Meta-analysis of the diagnostic accuracy of laparoscopic ultrasonography and intraoperative cholangiography in detection of common bile duct stones

Evaluating the Role of Indocyanine Green Fluorescence Imaging in Enhancing Safety and Efficacy During Laparoscopic Cholecystectomy: A Systematic Review

Laparoscopic cholecystectomy (LC) is the standard treatment for gallbladder disease, offering less invasive treatment and quicker recovery. However, bile duct injury (BDI) remains a critical complication. Indocyanine green (ICG) fluorescence imaging has emerged as a valuable technique to improve biliary structure visualization and potentially reduce BDI during LC. This systematic review assesses the efficacy of ICG in reducing BDI over the past decade. A comprehensive search of studies comparing ICG fluorescence and conventional white light (WL) in LC identified 14 studies. Key outcomes such as operative time, incidence of BDI, and visualization of biliary anatomy were analyzed. The results indicate that ICG significantly reduced operative times in complex cases, with an average reduction of approximately 20 minutes compared to WL (p<0.0001). In routine cases, no significant difference in operative time was observed between the two methods. ICG consistently enhanced visualization of key biliary structures, such as the cystic duct and common bile duct, with the greatest benefits seen in anatomically challenging cases. Although the overall incidence of BDI was low, use of ICG showed a trend toward lower BDI rates compared to WL, though the difference was not statistically significant. In conclusion, the use of ICG fluorescence in LC offers notable advantages, particularly in improving visualization of biliary anatomy and reducing operative time in complex cases. While the overall reduction in BDI rates may appear marginal, the clinical importance of avoiding even a single BDI should not be understated, given the serious complications associated with BDI. Our review suggests that the benefits of ICG are most pronounced in more complex cases where biliary anatomy is challenging to identify.

Benefits and risks of using laparoscopic ultrasonography versus intraoperative cholangiography during laparoscopic cholecystectomy for gallstone disease: a systematic review and meta-analysis

BACKGROUND

Intraoperative laparoscopic ultrasonography (LUS) or intraoperative cholangiography (IOC) can be used for visualisation of the biliary tract during laparoscopic cholecystectomy. The aim of this systematic review was to compare use of LUS with IOC.

METHODS

PubMed, Embase, the Cochrane Library, and Web of Science were searched (last update: April 2024). PICO: P = patients undergoing intraoperative imaging of the biliary tree during laparoscopic cholecystectomy for gallstone disease; I = intervention: LUS; C = comparison: IOC; O = outcomes: mortality, bile duct injury, retained gallstone, conversion to open cholecystectomy, procedural failure, operation time including imaging time. Included articles were critically appraised using checklists. Conclusions were based on studies without major risk of bias. Meta-analyses were performed using random effects models. Certainty of evidence was assessed according to GRADE.

RESULTS

Sixteen non-randomised studies met the PICO. Two before/after studies (594 versus 807 patients) contributed to conclusions regarding mortality (no events; very low certainty evidence), bile duct injury (1 versus 0 events; very low certainty evidence), retained gallstone (2 versus 2 events; very low certainty evidence), and conversion to open cholecystectomy (6 versus 21 events; risk ratio: 0.38 (95% confidence interval: 0.15-0.95); I2 = 0%; low certainty evidence). Seven additional studies, using intra-individual comparisons, contributed to conclusions regarding procedural failure; risk ratio: 1.12 (95% confidence interval: 0.70-1.78; I2 = 83%; very low certainty evidence). No studies reported operation time. Mean imaging time for LUS and IOC, reported in 12 studies, was 4.8‒10.2 versus 10.9‒17.9 min (mean difference: - 7.8 min (95% confidence interval: - 9.3 to - 6.3); I2 = 95%; moderate certainty evidence).

CONCLUSION

It is uncertain whether there is any difference in mortality/bile duct injury/retained gallstone using LUS compared with IOC, but LUS may be associated with fewer conversions to open cholecystectomy and is probably associated with shorter imaging time.

The Impact of Intraoperative Glucagon on the Diagnostic Accuracy of Intraoperative Cholangiogram for the Diagnosis of Choledocholithiasis: Experience from a Large Tertiary Care Center

A proportion of patients who undergo intraoperative cholangiogram (IOC) do not have bile duct stones at the time of endoscopic retrograde cholangiopancreatography (ERCP), either due to the spontaneous passage of stones or a false-positive IOC. Glucagon has been utilized as an inexpensive tool to allow the passage of micro-choledocholithiasis to the duodenum and resolve filling defects caused by stones or air bubbles. The purpose of our study is to understand the change in diagnostic accuracy of IOC to detect choledocholithiasis with intraoperative glucagon. We conducted a retrospective study at a tertiary care center on adult patients who underwent laparoscopic cholecystectomy with IOC. The diagnostic accuracy of IOC was assessed before and after the administration of intravenous glucagon. Of 1455 patients, 374 (25.7%) received intraoperative glucagon, and 103 of these 374 patients (27.5%) showed resolution of the filling defect with the passage of contrast to the duodenum. Pre- and post-glucagon administration comparison showed enhancement in specificity from 78% to 83%, an increase in positive predictive value from 67.3% to 72.4%, and an improvement in the diagnostic accuracy of IOC from 81.5% to 84.3%. Our findings suggest that intraoperative glucagon administration carries the potential to reduce the rate of false-positive IOCs, thereby reducing the performance of unnecessary ERCPs.

Ultrasound-guided robotic surgical procedures: a systematic review

INTRODUCTION

Ultrasound has been nicknamed "the surgeon's stethoscope". The advantages of laparoscopic ultrasound beyond a substitute for the sense of touch are considerable, especially for robotic surgery. Being able to see through parenchyma and into vascular structures enables to avoid unnecessary dissection by providing a thorough assessment at every stage without the need for contrast media or ionising radiation. The limitations of restricted angulation and access within the abdominal cavity during laparoscopy can be overcome by robotic handling of miniaturised ultrasound probes and the use of various and specific frequencies will meet tissue- and organ-specific characteristics. The aim of this systematic review was to assess the reported applications of intraoperative ultrasound-guided robotic surgery and to outline future perspectives.

METHODS

The study adhered to the PRISMA guidelines. PubMed, Google Scholar, ScienceDirect and ClinicalTrials.gov were searched up to October 2023. Manuscripts reporting data on ultrasound-guided robotic procedures were included in the qualitative analysis.

RESULTS

20 studies met the inclusion criteria. The majority (53%) were related to the field of general surgery during liver, pancreas, spleen, gallbladder/bile duct, vascular and rectal surgery. This was followed by other fields of oncological surgery (42%) including urology, lung surgery, and retroperitoneal lymphadenectomy for metastases. Among the studies, ten (53%) focused on locating tumoral lesions and defining resection margins, four (15%) were designed to test the feasibility of robotic ultrasound-guided surgery, while two (10.5%) aimed to compare robotic and laparoscopic ultrasound probes. Additionally two studies (10.5%) evaluated the robotic drop-in probe one (5%) assessed the hepatic tissue consistency and another one (5%) aimed to visualize the blood flow in the splenic artery.

CONCLUSION

The advantages of robotic instrumentation, including ergonomics, dexterity, and precision of movements, are of relevance for robotic intraoperative ultrasound (RIOUS). The present systematic review demonstrates the virtue of RIOUS to support surgeons and potentially reduce minimally invasive procedure times.

Feasibility and safety of intraoperative bile duct clearance by antegrade transcystic balloon sphincteroplasty: A prospective observational pilot study

BACKGROUND

Concomitant cholecystolithiasis and choledocholithiasis are common. Standard treatments are endoscopic retrograde cholangiography (ERC) followed by cholecystectomy or laparoendoscopic rendezvous. Endoscopic retrograde cholangiography has drawbacks, such as post-ERC pancreatitis or bleeding, and potentially more than one intervention is required to address common bile duct (CBD) stones. Safety and feasibility of an intraoperative antegrade transcystic single-stage approach during cholecystectomy with balloon sphincteroplasty and pushing of stones to the duodenum has not been evaluated prospectively. The aim of this pilot study was to evaluate this procedure regarding safety, feasibility, and stone clearance rate.

METHODS

Prospective single-center intervention study (SUPER Reporting-Guideline). Main inclusion criterion was confirmed choledocholithiasis (stones ≤6 mm) at intraoperative cholangiography. Success of the procedure was defined as CBD stone clearance at intraoperative control cholangiography, absence of symptoms and no elevated cholestasis parameters at 6 weeks follow-up. Simon's two-stage design was used to determine sample size.

RESULTS

From January 2021 to April 2022, a total of 57 patients fulfilled the final inclusion criteria and were included. Mild pancreatitis or cholangitis were present upon admission in 15 (26%) and 15 (26%) patients, respectively. Median number of CBD-stones was 1 (1-6). Median stone diameter was 4 mm (0.1-6 mm). Common bile duct stone clearance was achieved in 54 patients (94%). The main reason for failed CBD clearance was the inability to push the guidewire along the biliary stone into the duodenum. Median intervention time was 28 minutes (14-129 minutes). While there was no postoperative pancreatitis, two patients (3.5%) had asymptomatic hyperlipasemia 4 hours postoperatively.

CONCLUSION

Intraoperative CBD stone clearance by antegrade balloon sphincteroplasty appears to be safe and highly feasible. Its overall superiority to the current standards warrants evaluation by a randomized controlled trial.

LEVEL OF EVIDENCE

Therapeutic/Care Management, Level V.

Management of intraoperatively identified small bile duct stones in patients undergoing cholecystectomy

INTRODUCTION

The management of CBDS (common bile duct stones) in patients with co-existing gallbladder stones has been debated. Guidelines recommend patients with CBDS identified on imaging should be offered duct clearance; however, this is based on low-quality evidence. This study aimed to investigate the natural history of small CBDS identified using IOUS (intraoperative ultrasound) in patients undergoing cholecystectomy. This may provide evidence to support a short-term expectant management approach in such patients.

METHODS

Patients with CBDS diagnosed on IOUS during cholecystectomy were identified from a database of consecutive patients undergoing surgery. Patients with CBDS identified were divided into small stone (SS, ≤5 mm) and large stone (LS, >5 mm) groups. Intraoperative CBDS management, postoperative investigations, postoperative bile duct clearance, re-admissions, complications, length of stay (LOS) and follow-up are described.

RESULTS

Fifty-nine of 427 patients had CBDS identified on IOUS. In the SS group (n=51), 46 patients underwent short-term expectant management rather than immediate/planned bile duct clearance. Following short-term expectant management, 41/46 patients (89.1%) did not require postoperative endoscopic retrograde cholangiopancreatography and at >3 year follow-up, none has since presented with residual CBDS. Median LOS was 0 days in the short-term expectant management group and 2 days in the immediate/planned bile duct clearance group, P=0.039.

CONCLUSIONS

This study reports the natural history of small CBDS identified on IOUS in patients undergoing cholecystectomy. Such patients were safely treated with short-term expectant management associated with a reduced hospital LOS. This provides rationale for undertaking further research to establish this as a preferred management strategy.

Intra-operative ultrasound assessment of the biliary tree during robotic cholecystectomy

Image-guided assessment of bile ducts and associated anatomy during laparoscopic cholecystectomy can be achieved with intra-operative cholangiography (IOC) or laparoscopic ultrasound (LUS). Rates of robotically assisted cholecystectomy (RC) are increasing and herein we describe the technique of intra-corporeal biliary ultrasound during RC using the Da Vinci system. For intraoperative evaluation of the biliary tree during RC, in cases of suspected choledocholithiasis, the L51K Ultrasound Probe (Hitachi, Tokyo, Japan) is used. The extrahepatic biliary tree is scanned along its length, capitalising on the benefits of the full range of motion offered by the articulated robotic instruments and integrated ultrasonic image display using TileProTM software. Additionally, this technique avoids the additional time and efforts required to undock and re-dock the robot that would otherwise be required for selective IOC or LUS. The average time taken to perform a comprehensive evaluation of the biliary tree, from the hepatic ducts to the ampulla of Vater, is 164.1 s. This assessment is supplemented by Doppler ultrasound, which is used to fully delineate anatomy of the porta hepatis, and accurate measurements of the biliary tree and any ductal stones can be taken, allowing for contemporaneous decision making and management of ductal pathologies. Biliary tract ultrasound has been shown to be equal to IOC in its ability to diagnose choledocholithiasis, but with the additional benefits of being quicker and having higher completion rates. We have described our practice of using biliary ultrasound during robotically assisted cholecystectomy, which is ergonomically superior to LUS, accurate and reproducible.

A Systematic Review of Laparoscopic Ultrasonography During Laparoscopic Cholecystectomy

We aim to investigate the potential of laparoscopic ultrasonography (LUS) as a replacement for intraoperative cholangiography (IOC) in the context of laparoscopic cholecystectomy focusing on various aspects related to both techniques. We made our search through PubMed, Web of Science, Cochrane Library, and Scopus, with the use of the following search strategy: ("laparoscopic ultrasonography" OR LUS OR "laparoscopic US" OR "laparoscopic ultrasound") AND ("laparoscopic cholecystectomy" OR LC). We incorporated diverse studies that addressed our topic, offering data on the identification of biliary anatomy and variations, the utilization of laparoscopic ultrasound in cholecystitis, the detection of common bile duct stones, and the criteria utilized to assess the accuracy of LUS. A total of 1526 articles were screened and only 20 were finally included. This systematic review assessed LUS and IOC techniques in cholecystectomy. IOC showed higher failure rates due to common duct catheterization challenges, while LUS had lower failure rates, often linked to factors like steatosis. Cost-effectiveness comparisons favored LUS over IOC, potentially saving patients money. LUS procedures were quicker due to real-time imaging, while IOC required more time and personnel. Bile duct injuries were discussed, highlighting LUS limitations in atypical anatomies. LUS aided in diagnosing crucial conditions, emphasizing its relevance post surgery. Surgeon experience significantly impacted outcomes, regardless of the technique. A previous study discussed that LUS's learning curve was steeper than IOC's, with proficient LUS users adjusting practices and using IOC selectively. Highlighting LUS's benefits and limitations in cholecystectomy, we stress its value in complex anatomical situations. LUS confirms no common bile duct stones, avoiding cannulation. LUS and IOC equally detect common bile duct stones and visualize the biliary tree. LUS offers safety, speed, cost-effectiveness, and unlimited use. Despite the associated expenses and learning curve, the enduring benefits of using advanced probes in LUS imaging suggest that it could surpass traditional IOC. The validation of this potential advancement relies heavily on incorporating modern probe studies. Our study could contribute to the medical literature by evaluating their clinical validity, safety, cost-effectiveness, learning curve, patient outcomes, technological advancements, and potential impact on guidelines and recommendations for clinical professionals.

Intraoperative Cholangiography in Laparoscopic Cholecystectomy: A Systematic Review and Meta-Analysis

Background/Objectives

Routine intraoperative cholangiography (IOC) for laparoscopic cholecystectomy (LC) remains controversial. The primary outcomes of this meta-analysis were detection rates of choledocholithiasis, bile duct injuries (BDI), and missed stones in LCs.

Methods

A systematic literature search was conducted for the time period January 1, 1990 to July 31, 2022. Some studies reported LCs with conversion to open therefore subgroup analysis in BDI rates was performed for studies which included LCs with and without conversion to open. Studies including primary open cholecystectomies were excluded. I² statistics were used for heterogeneity analysis.

Results

Fourteen studies involving 440659 patients were included. In studies comparing routine and selective IOC policies in LC, 61.1% of patients underwent routine IOC; 38.9% underwent selective IOC. In studies comparing IOC to no IOC in LC, 17.3% of patients had IOC; 82.7% did not. Between the selective and routine IOC groups there was no difference in choledocholithiasis detection rate (odds ratio [OR] = 1.33, p = 0.20, 95% confidence interval [CI] = 0.86 - 2.04), no difference in the rate of missed stones (OR = 1.59, p = 0.58; 95% CI = 0.31 - 8.29), and no difference in BDI rates in selective compared to routine IOC (OR = 0.92, p = 0.92; 95% CI = 0.20 - 4.22). There was no difference in the BDI detection rates in LC with and without IOC (OR = 1.12, p = 0.77; 95% CI = 0.52 - 2.38).

Conclusion

This is the largest meta-analysis on this topic to date. There was no statistically significant difference in choledocholithiasis detection, missed stones, or BDI rates in the analyzed groups.

Application of imaging techniques in pancreaticobiliary maljunction

Imaging techniques are useful tools in the diagnosis and treatment of pancreaticobiliary maljunction (PBM). PBM is a precancerous lesion often relative to the disease of the pancreas and biliary tract, for example, cholecystolithiasis, protein plugs, and pancreatitis. For patients with PBM, early diagnosis and timely treatment are highly important, which is largely dependent on imaging techniques. The continuous development of imaging techniques, including endoscopic retrograde cholangiopancreatography, magnetic resonance cholangiopancreatography, computed tomography, ultrasound, and intraoperative cholangiography, has provided appropriate diagnostic and therapeutic tools for PBM. Imaging techniques, including non-invasive and invasive, have distinct advantages and disadvantages. The purpose of this paper is to review the application of various imaging techniques in the diagnosis and treatment of PBM.

A UK survey on variation in the practice of management of choledocholithiasis and laparoscopic common bile duct exploration (ALiCE Survey)

BACKGROUND

The practice of managing suspected/confirmed common bile duct stones (CBDS) can vary significantly in the UK. We aimed to assess this variability in practice and challenges to form a basis for future consensus.

METHODS

An electronic survey containing 40 questions on various aspects of management of CBDS was sent to surgeons who perform cholecystectomies via five surgical associations.

RESULTS

 A total of 132 surgeons responded to the survey. The speciality of surgeons includes upper gastro-intestinal (68%), general (18%), colorectal (12%), and others (2%). For patients with suspected CBD stones, 80% would choose magnetic resonance cholangio-pancreatography, and 14.4% would proceed to intra-operative imaging. Most surgeons preferred intra-operative cholangiogram over intra-operative ultrasound (83% vs 17%). For the treatment, 62.1% preferred a two-stage approach [endoscopic retrograde cholangio-pancreatography (ERCP) followed by laparoscopic cholecystectomy (LC)] and 33.4% chose a single-stage approach [LC + laparoscopic common bile duct exploration (LCBDE)]. Eighty (60.6%) responders performed LCBDE, and 19 (23.8%) of them performed > 10 LCBDEs in a year. Two third of surgeons (62.5%) preferred a trans-choledochal approach to CBDS. Half of the surgeons that perform LCBDE use a T-tube selectively and 1.6% routinely. The "availability of very good ERCP service" and "lack of formal training" were the two main reasons for surgeons not performing LCBDE. Both surgeons' speciality and whether they perform other complex laparoscopic surgery were significantly associated with choosing a two-stage approach over a one-stage approach (χ² test, speciality p = 0.033, complex surgery p = 0.011).

CONCLUSION

 Our survey confirms the significant variability in the diagnosis and management of CBDS. The two-stage approach is still the most common way of managing CBDS in the UK. The main reasons for the low uptake of the single-stage approach are the availability of good ERCP service, lack of equipment and lack of formal training in the technique of LCBDE.

Cost-effectiveness analysis of optimal diagnostic strategy for patients with symptomatic cholelithiasis with intermediate probability for choledocholithiasis

BACKGROUND AND AIMS

EUS, MRCP, and intraoperative cholangiogram (IOC) are the recommended diagnostic modalities for patients with intermediate probability for choledocholithiasis (IPC). The relative cost-effectiveness of these modalities in patients with cholelithiasis and IPC is understudied.

METHODS

We developed a decision tree for diagnosing IPC (base-case probability, 50%; range, 10%-70%); patients with a positive test were modeled to undergo therapeutic ERCP. The strategies tested were laparoscopic cholecystectomy with IOC (LC-IOC), MRCP, single-session EUS + ERCP, and separate-session EUS + ERCP. Costs and probabilities were extracted from the published literature. Effectiveness was assessed by assigning utility scores to health states, average proportion of true-positive diagnosis of IPC, and the mean length of stay (LOS) per strategy. Cost-effectiveness was assessed by extrapolating a net-monetary benefit (NMB) and average cost per true-positive diagnosis.

RESULTS

LC-IOC was the most cost-effective strategy to diagnose IPC (base-case probability of 50%) among patients with cholelithiasis in health state-based effectiveness analysis (NMB of $34,612), diagnostic test accuracy-based effectiveness analysis (average cost of $13,260 per true-positive diagnosis), and LOS-based effectiveness analysis (mean LOS of 4.13) compared with strategies 2 (MRCP), 3 (single-session EUS + ERCP), and 4 (separate-session EUS + ERCP). These findings were robust on deterministic and probabilistic sensitivity analyses.

CONCLUSIONS

For patients with cholelithiasis with IPC, LC-IOC is a cost-effective approach that should limit preoperative testing and may shorten hospital LOS. Our findings may be used to design institutional and organizational management protocols.

Controversies in ERCP: Technical aspects

The aim of the series of papers on controversies of biliopancreatic drainage procedures is to discuss pros and cons of the varying clinical practices and techniques in ERCP and EUS for drainage of biliary and pancreatic ducts. While the first part focuses on indications, clinical and imaging prerequisites prior to ERCP, sedation options, post-ERCP pancreatitis prophylaxis, and other related technical topics, the second part discusses specific procedural ERCP techniques including precut techniques and their timing as well as management algorithms. In addition, reviews on controversies in EUS-guided bile duct and pancreatic drainage procedures are under preparation.

The efficacy and safety of preoperative cholangiography via percutaneous transhepatic gallbladder drainage (PTGBD) for difficult laparoscopic cholecystectomy (LC)

BACKGROUND

Percutaneous transhepatic gallbladder drainage (PTGBD) is an important procedure for initial treatment of severe acute cholecystitis (AC) that is contraindicated for early laparoscopic cholecystectomy (LC). We presented our primary experience on a new approach of cholangiography via PTGBD (PTGBD-C) for preoperative delineation of biliary anatomy.

METHODS

A retrospective analysis was conducted on 93 patients who received PTGBD followed by LC for AC, with allocation into 2 groups that were PTGBD with (PTGBD-C group, 32 patients) or without (PTGBD-N group, 61 patients) cholangiography. All the clinical data, including demographics, cholangiography findings, operations, and complications, were collected and analyzed.

RESULTS

Cholangiography was attempted in 32 patients with a success of 31 cases, and the most common complication was transient fever in 3 patients. PTGBD-C group of patients showed significantly less operation time (83.2 ± 22.32 vs. 106.5 ± 40.25 min, P = 0.041) and conversion rate (0 vs. 2). There was no statistical difference in terms of postoperative hospitalization and complications.

CONCLUSIONS

PTGBD-C is a feasible and safe procedure for severe AC patients with delayed LC. It has advantages of direct cholangiography, being easy to perform and cost-effective, thus should be considered for clinical usage.

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.

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.

Application of Laparoscopic Technique in the Treatment of Hepatolithiasis

Hepatolithiasis is commonly encountered in Southeastern and East Asian countries, and its incidence is increasing in Western countries. For symptomatic hepatolithiasis or asymptomatic hepatolithiasis with signs of liver atrophy or malignancy, surgical intervention is needed, especially when peroral cholangioscopy and percutaneous transhepatic cholangioscopic lithotomy are not suitable or fail to be performed. Currently, laparoscopic surgery is gradually replacing traditional open surgery and becoming a better option. Various types of laparoscopic surgeries, including laparoscopic hepatectomy, laparoscopic biliary exploration through the common bile duct or the hepatic duct stump, and robotic-assisted laparoscopic surgery, have been developed for the treatment of simple hepatolithiasis, hepatolithiasis concomitant with choledocholithiasis, recurrent hepatolithiasis, and complicated hepatolithiasis. The related clinical experience is gradually accumulating. In this review, the laparoscopic applications and their advantages will be summarized. In most cases, the laparoscopic technique could provide the advantages of less trauma, reduced blood loss, and faster postoperative recovery.

Use of bacterial cellulose film for repair of bile duct injury in pigs

BACKGROUND/OBJECTIVE

The aim was to evaluate the use of bacterial cellulose film and bile duct autograft in repairing critical common bile duct injury in pigs.

METHODS

A prospective experimental analytical study was carried out on 20 Sus Domesticus, Piau suidae swine, divided into a control group (n = 10) and an experimental group (n = 10) divided into two subgroups: bacterial cellulose film E1 and bacterial cellulose film E2 to which bacterial cellulose film was randomly allocated. The control group underwent two complete critical common bile duct sections 10 mm apart, while the experimental group with a single critical common bile duct defect underwent a 10 mm section of the longitudinal shaft with edge resection. The defects in the control group were treated with end-to-end conventional anastomosis using polyglycolic 6-0 surgical thread and the experimental group with bacterial cellulose film by continuous suture using the same material. The animals were clinically evaluated throughout the experiment on days D150 (bacterial cellulose film E1), D225 (control group), and D330 (bacterial cellulose film E2) and by intraoperative ultrasound examination related to histopathological and biochemical findings.

RESULTS

The intraoperative ultrasonography detected the changes resulting from the common bile duct anastomosis in the control group that produced a considerable incidence of ductal narrowing and obstruction to the biliary flow. In the bacterial cellulose film E2 group, there was an increase in inflammation intensity, granulomatous reaction, fibrosis, and vessels density, without producing bile duct dilation in the ultrasonography assessment. Biochemical analysis of liver enzymes yielded results in the normal range confirming preservation of liver function at the different post-surgery time points.

CONCLUSION

Bacterial cellulose film, when used as a graft for bile duct repair, proved to be a biocompatible material that produced a complete healing process and biliary flow continuity.

The role of intraoperative cholangiography in patients undergoing laparoscopic cholecystectomy for acute gallstone pancreatitis: is magnetic resonance cholangiopancreatography needed?

INTRODUCTION

Intraoperative cholangiography is sporadically used in patients undergoing laparoscopic cholecystectomy to delineate common bile duct anatomy and exclude retained stones. In patients with acute gallstone pancreatitis, intraoperative cholangiography may reduce the need for preoperative magnetic resonance cholangiopancreatography.

MATERIALS AND METHODS

A retrospective review of a prospectively collected patient database was undertaken over a 15-year period. The primary objective was to evaluate intraoperative assessment of the common bile duct with intraoperative cholangiography in patients with acute gallstone pancreatitis.

RESULTS

A total of 2215 patients underwent laparoscopic cholecystectomy between October 1998 and December 2013; 113 patients (of whom 77 were women) with a mean age of 54 years (range 16-88 years) were diagnosed with acute gallstone pancreatitis. Of these, 102 patients (90%) underwent laparoscopic cholecystectomy with intraoperative cholangiography, which was normal in 89 cases. Thirteen patients had choledocholithiasis on intraoperative cholangiography, 11 of whom were managed with concomitant trans-cystic duct exploration and clearance. Two patients required postoperative endoscopic retrograde cholangiopancreatography.

CONCLUSIONS

In patients diagnosed with acute gallstone pancreatitis, it is reasonable to proceed directly to surgery using intraoperative cholangiography on the same admission as the definitive assessment of the common bile duct. This negates the need for magnetic resonance cholangiopancreatography and can translate into cost savings and reduced length of stay.

Biliary tract exploration through a common bile duct incision or left hepatic duct stump in laparoscopic left hemihepatectomy for left side hepatolithiasis: which is better?: A single-center retrospective case-control study

Laparoscopic left hemihepatectomy (LLH) followed by biliary tract exploration is used to treat left-sided hepatolithiasis (LSH). The purpose of this study was to compare the efficacy of 2 methods of biliary tract exploration in LLH:biliary tract exploration through a common bile duct (CBD) incision (with T-tube drainage) or through the left hepatic duct (LHD) stump (without T-tube drainage).LSH patients (113 patients) were recruited retrospectively in our hospital from December 2008 to January 2016. To compare different methods of biliary tract exploration during LLH, the patients were divided into 2 groups: 41 patients underwent biliary tract exploration through the LHD stump (LHD group), and 72 patients underwent biliary tract exploration through a CBD incision (CBD group). Baseline characteristics, surgical outcomes, surgery-related complications, postoperative hospital stay (PHS) and long-term results were compared between the 2 groups.There was no unplanned reoperation in the 2 groups. One patient in the CBD group had a residual stone, which was removed by choledochoscopy 2 months postoperation. Two patients in the LHD group and 3 patients in the CBD group had bile leakage and were cured with abdominal drainage. There were no significant differences in the total operation time, incidence of residual stones and bile leakage between the 2 groups (P > .05). The PHS and the incidence of hypokalemia or hyponatremia in the LHD group were significantly lower than those in the CBD group (P < .05). T-tube-related complications occurred in 13.9% (10/72) of the CBD patients. The mean follow-up period was 37.2 ± 13.8 months. There were no significant differences in the incidence of recurrence stones or cholangitis (P > .05) between the 2 groups.Exploration of the biliary tract through the LHD stump without T-tube drainage is safe with satisfactory short- and long-term results for selected LSH patients.

The added value of tomosynthesis in endoscopic retrograde cholangiography with radiography for the detection of choledocholithiasis

OBJECTIVE

The diagnostic performance of endoscopic retrograde cholangiography (ERC) with radiography is imperfect. We assessed the value of adding tomosynthesis to ERC with radiography for the detection of choledocholithiasis.

METHODS

This study included 102 consecutive patients (choledocholithiasis/non-choledocholithiasis, n = 57/45), who underwent both radiography and tomosynthesis for ERC in the same examination and were not diagnosed with malignancy. The reference standard for the existence of choledocholithiasis was confirmed by endoscopic stone extraction during ERC, intraoperative cholangiography, or follow up with magnetic resonance cholangiopancreatography (n = 78, 11, and 13, respectively). A gastroenterologist and a radiologist independently evaluated the radiographs and the combination of tomosynthesis and radiographic images in a blinded and randomised manner. Receiver operating characteristic analysis was used for statistical analysis.

RESULTS

The areas under the receiver operating characteristic curve for combined tomosynthesis and radiography were significantly higher than those for radiography alone for both readers: Reader 1/Reader 2, 0.929/0.956 [95% confidence interval (CI), 0.861-0.965/0.890-0.983) vs 0.803/0.769 (95% confidence interval, 0.707-0.873/0.668-0.846), respectively (p = 0.0047/< 0.0001).

CONCLUSION

Adding tomosynthesis to radiography improved the diagnostic performance of ERC for detection of choledocholithiasis. Advances in knowledge: Adding tomosynthesis to radiography improves detection of choledocholithiasis and tomosynthesis images can be obtained easily after radiographs and repeated immediately.

Laparoscopic ultrasonography: The wave of the future in renal cell carcinoma?

Laparoscopic or robotic surgery is the main method of treating renal cell carcinoma (RCC). Laparoscopic surgery can accurately target lesions and shorten patient recovery time. Renal endogenous tumors or inferior vena cava tumor thrombi are very difficult to remove using the laparoscopic approach. The emergence of laparoscopic ultrasonography (LUS) has solved this problem. LUS can assist in the detection of tumor boundaries and the extent of tumor thrombi. The lack of tactile feedback may hinder the development of laparoscopic surgery for the treatment of renal cancer. LUS has become an important tool that has improved the rates of successful surgery. LUS is applied in not only early and locally advanced RCC treatment but also in monitoring ablation therapy, testing renal blood perfusion, and exposing renal pedicles. Sonographic techniques used for LUS include initial B-mode, Doppler, and contrast-enhanced ultrasound (CEUS). Contrast agents applied for CEUS do not induce nephrotoxicity and can display renal perfusion more accurately than the regular color Doppler ultrasound. According to current literature, LUS is a promising technique for the treatment of RCC, especially for endogenous RCC or RCC with thrombosis, and for monitoring the effectiveness of radiofrequency ablation, although further well-designed studies are warranted.

Laparoscopic ultrasonography as an alternative to intraoperative cholangiography during laparoscopic cholecystectomy

AIM

To assess the role of laparoscopic ultrasound (LUS) as a substitute for intraoperative cholangiography (IOC) during cholecystectomy.

METHODS

We present a MEDLINE and PubMed literature search, having used the key-words “laparoscopic intraoperative ultrasound” and “laparoscopic cholecystectomy”. All relevant English language publications from 2000 to 2016 were identified, with data extracted for the role of LUS in the anatomical delineation of the biliary tract, detection of common bile duct stones (CBDS), prevention or early detection of biliary duct injury (BDI), and incidental findings during laparoscopic cholecystectomy. Data for the role of LUS vs IOC in complex situations (i.e., inflammatory disease/fibrosis) were specifically analyzed.

RESULTS

We report data from eighteen reports, 13 prospective non-randomized trials, 5 retrospective trials, and two meta-analyses assessing diagnostic accuracy, with one analysis also assessing costs, duration of the examination, and anatomical mapping. Overall, LUS was shown to provide highly sensitive mapping of the extra-pancreatic biliary anatomy in 92%-100% of patients, with more difficulty encountered in delineation of the intra-pancreatic segment of the biliary tract (73.8%-98%). Identification of vascular and biliary variations has been documented in two studies. Although inflammatory disease hampered accuracy, LUS was still advantageous vs IOC in patients with obscured anatomy. LUS can be performed before any dissection and repeated at will to guide the surgeon especially when hilar mapping is difficult due to fibrosis and inflammation. In two studies LUS prevented conversion in 91% of patients with difficult scenarios. Considering CBDS detection, LUS sensitivity and specificity were 76%-100% and 96.2%-100%, respectively. LUS allowed the diagnosis/treatment of incidental findings of adjacent organs. No valuable data for BDI prevention or detection could be retrieved, even if no BDI was documented in the reports analyzed. Literature analysis proved LUS as a safe, quick, non-irradiating, cost-effective technique, which is comparatively well known although largely under-utilized, probably due to the perception of a difficult learning curve.

CONCLUSION

We highlight the advantages and limitations of laparoscopic ultrasound during cholecystectomy, and underline its value in difficult scenarios when the anatomy is obscured.