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Abstract
Gallstone disease is a worldwide medical problem, but the incidence rates show substantial geographical variation, with the lowest rates reported in African populations. Publications in English language on gallstones which were obtained from reprint requests and PubMed database formed the basis for this paper. Data extracted from these sources included authors, country, year of publication, age and sex of patients, pathogenesis, risk factors for development of gallstones, racial distribution, presenting symptoms, complications and treatment. Gallstones occur worldwide, however it is commonest among North American Indians and Hispanics but low in Asian and African populations. High biliary protein and lipid concentrations are risk factors for the formation of gallstones, while gallbladder sludge is thought to be the usual precursor of gallstones. Biliary calcium concentration plays a part in bilirubin precipitation and gallstone calcification. Treatment of gallstones should be reserved for those with symptomatic disease, while prophylactic cholecystectomy is recommended for specific groups like children, those with sickle cell disease and those undergoing weight-loss surgical treatments. Treatment should be undertaken for a little percentage of patients with gallstones, as majority of those who harbor them never develop symptoms. The group that should undergo cholecystectomy include those with symptomatic gallstones, sickle cell disease patients with gall stones, and patients with morbid obesity who are undergoing laparotomy for other reasons.
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Affiliation(s)
- Gabriel E Njeze
- Department of Surgery, Enugu State University of Technology Teaching Hospital, Park Lane, Enugu, Nigeria
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2
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Cotton PB, Garrow DA, Gallagher J, Romagnuolo J. Risk factors for complications after ERCP: a multivariate analysis of 11,497 procedures over 12 years. Gastrointest Endosc 2009; 70:80-8. [PMID: 19286178 DOI: 10.1016/j.gie.2008.10.039] [Citation(s) in RCA: 426] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2008] [Accepted: 10/21/2008] [Indexed: 02/08/2023]
Abstract
BACKGROUND Complications of ERCP are an important concern. We sought to determine predictors of post-ERCP complications at our institution. METHODS GI TRAC is a comprehensive data set of patients who underwent ERCP at our institution from 1994 through 2006. Logistic regression models were used to evaluate 4 categories of complications: (1) overall complications, (2) pancreatitis, (3) bleeding, and (4) severe or fatal complications. Independent predictors of complications were determined with multivariable logistic regression. RESULTS A total of 11,497 ERCP procedures were analyzed. There were 462 complications (4.0%), 42 of which were severe (0.36%) and 7 were fatal (0.06%). Specific complications of pancreatitis (2.6%) and bleeding (0.3%) were identified. Overall complications were statistically more likely among individuals with suspected sphincter of Oddi dysfunction (SOD) (odds ratio [OR] 1.91) and after a biliary sphincterotomy (OR 1.32). Subjects with a history of acute or chronic pancreatitis (OR 0.78) or who received a temporary small-caliber pancreatic stent (OR 0.69) had fewer complications. Post-ERCP pancreatitis was more likely to occur after a pancreatogram via the major papilla (OR 1.70) or minor papilla (OR 1.54) and among subjects with suspected SOD with stent placement (OR 1.45) or without stent placement (OR 1.84). Individuals undergoing biliary-stent exchange had less-frequent pancreatitis (OR 0.38). Biliary sphincterotomy was associated with bleeding (OR 4.71). Severe or fatal complications were associated with severe (OR 2.38) and incapacitating (OR 7.65) systemic disease, obesity (OR 5.18), known or suspected bile-duct stones (OR 4.08), pancreatic manometry (OR 3.57), and complex (grade 3) procedures (OR 2.86). CONCLUSIONS This study characterizes a large series of ERCP procedures from a single institution and outlines the incidence and predictors of complications.
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Affiliation(s)
- Peter B Cotton
- Department of Medicine, Division of Gastroenterology and Hepatology, Digestive Disease Center, Medical University of South Carolina, Charleston, South Carolina 29425-2900, USA.
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Bang S, Kim MH, Park JY, Park SW, Song SY, Chung JB. Endoscopic papillary balloon dilation with large balloon after limited sphincterotomy for retrieval of choledocholithiasis. Yonsei Med J 2006; 47:805-10. [PMID: 17191309 PMCID: PMC2687820 DOI: 10.3349/ymj.2006.47.6.805] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Endoscopic papillary balloon dilation (EBD) for choledocholithiasis is known to be comparable to endoscopic sphincterotomy (EST) especially in cases of small stones. With larger stones, EBD with conventional balloon, which have a diameter of 6-8 mm, was reported as less effective for extraction of stones. We evaluated the efficacy and complications of EBD with large balloons (10-15 mm) after limited EST for retrieval of choledocholithiasis. From February 2005, we have performed EBD with limited EST for retrieval of common bile duct (CBD) stones. The patients who admitted with hyperamylasemia and gallstone pancreatitis were excluded. In cases without CBD dilation, EPBD with 12 mm for 40 seconds was performed. And in cases with CBD dilation, we dilated the sphincters with 15 mm sized balloon for 40 seconds. Total 22 patients (11 of male) were performed EBD with limited EST for retrieval of CBD stones. The median diameter of the stones was 10 mm (5-25 mm). Ten cases had multiple stones and 6 cases periampullary diverticuli. Successful stone removal in the initial session of ERCP with EBD was accomplished in 16 patients (72.7%). And complete retrieval of bile duct stones was achieved in all patients with repeated ERCP. In the aspect of complications, any episodes of perforation, bleeding was not developed. Only one case of mild grade of post-procedural pancreatitis was noted. However, post-procedural hyperamylasemia was developed in 16 cases (68.2%). EBD with larger balloon seems to be a feasible and safe alternative technique for conventional EST in CBD stone extraction.
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Affiliation(s)
- Seungmin Bang
- Division of Gastroenterology, Institute of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Myoung Hwan Kim
- Division of Gastroenterology, Institute of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jeong Youp Park
- Division of Gastroenterology, Institute of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Woo Park
- Division of Gastroenterology, Institute of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Si Young Song
- Division of Gastroenterology, Institute of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Bock Chung
- Division of Gastroenterology, Institute of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
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Freeman ML. Adverse outcomes of endoscopic retrograde cholangiopancreatography: avoidance and management. Gastrointest Endosc Clin N Am 2003; 13:775-98, xi. [PMID: 14986798 DOI: 10.1016/s1052-5157(03)00107-7] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Adverse outcomes of endoscopic retrograde cholangiopancreatography (ERCP) include technical failures and complications. Complications cause significant morbidity to patients and anxiety to endoscopists. The key to preventing complications is to understand which patients and procedures are at highest risk so that appropriate decisions can be made as to whether ERCP should be performed at all, and if so, how. Patients who need ERCP the least are often the ones most likely to develop complications. For marginal indications, ERCP should be avoided. Success rates are higher and complication rates lower for endocopists performing large numbers by endoscopists with adequate experience.
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Affiliation(s)
- Martin L Freeman
- University of Minnesota, Hennepin County Medical Center, Minneapolis 55415, USA.
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CHIKAMORI FUMIO, KUNIYOSHI NOBUTOSHI, KAWASHIMA TAKAHIKO, Takase Y. Technique of laparoscopic cholecystectomy combined with percutaneous papillary balloon dilatation under general anesthesia for cholecystocholedocholithiasis. Dig Endosc 2003. [DOI: 10.1046/j.1443-1661.2003.00235.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Affiliation(s)
- FUMIO CHIKAMORI
- Kochi Clinical Gastroenterology Study Group,
- Department of Surgery and
| | - NOBUTOSHI KUNIYOSHI
- Kochi Clinical Gastroenterology Study Group,
- Department of Internal Medicine, Kuniyoshi Hospital, Kochi,
| | | | - Yasuhiro Takase
- Department of Surgery, Tsukuba Gakuen Hospital, Ibaraki, Japan
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Stefanidis G, Karamanolis G, Viazis N, Sgouros S, Papadopoulou E, Ntatsakis K, Mantides A, Nastos H. A comparative study of postendoscopic sphincterotomy complications with various types of electrosurgical current in patients with choledocholithiasis. Gastrointest Endosc 2003; 57:192-7. [PMID: 12556783 DOI: 10.1067/mge.2003.61] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Whether the type of electrosurgical current used for endoscopic sphincterotomy influences the frequency of postsphincterotomy complications is unknown. METHODS One hundred eighty-six patients with choledocholithiasis were prospectively randomized to undergo endoscopic sphincterotomy with pure cutting current (n = 62, Group A), blended current (n = 62, Group B), or pure cutting initially followed by blended current (n = 62, Group C). Serum concentrations of amylase and lipase were evaluated in all patients 12 and 24 hours after sphincterotomy. Clinical pancreatitis was classified as mild, moderate, or severe. Postsphincterotomy bleeding was defined as a decrease in hematocrit of greater than 5%. RESULTS Serum concentrations of amylase and lipase were greater in Groups B and C at 12 and 24 hours after the procedure, as compared with Group A. Clinical mild pancreatitis occurred in 2 patients in Group A (3.2%), 8 in Group B (12.9%), and in 8 in Group C (12.9%). The differences were statistically significant for Group A compared with either Group B or Group C (p = 0.048). Postsphincterotomy bleeding occurred in 3 patients (1.6%), one in each group. CONCLUSION The use of pure cutting electrosurgical current during endoscopic sphincterotomy in patients with choledocholithiasis is associated with a lesser degree of pancreatic enzyme elevation and lower frequency of pancreatitis, whereas bleeding is not increased compared with blended current. Changing from pure cutting to blended current after the first 3 to 5 mm of the incision is associated with an increased rate of complications compared to the use of pure cutting current for the entire sphincterotomy.
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Affiliation(s)
- Martin L Freeman
- University of Minnesota, Division of Gastroenterology, Hennepin County Medical Center, Minneapolis, Minnesota 55415, USA
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Iodice G, Giardiello C, Francica G, Sarrantonio G, Angelone G, Cristiano S, Finelli R, Tramontano G. Single-step treatment of gallbladder and bile duct stones: a combined endoscopic-laparoscopic technique. Gastrointest Endosc 2001; 53:336-8. [PMID: 11231394 DOI: 10.1016/s0016-5107(01)70409-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND The introduction of laparoscopic cholecystectomy has given rise to a debate as to whether endoscopic retrograde cholangiopancreatography (ERCP) should be performed before or after cholecystectomy in patients with bile duct stones. METHODS This study evaluated the efficacy of treatment of cholecystocholedocholithiasis in a single step by performing ERCP during surgery in 52 patients (35 women, 17 men; mean age 57.0 years; age range 20 to 89 years). Laparoscopic intraoperative cholangiography via the cystic duct was carried out to confirm the presence of duct stones. A soft-tipped guidewire was passed through the cystic duct and papilla into the duodenum. A papillotome was inserted endoscopically over the guidewire. Endoscopic sphincterectomy was performed and the stones removed with balloon and basket catheters. RESULTS Endoscopic stone removal was successful in 94% of cases without complications related to ERCP or surgery. Although operative time was lengthened by about 20 minutes, the hospital stay was as short and equal to that for simple laparoscopic cholecystectomy (3 days on average). CONCLUSIONS The single-step combined endoscopic-laparoscopic technique is safe and effective for treatment of patients with gallbladder and bile duct stones.
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Affiliation(s)
- G Iodice
- Unità Operativa di Gastroenterologia ed Endoscopia Digestiva, Unità Operativa di Ecografia Diagnostica ed Ecointerventiva, and Unità Operativa di Chirurgia Miniinvasiva, Presidio Sanitario S.M. della Pietà, Casoria, Italy
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Mathur SK, Soonawalla ZF, Shah SR, Goel M, Shikare S. Role of biliary scintiscan in predicting the need for cholangiography. Br J Surg 2000; 87:181-5. [PMID: 10671924 DOI: 10.1046/j.1365-2168.2000.01300.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Currently used predictors for bile duct calculi in patients undergoing cholecystectomy have low specificity resulting in unnecessary cholangiograms being performed. The role of biliary scintiscan in predicting the presence of bile duct calculi was assessed. METHODS Seventy-five patients with symptomatic gallstone disease were studied prospectively regard- ing the value of a history of jaundice or acute pancreatitis, raised serum bilirubin and serum alkaline phosphatase levels, and visualization of stones or presence of dilated bile ducts on ultrasonography (standard criteria) in detecting bile duct calculi. Results of biliary scintiscan were evaluated against a combination of standard criteria. The 'gold standard' for evaluation was endoscopic or peroperative cholangiography. RESULTS Biliary scintiscan had a higher sensitivity and specificity (93 and 94 per cent) than a combination of the above standard and modified predictors for biliary calculi (89 and 71 per cent). A combination of ultrasonography and selective use of scintiscan, in the absence of bile duct dilatation only, had higher values (96 and 98 per cent). CONCLUSION A combination of ultrasonography and biliary scintiscan can accurately predict bile duct calculi and could be used as a guide for selective cholangiography.
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Affiliation(s)
- S K Mathur
- Department of Surgery and Gastrointestinal Surgical Services, King Edward VII Memorial Hospital, Bombay 400 012, India
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Chikamori F, Nishio S, LeMaster JC. Percutaneous papillary balloon dilatation as a therapeutic option for cholecystocholedocholithiasis in the era of laparoscopic cholecystectomy. Surg Today 1999; 29:856-61. [PMID: 10489125 DOI: 10.1007/bf02482775] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The present study was conducted to evaluate the effectiveness of percutaneous papillary balloon dilatation (PPBD) as a therapeutic option for cholecystocholedocholithiasis, in combination with laparoscopic cholecystectomy (LC). A total of 15 patients with both bile duct and gallbladder stones were clinically investigated. In 14 patients, PPBD was performed 2 to 7 days prior to LC, while in the remaining patient, PPBD was performed immediately after LC under general anesthesia in one continuous session. The bile duct stones were successfully pushed out into the duodenum in all the patients, seven of whom required two sessions for complete stone clearance, while the other eight needed only one session. Two patients had bile duct stones larger than 12 mm in diameter, necessitating electrohydraulic lithotripsy under cholangioscopy. The insertion of a percutaneous transhepatic biliary drainage tube did not cause intra-abdominal adhesions severe enough to contraindicate the use of LC. The operation times for LC varied from 80 to 184 min, with a mean operation time of 132 min, and the average postoperative and overall hospital stays were 9 and 26 days, respectively. There were no deaths or major complications, apart from transient hyperamylasemia. The findings of this study indicate that PPBD combined with LC is a safe and effective therapeutic option for cholecystocholedocholithiasis.
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Affiliation(s)
- F Chikamori
- Department of Surgery, Kuniyoshi Hospital, Kochi, Japan
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Bergamaschi R, Tuech JJ, Braconier L, Walsøe HK, Mårvik R, Boyet J, Arnaud JP. Selective endoscopic retrograde cholangiography prior to laparoscopic cholecystectomy for gallstones. Am J Surg 1999; 178:46-9. [PMID: 10456702 DOI: 10.1016/s0002-9610(99)00110-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- R Bergamaschi
- Department of Visceral Surgery, Angers University Hospital, France
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12
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Abstract
Treatment of gallstones by laparoscopic cholecystectomy has become standard therapy over the past decade and has received wide patient acceptance. Problems are infrequent but those such as biliary injury may be serious and continue to be a cause of concern. Biliary injury is more likely when surgery is performed in the presence of acute inflammation. Laparoscopic bile duct exploration is becoming standardized and the results are good. The role of other laparoscopic biliary procedures such as biliary bypass is still uncertain.
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Affiliation(s)
- S M Strasberg
- Section of Hepatobiliary-Pancreatic Surgery, Washington University, St. Louis, Missouri, USA
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Nourallah H, Issa H, Al-Salem AH. The role of ERCP in the evaluation, diagnosis, and therapy of biliary and pancreatic diseases in children. Ann Saudi Med 1999; 19:163-6. [PMID: 17337963 DOI: 10.5144/0256-4947.1999.163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- H Nourallah
- Departments of Medicine and Surgery, Qatif Central Hospital, Qatif, Saudi Arabia
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Abboud PA, Malet PF, Berlin JA, Staroscik R, Cabana MD, Clarke JR, Shea JA, Schwartz JS, Williams SV. Predictors of common bile duct stones prior to cholecystectomy: a meta-analysis. Gastrointest Endosc 1996; 44:450-5. [PMID: 8905367 DOI: 10.1016/s0016-5107(96)70098-6] [Citation(s) in RCA: 196] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The decision of whether or not to investigate for common bile duct stones before cholecystectomy utilizes clinical, laboratory, and radiologic information (indicators). There is tremendous individual variation among clinicians in the criteria used for making this decision. Our aim was to perform a meta-analysis of published data to estimate the performance characteristics of the most commonly used preoperative indicators of common bile duct stones. METHODS Using predetermined exclusion criteria, we selected articles from a MEDLINE search and bibliographic review. Weighted averages were used to determine summary sensitivity, specificity, and positive and negative likelihood ratios for each indicator for stones. RESULTS From 2221 citations identified, 22 studies met inclusion criteria. The 10 indicators examined were reported in a common fashion in three or more articles, and could be assessed preoperatively. Seven exhibited a specificity greater than 90%. Indicators with positive likelihood ratios of 10 or above were cholangitis, preoperative jaundice, and ultrasound evidence of common bile duct stones. Positive likelihood ratios for dilated common bile duct on ultrasound, hyperbilirubinemia, and jaundice ranged from almost 4 to almost 7. Elevated levels of alkaline phosphatase, pancreatitis, cholecystitis, and hyperamylasemia exhibited positive likelihood ratios of less than 3. CONCLUSIONS This meta-analysis has identified indicators for duct stones and ranked them according to likelihood ratios. These findings can be applied as guidelines for whether to investigate for duct stones before cholecystectomy.
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Affiliation(s)
- P A Abboud
- Division of General Internal Medicine, University of Pennsylvania, Philadelphia, USA
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Freeman ML, Nelson DB, Sherman S, Haber GB, Herman ME, Dorsher PJ, Moore JP, Fennerty MB, Ryan ME, Shaw MJ, Lande JD, Pheley AM. Complications of endoscopic biliary sphincterotomy. N Engl J Med 1996; 335:909-18. [PMID: 8782497 DOI: 10.1056/nejm199609263351301] [Citation(s) in RCA: 1623] [Impact Index Per Article: 58.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Endoscopic sphincterotomy is commonly used to remove bile-duct stones and to treat other problems. We prospectively investigated risk factors for complications of this procedure and their outcomes. METHODS We studied complications that occurred within 30 days of endoscopic biliary sphincterotomy in consecutive patients treated at 17 institutions in the United States and Canada from 1992 through 1994. RESULTS Of 2347 patients, 229 (9.8 percent) had a complication, including pancreatitis in 127 (5.4 percent) and hemorrhage in 48 (2.0 Percent). There were 55 deaths from all causes within 30 days; death was directly or indirectly related to the procedure in 10 cases. Of five significant risk factors for complications identified in a multivariate analysis, two were characteristics of the patients (suspected dysfunction of the sphincter of Oddi as an indication for the procedure and the presence of cirrhosis) and three were related to the endoscopic technique (difficulty in cannulating the bile duct achievement of access to the bile duct by "precut" sphincterotomy, and use of a combined percutaneous-endoscopic procedure). The overall risk of complications was not related to the patient's age, the number of coexisting illnesses, or the diameter of the bile duct. The rate of complications was highest when the indication for the procedure was suspected dysfunction of the sphincter of Oddi (21.7 percent) and lowest when the indication was removal of bile-duct stones within 30 days of laparoscopic cholecystectomy (4.9 percent). As compared with those who performed fewer procedures, endoscopists who performed more than one sphincterotomy per week had lower rates of all complications (8.4 percent vs. 11.1 percent, P=0.03) and severe complications (0.9 percent vs. 2.3 percent, P=0.01). CONCLUSIONS The rate of complications after endoscopic biliary sphincterotomy can vary widely in different circumstances and is primarily related to the indication for the procedure and to endoscopic technique, rather than to the age or general medical condition of the patients.
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Affiliation(s)
- M L Freeman
- Hennepin County Medical Center, Minneapolis, MN 55415, USA
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Legorreta AP, Brooks RJ, Staroscik RN, Xuan Y, Costantino GN, Zatz SL. Increased ERCP rate following the introduction of laparoscopic cholecystectomy. JOURNAL OF LAPAROENDOSCOPIC SURGERY 1995; 5:271-8. [PMID: 8845499 DOI: 10.1089/lps.1995.5.271] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Over the past 5 years there has been a remarkable change in the manner in which symptomatic gallstones are surgically managed. In this study we reviewed the experience of a large HMO to determine the relationship between the rate of increase of ERCP and that of cholecystectomy. All individuals enrolled in US Healthcare's HMO-PA, in the region of southeastern Pennsylvania from 1988 through 1993, were included in the analysis. Using the HMO claims database, patients who underwent an open or laparoscopic cholecystectomy during the study period were identified. We then identified those patients who had a pre- or post- operative ERCP. Over the study period, there has been a substantial increase in cholecystectomies per 1000 members-from 1.37 in 1988 to 2.16 (p < 0.0001) in 1993. In our study population there were 1261 ERCPs performed in 979 patients with an average of 1.3 ERCPs per patient during the study period. The ERCP rate per 1000 members has increased from 0.16 to 0.56 (p < 0.0001) from 1988 to 1993, at the same time that the cholecystectomy rate was substantially increasing. The correlation for the ERCP and cholecystectomy rates from 1988 to 1993 was 0.994 (p < 0.0001). Since the introduction of laparoscopic cholecystectomy in 1989-1990, many more ERCPs are now being performed. It is necessary to determine the implications related to the rapid diffusion of laparoscopic cholecystectomy, including the effect that this technology has had on other older and stable technologies such as ERCP. Our results describe the dramatic effect that laparoscopic cholecystectomy has had on the utilization of ERCPs.
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Erickson RA, Carlson B. The role of endoscopic retrograde cholangiopancreatography in patients with laparoscopic cholecystectomies. Gastroenterology 1995; 109:252-63. [PMID: 7797023 DOI: 10.1016/0016-5085(95)90292-9] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The best clinical strategy for using endoscopic retrograde cholangiopancreatography (ERCP) with laparoscopic cholecystectomy is unknown. The aim of this study is to use decision analysis to assess four different approaches to using ERCP in patients undergoing laparoscopic cholecystectomy. METHODS Decision trees were designed for four clinical strategies: (1) preoperative ERCP, with sphincterotomy for choledocholithiasis; (2) selective preoperative ERCP for patients at high risk for choledocholithiasis, choledocholithiasis found at surgery treated by postoperative ERCP; (3) no preoperative ERCP, choledocholithiasis detected intraoperatively treated by postoperative ERCP; and (4) no preoperative ERCP, choledocholithiasis detected intraoperatively treated with open common bile duct exploration. Using decision analysis with literature-derived data, the impact on outcome parameters was calculated. RESULTS Postoperative ERCP resulted in the lowest cost, procedure numbers, and hospital and back-to-work days. With high preoperative likelihood of choledocholithiasis, selective preoperative ERCP was probably a clinically equivalent strategy. Sensitivity analysis supported these conclusions when the probabilities and utilities were varied over a wide range. The open operative approach to choledocholithiasis was only favored if ERCP had < 75% diagnostic and < 50% therapeutic success rates or lengthened hospitalization by > 7 days. CONCLUSIONS This study suggests that performing ERCP after laparoscopic cholecystectomy minimizes costs and morbidity; however, when choledocholithiasis is likely, selective preoperative ERCP may be a clinically equivalent strategy.
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Affiliation(s)
- R A Erickson
- Department of Medicine, Department of Veterans Affairs Medical Center, Long Beach, California, USA
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Kitano S, Bandoh T, Yoshida T, Shuto K. Laparoscopic C-tube drainage via cystic duct following common bile duct exploration. ACTA ACUST UNITED AC 1995. [DOI: 10.1007/bf02348740] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Abstract
The authors report on a group of 114 patients with common bile duct (CBD) stones who were treated by laparoscopic surgery. Management through the cystic duct was considered the first option. Choledochotomy was used for those patients in which the cystic approach was not possible or was unsuccessful. Transcystic lithotripsy was considered for patients with CBD stones in disproportion with the size of the cystic duct. Laparoscopic antegrade sphincterotomy was indicated as a drainage procedure. The transcystic approach was used in 89.5% of the patients; choledochotomy was used in 6.2%; and both ways were used in 4.3%. Different procedures were used, including mechanical and electrohydraulic lithotripsy, choledochotomy with T-tube or endoprostheses drainage, laparoscopic sphincterotomy, end-to-end common bile duct anastomosis, and choledochoduodenum anastomosis. One of the patients was in the 21st week of pregnancy. The laparoscopic approach to choledocholithiasis was successfully performed in 94.8% of the patients. Mean hospital stay was 1.7 days. There was a 6.2% incidence of complications and the mortality rate was 0.9%. In 84.3% of the patients, the transcystic approach was used successfully, with a complication rate of 4.9% and a mean hospital stay of 1.6 days. Three patients were converted to open surgery early in this series. Thus far, one patients has presented residual CBD stones. The results obtained suggest that laparoscopic common bile duct exploration is a technically feasible procedure, with low complication and mortality rates, although it requires adequate selection of patients and a variety of techniques and types of equipment.
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Affiliation(s)
- A L DePaula
- Department of Surgery, Hospital Samaritano, Goiania-Go, Goias, Brazil
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21
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Rieger R, Sulzbacher H, Woisetschläger R, Schrenk P, Wayand W. Selective use of ERCP in patients undergoing laparoscopic cholecystectomy. World J Surg 1994; 18:900-4; discussion 904-5. [PMID: 7846916 DOI: 10.1007/bf00299101] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
With the advent of laparoscopic cholecystectomy (LCH) various strategies have been proposed for the management of common bile duct (CBD) stones. In a consecutive series of 1140 patients subjected to LCH, preoperative endoscopic retrograde cholangiopancreatography (ERCP) was attempted in 128 patients (11.2%) and successfully accomplished in 121 (94.5%). Based on the prediction of CBD stones by laboratory tests, ultrasonography, and intravenous cholangiography, prelaparoscopic ERCP was performed in 106 patients (9.3%). CBD stones were identified in 56 patients and benign papillary stenosis in 5 patients (57.5%). Of these 61 patients, 58 (95%) were treated by endoscopic sphincterotomy (ES) and stone extraction followed by LCH after a mean interval of 1.6 days. Three patients with failure of endoscopic ductal stone extraction required open CBD exploration. In 39 of the 106 patients (36.8%) ERCP was negative for ductal stones but revealed unexpected ampullary and pancreatic cancer in two cases. Six patients (of the 106) with preoperative ERCP cannulation failure (5.7%) were managed either by LCH and intraoperative cholangiography or by open CBD exploration. In 22 of the 1140 total patients (1.9%) ERCP was performed at various intervals after LCH. Retained CBD stones were found in eight patients, and ES and ductal clearance was achieved in all eight. There was no mortality among the entire surgical group who underwent perioperative ERCP/ES. Including two cases of ES-related pancreatitis, the overall morbidity was 5.5% (7 of 128). Perioperative ERCP/ES in conjunction with LCH is an attractive approach for patients with cholecystocholedocholithiasis, at least until laparoscopic ductal clearance becomes a standard procedure.
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Affiliation(s)
- R Rieger
- Second Department of Surgery, Ludwig Boltzmann Institute for Laparoscopic Surgery, General Hospital of Linz, Austria
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22
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Barkun AN, Barkun JS, Fried GM, Ghitulescu G, Steinmetz O, Pham C, Meakins JL, Goresky CA. Useful predictors of bile duct stones in patients undergoing laparoscopic cholecystectomy. McGill Gallstone Treatment Group. Ann Surg 1994; 220:32-9. [PMID: 7517657 PMCID: PMC1234284 DOI: 10.1097/00000658-199407000-00006] [Citation(s) in RCA: 214] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE The authors determined the most useful predictors of common bile duct (CBD) stones as diagnosed by endoscopic retrograde cholangiopancreatography (ERCP) in patients who underwent laparoscopic cholecystectomy (LC). METHODS Prospective and retrospective collection of historical, biochemical and ultrasonographic data was used. Receiver operating characteristics curve analysis was used to determine optimal biochemical cut-off values. Multivariate analysis using logistic regression with generation of the best model identifying independent predictors of CBD stones also was employed. Prospective validation of the model was performed on an independent group of patients. RESULTS Endoscopic retrograde cholangiopancreatographies were performed before LC in 106 patients, and after LC in 33. Only four of ten clinical variables evaluated independently predicted the presence of CBD stones. The optimal model predicted a 94% probability of CBD stones in a patient older than 55 years of age who presented with an elevated bilirubin (over 30 mumol/L) and positive ultrasound findings (a dilated CBD, and a CBD stone seen on ultrasound). This model was validated prospectively in a subsequent series of 49 patients in which the probability of CBD stone was only 8% when all four predictors were absent. CONCLUSIONS The identified independent clinical predictors of a CBD stone helps select a population of symptomatic gallstone bearers who benefit most from cholangiographic assessment.
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Affiliation(s)
- A N Barkun
- Division of Gastroenterology, McGill University, Montreal, Quebec, Canada
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23
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Schütte H, Yarmuch J, Latorre R, Gallo G, Bühler J, Scavenius R, Silva J. Endoscopic bile duct stone removal prior to laparoscopic cholecystectomy. JOURNAL OF LAPAROENDOSCOPIC SURGERY 1994; 4:191-7. [PMID: 7919507 DOI: 10.1089/lps.1994.4.191] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Of 1049 patients referred for laparoscopic cholecystectomy (LC) for symptomatic gallstone disease, 67 (6%) had clinical, biochemical, or echographic findings suggesting common bile duct stones. Patients in this group were studied preoperatively with endoscopic retrograde cholangiopancreatography (ERCP). In 26 patients (39%), the diagnosis was confirmed. In 12 other cases (18%), the macroscopic finding of a stripped or bleeding papilla without common bile duct stones suggested stone migration. ERCP in the remaining 29 patients (43%) was normal. Thirty-four endoscopic sphincterotomies (ES) were performed, 26 for common bile duct stones and 8 for cystic lithiasis or gallbladder microlithiasis. In the entire group of patients with choledocholithiasis, stone removal was possible. All 67 patients underwent laparoscopic cholecystectomy on an average of 2.8 days following the endoscopic procedure. Twenty-one patients (31%) had acute cholecystitis, and 5 had chronic scleroatrophic cholecystitis. Five (7.5%) of the 67 patients were converted to an open procedure. In 10 cases (16%), the cystic diameter was larger than an 8-mm M-L clip, which made necessary the use of endoligature or extra clips. No complications or deaths resulted from ERCP or ES. Two of the 62 patients (3.2%) who underwent LC had to be reoperated on, 1 because of a right subphrenic collection, and the other because of bilious ascites. No common bile duct lesions or deaths resulted in the analyzed group. The average hospitalization time, with the exception of those patients converted or reoperated on, was 8 days.
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Affiliation(s)
- H Schütte
- Department of Surgery, Clinical Hospital, Universidad de Chile, Santiago
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24
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Abstract
Demands for less invasive, more cost-effective therapy have revolutionized the management of gallstones over the past 10 years. There are no reliable methods of permanently reversing the pathophysiologic defects that cause gallstones. Open cholecystectomy (OC), the gold standard for managing symptomatic cholelithiasis, has been largely replaced by laparoscopic cholecystectomy (LC), which has the advantages of a minimal hospital stay and quicker return to work. Other adjunctive therapies, limited in applicability to selected patients, include oral bile acid therapy (BAT), dissolutional agents, and extracorporeal shock wave lithotripsy. Choledocholithiasis (CDL), formerly managed exclusively with surgical common duct exploration, is increasingly treated with therapeutic biliary endoscopy. Methods of laparoscopic common bile duct exploration are being developed. Optimal algorithms for applying these techniques to patients undergoing LC are evolving. In a sense, the solution to all, or certainly most, gallstones now can be seen through a scope.
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Affiliation(s)
- C F Gholson
- Department of Medicine, Louisiana State University School of Medicine, Shreveport 71130
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25
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Affiliation(s)
- N J Soper
- Washington University School of Medicine, Department of Surgery, St. Louis, MO 63110
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26
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Guelrud M, Rincones VZ, Jaen D, Toledano A, Arias Y. Endoscopic sphincterotomy and laparoscopic cholecystectomy in a jaundiced infant. Gastrointest Endosc 1994; 40:99-102. [PMID: 8163152 DOI: 10.1016/s0016-5107(94)70025-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- M Guelrud
- Gastroenterology Department, Hospital General del Oeste, MSAS, Los Magallanes, Caracas, Venezuela
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27
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Soper NJ, Brunt LM, Callery MP, Edmundowicz SA, Aliperti G. Role of laparoscopic cholecystectomy in the management of acute gallstone pancreatitis. Am J Surg 1994; 167:42-50; discussion 50-1. [PMID: 8311139 DOI: 10.1016/0002-9610(94)90052-3] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Laparoscopic cholecystectomy has rapidly become the prime modality for removal of the gallbladder. However, as laparoscopic techniques for treating choledocholithiasis are evolving, we reviewed our experience with acute gallstone pancreatitis since the inception of laparoscopic cholecystectomy. Between November 1989 and March 1993, we treated 57 patients with acute gallstone pancreatitis. Cholecystectomy was performed during the initial admission in 46 patients (81%, group I), while 11 (19%) underwent delayed cholecystectomy at a second admission 2 to 9 weeks later (group II). Within group I, eight patients (17%) were thought to have contraindications to laparoscopic cholecystectomy and underwent open cholecystectomy. In the remaining 38 patients of group I, laparoscopic cholecystectomy was completed successfully. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) was performed in 23 of these patients (61%) and endoscopic sphincterotomy was performed in 6 patients (26%). In four other patients, the intraoperative cholangiogram revealed common bile duct stones that were removed using laparoscopic techniques. The 11 patients in group II were all treated by laparoscopic cholecystectomy; of these patients, 3 underwent preoperative endoscopic stone removal and 1 had choledocholithiasis managed laparoscopically. Postoperative hospitalization averaged 4 +/- 1 days (mean +/- SEM), and there was no major morbidity or 30-day mortality. This is the first large series of acute gallstone pancreatitis in the era of laparoscopic cholecystectomy. Our experience suggests that laparoscopic cholecystectomy with or without ERCP should be the primary approach for treating acute gallstone pancreatitis in the 1990s.
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Affiliation(s)
- N J Soper
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri 63110
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28
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Chow M, von Waldenfels A, Pace R. An unusual case of a retained stone following laparoscopic cholecystectomy. JOURNAL OF LAPAROENDOSCOPIC SURGERY 1993; 3:513-8. [PMID: 8251670 DOI: 10.1089/lps.1993.3.513] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
A patient with gallstone pancreatitis was managed by endoscopic sphincterotomy followed by a laparoscopic cholecystectomy. At the time of surgery, an intraoperative cholangiogram disclosed the presence of a residual calculus, which was erroneously thought to be in the common bile duct. A repeat ERCP showed that the stone was, in fact, in a long cystic duct stump which was fortunately accessible to endoscopic extraction.
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29
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Abstract
In 1989 a new trend occurred in the surgical treatment of a diseased gall-bladder, laparoscopic cholecystectomy (LC). Laparoscopic surgery is now accepted world-wide as the choice of treatment with the advantages of less pain, good cosmesis, short hospital stay and early recovery. It is also a curative procedure for cholelithiasis as well as a cholecystectomy. The rate of conversion to open surgery is about 5% and the rates of bile duct injury are 0.1-0.6%. This new approach revives controversies concerning cholecystectomy; namely indication, use of intra-operative cholangiography, ductal calculi and pregnancy. There are new issues to consider, including use of a Veress needle for pneumoperitoneum, type of trocars, cardiovascular responses to pneumoperitoneum using carbon dioxide and so on. With increasing use, these difficulties will be overcome. Advances in technology are expected to make even more new types of surgery possible, even perhaps extending into robotic surgery.
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Affiliation(s)
- S Kitano
- Department of Surgery II, Kyushu University, Fukuoka, Japan
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30
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Kadakia SC. Biliary tract emergencies. Acute cholecystitis, acute cholangitis, and acute pancreatitis. Med Clin North Am 1993; 77:1015-36. [PMID: 8371614 DOI: 10.1016/s0025-7125(16)30208-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Acute cholecystitis, acute cholangitis, and acute pancreatitis represent the most common biliary tract emergencies. Most are due to gallstones in the gallbladder and bile ducts. Acute cholecystitis is treated by surgery in most cases. Laparoscopic cholecystectomy combined with endoscopic sphincterotomy may become more common in the future for treatment of acute cholecystitis as well as in cases of acute cholangitis and pancreatitis if the bile ducts are cleared of gallstones. Although the role of either surgery or endoscopic treatment may be more clearly defined in some biliary tract emergencies, in other situations either modality may be appropriate or they may compliment each other. Most biliary emergencies should be managed by gastroenterologists, surgeons, and radiologists working together in a harmonious fashion.
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Affiliation(s)
- S C Kadakia
- Gastroenterology Service, Brooke Army Medical Center, San Antonio, Texas
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31
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Abstract
After laparoscopic cholecystectomy, the patient can expect a hospital stay of < 2 days and a return to work within 2 weeks. The associated operative mortality rate is low at < 0.2 per cent. The increased incidence of bile duct injury with the laparoscopic technique compared with open cholecystectomy is a cause for concern but such injuries should decrease with proper training in laparoscopic surgery. The use of operative cholangiography (whether routine, selective or never) is controversial but there is no evidence that routine cholangiography will prevent major bile duct injury.
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Affiliation(s)
- I M Macintyre
- Surgical Review Office, Western General Hospital, Edinburgh, UK
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32
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Abstract
The author reviews his experience with the laparoscopic management of common duct pathology and compares it with the experience of others as reported in the literature. Routine intraoperative cholangiography is advocated. A variety of methods of managing common duct stones laparoscopically is presented. These include balloon-catheter manipulation, fluoroscopically guided basket extraction, and choledochoscopic evaluation and removal of stones. The accumulated experience indicates that more than 90% of common duct stones can be removed laparoscopically via the cystic duct. This approach significantly reduces the need for either preoperative or postoperative endoscopic retrograde cholangiopancreatography. Although laparoscopic choledochotomy has been employed in a number of cases and can be performed with a high degree of safety and efficacy, it is needed only infrequently. This form of management results in decreased dependence upon T-tubes, thereby reducing postoperative morbidity and the length of hospitalization. A rational protocol for the management of common duct pathology is presented.
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Affiliation(s)
- J B Petelin
- Department of Surgery, University of Kansas School of Medicine, Shawnee Mission 66204
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33
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Affiliation(s)
- D E Johnston
- Department of Medicine, New England Medical Center, Boston, MA 02111
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34
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Frakes JT, Bradley SJ. Endoscopic stent placement for biliary leak from an accessory duct of Luschka after laparoscopic cholecystectomy. Gastrointest Endosc 1993; 39:90-2. [PMID: 8454158 DOI: 10.1016/s0016-5107(93)70023-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- J T Frakes
- Department of Medicine, University of Illinois College of Medicine, Rockford
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35
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Deslandres E, Gagner M, Pomp A, Rheault M, Leduc R, Clermont R, Gratton J, Bernard EJ. Intraoperative endoscopic sphincterotomy for common bile duct stones during laparoscopic cholecystectomy. Gastrointest Endosc 1993; 39:54-8. [PMID: 8454146 DOI: 10.1016/s0016-5107(93)70011-5] [Citation(s) in RCA: 60] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- E Deslandres
- Department of Medicine (G.I. Division), Hotel-Dieu de Montreal, University of Montreal, Quebec, Canada
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36
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Abstract
Endoscopic sphincterotomy with stone extraction is the non-surgical method of choice for treatment of choledocholithiasis in patients unfit for surgery or with previous cholecystectomy. Its success rate is 85-90%. Many adjunctive methods have been developed to increase the clearance rate after initial failure and are reviewed in this paper. Collaboration among the surgeon, endoscopist and radiologist offers the patient a high opportunity for successful clearance of common bile duct (CBD) stones with the least morbidity and mortality. The application of endoscopic sphincterotomy combined with laparoscopic cholecystectomy to younger patients is now debated.
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Affiliation(s)
- G Pelletier
- Service des Maladies du Foie et de l'Appareil Digestif, Hôpital de Bicêtre, Kremlin-Bicêtre, France
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