Duodenoscopic sphincterotomy for biliary calculi

Selective use of preoperative endoscopic retrograde cholangiopancreatography in the era of laparoscopic cholecystectomy

BACKGROUND

The use of endoscopic retrograde cholangiopancreatography (ERCP) in the management of suspected common bile duct (CBD) stones prior to laparoscopic cholecystectomy is common. The associated morbidity can be significant. The present study determines significant predictors of CBD stones and improves the selection of patients for preoperative ERCP.

METHODS

All preoperative ERCP for suspected CBD stones in the year 1998 were studied retrospectively. Univariate and multivariate analyses of a number of clinical, biochemical and radiological variables were carried out to determine the best predictors of CBD stones.

RESULTS

A total of 112 patients had successful preoperative ERCP. Sixty-one per cent of these were negative for stones and the morbidity was 9%. Univariate analysis revealed the following variables as predictors: cholangitis (P = 0.006), abnormal serum bilirubin > or = 3 days (P = 0.002), serum alkaline phosphatase > or = 130 U/L (P = 0.002), deranged liver function tests (P = < 0.001) and CBD diameter > or = 8 mm (P = 0.009) with positive predictive values of 80%, 68%, 49%, 38% and 52%, respectively. Multivariate analysis revealed the model with the best ability to discriminate for CBD stones (P = 0.0005) was cholangitis, abnormal serum bilirubin for > or = 3 days and CBD diameter > or = 8 mm. The best predictors from this study had a sensitivity of 80% and a specificity of 27%.

CONCLUSIONS

The predictors of CBD stones are imprecise. Until laparoscopic exploration of CBD becomes widely available, ERCP prior to cholecystectomy will remain popular. The use of stricter selection criteria can reduce the number of negative preoperative ERCP.

Selective endoscopic retrograde cholangiography prior to laparoscopic cholecystectomy for gallstones

BACKGROUND

To assess the outcome of endoscopic retrograde cholangiography (ERC) before laparoscopic cholecystectomy (LC) for symptomatic gallbladder and suspected duct stones.

METHODS

During 3 years, one or more of four criteria led to ERC: jaundice, choledocus >8 mm, cholestasis, and severe biliary pancreatitis. Endoscopic extraction (ESE) of ductal stones was attempted before LC.

RESULTS

In all, 990 patients were prospectively included. There were no exclusions. There were no deaths. A multivariate logistic regression analysis identified jaundice (P = 0.001), pancreatitis (P = 0.001), and cholestasis (P = 0.001) as statistically significant predictors of ductal stones. Choledocus >8 mm was not a significant predictor (P = 0.12). A total of 155 (16%) patients underwent ERC for suspected stones: 21 of 155 (13%) patients had no stones; and 6 of 134 (4%) patients had stone impaction cleared at open surgery. ERC clearance rate was 95% (128 of 134). LC was performed in 149 of 155 patients after a median interval of 3 days (range 1 to 7). Morbidity rates were 3% (4 of 134), 2% (3 of 149), and nil (0 of 6) after ESE, LC, or open surgery, respectively. Median hospital stay was 11 days. A total of 835 patients underwent LC with a 1.5% complication rate. Laparoscopic fluoro-cholangiography showed < or =3 mm-sized stones in 10 of 835 (1.2%) patients. No stones were reported at a median follow-up of 4 months including 990 patients.

CONCLUSIONS

Ninety-five percent of patients with ductal stones can be successfully and safely managed by ERC prior to LC.

Diagnosis of common bile duct stones by intravenous cholangiography: prediction by ultrasound and liver function tests compared with endoscopic retrograde cholangiography

BACKGROUND

Routine intravenous cholangiography using the safer contrast medium, meglumine iotroxate, may be a useful investigation prior to laparoscopic cholecystectomy for the detection of suspected common bile duct stones. We compared this with endoscopic cholangiography.

METHODS

Eighty-one consecutive nonjaundiced patients (mean age 62 years; range 20 to 90) with suspected common bile duct stones referred for endoscopic cholangiography to one center underwent intravenous cholangiography that was considered positive if it detected ductal stones. The ability of ultrasound scans and liver function tests to predict ductal stones was also assessed.

RESULTS

Sixty patients had both endoscopic and intravenous cholangiograms performed. Thirteen out of 27 patients with ductal stones confirmed by endoscopic cholangiography had positive intravenous cholangiograms, and 29 out of 30 with no stones had negative intravenous cholangiograms. The sensitivity for intravenous cholangiography was 48%, specificity 97%, positive predictive value 93%, negative predictive value 67%, and accuracy 73%. For ultrasound scans the positive predictive value was 69%; negative predictive value was 78%. For liver function tests the positive predictive value was 68%; negative predictive value was 93%.

CONCLUSIONS

Intravenous cholangiography cannot be recommended instead of endoscopic cholangiography except in situations where the latter is not readily available. Ultrasound and liver function tests are useful in predicting ductal stones.

Gallbladder function and recurrent stones of the biliary tract in patients after endoscopic sphincterotomy

BACKGROUND

Change in gallbladder function may occur in patients with an intact gallbladder after endoscopic sphincterotomy (EST). This study was designed to evaluate the factors influencing gallbladder filling after EST and the correlation between gallbladder function and stone recurrence.

METHODS

Sixty Chinese patients with symptomatic choledocholithiasis and an intact gallbladder received EST to clear the bile ducts. They were further investigated with sphincter of Oddi manometry (SOM), quantitative cholescintigraphy (QC), and long-term clinical follow-up.

RESULTS

Fifty-six of the 60 patients in the study group were confirmed to have a loss of sphincteric function by SOM. QC showed normal gallbladder filling in 35 of these patients and delayed or non-filling in 21 patients. A significantly higher incidence of normal gallbladder filling occurred in patients with juxtapapillary diverticulum than in those without (P < 0.02), but preexisting cholecystolithiasis had no effect on it. During the follow-up period (median, 32 months: range, 9-54 months) 10 of 56 patients developed recurrent choledocholithiasis. There was no correlation between the status of gallbladder filling, preexisting cholecystolithiasis, and recurrent stones, but 9 of the 10 patients with recurrent stones had a juxtapapillary diverticulum. Repeated endoscopic treatment was satisfactory in eight patients, and only two patients received cholecystectomy.

CONCLUSIONS

EST does not alter gallbladder function in most patients. Juxtapapillary diverticulum may facilitate gallbladder filling after EST, but it is also a possible factor for recurrent choledocholithiasis.

Laparoscopic cholecystectomy: what national benefits have been achieved and at what cost?

Changes in the practice of surgery following the introduction of laparoscopic cholecystectomy (removing asymptomatic gallstones, duplicating procedures for diagnosing and managing common bile duct stones, and deferring laparoscopic management of complicated gallstones) as well as the increased rate of complications (particularly duct injury), have eroded the economic benefits to health care funders of shorter hospital stays. However, these benefits may be achieved if laparoscopic procedures are performed only by experienced surgeons and if the procedure is offered to all patients with gallstones, including complicated cases. Benefits to the community remain in terms of productivity savings as a result of an earlier return to work for patients.

Changes in the practice of biliary surgery and ERCP during the introduction of laparoscopic cholecystectomy to Australia: their possible significance

Two and a half years after the introduction of laparoscopic cholecystectomy to Australia in February 1990, estimates from Medicare statistics suggest that by July 1992, 69% of cholecystectomies were being performed laparoscopically. There was a smaller decline in the numbers of open cholecystectomies performed, suggesting a 28% rise in the rate of cholecystectomy. This has been associated with a 66% decline in the use of intra-operative cholangiography. Whereas 87% of cholecystectomies had an operative cholangiogram performed, now only 23% of all cholecystectomies do. It is suggested that in approximately half the patients, no attempt is made to exclude common duct stones. With those patients in whom an attempt is made, most surgeons rely on endoscopic retrograde cholangiopancreatography, as evidenced by a 43% increase in its use, or, more recently, a small proportion of surgeons have been using intravenous cholangiography, as evidenced by a 26% increase in its use. Once diagnosed, these stones are no longer being treated by open exploration of the bile duct, indicated by a 46% decrease in this procedure, but are being treated by endoscopic sphincterotomy, which has shown a 242% increase in its use. From the published results of the outcome of these treatments, the added risk, nationally, of these additional procedures in managing uncomplicated bile duct stones is predicted to increase mortality 1-3-fold and morbidity 10-15-fold. This risk can be reduced by the use of laparoscopic bile duct exploration. These techniques are already well established and can be learnt quickly if practice is achieved by performing routine intra-operative cholangiography.(ABSTRACT TRUNCATED AT 250 WORDS)

Common bile duct calculi at laparoscopic cholecystectomy: a technique for management

Laparoscopic cholecystectomy was attempted in 150 unselected patients. The use of routine intraoperative cholangiography prevented serious bile duct injury in one patient. It also showed 75% of patients suspected pre-operatively of having common duct stones, had passed them by the time of cholecystectomy. Eight of 12 diagnosed duct stones (5 suspected, 7 unsuspected) were removed laparoscopically. A technique is described using inexpensive and readily available equipment that allows the transcystic duct treatment of the majority of common duct stones. The development and use of such techniques to laparoscopically treat duct stones will once more allow surgeons to treat all biliary calculi at the one procedure and reduce unnecessary dependence on endoscopic retrograde cholangiopancreatography/sphincterotomy.

Laparoscopic cholecystectomy for complicated gallstone disease

After performing selectively 25 laparoscopic cholecystectomies (LC) to determine the place of LC in the management of complicated gallstones, all patients presenting with gallstones were evaluated by the authors for LC. Eighty-six consecutive patients were evaluated and 84 were studied. Follow-up in every case exceeded 6 months. In three of 10 patients with acute cholecystitis, LC was not possible; each had a history longer than 48 h and all had gangrene of the gallbladder. In four patients with empyema, LC was successful, but operative cholangiography failed. Operative cholangiography was successful in 76 of the remaining 77. Of eight patients suspected of having stones in the CBD, cholangiography excluded stones in six and confirmed them in two. Cholangiography identified three other patients with totally unsuspected CBD stones. Of the five patients with CBD stones, four had them flushed to the duodenum at LC following transcystic balloon dilatation of the papilla and one had a post-op. ERCP. Of four patients with acute pancreatitis, three had LC in the same admission. LC was possible in all three patients with morbid obesity. We conclude that with experience, LC is possible for complicated gallstones. In acute cholecystitis, the probability of success is higher with earlier operative intervention. Operative cholangiography is essential. It not only identifies unsuspected CBD stones but also allows LC without ERCP in those with suspected CBD stones and with modification it allows treatment of those stones.