecessary ERCPs.

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

AIM

Biliary imaging has decreased since the advent of laparoscopic cholecystectomy. This study aimed to examine the incidence of retained common bile duct (CBD) stones, using a selective policy of biliary imaging.

METHODS

A prospective computerised database was used to study patients who underwent laparoscopic cholecystectomy by one surgeon over 36 months. Two hundred and thirty-five patients (191 female, 44 male) were operated on. Ages ranged from 15 to 82 years (mean 47 years). Follow-up periods ranged from six to 39 months (mean 23.3 months). Selection for pre-operative endoscopic retrograde cholangiopacreatogram (ERCP), intraoperative cholangiography (IOC) or neither depended on liver function tests (LFTs) and CBD diameter on ultrasound prior to surgery. If LFTs were persistently raised and/or the CBD was dilated on ultrasound, patients underwent pre-operative ERCP. If LFTs were raised, and returned to normal promptly, IOC was performed.

RESULTS

Of 235 patients, 26 had pre-operative ERCP, 62 had IOC and 157 had neither. Ten patients had both ERCP and IOC. To date, one patient (0.43%) has radiologically-proven unsuspected retained CBD stones; these were successfully treated with ERCP.

CONCLUSION

Selective biliary imaging in patients undergoing laparoscopic cholecystectomy is safe. This process identifies the majority of patients with ductal calculi and minimises the need for unnecessary ERCP and peroperative cholangiography.

Preoperative risk factors for common bile duct stones: defining the patient at high risk in the laparoscopic cholecystectomy era

BACKGROUND

Common bile duct stones (CBDS) are present in 3-20% of patients with cholelithiasis. Intraoperative cholangiography has high sensitivity in detecting CBDS but its routine use is associated with increased costs and operating room time. The aim of our study was to define an accurate and simple model for the prediction of CBDS using preoperative variables.

METHODS

The study consisted of a retrospective analysis followed by a prospective study. Multivariate analysis of the retrospective data was used to create a predictive model for the presence of concurrent CBDS in patients undergoing cholecystectomy. The predictive model was then validated in a prospective series of 160 patients undergoing laparoscopic cholecystectomy.

RESULTS

Among the 19 potentially predictive variables for CBDS, only four were found to be statistically significant and independent: X1-alkaline phosphatase levels (UI/L); X2-number of gallbladder stones; X3-total serum bilirubin (mg/dL); and X4-CBD diameter (mm). Using these four variables, the multivariate analysis created the equation: score = 0.002 x X1 + 0.485 x X2 + 0.232 x X3 + 0.220 x X4 - 4.167 to define the risk of CBDS in each patient. The predictive model, tested prospectively in 160 patients undergoing laparoscopic cholecystectomy (LC), showed an elevated index of correlation (r = 0.75) among the predicted and the observed frequencies (chi2 = 126.6; P < 0.0001). The predictive model sensitivity and specificity were 92.9% and 99.3%, respectively.

CONCLUSIONS

In patients undergoing cholecystectomy, accurate prediction of the risk for concurrent CBDS can be achieved using four preoperative variables. The use of this predictive model can contribute to reducing the number of unnecessary common bile duct explorations.

Is laparoscopic intraoperative cholangiogram a matter of routine?

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.

Postoperative jaundice and total parenteral nutrition-associated hepatic dysfunction

Postoperative jaundice and TPN-induced hepatic abnormalities represent clinical situations that stem from multiple and frequently overlapping insults to the liver. The pattern of LFT abnormalities and appropriate imaging studies provide clues to the diagnosis. Greater insight into the molecular basis of cholestasis has shed light on the possible common pathways for the hepatic derangements that are seen in diverse situations. TPN-related hepatic dysfunction most likely involves a combination of nutritional deficiencies, hormonal imbalances, excessive calories, and possibly bacterial overgrowth in the small bowel. Growing clinical evidence points to a high incidence of severe liver disease in chronic TPN-dependent patients. Careful monitoring of patients is warranted in these circumstances and combined transplantation of the liver and small bowel may be the only possibility for long-term survival for such patients with progressive liver disease.

Effect of intraoperative cholangiography during cholecystectomy on outcome after gallstone pancreatitis

Acute gallstone pancreatitis has traditionally been managed by early cholecystectomy with intraoperative cholangiography (IOC). To evaluate the effect of IOC on patient outcome, we analyzed all patients operated on for acute gallstone pancreatitis at our institution over a 3-year period. A total of 200 patients (37 open, 163 laparoscopic) were evaluated. Nineteen of 34 patients who underwent preoperative endoscopic retrograde cholangiopancreatography (ERCP) were found to have common bile duct (CBD) stones. The 59 patients who underwent cholecystectomy with IOC had significantly longer operative times compared to the 141 patients who underwent cholecystectomy alone (167 vs. 105 minutes for open [P = 0.008] and 89 vs. 68 minutes for laparoscopic [P < 0.0001] operations). Of the 59 patients who underwent IOC, only nine (15%) had abnormal cholangiograms, and CBD exploration in seven revealed stones in four patients, edematous ampullae in two, and no abnormality in one. Six of eight patients (5 IOC, 3 no IOC) who required immediate postoperative ERCP were noted to have CBD stones. Patients who underwent IOC had significantly longer postoperative hospital stays (3.8 vs. 2.0 days [P = 0.007]). The incidence of retained CBD stones following surgery was similar (5.1% IOC, 2.8% no IOC). Although 7 of 122 patients who underwent laparoscopic cholecystectomy without IOC were readmitted, only one was found on ERCP to have a retained CBD stone. Age, sex, preoperative days, procedure type, and biliary-pancreatic complications after discharge did not differ significantly between patients with and without IOC. We conclude that IOC in patients operated on for acute gallstone pancreatitis results in a longer operative time and a prolonged postoperative course, but has no effect on the incidence of retained CBD stones.

Practical recommendations for the prediction and management of common bile duct stones in patients with gallstones

BACKGROUND

Approximately 10% of patients with symptomatic gallstones may have associated common bile duct stones (CBDS). However, the predictive value of noninvasive tests as well as the preoperative diagnosis and management of CBDS have not been well defined. The aim of this study was to define an accurate and simple model for the prediction and management of CBDS.

METHODS

A prospective database containing 986 cholecystectomies performed from 1994 through 1999 was evaluated. Univariate analysis using the Pearson chi-square test was performed to determine the factors significantly related to the presence of CBDS. Then logistic regression analysis was performed for multivariate analysis to discover independent predictors.

RESULTS

Of the 986 patients in this study, 48 (5%) had CBDS. Of the 48 patients with choledocholithiasis, 22 (46%) were men and 26 (54%) were women. The mean age was 55.3 years (range, 16-87 years). As a result of multivariate analysis, abdominal ultrasonographic findings suggestive of CBDS (common bile duct diameter exceeding 8 mm or visible stones), total bilirubin, and gamma glutamyl transpeptidase levels above normal were the independent predictors of CBDS in patients age 70 or younger. On the other hand, an elevated bilirubin level was found to be the single independent factor related to CBDS in the elderly.

CONCLUSIONS

For patients with gallstones, suggestive ultrasonographic findings in those younger than 71 years and elevated direct or total bilirubin level in those older than 70 years are the most valuable and practical predictors of CBDS, and thus are the proper indications for preoperative endoscopic retrograde cholangiography.

Selective Intraoperative Cholangiography during Laparoscopic Cholecystectomy: How Selective?

The necessity for intraoperative cholangiography during laparoscopic cholecystectomy has been debated for some time. Numerous retrospective studies favor selective intraoperative cholangiography. Surgeons in favor of the selective policy differ in their personal selective criteria. The aim of this prospective study was to evaluate whether intraoperative cholangiography can be safely omitted during laparoscopic cholecystectomy on all patients who fit a standard set of criteria: normal liver function tests, common bile duct diameter less than 10 mm, and no history of gallstone pancreatitis or jaundice. We undertook a prospective study on 155 consecutive patients treated in a county teaching hospital with symptomatic gallbladder disease who met the above standard set of criteria. One hundred and fifty-five patients meeting these criteria underwent laparoscopic cholecystectomy during a 2-year period from February 1996 through February 1998. Data analyzed included patient history, laboratory and ultrasound findings, operative results, postoperative stay, and intraoperative and postoperative complications. The patients were followed by periodic interviews, physical examination, liver function tests, and/or biliary ultrasound for up to 3 ½ years with a mean follow-up of 26 months for retained common bile duct stones. Intraoperative cholangiography was performed in only one of the 155 patients studied to confirm common bile duct injury. There were four postoperative complications (2.6%) and one common bile injury (0.6%). Postoperative stay averaged one day. No patients, by history, biliary ultrasound, liver function tests or endoscopy, were found to have retained common bile duct stones during the follow-up period. Our study shows that intraoperative cholangiography is not necessary for patients undergoing laparoscopic cholecystectomy who have normal liver functions tests, common bile duct diameter less than 10 mm, and no history of gallstone pancreatitis or jaundice.

The efficacy of preoperative endoscopic retrograde cholangiopancreatography in the detection and clearance of choledocholithiasis

BACKGROUND AND OBJECTIVES

Endoscopic retrograde cholangiopancreaticography has been reported to have a high success rate in the detection and treatment of choledocholithiasis. Although there is growing enthusiasm for laparoscopic common bile duct clearance, many patients who present with gallbladder disease and suspected choledocholithiasis have endoscopic retrograde cholangiopancreatography performed with choledocholithiasis cleared if detected. These patients are then referred for laparoscopic cholecystectomy. The purpose of this study is to determine the efficacy of preoperative endoscopic retrograde cholangiopancreatography in the diagnosis and clearance of bile duct stones at our institution.

METHODS

A retrospective review was performed of all patients at this institution who underwent preoperative endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis followed by laparoscopic cholecystectomy from January 1997 through July 1998.

RESULTS

Common bile duct stones were detected endoscopically in 12 of 17 (71%) patients. We found serum bilirubin level to be the best predictor of choledocholithiasis. In 12 of 12 procedures, the endoscopist performed an endoscopic sphincterotomy with stone extraction and reported a fully cleared common bile duct. Intraoperative cholangiogram performed during subsequent cholecystectomy revealed choledocholithiasis in 4 of these 12 patients. Laparoscopic techniques successfully cleared the choledocholithiasis in 3 of these patients with open techniques necessary in the fourth.

CONCLUSIONS

Our data suggests that even after presumed successful endoscopic clearance of the bile duct stones, many patients (33% in our series) still have choledocholithiasis present at the time of cholecystectomy. We recommend intraoperative cholangiography at the time of cholecystectomy even after presumed successful endoscopic retrograde cholangiopancreatography with further intervention, preferably laparoscopic, to clear the choledocholithiasis as deemed necessary.

The role of endosonography in the diagnosis of choledocholithiasis

Biliary endoscopic ultrasonography (EUS), even if complex and difficult to interpret, can depict with great accuracy the normal anatomy and abnormalities of this region. In case of choledocholithiasis, EUS has the unique ability to directly visualize the cause of biliary obstruction and to evaluate and integrate ductal abnormalities. For these tasks EUS is superior to conventional ultrasonography (US), computed tomography (CT) and also to new imaging techniques such as magnetic resonance cholangiography. The aim of this review is to provide an overview of the most significant EUS findings in choledocholithiasis together with the results of EUS in terms of diagnostic accuracy and cost-effectiveness. The role of EUS in the diagnosis of bile duct stones is therefore highlighted.

Timing of endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy in the treatment of choledocholithiasis

Although experience with laparoscopic approaches to common duct stones is increasing, endoscopic retrograde cholangiopancreatography (ERCP) performed either before or after laparoscopic cholecystectomy (LC) remains the most common approach. Debate remains as to the best timing for ERCP in patients with suspected choledocholithiasis. Because clinical, laboratory, and radiological data are poor predictors of choledocholithiasis, many ERCPs done before LC give negative results. ERCP performed after LC with a positive intraoperative cholangiogram (i.o.p.) would eliminate many unnecessary preoperative endoscopic studies. This is a retrospective analysis of the treatment of choledocholithiasis with the combination of LC and ERCP. All patients included could have had ERCP preoperatively or postoperatively; therefore, those with cholangitis requiring emergent preoperative ERCP were excluded. Two groups of patients were compared: those who underwent ERCP followed by LC and those who underwent LC and IOC followed by ERCP. No significant differences were found with respect to age, gender, health status, clinical presentation, laboratory values (most liver functions, white blood cell count, hemoglobin, and serum amylase), surgery time, blood loss, ERCP time, time between treatment modalities, and days to regular diet. However, the preoperative ERCP group was found to have a longer hospital stay (6.7 days vs. 3.5 days, p = 0.003) and higher hospital cost ($9,406.39 vs. $12,816.23, p = 0.05). The preoperative ERCP group had two patients requiring two ERCPs to clear the common duct, one patient requiring conversion to open procedure because of failed LC, and four minor complications. The postoperative ERCP group had no failed LC, IOC, or postoperative ERCPs and one minor complication. The rate of false positive IOC was 6.7% and of negative preoperative ERCP, 43%. We conclude that in the absence of cholangitis requiring emergent endoscopic decompression, suspected choledocholithiasis can be successfully managed first with LC, ERCP being reserved for patients with a positive IOC. This eliminates many negative preoperative ERCPs.

Investigation of bile ducts before laparoscopic cholecystectomy

BACKGROUND

Since the advent of laparoscopic cholecystectomy, there has been controversy about the investigation of the bile ducts and the management of common bile duct stones. Routine peroperative cholangiography (POC) in all cases has been recommended. We have adopted a policy of not performing routine POC, and the results of 700 cases are reported.

METHODS

Since 1990, all patients have undergone preoperative ultrasound scan. We have performed selective preoperative endoscopic retrograde cholangiopancreatography (ERCP) because of a clinical history of jaundice and/or pancreatitis, abnormal liver function tests and ultrasound evidence of dilated bile ducts (N=78, 11.1%). The remaining 622 patients did not have a routine POC, but selective peroperative cholangiogram (POC) was performed only in 42 patients (6%) because of unsuccessful ERCP or mild alteration in the criteria for the presence of bile duct stones. The remaining 580 patients did not undergo POC. Careful dissection of Calot's triangle was performed in all cases to reduce the risk of bile duct injuries.

RESULTS

The overall operative complications, postoperative morbidity and mortality was 1.71%, 2.14% and 0.43%, respectively. Bile duct injuries occurred in two patients (0.26%) and both were recognized during the operation and repaired. There was a single incidence of retained stone in this series of 700 cases (0.14%), which required postoperative ERCP.

CONCLUSIONS

This policy of selective preoperative ERCP, and not routine peroperative cholangiogram, is cost effective and not associated with significant incidence of retained stones or bile duct injuries after laparoscopic cholecystectomy.

Colangiografia transoperatória em colecistectomia laparoscópica

Com o objetivo de analisar os resultados e a experiência acumulada com a realização de colangiografia transoperatória nos pacientes submetidos à colecistectomia laparoscópica, revisamos os prontuários de 309 pacientes com colelitíase sintomática tratados por videocirurgia no nosso serviço entre maio de 1993 e junho de 1997. Realizamos a colangiografia transoperatória rotineiramente, o que foi possível em 244 (78,9%) pacientes. O principal motivo para a não realização do exame nos demais pacientes foi a presença do ducto cístico de pequeno calibre em 21 (6,8%) casos. Entre os pacientes nos quais foi realizado o exame, o resultado foi normal em 229 (93,8%). Em 11 (4,5%) identificou-se coledocolitíase, sendo insuspeita em sete (2,8%); em três (1,2%), o ducto cístico desembocava no ducto hepático direito, e, em um (0,4%), diagnosticou-se um grande cisto coledociano com calculose intra e extra-hepática. A colangiografia transoperat6ria durante colecistectomia laparoscópica mostrou-se um procedimento seguro nos pacientes em que conseguimos realizá-la, já que não tivemos complicações relacionadas ao exame. Ao definir a anatomia, previne ou demonstra alterações biliares e permite a detecção de coledocolitíase insuspeita. Assim, pelos dados analisados, recomendamos o seu emprego rotineiro.

The prediction of common bile duct stones using a neural network

BACKGROUND

The role of preoperative ERCP and endoscopic sphincterotomy (ES) in the diagnosis and treatment of suspected common bile duct stones (CBDS) in the laparoscopic age is controversial. The preoperative diagnosis of CBDS by ERCP and the removal of CBDS by ES are advantageous because of technical difficulties in performing laparoscopic exploration of the common bile duct. Approximately 50% of preoperative ERCP examinations are normal, however. The noninvasive diagnosis of CBDS has assumed new importance, but it has proved to be an elusive goal. Neural networks are a form of artificial computer intelligence that have been used successfully to interpret ECGs and to diagnose myocardial infarcts. The purpose of this study was to determine whether a neural network could be trained to predict CBDS accurately in patients at high risk of having duct stones.

STUDY DESIGN

We trained a back-propagation neural network to predict the presence of CBDS. Retrospective data from patients who had a cholecystectomy and either a preoperative ERCP or intraoperative cholangiogram were used to build the network, and it was tested using unseen data.

RESULTS

One hundred forty patients were used to train the network, and 16 patients were used to test it. The trained network was able to predict CBDS in 100% of the patients in both the training and test sets.

CONCLUSIONS

Screening of high-risk patients for CBDS by neural network analysis is highly accurate. This promising new, noninvasive, and inexpensive technique can potentially decrease the need for preoperative ERCP by 50%, but additional prospective evaluation is indicated.

Suspected biliary complications after laparoscopic and open cholecystectomy leading to endoscopic cholangiography: a retrospective comparison

To study how suspected postoperative biliary complications are influenced by surgical technique, we compared clinical profiles of 63 patients referred for ERCP after open (OC) and laparoscopic cholecystectomy (LC) over a four-year period. ERCP was not performed for postoperative pain alone and only six (9.5%) studies were normal. Referrals after LC were younger (mean 39.1 vs 53.6 years, P < 0.001) and ERCP was requested earlier (mean 71.6 vs 2360 days, P < 0.001) in the postoperative course. Choledocholithiasis (CDL) alone, the most common finding, was successfully managed with a single ERCP in 97.2% of cases. CDL after LC occurred in younger patients (35.5 vs 58.9 years, P < 0.01) who presented earlier (mean 98.6 days vs 5.1 years, P < 0.01), without biliary ductal dilatation (P < 0.01). Although CDL after LC was associated with higher ALT and bilirubin levels than after OC, the difference was not statistically significant. Cystic duct leaks (LC: six patients, OC: four patients) were typically associated with CDL after OC and 90% resolved with endoscopic therapy. Biliary ligation (four cases) was managed successfully with choledochojejunostomy. We conclude that findings at ERCP for suspected biliary obstruction or injury after OC or LC are similar and usually can be endoscopically managed. After LC, referrals currently are younger, present much earlier, and retained stones are less likely to be associated with ductal dilatation than after OC.

Comparison of preoperative endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy with operative management of gallstone pancreatitis

BACKGROUND

Preoperative endoscopic retrograde cholangiopancreatography (ERCP) with laparoscopic cholecystectomy (ERCP/LC) should reduce hospital stay when compared with laparoscopic cholecystectomy/intraoperative cholangiogram (LC/IOC) and selective common bile duct exploration (CBDE).

METHOD

Retrospective review of 82 patients with gallstone pancreatitis.

RESULTS

Thirty-one patients had preoperative ERCP/LC and 51 patients underwent LC/IOC. Nineteen percent in the ERCP/LC group developed postprocedure pancreatitis. The presence of choledocholithiasis was associated with an increased incidence of post-ERCP pancreatitis (38%) and an increased length of stay ([LOS] 24 versus 10 days). The development of post-ERCP pancreatitis markedly increased LOS to 30 days. Six percent in the LC/IOC group developed postoperative pancreatitis. The mean LOS was 10.1 days. Open CBDE increased the LOS to 14.5 days. Postoperative pancreatitis increased the LOS to 23 days. The LOS of patients with choledocholithiasis who underwent uncomplicated ERCP/ES or LC/IOC with open CBDE was similar.

CONCLUSIONS

The development of postprocedure pancreatitis is a more important determinant of hospital stay than an open operative procedure. LC/IOC with its lower incidence of postprocedure pancreatitis resulted in a shorter hospital LOS even when open CBDE was performed.

An analysis of perioperative cholangiography in one thousand laparoscopic cholecystectomies

BACKGROUND

We undertook this retrospective study to ascertain the proper role of perioperative cholangiography in the management of 1002 patients undergoing laparoscopic cholecystectomy for symptomatic cholelithiasis.

METHODS

Nine hundred forty-one patients were categorized as being at high or low risk for choledocholithiasis according to the presence or absence of jaundice, pancreatitis, elevated bilirubin, alkaline phosphatase, serum glutamic-oxaloacetic transaminase, or radiographic evidence of common bile duct stones (CBDSs).

RESULTS

Intraoperative cholangiography (IOCG) and preoperative endoscopic retrograde cholangiopancreatography (ERCP) were equivalent in the detection of CBDSs, and laparoscopic common bile duct exploration (CBDE) was successful in 12 of the 21 patients (57%) in whom it was attempted. The ducts of the other 52 patients with CBDSs were successfully cleared by preoperative or postoperative ERCP.

CONCLUSIONS

Laparoscopic IOCG is successful in detecting CBDS in high-risk patients and half of these ducts can be cleared laparoscopically. The incidence of CBDS in low-risk patients is 1.7%, a risk that does not warrant routine cholangiography. These data suggest ERCP should be reserved for those at-risk individuals in whom IOCG or laparoscopic duct clearance has been unsuccessful.

Abnormal common bile duct sonography. The best predictor of choledocholithiasis before laparoscopic cholecystectomy

We conducted a prospective study to determine the most reliable indicator of common bile duct stones before laparoscopic cholecystectomy. One hundred thirty-seven patients were referred for endoscopic retrograde cholangiography before laparoscopic cholecystectomy for suspected choledocholithiasis due to one or more of the following abnormalities: (a) altered liver function tests, (b) increased serum amylase levels, or (c) a dilated common bile duct (> 7 mm) with or without evidence of stones on sonography. Sensitivity, specificity, positive and negative predictive values, and the likelihood of the presence or absence of morbidity were calculated for 25 different variables. Common bile duct stones were detected in 63 (46%) patients. Abnormal result of sonography of the common bile duct was the best predictor of choledocholithiasis (p < 0.0001). Abnormalities of the combined liver function tests were statistically significant predictors only when combined with abnormal sonographic results. Improving liver function tests before endoscopy had a significant negative predictive value (p = 0.01). Stepwise logistic regression analysis showed that abnormal ultrasound and the presence of common bile duct stones on ultrasound were significant (p = 0.009 and p = 0.049, respectively). Abnormal result of sonography of the common bile duct is the best predictor of choledocholithiasis before laparoscopic cholecystectomy.

The management of choledocholithiasis in children in the era of laparoscopic cholecystectomy

Although laparoscopic cholecystectomy has become the procedure of choice for gallbladder removal in children, the treatment of children who have choledocholithiasis remains unclear. For adults who have suspected choledocholithiasis, preoperative endoscopic retrograde cholangiopancreatography (ERCP) is a well-described and effective approach, however, its use for common bile duct stones in children has not been defined. The authors reviewed the records of 131 consecutive children undergoing laparoscopic cholecystectomy on two surgical services to define the efficacy of ERCP followed by laparoscopic cholecystectomy in managing choledocholithiasis in children. Fourteen children were suspected of having common duct stones noted on preoperative ultrasound scan and laboratory data. At ERCP, six children had no stones visualized; eight had stones and underwent stone extraction and sphincter dilation or sphincterotomy. All 14 underwent laparoscopic cholecystectomy a mean of 3.8 days after ERCP. None of the 14 had evidence of retained stones. Only one of 117 children undergoing primary laparoscopic cholecystectomy had unsuspected common bile duct stones and was treated with laparoscopic common bile duct exploration and stone removal. A management plan incorporating ERCP followed by early laparoscopic cholecystectomy is a safe and effective strategy for children who have choledocholithiasis.